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ST. MARY’S COLLEGENURSING PROGRAM

Tagum City

A CASE STUDYon

Acute Pulmonary edema complicating Severe preeclampsia

Presented to

Ms. Lesley Cadua RN,MNMs. Joan Calzada RN, MN

In Partial Fulfillment of the Requirements

In

Related Learning Experience(RLE)

By

BSN 2-A

Pinky rose MarfilYvonne Obra

Axel Mae AbaricoZhendy Solis

Holy Eve PasoquinIan mizzelDulfina

RondelDadulaJose Mari Bernardino

John OcceñoNiel Sabino

02-03-13

I. INTRODUCTION

Background Study

The group chose Acute Pulmonary edema secondary to severe preeclampsia as our case to be study out of curiosity. This is our first time to encounter this kind of case and because of that, our group was interested in it. We are willing to do this case to challenge our mind in analyzing the problem and to enhance our hidden knowledge, and also to gain new experiences which would bring new learning’s for the member of the group.

This case study will help the group in understanding the disease process of the patient. This would also help the group in identifying primary needs of the patient with Acute Pulmonary edema with severe preeclampsia. By identifying such needs and health problems arise the group can now formulate an individualized care plan for the patient that would address these needs and problems effectively. Effective management of the problems identified will help the patient to recover faster and maintain a holistic sense of wellness even while in the hospital.

This case study would also equip the group with knowledge, skills and attitude on how to manage future patients with the same or similar disease.

GLOBAL

Cohort study - 62,917 consecutive pregnancies from 1989-1999, to describe the incidence, predisposing factors contributing to pulmonary edema in the pregnant patient. Fifty-one women (0.08%) were diagnosed with acute pulmonary edema during ante partum-post partum period. 24 patients (47%) antepartum, 7 patients (14%) intrapartum, 20 patients (39%) post partum. Most common causes: Tocolytics (25.5%) most commonly MgSO4 and SC terbutaline, Cardiac disease(25.5%), Fluid overload (21.5%) and preeclampsia (18%).

A. Aya et al. Patients with Severe Preeclampsia Experience Less Hypotension During Spinal Anesthesia for Elective Cesarean Delivery than Healthy Parturients: A Prospective Cohort Comparison. Anesthesia & Analgesia 2003;97:867-72

Philippine Setting

• According to Dept. of Health, Maternal Mortality Rate (MMR) – 162 out of 10,000 live births (Family Planning Survey 2006)– Maternal deaths account for 14% of deaths among women

• For the past 5 years, all of the causes of maternal deaths exhibited an upward trend.

– Pre-Eclampsia showed an increasing trend of 6.89%, 20%, 40%, and 100%

– 10 women die everyday in the Philippines due to pregnancy and childbirth-related causes, such as pre-eclampsia

http://www.doh.gov.ph/kp/statistics/maternal_deaths.html#2006

OBJECTIVES

Define what is acute pulmonary edema secondary to severe preeclampsia.

Trace the pathophysiology of acute pulmonary edema secondary to severe preeclampsia.

Enumerate the different signs and symptoms of acute pulmonary edema secondary to severe preeclampsia.

Formulate and apply nursing care plans utilizing the nursing process . To learn new clinical skills as well as sharpen our current clinical skills

required in the management of the patient with acute pulmonary secondary to severe preeclampsia.

To develop our sense of unselfish love and empathy in rendering nursing care to our patient so that we may be able to serve future clients with higher level of holistic understanding as well as individualized care.

II. ASSESSMENT

A. BIOGRAPHIC DATA

Patients Name: Butron, Lorna T.Address: Prk. 5, Sindahon, Panabo City, Davao del NorteSex: FemaleAge: 39 years oldCivil Status: Married

Birthdate: 03/05/1973Birthplace: MATI, DAVAO ORIENTALNationality: FilipinoReligion: CatholicOccupation: House keeper

B. CHIEF COMPLAINT

Dyspnea

C. History of present illness

D. Past medical and Nursing HistoryE. Personal, family and socio-economic historyF. Patient need assessment

PHYSIOLOGIC NEEDS

I. OXYGENATION BP__160/110__ RR 49 cpm____CR___149bpm

(CHARACTER) tachypnia___

LUNGS (per auscultation: character, lung sound, symmetry of chest

expansion, breathing character and pattern):crackles sounds heard upon

auscultation, w/ symmetrical chest expansion, intercostals retraction

noted, use of accessory muscles noted.

CARDIAC STATUS (per auscultation) sounds, character, chest pain.

__”Lub-dubb” sound heard with increased intensity per auscultation,

chest pain not noted

CAPILLARY REFILL bad capillary refill of less than 3

seconds_

SKIN CHARACTER AND COLOR_skin is brown, dry,

flaky and wrinkled.

II. TEMPERATURE MAINTENANCE

TEMPERATURE: 36.8 o C _

SKIN CHARACTER_Skin is dry, flaky, wrinkled and not warm to touch_

III NUTRITIONAL FLUID

HEIGHT/WT 5”2’/45 kg _ AMT. FOOD CONSUMED: w/ good appetite, able to

consumed the OF served

PRESCRIBED DIET: LSLF

EATING PATTERN: 3x a day_

INTAKE (IVF; FLUID/WATER: with IVF of D5LR 1L@30cc/hr, water = 300cc

Other OBSERVATION (related)\: Skin is dry, has poor skin turgor

IV ELIMINATION

Last BOWEL MOVEMENT(frequency, amount, character)__defecated on small

amount,

NORMAL PATTERN 1- 2x a day,

URINATION(Frequency, character, sensation)_able to urinate

V REST-SLEEP

BED TIME _6-7 pm_WAKING UP__5:30 am_

SLEEP (pattern, amount of sleep)_5-6hrs_

PROBLEM AS VERBALIZED –“dili ko kaayo makatulog”-

OTHER OBSERVATION (related)_Patient can easily be distracted, thus, having

difficulty in sleeping back again

VI PAIN AVOIDANCE

RATE PAIN_-can’t able to verbalize- TIME STARTED__7:30 PM_

LOCATION _genital area__BEHAVIOR (restlessness, facial expression,

irritable, diaphoretic)frequent change of position noted, grimace face and

guarding behavior noted on genital area

FREQUENCY_continuos_

CHARACTER can’t able to describe, can’t able to verbalize

OTHER observation (related) Patient has difficulty in sleeping due to pain felt

VII SEXUALITY REPRODUCTIVE

LMP__N/A__ AOG__N/A__

GRAVIDA/PARITY__G7P5__ PRENATAL__N/A__

MENSTRUAL CYCLE__N/A__ GYNECOLOGIC PROBLEM__N/A__

EDC__N/A__

FMILY PLANNING METHOD USE: calendar method

CHILDREN (no.) __6__ MENARCHE__N/A__

VIII STIMULATION ACTIVITY

WORK: Before: farmer During: needs assistance in performing activities of

RECREATION/PAST TIME: daily living,

HOBBIES/VICES: sleeping, a moderate smoker and drinker before

SAFETY AND SECURITY

MENTAL STATUS (Coherent, Responsive, conscious, unconscious) conscious,

able to respond by making incomprehensible sounds

EMOTIONAL PROBLEM (diaphoretic, trembling, restless)_restlessness: frequent

change of position due to pain felt________

LOVE BELONGING NEED

CHILDREN (living with?) Patient is loving and supportive

Wife (living with) husband. Due respect and care was given to her

SELF ESTEEM NEED

she is a good person and a loving mother. she has a moderate self esteem, also

because she is a friendly type of person and being loved by family members.

G. Physical Assessment

January 24, 2013

Skin

Brown skin generally uniform in color except in areas exposed to the sun Skin temperature uniform and within the normal range (370C) Dry skin folds

Nails with smooth texture Nail beds pink Prompt capillary refill time (4-5 seconds)

Head

Present of nodules or masses Symmetric facial features and movements Symmetric nasolabial folds Evenly distributed black hair No infestations

Eyes

Eyebrows symmetrically aligned with equal movement Eyelashes equally distributed and curled slightly outward Skin of eyelids intact with no discoloration Lids close symmetrically Bilateral blinking exhibited Presence of discharge, Yellowish sclera Pink palpebral conjunctiva Iris black in color Pupils equal in size with smooth borders Illuminated pupils constricts Pupils converge when near object is moved toward the nose When looking straight ahead, the client can see objects in the periphery Both eyes coordinated, move in unison with parallel alignment Eyeballs protruding

Ears

Color same as facial skin Symmetrically aligned Pinna immediately recoils after it is folded Pinna is not tender No lesions or discoloration Dry cerumen, grayish-tan color Normal voice tones audible Able to hear ticking of a watch in both ears

Nose

Symmetric and straight Nasal septum intact and in the midline

Mouth and Throat

Outer lips uniform bluish in color with symmetric contour, Buccal mucosa is of uniform pale in color Gums are pink Tongue slightly pink, not so moist, at central position

Neck

Head centered Lymph node palpable

Breast

Firm Generally symmetric in size

Cardiovascular

BP 160/110 PR 149 Symmetric pulse strength

Respiratory/Chest

Chest symmetric Chest wall intact, no tenderness, no masses Symmetric chest expansion and excursion RR: 49 bpm

Gastrointestinal/Abdomen

Straie present at hypogastric and iliac regions Linea nigra present No tenderness

Urinary

Absence of nocturia, dysuria, urgency, hesitancy Light yellow urine

Reproductive

Regular menstrual cycle G7p5

Musculoskeletal/Extremities

Muscle equal size on both sides of the body No tenderness Presence of edema Smooth coordinated movements

Neurologic

Can respond to verbal commands Oriented Conscious

H. Course in the ward

Date shift Nurse’s Assessment Nurse’s Intervention Medical Management

III. Laboratory and Diagnostic examinations

LAB EXAM NORMAL VALUE RESULT INTERPRETATION/IMPLICATIONWBC Count 3.98-10x109g/L 16.8 Abnormally high due to presence

of infection or inflammationRBC Count 4.20-6.30 T/L 4.96 NormalHemoglobin 120-160g/L 107 Below normal

Decreased Hgb count on pregnant is normal because of the increase in plasma volume during pregnancy.

Hematocrit 0.370-0.47g/L 0.345 Below normalDecreased hematocrit on pregnan is normal because of their increase in plasma volume.

Platelet count 140-440 G/L 322 normalUrine protein collection

0 +4 Abnormally high due to severe preeclampsia

IV. ANATOMY AND PHYSIOLOGY

Anatomy & Physiology of the Respiratory System

The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue. Move the pointer over the coloured regions of the diagram; the names will appear at the bottom of the screen)

The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the

right lung is composed of the upper, the middle and the lower lobes.

Mechanics of Breathing

To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by thepleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.

Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

Physiology of Gas Exchange

Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.

Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow

of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

V. SYMPTOMATOLOGY

SYMPTOMATOLOGY ACTUAL SYMPTOMS IMPLICATIONExtreme shortness of breath and difficulty breathing

PRESENT

Due to the presence of fluid in the lungs.

Tightness and pain in the chestWheezing, coughingPaleness Due to inadequate

blood perfusion.SweatingBluish nails and lips Due to inadequate

blood perfusion.Pink, frothy mucus coming from nose and mouthCrackleshttp://www.umm.edu/altmed/articles/pulmonary-edema-000137.htm

VI. ETIOLOGY OF THE DISEASE

Non-cardiogenic

Hypertensive crisis . The cause of pulmonary edema in the presence of a hypertensive crisis is probably due to a combination of increased pressures in the right ventricle and pulmonary circulation and also increased systemic vascular resistance and left ventricle contractility increasing the hydrostatic pressure within the pulmonary capillaries leading to extravasation of fluid and edema.

^ a b c d Ware LB, Matthay MA. Acute pulmonary edema. N Engl J Med 2005;353:2788-96. doi:10.1056/NEJMcp052699 PMID 163820

VII. Pathophysiology

Preeclampsia is a result of generalized vasospasm. The underlyingcause of the vasospasm remains a mystery, althoughsome of the pathophysiologic processes are known. In normalpregnancy, vascular volume and cardiac output increasesignificantly. Despite these increases, blood pressure does

not rise in normal pregnancy. This is probably because pregnantwomen develop resistance to the effects of vasoconstrictors,such as angiotensin II. Peripheral vascular resistancedecreases because of the effects of certain vasodilators, suchas prostacyclin (PGI2), PGE, and endothelium-derived relaxingfactor (EDRF).In preeclampsia, however, peripheral vascular resistanceincreases because some women are sensitive to angiotensinII. They also may have a decrease in vasodilators. For instance,the ratio of thromboxane (TXA2) to PGI2 increases.TXA2, produced by kidney and trophoblastic tissue, causesvasoconstriction and platelet aggregation (clumping). PGI2,produced by placental tissue and endothelial cells, causesvasodilation and inhibits platelet aggregation.Vasospasm decreases the diameter of blood vessels, whichresults in endothelial cell damage and decreased EDRF.Vasoconstriction also results in impeded blood flow and elevatedblood pressure. As a result, circulation to all body organs,including the kidneys, liver, brain, and placenta, is decreased.The following changes are most significant:

Decreased renal perfusion reduces the glomerular filtrationrate. Blood urea nitrogen, creatinine, and uricacid levels begin to rise.

Reduced renal blood flow results in glomerular damage,allowing protein to leak across the glomerularmembrane, which is normally impermeable to largeprotein molecules.

Loss of protein reduces colloid osmotic pressure andallows fluid to shift to interstitial spaces. This may resultin edema and a reduction in intravascular volume,which causes increased viscosity of the blood and arise in hematocrit. In response to reduced intravascularvolume, additional angiotensin II and aldosteronetrigger the retention of both sodium and water. Generalizededema may occur.

Decreased circulation to the liver impairs function andleads to hepatic edema and subcapsular hemorrhage,which can result in hemorrhagic necrosis. This is manifestedby elevation of liver enzymes in maternal serum.

Vasoconstriction of cerebral vessels leads to pressureinducedrupture of thin-walled capillaries, resulting insmall cerebral hemorrhages. Symptoms of arterial vasospasminclude headache and visual disturbances,such as blurred vision, “spots” before the eyes, and hyperactivedeep tendon reflexes.

Decreased colloid oncotic pressure can lead to pulmonary

capillary leak that results in pulmonaryedema. Dyspnea is the primary symptom.

Decreased placental circulation results in infarctionsthat increase the risk for abruptio placentae and DIC.

Pathologic processes of preeclampsia

Cardiovascular system Hematologic system Neurologic

system Renal system Hepatic system placenta

Response to angiotensin II

Blood pressure

Cardiac output

Systemic vascular

resistance

Plasma volume

Hemoconcentration

Viscosity

Platelet clumping

Thrombocytopenia

Endothelium damage

Thromboxane/prostacyclin ratio

Endothelium-derived relaxing factor

Vascular resistance

Blood pressure

Pathology

Arterial vasospasm

Rupture of small capillaries

Small hemorrhages

Headache, hyperreflexia

convulsions

Glomerular flow rate

Damage to glomeruli

Protinuria

Colloid osmotic pressure

Fluid shift(edema)

Hypovolemia

Hematocrit

Angiotensin II and

aldosterone

Further edema

Blood urea, nitrogen,

creatinine, and uric acide

Impaired function

Hepatic edema

Subcapsular

hemorrhage

Enzymes

Epigastric pain

Placental perfusion

Fetal hypoxemia

Acidosis

Perinatal death

Nutrients

IUGR

Blockage of lymphatic vessels

Inability to remove excess fluid from interstitial space

Accumulation of fluid in interstitial space

Pulmonary Edema

Pulmonary edema is excess water in the lung. The normal lung contains very little water or fluid. It is kept dry by lymphatic drainage and a balance among capillary hydrostatic pressure, capillary oncotic pressure, and capillary permeability.

Pulmonary edema result from obstruction of the lymphatic system. When lymph drainage is blocked, fluid accumulates in the lungs. Drainage can be blocked by an increase in systemic venous pressure, which elevates the hydrostatic pressure of the large pulmonary veins into which the pulmonary lymphatic system drains. Drainage also can be obstructed by compression of lymphatic vessels by edema, tumors, and fibrotic tissue.

VIII Planning

Nursing Care Plan

Problem Nursing Diagnosis

Objective Nursing Intervention

Rationale Evaluation

difficulty

of

breathing

Subjective

Cues:

“medyo

naglisod

ko og

ginhawa

labi na

kung mag

ubo ko”,

as

verbalized

by the

client

Ineffective

breathing

pattern r/t

lung

compliance

as a result of

accumulatio

n of fluid in

the

pulmonary

interstitium

At the end

of the

nursing

shift, the

Px will be

able to

experience

adequate

respiratory

fxn.

INDEPENDENT

> place Px in a

semi to high

fowler position if

not

contraindicated

> instruct &

assist Px to

change

position, deep

breathe, &

cough or “huff”

> this position

allow

increased

diaphragmatic

excursion &

maximum

lung

expansion,

which

promotes

optimal

alveolar

ventilation

> frequent

repositioning

At the end

of the

nursing

shift, the Px

was able to

experience

adequate

respiratory

fxn. as

evidencedof

the ff.:

> normal

rate, rhythm

& depth of

respiration

> improved

Objective

Cues:

> (+)

crackles

>rapid,

shallow,

irregular

respiration

> use of

accessory

muscles

when

coughing

>

abnormal

blood

gases

>

abnormal

chest x-

ray result

every 1-2 hours

> implement

measures to

reduce pain –

splint incision

with pillow

during coughing

& deep

breathing

DEPENDENT

> implement

helps loosen

secretions &

promotes a

more effective

cough. It also

promotes

maximum

lung

expansion &

stimulates

surfactant

production.

Coughing or

huffing

mobilizes

secretions &

facilitates

removal of

these

secretions

from the

respiratory

tract

> a Px with

pain often

guards

respiratory

efforts – pain

reduction

enables the

client to

breath

sounds

> (-)

crackles

> blood

gases

within

normal

ranges

> Px

verbalizes

relief from

difficulty of

breathing

measures to

facilitate

removal of

pulmonary

secretions –

suction – as

orderes

> maintain O2

therapy as

ordered

> administer

meds that may

be ordered to

improve Px’s

respiratory

status

breathe more

deeply which

enhances

alveolar

veltilation &

O2/CO2

exchange

> excessive

secretions

and inability

to clear

secretions

from the

respiratory

tract lead to

stasis of

secretions

>

supplemental

O2 increases

the

concentration

of oxygen in

the alveoli,

which

increases the

diffusion of O2

across the

alveolar –

capillary

membrane

> medication

therapy is an

integral part

of treating

many

respiratory

condition

Problem Nursing Diagnosi

s

Objective Nursing Interventions

Rationale Evaluation

fear

Subjective

Cues:

“nahadlok

jud ko, kay

ingon sa

doctor naa

daw koy

high blood.

Unya cge

pa jud kog

ka lipong.

Mao nang

paminaw

nako laing

jud kaayo

ako lawas.

Dili pa jud

ko katulog

Fear r/t

persistent

headache

At the end

of the

nursing

shift, the

Px will be

able to

experience

a

reduction

of fear

INDEPENDENT

> encourage

verbalization of

feelings &

concerns

> assure Px that

staff members

are nearby;

respond to call

signal as soon

as possible

> reinforce

>

verbalization

of feelings &

concerns

helps client

identify

factors that

are causing

anxiety

> close

contact & a

prompt

response to

requests

provide a

sense of

security &

facilitates

At the end of

the nursing

shift, the Px

will be able to

experience a

reduction of

fear as

evidenced by

the ff:

>

verbalization

of decreased

fear &

understanding

of the medical

procedures

og tarong

sa cge

huna-

huna”, as

verbalized

by the

client

Objective

Cues:

> disturbed

sleep

pattern

> weak

appearanc

e

physician’s

explanations &

clarify

misconceptions

the Px has

about the

diagnostic tests,

disease

condition,

treatment plan

& prognosis

> implement

measures to

reduce distress

DEPENDENT

> administer

prescribed

antianxiety

agents if

indicated

the

development

of trust, thus

reducing the

client’s

anxiety

> factual

information

& an

awareness

of what to

expect help

decrease the

anxiety that

arises from

uncertainty

>

improvement

of

respiratory

status helps

relieve

anxiety

associated

with the

feeling of not

being able to

breathe

> helps

reduce the

Px”s anxiety

Problem Nursing Diagnosi

s

Objective Nursing Interventio

ns

Rationale Evaluation

Ojective cues:

Weak and pale in

appearance

- Capillary

refill of 3-4

seconds

- RBC

Level=1.49

- Hgb level=

34g/L

- Bp=160/110

mmHg

Ineffective

tissue

perfusion

related to

decrease

in RBC,

hemoglobi

n and

hematocrit

level

After 4

hours of

nursing

intervention

s, the client

will exhibit

decrease in

oxygen

demand

and ability

to conserve

energy.

Assist client

in

performing

ADL

Place the

client in

trendelenbur

g position.

Maintain

adequate

ventilation.

Instruct

client to sit

and dangle

the feet

before

standing.

To

promote

safety

To

promote

venous

return

To promote oxygenation and good blood circulation

To prevent orthostatic hypotension

After 4

hours of

nursing

interventio

n, the

client will

exhibit

decrease

in oxygen

demand

and ability

to

conserve

energy.

Advise client

to increase

intake of

food rich in

iron and

folate such

as liver and

green leafy

vegetables.

Iron and folate are necessary for red blood cell production.

Discharge plan

Medicines: Diuretics: This medicine is given to remove excess fluid from

around your lungs and decrease your blood pressure. You may urinate more often when you take this medicine.

Heart medicine: These medicines may be given to make your heartbeat stronger or more regular, or to lower your blood pressure.

Vasodilators: Vasodilators may improve blood flow by making the blood vessels in your heart and lungs wider. This may decrease the pressure in your blood vessels and improve your symptoms.

Take your medicine as directed: Call your primary healthcare provider if you think your medicine is not helping or if you have side effects. Tell him if you are allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you take. Include the amounts, and when and why you take them. Bring the list or the pill bottles to follow-up visits. Carry your medicine list with you in case of an emergency.

Follow up with your primary healthcare provider or pulmonologist in 7 to 10 days or as directed.

You may need to return for more tests. Write down your questions so you remember to ask them during your visits.

Manage pulmonary edema

Limit your liquids as directed. Follow your primary healthcare provider or pulmonologist’s directions about how much liquid you should drink each day. Too much liquid can increase your risk for fluid build up.

Weigh yourself daily. Weigh yourself at the same time every morning after you urinate, but before you eat. Weight gain can be a sign of extra fluid in your body.

Rest as needed. Return to activities slowly, and do more each day. You may have trouble breathing when you are lying down. Use foam wedges or elevate the head of your bed. This may help you breathe easier while you are resting or sleeping. Use a device that will tilt your whole body, or bend your body at the waist. The device should not bend your body at the upper back or neck.

Use a device that will tilt your whole body, or bend your body at the waist. The device should not bend your body at the upper back or neck.

Limit or avoid alcohol: You will need to limit the alcohol you drink, or avoid alcohol completely. Alcohol can worsen your symptoms and increase your blood pressure. If you have heart failure, alcohol can make it worse.

Do not smoke or take drugs: If you smoke, it is never too late to quit. Do not take street drugs, such as cocaine. Smoking and drugs can make your condition and symptoms worse. Ask for information if you need help quitting.

limb to high altitudes slowly: Go slowly to allow your body to get used to a higher altitude. Ask your primary healthcare provider about the symptoms of high altitude pulmonary edema (HAPE). Ask what to do if you get these symptoms.

Contact your primary healthcare provider or pulmonologist if:

you have a fever you gain weight for no known reason you urinate more than usual you have new or increased swelling when you breathe you have questions or concerns about your condition or care.

PHARMACOLOGICAL MANAGEMENT

Doctor’s Order

Drug Action Indications Nursing Responsibilities

Magnesium sulfate

Blockage of neuromuscular transmission, vasodilation

Prevention and treatment of

eclamptic seizures, reduction in blood

pressure in preeclampsia and

eclampsia

Administer IV loading dose of 4-6

over 30 minutes, continue

maintenance infusion of

2-4g/hour as ordered monitor

serum magnesium levels closely

assess DTRs and check for ankle

clonus have calcium gluconate readily

available in case of toxicity monitor for

signs and symptoms of

toxicity, such as flushing, sweating, hypotension, and

cardiac and central nervous system

depressionHydralazinehydrochloride

(Apresoline)

Vascular smoothmuscle relaxant,thus improvingperfusion torenal, uterine,

and ce

Reduction in bloodpressure

Administer 5–10 mg by slow IV bolus every20 minutesUse parenteral form immediately after openingampuleWithdraw drug slowly to prevent possiblerebound hypertensionMonitor for adverse effects such aspalpitations, headache,

tachycardia,anorexia, nausea,

vomiting, and diarrhea

Labetalolhydrochloride

(Normodyne)

Alpha 1 and betablocker

Reduction in bloodpressure

Be aware that drug lowers blood pressurewithout decreasing maternal heart rate orcardiac outputAdminister IV bolus dose of 10–20 mg and thenadminister IV infusion of 2 mg/minute untildesired blood pressure value achievedMonitor for possible adverse effects such asgastric pain, flatulence, constipation,

dizziness, vertigo, and fatigue

Nifedipine(Procardia)

Calcium channelblocker/dilationof coronaryarteries,arterioles, andperipheral

arterioles

Reduction in bloodpressure,stoppage of

preterm labor

Administer 10 mg orally for three doses andthen every 4–8 hoursMonitor for possible adverse effects such asdizziness, peripheral edema, angina,

diarrhea, nasal congestions, cough

Sodiumnitroprusside

Rapid vasodilation(arterial and

venous)

Severe hypertensionrequiring rapidreduction in bloodpressure

Administer via continuous IV infusion with dosetitrated according to blood pressure

Pulmonary

levelsWrap IV infusion solution in foil or opaquematerial to protect from lightMonitor for possible adverse effects, such asapprehension, restlessness, retrosternalpressure, palpitations, diaphoresis,

abdominal pain

Furosemide(Lasix)

Diuretic action,inhibiting thereabsorption ofsodium andchloride fromthe ascending

loop of Henle

Pulmonary edema

Administer via slow IV bolus at a dose of10–40 mg over 1–2 minutesMonitor urine output hourlyAssess for possible adverse effects such asdizziness, vertigo, orthostatic hypotension,anorexia, vomiting, electrolyte imbalances,muscle cramps, and

muscle spasms

SYNTHESIS OF CLIENT’S CONDITION/STATUS FROM ADMISSION TO PRESENT

Conclusion

We therefore conclude that the study portrayed its importance and helped us know all about Acute pulmonary edema complicating severe preeclampsia. It also helped us understood the causes and effects of the diseases that enabled us to determine the predisposing and precipitating factors and traced the pathophysiology of these disorders. This also had given us the knowledge to identify where and when it had started and how the disease progressed and we had also interpreted the laboratory and diagnostic exam results of the client and recognized the implication of it. We also identified the different pharmacologic treatments indicated to the condition, considering the effects, actions and different nursing considerations with regards to the administration of the medications. We have also identified and formulated the nursing

interventions that we could render to the patient that will help us attain our goal of care to our patient basing from the nursing care plan we have formulated.

Patient’s prognosis

After some point in time, as the medical and the nursing management of

the patient is constantly done, a development of her present health status is anticipated.

Continuous administration of medications will result to termination of the signs and

symptoms that was caused by the patient’s disease such as shortness of breaths,

paleness, swelling, high blood pressure, face and hand edema, and dyspnea.

Furthermore, vital signs are expected to stabilize.

Recommendation

On the basis of the findings of this study, the following measures are

recommended:

1. Client should take his prescribed medications religiously. He must create a

schedule in order for him to be guided as when to take the medicines and for him

not to be able to forget in doing so.

2. Follow the prescribed diet. His prescribed diet is a low-salt, low-fat diet, therefore

client should avoid salty and fatty foods and client must take note that all canned

goods are high in sodium even if it says that it is good for the heart.

3. Have an oral fluid intake with in cardiac tolerance.

4. Lifestyle modification is also important in order to prevent the severity of the

condition that will further contribute complications such as cessation of smoking

and drinking alcoholic beverages.

5. Visit his doctor regularly for constant check-ups and to continuously monitor his

condition.

Evaluation of the objectives of the study

After few days of conducting study about the case of lorna, we were able to trace the

history of her disease locally, nationally and globally. We have come up with a

comprehensive assessment of the patient’s biographical data, cephalo-caudal physical

assessment as well as pertinent medical information with regards to the client’s health

condition. Apart from that, we were also able to have a clearer view on how the disease

affects the patient’s body by tracing the pathophysiology of the disease process and

identifying the different organs involved by reviewing its anatomy and physiology. By

understanding fully the mechanism and effects of the disease to the patient, we have

interpreted different laboratory results related to her condition. We have also identified

and traced some medications and how these drugs affect the patient’s physiological

functioning. Appropriate therapeutic care was well planned and provided to the client.

And lastly, we have come up with a discharge plan pertaining to the patient’s early

recovery.

Maternal & Child Health Nursing, 4th Edition by PillitteriEssentials of maternal and child nursing by Murray