Case Study Pre Eclampsia

Pre-Eclampsia Nursingcasestudy.blogspot.com Table of Contents Chapter 1 – Introduction Objectives Chapter 2 – Assessment Nursing Health History Personal Data of the Patient Chief Complaints History of Present Illness Past Medical History Family Health History Physical Assessment Diagnostic Procedure Anatomy and Physiology of the Systems affected a. Pathophysiology Chapter 3 – Planning A. List of Prioritized Nursing Diagnoses B. NCP C. Drug Study Chapter 4 – Discharge Planning Chapter 1 – Introduction We, group 1 of JRU BSN A314, would like to thank Sta. Rita de Baclaran Hospital for allowing us to choose a patient for our case. We also thank our clinical instructor, Mr. Belocura and our preceptor Ms. Hazel Ann Cruz, for patiently teaching us and making sure we learn the most from our clinical exposure. Objectives General Objectives – We did this case study for us to have a deeper understanding of what preeclampsia is, thus to give us an idea of how we could give proper nursing care for our clients with this condition. Specific Objective - We hope to be able to address the client’s health needs and also to assess for any health deficit or risks like acute pain, infection, and self-care. Chapter 2 Assessment A. Personal Data Name: A.K.A ‘CHURVA” Age: 30 yrs old Sex: Female Address: Baclaran City Chief complaint: Labor pains B. Past Medical History The patient’s past history was post CS. C. Present medical History The patient was admitted Dec 1 2007 at 11: am; chief complaint was severe abdominal pain and increasing B/P. She was admitted in Sta. Rita Medical Hospital. D. Family Health History There’s a history of hypertension in the client’s family. Her mother had hypertension. 3. Diagnostic Procedures Common laboratory tests to diagnose Pregnancy-induced hypertension would include blood test, renal function, creatinine, and BUN. But these tests were not noted on the client’s chart. What we found out instead is the continual rising of the client’s blood pressure from the time she got in the hospital at 10am until she was admitted. Blood pressure taking is one easy method to monitor the client’s blood pressure. The client’s blood pressure was at 170/90 at 10am then increased to 170/100 at 12nn and reached 190/100 at 1pm. While the normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre–hypertension", and a blood pressure of 140/90 or above is considered high. 4. Anatomy & Physiology The Circulatory (Cardiovascular) System The Circulatory System is designed to deliver oxygen and nutrients to all parts of the body and pick up waste materials and toxins for elimination. This system is made up of the heart, the veins, the arteries, and the capillaries. Circulation is achieved by a continuous one-way movement of blood throughout the body. The network of blood vessels that flow through the body is so extensive that blood flows within close proximity to almost every cell. Heart The heart is a muscular pump that propels blood throughout the body. The heart is located between the lungs, slightly to the left of center in the chest. The heart is broken down into four chambers including:     The right atrium, which is a chamber which receives oxygen- poor blood from the veins. The right ventricle which pumps the oxygen-poor blood from the right atrium to the lungs. The left atrium which receives the now oxygen-rich blood that is returning from the lungs. The left ventricle, which pumps the oxygenated blood through the arteries to the rest of the body. Blood Vessels Blood vessels are broken down into three groups: the arteries which carry blood out of the heart to the capillaries, the veins which transport oxygen-poor blood back to the heart, and the capillaries which transfer oxygen and other nutrients into the cells and removes carbon dioxide and other metabolic waste from these body tissues. Blood Pressure Blood pressure is the force exerted by the blood against the walls of the blood vessels. The output or direct pumping of the heart and the resistance to blood flow in the vessels determines blood pressure. Resistance is determined by blood viscosity and by friction between the blood and the wall of the blood vessel. Blood pressure = blood flow x resistance. PATHOPHYSIOLOGY OF PREGNANCY-INDUCED HYPERTENSION Vasopasm Peripheral Arteriole Vasoconstriction BLURRING OF VISON, HEADACHE INCREASED BLOOD PRESSURE PREGNANCY-INDUCED HYPERTENSION Chapter 3 – Planning Priority: 1. Acute pain 2. Risk for infection 3. Self-care deficit ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION Independent Subjective Cues: “Masakit ang tahi ko,” as verbalized by the patient. Acute pain related to surgical incision as evidenced by facial mask of pain. Within 8 hrs nursing intervention the patient will: > Identify and use appropriate interventions to manage pain/discomfort. > Verbalize lessening of level of pain. > Appear relaxed, able to sleep/rest appropriately. > Provide information and anticipatory guidance regarding causes of discomfort and appropriate interventions. > Promotes problem solving, helps reduce pain associated with anxiety and fear of the unknown, and provides sense of control. > Relaxes muscles, and redirects attention away from painful sensations. Promotes comfort, and reduces unpleasant distractions, enhancing sense of well-being. > Decreases gas formation and promotes peristalsis to relieve discomfort of gas accumulation, which often peaks on 3rd day after cesarean birth. > Promotes comfort, which improves psychological status and enhances mobility. Use of medication with limited ability to cross into milk allows lactating mother to enjoy feeding without adverse effects on infant. Goals met. Objective Cues: (+) Guarding behavior (+) Facial mask of pain > Reposition client, reduce noxious stimuli, and offer comfort measures, e.g., back rubs. Encourage use of breathing and relaxation techniques and distraction (stimulation of cutaneous tissue). > Encourage early ambulation. Collaborative > Administer analgesics every 3–4 hr prn. Medicate lactating client 45–60 min before breastfeeding. ASSESSMENT NURSING DIAGNOSIS Risk for infection related to tissue trauma/broken skin. PLANNING At the end of the 3 days of nursing intervention, the client will: > Demonstrate techniques to reduce risks and/or promote healing. > Display wound free of purulent drainage with initial signs of healing (i.e., approximation of wound edges), uterus soft/nontender, with normal lochial flow and character. INTERVENTION Independent > Encourage and use careful handwashing and appropriate disposal of soiled perineal pads, and contaminated linen. Discuss with client the importance of continuing these measures after discharge. > Encourage oral fluids and diet high in protein, vitamin C, and iron. RATIONALE EVALUATION Subjective Cues: “Paano maiiwasan ang impeksyon sa tahi ko?” > Helps prevent or retard spread of infection. > Goals met. Objective Cues: [Not applicable; presence of signs/symptoms establishes an actual diagnosis] > Prevents dehydration; maximizes circulation and urine flow. Protein and vitamin C are needed for collagen formation; iron is needed for Hb synthesis. > A sterile dressing covering the wound in the first 24 hr following cesarean birth helps protect it from injury or contamination. Oozing may indicate hematoma, loss of suture approximation, or wound dehiscence, requiring further intervention. Removing the dressing allows incision to dry and promotes healing. > These signs indicate wound infection. Wound infections are usually clinically apparent 3–8 days after the procedure. > Inspect abdominal dressing for exudate or oozing. Remove dressing, as indicated. > Inspect incision, evaluate healing process, noting localized redness, edema, pain, exudate, or loss of approximation of wound edges. ASSESSMENT NURSING DIAGNOSIS Self-care deficit related to decreased strength and endurance as evidenced by inability to ambulate independently. PLANNING At the end of a two hour nursing intervention, the client will: > Verbalization of inability to participate at level desired. > Demonstrate techniques to meet selfcare needs. > Identify/use available resources. INTERVENTION Independent > Assess client’s psychological status. RATIONALE EVALUATION Subjective Cues: “Kailan ko kaya maireresume ang normal na gawain ko?” Objective Cues: Inability to ambulate independently. > Physical pain experience may be compounded by mental pain that interferes with client’s desire and motivation to assume autonomy. > Improves self-esteem; increases feelings of well-being. Goals met. > Offer assistance as needed with hygiene (e.g., mouth care, bathing, back rubs, and perineal care). > Offer choices when possible (e.g., selection of juices, scheduling of bath, destination during ambulation). Collaborative > Administer analgesic agent every 3–4 hr, as needed. > Allows some autonomy, even though client depends on professional assistance. > Reduces discomfort, which could interfere with ability to engage in self-care. Chapter III Implementation Medical Management - Drug Study Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilities Hydralazine (Apresoline) Hydralazine is used to treat high blood pressure. It works by relaxing the blood vessels so that blood can flow more easily through the body. Essential hypertension, alone or as an adjunct. Management of moderate to severe hypertension, congestive heart failure, hypertension secondary to preeclampsia/eclampsia; treatment of primary pulmonary hypertension. Under indications. Start with 10 mg four times daily for the first 2 to 4 days, increase to 25 mg four times daily for the balance of the first week. For the second and subsequent weeks, increase dosage to 50 mg four times daily. For maintenance, adjust dosage to the lowest effective levels. Hypersensitivity to hydralazine; coronary artery disease; mitral valvular rheumatic heart disease.    flushing (feeling of warmth) headache eye tearing Check if the client takes the medication and if it is in the right patient and check also the doctor’s order. Observe for any reaction to the medication like headache, flushing, vomiting, etc. If any reaction occurs inform your physician. Monitor BP every 5 mins. Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibilities Arthrotec (Diclofenac Na) Used for treatmentfor rheumatoid, arthritis,dysmenorrheal, headache, post partum pain. Arthrotec contains dicoflenac sodium and misoprostol. Administration of misoprotol to women who are pregnant can cause abortion, premature birth , or birth defects. Uterine rupture has been reported when misoprostol was asministered in pregnant women to induce labor or to induce abortion beyond the 8th week of pregnancy. ARTHROTEC is indicated for treatment of the signs and symptoms of osteoarthritis or rheumatoid arthritis in patients at high risk of developing NSAIDinduced gastric and duodenal ulcers and their complications. ARTHROTEC is contraindicated in patients with hypersensitivity to diclofenac or to misoprostol or other prostaglandins.    .abdominal pain diarrhea GI symptoms Check if the client takes the medication. Check for the doctor’s order and if it is the right patient. Observe for any effect and if any side effects occur inform physician. Carefully consider the potential benefits and risks of ARTHROTEC and other treatment options before deciding to use ARTHROTEC. Use the lowest effective dose for the shortest duration consistent with individual patient treatment ... ARTHROTEC is administered as ARTHROTEC 50 (50 mg diclofenac sodium/200 mcg misoprostol) or as ARTHROTEC 75 (75 mg diclofenac sodium/200 mcg misoprostol). Name of Drug Use Indication/ Dosage Contraindication Side effects Nursing responsibiliries Penicillin G Penicillin G is used routinely for maternal infections during pregnancy. The early use of penicillin G was linked to increased uterine activity and abortion. It is not known whether this was related to impurities in the drug or to penicillin itself. A previous hypersensitivity reaction to any penicillin is a contraindication.    rash fever dizziness Before you administer penicillin, look at the solution closely. It should be clear and free of floating material. Gently squeeze the bag or observe the solution container to make sure there are no leaks. Do not use the solution if it is discolored, if it contains particles, or if the bag or container leaks. Use a new solution, but show the damaged one to your health care provider. Chapter IV Discharge Planning Medication Drug to be continued, Hydralazine (Apresoline) oral. For maintenance, adjust dosage to the lowest effective levels. Exercise The client should limit the no. of stairs she climbs to one flight/dayfor the first week at home. Beginning the second week, if her lochial discharge is normal, she may start to increase this activity. Limit stair climbing to only when necessary for first two weeks. Treatment Advice client to monitor blood pressure, take prescribed medications and perform wound care as needed. Health Teaching Teaching should focus on action to maintain comfort, to promote healing and restore wellness.  avoid heavy work (lifting or straining) for at least first 3 weeks after birth. (it is usually advised that she doesn’t return to an outside for at least 3 weeks (better 6 weeks) not only for her own health but also for enjoyment of the early weeks with her newborn. Explore with th client what she consider heavy work)  get lots of sleep. Sleep when baby sleeps. (Client should at least 1 rest period a day and try to get a good night’s sleep. She can rest during the day when her newborn is sleeping.)  take advantage of help from others.  avoid having sexual intercourse at least a month  call your health care provider if you have any of the warning signs of sickness: (fever greater than100F, severe pain, redness or swelling in the incision site, foul smelling vaginal discharge, increase bleeding, back ache or severe abdominal pain or cramping (unrelieved by medication).)  report increasing pain, swelling, or opening or gaping of wound edges.  teach the client how to change wound dressings and perform wound care.  instruct client to use pain medication as ordered.  emphasize the importance of hygiene and hand washing to prevent infection Out Patient follow-up The client should return to her physician 2-4 weeks after. Diet The client’s diet is high protein and low sodium diet.