A CASE STUDY PRESENTED
TO THE COLLEGE OF NURSING
IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS IN (NCM 109)
___________________________________
PREECLAMPSIA WITHOUT SEVERE FEATURES
_________________________________
Presented to:
Mr. Jayvee Balingit, RN, USRN, SGRN
Clinical Instructor
Submitted by:
Abegail Joy M. Ranien
BSN-II ABDELLAH Group-1
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TABLE OF CONTENTS
Title page ……………………………………………………………1
Table of Contents …………………………………………………….2
I.
Background of the Disease ………………………………………3
II. Demographic Profile …………………………………………… 3
III. Medical History ………………………………………………….3
I.
II.
Past Health History
Present Illness
IV. Physical Assessment………………………………………….4
V. Pathophysiology ………………………………………………5
VI. Drug Study………………………………………………………..7
VII. Nursing care Plan……………………………………………10
VIII. Discharge Planning…………………………………………22
IX. References ……………………………………………………23
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I.
BACKGROUND OF THE STUDY:
INTRODUCTION
Background of the disease:
A patient is said to be preeclamptic without severe features when they have proteinuria (1+ on
a urine drip or 300mg in a 24-hour urine protein collection or 0.3 or higher or a urine proteincreatinine ratio) and a blood pressure rise to 140/90 mm Hg taken on two occasions at least 4
hours apart. A second criterion for evaluating blood pressure is systolic blood pressure greater
than 30 mm Hg and a diastolic pressure greater than 15 mm Hg above prepregnancy values.
Proteinuria of 1+ to 2+ on a random sample; weight gain over 2lb per week in 2nd trimester and
1 lb per week in 3rd trimester; mild edema in upper extremities or face.
II.
DEMOGRAPHIC PROFILE
Patient KSP, 26 years old, female, born in Ospital Ng Palawan, Puerto Princesa City on August
17, 1996. Lives in Bgy. Masigla, Tagburos, Puerto Princesa City. Roman Catholic, Filipino
Nationality, married to a muslim, a former dicer in ACE Hardware, now became a housewife.
Studied Hospitality and Restaurant Management (HRM) for 2 years as a vocational course.
Admitted on July 15, 2023 12:55PM at Ospital ng Palawan in OB GYNE Ward, her admitting
physician is Dr. Romulo Vincent S. Perez, M.D., her attending physician is Dra. Ophelia O.
Nufuar, M.D., her admitting diagnosis is G1P1 (1001) PU delivery cephalic live term baby boy,
Apgar Score = 8, 9. Body Weight = 3175 by Low Segment Caesarean Section (LSCS) I,
preeclamptic.
III.
MEDICAL HISTORY:
Past Health History:
The patient has completed the vaccination when she was an infant, she received BCG, Hepa B,
Pentavalent Vaccine, Oral Polio Vaccine, Inactivated Polio Vaccine, Pneumococcal Conjugate
Vaccine, Measles, Mumps and Rubella Vaccine. She loves to eat fruits, one of her favorite fruits
Page 3 of 22
are mangoes, apples and oranges. She loves to eat vegetables and beans too, like string beans
and monggo, she likes to eat meat like pork, fish and chicken, but when she is married to a
muslim, she is now only eating chicken. They have history of hypertension both of her
grandparents in her father’s side, and she has not been hospitalized before. Her type of exercise
is walking and zumba.
Present Illness:
She has no other diseases or associated conditions prior to admission. On the day of admission,
the patient has complained about a watery vaginal bleeding at 4:00 AM
IV.
HEAD-TO-TOE ASSESSMENT
Head/Scalp
Round, smooth skull contour, no lumps or dandruff found.
Hair
Even distribution of hair.
Eyes
Equal distribution of hair in eyelashes and brows, no discharges
found in both left and right inner cantus, white sclera.
Ears
Bean-shaped earlobes, parallel and symmetrical.
Nose
Straight and symmetrical, no lesions, soreness and nose flaring
found.
Lips/Mouth
Pale lips.
Neck
Uniform in color, no masses/lumps found.
Chest
Quiet and rhythmic respiration, normal breathing rate without using
accessory muscles.
Skin
Abdomen
Extremities
No presence of rashes, uniform in color.
No tenderness and presence of lumps and masses.
Uniform in color, no fractures, pink nails, capillary refill at 1
second, edema found in both hands and feet.
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V.
PATHOPHYSIOLOGY:
Precipitating Factors:
Predisposing Factors:
•
•
Age: 26 y/o
Sex: Female
Decreased
Cardiac
Output
•
•
G1P1
Family Hx:
HTN in
Paternal Side
Endothelial
Cell Damage
Vasospasm
Interstitial Effect
Vascular Effect
Kidney Effect
Vasoconstriction
Decreased GFR & increases
permeability of glomeruli
membranes
Diffusion of fluid from
blood stream into
interstitial tissue.
Poor Organ
Perfusion
Increased blood serum, urea,
nitrogen, uric acid, and creatinine
Increased Blood
Pressure
VI.
PRE-ECLAMPSIA
LABORATORIES:
URINE ANALYSIS (July 5, 2023)
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Edema
Color
YELLOW
Transparency
SLIGHTLY HAZY
CHEMICAL EXAM:
Albumin:
NEGATIVE
Glucose:
NEGATIVE
pH:
6.0
Specific Grav.:
1.025
MICROSCOPIC
EXAM:
Pus cells:
0-2 /hpf
R B C:
0-2 /hpf
Epithelial Cells
Squamous e.c.:
FEW
Renal e.c.:
Bacteria:
FEW
Mucus Threads:
A. Urates:
Crystals
Calcium oxalates:
MODERATE
Uric Acid
Triple Phosphate
Ammonium Biurate
Proteinuria is not a reliable indicator of preeclampsia. Evidence demonstrates that kidney
or liver dysfunction can occur without signs of protein, and that the amount of protein in
the urine does not predict how severely the disease will progress.
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GENERIC
MECHANISM
NAME
OF ACTION
INDICATION
CONTRAINDICATION
SIDE
NURSING
EFFECTS
CONSIDERATION
Cefuroxim
Inhibits cell-wall
Perioperative
Contraindicated in patients
Nausea,
B: Conduct skin test
e Axetil
synthesis,
Prophylaxis
hypersensitive to drugs or
anorexia,
for any allergic
other cephalosphorins.
vomiting,
reaction.
promoting
1.5gm LD
osmotic
erythematous
D: Monitor patient
then
instability; usually
rashes, pain,
for signs and
750mg TIV bacterial.
temperature
symptoms of
q12° (-
elevation.
superinfections.
)ANST
A: Record and
document
administration of
drugs and any side
effects.
OMEPRA
Inhibits proton
ZOLE
Anti-ulcer
Contraindicated in patient
Dizziness,
B: Inform patient
pump activity by
hypersensitive to drug or
headache,
about the purpose of
binding to
its components.
abdominal
the drug.
40mg
hydrogen-
pain,
D: Monitor patient
PTOR TIV
potassium
constipation,
for any allergic signs
PTDR
adenosine
nausea.
and symptoms of the
triphosphatase,
drug.
located at
A: Record and
secretory surface
document
of gastric parietal
administration of
cells, to suppress
drug.
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gastric acid
secretion.
ACETAMI
Thought to
NOPHEN
For pain.
Contraindicated in patient
Anxiety,
B: Inform the patient
produce analgesic
hypersensitive to drug. IV
fatigue,
of the purpose of the
by inhibiting
form is contraindicated in
headache,
drug.
1gm IV
prostaglandin and
patient with severe hepatic
insomnia,
D: Monitor any side
Infusion
other substances
impairment or severe
hypotension,
effects.
q6° x 4
that sensitize pain
active liver disease.
peripheral
A: Record and
doses
receptors.
edema.
document
administration.
KETOROL May inhibit
Contraindicated in patients
Headache,
B: Assess vital signs
prostaglandin
who have previously
dizziness,
and explain the
synthesis to
demonstrated
drowsiness,
purpose of the drug.
30mg IVF
produce anti-
hypersensitivity to
edema,
D: Administer drug
q6° x 8
inflammatory,
ketorolac or allergic
increased
and monitor for any
doses (-
analgesic and
manifestations to aspirin or lacrimation,
allergic reactions.
)ANST
antipyretic effects.
other NSAIDs.
rhinitis,
A: Record and
throat
document
irritation.
administration of the
AC
For pain
drug.
Page 8 of 22
Thought to inhibit
For pain
Contraindicated in
Headache,
B: Assess vital signs
CELECOX prostaglandin
patients’ hypersensitivity
dizziness,
and explain the
IB
synthesis
to drug, sulfonamides,
insomnia,
purpose of the drug
impending
aspirin, or other NSAIDs.
HTN,
to the patient.
200mg/cap
cyclooxygenase-
peripheral
D: Monitor vital
BID
2, to produce anti-
edema.
signs and note any
inflammatory,
adverse reactions.
analgesic, and
A: Record and
anti-pyretic
document any drug
effects.
administration.
Page 9 of 22
NURSING CARE PLAN:
July 10, 2023
ASSESSMENT
DIAGNOSIS
PLANNING
Subjective:
Decreased
After 3-4 hours of
“Normal naman
Cardiac
nursing intervention,
po BP ko nakaraan Output
the patient will be able
ma’am.” As
related to
to:
verbalized by the
Hypertension
patient.
INTERVENTION
•
•
•
RATIONALE
•
EVALUATION
To note response
After 3-4 hours of nursing
signs
to activities and
intervention, the patient
frequently.
interventions.
may be able to:
Monitor vital
Assess and
•
May indicate
•
Display
Display
monitor for
evolving heart
hemodynamic
hemodynamic
client reports
attack, can also
stability (e.g. blood
Objectives:
stability (e.g.
of chest pain.
accompany
pressure)
Vital Signs
blood pressure)
Note location,
congestive heart
Verbalize
intensity,
failure. Chest
knowledge of the
RR = 20
knowledge of
characteristics,
pain may be
disease process,
O2Sat = 97%
the disease
and radiation
atypical in home,
individual risk
PR = 99
process,
of pain.
experiencing an
factors, and
Temp = 36.3
individual risk
MI and is often
treatment plan.
Pulse strength =
factors, and
atypical in the
+2
treatment plan.
elderly owing to
BP = 150/90
•
CRT = 1 sec
•
•
Verbalize
Identify signs of
cardiac
decompensation,
Page 10 of 22
Output = 360ml
•
Identify signs of
altered pain
after activities, and
GCS = 15
cardiac
perception.
seek help
Edema on both
decompensation,
hands and feet.
after activities,
vital signs,
and seek help
including
baseline for
appropriately.
cognitive
comparison to
status. Note
follow trends
vital sign
and evaluate
response to
response to
activity or
interventions.
•
appropriately.
Determine
•
Provides a
procedures
and time
required to
return to
baseline.
•
Administer
medications as
•
To manage
indicated.
systemic effects
(Hydralazine)
of
vasoconstrictions
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and low cardiac
output.
Page 12 of 22
ASSESSMENT DIAGNOSIS
PLANNING
Subjective:
Excess Fluid
After 8 hours of
“Nung huwebes
Volume
nursing
ma’am namaga
related to
intervention, the
na po ‘yong sap
Edema
patient will be able
INTERVENTION
•
Assess vital
RATIONALE
•
signs.
EVALUATION
To provide baseline
After 8 hours of
data.
nursing
intervention, the
To determine the
patient may be able
appetite;
presence of problems
to:
Stabilize
note the
associated with an
Baka dahil po
fluid
presence of
imbalance of
sa IV.” As
volume as
nausea and
electrolytes.
verbalized by
evidenced
vomiting.
the patient.
by balanced
aa, then ngayon
po sa kamay.
•
to:
•
input and
Assess
•
Identify
Stabilize
fluid
volume as
•
•
•
To ensure timely
evidenced
evaluation/intervention
by balanced
Objectives:
output
“danger”
input and
Vital Signs
(I&O), vital
signs
output
BP = 150/90
signs within
requiring
(I&O), vital
RR = 20
clients
notification
signs within
O2Sat = 97%
normal
of
clients
PR = 99
limits, stable
healthcare
normal
Temp = 36.3
weight, and
provider.
limits, stable
Pulse strength =
free of signs
+2
of edema.
weight, and
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CRT = 1 sec
•
Demonstrate
free of signs
Output = 360ml
behaviors to
of edema.
GCS = 15
monitor
Edema on both
fluid status
behaviors to
hands and feet.
and reduce
monitor
recurrence
fluid status
of fluid
and reduce
excess.
recurrence
•
Demonstrate
of fluid
excess.
Page 14 of 22
ASSESSMENT DIAGNOSIS
PLANNING
Subjective:
Anxiety
After 1 hour of nursing
“Tatakot po ako
related to
intervention, the patient
ma’am, kasi po
Lower
will be able to:
first baby ko
Segment
tapos gan’to po
Caesarean
agad.” As
Section
INTERVENTION
RATIONALE
•
•
Monitor physical
responses.
EVALUATION
To identify
After 1 hours of nursing
signs and
intervention, the patient
symptoms
may be able to:
associated
•
•
Verbalize
with both
awareness of
medical and
awareness of
verbalized by
feeling of
emotional
feeling of
the patient.
anxiety.
condition.
anxiety.
•
•
Appear relaxed
Objectives:
and report that
Vital Signs
anxiety is
BP = 150/90
•
•
Verbalize
Appear relaxed
Clients need
and report that
client’s anxiety or
honest and
anxiety is
reduced to a
fear. Respond
respectful
reduced to a
RR = 20
manageable
truthfully with facts
feedback to
manageable
O2Sat = 97%
level.
related to reality.
help them
level.
Use
Avoid denying or
recognize
Temp = 36.3
resources/support
reassuring client
unrealistic
resources/support
Pulse strength =
systems
that everything will
thinking.
systems
+2
effectively.
be alright.
False
effectively.
PR = 99
•
Acknowledge
CRT = 1 sec
reassurances
Output = 360ml
may be
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•
Use
GCS = 15
interpreted as
Edema on both
lack of
hands and feet.
understanding
or dishonesty,
further
isolating
client.
•
Teach, provide
•
Aids in
calming
meeting basic
measures/relaxation
human need,
techniques.
decreasing
sense of
isolation,
encouraging
client to
select
interventions
that work best
for them.
Page 16 of 22
ASSESSMENT DIAGNOSIS
PLANNING
Subjective:
Powerlessness After 2 hours of
“Iniisip ko po
related to
nursing intervention,
kasi ma’am
Caesarean
kung tama po
Section
INTERVENTION
•
After 8 hours of
client’s
the client
nursing intervention,
the patient will be
response to
understands
the patient may be
able to:
treatment
the purpose of able to:
regimen.
the treatment.
•
sense of
naman po s’ya.”
control over
As verbalized
by the patient.
Objectives:
•
Ascertain
•
Express
baby ko palang
Vital Signs
•
EVALUATION
To know if
ba na ma-CS po
ako kasi first
RATIONALE
•
•
Express
Discussing
sense of
client to
ways client
control over
the present
maintain a
can look at
the present
situation and
sense of
options and
situation and
future
perspective
make
future
outcome.
about the
decisions
outcome.
Acknowledge
situation.
based on
Encourage
•
Acknowledge
BP = 150/90
reality that
which ones
reality that
RR = 20
some areas
will be best
some areas
O2Sat = 97%
are beyond
leads to the
are beyond
PR = 99
individual’s
most effective
individual’s
Temp = 36.3
control.
solutions for
control.
Pulse strength =
situations.
+2
Page 17 of 22
CRT = 1 sec
•
Encourage
•
Negative
Output = 360ml
client to
thinking can
GCS = 15
think
result in
Edema on both
productively
feelings of
hands and feet.
and
powerlessness
positively
and learning
and take
to use
responsibility
positive
for choosing
thinking can
own
reverse this
thoughts.
pattern,
promoting
feelings of
control and
self-worth.
July 11, 2023
Page 18 of 22
ASSESSMENT DIAGNOSIS
PLANNING
Subjective:
Acute Pain r/t After 3 hours of
“Masakit po
Low Segment nursing
s’ya ma’am.
Caesarean
Makirot po.” As
Section
verbalized by
the patient. Pain
scale 9/10
INTERVENTION
•
RATIONALE
•
EVALUATION
Which usually
After 3 hours of
skin color
altered in acute
nursing
intervention, the
and
pain.
intervention, the
patient will be able
temperature
patient may be able
to:
and vital
to:
•
Monitor
signs.
Report pain
•
is relieved
or
•
•
Report pain
To maintain
is relieved
client’s
“acceptable”
or
Vital Signs
perception
level of pain.
controlled.
BP = 140/90
of pain,
Notify
RR = 27
along with
physician if
O2Sat = 94%
behaviors
regimen is
PR = 131
and cultural
inadequate to
Temp = 37.1
expectations
meet pain
Objectives:
controlled.
Assess
control goal.
Page 19 of 22
Pulse strength =
regarding
Combinations
+2
pain.
of medications
CRT = 1 sec
may be used on
GCS = 15
prescribed
PS = 9/10
intervals.
•
Edema on right
hand and both
feet.
•
To prevent
Encourage
fatigue that can
adequate
impair ability to
rest periods.
manage or cope
with pain.
Page 20 of 22
DISCHARGE PLANNING:
Medication: Refer to the physician for any take-home medications.
Environment: Keep environment clean and well-ventilated.
Treatment: Gently wash it with soap and water to remove the crust, do not scrub or soak the wound. Do not use rubbing alcohol, hydrogen
peroxide, or iodine, which can harm the tissue and slow wound healing. Air-dry the incision and pat dry with a clean, fresh towel before reapplying
the dressing.
Health Teaching: Use support when laughing or coughing. Limit activities but not too much. Get a lot of rest. Don’t lift anything heavier than
your baby until your healthcare provider tells you it’s okay.
Outpatient Referral: Have an appointment with the healthcare provider regarding the c-section recovery, managing hypertension and others.
Diet: Have a balanced diet filled with variety of fruits, vegetables, whole grains, lean proteins, healthy fats, and calcium rich foods.
Social/Spiritual/Sexual: Limit visitors to have adequate rest. Pray for assistance for fast recovery. Don’t have sex until after you’ve had a checkup
with your healthcare provider and you have decided on a birth control method.
Page 21 of 22
REFERENCE:
•
https://www.scribd.com/doc/4488151/pathophysiology-of-Preeclampsia
•
https://www.lecturio.com/nursing/free-cheat-sheet/preeclampsia-nursing-diagnosis/
•
Maternal and Child Health Nursing; JoAnn Silbert-Flagg, pg. 556
•
NCLEX-RN EXAMINATION; Silvestri, pg. 284
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