Upload
rad-king
View
6.660
Download
3
Tags:
Embed Size (px)
DESCRIPTION
Citation preview
POLYTECHNIC COLLEGE OF DAVAO DEL SUR MacArthur Highway, Digoc City
A CASE STUDY OF Pregnancy Induced Hypertension: Mild
IN PARTIAL FULFILLMENTOF THE REQUIREMENTS IN
RLE/NCM 102
Presented to Mr. Roberto C. Osol, RN
Presented by
Radee King R. Corpuz
February, 2009
INTRODUCTION
Pregnancy (latin graviditas) is the carrying of one or more offspring, known as a
fetus or embryo, inside the uterus of a female. In a pregnancy, there can be multiple
gestations, as in the case of twins or triplets. Human pregnancy is the most studied of all
mammalian pregnancies. Obstetrics is the surgical field that studies and cares for high
risk pregnancy. Midwifery is the non-surgical field that cares for pregnancy and pregnant
women.
Childbirth usually occurs about 38 weeks after fertilization (conception), i.e.,
approximately 40 weeks from the last normal menstrual period (LNMP) in humans. The
date of delivery is considered normal medically if it falls within two weeks of the
calculated date. The calculation of this date involves the assumption of a regular 28-day
period. Thus, pregnancy lasts almost nine months. The exact definition of the English
word “pregnancy” is a subject of political controversy, but it is not a matter of substantial
controversy in the medical community.
Pregnancy occurs as the result of the female gamete or oocyte being penetrated
by the male gamete spermatozoon in a process referred to, in medicine, as "fertilization",
or more commonly known as "conception". After the point of "fertilization" it is referred to
as an egg. The fusion of male and female gametes usually occurs through the act of
sexual intercourse. However, the advent of artificial insemination and in vitro fertilisation
have also made achieving pregnancy possible in cases where sexual intercourse does
not result in fertilization (e.g. through choice or male/female infertility).
Incidence of Preeclampsia: High blood pressure problems occur in 6 percent to 8
percent of all pregnancies in the U.S., about 70 percent of which are first-time
pregnancies. In 1998, more than 146,320 cases of preeclampsia alone were diagnosed
Prevalence of Preeclampsia: Preeclampsia is the most common hypertensive
disorder during pregnancy, affecting an estimated 5-8% of pregnant women annually in
the United States, and has the greatest effect on maternal and infant outcome.
(http://www.wrongdiagnosis.com/p/preeclampsia/stats.htm)
In the Philippines, according to the Department of Health (DOH), that in the
Leading Causes of Maternal Mortality Rate per 1,000 live birth, Preeclampsia is the
number 3, either Mild or Severe with a percentage of 40%, surveyed last January,
2008(DOH.gov.ph/calabarzon)
Pre-eclampsia (US: preeclampsia from Greek eklampsia, to shine forth, term
used by Hippocrates to suggest a sudden development) is a medical condition where
hypertension arises in pregnancy (pregnancy-induced hypertension) in association with
significant amounts of protein in the urine. Because pre-eclampsia refers to a set of
symptoms rather than any causative factor, it is established that there are many different
causes for the syndrome. It also appears likely that there is a substance or substances
from the placenta that may cause endothelial dysfunction in the maternal blood vessels
of susceptible women.[1] While blood pressure elevation is the most visible sign of the
disease, it involves generalized damage to the maternal endothelium and kidneys and
liver, with the release of vasopressive factors only secondary to the original damage.
Pre-eclampsia may develop from 20 weeks gestation (it is considered early onset
before 32 weeks, which is associated with increased morbidity) and its progress differs
among patients; most cases are diagnosed pre-term. Apart from abortion, Caesarean
section, or induction of labor, and therefore delivery of the placenta, there is no known
cure. It may also occur up to six weeks post-partum. It is the most common of the
dangerous pregnancy complications; it may affect both the mother and the fetus.[1]
IDENTIFICATION OF THE CASE
A. PERSONAL PROFILE
Name : Madam O
Address : NAPO, Paquibato (Pob), Davao City
Age : 29y/o
Gender : Female
Civil status : Married
Occupation : Housewife
Admitting Doctor : Dr. Oribello, Libnan
Admitting Diagnosis : Pregnancy Uterine, 39 4/7 wks AOG, cephalic
in labor, G2P1, PreEclampsia: Mild
Religion : Roman Catholic
Nationality : Filipino
Educational Attainment: High School Graduate
Spouse name : Mr. R
Occupation : Pedicab driver
Date of admission : February 04, 2009; 10:15pm
B. Background/History
DM HPN CA ASTHMA
Maternal
Paternal
C. Medical History
The patient had her second prenatal check-up at their barangay
hall. According to her, she had was hospitalized due to hypertension, but it
last for a week because the medicines given. The patient had completed
her immunization, and they used herbal medicine aside from low cost
medicine sponsored by the government. Our patient was not a non-
smoker and non-alcoholic.
D. History of Present Illness
The patient has a hypertensive condition, she experienced this in
the second birth, and she had a follow up check-up, for several times.
Six days prior to admission, patient experienced headache and dizziness,
but no consult was made. Instead, patient self-medicated with Aldomet
which afforded relief.
Three days prior to admission, headache persisted with increased
severity, which prompted patient to seek medical assistance at DMC
hospital, patient was given anti-hypertensive medication..
E. Socio-economic background
Patient O, had her second pregnancy and one sibling. Her family
was in average status, wherein they can provide the basic needs for their
patient. Her spouse was a pedicab driver, where his income had a
maximum of Php 500.00 a day, depends on a day.
DEFINITION OF TERMS
Age of Gestation – is the age of an embryo or fetus (or newborn infant). In humans, a common method of calculating gestational age starts counting either from the first day of the woman's last menstrual period (LMP) [1] or from 14 days before conception (fertilization). Counting from the first day of the LMP involves the assumption that conception occurred 14 days later. If the day of conception is known, the 14th day before conception is used in place of the LMP. Although this "LMP method" of calculating gestational age is convenient, other methods are in use or have been proposed.
Angiotensin – causes blood vessels to constrict, and drives blood pressure up. It is part of the renin-angiotensin system, which is a major target for drugs that lower blood pressure. Angiotensin also stimulates the release of aldosterone from the adrenal cortex. Aldosterone promotes sodium retention in the distal nephron, which also drives blood pressure up.
Hypertension – is a medical condition in which the blood pressure is chronically elevated. In current usage, the word "hypertension"[1] without a qualifier normally refers to systemic, arterial hypertension
PreEclampsia – is diagnosed when a pregnant woman develops high blood pressure (two separate readings taken at least 4 hours apart of 140/90 or more) and 300 mg of protein in a 24-hour urine sample (proteinuria).
Prostacyclin (PGI2) – chiefly prevents formation of the platelet plug involved in primary hemostasis (a part of blood clot formation). It is also an effective vasodilator
Thromboxane – is a vasoconstrictor and a potent hypertensive agent, and it facilitates platelet aggregation. It is in homeostatic balance in the circulatory system with prostacyclin,
ANATOMY AND PHYSIOLOGY
The Circulatory System
The
Circulatory System is the main
transportation and cooling system for the body. The Red Blood Cells act like billions of little UPS trucks carrying all sorts of packages that are needed by all the cells in the body. Instead of UPS, I'll call them RBC's. RBC's carry oxygen and nutrients to the cells. Every cell in the body requires oxygen to remain alive. Besides RBC's, there are also White Blood Cells moving in the circulatory system traffic. White Blood Cells are the paramedics, police and street cleaners of the circulatory system. Anytime we have a cold, a cut, or an infection the WBC's go to work.
The highway system of the Circulatory System consists off a lot of one way streets. The superhighways of the circulatory system are the veins and arteries. Veins are used to carry blood *to* the heart. Arteries carry blood *away* from the heart. Most of the time, blood in the veins is blood where most of the oxygen and nutrients have already been delivered to the cells. This blood is called deoxygenated and is very *dark* red. Most of the time blood in the arteries is loaded with oxygen and nutrients and the color is very *bright* red. There is one artery that carries deoxygenated blood and there are some veins that carry oxygenated blood. To get to the bottom of this little mystery we need to talk about the Heart and Lungs.
The Heart
This is a subject that is near and dear to my heart. The heart is a two sided, four chambered pump. It is made up mostly of muscle. Heart muscle is very special. Unlike
all the other muscles in the body, the heart muscle cannot afford to get tired. Imagine what would happen if every 15 minutes or so the pump got tired and decided to take a little nap! Not a pretty sight. So, heart muscle is always expanding and contracting, usually at between 60 and 100 beats per minute.
The right side of the heart is the low pressure side. Its main job is to push the RBC's, cargo bays mostly empty now, up to the lungs (loading docks and filling stations) so that they can get recharged with oxygen. Blood enters the right heart through a chamber called the Right Atrium. Atrium is another word for an 'entry room.' Since the right atrium is located *above* the Right Ventricle, a combination of gravity and an easy squeeze pushes the blood though the Tricuspid Valve into the right ventricle. The tricuspid valve is a valve made up of three 'leaflets' that allows blood to go from top to bottom in the heart but closes to prevent the blood from backing up into the right atrium when the right ventricle squeezes.
After the blood is in the right ventricle, the right ventricle begins its contraction to push the blood out toward the lungs. Remember that this blood is deoxygenated. The blood leaves the right ventricle and enters the *pulmonary artery.* This artery and its two branches are the only arteries in the body to carry deoxygenated blood. Important: Arteries carry blood *away* from the heart. There is nothing in the definition that says blood has to be oxygenated.
When the blood leaves the pulmonary arteries it enters *capillaries* in the lungs. Capillaries are very, very small blood vessels that act as the connectors between veins and arteries. The capillaries in the lungs are very special because they are located against the *alveoli* or air sacks. When blood in the capillaries goes past the air sacks, the RBC's pick up oxygen. The alveoli are like the loading docks where trucks pick up their load. Capillaries are so small, in some places, that only *one* RBC at a time can get through!
When the blood has picked up its oxygen, it enters some blood vessels known as the *cardiac veins.* This is fully oxygenated blood and it is now in veins. Remember: Veins take blood to the heart. The cardiac veins empty into the *left atrium.* The left side of the heart is the high pressure side, its job is to push the blood out to the body.
The left atrium sits on top of the *left ventricle* and is separated from it by the *mitral valve*. The mitral valve is named this because it resembles, to some people, a Bishop's Mitered Hat. This valve has the same function as the tricuspid valve, it prevents blood from being pushed from the left ventricle back up to the left atrium.
The left ventricle is a very high pressure pump. Its main job is to produce enough pressure to push the blood out of the heart and into the body's circulation. When the blood leaves the left ventricle it enters the Aorta. There are valves located at the opening of the Aorta that prevent the blood from backing up into the ventricle. As soon as the blood is in the aorta, there are arteries called *coronary arteries* that take some of the blood and use it to nourish the heart muscle.
The Aorta and the Arterial System
The aorta leaves the heart and heads toward, what else, the head. We have to keep our brains well nourished so we can make good grades in school. The arteries that take the blood to the head are located on something called the *aortic arch.* After the blood passes through the aortic arch it is then distributed to the rest of the body. The *descending aorta* goes behind the heart and down the center of the body.
Sometimes, if you are lying flat on your back, you can look down toward your feet and actually see your abdomen pulsate with each heart beat. This pulsation is really the aorta throbbing with each heart beat. Do not be alarmed, this is normal.
From the aorta, blood is sent off to many other arteries and arterioles (very small arteries) where it gives oxygen and nutrition to *every* cell in the body. At the end of the arterioles are, guess what, capillaries. The blood gives up its cargo as it passes through the capillaries and enters the venous system. The Venous System
The venous system carries the blood back to the heart. The blood flows from the capillaries, to venules (very small veins), to veins. The two largest veins in the body are the *superior* and *inferior* vena cavas. The superior vena cava carries the blood from the upper part of the body to the heart. The inferior vena cava carries the blood from the lower body to the heart. In medical terms, *superior* means above and *inferior* means under. Many people believe that the blood in the veins is *blue*; it is not. Venous blood is really dark red or maroon in color. Veins do have a bluish appearance and this may be why people think venous blood is blue. Both the superior and inferior vena cava end in the right atrium. The superior vena cava enters from the top and the inferior vena cava enters from the bottom.
This completes our little journey through the circulatory system. I hope the blood has continued to flow to your brain as you read this and you managed to stay awake. If you dozed off, it's o.k., I doze off myself from time to time when I read really boring stuff. There are lots of things that I did not talk about, such as how the cooling system works, but I thought that you might like to look some of this stuff up by yourself. As usual, I know you will have questions for me. I can't wait to hear from you.
During pregnancy, the fetal circulatory system works differently than after birth:
The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother's uterus during pregnancy.
Through the blood vessels in the umbilical cord, the fetus receives all the necessary nutrition, oxygen, and life support from the mother through the placenta.
Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother's circulation to be eliminated.
Blood from the mother enters the fetus through the vein in the umbilical cord. It goes to the liver and splits into three branches. The blood then reaches the inferior vena cava, a major vein connected to the heart.
Inside the fetal heart:
Blood enters the right atrium, the chamber on the upper right side of the heart. Most of the blood flows to the left side through a special fetal opening between the left and right atria, called the foramen ovale.
Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, (the large artery coming from the heart).
From the aorta, blood is sent to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava.
About one-third of the blood entering the right atrium does not flow through the foramen ovale, but, instead, stays in the right side of the heart, eventually flowing into the pulmonary artery.
Because the placenta does the work of exchanging oxygen (O2) and carbon dioxide (CO2) through the mother's circulation, the fetal lungs are not used for breathing. Instead of blood flowing to the lungs to pick up oxygen and then flowing to the rest of the body, the fetal circulation shunts (bypasses) most of the blood away from the lungs. In the fetus, blood is shunted from the pulmonary artery to the aorta through a connecting blood vessel called the ductus arteriosus.
Blood circulation after birth:
With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of blood is sent to the lungs to pick up oxygen.
Because the ductus arteriosus (the normal connection between the aorta and the pulmonary valve) is no longer needed, it begins to wither and close off.
The circulation in the lungs increases and more blood flows into the left atrium of the heart. This increased pressure causes the foramen ovale to close and blood circulates normally.
ETIOLOGY AND SYMPTOMATOLOGY
Etiology
Ideal Actual Justification
Pregnancy (+)
pregnant woman develops high blood pressure (two separate readings taken at least 4 hours apart of 140/90 or more) and 300 mg of protein in a 24-hour urine sample (proteinuria).
Symptomatology
Ideal Actual Justification
Hypertension (+)
a woman who normally has a low baseline blood pressure, such as 90/60, could be considered hypertensive at a blood pressure of less than that - especially if she has other symptoms. A rise in the diastolic (lower number) of 15 degrees or more, or a rise in the systolic (upper number) of 30 degrees or more is cause for concern.
Swelling or Edema (+)
-because of is the accumulation of excess fluid. It is particularly concerning when it accumulates in the face (eyes) or hands. It is normal to have trouble wearing rings throughout pregnancy.
Sudden Weight Gain(+)
-due to In general, eat normally and make every effort to include fresh raw fruit and vegetables, your prenatal vitamin, and a folic acid supplement in your diet
Headaches(+)
because of Dull, throbbing headaches, often described as migraine-like
Nausea or Vomiting(+)
- Nausea or vomiting is particularly significant when the onset is sudden and in the second or third trimesters.
Changes in Vision (+)
-Vision changes include temporary loss of vision, sensations of flashing lights, auras, light sensitivity, and blurry vision or spots. For some women who are farsighted, vision may actually improve.
Lower Back Pain (+)
Lower back pain is a very common complaint of pregnancy. However, sometimes it may indicate a problem with the liver, especially if it accompanies other symptoms or preeclampsia.
COMPLICATION
Most women with preeclampsia deliver healthy babies. The more severe your
preeclampsia and the earlier it occurs in your pregnancy, however, the greater the risks
for you and your baby. Complications of preeclampsia may include:
Lack of blood flow to the placenta. Preeclampsia affects the arteries carrying
blood to the placenta. If the placenta doesn't get enough blood, the baby may
receive less oxygen and nutrients. This can lead to slow growth, low birth weight,
preterm birth or stillbirth.
Placental abruption. Preeclampsia increases the risk of placental abruption, in
which the placenta separates from the inner wall of the uterus before delivery.
Severe abruption can cause heavy bleeding, which can be life-threatening for
both mother and baby.
HELLP syndrome. HELLP — which stands for hemolysis (the destruction of
red blood cells), elevated liver enzymes and low platelet count — syndrome can
rapidly become life-threatening for both mother and baby. Symptoms of HELLP
syndrome include nausea and vomiting, headache and upper right abdominal
pain. HELLP syndrome is particularly dangerous because it can occur before
signs or symptoms of preeclampsia appear.
Eclampsia. When preeclampsia isn't controlled, eclampsia — which is
essentially preeclampsia plus seizures — can develop. Symptoms of eclampsia
include upper right abdominal pain, severe headache, vision problems and
change in mental status, such as decreased alertness. Eclampsia can
permanently damage a mother's vital organs, including the brain, liver and
kidneys. Left untreated, eclampsia can cause coma, brain damage and death for
both mother and baby
PATHOPHYSIOLOGY
Predisposing factorsAgeHx of Pre-Ec, DM, Large placental mass
Placenta partiallyProduced prostacyclin & thromboxane
Precipitating factorsPregnancy
Changes in the ratio between the prostaglandins
Prostacyclin (potent vasodilator)& thromboxane (potent vasocontrictor
&platelet aggregator)
Prostacyclin Thromboxane
Effects of thromboxane dominates
Gradual loss of resistance to Angio II (potent vasoconstriction)
Concurrent maternal vasospasm
Renin-Angiotensin-Aldosterone mechanism
HPN
IncreasedSensitivity to
Angio II
Nitric Oxide production
Placental perfusion
Loss of Normal vasodilation ofUterine arteriols
Effects on fetus:Growth restrictionChronic hypoxia
Fetal distress
Renal perfusion
GFR
S/Sx Urea BUN Uric acid U.O.
Na+ retentionIn amounts
Extracellularvolume
Large protein molecules allowed
to escape in the uterine
S/Sx:ProteinuriaColloidal osmoticpressure Further movement
of fluid to extracellular spaces
S/SxEdema
Intravascularvolume
Viscosity of blood
S/SxHct
In normal pregnancy the lowered peripheral vascular resistance and the
increased maternal resistance to the pressor effects of angiotensin II result in
lowered blood pressure. In preeclampsia, blood pressure begins to rise after 20
week’s gestation, probably in response to a gradual loss of resistance to
angiotensin II. This response has been linked to the ration between the
prostaglandins prostacyclin and thromboxane.
Prostacyclin is a potent vasodilator. It is decreased in preeclampsia, often
several weeks before symptoms develop. This changes the ratio between the
two prostaglandins, allowing the potent vasoconstriction and platelet-aggregating
effects of thromboxane to dominate. These hormones are produced partially by
the placenta, which helps explain the reversal of the condition when the placenta
is removed and why the incidence is increased when there is a larger than
normal placental mass.
Nitric oxide, a potent vasodilation, plays a role in the pregnant woman’s
resistance to vasopressors. Decreased nitric oxide production in women with
preeclampsia may contribute to the development of hypertension. The loss of
normal vasodilation of uterine arteriols and the concurrent maternal vasospasm
result in decreased placental perfusion. The effect on the fetus may be growth
restriction, decrease in fetal movement, and chronic hypoxia or fetal distress.
Normal renal perfusion is decreased. With a reduction of the glomerular
filtration rate, serum levels of creatinine, BUN, and uric acid begin to rise from
normal pregnant levels, while urine output decreases. Sodium is retained in
increased amounts, which results in increased extracellular volume, increased
sensitivity to angiotensin II, and edema. Stretching of the capillary walls of the
glomerular endothelial cells, allows the large protein molecules, primarily albumin
to escape in the urine, decreasing serum albumin levels. The decreased serum
albumin concentration causes decreased plasma colloid osmotic pressure. This
lowered pressure results in further movement of fluid to the extracellular spaces,
which also contributes to the development of edema.
The decreased intravascular volume causes increased viscosity of the
blood and a corresponding rise in hematocrit.
MEDICAL MANAGEMENT
01/06/09
Referred to Dr. Armando
8:30am For repeat cranial CT scan STAT Monitor NVS every hour and record Refer
01/07/0910:30am
NPO Start Ranitidine 50mg IVTT every 8 hours Shave full head Refer
01/08/09
May have DAT Continue medz Continue IVF: PLR 1L to run at 130cc/hr D/C PNSS D/C omepirazole Open dressing Keep Jackson’s Pratt drain in negative
5:55pm D/C all medz Change dressing Refer
01/09/095:30
DAT Continue medz Change dressing Keep Jackson’s Pratt Drain in negative Full body bath Remove FBC
01/10/09
DAT with SAP ROM:
Laboratory
Test ResultNormal Values
Clinical Significance
Remarks
CBC Hemoglobin – L 97.0
115-155 Decreased in various anemias, pregnancy, severe or prolonged hemorrhage, and with execessive fluid intake
-decresed-
Hematocrit – L 0.37
0.30-0.48 Severe anemias, anemia of pregnancy, acute massive blood loss
-decreased-
RBC – L 3.66 4.20-6.10 Adequate number of Red Blood Cell primarily to ferry oxygen in blood to all cells of the body
-decreased-
WBC – H 15.78
5.0-10.0 Infection, leukemia, tissue necrosis
-increased-
Neutrophil – 71
55-75 -normal range-
Lymphocytes – L .18
0.2-0.4 Aplastic anemia, SLE, immunodeficiency including AIDS
-decreased-
Monocytes – 10
2-10 -normal range-
Eosinophil – 1
1-8 -normal range-
Basophil – 0 0-1 -normal range-MCV - 88.8 84-96 cubic
µm/red cell-normal range
MCH - 26.5 26-34 pg/cell -normal rangeMCHC – L29.8
31-37 g Hgb/dl
Severe hypochromic anemia
-decreased-
Albumin (+)Sugar (+)
NURSING ASSESSMENT
Physical Assessment
Assessment Normal Findings Yes No
Body Build,
Height and
Weight
Proportionate, varies
with lifestyle
Posture and
Gait
Clean, neat
Body and
Breath odor
No body or breath odor
Signs of
Distress
No distress noted
Signs of Health
or Illness
Healthy appearance
Attitude Cooperative
Affect/Mood Appropriate to situation
Quantity,
Quality and
Organization of
Speech
Understandable,
moderate pace,
exhibits thought
association
Relevance and
Organization of
Thoughts
Logical sequence,
makes sense, has
sense of reality
Assessment Normal Findings Yes Poor
Uniformity of
skin color
Uniformity except in
areas exposed to the
sun
Edema No edema
Skin Lesions No freckles, No
birthmarks, no
abrasions or lesions
Skin Moisture Moisture in skin folds
and the axillae
Skin
Temperature
Uniform, within normal
range
Skin Turgor Skin springs back to
previous state when
pinched
Assessment Normal Findings Yes No
Scalp Evenly distributed
Hair Thickness Thick hair
Hair Texture Silky, resilient hair
Amount of Body
Hair
Variable
Assessment Normal Findings Yes No
Nail Plate
Shape
Convex curvature
Texture Smooth
Nail Bed Color Highly vascular,
pink, prompt return
of pink color
Assessment Normal
Findings
Good Fair Poor
A. Skull and Face
Head Rounded,
symmetrica
l, smooth
skull
contour, no
nodule
B. Eyes and Vision
Eyebrows Hair evenly
distributed,
symmetrical,
skin intact
Eyelid Skin intact, no
discharges, no
discolorations,
symmetrical
Eyelashes Equally
distributed,
slightly curved
outward
Conjunctiva Transparent,
sometimes
appear white,
shiny, smooth,
pink or red
Lacrimal
Gland
No edema or
tearing
Cornea Transparent,
shiny and
smooth, blinks
when cornea
is touched
Pupils Black color,
equal size
Near Vision Able to read
newsprint
C. Ears and Hearing
Auricles Color is
uniform,
symmetric,
mobile,
firm, pinna
recoils
when
folded
Response to
Normal Voice
Tone
Normal
voice tone
audible
D. Nose and Sinuses
Nares Symmetric
and
straight, no
discharges,
no swelling,
uniform
color, not
tender
Lining of nose Nasal
septum in
midline
E. Mouth
Lips Buccal
Mucosa
Uniform
pink, soft,
symmetrica
l
Teeth and
Gums
Complete
child teeth,
smooth,
white tiny
tooth
enamel,
pink gums,
moist, firm,
no
retractions
Tongue Centrally
located,
pink in
color, freely
movable
Palates,
Uvula, Tonsils
Light pink,
smooth, no
discharges,
present
gag reflex
Assessment Normal Findings Good Fair Poor
Shape and
Symmetry
Symmetrical
Spinal
Deformities
Spine vertically
aligned
Assessment Normal Findings Good Fair Poor
Inspect Neck
Muscles
Symmetrical with head
centered
Observe Head
Movement
Coordinated, smooth,
movement with no
discomfort, equal
strength
Assessment Normal Findings Good Fair Poor
Muscle Size is symmetrical, no
contracture, normally
firm
Movement Smooth coordinated
movements, equal
strength
Bones No deformities, no
swelling or tenderness
Joints No swelling, tenderness
Range of
motion
Varies to some degree
NURSING MANAGEMENT
NURSING ASSESSMENT AND DIAGNOSIS
Take and record the blood pressure during each antepartal visit. If the blood
pressure rises, or if the normal decrease in blood pressure expected between 8
to 28 weeks of pregnancy does not occur, the woman should be followed closely.
Also check the woman’s urine for proteinuria at each visit.
If hospitalization becomes necessary, asses the following:
Blood pressure. Asses every 1 to 4 hours, or more frequently if indicated
by medications or other changes in the woman’s status.
Temperature. Take every 4 hours, or every 2 hours if elevated.
Pulse and respiration. Determine pulse rate and respiration along with
blood pressure.
Fetal heart rate. Check the fetal heart rate with the blood pressure, or
monitor cotinuously with the electronic fetal monitor if the situation
indicates.
Urinary output. Measure every voiding. Te woman frequently has
indwelling catheter. In this case, urine output can be assessed hourly.
Output should be 700mL or greater in 24 hours, or at least 30mL/hour.
Urine protein. Evaluate urinary protein hourly if an indwelling catheter is
in place or with each voiding. Reading of 3+ or 4+ indicates loss of 5g or
more of protein in 24hours.
Urine specific gravity. Check specific gravity of the urine hourly or with
each voiding. Readings over 1.040correlate with oliguria and proteinuria.
Weight. Weight the woman daily at the same robe or gown and slippers.
Weighing may be omitted if the woman is to maintain strict bed rest.
Pulmonary edema. Observe the woman for coughing. Auscultate the
lings for moist respirations.
Deep tendon reflexes. Assess the woman for evidence of hyperflexia in
the brachial, wrist, patellar, or Archilles tendons.
Placental separation. Assess hourly for vaginal bleeding and uterine
rigidity.
Headache. Ask about any visual blurring or changes or scotomata. The
results or the daily funduscopic examination should be recorded on the
chart.
Epigastric pain. Ask about any epigastric pain. It is important to
differentiate it from simple heartburn, which tends to be familiar and less
intense.
Laboratory blood test. Daily test of hematocrit to measure
hemoconcentration; BUN, creatinine, and uric acid levels to assess kidney
function; clotting studies for sings of thrombocytopenia or DIC; liver
enzymes; and electrolytes are all indicated. Magnesium levels are monitor
regularly in women receiving magnesium sulfate.
Levels of consciousness. Observe the woman for alertness, mood
changes, and any signs of impending convulsion.
Emotional response and level of understanding. Carefully assess the
woman’s emotional response so that support and teaching can be planned
accordingly.
In addition assess the effects of any medications administered. Become familiar
with the more commonly used medications and their purpose, implications, and
associated untoward or toxic effects.
NURSING THEORIES
Florence Nightingale
Her Notes on Nursing emphasized that a clean environment, warmth, ventilation, sunlight, and a quiet environment lead to good health.
Reaction: a non-stimulating environment is essential especially for our patient, in a way that it promotes faster recovery on our patient through minimizing external and stressful stimuli such as limiting visitors during resting periods that may worsen the situation of our client.
Virginia Henderson
Virginia Henderson defined nursing as "assisting individuals to gain independence in relation to the performance of activities contributing to health or its recovery"
Reaction: we can relate this theory in the case of our patient because our patient will soon be discharged from the unit. In order for her to gain independence in nourishing her child, we, student nurses, must render health teachings such as the importance of breast feeding, the proper positioning of the child during breastfeeding and Mothers who breastfeed longer than eight months also benefit
from bone re-mineralization and breastfeeding diabetic mothers require less insulin.
Hildegard Peplau
Hildegard Peplau used the term, psychodynamic nursing, to describe the dynamic relationship between a nurse and a patient. She identified nursing roles of the nurse and in our case this three roles fitted us for our client:
Counseling Role - working with the patient on current problems Teaching Role - offering information and helping the patient learn
Reaction: As a nursing student, we had many roles to perform to our patient. One of these roles is being a councilor. As a councilor, it is our duty to lessen if not alleviate the client’s problem.
As an educator it is our obligation to render knowledge to our patient. In our client’s case, who just delivered her baby, our co-student nurse taught the patient about performing self-care by means of proper perennial care.
HEALTH TEACHINGS
PRIMARY
1. Instruct the patient to have a proper diet that she can tolerate, such as fruits, to help promote wellness.
2. Instruct the patient to have deep breathing exercise, to promote non-pharmacological treatment
3. Advice the patient to have fluid intake or adequate hydration, to help her body re-hydrate to prevent fluid imbalance.
4. Assist patient to perform self-care activities she cannot tolerate, to help her maintain her activities of daily living.
5. Encourage patient to perform self care activities within her level of own ability.
6. Initiate and encourage patient to perform bed exercises to improve circulation ( ROM to arms, hands and fingers, feet and legs; leg flexion and leg lifting; abdominal and gluteal contraction)
7. Ask patient to perform as much as possible and then to call for assistance. Collaborate with patient for progressive activity before and after schedule activity.
SECONDARY
1. Administer medications as ordered by the physician2. Advice patient to have proper nutrition to enhance immune system
TERTIARY
1. Instruct patient to comply for medication regimen2. Discuss the importance of having a regular check-up with his physician
DISCHARGE PLAN
When the doctor noted that the patient is for discharge it is very important
to continue the medication depending on the duration the doctor ordered for the
total recovery of the patient. Patient with Post Normal Spontaneous Vaginal
Delivery needs to have a light exercise such as motor development in both arms
and feet, clear verbalization and spontaneous with the duration of 10-15 minutes
and must get enough rest. It is also important to maintain proper hygiene to
prevent further infection that may happen to the. She also needs to minimized
smoking and drinking alcoholic beverages.
She must have to relax in order to recover her present condition and
minimal exposure to a pressure and positive atmosphere can be a high risk
factor that may cause severity of her condition. The diet of the patient is also a
factor for fast recovery. She is encourage to eat nutritious foods such as fresh
fruits with vitamin C and fresh vegetables. The family of the patient plays a big
role for the fast recovery.
Regular consultation to the physician can be factor for recovery to assess
and monitor her condition
M- advice patient not to skip the meds that the doctor ordered
E- encourage patient to have exercise early in the morning at lease twice a day
T-
H- separate utensils for the mother and other personal things that will be use for the whole family
O- provide information about how to control or prevent the spread of the disease
D- encourage patient to eat nutritious food such as vegetable and fruits especially those that contains vitamin C
S- provide emotional support and provide care for the motherPROGNOSIS
Good Fair Poor JustificationDuration of Illness -
Duration of illness is good since the incident was and she was given ample treatment.
Onset of Illness
-
The onset is since right after the she was diagnosed, she was automatically brought to the Delivery room for a Post NSVD
Compliance to Medication
-
Patient can afford to sustain the needed laboratory exams and the feasibility of having the condition
Family Support -
The family members supported the patient both financially and emotionally.
Environment - The hospital setting is not well ventilated and
may promote for further infection of the patient’s current situation.
Age
-
Patient is 29 years old therefore she has a moderate chance of recovering for her immune system is still generating in the process of development.
Precipitating Factors
-
The patient manifested all the factors that may lead to Pregnancy Induced Hypertension which urged the family and the health provider to set-up the proper action
EVALUATION
Through our hardship in preparing for this research, tried to interact
and communicate our patient in good manner for us to gather the specific and
accurate data that we need that could help us in studying the disease which
could lead us into successful research.
The patient’s condition is in recovery period as she had already
undergone medication for certain, which thereby prevented occurrence of
complications. They are financially capable in sustaining such pregnancy
condition and the medications after. Her husband is the one taking good care
of her in throughout her hospitalization, giving emotional and moral support.
IMPLICATION
Nursing Practice
- this can be used as a guide for practice by other nurses. They may get many relevant ideas in giving proper care and interventions to patients with related illness or those who have the same illness (Post Normal Spontaneous Vaginal Delivery, with Pregnancy Induced Hypertension)
Nursing Education
- this study may serve as a helpful learning tool for student nurses. They may utilize this complied study as their reference for research; this will also give them good examples on nursing managements, and nursing diagnoses, which will be a very useful guide when they will be making their own Nursing Care Plans.
Nursing Research
- students may use this compilation as their guide for research. This will hand them good views and factual ideas which will be very essential for their added learning on knowledge for Post Normal Spontaneous Vaginal Delivery with Pregnancy Induced Hypertension condition
REFERENCES
http://en.wikipedia.org/wiki/Preeclampsia
http://en.wikipedia.org/wiki/Glascow_Coma_Scale
http://en.wikipedia.org/wiki/Placenta
http://hes.ucfsd.org/gclaypo/circulatorysys.html
http://www.brooksidepress.org/Products/OBGYN_101/ MyDocuments4/Lab/hemoglobin.htm
Fundamentals of Maternal and Child Nursing Care, 2 nd Ed., Vol 1, pp 354-358
Brunner and Suddarth’s Medical-Surgical Nursing, 11 th Ed,. Vol 2, pp.2578-2580, Diagnostic Studies and Interpretation