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