I.

INTRODUCTION

Cesarean Section is a surgical procedure in which incisions are made through a woman’s abdomen and uterus to deliver her baby. The most common reason that a cesarean

section is performed (35% of all cases according to the United States Public Health Service) is that the woman has had a previous Cesarean Section. “Once a Cesarean, always a

cesarean”. 30% of all cases of Cesarean section birth are due to difficult child birth due to non progressive labor. Another 12% of Cesarean Sections are performed to deliver a

baby in a breech presentation. 9% of all cases, Cesarean Sections are performed in response to fetal distress. 14% of Cesarean Sections are indicated by other serious factors (e.g.

Cord Prolapse)

Description of the Disease

Eclampsia it is a presence of unexplained grand mal seizures in a hypertensive, proteinuric pregnant woman after 20 weeks gestation. Predisposing factors are same

with mild and sever preeclampsia. Having a primary seizure disorder does not predispose a patient to eclampsia. The presenting symptoms are those present in

preeclampsia plus unexplained tonic-clonic seizures.

In addition symptoms of eclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid

• Epigastric pain

• Visual disturbances, persistent headache

• Pulmonary edema
 • Sustained blood pressure elevation greater or equal to 160/100.

• Proteinuria +3 to +4 or greater or equal to 5 grams on a 24-hour urine collection.

The etiology of eclampsia is a severe diffuse cerebral vasospasm resulting to decreased cerebral perfusion and cerebral edema.

The only real cure for preeclampsia and eclampsia is the birth of the baby. The treatment that can be done is to establish airway and protect patients tongue, and magnesium

sulfate administration. The complications are intracerebral hemorrhage and or death.

The group chose the case for the reason that they wanted to show the readers the process on how eclampsia occurs and for them to fully understand and be reminded on

one of the complications associated with pregnancy.

In developing countries: preeclampsia/eclampsia impact 4.4% of all deliveries (1)and may be as high as 18% in some settings in Africa (2) If the rate of life threatening

eclamptic convulsions (0.1% of all deliveries) is applied to all deliveries from countries considered to be the least developed, 50,000 cases of women experiencing this serious

complication can be expected each year. According to Safe Motherhood.org of the 585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia.

This case is a case of a 19 year old female, a resident of Norzagaray, Bulacan, who was admitted in Bulacan Medical Center on December 2, 2009 at 6:30 in the evening,

with the diagnosis of pregnancy uterine 35 5/7 weeks twin gestation cephalic in labor intrapartum eclampsia. She was transferred to the Operating Room and was given anesthesia

at 8:50pm and the operation started at 9:05PM.The procedure lasts for 40minutes and delivered at 9:45 pm. The baby boy 1 extracted at 9:17pm while baby boy 2 extracted at

9:18pm together the placenta and the operation ended at exactly 9:45PM
B. For the very reason that we are currently taking up Maternal and Child Nursing concerning Abnormal Cases. Our group had agreed upon to select this case for our Clinical Case

Study, further, we want to have deeper and comprehensive understanding of the knowledge and skills we have learned on the four corners of our classroom.

OBJECTIVES:

General Objective:

● To be able to present a comprehensive study of the cesarean section delivery in relation to eclampsia

Specific Objective:

Knowledge:

1. To be informed about cesarean delivery.

2. To acquire and import knowledge regarding the pathophysiology of eclampsia.

3. To be able to plan for needed interventions for the recovery of the patient that underwent cesarean section delivery.

4. To be able to develop Nursing Care Plan that will meet the needs of patient.

5. To be able to have a general and subsequent evaluation of the client’s conditions and well being.

Skills:

1. To be able to obtain sufficient data of the client’s history of past and present illness.

2. To be able to provide a drug study of the medication being administered after delivery and as well as the kind of diet which is allowable to a eclamptic patient.
 3. To be able to do a comprehensive physical examination to a woman who underwent cs delivery.

4. To be able to analyze the different laboratory examination to the woman who underwent cs delivery.

5. To be able to implement the said plan for the eclamptic patient..

Attitude:

1. To be able to effectively establish rapport, essential for the cooperation of the client to the health care.

2. To be able to practice the use of therapeutic use of self for the complete recovery of the patient.

3. To be able to recognize and understand the client’s situation.

4. To be able to work as a team necessary for this case study.

5. To be able to practice leadership, a unique trait a nurse should have.

Nurse-Centered Objectives:

Upon completion of this case study, the student nurse should be able to:

1. Identify the risk factor contributing to the occurrence of the disease.

2. Formulate significant nursing diagnosis, with the significantly related nursing care plan.
 3. Identify the different medications administered for this disease their indications, contraindications, side effect, and specific responsibility .

4. Identify the laboratory and diagnostic procedure done with the pre-eclamptic patient, their indication and purposes, and specific nursing responsibilities.

Client-Centered Objectives:

Upon completion of this case study, the client should be able to:

1. Understand awareness of her disease.

2. Know the possible causes of the disease.

3. Learn and understand why such laboratory examinations are being done.

A. BIOGRAPHIC DATA

I. Patients Personal Information:

Name: N.B.

Address: Old Barrio, Bigte Norzagaray, Bulacan

Birthday: September 28, 1990 Age: 19 y/o

Gender: Female
Marital Status: Single

Religion: Born Again

Race: Filipino

Occupation: Student

Birth Order: Eldest among 5 children

II. REASON FOR SEEKING HEALTH CARE

The patient’s chief complaints are abdominal pain, uterine contractions, and pain in the back that radiates around to the abdomen.

III. HISTORY OF PRESENT ILLNESS

 In giving birth to her two sons, the patient undergone to caesarian section because of some complications like temporary blindness, fever, hypertension, difficulty in

hearing, and convulsion.

IV. PAST MEDICAL HISTORY

Patient NB hasn’t experienced any childhood diseases and doesn’t hospitalized during her childhood years. She had measles when she was in grade 2. According to her

mother, she doesn’t have a complete immunization and she doesn’t have any allergies during her childhood.

B. FUNCTIONAL ASSESSMENT
 Functional Health Pattern Prior to hospitalization During Hospitalization
I. Health Perception and Health According to our patient, whenever she is sick, she only pray for her fast recovery When in hospital patient N.B. having her enough
Management and that she don’t take any kind of medicine, and she doesn’t even consult a meal in order to regain her energy loss during labor
physician. and delivery. She eat nutritious food to supply
adequate amount of nutrients needed by her body.
II. Nutritional and Metabolic Pattern According to our patient, when she got pregnant, she eats rice eight times a day When she gave birth, she only eat half cup of rice
excluding her snacks. every meal.

72 HOURS DIET RECALL

DATE BREAKFAST LUNCH DINNER
December Half serving Half cup Half cup
8, 2009 of Lugaw of rice of rice
2 glasses of 1 1 piece of
water serving fish and 1
of Pork serving
sinigang of
3 glasses noodles
of water
December Half cup of Half cup Half cup
9, 2009 Lugaw of rice of rice
2 glasses of 1 1 serving
water serving of
of pork ginataang
sinigang kalabasa
2 glasses 2 glasses
of water of water
December Half serving Half cup
10, 2009 of Pansit of rice
Half serving 1
of Lugaw serving
2 glasses of of Pork
water sinigang

III. Elimination Pattern

URINE STOOL URINE STOOL

5 times a day Once a day
FREQUENCY: 4 times a day 2-3 times a day Clear Green
COLOR: Clear Brown odorless Foul odor
ODOR: Odorless Foul Odor soft
CONSISTENCY: Soft

IV. Activity-Exercise Pattern Dancing is her only way of exercise No form of exercise. The client’s activity was spent
GROWTH AND DEVELOPMENT

Theorist Theory Stages Definition Explanation

12 years old—adulthood • The patient already

knew this stage but at
Freud Psychosexual Development Genital • Emerge of sexual the age of 19 years old,
interests and she was already
development of pregnant and this is not
relationship with the right time for
potential sexual having a child.
patterns.
18-25 years old As a 19 year old woman with a
twin children that are
• Develop commitments responsible. She attained
to others and to a life
Erikson Psychosocial Development Intimacy vs. Isolation productivity in regards to her
work.
study which is a 3rd year
college student. She already
recognized her individual
accomplishment as a mother
and as a student.

11+years old The client thinks more

systematically and deeply. She
• Able to see thinks about herself and not
relationships and to
Piaget Cognitive Development Formal Operations about the future of her child
reason in the abstract.
because she wants to finish her
study and she don’t really want
to have a child.

13+ years old She believes that trust is basis

for relationship. In this stage
• Individual understands the person words established
the morality of having
 democratically rules from authorities and the
established laws. reasons for decisions and
• It is “wrong” to violate behavior is that social and
other’s right. sexual rules and traditions
Level III: Post conventional • The person demand the response. But
understands the
Kohlberg Moral Development Stage 5: Social contract sometimes she doesn’t follow
principles of human
orientation rights and personal rules and regulations set by
conscience. Person government and other
Stage 6: Universal ethics
believes that trust is authorities like having a child
Orientation. basis for relationships. in her early age. There’s a rule
that if you are not in a right
age of having a child, first you
have to finish your study
before doing sexual intimacy
with your partner.

Adolescent The client says that during her

labor, it is GOD, the client
Fowler Stages of Faith Stage 3: Synthetic-Orientation • Questions values and herself, her family, friends and
Faith religious in an attempt
healthcare providers, provides
to form own identity.
her strength and trust.

PHYSICAL ASSESSMENT (OBSTETRIC)

 OBSTETRICAL HISTORY INITIAL PHYSICAL ASSESSMENT

a. Menarche: 14 yrs old d. LMP: Dec. 04, 2008 height:4’11’’ weight:47kg

b. EDC: Sept. 11, 2009 e. Trimester: Postpartum
c. AOG: 41 wks f. G: 5 P: 5 VITAL SIGNS
INITIAL PHYSICAL ASSESSMENT TPAL: 5-0-0-5

BP: 130/90 mmHg PR: 105 bpm RR:30rpm Temp:37.20C

Breast

1. size Equal [ ] Unequal [√ ] INITIAL PHYSICAL ASSESSMENT

2. shape Symmetrical[√ ] Asymmetrical[ ]
Remarks: ____________________ Fetal presentation: cephalic presentation Attitude: vertex

Nipples Fetal lie: LOA FHR: 140 bpm

Inverted [ ] Everted [√] Lump [ ] Engagement: engaged

Discharge: ___________________
SIGNS OF PREGNANCY
Color

Pinkish [√ ] Increased vein[√ ] First Trimester

Remarks: ____________________ 1. Presumptive signs Amenorrhea [√] Chadwick’s signs [√]

Abdomen Nausea & vomiting [√] Gonadotropic exams [√]

Linea Nigra[√ ] Striae Gravidarum[√ ] 2. Probable Signs Hegar’s sign [√] Goodell’s signs [√]

Other skin impairment [ ] Uterus within abdomen [√]

Remarks: ____________________ Changes in size, shape, & consistency of the uterus [√]

Perineum Secondary/Third Trimester

Scars [ ] Warts [ ] Rashes [ ] Quickening [√ ] date: October 23, 2006 Uterine enlargement apparent[√ ]
 Varicosities [ ] Discharge [√] Braxton Hick’s contraction [√] Chadwick’s sign [√]

Color: reddish Odor: fleshy Uterine soufflé [√] Melasma [√]

Appearance: moist Darkening of Areola of the nipples [√] Linea nigra [√]

Transparent [ ] Turbid [ ] Positive signs X-ray outline of the Fetal Skeleton [√]

Fetal movement felt by examiner [√]

Fetal heartbeat audible with stethoscope [√]

PHYSICAL ASSESSMENT

Patient: N. B. Date of Assessment:

 BODY AREAS TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS

A. GENERAL BODY PARTS

Body built Inspection and Proportionate; Varies with lifestyle
Observation

Posture Inspection Relaxed, Erect Posture Tense, bent posture, uncoordinated Deviation from normal due to
movement uncomfortably in her incision
on her abdomen

Overall hygiene and grooming Inspection and Clean and Neat Untidy and with presence of body Deviation from normal due to
Observation odor inability to take a bath

Body and breath odor Observation No presence of odor anywhere in the With presence of body odor Deviation from normal due to
body presence of body odor

Client’s attitude Observation Cooperative Cooperative while doing the Normal

procedure

Client’s mood/, emotional status Observation Appropriate to the situation The patient’s mood is appropriate to Normal
the situation

Quantity, quality, and Observation Understandable; moderate pace; exhibits Patient has understandable words and Normal
organization of speech thought association exhibits thought association

Vital Signs

1. Temperature Observation 36.5-37.50 C 370 C Normal

2. Pulse Rate Palpation 60-80 bpm 80 bpm Normal

20 cpm
3. Respiratory Rate Observation 12-21 cpm Normal

B. INTEGUMENTARY

Skin color Inspection Varies from light to dark brown Pallor Deviation from normal due to
blood loss

Uniformity of skin color Inspection Generally uniform except for the areas Her skin is uniform except for the Normal
 exposed to the sun areas exposed to sun

She has high pigmentation in her

neck, underarm, nipples and areola
Normal due to pregnancy

Presence of edema Palpation No presence of edema There is no presence of edema Normal

Skin moisture Palpation Moist in axilla and skin folds Has moisture especially in her Normal
underarm

Skin temperature Palpation Uniform varies with environment and Warm to touch Normal
climate

Skin turgor Palpation When pinched , skin springs back to Skin springs back to previous state Normal
previous state

C. NAILS

Plate shape (curvature and Inspection Convex curvature within 160˚ angle Has convex curvature Normal
angle)

Texture Inspection and Palpation Smooth Smooth texture Normal

Bed color Inspection Pink in color; vascular Pallor Deviation from normal due to
poor circulation

Blanch test Inspection and Palpation Prompt return of usual color in <4 Prompt return in 3 seconds Normal
seconds

D. HEAD

SKULL

Size, shape and symmetry Inspection Rounded (Normocephalic) and Normocephalic and symmetrical in Normal
symmetrical shape

Presence of masses, nodules and Inspection Smooth, Nodules and masses are absent. No presence of nodules Normal
depressions
 SCALP

Color and Appearance Inspection White in color; no dandruff With presence of dandruff and has Deviation from normal due to
oily scalp the presence of dandruff

Areas of Tenderness Palpation Smooth, Nodules and masses are absent. Rough Deviation from normal due to
rough texture of the scalp

Normal
No masses nor nodules

HAIR

Evenness of growth; Inspection Evenly distributed; no infection or Evenly distributed hair, no infestation Normal
infestation
Thickness or thinness Thick hair

E. FACE

Facial features Inspection Symmetric or slightly asymmetric facial The face has symmetric features Normal
feature

Facial Movements Inspection Symmetric Facial Movements Even facial movements Normal

F. EYES

EYEBROWS

Hair distribution. Alignment, Inspection Hair evenly distributed; symmetrically Hair evenly distributed; Normal
skin quality and movement aligned; has equal movements; no symmetrically aligned;
presence of lesions
Equal movement

EYELASHES

Evenness of distribution and Inspection Evenly distributed; no discharge; curl in Eyelashes are evenly distributed, no Normal
direction of curl outward direction discharge and curl in outward
direction

EYELIDS
Surface characteristics, position Inspection Pinkish; no visible sclera above corneas Skin intact, no charge, no Normal
in relation to the cornea; ability when lids open; lids closed discoloration
to blink; frequency of blinking symmetrically; 15-20 blinks per minute
Blinks 16 times per minute

CONJUNCTIVA

Bulbar conjunctiva (color, Inspection Transparent; no lesions; pinkish Conjunctiva is transparent, no lesions Normal
texture, presence of lesions) and pinkish

Palpebral conjunctiva (color, Inspection Shiny; smooth; pink in color Shiny, smooth, pale Deviation from normal due to
texture, presence of lesions) pale palpebral conjunctiva

SCLERA

Color and clarity Inspection Capillaries are sometime evident, sclera White in color Normal
appear white

CORNEA

Clarity and texture Inspection Transparent; smooth; shiny Transparent and shiny Normal

IRIS

Shape and color Inspection Rounded; light to dark brown in color; Rounded and black in color Normal
equal

PUPILS

1. Reaction to light Inspection Pupils equally round, react to light and Black in color, equal in size, round, Normal
accommodation smooth border, both pupils constrict
and dilate
When looking straight ahead, the client
2. Visual Fields Inspection can see objects in periphery

Extraocular Muscle Test Inspection Both eyes are coordinated in movement, Have coordinated movement Normal
moves in union with parallel alignments

G. EARS

Auricles
1. Color
2. Symmetry Inspection Color same as facial skin Color of the ears are slightly darker Deviated from normal
than facial skin
3. Texture and Elasticity
Inspection Symmetrical, auricle aligned with outer
canthus of the eye. Symmetrical, auricle aligned with normal
outer canthus of the eye.
Mobile , firm and not tender. Pinna
Inspection and Palpation recoils after it folded. Mobile , firm and not tender. Pinna
recoils after it folded.

Gross Hearing Acuity

1. Voice test Inspection Normal sound audible Normal voice tone audible Normal

H. NOSE

External Inspection Symmetric, no discharge No discharge or flaring, uniform in Normal

color

Nasal Septum Inspection Intact and in midline Septum is in midline and intact Normal

Pataency of Nasal Cavities Inspection Air moves freely as the client breathes Client breaths freely through her Normal
through the nares nares

Sinuses Inspection Not tender No tenderness Normal

I. MOUTH

Lips Inspection Uniform pink in color Smooth in texture, moist, no lesions Normal
but pale in color

Teeth Inspection 28-32 adult teeth Yellowish in color; with dental Deviation from normal due to
carries and with false teeth lack of oral hygiene

Mucosa Inspection Pink, without inflammation Pale in color, no lesions, moist and Normal
soft

Gums Inspection Pink gums; not tender; no lesions; no Light pink gums, moist and firm in Normal
 discharge texture

Uvula Inspection Positioned in the midline of soft palate Uvula is positioned in the middle if Normal
soft palate

J. PHARYNX

Mucosa Inspection No lesions Absence of lesions Normal

Tonsils Inspection Pink and Smooth; no discharge She has pink, smooth pharynx and no Normal
discharge

K. NECK

Neck Muscles Inspection Muscles equal in size, head centered; Equal size of muscle, head is Normal
coordinated, smooth movements with no centered; well coordinated
discomfort movements with no discomfort

Trachea Inspection Central placement in midline of neck, Position in the center, the spaces are Normal
spaces are equal in both side equal in both side

L. BREAST

Size, symmetry Inspection symmetrical Positive enlargement, equal in size, Normal due to pregnancy
symmetric

Areola Inspection color varies in every individual Round in shape and bilaterally the Normal due to pregnancy
same. Positive enlargement, dark
brown in color

Nipple Inspection Round, inverted; no discharge Round, everted and equal in size, Normal due to pregnancy
similar in color, both point in the
same direction, positive discharge is
present.

N. JUGULAR VEINS

Jugular veins Inspection Not visible and no lesions Not visible Normal

O. THORAX AND LUNGS

 Spine alignment Inspection Spine vertically aligned, spinal column is Her spine is vertically aligned and has Normal
straight straight spinal column

Breathing pattern Inspection Effortless, quiet Has effortless and quiet respirations Normal

P. MUSCULOSKELETAL MUSCLES

Size Inspection Equal in size on both sides of arm, thigh Size of both sides of arm, thigh and Normal
and calf calf are equal

Muscle tonicity Palpation Firm Muscle is firm Normal

Bones Inspection and palpation No deformities, edema or tenderness absence of deformities, no edema nor Normal
tenderness

Joints Inspection and palpation No deformities, edema or tenderness absence of deformities, no edema nor Normal
tenderness

Q. ABDOMEN

Skin Inspection Uniform color, no lesion Refused ---

Contour Inspection flat Refused ---

Tenderness Palpation No tenderness noted Refused ---

R. UPPER EXTREMITIES

Motor strength Inspection Equal strength on each body side Equal strength on each body side Normal

Muscle Tone Palpation Normally Firm Normally Firm Normal

Presence of lesions, deformities Inspection No lesion, no deformities No lesion, no deformities and no Normal
and varicosities tenderness
 S. LOWER EXTREMITIES

Motor strength Inspection Equal strength on each body side Equal strength on each body side Normal

Muscle Tone Palpation Normally Firm Firm Normal

Presence of lesions, deformities Inspection No lesion, no deformities No lesion, no deformities and no Normal
and varicosities tenderness

ANATOMY AND PHYSIOLOGY

Female reproductive system

Photograph of the vulva: A pictorial of the human female reproductive system. A pictorial of a non-lactating and lactating breast.

1. Pubic hair (shaved) 4. Labia majora

2. Clitoral hood 5. Labia minora

3. Clitoris 6. Perineum
FEMALE EXTERNAL REPRODUCTIVE ORGANS

Mons Pubis

The mons pubis is a softly rounded mound of subcutaneous fatty tissue beginning at the lowest portion of the anterior abdominal wall. Also known as the mons

veneris, this structure covers the front portion of the symphisis pubis after puberty. The mons pubis is covered with pubic hair, typically with the hairline forming at

transverse line across the lower abdomen. The hair is short in all women. The mons pubis protects the pelvic bones, especially during coitus.

Labia Majora

The labia majora are longitudinal, raised folds of pigmented skin, one on either side of the vulvar cleft. As the pair descends, they narrow and merge to form the

posterior junction of the perineal skin. Their chief function is to protect the structures lying between them.

Labia Minora

The labia minora are soft of skin within the labia majora that converge near the anus, forming the fourchette. Each labium minus has the appearance of shiny

mucous membrane, moist and devoid of hair follicles. The labia minora are rich in sebaceous glands, which lubricate and waterproof the vulvar skin and provide

bactericidal secretioins.
Clitoris

The clitoris, located between the labia minora, is about 5-6 mm long and 6-8 mm across. Each tissue is essentially erectile. The glands of the clitoris is partly

covered by the fold of skin called prepuce, or clitoral hood.

Urethral meatus and Paraurethral glands

The urethral meatus is located 1-2.5 cm beneath the clitoris in the midline of the vestibule: it often appears as a puckered, slitlike opening. At times the meatus is

difficult to visualize because of the presence of blind dimples or small mucosal folds. The paraurethral glands or Skene’s glands, open into the posterior wall of the

urethra close to its opening. Their secretions lubricate the vaginal opening, facilitating sexual intercourse.

Vaginal vestibule

The vaginal vestibule is a boat-shape depression and closed by the labia majora and visible when they are separated. The vestibule contains the vaginal opening, or

introitus, which is the border between the external and inter genitals

The hymen is a thin, elastic collar or semi-collar of tissue that surrounds the vaginal opening. The hymen essentially opening.

However, modern studies of female genital anatomy have revealed that the hymen surrounds rather than entirely covers the vaginal opening, and can be torn not

only through sexual intercourse but also through physical activity, masturbation, menstruation, or the use of tampons, thus dispelling old beliefs.
External to the hymen at the base of the vestibule are two small papular elevations containing the opening of the ducts of the vulvovaginal (Bartholin’s) gland. They

lie under the constrictor muscle of the vagina. This glands secrete a clear, thick, alkaline mucus that enhances the viability and motility of the sperm deposited at the

vaginal vestibule.

Perineal body

The perineal body is a wedge-shaped mass of fibromuscular tissue found between the lower part of the vagina and the anus.The superficial area between the anus

and the vagina is referred to as perineum. The muscles that meet at the perineal body are the external spinchter ani, both levator ani (the superficial and the deep

transverse perineal), and the bulvocarvernosus. These muscles mingle with elastic fibers and connective tissue in an arrangement that allows a remarkable amount of

stretching.

FEMALE INTERNAL REPRODUCTIVE ORGANS

The female internal reproductive organs are: the vagina, uterus, fallopian tube, and ovaries. These are trget organs for estrogenic hormones, and they play a unique

part in the reproductive cycle

Vagina

The vagina is a muscular and membranous tube that connects the external genital with the uterus. It extends from the vulva to the uterus to a position nearly parallel

to the pain of the pelvic brim. The vagina is often called the birth canal because it forms the lower part of the pelvis through which the fetus must pass during birth.

In the upper part of the vagina which is called the vaginal vault, there I is a recess or hallow around the cervix called the vaginal fornix. The upper 4th of the vagina

is separated from the rectum by the pouch of douglas. This deep pouch or recess is posterior to the cervix. The walls of the vagina are covered with ridges, or rugae

crisscrossing each other. These rugae allow the vaginal tissue to stretch enough for the fetus to pass through during child birth. The vagina has 3 functions; 1st serve

as the passage for sperm and for the fetus during birth; 2nd provide passage for the menstrual products from the uterine endometrium to the outside of the body; and

lastly, it protect against trauma from sexual intercourse and infection from pathogenic organisms.

Uterus

The uterus is a hallow, muscular, thick-walled organ shaped like an upside-down pear. It lies in the center of the pelvic cavity between the base of the bladder and

the rectum and above the vagina.

The uterus is divided into two major parts, an upper triangular portion called the corpus or uterine body and a lower cylindric portion called the cervix. The upper

2/3 of the uterus (the corpus or uterine body) composed of mainly of smooth muscle layer (myometrium). The lower third is cervix or neck. The rounded upper most

(dome shaped top) portion of the corpus that extends above the points of attachment of fallopian tubes is called the fundus. The elongated portion of the uterus

where the fallopian tubes enter is called the cornua. The isthmus is the portion of the uterus between the internal cervical OS and the endometrial cavity.
The isthmus takes on importance in pregnancy because it becomes lower uterine segment.

The function of the uterus is to provide safe environment for fetal development. The uterine lining is cyclically prepared by steroid hormones for implantation of the

embryo, a process known as nidation.

Uterine Corpus

The uterine corpus is made up of 3 layers. The outer most layers is the serosal layer or perimetrium which is composed of peritoneum. The middle layer is the

muscular uterine layer or myometrium this muscle uterine layer is continuous with the muscle layer of the fallopian tubes and the vagina. This continuity helps this

organs present a unified reaction to various stimuli-ovulation, or orgasm or the deposit of sperm to the vagina. The myometrium has 3 distinct layers of uterine

involuntary muscles. The outer layer, found mainly over the fundus is made up of longitudinal muscles that cause cervical effacement and expel the fetus during

birth. The thick middle layer is made up of interlacing muscle fibers in figure-8 pattern. The inner muscle layer is composing of circular fibers that form sphincter at

the fallopian tube attachment sites and at the internal OS. The internal OS sphincter inhibits the expulsion of the uterine contents during pregnancy but stretches in

labor as cervical dilation occurs. The sphincters at the fallopian tube prevent menstrual blood from flowing backward into the fallopian tube from the uterus. The

uterine contractions of labor are responsible from the dilatation\of the cervix and provide the major force for the passage of the fetus through pelvis and vaginal

canal at birth. The mucosal layer or the endometrium of the uterine corpus is the inner most layer. This single layer is composed of columnar epithelium, glands, and

stroma. The glands of the endometrium produce a thin, watery alkaline secretion that keeps the uterine cavity moist. This endometrial milk not only help sperm

travel to the fallopian tubes but also nourishes the developing embryo before it implants in the endometrium.
Cervix

The narrow neck of the uterus is the cervix it meets the body of the uterus at the internal OS and descends about 2.5 cm. to connect with the vagina at the external

OS. Thus it provides a protective entrance for the body of the uterus. Vaginal cervix appears pink and ends at the external OS. The cervical canal appears rosy red

and is lined with columnar ciliated epithelium, which contains mucus secreting glands. The cervical mucus has three functions, first is to lubricate vaginal canal;

second is to act as a bacteriostatic agent; to provide an alkaline environment to shelter deposited sperm from the acidic vagina.

At ovulation cervical mucus is clearer, thinner more profuse and more alkaline than at other times.

Fallopian Tubes

The two fallopian tubes, also known as the oviducts or uterine tubes, arise from each side of the uterus and reach almost to the sides of the pelvis, where they turn

toward the ovaries each tube is approximately 8 to13.5 cm long. A short section of each fallopian tube is inside the uterus; its opening into the uterus is only 1mm in

diameter, this linkage increase a woman’s biologic vulnerability to disease processes.

Each fallopian tube may be divided into three parts: the isthmus, the ampulla, and the infundibulum, or fimbria. The isthmus is straight and narrow, with a thick

muscular wall and an opening (lumen) 2 to 3mm in diameter. It is the site of tubal ligation, surgical pregnancy. Curve ampulla comprises the oute r 2/3 of the tube

the ampulla ends. The ampulla ends at the fimbria which is a funnel shaped enlargement with many projection, called fimbriae reaching out to the ovary. The

longest of these, the fimbria ovarica, is attached to the ovary to increase the chances of intercepting the ovum as it is released.
The wall of the fallopian tube is made up of 4 layers: peritoneal (serous), sub serous (adventitial), muscular and mucous tissues. The peritoneum covers the tube.

The sub serous contains the blood and nerve supply and the muscular layer is responsible for the peristaltic movement of the tube. The mucosal layer, immediately

next to muscular layer is composed of ciliated and non ciliated cell. The fallopian tube has 3 functions to provide transport for the ovary the uterus (transport time

through the fallopian tube varies from 3-4 days): to provide a site for fertilization: to serve as a warm, moist, nourishing environment for the ovum or zygote

(fertilized egg).

Ovaries

The ovaries are two almond shaped structures just below the pelvic brim. One ovary is located on each side of the pelvic cavity. The ovaries are composed of three

layers: the tunica albuginea, the cortex and the medulla. The tunica albuginea is dense and dull white and serves as a productive protective layer. The cortex is the

main functional part because it contains ova, graafian follicle, corpora lutea, the generated corpora lutea (corpora albicantia) and degenerated follicles. The medulla

is completely surrounded by the cortex can contain the nerves and the blood and the lymphatic vessels. Ovaries are the primary sources of the two important

hormones: the estrogen and the progesterone.

PATHOPHSIOLOGY

A. ALGORYTHM

Pregnant woman with blood pressure higher than 140/90mmHg

Before 20 weeks of Gestation After 20 weeks of Gestation

No/stable Proteinuria New/ proteinuria, dev’t of Proteinuria No Proteinuria

blood pressure/ HELLP syndrome

Preeclampsia Gestational HPN

Preeclampsia
 Eclampsia

A. EXPLANATION

The current concepts regarding the pathophysiology of eclampsia recognize that eclampsia is a multisystem disorder characterized by vasoconstriction,

metabolic changes, endothelial dysfunction, and activation of the coagulation cascade in conjunction with an inflammatory response. Women with

underlying microvascular disease, such as diabetes, hypertension, and collagen vascular disease, have a higher incidence of eclampsia.

Normal placental development involves progressive loss of the musculoelastic tissue in the spiral arteries that feed the vessels of the intervillous spaces,

which results in uterine blood flow increases of nearly 25% during the first trimester. This process of remodeling the maternal spiral arteries that

branch from the uterine artery is typically completed by 18-20 weeks' gestation.

this physiologic dilatation of the spiral arteries does not occur because the placental trophoblast cells do not invade the spiral arteries, resulting in

maintenance of narrow vessels with resultant placental hypoperfusion and ischemia. In severe cases, not only do the spiral arteries maintain their muscular

structure, but other pathologic changes also occur. Accumulation of fat-laden macrophages with fibrinoid necrosis (ie, acute atherosis), disruption of

the basement membranes, platelet deposition, mural thrombi, and proliferation of intimal and smooth muscle cells all decrease the luminal diameter.

The narrowed and damaged spiral arteries become thrombosed, resulting in placental infarction and necrosis. Uteroplacental blood flow is then reduced

by 50-75%. The anatomical reduction in blood flow may be complicated by vasospasm of the uteroplacental bed.
 The primary defect in preeclampsia appears to originate at the maternal-fetal interface (the placenta). Decreased placental perfusion is thought to lead

to fetoplacental ischemia. The ischemic placenta may produce circulating antiangiogenic factors that promote generalized maternal vascular

endothelium dysfunction, leading to systemic manifestations of preeclampsia. Associated abnormalities in clotting and platelet function contribute to

vasoconstriction and platelet adhesion and aggregation, as well as to the activation of coagulation factors that increase the risk of thromboembolic

formation.

The primary feature of preeclampsia, development of hypertension, occurs when normally extreme vasodilatation does not occur. Although cardiac

output increases 30-50%, the decreased peripheral vascular resistance (PVR) results in decreased BP, even in women with chronic hypertension. Women

who develop preeclampsia experience an increase in PVR and alterations in vascular sensitivity to endogenous hormones (eg, angiotensin II,

catecholamines, vasopressin). This increase in vascular reactivity to pressor hormones may be mediated, at least in part, through damage to vascular

endothelial cells, disrupting the normal prostaglandin balance.

The normal expansion of blood volume by 50% that occurs with pregnancy is decreased by 15-20% in patients with preeclampsia. This is the

result of diminished plasma volume, leading to the relative hemoconcentration observed in preeclampsia. The plasma volume abnormality involves a

redistribution of extracellular fluid, such that interstitial fluid volume is increased while the plasma volume is decreased. The hematocrit increases as

the severity of preeclampsia increases. Circulating blood volume is maintained by the increased vascular tone. Whether the vasospasm is the cause or
effect of the vascular endothelial injury is not known. Regardless, this injury likely results in the microangiopathic hemolysis and disseminated

intravascular coagulation that accompanies severe preeclampsia.

The complication of mild preeclampsia may lead to progression of severe preeclampsia and the complication of severe preeclampsia may now lead to

eclampsia which can cause tonic-clonic seizures/ convulsions.

REVIEW OF SYSTEM

Reproductive System
Uterus • Enlargement and thickening (hypertrophy) of the uterus; most marked in the fundus.
• At the level of umbilicus by the 20th weeks AOG, xiphoid by the 36th week; descends slightly during the last 3 weeks due to fetal
descent into the pelvis.
Cervix • Pronounced softening and cyanosis (due to increased vascularity, edema, hypertrophy and hyperplasia of cervical glands) –
Goodell’s sign
• Cervical plug formed by clot of thick mucus.
Ovaries • Ovulation ceases throughout pregnancy
vagina • Increase vascularity, hyperemia, and softening of perineum and vulva.
• Chadwick’s sign noted
• Vaginal mucosa increase in thickness, connective tissue loosen and small muscle cells hypertrophy
• Vaginal secretions increase; pH is 3.5-6 because of increased production of lactic acid (doderlein bacillus)
Breast • Tender and tingle in the early week of pregnancy
• Increased in size, larger in nipples, more pigmented
• Colostrum present by 2nd trimester
• Elevated glanda of Montgomery (hypertophic sebaceous glands)
Integumentary System
Striae gravidarum • Reddish, slightly depressed streaks in the abdomen wall, breast, and thighs.
Linea Nigra • Line of dark pigment extending from the umbilicus down the midline to the symphysis pubis.
Chloasma • “Mask of Pregnancy” are the brownish patches of pigment on the face.
Pigmentation • Pigmentary changes occur because of the melanocyte-stimulating hormone elevated from the second month of pregnancy.

Metabolic Changes
Weight Gain • Weight gain average is 11-13 kgs. (24-28 lbs)
• Fetus (3400 gm); Placenta (450 gm); Amniotic Fluid (900 gm); Uterus (1 gm); Breast Tissue (1400 gm); Blood Volume (1800 gm)
maternal stores (1800-3600 gm)
• Weight gain- steady, consistent is ideal; total of 24-28 lbs.
 • First trimester = 2-4 lbs; 12-14 lbs; Third trimester = 12-24 lbs; Third trimmest 8-12 lbs.
Water Metabolism • Average woman retains 6.5 liters of extra water during pregnancy.
Protein Metabolism • Fetus, uterus, and maternal blood re rich in protein.
Carbohydrate • Human Placental Lactogen, Estrogen, Progesterone, and Insulin produced by the placenta during pregnancy oppose the action of
Metabolism insulin during pregnancy.
• Pregnancy, potentially, can initiate diabetes, and DM may be aggravated by pregnancy.
• During pregnancy, there is “sparing” of glucose used by maternal tissues and a shunting of glucose to the placenta to the placenta for
use by bthe fetus.
Fat Metabolism • Fats are more completely absorbed during pregnancy; plasma lipid levrels increased during the second half of pregnancy.
Iron Metabolism • Iron requirement increases to 20-40 mg daily.
• During the last half of pregnancy, iron is transferred to the fetus and stored in the fetal liver.
Endocrine Changes
Placenta • Produces ESTROGEN, PROGESTERONE, HUMAN CHORIONIC GONADOTROPIN (hCG), HUMAN PLACENTAL
LACTOGEN (hPL)
Pituitary • Elevated estrogen and progesterone; suppressed LH, FSH, and Oxytocin.

Cardivascular
Changes
Heart • Heart is displaced upward by elevated diaphragm.
• There may be splitting of the first heart sound, with common systolic murmurs.

Circulation • Cardiac Volume increased by 40-50% causing slight cardiac hypertrophy and increased in cardiac output (cardiac output increases
when the woman turns from her back to her left side.
• (+) physiologic anemia
• Pulse rate increases 10-15 beats/minute during pregnancy
• Slight decrease in BP (30%) during the 2nd and 3rd trimester
• Hypertension – 140/90 or systolic increase of 30 mmHg or more above the baseline, diastolic rise 15 mmHg or more.
Hematologic • Total circulating red blood cells increases
 • Leukocyte count is elevated during labor
• Fibrinogen levels increase by 50% along with other clotting factors

Respiratory Changes
Ventilation • Hyperventilation occurs- increasing respiratory rate, tidal
• PCO2 lowers, causing mild respiratory alkalosis (that is compensated for by lowered bicarbonate concentration)
Diaphragm • Enlarging uterus elevates the diaphragm
Ureters • Ureters become dilated and elongated during pregnancy due to mechanical pressure.
GFR • GFR increases early in pregnancy
• Glucosuria may be evident because of decreased renal threshold for glucose
• Protein in the urine should be reported because it may be a sign of hypertensive disorder of pregnancy or renal problem

Changes in Physiologic System of a Eclamptic Person:

Integumentary • Edema generalized confided to face (periorbital) and fingers.

System
Metabolic Changes • Ptoteinuria (+) 1 g/day
• Weight gain- greater than 1 lb/wk
Cardiovascular • Hypertension 140/90 or systolic increase of 30mmHg more above the baseline, diastolic rise 15 mmHg or more.
Changes
Urinary Tract • Oliguria – absent output above 500 ml in 24 hrs.
Intra Uterine Growth • Absent
Retardation
DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic or Indication or Date Ordered and Results Normal Analysis and

Laboratory Purpose Date Results were Values Interpretation
Procedure released of Results
To determine infection or
Inflammation Pre- No infection or
WBC Count operation December 2, 2009 19.5 H 108/L 3.5-10.0 H 109/L inflammation
Assessment of the is present.
patient.
Decreased RBC count on
Pre-operation assessment pregnant is normal
RBC Count of December 2, 2009 4.23 1012/L 3.80-5.80 because of the increase in
The patient. plasma volume during
pregnancy.
The result indicates that a
1000 ml sample of
Pre-operation assessment blood contains 96 g of
Hemoglobin of December 2, 2009 133 g/L 110-165 L g/L hemoglobin. Decreased
the patient. hemoglobin on pregnant
is
normal because of their
increase in plasma.
. The result indicates that a
1000 ml sample of
Pre-operation assessment blood contains .29 g of
Hematocrit (%) of December 2, 2009 366 L 1/1 .350-.500 L 1/1 hemoglobin. Decreased
the patient. hematocrit on pregnant is
normal because of their
increasein plasma
volume.
Nursing Responsibilities during Different Laboratory Procedures

Before During After

 Explain to the patient that Ensure subdermal bleeding  If a hematoma develops at

the WBC test is used to detect an has stopped before removing pressure. the venipuncture site, apply warm
infection or inflammation. soaks. If the hematoma is large,
monitor pulses distal the venipuncture
 Tell the patient that the test site.
requires a blood sample. Explain who
will perform the venipuncture and  Inform the patient that he
when. may resume his usual diet, activity and
medicationsdiscontinued before the
White Blood Cell Count  Explain to the patient that test, as ordered.
he may experience slight discomfort
from the needle puncture and the  A patient with severe
tourniquet. leucopenia, they have little or no
resistance to infection and requires
 Inform the patient that he protective isolation.
should avoid strenuous exercise
for 24 hours before the test.
Also tell him that he should
avoid eating a heavy meal
before the test.
 If the patient is being
treated for an infection, advise him that
this test will be repeated to monitor his
progress.
  Notify the laboratory and
physician of medications the patient is
taking that may affect test results: they
may need to be restricted.

 Explain to the patient that  Ensure subdermal bleeding  If a hematoma develops at

RBC count is used to evaluate the has stopped before removing pressure. the venipuncture site, apply warm
number of RBCs and to detect possible soaks.
blood disorders.
 Tell the patient that the test
requires a blood sample. Explain who
will perform the venipuncture and
when.
Red Blood Cell Count
 Explain to the patient that
he may experience slight discomfort
from the needle puncture and the
tourniquet.
 Inform the patients that he
need not restrict foods and fluids.

 Ensure subdermal bleeding  If a hematoma develops at

has stopped before removing pressure. the venipuncture site, apply warm
 Explain to the patient that soaks.
the hbg test is used to detect anemia or
Hemoglobin polycythemia or to assess his response
to treatment.
 Tell the patient that the test
requires a blood sample. Explain who
 will perform the venipuncture and
when.
 Explain to the patient that
he may experience slight discomfort
from the needle puncture and the
tourniquet.

 Explain to the patient that  Ensure subdermal bleeding  If a hematoma develops at

hct is tested to detect anemia and other has stopped before removing pressure. the venipuncture site, apply warm
abnormal conditions soak.
 Tell the patient that the test
requires a blood sample. Explain who
will perform the venipuncture and
Hematocrit when.
 Explain to the patient that
he may experience slight discomfort
from the needle puncture and the
tourniquet.
 Inform the patients that he
need not restrict foods and fluids.
THE PATIENT AND HIS CARE

1. Medical Management

A. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy

Medical Date Ordered General Indication & Client Response

Management Description Purpose to Treatment
IVF 5% dextrose in lactated D5NM is administered by The patient responded well
D5LRS 1L ringers intravenous infusion for with no signs of irritation
30gtts/min Solution (Osmolarity of parenteral maintenance of and
527-hyprtonic, pH of 4.9) routine daily fluid and adverse reactions.
-provides calories and free electrolyte requirement with
water, provides electrolytes. minimal carbohydrates
Also contains sodium lactate calories and to correct or
which is used in treating replace fluid losses due to
mild to moderate metabolic change in the
acidosis. patient’s diet (NPO) and
during the cesarean
operation.
Nursing Responsibilities:

 Check the doctor’s order

 Explain the procedure to the patient

 Tell the patient that she might feel a discomfort from the tourniquet and the IV insertion

 Check and monitor IVF regulation and level of fluid

 Check if there is a need for removal and replacement of fluid

 Check if the tube is in the vein and signs of edema

 Check if there is a back-flow of blood

 Check if there is bubbles present in the tube

 Always Monitor V/S.

 B. Pharmacotherapy

Drugs Date Route of General action Indication with Adverse Reaction Nursing responsibilities
Generic administration purpose
name/
brand name

Cephalexin December Oral route First-generation Adults: 250 mg CNS: dizziness, Prior to During After
 2009 cephalosporin to 1 g PO 6 headache, fatigue, -Check for -Wait until -Instruct patient to report
that inhibits cell hours or 500 mg agitation, doctor’s patient for any adverse effects
wall synthesis, q 12 hours. confusion, order and swallow the such as; rush, diarrhea,
promoting Maximum of 4 hallucination. expired date drug properly yellow discoloration of
osmotic g daily. GI: anorexia, before before leaving the skin or eyes or lack of
instability; diarrhea, nausea, administrati the patient response
usually pseudomembranous on -May take 5 -Evaluate for
bactericidal. colitis, vomiting, -Check for meals for GI symptomatic
gastritis, abdominal patient upset improvement.
pain, oral impaired -Give patient
candidiasis. renal directed or
Other: anaphylaxis, function or complete
hypersensitivity severe prescription,
reaction, serum infection to obtain 5 R”s
sickness. know if you
increase
dose or
decrease

Drugs Date Route of General action Indication with Adverse Reaction Nursing responsibilities
Generic administration purpose
name/
brand name

Mefanamic December Oral route Aspirin- like Relief of post Gastrointestinal Prior to During After
acid 2009 500mg cap q 6 drug that has operative and experiences - Tell patient that
analgesic postpartum including drugs work best
antipyretic. pain. - abdominal pain, when taken
diarrhea, before pain
dyspepsia, flatulenc becomes severe.
e, gross bleeding/ -Recommend
perforation, heartbu abstinence from
rn, nausea, GI alcohol when
ulcers taking
(gastric/duodenal), medication.
vomiting, abnormal -Caution patient
renal function, ane that drug can
mia, dizziness, ede cause depen-
ma, dence.
elevated liver enzy
mes, headaches,
increased bleeding
time, pruritus,
rashes, tinnitus

Drugs Date Route of General action Indication with Adverse Reaction Nursing responsibilities
Generic administration Purpose
name/
brand name

Ferrous December PO Provides As a GI: nausea, Prior to During After

sulfate 2009 elemental iron, supplement epigastric pain, - Check for -Monitor -Tell patient to take
an essential during vomiting, the doctor’s hemoglobin tablets with juice
component in pregnancy 15- constipation, black order & drug level, (preferably orange
formation of 30 mg stool, diarrhea, expiration hematocrit, juice) or water, but not
hemoglobin. elemental iron anorexia. before and with milk or antacid.
PO daily during Other: temporarily administration reticulocyte -Advise patient to
last two stained teeth from -Ingestion of count. report constipation and
trimester. liquid forms. Calcium and change in stool color
iron and consistency.
supplements
with food can
decrease iron
absorption by
one-third.
Take between
meals.
-take a drug
history,
including
antacid use; or
any drugs
used that may
interact.
 Drugs Date Route of General action Indication with Adverse Reaction Nursing responsibilities
Generic administration Purpose
name/
brand name

Captopril December PO Action: Inhibits Hypertension: CNS: Dizziness, Prior to During After
2009 ACE, Adults: fainting, headache,
preventing Initially, 25mg malaise, fatigue, - Monitor -Inform -Tell patient that drug
conversion of PO b.i.d or t.i.d. fever. patient’s patient that causes the most frequent
angiotensin I to If dosage CV: Tachycardia, blood light- occurrence of cough,
angiotensin II, a control blood hypotension, angina pressure, headedness is compared with the ACE
potent pressure pectoris. and pulse possible, inhibitors.
vasoconstrictor. satisfactorily in GI: Abdominal rate especially
Less one or two pain, anorexia, frequently. during first
angiotensin II weeks, increase constipation, -Assess few days of
decreases it to 50 mg b.i.d diarrhea, dry patient’s therapy.
peripheral or t.i.d. If mouth, dysguesia, sign for
arterial dosage control nausea and angioedema.
resistance, blood pressure vomiting.
decreasing satisfactorily in Hematologic:
aldosterone another one or leukopenia,
secretion, which two weeks, agranulocytosis,
reduces sodium expect to add thrombocytopenia,
and water diuretic. If pancytopenia,
retention and patient needs anemia.
lower blood further blood Metabolic:
pressure. pressure hyperkalemia.
reduction Respiratory: dry,
dosage maybe persistent non-
raised to 150 productive cough,
mg t.i.d while dyspnea.
continuing Skin: urticarial
diuretics. rush,
Maximum daily maculopapular
dose is 450 mg. rush, pruritus,
alopecia.
Other: angioedema.
 Drugs Date Route of General action Indication with Adverse Reaction Nursing responsibilities
Generic administration Purpose
name/
brand name

Nifedipine December PO Thought to Vasospastic CNS: Dizziness, Prior to During After

2009 inhibit calcium Angina light-headedness,
ion influx (Prinzmetal or headache, -Monitor -Watch for -Advice patient to avoid
across cardiac variant angina), weakness, blood symptoms of taking drugs with
and smooth classic chronic somnolence, pressure heart failure. grapefruit juice.
muscle cells, stable angina syncope, regularly, -ALERT:
decreasing pectoris. nervousness. especially in Don’t use
contractility and CV: flushing, patients who capsules S.L
oxygen peripheral edema, take beta to rapidly
demand. Also heart failure, MI, blockers or reduce severe
may dilate hypotension, antihyper- high blood
coronary palpitations. tensive. pressure
arteries and EENT: nasal because the
arterioles. congestion. result maybe
GI: nausea, fatal.
diarrhea,
constipation,
abdominal
discomfort.
Musculoskeletal:
muscle cramps.
Respiratory:
dyspnea,
pulmonary edema,
cough.
Skin: rash, pruritus.
 C. Diet

Type of Diet Date Ordered, General Indication & Client

Date Performed, Description Purpose Response to
Date Administer Treatment
The patient is not allowed to This is done to prevent
NPO take alteration of the result of the The patient complied with
any oral food or liquid. fasting blood sugar.bcs intake the prescribed diet.
of food can increase glucose
level.
A diet of clear liquids This diet reduce stimulation of
maintains the digestive system, and
vital body fluids, salts, and leave no residue in the
minerals; and also gives some intestinal
Clear Liquid energy for patients when tract. This is why a clear liquid The patient complied with
Diet normal food intake must be diet is often prescribed the prescribed diet.
interrupted. Clear liquids are in preparation for surgery, and
easily absorbed by the body. is generally the first diet given
by mouth (NPO) for a long by mouth after surgery. Clear
time. This diet is also used in liquids are given when a
preparation for medical tests person has been without food
such as sigmoidoscopy, by
colonoscopy, or certain x-rays. mouth (NPO) for a long time.

D. Exercise

Activity General Description Purpose Date Order Client Response

Complete Bed Rest Prescribed maternal To provide adequate rest The client adhered to the order
complication of pregnancy with out complaints.
2. Surgical management

A. Description

Low transverse caesarian section is made in the non-contractile portion of the uterus and is the one most commonly used. The bladder must be dissected off the

lower uterine segment. It has a low chance of the uterine rupture in subsequent labor. Advantage of it is that a trial of labor in a subsequent pregnancy is safe; the

risk of bleeding and adhesions is less, and the disadvantage of it is that the fetus must be in longitudinal lie; the lower segment must be developed.

B. Patients response to operation

Before During After

The patient was obviously experiencing nervousness She was thinking about what will be the result of the Still, a little pain with a little discomfort was felt by
and pain, not because of the procedure to be done but procedure. She was completely worried for the the patient after the procedure.
because of the process of delivery. condition of her siblings.

C. Nursing care

Before During After

Explain the procedure to the client and place the Assist the physician during the operation. Instruct the client and her relatives to follow the
client in a lithotomic position. physician’s order and provide enough time to rest.
NURSING CARE PLAN

Assessment Diagnosis Inference Goals & Interventions Rationale Evaluation

Objectives

S: “Masakit padin Acute pain related Acute pain is an After 1-2 hours of Independent: After 1-2 hours of
yung tahi ko.” As to surgical incision unpleasant sensory nursing • Assess client’s • To nursing
verbalized by the as manifested by and emotional intervention, the attitude towards pain. evaluate intervention, the
patient. facial grimace, experience arising patient will be able client’s patient was able to
irritability and from actual or to tolerate the pain. response tolerate the pain.
O: sighing. potential tissue to pain.
 Irritability damage or • Encourage
 Sighing described in terms verbalization. • To
 Facial of such damage; minimize
Grimace sudden or slow pain.
 V/S Taken as onset of any
follows: intensity from mild • Encourage relaxation
to severe with an techniques such as • To lessen
BP: anticipated or breathing exercises. sensation
120/80mmHg predictable end of pain.
T: 37.1ºC and a duration of • Encourage use of
PR: 88bpm less than 6 months. diversional activities
RR: 18cpm like socialization with
others.
• To divert
• Provide quiet attention.
environment.
 • To
provide
additional
Dependent: comfort
Independent: and
• Administer lessen
medication PRN. anxiety.

• To relieve
pain
faster.
 Assessment Diagnosis Inference Goals & Objectives Interventions Rationale Evaluation
Independent:
Risk for infection Infection is an Short term Goal
S: Ø related to surgical increased risk for ●Assessment and ●To assess causative ●After 2 hours of
incision as being invaded After 2 hours of document skin Contributing factors. nursing intervention
O: manifested by pathogenic nursing intervention conditions at and the patient was be
 Increased increased organisms the patient will be around incision site. able to identify
environmenta environmental will be able to intervention to
l exposure to exposure to identify intervention ●Health teaching ●To prevent further prevent risk for
pathogen. pathogens, wound, to reduce/prevention about personal Development of infection
 wound redness and swelling. risk for infection hygiene practices possible infections.
 redness (eg. Hand washing)
 swelling Short term Goal
●Maintain adequate ●To maintain Goal met
After 2 days of hydration and wellness and boost
nursing intervention nutrition. (foods rich Immune response
the patient will be in vitamins
able to prevent especially zinc and
infection on the protein) ●After 2 days of
incision site. nursing intervention
Dependent : the patient was be
able to prevent
●Cleanse incision ●To maintain infection on the
wound site daily as cleanliness on the incision site
repaired. Use sterile wound site and
dressing. prevent transmission Goal met
of microorganisms

●Encourage to ●To alleviate pain

complete antibiotics
as prescribed by the
physician.
DISCHARGE PLANNING

Medications

Take the following medications as prescribed:

1. Cefalexin 500mg 1 cap thrice a day (8 am, 1 pm, 6 pm)

-Cefalexin is an antibiotic.

-Cephalexin may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

upset
 stomach

diarrhea

vomiting

mild skin rash

-It may cause an upset stomach. Take cephalexin with food or milk.
-Swallow whole and take with a full glass of water. Do not crush or chew.

- Continue to take cephalexin even if you feel well. Do not stop taking cephalexin without talking to your doctor.

2. Mefenamic Acid 500mg 1 cap thrice a day (8 am, 1 pm, 6 pm)

-Mefenamic acid is a non-steroidal anti-inflammatory drug used to treat pain.

-Its usual side effects are headache, nervousness and vomiting. Serious side effects may include diarrhea, bloody vomit, blurred vision, skin rash, itching and

swelling, sore throat and fever. It is advised to consult a doctor immediately if these symptoms appear while taking this medication

-Take with food or milk to prevent an upset stomach

-Drowsiness may occur so do not drink alcohol while taking this medicine.

-Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture

(not in the bathroom). Throw away any medication that is outdated or no longer needed.
3. Ferrous Sulfate 1 cap twice a day (8 am, 8 pm)

-Ferrous sulfate may cause side effects. Your stools will turn dark; this effect is harmless.

- Fish, meat (especially liver), and fortified cereals and breads are good dietary sources of iron; emphasize them in a well-balanced diet.

-Tell the doctor if either of these symptoms is severe or does not go away:

constipation

stomach upset

- Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture

(not in the bathroom). Throw away any medication that is outdated or no longer needed

4. Methylergometrine 1 cap thrice a day

- Oxytoxic drug, acts directly on the uterine smooth muscle to stimulate the rate, and amplitude of uterine contraction, induce in a rapid sustained tetanic, uterotonic

effect that shorten the third stage of labor and reduces blood loss, the uterine become more sensitive to the drug towards the end of pregnancy.

- used for management and prevention of postpartum and postbortal hemorrhage by producing firm uterine contraction and decreasing uterine bleeding
Environment / Exercise

- Increase physical activity and be independent as possible. This includes Personal Hygiene, getting in and out of bed, without assistance and walking.

- Spend time out of the bed each day. Get out of bed at least 2-3 times each day and walk for short distances or sit in a chair at the bedside to promote

circulation which prevents formation of blood clots and enhances healing.

- Avoid strenuous activity

- Riding in a car is allowed. Ride in an upright position with seatbelt fastened.

- Avoid bending from the waist. Bend with knees, keeping the back straight.

- Get enough sleep

- Stay in a calm free from noise environment.

Treatment

- Take the medications as prescribed and complete the course of anti biotics.
Health Teaching

- Encourage the client to practice a breastfeeding to her infant because of the advantages for both of them.

MOTHER:

* it is economical in terms of time, money, and effort.

* more rapid involution

* there are less incidence of breast cancer

BABY:

* to have a close relationship between mother and infant

* the milk of mother contains antibodies specially Immunoglobulin A that protect against common illness

* less incidence of gastrointestinal disorder

* also available at a light temperature

- Eat nutritious foods.

Outpatient

-See B. Bautista at Bulacan Maternity and Children’s Hospital for follow up check up two weeks after discharge.

Diet

-Eat a regular diet

-Consume foods rich in iron content such as meat (especially liver), and fortified cereals and breads which are good dietary sources of iron.

-Eat foods low in fiber content to reduce fecal mass and avoid intestinal

-Sample menu for one day:

 Breakfast

1/2 cup orange juice 1 egg (poached or egg substitute

1/2 cup skim milk or milk (2% fat) 1 two-inch slice of corn bread
1 teaspoon margarine or butter Hot, non-caloric beverage

Lunch

1 cup tomato juice 2 ounces broiled chicken

1/2 cup mashed potatoes 1/2 cup steamed kangkong
1 slice bread 1 banana
1 teaspoon margarine or butter 1 cup yogurt made from skim milk or
milk (2% fat)

Dinner

1/2 cup apple juice 1/2 cup steamed kangkong

1/2 cup white rice 1/2 cup steamed spinach
1 cup lettuce and peeled, seeded tomatoes 2 teaspoons oil and vinegar dressing
1 slice bread 1 teaspoon margarine or butter
1/2 cup skim milk or milk (2% fat) Hot, non-caloric beverage

- Include 6 to 8 cups of fluids, such as water, per day.

Spiritual

-Pray for a healthy life

-Attend mass every Sunday

CONCLUSION

Nurses can help the nation achieve National Health Goals. These goals speak directly to both fetus and the mother because pregnancy is a high risk

factor for them. Close monitoring in pregnant women and health teaching as much as possible about pregnancy could definitely reduce life threatening

complications.

Studies show that there is no certain facts that will give us the idea where pre-eclampsia arise. But there so many factors that could prevent this

complication such as diet modifications, proper compliance with the health care providers, proper exercise.And if the complication is already present, proper

monitoring, proper diet and drug compliance should be ruled in.

RECOMMENDATIONS

With this study, the student nurses were able to gain more knowledge and wider view and perspective of the complication of pregnancy which is pre-

eclampsia. Thus, the student nurses would like recommend and share some pointers on how to deal with different diseases with pregnancy specifically pre-

eclampsia.

To the government, primarily they should allocate sufficient budget to sustain and provide better facilities. They must be responsible enough to create

awareness program for care and management for all the Filipino people.

To the health care team, they should righteously implementing basic and ideal procedures regardless of the health care facilities where they belong.

They must observe and always remember to keep in line with their duties towards both the mother and the child during the pregnancy.

To the community and the family, that they must be insufficient coordination with the government and the health care team regarding promotion of

health before, during, and after the delivery of the baby.

BIBLIOGRPHY

Simply MCN Maternity Nursing, Jerome Balisnomo, RN, MAN, pages 179,181,189,

Fundamentals of Nusing, Delaune and Lander Book, pages 320-327