Foundation University

COLLEGE OF NURSING
Dumaguete City

Mission:

To enhance and promote a climate of excellence relevant to the challenges of the time, where individuals are committed to pursue new knowledge and life.

Vision:

Foundation University envisions itself as a dynamic, progressive environment that cultivates effective learning, generates creative ideas, response to societal
needs and offers equal opportunity for all.

Life Purpose:

To educate and develop individuals to become productive, creative, useful, and responsible citizens of the society.

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Core Values:

 Excellence
 Commitment
 Integrity
 Service

Central Objective

At the end of our one hour case presentation, the learners shall augment their knowledge, expand beginning skills, manifest positive attitude, and obtain
suitable values in the care of the patient who is in labor or about to deliver her newborn.

Specific Objectives

At the end of our case presentation, the learners will be able to:

 Define what is Pre-eclampsia and its classification

 Know the manifestation of Pre-eclampsia
 Enumerate the different signs and symptoms
 Present the anatomy and physiology of the system involved in relation to the condition of the patient
 Know the possible health teachings to be done to patients having pre-eclampsia
 Formulate and apply nursing care plans utilizing the nursing process

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 ACKNOWLEDGEMENT

We would like to take this opportunity to express our profound gratitude and deep regards to the persons who have contributed and supported the fulfillment
of our case study.

To Mr. John Robert General, RN, Dean, College of Nursing, for allowing us to have this exposure and for the all-out support.

To Ms. Kissie T. Largo, our clinical instructor, for the patience and time she extended in checking our paper works, for sharing suggestions and constructive
criticisms and for guiding us during the rotation, which meant so much for the completion of this study.

To our patient and to the SO, for being approachable, cooperative and for spending their time in answering all the questions being asked.

To our beloved family, for their unending emotional, moral, spiritual, and financial support.

And most of all, we would like to extend wholeheartedly the gratitude and praise to the author of knowledge and wisdom,

ever loving and merciful God for touching and bringing together those people who literally shared their abundant resources, talents, skills, time, and effort for the
completion of this study.

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The Student Nurses – II

January 9, 2019

Ms. Kissie T. Largo, RN

Clinical Instructor, Pedia Rotation
Foundation University College of Nursing
Dumaguete City

Dear Miss,

Greetings of peace and love!

We, Rexiey P. Amantillo, Annalee V. Ambos, Jehannah Mae Z. Callao and Maricon D. Duran, level II students of Foundation University College of Nursing,
currently in LR-DR Rotation at Negros Oriental Provincial Hospital, would like to apply for a case study regarding our client who had preeclampsia.
Our patient is M.R., 40 years old, and a resident of Dauin, Negros Oriental. She was admitted last February 18, 2019.
It is our privileged to conduct such study for this would enhance our knowledge, skills, and attitudes toward the delivery of our nursing care. With this, we would
like also to present information and share our learning to our fellow intellectual consumers through a case presentation after the study.
Thank you and we hope for your approval.

Respectfully yours,

ANNALEE V. AMBOS Approved by:

Group Representative
BS Nursing II MS. KISSIE T. LARGO, RN
Section A2 Clinical Instructor

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 INTRODUCTION

Preeclampsia, also referred as gestational hypertension, is a condition that pregnant women can get. A woman is said to have gestational
hypertension when she develops an elevated blood pressure (140/90 mmHg) but has no proteinuria or edema. The condition occurs in 5% to 7% of
pregnancies.(Pillitteri, 2014)

Ten million women develop preeclampsia each year around the world. Preeclampsia and related hypertensive disorders of pregnancy impact 5-
8% of all births in the United States. (World Health Organization, 2013)

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%. (Depratment of Health, 2014)

Based on the data from the Department of Health for 2015, Cebu City had 44, Mandaue City had three, and Lapu-Lapu City had five. Four cases
were also recorded in Cebu Province. Outside of Cebu, Bohol had 17, Siquijor had three, and Negros Oriental had 27. (Department of Health, 2015)

INTRODUCTION

Neck masses are bumps in the neck that can have many different causes. Sometimes they can be obvious and noticed by touching the neck. (Albany

Medical Center)

These cases were distributed into 166 (66%) midline, 55 (22%) lateral, and 31 (12%) entire neck masses. (J Oral Maxillofac Surg. 2007)

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 BRIEF DISCUSSION

Preeclampsia (PE) is a leading cause of maternal mortality and morbidity worldwide. It occurs in women with first or multiple pregnancies and is
characterized by new onset hypertension and proteinuria. Improper placentation is mainly responsible for the disease. If PE remains untreated, it moves towards
more serious condition known as eclampsia. Hypertension, diabetes mellitus, proteinuria, obesity, family history, nulliparity, multiple pregnancies and thrombotic
vascular disease contribute as the risk factors for PE. PE triggered metabolic stress causes vascular injury, thus contributing to the development of cardiovascular
disease (CVD) and/or chronic kidney disease (CKD) in future. This risk appears to be increased especially in women with a history of recurrent PE and eclampsia.
Clinically increased serum levels of sFlt-1 and decreased placental growth factor (PIGF) and vascular endothelial growth factor (VEGF) represent the severe
condition of PE. The clinical findings of sever PE are assorted by the presence of systemic endothelial dysfunction, microangiopathy, the liver (hemolysis, elevated
liver function tests and low platelet count, namely HELLP syndrome) and the kidney (proteinuria). The early detection of PE is one of the most important goals in
obstetrics. (Res, 2013)

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 Anatomy and Physiology
Integumentary System

The integumentary system consists of the skin, hair, nails, the subcutaneous tissue below the skin, and assorted glands.The most obvious function of the
integumentary system is the protection that the skin gives to underlying tissues. The skin not only keeps most harmful substances out, but also prevents the loss of
fluids.

A major function of the subcutaneous tissue is to connect the skin to underlying tissues such as muscles. Hair on the scalp provides insulation from cold for the
head. The hair of eyelashes and eyebrows helps keep dust and perspiration out of the eyes, and the hair in our nostrils helps keep dust out of the nasal cavities. Nails
protect the tips of fingers and toes from mechanical injury. Fingernails give the fingers greater ability to pick up small objects.

There are four types of glands in the integumentary system: sudoriferous (sweat) glands, sebaceous glands,
ceruminous glands, and mammary glands. These are all exocrine glands, secreting materials outside the cells and
body. Sudoriferous glands are sweat producing glands. These are important to help maintain body temperature.
Sebaceous glands are oil producing glands which help inhibit bacteria, keep us waterproof and prevent our hair and
skin from drying out. Ceruminous glands produce earwax which keeps the outer surface of the eardrum pliable and
prevents drying. Mammary glands produce milk.

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Epidermis
The outermost layer of the skin is composed of epithelial tissue and is known as the epidermis. It contains squamous cells or keratinocytes, which synthesize a tough
protein called keratin. Keratin is a major component of skin, hair, and nails. Keratinocytes on the surface of the epidermis lumenlearning2017
are dead and are continually shed and replaced by cells from beneath. This layer also contains specialized cells
called Langerhans cells that signal the immune system of an infection by presenting antigenic information to lymphocytes in lymphnodes. This aids in the
development of antigen immunity.

Dermis
The layer beneath the epidermis is the dermis. This is the thickest layer of skin composing almost 90 percent of its thickness. Fibroblasts are the main cell type
found in the dermis. These cells generate connective tissue as well as the extracellular matrix that exists between the epidermis and dermis. The dermis also contains
specialized cells that help regulate temperature, fight infection, store water, and supply blood and nutrients to the skin.

Hypodermis
The innermost layer of the skin is the hypodermis or subcutis. Composed of fat and loose connective tissue, this layer of the skin insulates the body and cushions
and protects internal organs and bones from injury. The hypodermis also connects skin to underlying tissues through collagen, elastin, and reticular fibers that
extend from the dermis.

A major component of the hypodermis is a type of specialized connective tissue called adipose tissue that stores excess energy as fat. Adipose tissue consists
primarily of cells called adipocytes that are capable of storing fat droplets. Adipocytes swell when fat is being stored and shrink when fat is being used. The storage
of fat helps to insulate the body and the burning of fat helps to generate heat. Areas of the body in which the hypodermis is most thick include the buttocks, palms,
and soles of the feet.

Accessory Structures:

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  Hair is a keratinous filament growing out of the epidermis. It is primarily made of dead, keratinized cells. Strands of hair originate in an epidermal
penetration of the dermis called the hair follicle.
 Nail is a specialized structure of the epidermis that is found at the tips of our fingers and toes. The nail body is formed on the nail bed, and protects the tips
of our fingers and toes as they are the farthest extremities and the parts of the body that experience the maximum mechanical stress. In addition, the nail
body forms a back-support for picking up small objects with the fingers. The nail body is composed of densely packed dead keratinocytes.
 Sweat Glands When the body becomes warm, sudoriferous glands produce sweat to cool the body. Sweat glands develop from epidermal projections into
the dermis and are classified as merocrine glands; that is, the secretions are excreted by exocytosis through a duct without affecting the cells of the gland.
There are two types of sweat glands, each secreting slightly different product.
 Sebaceous Gland is a type of oil gland that is found all over the body and helps to lubricate and waterproof the skin and hair. Most sebaceous glands are
associated with hair follicles. They generate and excrete sebum, a mixture of lipids, onto the skin surface, thereby naturally lubricating the dry and dead layer
of keratinized cells of the stratum corneum, keeping it pliable.

Melanin
Skin color is largely determined by a pigment called melanin but other things are involved. Your skin is made up of three main layers, and the most superficial of
these is called the epidermis. The epidermis itself is made up of several different layers.

The Role of Keratinocytes

People with darker skin have more active melanocytes compared to people with lighter skin. However, the pigment of our skin also involves the most abundant cells
of our epidermis, the keratinocytes. While melanocytes produce, store, and release melanin, keratinocytes are the largest recipients of this pigment. The transfer of
melanin from melanocytes to keratinocytes occurs thanks to the long tentacles each melanocyte extends to upwards of 40 keratinocytes. If a person is unable to
produce melanin, they have a condition called albinism.

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Skin Aging
Your skin changes as you age. You might notice wrinkles, age spots and dryness. Your skin also becomes thinner and loses fat, making it less plump and smooth.

Sunlight is a major cause of skin aging. You can protect yourself by staying out of the sun when it is strongest, using sunscreen with an SPF of 15 or higher, wearing
protective clothing, and avoiding sunlamps and tanning beds. Cigarette smoking also contributes to wrinkles. The wrinkling increases with the amount of cigarettes
and number of years a person has smoked.

Many products claim to revitalize aging skin or reduce wrinkles, but the Food and Drug Administration has approved only a few for sun-damaged or aging skin.
Various treatments soothe dry skin and reduce the appearance of age spots.

FEMALE REPRODUCTIVE SYSTEM

The female reproductive system is made up of the internal and external sex organs that function in reproduction of new offspring. In the human the female
reproductive system is immature at birth and develops to maturity at puberty to be able to produce gametes, and to carry a foetus to full term.

External Genitalia (vulva)

- Consist of the mons pubis, the labia majora and minora, the clitoris, the external urethral and vaginal
orifices, the hymen, and the greater vestibular glands.

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  Mons Pubis is a rounded fatty eminence overlying the pubic symphysis. mayoclinic2018

 Labia Majora two elongated, pigmented, hair-covered skin folds, which are homologous
 Labia Minora enclose of two smaller hair-free folds
 Perineum diamond-shaped region between the anterior end of the labial folds, the ischial tuberosities laterally, and the anus posteriorly.
 Clitoris is small protruding structure, homologous to penis. Like the counterpart, it is composed of highly sensitive, erectile tissue. It is hooded by skin folds
of the anterior labia minora, referred as the prepuce of the clitoris.
 Hymen vaginal opening is partially closed by thin fold of mucous, and is flanked by pea-sized, mucus-secreting greater vestibular glands.

Internal Organs

- Includes the vagina, uterus, uterine tubes, ovaries, and the ligaments supporting structures that suspend these organ in the pelvic cavity.

 Vagina extends for approximately 10cm (4inches) from the vestibule to the uterus superiorly. It serves
as a copulatory organ and birth canal and permits passage of the menstrual flow
 Uterus pear-shaped, situated between the bladder and the rectum, is a muscular organ with its narrow
end, the cervix, directed inferiorly. The major portion of the uterus is referred to as the body; its
superior rounded region above the entrance of the uterine tubes is the fundus. A fertilized egg is
implanted in the uterus, which houses the embryo of fetus during its development. In some cases, the
fertilized may implant in a uterine tube or even on the abdominal viscera, creating an ectopic

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lumenlearning2017
 pregnancy. The endometrium, the thick mucosal lining of the uterus, has a superficial function layer, or stratum functionalis, that sloughs off periodically
(about every 28 days) in response to cyclic changes in the levels of ovarian hormones in the woman’s blood. The sloughing-off process, which is
accompanied by bleeding, is referred to as menstruation, or menses. The deeper basal layer, or stratum basalis, forms a new functionalis after menstruation
ends.
 Uterine or fallopian, tubes are about 10 cm (4inches) long and extend from ovaries in the peritoneal cavity to the superolateral region of the uterus. The
distal ends of the tubes are funnel-shaped and have fingerlike projections is called fimbriae. Unlike in the male duct system, there is no actual contact
between the female gonad and the initial part of the female duct system – the uterine tube.
 Broad ligament is the fold that encloses the uterine tubes and uterus and secures them to the lateral body walls. The part of the broad ligament specially
anchoring the uterus is called the mesometrium and that anchoring the uterine tubes, the mesosalpinx. The round ligaments, fibrous cords run from the uterus
to the labia majora, and the uterosacral ligaments, which course posteriorly to the sacrum also help attach the uterus to the body wall. The ovaries are
supported medially by the ovarian ligaments (extendingfrom the uterus to the ovary), laterally by the suspensory ligaments, and posteriorly by a fold of the
broad ligaments,the mesovarium. The female gametes or eggs begin their development in saclike structures called follicles. The growing follicles also
produce estrogens. When a developing egg has reach appropriate stage of maturity, it is ejected from the ovary in an event called ovulation. The ruptured
follicle is then converted to a second time of endocrine structure called a corpus luteum,which secretes progesterone and some estrogens.

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Mammary Glands

- Mammary glands are the organs that, in the female mammal, produce milk for the sustenance of the young. These exocrine glands are enlarged and
modified sweat glands and are the characteristic of mammals which gave the class its name. Exist within the breast in both sexes but they normally have
a reproduction- related function only in females. The rounded, skin-covered mammary glands lie anterior to the pectoral muscle of the thorax, attached to
them by connective tissue. Slightly below the center of each breast is a pigmented area, the areola, which surrounds a centrally protruding nipple.
Interally each mammary gland consist of 15 to 25 lobes which radiate around the nipple and are separated by fibrous connective tissue and adipose, or
fatty tissue .Within each lobe are smaller chambers called lobules, containing the glandular alveoli that produce
milk during lactation . The alveoli of each lobule pass the milk into a number of lactiferous ducts, which join to
form an expanded storage chamber, the lactiferous sinus as they approach the nipple. The sinuses open to the
outside at the nipple.

lumenlearning2017

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CARDIOVASCULAR SYSTEM

The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the
heart, the blood vessel and the blood itself. The heart is the system’s pump and the blood vessels are like the delivery routes.
Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need
to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a
whole.

The heart’s job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of
the chest.

Structure of the Heart

The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium
is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a
special type of muscle called cardiac muscle.

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Chambers of the Heart

The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom
chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left atrium receives blood
from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles
pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The
ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body.

Blood Vessels

Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood
from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels
which connect to different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the
rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take
the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or
the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium.

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Valves

Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the
wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise
known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as the semilunar valves. The aortic valve is
found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body.
However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. (Myvmc2018)

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 Nursing History and Nursing Management
DEMOGRAPHIC PROFILE

NAME: M.R.
AGE: 40 years old
DATE OF BIRTH: August 28, 1978
SEX: Female
CIVIL STATUS: Single
NATIONALITY: Filipino
RELIGION: Roman Catholic
LMP: May 11, 2018
EDC: February 18, 2019
DATE OF ADMISSION: February 18, 2019
TIME: 1:00 a.m.
ATTENDING PHYSICIAN: Dr. Roleda

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 DEVELOPMENTAL TASK

Generativity versus stagnation is the seventh of eight stages of Erik Erikson’s theory of psychosocial development. This stage takes place during middle
adulthood between the ages of approximately 40 and 65. During this time, adults strive to create or nurture things that will outlast them; often by parenting children
or contributing to positive changes that benefit other people. Contributing to society and doing things to benefit future generations are important needs at the
generativity versus stagnation stage of development.

Generativity refers to "making your mark" on the world by caring for others as well as creating and accomplishing things that make the world a better place.
Stagnation refers to the failure to find a way to contribute. These individuals may feel disconnected or uninvolved with their community and with society as a
whole.

Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to
attain this skill will feel unproductive and uninvolved in the world. (Cherry, 2018 )

Correlation: Patient M.R is a 40 years old pregnant woman. She is a housewife and they are living together with her partner and they are currently living at Dauin,
Negros Oriental. Although she has already experienced giving birth, she has still the feeling of being scared but at the same time she is also very excited to welcome
her second baby. In correlation with Erik Erikson's Stages of Psychosocial Development (Generativity vs. Stagnation), the key characteristics of generativity include
making commitments to other people, developing relationships with family, mentoring others and contributing to the next generation. And as we all know, these
sorts of things are frequently realized through having and raising children and patient M.R is a mother of two already.

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CHIEF COMPLAINT: “Napakasakit nang aking panlikoran at tiyan” as verbalized by the patient.

HISTORY OF PRESENT ILLNESS: Patient has been diagnosed with gestational hypertension during her 5th month of pregnancy. She was taking her
maintenance medication as prescribed by the doctor, but she can’t recall the exact name of the drug. “Hindi ko masyado kabisado kung ano ang pangalan sa gamut
na pang high blood” as verbalized by the patient.
a. Location- abdomen
b. Quality- intermittent
c. Timing- upon uterine contraction
d. Quantity or Severity- not tolerable
e. Setting in which it occurs- upon contraction

GENERAL IMPRESSION: Received the patient on bed number 2 at the Delivery room, conscious, clenched fists and facial grimace. Restless and complaints of
pain in abdomen and lower back.

PAST HEALTH HISTORY: The patient has no surgery or injuries from the past. She is is asthmatic but has no known food/drug allergies.
FAMILY HISTORY: The patient has a history of leukemia and tuberculosis.
PSYCHOSOCIAL HISTORY: Patient is friendly and cooperative. She has a good relationship with her live in partner and family.

ENVIRONMENTAL HISTORY: Patient is living with his live in partner at Dauin, Negros Oriental. They live in a farm where his live in partner is working.

SPIRITUAL HEALTH: Patient’s religion is a Born Again Christian. According to the patient they seldom go to church.

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 COMPREHENSIVE HEALTH HISTORY AND PHYSICAL ASSESSMENT
General Survey:

Sate of Awareness: verbally responsive, coherent, alert and well oriented.

Obvious Signs of Distress: complaints of lower back and abdominal pain

Gait: non ambulatory

Posture: guarding position

Body Movements: well-coordinated movements.

Hygiene: poor hygiene noted, long fingernails and poor oral care.

Speech: coherent

Vital measurements:

Temparature: 37.5 celcius/ axilla

Pulse rate:

Respiratory rate:

BP: 150/100 mmHg

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INTEGUMENTARY SYSTEM

Health History

Doesn’t have any history of changes in the skin like lumps, sores, lesions that does not heal. Multiple scars noted on the legs and arms due to skin rashes and insect
bites. Dry skin noted on both arms and legs.

SKIN

Inspection
 The skin is dark brown, dry and the skin is generally warm.
 Multiple scars noted on the legs and arms at an average of 2 cm long.
 Dry skin noted.

Palpation

 The whole body is warm.

 Poor skin turgor noted.
 The IV insertion site was cold to touch. No tenderness when palpated except on the IV insertion site.
 No edema noted

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Nails

Inspection

 Fingernail plate has a convex curvature; angle of nail plate is about 160 degrees
 Has a brown pigmentation in longitudinal streaks.
 Intact epidermis on the surrounding nails noted.
 Fingernails and toe nails were not cut. It is slightly long.

Palpation

 Fingernails and toenails have a smooth texture.

 Capillary refill is less than 3 seconds (2 seconds).
 No tenderness when palpated.

Hair

Inspection

 Hair is black and evenly distributed.

 It is slightly thin and dry.

Palpation

 Tenderness of the scalp was noted upon palpation.

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Head

 There were no presence of lesions, deformities and lumps.

 Rounded normocephalic and symmetrical, smooth skull contour, still and upright, erect with no tremors.
 Absence of nodules or masses.

Face

 Contour: Oval shape, brown in color and has the same color with the rest of the body
 Symmetry: Symmetrical
 No edema noted.
 Absence of masses and pustules; no lesions noted.

Eyebrows

 Quantity: Equally distributed and curled slightly outward.

 No crusting or infestation.

Eyes

 Eyes clear and bright, in parallel alignment

 Skin intact with no discharges and no discoloration.
 No lesions.
 Sclera; appears white.

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  Eyelids; Lids close symmetrically and blinks involuntary.
 Eyeball; No protrusion beyond frontal bone.
 Lacrimal gland, Lacrimal sac, Nasolacrimal duct; No swelling. Redness or drainage.
 Bulbar conjunctiva; Transparent with capillaries slightly visible.

Ears

Inspection

 Normal shape and presence of landmarks; Helix, antihelix, antitragus, tragus and lobule.
 Drainage: cerumen is present.
 Absence of pits, creases or lesions.

Palpation

 Texture of the skin is smooth.

Nose

Inspection

 External structure of the nose was symmetrical, smooth, same color of the face with no deformity.
 Nasal mucosa, the color was pink and moist without lesions, there were no swelling, exudates and bleeding noted.
 Nasal Flaring noted.

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 Palpation

 Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness.

Mouth

 Lips; Dry lips noted.

 Teeth; dental carries noted
 Tongue; Central position, pink but with whitish coating which is normal, with veins prominent in the floor of the mouth.

Neck

 Positioned at the midline without tenderness and flexes easily. No masses palpated.

ABDOMEN

Health history

Had a normal vaginal delivery with her first baby nine years ago, no history of abortions. Defecates three times a week, preferably in the morning. No difficulties
and discomforts upon defecating as claimed.

Inspection

 The skin was brown with linea nigra and striae (stretched marks) noted.
 Abdomen is round and tender.

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Light palpation

 Uterine contractions noted.

CARDIOVASCULAR SYSTEM

Health History

Patient is asthmatic and a history of leukemia and Tuberculosis. Her activities include cleaning the house and farming. There were no known as other heredofamilial
disease in the family.

Inspection

 Pulsation was visible on the apical area, which was found on the

MUSCULOSKELETAL SYSTEM

Health History

Has no known history of muscle or skeletal injury. Patient does not have any limitations in performing her daily activities in terms of musculoskeletal problems.

Inspection

 Arms and legs were symmetrical upon inspection

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  Muscles are equal in size on both sides of the body.
 No deformities noted.

Palpation

 No joint swelling noted.

 No tenderness was reported when palpated.

NEUROLOGIC SYSTEM

Health History

The patient has no known problems of the neurologic system.

Language

 Coherent
 Proper response was elicited from the patient upon questioning.
 No abnormal speech patterns noted.

Orientation

 Oriented to people, time and place.

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Level of Consciousness

 Responded to questions spontaneously

 Maintained eye contact

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 Gordon’s Functional Health Pattern
Source of Information: M.R.

USUAL INITIAL
February 19,2019 February 19, 2019
I. Health Perception- Health Management
Pattern

 General Health  Perceives self as generally VITAL SIGNS:

 Health Practices healthy  Temperature:
 Concerns about Illness  Exercises by cleaning the house  Pulse Rate:
 Responsibility for health and gardening.  Respiratory rate:
restoration and maintenance.  She has no known food allergies  Blood pressure:
 She is responsible for her health  “Napakasakit nang aking tiyan
restoration and health at panlikuran” as verbalized by
maintenance by eating healthy the patient.
foods like fruits and vegetables  Rated pain at 10, 10 being the
and takes OTC medications highest and 0 being the lowest.
when is sick.  Guarding behavior
 Facial grimace

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  Uses “nilagang Tanglad” as her  Clenched fists
herbal medicines.  Restless
 Last menstrual period was  Takes medications as ordered by
 Last prenatal checkup was the physician.
December 5,2018

II. Nutritional- Metabolic Pattern

 Daily Food/Fluid Intake  Breakfast: she usually eats 1  “May gana naman akong
cup rice, 1 dried fish, 1 fried kumain” as verbalized by the
egg, 1 fried fish 1 bowl patient.
vegetable soup and coffee.  “Mahilig talaga ako sa sabaw
 Lunch:1 bowl vegetable soup, at gulay” as verbalized by the
1 cup rice, 1 fried fish, 1 small patient.
banana.  Long and dirty fingernails
 Snacks: 1 cup coffee, I piece noted and skin has a poor
cooked banana or kamote. turgor with hair untied.
 Dinner: 1 cup rice, 1 bowl
vegetable soup, 1 dried fish.
 She usually drinks 6 glasses of
water everyday

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  Weight loss/gain  She did not experienced sudden
weight loss for the past 6
months.
 Apetite  Appetite is good
 Dietary restrictions  No known for any food
allergies
 Healing potential of skin  Wounds and skin lesions heal
wounds/lesions accordingly.
 She doesn’t wear dentures but
there are dental caries was
observed.
 General body status  General body condition is
healthy.
III. Elimination Pattern
 Bowel Elimination pattern/problem  Did not experience elimination  “Hindi pa ako nakapag tae
of bowl difficulty; moves bowel ngayong araw” as verbalized by
every day with soft, formed and the patient.
brown stool.
 Urinary elimination  Did not experience urinary  “Isang beses pa lang ako naka
pattern/problem elimination difficulty, urinates at ihi” as verbalized by the patient.

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 least 1 liter a day with yellow
color urine, no foul odor and  Fluid intake is approximately
blood noted. 200 ml

 Perspiration pattern/problem  Normally perspires when doing  “Pinagpwisan ako nang marami
strenuous activities like kasi ang init nang aking
household chores. pakiramdam” as verbalized by
the patient.

IV. Activity-Exercise Pattern

 Energy Level  Rates energy level at 8 (0 being  Rates energy level at 4 (0 being
the lowest and 10 is the highest) the lowest and 10 is the highest)
 Exercise Pattern  Doing the household chores in “napagud ako sa panganganak ,
the morning as exercise. kinapus ako nang hininga” as
verbalized by the patient.
 Perceived Ability Feeding: 0 Grooming: 0 Feeding: 2 Grooming: 2
Bathing: 0 General mobility: 0 Bathing: 2 General mobility: 2
Toileting: 0 Cooking: 0 Toileting: 2 Cooking: 2
Home Maintenance: 0 Bed mobility: 0 Home Maintenance: 2 Bed mobility: 2

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 Dressing: 0 Shopping: 0 Dressing: 2 Shopping: 2

Functional Level Codes: Functional Level Codes:

 Level 0 – full self-care  Level 0 – full self-care
 Level I- requires use of equipment or  Level I- requires use of equipment or
device device
 Level II- requires assistance or supervision  Level II- requires assistance or supervision
from another person from another person
 Level III- requires assistance or supervision  Level III- requires assistance or supervision
from another person and equipment or from another person and equipment or
device device
 Level IV- is dependent and does not  Level IV- is dependent and does not
participate participate

 Leisure: watching T.V.  Able to move her body on

desired position.

V. Sleep-Rest Pattern
 Sleep problems  Wakes up at 5:00 a.am. and goes  “Hindi ako masyadong
 Rested/not rested after sleep to bed at 9:00 in the evening makapahinga dito sa ospital kasi

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 and 7:00 .am. eats breakfast . may maraming tao” as
 Eats lunch usually at 12:00 verbalized by the patient.
noon.
 Did not experience any sleep
problem.
 Feels rested upon waking up
 Use of sleeping aids  Does not use any sleeping aids

VI. Cognitive and Perception Pattern

 Sensory status  Visual: uses eye glasses.  Uses eye glasses.
 Memory  Auditory: auditory is  Sense of hearing, taste, smell,
 Intelligence exceptionally clear touch are good.
 Pain/discomfort  Olfactory: sense of smell is  No memory gap
excellent.  Experiencing pain on her
 Tactile: touch is sensitive. episiotomy. PAIN SCALE: 4(10
 Gustatory: can clearly tastes is the highest and 0 is the lowest
salty, sour, bitter, sweet and or no pain at all)
spicy.
 No memory gap
 No discomfort or pain

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 VII. Self-Perception Self Concept Pattern
 Body image  She is satisfied and happy.  “Natakot ako nung una kasi
 Self esteem  She is satisfied with her body hindi ako marunong umire” as
 Emotional state image. verbalized by the patient.
 She is a bit shy because she  “Masaya ako nang makita ko
doesn’t know how to speak ang aking anak” as verbalized
Cebuano/Bisaya. by the patient
 She knows how to handle
emotions.

VIII. Role Relationship Pattern

 Living arrangement  Currently living with her live in  “Kami lang dalawa nang asawa
 Family/significant others partner in the farm. ko kasi nasa Bicol lahat nang
 Communication  Close relationship with family kapatid ko” as verbalized by the
 Role and responsibilities in family and friends patient.

 Socialization  They communicate with her  “Boss nang aking asawa ang

 Finance siblings through calling. magbabayad nang lahat ng

 She also socializes with gastosin dito sa ospital” as
neighbors and friends. verbalized by the patient.

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  Her live in partner is working as
maintenance in the farm and he
is responsible for the financial
needs.
IX. Sexuality-Sexual Pattern
 Sexual relations  Verbalized that she sexually  G:1,T:0,P:0,A:0,L:0
 Sexual satisfaction active with her live in partner.  LMP: May 11, 2018
 Contraceptive  No sexual problems  EDC: February 18, 2019
 Reproductive/menstrual history  Doesn’t use an contraceptives  AOG:
 Menarche: 13 years old
 G:2,T:1,P:1,A:0,L:1

X. Coping-Stress Tolerance Pattern

 Stressors  Her stressors are financial  “Nalungkot talaga ako nang
 Coping mechanisms problem hindi ko kaya ilabas ang aking
 Major life changes  Her coping mechanism s toward anak dahil kinapos ako nang
 Problem management stress is she will do gardening hininga” as verbalized by the
and pray. patient
 She usually talked and shares  She was able to get financial
her problems with her live in assistance from her live in

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 partner. partner’s boss.
 She doesn’t use drugs, smoke
and drinks alcoholic beverages.

XI. Value-Belief Pattern

 Satisfaction with life  She is thankful and happy with   “Naniniwala ako na makakaraos
 Spiritually/religious beliefs her life din kami sa tulong nang Diyos”
 Religious practices  She is a religious person and as verbalized by the patient.
 Conflicts goes to church often.  “Hindi ako pinabayaan ng
 Believes that healing comes Diyos” as verbalized by the
with prayer. patient.
 Born Again Christian
 Does not have any religious
conflicts.

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 Genogram

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 Nursing Care Plan or M.R
Cues & Evidences Nursing Diagnosis Objectives Interventions Rationale Evaluation

SUBJECTIVE: Knowledge deficit Within our 4 hours Independent  Based on Maslow’s At the end of our 4 hours
related to lack of health teaching, the theory, basic physical health teaching, the patient
“May plano pa akong information resource patient will be able to: 1. Render physical needs must be was able to:
magka-anak ulit…” as comfort for the addressed before the
verbalized by the patient patient education.
patient.  Exhibit ability to Ensuring physical  Exhibited ability to
“depende sa kanya deal with health comfort allows the deal with health
[husband]”..she added situation and patient to concentrate situation and remain
remain in on what is being in control with life =
control with life discussed or UNMET
OBJECTIVE: demonstrated.
 Identify the risks  Identified the risks of
of advance 2. Grant a calm and  Allows the patient to advance maternal age
maternal age peaceful concentrate and focus = UNMET
environment more completely
 Verbalize sense without  Verbalized sense of
of understanding interruption understanding =
UNMET

3. Provide  Increases
information understanding of the
related to high- impact of high-risk
risk pregnancy, pregnancy on the
including clear, patient.
simple
explanations of
changes and
maternal and
fetal

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 implications.

4. Consider what is  Allowing the patient

important to the to identify the most
patient important content to
be presented first is
the most effective

5. Explore the  Helps to understand

reactions and how the learner may
feelings about respond to the
the changes information and
possibly how
successful the patient
may be with the
expected changes

6. Encourage  Questions facilitate

questions open communication
between patient and
health care
professionals and
allow verification of
understanding of
given information

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 CUES & NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
EVIDENCES DIAGNOSIS
INDEPENDENT:
SUBJECTIVE: Ineffective breathing After 4 hours of  Elevated head of  Elevation of the bed After 4 hours of nursing
pattern related to nursing intervention the head about facilitates respiratory intervention the client
 Madali akong shortness of breath the client will 30 degrees and function by use of manifested lessened
kapusin nang experience lessened ask the client to gravity. It also difficulty of breathing as
hininga.”as difficulty of breathing dorsal recumbent decreases pressure on manifested by decreased in
verbalize by the as manifested by position. the abdomen. RR from 27 cpm to 20 cpm
patient” decreased in RR from  Encourage deep  Promote chest with the absence of nasal
27 cpm to 20 cpm with breathing expansion flaring, and presence of
OBJECTIVE: the absence of nasal exercises calm breathing.
flaring, and presence  Monitored  Assesses the
 Shortness of of calm breathing. respiratory condition of the Goal met.
breath patterns client
 Rapid shallow including rate,
breathing depth, and effort.
 RR: 27 cpm
 Nasal flaring

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CUES & EVIDENCES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Pain related to uterine Within our 4 hours INDEPENDENT: Within our 4 hours
“Masakit ang aking contraction secondary to holistic nursing care, the holistic nursing care, the
tyan…” as verbalized by true labor. client will be able to 1. Monitor vital - To know baseline data client was be able to
the patient. report pain at signs. report pain at
manageable level as manageable level as
evidenced by: 2. Evaluate degree - To have a better evidenced by:
of discomfort. understanding
OBJECTIVES: regarding the
physiological changes
- Guarding - Eliminate and the attitudes and - Eliminated guarding
behavior guarding reactions to pain. behavior (UNMET)
behavior
3. Incorporate - To let the patient
- Facial grimace - Eliminate facial health teaching know about the -Eliminated facial
grimace regarding preferable diet for her grimace (UNMET)
modification of condition.
- Restless - Diminish diets. - Diminished
restlessness restlessness (UNMET)

- Uterine
contraction

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 DRUG STUDY

Generic name: HYDRALAZINE HYDROCHLORIDE

Brand name: Alazine, Apresoline
Classifications: CARDIOVASCULAR AGENT; NONNITRATE VASODILATOR; ANTIHYPERTENSIVE

Actions: Reduces BP mainly by direct effect on vascular smooth muscles of arterial-resistance vessels, resulting in vasodilation. Has little effect on venous-
capacitance vessels. Hypotensive effect may be limited by sympathetic reflexes, which increase heart rate, stroke volume, and cardiac output.

Therapeutic Effects :Diastolic response is often greater than systolic response. Vasodilation reduces peripheral resistance and substantially improves cardiac
output, and renal and cerebral blood flow. Postural hypotensive effect is reportedly less than that produced by ganglionic blocking agents.

Uses: Most commonly in stepped-care approach to treat moderate to severe hypertension. Also in early malignant hypertension and resistant hypertension that
persists after sympathectomy.
Contraindications: Coronary artery disease, mitral valvular rheumatic heart disease, MI, tachycardia, SLE. Safe use during pregnancy (category C) or lactation is
established.

Adverse Effects:
 Body as a Whole: Hypersensitivity (rash, urticaria, pruritus, fever, chills, arthralgia, eosinophilia, cholangitis, hepatitis, obstructive jaundice).
 CNS: Headache, dizziness, tremors. CV: Palpitation, angina, tachycardia, flushing, paradoxical pressor response. Overdose: arrhythmia, shock.
 Special Senses: Lacrimation, conjunctivitis. GI: Anorexia, nausea, vomiting, diarrhea, constipation, abdominal pain, paralytic ileus.
 Urogenital: Difficulty in urination, glomerulonephritis. Hematologic: Decreased hematocrit and hemoglobin, anemia, agranulocytosis (rare).
 Other: Nasal congestion, muscle cramps, SLE-like syndrome, fixed drug eruption, edema.

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NURSING IMPLICATIONS
Assessment & Drug Effects
 Make baseline and periodic determinations of BUN, creatinine clearance, uric acid, serum potassium, blood glucose, and ECG.
 Monitor BP and HR closely. Check every 5 min until it is stabilized at desired level, then every 15 min thereafter throughout hypertensive crisis.
 Monitor I&O when drug is given parenterally and in those with renal dysfunction.

Patient & Family Education

 Monitor weight, check for edema, and report weight gain to physician.
 Make position changes slowly and avoid standing still, hot baths/showers, strenuous exercise, and excessive alcohol intake.
 Do not breast feed while taking this drug without consulting physician.

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Generic Name: METHYLDOPA
Brand Name: Aldomet, Apo-Methyldopa , Dopamet , Novomedopa
Classifications: CARDIOVASCULAR AGENT; CENTRAL-ACTING, ANTIHYPERTENSIVE; AUTONOMIC NERVOUS SYSTEM AGENT; ALPHA-
ADRENERGIC AGONIST (SYMPATHOMIMETIC)

Actions: Structurally related to catecholamines and their precursors. Has weak neurotransmitter properties; inhibits decarboxylation of dopa, thereby reducing
concentration of dopamine, a precursor of norepinephrine. It also inhibits the precursor of serotonin.

Therapeutic Effects: Lowers standing and supine BP, and unlike adrenergic blockers, is not so prone to produce orthostatic hypotension, diurnal BP variations, or
exercise hypertension. Reduces renal vascular resistance; maintains cardiac output without acceleration, but may slow heart rate; tends to support sodium and water
retention.

Uses: Treatment of sustained moderate to severe hypertension, particularly in patients with kidney dysfunction. Also used in selected patients with carcinoid
disease. Parenteral form has been used for treatment of hypertensive crises but is not preferred because of its slow onset of action.

Contraindications: Active liver disease (hepatitis, cirrhosis); pheochromocytoma; blood dyscrasias. Safety during pregnancy (category C) is not established.

Cautious Use: History of impaired liver or kidney function or disease; angina pectoris; history of mental depression; lactation; young or older adult patients.

Adverse Effects
 Body as a Whole: Hypersensitivity (Fever, skin eruptions, ulcerations of soles of feet, flu-like symptoms, lymphadenopathy, eosinophilia).

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Nursing Implications
Assessment & Drug Effects
 Check BP and pulse at least q30min until stabilized during IV infusion and observe for adequacy of urinary output.
 Monitor fluid and electrolyte balance and I&O. Report oliguria and changes in I&O ratio. Weigh patient daily, and check for edema because methyldopa
favors sodium and water retention.
 Be alert to and report symptoms of mental depression (e.g., anorexia, insomnia, inattention to personal hygiene, withdrawal). Drug-induced depression may
persist after drug is withdrawn.

Patient & Family Education

 Avoid potentially hazardous tasks such as driving until response to drug is known; drug may affect ability to perform activities requiring concentrated mental
effort, especially during first few days of therapy or whenever dosage is increased.
 Do not to take OTC medications unless approved by physician.
 Do not breast feed while taking this drug without consulting physician.

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 Pathophysiology of Preeclampsia

Predisposing Factors
Precipitating Factors
40 years old
High in sodium
Parity
Hypertension

Failure of conversion of
spinal arteries to
vascular sinuses
Placental ischemia

Placenta produces thromboplastins causing DIC, retin

causing vasoconstriction

Fetal growth
retardation
Poor renal perfusion
Hypertension
Proteinuria
edema Preeclampsia

If untreated

Poor renal perfusion

Hypertension Eclampsia
Proteinuria
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edema
 NURSING THEORY
Orem’s self-care theory defined is “The act of assisting others in the provision and management of self-care to maintain or improve human functioning at
home level of effectiveness.” It focuses on each individual’s ability to perform self-care, defined as “the practice of activities that individuals initiate and perform on
their own behalf in maintaining life, health, and well-being.”

The assumptions of Dorothea Orem‘s Self-Care Theory are: (1) In order to stay alive and remain functional, humans engage in constant communication and
connect among themselves and their environment. (2) The power to act deliberately is exercised to identify needs and to make needed judgments. (3) Mature human
beings experience privations in the form of action in care of self and others involving making life-sustaining and function-regulating actions. (4) Human agency is
exercised in discovering, developing, and transmitting to others ways and means to identify needs for, and make inputs into, self and others. (5) Groups of human
beings with structured relationships cluster tasks and allocate responsibilities for providing care to group members.

Correlation: Dorothea Orem’s self-care theory focuses more on maintaining life, health and the well-being. As student nurses, we provide our most therapeutic care
to our patient and to compensate for the patient’s inability to engage in self-care when the patient needs continuous guidance.

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 Annotated Readings
What Is Preeclampsia?

Formerly called toxemia, preeclampsia is a condition that pregnant women develop. It's marked by high blood pressure in women who haven't had high blood
pressure before. Preeclamptic women will have a high level of protein in their urine and often also have swelling in the feet, legs, and hands. This condition usually
appears late in pregnancy, though it can happen earlier.

If undiagnosed, preeclampsia can lead to eclampsia, a serious condition that can put you and your baby at risk, and in rare cases, cause death. Women with
preeclampsia who have seizures are considered to have eclampsia.

There's no way to cure preeclampsia except for delivery, and that can be a scary prospect for moms-to-be. Even after delivery, signs and symptoms of preeclampsia
can last for 1 to 6 weeks.

But you can help protect yourself by learning the symptoms of preeclampsia and by seeing your doctor for regular prenatal care. Catching preeclampsia early may
lower the chances of long-term effects for both mom and baby.

What Causes Preeclampsia?

The exact causes of preeclampsia and eclampsia -- a result of a placenta that doesn't function properly -- are not known, although some researchers suspect poor
nutrition or high body fat can be potential contributors. Insufficient blood flow to the uterus could be associated. Genetics plays a role, as well.

Who Is at Risk for Preeclampsia?

Preeclampsia is most often seen in first-time pregnancies, in pregnant teens, and in women over 40. While it is defined as occurring in women have never had high
blood pressure before, other risk factors include:

 A history of high blood pressure prior to pregnancy

 A history of preeclampsia
 Having a mother or sister who had preeclampsia

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  A history of obesity
 Carrying more than one baby
 History of diabetes, kidney disease, lupus, or rheumatoid arthritis

What Are the Signs and Symptoms of Preeclampsia?

In addition to swelling, protein in the urine, and high blood pressure, preeclampsia symptoms can include:

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

 Abdominal pain
 Severe headaches
 Change in reflexes
 Reduced urine or no urine output
 Dizziness
 Excessive vomiting and nausea
 Vision changes

You should seek care right away if you have:

 Sudden and new swelling in your face, hands, and eyes (some feet and ankle swelling is normal during pregnancy.)
 Blood pressure greater than 130/80.
 Sudden weight gain over 1 or 2 days
 Abdominal pain, especially in the upper right side
 Severe headaches
 A decrease in urine
 Blurry vision, flashing lights, and floaters

You can also have preeclampsia and not have any symptoms. That's why it's so important to see your doctor for regular blood pressure checks and urine tests.

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How Can Preeclampsia Affect My Baby and Me?

Preeclampsia can prevent the placenta from receiving enough blood, which can cause your baby to be born very small. It is also one of the leading causes of
premature births, and the complications that can follow, including learning disabilities, epilepsy, cerebral palsy, hearing and vision problems.

In moms-to-be, preeclampsia can cause rare but serious complications that include:

 Stroke
 Seizure
 Water in the lungs
 Heart failure
 Reversible blindness
 Bleeding from the liver
 Bleeding after you've given birth

Preeclampsia can also cause the placenta to suddenly separate from the uterus, which is called placental abruption. This can cause stillbirth.

What Is the Treatment for Preeclampsia and Eclampsia?

The only cure for preeclampsia and eclampsia is to deliver your baby. Your doctor will talk with you about when to deliver based on how far along your baby is,
how well your baby is doing in your womb, and the severity of your preeclampsia.

If your baby has developed enough, usually by 37 weeks or later, your doctor may want to induce labor or perform a cesarean section. This is will keep
preeclampsia from getting worse.

If your baby is not close to term, you and your doctor may be able to treat preeclampsia until your baby has developed enough to be safely delivered. The closer
the birth is to your due date, the better for your baby.

If you have mild preeclampsia - also known as preclampsia with and without severe features, your doctor may prescribe:

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  Bed rest either at home or in the hospital; you'll be asked to rest mostly on your left side.
 Careful observation with a fetal heart rate monitor and frequent ultrasounds
 Medicines to lower your blood pressure
 Blood and urine tests

Your doctor also may recommend that you stay in the hospital for closer monitoring. In the hospital you may be given:

 Medicine to help prevent seizures, lower your blood pressure, and prevent other problems
 Steroid injections to help your baby's lungs develop more quickly

Other treatments include:

 Magnesium can be injected into the veins to prevent eclampsia-related seizures

 Hydralazine or another antihypertensive drug to manage severe blood pressure elevations
 Monitoring fluid intake and urine output

For severe preeclampsia, your doctor may need to deliver your baby right away, even if you're not close to term. After delivery, signs and symptoms of
preeclampsia should go away within 1 to 6 weeks. (WebMD, 2018)

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 SUMMARY and CONCLUSION
Pregnancy is divided into three trimesters. It includes 1st trimester, 2nd trimester and the 3rd trimester. The journey of the mother and the fetus on every stage
of pregnancy brings different issues and concerns. One of the most common complications is hypertension. Hypertension during pregnancy can be serious and can
cause problems. Therefore, woman with hypertension is considered as high risk. Chronic hypertension happens before the 20 weeks of gestation and Preeclampsia
occurs after the 20 weeks of gestation also known as gestational hypertension. Preeclampsia is an increased in blood pressure, presence of protein in the urine and
other systemic features, Gestational hypertension is similar with preeclampsia, and the difference is that it has no systemic features. The systemic feature includes
vision problem, liver and kidney problems. Some woman have mild symptoms but for others could be life threatening.

Our case study aims to determine the condition of our patient who was diagnosed with preeclampsia. She is 40 years old which is one of the risk factor that
can increase the chances of developing preeclampsia. As student nurses we performed assessment and provided nursing management needed for the patient’s care.
The experienced and knowledge will serve as our guide as we continue to embrace the challenges of our journey as student nurses. We have learned that
Preeclampsia is a very serious condition. It can be life-threatening for both mother and child. Therefore Early and consistent prenatal care can help diagnose
preeclampsia sooner and avoid complications.

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 REFERENCES
Books

Hall, et al (2017). Fundamentals of Nursing. Volume I. 9th ed. Singapore, Singapore 239519: Elsiever Inc.

Kelly, J. W. (2007). Health Assessment in Nursing. Philadelphia: Lippincott Williams and Wilkins.

Pilliterri, A (2014). MATERNAL & CHILD HEALTH NURSING: Care of the Childbearing & Childrearing Family. Volume I. 7 th ed. Philadelphia, PA 19103:
Lippincott Williams & Wilkins.

Skidmore-Roth, L. (2015). Mosby's Nursing Drug Reference. St. Louis, Missouri: Elsevier Inc.

Internet

cardiovascular system. (2018, may 15). Available at: www.myvmc.com: https://www.myvmc.com/anatomy/cardiovascular-system-heart/

Lumenlearning, 2017. Integumentary. Available at: https://courses.lumenlearning.com/wm-biology2/chapter/integumentary-system/

preeclampsia. (2018, november 16). Available at: www.mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/preeclampsia/symptoms-causes/

https://www.verywellmind.com/generativity-versus-stagnation-2795734

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881982/

https://www.webmd.com/baby/guide/preeclampsia-eclampsia#1

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