Our Lady of Fatima University

Marulas, Valenzuela City

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN CARE OF MOTHER AND

CHILD AND ADOLESCENT 217 RELATED LEARNING EXPERIENCE:
Case Study of a Patient with Preeclampsia

Presented by:
Aguilar, Charlene
Alicante, Sham Mae
Ancheta, Shereen
Apalisok, Alyssa
Biason, Monette
Bunag, Allyssa Marie
Cancino, Kristianne
Capicio, Jhenzen Joyce
Catay, Justine Mae
Cruz, Patricia Nicole
Dacillo, Alyssa Dane
BSN 2Y1-5

Submitted to:
Mrs. Ybeth Vitolinamisa
 OBJECTIVE

General Objective:

The general objective of the case study is to acquire comprehension knowledge

about the disease, to acquire and practice knowledge and skills through working with a
patient having pulmonary congestion, preeclampsia, gestational diabetes mellitus and
hepatitis B infection.

Specific Objective:

- To understand the anatomy, physiology and pathology.

- To know the signs and symptoms of the disease.

- To provide holistic care for the patient.

- To manage and meet the necessary needs of the patient

- To provide appropriate health teaching.

 Introduction

Preeclampsia is commonly defined as new onset of grand mal seizure activity

and/or unexplained coma during pregnancy or postpartum in a woman with signs and
symptoms of preeclampsia. It typically occurs during or after the 20th week of gestation
or in the postpartum period. Preeclampsia is a condition during pregnancy where there
is a sudden rise in blood pressure and swelling, mostly in the face, hands, and feet.
Preeclampsia is the most common complication to occur during pregnancy. It generally
develops during the third trimester and affects about 1 in 20 pregnancies. If the
preeclampsia remains untreated, it can develop to eclampsia, in which the mother can
experience convulsions, coma, and can even die. However, complications from
preeclampsia are extremely rare if the mother attends her prenatal appointments.

Symptoms

Initially, preeclampsia may present no symptoms; however, early signs, include:

high blood pressure (hypertension)

protein in the urine (proteinuria)

In the majority of cases, the woman will not be aware of these two signs, and will
only find out when a doctor observes her during an antenatal visit. Although 6 to 8
percent of all pregnant women experience high blood pressure, it does not necessarily
mean they have preeclampsia. The most telling sign is the presence of protein in the
urine. As the preeclampsia progresses, the woman may experience fluid retention
(edema), with swelling in the hands, feet, ankles, and face. Swelling is a common part
of pregnancy, especially during the third trimester, and tends to occur in the lower parts
of the body, such as the ankles and feet. Symptoms are typically milder first thing in the
morning and build up during the day. This is not preeclampsia, in which edema occurs
suddenly and tends to be much more severe.

Later on, the following signs and symptoms may develop:

blurry vision, sometimes seeing flashing lights

 headaches, often severe

malaise

shortness of breath

pain just below the ribs on the right side

rapid weight gain (caused by fluid retention)

vomiting

decrease in urine output

decrease in platelets in the blood

impaired liver function

The main sign of preeclampsia in the fetus is growth restriction due to decreased
blood supply to the placenta.

Causes

Experts are not sure why preeclampsia occurs. Most say that there is a problem with
the development of the placenta because the blood vessels that supply it are narrower
than normal and respond differently to hormonal signals. Because the blood vessels are
narrower than normal, blood flow is limited. Why the blood vessels develop differently is
not fully understood, but a number of factors may play a role; including:

damage to the blood vessels

insufficient blood flow to the uterus

immune system problems

genetic factors

Risk Factors

Risk factors associated with preeclampsia include:

First pregnancies: The chances of preeclampsia during a first pregnancy are
considerably higher than the subsequent ones.

Pregnancy gap: If the second pregnancy occurs at least 10 years after the first, the
second pregnancy has an increased risk of preeclampsia.

New paternity: Each pregnancy with a new partner raises the risk of preeclampsia
when compared with a second or third pregnancy with the same partner.

Family history: A woman whose mother or sister had preeclampsia has a higher risk of
developing it herself.

Personal history of preeclampsia: A woman who had preeclampsia in her first

pregnancy has a much greater risk of having the same condition in her subsequent
pregnancies.

Age: Women over 40 and teenagers are more likely to develop preeclampsia compared
with women of other ages.

Certain conditions and illnesses: Women with diabetes, high blood pressure,
migraines, and kidney disease are more likely to develop preeclampsia.

Obesity: Preeclampsia rates are much higher among obese women.

Multiple pregnancies: If a woman is expecting two or more babies, the risk is higher

Complications

If preeclampsia is not treated, there is a risk of serious complications. Complications are

rare if the woman goes to antenatal appointments. However, if the condition is not
diagnosed for some reason, the risks are considerably greater. The following
complications may develop from preeclampsia:

HELLP syndrome: HELLP can become life-threatening very quickly, for both the
mother and the baby. It stands for hemolysis, elevated liver enzymes, and low platelet
count. It is a combined liver and blood clotting disorder that most commonly occurs right
after giving birth but can appear at any time after the 20th week of pregnancy. Very
rarely, it may occur beforehand. The only way to treat HELLP syndrome effectively is to
deliver the baby as soon as possible.

Poor blood flow to the placenta: If blood flow to the placenta is restricted, the baby
might not be getting oxygen and nutrients, which may lead to slower growth, breathing
difficulties, and premature birth.

Placental abruption: The placenta separates from the inner wall of the uterus. In
severe cases, there may be heavy bleeding, which can damage the placenta. Any
damage to the placenta may place the baby's and mother's life at risk.

Eclampsia: This is a combination of preeclampsia and seizures. The woman may

experience pain under the ribs on the right side of her body, intense headache, blurry
vision, confusion, and decreased alertness. If left untreated the woman is at risk of
going into a coma, suffering permanent brain damage, and dying. The condition is life-
threatening for the baby as well.

Cardiovascular disease: Women who have preeclampsia have a higher risk of

developing cardiovascular diseases later in life.

Preeclampsia can have some long-term consequences for the developing baby.
Research has shown that high blood pressure in pregnant women may affect the baby's
cognitive skills, which can carry through into later life.
 NURSING HEALTH HISTORY

Patient’s Profile

Name: Aseo, Marife

Date of Birth: September 11, 1981

Age: 37

Sex: Female

Address: 76 San Nicasio St. Brgy. Gulod, Novaliches

Occupation: Lady Guard

Educational Attainment: College Graduate

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Clinical Data

Date of Admission: August 7, 2019

Vital Signs on Admission: None

Chief Complaint: Difficulty of Breathing

Admitting Diagnosis: G2P1 Pregnancy Uterine 36 2/7 weeks AOG, Intrauterine fetal
demise: pulmonary congestion; Pre-eclampsia with severe features; Overt Diabetes;
Hepatitis B Infection- low infectivity
History of Present Illness:

3 days prior to admission, patient was noted to have bilateral edema and easy
fatiguability. No other associated symptoms like difficulty of breathing, chest pain, fever,
headache, blurring of vision and dizziness.

Few hours prior to admission, still with the persistence of edema now accompanied by
shortness of breath, difficulty of breathing and labor pains, hence sought consult and
subsequently admitted.

Past Medical History

Patient had gestational hypertension at 33 weeks and gestational diabetes mellitus at

36 weeks AOG. No history of malignancy, and goiter. No other history of surgery and
blood transfusion.

Family History

The patient’s mother has Asthma no other heredofamilial diseases such as Diabetes
Mellitus, Hypertension, Malignancy, and Goiter.

Personal-Social History

The patient is the 4’’ of 5 siblings, college graduate, and a lady guard, married for 12 to
a 45-year-old security guard. She is a non-smoker, non-alcoholic beverage drinker, with
no illicit drug use. She has no allergies to medications and food.

Reproductive History

Last Menstrual Period: November 20,2018

Age of Gestation: 37 weeks 2/7 AOG by LMP

Estimated Date of Delivery: August 27, 2019

Gyne History:

Menarche: 13 years old Coitarche: 24 years old

Interval: 28-30 days No. of Sexual Partner: 1
Duration: 7 days Last sexual contact: June 2019
Amount: 6 pads/ day, moderately soaked Contraception: none
Symptom/s: (-) dysmenorrhea

Ob History:
G2P1 (1001)

2008, Full term, Normal spontaneous vaginal delivery, Mandaluyong

G1
Medical Center

G2 2019, Present pregnancy

Surname First MI Age Sex C.S. Ward Attending Physician

Aseo Name B. 37 F M OB Dr. Chang/Flores/Caparas/JI Nicdao

Marife

Physical Examination

General: Patient is conscious, in cardiorespiratory distress, with the following vital signs:

BP: 160/90 PR: 139 RR: 28 Temp: 36.0

Skin: with facial pallor, skin is fair, warm to touch, moist with skin turgor, with capillary
refill time <seconds

HEENT: Anicteric sclerae, pale palpebral conjunctiva, no nasoaural discharge, no

tonsillopharyngeal congestion, no cervico-lymphadenopathy, with neck vein distention

Chest & Lungs: Symmetrical chest expansion, no lagging, with retractions, (+) bilateral
crackles

Heart: Adynamic precordium, tachycardic, no murmur

Abdomen: Globular, Soft, Normoactive Bowel Sounds, Non tender

FH- 35cm EFW: 3720g FHT- not appreciated

LM1- Breech LM2- fetal back at right maternal side LM3- unengaged LM4-
cephalic

Internal Examination: Cervix is 4 cm dilated, 30% effaced, intact BOW, cephalic,

station -3

Extremities: Grossly normal extremities, with bilateral distal edema, no pallor or

cyanosis, full and equal pulses on both extremities

Neurologic Exam: Unremarkable

 GORDON HEALTH’S STATUS

Gordon’s 11 Functional Pattern Before Hospitalization During Hospitalization

HEALTH PERCEPTION- She is worrying on her

HEALTH MANAGEMENT According to the patient, she is condition because she may not
PATTERN taking ferrous sulfate twice a take care of her baby well due
day during her pregnancy. to her condition. She follows
properly the entire doctor’s
order because she wants to
recover as soon as possible for
her baby.

NUTRITIONAL- METABOLIC According to the patient, she The patient was on NPO. The
PATTERN eats a large amount of rice and IVF of the patient are D5LRS
drinks 7 glasses of water a 1L x 30 gtts/min @ the level of
day. She is not drinking coke, 50ml hooked @ the right arm,
milk and cold water and not PNSS 1L x KVO @ the level of
eating halo-halo. She also 550cc.
takes snack in between meals.

COGNITIVE The patient is a college The patient is not experiencing

PERCEPTUAL graduate. She doesn’t have dizziness and blurred vision.
PATTERN any problem with her senses. She answers questions
minimally.

ACTIVITY- EXERCISE According to the patient, she The patient is turning side to
PATTERN walks always. side to prevent bed sore.
Legs are elevated due to the
edema at her lower
extremities. She has difficulty
in moving due to the pain.

SLEEP- REST PATTERN According to the patient, she The patient verbalized that she
usually sleeps at 6pm and has difficulty in sleeping
wakes up at 5am. She takes a because of the environment.
nap for 2 hours at noon. She She takes a nap for at least 20
has no difficulty in getting minutes.
sleep.

ELIMINATION PATTERN The patient defecates 2x a day The urine color is yellow with
with bulky and well formed an amount of 675cc. There is
stool. She urinates 7x a day a presence of flatus but no
with a yellow amber in color. bowel movement.
She has no difficulty in
 defecating and urinating.

SELF PERCEPTION- SELF According to the patient, she The patient feels body
CONCEPT PATTERN was happy when she got weakness due to her condition
pregnant. She is excited to see but despite of that she is
herself with her growing baby. excited to be a mother

ROLE- RELATIONSHIP The patient feels the support of The patient has a good
PATTERN her family especially her relationship with her parents
husband. She cannot perform and siblings. She loves her
her role due to her condition. husband. She is a caring and a
loving wife and mother.

COPING STRESS She verbalized that whenever The patient verbalized that she
PATTERN she has a problem, she is is sharing her feelings with her
sharing it with her parents and mother and husband. She just
her husband. Sometimes, if thinks her baby to ease the
she is stress she managed it pain she feels. She doesn’t
by watching tv and by think that she is problem to her
socializing with their neighbors. family.

SEXUALITY- The patient had her menarche The patient is very happy in
REPRODUCTIVE PATTERN when she was 13 years old. giving birth of their second
She has no problem with her child which is a baby girl.
menstruation and don’t
experience dysmenorrhea
during menstruation. She had
her coitarche when she is 24
years old. They are not using
any contraceptive method.

VALUE- BELIEF PATTERN The patient is a Roman According to the patient, she
Catholic and she attends the always prays at night to
mass 3x a month. She often recover from her condition and
prays at night. She verbalized for the wellness of her baby.
that she do believe in quack She always asks guidance and
doctor but never consulted to a good health from God.
them.
 Anatomy and Physiology
Cardiovascular System
The cardiovascular system is an organ system that permits blood to circulate and
transport nutrients, oxygen, carbon dioxide, hormones, and blood cells to and from the
cells in the body to provide nourishment and help in fighting diseases, stabilize
temperature and pH, and maintain homoeostasis.
It is divided into two main parts:
Heart: The heart is a muscular organ which pumps blood through the blood vessels of
the circulatory system.

Blood vessels: Blood vessels transport blood throughout the human body. There are
three major types of blood vessels:
arteries (carry blood away from the heart),

capillaries (enable exchange of water and chemicals between the blood and the
tissues) and veins (carry blood from the capillaries back toward the heart).
The lymphatic system is connected with the cardiovascular system both structurally and
functionally.
The cardiovascular system has two distinct circulatory paths:
• Pulmonary circulation
• is the portion of the circulatory system which carries deoxygenated blood away
from the right ventricle of the heart, to the lungs, and returns oxygenated blood to
the left atrium and ventricle of the heart.
• The right side of the heart pumps blood to the lungs (pulmonary circulation). In
the lungs blood gets oxygenated from the air sacs. At the same time, carbon
dioxide diffuses into the air sacs and is exhaled into the atmosphere.

• Systemic circulation
• carries oxygenated blood from the left ventricle, through the arteries, to the
capillaries in the tissues of the body. From the tissue capillaries, the
deoxygenated blood returns through a system of veins to the right atrium of the
heart.
• The left side of the heart pumps blood into the systemic circulation which
supplies to the rest of the body. In the tissues, blood releases oxygen and
nutrients and collects carbon dioxide and wastes.
The cardiovascular system continuously pumps blood to all parts of the body. Its
functioning is regulated continuously to maintain adequate blood supply. In the absence
of adequate blood supply, tissue damage and cell death will result.
Pathophysiology of Preeclampsia
Definition of the Disease

Preeclampsia is a medical condition where hypertension arises in pregnancy

(pregnancy-induced hypertension) in association with significant amounts of protein in

the urine. Because preeclampsia refers to a set of symptoms rather than any causative
factor, it is established that there are many different causes for the syndrome. It also

appears likely that there is a substance or substances from the placenta that may cause

endothelial dysfunction in the maternal blood vessels of susceptible women.

Preeclampsia is a disorder that occurs only during pregnancy and the postpartum

period and affects both the mother and the unborn baby. Affecting at least 5-8% of all

pregnancies, it is a rapidly progressive condition characterized by high blood pressure

and the presence of protein in the urine. Swelling, sudden weight gain, headaches and

changes in vision are important symptoms; however, some women with rapidly

advancing disease report few symptoms.

Preeclampsia has been described as a disease of theories, because the cause is

unknown. Some theories include (1) endothelial cell injury, (2) rejection phenomenon

(insufficient production of blocking antibodies), (3) compromised placental perfusion, (4)

altered vascular reactivity, (5) imbalance between prostacyclin and thromboxane, (6)

decreased glomerular filtration rate with retention of salt and water, (7) decreased

intravascular volume, (8) increased central nervous system irritability, (9) disseminated

intravascular coagulation, (10) uterine muscle stretch (ischemia), (11) dietary factors,

and (12) genetic factors. The relatively new theory of endothelial injury explains many of

the clinical findings in preeclampsia. The theory emphasizes that there is more to

preeclampsia than hypertension. The vascular endothelium produces a number of

important substances including endothelial-derived relaxing factor or nitric oxide,

endothelin-1, prostacyclin, and tissue plasminogen activator. Thus, endothelial cells

modify the contractile response of the underlying smooth muscle cells, prevent
intravascular coagulation, and maintain the integrity of the intravascular compartment.

Several findings suggest endothelial injury in preeclampsia.

Predisposing / Precipitating Factors

Women with preeclampsia have abnormal blood vessels feeding the placenta,

although the exact cause of this abnormality is not know. There are no tests that can

reliably predict who will get preeclampsia, and there is no way to prevent it. Women with

one or more of the following characteristics have an increased risk of developing

preeclampsia:

 First pregnancy (excluding miscarriages)

 High blood pressure, kidney disease, lupus, or diabetes prior to pregnancy

 Gestational diabetes

 Multiple gestation (eg, twins or triplets)

 A family history of preeclampsia in a sister or mother

 A previous history of preeclampsia

 Age under 20 years and possibly age over 35 to 40 years

 Obesity

Conversely, women who do not develop preeclampsia in their first pregnancy are at low

risk of developing it in a subsequent pregnancy.

Other precipating factors may include: pregnancy, long interval pregnancy and urinary

tract infection.
Other predisposing factors may include: genetics, low socioeconomic status, race and

heart disease.

Signs and Symptoms

Signs of severe preeclampsia — Mild preeclampsia can worsen and become severe.

This usually occurs over several days to weeks, but may occur more quickly. Severe

preeclampsia may be characterized by one or more of the following signs or symptoms.

However, the signs of both mild and severe preeclampsia may be subtle, and patients

should not hesitate to mention any concerns about possible signs of preeclampsia to

their provider:

 Blood pressure ≥160/110 mmHg. Women with blood pressures in this range

have an increased risk of stroke

 Persistent severe headache

 Visual problems (blurred or double vision, blind spots, flashes of light or squiggly

lines, loss of vision)

 Abnormal kidney tests or decreased urination (urinating less than 500 mL in 24

hours)

 Fluid in the lungs, which may cause new shortness of breath

 Low platelet count; platelets help the blood to clot, which may cause easy

bruising or bleeding
  Liver abnormalities (detected by blood tests); symptoms may include nausea,

vomiting, or pain in the mid- or right upper abdomen (similar to heartburn)

 Destruction of red blood cells (hemolysis, which is detected by blood tests).

Partial or complete separation of the placenta from the uterus (called abruption);

symptoms include vaginal bleeding, uterine pain, and/or decreased fetal activity.
 LABORATORY AND DIAGNOSTIC RESULTS

RPR/Syphilis: non-reactive

HIV Screening Test: non-reactive

Na: 139

K: 4.0

AST: 29

ALT: 17

Crea: 69.6

BUN: 3.7

LDH: 292

Complete Blood Count with Blood Typing and RH

RBC (10^6/uL) 4.99 WBC: (10^3/uL) 12.23

HGB (g/L) 140 Neu% 42.9
HCT (%) 44.6 Lym% 52.1
MCV: 89.4 Mon% 4.3
MCH: 28.1 Eos% 0.6
MCHC: 314 Bas% 0.1
PT ct (10^9/L) 166
Blood Type: “A+” RH:

URINALYSIS

Color Yellow Blood Negative

Transparency Slightly turbid Bilirubin Negative
pH 6.5 Urobilinogen Normal
Specific Gravity .005 Ketones Negative
RBC 0-2 Protein +3
WBC 0-2 Nitrate Negative
Epithelial Cells Moderate Glucose Negative
Mucus Threads Leukocytes Negative
 Drug Study

Nursing
Drugs Mode of action Rationale Side effects
Consideration
Inhibits calcium ion CNS: headache,
influx across somnolence, fatigue,
Amlodipine cardiac and diziness
besylate smooth-muscle CV: edeme, flushing, Monitor BP
Classification: cells, dilates Decreases palpitation frequently during
Calcium coronary arteries blood pressure GI: nausea, abdominal pain initiation of
Channel and arterioles, amd Respiratory: pulmonary theraphy.
Blockers decreases BP and edema, dyspnea
myocardial oxygen Skin: pruritus, rush
demand
CNS: vertigo, dizziness,
paresthesia, weakness,
Inhibits sodium and •reduces extra
restlessness, fever
chloride fluid in the Monitor weight,
CV: ortjostatic hypertension,
Furosemide reabsorption at the body BP, and pulse
thrombhophlebitis with IV
Classification: proximal and distal •lowers the BP rate routinely
administration
loop diuretics tubules and the •makes the with long-term
GI: abdominal discomfort
ascending loop of patient urinate use
and pain, diarrhea, anorexia,
henle frequently
nausea, vomitting,
constipation, pancreatitis
Hydralazine CNS: headache, diziness
hydrochloride Cv: angina pectoris,
Brand: palpitations, tachycardia,
apresoline orthotastis hypotension,
Treatmemt for Monitor patient’s
Classification: Unknown. edema, flsuhing
hypertension BP
peripheral GI: nausea, vomitting,
dilators diarrhea, anorexia,
constipation, paralytic ileus

Replaves CNS: toxicity, weak or

magnesium and absent deep tendon
maintains reflexes, flaccid paralysis,
magnesium level; drowsiness, stupor
Keep IV calcium
Magnesium as an CV: slow, weak pulse;
available to
Sulfate anticonvulsants, arrhythmiad; flushing
reverse
Classification: reduces muscle GI: diarrhea
magnesium
minerals contractioms by Metabolic:hypocalcemia
intoxication
interfering with Skin: diaaphoresis
release of
acetylcholime at
myonueral junction
 COURSE IN THE WARD

The patient was admitted at the LR/DR on August 7, 2019 with consent for
admission and management. Patient was put on NPO and hooked to D5LR 1L to run
every 8 hours was inserted. IFC was inserted. Patient was given Magnesium Sulfate 6
grams as loading dose then MgSO4 drip: D5W 500cc + 2 amp of MgSO4 of 1g/hr x 24
and Hydralazine 5mg TIV and Furosemide 40mg TIV. CBC w/ BTRH, U/A, HbsAg,
VDRL, HIV, Na/K, BUN/Creatinine, SGPT/SGOT, PT/PTT with INR, LDH were
requested. Patient was for assisted vaginal delivery and consent was secured for the
procedure. Patient was referred to surgery for CVP insertion. Patients was referred to
Internal Medicine Department for co-management. Patient was seen and examined,
was hooked to mechanical ventilation with the following setting: TV of 450, FiO2 of
100%, PFR of 40, PEEP of 5, NGT was inserted, given with the following orders: started
nifedipine drip:D5W 90cc + nifedipine 10mg to run at 10cc/hr, titrated by 500cc/hr to
achieve SBP <140. Started isoket drip: D5W 90cc + 1SPN10mg to run at 10cc/hr with
BP prevention. Furosemide 40mg TIV now the q6. For TPAG. IVF to KVO. For FBS and
liquid profile. Patient was stabilized prior delivery. Patient was seen and examined by an
Anesthesiologist was given Omeprazole 40mg IV OD. Patient was referred to Internal
Medicine for CP Clearance. Vital signs were monitored for 1 hour. Patient was started
with Piperacillin-Tazobactam 2.25hm TIV every 8 hours and Levofloxacin 750mg TIV
every 48 hours. Additional laboratories were done: ETA, Gs/Cs and Blood CS x 2.
Patient delivered via spontaneous vaginal delivery. NGT was removed. Patient was
extubated. The following medication were started: (1) Cefuroxime 500mg/tab 1 tablet
every 8 hours for 7 days, (2) Ferrous sulfate 1 tablet once a day, (3) Ascorbic acid
500mg/tab 1 tablet once a day, (4) Amlodipine 5mg/tab 1 tablet once a day and (5)
Mefenamic acid 500mg/tab every 6 hours PRN for pain. She was advised to increase
oral fluid intake and general perineal hygiene. Vital signs monitored every 4 hours. The
rest of the hospital stay was unremarkable. Patient was discharged well and stable and
was advised to follow-up at the Out Patient Department after one week.
PROCEDURE: Spontaneous Vaginal Delivery under General Anesthesia

PLAN:

- For discharge
- Well-balanced diet
- Increase oral fluid intake
- Advised general perineal hygiene
- Continue oral medications
- Outpatient department follow-up after one week
MEDICATIONS:

- Ferrous Sulfate 1 tablet once a day

- Mefenamic Acid 500mg/tablet, 1 tablet every 6 hours as needed for pain
- Co-Amoxiclav 250mg/tablet, 1 tablet every 12 hours for 7 days
- Levofloxacin 750mg/tablet, 1 tablet once a day for 7 days
- Ascorbic Acid 500mg/tablet, 1 tablet once a day
- Amlodipine 5mg/tablet, 1 tablet once a day
FINAL DIAGNOSIS:

G2P2 (2002) Pregnancy Uterine, term, cephalic, delivered a live baby girl, with
birthweight of 3935g, score of 7,9, Ballard score of 38, LGA, via spontaneous vaginal
delivery; Pulmonary congestion-resolved, Pre-eclampsia with severe symptoms;
Gestational Diabetes; Hepatitis B infection – low infectivity.
 NURSING CARE PLAN

Preeclampsia with Severe Features

Aseo is a 35 y/o pregnant patient admitted at Quezon City General Hospital due
to Chief Complaint of Difficulty of Breathing. 3 days PTA the patient was noted to have a
bilateral edema and easy fatigability. Then few hours PTA, still with persistence edema
now accompanied with shortness of breath and difficulty of breathing and labor pain,
hence sought consultation and subsequently admitted.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Risk of • to reduced •monitor vital •to establish Patient has

• “Nahihilo ako at eclampsia BP to normal, signs baseline data reduced the
medyo related to i.e. 120/80 especially the risk of
nahihirapang preeclampsia •to reduce blood pressure eclampsia by
huminga.” as as evident by protein in regularly decreasing
verbalized by the hypertension, urine every 4 hour the blood
patient. BP = 160/90 •to improve •administer •to regulate pressure to
accompanied oxygenation anti- or maintain normal and
Objective: by pulmonary and resolve hypertensive blood reducing the
•patient is congestion and pulmonary drug as per pressure to protein
conscious, in a protein +3 congestion doctor’s order normal content in the
cardiorespiratory present in • to reduced •advise low fat •to decrease patient’s urea
distress, with vital urine the risk of and low salt protein and the
signs of: eclampsia diet content in patient is
BP: 160/90 urine relieved from
PR: 139 •administer •immediate pulmonary
RR: 26 magnesium control of life congestion
Temp.: 36 sulfate as threatening after
•protein +3 present ordered. convulsions regulating
in urine in the oxygenation
• with pulmonary treatment of
congestion toxemias
•administer o2 • to improve
sat via nasal the patient
cannula as oxygenation
ordered place and relieved
on moderate by pulmonary
high back rest congestion
 RECOMMENDATION/DISCHARGE SUMMARY

Patient Name: Marife Aseo

Age/Sex: 37 Year(s) Female
Medical Record Number: 10017286
Admission Date: August 7,2019
Discharge Date: Aug 15,2019
Attending Physician: Dr. Angeli Caparas
Dictated by: Dr. Angeli Caparas

Primary Care Physician:

Consulting Physician(s): Dr. Anna Flores
Dr. Angeli Caparas

Condition on Discharge: Discharge well and stable

Admitting Diagnosis: G2P1 (1001) Pregnancy Uterine 37 2/7 weeks AOG, Intrauterine
fetal demise, Pulmonary congestion, Pre-eclampsia with severe features, Overt
Diabetes, Hepa B infection-low infectivity

Discharge Diagnosis: G2P2 (2002) pregnancy Uterine, term, cephalic, delivered a live
girl, with birth weight of 3935g, APGAR score of 7,9, Ballard score of 38, LGA, via
spontaneous vaginal delivery, Pulmonary congestion-resolved, Pre-eclampsia with
severe symptoms; Gestational Diabetes; Hepatitis B infection – low infectivity

Operation Performed: with severe symptoms, Gestational Diabetes, Hepa B

infection-low infectivity, Spontaneous vaginal Delivery under General Anesthesia

Discharge Medications: Ferrous sulfate 1 tab once a day

Mefenamic Acid 500mg/tab 1 tab every 6hrs as needed for pain
Co-Amoxiclav 6250mg/tab 1 tab every 12hrs for 7 days
 Levofloxacin 350mg/tab 1 tab once a day for 7 days
Ascorbic acid 500mg/tab 1 tab once a day
Amlodipine 500mg/tab 1 tab once a day

Discharge Instructions: well-balanced diet

Increased fluid intake

Advised General Perineal Hygiene

Continue oral Medications

Outpatient department Follow up after 1 week