SOUTHERN BICOL COLLEGES

Mabini Street, Masbate City

College of Nursing

CASE
PRESENTATION
(SEVERE PREECLAMPSIA)

MEMBERS:
Fernandez, Rachelle B.
Brabante, Maria Lolett Ephraim M.
Gonzales, Jacob J.
Tunacao, Mary Thonie G.
Aninang, Kayla
Lamoste, Angela M.
Llanto, Hanna Mae U.
Pangantihon, Josam A.
Gulmatico, Dave D.
BSN-2D

Panelists:
Giselle Lebanto, RN
Elvisa Espares RN
Ampil Ruvy Pastor, RN
Ailene O. Arcenas, RN
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
TABLE OF CONTENTS

I. Introduction

II. Patient’s Profile

III. Developmental Task

IV. Theoretical Framework

V. 13 Areas of Assessment

VI. Anatomy and Physiology

VII. Pathophysiology

VIII. Doctor’s Order Laboratory Work-up

IX. Drug Study

X. Nursing Care Plan

XI. Medications, Discharge Plan and

Prognosis
XII. References
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Mabini Street, Masbate City
College of Nursing

I. INTRODUCTION
Severe preeclampsia is an advanced and potentially life-threatening form of
preeclampsia, a hypertensive disorder that occurs during pregnancy. It is characterized by
elevated blood pressure, significant proteinuria (protein in the urine), and signs of end-organ
dysfunction. Severe preeclampsia poses serious risks to both the pregnant individual and the
developing fetus, necessitating prompt recognition, intervention, and close monitoring to prevent
complications. The diagnostic criteria for severe preeclampsia typically include the presence of
one or more severe manifestations in addition to hypertension and proteinuria. These severe
features may include:

Severe Hypertension: Systolic blood pressure ≥160 mmHg or diastolic blood pressure ≥110
mmHg on two occasions at least 4 hours apart.

Proteinuria: Significant proteinuria, usually defined as ≥5 grams of protein in a 24-hour

urine collection or ≥3+ protein on a urine dipstick test.

Edema is swelling caused by too much fluid trapped in the body's tissues. Edema can affect
any part of the body. But it's more likely to show up in the legs and feet.

Neurological Symptoms: New-onset cerebral or visual disturbances, such as headaches,

visual changes (blurred vision or scotomata), hyperreflexia, seizures (eclampsia), altered
mental status, or focal neurological deficits.

Management of severe preeclampsia focuses on stabilizing maternal condition,

preventing complications, and optimizing fetal outcomes. This may involve hospitalization for
close monitoring, strict blood pressure control using antihypertensive medications,
administration of magnesium sulfate for seizure prophylaxis, and, in severe cases, expedited
delivery of the baby to mitigate maternal risks while balancing the potential for neonatal
morbidity and mortality associated with preterm birth.

Hypertension Symptoms
Type
Gestational Blood pressure is 140/90 mmHg or systolic pressure
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College of Nursing
Hypertension elevated 30
mmHg or diastolic pressure elevated 15 mmHg above
prepregnancy level; no proteinuria or edema; blood
pressure returns to normal after birth
Preeclampsia Blood pressure is 140/90 mmHg or systolic pressure
without elevated 30
severe mmHg or diastolic pressure elevated 15 mmHg above
features prepregnancy level; proteinuria of 1+ to 2+ on a
random sample;
weight gain over 2 lb/week in second trimester and 1
lb/week in
third trimester; mild edema in upper extremities or
face
Preeclampsia Blood pressure is 160/110 mmHg; proteinuria 3+ to 4+
with severe on a random
features sample and 5 g on a 24-hour sample; oliguria (500 ml
or less in 24
hours or altered renal function tests; elevated serum
creatinine
more than 1.2 mg/dl); cerebral or visual disturbances
(headache,
blurred vision); pulmonary or cardiac involvement;
extensive
peripheral edema; hepatic dysfunction;
thrombocytopenia;
epigastric pain
Eclampsia Either seizure or coma accompanied by signs and
symptoms of preeclampsia are present.

Mrs. G has a sign and symptoms of Severe Preeclampsia. As she arrived at the hospital she
has blurry vision, headache, dizziness, vomiting, and swelling on her feet and hands. As the Vital
Signs being assess her blood pressure is elevated compared to her normal blood pressure during
her pregnancy.

The patient’s Severe Preeclampsia causes/ risk factors include the following:
- Advanced Maternal Age
- Inadequate health care
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College of Nursing
- Poor Diet
- Work exposure

MRS. G SHOWN S/S OF SEVERE PREECLAMPSIA.

- High Blood Pressure measures 180/110
- Blurry Vision
- Swelling in Feet and Hands
- Nausea
- Dizziness
- Headache

Treatment and Diagnostic Procedures:

- Lower Uterine Segment Caesarian Section (LSCS)
- Laboratory test
- Medications such as (cefuroxime, hydralazine, magnesium sulfate, ferrous sulfate and etc.).
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Mabini Street, Masbate City
College of Nursing

II. PATIENT’S PROFILE

Name: Mrs. G
Sex: Female
Age: 38 yr. old
Occupation: Business Woman
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Address: Brgy. Espinosa, Masbate City
Age of gestation: 41 weeks
Last Menstrual Period: July 15, 2023
Expected Date of Confinement: April 23, 2024
OB Score: G3P1 (1011)
Fetal Presentation: Cephalic
FHR: 140 bpm (NORMAL 110 – 160 bpm)
Fundal Height: 36 cm (40 – 41 cm)
Menarche: 12 y/o
Date of admission: May 3, 2024
Date handled: May 4, 5, 6, 2024
Initial vital signs:
BP: 180/110 mmHg
Temp.: 36 C
PR: 100 bpm
RR: 20 cpm
Admitting Impression/Diagnosis:
G3P1 (1011) PU 41 6/7 weeks AOG by LMP, CIL PREV, CS R/T OLIGOHYDRAMNIOS: T/C
PREECLAMPSIA.
Surgical Procedure:
Lateral Segment Caesarean Section
Final Diagnosis:
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G3P2 (2012) PUDT Cephalic live boy APGAR score 8,9 Birth Weight 3.3 kg Ballard Score 39
by Lower Uterine Segment Caesarian Section (LSCS) Bilateral Tubal Ligation (BTL) Previous
Caesarian section 1 secondary to Oligohydramnios Preeclampsia severe.

Present Medical History

Mrs. G a referred patient from Masbate RHU Birthing Facility with complains of Dizziness,
Labor Pain, Headache, Blurry Vision, and positive difficulty in breathing.

Past Medical History

 She has previous Cesarian Section. (2017)

 She has history Hypertension. (Since 2017)
 She has history of Oligohydramnios on her previous pregnancy. (2017)

Family Health History

FATHER MOTHER
Hypertension Hypertension
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College of Nursing

III. DEVELOPMENTAL TASK

Psychosocial Theory or Stage Six Intimacy vs. Isolation
Erik Erikson
Erik Erikson’s psychosocial theory suggests that during young adulthood (generally between
ages 20 and 40), individuals face the psychosocial crisis of intimacy vs. isolation. This stage is
characterized by the struggle to form close and meaningful relationships with others, both
romantically and socially, while also maintaining a sense of identity and independence.
Successfully navigating this stage involves developing intimate relationships with others while
still preserving one's sense of self. Failure to do so may result in feelings of loneliness, isolation,
or a lack of connection with others.
The medical condition of preeclampsia during pregnancy. While a 38-year-old woman who
experienced preeclampsia during pregnancy may face challenges related to her health and well-
being, the concept of intimacy vs. isolation pertains more to her social and emotional
development.

Intimacy
Intimacy generally refers to a close, deep, and usually private emotional or physical
connection between people. It involves openness, vulnerability, trust, and a sense of closeness
and understanding. Intimacy can manifest in various forms, including emotional intimacy,
physical intimacy, intellectual intimacy, and experiential intimacy.

Isolation
Isolation refers to the state of being separated from others, either physically or emotionally.
It can occur voluntarily or involuntarily and can be temporary or prolonged. Isolation often
involves a lack of social interaction, support, or connection with others, leading to feelings of
loneliness, alienation, or solitude. It can have negative effects on mental and emotional well-
being if experienced for extended periods without adequate social contact or support.

Our client, Mrs. G, 38, was diagnosed with severe preeclampsia prior to her hospitalization.
Despite this, she managed to assist her husband in providing financial support for her family. She
is a businesswoman, operating a small sari-sari store in her hometown and gladly working to
meet her family's needs, particularly those of her two (2). Mrs. G presented with symptoms of
 SOUTHERN BICOL COLLEGES
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College of Nursing
blurred vision, mild deafness, fatigue, elevated blood pressure, facial edema, and pedal edema
upon admission to the Masbate Provincial Hospital. Additionally, the patient had a history of
hypertension. Mrs. G, sought medical care due to her pregnancy. Her husband gives full support
during pregnancy.

IV. THEORETICAL FRAMEWORK

Adaptation Model
Sr. Callista Roy
The adaptation model is a theoretical framework used in nursing and healthcare to
understand how individuals and groups respond to stressors and make adjustments to maintain
health and well-being. It emphasizes the dynamic interplay between the person and the
environment, highlighting the individual’s ability to adapt to changes through various coping
mechanisms. In the context of preeclampsia, the adaptation model helps nurses and healthcare
providers understand how pregnant individuals navigate the physiological and psychological
challenges associated with the condition, and how they can support them in optimizing their
health outcomes. The adaptation model offers valuable guidance for nurses and healthcare
professionals in several ways:

1. Assessment: By understanding the adaptive modes and adaptation level of individuals,

nurses can conduct comprehensive assessments to identify their strengths, challenges, and
areas needing support.

2. Intervention: Based on assessment findings, nurses can implement tailored interventions

to promote adaptive responses. This may include education, counselling, therapeutic
communication, and facilitating access to resources and support systems.

3. Holistic Care: The adaptation model encourages a holistic approach to care, considering
not only physical health but also psychological, social, and spiritual well-being. Nurses
address clients’ multifaceted needs and support their overall adaptation to health
challenges.

4. Individualized Care: Recognizing that adaptation is influenced by individual differences

and experiences, nurses provide individualized care plans that respect clients’
preferences, values, and cultural backgrounds.
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5. Promoting Coping Strategies: Nurses assist individuals in developing and utilizing
effective coping strategies to manage stressors and maintain equilibrium. This may
involve teaching relaxation techniques, problem-solving skills, and promoting resilience.

6. Supportive Environment: Nurses create a supportive environment that fosters

adaptation by promoting autonomy, fostering positive relationships, and advocating for
clients’ needs within the healthcare system.

Overall, the adaptation model guides nurses in promoting clients’ adaptation to health
challenges, empowering them to achieve optimal health and well-being despite facing adversity.
The adaptation model, developed by nursing theorist Sister Callista Roy, is a theoretical
framework used in nursing and healthcare to understand how individuals and groups respond to
stressors and make adjustments to maintain health and well-being.

Key components of the adaptation model include:

1. Adaptive System: Individuals are seen as holistic adaptive systems that constantly interact
with their environment. They have coping mechanisms to respond to internal and external
stimuli.
2. Stimuli: Stimuli are factors in the environment that provoke a response from the individual.
These can be physical, psychological, social, or spiritual in nature.
3. Adaptive Modes: Roy identified four adaptive modes through which individuals respond to
stimuli: physiological-physical, self-concept-group identity, role function, and interdependence.
These modes encompass various aspects of human functioning.
4. Adaptation Level: Each individual has a unique level of adaptation, influenced by genetic,
developmental, and experiential factors. This determines their ability to respond to stimuli
effectively.
5. Adaptation Process: Adaptation involves a continuous process of assessment, processing
information about stimuli, and implementing adaptive responses. This may involve coping
mechanisms, problem-solving, and seeking support.
6. Health and Nursing: The goal of nursing within the adaptation model is to promote
adaptation and achieve optimal health outcomes. Nurses assess individuals' adaptive abilities,
provide support, and intervene to facilitate adaptation when necessary.
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College of Nursing
Overall, the adaptation model provides a framework for understanding how individuals
navigate life's challenges and how healthcare professionals can support them in achieving
optimal adaptation and well-being.

The primary goal of Sister Callista Roy's Adaptation Model is to promote the adaptation of
individuals to changes in their environment, health status, and life circumstances in order to
achieve optimal health outcomes. This model emphasizes the dynamic interaction between
individuals and their environment, highlighting the importance of adaptation as a process of
coping, adjusting, and maintaining balance. Nurses using Roy's model aim to assess individuals'
adaptive responses, provide support and interventions to facilitate adaptation, and promote their
overall well-being. Ultimately, the goal is to empower individuals to effectively manage the
challenges they face and thrive in their circumstances.

Based on our patient, Mrs. G. with Severe Preeclampsia. We set goals to help her perform
certain activities necessary for her well-being and her baby’s health. On how can she control her
hypertension to maintain it in the normal range. It’s important to follow medical advice and
treatment prescribed by healthcare professional.

We educated her on health matters, particularly on how can she maintain her blood pressure
in the normal range. On what is the benefits if breastfeeding on her and her baby. to remain relax
in her everyday life to have a diet suitable for her case and what are the things that she avoids
while she is taking care of her child and keep her doctors’ appointments. Addressing Adaptation,
the theory that aims to empower individuals and enhance their independence. Promoting their
overall well-being and quality of life. Ultimately, the goal is to helps individual to control and
maintain their health. And to take care of themselves to the fullest extent possible, reducing their
dependence on other basic needs and promoting their self-esteem and self-efficacy.
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V. 13 AREAS OF ASSESSMENT
I. SOCIAL STATUS
Mrs. G, a 38-year-old resident of Brgy. Espinosa, Masbate City, Philippines, is a dedicated
businesswoman. She and her husband are raising two sons, aged 7 and 2 days old. Mrs. G is
known for her strong work ethic and entrepreneurial spirit. She does not consume alcohol or
tobacco.

II. MENTAL STATUS AND EMOTIONAL STATUS

Mrs. G, remained conscious and responsive during the assessment, though she expressed
discomfort due to back pain and soreness at the incision site from her emergency cesarean
section. As a mother of two children, she previously experienced a miscarriage during her second
pregnancy. Mrs. Grutas is grateful for her husband’s unwavering support throughout her
pregnancy and is relieved that despite her elevated blood pressure at 41 6/7 weeks of gestation,
her child was safely delivered.

III. SENSORY STATUS

a. Visual Status
Mrs. G, possesses brown eyes that she can move freely without any issues, though she
occasionally experiences blurry vision. We used an eye chart and let the client read unto
it.
b. Auditory Status
Mrs. G has partial hearing impairment and occasionally struggles to hear soft noises or
sounds. We assessed her hearing through talking in a distance with a low voice and asked
her if she can hear it clearly.
c. Olfactory status
Mrs. G’ sense of smell is functioning properly and is not impaired. We let her smell
different kind of scents.
d. Gustatory Status
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Mrs. G does not exhibit dry lips; rather, they appear pinkish in color. Her teeth are
aligned, though slightly yellowish, and her nails appear normal with a pinkish hue. She
can taste the flavor of her food well.
e. Tactile Status
The patient’s tactile status exhibits tenderness and sensitivity around the incision site
upon palpation. Other parts of the body does not show any signs of abnormality upon
palpation.
f. Language perception and Information
Mrs. G, speaks well initially, but eventually, she pauses to take deep breaths, showing
discomfort from her incision.

g. Sensory Environment
The environment is conducive with some people in the same room but Mrs. G is not
being disturbed. The patient has no issues except for finding the warm weather
uncomfortable.

IV. MOTOR STABILITY

Mrs. G, exhibits stable motor function showing small signs of impairment in coordination.
She finds it difficult to perform basic tasks such as standing, walking and sitting up on her bed
indicating that pain is still present on her incision site. The presence of motor deficits suggests
that she still needs more time to be able to recover successfully.

V. BODY TEMPERATURE
Date Time Body Temperature
May 04, 2024 8:00 am 36.8 °C
May 04, 2024 10:00 am 36.6 °C
May 04, 2024 1:00 pm 36.2 °C
May 04, 2024 3:00 pm 36.5 ° C

May 05, 2024 8:00am 36.2 °C

May 05, 2024 10:00 am 37.5 °C
May 05, 2024 1:00 pm 36.3 °C
May 05, 2024 3:00 pm 36.5 °C

May 06, 2024 8:00 am 36.8 °C

May 06, 2024 10:00am 36.7 °C
May 06, 2024 1:00 pm 36.6 °C
May 06, 2024 3:00 pm 36.8 °C

VI. RESPIRATORY STATUS

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Date Time RR
May 04, 2024 8:00 am 22 cpm
May 04, 2024 10:00 am 21 cpm
May 04, 2024 1:00 pm 21 cpm
May 04, 2024 3:00 pm 20 cpm

May 05, 2024 8:00 am 20 cpm

May 05, 2024 10:00 am 21 cpm
May 05, 2024 1:00 pm 20 cpm
May 05, 2024 3:00 pm 21cpm

May 06, 2024 8:00 am 21 cpm

May 06, 2024 10:00 am 20 cpm
May 06, 2024 1:00 pm 20 cpm
May 06, 2024 3:00 pm 21 cpm

VII. CIRCULATORY STATUS

Date Time Pulse BP
May 04, 2024 8:00 am 87 bpm 180/90 mmHg
May 04, 2024 10:00 am 88 bpm 180/80 mmHg
May 04, 2024 1:00 pm 87 bpm 180/90 mmHg
May 04, 2024 3:00 pm 90 bpm 130/80 mmHg

May 05, 2024 8:00 am 99 bpm 130/90 mmHg

May 05, 2024 10:00 am 101 bpm 130/90 mmHg
May 05, 2024 1:00 pm 98 bpm 140/90 mmHg
May 05, 2024 3:00 pm 99 bpm 130/90 mmHg

May 06, 2024 8:00 am 99 bpm 140/100 mmHg

May 06, 2024 10:00 am 95 bpm 140/90 mmHg
May 06, 2024 1:00 pm 98 bpm 130/100 mmHg
May 06, 2024 3:00 pm 100 bpm 140/100 mmhg

VIII. NUTRITIONAL STATUS

Mrs. G has a daily intake of carbs and foods rich in sodium such as dried fish for her three meals
per day. In addition to this, she maintains a healthy appetite and can eat well. The patient has a
chronic hypertension and this resulted to preeclampsia on her first pregnancy.

Weight: 58 kg. (Normal Range: 39-47.6 kg)

Height: 4’11 ft.
BMI: 25.8 (overweight) Normal Range: 18.5-24.9

IX. ELIMINATION STATUS

Mrs. G has normal elimination patterns, with bowel movements happening 1-2 times
daily and urination occurring 2-3 times daily without any issues.
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X. REPRODUCTIVE STATUS
Mrs. G reproductive health is normal. Furthermore, she and her partner are sexually active,
although not currently due to her present health condition. After the delivery of her third
child, she had BTL.

Age of gestation: 41 6/7 weeks

Last Menstrual Period: July 15. 2023
Expected Date of Confinement: April 23. 2024

XI. STATE OF PHYSICAL REST AND COMFORT

The patient is having difficulties in resting easily, primarily due to the presence of back pain
and discomfort at her incision site. Due to the high heat index the patient finds it difficult to rest.

XII. FLUID AND ELECTROLYTES STATUS

The patient's hydration status appears to be satisfactory and well-maintained, as she
consumes a sufficient number of fluids, equivalent to approximately 8-10 glasses of water per
day. This adequate intake supports her overall hydration levels, contributing to her optimal
health and well-being.

XIII. STATE OF SKIN AND APPENDAGES

 SKIN: The patient’s skin is cold to touch. The appearance of the incision site appears to
be clean, dry and pinkish but has no abnormal discoloration. This was assessed by
performing daily wound care to the client.
 HAIR: healthy, no lice and infestations present
 NAIL: nails appear pinkish in color
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VI. ANATOMY AND PHYSIOLOGY

 Cardiovascular System
The circulatory system is a system of organs that includes the heart, blood vessels, and blood
which is circulated throughout the entire body of a human or other vertebrate. It includes the
cardiovascular system, or vascular system, that consists of the heart and blood vessels.

HEART
Your heart is a vital organ. It is a muscle that pumps blood to all parts of your body. The blood
pumped by your heart provides your body with the oxygen and nutrients it needs to function.

PHYSIOLOGY OF THE HEART

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The heart is a fist-sized organ that pumps blood throughout your body. It's your circulatory
system's main organ. Muscle and tissue make up this powerhouse organ. Your heart contains
four muscular sections (chambers) that briefly hold blood before moving it.

BLOOD VESSELS
Five types of blood vessels are arteries, veins, capillaries, arterioles, and venules.

ARTERIES
Arteries distribute oxygen-rich blood to your body. Arteries, part of your circulatory
(cardiovascular) system, are the blood vessels that bring oxygen-rich blood from your heart to all
of your body’s cells. They play a crucial role in distributing oxygen, nutrients and hormones
throughout your body.

VEINS
Veins are blood vessels located throughout your body that collect oxygen-poor blood and return
it to your heart. Veins are part of your circulatory system. They work together with other blood
vessels and your heart to keep your blood moving

CAPILLIARIES
These tiny blood vessels have thin walls. Oxygen and nutrients from the blood can move through
the walls and get into organs and tissues. The capillaries also take waste products away from
your tissues. Capillaries are where oxygen and nutrients are exchanged for carbon dioxide and
waste.
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ARTERIOLES
Small blood vessels that carry blood away from your heart, are connectors between your arteries
and capillaries. They control your blood pressure and blood flow throughout your body, using
their muscles to change their diameter. They also link to capillaries to exchange oxygen,
nutrients and waste.
 WHAT HAPPENS TO ARTERIOLES
The constriction of arterioles increases resistance, which causes a decrease in blood flow to
downstream capillaries and a larger decrease in blood pressure. Dilation of arterioles causes a
decrease in resistance, increasing blood flow to downstream capillaries and a smaller decrease in
blood pressure.

VENULES
Venules are the smallest veins and receive blood from capillaries. They also play a role in the
exchange of oxygen and nutrients for water products. There are post-capillary sphincters located
between the capillaries and venules. The venule is very thin-walled and easily prone to rupture
with excessive volume.

*WHERE ARE VENULES FOUND?

Venules are vessels which lie between capillaries and veins

PHYSIOLOGY OF BLOOD VESSELS

The function of blood vessels is to deliver blood to the organs and tissues in your body. The
blood supplies them with the oxygen and nutrients they need to function. Blood vessels also
carry waste products and carbon dioxide away from your organs and tissues.

Blood is composed of formed elements (cells and cell fragments) which are suspended in the
liquid fraction known as plasma. Blood has three general functions: Transportation: e.g., oxygen,
carbon dioxide, nutrients, wastes, and hormones; Regulation: e.g., pH, temperature, and osmotic
pressures

FUNCTION of CIRCULATORY SYSTEM

Circulatory system function
Your circulatory system, also called the cardiovascular system or vascular system, moves
oxygen, nutrients and hormones to your body’s cells to use for energy, growth and repair.
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MAIN ORGANS
What are the main organs of the circulatory system
Image result for what are the main organs of the circulatory system
The parts of your circulatory system are your: Heart, a muscular organ that pumps blood
throughout your body. Blood vessels, which include your arteries, Veins and capillaries.

VII. PATHOPHYSIOLOGY
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VIII. DOCTOR’S ORDER

DATE/TIME PROGRESS DOCTOR’SORDER C E NOD.

NOTES SIG
May 3, 2024 LMP:  Admit under OB
1:00 pm 07/15/23  Secure consent
AOG: 41 6/7  IVF D5LR x 30 gtts/min
weeks  NPO
EDC:  Monitor VS q2h, FHT and
4/23/24 Progress of Labor
 Schedule for Emergency CS
 Meds:
 Hydralazine 5mg IV now
then 10mg IVT if
BP>160/110mmHg
 Magnesium Sulfate loading
dose
D5W 90ml+ 40 grams magsu to
run for 20 mins via soluset.
FF:
D5W 1L+ 20 grams magsu to run
for 50 cc/hr via soluset
Cefuroxime 1.5 mg IVTT
30mins) Prior to operation (PTOR)

May 4, 2024   May have soft diet

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5:00 am  Remove Including foley catheter
(IFCAT) 12 noon
 IVF to consume
 Start oral meds
 Cefuroxime 500 mg 1tab
BID x 7days
 Ibuprofen 400 mg 1tab BID
x pain
 Ferrous Sulfate 1tab OD
 Amlodipine 10 mg 1tab OD
 Watch out for bleeding (WOF)
 VS q4h
May 4, 2024 BP: 180/90
2:00 pm PR: 87  Daily code change of dressing
O2sat:99 (FN COD) today
Temp: 36.2  Bisacodyl suppository now
RR: 20  Diet as tolerated (DAT)
(+) flatus  Continue meds
 Daily hygiene
 VS q4h

May 5,2024 (+) flatus  May go home

6:00 am (+) BM  Continue meds
Change of  Daily hygiene
dressing  Follow up after 2 weeks
done well  Daily Change of dressing (COD)
coaptated & BP monitoring
wound no
wound
discharge
BP:130/90
PR: 99
Temp :36.2
RR ;20
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NURSES NOTES
DATE/TIME FOCUS (D-data A-action R- response)
May 3, 2024 Arrival CS + preeclampsia D- admitted Cs 38 years old
1:00 pm female G3p1 referral from
city health with ongoing,
conscious and coherent, not
in labor (+) headache, (-)
epigastric pain,
A- vs then recorded BP-
180/120 mmHg, FHT
140, So2 98%, RR 20
cpm, PR 88 bpm. With
sign consent for
admission, S/E by Dc.
R- to an endorsed
May 3, 2024 Pre-op  received patient a 38
8:20 pm Bp: 160/100 mmHg years old female,
PR: 84 bpm complete labor pain, PU
RR: 12 cpm 41 6/7 weeks AOG by
O2: 99% LMP, CIL, Prev Cs, T/c
preeclampsia, for
emergency CS+BTL
 consent signed for
cesarian section with BTL
and anesthesia signed
 NPO, no known allergies
 IVF: D5LR @ 30 ggts
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side drip of D5LR+ 20
grams of magsu
 Patient was brought to the
OR. Placed on an
9:08 pm operating table, position
at left lateral
 Spinal prep done, spinal
anesthesia induces by DR.
S
 Drapes applied
aseptically, time- eat
done.
 Initial count of
9:13 pm instruments, sharps,
needles, sutures,
emergency repeat
caesarian section + BTL
performed by Dra. O
 A live term male neonate,
9:20 pm Bby Boy 3.3 kg delivered
9:21 pm  Placenta manually
extracted current IVF
discarded then replaced
with the same IVF D5LR
+ 30 units of oxytocin to
run as regulated.
 Final counting of all
instruments, sponge,
needles, sharps, sutures
counted three times
correct and complete
 Skin layered suture by Dr.
Post op V/S O
10:30 pm Bp: 138/98 mmHg  End of procedure
O2: 99%  Top dressing applied and
PR: 100 bpm secured
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
RR 20 cpm  Transfer to OB ward
Temp: 36.5
May 3. 2024 Post operative care D- inform the OR/ Pacu via of
10: 45 pm ongoing IVF of D5LR + 30 units
oxytocin and 100 level infusing
well, conscious and coherent, an
IFC intact and patient with urine
output 300 cc
A- With bearable post operate
pain, with dry and intact wound
dressing; bp: 140/80mmhg, HR;
89 bpm RR; 20 cpm
As vs taken and recorded, due
mends given
Place in flat on bed; NPO
maintained
Keep monitoring
Daily hygiene and perineal care
advised
Daily wound dressing done and
advised
R –attended: endorsed

May 4 2024 Cont. of care D – IVF to consume, w/

7 am measurable pain; BP: 140/90
mmHg
A - v/s taken and recorded,
BF w SAP encountered;
daily hygiene keep
monitored
R- attended

May 5. 2024 For clearance D - meet order

7:00 am A –needs attended
R- for clearance
May 5. 2024 For discharge D- meet order
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
7:00 pm A – need attended
R- for clearance

Complete Blood Counts: May 4. 2024

Examination Results Normal Range

White Blood cells 12.84 (H) 5.00-10.00 10^9/L

Neutrophil 86.9 (H) 50.00-70.00%
Lymphocytes 9.2 (L) 20.00-40.00%
Monocytes 3.1 (L) 4.00-10.00%
Eosinophil 0.6 (L)2.00-8.00%
Basophil 0.2 0.00-1.00%
Red blood cells 3.5 (L) 4.00-5.50 10^12L
Hemoglobin 102 (L) 120.00-160.00 g/L
Hematocrit 29.2 (L) 40.00-50.00%
MCV 83.3 82.00-95.00 fL
MCH 29.2 27.00-31.00 pg
MCHC 351 320.00-360.00 g/L
Platelet count 161 150.00-450.00 10^9/L
Blood typing A Positive

White blood cells in patient with severe pre-eclampsia tend to be higher than normotensive
pregnancies whereas red blood cells, hemoglobin, hematocrit, lymphocyte, and monocyte in
severe pre-eclampsia normotensive pregnancies.
High WBC count when pregnant is very likely due to stress from pregnancy or if there's any
infection.

Complete Blood Counts: May 3. 2024

Examination Results Normal Range
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
White Blood cells 6.56 5.00-10.00 10^9/L
Neutrophil 66.4 50.00-70.00%
Lymphocytes 23.3 20.00-40.00%
Monocytes 4.6 4.00-10.00%
Eosinophil 5.3 2.00-8.00%
Basophil 0.4 0.00-1.00%
Red blood cells 4.37 4.00-5.50 10^12L
Hemoglobin 124 120.00-160.00 g/L
Hematocrit 6.8 (L) 40.00-50.00%
MCV 84.2 82.00-95.00 fL
MCH 28.4 27.00-31.00 pg
MCHC 337 320.00-360.00 g/L
Platelet count 184 150.00-450.00 10^9/L
Blood typing A Positive

During labor, there is further delayed in the neutrophil apoptosis which lead to further increase of
the white blood cell count after normal vaginal delivery Because the white blood cell and
neutrophil counts are physiologically high during early puerperium, therefore the white blood
cell count is not specific for Detection of postpartum infection
Complete blood count, or CBC, is a blood test that measures many different parts and features of
your blood, including:

 Red blood cells, which carry oxygen from your lungs to the rest of your blood.
 White blood cells, which fight infections and other disease. There are five major types of
white blood cells.
 Platelets, which stop bleeding by helping your blood to clot.
 Hemoglobin, a measurement of how much of your blood is made up of red blood cells.
 Mean corpuscular volume (MCV), a measure of the average size of your red blood
cells.

Other names for complete blood count: CBC, full blood count, blood cell count.

A complete blood count is a common blood test that is often part of a routine check-up.
Complete blood counts can help detect a variety of disorder including infections, anemia, disease
of the immune system, and blood cancers.

Blood Chemistry: May 3. 2024

 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
Examination Results Normal range

BUN 6.39 L 7.94-20.40 mg/dl

CREATININE 1.18 H 0.51-0.95 mg/dl

URIC ACID 4.88 2.60- 6.00 mg/dl

ALT / SGPT 14.31 0.00- 34.90 IU/L

AST / SGOT 27.50 0.00-34.90 IU/L

SODIUM (Na+) 136.0 L 138.00–146.00 mmol/L

POTASSIUM (K+) 4.23 3.50-4.90 mmpl/L

CHLORIDE (Cl-) 110.1 H 98.00-109.00 mmol/L

A blood chemistry study is a procedure in which a blood sample is checked to measure the
amounts of certain substances released into the blood by organs and tissues in the body. An
unusual (higher or lower than normal) amount of a substance can be a sign of disease in the
organ or tissue that makes it.

Serology: May 03, 2024

Test Result
ANTI-HAV IgG
IgM
DENGUE TEST IgG
IgM
NS1
H.PYLORI
HbsAG NON-REACTIVE
HCV
HIV
MALARIA
SYPHILIS NON-REACTIVE
TYPHIDOT IgG
IgM
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
Serologic tests are blood tests that look for antibodies in your blood. They can involve a number
of laboratory techniques. Different types of serologic tests are used to diagnose various disease
conditions.
Serologic tests have one thing in common. They all focus on proteins made by your immune
system. This vital body system helps keep you healthy by destroying foreign invaders that can
make you ill. The process for having the test is the same regardless of which technique the
laboratory uses during serologic testing.

Hematology (Coagulation Test): May 04, 2024

RESULT REFERENCE RANGE

PT 11.5 10.00-14.00 seconds

INR 1.00 0.70-1.30

Hematology is the study of blood and blood disorders. Hematologists and hematopathologists are
highly trained healthcare providers. They specialize in diseases of the blood and blood
components. These include blood and bone marrow cells. Hematological tests can help diagnose
anemia, infection, and hemophilia. They also include blood-clotting disorders, and leukemia.
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing

XI. DISCHARGE PLAN AND PROGNOSIS

DISCHARGE PLAN
Medication -Instruct the patient to take all medication that were prescribed by the
physician.
- Cefuroxime 500 mg 1tab BID x 7days
- Ibuprofen 400 mg 1tab BID x pain
- Ferrous Sulfate 1tab OD
- Amlodipine 10 mg 1tab OD

EXERCISE AND ACTIVITY

-strenuous exercise is not advised for the patient to give time for the body to recover from the
recent delivery.
- only basic exercise advice for the patient like slow walking and basic chores that does not
require too much effort

TREATMENT AND THERAPY

discussing the purpose of treatment to be done and continued at home
- always monitor the blood pressure and teach the client on how to do the proper perennial care.
- follow up checkup after 1 week.

HEALTH TEACHING
- advise the patient continue breastfeed - encourage client to provide adequate rest period
to avoid stress. - encourage patient to be more hygienic. - advice patient to have follow
up check ups

DIET
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
- advice low salt and low fats

SPIRITUALITY
- Advised patient to continue trust and communication with God.

PROGNOSIS
The prognosis in preeclampsia depends on how carefully a patient is monitored. Very careful
consistent monitoring allows quick decision to be made and improves the woman's prognosis is
still the most common cause of death and pregnancy woman are related to high blood pressure.

The outlook for full recovery from preeclampsia is very good. Most women begin to improve
within one to two days after delivery. And blood pressure returns to the normal pre pregnancy
range within the next 6 to 12 weeks in including proteinuria. Baby complication can be mostly
avoided if the condition is controlled.

Preeclampsia usually does not cause permanent damage or adversely affect the long-term health
of the mother but rest of preeclampsia is greater in subsequent pregnancies prenatal care can
dramatically reduce the complication and deaths of preeclampsia because woman who are
diagnosed while preeclampsia smile can receive treatment without any delay.

CRITERIA FAIR GOOD POOR RATIONALE

Onset of Illness  Our patient
found out about
her condition on
her first
pregnancy. The
patient has
chronic
hypertension and
this resulted on
her 1st pregnancy
Duration of Illness  Her illness started
during her first
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
pregnancy and is
still monitored up
to the present
since she was
advised by her
physician to
continuously
check her blood
pressure.
Environmental  Mrs. G, is not
Factor stressed about
her daily life but
she is having a
hard time
because of the
weather’s high
heat index.
Willingness to  The patient is
take the willing to take
medication and comply with
her treatment
regimen because
she knows that it
is for her own
benefit.
Age  The patient’s age
is 38.
Preeclampsia is
common with
age 35 and
above as well as
20 and below.
Family Support  Her family
supports her,
especially her
husband who
was with her
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing
most of the time
during her
pregnancy and
hospitalization.
Precipitating  The patient
Factor already has
family history of
hypertension on
both her mother
and father’s side
 SOUTHERN BICOL COLLEGES
Mabini Street, Masbate City
College of Nursing

XII. REFERENCES:
 https://www.ncbi.nlm.nih.gov/books/NBK570611/?
fbclid=IwZXh0bgNhZW0CMTAAAR1MFa_g-
L3Wi45tHtsam9Ulg7dmxVsCN9Nnsk26XkZzEnGMRsphJW9ii4E_aem_AcPz2YYu8lx
aDN-VYC_BISzrMIxNqHqjN8EmdQ77cgcCp_L65I-
LNzLQN2Gz0IUsLUBYefVPFl8_7ik_bW6863sw#:~:text=This%20includes
%20pregnancy%2Dinduced%20hypertension,two%20times%20greater%20than
%20baseline

 https://www.nichd.nih.gov/health/topics/preeclampsia/conditioninfo/diagnosed?
fbclid=IwZXh0bgNhZW0CMTAAAR2DMB6H-1ov9EwaBb-v8Z4QC9ZRC2IDB9-
cSkaEWnaCS4bx8SfeQl5ryS4_aem_AcMOSETY3NSIO6Qkgphy2QiNCfnTQprTUQgl
9vg8p17zyXu24ySB0CwUP78VTgCOHDYJnxsDhTv3WPHWGRPBzUgb#:~:text=If
%20the%20blood%20pressure%20reading,as%20well%20as%20other%20symptoms

 https://emedicine.medscape.com/article/1476919-overview?
fbclid=IwZXh0bgNhZW0CMTAAAR1MFa_g-
L3Wi45tHtsam9Ulg7dmxVsCN9Nnsk26XkZzEnGMRsphJW9ii4E_aem_AcPz2YYu8lx
aDN-VYC_BISzrMIxNqHqjN8EmdQ77cgcCp_L65I-
LNzLQN2Gz0IUsLUBYefVPFl8_7ik_bW6863sw&form=fpf

 https://emedicine.medscape.com/article/1476919-overview?
fbclid=IwZXh0bgNhZW0CMTAAAR1MFa_g-
L3Wi45tHtsam9Ulg7dmxVsCN9Nnsk26XkZzEnGMRsphJW9ii4E_aem_AcPz2YYu8lx
aDN-VYC_BISzrMIxNqHqjN8EmdQ77cgcCp_L65I-
LNzLQN2Gz0IUsLUBYefVPFl8_7ik_bW6863sw&form=fpf