Introduction
Pre-eclampsia is a condition unique to human pregnancy (Perry and Alden, 2012). The signs and symptoms for pre-eclampsia develop only during pregnancy and disappear soon after delivery of the baby and placenta. The cause of this is unknown. Pre eclampsia can progress a long a continuum from mild to severe pre-eclampsia to eclampsia. These changes are present long before the clinical diagnosis of pre-eclampsia is made (Roberts and Funai, 2009). Abnormalities in the development of blood vessels of the uterus and placenta very early in pregnancy appear to initiate a cascade of events that eventually cause pre-eclampsia (Perry and Alden, 2012).
Sign and symptoms of pre-eclampsia occur, in part, due to changes inside the small arteries that decrease blood flow to major maternal organs such as kidney, brain, liver and as well as placenta ( Porth and Matfin, 2009). Some of the symptoms that the client will come up with are head- ache, changes in vision, including temporary loss of vision, blurred vision or light sensitivity,nausea or vomiting and pain in the mid or right epigastrium (similar to heart burn). Most women with pre-eclampsia have mildly high blood pressure and a small amount of excess protein in the urine and do not experience any symptoms of the diseases.
For the foetal, pre – eclampsia can impair the ability of the placenta to provide adequate nutrition and oxygen to the baby, which can have the following effects: slowed growth of the baby, usually noted by ultrasound examination, decreased amount of amniotic fluid around the baby and decreased blood flow through the umbilical cord, noted on Doppler tests.
BIO DATA:
The patient is Mrs X, who is a 27 year old I-taukei female. She is a Methodist. Mrs X present address is in Benau. She is married. Mrs X attend FNU- in Lautoka, to do teaching. As for right now, Mrs X is teaching in Bethel Primary School for class 6.
Chief Complain:
According to Mrs X, she was having abdominal pain associated with head ache and fever.
History of present Illness:
Onset:
Mrs X developed abdominal pain when she was lying down watching television at her home in the evening after dinner. But her head aches and fever just started few hours after abdominal pain.
Location:
The location of the pain for Mrs X was on the upper region on the right side.
Radiation:
Mrs X describes that the abdominal pain radiates to the back and lumber region
Precipitating Factor:
Mrs X explained that when she is tired from work then all these things will always the cause of her illness.
Relieving Factor:
The only way for Mrs X to relieve pain is for her to take a rest, sleep or listen to soft music.
Associated Symptoms:
The associated symptoms for Mrs X was head ache and fever.
Past treatment& evaluation:
Actually this is a first time for Mrs X to be admitted in hospital with this condition.
Effect of symptoms on ADL’S: Functional pattern
• Eating pattern- according to Mrs X she always eats, three meals a day but when in this condition arise she only eats limited amount of food and not that much as before.
• Sleeping pattern- according to Mrs X she cannot sleep properly when in pain. Otherwise sleeping pattern is normal when pain is not present.
• BO & PU pattern: Mrs X passing of bowel and urine pattern is normal.
Personal History: Upon asking about her personal history, she got married when she was just 24 years of age. Up till now it has been eleven years of marriage and is a successful relationship between her and the husband. She got one child and is a boy of 4 years of age.
Past Medical / Obstetrics History:According to patient medical history, she got previous caesarean section on her eldest son Reason of caesarean section was because of thick meconium being notified. Otherwise Mrs X does not have any other previous medical condition.
Psychological Effect:According to the husband Mrs X always feel depressed quickly because of the tension of work at her work place in school and home as well. But during her admission in hospital, she was always worried about her condition and the baby that she was caring.This is only happening to her because of her pregnancy process. As according to (Townsend, 2015) this can lead to postpartum depression because it is associated with hormonal changes.
Family medical History:
As for Mrs X family medical background they have a history of hypertension. The client mother is a known case of hypertension. Actually for Mrs X this is the first time for her to have this condition (hypertension)
Family Psychiatric History:
Also Mrs X did not have any history of psychiatric illness in her family.
Social History:
Apart from all that, Mrs X social history, she does domestic duties. She does not smoke, drink neither alcohol nor smoke. She attends Methodist church in her village. Upon interviewing Mrs X, she lives in a very healthy environment. The client family lives in a tinned and wooden house with perfect sanitation in rural areas.
ASSESSMENT-(OBJECTIVE DATA)
AOG:
According to Mrs X she was 28 weeks.
Vital Signs:
Her initial vitals sign was taken, blood pressure of 139/91mm/HG, pulse of 78 beats per minutes, respiration of 24 breaths per minute and temperature of 37.3 degree Celsius. Mrs X weight was taken came to 94kg, capillary blood glucose 4.7mmol.
Weight: 96kg
Height: 1.63m
Inspection:
Mrs X was inspected from head to toe. Finger nails was short and cleaned. Hands were pinkish red blotches or swelling of hands. According to (Wilson and Giddens, 2009), this is due to an increase in estragon is termed as palmar erythema and is considered normal findings. Also breast inspection was done for Mrs X.Movements and sensation of hands was normal. Also it was noticed that Mrs X had got general edema that is from face till the leg.
Palpation:
Breast palpation- to rule out any masses and it reveals fullness and coarse nodularity (Wilson and Giddens, 2009).
Abdominal palpation:
Fundal palpation-to determine what part of the fetus is at the fundus
Lateral palpation-to identify the spines of the fetus.
Symphysis pubis palpation- to determine if the presenting part is engaged. For Mrs X, was not yet engaged.
*Also there was palpation of Mrs X lower extremities that is her leg, edema was being notified. Normally it occurs on pregnant mothers but as a nurse we should always palpate to help in determining the extent of edema. According to (Wilson and Giddens, 2009), vascular spiders or varicosities may appear on the lowest legs or thighs and are considered to be normal findings.
Percussion:
Percussion was done to know the patella reflex. For Mrs X, she was able to move her leg; she can walk and do most of the things when standing. It shows that she had a good reflex.
Auscultation:
Nurses Findings:
For critical cases it is very important to take bloods test. Mrs X blood results was shown that the creatinine level was >1.1mg/dL, platelet count is <100,000, uric acid > 7mg/100ml and the protein urea 0.3g/ or +1 to +2 on the qualitative scale, elevation of haematocrit that implies hemoconcentration which occurs as fluid leaves the intravascular space and enters the extravascular space (Marca, 1996) .Later on the evening Mrs X went for ultrasound scan to determine gestational age and to rule out any structural abnormalities such as cardiac and renal abnormalities and to know the status of the baby.
Looking at Mrs X folder as according to all the assessment being done by obstetrics doctor, she was finally diagnosed with pre-eclampsia when all the blood and urine results came out. As according to Mrs X folder she was been hospitalized and monitored closely by the medical professions. Lastly, she ended up having another caesarean section because of her baby’s condition being deteriorating. She managed to give birth to a healthy female baby, weighing 3.5kg.
NURSING CARE PLAN
Nursing Diagnosis Nursing Implementation/ Goals Nursing Intervention Rationale Evaluation
Decreased output related to decreased venous return After 8 hours of nursing interventions, the patient will participate in activities that decreases blood pressure or cardiac workload Independent:
-monitor blood pressure of the patient. Measure in both arms 3 times, 3-5 min apart while patient is at rest.
-observe skin colour, moisture, temperature and capillary refill time.
-Note dependent or general oedema
-provide calm, restful surroundings, minimize environmental activity or noises
-maintain activity restrictions
Collaborative
Dietician:
-implement dietary sodium, fat and cholesterol as indicated.
-comparison of pressure provides a scope of problem.
-presence of pallor, cool moist skin and delayed capillary refill time may be due to vasoconstrictions.
-may indicate heart and renal impairment.
-help reduce sympathetic stimulation promotes relaxation.
– reduce physical stress and tension that affect blood pressure
-help manage fluid retention -after 8 hours of nursing interventions the patient was able to participate in activities that reduces blood pressure or cardiac workload
Fluid volume deficit related to pressure, allowing fluid shift out of vascular compartment -client should be able to maintain weight and to be free from any signs of oedema Independent:
-Monitor weight daily
Collaborative:
– reviewed laboratory results
– Significant weight gain reflects fluid retention. Fluid moves from vascular to interstitial space, resulting in oedema
-to evaluate degree of fluid deficit. – Patient was free of signs of oedema
Ineffective tissue perfusion related to altered placental blood flow caused by vasoconstriction of blood vessel For patient to have sufficient bed rest to improve on her conditions. Independent:
– Promote bed rest
-patient should be in recumbent position on bed
Collaborative:
Dietician:
To ensure that the client improve on iron diet
-aiding increased evacuations of sodium and encouraging diuresis.
– Sodium tend to be excreted at a faster than during activity.
-To replace protein lost through kidney. Patient able to normalise her daily activity and improve on her diet.
Knowledge deficit related to lack of information about pre- eclampsia it’s treatment and the implications for the woman and her foetus -for the patient to be free from all worries and anxiety
-woman verbalizes her understanding of the conditions and its implications Dependant:
Independent:
-discuss pre-eclampsia and its implications for the client and foetus/newborn
-explain the purpose and importance of treatment measures
Collaborative:
-work with the woman/family to plan ways for them to deal with the hospitalization
-through information may help the woman/ family better understand the condition and its implications
-hospitalized during pregnancy is usually unanticipated and may cause a major disruption in the woman’s/ family’s life.
-woman/ family able to discuss pre-eclampsia disease process, and verbalize implications for mother and foetus/ newborn and importance of compliance with treatment measures.
Imbalanced nutrition, less than body requirements related to inadequate food intake manifested by nausea and anorexia -for the patient to be able to recuperate her eating pattern Independent:
-monitor eating pattern
-feed 2hourly
Collaborative:
Dietician to the counselling and do the diet list for the patient.
– so that she can have enough energy for her and especially the baby -able to practice her normal eating pattern
Risk for injury to foetus related to inadequate placental perfusion secondary to vasospasms or possible abruption placentae Foetus will tolerate the stress of maternal condition without injury Independent:
-report any signs of abruption placentae such as uterine tenderness, vaginal bleeding, change in foetal activity, change in foetal heart rate
Collaborative:
Refer the client to the obstetrics if any complications.
-vasospasm and high blood pressure of pre-eclampsia increase the risk of abruption placentae.
-to ensure that the patient is not in critical condition. – the fetal heart rate was in normal range from 120-160bpm
-mother reports no abdominal tenderness or bleeding.
Impaired sense of comfort (pain) related to uterine contractions -make sure that patient does not feel discomfort when contracting Idependant:
-assess the patient pain intensity level
-teach patient with the breath in anticipation of pain
-help the patient by rubbing or massaging on
the painful part
Collaborative:
-Reviewing of bloods.
– pain threshold will be able to determine appropriate action treatment with patient response to pain
-with a deep breath to relax the muscle, so that the oxygen demand on the tissue are met.
-to distract the patient
-to ensure that the patient is stable with all the blood counts. -pain is reduced without any discomfort for the patient
Risk of infection related to post-operative site -within 8 hours of nursing intervention, the client will be free from signs of infection. Independent:
-monitor vital signs especially temperature
-observe and report signs of infections such as redness, warmth and increased body temperature
-use appropriate hand hygiene
Collaborative:
-Refer the patient to the obstetricians if any complication about the incision site.
-increased body temperature may indicate infection
-fever of unknown origin is the most common sign of nosocomial infection
-to reduce transmission of antimicrobial resistant micro-organism and reduce infection rate
-to ensure that the patient is not having any complication with her incision site. To prevent infection.
-after 8 hours of nursing interventions, the client will be free from signs of infection as evidence by absence of redness, swelling and other signs of infection
Summary
Women with pre-eclampsia develop high blood pressure and generally have protein in their urine. It occurs mostly after 20 weeks of gestation or in the few days after delivery. Currently there are no test that can reliably predict who will get the disease. Majority of women with pre-eclampsia have no symptoms. The only cure for pre-eclampsia is delivery of the baby and placenta. Because women with pre-eclampsia sometimes develop seizure (called eclampsia), most are treated with an anticonvulsant medication which is Magnesium Sulphate. It is mostly given intravenously to the mother during labour and usually for 24 hours after delivery.
Most women who experience pre-eclampsia without severe features will not have it again in a future pregnancy. The risk of recurrence is higher in women with severe features of pre-eclampsia, especially when they occur in the second trimester. Those who develop pre-eclampsia most likely to be at risk of developing cardiovascular disease later in life, so regular health care may be important in this group of patients.
In conclusion, while doing this case study it makes me know and understand better about pre-eclampsia. Especially as a nurse one should know your role and responsisbilities when it comes to critical case such as pre-eclampsia.
(Approximate no: 2465 words)
REFFERENCE
Lowdermilk, Deitra Leonard, and Shannon E Perry. Maternity Nursing, 10th Edition, 2012, USA.
Marcra. S. Maternal Newborn Nursing, 5th Edition, 1996, California
Porth. C .M,Matfin.G. Pathophysiology, 8th Edition, 2009, China.
Richard . A. Pharmacology for Nursing Care, 8th Edition,2013,USA.
Willson.F.S ,Gidden. F.G. Health Assessment for Nursing Practise, 4th Edition,2009, Canada.
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