INTRODUCTION

A serious, statistically important disorder characterized by the development after

the twentieth week of gestation of hypertension, with proteinuria or edema or both. These

symptoms should be progressive in severity to actually make the diagnosis of pregnancy-

induced hypertension. If coma or convulsion–not caused by coincidental neurologic

disease–complicates the course of the illness, it is then called eclampsia.

Guided by our enlarging view of Severe preeclampsia, nurses are in a prime

position for aiding in promoting the optimal level of wellness in our patients. This begins

with thorough assessments. Blood pressure measurements should be accurate, and never

be treated as trivial. Other objective assessment data may include monitoring pertinent

laboratory values, proteinuria, and fetal surveillance. Subjective data such as visual

disturbances and headaches, which may be precursors to seizures, should also be

assessed. All of these assessments are important.

Nurses also should relish their role as patient advocates and patient educators. As patient

advocates, and armed with the knowledge of recent research, nurses are in a position to

promote care that is both evidence-based and appropriate. As patient educators, nurses

are able to increase their patients' ability to understand and participate in their own care to

achieve the optimal level of wellness.

A database of hospital discharge data from approximately 300,000 deliveries in

the United States found the overall incidence of severe preeclampsia was about 1 percent

of pregnancies. Studies of preeclampsia report about 5 percent of nulliparous women

develop preeclampsia and 40 to 50 percent of these women develop severe disease. Chief

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causes of the maternal death are aspiration (pneumonia), cerebral hemorrhage, cardiac

failure with pulmonary edema, or obstetrical hemorrhage associated with premature

separation of the placenta.

In the Philippines, according to Department of Health, Maternal Mortality Rate

(MMR) is 162 out of 10,000 live births (Family Planning Survey 2006). Maternal deaths

account for 14% of deaths among women. For the past five years all of the causes of

maternal deaths exhibited an upward trend. Preeclampsia showed an increasing trend of

6.89%; 20%; 40%; and 100%. Ten women die everyday in the Philippines from

pregnancy and childbirth related causes but for every mother who dies, roughly 20 more

suffer serious disease and disability. The UNFPA office in the Philippines declared that

family planning can help prevent maternal deaths by 35%. (http://hb4110.net/wp-

content/uploads/KIT_MATERNAL%20HEALTH_BASIC%20STATS.doc.)

Treatment of preeclampsia depends on the severity of the symptoms encountered, the

philosophy of the physician, and the understanding of the compliance of the client. She

and her family deserve careful teaching regarding her problem, its observation, and its

treatment. Regular, adequate prenatal care is the best insurance for control of the

complication. Magnesium sulfate is the first-line treatment of prevention of primary and

recurrent eclamptic seizures. It reduces transmission of nerve impulses from brain to

muscles.

We decided to use this as a subject for our case study because as what we all know this

kind of illness is said to be a silent killer if prompt medical attention is unmet. That is

why we want to know the root cause of such disease in order for us to know how we

could intervene and play our role as a nurse. We believe that by studying this case we

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will gain more information and knowledge about the disease and will lead us to a certain

perception as to how we will manage and care if ever we will experience again patients

with the same disease.

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 OBJECTIVES

General Objectives:

This study done by group 3 of BSN 3E aims to present all the details about Severe

Preeclampsia; its causative factors, its damage to the human physiology, and its

underlying complications if left untreated. This can be achieved through research, with

the use of the patient’s hospital records, article references and other materials, and

through interviewing the patient during hospitalization; also, to formulate a complete and

comprehensive definition of the diagnosis.

This study also aims to understand the medical principles that accompany

Preeclampsia. With this, we hope this will lead to insights on appropriate nursing care

and management that a patient with the same such ailments will need in the future.

Specific Objectives:

The specific aims of this study are:

• Establish a good interpersonal therapeutic relationship with the patient as well as

her family and significant others;

• Formulate an introduction related to the condition being studied, which includes

implication to nursing practice, research and education;

• Obtain patient’s data of the patient’s physical condition as wel as her overall body

system functioning;

• Assess patient’s background, such as medical history and family structure as well

as its function that could have affected that patient’s current health status;

• Assess the condition of the client through physical examination using

cephalocaudal approach;

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• Define the complete diagnosis of the patient coming from the different references

• Discuss the human anatomy and physiology of the systems involves in the disease

process of our client;

• Trace the pathophysiology of the disease from the possible cause

• Identify the symptoms, predisposing and precipitating factors that contribute to

the present illness of the client;

• Determine various laboratory and diagnostic examination used in relation to the

disease with its corresponding nursing intervention;

• Research the medications administered to the patient;

• Identify the different medical and nursing management that was carried out to the

patient.

• Make appropriate nursing care plans for the patient

• Health teachings that must be given to the patient

• Determine client’s prognosis on the disease

• Present all the references used in the case study

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 PATIENT’S DATA

Name:Mrs. X

Address:Cateel, Davao Oriental

Age:35 y.o.

Sex: Female

Civil Status:Married

Nationality:Filipino

Religion:Roman Catholic

Occupation:Physical therapist and housewife

Birthplace: Davao Oriental

Birth date: April 11, 1973

Educational Attainment: College graduate

Family Data:

Spouse: Mr. Y

Age: 34 y.o.

Occupation: Resigned airforce

Father's Name: Mr. A

Mother's Name: Mrs. B

Number of Children: 1

Clinical Data:

Patient's Name: Mrs. X

Age/Sex: 35 y.o./Female

Date of Admission: Sept. 3,2008

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Hospital: Davao Medical Hospital (DMC)

Ward: OB

Admitting Physician: Dr. Herera-Chua

Attending Physician: Dr. Orinello Mautilla

VS on Admission:

Temp: 36
BP: 110/70 mm Hg
PR: 80 bpm
RR: 20 bpm

Surgical Procedure: Stat. CS with BTL

Date of Operation: Sept.6,08

Anesthesiologist: Dr. Ongkingco

Surgeon: Dr. Dribello

Time of Operation: 10:25am- NA

Address: Cateel, Davao Oriental

Final Diagnosis: Pregnancy Uterine delivered by repeat low segment transverse CS 32

weeks by billiard score. Cephalic delivered to live birth baby girl felt heart rate by
auscultation. Pre-ecclampsia severe Stat. LSS with uncontrolled BP. Operation LS TCS
with BTL (Bilateral Tubal Ligation).

7
 FAMILY BACKGROUND

Health History

Mrs. X was born on April.11,1973. And she’s the 2nd among the 5 siblings of Mr. A and

Mrs. B. Both of her parents are living. Mrs. X is currently living with her husband and

has been blessed with 1 child. Mrs. X was born and raised in Cateel, Davao Oriental

where she lived and went to school. She took up Physical Therapy but since she had been

pregnant she stopped working and considered herself as a housewife. She has no vices,

does not drink nor smoke. The familial disease that runs in their family is hypertension.

They also have their business which is a small restaurant and sells meat and fishes too.

She gave priority on the food and the everyday fare of her daughter. Their family income

which is 1,500/week is enough to support their needs.

Past Health History

The patient experienced her first hospitalization and was admitted on 1998 at

Davao Medical Center to deliver her 1st baby. Aside from hypertension which is

hereditary in their family, she only experienced illnesses such as colds, cough and fever.

She also said that she experience migraine because of stress. She self medicates

whenever her condition is not that serious and only entertains the thought of seeking

consultation whenever her condition cannot be relieved by home meds. She had

completed her immunizations that have been given during her younger years.

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Menstrual History:

Her menarche occurred at the aged of 14 years old. She has regular monthly cycles and

lasts about 5-6 days. Sometimes she experienced primary dysmenorrhea, pain that occurs

typically in the lower abdomen and is crampy. Her last menstrual period was on Dec.29,

2007.

Contraceptive History

She didn’t experience to take any of those contraceptives.

History of Present Illness

Mrs. X had a Normal Spontaneous Vaginal Delivery (NSVD) on her first

pregnancy. On her 2nd,3rd,and 4th pregnancy was through Cesarean operation, her babies

died because of premature delivery. Her last menstrual period was on Dec.29, 2007. Her

estimated time on confinement is Oct. 6, 2008. Her age of gestation is 36weeks and 2/7

days. On her 5th pregnancy she was then given a shot of Tetanus Toxoid at Jan 7,2008

and completed her 5 shots in 9mos. And was told to have a cesarean section due to her

previous CS delivery and she had also decided to undergo Bilateral Tubal Ligation. On

Sept.3, 9:30a.m of this year, a days prior to patient’s admission, she complained of labor

pain. She was admitted at Davao Medical Center for further evaluation and tests. After

being seen and examined by her attending physician, high blood pressure, proteinuria,

migraine and pitting edema of about 2mm by 8mos. prior to her admission were noted

and diagnosed to have a severe preeclampsia.

The patient was willing to submit herself for the said procedure and voluntarily

signed her consent on Sept.6 ,08 at 10:30 am. In Davao Medical Center.

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Effects of Illness to self and family

The patient remains to be positive regarding her condition. They planned their

last pregnancy because their 2nd,3rd and 4th child died. And since their last baby died, she

decided to have a bilateral tubal ligation because she feared that her future pregnancy

might have the same condition. She said that she would want a speedy recovery so that

she would be able to work and manage her business again.

Her family members are supportive and taking turns in staying with her at the

hospital. Financially speaking, they are not bothered because they are able to support the

patient’s medical needs.

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 DEVELOPMENTAL DATA

Development implies a progressive and continuous process of change leading to a

state of organized and specialized functional capacity. These changes can be measured
quantitatively but more distinctly measured in qualitative changes. Development is the
behavioral aspect of growth and these proceeds from simple to complex, or from single
acts to integrated acts.

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 Theorist Theory Stage Result and

Justification

Robert Robert Mrs. X, is 35 years old Mrs. X has

Havighurst’s Havighurst and belongs to the early achieved the first

Developmental believed that adulthood (20-40) and the developmental

Milestones Theory learning is basic following are the tasks task which is

to life and that that the person must selecting a mate

people continue achieve during this stage. because she

to learn Developmental already found

throughout life. task someone to

A become his partner

1. Selecting a √
developmental in life in the
mate
task is a “task person of her

which arises at 2. Learning to √ husband.

or about certain live with a She has achieved

period in the life partner the second

of an individual, developmental
3. Starting a √
successful task which is
family
achievement of learning to live

which leads to with a partner

4. Rearing √
happiness and to because she has
children
success with been married for

later tasks, while 5. Managing a √ fourteen years and

failure leads to home in spite of their

unhappiness in marital problems

the individual, 6. Getting started √ they were able to

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disapproval in in an occupation adjust throughout

the society, and their marriage and

13
Psychosocial Erikson envisions Mrs. X belongs to the Our patient has

Theory of life as a sequence of stage of generativity partially achieved

Development by levels of versus stagnation this stage of

Erik Erikson. achievement. Each (25-65 years old). development.

stage signals a task The syntonic quality Though still at 35

that must be of adulthood is years of age she

achieved. The generativity., defined has showed

resolution of a task as “the generation of positive indicators

can be complete, new beings as well as that she can

partial, or new products and new achieve this task

unsuccessful. ideas”. It is successfully. She

Erikson believes concerned with plays significant

that the greater the establishing and roles in her

task achievement, guiding the next business and

the healthier the generation, includes households as well

personality of the the procreation of as in her

person; failure to children, production community. She

achieve a task of work, and the has one child and

influences the creation of new things raised her to be a

person’s ability to and ideas that good individual.

achieve the next contribute to the Being a mother and

task. Erikson’s building of a better a wife she does her

eight stages reflect world. The anisthesis best to continue

both positive and of generativity is learning by being

negative aspects of stagnation. It active in the

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the critical life happens when people community

periods. The become too absorbed activities. She

 DEFINITION OF COMPLETE DIAGNOSIS

Complete: Pregnancy Uterine delivered by repeat low segment transverse CS 32 weeks

by billiard score. Cephalic delivered to live birth baby girl felt heart rate by auscultation.

Pre-ecclampsia severe Stat. LSS with uncontrolled BP. Operation LS TCS with BTL

(Bilateral Tubal Ligation).

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UTERINE PREGNANCY

A normal pregnancy occurs when a fertilized egg is implanted in the uterus

(womb) and an embryo grows.

Source: http://www.emedicinehealth.com/pregnancy/article_em.htm

CAESAREAN SECTION DELIVERY

Caesarean delivery is the delivery of a fetus through a transabdominal incision of

the uterus. The basic purpose or use of caesarean delivery is to preserve the life and

health of the mother and her fetus. It is based on evidence of maternal or fetal stress.

Source: Essentials of Maternity Nursing, 3rd Edition, Bobak and Jensen

LOW SEGMENT CS DELIVERY

Lower segment caesarean delivery can be performed through a vertical or

transverse incision. It is more popular because it is easier to perform, is associated with

less blood loss and fewer postoperative infections, and is less likely to rupture in

subsequent pregnancies.

Source: Essentials of Maternity Nursing, 3rd Edition, Bobak and Jensen

CEPHALIC

Presentation of any part of the fetal head, usually the upper and back part as a

result of flexion such that the chin is in contact with the thorax in vertex presentation.

There may be degrees of flexion so that the presenting part is the large fontanel in

sincipital presentation, the brow in brow presentation, or the face in face presentation.

Source: http://cancerweb.ncl.ac.uk/cgi-bin/omd?cephalic+presentation

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SEVERE PRE-ECLAMPSIA

A woman when her blood pressure has risen to 160 mm Hg systolic and 110 mm

Hg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic

blood pressure is 30 mm Hg above her prepregnancy level. Marked proteinuria, 3+ or 4+

on a random urine sample or more than 5 g in a 24-hour sample, and extensive edema are

also present. With severe preeclampsia, the extreme edema will be noticeable as puffiness

in a woman's face and hands. It is most readily palpated over bony surfaces, such as over

the tibia on the anterior leg, the ulnar surface of the forearm, and the cheekbones, where

the sponginess of fluid-filled tissue can be palpated against bone. If there is swelling or

puffiness at these points to a palpating finger but the swelling cannot be indented with

finger pressure, the edema is nonpitting. If the tissue can be indented slightly, this is 1+

pitting edema; moderate indentation is 2+; deep indentation is 3+; and indentation so

deep it remains after removal of the finger is 4+ pitting edema.

Source:MCN pp.427-428 by Adele Pilliteri

The patient’s blood pressure rises to 160/110 mmHg or more on two separate

occasions 6 hours apart with pregnant woman on bed rest. Presence of proteinuria of 5-10

g/L in 24 hours or 2+ or more protein on dipstick, generalized edema, noticeable

puffiness of eyes, face, and fingers, pulmonary edema, hyperreflexia 3+ or more, ankle

clonus, oliguria (less than 100 ml/4 hr output), severe headache, blurred vision,

photophobia, blind spots on funduscopy, severe irritability, elevated serum creatinine,

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and presence of thrombocytopenia.

Source: Essentials of Maternity Nursing, 3rd Edition by Bobak, Jensen

BILATERAL TUBAL LIGATION (BTL)

Tubal ligation for women seeking out a safe, effective, permanent and convenient

form of contraception, may be a good option. The most common form of surgical

sterilization procedure used for women today is called a tubal ligation, often referred to

as "having your tubes tied". A tubal ligation procedure prevents the egg and sperm from

meeting and you from becoming pregnant. It is a permanent and highly effective form of

birth control. A tubal ligation typically is performed via a small incision in your belly

button . It can either be performed after delivery or at a latter time. When a tubal ligation

is performed after delivery it is called a post-partum tubal ligation and does not require

laparoscopy. If you have a tubal ligation and you are not pregnant, it is usually performed

by laparoscopic surgery. All forms of tubal ligation require either burning, cutting,

clamping or tying the mid section of your fallopian tubes.

Source: http://www.womenshealthcaretopics.com/surgical_sterilization.htm

PHYSICAL ASSESSMENT

General Survey:

Our patient, Mrs. X, 35 years old was assessed on September 7, 2008. She was

admitted at Obstetrical ward, Davao Medical Center on September 3, 2008. He weighs 67

kg. and a height of 5’0”. Patient was received lying on bed conscious, coherent and

responsive. She cooperates and participates in our physical assessment. She has 1 child.

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The patient’s body structure is endomorphic.

Vital signs:

12:00 am 4:00 am

BP - 140/100 BP -120/90

PR - 71 bpm PR - 77 bpm

RR - 20 bpm RR - 23 bpm

Temp. - 36 ۫ C Temp. – 36.2۫ C

Skin

Our patient has a brown complexion. She has cold clammy skin. She has a poor

skin turgor as skin slowly goes back to its previous state after being pinched and with

capillary refill of 3 seconds. Dry skin and has a rough texture. Presence of hairs noted in

the head and in the upper and lower extremities. Lesions, bleeding and bruises were not

seen upon observation. Nails are not properly trimmed and traces of dirt noted.

Hair

Hair is black in color and evenly distributed. No signs of dandruff and lice noted.

No swelling, laceration, bruises and tenderness were seen upon inspection.

Eyes

Eyes are symmetrical with each other. The cornea is moist and white in color. The

iris appears to be black on both eyes. Pupils are equally round and reactive to light

accommodation with a papillary size of 2-3 mm. She does not have any problem in her

eyesight. Eyebrows are thin and eyelashes are evenly distributed along the margin of the

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eyelids; both eyes move in unison; no signs of scratches on both eyes and no discharges

noted.

Ears

The shape of the pinnaes are oval and with no discharges noted. Upper margin of

the pinnaes is in line with the outer canthus of the eyes. Ears are firm and non-tender.

Patient can hear voices properly. Signs of lesions, lacerations, swelling and bruises were

not seen upon inspection.

Nose

External surface of the nose is smooth and oily. Nasal septum is in midline of the

head. Nasal mucosa is moist and nasal hairs present. Lesions and inflammation are not

present. No discharges noted.

Mouth

Lips are dry with minimal cracks. Teeth are not complete and there is a presence

of cavities noted. Gums and buccal mucosa are pinkish in color. Tongue is in the midline

of the mouth. Tonsils are not inflamed. No signs of inflammation and laceration on the

uvula. Bleeding, ulceration and swelling were not seen upon inspection. Patient has fair

dental hygiene.

Neck

The neck of our patient can move easily without any discomfort, which includes

right and left lateral, right and left rotation, flexion and hyperextension. Neck can

properly support the head. No signs of enlargement, masses on the thyroid. Carotid pulse

is palpable. No signs of swelling or enlargement of the lymph nodes. No deformities

noted.

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Chest and lungs

Chest expansion is symmetrical. Normal respiratory rate of 13 breathes per

minute with regular rhythm. No signs of productive cough and difficulty in breathing.

The patient has a clear breath sound. Crackles and wheezing sound are not present upon

auscultation. No lesion and bruises were seen upon inspection.

Abdomen

Patient’s abdomen is soft, flabby, nontender with bilaterally symmetric umbilicus

inverted at midline. She has normoactive bowel sound upon auscultation. With lateral

surgical incision on the abdomen.

Genito-urinary

Presence of pubic hair on mons pubis noted. The client has normal menstrual

cycles before she was pregnant. Normal discharges of urine were present as stated by the

patient. There was no presence of any unusual vaginal secretions as stated by the patient.

Upper extremities

Both arms can stretch, flex, rotate and extend without difficulty. No signs of

lesion and bruises noted. Fingernails are not properly trimmed and traces of dirt noted.

Lower extremities

Both legs can stretch, flex, rotate, extend and bend without any difficulty. Legs

cannot properly support. She needs assistance in walking. Signs of edema were observed

on the patient’s lower extremities. When poked the pitting of the edema was 2mm.

Toenails are trimmed and there are no traces of dirt noted. No signs of deformities,

lesions, lacerations, and bruises, bleeding were seen upon observation.

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 ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM

The Heart

The heart lies in the mediastinum, behind the body of the sternum. The shape of

the heart tends to resemble the chest. The heart has chambers divided into four cavities

with the right and left chambers (atria and the ventricles) separated by the septum.

The Blood Vessels

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 There are 3 types of blood vessels: the arteries, the veins and the capillaries. An

artery is a vessel that carries blood away from the heart. It carries oxygenated blood.

Small arteries are called arterioles. Veins, on the other hand are vessels that carries blood

toward the heart. It contains the deoxygenated blood. Small veins are called venules.

Often, very large venous spaces are called sinuses. Lastly, capillaries are microscopic

vessels that carry blood from small arteries to small veins (arterioles to venules) and back

to the heart.

The walls of the blood vessels, the arteries and veins have three main layers:

tunica adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous

type of vessel is a connective tissue that helps hold vessels open and prevents tearing of

the vessel wall during body movement. Tunica media is a smooth muscle, sandwiched

together with a layer of elastic connective tissue. It permits changes of the blood vessel

diameter. It allows the constriction and dilation of the vessels. Last but not the least is the

tunica intima. Tunica intima, which in Latin means inner coat, is made up of endothelium

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that is continuous with the endothelium that lines the heart. In arteries, it provides a

smooth lining. However in veins it maintains the one-way flow of the blood. The

endothelium, which makes up the thin coat of the capillary, is important because the

thinness of the capillary wall allows the exchange of materials between the blood plasma

and the interstitial fluid of the surrounding tissues.

Circulation of the blood in blood vessels

There are two circulatory routes of blood as it flows through the blood vessels: the

systemic and the pulmonary circulation. In systemic circulation, blood flows from the left

ventricle of the heart through blood vessels to all parts of the body (except gas exchange

tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand,

venous blood moves from the right atrium to right ventricle to pulmonary artery to lung

arterioles and capillaries where gases exchanged; oxygenated blood returns to the left

atrium via pulmonary veins; from left atrium, blood enters the left ventricle.

Vasomotor Control Mechanism

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 Blood distribution patterns, as well as BP can be influenced by factors that control

changes in the diameter of arterioles. Such factor might be said to constitute the

vasomotor control mechanism. Like most physiological control mechanisms, it consists

of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center

will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in

smooth muscle surrounding resistance vessels, arterioles, and veins of “the blood

reservoir” causing their constriction thus the vasomotor control mechanism plays an

important role both in the maintenance of the general BP and in the distribution of blood

to areas of special need.

Venous return of the Blood

Venous return refers to the amount of blood that is returned to the heart by the

way of veins. Various factors influence venous return, including the operation of venous

pumps that maintains the pressure gradients necessary to keep blood moving into the

central veins and from there the atria of the heart. Changes in the total volume of blood

vessels can also alter the venous return.

The return of venous blood to the heart can be influenced by the factors that

change the total volume of blood in the circulatory pathway. Stated simply, the more the

total volume of blood, the greater the volume of blood returned to the heart. The

mechanism that change the total blood volume most quickly, making them most useful in

maintaining constancy of blood flow, are those that cause water to quickly move into the

plasma or out of the plasma. Most of the mechanisms that accomplish such changes in

plasma volume operate by altering the body’s retention of the water.

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 The primary mechanisms for altering the water retention in the body- they are the

endocrine reflexes in the body. One is the ADH mechanism is released in the

neurohypophysis and acts on the kidneys in a way that reduces the amount of water lost

by the body. ADH does this by increasing the amount of water that kidneys reabsorb

from urine before the urine is excreted from the body. The more ADH is secreted, the

more water will be reabsorbed into the blood, and the greater the blood plasma volume

will become.

Another mechanism that changes the blood plasma volume is the rennin-

angiotensin mechanism of aldosterone secretion. Renin is an enzyme that is released

when the blood pressure in the kidney is low. Renin triggers a series of events that leads

to the secretion of aldosterone. Aldosterone promotes sodium retention by the kidney,

which in turn stimulates the osmotic flow of water to the kidney tubules back into the

blood plasma- but only when ADH is present to permit the movement of water. Thus,

low blood pressure increases the secretion of aldosterone, which in turn stimulates the

retention of water and thus an increase in blood volume. Another effect of renin-

angiotensin is the vasoconstriction of blood vessels caused by an intermediate compound

called angiotensin II. This complements the volume-increasing effects of the mechanism

and thus also promotes an increase in overall blood flow. Precision of blood volume

control contributes to the precision in controlling venous return, which in return yields to

the precise overall control of blood circulation

EXOCRINE SYSTEM

26
 The exocrine system’s main function is to regulate the volume and composition of

body fluids and excrete unwanted materials, but it is not the only system in the body that

is able to excrete unnecessary substances.

Kidneys

The kidneys resemble the lima beans in shape. The average-sized kidney

measures around 11cm by 7cm by 3cm. The left kidney is often larger than the right. The

kidneys are highly vascular organs. Approximately, one-fifth of the blood pumped from

the heart goes to the kidneys. The kidneys process blood plasma and form urine from

waste to be excreted and removed from the body. These functions are vital because they

27
maintain the homeostatic balance of the body. The kidneys maintain the fluid-electrolyte

and acid-base balance. In addition, they also influence the rate of secretion of the

hormones ADH and aldosterone.

Microscopic functional units called nephrons make up the bulk of the kidney. The

nephron is uniquely suited to its function of blood plasma processing and urine function.

A nephron contains certain structures in which fluid flows through them and they are as

follows: renal corpuscle, Bowman’s capsule, proximal convulted tubule, Loop of Henle,

distal convoluted tubule and the collecting tube. The Bowman’s capsule is a cup-shaped

mouth of a nephron. It is usually formed by two layers of epithelial cells. Fluids,

electrolytes and waste products that pass through the porous glomerular capillaries and

enter the space that constitute the glomerular filtrate, which will be processed in the

nephron to form urine.

The Glomerulus is the body’s well-known capillary network and is surely one of

the most important ones for survival. Glomerulus and Bowman’s capsule together are

called renal corpuscle. The permeability of the glomerular endothelium increases

sufficiently to allow plasma proteins to filter out into the capsule.

ENDOCRINE SYSTEM

The endocrine system performs their regulatory functions by means of chemical

messenger sent to specific cells. The endocrine system, secreting cells send hormones by

way of the bloodstream to signal specific target cells throughout the body. Hormones

diffuse into the blood to be carried to nearly every point in the body. The endocrine

glands secrete their products, hormones, directly into the blood. There are two

28
classifications of hormones: steroid hormones and non-steroid hormones. The steroid

hormones which are manufactured by the endocrine cells from cholesterol, is an

important lipid in the human body. Non-steroid hormones are synthesized primarily from

amino acids rather from the cholesterol. Non-steroid hormones are further subdivided

into two: protein hormones and glycoprotein hormones.

Aldosterone

Its primary function is the maintenance of the sodium homeostasis in the blood by

increasing the sodium reabsorption in the kidneys. It is secreted from the adrenal cortex;

it triggers the release of ADH which results to the conservation of water by the kidney.

Aldosterone secretion is controlled by the rennin- angiotensin mechanism.

Estrogen

It is secreted by the cells of the ovarian cells that promote and maintain the female

sexual characteristics.

Progesterone

It is secreted by the corpus luteum. It is also known as a pregnancy- promoting

steroid and it prevents the expulsion of the fetus in the uterus.

Anti-diuretic hormone (ADH)

It is secreted in the neurohypophysis (posterior pituitary); it literally opposes the

formation and production of a large urine volume. It helps the body to retain and

conserve water from the tubules of the kidney and returned to the blood.

REPRODUCTIVE SYSTEM

29
 The female reproductive system produces gametes may unite with a male gamete

to form the first cell of the offspring. The female reproductive system also provides

protection and nutrition to the developing offspring. The most essential organ is the ovary

which carries the ova. The uterus, the fallopian tubes and the vulva are accessory organs.

Ovaries

It is an almond-shape organ. It contains the ova and is responsible in expelling the

ova. It also produces estrogen and progesterone.

Fallopian Tubes

It usually measures approximately 10- 12 cm. It has two parts: the ampullae and

the fimbriae. The ampullae which is the largest part is where the fertilization takes place.

The fimbriae on the other hand, are responsible for the transportation of the ovum from

ovary to uterus. It holds the ovary.

30
Uterus

The uterus is a pear-shaped organ and has three parts: the fundus (upper), corpus (body),

and the isthmus (lower). It is known as the organ for menstruation. When pregnant, it

gives nourishment to the growing fetus.

ETIOLOGY

Predisposing Actual Rationale Justification

Factors
Sex  Pre-eclampsia is a disease of women The patient is

exposed to this

condition since she

is a female.
Age  Some of the more common chronic This is a

31
 diseases that may be present in women contributing factor

over 35, and which may affect a to the patient’s

pregnancy, are arthritis, hypertension, condition since she

and diabetes is already 35 years

old.
(http://www.expectantmothersguide.co

m/library/stlouis/ESLadv_maternal_ag

e.htm)
Family history  Pre-eclampsia is also more common in This is evident in

women who have preexisting our patient since

hypertension, diabetes, autoimmune she has relatives

diseases like lupus, various inherited having high blood

thrombophilias like Factor V Leiden, or pressure. Since

renal disease, in women with a family hypertension is a

history of pre-eclampsia, obese women, hereditary factor, it

and in women with a multiple gestation predisposes the

(twins, triplets, and more). patient to develop

hypertension and

Genetic predisposition may present as can result to the

an immunologic factor in determining progress of

the development of preeclampsia preeclampsia

among women. Research has shown a during her

greater frequency of preeclampsia pregnancy.

among daughters and granddaughters

32
 of women with a history of eclampsia,

which suggests an autosomal recessive

gene controlling the maternal immune

response. A history of chronic

hypertension in the family may also

increase the risk of developing

preeclampsia during pregnancy.

(http://en.wikipedia.org/wiki/Pre-

eclampsia)

(Lowdermilk and Perry.Maternity

Nursing 7th Ed. Mosby Year Book

Publishing, St.Louis. Missouri, USA.)

Primigravida X It is much more common in women Our patient already

who are pregnant for the first time and had her previous

its frequency drops significantly in pregnancies

second pregnancies. (multigravida).

(http://en.wikipedia.org/wiki/Pre-

eclampsia)
Race X Maternal race also influences the rate This is not evident

of pregnancy-associated hypertension. in our patient since

Asian or Pacific Islander women have she is an Asian.

33
 the lowest rate for hypertension

complicating pregnancy with a rate of

19.6 per 1000.

(Lowdermilk and Perry.Maternity

Nursing 7th Ed. Mosby Year Book

Publishing, St.Louis. Missouri, USA.)

Precipitating Actual Rationale Justification

Factors
Preeclampsia  The single most significant risk for This is evident in

in previous developing pre-eclampsia is having had our patient because

pregnancy pre-eclampsia in a previous pregnancy. during her

previous
(http://en.wikipedia.org/wiki/Pre-
pregnancies she
eclampsia)
was also diagnosed

with pre-

eclampsia.
Multiple  Mothers who are pregnant with This can be

pregnancies multiples are at extremely high risk for considered a factor

34
preeclampsia, also known as Toxemia to the patient’s

or Pregnancy Induced Hypertension condition since she

(PIH). already had her

previous

Women who are pregnant with more pregnancies

than one child, compared with those (multigravida).

expecting one child, are 2-4 times as

likely to experience complications of

childbirth.

(http://multiples.about.com/cs/medicali

ssues/a/preeclampsia.htm)

(Pathophysiology Adaptations and

Alterations in Function, 4th Edition by

Barbara L. Bullock)

35
Diet and X Some studies indicate that poorly This is not a factor

Nutrition nourished women develop in our patient since

preeclampsia more often. Studies of she knows that she

calcium supplementation for preventing needs to watch the

preeclampsia have had mixed results foods that she is

with some recent studies showing no eating. She is

effect. Pregnant women should make aware that her

sure their diet is adequate in food baby needs

sources of these vitamins and take only sufficient

the supplements prescribed by their nutrients.

prenatal care provider.

(http://parenting.ivillage.com/pregnanc

y/pcomplications/0,,4b0,00.html)

SYMPTOMATOLOGY

SYMPTOMS Actual Rationale Justification

Hypertension  The systolic blood pressure is the The client had a

pressure of the blood as a result of systolic BP of

contraction of the ventricles, that is, the 140 mmHg and

pressure of the height of the blood a diastolic BP of

36
 valve and the diastolic blood pressure 100 mmHg

is the pressure when the ventricles are therefore this

at rest. This happens because the heart symptom is

is forced to pump against the rising present in our

peripheral vascular resistance due to client.

vasospasm, therefore increasing the

blood pressure. A pregnant woman

with severe preeclampsia who is

experiencing hypertension has a blood

pressure of 160/110 mm Hg.

Proteinuria  Proteinuria is a condition in which Based on the

protein is present in the urine. It is patient’s

normally confined to the blood, spilling laboratory

into the urine because the small blood tests, the client

vessels in the kidneys become damaged had traces of

due to hypertension. A patient is protein (3+)

considered to be experiencing upon

proteinuria if the urine sample results undergoing

show 3+ or 4+. urinalysis.

(Maternal & Child Health Nursing, 4th

Edition by Pillitteri)
Edema  Edema develops because of the protein Signs of edema

loss, sodium and water retention due to were observed

lowered glomerular filtration rate. It is on the patient’s

37
 noticeable in the woman’s face and lower

hands as puffiness. It is most readily extremities.

palpated over the bony surfaces, such The pitting of

as over the tibia on the anterior leg, the the edema was

ulnar surface of the forearm, and on the 2mm.

cheekbones, where the sponginess of

the fluid tissue.

(Maternal & Child Health Nursing, 4th

Edition by Pillitteri)

Oliguria X Increased water retention due to the This is not

decreased release of ADH stimulated by evident in our

angiotensin II. It is a condition in which patient because

a person has a total urine output of less her urine

than 500ml over 24 hours. output is more

than 500 ml

per 24 hours.

Based on her I

and O records

she had a urine

output of 725

ml.
Scotomata or X Blurring of vision is caused by The patient

38
Blurred vision vasoconstriction which can be related to stated that she

hypoxia of the vessels of the head. It did not have

can damage the cerebral cortex which is any problem

the visual center in the brain with her

eyesight during

the course of

her pregnancy.

She can also

see clearly

without the use

of any

correctional

eyeglasses or

aid.
Hemolysis Hemoly X Due to the

sis increased

Due to the blood pressure,

increased blood the blood

pressure, the blood vessels will

vessels will rupture rupture that

that will lead to will lead to

RBC RBC

fragmentation. fragmentation.

39
Based on the  Due to increased blood pressure there The patient

patient’s is cerebral hypertension. stated that she

laboratory results, experienced

the patient has a episodes

normal RBC headache.

count.Headache
Seizures X Due to too much pressure exerted by The patient

the blood cranial blood vessels may be verbalized that

affected resulting to seizures. she was not

able to

experience any

episodes of

seizure.

PATHOPHYSIOLOGY

Whereas all hypertensive disorders in pregnancy (pre-eclampsia, essential

hypertension, 'secondary' hypertension) share high blood pressure as a common theme

(probably mediated by inappropriate vasoconstriction), pre-eclampsia is the only disorder

with multisystem abnormalities.

40
The triad of physiological derangements in pre-eclampsia is:

1. Intense vasospasm,

2. Local or disseminated intravascular coagulation,

3. Plasma volume contraction.

Although the cause of pre-eclampsia is unknown the placenta appears to be the

culprit - delivery of the placenta is the only known cure and the disorder is more frequent

with large placental mass, ex. Twins, or abnormal placenta. Current hypotheses propose

release of a toxic factor from the placenta which alters maternal endothelial cell

functions, though this is unproven.

Vasospasm follows due to excess production or sensitivity to vasoconstrictors

(angiotensin II, serotonin and endothelin are the most popular candidates) and/or

decreased production or sensitivity to vasodilators (prostacyclin and nitric oxide are the

current candidates here). This issue is by no means resolved.

Intravascular coagulation is associated with platelet activation, thrombocytopenia

and, often, reduced production of anti-thrombin III.

Plasma volume contraction follows vasospasm, capillary leakage and, in more

severe cases, reduction in plasma osmotic pressures. There is redistribution of fluid from

the intravascular to interstitial fluid spaces so that total extra cellular fluid volume

remains unaltered. These are important considerations as intravascular volume correction

may result in pulmonary edema when capillary permeability is high and plasma osmotic

pressure low.

41
 The net result of this triad of abnormal physiology is organ hypoperfusion.

Systems most commonly affected are the kidney (manifested by reduced GFR,

proteinuria, hyperuricaemia and occasionally oliguria), the liver (manifested by elevated

aspartate transaminase with or without epigastric and right upper quadrant pain), the

brain (manifested most commonly by transient visual scotomata due to occipital lobe

ischemia, severe headaches and rarely convulsions, ex. eclampsia) and the placenta

(manifested by intrauterine fetal growth retardation and less commonly placental

abruption or fetal death in utero). Peripheral edema is common but is not a useful clinical

sign; pulmonary edema is rare and when it occurs is usually teratogenic.

DOCTOR’S ORDER

Date Ordered Doctor’s Order Rationale Remarks

DONE
PRE OP ORDER Secure consent for legal purpose
September
3, For preparation for DONE
2008 On NPO surgery, to avoid
@ efflux of food that
8:30 am will cause aspiration
with anesthesia
Admitting physician VS q 4° Check the BP for DONE

42
Dr. Isip any changes
because the patient
has hypertension
Labs: CBC, BT, PC, CTBT, W/A, SGPT, Serum Measures and DONE
Creatinine, HBSOG evaluate the cellular
components of
bloods and its
function. It also
helps in diagnosing
the client’s
condition.
Start venoclysis D5water 500cc @ KVO rate Helps expand DONE
intravascular
volume, corrects an
underlying
imbalance in fluids
and electrolytes and
compensates the
loss in the body
Meds: An antihypertensive DONE
Hydralazine 5mg IVTT now, then for DPB ≥ 110 that relaxes the
mmHg smooth muscle in
the anterial wall.
MgSO4 in 100cc D5water Slow IVTT To increase water DONE
5gm MgSO4 IM in each buttock. in the intestines,
Start MgSO4 drip after 4 hours loading dose this may induce
D5water 80cc+20cc MgSO4 via soluset to run @ 25 defecation.
gtts/min in 4 hours x 6 cycles with toxicity precautions

To monitor the DONE

Insert Foley Catheter and attach to urobag intake and output of
the patient.
Baseline EFM For close DONE
monitoring of the
fetal status and
serves as a baseline
data.

I & O q Shift To monitor the DONE

intake and output

9:30 am Dexamethasone 6mg q 12° IVTT x 4 doses Anti-inflammatory DONE

43
 10:00 am  schedule stat CS (fetal distress) with BTL Cesarean delivery DONE
 secure consent For legal purposes. DONE
 inform OR/AROD/PRON For preparation. DONE
 cefazolin 1gram q 8° IVTT antibacterial DONE

 Refer

POST OP ORDERS  post LSTCS with BTL under spinal anesthesia DONE
@  to PACU then to ward once stable DONE
11:00 am  NPO temporarily Assess peristaltic DONE
movement
 VS q 15 mins until stable then hourly Check the BP for DONE
any changes
because the patient
has hypertension
 IVF: D5LR 1 L to run @ 120cc/hour To increase water DONE
 Meds: in the intestines,
1. cont. MgSO4 drip as ordered this may induce
defecation.

2. Tramadol 50mg IVTT q 6° To manage DONE

mild/severe pain
3. Ketorolac 30mg IVTT q 8° Non-steroidal anti- DONE
inflammatory drug
4. Metoclopramide 10mg IVTT q 8° Gastrointestinal DONE
stimulant
5. Ranitidine 50mg IVTT q 6° while on NPO Histamine DONE
antagonist
6. Cont. IV antibiotics as ordered DONE

 Oxygen by mask to supply sufficient DONE

amount of oxygen
 Keep patient warm To maintain body DONE
temperature in the
normal range.
 Keep uterus well contracted always Prevent hemorrhage DONE
 I & O q hourly Monitor intake and DONE
output
 Watch out for any unusualities DONE
 Refer DONE
DONE

44
 DONE
September  continue cefazolin IVTT x 3 days antibacterial
4  continue gentamycin 240mg OD Antibiotic DONE
2008  Remove FBC and refer if unable to void in 4-6 DONE
@ hours after.
7:30 am

DONE
September  please comply with antibiotic meds
6  may have clear liquid mgt. diet once with flatus Treatment for pain. DONE
2008
@  start • mefenamic acid 500mg/cap TID Treatment for
7:30 am • Ferrous Sulfate anemia
 continue gentamycin 240mg IVTT q 24 hrs OD antibiotic DONE
 continue cefazolin IVTT q 8° Antimicrobial and DONE
antiparasitic agents
 encourage ambulation DONE
 increase oral fluid intake To avoid DONE
dehydration

Anti-hypertensive DONE
10:00 am  Amlodipine 10mg OD
Under the service of  Metoprolol 100mg BID (6am-6pm) Antihypertensive DONE
DR. Mantilla  Low fat, low salt diet DONE
 VS q 4° Check the BP for DONE
any changes
because the patient
has hypertension
 Cont. IVF @ same rate & PO meds DONE
 D/C IVTT meds DONE

 Start PO meds – kindly transcribe to medication Antianemic-iron DONE

sheet about :
1. FeSO4 1 tab OD
2. Ascorbic acid 1 tab OD Vitamins and DONE
Minerals

45
 DIAGNOSTIC EXAM

IPD HEMATOLOGY
CBC + BLT
TEST RESULT UNIT REF. RANGES
Hemoglobin 128.0 g/L 115 – 155

- To identify the amount

of O2 carrying protein

contained within the

46
 RBC.

- Decreased Hgb

indicates anemia from

blood loss, dietary

defiency, and

malnutrition and kidney

disease.
Hematocrit 0.38 0.36 – 0.48

- To identify the

percentage of the blood

volume occupied by red

blood cells.

- Decreased Hct indicates

blood loss, anemia,

blood replacement

therapy, and fluid

balance, and screens red

blood cell status.

RBC Count 4.89 X10^6/uL 4.20 – 6.10

- To know the amount of

RBC in the blood. Rule

out anemia due to

nutritional deficiencies,

blood loss.
WBC Count 20.27 X10^3/uL 5.0 – 10.0

47
 - To determine infection

or inflammation in the

body and monitor its

responses to specific

therapies. Explain to the

patient the necessity of

undergoing the test that

it helps detect

occurrence of anemia

and polycythemia.

DIFFERENTIAL COUNT

TEST RESULT UNIT REF. RANGES

Neutrophil 81 55-75

- To indicate the presence

of bacterial infection and

amount of Leukocyte

Lymphocytes 15 20-35

- To identify if there is an

abnormal amount of

lymphocyte that may

indicate viral infection

such as HIV. A decreased

number of lymphocytes in

the peripheral circulation,

48
 occurring as a primary

hematologic disorder or

in association with

nutritional deficiency,

malignancy or infection

mononucleosis.

Monocytes 4 2-10

- Increase of these may

respond to corticosteroid,

with pus conditions,

hemorrhage.
Eosinophil 0 1-8

- High percentage of

eosinophil, may indicate

bacterial infestation or

allergies
Basophil 0 0-1

- Increase of basophil may

indicate parasite,

hypersensitiveness and

heartworm causing

endocrine disease,

chronic liver disease

Platelet count 436 X10³/uL 150-400

- The smallest cells in the

49
 blood are the platelets,

which are designed for a

single purpose—to begin

the process of

coagulation, or forming a

clot, whenever a blood

vessel is broken.

BLOOD TYPE (ABO + Rh)

TEST RESULT UNIT REF. RANGES

Blood type B

Blood type Rh

- In forward typing, if +

there’s agglutination,

the patient’s RBC’s

are mixed with anti-A

and anti-B serum, the A

and B antigen is

present, thus blood type

is O. This is to check

compatibility of the

donor and the patient

before transfusion

50
IMMUNOLOGY

TEST RESULT UNIT REF. RANGES

HBsAg qualitative

- to determine the -

existence of hep B

antigen.

CHEMISTRY RESULT UNIT REF. RANGES

SGPT 27 U/L 30-65
CREATININE 61.40 Umol/L 53.00-115
HBSAG NEGATIVE

QUALITATIVE

CLINICAL MICROSCOPY

A) P.E.

Color Dark yellow

Appearance Cloudy
Reaction 7.0
Specific Gravity 1.015

B) Chem. E.

Albumin
Sugar Negative

51
MICROSCOPIC EXAMINATION

Epithelial Cells:
Squamous Cast
Renal Hyaline
Pus cells 0-3 hpf Fine granular >20 lpf

RBC >100 hpf Course granular 1-20

lpf
Mucous threads
Bacteria
Yeast cells
Oil globules
Spermatozoa

INTERPRETATION:

Pregnancy alters urinary tract function and increases the risk of infection.

Asymptomatic bacteriuria frequently precedes symptomatic UTI, and it is important to

screen for this entity, as treatment during the first trimester has been shown to reduce the

incidence of pyelonephritis and possibly that of low birth weight.

The examination of urine provides information regarding the diseases involving

the kidney and lower urinary tract. The result of yellow color urine is due largely to the

pigment urochrome and to small amounts of urobilins and uroerythrin. Urochrome

excretion is thought to be proportional to the metabolic rate and is increased during fever,

thyrotoxicosis, and starvation. The uroerythrin may be deposited in uric acid or urate

crystals (brick dust deposit), and should not be confused with blood.

52
 NURSING RESPONSIBLITIES

Blood Typing:

• Inform the patient that the test determines her blood group.

• Check the patient’s history for recent administration of blood, dextran or

I.V.

• After the procedure, apply direct pressure to the venipuncture to the site

until bleeding stops.

Hematology:

• Explain that the test measures the amount, size and content of red blood

cells, and can help in identifying problems such as anemia.

• Observe the client for signs and symptoms of anemia including pallor,

dyspnea, chest pain and fatigue.

• Encourage rest period for client that is experiencing fatigue related to

anemia. Severe anemia may produce these symptoms from tissue hypoxia.

• Protect client from exposure to potential sources of infection such as

proper nutrition, hand washing.

• Watch out for signs and symptoms of infection such as fever, jaundice,

flashed skin, redness and swelling.

• Assess the client for unusual bruising, or prolonged bleeding from

venipuncture site.
53
Immunology:

• Explain that the test identifies the presence of HBsAg in the blood, which

can help in identifying problems such as infection with Hepatitis B or

chronic infection.

• Protect client from exposure to potential sources of infection such as

proper hand washing.

• Determine if the patient is reactive or nonreactive for Hepatitis B Surface

Antigen

• Assess client for unusual bruising, or prolonged bleeding from

venipuncture site.

Urinalysis:

• Ensure that urinalysis to be performed should be a clean catch specimen ,

midstream specimen, fresh urine specimen, frist morning specimen,12 or

24hour collection, multiple bottle voidings or a specimen obtained with a

catheter.

• Instruct female patients to separate the labia and uncircumcised male to

retract the foreskin.

• For a catheterized patient, collect urine from the port on the tubing, not the

urinary drainage bag, because this may be contaminated. Use a drip

method to collect urine from a urostoma.

54
• Evaluate client ability to perform ADL.

55
 Date Ordered: September 3, 2008 @ 8:30am

Generic Brand Classification Dosage & frequency Mechanism Indications

Name Name of actions
Hydrazaline Alazine, Antihypertensive Adults: initially, 10 mg P.O. q.i.d.; gradually Directly relaxes Essential
Hydrochloride Apresoline, increased to 50 mg q.i.d. arteriolar Hypertension (oral,
Novohylazin, Maximum recommended dosage is 200 mg smooth muscle. alone or in
Supres daily, but some patients may require 300 to combination with
400 mg daily. Can be given b.i.d. for CHF. other
I.V. - 10-20 mg given slowly and repeated as antihypertensive); to
necessary, generally q 4 to 6 hours. Switch to reduce after load in
oral antihypertensive as soon as possible. severe CHF ( with
I.M.- 20 to 40 mg repeated as necessary, nitrates); and severe
generally q 4 to 6 hours. Switch to oral essential
antihypertensive as soon as possible. hypertension
Children: initially, 0.75 mg/kg P.O. daily in (parenteral to lower
four divided doses (25 mg/m² daily). May blood pressure
increase gradually to 10 times this dosage if quickly)
necessary.
I.V.- gives slowly 1.7 to 3.5 mg/kg daily or 50
to 100 mg/m² daily in four to six divided doses.
I.M.- 1.7 to 3.5 mg/kg daily or 50 to 100
mg/m² daily in four to six divided doses.

56
 Contraindications Side Effects Adverse Nursing Responsibilities
Reactions
Breast-feeding—Hydralazine passes into breast milk. Less common • Use cautiously in cardiac
Although most medicines pass into breast milk in small Blood: diseases, CVA, or severe renal
amounts, many of them may be used safely while Blisters on skin; chest neutropenia, impairment and in those taking
breast-feeding. Mothers who are taking this medicine pain; general feeling of leukemia. other hypertensive.
and who wish to breast-feed should discuss this with discomfort or illness or • Monitor patient’s Vital signs and
their doctor. weakness; joint pain; CNS: body weight frequently. Some
muscle pain; numbness, peripheral clinicians combine hydralazine
Children—Although there is no specific information tingling, pain, or neuritis, therapy with diuretics and beta-
comparing use of hydralazine in children with use in weakness in hands or headache, adrenergic blocking agents to
other age groups, this medicine is not expected to cause feet; skin rash or itching; dizziness. decrease sodium retention and
different side effects or problems in children than it sore throat and fever; tachycardia, and to prevent
does in adults. However, the oral solution contains swelling of feet or lower CV: anginal attacks.
aspartame, which is converted to phenylalanine in the legs; swelling of lymph orthostatic • Watch patient closely for signs
body. Children with phenylketonuria cannot process glands hypotension, of lupus erythematosus-like
phenylalanine and high levels of this substance in body tachycardia, syndrome (sore throat, fever,
fluids may cause brain damage. Rare arrhythmias, muscle and joint aches, skin
angina, rash). Call doctor immediately if
Older adults—Many medicines have not been studied Fever; general feeling of palpitations, any of these develops.
specifically in older people. Therefore, it may not be discomfort or illness; sodium • Teach patient about his disease
known whether they work exactly the same way they sore throat; weakness retention. and therapy. Explain the
do in younger adults. Although there is no specific importance of taking this drug as
information comparing use of hydralazine in the Other side effects may GI: nausea, prescribed, even when he’s
elderly with use in other age groups, this medicine is occur that usually do not vomiting, feeling well. Tell outpatient not
not expected to cause different side effects or problems need medical attention. diarrhea, to discontinue this drug
in older people than it does in younger adults. These side effects may anorexia. suddenly, but to call the doctor if
go away during treatment unpleasant adverse reactions

57
 Skin: Rash. occurs.
Other medicines—Although certain medicines should as your body adjusts to • Instruct patient to check with
not be used together at all, in other cases two different the medicine. However, Other: lupus doctor or pharmacistbefore
medicines may be used together even if an interaction check with your doctor if erythematosus taking OTC medications.
might occur. In these cases, your doctor may want to any of the following side -like • Elderly patients maybe more
change the dose, or other precautions may be effects continue or are syndrome sensitive to hypotensive effects.
necessary. When you are taking hydralazine, it is bothersome: (especially • Inform the patient that
especially important that your health care professional with high orthostatic hypotension can be
know if you are taking the following: More common doses), weight minimized by rising slowly and
gain. avoiding sudden position
• Diazoxide (e.g., Proglycem)—Effect on blood Diarrhea; fast heartbeat; changes
pressure may be increased headache; loss of • Give this drug with meals to
appetite; nausea or increase absorption.
Other medical problems—The presence of other vomiting; pounding • Compliance may be improved by
medical problems may affect the use of hydralazine. heartbeat administering this drug b.i.d.
Make sure you tell your doctor if you have any other check with the doctor.
medical problems, especially: Less common
• CBC, lupus erythematosus cell
preparation, and antinuclear
• Heart or blood vessel disease or Constipation; dizziness antibody titer determinations
• Stroke—Lowering blood pressure may make or lightheadedness; should be done before therapy
problems resulting from these conditions worse redness or flushing of and periodically during long
face; shortness of breath; term therapy.
• Kidney disease—Effects may be increased stuffy nose; watery eyes
• Has been prescribed during
because of slower removal of hydralazine from
pregnancy for treatment of
the body Other side effects not
eclampsia. Administered I.V.
listed above may also
• Phenylketonuria—The oral solution of occur in some patients. If • I.V. use: give slowly and repeat
hydralazine contains aspartame, which is you notice any other as necessary, generally q4 to 6
converted to phenylalanine in the body. Patients effects, check with your hours. Switch to oral
with phenylketonuria cannot process doctor. antihypertensive as soon as
phenylalanine and high levels of this substance possible.

58
 in body fluids may cause brain damage

Generic Brand Classification Dosage & frequency Mechanism Indications

Name Name of actions
Magnesium Epsom Salt, Anticonvusant, • IM May decrease For
Sulfate Sulfamag miscellaneous; Anticonvulsant. acetylcholine Hypomagnesemi
(mag NEE see and laxative Adults: 1-5 g of a 25-50% solution up to 6 times/day. released by c seizures.
um SUL fate) saline Pediatric: 20-40 mg/kg using the 20% solution (may be nerve impulses, Seizures
repeated if necessary) but its secondary to
anticonvulsant hypomagnesemi
• IV mechanism is a in acute
Anticonvulsant. unknown. nephritis.
Adults: 1-4 g using 10-20% solution, not to exceed 1.5 Prevention or
ml/min of the 10% solution. control of
seizures in
Hypomagnesenia, mild. preeclampsia or
Adult: 1 g as a 50% solution q 6 hr for 4 times (or total of eclampsia
32.5 mEq/24hr)

Hypomagnesenia, severe
Adults up to 2 mEq/kg over 4 hr.

59
 • IV INFUSION
Anticonvulsant.
Adults: 4-5 g in 250 ml d5w @ a rate not to exceed 3
ml/min.

Hypomagnesenia, severe
Adults: 5 g (40 mEq) in 1000 ml D5W or sodium chloride
solution by slow infusion over period of 3 hr.

Hyperalimentation.
Adults: 8-24 mEq/day; infants: 2-10 mEq/day

• ORAL SOLUTION
Laxative
Adults: 10-15g; pediatrics: 5-10 g.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

In the presence of heart Stop taking magnesium sulfate and CNS: sweating, drowsiness, • Use cautiously in impaired renal function,
block or myocardial seek emergency medical attention if depressed reflexes, flaccid myocardial damage, and heart block, and in
damage. In toxemia of you experience an allergic reaction paralysis, hypothermia. women in labor.
pregnancy during the 2 (difficulty breathing; closing of your • Drug can decrease the frequency and the force
hr prior to delivery. throat; swelling of your lips, tongue, CV: hypotension, flushinh, of uterine contraction.
or face; or hives). circulatory collapse, • Keep I.V. calcium glucanate available to

60
 depressed cardiac function, reverse magnesium intoxication; however, use
Other, less serious side effects may heart block. cautiously in patients undergoing digitalization
be more likely to occur. Continue to due to danger of arrhythmias.
take magnesium sulfate and talk to OTHER: respiratory • I.V. use: Monitor vital signs every 15 mins.
your doctor if you experience paralysis, hypocalcemia. When giving drug I.V.
diarrhea or upset stomach. • Watch for respiratory depression and signs of
heart block. Respirations should should be
approximately 16/mins before each dose given.
• Monitor I & O. urine output should be 100ml or
more in 4 hr period before each dose.
• Check blood magnesium levels after repeated
doses. Disappearance of knee-jerk and patellar
reflexes is a sign of pending magnesium
toxicity.
• Maximum infusion rate is 150mg/min. rapid
drip will induce uncomfortable feeling of heat.
• Especially when given I.V. to toxemic mothers
within 24 hrs before delivery,observe neonates
for signs of magnesium toxicity, including
neuromuscular or respiratory depression.
• Signs of hypermagnesemia begin to appear at
blood levels of 4 mEq/L.
• Has been used as a tocolytic agent (suppresses
uterine contractions) to inhibit premature labor.

61
 Ordered @ 9:30 am

Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Dexamethasone Decadron, • Shock: 4 to 8 mg Decreases inflammation, For Cerebral edema,
deronil, dexone, Anti- intravenously initially, repeat mainly by stabilizing Infalammatory
hexadrol, inflamm if necessary to a total dose of leukocyte lysosomal conditions, allergic
mymethasone. atory 24 mg. membranes. Also reactions, neoplasias.
• Autoimmune diseases and suppresses the immune
inflammations: long-term response, stimulates bone
therapy with 0.5 to 1.5 mg marrow and influences
oral per day. Avoid more protein, fat, and
than 1.5 mg daily, because carbohydrate metabolism.
serious side effects are more
frequently encountered with
higher doses.
• Adjuvant to or part of
chemotherapy: individual
schedule
• Diagnostic purposes: special
schedule

62
 Contraindications Side Effects Adverse Nursing Responsibilities
Reactions
Some of these If dexamethasone is given orally or CNS: euphoria, • Contraindicated to fungal infections and for
contraindications are by injection (parenteral) over a insomia, psychotic alternate day theraphy. Also contraindicated
relative: period of more than a few days, behavior. in patients hypertensive to any component
side-effects common to systemic of the drug.
• Existing glucocorticoids may occur. These CV: CHF, • Use cautiously in GI ulceration or renal
gastrointestinal may include: hypertension, edema. disease, hypertension, osteoporosis,
ulceration varicella, vaccinia, exsanthema, diabetis
• Cushing's syndrome • Stomach upset, increased EENT: cataracts, mellitus, cushing’s syndrome,
• Severe forms of sensitivity to stomach acid to the glaucoma. thromboembolic disorders, seizures, CHF,
heart insufficiency point of ulceration of esophagus, tuberculosis, hypoalbuminemia, emotional
• Severe stomach, and duodenum GI: peptic ulcer, GI instability.
hypertension • Increased appetite leading to irritation, increased • Gradually reduce drug dosage after long-
• Uncontrolled significant weight gain appetite. term therapy. Tell patient not to discontinue
diabetes mellitus • A latent diabetes mellitus often drug abruptly or without doctor’s consent.
• Systemic becomes manifest. Glucose Metablic: possible • Always titrate to lowest effective dose.
tuberculosis intolerance is worsened in hypokalemia, • Monitor patient’s weight, blood pressure,
• Severe systemic patients with preexisting hyperglycemia and serum electrolytes.
viral, bacterial, and diabetes. carbohydrates
• Instruct patient to carry a card indicating his
fungal infections • Immunsuppressant action, intolerance.
need for supplemental systemic
• Preexisting wide particularly if given together
glucocorticoids during stress, especially as
angle glaucoma with other immunosuppressants Skin: delayed wound
dosage is decreased.
• Osteoporosis such as ciclosporine. Bacterial, healing, acne, various
skin eruptions. • Give a daily dosage in the morning for
viral, and fungal disease may
better results and toxicity.
progress more easily and can

63
 become life-threatening. Fever Local: atrophy at I.M. • Teach patient’s signs of early adrenal
as a warning symptom is often injection site. insufficiency: fatigue, muscular weakness,
suppressed. joint pain, fever, anorexia, nausea, dyspnea,
• Psychiatric disturbances, dizziness, and fainting.
including personality changes, • May mask or exacerbate infections,
irritability, euphoria, mania including latent amebiasis.
• Osteoporosis under long term • Watch for depression or psychotic episodes,
treatment, pathologic fractures especially in high dose therapy.
(e.g., hip) • Inspect patient’s skin for peteciae. Warn
• Muscle atrophy, negative protein patients about easy bruising.
balance (catabolism) • Patients with diabetes may need increased in
• Elevated liver enzymes, fatty insulin; monitor blood glucose.
liver degeneration (usually
• Monitor growth in infants and children on
reversible)
long term theraphy.
• Cushingoid (syndrome
resembling hyperactive adrenal • Gve P.O. dose with food when possible.
cortex with increase in adiposity,
hypertension, bone
demineralization, etc.)
• Depression of the adrenal gland
is usually seen, if more than 1.5
mg daily are given for more than
three weeks to a month.
• Hypertension, fluid and sodium
retention, edema, worsening of
heart insufficiency (due to
mineral corticoid activity)
• Dependence with withdrawal
syndrome is frequently seen.
• Increased intraocular pressure,
certain types of glaucoma,

64
 cataract (serious clouding of eye
lenses)
• Dermatologic: Acne, allergic
dermatitis, dry scaly skin,
ecchymoses and petechiae,
erythema, impaired wound-
healing, increased sweating,
rash, striae, suppression of
reactions to skin tests, thin
fragile skin, thinning scalp hair,
urticaria.
• Allergic reactions (though
infrequently): Anaphylactoid
reaction, anaphylaxis,
angioedema. (Highly unlikely,
since dexamethasone is given to
prevent anaphylactoid reactions.)

Other side-effects have been noted, and

should cause concern if they are more
than mild.

The short time treatment for allergic

reaction, shock, and diagnostic purposes
usually does not cause serious side
effects

65
Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Ancef, Antimicrobial and Adults: 250 mg I.M. or Inhibits cell wall synthesis, Cefazolin is mainly used to
Cefazolin Cefacidal, antiparasitic agents I.V. Q 8 hrs to 1 g 6 hrs. promoting osmotic treat bacterial infections of
Cefamezin, maximum 12 g/day in life- instability. Usually the skin. It can also be used to
Cefrina, threatening situations. bactericidal. treat moderately severe
Elzogram, bacterial infections involving
Faxilen, Children over 1 month: 25 the lung, bone, joint, stomach,
Gramaxin, to 100 mg/kg/day I.M. or blood, heart valve, and
Kefazol, Kefol, I.V.in three or four divided urinary tract. It is clinically
Kefzol, doses. effective against infections
Kefzolan, caused by staphylococci and
Kezolin, streptococci species of Gram
Novaporin, and positive bacteria. These
Zolicef. organisms are common on
normal human skin.
Resistance to cefazolin is
seen in several species of
bacteria.

66
 Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Do not use this medication • Use cautiously in impaired renal function and
if you are allergic to Blood: transient neutropenia, in those with history of sensitivity to
cefazolin, any type of Side effects from leucopenia, eosinophilia, penicillin. Ask patient if he’s ever had any
penicillin, or to other cefazolin are not anemia. reaction to cephalosporin or penicillin therapy
cephalosporin antibiotics, common. Possible side before administering first dose
such as: effects include: CNS: dizziness, headache, • Avoid doses greater than 4 g daily in patients
malaise, paresthesia. with severe renal impairment.
• cefaclor (Ceclor); • diarrhea • Obtain specimen for culture and sensitivity
• cefadroxil • stomach pain GI: pseudomembranous test before first dose. Therapy may begin
(Duricef); • upset stomach colitis, nausea, anorexia, pending test results.
• cefdinir (Omnicef); • vomiting vomiting, diarrhea, glossitis, • Because of long duration of effect, most
• cefditoren • rash dyspepsia, abdominal infections can be treated with dose q 8 hrs.
(Spectracef); cramps, anal pruritus, • Not as painful as other cephalosporin when
• cefixime (Suprax); tenesmus, oral candidiasis given I.M.
• cefotaxime (trush).
• I.V. use: alternate injection sites if I.V.
(Claforan;
therapy last longer that 3 days
• cefprozil (Cefzil); GU: genital pruritus and
• ceftazidime moniliasis, vaginitis. • Considered the first-generation cephalosporin
(Fortaz); of choice by most authorities.
• cefuroxime Skin: musculopapular and • With large doses or prolonged therapy,
(Ceftin); erythematous rashes, monitor for superinfection, especially in high
• cephalexin urticaria. risk patients.
(Keflex); and • Reconstituted cefazolin sodium is stable for
others. Local: @ injection site- pain, 24 hrs at room temp. or 96 hours under
induration, sterile abscesses, refrigerator.
Before using cefazolin, tell tissue sloughing; phlebitis • About 40% - 70% of patients receiving

67
 and thrombophlebitis with cephalosporin shows a false positive direct
your doctor if you are I>V> injection. Coombs’ test; only a few of these indicate
allergic to any drugs hemolytic anemia.
(especially penicillins), or
if you have:

• kidney disease;
• liver disease; or
• a stomach or
intestinal disorder
such as colitis.

68
 ORDERED during Post OP. .September 3, 2008 @ 11:00 am

Generic Brand Classification Dosage & frequency Mechanism of actions Indications

Name Name
Tramadol ultram Analgesics, central Doses range from 50–400 The mode of action of tramadol has is used to treat moderate and
acting mg daily, maximum dose yet to be fully understood, but it is severe pain and most types of
of 400 mg a day (webmed), believed to work through modulation neuralgia, including
with up to 600 mg daily of the noradrenergic and serotonergic trigeminal neuralgia. It has
when given IV/IM. The systems in addition to its mild been suggested that tramadol
formulation containing agonism of the μ-opioid receptor. The could be effective for
APAP contains 37.5 mg of contribution of non-opioid activity is alleviating symptoms of
tramadol and 325 mg of demonstrated by the analgesic effects depression and anxiety
paracetamol, intended for of tramadol not being fully because of its action on the
oral administration with a antagonised by the μ-opioid receptor noradrenergic and
common dosing antagonist naloxone. serotonergic systems, the
recommendation of one or involvement of which appear
two tabs every four to six Tramadol is marketed as a racemic to play a part in its ability to
hours. mixture with a weak affinity for the μ- alleviate the perception of
opioid receptor (approximately pain.
1/6000th that of morphine; Gutstein &
Akil, 2006). The (+)-enantiomer is

69
approximately four times more potent
than the (-)-enantiomer in terms of μ-
opioid receptor affinity and 5-HT
reuptake, whereas the (-)-enantiomer
is responsible for noradrenaline
reuptake effects (Shipton, 2000).
These actions appear to produce a
synergistic analgesic effect, with (+)-
tramadol exhibiting 10-fold higher
analgesic activity than (-)-tramadol
(Goeringer et al., 1997).

The serotonergic modulating

properties of tramadol mean that it has
the potential to interact with other
serotonergic agents. There is an
increased risk of serotonin syndrome
when tramadol is taken in combination
with serotonin reuptake inhibitors (e.g.
SSRIs) or with use of a light box,
since these agents not only potentiate
the effect of 5-HT but also inhibit
tramadol metabolism. Tramadol is
also thought to have some NMDA-
type antagonist effects which has
given it a potential application in
neuropathic pain states

70
Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Hypersensitivity to • Nausea, The most commonly reported adverse drug • Document indications for therapy, location,
tramadol. In acute vomiting, reactions are nausea, vomiting, sweating onset, and characteristics of symptoms. Use a
intoxication with sweating and and constipation. Drowsiness is reported, pain rating scale.
alcohol, hypnotics, constipation. although it is less of an issue than for other • Assess for history of drug addiction, allergy to
centrally acting Drowsiness. opioids. Respiratory depression, a common opiates or codeine, or seizures; drug may
analgesics,opiates, or • Stomach side effect of most opioids, is not clinically increase the risk of convulsions.
psychotropic drug. upset, significant in normal doses. By itself, it can • Monitor VS, I & O, liver and renal function
Use for preoperative increased decrease the seizure threshold. When studies; reduce dose with dysfunction and if
medication or for sensitivity to combined with SSRIs, tricyclic over 75 yrs. Old.
postdelivery stomach acid antidepressants, or in patients with epilepsy,
analgesia in nursing to the point of the seizure threshold is further decreased. CLIENT/FAMILY TEACHING
mothers. ulceration of Seizures have been reported in humans
esophagus, receiving excessive single oral doses (700 • Take only as directed. May be taken without
stomach, and mg) or large intravenous doses (300 mg). regard to meals. Do not exceed single or daily
duodenum An Australian study found that of 97 doses of tramadol; do not share meds, store
• Vasodilation, confirmed new-onset seizures, eight were safely out of reach of child.
liver failure, associated with Tramadol, and that in the • Do not perform activities that require mental
speech authors' First Seizure Clinic, "Tramadol is alertness; drug may cause drowsiness and
disorder.Derm the most frequently suspected cause of impair mental or physical performance.
atologic provoked seizure. Seizures caused by Alcohol may intensify drug effect.
problems. tramadol are most often tonic-clonic
• Report lack of response. Review list side
seizures. Dosages of coumadin/warfarin
effects (nausea, dizziness, constipation,
may need to be reduced for anticoagulated
somnolence, and pruritus) that one may
patients to avoid bleeding complications.
experience and report if persistent or
Constipation can be severe especially in the
intolerable.
elderly requiring manual evacuation of the
• May mask abdominal pathology and obscure

71
 bowel. intracranial pathology due to abnormal pupil
contraction.

Generic Brand Classification Dosage & frequency Mechanism of actions Indications

Name Name
Ketorolac Toradol non-steroidal anti- For oral dosage form The primary mechanism of action Ketorolac is indicated for
and inflammatory drug (tablets): responsible for ketorolac's anti- short-term management of
Acular inflammatory, antipyretic and pain (up to five days
For pain: analgesic effects is the inhibition of maximum).
prostaglandin synthesis by competitive
Adults (patients 16 years of blocking of the the enzyme
age and older)—One 10- cyclooxygenase (COX). Like most
milligram (mg) tablet four NSAIDs, ketorolac is a non-selective
times a day, four to six COX inhibitor.
hours apart. Some people
may be directed to take two As with other NSAIDs, the
tablets for the first dose mechanism of the drug is associated
only. with the chiral S form. Conversion of
the R enantiomer into the S

72
Children up to 16 years of enantiomer has been shown to occur
age—Use and dose must in the metabolism of ibuprofen; it is
be determined by your unknown whether it occurs in the
doctor. metabolism of ketorolac.

For injection dosage

form:

For pain:

Adults (patients 16 years of

age and older)—15 or 30
mg, injected into a muscle
or a vein four times a day,
at least 6 hours apart. This
amount of medicine may
be contained in 1 mL or in
one-half (0.5) mL of the
injection, depending on the
strength. Some people who
do not need more than one
injection may receive one
dose of 60 mg, injected
into a muscle.

Children up to 16 years of
age—Use and dose must
be determined by your
doctor.

73
Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Ketorolac is Rare Ketorolac may cause some • Use as a part of a regular analgesic
contraindicated in people to become dizzy or schedule rather than on an as needed
patients with a • Bleeding from the rectum or drowsy. If either of these basis.
previously bloody or black, tarry stools side effects occurs, do not • If given on p.r.n. basis, base the size of a
demonstrated • Bleeding or crusting sores on drive, use machines, or do repeat dose on duration of pain relief
hypersensitivity to lips anything else that could be from previous dose. If the pain returns
ketorolac, and in • Blue lips and fingernails dangerous if you are not within 3-5 hours, the next dose can be
patients with the • Chest pain alert. increased by up to 50% (as long as the
complete or partial • Convulsions total daily dose is not exceeded). If the
syndrome of nasal • Fainting Serious side effects can pain does not return for 8-12 hr, the next
polyps, angioedema, • Shortness of breath, fast, occur during treatment dose can be decreased by as much as
bronchospastic irregular, noisy, or troubled with this medicine. 50% or the dosing interval can be
reactivity or other breathing, tightness in chest, Sometimes serious side increased to q 8-12 hr.
allergic manifestations and/or wheezing effects can occur without • Shortening the dosing intervals
to aspirin or other non- • Vomiting of blood or material any warning. However, recommended will lead to an increased
steroidal anti- that looks like coffee grounds possible warning signs frequency and duration of side effects.
inflammatory drugs often occur, including • Correct hypovolemia prior to
(due to possibility of More common swelling of the face, administering.
severe anaphylaxis). As fingers, feet, and/or lower • Protect the injection from light
with all NSAIDs, • Swelling of face, fingers, legs; severe stomach pain,
• Document indications for therapy, onset,
ketorolac should be lower legs, ankles, and/or feet black, tarry stools, and/or
location, pain intensity/level, and
avoided in patients with • Weight gain (unusual) vomiting of blood or
characteristics of the symptoms.
renal (kidney) material that looks like
dysfunction. coffee grounds; unusual • Note any previous experience with
Less common
weight gain; and/or skin NSAIDs and the results.

74
 • Determine any renal or liver
• Bruising (not at place of rash. Also, signs of serious dysfunction; assess hydration.
injection) heart problems could occur • Avoid alcohol, ASA, and all OTC
• High blood pressure such as chest pain, agents without approval.
• Skin rash or itching tightness in chest, fast or • Report any unusual bruising/bleeding,
• Small, red spots on skin irregular heartbeat, or weight gain, swelling of feet and ankle,
• Sores, ulcers, or white spots on unusual flushing or warmth increased joint pain, change in urine
lips or in mouth of skin. Stop taking this patterns or lack of response.
medicine and check with
Rare your doctor immediately if
you notice any of these
• Abdominal or stomach pain, warning signs.
cramping, or burning (severe)
• Bloody or cloudy urine
• Blurred vision of other vision
change
• Burning, red, tender, thick,
scaly, or peeling skin
• Cough or hoarseness
• Dark urine
• Decrease in amount of urine
(sudden)
• Fever with severe headache,
drowsiness, confusion, and
stiff neck or back
• Fever with or without chills or
sore throat
• General feeling of illness
• Hallucinations (seeing,
hearing, or feeling things that
are not there)

75
• Hearing loss
• Hives
• Increase in amount of urine or
urinating often
• Light-colored stools
• Loss of appetite
• Low blood pressure
• Mood changes or unusual
behavior
• Muscle cramps or pain
• Nausea, heartburn, and/or
indigestion (severe and
continuing)
• Nosebleeds
• Pain in lower back and/or side
• Pain, tenderness, and/or
swelling in the upper
abdominal area
• Painful or difficult urination
• Pale skin
• Puffiness or swelling of the
eyelids or around the eyes
• Ringing or buzzing in ears
• Runny nose
• Severe restlessness
• Swollen and/or painful glands
• Swollen tongue
• Thirst (continuing)
• Unusual tiredness or weakness
• Yellow eyes or skin

76
Some side effects may occur that
usually do not need medical attention.
These side effects may go away
during treatment as your body adjusts
to the medicine. Also, your health care
professional may be able to tell you
about ways to prevent or reduce some
of these side effects. Check with your
health care professional if any of the
following side effects continue or are
bothersome or if you have any
questions about them:

More common

• Abdominal or stomach pain

(mild or moderate)
• Bruising at place of injection
• Diarrhea
• Dizziness
• Drowsiness
• Headache
• Indigestion
• Nausea

Less common or rare

• Bloating or gas
• Burning or pain at place of
injection

77
 • Constipation
• Feeling of fullness in
abdominal or stomach area
• Increased sweating
• Vomiting

Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Metoclopramide Metoclopramide Gastro intestinal Tablets, syrup, It appears to bind to dopamine By inhibiting the action of
Hydrochloride stimulant concentration D2 receptors where it is a prolactin-inhibiting hormone
Intensol®. receptor antagonist, and is also a (i.e., dopamine),
Reglan® Diabetic gastroparesis mixed 5-HT3 receptor metoclopramide has
Reglan® Syrup antagonist/5-HT4 receptor sometimes been used to
Adults: 10 mg 30 min agonist. stimulate lactation.
before meals and bedtime Metoclopramide increases
for 2-8 weeks(therapy The anti-emetic action of peristalsis of the jejunum and
should be reinstituted if metoclopramide is due to its duodenum, increases tone and

78
 symptoms recur). amplitude of gastric
antagonist activity at D2 contractions, and relaxes the
IM, IV receptors in the chemoreceptor pyloric sphincter and
Prophylaxis of vomiting trigger zone (CTZ) in the central duodenal bulb. These
due to chemotherapy. nervous system (CNS)—this prokinetic effects make
Initial: 1-2 mg/kg IV q 2 action prevents nausea and metoclopramide useful in the
hr for two doses, with the vomiting triggered by most treatment of gastric stasis
first dose 30 mins before stimuli.[2] At higher doses, 5-HT3 (e.g. after gastric surgery or
chemotherapy. antagonist activity may also diabetic gastroparesis), as an
contribute to the anti-emetic aid in gastrointestinal
PROPHYLAXIS of effect. radiology by increasing
POSTOPERATIVE transit in barium studies, and
N&V. The prokinetic activity of as an aid in difficult small
Adults: 10-20 mg IM metoclopramide is mediated by intestinal intubation. It is also
near the end of surgery. muscarinic activity, D2 receptor used in gastroesophageal
antagonist activity and 5-HT4 reflux disease
receptor agonist activity.[3][4] The (GERD/GORD).
prokinetic effect itself may also
contribute to the anti-emetic
effect.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Metoclopramide is • drowsiness Common adverse drug • Document indications for therapy, onset,
contraindicated in • restlessness reactions (ADRs) associated location, pain intensity/level, and
phaeochromocytoma. It • fatigue with metoclopramide therapy characteristics of the symptoms.
should be used with • constipation include: restlessness, • Determine any renal or liver

79
caution in Parkinson's • diarrhea drowsiness, dizziness, dysfunction; assess hydration.
disease since, as a lassitude, and/or dystonic • Avoid alcohol, ASA, and all OTC
dopamine antagonist, it If you experience any of the reactions. Infrequent ADRs agents without approval.
may worsen symptoms. following symptoms, call your include: headache, • Report any unusual bruising/bleeding,
Long-term use should be doctor immediately: extrapyramidal effects weight gain, swelling of feet and ankle,
avoided in patients with (EPSE) such as oculogyric increased joint pain, change in urine
clinical depression as it • involuntary movements of crisis, hypertension, patterns or lack of response
may worsen mental state. the limbs or eyes hypotension, • Metoclopramide is physically and/or
Also contraindicated with a • spasm of the neck, face, and hyperprolactinaemia leading chemically incompatible with a number
suspected bowel jaw muscles to galactorrhoea, diarrhoea, of drugs.
obstruction. • change in mood (depression) constipation, and/or • Report any persistent side effects so they
depression. Rare but serious can be properly evaluated and
ADRs associated with counteracted.
metoclopramide therapy • After PO use, absorption of certain
include: agranulocytosis, drugs from the GI tract may be affected.
supraventricular tachycardia,
• Inject slowly IV over 1-2 min to prevent
hyperaldosteronism,
transient feelings or anxiety and
neuroleptic malignant
restlessness.
syndrome and/or tardive
dyskinesia. • Assess abdomen for bowel sounds and
distention; note any N&V.
The risk of EPSEs is • Do not operate car hazardous machinery
increased in young adults until drug effects realized; drug has a
(<20 years) and children. sedative effect.
Such dystonic reactions are
usually treated with
benztropine or procyclidine.
The risk of tardive
dyskinesia and EPSE is
increased with high-dose
therapy and prolonged use.

80
 Tardive dyskinesias may be
persistent and irreversible in
some patients.

Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Ranitidine Zantac, Zantac Histamine H 2 Duodenal Ulcer (Active) Completitively inhibits the Treatment and maintenance
150, Zantac 300, antagonist Adults action of histamine (H2) at therapy of duodenal ulcer;
Zantac 75, receptors sites of the parietal management of
Zantac PO 150 mg twice daily or cells, decreasing gastric acid gastroesophageal reflux
EFFERdose 300 mg at bedtime. secretion. disease (GERD; including
Maintenance dose is 150 erosive or ulcerative disease);
mg at bedtime. short-term treatment of
IM/IV/Intermittent IV 50 benign gastric ulcer;
mg every 6 to 8 h. treatment of pathologic
hypersecretory conditions
Treatment of Duodenal (Zollinger-Ellison);
and Gastric Ulcers maintenance therapy for
Children 1 mo to 16 yr gastric ulcer patients at
of age reduced dosage after healing

81
 of acute ulcers; treatment of
PO 2 to 4 mg/kg twice endoscopically diagnosed
daily (max, 300 mg/day). erosive esophagitis;
maintenance of healing of
Maintenance of Healing erosive esophagitis.
of Duodenal and
Gastric Ulcers
Children 1 mo to 16 yr
of age

PO 2 to 4 mg/kg daily
(max, 150 mg/day).

Acute Benign Gastric

Ulcer and GERD
Adults

PO 150 mg twice daily.

IM/IV/Intermittent IV 50
mg every 6 to 8 h.

Treatment of GERD
and Erosive Esophagitis
Children 1 mo to 16 yr
of age

PO 5 to 10 mg/kg daily
usually given in 2
divided doses.

Pathologic

82
Hypersecretory
Conditions
Adults

PO 150 mg twice daily.

Individualize.

Erosive Esophagitis
Adults

PO 150 mg 4 times daily.

IM/IV/Intermittent IV 50
mg every 6 to 8 h.
Continuous IV 6.25
mg/h. For patients with
Zollinger-Ellison, start
infusion at rate of 1
mg/kg/h and adjust
upward in 0.5 mg/kg/h
increments according to
gastric acid output (max,
2.5 mg/kg/h; infusion
rate 220 mg/h).

83
 Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Standard considerations. • chest pain, fever, feeling • No known

short of breath, coughing up Cardiovascular contraindications
green or yellow mucus; • Drug is minimally
• easy bruising or bleeding, AV block; bradycardia; cardiac absorbed. Incidence of
unusual weakness; arrhythmias; premature ventricular beats. adverse reaction is low.
• fast or slow heart rate; • Tell patient for best
• problems with your vision; CNS results to take
• fever, sore throat, and sucralfate on an empty
headache with a severe Agitation; confusion; depression; stomach (1 hour before
blistering, peeling, and red dizziness; fatigue; hallucinations; each meal and at bed
skin rash; or headache; insomnia; malaise; motor time)
• nausea, stomach pain, low disturbances; somnolence; vertigo. • Pain and ulcer
fever, loss of appetite, dark symptoms may subside
urine, clay-colored stools, Dermatologic within the first few
jaundice (yellowing of the weeks of therapy.
skin or eyes). Alopecia; erythema multiforme; rash; However, for complete
vasculitis. healing, be sure patient
Less serious side effects may continues on prescribed
include: EENT regimen.
• Monitor for severe,
• headache (may be severe); Blurred vision. persistent constipation.
• drowsiness, dizziness;
• Studies suggest that
• sleep problems (insomnia); GI drug is as effective as
• decreased sex drive,
cimetidine in healing
impotence, or difficulty Abdominal discomfort; constipation; duodenal ulcers.
having an orgasm; or diarrhea; nausea; pancreatitis; vomiting. • Drug has been used to
• swollen or tender breasts (in
treat gastric ulcers, but

84
 men); effectiveness of this use
• nausea, vomiting, stomach Hematologic is still under
pain; or investigation.
• diarrhea or constipation. Acquired immune hemolytic anemia; • Drugs contains
agranulocytosis; autoimmune hemolytic aluminum but isn’t
or aplastic anemia; granulocytopenia; classified as antacid.
leukopenia; pancytopenia; • Urge patient to avoid
thrombocytopenia. smoking, as this may
increase gastric acid
Hepatic secretion and worsen
disease.
Cholestatic or hepatocellular effects.

Musculoskeletal

Arthralgias; myalgias.

Miscellaneous

Anaphylaxis; angioneurotic edema;

hypersensitivity reactions.

Precautions

Pregnancy

Category B .

Lactation

85
Excreted in breast milk.

Children

Safety and efficacy of ranitidine have

been established in children 1 mo to 16 yr
of age for the treatment of duodenal and
gastric ulcers, GERD and erosive
esophagitis, and the maintenance of
healed duodenal and gastric ulcer. Safety
and efficacy have not been established for
the treatment of pathological
hypersecretory conditions or the
maintenance of healing of erosive
esophagitis in children or in neonates less
than 1 mo of age.

Elderly

May have reduced renal function;

therefore, decreased drug Cl may be more
common.

Hypersensitivity

Rare cases of anaphylaxis have occurred

as well as rare episodes of
hypersensitivity.

86
Renal Function

Decreased Cl may occur; dosage

reduction may be needed. Hemodialysis
reduces level of ranitidine-dosage; timing
must be adjusted so that scheduled dose
coincides with end of hemodialysis.

Hepatic Function

Use drug with caution; decreased Cl may

occur.

Hepatocellular injury

May occur, manifested as reversible

hepatitis, hepatocellular or
hepatocanalicular or mixed, with or
without jaundice.

Rapid IV administration

May rarely result in bradycardia,

tachycardia, or premature ventricular
beats, usually in patients predisposed to
cardiac rhythm disturbances.

87
Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Gentamiin Gentacidin Antibiotic, Adults and children: Inhibits protein synthesis None significant
aminoglycoside instill 1 – 2 drops in
eye q 4 hrs. in severe
infections, may use
up to 2 drops q 1 hr.
apply ointment to
lowe conjunctival sac
B.I.D. or T.I.D.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Opthalmic use to treat Eyes: burning, stinging or blurred vision • Contraindicated in

dendritic keratitis, azotemia, cylindruria, dizziness, (with ointment), transient irritation (from aminoglycoside
vaccinia, varicella, hearing loss, hyposthenuria, solution). hypersensitivity. Use
mycobacterial injection site reaction, interstitial cautiously in impaired renal

88
infections of the eye, nephritis, myasthenia, proteinuria, function.
use with steroids after pyuria, renal tubular acidosis, renal Other: hypersensitivity, over growth of • Solution is not for injection.
uncomplicated removal tubular necrosis, tinnitus, vertigo, non susceptible organisms with long term In conjunctiva or in anterior
of a corneal foreign use. chamber of the eye.
body. Concurrent use • Have cultured taken before
with nephrotoxic drug giving drug.
or diuretics. Lactation. • If ophthalmic gentamicin is
administered, be sure to
carefully monitor serum
gentamicin concentration
level.
• Stress importance of
following recommended
therapy. Pseudomonas in
infections can cause
complete vision loss within
24 hrs if infection is not
controlled.
• Warn patient to avoid
sharing wash clothes and
towels with family members
during infection.
• Always wash hands before
and after applying ointment.
• Cleanse eye area of
excessive exudates before
application.
• Tell patient to watch signs
for sensitivity such as
itching lids, swelling, or

89
 constant burning.
• Teach patient on how to
instill. Advice him to wash
hands before and after
administering ointment or
solution, and not to touch tip
of tube to eye.
• Store away from heat.
• Tell patient not to share eye
medications to members.

Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
mefenamic acid ponstan Nonsteroidal Anti- Oral Mefenamic acid inhibits the Mild to moderate pain,
inflammatory MILD TO MODERATE enzymes cyclooxygenase dysmenorrheal.
Drugs (NSAIDs) PAIN (COX)-1 and COX-2 and
Adult: 250-500 mg tid. reduces the formation of
Child: >6 mth: 25 mg/kg prostaglandins and leukotrienes.

90
daily in divided doses for It also acts as an antagonist at
up to 7 days. prostaglandin receptor sites. It
DENTAL PAIN has analgesic and antipyretic
Adult: 250-500 mg tid. properties with minor anti-
Child: >6 mth: 25 mg/kg inflammatory activity.
daily in divided doses for
up to 7 days.
POSTOPERATIVE
PAIN
Adult: 250-500 mg tid.
Child: >6 mth: 25 mg/kg
daily in divided doses for
up to 7 days.
DYSMENORRHOEA
Adult: 250-500 mg tid.
Child: >6 mth: 25 mg/kg
daily in divided doses for
up to 7 days.
OSTEOARTHRITIS
AND RHEUMATOID
ARTHRITIS
Adult: 250-500 mg tid.
Child: >6 mth: 25 mg/kg
daily in divided doses for
up to 7 days.
MENORRHAGIA
Adult: 250-500 mg tid.
Child: >6 mth: 25 mg/kg
daily in divided

91
Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Inflammatory bowel None significant Abdominal pain, dyspepsia, constipation, • Contraindicated in GI

disease; peptic ulcer; diarrhoea, nausea, GI ulcers; oedema; ulceration or inflammation.
neonates; pregnancy bronchospasm; headache, drowsiness, • Use cautiously in hepatic or
(3rd trimester), insomnia, visual disturbances; CHF, renal disease, cardiovascular
lactation. Coronary hypertension, tachycardia, syncope; disease, blood dyscrasia,
artery bypass graft urticaria, rash; thrombocytopenia, aplastic diabetes mellitus, and a history
surgery, severe renal anaemia, agranulocytosis; tinnitus; of peptic ulcer disease, and in
impairment, and severe elevated liver enzymes; abnormal renal asthmatics with nasal polyps.
heart failure. function. • Serious GI toxicity can occur
at any time in patient’s chronic
NSAIDs therapy. Teach
patients signs and symptoms of
GI bleeding, and tell patient to
report these to the doctor
immediately.
• Concomitant use with aspirin,
alcohol, or steroids may
increase the risk of GI adverse
reactions.
• Warn patient against hazardous
activities that require alertness
until CNS effects of the drug
are known
• Severe hemolytic anemia may
occur with prolong use.
Monitor CBC every 4 to 6
months or as indicated.

92
• Stop drug if rash visual
disturbances or diarrhea
develops.
• Should not be administered for
more than one week at a time,
because risk of toxicity
increases.
• Administered with food to
minimize GI adverse reactions.
• False-positive reactions for
urine bilirubin using the diazo
tablet test have been reported.

93
 Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Ferrous sulfate Chem-Sol, Fe 50, Antianemic, iron Adults: 325 mg P.O. Provides elemental iron, an For iron deficiency,
Feosol, Fer-Gen- t.i.d or q.i.d. essential component in the prophylaxis for iron
Sol, Fer-in-Sol, alternatively, give 1 formation of hemoglobin deficiency anemia.
Feratab, Fero- delayed release capsule
Gradumet (160 or 525 mg) P.O.
Filmtab, FeroSul, twice daily
Ferra T.D. Caps,
Ferra-TD, Ferro- Children: 4 to 6 mg/kg
Bob, Ferro-Time, daily in 3 divided doses.
Ferrospace, Mol-
Iron, Slow Fe, Pregnant Women: 150
Yieronia mg P.O. daily during the
last 2 trimesters.

Premature and
undernourished infants: 1
to 2 mg/kg P.O. daily (as
elemental iron) in
divided doses.

94
Contraindications Side Effects Adverse Reactions Nursing Responsibilities

Hemosidersis, Less serious side effects may GI: nausea, vomiting, • For infants and young children,
hemochromatosis, include: constipation, black stools. administer liquid preparation with a dropper.
peptic ulcer, regional Deposit liquid well back against the cheek.
enteritis, and ulcerative • constipation; Others: elixir may stain your • Eggs and milk or coffee and tea
colitis. Hemolytic • upset stomach; teeth. consumed with a meal or one hour after may
anemia, pyridoxine- • black or dark-colored stools; significantly inhibit absorption of dietary
responsive anemia, and or iron.
cirrhosis of the liver. • Temporary staining of the • Ingestion of calcium and iron
Use in those which teeth. supplements with food can decrese iron
normal iron balance. absorption by 1/3 ; iron absorption is not
decrease if calcium carbonate is use and
taken between meals.
• Do not crash or chew sustained
releases products.
• Take a drug history including:
1. antacid use; any other drugs that may
interact.
2. OTC drugs, i.e., iron compounds or
vitamin E use.
3. allergy to sulfites or tartrazines.
• note any GI bleeding; tarry stools or
bright blood in stool.
• assess for thalassemia; obtain
hemoglobin, electrophoresis, as iron
administration could be lethal.
• note any complains and fatigue, pallor,
poor skin turgor, or change in mental

95
 status, especially in the elderly.
• assess nutritional status and diet history
through questioning and intake if
possible.
• review pregnancies and menstruation
history; note frequency, amounts, and
heavy bleeding. Pregnancy is an
indication for iron prophylactically.
• Monitor VS,CBC,CHEM profile, stool
for occult blood, reticulocytes, serum
trasferine , and iron panel results.

Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name
Amlodipine Norvasc • Calcium • Hypertension and Amlodipine inhibits the • Angina pectoris due to
channel angina: 5 mg transmembrane calcium influx coronary artery
blocker daily (single with greater effects on vascular spasm.
• Antianginal dose). smooth muscle than on cardiac • Chronic stable angina,
• Antihyperte muscle. Its main action is to alone or in

96
 nsive cause peripheral arterial combination with
• The dose may be vasodilatation and therapy a other drugs.
increased to 10 reduction in after load and blood • Essential hypertension
mg daily if pressure. Hence, it reduces alone or in
necessary myocardial oxygen demand combination with
more by an indirect effect than other
direct on cardiac muscle. Reflex antihypertensives.
tachycarida does not occur due
to slow onset of action.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

• Flushing, palpitations
and peripheral edema.
Known Along with its needed effects, a Dizziness, headache, • Monitor patient carefully (BP cardiac
hypersensitivity. medicine may cause some hypotension. rhythm and output) while adjusting drug
C ardiogenic shock. unwanted effects. Although not Rare effects: to therapeutic dose; use special caution if
Unstable angina. all of these side effects may Prutins, rashes, urtocardia. patient has CHF.
Significant aortic occur, if they do occur they may Nausea, abdominal pain. • Monitor BP carefully if patient is also on
stenosis need medical attention. Muscle pain, weakness, nitrates
paraesthesias etc. • Monitor cardiac rhythm regularly during
Pregnancy and Check with your doctor as soon Gum hyperplasic. stabilization of dosage and periodically
lactation as possible if any of the Importance during long-term therapy.
following side effects occur:  increased urinary • Administer drugs without regard to meals

97
More common frequency. • Take with meals if upset stomach occurs
Altered Liver functions • Tell patient to report irregular heart beat,
Swelling of ankles or feet elevate shortness of breath, swelling of the hands
Ion of serum liver or feet, pronounce dizziness, &
Less common Enzymes jaundice. constipation.
Gynaecomastia.
Dizziness

Pounding heartbeat

Rare

Chest pain

Dark yellow urine

Dizziness or lightheadedness
when getting up from a lying or
sitting position

Slow heartbeat

Yellow eyes or skin

Some side effects may occur that

usually do not need medical
attention. These side effects may
go away during treatment as
your body adjusts to the
medicine. Also, your health care
professional may be able to tell

98
you about ways to prevent or
reduce some of these side
effects. Check with your health
care professional if any of the
following side effects continue
or are bothersome or if you have
any questions about them:

More common

Abdominal pain

Flushing

Headache

Sleepiness or unusual
drowsiness

Less common Nausea

Unusual tiredness or weakness

99
 Generic Brand Name Classification Dosage & frequency Mechanism of actions Indications
Name

Metoprolol Apo-Metoprolol Beta1 – • Hypertension: Competitively blocks beta- • Essential hypertension

adrenergic receptors in the heart
(CAN), Betaloc selective initially, 100 mg/ and juxtaglomerular apparatus, • Tachycardia
(CAN), Lopressor, adrenergic day PO in single decreasing in the influence of the • Coronary heart
symphathetic nervous system on
Novometoprol blocker or divided doses, these tissues and the excitability disease (prevention of
(CAN), Nu-Metop gradually increase of the heart, decreasing cardiac angina attacks)
output and the release of rennin,
(CAN) Antihypertens dosage at weekly and lowering BP; acts in the • Secondary prevention
ive
intervals. Usual CNS to reduce symphathetic after a myocardial
outflow and vasoconstrictor
maintenance dose tone. infarction
is 100-450 • Treatment of heart
mg/day. failure.
• Angina pectoris: • Migraine prophylaxis
initially, 100
• Adjunct in treatment
mg/day PO in two
of hyperthyroidism
divided doses;

100
 maybe increased
gradually,
effective range,
100-400 mg/day.
• MI early
treatment: three
IV bolus doses of
5 mg each at 2-
min intervals with
careful
monitoring. If
these are
tolerated, give 50
mg PO 15 min
after the last IV
dose and q 6 hr
for 48 hr.
thereafter, give
maintenance dose
of 100 mg PO
Bid. Reduce

101
 initial PO doses
to 25 mg, or
discontinue in
patients who do
not tolerate the IV
doses.
• MI, late
treatment: 100 mg
PO bid as soon as
possible after
infarct,
continuing for at
least 3 mo and
possibly for 1-3
yrs.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

102
• Contraindic Slow heart rate, Tiredness, Dizziness, Fatigue, lethargy, Do not discontinue drug abruptly after long-
dizziness, bradycardia,
ated with sinus Diarrhea, Itching or unexplained rash, term therapy.
hypotension, CHF,
bradycardia (HR < Shortness of breath peripheral vascular Taper drug gradually 2 week with monitoring.
disease. Nausea,
45 beats/min), vomiting, diarrhea, skin • Ensure the patient swallows the
second or third- rash, dyspnea, ER tablets whole; do not cut, crush, or
bronchospasm, fever,
degree heart block arthralgias. chew. Toprol XL tablets may be divided
(PR interval > 0.24 at the score; divided tablets should be
sec), cardiogenic swallowed whole, not crushed or
shock, CHF, chewed.
systolic BP < 100 • Advice the patient to consult the
mm Hg; lactation. physician about withdrawing drug if
• Use patient is to undergo surgery.
cautiously with • Give oral drug with food to
diabetes or facilitate absorption.
thyrotoxicosis; • Provide continual cardiac
asthma or COPD; monitoring for patients receiving
pregnancy metoprolol
• Do not stop taking this drug
unless instructed to do so by your health
care provider.

103
• Swallow the extended-release
tablets whole; do not cut, crush or chew
if using Troplol XL, you can divide the
tablets at the score.

104
 Generic Brand Classification Dosage & frequency Mechanism of actions Indications
Name Name
Ascorbic acid Ascorbic acid antioxidant Dietary sources: citric • Toxicodynamics Ascorbic acid is
juices, fresh vegetables and recommended for prevention
(Vitamin C)
fruit, potatoes Hyperoxaluria may result after and treatment of scurvy
administration of ascorbic acid (disorder caused by lack of
Administered orally or IV Ascorbic acid may cause vitamin C). Its parenteral
acidification of the urine, administration is desirable for
Dietary supplementation occassionally leading to patients with an acute
(RDA: recommended daily precipitation of urate, cystine, or deficiency or for those
allowance): oxalate stones, or other drugs in absorption of orally ingested
the urinary tract. Urinary ascorbic acid uncertain.
Adults: 60mg per calcium may increase, and
day urinary sodium may decrease Symptoms of mild
after 3 to 6 g of ascorbic acid deficiency may include faulty
Scurvy: 100-300mg per daily. Ascorbic acid reportedly bone and tooth development,
day over several days will may affect glycogenolysis and gingivitis, bleeding gums, and
reverse scurvy effects may be diabetogenic but this is loosened teeth. Febrile states,
controversial. chronic illness and infection
Infants: (pneumonia, whooping
• Pharmacodynamics cough, tuberculosis,
preventive: 30mg per day diphtheria, sinusitis,
In humans, an exogenous source rheumatic fever, etc.) increase
treatment: 100-300mg per of ascorbic acid is required for the need for ascorbic.
day collagen formation and tissue
repair. Vitamin C is a co-factor

105
 in many biological processes
Premature infants: 75- including the conversion of
100mg per day dopamine to noradrenaline, in
the hydroxylation steps in the
Enhanced wound healing: synthesis of adrenal steroid
300-500mg per day for 7- hormones, in tyrosine
10 days pre- and post- metabolism, in the conversion of
operatively folic acid to folinic acid, in
carbohydrate metabolism, in the
Burn patients: 1-2 grams synthesis of lipids and proteins,
per day in iron metabolism, in resistance
to infection, and in cellular
respiration. Vitamin C may act
as a free oxygen radical
scavenger. The usefulness of the
antioxidant properties of vitamin
C in reducing coronary heart
disease were found not to be
significant.

Contraindications Side Effects Adverse Reactions Nursing Responsibilities

106
Ascorbic acid is Stomach upset, diarrhea, mouth sores, Faintness, dizziness with • Use cautiously in G6PD deficiency.
contraindicated in patients frequent urination, kidney stones develop, fast I.V. administration. • I.V. use: administer I.V. infusion
with hyperoxaluria and G- such as: abdominal/back pain, painful cautiously in patients with renal
6-PD deficiency urination. Nausea, vomiting, insufficiency.
diarrhea, epigastric • Avoid rapid I.V.administration.
burning. • When administering for urine
acidification, check urine pH to ensure
efficacy.
• Protect solution from light

107
 SURGICAL PROCEDURE

CAESAREAN SECTION

A caesarean section (or cesarean section in American English), also known as c-

section, is a form of childbirth in which a surgical incision is made through a mother's

abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies. It is

usually performed when a vaginal delivery would put the baby's or mother's life or health

at risk; although in recent times it has been also performed upon request for births that

would otherwise have been natural. The surgery is relatively safe for mother and baby.

Still, it is major surgery and carries risks. It also takes longer to recover from a C-section

than from vaginal birth. After healing, the incision may leave a weak spot in the wall of

the uterus. This could cause problems with an attempted vaginal birth later. However,

108
more than half of women who have a C-section can give vaginal birth later. C-sections

are also more common among women carrying more than one baby.

Types

There are several types of caesarean sections (CS). The differences between them

primarily lie in the deep incision made on the uterus, below the skin and subcutaneous

tissue, and should be differentiated from the skin incision, such as a Pfannenstiel incision.

• The classical caesarean section involves a midline longitudinal incision which

allows a larger space to deliver the baby. However, it is rarely performed today as

it is more prone to complications.

• The lower uterine segment section is the procedure most commonly used today; it

involves a transverse cut just above the edge of the bladder and results in less

blood loss and is easier to repair.

• An emergency caesarean section is a caesarean performed once labour has

commenced.

• A crash caesarean section is a caesarean performed in an obstetrical emergency,

where complications of pregnancy onset suddenly during the process of labor, and

swift action is required to prevent the deaths of mother, child(ren) or both.

• A caesarean hysterectomy consists of a caesarean section followed by the

removal of the uterus. This may be done in cases of intractable bleeding or when

the placenta cannot be separated from the uterus.

• Traditionally other forms of CS have been used, such as extraperitoneal CS or

Porro CS.

109
 • a repeat caesarean section is done when a patient had a previous section.

Typically it is performed through the old scar.

Indications

Caesarean section is recommended when vaginal delivery might pose a risk to the mother

or baby. Reasons for caesarean delivery include:

• precious (High Risk) Fetus

• prolonged labour or a failure to progress (dystocia)

• apparent fetal distress

• apparent maternal distress

• complications (pre-eclampsia, active herpes)

• catastrophes such as cord prolapse or uterine rupture

• multiple births

• abnormal presentation (breech or transverse positions)

• failed induction of labour

• failed instrumental delivery (by forceps or ventouse. Sometimes a 'trial of

forceps/ventouse' is tried out - This means a forceps/ventouse delivery is

attempted, and if the forceps/ventouse delivery is unsuccessful, it will be switched

to a caesarean section. This takes place in the operating theatre.

• the baby is too large (macrosomia)

• placental problems (placenta praevia, placental abruption or placenta accreta)

• umbilical cord abnormalities (vasa previa, multi-lobate including bi-lobate and

succenturiate-lobed placentas, velamentous insertion)

110
 • contracted pelvis

• Sexually transmitted infections such as genital herpes (which can be passed on to

the baby if the baby is born vaginally, but can usually be treated in with

medication and do not require a c-section)

• previous caesarean section (though this is controversial – see discussion below)

• prior problems with the healing of the perineum (from previous childbirth or

Crohn's Disease)

BILATERAL TUBAL LIGATION (BTL)

Tubal ligation (informally known as getting one's "tubes tied") is a permanent form of

female sterilization, in which the fallopian tubes are severed and sealed or "pinched shut",

in order to prevent fertilization. Hormone production, libido, and the menstrual cycle can

be affected by a tubal ligation.

A tubal ligation can be done in many forms; through a vaginal approach, through

laparoscopy, a minilaparotomy ("minilap"), or through regular laparotomy. Also, a

distinction is made between postpartum tubal ligation and interval tubal ligation, the

latter not being done after a recent delivery. There are a variety of tubal ligation

techniques; the most noteworthy are the Pomeroy type that was described by Ralph

Pomeroy in 1930, the Falope ring that can easily be applied via laparoscopy, and tubal

cauterization done usually via laparoscopy. In addition, a bilateral salpingectomy is

effective as a tubal ligation procedure. A tubal ligation can be performed as a secondary

procedure when a laparotomy is done; i.e. a cesarean section. Any of these procedures

may be referred to as having one's "tubes tied."

111
Tubal ligation can be performed under either general anesthesia or local anesthesia

(spinal or epidural, often supplemented witha tranquilizer to calm the patient during the

procedure). The default in tubal ligations following on from cesarean birth is usually

spinal/epidural, while the default in non-childbirth related situations may be general

anesthesia as a matter of doctor preference. However, tubal ligations under local

anesthesia, either inpatient or outpatient, may be performed under patient request.

Less commonly performed is the Essure procedure, in use since 2002. In this procedure

micro-inserts are placed within the fallopian tubes by means of catheter and

Hysteroscopy. The micro-inserts produce eventual occlusion of the fallopian tubes by

causing the in-growth of tissue.

Nursing Responsibilities

1. Facilitation of the patient’s and family understands of anesthesia, surgery, and

procedures

2. Relieving the patient’s and the family’s anxiety about the outcome with reasonable

information

3. Encourage patient to commence deep breathing, coughing and leg exercises.

4. Encouragement of good dietary and fluid intake during hospital stays prior to surgery.

5. Advice patient to comply with health regimen

112
 NURSING THEORY

Dorothea E. Orem (Self-Care Deficit Theory

Orem explicated self-care as a human need and nursing as a human service; she

emphasized nursing’s special concern for a person’s need for self-care actions on a

continuous basis to sustain life and health or to recover from disease or injury. She

formalized the Self-Care Deficit Theory of nursing as a general theory composed of the

following three related theories: (1) the Theory of Self-Care, (2) the Theory of Self-Care

Deficit, and (3) The Theory of Nursing Systems. Her work identifies three types of

nursing systems: (1) wholly compensatory (doing for the patient), (2) partly

compensatory (helping the patient do for himself or herself), and (3) supportive-educative

(helping the patient learn to do for himself or herself and emphasizing the important role

of the nurse in designing nursing care).

We, as nurses require a continuous and practical action to our patient to enable

them to know and meet therapeutic self-care demands to let them be aware of certain

limitations that could help them develop independence towards their needs necessary for

their living. When we had our interview to Mrs. X first, we were able to developed trust

towards the patient which is very important. And as we go through our interaction we

had provided guided teachings to help them resolve their problems but with limitations.

Limitations in which we only give some alternatives and they will be the one to help

theirselves function on the things they need to work with. Through a good therapeutic

communication Mrs. X was able to gain a lot of information in which it made her think to

make some changes with regards to her life style

113
Imogene King (Goal Attainment Theory)

King’s theory of goal attainment focuses on the interpersonal system and the

interactions that take place between individuals, specifically in the nurse-patient

relationship. In the nursing process, each member in the dyad perceives the other, makes

judgements, and takes actions. Together this activities culminate in reaction. Interaction

results and, if perceptual congruence exist and disturbances are conquered, transactions

occur. The system is open to permit feedback because each phase of the activity

potentially influences perception.

It is very much important that we establish rapport to our patient so that we could

extract some information available from research in nursing and related fields. In this

case, we have gained enough information about the client’s background. We have made

an appropriate approach because the patient was able to verbalize her own feelings of

her condition. And as much as possible we were being careful of the questions being

asked to the patient, because we might hurt her feelings and later on she might not gave

us the appropriate answers. We have also provided some individualized plan of care that

encouraged the patient to participate in the decision-making.

Jean Watson (Human Caring Relationship Theory)

Jean Watson proposed that the ultimate aim of nursing is caring with the purpose

of preserving the dignity and wholeness of humans. She emphasizes that caring may

occur without curing, but curing cannot occur without caring. Nursing as a discipline is

devoted to caring, to health, and to healing in their many meanings and interpretations.

114
Nursing occurs in caring occasions or moment through the use of ten carative factors in a

nurse-patient relationship known as transpersonal caring. The practice of nursing is both

a science and an art and focuses on the goals of growth, meaning, and self-healing rather

than the problem solving seen in the use of the nursing process.

As a student nurse our goal is to help the patient gain a higher degree of harmony

within the mind, body, and soul which generates self-knowledge, self reverence, self-

healing, and self-care. During our interview to our patient with regards to her condition,

we were able to gain her trust through the aspect of caring. We were able to develop the

helping-trust relationship that is why the patient was able to voice out his positive and

negative feelings about her condition. There was an effective communication because we

were able to get the trust of the patient and we showed some concern and care towards

her state of condition.

115
 Ineffective Peripheral Tissue Perfusion
Date Cues Need Nsg. Diagnosis Objective Intervention Evaluation
s
Septembe S/O: A Ineffective Tissue Within the span of 1. Monitored September
r - Edema C Perfusion related care, client will be blood 08, 2008 @
07, noted on T to able to pressure every 7am
2008 lower I vasoconstriction 4hours. GOAL MET
@ 11pm extremities V of blood vessels. - verbalizes ® This will serve
I understanding of as the baseline - client was
- cold, T R: Decreased in condition and data. able to
clammy skin Y oxygen resulting therapy regimen. 2. Instructed to demonstrate
noted. - in the failure to have enough rest increased
E nourish the - increased on perfusion.
- BP: X tissues at the perfusion as semi fowlers
140/100 E capillary level evidenced by position.  demons
R normal range of ® Sodium tends trate
C source: page 565, BP. to be excreted increased
I Nurse's Pocket at a faster rate. perfusion
S Guide, Marilynn E. - extremities 3. Instructed to as
E Doenges, Mary warm to touch eat evidenced
Frances low fat and low by

116
P Moorhouse, Alice salt palpable
A C. Murr diet. peripheral
T ® To reduce pulse
T edema that may 
E activate renin - BP: 120/90
R angiotensinaldost
N erone
system.
4. Administer
anti- hypertensive
drug as ordered.
® To control the
BP and to avoid
other
complications.

5. Determine the
factors related to
individual
situation.

117
® Diseases and
post-op
conditions may
help contribute to
the client’s
present state.
6. Identify
changes related
to systemic and
peripheral
alterations in
circulation.
® Altered vital
signs or pain may
be signs of
change.
7. Note
customary
baseline data.
® This provides

118
comparison with
current findings.
8. Measure
circumference of
extremities as
indicated.
® This will be
useful in
identifying edema
in involved
extremity.
9. Check for calf
tenderness
(Homans' sign),
swelling and
redness.
® This may
indicate thrombus
formation.
10. Review

119
laboratory
results.
® Results may
show client’s
Hb/Hct and
clotting times.
11. Encourage
early ambulation
when possible.
® This enhances
venous return.
12. Provide
comfortable bed.
® This may
provide comfort
and protect the
extremities.
13. Encourage
use of relaxation
techniques.

120
 ® This will
decrease tension
level.

Activity Intolerance

121
 Date Cues Need Nsg. Diagnosis Objective Intervention Evaluation
s
Septembe S/O: A Activity Within the span 1. Monitor client September
r - client C intolerance of care, client will VS. 09, 2008 @
08, required T related to edema be able to: ® This will serve 7am
2008 assistance in I on the lower as the baseline GOAL MET
@ 11pm transferring V extremities. - verbalize data.
from one bed I understanding of 2. Identify - client was
to another T R: Insufficient situation and condition/diagnos able to
Y physiological or safety measures. es that contribute verbalize
- Swelling on - psychological to difficulty understanding
her feet was E energy to endure walking. of situation
noted. X or complete ® Diseases, post- and safety
E required or op conditions, measures.
R desired daily and age may
C activities affect capability
I to walk properly.
S source: page 65, 3. Consult with
E Nurse's pocket patient or
Guide, Marilynn E. significant other.
P Doenges, Mary ® This is to

122
A Frances develop
T Moorhouse, Alice individual
T C. Murr mobility.
E 4. Discuss of
R demonstrate use
N of adjunctive
devices.
® This is to
provide
information vital
to patient.
5. Provide safety
measures as
indicated.
® Providing a
safe environment
for client may
decrease risk of
injury.
6. Involve client

123
and SO in care.
® This is to
enhance safety
for client and SO.
7. Reassess client
if she has
internalized the
previous
teachings well.
® Reassurance
means client has
fully understood
what was taught.

124
 Self-care Deficit
Date/tim Cues Need Nursing Objectives/Goal Nursing Evaluation
e s Diagnosis s Intervention

125
 S/O: A Self-Care Deficit Within my span of 1.Determine age Goal Met
Septembe >halitosis C related to pain or care, client will be or developmental >Client was
r 08, 2008 noted T discomfort as able to: issues affecting able to clean
@ >strong I evidenced by >Perform self- ability of her body
11PM body odor V halitosis, strong care activities individual to through
noted I body odor, poor within level of practice in own cleansing bed
>poor skin T skin turgor, dirty own ability. care. bath.
turgor noted Y and untrimmed >Identify ® This might be >halitosis
>fingernails fingernails individual areas an effect that and strong
noted E of weakness or causes the client odor were
> dandruffs X ® Inability to needs. not to perform absent.
noted E maintain proper > Demonstrate proper hygiene >Nails were
R hygiene techniques or and self-care. trimmed and
C lifestyle changes cleaned.
I source: Nurse's to meet self-care 2. Determine
S Pocket Guide, needs. client’s ability to >Hair was
E Marilynn E. participate in self- properly tied.
Doenges, Mary care activities. >Client
P Frances >Verbalize (scale of 0-5) verbalize the
A Moorhouse, Alice knowledge of ® Underlying importance of

126
T C. Murr healthcare condition dictates proper
T practices. level of deficit hygiene.
E >Identify needs affecting
R personal choice of
N resources that interventions.
can provide NOTE:
assistance. Psychological
factors (eg.
Depression,
motivation, and
degree of
support) also
have a major
impact on the
client’s abilities.

3. Provide
assistance with
activities as
necessary.

127
® Meet needs
while supporting
client
participation and
dependence.
4. Encourage or
use energy-
saving
techniques; eg.
Using bath towels
or tepid sponge
bath: doing tasks
in small
increments.
5. Recommend
scheduling
activities to allow
client sufficient
time to
accomplish tasks

128
to fullest extent
of ability.
® Unhurried
approach reduces
frustration,
promotes client
participation,
enhancing self-
esteem.

129
 Risk for Infection
Date/ Cues Needs Nursing Objectives/ Goal Intervention Evaluation
Time Diagnosis
September Subjective: H Risk for infection Within my 8 hours 1. Monitor vital September 10,
09, “lisod kaayo E related breakage in span of care the signs 2008 @ 7am
2008 mag atiman A continuity of skin patient will be ® to serve as Within my shift
@ 11pm sa akon tahi L secondary to able to: baseline data. GOAL MET
basin ma T surgical incision. 2. Encourage fluid The client
infect” as H - Verbalize intake of 2000 ml able to:
verbalized by ® At increased risk understanding of to 3000 ml of
the pt. P for being invaded individual water per day - Verbalize
E by pathogenic causative/risk (unless understanding
Objectives: R organisms factor contraindicated). of individual
C causative/risk
 Weak E source: Page 322, - Identify ® Fluids promote factor
looking P Nurse's Pocket intervention to diluted urine and - Identify
 restless T Guide by Marilyn E. prevent/reduce frequent emptying intervention to
ness I Doenges, Mary risk of infection of bladder; prevent/reduce
 Restless O Frances reducing stasis of risk of
noted N Moorhouse, Alice C. urine, in turn, infection

130
 Stitches Murr reduces risk of
in the - bladder infection
abdome H or urinary tract
n noted, E infection (UTI).
dressing A 3. Observe for
is dry L localized signs of
and T infection at
intact H insertion sites of
invasive lines,
M sutures, surgical
A incision.
N ® Signs of
A infection should
G be dealt with
E immediately.
M
E 4. Stress proper
N hand washing
T technique.
® A first line of

131
P defense against
A nosocomial
T infections., hand
T washing is the
E single most
R effective way of
N preventing the
spread of
microorganisms

5. Encourage early
ambulation, deep
breathing,
coughing,
positions change.
® This is to
mobilize
respiratory
secretions.

132
6. Maintain
adequate
hydration.
® This is to avoid
bladder distention.

7. Emphasize
necessity of taking
antibiotics as
directed.
® Premature
discontinuation of
treatment when
client begins to
feel well may
result in return of
infection.

8. Involve in
appropriate

133
community
education
programs.
® This is to
increase
awareness of
spread/ prevention
of communicable
diseases.

9. Discuss
importance of not
taking antibiotics /
using “leftover”
drug unless
specifically
instructed by
healthcare
provider
® Inappropriate

134
use can lead to
development of
drug-restrains/
secondary
infections

10. Encourage
balance diet,
emphasizing
proteins, fatty
acids and vitamins
® Immunity that
affected by
deficiencies in one
or more of these
nutrients

11. Teach the

client risk factors
contributing to

135
surgical wound
infection, smoking,
and higher body
mass index
® Theses are
some of the
factors associated
with risk of
surgical wound
infection
12. Instruct the
client about the
need for good
nutrition
® Optimal good
nutritional status
contributes to
health
maintenance and
the prevention of

136
 infection.

Acute Pain
Date/ Cues Needs Nursing Objectives/ Goal Intervention Evaluation
Time Diagnosis
September Subjective: C Acute pain related within 2-3 hours 1. Administer September 10,
09, “sakit akong O surgical incision span of care the analgesics or non 2008 @ 7am
2008 tahi gihapon” G secondary to patient will: steroidal Goal met as
@ 11pm as verbalized N cesarean delivery antiinflammatory evidence by
by the patient I drugs as patient:
T ® Unpleasant - Patients pain will prescribed.

137
Objectives: V sensory and no longer be noted ® To relieve mild
E emotional as evidence by or moderate - Patients pain
• Grimace experience arising patients pain scale pain. will no longer
d face P from actual or will reduce from be noted as
noted E potential tissue moderate six to 2. Reposition as evidence by
with R damage or mild three indicated. patients pain
moderat C described in terms ® May relieve scale will
e pain E of such damage; - Demonstrate pain and reduce from
scale of P sudden or slow use of relaxation enhance moderate six
6 T onset of any techniques and circulation. to mild three
• S/P U intensity form mild diversional
cesarea A to severe with an activities 3. Provide - Demonstrate
n L anticipated or additional use of
section predictable end comfort relaxation
P and a duration of measures like techniques
A less than 6 months back rub. and diversional
T ® Improves activities
T source: page 388, circulation,
E Nurse's Pocket reduces muscle
R Guide, Marilynn E. tension and

138
N Doenges, Mary anxiety
Frances associated with
Moorhouse, Alice C. pain.
Murr
4. Encourage use
of
relaxation
technique like
deep breathing
exercises.
® Relieves
muscle and
emotional
tension.

5. Provide a
comfortable
environment.
® comfortable
environment aids

139
in relaxation and
minimize
distraction

6. Encourage
patients to
verbalize feelings
and concern.
® to alleviate
anxiety.

7. Asses for
verbal and non-
verbal indicators
of pain and
evaluate response
to technique used.
® follow up
assessment
provides

140
information about
effectiveness of
comfort measures
used and need for
additional relief
measures.

8. Explain to the
client the pain
management
approach that has
been ordered,
including
therapies,
medication
administration,
side effect, and
complications.
® one of the most

141
important steps
towards improved
control of pain is a
better client
understanding of
the nature of pain,
it's treatment and
the role the client
needs to play in
pain control

9. Provide comfort
measures
® to provide
nonpharmacologic
al
pain management

10. Encourage
diversional

142
activities
® to divert his/her
attention to other
activities and to
relief

11. Encourage
adequate rest
® to prevent
fatigue

12. Reinforce the

importance of
taking pain
medications to
keep pain under
control.
® teaching clients
to stay on top of

143
their pain and
prevent it from
getting out of
control will
improve the ability
to accomplish the
goals of recovery

144
 DISCHARGE PLAN

M E T H O D
- Instruct the - Strenuous - Discuss to the - Inform patient - Inform the - Instruct patient

patient or activities are patient and the importance patient to return to follow a low

significant given significant of proper for follow up salt, low fat

others precautions to others regarding sanitation and check-up as diet. Fatty

regarding the prevent increase the purpose of hygiene. scheduled deposits are

compliance of of blood the medicines - Encourage Encourage to precipitating

medications to pressure. being given. client to have cooperate well factors in

hasten healing. - Patient should - Family should adequate rest with home hypertension

- Instruct to take have adequate encourage periods in order medications. due to deposits

medications rest periods patient to take to avoid stress. in the blood

with meal to recommended constricting

prevent GI medications and blood vessels.

upset. other Low sodium to

- Inform patient therapeutic prevent water

145
and significant regimen. retention.

others regarding

the proper

storage of

medications.

146
 PROGNOSIS

POOR(1) FAIR(2) GOOD(3) Justification

Onset of illness Patient’s onset of illness is
 gradual because she was able
to comply all the medications
that were given to her. She is
always given an immediate
care and proper actions are
done.

Duration of illness If there are any problems that

 occur in her body they
immediately seek for medical
attention to avoid it from
worsening.
Precipitating factor One factor which contributed
 to the patient’s condition is
her pregnancy.

Presdisposing Since the patient is 35 years

factor old his age and gender would
 tell that she is prone to
Preeclampsia.

Willingness to
follow treatment We rated are patient as such
regimen  because she is willingly
complying to her medications.
She is very cooperative to
some tests that were
performed. She puts on effort
on her process of curing so
that she could easily recover
with her condition.

Family support Her family is financially,

 emotionally and spiritually
supportive. As what we have
observed her husband was
always with her at the bedside.
They’ve been making ways to
help her cope up with her
condition.
TALLY:

147
Poor (1 x 2) = 2

Fair (2 x 1) = 2

Good (3 x 4) = 12

Overall: 16/ 6 = 2. 7

Impression:

Patient’s prognosis shows a good outcome. They are justified to the following

data that we had gathered. Patient is very cooperative in her ongoing treatment. Her

family was very much supportive in any ways. They immediately seek for medical

attention if ever problems occur. Since the patient is female and is now at the age of 35

years old, there is no doubt that she is prone to such kind of disease.

148
 RECOMMENDATION

For the family:

We recommend that the family will still continue to give the patient love and

support even though they lack support on their financial needs. It could still help the

patient survive when there is a strong bond of relationship within the family. The family

must learn to understand the patient’s situation. They must also be aware of some

medications that are really needed for the patient. They must find ways and means to

comply with such certain meds, because if patient is left untreated then it will lead to

certain complications that will even more add up to the expected amount.

For the patient:

The patient should be aware with her condition. She must be well oriented of the

facts about the things that she should be alarmed of. We recommend that the patient will

be complying all the medications given to her by the physician. And as a patient she must

follow all the doctor’s guidelines to her. She must discipline herself to all the things that

must be avoided. Also, patient must learn the importance of proper hygiene in order to

lessen other possible infections. Since the patient has hypertension we recommend her to

lessen strenuous activities.

For the community:

Pre-eclampsia is not always preventable for those at risk, however, steps can be

taken to lower the chance to develop and to delay the possible outcome. That’s why we

want to recommend all the pregnant women to stay healthy as much as possible. Women

149
who start their pregnancy at a normal body weight, are well nourished, those who don't

smoke are less likely to develop pre-eclampsia. If you are at higher risk, be sure to follow

all prenatal care advise and keep all the medical appointments.

150
 REFERENCES

• Nurse’s Pocket Guide by Marilyn Doenges, Mary Frances Moorhouse, and Alice

C. Murr

• Blackwell’s Nursing Dictionary

• Essentials of Maternity Nursing 3rd Edition by Bobak and Jensen

• Mosby’s Pocket Dictionary

• Nursing ’93 Drug Handbook

• 2005 Edition PDR, Nurses Drug Handbook

• Medical – Surgical Nursing by Black J. and Hawk J.H.

• http://hb4110.net/wp-content/uploads/KIT_MATERNAL%20HEALTH_BASIC

%20STATS.doc.

• http://www.emedicinehealth.com/pregnancy/article_em.htm

• http://cancerweb.ncl.ac.uk/cgi-bin/omd?cephalic+presentation

• MCN pp.427-428 by Adele Pilliteri

• http://www.womenshealthcaretopics.com/surgical_sterilization.htm

• http://www.expectantmothersguide.com/library/stlouis/ESLadv_maternal_age.ht

151
• http://en.wikipedia.org/wiki/Pre-eclampsia

• Lowdermilk and Perry.Maternity Nursing 7th Ed. Mosby Year Book Publishing,

St.Louis. Missouri, USA

• http://multiples.about.com/cs/medicalissues/a/preeclampsia.htm

• Pathophysiology Adaptations and Alterations in Function, 4th Edition by Barbara

L. Bullock

• http://parenting.ivillage.com/pregnancy/pcomplications/0,,4b0,00.html

• Maternal & Child Health Nursing, 4th Edition by Pillitteri

152