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Hana Akelley case study Patient's information clinical manifestation physical assessment Sharaa alsubaei is a 19 year old G1 P1 A0 L1 who delivered on Sunday at 30.03.13 C/S as emergency case with EBL 500ml. She delivered a baby girl with weight 1.7kg .Her only medical problem is chronic hypertension which was diagnosed during her pregnancy and she has a strong family history of chronic hypertension. She is currently receiving 40gms/100ml magnesium sulfate/hr via IV infusion pump . She is also receiving via IV 5mg of hydralazine hydrochloride . she doesn't have any surgical history, and with maternal risk factor of family history, her age and her first pregnancy
diagnosed with PET Pre-eclampsia toxemia is a condition that occurs only during pregnancy. Diagnosis is made by the combination of high blood pressure and protein in the urine, occurring after week 20 of pregnancy.
pre-eclampsia may also be called toxemia and is often precluded by gestational hypertension. affects about 2-6% of healthy, first time mom.. Signs of preeclampsia usually arise in the order: excessive weight gain, followed by edema, hypertension, and proteinuria eventually. In the mild pre-eclampsia found no subjective symptoms. In the severe pre eclampsia found in the area prontal headache, diplopia, blurred vision, pain in the epigastric region, nausea or vomiting. These symptoms are often found in pre-eclampsia is increased and is an indication that eclampsia will occur.. Start.. sharaa vital signs and initial assessment are as follows:
Temperature 37.2 C,
BP 164/112 and repeated 176/112 ,
respirations 20 , lungs clear bilaterally.
Her Wt was 60.90 kg and Ht 154.4 cm.
Sharaa fundus is firm, midline.
Her lochia is moderate rubra.
Homan’s sign is negative bilaterally.
Breasts are soft. She is breastfeeding her infant in a good positioning have been observed but she needs more education and intervention regarding that.
She is complaining of moderate to severe uterine pain when breastfeeding 4/10 in pain scale . VS & Assessment blood type: B positive .
Proteinuria: 9 (0 to 8 mg/dL)
Creatinine : 1.9 (0.5 - 1.4mg/dl)
uric acid : 7 (2.0–6.6 mg/dL)
Infant: blood type: B + Laboratory Manifestations Medications Sex : Female
Weight : 1.7 kg
Care of umbilical : cut and clamp + 2 arteries and 1 vine check on the umbilical site see any s/s of infection & clean it with alcohol swap and keep it dry
Care of eye: Erythromycin ophthalmic ointment 0.5% 1-2 cms ribbon into sub-conjunctival sac check if there is any s/s of infection & clean it with gauze of water for each eye in circular technique and from inner to outer Newborn assessment Apgar score Nursing Dignosis Discharge Health
Education HOME CARE IF DELIVERED. like our case
If the patient is discharged delivered, she needs to receive similar teaching because preeclampsia does not resolve immediately after delivery. HOME CARE IF UNDELIVERED.
If the patient is discharged undelivered, emphasize that follow-up appointments are important for timely diagnosis of progressive preeclampsia. Educate the patient on the importance of the left lateral position for bedrest. Tell the patient to notify the physician immediately for any of the following symptoms: headache; visual disturbance; right upper quadrant pain; change in level of consciousness or "feeling funny"; decreased urine output; increase in edema, especially facial; or any decrease in fetal movement. Tell the patient to weigh herself daily and notify the physician of a sudden weight gain. Be sure the patient understands the seriousness of the disorder and the potential complications to her and her infant. any questions patient perception of the illness: the patient accepts her condition and she follows the instructions as it is
but she is asking about the causes..
the patient believes that her condition
related to family history..
she is wondering if her age is the
cause or not..
when we explain that the history repeat it self. she was active and asking questions and wants to know more..
she is cooperative