case study report on preeclampsia carried out during …gicedab.000webhostapp.com/downloads/2....

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P.O BOX: 875, BAMENDA.

MOTTO: HOPE IS THE KEY

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS

FOR THE AWARD OF THE HIGHER NATIONAL DIPLOMA (HND) IN

NURSING

CASE STUDY REPORT ON PREECLAMPSIA

CARRIED OUT DURING AN INTERNSHIP AT THE

REGIONAL HOSPITAL BAMENDA 7 DECEMBER

2017 TO 7 JANUARY 2018

APRIL 2018

REPUBLIQUE DU CAMEROUN

---------------------------

PAIX-TRAVAIL-PATTIE

----------------------------------

MINISTERE DE L’ENSEIGNEMENT

SUPERIEUR

----------------------------

DIRECTION DE L’ENSEIGNEMENT

SUPERIEUR PRIVE

---------------------------------------

REPUBLIC OF CAMEROON

-----------------------------

PEACE-WORK-FATHERLAND

-------------------------------------

MINISTRY OF HIGHER

EDUCATION

---------------------------------

DEPARTMENT OF PRIVATE

EDUCATION

-----------------------------------

PRESENTED BY:

AMINATOU LEKA SUPERVISED BY: MFONFU DANIEL

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CERTIFICATION

This to certify that this case study was carried out during an internship at the

Bamenda Regional Hospital by Aminatou Leka from 7 December 2017 to 7

January 2018 for the award of Higher National Diploma [HND] in Nursing

STUDENT: AMINATOU LEKA SIGNATURE_______________DATE_______________

SUPERVISOR: DR. MFONFU DANIEL SIGNATURE__________DATE_______________

DEAN OF STUDIES: DR. MFONFU DANIEL SIGNATURE__________DATE __________

PRESIDENT OF JURY: Dr Mfonfu Daniel SIGNATURE________DATE 25 May 2018

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DEDICATION

This piece of work is dedicated Dr. Mfonfu Daniel who guided me throughout my

studies, my parents and mates who provided me with the means to enhance my

success.

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ACKNOWLEDGEMENT

My sincere gratitude goes to late Mr Ngalla Edward, the founder of Capitol

Higher Institute of health science and Beauty Therapies Bamenda.

My gratitude goes to my supervisor Dr Mfonfu Daniel for his patience and

guidance on editing this piece of work and the entire Capital staffs for their

support.

Enormous thanks goes to the General supervisor of the general hospital and

the entire staff who in their effort collaborated with us to participate in health

activities of the hospital.

Finally sincere appreciation goes to my entire family and friends who gave

me a helping hand socially and financially throughout my internship.

Honour and praise goes to God Almighty for his guidance and a sound

health to be able to carry out this work.

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LIST OF ABBREVIATIONS

MmHg………………………………………………...Millimetre of Mercury

GIT…………………………………………………....Gastro intestinal track

CNS……………………………………………………Central nervous system

EDD…………………………………………………...Expected date of delivery

LMP…………………………………………………...last menstrual period

IWC…………………………………………………...Infant welfare clinic

ANC………………………………………………..... Antenatal clinic

WHO……………………………………………….... World health organization

HIV………………………………………………….... Human immune deficiency

ATS………………………………………………….…Anti tetanus serum

SRN…………………………………………………….State registerrd nurses

NSAIDS…………………………………….Non-steroidal anti-inflammatory drugs

G2P2………………………………………………...... Gravida 2 para 2

DOA..........................................................................Date of admission

DOD..........................................................................Date of discharge

HND..........................................................................Higher National Diploma

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TABLE OF CONTENTS

Certification ---------------------------------------------------------------------------2

Dedication------------------------------------------------------------------------------3

Acknowledgement---------------------------------------------------------------------4

List of abbreviation--------------------------------------------------------------------5

Table of contents-----------------------------------------------------------------------6

CHAPTER ONE - General introduction ---------------------------------------7-10

CHAPTER TWO - Literature review of the disease -------------------------11-17

CHAPTER THREE – PRESENTATION OF CASE -------------------- 18-31

CHAPTER FOUR – REVIEW OF DRUGS ---------------------------------32-35

CHAPTER FIVE - DISCHARGE SUMMARY----------------------------36

CHAPTER SIX – CONCLUSION -----------------------------------------37-38

Reference-----------------------------------------------------------------------------------39

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CHAPTER ONE – GENERAL INTRODUCTION

1.1 Definition of Preeclampsia:

Preeclampsia is a pregnancy complication characterized by high blood pressure

and signs of damage to another organ system, often the kidneys – pitting oedema

and proteinuria. Preeclampsia usually begins after 20 weeks of pregnancy in a

woman whose blood pressure had been normal. Even a slight rise in blood pressure

may be a sign of preeclampsia (Mayo Clinic Staff) Pre-eclampsia or preeclampsia

(PE) is a disorder of pregnancy characterized by high blood pressure and a large

amount of protein in the urine. (http://en.wikipedia.org/wiki/Pre-eclampsia)

1.2 MOTIVATION FOR THE CASE

Literature on preeclampsia says pre-eclampsia occurs at about 20 weeks of

pregnancy but in this case preeclampsia started when the pregnancy was at term.

This preeclampsia at term motivated me to study it.

1.3 GENERAL OBJECTIVE (GOAL)

Successfully manage the case of preeclampsia as amember of the medical and

nursing team and submit the report of this case study in partial fulfilment to obtain

the HND in nursing.

1.4 SPECIFIC OBJECTIVES

a) Identify the patient

b) Describe the circumstances of arrival of the patient

c) Admit the patient

d) State the provisional diagnosis on admission, state source

e) Administer any emergency medications

f) Clerk/Assess the patient

g) Administer the medications prescribed by the medical officer, monitor

and record side effects on the patient

h) Establish daily drug chart

i) State results of confirmatory diagnostic tests

j) Develop and implement nursing care plans

k) Describe the evolution of the patient and vital signs

l) Revue the medications administered

m) Write the discharge summary

9

n) Identify positive findings, weaknesses; make recommendations; make

conclusions

1.4 BRIEF DESCRIPTION OF PLACE OF STUDY

The Bamenda Regional Hospital is located in Bamenda II Sub-Division, in the

North West Region precisely in the mankon on a well-ventilated topographical

area suited for the prevention and preservation of good health. This establishment

is to the left of the GMI police camp Bamenda and 100m away from hospital

round-about. It acts as a referral hospital for District hospitals, research centre and

a teaching hospital for student doctors, nurses, midwives and laboratory technician.

Inflow rate of patients is enormous.

The BRH comprises of many units/services where various activities are been

carried out. They include;

- M and F medical word

- M and Female surgical ward

- Paediatric ward

- Gynaecological ward

- Maternity

- Reanimation unit

- Ophthalmology department

- operating theatre

- X-ray department

- Dialysis department

- Diabetic unit

- Dental unit

- Tuberculosis unit

- Pharmacy

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- Emergency unit

- Outpatient department

1.4.1 Administrative Staffs and Their Job Description

There are about two hundred workers as both skilled and unskilled. This

total number of workers makes sure that the hospital runs well. The health care

team is made up of:

THE DIRECTOR: the director who supervises doctors, nurses, he record and direct

the functioning of the hospitals

THE GENERAL SUPERVISOR: who attains to various problems in wards,

make routine control, supervise activities in the hospital and evaluate students on

internship

DOCTORS: Refer patients to other hospitals, gives instructions to nurses, do

rounds, prescribe drugs, operate and attend to patients in the consultation room

THE WARD CHARGE: draw the duty roster, supervise the nurses, give

account on shortage and damages, evaluate the performance of the unit and is

responsible of the management in the ward

THE NURSE: these are those who actually perform routine tasks. They

assist doctors during rounds, give health talks and educate patients and guardians

and evaluate nursing care given to patients

NURSING ASSISTANCS: assist nurses in their duties

PHAMACIST: dispense drugs to wards

LABORATORY TECHNICIANS: collect specimen for examination

AUILARY STAFF: Maintain hygiene of the hospital

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ORGANIGRAM OF REGIONAL HOSPITAL

Director

Medical adviser General Supervisor

Chief or Service Ward charge

Doctor Nurses

Assistant Nurses

Auxiliary workers

Source: General supervisor

1.5.2 SHIFT SYSTERM

The BRH is made up of 2 shifts that is morning shift from 7am to 5pm and night

shift from 5 PM to 7am

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CHAPTER TWO – REVIEW OF LITERATURE ON PREECLAMPSIA

2.0. Classification of Preeclampsia (The women’s the royal women’s hospital)

Classification Blood Pressure Range

Mild 140-149 mmHg systolic 90-99 mmHg diastolic

Moderate 150-159 mmHg systolic 100-109 mmHg diastolic

Severe >160 mmHg systolic >110 diastolic

Blood pressure is defined in the above table: measured on at least two occasions

over several hours, combined with proteinuria >300 mg total protein in a 24-hour

urine collection, or ratio of protein to creatinine >30 mg/mmol

2.1 Causes (Mayo clinic)

Some causative factors include:

Abnormal placentation (formation and development of the placenta)

Immunologic factors

Pre-existing hypertension,

Obesity,

Dietary factors, e.g. low calcium in the body

Environnemental factor, e.g. air pollution

2.2 Pathophysiology

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During normal pregnancy, the placenta undergoes process of

vascularization to allow for blood flow between the mother and fetus

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

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

14

Abnormal development of the placenta leads to poor placental perfusion. The

placenta of women with preeclampsia is abnormal and characterized by poor

trophoblastic invasion. It is thought that this results in oxidative stress, hypoxia,

and release of factors that promote endothelial dysfunction, inflammation, and

other possible reactions The clinical manifestations of preeclampsia are associated

with general endothelial dysfunction, including vasoconstriction and end-organ

ischemia (http://en.wikipedia.org/wiki/Pre-eclampsia)

2.3 Risk factors (By Mayo Clinic Staff)

Known risk factors for preeclampsia include:

First pregnancy

Diabetes mellitus

Kidney disease

Chronic hypertension

Prior history of preeclampsia

Family history of preeclampsia

Advanced maternal age (>35 years)

Obesity

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

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Multiple gestation

Having donated a kidney.

New paternity

2.4 Complications (By Mayo Clinic Staff)

Complications of preeclampsia may include:

Lack of blood flow to the placenta. Preeclampsia affects the arteries

carrying blood to the placenta. If the placenta doesn't get enough blood, the

baby may receive less oxygen and fewer nutrients. This can lead to slow

growth, low birth weight or preterm birth.

Placental abruption. Preeclampsia increases the risk of placental abruption,

in which the placenta separates from the inner wall of your uterus before

delivery. Severe abruption can cause heavy bleeding and damage to the

placenta, which can be life-threatening for both the mother and the baby.

HELLP syndrome. HELLP — which stands for haemolysis (the destruction

of red blood cells), elevated liver enzymes and low platelet count —

syndrome can rapidly become life-threatening for both you and your baby.

Symptoms of HELLP syndrome include nausea and vomiting, headache, and

upper right abdominal pain. HELLP syndrome is particularly dangerous

because it represents damage to several organ systems. On occasion, it may

develop suddenly, even before high blood pressure is detected.

Eclampsia. When preeclampsia isn't controlled, eclampsia — which is

essentially preeclampsia plus seizures — can develop.

Cardiovascular disease. Having preeclampsia may increase your risk of

future heart and blood vessel (cardiovascular) disease.

2.5 Signs and symptoms (By Mayo Clinic Staff)

i. Sudden weight gain and swelling (pitting edema)

ii. Blood pressure that is 140/90 millimetres of mercury (mm Hg) or greater —

documented on two occasions, at least four hours apart — is abnormal

iii. Headaches

iv. Changes in vision, including temporary loss of vision, blurred vision or light

sensitivity

v. Upper abdominal pain, usually under your ribs on the right side

http://en.wikipedia.org/wiki/Kidney_transplantation

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vi. Nausea or vomiting

vii. Decreased urine output

viii. Shortness of breath, caused by fluid in the lungs

2.6 Diagnosis

It is diagnosed from the above signs and symptoms. It can also be diagnosed

in the laboratory by carrying out the following tests:

o Excess protein in urine (proteinuria)

o Decreased levels of platelets in the blood (thrombocytopenia)

o Impaired liver function

2.7 Treatments (Denis Palmer et al)

Strict bed rest/admit. Encourage patient to lie on the left side.

If foetus is viable, cervix ripe, head down, pelvis adequate, induce.

If foetus viable, cervix not ripe, pelvis inadequate, do CS.

If foetus not viable, mother stable or improving, monitor.

If foetus not viable, mother deteriorating, deliver anyway.

Administer MgSo4 5g stat IM.

Continue MgSo4 24hours after delivery

Drug of choice for hypertension should be administer if available (Labetalol

and Hydralazine).

IV fluids at 60 -150ml/hr unless there are excessive losses of fluids or blood.

2.7 Prognosis

If not treated preeclampsia can lead to eclampsia that may result in the death

of mother or the baby, or both

2.8 Preventions

Frequent prenatal visit

Encourage the woman to attend ANC regularly for frequent monitoring

of her weight, BP and urine testing.

Encourage the woman to do light sport

Encourage the woman to avoid excessive salts intake

Encourage the woman to eat a well-balanced diet and much vegetable.

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2.9 Definition of nursing care plan

A nursing care plan outlines the nursing care to be provided to an individual,

family and the community.

It is a set of action that the nurse will implement to resolve and support

nursing process. It guides in the ongoing provision of nursing care and assists in

the evaluation of the care W.H.O (3 November, 2015).

2.10 VIRGINAL HENDERSON’S 14 BASIC FUNDAMENTAL HUMAN

NEEDS

1. Breathe normally

2. Eat and drink adequately

3. Eliminate body waste

4. Move and maintain desirable posture

5. Sleep and rest

6. Maintain body temperature within normal range by adjusting clothing and

modifying the environment

7. Keep the body clean and well groomed and protect the integument

8. Avoid dangers in the environment and avoid injuring others

9. Communicate with others in expressing emotion, needs, fears or options

10. Worship according to one’s faith

11. Work in such a way that there is a sense of accomplishment

12. Play or participate in various form of recreation

13. Learn, discover, or satisfy the curiosity that leads to normal development

and health and use the available health facilities.

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2.11 Nurses’ responsibilities in the administration of drug

1. The nurse must respect the seven rights of drug administration also

known as the seven rules.

- The right patient

- The right drug

- The right dose

- The right time

- The right route

- The right procedure

- The right documentation

2. If a prescription is not clear, never assume what it could be. Always

Consult with the prescriber to verify that it is correct. Also, if you think

a B prescription is not appropriate, do not change it without consulting the

prescriber.

3. In case a prescription is order over the phone, document the

prescription and indicate that it was done through the phone. Sign below the

prescription and make sure that the prescriber signs immediately he is available

4. Read the medication label three times that is before removing

medication cupboard, before removing from the container and before returning it

after administration. This makes certain of what has been administered.

5. Never administer medication from drug container whose labels are not

visible.

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CHAPTER THREE- PRESENTATION OF CASE

3.1 DEMOGRAPHIC IDENTITY OF THE CASE ON ADMISSION

Name: patient x

Age: 19 years

Sex: female

Address: mile 90

Occupation: student

Religion: Presbyterian

Ward: Postnatal in private room one

Bed num ber: 2

Blood group O

Nationality: Cameroonian

LMP 09/03/2017

EDD 16/12/2017

DOA: 19/12/17

Gravida1

3.2 CONDITION ON ARRIVAL OF THE PATIENT IN THE HOSPITAL/ WARD AND

WHAT WAS DONE ON HER BERFORE ADMISSION.

From the casualty assessment, the 19 years old female gravida1 accompanied by

her mother at 3pm with complained of 4oweeks +3days gestational age . From the

Dr`s consultation, she has severe preeclampsia with blood pressure of

160/87mmHg,pulse of 104b/m, swelling legs and ankles. An induction of labour

was recommended 1/4cytotec by the Doctor . The fundal height of 40cm and foetal

heart beat of 134b/m.

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3.3 PROVISIONAL DIAGNOSIS BY MEDICAL DOCTOR AT

CASUALTY ON ADMISSION.

The provisional diagnosis on admission from clinical presentation was

Severe Preeclampsia.

3.4 PRELIMINARY LAB RESULTS.

Hemoglobin: 11.2g/dl

Blood Group O, Rhesus factor negative

3.5 MEDICAL PRESCRIPTION AND TREATMENT ON ADMISSION BY

THE DOCTOR AT THE CASUALTY.

The medical prescription was as follows:

Ringer lactate

Magnesium sulfate

¼ cytotec

3.6 CLERKING AND ASSESSMENT BY THE NURSE

History taking and examination:

Patient came into the ward with full consciousness from doctor’s consultation at

3pm accompanied by her mother with post term pregnancy, severe preeclampsia

and cervical dystocia. She had swollen hands and leg with blood pressure of

160/87mmhg. LMP-09 March 2017-EDD-16 December 2017.

HEAD TO TOE EXAMINATION

Head: clean and dark hair.

Eye: black pupil and she see well.

Nose: on inspection no nasal discharge.

Mouth: no swollen gums.

Chest on observation: no abnormality discovered

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Abdomen: patient had dark linear nigra

3.7 PAST MEDICAL HISTORY

Patient had once been admitted for appendicitis.

3.8 PAST SURGICAL HISTORY

Patient had once been operated for appendicitis.

3.9 FAMILY HISTORY

Hypertension is so common in their family.

3.10 SOCIAL HISTORY

Patient doesn’t smoke, does not drink alcohol but takes little of sweet drunks.

On Nutritional status

She does not have any nutritional dislike and her favourite is water fufu and erru

with enough meat which she eat often.

Patients love taking fruits such as bananas oranges, and pawpaw, no allergy to

food. She eats at least twice daily but 2 sometimes.

On health maintenance pattern

Patients take her drugs regularly whenever she is sick and usually buys from

hospital pharmacies.

On Elimination Pattern

Patient could pass out stool at least 3 times daily and urinate at least 4 times .

Sleep and Rest Pattern

Patient usually sleeps during the day and less in the night because of lower

abdominal pain.

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Gynaecologic obstetrics History

Patient started menstruating at the age of 15year old. Has never had any abortion.

This is her first pregnancy, regular menstrual bleeding of 28days cycle with 4days

of duration. Patient used at least 3 pads daily her menses, no cramps during

bleeding. She attended her first antenatal clinic at 5months and did an echography,

reviewed a male child that is G1pooo.

On Perceptive Pattern

Mental status, patient was oriented in her present condition. She understands

English, speak it well and able to communicate her worries and feelings to her

family.

3.11 Vital Signs On Physical Examination

BP 159/90mmHg

P 100b/min

R 24cy

W 76kg

Bowel 2 times

Urine 3times

Vomitus Nil

Intake about 2liter of water.

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Table1: Daily Drug chart; Date: 19/12/2017 – induction of labour

Table2: Daily Drug chart; Date: 20/12/2017

Time

8;15 Am

Drug Dose Route Frequency Remark Identity of

nurse

Morning magnesium 4g im 4hourly served SRN

Noon

12:15 pm/ 4:15

pm

magnesium 4g im 4hourly served SRN

Evening

9:15 Pm

magnesium 4g im 4hourly served SRN

Time

Drug Dose Route Frequency Remark Identity of

nurse

Noon Magnesium

sulphate

5g IM stat served HND

3:30 pm magnesium

sulphate

5g IM stat

Magnesium

sulphate

4g IVD stat

Ringer

lactec

+¼ cytotec

500cc IV stat served

Evening

7:30 Pm

Magnesium

sulphate

4g IM 4hourly served HND

11:30 Pm Magnesium

sulphate

4g IM 4 hourly served

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Time Drug Dose Route Frequency Remark Identity of

nurse

Morning

1:15 Am

Magnesium

sulphate

4g IM 4hrs served

6: 00 Am Ampicilin 1g IV 8hrs served

8: Am Novalgin 1amp IV 8hrs served

Noon Novalgin

Ampicilin

Magnesium

sulphate

1amp

1g

4mg

IVD

IV

IM

8hourly

4 hrs`

served HND

Evening

5:15 pm

Magnesium

sulphate

Novalgin

4g

1amp

IM

IV

4hrs

8hrs

Served

served

The induction failed and the doctor recommended a CS that was done on

21/12/2017.

Description of the Caesarean Section:

The CS was done under general anaesthesia. A live male baby was extracted with

an Apgar score of 10.

Post-operative prescription:

a) Magnesium

b) Novalgin

c) Ampicillin

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nurse

Morning

10 am

Novalgin

1amp IVD 8hourly served HND

Evening

6:00 pm

Novalgin 1amp IVD 8hourly served HND



nurse

Noon

12 PM

Novalgin

1 amp IVD 8 hrs served SRN



nurse

Morning

8 Am

Rapiclav

antalge

1TAB

1TAB

PO

PO

BD

TID

Taken

Taken

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19/12/17, Nursing care plan 1: Need to prevent elamptic state.

Nursing diagnosis: Risk of eclampsia related to as evidence by hypertension.

(160|87mmhgh)

Objectives Nursing intervention. Rationale Evaluation.

Reduce blood

pressure to

normal:

120/80mmgh.

To reduce the

risk of

eclampsia.

Restrict salt intake and

encourage water

intake.

To prevent fluid

and sodium

retention.

Patients risk for

eclampsia is reduced,

as evidenced by

reduced blood

pressure.

Administer

medications as

prescribed. E.g

Magnesium sulfate

Prevents seizures

In pregnant women

with conditions

such as

preeclampsia.

Patient blood pressure

reduced

Regularly monitor

blood pressure.

To assess the

effectiveness of

medications.

Regular blood

pressure monitoring

gives a baseline for

assessing effectiveness

of treatment.

27

20/12/17, Nursing care plan 2: Need: Need to be comfortable.

Nursing diagnosis: Discomfort related to caesarian section as evidenced as pain

and tenderness at the operation site.


Reduce

pain to the

acceptance

within two

days

level of

Encourage her to lie on the

supine position and help to

ambulate patient.

This helps to relieve

pain on incision site

by relaxing the

Patient

verbalization of

less pain after

muscles and also to

prevent pressure

sores.

nursing

management.

Advice patient to take sitz

bath.

To maintain

intactness of the

stitches.

Stitches should

not fall off

before due date

Monitor vital signs hourly

for the first two days post-

operative and twice every

day until discharge date.

To exclude heart

problems,

respiratory tract

abnormalities, the

presence of

infection that can be

indicated through

hyper psyrexia.

Normal

findings

throughout

hospitalization.

28

21/12/17, nursing care plan 3; Need to reduce excess fluid.

Nursing diagnosis: Fluid volume excess related to preeclampsia as evidenced by

edema over the legs and ankle and decreased urine output.


Maintenance

of ideal

body weight

Without

excess fluid

through

nursing

intervention

Explained to patient and

family the rationale of

fluid limitation

Fluid limitation is

done according to

urine out of the

patient

Upon evaluation,

patient has

reduced fluid

volume

Assess location and

extent of edema, and

type

To assessed crees in

pressure of edema

daily

Patient has

reduced edema

29

22/17/17: Nursing care plan 4: Need to keep the body clean and protected.

Nursing diagnosis: Risk of infection related to presence of urinary catheter and

intra venous cannula.


To reduce

level of

infection so

that patient

do not have

any

complication

through out

the hospital

stay and

beyond.

Taught patient about

self care

Help to reduce

level of infection

Infection is reduce

as evidence by

reduced redness

Removed urinary

catheter and cannula

Administered

antibiotics as ordered

Enhances healing

process by

providing comfort

to the patient.

Antibiotics help to

reduced infection

Patient felt satisfied

Assessed operated site

and vital signs daily

To reduce the level

of infection and the

progressive state of

the patient

Normal finding of

the general state of

the patient

23/12/17 , Nursing care plan 5: Need to eat adequately

Nursing diagnosis: Imbalanced nutrition less than the body requirement related to

anorexia, nausea and dietary restriction and altered oral mucus membrane

Objectives Nursing

intervention.

Rationale Evaluation.

To maintain adequate

nutrition status by reducing

nausea and increased appetite

Assess intake and

output of patient

Increase dietary

intake maintain

Patient maintain normal

nutritional status

according to lactation

30

Table No 3, Daily evolution chart of the patient

Date Time Observation Identity of nurse

19/12/2017

3:30pm Patient was presenting with lower

abdominal pain, edema of the legs

and ankle and 4oweeks and 3days

of gestational age.

HND

2O/12/2017 7:30am Blood pressure reduced. SRN

5:30pm Patient has lost of appetite SRN

21/12/2017 7:3Oam She complained of pain , edema

and stiffness around the injection

site

SRH

2am Patient was received from the

theatre on a stretcher with normal

saline infusion and a urinary

catheter in a semi conscious state

HND

23/12/2017 7:30am

Patient was calm with ,mild lower

abdominal pain ,blood pressure

and edema reduced

Mid wife

5:30pm Calm on shift and ambulate out of

bed

SRN

31

Date Time Observation

Identity of

nurse

24/12/2017 7:30am Patient was calm and

satisfied after removal of

urinary catheter

HND

5:30pm No complain HND

25/12/2017 7:30am No reduced edema ,blood

pressure body weight and no

infection on discharged

Mid wife

TABLE NO4: VITAL SIGNS CHART

Date Period To

C

BP Body

weig

ht

Pulse Respirati

on

Bow

el

Urin

e

Vomit

us

Inta

ke

19/12/

17 Evenin

g

37.

4

159/87mmH

g

76kg 104b/

m

24 2 3 1 0

20/12/

17

Morni

ng

37.

5

158/86mmH

g

76kg 9ob/

m

23 1 3 0 0

Evenin

g

37.

1

158/87mmH

g

76kg 90b/

m

21 2 5 0 0

21/12/

17

Morni

ng

37.

1

150/90mmH

g

76kg 84b/

m

25c/m 1 4 0 0

Evenin

g

36.

6

153/80mmH

g

71kg 86b/

m

24c/m 0 700

cc

0 0

22/12/

17

Morni

ng

37 145/80mmH

g

67kg 85b/

m

22c/m 0 8oo

cc

0 0

Evenin

g

37.

2

130/75mmH

g

69kg 82b/

m

20c/m 0 500

cc

0 0

23/12/

17

Morni

ng

36.

4

133/67mmH

gHg

69kg 82b/

m

23c/m 1 3 0 0

32

Date Period To

C

BP Body

weig

ht

Pulse Respirati

on

Bow

el

Urin

e

Vomit

us

Inta

ke

Evenin

g

37 136/70mmH

g

69kg 82b/

m

18c/m 2 3 0 0

23/12/

17

Morni

ng

36.

4

133/67mmH

g

67kg 81b/

m

23c/m 2 2 0 0

Evenin

g

37 136/70mmH

g

67kg 80b/

m

18c/m 2 4 0 0

24/12/

17

Morni

ng

37 140/76mmH

g

67kg 81b/

m

21c/m 2 3 0 0

Evenin

g

37.

1

137/70mmH

g

67kg 86b/

m

20c/m 1 2 0 0

33

CHAPTER FOUR – REVIEW OF MEDICATIONS

MEDICATION 1 Novalgin

Generic Name: Novalgin

Trade Name: Novalgin metaizem

Drug Class: Antispasmodic

Mechanism of action: it alters the mechanism of the heart regulating centre

and raises pain threshold. It help to relax the smooth muscle

Indication. Labour pains, cystitis, spastic, dysmenorrhea, post operative

romatic conditions, biliary colic, neuralgia, myocardia infection.

Dosage: Adults, one ample 3times daily, rout of administration, orally,

IV,IM, rectal or suppository

Side effect, vertigo, hypersensitivity, an anaphylactic reaction

Contraindication, allergic pregnancy, intermittent porphyria

Note, infants less than four months shouldn’t be given novalgin. The IV

injection should be given.

It must not be mixt with another for injection

Patient did not experience any side effect

MEDICATION2 oxytocin

Generic Name: oxytocin

Trade Name: Pitocin, syntocinony,

Drug Class:

Mechanism of action: selective stimulant on uterine muscle especially

towards term, during labour and post-partum. Sensitivity of the uterus to

oxytocin increases throughout the pregnancy reaching the maximum term.

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Oxytocin is a hormone used to help start and continue labour and to

control bleeding after delivery. It is also sometimes used to help milk

secretion in the breast feeding,

Dosage, Adult, 10units injected slowly into the vein or muscle.

Side effects, abdominal pain, nausea and vomiting, prostaglandin and risk of

uterine rupture and cervical laceration. Ergotamine, synergistic effect in

control of post-partum haemorrhage.

Contraindications, injection of an IV bolus should be avoided because it

may cause short term hypotension with flush and reflex tachycardia

Precaution: it must be administered in a hospital and under qualified

medical monitoring.

Administration of excessive doses of oxytocin may lead to foetal distress

asphyxia.

MEDICATION 3 Ampicillin

Generic Name: Ampicillin

Trade Name: Omnipen

Mechanism of action: Acts as an irreversible inhibits or of the enzyme

transpeptidasa which is needed by bacteria to make the cell wall inhibit the

third and final stage of bacteria cell wall synthesis in binary fission, which

ultimately leads to cell lysis, therefore ampicillin is usually bacteriolytic

Dose and mode of administration, Ampicillin 1gram and 2grams are

primarily for IV use, they may be administered IM. When the 250mg or

500mg vials are unavailable, ampicillin 125mg is intended primarily for

paediatric use.

It can be administered IV, IM, IVD, Orally.

Side effects Nausea, vomiting, rashes, diarrhoea, swelling of the tongue,

thrush and yeast infection.

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Contraindication, a history of previous hypersensitivity reaction to any

of the penicillin is a contraindication. Ampicillin is also contraindicated

in infections caused by penicillin as a producing organism.

Precaution, the possibility of supper infection mycitic organism or

bacterial pathogens should be kept in mind during therapy. In such cases,

discontinue the drug and substitute appropriate treatment

Patient did not experience any side effect.

MEDICATION 4 Magnesium sulphates

Generic Name: Mag NEE see um sulphate

Trade Name: Magnesium sulphate| sodium chloride, mgso4

Mechanism of action: it is use to prevent seizures in pregnant women with

conditions such as preeclampsia or toxaemia of pregnancy.

It is also used to treat hypomagnesaemia( low level of magnesium in blood)

Mode of administration, magnesium sulphate is injected into the muscle or

into the vein and must be received in the hospital or clinic setting. So that

breathing, BP, Oxygen levels will be watched while receiving magnesium

sulphate.

Dosage, for severe preeclampsia or eclampsia, initial dose 4g to 5grams in

250ml of appropriate diluent, with simultaneous IM administration of up to

5grams (10ml)

Magnesium maintenance dose 4 to 5grams IM in to alternate buttocks every

4hours as needed.

Side effects, difficult breading, swollen of the face, lips, tongue, diarrhoea

or upset stomach.

Contraindication, hypersensitivity, myocardia damage, diabetic coma,

heart block. Hypermagnasemia, hypocalcaemia.

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Administration during 2hours presiding delivery of mother with toxaemia of

pregnancy.

Precaution, patients with renal impairment ensure that renal excretory

capacity is not excided.

Foetal skeletal, hypocalcaemia and hypermagsema abnormalities reported

with continues term use (i.e. longer than 5.7days use) for off lable treatment

of preterm labour in pregnant women, the effect on the developing foetus

may result in neonates with skeletal abnormalities.

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CHAPTER FIVE - DISCHARGE SUMMARY

5. 1 Date of admission 19 12 2017

5.2 Date of discharge 2412 2018

5.3 Treatment received

Noualgin, magnesium sulphate, ampicilline, oxytocin,

5.4 Response to treatment: the induction failed. She had a CS; a live male baby

was delivered with Apgar 10.

5.5 CONDITION ON DISCHARGE

Patient after receiving her medications was in good and satisfactory condition with

no complain .the patient left the hospital with her baby ,thus in a healthy condition

5.6 Home Treatment

Oral rapiclav and antalgex

5.7 Advice on discharge

Patient was advised on hygiene, proper, breast feeding of the baby and to come

back if she has any complain.

And also to go for family planning

5.8 Appointment after six weeks for post partum examination

5.9 Follow up:

After patient was discharged, he went for appointment and was in good condition,

on calling she was very happy and satisfied for nursing care given to her in the

hospital and at home.

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CHAPTER SIX

6.1 Positive findings

The environment is good and contusive for learning; the nurses are very

welcoming and collaborative.

The hospital equipment are good.

Standard precaution are effective perform by the nurses.

6.2 Difficulties encountered

Inadequate bed for nursing mothers in the ward

Inadequate babies cot in the ward

Treatment are not always given on time

Lack of health personnel in the hospital, for that reason patient is not

properly care for.

Visitor does not respect visiting time in the hospital, hence disturbs patient

sleeping pattern

6.3 Proposed solutions:

The government should employ enough trained staff reduce work load on

the nurses and promote effectiveness.

Discipline should be placed on visitors to respect visiting time.

Recommendations:

The hospital lacks surgical equipment, dressing forceps and drapes are out

dated, the hospital need to purchase new ones and to also to improve on the

working condition of the staff.

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Conclusion:

Despite all the problems encountered, the case study carried at the

Bamenda Regional Hospital was a successful one because my case was well

managed .the secrete to its management is early prenatal visit.

Finally, the internship was a successful one because we did not only nurse a

patient with preeclampsia but other normal delivery mother and their babies.

case study report on preeclampsia carried out during …gicedab.000webhostapp.com/downloads/2....

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