PREECLAMPSIA

P r e e c l a m p s i a P a g e | 1

O B J E C T I V E S

Presentors will be able to:

Explain briefly the disease process: its causes, effects, management, treatment, and possible preventions.

Determine the pathophysiology of the condition with their rationale for occurrence of each manifestation.

Determine why certain management and medications are given and provided for the condition.

Explain briefly how and why certain diagnostic tests are done for the condition.

Review the concepts about the anatomy and physiology with regards to the condition.

Provide health teachings to the patient about certain interventions in the maintenance of health care.

Discuss options for surgical management for Preeclampsia.

Students or audience will be able :

To recognize the cause and risk factors of Preeclampsia.

To develop a comprehensive assessment for the disease process.

To understand the anatomy and physiology of the Renal/Urinary System, Cardiovascular System, Vascular System, and Female Reproductive

System.

Clinical Instructors will be:

Able to give recommendations or suggestions necessary for the improvement of the case sharing.

Able to ask questions regarding the case for further understandings.

G r o u p 2 A B G L N P P Q R Y


Able to evaluate the presentation with utmost fairness.

I N T R O D U C T I O N

Preeclampsia, also referred to as toxemia, is a medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension)

in association with significant amounts of protein in the urine. It refers to a set of symptoms rather than any causative factor. Preeclampsia has been

described as a disease of theories, because the cause is unknown.

Preeclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the

mother's urine (as a result of kidney problems). It is the most common of the dangerous pregnancy complications; it may affect both the mother and

the unborn child. Pre-eclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the

condition is known as eclampsia-the second leading cause of maternal death in the U.S. Preeclampsia is also a leading cause of fetal complications,

which include low birth weight, premature birth, and stillbirth.

Preeclampsia may develop from 20 weeks gestation (it is considered early onset before 32 weeks, which is associated with increased

morbidity). Its progress differs among patients; most cases are diagnosed pre-term. Preeclampsia may also occur up to six weeks post-partum.

Preeclampsia is classified into mild and severe. Preeclampsia is mild in 75% of cases and severe in 25% of them. In its extreme, the disease

may lead to liver and renal failure, disseminated intravascular coagulopathy (DIC), and central nervous system (CNS) abnormalities. If preeclampsia-

associated seizures develop, the disorder has developed into the condition called eclampsia.

Mild preeclampsia is defined as the presence of hypertension (BP ≥140/90 mm Hg) on 2 occasions, at least 6 hours apart, but without

evidence of end-organ damage in the patient.


http://www.medicinenet.com/script/main/art.asp?articlekey=33915

http://emedicine.medscape.com/article/253960-overview

http://www.medicinenet.com/script/main/art.asp?articlekey=472


Severe preeclampsia is defined as the presence of 1 of the following symptoms or signs in the presence of preeclampsia:

SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2 occasions at least 6 hours apart

Proteinuria of more than 5 g in a 24-hour collection or more than 3+ on 2 random urine samples collected at least 4 hours apart

Pulmonary edema or cyanosis

Oliguria (< 400 mL in 24 h)

Persistent headaches

Epigastric pain and/or impaired liver function

Thrombocytopenia

Oligohydramnios, decreased fetal growth, or placental abruption

The incidence of preeclampsia in the United States is estimated to range from 2% to 6% in healthy, nulliparous women. Among all cases of

the preeclampsia, 10% occur in pregnancies of less than 34 weeks' gestation. The global incidence of preeclampsia has been estimated at 5-14% of

all pregnancies.

In the Philippines, according to the 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%; and 40%;. Ten women die every day in the Philippines from pregnancy and

childbirth related causes but for every mother who dies, roughly 20 more suffer serious disease and disability.



The only known treatments for eclampsia or advancing preeclampsia are abortion or delivery, either by labor induction or Caesarean section.

Magnesium sulphate is the first-line treatment of prevention of primary and recurrent eclamptic seizures. The mother and the family deserve a careful

teaching regarding the problem, its observation, and its treatment. Regular, adequate prenatal care is the best insurance for control of the

complication.

D E F I N I T I O N O F T E R M S

Arteries - Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure.

Bladder - a triangle-shaped, hollow organ located in the lower abdomen.

Blood pressure - Blood pressure measures the force of blood against the walls of the blood vessels. Extra fluid in the body increases the amount of

fluid in blood vessels and makes blood pressure higher. Narrow, stiff, or clogged blood vessels also raise blood pressure.

Capillaries - The arterioles branch into the microscopic capillaries , or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by

the lymphatic system .

Eclampsia - seizures that cannot be attributable to other causes, in a woman with preeclampsia.

Endothelium - is the thin layer of cells that lines the interior surface of blood vessels, forming an interface between circulating blood in the lumen and

the rest of the vessel wall.

Filtration - The first step in formation of urine is filtration. Filtration is the process by which the blood that passes through the glomerulus is filtered

out, so that only certain structures pass through into the proximal convoluted tubule.


http://en.wikipedia.org/wiki/Lumen_(anatomy)

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

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

http://en.wikipedia.org/wiki/Cell_(biology)

http://webschoolsolutions.com/patts/systems/heart.htm#lymph%23lymph


http://sln.fi.edu/biosci/vessels/capillaries.html


http://sln.fi.edu/biosci/vessels/arteries.html



Glumerular filtration rate (GFR) – the total volume of renal filtrate that the kidneys form in 1 minute; average is 100-125 mL/minute.

Hyperreflexia - defined as overactive or over responsive reflexes.

Hypoxia - inadequate oxygen tension at the cellular level, characterized by tachycardia, hypertension, peripheral vasoconstriction, dizziness, and

mental confusion.

Intrauterine Growth Retardation (IUGR) – failure to grow at the expected rate in utero.

Oncotic pressure – is a form of osmotic pressure exerted by proteins in blood plasma that usually tends to pull water into the circulatory system.

Oligohydramnios - amniotic fluid volume that is less than expected for gestational age. It is typically diagnosed by ultrasound examination and may

be described qualitatively (eg, mild, moderate, or severe oligohydramnios) or quantitatively (eg, amniotic fluid index [AFI] <5).

Peripheral resistance - this term refers to the resistance the vessels offer to the flow of blood.

Proteinuria - The presence of abnormal quantities of protein in the urine, which may indicate damage to the kidneys.

Prostacyclin - is a prostaglandin with vasodilator properties.

Selective Reabsorption - This step is known as selective reabsorption because only some elements are reabsorbed back into the body.

Scotomata - A partial loss of vision or a blind spot in an otherwise normal visual field.

Thrombocytopenia - refers to lowering of the platelets, the blood cells that prevent us from bleeding. The medical term for a platelet is

Thrombocyte. “Thrombo” stems from Greek word "Thrombos" which means clot. Term “Penia” stems from Latin and means reduction.


http://www.answers.com/topic/water

http://www.answers.com/topic/blood-plasma-2

http://www.answers.com/topic/protein

http://www.answers.com/topic/turgor


Toxemia - an abnormal condition of pregnancy characterized by hypertension and edema and protein in the urine.

Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back.

Two ureters - narrow tubes that carry urine from the kidneys to the bladder.

Thromboxane - is a prostaglandin with vasoconstrictor properties.

Vasospasm - a condition in which blood vessels spasm, leading to vasoconstriction.

Veins - Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules , which in turn unite to form veins.


http://sln.fi.edu/biosci/vessels/veins.html

http://biomed.brown.edu/Courses/BIO189/Lab6/Ven&Cap.jpg


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

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


P H Y S I C A L A S S E S S M E N T & R E V I E W O F S Y S Y T E M

An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation,

percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient

may have from being physically exposed and vulnerable. The patient will be much more relaxed and cooperative if the nurse explains what will be

done and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the

unique focus of a nursing assessment is on the patient's responses to actual or potential problems.

The purposes for a physical assessment are:

To obtain baseline physical and mental data on the patient.

To supplement, confirm, or question data obtained in the nursing history.

To obtain data that will help the nurse establish nursing diagnoses and plan patient care.

To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.



Systems Mild Preeclampsia Severe Preeclampsia Review of Systems Problem Identified

General Appearance Weight gain 2 lbs/week in 2nd trimester and 1lb/wk in 3rd trimester

Weight gain of 3 or more lbs/wk in 2nd or 3rd trimester

Patient may verbalize body weakness

Fluid volume excess

Head/Hair/Face Mild edema Headache Edema in the Face,

Patient may report headache or dizziness.

Ineffective tissue perfusion Volume Excess

EENT none Blurred vision Patient may report blurring of vision

Risk for injury,Altered Sensory perception

Mouth and Pharynx none none none No problem identified

Neck none none none No problem identified

Thorax/Lungs none Shortness of Breath (use of accessory muscle)Pulmonary Edema

Patient may verbalize difficulty in breathing

Bradypnea,Ineffective breathing pattern



Back none none none No problem identified

Breast and Axilla none none none No problem identified

Cardiovascular/Peripheral Vascular

140/90 mmHg taken at least 6 hours.

160/110 mm HgThrombocytopenia

Patient may report chest pain and fatigue

Decreased cardiac output

Lymphatic none none none No problem identified

GIT Nausea Excessive Vomiting, nausea, Severe Epigastic Pain RUQ

Patient may report epigastric discomfort

Risk Fluid volume deficitAcute painAltered Comfort

GUT Oliguria Proteinuria of 1-2+ on a random sample

Proteinuria (3- 5 g on a 24 hr. sample)Elevated serum creatinine as lab test revealed Oliguria (500mL less than in 24 hrs)

Patient may verbalize decreased urine output

Less urine output

Musculoskeletal none Fatigue Patient may verbalize fatigue

Fatigue

Integumentary none Extensive edemaPuffiness in hands

Patient may verbalize body weakness

Ineffective Tissue perfusion

Neurologic Headache, dizziness Altered consciousness,Seizure/Brain damage

Patient may verbalize severe headache, dizziness

Risk for injuryAcute Pain

Endocrine none none none No problem identified



D I A G O S T I C T E S T

Diagnostic Test Purpose Normal Values

Results and interpretation Nursing responsibilities

Serum Creatinine-To assess glomerular filtration-to screen for renal damage

In men: 0.8to 1.2 mg/dLIn women: 0.6 to 0.9 mg/dL

Elevated levels generally indicate renal disease that has seriously damage 50% or more of the nephrons.

Pre test:-Explain to the patient that the test evaluates kidney function.

-Tell the patient that the test requires a blood sample. Explain who will perform the venipunture and when.

-Explain to the patient that he may experience slight discomfort from the



tourniquet and needle puncture.

-Instruct the patient that he need not restrict food and fluids.

-Notify the laboratory and physician of drugs he patient is taking that may affect test results it may be necessary to restrict them.

Post test:-Apply direct pressure to the venipuncture site until bleeding stops.-Inform the patient that he may resume his usual medications discontinued before the test.



Blood Urea Nitrogen

To evaluate Kidney function and aid in the diagnosis of renal disease and to aid in the assessment of hydration.

8-20mg/dL.Elevated levels: Renal disease. Reduced renal blood flow(caused by dehydration, for example) urinary tract obstruction and

Pre test:Tell the patient that this test is used to evaluate kidney function.Inform the patient that he



increased protein catabolism’s (such as burns)

Lower levels: Severe hepatic damage, malnutrition, and over hydration.

need not to restrict food and fluids but should avoid a diet high in meat.

Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.

Explain to the patient that he may experience slight discomfort from the tourniquet and the needle puncture.

Notify the laboratory and physician of drugs the patient is taking hat may affect test results they may be need to be restricted.

Post test:-apply direct pressure to the venipunture site until bleeding stops.-inform the patient that he may resume taking his usual medications stopped before the test.





Bleeding time -To assess overall hemostatic function (platelet response to injury and functional capacity of vasoconstriction)-To detect platelet function disorders.

3 to 6 minutes in the template method3 to 6 minutes in the ivy method1 to 3 minutes in the duke method

Abnormal bleeding time may indicate disorders linked to thrombocytopenia, such as hodgkins disease, acute leukemia, disseminated intravascular coagulation, hemolytic disease of the newborn.

Prolong bleeding time in a pt with normal platelet count suggest a platelet function disorder and requires further investigation with clot retraction, prothrombin consumption and platelet aggregation test.

Pre test:-Explain o the patient that the bleeding time test measures the time it takes to form a clot and sop bleeding.

-Tell the patient who will perform he test and when it will take place.

-Inform the patient that he may feel some discomfort from the incisions the antiseptic, and the tightness if the blood pressure cuff.



-Inform the patient that depending on the method used, incisions or punctures may leave tiny scars that should be barely visible when healed.

-Notify the laboratory and physician of drugs the patient is taking that may affect test results it may be necessary to restrict them.

Post test:-In a patient with a bleeding tendency, maintain a pressure bandage over the incision for 24-48 hours to prevent further bleeding. Check the test area frequently, keep the edges of the cuts aligned to minimize scaring.

-If bleeding hasn’t slowed after 15minutes, stop the test and apply direct pressure to the test site.-In other patients, a piece of gauze healed in place by an adhesive bandage is sufficient.

-Instruct the patient that he



may resume medications stopped before the test.



Liver Enzyme - Aspartate Aminotransferase (AST)

-To aid detection and differential diagnosis of acute hepatic disease.

-To monitor patient progress and prognosis in cardiac and hepatic diseases.

-To aid diagnosis of m.i in correlation with creatine kinase and lactate dehydrogenase levels.

12-31 units/liter

Ast levels fluctuate in response to the extent ofcellular necrosis, being transiently and minimally increase early in disease process and extremely increase durng the most acutephase. Depending on when the initial sample is drawn, ast levels may increase indicating increasing disease severity and tissue damage, or decrease, indicatinf disease resolution and tissue repair.

-Maximum elevations more than 20 times normal may indicate acute viral hepatitis , severe skeletal muscle

Pre test-Explain to pt that this test heart and liver functions.

-Inform the pt that the test usually requires three venipunctures one on admission and one each day for the next two days.

-Tell the pt that he need not restrict foods and fluids.

-Notify the laboratory and physician drug of the pt is taking that may affect test



trauma, extensive surgery, drug induced hepatic injury,or severe passive liver congestion-

-high levels 10 to 20 times normal may indicate a severe m.i, severe infectious mononucleosis, or alcoholic cirrhosis.

results it may be necessary to restrict them.

Post test-Apply direct to the venipuncture site until bleeding stops.

-Instruct the patient that he may resume medications stopped before the test.

Diagnostic Test Purpose Normal values


Nonstress, Fetal (NST, Fetal Activity

Determination)

-The NST is a method to evaluate the viability of a fetus. It documents the placenta’s ability to provide an adequate blood supply to the fetus. The NST can be used to evaluate any high-risk pregnancy in which fetal well-being may be threatened. These pregnancies includes those marked by

Acceleration of the FHR about 15 bets/min. and remained elevated for 15 seconds (done for 10-20 minutes).

Test results for the NST may be reactive (or normal)- 2 or more fetal heart rate increases in the testing period (usually 20 minutes)

Non-reactive-there is no change in the fetal heart rate when the fetus moves. This may be indicate a problem that requires further testing.

Pretest

-Explain the procedure to the client.

-Encourage the verbalization of the patient’s fears. The necessity for the study usually raises realistic fears in the expectant mother.

-If the patient is hungry, instruct her to eat before the NST is begun. Fetal activity is enhanced with a high maternal serum glucose level.



diabetes, hypertensive disease of pregnancy (toxemia), intrauterine growth retardation, Rh-factor sensitization, history of stillbirth, postmaturity, or low estriol levels.

During

-After the patient empties her bladder, place her in the Sim’s position.

-Place an external fetal monitor on the patient’s abdomen to record the FHR. The mother can indicate fetal movement by pressing a button on the fetal monitor whenever she feels the fetus move.

-The FHR and fetal movement are concomitantly recorded on a two-channel strip graph.

-Observe the fetal monitor for FHR accelerations associated with fetal movement.

-If the fetus is quiet for 20 minutes, stimulate fetal activity by external methods, such as rubbing or compressing the mother’s abdomen, ringing a bell near the abdomen, or placing the pan on the abdomen and hitting the pan.

-Note that a nurse performs the NST in approximately 20 to 40 minutes in the physician’s office or a hospital unit.



-Tell the patient that no discomfort is associated with the NST.

Post test

-If the results detect a nonreactive fetus, calmly inform the patient that she is a candidate for the CST.





Biophysical profile -Measures your baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid around your baby

Your baby will be scored on five things during the test. A score of 0 (abnormal) or 2 (normal) will be given in each of these categories:

-Muscle movements

-Body movements

-Breathing movements

-Amniotic fluid levels

-Heart rate

-A score of eight or 10 out of 10 provides a reassuring BPP score. If the score is eight, with a decrease in amniotic fluid volume, delivery may be indicated, with fetal maturity.

-A score of six arouses suspicions of chronic fetal hypoxia. A repeat test within four to six hours may be ordered. Delivery may be indicated if there is a reduction in the amniotic fluid volume.

-A score of four is suspicious of chronic fetal hypoxia. A fetal lung maturity test may be done to assess readiness for delivery. Delivery is indicated if a repeat BPP after 24 hours confirms a score of four or below.

-A score of zero to two elicits a strong suspicion of chronic fetal hypoxia. The BPP testing period may continue for two hours instead of the usual 30 minutes. If the two-hour score is four or below, delivery is indicated if the fetus has a good chance at extrauterine survival.

A towel or cloth can be used to wipe off excess gel and dry the abdomen after the test. In the event that test results indicate fetal compromise, a health care professional should remain with the mother to provide emotional support and answer questions as needed.


Results and Interpretation

Nursing Responsibilities



Platelet Count -To evaluate platelet production.

-To assess the effects of chemotherapy or radiation therapy on platelet production.

Adults: 140,000 to 400,000/ul

>A count below 50,000/ul can cause spontaneous bleeding when the count is below 5,000/ul, fatal central nervous system bleeding or massive GI hemorrhage is possible.

> A decreased count can result to from aplastic or hypoplastic bone marrow; infiltrative bone marrow disease sush as leukemia, or disseminated infection.

Pre test-Explain to the pt. that the platelet count determines whether the clots normally.

-Tell the pt that the test requires blood sample. Explain who will perform the venipuncture and when.

-Notify the laboratory and physician of drugs the pt is taking that may affect test results, it may be necessary to restrict them.

-Inform the pt that he need not to restrict food and fluids.

Post test-Make sure subdermal bleeding has stopped before removing pressure.

>Instruct the patient that he may resume his usual diet and medications discontinued before the test.

-If a large hematoma develops at the venipuncture site, monitor pulses.

Diagnostic Test Purpose Normal Value Results and Interpretation Nursing Resposibilities



Hematocrit -To aid diagnosis of polycythemia, anemia or abnormal states of hydration.-To aid in the calculation erythrocyte indices.

In men: 42% to 52%In women: 36% to 48%

>Low HCT suggest anemia, hemodilution, or massive blood loss>High HCT indicates polycythemia or hemoconcentration caused by blood loss and dehydration

Pre test-Explain to the pt. that the hct test detects anemia and other abdominal conditions.

-Tell that the test requires a blood sample.

-Explain to the pt that he may feel slight discomfort from the tourniquet and needle puncture.

-Inform the pt that he need not to restrict food and fluids.

-If a pt is a child explain to him and his parents that small amount of blood will be taken from his fingers and ear lobes.

Post test- Ensure subdermal bleeding has stopped before removing pressure.

- To aid in the calculation of erythrocyte.

Diagnostic Test Purpose Normal Values Results and interpretation Nursing Resposibilities



Alanine Aminotransferase (ALT)

-To detect and evaluate treatment of acute hepatic disease specially hepatitis and serosis without jaundice.

-To distinguish between myocardial and hepatic tissue damage (use with aspartate amino transferase ).

-To assess hepatotoxity of some drugs

8-50 iu/L -Very high ALT levels up to 50 times normal suggest viral or severe drug induced hepatitis or other hepatic disease with extensive necrosis.

-Moderate to high levels may indicate infectious mononucleosis, chronic hepatitis, intra hepatic cholestasis or cholicystitis, early or improving acute viral hepatitis, or severe hepatic congestion from heart failure.

-Slight to moderate elevations of alt may appear in any conditions that produces acute hepatocellular injury, such as active cirrhosis and drug induced or alcoholic hepatitis.-Marginal elevations occasionally occur in acute myocardial infarctions, reflecting secondary hepatic congestions or the release of small amounts of ALT from myocardial tissue.

Pre test-Explain to the PT. that this test assesses levels liver functions.

-Tell the patient tat the test requires a blood sample. Explain who will perform the venipuncture.

-Inform the pt. that he need not restrict food and fluids.

-Notify the laboratory and physician of drugs the pt is taking that may affect test results, it may be necessary to restrict them.Post test-Apply direct pressure to the venipuncture site until bleeding stops.

-Instruct the pt. that he may resume medications stop before the step.

Diagnostic Test purpose Normal values Results and Interpretation Nursing Responsibilities



Urinalysis (UA) -To screen the patient’s urine for the renal or urinary tract disease

-To help detect metabolic or systemic disease unrelated to renal disorder

-To detect substances (drugs)

Color, straw to dark yellow

Odor, slightly aromatic

Appearance, clear

Specific gravity, 100

Protein

- 0-8 mg/dl

- 50-80 mg/24 hr (at rest)

- <250 mg/24 hr (during exercise)

Protein

Increased Levels

Nephrotic syndrome Glomerulonephritis Malignant hypertension Diabetic glomerulosclerosis Polycystic disease Lupus erythematosus Goodpasture’s syndrome Heavy-metal poisoning Bacterial pyelonephritis Nephrotoxic drug therapy Renal disease involving the

glomeruli is associated with proteinuria.

Trauma.Protein can spill into the urine as a result of traumatic destruction of the blood-urine barrier.

Macroglobulinemia. With increased globulin within the blood, albumin is secreted in an attempt to to maintain ocncotic homeostasis.

Multiple myelomas. Classically, mulptiple myelomas produce large amounts of protein (e.g., Bence-Jones protein) in the urine.

Preeclampsia

Pretest:

Explain that this analysis helps to diagnose renal or urinary tract disease and to evaluate over all body functions.

Inform the patient that he need not restrict food and fluids.

Notify the laboratory and physician of drugs the patient is taking that may affect laboratory results.

Posttest:

Inform the patient that he may resume his usual diet and medications.



Congestive heart failure The pathophysiologic factors of

these observations are many. Suffice it to say that albumin leaks from the glomeruli, which are temporarily damage by this illnesses.

Orthostatic proteinuria. As many as 20% of normal male patients have small amounts of protein in the urine when urine specimens are obtained from patients in the upright position. The pathophysiology is not known with certainty. It may be associated with passive congestion of kidney in the upright position. This phenomenon is can be diagnosed by obtaining a urine specimen before arising and another after the patient has been up for two hours. The first has no protein, the latter does.

Severe muscle exertion. Prolonged muscular exertion can be associated with small amount of protein in the urine.

Renal vein thrombosis. Congestion of the kidney is associated with proteinuria.

Bladder tumors. Tumors of the bladder secrete protein into the



lumen of the bladder. Urethritis or prostatitis.

Inflammation in the periurethral glands or urethra can cause proteinuria.

Amyloidosis. Often associated with proteinuria, it may be o severe as to cause nephritic syndrome. Usually, amyloidosis of the kidney is due to other severe, ongoing disease.

Diagnostics Purpose Normal values Results and interpretation

Nursing responsibilities

Low albumin levels can suggest liver disease.

Check the albumin level from the protein



Serum albumin A serum albumin test measures the amount of this protein in the clear liquid portion of the blood.

3.4 - 5.4 g/dL Other liver enzyme tests are ordered to determine exactly which type of liver disease.Low albumin levels can reflect diseases in which the kidneys cannot prevent albumin from leaking from the blood into the urine and being lost. In this case, the amount of albumin (or protein) in the urine also may be measured.Low albumin levels can also be seen in inflammation, shock, and malnutrition.Low albumin levels may also suggest conditions in which your body does not properly absorb and digest protein (like Crohn's disease or sprue) or in which large volumes of protein are lost from the intestines.High albumin levels usually reflect dehydration.

electrophoresis results. Many clinical problems are the result of a serum albumin deficit.Assess for peripheral edema in the lower extremities when the albumin level is decreased.Albumin is the major protein compound responsible for plasma colloid osmotic pressure. With a decreased albumin level, fluid seeps out of the blood vessels into the tissue spaces.Assess for urinary output. Renal and collagen (lupus) diseases occur with abnormal protein fractions. Urine output should be 25mL/h or 600mL/24 hours.

Diagnostics Purpose Normal values Results and interpretation

Nursing responsibilities

1st-trimester fetal ultrasound is done to:

A towel or cloth can be



Fetal ultrasound Determine how your pregnancy is progressing.

Find out if you are pregnant with more than 1 fetus.

Estimate the age of the fetus (gestational age).

Estimate the risk of a chromosome defect, such as Down syndrome.

Check for birth defects that affect the brain or spinal cord.

2nd-trimester fetal ultrasound is done to:

Estimate the age of the fetus (gestational age).

Look at the size and position of the fetus, placenta, and amniotic fluid.

Determine the position of the

The developing baby, placenta, amniotic fluid, and surrounding structures are normal in appearance and appropriate for the gestational age.Note: Normal results may vary slightly. Talk to your doctor about the meaning of your specific test results.

Typically, a fetal ultrasound offers reassurance that a baby is growing and developing normally. If your health care provider wants more details about your baby's health, he or she may recommend additional tests.

used to wipe off excess gel and dry the abdomen after the test. In the event that test results indicate fetal compromise, a health care professional should remain with the mother to provide emotional support and answer questions as needed.


http://www.webmd.com/brain/picture-of-the-brain

http://www.webmd.com/baby/tc/birth-defects-testing-what-are-birth-defects-tests

http://www.webmd.com/hw-popup/chromosomes

http://www.webmd.com/hw-popup/gestational-age


fetus, umbilical cord, and the placenta during a procedure, such as an amniocentesis or umbilical cord blood sampling.

Detect major birth defects, such as a neural tube defect or heart problems.

3rd-trimester fetal ultrasound is done to:

Make sure that a fetus is alive and moving.

Look at the size and position of the fetus, placenta, and amniotic fluid.


http://www.webmd.com/heart/picture-of-the-heart

http://www.webmd.com/hw-popup/amniocentesis

http://www.webmd.com/hw-popup/umbilical-cord


N O R M A L A N A T O M Y & P H Y S I O L O G Y

Cardiovascular system

The cardiovascular/circulatory system transports food, hormones, metabolic wastes,and gases (oxygen, carbon dioxide) to and from

cells. Components of the circulatory system include:

•blood : consisting of liquid plasma and cells

•blood vessels (vascular system): the "channels" (arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from

the heart. Veins return blood to the heart. Capillaries are thin walled blood vessels in which gas/ nutrient/ waste Exchange occurs.)

•heart : a muscular pump to move the blood

There are two circulatory "circuits":

Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-

poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from

the lungs back to the "left heart."Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter

the system from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to

the "right heart" via the inferior and superior vena cava.


http://sln.fi.edu/biosci/systems/pulmonary.html

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A specialized component of the circulatory system is the lymphatic system , consisting o f

moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymphnodes , and organs ( bone marrow ,

Liver , spleen , thymus ). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the

body is able to eliminate the products of cellular breakdown and bacterial invasion.

Anatomy of the Heart

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline. The heart, along with the

pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood.

Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers of the heart, the

atria (singular: atrium), receive blood via veins. Passing throughvalves( atrioventricular (AV) valves) , blood then enters the lower chambers, the

ventricles . Ventricular contraction forces blood into the arteries.


http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossV.html#ventricle

http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossV.html#ventricle

http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossA.html#atrioventricular%20(AV)%20valve

http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossA.html#atrioventricular%20(AV)%20valve

http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossA.html#auricle

http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossA.html#auricle

http://www.innerbody.com/text/lymp04.html




http://www.innerbody.com/text/card10.html


http://biomed.brown.edu/Courses/BIO189/Lab5/bonemarrow.jpg







Oxygen-poor blood empties into the right atrium via the superior and inferior vena cava. Blood then passes through the tricuspid valve into

the right ventricle which contracts, propelling the blood into the pulmonary artery. The artery is the only artery that carries oxygen-poor blood.

It branches to the right and left lungs. There, gas exchange occurs -- carbon dioxide diffuses out, oxygen diffuses in.

Pulmonary veins, the only veins that carry oxygen-rich blood, now carry the oxygenated blood from lungs to the left atrium of the

heart. Blood passes through the bicuspid into the left ventricle. The ventricle contracts, sending blood under high pressure through the aorta, the

main artery for systemic circulation. The ascending aorta carries blood to the upper body; the descending aorta, to the lower body.


http://gened.emc.maricopa.edu/bio/bio181/biobk/BioBookglossPQ.html#pulmonary%20artery




Vascular System - the Blood Vessels

Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of

capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system , to move blood by pressure; veins use one-way

valves controlled by muscle contractions.

Arteries

Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into

progressively thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-

rich, with the exception o f thepulmonary artery, which carries blood to the lungs to be oxygenated.

Capillaries

The arterioles branch into the microscopic capillaries , or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by the

lymphatic system . Capillaries are the points of exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries by







http://biomed.brown.edu/Courses/BIO189/Lab6/arteriole.jpg



http://webschoolsolutions.com/patts/systems/nervous.htm#divisions

http://webschoolsolutions.com/patts/systems/nervous.htm#divisions


passing through or between the cells that line the capillary. The extensive network of capillaries is estimated at between 50,000 and 60,000 miles

long.

Veins

Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules , which in turn unite to form veins. Veins are

responsible for returning blood to the heart after theblood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is

low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood.

Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry oxygenated blood from the lungs back to the heart. The

major veins, like their companion arteries, often takethe name of the organ served. The exceptions are the superior vena cava and the inferior

vena cava, which collect body from all parts of the body (except from the lungs) and channel it back tothe heart.

BLOOD PRESSURE

High blood pressure (HBP) is a serious condition that can lead to coronary heart disease (also called coronary artery disease), heart

failure, stroke, kidney failure, and other health problems.

"Blood pressure" is the force of blood pushing against the walls of the arteries as the heart pumps blood. If this pressure rises and stays high over

time, it can damage the body in many ways.






http://sln.fi.edu/biosci/vessels/veins.html




Blood pressure is measured as systolic (sis-TOL-ik) and diastolic (di-a-STOL-ik) pressures. "Systolic" refers to blood pressure when the heart

beats while pumping blood. "Diastolic" refers to blood pressure when the heart is at rest between beats.

You most often will see blood pressure numbers written with the systolic number above or before the diastolic number, such as 120/80 mmHg.

(The mmHg is millimeters of mercury—the units used to measure blood pressure.)



Urinary System

How do the kidneys and urinary system work?

The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left

behind in the bowel and in the blood.

The kidney and urinary systems keep chemicals, such as potassium and sodium, and water in balance and remove a type of waste, called urea, from

the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is

carried in the bloodstream to the kidneys.



Other important functions of the kidneys include blood pressure regulation and the production of erythropoietin, which controls red blood cell

production in the bone marrow.

Kidney and urinary system parts and their functions:

Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste

from the blood in the form of urine; keep a stable balance of salts and other substances in the blood; and produce erythropoietin, a hormone

that aids the formation of red blood cells. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron

consists of a ball formed of small blood capillaries, called glomerulus, and a small tube called a renal tubule. Urea, together with water and

other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing

urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15

seconds, small amounts of urine are emptied into the bladder from the ureters.

Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and

the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical

healthy adult bladder can store up to two cups of urine for two to five hours.



Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the

bladder.

Nerves in the bladder - alert a person when it is time to urinate, or empty the bladder.

Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of

the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the

signals occur in the correct order, normal urination occurs.

URINE FORMATION



Urine Formation Steps

Filtration

The first step in formation of urine is filtration. Filtration is the process by which the blood that passes through the glomerulus is filtered out, so that



only certain structures pass through into the proximal convoluted tubule. The rate at which the blood is filtered is known as the glomerular filtration

rate, which is normally 125 ml/minute or 180 liters/day! The glomerulus lining is such that it only allows small molecules to filter through, like glucose,

plasma, ions like sodium and potassium, urea, etc. The larger molecules, like blood cells and protein cannot pass through the glomerulus. This is the

reason that when there are kidney diseases, the glomerulus lining is affected, due to which the protein molecules also pass through, leading to blood

and protein in urine.

Selective Reabsorption

As mentioned above, in filtration step of urine formation, there is only crude and elementary separation of waste products and a lot of water, glucose

and other important materials also pass through. Thus, there is need for reabsorption of these important elements back into the body, which is where

the second step, that is reabsorptions, comes in. This step is known as selective reabsorption because only some elements are reabsorbed back into

the body. Reabsorption occurs in two steps, which is active reabsorption (which requires energy) and passive reabsorption (which does not require

energy).

Due to the difference in concentration of the fluid inside and outside the tubules, 99% of the water returns into circulation and thus, is passively

absorbed, which is important for urine formation and flow. Provided the glucose levels are normal, almost all of the glucose is reabsorbed back into

the blood from the proximal tubules. This glucose is actively transported into the peritubular capillaries. However, when there is a very large amount

of glucose in the blood, then some of it passes into the urine, which is one of the signs of diabetes. Sodium ions are the only ions that are partially

absorbed from the renal tubules back into the blood.

Tubular Secretion

The last step in urine formation is tubular secretion. This is the step where the urine is made concentrated by increasing the concentration of waste

elements. Thus, in this stage, substances move into the distal and collecting tubules from blood in the capillaries around these tubules. These



substances are secreted by the mechanism of active transport. The substances secreted include hydrogen ions, potassium ions, ammonia, and

certain drugs or metabolic end products. Thus, the kidney tubules play a crucial role in maintaining the body's acid-base balance and maintaining the

electrolyte balance in the body.

The distal convoluted tubules then drain the urine into the collecting tubules. Then, several collecting tubules join together to drain their contents into

the collecting duct, which finally, after urine formation, flows into the ducts of Bellini. This then eventually reaches the renal pelvis, from where the

urine flows into the ureter to reach the urinary bladder.

Thus, these were the various urine formation steps that take place right from the time when blood flows into the kidneys, till urine is passed into the

ureters. The various urinary system diseases occur when there are problems with the functioning of the kidneys, which reflects in the final urine color,

odor and concentration.

The Female Reproductive System





The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called

the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally

occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make

its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In

addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.

During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When

the body no longer produces these hormones a woman is considered to be menopausal.

The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal

genital organs from infectious organisms. The main external structures of the female reproductive system include:

Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora

are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty,

the labia majora are covered with hair.

Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora,

and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries

urine from the bladder to the outside of the body).

Bartholin’s glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.



Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by

a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation

and can become erect.

The internal reproductive organs include:

Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.

Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix,

which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a

developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.

Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.

Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel

from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then

moves to the uterus, where it implants to the uterine wall.



PLACENTA AND FUNCTION



The placenta’s primary role is to ensure that oxygen is moved into your baby’s blood stream and carbon dioxide is carried away from your

baby – however the waste is not limited to oxygen and also includes cleaning out other waste which is produced by your baby. In the same way that

it ensures oxygen reaches your baby, it also plays a role in ensuring that some nutrients are received.

The placenta is an extremely complex piece of biological equipment. It is a little bit like an artificial kidney, it allows your blood and the baby's

to come into very close contact - but without ever mixing. This enables your blood to pass across nutrients and oxygen to the baby, and waste

products like carbon dioxide to go back from baby to mother. It acts as the lung, kidney and digestive system for the baby.

The placenta also plays an important role in hormone production. Human chronic gonadotropin, or hCG is produced by the placenta. This

hormone can be found in your baby’s blood stream as early as 10 days into your pregnancy. This is of course not the only hormone which the

placenta produces as it is also responsible for the production of estrogen and progesterone .

The placenta also performs the important function of protecting your baby for possible infection – however, it is not always able to distinguish

between what is a good substance and what isn’t – and this is why pregnant women are asked to avoid substances which may cause harm, such as

caffeine, alcohol, herbal substances and drugs.


http://www.pregnancy-calendars.net/hcg.aspx


P A T H O P H Y S I O L O G Y



N U R S I N G C A R E P L A N S

Problem: Epigastric pain (right upper quadrant)

Nursing diagnosis: Acute epigastric pain (right upper quadrant) related to poor oxygenation of the pancreas and liver secondary to preeclampsia

Cause analysis: In PIH, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces the blood supply to organs. Most markedly the kidney, pancreas, liver, brain and placenta. ISCHEMIA IN THE PANCREAS AND LIVER may result in EPIGASTRIC PAIN. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )

CUES OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

Patient may verbalize,

Pain on the right upper quadrant of the abdomen,

STO:

After 4 hours of relaxation, patient will be alleviated from pain as evidenced by absence of facial grimace and pain scale of 4/10.

INDEPENDENT

1. Determine pain history, e.g. location of pain, frequency, duration, and intensity using pain scale and relief measures used.

2. Explain that nerves are severed or damaged but that analgesics and narcotics are available

1. Change in pain characteristics may indicate developing complications

2. Reduces abdominal tension and promotes sense of control.

The patient is expected to manifest:

Decrease pain scale of 4/10 from 8/10.

Maintains rest without disturbance from pain

Maintains relaxation technique

Resumes ADL



OBJECTIVE:

Irritable. From 0-10, pain can be

rated as 8. Grimacing face

LTO:

After 2 days of duty, pain will be relieved and patient resumes to her normal physical activity such walking, reaching out objects, etc.

with doctor’s prescription.

3. Promote proper body positioning to promote comfort, such as semi fowler’s position and elevation of the arm on the affected side.

4. Provide alternative comfort measures such as backrubs and encourage relaxation techniques such as guided imagery, visualization, quiet diversional activities such as watching T.V and listening to radio.

5. Encourage protection and the avoidance of anything that can break through the skin barrier or impose stress on the arm and shoulder.

3. promotes relaxation

4. promote relaxation and enables client to refocus attention and may enhance coping.

5. Aids in relaxing the abdominal muscles

Reference: Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6 th edition



Problem: Edema

Nursing Diagnosis: Deficient fluid volume related to plasma protein loss, decreasing plasma colloid osmotic pressure allowing shifts out of vascular compartment secondary to preeclampsia

Cause analysis: Vasospasm in the kidney increase blood flow resistance. Degenerative changes develop in kidney glomeruli because of back-pressure. This lead to increase permeability of glomerular membrane, allowing the serum proteins albumin and globuline to escape into the urine (protinuria) . The degenerative changes also results in decreases in glomerular filtration so there is lowered urine output and clearance of creatinine. Increase kidney tubular reabsorption occurs because sodium retains fluid retention (EDEMA). Edema is further increase because protein is lost the osmotic pressure of the circulating blood falls and fluid diffuses from the circulatory system into the denser interstitial spaces to equalized the pressure. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )

CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:

The patient may report less amount of urination.

STO:

Within 8 hours of effective nursing interventions, patient will be able to manifest increase urine output as evidenced by BP within individual’s normal range and urine output

INDEPENDENT:

1. Set an appropriate rate of fluid intake/infusion throughout 24-hour period

2. Monitor urine specific gravity.

3. Weigh daily at same time of day, on same scale, with same equipment and clothing.

1. to prevent peaks/valleys in fluid level.

2. Measures the kidney’s ability to concentrate urine. In intrarenal failure, specific gravity is usually equal to/less than 1.010, indicating loss of ability to concentrate the urine.

3. Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day

The patient is expected to manifest :

Increase urine output as evidence by BP within normal range.

Stable weight Vital signs within



OBJECTIVE:

Edema

Decrease urine output(less than 30ml /hr).

Blood pressure above 140/90

Pulse rate greater than 100

Weight gain

within the range of 30-40ml/hr.

LTO:

Within 3 days of giving effective nursing interventions, patient will be able to manifest a fluid balance as evidenced by appropriate urinary output, stable weight, vital signs within normal range and absence of edema.

4. Assess skin, face, dependent areas for edema. Evaluate degree of edema (on scale of +1–+4).

5. Evaluate edematous extremities, change position frequently.

6. Auscultate lung and heart sounds.

7. Assess level of consciousness; investigate changes in mentation, presence of restlessness.

8. Place in semi-fowler’s position as appropriate

9. Suggest interventions, such as frequent oral care, chewing gum/hard candy,

suggests fluid retention.

4. Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area. Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected.

5. to reduce tissue pressure and risk of skin breakdown

6. Fluid overload may lead to pulmonary edema and HF evidenced by development of adventitious breath sounds, extra heart sounds. (Refer to ND: Cardiac Output, risk for decreased, following.)

7. May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.

8. to facilitate movement of

Normal range Absence of

EDEMA



use of lip balm.

10.Promote bed rest..

COLLABORATIVE:

1. Administer diuretics as prescribed after pregnancy.

diaphragm improving respiratory effort.

9. to reduce discomforts of fluid restrictions.

10.The best method of aiding increased evacuation of sodium and encouraging diuresis.

1. Promote adequate urine volume




Problem: Proteinuria

Nursing Diagnoses: Altered urinary elimination r/t fluid shifting secondary to preeclampsia

Cause analysis: Increase nutrient loses because of the excretion of the protein in the urine. Body proteins are use for energy when calorie intake is insufficient. Increase nutrient requirements as a pregnant women they need sufficient nutrients to provide their needs and to the fetus. Energy requirements are essential for fetal and placental growth but because of some food restrictions it is not well provided.( Med-Surgical 6 th edition by: Black,pg.1426.)A

Cues Objectives Nursing intervention

Rationale Evaluation

Subjective:

The patient may verbalized:

Complaints of some food restrictions.

Objective:

edema excess amount of

protein in the urine.

STO:

After 8 hours of effective nursing intervention patient will be able to verbalize understanding about dietary needs consist of intake of high protein foods such as milk product, fish, and poultry. Avoiding high sodium foods such as cheese, goat milk, carrot juice, butter.

LTO:

After 3 days of nursing interventions patient will be able to demonstrate knowledge of proper diet as evidenced by

Independent:

1. Assess client’s nutritional status, condition of hair and nails, and height and pregravid weight.

2. Provide information

1. Establishes guidelines for determining dietary needs and educating client. Malnutrition may be a contributing factor to the onset of PIH, specifically


Developed a dietary meal plan that was low sodium and low fat diet.



developing a dietary plan within own financial resources about normal weight gain in pregnancy, modifying it to meet client’s needs

because it places the fetus at risk for ketosis.

3. Provide oral/written information about action and uses of protein and its role in development of PIH.

4. Provide information about effect of bed rest and reduced activity on protein requirements.

When client follows a low-protein diet, has insufficient caloric intake, and is overweight or underweight by 20% or more before conception.

2.The underweight client may need a diet higher in

. calories; the obese client should avoid dieting

3. Daily intake of 80–100 g/day (1.5 g/kg) is



5. Use flavoring agents (e.g. lemon and herbs) is salt is restricted

6. Limit fiber/bulk if indicated

7. promote pleasant, relaxing environment, including socialization when possible

8. Prevent/minimize unpleasant

sufficient to replace proteins lost in urine and allow for normal serum oncotic pressure.

4. Reducing metabolic rate through bed rest and limited activity decreases protein needs.

5. to enhance food satisfaction and stimulate appetite

6. because it may lead to early satiety



odors/sights.

9. Encourage use of lozenges and so forth

10. Promote adequate/timely fluid intake

7. To enhance intake.

8. May have a negative effect on appetite/eating.

9. To stimulate salivation when dryness is a factor

10. Limiting fluids 1 hour prior to meal decreases possibility of early satiety



Collaborative:

Refer to dietitian, as indicated.

Helpful in creating individual dietary plan

incorporating specific needs/restrictions


Problem: Risk for Fetal Injury

Nursing Diagnosis: Risk for (Fetal) Injury related to reduce placental perfusion secondary to vasoconstriction secondary to preeclampsia

Cause Analysis: With severe preeclampsia, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces blood supply to organs, most markedly in the kidneys, pancreas, liver, brain, and PLACENTA. Poor placental perfusion may reduce the fetal nutrient and Oxygen supply. (Maternal and child nursing by PILLITTERI 5th edition pp.426)


Subjective: ST0:

After 8 hrs of nursing

Independent:

1. Monitor and assess vital signs.

Independent:

1. To obtain baseline

The fetus is expected to manifest:



Not applicable

Objective:

Patient

manifested:

A systemic vasoconstriction

Patient’s fetus

may manifest:

Intrauterine growth retardation

interventions, the patient’s placental perfusion will

increase sd rvidenced by fetal heart rate within 120-160 bpm.

LTO:

After 3 days of nursing

interventions, the patient will

demonstrate a decrease in systemic vasoconstriction

to increase uteroplacental circulation as evidenced by intrauterine growth during ultrasound.

2. Assess the patient’s general physical condition.

3. Instruct mother to assume a left lateral position.

4. Promote bed rest.

5. Encourage relaxation techniques such as deep Breathing.

6. Encourage patient to avoid constipation by increasing fiber intake.

7. Instruct mother on the possible complications the disease can cause to the fetus.

8. Discuss importance of having an adequate blood circulation going to the placenta.

2. To determine presence of abnormality.

3. To avoid putting pressure on the inferior vena cava.

4. To increase uteroplacental circulation and prevent too much workload on the heart.

5. To provide comfort.

6. Straining defecation might put pressure on the uterus which could injured the already compromised fetal health.

7. To enhance patient’s participation in the treatment regimen.

8. For patient

normal HR (120-160 bpm)

absence of signs of fetal distress

normal fetal movement in an hour (3

movements/hour)



Changes in fetal activity/ heart rate(less than or more than 120-160 bpm)

Fetal demise

Dependent:

1. Administer oxygen as indicated.

education..

1. To help in respiration.

Reference: Nurse’s Pocket Guide Book, 9 th edition by Doenges et.al pp.369

Problem identified; lack of knowledge

Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition,prognosis, self care and treatment needs related to lack of exposure/unfamiliarity with information resources, misinterpretation secondary to preeclampsia

Cause analysis: Anticipatory anxiety and patient lacks in psychological and educational information. Cause analysis: A new problem or condition will acquire the individual to learn new behaviors to help maintain optimal health & function. Some information will be used only temporarily while other information will result in lifelong behavior change. (NDCP by Neal et.al.)Individuals coping with present illness with varied pharmacological treatment regimen, unfamiliar and often complex procedures,commonly experience a deficit in knowledge.

(Medical surgical Nursing by Smeltzer and Bare 7th ed. pg. 1303)



Cues Objectives Nursing interventions Rationale

Questions/request for information misinterpretation

Verbalization of problem

Statement of misconception

Inaccurate follow-through of instructions, development of preventable complications

STO:

After 2-3 days of nursing interventions and health teachings, the patient will be able to verbalize accurate information about diagnosis, prognosis, and potential complications at own level of readiness.

LTO:

After 4-5 days of nursing interventions and health teachings, the patient will be able to verbalize understanding of the therapeutic needs and will be able to identify/use available resources appropriately.

Independent:

1. Assess client’s/couple’s knowledge of the disease process. 2. Provide information about pathophysiology of Pre-eclampsia, implications for mother and fetus; and the rationale for interventions, procedures, and tests, as needed.

3. Provide information about signs/symptoms indicating worsening of condition, and instruct client when to notify healthcare provider.

4. Keep client informed of health status, results

1. Establishes data base and provides information about areas in which learning is needed. Receiving information can promote understanding and reduce fear, helping to facilitate the treatment plan for the client. provide additional treatment options, such as using low-dose (60 mg/day) aspirin to reduce

thromboxane generation by platelets, limiting Note: Current research in progress may severity/incidence of PIH (pre-eclampsia)

2. Helps ensure that client seeks timely treatment and may prevent worsening of preeclamptic state or

The patient is expected to:

1. Verbalize accurate information about diagnosis, prognosis, and potential complications at own level of readiness.

2. Verbalize understanding of the therapeutic needs and will be able to identify/use available resources appropriately.



of tests, and fetal well-being.

5. Instruct client in how to monitor her own weight at home, and to notify healthcare provider if gain is in excess of 2 lb/wk, or 0.5 lb/day.6. Assist family members in learning the procedure for home monitoring of BP, as indicated.7. Review techniques for stress management and diet restriction.8. Provide information about ensuring adequate protein in diet for client with possible or mild preeclampsia.Review self-testing of urine for protein. Reinforce rationale for and implications of testing.

additional complications.

3. Fears and anxieties can be compounded when client/couple does not have adequate information about the state of the disease process or its impact on client and fetus.

4. Gain of 3.3 lbs or greater per month in second trimester or 1 lb or greater per week in third trimester is suggestive of PIH.

5. Encourages participation in treatment regimen, allows prompt intervention as needed, and may provide reassurance that efforts are beneficial.

6. Reinforces importance of client’s responsibility in treatment.

7. Protein is necessary for



intravascular and extravascular fluid regulation.

8. A test result of 2+ or greater is significant and needs to be reported to healthcare provider. Urine

specimen contaminated by vaginal discharge or RBCs

may produce positive test result for protein.

PROBLEM: Seizure

NURSING DIAGNOSIS: Risk for injury related to fluid excess in cerebral area secondary to Pregnancy induced hypertension



CAUSE ANALYSIS: in patient having PIH (severe stage) there is vasoconstriction thus decrease blood supply on the brain. Decrease tissue perfusion in the brain will eventually lead to seizures. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )

Cues Objectives Intervention Rationale Evaluation

Subjective:

The patient may verbalized:

-Occurrence of seizure after delivery.

Objective:

STO:

After giving nursing intervention, the pt will be able to explain ways to prevent injury as evidence by calling assistance whenever she goes to the restroom.

LTO:

Within 1 week of hospital stay, the pt will be able to be free from

INDEPENDENT

1. determined risk of falling2. Thoroughly orient to

environment. Show how to call assistance

3. Keep side rails up and maintain bed in low position; ensure that wheels are locked on bed and commode; keep dim light in room at right.

4. Assisted client to voiding at least every 4 hours. Take pt to the bathroom before bedtime.

5. Asked family or SO to stay with client.

DEPENDENT:

Administered medication as prescribed by physician;

1. it can help identify high risk of falling

2. This step alerts the nursing staff the increase risk of falls.

3. This safety measures are use as part of a fall prevention program.

4. studies have indicated that falls are often linked to the need in a hurry

5. To monitor pt and prevent pt from accidentally falling


Prevent cause of injury as evidence by calling assistance whenever she goes to the restroom.

Absence of seizures

Performs ADL Perform seizure

precautions



-Neurological deficit

-Altered level of consciousness

- Affected ADL.

-Onset of seizures after surgery

injuries as evidenced by an absence of seizure activity. magnesium sulfate

Essential for the activity of many enzymes. Plays an important role in neurotransmission and muscular excitability

REFERENCE: Tbers Cyclopedic Medical Dictionary 18th ed. by Thomas, Clayton p 441.

Problem Identified: Shortness of breath, dyspnea

Nursing Diagnosis: Ineffective breathing pattern related to pulmonary edema.

Cause Analysis: Pulmonary edema is one of the complications of PIH, and is due to the increased permeability of the capillaries causing the leakage of fluids to the insterstitial spaces of the lungs (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 .

CUES OBJECTIVES NURSING RATIONALE EVALUATION



INTERVENTION

Subjective:

The patient may complain of difficulty of breathing.

Objective:

Difficulty of breathing

Orthopnea May have a

respiratory rate of less than 12 bpm.

Crackles, wheezing

Nasal flaring Use of accessory

muscle

STO:

After 4 hours of proper nursing intervention the patient will be able to identify/demonstrate behaviors to achieve airway clearance as evidenced by absence of nasal flaring, use of accessory muscle, etc.

LTO:

After 2 days of proper nursing intervention the patient will display patent airway with breath sounds clearing; absence of dyspnea.

Independent:

1. Aauscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds: e.g., crackles, wheezes.

2. Aassess rate/depth of respirations and chest movement.

3. Eelevate head of bed, change position frequently.

1. Ddecreased airflow occurs in areas consolidated with fluid. Crackles and wheezes are heard on inspiration and/or expiration in response to fluid accumulation.

2. Ttachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung.

3. Kkeeping the head elevated lower diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep airway clear.


Aabsence of shortness of breath and dypsnea.

Clear breath sound. Nno nasal flaring Nno use of accessory

muscles



4. Aassist with frequent deep-breathing exercises. Demonstrate/help client to perform activity: e.g., effective coughing while in upright position.

5. Fforce fluids to at 3000mL/day (unless contratindicated). Offer warm, rather than cold, fluids.

Dependent:

1. Aadminister

4. Ddeep breathing facilitates maximum expansion of the lung/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airway, and an upright position favors deeper, more forceful cough effort.

5. Fliquids (especially warm liquids) aid in mobilization and expectoration of secretions.

1. Tto help in respiration.



oxygen as indicated for underlying pulmonary condition.

Reference: NCP by Doenges, Moorehouse & Geissler – Murr pp. 135-136.

Problem: Increased Blood pressure

Nursing Diagnosis: Decreased cardiac output related to vasoconstriction secondary to vasospasm and sensitivity to pressor substances

Cause Analysis: Normally, blood vessels during pregnancy are resistant to the effects of pressors substance such as angiotensin and norepinephrine, so blood pressure remains normal during pregnancy. With PIH, this reduce responsive to blood pressure changes appears to be lost. VASOCONSTRICTION occurs and blood pressure increase dramatically. (Maternal and Child nursing by ADELE PILLITTERI 5 th edition pp.426 )

CUES OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

Subjective:

The patient may verbalize :

Complaint of discomfort in neck, dizziness.

STO:

After 8 hours of giving effective dependent and independent nursing care, the patient will demonstrate increase perfusion as evidenced by decreased BP

Independent:1. Monitor BP in both

arms, 3-5 minutes apart while client is at rest, sitting, standing, for initial evaluation. Use correct cuff size and accurate technique.

1. Comparison of pressures provides more complete picture of vascular involvement.


Participated activities the reduced BP/cardiac workload.

Maintain BP within individually acceptable range.

Demonstrate stable cardiac rhythm and



Complaint of shortness of breath

Complaint of weakness and fatigue.

Objective:

Variation in blood pressure(>120/90 mmHg)/hemodynamic reading .

Edema Weak pulse pressure Decreased

peripheral pulses Cold, clammy skin

to 120/90 mmHg.

LTO

Within 3 days giving effective nursing care, the patient will demonstrate hemodynamic stability as evidenced of BP within acceptable range of 120/80-130/80.

2. Note presence, quality of central and peripheral pulses.

3. Identify changes related to systemic peripheral alterations in circulation.

4. Elevate head of bed and maintain head neck in midline or neutral position.

5. Measure urine output on a regular schedule of shift provides adequate fluid depending on client’s need.

6. Cautioned client to avoid activities that increase cardiac workload. And review ways of avoiding

2. Bounding carotid, jugular, radial, femoral pulses maybe observed/ palpated. pulses in the legs/feet maybe diminished, reflecting effects of vasoconstriction and venous congestion.

3. To assess causative/ contributing factors

4. To provide circulation/ venous drainage

5. To provide baseline

rate within client’s normal range 120/80-130/80.



constipation and encourage quiet, restful atmosphere.

7. Provide for diet restriction (DASH diet) and increase frequent small feedings.

8. Provide bed rest

9. Observe skin color, temperature, capillary refill time.

10.Provide calm and restful surroundings and minimize environmental activity/noise. Limit the number of visitors and length of stay.

11.Provide comfort measure, e.g. back and neck massage, elevation of head.

12. Instruct in relaxation

data

6. Conserves energy and lowers tissue oxygen demands.

7. To maintain adequate nutrition and fluid balance.

8. To avoid further increase of blood pressure.

9. Presence of pallor; cool,, and delayed capillary refill time



technique, guided imagery.

COLLABORATIVE:

1. Administer medication as indicated:

Hydralazine

maybe due to peripheral vasoconstriction or reflect cardiac decompensation

10.Help reduced sympathetic stimulation/ promote relaxation.

11.Decrease discomfort and may reduced sympathetic stimulation.

12.Can reduced stressful stimuli, produced calming effect, thereby reducing BP.



1. A direct- acting vasodilator that relaxes arteriolar smooth muscle

Reference: Nurse’s Pocket Guide Book, 9 th edition by Doenges et.al p.142

Problem: Risk for Fetal Injury

Nursing Diagnosis: Risk for (Fetal) Injury related to reduce placental perfusion secondary to vasoconstriction tertiary to Pregnancy Induced Hypertension.

Cause Analysis: With severe preeclampsia, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces blood supply to organs, most markedly in the kidneys, pancreas, liver, brain, and PLACENTA. Poor placental perfusion may reduce the fetal nutrient and Oxygen supply. (Maternal and child nursing by PILLITTERI 5th edition pp.426)


Subjective: ST0: Independent: Independent: The fetus is expected to manifest:



Not applicable

Objective:

Patient

manifested:

A systemic vasoconstriction

Patient’s fetus

may manifest:

Intrauterine growth retardation

After 8 hrs of nursing

interventions, the patient’s placental perfusion will

increase AEB fetal heart rate within 120-160 bpm.

LTO:

After 3 days of nursing

interventions, the patient will

demonstrate a decrease in systemic vasoconstriction

to increase uteroplacental circulation as evidence by absence of signs of fetal distress

9. Monitor and assess vital signs.

10.Assess the patient’s general physical condition.

11. Instruct mother to assume a left lateral position.

12.Promote bed rest.

13.Encourage relaxation techniques such as deep Breathing.

14.Encourage patient to avoid constipation by increasing fiber intake.

15. Instruct mother on the possible complications the disease can cause to the fetus.

16.Discuss importance of having an adequate

9. To obtain baseline

10.To determine presence of abnormality.

11.To avoid putting pressure on the inferior vena cava.

12.To increase uteroplacental circulation and prevent too much workload on the heart.

13.To provide comfort.

14.Straining defecation might put pressure on the uterus which could injured the already compromised fetal health.

15.To enhance patient’s participation in the treatment regimen.

normal HR (120-160 bpm)

absence of signs of fetal distress

normal fetal movement in an hour (3

movements/hour)



Changes in fetal activity/ heart rate(less than or more than 120-160 bpm)

Fetal demise

blood circulation going to the placenta.

Dependent:

2. Administer oxygen as indicated.

16.For patient education.

.

2. To help in respiration.


Problem: Risk for Injury

Nursing Diagnosis: Risk for Injury related to excess fluid build-up in the tissue secondary to retinal edema.

Cause Analysis: Spasm of the arteries in the retina leads to vision changes. Cerebral edema occurs, reports may be voiced of visual disturbances such as blurred vision or seeing spots before the eyes.( (Maternal and child nursing by PILLITTERI 5th edition pp.426)


Subjective: ST0: Independent: Independent: The patient is expected



The patient may verbalize:

blurring of vision severe headache

Objective:

Progressive loss of visual field.

After 4 hours of nursing intervention the patient will be able to identify factors that increase potential for injury.

LTO:

After 1 day of nursing intervention the patient will apply safety measures to prevent injury and family members will develop strategy to maintain safety.

1. Ascertain type/degree of visual loss.

2. Recommend measures to assist patient to manage visual limitations, e.g. arranging furniture

3. Orient patient to environment. Assess patient's ability to use call bell, side rails and bed positioning controls. Keep bed at lowest level, and conduct close night watch

4. Teach pt and family about need to safe illumination. Advise pt to wear sunglasses to reduce glare. advise using contrasting colors in household furnishings

5. Observe for factors that may cause or contribute to injury.

1. Affects choice of intervention and patients future expectations.

2. Reduces safety hazards related to changes in visual field and papillary accommodation to environmental light.

3. These measures will help patient cope with unfamiliar surroundings.

4. These measure will enhance visual discrimination

5. Increase awareness of patient, family members, and care

to:

Verbalize, enumerate factors that will increase potential for injury.

Enumerate plans and strategy to maintain safety.



6. Encourage bedrest.

Collaborative:

1. Administer medication as prescribed.

givers.

6. To reduce edema. Since if possible medication should not be prescribed since the patient is pregnant.


Problem identified; lack of knowledge

Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition,prognosis, self care and treatment needs related to lack of exposure/unfamiliarity with information resources, misinterpretation.

Cause analysis: Anticipatory anxiety and patient lacks in psychological and educational information. (Medical surgical Nursing by Smeltzer and Bare 7th ed. pg. 1303)

Cues Objectives Nursing interventions Rationale



Questions/request for information misinterpretation

Verbalization of problem

Statement of misconception

Inaccurate follow-through of instructions, development of preventable complications

STO:

After 2-3 days of nursing interventions and health teachings, the patient will be able to verbalize accurate information about diagnosis, prognosis, and potential complications at own level of readiness.

LTO:

After 4-5 days of nursing interventions and health teachings, the patient will be able to verbalize understanding of the therapeutic needs and will be able to identify/use available resources appropriately.

Independent:

1. Assess client’s/couple’s knowledge of the disease process. Provide information about pathophysiology of Pre-eclampsia, implications for mother and fetus; and the rationale for interventions, procedures, and tests, as needed.

2.Provide information about signs/symptoms indicating worsening of condition, and instruct client when to notify healthcare provider.

3.Keep client informed of health status, results of tests, and fetal well-being.

1. Establishes data base and provides information about areas in which learning is needed. Receiving information can promote understanding and reduce fear, helping to facilitate the treatment plan for the client. provide additional treatment options, such as using low-dose (60 mg/day) aspirin to reduce

thromboxane generation by platelets, limiting Note: Current research in progress may severity/incidence of PIH (pre-eclampsia)

2. Helps ensure that client seeks timely treatment and may prevent worsening of preeclamptic state or additional complications.

The patient is expected to:

3. Verbalize accurate information about diagnosis, prognosis, and potential complications at own level of readiness.

4. Verbalize understanding of the therapeutic needs and will be able to identify/use available resources appropriately.



4.Instruct client in how to monitor her own weight at home, and to notify healthcare provider if gain is in excess of 2 lb/wk, or 0.5 lb/day.

5.Assist family members in learning the procedure for home monitoring of BP, as indicated.

6.Review techniques for stress management and diet restriction.

7.Provide information about ensuring adequate protein in diet for client with possible or mild preeclampsia.

Fears and anxieties can be compounded when client/couple does not have adequate information about the state of the disease process or its impact on client and fetus.

4. Gain of 3.3 lbs or greater per month in second trimester or 1 lb or greater per week in third trimester is suggestive of PIH.

5. Encourages participation in treatment regimen, allows prompt intervention as needed, and may provide reassurance that efforts are beneficial.

6. Reinforces importance of client’s responsibility in treatment.



8.Review self-testing of urine for protein. Reinforce rationale for and implications of testing.

7. Protein is necessary for intravascular and extravascular fluid regulation.

8. A test result of 2+ or greater is significant and needs to be reported to healthcare provider. Urine

specimen contaminated by vaginal discharge or RBCs

may produce positive test result for protein.

Reference: Nurse’s Pocket Guide Book, 9 th edition by Doenges et.al.



H E A L T H E D U C A T I O N P L A N

Objectives:

After 30 minutes of rendering health teaching, the patient will be able to:

1. Understand the importance of proper nutrition and exercise to promote health and prevention of disease.

2. Understand the importance of adequate rest and avoidance of stress for fast recovery.

3. Verbalize feelings of understanding towards the health teaching.

Materials needed:1. Visual aids 2. Pentel pen 3. Coloring materials

General Specific health teachingSupport bed rest - Teach patient with severe preeclampsia, pregnant woman is

advice to be hospitalized so that bed rest can be enforced and she can be observed more closely.

- Encouraged the family that Visitors are restricted to support people ( e.g husband, father of the child, mother, or older children).

- Teach the patient to avoid a loud noise such as a crying baby or dropped tray of equipment may be sufficient to trigger a seizure



initiating eclampsia. - Instruct the patient to darken the room if possible because a

bright light can trigger seizures.

Promote Bed Rest - Encouraged patient to promote bed rest. Because when the body is in the recumbent position sodium tends to excreted at a faster rate than during activity. Bed rest, therefore, is the best method of aiding increased evacuation of sodium and encouraging dieresis. Rest should always be in lateral recumbent position to avoid uterine pressure in the vena cava.

Nutrition - Instruct the mother needs to continue her usual pregnancy diet. Eat nutritious and balanced diet (60 70 mg/day; 1200 mg calcium and adequate zinc, magnesium and vitamins).

- Teach the patient that there is no sodium restriction, however, consider limiting excessive salty foods(processed foods, potato chips, etc.) and add roughage ( bran, fruits, leafy vegetables) to your diet to decrease constipation.

- Encouraged pt. to eat rich in protein diet such as lean meat, green leafy vegetables, beans, and other rish in protein food.

Fluid intake - Encouraged to limit fluid intake up to 6 - 8 glasses/ day

Exercise - Teach the client on Circling of hands and feet or gently tensing and relaxing and leg muscles. This improves muscle tone, circulation, and sense of well - being.

- Encouraged deep breathing exercise- Instruct the patient to limit the no. of stairs she climbs to one

flight/day for the first week at home. Beginning the second week, if her lochial discharge is normal, she may start to increase this activity. Limit stair climbing to only when necessary for first two weeks.



Support system - Encourage family participate in the care management. Have significant others to assist you in the care of the house, children and etc.

Relaxation - Instruct the mother to relax to help cope with stress. Use guided imagery, pleasant scenes, and smoothing music.

Lifestyle - Avoid alcohol, limit caffeine intake, and avoid smoking and passive smoke exposure.

Supplementation - Supplementation of calcium, fish oil, and vitamins C and E



D I S C H A R G E P L A N

Medication

Medication Dosage/ frequency Nursing responsibilitiesHydralazine (Apresoline)

Methyldopa(Aldomet)

50 to 200 mg/day

250 mg PO bid/tid; increase q2d prn; not to exceed 3 g/d

Inform the patient for the possible side effects of the drugs such as headache, dizziness, palpitations, constipation, vomiting, and anxiety.

Take this drug exactly as prescribed and take this dug with food.

Instruct pt. to take dose at the same time everyday, alst dose of the day must be taken during bedtime. Do not double dose.

Encourage client to comply with additional hypertensive intervention (weight reduction, exercise, low sodium diet, stress management)

Instruct family and pt. on proper



Hydrochlorothiazide( Esidrix)

25-100 mg PO qd; not to exceed 200 mg/kg/d

monitoring of blood pressure. Inform pt. that urine may turn dark. Advise pt. that frequent oral hygiene can

minimize dry mouth.Instruct pt. to notify physician if unusualities occur.

Instruct pt. to take medication at the same time everyday. Do not double dose.

Instruct pt. to monitor weight biweekly and notify healthcare professional of significant changes.

Advise pt. to make position changes slowly, to avoid orthostatic hypotension.


Instruct pt. and family in correct technique for monitoring weekly blood pressure.

Exercise

Daily brisk walk for 30-60minutes Kegel’s exercise 10 times a day for 6 weeks



How to perform kegel’s exercise:

1. Identify the correct pelvic floor muscles by contracting them to stop the flow of urine while sitting on the toilet.2. Repeat this action several times to become familiar with it.3. Start the exercise by emptying the bladder.4. Tighten the pelvic muscles and hold for a count of ten seconds.5. Relax the muscles completely a count of 10 seconds6. Perform ten exercises at least three times daily and progressively increase.7. Perform the exercise in different position such as standing. Lying, and sitting.8. Keep breathing during exercises.9. Don’t contract the abdominal, thigh leg or buttocks muscles during these exercises.10.Relax while doing kegel’s exercises and concentrate on isolating the right muscles.11.Attempt to tighten the pelvic muscles before sneezing, jumping, or laughing to protect them for additional laxness.12.Be aware that you can perform kegel exercise anywhere and in any place without anyone noticing.

Therapy

Drug Therapy- It is recommended esp. drugs that aids in lowering the blood pressure of the certain person and to maintain blood pressure with normal ranges such as beta blockers. Example of this is Propranolol, Metoprolol, Nadolol, etc.

Health teachings:

Instruct patient to lose weight if overweight such as engaging in any activities. Restricts the intake of alcohol for this may cause vasoconstriction thus increasing blood pressure. Have an appropriate exercise regimen because regular activity is a significant factor in weight reduction. Maintain adequate intake of dietary potassium. Maintain adequate intake of dietary calcium and magnesium for general health. Stop smoking and reduce intake of dietary saturated fats and cholesterol for overall cardiovascular health. Stress reduction also is beneficial in any diseases. Encourage client to observe proper perineal hygiene.



Teach the client to report warning signs of problems and where to seek help to eliminate them. Instruct the woman for self – care and infant care.

OPD:

1. Have the client follow a check up schedule to visit physician in order to assess extent of treatment and further assessment.2. Obtain drugs that may be administered at home for further treatment.

Diet:

Encourage to eat nutritious, balanced diet (60 – 70 grams protein; 1200 mg calcium and adequate zinc, magnesium, and vitamins). Consult with registered dietician on the diet best suited for you as an individual.

There is no sodium restriction; however consider limiting excessively salty foods (luncheon meats, pretzel, potato chips, and pickles). Eat foods with roughage (whole grains, raw fruits, and vegetables). Avoid alcohol, and limit caffeine intake. Adequate fluid intake (6 – 8 glasses per day help to maintain optimal fluid volume and aids in renal perfusion). Avoid high fat diet.

Spiritual:

Encouraged to continue to seek God’s guidance and enlightenment.

Emphasized the importance of prayers in healing

Encouraged to ask for divine assistance in everything

Encouraged to continue to pray to God.

Encouraged to continue to have a positive outlook in life.

Encouraged to keep faith in God and not to give up easily when hard times come



M E D I C A L M A N A G E M E N T

Drugs Classification Indication Mechanism of Action

Dosage Adverse Effects Nursing Considerations

Magnesium Sulfate

(Epson Salt)

Pregnancy risk category B

Anticonvulsant -muscle relaxant

-prevents seizures

Mg depresses the CNS and control convulsion by blocking the release of acetylcholine and decrease the excitability of the motor membrane.

-Loading dose 4-6 IV

-Maintenance dose 1-2 g/h IV

CNS: depression

CV: flushing, hypotension, depression, of myocardium

Magnesium intoxication: Cardiac and CNS depression, preceding respiratory paralysis,

Before administering IV, check for the ff :

-Absent patellar reflex

- RR below 16/min

- Urine output below 100 ml in past 4 hours

- Early signs of hypermagnesemia;



circulatory collapse, flaccid paralysis.

flushing, sweating, hypotension or hypothermia

- Past history of heart block or myocardial damage, prolonged RR and widened QRS interval.

Hydralazine HCL

(Apresoline)

Pregnancy risk category C

Antihypertensive - preeclampsia, eclampsia

- heart failure

A direct- acting vasodilator that relaxes arteriolar smooth muscle.

- Initially, 5-10 mg IV, followed by 5-10 mg IV doses, (range 5-20 mg) q 20 to 30 min, prn or 0.5 to 10 mg/ hour IV infusion.

CNS: headache, dizziness

CV: tachycardia, angina pectoris, palpitations

EENT: nasal congestion

GI: nausea, vomiting, diarrhea, anorexia, constipation.

- Monitor pt. blood pressure, pulse rate, and body weight frequently.

- Instruct client to take with food to increase absorption.

Calcium Gluconate Electrolyte and replacement

Antidote for magnesium

Generally, replaces calcium and maintains

- 1g/ IV (10ml of a 10%

CV: mild drop of blood pressure, vasodilation,

- Warn pt. to avoid oxalic acid (in rhubarb and



Pregnancy risk category C

solutions toxicity calcium level; physiologically antagonize hypomagnesaemia effect.

solution) bradycardia, arrhythmias, cardiac arrest

GI: irritation, constipation, chalky taste, nausea, thirst, abdominal pain

GU: renal calculi

spinach), phytic acid (in barn and whole grain cereals), and phosphorus (in dairy products) in the meal preceding calcium consumption; these substances may interfere calcium absorption.

Diazepam (Valium)

Pregnancy risk category D

Anxiolytic Adjunct treatment for seizure disorder.

A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppresses the spread of seizure activity.

- Adults: 2 to 10 mg PO bid to qid.

CNS: drowsiness, fatigue, ataxia, headache, insomnia, minor changes in ECG patterns.

CV: hypotension, CV collapse, bradycardia

EENT: blurred vision

GI: nausea, constipation

- Warn pt. to avoid activities that require alertness and good coordination.

- Warn pt. not to abruptly stop drug cause withdraw symptoms may occur.



GU: incontinence, urine.

Hydrochlorothiazide

( Esidrix)

Diuretic

Antihypertensive

(loop)

Management of mild to moderate hypertension.

Increases excretion of sodium and water by inhibiting sodium reabsorption in the distal tubule. May produce arteriolar dilation.

Dosage:

25-100 mg PO qd; not to exceed 200 mg/kg/dPediatric

<6 months: 2-3 mg/kg/d PO divided bid>6 months: 2 mg/kg/d PO divided bid

Dizziness, drowsiness, hypotension, nausea, vomiting, hypokalemia, hypercalcemia, hypovolemia, muscle cramps, rashes.

Monitor blood pressure during dosage adjustment and periodically during therapy.

Instruct pt. to take medication at the same time everyday. Do not double dose.

Instruct pt. to monitor weight biweekly and notify healthcare professional of significant changes.

Advise pt. to make position changes slowly, to avoid orthostatic hypotension.

Caution pt, to wear protective clothing and use



sunscreen to prevent photosensitivity reactions.

Advise pt. to report muscle weakness, cramps, nausea, vomiting, diarrhea, or dizziness to health care professional.

Emphasize on routine follow up exams.


Instruct pt. and family in correct technique for monitoring weekly blood



pressure.May cause drowsiness; instruct pt. not to do activity requiring alertness.

S U R G I C A L M A N A G E M E N T

CESAREAN SECTION

Clients with mild preeclampsia can be managed at home with frequents follow-up care. If the preeclampsia is severe, a woman may be admitted to the health care facility. If the pregnancy is 36 weeks or further long or fetal lung maturity can be confirmed by amniocentesis, labor can be induced to end the pregnancy at this point. If the pregnancy is less than 36 weeks or amniocentesis reveals immature lung function, interventions will be instituted to attempt to alleviate the severe symptoms and allow the fetus to come to term. However, if fetus appears to be in imminent danger, cesarean birth is indicated.

Definition:

It is the delivery of the fetus through incisions in the abdominal wall and the uterus.

Indications:

The decision to have C-section delivery can depend on the obstetrician, delivery location, and the womans past deliveries or medical history. Some of the main reasons for C-section instead of vaginal delivery include the following:

Cephalopelvic Disproportion (CPD)- occurs when the babys head will not fit through the pelvis. This diagnosis may also be used to indicate the labor that fails to progress.

Fetal distress- the baby is not receiving enough oxygen. It may be indacated by an abnormal fetal tracing or a drop of a fetal heart rate when your heathcare provider listens to the rate during or after a contraction.



Abnomal Position of the Baby- Instead of the babys head presenting first in the pelvis with his/her chin tucked inward , the presenting part of the baby head extended outward, the shoulder, bottom or leg.

Prolapsed Cord- When the umbilical cord in the vagina head of the baby. This most commonly occurs the membranes rupture and the baby is in breech position is not well engaged in the pelvis. This is an emergency and an immediate cs is necessary to prevent the presenting part from compressing the cord and cutting off the oxygen supply to the baby.

Abruptio Placentae- The placenta partially separates from the uterine wall before the baby is born. This is an emergency cs birth is necssary yo prevent the mother from hemrrhaging, which can cause the baby to lose all or part.

Placenta Previa- A condition in which yhe placenta partilly covers the cervix. The degree of severity determines whether cs birth is indicated. If the cervix is completely coverd, a cesarean is mandatory since the placenta would deliver first in avaginal delivery and the baby would lose his/her oxygen supply.

Procedure:

Regional anesthesia is most frequently administered to the patient, who is awake. A low transverse or vertical incision consistent with

estimated size of the fetus is made. The rectus muscles are separated and the peritoneum incised. Hemostasis is assured. The bladder is

reflected from the lower uterine segment, and the uterus is incised. The amniotic sac is entered, and the fluid must be aspirated immediately.

Some surgeons prefer to use the suction tubing without a tip to avoid injury. The fetal head is delivered using manual pressure and counter

pressure on the fundus. Retactors are removed. As soon as the head is delivered the newborns nares are aspirated by bulb syringe

immediately but very gently; the delivery is completed. The umbilical cord is clamp and cut. The infant is received in a sheet and trasferred to

a gowned and gloved member of neonatal team. Standard precauions are observed. Resuscitative measures are provided to the neonate

under warming lamps. The pediatrician determines the infants Apgar score. Vernix caseosa and blood are wiped from the infants. Ointment

(Erythromycin 0.5%) is applied to the conjuctival sacs of the newborn. The placenta is delivered. The uterus is massaged to encouraged it to

contract. Tubal Ligation may be performed. Blood and amniotic fluid are aspirated. Hemostasis is assured. The edges of the uetrine incision

are clamped tio aid in its closure; the uterus and bladder are closed in a single or double layer.The peritoneum at the lower uterine segment is

sutured to its anatomic position. The wound is closed in layers. An abdominal dressing and perineal pad are applied. Warmed blanket is



placed over the mother. The mother and infant, in good condition, are given a moment to bond on the gurney. The infant is rushed to the

neonatal unit to be throughly clean and assessed.

Nursing Responsibilities:

Preoperative care:

• Assess the client knowledge of the procedure.

• The client is NPO after midnight.

• Relieving the patient’s and the family’s anxiety about the outcome with reasonable information

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

• Teach the client post operative expectations

Post operative care:

• Monitor vital sign every 15 minutes until the client is stable.

• Assess the need for pain relief.

• Assess the client for vaginal bleeding



P R O G N O S I S

Usually the high blood pressure, protein in the urine, and other effects of preeclampsia go away completely within 6 weeks after delivery.

However, sometimes the high blood pressure will get worse in the first several days after delivery. A woman with a history of preeclampsia is at risk

for the condition again during future pregnancies. Often, it is not as severe in later pregnancies. Women who have high blood pressure problems

during more than one pregnancy have an increased risk for high blood pressure when they get older.

The fetal prognosis in eclampsia is poor because of hypoxia and consequent fetal acidosis. If premature separation of the placenta from

vasospasm occurs, the fetal prognosis is even graver. If fetus must be delivered before term, all the risks of immaturity will be faced.

In preeclampsia, the fetal mortality rate is approximately 10%. If eclampsia develops, the mortality rate increases to as high as 25%

(Moldenhauer & Sibai, 2003).



B I B L I O G R A P H Y

Books

Doenges, Marilynn E. and et. al. Nurse’s Pocket Guide 11th Ed. Philadelphia: F.A. Davis Company, 2006.

Doenges, Marilynn E. and et. al. Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span. Philadelphia: F.A. Davis

Company, 2006.

Nursing 2009 Student Drug Handbook 10th Ed. Philadelphia: Lippincott Williams and Wilkins, 2009.

Nurse’s Quick Check: Diagnostic Tests. Philadelphia: Lippincott Williams and Wilkins, 2006.

Pacardo, Roselyn S. Compiled Notes on Maternal Nursing with Critical Thinking Exercises, 2010.

Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing & Childbearing Family 5 th Ed., Vol 1., Philadelphia: Lippincott Williams

and Wilkins, 2009.

Porth, Carol Mattson. Pathophysiology Concepts of Altered Health Status 7th Ed. Philadelphia: Lippincott Williams and Wilkins, 2005.

Scanlon, Valerie C. and Tina Sanders. Essentials of Anatomy and Physiology, 5th Ed. Philadelphia: FA Davis Company, 2007.

Internet


http://familydoctor.org/online/famdocen/home/women/pregnancy/complications/064.html




http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm

http://www.preeclampsia.org/research

http://hubpages.com/hub/PREGNANCY-AND-PRE-ECLAMPSIA-RISK-FACTORS

http://www.mayoclinic.com/health/preeclampsia/DS00583/DSECTION=risk-factors


http://www.preeclampsia.org/research

http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm

PREECLAMPSIA

Documents

presence of preeclampsia

severe preeclampsia

mild preeclampsia

risk factors of preeclampsia

n p p q r y pre eclampsia

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medical condition

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