ECLAMPSIA

CASE PRESENTATION

GROUP A

OBJECTIVETo have an overview of what is to be expected

from this discussion

After 1 and a half hour tackling aboutEclampsia the discussant and the observer willbe able to:

Identify precipitating factors regarding eclampsia Fully understand the disease process of eclampsia Recall pass understanding of the cardiovascular and

reproductive system Familiarize management designated of ECLAMPSIA Acknowledge primary independent nursing

intervention to implement on eclamptic patient Provide necessary health teachings in preventing

the occurrence of preeclampsia and eclampsia

ECLAMPSIA Eclampsia is a rare but severe condition that causes

seizures during pregnancy. Seizures are periods of disturbed brain activity that can cause episodes of staring, decreased alertness, and violent shaking (convulsions). Eclampsia affects about one in every 2,000 to 3,000 pregnancies, and it can affect you even if you do not have a history of seizures.

Eclampsia, a life-threatening complication of pregnancy, is a condition that causes a pregnant woman, usually previously diagnosed with preeclampsia (high blood pressure and protein in the urine), to develop seizures or coma). Seizures or coma may be the first recognizable sign that a pregnant woman has had preeclampsia. .

Toxemia of pregnancy is a common name formerly used to describe preeclampsia and eclampsia.

WARNING SIGNS

• severe headaches• blurred or double vision

• seeing spots• abdominal pain

• agitation

CAUSES OF

ECLAMPSIA

Factors that may have contributed to Eclampsia

High Blood Pressure Preeclampsia can cause your blood pressure (the force

of blood against the walls of your arteries) to become high enough to damage your arteries and other blood vessels. This damage may restrict blood flow and produce swelling in the blood vessels of your organs, including your brain. If this swelling interferes with your brain’s ability to function, seizures may occur.

Proteinuria Preeclampsia commonly affects kidney function.

Protein in your urine (proteinuria) is a key sign of the condition. Your kidneys filter waste from your blood but retain beneficial nutrients such as protein in the blood to be redistributed to your body. If the kidneys’ filters (glomeruli) become damaged, protein can leak through these filters and be excreted into your urine.

RISK FACTORS:

having hypertension (high blood pressure) having headaches being over age 35 being under age 20 being pregnant with twins being pregnant for the first time having a history of poor diet or malnutrition having diabetes or another condition that

affects your blood vessels

SYMPTOMS OF ECLAMPSIA

swelling in your face or hands headaches excessive weight gain nausea and vomiting vision problems problems urinating The following are common symptoms of

eclampsia: seizures loss of consciousness agitation headaches or muscle pain

PREVENTION OR TREATMENT:

Detection and management of pre-eclampsia is critical to reduce the risk of eclampsia. Appropriate management of women with pre-eclampsia generally involves the use of magnesium sulphate to prevent convulsions.

PHYSICAL

ASSESSMENTThis are physical manifestation of a patient

who has a case of eclampsia

ACTIVITY / RESTPatient may report…

Weakness, fatigue, shortness of breath, sedentary lifestyle

Patient may exhibit…Elevated heart rate, change in heart rhythm, tachypnea, shortness of breath with exertion.

CIRCULATIONPatient may report…

Intermittent or sustained elevation of diastolic or systolic blood pressure, episodes of palpitations

Patient may exhibits…Elevated blood pressure, postural hypertension, tachypnea,

Skin- Pallor and cyanosis

EGO INTEGRITY Patient may report…

History of personality changes, anxiety, depression

Patient may exhibit… Mood swings, restlessness, irritability, tense facial

muscles ( particularly in the eyes), quick physical movement, accelerated speech pattern

ELIMINATION

Patient may report… Past or present renal insult ( e.g., infection/ obstruction or past history of kidney disease

FOOD/ FLUID Patient may report…

Food preferences, which include high-salt, high-fat, high cholesterol foods ( e.g., fried foods, cheese, eggs), low dietary intake f potassium, calcium and magnesium, Nausea, vomiting, recent weight changes (gain/loss), current/ history of diuretic use

Patient may exhibit…Normal weight or obesity Presence of edema (may be generalized or

dependent), venous congestion

NEUROSENSORY Patient may report…

Fainting spells/ dizzines, episode of numbness, visual disturbance, episode of epistaxis,

Patient may exhibit:Changes in mental status and motor responses, exudates, marked retinal and sclerotic changes with edema

Pain may be reported:Intermittent pain in legs / claudication, severe occipital headache, abdominal pain

ANATOMY AND PHYSIOLOGY

THE FOUR GOALS OF THE TREATMENT OF ECLAMPSIA

•Convulsions suppression•High blood pressure management•Delivery•Monitoring

CONVULSIONS SUPPRESSION

Generic name: magnesium sulfate Classifications Therapeutic: mineral and electrolyte

replacements and supplements Pharmacologic: mineral and electrolytes Indications and usage:

Magnesium Sulfate Injection, USP is suitable for replacement therapy in magnesium deficiency, especially in acute hypomagnesemia accompanied by signs of tetany similar to those observed in hypocalcemia. In such cases, the serum magnesium (Mg++) level is usually below the lower limit of normal (1.5 to 2.5 mEq/liter) and the serum calcium (Ca++) level is normal (4.3 to 5.3 mEq/liter) or elevated. 

Magnesium Sulfate Injection, USP is also indicated for the prevention and control of seizures (convulsions) in pre-eclampsia and eclampsia, respectively.

DOSAGE AND ADMINISTRATION:

In Pre-eclampsia or Eclampsia• The total initial dose is 10 to 14 g of Magnesium Sulfate. • IV 4 to 5 g in 250 mL of 5% Dextrose Injection, USP or

0.9% Sodium Chloride Injection, USP may be infused. • Simultaneously, intramuscular doses of up to 10 g (5 g

or 10 mL of the undiluted 50% solution in each buttock) are given.

• Alternatively, the initial intravenous dose of 4 g may be given by diluting the 50% solution to a 10 or 20% concentration; the diluted fluid (40 mL of a 10% solution or 20 mL of a 20% solution) may then be injected intravenously over a period of three to four minutes.

• Subsequently, 4 to 5 g (8 to 10 mL of the 50% solution) are injected intramuscularly into alternate buttocks every four hours as needed, depending on the continuing presence of the patellar reflex and adequate respiratory function.

•

• Alternatively, after the initial I.V. dose, some clinicians administer 1 to 2 g/hour by constant I.V. infusion. Therapy should continue until paroxysms cease. A serum magnesium level of 6 mg/100 mL is considered optimal for control of seizures. A total daily (24 hr) dose of 30 to 40 g should not be exceeded. In the presence of severe renal insufficiency, the maximum dosage of Magnesium Sulfate is 20 grams/48 hours and frequent serum magnesium concentrations must be obtained.

• Continuous use of Magnesium Sulfate in pregnancy beyond 5 to 7 days can cause fetal abnormalities. 

ADVERSE REACTIONS: flushing, sweating, hypotension, depressed

reflexes, flaccid paralysis, hypothermia, circulatory collapse, cardiac and central nervous system depression proceeding to respiratory paralysis. Hypocalcemia with signs of tetany secondary to Magnesium Sulfate therapy for eclampsia has been reported.

CONTRAINDICATIONS: Parenteral administration of the drug is

contraindicated in patients with heart block or myocardial damage.

Warnings! FETAL HARM: Continuous administration of

Magnesium Sulfate beyond 5 to 7 days to pregnant women can lead to hypocalcemia and bone abnormalities in the developing fetus. These bone abnormalities include skeletal demineralization and osteopenia.

NURSING RESPONSIBILITIES

Closely monitor vital signs. Monitor fetal heart rate Urine output should be maintained at a level of 100 mL or more during the

four hours preceding each dose. Monitoring serum magnesium levels and the patient’s clinical status is

essential to avoid the consequences of over dosage in toxemia. Clinical indications of a safe dosage regimen include the presence of the

patellar reflex (knee jerk) and absence of respiratory depression (approximately 16 breaths or more/minute).

When repeated doses of the drug are given parenterally, knee jerk reflexes should be tested before each dose and if they are absent, no additional magnesium should be given until they return.

Serum magnesium levels usually sufficient to control convulsions range from 3 to 6 mg/100 mL (2.5 to 5 mEq/liter).

The strength of the deep tendon reflexes begins to diminish when magnesium levels exceed 4 mEq/liter.

Reflexes may be absent at 10 mEq magnesium/liter, where respiratory paralysis is a potential hazard.

An injectable calcium salt should be immediately available to counteract the potential hazards of magnesium intoxication in eclampsia.

Generic name: diazepam Brand name: Dizac Classifications:

Therapeutic: antianxiety agents, anticonvulsants, sedative/hypnotics, skeletal muscle relaxants (centrally acting)

Pharmacologic: benzodiazepines Schedule IV Pregnancy Category D  ACTIONS:

-Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter

-Produces skeletal muscle relaxation by inhibiting spinal polysynaptic afferent pathways

-Has anticonvulsants properties due to enhanced presynaptic inhibition.

Therapeutic Effects: -Relief of anxiety -Sedation -Amnesia -Skeletal muscle relaxation -Decreased seizure activity

  ROUTE AND DOSAGE:

Anti-anxiety/Anticonvulsant -PO (Adults): 2-10 mg 2-4 times daily □Status Epilepticus/Acute Seizure Activity -IV (Adults): 5-10 mg, may repeat q 10-15 min to

a total of 30 mg, may repeat regimen again in 2-4 hr (IM route may be used if IV route unavailable); larger doses may be required.

□Skeletal Muscle Relaxation

-PO (Adults): 2-10 mg 3-4 times daily or 15-30 mg of extended-release form once daily.

-IM, IV (Adults): 5-10 mg; may repeat in 2-4 hr (larger doses may be required for tetanus).

-IM, IV (Geriatric Patients or Debilitated Patients): 2-5 mg; may repeat in 2-4 hr (larger doses may be required for tetanus).

□Psychoneurotic Reactions -IM, IV (Adults): 2-10 mg, may be repeated in 3-4 hr.

ADVERSE REACTIONS AND SIDE EFFECTS

•CNS: dizziness, drowsiness, lethargy, depression, hangover, headache, paradoxical excitation

•EENT: blurred vision •Resp: respiratory depression •CV: hypotension (IV only) •GI: constipation, diarrhea, nausea, vomiting •Derm: rashes •Local: pain (IM), phlebitis (IV), venous thrombosis •Misc: physical dependence, psychological

dependence, tolerance.

CONTRAINDICATION(S):

•Hypersensitivity •Cross-sensitivity with other benzodiazepines may

occur •Comatose patients •Pre-existing CNS depression •Uncontrolled severe pain •Narrowangle glaucoma •Pregnancy or lactation •Some products contain alcohol, propylene glycol, or

tartrazine and should be avoided in patients with known hypersensitivity or intolerance.

Use Cautiously in: •Hepatic dysfunction •Severe renal impairment •History of suicide attempt or drug dependence •Geriatric or debilitated patients (dosage reduction

required) •Children (dosage should not exceed 0.25 mg/kg).

NURSING RESPONSIBILITIES:

Assessment: ■General Info: Monitor blood pressure, pulse, and respiratory rate

prior to and periodically throughout therapy frequently during IV therapy.

■Assess IV site frequently during administration; diazepam may cause phlebitis and venous thrombosis.

■Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. Observe depressed patients closely for suicidal tendencies.

■Anxiety: Assess degree of anxiety and level of sedation (ataxia, dizziness, slurred speech) prior to and periodically throughout therapy.

■Seizures: Observe and record intensity, duration, and location of seizure activity. The initial dose of diazepam offers seizure control for 15-20 min after administration. Institute seizure precautions.

■Muscle Spasms: Assess muscle spasm, associated pain, and limitation of movement prior to and throughout therapy.

■Alcohol Withdrawal: Assess patient experiencing alcohol withdrawal for tremors, agitation, delirium, and hallucinations. Protect patient from injury.

■Lab Test Considerations: Hepatic and renal function and CBC should be evaluated periodically throughout course of prolonged therapy.

HIGH BLOOD PRESSURE MANAGEMENT

GENERIC NAME: Hydralazine Hydrochloride Class: Peripheral vasodilator vasodilator that works by relaxing

the muscles in your blood vessels to help them dilate (widen). This lowers blood pressure and allows blood to flow more easily through your veins and arteries. Used to treat high blood pressure (hypertension).

SIDE EFFECTS: Get emergency medical help if you have any of these signs of an

allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

Call your doctor at once if you have a serious side effect such as: fast or pounding heartbeats; swelling in your face, stomach, hands, or feet; numbness, burning, pain, or tingly feeling; feeling like you might pass out; confusion, unusual thoughts or behavior; pale skin, easy bruising; painful or difficult urination; dark-colored urine; urinating less than usual or not at all; or joint pain or swelling with fever, chest pain, weakness or tired feeling.

Less serious side effects may include: nausea, vomiting, loss of appetite; diarrhea, constipation; headache; dizziness; anxiety; muscle or joint pain; runny or stuffy nose; or mild itching or skin rash.

IMPORTANT INFORMATION

You should not use this medication if you are allergic to hydralazine, or if you have coronary artery disease, or rheumatic heart disease affecting the mitral valve.

Before taking hydralazine, tell your doctor if you have kidney disease, lupus, angina pectoris (chest pain), or if you have ever had a stroke.

While taking hydralazine, avoid getting up too fast from a sitting or lying position, or you may feel dizzy. Get up slowly and steady yourself to prevent a fall.

Call your doctor at once if you have a serious side effect such as fast or pounding heartbeats, swelling, numbness or tingling, dark-colored urine, joint pain or swelling with fever, chest pain, weakness or tired feeling, and urinating less than usual or not at all.

To be sure this medication is helping your condition and is not causing harmful effects, your blood pressure will need to be checked often. You may also need occasional blood tests. Do not miss any scheduled appointments.

Keep using hydralazine as directed, even if you feel well. High blood pressure often has no symptoms, so you may not know when your blood pressure is high. You may need to use blood pressure medication for the rest of your life.

Generic Name: Calcium GluconateBrand Name: KalcinateClassifications: fluid and electrolytic and water balance agent; replacement solutionPregnancy Category: B

Availability   500 mg, 650 mg, 975 mg, 1 gm tablets;  10% injection

Actions Calcium is an essential element for regulating the excitation

threshold of nerves and muscles, for blood clotting mechanisms, cardiac function (rhythm, tonicity, contractility), maintenance of renal function, for body skeleton and teeth. Also plays a role in regulating storage and release of neurotransmitters and hormones; regulating amino acid uptake and absorption of vitamin B12, gastrin secretion, and in maintaining structural and functional integrity of cell membranes and capillaries. Calcium gluconate acts like digitalis on the heart, increasing cardiac muscle tone and force of systolic contractions (positive inotropic effect).

Therapeutic effects: Rapidly and effectively restores serum calcium levels in

acute hypocalcemia of various origins and effective cardiac stabilizer under conditions of hyperkalemia or resuscitation.

Uses: Negative calcium balance (as in neonatal tetany, hypoparathyroidism, vitamin D deficiency, alkalosis). Also to overcome cardiac toxicity of hyperkalemia, for cardiopulmonary resuscitation, to prevent hypocalcemia during transfusion of citrated blood. Also as antidote for magnesium sulfate, for acute symptoms of lead colic, to decrease capillary permeability in sensitivity reactions, and to relieve muscle cramps from insect bites or stings. Oral calcium may be used to maintain normal calcium balance during pregnancy, lactation, and childhood growth and to prevent primary osteoporosis. Also in osteoporosis, osteomalacia, chronic hypoparathyroidism, rickets, and as adjunct in treatment of myasthenia gravis and Eaton-Lambert syndrome.

Contraindicatons   Ventricular fibrillation, metastatic bone disease, injection into myocardium; administration by SC or IM routes; renal calculi, hypercalcemia, predisposition to hypercalcemia (hyperparathyroidism, certain malignancies); pregnancy (category B).

Cautious use Digitalized patients, renal or cardiac insufficiency, sarcoidosis, history of lithiasis, immobilized patients; lactation.

Route & Dosage Supplement for Osteoporosis

adult: PO  1–2 g b.i.d. to q.i.d.IV 7 mEq q 1–3d

Oral Ensure that chewable tablets are chewed or crushed

before being swallowed with a liquid. Give with meals to enhance absorption.

Intravenous      PREPARE  direct: May be given

undiluted intermittent: /continuous: May be diluted in 1000 mL of NS.

ADMINISTER  direct:  Give direct IV at a rate of 0.5 mL or a fraction thereof

over 1 min. Do not exceed 2 mL/min. intermittent: /continuous: Give slowly, not to exceed 200 mg/min, through a small-bore needle into a large vein to avoid possibility of extravasation and resultant necrosis. With children, scalp veins should be avoided.

Avoid rapid infusion. High concentrations of calcium suddenly reaching the heart can cause fatal cardiac arrest.

Indomethacin.   Injection should be stopped if patient complains of

any discomfort. · Patient should be advised to remain in bed for 15–30 min or more following injection, depending on response.

Adverse Effects BodyWhole: Tingling sensation. With rapid IV,

sensations of heat waves (peripheral vasodilation), fainting.GI: PO preparation: Constipation, increased gastric acid secretion.CV: (With rapid infusion) hypotension, bradycardia, cardiac arrhythmias, cardiac arrest,Skin: Pain and burning at IV site, severe venous thrombosis, necrosis and sloughing (with extravasation).

NURSING IMPLICATIONS  

Assessment & Drug Effects Assess for cutaneous burning sensations and

peripheral vasodilation, with moderate fall in BP, during direct IV injection.

Monitor ECG during IV administration to detect evidence of hypercalcemia: decreased QT interval associated with inverted T wave.

Observe IV site closely. Extravasation may result in tissue irritation and necrosis.

Monitor for hypocalcemia and hypercalcemia. Lab tests: Determine levels of calcium and

phosphorus (tend to vary inversely) and magnesium frequently, during sustained therapy. Deficiencies in other ions, particularly magnesium, frequently coexist with calcium ion depletion.

Patient & Family Education Report S&S of hypercalcemia  promptly to

your care provider. Milk and milk products are the best sources

of calcium (and phosphorus). Other good sources include dark green vegetables, soy beans, tofu, and canned fish with bones.

Calcium absorption can be inhibited by zinc-rich foods: nuts, seeds, sprouts, legumes, soy products (tofu).

Check with physician before self-medicating with a calcium supplement.

Do not breast feed while taking this drug without consulting physician.

MONITORING

NURSING CARE

PLANNursing intervention intended to patient who

has Eclampsia

INEFFECTIVE TISSUE PERFUSION

Related to vasoconstriction of blood vessels secondary to

pregnancy induce hypertension

ASSESSMENTSubjective Data:

“nanghupong akong mga tiil ug kamot ma’am.” as verbalized

Objective data: Patient is lethargic, Restless, Anxious, With peripheral edema on both arms and feet Pallor, Slight headache, With epigastric pain

DESIRED OUTCOME Within 8 hours of rendering holistic nursing

intervention, the patient will be able to… illustrate adequate tissue perfusion of the

extrenities Verbalized feeling of comfort and relief

INTERVENTIONS

Inspect patient for signs of pallor, cyanosis, mottling, and cool/clammy skin.

Monitor blood pressure every 15 mins.

Note presence and quality of central and peripheral pulses

Diminished cardiac output may be evidence by decreased skin per fusion

Comparison of pressure provides a picture of vascular involvement

Bounding pressure may be observed /palpated. Pulses in legs/ feet may be diminished, reflecting effect of vasoconstriction

INTERVENTION Note dependent /

general edema  Provide calm, restful

surrounding, minimizing environmental activity and noise

Maintain activity restriction such as strict bed rest and assist patient in self-care activities

Provide comfort measures

May indicate heart failure, renal or vascular impairment.

Help reduced sympathetic stimulation; promotes relaxation

Reduce physical stress and tension that affect blood pressure and the course of hypertension

Decreased discomfort and may reduced sympathetic stimulation

EVALUATION

After 8 hours of rendering nursing intervention, the patient was able to...

Experience comfort very after contractions Verbalizes slight relief from tension of anxiety

 

RISK FOR

INJURYRelated to sudden episode of seizure

secondary to eclampsia

ASSESSMENT

SUBJECTIVE: -“ma’am patulon ra ba na siya” as verbalized by the

husband, Ramon Magsaysay.

Objective Data: Patient is lethargic, Restless, Anxious, With peripheral edema on both arms and feet Pallor, Slight headache, With epigastric pain

DESIRED OUTCOMEwithin 9 hours of rendering

nursing care, the patient will be able to :

Restrain self from injury during episode of seizure.

Maintain safety at all times.Verbalize importance of administrating anticonvulsants.

INDEPENDENT INTERVENTION

Monitor patient’s vital signs.

Monitor or document seizure activity.

 

For baseline data for subsequent evaluation

To assess sudden episode of seizure relative to decreased magnesium level, hypoglycaemia, increased blood pressure.

INDEPENDENT INTERVENTIONS

Maintain patient’s airway if patient is experiencing seizure.

Padded side rail and lower bed position.

Assist patient with ambulation or position patient on a stretcher.

to ensure adequate gas exchange.

  To ensure safety at

all time To prevent fall with

resultant injury

DEPENDENT INTERVENTION

EVALUATIONAfter 8 hours of rendering holistic nursing intervention, the patient was able to...

Maintained stability throughout the labor process

Prevented injury due to episode of seizures