Final Copy for Pre-eclampsia

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PRE-ECLAMPSIA

GROUP 2

ABBAS,SITTIE OMAIMAHALMOJALLAS, DONNA

BADO, MARIEJOCALLET, JOSEPH

DEMIGILLO, GRACEGALEON, MAX ANTHONY

GENTALLAN, SHEENA CALIREMADRIA, JERYL

MARTURILLAS, KHALIDPACOT, LEONARD MITCHEL

REYES, HAZIEL MARIETOGONON, ROSE

ZERNA, ZOILO

3A

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OUTLINE: Pages

I. OBJECTIVES ................................................................................................3II. INTRODUCTION .........................................................................................4III. DEFINITION OF TERMS ..................................................................................7IV. ASSESSMENT

A.PEROS ................................................................................................8B.DIAGNOSTIC TEST ..................................................................................16

V. NORMAL ANATOMY & PHYSIOLOGY .............................................................28VI. RISK FACTORS & PATHOPHYSIOLOGY .............................................................40VII. NURSING MANAGEMENT

A.NCP..............................................................................................................41B.HEP .............................................................................................................C. DP .............................................................................................................

VIII. MEDICAL & SURGICAL MANAGEMENT ............................................................IX. PROGNOSIS .................................................................................................X. BIBLIOGRAPHY ................................................................................................

PRE-ECLAMPSIA Page 2

I. OBJECTIVES

After the case sharing, the students will be able to:

1. Understand what Preeclampsia is all about and know its different types and classification.2. Know the normal anatomy and physiologic changes during pregnancy and incorporate it on the disease.3. Identify several risk factors that will affect the occurrence of Preeclampsia and the disease process. Identify the prognosis of the patient having

Preeclampsia and to know the percentage of recovery.4. Identify the prognosis of the patient having Preeclampsia and to know the percentage of recovery.5. Determine problems that will be manifested during the malady and organize nursing care plans and actions.6. Be familiar with the treatment which will be needed to prevent necessary complication of the disease.7. To know some health teaching that the client may need in state of Preeclampsia.

After the case sharing, the presenters will be able to:

1. Discuss to the listeners effectively the parts of the case sharing from the introduction until the prognosis.2. Use different teaching techniques to get the attention of the listeners.3. Manifest confidence, coherence, logic and effective audience management.4. Make sure that the presentation of case will not be boring and may inject ice breakers to help increase attention span.5. Answer effectively the question raised for clarifications, corrections and learning purpose.6. Encouraged participation and interaction from the listeners for learning purposes.


II. INTRODUCTIONPre-eclampsia is a common problem during pregnancy. The condition sometimes referred to as pregnancy-induced hypertension, defined by high blood

pressure and excess protein in the urine after 20 weeks of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur

earlier. Often, pre-eclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications

for both mother and baby. Women with Pre-eclampsia will often also have swelling in the feet, legs, and hands. The symptoms of pre-eclampsia rapid weight gain

caused by significant increase in bodily fluid, abdominal pain, severe headaches, a change in reflexes, reduced output of urine or no urine, dizziness, and excessive

vomiting.

The exact causes of pre-eclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uteruses

possible causes.

The only real cure for pre-eclampsia and eclampsia is to deliver the baby, but this depends on the stage of pregnancy because being born prematurely can be

dangerous. Babies may also be 'small-for-dates' because of growth problems.

Apart from Caesarean section or induction of labor (and therefore delivery of the placenta), there is no known cure. It is the most common of the dangerous

pregnancy complications; it may affect both the mother and the unborn child.

Pre-eclampsia or eclampsia is also common among Filipino women. Most women enter pregnancy in apparent good health and achieve a normal pregnancy

and delivery without complications. In few women however, for reasons which are usually unclear, unexpected deviations, from the course of normal pregnancy

develops such complications that threaten the pregnancy outcome, the women health or both (Pillitteri, 1999).

There are various abnormalities, which fall under the category of pregnancy complications. One major complication is the mild or severe pre-eclampsia.


Mild preeclampsia Severe preeclampsia

BP of 140/90Absence visual problem

Absent headacheTransient irritability

Normal reflexionWeight gain of 2 lbs. per week on the 2nd trimester and 1 lbs. per week

on 3rd trimesterSlight edema in upper extremities and face

1+ to 2+ proteinuria on random

BP of 160/110Blurry vision, blind spots

Severe headacheSevere irritability

Hyperreflexia w/ possible ankle clonusweight gain of 3 lbs. per week on the 2nd trimester and 3rd trimester

generalized edema3+ to 4+ proteinuria on random

Although many pregnant women with high blood pressure have healthy babies without serious problems, high blood pressure can be dangerous for both

the mother and the fetus. Women with pre-existing, or chronic, high blood pressure are more likely to have certain complications during pregnancy than those

with normal blood pressure. However, some women develop high blood pressure while they are pregnant (often called gestational hypertension).

The effects of high blood pressure range from mild to severe. High blood pressure can harm the mother's kidneys and other organs, and it can cause low

birth weight and early delivery. In the most serious cases, the mother develops preeclampsia-or "toxemia of pregnancy"-which can threaten the lives of both the

mother and the fetus.

Around 1 in 100 women with pre-eclampsia go on to develop a serious complication called eclampsia. This can happen at any stage during pregnancy, but

it is more common during the last three months, and the first 48 hours after birth. Eclampsia is a type of seizure that can be life-threatening.


In developing nations, the incidence of the disease is reported to be 4-18%, with hypertensive disorders being the second most common obstetric cause of

stillbirths and early neonatal deaths in these countries as high as 18% in some settings in Africa while in 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. According to Safe Motherhood stated that over 585,000 maternal annually (3), 13%, or 76,050, are

due to eclampsia.


III. DEFINITION OF TERMSCerebral edema: Accumulation of excessive fluid in the substance of the brain. The brain is especially susceptible to injury from edema, because it is located within a confined space and cannot expand.

Diabetes: is a condition whereby the body is not able to regulate levels of glucose (a sugar) in the blood, resulting in too much glucose being present in the blood.

Eclampsia: is an extension of preeclampsia and is characterized by the client experiencing seizures.

Fetal distress: Compromise of the fetus during the antepartum period (before labor) or intrapartum period (birth process). The term "fetal distress" is commonly used to describe fetal hypoxia (low oxygen levels in the fetus).

Glomerular filtration rate (GFR): is a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute.

High blood pressure (HBP) or hypertension: means high pressure (tension) in the arteries.

Obesity: is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems.

Pre-eclampsia: is a medical condition in which hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine.

Pregnancy Induced Hypertension (PIH): High arterial blood pressure, in adults, usually defined as pressures exceeding 140/90.

Proteinuria: Excess protein in the urine. Some protein is normal in the urine. Too much means protein is leaking through the kidney, most often through the glomeruli. The main protein in human blood and the key to the regulation of the osmotic pressure of blood is albumin

Pulmonary edema: is an abnormal build-up of fluid in the air sacs of the lungs.


IV. ASSESSMENTA. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM

Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical

assessment should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part. It

is the first step in the nursing process. It provides the foundation for the nursing care plan in which your observations play an integral part in the assessment, intervention, and

evaluation phases. (Wikipedia.org)

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.


Through physical assessment and asking questions to the patient, we can be able to formulate nursing management needed for the patient. First, we must to differentiate

the stages of preeclampsia by its objective cues and possible subjective cues.We have mild preeclampsia and severe preeclampsia. Untreated preeclampsia may progress to

eclampsia.( Physical Examination and health assessment by Jarvis. Page 830).

Mild Preeclampsia

Systems Mild Preeclampsia

Physical Examination

Mild Preeclampsia

Review of Systems

Problem Identified

General Appearance A weight gain of more than 2 lb/wk in the second trimester

Weight gain of more than 1lb/wk in the third trimester

Edema begins to accumulate in the upper part of the body: slight pitting edema +1

Patient may report of headache absent or transient and dizziness

Fluid volume excess

Risk for injury

Neurologic Reflexes may be normal (using the reflex hammer, check the biceps, patellar, and ankle deep tendon reflexes.)

Patient may report for Headache

Patient may report for dizziness

Risk for Injury: Fall

Head/Hair/Face Edema may be noted in the face Patient may report of headache absent or transient and dizziness

Fluid volume excess

Disturbed Body Image


Chloasma is present

Risk for injury

EENT None Patient may report no visual disturbances at this stage

No problems identified

Neck The thyroid may be palpable( normal findings) None No problems identified

Thorax/Lungs none none No problems identified

Back none none No problems Identified

Breast and Axilla Dark areola

The breast are enlarged

none No problems identified

Cardiovascular/Peripheral Vascular Blood reading of 140/90 mmHg x 2, ≥4-6 hr apart, no more than 1 wk apart

CRT is > 3 seconds

Patient may report of headache and dizziness

Decreased cardiac output

Ineffective tissue perfusion

GIT none Patient may report no absent epigastric pain at

No problems identified


this stage

GUT Quantitative 24-hr urine analysis: Proteinuria of ≥0.3g in a 24-hr specimen

Qualitative dipstick: ≥30 mg/dl (≥/+) on dipstick

Urine output: Output matching intake, ≥30 ml/hr or <650 ml/24hr

Serum Creatinine: Normal

None Fluid volume deficit

Musculoskeletal Reflexes may be normal Patient may report limitation of motion due to edema that begins to accumulate in the upper part of the body

Activity intolerance

Extremities Edema begins to accumulate in the upper part of the body: slight pitting edema +1

CRT is > 3 seconds

Patient may report limitation of motion due to edema that begins to accumulate in the upper part of the body



Hematologic None None No problems identified

Severe Preeclampsia

Systems Severe Preeclampsia Severe Preeclampsia Problem Identified


Physical Examination

Review of Systems

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

Generalized Edema

Extreme edema will be noticeable as puffiness in a woman’s face and hands and as well as in the lower extremities: the lower extremities pitting edema grade is 2+ to 4+

Patient may verbalize body weakness

Patient may report of severe headache

Fluid volume excess

Risk for injury


Neurologic Hyperreflexia ≥3+, possible ankle clonus

In this picture, it showed that ankle clonus is elicited by stretching the Archille's tendon by dorsiflexing the foot

Patient may report severe headache

Risk for injury: fall

Head/Hair/Face Edema noted in the face Severe headache Altered comfort

Fluid volume excess

Risk for injury

EENT scotoma(blind spots) Blurred vision photophobia

Risk for injury


photophobia Seeing spots before the eyes scotoma(blind spots)

Disturbed sensory perception

Thorax/Lungs Shortness of breath

Dyspnea, crackles, wheezing

Patient may complain of having shortness of breath and dyspnea.

Ineffective breathing pattern

Ineffective airway clearance

Breast and Axilla Dark areola

The breast are enlarged

None No problems identified

Cardiovascular/Peripheral Vascular Rise to ≥160/110 mmHg on two separate occasions

CRT is > 3 seconds

Patient may report severe headache

Decreased cardiac output

Altered comfort

Risk for injury


GIT Patient may show facial grimace The patient may report nausea and vomiting

The patient may experience epigastric pain at RUQ

Altered comfort: Acute pain

Nutrition imbalanced: less than body requirements


GUT Quantitative 24-hr urine analysis: Proteinuria of > 2g in 24hr

Qualitative dipstick: 2+ to 3+ protein on dipstick

Urine output: 20ml/hr or < 400ml to 500 ml/hr

Oliguria( 500ml or less in 24hours) Serum Creatinine: Elevated serum

creatinine more than 1.2 mg/dl

The patient may verbalize small amount of urine

Fluid volume deficit

Musculoskeletal Hyperreflexia ≥3+, possible ankle clonus

The patient may report on twitching or spastic tendencies

Risk for injury: fall

Extremities Extreme edema will be noticeable as puffiness in a woman’s face and hands and as well as in the lower extremities.

CRT is > 3 seconds

Patient may report upper extremities edema as “my rings are so tight, I can’t get them off” and facial edema as “when I wake in the morning, my eyes are swollen shut or I can’t talk until I walk around a while.

Patient may report edema in the lower extremities by difficulty fitting into their bedroom slippers or kicking of their shoe at dinner time and then not being able to put them back on again.




Hematologic Thrombocytopenia (less than 100,000/mm3

None Increasing the risk of bleeding during and after labor

B. DIAGNOSTIC TEST

DIAGNOSTIC TEST PURPOSE NORMAL VALUES SIGNIFICANCE NURSING CONSIDERATIONS

BLOOD UREA NITROGEN

-To evaluate kidney function and aid in the diagnosis of renal disease

-To aid in the assess of hydration

-8 to 20 mg/dl Abnormal Results:

-Elevated levels: renal disease, reduced renal blood flow (e.g. caused by dehydration), urinary tract obstruction, and increased protein catabolism (such as burns)

-Low levels: suggest severe hepatic damage, malnutrition, and over hydration

-Apply direct pressure to the bleeding site.

-Inform the patient that he may resume taking his usual medications after the test.

BILIRUBIN, SERUM, DIRECT AND

-To evaluate liver function

To aid in the differential diagnosis of jaundice and monitor its progress

-In adults, normal indirect serum bilirubin levels are 1.1 mg/dl (SI, 19umol/L)

Abnormal Results:

-Elevated indirect serum bilirubin levels usually indicate hepatic damage

-Apply direct pressure to the venipuncture site to stop bleeding.


INDIRECT -To aid in the diagnosis of biliary obstruction and hemolytic anemia

-To determine whether a neonate requires an exchange transfusion or phototherapy because of dangerously high unconjugated bilirubin levels

-High levels of indirect bilirubin are also likely in severe hemolytic anemia

-If hemolysis continues, direct and indirect bilirubin levels may rise

-Other causes of elevated indirect bilirubin levels include congenital enzyme deficiencies such as Gilbert syndromeElevated direct serum bilirubin levels usually indicate biliary obstruction

-If obstruction continues, direct and indirect bilirubin levels may rise

-In severe chronic hepatic damage, direct bilirubin concentrations may return to normal or near normal levels, but indirect bilirubin levels remain elevatedthan 0.5 mg/dl(SI,<6.8umol/L)

SERUM CREATININE-To assess glomerular filtration

-To screen for renal damage

-In men, 0.8 to 1.2 mg/dl (SI, 62 to 115 umol/L)

-In women, 0.6 to 0.9 mg/dL (SI, 53 to 97 umol/L)

Abnormal Results:

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

-Apply direct pressure to the venipuncture site to stop bleeding.

-Inform the patient that he


-Elevated levels may also indicate gigantism and acromegaly

may resume his usual medications after 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 (SI, 3 to 6 min) in the template method; 3 to 6 minutes in the ivy method; and 1 to 3 minutes (SI, 1 to 3min) in the duke method.

Abnormal Results:

-Prolonged bleeding time may indicate disorders linked to thrombocytopenia, such as hodgkin’s disease, acute leukemia, disseminated intravascular coagulation, hemolytic disease of the newborn, schonlein-henoch purpura, severe hepatic disease (cirrhosis, for example), or severe deficiency of factors I,II,V,VII,VIII,IX, and XI.

-In a patient with a bleeding tendency (hemophilia), maintain a pressure bandage over the incision for 24 to 48 hours to prevent further bleeding.

-Check the test area frequently; keep the edges of the cuts aligned to minimize scarring.

-Instruct the patient that he/she may resume his/her medication after the tests

HEMATOCRIT

-To aid diagnosis of polycythemia, anemia, or abnormal states of hydration

-To aid in the calculation of erythrocyte indices

-HCT is usually measured electronically; electronic results are 3% lower than manual measurements which trap plasma in the column of packet RBC’s

-In men, 42% to 52% (SI, .42 to 0.52)

-In women, 36% to 48% (SI, 0.36 to 0.48)

Abnormal Results:

-Low HCT suggests anemia, hemodilution, or massive blood loss

-High HCT indicates polycythemia or hemoconcentration caused by blood loss and dehydration.

-Ensure subdermal bleeding has stopped before removing pressure

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


UNSTABLE HEMOGLOBIN -To detect of hemoglobin. -Heat stability test result is negative, isopropanol solubility test result is stable

Abnormal Results:

-A positive heat stability test result or unstable, solubility test result, especially with hemolysis, strongly suggest the presence of unstable Hb.

-Make sure the subdermal bleeding has stopped before removing pressure

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

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

PLATELET COUNT

-To evaluate platelet production

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

-To diagnose and monitor severe thrombocytosis or thrombocytopenia.

Adults: 140,000 to 400,000/ul (SI, 140 to 400x10/L)

Abnormal Results:

-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 (thrombocytopenia, 80 to 100 million platelets per ml) can result from aplastic or hypoplastic bone marrow; infiltrative bone marrow disease, such as leukemia, or disseminated infection.

-An increased count

-Make sure that subdermal bleeding has stopped before removing pressure

-Tell the patient that he may resume any medications stopped before the test

-If a large hematoma develops, monitor pulses distal to the venipuncture site


(thrombocytosis can result from hemorrhage, infectious disorders, iron deficiency anemia, recent surgery, pregnancy, splenectomy or inflammatory disorders. In such cases, the platelet count returns to normal after the patient recovers from the primary disorder

PROTHROMBIN TIME

-To evaluate the extrinsic coagulation system (factors V,VII, and prothrombin and fibrinogen)

-To monitor response to oral anticoagulant therapy

-PT should be 10-14 seconds (SI. 10 to 14s) depending on the source of tissue thromboplastin and the type of sensing devices used to measure clot formation

-In a patient receiving oral anticoagulants, PT should be from 1 to 2 ½ times the normal control value

Abnormal Results:

-Prolonged PT may indicate deficiencies in fibrinogen, prothrombin, factors V, VII, or X (specific assays can pinpoint such deficiencies), or vitamin K. it may also result from ongoing oral anticoagulant therapy

-A prolonged PT that exceeds 2 ½ times the control value usually indicates abnormal bleeding

-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 distal to the site.

Abnormal Results:


URIC ACID, URINE

-To detect enzyme deficiencies and metabolic disturbances (such as gout) that affect uric acid production

-To help measure the efficiency of renal clearance and to determine the risk of stone formation

-250 to 750 mg/24 hours (SI, 1.48 to 4.43 mmol/d), depending on patient’s diet.

-Increased levels may result from chronic myeloid leukemia, polycythemia, vera, multiple myeloma, early remision in pernicious anemia, lymphosarcoma and lymphatic leukemia during radiotherapy, or tubular reabsorption defects, such as fanconi’s syndrome and hepatolenticular degeneration

-Decreased levels occur in gout (when uric acid production in normal but excretion inadequate) and in severe renal damage such as that resulting from chronic glorulonephritis, diabetic glomerulosclerosis, and collagen disorders

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

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

-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


estriol levels. high maternal serum glucose level.

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.

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

SERUM URIC ACID-To confirm the diagnosis of gout

-To help detect renal dysfunction

In men, 3.4 to 7 mg/dlIn women,2.3 to 6 mg/dl

Abnormal Results:

-Increased uric acid levels may indicate gout or impaired kidney functions.

-Levels may also rise in heart failure, glycogen storage disease (type 1 von Gierke’s disease), infection, hemolytic and sickle cell anemia, polycythemia, neoplasms, and psoriasis

-Low uric acid levels may indicate defective tubular absorption such as acute hepatic atrophy.

-Apply direct pressure to the venipuncture site until bleeding stops.

-Inform the patient that he may resume he usual diet and medications stopped before the test.


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 yellowOdor: slightly aromaticAppearance: clearSpecific gravity: 100

Protein - 0-8 mg/dl - 50-80 mg/24 hr (at rest) - <250 mg/24 hr (during exercise)

Tests Results and Clinical SignificanceProtein

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.

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


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

Preeclampsia 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.


V. NORMAL ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM

The Heart

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

to resemble the chest. The heart has chambers divided into four cavities with the right and left chambers

(atria and the ventricles) separated by the septum.The Blood Vessels

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

that carries blood away from the heart. It carries oxygenatedblood.


Small arteries are called arterioles. Veins, on the other hand are vessels that carries blood toward the heart. It contains the deoxygenated blood. Small veins are

called venules. Often, very large venous spaces are called sinuses. Lastly, capillaries are microscopic vessels that carry blood from small arteries to small veins

(arterioles to venules) and back to

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

Tunica adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a connective tissue that helps hold vessels open and

prevents tearing of the vessel wall during body movement. Tunica media is a smooth muscle, sandwiched together with a layer of elastic connective tissue. It

permits changes of the blood vessel diameter. It allows the constriction and dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which

in Latin means inner coat, is made up of endothelium that is continuous with the endothelium that lines the heart. In arteries, it provides a smooth lining.

However in veins it maintains the one-way flow of the blood. The endothelium, which makes up the thin coat of the capillary, is important because the thinness of

the capillary wall allows the exchange of materials between the blood plasma and the interstitial fluid of the surrounding tissues. There are two circulatory routes

of blood as it flows through the blood vessels: the systemic and the pulmonary circulation. In systemic circulation, blood flows from the left ventricle of the heart

through blood vessels to all parts of the body (except gas exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous

blood moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged; oxygenated blood returns to

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

Blood distribution patterns, as well as BP can be influenced by factors that control changes in the diameter of arterioles. Such factor might be said to

constitute the vasomotor control mechanism. Like most physiological control mechanisms, it consists of many parts. An area in the medulla called vasomotor

center/ vasoconstrictor center will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in smooth muscle surrounding resistance vessels,

arterioles, and veins of “the blood reservoir” causing their constriction thus the vasomotor control mechanism plays an important role both in the maintenance of

the general BP and in the distribution of blood to areas of special need. Venous return of the Blood


Venous return refers to the amount of blood that is returned to the heart by the way of veins. Various factors influence venous return, including

the operation of venous pumps that maintains the pressure gradients necessary to keep blood moving into the central veins and from there the atria of the heart.

Changes in the total volume of blood vessels can also alter the venous return. The return of venous blood to the heart can be influenced by the factors that

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

heart. The mechanism that change the total blood volume most quickly, making them most useful in maintaining constancy of blood flow, are those that cause

water to quickly move into the plasma or out of the plasma. Most of the mechanisms that accomplish such changes in plasma volume operate by altering the

body’s retention of the water.

The primary mechanisms for altering the water retention in the body- they are the endocrine reflexes in the body. One is the ADH mechanism is

released in the neurohypophysis and acts on the kidneys in a way that reduces the amount of water lost by the body. ADH does this by increasing the amount of

water that kidneys reabsorb from urine before the urine is excreted from the body. The more ADH is secreted, the more water will be reabsorbed into the blood,

and the greater the blood plasma volume will become. Another mechanism that changes the blood plasma volume is the renninangiotensin mechanism of

aldosterone secretion. Renin is an enzyme that is released when the blood pressure in the kidney is low. Renin triggers a series of events that leads to the

secretion of aldosterone. Aldosterone promotes sodium retention by the kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back

into the blood plasma- but only when ADH is present to permit the movement of water. Thus, low blood pressure increases the secretion of aldosterone, which in

turn stimulates the retention of water and thus an increase in blood volume. Another effect of reninangiotensin is the vasoconstriction of blood vessels caused by

an intermediate compound called angiotensin II. This complements the volume-increasing effects of themechanism and thus also promotes an increase in overall

blood flow. Precision of blood volume control contributes to the precision in controlling venous return, which in return yields to the precise overall control of

blood circulation

ENDOCRINE SYSTEM


The endocrine system performs their regulatory functions by means of chemical messenger sent to specific cells. The endocrine system, secreting

cells send hormones by way of the bloodstream to signal specific target cells throughout the body. Hormones diffuse into the blood to be carried to nearly every

point in the body. The endocrine glands secrete their products, hormones, directly into the blood. There are two classifications of hormones: steroid hormones

and non-steroid hormones. The steroid hormones which are manufactured by the endocrine cells from cholesterol, is an important lipid in the human body. Non-

steroid hormones are synthesized primarily from amino acids rather from the cholesterol. Non-steroid hormones are further subdivided into two: protein

hormones and glycoprotein hormones. Aldosterone Its primary function is the maintenance of the sodium homeostasis in the blood byincreasing the sodium

reabsorption in the kidneys. It is secreted from the adrenal cortex; it triggers the release of ADH which results to the conservation of water by the kidney.

Aldosterone secretion is controlled by the renninangiotensin mechanism. Estrogen 29. It is secreted by the cells of the ovarian cells that promote and maintain

the female sexual characteristics.

LIVER

The liver is the largest organ in the body, normally weighing about 1.5kg (although this can increase to over

10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main

functions include:

Bile production

Storage of iron, vitamins and trace elements

detoxification

conversion of waste products for excretion by the kidneys

The liver is functionally divided into two lobes, right and left. The external division is marked on the front of the liver by the falciform ligament, which joins the

coronary ligament at the superior margin of the liver.


The right lobe is separated from the other lobes by the gallbladder fossa and the fossa for the inferior vena

cava on the visceral surface of the liver.

The left lobe includes the caudate and quadrate lobes. It is separated from these two lobes by the

attachment of the ligumentum teres, and the fissures for the ligumentum teres and the ligamentum

venosum.

The caudate lobe lies between the fissure for the ligamentum venosum and the fossa for the inferior vena ca

va.

The quadrate lobe is partly covered by the gallbladder in normal patients; anatomically, it lies between the

fissure for the ligamentum teres and the gallbladder fossa.

Each lobe hs its own arterial and venous supply and its own billiary drainage. all the lobes perform the same functions- there are no areas of specialisation.

REPRODUCTIVE SYSTEM

The female reproductive system produces gametes may unite with a male gamete to form the first cell of the offspring. The female reproductive

system also provides protection and nutrition to the

developing offspring. The most essential organ is the ovary

which carries the ova. The uterus, the fallopian tubes and

the vulva are accessory organs. Ovaries It is an almond-shape

organ. It contains the ova and is responsible in expelling the

ova. It also produces estrogen and progesterone.

Progesterone


It is secreted by the corpus luteum. It is also known as a pregnancy- promoting steroid and it prevents the expulsion of the fetus in the uterus.

Anti-diuretic hormone (ADH)

It is secreted in the neurohypophysis (posterior pituitary); it literally opposes the formation and production of a large urine volume. It helps the body to

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

Fallopian Tubes

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

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

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

uterus. It holds the ovary. UterusThe uterus is a pear-shaped organ and has three parts: the

fundus (upper), corpus (body), and the isthmus (lower). It is known as the organ for

menstruation. When pregnant, it gives nourishment to the growing fetus.

Formation of Placenta

As changes to the endometrium occur, cellular growth and the accumulation of glycogen

cause fetal and maternal tissue to come together. This formation makes the functional unit

called the placenta. The placenta does not mix blood between mother and fetus, but allows

nutrients and waste products to diffuse between the two blood systems. The placenta

provides protection by filtering out many harmful substances that the mother comes in

contact with. Unfortunately the placenta cannot protect against some teratogens including

but not limited to:


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Thalidomide

Heroin

Cocaine

Aspirin

Alcohol

Chemicals in cigarette smoke

Propecia, also known as Finasteride, which can cause birth defects simply by a woman handeling a broken pill during pregnancy.

Amniotic Fluid

Attached to placenta is the membranous sac which surrounds and protects the embryo. This sac is called the amnion. It grows and begins to fill, mainly

with water, around two weeks after fertilization. This liquid is called Amniotic fluid, it allows the fetus to move freely, without the walls of the uterus being too

tight against its body. Buoyancy is also provided here for comfort. After a further 10 weeks the liquid contains proteins, carbohydrates, lipids and phospholipids,

urea and electrolytes, all which aid in the growth of the fetus. In the late stages of gestation much of the amniotic fluid consists of fetal urine. The fetus swallows

the fluid and then voids it to prepare its digestive organs for use after birth. The fetus also "breathes" the fluid to aid in lung growth and development.

A small part of the placenta is shown at the bottom, while the fluid-filled amnion surrounds it


http://en.wikibooks.org/wiki/File:Fetus.jpg

Not enough amniontic fluid, or oligohydramnios, can be a concern during pregnancy. Oligohydramnios can be caused by infection, kidney dysfunction or

malformation (since much of the late amniotic fluid volume is urine), procedures such as chorionic villus sampling (CVS), and preterm, premature rupture of

membranes (PPROM). One possible outcome of oligohydramnios can cause is underdeveloped, or hypoplastic, lungs. This condition is potentially fatal and the

baby can die shortly after birth. Babies with too little amniotic fluid can also develop contractures of the limbs, including clubbing of the feet and hands.

As with too little fluid, too much fluid or polyhydramnios, can be a cause or an indicator of problems for the mother and baby. Polyhydramnios is a predisposing

risk factor for cord prolapse and is sometimes a side effect of a macrosomic pregnancy. In both cases, however, the majority of pregnancies proceed normally and

the baby is born healthy.

Preterm, premature rupture of membranes (PPROM) is a condition where the amniotic sac leaks fluid before 38 weeks of gestation. This can be caused by

a bacterial infection or by a defect in the structure of the amniotic sac, uterus, or cervix. In some cases the leak can spontaneously heal, but in most cases of

PPROM, labor begins within 48 hours of membrane rupture. When this occurs, it is necessary that the mother receive treatment immediately to postpone labor if

the fetus is not viable, for as long as is safe, and for antibiotic treatments to avoid possible infection in the mother and baby. If rupture occures too early in

pregnancy little can be done to save the fetus.

A very rare and most often fatal obstetric complication is an amniotic fluid embolism, or leakage of amniotic fluid into the mothers vascular systems

causing an allergic reation. This allergic reaction results in cardiorespiratory (heart and lung) collapse, developing into a condition known as disseminated

intravascular coagulation in which the mothers blood looses it's ability to clot.


Amniotic band syndrome, or ABS, occurs when the inner fetal membrane (amnion) ruptures without injury to the outer membrane (chorion). Fibrous

bands from the ruptured amnion float in the amniotic fluid and can entangle the fetus, reducing blood supply and causing congenital limb abnormalities dysmelia.

In some cases a complete "natural" amputation of a digit(s) or limb may occur before birth or the digit(s) or limbs may be necrotic (dead) requiring surgical

removal.

There are pituitary like hormones and steroid hormones secreted from the placenta. The pituitary like hormones are hCG and hCS. HCG is similar to LH and

helps maintain the mothers corpus luteum. HCS is like prolactin and growth hormone and help aid in increasing fat breakdown that spares the use of glucose from

the mothers tissues. This effect leaves more glucose available to the placenta and the fetus for necessary growth. The steroid hormones are progesterone and

estrogen. Progesterone helps maintain the endrometrium and supports the growth of mammary glands. Estrogen also helps maintain the endrometrium and

growth of mammary glands as well as inhibits prolactin secretion.

Umbilical Cord

This is the life support for a growing embryo. The umbilical cord stretches between the placenta and the fetus. This cord contains the umbilical arteries

and vein. The umbilical cord forms by week 5 of conception. The average cord is close to 22 inches long and may have the appearance of a coil. The umbilical cord

is very rich in stem cells and is often used for parents who choose to store their stem cells in a blood bank or donate it to a blood bank. These stem cells can be

used to treat over 45 disorders and is an alternative from extracting the stem cells from a donor.


Human placenta shown a few minutes after birth. The side shown faces the baby with the umbilical cord top right. The unseen side connects to the uterine wall.

The white fringe surrounding the bottom is the remnants of the amniotic sac. You can see the differences in the umbilical vein and arteries.

Umbilical Arteries

The exchange of gases, nutrients and oxygen takes place between the maternal blood and fetal blood. There are 2 main arteries.

Umbilical Vein

Vein that carries nutrients and oxygen away from the placenta to the growing fetus. It also carries oxygen and nutrient rich blood. There is only 1 main vein.

Fetus doesn't use its lungs for gas exchange, only a small amount of blood is pumped to fetal lungs in order to support their development.

During pregnancy, the fetal circulatory system works differently after birth:

The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother’s uterus during pregnancy.

Through blood vessels in the umbilical cord, the fetus receives all the necessary nutrients, oxygen and life support from the mother through the placenta.


http://en.wikibooks.org/wiki/File:Human_placenta_baby_side.jpg

Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother’s circulation to be eliminated.

Blood from the mother enters the fetus through the vein in the umbilical cord. it goes to the liver and splits into three branches. The blood reaches the inferior

vena cava, a major vein that is connect ed to the heart.

Inside the fetal heart

Blood enters the right atrium, the chamber of the upper right side of the heart.

Most of the blood flow to the left side through a special opening between the

left and right atria called the foramen ovale.

Blood then passes into the left ventricle (lower chamber of the heart) and then

to the aorta, blood is send to the head and upper extremities. After circulating

there, the blood returns to the right atrium of the heart through the superior

vena cava.

About one-third of the blood entering the right atrium does not flow through

the foramen ovale, but instead. Stays in the right side of heart, eventually

flowing into the pulmonary artery

Because the placenta does the work of exchange of oxygen and carbon dioxide through

a mother’s circulation, the fetal lungs are not use for breathing. Instead of blood

flowing to the lungs to pick up oxygen and then flowing to the rest of the body. The

fetal circulation shunts (bypasses) most of the away from the lungs in the fetus, blood

is shunted from the pulmonary artery to the aorta through a connecting blood vessel

called the ductus arteriosus.


Blood circulation after birth:

With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of blood is sens to the lungs to pick up oxygen

Because ductus arteriosus (the normal connection between aorta and the pulmonary valve) is no longer needed, it begins to wider and closes off

The circulation in the lungs increases and more blood flows into the left atrium of the heart. This increase pressure causes the foramen ovale to close and blood

circulates normally…

Maternal and Fetal Circulation (Maternal-Fetal Exchange) - Medical Illustration, Human Anatomy Drawin

VI. RISK FACTORS AND PATHOPHYSIOLOGY


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VII. NURSING MANAGEMENTA. NCP

Problem Identified: Increased Blood PressureNursing Diagnosis: Decreased Cardiac Output related to vasoconstriction secondary to Preeclampsia. Cause Analysis: The vascular spasm maybe caused by increased the cardiac output that injures the endothelial cell of the arteries and the action of the prostaglandins (notably decrease prostacycline and increase thromboxane ). 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 5th edition pp.426)

Cues Objectives Nursing Interventions Rationale EvaluationSubjective:The patient may complaint of headache and dizziness.

Objective: BP of above acceptable range

(more than 110/70)

STO:Within 8 hours of nursing intervention, patient will demonstrate increase perfusion as evidenced by decreased BP from 140/110 to 120/90 mmHg

LTO:Within 3 days of nursing intervention, patient will display hemodynamic stability as evidenced of BP within acceptable range.

INDEPENDENT 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.

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

Provide for diet restriction and increase frequent small feedings.

Provide bed rest

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

DEPENDENT: Administration of cardiac

medications.

Comparison of pressures provides more complete picture of vascular involvement.

To provide circulation/ venous drainage

To maintain adequate nutrition and fluid balance.

To avoid further increase of blood pressure.

Help reduced sympathetic stimulation/promote relaxation.

These medications are cardiac medication, which is very effective in-patient with increase BP or hypertension.

The patient is expected to manifest the following:

Maintain BP within individually acceptable range.

Absence of headache and dizziness.


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

Problem Identified: Decreased Urine OutputNursing Diagnosis: Fluid Volume Excesses related to decrease in glomerular filtration secondary to Preeclampsia.Cause Analysis: Vasospasm in the kidney increase blood flow resistance. Degenerative changes develop in kidney glomeruli because 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 t equalized the pressure. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426)

Cues Objectives Nursing Intervention Rationale EvaluationSubjective:The Patient may complaint difficulty of urination.

Objective: Edema Distension of the pelvis and

ureters Decrease urine output(less

than 30ml /hr) Blood pressure above 140/90 Pulse rate greater than 100 Weight gain

STO:Within 8 hours of effective nursing interventions, patient will be able to manifest increase urine output at least 100ml per hour.

LTO:Within 3 days of giving effective nursing interventions, pt will be able to manifest a fluid balance as evidenced by appropriate urinary output, vital signs within normal range.

INDEPENDENT Weigh daily at same time of day,

on same scale, with same equipment and clothing.

Place in semi-fowler’s position as appropriate

Evaluate edematous extremities, change position frequently.

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

Monitor heart rate (HR), BP, and JVD/CVP

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

To facilitate movement of diaphragm improving respiratory effort.

Evaluate edematous extremities, change position frequently.

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.

Tachycardia and hypertension can occur because of (1) failure

The patient are expected to manifest the following:

Absence of distended pelvis and uterus

Stable weight Vital Signs within normal

range Absence of Edema Increase Urine Output


Promote bedrest

Collaborative:

Calcium channel blockers

Insert/maintain indwelling catheter, as indicated.

of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia/hypotension or convert oliguric phase of renal failure, and/or (3) changes in the renin-angiotensin system. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function.

Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR.

Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.

Reference: NCP by Doenges, Moorehouse & Geissler – Murr pp. 521-522

Problem Identified: Epigastric Pain (Right Upper Quadrant)Nursing Diagnosis: Altered Comfort; Acute Pain related to reduce supply of blood in the pancreas 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 may result in epigastric pain. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426)

Cues Objectives Nursing Intervention Rationale EvaluationSubjective: STO: INDEPENDENT


Patient may complaint pain in the right upper quadrant of the abdomen. A pain scale from 0-10, pain can be rated as 7 or 8.

Objective: Irritable Grimacing face Restlessness

Within 8 hours of nursing intervention patient will be alleviated from pain.

LTO:Within 2 days of nursing intervention, patient will express comfort and relief from pain as evidenced by no grimacing face, not irritable, and is not restless.

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

Promote proper body positioning to promote comfort, such as semi fowler’s position.

Advise the patient to sleep 8 hours each night and to nap or rest for 2 hours in the afternoon.

Instruct the patient in in basic deep chest breathing, which is similar to normal breathing but slower and deeper.

Encourage client to acknowledge and express feelings.

Change in pain characteristics may indicate developing complications

Promote relaxation.

To alleviate fatigue

Deep chest breathing creates a sense of relaxation during episodes of pain.

Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anxiety and fear.

The patient is expected to manifest the following: Decrease pain scale of 4/10

from 8/10. Maintains rest without

disturbance from pain Maintains relaxation

technique

Reference: Nursing Diagnosis Reference Manual 6 th Edition by Spark s and Taylor’s page. 512-513

Problem Identified: EdemaNursing Diagnosis: Fluid Volume Deficit related to fluid loss secondary to capillary permeability. Cause Analysis: Vasospasm in the kidney increases the blood flow resistance. Degenerative changes develop in the kidney glomeruli because of back pressure. This leads to increase permeability of the glomerular membrane, allowing the serum protein to escape into the urine (protienia). The generative changes also result to decrease glomerular filtration, so there is lowered urine output and clearance of creatinine. Increase kidney tubular reabsorption of sodium occurs. Because sodium retains fluids, EDEMA results. More protein is lost, the osmotic pressure of the circulating blood falls and fluid diffuses from the circulatory system in to denser interstitial space to equalize the pressure. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426)


Cues Objectives Nursing Interventions Rationale EvaluationSubjective:Patient may complaint tightness of the hands, swelling in the upper body, heaviness of the upper body.

Objective: Slightly pitting Edema +1 Weight gain in a short

period of time Urine output of 400-

600ml ( Oliguria)

STO:Within 8 hours of nursing intervention, patient will be able to verbalize understanding the need for close monitoring of weight, BP, urine protein, and edema and participate in therapeutic regimen and monitoring, as indicated.

LTO:Within 3 days of nursing intervention, patient’s fluid volume will stabilized as evidenced by balanced I&O, stable weight and reduced signs of edema.

INDEPENDENT Carefully monitor intake and output

at least every 4 hours.

Weigh patient daily before breakfast.

Change patient’s position every 2 hours.

Increased patient’s activity level as tolerated; for example, ambulate and increase self-care measures performed by patient.

Educate Patient regarding: Environmental safety

measures. Fluid restriction and diet. Ways to prevent infection.

Collaborative: Schedule prenatal visit every 1–2

wk if PIH is mild; weekly if severe. Review moderate sodium intake of

up to 6 g/day. Instruct client to read food labels and avoid foods high in sodium (e.g., bacon, luncheon meats, hot dogs, canned soups, and potato chips)

Intake greater than output may indicate fluid retention or overload.

Sudden significant weight gain more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema.

To enhance venous return, and reduce edema.

Gradually increasing activity helps body adjust to increased tissue oxygen demand and possible increased venous return.

These measures encourage patient and family members to participate more fully in care.

Necessary to monitor changes more closely for the well-being of the client and fetus.

Some sodium intake is necessary because levels below 2–4 g/day result in greater dehydration in some clients. However, excess sodium may increase edema formation.

Nutritional consult may be beneficial in determining individual needs/dietary plan

The Patient is expected to manifest the following:

Reduce Edema Reduce Weight Absence of swelling, tightness

of the hands heaviness of the upper body.


Refer to dietician as indicated.

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

Problem Identified: Ineffective Tissue PerfusionNursing Diagnosis: Ineffective Tissue Perfusion related to vasoconstriction of blood vessels secondary to PreeclampsiaCause Analysis: Arterial spasm causes the bulk of the blood volume in the maternal circulation to be pooled in the venous circulation, so a woman has a deceptively low arterial intravascular volume. (Maternal and Child nursing by Pelliterri 5th edition p. 426)

Cues Objectives Nursing Interventions Rationale Evaluation


Subjective:Patient may report dizziness, fatigue,

Objective: Increased blood pressure of

more than 110/70. Weak peripheral pulse. CRT of more than 3

seconds. Increase Heart Rate of

more than 60 bpm. Edema

STO:Within 3 hours of nursing intervention, patient will be able to verbalize understanding about her condition as evidenced by question of clarification regarding the health teachings.

LTO:Within 3 days of nursing intervention, patient will demonstrate increased perfusion evidenced by strong peripheral pulse, vital signs within normal range, and absence of edema.

INDEPENDENT Monitor and document patient’s

vital signs every 2 hours.

Encourage patient to change position and participate in activity, as condition permits.

Encourage quiet, restful environment.

Encourage rest after meals.

Inform patient about: Proper use of medication

and possible adverse reactions.

Benefits of low-fat, low-cholesterol diet.

Need to avoid straining with bowel movements.

Collaborative: Administer fluid as needed. Maintain oxygen therapy as

ordered.

Decreased heart rate and blood pressure may indicate increased arteriovenous exchange, which leads to decreased tissue perfusion.

To enhance vital capacity and avoid lung congestion and skin break down.

To conserve energy, lowers tissue oxygen demands and maximize tissue perfusion.

To maximise blood flow to stomach enhancing digestion.

Effective teaching encourages patient to take an active role in health maintenance.

To maintain preload. To maximize oxygen exchange in

alveoli and at the cellular level.

The Patient is expected to manifest the following:

Normal range of vital signs. Verbalize understandings about

the health teachings or information given related to the condition experienced.

Strong peripheral CRT of less than 3 seconds. Absence of edema.

Reference: Nursing Diagnosis Reference Manual 6 th Edition by Sparks and Taylor’s page.331-332.

B. HEALTH EDUCATION PLAN


Objectives:1) After giving health teachings the patient and family will be able to gain adequate knowledge on how to help the client recover physically and emotionally.2) After giving health teachings the patient will be able to initiate necessary lifestyle changes and participate in treatment regimen.3) Maintain health management to prevent complications.

Materials needed:1. Manila paper2. Markers3. Visual aid

GENERAL HEALTH TEACHINGS SPICIFIC HEALTH TEACHINGS

Medication

Diet

Rest and Sleep

Doctors would recommend:

Medicines given into a vein to control blood pressure, as well as to prevent seizures and other complications.

Steroid injections (after 24 weeks) to help speed up the development of the baby's lungs.

Advice client to take his medication at regular basis. Teach the patient and SO the time , route , dosage ,adverse effect,

and special consideration of each medications.

Drinking extra glasses of water a day and eating less salt. Eating more fruits, vegetables, and low-fat dairy foods Cutting back on foods that are high in saturated fat, cholesterol, and

total fat

Instruct the patient on the importance of proper rest and sleep.

Getting bed rest at home, lying on your left side most or all


Exercise

of the time. Pregnancy will cause the patient to tire more easily. Prevention of fatigue through short rest periods is vital to

good health.

Advise client’s family to consult PT for proper exercise for the client.

C. DISCHARGE PLAN


MEDICATIONS DOSAGE/FREQUENCY NURSING INSTRUCTIONSNifedipine( Adalat, Procardia)

Clonidine(Catapres)

Hydrochlorothiazide( Esidrix)

Methyldopa(Aldomet)

IR cap: 10-30 mg per Orem three times a day; not to exceed 120-180 mg/dSR tab: 30-60 mg per Orem every day; not to exceed 90-120 mg/dBP >170/110 mm Hg: 10 mg per Orem initial; repeat dose may be administered in 30 min as needed.

Initial: 0.1 mg per Orem twice a dayMaintenance: 0.2-1.2 mg/d twice a day/ per Orem; not to exceed 2.4 mg/d

25-100 mg per Orem every day; not to exceed 200 mg/kg/d

250 mg per Orem twice a day/trice a day; increase every two days as needed; not to exceed 3 g/d

Instruct pt. to take medication at the same time everyday. Do not double dose. Advise pt. to make sure that enough medication is available during weekends,

holidays, trips, and vacations. Advise pt. that frequent oral hygiene can minimize dry mouth. Advise pt. to make position changes slowly, to avoid orthostatic hypotension. May cause drowsiness; instruct pt. not to do activity requiring alertness.

Caution pt. to avoid concurrent use of alcohol and other CNS depressants. Advise pt. to have her blood pressure taken weekly and to report to physician

significant changes.

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. Encourage client to comply with additional hypertensive intervention (weight

reduction, exercise, low sodium diet, stress management) Instruct pt. and family in correct technique for monitoring weekly blood pressure.

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 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.

EXERCISE

Moderate exercise means that you get warm, mildly out of breath, and mildly sweaty. It does not have to be intense. For example: brisk walking, dancing and other recreational activities to maintain mobility and normal functioning esp. of the GIT. You can even use normal activities as part of your exercise routine such as household chores or gardening. And also, consider a brisk walk when going to work or to the shops instead of using a car or bus, etc. For many people, a daily brisk walk for 30-60minutes is a realistic goal.

THERAPY

Recreational Activities - Encourage mother to engage in any activities or any recreational activities such as walking and household chores or any exercises that aids in losing weight. On the other hand, increase aerobic physical activity for at least 30-45minutes most days of the week.

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

1. Instruct patient to lose weight if overweight such as engaging in any activities.2. Restricts the intake of alcohol for this may cause vasoconstriction thus increasing blood pressure.3. Have an appropriate exercise regimen because regular activity is a significant factor in weight reduction.4. Maintain adequate intake of dietary potassium.5. Maintain adequate intake of dietary calcium and magnesium for general health.6. Stop smoking and reduce intake of dietary saturated fats and cholesterol for overall cardiovascular health.7. Stress reduction also is beneficial in any diseases.


OPD VISITS/REFERRALS

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

1. Avoid intake of foods that are high in sodium and fats such as salty foods and pork.2. Increase intake of fruits and vegetables for proper nourishment.3. Avoid intake of alcoholic beverages and tobacco not because smoking is related to hypertension, but because anyone with high blood pressure is

already at increased risk for heart disease, and smoking makes this risk even higher.4. Have adequate intake of dietary potassium (approximately 90mmol per day).5. Maintain also adequate intake of dietary calcium and as well as magnesium.

SPIRITUAL CARE

1. Encourage client to have daily prayer and have relationship with God for he is the greatest physician.2. Encourage also to read bibles or any inspiring books.

VIII. MEDICAL AND SURGICAL MANAGEMENTDrugs Classification Indication Mechanism of Action Dosage Adverse Effects Nursing Considerations


Magnesium Sulfate (Epson Salt)

Anticonvulsant - Muscle relaxant- Prevents

seizures

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

- loading dose 4-6g IV

- Maintenance dose 1-2 g/h IV

CNS: depressionCV: flushing, hypotension, depression of myocardium.Magnesium intoxication:Cardiac and CNS depression, preceding respiratory paralysis, circulatory collapse, flaccid paralysis.

Before administering IV check for the ff. conditions:

-Absent patellar reflex- RR below 16/min- urine output below 100 ml in past 4 hours.- Early signs of hypermagnesemia: flushing, sweating, hypotension or hypothermia.- past history of heart block or myocardial damage; prolonged RR and widened QRS interval.

A. MEDICATIONS


Hydralazine HCl (Apresoline)

Antihypertensive - Preeclempsia, eclapsia

- Heart failure

A direct-acting vasodilator that relaxes arteriolar smooth muscle.

- Initially, 5 to 10 mg IV, followed by 5-10 mg IV doses (range 5-20 mg) q 20 to 30 minutes, 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.

Diazepam (Valium) Anxiolytic Adjunct treatment for seizure disorder

A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppress 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, constipationGU: incontinence, urine retentionHepatic: jaundiceRespiratory: respiratory

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

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


depression, apnea.

Calcium Gluconate Electrolyte and replacement solutions

Antidote for magnesium toxicity

Generally, replaces calcium and maintains calcium level; physiologically antagonize hypomagnesaemia effect.

- 1g/ IV (10 mL of a 10% solution)

CV: mild drop of blood pressure, vasodilation, bradycardia, arrhythmias, cardiac arrest.GI: irritation, constipation, chalky taste, nausea, thirst, abdominal pain.GU: renal calculi.

- Warn patient to avoid oxalic acid (in rhubarb and spinach), phytic acid (in barn and whole grain cereals), and phosphorous (in dairy products) in the meal preceding calcium consumption; these substances may interfere calcium absorption.

Labetalol HCl (Normodyne)

Antihypertensive Hypertension May be related to reduced peripheral vascular resistance, as a result of alpha and beta blockade.

- 100 mg PO bid.- Maintenance

dosage: 200 to 400 mg bid

CNS: fatigue, headache, paresthesia, dizziness.CV: orthostatic hypotension, ventricular arrhythmiasRespiratory: dyspnea, bronchospasmGU: urine retention

- Monitor blood pressure frequently.

- Tell patient that stopping abruptly can worsen chest pain and trigger MI.


Methyldopa (Aldomet)

Antihypertensive Hypertension, hypertensive crisis

Thought to inhibit the central vasomotor centers, thereby decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature.

- Initially, 250 mg PO bid to tid in first 48 hours. Increase prn q 2 days.

CNS: dizziness, paresthesia, headacheCV: bradychardia, aggravated angina, myocarditis, edemaGU: galactorrheaHepatic: hepatic necrosis, hepatitis

- Weight pt everyday, if weight increases more that 5lbs, a possible sodium and water retention occurred.

- May take before sleeping (hs)

Nifedipine (Procardia)

Anti-anginals Hypertention Thought to inhibit calcium ion influx across cardiac and smooth-muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary arteries and arterioles.

- 30 or 60 mg PO od. Adjust over 7 to 14 days.

CNS: light-headedness, somnolence, weaknessCV: peripheral edema, hypotension, palpitation, heart failure, MI, flushingEENT: nasal congestionRespiratory: dyspnea, pulmonary edema, cough

- Watch for sign of heart failure.

- Instruct pt not to chew, break, or crush the tablet

- Monitor BP frequently or regularly

Aspirin Nonopioid Prophylactic for mothers Known to block the - 50 to 150 mg GI: GI distress, GI - Instruct client to


(Acetylsalicylic acid) analgesics and antipyretics

at high risk for preeclampsia.

action of an enzyme, clooxygenase, essential to the production of prostaglandins. Results in lowered levels of thromboxane, a vasoconstrictor, then vasodilator prostacyclin are not being significantly affected.

PO daily between 12-18 weeks’ gestation.

bleedingHematologic: prolonged bleeding timeHepatic: HepatitisOther: angioedema.

adhere on prescribed dosage, low-dose.

- Advice pt to take with food, milk, antacid, or large glass of water to reduce unpleasant GI reaction

B. MEDICAL MANAGEMENT

Induction of Labor

Definition

Induction of labor involves using artificial means to assist the mother in delivering her baby.

Purpose

Labor is brought on, or induced, when the pregnancy has extended significantly beyond the expected delivery date and the mother shows no signs of

going into labor. Generally, if the unborn baby is more than two weeks past due, labor will be induced. In most cases, a mother delivers her baby between 38 and

42 weeks of pregnancy. This usually means that labor is induced if the pregnancy has lasted more than 42 weeks. Labor is also induced if the mother is suffering


from diseases (preeclampsia, chronic hypertension); if there is an Rh blood incompatibility between the baby and the mother; or if the mother or baby has a

medical problem that requires delivery of the baby (like a premature rupture of the membranes).

Description

The uterus is the hollow female organ that supports the development and nourishment of the unborn baby during pregnancy. Sometimes labor is induced

by the rupturing the amniotic membrane to release amniotic fluid. This is an attempt to mimic the normal process of "breaking water" that occurs early in the

normal birth process. This method is sometimes enough stimulation to induce contractions in the mother's uterus. If labor fails to start, drugs are used.

Most labor is induced by using the drug Pitocin, a synthetic form of oxytocin. Oxytocin is a natural hormone produced in the body by the pituitary gland.

During normal labor, oxytocin causes contractions. When labor does not occur naturally, the doctor may give the mother Pitocin to start the contractions. Pitocin

makes the uterus contract with strength and force almost immediately. This drug is given through a vein in a steady flow that allows the doctor to control the

amount the mother is given.

Sometimes vaginal gels are used to induce labor. Normally, the baby will pass through the opening of the uterus (the cervix) into the birth canal during

delivery. Because of this, the cervix softens and begins to enlarge (dilate) during the early part of labor to make room for the baby to pass through. The cervix will

continue to dilate, and the contractions will eventually push the baby out of the mother's body. When labor needs to be induced, the cervix is often small, hard,

and not ready for the process. The doctor may need to prepare or "ripen" the cervix to induce labor. The hormone prostaglandin in a gel form may be applied

high in the vagina to soften and dilate the cervix, making the area ready for labor. This may be enough to stimulate contractions on its own. More often,

prostaglandin gel is used in conjunction with Pitrocin. If all attempts to induce labor fail, a cesarean section is performed

C. SURGICAL MANAGEMENT

Cesarean Section

Definition:


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

Indication:

The decision to have a C-section delivery can depend on the obstetrician, the delivery location, and the woman's 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 baby's head will not fit through the pelvis. This diagnosis may also be used to indicate a labor that

fails to progress, (a prolonged labor, an extended period of time since rupture of membranes or weak, ineffective contractions.)

Fetal Distress - The baby is not receiving enough oxygen. It may be indicated by an abnormal fetal tracing or a drop in the fetal heart rate when your

healthcare provider or labor nurse listens to the rate during or after a contraction.

Abnormal Position of the Baby - Instead of the baby's head presenting first in the pelvis with his/her chin tucked inward, the presenting part of the baby

may be his/her head extended outward, the shoulder, bottom (breech) or leg(s).

Prolapsed Cord - When the umbilical cord is in the vagina ahead of the baby. This most commonly occurs after the membranes rupture and the baby is in

a breech position or his/her head is not well engaged in the pelvis. This is an emergency and an immediate cesarean section 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 or completely separates from the uterine wall before the baby is born. This is an emergency and an

immediate cesarean birth is necessary to prevent the mother from hemorrhaging, which can cause the baby to lose all or part of his/her ox

Placenta Previa - A condition in which the placenta partially or completely covers the cervix. The degree of severity determines whether or not a

cesarean birth is indicated. If the cervix is completely covered, a cesarean is mandatory since the placenta would deliver first in a vaginal 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 (Kerr) or vertical (Krohnig) incision consistent with the

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 spontaneously entered, and 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 or by obstetric forceps and counter-pressure on the fundus.

Retractors are removed. As soon as the head is delivered, the newborn’s nares are aspirated by bulb syringe immediately but very gently; the delivery is

completed. Oxytocin is administered intravenously to encourage the uterus to contract and to decrease blood loss. The umbilical cord is clamped and cut. The

infant is received in a sheet and transferred to a gowned and gloved member of the neonatal team, e.g., the pediatrician. Standard Precautions are observed.

Resuscitative measures are provided to the neonate under warming lamps. The pediatrician determines the infant’s Apgar score. Vernix, etc., are wiped from the

infant’s skin. Ointment (erythromycin 0.5%) is applied to the conjunctival sacs of the newborn by a member of the neonatal team. The placenta is delivered. The

uterus is massaged to encourage it to contract. Tubal ligation may be performed. Blood, amniotic fluid, etc., are aspirated. Hemostasis is assured. The edges of the

uterine incision are clamped to aid in its closure; the uterus and bladder are closed in a single or a 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 blankets (from blanket warmer) are

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

further cleaned, weighed, etc.

IX. PROGNOSISAlthough the infant mortality rate with preeclampsia is nearly double that of babies born to mothers with normal blood pressure and no signs of

preeclampsia, the majority of women with preeclampsia deliver healthy babies. Proteinuria usually resolves within 6 weeks after delivery. Preeclampsia usually

does not cause permanent damage or adversely affect the long-term health of the mother, but risk of preeclampsia and eclampsia is greater in subsequent

pregnancies. Preeclampsia in the US is associated with higher than normal mortality and morbidity for mothers and newborns (neonates) and has been shown to

be responsible for 15% of premature births and 17.6% of pregnancy-related maternal deaths. Baby complications can be mostly avoided if the condition is

controlled.


Eclampsia is a much more significant complication of pregnancy, with a high potential for maternal death, particularly if it develops before delivery; the pre-

delivery (prenatal) maternal mortality rate is 5.6% to 11.8% in the US and UK. Approximately 50,000 maternal deaths due to eclampsia are reported annually

worldwide, with death occurring more often in women older than age 30 and in women who have had no prenatal care. Babies born to women with eclampsia

are at increased risk of morbidity and mortality due to prematurity, low birth weight, premature placental separation, and lack of oxygen in the uterus (fetal

hypoxia). Women with eclampsia have a 2% chance of having another episode with a subsequent pregnancy, and 25% will have high blood pressure in their next

pregnancy.

Preeeclampsia and Eclampsia depends on how carefully a patient is monitored. Very careful, consistent monitoring allows quick decisions to be made, and

improves the woman's prognosis. Still, the most common causes of death in pregnant women are related to high blood pressure.

More information on how preeclampsia and eclampsia develop is needed before recommendations can be made on how to prevent these conditions.

Research is being done with patients in high risk groups to see if calcium supplementation,aspirin, or fish oil supplementation may help prevent preeclampsia.

Most importantly, it is clear that careful monitoring during pregnancy is necessary to diagnose preeclampsia early.

X. BIBLIOGRAPHYBOOKS:

Medical- Surgical Nursing by Ignatavicius and Workman, 5th edition vol.2 Pathophysiology by Porth, 11th edition Medical- Surgical Nursing by Smeltzer and Bare, 11th edition vol.2, Introductory Medical Surgical Nursing by Timby and Smith, 9th edition Medical- Surgical Nursing by Black and Hawks, 6th edition vol.1 Medical- Surgical Nursing: Concepts and Clinical Applications by Udan, 2nd edition


Mosby’s Pocket Dictionary of Medicine, Nursing, and Allied Health, 4th edition Diagnostic Tests “Nurse’s Quick Check” by Williams and Wilkins Nursing spectrum drug handbook 2008 by Patricia Dwyer Schull Nursing care plan by Doenges, Moorhouse and Murr, 7th edition Physical Examination and Health Assessment by Jarvis, 4th ed Human anatomy and physiology by Marieb,7th edition, pp.

SUPPLEMENTARY SOURCES:

http//emedicine.medscape.com/article/238798-overview http//www.merck.com/mmpe/sec17/ch233c.html www.google.com www.askjeeves.com www.dictionrary.com www.about.com http://nursinglectures.blogspot.com/2009/01/post-operative-nursing.html www.medindia.com


http://nursinglectures.blogspot.com/2009/01/post-operative-nursing.html

http://www.about.com/

http://www.dictionrary.com/

http://www.askjeeves.com/

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