PRE ECLAMPSIA

INTRODUCTION

Preeclampsia, also referred to as toxemia, is a condition that pregnant women can get.

3 Cardinal Signs: 1.) Hypertension 2.) Proteinuria 3.) Edema

In addition, symptoms of preeclampsia can include:

• Rapid weight gain caused by a significant increase in bodily fluid

• Abdominal pain• Severe headaches• A change in reflexes• Reduced output of urine or no urine• Dizziness• Excessive vomiting and nausea

Important Statistics· Every minute, somewhere in the world a woman dies in pregnancy or childbirth.This amounts to 1400 women dying each day – and more than 500,000 each year– from pregnancy-related causes.1· If undetected, preeclampsia can lead to eclampsia which is one of the top fivecauses of maternal and infant illness and death, causing an estimated 13% of allmaternal deaths worldwide or literally a maternal death every 12 minutes.2· Approximately 5 to 8 percent of pregnancies are affected by preeclampsiameaning that more than 6.6 million women worldwide suffered from the diseasein 2002.3· Preeclampsia causes 15% of premature births in industrialized countries and itthe number one reason doctors decide to deliver a baby prematurely.

Who Is at Risk for Preeclampsia?• Preeclampsia is most often seen in first-time pregnancies

and in pregnant teens and women over 40. Other risk factors include:

• A history of chronic high blood pressure prior to pregnancy.• Previous history of preeclampsia• A history of preeclampsia in mother or sisters.• Obesity prior to pregnancy.• Carrying more than one baby.• History of diabetes, kidney disease, lupus or

rheumatoid arthritis.

Etiology:

The exact causes of preeclampsia and eclampsia are not known, although some researchers suspect poor nutrition, high body fat or insufficient blood flow to the uterus as possible causes.

Classifications:

1. Mild Preeclampsia - blood pressure greater than 140/90

2. Severe Preeclampsia – blood pressure greater than 160/110

NURSING HEALTH HISTORY

PATIENTS NAME: Ms. XYZADDRESS: Brgy. Buao Gandara, SamarSEX: FemaleSTATUS: SingleBIRTHDATE: November 11, 1980BIRTHPLACE: Gandara, Samar AGE: 31 years oldNATIONALITY: FilipinoRELIGION: Roman CatholicDATE OF ADMISSION: January 3, 2012TIME OF ADMISSION: 8:20amTYPE OF ADMISSION: NewADMITTING PHYSICIAN: Dr. NanoyCHIEF COMPLAINT: “High Blood Pressure”

HISTORY OF PRESENT ILLNESS

Patient was admitted at Malinao District Hospital last December 21, 2011 due to UTI. She had a normal blood pressure last December 30, 2011. When she had labored, her blood pressure in Malinao District Hospital was 200/130 mmHg. She was given Captropil 25g tab ½ tab OD, and Digoxin 0.25mg tab ½ tab OD. Persistence of increase blood pressure was referred at Samar Provincial Hospital for further evaluation and management hence admitted.

TENTATIVE DIAGNOSIS: Pre-eclampsia (pre and post-partum)

PAST HEALTH HISTORYMs. XYZ had complete immunizations during childhood.

FAMILY HEALTH HISTORYMs. XYZ’s MOTHER had a history of hypertension while she was pregnant.

PHYSICALASSESSMENT

GENERAL APPEARANCE

Ms. XYZ is 31-year old primigravida. She is conscious and coherent upon assessment. She has edema on her face and has difficulty upon ambulation.

VITAL SIGNSBP: 170/120 RR: 22 cpmPR: 105 bpm Temp.: 37⁰C

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Hair Evenly distributed, thick, silky, resilient hair

Shiny, evenly distributed

Normal

Head Rounded, absence of nodules or masses

Rounded, no injuries, absence of nodules

Normal

Face Round and brown in color, symmetrical with no masses and involuntary movements

Symmetrical with no masses and involuntary movements, edematous

Edema is due to increased tubular

reabsorption of sodium

Eyes Eyebrows evenly distributed, eyelashes equally distributed, no discoloration of eyelids, pupil black in color and equal in size

Eyebrows evenly distributed, pupil black in color and equal in size

Normal

Ears No discharge, auricles symmetrical, able to hear clearly and sounds can be heard on both ears

No discharge, auricles symmetrical, able to hear clearly

Normal

Nose No discharge, color uniform to skin, not tender, no lesion

No discharge, not tender, no lesions

Normal

Mouth Lips are pink in color, white, shiny tooth enamel, gum and surface of the tongue are pink

No bad odor, teeth is clean and white, gums pink in color

Normal

Skin Varies from light to deep brown, no edema, skin temp. is in normal range

Light brown , dry skin Decreased fluid intake

Nails Smooth fingernails and toenails texture

Smooth fingernails and toenails texture, short nails without nail polish

Normal

Neck Head centered, coordinated head movement, no discomfort

Head centered, coordinated head movement, no discomfort

Normal

Upper extremities No deformities No deformities Normal

Lungs No adventitious breath sounds

No adventitious breath sounds

Normal

Heart Full pulsation, thrusting quality upon auscultation

Full pulsation, thrusting quality upon auscultation

Normal

Breast Rounded shape, slightly unequal in size, areola is round, nipples are not inverted, no discharge except in pregnant or breastfeeding women

Rounded shape, slightly unequal in size, areola is round, nipples are not inverted, presence of milk coming out from the breast

Normal

Abdomen Unblemished skin, no evidence of enlargement of liver or spleen, symmetric movement caused by respiration

Presence of linea negra, presence of striae gravidarum, fundus is firm and below the umbilicus

Normal

Genitals Wide variation of pubic hair, no lesions, no inflammation

Presence of episiotomy, presence of vaginal discharge

Normal

Lower extremities No deformities No deformities Normal

ANATOMY &

PHYSIOLOGY

CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEMThe cardiovascular/circulatory system transports

food, hormones, metabolic wastes, and gases (oxygen, carbon dioxide) to and from cells. Components of the circulatory system include:

• Blood: consisting of liquid plasma and cells • Blood vessels (vascular system): the "channels"

(arteries, veins, capillaries) which carry blood to/from all tissues. (Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood vessels in which gas/ nutrient/ waste exchange occurs.)

• Heart: a muscular pump to move the blood

ANATOMY OF THE HEART

The heart is about the size of a man's fist. Located between the lungs, two-thirds of it lies left of the chest midline the heart, along with the pulmonary (to and from the lungs) and systemic (to and from the body) circuits, completely separates oxygenated from deoxygenated blood.

Internally, the heart is divided into four hollow chambers, two on the left and two on the right. The upper chambers of the heart, the atria receive blood via veins. Passing through valves (atrioventricular valves), Blood then enters the lower chambers, the ventricles. Ventricular contraction forces blood into the arteries.

BLOOD PRESSURE AND HEART RATE

One heartbeat, or cardiac cycle, includes atrial contraction and relaxation, ventricular contraction and relaxation, and a short pause.

The cardiac cycle consists of two parts: systole (contraction of the heart muscle in the ventricles) and diastole (relaxation of the ventricular heart muscles).

Medical Management

Nursing Management

NURSINGCAREPLAN

CUES NURSING DIAGNOSIS

GOAL NURSING INTERVENTIONS

RATIONALE EVALUATION

Subjective: Dyspnea FatigueObjective: Variation in

blood pressure readings

Edema Restlessness Postural

hypotension

Decreased cardiac output related to decreased venous return

At the end of the shift, the patient will participate in activities that reduce blood pressure or cardiac workload.

1. Monitor blood pressure of the patient.

2. Observe skin color, moisture, and temperature.

3. Encourage changing positions slowly, dangling legs before standing.

4. Give skin care and assist with frequent position changes.

5. Provide calm, restful surroundings, minimize unnecessary noise.

Comparison of pressures provides a more complete picture of vascular involvement.Presence of pallor, cool, moist skin maybe due to peripheral vasoconstriction.To reduce risk for orthostatic hypotension.

To prevent development of pressure sores.

Help reduce sympathetic stimulation and promotes relaxation.

Goal met as evidenced by patient is able to participate in activities that reduce blood pressure or cardiac work load.