ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION Subjective:Napansin ko nabigla na langbumigat angtimbang ko ( I noticed that I gained a lot

of weight ) asverbalized by thepatient.Objective: Variations inbloodpressure. Edema V/S taken asfollows:T: 37.1P: 78R: 20BP: 140/90Decreasedcardiac outputrelated todecreasedvenous return.Preeclampsia is acommon problemduring pregnancy.The condition sometimes referredto as pregnancy-induced hypertension is defined by highblood pressure andexcess protein in theurine after 20 weeksof pregnancy. Often,preeclampsia causesonly modestincreases in bloodpressure. Leftuntreated, however,preeclampsia canlead to serious even fatal complications forboth mother andbaby. After 8 hoursof nursinginterventions,the patient willparticipate inactivities thatreduce bloodpressure orcardiac workload. Independent: Monitor bloodpressure of thepatient. Measurein both arms orthighs threetimes, 3-5minutes apartwhile patient is atrest, then sitting,then standing forinitial evaluation. Observe skincolor, moisture,temperature andcapillary refilltime. Note dependentor generaledema. Provide calm,restfulsurroundings,minimizeenvironmentalactivity or noise. Maintain activityrestrictions. Comparison ofpressuresprovides a morecompletepicture ofvascularinvolvement orscope of theproblem. Presence ofpallor, cool,moist skin anddelayedcapillary refilltime may bedue toperipheralvasoconstriction May indicateheart failure,renal orvascularimpairment. Help reducesympatheticstimulation,promotesrelaxation. Reducesphysical stressand tension thataffect bloodpressure andcourse of After 8 hours ofnursinginterventions,the patient wasable toparticipate inactivities thatreduce bloodpressure orcardiac workload.

In hypertensive pregnant the following changes do occur: _there is thought to be a loss of resistance to the pressor effects of angiotensin II. In a normal pregnancy, the ratio of thromboxane, vasoconstrictors , and prostacyclin, vasodilator is 1:1. women with preeclampsia produce much more thromboxane than prostacyclin resulting in vasoconstriction and platelet aggregation. _during pregnancy, fluid tends to shift to the extracellular compartment because of the normal hemodilation or pregnancy reduces colloid osmotic pressure in the intravascular compartment. In preeclampsia , there is further movement of fluid in that direction as the result of: increased capillary permeability: increased capillary permeability in the kidneys allows albumin to escape in the urine, decreasing serum albumin levels. This further decreases plasma colloid osmotic pressure and moves even more fluid to extracellular spaces. decreased renal perfusion: the reduced glomerular filtration rate results in decreased urine output and increased serum levels of creatinine, BUN, uric acids, and sodium. Sodium retention further increases extracellular fluid and edema, it also increases sensitivity to the pressor, angiotensin

decreased intravascular volume: causes increased blood viscosity and elevated HCT. In hypertensive pregnant the following changes do occur: _there is thought to be a loss of resistance to the pressor effects of angiotensin II. In a normal pregnancy, the ratio of thromboxane, vasoconstrictors , and prostacyclin, vasodilator is 1:1. women with preeclampsia produce much more thromboxane than prostacyclin resulting in vasoconstriction and platelet aggregation. _during pregnancy, fluid tends to shift to the extracellular compartment because of the normal hemodilation or pregnancy reduces colloid osmotic pressure in the intravascular compartment. In preeclampsia , there is further movement of fluid in that direction as the result of: increased capillary permeability: increased capillary permeability in the kidneys allows albumin to escape in the urine, decreasing serum albumin levels. This further decreases plasma colloid osmotic pressure and moves even more fluid to extracellular spaces. decreased renal perfusion: the reduced glomerular filtration rate results in decreased urine output and increased serum levels of creatinine, BUN, uric acids, and sodium. Sodium retention further increases extracellular fluid and edema, it also increases sensitivity to the pressor, angiotensin decreased intravascular volume: causes increased blood viscosity and elevated HCT. Sign and symptoms Preeclampsia Syndrome of pregnancy- induced hypertension accompanied by proteinuria, edema and frequently other organ dysfunction. Mild preeclampsia Is characterized by: - hypertension: arise of 30 mmHg systolic and 15 mmHg diastolic, blood pressure:140/90 mmHg. - proteinuria:+2 or 1 g/l. - edema: generalized, facial, hands and fingers reflecting weight gain of over 0.7 kg/ week. Assessment: - it is essential of prenatal assessment of all women is to establish a baseline blood pressure. - in each prenatal visit blood pressure and other signs of hypertension are assessed. - assessment includes urine testing for proteinuria. - weighing on the same scale. - assessing for edema, headache, epigastric pain. - assessment of fetal movement, non stress test. Management: - initial management consists of rest and observation if patient is not a candidate for delivery. Bed rest maximizes uteroplacental flow. delivery should be accomplished by 38 th week or sooner if the fetus is mature.

Nursing intervention: - diet: increase protein diet with moderate sodium intake. - rest and activity: resting on the left lateral recumbent position is beneficial by increasing renal blood flow glomerular filtration rate and placental perfusion. Complete bed rest may not necessary , reduced activity is beneficial. - medical supervision: office visit are scheduled every 2 weeks or less depending on the symptoms for assessment of signs of preeclampsia. - danger sign: mother are instructed to report any sudden change in their condition such as generalized edema, headache, fever, muscle tremors, or seizures and sudden increase of body weight. Severe preeclampsia Characterized by: - blood pressure: consistently>(160 mmHg systolic) or >(110 mmHg diastolic) - new onset of proteinuria >2 g in 24 hours urine collection or >3 g in a randomly collected specimen. - edema : generalized, weight gain of 0.9 kg over a period of one week or less.

- platelets count: less than 100,000 ,hemolytic anemia and increase in lactic acid dehydrogenase (LDH) and direct bilirubin level. - headache, visual disturbances or other cerebral sign. - epigastric or right upper quadrant pain.67 - cardiac decompensation, pulmonary edema or cyanosis. - fetal growth retardation: due to reduction of intervillous perfusion. Assessment: - hospitalization is necessary. - the goal of care is prevent seizure, lowering blood pressure, establishing adequate renal function and to continue the pregnancy until fetal maturity. - if the pregnancy is at the 36 th week or more labor is induced or cesarean birth is performed. - serial examination recommended for preeclampsia hospitalized patients include: mother: Blood pressure four times daily. assessment for proteinuria, edema, weight, hyperreflexia, headache, visual disturbances, epigastric pain (daily) hematocrit, platelets count (every 2 day) serum uric acid and creatinine level, 24- hours urine for total protein and creatinine clearance( twice daily) liver function test (weekly) urinary output( at each voiding or by catheterization, should be more than 700 ml/ 24 hours or 30 ml/ hour). fetus: Fetal heart rate ( every 4 hours or continuously) Placental separation (hourly in case of severe preeclampsia) Ultrasound for fetal growth (every 2 weeks) Non stress test (twice weekly)

Management: - delivery is always the appropriate maternal therapy. - fetal risk must be balanced against maternal risk. _consider conservative management between 25_30 weeks. _delivery indicated for severe preeclampsia, IUGR or fetal distress. - treating hypertension _treat for greater than 160/110 mmHg. _goal is to lower diastolic to 90 to 100 mmHg. _drug therapy: hydralazine _carefully monitor urinary output. - preventing convulsion _drug of choice is magnesium sulfate _treat all preeclamptic patient during labor and 24 hours postpartum.

Nursing Care Plan Nursing diagnosis: Excess fluid volume related to pathophysiologic changes of gestational hypertension and increased fluid overload. Nursing intervention - monitor vital sign every hour - monitor intake and output strictly, notify health care provider if urine output is less than 30 ml/hr - An indwelling urinary catheter may be inserted to allow accurate recording of output. - control I.V fluid intake using continuous infusion pump. - assess edema status and report pitting edema of 2. - monitor hematocrit level to evaluate Intravascular fluid status - auscultate breath sound every 2 hrs and report sign of pulmonary edema wheezing, crackles, shortness of breath, increase pulse rate, increased respiratory rate Nursing diagnosis: Ineffective tissue perfusion related to altered placental blood flow caused by vasoconstriction of blood vessels.

Nursing intervention: - promote bed rest - When the body is in a recumbent position, sodium tend to be excreted at a faster than during activity. Bed rest, therefore, is the best method of aiding increased evacuation of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension syndrome. - monitor fetal activity - evaluate NST to determine fetal status. - increased protein intake to replace protein lost through kidney. Nursing diagnosis Risk for injury related to seizure or to prolonged bed rest or other therapeutic regimens. Nursing intervention: - instruct on the importance of reporting headaches, visual changes, dizziness and epigastric pain. - instruct to lie down on the left side if symptoms are present. - keep the environment quiet and as calm as possible. - if patient is hospitalized, side rails should be padded and remain up to prevent injury if seizures occurs. - if patient is hospitalized, have oxygen and suction setup along with a tongue blade and emergency medications, immediately available for treatment of seizures. - assess DTRs and clonus every 2 hrs. increase frequency of assessment as indicated by patients condition. Nursing diagnosis: Alteration in pattern of urinary elimination related to hypertension, proteinuria and edema. Nursing intervention: - check urinary output every hour. - report urinary output of less than 100 ml/4hour. - check intake every 8 hours. - check urine for protein every 8 hours Nursing diagnosis: Anxiety related to diagnosis and concern for self and fetus Nursing intervention: - explain the disease process and treatment plan including signs and symptoms of the disease process. - explain that preeclampsia doesnt lead to chronic hypertension. - discuss the effects of all medications on the mother and fetus - allow time to ask questions and discuss feelings regarding the diagnosis and treatment plan.

Source: http://www.nursing-lectures.com/2011/03/pregnancy-related-hypertension-and.html