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
five
causes of maternal and infant illness and death, causing an estimated 13% of
all
maternal deaths worldwide or literally a maternal death every 12 minutes.2
Approximately 5 to 8 percent of pregnancies are affected by preeclampsia
meaning that more than 6.6 million women worldwide suffered from the
disease
in 2002.3
Preeclampsia causes 15% of premature births in industrialized countries
and it
the 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. XYZ
ADDRESS: Brgy. Buao Gandara, Samar
SEX: Female
STATUS: Single
BIRTHDATE: November 11, 1980
BIRTHPLACE: Gandara, Samar
AGE: 31 years old
NATIONALITY: Filipino
RELIGION: Roman Catholic
DATE OF ADMISSION: January 3, 2012
TIME OF ADMISSION: 8:20am
TYPE OF ADMISSION: New
ADMITTING PHYSICIAN: Dr. Nanoy
CHIEF 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 tab OD, and Digoxin 0.25mg tab 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 HISTORY
Ms. XYZ had complete immunizations during
childhood.



FAMILY HEALTH HISTORY
Ms. XYZs MOTHER had a history of
hypertension while she was pregnant.

PHYSICAL
ASSESSMENT

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 SIGNS
BP: 170/120 RR: 22 cpm
PR: 105 bpm Temp.: 37C

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

Blood: consisting of liquid plasma and cells
Blood vessels (vascular system): the "channels"
(arteries, veins, capillaries) which carry blood
to/from all tissues. (Arteries carry blood away from
the heart. Veins return blood to the heart.
Capillaries are thin-walled blood vessels in which
gas/ nutrient/ waste exchange occurs.)
Heart: a muscular pump to move the blood



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


NURSING
CARE
PLAN

CUES NURSING
DIAGNOSIS
GOAL NURSING
INTERVENTION
S
RATIONALE EVALUATION
Subjective:
Dyspnea
Fatigue
Objective:
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.