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Pre eclampsia Page |1
O B J E C T I V E S

Presentors will be able to:
Explain briefly the disease process: its causes, effects, management, treatment, and possible preventions.
Determine the pathophysiology of the condition with their rationale for occurrence of each manifestation.
Determine why certain management and medications are given and provided for the condition.
Explain briefly how and why certain diagnostic tests are done for the condition.
Review the concepts about the anatomy and physiology with regards to the condition.
Provide health teachings to the patient about certain interventions in the maintenance of health care.
Discuss options for surgical management for Preeclampsia.
Students or audience will be able :
To recognize the cause and risk factors of Preeclampsia.

To develop a comprehensive assessment for the disease process.
To understand the anatomy and physiology of the Renal/Urinary System, Cardiovascular System, Vascular System, and Female Reproductive
System.
Clinical Instructors will be:
Able to give recommendations or suggestions necessary for the improvement of the case sharing.
Able to ask questions regarding the case for further understandings.
Able to evaluate the presentation with utmost fairness.
Group2 A B G L N P P Q R Y
I N T R O D U C T I O N
Preeclampsia, also referred to as toxemia, is a medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension) in
association with significant amounts of protein in the urine. It refers to a set of symptoms rather than any causative factor. Preeclampsia has been
described as a disease of theories, because the cause is unknown.
Preeclampsia is a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the
mother's urine (as a result of kidney problems). It is the most common of the dangerous pregnancy complications; it may affect both the mother and
the unborn child. Pre-eclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the
condition is known as eclampsia-the second leading cause of maternal death in the U.S. Preeclampsia is also a leading cause of fetal complications,
which include low birth weight, premature birth, and stillbirth.
Preeclampsia may develop from 20 weeks gestation (it is considered early onset before 32 weeks, which is associated with increased morbidity).
Its progress differs among patients; most cases are diagnosed pre-term. Preeclampsia may also occur up to six weeks post-partum.
Preeclampsia is classified into mild and severe. Preeclampsia is mild in 75% of cases and severe in 25% of them. In its extreme, the disease
may lead to liver and renal failure, disseminated intravascular coagulopathy (DIC), and central nervous system (CNS) abnormalities. If preeclampsia-
associated seizures develop, the disorder has developed into the condition called eclampsia.
Mild preeclampsia is defined as the presence of hypertension (BP 140/90 mm Hg) on 2 occasions, at least 6 hours apart, but without evidence
of end-organ damage in the patient.
Severe preeclampsia is defined as the presence of 1 of the following symptoms or signs in the presence of preeclampsia:
SBP of 160 mm Hg or higher or DBP of 110 mm Hg or higher on 2 occasions at least 6 hours apart
Proteinuria of more than 5 g in a 24-hour collection or more than 3+ on 2 random urine samples collected at least 4 hours apart
Pulmonary edema or cyanosis
Oliguria (< 400 mL in 24 h)
Persistent headaches
Epigastric pain and/or impaired liver function
Thrombocytopenia
Oligohydramnios, decreased fetal growth, or placental abruption
The incidence of preeclampsia in the 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.
In the Philippines, according to the Department of Health, Maternal Mortality Rate (MMR) is 162 out of 10,000 live births (Family Planning Survey,
2006). Maternal deaths account for 14% of deaths among women. For the past five years all of the causes of maternal deaths exhibited an upward
trend. Preeclampsia showed an increasing trend of 6.89%; 20%; and 40%;. Ten women die every day in the Philippines from pregnancy and childbirth
related causes but for every mother who dies, roughly 20 more suffer serious disease and disability.
The only known treatments for eclampsia or advancing preeclampsia are abortion or delivery, either by labor induction or Caesarean section.
Magnesium sulphate is the first-line treatment of prevention of primary and recurrent eclamptic seizures. The mother and the family deserve a careful
teaching regarding the problem, its observation, and its treatment. Regular, adequate prenatal care is the best insurance for control of the complication.
D E F I N I T I O N
O F
T E R M S

Arteries - Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure.
Bladder - a triangle-shaped, hollow organ located in the lower abdomen.
Blood pressure - Blood pressure measures the force of blood against the walls of the blood vessels. Extra fluid in the body increases the amount of
fluid in blood vessels and makes blood pressure higher. Narrow, stiff, or clogged blood vessels also raise blood pressure.
Capillaries - The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by
the lymphatic system.
Eclampsia - seizures that cannot be attributable to other causes, in a woman with preeclampsia.
Endothelium - is the thin layer of cells that lines the interior surface of blood vessels, forming an interface between circulating blood in the lumen and
the rest of the vessel wall.
Filtration - The first step in formation of urine is filtration. Filtration is the process by which the blood that passes through the glomerulus is filtered out,
so that only certain structures pass through into the proximal convoluted tubule.
Glumerular filtration rate (GFR) the total volume of renal filtrate that the kidneys form in 1 minute; average is 100-125 mL/minute.
Hyperreflexia - defined as overactive or over responsive reflexes.
Hypoxia - inadequate oxygen tension at the cellular level, characterized by tachycardia, hypertension, peripheral vasoconstriction, dizziness, and
mental confusion.
Intrauterine Growth Retardation (IUGR) failure to grow at the expected rate in utero.
Oncotic pressure is a form of osmotic pressure exerted by proteins in blood plasma that usually tends to pull water into the circulatory system.
Oligohydramnios - amniotic fluid volume that is less than expected for gestational age. It is typically diagnosed by ultrasound examination and may
be described qualitatively (eg, mild, moderate, or severe oligohydramnios) or quantitatively (eg, amniotic fluid index [AFI] <5).
Peripheral resistance - this term refers to the resistance the vessels offer to the flow of blood.
Proteinuria - The presence of abnormal quantities of protein in the urine, which may indicate damage to the kidneys.
Prostacyclin - is a prostaglandin with vasodilator properties.
Selective Reabsorption - This step is known as selective reabsorption because only some elements are reabsorbed back into the body.
Scotomata - A partial loss of vision or a blind spot in an otherwise normal visual field.
Thrombocytopenia - refers to lowering of the platelets, the blood cells that prevent us from bleeding. The medical term for a platelet is
Thrombocyte. Thrombo stems from Greek word "Thrombos" which means clot. Term Penia stems from Latin and means reduction.
Toxemia - an abnormal condition of pregnancy characterized by hypertension and edema and protein in the urine.
Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back.
Two ureters - narrow tubes that carry urine from the kidneys to the bladder.
Thromboxane - is a prostaglandin with vasoconstrictor properties.
Vasospasm - a condition in which blood vessels spasm, leading to vasoconstriction.
Veins - Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules, which in turn unite to form veins.
P H Y S I C A L
A S S E S S M E N T
& R E V I E W
O F
S Y S Y T E M

An accurate physical assessment requires an organized and systematic approach using the techniques of inspection, palpation,
percussion, and auscultation. It also requires a trusting relationship and rapport between the nurse and the patient to decrease the stress the patient
may have from being physically exposed and vulnerable. The patient will be much more relaxed and cooperative if the nurse explains what will be done
and the reason for doing it. While the findings of a nursing assessment do sometimes contribute to the identification of a medical diagnosis, the unique
focus of a nursing assessment is on the patient's responses to actual or potential problems.
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.
Systems Mild Preeclampsia Severe Preeclampsia Review of Systems Problem Identified
General Appearance Weight gain 2 lbs/week in Weight gain of 3 or more Patient may verbalize body Fluid volume excess
2nd trimester and 1lb/wk in lbs/wk in 2nd or 3rd weakness
3rd trimester trimester
Head/Hair/Face Mild edema Headache Patient may report Ineffective tissue perfusion
Edema in the Face, headache or dizziness. Volume Excess
EENT none Blurred vision Patient may report blurring Risk for injury,
of vision Altered Sensory perception
Mouth and Pharynx none none none No problem identified
Neck none none none No problem identified
Thorax/Lungs none Shortness of Breath (use of Patient may verbalize Bradypnea,

accessory muscle) difficulty in breathing Ineffective breathing pattern
Pulmonary Edema
Back none none none No problem identified
Breast and Axilla none none none No problem identified
Cardiovascular/Peripheral 140/90 mmHg taken at 160/110 mm Hg Patient may report chest Decreased cardiac output
Vascular least 6 hours. Thrombocytopenia pain and fatigue
Lymphatic none none none No problem identified
GIT Nausea Excessive Vomiting, Patient may report Risk Fluid volume deficit
nausea, Severe Epigastic epigastric discomfort Acute pain
Pain RUQ Altered Comfort
GUT Oliguria Proteinuria (3- 5 g on a Patient may verbalize Less urine output
Proteinuria of 1-2+ on a 24 hr. sample) decreased urine output
random sample Elevated serum creatinine
as lab test revealed
Oliguria (500mL less than
in 24 hrs)
Musculoskeletal none Fatigue Patient may verbalize Fatigue

fatigue
Integumentary none Extensive edema Patient may verbalize body Ineffective Tissue perfusion
Puffiness in hands weakness
Neurologic Headache, dizziness Altered consciousness, Patient may verbalize Risk for injury
Seizure/Brain damage severe headache, dizziness Acute Pain
Endocrine none none none No problem identified
P r e e c l a m p s i a P a g e | 10
D I A G N O S T I C
T E S T

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

Values
Serum Creatinine
-To assess glomerular In men: 0.8to Elevated levels generally indicate renal Pre test:
filtration 1.2 mg/dL disease that has seriously damage 50% -Explain to the patient that
-to screen for renal damage In women: 0.6 or more of the nephrons. the test evaluates kidney
to 0.9 mg/dL function.
-Tell the patient that the test

requires a blood sample.
Explain who will perform the
venipunture and when.
-Explain to the patient that he

may experience slight
discomfort from the
tourniquet and needle
puncture.
-Instruct the patient that he

need not restrict food and
fluids.
-Notify the laboratory and

physician of drugs he patient
is taking that may affect test
results it may be necessary
to restrict them.
Post test:
-Apply direct pressure to the
venipuncture site until
bleeding stops.
-Inform the patient that he
may resume his usual
medications discontinued
before the test.

Values
To evaluate Kidney . Pre test:

function and aid in the 8-20mg/dL Elevated levels: Tell the patient that this test is
Blood Urea Nitrogen diagnosis of renal disease Renal disease. Reduced renal used to evaluate kidney
and to aid in the blood flow(caused by dehydration, for function.
assessment of hydration. example) urinary tract obstruction and Inform the patient that he
increased protein catabolisms (such as need not to restrict food and
burns) fluids but should avoid a diet
high in meat.
Lower levels:
Severe hepatic damage, Tell the patient that the test
malnutrition, and over hydration. requires a blood sample.
Explain who will perform the
venipuncture and when.
Explain to the patient that he

may experience slight
discomfort from the
tourniquet and the needle

puncture.
Notify the laboratory and

physician of drugs the patient
is taking hat may affect test
results they may be need to
be restricted.
Post test:
-apply direct pressure to the
venipunture site until
bleeding stops.
-inform the patient that he
may resume taking his usual
medications stopped before
the test.

Values
Bleeding time -To assess overall 3 to 6 minutes Abnormal bleeding time may indicate Pre test:
hemostatic function in the template disorders linked to thrombocytopenia, -Explain o the patient that the
(platelet response to injury method such as hodgkins disease, acute bleeding time test measures
and functional capacity of 3 to 6 minutes leukemia, disseminated intravascular the time it takes to form a clot
vasoconstriction) in the ivy coagulation, hemolytic disease of the and sop bleeding.
-To detect platelet function method newborn.
disorders. 1 to 3 minutes -Tell the patient who will
in the duke Prolong bleeding time in a pt with perform he test and when it will
method normal platelet count suggest a platelet take place.
function disorder and requires further
investigation with clot retraction, -Inform the patient that he may
prothrombin consumption and platelet feel some discomfort from the
aggregation test. incisions the antiseptic, and the
tightness if the blood pressure
cuff.
-Inform the patient that

depending on the method
used, incisions or punctures
may leave tiny scars that
should be barely visible when
healed.
-Notify the laboratory and

physician of drugs the patient is
taking that may affect test
results it may be necessary to
restrict them.
Post test:
-In a patient with a bleeding
tendency, maintain a pressure
bandage over the incision for
24-48 hours to prevent further
bleeding. Check the test area
frequently, keep the edges of
the cuts aligned to minimize
scaring.
-If bleeding hasnt slowed after

15minutes, stop the test and
apply direct pressure to the test
site.
-In other patients, a piece of
gauze healed in place by an
adhesive bandage is sufficient.
-Instruct the patient that he may

resume medications stopped
before the test.

Values
Pre test
Liver Enzyme - -To aid detection and Ast levels fluctuate in response to the -Explain to pt that this test
Aspartate differential diagnosis of 12-31 extent ofcellular necrosis, being heart and liver functions.
Aminotransferase (AST) acute hepatic disease. units/liter transiently and minimally increase early
in disease process and extremely -Inform the pt that the test
-To monitor patient increase durng the most acutephase. usually requires three
progress and prognosis in Depending on when the initial sample is venipunctures one on
cardiac and hepatic drawn, ast levels may increase admission and one each day
diseases. indicating increasing disease severity for the next two days.
and tissue damage, or decrease,
-To aid diagnosis of m.i in indicatinf disease resolution and tissue -Tell the pt that he need not
correlation with creatine repair. restrict foods and fluids.
kinase and lactate
dehydrogenase levels. -Maximum elevations more than 20 -Notify the laboratory and
times normal may indicate acute viral physician drug of the pt is
hepatitis , severe skeletal muscle taking that may affect test
trauma, extensive surgery, drug results it may be necessary
induced hepatic injury,or severe to restrict them.
passive liver congestion-
Post test
-high levels 10 to 20 times normal may -Apply direct to the
indicate a severe m.i, severe infectious venipuncture site until
mononucleosis, or alcoholic cirrhosis. bleeding stops.
-Instruct the patient that he

may resume medications
stopped before the test.

values
Nonstress, Fetal (NST, -The NST is a method to Acceleration of Test results for the NST may Pretest
Fetal Activity evaluate the viability of a the FHR about be reactive (or normal)- 2 or
Determination) fetus. It documents the 15 bets/min. and more fetal heart rate increases -Explain the procedure to the client.
remained in the testing period (usually 20
placentas ability to -Encourage the verbalization of the
elevated for 15 minutes)
provide an adequate seconds (done patients fears. The necessity for the
blood supply to the fetus. for 10-20 Non-reactive-there is no study usually raises realistic fears in
The NST can be used to minutes). change in the fetal heart rate the expectant mother.
evaluate any high-risk when the fetus moves. This
pregnancy in which fetal may be indicate a problem that -If the patient is hungry, instruct her to
well-being may be requires further testing. eat before the NST is begun. Fetal
threatened. These activity is enhanced with a high
pregnancies includes maternal serum glucose level.
those marked by
During
diabetes, hypertensive
disease of pregnancy -After the patient empties her bladder,
(toxemia), intrauterine place her in the Sims position.
growth retardation, Rh-
factor sensitization, -Place an external fetal monitor on the
history of stillbirth, patients abdomen to record the FHR.
postmaturity, or low estriol The mother can indicate fetal
levels. 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 mothers 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
physicians office or a hospital unit.
-Tell the patient that no discomfort is

associated with the NST.
Post test
-If the results detect a nonreactive

fetus, calmly inform the patient that
she is a candidate for the CST.
Diagnostic Test Purpose Normal Results and interpretation Nursing

values responsibilities
Biophysical profile -Measures your baby's Your baby will be -A score of eight or 10 out of 10 provides a A towel or cloth can be
heart rate, muscle tone, scored on five reassuring BPP score. If the score is eight, used to wipe off excess
movement, breathing, things during the with a decrease in amniotic fluid volume, gel and dry the
and the amount of test. A score of 0 delivery may be indicated, with fetal maturity. abdomen after the test.
amniotic fluid around your (abnormal) or 2 In the event that test
baby (normal) will be -A score of six arouses suspicions of chronic results indicate fetal
given in each of fetal hypoxia. A repeat test within four to six compromise, a health
these categories: hours may be ordered. Delivery may be care professional
indicated if there is a reduction in the amniotic should remain with the
-Muscle fluid volume. mother to provide
movements emotional support and
-A score of four is suspicious of chronic fetal answer questions as
-Body hypoxia. A fetal lung maturity test may be needed.
movements done to assess readiness for delivery.
Delivery is indicated if a repeat BPP after 24
-Breathing hours confirms a score of four or below.
movements
-A score of zero to two elicits a strong
-Amniotic fluid suspicion of chronic fetal hypoxia. The BPP
levels testing period may continue for two hours
instead of the usual 30 minutes. If the two-
-Heart rate hour score is four or below, delivery is
indicated if the fetus has a good chance at
extrauterine survival.

Diagnostic Test Purpose Normal Results and Nursing Responsibilities
values Interpretation
Platelet Count -To evaluate platelet Adults: 140,000 >A count below 50,000/ul Pre test
production. to 400,000/ul can cause spontaneous -Explain to the pt. that the platelet count
bleeding when the count is determines whether the clots normally.
below 5,000/ul, fatal
-To assess the effects of central nervous system -Tell the pt that the test requires blood
chemotherapy or bleeding or massive GI sample. Explain who will perform the
radiation therapy on hemorrhage is possible. venipuncture and when.
platelet production.
> A decreased count can -Notify the laboratory and physician of
result to from aplastic or drugs the pt is taking that may affect test
hypoplastic bone marrow; results, it may be necessary to restrict
infiltrative bone marrow them.
disease sush as leukemia,
or disseminated infection. -Inform the pt that he need not to restrict
food and fluids.
Post test
-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.
Diagnostic Test Purpose Normal Value Results and Interpretation Nursing Resposibilities
Hematocrit -To aid diagnosis of In men: 42% to 52% >Low HCT suggest anemia, Pre test
polycythemia, anemia In women: 36% to hemodilution, or massive blood -Explain to the pt. that the hct
or abnormal states of 48% loss test detects anemia and other
hydration. >High HCT indicates abdominal conditions.
-To aid in the calculation polycythemia or
erythrocyte indices. hemoconcentration caused by -Tell that the test requires a
blood sample.
blood loss and dehydration
-Explain to the pt that he may
feel slight discomfort from the
tourniquet and needle puncture.
-Inform the pt that he need not

to restrict food and fluids.
-If a pt is a child explain to him

and his parents that small
amount of blood will be taken
from his fingers and ear lobes.
Post test
- Ensure subdermal bleeding
has stopped before removing
pressure.
- To aid in the calculation of

erythrocyte.
Diagnostic Test Purpose Normal Values Results and interpretation Nursing Resposibilities
Alanine Aminotransferase -To detect and evaluate 8-50 iu/L -Very high ALT levels up to 50 times Pre test
(ALT) treatment of acute hepatic normal suggest viral or severe drug -Explain to the PT. that this test
disease specially hepatitis induced hepatitis or other hepatic assesses levels liver functions.
and serosis without disease with extensive necrosis.
jaundice. -Tell the patient tat the test
-Moderate to high levels may requires a blood sample. Explain
-To distinguish between indicate infectious mononucleosis, who will perform the
myocardial and hepatic chronic hepatitis, intra hepatic venipuncture.
tissue damage (use with cholestasis or cholicystitis, early or
aspartate amino transferase improving acute viral hepatitis, or -Inform the pt. that he need not
). severe hepatic congestion from restrict food and fluids.
heart failure.
-To assess hepatotoxity of -Notify the laboratory and
some drugs -Slight to moderate elevations of alt physician of drugs the pt is taking
may appear in any conditions that that may affect test results, it may
produces acute hepatocellular be necessary to restrict them.
injury, such as active cirrhosis and Post test
drug induced or alcoholic hepatitis. -Apply direct pressure to the
-Marginal elevations occasionally venipuncture site until bleeding
occur in acute myocardial stops.
infarctions, reflecting secondary
-Instruct the pt. that he may
hepatic congestions or the release of
resume medications stop before
small amounts of ALT from
the step.
myocardial tissue.
Diagnostic Test purpose Normal values Results and Interpretation Nursing Responsibilities
Urinalysis (UA) -To screen the patients Color, straw to Protein Pretest:
urine for the renal or urinary dark yellow
tract disease Increased Levels Explain that this analysis
Odor, slightly helps to diagnose renal or
Nephrotic syndrome
aromatic urinary tract disease and to
Glomerulonephritis
Malignant hypertension evaluate over all body
-To help detect metabolic or Appearance, functions.
Diabetic glomerulosclerosis
systemic disease unrelated clear
Polycystic disease
to renal disorder Lupus erythematosus Inform the patient that he
Specific gravity, need not restrict food and
Goodpastures syndrome
100
Heavy-metal poisoning fluids.
-To detect substances Bacterial pyelonephritis
Nephrotoxic drug therapy Notify the laboratory and
(drugs)
Renal disease involving the physician of drugs the
glomeruli is associated with patient is taking that may
Protein proteinuria. affect laboratory results.
Trauma.Protein can spill into the
- 0-8 mg/dl urine as a result of traumatic Posttest:
destruction of the blood-urine
- 50-80 mg/24 barrier. Inform the patient that he
hr (at rest) Macroglobulinemia. With may resume his usual diet
increased globulin within the and medications.
- <250 mg/24 hr blood, albumin is secreted in an
(during exercise) attempt to to maintain ocncotic
homeostasis.
Multiple myelomas. 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.
Diagnostics Purpose Normal values Results and interpretation Nursing responsibilities

Low albumin levels can Check the albumin level
suggest liver disease. from the protein
Serum albumin A serum albumin test 3.4 - 5.4 g/dL Other liver enzyme tests electrophoresis results.
measures the amount of are ordered to determine Many clinical problems
this protein in the clear exactly which type of liver are the result of a
liquid portion of the blood. disease. serum albumin deficit.
Low albumin levels can Assess for peripheral
reflect diseases in which edema in the lower
the kidneys cannot prevent extremities when
albumin from leaking from the albumin level is
the blood into the urine and decreased.Albumin is
being lost. In this case, the the major protein
amount of albumin compound responsible
(or protein) in the urine also for plasma colloid
may be measured. osmotic pressure. With a
Low albumin levels can decreased albumin level,
also be seen fluid seeps out of the
in inflammation, shock, blood vessels into the
and malnutrition. tissue spaces.
Low albumin levels may Assess for urinary
also suggest conditions in output. Renal and
which your body does not collagen (lupus)
properly absorb and digest diseases occur with
protein (like Crohn's abnormal protein
disease or sprue) or in fractions. Urine output
which large volumes of should be 25mL/h or
protein are lost from the 600mL/24 hours.
intestines.
High albumin levels usually

reflect dehydration.
Diagnostics Purpose Normal values Results and Nursing

interpretation responsibilities
1st-trimester fetal
ultrasound is done to: A towel or cloth can be
Fetal ultrasound o Determine how your The developing baby, Typically, a fetal ultrasound used to wipe off excess
pregnancy is progressing. placenta, amniotic fluid, and offers reassurance that a gel and dry the
o Find out if you are pregnant surrounding structures are baby is growing and abdomen after the test.
with more than 1 fetus. normal in appearance and developing normally. If your In the event that test
o Estimate the age of the appropriate for the health care provider wants results indicate fetal
fetus (gestational age). gestational age. more details about your compromise, a health
o Estimate the risk of Note: Normal results may baby's health, he or she care professional should
a chromosome defect, such vary slightly. Talk to your may recommend additional remain with the mother
as Down syndrome. doctor about the meaning of tests. to provide emotional
o Check for birth defects that your specific test results. support and answer
affect the brain or spinal questions as needed.
cord.
2nd-trimester fetal
ultrasound is done to:
o Estimate the age of the
fetus (gestational age).
o Look at the size and
position of the fetus,
placenta, and amniotic fluid.
o Determine the position of
the fetus, umbilical cord,
and the placenta during a
procedure, such as
an amniocentesis or
umbilical cord blood
sampling.
o Detect major birth defects,

such as a neural tube defect
or heart problems.
3rd-trimester fetal
ultrasound is done to:
o Make sure that a fetus is
alive and moving.
o Look at the size and
position of the fetus,
placenta, and amniotic fluid.
N O R M A L
A N A T O M Y
& P H Y S I O L O G Y

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
There are two circulatory "circuits":
Pulmonary circulation, involving the "right heart," delivers blood to and from the lungs. The pulmonary artery carries oxygen-
poor blood from the "right heart" to the lungs, where oxygenation and carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from
the lungs back to the "left heart."Systemic circulation, driven by the "left heart," carries blood to the rest of the body. Food products enter
the system from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems ultimately return to
the "right heart" via the inferior and superior vena cava.
A specialized component of the circulatory system is the lymphatic system, consisting of

moving fluid (lymph/interstitial fluid); vessels (lymphatics); lymphnodes, and organs ( bone marrow,
Liver , spleen, thymus). Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the lymph, the body
is able to eliminate the products of cellular breakdown and bacterial invasion.
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 (singular:
atrium), receive blood via veins. Passing throughvalves(atrioventricular (AV) valves), blood then enters the lower chambers, the
ventricles. Ventricular contraction forces blood into the arteries.
Oxygen-poor blood empties into the right atrium via the superior and inferior vena cava. Blood then passes through the tricuspid valve into
the right ventricle which contracts, propelling the blood into the pulmonary artery. The artery is the only artery that carries oxygen-poor blood. It
branches to the right and left lungs. There, gas exchange occurs -- carbon dioxide diffuses out, oxygen diffuses in.
Pulmonary veins, the only veins that carry oxygen -rich blood, now carry the oxygenated blood from lungs to the left atrium of the
heart. Blood passes through the bicuspid into the left ventricle. The ventricle contracts, sending blood under high pressure through the aorta, the main
artery for systemic circulation. The ascending aorta carries blood to the upper body; the descending aorta, to the lower body.
Vascular System - the Blood Vessels
Arteries, veins, and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of
capillaries connecting them. Arteries use vessel size, controlled by the sympathetic nervous system, to move blood by pressure; veins use one-way
valves controlled by muscle contractions.
Arteries
Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into
progressively thinner tubes and eventually become fine branches called arterioles. Blood in arteries is oxygen-
rich, with the exception o f t h e pulmonary artery, which carries blood to the lungs to be oxygenated.
Capillaries
The arterioles branch into the microscopic capillaries, or capillary beds, which lie bathed in interstitial fluid, or lymph, produced by the
lymphatic system. Capillaries are the points of exchange between the blood and surrounding tissues. Materials cross in and out of the capillaries by
passing through or between the cells that line the capillary. The extensive network of capillaries is estimated at between 50,000 and 60,000 miles long.
Veins
Blood leaving the capillary beds flows into a series of progressively larger vessels, called venules, which in turn unite to form veins. Veins are
responsible for returning blood to the heart after theblood and the body cells exchange gases, nutrients, and wastes. Pressure in veins is
low, so veins depend on nearby muscular contractions to move blood along. Veins have valves that prevent back-flow of blood.
Blood in veins is oxygen-poor, with the exception of the pulmonary veins, which carry oxygenated blood from the lungs back to the heart. The
major veins, like their companion arteries, often takethe name of the organ served. The exceptions are the superior vena cava and the inferior
vena cava, which collect body from all parts of the body (except from the lungs) and channel it back tothe heart.
BLOOD PRESSURE
High blood pressure (HBP) is a serious condition that can lead to coronary heart disease (also called coronary artery disease), heart
failure, stroke, kidney failure, and other health problems.
"Blood pressure" is the force of blood pushing against the walls of the arteries as the heart pumps blood. If this pressure rises and stays high over time,
it can damage the body in many ways.
Blood pressure is measured as systolic (sis-TOL-ik) and diastolic (di-a-STOL-ik) pressures. "Systolic" refers to blood pressure when the heart
beats while pumping blood. "Diastolic" refers to blood pressure when the heart is at rest between beats.
You most often will see blood pressure numbers written with the systolic number above or before the diastolic number, such as 120/80 mmHg.
(The mmHg is millimeters of mercurythe units used to measure blood pressure.)
Urinary System
How do the kidneys and urinary system work?
The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind
in the bowel and in the blood.
The kidney and urinary systems keep chemicals, such as potassium and sodium, and water in balance and remove a type of waste, called urea, from
the blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried
in the bloodstream to the kidneys.
Other important functions of the kidneys include blood pressure regulation and the production of erythropoietin, which controls red blood cell production
in the bone marrow.
Kidney and urinary system parts and their functions:
Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to remove liquid waste
from the blood in the form of urine; keep a stable balance of salts and other substances in the blood; and produce erythropoietin, a hormone
that aids the formation of red blood cells. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron
consists of a ball formed of small blood capillaries, called glomerulus, and a small tube called a renal tubule. Urea, together with water and other
waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing
urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15
seconds, small amounts of urine are emptied into the bladder from the ureters.
Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and
the pelvic bones. The bladder's walls relax and expand to store urine, and contract and flatten to empty urine through the urethra. The typical
healthy adult bladder can store up to two cups of urine for two to five hours.
Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the
bladder.
Nerves in the bladder - alert a person when it is time to urinate, or empty the bladder.
Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the
bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals
occur in the correct order, normal urination occurs.
URINE FORMATION
Urine Formation Steps
Filtration
The first step in formation of urine is filtration. Filtration is the process by which the blood that passes through the glomerulus is filtered out, so that
only certain structures pass through into the proximal convoluted tubule. The rate at which the blood is filtered is known as the glomerular filtration
rate, which is normally 125 ml/minute or 180 liters/day! The glomerulus lining is such that it only allows small molecules to filter through, like glucose,
plasma, ions like sodium and potassium, urea, etc. The larger molecules, like blood cells and protein cannot pass through the glomerulus. This is the
reason that when there are kidney diseases, the glomerulus lining is affected, due to which the protein molecules also pass through, leading to blood
and protein in urine.
Selective Reabsorption
As mentioned above, in filtration step of urine formation, there is only crude and elementary separation of waste products and a lot of water, glucose
and other important materials also pass through. Thus, there is need for reabsorption of these important elements back into the body, which is where
the second step, that is reabsorptions, comes in. This step is known as selective reabsorption because only some elements are reabsorbed back into
the body. Reabsorption occurs in two steps, which is active reabsorption (which requires energy) and passive reabsorption (which does not require
energy).
Due to the difference in concentration of the fluid inside and outside the tubules, 99% of the water returns into circulation and thus, is passively
absorbed, which is important for urine formation and flow. Provided the glucose levels are normal, almost all of the glucose is reabsorbed back into
the blood from the proximal tubules. This glucose is actively transported into the peritubular capillaries. However, when there is a very large amount
of glucose in the blood, then some of it passes into the urine, which is one of the signs of diabetes. Sodium ions are the only ions that are partially
absorbed from the renal tubules back into the blood.
Tubular Secretion
The last step in urine formation is tubular secretion. This is the step where the urine is made concentrated by increasing the concentration of waste
elements. Thus, in this stage, substances move into the distal and collecting tubules from blood in the capillaries around these tubules. These
substances are secreted by the mechanism of active transport. The substances secreted include hydrogen ions, potassium ions, ammonia, and
certain drugs or metabolic end products. Thus, the kidney tubules play a crucial role in maintaining the body's acid-base balance and maintaining the
electrolyte balance in the body.
The distal convoluted tubules then drain the urine into the collecting tubules. Then, several collecting tubules join together to drain their contents into
the collecting duct, which finally, after urine formation, flows into the ducts of Bellini. This then eventually reaches the renal pelvis, from where the
urine flows into the ureter to reach the urinary bladder.
Thus, these were the various urine formation steps that take place right from the time when blood flows into the kidneys, till urine is passed into the
ureters. The various urinary system diseases occur when there are problems with the functioning of the kidneys, which reflects in the final urine color,
odor and concentration.
The Female Reproductive System
The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called
the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally
occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make
its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In
addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.
During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When
the body no longer produces these hormones a woman is considered to be menopausal.
The function of the external female reproductive structures (the genital) is twofold: To enable sperm to enter the body and to protect the internal genital
organs from infectious organisms. The main external structures of the female reproductive system include:
Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are
relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the
labia majora are covered with hair.
Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora,
and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries
urine from the bladder to the outside of the body).
Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion.
Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by
a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation
and can become erect.
The internal reproductive organs include:
Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.
Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix,
which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a
developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.
Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.
Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from
the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to
the uterus, where it implants to the uterine wall.
PLACENTA AND FUNCTION
The placentas primary role is to ensure that oxygen is moved into your babys blood stream and carbon dioxide is carried away from your baby
however the waste is not limited to oxygen and also includes cleaning out other waste which is produced by your baby. In the same way that it
ensures oxygen reaches your baby, it also plays a role in ensuring that some nutrients are received.
The placenta is an extremely complex piece of biological equipment. It is a little bit like an artificial kidney, it allows your blood and the baby's to
come into very close contact - but without ever mixing. This enables your blood to pass across nutrients and oxygen to the baby, and waste products
like carbon dioxide to go back from baby to mother. It acts as the lung, kidney and digestive system for the baby.
The placenta also plays an important role in hormone production. Human chronic gonadotropin, or hCG is produced by the placenta. This
hormone can be found in your babys blood stream as early as 10 days into your pregnancy. This is of course not the only hormone which the placenta
produces as it is also responsible for the production of estrogen and progesterone .
The placenta also performs the important function of protecting your baby for possible infection however, it is not always able to distinguish
between what is a good substance and what isnt and this is why pregnant women are asked to avoid substances which may cause harm, such as
caffeine, alcohol, herbal substances and drugs.
P A T H O P H Y S I O L O G Y

N U R S I N G
C A R E
P L A N S

Problem: Epigastric pain (right upper quadrant)
Nursing diagnosis: Acute epigastric pain (right upper quadrant) related to poor oxygenation of the pancreas and liver 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 AND LIVER may
result in EPIGASTRIC PAIN. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )
CUES OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
INDEPENDENT
SUBJECTIVE: STO: 1. Determine pain history, 1. Change in pain The patient is expected to
e.g. location of pain, characteristics may manifest:
Patient may verbalize, After 4 hours of frequency, duration, and indicate developing
relaxation, patient will be complications Decrease pain scale
intensity using pain scale
alleviated from pain as of 4/10 from 8/10.
and relief measures Maintains rest
Pain on the right upper evidenced by absence used. without disturbance
quadrant of the of facial grimace and
from pain
abdomen, pain scale of 4/10. 2. Explain that nerves are 2. Reduces abdominal Maintains relaxation
severed or damaged but tension and promotes technique
that analgesics and sense of control. Resumes ADL
narcotics are available
OBJECTIVE: with doctors prescription.
LTO:
Irritable. After 2 days of duty, 3. Promote proper body 3. promotes relaxation

From 0-10, pain can be pain will be relieved and positioning to promote
rated as 8. patient resumes to her comfort, such as semi
Grimacing face fowlers position and
normal physical activity
elevation of the arm on
such walking, reaching the affected side. 4. promote relaxation and
out objects, etc. enables client to refocus
4. Provide alternative attention and may
comfort measures such enhance coping.
as backrubs and
encourage relaxation
techniques such as
guided imagery,
visualization, quiet
diversional activities such 5. Aids in relaxing the
as watching T.V and abdominal muscles
listening to radio.
5. Encourage protection
and the avoidance of
anything that can break
through the skin barrier or
impose stress on the arm
and shoulder.
Reference: Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6th edition
Problem: Edema
Nursing Diagnosis: Deficient fluid volume related to plasma protein loss, decreasing plasma colloid osmotic pressure allowing shifts out of vascular
compartment secondary to preeclampsia
Cause analysis: Vasospasm in the kidney increase blood flow resistance. Degenerative changes develop in kidney glomeruli because of 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 to equalized the
pressure. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )
CUES OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION
INDEPENDENT:
SUBJECTIVE: STO: 1. Set an appropriate rate of 1. to prevent peaks/valleys in

fluid intake/infusion fluid level.
throughout 24-hour period
2. Monitor urine specific
The patient may Within 8 hours of gravity. 2. Measures the kidneys ability The patient is expected
report less effective nursing to concentrate urine. In to manifest :
amount of interventions, patient 3. Weigh daily at same time of intrarenal failure, specific
day, on same scale, with gravity is usually equal to/less Increase urine
urination. will be able to manifest
same equipment and than 1.010, indicating loss of output as
increase urine output evidence by BP
clothing. ability to concentrate the urine.
as evidenced by BP 3. Daily body weight is best within normal
within individuals monitor of fluid status. A range.
normal range and urine weight gain of more than 0.5 Stable weight
kg/day suggests fluid retention. Vital signs within
Normal range
output within the range 4. Assess skin, face, Absence of

of 30-40ml/hr. dependent areas for edema. EDEMA
Evaluate degree of edema 4. Edema occurs primarily in
(on scale of +1+4). dependent tissues of the body,
e.g., hands, feet, lumbosacral
area. Patient can gain up to 10
OBJECTIVE: lb (4.5 kg) of fluid before pitting
edema is detected.
5. Evaluate edematous
LTO: extremities, change position
Edema frequently. 5. to reduce tissue pressure and
risk of skin breakdown
Decrease
urine Within 3 days of
output(less giving effective nursing
than 30ml interventions, patient
/hr). will be able to manifest 6. Fluid overload may lead to
Blood 6. Auscultate lung and heart pulmonary edema and HF
a fluid balance as sounds.
pressure evidenced by development of
above 140/90 evidenced by adventitious breath sounds,
Pulse rate appropriate urinary extra heart sounds. (Refer to
greater than output, stable weight, 7. Assess level of ND: Cardiac Output, risk for
100 vital signs within consciousness; investigate decreased, following.)
Weight gain changes in mentation,
normal range and
presence of restlessness.
absence of edema.
7. May reflect fluid shifts,
accumulation of toxins,
8. Place in semi-fowlers acidosis, electrolyte
position as appropriate imbalances, or developing
hypoxia.
9. Suggest interventions, such
as frequent oral care,
chewing gum/hard candy, 8. to facilitate movement of

use of lip balm. diaphragm improving
respiratory effort.
10. Promote bed rest..

9. to reduce discomforts of fluid
restrictions.
COLLABORATIVE:
10. The best method of aiding
increased evacuation of
sodium and encouraging
1. Administer diuretics as diuresis.
prescribed after pregnancy.
1. Promote adequate urine

volume
Reference: Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6 th edition
Problem: Proteinuria
Nursing Diagnoses: Altered urinary elimination r/t fluid shifting secondary to preeclampsia
Cause analysis: Increase nutrient loses because of the excretion of the protein in the urine. Body proteins are use for energy when calorie intake is
insufficient. Increase nutrient requirements as a pregnant women they need sufficient nutrients to provide their needs and to the fetus. Energy
requirements are essential for fetal and placental growth but because of some food restrictions it is not well provided.( Med-Surgical 6th edition by:
Black,pg.1426.)A
Cues Objectives Nursing Rationale Evaluation

intervention
Subjective: STO: The patient

is expected
The patient may verbalized: After 8 hours of effective nursing intervention patient will be Independent: 1. Establishes to manifest:
able to verbalize understanding about dietary needs consist of guidelines for
Complaints of some food intake of high protein foods such as milk product, fish, and 1. Assess determining
restrictions. poultry. Avoiding high sodium foods such as cheese, goat milk, clients dietary needs
carrot juice, butter. nutritional and educating
status, condition client. Developed
Objective: of hair and nails, Malnutrition may a dietary
and height and be a contributing meal plan
LTO: pregravid that was
factor to the
weight. low sodium
edema
excess amount of After 3 days of nursing interventions patient will be able to 2. Provide onset of PIH, and low fat
protein in the urine. demonstrate knowledge of proper diet as evidenced by information specifically diet.
developing a dietary plan within own financial resources about normal
weight gain in When client
pregnancy, follows a low-
modifying it to protein diet, has
meet clients insufficient
needs caloric intake,
and is
because it overweight or
places the fetus underweight by
at risk for 20% or more
ketosis. before
conception.
3. Provide
oral/written 2.The
information underweight
about action and client may need
uses of protein a diet higher in
and its role in
development of . calories; the
PIH. obese client
should avoid
4. Provide dieting
information
about effect of
bed rest and
reduced activity
on protein 3. Daily intake of

requirements. 80100 g/day
(1.5 g/kg) is
sufficient to
5. Use flavoring replace proteins
agents (e.g. lost in urine and
lemon and allow for normal
herbs) is salt is serum oncotic
restricted pressure.
4. Reducing
metabolic rate
6. Limit through bed rest
fiber/bulk if and limited
indicated activity
decreases
protein needs.
7. promote
pleasant,
relaxing 5. to enhance
environment, food satisfaction
including and stimulate
socialization appetite
when possible
8. 6. because it
Prevent/minimiz may lead to
e unpleasant early satiety
odors/sights.
7. To enhance
9. Encourage intake.
use of lozenges
and so forth
10. Promote
adequate/timely 8. May have a
fluid intake negative effect
on
appetite/eating.
9. To stimulate
salivation when
dryness is a
factor
10. Limiting
fluids 1 hour
prior to meal
decreases
possibility of
early satiety
Collaborative:
Helpful in
Refer to creating
dietitian, as individual dietary
indicated. plan
incorporating
specific
needs/restriction
s
Reference: Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6 th edition
Problem: Risk for Fetal Injury
Nursing Diagnosis: Risk for (Fetal) Injury related to reduce placental perfusion secondary to vasoconstriction secondary to preeclampsia
Cause Analysis: With severe preeclampsia, the cardiac system can become overwhelmed because the heart is forced to pump against rising
peripheral resistance. This reduces blood supply to organs, most markedly in the kidneys, pancreas, liver, brain, and PLACENTA. Poor placental
perfusion may reduce the fetal nutrient and Oxygen supply. (Maternal and child nursing by PILLITTERI 5 th edition pp.426)
Subjective: ST0: Independent: Independent: The fetus is expected to

manifest:
Not applicable After 8 hrs of nursing 1. Monitor and assess vital 1. To obtain baseline
signs. normal HR (120-160
interventions, the patients 2. To determine bpm)
placental perfusion will 2. Assess the patients presence of
general physical abnormality.
increase sd rvidenced by condition. absence of signs of
fetal heart rate within 120- 3. To avoid putting fetal distress
160 bpm. 3. Instruct mother to pressure on the
assume a left lateral inferior vena cava.
position.
4. To increase normal fetal movement in
LTO:
4. Promote bed rest. uteroplacental
an hour (3
circulation and
prevent too much movements/hour)
After 3 days of nursing workload on the
Objective: heart.
5. Encourage relaxation
interventions, the patient techniques such as deep
will Breathing. 5. To provide comfort.
Patient demonstrate a decrease in
6. Encourage patient to
systemic vasoconstriction avoid constipation by 6. Straining defecation
manifested:
increasing fiber intake. might put pressure
to increase uteroplacental
A systemic on the uterus which
vasoconstriction circulation as evidenced could injured the
by intrauterine growth already
7. Instruct mother on the
during ultrasound. compromised fetal
possible complications
Patients fetus the disease can cause to
health.
the fetus.
may manifest: 7. To enhance patients

8. Discuss importance of participation in the
Intrauterine having an adequate treatment regimen.
growth blood circulation going to
retardation the placenta. 8. For patient
Changes in fetal education.
activity/ heart .
rate(less than or Dependent:
more than 120- 1. To help in
160 bpm) respiration.
Fetal demise
1. Administer oxygen as
indicated.
Reference: Nurses Pocket Guide Book, 9th edition by Doenges et.al pp.369
Problem identified; lack of knowledge
Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition,prognosis, self care and treatment needs related to lack of
exposure/unfamiliarity with information resources, misinterpretation secondary to preeclampsia
Cause analysis: Anticipatory anxiety and patient lacks in psychological and educational information. Cause analysis: A new problem or condition will
acquire the individual to learn new behaviors to help maintain optimal health & function. Some information will be used only temporarily while other
information will result in lifelong behavior change. (NDCP by Neal et.al.)
Individuals coping with present illness with varied pharmacological treatment regimen, unfamiliar and often complex procedures,
commonly experience a deficit in knowledge.
(Medical surgical Nursing by Smeltzer and Bare 7th ed. pg. 1303)
Cues Objectives Nursing interventions Rationale
STO: Independent: The patient is expected to:
Questions/request for After 2-3 days of nursing 1. Assess 1. Establishes data base 1. Verbalize accurate
information interventions and health clients/couples and provides information information about
misinterpretation teachings, the patient will knowledge of the about areas in which diagnosis,
Verbalization of prognosis, and
be able to verbalize disease process. learning is needed.
problem potential
Statement of accurate information 2. Provide information Receiving information can complications at own
misconception about diagnosis, about pathophysiology promote understanding level of readiness.
Inaccurate follow- prognosis, and potential of Pre-eclampsia, and reduce fear, helping to 2. Verbalize
through of complications at own level implications for mother facilitate the treatment plan understanding of the
instructions, of readiness. and fetus; and the for the client. provide therapeutic needs
development of rationale for additional treatment and will be able to
preventable identify/use available
interventions, options, such as using low-
complications resources
LTO: procedures, and tests, dose (60 mg/day) aspirin appropriately.
as needed. to reduce
After 4-5 days of nursing
interventions and health thromboxane generation
teachings, the patient will by platelets, limiting Note:
be able to verbalize Current research in
understanding of the progress may
3. Provide information severity/incidence of PIH
therapeutic needs and will about signs/symptoms
be able to identify/use (pre-eclampsia)
indicating worsening of
available resources condition, and instruct
appropriately.
client when to notify 2. Helps ensure that client

healthcare provider. seeks timely treatment and
may prevent worsening of
4. Keep client informed preeclamptic state or
of health status, results additional complications.
of tests, and fetal well-
being.
3. Fears and anxieties can
be compounded when
5. Instruct client in how client/couple does not
to monitor her own have adequate information
weight at home, and to about the state of the
notify healthcare disease process or its
provider if gain is in impact on client and fetus.
excess of 2 lb/wk, or 0.5
lb/day.
6. Assist family 4. Gain of 3.3 lbs or
members in learning the greater per month in
procedure for home second trimester or 1 lb or
monitoring of BP, as greater per week in third
indicated. trimester is suggestive of
7. Review techniques PIH.
for stress management
and diet restriction. 5. Encourages
8. Provide information participation in treatment
about ensuring regimen, allows prompt
adequate protein in diet intervention as needed,
for client with possible and may provide
or mild preeclampsia.
Review self-testing of reassurance that efforts

urine for protein. are beneficial.
Reinforce rationale for
and implications of 6. Reinforces importance
testing. of clients responsibility in
treatment.
7. Protein is necessary for

intravascular and
extravascular fluid
regulation.
8. A test result of 2+ or
greater is significant and
needs to be reported to
healthcare provider. Urine
specimen contaminated by
vaginal discharge or RBCs
may produce positive test

result for protein.
PROBLEM: Seizure
NURSING DIAGNOSIS: Risk for injury related to fluid excess in cerebral area secondary to Pregnancy induced hypertension
CAUSE ANALYSIS: in patient having PIH (severe stage) there is vasoconstriction thus decrease blood supply on the brain. Decrease tissue
perfusion in the brain will eventually lead to seizures. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426 )
Cues Objectives Intervention Rationale Evaluation
INDEPENDENT
Subjective: 1. determined risk of The patient is expected

falling to manifest:
The patient may 2. Thoroughly orient to 1. it can help identify high
verbalized: environment. Show how risk of falling Prevent cause of
STO: to call assistance 2. This step alerts the injury as evidence
-Occurrence of seizure 3. Keep side rails up and nursing staff the by calling
after delivery. After giving nursing maintain bed in low increase risk of falls. assistance
intervention, the pt will position; ensure that 3. This safety measures whenever she
be able to explain ways wheels are locked on are use as part of a fall goes to the
to prevent injury as bed and commode; prevention program. restroom.
evidence by calling keep dim light in room 4. studies have indicated Absence of
at right. that falls are often seizures
assistance whenever
4. Assisted client to linked to the need in a Performs ADL
she goes to the
voiding at least every 4 hurry Perform seizure
restroom. hours. Take pt to the 5. To monitor pt and precautions
bathroom before prevent pt from
bedtime. accidentally falling
5. Asked family or SO to
LTO:
stay with client.
Objective: Within 1 week of DEPENDENT:
hospital stay, the pt will
be able to be free from
-Neurological deficit injuries as evidenced by Administered medication as
an absence of seizure prescribed by physician;
-Altered level of Essential for the activity of
activity.
consciousness many enzymes. Plays an
important role in
- Affected ADL. magnesium sulfate
-Onset of seizures after neurotransmission and

surgery muscular excitability
REFERENCE: Tbers Cyclopedic Medical Dictionary 18th ed. by Thomas, Clayton p 441.
Problem Identified: Shortness of breath, dyspnea
Nursing Diagnosis: Ineffective breathing pattern related to pulmonary edema.
Cause Analysis: Pulmonary edema is one of the complications of PIH, and is due to the increased permeability of the capillaries causing the
leakage of fluids to the insterstitial spaces of the lungs (Maternal and Child nursing by ADELE PILLITTERI 5 th edition pp.426 .
CUES OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: STO: Independent: The patient is expected to

manifest:
The patient may After 4 hours of proper 1. Aauscultate lung 1. Ddecreased airflow
complain of difficulty of nursing intervention the fields, noting occurs in areas Aabsence of
breathing. patient will be able to areas of consolidated with fluid. shortness of breath
decreased/absent Crackles and wheezes and dypsnea.
identify/demonstrate
airflow and are heard on Clear breath sound.
behaviors to achieve airway adventitious inspiration and/or Nno nasal flaring
clearance as evidenced by breath sounds: expiration in response Nno use of accessory
absence of nasal flaring, use e.g., crackles, to fluid accumulation. muscles
of accessory muscle, etc. wheezes.
2. Ttachypnea, shallow
Objective: respirations, and
2. Aassess asymmetric chest
Difficulty of movement are
rate/depth of
breathing frequently present
respirations and
Orthopnea because of discomfort
chest movement.
May have a of moving chest wall
respiratory rate of LTO:
and/or fluid in lung.
less than 12 bpm.
After 2 days of proper
Crackles, 3. Kkeeping the head
wheezing nursing intervention the
3. Eelevate head of elevated lower
Nasal flaring patient will display patent
diaphragm, promoting
airway with breath sounds bed, change
Use of accessory clearing; absence of position chest expansion,

muscle dyspnea. frequently. aeration of lung
segments, and
mobilization and
expectoration of
secretions to keep
airway clear.
4. Ddeep breathing
facilitates maximum
expansion of the
4. Aassist with lung/smaller airways.
frequent deep- Coughing is a natural
breathing self-cleaning
exercises. mechanism, assisting
Demonstrate/help the cilia to maintain
client to perform patent airway, and an
activity: e.g., upright position favors
effective coughing deeper, more forceful
while in upright cough effort.
position.
5. Fliquids (especially
warm liquids) aid in
mobilization and
expectoration of
secretions.
5. Fforce fluids to at
3000mL/day
(unless 1. Tto help in respiration.
contratindicated).
Offer warm, rather
than cold, fluids.
Dependent:
1. Aadminister
oxygen as
indicated for
underlying
pulmonary
condition.
Reference: NCP by Doenges, Moorehouse & Geissler Murr pp. 135-136.
Problem: Increased Blood pressure
Nursing Diagnosis: Decreased cardiac output related to vasoconstriction secondary to vasospasm and sensitivity to pressor substances
Cause Analysis: 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 5 th edition pp.426 )
CUES OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: 1. Comparison of The patient is expected to

STO: Independent: pressures provides manifest:
1. Monitor BP in both more complete
arms, 3-5 minutes picture of vascular Participated
The patient may verbalize : After 8 hours of giving apart while client is at involvement. activities the
effective dependent and rest, sitting, standing, reduced BP/cardiac
independent nursing care, for initial evaluation. workload.
the patient will Use correct cuff size Maintain BP within
Complaint of and accurate
demonstrate increase individually
discomfort in neck, technique. acceptable range.
dizziness. perfusion as evidenced by
Demonstrate stable
Complaint of decreased BP to 120/90 cardiac rhythm and
shortness of breath mmHg. 2. Note presence, quality rate within clients
Complaint of of central and 2. Bounding carotid,
normal range
weakness and peripheral pulses. jugular, radial,
120/80-130/80.
fatigue. femoral pulses
maybe observed/
palpated. pulses in
the legs/feet maybe
diminished,
reflecting effects of
LTO 3. Identify changes vasoconstriction and
related to systemic venous congestion.
peripheral alterations in
Objective:
Within 3 days giving circulation.
effective nursing care, the 3. To assess
Variation in blood
patient will demonstrate causative/
pressure(>120/90
contributing factors
mmHg)/hemodynamic hemodynamic stability as
4. Elevate head of bed
reading . evidenced of BP within and maintain head
Edema acceptable range of neck in midline or
Weak pulse pressure
120/80-130/80. neutral position.
Decreased peripheral
pulses
Cold, clammy skin 4. To provide

5. Measure urine output circulation/ venous
drainage
on a regular schedule
of shift provides
adequate fluid
depending on clients
need.
6. Cautioned client to
avoid activities that
increase cardiac 5. To provide baseline
workload. And review data
ways of avoiding
constipation and
encourage quiet, restful
atmosphere.
7. Provide for diet

restriction (DASH diet)
and increase frequent 6. Conserves energy
small feedings. and lowers tissue
oxygen demands.
8. Provide bed rest
9. Observe skin color,

temperature, capillary
refill time.
10. Provide calm and 7. To maintain

restful surroundings adequate nutrition
and minimize and fluid balance.
environmental
activity/noise. Limit the
number of visitors and 8. To avoid further
length of stay. increase of blood
pressure.
11. Provide comfort
measure, e.g. back and
neck massage, 9. Presence of pallor;
elevation of head. cool,, and delayed
capillary refill time
maybe due to
12. Instruct in relaxation peripheral
technique, guided vasoconstriction or
imagery. reflect cardiac
decompensation
10. Help reduced

sympathetic
stimulation/ promote
relaxation.
COLLABORATIVE:
1. Administer 11. Decrease discomfort

medication as and may reduced
indicated: sympathetic
stimulation.
Hydralazine
12. Can reduced

stressful stimuli,
produced calming
effect, thereby
reducing BP.
1. A direct- acting
vasodilator that
relaxes arteriolar
smooth muscle
Reference: Nurses Pocket Guide Book, 9th edition by Doenges et.al p.142
Problem: Risk for Fetal Injury
Nursing Diagnosis: Risk for (Fetal) Injury related to reduce placental perfusion secondary to vasoconstriction tertiary to Pregnancy Induced
Hypertension.
Cause Analysis: With severe preeclampsia, the cardiac system can become overwhelmed because the heart is forced to pump against rising
peripheral resistance. This reduces blood supply to organs, most markedly in the kidneys, pancreas, liver, brain, and PLACENTA. Poor placental
perfusion may reduce the fetal nutrient and Oxygen supply. (Maternal and child nursing by PILLITTERI 5 th edition pp.426)
Subjective: ST0: Independent: Independent: The fetus is expected to

manifest:
Not applicable After 8 hrs of nursing 9. Monitor and assess vital 9. To obtain baseline
signs. normal HR (120-160
interventions, the patients 10. To determine bpm)
placental perfusion will 10. Assess the patients presence of
general physical abnormality.
increase AEB fetal heart condition. absence of signs of
rate within 120-160 bpm. 11. To avoid putting fetal distress
11. Instruct mother to pressure on the
assume a left lateral inferior vena cava.
position.
LTO:
12. To increase normal fetal movement in
12. Promote bed rest. uteroplacental
an hour (3
circulation and
prevent too much movements/hour)
After 3 days of nursing
workload on the
Objective: interventions, the patient heart.
13. Encourage relaxation
will techniques such as deep
Breathing. 13. To provide comfort.
Patient demonstrate a decrease in 14. Encourage patient to 14. Straining defecation

systemic vasoconstriction avoid constipation by might put pressure
manifested: increasing fiber intake. on the uterus which
to increase uteroplacental could injured the
A systemic circulation as evidence by already
vasoconstriction compromised fetal
absence of signs of fetal
health.
distress 15. Instruct mother on the
Patients fetus possible complications
the disease can cause to 15. To enhance patients
may manifest: the fetus. participation in the
treatment regimen.
Intrauterine 16. Discuss importance of
growth having an adequate 16. For patient
retardation blood circulation going to education.
Changes in fetal the placenta. .
activity/ heart
rate(less than or
more than 120-
160 bpm)
Fetal demise Dependent:
2. Administer oxygen as
indicated.
2. To help in
respiration.
Reference: Nurses Pocket Guide Book, 9th edition by Doenges et.al pp.369
Problem: Risk for Injury
Nursing Diagnosis: Risk for Injury related to excess fluid build-up in the tissue secondary to retinal edema.
Cause Analysis: Spasm of the arteries in the retina leads to vision changes. Cerebral edema occurs, reports may be voiced of visual disturbances
such as blurred vision or seeing spots before the eyes.( (Maternal and child nursing by PILLITTERI 5 th edition pp.426)
Subjective: ST0: Independent: Independent: The patient is expected

to:
1. Ascertain type/degree of 1. Affects choice of
visual loss. intervention and Verbalize,
The patient may After 4 hours of nursing patients future enumerate factors
verbalize: intervention the patient will expectations. that will increase
be able to identify factors 2. Recommend measures potential for injury.
blurring of vision that increase potential for to assist patient to 2. Reduces safety Enumerate plans
severe headache manage visual hazards related to and strategy to
injury.
limitations, e.g. changes in visual maintain safety.
arranging furniture field and papillary
accommodation to
environmental light.
3. Orient patient to
LTO: 3. These measures will
Objective: environment. Assess
patient's ability to use help patient cope
After 1 day of nursing with unfamiliar
Progressive loss call bell, side rails and
intervention the patient will surroundings.
of visual field. bed positioning controls.
apply safety measures to Keep bed at lowest level,
prevent injury and family and conduct close night
watch
members will develop 4. Teach pt and family

strategy to maintain safety. about need to safe
illumination. Advise pt to 4. These measure will
wear sunglasses to enhance visual
reduce glare. advise discrimination
using contrasting colors
in household furnishings
5. Increase awareness
5. Observe for factors that
of patient, family
may cause or contribute
members, and care
to injury.
givers.
6. To reduce edema.
Since if possible
6. Encourage bedrest. medication should
not be prescribed
since the patient is
pregnant.
Collaborative:
1. Administer medication
as prescribed.
Reference: Nurses Pocket Guide Book, 9 edition by Doenges et.al pp.3
th
Problem identified; lack of knowledge
Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition,prognosis, self care and treatment needs related to lack of
exposure/unfamiliarity with information resources, misinterpretation.
Cause analysis: Anticipatory anxiety and patient lacks in psychological and educational information. (Medical surgical Nursing by Smeltzer and Bare
7th ed. pg. 1303)
Cues Objectives Nursing interventions Rationale
STO: Independent: The patient is expected to:
Questions/request for After 2-3 days of nursing 1. Assess clients/couples 1. Establishes data base 3. Verbalize accurate
information interventions and health knowledge of the disease and provides information information about
misinterpretation teachings, the patient will process. Provide about areas in which diagnosis,
Verbalization of prognosis, and
be able to verbalize information about learning is needed.
problem potential
Statement of accurate information pathophysiology of Pre- Receiving information can complications at own
misconception about diagnosis, eclampsia, implications for promote understanding level of readiness.
Inaccurate follow- prognosis, and potential mother and fetus; and the and reduce fear, helping to 4. Verbalize
through of complications at own level rationale for interventions, facilitate the treatment plan understanding of the
instructions, of readiness. procedures, and tests, as for the client. provide therapeutic needs
development of needed. additional treatment and will be able to
preventable identify/use available
options, such as using low-
complications resources
LTO: dose (60 mg/day) aspirin appropriately.
to reduce
After 4-5 days of nursing
interventions and health thromboxane generation
2.Provide information by platelets, limiting Note:
teachings, the patient will about signs/symptoms
be able to verbalize Current research in
indicating worsening of
understanding of the condition, and instruct progress may

therapeutic needs and will client when to notify severity/incidence of PIH
be able to identify/use healthcare provider. (pre-eclampsia)
available resources
appropriately. 3.Keep client informed of
health status, results of 2. Helps ensure that client
tests, and fetal well-being. seeks timely treatment and
may prevent worsening of
preeclamptic state or
additional complications.
4.Instruct client in how to

monitor her own weight at
home, and to notify Fears and anxieties can be
healthcare provider if gain compounded when
is in excess of 2 lb/wk, or client/couple does not
0.5 lb/day. have adequate information
about the state of the
disease process or its
5.Assist family members in impact on client and fetus.
learning the procedure for
home monitoring of BP, as
indicated. 4. Gain of 3.3 lbs or
greater per month in
second trimester or 1 lb or
6.Review techniques for greater per week in third
stress
management and diet trimester is suggestive of

restriction. PIH.
5. Encourages
7.Provide information participation in treatment
about ensuring adequate regimen, allows prompt
protein in diet for client with intervention as needed,
possible or mild and may provide
preeclampsia. reassurance that efforts
are beneficial.
6. Reinforces importance
8.Review self-testing of of clients responsibility in
urine for protein. Reinforce treatment.
rationale for and
implications of testing. 7. Protein is necessary for
intravascular and
extravascular fluid
regulation.
8. A test result of 2+ or
greater is significant and
needs to be reported to
healthcare provider. Urine
specimen contaminated by
vaginal discharge or RBCs
may produce positive test

result for protein.
Reference: Nurses Pocket Guide Book, 9th edition by Doenges et.al.
H E A L T H
E D U C A T I O N
P L A N

Objectives:
After 30 minutes of rendering health teaching, the patient will be able to:
1. Understand the importance of proper nutrition and exercise to promote health and prevention of disease.
2. Understand the importance of adequate rest and avoidance of stress for fast recovery.
3. Verbalize feelings of understanding towards the health teaching.
Materials needed:
1. Visual aids
2. Pentel pen
3. Coloring materials
General Specific health teaching

Support bed rest - Teach patient with severe preeclampsia, pregnant woman is
advice to be hospitalized so that bed rest can be enforced and
she can be observed more closely.
- Encouraged the family that Visitors are restricted to support
people ( e.g husband, father of the child, mother, or older
children).
- Teach the patient to avoid a loud noise such as a crying baby or
dropped tray of equipment may be sufficient to trigger a seizure
initiating eclampsia.
- Instruct the patient to darken the room if possible because a
bright light can trigger seizures.
Promote Bed Rest - Encouraged patient to promote bed rest. Because when the body
is in the recumbent position sodium tends to excreted at a faster
rate than during activity. Bed rest, therefore, is the best method of
aiding increased evacuation of sodium and encouraging dieresis.
Rest should always be in lateral recumbent position to avoid
uterine pressure in the vena cava.
Nutrition - Instruct the mother needs to continue her usual pregnancy diet.
Eat nutritious and balanced diet (60 70 mg/day; 1200 mg calcium
and adequate zinc, magnesium and vitamins).
- Teach the patient that there is no sodium restriction, however,

consider limiting excessive salty foods(processed foods, potato
chips, etc.) and add roughage ( bran, fruits, leafy vegetables) to

your diet to decrease constipation.
- Encouraged pt. to eat rich in protein diet such as lean meat,
green leafy vegetables, beans, and other rish in protein food.
Fluid intake - Encouraged to limit fluid intake up to 6 - 8 glasses/ day
Exercise - Teach the client on Circling of hands and feet or gently tensing
and relaxing and leg muscles. This improves muscle tone,
circulation, and sense of well - being.
- Encouraged deep breathing exercise
- Instruct the patient to limit the no. of stairs she climbs to one
flight/day for the first week at home. Beginning the second week,
if her lochial discharge is normal, she may start to increase this
activity. Limit stair climbing to only when necessary for first two
weeks.
Support system - Encourage family participate in the care management. Have

significant others to assist you in the care of the house, children
and etc.
Relaxation - Instruct the mother to relax to help cope with stress. Use guided
imagery, pleasant scenes, and smoothing music.
Lifestyle - Avoid alcohol, limit caffeine intake, and avoid smoking and
passive smoke exposure.
Supplementation - Supplementation of calcium, fish oil, and vitamins C and E
D I S C H A R G E
P L A N

Medication
Medication Dosage/ frequency Nursing responsibilities
Hydralazine (Apresoline) 50 to 200 mg/day Inform the patient for the possible side
effects of the drugs such as headache,
dizziness, palpitations, constipation,
vomiting, and anxiety.
Take this drug exactly as prescribed and
take this dug with food.
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
Methyldopa 250 mg PO bid/tid; increase q2d prn; not to hypertensive intervention (weight reduction,
(Aldomet) exceed 3 g/d 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.
Instruct pt. to take medication at the same

time everyday. Do not double dose.
25-100 mg PO qd; not to exceed 200 mg/kg/d Instruct pt. to monitor weight biweekly and
Hydrochlorothiazide notify healthcare professional of significant
( Esidrix) 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.
Exercise
Daily brisk walk for 30-60minutes

Kegels exercise 10 times a day for 6 weeks
How to perform kegels exercise:
1. Identify the correct pelvic floor muscles by contracting them to stop the flow of urine while sitting on the toilet.
2. Repeat this action several times to become familiar with it.
3. Start the exercise by emptying the bladder.
4. Tighten the pelvic muscles and hold for a count of ten seconds.
5. Relax the muscles completely a count of 10 seconds
6. Perform ten exercises at least three times daily and progressively increase.
7. Perform the exercise in different position such as standing. Lying, and sitting.
8. Keep breathing during exercises.
9. Dont contract the abdominal, thigh leg or buttocks muscles during these exercises.
10. Relax while doing kegels exercises and concentrate on isolating the right muscles.
11. Attempt to tighten the pelvic muscles before sneezing, jumping, or laughing to protect them for additional laxness.
12. Be aware that you can perform kegel exercise anywhere and in any place without anyone noticing.
Therapy
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:
Instruct patient to lose weight if overweight such as engaging in any activities.

Restricts the intake of alcohol for this may cause vasoconstriction thus increasing blood pressure.
Have an appropriate exercise regimen because regular activity is a significant factor in weight reduction.
Maintain adequate intake of dietary potassium.
Maintain adequate intake of dietary calcium and magnesium for general health.
Stop smoking and reduce intake of dietary saturated fats and cholesterol for overall cardiovascular health.
Stress reduction also is beneficial in any diseases.
Encourage client to observe proper perineal hygiene.
Teach the client to report warning signs of problems and where to seek help to eliminate them.
Instruct the woman for self care and infant care.
OPD:
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:
Encourage to eat nutritious, balanced diet (60 70 grams protein; 1200 mg calcium and adequate zinc, magnesium, and vitamins). Consult
with registered dietician on the diet best suited for you as an individual.
There is no sodium restriction; however consider limiting excessively salty foods (luncheon meats, pretzel, potato chips, and pickles).
Eat foods with roughage (whole grains, raw fruits, and vegetables).
Avoid alcohol, and limit caffeine intake.
Adequate fluid intake (6 8 glasses per day help to maintain optimal fluid volume and aids in renal perfusion).
Avoid high fat diet.
Spiritual:
Encouraged to continue to seek Gods guidance and enlightenment.

Emphasized the importance of prayers in healing
Encouraged to ask for divine assistance in everything
Encouraged to continue to pray to God.
Encouraged to continue to have a positive outlook in life.
Encouraged to keep faith in God and not to give up easily when hard times come
M E D I C A L
M A N A G E M E N T

Drugs Classification Indication Mechanism of Dosage Adverse Effects Nursing

Action Considerations
Magnesium Sulfate Anticonvulsant -muscle relaxant Mg depresses the -Loading dose CNS: depression Before
CNS and control 4-6 IV administering IV,
(Epson Salt) -prevents convulsion by CV: flushing, check for the ff :
seizures blocking the -Maintenance hypotension,
Pregnancy risk dose 1-2 g/h IV depression, of -Absent patellar
category B release of
acetylcholine and myocardium reflex
decrease the Magnesium - RR below 16/min
excitability of the intoxication:
motor membrane. Cardiac and CNS - Urine output
depression, below 100 ml in
preceding past 4 hours
respiratory - Early signs of
paralysis, hypermagnesemia;
circulatory collapse, flushing, sweating,
flaccid paralysis. hypotension or
hypothermia
- Past history of
heart block or
myocardial
damage,
prolonged RR and
widened QRS
interval.
Hydralazine HCL Antihypertensive - preeclampsia, A direct- acting - Initially, 5-10 CNS: headache, - Monitor pt. blood
eclampsia vasodilator that mg IV, followed dizziness pressure, pulse
(Apresoline) relaxes arteriolar by 5-10 mg IV rate, and body
- heart failure smooth muscle. doses, (range CV: tachycardia, weight frequently.
Pregnancy risk angina pectoris,
category C 5-20 mg) q 20
to 30 min, prn palpitations - Instruct client to
or 0.5 to 10 mg/ take with food to
EENT: nasal increase
hour IV congestion
infusion. absorption.
GI: nausea,
vomiting, diarrhea,
anorexia,
constipation.
Calcium Gluconate Electrolyte and Antidote for Generally, - 1g/ IV (10ml CV: mild drop of - Warn pt. to avoid
replacement magnesium replaces calcium of a 10% blood pressure, oxalic acid (in
Pregnancy risk solutions toxicity and maintains solution) vasodilation, rhubarb and
category C calcium level; bradycardia, spinach), phytic
physiologically arrhythmias, acid (in barn and
antagonize cardiac arrest whole grain
hypomagnesaemia cereals), and
effect. GI: irritation, phosphorus (in
constipation, chalky dairy products) in
taste, nausea, the meal preceding
thirst, abdominal calcium
pain consumption;
GU: renal calculi these substances
may interfere
calcium
absorption.
Diazepam (Valium) Anxiolytic Adjunct treatment A benzodiazepine - Adults: 2 to 10 CNS: drowsiness, - Warn pt. to avoid
for seizure that probably mg PO bid to fatigue, ataxia, activities that
Pregnancy risk disorder. potentiates the qid. headache, require alertness
category D effects of GABA, insomnia, minor and good
depresses the changes in ECG coordination.
CNS, and patterns.
suppresses the - Warn pt. not to
spread of seizure CV: hypotension, abruptly stop drug
activity. CV collapse, cause withdraw
bradycardia symptoms may
occur.
EENT: blurred
vision
GI: nausea,
constipation
GU: incontinence,
urine.
Hydrochlorothiazide Diuretic Management of Increases Dosage: Dizziness, Monitor blood

mild to moderate excretion of drowsiness, pressure during
( Esidrix) Antihypertensive hypertension. 25-100 mg PO hypotension, dosage
sodium and water
qd; not to adjustment and
(loop) by inhibiting exceed 200 nausea, vomiting, periodically
sodium mg/kg/d hypokalemia, during therapy.
reabsorption in the hypercalcemia,
distal tubule. May Pediatric hypovolemia, Instruct pt. to

produce arteriolar <6 months: 2-3 muscle cramps, take medication
dilation. mg/kg/d PO rashes. at the same time
divided bid everyday. Do not
>6 months: 2 double dose.
mg/kg/d PO Instruct pt. to
divided bid monitor weight
biweekly and
notify healthcare
professional of
significant
changes.
Advise pt. to
make position
changes slowly,
to avoid
orthostatic
hypotension.
Caution pt, to
wear protective
clothing and use
sunscreen to
prevent
photosensitivity
reactions.
Advise pt. to
report muscle
weakness,
cramps, nausea,
vomiting,
diarrhea, or
dizziness to
health care
professional.
Emphasize on
routine follow up
exams.
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.
May cause
drowsiness;
instruct pt. not to
do activity
requiring alertness.
S U R G I C A L
M A N A G E M E N T

CESAREAN SECTION
Clients with mild preeclampsia can be managed at home with frequents follow-up care. If the preeclampsia is severe, a woman may be admitted
to the health care facility. If the pregnancy is 36 weeks or further long or fetal lung maturity can be confirmed by amniocentesis, labor can be induced
to end the pregnancy at this point. If the pregnancy is less than 36 weeks or amniocentesis reveals immature lung function, interventions will be
instituted to attempt to alleviate the severe symptoms and allow the fetus to come to term. However, if fetus appears to be in imminent danger, cesarean
birth is indicated.
Definition:
It is the delivery of the fetus through incisions in the abdominal wall and the uterus.
Indications:
The decision to have C-section delivery can depend on the obstetrician, delivery location, and the womans 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 babys head will not fit through the pelvis. This diagnosis may also be used to indicate the
labor that fails to progress.
Fetal distress- the baby is not receiving enough oxygen. It may be indacated by an abnormal fetal tracing or a drop of a fetal heart rate when
your heathcare provider listens to the rate during or after a contraction.
Abnomal Position of the Baby- Instead of the babys head presenting first in the pelvis with his/her chin tucked inward , the presenting part of
the baby head extended outward, the shoulder, bottom or leg.
Prolapsed Cord- When the umbilical cord in the vagina head of the baby. This most commonly occurs the membranes rupture and the baby is
in breech position is not well engaged in the pelvis. This is an emergency and an immediate cs 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 separates from the uterine wall before the baby is born. This is an emergency cs birth is necssary yo
prevent the mother from hemrrhaging, which can cause the baby to lose all or part.
Placenta Previa- A condition in which yhe placenta partilly covers the cervix. The degree of severity determines whether cs birth is indicated. If
the cervix is completely coverd, a cesarean is mandatory since the placenta would deliver first in avaginal 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 or vertical incision consistent with 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 entered, and the 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 and counter pressure on the
fundus. Retactors are removed. As soon as the head is delivered the newborns nares are aspirated by bulb syringe immediately but very gently;
the delivery is completed. The umbilical cord is clamp and cut. The infant is received in a sheet and trasferred to a gowned and gloved member
of neonatal team. Standard precauions are observed. Resuscitative measures are provided to the neonate under warming lamps. The
pediatrician determines the infants Apgar score. Vernix caseosa and blood are wiped from the infants. Ointment (Erythromycin 0.5%) is applied
to the conjuctival sacs of the newborn. The placenta is delivered. The uterus is massaged to encouraged it to contract. Tubal Ligation may be
performed. Blood and amniotic fluid are aspirated. Hemostasis is assured. The edges of the uetrine incision are clamped tio aid in its closure;
the uterus and bladder are closed in a single or 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 blanket is 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 throughly clean and
assessed.
Nursing Responsibilities:
Preoperative care:
Assess the client knowledge of the procedure.
The client is NPO after midnight.
Relieving the patients and the familys anxiety about the outcome with reasonable information
Encourage patient to commence deep breathing, coughing and leg exercises.
Teach the client post operative expectations
Post operative care:
Monitor vital sign every 15 minutes until the client is stable.
Assess the need for pain relief.
Assess the client for vaginal bleeding
P R O G N O S I S

Usually the high blood pressure, protein in the urine, and other effects of preeclampsia go away completely within 6 weeks after delivery.
However, sometimes the high blood pressure will get worse in the first several days after delivery. A woman with a history of preeclampsia is at risk for
the condition again during future pregnancies. Often, it is not as severe in later pregnancies. Women who have high blood pressure problems during
more than one pregnancy have an increased risk for high blood pressure when they get older.
The fetal prognosis in eclampsia is poor because of hypoxia and consequent fetal acidosis. If premature separation of the placenta from
vasospasm occurs, the fetal prognosis is even graver. If fetus must be delivered before term, all the risks of immaturity will be faced.
In preeclampsia, the fetal mortality rate is approximately 10%. If eclampsia develops, the mortality rate increases to as high as 25% (Moldenhauer
& Sibai, 2003).
B I B L I O G R A P H Y

Books
Doenges, Marilynn E. and et. al. Nurses Pocket Guide 11th Ed. Philadelphia: F.A. Davis Company, 2006.
Doenges, Marilynn E. and et. al. Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span. Philadelphia: F.A. Davis Company,
2006.
Nursing 2009 Student Drug Handbook 10th Ed. Philadelphia: Lippincott Williams and Wilkins, 2009.
Nurses Quick Check: Diagnostic Tests. Philadelphia: Lippincott Williams and Wilkins, 2006.
Pacardo, Roselyn S. Compiled Notes on Maternal Nursing with Critical Thinking Exercises, 2010.
Pillitteri, Adele. Maternal and Child Health Nursing: Care of the Childbearing & Childbearing Family 5 th Ed., Vol 1., Philadelphia: Lippincott Williams
and Wilkins, 2009.
Porth, Carol Mattson. Pathophysiology Concepts of Altered Health Status 7th Ed. Philadelphia: Lippincott Williams and Wilkins, 2005.
Scanlon, Valerie C. and Tina Sanders. Essentials of Anatomy and Physiology, 5th Ed. Philadelphia: FA Davis Company, 2007.
Internet
http://emedicine.medscape.com/article/1476919-overview
http://familydoctor.org/online/famdocen/home/women/pregnancy/complications/064.html
http://www.nlm.nih.gov/medlineplus/ency/article/000898.htm
http://www.preeclampsia.org/research
http://hubpages.com/hub/PREGNANCY-AND-PRE-ECLAMPSIA-RISK-FACTORS
http://www.mayoclinic.com/health/preeclampsia/DS00583/DSECTION=risk-factors

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Pre eclampsia Page |1

Presentors will be able to:

Students or audience will be able :

To recognize the cause and risk factors of Preeclampsia.

Clinical Instructors will be:

Bladder - a triangle-shaped, hollow organ located in the lower abdomen.

Hyperreflexia - defined as overactive or over responsive reflexes.

Prostacyclin - is a prostaglandin with vasodilator properties.

Thromboxane - is a prostaglandin with vasoconstrictor properties.

Vasospasm - a condition in which blood vessels spasm, leading to vasoconstriction.

The purposes for a physical assessment are:

To obtain baseline physical and mental data on the patient.

Systems Mild Preeclampsia Severe Preeclampsia Review of Systems Problem Identified

Mouth and Pharynx none none none No problem identified

Neck none none none No problem identified

Thorax/Lungs none Shortness of Breath (use of Patient may verbalize Bradypnea,

Back none none none No problem identified

Breast and Axilla none none none No problem identified

Lymphatic none none none No problem identified

Musculoskeletal none Fatigue Patient may verbalize Fatigue

Endocrine none none none No problem identified

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

-Tell the patient that the test

-Explain to the patient that he

-Instruct the patient that he

-Notify the laboratory and

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

To evaluate Kidney . Pre test:

Explain to the patient that he

tourniquet and the needle

Notify the laboratory and

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

-Inform the patient that

-Notify the laboratory and

-If bleeding hasnt slowed after

-Instruct the patient that he may

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

-Instruct the patient that he

Diagnostic Test Purpose Normal Results and interpretation Nursing responsibilities

-The FHR and fetal movement are

-Observe the fetal monitor for FHR

-If the fetus is quiet for 20 minutes,

-Note that a nurse performs the NST in

-Tell the patient that no discomfort is

-If the results detect a nonreactive

Diagnostic Test Purpose Normal Results and interpretation Nursing

>Instruct the patient that he may resume

-If a large hematoma develops at the

-Inform the pt that he need not

-If a pt is a child explain to him

- To aid in the calculation of

Multiple myelomas. Classically,

can be associated with small

Diagnostics Purpose Normal values Results and interpretation Nursing responsibilities

High albumin levels usually

Diagnostics Purpose Normal values Results and Nursing

o Detect major birth defects,

blood :consisting of liquid plasma and cells

heart : a muscular pump to move the blood

There are two circulatory "circuits":

A specialized component of the circulatory system is the lymphatic system, consisting of

Anatomy of the Heart

Vascular System - the Blood Vessels