ANGELES UNIVERSITY FOUNDATION McArthur Hi-Way, Angeles City College of Nursing

PREGNANCY-INDUCED HYPERTENSION
(Maternal and Child Health Nursing Delivery Room)

Presented by: Bognot, Mylene Angelie M. Guinto, Marylou S. Lim, Raymond Christopher P. Group 8, BSN III - 2

Presented to: Brenda B. Policarpio, RN, MN

Presented on: April 19, 2012

I. Introduction

Pregnancy represents one of the great unknowns in life. Everyones at least a little worried about how it will turn out.

- Lawrence Kutner Pregnancy is a time of physical and psychological preparation for birth and parenthood. Becoming a parent is considered one of the maturational milestones of adult life. (Lowdermilk and Perry, 2007 p. 380) Women of all ages use the months of pregnancy to adapt to the maternal role, a complex process of social and cognitive learning. Pregnancy is a maturational milestone that can be stressful but also rewarding as the woman prepares for a new level of caring and responsibility. Her self - concept changes in readiness for parenthood as she prepares for her new role. She moves gradually from being self-contained and independent to being committed to a life long concern for another human being. This event requires mastery of certain developmental tasks: accepting the pregnancy, identifying with the role of mother, reordering the relationships between herself and her partner with the unborn child, and preparing for the birth experience. Some pregnant women may experience feelings of hostility toward the pregnancy or unborn child from time to time. Body sensations from a disease such as headache, shortness of breath, and easy fatigability, feelings of dependence or the realization of the responsibilities of child care can also generate such feelings. Hypertensive disorders of pregnancy, previously know as Pregnancy induced hypertension (PIH), are high blood pressure disorders of pregnancy. It has long been one of the major problems for mothers in pregnancy, along with infection and postpartum hemorrhage. Preeclampsia affects 5-8% of all pregnancies but 10-20% of mothers will have a hypertensive disorder during pregnancy.

II. Disease Condition

PREGNANCY-INDUCED HYERTENSION Pregnancy-Induced Hypertension is a condition in which vasospasm occurs during pregnancy in both small and large arteries. Cardinal signs include hypertension, edema, and proteinuria. The condition was initially called toxemia as physicians theorized that a toxin was being produced by a woman in response to the foreign protein in the growing fetus. The condition is unique to pregnancy and occurs in almost 5% to 7% of all pregnancies. There are four different levels of hypertensive disorders in pregnancy: 1. Chronic Hypertension (Discovered prior to 20 weeks gestation.) 2. Gestational Hypertension 3. Preeclampsia/Eclampsia 4. Preeclampsia/Eclampsia superimposed on chronic hypertension PIH can be detected early during regular prenatal visits, which is one of the reasons they are so very important. If you have PIH and it is untreated you may wind up with a preterm baby, a stillborn baby or a baby who has growth restriction (IUGR), not to mention the effects on your health. There are still different opinions on the causes of PIH. There are speculations of placental involvement, underlying disease, hormonal involvement etc. If you experience any of the following warning signs, report them to your practitioner:

Rapid weight gain, 4 - 5 lbs in a single week A rise in your blood pressure Protein in your urine

Severe headaches Blurry vision Seeing spots in your eyes Severe pain over your stomach, under your ribs Decrease in the amount of urine

Not all of these symptoms or signs may be detected by an individual. This is one of the reasons that it is so important that you keep your regular prenatal appointments is to screen all women for the above symptoms as well as other signs of PIH. If you must miss an appointment be sure to reschedule it right away. There are treatment options for those women suffering from chronic hypertension or gestational hypertension, including hypertensive medications. Some practitioners recommend strategies that are dietary, while others involve exercise and rest. Recently it has been shown that aspirin doesn't help in the treatment for women in a low risk group but can be helpful for a select high risk group. If you have preeclampsia, the only cure is delivering the baby. Talk to your practitioner about which options are best for you because this is critical. The important thing to remember is that PIH is a very serious illness. You must be followed closely by your medical professional to help prevent prematurity and death of your baby and other severe complications in the most severe cases. Now it is also known that even slight rises in the blood pressure during pregnancy can have a lasting effect. Women who have PIH or more severe forms are at greater risk for coronary artery disease later in life.

Etiology and Risk Factors The cause of pregnancy-induced hypertension is unknown. However, the disorder is highly correlated with the antiphospholipid syndrome or the presence of antiphospholipid antibodies. Pregnancy-induced hypertension is common among black and Caucasian women, primiparas younger than 20 years old or older than 40 years, women from low socioeconomic status, those who have five or more deliveries, those who have hydramnios, or those who have an underlying disease such as heart disease, diabetes with vessel or renal involvement, and essential hypertension. III. Anatomy and Physiology

The cardiovascular system can be thought of as the transport system of the body. This system has three main components: the heart, the blood vessel and the blood itself. The heart is the system's pump and the blood vessels are like the delivery routes. Blood can be thought of as a fluid which contains the oxygen and nutrients the body needs and carries the wastes which need to be removed. The following information describes the structure and function of the heart and the cardiovascular system as a whole.

Function and Location of the Heart The heart's job is to pump blood around the body. The heart is located in between the two lungs. It lies left of the middle of the chest. Structure of the Heart The heart is a muscle about the size of a fist, and is roughly cone-shaped. It is about 12cm long, 9cm across the broadest point and about 6cm thick. The pericardium is a fibrous covering which wraps around the whole heart. It holds the heart in place but allows it to move as it beats. The wall of the heart itself is made up of a special type of muscle called cardiac muscle. Chambers of the Heart The heart has two sides, the right side and the left side. The heart has four chambers. The left and right side each have two chambers, a top chamber and a bottom chamber. The two top chambers are known as the left and right atria (singular: atrium). The atria receive blood from different sources. The left atrium receives blood from the lungs and the right atrium receives blood from the rest of the body. The bottom two chambers are known as the left and right ventricles. The ventricles pump blood out to different parts of the body. The right ventricle pumps blood to the lungs while the left ventricle pumps out blood to the rest of the body. The ventricles have much thicker walls than the atria which allows them to perform more work by pumping out blood to the whole body. Blood Vessels Blood Vessel are tubes which carry blood. Veins are blood vessels which carry blood from the body back to the heart. Arteries are blood vessels which carry blood from the heart to the body. There are also microscopic blood vessels which connect arteries and veins together called capillaries. There are a few main blood vessels which connect to

different chambers of the heart. The aorta is the largest artery in our body. The left ventricle pumps blood into the aorta which then carries it to the rest of the body through smaller arteries. The pulmonary trunk is the large artery which the right ventricle pumps into. It splits into pulmonary arteries which take the blood to the lungs. The pulmonary veins take blood from the lungs to the left atrium. All the other veins in our body drain into the inferior vena cava (IVC) or the superior vena cava (SVC). These two large veins then take the blood from the rest of the body into the right atrium. Valves Valves are fibrous flaps of tissue found between the heart chambers and in the blood vessels. They are rather like gates which prevent blood from flowing in the wrong direction. They are found in a number of places. Valves between the atria and ventricles are known as the right and left atrioventricular valves, otherwise known as the tricuspid and mitral valves respectively. Valves between the ventricles and the great arteries are known as thesemilunar valves. The aortic valve is found at the base of the aorta, while the pulmonary valve is found the base of the pulmonary trunk. There are also many valves found in veins throughout the body. However, there are no valves found in any of the other arteries besides the aorta and pulmonary trunk. What is the Cardiovascular System The cardiovascular system refers to the heart, blood vessels and the blood. Blood contains oxygen and other nutrients which your body needs to survive. The body takes these essential nutrients from the blood. At the same time, the body dumps waste products like carbon dioxide, back into the blood, so they can be removed. The main function of the cardiovascular system is therefore to maintain blood flow to all parts of the body, to allow it to survive. Veins deliver used blood from the body back to the heart. Blood in the veins is low in oxygen (as it has been taken out by the body) and high in carbon dioxide (as the body has unloaded it back into the blood). All the veins drain into the superior and inferior vena cava which then drain into the right atrium. The right atrium pumps blood into the right ventricle. Then the right ventricle pumps blood to

the pulmonary trunk, through the pulmonary arteries and into the lungs. In the lungs the blood picks up oxygen that we breathe in and gets rid of carbon dioxide, which we breathe out. The blood is becomes rich in oxygen which the body can use. From the lungs, blood drains into the left atrium and is then pumped into the left ventricle. The left ventricle then pumps this oxygen-rich blood out into the aorta which then distributes it to the rest of the body through other arteries. The main arteries which branch off the aorta and take blood to specific parts of the body are: Carotid arteries, which take blood to the neck and head Coronary arteries, which provide blood supply to the heart itself Hepatic artery, which takes blood to the liver with branches going to the stomach Mesenteric artery, which takes blood to the intestines Renal arteries, which takes blood to the kidneys Femoral arteries, which take blood to the legs The body is then able to use the oxygen in the blood to carry out its normal functions. This blood will again return back to the heart through the veins and the cycle continues.

All living things reproduce. This is something that sets the living apart from non-living. Even though the reproductive system is essential to keeping a species alive, it is not essential to keeping an individual alive. Reproduction Reproduction can be defined as the process by which an organism continues its species. In the human reproductive process, two kinds of sex cells (testes) are involved: the male (sperm), and the female (egg or ovum). These two gonads meet within the female's uterine tubes located one on each side of the upper pubic cavity, and begin to create a new individual. The female needs a male to fertilize her egg; she then carries offspring through pregnancy and childbirth.

Female Reproductive System

Produces eggs (ova) Secretes sex hormones Receives the male spermatozoa during Protects and nourishes the fertilized egg until it is fully developed Delivers fetus through birth canal

Provides nourishment to the baby through milk secreted by mammary glands in the breast

External Genitals

Vulva The external female genitals are collectively referred to as The Vulva. This consists of the labia majora and labia minora (while these names translate as "large" and "small" lips, often the "minora" can be larger, and protrude outside the "majora"), mons pubis, clitoris, opening of the urethra (meatus), vaginal vestibule, vestibular bulbs, vestibular glands. The term "vagina" is often improperly used as a generic term to refer to the vulva or female genitals, even though - strictly speaking - the vagina is a specific internal structure and the vulva is the exterior genitalia only. Calling the vulva the vagina is akin to calling the mouth the throat. Mons Veneris The mons veneris, Latin for "mound of Venus" (Roman Goddess of love) is the soft mound at the front of the vulva (fatty tissue covering the pubic bone). It is also referred to as the mons pubis. The mons veneris is sexually sensitive in some women and protects the pubic bone and vulva from the impact of sexual intercourse. After puberty it is covered with pubic hair, usually in a triangular shape. Heredity can play a role in the amount of pubic hair an individual grows. Labia Majora

The labia majora are the outer "lips" of the vulva. They are pads of loose connective and adipose tissue, as well as some smooth muscle. The labia majora wrap around the vulva from the mons pubis to the perineum. The labia majora generally hides, partially or entirely, the other parts of the vulva. There is also a longitudinal separation called the pudendal cleft. These labia are usually covered with pubic hair. The color of the outside skin of the labia majora is usually close to the overall color of the individual, although there may be some variation. The inside skin is usually pink to light brown. They contain numerous sweat and oil glands. It has been suggested that the scent from these oils are sexually arousing. Labia Minora Medial to the labia majora are the labia minora. The labia minora are the inner lips of the vulva. They are thin stretches of tissue within the labia majora that fold and protect the vagina, urethra, and clitoris. The appearance of labia minora can vary widely, from tiny lips that hide between the labia majora to large lips that protrude. There is no pubic hair on the labia minora, but there are sebaceous glands. The two smaller lips of the labia minora come together longitudinally to form the prepuce, a fold that covers part of the clitoris. The labia minora protect the vaginal and urethral openings. Both the inner and outer labia are quite sensitive to touch and pressure. Clitoris The clitoris, visible as the small white oval between the top of the labia minora and the clitoral hood, is a small body of spongy tissue that functions solely for sexual pleasure. Only the tip or of the clitoris shows externally, but the organ itself is elongated and branched into two forks, the crura, which extend downward along the rim of the vaginal opening toward the perineum. Thus the clitoris is much larger than most people think it is, about 4" long on average. glans

The clitoral glans or external tip of the clitoris is protected by the prepuce, or clitoral hood, a covering of tissue similar to the foreskin of the male penis. However, unlike the penis, the clitoris does not contain any part of the urethra. During sexual excitement, the clitoris erects and extends, the hood retracts, making the clitoral glans more accessible. The size of the clitoris is variable between women. On some, the clitoral glans is very small; on others, it is large and the hood does not completely cover it. Urethra The opening to the urethra is just below the clitoris. Although it is not related to sex or reproduction, it is included in the vulva. The urethra is actually used for the passage of urine. The urethra is connected to the bladder. In females the urethra is 1.5 inches long, compared to males whose urethra is 8 inches long. Because the urethra is so close to the anus, women should always wipe themselves from front to back to avoid infecting the vagina and urethra with bacteria. This location issue is the reason for bladder infections being more common among females. Hymen The hymen is a thin fold of mucous membrane that separates the lumen of the vagina from the urethral sinus. Sometimes it may partially cover the vaginal orifice. The hymen is usually perforated during later fetal development. Because of the belief that first vaginal penetration would usually tear this membrane and cause bleeding, its "intactness" has been considered a guarantor of virginity. However, the hymen is a poor indicator of whether a woman has actually engaged in sexual intercourse because a normal hymen does not completely block the vaginal opening. The normal hymen is never actually "intact" since there is always an opening in it. Furthermore, there is not always bleeding at first vaginal penetration. The blood that is sometimes, but not always,

observed after first penetration can be due to tearing of the hymen, but it can also be from injury to nearby tissues. A tear to the hymen, medically referred to as a "transection," can be seen in a small percentage of women or girls after first penetration. A transection is caused by penetrating trauma. Masturbation and tampon insertion can, but generally are not forceful enough to cause penetrating trauma to the hymen. Therefore, the appearance of the hymen is not a reliable indicator of virginity or chastity. Perineum The perineum is the short stretch of skin starting at the bottom of the vulva and extending to the anus. It is a diamond shaped area between the symphysis pubis and the coccyx. This area forms the floor of the pelvis and contains the external sex organs and the anal opening. It can be further divided into the urogenital triangle in front and the anal triangle in back. The perineum in some women may tear during the birth of an infant and this is apparently natural. Some physicians however, may cut the perineum preemptively on the grounds that the "tearing" may be more harmful than a precise cut by a scalpel. If a physician decides the cut is necessary, they will perform it. The cut is called an episiotomy. Internal Genitals Vagina The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman. The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes, which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the opening of the vagina. The vagina receives sperm

during sexual intercourse from the penis. The sperm that survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur. The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the penis. The middle layer has glands that secrete acidic mucus (pH of around 4.0.) that keeps bacterial growth down. The outer muscular layer is especially important with delivery of a fetus and placenta. Purposes of the Vagina

Receives a males erect penis and semen during sexual intercourse. Pathway through a womans body for the baby to take during childbirth. Provides the route for the menstrual blood (menses) from the uterus, to leave the body. May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.

Cervix The cervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience. Evidence for this is given by the fact that some women's cramps

subside or disappear after their first vaginal birth because the cervical opening has widened. The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. Uterus The uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may be possible.

The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus. Helping support the uterus are ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids, pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate hormone therapy due to the lack of ovaries and hormone production.

Fallopian Tubes At the upper corners of the uterus are the fallopian tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian tubes are about four inches long and

about as wide as a piece of spaghetti. Within each tube is a tiny passageway no wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg. When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae. Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the fallopian tube, possible hemorrhage and possible death of the mother. PLACENTA

The placenta is an ephemeral (temporary) organ present in female placental vertebrates during gestation (pregnancy), but a placenta has evolved independently also in other animals as well, for instance scorpions and velvet worms.

IV. Pathophysiology *The vascular spasm may be caused by: (a) the increased cardiac output that occurs with pregnancy and injures the endothelial cells of the arteries or (b) the action of prostaglandins (decreased prostacyclin, a vasodilator; increased thromboxane, a vasoconstrictor and stimulant of platelet aggregation) *The vascular spasm and subsequent hypertension can cause the heart to overwork in order to overcome rising peripheral resistance. This reduces blood flow to the kidneys, brain, pancreas, liver, and other organs. *Vascular spasm to the kidneys increases blood flow resistance. Back-pressure then causes degenerative damages to the glomerulus, allowing increased permeability of the glomerular membrane. Due to this event, serum proteins albumin and globin escape into the urine (proteinuria). The degenerative changes also cause decreased glomerular filtration, resulting to low urine output and clearance of creatinine. There is increased kidney tubular absorption of sodium. Edema occurs as a result of the water attracting property of sodium. With the loss of proteins, colloid oncotic pressure is also lost, leading to exaggeration of edema. *Vascular spasm causes the blood volume in the maternal circulation to be pooled into venous circulation; a woman is then deprived of intravascular volume. Thrombocytopenia occurs as platelets cluster at the site of damage.

Types There are basically four main types of PIH, with one variation, the HELLP syndrome. Below is a table showing the differences of the four types of PIH. TYPE BLOOD PRESSURE PROTEINURIA EDEMA OTHER MANIFESTATIONS

140/90 mmHg systolic pressure above Gestational Hypertension mmHg; diastolic pressure elevated pregnancy level is 15 No proteinuria No edema 30

mmHg above

140/90 mmHg systolic pressure Mild Pre-Eclampsia above mmHg; diastolic pressure elevated pregnancy 15 30 Proteinuria random is sample of Mild edema +1 to +2 on a on the upper extremities and the face Weight gain over 2lb per week in second trimester

and 1 lb per week in third trimester

mmHg above

level

Oliguria of 500 mL or less in 24 hours; Cerebral or visual Proteinuria Severe Pre-Eclampsia 160/110 mmHg random sample and 5 g on a 24-hour sample of Extensive peripheral edema disturbances; Pulmonary cardiac involvement; Hepatic dysfunction; Thrombocytopenia; Epigastric pain or +3 to +4 on a

Eclampsia

Seizure or coma with signs and symptoms of pre-eclampsia

HELLP Syndrome is a variation of pregnancy-induced hypertension named after the cardinal signs and symptoms of the disorder, namely, hemolysis, elevation of liver enzymes that lead to epigastric pain, and low platelets that lead to abnormal bleeding/clotting and petechiae. Women with severe pre-eclampsia develop HELLP Syndrome. Though the exact mechanism is unknown, the development of the disorder is linked with antiphospholipid syndrome, or the presence of antiphospholipid antibodies. Nursing Diagnoses Several nursing diagnoses may be formulated for the woman with pregnancy-induced hypertension. Problems are similar as to a non-pregnant person who is hypertensive. Ineffective Tissue Perfusion relate to vasoconstriction of blood vessels

Deficient Fluid Volume related to fluid loss to subcutaneous tissue Risk for Fetal Injury related to reduced placental perfusion secondary to vasospasm Social Isolation secondary to prescribed bed rest Nursing Management for a Woman with Mild PIH Clients with mild pre-eclampsia may be managed at home with frequent follow-up care. Regardless of the setting, the care given is similar. 1. Monitor antiplatelet therapy. Administer a low-dose aspirin as ordered, to prevent the platelets from clustering along the arterial wall. This may delay the development of preeclampsia. 2. Promote bed rest. Bed rest is the best method to aid increased evacuation of sodium and promotion of diuresis. Position the client to a lateral recumbent position to avoid pressure on the vena cava and prevent supine hypotension syndrome. 3. Promote good nutrition. Promote a low-salt diet. Educate the woman on the need to have a balanced diet for optimal fetal development. 4. Provide emotional support. 5. Provide health education. Nursing Management for a Woman with Severe PIH Clients with severe pre-eclampsia are usually brought to the hospital or any health facility. If pregnancy is at 36 weeks or further along or fetal lung maturity can be confirmed by amniocentesis, labor can be induced or a cesarean birth may be performed to end the pregnancy. If the pregnancy is less than 36 weeks or if

amniocentesis reveals immature lung function, interventions will be instituted to alleviate the severe symptoms and allow the fetus to come to term. 1. Support bed rest. Restrict visitors to support people only. Darken the room and reduce all possible stimulants to prevent seizure from occurring. Raise side rails to prevent any injury in case a seizure episode occurs. 2. Monitor maternal well-being. Take blood pressure every four hours to detect any increase, which may indicate that a womans condition is worsening. Obtain blood studies as ordered to assess renal and liver function, and to determine the development of DIC, which often accompanies severe vasospasm. Monitor hematocrit levels daily to assess blood concentration. Obtain weight daily. Assure that a client is wearing the same type of clothing at the same time of the day. 3. Monitor fetal well-being. Assist in monitoring the fetus as ordered. Nonstress tests and biophysical profiles may be done to determine the status of the fetus. 4. Support a nutritious diet. Administer fluids to reduce hemoconcentration and hypovolemia. 5. Administer medications to prevent eclampsia. Administer antihypertensive drugs as ordered (hydralazine, labetalol, nifedipine, magnesium sulfate). Monitor clients response to pharmacologic therapy. Ready calcium gluconate at bedside in case magnesium sulfate toxicity occurs. 6. Provide health education. Nursing Management for a Woman with Eclampsia

Transition from pre-eclampsia to eclampsia occurs when cerebral irritation from increasing cerebral edema becomes so acute that a seizure occurs. 1. Monitor tonic-clonic seizures. A preliminary signal or aura may occur before each seizure episode. The aura of seizure is usually a high-grade fever. The tonic phase of the eclamptic seizure is characterized by arching of the back, stiffening of the arms and legs, and abrupt closure of the jaws. Cyanosis occurs due to the halting of respirations brought about by contracting thoracic muscles. The clonic phase is characterized by relaxation of the bladder and bowel muscles. Breathing is not entirely effective. The third stage, or postictal stage is characterized by the woman in a semicomatosed condition. The woman is not responsive to pain for 1 to 4 hours. Maintain a patent airway. Have the woman turn to her side to prevent aspiration. Assess oxygenation by pulse oximetry. Monitor fetal well-being by applying an external fetal heart monitor. Check for vaginal bleeding for possible placental separation. Never restrain the woman. 2. Assist with birthing of the fetus. The choice of delivery is vaginal birth. Pharmacologic Management for PIH

DRUG

INDICATION

INTERVENTIONS

Magnesium sulfate

Drug

of

choice

to Infuse loading dose slowly over 15 to 30 minutes.

prevent

eclampsia;

Dosage: Loading Reduces

edema; Always administer as a piggyback

dose 4-6 g; Maintenance dose 1-2 g/hour

Lessens seizures

possibility

of

infusion. Assess RR, UO, DTR, and clonus every hour. Urine output should be over 30 mL/hour and respiratory rate over 12/min. Serum magnesium level should remain below 7.5 mEq/L.

Hydralazine mg/IV

Antihypertensive; vasodilator used to

Administer slowly to avoid sudden fall in blood pressure. mmHg to adequate placental filling.

Dosage: 5 10 Peripheral

decrease Maintain diastolic pressure over 90

hypertension

Diazepam Dosage: 5 10 mg/IV

Anticonvulsant

Administer

slowly.

Dose

may

be

repeated every 5 to 10 minutes (up to 30 mg/hour). Observe for respiratory depression or hypotension in mother and respiratory depression and hypotonia in infant at birth.

Calcium gluconate Dosage: 1 g/IV

Antidote magnesium intoxication

for Prepare

at

bedside

when

administering magnesium sulfate. Administer at 5mL/min.

Clinical Manifestations: A. Mild Preeclampsia

BP of 140/90

1+ to 2+ proteinuria on random weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester Slight edema in upper extremities and face BP of 160/110 3-4+ protenuria on random Oliguria (less than 500 ml/24 hrs) Cerebral or visual disturbances Epigastric pain Pulmonary edema Peripheral edema Hepatic dysfunction

B. Severe Preeclampsia

C. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures. Diagnostic Evaluation: 1. Based on the presenting symptoms. Often the disease process has been developing and affecting the renal and vascular system 2. Frequently a sudden weight gain will occur, of 2 lb. or more in 1 week, or 6 lb. or more within 1 month. This often occurs before the edema is present. Medical Treatment and Evaluation: 1. Magnesium Sulfate (Pregnancy risk category B) muscle relaxant, prevent seizures loading dose 4-6g, maintenance dose 1-2g/h IV infuse IV dose slowly over 15-30 min. Always administer as a piggy back infusion. Assess PR, urine output, DTR, and clonus every hour. Observe for CNS depression and hypotonia in infant at birth. 2. Hydrazaline (Apresoline) Pregnancy risk category C anti hypertensive (peripheral vasodilator) use to decrease hypertension 5-10mg/IV

Administer slowly to avoid sudden fall of BP Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling. 3. Diazepam (Valium) Pregnancy risk category D halt seizures 5-10mg/IV administer slowly. Dose may be repeated every 10-15 min. (up to 30mg/hr) Observe for respiratory depression for both mother and infant at birth. 4. Calcium Gluconate (Pregnancy risk category C) antidote for Magnesium Sulfate 1g/IV (10 mL of a 10% solution) have prepared at bed side when administering Magnesium Sulfate administer at 5mL/min. Complications of PIH: 1. Intrauterine growth restriction (IUGR) an abnormally restricted symmetric or asymmetric growth of fetus 2. Oligohydramnios abnormally low volume of amniotic fluid 3. Risk of placental abruption premature separation of a normally situated placenta from the wall of uterus 4. Risk of preterm delivery (often iatrogenic) delivery before 37 weeks of gestation 5. Coagulopathy 6. Stillbirth 7. Seizures 8. Coma 9. Renal failure 10. Maternal hepatic damage 11. Hemolysis 12. Elevated liver enzymes levels 13. Low platelet count (HELLP syndrome)

Nursing Interventions: Intervention for mild PIH: 1. Assess maternal VS and fetal heart rate. 2. Encourage elevation of edematous arms and legs. 3. Encourage compliance with bed rest in a lateral recumbent position. -to increase evacuation of sodium and encouraging diuresis and lateral recumbent position can avoid uterine pressure on the vena cava and prevent supine hypotension syndrome. 4. Provide emotional support. -this can make a women underestimate the severity of the situation. 5. Support patient with bed rest and darken the room if possible. 6. Obtain daily hematocrit levels -to monitor blood concentration and help to the as ordered. extent of plasma loss to interstitial space or extent of the edema. 7. Obtain blood studies (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation). 8. Obtain daily weights at the same time each day. 9. Raise side rails. 10. Support nutritious diet of moderate to high in protein and moderate in sodium. 11. An indwelling catheter may be inserted as ordered. -to allow accurate recording of output and comparison with intake. -to help prevent injury if seizure should occur. -to compensate for protein she is losing in her urine. -to assess for renal and liver function and the development of disseminated intravascular coagulation which often accompanies severe vasospasms. -to evaluate tissue fluid retention. -because a bright light can trigger seizures. Rationale: -to detect any increase which is warning that a womens condition is worsening. -to increase venous blood return.

12. Oxygen administration to the -to maintain adequate fetal oxygenation and prevent

mother may be given as ordered. 13. Administer medication for seizures and hypertension episodes as ordered.

fetal bradycardia.

-to prevent seizures and hypertension.

Intervention for severe PIH: 1. Maintain patients airway by not putting a tongue blade between a womens teeth during seizures. 2. Turn a woman on her side.

Rationale: -to prevent broken of teeth which could then be aspirated.

-to allow secretions to drain from her mouth.

Discharge Plan: Exercise 1. encourage patients on deep breathing exercises. 2. move extremities when lying. 3. elevate the head part when sleeping, to promote increase peripheral circulation 4. encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth. 5. exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery. Treatment: 1. use of drugs 2. catheterization 3. obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation) Health Teaching: 1. Encourage patient foe sodium restriction. 2. Encourage to avoid foods rich in oil and fats. 3. Encourage patient to limit her daily activities and exercises.

Ongoing Assessment: 1. Observe carefully for symptoms at prenatal visit. 2. Give instruction about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits. Diet: 1. low fats and sodium diet, restriction if possible. 2. high in protein, calcium and iron. 3. Adequate fluid intake Sex: 1. limit sexual activity 2. sexual intercourse at 2nd trimester should be avoided.

III. Conclusion To conceive a life is a priceless and exceptional moment in every womans life. Every mother aims to experience a healthy pregnancy as well as to deliver a healthy child.As nurses who provide good quality of living for the people especially their patients, they have the responsibility to disseminate information regarding the health and the risks of the patients ADLs that may affect the clients health status. For the patients they have the right to know all possible options in their treatment. If all the members of a health care team can provide as much as information to the patients, then there will be a chance that patients trust to health care professionals will increase, therefore patients will be compliant to all treatments and all health teachings given by nurses. Through this, the nurses and the patient as well will be able to gain learnings regarding the disease, not only the description of the disease, rather they will also know the current trends in the delivery room, as well as the interventions they could render to their clients.

The study is recommended to the women on child bearing age to make them knowledgeable about the factors that can make them at risk to the said condition. To make them aware of the signs and symptoms for early detection of the tumor and to prepare them for the different procedure that they will be undergoing if they have the said disease. As part of the health care team, the student nurse concluded that pre, intra and postoperative tasks are vital in the health of the patient so as to prevent complications such as susceptibility from infection and avoid the chances of death.

As a final conclusion, the student nurses concluded that theories alone is not enough to be efficient during the operation, it should be partnered with a skillful application and that what makes a nurse to be more productive and efficient.

References:

Maternal and child health nursing by Adele Pillitteri 5th edition;volume 1 page 426433;page 329-332 All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN Maternal neonatal nursing;page 30 by Lippincott Williams and Wilkins Luckman and Sorensens Medical-Surgical Nursing a Physiologic Approach 4th edition Volume 1 page 734

Brunner & Suddarths Textbook of Medical-Surgical Nursing-11th edition by Suzanne C. Smeltzer (et. al.)

Black, Joyce M., and Jane Hokanson. Hawks. Medical-surgical Nursing: Clinical Management for Positive Outcomes. St. Louis, Mo.: Saunders/Elsevier, 2009. Print.