CT 11: Hypertensive Disorder in Pregnancy

1. MAKE 2 PRIORITY NURSING CARE PLAN FOR PATIENT WITH ECLAMPSIA (ADPIE)

ASSESSMENT NURSING GOALS OF CARE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
OBJECTIVE: Decrease Cardiac SHORT TERM INDEPENDENT After 30 minutes of
 Tachycardia as the Output related to Within 30 minutes of 1. Assessed the 1. Blood pressure nursing interventions, the
body’s increased systemic nursing interventions, client’s vital signs, and pulse rates patient:
compensatory vascular resistance the patient will be able especially blood are good  Exhibited stability in
mechanism as manifested by to: pressure every hour indicators of the cardiac rate and
 Increased blood tachycardia, or as indicated. cardiac volume rhythm
pressure increased blood  Exhibit stability in Used the correct and cardiac  Maintained blood
 Diminished pressure and the cardiac rate cuff size and output. An pressure within the
peripheral pulses diminished and rhythm accurate technique. increase in blood acceptable level of
 Edema peripheral pulses.  Maintain blood pressure occurs >140/90 mmHg
 Decreased urine pressure within the because of the
output acceptable level of increase in Vital Signs:
>140/90 mmHg systemic vascular HR: 95 bmp
VS taken as resistance, while RR: 18 cpm
follows: LONG TERM the decrease in BP: 120/80 mmHg
 HR- 120 bpm Within 1 week of cardiac output is
nursing interventions, associated with LONG TERM
 RR- 30 cpm
the patient will be able diminished After 1 week of nursing
 BP- 160/100
to: peripheral pulses. interventions, the patient
mmHg
 Participate in was able to:
interventions to 2. Assessed the 2. Decreased  Participate in
help decrease client’s peripheral cardiac output interventions to help
cardiac load and pulses and may manifest as decrease cardiac
blood pressure. auscultate for the diminished load and blood
 Alters activity level apical pulse. peripheral pulses pressure.
as the condition while the body  Alters activity level as
warrants. may compensate the condition
 The client remains for the decrease in warrants.
normotensive circulating blood  The client remains
throughout the volume by normotensive
remainder of the increasing the throughout the
pregnancy. heart rate to reach remainder of the
the peripheries. pregnancy.

3. Assessed for the 3. Mean arterial THE GOAL WAS MET.

client’s mean pressure is an
arterial pressure isolated biomarker
(MAP). to predict the
development of
pre-eclampsia at
11-13 weeks
gestation as
recommended by
the National
Institute for Health
and Care
Excellence (NICE)
guidelines (Tan et
al., 2018).

4. Auscultated for 4. The presence of

breath sounds. crackles or
wheezes may
indicate
pulmonary
congestion
secondary to
developing or
chronic heart
failure.

5. Monitored the 5. Oliguria may

client’s urine output develop in pre-
as indicated. eclamptic clients
because of
vasoconstriction
and the body’s
compensatory
 mechanism to
decreased cardiac
output that allows
for retention of
water and sodium
(Anthony &
Schoemann,
2013).

6. Assessed the client 6. The occurrence of

for signs of eclampsia may
impending warrant the
premature delivery. immediate
Assess for uterine delivery of the
contractions. fetus. The fetal
blood supply can
be cut off if
delivery is not
performed
immediately.

7. Noted dependent 7. Edema may

and generalized indicate heart or
edema. kidney failure or
vascular
impairment. This
may occur due to
the fluid shift from
the intravascular
to the interstitial
spaces.

8. Assisted the client 8. Including the client

in planning for her in the planning
activity and rest may improve her
schedule. adherence to the
regimen.
9. Instructed the client 9. Elevating the
to elevate the lower lower extremities
extremities when decreases venous
lying or sitting. stasis and
promotes effective
circulation of the
blood volume
throughout the
body.

10. Provided calm, 10. Removing harmful

restful surroundings environmental
and minimize stimuli from the
environmental client’s
activity and noise. surroundings
reduces
sympathetic
stimulation and
promotes
relaxation.

11. Educated the client 11. For the outpatient

about proper BP client, educate
monitoring at home. them and
significant others
on how to
accurately monitor
their blood
pressure at home.
12. Provide comfort
measures and 12. A back or neck
instruct in relaxation massage or
techniques as elevation of the
appropriate. head decreases
discomfort and
may reduce
sympathetic
stimulation.
 Relaxation
techniques also
reduce stressful
stimuli and
produce a calming
effect, therefore
reducing the
client’s blood
DEPENDENT/ pressure.
COLLABORATIVE
1. Administered
prescribed 1. Hydralazine
medications, as reduces blood
indicated pressure by
(hydralazine, relaxing the
labetalol, smooth muscles,
methyldopa, and the
nifedipine, etc.). vasodilation effect
reduces vascular
resistance. Beta-
blockers such as
labetalol and
methyldopa are
recommended for
BP control
because they
decrease the
workload of the
heart and promote
vasodilation,
thereby slowing
the heart rate.
Calcium channel
blockers such as
nifedipine affect
the blood vessel
by dilating them
and relaxing the
 smooth muscle.

2. Implemented 2. Red calories and

dietary restrictions avoiding refined
as indicated. carbohydrates,
sodium, fat, and
cholesterol should
be included in the
client’s dietary
regimen as
advised by the
healthcare
provider and a
dietitian. Limiting
sodium and
sodium-rich
processed foods
can help manage
fluid retention and
decrease
myocardial
workload.

3. Assisted in the 3. The only cure for

preparation for an pre-eclampsia is
imminent delivery the delivery of the
as indicated. fetus (Leifer,
2018). The fetus is
at risk for death
while in the uterus
of a pre-eclamptic
mother because
its oxygen supply
can be cut off.
 ASSESSMENT NURSING GOALS OF CARE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE: Altered Tissue SHORT TERM INDEPENDENT SHORT TERM
• Elevated blood Perfusion related Within 30 minutes of 1. Monitored vital 1. Indicators of After 30 minutes of
pressure to increased nursing interventions, signs, palpated adequacy of nursing interventions, the
• Edema, especially cardiac workload the client will peripheral pulses systemic patient blood
of the hands and as evidenced by demonstrate and note capillary perfusion, fluid/ pressure is below
face elevated blood adequate perfusion, refill, assess urinary blood, needs, and 120/90mmHg,
• Sudden weight pressure, visual as evidenced by output, weigh client developing urine output of
gain disturbances and stable vital signs, daily and evaluate complications. above 30ml/hour,
• Proteinuria (1+ up edema of hand and palpable pulses, and changes in fetal heart rate
to 4+) face. alert and oriented, mentation. is 130 beats per min,
• Headache absence of seizure absence of seizure
• Visual episodes, balanced 2. Placed client on left 2. This is to avoid episodes, decrease in
disturbances intake and output, recumbent position. uterine pressure presence of
• Epigastric pain decrease in presence on the vena cava edema.
• Decreased urine of edema and good and prevent
 output fetal status supine LONG TERM
• Elevated BUN, evaluation. hypotension After 1 week of nursing
 creatinine, uric syndrome. interventions, the patient
acid LONG TERM verbalizes plans upon
• Decreased Within 1 week of 3. Monitored maternal 3. Woman’s BP discharge, participates
hematocrit and nursing interventions, well- being should be taken at during lecture-
hemoglobin the patient will be able periodically. least every 4 discussion sessions, and
to demonstrate hours to detect for demonstrates willingness
VS taken as readiness during the increase which is to perform monitoring
follows: postpartal period in a warning of measures.
 HR- 120 bpm monitoring one’s worsening; if
 RR- 30 cpm health and involving fluctuating, it THE GOAL WAS MET.
 BP- 160/100 oneself to dietary should be done
mmHg restrictions and hourly.
medical follow up
checkups and 4. Ensured safety by 4. Convulsions are
intervention. putting the side rails evident in
always up and Eclampsia so it
monitor client for should be
 tonic- clonic watched out and
convulsions. monitored.

DEPENDENT

1. Administered 1. To ensure supply

oxygen as of oxygen to both
prescribed. the mother and
the fetus.

2. Urine output
2. Inserted Foley should be in
catheter as congruence with
indicated by the fluid intake.
physician and
monitor urine
output.

3. Administered 3. This drug is

Magnesium Sulfate usually given to
as ordered by the control the blood
physician and pressure of
monitor for signs for client’s with
toxicity. pregnancy
induced
hypertension.

4. Administer fluids as 4. Replacement of

prescribed. fluids maintains
circulating volume
and tissue
perfusion.

2. CONCEPTUALIZE PATHOPHYSIOLOGY OF CHRONIC HYPERTENSION, PREECLAMPSIA AND ECLAMPSIA

RISK FACTORS:

- 1ST Pregnancy
- Multiple Gestations
- Mother > 35 years old  Blood pressure ≥140 mm Hg
systolic and/or 90 mm Hg
- Diabetes
diastolic before pregnancy or,
- Obesity
before 20 weeks of gestation
- Chronic Hypertension
 Use of antihypertensive
medications before
pregnancy
 Persistence of hypertension
for >12 weeks after delivery.

Development of an abnormal
placenta

Uteroplacental artery becomes

fibrous

Narrows- < blood gets into

placenta

 Intrauterine Growth
Restriction
 Possible Fetal Death
 Releases pro- inflammatory
proteins

Gets into mother circulation

Epithelial Cells becomes dysfunctional

Kidneys retain more salt

Vasoconstriction

PREECLAMPSIA

 Systolic is equal or > 140 mmHg

 Diastolic is equal or > 90 mmHg

Severe Preeclampsia

 Systolic is equal or > 60 mmHg

 Diastolic is equal or > 110
mmHg

Hemorrhagic Inc. Vascular Formation of Placental

Local Vasospasm
Stroke Permeability Thrombi Abruption
 Water slip out of vessels and get
into tissues HELLP SYNDROME
Kidney
Hemolysis
- Oliguria
- Proteinuria: Elevated Liver enzyme
Glumerular Damage
Generalized Edema Low
(Legs, face, hand) Platelets
Retina

- Blurred vision
Pulmonary Edema
- Flushing light
- Scotoma (Cough, SOB)

Central Edema
Liver
(Headache, confusion,
- Injury and swelling seizures)
- Elevation in liver
enzymes
- Epigastric pain:
cardinal signs of
severe pre-eclampsia
ECLAMPSIA

TREATMENT

Delivery of Fetus and Placenta

Depends on:
- Gestational age of fetus
- Severity of disease
- Fetal and Maternal Health
Management of symptoms after
delivery
(Subside on their own)

Additional Measures

- Supplemental Oxygen
- Medications