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Intrapartal Hypertension Nursing Diagnosis (NANDA)

Intrapartal Hypertension Nursing Diagnosis (NANDA)

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Published by api-3701489
Nursing Diagnosis
Nursing Diagnosis

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Published by: api-3701489 on Oct 18, 2008
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Intrapartal Hypertension
PIH may have been diagnosed during the prenatal period, necessitating induction of labor/cesarean birth, or onset of symptoms may occur during labor (or early postpartum).Early recognition and prompt intervention promote optimal outcomes for client and fetus.This plan of care is to be used in conjunction with the first five care plans in this chapter,which concern the three stages of labor, or with CPs: Induced/Augmented Labor CesareanBirth, as indicated.
CLIENT ASSESSMENT DATA BASE
(Refer to CP: Pregnancy-Induced Hypertension and to the intrapartal assessment tool atthe beginning of this chapter.)
Circulation
May have been monitored/treated for prenatal hypertension either at home or in hospitalsetting, or may have been normotensive throughout the pregnancy.Blood pressure may be elevated at the onset of labor.Progressive fluid retention may be present.
Safety
May be receiving an oxytocin infusion for induction or to offset tocolytic effects of MgSO4.
Sexuality
May be scheduled for induction (if cervix is favorable) or cesarean birth (preferably after 36weeks’ gestation) because of deteriorating maternal and placental status.Pregnancy may or may not be full term (with uterus at xiphoid process).
DIAGNOSTIC STUDIES
Kidney, liver, and coagulation studies may show altered function.(Refer to CP: Pregnancy-Induced Hypertension.
NURSING PRIORITIES
1.Reduce/alleviate maternal hypertension.2.Monitor client and fetal status.3.Maintain/optimize placental circulation.4.Prevent eclamptic state.
NURSING DIAGNOSIS:Fluid Volume excess/[circulating deficit]May Be Related To:
Compromised regulatory mechanism (pathologicalstate with fluid shifts), excessive fluid intake, effectsof drug therapy (oxytocin infusion)
Possibly Evidenced By:
Blood pressure changes, edema, weight gain, changesin mentation
DESIRED OUTCOMES/EVALUATION
Display usual mentation; BP, pulse, urine output,
 
CRITERIA—CLIENT WILL:
and specific gravity WNL; deep tendon reflexes (DTRs)2+ (normal); free of headache and visualdisturbances, absence of clonus.
ACTIONS/INTERVENTIONSRATIONALEIndependent
Assess location and extent of edema. Note Hb and Helps determine degree of fluid retention andHct levels.possible shifts to extracellular tissues. If thepathological state is excessive, involving vasospasmsand hypertension, fluid that has shifted from theintravascular space to extracellular tissue may beginto reenter the circulatory system, contributing to fluidoverload and significant increase in BP.Assess BP and pulse as indicated, especially if Preexisting elevated BP may rise even higher inclient is receiving oxytocin.the intrapartal period, or a normotensive client maybecome hypertensive during labor in response toincreased basal metabolic rate, anxiety, and/orsodium and water retention from oxytocin infusion.Assess ankle clonus, DTRs, lung sounds, visual Progressive edema may be manifested byacuity, presence of RUQ/epigastric pain. hyperreflexia or by cerebral, liver, or lunginvolvement. (Refer to CP: Pregnancy-InducedHypertension; ND: Fluid Volume deficit [isotonic].)Monitor urine output. Measure specific gravity; Kidney function is directly correlated tocheck albumin by dipstick test.circulatory fluid volume, so that if fluid is trapped inthird spaces, output decreases and specific gravityincreases.Position client on left or right side during stage I Prevents compression of aorta and inferior venaand II labor, or place wedge underneath right buttock.cava; increases venous return, placental circulation,and kidney perfusion.
Collaborative
Administer antihypertensives (e.g., hydralazine Vasodilator drugs relax smooth muscle of blood[Apresoline], sodium nitroprusside [Nipride]) vessels, thereby reducing BP immediately. InIV by infusion pump, if diastolic readings are emergency situations, sodium nitroprusside actsgreater than 110 mm Hg.within 30 sec, providing a rapid decline in bloodpressure.Insert indwelling urinary catheter. Provides accurate hourly totals of urine output, andmonitors client for developing renal problems oroliguria. (Refer to CP: Pregnancy-InducedHypertension; ND: Tissue Perfusion, altered renal.)Administer PO/IV fluids as ordered.Controversy exists as to whether these individualsshould receive approximately 125 ml/hr to correctcirculatory deficits, or have fluids restricted atapproximately 75 ml/hr to reduce risk of pulmonaryedema. Note: Fluid restriction increases client’ssensitivity to vasodilators with risk of fetal distress,and inability to use epidural anesthesia safely.
 
Administer furosemide (Lasix) if indicated.On occasion, circulatory overload/failure may causepulmonary edema requiring aggressive therapy.Otherwise, it is contraindicated as it may causedehydration.
NURSING DIAGNOSIS:Gas Exchange, risk for impaired fetalRisk Factors May Include:
Altered blood flow, vasospasms, and/or prolongeduterine contractions
Possibly Evidenced By:
[Not applicable; presence of signs/symptomsestablishes an
actual 
diagnosis]
DESIRED OUTCOMES/EVALUATION
Be free of late deceleration.
CRITERIA—FETUS WILL:
Manifest good variability.Demonstrate a baseline heart rate of 120–150 bpm.
ACTIONS/INTERVENTIONSRATIONALEIndependent
Assess FHR; note periodic changes (accelerations Recurrent or late decelerations combined withand decelerations) and patterns of short- or long-reduced variability or tachycardia and thenterm variability. Report reduced variability and bradycardia may indicate uteroplacentallate decelerations, if present.insufficiency or potential fetal compromise/demise.Position client on side; use wedge under right Prevents supine hypotensive syndrome; increasesbuttock if client is supine.placental perfusion, which is especially critical in thehypertensive client who has low fetal reservemanifested as late decelerations.
Collaborative
Note findings of prenatal testing, especially Helps in predicting fetal response to labor and inamniocentesis, nonstress test, contraction stress test,evaluating newborn’s ability to establishgestational age of fetus, and fetal lung maturity.respiratory function in the early neonatal period.Apply internal electrode to presenting part.Accurately monitors fetal response and variability.Note administration of MgSO4or diazepam May reduce beat-to-beat variability and depress(Valium) to client.newborn. Note: Valium use is generally restricted totreatment of severe eclampsia/seizure control.In the event of late decelerations:Continuation of pattern for more than 30 minmarkedly increases risk of negative effects of fetalhypoxia, acidosis, and asphyxia.

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