NCM 109: MCN

Semifinals: PIH | April 05, 2023

Quezon, Britney Kim E. | BSN 2-L
PREGNANCY-INDUCED HYPERTENSION Gestational Hypertension  Obtain daily hematocrit levels as ordered
- A condition in which vasospasm occurs during pregnancy in both  Bp 140/90 mmHg, or  Assess weight: same time, daily
small and large arteries.  Systolic Bp >30 mmHg; Diastolic > 15 mmHg above pregnancy  Indwelling catheter may be inserted.
Risk Factors level 3. Monitor fetal well-being
1. Multiple pregnancy
 No proteinuria nor edema  External fetal monitor is attached
2. Primiparas younger than 20 y.o. or older than 40 y.o.
3. Women who have hydramnios  Bp returns to normal after birth.  O2 adm. may be necessary to maintain adequate fetal oxygenation
4. Low socioeconomic background Mild Preeclampsia 4. Support a nutritious diet
5. Women with underlying disease  Bp 140/90 mmHg  Moderate to high protein diet
- heart disease  Systolic Bp >30 mmHg; Diastolic > 15 mmHg above pregnancy  Moderate sodium in the diet
- diabetes level  IVF line should be initiated and maintained to serve as an
- essential hypertension  Proteinuria +1 to +2 emergency route for drug adm.
Signs and Symptoms  Weight gain 2 lbs/wk. in 2nd trimester; 1 lb./wk in 3rd trimester. 5. Administer medications to prevent eclampsia
1. hypertension  Mild edema in upper extremities or face.  Hydralazine (Apresoline) to reduce hypertension (5 – 10 mg/IV)
2. edema Severe Preeclampsia - Lowers Bp by peripheral dilatation
3. proteinuria
Pathophysiology of PIH  Bp 160/110 mmHg - Can cause tachycardia
 Proteinuria: 3+ to 4+ on a random sample - Assess pulse & Bp before & after adm.
- Diastolic should not be lowered below 80 – 90 mmHg or
 Oliguria: 500 ml or less in 24 hrs.
inadequate placental perfusion could occur.
 Visual disturbances: blurred vision due to spasm of arteries
 Magnesium Sulfate (5-8 mg/100 ml)
 Cerebral disturbances: severe headache due to extreme edema - Muscle relaxant
 Pulmonary involvement: shortness of breath - Prevent seizures
 Hepatic dysfunction - Has CNS depressant action by blocking peripheral
 Epigastric pain due to ischemia in the pancreas neuromuscular transmission
Eclampsia - Reduces edema by causing a shift in fluid from extracellular
 Seizure or coma occurs. spaces into the intestine
 Signs & symptoms of preeclampsia - Symptoms of Overdose:
Nursing Diagnosis  Decreased urine output
1. Ineffective tissue perfusion r/t vasoconstriction of blood vessels  Depressed RR
2. Deficient fluid volume r/t fluid loss to subcutaneous tissue  Reduced consciousness
3. Risk for fetal injury r/t reduced placental perfusion 2° to vasospasm  Decreased tendon reflexes
4. Social isolation r/t prescribed bed rest  Calcium gluconate
Nursing Intervention: - Antidote for MgSO4 intoxication.
Mild preeclampsia - 10 ml of a 10% calcium gluconate must be prepared at
1. Promote bed rest bedside when administering MgSO4.
2. Promote good nutrition Eclampsia
3. Provide emotional support  Preliminary signs before seizure:
Severe Preeclampsia 1. Bp rises suddenly from additional spasm.
1. Support Bed Rest 2. Temperature rises (39.4 - 40°C) from increased cerebral
 Needs hospitalization so bed rest can be enforced and woman can pressure
be observed closely. 3. Blurring of vision or severe headache from increased cerebral
 Restrict visitors to support people (e.g. husband) edema
 Raise side rails to prevent injury 4. Hyperactive reflexes
5. Epigastric pain & nausea from vascular congestion of the liver
 Room needs to be dimly lit.
or pancreas
2. Monitor maternal well-being
 Tonic-Clonic Seizures
 Monitor Bp
A. Tonic Seizures
 Obtain blood studies as ordered. - Back arches
NCM 109: MCN
Semifinals: PIH | April 05, 2023
Quezon, Britney Kim E. | BSN 2-L
- Arms & legs stiffen
- Jaw closes abruptly
- Respirations stop
- Lasts for approx. 20 sec.
- Maintain patent airway
- Adm. O2 by mask
- Assess O2 saturation via pulse oxymeter
- Apply an external fetal monitor
- Turn woman on her side to allow secretions to drain from
her mouth
B. Clonic Seizure
- Body muscles contract & relax repeatedly.
- Inhales & exhales irregularly
- Incontinence of urine & feces may occur
- Lasts up to 1 min.
- O2 therapy continued
- MgSO4 or diazepam (Valium) may be administered IV as
an emergency measure
C. Postictal State
- Semi-comatose
- Extremely close observation is necessary because
seizure may cause premature separation of the placenta
and labor may begin.
- Painful stimulus of contraction may initiate another
seizure.
- Keep woman on side lying position.
- Keep NPO
- Continue monitoring FHR and uterine contractions.
- Check for vaginal bleeding every 15 min.
Birth
 Labor may be induced as soon as the woman’s condition
stabilizes, usually 12 – 24 hrs. after seizure.
 Preferred method of delivery for eclamptic patient is vaginal
delivery
 C/S is preferred if fetus is in imminent danger.