Introduction to Preeclampsia Although many pregnant women with high blood pressure have healthy babies without serious

problems, high blood pressure can be dangerous for both the mother and the fetus. Women with pre-existing, or chronic, high blood pressure are more likely to have certain complications during pregnancy than those with normal blood pressure. However, some women develop high blood pressure while they are pregnant (often called gestational hypertension). The effects of high blood pressure range from mild to severe. High blood pressure can harm the mother's kidneys and other organs, and it can cause low birth weight and early delivery. In the most serious cases, the mother develops preeclampsia-or "toxemia of pregnancy"-which can threaten the lives of both the mother and the fetus What is preeclampsia? Preeclampsia is a condition that typically starts after the 20th week (late 2nd or 3rd trimester) of pregnancy and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. There is no proven way to prevent preeclampsia. Most women who develop signs of preeclampsia, however, are closely monitored to lessen or avoid related problems. The way to "cure" preeclampsia is to deliver the baby. The exact cause of preeclampsia is not known. Possible causes include:

Autoimmune disorders Blood vessel problems Diet Genes

Preeclampsia occurs in a small percentage of pregnancies. Risk factors include:

First pregnancy Multiple pregnancy (twins or more) Women with chronic hypertension (high blood pressure before becoming pregnant). Obesity Pregnant women under the age of 20 or over the age of 40. Past history of diabetes, high blood pressure, or kidney disease

Symptoms of preeclampsia can include:

Swelling of the hands and face/eyes (edema) Weight gain o More than 2 pounds per week o Sudden weight gain over 1 - 2 days

Note: Some swelling of the feet and ankles is considered normal with pregnancy. Symptoms of more severe preeclampsia:

Headaches that are dull or throbbing and will not go away Abdominal pain, mostly felt on the right side, underneath the ribs. Pain may also be felt in the right shoulder, and can be confused with heartburn, gallbladder pain, a stomach virus, or the baby kicking Agitation Decreased urine output, not urinating very often Nausea and vomiting (worrisome sign) Vision changes -- temporary loss of vision, sensations of flashing lights, auras, light sensitivity, spots, and blurry vision

Exams and Tests The doctor will perform a physical exam and order laboratory tests. Signs of preclampsia include:

High blood pressure, usually higher than 140/90 mm/Hg Protein in the urine (proteinuria)

The physical exam may also reveal:

Swelling in the hands and face Weight gain

Blood and urine tests will be done. Abnormal results include:

Protein in the urine (proteinuria) Higher-than-normal liver enzymes Platelet count less than 100,000 (thrombocytopenia)

Treatment The only way to cure preeclampsia is to deliver the baby.

If your baby is developed enough (usually 37 weeks or later), your doctor may want your baby to be delivered so the preeclampsia does not get worse. You may receive different treatments to help trigger labor, or you may need a c-section. If your baby is not fully developed and you have mild preeclampsia, the disease can often be managed at home until your baby has a good chance of surviving after delivery. The doctor will probably recommend the following:

Getting bed rest at home, lying on your left side most or all of the time Drinking extra glasses of water a day and eating less salt Following-up with your doctor more often to make sure you and your baby are doing well Taking medicines to lower your blood pressure (in some cases)

Immediately call your doctor if you gain more weight or have new symptoms. In some cases, a pregnant woman with preeclampsia is admitted to the hospital so the health care team can more closely watch the baby and mother. Treatment may involve:

Medicines given into a vein to control blood pressure, as well as to prevent seizures and other complications Steroid injections (after 24 weeks) to help speed up the development of the baby's lungs

You and your doctor will continue to discuss the safest time to deliver your baby, considering:

How close you are to your due date. The further along you are in the pregnancy before you deliver, the better it is for your baby. The severity of the preeclampsia. Preeclampsia has many severe complications that can harm the mother. How well the baby is doing in the womb.

Outlook (Prognosis) 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.

Death of the mother due to preeclampsia is rare. The infant's risk of death depends on the severity of the preeclampsia and how prematurely the baby is born. Prevention Although there is no known way to prevent preeclampsia, it is important for all pregnant women to start prenatal care early and continue it through the pregnancy. This allows the health care provider to find and treat conditions such as preeclampsia early. Proper prenatal care is essential. At each pregnancy checkup, your health care provider will check your weight, blood pressure, and urine (through a urine dipstick test) to screen you for preeclampsia. As with any pregnancy, a good prenatal diet full of vitamins, antioxidants, minerals, and the basic food groups is important. Cutting back on processed foods, refined sugars, and cutting out caffeine, alcohol, and any medication not prescribed by a doctor is essential. Talk to your health care provider before taking any supplements, including herbal preparations.

IV THERAPY Indications Establish or maintain a fluid or electrolyte balance Administer continuous or intermittent medication Administer bolus medication Administer fluid to keep vein open (KVO) Administer blood or blood components Administer intravenous anesthetics Maintain or correct a patient's nutritional state Administer diagnostic reagents Monitor hemodynamic functions

IV Devices Steel Needles Example: Butterfly catheter. They are named after the wing-like plastic tabs at the base of the needle. They are used to deliver small quantities of medicines, to deliver fluids via the scalp veins in infants, and sometimes to draw blood samples (although not routinely, since the small diameter may damage blood cells). These are small gauge needles (i.e. 23 gauge).

Over the Needle Catheters Example: peripheral IV catheter. This is the kind of catheter you will primarily be using.

A Word About Gauges And now, a word about gauges: Catheters (and needles) are sized by their diameter, which is called the gauge. The smaller the diameter, the larger the gauge. Therefore, a 22-gauge catheter is smaller than a 14-gauge catheter. Obviously, the greater the diameter, the more fluid can be delivered. To deliver large amounts of fluid, you should select a large vein and use a 14 or 16-gauge catheter. To administer medications, an 18 or 20-gauge catheter in a smaller vein will do.

IV Fluid There are three main types of fluids: Isotonic fluids Close to the same osmolarity as serum. They stay inside the intravascular compartment, thus expanding it. Can be helpful in hypotensive or hypovolemic patients. Can be harmful. There is a risk of fluid overloading, especially in patients with CHF and hypertension. Isotonic fluids contain an approximately equal number of molecules (blue dots) as serum so the fluid stays within the intravascular space. Remember that fluid flows from an area of lower concentration of molecules to an area of high concentration of molecules (osmosis) to achieve equilibrium (fluid balance). In this example, there is no fluid flow into or out of the intravascular space. Examples: Lactated Ringer's (LR), NS (normal saline, or 0.9% saline in water).

Hypotonic fluids Have less osmolarity than serum (i.e., it has less sodium ion concentration than serum). It dilutes the serum, which decreases serum osmolarity. Water is then pulled from the vascular compartment into the interstitial fluid compartment. Then, as the interstitial fluid is diluted, its osmolarity decreases which draws water into the adjacent cells. Can be helpful when cells are dehydrated such as a dialysis patient on diuretic therapy. May also be used for hyperglycemic conditions like diabetic ketoacidosis, in which high serum glucose levels draw fluid out of the cells and into the vascular and interstitial compartments. Can be dangerous to use because of the sudden fluid shift from the intravascular space to the cells. This can cause cardiovascular collapse and increased intracranial pressure (ICP) in some patients. Example: D5NS.45 (5% dextrose in 1/2 normal saline).

Hypotonic fluids Contain a lower number of molecules than serum so the fluid shifts from the intravascular space to the interstitial space (represented by the green arrows). This decreases the interstitial space osmolarity (because of the increase of fluid and constant number of molecules within it) which then causes fluid to move into the cells. Note that the green arrows represent fluid movement, not molecule movement.

Hypertonic fluids Have a higher osmolarity than serum. Pulls fluid and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Can help stabilize blood pressure, increase urine output, and reduce edema. Rarely used in the prehospital setting. Care must be taken with their use. Dangerous in the setting of cell dehydration. Examples: 9.0% NS, blood products, and albumin.

Hypertonic fluids Contain a higher number of molecules than serum so the fluid shifts from the interstitial space to the intravascular space (represented by the green arrows). This increases the interstitial space osmolarity (because of the loss of fluid and constant number of molecules within it) that then causes fluid to leak out of the cells.

Flow Rates You will often need to calculate IV flow rates. The administration sets come in two basic sizes:

Microdrip sets Allow 60 drops (gtts) / mL through a small needle into the drip chamber. Good for medication administration or pediatric fluid delivery Macrodrip sets Allow 10 to 15 drops / mL into the drip chamber. Great for rapid fluid delivery. Also used for routine fluid delivery and KVO

Vein Selection

Veins of the Hand 1. Digital Dorsal veins 2. Dorsal Metacarpal veins 3. Dorsal venous network 4. Cephalic vein 5. Basilic vein

Veins of the Forearm 1. Cephalic vein 2. Median Cubital vein 3. Accessory Cephalic vein 4. Basilic vein 5. Cephalic vein 6. Median antebrachial vein

In general, locate the vein section with the straightest appearance. Choose a vein that has a firm, round appearance or feel when palpated. Avoid areas where the vein crosses over joints. Technique It is important to point out that starting an IV is an art-form which is learned with experience accumulated after performing many IVs. Some patients are easy but many are difficult.

Preparation It is important to gather all the necessary supplies before you begin. You will need:

Absorbent disposable sheet 1 alcohol prep pad

1 betadine swab Tourniquet IV catheter IV tubing Bag of IV fluid 4 pieces of tape (preferably paper tape or easy to remove tape which has been precut to approximately 4 inches (10cm) in length and taped conveniently to the table or stretcher. Disposable gloves Gauze (several pieces of 4x4 or 2x2)

Prepare the IV fluid administration set

Inspect the fluid bag to be certain it contains the desired fluid, the fluid is clear, the bag is not leaking, and the bag is not expired.

Select either a mini or macro drip administration set and uncoil the tubing. Do not let the ends of the tubing become contaminated. Close the flow regulator (roll the wheel away from the end you will attach to the fluid bag). Remove the protective covering from the port of the fluid bag and the protective covering from the spike of the administration set. Insert the spike of the administration set into the port of the fluid bag with a quick twist. Do this carefully. Be especially careful to not puncture yourself!

Hold the fluid bag higher than the drip chamber of the administration set. Squeeze the drip chamber once or twice to start the flow. Fill the drip chamber to the marker line (approximately one-third full). If you overfill the chamber, lower the bag below the level of the drip chamber and squeeze some fluid back into the fluid bag.

Open the flow regulator and allow the fluid to flush all the air from the tubing. Let it run into a trash can or even the (now empty) wrapper the fluid bag came in. You may need to loosen or remove the cap at the end of the tubing to get the

fluid to flow although most sets now allow flow without removal. Take care not to let the tip of the administration set become contaminated. Turn off the flow and place the sterile cap back on the end of the administration set (if you've had to remove it). Place this end nearby so you can reach it when you are ready to connect it to the IV catheter in the patient's vein.

Perform the venipuncture

Be sure you have introduced yourself to your patient and explained the procedure. Apply a tourniquet high on the upper arm. It should be tight enough to visibly indent the skin, but not cause the patient discomfort. Have the patient make a fist several times in order to maximize venous engorgement. Lower the arm to increase vein engorgement. Select the appropriate vein. If you cannot easily see a suitable vein, you can sometimes feel them by palpating the arm using your fingers (not your thumb) The vein will feel like an elastic tube that "gives" under pressure. Tapping on the veins, by gently "slapping" them with the pads of two or three fingers may help dilate them. If you still cannot find any veins, then it might be helpful to cover the arm in a warm, moist compress to help with peripheral vasodilatation. If after a meticulous search no veins are found, then release the tourniquet from above the elbow and place it around the forearm and search in the distal forearm, wrist and hand. If still no suitable veins are found, then you will have to move to the other arm. Be careful to stay away from arteries, which are pulsatile.

Don disposable gloves. Clean the entry site carefully with the alcohol prep pad. Allow it to dry. Then use a betadine swab. Allow it to dry. Use both in a circular motion starting with the entry site and extending outward about 2 inches. (Using alcohol after betadine will negate the effect of the betadine) Note that some facilities may require an alcohol prep without betadine.

To puncture the vein, hold the catheter in your dominant hand. With the bevel up, enter the skin at about a 30 to 45 degree angle and in the direction of the vein. Use a quick, short, jabbing motion. After entering the skin, reduce the angle of the catheter until it is nearly parallel to the skin. If the vein appears to "roll" (move around freely under the skin), begin your venipuncture by apply counter tension against the skin just below the entry site using your nondominant hand. Many people use their thumb for this. Pull the skin distally toward the wrist in the opposite direction the needle will be advancing. Be carefully not to press too hard which will compress blood flow in the vein and cause the vein to collapse. Then pierce the skin and enter the vein as above. Advance the catheter to enter the vein until blood is seen in the "flash chamber" of the catheter.

If not successful If you are unsuccessful in entering the vein and there is no flashback, then slowly withdraw the catheter, without pulling all the way out, and carefully watch for the flashback to occur. If you are still not within the vein, then advance it again in a 2nd attempt to enter the vein. While withdrawing always stop before pulling all the way out to avoid repeating the painful initial skin puncture. If after several manipulations the vein is not entered, then release the tourniquet, place gauze over the skin puncture site, withdraw the catheter and tape down the gauze. Try again in the other arm. Otherwise, After entering the vein, advance the plastic catheter (which is over the needle) on into the vein while leaving the needle stationary. The hub of the catheter should be all the way to the skin puncture site. The plastic catheter should slide forward easily. Do not force it!!

Release the tourniquet.

Apply gentle pressure over the vein just proximal to the entry site to prevent blood flow. Remove the needle from within the plastic catheter. Dispose of the needle in an appropriate sharps container. NEVER reinsert the needle into the plastic catheter while it is in the patient's arm! Reinserting the needle can shear off the tip of the plastic catheter causing an embolus. Remove the protective cap from the end of the administration set and connect it to the plastic catheter. Adjust the flow rate as desired.

Tape the catheter in place using the strips of tape and/or a clear dressing. It is advisable not to use the "chevron" taping technique. Label the IV site with the date, time, and your initials. Monitor the infusion for proper flow into the vein (in other words, watch for infiltration).

Occasionally, you may inadvertently enter an artery. You'll recognize this because bright red blood is quickly seen in the IV tubing and the IV bag because of the high pressure that exists. If this occurs, stop the fluid flow, remove the catheter, and put pressure on the site for at least 5 minutes. To discontinue an IV Remember to observe universal precautions. Start by clamping off the flow of fluids. Then gently peel the tape back toward the IV site. As you get closer to the site and the catheter, stabilize the catheter and remove the rest of the tape from the patient's skin. Then place a 4 x 4 gauze over the site and gently slide the plastic catheter out of the patient's arm. Use direct pressure for a few minutes to control any bleeding. Finally, place a band aide over the site.

JMJ MARIST BROTHERS NOTRE DAME OF DADIANGAS UNIVERSITY GENERAL SANTOS CITY COLLEGE OF NURSING

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Pre-eclampsia and IV Therapy

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In Partial Fulfillment of the Requirements In NCM 113

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Presented to:

Ms. Recca Rose Tuban, RN Clinical Instructor

Presented by: Camille Bianca Arevalo Jessa Jane Broce BSN-3B Group 1

September 2011