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Among the most fatal part of pregnancy-induced hypertension is eclampsia.

The status of having an eclampsia is an introductory phase for having convulsions when the case is not managed properly. Previous researchers attempted to cite out the cause of hypertension but until now they could not point it out. Only contributing factors are sited such as heredity, lifestyle and supporting vessels. Previously, eclampsia is called toxaemia since researchers thought a certain toxin may cause the hypertensive episodes on mothers. In diagnosing pregnant mothers in the pre-eclamptic stage, a triad of signs and symptoms are observed: 1. Intense Vasospasm 2. Local or disseminated intravascular coagulation 3. Plasma volume contraction

Eclampsia can only be squared down when the following signs and symptoms are present:

hypertension proteinuria edema

Predisposing factors: 1. 2. 3. 4. 5. Multiparity Being pregnant under 20 years old Being pregnant more than 30 years old Being in a low socio-economic status Previous diagnosed illness such as heart disease, diabetes mellitus and essential hypertension

Eclampsia Nursing Care Plan-Altered tissue perfusion


Nursing Diagnosis Objectives Nursing Interventions Nursing Actions 1. Monitor vital signs, palpate peripheral pulses and note capillary refill, assess 1. Rationale Rationale Indicators of adequacy of systemic perfusion, fluid/ blood, needs, and Evaluation Outcome Criteria: Clients blood pressure is below 140/90mmHg

Goals/ Nursing Diagnosis: Objectives: Altered tissue perfusion (Cerebral, peripheral and renal) Short term goal: Possible Etiologies: (Related to) Client will demonstrate

Arterial adequate vasospam/ perfusion, constriction of as blood vessels evidenced Decreased by stable prostaglandin vital signs, levels palpable Sensitivity to pulses, and angiotensin II alert and Impaired oriented, glomerular absence of perfusion seizure Decreased episodes, uteroplacental balanced perfusion intake and Increased output, cardiac decrease in workload presence of Vascular edema and damage good fetal Red blood cell status damage evaluation Alteration in within a liver function in week. severe cases Unusual Long term sensitivity to goal: blood loss probably Client will because of demonstrate leakage of blood readiness components into during the the postpartal extravascular period in space. monitoring ones health Defining and characteristics: involving (Evidenced by) oneself to dietary Elevated blood restrictions pressure and medical Edema, follow up especially of the checkups hands and face and Sudden weight intervention

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urinary output, weigh client daily and evaluate changes in mentation. Place client on left recumbent position.Moni tor maternal well- being periodically. Administer oxygen as prescribed. Ensure safety by putting the side rails always up and monitor client for tonicclonic convulsions. Insert foley catheter as indicated by the physician and monitor urine output. Administer Magnesium Sulfate as ordered by the physician and monitor for signs for toxicity. Administer fluids as prescribed. Assist in the delivery of the baby.

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developing , urine output complications. of above This is to avoid 30ml/hour, uterine pressure fetal heart on the vena rate is cava and between 120prevent supine 160 beats per hypotension min, absence syndrome. of seizure Womans BP episodes, should be taken decrease in at least every 4 presence of hours to detect edema. for increase which is a Client warning of verbalizes worsening; if plans upon fluctuating, it discharge, should be done participates hourly. during To ensure lecturesupply of discussion oxygen to both sessions, and the mother and demonstrates the fetus. willingness to Convulsions perform are evident in monitoring Eclampsia so it measures. should be watched out and monitored. Urine output should be in congruence with fluid intake. This drug is usually given to control the blood pressure of clients with pregnancy induced hypertension. Replacement of fluids maintains

gain . Proteinuria (1+ up to 4+) Hyperreflexia Headache Visual disturbances Epigastric pain Fetal status Decreased urine output Rales, if pulmonary edema is present Elevated BUN, creatinine, uric acid Decreased hematocrit and haemoglobin Seizure

circulating volume and tissue perfusion.Deliv ery of the baby is considered the only cure for Eclampsia.

References: Maternal and Child Health Nursing: Care of the Childbearing and Childrearing Family Philippine Edition of Pillitteri, A.(1992) Phantom Notes in Nursing: Maternal Newborn 1st Edition of Glickman Jr., J. (1995).