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ABBAS,SITTIE OMAIMAH ALMOJALLAS, DONNA BADO, MARIEJO CALLET, JOSEPH DEMIGILLO, GRACE GALEON, MAX ANTHONY GENTALLAN, SHEENA CALIRE MADRIA, JERYL MARTURILLAS, KHALID PACOT, LEONARD MITCHEL REYES, HAZIEL MARIE TOGONON, ROSE ZERNA, ZOILO 3A

OUTLINE:
I. II. III. IV.

Pages

OBJECTIVES ................................................................................................3 INTRODUCTION .........................................................................................4 DEFINITION OF TERMS ..................................................................................7 ASSESSMENT A. PEROS ................................................................................................8 B. DIAGNOSTIC TEST ..................................................................................16 V. NORMAL ANATOMY & PHYSIOLOGY .............................................................28 VI. RISK FACTORS & PATHOPHYSIOLOGY .............................................................40 VII. NURSING MANAGEMENT A. NCP ..............................................................................................................41 B. HEP ............................................................................................................. C. DP ............................................................................................................. VIII. MEDICAL & SURGICAL MANAGEMENT ............................................................ IX. PROGNOSIS ................................................................................................. X. BIBLIOGRAPHY ................................................................................................
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I.

OBJECTIVES

After the case sharing, the students will be able to: 1. Understand what Preeclampsia is all about and know its different types and classification. 2. Know the normal anatomy and physiologic changes during pregnancy and incorporate it on the disease. 3. Identify several risk factors that will affect the occurrence of Preeclampsia and the disease process.Identify the prognosis of the patient having Preeclampsia and to know the percentage of recovery. 4. Identify the prognosis of the patient having Preeclampsia and to know the percentage of recovery. 5. Determine problems that will be manifested during the malady and organize nursing care plans and actions. 6. Be familiar with the treatment which will be needed to prevent necessary complication of the disease. 7. To know some health teaching that the client may need in state of Preeclampsia.

After the case sharing, the presenters will be able to: 1. 2. 3. 4. 5. 6. Discuss to the listeners effectively the parts of the case sharing from the introduction until the prognosis. Use different teaching techniques to get the attention of the listeners. Manifest confidence, coherence, logic and effective audience management. Make sure that the presentation of case will not be boring and may inject ice breakers to help increase attention span. Answer effectively the question raised for clarifications, corrections and learning purpose. Encouraged participation and interaction from the listeners for learning purposes.

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II.

INTRODUCTION

Pre-eclampsia is a common problem during pregnancy. The condition sometimes referred to as pregnancy-induced hypertension, defined by high blood pressure and excess protein in the urine after 20 weeks of pregnancy, generally in the latter part of the second or in the third trimesters, although it can occur earlier. Often, pre-eclampsia causes only modest increases in blood pressure. Left untreated, however, preeclampsia can lead to serious even fatal complications for both mother and baby. Women with Pre-eclampsia will often also have swelling in the feet, legs, and hands. The symptoms of pre-eclampsia rapid weight gain caused by significant increase in bodily fluid, abdominal pain, severe headaches, a change in reflexes, reduced output of urine or no urine, dizziness, and excessive vomiting.

The exact causes of pre-eclampsia are not known, although some researchers suspect poor nutrition, high body fat, or insufficient blood flow to the uteruses possible causes.

The only real cure for pre-eclampsia and eclampsia is to deliver the baby, but this depends on the stage of pregnancy because being born prematurely can be dangerous. Babies may also be 'small-for-dates' because of growth problems.

Apart from Caesarean section or induction of labor (and therefore delivery of the placenta), there is no known cure. It is the most common of the dangerous pregnancy complications; it may affect both the mother and the unborn child.

Pre-eclampsia or eclampsia is also common among Filipino women. Most women enter pregnancy in apparent good health and achieve a normal pregnancy and delivery without complications. In few women however, for reasons which are usually unclear, unexpected deviations, from the course of normal pregnancy develops such complications that threaten the pregnancy outcome, the women health or both (Pillitteri, 1999). There are various abnormalities, which fall under the category of pregnancy complications. One major complication is the mild or severe pre-eclampsia.

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Mild preeclampsia

Severe preeclampsia

BP of 140/90 Absence visual problem Absent headache Transient irritability Normal reflexion Weight gain of 2 lbs. per week on the 2nd trimester and 1 lbs. per week on 3rd trimester Slight edema in upper extremities and face 1+ to 2+ proteinuria on random

BP of 160/110 Blurry vision, blind spots Severe headache Severe irritability Hyperreflexia w/ possible ankle clonus weight gain of 3 lbs. per week on the 2nd trimester and 3rd trimester generalized edema 3+ to 4+ proteinuria on random

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.

Around 1 in 100 women with pre-eclampsia go on to develop a serious complication called eclampsia. This can happen at any stage during pregnancy, but it is more common during the last three months, and the first 48 hours after birth. Eclampsia is a type of seizure that can be life-threatening.

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In developing nations, the incidence of the disease is reported to be 4-18%, with hypertensive disorders being the second most common obstetric cause of stillbirths and early neonatal deaths in these countries as high as 18% in some settings in Africa while in United States is estimated to range from 2% to 6% in healthy, nulliparous women. Among all cases of the preeclampsia, 10% occur in pregnancies of less than 34 weeks' gestation. The global incidence of preeclampsia has been estimated at 5-14% of all pregnancies. According to Safe Motherhood stated that over 585,000 maternal annually (3), 13%, or 76,050, are due to eclampsia.

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III.

DEFINITION OF TERMS

Cerebral edema: Accumulation of excessive fluid in the substance of the brain. The brain is especially susceptible to injury from edema, because it is located within a confined space and cannot expand. Diabetes: is a condition whereby the body is not able to regulate levels of glucose (a sugar) in the blood, resulting in too much glucose being present in the blood. Eclampsia: is an extension of preeclampsia and is characterized by the client experiencing seizures. Fetal distress: Compromise of the fetus during the antepartum period (before labor) or intrapartum period (birth process). The term "fetal distress" is commonly used to describe fetal hypoxia (low oxygen levels in the fetus). Glomerular filtration rate (GFR): is a test used to check how well the kidneys are working. Specifically, it estimates how much blood passes through the tiny filters in the kidneys, called glomeruli, each minute. High blood pressure (HBP) or hypertension: means high pressure (tension) in the arteries. Obesity: is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. Pre-eclampsia: is a medical condition in which hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine. Pregnancy Induced Hypertension (PIH): High arterial blood pressure, in adults, usually defined as pressures exceeding 140/90. Proteinuria: Excess protein in the urine. Some protein is normal in the urine. Too much means protein is leaking through the kidney, most often through the glomeruli. The main protein in human blood and the key to the regulation of the osmotic pressure of blood is albumin Pulmonary edema: is an abnormal build-up of fluid in the air sacs of the lungs.

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IV.

ASSESSMENT

A. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM Physical assessment is an organized systemic process of collecting objective data based upon a health history and head-to-toe or general systems examination. A physical assessment should be adjusted to the patient, based on his needs. It can be a complete physical assessment, an assessment of a body system, or an assessment of a body part. It is the first step in the nursing process. It provides the foundation for the nursing care plan in which your observations play an integral part in the assessment, intervention, and evaluation phases. (Wikipedia.org)

The purposes for a physical assessment are:


To obtain baseline physical and mental data on the patient. To supplement, confirm, or question data obtained in the nursing history. To obtain data that will help the nurse establish nursing diagnoses and plan patient care. To evaluate the appropriateness of the nursing interventions in resolving the patient's identified pathophysiology problems.

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Through physical assessment and asking questions to the patient, we can be able to formulate nursing management needed for the patient. First, we must to differentiate the stages of preeclampsia by its objective cues and possible subjective cues.We have mild preeclampsia and severe preeclampsia. Untreated preeclampsia may progress to eclampsia.( Physical Examination and health assessment by Jarvis. Page 830).

Mild Preeclampsia
Systems Mild Preeclampsia Physical Examination Mild Preeclampsia Review of Systems Problem Identified

General Appearance

y y y

A weight gain of more than 2 lb/wk in the second trimester Weight gain of more than 1lb/wk in the third trimester Edema begins to accumulate in the upper part of the body: slight pitting edema +1 Reflexes may be normal (using the reflex hammer, check the biceps, patellar, and ankle deep tendon reflexes.)

Patient may report of headache absent or transient and dizziness

y y

Fluid volume excess Risk for injury

Neurologic

Patient may report for Headache Patient may report for dizziness

Risk for Injury: Fall

Head/Hair/Face

Edema may be noted in the face

Patient may report of headache absent or transient and dizziness

y y

Fluid volume excess Disturbed Body Image

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Risk for injury

y EENT y

Chloasma is present None y Patient may report no visual disturbances at this stage None none none none y No problems identified

Neck Thorax/Lungs Back Breast and Axilla

y y y y y

The thyroid may be palpable( normal findings) none none Dark areola The breast are enlarged

y y y y

y y y y

No problems identified No problems identified No problems Identified No problems identified

Cardiovascular/Peripheral Vascular

Blood reading of 140/90 mmHg x 2, 4-6 hr apart, no more than 1 wk apart CRT is > 3 seconds none

Patient may report of headache and dizziness

y y

Decreased cardiac output Ineffective tissue perfusion

y GIT y

Patient may report no absent epigastric pain at

No problems identified

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this stage GUT y Quantitative 24-hr urine analysis: Proteinuria of 0.3g in a 24-hr specimen Qualitative dipstick: 30 mg/dl ( /+) on dipstick y None y Fluid volume deficit

Urine output: Output matching intake, 30 ml/hr or <650 ml/24hr Serum Creatinine: Normal

Musculoskeletal

Reflexes may be normal

Patient may report limitation of motion due to edema that begins to

Activity intolerance

accumulate in the upper part of the body


Extremities y Edema begins to accumulate in the upper part of the body: slight pitting edema +1 CRT is > 3 seconds y Patient may report limitation of motion due to edema that begins to y y Activity intolerance Ineffective tissue perfusion

accumulate in the upper part of the body


None No problems identified

Hematologic

None

Severe Preeclampsia

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Systems

Severe Preeclampsia Physical Examination

Severe Preeclampsia Review of Systems

Problem Identified

General Appearance

Weight gain of 3 or more lbs/wk in 2nd or 3rd trimester Generalized Edema Extreme edema will be noticeable as puffiness in a woman s face and hands and as well as in the lower extremities: the lower extremities pitting edema grade is 2+ to 4+ Hyperreflexia 3+, possible ankle clonus

Patient may verbalize body weakness Patient may report of severe headache

y y

Fluid volume excess Risk for injury Activity intolerance

y y

Neurologic

Patient may report severe headache

Risk for injury: fall

In this picture, it showed that ankle clonus is elicited by stretching the Archille's tendon by dorsiflexing the foot Head/Hair/Face y Edema noted in the face y Severe headache y y y EENT PRE-ECLAMPSIA y scotoma(blind spots) y Blurred vision y Altered comfort Fluid volume excess Risk for injury Risk for injury Page 12

photophobia

y y

photophobia Seeing spots before the eyes scotoma(blind spots)

Disturbed sensory perception

Thorax/Lungs

y y

Shortness of breath Dyspnea, crackles, wheezing Dark areola The breast are enlarged Rise to 160/110 mmHg on two separate occasions CRT is > 3 seconds

Patient may complain of having shortness of breath and dyspnea. None

y y y

Ineffective breathing pattern Ineffective airway clearance No problems identified

Breast and Axilla

y y

Cardiovascular/Peripheral Vascular

Patient may report severe headache

y y

Decreased cardiac output Altered comfort Risk for injury Ineffective tissue perfusion Altered comfort: Acute pain Nutrition imbalanced: less than body requirements

y y GIT y Patient may show facial grimace y y The patient may report nausea and vomiting The patient may experience epigastric pain at RUQ y y

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GUT

Quantitative 24-hr urine analysis: Proteinuria of > 2g in 24hr Qualitative dipstick: 2+ to 3+ protein on dipstick Urine output: 20ml/hr or < 400ml to 500 ml/hr Oliguria( 500ml or less in 24hours) Serum Creatinine: Elevated serum creatinine more than 1.2 mg/dl

The patient may verbalize small amount of urine

Fluid volume deficit

Musculoskeletal

Hyperreflexia 3+, possible ankle clonus Extreme edema will be noticeable as puffiness in a woman s face and hands and as well as in the lower extremities. CRT is > 3 seconds

The patient may report on twitching or spastic tendencies y Patient may report upper extremities edema as my rings are so tight, I can t get them off and facial edema as when I wake in the morning, my eyes are swollen shut or I can t talk until I walk around a while. Patient may report edema in the lower extremities by difficulty

Risk for injury: fall

Extremities

y y

Activity intolerance Ineffective tissue perfusion

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fitting into their bedroom slippers or kicking of their shoe at dinner time and then not being able to put them back on again.

Hematologic

Thrombocytopenia (less than 100,000/mm3

None

Increasing the risk of bleeding during and after labor

B. DIAGNOSTIC TEST DIAGNOSTIC TEST PURPOSE NORMAL VALUES SIGNIFICANCE NURSING CONSIDERATIONS

-To evaluate kidney function and -8 to 20 mg/dl aid in the diagnosis of renal disease BLOOD UREA NITROGEN -To aid in the assess of hydration

Abnormal Results: -Elevated levels: renal disease, reduced renal blood flow (e.g. caused by dehydration), urinary tract obstruction, and increased protein catabolism (such as burns) -Apply direct pressure to the bleeding site. -Inform the patient that he may resume taking his usual medications after the test.

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-To evaluate liver function

Abnormal Results:

-Apply direct pressure to To aid in the differential diagnosis -In adults, normal indirect serum bilirubin -Elevated indirect serum the venipuncture site to of jaundice and monitor its levels are 1.1 mg/dl (SI, 19umol/L) bilirubin levels usually indicate stop bleeding. progress hepatic damage BILIRUBIN, SERUM, DIRECT AND -To aid in the diagnosis of biliary INDIRECT obstruction and hemolytic anemia -To determine whether a neonate requires an exchange transfusion or phototherapy because of dangerously high unconjugated bilirubin levels -High levels of indirect bilirubin are also likely in severe hemolytic anemia -If hemolysis continues, direct and indirect bilirubin levels may rise -Other causes of elevated indirect bilirubin levels include congenital enzyme deficiencies such as Gilbert syndrome Elevated direct serum bilirubin levels usually indicate biliary obstruction

-If obstruction continues, direct and indirect bilirubin levels may rise -In severe chronic hepatic damage, direct bilirubin concentrations may return to normal or near normal levels, but indirect bilirubin levels remain elevated than 0.5 mg/dl(SI,<6.8umol/L)

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Abnormal Results: -To assess glomerular filtration SERUM CREATININE -To screen for renal damage -In men, 0.8 to 1.2 mg/dl (SI, 62 to 115 -Elevated levels generally umol/L) indicate renal disease that has seriously damaged 50% or more -In women, 0.6 to 0.9 mg/dL (SI, 53 to 97 of the nephrons umol/L) -Elevated levels may also indicate gigantism and acromegaly Abnormal Results: -To assess overall hemostatic function (platelet response to injury and functional capacity of vasoconstriction) -To detect disorders platelet function -3 to 6 minutes (SI, 3 to 6 min) in the template method; 3 to 6 minutes in the ivy method; and 1 to 3 minutes (SI, 1 to 3min) in the duke method. -Prolonged bleeding time may indicate disorders linked to thrombocytopenia, such as hodgkin s disease, acute leukemia, disseminated intravascular coagulation, hemolytic disease of the newborn, schonlein-henoch purpura, severe hepatic disease (cirrhosis, for example), or severe deficiency of factors I,II,V,VII,VIII,IX, and XI. -In a patient with a bleeding tendency (hemophilia), maintain a pressure bandage over the incision for 24 to 48 hours to prevent further bleeding. -Check the test area frequently; keep the edges of the cuts aligned to minimize scarring. -Apply direct pressure to the venipuncture site to stop bleeding. -Inform the patient that he may resume his usual medications after the test.

BLEEDING TIME

-Instruct the patient that he/she may resume his/her medication after the tests Abnormal Results: -To aid polycythemia, PRE-ECLAMPSIA diagnosis anemia, of -HCT is usually measured electronically; -Low HCT suggests anemia, -Ensure or electronic results are 3% lower than hemodilution, or massive blood bleeding subdermal stopped Page 17

has

abnormal states of hydration HEMATOCRIT -To aid in the calculation of erythrocyte indices

manual measurements which trap plasma loss in the column of packet RBC s -High HCT indicates polycythemia or -In men, 42% to 52% (SI, .42 to 0.52) hemoconcentration caused by blood loss and dehydration. -In women, 36% to 48% (SI, 0.36 to 0.48)

before removing pressure -If large hematoma develops at the venipuncture site, monitor distal pulses.

Abnormal Results: UNSTABLE HEMOGLOBIN -To detect of hemoglobin. -Heat stability test result is negative, -A positive heat stability test isopropanol solubility test result is stable result or unstable, solubility test result, especially with hemolysis, strongly suggest the presence of unstable Hb. -Make sure the subdermal bleeding has stopped before removing pressure -Instruct the patient that he may resume medications stopped before the test. -If a large hematoma develops at the venipuncture site, monitor pulses distal to the site. Abnormal Results: -To evaluate platelet production Adults: 140,000 to 400,000/ul (SI, 140 to -A count below 50,000/ul can 400x10/L) cause spontaneous bleeding, -To assess the effects of when the count is below chemotherapy or radiation 5,000/ul, fatal central nervous therapy on platelet production system bleeding or massive GI hemorrhage is possible -To diagnose and monitor severe thrombocytosis or -A decreased count thrombocytopenia. (thrombocytopenia, 80 to 100 -Make sure that subdermal bleeding has stopped before removing pressure -Tell the patient that he may resume any medications stopped before the test

PLATELET COUNT

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million platelets per ml) can result from aplastic or hypoplastic bone marrow; infiltrative bone marrow disease, such as leukemia, or disseminated infection. -An increased count (thrombocytosis can result from hemorrhage, infectious disorders, iron deficiency anemia, recent surgery, pregnancy, splenectomy or inflammatory disorders. In such cases, the platelet count returns to normal after the patient recovers from the primary disorder

-If a large hematoma develops, monitor pulses distal to the venipuncture site

Abnormal Results: -To evaluate the extrinsic -PT should be 10-14 seconds (SI. 10 to 14s) coagulation system (factors V,VII, depending on the source of tissue and prothrombin and fibrinogen) thromboplastin and the type of sensing devices used to measure clot formation -To monitor response to oral anticoagulant therapy -In a patient receiving oral anticoagulants, PT should be from 1 to 2 times the normal control value -Prolonged PT may indicate deficiencies in fibrinogen, prothrombin, factors V, VII, or X (specific assays can pinpoint such deficiencies), or vitamin K. it may also result from ongoing oral anticoagulant therapy -Make sure subdermal bleeding has stopped before removing pressure

PROTHROMBIN TIME

-Instruct the patient that he may resume his usual diet and medications discontinued before the -A prolonged PT that exceeds 2 test times the control value usually indicates abnormal -If a large hematoma bleeding develops at the venipuncture site, monitor pulses distal to the site. Page 19

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Abnormal Results: -To detect enzyme deficiencies -250 to 750 mg/24 hours (SI, 1.48 to 4.43 and metabolic disturbances (such mmol/d), depending on patient s diet. as gout) that affect uric acid production -To help measure the efficiency of renal clearance and to determine the risk of stone formation -Increased levels may result -Instruct the patient that he from chronic myeloid leukemia, may resume his usual diet polycythemia, vera, multiple and medications. myeloma, early remision in pernicious anemia, lymphosarcoma and lymphatic leukemia during radiotherapy, or tubular reabsorption defects, such as fanconi s syndrome and hepatolenticular degeneration -Decreased levels occur in gout (when uric acid production in normal but excretion inadequate) and in severe renal damage such as that resulting from chronic glorulonephritis, diabetic glomerulosclerosis, and collagen disorders

URIC ACID, URINE

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Nonstress, Fetal (NST, Fetal Activity Determination)

-The NST is a method to evaluate the viability of a fetus. It documents the placenta s ability to provide an adequate blood supply to the fetus. The NST can be used to evaluate any high-risk pregnancy in which fetal wellbeing may be threatened. These pregnancies includes those marked by diabetes, hypertensive disease of pregnancy (toxemia), intrauterine growth retardation, Rh-factor sensitization, history of stillbirth, postmaturity, or low estriol levels.

-Explain the procedure to the client. -Encourage the verbalization of the patient s fears. The necessity for the study usually raises realistic fears in the expectant mother. -If the patient is hungry, instruct her to eat before the NST is begun. Fetal activity is enhanced with a high maternal serum glucose level. During -After the patient empties her bladder, place her in the Sim s position. -Place an external fetal monitor on the patient s abdomen to record the FHR. The mother can indicate fetal movement by pressing a button on the fetal monitor whenever she feels the fetus move. -The FHR and fetal movement are concomitantly recorded on a two-channel strip graph.

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-Observe the fetal monitor for FHR accelerations associated with fetal movement. -If the fetus is quiet for 20 minutes, stimulate fetal activity by external methods, such as rubbing or compressing the mother s abdomen, ringing a bell near the abdomen, or placing the pan on the abdomen and hitting the pan. -Note that a nurse performs the NST in approximately 20 to 40 minutes in the physician s office or a hospital unit. -Tell the patient that no discomfort is associated with the NST. After -If the results detect a nonreactive fetus, calmly inform the patient that she is a candidate for the CST.

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Abnormal Results: -To confirm the diagnosis of gout SERUM URIC ACID -To help detect renal dysfunction In men, 3.4 to 7 mg/dl In women,2.3 to 6 mg/dl -Increased uric acid levels may -Apply direct pressure to indicate gout or impaired kidney the venipuncture site until functions. bleeding stops. -Levels may also rise in heart failure, glycogen storage disease (type 1 von Gierke s disease), infection, hemolytic and sickle cell anemia, polycythemia, neoplasms, and psoriasis -Low uric acid levels may indicate defective tubular absorption such as acute hepatic atrophy. Tests Results and Clinical Significance Protein -To screen the patient s urine for Color: straw to dark yellow the renal or urinary tract disease Odor: slightly aromatic Appearance: clear -To help detect metabolic or Specific gravity: 100 systemic disease unrelated to renal disorder Protein -To detect substances (drugs) - 0-8 mg/dl - 50-80 mg/24 hr (at rest) - <250 mg/24 hr (during exercise) Increased Levels  Nephrotic syndrome  Glomerulonephritis  Malignant hypertension  Diabetic glomerulosclerosis  Polycystic disease  Lupus erythematosus  Goodpasture s syndrome  Heavy-metal poisoning  Bacterial pyelonephritis  Nephrotoxic drug therapy -Inform the patient that he may resume he usual diet and medications stopped before the test.

Urinalysis (UA)

-Inform the patient that he may resume his usual diet and medications.

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Renal disease involving the glomeruli is associated with proteinuria. Trauma.Protein can spill into the urine as a result of traumatic destruction of the blood-urine barrier. Macroglobulinemia. With increased globulin within the blood, albumin is secreted in an attempt to to maintain ocncotic homeostasis. Multiple myelomas. Classically, mulptiple myelomas produce large amounts of protein (e.g., BenceJones protein) in the urine. Preeclampsia Congestive heart failure The pathophysiologic factors of these observations are many. Suffice it to say that albumin leaks from the glomeruli, which are temporarily damage by this illnesses. Orthostatic proteinuria. As many as 20% of Page 24

  

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normal male patients have small amounts of protein in the urine when urine specimens are obtained from patients in the upright position. The pathophysiology is not known with certainty. It may be associated with passive congestion of kidney in the upright position. This phenomenon is can be diagnosed by obtaining a urine specimen before arising and another after the patient has been up for two hours. The first has no protein, the latter does. Severe muscle exertion. Prolonged muscular exertion can be associated with small amount of protein in the urine. Renal vein thrombosis. Congestion of the kidney is associated with proteinuria. Bladder tumors. Tumors of the bladder secrete protein into the lumen of the bladder. Urethritis or prostatitis. Page 25

Inflammation in the periurethral glands or urethra can cause proteinuria. Amyloidosis. Often associated with proteinuria, it may be o severe as to cause nephritic syndrome. Usually, amyloidosis of the kidney is due to other severe, ongoing disease.

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V.
The Heart

NORMAL ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM

The heart lies in the mediastinum, behind the body of thesternum. The shape of the heart tends to resemble the chest. Theheart has chambers divided into four cavities with the right and leftchambers (atria and the ventricles) separated by the septum. The Blood Vessels There are 3 types of blood vessels: the arteries, the veins and the capillaries. An artery is a vessel that carries blood away from the heart. It carries oxygenatedblood. Small arteries are called arterioles. Veins, on the other hand are vessels that carries blood toward the heart. It contains the deoxygenated blood. Small veins are called venules. Often, very large venous spaces are called sinuses. Lastly, capillaries are microscopic vessels that carry blood from small arteries to small veins (arterioles to venules) and back to the heart. The walls of the blood vessels, the arteries and veins have three main layers:

Tunica adventitia, tunica media and tunica intima. Tunica adventitia which is a fibrous type of vessel is a connective tissue that helps hold vessels open and prevents tearing of the vessel wall during body movement. Tunica media is a smooth muscle, sandwiched together with a layer of elastic connective tissue. It permits changes of the blood vessel diameter. It allows the constriction and dilation of the vessels. Last but not the least is the tunica intima. Tunica intima, which in Latin means inner coat, is made up of endothelium that is continuous with the endothelium that lines the heart. In arteries, it provides a smooth lining. However in veins it maintains the one-way flow of the blood. The endothelium, which makes up the thin coat of the capillary, is important because the thinness of the capillary wall allows the exchange of materials between the blood plasma and the interstitial fluid of the surrounding tissues. There are two circulatory routes of blood as it flows through the blood vessels: the systemic and the pulmonary circulation. In systemic circulation, blood flows from the left ventricle of the heart
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through blood vessels to all parts of the body (except gas exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to right ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters the left ventricle. Vasomotor Control Mechanism

Blood distribution patterns, as well as BP can be influenced by factors that control changes in the diameter of arterioles. Such factor might be said to constitute the vasomotor control mechanism. Like most physiological control mechanisms, it consists of many parts. An area in the medulla called vasomotor center/ vasoconstrictor center will, when stimulated initiate an impulse outflow via sympathetic fibers that ends in smooth muscle surrounding resistance vessels, arterioles, and veins of the blood reservoir causing their constriction thus the vasomotor control mechanism plays an important role both in the maintenance of the general BP and in the distribution of blood to areas of special need. Venous return of the Blood

Venous return refers to the amount of blood that is returned to the heart by the way of veins. Various factors influence venous return, including the operation of venous pumps that maintains the pressure gradients necessary to keep blood moving into the central veins and from there the atria of the heart. Changes in the total volume of blood vessels can also alter the venous return. The return of venous blood to the heart can be influenced by the factors that change the total volume of blood in the circulatory pathway. Stated simply, the more the total volume of blood, the greater the volume of blood returned to the heart. The mechanism that change the total blood volume most quickly, making them most useful in maintaining constancy of blood flow, are those that cause water to quickly move into the plasma or out of the plasma. Most of the mechanisms that accomplish such changes in plasma volume operate by altering the body s retention of the water.

The primary mechanisms for altering the water retention in the body- they are the endocrine reflexes in the body. One is the ADH mechanism is released in the neurohypophysis and acts on the kidneys in a way that reduces the amount of water lost by the body. ADH does this by increasing the amount of water that kidneys reabsorb from urine before the urine is excreted from the body. The more ADH is secreted, the more water will be reabsorbed into the blood, and the greater the blood plasma volume will become. Another mechanism that changes the blood plasma volume is the renninangiotensin mechanism of

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aldosterone secretion. Renin is an enzyme that is released when the blood pressure in the kidney is low. Renin triggers a series of events that leads to the secretion of aldosterone. Aldosterone promotes sodium retention by the kidney, which in turn stimulates the osmotic flow of water to the kidney tubules back into the blood plasma- but only when ADH is present to permit the movement of water. Thus, low blood pressure increases the secretion of aldosterone, which in turn stimulates the retention of water and thus an increase in blood volume. Another effect of reninangiotensin is the vasoconstriction of blood vessels caused by an intermediate compound called angiotensin II. This complements the volume-increasing effects of themechanism and thus also promotes an increase in overall blood flow. Precision of blood volume control contributes to the precision in controlling venous return, which in return yields to the precise overall control of blood circulation

ENDOCRINE SYSTEM The endocrine system performs their regulatory functions by means of chemical messenger sent to specific cells. The endocrine system, secreting cells send hormones by way of the bloodstream to signal specific target cells throughout the body. Hormones diffuse into the blood to be carried to nearly every point in the body. The endocrine glands secrete their products, hormones, directly into the blood. There are two classifications of hormones: steroid hormones and non-steroid hormones. The steroid hormones which are manufactured by the endocrine cells from cholesterol, is an important lipid in the human body. Nonsteroid hormones are synthesized primarily from amino acids rather from the cholesterol. Non-steroid hormones are further subdivided into two: protein hormones and glycoprotein hormones. Aldosterone Its primary function is the maintenance of the sodium homeostasis in the blood byincreasing the sodium reabsorption in thekidneys. It is secreted from the adrenal cortex; it triggers the release of ADH which results to the conservation of water by the kidney. Aldosterone secretion is controlled by the rennin- angiotensin mechanism. Estrogen 29. It is secreted by the cells of the ovarian cells that promote and maintain the female sexual characteristics.

LIVER

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The liver is the largest organ in the body, normally weighing about 1.5kg (although this can increase to over 10kg in chronic cirrhosis). The liver is the main organ of metabolism and energy production; its other main functions include:
y y y y

Bile production Storage of iron, vitamins and trace elements detoxification conversion of waste products for excretion by the kidneys

The liver is functionally divided into two lobes, right and left. The external division is marked on the front of the liver by the falciform ligament, which joins the coronary ligament at the superior margin of the liver.

The right lobe is separated from the other lobes by the gallbladder fossa and the fossa for the inferior vena cava on the visceral surface of the liver.

The left lobe includes the caudate and quadrate lobes. It is separated from these two lobes by the attachment of the ligumentum teres, and the fissures for the ligumentum teres and the ligamentum venosum.

The caudate lobe lies between the fissure for the ligamentum venosum and the fossa for the inferior vena cava.

The quadrate lobe is partly covered by the gallbladder in normal patients; anatomically, it lies between the fissure for the ligamentum teres and the gallbladder fossa.

Each lobe hs its own arterial and venous supply and its own billiary drainage. all the lobes perform the same functions- there are no areas of specialisation.

REPRODUCTIVE SYSTEM

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The female reproductive system produces gametes may unite with a male gamete to form the first cell of the offspring. The female reproductive system also provides protection and nutrition to the developing offspring. The most essential organ is the ovary which carries the ova. The uterus, the fallopian tubes and the vulva are accessory organs. Ovaries It is an almond-shape organ. It contains the ova and is responsible in expelling the ova. It also produces estrogen and progesterone. Progesterone It is secreted by the corpus luteum. It is also known as a pregnancy- promoting steroid and it prevents the expulsion of the fetus in the uterus. Anti-diuretic hormone (ADH) It is secreted in the neurohypophysis (posterior pituitary); it literally opposes the formation and production of a large urine volume. It helps the body to retain and conserve water from the tubules of the kidney and returned to the blood.

Fallopian Tubes It usually measures approximately 10- 12 cm. It has two parts: the ampullae and the fimbriae. The ampullae which is the largest part is where the fertilization takes place. The fimbriae on the other hand, are responsible for the transportation of the ovum from ovary to

uterus. It holds the ovary. UterusThe uterus is a pear-shaped organ and has three parts: the fundus (upper), corpus (body), and the isthmus (lower). It is known as the organ for menstruation. When pregnant, it gives nourishment to the growing fetus.
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Formation of Placenta As changes to the endometrium occur, cellular growth and the accumulation of glycogen cause fetal and maternal tissue to come together. This formation makes the functional unit called the placenta. The placenta does not mix blood between mother and fetus, but allows nutrients and waste products to diffuse between the two blood systems. The placenta provides protection by filtering out many harmful substances that the mother comes in contact with. Unfortunately the placenta cannot protect against some teratogens including but not limited to:
y y y y y y y

Thalidomide Heroin Cocaine Aspirin Alcohol Chemicals in cigarette smoke Propecia, also known as Finasteride, which can cause birth defects simply by a woman handeling a broken pill during pregnancy.

Amniotic Fluid Attached to placenta is the membranous sac which surrounds and protects the embryo. This sac is called the amnion. It grows and begins to fill, mainly with water, around two weeks after fertilization. This liquid is called Amniotic fluid, it allows the fetus to move freely, without the walls of the uterus being too tight against its body. Buoyancy is also provided here for comfort. After a further 10 weeks the liquid contains proteins, carbohydrates, lipids and phospholipids, urea and electrolytes, all which aid in the growth of the fetus. In the late stages of
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gestation much of the amniotic fluid consists of fetal urine. The fetus swallows the fluid and then voids it to prepare its digestive organs for use after birth. The fetus also "breathes" the fluid to aid in lung growth and development.

small part of the placenta is shown at the bottom, while the fluid-filled amnion surrounds it

Not enough amniontic fluid, or oligohydramnios, can be a concern during pregnancy. Oligohydramnios can be caused by infection, kidney dysfunction or malformation (since much of the late amniotic fluid volume is urine), procedures such as chorionic villus sampling (CVS), and preterm, premature rupture of membranes (PPROM). One possible outcome of oligohydramnios can cause is underdeveloped, or hypoplastic, lungs. This condition is potentially fatal and the baby can die shortly after birth. Babies with too little amniotic fluid can also develop contractures of the limbs, including clubbing of the feet and hands. As with too little fluid, too much fluid or polyhydramnios, can be a cause or an indicator of problems for the mother and baby. Polyhydramnios is a predisposing risk factor for cord prolapse and is sometimes a side effect of a macrosomic pregnancy. In both cases, however, the majority of pregnancies proceed normally and the baby is born healthy.

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Preterm, premature rupture of membranes (PPROM) is a condition where the amniotic sac leaks fluid before 38 weeks of gestation. This can be caused by a bacterial infection or by a defect in the structure of the amniotic sac, uterus, or cervix. In some cases the leak can spontaneously heal, but in most cases of PPROM, labor begins within 48 hours of membrane rupture. When this occurs, it is necessary that the mother receive treatment immediately to postpone labor if the fetus is not viable, for as long as is safe, and for antibiotic treatments to avoid possible infection in the mother and baby. If rupture occures too early in pregnancy little can be done to save the fetus.

A very rare and most often fatal obstetric complication is an amniotic fluid embolism, or leakage of amniotic fluid into the mothers vascular systems causing an allergic reation. This allergic reaction results in cardiorespiratory (heart and lung) collapse, developing into a condition known as disseminated intravascular coagulation in which the mothers blood looses it's ability to clot.

Amniotic band syndrome, or ABS, occurs when the inner fetal membrane (amnion) ruptures without injury to the outer membrane (chorion). Fibrous bands from the ruptured amnion float in the amniotic fluid and can entangle the fetus, reducing blood supply and causing congenital limb abnormalities dysmelia. In some cases a complete "natural" amputation of a digit(s) or limb may occur before birth or the digit(s) or limbs may be necrotic (dead) requiring surgical removal.

Endocrine Function of the Placenta There are pituitary like hormones and steroid hormones secreted from the placenta. The pituitary like hormones are hCG and hCS. HCG is similar to LH and helps maintain the mothers corpus luteum. HCS is like prolactin and growth hormone and help aid in increasing fat breakdown that spares the use of glucose from the mothers tissues. This effect leaves more glucose available to the placenta and the fetus for necessary growth. The steroid hormones are progesterone and estrogen. Progesterone helps maintain the endrometrium and supports the growth of mammary glands. Estrogen also helps maintain the endrometrium and growth of mammary glands as well as inhibits prolactin secretion.

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Umbilical Cord This is the life support for a growing embryo. The umbilical cord stretches between the placenta and the fetus. This cord contains the umbilical arteries and vein. The umbilical cord forms by week 5 of conception. The average cord is close to 22 inches long and may have the appearance of a coil. The umbilical cord is very rich in stem cells and is often used for parents who choose to store their stem cells in a blood bank or donate it to a blood bank. These stem cells can be used to treat over 45 disorders and is an alternative from extracting the stem cells from a donor.

Human placenta shown a few minutes after birth. The side shown faces the baby with the umbilical cord top right. The unseen side connects to the uterine wall. The white fringe surrounding the bottom is the remnants of the amniotic sac. You can see the differences in the umbilical vein and arteries.
y

Umbilical Arteries

The exchange of gases, nutrients and oxygen takes place between the maternal blood and fetal blood. There are 2 main arteries.
y

Umbilical Vein

Vein that carries nutrients and oxygen away from the placenta to the growing fetus. It also carries oxygen and nutrient rich blood. There is only 1 main vein.
y

Fetus doesn't use its lungs for gas exchange, only a small amount of blood is pumped to fetal lungs in order to support their development.
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During pregnancy, the fetal circulatory system works differently after birth: y y y The fetus is connected by the umbilical cord to the placenta, the organ that develops and implants in the mother s uterus during pregnancy. Through blood vessels in the umbilical cord, the fetus receives all the necessary nutrients, oxygen and life support from the mother through the placenta. Waste products and carbon dioxide from the fetus are sent back through the umbilical cord and placenta to the mother s circulation to be eliminated.

Blood from the mother enters the fetus through the vein in the umbilical cord. it goes to the liver and splits into three branches. The blood reaches the inferior vena cava, a major vein that is connect ed to the heart.

Inside the fetal heart y Blood enters the right atrium, the chamber of the upper right side of the heart. Most of the blood flow to the left side through a special opening between the left and right atria called the foramen ovale. y Blood then passes into the left ventricle (lower chamber of the heart) and then to the aorta, blood is send to the head and upper extremities. After circulating there, the blood returns to the right atrium of the heart through the superior vena cava. y About one-third of the blood entering the right atrium does not flow through the foramen ovale, but instead. Stays in the right side of heart, eventually flowing into the pulmonary artery Because the placenta does the work of exchange of oxygen and carbon dioxide through a mother s circulation, the fetal lungs are not use for breathing. Instead of blood flowing to the lungs to pick up oxygen and then flowing to the rest of the body. The fetal circulation shunts (bypasses) most of the away from the lungs in the fetus, blood
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is shunted from the pulmonary artery to the aorta through a connecting blood vessel called the ductus arteriosus.

Blood circulation after birth: With the first breaths of air the baby takes at birth, the fetal circulation changes. A larger amount of blood is sens to the lungs to pick up oxygen Because ductus arteriosus (the normal connection between aorta and the pulmonary valve) is no longer needed, it begins to wider and closes off The circulation in the lungs increases and more blood flows into the left atrium of the heart. This increase pressure causes the foramen ovale to close and blood circulates normally

Maternal and Fetal Circulation (Maternal-Fetal Exchange) - Medical Illustration, Human Anatomy Drawin

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VI.

RISK

FACTORS AND

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PATHOPHYSIOLOGY VII. NURSING MANAGEMENT


A. NCP
Problem Identified: Increased Blood Pressure Nursing Diagnosis: Decreased Cardiac Output related to vasoconstriction secondary to Preeclampsia. Cause Analysis: The vascular spasm maybe caused by increased the cardiac output that injures the endothelial cell of the arteries and the action of the prostaglandins (notably decrease prostacycline and increase thromboxane ). Normally, blood vessels during pregnancy are resistant to the effects of pressors substance such as angiotensin and norepinephrine, so blood pressure remains normal during pregnancy. With PIH, this reduce responsive to blood pressure changes appears to be lost. Vasoconstriction occurs and blood pressure increase dramatically. (Maternal th and Child nursing by ADELE PILLITTERI 5 edition pp.426) Cues Objectives Nursing Interventions Rationale Evaluation Subjective: STO: INDEPENDENT The patient may complaint of Within 8 hours of nursing y Monitor BP in both arms, 3-5 y Comparison of pressures provides The patient is expected to manifest headache and dizziness. intervention, patient will minutes apart while client is at more complete picture of vascular the following: demonstrate increase perfusion as rest, sitting, standing, for initial involvement. y Maintain BP within evidenced by decreased BP from evaluation. Use correct cuff size individually acceptable 140/110 to 120/90 mmHg and accurate technique. range. y Elevate head of bed and maintain y Absence of headache and head neck in midline or neutral y To provide circulation/ venous dizziness. LTO: drainage position. Objective: Within 3 days of nursing y Provide for diet restriction and intervention, patient will display y BP of above acceptable range increase frequent small feedings. hemodynamic stability as evidenced y Provide bed rest (more than 110/70) y To maintain adequate nutrition and of BP within acceptable range. fluid balance. y Provide calm and restful surroundings and minimize environmental activity/ noise. Limit the number of visitors and length of stay. DEPENDENT: y Administration medications. y To avoid further increase of blood pressure. y Help reduced sympathetic stimulation/promote relaxation.

of

cardiac y These medications are cardiac

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medication, which is very effective in-patient with increase BP or hypertension.

Reference:Nurse s Pocket Guide Book, 9 edition by Doenges et.al p.142

th

Problem Identified: Decreased Urine Output Nursing Diagnosis: Fluid Volume Excesses related to decrease in glomerular filtration secondary to Preeclampsia. Cause Analysis: Vasospasm in the kidney increase blood flow resistance. Degenerative changes develop in kidney glomeruli because back-pressure. This lead to increase permeability of glomerular membrane, allowing the serum proteins albumin and globuline to escape into the urine (protinuria). The degenerative changes also results in decreases in glomerular filtration so there is lowered urine output and clearance of creatinine. Increase kidney tubular reabsorption occurs because sodium retains fluid retention (EDEMA). Edema is further increase because protein is lost the osmotic pressure of the circulating blood falls and fluid diffuses from the circulatory system into the denser interstitial spaces t equalized the pressure. (Maternal and Child nursing by th ADELE PILLITTERI 5 edition pp.426) Cues Subjective: The Patient may complaint difficulty of urination. Objectives STO: Within 8 hours of effective nursing interventions, patient will be able to manifest increase urine output at least 100ml per hour. Nursing Intervention INDEPENDENT y Weigh daily at same time of day, on same scale, with same equipment and clothing. y Place in semi-fowler s position as appropriate Objective: y Edema y Distension of the pelvis and ureters y Decrease urine output(less than 30ml /hr) y Blood pressure above 140/90 y Pulse rate greater than 100 y Weight gain LTO: Within 3 days of giving effective nursing interventions, pt will be able to manifest a fluid balance as evidenced by appropriate urinary output, vital signs within normal range. y Evaluate edematous extremities, change position frequently. y Assess skin, face, and dependent areas for edema. Evaluate degree of edema (on scale of +1 +4). Rationale y Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kg/day suggests fluid retention. y To facilitate movement of diaphragm improving respiratory effort. y Evaluate edematous extremities, change position frequently. y Edema occurs primarily in dependent tissues of the body, e.g., hands, feet, lumbosacral area. Patient can gain up to 10 lb (4.5 kg) of fluid before pitting edema is detected. Evaluation The patient are expected to manifest the following: y Absence of distended pelvis and uterus y Stable weight y Vital Signs within normal range y Absence of Edema y Increase Urine Output

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y Monitor heart rate (HR), BP, and JVD/CVP y Promote bedrest

Collaborative:

y Tachycardia and hypertension can occur because of (1) failure of the kidneys to excrete urine, (2) excessive fluid resuscitation during efforts to treat hypovolemia/hypotension or convert oliguric phase of renal failure, and/or (3) changes in the renin-angiotensin system. Note: Invasive monitoring may be needed for assessing intravascular volume, especially in patients with poor cardiac function. y Given early in nephrotoxic ATN to reduce influx of calcium into kidney cells, thereby helping to maintain cell integrity and improve GFR. y Catheterization excludes lower tract obstruction and provides means of accurate monitoring of urine output during acute phase; however, indwelling catheterization may be contraindicated because of increased risk of infection.

Calcium channel blockers

Insert/maintain indwelling catheter, as indicated.

Reference:NCP by Doenges, Moorehouse & Geissler Murr pp. 521-522

Problem Identified: Epigastric Pain (Right Upper Quadrant) Nursing Diagnosis: Altered Comfort; Acute Pain related to reduce supply of blood in the pancreas secondary to Preeclampsia. Cause Analysis: In PIH, the cardiac system can become overwhelmed because the heart is forced to pump against rising peripheral resistance. This reduces the blood supply to organs. Most th markedly the kidney, pancreas, liver brain and placenta. Ischemia in the pancreas may result in epigastric pain. (Maternal and Child nursing by ADELE PILLITTERI 5 edition pp.426)

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Cues Subjective: Patient may complaint pain in the right upper quadrant of the abdomen. A pain scale from 0-10, pain can be rated as 7 or 8.

Objectives STO: Within 8 hours of nursing intervention patient will be alleviated from pain.

Nursing Intervention INDEPENDENT y Determine pain history, e.g. location of pain, frequency, duration, and intensity using pain scale and relief measures used. y Promote proper body positioning to promote comfort, such as semi fowler s position. y Advise the patient to sleep 8 hours each night and to nap or rest for 2 hours in the afternoon. y Instruct the patient in in basic deep chest breathing, which is similar to normal breathing but slower and deeper. y Encourage acknowledge feelings. client to and express

Rationale y Change in pain characteristics may indicate developing complications

Evaluation The patient is expected to manifest the following: y Decrease pain scale of 4/10 from 8/10. y Maintains rest without disturbance from pain y Maintains relaxation technique

y Promote relaxation.

Objective: y Irritable y Grimacing face y Restlessness

LTO: Within 2 days of nursing intervention, patient will express comfort and relief from pain as evidenced by no grimacing face, not irritable, and is not restless.

y To alleviate fatigue

y Deep chest breathing creates a sense of relaxation during episodes of pain.

y Verbalization of feelings or talking down in a non-threatening environment is helpful to relieve the client s anxiety and fear.

Reference:Nursing Diagnosis Reference Manual 6th Edition by Spark s and Taylor s page. 512-513

Problem Identified: Edema Nursing Diagnosis: Fluid Volume Deficit related to fluid loss secondary to capillary permeability. Cause Analysis:Vasospasm in the kidney increases the blood flow resistance. Degenerative changes develop in the kidney glomeruli because of back pressure. This leads to increase permeability of the glomerular membrane, allowing the serum protein to escape into the urine (protienia). The generative changes also result to decrease glomerular filtration, so there is lowered urine

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output and clearance of creatinine. Increase kidney tubular reabsorption of sodium occurs. Because sodium retains fluids, EDEMA results. More protein is lost, the osmotic pressure of the circulating blood falls and fluid diffuses from the circulatory system in to denser interstitial space to equalize the pressure. (Maternal and Child nursing by ADELE PILLITTERI 5th edition pp.426)

Cues Subjective: Patient may complaint tightness of the hands, swelling in the upper body, heaviness of the upper body.

Objectives Nursing Interventions STO: INDEPENDENT Within 8 hours of nursing y Carefully monitor intake and output intervention, patient will be able to at least every 4 hours. verbalize understanding the need for close monitoring of weight, BP, y Weigh patient daily before urine protein, and edema and breakfast. participate in therapeutic regimen and monitoring, as indicated.

Rationale y Intake greater than output may indicate fluid retention or overload. y Sudden significant weight gain more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema. y To enhance venous return, and reduce edema. y Gradually increasing activity helps body adjust to increased tissue oxygen demand and possible increased venous return. y These measures encourage patient and family members to participate more fully in care.

Evaluation The Patient is expected to manifest the following: y Reduce Edema y Reduce Weight y Absence of swelling, tightness of the hands heaviness of the upper body.

Objective: y Slightly pitting Edema +1 y Weight gain in a short period of time y Urine output of 400600ml ( Oliguria)

LTO: Within 3 days of nursing intervention, patient s fluid volume will stabilized as evidenced by balanced I&O, stable weight and reduced signs of edema.

y Change patient s position every 2 hours. y Increased patient s activity level as tolerated; for example, ambulate and increase self-care measures performed by patient. y Educate Patient regarding:  Environmental safety measures.  Fluid restriction and diet.  Ways to prevent infection. Collaborative: y Schedule prenatal visit every 1 2 wk if PIH is mild; weekly if severe. y Review moderate sodium intake of up to 6 g/day. Instruct client to read food labels and avoid foods

y Necessary to monitor changes more closely for the well-being of the client and fetus. y Some sodium intake is necessary because levels below 2 4 g/day result in greater dehydration in some clients. However, excess sodium may

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high in sodium (e.g., bacon, luncheon meats, hot dogs, canned soups, and potato chips) y Refer to dietician as indicated.

increase edema formation. y Nutritional consult may be beneficial in determining individual needs/dietary plan

Reference:Joyce M. Black, et.al. , Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6th edition

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Problem Identified: Ineffective Tissue Perfusion Nursing Diagnosis: Ineffective Tissue Perfusion related to vasoconstriction of blood vessels secondary to Preeclampsia Cause Analysis:Arterial spasm causes the bulk of the blood volume in the maternal circulation to be pooled in the venous circulation, so a woman has a deceptively low arterial intravascular volume. (Maternal and Child nursing by Pelliterri 5th edition p. 426) Cues Subjective: Patient may fatigue, report dizziness, Objectives STO: Within 3 hours of nursing intervention, patient will be able to verbalize understanding about her condition as evidenced by question of clarification regarding the health teachings. Nursing Interventions INDEPENDENT y Monitor and document patient s vital signs every 2 hours. Rationale y Decreased heart rate and blood pressure may indicate increased arteriovenous exchange, which leads to decreased tissue perfusion. y To enhance vital capacity and avoid lung congestion and skin break down. y To conserve energy, lowers tissue oxygen demands and maximize tissue perfusion. y To maximise blood flow to stomach enhancing digestion. y Effective teaching encourages patient to take an active role in health maintenance. Evaluation The Patient is expected to manifest the following: y Normal range of vital signs. y Verbalize understandings about the health teachings or information given related to the condition experienced. y Strong peripheral y CRT of less than 3 seconds. y Absence of edema.

Objective: y Increased blood pressure of more than 110/70. y Weak peripheral pulse. y CRT of more than 3 seconds. y Increase Heart Rate of more than 60 bpm. y Edema

LTO: Within 3 days of nursing intervention, patient will demonstrate increased perfusion evidenced by strong peripheral pulse, vital signs within normal range, and absence of edema.

y Encourage patient to change position and participate in activity, as condition permits. y Encourage quiet, restful environment.

y Encourage rest after meals.

y Inform patient about:  Proper use of medication and possible adverse reactions.  Benefits of low-fat, lowcholesterol diet.  Need to avoid straining with bowel movements.

Collaborative: y Administer fluid as needed. y Maintain oxygen therapy ordered.

as

y To maintain preload. y To maximize oxygen exchange in alveoli and at the cellular level.

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Reference: Nursing Diagnosis Reference Manual 6 Edition by Sparks and Taylor s page.331-332.

th

B. HEALTH EDUCATION PLAN Objectives: 1) After giving health teachings the patient and family will be able to gain adequate knowledge on how to help the client recover physically and emotionally. 2) After giving health teachings the patient will be able to initiate necessary lifestyle changes and participate in treatment regimen. 3) Maintain health management to prevent complications. Materials needed: 1. Manila paper 2. Markers 3. Visual aid

GENERAL HEALTH TEACHINGS

SPICIFIC HEALTH TEACHINGS

Doctors would recommend:


Medication
y y y y

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. Advice client to take his medication at regular basis. Teach the patient and SO the time , route , dosage ,adverse effect, and special consideration of each medications.

Diet

y y y

Drinking extra glasses of water a day and eating less salt. Eating more fruits, vegetables, and low-fat dairy foods Cutting back on foods that are high in saturated fat, cholesterol, and total fat
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Rest and Sleep

Instruct the patient on the importance of proper rest and sleep.  Getting bed rest at home, lying on your left side most or all of the time.  Pregnancy will cause the patient to tire more easily.  Prevention of fatigue through short rest periods is vital to good health.

Exercise

Advise client s family to consult PT for proper exercise for the client.

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C. DISCHARGE PLAN

MEDICATIONS Nifedipine ( Adalat, Procardia)

DOSAGE/FREQUENCY NURSING INSTRUCTIONS IR cap: 10-30 mg per Orem three  Instruct pt. to take medication at the same time everyday. Do not double dose. times a day; not to exceed 120 Advise pt. to make sure that enough medication is available during weekends, 180 mg/d holidays, trips, and vacations. SR tab: 30-60 mg per Orem every  Advise pt. that frequent oral hygiene can minimize dry mouth. day; not to exceed 90-120 mg/d  Advise pt. to make position changes slowly, to avoid orthostatic hypotension. BP >170/110 mm Hg: 10 mg per  May cause drowsiness; instruct pt. not to do activity requiring alertness. Orem initial; repeat dose may be administered in 30 min as needed.

Clonidine (Catapres)

Initial: 0.1 mg per Orem twice a day Maintenance: 0.2-1.2 mg/d twice a day/ per Orem; not to exceed 2.4 mg/d

 Caution pt. to avoid concurrent use of alcohol and other CNS depressants.  Advise pt. to have her blood pressure taken weekly and to report to physician significant changes.

Hydrochlorothiazide ( Esidrix)

25-100 mg per Orem every day; not to exceed 200 mg/kg/d

 Instruct pt. to take medication at the same time everyday. Do not double dose.  Instruct pt. to monitor weight biweekly and notify healthcare professional of significant changes.  Advise pt. to make position changes slowly, to avoid orthostatic hypotension.  Encourage client to comply with additional hypertensive intervention (weight reduction, exercise, low sodium diet, stress management)  Instruct pt. and family in correct technique for monitoring weekly blood pressure.
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Methyldopa (Aldomet)

250 mg per Orem twice a day/trice a day; increase every two days as needed; not to exceed 3 g/d

 Instruct pt. to take dose at the same time everyday, alst dose of the day must be taken during bedtime. Do not double dose.  Encourage client to comply with additional hypertensive intervention (weight reduction, exercise, low sodium diet, stress management)  Instruct family and pt. on proper monitoring of blood pressure.  Inform pt. that urine may turn dark.  Advise pt. that frequent oral hygiene can minimize dry mouth.  Instruct pt. to notify physician if unusualities occur.

EXERCISE Moderate exercise means that you get warm, mildly out of breath, and mildly sweaty. It does not have to be intense. For example: brisk walking, dancing and other recreational activities to maintain mobility and normal functioning esp. of the GIT. You can even use normal activities as part of your exercise routine such as household chores or gardening. And also, consider a brisk walk when going to work or to the shops instead of using a car or bus, etc. For many people, a daily brisk walk for 30-60minutes is a realistic goal. THERAPY  Recreational Activities- Encourage mother to engage in any activities or any recreational activities such as walking and household chores or any exercises that aids in losing weight. On the other hand, increase aerobic physical activity for at least 30-45minutes most days of the week.  Drug Therapy- It is recommended esp. drugs that aids in lowering the blood pressure of the certain person and to maintain blood pressure with normal ranges such as beta blockers. Example of this is Propranolol, Metoprolol, Nadolol, etc.

HEALTH TEACHINGS 1. Instruct patient to lose weight if overweight such as engaging in any activities. 2. Restricts the intake of alcohol for this may cause vasoconstriction thus increasing blood pressure.
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3. 4. 5. 6. 7.

Have an appropriate exercise regimen because regular activity is a significant factor in weight reduction. Maintain adequate intake of dietary potassium. Maintain adequate intake of dietary calcium and magnesium for general health. Stop smoking and reduce intake of dietary saturated fats and cholesterol for overall cardiovascular health. Stress reduction also is beneficial in any diseases.

OPD VISITS/REFERRALS 1. Have the client follow a check up schedule to visit physician in order to assessextent of treatment and further assessment. 2. Obtain drugs that may be administered at home for further treatment

DIET 1. 2. 3. 4. 5. Avoid intake of foods that are high in sodium and fats such as salty foods and pork. Increase intake of fruits and vegetables for proper nourishment. Avoid intake of alcoholic beverages and tobacco not because smoking is related to hypertension, but because anyone with high blood pressure is already at increased risk for heart disease, and smoking makes this risk even higher. Have adequate intake of dietary potassium (approximately 90mmol per day). Maintain also adequate intake of dietary calcium and as well as magnesium.

SPIRITUAL CARE 1. 2. Encourage client to have daily prayer and have relationship with God for he is the greatest physician. Encourage also to read bibles or any inspiring books.

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VIII. MEDICAL AND SURGICAL MANAGEMENT


A. MEDICATIONS

Drugs Magnesium Sulfate (Epson Salt)

Classification Anticonvulsant

Indication Muscle relaxant Prevents seizures

Mechanism of Action Mg depresses the CNS and control convulsion by blocking release of acetylcholine and decrease the excitability of the motor membrane

Dosage loading dose 46g IV Maintenance dose 1-2 g/h IV

Adverse Effects CNS: depression CV: flushing, hypotension, depression of myocardium. Magnesium intoxication: Cardiac and CNS depression, preceding respiratory paralysis, circulatory collapse, flaccid paralysis.

Nursing Considerations Before administering IV check for the ff. conditions: -Absent patellar reflex - RR below 16/min - urine output below 100 ml in past 4 hours. - Early signs of hypermagnesemia: flushing, sweating, hypotension or hypothermia. - past history of heart block or myocardial damage; prolonged RR and widened QRS interval.

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Hydralazine HCl (Apresoline)

Antihypertensive

Preeclempsia, eclapsia Heart failure

A direct-acting vasodilator that relaxes arteriolar smooth muscle.

Initially, 5 to 10 mg IV, followed by 510 mg IV doses (range 5-20 mg) q 20 to 30 minutes, prn or 0.5 to 10 mg/hour IV infusion.

CNS: headache, dizziness. CV: tachycardia, angina pectoris, palpitations. EENT: nasal congestion. GI: nausea, vomiting, diarrhea, anorexia, constipation.

Monitor pt. blood pressure, pulse rate, and body weight frequently. Instruct client to take with food to increase absorption.

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Diazepam (Valium)

Anxiolytic

Adjunct treatment for seizure disorder

A benzodiazepine that probably potentiates the effects of GABA, depresses the CNS, and suppress the spread of seizure activity.

- Adults: 2 to 10 mg PO bid to qid.

CNS: drowsiness, fatigue, ataxia, headache, insomnia, minor changes in ECG patterns. CV: hypotension, CV collapse, bradycardia. EENT: blurred vision. GI: nausea, constipation GU: incontinence, urine retention Hepatic: jaundice Respiratory: respiratory depression, apnea. CV: mild drop of blood pressure, vasodilation, bradycardia, arrhythmias, cardiac arrest. GI: irritation, constipation, chalky taste, nausea, thirst, abdominal pain. GU: renal calculi.

Warn pt to avoid activities that require alertness and good coordination. Warn pt not to abruptly stop drug cause withdraw symptoms may occur.

Calcium Gluconate

Electrolyte and replacement solutions

Antidote for magnesium toxicity

Generally, replaces calcium and maintains calcium level; physiologically antagonize hypomagnesaemia effect.

1g/ IV (10 mL of a 10% solution)

Warn patient to avoid oxalic acid (in rhubarb and spinach), phytic acid (in barn and whole grain cereals), and phosphorous (in dairy products) in the meal preceding calcium consumption; these substances may interfere calcium absorption.

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Labetalol HCl (Normodyne)

Antihypertensive

Hypertension

May be related to reduced peripheral vascular resistance, as a result of alpha and beta blockade.

100 mg PO bid. Maintenance dosage: 200 to 400 mg bid

Methyldopa (Aldomet)

Antihypertensive

Hypertension, hypertensive crisis

Thought to inhibit the central vasomotor centers, thereby decreasing sympathetic outflow to the heart, kidneys, and peripheral vasculature.

Initially, 250 mg PO bid to tid in first 48 hours. Increase prn q 2 days.

CNS: fatigue, headache, paresthesia, dizziness. CV: orthostatic hypotension, ventricular arrhythmias Respiratory: dyspnea, bronchospasm GU: urine retention CNS: dizziness, paresthesia, headache CV: bradychardia, aggravated angina, myocarditis, edema GU: galactorrhea Hepatic: hepatic necrosis, hepatitis

Monitor blood pressure frequently. Tell patient that stopping abruptly can worsen chest pain and trigger MI.

Weight pt everyday, if weight increases more that 5lbs, a possible sodium and water retention occurred. May take before sleeping (hs)

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Nifedipine (Procardia)

Anti-anginals

Hypertention

Thought to inhibit calcium ion influx across cardiac and smooth-muscle cells, decreasing contractility and oxygen demand. Also may dilate coronary arteries and arterioles. Known to block the action of an enzyme, clooxygenase, essential to the production of prostaglandins. Results in lowered levels of thromboxane, a vasoconstrictor, then vasodilator prostacyclin are not being significantly affected.

30 or 60 mg PO od. Adjust over 7 to 14 days.

Aspirin (Acetylsalicylic acid)

Nonopioid analgesics and antipyretics

Prophylactic for mothers at high risk for preeclampsia.

50 to 150 mg PO daily between 12-18 weeks gestation.

CNS: light-headedness, somnolence, weakness CV: peripheral edema, hypotension, palpitation, heart failure, MI, flushing EENT: nasal congestion Respiratory: dyspnea, pulmonary edema, cough GI: GI distress, GI bleeding Hematologic: prolonged bleeding time Hepatic: Hepatitis Other: angioedema.

Watch for sign of heart failure. Instruct pt not to chew, break, or crush the tablet Monitor BP frequently or regularly

Instruct client to adhere on prescribed dosage, low-dose. Advice pt to take with food, milk, antacid, or large glass of water to reduce unpleasant GI reaction

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B. MEDICAL MANAGEMENT

Induction of Labor Definition Induction of labor involves using artificial means to assist the mother in delivering her baby. Purpose Labor is brought on, or induced, when the pregnancy has extended significantly beyond the expected delivery date and the mother shows no signs of going into labor. Generally, if the unborn baby is more than two weeks past due, labor will be induced. In most cases, a mother delivers her baby between 38 and 42 weeks of pregnancy. This usually means that labor is induced if the pregnancy has lasted more than 42 weeks. Labor is also induced if the mother is suffering from diseases (preeclampsia, chronic hypertension); if there is an Rh blood incompatibility between the baby and the mother; or if the mother or baby has a medical problem that requires delivery of the baby (like a premature rupture of the membranes). Description

The uterus is the hollow female organ that supports the development and nourishment of the unborn baby during pregnancy. Sometimes labor is induced by the rupturing the amniotic membrane to release amniotic fluid. This is an attempt to mimic the normal process of "breaking water" that occurs early in the normal birth process. This method is sometimes enough stimulation to induce contractions in the mother's uterus. If labor fails to start, drugs are used. Most labor is induced by using the drug Pitocin, a synthetic form of oxytocin. Oxytocin is a natural hormone produced in the body by the pituitary gland. During normal labor, oxytocin causes contractions. When labor does not occur naturally, the doctor may give the mother Pitocin to start the contractions. Pitocin makes the uterus contract with strength and force almost immediately. This drug is given through a vein in a steady flow that allows the doctor to control the amount the mother is given.

Sometimes vaginal gels are used to induce labor. Normally, the baby will pass through the opening of the uterus (the cervix) into the birth canal during delivery. Because of this, the cervix softens and begins to enlarge (dilate) during the early part of labor to make room for the baby to pass through. The cervix will
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continue to dilate, and the contractions will eventually push the baby out of the mother's body. When labor needs to be induced, the cervix is often small, hard, and not ready for the process. The doctor may need to prepare or "ripen" the cervix to induce labor. The hormone prostaglandin in a gel form may be applied high in the vagina to soften and dilate the cervix, making the area ready for labor. This may be enough to stimulate contractions on its own. More often, prostaglandin gel is used in conjunction with Pitrocin.If all attempts to induce labor fail, a cesarean section is performed

C. SURGICAL MANAGEMENT

Cesarean Section Definition: It is the delivery of the fetus through incisions in the abdominal wall and the uterus. Indication: The decision to have a C-section delivery can depend on the obstetrician, the delivery location, and the woman's past deliveries or medical history. Some of the main reasons for C-section instead of vaginal delivery include the following:  Cephalopelvic Disproportion (CPD) - Occurs when the baby's head will not fit through the pelvis. This diagnosis may also be used to indicate a labor that fails to progress, (a prolonged labor, an extended period of time since rupture of membranes or weak, ineffective contractions.)  Fetal Distress - The baby is not receiving enough oxygen. It may be indicated by an abnormal fetal tracing or a drop in the fetal heart rate when your healthcare provider or labor nurse listens to the rate during or after a contraction.  Abnormal Position of the Baby - Instead of the baby's head presenting first in the pelvis with his/her chin tucked inward, the presenting part of the baby may be his/her head extended outward, the shoulder, bottom (breech) or leg(s).  Prolapsed Cord - When the umbilical cord is in the vagina ahead of the baby. This most commonly occurs after the membranes rupture and the baby is in a breech position or his/her head is not well engaged in the pelvis. This is an emergency and an immediate cesarean section is necessary to prevent the presenting part from compressing the cord and cutting off the oxygen supply to the baby.

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 Abruptio Placentae - The placenta partially or completely separates from the uterine wall before the baby is born. This is an emergency and an immediate cesarean birth is necessary to prevent the mother from hemorrhaging, which can cause the baby to lose all or part of his/her ox  Placenta Previa - A condition in which the placenta partially or completely covers the cervix. The degree of severity determines whether or not a cesarean birth is indicated. If the cervix is completely covered, a cesarean is mandatory since the placenta would deliver first in a vaginal delivery and the baby would lose his/her oxygen supply.

Procedure: Regional anesthesia is most frequently administered to the patient, who is awake. A low transverse (Kerr) or vertical (Krohnig) incision consistent with the estimated size of the fetus is made. The rectus muscles are separated and the peritoneum incised. Hemostasis is assured. The bladder is reflected from the lower uterine segment, and the uterus is incised. The amniotic sac is spontaneously entered, and fluid must be aspirated immediately. Some surgeons prefer to use the suction tubing without a tip to avoid injury. The fetal head is delivered using manual pressure or by obstetric forceps and counter-pressure on the fundus. Retractors are removed. As soon as the head is delivered, the newborn s nares are aspirated by bulb syringe immediately but very gently; the delivery is completed. Oxytocin is administered intravenously to encourage the uterus to contract and to decrease blood loss. The umbilical cord is clamped and cut. The infant is received in a sheet and transferred to a gowned and gloved member of the neonatal team, e.g., the pediatrician. Standard Precautions are observed. Resuscitative measures are provided to the neonate under warming lamps. The pediatrician determines the infant s Apgar score. Vernix, etc., are wiped from the infant s skin. Ointment (erythromycin 0.5%) is applied to the conjunctival sacs of the newborn by a member of the neonatal team. The placenta is delivered. The uterus is massaged to encourage it to contract. Tubal ligation may be performed. Blood, amniotic fluid, etc., are aspirated. Hemostasis is assured. The edges of the uterine incision are clamped to aid in its closure; the uterus and bladder are closed in a single or a double layer. The peritoneum at the lower uterine segment is sutured to its anatomic position. The wound is closed in layers. An abdominal dressing and perineal pad are applied. Warmed blankets (from blanket warmer) are placed over the mother. The mother and infant, in good condition, are given a moment to bond on the gurney. The infant is rushed to the neonatal unit to be further cleaned, weighed, etc.

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IX.

PROGNOSIS

Although the infant mortality rate with preeclampsia is nearly double that of babies born to mothers with normal blood pressure and no signs of preeclampsia, the majority of women with preeclampsia deliver healthy babies. Proteinuria usually resolves within 6 weeks after delivery. Preeclampsia usually does not cause permanent damage or adversely affect the long-term health of the mother, but risk of preeclampsia and eclampsia is greater in subsequent pregnancies. Preeclampsia in the US is associated with higher than normal mortality and morbidity for mothers and newborns (neonates) and has been shown to be responsible for 15% of premature births and 17.6% of pregnancy-related maternal deaths. Baby complications can be mostly avoided if the condition is controlled. Eclampsia is a much more significant complication of pregnancy, with a high potential for maternal death, particularly if it develops before delivery; the predelivery (prenatal) maternal mortality rate is 5.6% to 11.8% in the US and UK. Approximately 50,000 maternal deaths due to eclampsia are reported annually worldwide, with death occurring more often in women older than age 30 and in women who have had no prenatal care. Babies born to women with eclampsia are at increased risk of morbidity and mortality due to prematurity, low birth weight, premature placental separation, and lack of oxygen in the uterus (fetal hypoxia). Women with eclampsia have a 2% chance of having another episode with a subsequent pregnancy, and 25% will have high blood pressure in their next pregnancy. Preeeclampsia and Eclampsia depends on how carefully a patient is monitored. Very careful, consistent monitoring allows quick decisions to be made, and improves the woman's prognosis. Still, the most common causes of death in pregnant women are related to high blood pressure. More information on how preeclampsia and eclampsia develop is needed before recommendations can be made on how to prevent these conditions. Research is being done with patients in high risk groups to see if calcium supplementation,aspirin, or fish oil supplementation may help prevent preeclampsia. Most importantly, it is clear that careful monitoring during pregnancy is necessary to diagnose preeclampsia early.

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X.
y y y y y y y y y y y y

BIBLIOGRAPHY
Medical- Surgical Nursing by Ignatavicius and Workman, 5th edition vol.2 Pathophysiology by Porth, 11th edition Medical- Surgical Nursing by Smeltzer and Bare, 11th edition vol.2, Introductory Medical Surgical Nursing by Timby and Smith, 9th edition Medical- Surgical Nursing by Black and Hawks, 6th edition vol.1 Medical- Surgical Nursing: Concepts and Clinical Applications by Udan, 2nd edition Mosby s Pocket Dictionary of Medicine, Nursing, and Allied Health, 4th edition Diagnostic Tests Nurse s Quick Check by Williams and Wilkins Nursing spectrum drug handbook 2008 by Patricia Dwyer Schull Nursing care plan by Doenges, Moorhouse and Murr, 7th edition Physical Examination and Health Assessment by Jarvis, 4th ed Human anatomy and physiology by Marieb,7th edition, pp.

BOOKS:

SUPPLEMENTARY SOURCES: y y y y y y y y http//emedicine.medscape.com/article/238798-overview http//www.merck.com/mmpe/sec17/ch233c.html www.google.com www.askjeeves.com www.dictionrary.com www.about.com http://nursinglectures.blogspot.com/2009/01/post-operative-nursing.html www.medindia.com

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