Assignment On Preeclampsia Maternal Child and Nursing Care (Nur 333)

Prepared For Rachel Thiessen Instructor

Prepared by Md.Kabir Hossain ID# 09312005 Program: BSN

IUBAT International University of Business Agriculture and Technology Dated: 18th July, 2012

Introduction: Preeclampsia is defined as hypertension develops after 20 weeks of gestation age of a pregnant woman who was had not HTN previously and with or without the presence of proteinuria. The arteriolar vasospasm usually causes to develop preeclampsia in pregnant woman. My thesis statement is Arteriolar vasospasm diminishes the dilation of blood vessel, which impedes blood flow to all organs and raises blood pressure (Working Group, 2000). The vasospasm causes endothelial cell to be damaged and decreases placental perfusion and affects all organ system including placenta, kidneys, liver, and brain resulting preeclampsia. Pathophysiology: The normal physiology of a pregnant woman is increased blood volume, vasodilatation, increased cardiac output, decreased systemic vascular resistance, and decreased colloid osmotic pressure. The vasospasm causes poor perfusion that constricts the diameter of blood vessel decreasing the supply of blood to all organs and increases blood pressure. However, the vasospasm of blood vessel causes to increase thromboxane in increased sensitivity to circulating pressure in angiotensin 2 and decreased nitric oxide. The fluid is shifted from intravascular space to intracellular space resulting decreased blood plasma level and increased hematocrit of blood plasma level. The arteriolar vasospasm damages the endothelial cell causing increased capillary permeability resulting pulmonary edema. So the generalized vasoconstriction constricts the blood vessel to increase hypertension for the diagnosed pregnant woman. As placenta gets nutrition and gets blood from mothers supply, this vasospasm decreases placental perfusion due to the endothelin the toxin production of endothelial cells. The lesion of uteroplacenta causes intrauterine growth restrictions and placenta abruption due to increase number of uterus contraction. Preeclampsia decreases glumerular filtration rate resulting glumerular damage that causes proteinuria and oliguria. Preeclampsia also affects brain circulation that causes cortical brain

spasm, so the pregnant woman feels headaches, hyperreflexia and seizure activity. Due to pulmonary edema, the pregnant woman faces dyspnea. There is vasospasm of retina due to preeclamsia causes blurred vision and blind spots in eye. The hemolysis of red blood cells causes hypoxia increased maternal bilirubin production. Preeclamsia decreases liver function and also damages liver resulting elevated liver enzymes, epigastric pain, nausea, vomiting, right uppper quadrant pain, low blood glucose level, the rupture of liver. Due to intravascular coagulation, there will be platelet aggregation and fibrin deposition results low platelet count called thrombocytopenia that causes disseminated coagulopathy. Risk factors: Chronic renal disease Chronic HTN Family history of preeclampsia Multiple gestation Primigravida or new partner Maternal age less than 19 years and older than 40 years Diabetes Mellitus Rh incompatibility Obesity Maternal effects: In case of mild preeclampsia, there is 140/90 BP readings in which the mean arterial pressure is more than 105 mm Hg. In severe preeclamsia, there is increased BP more than 160/110 mm Hg in two times BP readings. In a 24 hour specimen there is proteinuria of more than 0.3 g on dipstick in mild preeclamsia and there is more than 2 g proteinuria in 24 hour dipstick specimen. The reflexes usually are normal and hyperreflexia results in severe preeclampsia in ankle clonus. In case of mild preeclampsia, the urine output is more than 30 ml/hr and 20 ml/hr for severe preeclampssia. The pregnant woman may or may not feel headache in mild preeclampsia and severe headache for severe preeeclamsia. Due to

severe preeeclamsia, there will be blurred vision, photophobia and blind spots on fundoscopy. There is decreased or damaged liver function causes severe epigastric pain for severe preeclampsia. The serum creatinine level is normal for mild preeclampsia and elevated serum creatinine for severe preeclampsia. Due to intravascular coagulation, the thrombocytopenia will result in severe preeclampsia and low platelet is absent for mild preeclampsia. Due to decreased liver function, the AST is elevated in severe preeclampsia and AST level is normal for mild preeclampsia. Fetal effects: There is decreased placental perfusion due to intravascular coagulation mother affects on placenta perfusion on mild preeclampsia and it becomes severe in severe preeclampsia causing intrauterine growth restriction for fetus and the decelerations is late. In time of birth for severe preeclampsia, there are smaller placenta, broken synctia, ischemic necroses, red infarcts, prematurity of placenta and there is premature placental aging for mild preeclampsia. Management and psychosocial consequences of preeclamsia: It is easy to manage mild preeclampsia at home. The pregnant woman may be encouraged to perform self-assessment. So, she can be taught about how to measure weight, urine dipstick, BP, fetal movement counting etc. The pregnant woman need to consult with doctor twice a week, ultrasound to see for fetal growth and non stress test every 3 weeks and in case of any subjective changes, she can go to the high risk clinics. Adequate bed rest for mild preeclampsia helps to decrease blood pressure and promote diuresis. The kegel exercise helps to maintain muscle tone, blood flow, bowel movement, and feeling better. Relaxation can manage stress and makes prepared for labor and birth. The high enriched protein and low salt intake foods help to prevent preeeclamsia but the pregnant woman needs salt to increase blood volume and placental perfusion except chronic HTN pregnant woman. The pregnant women have to

take enough hydration from fluid to maintain optimum blood volume and for functioning kidney. It is very important to recognize signs and symptoms of preeclampsia to prevent maternal and perinatal death. Cesarean section is urgent in case of undilated and uneffaced cervix, and prolonged labor. According to severe condition, the pregnant woman may be admitted to intensive care unit for monitoring homodynamic condition. It is critical to monitor urinary output as kidney excretes magnesium. The nurses have to be alert during assessing fetal because hypoxia may result due to uteroplacenta insufficiency. To monitor urinary output and to understand renal function, indwelling urinary catheter needs to be inserted. Vaginal exam may be done to understand cervical condition. To know fetal status, electronic monitoring can be performed once a day. The palpation of abdomen ensures uterine tonicity, fetal size, activity, and fetal position for pregnant woman. The environment of the room should be kept noise free and nonstimualting. Due to severe preeclampsia, pregnant woman may have seizure that needs to take into consideration. To prevent seizure, suctioning equipment and oxygen need to keep in the patient room as well as emergency medication, calcium gluconate, magnesium sulphate need to make ready to use. There should be continuous assessment to monitor maternal and fetal condition. To prevent preeclampsia, the magnesium sulphate is administered that reduces the risk of eclampsia and maternal death. The magnesium sulphate is administered into intravenuous by infusion pump. During loading dose, magnesium sulphate lowers blood pressure and relaxes smooth muscles. It also improves perfusion, in which fluid shifts from interstitial spaces to vascular spaces reducing edema. There are side effects from magnesium sulphate as it is a CNS depressant and acts as a tocolytic agent that increases the duration of labor. But it does not affect fetal heart rate. During convulsions, the nurse has to ensure patent airway to prevent aspiration and vomiting. After stopping convulsion, fluid and foods are taken out by suctioning and oxygen is administered.

Nurses have to build trust that will make good understanding, comfortable, good care for the pregnant woman. They have to inform patient and family member what they want to do and the rationale for performing those caring. The nurses should not make them scared rather support and care them if they have any concerns regarding their health that promotes sense of well being. In addition they can teach them how to manage stress that may include massaging, warm bathing, squating position and family member can stay beside them. However, nurses need to respect and maintain privacy during performing any procedures. The room needs to be kept calm. quiet, comfortable and call button is kept beside the bed so that the pregnant can press call button whenever she feels bad or something emergent. Moreover woman may feel her child will not survive and she may also feel dying. So the nurses have to encourage patient telling they try to give their best care and it is possible to give safe birth and she will recover as well according to mother condition. Implications for clinical practice: During my clinical practice to deal with patient having preecalamsia, I would like to perform consistent and recoding BP measurement appropriately. I have to observe for edema in lung, periorbital or facial edema. For severe preeclampsia, there is epigastric pain, right upper quadrant pain and elevated AST that I have look for observation and patient feels through assessment. I have to assess for deep tendon reflexes that may happen in severe preeclampsia. To determine fetal status as it worsens due to presence of accelerations and decelerations. In addition, I would like encourage patient to test NST, ultrasonography in each 3 weeks, contractions stress testing. Moreover the pregnant woman is to understand what preeclampsia she has mild or severe preecalmpsia according to her signs and symptopms. It is easy to prevent mild preeclamsia resting at home by self assessment including fetal movement counting, adequate amount of water, high enriched protein foods and low salt intake help to prevent preeeclamsia but

the pregnant woman needs salt to increase blood volume and placental perfusion except chronic HTN pregnant woman. In case of any subjective changes, the pregnant woman is encouraged to come to hospital and consult with doctor twice a week. For severe preeclampsia, I would like to insert indwelling catheter to monitor urine output for proteinuria and oliguria. Conclusion: It is easy to prevent mild preeclampsia at home by self assessment. So we nurses can teach them how to count fetal movement, measure blood pressure, measure weight, urine dipstick and for any subjective changes need to go hospital. We can also teach them the signs and symptoms of severe preeclampsia. Encourage the pregnant to eat high protein enriched foods and decrease salt intake. For severe preeclamsia , the nurses perform consistent monitoring and assessment on blood pressure, urine output for proteinuria and oliguria, lung sound for pulmonary edema, epigastric and right upper quadarnt pain, elevated AST for decreased liver function, brain spasm, seizure precaution, especial monitoring on fetal status due to decreased placental perfusion, looking for test like NST, ultrasonography, low platelet count etc. However, we nurses always have to inform patient and her family member what is the condition of her health and what is our plan to care for that. To reduce her stress, we can give her massage, warm bath, repositioning, teaching about coping strategies. References: Wong, D.L., & Perry, S.E. (2006) .Maternal Child Nursing Care. (3rd ed.) . St. Louis: Mosby.