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INTRODUCTION

Hypertensive disorders in Pregnancy is regarded as one of the most serious medical

disordersin pregnancy
It may complicate 5-15% of all pregnancies and is responsible for 15-20% of
allmaternal mortality in developing and developed countries
There is a generalized vasospasm leading to systemic disorders involving the vital organs
ofthe body. Hence, any vital organ failure can lead to chronic illness

Classification of Hypertensive Disorders In Pregnancy

1. Gestational Hypertension or Pregnancy Induced Hypertension or
TransientHypertension
2. Pre-eclampsia
3. Eclampsia
4. Superimposed Pre-eclampsia
5. Chronic Hypertension

Chronic Hypertension may be associated

with: Essential Hypertension
Chronic Renal Diseases
Co-arctation of Aorta
Pheochromocytoma
Thyrotoxicosis (hyperthyroidism)
Connective Tissue Disease
Systemic Lupus Erythematous
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Definition of Terms
1. Normal Blood Pressure
Normal Blood Pressure normally falls in pregnancy with no change in systolic blood
pressure but diastolic blood pressure is lowered by 10 mmHg with lowest recording
at14-20 weeks of pregnancy, before rising to pre-pregnancy value by term
the mid trimester fall in blood pressure is due to significant decrease in vascular
tonefollowing the cardiovascular alterations leading to peripheral vasodilation

2. Gestational Hypertension
It is a condition in which systolic blood pressure is greater than 140mmHg and
diastolic blood pressure is greater than 90 mmHg or more on at least two
occasionsfour or more hours apart beyond 20th weeks of gestation or during 24
hours after deliver in previously normotensive woman

3. Pre-eclampsia
Pre-eclampsia is Pregnancy Induced Hypertension in association with
significantProteinuria

4. Eclampsia
Eclampsia is defined as seizures that cannot be attributed to any other cause in
womenwith pre-eclamsia

5. Chronic hypertension
Chronic Hypertension is hypertension antedating pregnancy or
hypertensiondiagnosed before 20 weeks of pregnancy but not attributable
to gestational trophoblastic disease
It is also known hypertension before pregnancy or hypertension.
Diagnosed in first trimester before 20 weeks of pregnancy and persisting 12 weeks
ofpostpartum is also considered as chronic hypertension
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6. Super-imposed Pre-eclampsia
It is the development of pre-eclampsia in a patient with chronic hypertensive
vascularor renal disease when hypertension antedates the pregnancy as established
by previous blood pressure recordings.

Criteria
A rise in systolic blood pressure by 30 mmHg or
A rise in diastolic blood pressure by 15 mmHg
and Development of proteinuria or edema or
both

Above criteria should be fulfilled during pregnancy to establish the diagnosis

ofSuper-imposed Pre-eclampsia

OBJECTIVES
The main objective of this case study is enabling students to develop knowledge
regardingthe normal reproductive process, and skill and practice in providing nursing
care, provide advices, health teaching to patient and family for management of the
disease.
During this process I got opportunities to learn about disease condition, its complications
andother potential gynecological and obstetric abnormalities and complication that arise
due to the disease.
General Objectives:
To obtain detail obstetric and gynecological history of patient
To perform physical assessment of a woman with gynecological and obstetric problem
To provide advices, health teaching to patient and family for management of the
disease,
medications and complications
To identify minor and major discomfort and advice the woman relieving measures
To apply nursing process to care the client with obstetric and gynecological
problemsas per her need

BIOGRAPHICAL DATA OF THE PATIENT

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1. Demographic Data
• Name of Patient: Angelica Morales
• Age: 29 years
• Sex:Female
• Religion: Catholic
• Marital status: Married No. of Children: 1
• Address: Tarlac City
• Name of Guardian: Patrick Mangahas

2. Chief Presenting Complaints

1. Epigastric pain X 1-2 hour
2. Vomiting (2 episodes)
3. Headache absent
4. Blurring of vision absent
5. Perceiving good fetal movement

3. History Of Present Illness

Past history of Intra Uterine Fetal Death (IUFD) 3 years back at Prasuti Griha, Thapathali
due to PIH
Sudden onset of severe Epigastric pain accompanied by vomiting, no symptoms
perceivedearlier

4. Elaboration Of Patient Chief Complaints In Detail

Amenorrhea X 6 months
Patient was pregnant with 26+4 weeks of Gestation
Patient complained severe heartburn which occurred suddenly before 1-2 hours
accompaniedby two episodes of vomiting
No history of blurring of vision and
headachePatient was perceiving good Fetal
movement
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5. Obstetric History
Married for: 10 years Age of marriage: 16
years

a. Abortions (Spontaneous, Induced, Duration Of Pregnancy):

Once
Induced second Trimester abortion (medical termination of pregnancy) on 2070/1/21 at
Lapaz Medical Teaching Hospital due to PIH complicated by Pre-eclampsia and HELLP
syndromeat 26+6 WOG

b. Type Of Previous Deliveries (Normal/ Instrumental/ LSCS)

Normal vaginal delivery of 1st child (daughter) on 2061/2/26
Induced Spontaneous Vaginal Delivery of Second child (son) IUFD 3 years back
(2066/4/27) at Thapathali due to IUFD secondary to PIH at 37 WOG
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Third child (daughter) medical termination of pregnancy on 2070/1/21 at

Lapaz Medical Teaching Hospital by spontaneous vaginal delivery as indicated by
deteriorating maternal fetal condition due to PIH complicated by Pre-eclampsia
andHELLP syndrome at 26+6 WOG

c. Significant Antenatal Problem/ 3rd Stage Puerperal Complications In Previous Deliveries:

No any significant problem during pregnancy and delivery of first
child Antenatal period complicated by PIH on other two pregnancies

d. Year Of Marriage, Gravida, Para, Abortion, Living Issues

No. Year ANC attendance/ Period of Type of Complications in

pregnancy gestation delivery/ puerperium
complicatio abortion
n s
1 2061 4 visits/ no any 37+WOG SVD No any
significant significant
complication complication
s s
2 2066 4 visits/ IUFD due to 37WOG Instrumental No any
PIH delivery (Forcep significant
delivery) complications

3 2070 2 visits / MTP due 26+WOG SVD No any

toPIH significant
complication
s

Age of last child birth/ year of last pregnancy: 3 years, 2066/4/27

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SUMMARY OF FINDINGS
Physical examination was performed from head to toe OF Mrs. Angelica \, 29 years female
with diagnosis of PIH with severe pre-eclampsia on 2070/1/19. The findings obtainedare
listed below
Weight:
156cmHeight:
56kg

Vital Signs
Temperature: 97º
fPulse: 82/m
Respiration: 20/m
Blood Pressure: 140/110mm Hg and 150/110 mm Hg

Findings:
General Appearance: weak
appearanceGait: Imbalanced
Nutritional Status: well built
Facial Expression: frowning
Skin: pale and yellowish
Bilateral pedal edema present, Peri- orbital edema present around
eyesHead: normal contour, no lesions were observed
Chest: no added murmur sounds were heard, no adventitious breathe sound heard
Abdomen: no organomegaly (hepatomegaly/ spleenomegaly), no dilated veins over
abdomen,straie gravidarum and linea nigra present, no masses and tenderness over
abdomen present Genitalia: No discoloration, swelling, or redness, No abnormal vaginal
discharge present Musculoskeletal: weak muscle strength
Reflexes: normal reflexes
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DEVELOPMENTAL NEED AND TASK

As my patient is 29 years old female, she is at young adulthood stage (18-35years) in her life.

According to book
According to Diekelmann (1976) there are five developmental task of young adulthood
andthey are:
The young adult achieve independence from parental control
They begin to develop strong friendships and intimate relationship outside the
family They establish personal set of values
They develop a sense of personal identity
They prepare for life work and develop the capacity for intimacy

In my patient
She achieved independence from parental control
She formed an intimate relationship with her
husband She has her own set of personal values
She has developed a sense of personal identity
She has prepared herself for life and has already built the capacity for
intimacy
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6. Menstrual History
Age of menarche: 14
years Duration of flow: 6-
7 days
Length of cycle (from 1st day of one cycle to 1st day of next cycle): 30
days Regular/ irregular (range of shortest – longest cycle) : 28- 30 days
Amount of flow, passage of clots, no. of soaked pads/ day : normal, passage of
someclots, 2pads/day
Dysmenorrhea (severity, duration): No history of
dysmenorrhea Intermenstrual bleeding: Absent
Post coital bleeding: Absent
Last menstrual period (LMP): 2069/7/15

7. Contraceptive History
Type of contraception, duration, cause of discontinuation: Oral Contraceptive Pills, 3
years,for conception

8. Past History: Pregnancy Induced Hypertension 3 years back

9. Medical History
Immunization: Done
Allergies (food, drug, environment): Absent
Previous hospitalizations ( if yes reasons): 22 days on 2nd pregnancy due PIH on
thirdtrimester
Injuries/ accidents: Not any
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PHYSICAL ASSESSMENT AND CLINICAL MENIFESTATIONS (by ROD)

➢ General Appearance:
o Conscious, Coherent, Not in Cardio Respiratory Distress
➢ HEENT
o Anicteric Sclera
o Pale Conjunctiva
o Supple Neck
➢ Skin
o Serile Skin Turgor
➢ Chest and Lungs
o Decrease Breath Sound, Right Lung Field
➢ Heart
o Adynamic Precordium, Tachy
➢ Abdomen
o Flabby, Normal Active Bowel Sound, Soft
➢ Extremities
o Negative Edema Full + Equal Pulses
o No Cyanosis Noted
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10. Chronic Illness

SN Diseases In patient In family

Yes No Yes No
1 Hypertension Yes No
2 Cardiovascular diseases No No
3 Diabetes No No
4 Tuberculosis No No
5 Asthma No No
6 Cancer No No
7 Malaria No No
8 Filarial No No
9 Others No No

11. Surgical History

Surgeries/ operations (minor/ major), year, type, indication: Not Any

12. Treatment History

Any treatment done for present illness or any medication which patient is
takingregularly? Not Any
Traditional healer prescription: Not Any
Medical practitioner’s prescription: treated for gestational hypertension on last
pregnancy 3 years back but as symptom subsided after delivery and blood
pressurereturned to normal no any treatment continued at home
Self prescription: Not Any

13. Personal History

Smoking: Absent
Alcohol intake: Absent
Rest and sleep: adequate rest and
sleep Recreation habit: watching
television
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Elimination: normal bowel and bladder

habitHygiene: hygienic

Dietary habits: balanced diet supplemented by extra sources of vitamins, minerals

andproteins like meat, milk, fruits and vegetables

PATHOPHYSIOLOGY

Primary cause unknown (genetic/

immunological)Initial phase: vascular

pathology

Failure of second wave of trophoblast

invasionDecrease blood flow in spiral artery

Decrease placental blood flow

Placental bed ischemia

Stimulation of macrophage

system

Liberation of TNF α (trigger)

interleukins

oxygen free

radicalslipid

peroxides

Endothelial damage/ dysfunction

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LABORATORY STUDIES AND RESULTS

Investigations Findings in my patient Normal values

Blood Pressure 160/110 – 150/90mmHg 120/80 mmHg
TLC 12,800/mm³ 4,000-12,000
DLC:
Neutrophils 60 54-62%
Lymphocytes 38 25-30%
Eosinophils 02 1-3%
HB 9mg/dl 12-15mg/dl
Platelets 86,000/cumm 1,50,000-
4,50,000/cumm
Blood Grouping and cross A Negative
matching
Coagulation Profile:
BT- 10min 1-6min
CT- 14min 1-10min
INR- 9.0 0.8-1.2
Biochemistry:
Urea 25mg/dl 10-40mg/dl
Creatinine 1.1mg/dl 0.4-1.4mg/dl
Sodium 142mmol/l 135-146mmol/L
Potassium 2.9mmol/dl 3.5-5.2mmol/L
Bilirubin total 4.76 mg/dl Up to 1.0mg/dl
Bilirubin direct 3.2 mg/dl Up to 0.2mg/dl
SGOT (AST) 1837U/L 0-40U/L
SGPT (ALT) 913U/L 0-40U/L
Total Protein 7.2 gm/dl 6-8gm/dl
Albumin 4.8 gm/dl 3.5-5.5gm/dl
LDH 2057IU/L <480 IU/L
RBS 83mg/dl Up to 140mg/dl
Uric Acid 4.7mg/dl 2.4-5.7mg/dl
Urinalysis: Reaction: alkaline
Colour: yellow
Epi cells: 16-
18/hpfRBC: 10-
12/hpf WBC: 14-
16/hpf
Albumin: 3+
24 hour urine Protein Positive
Fundoscopy No retinal detachment seen
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USG Singleton preganancy of 25

WOG

PROGNOSIS

Pre-eclampsia is usually insidious in onset and runs a slow course. Rarely onset may be
acuteand follows a rapid course of events. The prognosis of pre-eclampsia depends on the
period of gestation, severity of disease and response to treatment

The following courses may occur:

If detected early: with prompt and effective treatment the pre-eclamptic features may subside
completely

If left untreated:
a. The Pre-eclamptic features remain stationary at varying degrees till delivery

b. Aggravation of the pre-eclamptic features with appearance of symptoms of

acutefulminating pre-eclampsia. Most commonly occurs in cases with acute
onset

c. Eclampsia

d. Spontaneous remission of Pre-eclamptic features

APPLICATION OF NURSING THEORY

While providing care to my patient, I applied Orem’s Theory of
Nursing.Orem’s Theory consists of
1. Theory of self care
2. Theory of self care deficit
3. Theory of Nursing System
My patient Angelica, 29years female was admitted on Gynaecology ward of Lapaz
Medical Teaching Hospital with diagnosis of Pregnancy inducedHypertension with Severe
Pre-eclampsia with HELLP syndrome.
Before termination of pregnancy my patient’s condition was critical, and was partly
conscious, she was pale, weak and was in need of assistance to meet her needs but after
pregnancy her condition gradually progressed and she was able to carry out activities of
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dailyliving by herself and needed no assistance to meet her needs. Thus, I applied Orem’s
theory as it appeared to be the best possible theory to meet my client’s need while
providing nursingcare.
Orem’s Theory of Nursing Care
Orem’s theory of nursing has three related theories
1. Theory of self care
2. Theory of self care deficit and
3. Theory of nursing system

By assessing condition of my patient I figured out theory of nursing system as most

suitabletheory for caring my patient

Theory of nursing system.

It describes how the patients self care needs will be met by the nurse, patient and
both It identifies three classifications of nursing system to meet the self care requisites
of thepatient
- Wholly compensatory system
- Partly compensatory system
- Supportive- educative system
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Wholly compensatory nursing system is represented by a situation in which the individual

isunable to engage in self care actions requiring self directed and controlled ambulation
and manipulative movement or the medical prescription to refrain from such activities
Person with these limitations are socially dependent on others for their continued
existenceand wellbeing. Example patient in coma

Partly compensatory nursing system represented by a situation in which both nurse and
patient perform care measures or other action involving manipulative tasks or ambulation.
Either patient or nurse may have major role in performance of self care measures. Examples
aperson who recently had surgery

Supportive- educative system: in this system the person is able to perform or can and
shouldlearn to form required measures of externally or internally oriented therapeutic
self care but cannot do so without assistance. This is also known a supportive
developmental system.
In this system patient is doing all of his self care. The patient’s requirements for help
areconfined to decision makings behavior control, and acquiring knowledge and
skills.
The nurse’s role is to promote the patient as a self care agent. Example chronic
diseasepatients like hypertension

I applied Partly compensatory by

- By providing all self care activities like mouth care, back care when my patient
waspartly conscious
- Her elimination need was fulfilled by catheterization
- Medication
- Providing safe environment

And I applied supportive educative theory by

- Providing information about disease condition
- Medication
- Complication and it’s prognosis
- Home based management of disease and possible risks
- Diet
- Follow up
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NURSING CARE PLAN

Demographic Data
Name of patient: Angelica Morales
Age: 29 years Sex: Female
Caste: Gurung Religion: Roman Catholic
Marital status: Married No. of Children: 1
Date Of Admission: 2070/1/19 Inpatient number:
19381 Medical Diagnosis:
Provisional Diagnosis: G3P2L1 at 26+4 WOG with PIH
Final Diagnosis: Pre-eclamsia with HELLP syndrome

Assessment
My patient presented with chief complain of amenorrhea for last six months, Epigastric
painfor 1-2 hours, vomiting two episodes and headache on emergency and was admitted
with diagnosis of PIH but later she developed severe eclampsia followed by HELLP
syndrome.
My patient had fetus with 26 WOG she wanted to continue pregnancy but later her
conditionworsened and she developed HELLP syndrome thus, medical termination of
pregnancy was done at 26+5 WOG by inducing labour on 2070/1/21
All symptoms subsided 5 days after MTP and patient was discharged

Nursing Diagnosis
Ineffective Cerebral Tissue Perfusion related to decreased cardiac output secondary
tovascular vasopasm.
Impaired Gas Exchange related to accumulation of fluid in the lungs
pulmonaryedema.
Activity Intolerance related to weakness.
Self care deficit related to decreased strength and endurance as evidenced by
inabilityto ambulate independently
Impaired Urinary Elimination related to impaired glomerular filtration as
evidencedby anuria and oliguria
Risk for Injury related to diplopia and increased intra-cranial pressure, seizures.
Risk for impaired skin integrity related to impaired physical mobility and
invasiveprocedure (deep IM injections)
Knowledge Deficit related to the management and treatment of disease
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S.N. Assesment Nursing Nursing Goal Nursing intervention Rationale Evaluation

Diagnosis
1 Subjective data: Ineffective Maintain Monitor neurological To detect early signs
I feel dizziness Cerebral Tissue effective statusand compare it to of impaired cerebral Goal met patient’s
Perfusion cerebral tissue normal state. tissue perfusion condition was
Objective data: relatedto perfusion stabilized after
- Partly decreased withno signs Monitor vital signs. Assess condition of intervention as
consciou cardiac output of impaired patient. evidenced by
s secondary to GCSwithin 4 increase verbal
- No response to vascular hoursof Indicates communication
Record changes such as
verbal vasopasm. intervention theblindness of vision, or neurological and regain of
command visual field disturbances in impairment consicousness
perception. andimpaired
- Impaired
tissueperfusion
communicatio
n Assess the higher
functions,such as speech To assess
- Not neurological
orientedto function.
statusand plan
time place early intervention
and person

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Put head slightly elevated To improve blood

position. circulation and
decrease blood flow
resistance

Maintain a state of bed rest To prevent potential

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Create injuries
peaceful To provide rest to
environment patient

Limit the activities of To eliminate fatigue

visitors or patients as and agitation
indicated.

Provide oxygen therapy To improve tissue

asindicated perfusion

2 Subjective Impaired Gas Maintain gas Encourage deep breathing Promotes chest
Data: Exchange related exchange and and coughing exercise expansion Goal met oxygen
oxygen
I have chest to accumulation of saturation was
saturation
pain while fluid in the lungs within 3 hour Elevate head of bed to semi- Facilitates maintained at
breathing pulmonary edema. fowler’s position respiratory function 96% with oxygen
by use of gravity at 2l/min
Objective Data:
Respiratory It may cause
Rate: 32/m Avoid restrains agitation with
SpO2 86% Administer oxygen increased
without oxygen therapyas indicated cardiac
workload
sign of
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cyanosis: Stop MgSO4 immediately if MgSO4 toxicity

bluish lips seen sings of respiratory occurs causes depression of
respiratory centre
To maintain oxygen

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Administer oxygen at saturation

2l/min
3 Subjective data: Activity Increase Assess patient's level of To assess patient’s
I can’t do it, I Intolerance tolerance to mobility condition Goal met as
feel weak relatedto simple activity patient did
weakness. after 2 hour Assess potential for physical To prevent shortrange of
Objective data: injury with activity (falls or potentialhazards motion
Decreased overexertion) exercises and
activity tolerated the
Weak Assess patient's To assess patients exertion after
appearanc cardiopulmonary ability to carry out encouraging
e statusbefore activity activities her

To gradually
Assist for ambulation
increase tolerance
andshort range of
toactivities and
motion exercises as
make
tolerated
patient independent

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4 Subjective data Self care deficit Provide and Assess client level to To obtain baseline Goal met ,
I have difficulty related to assist in self perform ADLS data and evaluate patient’s hygiene
doing works decreased care activities patient’s ability was maintained
strengthand after assisting
endurance as Assist client with daily To maintain hygiene herand
evidenced by activities and promote comfort encouraging her
inability to it perform it by
ambulate Provide positive To encourage client herself
independently

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Objective data: reinforcement and build up

Patient cannot duringactivity. positiveattitude
mobilize and Allow patient to perform To maintain client’s
carry out tasks at his or her own self esteem
activities by rate
herself To promote client’s
Encourage ability
independentactivity as
able and safe
5 Subjective data: Impaired Urinary Maintain Assess the signs of fluid Intravascular fluid
- Elimination fluidvolume volume excess, iscontracted and Gal was met as
relatedto impaired and increase respiratorydistress due to sudden shift of fluid Oliguria
Objective data: glomerular urine output pulmonary edema into intravascular subsided24 hour
urine output filtration as to 30ml/hour compartment after MTP
less than evidenced by within 24 causesfluid volume
30ml/hour anuria and hour excess
Generalized oliguria Monitor input output strictly
edema To monitor
Oliguriaand
maintain fluid
balance

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Avoid over resuscitation of To avoid

fluid
Change patients
positionfrequently
Administer IV fluids
complication like
pulmonary
edema
To maintain fluid
volume with
gravityTo manage
persistent Oliguria

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6 Subjective data: Risk for Injury Patients Monitor blood The pressure over Goal met as
- related to remains free pressure every 2 hourly 110 mmHg patient didn’t
diplopiaand ofinjury diastoleand systole hadany seizure
Objective data: increased intra- 160 or more an episodes and
Diplopia and cranial pressure, indication of PIH. remained free
blurring of seizures. from injuries
vision due to Record the patient's level of
The decline of
pressure consciousness
consciousness as
causedon small anindication of
capillaries of decreased cerebral
eye blood flow.
Increased Assess signs of eclampsia
bloodpressure (hyper active, the The symptoms are a
patellarreflexes, manifestation of
decreased pulse and changes in the
respiration, epigastric brain,kidney, heart
pain and oliguria) and lung that
precedes seizure
status.

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Monitor for signs Seizures will

and symptoms of increase the
labor or uterine sensitivity of the
contractions. uterus which will
allow the delivery.

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Administer Anti-
antihypertensiveas hypertensionto
prescribed to reduced blood lower blood
pressure pressure.
7 Subjective data: Risk for impaired Maintain Maintain adequate To maintain Goal met
- skin integrity skinintegrity fluidintake turgorof skin patientshowed
related to no signsof skin
Objective data: impairedphysical Elevate lower extremities To decrease fluid breakdown and
prolonged mobility and volume in pressure sores
immobilization invasive Extracellular
redness on procedure (deep compartment
backsacral area IM injections) anddecrease
Ecchymosis on Keep bed sheets clean and edema
buttocks due to dry, tug bed sheets
IM injection properlyand avoid To reduce
given wrinkles shearingforce of
linen and prevent
skin breakdown

Inspect skin surfaces To detect early signs

toassess skin of skin breakdown
breakdowns

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Change position every To prevent bed sore

twohourly and maintain skin
Provide back care integrity

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