INTRODUCTION

Hypertension (high blood pressure) is the most frequently occurring medical

problem experienced by mothers during pregnancy. Preeclampsia (also written as pre-
eclampsia) is the most common serious pregnancy complication, affecting 4-8% of all
pregnancies. It is a de novo (i.e. not linked to pre-existing disorders) hypertensive
syndrome, which if left untreated can develop into Eclampsia, an extremely dangerous and

often fatal condition characterized by blood-clots and seizures. Gestational diabetes

mellitus (GDM) is a condition in which a hormone made by the placenta prevents the body
from using insulin effectively. Glucose builds up in the blood instead of being absorbed by
the cells.

I am V.Kanagalakshmi , M.Sc .Nursing II Year Student. I am posted in the

Antenatal ward. I have opportunity to give comprehensive nursing care for the patient. I
have selected the client Mrs. Karuppayee for my care study. I had opportunity to learn
about chronic hypertension and gestational diabetes mellitus complicating pregnancy and
it’s management.

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OBJECTIVES OF THE CARE STUDY:

 Establish rapport with the client and her family members.

 To do complete physical assessment for the client with preeclampsia

 To identify the nursing needs of the client.

 To formulate the nursing diagnosis preeclampsia.

 To acquire the knowledge and understanding about preeclampsia

 To provide comprehensive nursing care of the client.

 To restore the normal activity of the client as soon as possible and to alleviate fear and

anxiety of the client.

 To prevent further complication through effective nursing management.

 To educate patient and family members regarding different aspect of disease and

management.

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 TIME PLAN:

Date and Intervention

Time

13.08.2022  Greeted and introduced myself to the staff.

 Established rapport with the client and family members.
7.00am-
 Provide comfortable Bed to the client
4.00pm
 Collect all history from the client.
 Physical Examination done.
Height – 151cm
Weight - 80 Kg
 Sent blood samples for investigations to lab
 Checked blood pressure at 8am and 12 Noon.
 Administered insulin and oral medications as per Doctor’s order.

14.08.2022  Wished for the day.

 Monitored vital signs.
Temperature :98.4°F
7.00am- Pulse :88 beats/min
1.00pm Respiration :16/min
Blood pressure :140/90mm of hg.
 Obstetrical examination was done.
Fetal heart rate – 138 beats/mt
Daily fetal movement – 16/ 12 hours
 Administered medication to the client.
 Explained about the disease condition to the client.
 Provide health education regarding meal plan
 Checked weight.

15.08.2022  Wished for the day.-

 Bed making done.
7.00am-
 Monitored vital signs.
1.00pm
Temperature :98.4°F

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 Pulse :86 beats/min
Respiration :18/min
 Blood pressure :140/80mm of Hg
 Health assessment done
Fetal heart rate – 138 beats/mt
Daily fetal movement – 16/ 12 hours
 Administered medication to the client.
 Explained about management of disease condition.
 Samples collected (Urine sample for albumin and sugar, blood
sample for post prandial blood sugar for investigation and sent to
laboratory.
 Health education given about self administration of insulin

17.08.2022  Wished for the day.

 Bed making done.
7.00am-
 Monitored vital signs.
4.00pm
Temperature :98.6°F
Pulse :88 beats/min
Respiration :18/min
Blood pressure :140/90mm of Hg
 Health assessment done
Fetal heart rate – 140 beats/mt
Daily fetal movement – 14/ 12 hours
 Maintained Intake output chart and daily fetal movement chart
 Administered medication to the client.
 maintenance of records an reports

18.08.2022  Wished for the day.

 Bed making done.
7.00am-
 Monitored vital signs.
4.00pm
Temperature :98.4°F
Pulse :88 beats/min
Respiration :18/min
Blood pressure :140/100mm of Hg
 Health assessment done

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 Fetal heart rate – 140 beats/mt
Daily fetal movement – 18/ 12 hours
 Administered medication to the client.
 Samples collected for investigation and sent to the laboratory.
 Provide health education about warning signs of preeclampsia.
 Maintained records and reports.

19.08.2022  Wished for the day.

 Bed making done.
7.00am-
 Health assessment done.
4.00pm
 Monitored vital signs.
Temperature :98.4°F
Pulse :88 beats/min
Respiration :18/min
Blood pressure :140/100mm of Hg.
 Health assessment done
Fetal heart rate – 140 beats/mt
Daily fetal movement – 10/ 12 hours
 Mother sent to diabetologist opinion.
 Maintained records and reports.

20.08.2022  Wished for the day.

 Bed making done.
7.00am-
 Health assessment done.
4.00pm
 Monitored vital signs.
Temperature :98.4°F
Pulse :88 beats/min
Respiration :18/min
Blood pressure :140/100mm of Hg.
 Health assessment done
Fetal heart rate – 140 beats/mt
Daily fetal movement – 10/ 12 hours
 Cadiotocography was done for fetal wellbeing.

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  Maintained records and reports.

ANTENATAL ASSESSMENT

DEMOGRAPHIC DATA:

Name : Mrs. Karuppayee

Age : 30years

Ward/Unit : Antenatal ward /IV OG

I.P.No : 4778

Educational Level : 7th Standard

Occupation : Housewife

Religion : Hindu

Husband’s Name : Mr. Bala Murugan

Age : 35 years

Educational level : 9th Standard

Occupation : Cooly

Income : Rs.9000/Month

Address : 15A, East street, Kodimangalam, Madurai.

Date and Time of Admission : 13.8.22 at 9.40am

Source of Informant : Mother and Case sheet

Diagnosis : Chronic hypertension with Gestational diabetes mellitius

Last Date of Menstrual Period : 21.11.2021

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 Expected Date of Delivery : 28.08.2022

Obstetrical Score : G1P0L0A0

Date of Care study started : 13.08.2022

Date of care study ended : 20.08.2022

REASON FOR HOSPITALIZATIO/NEED FOR SEEKING HEALTH CARE:

Referred from Thirumangalam primary health centre as a case of chronic hypertension and
admitted with complaints of increase blood pressure .

PRESENT MEDICAL HISTORY

Diagnosed as chronic hypertension at the 16th week of pregnancy and gestational diabetes mellitus
at the 22 weeks of pregnancy. Patient has blood pressure = 140/100 mm of hg .Labetalol 100 mg
bd taken .admitted for safe confinement.

PAST MEDICAL HISTORY

No past history of bronchial asthma and heart disease. There is no signifigant any surgical illness.

PERSONAL HISTORY:

Nutrition : She is vegetarian and non-vegetarian

Habits : She takes tea twice a day. meals 3 times a day.

Rest and Sleep :8-10 hours of sleep.6 hours sleeps during night and takes 2 hours rest in

Day time and intermittent disturbed sleep in hospital.

Drugs : Takes on prescription

Exercises : Do’s household activities only

Hygiene : Maintain adequate hygienic practices

Urinary pattern : Normal micturition

Bowel pattern : Regular bowel pattern

Immunization History : Immunized with two doses of injection tetanus toxoid.

SOCIO ECONOMICHISTORYHISTORY:

Home : She belongs to a joined family.

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 She lives in own house,

Electricity and corporation water supply was available.

No kitchen garden and pet animals.

Occupation : Her husband is the Breadwinner of the family.

FAMILY HISTORY:

Join family .no family history of genetic disorders ,twin pregnancy,and congenital anomalies

S.No Name of the family Age and Educational Occupation Relationship with Health Status
members mother
Sex Status

1 Mr.Muthupandi 67 y/M - Cooly Father in law Healthy

2 Mrs.Pitchaiyammal 59y/F - - Mother in law Healthy

3 Mr.balamurugan 35y/M 9th std Cooly Husband Healthy

4 Mr.Karupayee 30y/F 7 th std - client

Family Pedigree:

Family pedigree
55 Yrs. 67 Yrs. 59Yrs.
50 Yrs.

25 Yrs. 35 Yrs.
30 Yrs. 28 Yrs.

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 KEY NOTES

 Male

 Female

 Client

 Present pregnancy

MENSTRUAL HISTORY:

She attained menarche at age of 13years.

Regular Menstrual period. Blood flow- 3/30days.

No complaints during menstruation.

MARITAL HISTORY:

She got married at the age of 19 years.

Non consanguineous Marriage.

OBSTETRICAL HISTORY:

Past Obstetrical History : Nil

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Present Obstetrical history :

Last Date of Menstrual Period : 21.11.2021

Expected Date of Delivery : 28.08.2022

Weeks of gestation :38 weeks

1st trimester :Pregnancy confirmed by UPT

Booked and Immunized with first dose of Injection. DT

Routine investigation done.

Viability scan was done and its appropriate to gestational age.

No h/o excessive weight gain

History of Nausea and Vomiting present

2nd trimester : Quickening felt by mother at 5 th month

Weight gain present.Inj. DT 2 nd dose taken

Anomaly scan was taken.

Iron and folic acid tablets was taken regularly

Diagnosed as chronic hypertension at 16th weeks of gestation and on regular

Treatment and diagnosed as gestational diabetes mellitus at 22th weeks of

Gestation and on meal plan.

3rd trimester : Lightening present

Maturity scan taken

Fetal movement present

Mild edema present

No h/o vaginal discharge and vaginal bleeding

Regular antenatal check up

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 Referred from primary health centre for expert management.

Attendances:

Date Weight Urine B.P F.H. Findings Treatment Remarks

Sugar Albumin

21.11.21 65kg Nil Nil 120/70mm Hg - - BCT Good -

07.12.21 66kg Nil Nil 120/80mm Hg - - FST Bd Good

05.3.22 68kg Nil Nil 140/90mmHg 136/min 14wks T.Cal Good

06.05.22 70kg Nil Trace 140/90 mmHg 136/min 23 wks T. Labetelol Good

100mg bd
05.07.22 74Kg + Trace 150/100 mmHg142/min 32wks and Good

2 days From 16th

Week.

PHYSICAL ASSESSMENT:

General Appearance:

Moderate body built, brownish complexion, active allert

Conscious, Oriented to time, place, person.

Weight: 74kg, Height:151cm, BMI - 29.09

Head:

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 Hair is black in color. Evenly distributed. Small dense tiny hair is present.

No dandruff, no pediculosis.

Face

Puffiness present.

Chloasma not present.

Not pallor.

Eyes:

Symmetrical , Both pupils are equally react to light.Normal vision, Conjunctiva is

pale, No discharge.

Ears: Symmetrical, Hearing ability is good, no wax discharge.

Nose : Septum is midline , no septal deviation ,no discharge.

Mouth:

Lips : Dry lips.

Tongue: No coated tongue

Teeth : No dental caries

Gums : euplis present

Neck:

Trachea is midline ,normal neck movements present, no thyroid gland enlargement.

JVP not elevated, no lymph node enlargement

Chest:

Symmetrical chest wall movement.

S1,S2 heard, no murmur.

Respiration rate is 20/min

Breast:
Inspection:

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 Symmetrical,
Enlarged,
Soft consistency,
Primary and secondary areola present,
Mangtomary tubercle is present,
Erectile nipple.
Not visible veins,no discolouration.
Palpation:

No axcillary lymph nodes, no lumps

Normal breast consistency present

Abdomen:

Inspection:

Size : Appropriate to gestational age.

Shape : Ovoid shape

Skin changes : Linea niagra and Striae gravidarum present

Scar : No surgical scar

Contour : firm

Umbilicus : flat

Fetal movements : Not seen during inspection

Flanks : full

Abdominal girth : 110cm.

Fundal height : 32cm

Palpation:

Fundus palpation: A broad soft boggy mass felt on the upper pole of the uterus.. It indicates fetal
buttocks.

Lateral palpation:

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Left : Continuous C shaped curvature is present in mothers left side abdomen.it denotes foetal spine

Right : Irregular buds like projection present in the mothers right side abdomen .it denotes foetal
limbs.

Pelvic palpation:

Grip I : Hands are convergent, head is not engaged.

Grip II : Head is ballotable , i.e head is not engaged.

Auscultation : Fetal heart rate is 140 beats/min

Obstetrical Findings:

Lie : Longitudinal

Position : Left occipito Anterior (LOA)

Presentation : Cephalic presentation

Attitude : Good flexion

Height of fundus : 32cm

Engaged/not engaged : Not engaged

Fetal heart rate : 140 beats/min

Genitalia :

Clean and no discharge.

No vulval edema ,

Extremities:

Upper limbs :All range of motion is possible. Green venflon present in right forearm.

Lower limbs :All range of motion is possible. Pedal edema present.

Spine : Lordosis is present

Anus and Rectus :No hemorrhoids

Reflexes :Normal

Vital signs:
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Temperature : 98.4°F
Pulse : 88beats/min
Respiration : 16/min
Blood pressure : 150/100mm /Hg
Pain : Nil
Spo2 :98% in room air.
INVESTIGATION CHART:

S.No Name of the investigationClient’s value Normal value Remarks

1 Hb 13.8gms% 12-14gms% Normal

2 Blood

TC 10500cells/cumm 4000-11000cells/cumm Increased

DC P-63%,L-32%,E-5 % P-50-70%,L-20-40%,E-0-2%Normal

3 Urine

Sugar Nil Nil Normal

Albumin 1+ Nil Normal

4 Platelet 4.5lakhs 1.5-4.0lakhs Normal

5 BloodSugar 135mg/dl 80- 120 mg/dl Increased

Urea 23 mg/dl 20-40 mg/dl Normal

Creatinine 0.8 mg/dl 0.1-1mg/dl Normal

6 Serum

Bilirubin 0.3 mg/dl 0.2-1.2 mg/dl Normal

Direct 0.2 mg/dl <0.3 mg/dl Normal

Indirect 0.1 mg/dl 0.3-1 mg/dl Normal

SGOT 20 U/L 5-40 U/L Normal

SGPT 28 U/L 7-56 U/L Normal

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 ALP 115 U/L 40-150 U/L Normal

Other Investigations

Blood group : B+ve

Echo: Normal study

PPTCT: Non reactive

HbsAg - Negative

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 DRUG CHART:

S.No Name of the

Dosage Route Frequency Action/Group Side effects Nurses responsibility
drug

1 Tab.Labetolol 100 mg Oral Bd Post synaptic alpha1- Hypotension Monitor BP every

adrenergic and Feeling weak, 4th hourly, palpitation

nonselective drowsiness,

Beta adrenergic receptors Low energy

4 T.B complex 30mg Oral Bd Vitamin supplementation Nausea and vomiting Monitor
hypersensitivity
Headache, dizziness
2 Reactions.

5 T.Fst 100mg Oral Bd Iron supplementation Parasthesia, headache Assess the client

3 Flushing, dizziness condition

6 T.Calcium 200mg Oral Bd Calcium supplementationGastritis Don’t give along with

4 iron

Injection . 4Units Sc Bd Fast acting insulin lowers Hypoglycaemia, Monitor blood sugar.
Human

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5 Actrapid the blood glucose level. Nausea, Watch for
hypoglycaemic
Vomiting
reactions.

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 CHRONIC HYPERTENSION

Hypertension (high blood pressure) is the most frequently occurring medical problem
experienced by mothers during pregnancy. Preeclampsia (also written as pre-eclampsia) is the most
common serious pregnancy complication, affecting 4-8% of all pregnancies. It is a de novo (i.e. not
linked to pre-existing disorders) hypertensive syndrome, which if left untreated can develop into
Eclampsia, an extremely dangerous and often fatal condition characterized by blood-clots and

seizures.

Pregnancy induced hypertension

Gestational hypertension or pregnancy-induced hypertension (PIH) is the

development of new hypertension in a pregnant woman after 20 weeks of gestation.

Classification of hypertension in pregnancy

 Hypertension
 Gestational hypertension
 Preeclampsia
 Eclampsia
 HELLP syndrome
 Chronic hypertension
 Super imposed preeclampsia or eclampsia

Hypertension

BP ≥ 140/90 mm/Hg measured two times with at least 6-hour interval

Chronic hypertension

BP ≥ 140/90 mm/Hg for the first time in pregnancy before 20 weeks without
proteinuria.

Gestational hypertension

BP ≥ 140/90 mm/Hg for the first time in pregnancy after 20 weeks without proteinuria

Preeclampsia

Gestational hypertension with proteinuria

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Eclampsia

Women with preeclampsia complicated with grandma seizures and/ or coma.

HELLP syndrome

Hemolysis, elevated liver enzymes and low platelet count

Super imposed preeclampsia or Eclampsia

Outcome of new onset of proteinuria in women with chronic hypertension.

Risk factors of chronic hypertension.

Primi gravida
Mothers under 20 or over 40 years old
Family history
Obesity
Past history of diabetes mellitus, hypertension and renal disease
Thrombophilias
Multiple gestation
Placental abnormalities – Hyperplacentosis, placental ischemia

Etiopathogenesis of chronic hypertension

Endothelial dysfunction and vasospasm

 Increased circulating pressor substances
 Increased sensitivity of the vascular system to normally circulating pressor substances
 Failure of trophoblast invasion
 Inflammatory mediators (cytokins)
 Increased oxygen free radicals
 Imbalance of angiogenic and anti angiogenic proteins
 Genetic predisposition

20
Pathophysiology (placenta)
Premature aging of utero placental bed

Proliferation of cytotrophoblast and thickening of basement layer

Fail to occur endovascular invasion of cytotrophoblast into spiral

arteries

Myovascular tissue responds to vascular constrictor resulting

decreased blood flow

Functional and anatomical changes in the placenta (1/3 of blood flow

decreased)

Kidney

Endothelial cells swells up

Deposit of fibrin in the basement membrane of the glomeruli

Lumen may be occluded

Interstitial cells in between capillaries proliferated

Spasm on the afferent glomerular arterioles

Patchy areas of damaged epithelial tissue due to anoxia

Reduced renal blood flow and glomerular filtration rate and

impaired tubular reabsorption or secretory function

Blood vessels –endothelial damage

Liver

Thrombosis of the arterioles

Peripheral hemorrhagic necrosis of the live

Necrosis of liver lobe

Subcapsular haematoma

Hepatic insufficiency

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CLINICAL FEATURES

Symptoms

 fatigue
 Nausea and vomiting
 diminished urinary output
 disturbed sleep
 epigastric pain
Signs

 Sudden weight gain

 Increased blood pressure
 Edema
 Difficulty in breathing
 Irregular heart beat
 placental insufficiency – scanty liquor, IUGR

INVESTIGATIONS

Screening tests

Doppler ultrasound

High resistance in the uterine artery

Renal function test- serum uric acid

Urine albumin – micro albumin uria

Average mean arterial pressure - ≥ 90mm/Hg

Maternal serum level of SFit- I - increased

Fetal DNA – present in maternal plasma

Roll over test – 28 – 32 weeks

Urine – proteinuria

22
 Opthalmoscopic examination – retinal edema, constriction of arterioles

Blood values – urea, uric acid, liver enzymes and coagulation profiles

Antenatal fetal monitoring – fetal kick count, ultrasonography, umbilical artery

flow velocimetry.

Management of preeclampsia

Objectives

1. To stabilize hypertension and prevent progression to severe preeclampsia

2. To prevent complications
3. To prevent Eclampsia
4. Delivery of the healthy baby in optimal time
5. Restoration of health of mother in puerperium

Home care

 Advise rest, high protein diet, frequent BP checking

 Warned against the ominous symptoms such as head ache, visual disturbances,
vomiting epigastric pain and scanty urine.
 Hospital management

Rest – left lateral position

Diet – no restriction. 1600 Kcal

Diuretics – indications
Cardiac failure
Pulmonary edema
Massive edema
Along with antihypertensive drugs
Inj. lasix 40 mg 5 days /week

Antihypertensive drugs

Methyldopa –central and peripheral antiadrenergic action

Labetolol – adrenoceptor antagonist(α &β)

23
 Nifidepin – calcium channel blocker

Hydralazine – vascular smooth muscle relaxant

Progress chart

 Daily evaluation of omniou symptoms

 6 th hourly blood pressure
 Daily urine examination and 24 hours urine examination
 Blood hematocrit , platelet count, renal and liver function test once a week.
 Optholmoscopic examination
 Fetal well being assessment

DEFINITIVE TREATMENT

Termination of pregnancy

Depending on response to treatment patients are grouped

a. preeclamptic features subside and hypertension is mild

b. partial control – BP high
c. persistently increasing BP to severe level

Group A

If the duration of pregnancy remote to term, wait for 37 weeks then decide for
delivery or spontaneous onset of labour.

Group B

Deliver the baby if 37 weeks or continue expectant managemen at least 34 weeks.

Group C

Termination of pregnancy irrespective of duration of gestation.

Steroid therapy if the pregnancy is less than 34 weeks for lung maturity.

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Methods of delivery

Induction of labour.

If the cervix is ripe, surgical induction by low rupture of membrane. oxytocin

drip may be added.

If the cervix is unripe, prostaglandin gel (PGE2) 500 µgintracervical or 1-2 mg

in the posterior fornix

Antihypertensive drugs can be used during induction.

Cesarean section

 When urgent termination is indicated and the cervix is unfavorable

 Severe preeclampsia
 Associated complicating factors

Management during labour

 Bed rest
 Moniter blood pressure and urinaryoutput
 Antihypertensive drugs
 Prophylactic MgSO4 if systolic ≥160mm/Hg diastolic ≥ 110 mm/Hg , MAP ≥
125mm/Hg
 Careful monitoring of the fetal well being
 Labour duration should be curtailed by low rupture of membrane at first stage, forceps
or ventous in second stage.
 Inj. Ergometrine should not be given.

Puerperium management

 Close monitoring for 48 hours

 Continue antihypertensive drugs if BP high.( systolic ≥150mm/Hg diastolic ≥ 100
mm/Hg)
 Nifidepin to be given 6th hourly till BP remain below hypertensive level for 48 hours.

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PREVENTION OF PRE ECLAMPSIA

Preventive measures against pre-eclampsia have been heavily studied. Because the
pathogenesis of pre-eclampsia is not completely understood, prevention remains a complex
issue. Below are some of the currently accepted recommendations.

Diet

Supplementation with a balanced protein and energy diet does not appear to reduce
the risk of pre-eclampsia. Further, there is no evidence that changing salt intake has an effect.

Supplementation with antioxidants such as vitamin C, D and E has no effect on pre-

eclampsia incidence; therefore, supplementation with vitamins C, E, and D is not
recommended for reducing the risk of pre-eclampsia.

Calcium supplementation of at least 1 gram per day is recommended during

pregnancy as it prevents pre-eclampsia where dietary calcium intake is low, especially for
those at high risk. Low selenium status is associated with higher incidence of pre-eclampsia.

Aspirin

Taking aspirin is associated with a 1 to 5% reduction in pre-eclampsia and a 1 to 5%

reduction in premature births in women at high risk. The World Health Organization
recommends low-dose aspirin for the prevention of pre-eclampsia in women at high risk and
recommends it be started before 20 weeks of pregnancy. The United States Preventive
Services Task Force recommends a low-dose regimen for women at high risk beginning in
the 12th week. Benefits are less if started after 16 weeks.

Physical activity

There is insufficient evidence to recommend either exercise or strict bed rest as

preventive measures of pre-eclampsia.

Smoking cessation

In low-risk pregnancies, the association between cigarette smoking and a reduced risk
of pre-eclampsia has been consistent and reproducible across epidemiologic studies. High-
risk pregnancies (those with pregestational diabetes, chronic hypertension, history of pre-
eclampsia in a previous pregnancy, or multifetal gestation) showed no significant protective
effect. The reason for this discrepancy is not definitively known; research supports
speculation that the underlying pathology increases the risk of pre-eclampsia to such a degree

26
that any measurable reduction of risk due to smoking is masked However, the damaging
effects of smoking on overall health and pregnancy outcomes outweighs the benefits in
decreasing the incidence of pre-eclampsia. It is recommended that smoking be stopped prior
to, during and after pregnancy

COMPLICATIONS

Immediate complications - Maternal

Preeclampsia
Eclampsia
Accidental hemorrhage
Oliguria or anuria
Diminished vision or blindness
Preterm labour
HEELP syndrome
Cerebral hemorrhage
Acute respiratory distress syndrome
post partum hemorrhage
Shock
sepsis

Fetal complications

Intrauterine death
Intrauterine growth retardation
Asphyxia
Prematurity

Remote complications

 Residual hypertension
 Recurrent Eclampsia
 Chronic renal disease
 HELLP syndrome

27
 GESTATIONAL DIABETES MELLITUS

Gestational diabetes mellitus (GDM) is a condition in which a hormone made by the

placenta prevents the body from using insulin effectively. Glucose builds up in the blood
instead of being absorbed by the cells.

Risk factors:

 Overweight or obesity
 Family history of diabetes
 Having given birth previously to an infant weighing greater than 9 pounds
 Age (women who are older than 25 are at a greater risk for developing gestational
diabetes than younger women)
 Race (women who are African-American, American Indian, Asian American,
Hispanic or Latino, or Pacific Islander have a higher risk)
 Prediabetes, also known as impaired glucose tolerance

Treatment for gestational diabetes focuses on keeping blood glucose levels in the normal
range. Treatment may include:

 Special diet
 Exercise
 Daily blood glucose monitoring
 Insulin injections

Fetal Complications:

 Macrosomia. Macrosomia refers to a baby who is considerably larger than normal.

All of the nutrients the fetus receives come directly from the mother's blood. If the
maternal blood has too much glucose, the pancreas of the fetus senses the high
glucose levels and produces more insulin in an attempt to use this glucose. The fetus
converts the extra glucose to fat. Even when the mother has gestational diabetes, the
fetus is able to produce all the insulin it needs. The combination of high blood glucose
levels from the mother and high insulin levels in the fetus results in large deposits of
fat which causes the fetus to grow excessively large.

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 Hypoglycemia. Hypoglycemia refers to low blood sugar in the baby immediately
after delivery. This problem occurs if the mother's blood sugar levels have been
consistently high, causing the fetus to have a high level of insulin in its circulation.
After delivery, the baby continues to have a high insulin level, but it no longer has the
high level of sugar from its mother, resulting in the newborn's blood sugar level
becoming very low. The baby's blood sugar level is checked after birth, and if the
level is too low, it may be necessary to give the baby glucose intravenously.

29
MERCERS MODEL OF RELATIONSHIP BETWEEN ANTEPARTUM STRESS AND FAMILY FUNCTIONING

Self esteem

Negative life events sense of mastery

Anxiety

Pregnancy risk Health status

Family functioning

Child birth risk Parental competence depression

Social support

30
THEORIES OF ANTE PARTUM STRESS AND MATERNAL ROLE ATTAINMENT

INTRODUCTION ABOUT THEORIST

Mercer is the only theorist whose work has been exclusively concerned with understanding
the process of childbearing who is included in a collection considering the work of the major
theorists in nursing.

Her work has been greatly influenced by Rubin, who was the professor in maternity
nursing at the university where Mercer obtained her doctoral degree.

By 1988, Mercer had published four books. Mercer has been responsible for the
development of a range of measurement tools for use in research which have been widely
used by other researches.

Her theory is extremely practice oriented. She published articles such as, “First time
Motherhood” (1986) and “The Nurse and Maternal tasks of the Early Postpartum”.

Mercer has undertaken theory building and research in two main areas.

1. The effects of ante partum stress.

2. Attainment of maternal role.

THE EFFECT OF ANTEPARTUM STRESS ON THE FAMILY

Mercer’s research is concerned with a number of other measures of effects of antenatal

stress relating to the functioning of the family unit. Mercer and her colleagues have been
seeking to understand the effects of antenatal stress on family functioning, as a whole; on
functioning of pairs of individuals in family, and on health status.

Mercer et al (1986) identify six variables from research and other literature which are
related to health status, dyadic relationships and family functioning: ante partum stress, social
support, self - esteem, sense of mastery, anxiety and depression.

31
The outcome variables are defined as follows.

For health status, they were: the mother’s and father’s perception of their prior health,
current health outlook, resistance — susceptibility to illness, healthy worry concerns,
sickness orientation, and rejection of the sick role.

Infant health status is defined as the extent of any pathology combined with the parental
rating of the infant’s overall health.

Ante partum stress is described as resulting from a combination of negative_ associated with
the pregnancy.

Ante partum stress is defined as a dynamic system which includes subsystems -

individuals (mother, father fetus! infant) and dyads (Mother I father, mother – fetus/ infant,
and father - fetus /infant) with in the overall family system.Mercer et al describe the
outcomes (actions, in terms of family functioning or health status) as being affected by
external influences. These include the whole spectrum of negative life events.

Stress from negative - life events and pregnancy risk were predicted have direct
negative effects on self - esteem and health status; self - health status and social support were
predicted to have direct positive effects on sense of mastery; Sense of mastery was predicted
to have direct negative effects on anxiety and depression which in turn have direct negative
effects on family functioning.

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 NURSING DIAGNOSES

 .Excess fluid volume related to collection of fluid in the lower extremity evidenced by pedal

edema.

 Deficient knowledge regarding self administration of insulin and diet evidenced by

repeatedly asking doubts.

 Anxiety related to outcome of the fetus as evidenced by anxious look.

 Activity intolerance related to edematous leg and abdomen as evidenced by anxious

look

 Imbalanced nutrition more than body requirement related to improper glucose maintenance

evidenced by increased blood sugar.

 Disturbed sleep pattern related to altered comfort level as evidenced by dull look and

fatigue.

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Subjective Data : The client verbalized that she was having loss of appetite.
Objective Data : The client looks dull and tired.
Nursing Diagnosis : . Excess fluid volume related to collection of fluid in the lower extremity evidenced by pedal edema.
Goal : Maintain normal fluid volume.

Plan of Action Implementation Rationale Expected outcomes

Establish rapport with the Established rapport with the mother It will help to wins the confidence Normal fluid volume will be
mother of the mother maintained.

Monitor vital signs. Monitored vital signs. It will provide baseline data.

Temperature:98.4°F

Pulse :88beats/min

Respiration:20/min

Blood Pressure:140/90mm hg

Assess the edema Assessed edema by using edema It will help to assess the fluid
scale. 1+ volume

Record daily weight Recorded weight 74kg It will help to measure weight
gain.

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Maintain intake and output Maintained intake and output chart It will help to calculate the volume
chart of fluid intake.

Provide comfortable devices Provided extra pillows for foot It will help to reduce edema.
elevation

Administer oral Administered T. Labetelol 100mg bd It will help to control blood

antihypertensives given pressure.

Reassess the mother Reassessed the mother It will help in further planning

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 Subjective Data :The client verbalized that she had able to perform daily work

Objective Data :The client looks dull,tired,lethargy and anxious.

Nursing Diagnosis :Fatigue related to improper intake of food as evidenced by dull and tired.

Goal :The client will feels comfort.

Plan of Action Implementation Rationale Expected outcomes

Establish rapport with the Established rapport with the It will help to wins the confidence of the
mother mother mother

Provide comfort to the client. Provided comfort to the client. It will help to comfort to the client.

Monitor vital signs. Monitored vital signs. It will provide the baseline data of the
client.
Temperature :98.4°F

Pulse
:88beats/min

Respiration :16/min

Blood Pressure:120/70mm hg

Encourage the client to take Encouraged the client to take iron It will improve the client’s condition
iron rich diet rich diet like green leaf vegetables
,dates ,jaggery .

Encourage the client to take Encouraged the client to take It will help to reduce fatigue

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adequate rest adequate rest in day time . The client feels

Encourage the mother to do Encouraged the mother to do mild It will help to improve the client’s comfort
mild antenatal exercises antenatal exercises like breathing condition
exercise and butter fly exercise.

Reassess the client’s Reassessed the client’s condition. It will help to know the effectiveness of
condition. nursing care.

Subjective Data :The client verbalized that she was having difficulty in falling asleep.

37
 Objective Data :The client looks dull and tired.
Nursing Diagnosis : Disturbed Sleep pattern related to altered level of comfort as evidenced by pallor.
Goal : To improve sleep pattern.

Plan of Action Implementation Rationale Expected

outcomes

Establish rapport with the Established rapport with the mother It helps to wins the confidence of the Mother’s sleep pattern
mother mother improved.

Provide comfort to the client. Provided comfort to the client. It helps to comfort to the client.

Monitor vital signs. Monitored vital signs. To know the baseline data of the client.

Temperature :98.4°F

Pulse :88beats/min

Respiration :18/min

Blood Pressure:120/70mm hg

Provide conductive Provided conductive environment It helps to provide well ventilated

environment to the mother. environment to the mother.
1,opened door

2,switched on the fan

Advice the client to drink milk Adviced the client to drink 200ml Milk contain Tryptophan.It induce sleep

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 of milk

Advice to take warm bath Adviced to take warm bath before It helps to promote sleep at night
before bed bed

Reassess the client’s Reassessed the client’s condition. It help to know the effectiveness of care.
condition.

Subjective Data :The client verbalized that she had fear to administer insulin.

39
 Objective Data :The client looks confused.
Nursing Diagnosis : Deficient knowledge regarding self administration of insulin and diet evidenced by repeatedly asking doubts.

Goal :Improve sleep pattern.

Plan of Action Implementation Rationale Expected

outcomes

Assess the educational level of Assessed the educational level of It will help to select the way to educate Mother’s knowledge will
the mother mother. She studied upto 7th std. be improved.

Explain about the Explained about the administration It will help her to learn about
administration of insulin of insulin administration of insulin

Educate about the pre Educated about the pre requisties It will help to make necessary
requisties before insulin before insulin administration like arrangements before administer insulin
administration. the readiness of diet.

Demonstrate insulin Demonstrated about the It will help to know how to administer
administration. administration of insulin. insulin

Guide mother to put insulin Guided the mother to put insulin. It will help to get confidence.
She administer 4 unit of insulin
subcutaneously.

40
Reassess the client Reassessed the client It will help in further planning

41
42
HEALTH EDUCATION

Regarding diet:

 Advice the mother to take iron riched foods such as green leafy
vegetables,spinach,egg,liver,ragi and wheat.
 Advice the mother to take salt restricted diet
 Advice them to take protein rich foods such as cereals, grains, etc…
 Advice her to take high calcium diet such as sappota, clustered apple, ragi, fish etc

Regarding exercise:

 Advice them to antenatal exercises to prevent complication.

 Educate her relaxation technique such as listening music, reading books
 Encourage her to do range of motion exercises

Regarding hygiene:

 Educate the client to maintain the personal hygiene.

 Encourage her to use soft tooth brush to brush her teeth.

Regarding medicine:

 Advice her to take antihypertensive drugs at correct time

 Advice the client to take iron tablets on correct time.

Regarding follow up care:

 Inform her about the warning signs (head ache, blurred vision, epigastric pain, nausea and
vomiting and decreased urine output)
 Advice her about the importance of regular checkup
 Advice her to come for hospital if any complication occur.
 Advice her to keep the records during hospital visits

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Conclusion

I hereby conclude that by doing this care study I have given care to my patient and I
gained profound knowledge on chronic hypertension and gestational diabetes mellitus and its
management and formulating nursing diagnosis, planning nursing care, implementing &
evaluating the care provided & understanding the purpose of diagnostic tests. I heartedly
thank my patient for her co- operation . I really thank our madams for giving this opportunity
to me.

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BIBLIOGRAPHY

 Adelle Pillitery (2006) “Maternal and Child Health Nursing”, 2 nd edition, Lippincott
and Williams Publishers.
 D.C. Dutta (2004), “Text book of Obstetrics”, 6th edition, Published by New central
Book Agency (P) Ltd.,.
 V. Ruth Bennet (2005) “Myles Text Book for Midwives”, 12 th edition, Published by
English Language Book Society
 M C Kinney, “Maternal-Child Nursing”, 2nd edition, Elsevier, Philadelphia.
 Lowdermilk, “Maternity and Women’s Health Care” 9th edition, Mosby, Missouri.
 Reeder (1972), “Maternity Nursing” 18th edition, Lippincott, Philadelphia.
 Neelam Kumari, “A Textbook of midwifery and gynanecological nursing”,2011
edition
 Published by S vilcas & company
 Annamma Jacob, “comprehensive text book of midwifery” 2 nd edition, published by
Jaypee
brothers
 Gloria Leifer, “Maternity nursing”, 10th edition, published by Saunder elesevier.

JOURNAL:

Zeeman gerda g. MD; Dekker, Gustaaf a. Md, phd, : journal of clinical obstetric and
gynaecology vol 35, (june-1992),P.P-317-337 published by Wolters Kluwer.

NET REFERENCES:

1. http://www.nlm.nih.gov/MEDLINEPLUS
2. http://www. myoclinic.com
3. http://www.Wikipedia.com
4. http://www.webMD

45
 COLLEGE OF NURSING
MADURAI MEDICAL COLLEGE—MADURAI-20.

OBSTETRICS AND GYNAECOLOGICAL NURSING

CARE STUDY ON

ANTENATAL MOTHER WITH PREECLAMPSIA

SUBMITTED TO :

MRS.SOBANA JOY JOHN M.SC (N),M.SC (PSY),

READER,CONMMC,MADURAI.

MRS.N.RAJALAKSHMI,MSC(N),

NURSING TUTOR GR II, SUBMITTED BY:

V.KANAGALAKSHMI

II YEAR M.Sc NURSING,

CON,MMC,MDU-20

SUBMITTED ON : SIGNATURE OF FACULTY

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