PREGNANC

Y INDUCED
HYPERTENS
ION
Case Presentation | Group 3
Angela Mancilla Trisha Faye Ortega
Mitsui Deneb Manibo Lyra Monique Pelgone
Roiete Millena John Walter Ragragio
Alvin Dominic Nual Ira Krystel Ramos
Ramylle Obusan
INTRODUCTION
Angela A. Mancilla
Mitsui Deneb R. Manibo
 DEFINITION

● Pregnancy induced hypertension (PIH) is a condition wherein

vasospasm occurs during pregnancy in both the small and large
arteries in the body.
● Also known as gestational hypertension.
● Pregnancy Induced Hypertension is a form of high blood
pressure in pregnancy.
● It occurs in about 5 percent to 8 percent of all pregnancies.
PATHOPHYSIOLOGY

 Increased cardiac output occurs with pregnancy, and it can

injure the epithelial cell of the arteries.
 Prostaglandin, a vasodilator, may also contribute to the
injury.
 Reduced responsiveness of the blood vessels to the blood
pressure is lost.
 There is vasoconstriction, and blood pressure increases.
 CLASSIFICATIONS

● Gestational Hypertension
● Mild Preeclampsia
● Severe Preeclampsia
● Eclampsia
 HELPP Syndrome
HELLP syndrome is a complication of severe
preeclampsia or eclampsia. HELLP syndrome is a
group of physical changes including the
breakdown of red blood cells, changes in the liver,
and low platelets (cells found in the blood that are
needed to help the blood to clot in order to control
bleeding)
SIGNS AND SYMPTOMS
• Hypertension. An increase in the usual
blood pressure of the woman is the first
indicator of this disease.
• Proteinuria. Protein leaks out during this
condition and can be detected in the urine.
• Edema. Since protein has already leaked
out and it is responsible for containing
water inside the vessels, edema starts to
occur.
DIAGNOSTIC TESTS

 Blood Pressure Measurement

 Urine Testing
 Assessment of Edema
 Blood Clotting Tests
 Frequent Weight Measurements
 Liver And Kidney Function Tests
 Eye Examination To Check For Retinal Changes
 RISK
FACTORS
Roiete M. Millena
Alvin Dominic O. Nual
 RISK FACTORS
AGE POOR NUTRITION
01 < 18 years or > 40 years 02 Being overweight or obese

PRE-EXISTING HIGH
BLOOD PRESSURE UNDERLYING DISEASE
03 Elevation in blood pressure may 04 Kidney disease and diabetes
further rise during pregnancy
 RISK FACTORS
PRIMIGRAVIDAS WOMEN OF COLOR
05 First pregnancy 06 Non-white ethnicity

MULTIPLE GENETIC FACTORS

07 PREGNANCIES 08 May also have a family history of
Two or more babies pregnancy-induced hypertension
NURSING CARE
MANAGEMENT
Shelanie Almira M. Oliquino | 2A Group 3
CUES NURSING GOALS NURSING EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective Data Deficient Fluid After the 1. Admit the patient. Goals are met.
• Adora Volume r/t implementation of 2. Insert D5NM IV
• 42 years old osmotic nursing fluid, regulated @ 1. The patient’s vital
• Married interventions: 8 – 10 gtts/min. signs were taken
• Cc. Dizziness &
pressure 1. The patient’s vital 3. Insert indwelling and recorded to
vomiting evidenced by signs is expected catheter be within the
edema to be within the 4. Help with insertion normal range.
formation normal range. of lines. 2. The patient
Objective Data 2. The patient should 5. Complete bed rest understood and
• G4P3 engage in the Š bathroom engaged in the
• Edematous therapeutic privilege therapeutic
upper & lower regimen. 6. Measure and regimen.
extremities, & 3. The patient will be record I/O every 3. Patient showed
periorbital area free of signs of shift. Note the no signs of
• Vital signs edema in upper urine color. edema in upper
• BP – 210/110 and lower 7. Weight the patient and lower
mmHg extremities as well and record it extremities as
• T – 36.8°C as in the regularly. well as in the
• PR – 84 bpm periorbital area periorbital area
• RR – 84 bpm
• Height – 5’1
• Weight – 94 kgs.
CUES NURSING GOALS NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
8. Differentiate physiological and
pathological edema. Locate and
determine the degree of pitting.
9. Note signs of progressive or
excessive edema and assess
for possible eclampsia
10. Check the dietary intake,
emphasize the low salt and low
fat diet as well as give
information as needed.
11. Provide information on the
necessary laboratories to the
patient.
12. Schedule and follow the
referral laboratories, as ordered.
13. Monitor the laboratory
results and inform the physician.
14. Review sodium intake of up
to 6g/day and inform the patient
to avoid foods high in sodium.
CUES NURSING GOALS NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
15. Collaborate with dietician, as
indicated.
16. Encourage lateral position.
17. Educate patient and family
members on care program, as
appropriate.
NURSING CARE
MANAGEMENT
Ramylle Obusan | 2A Group 3
 OBJECTIVE INTERVENTI EVALUATIO
CUES DIAGNOSIS OUTCOMES RATIONALE
S ONS N

Subjective: Nutrition Decreased After 1. Provide an 1. Nausea Severity of

Dizziness imbalanced severity of Interventions emesis basin and vomiting Nausea and
and Vomiting r/t Nausea nausea and are applied: within easy are closely vomiting was
and Vomiting vomiting 1. Nutrional reach of the related. decreased.
Objective: imbalance patient. Keep emesis Nutritional
Upper and would be basin out of imbalanced
lower neutralized sight but neutralized
extremities within the and patient
edema and 2. Patient will patient’s gains
periorbital have reach if awareness
edema knowledge nausea has on situations
on situations a related to
V/S: psychogenic nausea and
BP:210/110 component. Vomiting.
RR: 84 bpm
 OBJECTIVE INTERVENTI EVALUATIO
CUES DIAGNOSIS OUTCOMES RATIONALE
S ONS N

2. Assist the 2. Series of

patient in tests may be
diagnostic used to
testing determine
preparation. the
contributing
factor
3. Maintain 3. Sufficient
fluid balance hydration
in patient has been
shown to
reduce the
risk of
nausea.
 OBJECTIVE INTERVENTI EVALUATIO
CUES DIAGNOSIS OUTCOMES RATIONALE
S ONS N

4. Allow the 4. These

patient to use methods have
nonpharmacolo helped patients
gical nausea alleviate the
control condition but
techniques needs to be
used before it
occurs.

5.Give 5. help
frequent, small maintain
amounts of nutritional
foods that status.
appeal to the Strong and
patient and noxious odors
avoid foods can contribute
that triggers to nausea.
nausea.
patient
 OBJECTIVE INTERVENTI EVALUATIO
CUES DIAGNOSIS OUTCOMES RATIONALE
S ONS N

6. Position 6. This can

the patient be helpful in
upright while reducing the
eating and risk.
for 1 to 2
hours post-
meal

7. Review 7. Having too

about the much iron
prenatal may cause
vitamins the nausea, and
patient is switching to
taking a different
vitamin could
help
 OBJECTIVE INTERVENTI EVALUATIO
CUES DIAGNOSIS OUTCOMES RATIONALE
S ONS N

8. Keep 8. Promotes
rooms well- easier
ventilated. If breathing.
possible,
assist the
patient to go
outside to
get some 9.So the
fresh air. patient
becomes
9. Patient aware of
Education situations
and possible
self-induced
Interventions
INDEPENDENT
NURSING
FUNCTIONS
Trisha Faye P. Ortega
Lyra Monique O. Pelgone
PRIOR TO ADMISSION

● Prepare the bed of the patient. Make

sure that there is an IV pole beside the
bed.

● Regulate the environment. Adjust the

temperature and ventilation of the
room
ASSESSING THE CLIENT

1. Assess and record the client’s FHR and vital

signs, especially the blood pressure and
continuously monitor every 4 hrs.
2. Assess and record the client’s weight.
3. Assess the patient for the presence of edema
besides her upper and lower extremities and
periorbital area.
4. Assess laboratory results such as CBC,
urinalysis, FBS, cholesterol, creatinine, BUN,
SGOT, and SGPT.
NURSING INTERVENTIONS

● Promote CBR without BRP. ● Weight the patient daily.

● Position the patient in left ● Promote a balanced diet with

lateral recumbent or side- low salt and low fat diet.
lying position.
● Provide emotional support.
● Monitor intake and output.
EVALUATING THE CLIENT

Patient must exhibit a

normal blood pressure of
120/70 mmHg.

No presence of protein should

be detected on her urine.

Edema should be confined to

the lower extremities only.
Dependent Nursing Functions

• Administer medications to the patient

according to the doctor’s order.
HYDRALAZINE
CLASSIFICATION: Vasodilator

INDICATION:
Hydralazine is a drug used to treat high blood pressure. It is
indicated for patients with hypertension.

ACTION:
Hydralazine is an antihypertensive. It lowers blood pressure
by exerting a peripheral vasodilating effect through a direct
relaxation of vascular smooth muscle.

DOSAGE: 0.8 mg stat, 0.4 mg every 6 hours

NURSING RESPONSIBILITIES

• Inform patient about the medication

• Review pertinent data and doctor’s order prior to medication
administration
• Administer and document the given medication
• Assess for any allergic reaction.
• Advise the patient to not perform any strenuous activity.
• Evaluate appropriateness and accuracy of medication order for client.
• Stop the drug use if side effects like rashes, severe tiredness and dizziness,
fever, and bleeding occur.
 D5NM
(Dextrose 5% in Normosol M Solution)
CLASSIFICATION: Nutrient Replenisher

INDICATION:
D5NM is indicated for parenteral maintenance of routine daily fluid and
electrolyte requirements with minimal carbohydrate calories from
dextrose.

ACTION:
Normosol-M and 5% Dextrose Injection provides water and electrolytes
for maintenance of daily fluid and electrolyte requirements, plus minimal
carbohydrate calories.

DOSAGE: 8-10 drops per minute

NURSING RESPONSIBILITIES

• Do not administer unless solution is clear and container is

undamaged.
• Observe aseptic technique when changing IV fluid.
• Caution must be exercised in the administration of
parenteral fluids.
• Properly label the IV Fluid
• Discard unused portion.
 CARE OF
CONTRAPTIONS
Trisha Faye P. Ortega
Lyra Monique O. Pelgone
INDWELLING
CATHETER
Used for:
 Promoting urinary elimination
 Measuring accurate urine output
 Preventing skin breakdown
 Facilitating wound management
 Allowing surgical repair of urethra, bladder, or
surrounding structures
 Instilling irrigation fluids or medications
 Assessing abdominal/pelvic pain
 Investigating conditions of the genitourinary
system
SAFETY CONSIDERATIONS

· Perform hand hygiene. · Apply principles of asepsis and safety.

· Check room for additional precautions. · Check vital signs.
· Introduce yourself to patient. · Complete necessary focused
· Confirm patient ID using two patient assessments.
identifiers (e.g., name and date of birth).
· Explain process to patient.
· Listen and attend to patient cues.

· Ensure patient’s privacy and dignity.

· Assess ABCCS/suction/oxygen/safety.
INSERTION OF CATHETER
1. Verify physician order for catheter insertion. Assess for bladder fullness and pain by palpation or by
using a bladder scanner.
2. Position patient prone to semi-upright with knees raised; apply gloves; and inspect perineal region
for erythema, drainage, and odor. Also assess perineal anatomy.
3. Remove gloves and perform hand hygiene.
4. Gather supplies:
• Sterile gloves
• Catheterization kit
• Cleaning solution
• Lubricant (if not in kit)
• Prefilled syringe for balloon inflation as per catheter size
• Urinary bag
• Foley catheter
INSERTION OF CATHETER
5. Check for size and type of catheter, and use smallest size of catheter possible.
6. Place waterproof pad under patient.
7. Position patient on back with knees flexed and thighs relaxed so that hips rotate to expose perineal
area. Alternatively, if patient cannot abduct leg at the hip, patient can be side-lying with upper leg
flexed at knee and hip, supported by pillows.
8. Place a blanket or sheet to cover patient and expose only required anatomical areas.
9. Apply clean gloves and wash perineal area with warm water and soap or perineal cleanser
according to agency policy.
10. Ensure adequate lighting.
11. Perform hand hygiene.
12. Add supplies and cleaning solution to catheterization kit, and according to agency policy.
INSERTION OF CATHETER
13. If using indwelling catheter and closed drainage system, attach urinary bag to the bed and ensure
that the clamp is closed.
14. Apply sterile gloves using sterile technique.
15. Drape patient with drape found in catheterization kit, either using sterile gloves or using ungloved
hands and only touching the outer edges of the drape. Ensure that any sterile supplies touch only
the middle of the sterile drape (not the edges), and that sterile gloves do not touch non-sterile
surfaces. Drape patient to expose perineum.
16. Lubricate tip of catheter using sterile lubricant included in tray, or add lubricant using sterile
technique.
17. Check balloon inflation using a sterile syringe.
18. Place sterile tray with catheter between patient’s legs.
19. Clean perineal area as follows.
INSERTION OF CATHETER
• Separate labia with fingers of non-dominant hand (now contaminated and no longer sterile).
Using sterile technique and dominant hand, clean labia and urethral meatus from clitoris to anus,
and from outside labia to inner labial folds and urethral meatus. Use sterile forceps and a new
cotton swab with each cleansing stroke.
20. Pick up catheter with sterile dominant hand 7.5 to 10 cm below the tip of the catheter.
21. Insert catheter as follows.
• Ask patient to bear down gently (as if to void) to help expose urethral meatus.
• Advance catheter 5 to 7.5 cm until urine flows from catheter, then advance an additional 5 cm.
Note: If urine does not appear in a female patient, the catheter may be in the patient’s vagina. You
may leave catheter in vagina as a landmark, and insert another sterile catheter.
INSERTION OF CATHETER
22. Place catheter in sterile tray and collect urine specimen if required.
23. Slowly inflate balloon for indwelling catheters according to catheter size, using prefilled syringe.
Note: If patient experiences pain on balloon inflation, deflate balloon, allow urine to drain,
advance catheter slightly, and reinflate balloon.
24. After balloon is inflated, pull gently on catheter until resistance is felt and then advance the
catheter again.
25. Connect urinary bag to catheter using sterile technique. Keep urinary bag below level of patient’s
bladder.
26. Secure catheter to inner thigh, allowing enough slack to prevent tension.
27. Dispose of supplies following agency policy.
28. Remove gloves and perform hand hygiene.
29. Document procedure according to agency policy, including patient tolerance of procedure, any
unexpected outcomes, and urine output.
BEST PRACTICES FOR MANAGEMENT

· Document in the patient’s medical record cleanser.

all procedures involving the catheter or · Use of an antiseptic or meatal care is
drainage system. unnecessary, use soap and water.
· Also practice hand hygiene prior to · Avoid routine or arbitrary catheter
performing catheter care. changing schedules in the absence of
· Remove catheter as soon as possible to infection.
reduce the risk of CAUTIs. Insert the
catheter using an aseptic technique.
· Use the smallest size catheter possible.
· Cleanse the catheter insertion site daily
with soap and water or with a perineal
BEST PRACTICES FOR MANAGEMENT

· Maintain a uniform and adequate daily fluid intake to continuously flush the urinary
drainage system.
· Clamping the catheter prior to removal is unnecessary.
· Routine catheter and bladder irrigations and/or instillations are not recommended.
· Avoid routine urine cultures in the absence of infection.
· Avoid inappropriate use of antibiotics and antimicrobials.
· Maintain the acidification of urine.
· Acute and long-term care staff should be educated through quality improvement
programs about the selection, insertion, and management of indwelling catheters to
reduce UTI incidence.
BEST PRACTICES FOR MANAGEMENT
 Daily catheter care should include:
- Labeling on bag insertion date, time and
place (e.g. OR, ER).
- Maintain a closed urinary drainage system to
prevent introduction of bacteria into the
urinary tract.
- Adequately secure and anchor the catheter to
prevent urethral and bladder-neck tension.
- Ensure that urine drainage is unobstructed
and continuous by avoiding dependent loops,
ensuring no kinks in tubing and bag is
positioned below the bladder but not on the
floor.
- Scan the bladder if no urine is draining to
determine if system is obstructed.
- Use needleless sampling port for urine
specimen collection
- Anchor and secure catheter
- Empty bag if > 400 mls to prevent tension
on catheter and to prevent the migration of
bacteria ascending from bag to catheter.
 DO’S AND DON’TS
● Do perform peri-care using only soap and water
● Do keep the catheter and tubing from kinking
and becoming obstructed
● Do keep catheter systems closed when using
urine collection bags or leg bags
● Do replace catheters and collection bags that
become disconnected
● Do ensure the resident's
identifier/implementation date is on their urine
collection containers
● Do make sure to disinfect the sampling port
before obtaining a sample
● Don't change catheters or drainage bags at routine,
fixed intervals
● Don't administer routine antimicrobial prophylaxis
● Don't use antiseptics to cleanse the periurethral area
while a catheter is in place
● Don't clean the periurethral area vigorously
● Don't irrigate the bladder with antimicrobials
● Don't instill antiseptic or antimicrobial solutions into
drainage bags
● Don't routinely screen for asymptomatic bacteriuria
● Don't contaminate the catheter outlet valve during
collection bag emptying
INTRAVENOUS
FLUID
• Intravenous fluids are liquids given to replace water,
sugar and salt that a patent needs.
• IV fluids are given straight into a vein through a drip.
• Making sure that everyone in hospital is getting the right
amount of fluid is really important for good patient care.
INTRAVENOUS FLUID

01 Review physician’s order. 02 Check the patient’s name and

secure consent.

Explain the procedure to the

03 patient. 04 Place the patient in a
comfortable position.
INTRAVENOUS FLUID

05 Follow strict aseptic technique

throughout the procedure. 06 Watch the patient constantly for any
unfavorable symptoms.

Frequent observation of the vital signs

07 throughout the procedure. 08 Always check the expiry date of the
fluid before opening the bottles.
Prepare and insert the IV catheter
following the right procedure for
administration of intravenous fluid.
 INTRAVENOUS FLUID
Record and document the
10 necessary data on the nurses 11
record with date and time.
• Type of fluid administered
• •
The concentration of the solution
• The amount of fluid
• The rate of flow of fluid
• •
Any reaction noticed in the patient
Return to the bedside to assess
the comfort of the patient and to
observe any complications
developing in the patient.
Watch for any unfavorable signs
such as headache, chills, nausea,
restlessness, and dyspnea.
Watch the infusion site for
swelling, and pain.
 MONITORING

The condition of IV sites and IV equipment

should be monitored every one to two hours to
ensure that they are working properly and that
no signs of infections or complications are
present in the patient.
DOCUMENTATION OF
IV CATHETER REMOVAL

• Date and Time

• Size, type, and condition of catheter upon removal
• Condition of the IV site
• Type of dressing applied
• Patient’s tolerance of the procedure
END.
DISCHARGE
PLAN
Ira Krystel Ramos | BSN-2A
MEDICATION
Instruct patient to take the medication ordered by the doctor, including the frequency and time.
Include also information on what it is for
Daily low-dose aspirin
01 Daily low-dose aspirin may be recommended if you are at high risk for preeclampsia. Aspirin
may help prevent preeclampsia or problems it can cause.

Medicine is given to lower BP.

02 The dose of current BP medicine you take will depend on the doctor orders and must be
followed strictly.

Take medication as directed

03 Instruct to take medication as directed. Instruct patient to contact healthcare provider if she
think the medicine is not helping or if she experience any side effects.
 EXERCISE

ENVIRONMENT
EXERCISE | ENVIRONMENT

Elevate head part

Elevate head part when
sleeping to promote increase
Enough rest peripheral circulation

Elevate feet several times Limit sexual activity

during the day
ENCOURAGE EXERCISE
Encourage overall passive and active exercises program during pregnancy to:

prevent need for cesarean birth & promote ease in delivery

reduce stress level
help lower your BP

Tailor sitting Squatting Kegel exercises Walking

TREATMENT
Use of drugs
Blood pressure medicines can keep blood pressure at a
healthy level by: Causing your body to get rid of
water, relaxing your blood vessels or making your
heart beat with less force.

Obtaining labs
CBC, platelet count, liver
function, BUN and creatinine
DIET
Instruct the patient to adhere with fixed meal plans, dietary
guidelines, and follow a split meal pattern.

Milk and milk products (preferably

Eat food high in protein,
low fat)
calcium, and iron Nuts and fish

Consume at least 2-3 liters of water

Adequate fluid intake daily.

Eat fresh green healthy

At least 3 servings
vegetables and fresh fruits

Encourage patient for sodium

Limit intake to 1 teaspoon/day
restriction
OUT-PATIENT
DEPARTMENT
FOLLOW-UP
OPD FOLLOW-UP

● Encourage patient to have ● Know when to return

follow-up check-up immediately

- to monitor patient’s condition - Instruct the patient to return

immediately to the clinic or
emergency department if any of
the warning signs reappear
 HEALTH TEACHINGS
for
Pregnancy-Induced Hypertension
John Walter V. Ragragio
BSN 2A, RLE Group 3
 Discuss Pregnancy-
Induced Hypertension
and its implications
for the mother, as
well as for the fetus.
Explain the purpose and
importance of each
treatment measures and
procedures.
Propose a plan to the
mother / family
regarding ways for
them to deal with
hospitalization.
Counsel the mother to
maintain a healthy
weight prior to and
during pregnancy