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Pregnancy Induced Hypertension - Nursing Diagnosis (NANDA) | Fetus | Preterm Birth

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Nursing Process
  Pregnancy-Induced Hypertension The exact etiology of this disorder is unknown, with several theories being advanced.Data have suggested that PIH may be the result of increased peripheral vascular resistancesecondary to generalized vasospasm when the vessels are no longer refractory to the effectsof pressor agents. New research proposes that elevated cardiac output and associatedhyperdynamic vasodilation during the first trimester result in damage to the endothelium withcompensatory vascular vasodilation. Regardless of the mechanisms, PIH is a chronic diseaseprocess, with a decrease in placental perfusion occurring before the late sign of hypertensionis detected.(This plan of care is to be used in conjunction with the Trimesters and the High-RiskPregnancy CPs.) CLIENT ASSESSMENT DATA BASECirculation Persistent increase in BP over pregravid or first-trimester baseline readings after 20 wk of pregnancy (systolic elevation > 30 mm Hg, diastolic elevation > 15 mm Hg or a BP> 140/90 mm Hg on two consecutive readings assessed at least 6 hr apart).History of chronic hypertension.Jugular venous distension.Gallop rhythm may be present.Pulse may be decreased.May have spontaneous bruising, prolonged bleeding, or epistaxis (thrombocytopenia). Elimination Oliguria/anuria may be present.Hematuria may be noted. Food/Fluid Nausea/vomiting.Weight gain of 2+ lb in 1 wk, 4 lb or more per month (depending on length of gestation).Malnourished (overweight or underweight by 20% or greater); poor protein/caloric intake.Edema may be present, ranging from mild to severe/generalized; and may involve facies,extremities, and organ systems (i.e., liver, brain).Glycosuria (diabetes mellitus). Neurosensory Dizziness, frontal headaches.Decreased responsiveness/somnolence.Diplopia, blurred vision, or even loss of visual fields; scotomata (spots before eyes).Hyperreflexia; clonus.Convulsions—tonic, then tonic-clonic phases, followed by a period of loss of consciousness.Funduscopic examination may reveal edema or vascular spasm. Pain/Discomfort Epigastric pain (right upper quadrant [RUQ] region) Respiration Respirations may be less than 14/min.Bibasilar crackles may be present.  Dyspnea. Safety Rh incompatibility may be present. Sexuality Primigravida, multiple gestation, hydramnios, gestational trophoblastic disease (e.g.,:hydatidiform mole), hydrops fetalis (Rh antigen-antibody)Fetal movement may be diminishedSigns of abruptio placentae may be present (e.g., uterine tetany, tenderness) Teaching/Learning Adolescent (under age 15 yr) and older primigravida (age 35 yr or older) are at greatest riskFamily history of pregnancy-induced hypertension (PIH) DIAGNOSTIC STUDIES Supine Pressor Test (“rollover test”): May be used to screen for clients at risk for PIH,28–32 wk gestation, although accuracy is questionable; an increase of 20–30 mm Hg insystolic pressure or 15–20 mm Hg in diastolic pressure indicates a positive test. Mean Arterial Pressure (MAP): 90 mm Hg at second trimester indicates PIH. Hematocrit (Hct): Elevated with fluid shifts, or decreased in HELLP syndrome ( h emolysis, e levated l  iver enzymes, l  ow  p latelet count). Hemoglobin (Hb): Low when hemolysis occurs (HELLP syndrome). Peripheral Smear: Distended blood cells or schistocytes in HELLP syndrome or intravascularhemolysis. Serum Platelet Counts: Less than 100,000/mm3in disseminated intravascular coagulation(DIC) or in HELLP syndrome, because platelets adhere to collagen released fromdamaged blood vessels. Serum Creatinine Level: Elevated above 1.0 mg/dL and blood urea nitrogen (BUN):Greater than 10 mg/dL reflects severe renal involvement. AST, LDH, and Serum Bilirubin Levels (indirect particularly): Elevated in HELLPsyndrome with liver involvement. Uric Acid Level: Greater than 5 mg/100 mL. Helpful in distinguishing preeclampsia fromuncomplicated chronic hypertension. Prothrombin time (PT), Partial Thromboplastin Time (PTT), Clotting Time: Prolonged; fibronogen decreased, FSP and FDP positive when coagulopathy occurs (DIC). Urine-Specific Gravity: Elevated, reflecting fluid shifts/vascular dehydration. Proteinuria: By dipstick, may be 1+ to 2+ (moderate), 3+ to 4+ (severe), or greater than500 mg/dL in 24 h. Creatinine Clearance: Decreased in preeclampsia (before serum BUN/Creatinine elevated). Urinary/Plasma Estriol Levels: Decline indicates reduced placental functioning. (Estroilsare not as useful a predictor as biophysical profile [BPP] because of the lag time betweenfetal problem and test results.) Human Placental Lactogen Levels: Less than 4 mEq/ml suggests abnormal placentalfunctioning (not frequently done n PIH screening). Ultrasonography: At 20–26 weeks’ gestation and repeated 6–10 wk later, establishesgestational age and detects IUGR. Tests of Amniotic Fluid (lecithin sphingomyelin [L/S] ratio, phosphalidylglycerol(PG), saturated phosphatidylcholine levels): Determine fetal lung maturity. Biophysical Profile (BPP) (amniotic fluid volume, fetal tone, fetal breathingmovements [FMB], fetal movements, and fetal heart rate [FHR]reactivity)/Nonstress Test (NST): Determines fetal risk/well-being. CST: Assesses the response of the fetus to the stress of uterine contractions. NURSING PRIORITIES  1.Monitor maternal, fetal, and placental status.2.Prevent or reduce progressive fluid accumulation and other complications.3.Promote positive maternal/fetal outcome.4.Provide information to enhance self-care and therapeutic management. DISCHARGE GOALS (Inpatient care generally not required, unless fetal compromise or eclampsia develops, orwhen labor process begins.)If hospitalized:1.Hemodynamically stable, free-of-seizure activity2.Fetus active and in no distress3.Condition, prognosis, therapeutic regimen understood4.Participating in care with plan in place for home monitoring/management NURSING DIAGNOSIS:Fluid Volume deficit [isotonic]May Be Related To: Plasma protein loss, decreasing plasma colloid osmoticpressure, allowing fluid shifts out of the vascularcompartment Possibly Evidenced By: Edema formation, sudden weight gain,hemoconcentration, nausea/ vomiting, epigastric pain,headaches, visual changes, decreased urine output DESIRED OUTCOMES/EVALUATION Verbalize understanding of need for close CRITERIA—CLIENT WILL: monitoring of weight, BP, urine protein, and edema.Participate in therapeutic regimen and monitoring, asindicated.Display Hct WNL and physiological edema with nosigns of pitting.Be free of signs of generalized edema (i.e., epigastricpain, cerebral symptoms, dyspnea, nausea/vomiting). ACTIONS/INTERVENTIONSRATIONALEIndependent Weigh client routinely. Encourage client to Sudden, significant weight gain (e.g., more thanmonitor weight at home between visits.3.3 lb (1.5 kg)/month in the second trimester or morethan 1 lb (0.5 kg)/wk in the third trimester) reflectsfluid retention. Fluid moves from the vascular tointerstitial space, resulting in edema.Distinguish between physiological and pathological The presence of pitting edema (mild, 1+ to 2+;severe,edema of pregnancy. Monitor location and 3+ to 4+) of face, hands, legs, sacral area, or abdo-degree of pitting.minal wall, or edema that does not disappear after 12hr of bedrest is significant. Note: Significant edemamay actually be present in nonpre-eclamptic clientsand absent in clients with mild or moderated PIH.  Note signs of progressive or excessive edema Edema and intravascular fibrin deposition (in(i.e., epigastric/RUQ pain, cerebral symptoms, HELLP syndrome) within the encapsulated livernausea, vomiting). Assess for possible eclampsia.are manifested by RUQ pain; dyspnea, indicating(Refer to ND: Injury, risk for maternal.)pulmonary involvement; cerebral edema, possiblyleading to seizures; and nausea and vomiting,indicating GI edema.Note changes in Hct/Hb levels.Identifies degree of hemoconcentration caused byfluid shift. If Hct is less than 3 times Hb level,hemoconcentration exists.Reassess dietary intake of proteins and calories. Adequate nutrition reduces incidence of prenatalProvide information as needed.hypovolemia and hypoperfusion; inadequateprotein/calories increases the risk of edemaformation and PIH. Intake of 80–100 g of protein maybe required daily to replace losses.Monitor intake and output. Note urine color, and Urine output is a sensitive indicator of circulatorymeasure specific gravity as indicated.blood volume. Oliguria and specific gravity of 1.040indicate severe hypovolemia and kidney involvement.Note: Administration of magnesium sulfate (MgSO4)may cause transient increase in output.Test clean, voided urine for protein each visit, or Aids in determining degree of severity/daily/hourly as appropriate if hospitalized. progression of condition. A 2+ reading suggestsReport readings of 2+, or greater.glomerular edema or spasm. Proteinuria affects fluidshifts from the vascular tree. Note: Urinecontaminated by vaginal secretions may test positivefor protein, or dilution may result in a false-negativeresult. In addition, PIH may be present withoutsignificant proteinuria.Assess lung sounds and respiratory rate/effort.Dyspnea and crackles may indicate pulmonaryedema, which requires immediate treatment.Monitor BP and pulse. (Refer to ND: Cardiac Elevation in BP may occur in response toOutput, decreased.)catecholamines, vasopressin, prostaglandins, and, asrecent findings suggest, decreased levels of prostacyclin.Answer questions and review rationale for Diuretics further increase state of dehydration byavoiding use of diuretics to treat edema.decreasing intravascular volume and placentalperfusion, and they may cause thrombocytopenia,hyperbilirubinemia, or alteration in carbohydratemetabolism in fetus/newborn. Note: May be usefulin treating pulmonary edema. Collaborative Schedule prenatal visit every 1–2 wk if PIH is mild; Necessary to monitor changes more closely for theweekly if severe.well-being of the client and fetus.Review moderate sodium intake of up to 6 g/day. Some sodium intake is necessary because levelsInstruct client to read food labels and avoid foodsbelow 2–4 g/day result in greater dehydration inhigh in sodium (e.g., bacon, luncheon meats, some clients. However, excess sodium mayhot dogs, canned soups, and potato chips).increase edema formation.Refer to dietitian as indicated.Nutritional consult may be beneficial in determiningindividual needs/dietary plan.
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