Pregnancy Induced HTN(Preeclampsia)
Diagnosis: Urinalysis, Pap smearabnormal cervix, HbA1C,
Proteinuria+,Znormal platelet
Labs: CBC, urine specific gravity-1.005,
O blood typing, glucose 72 H&H WBC,
1hr glucose test, HSV, Low Platelet, liver
enzymes, negative ketone
Patient Presentation
A, P.W. 38year Old Female Gravida2Para0 admitted
4/8/21 presented to the L& D for Scheduled
Induction. GA: 37 wk2, on full code, weight 233Ib,
BMI at 36.61. She has sulfa antibiotics as allergies.
Her PMH include GHTN, HSV, Low lying Placenta,
anemia, abnormal pap smear, Past SurgicalTherapeutic abortion, umbilical hernia repair and
wisdom tooth extraction.
Health Assessment:
Neuro: A&Ox4, visual impairment,
headache, CNS irritability. Cardio: S1, S2,
no murmurs, capillary refill 2+ HTN with
elevated BP 163/92 after 20th week of
pregnancy, Paulse 87, +2 dependent edema,
and facial puffiness s, hands, and leg
swelling.no chest tightness, noted fatigue no
nausea and vomiting, fetal well-being, with
normal FHR fetus is active. Respiratory:
Chest symmetry, lungs sound clear
bilaterally, RR16, O2 98% FHR manually or
electronically checked.GI /GU: Epigastric
pain subtle, urine oliguria and straw color,
Proteinuria in urine and liver enzymes
leading to causes organ damage and
potential for seizure, Skin: weight gain,
peripheral edema, edema of hands and feet,
deep tendon reflexes 2+, ankle clonus subtle.
reproductary: breast engorged with striae,
perinium at 2cm. IV patent at 2o gauge
# 1Nursing Diagnosis
Risk for Maternal Injury r/t eclamptic seizure as
evidenced by BP of 163/ 92 and diagnosis of
preeclampsia on BP and p/c ratio before 36th wks.
Intervention: Put Patient on bed rest and seizure
precautions- by providing bed alarms and side rails.
-seizure precautions-reduced stimulation-bed restdim light Raise head of bed, Monitor Level of
consciousness, Monitor headache or irritation
caused by cerebral ischemia. Monitor Patient BP to
reduce to 120/70.Delivery of Fetus only cure for
Patient condition. Outcome: Patient will be free of
irritation, visual disturbances, or headache/changes
in mental status during shift. Implementation of
safety measures and prevent ion of injury during
shift. Patient’s BP to normalize to 120/70 and test
of Protein during shift. Evaluation: Patient was free
from signs of irritation r/t cerebral ischemia and
Patient did not experience visual disturbances
during shift. Patient was alert and oriented for the
shift, Patient was safe from injury during shift with
BP at 120/70 mmHg to reduce incidence of stroke.
Protein Test was negative on her urine for the shift.
Pathophysiology: The progressive pregnancy
induced hypertension promotes,
vasoconstriction and vasospasms of blood
vessels particularly epithelial cells of the
arteries which constricts and contribute to
hypoxia of maternal organ tissues -brain,
kidney, liver heart. The reduced uterine blood
flow reduces placental perfusion, hypoxia
resulting in reduced gas exchange and
impaired nutritional functioning of the
placenta. Maternal syndrome results in
maternal complication of HELLP syndrome
affecting the blood and liver.
Risk Factors: First Pregnancy,
Maternal age, African decent, obesity
at BMI, Family Hx of HTN, low
socio-economic Background,
underlying Disease,
#2 Nursing Diagnosis: Altered Tissue
Perfusion r/t interruption of blood flowprogressive vasospasm of spiral arteries
evidenced by changes in fetal
activities/heart rate secondary to
preeclampsia based on proteinuria before
36 weeks. Intervention:1. evaluate fetal
growth, monitor t fetal activity2. assess
fetal response to BPP criteria3 check fetal
FHR manually /electronically4. Give
betamethasone IM 7 days before delivery
for fetal lung development 5. assess
maternal plasma volume Outcome:
Patient demonstrate normal CNS reactivity
on NST during shift, Patient is free of late
decelerations during shift, Patient
monitored for progressive full term during
shift. Evaluation: Patient did not exhibit
late decelerations during shift. Patient has
no decrease in FHR on contraction as she
progresses on labor during shift.
Key: Red-Assessment
Blue- medication
Brown-Patho
Tx-Green
Medication: Antihypertensive to reduce
BP, baby Aspirin- reduces the risk of
heart attack due to blocked arteries and
stroke. Fexofenadine HCL is an
antihistamine, iron for energy, Vit C,65125mg, Valacyclovir (Valtrex)500mg to
Tx HSV, Betamethasone given for Fetal
lung development. Lactated Ringers
1,000ml bolus, infusion at 100mls/hr
Stadol PRN for L&D.
#3 Nursing Diagnosis: Risk for Preterm
delivery r/t to best /only cure of
preeclampsia. Intervention:1 NST
baseline 140,2. Fetal Assessment place
Patient on continuous FHR monitor.3.
Administer Betamethasone for lung
development .4 Assess fetal movement 4.
Have mother do fetal kick.5 Introduction of
Epidural by 5cm dilation as per client
request to manage pain at labor. Outcome:
Fetus will display moderate variability
during shift. Fetal will not have late
decelerations or abnormal heart rate
during shift. Contractions progress in
frequency and intensity before end of shift
Evaluation: Fetus displayed moderate
variability during shift, Fetal did not have
late decelerations nor abnormal heart rate
during shift. Fetal monitored for
progressive growth & term delivery during
shift.
Treatment: 1. Bed rest.2. Neuro checks,
Vitals q4Reduce salt intake.3Give antihypertensive medications4. Provide
Magnesium therapy to prevent seizures
and limit complications Have Calcium
Gluconate at hand,.5. Induction for
preterm delivery of baby by 37th weeks
the major solution to preeclampsia.
Cytotec, Oxytocin, LR, Methylerg onovine, Hem abate, Zofran, Cefazolin,
and other scheduled medications for
Labor and postpartum administration.
Patient Education: Teach Patient
understanding of disease process and
appropriate treatment plan. Teach
Patient about lifestyle/behavior
changes as indicated. Teach
importance of patient promptly
reporting signs/symptoms of CNS
involvement
Reference
NANDA International & Herdman, T. H. (2012). NANDA International Nursing diagnoses: Definitions and
classification 2012-14. Wiley-Blackwell
Ricci, S., Kyle, T., & Carman, S. (2009). Nursing Management During the Postpartum Period. In Maternity
and pediatric nursing (4th ed.). Lippincott Williams & Wilkins
Roberts, J. M., & Gammill, H. S. (2005). Preeclampsia. Hypertension, 46(6), 1243-1249.
https://doi.org/10.1161/01.hyp.0000188408.49896.c5