Classification of Hypertensive Disorders
•
Chronic hypertension -elevated BP prior to pregnancy
or develops prior to 20 weeks (1% affected)
•
Gestational hypertension-BP up (140/90) after 20
wks w/o proteinuria. (May progress to preeclampsia) (5-6%)
•
Preeclampsia (most common)-BP= to or >140/90, after
20 wks w/proteinuria; multisystem disease process
•
Mild or severe
•
Eclampsia- onset of seizures in a pt w/preeclampsia
•
Chronic hypertension w/superimposed preeclampsia:
occurs in 20% of pregnant women
•
12% of all maternal deaths are due to preeclampsia
Classic Signs of Preeclampsia
1. Hypertension – sustained BP of 140/90
2. Proteinuria -usually develops later than edema &
increased BP;
a. 300mg/dl or more of protein/24 hr period or
b. 100mg/dl in 2 random samples 6 hrs apart
3. Generalized edema – due to fluid retention
especially in hands & face
4. Other S/S- headache, drowsiness, mental confusion, visual
changes, upset stomach, decrease in output, brisk DTRs
Risk Factors:
•
First pregnancy, 1st pregnancy for FOB
•
Extreme ages: Age less than 17 years or > 35 yrs
•
Family history of PIH, FOB history of fathering
•
Obesity
•
Chronic renal disease, clotting disorders
•
Diabetes mellitus
•
Multiple gestation
•
Chronic hypertension or preexisting vascular disease
•
African-Americans
Preeclampsia Pathophsiology
• 1st stage-Widespread vasospasm
& hypoperfusion to all organs
including placenta.
• 2nd stage-woman’s response to
abnormal placentation (s/s appear
HTN, proteinuria, & edema due to
hypoperfusion)
Pathophysiology (cont’d)
• Decreased brain perfusion-small cerebral
hemorrhages, & s/s of arterial vasospasm
• Headaches
• Visual disturbances
• Blurred vision
• Hyperactive DTRs
Pathophysiology
Decreased kidney perfusion- Body responds to
hypovolemia by producing more angiotension
II & aldosterone (retain both salt&water).
 Decreased urine output,
 Increased serum Na, BUN, uric acid, &
creatinine.
 Edema
 Excessive wt gain (greater than 2 lbs/wk)
 Leads to pulmonary edema & generalized
edema.
Pathophysiology
Decreased uterine/placental perfusion
–
may result in:
•
Fetal growth restriction (FGR)
•
Abruptio placenta
•
Higher risk for fetal death.
Pathophysiology
• Decreased liver perfusion- leads to impaired
liver function, hepatic edema, & subcapsular
hemorrhage.
• Elevation of liver enzymes
• Epigastric pain
Edema
• Treatment
• Bed rest
• Reducing environmental stimuli
• Administering anticonvulsants
Nursing Actions:
•
Pharmacotherapy
•
Magnesium sulfate IV infusion
•
Apresoline/Hydralazine IV Push
•
Continuous fetal monitoring
•
Bed rest; lateral position
•
Non-stimulating environment
•
Seizure precautions
•
Hourly intake & output, vital signs, DTR’s
•
Daily weights
•
Serum Magnesium levels
DTRs Scale
Assessing DTRs (patellar)
Assessing DTRs
The Patient With Preeclampsia
• Nursing Diagnosis: Altered tissue perfusion
• R/T increased peripheral vascular resistance
• AEB:
**urine output less than 500ml in 24 hrs
**3+ pitting edema of feet
**generalized edema of face and hands
• Goal: Increased tissue perfusion over next 48 hrs
• AEB:
**urine output increased to > 750ml in 24 hrs
**2+ pitting edema or less in feet
**decreased generalized edema of face & hands
The Patient With Preeclampsia
• Nursing Actions:
• Monitor
1.Edema in lower extremities & generalized edema of
face/hands q 4 hrs.
2.Amount of protein in urine.
Increased peripheral resistance causes reduced blood flow to
kidneys. Results in glomerular damage- allows protein to leak
across glomerular membrane.
Loss of protein reduces colloid osmotic pressure & allows fluid
to shift to interstitial spaces causing edema.
3. BP Q1H or as ordered by M.D.
Vasospasm decrease diameter of blood vessels, which results
in endothelial damage & decreased blood flow to all body
organs. Decreased blood flow in renal system can cause
damage to glomerular filtration system, causing a shift in fluid
from intravascular space to interstitial space.
The Patient With Preeclampsia
**The patient’s urine output hourly.
Reduced blood flow to kidney reduces the glomerular filtration,
thereby reducing urine output.
**Monitor lung sounds q 2 hrs.
**Monitor for dyspnea
Decreased colloid oncotic pressure can lead to pulmonary
capillary leak that results in pulmonary edema.
Manage:
**Administer Mag S04 – usually 2 gms/hr IV.
Mag S04 used to control seizures that result from inadequate
blood flow to brain & hyper-irritability caused from reduced
flow.
Mag S04 relaxes smooth muscle & reduces vasoconstriction.
Increases circulation to vital organs; increased circulation to
kidneys leads to diuresis, as interstitial fluid is shifted to
vascular space & excreted.
The Patient With Preeclampsia
**Place foley catheter for urine output measurement.
Most accurate way to assess it.
**Monitor amount of fluids patient receiving hourly.
Usually patient on fluid restriction – 100ml/hr.
Pulmonary edema can result from Preeclampsia.
Evaluation: The goal of increased tissue perfusion was met in
48 hours AEB:
**Urine output has increased to 1000ml in 24 hr period.
**Pitting edema decreased from 3+ to 2+ in lower
extremities.
**No generalized edema of face & only a sm amt in hands.
Chronic Hypertension
• Women with chronic hypertension are at
increased risk for preeclampsia.
• Should be monitored closely for proteinuria &
edema.
• Antihypertensive medication should be
initiated if blood pressure is higher than
160/110 mg Hg.
• No more treratment of 140/90 due to
masking of S/S.
• Aldomet (drug of choice)-promotes circulation
toElsevier
placenta
items and derived items © 2013, 2009, 2005 by Saunders, an imprint of
20
Elsevier Inc.
Hemolysis, Elevated Liver Enzymes,
& Low Platelets (HELLP)
• Hemolysis, elevated liver enzymes, and low
platelets (HELLP) syndrome
• Hemolysis occurs as result of fragmentation &
distortion of erythrocytes during passage through
damaged blood vessels.
• Liver enzyme levels increase when hepatic blood
flow is obstructed by fibrin deposits.
• Low platelet levels are caused by vascular
damage resulting from vasospasm.
Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of
Elsevier Inc.
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Safe Antihypertensive Meds
• Apresoline (Hydralazine) for BP of
>160/110
• Aldomet (drug of choice) for chronic
HTN
• Nifedipine (Procardia) or Labetatol