Pregnancy Induced Hypertension - Nursing Case Study

by - June 24, 2020

DESCRIPTION:
Hypertensive disorders in pregnancy includes gestational hypertension, pre – eclampsia, and eclampsia. Gestational hypertension or Pregnancy Induced Hypertension (PIH) is a condition in which vasospasm occurs in both small and large arteries during pregnancy. Pre – eclampsia is an increased in blood pressure and proteinuria which is caused by producing a toxin as a response to the foreign protein of the growing fetus. On the other hand, eclampsia is the most severe classification of pregnancy related hypertensive disorders because a woman already had a cerebral edema that is so acute a grand mal seizure or coma has occurred.
FOCUS ASSESSMENT (SIGNS AND SYMPTOMS):
A woman who have a gestational hypertension usually have a 140/90 mmHg or systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above pregnancy level, there is no proteinuria or edema, and blood pressure returns to normal after birth. If a woman has a pre – eclampsia without severe features her blood pressure is 140/90 mmHg or systolic pressure elevated 30 mmHg or diastolic pressure elevated 15 mmHg above pregnancy level, proteinuria of 1+ and 2+ on a random sample, weight gain over 2lb per week in second trimester and 1lb per week in third trimester, and mild edema on the upper extremities or face. When a woman has a pre – eclampsia with severe features then her blood pressure will be 160/110 mmHg, proteinuria 3+ to 4+ on a random sample, oliguria, cerebral or visual disturbances, pulmonary or cardiac involvement, extensive peripheral edema, hepatic dysfunction, thrombocytopenia, and epigastric pain. And when a woman is experiencing eclampsia she will have a seizure or coma accompanied by signs and symptoms of pre – eclampsia.

DIAGNOSTIC AND LABORATORY TEST:
The woman in this condition might need to have urinalysis test in order to determine the presence of protein in the urine and classify in what kind of gestational hypertensive she is experiencing. If a woman have a pre – eclampsia with severe features she needs to obtain her blood studies such as complete blood count, platelet count, liver function, blood urea nitrogen, and creatine and fibrin degradation products to assess renal and liver function and development of DIC, which often accompanies sever vasospasm, plasma estriol levels, and electrolyte level. A blood sample for type and cross – match will be obtained since they are high risk for premature separation of placenta that could result to hemorrhage. Daily hematocrit levels will be get in order to monitor the blood concentration. Ultrasound is needed to perform in order to determine if the baby have a reduced fetal breathing movements.

RISK FACTORS:
The risk factors that are associated with these condition are women of color, multiple pregnancy, primiparas younger than 20 years or older than 40 years old, women from low socioeconomic backgrounds, have five or more pregnancies, polyhydramnios, those who have an underlying heart disease such as diabetes with vessel or renal involvement, and essential hypertension.

PATHOPHYSIOLOGY:
NURSING DIAGNOSES BY PRIORITY:
Ineffective tissue perfusion related to vasoconstriction of the blood levels
Decreased cardiac output related to decreased venous return
Fluid volume excess related to compromised regulatory mechanism as evidenced by edema
Social isolation related to prescribed bed rest
Risk for fetal injury related to reduced placental perfusion secondary to vasospasm

NURSING CARE PLAN:
Ineffective tissue perfusion related to vasoconstriction of the blood levels
Decreased cardiac output related to decreased venous return
Fluid volume excess related to compromised regulatory mechanism as evidenced by edema
NURSING MANAGEMENT / INTERVENTION:
A woman with pre – eclampsia without severe features prior to full term can manage the condition in their home. Having a monitoring on antiplatelet therapy is needed because there is a tendency for the platelets to cluster along the arterial walls. So it important to make sure that the women is not taking lightly the low – dose aspirin that is being prescribed to her because if this was use excessively she might have a maternal bleeding at the time of birth. Encourage the mother to have a bed rest because it can increased the evacuation of the sodium and encourage diuresis of edema fluid. Make her practice the lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension. Advise the mother to have her usual pregnancy nutrition and assess if there is someone that will help her to prepare her food to know if either her bed rest or nutrition may be compromised. Provide emotional support to the mother and ask her questions that will help you to analyze the problems that may arise so you give a suggestions on how to solve her problem.

If a woman with pre – eclampsia with severe features is in her pregnancy that is less than 37 weeks, certain interventions will need to do in order to alleviate the severity of the symptoms. A woman in these condition are usually admitted in the hospital so it is better to bed rest although going to the bathroom is not contraindicated. However, the nurse should explain to her that there will be a visitor restrictions because loud noise can trigger a seizure that usually initiates eclampsia. The woman’s room should be dark but not to the point that the caregivers will need to use the flashlight to make an assessment because shining a flashlight beam is kind of sudden stimulation that is needed to be avoided. Make her to express her feelings so that she will feel light after releasing what she needs to release. Frequently take her blood pressure to detect any increase that might worsen her condition. There is a need to obtain daily weight on the same time of the day with same amount of clothes in order to evaluate the fluid retention. There is a need to monitor the fetal well – being by using a single Doppler for auscultation and nonstress test or biophysical profile to assess the uteroplacental sufficiency. Give the mother a support in her nutrition so that she will be able to follow a nutritious intake which is a diet moderate to high in protein and moderate in sodium to compensate the protein that she is losing while she is urinating. While administering hydralazine, labetalol, or nifedipine the nurse need to assess the pulse and blood pressure before and after the administration. Urine output should be monitored closely to ensure adequate elimination. If there is a continuous intravenous infusion being used, always asked the mother what is her name and address, assess her ankle clonus which should be minimal and a presence of a deep tendon reflexes by the patellar. If there is an epidural block given, assessing the biceps or triceps reflexes should be done. If the mother is in magnesium therapy, there is a need to monitor the fetal heart rate because it may show loss of variability of the heartbeat and to observe the other signs of fetal effects such as late deceleration with labor contractions.

            If a woman reached the eclampsia, wherein she is experiencing tonic – clonic seizures, it is a must to maintain a patent airway. To prevent aspiration, turn her onto her side to allow secretions to drain from her mouth. Assess the oxygen saturation by using a pulse oximeter. Applying an external fetal hear monitor if one is not ready in place to assess the fetal heart tone. Usually, seizure is the beginning of labor so it is a must to assess the uterine contractions and checking of vaginal bleeding every 15 minutes to detect placental separation. And give her nothing to eat or drink.

MEDICAL / SURGICAL MANAGEMENT:
A woman with pre – eclampsia without severe features prior to full term will need to take a mild antiplatelet agent like a low – dose aspirin will be prescribed in order to prevent or delay the development of pre – eclampsia.

A woman with pre – eclampsia with severe features will need an indwelling urinary catheter to be inserted in order to allow for an accurate recording of output and compare it with the intake. If it was noted that the there is a fetal bradycardia during the monitoring of fetal well – being, then there is a need to administer oxygen to the mother to maintain adequate fetal oxygenation. An intravenous fluid line will be initiated to serve as an emergency route for drug administration and fluids to reduce hemoconcentration and hypovolemia. Hydralazine, labetalol, or nifedipine may be prescribed in order to reduce hypertension. Magnesium sulfate may be administered too because it can reduce edema and lessens the possibility of seizures. A solution of 10mL of 10% calcium gluconate solution or 1g should be kept ready nearby for immediate intravenous administration so she will not develop any signs and symptoms that indicate magnesium toxicity.

            If a woman reached is having a tonic – clonic seizures, she will be administered magnesium sulfate and diazepam intravenously as an emergency measures. Administering oxygen mask by face is needed to protect fetal oxygenation.

            If the fetus reached thee viability stage, there is a need to choose what kind of delivery method should be done after 12 to 4 hours of the seizure attack. The preferred birth is through vaginal delivery with minimum of anesthesia. But if the labor does not begin, rupture of membranes or induction of labor with intravenous oxytocin may be instituted. But if it still ineffective and the fetus appears to be in danger, cesarean birth becomes the birth method of choice.

REFERENCES:

  • Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. Philadelphia, Pennsylvania: F.A. DAVIS COMPANY
  • Potter et. Al (2017). Fundamentals of Nursing (9th ed.). Singapore: Elsevier Inc.

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