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INTRODUCTION
Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. It accounts
to 28.4% of maternal morbidity and mortality in the Philippines according to DOH (as of Feb. 2008).
The condition — sometimes referred to as pregnancy-induced hypertension — is defined by high
blood pressure and excess protein in the urine after 20 weeks of pregnancy.
Often, preeclampsia causes only modest increases in blood pressure. Left untreated,
however, preeclampsia can lead to serious — even fatal — complications for both mother and
baby.
The only cure for preeclampsia is delivery of the baby. If preeclampsia develops near the end of
your pregnancy, delivery is the obvious solution. If you're diagnosed with preeclampsia earlier in
your pregnancy, you and your doctor face the delicate task of prolonging your pregnancy to allow
your baby more time to mature, without putting you or your baby at risk of serious complications.
The signs of preeclampsia are elevated blood pressure (hypertension) and the presence of
excess protein in your urine (proteinuria) after 20 weeks of pregnancy. The excess protein is related
to problems with your kidneys. Your doctor may identify these signs of preeclampsia at one of your
regular prenatal visits.
Other signs and symptoms of preeclampsia — which can develop gradually or strike
suddenly, often in the last few weeks of pregnancy — may include:
• Severe headaches
• Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
• Upper abdominal pain, usually under the ribs on the right side
• Nausea or vomiting
• Dizziness
• Decreased urine output
• Sudden weight gain, typically more than 2 pounds a week
Swelling (edema), particularly in the face and hands, often accompanies preeclampsia as
well. Swelling isn't considered a reliable sign of preeclampsia, however, because it also occurs in
many normal pregnancies.
CAUSES
Preeclampsia used to be called toxemia because it was thought to be caused by a toxin in a
pregnant woman's bloodstream. Although this theory has been debunked, researchers have yet to
determine what causes preeclampsia. Possible causes may include:
• Insufficient blood flow to the uterus
• Damage to the blood vessels
• A problem with the immune system
RISK FACTORS
Preeclampsia develops only during pregnancy. Risk factors include:
• History of preeclampsia. A personal or family history of preeclampsia increases your risk of
developing the condition.
• First pregnancy. The risk of developing preeclampsia is highest during your first pregnancy or
your first pregnancy with a new partner.
• Age. The risk of preeclampsia is higher for pregnant women who are older than age 35.
• Obesity. The risk of preeclampsia is higher if you're obese.
• Multiple pregnancy. Preeclampsia is more common in women who are carrying twins, triplets or
other multiples.
• Gestational diabetes. Women who develop gestational diabetes have a higher risk of
developing preeclampsia as the pregnancy progresses.
• History of certain conditions. Having certain conditions before you become pregnant — such as
chronic high blood pressure, diabetes, kidney disease or lupus — increases the risk of
preeclampsia.
OBJECTIVES
GENERAL
1. To enhance skills in handling patient with pre-eclampsia.
2. To have an additional knowledge and information about pre-eclampsia.
3. To perform appropriate management by utilizing the nursing process.
SPECIFIC
1. To define what is pre-eclampsia.
2. To discuss the anatomy and physiology of pre-eclampsia.
3. To know the etiology, risk factors and its complication.
4. To plan and execute appropriate nursing interventions.
5. To evaluate the effectiveness of discharge planning.
6. To create awareness about pre-eclampsia to the client and to the family members.
DEMOGRAPHIC
A. PERSONAL DATA
Name:XY
Age:31
Sex: FEMALE
Date of birth: NOVEMBER 1, 1977
Place of birth: MONTALBAN, RIZAL
Civil status: MARRIED
Religion: CATHOLIC
Nationality: FILIPINO
ADMISSION
Date: NOVEMBER 22, 2008
Room: 3016-F2
Diagnosis: G5P4, 32 WEEKS AOG
Attending physician:DR. ALMA F. FONTE-RAMIREZ
ADMITTING HISTORY
XY was 8th month pregnant when she was rushed to East Avenue Hospital in Quezon City
on the November 22, 2008. Upon admission, she had pain, headache, bloodshow but no signs of
seizure. She was conscious and coherent, not in cardio respiratory distress. With Bp of 190/110,
afebrile, with retractions with clear breath sounds and positive bipedal edema. She had a previous
consultation in Infirmary hospital in Montalban. She had a normal spontaneous delivery last
November 22, 2008, she delivered twin boys.
Social History
XY, 31 years old, who resides with her husband in Montalban Rizal. According to her though
their income is still insufficient for them, she is still happy and contented. With regard to their
community, she said that the environment is peaceful and their neighbors are very accommodating.
According to her that part of her leisure is chatting with her neighbors.
GORDON’S PATTERN
Person Approach
PSYCHOLOGICAL
• Self Perception Pattern
XY is a very jolly individual. She seems very satisfied to the life that she has. Just being
with her partner she feels complete and secure. She is very appreciative even on the simple things
being done to her, especially with her husband. Though they’re having some problems on their
finances she maintains the composure of being fine and happy. Her family, especially her twins is
her inspiration right now. She entrusts everything on the Lord. She sees problems as test of
courage and faith to Him.
ELIMINATION
She has a regular bowel movement and she micturates regularly. In regards to the amount
and character, everything is regular and normal. No discomfort or any pain being felt. She is clean
and seems to practice good hygiene routine.
SAFE ENVIRONMENT
The patient has no allergies on any medications and/ foods. In regards with her skin
integrity there are no evident lesions. It appears to be some how smooth.
OXYGENATION
XY has no difficulty in breathing.
NUTRITION
XY cooks their food but there would be times that she buys outside. Her favorite foods
would be anything with fish and vegetables. There is nothing in particular that she dislikes. She eats
three times a day with snacks in the afternoon. She has a big appetite. There are times that quantity
and quality of food is being sacrificed because of tight budgeting.
PHYSICAL ASSESSMENT
GENERAL ASSESMENT:
VITAL SIGNS (11/23/08):
BP 180/100
PR 83
RR 22
TEMP 36.8 C
HEIGHT 5’1”
WEIGHT 140 lbs
Patient conscious and coherent, able to understand and respond to questions appropriately
and reasonably quickly. No signs of respiratory distress. Skin appears to be dry with some visible
scars at both upper and lower extremities. She has a medium built frame, short stature with
apparent globular abdomen. She sat comfortably with a slouched posture, no involuntary
movements shown. Dressed in a simple red/ black duster, appear to be neat. However, fingers on
both hands and feet are noticeably unclean. No odor of body and breath noted. She covers her
mouth the whole time of the conversation, conscious of her uneven lower teeth and the absence of
upper incisors. Manner of speaking is quite unclear. She also has asymmetrical facial features, due
to her Bell’s Palsy/ facial hemiparesis.
SPECIFIC ASSESMENT:
PARTS TECHNIQUE NORMAL ACTUAL FINDINGS INTERPRETATION
FINDINGS
HEAD AND FACE
Skull Inspection Proportional to body Proportional to the Normal Findings
size patients size
Palpation Smooth, uniform Absence of nodules or Normal Findings
consistency, masses
absence of nodules
or masses
Scalp Inspection Smooth contour Smooth contour Normal Findings
Palpation No lesions Absence in lesions, Normal Findings
No mass mass, and area of
No area of tenderness
tenderness
Hair Inspection Evenly distributed Evenly distributed with Normal
Condition No gray hair a number of gray hair Gray hair is influenced by
decreased in melanocytes
due to aging process
No Seborrhea, No seborrhea, Normal Findings
dermatitis dermatitis
Smooth and shiny Smooth and shiny Normal Findings
Face Inspection Symmetrical facial Asymmetrical Bell’s Palsy (facial
feature hemiparesis due to
oedema of 7th /facial
cranial nerve)
- occurred when she was
5y/o, no continuous
treatment / therapy done
EYES
Eye Inspection Skin Intact; Skin intact Normal Findings
Condition no discharge; No discharge
no discoloration No discoloration
Lids close Lids close
symmetrically symmetrically
MOUTH
Lips Inspection Symmetry of Asymmetrical of Bell’s Palsy (facial
contour contour hemiparesis due to
oedema of 7th /facial
cranial nerve)
- occurred when she
was 5y/o, no continuous
treatment / therapy done
Tongue Inspection Pinkish to reddish in Pinkish to reddish in Normal Findings
color color
With frenulum at the With frenulum at the Normal Findings
center center
Teeth Inspection No dental caries With dental caries Dental carries, plaque
No plaque or With plaque and and cavities due to poor
cavities cavities dental hygiene.
Gums with no No lesions Normal Findings
lesions
32 permanent teeth - 28 permanent teeth Poor dental hygiene led
with irregularities in to cavities and decay.
growth
- upper incisors
missing
Absence of bleeding Absence of bleeding Normal Findings
Neck Inspection Proportional to the Proportional to the size Normal Findings
size of the body of the body
Palapation No palpable lymph No palpable lymph Normal Findings
nodes nodes
CHEST
Inspection Respiratory rate of RR – 22 bpm The RR was taken on a
16-20 breaths per sitting position, there was
min shortness of breath due
to mechanical
impingement on the
diaphragm.
No mass and are Absence of mass Normal Findings
of tenderness and are of
tenderness
Palpation Vesicular and Diminish breath Shallow breath may
bronchovesicular sounds produces diminish breath
breath sounds sounds due to pleural
effusion
Auscultation Absence of Absence of Normal Findings
adventitious and adventitious and
bronchial breath bronchial breath
sounds sounds
Lungs Auscultation Symmetric Symmetric contour, Normal Findings
contour, no no lesions, scars
lesions, scars and and rashes
rashes
Abdomen Inspection Unblemished skin Unblemished skin Normal Findings
Uniform color Uniform color
Flat, Distended (bulging Distention is present
rounded(convex), flanks); abdominal because of portal
or girth of 93.98cm hypertension resulting to
scaphoid(concave) accumulation of fluid in
the peritoneal cavity
thus, the weight of fluid
pushes against the side
walls.
Auscultation Audible bowel Absence of bowel Normal Findings
sounds sounds
Absence of arterial Absence of arterial
bruit bruits
Absence of friction Absence of friction
rub rub
Percussion Tympany over the Tympanitic over the The tympany over the
stomach and gas umbilicus and dull umbilicus occurs in
filled bowels; over the lateral ascites because bowel
dullness, abdomen and flank floats to the top of the
especially over the areas. abdominal fluid at the
liver and spleen, or level of the fluid
full bladder meniscus.
Palpation No tenderness; tenderness noted; There is discomfort upon
consistent tension increase tension palpation because of
abdominal distention.
UPPER EXTREMITIES
Arms and Inspection Symmetric, absence of Symmetric, absence of Normal findings
Hands lesions, mass and mass and area of
area of tenderness tenderness
- presence of scars noted
Palpation Warm moist skin, Dry and scaly skin, Presence of dry
pules palpable Palpable bilateral pulses and scaly skin is
bilateral 2+ due to the
restriction of
fluid intake and
excessive fluid
loss.
Fingers Inspection Complete number of Five fingers on both hands Normal findings
digits
Nails Inspection Shiny, smooth, convex Pallor, smooth, convex Pallor is due to
curvature poor circulation
Nails are unclean Unclean nails
due to poor
body hygiene
Palpation of Capillary Refill time Capillary refill time is about Slight delay in
Capillary less than 3 seconds 4 seconds capillary refill
Refill Test time is due to
circulatory
impairment
LOWER EXTREMITIES
Skin Inspection Absence of coldness Absence of coldness and Normal findings
and clamminess clamminess
No lesions No lesions
No bleeding No bleeding
Palpation No mass Absence of masses Normal findings
Legs Inspection Complete legs (left Both two legs are complete Normal findings
and right leg) (left and right)
No mass and lesions Bipedal edema increased
Weak popliteal pulse noted plasma volume
and sodium
retention
Pinkish in color Pallor Pallor is due to
poor circulation
Nails Inspection Hard Hard Normal findings
Complete toe nails Complete toe nails Normal findings
Nails are unclean Unclean nails
due to poor
body hygiene
Palpation in Capillary Refill time Capillary refill time is about Slight delay in
capillary less than 3 seconds 4 seconds capillary refill
refill time time is due to
circulatory
impairment
DIAGNOSTIC EXAMINATION
1. CBC count
• Microangiopathic hemolytic anemia (HELLP)
• Thrombocytopenia / Platelet count less than 100,000
• Hemoconcentration may occur in severe preeclampsia.
2. Liver function tests: Transaminase levels are elevated from hepatocellular injury and in HELLP
syndrome.
3. Serum creatinine level: levels are elevated due to decreased intravascular volume and
decreased glomerular filtration rate (GFR).
4. Urinalysis
• Proteinuria is one of the diagnostic criteria for preeclampsia.
• Proteinuria is defined as greater than or equal to 1+ protein on urine dipstick.
Alternatively, protein concentration of 300 mg/L or more on urine dipstick.
• Proteinuria is also defined as 300 mg or more of protein in a 24-hour urine sample.
5. Elevated PT, aPTT, fibrin split products, and decreased fibrinogen
6. Disseminated intravascular coagulopathy testing
7. Uric acid
• Uric acid levels are increased in preeclampsia.
• Serial levels may be useful to indicate disease progression.
8. Increase in blood pressure
CLINICAL MICROSCOPY
II. Microscopic
A. RBC( Red 1 - 3/hpf 0-2/hpf Above the Slight increase is
Blood Cell) normal suggestive of bleeding but
range assumption is to be renal
in origin.
B. WBC(White 15 – 20/hpf 0-5/hpf Above the Conclusive of renal
Blood Cell) normal disease.
range
C. Epithelial Cells Many Moderate Abnormal Seen in cases of acute
tubular necrosis
D. Mucus Threads Moderate Few present Abnormal Suggestive of advanced
renal disease
E. Bacteria Moderate Few present Abnormal Urinary tract infection is
present.
F. Crystals Few A, Urates - Few Normal
G. Cost none none Normal
III. Biochemical
A. Urobilinogen --- 1.20
B. Nitrate --- Negative
C. Blood --- Negative
D. Bilirubin --- Negative
E. Ketone --- Negative
F. Leukocyte --- Negative
CLINICAL CHEMISTRY
ANATOMY
CARDIOVASCULAR SYSTEM
The vital role of the cardiovascular system in maintaining homeostasis depends on the continuous
and controlled movement of blood through the thousands of miles of capillaries that permeate every
tissue and reach every cell in the body. It is in the microscopic
capillaries that blood performs its ultimate transport function.
Nutrients and other essential materials pass from capillary blood
into fluids surrounding the cells as waste products are removed.
Heart
It is located between the lungs in the middle of the chest, behind and slightly to the left of the
breastbone (sternum). A double-layered membrane called the pericardium surrounds the heart like
a sac. The outer layer of the pericardium surrounds the roots of the heart's major blood vessels and
is attached by ligaments to your spinal column, diaphragm, and other parts of your body. The inner
layer of the pericardium is attached to the heart muscle. A coating of fluid separates the two layers
of membrane, letting the heart move as it beats, yet still be attached to your body.
Blood
Blood Vessels
Blood vessels are the channels or conduits through which blood is distributed to body tissues. The
vessels make up two closed systems of tubes that begin and end at the heart. One system, the
pulmonary vessels, transports blood from the right ventricle to the lungs and back to the left atrium.
The other system, the systemic vessels, carries blood from the left ventricle to the tissues in all
parts of the body and then returns the blood to the right atrium. Based on their structure and
function, blood vessels are classified as arteries, capillaries, or veins.
a. Arteries
Arteries carry blood away from the heart. Pulmonary arteries
transport blood that has low oxygen content from the right ventricle
to the lungs. Systemic arteries transport oxygenated blood from the
left ventricle to the body tissues. Blood is pumped from the
ventricles into large elastic arteries that branch repeatedly into
smaller and smaller arteries until the branching results in
microscopic arteries called arterioles. The arterioles play a key role
in regulating blood flow into the tissue capillaries. About 10 percent of the total blood volume is in
the systemic arterial system at any given time.
The wall of an artery consists of three layers. The innermost layer, the tunica intima (also called
tunica interna), is simple squamous epithelium surrounded by a connective tissue basement
membrane with elastic fibers. The middle layer, the tunica media, is primarily smooth muscle and is
usually the thickest layer. It not only provides support for the vessel but also changes vessel
diameter to regulate blood flow and blood pressure. The outermost layer, which attaches the vessel
to the surrounding tissue, is the tunica externa or tunica adventitia. This layer is connective tissue
with varying amounts of elastic and collagenous fibers. The connective tissue in this layer is quite
dense where it is adjacent to the tunic media, but it changes to loose connective tissue near the
periphery of the vessel.
b. Capillaries
Capillaries, the smallest and most numerous of the blood
vessels, form the connection between the vessels that
carry blood away from the heart (arteries) and the vessels
that return blood to the heart (veins). The primary function
of capillaries is the exchange of materials between the
blood and tissue cells. Smooth muscle cells in the
arterioles where they branch to form capillaries regulate
blood flow from the arterioles into the capillaries.
c. Veins
Veins carry blood toward the heart. After blood passes
through the capillaries, it enters the smallest veins, called
venules. From the venules, it flows into progressively
larger and larger veins until it reaches the heart. In the
pulmonary circuit, the pulmonary veins transport blood
from the lungs to the left atrium of the heart. This blood
has a high oxygen content because it has just been
oxygenated in the lungs. Systemic veins transport blood
from the body tissue to the right atrium of the heart. This
blood has a reduced oxygen content because the oxygen
has been used for metabolic activities in the tissue cells.
The walls of veins have the same three layers as the
arteries. Although all the layers are present, there is less
smooth muscle and connective tissue. This makes the
walls of veins thinner than those of arteries, which is
related to the fact that blood in the veins has less pressure
than in the arteries. Because the walls of the veins are
thinner and less rigid than arteries, veins can hold more
blood.
Blood Flow
Blood flow refers to the movement of blood through the vessels from arteries to the capillaries and
then into the veins. Pressure is a measure of the force that the blood exerts against the vessel walls
as it moves the blood through the vessels. Like all fluids, blood flows from a high pressure area to a
region with lower pressure. Blood flows in the same direction as the decreasing pressure gradient:
arteries to capillaries to veins.
The rate, or velocity, of blood flow varies inversely with the total cross-sectional area of the blood
vessels. As the total cross-sectional area of the vessels increases, the velocity of flow decreases.
Blood flow is slowest in the capillaries, which allows time for exchange of gases and nutrients.
Resistance is a force that opposes the flow of a fluid. In blood vessels, most of the resistance is due
to vessel diameter. As vessel diameter decreases, the resistance increases and blood flow
decreases.
Very little pressure remains by the time blood leaves the capillaries and enters the venules. Blood
flow through the veins is not the direct result of ventricular contraction. Instead, venous return
depends on skeletal muscle action, respiratory movements, and constriction of smooth muscle in
venous walls.
Pulse refers to the rhythmic expansion of an artery that is caused by ejection of blood from the
ventricle. It can be felt where an artery is close to the surface and rests on something firm.
In common usage, the term blood pressure refers to arterial blood pressure, the pressure in the
aorta and its branches. Systolic pressure is due to ventricular contraction. Diastolic pressure occurs
during cardiac relaxation. Pulse pressure is the difference between systolic pressure and diastolic
pressure. Blood pressure is measured with a sphygmomanometer and is recorded as the systolic
pressure over the diastolic pressure. Four major factors interact to affect blood pressure: cardiac
output, blood volume, peripheral resistance, and viscosity. When these factors increase, blood
pressure also increases.
The blood vessels of the body are functionally divided into two distinctive circuits: pulmonary circuit
and systemic circuit. The pump for the pulmonary circuit, which circulates blood through the lungs,
is the right ventricle. The left ventricle is the pump for
the systemic circuit, which provides the blood supply
for the tissue cells of the body.
a. Pulmonary Circuit
Pulmonary circulation transports oxygen-poor blood
from the right ventricle to the lungs where blood picks
up a new blood supply. Then it returns the oxygen-
rich blood to the left atrium.
b. Systemic Circuit
The systemic circulation provides the functional blood
supply to all body tissue. It carries oxygen and
nutrients to the cells and picks up carbon dioxide and
waste products. Systemic circulation carries
oxygenated blood from the left ventricle, through the
arteries, to the capillaries in the tissues of the body.
From the tissue capillaries, the deoxygenated blood returns through a system of veins to the right
atrium of the heart.
LIVER
The liver is an organ present in vertebrates and some other animals. It plays a major role in
metabolism and has a number of functions in the body, including glycogen storage, decomposition
of red blood cells, plasma protein synthesis, and detoxification. This organ also is the largest gland
in the human body. It lies below the diaphragm in the thoracic region of the abdomen. It produces
bile, an alkaline compound which aids in digestion, via the emulsification of lipids. It also performs
and regulates a wide variety of high-volume biochemical reactions requiring very specialized
tissues.
KIDNEY
The kidneys are organs that filter wastes (such as urea) from the blood and excrete them, along
with water, as urine. In humans, the kidneys are located in the posterior part of the abdomen. There
is one on each side of the spine; the right kidney sits just below the liver, the left below the
diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the
suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the
right kidney being slightly lower than the left one while the left kidney is located slightly more
medial.
a. Homeostasis
The kidney is one of the major organs involved in whole-body homeostasis. Among its homeostatic
functions are acid-base balance, regulation of electrolyte concentrations, control of blood volume,
and regulation of blood pressure. The kidneys accomplish these homeostatic functions
independently and through coordination with other organs, particularly those of the endocrine
system. The kidney communicates with these organs through hormones secreted into the
bloodstream.
b. Acid-base balance
The kidneys regulate the pH, by eliminating H ions concentration called augmentation mineral ion
concentration, and water composition of the blood.
c. Blood pressure
Sodium ions are controlled in a homeostatic process involving aldosterone which increases sodium
ion reabsorption in the distal convoluted tubules.
When blood pressure becomes low, a proteolytic enzyme called Renin is secreted by cells of the
juxtaglomerular apparatus (part of the distal convoluted tubule) which are sensitive to pressure.
Renin acts on a blood protein, angiotensinogen, converting it to angiotensin I (10 amino acids).
Angiotensin I is then converted by the Angiotensin-converting enzyme (ACE) in the lung capillaries
to Angiotensin II (8 amino acids), which stimulates the secretion of Aldosterone by the adrenal
cortex, which then affects the renal tubules.
Aldosterone stimulates an increase in the reabsorption of sodium ions from the kidney tubules
which causes an increase in the volume of water that is reabsorbed from the tubule. This increase
in water reabsorption increases the volume of blood which ultimately raises the blood pressure.
d. Plasma volume
Any significant rise or drop in plasma osmolality is detected by the hypothalamus, which
communicates directly with the posterior pituitary gland. A rise in osmolality causes the gland to
secrete antidiuretic hormone, resulting in water reabsorption by the kidney and an increase in urine
concentration. The two factors work
together to return the plasma
osmolality to its normal levels.
Hormone secretion
The kidneys secrete a variety of
hormones, including erythropoietin,
urodilatin, renin and vitamin D.
ANGIOTENSIN
Angiotensin is an oligopeptide in the
blood that causes vasoconstriction,
increased blood pressure, and
release of aldosterone from the
adrenal cortex. It is a powerful
dipsogen. It is derived from the
precursor molecule angiotensinogen,
a serum globulin produced in the liver.
It plays an important role in the renin-
angiotensin system. Renin's primary
function is therefore to eventually
cause an increase in blood pressure,
leading to restoration of perfusion
pressure in the kidneys.
Types of Angiotensin
a. Angiotensin I
Angiotensin I is formed by the action of renin on angiotensinogen. Renin is produced in the kidneys
in response to both decreased intra-renal blood pressure at the juxtaglomerular cells, or decreased
delivery of Na+ and Cl- to the macula densa. If more Na+ is sensed, renin release is decreased.
Renin cleaves the peptide bond between the leucine (Leu) and valine (Val) residues on
angiotensinogen, creating the ten amino acid peptide (des-Asp) angiotensin I.
b. Angiotensin II
Angiotensin I is converted to angiotensin II through removal of two terminal residues by the enzyme
Angiotensin-converting enzyme (ACE, or kinase), which is found predominantly in the capillaries of
the lung. ACE is actually found all over the body, but has its highest density in the lung due to the
high density of capillary beds there. Angiotensin II acts as an endocrine, autocrine/ paracrine, and
intracrine hormone. ACE is a target for inactivation by ACE inhibitor drugs, which decrease the rate
of angiotensin II production. Angiotensin II increases blood pressure by stimulating the Gq protein in
vascular smooth muscle cells (which in turn activates contraction by an IP3-dependent
mechanism). ACE inhibitor drugs are major drugs against hypertension.
c. Angiotensin III
Angiotensin III has 40% of the pressor activity of Angiotensin II, but 100% of the aldosterone-
producing activity.
d. Angiotensin IV
Angiotensin IV is a hexapeptide which, like angiotensin III, has some lesser activity.
Cardiovascular effects
It is a potent direct vasoconstrictor, constricting arteries and veins and increasing blood pressure.
Renal effects
Angiotensin II has a direct effect on the proximal tubules to increase Na+ absorption. Although it
slightly inhibits glomerular filtration by indirectly (through sympathetic effects) and directly
stimulating mesangial cell constriction, its overall
effect is to increase the glomerular filtration rate by
increasing the renal perfusion pressure via efferent
renal arteriole constriction. Angiotensin II causes the
release of prostaglandins from the kidneys.
HYPERTENSION
EDEMA
It is the medical term for when excess fluid collects in your tissue. It's normal to have a certain
amount of this swelling during pregnancy because you retain more water while you are pregnant,
and certain changes in your blood chemistry cause some fluid to shift into your tissue.
When one is pregnant, the growing uterus puts pressure on the pelvic veins and on the vena cava
(a large vein on the right side of your body that receives blood from your lower limbs and carries it
back to the heart). The pressure slows down circulation and causes blood to pool in your legs,
forcing fluid from your veins into the tissues of your feet and ankles. This increased pressure is
relieved when you lie on your side. And since the vena cava is on the right side of your body, left-
sided rest works best.
A certain amount of edema is normal in the ankles and feet during pregnancy. However, swelling in
of face or puffiness around the eyes, more than slight swelling of the hands, or excessive or sudden
swelling of feet or ankles could be a sign of preeclampsia, a serious condition. A
Edema forms in people with kidney disease primarily for one of two reasons: either a heavy loss of
protein in the urine or impaired kidney (renal) function. In the first situation, the people have normal
or fairly normal kidney function. The heavy loss of protein in the urine (over 3.0 grams per day) is
termed the nephrotic syndrome and results in a reduction in the concentration of albumin in the
blood (hypoalbuminemia). Since albumin helps to maintain blood volume in the blood vessels, a
reduction of fluid in the blood vessels occurs. The kidneys then register that there is depletion of
blood volume and, therefore, attempt to retain salt. Consequently, fluid moves into the interstitial
spaces, thereby causing pitting edema.
People who have kidney diseases that impair renal function develop edema because of a limitation
in the kidneys' ability to excrete sodium into the urine. Thus, people with kidney failure from
whatever cause will develop edema if their intake of sodium exceeds the ability of their kidneys to
excrete the sodium.
Vasospasm effects on the interstitial tissues fluid diffusion from vascular space into interstitial
space edema
ALBUMINURIA/ PROTEINURIA
The presence of excessive protein (chiefly albumin but also globulin) in the urine; usually a
symptom of kidney disorder.
Vasospasm effects on renal system reduced glomerular filtration rate; increased glomerular
membrane permeability increased serum blood urea nitrogen and creatinine levels oliguria
and protenuria
PATHOPHYSIOLOGY
BOOK BASED
NORMAL PLACENTAL DEVELOPMENT
From 9-12 weeks gestation the uterine spiral arteries are
transformed from thick-walled, muscular vessels, to more
flaccid tubes to accommodate a 10-fold increase in uterine
blood flow to support the pregnancy
Preeclampsia is a state of high systemic vascular resistance with normal or relatively low
intravascular volume.
PLACENTAL PATHOPHYSIOLOGY
STAGE 1
VASOSPASM
Poor tissue perfusion to all Increases total peripheral Increases endothelial cell
maternal organs resistance resulting in permeability, (“leaky
elevated blood pressure capillaries”) fluid shifts from
* Vasospasm causes poor intravascular to intracellular
tissue perfusion to all organs, space resulting in:
* Vasospasm and endothelial
leading to organ dysfunction. > Decreased plasma volume,
damage upset the delicate increased hematocrit
* Decreased perfusion to the
balance between > Generalized tissue and organ
kidney results in decreased
vasoconstrictors and edema
glomerular filtration, allowing
vasodilators. This imbalance
protein, mainly
causes generalized * Vasospasm of maternal blood
albumin, to be lost into the
vasoconstriction, which vessels causes damage to
urine. Oliguria develops as the
increases peripheral vascular endothelial cells, causing them
disease worsens
resistance, resulting in to become more permeable.
hypertension Fluid “leaks” out of the blood
vessels into the tissues,
causing tissue and organ
edema
CLIENT BASED:
The placenta doesn't grow normally in the first half of pregnancy/ blood
vessels that go to the placenta don't grow properly. This means not
enough blood reaches the placenta in the second half of pregnancy/
placenta doesn't get enough blood from the client.
The unhealthy placenta sends harmful chemicals back into the client’s
bloodstream. The chemicals damage the lining of the blood vessels,
causing high blood pressure, problems with the kidneys, and swelling.
NURSING CARE PLAN
Dependent:
• Administer diuretics • To prevent
such as mannitol, as volume overload
ordered. or deficit.
• To prevent
increased ICP.
Subjective: Acute pain r/t Episiotomy Short term: Independent: Goal met.
“Masakit pa to episiotomy. • Assess perineum for • To verify extent of After 8 hours of
rin po ang Cellular Injury After 8 hours of edema. wound. continuous
sugat ko.”as continuous nursing
verbalized by Vasodilation nursing • Apply ice pack for intervention
the patient. intervention the 20mins.remove for at • Cold compress the mother
Vasoconstriction mother will state least 10mins. Before constricts blood stated that
Objective: that discomfort reapplying. vessels therefore discomfort has
Facial Increase has decreased. reduces pain. decreased as
Grimacing Vascular • Teach mother to evidenced by
Pain scale of 7 permeability squeeze buttocks absence of
BP:180/100 together before • To prevent pressure facial grimace
RR:28 Inflammation sitting, release after on the area. pain scale of 0.
PR:114 sitting.
Pain
• Encourage mother to
practice kegel • Kegel exercise is
exercise. deisgned to
strengthen
pubococcygeal
Dependent: muscles.
• Administer analgesic
as ordered.
• Relief of pain.
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATIO
DIAGNOSI PLANNING INTERVENTION N
S
• Support patient/SO in
dealing with the
realities of the • Coping mechanisms
situation, especially in and participation in
planning for long treatment regimen
recovery period. may be enhanced as
Involve patient in patient learns to deal
planning and with the outcomes of
participating in care the illness and
regains some sense
• Develop activity of control
program within limits
of physical ability
• Provides a healthy
outlet for energy
generated by feelings
DRUG STUDY
Discharge Planning is a process of preparing a client to leave one level of care for another
DISCHARGE CONSIDERATION:
Starts from the moment patient is admitted to the hospital, where length of stays are
considerably shortened.
Discharge teaching should begin during the perinatal period, and continue throughout the
intrapartum and postpartum period. The main tasks of the caregiver who attends the postpartum
period is to measure and record blood pressure after delivery, to swiftly identify symptoms that
could be indicative of preeclampsia (headache, visual disturbances, epigastric pain), to protect
the woman from damage during fits, and to arrange transport to a hospital or referral centre in
case of a serious rise of blood pressure combined with these symptoms.
Attention should also be given to signs of emotional and physical fatigue and other
problems that might arise from them.
Community health nurses have the opportunity to have ongoing assessments as well as
caregivers in their environment. They can provide support and resources as needed.
DISCHARGE GOALS:
• Age: 31
• G5P4
• BP: 180/100
• HR: 83
• RR: 22
• Temp: 36.8 C
• Pale palpebral conjuctiva, anicteric sclera
• Supple neck, no clads
• Symmetrical chest expansion
• Clear breath sounds
• Globular abdomen with abdominal girth of 93.98cm
• (+) bipedal edema
Upon admission, the patient was placed on NPO temporarily and was hooked to IVF.
Vital signs were monitored. Laboratories were done. Patient underwent NSD. Patient tolerated
the procedure well and had routine post-op care. Patient eventually transferred to ward and
eventually cleared for discharged.
DISCHARGE INSTRUCTIONS:
M - MEDICATION
E - EXERCISE/ ENVIRONMENT
T - TREATMENT
H - HYGIENE/ HEALTH TEACHINGS
O - OUT-PATIENT FOLLOW-UPS
D - DIET
S - SPIRITUAL
MEDICATION REGIMEN
Recognizing that there are finite limits to the amount of money and health care providers
available, desirable outcomes often compete for the resources.
High blood pressure and protein in the urine resolve after delivery, usually within a few
days. Severe hypertension should be treated, and some women will require a high blood
pressure medication after being discharged from the hospital. This can be discontinued when the
blood pressure returns to normal levels, usually within six weeks.
Blood pressure that continues to be elevated beyond 12 weeks after delivery is unlikely to
be related to preeclampsia and may require long-term treatment.
Reinforce importance of medication compliance to patient and her relatives; its time,
frequency, duration dosage and route.
MEDICATION DOSAGE
• After delivery, the mother needs time to rest, sleep, and regain her strength.
• After 3 weeks, the uterine lining is normally completely healed and a new endometrium
regenerated. At this point, most normal activities can be resumed, although strenuous
physical activity is usually restricted until after 6 weeks.
• Prolonged bedrest is neither necessary nor desirable. There are a few cautionary notes:
While she may be up walking, strenuous physical activity will
increase her bleeding and is not a good idea.
The first time she gets up, someone should be with her to
assist in getting her back down if she feels light-headed.
• Encourage the patient to do some exercise every morning such as a simple walking.
• Provide environment within normal room and body temperature.
• Maintain safe environment.
• Institute seizure precaution.
• Teach patient to perform passive range of motion exercises on patient’s extremities.
• Education about abdominal muscle tone and exercises is explained.
TREATMENT
Maternal temperature should be periodically assessed. Any persistent fever (>100.4 twice
over at least 6 hours) indicates the possibility of infection and should be investigated.
Blood pressure should also be checked several times during the first day and periodically
thereafter. Abnormally high blood pressure can indicate late-onset pre-eclampsia. Low blood
pressure may indicate hypovolemia.
Encourage and explain the importance of breast feeding to the client. Breastfeeding
especially the first milk, colostrum, can reduce postpartum bleeding/hemorrhage in the mother,
and to pass immunities and other benefits to the baby.
Advice client to let her child expose to mild sunlight in order to balance and avoid excess
bilirubin in the blood.
Mother and her support person are informed of abnormal signs or symptoms to watch for
in the first several days following discharge and given written instructions on how to receive
assistance if questions or emergencies arise.
It is important to establish bladder function early in the post partum phase. Because
bladder distention due to post partum bladder atony or urethral obstruction is common,
encourage the woman to void early and often.
OUT-PATIENT
DIET (collaborative)
Advice client to eat proper diet. Encourage her to eat more vegetables and frequent
intake of liquids. Advise her to eat food which are rich in protein, iron and vitamin C. Protein
helps to repair body tissues, iron provides formation of Red blood cells and ascorbic acid for
helping absorption of iron.
SPIRITUAL ASPECT
• Belief
• Faith
• Hope
• Verbalization with significant others