CASE PRESENTATION

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CASE PRESENTATION

• PREPARED BY
• DIANA ROSE S. DELA CUEVA
• LR/DR DEPARTMENT

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DEMOGRAPHIC DATA

• CASE NO 11155
• NAME MS. S.G. AGE 26 Y/O SEX FEMALE
• DIAGNOSIS PIH
• (PREGNANCY INDUCED HYPERTENTION)
• SEVERE PREECLAMPSIA vs SEVERE GESTATIONAL
  HYPERTENTION

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PHYSICAL ASSESSMENT

• An assessment is conducted starting at the head
  and proceeding in a systemic and efficient
  downward (head to toe). The procedure varies
  according to age, belief, religion of the
  subject, the severity of illness of the patient,
  the location of the examination, the priorities
  and procedures.

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GENERAL

• The patient is 26 years of age, FEMALE, weighs 90
  kgs.
• She is conscious, coherent, with the following
  Vital Signs
• BP 160/110mmHg
• PR87 bpm
• RR 22 cpm
• Temp37 C
• SPO² 96

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SKIN

• Fair complexion
• No palpable masses or lesions, moist, with good
  turgor

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HEAD

• Maxillary, frontal, and ethmoid sinuses are not
  tender.
• No palpable masses and lesions
• No areas of deformity
• Always complaining of headache

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LEVEL OF CONSCIOUSNESS AND ORIENTATION

• Awake and alert
• Oriented to persons
• (knows some of our name)
• Place
• ( she can tell where she is)
• Time
• ( knows the day, date and always asking the
  time)
• She knows the function of something like BP
  apparatus

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EYES

• Pink conjunctivae and no dryness
• Pupils equally round and reactive to light
• But according to patient sometimes she
  experienced changes in vision including blurring
  of vision or light sensitivity

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EARS

• No usual discharges noted

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NOSE

• Pink nasal mucosa
• No unusual nasal discharges
• No tenderness in sinuses

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MOUTH

• Pink and moist oral mucosa and free of swelling
  and lesions

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NECK AND THROAT

• No palpable lymph nodes
• No masses and lesions seen

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CHEST AND LUNGS

• Equal chest expansion
• No retraction
• Clear breath sounds

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HEART

• ECG report sinus, no ST-T changes, no sign of
  Chronic hypertension

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ABDOMEN

• Globular abdomen
• The patient always complained of epigastric pain
  
• USG report
• Pregnancy Uterine 24 weeks and 5 days
• Singleton in cephalic presentation
• Female fetus, good cardiac and somatic activity
• Adequate amniotic Fluid Volume
• Umbilical Artery Doppler indices revealed
  increased resistance to flow in the
  Uteroplacental unit probably secondary to
  Hypertension

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GENITALS

• No usual bleeding, no leaking per vagina

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EXREMITIES

• Presence of edema on both legs
• Pulse full and equal
• No lesions noted

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PATIENT HISTORY

• C/O Amenorrhea for 6 months duration
• MEDICAL HISTORY Primigravida, LMP 5/8/1433
  EDD23/5/1434, Severe Gestational Hypertention,
• ON EXAMINATION BP 190/115mmHg, PR 78 bpm,
  RR20 cpm, Temp. 37 ?C. on admission she is not
  pale
• INVESTIGATION
• U/S abdomen 3/2/1434 single, active fetus,
  cephalic. Gestational age 22 weeks. Placenta
  anterior and low lying, average amount of
  Amniotic Fluid and no major congenital anomalies
  seen.
• hGb 12.5 g/dL, PLT 4.78, RBS 4.78, Blood
  Group A positive INR0.9 Urine for albumin
  positive
• TREATMENT On Hydralazine infusion 40 mg 80 ml/
  hour. Tablet Aldomet 500 mg 8 hourly tablet
  Labetalol 100mg BID. Tablet ASA 81mg OD

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PRESENT MEDICAL HISTORY

• C/O Uncontrolled Hypertension
• MEDICAL HISTORY Primigravida with pregnancy 23
  wks 4 days by USG 26 wks by LMP, PIH
  (Gestational Hypertension vs Severe Preeclampsia)
  No history of hypertension at Pre-pregnancy
  state.
• ON EXAMINATION BP 160/110mmHg, PR 87 bpm, RR
  22 cpm, Temp. 37 C SPO²- 96, with usual knee
  jerk, ECG(sinus, no ST-T changes, no sign of
  Chronic Hypertension)
• INVESTIGATION
• BPS w/ Doppler 24 weeks 5 days, Adequate Fluid ,
  Symmetrical ( no IUGR) BPP 8/8
• Urine Protein by Urinalysis , Platelet 154
  (normal) LDH 236.44 (increase slightly) Mg
  0.95, Liver enzymes average
• TREATMENT continue Tablet Methyldopa 500mg q 6?,
  continue Labetalol infusion after 20mg IV slow
  push _at_ 1-2 mg/min, Tablet ASA 81mg OD, inj.
  Dexamethasone 6mg q 12?, tablet Labetalol 200 mg
  TID
•  

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INTRODUCTION

• Pregnancy Induced Hypertension (PIH) is a
  condition in which vasospasms occur during
  pregnancy in both small and large arteries. Signs
  of hypertension, proteinuria, and edema develop.
• Despite years of research, the cause of the
  disorder is still unknown.
• Originally it was called toxemia
• A condition separate from chronic hypertension
• PIH is classified as gestational hypertension
• mild preeclampsia, severe preeclampsia and
  eclampsia

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Mild Preeclampsia

• BP of 140/90
• 1 to 2 proteinuria on random
• weight gain of 2 lbs per week on the 2nd
  trimester and 1 lb per week on the 3rd trimester
• Slight edema in upper extremities and face

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Severe Preeclampsia

• BP of 160/110
• 3-4 protenuria on random
• Oliguria (less than 500 ml/24 hrs)
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema
• Peripheral edema
• Hepatic dysfunction

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Eclampsia

• is an extension of preeclampsia and is
  characterized by the client experiencing seizures.

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ILLUSTRATION
PREGNANT WOMAN BP gt 140/90 mmHg

20 weeks of gestation?
YES
NO
PROTEINURIA?
PROTEINURIA?
YES
NO
BP gt160/110 mmHg PROTEINURIA gt 5g/ 24 hours
NEW OR INCREASED
NO, or STABLE
GESTATIONAL HYPERTENTION
YES
NO
PREECLAMPSIA SUPERIMPOSED ON HYPERTENSION
CHRONIC HYPERTENSION
SEVERE PREECLAMPSIA
PREECLAMPSIA
SEIZURES
ECLAMPSIA
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ANATOMY AND PHYSIOLOGY
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RISK FACTOR MULTIPLE PREGNANCY OR PRIMIPARAS
YOUNGER THAN 20 YEARS OF AGE OR 40 YEARS
DIETARY FACTOR POOR NUTRITION
DISTURBED SLEEPING PATTERN
HYDRAMNIOS DIABETES, HEART DISEASE OR RENAL
INVOLVEMENT
CAUSE UNKNOWN
VASOSPASM
VASCULAR EFFECTS
INTERSTITIAL EFFECTS
KIDNEY EFFECTS
VASOCONSTRICTION
DIFFUSION OF FLUID FROM BLOOD STREAM INTO
INTERSTITIAL TISSUE
DECREASED GLOMERULI FILTRATION RATE AND
ULIINCRESED PERMEABILITY OF GLOMERULI MEMBRANES
POOR ORGAN PERFUSION
INCREASED SERUM BLOOD UREA NITROGEN, URIC ACID
AND CREATININE
INCREASED BLOOD PRESSURE
DECREASED URINE OUTPUT AND PROTEINURIA
EDEMA
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VII. SIGNS AND SYMPTOMS
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VIII. NURSING INTERVENTION

• Intervention for mild PIH
• Assess maternal VS and fetal heart rate.
• Promote bed rest
• Encourage elevation of edematous arms and legs
• Obtain daily hematocrit levels as
  ordered(reference ranges 34.1-44.9)
• Obtain blood studies (CBC, platelets count, liver
  function, BUN and creatinine, and fibrin
  degregation).
• Obtain daily weights at the same time each day
• Promote good nutrition
• Support nutritious diet of low salt low fat.
• Provide emotional support

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Intervention for severe PIH

• Maintain patients airway by putting a tongue
  blade or airway between a womans teeth during
  seizures.
• Turn a woman on her side.
• Raise side rails.
• Encourage compliance with bed rest in a lateral
  recumbent position
• Support patient with bed rest and darken the room
  if possible.
• Monitor maternal well being
• Monitor fetal well being
• Support a nutritious diet
• Administer medications to prevent eclampsia
• Provide emotional support.

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TREATMENT

• Use of drugs
• Catheterization
• Obtaining labs

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MEDICAL TREATMENT
NAME OF DRUG DOSAGE ROUTE TIME DURATION FREQUENCY
Labetalol 100mg/20ml 20mg IV 0125H STAT If diastolic BP gt110mmHg may give 40 mg IV
Labetalol infusion 30ml NSS 20ml labetalol IV IV 1-2mg/ min STAT
Labetalol Tablet 200mg PO 0600H- 1200H- 1800H 1 DAY TID
Diazepam (Valium) Pregnancy risk category D 5mg IV 0150H STAT
Methyldopa (ALDOMET TABLET) 500mg PO 0400H-1000H-1600H-2200H 1 DAY q6
Nifedifine 20mg PO 0100H- 0900H- 1700H 1 DAY q8
Aspirin 81mg PO 0600H 1 DAY OD
Ranitidine Tablet (Rantag) 150mg PO 0600H- 1200H- 1800H 1 DAY TID
Dexamethasone 6mg IM 0130H-1330H 1 DAY q12
Calcium Tablet 600mg PO 1800H 1 DAY OD
FeSO4 Tablet 100mg PO 0600H 1 DAY OD
ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS ADDITIONAL MEDICATIONS
Hydrazaline (Apresoline) Pregnancy risk category C 5mg IV
Magnesium Sulfate (Pregnancy risk category B) 4mg IV
Calcium Gluconate (Pregnancy risk category C) 1g IV
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LABORATORY TEST

• Assessment for High Risk of Developing
  PreeclampsiaGoal Establish baseline levels
  early in pregnancy and monitor for progression to
  HELLP or severe preeclampsia.

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TEST RESULT RESULT RESULT RESULT RESULT REFERENCE RANGE
27/12/12 28/12/12 29/12/12 31/12/12 1/1/13
Glucose(random) 4.0 3.9-7.8 mmol/L
Urea 2.4 3.7 1.8-8.3 mmol/L
Creatinine 41.8 41.4 34.7 F 46-92 mmol/L
Uric acid 341.7 F 50-340 Umol/L
Sodium 135 133 135-150 mmol/L
Potassium 4.0 4.4 3.5-5.0 mmol/L
Magnesium 0.95 0.65-1 mmol/L
Chloride 108 105 98-111 mmol/L
Calcium 2.16 2.20-2.55 mmol/L
AST(SGOPT) 22.8 17.6 16.4 10-38 U/L
ALT(SGPT) 17.2 12.9 11.3 10-41 U/L
Albumin 31.6 33.3 28.9 34-48g/L
Cholesterol 5.01 5.18 3.1-5.2 mmol/L
Triglycerides 1.40 1.67 0.34-2.30 mmol/L
HDLc 1.12 1.09 1.01-2.49 mmol/L
LDLc 3.35 3.41 221.38 3.9-4.7 mmol/L
Alkaline phosphate 65.1 35-129 U/L
LDH 236.44 214.47 135-225 U/L
CBC Hbg Hct Plt 11.9 33.2 184 11.0 30.6 198 10.9 30.5 187 12.3 33.6 173 11.2-15.7 g/dL 34.1-44.9 182-369/UL
Urinalysis Total Protein Pus cells 3 2-3/HPF 2 1-3/HPF 2 10-15/HPF 1 8-12/HPF
24 Urine Protein 3383.34 10-140 mg/ 24 hrs
Fibrinogen 324 168-435 mg/dL
PT APTT 13.3 44.2 12.5 40.4 10.1-17.0 seconds 26.1-36.3 seconds
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• Diagnosis of HELLP Syndrome
• Hemolysis
• Bilirubin gt1.2 mg/dL
• Peripheral blood smear abnormal
• Lactate dehydrogenase gt600 U/L
• Liver function tests
• ALT AST elevated
• Platelet count lt100 x109/L
• Diagnosed Preeclampsia (Therapeutic Monitoring)
• All of the above
• Albumin
• Coagulation testing

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COMPLICATIONS OF PIH

• Intrauterine growth restriction (IUGR)
• an abnormally restricted symmetric or asymmetric
  growth of fetus
• 2. Oligohydramnios
• abnormally low volume of amniotic fluid (less
  than 300 ml in total)
• AVERAGE VALUE 800-1200ml
• 3. Risk of placental abruption
• premature separation of a normally situated
  placenta from the wall of uterus
• 4. Risk of preterm delivery (often iatrogenic)
• delivery before 37 weeks of gestation
• 5. Coagulopathy
• 6. Stillbirth
• 7. Seizures
• 8. Coma
• 9. Renal failure
• 10. Maternal hepatic damage
• 11. Hemolysis
• 12. Elevated liver enzymes levels
• 13. Low platelet count (HELLP syndrome)
•  

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PRIORITIZATION OF NURSING PROBLEMS

• Ineffective Cerebral Tissue Perfusion related to
  decreased cardiac output secondary to vascular
  vasospasm.
• Impaired Gas Exchange related to accumulation of
  fluid in the lungs pulmonary edema.
• Knowledge Deficit the management of therapy and
  treatment related to misinterpretation of
  information.

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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
SUBJECTIVE I feel headache OBJECTIVE 1. Rising BP or widening pulse pressure 2.Followed by hypotension and labile vital signs 3.Pulse changes with bradycardia changing to tachycardia 4.Respiratory irregularities Hyperthermia followed by hypothermia V/S taken as follows BP 160/110 mmHg PR 87 bpm RR 22 cpm Temp. 37?C Ineffective cerebral perfusion related to decreased cardiac output secondary to vascular vasospasm Within 12 hours of nursing intervention , patient will have stable Vital Signs Establish and maintain airway, breathing, and circulation 2. Encourage deep slow or pursed lip brathing as tolerated 3. Position on side 4. Administer antihypertensive drugs as ordered Tachycardia changes in BP can reflect effect of systemic hypoxemia on cardiac funtion Oxygen delivery may be improved breathing exercises help to decrease dyspnea work of breathing to promote placental perfusion To lower the pressure in the blood stream After 12 hours of nursing intervention, the goal was partially met as evidenced by BP and other vital parameters stable
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ASSESSMENT ASSESSMENT PLANNING IMPLEMENTATION IMPLEMENTATION EVALUATION
CUES/ EVIDENCE NURSING DIAGNOSIS GOALS DESIRED OUTCOME NURSING ORDER/ACTION RATIONALE FOR ACTION EVALUATION
SUBJECTIVE lesh ana alatul fi sudha? (Why do I always feel headache?) as verbalized by the patient. OBJECTIVE 1. Request for information. 2.Agitated behavior 3.Inaccurate follow through of instructions. V/S taken as follows BP 160/110 mmHg PR 87 bpm RR 22 cpm Temp. 37?C Knowledge Deficit the management of therapy and treatment related to misinterpretation of information. After 12 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen. 1. Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain. 2. Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. 3. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. 4. Suggest frequent position changes, leg exercises when lying down. 5. Help patient identify sources of sodium intake. 6. Stress importance of accomplishing daily rest periods. 1. Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. 2. These risk factors have been shown to contribute to hypertension. 3. Lack of cooperation is common reason for failure of antihypertensive therapy. 4. Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. 5. Two years on moderate low salt diet may be sufficient to control mild hypertension. 6. Alternating rest and activity increases tolerance to activity progression. After 12 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.
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NURSING HEALTH TEACHING

• Encourage patient for sodium restriction.
• Encourage to avoid foods rich in oil and fats.
• Encourage patient to limit her daily activities
  and exercises.
• limit sexual activity
• Sexual intercourse at 2nd trimester should be
  avoided.
• Exercise
• Encourage patients on deep breathing exercises.
• Move extremities when lying.
• Elevate the head part when sleeping, to promote
  increase peripheral circulation
• Encourage overall passive and active exercises
  program during pregnancy to prevent need for
  cesarean birth.
• Exercises like tailor sitting, squatting, Kegel
  exercise, pelvic rocking, and abdominal muscle
  contraction will promote easy delivery. 

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CONCLUSION

• Presented a case of a 26 y/o Primigravida with
  pregnancy 26 wks 5 days with Severe
  Preeclampsia with BP gt140/90 mmHg, 3 protein
  urine, 24 hour urine protein and other labs
  pertaining to severe preeclampsia
• On conservative management such as antenatal
  screening, BPP with Doppler velocimetry twice
  weekly
• Hypertensive work up CBC, UA, liver enzymes,
  creatinine, LDH, twice weekly
• Anti hypertensive medications such as Labetalol,
  Diazepam (Valium), Methyldopa, Nifedifine
• Given that effective preventative measures and
  screening tools, routine nursing assessments of
  the signs/symptoms indicative of Severe
  Preeclampsia remains critical.
• Nurse-led patient education and the provision of
  a supportive environment are essential to the
  optimal management of Severe Preeclampsia
• Individually tailored and compassionate nursing
  care of women with Severe preeclampsia will serve
  to enhance the wellbeing of mother and baby

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• Thank you!! ?