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I. Intro a. Intro about the topic (overview/definition of the dse.

Hypertension (high blood pressure) that develops after the twentieth week of pregnancy in a woman with no history of hypertension can either be gestational hypertension or preeclampsia. Distinguishing the two may be difficult. Preeclampsia is characterized by protein in the urine (proteinuria) and swelling (edema). Gestational hypertension is high blood pressure without these additional symptoms. Either condition may be problematic, but preeclampsia generally poses more of a danger to both mother and baby (http://www.netplaces.com/pregnancy-over-35/risks/preeclampsia.htm).

Hypertensive disorders of pregnancy, previously known as Pregnancy induced hypertension (PIH), are high blood pressure disorders of pregnancy. It has long been one of the major problems for mothers in pregnancy, along with infection and postpartum hemorrhage. Pregnancy-induced hypertension is also called toxemia or preeclampsia. It occurs most often in young women with a first pregnancy. It is more common in twin pregnancies, and in women who had PIH in a previous pregnancy (http://www.chw.org). According to Pillitteri, Pregnancy-induced Hypertension is a condition in which vasospasm occurs during pregnancy in both large and small arteries. Signs of hypertension, proteinuria and edema develop. Despite years of research, the cause of the disorder is still unknown although it is highly correlated with the antiphospholipid syndrome. Originally it was called toxemia because researchers pictured a toxin of some kind being produced being produced by a woman in response to foreign protein of the growing fetus (Pillitteri, 2010, p. 575)
b. Incidence and statistics PIH is a condition separate from chronic hypertension, PIH tends to occur most frequently in women of color or with a multiple pregnancies, primiparas younger than 20 years or older than 40 years, women from low socioeconomic backgrounds, those who have had 5 or more pregnancies, those who have hydramnios, or those who have underlying disease such as heart disease, diabetes with vessel and renal involvement, and essential hypertension (pillitteri, 2010, p. 575).

Preeclampsia affects 5-8% of all pregnancies but 10-20% of mothers will have a hypertensive disorder during pregnancy (http://pregnancy.about.com).

The term eclampsia refers to the occurrence of epileptic seizures in pregnancy, not caused by trauma or other neurological disease. Hence, Pre-eclampsia is a condition before the occurrence of epileptic seizures. Eclampsia occurs in 0.2-0.5% of all deliveries. 75% of cases

occur before delivery, and 50% of post-partum eclamptic seizures occur in the first 48 hours after delivery but may occur up to 6 weeks post-partum (http://www.virtualmedicalcentre.com)

c. Mortality/Morbidity According to Cande V. Ananth1 and Olga Basso2. PIH increased from 3.0% in 1990

to 3.9% in 2004. In both 1990-91 and 2003-04 periods, PIH was associated with an increased risk of stillbirth and neonatal death. We explored this in more detail in 2003-04, and observed that the increased risk of stillbirth was higher in women having their second or higher order births (OR=2.24, 95% confidence interval (CI)=2.11-2.37) compared with women having their first birth (OR=1.52, 95% CI=1.40-1.64). Patterns were similar for neonatal death (OR=1.30, 95% CI=1.18-1.43 in first and OR=1.64, 95% CI=1.51-1.78 in second or higher order births). Among multiparas, the association between PIH and stillbirth was stronger in Blacks (OR=2.93, 95% CI=2.66-3.22) than Whites (OR=1.98, 95% CI=1.83-2.14).( http://www.ncbi.nlm.nih.gov). Current trends

Paternal role in pre-eclampsia etiology confirmed


16 September 2005 A study of Norwegian birth registry data has confirmed that fetal genes from both the mother and father, as well as maternal genes, contribute to the risk of pre-eclampsia. The analysis, which used data from 1967 to 2003, showed that the daughters of women who suffered pre-eclampsia during pregnancy had more than twice the risk of developing the condition themselves than other women. In contrast, men born of a pre-eclamptic pregnancy had just a 50 percent increased risk of fathering another pre-eclamptic gestation. Rolv Skjaerven (University of Bergen) and colleagues suggest that the daughters transmit this higher risk because in addition to transmitting independent risk factors to their fetus, they carry susceptibility genes themselves, whereas the paternal contribution would only be transmitted through the unborn child.

The study also demonstrated that sisters of affected men and women who were not, themselves, born after a pre-eclamptic pregnancy had double the risk of women with no family history of the condition, whereas, for brothers, the corresponding risk was comparable to that of men with no such family history. This suggests that "the genes that determine maternal susceptibility to pre-eclampsia differ from the paternal genes that may trigger pre-eclampsia through the fetus," says the team(http://m.medwire-news.md).
II. Anatomy/Pathophysiology
Anatomy and Physiology: When most people hear the term cardiovascular system, they immediately think of the heart. We have all felt our own heart "pound" from time to time, and we tend to get a bit nervous when this happens. The crucial importance of the heart has been recognized for a long time. However, the cardiovascular system is much more than just the heart, and from a scientific and medical standpoint, it is important to understand why this system is so vital to life. Most simply stated, the major function of the cardiovascular system is transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital for body homeostasis to and from the cells. The force to move the blood around the body is provided by the beating heart. The cardiovascular system can be compared to a muscular pump equipped with one-way valves and a system of large and small plumbing tubes within which the blood travels. HEART: The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions. The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior to the sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semilunar valve, and the pulmonary semilunar valve. Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away

from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation. Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung. Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood. Pulmonary arteries The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen. Systemic arteries Systemic arteries can be subdivided into two types muscular and elastic according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged. The Aorta The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries. Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The aorta brings oxygenated blood to all parts of the body in the systemic circulation. The aorta is usually divided into five segments/sections: Ascending aortathe section between the heart and the arch of aorta Arch of aortathe peak part that looks somewhat like an inverted "U"

Descending aortathe section from the arch of aorta to the point where it divides into the common iliac arteries o o Thoracic aortathe half of the descending aorta above the diaphragm Abdominal aortathe half of the descending aorta below the diaphragm

Arterioles Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries. Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart. Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small.

Superficial veins Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries. Deep veins Deep veins are deeper in the body and have corresponding arteries. Pulmonary veins The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart. Systemic veins Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart. Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood to return to the heart. There is at least one atrium in animals with a closed circulatory system. Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix. Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve. Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than a ventricle) and pumps it out of the heart. Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk. Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve.

A. Book Centered a. schematic diagram\ . Synthesis of the dse. (risk fxr./signs and symptoms/ possible complicaton with rationale) III. Nsg. Manangement _important NCP atleast 3 or 5

IV. Medical Management. Diagnostic and Lab examm Drugs


Medical Treatment and Evaluation: 1. Magnesium Sulfate (Pregnancy risk category B) muscle relaxant, prevent seizures

loading dose 4-6g, maintenance dose 1-2g/h IV infuse IV dose slowly over 15-30 min. Always administer as a piggy back infusion. Assess PR, urine output, DTR, and clonus every hour. Observe for CNS depression and hypotonia in infant at birth.

2. Hydrazaline (Apresoline) Pregnancy risk category C


anti hypertensive (peripheral vasodilator) use to decrease hypertension 5-10mg/IV Administer slowly to avoid sudden fall of BP Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling. 3. Diazepam (Valium) Pregnancy risk category D halt seizures 5-10mg/IV administer slowly. Dose may be repeated every 10-15 min. (up to 30mg/hr) Observe for respiratory depression for both mother and infant at birth. 4. Calcium Gluconate (Pregnancy risk category C) antidote for Magnesium Sulfate 1g/IV (10 mL of a 10% solution) have prepared at bed side when administering Magnesium Sulfate administer at 5mL/min.

V. References

http://pregnancy.about.com/od/hypertensionpre/a/pihinpg.htm http://www.americanpregnancy.org/pregnancycomplications/pih.htm http://www.chw.org/display/PPF/DocID/23203/router.asp http://www.medicinenet.com/pregnancy_induced_hypertension/article.htm http://www.virtualmedicalcentre.com/diseases/preeclampsia-toxemia-pregnancyinduced-hypertension/512 http://www.netplaces.com/pregnancy-over-35/risks/preeclampsia.htm http://m.medwire-news.md/45/39006/Obstetrics_and_gynecology/Paternal_role_in_preeclampsia_etiology_confirmed http://emedicine.medscape.com/article/1476919-overview http://nursingcrib.com/case-study/pregnancy-induce-hypertension-case-study/

mali ba cnav ko?? ahahaha e2 pala SHORT BAND PAPER/FORMAL FRONT PAGE DI KO ALAN ANG FONT SIZE AND STYLE http://www.scribd.com/doc/66170616/Pregnancy-Induced-Hypertension-Case-Study http://www.slideshare.net/kiarratot/case-study-pregnancy-induced-hypertension http://nursingcrib.com/case-study/pregnancy-induce-hypertension-case-study/ http://www.yalemedicalgroup.org/stw/Page.asp?PageID=STW026846

Cues S= O= pt. Maymanifest:>p allor>nonpitting/pittinged ema>hypertens ion>bodymalais e>variationsin bloodpressure >anxietyandrest lessness

Nursing Diagnosis Decreasedcardi acoutput r/taltered heartrate AEBincreasedb loodpressure

Scientific Explanation A hypertensivepregna ntwoman iscaused bysudden weightgain. This wouldbringcomplica tions inthe bodybecause there isan inadequateblood pumpedby the heart tomeet themetabolicdeman ds of thebody, there isan alteration of her V/Sespecially onthe blood pressure andheart rate. As aresult, adecreasedvolume bloodpumped byeither ventricleof the hearteach minute.

objectives ShortTerm: After 2-3hours ohnursingintervention s the pt. willbe able todemonstrate stablecardiacrhythm andrate withinpatientsnormalra nge. LongTerm: After 2-3days the pt.will be abletoparticipatein activitiesthat reducebloodpressure orcardiacworkload.

Nursing interventions 1. Assess otherprecipitating factors.2. Involve client informulation of plan of care at level of ability.3. Note presence,quality of central andperipheral pulses.4. Monitor bloodpressure of the patient.Measure in both arms/thighs threetimes, 3-5 min., thensitting, then standingfor initial evaluation.Use correct cuff sizeand accurate technique.5. Observe skin color,moisture, temperatureand capillary refill time.6. Note independent orgeneral edema.7.Position the clientwith legs elevated8. Encourage legexercise such as flexionand extension of thefeet, active andrelaxation of the calf muscles9. Place the client in a highfowlers position10. Instruct the clientthe importance of maintaining regularphysical ability11. Provide calm, restfulsurroundings, minimizeenvironmental activityor noise.12. Maintain activityrestrictions; providecomfort measures, e.g.back and neckmassage, elevation of head.13. Instruct pt. inrelaxation techniqueand guided imagery. 14. Monitor response tomedications to controlhigh blood pressure.

Rationale Enhances ideas toprioritize things.Enhances sense of control and aids incooperation andmaintenance of independence.Bounding carotid, jugular, radial, femoralpulses may beobserved or palpated.Pulses in the legs orfeet may bediminished, reflectingeffects of vasoconstriction andvenous congestion. Comparison of pressures provides amore complete pictureof vascularinvolvement or scopeof the problem.Presence of pallor,cool, moist skin anddelayed capillary refilltime may be due toperipheralvasoconstriction.May indicate heartfailure, renal orvascular impairment. To promote venousreturn to the heart To improve blood flowand reduce venousstagnation To decrease preloadand reduce pulmonarycongestion To promote circulationand vascular healthCan reduce stressfulstimuli producecalming effect therebyreduces bloodpressure.Help reducesympatheticstimulation promotesrelaxation.Reduces physicalstress and tension thataffect blood pressure and causeshypertension.Response to drugtherapy is dependenton both individualswell as the

synergisticeffects of the drugs.Because side effects,drug interactions andpatients motivation fortakingantihypertensivemedication, it isimportant to use thesmallest number andlowest dosage of medications.

Cues S= O=patientmaym anifest thefollowing:>e dema>maternal bloodpressure of 160/100mm Hg>increasedord ecreasedfetal hearttone>positi vehomanssign

Nursing Diagnosis Ineffectiveutero placental tissueperfusion related tovasospasm of spiral arteriessecond ary topreeclampsia

Scientific Explanation Preeclampsia ischaracterizedby an increasedin bloodpressureresult ing fromvasospasm of arteries (for thiscase, we arepertaining tothe spiralartery) thatcausesvasoconstri ction. This then leadsto decrease inoxygen supplyto the placentawhich isotherwiseknown asineffectiveuropla centalperfusion.

objectives shortTerm: After 2hours of nursingintervention s, thepatient willbe able toverbalizeunderstan ding of condition,therapyregi menand sideeffects of medications. Long Term: After 2-3days of nursingintervention , the patientwill be abletodemonstrate increasedperfusion asindividuallyappropri ate(e.g. vitalsigns,especiallyblood pressure,withinclientsno rmalrange andabsence of edema)

Nursing interventions 1. Assist the patient inidentifying lifestyleadjustment (e.g.,avoiding prolongedsitting, sitting withcrossed legs, orstanding; developingexercise plan forcardiovascular fitnessduring pregnancy;avoiding wearingconstrictive clothing;maintaining a balancediet with adequatehydration) that may beneeded because of changes in physiologicfunction duringpregnancy.2. Check and monitorvital signs hourly. 3. Monitor fetal heartrate and well being.4. Institute O2, with aninitial volume of at least2L/min.5. Monitor intake andoutput every hour.6. Instruct the patient toassume the left sidelying position whenlying down. 7. Provide quiet, nonstimulatingenvironment for thepatient.8. Provide the patientand family factualinformation and supportas needed.9. Provide lowsodiumdiet (not more than 6gdaily or

Rationale Decreases factors thatcould lead todecreased perfusion of oxygen to uterus,placenta, and fetusPermits monitoring of cardiovascularresponse to illnessstate and providesearly warning of perfusion problems. Provides early warningof perfusion problems,and promotes earlyintervention.It enhancesuteroplacentalperfusion therebydecreasing fetal heartworkload. To check for renalperfusion and todetermine fluid lossand need forreplacement or fluidexcess which furtherincreases BP To promote placentalperfusion and preventthe compression of vena cava. It reduces anxiety andpromotes rest. Bothmeasures will assist inmaintaining peripheralcirculation by avoidingvasoconstriction.It reduces anxiety andprovides teachingopportunity.It assists in controllingblood pressure.Restriction of proteinhelps limit BUN.Provides support andfosters cost-effectivecollaboration throughuse of readily availableresources

less than 2.5 gdaily). Restrict intake of protein.10. Refer to otherhealth careprofessionals as necessary

Cues S= O=Pt. maymanifestpallor>nonpittingedema>h ypertension>bo dymalaise>vari ationsin bloodpressure> anxietyandrestl essness

Nursing Diagnosis Activityintoleran ce r/timbalanceoxy gensupply anddemand AEBabnormalh eart rate orbloodpressur eresponse

Scientific Explanation When there is ahigh bloodpressure, thereis aninadequateblood flow.Inadequateblood flowdecreases thenutrients andoxygen in thetissues in thebody as well asin metabolicdemands. Bythen, a personwill not be ableto meet herdesiredactivities because of depleted energythat the bodyneeds to sustainnormalmeta bolic rate.

objectives When there is ahigh bloodpressure, thereis aninadequateblood flow.Inadequateblood flowdecreases thenutrients andoxygen in thetissues in thebody as well asin metabolicdemands. Bythen, a personwill not be ableto meet herdesiredactivitiesbe cause of depleted energythat the bodyneeds to sustainnormalmetabo lic rate.

Nursing interventions 1. Assess for otherprecipitators or causesof treatment and pain.2. Involve client informulation of plan of care at level of ability3. Assess the patientsresponse to activity,nothing pulse rate morethan 20 beats/min.faster than resting rate ;marked increase inblood pressure duringor after activity;dyspnea or chest pain;excessi ve fatigue andweakness; diaphoresis;dizziness or syncope. 4. Determine currentcap[abilities andbarriers to participationin self care.5. Evaluate acceleratingactivity intolerance.6. Provide assistancewith self-care activity asindicated, intersperseactivity period with restperiod.7. Instruct clientenergyconservingtechniques. 8. Encourageprogressive activitywhen tolerated.

Rationale Fatigue is a side effectof some medications.Pain and stressfulregimens also extractenergy and producefatigue.Enhances sense of control and aids incooperation andmaintenance of independence. The stated parametersare helpful inassessing physicalresponses to the stressof activity and if present are indicatorsof over exertion. Comprehensivefunctional assessmentincludes independentperformance of basicADLs, social activities,sensory abilities,cognition and ability toambulate.May denote increasingcardiacdecompensation rat herthan over activity.Meets clients personalcare needs withoutundue myocardialstress or excessiveoxygen demand.Energy savingtechniques reducedthe energyexpenditures, therebyassisting in equalization of oxygensupply and demand.Gradual activityintoleranceprogression

prevents asudden increase incardiac workload.

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