Name: Madison Pleasants Critical Thinking Map
Priority Assessments (Physiological
Adaptation) (2.5 pts).
1. Complete comprehensive vital signs
assessment focusing on BP, Spo2, and HR.
2. Review lab values and diagnostic test
results for accurate treatment/management
plan.
3. Complete a pharmacological /treatment
reconsolidation sheet to prevent drug-drug
interactions.
Risk Factors (Health Promotion &
Maintenance/Reduction of Risk Potential)
(1pt)
1.Primigravida
2. Age < 19 or >40 years old
3. Preeclampsia in previous pregnancy
4. Rh incompatibility
5. Preexisting HTN or DM
Concept: Preeclampsia
Brief Pathophysiology (Physiological Adaptation)
(2.5pts.)
Preeclampsia is a disease involving the placenta.
More specifically, women with preeclampsia have a
distinct lesion in the placenta (Ward & Hisley, 2016,
p.350) that interrupts blood flow and can cause
placenta necrosis leading to poor placenta perfusion
and hypoxia. The causes of preeclampsia are
vasospasms and endothelial cell damage. Vasospasms
elevate the arterial blood pressure while the
damaged endothelial cells trigger the use of platelets
and fibrinogen. These events decrease placenta size
and active the coagulation cascade. This puts the
mother at risk for blood clots, DVTs and PEs while
the baby is at risk for hypoxia and poor organ
development.
Priority Nursing Diagnosis (2.5pts.)
1. Ineffective cerebral tissue perfusion r/t decreased
cardiac output aeb vascular vasospasm and damaged
endothelial cells.
2. Impaired gas exchange r/t poor placental perfusion
aeb activation of coagulation cascade and vascular
vasospasm.
3. Excess fluid volume r/t impaired glomerular
function aeb decreased cardiac output, peripheral and
pulmonary edema, and unstable electrolytes.
Date: 10/27/16
Nursing Interventions (Basic Care & Comfort/ Safety &
Infection Control) (2.5 pts)
1. Promote lying in the lateral side position to decrease
pressure on the vena cava. This increases venous return,
circulatory volume, and placental/renal perfusion.
2. Promote rest at home/hospital to assist in reducing
edema, aid in sodium secretion, and decrease stress.
3. Assess the mother for any knowledge deficient or
emotional concerns and address accordingly.
Medications (Pharmacological & Parenteral Therapies)
(5pts)
1. Hydralazine (vasodilator)- 5mg IV/IM then 5-10 mg
q20-40 min OR constant 0.5-10mg/hr; S/E: tachycardia,
dizziness, headache, sodium retention; contraindicated
in those with cadio/renal/ hepatic disease and when
used with products that contain tartazine.
2. Magnesium Sulfate (anticonvulsant in severe
preeclampsia)- Piggyback solution of 40mg magnesium
sulfate with 1,000 mL lactated Ringer loading dose- bolus
4-6g over 15-30min then 1-3mg/hr OR 4-5g IM each
buttock q4 PRN z-track; S/E: drowsiness, decreased RR,
bradycardia, diarrhea, hypothermia; contraindicated in
hypermagnesemia, hypocalcemia, anuria, heart block,
active labor, and two hours before labor
3. Nifedipine (Ca Channel Blocker)- 10-30mg PO PRN OR
30-120mg PO per day of a slow-release preparation; S/E:
headache, peripheral edema, flushing, dizziness, anxiety;
contraindicated in sick sinus syndrome, AV block, systolic
BP <90, coadministration with grapefruit juice, rifampin,
rifabutin, phenytoin, phenobarbital, carbamazepine, and
St. Johns wart
 Name: Madison Pleasants
Psychosocial Concerns (Psychosocial Integrity)
(1 pt)
1. PTSD r/t severe traumatic event
2. PPD r/t depression following complicated and
uncomplicated pregnancy
3. Family/Partner relationship strain
Labs & Diagnostics (Reduction of Risk Potential)
(2.5 pt)
1. Urinalysis: marked 3+ or 4+ and increased
serum creatinine concentrations r/t renal
impairment
2. Thrombocytopenia: platelets less than 100)
r/t
3. Elevated blood concentration of liver enzymes
and/or RUQ epigastric pain r/t impaired liver
function
Critical Thinking Map
Potential & actual complications from
treatments/ procedures (Physiological
Adaptation/Reduction of Risk Potential) (2pt)
1. HELLP syndrome: represented as hemolysis,
elevated liver enzymes and low platelet count r/t
multiple organ damage.
2. Placental abruption: preeclampsia can cause the
placental to separate from the uterine lining which
can be fatal for mother and baby.
3. Eclampsia: uncontrolled preeclampsia
characterized by seizures.
Date: 10/27/16
Patient Teaching (Health Promotion &
Maintenance/Safety & Infection Control/
Management of Care) (2.5 pt)
1. Emphasize the importance of an adequate
environment to rest throughout the day.
2. Educate on s/s of HTN, visual changes,
epigastric pain, nausea, vomiting, bleeding gums,
headache, increased edema, decreased urine
output, and decreased fetal movement.
3. Remind mother to keep all prenatal
appointments and to speak with her PCP with any
concerns.
Name: Madison Pleasants Critical Thinking Map Date: 10/27/16

References

Ward, S. & Hisley, S. (2016).Maternal-Child Nursing Care: Optimizing Outcomes for Mothers, Children, & Families, (2nd ed.), Philadelphia, PA: FA

Davis

Vallerand, A. H., Sanoski, C.A., & Deglin, J.H. (2015). Daviss drug guide for nurses (14th ed.). Philadelphia, PA: F.A. Davis