CASE PRESENTATION

PREPARED BY: DIANA ROSE S. DELA CUEVA

LR/DR DEPARTMENT

• CASE NO: 11155• NAME: MS. S.G. AGE: 26 Y/O SEX:

FEMALE• DIAGNOSIS: PIH

(PREGNANCY INDUCED HYPERTENTION) SEVERE PREECLAMPSIA vs SEVERE

GESTATIONAL HYPERTENTION

DEMOGRAPHIC DATA

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.

GENERAL

• The patient is 26 years of age, FEMALE, weighs 90 kgs.

• She is conscious, coherent, with the following Vital Signs:– BP= 160/110mmHg– PR=87 bpm– RR= 22 cpm– Temp=37 ⁰C– SPO²= 96%

SKIN

• Fair complexion• No palpable masses or

lesions, moist, with good turgor

HEAD

• Maxillary, frontal, and ethmoid sinuses are not tender.

• No palpable masses and lesions• No areas of deformity• Always complaining of headache

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

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

EARS

• No usual discharges noted

NOSE• Pink nasal mucosa• No unusual nasal

discharges• No tenderness in sinuses

MOUTH

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

NECK AND THROAT

• No palpable lymph nodes• No masses and lesions

seen

CHEST AND LUNGS•Equal chest expansion•No retraction•Clear breath sounds

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

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

GENITALS

•No usual bleeding, no leaking per vagina

EXREMITIES• Presence of edema on both

legs• Pulse full and equal• No lesions noted

PATIENT HISTORY

C/O: Amenorrhea for 6 months durationMEDICAL HISTORY: Primigravida, LMP= 5/8/1433 EDD=23/5/1434,

Severe Gestational Hypertention, ON EXAMINATION: BP: 190/115mmHg, PR: 78 bpm, RR:20 cpm,

Temp. 37 ◦C. on admission she is not paleINVESTIGATION:

» 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 INR=0.9 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

PRESENT MEDICAL HISTORYC/O: Uncontrolled HypertensionMEDICAL 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 ⁰C 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: averageTREATMENT: continue Tablet Methyldopa 500mg q 6◦, continue

Labetalol infusion after 20mg IV slow push @ 1-2 mg/min, Tablet ASA 81mg OD, inj. Dexamethasone 6mg q 12◦, tablet Labetalol 200 mg TID

•

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

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

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

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

≥ 20 weeks of

gestation?

≥ 20 weeks of

gestation?

PREGNANT WOMANBP > 140/90 mmHg

PREGNANT WOMANBP > 140/90 mmHg

YESYES NONO

PROTEINURIA?PROTEINURIA?

PROTEINURIA?PROTEINURIA?YESYES NONO

NEW OR INCREASED

NEW OR INCREASED

NO, or STABLENO, or

STABLE

YESYES NONO

PREECLAMPSIA SUPERIMPOSED ON

HYPERTENSION

PREECLAMPSIA SUPERIMPOSED ON

HYPERTENSION

CHRONIC HYPERTENSION

CHRONIC HYPERTENSION

SEVERE PREECLAMPSIA

SEVERE PREECLAMPSIA

PREECLAMPSIAPREECLAMPSIA

SEIZURESSEIZURES

ECLAMPSIAECLAMPSIA

ILLUSTRATION:

GESTATIONAL HYPERTENTION

BP >160/110 mmHg

PROTEINURIA > 5g/ 24 hours

ANATOMY AND PHYSIOLOGY

VASOSPASMVASOSPASM

VASCULAR EFFECTS

VASCULAR EFFECTS

KIDNEY EFFECTSKIDNEY EFFECTS INTERSTITIAL EFFECTS

INTERSTITIAL EFFECTS

VASOCONSTRICTIONVASOCONSTRICTION DECREASED GLOMERULI FILTRATION RATE AND ULIINCRESED PERMEABILITY OF GLOMERULI MEMBRANES

DECREASED GLOMERULI FILTRATION RATE AND ULIINCRESED PERMEABILITY OF GLOMERULI MEMBRANES

DIFFUSION OF FLUID FROM BLOOD STREAM INTO INTERSTITIAL TISSUE

DIFFUSION OF FLUID FROM BLOOD STREAM INTO INTERSTITIAL TISSUE

POOR ORGAN PERFUSION

POOR ORGAN PERFUSION

INCREASED SERUM BLOOD UREA NITROGEN, URIC ACID AND CREATININE

INCREASED SERUM BLOOD UREA NITROGEN, URIC ACID AND CREATININE

INCREASED BLOOD PRESSURE

INCREASED BLOOD PRESSURE

DECREASED URINE OUTPUT AND PROTEINURIA

DECREASED URINE OUTPUT AND PROTEINURIA

EDEMAEDEMA

RISK FACTOR:MULTIPLE PREGNANCY OR PRIMIPARAS YOUNGER THAN 20 YEARS OF AGE OR 40 YEARS

DIETARY FACTOR

POOR NUTRITION

DISTURBED SLEEPING PATTERN

HYDRAMNIOSDIABETES, HEART

DISEASE OR RENAL INVOLVEMENT

CAUSE:UNKNOWN

VII. SIGNS AND SYMPTOMS

VIII. NURSING INTERVENTIONIntervention for mild PIH:

1. Assess maternal VS and fetal heart rate.2. Promote bed rest3. Encourage elevation of edematous arms and legs4. Obtain daily hematocrit levels as ordered(reference

ranges 34.1-44.9%)5. Obtain blood studies (CBC, platelets count, liver

function, BUN and creatinine, and fibrin degregation).6. Obtain daily weights at the same time each day7. Promote good nutrition8. Support nutritious diet of low salt low fat.9. Provide emotional support

Intervention for severe PIH:

1. Maintain patient’s airway by putting a tongue blade or airway between a woman’s teeth during seizures.

2. Turn a woman on her side.3. Raise side rails.4. Encourage compliance with bed rest in a lateral recumbent

position5. Support patient with bed rest and darken the room if possible.6. Monitor maternal well being7. Monitor fetal well being 8. Support a nutritious diet9. Administer medications to prevent eclampsia10. Provide emotional support.

TREATMENT

1.Use of drugs2.Catheterization3.Obtaining labs

NAME OF DRUG DOSAGE ROUTE TIME DURATION FREQUENCY

1. Labetalol 100mg/20ml 20mg IV 0125H STAT If diastolic BP >110mmHg may give 40

mg IV

1. Labetalol infusion 30ml NSS + 20ml labetalol IV

IV 1-2mg/ min STAT

1. Labetalol Tablet 200mg PO 0600H- 1200H- 1800H 1 DAY TID

1. Diazepam (Valium) Pregnancy risk category D

5mg IV 0150H STAT

1. Methyldopa (ALDOMET TABLET) 500mg PO 0400H-1000H-1600H-2200H

1 DAY q6°

1. Nifedifine 20mg PO 0100H- 0900H- 1700H 1 DAY q8°

1. Aspirin 81mg PO 0600H 1 DAY OD1. Ranitidine Tablet (Rantag) 150mg PO 0600H- 1200H- 1800H 1 DAY TID

1. Dexamethasone 6mg IM 0130H-1330H 1 DAY q12°1. Calcium Tablet 600mg PO 1800H 1 DAY OD1. FeSO4 Tablet 100mg PO 0600H 1 DAY ODADDITIONAL MEDICATIONS:1. Hydrazaline (Apresoline)

Pregnancy risk category C5mg IV

1. Magnesium Sulfate (Pregnancy risk category B)

4mg IV

1. Calcium Gluconate (Pregnancy risk category C)

1g IV

MEDICAL TREATMENT

LABORATORY TEST

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

TEST RESULT REFERENCE RANGE

27/12/12 28/12/12 29/12/12 31/12/12 1/1/13Glucose(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/LALT(SGPT) 17.2 12.9 11.3 10-41 U/LAlbumin 31.6 33.3 28.9 34-48g/LCholesterol 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/LLDH 236.44 214.47 135-225 U/LCBC Hbg Hct Plt

11.933.2184

11.030.6198

10.930.5187

12.333.6173

11.2-15.7 g/dL34.1-44.9%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

PTAPTT

13.344.2

12.540.4

10.1-17.0 seconds26.1-36.3 seconds

• Diagnosis of HELLP Syndrome• Hemolysis

– Bilirubin >1.2 mg/dL– Peripheral blood smear abnormal– Lactate dehydrogenase >600 U/L

• Liver function tests– ALT & AST elevated

• Platelet count <100 x109/L• Diagnosed Preeclampsia (Therapeutic Monitoring)• All of the above• Albumin• Coagulation testing

COMPLICATIONS OF PIH

1. 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. Coagulopathy6. Stillbirth7. Seizures8. Coma9. Renal failure10. Maternal hepatic damage11. Hemolysis12. Elevated liver enzymes levels13. Low platelet count (HELLP syndrome)

PRIORITIZATION OF NURSING PROBLEMS

1. Ineffective Cerebral Tissue Perfusion related to decreased cardiac output secondary to vascular vasospasm.

2. Impaired Gas Exchange related to accumulation of fluid in the lungs: pulmonary edema.

3. Knowledge Deficit: the management of therapy and treatment related to misinterpretation of information.

ASSESSMENT PLANNING IMPLEMENTATION EVALUATIONCUES/

EVIDENCENURSING

DIAGNOSISGOALS & 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 signs3.Pulse changes with bradycardia changing to tachycardia 4.Respiratory irregularities Hyperthermia followed by hypothermiaV/S taken as follows:BP: 160/110 mmHgPR: 87 bpmRR: 22 cpmTemp.: 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

1. 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

1. Tachycardia & changes in BP can reflect effect of systemic hypoxemia on cardiac funtion

2. Oxygen delivery may be improved & breathing exercises help to decrease dyspnea & work of breathing

3. to promote placental perfusion

4. 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

ASSESSMENT PLANNING IMPLEMENTATION EVALUATIONCUES/

EVIDENCENURSING

DIAGNOSISGOALS & DESIRED

OUTCOMENURSING

ORDER/ACTIONRATIONALE 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 behavior3.Inaccurate follow through of instructions.V/S taken as follows:BP: 160/110 mmHgPR: 87 bpmRR: 22 cpmTemp.: 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 withoutsymptom 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.

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.

CONCLUSION Presented a case of a 26 y/o Primigravida with pregnancy 26 wks + 5 days

with Severe Preeclampsia with BP >140/90 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

Thank you!!