University:
Stevenson University
Course:
NURS 460 | Medical/Surgical Nursing II
Academic year:

2022
Views:

406

Pages:

1
Author:

Edgar Rowe

System Disorder STUDENT NAME _____________________________________ Preeclampsia DISORDER/DISEASE PROCESS __________________________________________________________ REVIEW MODULE CHAPTER ___________ Alterations in Health (Diagnosis) Risk for imbalanced fluid volume risk for injury:fetal Risk for unstable blood pressur Anxiety related to uknown Pathophysiology Related to Client Problem Health Promotion and Disease Prevention occurs in pregnancy when client has elevated BP at 140/90mmHg or greater recorded on two different occassions,at last 4 hours apart blood pressure screening diet low in sodium exercise stress managment ASSESSMENT SAFETY CONSIDERATIONS Risk Factors maternal age younger than 19 or older than 40 years first pregnancy morbid obesity multifetal gestation chronic kidney disease chronic hypertension family history of preeclampsia diabetus mellitus reumathoid arthritis systemic lupus erthematosus Laboratory Tests Elevated liver enzymes(LDH,AST) Increased creatinine increased plasma uric acid thrombocytopenia Decreased Hgb Hyperbilirubinemia Expected Findings severe continous headache nausea blurring vision flashes or lights dots before the eyes hypertension proteinuria periorbital,facial,hand abdominal enema pitting edema in lower extremities vomiting oliguria hyperreflexia epigastric pain Diagnostic Procedures 24-hr urine collection for protein and creatine clearance nonstress test,biophysical profile,and serial ultrasounds to determine fetal status PATIENT-CENTERED CARE Nursing Care monitor level of conciousness obtain pulse oximetry monitor I&O obtain daily weights monitor vital signs with careful attention to BP measurement(using proper size cuff,avoid talking to client during measurement) encourage lateral positioning perform NST and daily kick counts monitor deep tendon reflexes Therapeutic Procedures IV fluids blood pressure and pulse ox monitoring fetal heart monitoring seizures renal dysfunction stroke maternal death fetal death premature birth Complications Medications Methyldopa nifedipine hydralazine labetalol avoid ACE inhibitors and angiotensin II receptor blockers Anticonvulsant meds:Magnesium sulfate Medication of choice to depress the CNS and prevent seizures Client Education maintain bed rest and encourage side-lying position promote diversional activities(TV,visits fromfamily, friends,gentle exercise) avoid foods that are high in sodium avoid alcohol and tabacco,and limit caffeine intake drink six to eight 8-oz glasses of water per day maintain a dark,quiet environment to avoid stimuli that can precipitate a seizure maintain a patent airway in the event of aseizure administer antihypertensive medications as prescribed Interprofessional Care nursing department dietary department pediatricin venticular hyperthrophy heart failure CVA chronic renal damage superimposed preeclampsia placental abruption fetal growth resrtiction