CASE PRESENTATION

1. CASE PRESENTATION PREPARED BY: DIANA ROSE S. DELA CUEVA LR/DR DEPARTMENT

2. 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

3. 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.

4. 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%

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

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

7. 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

8. 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

9. EARS • No usual discharges noted

10. NOSE • Pink nasal mucosa • No unusual nasal discharges • No tenderness in sinuses

11. MOUTH • Pink and moist oral mucosa and free of swelling and lesions

12. NECK AND THROAT • No palpable lymph nodes • No masses and lesions seen

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

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

15. 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

16. GENITALS • No usual bleeding, no leaking per vagina

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

18. PATIENT HISTORY C/O: Amenorrhea for 6 months duration MEDICAL 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 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 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

19. 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 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: average TREATMENT: 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

20. 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

21. 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

22. 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

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

24. ILLUSTRATION: PREGNANT WOMAN BP > 140/90 mmHg ≥ 20 weeks of gestation? YES NO PROTEINURIA? PROTEINURIA? YES NO • BP >160/110 mmHg • PROTEINURIA > 5g/ 24 hours • GESTATIONAL HYPERTENTION NEW OR INCREASED NO, or STABLE YES NO PREECLAMPSIA SUPERIMPOSED ON HYPERTENSION CHRONIC HYPERTENSION SEVERE PREECLAMPSIA PREECLAMPSIA SEIZURES ECLAMPSIA

25. ANATOMY AND PHYSIOLOGY

26. DIETARY FACTOR POOR NUTRITION RISK FACTOR: MULTIPLE PREGNANCY OR PRIMIPARAS YOUNGER THAN 20 YEARS OF AGE OR 40 YEARS 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

27. VII. SIGNS AND SYMPTOMS

29. 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

30. Intervention for severe PIH: • Maintain patient’s airway by putting a tongue blade or airway between a woman’s 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.

31. TREATMENT • Use of drugs • Catheterization • Obtaining labs

32. MEDICAL TREATMENT

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

35. 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

36. 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)

37. 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.

40. 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. 

41. 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

42. Thank you!! 