Question

AT&T LTE 11:43 AM A 40 year old 36 week pregnant patient presents to L&D. She is a G2P1. She complains of a headache, edema that has worsened in her face, right upper quadrant pain, and nausea. She also complains of visual changes and fatigue. She has 2+ protein in her urine on dipstick, and 2+ edema in her lower extremities. The fetal heart rate is 145 with moderate variability. She has no contractions, and her abdomen is soft. Her vital signs are: BP 138/86 HR 86 RR 20 Temp 98.4 What might the nurse expect is the patient's main problem? What would you want to know from her history? What further testing might be expected? What is your priority nursing diagnosis for her and what assessment findings validate this? What nursing interventions would you expect?

Answer 1

Answer :

1) in above information , the patient is having pre eclampsia

Pre eclampsia : pre eclampsia is a multisystem disorder of unknown etiology characterized by development of hypertension to the extent of 140 / 90 mm hg of more with proteinuria after the 20 th week in a previously normotensive and non proteinuric women .

- some amount of oedema is common in a normal pregnancy .

2) answer :

• Nurse should ask about the past obstetrical history about the gestational hypertension in her previous delivery.
• Nurse should ask about history of pre existing vascular diseases.
• Late pregnancy ( elderly primigravida ) is also one of the risk for gestational hypertension .
• Nurse should ask about any family history of pre eclampsia and hypettension .
• Obesity also one of the risk factor ,so nurse should collect the dietary habits of mother .

3) answer :

Diagnostic critercriteria for pre eclampsia :

• Check the BP : an absolute rise of BP of at least 140/90 mmhg.of rise of systolic blood pressure. About 30 mm hg and diastolic blood pressure about15 mm hg than previous BP.
• Opthalmoscopic examination : in severe cases there may be retinal edema .constriction of arterioles , nicking of veins and there may be a hemorrhage .
• Blood values : serum uric acid level more than 4.5 mg / dl
• Serum creatinine levels may be more than 1 mg .
• Hepatic enzymes levels increased
• Antenatal fetal monitoring : antenatal fetal well being assessment is done by clinical examination ,daily fetal kick count , ultrasonography for fetal growth and liquor pockets .
• Cardio tocography.
• Umbilical artery flow velocimetry and bio physical profile .

4) answer :

Nursing diagnosis :

• Fluid volume excess related to disease condition .
• Acute pain related to increased blood pressure
• Risk for injury related to blurred vision
• Sleep disturbance related to increased fetal movements .
• Decreased urine out put related to disease process .

5) answer :

Nursing intervention :

Objectives :

• To stabilize hypertension to prevent the patient for eclampsia .
• To prevent complications.
• To prevent eclampsia.
• To deliver the healthy baby in optimal time .
• Restoration of health of the mothervin purperium.

Nurse should monitor the BP of the mother

Nurse should advixe the mother for adequate rest and sleep

Advice the mother to take high protein diet.

Nurse should warned the mother about headache , visual disturbance ,vomitings , epigastric pain and scanty urine .

Administer the medications such as antihypertensives tab. Methyl dopa 250 mg tid .or nifedipine 10- 20 mg bd .

- advice the mother for caesarian section as possible if incase any abnormal health events of foetus on mother womb.

Monitor for eclampsic symptoms .