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Case study pregnancy induced hypertension


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Case study pregnancy induced hypertension

  1. 1. I. Pregnancy Induced HypertensionII. Introduction Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur duringpregnancy 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 toxemiabecause researchers pictured a toxin of some kind being produced by a women in response to foreignprotein of the growing fetus, the toxin leading to the topical symptoms. No such toxins have ever beenidentified. A condition separate from chronic hypertension, PIH tends to occur most frequently in women ofcolor or with a multiple pregnancy; primiparas are younger than 20 years of age or older than 40 years,women from low socio economic backgrounds, those who have an underlying disease such as heartdisease, diabetes with vessel or renal involvement and essential hypertension. PIH is classified as gestational hypertension, mild preeclampsia, severe preeclampsia and eclampsia,depending on how far development advances. Gestational hypertension when develops an elevated bloodpressure but has no proteinuria or edema. Perinatal mortality is not increased with simple gestationalhypertension, so no drug therapy is necessary; and blood pressure returns to normal after birth.Mild preeclampsia when blood pressure rises to 140/90 mmHg or systolic pressure elevated 15 mmHgabove pregnancy level; mild edema in upper extremities or face. Severe preeclampsia when bloodpressure has risen to 160 mmHg systolic and 110 mmHg diastolic; proteinuria; pulmonary or cardiacinvolvement; extensive peripheral edema; hepatic dysfunction; theombocytopenia. Eclampsia is the mostsevere classification of PIH and seizure or coma Accompanied by s/s of preeclampsia. Any woman whofalls into one of the high-risk categories for PIH should be observed carefully for symptoms at prenatalvisits. She needs instructions about what symptoms to watch for so she can alert her clinician if additionalsymptoms occur between visits.Anatomy and Physiology: When most people hear the term cardiovascular system, they immediately think of the heart. Wehave all felt our own heart "pound" from time to time, and we tend to get a bit nervous when this happens.The crucial importance of the heart has been recognized for a long time. However, the cardiovascularsystem is much more than just the heart, and from a scientific and medical standpoint, it is important tounderstand why this system is so vital to life.Most simply stated, the major function of the cardiovascular system is transportation. Using blood as thetransport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substancesvital for body homeostasis to and from the cells. The force to move the blood around the body is providedby the beating heart. The cardiovascular system can be compared to a muscular pump equipped with one-way valves and a system of large and small plumbing tubes within which the blood travels.HEART:The heart is a muscular organ found in all vertebrates that is responsible for pumping bloodthroughout the blood vessels by repeated, rhythmic contractions.The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac iscalled the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, andprevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior tothe sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficiallayer, called the visceral layer, the middle layer, called the myocardium, and the third layer which iscalled the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The
  2. 2. atria are the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semilunar valve, and the pulmonary semilunar valve. Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation. Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung. Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood. Pulmonary arteries: The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen. Systemic arteries: Systemic arteries can be subdivided into two types – muscular and elastic – according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged. The Aorta:The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries. Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The aorta brings oxygenated blood to all parts of the body in the systemic circulation. The aorta is usually divided into five segments/sections: Ascending aorta—the section between the heart and the arch of aorta Arch of aorta—the peak part that looks somewhat like an inverted "U" Descending aorta—the section from the arch of aorta to the point where it divides into the common iliac arteries o Thoracic aorta—the half of the descending aorta above the diaphragm o Abdominal aorta—the half of the descending aorta below the diaphragm Arterioles: Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries. Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart. Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small. Superficial veins: Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries. Deep veins: Deep veins are deeper in the body and have corresponding arteries.
  3. 3. Pulmonary veins: The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs tothe heart.Systemic veins: Systemic veins drain the tissues of the body and deliver deoxygenated blood to theheart.Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventriclein the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood toreturn to the heart. There is at least one atrium in animals with a closed circulatory system.Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receivesdeoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it intothe right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix.Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from thepulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve.Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than aventricle) and pumps it out of the heart.Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receivesdeoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary arteryvia the pulmonary valve and pulmonary trunk.Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receivesoxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aorticvalve.Pathophysiology of Pregnancy Induced Hypertension (PIH): Preeclampsia is a characterized, by vasospasms, changes in the coagulation system, anddisturbances in systems related to volume and BP control. Vasospasms results from an increasedsensitivity to circulating pressures, such as angiotensin II, and possibly an imbalance between theprostaglandins prostacyclin and thromboxane A1.Endothelial cell dysfunction, believed to result from decreased placental perfusion, may account for manychanges in preeclampsia. Arteriolar vasospasm may cause endothelial damage and contribute to anincreased capillary permeability. This increase edema and further decreases intravascular volume,predisposing the woman with preeclampsia to pulmonary edema.Immunologic factors may play an important role in the development of preeclampsia. The presence of aforeign protein, the placenta, or the fetus maybe perceived by the mother’s immune system as an antigen.This may then trigger an abnormal immunologic response. This theory is supported by the increasedincidence of preeclampsia or eclampsia in first-time mothers or to multiparous woman pregnant by a newpartner. Preeclampsia maybe an immune complex disease in which the maternal antibody system isoverwhelmed from excessive fetal antigens in the maternal circulation. This theory seems compatiblewith the high incidence ofpreeclampsia among women exposed to a large mass of trophoblastic tissue asseen in twin pregnancies or hydatidiform moles. Genetic predisposition maybe another immunologic factor. Dekker reported a greater frequencyof preeclampsia and eclampsia among daughters and granddaughters of women with a history ofeclampsia, which suggests an autosomal recessive gene controlling the maternal immune response.Paternal factors are also examined.Diets in inadequate nutrients, especially protein, calcium, sodium, magnesium, and vitamin E and C,maybe an etiologic factor in preeclampsia. Some practitioners prescribed high-protein diets (90 mgsupplemental protein) without caloric restriction and moderate sodium intake in the prevention andtreatment of this disorder. However, data are limited regarding the association between dietand preeclampsia.
  4. 4. Preeclampsia progress along a continuum from mild disease to severe preeclampsia, HELLP syndrome, or eclampsia. The pathophysiology of preeclampsia reflects alteration in the normal adaptations of pregnancy. Normal physiologic adaptations to pregnancy include increase blood plasma volume, vasodilation, and decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathologic changes in the endothelial cells of the glomeruli are uniquely characteristic of preeclampsia, particularly in nulliparous women. The main pathogenic factor is not an increase in BP but poor perfusion as a result vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises BP. Function in organs such as the placenta, kidneys, liver and brain is deceased by as much as 40% to 60%. Clinical Manifestations: A. 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 B. 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 C. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures
  5. 5. III. General Patient History NerissaMantala, 18 years old, female currently residing at Barangay Ilaya, Calapan City wasadmitted to the hospital by stretcher with guard last December 25, 2011, with chief complaint ofdizziness and blurred vision and vomiting. Patient can’t manipulate finger because of edema.Patients’blood pressure is 190/ 130mmHg. Nerissa is G1P0, 33 4/7 weeks of gestation. Her husband is SamuelMantala, 23 years old, OFW in Dubai. Her last menstrual period was May 4, 2011 and her weight of 150 lbs. Her mother also has ahistory of hypertension. She has no hospitalization record except when she was 8 years old; she wasoperated because of appendicitis.
  6. 6. IV. Nursing AssessmentActivities of Daily Living and Lifestyle Before Hospitalization During Hospitalization Sleep Sleep 7-8 hours 10 hours with nap during afternoon and morning Eating pattern Eating pattern 4 times a day eating NPO, IV fluid (3 cups of rice every meal Activities with meat & no vegetables), Complete bed rest (merienda: 2 packs of chicharon,150 grams packs per pack) Activities Watching television, going to the market, cooking meals, Going to the park and visiting the health center, go to church weeklyV. Physical Assessment Patient lying on bed, hair untidy, with catheter and IV fluid of 500mL on the right arm General appearance Clean, no unusual odor and clothing is in good condition and appropriate for climate. Temperature: 37.2°C Pulse rate: 120bpm(60 to 100 normal range) Respiratory rate: 30 breaths per minute Blood pressure: 190/130mmHg FHT: 150 Skin, Hair and Nails Skin: normal color (light brown) Dry skin, warm to touch Hair: normal distribution of hair, silky Nail beds are pink Head: symmetrical Eyes Symmetrical, no discharge Ears Pinna recoils back, symmetrical
  7. 7. Mouth, Throat, Nose and Sinuses Dry mouth because she was NPO Stomach Bowel movement normal Hands and soles of the feet Warm to touch 3+ edema on extremities, can’t wear wedding ringVI. Review of System  Circulatory System: rapid heart rate, increase of blood pressure  Digestive System: vomiting, normal bowel movement  Endocrine System: normal  Integumentary System: formation of edema on extremities  Musculoskeletal System: altered body movements  Respiratory System: tachypnea  Urinary System: micturition with catheter  Reproductive System: no discharge  Nervous System: seizure  Lymphatic System: normal
  8. 8. Pregnancy- InducedHypertension Case Study Submitted to: Mrs. Matimtiman Chavez, RN Clinical Instructor Submitted by: Cleofe, Russwyn L. De Guzman, Prince Lester M. Ignacio, Kiarra Levina A. Macagaling, Reah A.
  9. 9. BSN 2Discharge planning:Exercise 1. Encouragepatients on deep breathing exercises. 2. Move extremities when lying. 3. Elevate the head part when sleeping, to promote increase peripheral circulation 4. Encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth. 5. Exercises like tailor sitting, squatting, Kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery.Treatment: 1. Use of drugs 2. Catheterization 3.Obtaining labs. (CBC, platelets count, liver function, BUN and creatinine,Health Teaching: 1. Encourage patient foe sodium restriction. 2. Encourage to avoid foods rich in oil and fats. 3. Encourage patient to limit her daily activities and exercises.Ongoing Assessment: 1. Observe carefully for symptoms at prenatal visit. 2. Give instruction about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.Diet: 1. Low fats and sodium diet, restriction if possible. 2. High in protein, calcium and iron. 3. Adequate fluid intakeSex: 1. limit sexual activity