Transcript CASE PRESENTATION - Dr. Ahmad Abanamy Hospital

CASE PRESENTATION
PREPARED BY:
DIANA ROSE S. DELA CUEVA
LR/DR DEPARTMENT
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
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 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
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
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.
ILLUSTRATION:
PREGNANT WOMAN
BP > 140/90 mmHg
YES
≥ 20 weeks
of
gestation?
NO
PROTEINURIA?
PROTEINURIA?
YES
NO
BP >160/110
mmHg
PROTEINURIA >
5g/ 24 hours
GESTATIONAL
HYPERTENTION
NEW OR
INCREASED
NO, or
STABLE
PREECLAMPSIA
SUPERIMPOSED ON
HYPERTENSION
CHRONIC
HYPERTENSION
NO
YES
SEVERE
PREECLAMPSIA
PREECLAMPSIA
SEIZURES
ECLAMPSIA
ANATOMY AND PHYSIOLOGY
RISK FACTOR:
MULTIPLE PREGNANCY OR
PRIMIPARAS YOUNGER
THAN 20 YEARS OF AGE OR
40 YEARS
DIETARY
FACTOR
POOR
NUTRITION
DISTURBED
SLEEPING
PATTERN
HYDRAMNIOS
DIABETES, HEART
DISEASE OR RENAL
INVOLVEMENT
CAUSE:
UNKNOWN
VASOSPASM
VASCULAR
EFFECTS
VASOCONSTRICTION
POOR ORGAN
PERFUSION
INCREASED BLOOD
PRESSURE
KIDNEY EFFECTS
DECREASED GLOMERULI
FILTRATION RATE AND
ULIINCRESED
PERMEABILITY OF
GLOMERULI MEMBRANES
INTERSTITIAL
EFFECTS
DIFFUSION OF FLUID
FROM BLOOD
STREAM INTO
INTERSTITIAL TISSUE
INCREASED SERUM
BLOOD UREA
NITROGEN, URIC ACID
AND CREATININE
DECREASED URINE
OUTPUT AND
PROTEINURIA
EDEMA
VII. SIGNS AND SYMPTOMS
VIII. NURSING INTERVENTION
Intervention for mild PIH:
1.
2.
3.
4.
5.
6.
7.
8.
9.
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
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
position
5. Support patient with bed rest and darken the room if
possible.
6. Monitor maternal well being
7. Monitor fetal well being
8. Support a nutritious diet
9. Administer medications to prevent eclampsia
10. Provide emotional support.
TREATMENT
1.Use of drugs
2.Catheterization
3.Obtaining labs
MEDICAL TREATMENT
NAME OF DRUG
DOSAGE
ROUTE
TIME
DURATION
FREQUENCY
20mg
IV
0125H
STAT
If diastolic BP
>110mmHg
may give 40
mg IV
30ml NSS + 20ml
labetalol IV
IV
1-2mg/ min
STAT
200mg
PO
0600H- 1200H- 1800H
1 DAY
5mg
IV
0150H
STAT
1 DAY
q6°
1 DAY
q8°
1.
Labetalol 100mg/20ml
1.
Labetalol infusion
1.
Labetalol Tablet
1.
Diazepam (Valium) Pregnancy
risk category D
1.
Methyldopa (ALDOMET TABLET)
500mg
PO
1.
Nifedifine
20mg
PO
0400H-1000H-1600H2200H
0100H- 0900H- 1700H
1.
1.
Aspirin
Ranitidine Tablet (Rantag)
81mg
150mg
PO
PO
0600H
0600H- 1200H- 1800H
1 DAY
1 DAY
OD
TID
1.
1.
1.
Dexamethasone
Calcium Tablet
FeSO4 Tablet
6mg
600mg
100mg
IM
PO
PO
0130H-1330H
1800H
0600H
1 DAY
1 DAY
1 DAY
q12°
OD
OD
ADDITIONAL MEDICATIONS:
1. Hydrazaline (Apresoline)
Pregnancy risk category C
5mg
IV
1.
Magnesium Sulfate (Pregnancy
risk category B)
4mg
IV
1.
Calcium Gluconate (Pregnancy
risk category C)
1g
IV
TID
LABORATORY TEST
• Assessment for High Risk of
Developing Preeclampsia
Goal: Establish baseline levels
early in pregnancy and
monitor for progression to
HELLP or severe preeclampsia.
TEST
Glucose(random)
RESULT
27/12/12
4.0
Urea
2.4
Creatinine
41.8
28/12/12
29/12/12
REFERENCE RANGE
31/12/12
1/1/13
3.9-7.8 mmol/L
41.4
Uric acid
3.7
1.8-8.3 mmol/L
34.7
F: 46-92 mmol/L
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
Chloride
108
Calcium
2.16
AST(SGOPT)
ALT(SGPT)
Albumin
Cholesterol
22.8
17.2
31.6
5.01
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
65.1
236.44
214.47
Alkaline phosphate
LDH
CBC

Hbg

Hct

Plt
Urinalysis

Total Protein

Pus cells
24 ° Urine Protein
11.9
33.2
184
105
33.3
11.0
30.6
198
17.6
12.9
28.9
5.18
16.4
11.3
10-38 U/L
10-41 U/L
34-48g/L
3.1-5.2 mmol/L
221.38
3.9-4.7 mmol/L
35-129 U/L
135-225 U/L
10.9
30.5
187
12.3
33.6
173
2+
1-3/HPF
2+
10-15/HPF
3383.34
11.2-15.7 g/dL
34.1-44.9%
182-369/UL
1+
8-12/HPF
10-140 mg/ 24 hrs
324
13.3
44.2
98-111 mmol/L
2.20-2.55 mmol/L
3+
2-3/HPF
Fibrinogen
PT
APTT
0.65-1 mmol/L
168-435 mg/dL
12.5
40.4
10.1-17.0 seconds
26.1-36.3 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. 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)
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
CUES/
NURSING
EVIDENCE
DIAGNOSIS
SUBJECTIVE:
“ I feel
headache”
OBJECTIVE:
1. Rising BP or
widening pulse
pressure
2.Followed by
hypotension and
labile vital signs
3.Pulse changes
with bradycardia
changing to
tachycardia
4.Respiratory
irregularities
Hyperthermia
followed by
hypothermia
V/S taken as
follows:
BP: 160/110
mmHg
PR: 87 bpm
RR: 22 cpm
Temp.: 37◦C
Ineffective
cerebral
perfusion
related to
decreased
cardiac
output
secondary
to vascular
vasospasm
PLANNING
GOALS &
DESIRED
OUTCOME
IMPLEMENTATION
NURSING
RATIONALE FOR
ORDER/ACTION
ACTION
1. Establish and
1. Tachycardia &
Within 12
maintain airway,
changes in BP
hours of
breathing, and
can reflect effect
nursing
circulation
of systemic
intervention ,
hypoxemia on
patient will
cardiac funtion
have stable
2. Encourage deep
2. Oxygen delivery
Vital Signs
slow or pursed lip
may be
brathing as
tolerated
3. Position on side
4. Administer
antihypertensive
drugs as ordered
EVALUATION
EVALUATION
After 12
hours of
nursing
intervention,
the goal was
partially met
as evidenced
by:
improved &
breathing
BP and other
exercises help to vital
decrease
parameters
dyspnea & work
stable
of breathing
3. to promote
placental
perfusion
4. To lower the
pressure in the
blood stream
ASSESSMENT
PLANNING
CUES/
NURSING GOALS & DESIRED
EVIDENCE
DIAGNOSIS
OUTCOME
SUBJECTIVE:
“lesh ana alatul
fi sudha?”
(Why do I
always feel
headache?)
as verbalized by
the patient.
OBJECTIVE:
1. Request for
information.
2.Agitated
behavior
3.Inaccurate
follow through
of instructions.
V/S taken as
follows:
BP: 160/110
mmHg
PR: 87 bpm
RR: 22 cpm
Temp.: 37◦C
Knowledge
Deficit: the
management
of therapy
and
treatment
related to
misinterpreta
tion of
information.
After 12 hours of
nursing
interventions, the
patient will
verbalize
understanding of
the disease process
and treatment
regimen.
IMPLEMENTATION
NURSING
RATIONALE FOR ACTION
ORDER/ACTION
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 without
symptom 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.
EVALUATION
EVALUATION
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!! 