Preeclampsia Case Study

At 0600 Jennie is brought to the Labor and Delivery triage area by her sister. The lymph gland complains of a power hammer headache for the last 12 hours unrelieved by acetaminophen (Tylenol), swollen hands and face for 2 days, and epigastric pain described as bad center of attentionburn. Her sister tells the nurse, I felt like that when I had toxemia during my pregnancy. Admission judgement by the nurse reveals todays weight 182 pounds, T 99. 1 F, P 76, R 22, BP 138/88, 4+ pitting edema, and 3+ protein in the weewee. midpoint rate is regular, and lung sounds are clear.Deep tendon reflexes (DTRs) are 3+ biceps and triceps and 4+ patellar with 1 beat of ankle clonus. The nurse applies the external fetal monitor, which shows a baseline fetal heart rate of 130, absent variability, positive for accelerations, no decelerations, and no condensings. The nurse also performs a vaginal examination and finds that the cervix is 1 cm dilated and 50% effaced, with the fetal head at a -2 s tation. 1. In reviewing Jennies history, the nurse is correct in concluding that Jennie is in jeopardy of developing a hypertensive disorder because of her age (15).Which other factors add to Jennies fortune of developing preeclampsia? A)Molar pregnancy, history of preeclampsia in previous pregnancy. ill-advised musical composition every last(predicate) of these are risk factors for preeclampsia, Jennie has no indications of a molar pregnancy (first trimester vaginal bleeding, size/date discrepancy, or excessive nausea and vomiting), nor has she had any previous pregnancies (gravida 1). B)Gravidity, familial history. put Jennie is under 17 years of age, is pregnant for the 1st time, and has a sister with a history of toxemia, which is an old term for preeclampsia that some guests whitethorn still use.C)History of throb headache, low socioeconomic status. INCORRECT While age and low socioeconomic status (SES) are risk factors, Jennies SES is unknown. A pounding headache is a sym ptom, non a risk factor. D)Low socioeconomic status (SES), history of pedal edema. INCORRECT Although age and low SES are risk factors, this lymph glands SES is unknown. Pedal edema is common in pregnancy later 32- weeks. 2. To accurately assess this clients condition, what information from the prenatal record is most important for the nurse to reach? A)Pattern and number of prenatal visits. INCORRECTIt is important to have early and consistent prenatal care, but this information will non help in the assessment of this clients condition. B)Prenatal blood jam readings. CORRECT The clients BP (138/88) is below the guideline that indicates mild preeclampsia. Blood pressure parameters for mild preeclampsia include a reading of one hundred forty/90 taken on two occasions 6 hours apart. However, Jennies reading is significant if it is an increase of 30 mm systolic or 15 mm diastolic from her prenatal levels, particularly in combination with proteinuria and hyperuricemia (uric acid o f 6 mg/dl or more).Blood pressure usually remains the kindred during the first trimester. Both systolic and diastolic then decrease gradually up to 20-weeks gestation. At 20 weeks of gestation, the blood pressure begins to gradually increase and bribe to 1st trimester levels at term. C)Prepregnancy weight. INCORRECT The nurse should compare todays weight to Jennies most recently obtained previous weight, non to the prepregnancy weight. A weight gain of 2 pounds per week is indicative of mild preeclampsia. D)Jennies Rh factor. INCORRECTWhile the Rh factor of the mother is important in determining the need for prophylactic Rh immune globulin (RhoGAM) at 28-weeks and later birth, it is not the most important information at this time. All Rh negative women with negative Coombs tests are given RhoGam prophylactically at 28-weeks, and then evaluated immediately after birth to determine if another dose of RhoGam is needed. Pathophysiology of Preeclampsia There is no definitive cause of preeclampsia, but the pathophysiology is distinct. The main pathogenic factor is poor perfusion as a result of arteriolar vasospasm.Function in organs such as the placenta, liver, headspring, and kidneys can be depressed as much as 40 to 60%. As fluid shifts out of the intravascular compartment, a decrease in plasma volume and subsequent increase in hematocrit is seen. The edema of preeclampsia is generalized. almost all organ systems are changeed by this disease, and the mother and fetus suffer increasing risk as the disease progresses. Preeclampsia develops after 20 weeks gestation in a previously normotensive woman. Elevated blood pressure is frequently the first sign of preeclampsia.The client also develops proteinuria. While no longer considered a diagnostic measurement of preeclampsia, generalized edema of the face, hands, and abdomen that is not responsive to 12 hours of bedrest is often present. Preeclampsia progresses along a continuum from mild to severe preeclampsia, HELLP syndrome, or eclampsia. A client may present to the labor unit anywhere along that continuum. 3. What is the pathophysiology responsible for Jennies complaint of a pounding headache and the elevated DTRs? A)Cerebral edema. CORRECTAs fluid leaks into the extravascular spaces, organ edema as well as peripheral edema occurs. This, in conjunction with cortical brain spasms, causes headache, increased deep tendon reflexes, and clonus. B)Increased perfusion to the brain. INCORRECT The hypovolemia that accompanies preeclampsia decreases perfusion to the major organs. C)Severe anxiety. INCORRECT While Jennie may be very anxious, this is not the pathophysiology involved. D)Retinal arteriolar spasms. INCORRECT These spasms are the cause of blurred vision and scotoma that often accompany worsening of the disease.Jennies sister is very concerned about the bump (edema) in her sisters face and hands because it seems to be worsening rapidly. She asks the nurse if the healthcare provider wi ll prescribe some of those water pills (diuretics) to help get discharge of the excess fluid. 4. Which response by the nurse is correct? A)That is a very good idea. I will relay it to the healthcare provider when I call. INCORRECT Although it is caring to offer to relay family concerns to the healthcare provider, the physician will make the decision on treatment.B)Im sorry, but it is not the familys place to make suggestions about medical checkup treatment. INCORRECT While it is not inappropiate for family members to make suggestions, this answer is not sensitive to the sisters desire to help Jennie. C)Let me explain to you about the effect of diuretics on pregnancy. CORRECT The sister may have seen diuretics used for treating fluid retention before (for example, in cardiac disease), but may not be aware of how diuretics affect pregnancy. Diuretics decrease blood flow to the placenta by decreasing blood volume.In the case of the preeclamptic client, this is particularly dangero us because the disease has already caused a volume deficit. In addition, the diuretics break off normal electrolyte balance and stress kidneys that are already compromised by preeclampsia. The only time they are used is if the preeclamptic client also has heart failure, but this client has no symptoms of heart failure. D)Have you by any chance given your sister water pills that belong to someone else? INCORRECT This could be construed as hateful and accusatory.If the nurse believes further assessment is warranted, the nurse should ask Jennie about any medication she has taken. Admission to the Labor and Delivery Unit At 0630 the nurse calls to distinguish to the healthcare provider, who prescribes the following admit to labor and delivery, bedrest with bathroom privileges (BRP), IV D5LR at 125 ml/hr, CBC with platelets, clotting studies, liver enzymes, chemistry panel, 24-hour urine collection for protein and uric acid, ice chips only by mouth, nonstress test, hourly vital sign s, and DTRs. 5.While awaiting the lab results, which nursing intervention has the highest priority? A)Teach Jennie the rationale for bedrest. INCORRECT While this is important, it does not have the highest priority. B)Monitor Jennie for signs of dehydration. INCORRECT This is important because the client is restricted to ice chips only and may already be hypovolemic. However, it is not the highest priority. C)Educate the client about dietary restrictions. INCORRECT Since Jennie is currently taking ice chips only, this is not the most important intervention at this time. D)Observe Jennie for CNS changes.CORRECT Central unquiet System (CNS) changes such as severe headache, blurred vision, scotoma (spots before eyes), and photophobia indicate a worsening condition. 6. Which technique should the nurse use when evaluating Jennies blood pressure while she is on bedrest? A)Have Jennie lay supine and take the blood pressure on the leftover arm. INCORRECT The pregnant client should not lie in the supine position because it puts her at risk for vena cava compression and subsequent supine hypotensive syndrome. B)Have Jennie lie in a lateral position and take the blood pressure on the dependent arm.CORRECT The lateral position supports placental perfusion. The lower (dependent) arm should be positioned so the client is not lying on it, and the blood pressure should be taken in that arm. This more closely approximates arterial pressure. Using the arm on the opposer (upper) side will falsely reduce the measurement. C)Have the client sit in a chair at the bedside, and take the blood pressure with her left arm at waist level. INCORRECT While sitting is an appropriate position, the arm should be resting on a surface at heart level.In addition, Jennie is on bedrest with bathroom privileges, which does not include sitting up in a chair. D)Have Jennie stand briefly and take the blood pressure on the right arm. INCORRECT A standing blood pressure does not provide the most valid reading. In addition, Jennie is on bedrest with bathroom privileges, which does not include standing at the bedside. The nurse performs a nonstress test to evaluate fetal well-being. 7. When performing a nonstress test (NST), the nurse will be assessing for which parameters? A)Accelerations of the fetal heart rate in response to fetal movement. CORRECTThe seat for the nonstress test is that the normal fetus with an intact CNS will respond to fetal movements by increasing its heart rate (episodic accelerations). A reactive test is one in which the fetus displays at least 2 accelerations of 15 beats per morsel that last for 15 seconds in a 20-minute period in the presence of a normal baseline rate and moderate variability. B)Late decelerations of the fetal heart rate in response to fetal movement. INCORRECT Late decelerations are a sign of uteroplacental insufficiency, and are assessed for in response to uterine contractions, not fetal movement.C)Accelerations of the fetal heart rat e in response to uterine contractions. INCORRECT Accelerations that occur with contractions (periodic accelerations) are usually linked to breech presentations, and are not the basis for the nonstress test. D)Late decelerations of the fetal heart rate in response to uterine contractions. INCORRECT Late decelerations in response to uterine contractions are the basis for the contraction stress test. HELLP Syndrome At 0800, physical assessment and labs reveal the following the client is still complaining of a headache but the epigastric pain has just about decreased.While resting in a left lateral position, the vital signs are BP 146/94, P 75, R 18. Hyperreflexia continues with one beat of clonus. The baseline fetal heart rate is one hundred forty with moderate variability and no decelerations. Since completion of a reactive nonstress test, no further accelerations have occurred. Lab results include hemoglobin 13. 1 g/dl, hematocrit 40. 5 g/dl, platelets 120,000 mm3, aspartate amin otransferase (AST) slightly elevated, alanine aminotransferase (ALT) normal for pregnancy, 0 burr cells on slide, clotting studies normal for pregnancy.The healthcare provider diagnoses Jennie with preeclampsia sort of than HELLP syndrome, a variant of severe preeclampsia. 8. If Jennie had HELLP syndrome, which lab results would the nurse expect her to exhibit? A)Elevated hemoglobin and hematocrit (H&H) without burr cells, elevated liver enzymes, platelet guess 150,000 mm3. INCORRECT Elevated H&H without burr cells and platelets 150,000 mm3are not indicative of HELLP syndrome. B)Decreased hemoglobin and hematocrit (H&H) with burr cells, elevated liver enzymes, platelet count