High Risk OB: Hypertensive Disorders in Pregnancy
risk factors for pre E
age, first pregnancy/new partner, maternal medical conditions (renal disease, molar pregnancy, diabetes, chronic HTN), multiple gestation
vasospasm (eyes)
scotomata - a partial loss of vision or blindspot can see the vasculature in retina without being invasive
magnesium sulfate
smooth muscle relaxant, anticonvulsant, interferes with the ability of ACh to decrease CNS irritability decreases BP
What happens in hemolysis?
*KNOW* vasospasm --> endothelial damage (leaky vessels) --> platelet plugs (use faster than you can make them) --> platelet clumps --> irregular vessel lining --> tear and break RBC as they try to pass through --> hemolysis --> burr cells
What is the therapeutic blood level of MgSO4?
4-7 mEq/L; need to make sure patient is peeing because pt excretes through the kidneys. If too high --> respiratory distress. If higher --> code.
What % of pregnancies are affected by HTN?
6-8%
How often should a baby move?
> 10 times per hour
mild pre E
BP > 140/90 protein > 1+ 30 mg/dL 300 mg in 24 hr urine
severe pre E
BP > 160/90 protein > 2+ 2 grams in 24 hour urine swollen fingers and toes (peri-orbital edema)
Why do you need to continually assess patient after BP has decreased from hypertensive crisis?
Baby was tolerating 160/110 but once BP is down to 130/80, you may see late decelerations.
vasospasm (renal)
Decreased GFR, retained BUN, creatinine, uric acid, Na, H2O, lost protein (albumin) eventual oliguria (small amounts of urine) decreased colloid osmotic pressure leads to edema intravascular shifts lead to hemoconcentration
calculation of MgSO4
Dosage = 40g in 1000mL IVF Give a 4-6g load bolus then 2g/hr
HELLP syndrome
H - hemolysis EL - elevated liver enzymes LP - low platelets
Lab results in pre E
H&H increase platelets decrease liver enzymes increase BUN, creatinine, uric acid increase urine protein
RN intervention for mild pre E
Patient teaching - daily weights, BP, urine dipstick, kick counts, modified bedrest, follow-up visits 2-3 times per week, medications (methyldopa, Aldomet)
maternal risk factors for HRP
age extremes, inadequate prenatal care, unmarried status, non-white race, low education
A client with mild pre E is admitted to the high-risk prenatal unit because her blood pressure is progressively increasing. The nurse reviews the practitioner's prescriptions. What prescriptions does the nurse expect? Select all that apply. a. daily weight b. side-lying bed rest c. 2-gram sodium diet d. deep tendon reflexes e. glucose tolerance test
a, b, d side-lying increases perfusion
Which interventions are included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. a. Monitoring deep tendon reflexes b. Assessing urine output every 8 hours c. Maintaining a dark, quiet environment d. Using a pump to regulate the medication e. Having calcium gluconate available at the bedside f. Notifying the care provider if the respiratory rate is slower than 20 breaths/min
a, c, d, e *Measure urine every hour and <12 breaths/min
high risk pregnancy
any pregnancy in which the life or health of the mother or baby is endangered by a disorder either coincidental with the pregnancy or unique to the pregnancy (biophysical, psychosocial, sociodemographic, environmental)
A nurse in the prenatal clinic is assessing a woman at 34 weeks' gestation. The client's blood pressure is 166/100 mmHg and her urine is +3 for protein. She states that she has a severe headache and occasional blurred vision. Her baseline blood pressure was 100/62 mmHg. What is the priority nursing action? a. Arranging transportation to the hospital b. Obtaining a prescription for an antihypertensive c. Rechecking the blood pressure within 30 minutes d. Obtaining a prescription for acetaminophen to relieve the headache
arranging transportation to the hospital
What happens to DTRs in HTN?
become brisk
clonus sign
bend toes to nose rapidly; count how many times it bounces (more bounces, increases the risk of a seizure)
underlying result of pre E
blood vessels don't dilate correctly so blood increases and vasospasms occur --> decreased vessel size --> elevated BP --> decreased perfusion
burr cells
broken RBCs
chronic vs. gestational HTN in pregnancy
chronic - patient already diagnosed with HTN who just happens to be pregnant; gestational - elevated BP dx after 20 wks GA, no other symptoms high BP > 140/90
newborn risk factors of HRP
congenital abnormalities, preterm/LBW, SIDS, respiratory distress, maternal complications (HTN, diabetes, heart problems), racial/ethnicity
vasospasm (liver)
decreased liver fx, elevated enzymes liver swells and causes epigastric pain
hemolysis
destruction of RBCs on platelets in blood vessels
s/s pre E
elevated BP, proteinuria, edema
hepatic edema
epigastric or RUQ pain, capsular rupture
If patient's BP is consistently >160/110 and the patient enters hypertensive crisis, what medication to give?
hydralazine (Apressoline) push slowly over 3-5 min or BP will crash, N/V, dizzy, baby crashes. Take BP q5min 3X after.
RN assessment for pre E
interview physical exam (weight, BP, edema, fundoscopy - look @ back of eye and retina for vasculature, DTR/clonus - deep tendon reflex), labs (H&H, liver enzymes, BUN, uric acid #s will increase) fetus - FHT, BPP, US, Doppler flow - measures the pressure and perfusion in the umbilical cord increased weight, BP, edema DTR will become hyperactive
vasospasm (fetus)
intrauterine growth restriction (IUGR), placenta gets old and calcifies
cerebral edema
irritability in CNS --> seizures
peripheral and pulmonary edema
lower extremity edema is not unusual in pregnancy. pulmonary edema s/s: crackles in lungs, decreased pulse ox, wet-sounding cough
causes of pre E
placenta-related
With regard to pre E and eclampsia, nurses should be aware that:
pre E results in decreased function in such organs as the placenta, kidneys, liver, and brain
preeclampsia (pre E)
pregnancy-only condition, "cure" is to not be pregnant anymore. There are spiral arteries that go to uterus, supposed to dilate but in pre E, they don't dilate.
RN interventions for severe pre E
steroids, external fetal monitoring (EFM), patient teaching, seizure precautions, medications to increase fetal maturity (surfactant on fetal lungs), induction of labor in hospital Listen for crackles on Mama's lungs, O2 sat, urinary output (30 mL/hr = adequate), check monitor, and DTRs.
eclampsia
the onset of seizure activity or coma in a patient with no previous history 1/3 occur in pregnancy, 1/3 occur in labor, 1/3 occur within 72 hrs postpartum
RN interventions for eclampsia seizures
time the seizure, move anything around them, stay in the room (hit call light/call for help), evaluate at the end