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Included In This Lesson
Study Tools
Hypertension Assessment (Picmonic)
Preeclampsia Interventions (Picmonic)
Preeclampsia Assessment (Picmonic)
Preeclampsia Pathochart (Cheat Sheet)
HELLP Syndrome Pathochart (Cheat Sheet)
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Example Nursing Diagnosis for Gestational Hypertension, Preeclampsia, Eclampsia
- Risk for Maternal Injury: Preeclampsia can lead to maternal harm due to complications such as seizures, organ dysfunction, or placental abruption. This diagnosis highlights the potential risks.
- Altered Fluid Volume: Preeclampsia often involves fluid retention and edema. This diagnosis addresses the imbalances in fluid volume.
- Anxiety: Patients with preeclampsia may experience anxiety due to the uncertainty and potential severity of the condition, warranting assessment and intervention.
Transcript
Hey guys, today, we're going to go over gestational hypertension and how to put this on a care plan.
First, let's go through what we are going to cover in this lesson. Obviously we're going to be covering gestational hypertension, but I also want to note that we're going to kind of break this down and make sure you understand the difference between that, preeclampsia and eclampsia, because they can all run together and some of our assessment data that we'll see, will overlap. So we'll go through that. We're going to look at the outcome that we want for this patient, the expected outcome. We're going to look at the subjective data and the objective data that we gather to put on our care plan and then of course, how we're going to intervene. So some nursing interventions, as well as the rationales.
So, why are we doing what we're doing and what should we see happen? For this care plan, our medical diagnosis is going to be gestational hypertension, our pathophysiology of this. This is high blood pressure and what's important to know is it's during the second half of pregnancy. So, the patient has to be over 20 weeks pregnant. Okay, If they are under 20 weeks, then don't do gestational hypertension for your care plan. That patient won't be chronic hypertensive. They have to be 20 weeks pregnant or more and then, they have to have a few blood pressures, at least two that are 140 over 90 or in that range. Then hopefully, we'll have this resolved at around six weeks after delivery. So our etiology, the cause is a little bit unknown, but there's definitely some things that are going to put a patient more at risk. If the patient already has some kidney disease or diabetes that they're dealing with prior to pregnancy, those patients will be more at risk. Also, if they've had gestational hypertension in a previous pregnancy, then they'll be more at risk to have it again. Some other risk factors are going to be twins or carrying multiples. Think about it, you have extra volume, extra weight on you because you're growing more than one baby. They're also going to be more at risk if they're younger than 20 or older than 40 and being African-American is another risk factor for these patients. So what is our desired outcome? These patients will have a controlled blood pressure at, or below 140 over 90. That is our outcome that we want to achieve. This will help with optimal functioning of the organ system. So we're not going to cause chronic damage. If we can get our blood pressures in a good range, we want to see good kidney function and good organ function and then the patient will hopefully carry the pregnancy as close to term as possible.
Okay, so here's our care plan and we're going to go through our subjective and objective data first and then we'll go through some interventions and rationale. So our subjective data, remember that's what the patient observes. So what is the patient reporting? So if they're telling us they have a headache, vision changes, they're nauseous, some stomach pain, which is usually the upper right side of the abdomen, or we know it as epigastric pain, but they'll just refer to it as stomach pain, those are our subjective data that will gather for our care plan.
Objective data. So what we are observing is a blood pressure over 140 over 90. Remember, they have to have that as a diagnostic tool for this. Some other signs are swelling of face, hands and feet. So this area, face, hands and feet are the most common areas that they'll start to all of a sudden get really swollen and retain water, as well as sudden weight gain because they're retaining water. They might have some vomiting and decreased urine output, especially if those kidneys are not being perfused because of the high blood pressure and then proteinuria. So, let me make this clear. Proteinuria is going to go with preeclampsia. So, if this patient has gestational hypertension and suddenly they start having proteinuria, they're going to be diagnosed with preeclampsia and we'll get to that in our interventions as well as what we'll do for that and the rationale behind it.
Alright, so these are our first three interventions I want to look at for our subject of data. We're going to monitor a patient's vital signs, particularly blood pressure, assess for edema and then weigh the patient or have her weigh herself if she's at home. So, why are we doing this? Let's look at our rationale. We're monitoring the vital signs, particularly the blood pressure, because remember this is our big diagnosis of this, right, is that 140 over 90 or more? So, our big diagnostics tool... So looking at that blood pressure, the blood pressure may fluctuate some or spike quickly. So, we're just going to monitor for changes in those elevations. Then we're going to assess for edema, and remember, typically the hands, face and feet, so just checking for signs of the edema. Now, swelling is totally normal for pregnant women, but if they're all of a sudden getting super swollen, especially in the hands and the face, we're going to be concerned about that, so we're going to watch for that and pay attention to it. Then, we are specifically also looking at pitting edema too. That's just a lot of fluid coming on fast and we worry about as they're getting closer into the preeclampsia phase and then weigh the patients. So remember, they're getting that extra volume on board, so weighing them, we'll see those rapid fluctuations in weight gain. Watch for fluid retention and remember that fluid retention when they have that, it's just kind of signifying that there's a progression of the disease and that we're having impaired renal function because the kidneys can't get it out.
Alright guys, so that is all your subjective data with your interventions and your rationale. Now, next let's take a look at our objective data. For our interventions, we are going to assess the heart and lungs. We're going to note the rate and the rhythm. We're going to administer IV fluids and medications as appropriate and then we're also going to monitor the fetal heart rate. Now, let's look at our rationale for this. So what are we doing? We are going to assess the heart and lungs, noting the rate and rhythm. The reason for this is that we basically want to monitor for our fluid signs. So, are we hearing some crackles in there, is there fluid, we're checking for fluid overload now and administering IV fluids. This is going to vary if the patient's fluid-overloaded. We're probably not going to give too much fluid, right, but if appropriate, we'll administer and the big thing here is our medications. So our big drug that we give, labetalol and hydralazine, so giving some antihypertensives to help bring down that blood pressure. And then, if the patient has that proteinuria, so if they are Preeclamptic and remember to be preeclamptic, you have to have protein, just remember the P and the P, those patients are going to get mag sulfate given to them. That mag sulfate is given to prevent seizures. A seizure happening means the patient has gone from preeclamptic to eclamptic and just refer to our lesson in the OB section on hypertensive in hypertension in pregnancy to go over more in detail, but we're going to give mag sulfate and the reason why is that it's a seizure prevention medication, but it's also going to lower blood pressure. So, kind of killing two birds with one stone. So, mag sulfate, alright, so we're going to give those meds. Now, we're going to monitor the fetal heart rate. We'll remember we don't just have a mom as a patient here, right? A pregnant patient, so we have a baby there too. That's also our patient. We need to monitor that fetal heart rate to make sure that it's tolerating. So we need a good heart, a fetal heart and that's going to help indicate that the baby's doing okay in the environment. If at any time the baby is not tolerating or doing well, then we can deliver that baby, if we're close to that point in the pregnancy. This is going to show that the baby's not in fetal distress. So think about this okay, if the mom's blood pressure is super high, then blood flow through the placenta is not going to go well, so we have decreased placental blood flow through that placenta and that means that the fetus is not getting the oxygen and the nutrients that it needs, and that will be shown in the heart rate. So, if the fetal heart rate is starting to not look so good, then it's because we don't have good blood flow coming through that placenta.
Okay guys, here is the whole care plan for you to take a look at, with all of our interventions and our rationales. Alright guys, I hope that helped you break down gestational hypertension for your care plan. We love you guys. Now, go out and be your best self today and as always, happy nursing!
First, let's go through what we are going to cover in this lesson. Obviously we're going to be covering gestational hypertension, but I also want to note that we're going to kind of break this down and make sure you understand the difference between that, preeclampsia and eclampsia, because they can all run together and some of our assessment data that we'll see, will overlap. So we'll go through that. We're going to look at the outcome that we want for this patient, the expected outcome. We're going to look at the subjective data and the objective data that we gather to put on our care plan and then of course, how we're going to intervene. So some nursing interventions, as well as the rationales.
So, why are we doing what we're doing and what should we see happen? For this care plan, our medical diagnosis is going to be gestational hypertension, our pathophysiology of this. This is high blood pressure and what's important to know is it's during the second half of pregnancy. So, the patient has to be over 20 weeks pregnant. Okay, If they are under 20 weeks, then don't do gestational hypertension for your care plan. That patient won't be chronic hypertensive. They have to be 20 weeks pregnant or more and then, they have to have a few blood pressures, at least two that are 140 over 90 or in that range. Then hopefully, we'll have this resolved at around six weeks after delivery. So our etiology, the cause is a little bit unknown, but there's definitely some things that are going to put a patient more at risk. If the patient already has some kidney disease or diabetes that they're dealing with prior to pregnancy, those patients will be more at risk. Also, if they've had gestational hypertension in a previous pregnancy, then they'll be more at risk to have it again. Some other risk factors are going to be twins or carrying multiples. Think about it, you have extra volume, extra weight on you because you're growing more than one baby. They're also going to be more at risk if they're younger than 20 or older than 40 and being African-American is another risk factor for these patients. So what is our desired outcome? These patients will have a controlled blood pressure at, or below 140 over 90. That is our outcome that we want to achieve. This will help with optimal functioning of the organ system. So we're not going to cause chronic damage. If we can get our blood pressures in a good range, we want to see good kidney function and good organ function and then the patient will hopefully carry the pregnancy as close to term as possible.
Okay, so here's our care plan and we're going to go through our subjective and objective data first and then we'll go through some interventions and rationale. So our subjective data, remember that's what the patient observes. So what is the patient reporting? So if they're telling us they have a headache, vision changes, they're nauseous, some stomach pain, which is usually the upper right side of the abdomen, or we know it as epigastric pain, but they'll just refer to it as stomach pain, those are our subjective data that will gather for our care plan.
Objective data. So what we are observing is a blood pressure over 140 over 90. Remember, they have to have that as a diagnostic tool for this. Some other signs are swelling of face, hands and feet. So this area, face, hands and feet are the most common areas that they'll start to all of a sudden get really swollen and retain water, as well as sudden weight gain because they're retaining water. They might have some vomiting and decreased urine output, especially if those kidneys are not being perfused because of the high blood pressure and then proteinuria. So, let me make this clear. Proteinuria is going to go with preeclampsia. So, if this patient has gestational hypertension and suddenly they start having proteinuria, they're going to be diagnosed with preeclampsia and we'll get to that in our interventions as well as what we'll do for that and the rationale behind it.
Alright, so these are our first three interventions I want to look at for our subject of data. We're going to monitor a patient's vital signs, particularly blood pressure, assess for edema and then weigh the patient or have her weigh herself if she's at home. So, why are we doing this? Let's look at our rationale. We're monitoring the vital signs, particularly the blood pressure, because remember this is our big diagnosis of this, right, is that 140 over 90 or more? So, our big diagnostics tool... So looking at that blood pressure, the blood pressure may fluctuate some or spike quickly. So, we're just going to monitor for changes in those elevations. Then we're going to assess for edema, and remember, typically the hands, face and feet, so just checking for signs of the edema. Now, swelling is totally normal for pregnant women, but if they're all of a sudden getting super swollen, especially in the hands and the face, we're going to be concerned about that, so we're going to watch for that and pay attention to it. Then, we are specifically also looking at pitting edema too. That's just a lot of fluid coming on fast and we worry about as they're getting closer into the preeclampsia phase and then weigh the patients. So remember, they're getting that extra volume on board, so weighing them, we'll see those rapid fluctuations in weight gain. Watch for fluid retention and remember that fluid retention when they have that, it's just kind of signifying that there's a progression of the disease and that we're having impaired renal function because the kidneys can't get it out.
Alright guys, so that is all your subjective data with your interventions and your rationale. Now, next let's take a look at our objective data. For our interventions, we are going to assess the heart and lungs. We're going to note the rate and the rhythm. We're going to administer IV fluids and medications as appropriate and then we're also going to monitor the fetal heart rate. Now, let's look at our rationale for this. So what are we doing? We are going to assess the heart and lungs, noting the rate and rhythm. The reason for this is that we basically want to monitor for our fluid signs. So, are we hearing some crackles in there, is there fluid, we're checking for fluid overload now and administering IV fluids. This is going to vary if the patient's fluid-overloaded. We're probably not going to give too much fluid, right, but if appropriate, we'll administer and the big thing here is our medications. So our big drug that we give, labetalol and hydralazine, so giving some antihypertensives to help bring down that blood pressure. And then, if the patient has that proteinuria, so if they are Preeclamptic and remember to be preeclamptic, you have to have protein, just remember the P and the P, those patients are going to get mag sulfate given to them. That mag sulfate is given to prevent seizures. A seizure happening means the patient has gone from preeclamptic to eclamptic and just refer to our lesson in the OB section on hypertensive in hypertension in pregnancy to go over more in detail, but we're going to give mag sulfate and the reason why is that it's a seizure prevention medication, but it's also going to lower blood pressure. So, kind of killing two birds with one stone. So, mag sulfate, alright, so we're going to give those meds. Now, we're going to monitor the fetal heart rate. We'll remember we don't just have a mom as a patient here, right? A pregnant patient, so we have a baby there too. That's also our patient. We need to monitor that fetal heart rate to make sure that it's tolerating. So we need a good heart, a fetal heart and that's going to help indicate that the baby's doing okay in the environment. If at any time the baby is not tolerating or doing well, then we can deliver that baby, if we're close to that point in the pregnancy. This is going to show that the baby's not in fetal distress. So think about this okay, if the mom's blood pressure is super high, then blood flow through the placenta is not going to go well, so we have decreased placental blood flow through that placenta and that means that the fetus is not getting the oxygen and the nutrients that it needs, and that will be shown in the heart rate. So, if the fetal heart rate is starting to not look so good, then it's because we don't have good blood flow coming through that placenta.
Okay guys, here is the whole care plan for you to take a look at, with all of our interventions and our rationales. Alright guys, I hope that helped you break down gestational hypertension for your care plan. We love you guys. Now, go out and be your best self today and as always, happy nursing!
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