Introduction

Terminology used in describing hypertension in pregnancy has changed over many years

of studying the disease process. Hypertension as defined by the National High Blood Pressure in

Pregnancy (2000) is a blood pressure 140 mmHg systolic or higher or 80 mmHg diastolic or

higher. The classifications of pregnancy-induced hypertension are as follows: 1. Pre-eclampsia-

eclampsia, is pregnancy-specific syndrome usually occurring after twenty weeks’ gestation. The

diagnosis is determined by (1) increased blood pressure, over 140mmHg systolic or over

80mmHg diastolic in a woman who has had normal blood pressure before twenty weeks’

gestation; and (2) preoteinuria, which is defined as more than 0.3 g of protein in a 24-hour urine

collection. Eclampsia, is the occurrence of seizures in a pregnant woman who has pre-eclampsia

that cannot be attributed to another cause. 2. Gestational hypertension, is used to describe blood

pressure elevation occurring for the first time after midpregnancy and without proteinuria. This

diagnosis may change to that of pre-eclampsia if other symptoms develop. Moreover, the

definitive diagnosis of gestational hypertension can only be made if the hypertension has

resolved after 12 weeks postpartum.

There are other hypertensive disorders that are present in a pre-pregnant woman that also

progress during pregnancy, these hypertensive disorders are not directly regarded as pregnancy-

induced: 1. Chronic Hypertension, is defined as hypertension that occurs before pregnancy or is

diagnosed before 20 weeks’ gestation. Hypertension diagnosed for the first time during

pregnancy that persists beyond the postpartum period also is classified as chronic hypertension.

The cause of chronic hypertension had been determine, the goals of care are to prevent the
development of pre-eclampsia and to ensure normal growth of fetus. 2. Chronic hypertension

with superimposed pre-eclampsia, is “highly likely”with the findings of (1) women with

hypertension and no proteinuria before 20 weeks of gestation that have new onset of proteinuria;

and (2) women who have hypertension and proteinuria before 20 weeks’ gestation who develop

any of the following: (a) sudden increase in proteinuria, (b) sudden increase in blood pressure,

(c) thrombocytopenia, (d) increase in alanine aminotransferase or aspartate aminotransferase. A

woman with chronic hypertension who develops superimposed preeclampsia often progresses

quickly to eclampsia, sometimes before 30 weeks of pregnancy.

Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during

pregnancy in both small and large arteries. It is the development of new arterial hypertension in

a pregnant woman after 20 weeks gestation. If the patient have high blood pressure before twenty

weeks, it is likely the patient had it before she become pregnant. If that is the case, she has

essential or chronic hypertension, a pre-existing condition. Moreover, hypertension can arise

before twenty weeks if the woman has multiple fetuses or a hydatidiform mole.
HYPERTENSIVE DISORDERS OF PREGNANCY.

CHRONIC TYPE CRITERIA

1. Chronic Hypertension 2. BP = above or exactly 140/90 mmHg
before pregnancy or 20 weeks’ gestation.
3. BP elevation persists beyond the
postpartum period.

2. Chronic Hypertension with 1. Chronic Hypertension that progresses to

superimposed pre-eclampsia preeclampsia.

PREGNANCY-INDUCED
TYPE
1. Pre-eclampsia-eclampsia 2. BP= above or exactly140/90 or mmHg
after 20 weeks gestation.
3. With proteinuria.

2. Gestational Hypertension* 1. BP= above or exactly 140/90mmHg

2. Occurring for the first time after 20
weeks’ gestation.
3. Without proteinuria.

High blood pressure in pregnancy (gestational hypertension) is usually mild. It probably

would not cause any problems for the baby. Still, experts say that prenatal care will be best

managed by an obstetrician if you develop gestational hypertension. If the blood pressure is

found to be too high the patient may be prescribed with drugs, which are safe for the baby, to

lower the blood pressure.

Statistics

It is occurs in 5% to 7% of pregnancies in the United States. Despite years of research,

the cause of the disorder is still unknown. Originally it was called toxemia because researchers

pictured a toxin of some kind being produced by a women in response to foreign protein of the

growing fetus, the toxin leading to the topical symptoms. No such toxins have ever been

identified.

Preeclampsia in Southeastern Asia (Extrapolated Statistics)

East Timor 548 1,019,252
Indonesia 128,273 238,452,952
Laos 3,264 6,068,117
Malaysia 12,653 23,522,482
Philippines 46,392 86,241,697
Singapore 2,342 4,353,893
Thailand 34,893 64,865,523
Vietnam 44,467 82,662,800
 A condition separate from chronic hypertension, PIH tends to occur most frequently in

women of color or with a multiple pregnancy; primiparas 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 heart disease, diabetes with vessel or renal involvement and essential

hypertension.

At the end of this case study, the student nurses will be able to:

Define and verbalize understanding regarding the different factors that could lead to

Pregnancy induced hypertension and its effects/complications on the patient’s physiological and

psychological conditions

1. Identify and enumerate signs and symptoms of gestational hypertension

2. Identify and enumerate nursing responsibilities in providing care to the patient

3. Verbalize understanding regarding the pathophysiology of gestational hypertension

II. NURSING ASSESSMENT

1. Personal Data

A. Demographic Data

Mrs PIH, 24 years of age, was born on May 17, 1985 in Mindanao Agusan del Sur, a Roman Catholic,

and a natural born Filipino citizen. She is married to Mr PIH, who is 44 years of age, and is currently residing at

Pandacaqui Camias. She was admitted last July 12, 2010 with chief compliant of labor pain.

B. Socio-economic and Cultural Factors

 Mrs. PIH is currently a plain housewife, and a fulltime mother to their 4 children. Her husband, Mr. PIH,

is a palamig vendor in front of university somewhere in San Fernando. Mr. PIH sister helps, finances the

couple’s hospitalization.

Mrs. PIH does not believe in faith healers and “herbularyos”. Whenever she has fever, colds, or cough,

she buys over-the-counter drugs. And sometimes they consult to health center near their house.

C. Environmental Factors

Mrs. PIH and Mr., PIH were living in a medium concrete house with an adequate ventilation and

space for living together with their sisters (husband side). They also have an organized and proper garbage

disposal system that safeguards them from hazardous health risks.

 Family Health History

Schematic diagram

Ingracia
Mercado Froilan Mercado
Carmelita Zamuel
Magachulon Mangubat

Patien Husban
F F F M F F
t d

M
F F M M
LEGENDS: NB

= Deceased
 Mrs PIH is fourth among the 5 children of Carmelita and zamuel, while Mr. PIH is the eldest among the
3, and his father died because of gunshot and eventually his mother also died due to heart attack. According to
them both sides has no history of hypertension.

4. Maternal History

a. Maternal and obstetrics record

According to Mrs. PIH she had her first menstruation when she was 16 years old. She is not married and

at the age of 18 when she had her first sexual intercourse. Her OB score is G5P5 (5005), all her pregnancies

were delivered via NSD. Her last menstrual period is October 14, 2009. Expected date of confinement was

July 21, 2010 with an age of gestation of 38 5/7 weeks. She had delivered her youngest child last July 12, 2010

at Balitucan District Hospital.

Prenatal preparation

According to Mrs. PIH, she visits her obstetrician regularly as ordered on her previous pregnancies. But

on her last baby, she only had three prenatal checkups.

5. History of present illness

According to Mrs. PIH she did not have any issues regarding her pregnancies. According to her, she is

not aware that her blood pressure rises whenever pregnant. Furthermore, she did not have any problems

regarding her previous pregnancies in relation to the present disease condition.

6. Physical examination (IPPA-Cephalocaudal Approach)

July 12, 2010 (initial and final nurse patient interaction)

Vital signs:
 Temp: 37.3°C

PR: 100bpm

RR: 26bpm

BP: 140/80mmHg

SKIN: fair complexion, dry skin, no jaundice, pinched skin goes back immediately. Capillary refill at 2 seconds

HEAD: head is proportional to the body, no tenderness palpated,

EYES: (+) PERRLA, eyebrows are well-distributed, no cataract observed, pink palpebral conjunctiva and

anicteric sclera

EARS: are symmetrical, no tinnitus, no discharges, no lesion

NOSE: no difficulty of breathing

MOUTH AND THROAT: dry lips, low voice, tongue can be protruded, and teeth are complete.

NECK: full neck motion without pain, there is no inflammation upon palpation, no lump and no swollen lymph

node.

CHEST: symmetrical chest expansion, no masses and tenderness upon palpation

GASTROINTESTINAL: no ulcer

PERIPHERAL VASCULAR: nail beds are pink, with good capillary refill time (2sec)

UPPER EXTREMITIES: hands and arms are well shaped and are proportional to the body, no swelling and

no tenderness observed.

LOWER EXTREMITIES: (-) Homan’s sign, bipedal edema grade 1.

NEUROLOGIC: general body weakness due to presence of pain

III. DIAGNOSIS AND LABORATORY PROCEDURE

Diagnostic/ Indications or Date Results Normal Values Analysis and

Laboratory Purpose Ordered/ Interpretation
Procedure Date Results of Results
were release

Hematocrit -Hemoglobin is a 07/12/08 HGB – 12.2 HGB: HGB is normal,

and protein in red
Hemoglobin blood cells that HCT – 39.0% F: 12-16 HCT is normal,
carries oxygen-to M: 14-18
ensure both
adequate oxygen HCT:
carrying capacity
F: 40-54
and hemostasis
M: 37-47
- Hematocrit is a
blood test that
measures the
percentage of the
volume of whole
blood that is
made up of red
blood cells. This
measurement
depends on the
number of red
blood cells and
the size of red
blood cells.

-The hematocrit
is almost always
ordered as part of
a complete blood
count.

- To determine
the patient’s
blood type for
possible blood
transfusion if
massive
 hemorrhage
occurs.

Blood Blood type

Typing “B”

Anatomy and Physiology:

Data have suggested that PIH may be the result of increased peripheral vascular resistance secondary to

generalized vasospasm when the vessels are no longer refractory to the effects of pressor agents. New research

proposes that elevated cardiac output and associated hyper dynamic vasodilation during the first trimester result

in damage to the endothelium with compensatory vascular vasodilation. Regardless of the mechanisms, PIH is a

chronic disease process, with a decrease in placental perfusion occurring before the late sign of hypertension is

detected.

When most people hear the term cardiovascular system, they immediately think of the heart. We have 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 cardiovascular system is much more

than just the heart, and from a scientific and medical standpoint, it is important to understand why this system is

so vital to life.

Most simply stated, the major function of the cardiovascular system is transportation. Using blood as the

transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital

for body homeostasis to and from the cells. The force to move the blood around the body is provided by 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.
Blood Pressure Mechanisms

Central Nervous System

Medulla Oblongata; it relays motor and sensory impulses between other parts of the brain and the spinal

cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal.

Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter.

Hypothalamus; it controls and integrates activities of the autonomic nervous system and pituitary gland.

It regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates

eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Moreover, it

also produces the hormones oxytocin and antidiuretic hormone.

Cardiovascular System

Baroreceptor; are pressure-sensitive sensory receptors, located in the aorta, internal carotid arteries, and

other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla

oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus

reflex and the aortic reflex.

Chemoreceptors; are sensory receptors that monitor the chemical composition of blood, are located close to the

baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic

bodies, respectively. These chemoreceptors detect changes in blood level of O2, CO2, and H+.

Renal System

Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases,

juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin

converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises

blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by

increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases

reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood vlume,

which increases blood pressure.

Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in

response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which

increases blood pressure.

Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing

vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume.
HEART:

The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout

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 is called the

fibrous pericardium. This sac protects

the heart, anchors its surrounding

structures, and prevents overfilling of

the heart with blood. It is located

anterior to the vertebral column and

posterior to the sternum. The size of

the heart is about the size of a fist and

has a mass of between 250 grams and

350 grams. The heart is composed of

three layers, all of which are rich with

blood vessels. The superficial layer,

called the visceral layer, the middle

layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers,

two superior atria and two inferior ventricles. The 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.

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.
 Systemicveins

Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.

Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral

ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood

to return 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 receives

deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the 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 the

pulmonary 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 a

ventricle) and pumps it out of the heart.

Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives

deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the

pulmonary valve and pulmonary trunk.

Ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives

oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve
IV. PATHOPHYSIOLOGY (BOOK-BASED)

SCEMATIC DIAGRAM OF PREGNANCY INDUCED HYPERTENSION

2. Synthesis of the disease

A. Definition of the Disease

Gestational hypertension is characterized by hypertension occurring for the first time

after midpregnancy without proteinuria. It is called transient hypertension if preeclampsia does

not develop and if the blood pressure returns to normal within 12weeks following childbirth.

Pregnancy-induced hypertension is classified into three categories: 1. gestational

hypertension, 2. mild preeclampsia, 3. severe preeclampsia and 4. eclampsia, depending on how

far development advances. It is Gestational hypertension when the patient develops an elevated

blood pressure but has no proteinuria or edema. Perinatal mortality is not increased with simple

gestational hypertension, so no drug therapy is necessary; and blood pressure returns to normal

after birth. It is mild preeclampsia when blood pressure rises to 140/90 mmHg or systolic

pressure elevated 15 mmHg above pregnancy level; mild edema in upper extremities or face.

Lastly, Severe preeclampsia when blood pressure has risen to 160 mmHg systolic and 110

mmHg diastolic; proteinuria; pulmonary or cardiac involvement; extensive peripheral edema;

hepatic dysfunction; thrombocytopenia. Eclampsia is the most severe classification of PIH and it

is manifested by seizure and accompanied by signs and symptoms of preeclampsia.

Predisposing/Precipitating Factors

Many theories regarding the cause of gestational hypertension have been proposed but

none were proven. Gestational hypertension has been shown to occur commonly in the

primipara, in women with gestational diabetes mellitus, in multiple gestation pregnancies and in

older women who have an increased incidence of chronic hypertension.

 The etiology of preeclampsia is not fully understood. The exact causes of preeclampsia
and eclampsia are not known, although some researchers suspect poor nutrition, high body fat or
insufficient blood flow to the uterus as possible causes. Other causes may include altered
cardiovascular reactivity, increased capillary permeability, widespread vasospasm and
hypertension.

Risk factors may include the following: previous history of preeclampsia, relative with a
history of preeclampsia, multiple fetuses, teenaged patient or patient older than 35 years,
primigravida, lower socioeconomic status, gestational diabetes, history of renal disease and
obesity prior to pregnancy.

B. Pathologic Changes

Maternal

Central nervous system changes associated with gestational hypertension are headache,

sub occipital region- pain and edema. Cerebral vasospasm causes headache, pain in the sub

occipital region is due to elevated blood pressure, and edema is a common manifestation in

pregnancy. There is also increased risk for renal failure, abrupio placenta, DC, ruptured liver,

and pulmonary embolism if the patient progress to pre-eclampsia..

Fetal-neonatal

Infants with gestational hypertension tends to be small for gestational age (SGA). The

cause is related specifically to maternal vasospasm and hypovolemia, which results in fetal

hypoxia and malnutrition.

 The symptoms of preeclampsia affect almost all organs. The effects of preeclampsia are
primarily due to the vasospasm of blood vessels. Vascular spasm maybe caused by the increased
cardiac output that injures the endothelial cells of the arteries and imbalance between
prostacycline (vasodilator) and thromboxane (vasoconstrictor) leading to vasoconstriction of
blood vessels and blood pressure increases. Because of this, peripheral resistance increases and
the heart is forced to pump rapidly to supply blood to peripheral organs.

Peripheral resistance reduces blood supply to organs especially to the kidneys, brain and
placenta. Because of low blood and oxygen supply, degenerative changes occur within the
organs and manifested by various symptoms. The effects of vasospasm are more on vascular,
kidney and interstitial effects. If accompanied by seizures, it is eclampsia.

In the kidneys, vasospasm leads to increased permeability of the glomerular membrane,

allowing albumin to escape into the urine (proteinuria). Other changes include a decreased
glomerular filtration leading to oliguria and increased kidney tubular reabsorption of sodium
leading to edema. Also, the osmotic pressure of the circulating blood falls and fluid diffuses from
the circulatory system into the interstitial spaces resulting in increased edema. As a result of
significant increase in bodily fluid, rapid weight gain occurs. Poor placental perfusion may
reduce the fetal nutrient and oxygen supply putting the fetus at risk.

In preeclampsia, edema accumulates in the upper part of the body (face and hands).
Cerebral edema (swelling of the brain tissue due to an accumulation of fluid) can also occur as a
result of fluid retention in the brain. Symptoms of cerebral edema include blurred vision and
severe headache. Cerebral edema can lead to seizure which is the hallmark of eclampsia.

ORGAN OR SYSTEM POTENTIAL CHANGES AND

 COMPLICATIONS
MATERNAL

Cardiopulmonary Pulmonary edema, hypertensive crisis,

stroke.

Hematolgic Thrombocytopenia, hemorrhage,

disseminated intravascular coagulation.

Hepatic Hematoma, rupture.

Neurologic Retinal detachment(rarely), cerebral

edema, seizres, cerebral hemorrhage,
coma.

Renal Decreased glomerular filtration,

increased plasma uric acid and
creatinine, necrosis (rarely)
FETAL Intrauterine growth restriction, hypoxia,
intrauterine growth, prematurity.

Pathologic changes are directly associated with the elevation of blood pressure of about

140/80 mmHg in any type of hypertensive disorders during pregnancy such as gestational

hypertension. Pathologic complications are associated with the severe elevation of blood

pressure that commonly manifests in eclampsia.

C. Signs and Symptoms

Triad of Symptoms (3 classic signs of preeclampsia)

1. Hypertension (systolic BP greater than 160 mm Hg or diastolic BP greater than

110 mm Hg)
 Vasospasm of blood vessels causes vasoconstriction and increased
peripheral resistance leading to an increase in blood pressure.
2. Proteinuria
 Vasospasm in the kidneys increases blood flow resistance leading to
increased permeability of the glomerular membrane because of back
pressure. This allows protein (albumin) to escape into the urine.
3. Edema
 Caused by an increased kidney tubular reabsorption of sodium and
sodium retains fluid causing edema. Fluid diffuses from the circulatory
system into the interstitial spaces because of decreased osmotic pressure
causing extensive edema.

Other symptoms associated with eclampsia:

 Rapid weight gain (over 2 lbs per week in the second trimester, 1 lb per
week in the third trimester)
1. Caused by a significant increase in bodily fluid.
 Oliguria (decreased urine output)
1. a decreased in glomerular filtration leads to a lowered urine output
 Puffy face, hands, and dependent areas such as ankles and lower legs
1. caused by fluid retention in the upper portion of the body including
the brain (cerebral edema)
 Severe headache
1. caused by the swelling of the brain tissue due to an accumulation
of fluid(cerebral edema) which increases pressure on the cerebral
arteries
  Blurring of vision
1. Spasm of the arteries in the retina leads to vision changes and the
presence of cerebral edema
 Epigastric pain and nausea
1. caused by the vascular congestion and ischemia of the liver
 Impaired liver function (elevated hepatic enzymes-alanine
aminotransferase (ALT) (new name for SGPT) or aspartate aminotransferase (AST)(new
name for SGOT)
1. due to decreased hepatic perfusion
 Thrombocytopenia
1. due to platelet aggregation
 Fetal growth restriction
1. due to decreased uteroplacental perfusion or placental ischemia
 Precipitating
PREECLAMPSIA-ECLAMPSIA (Client-Centered)
factors

• Diet
Predisposing factors
• Low socioeconomic
• Family History of factor
Hypertension
• Multiple Pregnancy

Decreased level of Prostacyclin and

increased level of thromboxane

Vasospasm

Vascular Effect on Effects on the

effects kidney interstitial
tissue
Vasoconstrictio
n Decreased renal Fluid diffusion
perfusion from vascular
Hypertension space into
Decreased GFR intensive because
JULY 12,
Glomerular of decreased
capillary
Bipedal Edema

July 12, 2010

Decease Increased
Bipedal Edema
d serum sodium
albumin reention July 12, 2010
Decreased plasma colloid osmotic
pressure

Increased extracellular fluid

Decreased intravascular

Hypertension

JULY 12,
2010
2. Synthesis of the disease

Gestational hypertension is characterized by hypertension occurring for the first time after

midpregnancy without proteinuria. It is called transient hypertension if preeclampsia does not develop

and if the blood pressure returns to normal within 12weeks following childbirth.

CLIENT CENTERED

Predisposing/Precipitating factors

• Multiple Pregnancy- G5P5

• Low socioeconomic status – related to inadequate and insufficient nutrition
• Diet- patient likes to eat food rich in fats

Sign and symptoms

• Hypertension- July 12, 2010(140/10 mmHg)

• Bipedal Edema – July 12, 2010
V. PATIENT AND HER CARE

1. Medical Management
a. Intravenous Fluids

Medical Date ordered Indication Client’s

Management Response to
Date treatment
Discontinued

5% Dextrose July 12, 2010 To increase The patient did

in Lactated vascular/ not manifest
Ringer’s plasma any allergic
Solution July 12, 2010 volume reaction or
necessary irritation on
(30gtts/min) during the
bleeding or venipuncture
blood loss site.

It also serves
as medium for
administration
of
medications.

Nursing responsibilities
-Verify the doctor’s order.
-Establish rapport with the patient.
-Confirm patient’s identification.
-Explain the procedure to the patient.
-Practice hand hygiene.
-Set-up appropriate equipment and supplies to be use.
- Choose appropriate vein.
-Perform venipuncture according to standards.
-Regulate the flow rate according to doctor’s order.
-Monitor IV infusion or any untoward reaction.

b. Pharmacotherapy

Name of Date Route, Classificatio Client’s

Drugs Ordered Dose & n& Response
Frequenc Mechanism to
Date y of Action Treatmen
Change t
d

Amoxicilli July 12, Oral Antibiotic

n 2010

500mg Bactericidal:
Generic Inhibits
Name: synthesis of
T.I.D cell wall of
Amoxicillin sensitive
trihydrate organisms,
causing cell
death.
Brand
Name:

Apo-Amoxi

Nursing Responsibilities

BEFORE
-Verify the doctor’s order.
-Confirm patient’s identification.

DURING
-Inform the patient about the name of the drug, its action, and what she can expect after taking it.
-Advise the patient to take the drug before meals to enhance bioavailability of the drug.

AFTER
-Monitor the patient for any untoward reaction.
 Name of Date Route, Classificatio Client’s
Drugs Ordered Dose & n& Response
Frequenc Mechanism to
Date y of Action Treatment
Change
d

Mefenami July 12, Oral NSAID

c Acid 2010

500mg Anti-
Generic inflammatory,
Name: analgesic, and
T.I.D antipyretic
Mefenamic activities
acid related to
inhibition of
prostaglandin
Brand synthesis;
Name: exact
mechanisms
Ponstan
of action are
not exact.

Nursing Responsibilities

BEFORE
-Verify the doctor’s order.
-Confirm patient’s identification.
DURING
-Inform the patient about the name of the drug, its action, and what she can expect after taking it.
-Advise to take the drug with food to decrease GI upset.
-Advise to take only the prescribed dosage.

AFTER
-Check if the patient manifests any untoward side effects of the drug.

Name of Drugs Date Route, Classification Client’s

Ordered Dose & & Mechanism Response
Frequency of Action to
Date Treatment
Changed

July 12, Oral Oxytocic

2010
Methergine

0.2mg A partial
agonist or
Generic Name: antagonist at
Methylergonovine T.I.D alpha receptors;
maleate as a result, it
increases the
strength,
duration, and
Brand Name:
frequency of
Methergine uterine
contraction.
Nursing Responsibilities

BEFORE
-Verify the doctor’s order.
-Confirm patient’s identification.

DURING
-Inform the patient about the name of the drug, its action, and what she can expect after taking it.

AFTER
-Monitor the post partum women for BP changes, amount and character of vaginal bleeding, and for any
untoward reaction of the drug.

Name Date Route, Classification & Client’s

of Ordered Dose & Mechanism of Response
Drugs Frequenc Action to
Date y Treatmen
Change t
d

Ferrou July 12, Oral Iron preparation

s 2010
Sulfate
325mg Elevates the
serum iron
Generic concentration,
Name: O.D. which helps to
form Hgb or
Ferrous trapped in the
 Sulfate reticuloendothelia
l cells for storage
and eventual
Brand conversion to a
Name: usable form of
iron.
Apo-
ferrous
Sulfate

Nursing Responsibilities

BEFORE
-Verify the doctor’s order.
-Confirm patient’s identification.

DURING
-Inform the patient about the name of the drug, its action, and what she can expect after taking it.
-Advise to take the drug with food to prevent GI discomfort.
-Warn patient that her stool may be dark or green.
-Advise to avoid foods like milk, eggs, coffee, and tea because this will decrease the absorption of the
drug.

AFTER
-Monitor the patient for any untoward reaction.

Name of
drugs Date Ordered Route of Client’s response
(Generic taken/given administration General Classification/ to the medication
Name/ Brand Date Change/ Dosage and with actual side
Name) Mechanism of Action
D/C Frequency effects

Generic DO: July 10, 10mg IV if BP Antihypertensive The BP of the

Name 2009 140/90mmHg patient was
Hydralazine is a vasodilator reduced from
that works by relaxing the
Hydralazine muscles in your blood vessels 180/80mmHg to
to help them dilate (widen). 150/90mmHg
DC: July 11, 50mg tab BID This lowers blood pressure
2009 and allows blood to flow more
Brand Name
easily through your veins and
Hydralazine arteries. Hydralazine is used to
HCl treat high blood pressure
(hypertension)

NURSING RESPONSIBILITIES:

Before

Wash hands before preparing medications.

Check and verify doctor’s order.

Check the drug label and expiration date.

During

Verify patient’s name.

Use aseptic technique.

Administer the medication slowly to reduce the pain felt by the patient.

Inform client to take it with meals.

After

Chart the medication that means it is given.

c. Diet

Type of Date General Indication Client’s

Diet Ordered Description Response

Date
Changed

Nothing July 12, Withhold To Client

Per 2010 oral foods decrease complied,
Orem and fluids the no
(NPO) from a workload unusual
July 12, patient. of the reactions
2010 stomach noted.
and
intestine.

Nursing Responsibilities

Before
-Check for doctor’s order.
- Check for the patient’s name.

During
-Explain to the patient the purpose of the ordered diet.
-Monitor patient participation in the said order.

After
-Closely monitor for signs or adverse effect.
- Monitor for patients vital signs

Type of Date General Indication Client’s

Diet Ordered Description Response

Date
Changed
 Diet As July 12, Diet that To replace No
Tolerated 2010 includes all caloric evidence
foods that daily of GI
(DAT) are nutrient upset
considered loss. noted.
as a
person’s
daily diet. It is
ordered
when a
client is
already
capable of
resuming
its normal
GIT worth
load
tolerance.

Nursing Responsibilities

Before
-Check for doctor’s order.
- Check for the patient’s name.

During
-Explain to the patient the purpose of the ordered diet.
-Monitor patient participation in the said order.

After
-Closely monitor for signs or adverse effect.
- Monitor for patients vital signs

d. Activity/Exercises
Type of Exercise Date ordered/ General Indication/ Purpose Client’s Response
Date changed Description
Light Range of DO: July 12, Includes bed In response with the Client participated
Motion 2010 exercises arm effect of the well.
motion, leg rotation surgical
and side lying 2hrs/ management with
each side the patient.

Nursing Responsibilities:

Before:

· Check for the doctor’s order

· Check for the patient identification
During:

· Explain the procedure

· Support the patient during exercise.
· Check and remove for the hazardous things close to the patient.
After:

· Check for the clients reaction and response

· Check for the bleeding of the incision
· Monitor for the vital sign
Type of exercise Date Ordered/ General Indication / Clients reaction
Date Started/ Description Purpose to the activity /
Date Change exercise

Bed Rest (no actual order Bed rest is This is indicated Client was able to
set) necessary to help for the client to rest and condition
client regain help her rest and somehow became
This is somehow strength and avoid regain strength better.
done after the
 operation. aggravation of the
disease

Early Walking/ (no actual order Brisk Walking Walking is a best (not evaluated)
Ambulation set) exercise for it
helps enhance
Preferably when body circulation
client gained for faster healing
control of herself and coping.
well.

Passive Exercise (no actual order Client should This promotes (not evaluated)
set) assisted by proper blood
significant other in circulation and
Preferably when performing good muscle tone
client gained exercises like arm even if client is
control of herself and leg flexion inactive due to her
well. and rotation condition.

Nursing responsibilities

In bed rest:

1. Explain to the significant other the importance of bed rest.

2. Tell SO that bed rest is necessary in order to prevent complications of the client’s disease
condition.

In Early Walking/Ambulation & Passive Exercise:

1. Explain the procedure to the client

2. Explain to the patient the relevance of the exercise especially to her health
Advice patient to perform each series of exercise twice
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
Cues Explanation
Acute Pain related
Subjective: to cerebrovascular Unpleasant After 4 hours of Monitored vital Provides baseline The patient will:
pressure as sensory and Nursing sign. for comparison
“Sumasakit ang evidence by pain emotional Intervention the and evaluate -Demonstrate use
batok ko.” in suboccipital experience arising patient will be able response for of relaxation
region from the actual or to: intervention technique skill and
potential dsamage. diversional
Objective: -Demonstrate use To reduce tension acitivities
of relaxation skill Instructed to use
T: 36.5 and diversional relaxation -Report is
PR: 65 activities technique such as relieved/contolled
RR: 26 breathing To evaluate
BP: 140/80 -Report is response for -Pain scale will
relieved/contolled Encouraged intervention decrease from 8/10
verbalization of to 3/10
-Diaphoresis -Pain scale will feelings about pain
decrease from 8/10 To prevent fatigue
-Irritable to 3/10. Encouraged
adequate rest
-Restless periods To promote
nonpharmacologic
-Facial Grimace Provided comfort al pain
measure management
-Pain Scale of For the patient to
8/10 know that it can
affect responses to
Determined factors analgesic/ choice
in client’s lifestyle, of interventions for
such as alcohol pain management
and drug abuse
S: O: A: P: I: E:

“Sumasakit ang T: 36.5 Acute Pain related After 4 hours of Monitored vital The patient will:
batok ko.” PR: 65 to cerebrovascular Nursing Intervention sign.
RR: 26 pressure as evidence the patient will be -Demonstrate use of
BP: 140/80 by pain in able to: Instructed to use relaxation technique
suboccipital region relaxation technique skill and diversional
-Diaphoresis such as breathing acitivities
-Demonstrate use of
-Irritable relaxation skill and Encouraged -Report is
diversional activities verbalization of relieved/contolled
-Restless feelings about pain
-Report is -Pain scale will
-Facial Grimace relieved/contolled Encouraged decrease from 8/10
adequate rest to 3/10
-Pain Scale of 8/10 -Pain scale will periods
decrease from 8/10
to 3/10. Provided comfort
measure

Determined factors
in client’s lifestyle,
such as alcohol and
drug abuse
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
Cues Explanation
Decrease Cardiac
Subjective: Output related to Inadequate blood After 4 hours of Monitored vital Provides baseline
altered heart pumped by the Nursing sign. for comparison
rhythm as heart to meet the Intervention the and evaluate
Objective: evidence by BP of metabolic demands patient will be able response for
140/80, pallor and of the body. to: intervention
T: 36.5 delayed capillary >
PR: 65 2 secs. -Participate in To note
RR: 26 activities that Monitored cardiac effectiveness of
BP: 140/80 reduce the rhythm meds/ assistive
workload of the device
-Tachypnea heart, such as
stress To promote
-Pallor management, Provided quiet adequate rest
balanced environment
-Cool moist skin activity/rest plan To decrease
Kept client on bed oxygen
-Capillary refill -Manifest a and rest position of consumption and
> 2 secs decrease in blood comfortable. risk of
pressure from decompensate
-Use of 140/80 to 120/80.
accessory Encourage To reduce anxiety
muscle relaxation
technique
-nasal flaring To increase oxygen
Administered high available for
flow oxygen cardiac function
and tissue
perfusion
S: O: A: P: I: E:

T: 36.5 Decrease Cardiac After 4 hours of Monitored vital The patient will
PR: 65 Output related to Nursing signs. demonstrate
RR: 26 altered heart rhythm Intervention the decrease episodes
BP: 140/80 as evidence by BP patient will be able Kept client on bed of dysrhythmias
of 140/80, pallor to: and rest position of and will participate
-Tachypnea and delayed comfortable. in activities that
capillary > 2 secs. -Participate in reduce the
-Pallor activities that Provided quiet workload of the
reduce the environment heart, such as stress
-Cool moist skin workload of the management and
heart, such as stress Encourage balance activity/
-Capillary refill > management, relaxation technique rest plan.
2 secs balanced
activity/rest plan Administered high
-Use of accessory flow oxygen
muscle -Manifest a
decrease in blood
-nasal flaring pressure from
140/80 to 120/80.
Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation
Cues Explanation
Ineffective tissue
Subjective: perfusion related Increase cardiac After 4 hours of Monitored blood To know the After 4 hours of
to vasoconstriction output that endures Nursing pressure. current blood Nursing
Objective: of the blood the endothelial Intervention the pressure of the intervention the
vessels cells of the arteries patient blood patient patient blood
BP: 140/80 and the action of pressure will pressure was
prostaglandins. decrease form Instructed to have To prevent sudden decrease from
Capillary refill Vasoconstriction 140/80 mmHg to enough rest and increase of blood 140/80 mmHg to
>3 sec occurs and blood 120/80 mmHg semi fowlers pressure and for 120/80 mmHg.
pressure increase. position lung expansion.
Oliguria

Sodium tends to be
Instructed to eat exerted at faster
low salt and low rate
fat diet
To control BP and
Administered anti- avoid other
hypertensive drug complication that
as ordered may manifest.

To decrease the
Encouraged use of tension level
relaxation
activities.
S: O: A: P: I: E:

T: 36.5 Ineffective tissue After 4 hours of Monitored blood After 4 hours of

PR: 65 perfusion related Nursing pressure. Nursing
RR: 20 to vasoconstriction Intervention the intervention the
BP: 140/80 of the blood patient blood Instructed to have patient blood
vessels pressure will enough rest and pressure was
Capillary refill >3 decrease form semi fowlers decrease from
sec 140/80 mmHg to position 140/80 mmHg to
120/80 mmHg 120/80 mmHg.
Oliguria Encouraged use of
relaxation
activities.

Instructed to eat
low salt and low
fat diet

Administered anti-
hypertensive drug
as ordered
 VII. DISCHARGE PLANNING

M Instructed patient to continue the following medications:

• Hydralazine 59mg/tab BID (10am-3pm)

• Methergine
• Ferrous sulfate
• antibiotics

E Encouraged to avoid strenuous activities to prevent further complication.

Continue/ follow medication regimen strictly in appropriate dosage and

T frequency.

H Encouraged patient to have a complete bed rest.

Encouraged patient to have a diversional activities such as reading

newspaper or watching T.V

Encouraged patient to eat nutritious foods rich in Iron and Vitamins

such as green leafy vegetables and fruits.

O Instructed patient to come back on July 20 2010 at 10am for follow up

check-up.

D Diet as tolerated
X. RECOMMENDATIONS

. In this case study, it is of utmost importance that the schedule for prenatal check-ups should be

meticulously followed, because PIH is fatal if untreated. The patients should be instructed regarding
their schedule of prenatal checkups, constantly reminding them of the possible risk if they did not

comply.

Medical researchers have been attempting to discover ways to prevent and predict pregnancy-

induced hypertension because of the effects this condition can have on the woman and her fetus. Various

methods have been tried to prevent the condition, including high-protein, low-salt diets; low-dose

aspirin and calcium supplementation. None of these therapies has been found to be effective in

preventing PIH specifically preeclampsia. Prenatal checkup is still the most effective way in order to

determine complications in pregnancy, because there are no diagnostic tests available that can predict

which woman will develop PIH, early detection through regular quality prenatal care is the best

alternative.

As student nurses, post partum management includes the following health teachings:

Maintain bed rest- frequent rest periods are advisable. At a minimum, a woman should rest twice

a day for 1 hour periods of time.

1. Diet- high protein and moderate/low sodium diet.

2. Adhere to medication regimen

3. Monitor blood pressure and attend check ups.

CONCLUSION

Pregnancy-induced hypertension is one of leading cause of maternal morbidity and

mortality, complicating 6% to 8% of all pregnancies and responsible for almost 15% of maternal

deaths. These disorders are not only dangerous for the pregnant woman but also significantly

increase the risk for the fetus

 Any type of high blood pressure occuring during pregnancy is a type of "gestational

hypertension". Gestational hypertension is a condition in pregnant women with elevated systolic

(>140 mm Hg) and diastolic (>90 mm Hg) blood pressure on at least two occasions 6 h apart.

HYPERTENSION complicates 8-10% of all pregnancies, generally after 20 weeks of gestation.

Gestational hypertension can be divided into several broad categories according to the

complexity and associated symptoms, such as edema; proteinuria; seizures; abnormalities in

blood coagulation and liver functions.

The goals of medical management are prevention of cerebral hemorrhage, convulsion,

hematologic complications and renal and hepatic diseases, and born of uncompromised newborn

as close to term as possible. Reduction of elevated blood pressure is essential in accomplishing

these goals.

Diet should be well balanced and nutritious. Sodium intake should be moderate, not to

exceed 6g/day. Excessively salty foods should be avoided, but strict sodium restriction and

diuretics are no longer used in treating preeclampsia but if the condition is only gestational

hypertension the preventive measures can be utilized. Regardless of the setting, promoting bed

rest, good nutrition and emotional support is necessary in providing care for the patient.

This case study was completed not only to view the patient as an example and illustration

but also to find ways on how to help other people who have the same case not only physically

instead holistically. We, as student nurses are called for to help these patients cope with the

disease and with the situation.