Nur 264 – Unit 1: Pregnancy & HTN/Cardiomyopathy – Flashcards
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Hypertension Classifications
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• Chronic Hypertension • Preeclampsia Superimposed on Chronic Hypertension • Gestational Hypertension • Preeclampsia • Eclampsia
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Gestational Hypertension (PIH)
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• BP of 140/90 mmHg for the first time during pregnancy • There is *NO proteinuria* • Within *12 weeks postpartum*, the BP will return to a normotensive state
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Preeclampsia:
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Develops *AFTER 20 weeks* gestation • Types: Mild or Severe • Cardinal Signs: BP of 140/90 or greater - *Proteinuria*: 300mg/24h - Edema is *no longer* a symptom but essential monitoring required with sudden onset severe edema
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Preeclampsia: Risk Factors
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• Chronic Renal Disease • Chronic Hypertension • Family Hx of PIH • Multiple Gestation • Primigravida: Under 20, Over 35 • Rh Incompatibility • Age 40 years • Obesity, Diabetes, Poor Nutrition
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Preeclampsia: Normal Pregnancy Patho
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• Plasma volume increases • Systemic vascular resistance decreases • Increased maternal resistance to vasopressor effects of angiotensin II result in *lowered BP*
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Preeclampsia: Pathophysiology
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• Arterial *vasospasm* damages endothelial layer of small vessels, causing lesions. • At the lesion sites platelets aggregate, forming a fibrin network - causes RBC's to *hemolyze* when forced through under pressure • Possibly linked to gradual decreased resistance to angiotensin II
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Preeclampsia: Decreased Renal Perfusion
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• GFR falls: Urine output decreases • *Rise* in BUN, creatinine and uric acid • Sodium retained: Increased extracellular volume and edema • Decreased Intravascular volume: increased blood viscosity and *elevated* hematocrit • Stretching of the capillary walls permits large molecules of albumin to spill out
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Preeclampsia: Central Nervous System
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• Hyperreflexia: exaggerated DTR's • Clonus • Cerebral vasoconstrictive ischemia can result in *Eclampsia*
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Preeclampsia: Mild
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*Blood Pressure* • 140/90 mm Hg or higher • Systolic increase of 30 mm Hg • Diastolic increase of 15 mm Hg • Must occur on 2 separate occasions at least *6 hours apart*
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Preeclampsia: Mild
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*Proteinuria* • 24 hour urine: 300 mg/L-1g/L • Dipstick Albumin: 1+ to 2+ • Must occur in at least 2 random urine samples at least *6 hours apart*
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Preeclampsia: Mild
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*Edema* may be seen • Generalized: puffy hands/face or dependent areas • Weight Gain: 3.3 lbs/mo in 2nd trimester - 3rd: 1.1 lbs/wk • Measured 1+-4+
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Preeclampsia: Severe
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• Blood Pressure: 160/110 mm Hg or higher • Proteinuria: >2 g/L or more (24 hour urine) - Dipstick Albumin: > 2+ • Must occur in at least 2 random urine samples at least *4 hours apart*
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Preeclampsia: Severe
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*Labs* • 24 hour urine: < 500 mL (Oliguria) • Decreased: Platelets (Thrombocytopenia) • Elevated: Hematocrit - Serum Creatinine - Uric Acid
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Preeclampsia: Severe
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• Patient Verbalization - Epigastric/RUQ pain: *Impending seizure* - Irritable, SOB • CNS: Cerebral (altered LOC) - Frontal H/A's, Visual Disturbances, - Hyperreflexia (3+), Possible Clonus
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Preeclampsia: Severe
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*Fetal Effects* • Decreased Placental Perfusion: causes hypoxia and malnutrition, IUGR, FHR: late decel's • Oversedated Newborn: due to medications and possible hypermagnesemia • Placental infarcts & appears smaller
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Preeclampsia: Home Management
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• Daily B/P, urine protein & weight monitoring • Fetal movement monitoring • Prenatal Visits: 2-3/week • Bedrest: *Lateral Recombent* - decreases B/P & promotes diuresis
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Preeclampsia: Patient Education
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• Weigh same time of day • Same b/p cuff, same arm • Avoid high sodium food, eat protein • Stay well hydrated • Diversionary activities • Stretching/Kegel exercises • Stress management
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Preeclampsia: Hospital Management
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*Only known cure is delivery of baby/placenta* • =/> 37 Weeks Gestation: delivery • < 37 Weeks Gestation: - Magnesium Sulfate (seizure prophylaxis), Antihypertensives - CEFM/Ultrasound - Amnio: L/S ratio 2:1 - Bedrest, Hydration - Diet: High protein, Moderate salt
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Preeclampsia: Nursing Interventions
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• Left Lateral Recombent • Limit visitors, Quiet, Low stimulI *During Seizure* • Tonic Phase: muscular rigidity/relax - turn to lateral position, face down - for placental circulation • Clonic phase: thrashing subsides - Oral airway, suction, O2
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Magnesium Sulfate
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• Action: CNS depressant • Irritates IV site • Crosses the placenta • Nursing Management: VS, I&O, DTR's, - respirations q1-2 hours
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Magnesium Sulfate: Side Effects/Early Signs of Toxicity
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• Flushing, Feeling of Warmth, • Slurred Speech, N/V, • Lethargy, Muscle Weakness, • Respiratory Depression
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Magnesium Sulfate: Dosage
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*Always* via IV Pump • 4-6 gram bolus over 15-20 minutes • Additional bolus indicated when increasing CNS irritability • Maintenance: 2-3 grams
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Magnesium Sulfate: Levels
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• Normal: *2-4* mg/dl • Therapeutic: 4-7 mg/dl • Toxic: - 8-10 mg/dl: lose patellar DTR's - 10-12 mg/dl: respiratory depression - > 15 mg/dl: *cardiac arrest* due to loss of cardiac conduction reflex
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Magnesium Sulfate: Calcium Gluconate
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*Antagonist of Magnesium Sulfate* • 1 gram IV push over 3 minutes • Always keep at the bedside when administering Magnesium Sulfate • Monitor *fetal heart tones*
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Magnesium Sulfate: Monitoring
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• VS: q15-30 minutes during loading dose - q1-2 hours there after • Monitor S&S of toxicity • Circulates free and unbound to protein • Excreted in Urine: Monitor UO
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Antihypertensives
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• Labetalol: Given for *diastolic* B/P of *110 mm Hg* or above in critical gestational age range of *25-30* weeks • Hydralazine: usually 160/110
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Hospital Assessment: Review
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• Vision, Vital Signs • DTR's, Clonus • Weight, Pulmonary Edema • FHR, Placental Abruption • Urine: protein, output, creatinine
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Preeclampsia Superimposed on Chronic Hypertension
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• Hypertension before 20 weeks with *new-onset * Proteinuria, • Hypertension *and* Proteinuria before 20 weeks gestation, *OR* • Sudden increase in BP in well controlled HTN • Thrombocytopenia • Elevated liver enzymes • Often will have sudden onset Eclampsia
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Preeclampsia Superimposed on Chronic Hypertension: Management
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*Observe for on 2 occasions of 6 hours apart:* • Systolic: 30 mmHg above baseline or • Diastolic:15-20 mmHg above baseline • Proteinuria • Upper Body Edema
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Chronic Hypertension
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Hypertension with: • BP of 140/90 mmHg before pregnancy or Before 20 weeks gestation *OR* • Gestational Hypertension that persists 42 days after delivery
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Perinatal Hypertension: Treatment Goals
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• To prevent Preeclampsia • Ensure normal fetal growth • Education: - Normal rest periods in LLR position - B/P home monitoring - Sodium: limit to 2.4g/day - *Aldomet*: for BP >160/110
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Eclampsia
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• Occurrence of tonic and clonic seizure(s) or coma in a patient with preeclampsia • Occurs more often in *primigravida* • No underlying neurological or febrile origin • Can occur during pregnancy or shortly after birth
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Eclampsia: Nursing Interventions
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• Immediate Magnesium Sulfate bolus of 4-6g IV over 5 min. • Assess for Renal or Circulatory Failure - Lasix and Digitalis may be given • Hourly I&O & q15 min. VS • Check q15 min vaginal bleeding and abdominal rigidity (Abruptio Placenta) • Once stabilized = *deliver*
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Eclampsia: Postpartum Care
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*First 48 hours, at risk for seizures* • May still need anti-HTN and/or Mag Sulfate • Monitor VS, I&O, • Risk For: Boggy Uterus, large Lochia flow from Mag Sulfate • Ergot products (Methergine): contraindicated because of B/P • Recurrence is approx. 30%
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Eclampsia: Nursing Diagnosis
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• *Deficient Diversional Activity* r/t imposed bedrest • *Risk for Injury* r/t signs of preeclampsia
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HELLP Syndrome
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• Multiple Organ System Failure associated with severe Preeclampsia • High morbidity and mortality • *H*: Hemolysis of RBC's • *EL*: Elevated Liver Enzymes • *LP*: Low platelets • Can present as *normotensive* - thus misdiagnosed
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HELLP Syndrome: Hemolysis (H)
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*Microangiopathic Hemolytic Anemia* • RBC's are distorted and fragmented during passage through small, damaged vessels
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HELLP Syndrome: Elevated Liver Enzymes (EL)
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• Due to obstructed blood flow resulting from *fibrin deposits* • May see Hyperbilirubinemia & Jaundice • Epigastric pain from liver distention
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HELLP Syndrome: Thrombocytopenia (LP)
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• Low Platelet Count: < 100,000/mm3 • Vasospasm: causes vascular damage - causes platelet aggregation at damaged sites - causes a decrease in platelets • Treatment: stabilize and deliver - transfuse when PLT <20,000/mm3
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Peripartum Cardiomyopathy (PPCM)
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Development of congestive heart failure in the *last month* of pregnancy or within the *first 5 postpartum months* • Lack of another cause for heart failure • Absence of heart disease before the last month of pregnancy
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Peripartum Cardiomyopathy: Risk Factors & Complications
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• Risk Factors: Maternal age > 35 - Mutifetal Gestation, Multiparity - Preeclampsia, Prolonged Tocolytic Therapy - Gestational Hypertension - Black • Complications: Activity Intolerance - Cardiac &/or Respiratory Failure - Shock
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Peripartum Cardiomyopathy: Signs & Symptoms
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• Fatigue, Chest Pain • Dyspnea on Exertion • Orthopnea, Tachycardia • Peripheral Edema • S3 and S4 Heart Sounds • Murmur
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Peripartum Cardiomyopathy: Diagnostic Tests
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• ECG, Echo • Cardiac Cath • Radionuclide Ventriculogram • Chest X-ray • Serum Cardiac Enzymes & Electrolytes • Endocardial Biopsy
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Peripartum Cardiomyopathy: Nursing Assessment
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• VS & O2 Sat • Heart & Breath Sounds • Edema & Ascites • Uterine Tone and Fundal Height
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Peripartum Cardiomyopathy: Cardiac Decompensation
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*Subjective S&S:* • Increasing fatigue, difficulty breathing or both • Feeling of smothering • Frequent cough • Palpitations • Swelling of face, feet, legs, fingers
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Peripartum Cardiomyopathy:
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*Objective S&S:* • HR: > 100 bpm, irregular weak & rapid • Progressive, generalized edema • Crackles at lung bases after *2* inspirations & expirations • Orthopnea; Increasing Dyspnea • Respirations: > 25 breaths/min • Moist, frequent cough • Cyanosis of nailbeds and lips
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Peripartum Cardiomyopathy: Interventions
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• Monitor for decreased cardiac output • Assess client activity level. - Offer, encourage and assist with ADL's • Daily weights, I&Os • *LLR* position with HOB elevated
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Peripartum Cardiomyopathy: Interventions
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• Stool softeners • Progressive ambulation • Assess for hemorrhage • Observe for neonatal dehydration with maternal diuretic use • Assist with maternal-child bonding
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Peripartum Cardiomyopathy: Treatment
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• Diuretics, ACE inhibitors • Calcium Channel or Beta Blockers • Digoxin • Anti-Arrhymic Agents: control dysrhythymias • Anticoagulants: prevent thrombus formation
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Peripartum Cardiomyopathy: Treatment
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• Potassium supplements: potassium excreted in urine during diuresis • Sodium and Fluid Restriction • Dual Chamber Pacemaker • Implantable Cardioverter: defibrillator • Intra-aortic Balloon Pump
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Peripartum Cardiomyopathy: Prognosis
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Women whose heart remains enlarged *6 months postpartum* will have PPCM in future pregnancies • High morbidity and mortality rate.
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Peripartum Cardiomyopathy: Discharge Teaching
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• Avoid Oral Contraceptives: increased risk of thrombophlebitis • Avoid IUD's: risk of infection if valve replacement is needed • Alternative: Progestin injections or condoms • Rest • Low Sodium Diet • Medication Compliance
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Peripartum Cardiomyopathy: Nursing Diagnosis
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• *Decreased Cardiac Output* r/t ineffective cardiac muscle contractility • *Excess Fluid Volume* r/t edema • *Deficient Knowledge* r/t condition, treatment, and home care • *Activity Intolerance* r/t decreased tissue perfusion • *Anxiety* r/t fear of death • *Risk for Impaired Gas Exchange* • *Ineffective Breastfeeding* r/t fatigue from cardiac condition
