Clinical Focus Paper Part I: Preeclampsia. Molly Boyle. Northwest University

Transcription

1 Running head: CLINICAL FOCUS PAPER PART II: PREECLAMPSIA 1 Clinical Focus Paper Part I: Preeclampsia Molly Boyle Northwest University Author Note Molly A. Boyle, Buntain School of Nursing, Northwest University. Correspondence concerning this article should be addressed to Molly A. Boyle, Buntain School of Nursing, Northwest University, 5520 NE 108 th Ave, Kirkland, WA molly.boyle10@northwestu.edu

2 Non-stress test LABS -Hydralazine 5mg IV 0720 (reassess for maint. 0740) -Mag. Sulfate (Reassess for maint. dose Initiate IV Fluids 120/hr 120/hr 120/hr 120/hr 120/hr 120/hr 120/hr Betamethasone 12mg IM BS check and administer insulin according to protocol *At any time that pt s status declines, this plan may need to be interrupted in order to induce labor or emergent cesarean birth Physician s Orders: Strict intake and output Bed rest EFM on admission and intermittent non-stress tests Q2 or as client s status changes CBC Liver studies Renal studies UA Dip stick urine on admission Administer Hydralazine 5mg IV push now. May repeat in 20 minutes if blood pressure greater than 160/110. Notify Provider if second dose required (Take BP Q5 minutes until 30 minutes after the last dose of Hydralazine is given) Magnesium sulfate bolus: 4g (1 ml) over 20 minutes o Maintenance dose 2g (50mL IV per hour) Betamethasone 12mg IM Q24 if delivery able to be delayed for 48 hours IV Fluids: 120/hour IV Fentanyl 0.5-1mcg/kg/hour Blood sugar checks AC/HS, sliding scale insulin according to protocol Vital signs, DTR's, minutes on admission and with bolus until stable dose of magnesium sulfate reached, then every 30 minutes for 2 hours if stable, then hourly for 4 hours if stable, then Q4 hours Continuous pulse oximetry Weigh on admission, and daily Sodium restricted diet 2g Notify prenatal care provider of: o Loss of reflexes o UO less than 30/hr o Respiratory depression

3 3 o Pulse ox <90% o Diastolic pressure greater than 100mmHg o Worsening signs such as increasing epigastric pain or changes in vision or LOC Magnesium toxicity signs Medical diagnosis: Pre-eclampsia Primary system affected: Multiple systems affected depending on severity (Respiratory, GU, Cardiac, Neurologic, Hematologic, Metabolic) Real problems: Poor tissue/organ perfusion Poor uteroplacental perfusion Thrombocytopenia Impaired renal function Liver damage Pain (real problem): Ineffective tissue perfusion related to preeclampsia secondary to arteriolar vasospasm Trended data: Focused assessment - What data will you collect to track the progress of this real problem? Remember that assessment is the gathering of essential, targeted data. It is also an essential nursing intervention something that you do for the patient. Interventions: What interventions will you employ to help the patient progress toward problem resolution? Remember that some problems can t be fixed, they can only be managed. Evaluation: How will you know if interventions are leading to improvement of the problem or if the problem is getting worse? Establish baseline data (wt, degree of edema) to use as basis for evaluating effectiveness of treatment Monitor intake and output, edema, and weight to assess for evidence of vasodilation and increased tissue perfusion Trend renal and liver study labs to assess the degree of organ injury Fetal heart monitoring to assess for fetal hypoxia r/t lack of perfusion Place woman on bed rest in a side-lying position to maximize uteroplacental blood flow, reduce blood pressure, and promote diuresis Administer Lactated Ringers IV for fluid replacement to improve tissue/organ/placental perfusion Continue management by trending data I will know if the interventions are effective if the blood pressure decreases, urine output is increased Renal studies will be with in normal limit s Fetal heart rate will be reassuring with no late decelerations if status is improving However, I will know if patient status is worsening if urine output is non-existent, patient is seizing, or there are signs of fetal

4 4 distress with a non-reassuring strip (real problem): Acute epigastric pain secondary to severe preeclampsia Adjusted interventions: What will you do if the patient s condition is deteriorating (the problem is getting worse)? Describe in terms of trended data and nursing interventions. If the pt s condition continues to deteriorate, it is of extreme danger to the mother and the child, so delivery is the only cure and will need to be induced if perfusion is not resolved or improved Trended data will include monitoring: blood pressure, respiratory, urine output, FHM, s/sx: seizures In the presence of a seizure protocol interventions will be implemented and labor will be induced with Pitocin once mother is stable Trended data: Assess pt s pain: severity, quality, location, characteristics every hour Interventions: Administer IV Fentanyl PRN Apply heat/colt therapy Reassess pain Evaluation: The pt will report pain being at more tolerable level If problem gets worse pt will either report pain uncontrolled, unrelieved or show non-verbal signs of pain (grimace, rigid, etc) Adjusted interventions: Administer another dose of ordered pain medications, increase dose Continue to offer non-pharmacological methods of pain relief: heat/cold therapy, emotional support, etc. Potential ( at risk ) problems: Anticipate Risk for hypovolemic shock At risk for seizures Intrauterine growth restriction At risk for fetal distress At risk for impaired gas exchange r/t pulmonary edema At risk for Postpartum Depression At risk for DIC Risk for hypovolemic shock secondary to preeclampsia r/t risk for abruptio Trended data: Focused assessment - What data will you collect to track the potential development of this problem? Labs: platelets, coagulation studies Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation Assess and monitor for signs of shock: o Change in mental status o Change in respiratory status o Change in blood pressure o Decreased urine output

5 5 placenta and thrombocytopenia Interventions: What interventions will you employ to keep this potential problem from developing? What interventions may help you prepare for the possible development of this problem? e.g. Set up suction for patients at risk for gastrointestinal bleeding Obtain Type-and-cross Administer IV fluid boluses Give plasma if needed to maintain hemodynamic stability Induce labor though if more severe, emergency cesarean birth may be indicated Risk for fetal distress related to impaired placental perfusion secondary to preeclampsia as evidenced by nonreassuring fetal monitor strip Risk for impaired gas exchange related to risk for pulmonary edema secondary to preeclampsia Risk for seizures related to CNS Evaluation: How will you know if this potential problem has become a real problem? If mother is positive for signs of shock: sudden hypotension, tachycardia, tachypnea, oliguria Any signs for profuse bleeding Non-reassuring FHM strip Trended data: Continue to monitor fetal heart rate Conduct fetal non-stress test Monitor mother s vital signs Interventions: Administer Betamethasone if delivery will need to be induced prematurely Turn pt on side to improve uteroplacental perfusion Administer Lactated Ringers intravenously to improve circulation to the fetus In the case of a non-reassuring strip with late decelerations or fetal distress with tachycardia, the baby will need to be delivered and labor will need to be induced Evaluation: Non-stress test will be non-reassuring, FHR will be tachycardic showing signs of fetal distress Trended data: Auscultate breath sounds Assess oxygen saturation, respiration rate Interventions: Elevate HOB to high-fowlers Administer oxygen as ordered Get chest x-ray to confirm cause Administer medications as prescribed (morphine, etc) Induce labor Evaluation: Pt will have SOB, orthopnea, coughing up blood or thick sputum Pt will also exhibit signs of respiratory distress: decreased oxygen saturation, increased respiratory rate Trended data: Assess for DTR s/clonus Monitor maternal vital signs and FHR Assess serum levels of magnesium sulfate to assess for and prevent toxicity (depressed

6 6 irritability and lack of cerebral perfusion Trended data: respirations, oliguria, sudden hypotension, hyporeflexia, fetal distress) Assess for altered mental status Assess for seizure activity or posturing Interventions: Initiate seizure precautions Administer Magnesium Sulfate as ordered Administer maintenance doses as needed Have Calcium Gluconate available if needed for antidote of Magnesium toxicity Maintain a quiet, darkened environment to avoid stimuli that may precipitate seizure activity Have suction and oxygen ready in room In the case of a seizure: Turn patient on side Call for assistance Protect with side rails up Observe, time, and record convulsion activity Administer O2 via face mask Monitor blood pressure Monitor fetal and uterine status At risk for postpartum depression secondary to gestational complications and status of fetal viability Once mother is stable, initiate protocol for Pitocin induction to deliver Evaluation: Patient has a convulsion Patient is hyporeflexic Patient has altered LOC or mental status Signs of fetal distress, non-reassuring strip Trended data: Trend pt s emotional status Assess support system, coping mechanisms Assess for other psychosocial stressors: socioeconomic status, etc. Interventions: Provide emotional support Refer to social worker or counselor Provide client with community resources to reduce stress and increase support Depending on outcome, refer to specialty support groups Discuss positive coping mechanisms, importance of self-care and communication Evaluation: If baby survives, pt may show signs of detachment or issues bonding with child Pt may also show signs of: insomnia, loss

7 7 of appetite, emotional instability, fatigue, mood swings, withdrawal, or psychosis Conclusion These last four years, and especially the last two have been one wild ride. It is only by the grace of God that I have now made it to this point. And it is much to my own surprise that He is leading me in the direction He is. When I first found out about the nursing program at Northwest and the cross-cultural trip they offer, my first thought is why anyone would ever want to go to Alaska if they had the opportunity to adventure around the world. Well, fast forward a few years and God began to relentlessly tug on my heart for the Native people throughout the United States, but especially Alaska. Persistently I was stubborn, still desiring India as my top choice, but low and behold, He talked me into putting it as my top choice and that s exactly where I went. God has a funny way of working because I loved every second of it and God exploded me with His heart for those people. That s the extremely short version, but He has been continuing to impart His dreams to me for that place and His children there. And that s only the beginning of the adventures there are to come and I feel so utterly blessed to have made it to this point and am excited to see where He will use this tool and gift of nursing inline with His will and my calling.

8 8 References Norwitz, Errol R., MD, PhD, and Edmund F. Funai, MD. "Expectant Management of Severe Preeclampsia." (2013): UpToDate. Web. 25 Apr < management-of-severe-preeclampsia?source=search_result&search=preeclampsia& selectedtitle=4~150#h2>. Perry, Shannon E. Maternal Child Nursing Care. Maryland Heights, MO: Mosby Elsevier, Print.