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LECTSTEPHEN
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
“Preeclampsia is the result of generalized vasospasms. The underlying cause of vasospasm remains a mystery, but some of
the physiologic processes are known. In a normal pregnancy, vascular volume is significantly increased, and cardiac output
is increased. Despite these factors, blood pressure does not rise in a normal pregnancy, probably because pregnant
women develop resistance to the effects of vasoconstrictors such as angiotensin II. Moreover, a decrease in peripheral
vascular resistance occurs from the effects of certain vasodilators, such as prostacyclin (PGI2), prostaglandin E2 (PGE2),
and endothelium-derived relaxing factor (EDRF). In preeclampsia, however, peripheral vascular resistance increases
because of the sensitivity of some women to angiotensin II and a decrease in vasodilators. For example, the ratio of
thromboxane A2 to PGI2 increases. Thromboxane, produced by kidney and trophoblastic tissue, causes vasoconstriction
and platelet aggregation (clumping)/ PGI2, produced by placental tissue and endothelial cells causes vasodilation and
inhibits platelet aggregation.” (McKinney, James, Murray, Nelson, & Ashwill, 2018)
“Severe preeclampsia consists of blood pressure that is 160/110 mm Hg or greater, proteinuria greater than 3+, oliguria,
elevated blood creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision,
hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic
dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia.” (Holman et al., 2019)
DIAGNOSTIC TESTS PATIENT INFORMATION EXPECTED PHYSICAL FINDINGS
(REASON & RESULTS)
Elevated liver enzymes Olivia Jones Hypertension
(LDH, AST) Adm DX: Severe Preeclampsia “Deep tendon reflexes (DTRs) may be very
Increased creatinine Gender: Female brisk (hyperreflexia)
Increased plasma uric DOB: 7/6/1996 (23 y) “headache, drowsiness, or mental
acid Height: 168 cm confusion.”
Thrombocytopenia Weight: 110kg “Visual disturbances, such as blurred or
Hgb (decreased in Allergies: NA double vision or spots before the eyes.”
HELLP, increased in “epigastric pain or “upset stomach”, are
preeclampsia) particularly ominous because they indicate
Chemistry profile distention off the hepatic capsule and often
Dipstick testing of urine warn that a seizure is imminent.”
for proteinuria Seizures
Pitting edema of lower extremities
(Holman et al., 2019) Proteinuria
Jaundice
(McKinney, James, Murray, Nelson, & Ashwill,
2018)
(Holman et al., 2019)
ANTICIPATED NURSING INTERVENTIONS
“Preform actions that reduce the risk of seizures and prevent maternal or fetal injury if seizures do occur.”
“Monitor for signs of impending seizures.”
Keeping the lights low and visitors at a minimum.
“assess level of consciousness”
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“Monitor urine output”
“Monitor vital signs with careful attention to blood pressure measurement (using proper size cuff, not talking to
client during measurement).
“Instruct patient to monitor I&O.”
(McKinney, James, Murray, Nelson, & Ashwill, 2018)
INTRODUCTION Nursing Student, Labor and Delivery
Your name, position (RN), unit you
are working on
SITUATION Olivia Jones is a 23-year-old female that was admitted to the labor and
Patient’s name, age, specific reason birthing unit with a diagnosis of severe preeclampsia. Thus far her pregnancy
for visit has been unremarkable until her prenatal visit at 30 weeks in which she had
elevated an elevated blood pressure of 146/92 mm Hg, proteinuria,
developing mild preeclampsia, and has gained 3 pounds since her prenatal
visit one week ago. Until her admission today she has been on bed rest at
home.
BACKGROUND Olivia Jones was admitted on August 3rd with a diagnosis of severe
Patient’s primary diagnosis, date of preeclampsia. She has gained 3 pounds since her last prenatal visit 1 week ago
admission, current orders for patient and had an elevated blood pressure of 146/92 mm Hg which lead to her
admission. The patient is on bed rest with bathroom privileges, we are taking
BP Q 1 hr. x2 and then Q 4 hours, she has continuous pulse oximetry, and deep
tendon reflexes need to be checked Q 1 hrs. She has an IV in place and is
currently on lactated ringers. The doctor has ordered Platelets, coagulation
screen, comprehensive metabolic panel, hepatic function panel, liver function,
and uric acid STAT.
Assessment Olivia vital signs are as followed- HR 116, pulse is present and strong at 115,
Current pertinent assessment data blood pressure: 171/102 mmHg, respirations 22, SpO2 91, temp 37C and FHR
using head to toe approach, is 160. Lungs were clear to auscultate; heart sounds were regular without
pertinent diagnostics, VS murmurs and normal bowel sounds were heard. Patient stated she had pain
in the upper center of her stomach and under her right breast and rated the
pain a 4/10. Patient stated she had a headache and rated that a 5/10. When
asked if she needed pain medication she denied. I palpated the uterus for
contractions and the uterus tone was moderate between contractions. Fetal
movement was felt. A fetal monitoring device was then attached. Deep
tendon reflexes were very brisk, hyper reflexive and with clonus with grade of
+4.
RECOMMENDATION I recommend continuing to take the patients’ blood pressure Q 1 hour,
Any orders or recommendations you monitor her I&O’s, level of consciousness, and monitor vital signs with careful
may have for this patient attention to blood pressure measurement. Patient should remain on bed rest
with bathroom privileges and assess pain regularly.
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LECTSTEPHEN
CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
“Preeclampsia is the result of generalized vasospasms. The underlying cause of vasospasm remains a mystery, but some of
the physiologic processes are known. In a normal pregnancy, vascular volume is significantly increased, and cardiac output
is increased. Despite these factors, blood pressure does not rise in a normal pregnancy, probably because pregnant
women develop resistance to the effects of vasoconstrictors such as angiotensin II. Moreover, a decrease in peripheral
vascular resistance occurs from the effects of certain vasodilators, such as prostacyclin (PGI2), prostaglandin E2 (PGE2),
and endothelium-derived relaxing factor (EDRF). In preeclampsia, however, peripheral vascular resistance increases
because of the sensitivity of some women to angiotensin II and a decrease in vasodilators. For example, the ratio of
thromboxane A2 to PGI2 increases. Thromboxane, produced by kidney and trophoblastic tissue, causes vasoconstriction
and platelet aggregation (clumping)/ PGI2, produced by placental tissue and endothelial cells causes vasodilation and
inhibits platelet aggregation.” (McKinney, James, Murray, Nelson, & Ashwill, 2018)
“Severe preeclampsia consists of blood pressure that is 160/110 mm Hg or greater, proteinuria greater than 3+, oliguria,
elevated blood creatinine greater than 1.1 mg/dL, cerebral or visual disturbances (headache and blurred vision,
hyperreflexia with possible ankle clonus, pulmonary or cardiac involvement, extensive peripheral edema, hepatic
dysfunction, epigastric and right upper-quadrant pain, and thrombocytopenia.” (Holman et al., 2019)
DIAGNOSTIC TESTS PATIENT INFORMATION EXPECTED PHYSICAL FINDINGS
(REASON & RESULTS)
Elevated liver enzymes Olivia Jones Hypertension
(LDH, AST) Adm DX: Severe Preeclampsia “Deep tendon reflexes (DTRs) may be very
Increased creatinine Gender: Female brisk (hyperreflexia)
Increased plasma uric DOB: 7/6/1996 (23 y) “headache, drowsiness, or mental
acid Height: 168 cm confusion.”
Thrombocytopenia Weight: 110kg “Visual disturbances, such as blurred or
Hgb (decreased in Allergies: NA double vision or spots before the eyes.”
HELLP, increased in “epigastric pain or “upset stomach”, are
preeclampsia) particularly ominous because they indicate
Chemistry profile distention off the hepatic capsule and often
Dipstick testing of urine warn that a seizure is imminent.”
for proteinuria Seizures
Pitting edema of lower extremities
(Holman et al., 2019) Proteinuria
Jaundice
(McKinney, James, Murray, Nelson, & Ashwill,
2018)
(Holman et al., 2019)
ANTICIPATED NURSING INTERVENTIONS
“Preform actions that reduce the risk of seizures and prevent maternal or fetal injury if seizures do occur.”
“Monitor for signs of impending seizures.”
Keeping the lights low and visitors at a minimum.
“assess level of consciousness”
Downloaded by: dennys |
Distribution of this document is illegal
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
“Monitor urine output”
“Monitor vital signs with careful attention to blood pressure measurement (using proper size cuff, not talking to
client during measurement).
“Instruct patient to monitor I&O.”
(McKinney, James, Murray, Nelson, & Ashwill, 2018)
INTRODUCTION Nursing Student, Labor and Delivery
Your name, position (RN), unit you
are working on
SITUATION Olivia Jones is a 23-year-old female that was admitted to the labor and
Patient’s name, age, specific reason birthing unit with a diagnosis of severe preeclampsia. Thus far her pregnancy
for visit has been unremarkable until her prenatal visit at 30 weeks in which she had
elevated an elevated blood pressure of 146/92 mm Hg, proteinuria,
developing mild preeclampsia, and has gained 3 pounds since her prenatal
visit one week ago. Until her admission today she has been on bed rest at
home.
BACKGROUND Olivia Jones was admitted on August 3rd with a diagnosis of severe
Patient’s primary diagnosis, date of preeclampsia. She has gained 3 pounds since her last prenatal visit 1 week ago
admission, current orders for patient and had an elevated blood pressure of 146/92 mm Hg which lead to her
admission. The patient is on bed rest with bathroom privileges, we are taking
BP Q 1 hr. x2 and then Q 4 hours, she has continuous pulse oximetry, and deep
tendon reflexes need to be checked Q 1 hrs. She has an IV in place and is
currently on lactated ringers. The doctor has ordered Platelets, coagulation
screen, comprehensive metabolic panel, hepatic function panel, liver function,
and uric acid STAT.
Assessment Olivia vital signs are as followed- HR 116, pulse is present and strong at 115,
Current pertinent assessment data blood pressure: 171/102 mmHg, respirations 22, SpO2 91, temp 37C and FHR
using head to toe approach, is 160. Lungs were clear to auscultate; heart sounds were regular without
pertinent diagnostics, VS murmurs and normal bowel sounds were heard. Patient stated she had pain
in the upper center of her stomach and under her right breast and rated the
pain a 4/10. Patient stated she had a headache and rated that a 5/10. When
asked if she needed pain medication she denied. I palpated the uterus for
contractions and the uterus tone was moderate between contractions. Fetal
movement was felt. A fetal monitoring device was then attached. Deep
tendon reflexes were very brisk, hyper reflexive and with clonus with grade of
+4.
RECOMMENDATION I recommend continuing to take the patients’ blood pressure Q 1 hour,
Any orders or recommendations you monitor her I&O’s, level of consciousness, and monitor vital signs with careful
may have for this patient attention to blood pressure measurement. Patient should remain on bed rest
with bathroom privileges and assess pain regularly.
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