NCM 109 Module 1 Lesson 4

NURSING CARE
MANAGEMENT 109
Care for the Mother and Child at risk
(Acute and Chronic)
Ken Ryan B. Dizon, MBA-HP, MN, RN

Clinical Instructor
LESSON 4
WEEK 4
Eclampsia
(in-depth discussion)
MAJOR COMPLICATIONS
Cerebral haemorrhage
Aspiration pneumonia
Hypoxic encephalopathy
Coma
Thromboembolic events
Maternal death
Perinatal death
NURSING RESPONSIBILITY
HOW TO PREVENT ECLAMPSIA:
Monitoring of the preeclampsia patients
During the assessment, the nurse should include the

following parameters:
• Auscultation of heart sounds, lungs, and breath sounds
• Presence and degree of edema
• Early signs or symptoms of pulmonary edema, such as
tachycardia and tachypnea
• Daily weight taken at the same time of the day and on the
same scale
• Skin color, temperature, and turgor
• Capillary refill, which may indicate decreased perfusion or
vasoconstriction if >3 seconds
EDEMA
Edema was an important component of the triad considered along
with hypertension and proteinuria to diagnose preeclampsia.
However, edema is a common finding in pregnancy.
Dependent edema in the absence of hypertension or proteinuria is
generally related to changes in the interstitial and intravascular
hydrostatic pressures that facilitate the movement of intravascular
fluid into the tissues. When preeclampsia is present, continuous
capillary leakage combined with a decreased colloidal pressure can
lead to pulmonary edema. In this situation, intravascular fluid leaks
out through holes (caused by vasospasms) in the endothelial lining
of the blood vessels. Pulmonary edema can occur very suddenly,
especially if the patient receives an overload of intravenous fluid.
Because of the potential for rapid development of this life-
threatening complication, the nurse must frequently perform a
careful assessment of the patient’s pulmonary status and
meticulously monitor the total intake and output.
HELLP
Syndrome
HELLP is an acronym for: Hemolysis, Elevated Liver enzymes
and Low Platelets
Due to the arteriolar vasospasms in the cardiovascular

system that occur in preeclampsia, the circulating red blood
cells (RBCs) are destroyed as they try to navigate through
the constricted vessels (Hemolysis). Vasospasms decrease
blood flow to the liver, resulting in tissue ischemia and
hemorrhagic necrosis (Elevated Liver enzymes). In response
to the endothelial damage caused by the vasospasms (small
openings develop in the vessels), platelets aggregate at the
site and a fibrin network is set up, leading to a decrease in
the circulating platelets (Low Platelets).
HELLP syndrome is a serious
complication of preeclampsia that can
manifest itself at any time during
pregnancy and the puerperium, but
like preeclampsia, it is rare before 20
weeks’ gestation.
HELLP syndrome is actually a

laboratory diagnosis for a variant of
severe preeclampsia. The primary
presentation is consistent with
hepatic dysfunction evidenced by fi
ndings from the patient’s liver
function tests
CHARACTERISTICS:
 Rapidly deteriorating liver function and thrombocytopenia

 Liver capsule distention often produces epigastric pain.
 liver rupture - one of the most ominous
*Therapy for HELLP syndrome centers on improving the

platelet count by transfusion of fresh-frozen plasma or
platelets and delivery as soon as feasible by vaginal or
cesarean birth.
seminated Intravascu
Coagulopathy
Disseminated intravascular coagulopathy (DIC) is a
hematological disorder characterized by a pathological
form of clotting that is diffuse and consumes large
amounts of clotting factors. DIC causes widespread
external or internal bleeding or both.
The most common causes of DIC in pregnancy are
excessive blood loss with inadequate blood component
replacement, placental abruption, amniotic fluid
embolism, and severe preeclampsia/HELLP syndrome.
Because DIC is a consumptive coagulopathy that results
in depletion of the platelets and clotting factors, early
diagnosis and prompt and appropriate management are
critical in reducing maternal and perinatal death and
complication rates.
Nursing management
 Nursing care includes continued meticulous assessment
for signs of bleeding (e.g., petechiae, oozing from
injection sites, hematuria).
 Use of an indwelling catheter for monitoring urinary
output is essential because renal failure is a potential
consequence of DIC.
 Vital signs and fetal assessments are monitored
frequently and the patient is maintained in a side-lying tilt
to enhance blood flow to the uterus.
 Oxygen may be administered through a rebreathing
mask at 8 to 10 L/min and blood and blood products are
administered according to physician orders
TORCH DISEASES
clinical manifestations diagnostic findings
Questions?

NCM 109 Module 1 Lesson 4

Uploaded by

Copyright:

Available Formats

NCM 109 Module 1 Lesson 4

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

NCM 109 Module 1 Lesson 4

Uploaded by

Copyright:

Available Formats

NURSING CARE

Ken Ryan B. Dizon, MBA-HP, MN, RN

During the assessment, the nurse should include the

Due to the arteriolar vasospasms in the cardiovascular

HELLP syndrome is actually a

 Rapidly deteriorating liver function and thrombocytopenia

*Therapy for HELLP syndrome centers on improving the

You might also like