Simulation Paperwork h202z

Simulation Paperwork

1. What are the major differences between mild Gestational HTN, mild preeclampsia and severe preeclampsia? What is the pathophysiology that leads to these conditions?

a. Hypertension that develops 20 weeks gestation, during labor or during the early postpartum period in a woman who previously had a normal blood pressure. Gestational hypertension may progress from pregnancy induced hypertension to pre-eclampsia to eclampsia b. Pre-eclampsia is defined as hypertension and proteninuria in a woman whose blood pressure has been previously normal after 20 weeks. Mild pre-eclampsia is diagnosed when pregnancy is greater than 20 weeks. Blood pressure is greater than 140 systolic or 90 diastolic. 0.3g of protein is collected in a 24-hour urine sample, or persistant 1+ protein measurement on urine dipstick. c. Severe preeclampsia is a more serious problem. Diagnosis of severe preeclampsia requires the basic features of mild preeclampsia as well as some indication of additional problems with either the mother or the baby. Thus, one of the following findings is also necessary for a diagnosis of severe preeclampsia: signs of central nervous system problems (severe headache, blurry vision, altered mental status) signs of liver problems (nausea and/or vomiting with abdominal pain) at least twice the normal measurements of certain liver enzymes on blood test. Very high blood pressure (greater than 160 systolic or 110 diastolic). Thrombocytopenia. Greater than 5g of protein in a 24-hour sample. Very low urine output (less than 500mL in 24 hours). Signs of respiratory problems (pulmonary edema, bluish tint to the skin). Severe fetal growth restriction. Stoke. The distinction between mild and severe preeclampsia is important because the management strategies are very different. d. The cause of gestational hypertension and pre-eclampsia is unknown some conditions that increase the risk are: pre-existing hypertension, kidney disease, diabetes, PIH with previous pregnancy, mother’s age younger than 20 or older than 40, and multiple fetuses. Pathophysiology such as decreased cerebral blood flow, decreased uterine blood flow, decreased renal blood flow, and increased peripheral vascular resistance. 2. What assessments need to be frequently conducted for the patient with gestational HTN/Preclampsia? need to monitor blood pressure, daily weights, dipstick urine for protein, fetal movements, possible weekly or biweekly NST, and diet.

3. Identify the common lab tests indicated for the patient with Gestational          

HTN/Preeclampsia. & discuss the cause of abnormal findings.

hemoglobin (often elevated due to hemoconcentration) WBC (increased) platelets (decreased) creatinine, urea, uric acid (increased) blood film for hemolysed cells PTT, INR, fibrinogen, D-dimer (increased) ALT, AST, bilirubin, LDH (increased) 24 hour urine collection or a protein/creatinine ratio o >300mg/24hr o >5g/24 hr severe fragmented RBCs on smear urine dipstick o 2+ significant o 3-4+ severe

4. What drugs are used to treat Gestational HTN/Preeclampsia and what risks do they carry? What is the nursing management for each? Metaldopa, this drug is considered a safe choice because it does not alter cardiac blood flow to the kidneys or the fetus. Side effects may include drowsiness, headache, muscle weakness, and swelling of the ankles or feet. The nurse would continue to monitor blood pressure and fetal heart rate. Procardia, you would continue to monitor the mother’s blood pressure and fetal heart rate. Magnesium sulfate, can easily develop toxicity, complete disappearance of knee jerks, respiratory paralysis, and possible cardiac arrest. The nurse would monitor patellar knee jerks, urine output, respirations, and serum magnesium level. 5. Discuss why a patient with Gestational HTN/Preeclampsia is at risk for seizures. What are seizure precautions & how are they instituted? Pre-eclampsia can progress to eclampsia which is defined as the development of seizures or coma in a woman diagnosed with pre-eclampsia. The end result of the pathological process of pre-eclampsia is development of eclampsia that results in seizures, coma, and or death. The only treatment is delivery of the fetus. A.. Make certain that the patient has the following equipment:

Nasal cannula and tubing; Oxygen flow meter; Suction gauge; Suction canister; Suction tubing to connect to canister; B. Assign patient to room in close proximity to the nurses station; C. Maintain continuous observation via video monitor; D. Maintain assembled suction equipment in room;5. Maintain assembled oxygen

equipment at bedside; E. Pad side rails of bed; F. Keep bed in low position with all side rails up at all times; G. Keep unnecessary equipment out of patients room; H. Instruct patient not to get out of bed without assistance; I. Assure that call bell is always within patients reach. Make sure that the family knows where it is and how to use it; J. Avoid use of restraints; K. Obtain one-to-one sitter if patient is unable to follow instructions to maintain safety; L. Check vital signs every fifteen minutes and maintain airway patency during the post ichtal phase (period of time immediately following the seizure, during which the patient remains comatose or stuperous). During a convulsion, if the patient is not already on magnesium sulfate then it can be istered IV push up to 6 grams. Fetal responses to maternal convulsion includes transient fetal bradycardia, decreased FHR, variability, and compensatory tachycardia. First ensure patent airway and maintain oxygenation. During a convulsion turn to side to prevent aspiration. After convulsion: suction, ister oxygen by face mask, monitor fetal well being, assess uterine activity, cervical status, ROM. 6. What are the causes of postpartum hemorrhage? And how is it treated? Occasionally, cervical lacerations, deep tears in your vagina or perineum, or even a large episiotomy may be the source of a postpartum hemorrhage. A ruptured or inverted uterus may cause profuse bleeding, but these are relatively rare occurrences. Finally, a systemic blood clotting disorder may cause a hemorrhage. (A clotting disorder may be an inherited condition or it may develop during pregnancy as a result of certain complications, such as severe preeclampsia or HELLP syndrome or a placental abruption.) And a hemorrhage itself can cause clotting problems, leading to even heavier bleeding; There are a number of steps that your medical team will

take right away if you begin to bleed excessively. Since uterine atony (loss of tone) is the most common cause of PPH, your caregiver will massage your uterus to help it contract while you get intravenous oxytocin. (If you don't already have an IV, the nurse will start one immediately.) You will also be catheterized to make sure your bladder is empty since a full bladder makes it more difficult for your uterus to contract. If your placenta hasn't come out yet, your practitioner will attempt to deliver it, which in some cases requires her to reach up inside your uterus and remove it manually. You'll receive some pain medication before the procedure, and if you're in a birthing room you'll be moved to an operating room. If you start bleeding – or continue to bleed – from your uterus after the placenta is out, you'll receive other medications in addition to oxytocin while your caregiver continues to massage your uterus. In most cases, the medication works very quickly and the uterus contracts, stopping the bleeding. If need be, your practitioner will insert a hand inside your vagina and place her other hand on your belly, and compress your uterus between her two hands. This measure in combination with medication is usually enough to stem the tide. If you continue to bleed, you'll be transferred to the operating room and given pain medication to keep you comfortable. The doctor will carefully check to make sure that there are no lacerations that appear to be the primary source of your bleeding. She will also "explore" your uterus (via your vagina) to check for fragments of the placenta that may remain. In some cases, you'll need a procedure called dilation and curettage (D&C) to remove them. If your bleeding is extensive and doesn't stop or your vital signs aren't stable, you'll get a blood transfusion. This is necessary only in rare cases. Even more rarely, you'll need abdominal surgery and possibly a hysterectomy to stop a hemorrhage. Regardless of the cause of the hemorrhage, your blood pressure and pulse will be taken frequently to help your caregiver gauge how your body is coping with the blood loss. (This is done right after birth anyway to help determine the amount of postpartum blood loss.) An abnormally low blood pressure or high pulse will provide your caregiver with valuable information. You'll also have blood tests to check for anemia and, if necessary, to see whether your blood is clotting normally. 7. What are the indications and contraindications of common medications used to treat postpartum hemorrhage?

Medications used to control postpartum hemorrhage (PPH) are in the category of uterotonic drugs. These drugs stimulate contraction of the uterine muscle, helping to control PPH. Common medications include: Pitocin (oxytocin)- given by continuous infusion to maintain firm contraction of the uterus. Every patient receives Pitocin to firm the uterus but the dosage is increased in patients experiencing hemorrhage. Methergine- is used as an additive with Pitocin to further contract the uterus. Methergine increases blood pressure and is contraindicated in patients with

hypertension or cardiac disease. Hemabate- is used as an additive to Pitocin to further contract the uterus and is contraindicated with respiratory issues such as asthma. Hemabate can cause diarrhea, and nausea and vomiting. If the patient has pre-eclampsia and asthma and is experiencing postpartum hemorrhage, give the Methergine instead of Hemabate as respiratory function is more important and blood pressure can be controlled with other medications. Cytotec- is used for uterine contraction and may cause headaches, nausea and vomiting, and diarrhea. Cytotec is contraindicated with an allergy to prostaglandins.