Question

A woman in her 40s is around 34 weeks gestation and is sent to the hospital for labor and delivery by her health care provider due to a BP of 165/90 which is high compared to her normal.

Suspecting preeclampsia what are questions a nurse should ask on admission?

What are physical assessment data that must be collected?

Answer 1

Pre-eclampsia :

Pre-eclampsia is a multisystem disorder characterized by development of hypertension to the extent of 140/90mmhg or more with proteinurea.this condition usually develop after 20 week of gestation.

In the above case the Bp is 165/90mmhg,the medical treatment is necessary to this patient. the increase of systolic Bp greater than or equal to 30mmhg and diastolic Bp greater than or equal to 15 mmhg from normal range is considered as pre-eclampsia .this patient have high Bp .provide medical treatment and bedrest, if bp decrease or reduce all symptoms of pre-eclampsia wait to deliver at the term. Close monitoring is needed .

Assessment of pre-eclampsia patient on admission

Possible questions the nurse ask while admission:

_ask about the general condition of patient.

_ask the patient to have the symptoms like head ache, visual disturbance, and edema.

_whether the patient have epigastric pain and oliguria.

_ask about the history of present illness and past medical history.

_ask about the weight gain during her gestation period.

_ask about her family history of hypertension.

_ask about her gravidity (primipara or multipara)

_ask about her socioeconomic status.

Physical assessment of pre-eclampsia :

:check vital signs hourly to know the range of Bp. At least four times a day should check the Bp.

:state of edema and daily weight record. Edema is characterized by pitting edema over the ankles. Rapid weight gain is the sign of pre-eclampsia .

:fluid intake and urinary output.

:urine examination for protein daily.

:blood for hematocrit, platelet count, uric acid, creative and liver enzymes and coagulation profile.

:ophthalmoscopic examination.

:assessment of fetal well-being by Doppler, NST and CTG .

:auscultate lung sound (fine crepitus present if pulmonary edema occur)

:assessment of fundamental height.