1 Patient: Mrs. Smith, 31 years of age,
36 weeks gestation, G2 P0 A1.
Admitted due to patient feeling
lightheaded and epigastric pain.
2 Risk of development of
preeclampsia r/t high blood
pressure above 140/90, and preexisting high blood pressure prior to pregnancy.
2.1 Risk of placental
due to the negative
effects of severe
preeclampsia and smoking combined
2.1.1 May also lead to
restriction. This is due to
insufficient blood supply to
allow placental and fetal
growth and decelopment
220.127.116.11 External fetal monitoring
and ultrasound need to
monitor current fetal
heart and activity level
and to be able to
appropriately see fetal
and placental growth and
2.2 Continually monitor patients blood pressure. If blood
pressure continues to be elevated and patient is
diagnosed as being preeclamptic, administer
2.3 Risk of developing
2.4 Induction of
labour when safe
for patient if
2.4.1 Being oxytocin
6 units in 2/3
&1/3 at a rate
3 Risk of
increased stress r/t
and/or loss of
3.1 Spontaneous loss of
previous pregnancy at
18 weeks gestation.
Why did this occur?
Did this cause
on the patient.
3.1.1 Engage in fetal stress test and place patient on continuious
fetal heart monitoring. This will ensure that the fetus is not
in distress and appears to be happy and healthy. Further
ultrasound testing may be needed to look at fetal placement,
fetal growth and so forth.
3.1.2 Multidisciplinary approach with social
work to add support to the family as the
last pregnancy was not desirable.
4 Risk of a cardiovascular
accident or seizure activity r/t the effects of
hypertension and smoking
4.1 Ensure magnesium sulfate is initated
24 hours prior to delivery and
continues during delivery to ensure
the patient does not experience
seizure activity during the labour
4.2 Patient feeling lightheaded puts
heavier need on closely
monitoring patient for seizure
activity. Even though this may be
caused by other factors such as
hydration, it may also be solely
4.3 Take on a holistic approach to nursing interventions.
This means continually checking blood pressure and
other needed diagnostic testing as well as continually
asking the patient of their well-being. Also ensure
patient teaching on seizure and stroke signs and symptoms (visual
changes, nausea, urinary incontinence, headache, etc).
4.4 Is the patient in
5 History of pregnancy: patient states that this
pregnancy seemed normal, no reports of high
blood pressure up to this point. Although the
patient explained that she experienced
moderate high blood pressure previous to
pregnancy. Stress is present during this
pregnancy due to the fear of misscarrying
again and fetal overall health. No alcohol use.
Smokes occasionally. Only medications are
6 Objective Values: BP- 142/94, temp- 37.2,
resp- 18, urinanalysis- ph 6.050, protien-
+++, all other values were negative. Blood
tests show increase in uric acid, increase
in hemocrit, slight decrease in platelet
count, increase in pt/PTT, increase in
creatinine, increase in AST and ALT,
normal total billirubin.