Intrapartal Hypertension - ,/cesareanbirth,oronset...

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Intrapartal Hypertension PIH may have been diagnosed during the prenatal period, necessitating induction of labor/cesarean birth, or onset  of symptoms may occur during labor (or early postpartum). Early recognition and prompt intervention promote optimal  outcomes for client and fetus. This plan of care is to be used in conjunction with the first five care plans in this chapter, which concern the three  stages of labor, or with CPs: Induced/Augmented Labor Cesarean Birth, as indicated. CLIENT ASSESSMENT DATA BASE (Refer to CP: Pregnancy-Induced Hypertension and to the intrapartal assessment tool at the beginning of this  chapter.) Circulation May have been monitored/treated for prenatal hypertension either at home or in hospital setting, or may have been  normotensive throughout the pregnancy. Blood pressure may be elevated at the onset of labor. Progressive fluid retention may be present. Safety May be receiving an oxytocin infusion for induction or to offset tocolytic effects of MgSO 4 . Sexuality May be scheduled for induction (if cervix is favorable) or cesarean birth (preferably after 36 weeks’ gestation) because  of deteriorating maternal and placental status. Pregnancy may or may not be full term (with uterus at xiphoid process). DIAGNOSTIC STUDIES Kidney, liver, and coagulation studies may show altered function. (Refer to CP: Pregnancy-Induced Hypertension. NURSING PRIORITIES 1. Reduce/alleviate maternal hypertension. 2. Monitor client and fetal status. 3. Maintain/optimize placental circulation. 4. Prevent eclamptic state. NURSING DIAGNOSIS: Fluid Volume excess/[circulating deficit] May Be Related To: Compromised regulatory mechanism (pathological state with fluid  shifts), excessive fluid intake, effects of drug therapy (oxytocin  infusion) Possibly Evidenced By: Blood pressure changes, edema, weight gain, changes in mentation DESIRED OUTCOMES/EVALUATION  Display usual mentation; BP, pulse, urine output,  CRITERIA—CLIENT WILL: and specific gravity WNL; deep tendon reflexes (DTRs) 2+ (normal);  free of headache and visual disturbances, absence of clonus.
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ACTIONS/INTERVENTIONS RATIONALE Independent Assess location and extent of edema. Note Hb and  Helps determine degree of fluid retention and  Hct levels. possible shifts to extracellular tissues. If the  pathological state is excessive, involving vasospasms  and hypertension, fluid that has shifted from the  intravascular space to extracellular tissue may begin  to reenter the circulatory system, contributing to fluid  overload and significant increase in BP.
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