Second Trimester Complications

1. 4. Assessment - hospitalized woman:
      1. Vital signs (blood pressure in side-lying position, pulse, respirations) - q2-4h, while awake (if mild to moderate preeclampsia) or as necessary. Note: Record, report persistent hypertension.
      2. Fetal heart tones at time of vital signs.
      3. Deep-tendon reflexes (DTR) and clonus - to identify/monitor CNS hyperirritability.
      4. I&O - to identify diuresis. (Note: oliguria indicates pathologic progression.)
      5. Urinalysis (clean-catch) for protein, daily or after each voiding, as necessary.
      6. Signs of pathologic progression.
      7. Signs of labor, abruptio placentae (Note: high blood pressure, or a rapid drop, may initiate abruptio), DIC.
      8. Emotional status.
      9. Daily weight, amount/distribution of edema (pitting; pedal, digital, periorbital)—to identify signs of mobilization of tissue fluid, diuresis.
   5. Analysis/nursing diagnosis:
      1. Fluid volume excess: hemoconcentration, edema related to altered blood osmolarity and sodium/water retention.
      2. Altered nutrition» less than body requirements: protein deficiency related to loss through damaged renal membrane.
      3. Altered tissue perfusion related to increased peripheral resistance and vasospasm in renal, cardiovascular system.
      4. Altered urinary elimination: oliguria, anuria related to hypovolemia, vasospasm.
      5. Sensory/perceptual alterations: visual disturbances, hyperirritability related to cerebral edema, decreased oxygenation to brain.
      6. Anxiety related to symptoms, implications of pathophysiology.
      7. Diversional activity deficit related to need for reduced environmental stimuli, bed rest.
      8. Risk for injury related to seizure.
   6. Prognosis:
      1. Good - symptoms mild, respond to treatment.
      2. Poor - convulsions (number and duration); persistent coma; hyperthermia, tachycardia (120 beats/min); cyanosis, and liver damage.
      3. Terminal - pulmonary edema, congestive heart failure, acute renal failure, cerebral hemorrhage. The earlier the symptoms appear, the poorer the outcome for the pregnancy.
   7. Nursing care plan/implementation: Goal: health teaching.
      1. Rest - frequent naps in lateral Sims position.
      2. Immediate report of danger signs:
         • Digital and periorbital edema.
         • Severe headache, irritability.
         • Visual disturbances.
         • Epigastric pain.
      3. Do roll-over test (blood pressure while on back and lateral positions).
      4. Importance of regular prenatal visits.
      5. Monitoring own blood pressure between prenatal visits.
   8. Nursing care plan/implementation - hospitalized woman:
      1. Goal: reduce environmental stimuli to minimize stimulation of hyperirritable CNS. Limit visitors and phone calls.
      2. Goal: emotional support.
         • Encourage verbalization of anxiety, fears, concerns.
         • Explain all procedures, seizure precautions.
      3. Goal: supportive care.
         • Encourage bed rest - to increase tissue perfusion, promote diuresis.
         • Position: lateral Sims’ - to reduce risk of supine hypotensive syndrome.
      4. Goal: health teaching. Rest with reduced stimuli.
      5. Goal: monitor and administer drugs as ordered.
         • Anticonvulsants (especially magnesium sulfate).
         • Antihypertensives.
         • Diuretics (used rarely, and only in presence of congestive heart failure [CHF]).
         • Blood volume expanders.
      6. Goal: seizure precautions. To safeguard mater-nal/fetal status:
         • Observe for signs and symptoms of impending convulsion:
           1. Frontal headache.
           2. Epigastric pain.
           3. Sharp cry.
           4. Eyes fixed; unresponsive.
           5. Facial twitching.
         • Emergency items (suction equipment, airway, drugs, IV fluids) immediately available.
      7. Goal: convulsion care (woman with eclampsia).
         • Maintain patent airway; administer oxygen.
         • Safety - padded bed rails.
         • Reduce environmental stimuli: dim lights, quiet.
         • Observe, report, and record:
           1. Onset and progression of convulsion.
           2. If followed by coma or incontinence.
         • Prepare for immediate cesarean delivery; check FHR. Close observation for 48 hours postpartum, even if no further convulsions (or no convulsions to date).
   9. Evaluation/outcome criteria:
      1. Woman complies with medical/nursing plan of care.
      2. Woman’s symptoms respond to treatment; progression halted.
      3. Woman carries uneventful pregnancy to successful termination.