Introduction:

Pregnancy Induced Hypertension (PIH) is a condition in which vasospasms occur during pregnancy in both small and large arteries. Signs of hypertension, proteinuria, and edema develop. It is unique to pregnancy and occurs in 5% to 7% of pregnancies in the united states. Despite years of research, the cause of the disorder is still unknown. Originally it was called toxemia because researchers pictured a toxin of some kind being produced by a women in response to foreign protein of the growing fetus, the toxin leading to the topical symptoms. No such toxins have ever been identified.

A condition separate from chronic hypertension, PIH tends to occur most frequently in women of color or with a multiple pregnancy; primiparas are younger than 20 years of age or older than 40 years, women from low socio economic backgrounds, those who have an underlying disease such as heart disease, diabetes with vessel or renal involvement and essential hypertension.

PIH is classified as gestational hypertension, mild preeclampsia, severe preeclampsia and eclampsia, depending on how far development advances. Gestational hypertension when develops an elevated blood pressure but has no proteinuria or edema. Perinatal mortality is not increased with simple gestational hypertension, so no drug therapy is necessary; and blood pressure returns to normal after birth. Mild preeclampsia when blood pressure rises to 140/90 mmHg or systolic pressure elevated 15 mmHg above pregnancy level; mild edema in upper extremities or face. Severe preeclampsia when blood pressure has risen to 160 mmHg systolic and 110 mmHg diastolic; proteinuria; pulmonary or cardiac involvement; extensive peripheral edema; hepatic dysfunction; theombocytopenia. Eclampsia is the most severe classification of PIH and seizure or coma Accompanied by s/s of preeclampsia. Any woman who falls into one of the high-risk categories for PIH should be observed carefully for symptoms at prenatal visits. She needs instructions about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.

Anatomy and Physiology:

When most people hear the term cardiovascular system, they immediately think of the heart. We have all felt our own heart "pound" from time to time, and we tend to get a bit nervous when this happens. The crucial importance of the heart has been recognized for a long time. However, the cardiovascular system is much more than just the heart, and from a scientific and medical standpoint, it is important to understand why this system is so vital to life.

Most simply stated, the major function of the cardiovascular system is transportation. Using blood as the transport vehicle, the system carries oxygen, nutrients, cell wastes, hormones, and many other substances vital for body homeostasis to and from the cells. The force to move the blood around the body is provided by the beating heart. The cardiovascular system can be compared to a muscular pump equipped with one-way valves and a system of large and small plumbing tubes within which the blood travels.

HEART:

The heart is a muscular organ found in all vertebrates that is responsible for pumping blood throughout the blood vessels by repeated, rhythmic contractions.
The heart is enclosed in a double-walled sac called the pericardium. The superficial part of this sac is called the fibrous pericardium. This sac protects the heart, anchors its surrounding structures, and prevents overfilling of the heart with blood. It is located anterior to the vertebral column and posterior to the sternum. The size of the heart is about the size of a fist and has a mass of between 250 grams and 350 grams. The heart is composed of three layers, all of which are rich with blood vessels. The superficial layer, called the visceral layer, the middle layer, called the myocardium, and the third layer which is called the endocardium. The heart has four chambers, two superior atria and two inferior ventricles. The atria are the receiving chambers and the ventricles are the discharging chambers. The pathway of blood through the heart consists of a pulmonary circuit and a systemic circuit. Blood flows through the heart in one direction, from the atrias to the ventricles, and out of the great arteries, or the aorta for example. This is done by four valves which are the tricuspid atrioventicular valve, the mitral atrioventicular valve, the aortic semilunar valve, and the pulmonary semilunar valve.
Systemic circulation is the portion of the cardiovascular system which carries oxygenated blood away from the heart, to the body, and returns deoxygenated blood back to the heart. The term is contrasted with pulmonary circulation.

Pulmonary circulation is the portion of the cardiovascular system which carries oxygen-depleted blood away from the heart, to the lungs, and returns oxygenated blood back to the heart. The term is contrasted with systemic circulation. A separate system known as the bronchial circulation supplies blood to the tissue of the larger airways of the lung.

Arteries are blood vessels that carry blood away from the heart. All arteries, with the exception of the pulmonary and umbilical arteries, carry oxygenated blood.

Pulmonary arteries
The pulmonary arteries carry deoxygenated blood that has just returned from the body to the heart towards the lungs, where carbon dioxide is exchanged for oxygen.

Systemic arteries
Systemic arteries can be subdivided into two types – muscular and elastic – according to the relative compositions of elastic and muscle tissue in their tunica media as well as their size and the makeup of the internal and external elastic lamina. The larger arteries (>10mm diameter) are generally elastic and the smaller ones (0.1-10mm) tend to be muscular. Systemic arteries deliver blood to the arterioles, and then to the capillaries, where nutrients and gasses are exchanged.

The Aorta
The aorta is the root systemic artery. It receives blood directly from the left ventricle of the heart via the aortic valve. As the aorta branches, and these arteries branch in turn, they become successively smaller in diameter, down to the arteriole. The arterioles supply capillaries which in turn empty into venules. The very first branches off of the aorta are the coronary arteries, which supply blood to the heart muscle itself. These are followed by the branches off the aortic arch, namely the brachiocephalic artery, the left common carotid and the left subclavian arteries.

Aorta the largest artery in the body, originating from the left ventricle of the heart and extends down to the abdomen, where it branches off into two smaller arteries (the common iliacs). The aorta brings oxygenated blood to all parts of the body in the systemic circulation.

The aorta is usually divided into five segments/sections:

• Ascending aorta—the section between the heart and the arch of aorta
• Arch of aorta—the peak part that looks somewhat like an inverted "U"
• Descending aorta—the section from the arch of aorta to the point where it divides into the common iliac arteries
  o    Thoracic aorta—the half of the descending aorta above the diaphragm
  o    Abdominal aorta—the half of the descending aorta below the diaphragm

Arterioles
Arterioles, the smallest of the true arteries, help regulate blood pressure by the variable contraction of the smooth muscle of their walls, and deliver blood to the capillaries.
Veins are blood vessels that carry blood towards the heart. Most veins carry deoxygenated blood from the tissues back to the lungs; exceptions are the pulmonary and umbilical veins, both of which carry oxygenated blood. Veins differ from arteries in structure and function; for example, arteries are more muscular than veins and they carry blood away from the heart.
Veins are classified in a number of ways, including superficial vs. deep, pulmonary vs. systemic, and large vs. small.

Superficial veins
Superficial veins are those whose course is close to the surface of the body, and have no corresponding arteries.

Deep veins
Deep veins are deeper in the body and have corresponding arteries.

Pulmonary veins
The pulmonary veins are a set of veins that deliver oxygenated blood from the lungs to the heart.

Systemic veins
Systemic veins drain the tissues of the body and deliver deoxygenated blood to the heart.
Atrium sometimes called auricle, refers to a chamber or space. It may be the atrium of the lateral ventricle in the brain or the blood collection chamber of a heart. It has a thin-walled structure that allows blood to return to the heart. There is at least one atrium in animals with a closed circulatory system.

Right atrium is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the superior and inferior vena cava and the coronary sinus, and pumps it into the right ventricle through the tricuspid valve. Attached to the right atrium is the right auricular appendix.

Left atrium is one of the four chambers in the human heart. It receives oxygenated blood from the pulmonary veins, and pumps it into the left ventricle, via the atrioventricular valve.
Ventricle is a chamber which collects blood from an atrium (another heart chamber that is smaller than a ventricle) and pumps it out of the heart.
Right ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives deoxygenated blood from the right atrium via the tricuspid valve, and pumps it into the pulmonary artery via the pulmonary valve and pulmonary trunk.

Left ventricle is one of four chambers (two atria and two ventricles) in the human heart. It receives oxygenated blood from the left atrium via the mitral valve, and pumps it into the aorta via the aortic valve.

Pathophysiology of Pregnancy Induced Hypertension (PIH):

Clinical Manifestations:

A.  Mild Preeclampsia

• BP of 140/90
• 1+ to 2+ proteinuria on random
• weight gain of 2 lbs per week on the 2nd trimester and 1 lb per week on the 3rd trimester
• Slight edema in upper extremities and face

B. Severe Preeclampsia

• BP of 160/110
• 3-4+ protenuria on random
• Oliguria (less than 500 ml/24 hrs)
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema
• Peripheral edema
• Hepatic dysfunction

C. Eclampsia is an extension of preeclampsia and is characterized by the client experiencing seizures.

Diagnostic Evaluation:

1. Based on the presenting symptoms. Often the disease process has been developing and affecting the renal and vascular system
2. Frequently a sudden weight gain will occur, of 2 lb. or more in 1 week, or 6 lb. or more within 1 month. This often occurs before the edema is present.

Medical Treatment and Evaluation:

1. Magnesium Sulfate (Pregnancy risk category B)
     muscle relaxant, prevent seizures
     loading dose 4-6g, maintenance dose 1-2g/h IV
     infuse IV dose slowly over 15-30 min.
      •Always administer as a piggy back infusion.
      •Assess PR, urine output, DTR, and clonus every hour.
      •Observe for CNS depression and hypotonia in infant at birth.
2. Hydrazaline (Apresoline) Pregnancy risk category C
     anti hypertensive (peripheral vasodilator) use to decrease hypertension
     5-10mg/IV
     Administer slowly to avoid sudden fall of BP
      •Maintain diastolic pressure over 90 mmHg to ensure adequate placental filling.
3. Diazepam (Valium) Pregnancy risk category D
     halt seizures
     5-10mg/IV
     administer slowly. Dose may be repeated every 10-15 min. (up to 30mg/hr)
      •Observe for respiratory depression for both mother and infant at birth.
4. Calcium Gluconate (Pregnancy risk category C)
     antidote for Magnesium Sulfate
     1g/IV (10 mL of a 10% solution)
     have prepared at bed side when administering Magnesium Sulfate
     administer at 5mL/min.

Complications of PIH:

1. Intrauterine growth restriction (IUGR) – an abnormally restricted symmetric or asymmetric growth of fetus
2. Oligohydramnios – abnormally low volume of amniotic fluid
3. Risk of placental abruption – premature separation of a normally situated placenta from the wall of uterus
4. Risk of preterm delivery (often iatrogenic) – delivery before 37 weeks of gestation
5. Coagulopathy
6. Stillbirth
7. Seizures
8. Coma
9. Renal failure
10. Maternal hepatic damage
11. Hemolysis
12. Elevated liver enzymes levels
13. Low platelet count (HELLP syndrome)

Nursing Interventions:

Discharge Plan:

Exercise

1. encourage patient’s on deep breathing exercises.
2. move extremities when lying.
3. elevate the head part when sleeping, to promote increase peripheral circulation
4. encourage overall passive and active exercises program during pregnancy to prevent need for cesarean birth.
5. exercises like tailor sitting, squatting, kegel exercise, pelvic rocking, and abdominal muscle contraction will promote easy delivery. 

Treatment:

1. use of drugs
2. catheterization
3. obtaining labs. (CBC, platelets count, liver function, BUN and creatinine, and fibrin degregation)

Health Teaching:

1. Encourage patient foe sodium restriction.
2. Encourage to avoid foods rich in oil and fats.
3. Encourage patient to limit her daily activities and exercises.

Ongoing Assessment:

1. Observe carefully for symptoms at prenatal visit.
2. Give instruction about what symptoms to watch for so she can alert her clinician if additional symptoms occur between visits.

Diet:

1. low fats and sodium diet, restriction if possible.
2. high in protein, calcium and iron.
3. Adequate fluid intake

Sex:

1. limit sexual activity
2. sexual intercourse at 2nd trimester should be avoided.

View Nursing Care Plan – Pregnancy Induced Hypertension (PIH)

References:

• Maternal and child health nursing by Adele Pillitteri 5th edition;volume 1 page 426-433;page 329-332
• All-in-one care planning resource page 748; by Pamela L. Swearlngen, RN
• Maternal neonatal nursing;page 30 by Lippincott Williams and Wilkins
• Luckman and Sorensen’s Medical-Surgical Nursing a Physiologic Approach 4th edition Volume 1 page 734
• http://wikipedia.org
• http://nursingcrib.com

Related posts:

1. Nursing Care Plan – Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia)
2. Fetal Circulation
3. Pathophysiology of Congestive Heart Failure

Preeclampsia is a characterized, by vsospasms, changes in the coagulation system, and disturbances in systems related to volume and BP control. Vasospasms results from an increased sensitivity to circulating pressors, such as angiotensin II, and possibly an imbalance between the prostaglandins prostacyclin and thromboxane A1.

Endothelial cell dysfunction, believed to result from decreased placental perfusion, may account for many changes in preeclampsia. Arteriolar vasospasm may cause endothelial damage and contribute to an increased capillary permeability. This increase edema and further decreases intravascular volume, predisposing the woman with preeclampsia to pulmonary edema.

Immunologic factors may play an important role in the development of preeclampsia. The presence of a foreign protein, the placenta, or the fetus maybe perceived by the mother’s immune system as an antigen. This may then trigger an abnormal immunologic response. This theory is supported by the increased incidence of preeclampsia or eclampsia in first-time mothers or to multiparous woman pregnant by a new partner. Preeclampsia maybe an immune complex disease in which the maternal antibody system is overwhelmed from excessive fetal antigens in the maternal circulation. This theory seems compatible with the high incidence of preeclampsia among women exposed to a large mass of trophoblastic tissue as seen in twin pregnancies or hydatidiform moles.

Genetic predisposition maybe another immunologic factor. Dekker reported a greater frequency of preeclampsia and eclampsia among daughters and granddaughters of women with a history of eclampsia, which suggests an autosomal recessive gene controlling the maternal immune response. Paternal factors are also examined.

Diets in inadequate nutrients, especially protein, calcium, sodium, magnesium, and vitamin E and C, maybe an etiologic factor in preeclampsia. Some practitioners prescribed high-protein diets (90 mg supplemental protein) without caloric restriction and moderate sodium intake in the prevention and treatment of this disorder. However, data are limited regarding the association between diet and preeclampsia.

Preeclampsia progress along a continuum from mild disease to severe preeclampsia, HELLP syndrome, or eclampsia. The pathophysiology of preeclampsia reflects alteration in the normal adaptations of pregnancy. Normal physiologic adaptations to pregnancy include increase blood plasma volume, vasodilation, and decreased systemic vascular resistance, elevated cardiac output, and decreased colloid osmotic pressure. Pathologic changes in the endothelial cells of the glomeruli are uniquely characteristic of preeclampsia, particularly in nulliparous women. The main pathogenic factor is not an increase in BP but poor perfusion as a result vasospasm. Arteriolar vasospasm diminishes the diameter of blood vessels, which impedes blood flow to all organs and raises BP. Function in organs such as the placenta, kidneys, liver and brain is deceased by as much as 40% to 60%.

Related posts:

1. Nursing Care Plan – Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia)
2. Pregnancy Induce Hypertension Case Study
3. Pregnancy Complications

According to the Department of Health (DOH), 16 out of the 20 DOH-retained hospitals in Metro Manila have fully complied with the directive on phasing out the use of all apparatuses or devices in the healthcare system that contain mercury.

The phase-out is in connection with the Administrative Order No. 2008-0021 which mandates the gradual phase-out of mercury in all Philippine health care facilities and institutions.

The move to stop the use of all medical devices containing mercury was jumpstarted in 1991, when the World Health Organization (WHO) concluded that a safe level for mercury that would not have any adverse effects on a person’s health has never been established.

The following are the list of DOH-hospitals in Metro Manila which are fully-compliant:

1. San Lorenzo Ruiz Women’s Hospital
2. Dr. Jose N. Rodriguez Memorial Hospital
3. Philippine Orthopedic Center
4. Valenzuela Medical Center
5. National Center for Mental Health
6. East Avenue Medical Center
7. San Lazaro Hospital
8. Research Institute for Tropical Medicine
9. Dr. Jose R. Reyes Memorial Medical Center
10. Jose Fabella Memorial Hospital
11. Las Pinas General Hospital and Satellite Trauma Center
12. Rizal Medical Center
13. Quirino Memorial Medical Center
14. Tondo Medical Center
15. Lung Center of the Philippines a
16. Philippine Children’s Medical Center

In a report to Health Secretary Esperanza Cabral last 24 February 2010, there were only four remaining DOH-retained hospitals in Metro Manila that have not yet fully complied with the phase-out.

These four hospitals are the National Children’s Hospital, Amang Rodriguez Medical Center, Philippine Heart Center and National Kidney and Transplant Institute.

The National Children’s Hospital is still using mercurial sphygmomanometers while awaiting delivery of digital sphygmomanometers, while the Heart Center has fully phased out mercurial thermometers, but still has functioning mercurial blood pressure devices that are waiting to be replaced.

The National Kidney and Transplant Institute is still using 11 mercurial sphygmomanometers but these are only used as back up in their hemodialysis units and are awaiting replacements. The Amang Rodriguez Medical Center retrieved nine mercurial blood pressure apparatuses from the condemned equipment damaged by Typhoon Ondoy but these too are due to be replaced soon.

Meanwhile, four compliant hospitals were recognized by the group Health Care Without Harm-Southeast Asia. These are the San Lazaro Hospital, Research Institute for Tropical Medicine, Las Pinas General Hospital and Satellite Trauma Center, and the Philippine Children’s Medical Center.

According to the Health Chief, mercury must be phased out because of its potentially harmful effects to a person’s health. Mercury can damage the nervous, digestive, respiratory, endocrine and immune systems. It can also cause tremors, impaired vision and hearing, paralysis, insomnia, emotional instability, developmental effects on a fetus, and attention deficit and developmental delays during childhood.

“With all the hazards posed by mercury, it is high time that we complete the implementation of its total phase-out in all hospitals and health facilities”, Cabral concluded.

Source: DOH

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Success is not measured by how much you have accumulated wealth nor by just establishing yourself as a skilled practitioner of your chosen career or position. It includes developing maturity and responsibility in how you live your life. It involves the pursuit of wisdom more than the pursuit of arbitrary knowledge.

Nursing remains to be one of the toughest, most demanding and most stressful job, but it’s more than worth it if you’ve got the skills and aptitude for it.

Here is an OFW Nurse story who has performed an exemplary service to the citizens of Singapore. The letter is written by Irma Suing-Peñaranda, 43, currently works as corporate planning officer in a government financing corporation. Published in Philippine Star last February 25, 2010.

One of my younger sisters is an OFW who works as staff nurse at a government hospital in Singapore. She started her stint in that institution in October 2000 as a nursing aide, despite being a full-fledged registered nurse in the Philippines. After the initial work contract of two years, some of her batch mates moved to Canada, the UK, the US, and elsewhere in the world to seek greater compensation they deemed commensurate to their profession and expertise.

But my sister opted to stay. In her batch of more than a dozen nurses and midwives sent by the placement agency based here in the Philippines back in 2000, I believe she is the only one left in that hospital now. She is a very patient and dedicated person. From being a nursing aide, she was gradually promoted (with similarly minimal salary adjustments). And every year or so, she is a regular recipient of an award or citation for her dependability, dedication, competence and efficiency in her chosen profession.

During the SARS scare in 2003, she was home for a monthlong vacation to visit my ailing father, who passed eventually away in December of the same year. Worried that she might get infected with the dreaded syndrome, we, her siblings tried to persuade her not to return to Singapore, but to no avail. She returned as promised to her “sister” or Nursing Supervisor and upon resuming her duties at the hospital, was immediately quarantined for a few weeks with the sick and the dying. When SARS has been finally contained and things were back to normal in countries affected by it, my sister was one of the recipients of citations and medals from the government of Singapore for helping those who had battled the disease, particularly the medical workers.

Sometimes I could not understand why she opts to remain in Singapore despite the lure of higher pay in other foreign countries accepting Philippine nurses in their medical staff.  I presume if she had moved on to US, Canada or the UK, she could have easily been a millionaire by now (by Philippine standards) like some of her former colleagues. My mother at times would say in jest that in our place people think that she has lots of money and is well provided because she has an OFW daughter. If they only knew that my sister is a rare breed, not someone who really wants to earn too much. Someone who is very much focused on her nurse’s pledge to care for the sick.

Nevertheless, our family respects her decision not to be dictated by material gains. My sister puts more heart in her career than most other individuals who are in the same profession. She believes nursing, as a vocation, is a response to a divine call to help the ailing. Through all the years she has been employed in that hospital, she has been assigned in the oncology department, serving patients afflicted with the big “C.” Day after day she is a witness to many dramas of life unfolding in that corner of her world, where sometimes a ray of hope may peek amidst the darkening clouds. And at other times she tearfully shares that the only thing you can do for the case on record is to pray and hold the patient’s hand.

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Florence Nightingale was born in Italy on 12th May 1820. Despite opposition from her family she decided to devote her life to nursing and campaigning for better health care and sanitation for all. It was her work during the Crimean War that created the legend of the Lady with the Lamp and it was her experience here that drove her to continue, researching, writing and tirelessly campaigning.

After the Crimean War she demanded a Royal Commission into the Military Hospitals and the health of the Army, she began investigating the health and sanitation in the British Army in India, and the local population. Money which had been sent by the general public to thank her for her work in the Crimea was used to establish the first organised, training school for nurses, the Nightingale Training School at St Thomas’ Hospital.

Her greatest achievement was to make nursing a respectable profession for women. Florence’s writings on hospital planning and organization had a profound effect in England and across the world, publishing over 200 books, reports and pamphlets.

Florence died at the age of 90, on 13th August 1910, she had become one of the most famous and influential women of the 19th century. Her writings continue to be a resource for nurses, health managers and planners to this day.

Florence Nightingale is famous for being the ‘Lady with the Lamp’ who nursed soldiers during the Crimean War, but this was just one of her many great achievements.

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The Department of Health (DOH) may recommend to the Department of Environment and Natural Resources (DENR) the banning on the importation of mercury-containing products in the Philippines.

In a telephone interview, Health Secretary Esperanza Cabral reiterated that mercury is highly toxic so the use of any product containing the substance should be prohibited.

“I think products like fluorescent lamps have mercury. We will propose to the DENR that these products be banned. We will see,” she said.

Mercury is a potent neurotoxin that can affect the kidney and the nervous, digestive, respiratory and immune systems.

In 2008, the DOH issued Administrative Order (AO) No. 21 imposing the “gradual phaseout of mercury in all Philippine health care facilities and institutions.”

The AO is in line with the stand of the World Health Organization in 1991 that a “safe level of mercury exposure, below which no adverse effect,” has never been established.

Cabral reminded all hospitals, infirmary, lying-in clinics and other health facilities that they have until December this year to comply with the phaseout.

“The DOH has not been registering thermometer and blood pressure apparatus with mercury (because of that AO). We want to remind health care facilities that they have until this year to switch to alternative devices,” she said.

The two medical devices that contain mercury are thermometers and sphygmomanometers used to take the blood pressure of a person.

The non-governmental organization Health Care Without-Southeast Asia, which has been advocating for the ban, gave assurance that digital alternatives for these devices are easily available and affordable.

By next year, Cabral said there should be no mercury devices in the Philippines so health care facilities should have already started phasing them out.

Source: Philstar

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