Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks' gestation and can present as late as 4-6 weeks postpartum. It is clinically defined by hypertension and proteinuria, with or without pathologic edema.
Nursing Assessment for Preeclampsia
Subjective data
Objective Data
Examination
- Age is usually common in primi gravida, less than 20 years or more than 35 years.
- Maternal health history is now: an increase in blood pressure, edema, headache, epigastric pain, nausea, vomiting, blurred vision.
- Mother's previous medical history: kidney disease, anemia, vascular essential, chronic hypertension, DM
- Pregnancy history: a history of multiple pregnancy, hydatidiform mole, hydramnios and pregnancy history with pre eclampsia or eclampsia before.
- Nutritional patterns: either the type of food consumed staple food and distraction.
- Social psycho-spiritual: Emotions are not stable can cause anxiety, therefore, need moral readiness to face the risks.
Objective Data
- Inspection: edema that does not disappear within 24 hours
- Palpate: to know the height of fundus of the uterus, the fetus, the location of edema.
- Auscultation: listening to fetal heart rate to determine the presence of fetal distress.
- Percussion: to know the patellar reflex.
Examination
- Vital signs are measured in a lying or sleeping position, measured 2 times at intervals of 6 hours
- Laboratory: urine protein, with a catheter or midstream (usually increased to 0.3 g / l or 1 to 2 on a qualitative scale), decreased hematocrit levels, increased urine specific gravity, serum creatinine increased, uric acid is usually more than 7 mg/100 ml
- Weight loss: an increase of more than 1 kg / week
- Level of consciousness: a reduction in GCS as a sign of abnormalities in the brain
- Ultrasound; to know the state of the fetus
- NST: to determine fetal well-being.
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