NUR 4130 Clinical vSim Assignment Olivia Jones

DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Preeclampsia is characterized by high blood pressure after 20 weeks gestation. It is grouped into mild and severe and then progresses to eclampsia. Mild preeclampsia is blood pressure >140/90 mm Hg and severe is >160/110 mm Hg. The pathophysiology is largely unknown but it involves both vasospasm and hypoperfusion. It causes pulmonary edema, oliguria, seizures, thrombocytopenia, and abnormal liver enzymes. DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS Ultrasound to monitor FHR Pitting dependent edema, increased BP, >140/90, Hepatic Function Panel to monitor for organ damage facial edema, weight gain, oliguria, headache, AST/ALT to monitor for organ damage difficulty breathing, epigastric pain, visual changes CBC to monitor for platelets, RBCs, MCH, MCHC Urine dip stick to monitor for proteinuria; a warning sign ANTICIPATED NURSING INTERVENTIONS Monitor labs CBC, urine dip stick, liver function tests Monitor BP and HR frequently Auscultate lung sounds Attach electronic FHR monitor Obtain ultrasound Assess for dependent edema Monitor SpO2 Limit stimuli such as visitors, light, and sound Apply nonrebreather mask Assess for visual changes Administer medications as ordered Provide emotional support Provide pt education Monitor for progression of preeclampsia Provide pt safety including maintainin