CONCEPT MAP WORKSHEET
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 PATIENT INFORMATION ANTICIPATED PHYSICAL
(REASON FOR TEST AND RESULTS) 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 maintaining the bed in low and locked position
Pad railings and implement seizure precautions
Assess deep tendon reflexes
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION
Your name, position (RN), unit you are
working on
SITUATION Olivia Jones, 23, admitted for severe preeclampsia
Patient’s name, age, specific reason for visit
BACKGROUND Pt is diagnosed with severe preeclampsia, admitted 5/7/2020, current
orders are NPO until serum lab results are in, bed rest with bathroom
Patient’s primary diagnosis, date of privileges, BP Q1Hx2 then Q4H, T, HR, RR Q1H, breath sounds Q4H,
admission, current orders for patient FHR/UC monitoring, DTR Q1H, head to toe Q4H, continuous SpO2,
IV care, ultrasound, foley catheter, place seizure pads, minimize
stimuli, NRB mask for SpO2 <92%
ASSESSMENT BP 164/98
T 99F
Current pertinent assessment data using head RR 22
to toe approach, pertinent diagnostics, vital HR 110
SpO2 92%
signs
Pt c/o visual changes, headache, and epigastric pain
The pt has crackles in the lower lobes of the lungs
The pt has low platelets, RBCs, MCH, MCHC and elevated creatinine,
BUN, ALT/AST and has protein in the urine >455 mg/24H
RECOMMENDATION I recommend the pt be placed on seizure precautions and
environmental stimuli be limited, including visitors. She should
Any orders or recommendations you may have continue to be monitored for progression of preeclampsia to eclampsia.
for this patient She should be fitted for a risk for falls pt bracelet. The pt should be
educated on condition and medications. Continue to monitor for
contractions. Monitor BP Q1H.
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 PATIENT INFORMATION ANTICIPATED PHYSICAL
(REASON FOR TEST AND RESULTS) 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 maintaining the bed in low and locked position
Pad railings and implement seizure precautions
Assess deep tendon reflexes
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION
Your name, position (RN), unit you are
working on
SITUATION Olivia Jones, 23, admitted for severe preeclampsia
Patient’s name, age, specific reason for visit
BACKGROUND Pt is diagnosed with severe preeclampsia, admitted 5/7/2020, current
orders are NPO until serum lab results are in, bed rest with bathroom
Patient’s primary diagnosis, date of privileges, BP Q1Hx2 then Q4H, T, HR, RR Q1H, breath sounds Q4H,
admission, current orders for patient FHR/UC monitoring, DTR Q1H, head to toe Q4H, continuous SpO2,
IV care, ultrasound, foley catheter, place seizure pads, minimize
stimuli, NRB mask for SpO2 <92%
ASSESSMENT BP 164/98
T 99F
Current pertinent assessment data using head RR 22
to toe approach, pertinent diagnostics, vital HR 110
SpO2 92%
signs
Pt c/o visual changes, headache, and epigastric pain
The pt has crackles in the lower lobes of the lungs
The pt has low platelets, RBCs, MCH, MCHC and elevated creatinine,
BUN, ALT/AST and has protein in the urine >455 mg/24H
RECOMMENDATION I recommend the pt be placed on seizure precautions and
environmental stimuli be limited, including visitors. She should
Any orders or recommendations you may have continue to be monitored for progression of preeclampsia to eclampsia.
for this patient She should be fitted for a risk for falls pt bracelet. The pt should be
educated on condition and medications. Continue to monitor for
contractions. Monitor BP Q1H.
