Preeclampsia-Eclampsia
RAPID Reasoning
Dana Myers, 40 years old
Primary Concept
Intracranial Regulation
Interrelated Concepts (In order of emphasis)
1. Perfusion
2. Reproduction
3. Clinical Judgment
RAPID Reason
...
Preeclampsia-Eclampsia
RAPID Reasoning
Dana Myers, 40 years old
Primary Concept
Intracranial Regulation
Interrelated Concepts (In order of emphasis)
1. Perfusion
2. Reproduction
3. Clinical Judgment
RAPID Reasoning Case Study: STUDENT
Preeclampsia-Eclampsia
History of Present Problem:
Dana Myers is a 40-year-old woman, G-3 P-2 who is 34 weeks gestation. Her health care provider has been monitoring
her weekly because her blood pressure has been increasing the past month and is currently 146/88. Last week she had 1+
non-pitting edema of both lower extremities (BLE) and her urine was negative for protein. Today during her clinic visit,
Dana’s BP was 168/90. She had 2+ proteinuria and 3+ pitting edema BLE. She also complained of a mild headache in
the center of her forehead, and seeing “spots.” Fetal heart tones via Doppler are 136/minute in the lower left quadrant.
Abdominal measurement from pubic bone to top of fundus is 31 cm.
The primary care provider was concerned and Dana has been admitted to the community hospital labor and delivery
unit to be evaluated for severe preeclampsia. You are the admitting nurse responsible for her care.
Personal/Social History:
Dana has two children, ages two and four. She is married and both she and her husband are excited to have another
baby, but have been concerned about this pregnancy. Dana’s previous two pregnancies were healthy, without incident,
resulting in the vaginal births of a boy, then a girl. Dana’s parents live in the same town and are supportive.
Dana works part-time teaching English at the local community college. Her husband is an engineer who works full
time and is occasionally out of town for work. Dana is generally healthy, without any chronic illnesses. She does not
smoke or use recreational drugs. She reports drinking socially but refrains while pregnant.
What data from the histories are RELEVANT and has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Increasing blood pressure.
+2 proteinuria
Pitting edema BLE
Mild headache in the center of forehead and
seeing spots.
These are all manifestations of preeclampsia.
RELEVANT Data from Social History: Clinical Significance:
Two children ages 2 and 4.
Married.
Parents live in same town.
Part-time teaching English.
Husband engineer.
Dana already has two younger children, which could be stressful with
being pregnant and having complications. With Dana being married and
having her parents living in the same town, shows that she has a good
support system. Dana works part-time and her husband is an engineer, so
they are financially stable.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 98.4 F/36.9 C (oral) Provoking/Palliative: None
P: 84 (regular) Quality: Stabbing/throbbing
R: 20 (regular) Region/Radiation: Eyes, forehead
BP: 164/98 Severity: 5/10
O2 sat: 95% room air Timing: Constant, unrelieved by acetaminophen
What VS data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT VS Data: Clinical Significance:
BP:164/98
Constant, stabbing,
throbbing pain in eyes and
forehead and is unrelieved
by acetaminophen.
High blood pressure is related to preeclampsia.
Headaches and vision changes can be associated with CNS irritation or could indicate cerebral
edema.
Website. “Preeclampsia - Signs-And-Symptoms.” Preeclampsia Foundation - Helping Save Mothers and Babies from
Illness and Death Due to Preeclampsia, www.preeclampsia.org/signs-and-symptoms.
Current Assessment:
GENERAL
APPEARANCE:
Appears uncomfortable
RESP: Breath sounds clear with equal aeration bilaterally, non-labored respiratory effort
CARDIAC: Pink, warm/dry, 3+ non-pitting edema of BLEs with generalized edema of hands, face, and
sacrum, heart sounds regular with no abnormal beats, equal with palpation at
radial/pedal/post-tibial landmarks
NEURO: Alert and oriented to person, place, time, and situation (x4). Reflexes are brisk with no
clonus, c/o headache and continues to see “spots”
GI: Abdomen soft/non-tender, slight epigastric discomfort, bowel sounds audible per
auscultation in all four quadrants, no contractions palpated, uterus soft.
GU: Voiding without difficulty, urine clear/yellow, urine 2+ by dipstick.
SKIN: Skin integrity intact
What assessment data are RELEVANT and must be recognized as clinically significant by the nurse?
RELEVANT Assessment Data: Clinical Significance:
3+ non-pitting edema of BLEs
Generalized edema of hands, face, and
sacrum.
Slight epigastric discomfort.
Urine 2+ by dipstick.
Due to fluid retention in the body’s tissues.
Epigastric gastric pain could be related to many different factors. It is also a
manifestation of preeclampsia.
Non-stress Test
What results are RELEVANT that must be recognized as clinically significant to the nurse?
RELEVANT Results: Clinical Significance:
The non-stress test is nonreactive.
Fetal heart rate baseline
130, with minimum
variability and no
accelerations. No
decelerations are noted.
Non-stress test non-reactive indicates baby did not make the minimum number of movements
for the time period. Baby could be sleeping.
Fetal heart rate is normal with minimal fluctuation in heart rate.
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