Discharge And Home Healthcare Guidelines

TEACHING. Teach the patient how to check her own fundus and do a fundal massage; this is especially important for patients at risk who are discharged early from the hospital. Advise the patient to contact the physician for the following: a boggy uterus that does not become firm with massage, excessive bright red or dark red bleeding, many large clots, fever above 100.4°F, persistent or severe perineal pain or pressure.

MEDICATIONS. If iron supplements are provided, teach the patient to take the drug with orange juice and expect some constipation and dark-colored stools. If oxytocics are ordered, emphasize the importance of taking them around the clock as prescribed. If antibiotics are ordered, teach the patient to finish the prescription, even though the symptoms may have ceased.

Preeclampsia

DRG Category: 373

Mean LOS: 1.9 days

Description: MEDICAL: Vaginal Delivery without

Complicating Diagnoses DRG Category: 370 Mean LOS: 4.9 days Description: SURGICAL: Cesarean Section with CC

Preeclampsia is a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation that affects approximately 7% of all pregnant women. It is characterized by hypertension (blood pressure [BP]>140/90) and proteinuria (300 mg in 24 hours or 1 + dipstick) after 20 weeks' gestation. Edema is no longer included as a diagnostic criterion for preeclampsia, although it is often present, as it is an expected occurrence in pregnancy and has not shown to be discriminatory.

If untreated (or sometimes even with aggressive treatment), the symptoms get progressively worse. Symptoms relate to decreased perfusion to the major organs: kidneys (proteinuria, oliguria), liver (epigastric pain, elevated enzymes), brain (headache, blurred vision, hyperreflexia, clonus, seizures) and the placenta (fetal distress, intrauterine growth restriction). The devastating sequence of events after preeclampsia is as follows: eclampsia (seizure occurs), HELLP syndrome (hemoly-sis, elevated liver enzyme levels, low platelet count), followed by disseminated intravascular coagulation (DIC), which is often fatal. Not only is preeclampsia life-threatening for the mother, but it can also cause intrauterine growth retardation, decreased fetal movement, chronic hypoxia, or even death in the fetus caused by decreased placental perfusion. If seizures occur, the patient has a risk for placental abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopul-monary arrest, acute renal failure, and death. Fetal bradycardia is typical during the seizure, usually with slow recovery to the baseline heart rate upon the seizure ending.

In addition to preeclampsia, there are four other categories of hypertension disorders in pregnancy: (1) Gestational Hypertension—BP of 140/90 in a normotensive woman, no proteinuria, and the BP returns to normal postpartum; (2) Eclampsia—The development of seizures along with preeclampsia; (3) Superimposed preeclampsia on chronic hypertension—New onset of proteinuria in a hypertensive woman; and (4) Chronic hypertension—BP of greater than 140/90 before pregnancy occurred or hypertension diagnosed after 20 weeks that persists past the post-partum period. The remainder of this chapter will focus on preeclampsia.

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