HELLP Syndrome Nursing Diagnosis & Care Plan

HELLP syndrome is a life-threatening pregnancy complication usually considered to be a variant of preeclampsia. It is characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count.

This condition can rapidly become severe and poses significant risks to both the mother and the fetus. Prompt recognition and management of HELLP syndrome are crucial for positive outcomes.

Causes (Related to)

HELLP syndrome typically occurs in the later stages of pregnancy or shortly after childbirth. While the exact cause is unknown, several factors may contribute to its development:

• Preeclampsia or eclampsia
• Genetic predisposition
• Maternal age over 35
• Multiple pregnancies
• History of HELLP syndrome in previous pregnancies
• Obesity
• Chronic hypertension
• Diabetes mellitus

Signs and Symptoms (As evidenced by)

HELLP syndrome can present with a variety of signs and symptoms. During a physical assessment, a patient with HELLP syndrome may exhibit one or more of the following:

Subjective: (Patient reports)

• Right upper quadrant or epigastric pain
• Nausea and vomiting
• Headache
• Visual disturbances
• Fatigue

Objective: (Nurse assesses)

• Hypertension (blood pressure ≥ 140/90 mmHg)
• Edema
• Proteinuria
• Jaundice
• Petechiae or ecchymoses
• Altered mental status
• Seizures (in severe cases)

Laboratory findings:

• Hemolysis on peripheral blood smear
• Elevated liver enzymes
• Low platelet count
• Elevated LDH
• Elevated bilirubin
• Decreased haptoglobin levels

Expected Outcomes

The following are common nursing care planning goals and expected outcomes for HELLP syndrome:

• The patient will maintain stable vital signs within normal limits.
• The patient will report relief of pain and discomfort.
• The patient will demonstrate improved laboratory values.
• The patient will remain free from complications such as DIC, placental abruption, or eclampsia.
• The patient will verbalize understanding of the condition and necessary follow-up care.
• Fetal well-being will be maintained or improved.

Nursing Assessment

The first step in nursing care is a thorough assessment. The nurse will gather physical, psychosocial, emotional, and diagnostic data. The following section covers subjective and objective data related to HELLP syndrome.

1. Monitor vital signs closely.
   Assess blood pressure, heart rate, respiratory rate, and temperature every 1-2 hours or as ordered. Hypertension is a feature of HELLP syndrome, and changes in vital signs can indicate worsening of the condition.
2. Perform a focused physical examination.
   Look for signs of edema, especially in the face and hands. Assess for right upper quadrant or epigastric tenderness. Check for any signs of bleeding or bruising.
3. Assess neurological status.
   Evaluate the level of consciousness, presence of headaches, visual disturbances, or seizure activity. These can be indicators of central nervous system involvement or impending eclampsia.
4. Monitor fetal status.
   Perform continuous fetal heart rate monitoring and assess for signs of fetal distress. Evaluate for any vaginal bleeding or changes in fetal movement.
5. Review laboratory results.
   Monitor complete blood count, liver function tests, coagulation studies, and urinalysis. Pay close attention to platelet count, hemoglobin, hematocrit, and liver enzymes.
6. Assess for signs of complications.
   Be vigilant for signs of disseminated intravascular coagulation (DIC), pulmonary edema, or renal failure.
7. Evaluate psychosocial status.
   Assess the patient’s and family’s understanding of the condition, anxiety levels, and support systems.
8. Prepare for potential interventions.
   Ensure availability of emergency equipment and medications. Be prepared for possible need for magnesium sulfate administration, antihypertensive therapy, or emergency cesarean section.

Nursing Interventions

Nursing interventions are crucial for managing HELLP syndrome and preventing complications. The following section outlines possible nursing interventions for a patient with HELLP syndrome.

1. Maintain strict bed rest in left lateral position.
   This position helps maximize uteroplacental blood flow and reduces pressure on the inferior vena cava.
2. Administer medications as ordered.
   This may include antihypertensives to control blood pressure, magnesium sulfate for seizure prophylaxis, and corticosteroids to improve platelet count and promote fetal lung maturity if preterm delivery is anticipated.
3. Monitor intake and output closely.
   Maintain accurate fluid balance records. Be alert for signs of fluid overload or decreased urine output.
4. Provide oxygen therapy as needed.
   Administer oxygen to maintain saturation > 95% and ensure adequate oxygenation to the fetus.
5. Prepare for potential blood product transfusions.
   Be ready to administer platelets, packed red blood cells, or fresh frozen plasma as ordered.
6. Implement seizure precautions.
   Ensure padded side rails are up, suction equipment readily available, and emergency medications are available.
7. Provide emotional support and education.
   Explain procedures, answer questions, and address patient and family concerns. Provide information about the condition and its management.
8. Prepare for potential delivery.
   Assist with preparations for emergency cesarean section if indicated. Coordinate with the neonatal team for potential preterm delivery.
9. Monitor for postpartum complications.
   Be vigilant for signs of postpartum hemorrhage, eclampsia, or worsening HELLP syndrome even after delivery.
10. Initiate postpartum care and education.
    Provide education on signs and symptoms to report, importance of follow-up care, and future pregnancy considerations.

Nursing Care Plans

The following nursing care plans address the most common nursing diagnoses associated with HELLP syndrome. Each plan includes the nursing diagnosis statement, related factors/causes, nursing interventions with rationales, and desired outcomes.

Care Plan 1: Risk for Maternal/Fetal Injury

Nursing Diagnosis: Risk for Maternal/Fetal Injury related to HELLP syndrome as evidenced by elevated blood pressure, abnormal laboratory values, and potential for complications.

Related factors/causes:

• Pathophysiology of HELLP syndrome
• Multisystem organ involvement
• Potential for rapid deterioration

Nursing Interventions and Rationales:

1. Monitor vital signs, including blood pressure, every 1-2 hours.
   Rationale: Frequent monitoring allows for early detection of worsening hypertension or other vital sign changes indicative of deterioration.
2. Assess for signs and symptoms of worsening condition (severe headache, visual disturbances, epigastric pain).
   Rationale: Early recognition of worsening symptoms allows for prompt intervention and prevention of complications.
3. Administer antihypertensive medications as ordered and monitor response.
   Rationale: Controlling blood pressure is crucial in preventing maternal and fetal complications.
4. Perform continuous fetal monitoring and report any signs of fetal distress.
   Rationale: Fetal well-being can be compromised in HELLP syndrome, and early detection of distress is crucial for timely intervention.
5. Prepare for potential emergency cesarean delivery.
   Rationale: Delivery is often the definitive treatment for HELLP syndrome, and readiness for emergency delivery can improve outcomes.

Desired Outcomes:

• Maternal blood pressure will be maintained within the target range.
• The patient will remain free from signs and symptoms of a worsening condition.
• Fetal heart rate and movement patterns will remain within normal limits.

Care Plan 2: Acute Pain

Nursing Diagnosis: Acute Pain related to liver capsule distention and tissue hypoxia secondary to HELLP syndrome as evidenced by patient reports of right upper quadrant or epigastric pain.

Related factors/causes:

• Liver involvement in HELLP syndrome
• Tissue hypoxia due to microthrombi formation

Nursing Interventions and Rationales:

1. Assess pain characteristics (location, intensity, quality) using a standardized pain scale every 2-4 hours.
   Rationale: Regular pain assessment allows for monitoring disease progression and interventions’ effectiveness.
2. Position the patient on her left side with the right side elevated on pillows.
   Rationale: This position can help relieve pressure on the liver and reduce pain.
3. Administer analgesics as ordered and evaluate their effectiveness.
   Rationale: Proper pain management improves patient comfort and reduces stress on the maternal-fetal unit.
4. Apply cold or warm compresses to the painful area as tolerated.
   Rationale: Temperature therapy can provide local pain relief and improve comfort.
5. Teach relaxation techniques such as deep breathing and guided imagery.
   Rationale: Non-pharmacological pain management techniques can complement medication and improve pain control.

Desired Outcomes:

• The patient will report pain levels at 3/10 or less on the pain scale.
• The patient will demonstrate the use of non-pharmacological pain management techniques.
• The patient will verbalize improved comfort and ability to rest.

Care Plan 3: Risk for Impaired Gas Exchange

Nursing Diagnosis: Risk for Impaired Gas Exchange related to potential pulmonary edema secondary to HELLP syndrome.

Related factors/causes:

• Fluid shifts and capillary leak associated with HELLP syndrome
• Potential for acute respiratory distress syndrome (ARDS)

Nursing Interventions and Rationales:

1. Assess respiratory rate, depth, and effort every 2 hours.
   Rationale: Early detection of respiratory changes allows for prompt intervention.
2. Auscultate lung sounds every 4 hours and document any abnormalities.
   Rationale: Crackles or decreased breath sounds may indicate developing pulmonary edema.
3. Monitor oxygen saturation continuously and administer oxygen as ordered to maintain SpO2 > 95%.
   Rationale: Adequate oxygenation is crucial for maternal and fetal well-being.
4. Position the patient in semi-Fowler’s position unless contraindicated.
   Rationale: An elevated head of bed can improve lung expansion and ease breathing effort.
5. Monitor fluid intake and output strictly, reporting any imbalances.
   Rationale: Careful fluid management is crucial in preventing pulmonary edema.

Desired Outcomes:

• The patient will maintain oxygen saturation > 95% on room air or prescribed oxygen therapy.
• The patient will demonstrate clear breath sounds bilaterally.
• The patient will remain free from signs and symptoms of pulmonary edema.

Care Plan 4: Risk for Bleeding

Nursing Diagnosis: Risk for Bleeding related to thrombocytopenia and potential disseminated intravascular coagulation (DIC) associated with HELLP syndrome.

Related factors/causes:

• Low platelet count characteristic of HELLP syndrome
• Potential for coagulation abnormalities and DIC

Nursing Interventions and Rationales:

1. Monitor complete blood count (CBC) results, particularly platelet count, every 6-12 hours or as ordered.
   Rationale: Tracking platelet trends helps in assessing disease progression and bleeding risk.
2. Assess for any signs of bleeding (petechiae, ecchymoses, bleeding gums) every 4 hours.
   Rationale: Early detection of bleeding allows for prompt intervention.
3. Minimize invasive procedures and use small gauge needles when necessary.
   Rationale: Reduces the risk of bleeding from puncture sites.
4. Apply pressure to venipuncture sites for at least 5 minutes.
   Rationale: Prolonged pressure helps ensure clotting at puncture sites.
5. Prepare for potential administration of blood products as ordered.
   Rationale: Platelet transfusions or other blood products may be necessary to prevent or manage bleeding.

Desired Outcomes:

• The patient will remain free from signs of active bleeding.
• The patient’s platelet count will stabilize or improve.
• The patient will verbalize understanding of bleeding precautions.

Care Plan 5: Anxiety

Nursing Diagnosis: Anxiety related to high-risk pregnancy status and potential maternal/fetal complications as evidenced by expressed concerns and increased tension.

Related factors/causes:

• Uncertainty about maternal and fetal outcomes
• Hospitalization and separation from support system
• Potential for preterm delivery

Nursing Interventions and Rationales:

1. Assess anxiety levels using a standardized scale every shift.
   Rationale: Regular assessment allows for monitoring the patient’s emotional state and the effectiveness of interventions.
2. Provide concise information about HELLP syndrome, treatment plan, and prognosis.
   Rationale: Knowledge can help reduce fear of the unknown and promote a sense of control.
3. Encourage expression of feelings and concerns.
   Rationale: Allowing the patient to verbalize fears can help reduce anxiety and identify areas needing further support or education.
4. Facilitate communication between the patient, family, and healthcare team.
   Rationale: Open communication promotes trust and can alleviate anxiety related to uncertainty.
5. Teach relaxation techniques such as deep breathing and progressive muscle relaxation.
   Rationale: These techniques can help reduce physical symptoms of anxiety and promote calm.

Desired Outcomes:

• The patient will verbalize decreased anxiety levels.
• The patient will demonstrate the use of coping strategies to manage stress.
• The patient and family will verbalize understanding of the condition and treatment plan.

References

1. American College of Obstetricians and Gynecologists. (2020). Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstetrics & Gynecology, 135(6), e237-e260.
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7. Society for Maternal-Fetal Medicine. (2020). SMFM Consult Series #53: Intrahepatic cholestasis of pregnancy. American Journal of Obstetrics and Gynecology, 223(5), B2-B9.
8. Wallace, K., Harris, S., Addison, A., & Bean, C. (2018). HELLP Syndrome: Pathophysiology and Current Therapies. Current Pharmaceutical Biotechnology, 19(10), 816-826.