Preeclampsia Nursing Diagnosis and Care Plans

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Preeclampsia Eclampsia Nursing Care Plans Diagnosis and Interventions

Preeclampsia NCLEX Review and Nursing Care Plans

Pre-eclampsia is a medical condition that arises from persistent high blood pressure at around 20 weeks of pregnancy, causing damage to organs such as kidneys and liver.

Kidney damage is characterized by the presence of protein in the urine, known as proteinuria.

If left untreated, pre-eclampsia can lead to eclampsia, a serious complication where in the high blood pressure results to the occurrence of seizures.

This is life-threatening for both the mother and her baby. One in every 200 pregnant women with pre-eclampsia develops eclampsia in the United States. The most effective treatment for pre-eclampsia or eclampsia is the delivery of the baby.

Signs and Symptoms of Preeclampsia

It can be asymptomatic at first, and blood pressure may start creeping up slowly

  • Persistently high blood pressure (above 140/90 mmHg) – checked for at least 2 occasions, 4 hours apart
  • Proteinuria
  • Severe headaches
  • Visual disturbances (blurry vision, light sensitivity, temporary loss of vision)
  • Upper abdominal pain
  • Nausea / vomiting
  • Decreased urine output
  • Swelling /edema – usually seen on the face and hands and can also be in the lower limbs
  • Shortness of breath (if fluid starts to fill the lungs)
  • Sudden weight gain

Eclampsia

In addition to the signs and symptoms of pre-eclampsia, a patient with eclampsia may have seizure symptoms such as:

  • Staring
  • Decreased level of alertness
  • Convulsions or violent shaking

Causes of Preeclampsia

During pregnancy, new blood vessels are formed to deliver blood efficiently to the placenta in order to nourish the fetus.

These blood vessels may be narrower or dysfunctional in women with pre-eclampsia, limiting the blood flow to the placenta. Damage to the blood vessels, immune system disorders, genetics, or other hypertension-related disorders can cause this damage of the blood vessels.

Pregnancy-induced hypertension, if poorly managed or left untreated, can result to the development of pre-eclampsia and subsequent eclampsia.

The risk factors for pre-eclampsia include a personal history of pre-eclampsia in previous pregnancies, a family history of pre-eclampsia, first pregnancy, multiple pregnancy, chronic hypertension (patient is hypertensive even before pregnancy), age (very young women and women above 35 years of age), obesity, in vitro fertilization, history of diabetes or kidney disease, and race (African American women are at higher risk than other races).

Complications of Preeclampsia

  1. Preterm birth. Severe pre-eclampsia requires prompt delivery of the baby to prevent the development of eclampsia or seizures in order to save the life of both the mother and the baby. Preterm babies may suffer from lung or other organ problems or low birth weight.
  2. Fetal growth restriction. Pre-eclampsia involves the low oxygen and blood supply to the placenta. The baby may suffer from growth retardation due to this.
  3. Abruptio placentae. The placenta may separate from the inner uterine wall before the delivery of the baby, due to pre-eclampsia. This can cause life-threatening heavy bleeding.
  4. HELLP syndrome. The name of this syndrome stands for Hemolysis (wherein red blood cells are destroyed), Elevated Liver enzymes and Low platelet count..

Diagnosis of Preeclampsia

  • Blood pressure checks
  • Urinaysis –  to find any protein in the urine (proteinuria)
  • Blood tests – full blood count and biochemistry –to check for low platelet count and signs of kidney problems and/or impaired liver function
  • Imaging – find fluid in the lungs (pulmonary edema)
  • Physical assessment –new onset of headaches or visual disturbances
  • Fetal ultrasound – to closely monitor for the growth of the baby
  •  Non-stress test or biophysical profile -to check for the baby’s heart rate reacts when the baby moves

Treatment of Preeclampsia

  1. Delivery. The most important and effective treatment is to deliver the baby. Induced labor or C-section may be done to facilitate the delivery of the baby.
  2. Antihypertensives. To lower blood pressure levels, antihypertensives that are safe for pregnancy should be prescribed.
  3. Corticosteroids. Severe pre-eclampsia may require corticosteroids to help boost platelets and liver function, as well as to speed up the maturity of the baby’s lungs.
  4. Anticonvulsants. To prevent seizures, magnesium sulfate may be prescribed.
  5. More frequent prenatal visits. This is necessary to closely monitor maternal health and fetal well being.
  6. Diet and supplements. Low salt, low caloric diet is advised to prevent the development of pre-eclampsia. Garlic or fish oil as well as calcium supplements may also be recommended by the physician.

Nursing Diagnosis for Preeclampsia

Nursing Care Plan for Preeclampsia 1

Nursing Diagnosis: Decreased cardiac output related to increased systemic vascular resistance secondary to preeclampsia, as evidenced by an average blood pressure level of 180/90, shortness of breath, and edema of the palms

Desired Outcome: The patient will have an improved cardiac output through well-controlled blood pressure levels throughout the remainder of her pregnancy.

Nursing Interventions for preeclampsiaRationale
Assess vital signs, conduct physical examination, and commence daily weight monitoring.Edema, headaches, visual disturbances, and epigastric pain are associated with the patient’s high blood pressure level. Weight gain is an important symptom of preeclampsia. Fluid retention may be evident if the mother has a weight gain of more than 1.5kg/month during the 2nd trimester, or more than 0.5 kg/week during the 3rd trimester.
Instruct the patient to have bedrest and avoid environmental stressors.To lower blood pressure levels, improve cardiac rate, and enhance renal-placental perfusion.
Administer hypertensives as prescribed.To lower blood pressure levels. Common antihypertensives for preeclampsia include hydralazine, MgSO4, and nifedipine.
Prepare to deliver the baby either by labor induction or Cesarean section.The baby may be delivered earlier than expected if the risks for the mother and the baby become higher. Pregnancy induced-hypertension, which is related to pre-eclampsia, usually goes away 6 months post partum

Nursing Care Plan for Preeclampsia 2

Nursing Diagnosis: Altered Uteroplacental Tissue Perfusion related to maternal hypovolemia secondary to pre-eclampsia as evidenced by intrauterine fetal growth retardation viewed in the scans, and changes in fetal heart rate

       Desired Outcome: Patient’s baby will have a stable fetal heat rate when subjected to contraction stress test.

Nursing Interventions for preeclampsiaRationales
Teach the patient and her partner or next of kin on how to perform home assessment which includes noting daily fetal movements and identifying signs of fetal distress and how to get help immediately.Decrease in fetal activity may mean fetal compromise or distress, which requires immediate medical attention.  
Encourage the pregnant patient to follow a healthy lifestyle, such as smoking cessation and avoidance of illegal drug use, proper hydration, enough sleep, and appropriate diet.Fetal movement and activity can be affected by cigarette smoking, drug abuse, dehydration, sleep deprivation, and poor dietary choices.
Educate the patient on the signs of abruptio placenta and instruct to get help immediately if any of these occur.To give the patient enough information on the warning signs of abruptio placentae, which include uterine tenderness, vaginal bleeding, decreased fetal activity, and abdominal pain.  
Monitor fetal growth by measuring the fundus, and check fetal heart rate at each clinic visit.To determine if the baby is experiencing intrauterine growth retardation related to preeclampsia.  
If the baby needs to be delivered prematurely, give IM corticosteroids as prescribed, not more than 7 days prior to expected date of delivery.To enhance the production of surfactants which are necessary to speed up the pulmonary maturity of the fetus and avoid respiratory distress syndrome.

Nursing Care Plan for Preeclampsia 3

Risk for Imbalanced Fluid Volume

Nursing Diagnosis: Risk for Imbalanced Excess Fluid Volume related to shifting of fluid to interstitial space from intravascular space and Hormonal changes in pregnancy secondary to pre-eclampsia.

As a risk nursing diagnosis, Risk for Imbalanced Fluid Volume is not associated with any signs and symptoms since it still has not manifested in the patient and preventive measures will be done instead.

Desired Outcome: The patient will show a willingness to adhere to therapeutic activities by actively participating in the monitoring of the therapeutic progress, Will demonstrate understanding of the need to closely monitor and how to properly obtain the Blood Pressure, body weight, and signs of edema, Will be free from any headache, confusion, nausea, vomiting and difficulty in breathing as these can be signs of pulmonary, cerebral and generalized edema and the patient will show normal hemoconcentration as evidenced by hemoglobin value, hematocrit value and protein levels in the normal range.

Nursing Interventions for preeclampsiaRationale
Bring the patient to a quiet room, Perform posterior, lateral, and anterior chest auscultation on the apices, middle, and lower lung areas using the diaphragm of the stethoscope, compare each side and listen to at least one complete respiratory cycle, have the patient take deep breaths. Note any adventitious sounds and the breath sounds and determine the time of inspiration and expiration.Dyspnea and crackles could indicate pulmonary edema, which necessitates prompt medical attention. The loss of intravascular protein in preeclampsia permits fluid to flow out of the intravascular spaces, overloading other surrounding organs, such as the lungs in this case. An increased venous return of fluid from the lower extremities that may reach the lungs might cause orthopnea and paroxysmal nocturnal dyspnea.
Demonstrate to the patient the proper way of taking the bodyweight at home and educate the patient that when checking at home, it should be at the same time every day. Take the patient’s weight during hospital visits and explain the importance of maintaining the weight record in-between visits.On the same scale, in the same sort of clothing, and at the same time of day, weigh yourself. Fluid retention implies rapid, noticeable weight gain (e.g., more than 3.5 lb (1.8 kg) per week in the second or third trimester) and may suggest preeclampsia. Generalized edema occurs when fluid transfers from the vascular to the interstitial region.
Closely monitor and document the patient’s Vital signs, always check and teach the patient how to properly obtain the Blood pressure and pulse rate in one full minute at home.Catecholamines, vasopressin, prostaglandins, and, according to new discoveries, lower levels of prostacyclin, can all cause a rise in blood pressure. Low intravascular colloid-osmotic pressure induced by enhanced capillary permeability might cause an increase in pulse rate. This results in increased fluid retention and decreased hydrostatic pressure, which obstructs fluid circulation and causes lungs congestion.
Determine if there’s the presence of edema, tenderness upon palpation, skin discoloration, and elevated temperature when touched. Assess if there is pitting edema by applying pressure to the edematous area, note its timing, exact location, and extent.Pitting edema of the face, hands, legs, sacral area, or abdominal wall (moderate, 1+ to 2+; severe, 3+ to 4+) or edema that does not go away after 12 hours of bed rest is critical. The distribution, pitting, and degree of edema are all evaluated. The most reliant body parts, where hydrostatic pressure is greatest, may have edema. It may also be more noticeable in the ambulatory pregnant woman’s feet and ankles.
Educate the patient about the importance of reporting any signs of excessive or progressive swelling/ edema. Advice the patient to call the nurse immediately if the following symptoms are felt: epigastric pain, feeling nauseated, vomiting, and severe headache.Epigastric discomfort, cerebral symptoms, nausea, and vomiting are all signs of potential eclampsia. Right upper quadrant pain, dyspnea, indicating lung involvement, cerebral edema, perhaps leading to seizures, and nausea and vomiting, showing GI edema are all symptoms of edema and intravascular fibrin deposition (in HELLP syndrome).
Note any deviation in the patient’s Hemoglobin or Hematocrit level and advice the attending physician immediately.The degree of hemoconcentration produced by fluid shift is determined. Hemoconcentration is present when the hematocrit is less than three times the hemoglobin level. Hemoconcentration occurs when the amount of plasma increases faster than the rate of erythrocyte formation.
Document the patient’s intake and output, note the urine color and specific gravity as required. Report any imbalance in the intake and output immediately.Urine production is a sensitive indicator of blood volume in the circulatory system. Urine output is reduced when blood supply to the kidneys is reduced. Severe hypovolemia and renal involvement are indicated by oliguria and a specific gravity of 1.040. The usage of magnesium sulfate can result in a temporary rise in urine production.
Encourage the patient to eat more protein by including lean meat, fish, poultry, eggs, and dairy products in the patient’s diet.Inadequate protein/calories raise the risk of edema formation and preeclampsia; proper nutrition reduces the incidence of prenatal hypovolemia and hypoperfusion. To replenish protein losses, a daily intake of 80–100 g of protein may be required. Protein is depleted as the glomeruli get damaged and no longer have the ability to keep it from being eliminated in the urine.
Educate the patient, family members, or significant others about home monitoring of Blood pressure, pulse rate, body weight, intake, and output, the importance of reporting any deviation from the normal values immediately, and strict adherence to the therapeutic regimen. However, advise day-care programs if intended.If proper supervision and support are provided, and the client/family actively participates in the treatment regimen, some slightly hypertensive clients without proteinuria may be treated on an outpatient basis.
Explain to the patient to consider a moderate salt intake of up to 6 g/day. Encourage the patient to study every food label and stay away from high-sodium intakes.Because sodium levels below 2–4 g/day cause dehydration in some customers, some sodium intake is required. Processed meats, such as bacon, luncheon meats, hot dogs, and potato chips, are high in salt. Excess sodium, on the other hand, can cause edema and raise the risk of hypertension.

Nursing Care Plan for Preeclampsia 4

Risk for Injury

Nursing Diagnosis: Risk for Injury related to Altered state of mind, hypoxia of the tissues, atypical blood profile and clotting factors, and episodes of tonic-clonic convulsions secondary to Pre-eclampsia.  As a risk nursing diagnosis, Risk for Injury is not associated with any signs and symptoms since it still has not manifested in the patient and preventive measures will be done instead.

Desired Outcome: To protect oneself and improve safety, the client participates in treatment and environmental adjustments, Will verbalize the absence of visual disturbances, headache, changes in mentation that may indicate symptoms of cerebral ischemia, The patient’s clotting factors and liver enzymes will be within acceptable limits, and the patient will strictly follow a treatment plan and report any signs and symptoms in order to reduce or totally eliminate seizure activity.

Nursing Interventions for preeclampsiaRationale
Assess the patient for central nervous system or CNS involvement, document any signs of headache, irritability, and visual disturbances or changes upon fundoscopic exam. Emphasize to the patient the importance of promptly reporting the presence of severe, persistent headaches, impaired vision, photophobia, epigastric discomfort, or heartburn as these are all common symptoms that accompany a convulsion.Symptoms, behaviors, and retinal changes can all be used to assess cerebral edema and vasoconstriction. Preeclampsia produces a disruption in the autoregulation of the cerebral vasculature, resulting in hypoperfusion, endothelial injury, and edema. Headaches, irritation, vision abnormalities, and alterations on fundoscopic examination are examples of these symptoms. Tonic-clonic convulsions or eclampsia might occur if treatment is delayed or symptoms appear gradually.
Assess and document the patient’s ankle clonus and deep tendon reflexes (3+ to 4+). The nurse should perform the assessment by supporting the leg with the knee flexed, then sharply dorsiflexing the foot with the other hand, holding the posture for a brief while, and then releasing the foot. When the foot is kept in dorsiflexion and no rhythmic oscillations are sensed, the response is normal (negative clonus). When the nurse feels and sees the oscillations against this pressure, an abnormal response (positive clonus) is noted.Because of the irritation of the central nervous system, deep tendon reflexes become hyperactive. Hyperreflexia is usually present with ankle clonus.
Assess the patient for any signs of labor in every antenatal check-up. Ask the patient and note if there is a presence of vaginal bleeding, signs of contractions, note the duration and frequency of contractions, and leaking of fluid.Determine if the client is experiencing any signs of contractions, vaginal bleeding, or fluid leaking. Prenatal care is used to identify any pregnancy issues and, if necessary, execute early interventions.
Help the patient in identifying and minimizing the environmental factors that may aggravate seizure episodes. Always keep a dimly lit and quiet environment with good ventilation in the patient’s bedroom, advise to limit the visits, avoid stress and prepare a scheduled bedtime and adequate rest periods.Environmental elements that may excite an irritable cerebrum and create a convulsive condition are reduced by keeping the room quiet and dimly lighted, restricting visitors, planning and coordinating care, and encouraging rest.
If prodromal indications or aura are present, Advise the patient to keep tight bedrest and explain why this is necessary.Explain that prodromal symptoms such as a prolonged headache, blurred vision, severe epigastric pain, impaired mental status, and stomach discomfort frequently precede eclampsia. During the auditory phase, the client may become restless. Understanding the necessity of meeting one’s own safety needs might help clients cooperate more effectively.
Evaluate and report any deviation in the clotting time, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen levels test results.These tests can reveal coagulation factor depletion and fibrinolysis, as well as disseminated intravascular coagulation (DIC), which implies preeclampsia worsening. Clots form as blood vessels constrict in order to heal endothelial damage until the body’s platelet supply is depleted.

Nursing Care Plan for Preeclampsia 5

Deficient Knowledge

Nursing Diagnosis: Deficient Knowledge related to inadequate exposure, unawareness of available information sources, and misinterpretation of data secondary to Pre-eclampsia as evidenced by repetitive requests for an explanation, statement of misconception about the disease process, unable to follow instructions correctly, and complications of the disease that could have been avoided.

Desired Outcome: The patient will express verbally the comprehension of the disease process and therapeutic options. Thus, will promptly report signs or symptoms that necessitate medical attention, Will be able to maintain the blood pressure within acceptable limits, and the patient will strictly and correctly follow the instructions and will make lifestyle/behavioral modifications.

Nursing Interventions for preeclampsiaRationale
Assess the patient or family member’s understanding of the disease process by providing a thorough explanation about the disease, etiology of preeclampsia, signs and symptoms, risk factors, and the consequences for both the mother and the fetus if not treated/ controlled.Creates a database and provides data to it. Provide details on the areas where learning is required. Reduced placental perfusion causes systemic vascular endothelial dysfunction, which is the pathophysiology of pregnancy-induced hypertension. This occurs when the uterine spiral arteries are unable to vasodilate, reducing the fetus’ blood and food supply while raising the mother’s blood pressure.
Inform the patient to report immediately any signs/symptoms that indicate a worsening of the condition and when to contact the healthcare professional. Instruct the client to report any new-onset of headaches, vision abnormalities, epigastric or RUQ pain, decreased fetal movement, or severe dyspnea.Aids in ensuring that the patient seeks care as soon as possible, potentially preventing the preeclamptic state from worsening or causing extra difficulties. These signs and symptoms indicate severe preeclampsia, which can proceed to eclampsia and necessitates prompt medical attention.
Educate the patient on how to keep track of her weight at home by getting her weight daily using the same scale, at the same time of the day, and with the same clothing material and to contact her doctor if she gains more than 2 lbs (0.9 kg) per week or 0.5 lb (0.23 kg) per day.Preeclampsia is diagnosed when a woman gains 3.5 pounds (1.59 kg) or more per month in the second trimester, or 1 pound (0.45 kg) or more per week in the third trimester.
Educate the patient and help family members in learning how to use and monitor blood pressure at home.Encourages participation in the treatment regimen, enables prompt intervention if necessary, and may provide reassurance that efforts are worthwhile. Family members should be taught to check their blood pressure two to four times each day in the same arm and position.
Instruct the patient to follow the recommended dietary plan, which includes a low-sodium, low-saturated-fat, and low-cholesterol diet.Nutritional concerns in preeclampsia include excessive saturated fats, cholesterol, salt, and calories. A low-fat, high-polyunsaturated-fat diet lowers blood pressure.
 Educate the patient about the importance of adherence to treatment plans and keeping follow-up appointments.Antihypertensive therapy failure is frequently caused by a lack of participation in the treatment plan. Patient engagement must be evaluated on a regular basis in order for treatment to be successful.  
Review and discuss with the patient different kinds of stress management techniques that may reduce mental stress such as moderate walking, stretching, and yoga. Emphasize also the diet restrictions.The relevance of the client’s responsibility in treatment is emphasized. Healthcare professionals must assess a pregnant woman’s stress levels and make practical stress management recommendations based on her specific stressors and conditions. The risk of gestational hypertension has been linked to mental stress throughout pregnancy.
Discuss with the patient the reason for prescription medications, dosage, expected and adverse side effects, and any unique characteristics.The patient’s commitment to the treatment plan might be boosted with adequate information and comprehension of the negative effects.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

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Nursing Stat Facts

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