Cholestasis of pregnancy, also known as intrahepatic cholestasis of pregnancy (ICP), is a liver condition that occurs in late pregnancy. It is characterized by intense itching, usually without a rash, and abnormal liver function tests. The exact cause is not fully understood, but it is thought to be related to pregnancy hormones affecting the flow of bile acids from the liver. While cholestasis of pregnancy primarily affects the mother, it poses risks to the fetus and requires careful nursing management.
Nursing Care Plans
Nursing care planning for patients with cholestasis of pregnancy focuses on alleviating maternal discomfort, monitoring fetal well-being, and preventing potential complications. Key aspects of nursing management include managing pruritus, educating the patient about the condition and its management, and preparing for potential interventions and delivery.
Risk for Impaired Liver Function
Cholestasis of pregnancy inherently involves impaired liver function due to the disruption of bile flow. Elevated bile acids and liver enzymes are hallmarks of the condition. While in most cases liver function returns to normal after delivery, during pregnancy, it requires vigilant monitoring to prevent further complications for both mother and fetus.
Nursing Diagnosis
- Risk for Impaired Liver Function
Risk factors may include
- Hormonal changes of pregnancy affecting bile flow
- Genetic predisposition to cholestasis
- History of cholestasis in previous pregnancies
Possibly evidenced by
- This is a risk diagnosis, not evidenced by actual findings but potential for development.
Desired Outcomes
- The patient will maintain liver function within acceptable limits for pregnancy, as evidenced by liver function tests.
- The patient will verbalize understanding of factors that can exacerbate liver dysfunction.
- The patient will adhere to recommended monitoring and management strategies.
Nursing Assessment and Rationales
1. Review patient history for risk factors: Assessing for prior episodes of cholestasis, family history, and other liver conditions helps determine the patient’s baseline risk and guides the intensity of monitoring.
2. Monitor liver function tests (LFTs) regularly: LFTs, including bile acids, AST, ALT, alkaline phosphatase, and bilirubin, are crucial for diagnosing and monitoring the severity of cholestasis. Serial measurements help track disease progression and response to interventions.
3. Assess for signs and symptoms of worsening liver dysfunction: While itching is the primary symptom, nurses should also monitor for jaundice (though less common in ICP), right upper quadrant pain (rare in uncomplicated ICP but important to rule out other conditions), fatigue, and dark urine. These could indicate more severe liver involvement or other complications.
4. Evaluate medication history: Certain medications can be hepatotoxic and may worsen liver function in the context of cholestasis of pregnancy. A thorough medication review is essential.
Nursing Interventions and Rationales
1. Educate the patient about the importance of regular monitoring of liver function: Understanding the rationale behind frequent blood tests improves patient compliance and reduces anxiety associated with monitoring.
2. Administer medications as prescribed to manage bile acid levels: Ursodeoxycholic acid (UDCA) is the first-line treatment for cholestasis of pregnancy. It helps improve bile flow and may reduce fetal risks. Nurses are responsible for accurate administration and monitoring for side effects.
3. Collaborate with the healthcare provider regarding delivery timing: Depending on the severity of cholestasis and gestational age, early delivery may be recommended to mitigate fetal risks. Nurses play a crucial role in preparing the patient for potential induction or cesarean delivery.
4. Provide supportive care to manage symptoms: While not directly improving liver function, interventions to manage pruritus (discussed further below) can improve the patient’s overall well-being and reduce stress on the liver.
5. Monitor for and report signs of complications: Although rare, severe liver dysfunction can occur. Nurses should be vigilant for signs of liver failure and report them promptly to the physician.
Risk for Fetal Distress
Cholestasis of pregnancy increases the risk of adverse fetal outcomes, including preterm birth, meconium staining of amniotic fluid, and stillbirth. Elevated bile acids are thought to be toxic to the fetal heart and can lead to fetal distress and sudden intrauterine death. Therefore, continuous fetal monitoring and timely intervention are critical.
Nursing Diagnosis
- Risk for Fetal Distress
Risk factors may include
- Elevated maternal bile acid levels
- Reduced placental function due to cholestasis
- Potential for fetal exposure to high levels of bile acids
Possibly evidenced by
- This is a risk diagnosis, not evidenced by actual findings but potential for development.
Desired Outcomes
- The fetus will maintain stable fetal heart rate patterns within normal limits throughout pregnancy.
- The patient will demonstrate understanding of the importance of fetal monitoring and report any changes in fetal movement.
- The patient will adhere to the recommended fetal surveillance schedule.
Nursing Assessment and Rationales
1. Monitor fetal heart rate (FHR) regularly: Antepartum fetal heart rate monitoring, including non-stress tests (NSTs) and biophysical profiles (BPPs), is essential to assess fetal well-being. Frequency of monitoring increases with gestational age and severity of cholestasis.
2. Assess fetal movement: Patient education on fetal kick counts is important. Decreased fetal movement can be an early sign of fetal compromise and should be reported immediately.
3. Evaluate amniotic fluid for meconium staining: Meconium aspiration syndrome is a potential complication associated with cholestasis. Observing for meconium-stained amniotic fluid during labor is crucial for anticipating and managing potential respiratory distress in the newborn.
4. Review bile acid levels and correlate with fetal monitoring results: Higher bile acid levels are generally associated with increased fetal risk. Integrating bile acid results with fetal monitoring helps in risk stratification and guides management decisions.
Nursing Interventions and Rationales
1. Implement and interpret fetal monitoring as per protocol: Nurses are responsible for performing and interpreting NSTs and BPPs, recognizing non-reassuring patterns, and escalating concerns to the healthcare provider.
2. Educate the patient on fetal kick counting and when to report decreased fetal movement: Empowering patients to monitor fetal activity at home promotes early detection of potential problems and timely intervention.
3. Prepare for potential early delivery: Given the increased risk of stillbirth, especially in pregnancies with high bile acid levels, early delivery (typically around 37-38 weeks, or earlier in severe cases) is often recommended. Nurses should prepare the patient physically and emotionally for potential induction or cesarean delivery.
4. Ensure availability of neonatal resuscitation equipment and personnel at delivery: Anticipating potential fetal distress and meconium aspiration requires ensuring that appropriate neonatal resuscitation resources are readily available at the time of delivery.
5. Provide emotional support to the patient and family: The anxiety associated with fetal risks in cholestasis of pregnancy can be significant. Nurses should provide empathetic support, answer questions honestly, and facilitate communication between the patient, family, and healthcare team.
Impaired Skin Integrity related to Pruritus
Pruritus is the hallmark symptom of cholestasis of pregnancy and can be severe and debilitating, significantly impacting the patient’s quality of life. The itching is thought to be caused by elevated bile acids in the skin and can lead to skin breakdown from scratching.
Nursing Diagnosis
- Impaired Skin Integrity related to Pruritus
Risk factors may include
- Elevated bile acid levels causing intense itching
- Frequent scratching due to pruritus
- Dry skin exacerbated by pregnancy and itching
Possibly evidenced by
- Reports of intense itching (pruritus)
- Presence of excoriations, lesions, or broken skin due to scratching
- Patient verbalization of discomfort and frustration related to itching
Desired Outcomes
- The patient will report a reduction in the intensity of pruritus.
- The patient will demonstrate behaviors to minimize skin damage from scratching.
- The patient’s skin will remain intact without signs of infection.
Nursing Assessment and Rationales
1. Assess the severity and location of pruritus: Using a pruritus scale (e.g., visual analog scale) helps quantify the intensity of itching. Documenting the location and pattern of itching can guide targeted interventions.
2. Inspect skin for excoriations, lesions, and signs of infection: Frequent scratching can lead to skin breakdown, increasing the risk of secondary bacterial infections. Regular skin assessment is crucial.
3. Evaluate the impact of pruritus on the patient’s sleep and daily activities: Severe itching can disrupt sleep and significantly impair daily functioning. Assessing the impact on quality of life helps prioritize interventions.
4. Identify factors that exacerbate pruritus: Heat, stress, and certain fabrics can worsen itching. Identifying triggers allows for patient education on avoidance strategies.
Nursing Interventions and Rationales
1. Provide and educate on skin care measures to alleviate pruritus:
- Cool baths or showers: Cool water can provide temporary relief from itching.
- Emollients and moisturizers: Keeping the skin well-hydrated is crucial to reduce dryness and itching. Recommend fragrance-free and hypoallergenic products.
- Loose, cotton clothing: Avoiding tight-fitting and synthetic fabrics can minimize skin irritation.
- Avoidance of hot environments: Heat can exacerbate itching. Keeping the environment cool can help.
2. Administer topical medications as prescribed: Topical corticosteroids or calamine lotion may be prescribed for symptomatic relief. Nurses should educate patients on proper application and potential side effects.
3. Encourage the use of cool compresses: Applying cool, moist compresses to itchy areas can provide localized relief.
4. Promote measures to prevent skin breakdown from scratching:
- Keep fingernails short and smooth: Reduces skin trauma from scratching.
- Encourage gentle patting or rubbing instead of scratching: Less damaging to the skin.
- Suggest wearing gloves at night: May help reduce unconscious scratching during sleep.
5. Administer oral medications as prescribed: Ursodeoxycholic acid (UDCA) is the primary medication to reduce bile acid levels and often improves pruritus. Antihistamines may be used for nighttime sedation and to help with itching, although they are often not very effective for cholestasis-related pruritus.
6. Monitor for signs of skin infection: Educate the patient on signs of infection (increased redness, warmth, pain, purulent drainage) and when to seek medical attention.
Anxiety related to Maternal and Fetal Well-being
Cholestasis of pregnancy can cause significant anxiety for expectant mothers due to the intense discomfort of pruritus and concerns about potential fetal complications, including stillbirth. Providing emotional support and addressing knowledge deficits is essential.
Nursing Diagnosis
- Anxiety related to Maternal and Fetal Well-being
Risk factors may include
- Uncertainty about the course and prognosis of cholestasis of pregnancy
- Fear of fetal complications, including preterm birth and stillbirth
- Physical discomfort from pruritus
- Hormonal changes of pregnancy contributing to emotional lability
Possibly evidenced by
- Verbalization of worry and fear about fetal health
- Expressed concerns about the severity and duration of pruritus
- Restlessness, irritability, difficulty sleeping
- Increased heart rate, rapid breathing
Desired Outcomes
- The patient will verbalize a reduction in anxiety and increased sense of control.
- The patient will demonstrate coping mechanisms to manage anxiety.
- The patient will utilize available support systems.
- The patient will express understanding of the management plan and fetal monitoring.
Nursing Assessment and Rationales
1. Assess the patient’s level of anxiety using a standardized anxiety scale: Quantifying anxiety levels helps track progress and tailor interventions.
2. Provide opportunities for the patient to express concerns and fears: Active listening and creating a safe space for open communication are crucial for emotional support.
3. Evaluate the patient’s understanding of cholestasis of pregnancy and the management plan: Knowledge deficits can exacerbate anxiety. Assessing understanding allows for targeted education.
4. Observe for nonverbal cues of anxiety: Restlessness, fidgeting, rapid speech, and avoidance of eye contact can indicate underlying anxiety.
Nursing Interventions and Rationales
1. Provide accurate and understandable information about cholestasis of pregnancy: Addressing knowledge gaps and misconceptions reduces uncertainty and fear.
2. Explain the rationale for fetal monitoring and management strategies: Understanding the purpose of interventions can increase patient cooperation and reduce anxiety related to the unknown.
3. Encourage the patient to verbalize feelings and concerns: Active listening and validation of feelings are essential components of emotional support.
4. Teach relaxation techniques: Deep breathing, guided imagery, and mindfulness exercises can help manage anxiety symptoms.
5. Facilitate access to support systems: Connecting patients with support groups, counselors, or other pregnant women with cholestasis can provide peer support and reduce feelings of isolation.
6. Involve the patient’s partner or family in education and support: Family support is crucial. Including partners or family members in discussions can strengthen the patient’s support network.
7. Collaborate with mental health professionals if needed: For patients with significant anxiety or pre-existing mental health conditions, referral to a mental health professional may be necessary.
Deficient Knowledge related to Cholestasis of Pregnancy
Many patients are unfamiliar with cholestasis of pregnancy prior to diagnosis. Deficient knowledge about the condition, its management, and potential implications can lead to increased anxiety and poor adherence to the care plan. Patient education is a cornerstone of nursing care.
Nursing Diagnosis
- Deficient Knowledge related to Cholestasis of Pregnancy
May be related to
- Lack of prior exposure to information about cholestasis of pregnancy
- Misinformation or limited access to reliable resources
- Cognitive limitations or learning barriers
- Anxiety affecting information processing
Possibly evidenced by
- Requests for information about cholestasis of pregnancy
- Verbalization of misunderstandings about the condition
- Inaccurate follow-through of recommendations
- Questions about fetal risks and management
Desired Outcomes
- The patient will verbalize understanding of cholestasis of pregnancy, its causes, and management.
- The patient will accurately describe the importance of fetal monitoring and interventions.
- The patient will identify signs and symptoms to report to the healthcare provider.
- The patient will access and utilize reliable resources for further information.
Nursing Assessment and Rationales
1. Assess the patient’s current level of knowledge about cholestasis of pregnancy: Open-ended questions and assessing prior experiences with similar conditions help determine the starting point for education.
2. Identify the patient’s learning needs and preferred learning style: Tailoring education to individual needs and preferences enhances learning and retention.
3. Determine any barriers to learning: Language barriers, literacy levels, cognitive impairments, and anxiety can affect learning. Addressing these barriers is essential for effective education.
4. Evaluate the patient’s understanding throughout the education process: Regularly checking for understanding ensures that information is being grasped correctly and allows for clarification of misconceptions.
Nursing Interventions and Rationales
1. Provide comprehensive education about cholestasis of pregnancy:
- Explain the pathophysiology of the condition in simple terms: Focus on the disruption of bile flow and the role of bile acids.
- Discuss the maternal and fetal implications: Clearly explain the risks and benefits of management strategies.
- Describe the diagnostic process and monitoring procedures: Explain the purpose of LFTs and fetal monitoring.
- Outline the treatment plan, including medications and potential delivery timing: Provide a clear roadmap of the care plan.
2. Utilize various teaching methods to accommodate different learning styles: Verbal explanations, written materials, diagrams, and videos can enhance understanding and cater to different learning preferences.
3. Provide reliable written resources and online links: Reinforce verbal education with written materials and direct patients to reputable online sources for further information.
4. Encourage questions and provide clear and concise answers: Creating an open environment for questions promotes active learning and addresses individual concerns.
5. Teach the patient about self-management strategies: Emphasize skin care measures to manage pruritus, the importance of fetal kick counting, and adherence to medication regimens and monitoring schedules.
6. Review signs and symptoms that require immediate medical attention: Ensure the patient knows when to contact the healthcare provider, such as decreased fetal movement, worsening jaundice (though rare), or signs of skin infection.
7. Provide education in multiple sessions if needed: Breaking down information into smaller, manageable chunks can improve comprehension and retention, especially for complex topics or anxious patients.
Recommended Resources
- American College of Obstetricians and Gynecologists (ACOG)
- Society for Maternal-Fetal Medicine (SMFM)
- Liver Disease Foundations
These resources provide evidence-based information and support for patients and healthcare providers regarding cholestasis of pregnancy.
See also
- Nursing Care Plan for Hyperbilirubinemia
- Nursing Care Plan for High-Risk Pregnancy
This nursing care plan provides a framework for managing patients with cholestasis of pregnancy. Individualized care should be based on the patient’s specific needs, preferences, and the severity of their condition, always in collaboration with the healthcare team.
