Preeclampsia stands as a significant hypertensive disorder of pregnancy, impacting 5-7% of pregnancies globally. This condition is marked by the emergence of new-onset hypertension (blood pressure ≥ 140/90 mmHg) coupled with proteinuria after the 20th week of gestation. Current research indicates that preeclampsia can stem from placental development anomalies, genetic predispositions, environmental influences, and changes in maternal cardiovascular and inflammatory systems.
Untreated preeclampsia can severely impede fetal growth, elevate the risk of placental abruption, induce organ damage in the mother, and escalate to eclampsia, a life-threatening condition characterized by seizures.
Delivery of the baby remains the definitive treatment for preeclampsia. Post-delivery, symptoms typically subside within days to weeks.
This article delves into the nursing process for preeclampsia, emphasizing nursing assessments, interventions, and care plans centered around NANDA nursing diagnoses, crucial for nurses managing patients with this condition.
The Nursing Process for Preeclampsia
Nurses play a pivotal role in identifying and managing high-risk pregnancies to mitigate preeclampsia. A comprehensive nursing approach, including thorough assessment, patient education, and diligent antenatal care, is paramount.
Many preeclampsia cases are potentially preventable. Key nursing interventions include:
- Continuous monitoring of blood pressure and related symptoms.
- Implementing stress management techniques.
- Guiding weight management strategies.
- Ensuring proper nutritional intake.
- Vigilant fetal heart rate (FHR) monitoring.
- Facilitating regular OB/GYN check-ups and prenatal care.
Nursing Assessment for Preeclampsia
The initial phase of nursing care involves a detailed nursing assessment to gather physical, psychosocial, emotional, and diagnostic data. This section outlines both subjective and objective data pertinent to preeclampsia.
Review of Health History
1. Identify General Preeclampsia Symptoms. The classic triad of preeclampsia symptoms includes hypertension, proteinuria, and edema. Additional symptoms may include:
- Persistent, intense headaches.
- Visual disturbances.
- Dyspnea or shortness of breath.
- Epigastric pain.
2. Determine Risk Factors. Certain factors heighten a woman’s susceptibility to preeclampsia:
- Multifetal gestation.
- Obesity.
- Gestational diabetes mellitus.
- Family history or prior incidence of preeclampsia.
- Nulliparity (first pregnancy).
- Advanced maternal age (over 40) or teenage pregnancy (under 20).
- Polyhydramnios (excessive amniotic fluid).
- Pre-existing conditions such as hypertension, diabetes, renal disease, and autoimmune disorders.
- African American ethnicity.
- Assisted reproductive technology (IVF).
3. Medication Review. Certain medications used during pregnancy may increase the risk of preeclampsia:
- Antidepressants.
- Benzodiazepines.
- Nonsteroidal anti-inflammatory drugs (NSAIDs).
- Antiretrovirals for HIV.
- Triptans for migraine treatment.
- Asthma medications (montelukast).
- Methamphetamine use.
4. Assess Patient’s Preeclampsia Knowledge. Evaluate the patient’s current understanding of preeclampsia. Misconceptions may arise from prior knowledge, cultural beliefs, or family experiences.
Physical Assessment
1. Monitor Maternal Vital Signs. Elevated systolic or diastolic blood pressure should raise suspicion for preeclampsia. Consistent readings of 140/90 mmHg or higher after 20 weeks gestation, confirmed by diagnostic tests, are indicative of preeclampsia.
2. Respiratory Status Assessment. Auscultate lung sounds to identify pulmonary abnormalities, especially if the patient reports shortness of breath, which could indicate pulmonary edema.
3. Abdominal Palpation. Palpate the right upper quadrant and epigastric area for tenderness, which may suggest liver involvement, occurring in approximately 10% of severe preeclampsia cases.
4. Edema Assessment. Evaluate for edema, noting the location and severity. While mild edema is common in pregnancy, rapid onset or significant edema, particularly in the face and hands, warrants close monitoring.
5. Fetal Growth Monitoring. Preeclampsia can impair blood flow to the placenta, potentially causing fetal growth restriction due to insufficient oxygen and nutrient supply.
6. Regular Weight Monitoring. Rapid weight gain exceeding 3–5 pounds per week may indicate fluid retention associated with preeclampsia.
7. Intake and Output Tracking. Decreased urine output may signify impaired renal function resulting from reduced circulatory blood volume. Urinary retention can exacerbate edema and hypertension.
8. Monitor for Seizures. Seizure activity in a preeclamptic patient, without other identifiable causes, signifies progression to eclampsia.
Diagnostic Procedures
1. Urine Tests. Urine analysis is crucial for diagnosing preeclampsia:
- Urine dipstick: 1+ protein or higher.
- 24-hour urine collection: ≥ 300 mg protein.
- Urine protein to creatinine ratio: > 0.3.
2. Blood Tests. Blood tests help identify abnormalities associated with preeclampsia:
- Complete Blood Count (CBC): Assess for thrombocytopenia (platelet count < 100,000/mm³).
- Complete Metabolic Panel (CMP): Evaluate liver function (elevated liver enzymes).
- Renal Function Tests: Check for renal insufficiency (increased creatinine > 1.1 mg/dL).
3. Fetal Status Assessment. Fetal well-being is assessed using:
- Non-stress tests (NSTs) and biophysical profiles (BPPs).
- Ultrasound assessment of amniotic fluid index (AFI).
- Estimated fetal weight (EFW).
4. CT Scan or MRI. In cases of severe headaches, neurological deficits, or seizures, CT scans or MRI may be used to evaluate for intracranial abnormalities.
Nursing Interventions for Preeclampsia
Effective nursing interventions are vital for managing preeclampsia and ensuring patient recovery. The following section details key nursing interventions.
Managing Pregnancy-Induced Hypertension
1. Early Diagnosis. Prompt diagnosis and intervention are paramount in preeclampsia management, focusing on effective blood pressure control and seizure prevention.
2. Medication Administration. Administer antihypertensive medications as prescribed, such as beta-blockers or calcium channel blockers, to stabilize blood pressure fluctuations. Common medications include:
- IV labetalol.
- IV hydralazine.
- Oral nifedipine.
3. Aspirin Therapy. Low-dose aspirin therapy may be initiated in women at high risk for preeclampsia, starting in the late first trimester and continuing through the third trimester to reduce preeclampsia risk.
4. Activity Modification. While strict bed rest is not typically required, reducing physical activity can help lower blood pressure, though it does not halt preeclampsia progression.
5. Patient Education on Expectant Management. For stable patients undergoing expectant management, educate them on the importance of frequent monitoring, including:
- Serial ultrasonography.
- Weekly antepartum testing.
- Close monitoring of symptoms and blood pressure.
- Routine laboratory assessments.
6. Delivery of the Fetus. Delivery is the only definitive treatment for preeclampsia.
- Delivery is generally recommended at 37 weeks for gestational hypertension or preeclampsia without severe symptoms.
- In cases of severe preeclampsia, delivery may be indicated as early as 34 weeks.
7. Betamethasone Administration. If preterm delivery before 34 weeks is anticipated, administer corticosteroids like betamethasone to accelerate fetal lung maturation.
8. Seizure Prevention. Intravenous magnesium sulfate is the primary agent for seizure prophylaxis in patients with preeclampsia, particularly those with severe features, to prevent progression to eclampsia.
Preventing Complications
1. Postpartum Monitoring. Preeclampsia typically resolves after delivery, but hypertension and seizures can still occur up to six weeks postpartum, necessitating continued monitoring.
2. Dietary Recommendations. Educate patients on dietary modifications to help manage edema and hypertension. Recommendations include reducing sodium intake and increasing calcium, magnesium, and potassium intake through diet. Advise limiting processed meats, white bread, fried foods, salty snacks, and sugary drinks.
3. Recognize When to Seek Medical Attention. Instruct patients to promptly contact their healthcare provider if they experience:
- Seizures.
- Breathing difficulties.
- Severe abdominal pain.
- Blurred vision.
- Persistent headaches.
- Decreased fetal movement.
- Vaginal bleeding.
4. Promote Treatment Adherence. Emphasize the importance of adhering to prescribed medications, dietary and lifestyle recommendations, and scheduled prenatal appointments and tests.
5. Stress Management Techniques. Stress can exacerbate hypertension during pregnancy. Encourage stress-reducing practices such as deep breathing exercises, relaxation techniques, and appropriate physical activities.
6. Educate on Future Pregnancy Risks. Inform patients that a history of preeclampsia increases the risk in subsequent pregnancies, with higher recurrence rates associated with severe preeclampsia.
7. Cardiovascular Disease Risk Education. Advise women who have had preeclampsia about their increased lifetime risk of cardiovascular disease (CVD). Counsel on the importance of regular blood pressure screenings and lifestyle modifications like exercise, weight management, a healthy diet, and avoiding smoking and excessive alcohol to mitigate CVD risk.
Nursing Care Plans and NANDA Diagnoses for Preeclampsia
Once nursing diagnoses are identified based on NANDA-I, nursing care plans become essential tools for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Below are examples of nursing care plans utilizing NANDA diagnoses relevant to preeclampsia.
Decreased Cardiac Output
Nursing Diagnosis: Decreased Cardiac Output, related to hypovolemia, decreased venous return, and increased systemic vascular resistance secondary to preeclampsia, as evidenced by alterations in blood pressure, edema, and dyspnea.
Related Factors:
- Hypovolemia.
- Decreased venous return.
- Increased systemic vascular resistance.
Defining Characteristics:
- Alterations in blood pressure.
- Alterations in hemodynamic readings.
- Edema.
- Dyspnea.
- Alterations in mental status.
Expected Outcomes:
- Patient will maintain blood pressure within acceptable parameters.
- Patient will demonstrate improved hemodynamic stability.
Nursing Assessments:
1. Monitor Blood Pressure. Hypertension in pregnancy is defined as BP >140/90 mmHg. New-onset hypertension with proteinuria after 20 weeks confirms preeclampsia.
2. Assess for Heart Failure Indicators. Assess for signs of poor cardiac function:
- Excessive fatigue.
- Exertional intolerance.
- Sudden weight gain.
- Peripheral edema.
- Worsening dyspnea.
3. Evaluate Platelet Count. Low platelet counts in preeclamptic women are associated with increased risk of abnormal coagulation and reduced cardiac output.
4. Assess Fetal Growth. Preeclampsia-related reduced cardiac output can impair placental blood flow, potentially causing fetal growth restriction.
Nursing Interventions:
1. Position Patient in Left Lateral Decubitus. Left side-lying enhances circulation, facilitating optimal blood flow to the placenta.
2. Administer Oxygen Therapy. Supplemental oxygen increases oxygen availability for both maternal cardiac function and placental perfusion.
3. Administer Antihypertensives as Prescribed. Use medications cautiously, considering both maternal and fetal safety.
4. Fluid Management. Restrict fluids if edema or pulmonary congestion is present, as ordered.
5. Promote Rest and Reduced Activity. Rest periods reduce cardiac demand and improve placental blood flow.
6. Prepare for Cesarean Delivery if Indicated. In cases of severe complications due to decreased cardiac output, emergency cesarean delivery may be necessary to protect both mother and fetus.
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to lack of exposure to information regarding preeclampsia pathophysiology, management, risk factors, self-care, and potential complications, as evidenced by inquiries about the condition and misconceptions.
Related Factors:
- Lack of exposure to information.
- Misinformation.
- Misconceptions.
Defining Characteristics:
- Expressed concerns and questions about preeclampsia.
- Inaccurate understanding of preeclampsia.
- Development of preventable complications due to delayed recognition.
Expected Outcomes:
- Patient will verbalize accurate understanding of preeclampsia, its management, and potential complications.
- Patient will demonstrate appropriate self-care behaviors.
Nursing Assessments:
1. Assess Current Knowledge Level. Determine the patient’s existing understanding of preeclampsia to tailor education effectively.
2. Identify Misconceptions. Address any misunderstandings or misinformation the patient may have about preeclampsia.
3. Assess Readiness to Learn. Ensure the patient is receptive to learning and provide education at an opportune time, free from distractions.
Nursing Interventions:
1. Educate on Reportable Symptoms. Provide clear verbal and written instructions on symptoms requiring immediate reporting, such as visual changes, headaches, epigastric pain, and dyspnea.
2. Involve Support System. Include the patient’s partner and family in education to enhance support and promote healthy behaviors.
3. Utilize Positive Reinforcement. Encourage behavior modification and learning through positive feedback and support.
4. Instruct on Importance of Follow-Up Care. Emphasize the necessity of attending all scheduled appointments and undergoing recommended tests to ensure a healthy pregnancy.
Impaired Skin Integrity
Nursing Diagnosis: Impaired Skin Integrity related to edema, hypertension, and potential thrombocytopenia associated with preeclampsia, as evidenced by edema and petechiae.
Related Factors:
- Disease process of preeclampsia.
- Hypertension.
- Edema.
- Decreased platelets.
Defining Characteristics:
- Petechiae.
- Pitting edema.
Expected Outcomes:
- Patient will maintain intact skin integrity.
- Patient will demonstrate understanding of interventions to promote skin health.
Nursing Assessments:
1. Assess Extent of Skin Impairment. Document the severity of edema and presence of petechiae, noting the grade of pitting edema and any signs of bleeding.
2. Review Skin Care Practices. Evaluate the patient’s current skin care routine and correct any practices that may exacerbate skin impairment.
Nursing Interventions:
1. Administer Antihypertensives as Ordered. Managing hypertension helps reduce edema and prevent further skin compromise.
2. Educate on Normal vs. Abnormal Edema. Differentiate between normal pregnancy-related swelling and edema indicative of preeclampsia, especially sudden or severe edema.
3. Encourage Leg Elevation. Elevating legs promotes venous return and reduces edema in the lower extremities.
4. Advise Comfortable Clothing and Footwear. Recommend loose, comfortable clothing and shoes to prevent skin irritation.
5. Suggest Compression Stockings. Compression stockings can help manage edema and improve circulation.
6. Instruct to Avoid Straining. Educate the patient to avoid activities that cause straining, which can contribute to petechiae.
Risk for Imbalanced Fluid Volume
Nursing Diagnosis: Risk for Imbalanced Fluid Volume related to fluid shifts, decreased osmotic pressure, and sodium retention secondary to preeclampsia.
Related Factors:
- Plasma protein loss.
- Decreased osmotic pressure.
- Fluid shifting out of vascular space.
- Sodium retention.
- Decreased kidney filtration.
Defining Characteristics:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- Patient will maintain balanced fluid volume, as evidenced by stable blood pressure and absence of pulmonary edema.
- Patient will demonstrate appropriate fluid intake and output balance.
Nursing Assessments:
1. Monitor Blood Pressure. Elevated blood pressure is a key indicator of fluid volume imbalance and preeclampsia.
2. Assess for Edema, Proteinuria, and Weight Gain. These are classic signs of fluid imbalance in preeclampsia.
3. Monitor Fetal Well-Being. Fluid imbalance can compromise fetal well-being due to reduced placental perfusion.
Nursing Interventions:
1. Preeclampsia Management. Collaborate with the healthcare team to manage preeclampsia effectively.
2. Administer IV Fluids Cautiously. Administer IV fluids as prescribed, carefully monitoring for fluid overload.
3. Diet Education. Reinforce dietary recommendations to limit sodium and ensure adequate intake of calcium, magnesium, and potassium.
4. Monitor Intake and Output. Closely track fluid intake and urine output to assess fluid balance and renal function.
Risk for Unstable Blood Pressure
Nursing Diagnosis: Risk for Unstable Blood Pressure related to uteroplacental perfusion problems, hormonal changes, and fluid retention associated with preeclampsia.
Related Factors:
- Disease process of preeclampsia.
- Uteroplacental perfusion issues.
- Hormonal changes.
- Fluid retention.
Defining Characteristics:
Risk diagnoses are not evidenced by signs and symptoms as the problem has not yet occurred. Interventions are preventative.
Expected Outcomes:
- Patient will maintain blood pressure at or below 140/90 mmHg.
- Patient will demonstrate understanding of interventions to manage blood pressure.
Nursing Assessments:
1. Monitor Blood Pressure Regularly. Accurate and frequent blood pressure monitoring is crucial for early detection and management.
2. Review Blood and Urine Tests. Assess lab results for indicators of renal function and proteinuria.
3. Assess Fetal Health via Ultrasound. Monitor fetal growth and amniotic fluid volume to assess the impact of maternal blood pressure fluctuations.
Nursing Interventions:
1. Administer Antihypertensive Medications. Administer prescribed antihypertensive medications to manage blood pressure.
2. Dietary Salt Restriction Education. Educate the patient on limiting sodium intake to help manage blood pressure.
3. Lifestyle Modification Counseling. Advise on stress reduction, relaxation techniques, and avoiding strenuous activity.
4. Postpartum Monitoring Instructions. Instruct the patient to continue monitoring for hypertension postpartum and to report any concerning symptoms.
References
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- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Karrar, S. A., & Hong, P. L. (2023, February 13). Preeclampsia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK570611/
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