Preeclampsia is a significant pregnancy complication, affecting 5-7% of pregnancies globally. It’s defined by the new onset of hypertension (blood pressure > 140/90 mmHg) and proteinuria after the 20th week of gestation. Research indicates that preeclampsia can stem from placental development issues, genetic predispositions, environmental factors, and maternal cardiovascular and inflammatory changes.
This condition can impede fetal growth, elevate the risk of placental abruption, cause organ damage in the mother, and potentially progress to eclampsia, a severe form of preeclampsia marked by seizures.
Delivery of the baby is the definitive treatment for preeclampsia. Typically, the condition resolves within days to weeks postpartum.
Nursing Process for Preeclampsia
Nurses play a crucial role in preventing and managing preeclampsia, starting with identifying high-risk pregnancies. A comprehensive nursing approach emphasizes thorough assessment, patient education, and diligent antenatal care.
Many preeclampsia cases are preventable through effective interventions, including:
- Regular monitoring of blood pressure and symptoms
- Stress management techniques
- Weight management strategies
- Balanced nutrition guidance
- Fetal heart rate (FHR) monitoring
- Consistent OB/GYN follow-ups and prenatal care
Nursing Assessment for Preeclampsia
The nursing assessment is the foundation of care, involving the collection of physical, psychosocial, emotional, and diagnostic data. This section details subjective and objective data pertinent to preeclampsia.
Review of Health History
1. Identify General Preeclampsia Symptoms. The classic triad of preeclampsia includes hypertension, proteinuria, and edema. However, be vigilant for other symptoms such as:
- Persistent, severe headaches
- Visual disturbances (blurred vision, light sensitivity, seeing spots)
- Shortness of breath or dyspnea
- Epigastric pain (upper abdominal pain)
2. Determine Preeclampsia Risk Factors. Certain factors increase a woman’s susceptibility to preeclampsia:
- Multifetal gestation (twins, triplets, etc.)
- Obesity or being overweight
- Gestational diabetes or pre-existing diabetes
- Family history of preeclampsia or personal history in previous pregnancies
- Nulliparity (first pregnancy)
- Age extremes: younger than 20 or older than 40 years
- Polyhydramnios (excessive amniotic fluid)
- Pre-existing conditions: hypertension, diabetes, renal disease, autoimmune disorders (like lupus or antiphospholipid syndrome)
- African American ethnicity
- In vitro fertilization (IVF) pregnancies
3. Medication Review for Potential Links to Preeclampsia. Certain medications used during pregnancy might be associated with an increased risk of preeclampsia:
- Antidepressants (especially SSRIs and SNRIs)
- Benzodiazepines
- Nonsteroidal anti-inflammatory drugs (NSAIDs), particularly in the third trimester
- Antiretrovirals used in HIV treatment
- Triptans for migraine management
- Asthma medications like montelukast
- Methamphetamine use
4. Assess Patient’s Preeclampsia Knowledge. Evaluate the patient’s understanding of preeclampsia. Misconceptions can arise from prior knowledge, cultural beliefs, or family experiences.
Physical Assessment
1. Monitor Maternal Vital Signs Diligently. Elevated blood pressure is a primary indicator. Preeclampsia is diagnosed when blood pressure readings are ≥ 140/90 mmHg on two occasions, at least four hours apart, after 20 weeks of gestation, accompanied by proteinuria or other end-organ damage.
2. Evaluate Respiratory Status. Auscultate lung sounds, especially if the patient reports shortness of breath. Crackles or wheezing might indicate pulmonary edema, a complication of severe preeclampsia.
3. Abdominal Palpation. Palpate the right upper quadrant and epigastric area for tenderness. Liver involvement occurs in about 10% of severe preeclampsia cases, causing pain due to liver capsule distention.
4. Edema Assessment. Assess for edema. While some swelling is normal in pregnancy, be alert for:
- Rapid increase in dependent edema (lower extremities)
- Edema in non-dependent areas like hands and face
- Pitting edema severity
5. Fetal Growth Monitoring. Preeclampsia can impair blood flow to the placenta, leading to fetal growth restriction. Fundal height measurement and ultrasound assessments are crucial to monitor fetal growth.
6. Regular Weight Monitoring. Sudden weight gain (over 3-5 pounds per week) can indicate fluid retention associated with preeclampsia.
7. Intake and Output Tracking. Decreased urine output may signal reduced kidney function due to decreased circulatory volume. Oliguria can contribute to edema and hypertension.
8. Observe for Seizures. Seizures in a preeclamptic patient, without other identifiable causes, indicate progression to eclampsia, a medical emergency.
Diagnostic Procedures
1. Urine Tests for Proteinuria. Preeclampsia diagnosis relies on urine protein assessment:
- Urine dipstick: ≥ 1+ protein
- 24-hour urine collection: ≥ 300 mg protein
- Urine protein-to-creatinine ratio: ≥ 0.3
2. Blood Tests for Systemic Impact. Blood tests help evaluate the severity and systemic effects of preeclampsia:
- Complete Blood Count (CBC): Thrombocytopenia (platelet count < 100,000/mm³) indicates severe preeclampsia and risk for bleeding.
- Complete Metabolic Panel (CMP): Liver function tests (AST, ALT) elevation indicates liver involvement.
- Renal Function Tests: Serum creatinine > 1.1 mg/dL may indicate renal insufficiency.
3. Fetal Status Evaluation. Assess fetal well-being and growth:
- Non-stress test (NST) and Biophysical Profile (BPP): Assess fetal heart rate patterns and overall fetal condition.
- Amniotic Fluid Index (AFI) Ultrasound: Evaluates amniotic fluid volume, which can be affected by placental insufficiency.
- Estimated Fetal Weight (EFW) Ultrasound: Monitors fetal growth. Doppler studies may assess umbilical artery blood flow.
4. Advanced Imaging (CT or MRI). In cases of severe headaches, neurological deficits, or seizures, CT scans or MRI may be used to rule out intracranial hemorrhage or other abnormalities.
Alt text: A nurse is measuring the blood pressure of a pregnant woman during a prenatal checkup, highlighting the importance of monitoring vital signs for early detection of preeclampsia.
Nursing Interventions for Preeclampsia
Effective nursing interventions are crucial for managing preeclampsia and ensuring positive outcomes.
Managing Pregnancy-Induced Hypertension
1. Early Diagnosis is Key. Prompt diagnosis and intervention are paramount. Emphasize blood pressure control and seizure prevention.
2. Administer Antihypertensive Medications as Prescribed. Manage hypertension with medications like:
- IV Labetalol: Beta-blocker, often first-line for acute hypertension.
- IV Hydralazine: Vasodilator, another common agent for acute management.
- Oral Nifedipine: Calcium channel blocker, used for less acute situations and maintenance.
3. Implement Low-Dose Aspirin Therapy for High-Risk Patients. For women at high risk, low-dose aspirin (81mg) from late first trimester to 36 weeks gestation can reduce preeclampsia risk.
4. Recommend Reduced Physical Activity. While strict bed rest is not universally recommended, reducing strenuous activity can help lower blood pressure.
5. Educate on Expectant Management. For stable patients, expectant management involves:
- Serial ultrasonography to monitor fetal growth and well-being.
- Weekly antepartum testing (NST, BPP).
- Close monitoring of maternal symptoms and blood pressure at home.
- Routine laboratory tests to assess maternal condition.
6. Delivery is the Definitive Treatment. Delivery timing depends on gestational age and disease severity:
- Gestational hypertension or preeclampsia without severe features: Delivery typically at 37 weeks.
- Severe preeclampsia: Delivery may be indicated as early as 34 weeks, or earlier depending on maternal and fetal status.
7. Betamethasone Administration for Preterm Delivery. If delivery is anticipated before 34 weeks, betamethasone (corticosteroid) is given to promote fetal lung maturity.
8. Seizure Prophylaxis. Intravenous magnesium sulfate is the primary agent for seizure prevention in preeclampsia with severe features.
Preventing Complications of Preeclampsia
1. Postpartum Monitoring is Essential. Preeclampsia can persist or even develop postpartum (up to 6 weeks). Continue blood pressure monitoring and symptom assessment.
2. Dietary Recommendations. Educate on diet to help manage symptoms:
- Reduce sodium intake to minimize fluid retention.
- Increase intake of calcium, magnesium, and potassium through diet or supplements, as these may have protective effects.
- Limit processed foods, fried foods, salty snacks, and sugary drinks.
3. Educate on Warning Signs Requiring Immediate Medical Attention. Instruct patients to seek immediate care for:
- Seizures
- Difficulty breathing or severe shortness of breath
- Severe or persistent headache
- Visual disturbances (blurred vision, spots)
- Epigastric pain or right upper quadrant pain
- Decreased fetal movement
- Vaginal bleeding
4. Promote Treatment Adherence. Emphasize the importance of:
- Taking prescribed medications consistently.
- Following dietary and lifestyle recommendations.
- Attending all prenatal and postpartum appointments.
5. Stress Management Techniques. Stress can exacerbate hypertension. Recommend stress-reducing practices:
- Deep breathing exercises
- Relaxation techniques (meditation, yoga)
- Moderate aerobic exercise (as approved by healthcare provider).
6. Counsel on Future Pregnancy Risks. A history of preeclampsia increases recurrence risk in subsequent pregnancies, especially with severe preeclampsia.
7. Educate on Long-Term Cardiovascular Disease Risk. Women with preeclampsia have a higher lifetime risk of cardiovascular disease. Advise on:
- Regular blood pressure screenings post-pregnancy.
- Heart-healthy lifestyle: exercise, healthy diet, weight management, avoiding smoking and excessive alcohol.
Alt text: A nurse is providing patient education to a pregnant woman, likely discussing prenatal care, healthy habits, or potential pregnancy complications like preeclampsia, emphasizing preventative measures and symptom awareness.
Nursing Care Plans for Preeclampsia
Nursing care plans provide a structured approach to prioritize assessments and interventions, addressing both immediate and long-term care goals for preeclampsia.
Nursing Care Plan 1: Decreased Cardiac Output
Decreased cardiac output in preeclampsia is linked to increased cardiac workload and reduced blood volume.
Nursing Diagnosis: Decreased Cardiac Output
Related Factors:
- Hypovolemia (relative due to fluid shift)
- Decreased venous return
- Increased systemic vascular resistance
Evidenced By:
- Elevated blood pressure readings
- Hemodynamic changes (if monitored invasively)
- Edema (generalized)
- Dyspnea, orthopnea
- Altered mental status (restlessness, confusion)
Desired Outcomes:
- Patient will maintain blood pressure within acceptable parameters for pregnancy.
- Patient will demonstrate improved cardiac function as evidenced by stable vital signs and absence of respiratory distress.
Assessments:
1. Monitor Blood Pressure Regularly. Hypertension is a hallmark of preeclampsia. Blood pressure > 140/90 mmHg is diagnostic in the context of proteinuria after 20 weeks gestation.
2. Assess for Heart Failure Indicators. Signs of poor cardiac function and impending heart failure include:
- Excessive fatigue and weakness
- Exertional intolerance
- Sudden weight gain (fluid retention)
- Peripheral edema (especially worsening edema)
- Progressive shortness of breath, cough, orthopnea
3. Monitor Platelet Count. Thrombocytopenia is associated with increased risk of coagulopathy and decreased cardiac output in preeclampsia.
4. Assess Fetal Growth and Well-being. Reduced cardiac output can compromise placental blood flow, leading to fetal growth restriction and hypoxia.
Interventions:
1. Position Patient in Left Lateral Recumbent Position. Left side-lying optimizes circulation, facilitating blood flow to the placenta and fetus.
2. Administer Supplemental Oxygen as Ordered. Oxygen therapy increases oxygen availability for both mother and fetus, supporting cardiac function and placental perfusion.
3. Administer Antihypertensive Medications as Prescribed. Antihypertensives reduce afterload and improve cardiac function. Choose medications safe for pregnancy.
4. Fluid Restriction if Indicated. In cases of edema and pulmonary congestion, fluid restriction may be necessary to prevent fluid overload. Monitor intake and output closely.
5. Encourage Rest and Reduced Activity. Rest minimizes cardiac workload and promotes placental blood flow. Complete bed rest is not routinely indicated but reduced activity is beneficial.
6. Prepare for Potential Cesarean Delivery. If maternal or fetal status deteriorates due to decreased cardiac output, emergency cesarean delivery may be necessary to save both lives.
Nursing Care Plan 2: Deficient Knowledge
Deficient knowledge about preeclampsia can lead to delayed recognition of symptoms and poorer outcomes.
Nursing Diagnosis: Deficient Knowledge
Related Factors:
- Lack of information regarding preeclampsia pathophysiology, management, risk factors, self-care needs, and potential complications.
- Misinformation or misconceptions about preeclampsia.
- Limited prior exposure to preeclampsia.
Evidenced By:
- Expressed lack of understanding about preeclampsia.
- Questions about preeclampsia, its causes, and management.
- Misconceptions about preeclampsia prevention or treatment.
- Development of preventable complications due to lack of knowledge.
- Rapid progression of preeclampsia due to delayed recognition of symptoms.
Desired Outcomes:
- Patient will verbalize understanding of preeclampsia, its causes, and management.
- Patient will identify reportable symptoms and when to seek medical attention.
- Patient will demonstrate adherence to recommended lifestyle modifications and self-care practices for preeclampsia management.
Assessments:
1. Assess Current Knowledge Level. Determine the patient’s baseline understanding of preeclampsia to tailor education effectively.
2. Identify Misconceptions and Concerns. Address any inaccurate beliefs or anxieties the patient may have about preeclampsia.
3. Assess Readiness to Learn. Ensure the patient is receptive to learning and provide education at a suitable time, minimizing distractions.
Interventions:
1. Educate on Reportable Symptoms. Provide clear verbal and written instructions on symptoms requiring immediate reporting (headache, visual changes, epigastric pain, decreased fetal movement, etc.).
2. Involve Support System in Education. Include the patient’s partner or family in education sessions to enhance support and understanding.
3. Utilize Positive Reinforcement. Encourage positive behavior changes and self-management strategies through positive feedback and encouragement.
4. Provide Information on Appointments and Tests. Explain the importance of follow-up appointments, blood pressure monitoring, urine testing, and fetal monitoring to ensure optimal pregnancy outcomes.
Nursing Care Plan 3: Impaired Skin Integrity
Edema and potential petechiae in preeclampsia can compromise skin integrity.
Nursing Diagnosis: Impaired Skin Integrity
Related Factors:
- Edema related to fluid shifts and hypertension
- Disease process of preeclampsia
- Decreased platelet count (increasing risk of petechiae/bruising)
Evidenced By:
- Pitting edema (lower extremities, hands, face)
- Petechiae or ecchymosis
Desired Outcomes:
- Patient will maintain intact skin integrity throughout pregnancy and postpartum.
- Patient will demonstrate understanding of skin care measures to promote skin health and prevent breakdown.
Assessments:
1. Assess Extent of Skin Impairment. Evaluate the severity of edema (pitting scale), presence and extent of petechiae or bruising.
2. Review Skin Care Practices. Identify any patient practices that may exacerbate skin issues and provide corrective education.
Interventions:
1. Administer Antihypertensives as Ordered. Controlling hypertension is crucial to reducing edema and improving skin integrity.
2. Educate on Normal vs. Abnormal Swelling. Differentiate between normal pregnancy edema and edema warranting concern (rapid onset, facial/hand edema).
3. Encourage Leg Elevation. Elevating legs when sitting or lying down promotes venous return and reduces dependent edema.
4. Recommend Comfortable Clothing and Footwear. Avoid tight clothing or shoes that can constrict circulation and irritate the skin.
5. Suggest Compression Stockings. Compression stockings can help reduce edema and discomfort in the lower extremities.
6. Instruct to Avoid Straining. Straining during bowel movements, coughing, or lifting can increase pressure and potentially lead to petechiae.
Nursing Care Plan 4: Risk for Imbalanced Fluid Volume
Preeclampsia pathophysiology puts patients at risk for fluid volume imbalance.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related Factors:
- Plasma protein loss leading to decreased osmotic pressure
- Fluid shift from vascular space to interstitial space
- Narrowing of blood vessels and hemoconcentration
- Elevated blood flow resistance
- Decreased kidney filtration and sodium retention
Evidenced By:
A risk diagnosis does not have “evidenced by” factors as the problem has not yet occurred. Interventions are preventative.
Desired 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.
- Patient will remain free from signs of fluid overload (pulmonary edema, worsening edema).
Assessments:
1. Monitor Blood Pressure Trends. Elevated blood pressure is a key indicator of fluid volume shifts in preeclampsia.
2. Assess for Edema, Proteinuria, and Weight Gain. These are classic signs of fluid volume imbalance in preeclampsia. Monitor for:
- Proteinuria (dipstick or 24-hour urine)
- Edema (location, severity)
- Weight gain patterns
3. Monitor Fetal Well-being. Fluid imbalance can impact placental perfusion and fetal oxygenation.
Interventions:
1. Manage Preeclampsia Actively. Collaborate with the healthcare team to manage preeclampsia effectively, addressing the underlying cause of fluid imbalance.
2. Administer Intravenous Fluids Judiciously. IV fluids may be needed in certain situations, but careful monitoring is essential to prevent fluid overload, especially pulmonary edema.
3. Provide Dietary Guidance. Educate on sodium restriction and importance of adequate calcium, magnesium, and potassium intake.
4. Monitor Intake and Output. Track fluid intake and urine output to assess fluid balance and kidney function. Oliguria should be reported promptly.
Nursing Care Plan 5: Risk for Unstable Blood Pressure
Preeclampsia disrupts normal blood pressure regulation in pregnancy.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related Factors:
- Pathophysiology of preeclampsia affecting uteroplacental circulation
- Cardiac dysrhythmias (potential complication)
- Hormonal changes of pregnancy
- Fluid retention
Evidenced By:
A risk diagnosis does not have “evidenced by” factors as the problem has not yet occurred. Interventions are preventative.
Desired Outcomes:
- Patient will maintain blood pressure at or below 140/90 mmHg.
- Patient will demonstrate understanding of interventions to stabilize blood pressure.
- Patient will report absence of symptoms associated with unstable blood pressure (headache, dizziness, visual changes).
Assessments:
1. Frequent Blood Pressure Monitoring. Accurate and frequent blood pressure measurement is critical for early detection and management of unstable blood pressure.
2. Review Blood and Urine Test Results. Assess renal function and proteinuria as indicators of preeclampsia severity and impact on blood pressure regulation.
3. Assess Fetal Health via Ultrasound. Unstable maternal blood pressure can affect fetal well-being and growth. Ultrasound monitors fetal growth and amniotic fluid.
Interventions:
1. Administer Antihypertensive Medications as Indicated. Antihypertensives are essential to manage and stabilize blood pressure.
2. Educate on Sodium Restriction. Limiting sodium intake helps minimize fluid retention and blood pressure elevation.
3. Instruct on Lifestyle Modifications for Blood Pressure Control. Recommend stress reduction, relaxation techniques, and avoiding strenuous activity.
4. Postpartum Blood Pressure Monitoring and Education. Hypertension can persist or develop postpartum. Educate patients to continue monitoring for symptoms and follow-up with their provider.
References
- Cleveland Clinic. (2021, October 14). Preeclampsia: Symptoms, causes, treatments & prevention. Retrieved May 2023, from https://my.clevelandclinic.org/health/diseases/17952-preeclampsia
- 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/
- Lim, K. H. (2022, April 13). Preeclampsia: Practice essentials, overview, pathophysiology. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/1476919-overview
- Moura, S. B., Lopes, L. M., Murthi, P., & Costa, F. D. (2012, December 17). Prevention of Preeclampsia. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534321/
- Norwitz, E. R. (2023). Patient education: Preeclampsia (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/preeclampsia-beyond-the-basics/print
- Pillitteri, A., & Silbert-Flagg, J. (2015). Nursing Care of a Family Experiencing a Sudden Pregnancy Complication. In Maternal & child health nursing: Care of the childbearing & Childrearing family (8th ed., pp. 1210-1224). LWW.
- Sahlman, H., Koponen, M., El‐Nezami, H., Vähäkangas, K., & Keski‐Nisula, L. (2019). Maternal use of drugs and preeclampsia. British Journal of Clinical Pharmacology, 85(12), 2848-2855. https://doi.org/10.1111/bcp.14117
- Silvestri, L. A., & CNE, A. E. (2019). Risk Conditions Related to Pregnancy. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 687-688). Saunders.
