Preeclampsia Eclampsia Nursing Care Plans Diagnosis and InterventionsPreeclampsia NCLEX Review and Nursing Care Plans Show
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 PreeclampsiaIt can be asymptomatic at first, and blood pressure may start creeping up slowly
Eclampsia In addition to the signs and symptoms of pre-eclampsia, a patient with eclampsia may have seizure symptoms such as:
Causes of PreeclampsiaDuring 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
Treatment of Preeclampsia
Nursing Diagnosis for PreeclampsiaNursing Care Plan for Preeclampsia 1Nursing 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 Care Plan for Preeclampsia 2Nursing 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 Care Plan for Preeclampsia 3Risk 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 Care Plan for Preeclampsia 4Risk 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 Care Plan for Preeclampsia 5Deficient 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 ReferencesAckley, 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 Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What are nursing interventions for severe preeclampsia?The overall management of preeclampsia includes supportive treatment with antihypertensives and anti-epileptics until definitive treatment - delivery. In preeclampsia without severe features, patients are often induced after 37 weeks gestation after with or without corticosteroids to accelerate lung maturity.
What are interventions for preeclampsia?Treatment of severe preeclampsia
Antihypertensive drugs to lower blood pressure. Anticonvulsant medication, such as magnesium sulfate, to prevent seizures. Corticosteroids to promote development of your baby's lungs before delivery.
Which nursing intervention is most effective in preventing a seizure in a client with severe preeclampsia?Magnesium sulfate can help prevent seizures in women with postpartum preeclampsia who have severe signs and symptoms. Magnesium sulfate is typically taken for 24 hours.
What nursing assessments should be made for the woman with preeclampsia?Imbalanced Fluid Volume Assessment. Monitor blood pressure. High blood pressure during pregnancy causes a concern for preeclampsia. ... . Assess for edema, proteinuria, and weight gain. Proteinuria, edema, and weight gain are symptoms of preeclampsia. ... . Monitor fetal well-being and status.. |