Preeclampsia is a serious complication that occurs during pregnancy, affecting 5-7% of pregnancies worldwide. It is characterized by new-onset high blood pressure (> 140/90 mmHg) and protein in the urine (proteinuria) after 20 weeks gestation. Research shows that preeclampsia may be caused by abnormalities in the development of the placenta, genetic or environmental factors, and maternal cardiovascular and inflammatory changes.
Preeclampsia can hinder the baby’s growth, increase the risk of placental abruption, lead to maternal organ damage, and worsen into eclampsia. Eclampsia is a severe complication of preeclampsia that causes seizures.
The only way to treat preeclampsia is to deliver the baby. After delivery, preeclampsia usually resolves within days to weeks.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Skin Integrity
- Risk for Imbalanced Fluid Volume
- Risk for Unstable Blood Pressure
Nursing Process
Nurses can first identify high-risk pregnancies to prevent preeclampsia. Focus on a thorough nursing assessment, education, and antenatal care.
The majority of cases are avoidable. Interventions include:
- Monitoring the patient’s blood pressure and symptoms
- Stress management
- Weight management
- Proper nutrition
- Monitoring fetal heart rate (FHR)
- Regular OB/GYN follow-ups and prenatal care
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to preeclampsia.
Review of Health History
1. Assess for general symptoms of preeclampsia.
Hypertension, proteinuria, and edema are the classic triad symptoms of preeclampsia. Other symptoms include:
- Frequent, severe headaches
- Vision abnormalities
- Shortness of breath
- Epigastric pain
2. Determine the patient’s risk.
The following risk factors increase the chance of a woman developing preeclampsia:
- Multiple-gestation pregnancy
- Obesity
- Gestational diabetes
- Family or personal history of preeclampsia
- Giving birth for the first time
- Women younger than 20 years of age or older than 40 years of age
- Overproduction of amniotic fluid (polyhydramnios)
- Underlying diseases like hypertension, diabetes, renal disease, and autoimmune disorders
- African American ethnicity
- Use of in vitro fertilization
3. Review the patient’s medications.
Preeclampsia development may be increased by using certain medications during pregnancy, such as:
- Antidepressants
- Benzodiazepines
- NSAIDs
- Antiretrovirals for HIV treatment
- Triptans used to treat migraines
- Asthma medication (montelukast)
- Methamphetamine
4. Identify the patient’s knowledge of preeclampsia.
Evaluate the patient’s current knowledge and understanding of preeclampsia. The patient may misinterpret preeclampsia due to prior knowledge or cultural or familial influences.
Physical Assessment
1. Monitor the maternal vital signs closely.
Patients should be suspected of having preeclampsia if their systolic or diastolic blood pressure is elevated. Blood pressure readings of 140/90 mmHg or greater from two measurements taken more than 20 weeks into pregnancy diagnose preeclampsia along with diagnostic testing.
2. Assess the respiratory status.
Auscultation of the lungs checks for pulmonary abnormalities if the patient complains of shortness of breath. This finding is associated with fluid buildup in the lungs.
3. Palpate the abdomen.
Palpate the right upper quadrant and the epigastric region to check for tenderness. 10% of women with severe preeclampsia will experience liver involvement.
4. Assess for edema.
Assess for the presence of edema. While swelling in pregnancy is normal, monitor closely for a rapid increase in dependent edema in the lower extremities or edema in the hands or face.
5. Monitor fetal growth.
Preeclampsia can damage the arteries which supply blood to the placenta and decrease cardiac output. Fetal growth restriction occurs if the fetus does not receive enough oxygen and nutrients from the mother.
6. Weigh the patient regularly.
A weekly weight gain of over 3–5 pounds may indicate preeclampsia due to fluid retention.
7. Track intake and output.
Decreased urine production may indicate impaired kidney function due to low blood volume in circulation. The inability to excrete urine can cause water retention (edema) and hypertension due to damaged blood vessels.
8. Monitor for seizures.
Seizure activity in preeclampsia without another causative factor indicates progression to eclampsia.
Diagnostic Procedures
1. Collect samples for urine tests.
The following urine tests diagnose preeclampsia:
- Urine dipstick result of 1+ or greater
- 24-hour urine collection with 300 mg of protein
- Urine protein to creatinine ratio > 0.3
2. Check the blood for any abnormalities.
- Complete blood count: thrombocytopenia (platelet count of less than 100,000/mm³)
- Complete metabolic panel: impaired liver function (elevation of liver enzymes)
- Renal insufficiency: increased creatinine > 1.1 mg/dL
3. Assess the fetal status.
Fetal assessment includes:
- Non-stress tests and biophysical profiles
- Ultrasound of the amniotic fluid index
- Estimated fetal weight
4. Assist with CT scans or MRI.
CT scanning or MRI may be utilized to assess for intracranial abnormalities if the patient displays severe headaches, neurological deficits, and seizures.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with preeclampsia.
Manage Pregnancy-Induced Hypertension
1. Diagnose early.
Early diagnosis and intervention are the first steps in managing preeclampsia. Emphasize effective blood pressure management and seizure prevention.
2. Administer medications as ordered.
Control the blood pressure using beta-blockers or calcium channel blockers. Medications stabilize fluctuations in blood pressure readings, such as:
- IV labetalol
- IV hydralazine
- Oral nifedipine
3. Implement aspirin therapy.
Women at high risk for preeclampsia may take low-dose aspirin in the late first trimester through the third trimester to lower the risk of developing preeclampsia.
4. Reduce physical activity.
Bed rest is not required, but a reduction in physical activity can lower blood pressure, though it will not prevent the worsening of preeclampsia.
5. Educate on expectant management.
Expectant management is undertaken in stable patients, and the patient must be educated on the importance of frequent monitoring through:
- Serial ultrasonography
- Weekly antepartum testing
- Close observation of symptoms and blood pressure
- Routine laboratory tests
6. Deliver the fetus.
Delivery of the fetus is the only effective treatment for preeclampsia.
- Patients diagnosed with gestational hypertension or preeclampsia without significant symptoms will deliver at 37 weeks.
- Patients with severe preeclampsia may deliver at 34 weeks.
7. Administer betamethasone.
If delivery is expected before 34 weeks, administer steroids to speed up the development of the fetus’s lungs.
8. Prevent seizures.
Eclampsia is severe pre-eclampsia-related seizure activity that occurs during pregnancy. Intravenous magnesium sulfate therapy is the initial choice for seizure prophylaxis in individuals with preeclampsia with severe symptoms.
Prevent Complications
1. Monitor in the post-partum period.
Preeclampsia normally resolves after delivery, but hypertension and seizures may occur up to six weeks after delivery.
2. Educate about food recommendations.
Preeclamptic patients can delay the development of edema and hypertension by reducing their salt intake and supplementing with calcium, magnesium, and potassium. Avoid processed meat, white bread, fried foods, salty snacks, and sodas.
3. Advise the patient when to seek immediate medical attention.
Advise the patient to call their obstetrician if the following symptoms appear:
- Seizures
- Difficulty breathing
- Sharp abdominal pain
- Blurry vision
- Persistent headaches
- Decreased fetal activity
- Vaginal bleeding
4. Encourage treatment adherence.
Treatment adherence includes taking prescribed medications, following the recommended diet and lifestyle changes, and adhering to prenatal care and testing.
5. Manage stress.
High blood pressure during pregnancy may be caused by stress—Institute stress management, such as deep breathing exercises, relaxation techniques, and aerobic physical activities as advised.
6. Educate on the risk of preeclampsia in future pregnancies.
A history of preeclampsia increases the risk for future preeclampsia, though the risk of recurrence is greater with severe features of preeclampsia.
7. Instruct on the risk of cardiovascular disease.
Women who develop preeclampsia are at an increased risk of developing CVD later in life. Instruct on the importance of regular blood pressure screenings and to reduce the risk through exercise, weight loss, a healthy diet, and avoiding alcohol.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for preeclampsia, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for preeclampsia.
Decreased Cardiac Output
Decreased cardiac output associated with preeclampsia can be caused by increased cardiac demands and decreased blood supply.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Hypovolemia
- Decreased venous return
- Increased systemic vascular resistance
As evidenced by:
- Alterations in blood pressure
- Alterations in hemodynamic readings
- Edema
- Dyspnea
- Alterations in mental status
Expected outcomes:
- Patient will be able to maintain adequate blood pressure within acceptable limits.
Assessment:
1. Assess the patient’s blood pressure.
During pregnancy, hypertension is defined as blood pressure >140/90 mm Hg. Preeclampsia is diagnosed with new onset hypertension with proteinuria after 20 weeks of pregnancy.
2. Assess for indications of poor cardiac function and impending heart failure.
The nurse can assess for the following symptoms:
- Excessive fatigue
- Intolerance to exertion
- Sudden or rapid weight gain
- Edema in the extremities
- Progressive or worsening shortness of breath
4. Assess the patient’s platelet count.
In preeclamptic women, a low platelet count is linked to a higher risk of abnormal coagulation and decreased cardiac output.
5. Assess for fetal growth.
Preeclampsia reduces cardiac output and can affect the arteries that provide blood to the placenta. The fetus may not get enough oxygen or nutrients which may result in fetal growth restriction.
Interventions:
1. Position the patient comfortably on the left side-lying position.
Left side-lying promotes adequate circulation. This position makes it easier for nutrient-rich blood to flow from the heart to the placenta to support the fetus.
2. Administer oxygen as prescribed.
Increase the amount of oxygen available for heart function which will increase the blood supply to the placenta and fetus.
3. Administer antihypertensives.
Cardiac medications should be administered to reduce hypertension with precautions that are safe for the mother and the fetus.
4. Restrict fluids as ordered.
If there is the presence of edema and cardiopulmonary congestion, restrict fluid intake as ordered.
6. Encourage reduced activity.
Rest periods and reduced activity is recommended. Physical activity diverts blood away from the placenta. Complete bed rest is not necessary.
7. Prepare for cesarean section.
If complications of preeclampsia due to decreased cardiac output are present, an emergency cesarean section is performed. This is to prevent maternal and fetal death.
Deficient Knowledge
Deficient knowledge associated with preeclampsia can result in delayed recognition and treatment and poorer outcomes.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Pathophysiology of preeclampsia
- Management of preeclampsia
- Risk factors for preeclampsia
- Self-care and nutritional needs of preeclampsia
- Complications of preeclampsia
- Lack of exposure to preeclampsia
- Inaccurate information about preeclampsia
- Misconceptions about preeclampsia
As evidenced by:
- Rapid progress of preeclampsia
- Development of preventable complications
- Unawareness of symptoms
- Inquiries about preeclampsia
- Misconceptions about preeclampsia
- Inaccurate or insufficient instructions in the prevention or management of preeclampsia
Expected outcomes:
- Patient will be able to verbalize understanding of preeclampsia and its management.
- Patient will be able to verbalize possible complications and when to contact a healthcare provider.
- Patient will be able to demonstrate behavior and lifestyle modifications in the prevention of preeclampsia.
Assessment:
1. Determine the patient’s knowledge level of preeclampsia.
Assessing the patient’s current knowledge and understanding of preeclampsia will help the nurse determine appropriate resources to guide learning.
2. Determine misconceptions about preeclampsia.
Preeclampsia can be misinterpreted by the patient due to past information or influences by family, friends, and cultures. Ask the patient directly about their understanding and clarify any questions as needed.
4. Assess readiness to learn.
Pregnancy can be an exciting and frightening journey, especially for first-time moms. Establish an uninterrupted time to provide information on preeclampsia that is not overwhelmed by other instructions.
Interventions:
1. Instruct on symptoms to report.
Provide verbal and written instructions on symptoms to report to the healthcare provider such as blurred vision, headaches, epigastric pain, or difficulty breathing.
2. Involve the support system.
A mother requires support from her partner and family members. Information can be provided to support persons to monitor the patient and encourage healthy habits.
3. Encourage using positive reinforcement.
Positive reinforcement can be used to encourage behavior modification and teach new skills. It promotes motivation for further attempts at learning.
4. Instruct on appointments and tests.
Completing follow-up appointments, glucose monitoring, and blood pressure assessments will ensure a healthy pregnancy and delivery.
Impaired Skin Integrity
Pregnant patients with preeclampsia may exhibit edema in the hands, fingers, neck, face, and feet and petechiae (tiny red dots) on the skin, indicating underlying bleeding due to excessive pressure in the blood vessels.
Nursing Diagnosis: Impaired Skin Integrity
Related to:
- Disease process
- Hypertension
- Edema
- Decreased platelets
As evidenced by:
- Petechiae
- Pitting edema
Expected outcomes:
- Patient will maintain intact skin integrity.
- Patient will verbalize understanding of the condition and demonstrate interventions that promote skin health.
Assessment:
1. Assess and determine the extent of skin impairment.
It is important to determine the severity of edema and petechiae by noting the grade of pitting edema and the amount of skin bleeding or bruising.
2. Assess the patient’s skin care practices.
The patient’s skin care practices can further aggravate impaired skin integrity. Correct misconceptions and inappropriate skin care practices to prevent further skin damage.
Interventions:
1. Administer antihypertensives as ordered.
Antihypertensives can help resolve the elevated blood pressure of preeclamptic patients. Resolving the underlying cause will help correct and prevent skin impairments like edema and petechiae.
2. Educate on normal vs. abnormal.
Edema and swelling are normal findings in pregnancy, but swelling that suddenly worsens, especially in the face or hands, warrants further investigation for preeclampsia.
3. Encourage the patient to keep the legs elevated.
To reduce the swelling and prevent further aggravation of pitting edema, keeping the legs elevated higher than the level of the heart when lying down is encouraged to improve blood circulation and venous return. A footstool may be used to keep the legs elevated when sitting down.
4. Encourage the patient to wear comfortable clothing and shoes.
Patients are encouraged to wear comfortable shoes without tight straps that can pinch and cause irritation or breakdown.
5. Encourage the patient to use compression stockings.
Compression stockings are also helpful in reducing swelling, aching, and the development of varicose veins associated with pregnancy.
6. Instruct the patient to avoid straining.
Prolonged straining when coughing, weight lifting, and vomiting can result in the formation of petechiae of the chest, neck, and face in pregnant women. Instructing the patient to avoid straining can help reduce the appearance of petechiae.
Risk for Imbalanced Fluid Volume
Risk for imbalanced fluid volume associated with preeclampsia is caused by fluid shifts which can lead to overloading organs and tissues.
Nursing Diagnosis: Risk for Imbalanced Fluid Volume
Related to:
- Plasma protein loss
- Decreased osmotic pressure
- Fluid shifting out of the vascular space
- Narrowing of the blood vessels
- Highly concentrated blood (Hemoconcentration)
- Elevated blood flow resistance
- Body cell degeneration (for pregnant mothers of older age)
- Decreased kidney filtration
- Sodium retention
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will be able to maintain adequate fluid volume as evidenced by blood pressure within normal limits.
- Patient will be able to demonstrate efficient fluid intake and output.
- Patient will remain free from generalized or pulmonary edema.
Assessment:
1. Monitor blood pressure.
High blood pressure during pregnancy causes a concern for preeclampsia. Increased blood pressure may cause the heart to have to work harder due to the additional fluid in the body.
2. Assess for edema, proteinuria, and weight gain.
Proteinuria, edema, and weight gain are symptoms of preeclampsia. Protein in the urine (proteinuria) occurs from impaired renal filtration. Weight gain is likely related to fluid retention.
Note the following symptoms:
- Proteinuria of 1+ to 2+ on a random sample
- Minor facial or upper extremity edema
- Weight gain of more than 2 pounds per week in the second trimester and less than 1 pound per week in the third trimester
3. Monitor fetal well-being and status.
Preeclampsia is a significant factor in fetal death. If fluid is not balanced, the fetus is at higher risk of hypoxia and growth retardation.
Interventions:
1. Manage preeclampsia.
Collaborate with the healthcare team in treating preeclampsia to manage symptoms of fluid volume imbalance and prevent further complications.
2. Administer fluids.
IV fluids are administered to expand the intravascular volume. Care must be taken to not worsen or cause pulmonary edema.
3. Instruct on diet recommendations.
Limiting sodium and taking calcium, magnesium, and potassium supplements prevent the progression of edema and hypertension in preeclampsia.
4. Monitor intake and output.
Oliguria or reduced urine output can signal decreased kidney function from poor circulatory blood volume.
Risk for Unstable Blood Pressure
Blood vessels develop in the uterus to supply nutrients and oxygen to the placenta and the fetus. In patients with preeclampsia, the development of these blood vessels is faulty, causing irregularities in placental blood circulation, which will also result in maternal cardiovascular and inflammatory changes.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Disease process
- Uteroplacental perfusion problems
- Cardiac dysrhythmia
- Hormonal changes
- Fluid retention
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure at or below 140/90 mmHg.
- Patient will demonstrate interventions to help reduce fluctuations in blood pressure.
- Patient will not experience blurred vision, dizziness, or headaches.
Assessment:
1. Assess and monitor the patient’s blood pressure.
Accurate measurement and monitoring of the patient’s blood pressure is essential in the early detection and prompt management of preeclampsia. Increasing blood pressure can indicate the progression of preeclampsia in pregnant patients, leading to complications like seizures. High blood pressure in pregnancy is defined as more than 140 mmHg systolic or 90 mmHg diastolic.
2. Assess blood and urine test results.
Blood and urine tests are indicated to assess the effect on kidney function. Protein in the urine can signal impaired renal function due to elevated blood pressure.
3. Assess fetal health through an ultrasound.
Fluctuating blood pressure in pregnant women can affect the fetus’s growth and development. With a fetal ultrasound, fetal weight can be closely monitored, along with the amount of amniotic fluid present in the uterus.
Interventions:
1. Administer medications as indicated.
Antihypertensives are indicated to help manage hypertension in preeclamptic patients.
2. Instruct the patient to limit salt intake.
Limiting salt intake can help prevent sodium and water retention and reduce the risk of blood pressure elevation.
3. Instruct on lifestyle modifications.
Instruct the patient to reduce stress, promote relaxation, and reduce strenuous activities to prevent unstable blood pressure.
4. Continue to monitor after delivery.
High blood pressure may still be an issue following delivery. Instruct the patient to alert their provider to headaches, nausea or vomiting, or vision changes that are signs of high blood pressure.
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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