Preeclampsia is a serious complication that occurs during pregnancy and affects 5-7% of pregnancies worldwide. It is characterized by high blood pressure and protein in the urine (proteinuria). The exact cause is unknown though research shows genetics or blood vessel abnormalities with the placenta could be a potential cause.
The following risk factors increase the chance of a woman developing preeclampsia:
- Multiple-gestation pregnancy
- Family history of preeclampsia
- Women 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
Hypertension, proteinuria, and edema are the classic triad symptoms of preeclampsia. Other symptoms include:
- Constant headaches
- Vision abnormalities
- Shortness of breath
- Epigastric pain
- Fluctuations in fetal heart rate
- Vaginal bleeding
Preeclampsia, if untreated, can hinder the baby’s growth and may develop into eclampsia. Eclampsia is a severe complication of preeclampsia that can lead to seizures.
The only way to treat preeclampsia is to deliver the baby. After delivery, preeclampsia usually resolves within days to weeks.
The 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 Care Plans Related to Preeclampsia
Risk for Imbalanced Fluid Volume Care Plan
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
- 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. Interventions are aimed at prevention.
- 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
Imbalanced Fluid Volume 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.
Imbalanced Fluid Volume 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.
Decreased Cardiac Output Care Plan
Decreased cardiac output associated with preeclampsia can be caused by increased cardiac demands and decreased blood supply.
Nursing Diagnosis: Decreased Cardiac Output
- Decreased venous return
- Increased systemic vascular resistance
As evidenced by:
- Alterations in blood pressure
- Alterations in hemodynamic readings
- Alterations in mental status
- Patient will be able to maintain adequate blood pressure within acceptable limits
Decreased Cardiac Output 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.
Decreased Cardiac Output 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 Care Plan
Deficient knowledge associated with preeclampsia can result in delayed recognition and treatment and poorer outcomes.
Nursing Diagnosis: Deficient Knowledge
- 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
- 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
Deficient knowledge 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.
Deficient knowledge 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.
References and Sources
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- 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/
- 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.
- 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.