Preeclampsia
Hayley Elizabeth Webb
April 11, 2018
Guilford Technical Community College
Preeclampsia is defined as hypertension noted after 20 weeks gestation which is also presented with proteinuria and ankle edema. Pregnant women that present with preeclampsia do not present with any hypertension prior to pregnancy or earlier than 20 weeks gestation during prenatal visits. Preeclampsia can be defined as mild, moderate, or severe. Mild preeclampsia is associated with a blood pressure of 140/90 with 1+ proteinuria where as severe has a blood pressure of 160/110 with 3+ proteinuria (Ladewig, London, & Davidson, 2017). This disease process can be prevented and side effects of already existing preeclampsia can be decreased with early detection from lab work along with proper medication and lifestyle modifications.
Assessment
The most important piece to assess for a client at risk for preeclampsia is vital signs. Blood pressure should be measured at each prenatal visit to ensure a baseline for that patient along with a urinalysis to measure protein creatinine ratio. The nurse should be sure to ask if the patient has been suffering from severe headache, blurred vision, or ankle edema (Townsend, R., O’Brien, P., & Khalil, A, 2015). These complaints will warrant further testing to determine the cause which may lead to the diagnosis of preeclampsia. During a health history, the nurse should also assess the clients output of urine as a decrease can be a symptom of preeclampsia along with consistent epigastric pain that does not decrease even with continued antacid use. Comprehensive metabolic panel (CMP) along with electrolyte levels should be drawn to assess renal and kidney function along with electrolyte imbalances. An imbalance associated with magnesium can cause hyperreflexia symptoms in these patients. Breath sounds should be monitored as moist lung sounds can be indicative of severe preeclampsia along with a visual assessment watching for labored breathing and dyspnea (Ladewig, London, & Davidson, 2017).
Diagnosis
The patient can not be positively diagnosed with preeclampsia unless a systolic blood pressure above 140 or a diastolic pressure above 90 is noted on two or more visits (Townsend, R., O’Brien, P., & Khalil, A, 2015). An increase in blood pressure will be presented in the patient with complaints of severe headache and blurred vision. These complaints should warrant concern in a nurse to perform other testing including a urine dipstick. Urine dipstick will be the next step for diagnosis since it will always accompany preeclampsia. A urinalysis is tested for protein creatinine ratio with a result of 30 mg or more indicating a significant amount of protein being excreted. When a positive protein creatinine ratio has resulted, it is imperative to schedule a 24 hour urine collection that will measure for proteinuria. When a result of 300 mg per day or more has resulted from this exam, it is indicative that this patient is suffering from preeclampsia. These urine samples need to be collected at least 4 hours apart with two different positive tests whether urinalysis or 24 hour urine specimen (Ladewig, London, & Davidson, 2017). A patient with preeclampsia may also have oliguria so it is important to measure urine output while assessing a 24 hour urine specimen. Compressive Metabolic Panel will be important to assess renal and hepatic function indicating failure in these organs or decreased excretion of waste. AST and ALT labs are the most important hepatic labs to monitor in these patients (Townsend, R., O’Brien, P., & Khalil, A, 2015). These labs not only diagnosis preeclampsia but again the stage of preeclampsia the client is experiencing whether it is mild, moderate, or severe. One of the most important nursing diagnosis associated with preeclampsia is fluid volume deficit as the kidneys ability to excrete urine decreases causing an intravascular shift of fluid to extravascular space leading to third spacing or edema along with electrolyte shifts which may include imbalance of magnesium (Ladewig, London, & Davidson, 2017). The imbalance of magnesium can also warrant a nursing diagnosis of risk for injury as there would be significant neurological impairment presented in these patients.
Planning
After the nurse obtains an assessment, along with further testing, they will collaborate with other healthcare professionals to devise a plan of care for the patient to decrease progression of the disease process. These patients will need education on proper management of their disease to prevent further progression which can cause severe complications. Education planning for these patients will include how to monitor blood pressure and weight at home along with how to perform urine dipsticks daily to monitor protein. Weight gain of more than 3 pounds in 24 hours should be concerning for the patient and warrant a call to her health care provider for further evaluation. Providers may also incorporate non-stress tests (NST) and biophysical profiles (BPPs) into the patients care plan occurring once a week up to daily depending on state of preeclampsia and physician assessments. A dietician may speak with the client on decreasing sodium intake while increase protein intake to replace what is lost in the urine (Ladewig, London, & Davidson, 2017).
Intervention
Nursing interventions will depend on the state of preeclampsia the client is experiencing but are also used to decrease maternal and fetal risks of the disease. The patient should be weighed daily to determine if water retention is occurring. If weight gain is noted, edema should be assessed. When the clients condition is severe, she is placed on bed rest will having her lie on her left side to decrease pressure exerted on the heart. The nurse will assess the urine dipstick daily for protein while vital signs, including blood pressure, should be at least checked 4 times a day (Ladewig, London, & Davidson, 2017). Ultrasound is necessary to assess any fetal risks and abnormalities that may be present due to the disease. Hypertension medication is necessary to manage this disease and would include nifedipine, hydralazine, or labetolol (Townsend, R., O’Brien, P., & Khalil, A, 2015). To decrease the neurological risks posed to the mother and fetus along with management of preeclampsia, the nurse will administer magnesium sulfate. The nurse should monitor deep tendon reflexes and clonus during and after administration of this medication to make sure the client is neurologically intact. The patient will be at risk for pre term labor which will require them to receive betamethasone to facilitate lung development if under 36 weeks gestation(Ladewig, London, & Davidson, 2017). The nurse should continuously monitor blood pressure and neurological function in patients that are receiving intravenous medications for management of this disease.
Evaluation
The patient will be continuously monitored and evaluated for effectiveness of treatment during prenatal visits, during intrapartum assessments, and during postpartum management. Blood pressure should be assessed in these patients periodically especially when hypertensive medications are being administered. Neurologically assessments with deep tendon reflexes (DTR) and clonus will be monitored to determine if side effects are being exhibited from magnesium sulfate. Evaluation of the patient during postpartum care is crucial as their condition should rapidly improve after giving birth to both the baby and placenta(Ladewig, London, & Davidson, 2017). Evaluation is measured through the effectiveness of decreased or unchanged blood pressure, protein creatinine ratio, and edema. Along with decreased side effects of vision changes, severe headache, and oliguria. It is an important aspect of the nurse’s job to assess and determine a clients risk for preeclampsia as well as indications for further testing. The knowledge of this disease process can be the difference between any further maternal and fetal risks that are associated.
References
London, M. L., Ladewig, P. W., Davidson, M. R., Ball, J., Bindler, R. M., & Cowen, K. J. (2017).
Maternal & child nursing care (5th ed.). Boston: Pearson Education.
Townsend, R., O’Brien, P., & Khalil, A. (2015). Diagnosis and management of preeclampsia: A clinical perspective on recent advances in the field. British Journal Of Midwifery, 23(4), 252-258.