Tuesday, August 17, 2010

Nursing Care Plan | NCP Preeclampsia

Preeclampsia is a pregnancy-specific syndrome of reduced organ perfusion secondary to vasospasm and endothelial activation that affects approximately 7% of all pregnant women. It is characterized by hypertension (blood pressure [BP] 140/90) and proteinuria (300 mg in 24 hours or 1 dipstick) after 20 weeks’ gestation. Edema is no longer included as a diagnostic criterion for preeclampsia, although it is often present, as it is an expected occurrence in pregnancy and has not shown to be discriminatory.

If untreated (or sometimes even with aggressive treatment), the symptoms get progressively worse. Symptoms relate to decreased perfusion to the major organs: kidneys (proteinuria, oliguria), liver (epigastric pain, elevated enzymes), brain (headache, blurred vision, hyperreflexia, clonus, seizures) and the placenta (fetal distress, intrauterine growth restriction). The devastating sequence of events after preeclampsia is as follows: eclampsia (seizure occurs), HELLP syndrome (hemolysis, elevated liver enzyme levels, low platelet count), followed by disseminated intravascular coagulation (DIC), which is often fatal. Not only is preeclampsia life-threatening for the mother, but it can also cause intrauterine growth retardation, decreased fetal movement, chronic hypoxia, or even death in the fetus caused by decreased placental perfusion. If seizures occur, the patient has a risk for placental abruption, neurological deficits, aspiration pneumonia, pulmonary edema, cardiopulmonary arrest, acute renal failure, and death. Fetal bradycardia is typical during the seizure, usually with slow recovery to the baseline heart rate upon the seizure ending.

In addition to preeclampsia, there are four other categories of hypertension disorders in pregnancy: (1) Gestational Hypertension—BP of 140/90 in a normotensive woman, no proteinuria, and the BP returns to normal postpartum; (2) Eclampsia—The development of seizures along with preeclampsia; (3) Superimposed preeclampsia on chronic hypertension—New onset of proteinuria in a hypertensive woman; and (4) Chronic hypertension—BP of greater than 140/90 before pregnancy occurred or hypertension diagnosed after 20 weeks that persists past the postpartum period. The remainder of this chapter will focus on preeclampsia.
Nursing care plan
The cause of preeclampsia is unknown; it is often called the “disease of theories” because many causes have been proposed, yet none has been well established. Experts believe that decreased levels of prostaglandins and a decreased resistance to angiotensin II lead to a generalized arterial vasospasm that then causes endothelial damage. The brain, liver, kidney, and blood are particularly susceptible to multiple dysfunctions. Several risk factors have been identified that may predispose a woman to developing preeclampsia: nulliparity; familial history; multiple gestation; patient history of diabetes mellitus, chronic hypertension, renal disease, trophoblastic disease, and malnutrition.

Nursing care plan assessment and physical examination
Obtain a thorough medical and obstetric history early in the pregnancy to determine if the patient has any of the risk factors. If she had a previous delivery, obtain information on any problems that occurred. Assess the patient’s level of consciousness and orientation because her mental status may deteriorate as preeclampsia progresses. Ask the patient if she has noticed an increase in edema, especially in her face; nondependent edema is more significant than dependent edema. The significant other may report that the patient’s face is “fuller.” Ask the patient if her hands and feet swell overnight and if her rings feel tight; she may even report that she is unable to take off her rings. Question her about any nausea, headaches, visual disturbances (blurred, double, spots), or right upper quadrant pain. Ask the patient and significant others if she has had seizures.

Inspect the patient for pitting edema. Although most pregnant women experience some edema, it has a more abrupt onset in preeclampsia. Weigh the patient daily, in the same clothes, at the same time, to help estimate fluid retention; often, the patient gains several pounds in 1 week. BP should be taken on the right arm while the patient is supine and also in the left lateral position. Compare BP readings to determine increasing trends.

A funduscopic inspection of the retina may reveal vascular constriction and narrowing of the small arteries. Auscultate the patient’s lungs bilaterally to assess for pulmonary edema. Assess the deep tendon reflexes and assign a rating from 1 to 4; with PIH, reflexes are brisker than normal. Check for clonus bilaterally by dorsiflexing the foot briskly and checking if the foot comes back and “taps” your hand. Count the beats of clonus present; presence of clonus is indicative of central nervous system (CNS) involvement. Perform a sterile vaginal examination to determine if the patient is in labor or to determine the “ripeness” of her cervix for labor. Also note if the amniotic sac is intact or ruptured and if there is any bloody “show,” which signals the onset of labor. If the amniotic sac is ruptured, note the color, amount, and presence of odor of the fluid. Assess the uterus for the presence of contractions, noting the frequency, duration, and intensity. Place the patient on the fetal monitor immediately to determine the status of the fetus. Provide ongoing assessments of the baseline fetal heart rate and of the presence or absence of variability, accelerations, and decelerations in the heart rate. Often, a nonstress test (NST) is done on admission to assess the fetus’ well-being.

Remember that the patient’s condition can deteriorate rapidly. Vigilantly monitor for signs and symptoms of progressive disease and impending eclampsia and HELLP. Assess the blood pressure, pulse, respirations, and urine output hourly. Check deep tendon reflexes and for clonus hourly or as ordered. Report upward trends. Be alert for such signs and symptoms of impending eclampsia as accelerating hypertension, headache, epigastric pain, nausea, visual disturbances, and altered sensorium, and also increased bleeding tendencies.

Many women expect pregnancy to be a happy and normal process; the hospitalization is unexpected. Assess the patient’s ability to cope with the disorder and her social supports. In addition to concern about the pregnancy, she may have other children that need care while she is hospitalized. Assess the resources of the patient and significant others to manage job, childcare, financial, and social responsibilities.

Nursing care plan primary nursing diagnosis: Altered tissue perfusion (cardiopulmonary, cerebral, peripheral, renal) related to arterial vasospasm and obstruction to flow.

Nursing care plan intervention and treatment plan
Often, preeclampsia occurs before the fetus is term. The goals of treatment are to prevent seizures, intracranial hemorrhage, and serious organ damage in the mother and to deliver a healthy term infant. The only cure for preeclampsia is delivery of the infant; however, if the infant is preterm, care is balanced between preventing maternal complications and allowing the fetus more time in utero. If the symptoms in preeclampsia are mild, often the patient is treated at home on bedrest, with careful instructions and education on the danger signs and frequent prenatal visits to monitor progression of the disorder. Antihypertensives are usually not prescribed for mild preeclamptics; no differences in gestational age or birthweight have been noted, and growth-restricted infants were twice as frequent in mothers who took labetalol than those treated with bedrest/hospitalization alone. Mild preeclampsia is really a misnomer, because it can become severe very rapidly. Frequent tests of fetal well-being are done throughout the pregnancy, including an NST and biophysical profile, to detect the effects of preeclampsia on the fetus.

If symptoms of preeclampsia worsen, hospitalization is mandatory. Maintain the patient on complete bedrest. If the urine output is below 30 mL/hr, suspect renal failure and notify the physician. Readings of 2 to 4 protein in the urine and urine-specific gravities of greater than 1.040 are associated with proteinuria and oliguria. Hemodynamic monitoring with a central venous pressure catheter or a pulmonary artery catheter may be initiated to regulate fluid balance. Magnesium sulfate is given via intravenous (IV) infusion to prevent seizures. Serum magnesium levels are done to determine if the level has reached the therapeutic level; serum levels also alert the caregiver of a move toward toxicity. If the magnesium sulfate infusion does not prevent seizure, the physician may order phenobarbital or benzodiazepines. Using either low doses of aspirin or dietary calcium supplementation is being explored as means to prevent preeclampsia.

If the patient is alert and is not nauseated, a high-protein, moderate-sodium diet is appropriate. Low-salt diets are not indicated. Glucocorticoids may be given to the mother intramuscularly at least 48 hours before delivery to assist in maturing fetal lungs to decrease the severity of respiratory difficulties in the preterm neonate. A cesarean section is indicated if the fetus is showing signs of distress or if preeclampsia is severe and the patient is not responding to aggressive treatment. All efforts are made to stabilize the patient’s condition before surgery.

Maintain the patient on bedrest in the left lateral position as much as possible. This position assists with venous return and organ perfusion. Maintain a quiet, dim environment for rest, close to the nurse’s station. Eliminate extraneous noises, lights, visitors, and interruptions that might precipitate a seizure. Plan assessments and care to ensure optimal rest. Pad the side rails, and keep the bed in the low position with the call light in reach at all times. To be prepared for emergencies, keep a “toxemia kit,” which includes an artificial airway, calcium gluconate (antidote for magnesium sulfate), syringes, alcohol pads, and other medications, at the bedside. If the patient is receiving magnesium sulfate, monitor for signs of magnesium toxicity: hyporeflexia, decreased respirations, and oliguria. Expect the patient receiving magnesium sulfate to be lethargic.

If the patient is in labor, closely monitor fetal heart rate patterns and contractions. If the fetal heart rate shows signs of stress, turn the patient to her left side, increase the rate of the IV fluids, administer a humidified oxygen per mask at 10 L/min, and notify the physician. Because abruptio placentae is a potential complication of preeclampsia, be alert for any of the following signs of placental detachment: profuse vaginal bleeding, increased abdominal pain, and a rigid abdomen. The fetus also shows signs of distress (late decelerations, bradycardia).

Provide emotional support to the patient and family. The onset and severity of preeclampsia, along with its potential outcomes for the infant, are worrisome. If delivery of a preterm infant is imminent, educate the family on the environment and care given in the neonatal intensive care unit (NICU). Tour the NICU with the father, and explain what can be expected after the birth. This preparation helps alleviate some of the new parents’ fears after the delivery.

After delivery, complications of preeclampsia can still manifest over the next 48 hours. Continue ongoing monitoring; be alert for seizures and indications that the patient is going into
HELLP syndrome.

Nursing care plan discharge and home health care guidelines
If the patient is discharged undelivered, emphasize that follow-up appointments are important for timely diagnosis of progressive preeclampsia. Educate the patient on the importance of the left lateral position for bedrest. Tell the patient to notify the physician immediately for any of the following symptoms: headache; visual disturbance; right upper quadrant pain; change in level of consciousness or “feeling funny”; decreased urine output; increase in edema, especially facial; or any decrease in fetal movement. Tell the patient to weigh herself daily and notify the physician of a sudden weight gain. Be sure the patient understands the seriousness of the disorder and the potential complications to her and her infant. If the patient is discharged delivered, she needs to receive similar teaching because preeclampsia does not resolve immediately after delivery.

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