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Management of Care Assignment Form
Clinical Condition or Medical Diagnosis; Severe Preeclampsia
Submitted by; Marietta Altenor and Jaimy Phelps
Definition and description of the clinical condition or medical diagnosis:
Preeclampsia is a pregnancy induced condition in which hypertension and proteinuria develop after 20 weeks of
gestation in women with or without a previous history of hypertension and lasting at least 4-6 weeks
postpartum. Although the pathophysiology of severe preeclampsia is unknown, the criteria remain the same. It
is defined by having a new onset of proteinuria >0.3g in a 24 hour sample with or without edema ,and a
diastolic blood pressure of at least 110mmHg and/ or a systolic blood pressure of 160 mmHg. A systolic
increase of 30 mmHg or a diastolic increase of 15 mmHg from the baseline can also be a sign of severe
preeclampsia. Severe preeclampsia is a vasospastic, systemic disorder that can lead to eclampsia, along with
other conditions, if left untreated. Since severe preeclampsia is a significant contributor to maternal and
perinatal morbidity and mortality, it is vital for women to be hospitalized immediately so that fetal monitoring
can be initiated. By 34 weeks gestation, the risks of continuing pregnancy are considered greater than the risks
of pre term birth so the baby is delivered either by cesarean or after labor induction. If the woman is less than
34 weeks gestation then pharmacological therapy, such as magnesium sulfate, can be used to prevent seizures
and control blood pressure. Monitoring for worsened conditions will continue. If the woman is less than 34
weeks gestation, blood pressure is controlled, and fetal testing is normal, the woman may continue pregnancy.
Immediate birth is indicated, regardless of gestation age, if signs of fetal stress, placental abruption, HELLP
syndrome, oliguria, pulmonary edema, eclampsia, or uncontrolled high blood pressure develop.
Risk Factors:
First pregnancy or first pregnancy with new partner
Extremities in maternal age below 19 or above 40
BMI of 35 or more (obesity)
Family history of preeclampsia
Ten years from last child
Pre existing hypertension, renal disease, or diabetes, collagen disease
Periodontal disease
Nursing Diagnosis #1: Risk for injury (maternal) Risk factors: CNS irritability (seizures)
Goals or Expected Outcomes:
Patient will show diminished signs of seizures
Deep tendon reflexes will be less than 2+
Patient shows absence of clonus
Focused Nursing Assessment:
OBJECTIVE DATA
1. Patients urine output is decreased with less than
30ml/hour
SUBJECTIVE DATA
1. Patients complains of blurred vision
2. Patient is vomiting frequently
2. Patient complains of persistent headache
3. Patients blood pressure is 140/90 or more, or the
systolic is increased by 30mmHg and/or diastolic
increased by 15mmHg from their baseline
3. Patients states she is experiencing upper abdominal
pain
4. Patients urine shows high levels of protein with a
value >0.3g within a 24 hour period
4. Patient states her feet look extremely swollen
5. Patient shows deep tendon reflexes greater than 2+
when bicep and patellar reflexes were assessed
5. Patients states she feels “like something bad is
going to happen”
6. Assessment for clonus is positive
6.
Interventions (you can include both nursing interventions and medical management, example medications that
you would expect to be administering:
INTERVENTIONS
1.Establish a baseline for blood pressure, clonus, deep
tendon reflexes, fetal heart rate, and level of
consciousness
2. Monitor maternal vital signs every 15 minutes, level
of consciousness, fetal heart rate less than
110beats/min, deep tendon reflexes, urine output less
than 30ml/hr, proteinuria, IV flow rate, serum levels of
magnesium sulfate between 4-7mEq/L
RATIONALE
1. To use as a basis for evaluating effectiveness of
treatment
2. To assess for and prevent magnesium sulfate
toxicity, slurred speech, lethargy, drowsiness, fetal
distress, oliguria, depressed respirations, sudden drop
in blood pressure, decreased kidney function, and
hyperreflexia
3. Administer IV magnesium sulfate per physicians
orders, 4g IV bolus then 2g every hour through IV
infusion pump
3. Administered to decrease hyperreflexia and
minimize risk of seizure activity
4. Have calcium gluconate on the unit
4. To be available if needed as an antidote for
magnesium sulfate toxicity
5. Maintain a quiet, darkened environment
5. To avoid stimuli that may precipitate seizure
activity
6. Place in seizure precautions with raised and padded
side rails
6. To prevent injury during seizure activity
Nursing Diagnosis #2: Risk for injury (fetal) Risk factor: uteroplacental insufficiency
Goals or Expected Outcomes:
Fetus will remain free of injuries
Fetus will maintain normal, baseline heart rate
Fetus will maintain adequate oxygenation
Fetus will show no signs of late decelerations
Focused Nursing Assessment:
OBJECTIVE DATA
1. Fetus displays abnormal heart rate of 110beats/min
or less with continuous EFM
SUBJECTIVE DATA
1. Patient states she feels less fetal movement than the
babies normal trend
2. Non stress test shows insufficient accelerations over
40 minutes leading to a nonreactive result
2. Patient states she feels her belly has not shown
much growth
3. Contraction stress test shows late decelerations
occurring with at least 50% of contractions
3.
4. Ultrasound shows oligohydramnios
4.
5. Doppler blood flow analysis shows absent or
reversed flow during diastole
5.
6. Amniocentesis shows L/S ratio less than 2:1 and a
negative PG
6.
Interventions (you can include both nursing interventions and medical management, example medications that
you would expect to be administering:
INTERVENTIONS
1. Establish baseline data for fetal heart rate with
EFM, should be maintained between 110160beats/min
RATIONALE
1. To assess for signs of fetal distress
2. Perform non stress test to monitor for fetal
reactivity, for reactive NST fetus should show at least
2 movements/accelerations in 20 minutes
2. To determine the well being of the fetus
3. Perform a contraction stress test to assess the fetus’
response to stress, test should be negative showing no
late decelerations with a minimum of 3 contractions
over 10 minutes
3. To determine the presence of late decelerations in a
continued pattern for more than 30 minutes which
increases the risk of the negative effects of fetal
hypoxia, acidosis, and asphyxia
4. Review ultrasound results to determine amniotic
fluid volume, normal AFI is between 10 and 25cms
4. To determine the existence of oliohydramnios, an
AFI of less than 5cms, which would indicate renal
insufficiency in the fetus
5. Review doppler blood flow analysis, blood should
flow freely with no signs of decreased, reversed, or
absent flow during diastole
5. To assess for blood flow through the uterine artery,
severely restricted uterine artery blood flow is
indicated by absent or reversed flow during diastole,
abnormal results indicate uteroplacental insufficiency
6.Review results of amniocentesis, should show an
L/S ratio of 2:l or greater with a positive PG
6. To determine fetal lung maturity
Nursing Diagnosis #3: Excess fluid volume related to high blood pressure and decreased kidney function
Goals or Expected Outcomes:
Extremities and dependent areas free of edema
BUN and creatinine levels are maintained within normal limits
Maintain a safe blood pressure, pulse, and body temperature
Maintain adequate urine output at least 30 mL per hour
Focused Nursing Assessment:
OBJECTIVE DATA
1. Increased generalized edema that takes longer than
30 seconds to disappear
SUBJECTIVE DATA
1. Patient states increased feeling of thirst
2. Decreased urine output less than 30ml/hr
2. Patient complains of cold, moist skin
3. Increased protein in the urine (greater than 0.3g)
and elevated levels of creatinine in the blood (greater
than 1.2mg/dl)
3. Patient states feet look swollen
4. Patient gained more than 4lbs in a week
4. Patient states “I am having difficulty breathing”
5.
5.
6.
6.
Interventions (you can include both nursing interventions and medical management, example medications that
you would expect to be administering:
INTERVENTIONS
1. Monitor patient for increased edema, elevated
serum creatinine, and dyspnea
RATIONALE
1. To detect increased fluid volume due to decreased
kidney function
2. Monitor intake and output, watch for trends
reflecting decreased urine output from foley catheter
in relation to fluid intake
2. To assess for adequate output of at least 30ml/hr
3. Monitor daily weight for increases; use the same
scale and type of clothing and weigh at the same time
each day, preferably in the morning
3. Changes in body weight reflect changes in body
fluid volume
4. Listen to lung sounds for crackles and monitor
respirations for effort
4. To assess for pulmonary edema which results from
excessive shifting of fluid from the vascular space into
the pulmonary interstitial space and alveoli resulting in
dyspnea
5. Implement fluid restriction, as ordered
5. Fluid restriction may decrease intravascular fluid
volume
6. Administer IV magnesium sulfate per physicians
orders, 4g IV bolus then 2g every hour through the IV
infusion pump
6. To relax vasospasms and increase renal perfusion
Nursing Diagnosis #4: Risk for ineffective cerebral tissue perfusion Risk factors: cerebral vasospasms and
cerebral edema
Goals or Expected Outcomes:
State absence of headache
Demonstrate appropriate orientation to person, place, time, and situation
Demonstrate stable vital signs and absence of signs in ICP
Shows diminished signs of seizures
Focused Nursing Assessment:
OBJECTIVE DATA
1. Patient is disoriented to place and time
SUBJECTIVE DATA
1. Patient complains of a headache
2. Patient is grimacing while holding her head
2. Patients complains of pressure in her head
3. Patient speech is slurred
3. Patient complains of blurry vision
4. Patient is restless
4. Patient complains of dizziness
5. Changes in vital signs from baseline, increase in
blood pressure and decrease in heart rate and
respirations
5.
6.
6.
Interventions (you can include both nursing interventions and medical management, example medications that
you would expect to be administering:
INTERVENTIONS
RATIONALE
1. Monitor and record the neurological status every 30
minutes and compare it to the standard or normal state
1. Assesses trends in LOC and potential for increased
intracranial pressure, decreased mental status is
suggestive of decreased cerebral perfusion
2. Assess for changes in vision such as blindness or
visual field disturbances
2. Visual impairments can be indicative of decreased
cerebral perfusion
3. Maintain bed rest by creating a peaceful
environment and limiting activities and visitors
3. To decrease overstimulation which can lead to
increased ICP causing further confusion and possible
seizure activity
4. Monitor vital signs, especially blood pressure, pulse
rate, and respirations, every 30 minutes to determine
deviations from the baseline
4. Fluctuations in pressure may occur because of
cerebral pressure, changes in heart rate, especially
bradycardia can occur because of brain damage,
irregularities in respirations can suggest an increase in
ICP
5. Changes in cognitive function and speech are
indicative of location and degree of cerebral damage
and may indicate ICP
5. Assess higher functions including speech, if patient
is alert
6. Administer magnesium sulfate, 4g IV bolus then 2g
every hour through IV infusion pump
6. To decrease vasospasms and increase renal
perfusion which can lead to a decrease in cerebral
edema
Diagnostic Studies or Lab Results that should be reviewed by the nurse:
1. Platelet count- preeclampsia may lead to an abnormally low number of platelets which can prevent normal
clotting during bleeding
2. Liver enzymes- to determine how well the liver is functioning
3. Serum creatinine- an elevation would indicate a decrease in kidney function
4. BUN- an elevation would indicate a decrease in kidney function
5. Hematocrit- a high level means the body tissues are absorbing more blood plasma and concentrating the
blood
6. Electrolytes- the amounts of electrolytes in the body can change if a decrease in kidney function occurs or if
fluid leaks out of the blood vessels and into the surrounding tissue
7. Magnesium levels- should be monitored closely with the infusion of magnesium sulfate to prevent toxicity
8. Fibrinogen- high levels contribute to the hypercoagulability seen in preeclampsia
9. Prothrombin time- a measure of the time it takes for blood to clot which could be increased with
preeclampsia
10. Uric acid- an increase would indicate a decrease in kidney function
References
Ackley, B. J., &Ladwig, G. B. (2011). Nursing diagnosis handbook. (9 ed., pp. 619-624 397401 521-523). St. Louis: Elsevier Inc.
Ameh, C., Ekechi, C., &Turkr, J. (2012). Monitoring severe pre-eclampsia and eclampsia treatment in resources poor
countries: skilled birth attendant perception of a new treatment and monitoring chart (LIVKAN Chart).
Maternal & Child Health Journal, 16(5), 941-946. doi:10.1007/s10995-011-0832-7
Jakobson,T., Clausen, F., Rode, L., Dziegiel, M.,& Tabor, A. (2013) Identifying mild and severe preeclampsia in
asymptomatic pregnant women by level of cell-free fetal DNA. Transfusion,53(9), 1956-1964.doi:
10.1111/trf.12073
Lowdermilk, D., Perry, S. E., Cashion, K., & Alden, K. R. (2012). Maternity and women's health
care. (10 ed., pp. 656-663). St. Louis: Elsevier Inc.
Shaker, O., & Shehata,H. (2011). Early prediction of preeclampsia in high –risk women.Journal Of
Women’s Health , 20(4), 539-544.doi: 10.1089/jwh.2010.2378