NURSING CARE PLAN

Preeclampsia Nursing Diagnosis

Fetus: D.S 34y/o female Primigravida at 32 weeks of gestation At her prenatal visit: she has a BP of 140/90 Has 2+ ankle edema Labs: AST >70 Proteinuria: 0.9g She states she has gained weight-about 2 pounds per week, feels fatigued during the day and has. She also states she easily gets nauseated. Fetus: FHR: Baseline is 135 with moderate variability. No late or prolonged decelerations Accelerations: 15x15. Ineffective tissue perfusion :fetal: related poor maternal oxygenation secondary to preeclampsia as evidenced by abnormal FHR patterns, delayed growth and development of the fetus (low weight), decreased fetal movements, and decreased amniotic fluid

Date: 4/4/12

Assessment

Goal
Fetus will not have any preeclampsia related complications.

Objectives/Outcome Criteria
1 Fetus will have more than four daily counts of movements, have normal FHR: no late or prolonged decelerations, show signs of normal growth and development throughout the prenatal testing

Nursing Intervention
1 Monitor daily fetal movement counts and nonstress testing should be done. 2. Perform an Ultrasound evaluation of amniotic fluid volume and determine the estimated fetal weight.

Rationale
1 Monitoring fetal heart rate and movements allows the nurse to evaluate how the fetus is doing. 2. Preeclampsia can cause a decrease in the amniotic fluid, so the levels should be measured to make sure that the fetus has the needed protection. 3. To assess for evidence of adequate uteroplacental oxygenation (Lowdermilk, et. al, pg. 664).

Evaluation of Outcome Criteria

The fetal heart rate is within the normal limits and has more than four movements per day. Fetus is also showing normal growth and development seen as observed via the ultrasound. Goal is met. Continue monitoring the fetus and the mother till delivery.

3. Monitor the fetal heart for rate, baseline variability, and absence of late decelerations.

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2. During delivery, the mother will not show signs and symptoms of preeclampsia related complications that can affect her and the fetus such as impaired gas exchange, decreased blood flow to the fetus, dyspnea etc.

1 Monitor the woman for signs of impaired gas exchange (increased respirations, dyspnea, altered blood gases, hypoxemia) 2. Monitor the fetus for abnormal

1 To detect fpotential complications (Lowdermilk, et. al., pg. 664).

2. To prevent complications (Lowdermilk, et.

During the delivery, the mother did have a slight increase in her blood pressure (136/98) from her usual but had no other symptoms and was able to breathe without any symptoms of dyspnea. The fetus showed good variability on the strip and

(nonassuring) signs (decreased fetal activity, decreased fetal heart rate) 3. Record findings and report signs of increasing problems to the physician Risk for excess fluid volume related to preeclampsia as evidenced by increased b/p, weight gain, +1 edema, >50mL of urine output and fatigue

al., pg. 664).

3. To enable timely interventions (Lowdermilk, et. al., pg. 664).

was born without much difficulty. Had apgar scores of 8 and 9 (accrocyanosis on the first scoring). Perform maternal and fetal assessments during the postpartum period.

Patient will remain free of symptoms of excess fluid volume

Patient will remain free of edema, dyspnea while maintaining clear lung sounds and appropriate weight gain throughout pregnancy.

1 Monitor intake and output; note trends reflecting decreasing urine output in relation to fluid intake. 2. Provide a restricted-sodium diet as appropriate if ordered.

1 Accurately measuring intake and output is vital for the client with fluid volume overload (Ackley and Ladwig, 2008, pg. 377). 2. Restricting the sodium in the diet will favor the renal excretion of excess fluid. Take care to avoid hyponatremia. Decreasing sodium can be just as important as restricting fluid intake with fluid (Ackley and Ladwig, pg. 377). 3. Diuretics help with excretion of excess fluid (Kaur).

Patient has O2 saturations of above 95% showing adequate tissue perfusion, her lung sounds were clear and had appropriate weight gain. Goal met thus far, continue monitoring patient for signs and symptoms of excess fluid volume.

Intrapersonal: preeclampsia, pain, changes in lab values (Hgb, hct, platelet count)

Interpersonal:

3. Administer prescribed diuretics as appropriate; check blood pressure before administration to ensure it is adequate.

Separation from family members if hospitalized due to condition, disturbed care for other children.

Extrapersonal: Activity restriction, multiple hospital visits and stays, financial concerns, management of the household and worries about other children (if any), work.

Patient will verbalize education on signs and symptoms of excess fluid volume and measures that they can take to treat and prevent the excess in fluid volume during discharge from a prenatal visit after being assessed for the risk of fluid volume excess.

1 Teach about signs and symptoms of both excess and deficient fluid volume and when to call the physician. 2. Teach and reinforce knowledge of medications. Instruct the client not to use overthe-counter medications (e.g., diet medications) without first consulting the physician. 3. Assess client and family knowledge and compliance with medical regimen, including medications, diet, rest, and exercise. Assist family with intergrating restrictions into daily living.

1 Fluid volume balance can change rapidly with aggressive treatment (Ackley and Ladwig, pg. 378). 2. Instructing the clients on not taking over the counter medications without consulting the physician to prevent overdosing.

3. Assistance with intergration of cultural values, especially those related to foods, with medical regimen promotes compliance and decreased risk for complications (Ackley and Ladwig, pg. 378).

References: Ackely, B.J, & Ladwig, G.B. (2008). Nursing diagnosis handbook. St. Louis: Mosby Elsevier. Lowdermilk, D.L, & Perry, S.E. (2012). Maternity nursing. St. Louis: Elsevier Mosby.