Preeclampsia Care Plan

Care Plan NANDA #1: Risk for imbalanced fluid volume r/t fluid shift from intravascular to extravascular space secondary to vasospasm. Goal: Pt will have at least 30 mL/hr urinary output during my shift. Interventions Encourage mother to lie in left lateral recumbent position Assess blood pressure every 1-4 hrs as necessary Monitor urine for volume and proteinuria Assess DTR and clonus Assess for edema Rationales Left lateral recumbent position decreases pressure on vena cava and aorta, thereby increasing venous return, circulatory volume, and placental and renal perfusion. This leads to improved renal blood flow, which promotes diuresis and lowers blood pressure. Frequent monitoring will assess for progression of preeclampsia and allow for early intervention to ensure maternal and fetal health and well-being. Monitoring provides information to assess renal perfusion. Proteinuria is the last cardinal sign of preeclampsia to appear. Urinary output decreases when there is a reduction of GFR. Hyperreflexia may occur as preeclampsia worsens. Assessing DTR provides information about CNS status and is also used to assess for magnesium sulfate toxicity. The presence of clonus indicates a more pronounced hyperreflexia and is indicative of CNS irritability. Edema develops as fluid shifts from the intravascular to extravascular spaces. Edema is assessed either by weight gain or monitoring for pitting edema. NANDA #2: Risk for injury to the fetus r/t uteroplacental insufficiency secondary to vasospasm. Goal: The fetus will have an adequate supply of oxygen and nutrients AEB absence of signs of nonreassuring fetal status and fetal diagnostic test results within normal limits during my shift. Interventions Rationales Instruct pt to count fetal movements three times a day for 20-30 mins Encourage patient to rest in the left lateral recumbent position Assist with serial US Perform NST as ordered Describe for the woman the purposes of a BPP Fetal activity provides reassurance of fetal well-being. Decrease in fetal movement or cessation of movement may indicate fetal compromise. Lying in left lateral recumbent position decreases pressure on vena cava, which increases venous return, circulatory volume, and placental and renal perfusion. Blood flow to the fetus is increased, thereby reducing the risk of fetal hypoxia and malnutrition. Maternal vasospasm and hypovolemia result from preeclampsia, which may lead to IUGR and oligohydramnios. US provides assessment of fetal growth and fluid levels. NST is performed to assess FHR in response to fetal movement. Accelerations of fetal heart rate with fetal movement may indicate the fetus has adequate oxygenation and intact CNS. BPP is an assessment tool used to evaluate fetal well-being. Providing explanation on the diagnostic test helps relieve anxiety and ensures the woman understands what the test evaluates and what the results mean. NANDA #3: Ineffective health maintenance r/t deficient knowledge about new diagnosis AEB development of preventable complications. Goal: Pt will demonstrate understanding of diagnosis AEB verbalizing the condition and treatment regimen during my shift. Interventions Assess mother and the family’s understanding of preeclampsia and its implications for pregnancy Provide information about the disease process, impact on maternal well-being, risks of progression, implications for the fetus, and Rationales Assessment provides information about the woman’s cognitive level and her understanding of her diagnosis. Behavior changes occur when teaching strategies are appropriate for the woman and family’s cognitive level. Basic understanding of the condition and its implications is necessary for the mother to understand the treatment plan. A mother who dangers of eclampsia Emphasize the importance of self-monitoring for signs that her condition is worsening and the importance of regular prenatal care for the purpose of maternal and fetal surveillance shows signs of early preeclampsia often feels well and may have difficulty accepting the need to rest. The mother should be able to identify signs of disease progression, including evidence of increasing edema, decreased urine output, signs of cerebral disturbance, epigastric or RUQ pain, N/V, and increased irritability. (Ackley et al., 2020; Davidson et al., 2020)