Preeclampsia is new high blood pressure after 20 weeks of pregnancy with signs of organ stress, like protein in the urine. Care protects both the mother and the baby and prevents seizures.
A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation
Each care plan below follows the nursing process (ADPIE).
CARE PLAN 1 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Risk for Injury (Maternal Seizure)
Related to
- Severe hypertension and cerebral irritability
As evidenced by
- (Risk diagnosis)
Short-term goals
- Client remains free of seizures
Long-term goals
- Mother and baby deliver safely
- BP, headache, vision changes, and right upper quadrant pain
- Deep tendon reflexes
- Fetal heart rate
| INTERVENTION | RATIONALE |
|---|---|
| Give magnesium sulfate as ordered | Prevents eclamptic seizures. |
| Check reflexes, respiratory rate, and urine output hourly while on magnesium | Loss of reflexes, a respiratory rate under 12, or low urine output signals toxicity. |
| Keep calcium gluconate at the bedside | It is the antidote for magnesium toxicity. |
| Seizure precautions in a quiet, dim room | Less stimulation lowers seizure risk. |
EVALUATION
- No seizures
- Reflexes present and breathing normal
CARE PLAN 2 · NURSING DIAGNOSIS
PLANNING · EXPECTED OUTCOMES
ASSESSMENT
Risk for Decreased Cardiac Tissue Perfusion (Placental)
Related to
- Vasospasm reduces blood flow to the placenta
As evidenced by
- (Risk diagnosis)
Short-term goals
- Fetal heart rate stays reassuring
Long-term goals
- Healthy delivery
- Continuous fetal monitoring
- Maternal BP
| INTERVENTION | RATIONALE |
|---|---|
| Position on the left side | Improves blood flow to the placenta. |
| Give antihypertensives as ordered | Lowers dangerous blood pressure. |
EVALUATION
- Fetal heart rate is reassuring
Practice this in SBAR Shift Master
Take report on a client with severe preeclampsia.
Play SBAR Shift MasterQuick answers
What is the antidote for magnesium sulfate?
Calcium gluconate.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.