What is the priority nursing intervention for a client with severe preeclampsia?

Preeclampsia and eclampsia are complications of pregnancy. The nurse plays a vital role in helping detect these conditions. Therefore, it’s important to know how to detect this condition in a pregnant patient. In this review you will learn about:

• Preeclampsia vs. Eclampsia
• Risk Factors for Preeclampsia
• Pathophysiology of Preeclampsia
• Signs and Symptoms
• Nursing Care and Treatment

Lecture on Preeclampsia and Eclampsia

Preeclampsia and Eclampsia Nursing Maternity Review

What’s Preeclampsia? It’s a type of hypertensive disorder that occurs during pregnancy. It tends to occur after 20 weeks of gestation, which is the halfway point of a typical 40 week pregnancy. However, it’s important to note that this condition can present during the postpartum period (this is after delivery of the baby).

Preeclampsia, if severe, can turn into a condition called eclampsia (note how similar their names are). Pre means “before” and eclampsia means “a convulsive state”, according to Merriam-Webster’s Dictionary (“Eclampsia Merriam-Webster”, n.d.).

Therefore, eclampsia causes seizure activity, which can lead to coma and death. It is very important every pregnant patient is monitored for preeclampsia so it can be managed, which can help with the prevention of eclampsia in most cases.

How Preeclampsia is Diagnosed?

As the nurse it is important you’re aware of how this condition is diagnosed. This is because you will be responsible for collecting the information that helps diagnose preeclampsia and will report that abnormal information to the physician, who will make the diagnosis.

So, what are the criteria for the patient to be diagnosed with this condition? The American College of Obstetricians and Gynecologists (ACOG) sets the guidelines for preeclampsia.  The criteria are based on three things:

• Blood pressure measurement
• Results of urine sample (proteinuria)
• Signs and symptoms of organ injury

Blood Pressure Measurement:

What is considered an elevated blood pressure for preeclampsia?

At every prenatal visit a woman will have her blood pressure measured. With preeclampsia, the blood pressure is usually normal at the beginning of the pregnancy, but around 20 weeks gestation it starts to elevate. As the nurse, you want to watch out for the following measurements:

• >140/90 (>140 mmHg systolic & >90 mmHg diastolic)
  • Is one reading sufficient? No, there must be TWO separate readings that are at least 4 or 6 hours apart.

How is preeclampsia different than gestational hypertension? They’re both considered hypertensive disorders BUT gestational hypertension doesn’t cause injury to organs in the body or proteinuria, and this leads us to the next criteria.

Results of Urine Sample

At every prenatal visit a woman will have her urine assessed for protein and glucose (glucose measurement is important for detecting gestational diabetes).

What is considered proteinuria for preeclampsia?

• > +1 with a dipstick test
• > 300 mg with a 24-hour urine
• > 0.3 mg/dL creatinine/protein ratio

Guideline Source: “New Guidelines in Preeclampsia Diagnosis and Care Include Revised Definition of Preeclampsia”, 2013)

Signs and Symptoms of Organ Injury

The liver, brain, and kidneys tend to be affected the most with preeclampsia. We will discuss more about this in the pathophysiology section, which will correlate with the signs and symptoms you will see in the patient.

RECAP: You’re assessing for new onset of hypertension (>140/90…most likely to start occurring at 20 weeks and onward), protein in the urine “proteinuria”, signs and symptoms of organ injury.

Risk Factors for Preeclampsia

• History of preeclampsia in previous pregnancy or family history
• First pregnancy (primigravida)
• Significant health history prior to pregnancy: Diabetes, lupus, high blood pressure, kidney disease
• Obese (BMI >30)
• Having more than one baby (twin, triplets etc.)
• Age (young <18 or advanced >35)

Pathophysiology of Preeclampsia

To help us understand the signs and symptoms of preeclampsia, we are going to mesh the pathophysiology with the signs and symptoms. Because if you can understand what is going on in mom’s body, the signs and symptoms make so much sense and you don’t have to memorize them.

Key Players of Preeclampsia:

• Spiral arteries of the uterus
• Placenta
• Mom’s body, specifically her endothelial cells

The spiral arteries of the uterus play an important role in providing blood flow to the growing placenta and baby. Normally during pregnancy, the spiral arteries within the uterus widen in diameter to help increase blood flow to the placenta, which is very vital as the pregnancy progresses and baby requires more nutrients and oxygen.

This widening of the spiral arteries is thought to be influenced by how well the trophoblast burrowed into the uterus during early pregnancy. If the trophoblast failed to do this properly, the spiral arteries stay narrow and fail to widen as the pregnancy progresses, which will cause an ischemic placenta (the placenta is deprived of oxygen-rich blood flow it needs to flourish and grow).

The oxygen deprived placenta does not like this and becomes stressed out so it releases substances into mom’s circulation in hopes of increasing blood flow to it. However, these substances are very toxic to mom’s endothelial cells.

What are endothelial cells, where do they live, and what do they do? These cells can be found lining the inside of blood vessels throughout the body and organs.

Two functions they perform: Give tone to the vessels (contraction and dilation of the vessel) and have a role with vessel permeability

When endothelial cells are exposed to the toxic substances by the placenta they become damaged and do not work properly. This is where we start to see the signs and symptoms of preeclampsia (they really stem from the damaged endothelial cells). The damaged endothelial cells fail to function properly and cause:

• vasospasm (lose their tone so they cause vessel contraction)
• increase in permeability (in other words they cause vessels to leak)

Signs and Symptoms of Preeclampsia

Hypertension: damaged endothelial cells lose their tone, therefore, vasospasm (contraction of the vessel) starts to occur and this leads to increase pressure within the vessel…hence causes hypertension

Proteinuria: this is due to kidney injury…the kidneys are being deprived of proper blood flow and endothelial cells that line the glomerulus (this structure filters the blood and it normally does NOT filter large molecules like protein) are damaged. The damaged cells of the glomerulus start to leak protein from the blood into the urine causing proteinuria. Note: this also drops protein levels in the blood (why the woman needs a protein-rich diet)

• Also due to kidney compromise: uric acid and creatinine levels INCREASE and urinary output will DECREASE

Edema (eyes, face, extremities, pulmonary edema, increase weight gain, cerebral edema): the increase in permeability of the endothelial cells causes protein to escape the vessel. Remember protein helps regulate oncotic pressure…so where protein goes, so does water. Therefore, water will leave the intravascular area and shift to the interstitial tissue and cause swelling. This further complicates things because it decreases blood volume. So, there is less blood volume being used to perfusion the organs and this cause further organ injury.

• Lungs: fluid can start to accumulate in the lungs leading to difficulty breathing
• Brain: due to brain swelling and decreased perfusion the woman may experience headache, vision changes, hyperreflexia, clonus (if this is present there is a HIGH risk for seizures due to central nervous system irritability)

Upper abdominal pain and increase in liver enzymes (AST and ALT): the liver is affected due to decrease perfusion and swelling

Decreased platelets (leading the DIC), hemolysis (rupture of red blood cells)…leading to HELLP Syndrome: the damaged endothelial cells cause red blood cells to rupture and it causes the body to want to repair the cells…so platelets start to congregate at these cells (note in severe cases there are many damaged endothelial cells in the body so that requires a lot of platelets)…this depletes the platelet stores and cause micro-clot development with the vessels, which decreases perfusion even more.

NOTE: Preeclampsia varies in how severe it gets…some women have mild cases while others have severe cases that progress to seizures and/or coma and the complications below.

Severe preeclampsia condition can lead to:

• HELLP Syndrome: hemolysis (rupture of RBCs), elevated liver enzymes, low platelets
• Eclampsia: seizures
• Placental Abruption
• Restrict fetal growth or death
• Important to note that preeclampsia can occur in some women after birth….educate to watch for vision changes, headaches, swelling, shortness of breath etc. and to report to OB.

Nursing Interventions for Preeclampsia & Treatment

To help us take everything we learned about the patho and signs and symptoms and incorporate it with the nursing interventions and treatment, let’s remember the word:

“PREECLAMPSIA”

Proteinuria monitoring: check urine for protein at every prenatal visit (some women may be taught to do this at home with a dipstick test):

• Labs to remember:
  • >1+ dipstick test (if hypertension is present along with protein in the urine the physician may order the woman to complete a 24-hour urine)
  • 24-hour urine: >300 mg
  • >0.3 mg/dL creatinine to protein ratio
    • Other prenatal labs that may be ordered: CBC (platelets <100,000, red blood cells or peripheral smear to check for hemolysis, creatinine, BUN), liver enzymes (AST or ALT)…if preeclampsia suspected

Reflexes hyperactive (deep tendon reflexes…patellar and bicep)

• Watch for exaggerated reflexes called “hyperreflexia” like 4+
  • Indicates the CNS is stressed out and at risk for a seizures:
    • assess neuro status, vision changes, headaches, ankle clonus (check out the lecture to see how to check for this)
    • Magnesium Sulfate may be ordered to decrease the risk of seizure activity: Watch for decreased or absent reflexes because this could indicate Magnesium Sulfate Toxicity

Evaluate blood pressure for hypertension: monitored at every prenatal visit and educate mother to monitor at home

• Remember hypertension criteria: >140/90 two separate times at least 4 or 6 hours apart

Edema monitoring (watch for and educate mother about this):

• weight gain of 2 lbs or more in a week and weigh self daily
• Edema can be in the face, eyes, and extremity swelling
• Monitor urinary output
• Lung sounds (pulmonary edema…short of breath)

Calcium gluconate: antidote for magnesium sulfate toxicity…be sure to have it handy

Left side-lying position (helps prevent placenta ischemia and increases blood flow to baby), bed rest/limit stimulation, fetal heart rate monitoring (report decrease in fetal activity)

Assess for seizure activity “eclampsia”: there is a risk during and after labor (up to 48 hours)

• Follow hospital’s protocol: have seizures precautions in place beforehand if there is a risk (suction, airway management supplies, padded side rails etc.)
  • checks reflexes and clonus per protocol:
    • To check for ankle clonus: quickly dorsiflex the patient’s foot (point toes upward) and see response…if positive (clonus) foot will start to bounce back and forth (it attempts to plantarflex) >3 bounces or more is positive
    • Seizure interventions:
      • eclampsia…early may see facial twitching, changes in neuro status, followed by full body tonic-clonic seizure (contraction and stiffening of body followed by jerking of muscles)
      • Stay with patient and get help, don’t restrain patient, get on left side (helps prevent aspiration, opens airway, and helps with blood flow to placenta), oxygen 8 to 10 L, monitor baby, timing and characteristics of seizure, may need medication and delivery of baby…delivery of baby tends to be the treatment to help but can have seizures after delivery)

Magnesium sulfate administered to prevent seizures during and after labor (risk for seizures up to 48 hours after delivery)

• Monitor for toxicity: Early pt may report feeling warm or note flushing, RR: <12, DTRs: decreased/absent, UOP: <30 cc/hr, EKG changes etc.

Protein-rich diet (remember there may be low protein in blood due to proteinuria…protein leaks into the urine and leaves blood)

• watch salt intake (sodium levels can increase due to renal dysfunction and start to keep sodium in the blood)

Severe complications to watch for:

• HELLP Syndrome: hemolysis (rupture of RBCs), elevated liver enzymes, low platelets,
• DIC
• Placental abruption
• Stroke
• Fetal distress or restriction of growth

I & Os: strict monitoring (may need Foley catheter), abnormal sign: low urinary output less than 30 cc/hr (kidneys aren’t being perfused very well)

Antihypertensives (labetalol, hydralazine)

• There is a fine line that has to be followed when using blood pressure medication on a pregnant woman because blood flow must be maintained to the placenta and baby. They are used with caution.

Test your knowledge: Preeclampsia NCLEX Questions

References:

Gestational Hypertension and Preeclampsia. Retrieved 19 March 2020, from https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/01/gestational-hypertension-and-preeclampsia

Merriam-Webster. (n.d.). Eclampsia. In Merriam-Webster.com dictionary. Retrieved April 2, 2020, from https://www.merriam-webster.com/dictionary/eclampsia

New Guidelines in Preeclampsia Diagnosis and Care Include Revised Definition of Preeclampsia. (2013). Retrieved 19 March 2020, from https://www.preeclampsia.org/the-news/1-latest-news/299-new-guidelines-in-preeclampsia-diagnosis-and-care-include-revised-definition-of-preeclampsia

Phipps, E., Prasanna, D., Brima, W., & Jim, B. (2016). Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines. Clinical journal of the American Society of Nephrology : CJASN, 11(6), 1102–1113. https://doi.org/10.2215/CJN.12081115

What are nursing interventions for severe preeclampsia?

What are interventions for preeclampsia?

Which nursing intervention is most effective in preventing a seizure in a client with severe preeclampsia?

What nursing assessments should be made for the woman with preeclampsia?