eclampsia nursing care plan

Hypertensive disorders of pregnancy are a leading cause of morbidity, mortality, hospitalization, and resource utilization for both mothers and their neonates globally. It accounts for approximately 14% of all maternal deaths worldwide. In 2013, the American Congress of Obstetricians and Gynecologists guidelines on hypertensive disorders complicating pregnancy generally classified into four categories: gestational hypertension, pre-eclampsia/eclampsia, chronic hypertension, and chronic hypertension complicated with pre-eclampsia/eclampsia.

Eclampsia is a known complication of pre-eclampsia during pregnancy and is associated with morbidity and mortality of both the mother and fetus if not properly diagnosed. Eclampsia is defined today as the new onset of generalized tonic-clonic seizures in a woman with pre-eclampsia. Eclamptic seizures can occur antepartum, 20 weeks after gestation, intrapartum, and postpartum (Magley & Hinson, 2021).

In the United States, African-American women have a higher incidence of pre-eclampsia with a 3-fold higher rate of maternal mortality compared to their white counterparts. Additionally, risk factors for pre-eclampsia include increasing maternal age above 40, a prior history of pre-eclampsia, multifetal gestation, obesity, chronic hypertension, pregestational diabetes, renal disease, etc (Magley & Hinson, 2021).

Eclampsia

Eclampsia is a disease process primarily related to the diagnosis of pre-eclampsia and can occur antepartum, during delivery, and up to 6 weeks postpartum. The pathogenesis of pre-eclampsia is linked to abnormal placentation there is an inadequate invasion of cytotrophoblasts which causes poor dilatation of the spiral arteries, reducing the blood supply to the placenta. Abnormal blood supply leads to increased uterine arterial resistance and vasoconstriction, leading to placental ischemia and oxidative stress. Oxidative stress negatively affects maternal endothelial function, and endothelial disruption occurs not only at the uterus but also at the cerebral endothelium causing neurological disorders such as eclampsia.

Hypertensive disorders of pregnancy are often diagnosed at routine prenatal care visits, therefore, the nurse should be meticulous in assessing the client especially because most women present as asymptomatic at the time. Prenatal care affords the opportunity of prevention, early diagnosis, management, and treatment of hypertensive disorders, with the hope of avoiding the progression of the disease process to eclampsia. Adherence to the therapeutic regimen and nursing care plans is associated with reduced maternal morbidity and mortality, which is the highest goal of every healthcare professional.

Nursing care planning for clients with eclampsia begins during the assessment of the nurse and progresses towards the identification of possible nursing diagnoses that will help structure the care plan and the nursing management of the disease as a whole. The following are nursing diagnoses associated with the management of pre-eclampsia/eclampsia.

  • Decreased Cardiac Output
  • Ineffective Tissue Perfusion
  • Risk for Imbalanced Fluid Volume
  • Risk for Injury
  • Deficient Knowledge

Eclampsia  Nursing Care Plan 

Below are sample nursing care plans for the problems identified above.

Decreased Cardiac Output

Cardiac output is determined by stroke volume and heart rate; stroke volume is related to myocardial contractility and to the size of the vascular compartment. In a client with a hypertensive disorder of pregnancy, there is a decrease in the volume of circulating blood due to the shifting of fluid from the intravascular to the interstitial spaces. The decrease in circulating blood volume and an increase in systemic vascular resistance results in a decrease in heart rate and stroke volume. Because both heart rate and stroke volume are components of cardiac output, these mechanisms result in a decrease in the client’s cardiac output.

Nursing Diagnosis

  • Decreased cardiac output

Related Factors

  • Decrease in circulating blood volume and total vascular volume
  • Increased systemic vascular resistance

Evidenced by

  • Tachycardia as the body’s compensatory mechanism
  • Increased blood pressure
  • Diminished peripheral pulses
  • Edema
  • Decreased urine output

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Exhibit stability in the cardiac rate and rhythm
  • Maintain blood pressure within the acceptable level of >140/90 mmHg
  • Participates in interventions to help decrease cardiac load and blood pressure
  • Engages in a lifestyle that prevents the development of eclampsia.

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs, especially blood pressure every hour or as indicated. Use the correct cuff size and accurate technique. Blood pressure and pulse rates are good indicators of cardiac volume and cardiac output. An increase in blood pressure occurs because of the increase in systemic vascular resistance, while the decrease in cardiac output is associated with diminished peripheral pulses. a gradually increasing blood pressure may signal the development of pre-eclampsia.
Assess the client’s peripheral pulses and auscultate for the apical pulse. Decreased cardiac output may manifest as diminished peripheral pulses while the body may compensate for the decrease in circulating blood volume by increasing the heart rate to reach the peripheries.
Assess for the client’s mean arterial pressure (MAP). Mean arterial pressure is an isolated biomarker to predict the development of pre-eclampsia at 11-13 weeks gestation as recommended by the National Institute for Health and Care Excellence (NICE) guidelines (Tan et al., 2018). MAP is the average arterial pressure throughout one cardiac cycle and is influenced by cardiac output. Clients with early-onset pre-eclampsia have been found to have a higher MAP at 20 weeks of gestation (Mayrink et al., 2019).
Auscultate for breath sounds. The presence of crackles or wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure. the shift of fluid from the intravascular to interstitial spaces may overwhelm other essential organs.
Monitor the client’s urine output as indicated. Oliguria may develop in pre-eclamptic clients because of vasoconstriction and the body’s compensatory mechanism to decreased cardiac output that allows for retention of water and sodium (Anthony & Schoemann, 2013).
Assess the client for signs of impending premature delivery. Assess for uterine contractions. The occurrence of eclampsia may warrant the immediate delivery of the fetus. The fetal blood supply can be cut off if delivery is not performed immediately. Be certain to monitor the client’s uterine contractions because if labor begins during the postictal stage, the client would be unable to report the sensation of contractions (Pillitteri & Silbert-Flagg, 2018).
Note dependent and generalized edema. Edema may indicate heart or kidney failure or vascular impairment. This may occur due to the fluid shift from the intravascular to the interstitial spaces.
Independent
Assist the client in planning for her activity and rest schedule. Including the client in the planning may improve her adherence to the regimen. alternate periods of activity and rest reduce physical stress and tension that may affect the blood pressure and the course of hypertension.
Instruct the client to elevate the lower extremities when lying or sitting. Elevating the lower extremities decreases venous stasis and promotes effective circulation of the blood volume throughout the body.
Provide calm, restful surroundings and minimize environmental activity and noise. Removing harmful environmental stimuli from the client’s surroundings reduces sympathetic stimulation and promotes relaxation. Advise limitation of the number of visitors or length of visitation to allow for peaceful rest periods.
Educate the client about proper BP monitoring at home. For the outpatient client, educate them and significant others on how to accurately monitor their blood pressure at home. Monitoring should be done two to four times per day in the same arm and at the same position. Advise them to keep a record of their blood pressure readings to show to their healthcare provider to determine the development of the disease process and institute interventions as needed.
Provide comfort measures and instruct in relaxation techniques as appropriate. A back or neck massage or elevation of the head decreases discomfort and may reduce sympathetic stimulation. Relaxation techniques also reduce stressful stimuli and produce a calming effect, therefore reducing the client’s blood pressure.
Monitor the client’s response to the medications administered for control of BP. Response to drug therapy may vary for every client. Because of potential side effects and drug interactions, it is important to use the smallest number and lowest dosage of medications as possible.
Dependent/Collaborative
Administer prescribed medications, as indicated (hydralazine, labetalol, methyldopa, nifedipine, etc.). Hydralazine reduces blood pressure by relaxing the smooth muscles, and the vasodilation effect reduces vascular resistance. Beta-blockers such as labetalol and methyldopa are recommended for BP control because they decrease the workload of the heart and promote vasodilation, thereby slowing the heart rate. Calcium channel blockers such as nifedipine affect the blood vessel by dilating them and relaxing the smooth muscle.
Implement dietary restrictions as indicated. Red calories and avoiding refined carbohydrates, sodium, fat, and cholesterol should be included in the client’s dietary regimen as advised by the healthcare provider and a dietitian. Limiting sodium and sodium-rich processed foods can help manage fluid retention and decrease myocardial workload. A diet rich in potassium, calcium, and magnesium may help in decreasing the client’s BP.
Assist in the preparation for an imminent delivery as indicated. The only cure for pre-eclampsia is the delivery of the fetus (Leifer, 2018). The fetus is at risk for death while in the uterus of a pre-eclamptic mother because its oxygen supply can be cut off.

Ineffective Tissue Perfusion

Poor dilatation of the spiral arteries in pre-eclampsia reduces maternal blood flow and nutrition through the placenta and decreases the oxygen available to the fetus. Fetal hypoxia may result in meconium passage into the amniotic fluid or fetal distress. The fetus may also have intrauterine growth restriction, and fetal death sometimes occurs.

Nursing Diagnosis

  • Ineffective Tissue Perfusion

Related Factors

  • Vasoconstriction of the spiral arteries
  • Decreased maternal blood flow to the placenta

Evidenced by

  • Fetal hypoxia
  • Changes in the fetal heart rate (FHR) and activity
  • Intrauterine fetal growth restriction
  • Preterm birth
  • Small for gestational age neonate
  • Decreased urine output
  • Maternal tachycardia
  • Fetal death

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Exhibit normal FHR on contraction stress test and fetal activity
  • Demonstrate normal CNS reactivity on a nonstress test (NST)
  • Deliver full-term with an appropriate for gestational age neonate

Nursing Interventions

Assessment Rationale
Assess the client’s fundal height regularly to evaluate fetal growth. Uteroplacental insufficiency caused by the poor remodeling of the spiral arteries restricts the growth of the fetus. The placenta is the fundamental source of fetal programming in the intrauterine environment and the metabolic effect of reduced uterine perfusion causes the progression towards a more severe form of fetal growth restriction (McClements et al., 2022).
Assess the fetal heart rate (FHR) and fetal activity through cardiotocography (CTG) as indicated. Cardiotocography or continuous fetal monitoring is a method of tracking the FHR along with the occurrence of uterine contractions. It provides real-time information about the neurologic and cardiovascular status of the fetus (Kauffmann, 2021).
Assess the amniotic fluid volume (AFV) as indicated. Assessment of AFV allows the detection of oligohydramnios. AFV can be assessed by amniotic fluid index to prevent adverse perinatal outcomes (Fox et al., 2019).
Assess fetal response to biophysical profile (BPP) or contraction stress test (CST). BPP, which utilizes antenatal CTG alongside ultrasound assessments of fetal movements, breathing, tone, and amniotic fluid volume, is another method of monitoring fetal wellbeing and is recommended in the American guidelines (Fox et al., 2019).
Independent
Position the client on her left side during bed rest. Positioning the client on her left side helps improve blood flow to the placenta and more effectively provides oxygen and nutrients to the fetus.
Assist the client in planning activity restrictions and rest periods. The nurse should help the client understand the importance of reduced activity and frequent rest periods and plan ways to manage them. Activity diverts blood from the placenta, reducing the fetus’ oxygen supply, so the nurse must impress on the client how important rest is to her child’s well-being (Leifer, 2018).
Educate the client about fetal home monitoring and the factors that affect fetal activity. The client should be able to perform an effective maternal assessment at the home of the fetus’ activity or “kick counts” and report a decrease in movements or if none occur during 3 hours. Identifying factors that can affect fetal activity such as cigarette smoking, certain medications, serum blood glucose levels, the sleep-wake cycle of the fetus, and the time of the day would help the client determine the variability of fetal activity.
Educate the client and family members about when to seek immediate medical attention. Signs of abruptio placentae such as vaginal bleeding, uterine tenderness, abdominal pain, and decreased fetal movements need immediate intervention to prevent fetal demise. when the vascular structures that deliver oxygen to the fetus are compromised, they may detach from the placenta and warrant immediate delivery of the fetus.
Dependent/Collaborative
Administer antenatal corticosteroids IM between 26 and 34 weeks of gestation for at least 24-48 hours, as indicated. Antenatal corticosteroids are recommended if the client with pre-eclampsia is suspected to deliver prematurely within the next 7 days. a single course of corticosteroids reduces the risk of perinatal death and neonatal complications including respiratory distress syndrome. Most evidence for the administration of antenatal corticosteroids to minimize fetal and neonatal complications supports its use between 26 and 34 weeks of gestation (Fox et al., 2019).
Administer magnesium sulfate IV within 24 hours as indicated. Magnesium sulfate is given as primary and secondary prophylaxis of seizures in clients with pre-eclampsia regardless of gestation and is also recommended in planned or expected preterm delivery for its neuroprotective effects in the offspring.
Assist in Doppler ultrasonography of the fetal umbilical artery. Doppler ultrasound of the fetal umbilical artery measures the blood flow patterns through the artery as an indicator of placental perfusion. If the umbilical artery flow is absent or reversed during end-diastole, this illustrates abnormally high placental resistance, hence reduced blood flow, and is an indicator or risk of adverse fetal outcome including perinatal mortality (Fox et al., 2019).
Assist in the preparation for delivery of the fetus. the only definitive treatment for pre-eclampsia is delivery. Optimal timing of delivery requires a careful balance of maternal and fetal risks, including the gestation of the fetus. fetal complications such as abnormalities in fetal ultrasound or CTG monitoring may result in the decision for early birth (Fox et al., 2019).

Risk for Imbalanced Fluid Volume

During pregnancy, the fetus metabolizes albumin passed across the placenta causing a depletion that cannot always be maintained by the maternal pool of albumin (Johnson & Winlow, 2021). Additionally, because of the decreased perfusion in the kidneys, protein cannot be filtered properly by the glomeruli and is excreted in great amounts in the urine. Loss of protein from the intravascular space leads to leaking of fluid towards the interstitial space, resulting in generalized edema.

Nursing Diagnosis

  •  Risk for Imbalanced Fluid Volume

Risk Factors

  • Decreased oncotic pressure
  • Decreased plasma protein
  • Decreased glomerular filtration rate (GFR)
  • Glomerular permeability

Evidenced by

  • Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Verbalize understanding of the importance of close monitoring of BP, weight, edema, and protein.
  • Exhibit absence of generalized, pulmonary, or pitting edema.
  • Exhibit laboratory values within the acceptable range.
  • Adhere to the treatment regimen and care plan.

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs, especially the BP and pulse. Hypertensive diseases lead to an imbalanced fluid volume due to increased capillary permeability as a result of endothelial damage. There is increased blood pressure due to changes in vascular tone caused by endothelial damage (Froes et al., 2020). The body compensates for the decreased intravascular fluid volume by increasing the heart rate to reach the peripheries.
Weigh the client regularly. Because there is decreased oncotic pressure to prevent the shifting of fluids from the intravascular to the interstitial space, edema develops, which adds to the normal weight gain of pregnancy. Sudden, significant weight gain of more than 1.8 kg per week may indicate the development of pre-eclampsia.
Auscultate lung sounds and evaluates respiratory effort. Nearby organs such as the lungs can be overwhelmed by the excessive fluid in the interstitial space. Orthopnea and paroxysmal dyspnea may result from the excessive venous return of fluid from the lower limbs that reaches the lungs, overcharging them (Froes et al., 2020).
Assess for signs of pitting and facial edema. Edema exists in many pregnant women, but a sudden increase in edema or facial edema is suggestive of pre-eclampsia. The edema of pre-eclampsia occurs by a distinct mechanism that is similar to that of angioneurotic edema.
Assess for protein in the urine. Proteinuria occurs due to the decreased glomerular permeability that allows for the escape of protein to be excreted through the urine.
Independent
Monitor the client’s intake and output. Oliguria appears as a direct consequence of vascular alterations in pre-eclampsia. Retention of fluid and sodium occurs as the body holds on to the fluid volume left in the intravascular spaces. Urine production is decreased because of decreased blood flow to the kidneys.
Review the client’s hemoglobin and hematocrit levels. Decreased hemoglobin and hematocrit occur because of increased plasmatic volume which is higher than the increase in erythrocyte production, causing pregnancy physiological anemia (Froes et al., 2020).
Encourage the client to increase protein intake and consume moderate amounts of sodium. Sodium intake is still a necessary part of the client’s diet, however, it should not exceed 6g/day. a high sodium diet predisposes the client to more fluid retention. Intake of 80-100g of protein daily is required to replace protein losses.
Advise the client to elevate the lower extremities when sitting or lying down and massaging the lower limbs. Pelvic and femoral vasocompression increases hydrostatic pressure, causing vein dilatation, damaging the venous flow return, leading to edema of the lower limbs. this can be prevented by elevating the lower extremities or gently massaging the lower limbs.
Dependent
Administer fluids intravenously using an infusion pump. Administer fluids cautiously to replace intravascular losses. the use of an infusion pump allows for more accurate delivery of fluids. The client should be fluid restricted when possible, at least until the period of postpartum diuresis to prevent pulmonary edema.
Insert an indwelling catheter as indicated. Measuring the urine output is more accurate through an indwelling catheter. Since there is fluid and sodium retention, strict monitoring of output should be done especially if it is less than 50 ml/hr, which may indicate an impending renal failure.
Collaborative
Assist with insertion of central lines for invasive hemodynamic monitoring. Measuring hemodynamic parameters such as central venous pressure and pulmonary artery wedge pressure invasively provides an accurate fluid volume result.

Risk for Injury

Eclampsia is a known complication of pre-eclampsia during pregnancy and is associated with morbidity and mortality of both the mother and the fetus if not properly diagnosed. The endothelial damage that occurs in pre-eclampsia does not only occur at the site of the uterus but also in the cerebral endothelium, which leads to neurological disorders, including eclampsia. The client has passed into this stage when cerebral edema is so acute a grand mal (tonic-clonic) seizure or coma has occurred. With eclampsia, maternal mortality can be as high as 20% from causes such as cerebral hemorrhage, circulatory collapse, or renal failure.

Nursing Diagnosis

  •  Risk for Injury

Risk Factors

  • Tonic-clonic or grand mal seizures
  • Cerebral edema
  • Altered consciousness
  • Tissue hypoxia

Evidenced by

  • Not applicable on risk diagnosis; the presence of signs and symptoms establishes an actual diagnosis

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Be free of signs of cerebral edema such as headache, altered mental status, and visual disturbances.
  • Be free from any bodily injury during and after a seizure.
  • Adhere to the therapeutic regimen and participate in the treatment and environmental modifications to enhance safety.
  • Verbalizes understanding of the factors that may contribute to the development of seizure activity.

Nursing Interventions

Assessment Rationale
Assess the client’s vital signs, especially the BP, at least every 4 hours. The client has passed to pre-eclampsia with severe features when her blood pressure rises to 160 mmHg systolic and 110 mmHg diastolic or above on at least two occasions 6 hours apart at bed rest or her diastolic pressure is 30 mmHg above her prepregnancy level. If pulmonary edema has developed, the client may report feeling short of breath (Pillitteri & Silbert-Flagg, 2018).
Assess the client’s level of consciousness or any alterations in the mental state. Vasospasm of the cerebral blood vessels may reduce the blood supply to the brain and reduce oxygen consumption, which may lead to cerebral hypoxia and coma.
Assess for any signs of an impending seizure. Immediately before a seizure, the client’s blood pressure rises suddenly from additional vasospasm. the increased cerebral pressure causes her temperature to rise sharply from 103℉ to 104℉ (39.4 to 40℃). the client may notice blurring of vision or severe headache and hyperactive reflexes.
Assess the client’s deep tendon reflexes and ankle clonus. Cerebral edema produces marked hyperreflexia and perhaps ankle clonus (a pulsed motion of the foot after flexion). Elicit the patellar reflex by placing the client in a supine position and bending her knee slightly, then strike the patellar tendon just below the kneecap. If the leg moves, a patellar reflex is present. To elicit an ankle clonus, dorsiflex the client’s foot three times in rapid succession. If no further motion is present after taking your hand away, no ankle clonus is present.
Assess for epigastric or abdominal pain and nausea and vomiting. Epigastric pain or nausea occurs because of liver edema, ischemia, and necrosis and often precedes a convulsion. Abdominal pain may also occur because of pancreatic and liver edema.
Assess the client’s urinary output. Decreased blood flow to the kidneys reduces urine production or oliguria and worsens hypertension. Urine output may decrease abruptly to less than 30 ml/hr.
Assess for visual disturbances regularly. Visual disturbances such as blurred or double vision or “spots before the eyes” occur because of arterial spasms and edema surrounding the retina. Visual disturbances often precede a convulsion.
Independent
Encourage the client to attend prenatal care visits regularly. The nurse should promote awareness of how prenatal care allows risk identification and early intervention if complications arise. Help the client feel like an individual, thus encouraging her to return regularly.
Promote frequent rest periods and plan activity restrictions with the client. The nurse should help the client understand the importance of reduced activity and frequent rest periods and help plan ways to manage them. Activity diverts blood from the placenta, reducing the fetus’ oxygen supply.
Turn the client to the left side during bed rest. Positioning the client on her left side during bed rest helps to improve blood flow to the placenta and more effectively provides oxygen and nutrients to the fetus.
Provide a quiet, calm environment. A quiet, low-light environment reduces the risks for seizures. Stimulation such as loud noises or bumping of the bed should be avoided. Visitors are usually limited to one or two support people.
Review laboratory results significant to the client’s condition. HELLP syndrome is a complication of hypertensive disorders of pregnancy. Hemolysis occurs as erythrocytes break up when passing through small blood vessels damaged by hypertension. Obstruction of hepatic blood flow causes liver enzyme levels to become elevated. Low platelet levels occur when the platelets gather at the site of blood vessel damage, reducing the number available in the general circulation, thereby causing abnormal blood clotting.
Instruct the client to report for signs of an impending seizure or “aura”. The client sometimes experiences a premonition or “aura” that “something is about to happen”. The client should also report immediately if she feels a severe headache or blurring of vision, which usually precedes a seizure episode.
In the event of a seizure:
Promote a patent airway by turning the client on her side immediately. Aspiration of secretions can occur during a seizure, so the client should be turned to her side before the seizure begins to allow the secretions to drain freely from her mouth. Suction may be done to help with oral secretions.
Lower the bed to its lowest position and keep padded side rails up. During seizures and the client is on her bed, the nurse should also focus on preventing injury. Lowering the bed and raising the padded side rails would prevent the client from falling and sustaining fractures during the seizure.
Avoid restraining or restricting the client’s movements during the seizure activity. The nurse should not forcibly hold the client’s body during a seizure because it may cause physical injuries. Gently cradle the client’s head or place it in a soft area if the client is on the floor. Remove obstructions that the client may hit during their seizure that can cause bodily injuries.
Ensure the patency of the IV line before administering medications. Before giving IV medications, ensure that the line is patent. Use a gauge 18 needle because it can push fluids rapidly. Magnesium sulfate or diazepam may be administered intravenously as emergency measures. A loading dose of 4 to 6 grams should be given intravenously over 15 to 20 minutes. Magnesium treatment should be continued for at least 24 hours after the client’s last seizure (Magley & Hinson, 2021).
Administer oxygen by face mask. Administer oxygen 10L/minute to improve fetal oxygenation. Assess the client’s oxygen saturation continuously using a pulse oximeter.
Attach continuous fetal monitoring and assess for signs of impending labor. Labor may progress rapidly after a seizure, often while the client is still drowsy, and the fetus is monitored continuously. Apply an external fetal heart monitor if one is not already in place to assess the FHR. the seizure may announce the beginning of labor, so assess as well for uterine contractions.
Assess for signs of placental separation. Check for vaginal bleeding to detect placental separation, although evidence placental separation has occurred will probably appear first on the fetal heart record; vaginal bleeding will strengthen presumption.
Dependent
Administer magnesium sulfate intravenously and monitor for potential side effects. Magnesium sulfate is an anticonvulsant administered to prevent seizures. It may also slightly reduce blood pressure, but its main purpose is as an anticonvulsant. It is usually given by intravenous infusion controlled with an infusion pump. A maintenance dose of 2g per hour should subsequently be administered. Special attention must be made when giving this medication as it can lead to toxicity and cause respiratory paralysis, CNS depression, and cardiac arrest. It is essential to monitor reflexes, creatinine function, and urine output with magnesium administration.
Prepare calcium gluconate and keep it on hand as appropriate. Calcium gluconate is an antidote to counteract magnesium toxicity. Close monitoring of the respiratory rate is essential in clients who receive magnesium sulfate. Calcium gluconate reverses the effects of magnesium and should be available for immediate use when the client receives magnesium sulfate.
Monitor contractions as indicated during the administration of magnesium sulfate. Magnesium inhibits contractions. Most clients receiving the drug during labor must also receive oxytocin to strengthen labor contractions. These clients are at increased risk for postpartum hemorrhage because the uterus does not contract firmly on bleeding vessels after birth. an essential nursing responsibility when caring for clients receiving magnesium is to monitor contractions during labor and to take measures to maintain a firm uterine fundus postpartum.
Collaborative
Assist in preparing for cesarean birth or vaginal delivery as indicated. If the fetus has reached a point of viability, a decision about birth will be made as soon as the client’s condition stabilizes, usually 12 to 24 hours after the seizure. Cesarean birth is always more hazardous for the fetus than vaginal birth because of the association of retained lung fluid. furthermore, a client with severe hypertension is not a good candidate for surgery. If labor does not begin spontaneously, rupture of the membranes or induction of labor with intravenous oxytocin may be instituted. If this is ineffective and the fetus appears to be in imminent danger, cesarean birth becomes the birth method of choice.

Deficient Knowledge

The client who has an undiagnosed hypertensive disorder of pregnancy may easily attribute the symptoms to normal pregnancy symptoms. It is important for the nurse to encourage the client to attend her prenatal care visits regularly for early detection of any complications that may arise due to her condition. Lack of prenatal care may compromise the mother and fetus’ lives, therefore, strict monitoring of an eclamptic client is imperative.

Nursing Diagnosis

  •  Deficient Knowledge

Related Factors

  • Information misinterpretation
  • Unfamiliarity with the disease process
  • Denial of diagnosis
  • Lack of knowledge and recall

Evidenced by

  • Request for information
  • Verbalization of misconceptions
  • Inaccurate demonstration of procedures
  • Lack of participation in the treatment regimen

Desired Outcomes

After implementation of nursing interventions, the client is expected to:

  • Verbalize understanding of the disease process and treatment regimen
  • Identify possible complications and their risk factors
  • Maintain BP within an acceptable range
  • Participate in the treatment regimen appropriately

Nursing Interventions

Assessment Rationale
Assess the client’s and family members’ knowledge about the disease and its known complications. This will help identify the common misconceptions that need to be addressed immediately. Identifying the complications that may arise may contribute to the client’s motivation to prevent their development.
Assess the client’s knowledge about modifiable risk factors. Modifiable risk factors such as obesity; a diet high in sodium, saturated fats, and cholesterol; a sedentary lifestyle; and a stressful environment contribute to the development of eclampsia and its complications.
Independent
Educate the client and family members about self-monitoring of BP at home and let them return demonstrate. Monitoring the BP at home is reassuring to the client because it provides visual feedback to determine treatment outcomes and helps promote early detection of deleterious changes. Blood pressure monitoring 2 to 4 times per day in the same arm and the same position should be taught to family members.
Educate the client on how to monitor how weight at home. A gain of 3.5 lbs (1.59kg) or greater per month in the second trimester or 1 lb (0.45 kg) or greater per week in the third trimester may indicate the development of pre-eclampsia, which could progress rapidly to eclampsia if not detected early.
Assist the client in developing a simple, convenient schedule for intake of medications. Individualizing the schedule to fit the client’s personal habits may make it easier to get in the habit of including antihypertensives in healthcare management activities.
Explain prescribed medications along with their rationale, dosage, expected, and adverse effects. Adequate information and understanding about side effects can enhance the client’s commitment to the treatment plan.
Reinforce the importance of adhering to treatment regimens and keeping follow-up prenatal visits. Lack of engagement in the treatment plan is a common reason for the failure of antihypertensive therapy. when the client understands the causative factors and complications of inadequate intervention and is motivated to achieve health, the client will participate in the treatment regimen.
Educate the client on how to identify signs and symptoms that should be reported to the healthcare provider. Instruct the client to report any signs of an impending seizure activity such as severe headache, visual disturbances, epigastric or abdominal pain, or decreased fetal movement immediately. Early detection and reporting of developing complications, decreased effectiveness of drug regimen, or adverse reactions allow for timely interventions.
Help the client identify ways to institute appropriate lifestyle changes to reduce modifiable risk factors. Changing “comfortable or usual” behaviors can be extremely difficult and stressful, especially for pregnant women. Support, guidance, and empathy may enhance the client’s success in accomplishing her goals for a healthy and safe delivery.
Encourage the client to adhere to the prescribed dietary regimen. A typical dietary regimen prescribed for a client with eclampsia includes a diet low in sodium, saturated fat, and cholesterol. Excess saturated fats, cholesterol. sodium and calories have been defined as nutritional risks in eclampsia. A diet low in fat and high in polyunsaturated fat reduces BP.
Help the client identify sources of sodium intake and stress the importance of reading ingredient labels of foods. Foods such as table salt, salty snacks, processed meats and cheeses, sauerkraut, sauces, canned soups and vegetables, and monosodium glutamate have high concentrations of sodium. A moderately low salt diet may be sufficient to control BP or reduce or eliminate the need for drug therapy to control BP.
Encourage the client to eat foods rich in essential fatty acids, such as salmon, cod, mackerel, and tuna. Omega-3 fatty acids in fish tend to relax artery walls, reducing blood pressure. They also make blood thinner and less likely to clot.

Sample Eclampsia Nursing Care Plan

Nursing Diagnosis: Altered tissue perfusion (Cerebral, peripheral, and renal)

Nursing DiagnosisObjectiveNursing InterventionsRationaleEvaluation
Nursing Diagnosis: Altered
tissue perfusion (Cerebral,
peripheral and renal)
Possible Etiologies: (Related
to)

• Arterial vasospasm/
constriction of blood
vessels
• Decreased
prostaglandin levels
• Sensitivity to
angiotensin II
• Impaired glomerular
perfusion
• Decreased
uteroplacental
perfusion
• Increased cardiac
workload
• Vascular damage
• Red blood cell damage
• Alteration in liver
function in severe
cases
• Unusual sensitivity to blood loss probably
because of leakage of
blood components into the extravascular
space.


Defining characteristics:
(Evidenced by)

• Elevated blood
pressure
• Edema, especially of
the hands and face
• Sudden weight gain
• Proteinuria (1+ up to 4+)
• Hyperreflexia
• Headache
• Visual disturbances
• Epigastric pain
• Fetal status
• Decreased urine
output
• Rales, if pulmonary
edema is present
• Elevated BUN,
creatinine, uric acid
• Decreased hematocrit
and haemoglobin
• Seizure

Goals/Objectives
Short term goal:

Client will
demonstrate adequate
perfusion, as evidenced by stable
vital signs, palpable
pulses, and alert and
oriented, absence of
seizure episodes,
balanced intake and
output, decrease in
presence of edema and good fetal status
evaluation within a
week.

Long term goal:
Client will demonstrate readiness during the postpartal period in monitoring one’s health and involving oneself to dietary restrictions and medical follow up
checkups and
intervention.
Nursing Actions
1. Monitor vital signs,
palpate peripheral pulses and note capillary refill, assess urinary output, weigh client daily and evaluate changes in
mentation.

2. Place client on left
recumbent position.
Monitor maternal well- being periodically.

3. Administer oxygen as prescribed.

4. Ensure safety by putting the side rails always up and monitor client for
tonic- clonic convulsions.

5. Insert Foley catheter as indicated by the physician and monitor urine output.

6. Administer Magnesium Sulfate as ordered by the physician and monitor for signs for toxicity.

7. Administer fluids as
prescribed.

8. Assist in the delivery of the baby.
1. Indicators of adequacy of systemic perfusion, fluid/ blood, needs, and developing complications.

2. This is to avoid uterine pressure
on the vena cava and prevent supine hypotension syndrome.

3. Woman’s BP should be taken at least every 4 hours to detect for
increase which is a warning of worsening; if fluctuating, it should be done hourly.

4. To ensure supply of oxygen to both the mother and the fetus.

5. Convulsions are evident in Eclampsia so it should be
watched out and monitored.

6. Urine output should be in congruence with fluid intake.

7. This drug is usually given to control the blood pressure of
client’s with pregnancy induced
hypertension.

8. Replacement of fluids maintains
circulating volume and tissue perfusion. Delivery of the baby is
considered the only cure for Eclampsia.
Outcome
Criteria:

Client’s blood
pressure is
below 140/90mmHg,
urine output of
above 30ml/hour,
fetal heart rate
is between 120-160 beats per min,
absence of seizure
episodes, decrease in
presence of
edema.

Client
verbalizes
plans upon discharge,
participates during lecture- discussion sessions, and demonstrates
willingness to
perform monitoring
measures.

References

  1. Anthony, J., & Schoemann, L. K. (2013, July 26). Fluid management in pre-eclampsia. Obstetric Medicine, 6(3), 100-104. 10.1177/1753495X13486896
  2. Fox, R., Kitt, J., Leeson, P., Aye, C. Y.L., & Lewandowski, A. J. (2019, October 4). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of Clinical Medicine, 8(1625). 10.3390/jcm8101625
  3. Froes, N. B. M., Lopes, M. V. d. O., Pontes, C. M., Ferreira, G. L., & Aquino, P. d. S. (2020, April 17). Middle range theory for the nursing diagnosis Excess Fluid Volume in pregnant women. Revista Brasileira de Enfermagem, 73(supplement 4). https://doi.org/10.1590/0034-7167-2019-0334
  4. Johnson, A. S., & Winlow, W. (2021, November 23). PRE-ECLAMPSIA, HYPOALBUMINAEMIA, AND ALBUMIN THERAPY. European Journal of Biomedical and Pharmaceutical Sciences, 8(12), 75-76. https://www.researchgate.net/profile/Andrew-Johnson-53/publication/356727351_PRE-ECLAMPSIA_HYPOALBUMINAEMIA_AND_ALBUMIN_THERAPY/links/61a8e287092e735ae2d5b065/PRE-ECLAMPSIA-HYPOALBUMINAEMIA-AND-ALBUMIN-THERAPY.pdf
  5. Kauffmann, T. (2021, October 7). Fetal Monitoring Article. StatPearls. Retrieved February 2, 2022, from https://www.statpearls.com/ArticleLibrary/viewarticle/21712
  6. The Lancet. (2021, September 11-17). Worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. The Lancet, 398(10304), 957-980. https://doi.org/10.1016/S0140-6736(21)01330-1
  7. Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
  8. Magley, M., & Hinson, M. R. (2021, June 12). Eclampsia – StatPearls. NCBI. Retrieved February 1, 2022, from https://www.ncbi.nlm.nih.gov/books/NBK554392/
  9. Mayrink, J., Souza, R. T., Feitosa, F. E., Rocha Filho, E. A., Leite, D. F., Vettorazi, J., Calderon, I. M., Costa, M. L., Kenny, L., Baker, P., & Cecatti, J. G. (2019, December 3). Mean arterial blood pressure: potential predictive tool for preeclampsia in a cohort of healthy nulliparous pregnant women. BMC Pregnancy and Childbirth, 19(460). https://doi.org/10.1186/s12884-019-2580-4
  10. McClements, L., Richards, C., Patel, N., Chen, H., Sesperez, K., Bubb, K. J., Karlstaedt, A., & Aksentijevic, D. (2022, January 21). Impact of reduced uterine perfusion pressure model of preeclampsia on metabolism of placenta, maternal and fetal hearts. Scientific Reports, 12. https://www.nature.com/articles/s41598-022-05120-2
  11. Pillitteri, A., & Silbert-Flagg, J. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer.
  12. Saxena, T., Ali, A. O., & Saxena, M. (2018, November 15). Pathophysiology of essential hypertension: an update. Expert Review of Cardiovascular Therapy, 16(12), 879-887. https://doi.org/10.1080/14779072.2018.1540301
  13. Tan, M. Y., Wright, D., Syngelaki, A., Akolekar, R., Cicero, S., Janga, D., Singh, M., Greco, E., Wright, A., Maclagan, K., Poon, L. C., & Nicolaides, K. H. (2018, March 14). Comparison of diagnostic accuracy of early screening for pre-eclampsia by NICE guidelines and a method combining maternal factors and biomarkers: results of SPREE. Ultrasound in Obstetrics and Gynecology, 51(6), 743-750. https://doi.org/10.1002/uog.19039
This is a community of professional nurses gifted with literary skills who share theoretical and clinical knowledge, nursing tidbits, facts, statistics, healthcare information, news, disease data, care plans, drugs and anything under the umbrella of nursing. All information expressed here are courtesies of the respective authors. Views on topics do not generally reflect that of the entire community. Articles submitted here are original but are checked for minor typographical errors, and are formatted for site compatibility.This is a site that continuously improves and broadcasts healthcare information relevant to today's ever-changing world.

LEAVE A REPLY

Please enter your comment!
Please enter your name here