Nursing Diagnosis and Nursing Interventions for Preeclampsia

Nursing Diagnosis and Nursing Interventions for Preeclampsia

Nursing Diagnosis for Preeclampsia

1. High risk of seizures in pregnant women associated with decreased organ function (vasospasm and increased blood pressure).
2. High risk of fetal distress related to changes in the placenta
3. Impaired sense of comfort (pain) related to uterine contractions.

Nursing Interventions for Preeclampsia

1. High risk of seizures in pregnant women related to decreased organ function (vasospasm and increased blood pressure).
   
   Goal :
   After the treatments, no seizures occurred in pregnant women
   
   Results expected :
   • Awareness: composmentis, GCS: 15 (E4 - V5 - M6)
   • Vital signs:
     • Blood Pressure: 100-120 / 70-80 mmHg
     • Temperature: 36-37 C
     • Nadi: 60-80 x / mnt
     • RR: 16-20 x / mnt
   
   Intervention :
   • Monitor blood pressure every 4 hours
     Rational: The pressure over 110 mmHg diastole and systole 160 or more an indication of PIH.
   • Record the patient's level of consciousness
     Rational: The decline of consciousness as an indication of decreased cerebral blood flow.
   • Assess signs of eclampsia (hyper active, the patellar reflexes, decreased pulse and respiration, epigastric pain and oliguria)
     Rational: The symptoms are a manifestation of changes in the brain, kidney, heart and lung that precedes seizure status.
   • Monitor for signs and symptoms of labor or uterine contractions.
     Rationale: Seizures will increase the sensitivity of the uterus which will allow the delivery.
   • Collaboration with the medical team in the provision of anti-hypertension
     Rationale: Anti-hypertension to lower blood pressure.
2. High risk of fetal distress related to changes in the placenta
   
   Goal :
   After the treatments did not occur fetal distress
   
   Expected results:
   Fetal heart rate (+): 12-12-12
   
   Intervention :
   • Monitor fetal heart rate as indicated
     Rationale: Increased fetal heart rate as an indication of hipoxia, premature and solusio placenta.
   • Review on fetal growth
     Rational: Decrease in placental function may be caused by hypertension, causing IUGR.
   • Explain the signs of solutio placenta (abdominal pain, bleeding, uterine tension, decreased fetal activity)
     Rational: Pregnant women may know the signs and symptoms of solutio placenta. Pregnant women can learn from hipoxia in the fetus.
   • Collaboration with the medical ultrasound and NST.
     Rational: ultrasound and NST to a known state / welfare of the fetus.
   
   
   
3. Impaired sense of comfort (pain) related to uterine contractions
   
   Goal :
   Pain is reduced / no pain
   
   Results expected:
   • Pregnant women understand the causes of pain
   • Pregnant women are able to adapt to the pain
   
   Intervention :
   • Assess the patient's pain intensity level
     Rational: The threshold of pain everyone is different, thus will be able to determine appropriate action treatment with the patient's response to pain.
   • Explain the causes of pain
     Rational: Pregnant women can understand the causes of pain
   • Teach the pregnant woman with the breath in anticipation of pain arise when HIS
     Rational: With a deep breath to relax the muscles, there was vasodilatation of blood vessels, optimal lung expansion, so that the oxygen demand on the tisue are met.
   • Help the pregnant woman by rubbing / massage on the painful part.
     Rational: To distract the patient.