Nursing Diagnoses


For Mild Preeclampsia:

RISK FOR INJURY RELATED TO SIGNS OF PREECLAMPSIA.

Interventions:

Review warning signs/symptoms of preeclampsia to ensure adequate knowledge base exists for decision making.
Assess home environment, including woman's ability to assume self-management responsibilities, support systems, language, age, culture, beliefs, and effects of illness to determine if home care is a viable option.
Teach woman how to do a self-assessment for clinical signs of preeclampsia to provide immediate evidence of a worsening condition.
Teach women about use of rest and relaxation as palliative treatment options to decrease blood pressure and promote diuresis.

FEAR/ANXIETY RELATED TO PREECLAMPSIA AND ITS EFFECT ON THE FETUS.

Interventions:

Provide a clam, soothing atmosphere and teach family to provide emotional support to facilitate coping.
Encourage verbalization of fears to decrease intensity of emotional response.
Involve woman and family in the management of her preeclampsia condition to promote a greater sense of control.
Help woman identify and use appropriate coping strategies and support symptoms to reduce fear/anxiety.

(Perry et al, 2010, p. 344)

For Severe Preeclampsia:

RISK FOR INJURY TO MOTHER AND FETUS RELATED TO CNS IRRITABILITY.

Interventions:

Establish baseline data to use as a basis for evaluating effectiveness of treatment.
Administer IV magnesium sulfate per physician's orders to decrease hyperreflexia and minimize risk of convulsions.
Monitor maternal vital signs, FHR, urine output, DTRs, IV flow rate, and serum levels of magnesium sulfate to assess for and prevent magnesium sulfate toxicity.
Maintain a quiet, darkened environment to avoid stimuli that may precipitate seizure activity.

INEFFECTIVE TISSUE PERFUSION RELATED TO PREECLAMPSIA SECONDARY TO ARTERIOLAR VASOSPASM.

Interventions:

Establish baseline data (weight, degree of edema) to use as basis for evaluating effectiveness of treatment.
Administer IV magnesium sulfate per physician order, which serves to relax vasospasms and increase renal perfusion.
Place woman on bed rest in a side-lying position to maximize uteroplacental blood flow, reduce blood pressure, and promote diuresis.
Monitor intake and output, edema, and weight to assess for evidence of vasodilation and increased tissue perfusion.

(Perry et al, 2010, p. 345)