Tuesday, November 27, 2007

Preeclamptic Client: Nursing Strategies and their Disadvantages

A Review of Literature
Many of the maternal and fetal complications related to preeclampsia are life threatening. Nursing management plays a vital role in the care of the mother and fetus during pregnancy related complications.

According to Wagner (2004), preeclampsia affects approximately five to seven percent of pregnancies and complications of hypertension are the third leading cause of pregnancy related deaths. Early recognition of the signs and symptoms of this syndrome is vital for an optimal outcome for both mother and fetus. Arafeh (2006) states that “preeclampsia can develop with alarming speed” (para. 4); therefore, nurses must understand the pathophysiology of preeclampsia to provide optimal nursing management of a preeclamptic client. Once a diagnosis of preeclampsia is established, nurses must utilize assessment skills, proper nursing interventions and patient teaching to promote a safe environment for labor and delivery.
The pathophysiology of preeclampsia is still under research and only theories exist to explain what is happening inside the body. Wagner (2004) describes one theory with the problem being implantation of the placenta at the trophoblastic level. According to Arafeh (2006), “ischemia of the placenta causes an imbalance of angiogenic factors” and the imbalance contributes to the damage of the endothelium seen in preeclampsia (para. 5). Schroeder (2002) identifies physiologic changes of intense vasospasm and hemoconcentration. Wagner (2004) associates the decrease in systemic organ perfusion to the intensive vasospasms. She also states that there is an inflammatory response, abnormal endothelial activation and activation of the coagulation cascade that results in the formation of microthrombi. These factors further compromise blood flow to systemic organs, which can cause major maternal and fetal complications.
Management of preeclampsia is a balancing act. The risk of complications to the fetus is higher when a diagnosis of preeclampsia is found in the second or early third trimester of the pregnancy. The only cure is delivery of the fetus, but timing of the delivery is crucial for both the mother and the fetus. If delivered too early, the fetus faces the complications of prematurity. Waiting too long to deliver, the fetus is at risk for complications associated with placental abruption, fetal distress, oligohydramnios, and intrauterine growth restrictions (Schroeder, 2002). Maternal complications are also a major concern when caring for a preeclamptic patient. The maternal complications directly result from a decrease in perfusion to all organ systems. Wagner (2004) points out that delivery is necessary when there is progressive deterioration of liver or kidney function, platelet count below 100 x 103 per mm3 (100 x 109 per L), suspected placental abruption, continuous severe headache or visual changes, severe epigastric pain, nausea, vomiting, or eclamptic seizures. Schroeder (2002) states that “maternal mortality is usually associated with intracranial hemorrhage” (p. 2).
Nursing management is a critical variable in promoting a positive outcome for both the mother and fetus. This begins with a review of prenatal records and an interview with the patient to clarify history and take note of any severe headaches, visual disturbances or severe epigastric pain. The physical examination includes baseline vital signs and nurses must be consistent when taking and recording blood pressure. Assessing edema, deep tendon reflexes, breath sounds for crackles, level of consciousness, and intake and output is essential when caring for a preeclamptic patient (Wong, Perry, Hockenberry, Lowdermilk, and Wilson, 2006). Determining fetal status and monitoring the fetus is also a nursing priority. The nurse should assess for fetal heart rate variability and accelerations. Late decelerations or a decrease or absence in variability indicates that the fetus is in distress. Evaluate uterine tonicity for signs of abruption. An essential nursing assessment is monitoring cervical changes to assess and document the progression of labor. The nurse must be aware of current laboratory results noting any changes from previous levels. It is also imperative that the nurse is prepared at all times for an emergency delivery because of the high risk of complications. Continual assessment of the central nervous system is critical, as changes could progress to eclamptic seizures. An environment that is non-stimulating and quiet is encouraged.
Medical management of complications during labor is aimed at preventing eclamptic seizures and hypertensive crises in the mother. Schroeder (2002) states that the most common antihypertensive used during labor is hydralazine IV in five to ten milligram doses or labetalol IV twenty milligram bolus, followed by forty milligrams after ten minutes. Magnesium sulfate is the drug of choice to prevent and treat eclamptic seizures during labor. Wong, Perry, Hockenberry, Lowdermilk, and Wilson (2006) suggest administering magnesium sulfate piggyback with a loading dose of four to six grams diluted in a hundred milliliters of intravenous fluid infused over fifteen to thirty minutes, followed by a maintenance dosage according to the provider’s orders.
Magnesium sulfate treatment for the mother has many nursing implications; monitoring the patient for toxicity is critical. Wong, Perry, Hockenberry, Lowdermilk, and Wilson (2006) note the signs of toxicity to include respiratory depression, hyporeflexia, urine output less than thirty milliliters an hour, a drop in pulse or blood pressure, signs of fetal tachycardia or bradycardia, or serum magnesium levels greater than 9.6 mg/dl. If toxicity is evident, nursing interventions include discontinuing the IV infusion of magnesium sulfate, notifying the provider immediately, administering calcium gluconate as ordered, and monitoring for the reversal of signs of toxicity.
In the inpatient setting, educating the patient and her significant other on the disease process and the management rationale is a primary nursing action. It is important for the woman and her family to understand what is physiologically happening within the body to have a greater understanding of the treatment plan. The nurse should review the signs and symptoms that need reporting immediately to the nursing staff. Assess the patient’s current knowledge of preeclampsia and add additional information in terms that the patient can understand. The nurse should explain the current treatment plan and what variables will change the plan of care. Inform the patient that these variables can change the plan of care. This will ensure that the patient and her significant other will be prepared for any further complications that may arise. Involving the woman and significant other in the management will provide a sense of control over the situation. In turn, this may help reduce the anxiety associated with this complication of pregnancy. Promoting a trusting relationship with the patient will include being supportive and answering questions honestly.
The nurse is responsible for caring for both the mother and fetus during labor and delivery, which will require optimal nursing care to promote the most favorable outcome. Understanding the maternal and fetal effects of preeclampsia will aid the nurse in performing thorough assessments. The information found on assessment will determine the nursing care and interventions needed to support the laboring woman and fetus. Providing the patient and family with knowledge and support is vital nursing care. The nursing management of a preeclamptic patient will be a major factor in the outcome for both mother and child.
References
Arafeh, J. M. (2006). Preeclampsia: pieces of the puzzle revealed. Journal of Perinatal & Neonatal Nursing, 20(1), 85-. Retrieved January 26, 2007, from Expanded Academic ASAP database.
Bridges, E. J., Womble, S., Wallace, M. & McCartney, J. (2003). Hemodynamic monitoring high-risk obstetrics patients, II: pregnancy – induced hypertension and preeclampsia. Critical Care Nurse, 23(5), 52-. Retrieved January 26, 2007, from Expanded Academic ASAP database.
Schroeder, B. M., (2002). ACOG practice bulletin on diagnosing and managing preeclampsia and eclampsia. American Family Physician, 66(2), 330-. Retrieved January 26, 2007, from ProQuest database.
Wagner, L. K. (2004). Diagnosis and management of preeclampsia. American Family Physician, 70(12), 2317-. Retrieved January 26, 2007, from ProQuest database.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal Child Nursing Care (3rd ed.). St. Louis: Mosby Elsevier.
Zamorski, M. A. & Green, L. A. (1996). Preeclampsia and hypertensive disorders of pregnancy. American Family Physician, 53 (5), 1595-. Retrieved January 26, 2007, from Expanded Academic ASAP database.


Intervention # 1 - Nursing Interview and Assessment
Disadvantage # 1 - Individual Limitations to a Thorough Nursing History
A through nursing history is imperative to provide care to a preeclamptic client. According to Taylor (2002), “The two most significant sets of documents used by the nursing staff were the patient’s history (often referred to as progress notes) and the nursing care plan.” (p. 16). Upon admission to the labor and delivery unit, it is the admitting nurse’s responsibility to obtain and document the client’s obstetrical, gynecological, medical, surgical, and social history. The oncoming nursing staff relies on the documentation of the admitting history. If this information has not been obtained thoroughly and documentation completed it could adversely affect the nursing care provided. In addition, documentation of subsequent nursing assessments, treatments, and outcomes is vital to provide on coming nursing staff with information that is needed to provide this client with the best possible care.
Disadvantage # 2 - Individual Limitations to a Thorough Nursing Assessment
The data gathered while performing a nursing assessment is critical for a preeclamptic client. The many assessments that need to be preformed will affect the nursing and medical care that the client receives. According to North & Serkes (1996), a “JCAHO accreditation report stated that nursing had a notable deficiency in completion and use of the initial nursing assessment for a new patient admission.” (p. 30). If vital information is over looked during assessment, the nurse is responsible for any adverse outcomes that may occur from the failed assessment. With obstetrics being one of the highest legally liable fields of medicine, it is extremely important to provide a thorough assessment and document the assessment completely. When physical assessment is performed, it is critical that the nurse knows what is normal and abnormal for a preeclamptic client and what assessment warrants a call to the physician. When interviewing the client regarding what signs and symptoms are being experienced, it is imperative to know how to obtain all the information needed from the client. A thorough interview and physical assessment will provide the nurse with a clear clinical picture of how the client and fetus is doing.
Intervention # 2 - Education of Client and Significant Other
Disadvantage # 1 - Providing Education Based on Client Understanding
The ability of the nurse to provide client education in a manner that the client can understand is very important in all areas of nursing. Hill (2004) discusses client education and states that our interactions be personalized toward the client. Explaining the physiological process of preeclampsia to clients with different educational background can be a challenge. It is the nurse’s responsibility to provide that education in a manner that the client will be able to comprehend. If the education that the nurse provides fails, it can put the mother and fetus at risk for major complications. Teaching the client what clinical signs need to be reported right away and having the client repeat back what is understood is one method of ensuring the client’s comprehension. A second method of ensuring that the client understands the information that the nurse is providing is to ask questions that would reiterate the information provided. It is the nurse’s responsibility to provide client education and to ensure that the information is comprehended.
Disadvantage # 2 - Communication failures between Nurse and Client
Communication failures between the client and nurse can lead to an adverse outcome for the mother and the fetus. According to Wong, Perry, Hockenberry, Lowdermilk, & Wilson (2006), communication is vital between the nurse and the client. Failure can occur at many levels of communication. The nurse could ask a question that was misinterpreted by the client. The nurse can misinterpret the response of the client or failure to listen thoroughly could lead to failure in the communication process. Fiesta (1998) states that, “difficulty in communication occurs when health care providers fail to listen carefully to their patients.” (p. 24). Body language is an area of communication that can fail to provide the message that was intended. Different cultural backgrounds can cause some difference of communication styles that could lead to a misunderstanding between the nurse and the client. If the primary language of the client is not the same as the nurse, it is important to have an interpreter to ensure that both parties understand. Communication is vital to the nurse taking care of a client with preeclampsia to provide to nursing care that will lead to a healthy outcome for both the mother and fetus.


References
Fiesta, J. (1998). Failure to communicate. Nursing Management, 29 (2) 22-. Retrieved on October 28, 2007, from EBSCO host database.
Hill, M. J. (2004). Nurses and patient education. Dermatology Nursing, 16 (4) 323-. Retrieved on October 28, 2007, from EBSCO host database.
North, S. D. & Serkes, P. C. (1997). Improving documentation of initial nursing assessment. Nursing Management, 27 (4) 30-. Retrieved on October 28, 2007, from EBSCO host database.
Taylor, C. (2002). Assessing patients’ needs: does the same information guide expert and novice nurses?. International Nursing Review, 49 (1) 11-. Retrieved on October 28, 2007, from EBSCO host database.
Wong, D. L., Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2006). Maternal Child Nursing Care (3rd ed.). St. Louis: Mosby Elsevier.

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