- Decreased Cardiac Output related to Hypovolemia Decreased venous return as evidenced by Alterations in blood pressure and Alterations in hemodynamic readings
- Deficient Knowledge related to Pathophysiology of preeclampsia and Management of preeclampsia as evidenced by Rapid progress of preeclampsia and Inaccurate or insufficient instructions in the prevention or management of preeclampsia
- Impaired Skin Integrity related to Edema and Decreased platelets as evidenced by Petechia and Pitting edema
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes giddiness Objective data: -Alterations in blood pressure -Alterations in hemodynamic readings -Edema -Dyspnea Alterations in mental status | Decreased Cardiac Output related to Hypovolemia Decreased venous return as evidenced by Alterations in blood pressure and Alterations in hemodynamic readings | Patient will be able to maintain adequate blood pressure within acceptable limits. | 1. Position the patient comfortably on the left side-lying position. Left side-lying promotes adequate circulation. This position makes it easier for nutrient-rich blood to flow from the heart to the placenta to support the fetus. 2. Administer oxygen as prescribed. Increase the amount of oxygen available for heart function which will increase the blood supply to the placenta and fetus. 3. Administer antihypertensives. Cardiac medications should be administered to reduce hypertension with precautions that are safe for the mother and the fetus. 4. Restrict fluids as ordered. If there is the presence of edema and cardiopulmonary congestion, restrict fluid intake as ordered. 6. Encourage reduced activity. Rest periods and reduced activity is recommended. Physical activity diverts blood away from the placenta. Complete bed rest is not necessary. 7. Prepare for cesarean section. If complications of preeclampsia due to decreased cardiac output are present, an emergency cesarean section is performed. This is to prevent maternal and fetal death. | Patient maintained adequate blood pressure within acceptable limits. |
| Subjective data: -Verbalizes poor understanding -Seeks additional information Objective data: -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition | Deficient Knowledge related to Pathophysiology of preeclampsia and Management of preeclampsia as evidenced by Rapid progress of preeclampsia and Inaccurate or insufficient instructions in the prevention or management of preeclampsia | Patient will be able to verbalize understanding of preeclampsia and its management. Patient will be able to verbalize possible complications and when to contact a healthcare provider. Patient will be able to demonstrate behavior and lifestyle modifications in the prevention of preeclampsia. | 1. Instruct on symptoms to report. Provide verbal and written instructions on symptoms to report to the healthcare provider such as blurred vision, headaches, epigastric pain, or difficulty breathing. 2. Involve the support system. A mother requires support from her partner and family members. Information can be provided to support persons to monitor the patient and encourage healthy habits. 3. Encourage using positive reinforcement. Positive reinforcement can be used to encourage behavior modification and teach new skills. It promotes motivation for further attempts at learning. 4. Instruct on appointments and tests. Completing follow-up appointments, glucose monitoring, and blood pressure assessments will ensure a healthy pregnancy and delivery. | Patient verbalized understanding of preeclampsia and its management. Patient verbalized possible complications and when to contact a healthcare provider. Patient demonstrated behavior and lifestyle modifications in the prevention of preeclampsia. |
| Subjective data: -Pain -Itching -Numbness to affected and surrounding skin Objective data: -Changes to skin color (erythema, bruising, blanching) -Warmth to skin -Swelling to tissues -Observed open areas or breakdown, excoriation | Impaired Skin Integrity related to Edema and Decreased platelets as evidenced by Petechia and Pitting edema | Patient will maintain intact skin integrity. Patient will verbalize understanding of the condition and demonstrate interventions that promote skin health. | 1. Administer antihypertensives as ordered. Antihypertensives can help resolve the elevated blood pressure of preeclamptic patients. Resolving the underlying cause will help correct and prevent skin impairments like edema and petechiae. 2. Educate on normal vs. abnormal. Edema and swelling are normal findings in pregnancy, but swelling that suddenly worsens, especially in the face or hands, warrants further investigation for preeclampsia. 3. Encourage the patient to keep the legs elevated. To reduce the swelling and prevent further aggravation of pitting edema, keeping the legs elevated higher than the level of the heart when lying down is encouraged to improve blood circulation and venous return. A footstool may be used to keep the legs elevated when sitting down. 4. Encourage the patient to wear comfortable clothing and shoes. Patients are encouraged to wear comfortable shoes without tight straps that can pinch and cause irritation or breakdown. 5. Encourage the patient to use compression stockings. Compression stockings are also helpful in reducing swelling, aching, and the development of varicose veins associated with pregnancy. 6. Instruct the patient to avoid straining. Prolonged straining when coughing, weightlifting, and vomiting can result in the formation of petechiae of the chest, neck, and face in pregnant women. Instructing the patient to avoid straining can help reduce the appearance of petechiae. | Patient maintained intact skin integrity. Patient verbalized understanding of the condition and demonstrate interventions that promote skin health. |