Assess
FHR
Administer
magnesiu
m sulfate
(calcium
gluconate
available)
Initiate
seizure
precauti
ons
MED DX
PATHO
Subjective
Data
Assessment data
/ Objective Data
/ Clinical
Manifestations
NSG
DX
NSG
Intervention
Desired
Outcome
SEVERE PRECLAMPSIA
Risk for fetal
injury r/t
severe
preeclampsia
Since being admitted her
severe preeclampsia has
progressed.
She has gained 3 pounds
since prenatal visit 1 week
ago. Protein dipstick is +4,
(-) ketones, (-) glucose, +2
dependent edema, and facial
puffiness.
Severe preeclampsia is a
new onset of hypertension
in pregnancy after 20
weeks gestation and with
proteinuria. BP is greater
than 160/110 mmHg, 3+
on random dipstick urine
samp sa
Olivia Jones is 23 y/o female,
G1P0 @ 36 weeks’ gestation.
She was admitted for DX of
severe preeclampsia and was
admitted to L&D unit for
assessment and surveillance.
Initial Assessment of client
in Labor and Delivery
admitted with escalating
severe preeclampsia
Pt reports headache that is not
resolved with acetaminophen.
She presents with nausea and
fatigue & complains of
epigastric pain, visual
changes and chest tightness.
Client wants to have a Pt will appear more relaxed and maternal
vital signs will be within normal limits –
Healthy baby, 1st
GOAL WAS MET.
child
Pt will maintain pregnancy until possible
fetal maturity-goal not met (pt went home
after this visit)
PT will identify s/s requiring evaluation and
Intervention-Goal was met (pt reports
epigastric pain and blurred vision)
Anxiety r/t
threat to fetus
harm related
to DX of
severe
preeclampsia
PT verbalized feeling
anxious about epigastric
pain and s/s of severe
eclampsia
Explain the
procedures, keep
communication
open and answer
PT questions
Encourage
verbalization
of fears or
concerns.
Monitor
maternal and
fetal vital
signs
The pt was not alone and
has sister with her
Deficient
knowledge r/t
lack of info to
disease process
of severe
preeclampsia
Pt did not have knowledge of
severe preeclampsia signs and
symptoms
Pt asked questions about events
taking place and communicated
where she has pain
Assess PT
knowledge about
signs and symptoms
of preeclampsia and
eclampsia.
Assess the client’s
readiness to learn
about maternal
changes
Identify signs
and symptoms
PT should report
to doctor
immediately.
RICCI, 2018