NR 327 Amber Rhodes Simulation

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Introduction

While providing care for a patient with preeclampsia and HELLP Syndrome, nurses must remain vigilant and observe various maternal assessment findings that can indicate the severity of the condition. Hypertension, marked by elevated blood pressure, is a prominent characteristic, and regular monitoring is crucial to detect any fluctuations or sustained elevation. Patients with preeclampsia often experience rapid weight gain and generalized edema due to fluid retention, primarily affecting the face, hands, and lower extremities. Proteinuria, the presence of protein in the urine, is assessed to evaluate kidney involvement.

In addition to these findings, preeclampsia can manifest vascular constriction in the retina, affecting the blood vessels in the eyes. Nurses can identify signs of retinal vascular compression through a fundoscopic examination. Brisk deep tendon reflexes, known as hyperreflexia, are commonly observed in preeclamptic patients, reflecting abnormal neurological effects. Epigastric pain, severe upper abdominal or epigastric discomfort, may indicate liver involvement and potential complications.

NR 327 Amber Rhodes Simulation

HELLP Syndrome, a severe preeclampsia, is characterized by specific laboratory findings, including hemolysis (red blood cell breakdown), elevated liver enzymes, and low platelet counts. These markers indicate significant organ dysfunction and potential risks, and regular monitoring of blood tests is necessary. Regarding fetal assessment, nurses caring for preeclamptic patients with HELLP Syndrome should observe several indicators. Reduced fetal movement or decreased activity may suggest compromised fetal well-being. Preeclampsia can also lead to intrauterine growth restriction (IUGR), resulting in a smaller-than-expected fetal size. Fundal height measurements and ultrasounds monitor fetal growth and ensure proper development.

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Nurses closely monitor the fetal heart rate pattern during labor, paying attention to signs of deceleration. Late decelerations in the fetal heart rate tracing are associated with placental insufficiency and insufficient oxygen supply to the fetus. Preeclampsia can also cause decreased fetal heart rate tracing variability, indicating fetal distress. Any significant changes or reduced variability should be noted. During labor, continuous monitoring of both the mother and fetus is crucial. The nurse assesses the fetus for persistent late decelerations during contractions, decreased variability, or any other reassuring patterns in the fetal heart rate tracing that indicate a healthy fetal response to labor. Simultaneously, the nurse closely observes the mother for signs of an impending seizure, as preeclampsia can progress to eclampsia. Visual disturbances, changes in the level of consciousness, headaches, and regular labor signs such as effacement and cervical dilation are assessed for the early detection of seizure activity.

NR 327 Amber Rhodes Simulation

By closely monitoring these maternal and fetal assessment findings, nurses can provide appropriate care and promptly intervene to ensure the well-being and safety of the mother and the fetus during the challenging management of preeclampsia with HELLP Syndrome.

Nursing Considerations for Magnesium Sulfate

Nurses must consider several essential factors when caring for preeclamptic patients receiving magnesium sulfate. Magnesium sulfate is primarily used to prevent seizures in these patients but can also be utilized to halt preterm labor contractions. During administering magnesium sulfate, the nurse must maintain awareness of the therapeutic levels, which typically range from 4 to 8 mg/dL. The nurse must have calcium gluconate, the antidote for magnesium sulfate, readily available in case of toxicity. Vigilance for signs of magnesium toxicity is essential, including a respiratory rate below 12 breaths per minute, urine output less than 30 mL per hour, absence of deep tendon reflexes (DTR), a consistent oxygen saturation reading of less than 95%, sweating or flushing, and decreased level of consciousness. Recognizing these signs promptly is critical for the safety and well-being of the patient.

Safety Considerations

When caring for preeclamptic patients with HELLP syndrome, it is vital to prioritize safety and consider specific environmental factors. Several safety considerations should be considered, including the risk of seizures, falls, and orthostatic hypotension. To address these concerns, nurses should implement appropriate nursing interventions. Seizure precautions should be diligently followed, which may involve ensuring a safe environment free of potential hazards, padding the bedrails, and keeping emergency equipment readily available.

NR 327 Amber Rhodes Simulation

Additionally, the patient should be identified as at risk for falls by providing them with a hospital bracelet or other means of identification. The patient should be educated on the importance of calling for assistance when getting up, emphasizing the need to avoid sudden movements or standing up without support. Regular assessments of orthostatic blood pressure should be conducted to monitor for any signs of orthostatic hypotension and take appropriate measures to prevent falls. By implementing these safety measures and interventions, the nurse can help mitigate potential risks and ensure the well-being of the preeclamptic patient with HELLP syndrome.

References

McKinney, E.S. & Murray, S.S. (2014). Foundations of Maternal-Newborn and Women’s Health Nursing. (6th Ed.). St. Louis, Missouri: Elsevier Inc.