Nursing Diagnosis: Aurelio, Lyca Mae M. BSN II-D

Aurelio, Lyca Mae M.
BSN II-D
Nursing Diagnosis
Risk for maternal injury related to tonic-clonic convulsions
Nursing Inference
Preeclampsia by definition is a prodrome for eclampsia, a condition that only occurs
during pregnancy and causes seizures. The blood pressure, or the force of blood against the walls
of arteries, becomes high enough to damage the arteries and other blood vessels. Damage to the
arteries may restrict blood flow. It can produce swelling in the blood vessels in the brain and to
the growing baby. If this abnormal blood flow through vessels interferes with the brain’s ability
to function, pre-eclampsia will progressed into eclampsia, thus tonic-clinic convulsions will occur.
With eclampsia, the maternal mortality is high from cause such as cerebral hemorrhage,
circulatory collapse or renal failure.
Nursing Goal
After 8 hours of nursing interventions the patient’s condition will not be able to progress into
pre-eclampsia to eclampsia state and tonic-clonic convulsions will not occur.
Nursing Intervention Rationale

Stress importance of client promptly Delayed treatment or progressive onset of
reporting Delayed treatment or progressive symptoms signs/symptoms of CNS
onset of symptoms signs/symptoms of CNS involvement may result in tonic-clonic
involvement convulsions or eclampsia.
Assess for signs of impending eclampsia: Generalized edema/vasoconstriction,
hyperactivity of deep tendon reflexes (3+ to manifested by severe CNS, kidney, liver,
4+), ankle clonus, decreased pulse and cardiovascular, and respiratory involvement,
respirations, epigastric pain, and oliguria (less precede convulsive state.
than 50 ml/hr).
Keep room quiet and dimly lit, limit visitors, Institute measures to reduce likelihood of
plan and coordinate care, and promote rest. seizures by reducing environmental factors
that may stimulate irritable cerebrum and
cause a convulsive state.
Implement seizure precautions per protocol. If seizure does occur, reduces risk of injury.
In the event of a seizure:
Turn client on side; insert airway/bite block Maintains airway by reducing risk of
only if mouth is relaxed; suction nasopharynx, aspiration and preventing tongue from
as indicated; administer oxygen; remove occluding airway. It also maximizes
restrictive clothing; do not restrict movement. oxygenation.
Document motor involvement, duration of
seizure, and postseizure behavior.
Palpate for uterine tenderness or rigidity; These signs may indicate abruptio placentae,
check for vaginal bleeding. Note history of especially if there is a preexisting medical
other medical problems. problem, such as diabetes mellitus, or a renal
or cardiac disorder causing vascular
involvement
Observe for signs and symptoms of labor or Convulsions increase uterine irritability; labor
uterine contractions. may ensue.
Assess fetal well-being, noting FHR. During seizure activity, fetal bradycardia may
occur.
Hospitalize if CNS involvement is present. Prompt initiation of therapy helps to ensure
safety and limit complications.
Administer magnesium sulfate via IM or IV Magnesium sulfate, a CNS depressant,
infusion pump as prescribed. decreases acetylcholine release, blocks
neuromuscular transmission, and prevents
seizures. It has a transient effect of lowering
BP and increasing urine output by altering
vascular response to pressor substances
Monitor BP before, during, and after MgSO4 To ensure that the therapeutic level of
administration. Note serum magnesium levels magnesium sulfate is achieved (4.0–7.5 mEq/L
in conjunction with respiratory rate, or 6–8 mg/dL) and adverse/toxic reactions did
patellar/deep tendon reflex (DTRs), and urine not develop (above 10–12 mg/dL).
output.
Administer calcium gluconate as prescribed Serves as antidote to counteract
adverse/toxic effects of magnesium sulfate.
Administer amobarbital or diazepem Depresses cerebral activity; has sedative
(Valium), as prescribed. effect when convulsions are not controlled by
MgSO4 however it is not recommended as
first-line therapy because sedative effect also
extends to the fetus.
Prepare for cesarean birth if PIH is severe, When fetal oxygenation is severely reduced
placental functioning is compromised, and owing to vasoconstriction within
cervix is not ripe or is not responsive to malfunctioning placenta, immediate delivery
induction. may be necessary to save the fetus.
Nursing Evaluation
After 8 hours of nursing interventions, the goal is met, the patient’s condition did not
progress into pre-eclampsia to eclampsia state and tonic-clonic convulsions did not occurred.

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