Preeclampsia nursing care: what to assess and what to do first

The clinical picture

Preeclampsia is new-onset hypertension, systolic 140 mmHg or higher or diastolic 90 mmHg or higher on two occasions at least four hours apart, arising after 20 weeks of gestation in a woman with previously normal blood pressure. It is accompanied by proteinuria, typically 300 mg or more in a 24-hour urine collection, or a protein-to-creatinine ratio of 0.3 or higher. In the absence of proteinuria, new hypertension plus thrombocytopenia, impaired liver function, renal insufficiency, pulmonary oedema, or new cerebral or visual symptoms meets criteria as well.

The disease is a placental and endothelial problem, not simply raised blood pressure. Poor placental perfusion triggers release of anti-angiogenic factors into the maternal circulation, causing widespread vasospasm and endothelial injury across kidneys, liver, brain and the placental bed itself. That is why preeclampsia is systemic: it explains proteinuria, deranged liver enzymes, low platelets, and cerebral irritability all from one process. Severe features, blood pressure of 160/110 mmHg or higher, platelets below 100,000, liver enzymes more than twice normal, renal impairment, pulmonary oedema, or new headache or visual changes, mark the point at which the risk of eclampsia and other end-organ damage rises sharply.

Assessment: what to look for and in what order

Blood pressure first, taken with the correct cuff size, patient seated or in left lateral tilt, repeated to confirm before acting. Then urine protein, either dipstick as a screen or a sent sample for protein-to-creatinine ratio. Weigh the patient and compare against baseline; rapid weight gain from oedema is a supporting sign, though it is no longer a diagnostic criterion on its own.

Next, ask about headache, specifically whether it is new, severe, or unlike any she has had before, and ask about visual changes, blurring, spots, flashing lights, or scotomata. This pairing, a severe headache with visual disturbance in a woman with hypertension and proteinuria after 20 weeks, is the clinical sign that eclampsia is imminent and takes priority over any other finding on the list. Follow with right upper quadrant or epigastric pain, which suggests hepatic involvement, and check deep tendon reflexes for hyperreflexia and sustained clonus, both markers of CNS irritability.

Round out the assessment with fetal status, continuous monitoring for heart rate and reduced movement, and bloods: full blood count for platelets, liver function tests, renal function, and consider LDH and a peripheral smear if HELLP syndrome is suspected. Assess urine output hourly if severe features are present; oliguria below 30 mL/hour signals renal compromise.

Immediate interventions

If the patient reports a severe headache with visual changes, treat it as a pre-seizure warning, not a routine complaint. Notify the provider immediately, place the patient on continuous fetal and maternal monitoring, and prepare for magnesium sulfate administration per unit protocol, typically a 4-6 g loading dose over 20-30 minutes followed by a maintenance infusion, to prevent progression to eclampsia.

For severe hypertension, systolic 160 mmHg or higher or diastolic 110 mmHg or higher sustained over 15 minutes, antihypertensive treatment is urgent, commonly labetalol, hydralazine, or oral nifedipine depending on unit protocol and how quickly access is needed. Seizure precautions go up at the same time: padded side rails, suction and oxygen at the bedside, and the room kept dim and quiet to reduce stimulation that can provoke seizure activity.

Insert an indwelling catheter to track hourly output if severe features are present, since magnesium sulfate is renally cleared and oliguria raises the risk of toxicity. Have calcium gluconate available at the bedside as the antidote for magnesium toxicity, and confirm patellar reflexes, respiratory rate above 12 per minute, and adequate urine output before and during each magnesium dose.

Ongoing nursing management

Reassess blood pressure at the interval set by severity, every 15 to 30 minutes if severe, hourly or per protocol if not. Continue neurological checks: reflexes, clonus, level of consciousness, and repeat questioning about headache and vision at every assessment cycle rather than only on admission.

Monitor for magnesium toxicity throughout the infusion: diminished or absent deep tendon reflexes, respiratory depression, and decreasing urine output are the sequence to watch, in that order of onset for most patients. Trend liver enzymes and platelets on the schedule the provider sets, since a falling platelet count or rising AST/ALT can signal progression toward HELLP syndrome even when blood pressure looks stable.

Maintain continuous or frequent fetal surveillance, and document intake and output strictly. Position the patient in left lateral tilt when possible to optimise placental perfusion, and keep the environment as free of sudden stimuli as the unit allows for the duration of magnesium therapy.

Patient and family education

Explain in plain terms why headache and visual changes must be reported the moment they start, not at the next scheduled check. Tell the patient that this is not the same as an ordinary headache and that reporting it early is what prevents the disease progressing to seizure.

Describe what magnesium sulfate does and why it may cause flushing, warmth, or a heavy feeling, so the sensation itself does not alarm her. Cover what recovery looks like: blood pressure and proteinuria usually begin resolving after delivery, though hypertension can persist for days to weeks, and follow-up blood pressure checks are needed even after discharge.

Tell the family what seizure precautions mean and why the room is kept dim, so they understand the environment rather than assume something has gone wrong. Reinforce that future pregnancies carry a higher risk of preeclampsia recurring and that early, regular prenatal care is the primary way that risk is managed.

How this appears on the NCLEX

NCLEX items on preeclampsia frequently test whether the candidate recognises the headache-plus-visual-changes combination as the priority finding over a mildly elevated blood pressure reading or routine oedema. Expect a question stem listing several assessment findings and asking which to report first, or which finding indicates the condition is worsening toward eclampsia.

Magnesium sulfate questions test the toxicity triad, absent reflexes, low respiratory rate, and reduced urine output, and expect the test-taker to know calcium gluconate as the antidote. Questions may also test prioritisation: given several tasks, choosing to assess deep tendon reflexes and respiratory rate before continuing a magnesium infusion, or choosing to notify the provider before administering the next dose when a finding is abnormal.