What is the immediate nursing care plan for a 36-week pregnant patient with pre-eclampsia, controlled blood pressure (120/90 mmHg), on methyldopa and receiving Intravenous (IV) fluid (Peripheral Nutrition Support Solution (PNSS)) at 40 drops per minute (gtts/min)?

Nursing Care Plan for 36-Week Pregnant Patient with Controlled Pre-eclampsia

Immediate Nursing Priorities

Continue current management with methyldopa and IV fluids while implementing intensive maternal-fetal monitoring, as this patient has controlled blood pressure (120/90 mmHg) but remains at risk for rapid progression to severe pre-eclampsia or eclampsia at any time. 1, 2

Blood Pressure Monitoring and Management

• Measure blood pressure every 1-2 hours using proper technique with appropriate cuff size, as errors in BP measurement have been implicated in maternal deaths 1
• Maintain target BP below 160/110 mmHg to prevent hypertensive emergency and maternal stroke 1, 2
• Current BP of 120/90 mmHg indicates adequate control with methyldopa, which is appropriate first-line therapy 1, 2, 3
• Prepare for immediate intervention if systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg, as this constitutes a hypertensive emergency requiring treatment within 15 minutes 2, 4

Neurological Assessment

• Assess for symptoms of imminent eclampsia every 2-4 hours: severe headache, visual disturbances (blurred vision, scotomata, photophobia), altered mental status, and hyperreflexia 1, 5, 6
• Monitor for seizure activity continuously, as 34% of eclamptic women have maximum diastolic BP ≤100 mmHg, meaning seizures can occur even with controlled BP 1
• Keep magnesium sulfate readily available for seizure prophylaxis if severe features develop 2, 3

Renal and Hepatic Monitoring

• Check urine protein at least daily using dipstick, as new or worsening proteinuria indicates disease progression 1, 5
• Monitor for oliguria (urine output <30 mL/hour), which signals renal impairment and requires immediate physician notification 5, 3
• Assess for epigastric or right upper quadrant pain every 4 hours, as this indicates hepatic involvement and potential HELLP syndrome 1, 5, 3

Fluid Management

• Maintain IV PNSS at 40 gtts/min as ordered, but monitor closely for fluid overload, as pre-eclamptic patients are at high risk for pulmonary edema 1, 3
• Strict intake and output monitoring with hourly urine output measurement 3
• Assess for signs of pulmonary edema: dyspnea, tachypnea, crackles on auscultation, oxygen saturation <95% 5, 3
• Limit total IV fluids to avoid volume overload, as endothelial dysfunction in pre-eclampsia causes capillary leak 5

Fetal Surveillance

• Continuous fetal heart rate monitoring to detect fetal distress, as placental insufficiency is common in pre-eclampsia 1, 5
• Ask patient about fetal movements every shift, as reduced movements indicate fetal compromise requiring immediate evaluation 1
• Prepare for potential delivery, as severe pre-eclampsia at ≥34 weeks requires prompt delivery regardless of gestational age 1

Laboratory Monitoring

• Daily complete blood count to monitor for thrombocytopenia (<100,000/μL), which is a severity criterion 5, 3
• Daily liver function tests to detect elevated transaminases (>2x normal) indicating HELLP syndrome 5, 3
• Daily renal function tests (creatinine, BUN) to assess for renal impairment 5, 3

Patient Education and Symptom Recognition

• Educate patient to immediately report: severe headache, visual changes, epigastric pain, decreased fetal movement, or any new symptoms 1
• Explain that pre-eclampsia can progress rapidly (average 2 weeks from diagnosis to life-threatening complications), even with controlled BP 1
• Ensure patient understands the importance of bed rest and avoiding sudden position changes 3

Preparation for Potential Complications

• Keep emergency equipment at bedside: oxygen, suction, airway management supplies, IV labetalol or hydralazine for hypertensive crisis 1, 4
• Have magnesium sulfate protocol readily available with calcium gluconate antidote at bedside 2, 3
• Coordinate with obstetric team for potential delivery planning, as this patient is at 36 weeks and may require delivery if severe features develop 1, 5

Critical Red Flags Requiring Immediate Physician Notification

• BP ≥160/110 mmHg (hypertensive emergency) 1, 2, 4
• New onset of severe headache or visual disturbances (imminent eclampsia) 1, 5
• Epigastric or right upper quadrant pain (hepatic involvement/HELLP) 1, 5
• Oliguria <30 mL/hour for 2 consecutive hours (renal failure) 5, 3
• Decreased fetal movement or non-reassuring fetal heart rate (fetal compromise) 1, 5

Postpartum Considerations

• Continue methyldopa postpartum initially, but avoid long-term use due to risk of postpartum depression 1
• Monitor BP closely for 5-7 days postpartum, as BP typically rises during this period 1
• Plan for BP assessment at 6 weeks postpartum to evaluate for persistent hypertension 1