SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

TITLE: MAGNESIUM SULFATE ADMINISTRATION FOR ANTEPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITH PREECLAMPSIA (obs03) Nursing DATE: REVIEWED: PAGES: 09/83 08/11 1 of 8

ISSUED FOR: PURPOSE:

RESPONSIBILITY: RN-Obstetrics To outline nursing responsibility in the safe administration of intravenous Magnesium Sulfate. 1. 2. To safely and adequately provide care to patients receiving Magnesium Sulfate. To promote fetal and/or maternal well-being during Magnesium Sulfate administration. Magnesium Sulfate is used in the treatment and control of seizure activity in gestational hypertension (previously pregnancy induced hypertension). Magnesium Sulfate competes with the calcium necessary for conduction of nerve impulses by blocking the release of acetylcholine at the synapses thus decreasing neuromuscular irritability. Pre-eclampsia is defined as blood pressure of 140 mm HG systolic or higher or 90 mm HG diastolic or higher that occurs after 20 weeks of gestation in a woman with previously normal blood pressure and proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen). Severe pre-eclampsia is defined as the presence of one or more of the following in women diagnosed with preeclampsia Blood pressure of at least 160mmHg or diastolic of at least 110mmHg Proteinuria of at least 5 g in 24-hour collection or 3+ or greater on dipstick (ACOG 2002) Oliguria < 400 to 500 ml/24hr or persistent urine output of less than 30 ml/hr Elevated serum creatinine Cerebral and visual disturbances: altered consciousness, headache, blurred vision, and scotomata Epigastric or right upper quadrant pain Thrombocytopenia Hepatic dysfunction Fetal intrauterine growth restriction (IUGR) Development of eclampsia (below) or HELLP syndrome (hemolysis, elevated liver enzymes, lowered platelets)

OBJECTIVE:

DEFINITION:

1.

2.

3.

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)
4.

Page 2 of 8

Eclampsia Preeclamsia with seizures not attributed to other causes Reinforce the physicians explanation of the procedure. Inform the patient and support persons that the patient can expect to feel hot and have a flushed face following the bolus dose of the drug. Reinforce the need for strict bed rest in a lateral recumbent position. Encourage the patient to relax. Encourage questions, reassure patient that she (and baby, when applicable) will be observed closely. Educate the patient regarding the signs and symptoms to report to the nurse: headache, visual disturbances, epigastric distress, nausea, vomiting, right upper quadrant pain. Alleviate fears by explaining equipment, procedures, etc. prior to use, when feasible.

PATIENT EDUCATION:

1. 2.

3. 4. 5.

6.

EQUIPMENT:

Assemble the following from the nursing unit: 1. 1. 2. 3. 4. 5. 6. Ensure that proper resuscitation equipment is available in all rooms (i.e. oral airway). Oxygen and suction ready for use. Have equipment readily available to assess deep tendon reflexes. Calcium Gluconate 1g (10mL of a 10% solution) will be accessible in the pyxis, 3 ml syringes, and alcohol wipes Intravenous Administration Set, #18 peripheral cannula, alcohol wipe, 1-inch tape. Mainline intravenous solution as ordered, tubing, and extension set. Magnesium Sulfate is a high alert medication and requires independent verification each time a new bag is hung or there is a rate change. Initial Bolus dose of 4 or 6 gms Magnesium Sulfate in 50ml Sterile Water (follow physicians orders), pump tubing Maintenance dose of 250 ml Lactated ringers with 20 grams magnesium sulfate to run at 0.5-4 gms per hour as ordered by provider, (use pump tubing from initial Magnesium Sulfate bolus dose). Infusion pump. Electronic fetal monitor. Automated blood pressure monitor.

7. 8.

9. 10. 11. PROCEDURE:

BEFORE AND DURING MAGNESIUM SULFATE ADMINISTRATION: 1. 2. Ensure proper patient identification. Assess maternal vital signs, oxygen saturation, level of consciousness, characteristics of the fetal heart rate, and uterine activity.

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)
3. 4. 5.

Page 3 of 8

6.

Provide quiet, dimly lit environment when feasible. Position patient on her (L) or (R) side to promote adequate placental perfusion. Infuse magnesium sulfate as ordered by provider. Ensure compatibility of all other IV medications with magnesium sulfate. Obtain hourly intake/output a. If severe pre-eclampsia, obtain order for an indwelling Foley catheter. Notify the provider for output less than 30 ml/hour. If the provider does not want a Foley catheter inserted, encourage the patient to void every one to two hours. b. Monitor intravenous fluids carefully via electronic infusion device to prevent overload. Maintain fluid restrictions per physician order. CAUTION NOTE: Magnesium Sulfate is excreted through the kidneys. If the patients output is high, an increase in Magnesium Sulfate may be indicated. If the output is low (30ml/hour), a lower dose may be needed. The patient with a low output is at an increased risk for Magnesium Sulfate toxicity.

7.

Assess important physical parameters and document findings: a. Assess deep tendon reflexes utilizing patellar or biceps tendon bilaterally at the initiation of the bolus, PRN and as ordered by physician. Responses are as follows: 1) 0 = absent (abnormal). Notify physician and DO NOT administer Magnesium Sulfate/discontinue Magnesium Sulfate. 2) +1 = diminished. Notify physician before continuing Magnesium Sulfate administration. 3) +2 = average/normal response. Safe for Magnesium Sulfate administration. 4) +3 = brisker than average. 5) +4 = very brisk. Initiate/continue Magnesium Sulfate administration and notify provider immediately. b. Vital signs 1) Antepartum BP, pulse, respirations and 02 saturation at start of bolus dose (over 20-30 minutes) (an RN should remain at the bedside during the bolus infusion), then every 15 minutes x 4, hourly x 2, then every 2 hours or as ordered by provider for antepartum patients not in labor. 2) Intrapartum - BP, pulse, respirations and 02 saturation

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)

Page 4 of 8

at the start of the bolus dose (over 20-30 minutes) (an RN should remain at the bedside during the bolus infusion), then every 15 minutes x4, then a minimum of every 30 minutes or hourly or per labor protocol. 3) Post Partum - BP, pulse, respirations and 02 saturation every 15 minutes x 4 in recovery room. Then, if stable, hourly x 2, then every 1-2 hours while on Magnesium Sulfate, unless otherwise ordered by the provider. NOTE: Blood pressure can be obtained in semifowlers position with the arm at heart level. Reposition as needed. Be sure the patient is not lying on the cuff, as this will give a false elevated pressure. c. Fetal Monitoring: 1) Antepartum Electronic fetal monitoring per physician order. If deemed stable by the physician and transferred to the Antepartum Unit. 2) Intrapartum - Continuous external or internal electronic fetal monitoring. CAUTION NOTE: Severe pre-eclampsia puts the fetus at risk for abruptio placentae and hypoxia, due to uteroplacental insufficiency. The fetus must be constantly monitored electronically for the presence of late decelerations or other signs of hypoxia. Magnesium Sulfate may depress the central nervous system of the fetus, and therefore may diminish variability. d. Monitor labwork as ordered by provider. Notify provider of abnormal reports and non-reassuring fetal heart rate tracing. Increased hematocrit and decreased platelets may be ominous signs of worsening pre-eclampsia. Monitor serum Magnesium Sulfate levels as ordered by provider. A therapeutic range for our patients on Magnesium Sulfate therapy is 5-7mg/dL. e. Evaluate face, hands and feet for edema and record at least every shift. f. Auscultate chest for any adventitious sounds, such as: congestion, rales and rhonchi every 4 hours and PRN. g. Notify provider of signs and symptoms of pulmonary edema: 1) Tightness in chest 2) Shortness of breath 3) Shallow, rapid respirations 4) Wheezing 5) Coughing, with or without frothy sputum 6) Tachycardia

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)

Page 5 of 8

8. 9.

h. Observe for signs of impending eclampsia, such as: 1) Epigastric pain and/or right upper quadrant pain, nausea and vomiting 2) Headache, visual disturbances 3) Increased hyperactivity 4) Tremors 5) Clonus Limit visitors. Keep side rails up. Follow Seizure Precautions Procedure (neu05):

DURING SEIZURES 1. Provide privacy for the patient. 2. Loosen restrictive clothing, particularly around the neck. 3. Stay with the patient during the seizure; press the call light but do not leave the patient. 4. If patient falls to the floor, protect the head with padding, e.g., blanket, pillows. 5. If seated when seizure occurs, lower to the floor and place in a side-lying position. 6. Never forcefully turn neck or rigid extremity once the seizure starts. 7. Turn the patient to the side to maintain open airway, if possible and to prevent aspiration. Assess breathing pattern (labored, apnea, etc.) and apply oxygen if needed. 8. Do not try to move the patient to another place. 9. Do not attempt to open the patients mouth during a seizure. DO NOT try to force a spoon, padded tongue blade, oral airway or your finger between the patients teeth during the seizure. Forcing anything in can push the tongue into the throat and occlude the airway. 10. Administer magnesium sulfate as ordered by provider to control seizure activity as a result of preeclampsia/eclampsia. PRECAUTIONS/CARE AFTER THE SEIZURE 1. Remain with the patient. 2. When the patient is in a safe position, remove as much excess secretion from the mouth as possible. A low suction device may be used if available. 3. Use an oral airway only if the patient is unable to maintain his/her own airway and there is no gag reflex (patient will gag on oral airway and vomit, increasing risk of aspiration). If patient has gag reflex, clenched teeth and still has upper airway stridor or sign of obstruction, a naso-pharyngeal airway may be tried. 4. Cover the patient to keep him/her warm and protect him/her from the embarrassment of incontinence. 5. Seek help now if needed. 6. Be conscious that the sense of hearing is the first to return. Speak quietly and calmly to the patient.

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)

Page 6 of 8

7. Do not give the patient anything to eat or drink until he/she is fully awake. 8. Anticipate medication orders and/or IV orders. 9. Monitor vital signs, including pulse oximetry. 10. Keep the bed height at the lowest level. 11. Keep O2 and suctioning equipment at the patients beside. 12. Continue to observe the patient, including frequent neurological checks. Documentation to include: 1. Presence or absence of an aura. 2. Time seizure began and duration of seizure. 3. Progression of the seizure; e.g., localized or spread from one body part to another. 5. Describe specific activity during seizure (stiffening, jerking, and tremors). 6. Describe falls before or during seizure. 7. Level of consciousness during seizure. 8. Respiratory changes (dyspnea, apnea, and cyanosis). 9. Deviation of head and eyes during seizure. 10. Pupil reaction after seizure. 11. Incontinence of urine or feces. Post seizure information including weakness, paralysis, speech difficulty, discomfort, headache, behavioral changes and patient recollection of seizure if any. 12. Monitor fetal well-being by observing for: a. Hyperactivity of uterus. b. Decreased baseline variability, which may indicate depressed fetal CNS. c. Intrapartum complications, e.g., hemorrhage, abruption, shock, maternal respiratory distress. 13. Provide psychological support. Keep patient and family informed. 14. Administer sedation as ordered. Monitor and document the patients response. 15. Start mainline intravenous access, if not in progress. May consider a second site. 16. Magnesium Sulfate solution will be mixed per pharmacy as ordered and administered IVPB utilizing an Infusion Pump. 17. Label IV with time of start. Independent verification required. 18. Common methods of Magnesium Sulfate administrations are IV, IM, or a combination of the two. a. IM - 10gm (5 each buttock), 50% solution, initial dose, and then 5gm every 4 hours. All IM Magnesium Sulfate is given with a 3-inch needle, deep Z-track, slowly. Effects last 3 to 4 hours with IM administration. b. IV 4 to 6 gm in 50ml SW infused over 20-30 minutes, followed by maintenance dose of 1 to 4 gm/hour by infusion

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)

Page 7 of 8

pump. Any subsequent bolus dose of Magnesium Sulfate will be 50 ml SW with 4 to 6 gms Magnesium Sulfate over 20-30 minutes. c. Maintenance dose of Magnesium Sulfate is 20 gms in 250 ml Lactated Ringers to infuse at 1- 4 gm/hour. d. All Magnesium Sulfate IVs should be maintained on an infusion pump. *Special note* All Magnesium Sulfate IV bags should be attached to the mainline IV tubing with extension set. The port on the extension set closest to the patient is the one to be used. CAUTION NOTES: a. Prior to repeating Magnesium Sulfate, if increasing dosages or giving IM, perform independent verification of medication and reassess the patient for: 1) Deep tendon reflexes are present. 2) Respiratory rate is more than 12/minute. 3) Urine output is at least 30ml/hour. b. Patient response to rise in serum levels: 1) Therapeutic: 5-7.mg/dL 2) Loss of deep tendon reflexes: 10 mg/dL 3) Respiratory failure: 12 mg/dL Calcium Gluconate is the antidote for Magnesium Sulfate toxicity. If ordered, administer Calcium Gluconate 1gm (10 ml of a 10 % solution) IV over 3 minutes. c. The signs of Magnesium Sulfate toxicity include: 1) Absent DTRs 2) Respirations less than 12/minute, shortness of breath, or respiratory arrest 3) Chest pain 4) Urinary output less than 30ml/hour 5) A significant drop in pulse or BP 6) Signs of fetal distress 7) Coma CAUTION NOTES: If magnesium sulfate toxicity is suspected, discontinue infusion, notify provider, and Rapid Response Team (3911) if necessary 19. After delivery of the infant, the post partum patient on Magnesium Sulfate may be transferred to Mother Baby Unit after 6 hours if patient is stable. No patient on Magnesium Sulfate will be transferred to 10 WT. 20. When care is transferred to another nurse, have both nurses together at the bedside review the pump settings for both the magnesium sulfate and the mainline IV fluids and review the providers orders for magnesium sulfate in carevision.

MAGNESIUM SULFATE ADMINISTRATION FOR ANETPARTUM, INTRAPARTUM AND POSTPARTUM PATIENTS WITHPRE-ECLAMPSIA (obs03)
DOCUMENTATION: 1. 2. 3. 4. 5.

Page 8 of 8

Pertinent maternal and fetal assessments. Initiation of all protocols used in patient care. All nursing and medical interventions and patient response. Physician notification including indication and response. Any seizure activity and subsequent fetal and maternal responses.

REFERENCE(S):

1. American Congress of Obstetricians and Gynecologists (2007): Diagnosis and management of Preeclampsia and Eclampsia. ACOG Practice Bulletin Number 33, original date: 2002. 2. Mattson, s., Smith, J. (2004). Core Curriculum for MaternalNewborn Nursing (Third edition). Saunders. St. Louis, MO. 3. Seizure Precautions Nursing Procedure (neu05). Reviewed by Shannon McClain, RN, BSN, Clinical Practice Specialist Neuro/Urology Unit. (11/10).

REVIEWING AUTHOR(S): Debbie Dietz, RNC, MSN, APN, Labor and Delivery Renee Maietta, RNC, CPS, Mother Baby Unit/Antepartum