Nursing Diagnosis for Pregnancy Induced Hypertension: A Comprehensive Guide

Preeclampsia, a significant complication arising during pregnancy, affects 5-7% of pregnancies globally. It’s defined by the new onset of elevated blood pressure (≥ 140/90 mmHg) and the presence of protein in the urine (proteinuria) after the 20th week of gestation. Research indicates that preeclampsia can stem from placental development issues, genetic predispositions, environmental factors, and changes in the mother’s cardiovascular and inflammatory systems.

This condition can impede fetal growth, elevate the risk of placental abruption, damage maternal organs, and potentially progress to eclampsia, a severe state characterized by seizures. Delivery of the baby remains the only definitive treatment for preeclampsia, with symptoms typically resolving within days to weeks postpartum.

This article delves into the critical role of nursing in managing pregnancy-induced hypertension, focusing on nursing assessments, interventions, and care plans tailored to address various nursing diagnoses associated with this condition.

The Nursing Process in Managing Pregnancy Induced Hypertension

Nurses play a crucial role in the early identification and management of high-risk pregnancies to mitigate the impact of pregnancy-induced hypertension. A thorough nursing assessment, coupled with patient education and consistent antenatal care, forms the cornerstone of effective intervention. Many cases of pregnancy-induced hypertension and preeclampsia are potentially avoidable with timely and appropriate nursing actions.

Key nursing interventions include:

• Continuous monitoring of the patient’s blood pressure and associated symptoms.
• Implementation of stress management techniques.
• Guidance on weight management.
• Ensuring proper nutrition.
• Regular monitoring of the fetal heart rate (FHR).
• Facilitating consistent OB/GYN follow-ups and comprehensive prenatal care.

Nursing Assessment for Pregnancy Induced Hypertension

The initial phase of nursing care involves a comprehensive nursing assessment. This process encompasses gathering physical, psychosocial, emotional, and diagnostic data. We will explore both subjective and objective data pertinent to pregnancy-induced hypertension and preeclampsia.

Review of Health History

1. Identifying General Symptoms of Preeclampsia. The classic triad of symptoms for preeclampsia includes hypertension, proteinuria, and edema. However, nurses should also assess for other indicative symptoms:

• Frequent and severe headaches
• Vision abnormalities (e.g., blurred vision, seeing spots)
• Shortness of breath or dyspnea
• Epigastric pain (upper abdominal pain)

2. Determining Patient Risk Factors. Identifying risk factors is crucial for early recognition of women at higher risk for developing pregnancy-induced hypertension and preeclampsia:

• Multiple-gestation pregnancy (twins, triplets, etc.)
• Pre-pregnancy obesity
• Pre-existing gestational diabetes or family history of diabetes
• Family or personal history of preeclampsia
• Nulliparity (first pregnancy)
• Advanced maternal age (over 40 years) or teenage pregnancy (under 20 years)
• Polyhydramnios (excessive amniotic fluid)
• Pre-existing conditions such as chronic hypertension, diabetes, renal disease, and autoimmune disorders (e.g., lupus).
• African American ethnicity
• Use of assisted reproductive technology like in vitro fertilization (IVF)

3. Medication Review. Certain medications taken during pregnancy may increase the risk of developing pregnancy-induced hypertension:

• Antidepressants, particularly SSRIs and SNRIs
• Benzodiazepines
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Antiretroviral medications for HIV treatment
• Triptans used for migraine treatment
• Asthma medication montelukast
• Methamphetamine use

4. Assessing Patient Knowledge of Preeclampsia. Evaluate the patient’s current understanding of pregnancy-induced hypertension and preeclampsia. Misconceptions may arise from prior knowledge, cultural beliefs, or familial experiences. Understanding their baseline knowledge is essential for tailored education and support.

Physical Assessment

1. Close Monitoring of Maternal Vital Signs. Elevated blood pressure is a primary indicator. Preeclampsia is diagnosed when blood pressure readings are ≥ 140/90 mmHg on two separate occasions, at least four hours apart, after 20 weeks of gestation, accompanied by diagnostic testing results.

2. Respiratory Status Assessment. Auscultate the lungs, especially if the patient reports shortness of breath. Adventitious breath sounds (e.g., crackles or rales) could indicate pulmonary edema, a serious complication associated with fluid overload in preeclampsia.

3. Abdominal Palpation. Palpate the right upper quadrant and epigastric region for tenderness. Liver involvement, indicated by tenderness in these areas, occurs in approximately 10% of severe preeclampsia cases, suggesting HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).

4. Edema Assessment. Assess for edema, noting its location and severity. While mild edema in the lower extremities is common in pregnancy, rapid increases in dependent edema or the presence of edema in the hands and face are more concerning and indicative of fluid retention associated with preeclampsia.

Image alt text: A nurse using a sphygmomanometer to measure the blood pressure of a pregnant woman in a clinic setting, illustrating routine prenatal monitoring for hypertension.

5. Fetal Growth Monitoring. Preeclampsia can impair blood flow to the placenta, potentially leading to fetal growth restriction due to insufficient oxygen and nutrient supply to the fetus. Fundal height measurements and fetal ultrasounds are used to monitor fetal growth.

6. Regular Weight Monitoring. Sudden weight gain exceeding 3–5 pounds per week can be a sign of fluid retention associated with preeclampsia. Regular weight checks are important for identifying rapid fluid accumulation.

7. Intake and Output Tracking. Decreased urine output (oliguria) may signify impaired kidney function due to reduced circulatory blood volume. Reduced urine production can exacerbate fluid retention (edema) and hypertension. Monitoring intake and output helps assess fluid balance and kidney function.

8. Monitoring for Seizures. Seizure activity in a patient with preeclampsia, without other identifiable causes, indicates progression to eclampsia, a medical emergency. Continuous monitoring for neurological changes is crucial.

Diagnostic Procedures

1. Urine Tests. Urine tests are essential for diagnosing proteinuria, a hallmark of preeclampsia:

• Urine dipstick: A result of 1+ protein or greater on a random urine sample.
• 24-hour urine collection: Protein excretion of 300 mg or more in 24 hours.
• Urine protein to creatinine ratio: A ratio greater than 0.3 indicates significant proteinuria.

2. Blood Tests. Blood tests assess for abnormalities associated with preeclampsia severity:

• Complete blood count (CBC): To detect thrombocytopenia (platelet count < 100,000/mm³), which is indicative of HELLP syndrome or severe preeclampsia.
• Complete metabolic panel (CMP): To evaluate liver function by checking for elevated liver enzymes (AST and ALT), also associated with HELLP syndrome. It also assesses renal function by measuring creatinine levels.
• Renal function tests: Increased serum creatinine (> 1.1 mg/dL) may indicate renal insufficiency.

3. Fetal Status Assessment. Assessing fetal well-being is critical:

• Non-stress test (NST) and biophysical profile (BPP): To evaluate fetal heart rate patterns, movement, breathing, and amniotic fluid volume.
• Ultrasound: To assess amniotic fluid index (AFI) and estimated fetal weight, monitoring fetal growth and well-being.
• Doppler velocimetry: To assess blood flow in the umbilical artery and middle cerebral artery, indicating placental function and fetal adaptation.

4. Advanced Imaging. In cases of severe headaches, neurological deficits, or seizures, CT scans or MRI of the brain may be utilized to rule out intracranial abnormalities or complications like cerebral edema or hemorrhage.

Nursing Interventions for Pregnancy Induced Hypertension

Effective nursing interventions are vital for managing pregnancy-induced hypertension and ensuring positive outcomes for both mother and baby.

Managing Pregnancy-Induced Hypertension

1. Early Diagnosis and Intervention. Prompt diagnosis is paramount. Emphasize vigilant blood pressure management and seizure prevention strategies as primary goals.

2. Medication Administration. Antihypertensive medications are crucial for controlling blood pressure. Common medications include:

• IV Labetalol: A beta-blocker often used for rapid blood pressure control.
• IV Hydralazine: A vasodilator used to lower blood pressure.
• Oral Nifedipine: A calcium channel blocker for blood pressure management.

3. Aspirin Therapy. For women at high risk of developing preeclampsia, low-dose aspirin therapy (81mg daily) is often recommended, initiated in the late first trimester and continued through the third trimester to reduce the risk.

4. Activity Modification. While strict bed rest is no longer routinely recommended, reducing strenuous physical activity can help lower blood pressure. Advise patients to avoid overexertion and ensure adequate rest periods.

5. Expectant Management Education. For stable patients undergoing expectant management (delaying delivery), thorough education is essential:

• Serial ultrasonography to monitor fetal growth and well-being.
• Weekly antepartum testing (NST, BPP) to assess fetal health.
• Close monitoring of maternal symptoms and blood pressure at home.
• Routine laboratory tests to assess maternal condition.

6. Delivery of the Fetus. Delivery is the only cure for preeclampsia. Timing of delivery depends on gestational age and disease severity:

• Gestational hypertension or preeclampsia without severe features: Delivery is typically planned at 37 weeks of gestation.
• Severe preeclampsia: Delivery may be indicated as early as 34 weeks, or earlier depending on maternal and fetal status.

7. Betamethasone Administration. If preterm delivery is anticipated before 34 weeks, betamethasone (a corticosteroid) is administered to the mother to accelerate fetal lung maturation and reduce the risk of neonatal respiratory distress syndrome.

8. Seizure Prevention. Intravenous magnesium sulfate is the primary medication for seizure prophylaxis in women with preeclampsia, particularly those with severe features. Magnesium sulfate helps prevent eclampsia by acting as a central nervous system depressant.

Image alt text: A nurse carefully adjusting the flow rate of an intravenous (IV) drip, highlighting the administration of medication in managing preeclampsia.

Preventing Complications

1. Postpartum Monitoring. Preeclampsia typically resolves after delivery, but hypertension and seizures can still occur up to six weeks postpartum. Continue monitoring blood pressure and symptoms during postpartum follow-up visits.

2. Dietary Recommendations. Educate patients on dietary modifications to help manage blood pressure and edema:

• Reduce sodium intake to minimize fluid retention.
• Increase intake of calcium, magnesium, and potassium through diet or supplements, as these nutrients play roles in blood pressure regulation.
• Limit processed foods, fried foods, salty snacks, and sugary drinks.
• Encourage a balanced diet rich in fruits, vegetables, lean proteins, and whole grains.

3. Patient Education on Warning Signs. Instruct patients to seek immediate medical attention if they experience any of the following postpartum symptoms:

• Seizures
• Difficulty breathing or worsening shortness of breath
• Severe or sharp abdominal pain
• Blurred vision or other visual disturbances
• Persistent, severe headaches
• Decreased fetal movement (if still pregnant)
• Vaginal bleeding

4. Treatment Adherence. Emphasize the importance of adherence to prescribed medications, dietary and lifestyle modifications, and scheduled prenatal and postpartum care appointments.

5. Stress Management Techniques. Stress can exacerbate hypertension. Educate patients on stress management techniques:

• Deep breathing exercises
• Relaxation techniques (e.g., meditation, yoga)
• Gentle aerobic exercise, as advised by healthcare provider.

6. Counseling on Future Pregnancy Risks. Inform women with a history of preeclampsia about the increased risk of recurrence in subsequent pregnancies. The risk is higher with a history of severe preeclampsia. Early and close prenatal care is essential in future pregnancies.

7. Cardiovascular Disease Risk Education. Women who have had preeclampsia are at a higher lifetime risk of developing cardiovascular disease. Counsel them on the importance of regular blood pressure screenings and lifestyle modifications to reduce CVD risk, including exercise, weight management, a heart-healthy diet, and avoiding smoking and excessive alcohol.

Nursing Care Plans for Pregnancy Induced Hypertension

Once nursing diagnoses are identified, nursing care plans guide the prioritization of assessments and interventions to achieve both short-term and long-term care goals. Here are examples of nursing care plans for common nursing diagnoses associated with pregnancy-induced hypertension.

Decreased Cardiac Output

Decreased cardiac output in preeclampsia can result from increased cardiac demands and reduced blood volume.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Hypovolemia
• Decreased venous return
• Increased systemic vascular resistance

As evidenced by:

• Alterations in blood pressure (hypertension)
• Hemodynamic changes
• Edema
• Dyspnea
• Alterations in mental status (anxiety, restlessness)

Expected outcomes:

• Patient will maintain blood pressure within acceptable parameters for pregnancy.
• Patient will demonstrate improved cardiac function as evidenced by stable vital signs and absence of worsening edema or dyspnea.

Assessments:

1. Monitor blood pressure frequently. Hypertension (>140/90 mmHg) is a key indicator of preeclampsia and decreased cardiac output.
2. Assess for signs of heart failure. Monitor for excessive fatigue, exertion intolerance, sudden weight gain, peripheral edema, and worsening shortness of breath, which can indicate impaired cardiac function.
3. Assess platelet count. Thrombocytopenia can increase the risk of abnormal coagulation and further reduce cardiac output.
4. Monitor fetal growth. Reduced cardiac output can compromise placental blood flow and lead to fetal growth restriction.

Interventions:

1. Position patient in left lateral decubitus position. This position enhances venous return and placental blood flow, optimizing cardiac output.
2. Administer supplemental oxygen as ordered. Increases oxygen availability to the heart and placenta, improving oxygenation to both mother and fetus.
3. Administer antihypertensive medications as prescribed. Reduces afterload and workload on the heart, improving cardiac output.
4. Restrict fluids if indicated. In cases of edema and pulmonary congestion, fluid restriction may be necessary to prevent fluid overload.
5. Promote rest and reduce activity. Reduces cardiac workload and promotes placental blood flow.
6. Prepare for possible cesarean delivery. In severe cases with compromised cardiac output, cesarean delivery may be necessary to prevent maternal and fetal morbidity and mortality.

Deficient Knowledge

Deficient knowledge regarding preeclampsia can lead to delayed recognition, treatment, and adverse outcomes.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Pathophysiology of preeclampsia
• Management strategies
• Risk factors
• Self-care needs and nutritional requirements
• Potential complications
• Lack of prior exposure to information
• Misinformation or misconceptions

As evidenced by:

• Rapid progression of preeclampsia
• Development of preventable complications
• Unawareness of symptoms
• Expressed concerns and questions
• Misconceptions about preeclampsia
• Inaccurate self-management practices

Expected outcomes:

• Patient will verbalize understanding of preeclampsia, its causes, and management.
• Patient will identify potential complications and warning signs requiring medical attention.
• Patient will demonstrate appropriate self-care behaviors and lifestyle modifications.

Assessments:

1. Assess patient’s current knowledge level. Determine baseline understanding of preeclampsia to tailor education effectively.
2. Identify misconceptions. Clarify any misunderstandings about preeclampsia to ensure accurate knowledge base.
3. Assess readiness to learn. Ensure patient is receptive to learning and create a conducive environment for education.

Interventions:

1. Educate on reportable symptoms. Provide clear verbal and written instructions on symptoms requiring immediate reporting (e.g., blurred vision, headaches, epigastric pain, dyspnea).
2. Involve support system. Include partner and family members in education to enhance support and monitoring at home.
3. Use positive reinforcement. Encourage and praise efforts in learning and adopting self-management strategies.
4. Instruct on importance of appointments and tests. Emphasize adherence to follow-up appointments, glucose monitoring, blood pressure checks, and other recommended tests.

Impaired Skin Integrity

Edema and potential for petechiae in preeclampsia can compromise skin integrity.

Nursing Diagnosis: Impaired Skin Integrity

Related to:

• Disease process (preeclampsia)
• Hypertension
• Edema
• Thrombocytopenia

As evidenced by:

• Petechiae
• Pitting edema

Expected outcomes:

• Patient will maintain intact skin integrity throughout pregnancy.
• Patient will demonstrate understanding of interventions to promote skin health.

Assessments:

1. Assess extent of skin impairment. Document severity of edema (pitting scale) and presence of petechiae or bruising.
2. Assess skin care practices. Identify any practices that may exacerbate skin impairment and provide corrective education.

Interventions:

1. Administer antihypertensives as ordered. Reduces hypertension, addressing the underlying cause of edema and petechiae.
2. Educate on normal vs. abnormal edema. Differentiate between normal pregnancy-related edema and concerning edema associated with preeclampsia.
3. Encourage leg elevation. Promotes venous return and reduces edema in lower extremities.
4. Advise on comfortable clothing and shoes. Avoid tight clothing and shoes that can constrict circulation and irritate skin.
5. Recommend compression stockings. Helps reduce edema and support venous circulation.
6. Instruct to avoid straining. Reduces pressure in blood vessels and minimizes petechiae formation.

Risk for Imbalanced Fluid Volume

Fluid shifts in preeclampsia pose a risk for fluid volume imbalance.

Nursing Diagnosis: Risk for Imbalanced Fluid Volume

Related to:

• Plasma protein loss
• Decreased osmotic pressure
• Fluid shifting out of vascular space
• Vasoconstriction
• Hemoconcentration
• Decreased kidney filtration
• Sodium retention

As evidenced by:
(Risk diagnosis – no “as evidenced by” factors, interventions are preventative)

Expected outcomes:

• Patient will maintain adequate fluid volume balance.
• Patient will demonstrate balanced fluid intake and output.
• Patient will remain free from generalized or pulmonary edema.

Assessments:

1. Monitor blood pressure. Elevated blood pressure is a key indicator of fluid volume imbalance in preeclampsia.
2. Assess for edema, proteinuria, and weight gain. These are classic signs of fluid retention and imbalance.
3. Monitor fetal well-being. Fluid imbalance can compromise placental perfusion and fetal well-being.

Interventions:

1. Manage preeclampsia. Collaborate with healthcare team to manage preeclampsia and its associated fluid imbalances.
2. Administer fluids cautiously. IV fluids may be necessary, but administer carefully to avoid fluid overload and pulmonary edema.
3. Educate on dietary recommendations. Limit sodium intake and ensure adequate intake of calcium, magnesium, and potassium.
4. Monitor intake and output. Closely track fluid intake and urine output to assess fluid balance and kidney function.

Risk for Unstable Blood Pressure

Preeclampsia inherently carries a risk for unstable blood pressure due to pathophysiological changes.

Nursing Diagnosis: Risk for Unstable Blood Pressure

Related to:

• Disease process (preeclampsia)
• Uteroplacental perfusion problems
• Cardiac dysrhythmias
• Hormonal changes
• Fluid retention

As evidenced by:
(Risk diagnosis – no “as evidenced by” factors, interventions are preventative)

Expected outcomes:

• Patient will maintain blood pressure at or below 140/90 mmHg.
• Patient will demonstrate interventions to stabilize blood pressure.
• Patient will not experience symptoms of unstable blood pressure (blurred vision, dizziness, headaches).

Assessments:

1. Monitor blood pressure meticulously. Frequent and accurate blood pressure monitoring is essential for early detection and management of fluctuations.
2. Assess blood and urine test results. Evaluate renal function and proteinuria to assess disease severity and impact on blood pressure.
3. Assess fetal health via ultrasound. Monitor fetal growth and amniotic fluid volume, as unstable blood pressure can affect fetal well-being.

Interventions:

1. Administer antihypertensive medications as indicated. Maintain blood pressure within safe parameters.
2. Instruct on limiting salt intake. Reduces sodium and water retention, helping stabilize blood pressure.
3. Educate on lifestyle modifications. Stress reduction, relaxation techniques, and avoiding strenuous activity can help manage blood pressure.
4. Continue postpartum monitoring. Blood pressure instability can persist postpartum, requiring ongoing monitoring and management.

References

1. Cleveland Clinic. (2021, October 14). Preeclampsia: Symptoms, causes, treatments & prevention. Retrieved May 2023, from https://my.clevelandclinic.org/health/diseases/17952-preeclampsia
2. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
3. Karrar, S. A., & Hong, P. L. (2023, February 13). Preeclampsia – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved May 2023, from https://www.ncbi.nlm.nih.gov/books/NBK570611/
4. Lim, K. H. (2022, April 13). Preeclampsia: Practice essentials, overview, pathophysiology. Diseases & Conditions – Medscape Reference. Retrieved May 2023, from https://emedicine.medscape.com/article/1476919-overview
5. Moura, S. B., Lopes, L. M., Murthi, P., & Costa, F. D. (2012, December 17). Prevention of Preeclampsia. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534321/
6. Norwitz, E. R. (2023). Patient education: Preeclampsia (Beyond the Basics). UpToDate. https://www.uptodate.com/contents/preeclampsia-beyond-the-basics/print
7. Pillitteri, A., & Silbert-Flagg, J. (2015). Nursing Care of a Family Experiencing a Sudden Pregnancy Complication. In Maternal & child health nursing: Care of the childbearing & Childrearing family (8th ed., pp. 1210-1224). LWW.
8. Sahlman, H., Koponen, M., El‐Nezami, H., Vähäkangas, K., & Keski‐Nisula, L. (2019). Maternal use of drugs and preeclampsia. British Journal of Clinical Pharmacology, 85(12), 2848-2855. https://doi.org/10.1111/bcp.14117
9. Silvestri, L. A., & CNE, A. E. (2019). Risk Conditions Related to Pregnancy. In Saunders comprehensive review for the NCLEX-RN examination (8th ed., pp. 687-688). Saunders.