Nursing Diagnosis: Pregnancy-Induced Hypertension – A Comprehensive Guide for Nurses

Preeclampsia, or pregnancy-induced hypertension (PIH), is a serious condition affecting 5-7% of pregnancies globally. Defined by the new onset of high blood pressure (greater than 140/90 mmHg) and proteinuria after the 20th week of gestation, preeclampsia poses significant risks to both mother and baby. Research indicates that preeclampsia stems from placental development issues, genetic predispositions, environmental factors, and changes in the mother’s cardiovascular and inflammatory systems.

If left unmanaged, preeclampsia can impede fetal growth, elevate the risk of placental abruption, cause organ damage in the mother, and escalate to eclampsia, a severe complication marked by seizures. The definitive treatment for preeclampsia is delivery of the baby, after which the condition typically resolves within days to weeks.

This article delves into the nursing process for managing pregnancy-induced hypertension, offering a detailed guide for healthcare professionals.

The Nursing Process for Pregnancy-Induced Hypertension

Nurses play a crucial role in identifying and managing high-risk pregnancies to prevent preeclampsia and its complications. A thorough nursing assessment, comprehensive patient education, and consistent antenatal care are paramount. Many cases of preeclampsia can be effectively managed through timely and appropriate interventions, including:

• Continuous monitoring of blood pressure and related symptoms.
• Implementing stress management techniques.
• Guiding weight management strategies.
• Ensuring proper nutrition.
• Monitoring fetal heart rate (FHR).
• Facilitating regular OB/GYN check-ups and prenatal care.

Nursing Assessment for Pregnancy-Induced Hypertension

The nursing assessment is the cornerstone of care, involving the collection of physical, psychosocial, emotional, and diagnostic data. Here, we outline both subjective and objective data pertinent to pregnancy-induced hypertension.

Review of Health History

1. Identify General Symptoms of Preeclampsia: The classic triad of preeclampsia symptoms includes hypertension, proteinuria, and edema. However, other indicators can also be present:

• Persistent and severe headaches.
• Visual disturbances.
• Shortness of breath or dyspnea.
• Epigastric pain.

2. Determine Risk Factors: Assessing a patient’s risk is crucial. Factors that increase the likelihood of developing preeclampsia include:

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

3. Medication Review: Certain medications used during pregnancy may elevate the risk of preeclampsia:

• Antidepressants.
• Benzodiazepines.
• Nonsteroidal anti-inflammatory drugs (NSAIDs).
• Antiretroviral medications for HIV treatment.
• Triptans (used for migraine treatment).
• Montelukast (asthma medication).
• Methamphetamine.

4. Assess Patient Knowledge: Evaluate the patient’s understanding of preeclampsia. Misconceptions due to prior knowledge, cultural beliefs, or familial influences may exist and need to be addressed.

Physical Assessment

1. Monitor Maternal Vital Signs: Close monitoring of vital signs, especially blood pressure, is essential. Preeclampsia is suspected when blood pressure readings are 140/90 mmHg or higher on two separate occasions after 20 weeks of gestation, confirmed with diagnostic tests.

2. Respiratory Assessment: Auscultate lung sounds, particularly if the patient reports shortness of breath. Adventitious lung sounds may indicate pulmonary edema, a complication of severe preeclampsia.

3. Abdominal Palpation: Palpate the right upper quadrant and epigastric area for tenderness. Liver involvement occurs in approximately 10% of severe preeclampsia cases.

4. Edema Assessment: Assess for edema. While some swelling is normal in pregnancy, rapid onset or worsening of dependent edema, especially in the hands and face, warrants further investigation.

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.

6. Regular Weight Monitoring: Rapid weight gain (over 3-5 pounds per week) may indicate fluid retention associated with preeclampsia.

7. Intake and Output Tracking: Reduced urine output can signal compromised kidney function due to decreased circulating blood volume, a hallmark of preeclampsia.

8. Seizure Monitoring: Monitor for seizure activity, as new-onset seizures in a preeclamptic patient without other identifiable causes indicate progression to eclampsia.

Diagnostic Procedures

1. Urine Tests: Urine analysis is crucial for diagnosing preeclampsia:

• Urine dipstick: a result of 1+ protein or greater is significant.
• 24-hour urine collection: protein levels of 300 mg or more are diagnostic.
• Urine protein-to-creatinine ratio: a ratio greater than 0.3 is indicative of proteinuria.

2. Blood Tests: Blood tests help identify abnormalities associated with preeclampsia:

• Complete blood count (CBC): thrombocytopenia (platelet count < 100,000/mm³) is a concerning finding.
• Complete metabolic panel (CMP): elevated liver enzymes indicate impaired liver function.
• Serum creatinine: elevated creatinine (> 1.1 mg/dL) suggests renal insufficiency.

3. Fetal Status Assessment: Assessment of fetal well-being includes:

• Non-stress tests (NSTs) and biophysical profiles (BPPs).
• Ultrasound evaluation of amniotic fluid index (AFI).
• Estimation of fetal weight (EFW).

4. CT Scan or MRI: In cases of severe headaches, neurological deficits, or seizures, CT scans or MRIs may be necessary to rule out intracranial abnormalities.

Nursing Interventions for Pregnancy-Induced Hypertension

Effective nursing interventions are critical 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 and intervention are paramount. Focus on effective blood pressure control and seizure prevention strategies.

2. Medication Administration: Administer antihypertensive medications as prescribed to manage blood pressure. Common medications include beta-blockers and calcium channel blockers:

• Intravenous labetalol.
• Intravenous hydralazine.
• Oral nifedipine.

3. Aspirin Therapy: For women at high risk of preeclampsia, low-dose aspirin therapy initiated in the late first trimester and continued through the third trimester can reduce the risk of developing the condition.

4. Activity Modification: While strict bed rest is not always necessary, reducing physical activity can help lower blood pressure, although it does not prevent preeclampsia progression.

5. Patient Education on Expectant Management: For stable patients undergoing expectant management, educate them about the importance of frequent monitoring, including:

• Serial ultrasonography.
• Weekly antepartum testing.
• Close monitoring of symptoms and blood pressure at home.
• Routine laboratory tests.

6. Delivery of the Fetus: Delivery remains the only definitive treatment for preeclampsia.

• For gestational hypertension or preeclampsia without severe features, delivery is typically recommended at 37 weeks of gestation.
• In cases of severe preeclampsia, delivery may be indicated as early as 34 weeks.

7. Betamethasone Administration: If preterm delivery is anticipated before 34 weeks, administer corticosteroids like betamethasone to accelerate fetal lung maturation.

8. Seizure Prevention: Intravenous magnesium sulfate is the primary medication for seizure prophylaxis in patients with preeclampsia exhibiting severe features to prevent eclampsia.

Preventing Complications

1. Postpartum Monitoring: Preeclampsia typically resolves after delivery, but hypertension and seizures can still occur up to six weeks postpartum. Continued monitoring is essential.

2. Dietary Guidance: Educate patients on dietary recommendations to help manage edema and hypertension. This includes reducing sodium intake and potentially supplementing with calcium, magnesium, and potassium. Advise limiting processed meats, white bread, fried foods, salty snacks, and sodas.

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

• Seizures.
• Difficulty breathing.
• Severe abdominal pain.
• Blurred vision.
• Persistent headaches.
• Decreased fetal movement.
• Vaginal bleeding.

4. Treatment Adherence Encouragement: Emphasize the importance of adhering to prescribed medications, dietary and lifestyle modifications, and prenatal care appointments and testing.

5. Stress Management Techniques: High blood pressure can be exacerbated by stress. Recommend stress management techniques such as deep breathing exercises, relaxation methods, and appropriate physical activity as advised by their healthcare provider.

6. Education on Future Pregnancy Risks: Inform patients with a history of preeclampsia about the increased risk of recurrence in subsequent pregnancies, particularly if they experienced severe preeclampsia.

7. Cardiovascular Disease Risk Education: Women with a history of preeclampsia have an elevated risk of developing cardiovascular disease later in life. Counsel them on the importance of regular blood pressure screenings and adopting heart-healthy lifestyle habits, including exercise, weight management, a balanced diet, and avoiding smoking and excessive alcohol intake.

Nursing Care Plans for Pregnancy-Induced Hypertension

Nursing care plans are crucial for prioritizing assessments and interventions for patients with preeclampsia, addressing both short-term and long-term goals. Here are examples of nursing diagnoses and associated care plan components relevant to preeclampsia:

Decreased Cardiac Output

Decreased cardiac output in preeclampsia can arise from increased cardiac demands and reduced blood supply.

Nursing Diagnosis: Decreased Cardiac Output

Related Factors:

• Hypovolemia.
• Decreased venous return.
• Increased systemic vascular resistance.

As Evidenced By:

• Alterations in blood pressure.
• Hemodynamic changes.
• Edema.
• Dyspnea.
• Changes in mental status.

Expected Outcomes:

• Patient will maintain blood pressure within acceptable parameters.

Assessments:

1. Blood Pressure Monitoring: Hypertension in pregnancy is defined as BP >140/90 mmHg. Preeclampsia is diagnosed with new-onset hypertension and proteinuria after 20 weeks.
2. Signs of Poor Cardiac Function/Heart Failure: Assess for:
   • Excessive fatigue.
   • Exertional intolerance.
   • Sudden weight gain.
   • Edema in extremities.
   • Worsening shortness of breath.
3. Platelet Count: Low platelet count in preeclampsia is associated with increased risk of coagulation issues and decreased cardiac output.
4. Fetal Growth: Preeclampsia reduces cardiac output and placental blood flow, potentially leading to fetal growth restriction.

Interventions:

1. Positioning: Place patient in a comfortable left side-lying position to promote optimal circulation and placental blood flow.
2. Oxygen Administration: Administer oxygen as prescribed to increase oxygen availability for both mother and fetus.
3. Antihypertensive Medications: Administer cardiac medications cautiously to manage hypertension, ensuring safety for both mother and fetus.
4. Fluid Restriction: If edema and cardiopulmonary congestion are present, restrict fluids as ordered.
5. Activity Reduction: Encourage rest and reduced activity. Physical exertion can divert blood flow away from the placenta. Complete bed rest is not always required.
6. Prepare for Cesarean Delivery: In cases of severe complications due to decreased cardiac output, prepare for an emergency cesarean section to prevent maternal and fetal demise.

Deficient Knowledge

Deficient knowledge about preeclampsia can lead to delayed recognition and treatment, resulting in poorer outcomes.

Nursing Diagnosis: Deficient Knowledge

Related Factors:

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

As Evidenced By:

• Rapid progression of preeclampsia.
• Development of preventable complications.
• Unawareness of symptoms.
• Questions about preeclampsia.
• Misconceptions.
• Inadequate understanding of prevention and management.

Expected Outcomes:

• Patient will verbalize understanding of preeclampsia and its management.
• Patient will verbalize potential complications and know when to contact healthcare providers.
• Patient will demonstrate healthy behaviors and lifestyle modifications for preeclampsia management.

Assessments:

1. Knowledge Level Assessment: Determine the patient’s current understanding of preeclampsia to tailor education appropriately.
2. Identify Misconceptions: Address any misinformation or misconceptions stemming from personal experiences, cultural beliefs, or family influences.
3. Assess Readiness to Learn: Ensure the patient is receptive to learning and provide education at a suitable time, free from distractions.

Interventions:

1. Symptom Education: Provide clear verbal and written instructions on symptoms to report, such as blurred vision, headaches, epigastric pain, and dyspnea.
2. Involve Support System: Include the patient’s partner and family in education to foster a supportive environment and encourage healthy behaviors.
3. Positive Reinforcement: Use positive reinforcement to encourage learning and behavior modifications.
4. Appointment and Testing Education: Emphasize the importance of follow-up appointments, glucose monitoring, and blood pressure checks for a healthy pregnancy and delivery.

Impaired Skin Integrity

Preeclampsia can cause edema and petechiae, indicating increased pressure in blood vessels and potential bleeding.

Nursing Diagnosis: Impaired Skin Integrity

Related Factors:

• Disease process (preeclampsia).
• Hypertension.
• Edema.
• Decreased platelets.

As Evidenced By:

• Petechiae.
• Pitting edema.

Expected Outcomes:

• Patient will maintain intact skin integrity.
• Patient will verbalize understanding of skin health and demonstrate preventive measures.

Assessments:

1. Extent of Skin Impairment: Assess the severity of edema (pitting edema grade) and petechiae (amount and location of skin bleeding/bruising).
2. Skin Care Practices: Evaluate the patient’s current skin care practices to identify any that may exacerbate skin issues.

Interventions:

1. Antihypertensive Administration: Administer antihypertensives to manage blood pressure and reduce edema and petechiae.
2. Normal vs. Abnormal Edema Education: Educate patients that while some swelling is normal, sudden worsening, especially in the face and hands, is concerning.
3. Leg Elevation: Encourage leg elevation when sitting or lying down to improve venous return and reduce edema.
4. Comfortable Clothing and Shoes: Advise wearing loose, comfortable clothing and shoes without tight straps to prevent skin irritation.
5. Compression Stockings: Recommend compression stockings to reduce swelling and discomfort.
6. Avoid Straining: Instruct patients to avoid prolonged straining during activities like coughing, lifting, or vomiting, which can worsen petechiae.

Risk for Imbalanced Fluid Volume

Fluid shifts in preeclampsia can lead to fluid overload in organs and tissues.

Nursing Diagnosis: Risk for Imbalanced Fluid Volume

Related Factors:

• Plasma protein loss.
• Decreased osmotic pressure.
• Fluid shifting out of vascular space.
• Blood vessel narrowing.
• Hemoconcentration.
• Increased blood flow resistance.
• Age-related cellular degeneration in older mothers.
• Decreased kidney filtration.
• Sodium retention.

As Evidenced By:

• Risk diagnosis, not evidenced by signs/symptoms.

Expected Outcomes:

• Patient will maintain adequate fluid volume, with blood pressure within normal limits.
• Patient will demonstrate balanced fluid intake and output.
• Patient will remain free from generalized or pulmonary edema.

Assessments:

1. Blood Pressure Monitoring: High blood pressure is a key indicator of fluid volume imbalance in pregnancy and a hallmark of preeclampsia.
2. Edema, Proteinuria, Weight Gain: Monitor for these classic preeclampsia symptoms, indicating fluid retention and renal impairment. Note:
   • Proteinuria (1+ to 2+ on dipstick).
   • Mild facial or upper extremity edema.
   • Weight gain >2 lbs/week in 2nd trimester or >1 lb/week in 3rd trimester.
3. Fetal Well-being: Monitor fetal status as fluid imbalance can lead to fetal hypoxia and growth restriction.

Interventions:

1. Preeclampsia Management: Collaborate with the healthcare team to manage preeclampsia and address fluid volume imbalances.
2. Fluid Administration: Administer IV fluids cautiously to expand intravascular volume, avoiding fluid overload and pulmonary edema.
3. Dietary Recommendations: Advise limiting sodium intake and consider calcium, magnesium, and potassium supplementation.
4. Intake and Output Monitoring: Track intake and output closely, as oliguria can indicate reduced kidney function.

Risk for Unstable Blood Pressure

Faulty blood vessel development in the uterus in preeclampsia leads to placental circulation irregularities and maternal cardiovascular changes, increasing the risk for unstable blood pressure.

Nursing Diagnosis: Risk for Unstable Blood Pressure

Related Factors:

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

As Evidenced By:

• Risk diagnosis, not evidenced by signs/symptoms.

Expected Outcomes:

• Patient will maintain blood pressure at or below 140/90 mmHg.
• Patient will demonstrate interventions to manage blood pressure fluctuations.
• Patient will not experience symptoms like blurred vision, dizziness, or headaches.

Assessments:

1. Blood Pressure Monitoring: Accurate and frequent blood pressure monitoring is crucial for early detection and management of preeclampsia. Hypertension is defined as >140 mmHg systolic or >90 mmHg diastolic.
2. Blood and Urine Tests: Assess lab results for kidney function, as proteinuria indicates renal impairment due to hypertension.
3. Fetal Ultrasound: Monitor fetal growth and amniotic fluid volume via ultrasound, as unstable blood pressure can affect fetal well-being.

Interventions:

1. Medication Administration: Administer antihypertensive medications as prescribed.
2. Sodium Restriction: Advise limiting salt intake to prevent sodium and water retention and reduce blood pressure elevation.
3. Lifestyle Modifications: Instruct on stress reduction, relaxation techniques, and avoiding strenuous activities to promote blood pressure stability.
4. Postpartum Monitoring: Continue monitoring blood pressure postpartum and educate patients to report headaches, nausea, vomiting, or vision changes, which may indicate ongoing hypertension.

References

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