Hypertensive disorders of pregnancy (also known as pregnancy-associated hypertensive disorders, pregnancy induced hypertension) are the most common complications that occur during pregnancy and are a major cause of maternal and fetal morbidity and mortality. These disorders include gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and chronic hypertension with superimposed preeclampsia. If left untreated, preeclampsia can lead to a life-threatening complication called HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. It is estimated that preeclampsia alone complicates 2-8% of pregnancies globally.
Hypertensive disorders in pregnancy include five categories of hypertension and are defined as such by the American College of Obstetricians and Gynecologists (ACOG):
Gestational Hypertensive Disorders
- Gestational hypertension. Defined as a systolic blood pressure of 140 mm Hg or more, and/or diastolic blood pressure of 90 mm Hg or more on two blood pressure readings at least four (4) hours apart after 20 weeks of gestation in a woman with previously normal blood pressure. Gestational hypertension does not persist longer than 12 weeks postpartum and usually resolves after a week postpartum.
- Preeclampsia. Preeclampsia is a pregnancy-specific condition and is defined as a new-onset of hypertension that occurs most often after 20 weeks of gestation. Blood pressure is elevated more than 140 mm Hg systolic, more than 90 mm Hg diastolic. Hypertension is usually accompanied by new-onset proteinuria although other signs and symptoms of preeclampsia (thrombocytopenia, impaired liver function, pulmonary edema, visual disturbance) may present in some women in the absence of proteinuria.
- Eclampsia. Eclampsia is the onset of seizure activity or coma in a woman with preeclampsia with no history of preexisting pathology that can result in seizure activity. Seizure leads to severe maternal hypoxia, injury, and aspiration pneumonia. Eclampsia has an increased maternal mortality rate especially in settings with low resources.
Chronic Hypertensive Disorders
- Chronic hypertension. Chronic hypertension as hypertension diagnosed or present before pregnancy or before 20 weeks of gestation. It is more prevalent with increasing late childbearing and in persons with obesity. Additionally, hypertension that is diagnosed for the first time during pregnancy and that does not resolve postpartum is also classified as chronic hypertension.
- Chronic hypertension with superimposed preeclampsia. Preeclampsia is considered superimposed when it complicates preexisting chronic hypertension. About half of women with chronic hypertension may develop superimposed preeclampsia. It is associated with increased maternal or fetal mortality.
Nursing Care Plans
Nursing care planning and management for pregnant clients with hypertensive disorders or preeclampsia involve early detection, thorough assessment, and prompt treatment of preeclampsia. Another priority is to ensure the mother’s safety and deliver a healthy newborn as close to a full term as possible.
- Decreased Cardiac Output UPDATED!
- Risk for Imbalanced Fluid Volume UPDATED!
- Ineffective Tissue Perfusion UPDATED!
- Risk for Injury UPDATED!
- Imbalanced Nutrition: Less Than Body Requirements UPDATED!
- Deficient Knowledge UPDATED!
- Other Possible Nursing Care Plans NEW!
Risk for Imbalanced Fluid Volume
In a normal pregnancy, fluid retention is a common and expected feature. However, when pregnancy-induced hypertension is a concern, low placental perfusion causes a decrease in GFR and altered glomerular permeability, resulting in protein loss through the kidneys. The loss of intravascular protein results in a decrease in intravascular osmolality and loss of fluid to the interstitial spaces resulting in edema and excessive extravascular fluid retention.
- Risk for Imbalanced Excess Fluid Volume
Risk factors may include
- Osmotic pressure
- Decreased plasma protein
- Decreasing plasma colloid
- A fluid shift from intravascular space to the interstitial space
- Hormonal alterations in pregnancy
Possibly evidenced by
- Not applicable on risk diagnoses. The presence of signs and symptoms establishes an actual diagnosis.
- The client adheres to the therapeutic regimen and participates in the monitoring, as indicated.
- The client verbalizes understanding of the need for close monitoring of weight, BP, urine protein, and edema.
- The client is free of signs of generalized, pulmonary, and cerebral edema (i.e., epigastric pain, headaches, confusion, dyspnea, nausea/vomiting)
- The client exhibits hemoglobin and hematocrit values and protein levels within normal limits.
- The client exhibits physiological edema with no signs of pitting.
Nursing Assessment and Rationales
1. Assess lung sounds and respiratory rate and effort.
Dyspnea and crackles may mean pulmonary edema, which needs immediate treatment. In preeclampsia, the loss of intravascular protein allows fluid to seep out of the intravascular spaces, overwhelming other nearby organs, in this case, the lungs. Orthopnea and paroxysmal nocturnal dyspnea may occur due to an excessive venous return of fluid from the lower extremities that may reach the lungs.
2. Weigh the client regularly during hospital visits. Advise the client to record weight at home in-between visits.
Weight measurement should be on the same scale, in the same type of clothing, and at the same time of day. Abrupt, notable weight gain (e.g., more than 3.5 lb (1.8 kg) per week in the second or third trimester reflects fluid retention and may indicate preeclampsia. Fluid shifts from the vascular to the interstitial space, resulting in generalized edema.
3. Assess the client’s vital signs, closely monitoring blood pressure and pulse.
A rise in blood pressure may happen in response to catecholamines, vasopressin, prostaglandins, and, as recent findings suggest, decreased levels of prostacyclin. Increased pulse rate can be due to low intravascular colloid-osmotic pressure caused by increased capillary permeability. This creates higher fluid retention and decreased hydrostatic pressure, inhibiting fluid circulation and congesting the lungs (Froes, 2020).
4. Assess for the presence of edema and degree of pitting edema.
The presence of pitting edema (mild, 1+ to 2+; severe, 3+ to 4+) of face, hands, legs, sacral area, or abdominal wall, or edema that does not disappear after 12 hours of bed rest is vital. Edema is assessed for distribution, pitting, and degree. Edema may be present on the most dependent body parts where hydrostatic pressure is greatest. It may also be more evident in the feet and ankles of the ambulatory pregnant woman.
5. Assess for signs of progressive or excessive edema. Assess for possible eclampsia.
Signs for possible eclampsia include epigastric pain, cerebral symptoms, nausea, vomiting. Edema and intravascular fibrin deposition (in HELLP syndrome) within the encapsulated liver are manifested by right upper quadrant pain; dyspnea, indicating pulmonary involvement; cerebral edema, possibly leading to seizures; and nausea, and vomiting, indicating GI edema.
Nursing Interventions and Rationales
1. Note alterations in hematocrit/hemoglobin levels.
Identifies degree of hemoconcentration caused by fluid shift. If hematocrit is less than three times hemoglobin level, hemoconcentration exists. Hemoconcentration occurs due to an increase in plasma volume which is higher than the increase in erythrocyte production.
2. Monitor intake and output. Note urine color, and measure specific gravity as indicated.
Urine output is a sensitive indicator of circulatory blood volume. Decreased blood flow to the kidneys reduces urine production. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Administering magnesium sulfate can cause a transient increase in urine output.
3. Encourage the client to increase protein intake.
Proper nutrition decreases the incidence of prenatal hypovolemia and hypoperfusion; insufficient protein/calories increases the risk of edema formation and preeclampsia. Intake of 80–100 g of protein may be required daily to replace losses. Protein becomes depleted as the glomeruli become damaged and cannot prevent it from being excreted through the urine.
4. Review moderate sodium intake of up to 6 g/day. Advise clients to read food labels and avoid foods high in sodium.
Some sodium intake is necessary because levels below 2–4 g/day result in greater dehydration in some clients. High sodium foods include processed meat such as bacon, luncheon meats, hot dogs, potato chips, etc. However, excess sodium may increase edema formation and increase the risk for hypertension.
5. Schedule prenatal visit every 1-2 weeks if mild preeclampsia; weekly if severe.
Important to monitor changes more closely for the well-being of the client and fetus. BP monitoring twice weekly combined with fetal non-stress test, amniotic fluid index evaluation, and laboratory evaluations may be indicated (Luger & Knight, 2021).
6. Educate the client and family members or significant others on home monitoring/day-care programs, as appropriate.
Some mildly hypertensive clients without proteinuria may be managed on an outpatient basis if adequate surveillance and support are provided, and the client/family actively participates in the treatment regimen.
7. Substitute fluids orally or parenterally via an infusion pump, as indicated.
Fluid replacement treats hypovolemia yet must be given cautiously to prevent overload, especially if interstitial fluid is drawn back into circulation when activity is reduced. With renal involvement, fluid intake is restricted; i.e., if the output is reduced (less than 700 ml/24 hr), total fluid intake is restricted to approximate output plus insensible loss. The use of an infusion pump allows more accurate control delivery of IV fluids.
8. Respond to questions and review rationale for avoiding the use of diuretics to treat edema.
Diuretics further increase the chances of dehydration by decreasing intravascular volume and placental perfusion, and they may cause thrombocytopenia, hyperbilirubinemia, or alteration in carbohydrate metabolism in fetus/newborn. Diuretics may be useful in treating pulmonary edema.
9. Examine clean-catch, first-voided urine specimen for protein each visit, or daily/hourly as appropriate if hospitalized. Report readings of 2+ or greater.
Aids in identifying the degree of severity/progression of the condition. A 2+ reading implies glomerular edema or spasm. Proteinuria affects fluid shifts from the vascular tree. Urine contaminated by vaginal secretions may test positive for protein, or dilution may result in a false-negative result. In addition, preeclampsia may be present without significant proteinuria.
10. Collaborate with a dietitian as indicated.
A nutritional consult may be beneficial in determining individual needs/dietary plans. Dietary sodium and potassium intake are believed to significantly contribute to the changes in blood pressure in the general and hypertensive population (Lu et al., 2018).
When the fluid deficit is severe, and the client is hospitalized:
11. Insert indwelling catheter if kidney output is reduced or is less than 50 ml/hr.
Allows more accurate monitoring of output/renal perfusion. Decreased cardiac output results in impaired kidney perfusion, sodium and water retention, and reduced urine output.
12. Assist with insertion of lines and monitoring of invasive hemodynamic parameters, such as central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP).
Gives a more precise measurement of fluid volume. In normal pregnancy, plasma volume increases by 30%–50%, yet this increase does not occur in preeclampsia clients.
13. Monitor serum uric acid and creatinine levels and blood urea nitrogen (BUN).
Uric acid clearance is decreased, but serum uric acid levels increase. Elevated uric acid levels indicate impaired kidney function, worsening maternal condition, and poor fetal outcome. Elevated serum uric acid is also a biomarker for preeclampsia and contributes to the pathogenesis of maternal and fetal manifestations (Johnson et al., 2011).
14. Administer platelets, fibrinogen, or fresh, frozen plasma (FFP) as indicated.
Clients with HELLP syndrome awaiting delivery of the fetus may benefit from transfusion of platelets when the count is below 5,000 u/L with active bleeding or hemorrhage risk. In the case of coagulopathy, the coagulation factors must be corrected with fibrinogen and fresh, frozen plasma (El Allani et al., 2020).
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her infant:
- Abruptio Placenta | 3 Care Plan
- Cesarean Birth | 10 Care Plans UPDATED!
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans UPDATED!
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans UPDATED!
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans UPDATED!
- Postpartum Thrombophlebitis | 5 Care Plans UPDATED!
- Prenatal Hemorrhage | 9 Care Plans UPDATED!
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans UPDATED!
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 7 Care Plans UPDATED!
- Puerperal Infection | 4 Care Plans
References and Sources
References and sources for this nursing care plan for hypertensive disorders in pregnancy.
- Abais-Battad, J. M., Lund, H., Fehrenbach, D. J., Dasinger, J. H., Alsheikh, A. J., & Mattson, D. L. (2018, 31 December). Parental Dietary Protein Source and the Role of CMKLR1 in Determining the Severity of Dahl Salt-Sensitive Hypertension. Hypertension, 73(2).
- American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice. (2020). Practice Bulletin #222: Gestational Hypertension and Preeclampsia. Obstetrics & Gynecology, 135, 237-260.
- Arulkumaran, N., & Lightstone, L. (2013). Severe pre-eclampsia and hypertensive crises. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(6), 877-884.
- Benigni, A., Gregorini, G., Frusca, T., Chiabrando, C., Ballerini, S., Valcamonico, A., … & Remuzzi, G. (1989). Effect of low-dose aspirin on fetal and maternal generation of thromboxane by platelets in women at risk for pregnancy-induced hypertension. New England Journal of Medicine, 321(6), 357-362.
- Braunthal, S., & Brateanu, A. (2019, April 10). Hypertension in pregnancy: Pathophysiology and treatment. SAGE, 7.Chakraborty, A., & Can, A. S. (2021, July 2). Calcium Gluconate – StatPearls. NCBI. Retrieved December 14, 2021.
- El Allani, L., Benlamkaddem, S., Berdai, M. A., & Harandou, M. (2020, June 9). A case of massive hepatic infarction in severe preeclampsia as part of the HELLP syndrome. The Pan African Medical Journal, 36(78).
- Espinoza, J. (2012). Uteroplacental ischemia in early‐and late‐onset preeclampsia: a role for the fetus?. Ultrasound in obstetrics & gynecology, 40(4), 373-382.
- Fantasia, H. C. (2018). Low-dose aspirin for the prevention of preeclampsia. Nursing for women’s health, 22(1), 87-92.
- Fox, R., Kitt, J., Leeson, P., Aye, C. Y.L., & Lewandowski, A. J. (2019, October 4). Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. Journal of Clinical Medicine, 8(10), 5-6. MDPI.
- Fróes, N. B. M., Lopes, M. V. D. O., Pontes, C. M., Ferreira, G. L., & Aquino, P. D. S. (2020). Middle range theory for the nursing diagnosis Excess Fluid Volume in pregnant women. Revista Brasileira de Enfermagem, 73.
- Gallo, D., Poon, L. C., Fernandez, M., Wright, D., & Nicolaides, K. H. (2014, April 15). Prediction of Preeclampsia by Mean Arterial Pressure at 11–13 and 20–24 Weeks’ Gestation. Fetal Diagnosis and Therapy.
- Ghulmiyyah, L., & Sibai, B. (2012, February). Maternal mortality from preeclampsia/eclampsia. In Seminars in perinatology (Vol. 36, No. 1, pp. 56-59). WB Saunders.
- He, G., Chen, Y., Chen, M., He, G., & Liu, X. (2020, November 13). Efficacy and safety of low dose aspirin and magnesium sulfate in the treatment of pregnancy-induced hypertension A protocol for systematic review and meta-analysis. Medicine (Baltimore), 99(46).
- Johnson, R. J., Kanbay, M., Kang, D.-H., Lozada, L. G. S.-., & Feig, D. (2011, August 29). Uric Acid A Clinically Useful Marker to Distinguish Preeclampsia From Gestational Hypertension. Hypertension, 58(4), 704-708.
- Khooshideh, M., Ghaffarpour, M., & Bitarafan, S. (2017, July 6). The comparison of anti-seizure and tocolytic effects of phenytoin and magnesium sulfate in the treatment of eclampsia and preeclampsia: A randomised clinical trial. Iranian Journal of Neurology, 16(3), 125-129.
- Leeners, B., Wagner, P. N.-., Kuse, S., Stiller, R., & Rath, W. (2009, July 07). Emotional Stress and the Risk to Develop Hypertensive Diseases in Pregnancy. Hypertension in Pregnancy, 26(2), 211-226.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing (8th ed., Vol. 1). Elsevier.
- Lu, Y., Chen, R., Cai, J., Huang, Z., & Hong Yuan. (2018, October 29). The management of hypertension in women planning for pregnancy. British Medical Bulletin, 128(1), 75-84.
- Luger, R. K., & Knight, B. P. (2021, October 9). Hypertension In Pregnancy. Statpearls. Retrieved December 8, 2021.
- Mayrink, J., Souza, R. T., Feitosa, F. E., Rocha Filho, E. A., Leite, D. F., Vettorazzi, J., … & Cecatti, J. G. (2019). Mean arterial blood pressure: potential predictive tool for preeclampsia in a cohort of healthy nulliparous pregnant women. BMC pregnancy and childbirth, 19(1), 1-8.
- O’Brien, L. M., Bullough, A. S., Owusu, J. T., Tremblay, K. A., Brincat, C. A., Chames, M. C., … & Chervin, R. D. (2012). Pregnancy-onset habitual snoring, gestational hypertension, and preeclampsia: prospective cohort study. American journal of obstetrics and gynecology, 207(6), 487-e1.
- Pradhan, M., Kishore, S.V., & Champatiray, J. (2020, April 4). Effect of low dose aspirin on maternal outcome in women at risk for developing pregnancy-induced hypertension. International Journal of Reproduction, Contraception, Obstetrics and Gynecology, 9(4), 1590+.
- Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., Wilson, D., Alden, K. R., & Cashion, M. C. (2017). Maternal child nursing care-E-Book. Elsevier Health Sciences.
- Rasouli, M., Pourheidari, M., & Gardesh, Z. H. (2019, February 12). Effect of Self-care Before and During Pregnancy to Prevention and Control Preeclampsia in High-risk Women. International Journal of Preventive Medicine, 10(21).
- Schiff, E., Peleg, E., Goldenberg, M., Rosenthal, T., Ruppin, E., Tamarkin, M., … & Mashiach, S. (1989). The Use of Aspirin to Prevent Pregnancy-Induced Hypertension and Lower the Ratio of Thromboxane A2 to Prostcyclin in Relatively High-Risk Pregnancies. New England Journal of Medicine, 321(6), 351-356.
- Schmidt P, Skelly CL, Raines DA. Placental Abruption. [Updated 2021 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.
- Sinkey, R. G., Battarbee, A. N., Bello, N. A., Ives, C. W., Oparil, S., & Tita, A. T.N. (2020, August 27). Prevention, Diagnosis, and Management of Hypertensive Disorders of Pregnancy: a Comparison of International Guidelines. Current Hypertension Reports, 22(66), 2. Topical Collection on Preeclampsia.
- Weight Gain During Pregnancy | Pregnancy | Maternal and Infant Health. (2021, May 26). CDC.
- Wisner, K. (2019). Gestational hypertension and preeclampsia. MCN: The American Journal of Maternal/Child Nursing, 44(3), 170.
- Xu, T. T., Zhou, F., Deng, C. Y., Huang, G. Q., Li, J. K., & Wang, X. D. (2015). Low‐Dose aspirin for preventing preeclampsia and its complications: a meta‐analysis. The Journal of Clinical Hypertension, 17(7), 567-573.
- Zelalem, A., Endeshaw, M., Ayenew, M., Shiferaw, S., & Yirgu, R. (2017, July 25). Effect of Nutrition Education on Pregnancy Specific Nutrition Knowledge and Healthy Dietary Practice among Pregnant Women in Addis Ababa. Clinics in Mother and Child Health.
With contributions by Marianne B., and Matt V.