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!
Ineffective Tissue Perfusion
Hypertensive disorders of pregnancy cause a reduction in the maternal blood and nutrition flow through the placenta and decrease the oxygen available to the fetus. The fetus may have intrauterine growth restriction, and fetal death may sometimes occur.
- Ineffective Uteroplacental Tissue Perfusion
May be related to
- Interruption of maternal blood flow (progressive vasospasm of spiral arteries)
Possibly evidenced by
- Intrauterine growth retardation
- Changes in fetal activity/heart rate
- Premature delivery
- Fetal demise
- The client demonstrates normal central nervous system (CNS) reactivity on a nonstress test (NST).
- The client is free of late decelerations.
- The client has no decrease in FHR on the contraction stress test/oxytocin challenge test (CST/OCT).
- The client is full-term, appropriate for gestational age (AGA).
Nursing Assessment and Rationales
1. Evaluate fetal growth through McDonald’s measurement; measure progressive fundal growth at each office visit or periodically during home visits, as appropriate.
Reduced placental functioning may accompany pregnancy-induced hypertension, resulting in intrauterine growth restriction (IUGR). Blood and nutrition flow through the placenta is reduced, decreasing the oxygen available to the fetus. Chronic intrauterine stress and uteroplacental insufficiency decrease the amount of fetal contribution to the amniotic fluid pool.
2. Assess fetal heart rate (FHR) manually or electronically, as indicated.
Helps evaluate fetal well-being. An elevated FHR may show a compensatory response to hypoxia, prematurity, or abruptio placentae.
3. Assess fetal response to biophysical profile (BPP) criteria or contraction stress test (CST), as maternal status indicates.
BPP helps evaluate fetus and fetal environment on five specific parameters to assess CNS function and fetal contribution to the amniotic fluid volume. CST assesses placental functioning and reserves.
4. Assess for amniotic fluid volume (AFV), as indicated.
Assessment of AFV allows the detection of oligohydramnios. AFV can be assessed with ultrasound measurements or by amniotic fluid index. Abnormal placentation occurs due to the failure of appropriate remodeling of the spiral arteries, resulting in higher resistance to placental blood flow and hypoperfusion of the placenta. These processes can result in oligohydramnios, fetal hypoxia, and fetal distress (Fox et al., 2019).
Nursing Interventions and Rationales
1. Advise bedrest and restriction of activities.
Activity restriction allows blood that would be circulated to the skeletal muscles to be conserved for circulation to the mother’s vital organs and the placenta. The woman should remain on reduced activity with frequent rest periods lying on her side to improve blood flow to the placenta.
2. Educate the mother and family members about the home assessment or identifying daily fetal movements and when to seek immediate medical attention.
Decrease in placental blood flow results in reduced gas exchange and impaired healthy functioning of the placenta. Potential outcomes of poor placental perfusion include a malnourished, low birth weight infant, and prematurity associated with early delivery, abruptio placentae, and fetal death. Reduced fetal activity means fetal compromise.
3. Identify and educate the mother and family members about fetal activity factors.
Cigarette smoking, medications, drug use, serum glucose levels, environmental sounds, time of day, and the sleep-wake cycle of the fetus can increase or decrease fetal movement. The woman should report a decrease in movements or if none occur during 3 hours.
4. Report signs of abruptio placentae (i.e., vaginal bleeding, uterine tenderness, abdominal pain, and decreased fetal activity).
Immediate attention and intervention increase the likelihood of a positive outcome. Placental abruption occurs when there is a compromise of the vascular structures supporting the placenta. These vascular structures deliver oxygen and nutrients to the fetus (Schmidth et al., 2021).
5. Present contact number for the client and family members to direct questions, address changes in daily fetal movements and maternal condition.
Provides a chance to address concerns and misconceptions and intervene promptly, as indicated.
6. Note the fetal response to medications such as magnesium sulfate (MgSO4), phenobarbital, and diazepam.
Depressant effects of medication reduce fetal respiratory and cardiac function and fetal activity level, even though placental circulation may be adequate.
7. Assist with assessing fetal maturity and well-being using lecithin-sphingomyelin (L/S) ratio, prostaglandins, estriol levels, fetal breathing movements, and sequential sonography beginning at 20–26 weeks’ gestation.
In the event of declining maternal/fetal condition, risks of delivering a preterm infant are weighed against the risks of continuing the pregnancy, using results from evaluative studies of lung and kidney maturity, fetal growth, and placental functioning. Intrauterine growth restriction (IUGR) is associated with reduced maternal volume and vascular changes.
8. Assist with assessing maternal plasma volume at 24–26 weeks’ gestation using Evans’ blue dye when indicated.
Identifies fetus at risk for IUGR or intrauterine fetal demise associated with reduced plasma volume and reduced placental perfusion.
9. Assist in Doppler ultrasound of the fetal umbilical artery.
The use of umbilical artery Doppler ultrasound for fetal surveillance in high-risk pregnancies is supported by several RCTs and systematic reviews. Doppler ultrasound of the fetal umbilical artery measures the blood flow patterns through the artery as an indicator of placental perfusion. If the umbilical artery flow is absent or reversed during end-diastole, this illustrates abnormally high placental resistance, reducing fetal blood flow (Fox et al., 2019).
10. Utilizing ultrasonography assist with the assessment of placental size.
Reduced placental function and size are associated with preeclampsia. A common pathological feature of preeclampsia is the failure of the maternal arteries supplying the placenta to undergo the physiological adaptations of a normal pregnancy that facilitate adequate placental perfusion (Schmidt et al., 2021).
11. Administer a single course of corticosteroid (dexamethasone, betamethasone) IM for at least 24–48 hr, but not more than seven days before delivery, when severe preeclampsia necessitates premature delivery between 26 and 34 weeks gestation.
Corticosteroids are thought to induce fetal pulmonary maturity (surfactant production) and prevent respiratory distress syndrome, at least in a fetus delivered prematurely because of condition or inadequate placental functioning. Best results are obtained when the fetus is less than 34 weeks gestation and delivery occurs within a week of corticosteroid administration.
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.
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With contributions by Marianne B., and Matt V.