6 Preeclampsia & Gestational Hypertensive Disorders Nursing Care Plans

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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

  1. 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.
  2. 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.
  3. 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

  1. 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. 
  2. 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. 

Here are six nursing diagnoses for your nursing care plans for pregnant patients with hypertensive disorders, focusing on managing clients with preeclampsia. 

  1. Decreased Cardiac Output UPDATED!
  2. Risk for Imbalanced Fluid Volume UPDATED!
  3. Ineffective Tissue Perfusion UPDATED!
  4. Risk for Injury UPDATED!
  5. Imbalanced Nutrition: Less Than Body Requirements UPDATED!
  6. Deficient Knowledge UPDATED!
  7. Other Possible Nursing Care Plans NEW!
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Risk for Injury

Vasospasm and decreased organ perfusion are the main characteristics of preeclampsia, which can lead to cerebral vasospasm. Endothelial dysfunction occurs at the site of the uterus and at the cerebral endothelium, which leads to neurological disorders, including eclampsia. Progression to eclampsia occurs when the woman has one or more generalized tonic-clonic seizures. An eclamptic seizure may result in cerebral hemorrhage, abruptio placentae, fetal compromise, or death of the mother or fetus.

Nursing Diagnosis

  • Risk for Injury

Risk Factors

  • Tissue edema/hypoxia
  • Tonic-clonic convulsions
  • Abnormal blood profile and/or clotting factors
  • Altered consciousness

Possibly evidenced by

  • Not applicable on risk diagnoses. The presence of signs and symptoms establishes an actual diagnosis. 

Desired Outcomes

  • The client participates in treatment and/or environmental modifications to protect herself and enhance safety.
  • The client is free of signs of cerebral ischemia (visual disturbances, headache, changes in mentation).
  • The client displays normal levels of clotting factors and liver enzymes.
  • The client maintains a treatment regimen to control or eliminate seizure activity.

Nursing Assessment and Rationales

1. Assess for central nervous system (CNS) involvement.
Cerebral edema and vasoconstriction can be evaluated in terms of symptoms, behaviors, or retinal changes. Elevated blood pressure from preeclampsia causes dysfunction of autoregulation of the cerebral vasculature, which causes hypoperfusion, endothelial damage, or edema. These symptoms include headache, irritability, visual disturbances, or changes on fundoscopic examination. 

2. Assess for alterations in level of consciousness.
In progressive preeclampsia, vasoconstriction and vasospasms of cerebral blood vessels reduce oxygen consumption by 20% and cerebral ischemia.

3. Assess the client’s deep tendon reflexes (3+ to 4+) and ankle clonus.
Deep tendon reflexes become hyperactive because of central nervous system irritability. Ankle clonus is generally accompanied by hyperreflexia. To assess for ankle clonus, the nurse supports the leg with the knee flexed with one hand. Using the other hand, the nurse sharply dorsiflexes the foot and holds the position for a moment, and then releases the foot. Normal response (negative clonus) is elicited when no rhythmic oscillations are felt while the foot is held in dorsiflexion. Abnormal response (positive clonus) is recorded when the nurse feels and sees the oscillations against this pressure. Video for sustained ankle clonus can be watched here

4. Assess for signs of labor at every visit.
Ask the client if she feels any signs of contractions, vaginal bleeding, or leaking of fluid. Prenatal care is performed to determine any pregnancy complications and perform early interventions, as indicated.

5. Assess the client’s vital signs.
A client with systolic blood pressure greater than or equal to 140 mmHg and diastolic blood pressure greater than 90 mmHg meets the criteria for new-onset hypertension. Additionally, shortness of breath may suggest pulmonary edema, which is concerning for the development of preeclampsia.

6. Assess for the presence of epigastric or RUQ pain.
Assess the client for any complaints of epigastric pain, RUQ pain, or even heartburn. Liver ischemia is caused by decreased organ perfusion leading to pain in the epigastric area, nausea and vomiting, and elevated liver enzymes.

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7. Perform fundoscopic examination regularly.
It helps to evaluate changes or severity of retinal involvement. Visual disturbances such as blurring of vision, scotoma, and photopsia are common in women with preeclampsia and eclampsia. Vasoconstriction causes retinal arteriolar spasm, which in turn results in visual disturbances. 

8. Palpate for uterine tenderness or rigidity; check for vaginal bleeding—review history of other medical problems.
These signs may indicate abruptio placentae, especially if a pre-existing medical problem, such as diabetes mellitus or a renal or cardiac disorder, causes vascular involvement.

Nursing Interventions and Rationales

1. Emphasize the importance of the client promptly reporting signs/symptoms of CNS involvement.
Delayed treatment or progressive onset of symptoms may result in tonic-clonic convulsions or eclampsia. Symptoms that commonly precede a convulsion are severe, persistent headaches, blurred vision, photophobia, epigastric pain, or heartburn.

2. Establish measures to lessen the likelihood of seizures.
Keeping the room quiet and dimly lit, limiting visitors, planning and coordinating care, and promoting rest lessen environmental factors that may stimulate irritable cerebrum and cause a convulsive state.

3. Review test results of clotting time, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen levels.
These tests can indicate depletion of coagulation factors and fibrinolysis and may suggest disseminated intravascular coagulation (DIC), which indicates a worsening of preeclampsia. As the blood vessels constrict, the formation of clots occurs to repair the endothelial damage until the body’s platelet supply is diminished.

4. Enforce seizure precautions per protocol.
If a seizure does occur, a seizure protocol reduces the risk of injury.

5. Advise the client to maintain strict bedrest if prodromal signs or aura are experienced and explain the necessity for these actions.
Explain that eclampsia is usually preceded by prodromal signs such as persistent headache, blurring of vision, severe epigastric pain, altered mental status, and abdominal pain. The client may feel restless during the aural phase. Understanding the importance of providing for own safety needs may enhance client cooperation. 

In the event of a seizure, ensure a patent airway and promote client safety. 

6. Stay with the client during and after a seizure. Do not leave the bedside and call for assistance.
Promotes client safety and reduces the sense of isolation during the event. 

7. Keep padded side rails up pillows or folded blankets. Set the bed in the lowest position.
Women with eclampsia are prone to sustaining fractures from falling out of bed during seizures. Minimizes injury should frequent or generalized seizures occur while the client is in bed. 

8. Do not attempt to restrain or restrict the client’s movements during the seizure.
Cradle the client’s head, place it on a soft area and assist to the floor if out of bed. Gentle guiding of extremities reduces risk or physical injury when the client lacks voluntary muscle control. If an attempt is made to restrain the client during the seizure, erratic movements may increase, and the client may injure themselves or others. 

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9. Note the time of onset and duration of the seizure. Document motor involvement, duration of seizure, and post-seizure behavior. 
Helps localize the cerebral area of involvement and may be useful in helping the client and family members manage seizure activity.

10. Turn the client’s head on the side; insert airway/bite block per facility protocol only if the jaw is relaxed; suction nasopharynx, as indicated.
Helps ensure a patent airway and reduces the risk of oral trauma but should not be “forced” or inserted when teeth are clenched because dental and soft-tissue damage may result.

11. Check for the patency of the intravenous line. Restart the IV line immediately if infiltrated. 
Check whether the IV line is still patent after seizure activity. Start a new line with a gauge 18 needle and administer magnesium sulfate as ordered. See interventions for magnesium sulfate administration below. 

12. Administer oxygen 10 L/min by non-rebreather face mask. Monitor pulse oximetry.
After convulsions, administration of supplementary oxygen treats postictal hypoxemia

13. Observe for signs and symptoms of labor or uterine contractions. Assess uterine activity, cervical status, and fetal status.
Convulsions increase uterine irritability, becoming hypercontractile and hypertonic. As a result, the membranes may have ruptured, or the cervix may have dilated rapidly. Labor and birth may ensue after seizure activity. 

14. Assess fetal well-being, noting fetal heart rate (FHR).
During seizure activity, fetal bradycardia may occur, including late decelerations. The placental blood flow can be cut off, which will lead to fetal distress and death.

15. Monitor for signs of disseminated intravascular coagulation (DIC), easy/spontaneous bruising, prolonged bleeding, epistaxis, GI bleeding.
Abruptio placentae with the release of thromboplastin predispose the client to DIC. DIC occurs when platelets rush to repair the endothelial damage until their numbers are diminished, resulting in bleeding in the woman.

16. Be prepared to assist with birth when the client is stable.
Following an eclamptic seizure and after stabilizing the client and fetus, a decision is made regarding the timing and method of birth. Eclampsia, by itself, is not an indication of immediate cesarean birth. The route and timing of birth depending on the condition of the mother and fetus, gestational age of the fetus, presence of labor, and cervix score. 

17. Administer magnesium sulfate (MgSO4) intramuscularly or IV using an infusion pump. Magnesium sulfate is the drug of choice for treating eclamptic seizures and preventing repeated seizures. MgSO4 is a CNS depressant that decreases acetylcholine release, blocks neuromuscular transmission, and prevents seizures. It has a transient effect of lowering BP and increasing urine output by altering vascular response to pressor substances. Although IV administration of MgSO4 is easier to regulate and reduces the risk of a toxic reaction, some facilities may still use the IM route if continuous surveillance is not possible or if appropriate infusion apparatus is not available (He, Chen et al., 2020). Note: Adding 1 ml of 2% lidocaine to the IM injection may reduce associated discomfort. Current research suggests the use of phenytoin infusion may be effective in treating eclampsia without the adverse side effects, such as respiratory depression and tocolytic effect on uterine smooth muscle, which can impede labor intrapartum therapy (Khooshideh et al., 2017).

18. Monitor BP before, during, and after magnesium sulfate (MgSO4) administration. Note serum magnesium levels in conjunction with respiratory rate, patellar/deep tendon reflex (DTRs), and urine output. 
A therapeutic level of MgSO4 is achieved with serum levels of 4.0–7.5 mEq/L or 6–8 mg/dL. Adverse/toxic reactions develop above 10–12 mg/dL, with loss of DTRs occurring first, respiratory paralysis between 15–17 mg/dL, or heart block occurring at 30–35 mg/dL.

19. Prepare calcium gluconate. Give 10 ml (1 g/10 ml) over 3 minutes as indicated.
It serves as an antidote to counteract the adverse/toxic effects of MgSO4. Magnesium toxicity can present in several ways, including diminished deep tendon reflexes, cardiopulmonary arrest, and respiratory depression (Chakraborty & Can, 2021).

20. Administer amobarbital (Amytal) or diazepam (Valium), as indicated. 
Depresses cerebral activity; has a sedative effect when MgSO4 does not control convulsions. These are usually not recommended as first-line therapy because they depress the gag reflex, and their sedative effects also affect the fetus. 

21. Review the results of sequential platelet count. Avoid amniocentesis if the platelet count is less than 50,000/mm3. If thrombocytopenia is present during the operative procedure, use general anesthesia. As indicated, transfuse with platelets, packed red blood cells, fresh frozen plasma, or whole blood. Rule out HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. 
Thrombocytopenia may arise because of platelet adherence to disrupted endothelium or reduced prostacyclin levels (a potent inhibitor of platelet aggregation). Invasive procedures or anesthesia requiring needle puncture (such as spinal/epidural) could result in excessive bleeding.

22. Monitor liver enzymes and bilirubin; note hemolysis and presence of Burr cells on peripheral smear.
An elevated liver enzyme (aspartate transaminase [AST], alanine transaminase [ALT]) and bilirubin levels, microangiopathic hemolytic anemia, and thrombocytopenia may indicate the presence of HELLP syndrome, signifying a need for immediate cesarean delivery if the condition of the cervix is unfavorable for induction of labor.

23. Hospitalize if central nervous system (CNS) involvement is present. 
Immediate introduction of therapy helps to ensure safety and limit complications.

24. Prepare for cesarean birth if preeclampsia is severe, placental functioning is compromised, and cervix is not ripe or responsive to induction.
When fetal oxygenation is severely reduced owing to vasoconstriction within the malfunctioning placenta, immediate delivery may be necessary to save the fetus.

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Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

Other care plans related to the care of the pregnant mother and her infant:

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.

Gil Wayne graduated in 2008 with a bachelor of science in nursing. He earned his license to practice as a registered nurse during the same year. His drive for educating people stemmed from working as a community health nurse. He conducted first aid training and health seminars and workshops for teachers, community members, and local groups. Wanting to reach a bigger audience in teaching, he is now a writer and contributor for Nurseslabs since 2012 while working part-time as a nurse instructor. His goal is to expand his horizon in nursing-related topics. He wants to guide the next generation of nurses to achieve their goals and empower the nursing profession.
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