Pregnancy induced hypertension, also known as gestational hypertension, is a potentially life-threatening disorder that usually develops late in the second trimester or in the third trimester. The non-convulsive form of PIH is termed as preeclampsia ranging from mild to severe. The convulsive form is eclampsia. The cause of this disorder is unknown but geographic, ethnic, racial, nutritional, immunologic, and familial factors and preexisting vascular disease may contribute to its development.
Nursing Care Plans
Nursing care for PIH involves providing adequate nutrition, good prenatal care, and control of pre-existing hypertension during pregnancy decrease the incidence and severity of preeclampsia. Early recognition and prompt treatment of preeclampsia can prevent progression to eclampsia.
- Deficient Fluid Volume
- Decreased Cardiac Output
- Altered Tissue Perfusion (Uteroplacental)
- Risk for Maternal Injury
- Risk for Imbalanced Nutrition: Less Than Body Requirements
- Deficient Knowledge
Deficient Fluid Volume: It is defined as decreased intravascular, interstitial, and intracellular fluid.
May be related to
- Osmotic pressure
- Plasma protein loss
- Decreasing plasma colloid
- Allowing fluid shifts out of the vascular compartment
Possibly evidenced by
- Edema formation
- Sudden weight gain
- Decreased urine output
- Epigastric pain
- Visual changes
- Patient engages in therapeutic regimen and monitoring, as indicated.
- Patient verbalizes understanding of need for close monitoring of weight, BP, urine protein, and edema.
- Patient is free of signs of generalized edema (i.e., epigastric pain, cerebral symptoms, dyspnea, nausea/vomiting)
- Patient exhibits Hct WNL and physiological edema with no signs of pitting.
|Weigh patient regularly. Tell patient to record weight at home in between visits.||Abrupt, notable weight gain (e.g., more than 3.3 lb (1.5 kg)/month in the second trimester or more than 1 lb (0.5 kg)/wk in the third trimester) reflects fluid retention. Fluid moves from the vascular to interstitial space, resulting in edema.|
|Differentiate physiological and pathological edema of pregnancy. Locate and determine degree of pitting.||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 12hr of bedrest is vital. Note: Significant edema may actually be present in nonpre-eclamptic patient sand absent in patients with mild or moderated PIH.|
|Note signs of progressive or excessive edema i.e., epigastric/RUQ pain, cerebral symptoms, nausea, vomiting). Assess for possible eclampsia.||Edema and intravascular fibrin deposition (in HELLP syndrome) within the encapsulated liver are manifested by RUQ pain; dyspnea, indicating pulmonary involvement; cerebral edema, possibly leading to seizures; and nausea and vomiting, indicating GI edema.|
|Note alteration in Hct/Hb levels.||Identifies degree of hemoconcentration caused by fluid shift. If Hct is less than 3 times Hb level, hemoconcentration exists.|
|Check on dietary intake of proteins and calories. Give information as needed.||Proper nutrition decreases incidence of prenatal hypovolemia and hypoperfusion; insufficient protein/calories increases the risk of edema formation and PIH. Intake of 80–100 g of protein may be required daily to replace losses.|
|Monitor intake and output. Note urine color, and measure specific gravity as indicated.||Urine output is a sensitive indicator of circulatory blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement. Note: Administration of magnesium sulfate (MgSO4)may cause transient increase in output.|
|Examine clean, voided urine for protein each visit, or daily/hourly as appropriate if hospitalized. Report readings of 2+, or greater.||Aids in identifying degree of severity/progression of condition. A 2+ reading implies glomerular edema or spasm. Proteinuria affects fluid shifts from the vascular tree. Note: Urine contaminated by vaginal secretions may test positive for protein, or dilution may result in a false-negative result. In addition, PIH may be present without significant proteinuria.|
|Assess lung sounds and respiratory rate/effort.||Dyspnea and crackles may mean pulmonary edema, which needs immediate treatment.|
|Check BP and pulse.||Rise in BP may happen in response to catecholamines, vasopressin, prostaglandins, and, as recent findings suggest, decreased levels of prostacyclin.|
|Respond to questions and review rationale for avoiding use of diuretics to treat edema.||Diuretics further increase chances of dehydration by decreasing intravascular volume and placental perfusion, and they may cause thrombocytopenia, hyperbilirubinemia, or alteration in carbohydrate metabolism in fetus/newborn. Note: May be useful in treating pulmonary edema.|
|Schedule prenatal visit every 1–2 wk if PIH is mild; weekly if severe.||Important to monitor changes more closely for the well-being of the patient and fetus.|
|Review moderate sodium intake of up to 6 g/day. Tell patient to read food labels and avoid foods high in sodium (e.g., bacon, luncheon meats, hot dogs, canned soups, and potato chips).||Some sodium intake is necessary because levels below 2–4 g/day result in greater dehydration in some patients. However, excess sodium may increase edema formation.|
|Collaborate with dietitian as indicated.||Nutritional consult may be beneficial in determining individual needs/dietary plan.|
|Place patient on strict regimen of bedrest; encourage lateral position.||Lateral recumbent position decreases pressure on the vena cava, increasing venous return and circulatory volume. This enhances placental and renal perfusion, reduces adrenal activity, and may lower BP as well as account for weight loss through diuresis of up to 4 lb in 24-hr period.|
|Educate patient and family members or significant others on home monitoring/day-care program, as appropriate.||Some mildly hypertensive patients without proteinuria may be managed on an outpatient basis if adequate surveillance and support is provided and the patient/family actively participates in the treatment regimen.|
|Substitute fluids either orally or parenterally via 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 output is reduced (less than 700 ml/24 hr), total fluid intake is restricted to approximate output plus insensible loss. Use of infusion pump allows more accurate control delivery of IV fluids.|
|When fluid deficit is severe and patient is hospitalized:|
|Allows more accurate monitoring of output/renal perfusion.|
|Gives a more precise measurement of fluid volume. In normal pregnancy, plasma volume increases by 30%–50%, yet this increase does not occur in the patient with PIH.|
|Elevated levels, especially of uric acid, indicate impaired kidney function, worsening of maternal condition, and poor fetal outcome.|
|Patients with HELLP syndrome awaiting delivery of the fetus may benefit from transfusion of platelets when count is below 20,000.|
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Maternal and Newborn Care Plans
Nursing care plans related to the care of the pregnant mother and her infant. See care plans for maternity and obstetric nursing:
- Abruptio Placenta| 3 Care Plan
- Cesarean Birth | 10 Care Plans
- Cleft Palate and Cleft Lip | 6 Care Plans
- Dysfunctional Labor (Dystocia) | 4 Care Plans
- Elective Termination | 6 Care Plans
- Gestational Diabetes Mellitus | 4 Care Plans
- Hyperbilirubinemia | 4 Care Plans
- Labor Stages, Induced and Augmented Labor | 36 Care Plans
- Neonatal Sepsis | 5 Care Plans
- Perinatal Loss | 5 Care Plans
- Placenta Previa | 3 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 4 Care Plans
- Prenatal Hemorrhage | 7 Care Plans
- Prenatal Substance Dependence/Abuse | 6 Care Plans
- Precipitous Labor | 3 Care Plans
- Pregnancy Induced Hypertension | 6 Care Plans
- Premature Dilation of the Cervix | 3 Care Plans
- Prenatal Infection | 3 Care Plans
- Preterm Labor | 6 Care Plans
- Puerperal Infection | 4 Care Plans
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- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
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