NCP for Pregnancy Induced Hypertension

NURSING Fluid Volume deficit [isotonic]

DIAGNOSIS:
Plasma protein loss, decreasing plasma colloid
May Be Related To: osmotic
pressure, allowing fluid shifts out of the vascular
compartment.

Edema formation, sudden weight gain,

Possibly Evidenced
hemoconcentration, nausea/ vomiting,
By: epigastric pain, headaches, visual changes,
decreased urine output

DESIRED
OUTCOMES/EVALU
ATION CRITERIA—
Verbalize understanding of need for close
CLIENT WILL:
monitoring of weight, BP, urine protein, and
edema. Participate in therapeutic regimen and
monitoring, as indicated. Display Hct WNL and
physiological edema with no signs of pitting.

Be free of signs of generalized edema (i.e.,

epigastric pain, cerebral symptoms, dyspnea,
nausea/vomiting.

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NCP for Pregnancy Induced Hypertension

ACTIONS/INTERVE RATIONALE
NTIONS
Independent

Sudden, significant weight gain (e.g., more than

Weigh client
monitor weight at home between visits.
routinely. Encourage
3.3 lb (1.5 kg)/month in the second trimester or
client to monitor
more than 1 lb (0.5 kg)/wk in the third
weight at home
trimester) reflects fluid retention. Fluid moves
between visits.
from the vascular to interstitial space, resulting
in edema.

Distinguish between The presence of pitting edema (mild, 1+

physiological and
pathological
severe, edema of
pregnancy. Monitor
location and degree
of pitting.
to 2+ 3+ to 4+) of face, hands, legs,
sacral area, or abdo - minal wall, or edema
that does not disappear after 12
hr of bedrest is significant. Note: Significant
edema may actually be present in nonpre-
eclamptic clients and absent in clients with mild
or moderated PIH.

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NCP for Pregnancy Induced Hypertension
Note signs of
progressive or
excessive edema
(i.e., epigastric/RUQ
pain, cerebral
symptoms,
nausea, vomiting).
Assess for possible
eclampsia. (Refer to
ND: Injury, risk for
maternal.)
Note changes in
Hct/Hb levels.
Reassess dietary
intake of proteins
and calories.
Monitor intake and
output. Note urine
color, and
measure specific
gravity as indicated.
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.
Identifies degree of hemoconcentration caused
by fluid shift. If Hct is less than 3 times Hb
level, hemoconcentration exists.
Adequate nutrition reduces incidence of prenatal
hypovolemia and hypoperfusion; inadequate
protein/calories increases the risk of edema
formation and PIH. Intake of 80–100 g of
protein may be required daily to replace losses.
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.
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NCP for Pregnancy Induced Hypertension

Test clean, voided Aids in determining degree of severity/

urine for protein progression of condition. A 2+ reading suggests
each visit, or glomerular edema or spasm. Proteinuria affects
fluid shifts from the vascular tree. Note: Urine
daily/hourly as contaminated by vaginal secretions may test
appropriate if positive for protein, or dilution may result in a
hospitalized. false-negative result. In addition, PIH may be
present without significant proteinuria.
Report readings of
2+, or greater.

Assess lung sounds

Dyspnea and crackles may indicate pulmonary
and respiratory edema, which requires immediate treatment.
rate/effort.

Monitor BP and Elevation in BP may occur in response to

catecholamines, vasopressin, prostaglandins,
pulse. (Refer to ND:
and, as recent findings suggest, decreased
Cardiac Output, levels of prostacyclin.
decreased.)

Answer questions Diuretics further increase state of dehydration

and review rationale
for avoiding use of
diuretics to treat
edema.
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.

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NCP for Pregnancy Induced Hypertension

Collaborative
Schedule prenatal Necessary to monitor changes more closely for
visit every 1–2 wk if the well-being of the client and fetus.
PIH is mild;
weekly if severe.

Review moderate Some sodium intake is necessary because levels

sodium intake of up below 2–4 g/day result in greater dehydration in
to 6 g/day. some clients. However, excess sodium may
Instruct client to increase edema formation.
read food labels and
avoid foods
high in sodium (e.g.,
bacon, luncheon
meats,
hot dogs, canned
soups, and potato
chips).

Nutritional consult may be beneficial in

Refer to dietitian as
determining individual needs/dietary plan.
indicated.

Lateral recumbent position decreases pressure

Place client on strict
regimen of bedrest;
encourage lateral
position.
onthe 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.

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NCP for Pregnancy Induced Hypertension
Refer to home
monitoring/day-care
program, as
appropriate.
Replace fluids either
orally or parenterally
via infusion pump, as
indicated.
When fluid deficit
is severe and
client is
hospitalized:
Insert indwelling
catheter if kidney
output is reduced or
is less than 50 ml/hr.
Assist with insertion
of lines and/or
monitoring of nvasive
hemodynamic
parameters, such as
CVP and pulmonary
artery wedge
pressure (PAWP).
Some mildly hypertensive clients without
proteinuria may be managed on an outpatient
basis if adequate surveillance and support is
provided and the client/family actively
participates in the treatment regimen.
Fluid replacement corrects hypovolemia, yet
must be administered 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.
Allows more accurate monitoring of output/renal
perfusion.
Provides a more accurate measurement of fluid
volume. In normal pregnancy, plasma volume
increases by 30%–50%, yet this increase does
not occur in the client with PIH.
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NCP for Pregnancy Induced Hypertension

Monitor serum uric Elevated levels, especially of uric acid, indicate

acid and creatinine impaired kidney function, worsening of maternal
levels, and BUN. condition, and poor fetal outcome.

Administer platelets Clients with HELLP syndrome awaiting delivery

as indicated. When of the fetus may benefit from transfusion of
count is below 20, platelets.
000.

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NCP for Pregnancy Induced Hypertension

NURSING Cardiac Output, decreased

DIAGNOSIS:

Hypovolemia/decreased venous return,

May Be Related To: increased systemic vascular resistance.

Possibly Evidenced
Variations in blood pressure/hemodynamic
By:
readings, edema, shortness of breath, change in
mental status.

DESIRED Remain normotensive throughout remainder of

OUTCOMES/EVALU pregnancy. Report absence and/or decreased
ATION CRITERIA— episodes of dyspnea. Alter activity level as
CLIENT WILL: condition warrants.

ACTIONS/INTERVE RATIONALE
NTIONS:
The client with PIH does not manifest the
Independent normal cardiovascular response to pregnancy
Monitor and graph (left ventricular hypertrophy, increase in
BP and pulse. plasma volume, vascular relaxation with
decreased peripheral resistance).
Hypertension (the second
manifestation of PIH after edema) occurs
owing to increased sensitization to angiotensin
II, which increases BP, promotes aldosterone
release to increase sodium/water reabsorption
from the renal tubules, and constricts blood
vessels.

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NCP for Pregnancy Induced Hypertension

Assess MAP at 22 Pulmonary edema may occur, with changes in

weeks’ gestation. A peripheral vascular resistance and decline in
pressure of 90 mm plasma colloid osmotic pressure.
Hg is considered
predictive of PIH.
Assess for crackles,
wheezes, and
dyspnea; note
respiratory
rate/effort.

Institute bedrest Increases venous return, cardiac output, and

with client in lateral renal/placental perfusion.
position.

Collaborative
Monitor invasive Provides accurate picture of vascular changes
hemodynamic and fluid volume. Prolonged vascular
parameters. constriction, increased hemoconcentration, and
fluid shifts decrease cardiac output.

Administer
antihypertensive If BP does not respond to conservative
drug such as measures, short-term medication may be
hydralazine necessary in conjunction with other therapies,
(Apresoline) PO/IV, e.g., fluid replacement and MgSO4.
so that diastolic Antihypertensive drugs act directly on arterioles
readings are to promote relaxation of cardiovascular smooth
between 90 and 105 muscle and help increase blood supply to
mm Hg. Begin cerebrum, kidneys, uterus, and placenta.
maintenance therapy Hydralazine is the drug of choice because it
as needed, e.g., does not produce effects on the fetus. Sodium
methyldopa nitroprusside is being used with some success to
(Aldomet) or lower BP (especially in HELLP syndrome).
nifedipine
(Procardia).

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NCP for Pregnancy Induced Hypertension

Monitor BP and side Side effects such as tachycardia, headache,

effects of nausea, and vomiting, and palpitations may be
antihypertensive treated with propranolol.
drugs. Administer
propranolol
(Inderal), as
appropriate.

Prepare for birth of If conservative treatment is ineffective and

fetus by cesarean labor induction is ruled out, then surgical
delivery, when procedure is the only means of halting the
severe PIH/eclamptic hypertensive problems.
condition is
stabilized, but
vaginal delivery is
not feasible.

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NCP for Pregnancy Induced Hypertension

NURSING Tissue Perfusion, altered: uteroplacental

DIAGNOSIS:

May Be Related To:

Maternal hypovolemia, interruption of blood flow
(progressive vasospasm of spiral arteries)

Possibly Evidenced Intrauterine growth retardation, changes in fetal

By: activity/heart rate, premature delivery, fetal
demise.

DESIRED
OUTCOMES/EVALU Demonstrate normal CNS reactivity on
ATION CRITERIA— nonstress test (NST); be free of late
FETUS WILL: decelerations; have no decrease in FHR on
contraction stress test/oxytocin challenge test
(CST/OCT).

ACTIONS/INTERVE RATIONALE
NTIONS

Independent
Provide information
Reduced placental blood flow results in reduced
to client/couple
gas exchange and impaired nutritional
regarding home functioning of the placenta. Potential outcomes
assessment/recordin of poor placental perfusion include a
malnourished, LBW infant, and prematurity
g of daily fetal
associated with early delivery, abruptio
movements and placentae, and fetal death. Reduced fetal activity
when to seek indicates fetal compromise (occurs before
detectable
immediate
alteration in FHR and indicates need for
medical attention. immediate
evaluation/intervention.

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NCP for Pregnancy Induced Hypertension

Identify factors Cigarette smoking, medication/drug use, serum

glucose levels, environmental sounds, time of
affecting fetal day, and sleep-wake cycle of the fetus can
activity. increase or decrease fetal movement.

Review signs of Prompt recognition and intervention increases

abruptio placentae the likelihood of a positive outcome.
(i.e., vaginal
bleeding, uterine
tenderness,
abdominal pain,
and decreased fetal
activity).

Provide contact
number for client to Provide contact number for client to ask
ask questions, report questions, misconceptions and intervene in a
changes in daily fetal timely manner, as indicated.
movements, and so
forth.

Evaluate fetal
growth; measure Decreased placental functioning may accompany

progressive fundal PIH, resulting in IUGR. Chronic intrauterine

growth at each office stress and uteroplacental insufficiency decrease

visit or periodically amount of fetal contribution to amniotic fluid

during home visits, pool.

as appropriate.

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NCP for Pregnancy Induced Hypertension

Note fetal response Depressant effects of medication reduce fetal

to medications such respira tory and cardiac function and fetal
as MgSO4, activity level, even though placental circulation
phenobarbital, and may be adequate.
diazepam.

Monitor FHR Helps evaluate fetal well-being. An elevated FHR

may indicate a compensatory response to
manually or
hypoxia, prematurity, or abruptio placentae.
electronically, as
indicated.
Collaborative
Assess fetal response
BPP helps evaluate fetus and fetal environment
to BPP criteria or
on five specific parameters to assess CNS
CST, as maternal
function and fetal contribution to amniotic fluid
status indicates.
volume. CST assesses placental functioning and
(Refer to ND: Injury,
reserves.
risk for maternal.)

Assist with
In the event of deteriorating maternal/fetal
assessment of fetal
condition, risks of delivering a preterm infant are
maturity and
weighed against the risks of continuing the
well-being using L/S
pregnancy, using results from evaluative studies
ratio, presence of PG,
of lung and kidney maturity, fetal growth, and
estriol levels, FBM,
placental functioning. IUGR is associated with
and sequential
reduced maternal volume and vascular changes.
sonography
beginning at 20–26
weeks’ gestation.
(Refer to CP: The
High-Risk Frequency;
ND: Injury, risk for
fetal.)

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NCP for Pregnancy Induced Hypertension

Assist with Identifies fetus at risk for IUGR or intrauterine

assessment of fetal demise associated with reduced plasma
maternal plasma volume and reduced placental perfusion.
volume
at 24–26 weeks’
gestation using
Evans’ blue dye
when indicated.

Using Decreased placental function and size are

ultrasonography, associated with PIH.
assist with
assessment of
placental size.

Administer Corticosteroids are thought to induce fetal

pulmonary maturity (surfactant production) and
corticosteroid prevent respira tory distress syndrome, at least
(dexamethasone, in a fetus delivered prematurely because of
betamethasone) IM condition or inadequate placental functioning.
Best results are obtained when fetus is less than
for at least 24–48 hr, 34 weeks’ gestation and delivery occurs within a
but not more than 7 week of corticosteroid administration.
days before delivery,
when severe
PIH necessitates
premature delivery
between
28 and 34 weeks’
gestation.

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NCP for Pregnancy Induced Hypertension

NURSING Injury, risk for maternal

DIAGNOSIS:

May Be Related To: Tissue edema/hypoxia, tonic-clonic convulsions,

abnormal blood profile and/or clotting factors

DESIRED
OUTCOMES/EVALU Participate in treatment and/or environmental
ATION CRITERIA— modifications to protect self and enhance safety.
CLIENT WILL:
Be free of signs of cerebral ischemia (visual
disturbances, headache, changes in mentation).
Display normal levels of clotting factors and liver
enzymes.

ACTIONS/INTERVE RATIONALE
NTIONS

Independent Cerebral edema and vasoconstriction can be

Assess for CNS evaluated in terms of symptoms, behaviors, or
involvement (i.e., retinal changes.
headache,
irritability, visual
disturbances or
changes on
funduscopic
examination).

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NCP for Pregnancy Induced Hypertension

Stress importance of Delayed treatment or progressive onset of

client promptly symptoms may result in tonic-clonic convulsions
reporting or eclampsia.
signs/symptoms of
CNS involvement.

Note changes in level In progressive PIH, vasoconstriction and

of consciousness. vasospasmsof cerebral blood vessels reduce
oxygen consumptionby 20% and result in
cerebral ischemia.

Assess for signs of Generalized edema/vasoconstriction, manifested

impending by severe CNS, kidney, liver, cardiovascular, and
eclampsia: respiratory involvement, precede convulsive
hyperactivity of deep state.
tendon reflexes (3+
to 4+),
ankle clonus,
decreased pulse and
respirations,
epigastric pain, and
oliguria (less than 50
ml/hr).

Institute measures Reduces environmental factors that may

to reduce likelihood stimulate irritable cerebrum and cause a
of seizures; convulsive state.
i.e., keep room quiet
and dimly lit, limit
visitors, plan and
coordinate care, and
promote rest.

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NCP for Pregnancy Induced Hypertension

Implement seizure If seizure does occur, reduces risk of injury.

precautions per
protocol.

In the event of a Maintains airway by reducing risk of aspiration

seizure: and onlypreventing tongue from occluding
Turn client on side; airway. Maximizes oxygenation. Note: Be
insert airway/bite cautious with when jaws are set may result in
block only if mouth is injury.
relaxed; suction
nasopharynx, as
clothing; do not
restrict movement.
Document
motor involvement,
duration of seizure,
and postseizure
behavior.

Palpate for uterine These signs may indicate abruptio placentae,

tenderness or especially if there is a preexisting medical
rigidity; problem, such as diabetes mellitus, or a renal or
check for vaginal cardiac disorder causing vascular involvement.
bleeding. Note
history of other
medical problems.

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NCP for Pregnancy Induced Hypertension
Monitor for signs and
symptoms of labor
or uterine
contractions.
Assess fetal well-
being, noting FHR.
Monitor for signs of
DIC asy/spontaneous
bruising, prolonged
bleeding, epistaxis,
GI bleeding.
(Refer to CP: renatal
Hemorrhage.)
Collaborative
Hospitalize if CNS
involvement is
present.
Administer
MgSO4 IM or IV
using infusion pump.
Convulsions increase uterine irritability; labor
may ensue.
During seizure activity, fetal bradycardia may
occur.
Abruptio placentae with release of
thromboplastin predisposes client to DIC.
Prompt initiation of therapy helps to ensure
safety and limit complications.
MgSO4 a CNS depressant, 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
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NCP for Pregnancy Induced Hypertension

Surveillance is not possible and/or if appropriate

infusion apparatus is not available. 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 the treatment of PIH without the
adverse side effects, such as respiratory
depression, and tocolytic effect on uterine
smooth muscle, which can impede labor during
intrapartal therapy.)

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

Have calcium
Serves as antidote to counteract adverse/toxic
gluconate available.
effects of MgSO4.
Administer 10 ml (1
g/10 ml) over 3 min
as indicated.

Administer
amobarbital (Amytal) Depresses cerebral activity; has sedative effect
when convulsions are not controlled by MgSO4.
or diazepem Notrecommended as first- line therapy because
(Valium), as sedativeeffect also extends to the fetus.
indicated.

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NCP for Pregnancy Induced Hypertension

Perform funduscopic Helps to evaluate changes or severity of retinal

examination daily. involvement.

Monitor test results Such tests can indicate depletion of coagulation

of clotting time, PT, factors and fibrinolysis, which suggests DIC.
PTT, fibrinogen
levels, and FPS/FDP.

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NCP for Pregnancy Induced Hypertension

NURSING Nutrition: altered, risk for less than body

DIAGNOSIS: requirements

May Be Related To: Intake insufficient to meet metabolic demands

and replace losses

DESIRED Verbalize understanding of individual dietary

OUTCOMES/EVALU needs.
ATION CRITERIA—
CLIENT WILL: Demonstrate knowledge of proper diet as
evidenced by developing a dietary plan within
own financial resources. Display appropriate
weight gain.

ACTIONS/INTERVE RATIONALE
NTIONS

Independent Establishes guidelines for determining dietary

Assess client’s needs and educating client. Malnutrition may be
nutritional status,
a contributing factor to the onset of PIH,
condition of
specifically
hair and nails, and
when client follows a low-protein diet, has
height and pregravid
insufficient caloric intake, and is overweight or
weight.
underweight by 20% or more before conception.

Provide information
about normal weight The underweight client may need a diet higher
in calories; the obese client should avoid dieting
gain in
pregnancy, because it places the fetus at risk for ketosis.
modifying it to meet
client’s needs.

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NCP for Pregnancy Induced Hypertension

Provide oral/written Daily intake of 80–100 g/day (1.5 g/kg) is

information about sufficient to replace proteins lost in urine and
action and uses of allow for normal serum oncotic pressure.
protein and its role
in development of
PIH.

Provide information
about effect of Reducing metabolic rate through bedrest and
bedrest and limited activity decreases protein needs.
reduced activity on
protein
requirements.

Collaborative
Refer to dietitian, as Helpful in creating individual dietary plan
indicated. incorporating specific needs/restrictions.

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NCP for Pregnancy Induced Hypertension

NURSING Knowledge deficit [Learning Need]

regardingcondition, prognosis, self care
DIAGNOSIS: and treatmentneeds

May Be Related To: Lack of exposure/unfamiliarity with information

resources, misinterpretation

Possibly Evidenced Request for information, statement of

By: misconceptions,inaccurate follow-through of
instructions, developmentof preventable
complications

DESIRED Verbalize understanding of disease process and

OUTCOMES/EVALU appropriate treatment plan. Identify
ATION CRITERIA—
signs/symptoms requiring medical evaluation.
CLIENT/COUPLE
Perform necessary procedures correctly.
WILL:
Initiate lifestyle/behavior changes as indicated.

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NCP for Pregnancy Induced Hypertension

RATIONALE
ACTIONS/INTERVE
NTIONS

Independent Establishes data base and provides information

Assess about areas in which learning is needed.
Receiving information can promote
client’s/couple’s
understanding and reduce fear, helping to
knowledge of the facilitate the treatment plan for the client. Note:
disease process. Current research in progress may provide
additional treatment options, such as using low-
Provide information
dose (60 mg/day) aspirin to reduce
about thromboxane generation by platelets, limiting
pathophysiology of the severity/incidence of PIH.
PIH, implications for
mother and fetus;
and the rationale for
interventions,
procedures, and
tests, as needed.

Provide information
about Helps ensure that client seeks timely treatment
signs/symptoms and may prevent worsening of preeclamptic
indicating worsening state or additional complications.
of condition, and
instruct client when
to notify healthcare
provider.

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NCP for Pregnancy Induced Hypertension

Keep client informed Fears and anxieties can be compounded when

of health status, client/couple does not have adequate
results of tests, and information about the state of the disease
fetal well-being. process or its impact on client and fetus.

Instruct client in how Gain of 3.3 lb or greater per month in second

to monitor her own trimester or 1 lb or greater per week in third
weight at home, and trimester is suggestive of PIH.
to notify healthcare
provider if gain is in
excess of 2 lb/wk, or
0.5 lb/day.

Assist family Encourages participation in treatment regimen,

members in learning allows prompt intervention as needed, and may
the procedure provide reassurance that efforts are beneficial.
for home monitoring
of BP, as indicated.

Review techniques Reinforces importance of client’s responsibility in

for stress treatment.
management and
diet restriction

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NCP for Pregnancy Induced Hypertension

Provide information Protein is necessary for intravascular and

about ensuring extravascular fluid regulation.
adequate protein in
diet for client with
possible or mild
preeclampsia.

Review self-testing of A test result of 2+ or greater is significant and

urine for protein.
Reinforce rationale
for and implications
of testing.
needs to be reported to healthcare provider.
Urine specimen contaminated by vaginal
discharge or RBCs may produce positive test
result for proteins.

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