Gestational hypertension is a pregnancy complication characterized by high blood pressure that develops after 20 weeks of pregnancy in previously normotensive women. This nursing diagnosis focuses on identifying and managing elevated blood pressure during pregnancy while preventing complications for both the mother and fetus.
Causes (Related to)
Gestational hypertension can develop due to various risk factors:
- First pregnancy
- Multiple pregnancies
- Advanced maternal age (>35 years)
- Obesity
- Family history of preeclampsia
- Previous history of gestational hypertension
- Chronic conditions such as:
- Diabetes
- Kidney disease
- Autoimmune disorders
- Environmental factors include:
- High-stress levels
- Poor nutrition
- Inadequate prenatal care
Signs and Symptoms (As evidenced by)
Subjective: (Patient reports)
- Headaches
- Visual disturbances
- Upper abdominal pain
- Shortness of breath
- Anxiety about blood pressure readings
- Fatigue
- Swelling in hands and face
Objective: (Nurse assesses)
- Blood pressure ≥140/90 mmHg
- Rapid weight gain
- Edema
- Proteinuria
- Decreased urine output
- Hyperreflexia
- Altered laboratory values
Expected Outcomes
- Blood pressure will stabilize within the target range
- The patient will remain free from preeclampsia symptoms
- Fetal growth and development will remain within normal parameters
- The patient will demonstrate an understanding of warning signs
- The patient will maintain adequate urine output
- The patient will adhere to the prescribed medication regimen
- The patient will successfully carry the pregnancy to term if possible
Nursing Assessment
Monitor Vital Signs
- Check blood pressure every 4 hours or as ordered
- Monitor heart rate and respiratory rate
- Track temperature
- Document all readings
Assess Fetal Well-being
- Monitor fetal heart rate
- Track fetal movement
- Note uterine activity
- Document fetal assessment findings
Evaluate Fluid Status
- Monitor intake and output
- Assess for edema
- Check skin turgor
- Monitor daily weights
- Assess for signs of fluid overload
Check for Complications
- Monitor for preeclampsia signs
- Assess neurological status
- Watch for HELLP syndrome indicators
- Check for placental insufficiency signs
Review Risk Factors
- Document family history
- Assess lifestyle factors
- Review medical history
- Monitor medication compliance
Nursing Care Plans
Nursing Care Plan 1: Risk for Maternal/Fetal Injury
Nursing Diagnosis Statement:
Risk for Maternal/Fetal Injury related to elevated blood pressure and potential placental insufficiency as evidenced by BP readings >140/90 mmHg.
Related Factors:
- Elevated blood pressure
- Altered placental perfusion
- Compromised uteroplacental blood flow
- Maternal anxiety
Nursing Interventions and Rationales:
- Monitor blood pressure q4h
Rationale: Early detection of dangerous BP elevations - Position patient in left lateral position
Rationale: Improves uteroplacental perfusion - Monitor fetal heart rate
Rationale: Detects early signs of fetal distress - Educate about warning signs
Rationale: Promotes early intervention
Desired Outcomes:
- Blood pressure will stabilize within the target range
- Fetal heart rate will remain within normal limits
- The patient will recognize and report warning signs promptly
Nursing Care Plan 2: Anxiety
Nursing Diagnosis Statement:
Anxiety related to concerns about maternal and fetal well-being as evidenced by verbalized worry and increased tension.
Related Factors:
- Uncertain pregnancy outcome
- Fear of complications
- Lack of knowledge
- Lifestyle modifications
Nursing Interventions and Rationales:
- Provide clear information about the condition
Rationale: Reduces fear of the unknown - Teach stress reduction techniques
Rationale: Helps manage anxiety - Include family in education
Rationale: Builds support system
Desired Outcomes:
- The patient will demonstrate reduced anxiety levels
- The patient will utilize effective coping mechanisms
- The patient will verbalize understanding of the condition
Nursing Care Plan 3: Excess Fluid Volume
Nursing Diagnosis Statement:
Risk for Excess Fluid Volume related to pregnancy-induced hypertension as evidenced by edema and rapid weight gain.
Related Factors:
- Sodium retention
- Decreased plasma oncotic pressure
- Altered regulatory mechanisms
- Compromised renal function
Nursing Interventions and Rationales:
- Monitor daily weights
Rationale: Tracks fluid retention - Assess edema
Rationale: Indicates fluid status - Monitor intake and output
Rationale: Ensures fluid balance
Desired Outcomes:
- The patient will maintain appropriate weight gain
- Edema will remain within acceptable limits
- The patient will maintain adequate urine output
Nursing Care Plan 4: Knowledge Deficit
Nursing Diagnosis Statement:
Knowledge Deficit related to unfamiliarity with gestational hypertension management as evidenced by questions about self-care and monitoring.
Related Factors:
- Lack of exposure to information
- Misinterpretation of information
- Language barriers
- Stress affecting learning
Nursing Interventions and Rationales:
- Provide education about the condition
Rationale: Increases understanding - Teach home BP monitoring
Rationale: Promotes self-care - Review medication regimen
Rationale: Ensures compliance
Desired Outcomes:
- The patient will demonstrate an understanding of the condition.
- The patient will correctly perform BP monitoring
- The patient will comply with the treatment plan
Nursing Care Plan 5: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to prescribed activity restrictions as evidenced by limited activity tolerance.
Related Factors:
- Medical restrictions
- Safety precautions
- Fatigue
- Physical discomfort
Nursing Interventions and Rationales:
- Assist with position changes
Rationale: Maintains safety - Implement activity restrictions
Rationale: Prevents complications - Teach safe movement techniques
Rationale: Promotes independence
Desired Outcomes:
- The patient will maintain the prescribed activity levels
- The patient will avoid injury
- The patient will maintain muscle strength
References
- Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
- ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia. Obstet Gynecol. 2019 Jan;133(1):1. doi: 10.1097/AOG.0000000000003018. PMID: 30575675.
- Bajpai D, Popa C, Verma P, Dumanski S, Shah S. Evaluation and Management of Hypertensive Disorders of Pregnancy. Kidney360. 2023 Oct 1;4(10):1512-1525. doi: 10.34067/KID.0000000000000228. PMID: 37526641; PMCID: PMC10617800.
- Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. Obstet Gynecol. 2020 Jun;135(6):e237-e260. doi: 10.1097/AOG.0000000000003891. PMID: 32443079.
- Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
- Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
- Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
