PHINMA - Cagayan de Oro College

Max Y. Suniel Street, Carmen Cagayan de Oro City 9000

Maternal and Child Health Nursing:

Pregnancy Induced Hypertension (PIH)

Clinical Instructor:
Mrs. Permalie P. Dizon, RN

Prepared by:
Abella, Edgar Vince
Acao, Hazel
Acop, Vanissa Joy
Cariaso, Claudine
Haim, Hejara
Lacapag, Gracelyn
Mangondato, Haula
Mendoza, Camille
Tancinco, Archduke
Telin, Criselda

Date Submitted: January 7, 2020

PREGNANCY INDUCED HYPERTENSION (PIH)

Pregnancy-induced hypertension (PIH) is one of the most common complications of pregnancy. This
occurs during the 20th week of gestation or late in the second trimester of pregnancy. This is a health
condition wherein there is a rise in the blood pressure and disappears after termination of pregnancy or
delivery. PIH was formerly called toxaemia or the presence of toxins in the blood. This is because its
occurrence was not well understood in the clinical field. Its common manifestations are hypertension,
proteinuria (presence of protein in the urine), and edema. There are 2 main types of pregnancy-induced
hypertension namely: pre-eclampsia and eclampsia.

TYPES
 Pre-eclampsia—this is the non-convulsive form of PIH. This affects 7% of all pregnant women. Its
incidence is higher in lower socio-economic groups. It may be classified either mild or severe.
 Eclampsia—this is the convulsive form of PIH. It occurs with 5% of all pre-eclampsia cases.
Mortality rate among mothers is nearly 20% and fetal mortality is also high due to premature
delivery.

NORMAL ANATOMY AND PHYSIOLOGY

Anatomy
There are a lot of bodily changes that happens during a normal pregnancy. There are external changes
that are noticeable, and there are internal changes that can only be appreciated through thorough clinical
examinations. Most of the changes are the body’s response to the changes in levels of hormones and the
growing demands of the fetus.

The two dominant female hormones, estrogen and progesterone, changes in normal level. Along with this,
a significant rise/appearance of 4 more major hormones take place; these are: 1. human chorionic
gonadotropin (HCG), 2. human placental lactogen, 3. prolactin, and 4. oxytocin. All these 6 hormones
interact with each other simultaneously to maintain normal pregnancy as it progresses.

The following are the major effects of these hormones in the body:

BREAST *enlarged
*dark end Areola
*production of colostrum (first milk)
OVARIES *ovum production stops
*corpus luteum continues production of hormones up to
10-12 weeks of gestation, or until the placenta takes over
UTERUS *amenorrhea (absence of menstruation)
*Hegar’s sign (increased vascularity of the lower segment
of the uterus)
*there is growth due to hypertrophy and hyperplasia of
muscles and connective tissues
*there is continuous rise of the fundal height
CERVIX *Goodell’s sign(softening)
*Chadwick’s sign (blue purple discoloration)
*edema
 *hyperplasia
*thickening of mucous lining
*increased mucus production
*(+) mucus plug by the end of the 2nd month
*shorter
*more elastic
*thicker
VAGINA *Chadwick’s sign (deeper color)
*hypertrophy
*hyperplasia
*acidity: pH 4.0-6.0
PERINEUM *increased in size
*deepened color

Physiology

The exact cause of pregnancy-induced hypertension is unknown; however, it is highly linked to

angiotensin gene T235 and the existence of other risk factors. Malnutrition and inadequate prenatal care
are the greatest risk factors. The history and presence of diabetes mellitus (DM), multifetal gestation (twin
pregnancies), polyhydramnios (excessive amniotic fluid), and renal diseases are also among the major
contributory factors in the development of PIH. In the past, the mystery revolving around PIH postulated
a lot of theories on its true origin, most of them were believed to be of toxic nature. Among these are
placental infarcts, autointoxication, uremia, pyelonephritis, and maternal sensitization to total proteins.
PATHOPHYSIOLOGY
SIGNS AND SYMPTOMS
The signs and symptoms of the type of PIH present in a pregnant woman is based on the presentation of
evident clinical manifestations. These are shown in the table below:
TYPE MANIFESTATIONS
Mild pre-eclampsia Hypertension:
-Systolic- a rise of more than 30 mmHg
-Diastolic- a rise of more than 15 mmHg
Proteinuria: 1 g/day
Edema: digital and periorbital
Weight gain:
 -2nd trimester-3 lbs/week
-3rd trimester-1 lb/week

Severe pre-eclampsia Hypertension:

-Systolic- a rise of more than 50 mmHg
-Diastolic- a rise of more than 30 mmHg
Proteinuria: 5 g/day
Edema: generalized
Other signs and symptoms:
*Urine-oliguria (less than 400 ml/day)
*Blood-hemoconcentration
-hypernatremia
-hypoproteinemia
-hypovolemia
*Cerebral-disorientation
-somnolence
-severe frontal headache
-hyperreflexia
-irritability
Vision: blurred, halo, dimness, blind spot
*HELLP syndrome-hemolysis, elevated liver enzymes, and low platelet
count

Eclampsia All manifestations of both pre-eclampsias are magnified plus the

following:
*coma
*convulsions (tonic and clonic)
*premature labor
*stillbirth*renal failure (oliguria and anuria)

COMPLICATIONS
Based on the severity of the PIH present to a person or the extent of damage left/occurred, a list of
possible complications can be drawn.
1. Abruption placenta
2. Disseminated intravascular coagulation (DIC)
3. Prematurity
4. Intrauterine growth retardation (IUGR)
5. HELLP syndrome
6. Maternal and/or fetal death

PROGNOSIS
The changes of the mother and/or fetus to survive after an episode of convulsion or until delivery depends
on the threshold on the effects of PIH and its complications. This can be:
1. Good—if the symptoms are mild or those that are with mild pre-eclampsia and is responding well
to treatment regimen
2. Poor—if there are multiple and long episodes of convulsions which are associated or leads to the
development of persistent coma, hyperthermia, cyanosis, tachycardia, and liver damage.
 3. Terminal—if there are development of one or more of the following complications:
a) Congestive heart failure (CHF)
b) Pulmonary edema
c) Cerebral hemorrhage
d) Renal failure

DIAGNOSTIC EVALUATIONS
Diagnostic evaluations are performed after episodes of convulsions or after the client has been rushed to
a health care facility. These are routinely done to assess the damages and will serve as the basis for the
plan of treatment.
1. 24-hour urine-protein— health problem through protein determination from the involvement of
the renal system.
2. Serum BUN and creatinine—to evaluate renal functioning.
3. Ophthalmic examination—to assess spasm, papilledema, retinal edema/detachment, and/or
hemorrhages.
4. Ultrasonography with stress and non-stress test—to evaluate fetal well-being after.

1. Stress test—fetal heart tone (FHT) and fetal activity are electronically monitored after oxytocin induction
which causes uterine contraction.
2. Non-stress test—fetal heart tone (FHT) and fetal activity are electronically monitored during fetal activity
(no oxytocin induction).
NURSING CARE PLAN

A 21-year-old pregnant woman, gravida 2 para 1, presented with hypertension at 20 weeks of gestation.
Her previous pregnancy was normal. Family history was remarkable for her mother's diagnosis of
hypertension in her fourth decade. Her father and five siblings, including a twin sister, were healthy. She
did not smoke nor drink any alcohol. She was not taking any regular medications, health products, or
herbs.

At 20 weeks of gestation, blood pressure was found to be elevated at 145/100 mmHg during a routine
antenatal clinic visit. Aside from a mild headache and easily get tired, she reported no other symptoms.
On physical examination, she was tachycardic with heart rate 100 beats per minute. Body mass index was
16.9 kg/m2. Heart sounds were normal, and there were no signs suggestive of congestive heart failure.
Radial-femoral pulses were congruent, and there were no audible renal bruits.

Baseline laboratory investigations showed normal renal and liver function with normal serum urate
concentration. Random glucose was 3.8 mmol/l. Complete blood count revealed microcytic anemia with
hemoglobin level 8.3 g/dl (normal range 11.5–14.3 g/dl) and a slightly raised platelet count of 446 × 109/l
(normal range 140–380 × 109/l). Iron-deficient state was subsequently confirmed. Quantitation of urine
protein indicated no signs proteinuria with protein: creatinine ratio of 28mg/mmol (normal range <30
mg/mmol in pregnancy).

SUBJECTIVE DATA OBJECTIVE DATA

 Parent stated that she easily gets tired.  Hemoglobin level: 8.3 g/dL
 Heart rate: 100 beats per minute

NURSING DIAGNOSIS
 Fatigue related to decreased hemoglobin and diminished oxygen carrying capacity of blood

PLANNING
At the end of 2 hours, patient will:
 Verbalize use of energy conservation principles.
 Verbalize reduction of fatigue as evidenced by reports of increased energy and ability to
perform desired activities.
 Demonstrate behaviors, lifestyle changes to reduce risk factors and protect the client from
injury.
 Modify environment as indicated to enhance safety.
 Be free of injury.

INTERVENTION
Assist the client in planning and prioritizing
activities of daily planning.
RATIONALE
Fatigue can limit the client’s ability to participate
in self-care and perform his or her role
responsibilities in family and society, such as
working outside the home.

Assist the client in developing a schedule for daily Energy reserves may be depleted unless the
activity and rest. Stress the importance of client respects the body’s need for increased rest.
frequent rest periods. A plan that balances periods of activity with
 periods of rest can help the client complete
desired activities without adding levels to fatigue.

Educate energy-conservation technique.
Clients and caregivers may need to learn skills for
delegating task to others, setting priorities, and
clustering care to use available energy to
complete desired activities. Organization and
time management can help the client conserve
energy and reduce fatigue.

Provide supplemental oxygen therapy as needed. Oxygen saturation should be kept at 90% or
greater.

Dependent: Iron supplements are particularly important

Administer iron supplements as prescribed by the for pregnant women. If there isn't enough iron in
physician. the blood, the amount of hemoglobin in the
blood decreases too. This can reduce the oxygen
supply to cells and organs.

EVALUATION
After 1 hour of nursing interventions:
 Client verbalized use of energy-conservation principles.
 Client verbalized reduction of fatigue as evidenced by reports of increased energy and ability
to perform desired activities.
 Client responses to interventions, teaching, and actions performed.
 Specific actions and changes that are made.
 Attainment or progress toward desired outcome(s).
 Modifications to plan of care.

SUBJECTIVE DATA OBJECTIVE DATA

 Mild headache as verbalized by the  Blood pressure: 145/100 mmHg
patient.  Pulse rate: 100 beats per minute
 BMI: 16.9kg/m²

NURSING DIAGNOSIS
 Decreased cardiac output related to increased systemic vascular resistance as evidenced by
elevated blood pressure

PLANNING
At the end of 2 hours, patient will:
 Participate and display improved outcome to reduce blood pressure and cardiac workload.
 Demonstrate behaviors, lifestyle changes to reduce risk factors and protect the client from
injury.
 Modify environment as indicated to enhance safety.
  Be free of injury.

INTERVENTION RATIONALE
Monitor vital signs frequently especially blood To note response to activities and interventions;
pressure. Comparison of pressures provides a more
complete picture of vascular involvement or
scope of problem.

Evaluate patient reports of extreme fatigue, To maximize participation.

intolerance for activity.

Elevate legs when in sitting position. To promote peripheral circulation and limit
complications associated with poor perfusion;
avoid sharp angulation of the hips or knees.

Assess intake and output. For close monitoring of urine output.

Provide calm environment. To reduce stress and improve wellbeing.

Provide adequate rest. Schedule activities for periods when client has
the most energy to maximize participation.

Encourage relaxation techniques. Promotes release of endorphins and aids in

developing internal locus of control, reducing
fear and anxiety.

Encourage changing position slowly and dangling To reduce risk for orthostatic hypotension.
legs before standing.

Teach home monitoring for vital signs. To detect change and allow for timely
intervention.

Dependent: To lower harmful high pressures and

Administer anti-hypertensive drug as prescribed protect important organs, such as the brain,
by the physician. heart, and kidneys.

EVALUATION
After 1 hour of nursing interventions:
 Client verbalized use of energy-conservation principles.
 Client verbalized reduction of fatigue as evidenced by reports of increased energy and ability
to perform desired activities.
 Client responses to interventions, teaching, and actions performed.
 Specific actions and changes that are made.
 Attainment or progress toward desired outcome(s).
 Modifications to plan of care.
SUBJECTIVE DATA OBJECTIVE DATA
 Mild headache as verbalized by the  Blood pressure: 145/100 mmHg
patient.  BMI: 16.9kg/m²
 Random glucose was 3.8 mmol/L
 Hemoglobin level of 8.3 g/dL
 Platelet count of 446 x 109/L
 Protein: creatinine ration of 28mg/mmol

NURSING DIAGNOSIS
 Imbalanced nutrition: less than body requirements related to inability to meet metabolic
supply demands as evidenced by low BMI of 16.9 kg/m²

PLANNING
General Objectives
1. Patient will be able:
a. Understand the importance of nutritional diet during pregnancy
b. Demonstrate sufficient knowledge to create her own regular diet plan that is in range
with her own finances
c. Display appropriate weight gain within the normal range throughout the pregnancy

Specific Objectives
At the end of nursing interventions, patient will be able to:
1. Gain 5 lbs. at the remaining of the second trimester of the pregnancy
2. Gain 1 lb. per week after the second trimester of the pregnancy
3. Have a weight gain of 28-40lbs of total weight gain throughout the pregnancy

INTERVENTION
Determine the patient’s nutritional status
(height, weight, BMI, etc.)
RATIONALE
Establishing guidelines for determining the
dietary needs and educating the patient.
Malnutrition may also contribute in the
developing PIH.

Provide information about normal weight gain of Providing information to the patient will help
pregnancy them to understand the importance of nutrition.

Present information about action and uses of Providing information to the patient will help
protein and its role in the development of PIH. them to understand PIH.

Provide information regarding effect bedrest Bedrest decrease metabolic rate and reduces
protein needs.

Provide sample for creating her own diet plan. Allowing patient to create and choose her own
food for her own diet plan will prove her
understanding towards the importance of
nutritional diet during pregnancy.
Allow patient to choose foods that appeal for Allowing patient to create and choose her own
their dietary changes during pregnancy. food for her own diet plan will prove her
understanding towards the importance of
nutritional diet during pregnancy.

Offer small frequent meals to patient. To avoid nausea and vomiting.

EVALUATION
 The patient has verbalized understanding on the importance of nutritional diet during
pregnancy.
 The patient demonstrates sufficient knowledge by creating her own diet plan.
 The patient was able to display appropriate weight gain gaining 10 lbs. of weight on the 24th
week of gestation.
 The patient was able to cope up from nutrient deficiency during her 2nd trimester.