Preeclampsia Nursing Care Plan, Diagnosis, and Interventions

Jump to Sections

• What is Preeclampsia?
• Causes
• Signs & Symptoms
• Nursing Assessment for Preeclampsia
• Preeclampsia Nursing Diagnosis
• Expected Outcomes & Goals
• Preeclampsia Nursing Interventions
• Preeclampsia Care Plan Examples
• Additional Resources

Preeclampsia is more than just high blood pressure during pregnancy. 

It’s a serious condition that can escalate quickly if not carefully managed. That’s why having the right nursing diagnosis for preeclampsia, along with a solid nursing care plan and targeted interventions, is essential.

What is Preeclampsia? 

Accurate identification and management of preeclampsia begins with a solid understanding of the condition. 

A well-informed nursing care plan for a patient with preeclampsia helps guide clinical decision-making and interventions.

Definition and Overview 

Preeclampsia is a hypertensive disorder during pregnancy characterized by high blood pressure (> 140/90 mmHg) and proteinuria after 20 weeks of gestation. 

It’s a multisystem disorder affecting the cardiovascular, renal, hepatic, and central nervous systems, potentially leading to life-threatening complications for the mother and fetus. 

Pathophysiology of preeclampsia 

• Abnormal placental development: Impaired placental perfusion leads to hypoxia and the release of anti-angiogenic factors, causing endothelial dysfunction 

• Endothelial dysfunction: Increases vascular permeability and leads to hypertension, proteinuria, and edema.
• Vasospasm and coagulation abnormalities: Result in decreased organ perfusion and damage to vital organs, including the liver, kidneys, and brain 

Differences Between Gestational Hypertension vs. Preeclampsia 

Gestational Hypertension: 

• Hypertension (high blood pressure):  > 140/90 millimeters of mercury (mmHg) without proteinuria after 20 weeks of pregnancy 

• Resolves within 12 weeks postpartum 

Preeclampsia: 

• Preeclampsia is high blood pressure with proteinuria or end-organ dysfunction. 
• May progress to eclampsia (seizures) or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. 

Causes of Preeclampsia (Related To) 

Knowing the root causes of preeclampsia helps inform the nursing diagnosis for a preeclampsia patient and guides focused interventions. 

Understanding the “why” behind the condition is key to managing it effectively.

Placental Abnormalities 

• Inadequate trophoblastic invasion during placental development 
• Abnormal remodeling of spiral arteries leading to reduced placental perfusion 

Maternal Risk Factors 

• Obesity and diabetes: Increased insulin resistance and chronic inflammation 
• Chronic hypertension: Pre-existing hypertension predisposes to superimposed preeclampsia 
• Renal disease: Impaired renal function and altered fluid-electrolyte balance 

Genetic and Environmental Influences 

• Family history: Genetic predisposition from maternal or paternal lineage 
• Environmental factors: Stress, poor nutrition, and lack of prenatal care 

Signs and Symptoms of Preeclampsia (As Evidenced By) 

Catching preeclampsia early is all about knowing what to look for. 

These key signs and symptoms help confirm the diagnosis and guide the next steps in care.

High Blood Pressure (> 140/90 mmHg) 

• Severe preeclampsia: Blood pressure (BP) > 160/110 mmHg on two occasions at least four hours apart

Proteinuria (Protein in Urine) 

• Dipstick test: > 1+ protein on two occasions 
• 24-hour urine collection: > 300 mg of protein 

Severe Headaches and Visual Disturbances 

• Headaches: Persistent, severe headaches not relieved by analgesics
• Visual changes: Blurred vision, photophobia, or scotomata (spots) 

Edema and Sudden Weight Gain 

• Generalized edema, including facial and hand swelling 
• Rapid weight gain due to fluid retention 

Epigastric Pain, Nausea, and Vomiting 

• Right upper quadrant or epigastric pain because of hepatic distension or subcapsular hematoma 
• Nausea and vomiting often associated with severe preeclampsia 

Risk Factors for Preeclampsia 

• First-time pregnancy (primigravida) or multiple pregnancies (twins or more) 
• Maternal age: Under 20 or over 35 years 
• History of chronic hypertension or kidney disease 
• Family history: Maternal history of preeclampsia 
• Autoimmune disorders: Lupus, antiphospholipid syndrome
• In vitro fertilisation pregnancy: Increased placental volume and abnormal implantation 

Nursing Assessment for Preeclampsia 

A thorough assessment lays the foundation for safe and effective care. 

In preeclampsia, objective and subjective data play a key role. Clinical signs and patient-reported symptoms help guide an accurate diagnosis and a focused nursing care plan.

Objective Data 

Blood Pressure Monitoring

• Measure blood pressure in a seated position with the arm at heart level. 
• Confirm elevated readings on two separate occasions at least four hours apart. 

Laboratory Tests

• Urinalysis: Proteinuria assessment using dipstick or 24-hour urine collection 

• Liver function tests: Elevated liver enzymes — aspartate aminotransferase (AST), alanine aminotransferase (ALT) 

• Platelet count: Thrombocytopenia — < 100,000/millimeters cubed (mm³) in severe cases 

• Serum creatinine: Elevated levels indicating renal dysfunction 

• Coagulation profile: To assess for HELLP syndrome 

Subjective Data 

Patient Complaints 

• Headache: Severe, persistent headache not relieved by medication 
• Visual disturbances: Blurred vision, double vision, or seeing spots 
• Swelling and rapid weight gain: Especially in the face, hands, and feet 
• Epigastric pain and nausea: Indicative of liver involvement 

Nursing Diagnosis for Preeclampsia 

When it comes to management, identifying the right preeclampsia nursing diagnosis sets the stage for everything that follows. Here are the top-priority diagnoses to focus on — along with what to look for and why they matter.

Risk for Imbalanced Fluid Volume Related to Hypertension and Vascular Permeability Changes 

• Related to: Hypertension and increased vascular permeability 
• As evidenced by: Generalized edema, proteinuria, and sudden weight gain 

Risk for Unstable Blood Pressure Related to Increased Vascular Resistance 

• Related to: Increased vascular resistance and endothelial dysfunction 
• As evidenced by: Persistent hypertension ( > 140/90 mmHg) 

Deficient Knowledge Related to Condition Management and Complications 

• Related to: Lack of understanding about condition management and complications 
• As evidenced by: Anxiety, non-compliance with lifestyle modifications, and frequent questions 

Risk for Fetal Injury Related to Placental Insufficiency 

• Related to: Placental insufficiency and decreased uteroplacental perfusion
• As evidenced by: Abnormal fetal heart rate (FHR) patterns, reduced fetal movements, and intrauterine growth restriction (IUGR) 

Note: Could be an acute pain nursing diagnosis as well.

Expected Outcomes & Nursing Goals 

Once a nurse makes a diagnosis, it’s all about setting clear goals and staying one step ahead. 

These expected outcomes and nursing goals help guide care, track progress, and prevent preeclampsia from becoming more serious.

Maintain Blood Pressure Within a Safe Range

• Mild preeclampsia: BP < 140/90 mmHg with lifestyle modifications
• Severe preeclampsia: BP < 160/110 mmHg with antihypertensive therapy

Prevent Complications

• Avoid progression to eclampsia or HELLP syndrome. 
• Monitor and manage signs of disseminated intravascular coagulation (DIC). 

Ensure Fetal Well-being 

• Perform continuous fetal heart rate monitoring. 
• Perform BBPs and Doppler studies for placental insufficiency. 

Educate the Patient: 

• Recognize early warning signs (e.g., headache, visual changes, and epigastric pain). 
• Adhere to prescribed medications and lifestyle modifications. 
• Emphasize the importance of regular prenatal appointments and fetal monitoring. 

Nursing Interventions for Preeclampsia 

Effective nursing interventions for preeclampsia focus on monitoring and managing hypertension, preventing seizures, ensuring fetal well-being, and educating the patient to recognize warning signs. 

These interventions help prevent the progression of preeclampsia to eclampsia or HELLP syndrome, safeguarding maternal and fetal health. 

Monitor and Manage Hypertension/Frequent BP monitoring 

• Purpose: To detect worsening hypertension and prevent complications such as eclampsia, placental abruption, or stroke 

Frequency

• Every 15-30 minutes for severe preeclampsia 
• Every four to six hours for mild to moderate preeclampsia 
• Continuous BP monitoring if on magnesium sulfate or IV antihypertensives 

Techniques

• Measure BP in a seated position with the patient’s arm at heart level. 
• Use the same arm and cuff size consistently for accuracy. 
• Make sure the patient rests for at least five minutes before measurement. 

Target BP

• Mild preeclampsia: Maintain BP < 140/90 mmHg. 
• Severe preeclampsia: Maintain BP < 160/110 mmHg but not lower than 90/60 mmHg to ensure placental perfusion. 

Nursing Actions: 

• Document BP readings accurately with time and position. 

• Monitor for symptoms of severe hypertension, including headaches, visual disturbances, and epigastric pain. 

• Report sustained BP readings > 160/110 mmHg to the health care provider immediately. 

Administer Antihypertensive Medications

Purpose: To lower BP safely and prevent complications such as stroke or placental abruption 

Common Medications: 

• Labetalol: Alpha and beta-blocker used for acute BP management 
  • Dose: IV bolus of 20 mg, followed by 40-80 mg every 10 minutes as needed (maximum 300 mg)

• Contraindications: Asthma, heart failure, bradycardia. 

• Hydralazine: Vasodilator for rapid BP reduction 
  • Dose: IV bolus of 5-10 mg every 20 minutes as needed 
  • Side Effects: Tachycardia, headache, flushing 

• Nifedipine: Oral calcium channel blocker for long-term BP control 
  • Dose: 10-20 mg orally every four to six hours 
  • Note: Monitor for reflex tachycardia and headache 

Nursing Actions: 

• Administer antihypertensives as prescribed, monitoring BP and pulse before and after administration. 
• Monitor for adverse effects, including hypotension, bradycardia, or dizziness. 
• Educate the patient on the purpose, dosage, and potential side effects of medications. 
• Collaborate with the health care team to adjust dosages based on BP response. 

Prevent Seizures and Complications: 

1. Magnesium Sulfate Administration 

• Purpose: Magnesium sulfate is the drug of choice for seizure prophylaxis in preeclampsia and for controlling seizures in eclampsia. 

• Mechanism of action: Central nervous system (CNS) depressant that blocks neuromuscular transmission, stabilizes the neuronal membrane, and reduces cerebral edema. 

Dosage and Administration 

• Loading dose: 4-6 grams IV over 15-30 minutes
• Maintenance dose: 1-2 grams per hour IV infusion 
• Duration: Continue for at least 24 hours postpartum or until the patient is stable 

Therapeutic Range

• 4-7 milliequivalents per liter (mEq/L)
• Toxicity signs: Respiratory depression, hyporeflexia, oliguria, decreased urine output — < 30 milliliters per hour (mL/hr), and cardiac arrest

2. Monitoring for Magnesium Toxicity 

Deep Tendon Reflexes (DTRs)

• Assess every  one to two hours. 
• Hyporeflexia or absent reflexes indicate toxicity. 

Respiratory Rate

• Monitor hourly; report if less than 12 breaths per minute. 

Urine Output

• Monitor hourly to ensure less than 30 mL/hr. 

Level of Consciousness

• Monitor for lethargy, confusion, or decreased responsiveness. 

Cardiac Monitoring

• Perform continuous electrocardiogram (ECG) monitoring for arrhythmias. 

3. Antidote and Emergency Measures 

• Calcium Gluconate: Antidote for magnesium toxicity 
  • Dose: Administer one gram IV over three minutes. 
  • Keep at bedside: Always keep calcium gluconate readily available when administering magnesium sulfate. 

Monitor for signs of eclampsia 

Eclampsia is a life-threatening preeclampsia complication characterized by the onset of convulsions or seizures in a pregnant or postpartum woman. 

It requires immediate intervention to prevent maternal and fetal morbidity and mortality. Monitoring for early warning signs of eclampsia allows for timely intervention and management. 

Key Signs and Symptoms of Impending Eclampsia 

• Severe persistent headache: Unrelieved by analgesics and often described as throbbing or pulsating. 

• Visual disturbances: 
  • Blurred vision or visual field defects
  • Photophobia (sensitivity to light) 
  • Scotomata (seeing spots or flashing lights) 

• Epigastric or right upper quadrant pain: 
  • Indicative of hepatic involvement or subcapsular hematoma 
  • Often described as sharp, severe, and radiating to the back 

• Nausea and vomiting: Associated with liver dysfunction or increased intracranial pressure 

• Altered mental status:
  • Restlessness, irritability, confusion, or agitation. 
  • Decreased level of consciousness or disorientation. 

• Hyperreflexia and clonus: Hyperactive DTRs with 3+ or 4+ brisk reflexes
• Clonus: Rapid rhythmic contractions and relaxations of muscles, usually at the ankle 

Ensure Fetal Well-Being: Fetal heart rate monitoring 

1. Fetal Heart Rate Monitoring 

• Purpose: To assess fetal well-being and detect early signs of distress because of placental insufficiency

Continuous Electronic Fetal Monitoring (EFM): 

• Frequency
  • Continuous during severe preeclampsia or while on magnesium sulfate 
  • Every four hours for mild preeclampsia 

• Expected findings 
  • Normal baseline FHR: 110-160 bpm. 
  • Variability: Moderate variability indicates fetal well-being. 
  • Abnormal findings: Late decelerations, decreased variability, or bradycardia indicating placental insufficiency

Nursing Actions 

• Monitor and document FHR patterns accurately. 
• Report abnormal FHR patterns (e.g., late decelerations, bradycardia) immediately. 
• Position the patient on the left side to optimize uteroplacental perfusion. 

Biophysical Profile and Doppler studies 

Biophysical Profile (BPP): 

• Combines ultrasound and non-stress test to assess fetal well-being 
• Evaluates: Fetal movements, tone, breathing, amniotic fluid volume, and FHR
• Normal score: 8-10 
• Abnormal score: < 6 requires further evaluation 

Doppler Studies 

• Assess umbilical artery blood flow to detect placental insufficiency. 
• Abnormal Doppler findings indicate increased resistance in placental circulation. 

Nursing Actions 

• Educate the patient on the purpose of BPP and Doppler studies. 
• Schedule and prepare the patient for ultrasound examinations. 
• Communicate abnormal findings to the health care provider promptly. 

Educate the Patient 

1. Lifestyle Modifications 

• Bed rest and activity restriction:
  • Encourage partial bed rest in a lateral position to enhance uteroplacental perfusion. 
  • Avoid complete bed rest to reduce the risk of venous thromboembolism. 

• Dietary modifications: 
  • Educate on a balanced, low-sodium diet to prevent fluid retention and hypertension. 
  • Encourage protein intake to compensate for proteinuria. 

• Hydration: Encourage adequate fluid intake unless contraindicated by renal dysfunction. 

2. Recognizing Symptoms Requiring Emergency Care 

Educate the Patient on Warning Signs 

• Severe headache not relieved by analgesics 
• Visual disturbances (e.g., blurred vision, flashing lights) 
• Acute Pain: Epigastric pain or right upper quadrant pain 
• Nausea and vomiting, dizziness, or sudden shortness of breath 
• Decreased fetal movements 

Emergency Management of Eclampsia 

1. During Seizure (Tonic-Clonic Activity)

• Positioning: Turn the patient on their left side to maintain the airway and prevent aspiration. 
• Airway management: Clear the airway and provide supplemental oxygen — 8 to 10 liters per minute (L/min). 

• Safety precautions:
  • Don’t restrain the patient but ensure safety by padding side rails.
  • Protect the patient’s head from injury. 

2. Post-Seizure (Postictal Phase)

• Maintain airway and oxygenation: Administer oxygen and suction secretions. 

• Assess vital signs and neurological status: 
  • Monitor BP, heart rate, respiratory rate, and oxygen saturation. 
  • Assess for altered level of consciousness (LOC), confusion, or agitation. 

• Administer magnesium sulfate: 
  • Additional bolus dose: Two grams IV over three to five minutes if seizure recurs 

3. Notify the Health Care Provider 

• Notify the health care provider immediately for all eclamptic seizures. 
• Prepare for emergency delivery if maternal or fetal status is compromised. 
• Patient education for emergency management

Seek immediate medical attention for severe symptoms.

Educate on contacting health care provider for BP readings >160/110 mmHg. 

Preeclampsia Nursing Care Plan Examples 

The following examples illustrate a nursing care plan for preeclampsia, outlining priority diagnoses, related factors, and clinical indicators to support effective management.

Care Plan #1: Severe Preeclampsia with Hypertension 

Nursing Diagnosis 

Risk for Unstable Blood Pressure 

Related To: 

• Increased vascular resistance due to endothelial dysfunction 
• Impaired placental perfusion leading to the release of vasoconstrictive substances 
• Inability to regulate blood pressure secondary to severe preeclampsia 

As Evidenced By: 

• Blood pressure > 160/110 mmHg on two occasions at least four hours apart 
• Severe headache unrelieved by analgesics 
• Visual disturbances (blurred vision, scotomata) 
• Epigastric pain or right upper quadrant pain 

Expected Outcomes 

Short-Term Goals 

• Maintain blood pressure less than 160/110 mmHg within 24 hours. 
• Prevent progression to eclampsia or HELLP syndrome. 
• Relieve symptoms of headache and visual disturbances within 24 hours. 

Long-Term Goals 

• Stabilize blood pressure within a safe range (less than 140/90 mmHg) by discharge. 
• Prevent long-term complications, including cardiovascular disease and renal dysfunction. 
• Educate the patient on lifestyle modifications and medication adherence. 

Assessment 

Objective Data 

• BP monitoring
  • Every 15-30 minutes for severe hypertension
  • Continuous BP monitoring if on magnesium sulfate or IV antihypertensives. 

• Laboratory tests
  • Liver function tests: Elevated AST and ALT 
  • Platelet count: Thrombocytopenia (< 100,000/mm³) 
  • Serum creatinine: Elevated, indicating renal involvement 

• Neurological assessment: Assess for headache, visual changes, and altered mental status. 

Subjective Data 

• Complaints of severe headache unrelieved by medication 
• Reports of blurred vision, seeing spots, or light sensitivity 
• Descriptions of epigastric or right upper quadrant pain 

Interventions 

Frequent Blood Pressure Monitoring

• Measure BP every 15 to 30 minutes until stabilized. 
• Use the same arm and position for consistency. 

Administer Antihypertensive Medications

• Labetalol: 20 mg IV bolus, followed by 40-80 mg every 10 minutes as needed 
• Hydralazine: 5-10 mg IV every 20 minutes if BP remains elevated 
• Nifedipine: 10-20 mg orally for long-term BP control 

Neurological Monitoring: 

• Assess DTRs every one to two hours. 
• Monitor for hyperreflexia or clonus, indicating CNS irritability. 
• Check for signs of magnesium sulfate toxicity if administered. 

Seizure Precautions and Safety: 

• Maintain a quiet, dark environment to minimize stimuli. 
• Pad side rails and keep the bed in a low position. 
• Keep oxygen and suction equipment at the bedside. 

Care Plan #2: Preeclampsia with Risk for Eclampsia 

Nursing Diagnosis 

Risk for Seizures 

Related To: 

• CNS irritability due to cerebral edema and vasospasm 
• Severe hypertension and endothelial dysfunction 
• Electrolyte imbalances contributing to neuromuscular excitability 

As Evidenced By: 

• Severe headache and visual disturbances 
• Hyperreflexia and clonus 
• Epigastric pain, nausea, and vomiting 

Expected Outcomes 

Short-Term Goals 

• Prevent the occurrence of seizures throughout hospitalization. 
• Maintain therapeutic magnesium sulfate levels (4 to 7 mEq/L). 
• Manage and relieve severe headaches and visual disturbances. 

Long-Term Goals 

• Prevent progression to eclampsia or neurological complications. 
• Educate the patient and their family members on how to recognize warning signs. 
• Ensure a safe delivery and postpartum recovery. 

Assessment 

Neurological Assessment

• DTRs: Assess every one to two hours for hyperreflexia or clonus. 
• Mental status: Monitor for confusion, agitation, or decreased LOC. 
• Visual assessment: Check for blurred vision, photophobia, or scotomata. 

Laboratory Tests

• Magnesium levels: Monitor every four to six hours to maintain therapeutic range (4 to 7 mEq/L). 
• Serum electrolytes: Monitor sodium, potassium, and calcium. 

Interventions 

• Administer magnesium sulfate: 
  • Maintenance dose: 1-2 grams per hour IV infusion 
  • Monitor for magnesium toxicity.

• DTRs: Hyporeflexia or absent reflexes indicate toxicity 
• Respiratory rate: Report if <12 breaths per minute. 
• Urine output: Monitor hourly; maintain >30 mL/hr. 

• Emergency equipment and safety: 
  • Keep calcium gluconate (1 gram IV) at the bedside as an antidote. 
  • Prepare suction equipment and oxygen for emergency use. 

Care Plan #3: Preeclampsia with Risk for Fetal Complications 

Nursing Diagnosis 

Risk for Fetal Injury 

Related To: 

• Placental insufficiency due to vasospasm and endothelial dysfunction. 
• Reduced uteroplacental perfusion leading to fetal hypoxia. 

As Evidenced By: 

• Abnormal FHR patterns 
• IUGR 
• Reduced fetal movements 

Expected Outcomes 

Short-Term Goals

• Maintain normal FHR (110-160 bpm) and moderate variability. 
• Detect signs of fetal distress and respond promptly. 

Long-Term Goals

• Ensure safe delivery with optimal fetal outcomes. 
• Prevent complications such as preterm birth or stillbirth. 

Assessment 

• FHR monitoring: 
  • Continuous EFM for severe preeclampsia 
  • Every four hours for mild to moderate preeclampsia 

• BPP: Ultrasound to assess fetal movements, tone, breathing, and amniotic fluid volume 

• Doppler studies: Assess umbilical artery blood flow for placental insufficiency. 

Interventions 

• Continuous fetal monitoring: 
  • Monitor and document FHR patterns and variability. 
  • Report late decelerations or decreased variability immediately. 

• Positioning: Place the patient in a left lateral position to enhance uteroplacental perfusion. 

• BPP and Doppler studies:
  • Schedule and prepare the patient for ultrasound assessments. 
  • Communicate abnormal findings to the health care provider. 

• Emergency preparation: 
  • Prepare for emergency delivery (cesarean section) if fetal distress persists. 
  • Collaborate with obstetric and neonatal teams for high-risk delivery. 

Prevention of Preeclampsia and Long-Term Management 

Preventing preeclampsia starts with early prenatal care, but it doesn’t stop there. 

Ongoing monitoring and long-term management are as important to protect the patient’s health during pregnancy and after delivery.

Early Prenatal Care and Screening 

Routine Prenatal Visits 

• Purpose: To monitor maternal health and fetal development, enabling early detection of preeclampsia. 

• Frequency: 
  • Every four weeks during the first and second trimesters 
  • Every two weeks from 28 to 36 weeks gestation 
  • Weekly visits from 36 weeks until delivery 

Key Assessments 

• BP monitoring: At every prenatal visit to establish a baseline and detect hypertension early. 
  • Normal BP: < 140/90 mmHg 
  • Preeclampsia suspected:  > 140/90 mmHg on two occasions at least four hours apart 

• Weight monitoring: Sudden weight gain (>2 kg/week) may indicate fluid retention. 

• Urinalysis: 
  • Check for proteinuria at every visit using a dipstick. 
  • Confirm with a 24-hour urine collection if > 1+ protein is detected. 

• Blood tests: 
  • Liver function tests: ALT, AST to detect liver involvement
  • Renal function tests: Serum creatinine and BUN for kidney function 
  • Platelet count: To detect thrombocytopenia 

Lifestyle Modifications to Reduce Risk

1. Dietary Recommendations 

• Balanced nutrition: 
  • High in fruits, vegetables, lean proteins, and whole grains 
  • Adequate intake of calcium, magnesium, and potassium 

• Low sodium diet: Limit sodium intake to < 2,300 mg/day to reduce fluid retention and hypertension. 

• Adequate hydration: Encourage at least eight to 10 glasses of water daily to maintain fluid balance. 

2. Weight Management

Achieve a healthy pre-pregnancy weight (BMI 18.5–24.9). 

Gradual weight gain according to gestational guidelines: 

• Normal BMI: Gain 25-35 lbs. 
• Overweight (BMI 25-29.9): Gain 15-25 lbs. 
• Obese (BMI > 30): Gain 11-20 lbs. 

3. Physical Activity and Exercise 

Recommendations

• Get at least 150 minutes of moderate-intensity aerobic exercise per week (e.g., walking, swimming). 
• Incorporate low-impact activities such as prenatal yoga or stretching exercises. 

Precautions 

• Avoid high-impact activities or exercises involving lying flat on the back after 20 weeks. 
• Monitor for warning signs: Vaginal bleeding, dizziness, shortness of breath, or contractions 

4. Stress Reduction and Emotional Support 

Strategies

• Relaxation techniques: Encourage deep breathing, meditation, and prenatal massage. 
• Emotional support: Encourage participation in prenatal classes and support groups. 
• Mental health screening: Screen for anxiety and depression at each visit. 

Postpartum Monitoring for Hypertension 

Blood Pressure Monitoring 

• Purpose: To detect postpartum preeclampsia or chronic hypertension 

• Frequency: 
  • Daily BP monitoring for at least 72 hours postpartum. 
  • Weekly BP checks for six weeks postpartum if hypertension was present during pregnancy. 

• Abnormal findings:
  • Postpartum hypertension: BP > 140/90 mmHg
  • Severe hypertension: BP > 160/110 mmHg, requiring antihypertensive therapy

Patient Education & Discharge Planning 

Education doesn’t stop at discharge. 

Teaching patients how to monitor blood pressure at home is a key part of preventing complications and catching red flags early.

Home BP monitoring 

• Purpose: To detect hypertension early and prevent complications. 

Techniques 

• Measure BP twice daily, morning and evening. 
• Rest for at least five minutes before measurement. 
• Record readings consistently with time and date. 

Target Range: 

• Normal: < 140/90 mmHg
• Alert provider: BP > 160/110 mmHg or if symptoms develop

Medication Adherence and Follow-up Visits 

• Educate on the purpose, dosage, and side effects of antihypertensive medications. 
• Emphasize the importance of taking medication consistently. 

Follow-Up Visits

• Regular follow-ups with obstetrician and primary care provider. 
• Monitor for postpartum hypertension and long-term cardiovascular health. 

Signs of Worsening Condition Requiring Emergency Care 

Emergency Warning Signs 

• Severe headache not relieved by painkillers 
• Visual disturbances (blurred vision, flashing lights) 
• Severe epigastric or right upper quadrant pain 
• Shortness of breath, nausea, vomiting, or dizziness 
• Reduced fetal movements 

Emergency Actions

• Contact the health care provider immediately for severe symptoms. 
• Seek emergency medical attention if BP ≥160/110 mmHg. 

Recommended Resources for Preeclampsia Nursing Care 

These trusted resources offer clear, reliable info to help guide safe and effective care.

• American College of Obstetricians and Gynecologists (ACOG) – Guidelines for hypertensive disorders in pregnancy.

• Preeclampsia Foundation – Patient education and support resources. 

• National Institute for Health and Care Excellence (NICE) – Management guidelines for preeclampsia. 

Nursing Care Plan Resources

• Nursing Diagnosis
• Nursing Interventions
• Nursing Care Plan Template
• Nursing Process
• ADPIE

Putting It All Together: Safe, Effective Care for Preeclampsia

Preeclampsia calls for quick thinking, accurate nursing diagnoses, and timely interventions to keep the patient safe. 

Well-structured nursing care plans for preeclampsia support clinical decision-making, helping nurses prevent complications and promote better outcomes.

References and Sources 

1. American College of Obstetricians and Gynecologists. Hypertension in Pregnancy. ACOG Practice Bulletin No. 222. 2020. 

2. Preeclampsia Foundation. Preeclampsia and Hypertension in Pregnancy. Accessed February 25, 2025. 

3. National Institute for Health and Care Excellence. Hypertension in Pregnancy: Diagnosis and Management. NICE Guideline [NG133], 2019. 

4. Mayo Clinic. Preeclampsia. Accessed February 25, 2025. 

5. Green, Carol J. Maternal Newborn Nursing Care Plans. 3rd ed., Jones & Bartlett Learning, 2016. 

6. Gulanick, Meg, and Judith L. Myers. Nursing Care Plans: Diagnoses, Interventions, and Outcomes. 11th ed., Elsevier, 2025.