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High Blood Pressure (Hypertension) During Pregnancy With Dr. Sean Daneshmand | San Diego Health

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Monitoring and managing blood pressure (BP)

Continuous monitoring of BP is essential because the BP can fluctuate or spike quickly. It is important for nurses to recognize elevations in the patient's BP and provide treatment promptly.

Monitoring for signs and symptoms

Patients often experience signs and symptoms such as blurred vision, headache, epigastric pain, edema, and protein in the urine when they have severe BP or preeclampsia (Morton et al., 2019). These signs and symptoms can be monitored by asking the patients if they have any of these symptoms, performing physical assessments, and monitoring lab values. Nurses must provide adequate assessments.

Monitoring of Maternal and Fetal Wellbeing

Delivery is indicated when there is worsening maternal and fetal well-being or at any time with deterioration of maternal and fetal status (Rana et al., 2019). It is important that nurses assess and evaluate both maternal and fetal wellbeing and immediately notify the provider of any sign of deterioration to provide proper intervention.

Providing Patient Education

Nurses need to educate the patient's on how they can manage BP.

For example:

Educating about and encouraging a low sodium diet to help reduce edema.

Educating about and encouraging bed rest and elevation of the feet to reduce BP.

Educating and encouraging patients to rest on the left side to prevent compression of the vena cava.

Nurses caring for pregnant women provide continuous monitoring, treatment, and patient education for early detection, timely intervention, and management. These nursing involvement allows for the prevention of further complications and better patient outcomes. However, there are still barriers that limit the nurses' involvement, affecting the quality of care and patient outcome.

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Nurses' involvement is crucial in preventing, managing, and improving outcomes of patients with gestational hypertension. Nurses provide constant care and monitoring of patients during the peripartum and postpartum phase, which allows them to notice any changes and implement intervention promptly to prevent further progression and worsening of maternal and fetal wellbeing. For these reasons, nurses must understand how to recognize the changes in patient status and understand the necessary intervention.
Nurses also play a vital role in communication between the patient and the physician. When the patients present with signs and symptoms, timely and effective communication to the physician by the nurse can prevent delays in treatment and preventable deaths.

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Analysis: Barriers For Nurse Involvement

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Analysis: Barriers For Nurse Involvement

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Lack of knowledge
According to Folk et al. (2018), healthcare providers may still overlook or be unaware of signs and symptoms that require immediate evaluation and treatment despite current guidelines that address diagnosis and management of hypertensive disorders in pregnancy.
During preceptorship at the Labor and Delivery unit, I have encountered situations where the patient's blood pressure (BP) cuff size was not a proper fit. Some were too small, and some were too big for the patient. This can alter the BP values and lead to missed treatment. However, it was not a concern for many nurses on the unit. This experience made me aware that some nurses may be unaware of the importance of obtaining proper BP value to implement interventions accordingly.

Systems Issues
According to Morton et al. (2019), cesareans delivery among clinically unstable women is delayed, due to systems issues, such as insufficient staffing, unavailable physicians, or lack of ready access to an operating room. During preceptorship, I have seen situations where the patient required an immediate c-section due to fetal heart rate indicating fetal deterioration. However, we could not go to the operating room as quickly as we wanted to due to the lack of operating rooms. This is sometimes out of nurses' control. However, nurses advocate for a better coordination system with the team or improvement in the unit system to improve the quality of care for the patients.

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What is the problem, situation, or concern?
Gestational hypertension is also referred to as pregnancy-induced hypertension. This condition is characterized by high blood pressure (BP) during pregnancy. When this condition is not treated, it can lead to many complications for both the mother and the fetus.

Who is directly affected?
According to the American Pregnancy Association (n.d.), gestational hypertension affects about 6-8% of pregnant women. When untreated, it can affect both the mother and the baby.

How
Untreated hypertension during pregnancy can lead to complications such as abnormal uterine contraction, increased risk of postpartum hemorrhage, and cardiovascular events (Ouyang et al., 2022). It can also affect the fetus because hypertension can cause placental insufficiency. This means less oxygen and nutrition are being delivered to the placenta, which may lead to fetal growth restrictions and low birth rates (Sinkey et al., 2020).

Where
Hypertensive disorders of pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia, is prevalent internationally and is one of the leading causes of maternal and fetal death world wide (Rana et al., 2019).

When
Gestational hypertension is defined as high BP that develops after 20 weeks of pregnancy and goes away after delivery. Gestational hypertnesion can lead to preeclamsia and patients may continue to have complications post delivery.

Why
Hypertension during pregnancy needs to be detected and treated properly in the early stage of pregnancy to prevent escalation to a more serious stage which can cause much more serious side effects to both the mother and the baby.

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Maternal and Fetal Morbidity and Mortality

Hypertensive disorders of pregnancy (HDP), including gestational hypertension, is the leading cause of morbidity, mortality, hospitalization, and resource utilization for both mothers and their neonates (Sinkey et al., 2020). This article looked at the different guidelines internationally for the prevention, diagnosis, and management of HDP. The guidelines acknowledged that a combination of prevention, timely diagnosis, prompt treatment, and delivery when indicated is important to improve the quality of care and outcome for patients with HDP.

Cardiovascular Effects

According to Folk et al. (2018), women with a history of HPD have higher chances of experiencing cardiovascular events (e.g. stroke) when compared to women with uncomplicated pregnancies.

The risk of a cardiovascular event within ten years in women with a history of preeclampsia is 18.2% versus 1.7% for women with uncomplicated pregnancies (Folk et al., 2018).

Uncontrolled gestational hypertension can also increase the risk of postpartum hemorrhage, another cause of maternal death (Folk et al., 2018).

This article addresses the importance of viewing HPD as a life-threatening emergency with potential lifelong morbidity. Healthcare providers must understand the significance and treat and manage this condition with the best evidence-based practice to improve outcomes.

Psychological Effects

According to Ouyang et al. (2022), studies have revealed that hypertension during pregnancy can often be accompanied by negative emotions such as depression and anxiety, affecting their quality of life. This article addressed the importance of holistic care for patients with hypertension during pregnancy to improve quality of care to improve quality of life.

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Nurse Education

Educating nurses on the importance of continuous monitoring and evaluation of BP trends to improve early detection can aid in overcoming the barriers nurses may face.

Educating nurses on proper methods to obtain consistent and accurate BP values helps prevent false readings and missed treatment.

Implementing and educating nurses on standardized policies and protocols for managing HDP is crucial for quality improvement (Morton et al., (2019).

For example:

Vital signs policy and protocol

Magnesium sulfate protocol

Antihypertensive medication protocol

Educate nurses on the signs and symptoms of preeclampsia and worsening conditions.

Improve Nurse-Physician Communication

Ineffective communication between the nurse and the physician can lead to delayed treatment and may lead to poor outcomes.

It is important that the nurse understand the proper term to communicate the signs and symptoms of preeclampsia to prevent misunderstanding (Morton et al., 2019).

It is also important for the nurses to understand when to notify the providers so that they are aware of the patient's condition and make necessary orders.

Patient Education

Standardized patient education is essential during pregnancy and after childbirth on signs and symptoms of preeclampsia (Morton et al., 2019).

It is also important to include when and where to seek medical help because patients may still be at risk for cardiovascular events after delivery.

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Nursing Process
One of the concepts I have learned in the curriculum is the nursing process. The nursing process includes assessment, diagnosis, planning, implementation, and evaluation. The nursing process guides the nurses in providing patient care and is also helpful in caring for patients with gestational hypertension. Caring for patients with gestational hypertension requires constant use of the nursing process. For example, the nurse needs to assess the patient for any signs and symptoms, come up with a diagnosis such as "risk for seizure related to elevated blood pressure", and plan and implement interventions such as administering antihypertensive medications and seizure prophylaxis, then evaluate if the intervention was effective in lowering the blood pressure by rechecking the blood pressure. Proper implementation of the nursing process allows for improved quality of care and outcome.

Interprofessional Communication
Another concept I have learned in the curriculum is interprofessional communication. Interprofessional communication involves communication with the patients and their families and with other members of the health care teams and is essential when caring for patients. Communication skills that are professional and honest promote good nurse-to-patient rapport and relationships. During clinical at the labor and delivery unit, the patient's family member shared that he appreciated the nurses communicating with the patient and the family about the care plan. He shared that he felt safe for his wife to deliver their baby at this hospital because we provided frequent assessments, updated them, and asked for any questions or concerns about what may happen as the labor progressed. During the process of labor, frequent communication occurred as a nurse. We updated the charge nurse when we provided interventions such as administering magnesium sulfate as seizure prophylaxis to patients with high blood pressure. We also notified the physicians of any changes or concerning assessment results. When the communication was effective, patients received necessary care promptly and had better outcomes.

Leadership
Both of these concepts are important for leadership. As a healthcare leader, improving the quality of care to obtain optimal patient outcomes is a top priority. The nursing process allows us to look at the patient holistically and provide patient-centered care. Thereby, I can use the nursing process as a healthcare leader to aid in the development of high-quality practices and patient care methodologies for the healthcare team.
The concept of interprofessional communication also aids in improving patient outcomes. As a healthcare leader, I can use effective communication skills to encourage teamwork and collaboration to provide quality care to patients and their families.