Hypertension 5 Nursing Diagnosis and Interventions

Hypertension is the term used to describe high blood pressure.

Blood pressure is a measurement of the force against the walls of your arteries as the heart pumps
blood through the body.
The top number is called the systolic blood pressure, and the bottom number is called the diastolic
blood pressure.
Normal blood pressure is when blood pressure is lower than 120/80 mmHg most of the time.
High blood pressure (hypertension) is when blood pressure is 140/90 mmHg or above most of
the time.

If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called prehypertension.

Many factors can affect blood pressure, including:

How much water and salt you have in your body

The condition of your kidneys, nervous system, or blood vessels

The levels of different body hormones

Most of the time, there are no symptoms. Symptoms that may occur include:

Confusion
Ear noise or buzzing
Fatigue
Headache
Irregular heartbeat
Nosebleed
Vision changes

Nursing Care Plan for Hypertension

Nursing Diagnosis I :
Decreased Cardiac Output
NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body
NOC:

Demonstrate stable cardiac rhythm and rate within patients normal range.

Maintain blood pressure within individually acceptable range.

Participate in activities that reduce blood pressure /cardiac workload.

Interventions :
1. Monitor blood pressure, measure in both arms/thighs three times, use correct cuff size and
accurate technique.
Rationale : Comparison of pressures provides a more complete picture of vascular
involvement/scope of problem. Systolic hypertension also is an established risk factor for
cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.
2. Note dependent/general edema.
Rationale : May indicate heart failure, renal or vascular impairment.
3. Note presence, quality of central and peripheral pulses.
Rationale : Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction
(increased systemic vascular resistance [SVR]) and venous congestion.

4. Observe skin color, moisture, temperature, and capillary refill time.

Rationale : Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to
peripheral vasoconstriction or reflect cardiac decompensation/decreased output.
Nursing Diagnosis II :
Acute Pain
NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person
says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual
or potential tissue damage or described in terms of such damage (International Association for the
Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or
predictable end and a duration of
NOC :

Verbalize methods that provide relief.

Report pain/discomfort is relieved/controlled.

Follow prescribed pharmacological regimen.

Interventions :
1. Assess pain scale. Determine specifics of pain, e.g., location, characteristics.
Rationale : Helpful in evaluating effectiveness of therapy.
2. Encourage bedrest during acute phase.
Rationale : Minimizes stimulation/promotes relaxation.
3. Assist patient with ambulation as needed.
Rationale : Patient may also experience episodes of postural hypotension, causing weakness when
ambulating.
4. Minimize vasoconstricting activities that may aggravate headache.
Rationale : Activities that increase vasoconstriction accentuate the headache in the presence of
increased cerebral vascular pressure.
Nursing Diagnosis III :
Activity Intolerance
NANDA Definition: Insufficient physiological or psychological energy to endure or complete required
or desired daily activities
NOC :

Demonstrate a decrease in physiological signs of intolerance.

Participate in necessary/desired activities.

Report a measurable increase in activity tolerance.

Interventions :
1. Encourage progressive activity/self-care when tolerated. Provide assistance as needed.
Rationale : Gradual activity progression prevents a sudden increase in cardiac workload. Providing
assistance only as needed encourages independence in performing activities.
2. Instruct patient in energy-conserving techniques, e.g., using chair when showering, sitting to
brush teeth or comb hair, carrying out activities at a slower pace.
Rationale : Energy-saving techniques reduce the energy expenditure, thereby assisting in
equalization of oxygen supply and demand.
Nursing Diagnosis IV :
Imbalanced Nutrition : more than body requirements
NANDA Definition: Intake of nutrients that exceeds metabolic needs

NOC :
Initiate/maintain individually appropriate exercise program.
Nutritional Status: Nutrient Intake (NOC) Demonstrate change in eating patterns (e.g., food
choices, quantity) to attain desirable body weight with optimal maintenance of health.

Identify correlation between hypertension and obesity.

Interventions :

1. Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar as
indicated.
Rationale : Excessive salt intake expands the intravascular fluid volume and may damage kidneys,
which can further aggravate hypertension.
2. Determine patients desire to lose weight.
Rationale : Motivation for weight reduction is internal. The individual must want to lose weight.
3. Review usual daily caloric intake and dietary choices.
Rationale : Identifies current strengths/weaknesses in dietary program.
4. Instruct and assist in appropriate food selections, such as a diet rich in fruits, vegetables, and
low-fat dairy foods.
Rationale : Avoiding foods high in saturated fat and cholesterol is important in preventing
progressing atherogenesis.
Nursing Diagnosis V :
Deficient Knowledge
NANDA Definition: Absence or deficiency of cognitive information related to a specific topic
NOC :
Identify drug side effects and possible complications that necessitate medical attention.
Verbalize understanding of disease process and treatment regimen.
Maintain blood pressure within individually acceptable parameters.
Interventions :
1. Define and specify the desired blood pressure limits. Describe hypertension and its effect on the
heart, blood vessels, kidneys, and brain.
Rationale : Provides a basis for understanding blood pressure elevation, and describes commonly
used medical terms. Understanding that high blood pressure can occur without symptoms is the
center allows patients to continue treatment, even when it feels good.
2. Assist patients in identifying the risk factors that can be modified, for example, obesity, a diet high
in sodium, saturated fat, and cholesterol, sedentary lifestyle, smoking, alcohol consumption, stress
lifestyle.
Rationale : Risk factors that have been shown to contribute to hypertension and cardiovascular and
renal disease.

Nursing Diagnosis:
Decreased cardiac output related to increased peripheral vascular resistance secondary to hypertension as evidence

Subjective Data:

A 65 year old male comes into the ER complaining of blurred vision and a very painful headache. He states his w

scared him so that is why he came to the hospital. Pt admits to not taking Clonidine for the past week because it ma

Objective Data:

The patient has the following history: TIA (2005), Diabetes Type 2, Hyperlipidemia, Hypertension, and 2 Cardiac S
night, Plavix 75 mg PO Daily, Coumadin 2 mg PO once a day, and Clonidine 2 mg PO Daily. Current VS: HR 85,

Nursing Outcomes:
-Pts BP will be SBP 120-130 and DBP 80-95 within 24 hours.
-Pt will verbalize an absent in a headache and blurred vision within 12 hours.

-Pt will verbalized his understanding of never stopping a medication without the advice of a doctor.

Nursing Interventions:
-The nurse will administer and titrate vasodilator medications to meet md parameters for blood pressure.
-The nurse will assess the patients blood pressure every hour until meeting md parameters.

-The nurse will assess the patients headache pain level and blurred vision every 4 hours until absent.

-The nurse will educate the patient on how to consult with his doctor before stopping a medication.

4 Nursing Diagnosis Interventions for Hypertension

Nursing Diagnosis for Hypertension - Nursing Care Plan for Hypertension

1. Risk for decreased cardiac output related to increased afterload, vasoconstriction, myocardial
ischemia, ventricular hypertrophy.
Purpose: afterload is not increased, there was no vasoconstriction, and myocardial ischemia does not
occur.
Expected outcomes:
Maintaining blood pressure within an acceptable range.
Showed stable cardiac rhythm and frequency.
Participate in activities that lower blood pressure.
Nursing interventions:
>Monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of
measuring blood pressure.
>Auscultation of breath sounds and heart tone. Observe skin color, moisture, temperature and capillary
refill time.

Note the presence, quality of the central and peripheral pulses.

Maintain restrictions on activities such as rest in bed or chair.

Assist in performing self-care activities as needed.

Provide a quiet environment, convenient, and therapeutic and reduce activity. Note the general
edema.

Monitor response to medication to control blood pressure. Give fluid and dietary sodium
restriction as indicated.
Medical collaboration in the provision of drugs as indicated.
2. Acute pain: headache related to increased cerebral vascular pressure.
Purpose: The pressure does not increase cerebral vascular
Expected Outcomes: Patients revealed the absence of headache and looked comfortable.
Nursing interventions:

Maintain bed rest, quiet neighborhood, a little light.

Limit of patients in the activity.

Minimize disruption and environmental stimuli.

Give a fun action according to indications such as ice packs, the position of comfort, relaxation
techniques, counseling imagination, avoid constipation.
Medical collaboration in providing analgesic and sedative drugs.
3. Ineffective Tissue Perfusion: cerebral, renal, cardiac related to impaired circulation.
Purpose: The circulation of the body is not impaired.
Expected outcomes :

Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within
acceptable limits, no complaints of headache, dizziness, laboratory values within normal limits.
Stable vital signs.
Urine output 30 ml / min.
Nursing interventions:

Maintain bed rest, elevate the head position in bed patients.

Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure
monitoring if it is available.

Measure the input and discharge.

Observe the sudden hypotension.

Ambulation within your means and avoid fatigue in patients.

Monitor electrolytes, creatinine according to medical advice.

Maintain fluids and medications according to medical advice.

4. Knowledge deficit related to lack of information about the disease process and self-care.
Purpose : patients are met in terms of information about hypertension.
Expected outcomes :

Patients can express their knowledge and skills of the management of early treatment of
hypertension.
Reported the use of drugs according to medical advice.
Nursing interventions:

Describe the nature of the disease and the purpose of the procedure and the treatment of
hypertension.

Explain the importance of a peaceful environment and theraupetik, and management of stressors.

Discuss the importance of maintaining a stable weight.

Discuss the need for low-calorie diet, low in sodium to order.

Discuss the importance of avoiding fatigue in the activity.

Explain the need to avoid constipation in the bowel movement.

Explain penetingnya maintain proper fluid intake, amount allowed, restrictions such as caffeinated
coffee, tea and alcohol.

Discuss the symptoms of relapse or progression of complications reported to the doctor:

headache, dizziness, fainting, nausea and vomiting.

Talk about drugs: the name, dosage, time of administration, purpose and side effects or toxic
effects.

Explain the need to avoid drug-free, without a doctor's examination.