Hypertension Nursing Care Plan 1ccz

Nursing Diagnosis Nursing Diagnosis: Risk for decreased cardiac output related to increased vascular vasoconstriction Assessment: Subjective Data: “I do not really feel well, right now. My blood pressure is always high and I feel light headed when I suddenly move.” as claimed by patient. Objective Data: -Pale in color -Skin cool and moist to touch -Jugular vein can be easily seen and bounding upon palpation -Verbalized light headedness on sudden change of position -Easy fatigability and occasional dyspnic occurrences upon exertion -Blood pressure ranging from 140/90 to 150/100 mmHg, BP as of 6:00 A.M. 04/17/12 is 150/90 mmHg -Pulse rate of 110 beats per

Patient Outcomes Outcome Identification: 

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The patient will participate in activities that reduce cardiac workload by 04/18/12. The patient will maintain blood pressure within acceptable range by 04/19/12. The patient will demonstrate stable cardiac rhythm and rate within patient’s normal range by 04/19/12.

Nursing Interventions

Nursing Interventions

Independent:

Nursing Care Plan for Hypertension

1. Monitor blood pressure periodically. Measure both arms three times; 3-5 mins apart while patient is at rest for initial evaluation. 2. Note presence of, quality of central and peripheral pulses. 3. Auscultate heart tones and breath sounds 4. Observe skin color, moisture, temperature and capillary refill time. 5. Note independent or general edema 6. Provide a calm environment; minimizing noise; limiting visitors and length of stay. 7. Maintain activity restrictions (bed rest) and assist patient with self- care activities. 8. Provide comfort measures, i.e. elevation of head 9. Encourage relaxation techniques like guided imagery and distractions 10. Monitor response to

1. Bounding carotid, jugular, radial, femoral pulses may be observed/ palpated. Pulses in the leg may be diminished, implicating effects of vasoconstriction and venous congestion. 2. S3 and S4 heart sounds may indicate atrial and venous hypertrophy and impaired functioning. 3. Presence of adventitious breath sounds may indicate pulmonary congestion secondary to developing heart failure. 4. Presence of pallor; cool and moist skin and delayed capillary refill may be due to peripheral vasoconstriction or decreased cardiac output. 5. It may indicate heart failure, vascular or renal impairment. 6. Promotes relaxation. 7. It reduces physical stress and stimuli that

Nursing Interventions Please refer to the Patient Outcomes tab

minute as of 6:00 A.M. 04/17/12

medications to control blood pressure 8.

-Capillary refill of 2-3 seconds

Depedent 11. ister medications like diuretics, alpha and beta antagonists, calcium channel blockers, and vasodilators.

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Collaborative 12. Instruct and implement to patient dietary restrictions in sodium, fat and cholesterol

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affect the blood pressure. Decreases discomfort and may reduce sympathetic stimulation It helps reduce stressful stimuli, thereby decreases blood pressure. Response to drug is dependent on both the individual and the synergistic effect of the drug. It is also important to check for any untoward signs and symptoms of the medications. These medications should be medically prescribed by the physician and dose and timing of medications should be followed. Checking BP prior to giving of medications is always a must to prevent hypotension. This restrictions help manage fluid retention and decrease myocardial workload.