Nuirsing Care Plan For Hypertension 36501z

NURSING CARE PLAN FOR A PATIENT WITH HYPERTENSION Assessment Subjective data: •

´´I experience pain while ing urine, headaches, headaches, I do not see well, and even after doing something small, I become very tired easily and for the first time I have experienced nose bleeding. So I do not understand what is happening to me these days´´ verbalised Mr Neck.

Objective data: •

Decreased cardiac output

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Decreased stroke volume

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Increased peripheral vascular resistance

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Vitals taken as follows:

-Temperature: 37.2 °C -Pulse rate: 83beats/minutes -Respiration rate: 18breaths/minutes -Blood pressure: 180/100mmHg

Nursing diagnosis: Knowledge deficit related to the underlying heart disease, its consequences and treatment regimen evidenced by verbalisation of patient. Goal

Nursing intervention

Rationale

-Patient will demonstrate understanding of underlying disease process and identify own risk factors or precipitating conditions that require modification within 2 days of nursing interventions.

-Assess knowledge of hypertension, underlying disease process, and expectations of disease progression.

-Assessment establishes baseline data from which to build or determine need to alter misconceptions.

-Assess readiness to learn.

-Readiness facilitates more effective learning.

-Implement teaching plan, which should include: • Explanation of

-Patient and family have a right to receive information about the disease, treatment, and

Evaluation

-After 2 days of the nursing intervention, the patient was able to demonstrate an understanding of the underlying disease process and was able to -Encourage -It promotes the patient identify own risk verbalisation of patient and family engagement factors or precipitating and family concerns in the nursing care. conditions that require and their learning modification. needs.

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normal heart, heart failure, and underlying disease process. Explanation of signs and symptoms and risk factors and factors which will aggravate the symptoms of heart failure and methods to modify them. Explanation of medication regimen (names, dosage, frequency, action and possible side effects. Explanation of diet modification if indicated.

prognosis: understanding enhances compliance; knowledge allays anxieties and the adverse effects associated with psychological stress.

-Assist patient/family in identifying family strengths and resources.

- This helps to enhance self confidence.

-Make the patient a handout to read in simple language about the disease which may incorporate weight control, dietary habits and medication

-This will help equip the patient with more knowledge and enable them make appropriate decisions about life style changes and compliance to medication.

Nursing diagnosis Anxiety, related to potential for lifestyle modification, intensive care setting and diagnosis made evidenced by patient verbalising feelings of fears. Goal

Nursing intervention

Rationale

Evaluation

Patient will verbalize feelings of less anxiousness and fears within 24 hours of nursing intervention.

-Obtain baseline assessment of anxiety level and coping patterns from patient, family , or

-Baseline data are essential in evaluating the effectiveness of therapeutic interventions and the

After 24 hours, the patient was able to verbalize feelings of less anxiousness and fears.

significant others.

patients ability to cope.

-Assess level of anxiety; include heart rate, blood pressure, increased muscle tension, change in sleeping patterns, irritability.

-Assists in determining the underlying cause of anxiety and provides a basis f or intervention.

-Determine what the individual´s needs are and what resources can be mobilized to decrease feelings of anxiety; provide positive reinforcement when appropriate.

-Positive helps nurture confidence.

-Helps to create a -Implement therapeutic trusting relationship; measures to decrease reassures patient that he anxiety. is not alone. • Encourage the patient/family -Knowing what to to verbalize expect will help reduce anxieties and anxiety. concerns; encourage them to ask questions. • Explain procedures and -Will decrease anxiety by re-establishing sense limitations to of control and purpose. patient and family. • Familiarize patient with ICU staff, routines, and equipments. • Involve patients in their own care within physical limitations. Nursing diagnosis Non-compliance with the plan of therapy related to knowledge deficit, failure to follow a prescribed regimen, inadequate system, or lack of involvement in the treatment plan evidenced by the patient verbalizing about forgetting medication time. Goal Nursing intervention Rationale Evaluation Patient demonstrate a

- Assess patients

-Inaccurate perception

-After the first one

understanding, perception of his illness acceptance, and and treatment. implementation of the prescribed treatment regimen within the first week of nursing care.

held by the patient about the disease and its treatment must be identified and corrected because misconceptions about the disease can easily affect compliance.

week of nursing care, the patient had an understanding, acceptance, and implementation of the prescribed treatment regimen.

-Assess patient´s self care performance a) Determine baseline compliance regarding medications, diet, weight, exercise, stress management, smoking and alcohol. b) Monitor and record improvement in compliance. Encourage the patient to express fears or frustrations he has related to his health needs

Fears and frustrations about prescribed treatment can interfere with compliance.

-Encourage active participation by the patient and the family for example monitor their blood pressure from home if he has the blood pressure machine.

-Patient is likely to take an active role in his care if he believes that he has control over treatment outcomes.

-Provide continual and reinforcement of adherence behaviour.

-This enhances compliances and satisfaction.

-Explain the regimen to -Enhances compliance the patient, its benefits and satisfaction. and some of the problems he will encounter.

Nursing diagnosis Decreased Cardiac Output related to malignant hypertension as evidenced by decreased stroke

volume. Goal Short term goal After 6 hours of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits.

Nursing intervention

Rationale

Evaluation

1. Monitor BP every 1-2 hours, or every 5 minutes during active titration of vasoactive drugs.

1.To monitor baseline data.

2. Monitor ECG for dysrrhythmias, conduction defects and for heart rate.

2. Caffeine is a cardiac stimulant and may adversely affect cardiac function.

Short term goal After 8 hours of nursing interventions, blood pressure maintained within set parameters for the client. Goal was met.

Long term goal After 5 days of nursing interventions, the client will maintain adequate cardiac output and cardiac index.

3. Suggest frequent position changes.

3. These drugs have rapid action and may decrease the blood pressure too rapidly, resulting in complications.

4. Encourage patient to decrease intake of caffeine, cola and chocolates.

4. May indicate cyanide toxicity from increasing intracranial pressure.

5. Observe skin colour, temperature, capillary refill time and diaphoresis.

5. Input and Output will give an indication of fluid balance or imbalance, thus allowing for changes in treatment regimen when required.

6.Monitor for sudden onset of chest pain. 7. Monitor ECG for changes in rate, rhythm, dysrhythmias and conduction defects. 8. Observe extremities for swelling, erythema, tenderness and pain. Observe for

6. May indicate dissecting aortic aneurysm. 7. Decreased perfusion may result in dysrhythmias caused by decrease in oxygen. 8.Bed rest promotes venous statis which can increase the risk of thromboembolus

Long term goal After 6 days of nursing interventions, the client had an adequate tissue perfusion to his body systems. Goal was met.

decreased peripheral pulses, pallor, coldness and cyanosis.

9. Instruct client in signs/symptoms to report to physician such as headache upon rising, increased blood pressure, chest pain, shortness of breath, increased heart rate, visual changes, oedema, muscle cramps and nausea and vomiting.

formation. If treatment is too rapid and aggressive in decreasing the blood pressure, tissue perfusion will be impaired and ischaemia can result. 9. Promotes knowledge and compliance with treatment. Promotes prompt detection and facilitates prompt intervention.

Nursing Diagnosis

Goal

Intervention

Rationale

Evaluation

Activity intolerance related to the disease process evidenced by the patient verbalizing that they get tired easily when performing relatively easy tasks for example weeding the flower garden.

The patient will be able to tolerate easy exercises and will be able to know what exercises they able to do by the time they leave the hospital

Monitor the patients vital signs especially the blood pressure every two hours.

This helps in getting the base information of how the patient is performing.

The patient was able to tolerate exercises by the time they left the hospital.

Teach the patient relatively easy exercises like stretching, walking.

So that they stop over straining their heart with heavy exercises.

Refer the patient to a physiotherapist so that they can continue to teach the patient on what exercises they are able to do with out over stressing the heart.

So that they give them more assistance with the exercises.

ister medications that

These drugs reduce the work

Risk of altered tissue perfusion.

reduce the the hypertension as prescribed by a medical doctor.

load of the heart.

Reassure the patient that they would improve.

This reduces the anxiety of the patient so reduces the stress.

The patient will Monitor the vital not develop tissue signs of the oedema during patient. there stay in hospital.

This provides base line information for the nurse, thus improves care given to the patient.

Monitor patient fluid intake and out put by charting the input and output volumes.

To avoid fluid overload that would precipitate tissue perfusion or oedema.

Monitor the patient's diet especially salt intake which should be low.

The patient did not develop oedema from altered tissue perfusion.

High salt diet increase tissue perfusion as water follows salt.

Diuretics like ister frusemide reduce medications for tissue perfusion or example diuretics oedema. like frusemide as prescribed by the medical doctor. To monitor if the Weigh the patient patient weight is twice a day in the relatively constant morning and and is not evening. increasing because of oedema. Altered health maintenance related to the disease process evidenced by the patient verbalizing “I can not do things like going

The patient's basic needs will be taken of daily during there stay in the hospital.

Give the patient a bed bath in the morning and evening.

Acts as a massage and allows blood flow and reduces bed sores.

Change the This reduces bed patients bed sheets sores. and give them

The patient´s basic needs were taken care of during their stay in hospital.

to the toilet, bathing by my self.”

clean ones.

REFERENCE KOZIER B., ERB G., BERMAN A., LAKE R., 2008. Fundamentals of Nursing: concepts, process and practise. Pearson Education Limited. SANDRA L. UNDERHILL et al, 2007. Cardiac Nursing. 2nd ed p. 841-842. J.B Lippincott Company.