DESCRIBE THE THE CARE PLAN UTILIZING THE NURSES DIAGNOSIS RISK FOR
HYPERTENSION
Hypertension is high blood pressure. Anything above 120/80 mmHg is considered elevated, and stage 1
hypertension is diagnosed at 130/80 mmHg. BP of less than 90/60 mmHg is considered hypotensive.
Hypertension is the most common preventable risk factor for cardiovascular disease and places unnecessary stress
on the arteries increasing the risk for stroke, heart attack, and atherosclerosis.
CONTENT
Nursing Process
Nursing Care Plans
Decreased Cardiac Output
Deficient Knowledge
Excess Fluid Volume
Risk for Unstable Blood Pressure
References
Nursing Process
Nurses assist patients in recognizing risk factors such as smoking, poor diet choices, and stress and sensitizing on
ways to reduce their risks. Controlling blood pressure prevents complications and poor health outcomes.
Nursing Care Plans
Nursing care plan for hypertension:
1.Decreased Cardiac Output-Vasoconstriction from chronic hypertension and vessel resistance can result in
decreased cardiac output.
Diagnosis: Decreased Cardiac Output
Related to:
Impaired cardiac muscle contraction
Structural impairment of the heart
Difficulty of the heart muscle to pump
Increased exertion in workload
Alteration in stroke volume
High blood viscosity
Sedentary lifestyle
As evidenced by:
1. Increased central venous pressure (CVP)
2. Increased pulmonary artery pressure (PAP)
3. Ejection fraction less than 40%
4. Decreased oxygen saturation
5. Presence of abnormal S3, S4 heart sounds upon auscultation
, 6. Chest pain (angina)
7. Presence of abnormal lung sounds upon auscultation
8. Difficulty breathing (dyspnea)
9. Rapid breathing (tachypnea)
Expected outcomes:
Patient will show blood pressure and pulses within acceptable limits.
Patient will not develop complications from hypertension.
Patient will adhere to lab testing, medications, and follow-up appointments for hypertension.
Assessment:
1. Auscultate the heart sounds.
The existence of an S4 heart sound will indicate a rigid left ventricle, causing left ventricular hypertrophy and
diastolic dysfunction. Both S3 and S4 sounds indicate heart failure.
2. Obtain ECG.
An electrocardiogram to check for left ventricular hypertrophy, assessing heart attacks and thickening/enlargement
(hypertrophy) of the heart wall or muscle.
3. Perform checkups on the patient’s risk factors for hypertension.
Check on Electrolytes
Blood urea nitrogen (BUN) and creatinine levels for renal failure
Lipid profile for cholesterol levels
Hormone (adrenal gland or thyroid gland) levels
Urine tests
Imaging scans, such as kidney ultrasound and CT scan of the abdomen to assess kidneys and adrenal glands
4. Assess for signs and symptoms, which would include
A Stroke
Hypertensive encephalopathy
Chest pain
Shortness of breath
Heart failure
Kidney problems
Vision changes
Interventions:
1. Assist the patient to understand the lifelong change.
Since hypertension is a chronic disorder, it requires constant monitoring and management. Exercise, weight
management, and limiting alcohol and smoking are crucial to minimizing cardiovascular risk that should be added to
the patients livelihood.
HYPERTENSION
Hypertension is high blood pressure. Anything above 120/80 mmHg is considered elevated, and stage 1
hypertension is diagnosed at 130/80 mmHg. BP of less than 90/60 mmHg is considered hypotensive.
Hypertension is the most common preventable risk factor for cardiovascular disease and places unnecessary stress
on the arteries increasing the risk for stroke, heart attack, and atherosclerosis.
CONTENT
Nursing Process
Nursing Care Plans
Decreased Cardiac Output
Deficient Knowledge
Excess Fluid Volume
Risk for Unstable Blood Pressure
References
Nursing Process
Nurses assist patients in recognizing risk factors such as smoking, poor diet choices, and stress and sensitizing on
ways to reduce their risks. Controlling blood pressure prevents complications and poor health outcomes.
Nursing Care Plans
Nursing care plan for hypertension:
1.Decreased Cardiac Output-Vasoconstriction from chronic hypertension and vessel resistance can result in
decreased cardiac output.
Diagnosis: Decreased Cardiac Output
Related to:
Impaired cardiac muscle contraction
Structural impairment of the heart
Difficulty of the heart muscle to pump
Increased exertion in workload
Alteration in stroke volume
High blood viscosity
Sedentary lifestyle
As evidenced by:
1. Increased central venous pressure (CVP)
2. Increased pulmonary artery pressure (PAP)
3. Ejection fraction less than 40%
4. Decreased oxygen saturation
5. Presence of abnormal S3, S4 heart sounds upon auscultation
, 6. Chest pain (angina)
7. Presence of abnormal lung sounds upon auscultation
8. Difficulty breathing (dyspnea)
9. Rapid breathing (tachypnea)
Expected outcomes:
Patient will show blood pressure and pulses within acceptable limits.
Patient will not develop complications from hypertension.
Patient will adhere to lab testing, medications, and follow-up appointments for hypertension.
Assessment:
1. Auscultate the heart sounds.
The existence of an S4 heart sound will indicate a rigid left ventricle, causing left ventricular hypertrophy and
diastolic dysfunction. Both S3 and S4 sounds indicate heart failure.
2. Obtain ECG.
An electrocardiogram to check for left ventricular hypertrophy, assessing heart attacks and thickening/enlargement
(hypertrophy) of the heart wall or muscle.
3. Perform checkups on the patient’s risk factors for hypertension.
Check on Electrolytes
Blood urea nitrogen (BUN) and creatinine levels for renal failure
Lipid profile for cholesterol levels
Hormone (adrenal gland or thyroid gland) levels
Urine tests
Imaging scans, such as kidney ultrasound and CT scan of the abdomen to assess kidneys and adrenal glands
4. Assess for signs and symptoms, which would include
A Stroke
Hypertensive encephalopathy
Chest pain
Shortness of breath
Heart failure
Kidney problems
Vision changes
Interventions:
1. Assist the patient to understand the lifelong change.
Since hypertension is a chronic disorder, it requires constant monitoring and management. Exercise, weight
management, and limiting alcohol and smoking are crucial to minimizing cardiovascular risk that should be added to
the patients livelihood.
