- Decreased Cardiac Output
- Deficient Knowledge
- Excess Fluid Volume
- Risk for Unstable Blood Pressure
- Sedentary Lifestyle
Nursing Process
Almost 50% of adults in the United States have hypertension. As a nurse, it is one of the most common comorbidities that require management and treatment.
Patients cannot change risk factors such as family history or ethnicity, but can change lifestyle behaviors. Nurses can assist patients in recognizing risk factors such as smoking, poor diet choices, and stress and educating on ways to reduce their risks. Controlling blood pressure prevents complications and poor health outcomes.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for hypertension, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for hypertension.
Decreased Cardiac Output
Vasoconstriction from chronic hypertension and vessel resistance can result in decreased cardiac output.
Related to:
- Impaired cardiac muscle contraction
- Conditions that compromise blood flow
- Structural impairment of the heart
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Alteration in stroke volume
- Plaque formation
- High blood viscosity
- Atherosclerosis
- Sedentary lifestyle
As evidenced by:
- Increased central venous pressure (CVP)
- Increased pulmonary artery pressure (PAP)
- Tachycardia
- Dysrhythmias
- Ejection fraction less than 40%
- Decreased oxygen saturation
- Presence of abnormal S3, S4 heart sounds upon auscultation
- Chest pain (angina)
- Presence of abnormal lung sounds upon auscultation
- Difficulty breathing (dyspnea)
- Rapid breathing (tachypnea)
- Restlessness
- Fatigue
- Intolerance in activities
- Prolonged capillary refill time
- Significant weight gain
- Edema
Expected outcomes:
- Patient will manifest 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 indicates a rigid left ventricle, causing left ventricular hypertrophy and diastolic dysfunction. Both S3 and S4 sounds indicate heart failure.
2. Obtain ECG.
Patients with hypertension are given an electrocardiogram to check for silent myocardial infarction or left ventricular hypertrophy. ECG is useful for assessing heart attacks and thickening/enlargement (hypertrophy) of the heart wall or muscle, which are effects of high blood pressure.
3. Determine the patient’s risk factors for hypertension.
The following tests check for possible causes of hypertension:
- 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.
Hypertension may be asymptomatic, and the diagnosis is discovered by chance during the recording or measurement of blood pressure. Chronic hypertension results in organ damage such as:
Interventions:
1. Assist the patient in 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.
2. Administer beta-blockers or calcium-channel blockers as prescribed.
Beta-blockers and calcium channel blockers offer quick heart rate control at rest and during activity. They can be administered intravenously (IV) or orally.
3. Use CPAP or supplemental oxygen at night.
Obstructive sleep apnea requires treatment to reduce sympathetic nervous system stimulation to reduce cardiac workload and blood pressure.
4. Monitor and increase activity as tolerated.
Exercise is a necessity to strengthen the heart and lower blood pressure. Closely monitor the patient’s response to activity through their HR and BP.
5. Limit salt intake.
Consuming excess salt raises the incidence of cardiovascular disease and hypertension. Hypertension results from increased salt absorption leading to increased volume, reduced renin-angiotensin-aldosterone system (RAAS) response, and increased sympathetic nervous system activity.
Deficient Knowledge
A lack of understanding of hypertension prevents the patient from making appropriate lifestyle choices and places them at risk for worsening health conditions.
Related to:
- Lack of understanding of hypertension and its effect on the body
- Lack of knowledge of risk factors
- Poor health literacy
- Lack of interest or motivation
As evidenced by:
- Worsening blood pressure
- Inability to recall information provided
- Incorrect follow-through with diet or lifestyle recommendations
- Development of a chronic condition due to uncontrolled hypertension
Expected outcomes:
- Patient will “teach-back” education provided to them regarding how to manage their blood pressure.
- Patient will state their personal risk factors for hypertension.
- Patient will explain the action of their blood pressure medications and the importance of not missing doses.
Assessment:
1. Assess the patient’s understanding of hypertension.
Many patients do not understand the role high blood pressure plays in contributing to other conditions and placing them at risk for stroke or heart disease. Assess the patient’s knowledge deficit to fill in the gaps.
2. Assess barriers to learning.
Assess for cognitive, cultural, or language barriers. Perception of the problem and motivation for change is also important. If the patient is not yet ready to learn or does not perceive a reason to, learning will not take place.
3. Assess support systems.
Patients who have difficulty remembering to take medications, monitor their BP, limit salt intake, or follow-up with appointments may need support from family members or friends in order to manage their condition.
Interventions:
1. Help the patient identify their personal risk factors.
Educate between modifiable (stress, diet, weight, tobacco use) vs. non-modifiable risk factors (age, family history, ethnicity). From there, patients can identify areas of improvement.
2. Teach the patient how to monitor blood pressure.
Educate the patient on what their blood pressure number should be, and what is considered high or low. Have the patient bring in their own BP monitor to calibrate it and observe them using it to ensure accuracy of readings.
3. Provide positive reinforcement.
Do not criticize a patient for mistakes or difficulty in implementing their treatment plan. Reinforce any attempt to learn more or even a slight improvement.
4. Review medications thoroughly.
Patients may not understand the purpose of their medications and may skip or miss doses. Review the action, side effects, and rationale of each blood pressure medication as well as the frequency and interactions with other drugs.
Excess Fluid Volume
An increase in the circulating blood volume will cause the heart to pump harder, increasing blood pressure.
Related to:
- Chronic conditions: heart failure, kidney disease
- Excess fluid intake
- Excess sodium intake
As evidenced by:
- Weight gain
- Edema in extremities
- Jugular vein distention
- High blood pressure
- Tachycardia
Expected outcomes:
- Patient will maintain stable fluid volume as evidenced by balanced intake and output, weight at baseline, and no signs of edema.
- Patient will verbalize the importance of reducing sodium intake.
Assessment:
1. Assess for peripheral edema and weight gain.
Excess fluid causes swelling to the extremities, usually the lower legs and feet/ankles. The patient may also notice a sudden weight gain.
2. Assess lab values.
Monitor electrolyte imbalances that are caused by fluid overload such as increased sodium levels or decreased potassium. Monitor renal values that show evidence of fluid retention: BUN, creatinine, urine specific gravity.
3. Assess diet and fluid intake.
An unbalanced diet with either a large amount of sodium or water intake can contribute to fluid overload and increase blood pressure.
Interventions:
1. Educate on fluid and/or sodium restrictions.
Patients with hypertension must be aware of their sodium and fluid intake. This is even more important when coupled with kidney disease or heart failure as this complicates the ability to regulate this balance.
2. Administer diuretics.
Diuretics may be required to rid the body of extra fluid if the patient is displaying symptoms such as shortness of breath or extremely elevated blood pressure.
3. Elevate extremities.
Edematous extremities should be elevated above the level of the heart in order to aid in circulation. Frequent positioning and use of pillows will also prevent skin breakdown.
4. Instruct on low-sodium options.
Patients are often unaware of the amount of sodium in foods. Frozen dinners, canned food, and most restaurant entrees are overloaded with sodium. Educate patients on their daily recommended sodium intake and to limit processed foods and opt for low-sodium options.
Risk for Unstable Blood Pressure
Hypertension correlates with the risk for unstable blood pressure (BP) as medical or pharmacologic causes result in elevations in blood pressure.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Structural impairment of the heart
- Difficulty of the heart muscle to pump
- Increased exertion in workload
- Dysrhythmias
- Electrolyte imbalances
- Excess fluid volume
- Adverse effects of medications
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will maintain blood pressure within normal limits.
- Patient will remain asymptomatic with elevations in blood pressure.
- Patient will adhere to their antihypertensive medications to prevent unstable blood pressure.
Assessment:
1. Regularly measure the patient’s blood pressure.
High blood pressure often has no symptoms or warning indications. Many patients are unaware they have it. Regular monitoring is necessary to prevent or detect hypertension.
2. Screen for secondary causes of hypertension.
Renal disease, obstructive sleep apnea, thyroid disorders, and alcohol-induced hypertension require their own management to control blood pressure.
3. Assess caffeine consumption.
High caffeine intake stimulates sympathetic activity, which increases blood pressure. Assess how much caffeine the patient consumes each day.
4. Review the patient’s treatment list.
Numerous drugs and nutritional supplements increase blood pressure. Aspirin used in excessive quantities, NSAIDs, antidepressants, decongestants, and birth control pills are a few examples. Some herbal remedies may interact with antihypertensive medications.
Interventions:
1. Decrease the risk.
Ensure the patient understands that substances such as cocaine, synthetic cannabinoids, cigarette smoking, and excessive alcohol increase the risk of cardiovascular effects and hypertension.
2. Teach the importance of treatment adherence.
Educate on the importance of adhering to blood pressure medication regimens. Uncontrolled blood pressure is the most common cause of a hypertensive crisis: a BP of 180/120 mmHg or higher.
3. Remind the patient to report all medications and remedies.
It is best if the patient keeps an updated list and has this available at all appointments. The nurse can reconcile medications, over-the-counter drugs, and herbal remedies for interactions that may cause unstable blood pressure.
4. Remind the patient to keep BP logs.
Home BP readings should be kept and evaluated at least every three months to monitor the effectiveness of treatment.
Sedentary Lifestyle
A sedentary lifestyle is a risk factor for developing hypertension. Inactivity naturally contributes to a higher heart rate causing the heart to work harder. Those who exercise regularly normally have a lower heart rate, decreasing stress on the heart and arteries.
Nursing Diagnosis: Sedentary Lifestyle
Related to:
- Lack of interest in physical activity
- Inability to participate due to health or physical limitations
- Lack of knowledge related to the benefit of exercise on blood pressure
As evidenced by:
- Deconditioned appearance
- Overweight/obese or very frail
- Activity intolerance
- Tachycardia at rest
- Abnormal heart rate or BP response to activity
Expected outcomes:
- Patient will participate in physical activity within their capabilities at least 3 times per week.
- Patient will report an improvement in their ability to exercise as evidenced by no shortness of breath with minimal exertion and heart rate within safe limits.
- Patient will report a decrease in their blood pressure after 1 month of exercising.
Assessment:
1. Build a rapport.
Exercise can be a difficult subject to broach with patients. Those with a sedentary lifestyle may balk at changing their behavior. It’s important for the nurse to first form a therapeutic relationship with the patient in order to understand and overcome resistance.
2. Assess their history and interests.
Instead of simply telling the patient to move more, get to know what types of exercise or activities they’ve done in the past. Patients are more likely to create a habit when they enjoy what they’re doing.
3. Ensure the patient is safe for activity.
The provider will advise if exercise is unsafe for the patient, but most patients will benefit from some kind of movement. If the patient becomes very short of breath, fatigued, or dizzy from a certain exercise, it should be avoided or decreased.
Interventions:
1. Help with coaching and goal setting.
Depending on the patient’s activity level, strength, age, and health status, meet them where they are in their journey. Walking to the mailbox daily may be a great goal for some, while others may be able to handle more strenuous activity. Start slow and create attainable goals the patient will be excited to reach.
2. Keep track of progress.
Instruct the patient to keep a log of activity completed, time spent exercising, and improvement in physiological responses or weight loss. Along with this, the patient should be monitoring their BP as directed by their provider, and they may notice a decrease in their blood pressure along with regular exercise.
3. Refer to PT, cardiac rehab, or local programs.
Patients who require a more supervised approach may need PT evaluation for safety modifications. Cardiac rehab teaches exercise training specific to heart health. Patients may also find support from their local gym or programs that offer free or low-cost classes.
4. Educate on the benefits and necessity of exercise.
Exercise not only benefits the heart and circulation, but it also improves muscle strength, coordination and boosts mood. Patients should not be scared into exercising for fear of illness, but providing the positive aspects that are relevant to them (more time with grandkids, for example) will help them see the benefits.
References
- Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and Control of Hypertension: JACC Health Promotion Series. Journal of the American College of Cardiology, 72(11), 1278–1293. https://doi.org/10.1016/j.jacc.2018.07.008
- Centers for Disease Control and Prevention. (2022, October 18). High blood pressure symptoms, causes, and problems | cdc.gov. Retrieved February 2023, from https://www.cdc.gov/bloodpressure/about.htm
- Centers for Disease Control and Prevention. (2021, September 27). Facts About Hypertension | cdc.gov. CDC. Retrieved February 2, 2022, from https://www.cdc.gov/bloodpressure/facts.htm
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Exercise: A drug-free approach to lowering high blood pressure. (2021, May 18). Mayo Clinic. Retrieved February 2, 2022, from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045206
- Hür, E., Özişik, M., Ural, C., Yildiz, G., Mağden, K., Köse, S. B., Köktürk, F., Büyükuysal, Ç., Yildirim, I., Süleymanlar, G., Ateş, K., & Duman, S. (2014). Hypervolemia for hypertension pathophysiology: a population-based study. BioMed research international, 2014, 895401. https://doi.org/10.1155/2014/895401
- Mayo Clinic. (2022, September 15). High blood pressure (hypertension) – Symptoms and causes. Retrieved February 2023, from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/symptoms-causes/syc-20373410
- National Center for Biotechnology Information. (2022, July 4). Essential hypertension – StatPearls – NCBI bookshelf. Retrieved February 2023, from https://www.ncbi.nlm.nih.gov/books/NBK539859/
- World Health Organization (WHO). (2021, August 25). Hypertension. Retrieved February 2023, from https://www.who.int/news-room/fact-sheets/detail/hypertension
