Hypertension, commonly known as high blood pressure, is a prevalent health concern affecting nearly half of adults in the United States. The American College of Cardiology updated its guidelines in 2017, defining normal blood pressure as less than 120/80 mmHg. Readings above this are considered elevated, with stage 1 hypertension diagnosed at 130/80 mmHg. Conversely, blood pressure below 90/60 mmHg is classified as hypotension. As a critical modifiable risk factor for cardiovascular disease, hypertension places undue strain on arteries, significantly increasing the likelihood of severe conditions such as stroke, heart attack, and atherosclerosis. For nurses, understanding and addressing the Nursing Diagnosis Of Hypertension is paramount in delivering effective patient care.
The Nursing Process and Hypertension Management
Given its widespread impact, hypertension is a common comorbidity that nurses frequently encounter and must effectively manage. While certain hypertension risk factors, like family history and ethnicity, are unchangeable, lifestyle behaviors present significant opportunities for intervention. Nurses play a pivotal role in guiding patients to identify modifiable risk factors, including smoking, unhealthy dietary habits, and stress. Educating patients on risk reduction strategies and the importance of blood pressure control is crucial in preventing complications and promoting positive health outcomes. This comprehensive approach to patient care is underpinned by accurate nursing diagnosis of hypertension.
Developing Nursing Care Plans for Hypertension
Once a nurse has established the relevant nursing diagnoses for a patient with hypertension, the development of nursing care plans becomes essential. These plans serve as roadmaps for prioritizing assessments and interventions, setting both short-term and long-term care goals. The following sections provide detailed examples of nursing care plan components for common hypertension nursing diagnoses.
Nursing Diagnosis: Decreased Cardiac Output
Chronic hypertension and increased vascular resistance can lead to vasoconstriction, ultimately resulting in decreased cardiac output. This nursing diagnosis, Decreased Cardiac Output, is crucial in patients with hypertension as it directly impacts the heart’s efficiency.
Related Factors:
Several factors can contribute to decreased cardiac output in hypertensive patients:
- Impaired cardiac muscle contraction, reducing the heart’s pumping force.
- Conditions that compromise blood flow, such as arterial stiffness due to hypertension.
- Structural impairment of the heart, potentially from long-term hypertension.
- Difficulty of the heart muscle to pump against increased vascular resistance.
- Increased exertion in workload on the heart due to elevated blood pressure.
- Alteration in stroke volume, the amount of blood pumped per beat, often reduced in hypertension.
- Plaque formation in arteries, a consequence of atherosclerosis accelerated by hypertension.
- High blood viscosity, making it harder for the heart to pump blood effectively.
- Atherosclerosis, a common comorbidity and complication of chronic hypertension.
- Sedentary lifestyle, exacerbating cardiovascular strain.
As Evidenced By:
Objective and subjective data can confirm decreased cardiac output:
- Increased central venous pressure (CVP), indicating fluid overload and reduced cardiac efficiency.
- Increased pulmonary artery pressure (PAP), suggesting back pressure due to heart dysfunction.
- Tachycardia as the heart attempts to compensate for reduced output.
- Dysrhythmias, irregular heart rhythms that impair effective pumping.
- Ejection fraction less than 40%, a critical measure of reduced heart pumping function.
- Decreased oxygen saturation, reflecting inadequate tissue perfusion due to poor cardiac output.
- Presence of abnormal S3, S4 heart sounds upon auscultation, indicative of heart failure and ventricular dysfunction.
- Chest pain (angina) due to myocardial ischemia from reduced blood supply.
- Presence of abnormal lung sounds upon auscultation (crackles, wheezes), suggesting pulmonary congestion.
- Difficulty breathing (dyspnea) and Rapid breathing (tachypnea) as the body tries to compensate for reduced oxygen delivery.
- Restlessness and Fatigue due to inadequate cerebral and systemic perfusion.
- Intolerance in activities, reflecting the heart’s inability to meet increased demands.
- Prolonged capillary refill time, indicating poor peripheral circulation.
- Significant weight gain and Edema due to fluid retention from heart failure.
Expected Outcomes:
Realistic goals for patients with decreased cardiac output include:
- Patient will manifest blood pressure and pulses within acceptable limits for their age and condition.
- Patient will not develop further complications directly related to hypertension and decreased cardiac output.
- Patient will actively participate in lab testing, medication regimens, and follow-up appointments essential for hypertension management.
Nursing Assessment:
Thorough assessment is vital for this nursing diagnosis:
1. Auscultate the heart sounds.
The presence of an S4 heart sound often signifies a stiff left ventricle, a consequence of left ventricular hypertrophy and diastolic dysfunction, common in chronic hypertension. Both S3 and S4 heart sounds are concerning and can indicate developing heart failure.
2. Obtain an ECG.
Electrocardiograms are essential for hypertensive patients to screen for silent myocardial infarction or left ventricular hypertrophy. ECGs are valuable tools for detecting heart attacks and assessing thickening or enlargement (hypertrophy) of the heart muscle, both potential effects of prolonged high blood pressure.
3. Determine the patient’s risk factors for hypertension.
Identifying underlying causes and contributing factors is key. Diagnostic tests to consider include:
- Electrolytes panel to assess for imbalances that can affect blood pressure.
- Blood urea nitrogen (BUN) and creatinine levels to evaluate renal function, as kidney disease can cause hypertension.
- Lipid profile to check cholesterol levels, a major cardiovascular risk factor alongside hypertension.
- Hormone levels (adrenal gland or thyroid gland) to rule out endocrine causes of hypertension.
- Urine tests, including urinalysis and urine albumin, to assess kidney health.
- Imaging scans, such as kidney ultrasound and CT scan of the abdomen, to visualize the kidneys and adrenal glands for structural abnormalities.
4. Assess for signs and symptoms of decreased cardiac output and organ damage.
Hypertension is frequently asymptomatic, often discovered incidentally during routine blood pressure checks. However, chronic hypertension can lead to significant organ damage. Nurses should be vigilant for:
- Stroke symptoms (sudden weakness, speech difficulties).
- Hypertensive encephalopathy (severe headache, altered mental status).
- Chest pain (angina) indicating cardiac ischemia.
- Shortness of breath, possibly indicating heart failure or pulmonary edema.
- Heart failure signs and symptoms (edema, fatigue, dyspnea).
- Kidney problems (changes in urine output, edema).
- Vision changes (blurred vision, visual disturbances).
Nursing Interventions:
Effective interventions are crucial to manage decreased cardiac output:
1. Assist the patient in adopting lifelong lifestyle modifications.
Hypertension is a chronic condition demanding ongoing management. Nurses should counsel patients on the importance of: regular exercise, weight management, limiting alcohol consumption, and complete smoking cessation. These changes are vital for minimizing cardiovascular risk long-term.
2. Administer beta-blockers or calcium-channel blockers as prescribed.
These medications are crucial for rapid heart rate control both at rest and during physical activity. They can be administered intravenously (IV) in acute settings or orally for maintenance therapy, as per physician orders.
3. Utilize CPAP or supplemental oxygen at night, if indicated.
Obstructive sleep apnea (OSA) is a significant secondary cause of hypertension. If OSA is diagnosed or suspected, treatment with CPAP is essential to reduce sympathetic nervous system stimulation, thereby decreasing cardiac workload and lowering blood pressure. Supplemental oxygen may be needed to improve oxygenation and reduce cardiac strain.
4. Monitor and progressively increase activity as tolerated.
Regular exercise is fundamental for strengthening the heart and lowering blood pressure. Nurses should closely monitor the patient’s physiological response to activity, paying particular attention to heart rate (HR) and blood pressure (BP), and adjust activity levels accordingly.
5. Emphasize limiting salt intake.
Excessive sodium consumption significantly increases the incidence of cardiovascular disease and hypertension. High salt intake leads to increased fluid volume, blunted renin-angiotensin-aldosterone system (RAAS) response, and heightened sympathetic nervous system activity, all contributing to elevated blood pressure. Dietary education on sodium restriction is critical.
Nursing Diagnosis: Deficient Knowledge
A lack of adequate understanding about hypertension and its implications can prevent patients from making informed lifestyle choices, increasing their risk for deteriorating health. This nursing diagnosis, Deficient Knowledge, is central to patient education and empowerment in hypertension management.
Related Factors:
Knowledge deficits may stem from:
- Lack of understanding of hypertension itself and its systemic effects on the body.
- Lack of knowledge regarding personal risk factors for developing hypertension.
- Poor health literacy, making it difficult to comprehend medical information.
- Lack of interest or motivation to learn about or manage their condition.
As Evidenced By:
Signs of deficient knowledge include:
- Worsening blood pressure control despite interventions, indicating a lack of understanding or adherence.
- Inability to recall information provided about hypertension management.
- Incorrect follow-through with dietary or lifestyle recommendations, suggesting misunderstanding or lack of knowledge.
- Development of chronic conditions or complications directly attributable to uncontrolled hypertension.
Expected Outcomes:
Desired outcomes for addressing deficient knowledge include:
- Patient will accurately “teach-back” key education points regarding effective blood pressure management strategies.
- Patient will clearly state their individual risk factors for hypertension.
- Patient will comprehensively explain the purpose and action of their prescribed blood pressure medications and articulate the critical importance of medication adherence and avoiding missed doses.
Nursing Assessment:
Assessing the patient’s knowledge base is essential:
1. Assess the patient’s baseline understanding of hypertension.
Many patients are unaware of the significant role high blood pressure plays in contributing to conditions like stroke and heart disease. A thorough assessment of the patient’s current knowledge base helps identify specific gaps in understanding that need to be addressed through targeted education.
2. Assess potential barriers to effective learning.
Nurses must identify and address any cognitive, cultural, or language barriers that may impede learning. Evaluating the patient’s perception of the problem and their intrinsic motivation for change is also crucial. If a patient does not recognize the problem or is not motivated to learn, educational interventions will be less effective.
3. Assess the patient’s available support systems.
Patients who struggle with medication adherence, blood pressure monitoring, dietary restrictions, or follow-up appointments may require support from family members, friends, or caregivers to effectively manage their hypertension. Assessing the availability and strength of their support network is vital for developing a realistic and effective care plan.
Nursing Interventions:
Educational interventions are key to addressing knowledge deficits:
1. Help the patient identify their personal risk factors for hypertension.
Educate patients about the distinction between modifiable risk factors (stress, diet, weight, tobacco use) and non-modifiable risk factors (age, family history, ethnicity). This personalized approach helps patients pinpoint areas where they can make positive changes and take control of their health.
2. Teach the patient proper techniques for home blood pressure monitoring.
Educate the patient on target blood pressure ranges and what constitutes high or low readings. If the patient uses a home BP monitor, have them bring it to an appointment for calibration and observe their technique to ensure accurate readings and proper use.
3. Provide consistent positive reinforcement and encouragement.
Avoid criticizing patients for mistakes or difficulties encountered while implementing their treatment plan. Instead, focus on positive reinforcement, acknowledging and praising any attempt to learn more or any small improvements made in their self-management behaviors. This fosters a supportive learning environment.
4. Conduct a thorough review of all prescribed medications.
Patients may not fully understand the purpose of their medications, leading to unintentional skipping or missing doses. For each blood pressure medication, thoroughly review its action, potential side effects, and the rationale for its use. Also, discuss the importance of adherence to prescribed frequency and potential interactions with other medications or supplements.
Nursing Diagnosis: Excess Fluid Volume
An increase in circulating blood volume directly increases the workload on the heart, leading to elevated blood pressure. The nursing diagnosis of Excess Fluid Volume is pertinent in hypertensive patients, especially those with comorbidities.
Related Factors:
Factors contributing to excess fluid volume in hypertensive patients include:
- Chronic conditions such as heart failure and kidney disease, which impair fluid regulation.
- Excess fluid intake, exceeding the body’s ability to eliminate fluids effectively.
- Excess sodium intake, leading to water retention and increased blood volume.
As Evidenced By:
Signs and symptoms of excess fluid volume:
- Weight gain, often rapid, due to fluid retention.
- Edema in extremities, typically in the lower legs, feet, and ankles.
- Jugular vein distention (JVD), visible distention of the jugular veins in the neck, indicating increased venous pressure.
- High blood pressure, as increased fluid volume directly elevates blood pressure.
- Tachycardia, as the heart attempts to circulate the increased fluid volume.
Expected Outcomes:
Desired outcomes related to fluid volume management include:
- Patient will maintain stable fluid volume, demonstrated by balanced fluid intake and output, weight returning to baseline, and absence of edema.
- Patient will verbalize understanding of the importance of reducing sodium intake in managing fluid volume and blood pressure.
Nursing Assessment:
Assessment focuses on identifying fluid overload:
1. Assess for peripheral edema and unexplained weight gain.
Excess fluid accumulation causes swelling, most noticeably in dependent extremities like the lower legs and feet/ankles. Patients may also report or exhibit a sudden, unexplained weight gain, often over a short period.
2. Assess relevant laboratory values.
Monitor serum electrolyte imbalances that can result from fluid overload, such as dilutional hyponatremia (low sodium) or changes in potassium levels. Also monitor renal function indicators such as BUN, creatinine, and urine specific gravity, which can provide evidence of fluid retention or kidney dysfunction.
3. Assess dietary habits, particularly sodium and fluid intake.
An imbalanced diet high in sodium or excessive fluid intake can directly contribute to fluid overload and subsequent increases in blood pressure. Dietary history should include typical daily sodium and fluid consumption.
Nursing Interventions:
Interventions aim to restore fluid balance:
1. Educate the patient on fluid and/or sodium restrictions.
Patients with hypertension, especially those with coexisting kidney disease or heart failure, must understand and adhere to recommended sodium and fluid restrictions. These conditions significantly impair the body’s ability to regulate fluid balance, making dietary modifications crucial.
2. Administer diuretics as prescribed.
Diuretics may be necessary to promote fluid excretion and reduce excess fluid volume, particularly if the patient is exhibiting symptoms of fluid overload such as shortness of breath or severely elevated blood pressure. Administer diuretics as ordered and monitor for effectiveness and side effects.
3. Elevate edematous extremities.
For patients with peripheral edema, elevating the affected extremities above the level of the heart promotes venous return and aids in fluid mobilization. Frequent repositioning and the use of pillows to elevate legs can also help prevent skin breakdown in edematous areas.
4. Provide detailed instruction on low-sodium dietary options.
Patients are often unaware of the high sodium content in many common foods. Emphasize that processed foods, frozen dinners, canned goods, and most restaurant meals are typically very high in sodium. Educate patients on recommended daily sodium intake limits and guide them to choose fresh, unprocessed foods and low-sodium alternatives.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Hypertension inherently increases the risk for unstable blood pressure. This nursing diagnosis, Risk for Unstable Blood Pressure, acknowledges the fluctuating nature of blood pressure in hypertensive individuals and the factors that can exacerbate it. Medical or pharmacological factors can further contribute to blood pressure elevations.
Related Factors:
Factors that can contribute to unstable blood pressure in hypertensive patients include:
- Structural impairment of the heart affecting its ability to regulate blood pressure.
- Difficulty of the heart muscle to pump efficiently, leading to blood pressure instability.
- Increased exertion in workload on the heart, causing fluctuations in blood pressure.
- Dysrhythmias, which can disrupt normal blood pressure regulation.
- Electrolyte imbalances, affecting fluid balance and vascular tone, leading to unstable BP.
- Excess fluid volume, directly contributing to blood pressure variability.
- Adverse effects of medications, including both antihypertensive and other medications.
As Evidenced By:
A “Risk for” nursing diagnosis is defined by the presence of risk factors, not by actual signs and symptoms, as the problem has not yet manifested. Nursing interventions are primarily focused on prevention.
Expected Outcomes:
Desired preventative outcomes include:
- Patient will maintain blood pressure consistently within individualized normal limits.
- Patient will remain asymptomatic despite potential fluctuations in blood pressure.
- Patient will consistently adhere to their prescribed antihypertensive medication regimen to prevent episodes of unstable blood pressure.
Nursing Assessment:
Assessment focuses on identifying risk factors and monitoring blood pressure trends:
1. Regularly measure and monitor the patient’s blood pressure.
High blood pressure often presents without noticeable symptoms or warning signs. Many individuals are unaware they have hypertension until it is detected during routine screening. Regular blood pressure monitoring is essential for early detection and ongoing management to prevent complications.
2. Screen for secondary causes of hypertension.
Certain underlying conditions can cause or exacerbate hypertension. Nurses should screen for potential secondary causes such as: renal disease, obstructive sleep apnea, thyroid disorders, and alcohol-induced hypertension. Identifying and managing these underlying conditions is often crucial for effective blood pressure control.
3. Assess caffeine consumption habits.
High caffeine intake can stimulate the sympathetic nervous system, leading to increased heart rate and blood pressure. Assess the patient’s daily caffeine consumption from coffee, tea, energy drinks, and other sources to identify a potential modifiable risk factor.
4. Review the patient’s complete medication list.
Numerous prescription and over-the-counter drugs, as well as nutritional supplements, can elevate blood pressure or interfere with antihypertensive medications. Examples include: excessive aspirin use, NSAIDs, antidepressants, decongestants, and oral contraceptives. Certain herbal remedies can also interact negatively with blood pressure medications. A thorough medication review is crucial.
Nursing Interventions:
Interventions aim to mitigate risk factors and promote blood pressure stability:
1. Educate on substance use and associated risks.
Ensure patients understand that substances like cocaine, synthetic cannabinoids, cigarette smoking, and excessive alcohol consumption significantly increase the risk of cardiovascular events and exacerbate hypertension. Counsel on avoidance or cessation of these substances.
2. Emphasize the critical importance of treatment adherence.
Educate patients thoroughly about the importance of consistently adhering to their prescribed antihypertensive medication regimens. Uncontrolled hypertension is the most common precipitating factor for hypertensive crisis, defined as a dangerously high blood pressure reading of 180/120 mmHg or higher, which is a medical emergency.
3. Remind the patient to report all medications and herbal remedies.
Advise patients to maintain an updated list of all medications, over-the-counter drugs, and herbal remedies they are taking and bring this list to all medical appointments. Nurses can then perform medication reconciliation to identify potential drug interactions or medications that may be contributing to unstable blood pressure.
4. Encourage the patient to maintain home blood pressure logs.
Instruct patients to keep a log of their home blood pressure readings, including dates and times of measurements. These logs should be reviewed and evaluated at least every three months by healthcare providers to assess the effectiveness of the treatment plan and make necessary adjustments.
Nursing Diagnosis: Sedentary Lifestyle
A sedentary lifestyle is a well-established risk factor for developing hypertension. Physical inactivity contributes to a higher resting heart rate, forcing the heart to work harder even at rest. Conversely, regular physical activity typically results in a lower resting heart rate, reducing stress on the heart and arteries. The nursing diagnosis of Sedentary Lifestyle is essential to address in hypertensive patients to promote cardiovascular health.
Related Factors:
Factors contributing to a sedentary lifestyle include:
- Lack of interest or perceived enjoyment in physical activity.
- Inability to participate in physical activity due to underlying health conditions or physical limitations.
- Lack of knowledge or understanding regarding the significant benefits of exercise on blood pressure and overall health.
As Evidenced By:
Observable signs of a sedentary lifestyle include:
- Deconditioned physical appearance, such as muscle weakness or poor posture.
- Overweight or obese body habitus, or conversely, being very frail and lacking muscle mass.
- Activity intolerance, experiencing fatigue or shortness of breath with minimal exertion.
- Tachycardia even at rest, indicating poor cardiovascular fitness.
- Abnormal heart rate or blood pressure response to even mild physical activity, such as excessive increase or slow recovery.
Expected Outcomes:
Desired outcomes for promoting a more active lifestyle include:
- Patient will actively participate in physical activity within their individual capabilities at least 3 times per week.
- Patient will report subjective improvement in their ability to exercise, evidenced by reduced shortness of breath with minimal exertion and heart rate remaining within safe limits during activity.
- Patient will report a measurable decrease in their average blood pressure readings after one month of consistently engaging in regular exercise.
Nursing Assessment:
Assessment focuses on understanding the patient’s current activity level and barriers:
1. Build a strong rapport and therapeutic relationship.
Exercise and lifestyle changes can be sensitive topics for patients. Individuals with a long-standing sedentary lifestyle may be resistant to change. Establishing a trusting nurse-patient relationship is crucial to effectively address this issue, understand the patient’s perspective, and overcome potential resistance to lifestyle modifications.
2. Assess the patient’s physical activity history and interests.
Instead of simply advising the patient to “move more,” take time to understand their past experiences with exercise and activities they might find enjoyable. Patients are more likely to adopt and maintain an active lifestyle when they engage in activities they find intrinsically motivating and enjoyable.
3. Ensure the patient is medically safe for increased physical activity.
While the healthcare provider ultimately determines exercise safety, nurses play a role in ongoing assessment. Most patients will benefit from increased physical activity, but it is crucial to monitor for adverse responses. If a patient experiences significant shortness of breath, excessive fatigue, chest pain, or dizziness during exercise, the activity should be modified or avoided, and the provider should be notified.
Nursing Interventions:
Interventions focus on promoting physical activity:
1. Provide coaching and collaborative goal setting.
Tailor exercise recommendations to the patient’s current activity level, physical strength, age, overall health status, and individual preferences. Start where the patient is and set realistic, attainable goals. For some, a starting goal might be simply walking to the mailbox daily, while others may be ready for more structured exercise. Emphasize gradual progression and celebrate small successes.
2. Encourage tracking progress and provide positive feedback.
Instruct patients to keep a log of their physical activity, including the type of activity, duration, and perceived exertion. They should also monitor for improvements in physiological responses to exercise, such as decreased heart rate, improved breathing, and potential weight loss. Reinforce the connection between exercise and blood pressure management, encouraging them to monitor their BP as directed and note any reductions associated with increased activity.
3. Provide referrals to appropriate resources.
Patients who require more structured or supervised exercise programs may benefit from referrals to physical therapy (PT) for individualized exercise plans and safety modifications. Cardiac rehabilitation programs offer specialized exercise training tailored to heart health. Also, explore local community resources such as gyms, YMCA programs, or free or low-cost exercise classes that can provide support and motivation.
4. Educate on the diverse benefits of exercise.
Emphasize that the benefits of exercise extend far beyond just heart health and blood pressure control. Discuss how physical activity improves muscle strength, coordination, balance, mood, and overall quality of life. Frame the benefits in a positive and motivating way, focusing on what the patient gains (e.g., more energy to spend time with family, improved ability to perform daily activities) rather than solely on fear of illness.
References
Hypotension Nursing Diagnosis & Care Plan
Stroke (Cerebrovascular Accident) Nursing Diagnosis & Care Plan
Myocardial Infarction (Heart Attack) Nursing Diagnosis & Care Plan
Smoking Nursing Diagnosis & Care Plan
Stress Overload Nursing Diagnosis & Care Plan
Nursing Diagnosis Guide: Complete List for Nurses
Nursing Care Plans (NCP): Ultimate Guide and Database
Decreased Cardiac Output Nursing Diagnosis & Care Plan
Tachycardia Nursing Diagnosis & Care Plan
Chest Pain (Angina) Nursing Diagnosis & Care Plan
Heart Failure Nursing Diagnosis & Care Plan
Myocardial Infarction Nursing Diagnosis & Care Plan
Calculate IV Drip Rate: Drop Factor Formula
Knowledge Deficit Nursing Diagnosis & Care Plan
Excess Fluid Volume Nursing Diagnosis & Care Plan
Chronic Kidney Disease Nursing Diagnosis & Care Plan
Risk For Electrolyte Imbalance Nursing Diagnosis & Care Plan
Nursing Interventions: Comprehensive Guide
Aspirin: Nursing Considerations & Management
Obesity Nursing Diagnosis & Care Plan
Activity Intolerance Nursing Diagnosis & Care Plan
Shortness Of Breath (Dyspnea) Nursing Diagnosis & Care Plan
Fatigue Nursing Diagnosis & Care Plan
Safety Nursing Diagnosis & Care Plan
Edema Nursing Diagnosis & Care Plan
