Blood pressure is a measurement of the force against the walls of your arteries as the heart pumps blood through the body.
The top number is called the systolic blood pressure, and the bottom number is called the diastolic blood pressure.
- Normal blood pressure is when blood pressure is lower than 120/80 mmHg most of the time.
- High blood pressure (hypertension) is when blood pressure is 140/90 mmHg or above most of the time.
- If your blood pressure numbers are 120/80 or higher, but below 140/90, it is called pre-hypertension.
- Many factors can affect blood pressure, including:
- How much water and salt you have in your body
- The condition of your kidneys, nervous system, or blood vessels
- The levels of different body hormones
Most of the time, there are no symptoms. Symptoms that may occur include:
- Ear noise or buzzing
- Irregular heartbeat
- Vision changes
Nursing Care Plan for Hypertension
Nursing Diagnosis I :
Decreased Cardiac Output
NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body
- Demonstrate stable cardiac rhythm and rate within patient’s normal range.
- Maintain blood pressure within individually acceptable range.
- Participate in activities that reduce blood pressure /cardiac workload.
1. Monitor blood pressure, measure in both arms/thighs three times, use correct cuff size and accurate technique.
Rationale : Comparison of pressures provides a more complete picture of vascular involvement/scope of problem. Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.
2. Note dependent/general edema.
Rationale : May indicate heart failure, renal or vascular impairment.
3. Note presence, quality of central and peripheral pulses.
Rationale : Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.
4. Observe skin color, moisture, temperature, and capillary refill time.
Rationale : Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output.
Nursing Diagnosis II :
NANDA Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain) sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of
- Verbalize methods that provide relief.
- Report pain/discomfort is relieved/controlled.
- Follow prescribed pharmacological regimen.
1. Assess pain scale. Determine specifics of pain, e.g., location, characteristics.
Rationale : Helpful in evaluating effectiveness of therapy.
2. Encourage bedrest during acute phase.
Rationale : Minimizes stimulation/promotes relaxation.
3. Assist patient with ambulation as needed.
Rationale : Patient may also experience episodes of postural hypotension, causing weakness when ambulating.
4. Minimize vasoconstricting activities that may aggravate headache.
Rationale : Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.
Nursing Diagnosis III :
NANDA Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities
- Demonstrate a decrease in physiological signs of intolerance.
- Participate in necessary/desired activities.
- Report a measurable increase in activity tolerance.
1. Encourage progressive activity/self-care when tolerated. Provide assistance as needed.
Rationale : Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.
2. Instruct patient in energy-conserving techniques, e.g., using chair when showering, sitting to brush teeth or comb hair, carrying out activities at a slower pace.
Rationale : Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.
Nursing Diagnosis IV :
Imbalanced Nutrition : more than body requirements
NANDA Definition: Intake of nutrients that exceeds metabolic needs
- Initiate/maintain individually appropriate exercise program.
- Nutritional Status: Nutrient Intake (NOC) Demonstrate change in eating patterns (e.g., food choices, quantity) to attain desirable body weight with optimal maintenance of health.
- Identify correlation between hypertension and obesity.
1. Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar as indicated.
Rationale : Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate hypertension.
2. Determine patient’s desire to lose weight.
Rationale : Motivation for weight reduction is internal. The individual must want to lose weight.
3. Review usual daily caloric intake and dietary choices.
Rationale : Identifies current strengths/weaknesses in dietary program.
4. Instruct and assist in appropriate food selections, such as a diet rich in fruits, vegetables, and low-fat dairy foods.
Rationale : Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis.
Nursing Diagnosis V :
NANDA Definition: Absence or deficiency of cognitive information related to a specific topic
Identify drug side effects and possible complications that necessitate medical attention.
Verbalize understanding of disease process and treatment regimen.
Maintain blood pressure within individually acceptable parameters.
1. Define and specify the desired blood pressure limits. Describe hypertension and its effect on the heart, blood vessels, kidneys, and brain.
Rationale : Provides a basis for understanding blood pressure elevation, and describes commonly used medical terms. Understanding that high blood pressure can occur without symptoms is the center allows patients to continue treatment, even when it feels good.
2. Assist patients in identifying the risk factors that can be modified, for example, obesity, a diet high in sodium, saturated fat, and cholesterol, sedentary lifestyle, smoking, alcohol consumption, stress lifestyle.
Rationale : Risk factors that have been shown to contribute to hypertension and cardiovascular and renal disease.