Hypertension
is the term used to describe high blood pressure. Hypertension is repeatedly elevated
blood pressure exceeding 140 over 90 mmHg. It is categorized as primary or
essential (approximately 90% of all cases) or secondary, which occurs as a result of an
identifiable, sometimes correctable pathological condition, such as renal disease or
primary aldosteronism.
Nursing Care Plans
Diagnostic Studies
Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to
fluid volume (viscosity) and may indicate risk factors such as
hypercoagulability, anemia.
Blood urea nitrogen (BUN)/creatinine: Provides information about renal
perfusion/function.
Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension)
may result from elevated catecholamine levels (increases hypertension).
Serum potassium: Hypokalemia may indicate the presence of primary
aldosteronism (cause) or be a side effect of diuretic therapy.
Serum calcium: Imbalance may contribute to hypertension.
Lipid panel (total lipids, high-density lipoprotein [HDL], low-density
lipoprotein [LDL], cholesterol, triglycerides, phospholipids): Elevated
level may indicate predisposition for/presence of atheromatous plaques.
Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction
and hypertension.
Serum/urine aldosterone level: May be done to assess for primary
aldosteronism (cause).
Urinalysis: May show blood, protein, or white blood cells; or glucose
suggests renal dysfunction and/or presence of diabetes.
Creatinine clearance: May be reduced, reflecting renal damage.
Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation
may indicate presence of pheochromocytoma (cause); 24-hour urine VMA
may be done for assessment of pheochromocytoma if hypertension is
intermittent.
Uric acid: Hyperuricemia has been implicated as a risk factor for the
development of hypertension.
Renin: Elevated in renovascular and malignant hypertension, salt-wasting
disorders.
Urine steroids: Elevation may indicate hyperadrenalism,
pheochromocytoma, pituitary dysfunction, Cushing’s syndrome.
Intravenous pyelogram (IVP): May identify cause of secondary
hypertension, e.g., renal parenchymal disease, renal/ureteral calculi.
Kidney and renography nuclear scan: Evaluates renal status (TOD).
Excretory urography: May reveal renal atrophy, indicating chronic renal
disease.
Chest x-ray: May demonstrate obstructing calcification in valve areas;
deposits in and/or notching of aorta; cardiac enlargement.
Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or
encephalopathy or to rule out pheochromocytoma.
Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns,
conduction disturbances. Note: Broad, notched P wave is one of the earliest
signs of hypertensive heart disease.
Nursing Priorities
1. Maintain/enhance cardiovascular functioning.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment regimen.
4. Support active patient control of condition.
Discharge Goals
1. BP within acceptable limits for individual.
2. Cardiovascular and systemic complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Necessary lifestyle/behavioral changes initiated.
5. Plan in place to meet needs after discharge.
1. Decreased Cardiac Output
Nursing Diagnosis
Cardiac Output, risk for decreased
Risk factors may include
Increased vascular resistance, vasoconstriction
Myocardial ischemia
Ventricular hypertrophy/rigidity
Possibly evidenced by
Not applicable. Existence of signs and symptoms establishes an actual
nursing diagnosis.
Desired Outcomes
Participate in activities that reduce BP/cardiac workload.
Maintain BP within individually acceptable range.
Demonstrate stable cardiac rhythm and rate within patient’s normal range.
Participate in activities that will prevent stress (stress management, balanced
activities and rest plan).
Nursing Interventions Rationale
Review clients at risk as noted in Related Persons with acute or chronic conditions may
Factors as well as individuals with conditions compromise circulation and place excessive
that stress the heart. demands on the heart.
Check laboratory data (cardiac markers,
complete blood ell count, electrolytes, ABGs,
blood urea nitrogen and creatinine, cardiac To identify contributing factors
enzymes, and cultures, such as blood, wound or
secretions).
Comparison of pressures provides a more
complete picture of vascular involvement or
scope of problem. Severe hypertension is
Monitor and record BP. Measure in both arms classified in the adult as a diastolic pressure
and thighs three times, 3–5 min apart while elevation to 110 mmHg; progressive diastolic
patient is at rest, then sitting, then standing for readings above 120 mmHg are considered first
initial evaluation. Use correct cuff size and accelerated, then malignant (very severe).
accurate technique. Systolic hypertension also is an established risk
factor for cerebrovascular disease and ischemic
heart disease, when diastolic pressure is
elevated.
Note presence, quality of central and peripheral Bounding carotid, jugular, radial, and femoral
pulses. pulses may be observed and palpated. Pulses in
the legs and feet may be diminished, reflecting
effects of vasoconstriction (increased systemic
Nursing Interventions Rationale
vascular resistance [SVR]) and venous
congestion.
S4 heart sound is common in severely
hypertensive patients because of the presence
of atrial hypertrophy (increased atrial volume and
pressure). Development of S3 indicates
Auscultate heart tones and breath sounds.
ventricular hypertrophy and impaired functioning.
Presence of crackles, wheezes may indicate
pulmonary congestion secondary to developing
or chronic heart failure.
Presence of pallor; cool, moist skin; and delayed
Observe skin color, moisture, temperature, and capillary refill time may be due to peripheral
capillary refill time. vasoconstriction or reflect cardiac
decompensation and decreased output.
May indicate heart failure, renal or vascular
Note dependent and general edema.
impairment.
Evaluate client reports or evidence of extreme
fatigue, intolerance for activity, sudden or To assess for signs of poor ventricular function
progressive weight gain, swelling of extremities, or impending cardiac failure.
and progressive shortness of breath.
Provide calm, restful surroundings, minimize
Helps lessen sympathetic stimulation; promotes
environmental activity and noise. Limit the
relaxation.
number of visitors and length of stay.
Maintain activity restrictions (bedrest or chair
Lessens physical stress and tension that affect
rest); schedule periods of uninterrupted rest;
blood pressure and the course of hypertension.
assist patient with self-care activities as needed.
Provide comfort measures (back and neck Decreases discomfort and may reduce
massage, elevation of head). sympathetic stimulation.
Instruct in relaxation techniques, guided Can reduce stressful stimuli, produce calming
imagery, distractions. effect, thereby reducing BP.
Monitor response to medications to control blood Response to drug therapy (usually consisting of
pressure. several drugs, including diuretics, angiotensin-
converting enzyme [ACE] inhibitors, vascular
smooth muscle relaxants, beta and calcium
Nursing Interventions Rationale
channel blockers) is dependent on both the
individual as well as the synergistic effects of the
drugs.Because of side effects, drug interactions,
and patient’s motivation for taking
antihypertensive medication, it is important to
use the smallest number and lowest dosage of
medications.
Administer medications as indicated:
Diuretics are considered first-line medications for
uncomplicated stage I or II hypertension and
Thiazide diuretics: chlorothiazide (Diuril); may be used alone or in association with other
hydrochlorothiazide (Esidrix/HydroDIURIL); drugs (such as beta-blockers) to reduce BP in
bendroflumethiazide (Naturetin); indapamide patients with relatively normal renal function.
(Lozol); metolazone (Diulo); quinethazone These diuretics potentiate the effects of other
(Hydromox); antihypertensive agents as well, by limiting fluid
retention, and may reduce the incidence of
strokes and heart failure.
These drugs produce marked diuresis by
Loop diuretics: furosemide (Lasix); ethacrynic inhibiting resorption of sodium and chloride and
acid (Edecrin); bumetanide (Bumex), torsemide are effective antihypertensives, especially in
(Demadex); patients who are resistant to thiazides or have
renal impairment.
Potassium-sparing diuretics: spironolactone
May be given in combination with a thiazide
(Aldactone); triamterene (Dyrenium); amiloride
diuretic to minimize potassium loss.
(Midamor);
Alpha, beta, or centrally acting adrenergic Beta-Blockers may be ordered instead of
antagonists: doxazosin (Cardura); propranolol diuretics for patients with ischemic heart
(Inderal); acebutolol (Sectral); metoprolol disease; obese patients with cardiogenic
(Lopressor), labetalol (Normodyne); atenolol hypertension; and patients with concurrent
(Tenormin); nadolol (Corgard), carvedilol supraventricular arrhythmias, angina, or
(Coreg); methyldopa (Aldomet); clonidine hypertensive cardiomyopathy. Specific actions of
(Catapres); prazosin (Minipress); terazosin these drugs vary, but they generally reduce BP
(Hytrin); pindolol (Visken); through the combined effect of decreased total
peripheral resistance, reduced cardiac output,
inhibited sympathetic activity, and suppression of
Nursing Interventions Rationale
renin release. Note: Patients with diabetes
should use Corgard and Visken with caution
because they can prolong and mask the
hypoglycemic effects of insulin. The elderly may
require smaller doses because of the potential
for bradycardia and hypotension. African-
American patients tend to be less responsive to
beta-blockers in general and may require
increased dosage or use of another drug
(monotherapy with a diuretic).
May be necessary to treat severe hypertension
Calcium channel antagonists: nifedipine when a combination of a diuretic and a
(Procardia); verapamil (Calan); diltiazem sympathetic inhibitor does not sufficiently control
(Cardizem); amlodipine (Norvasc); isradipine BP. Vasodilation of healthy cardiac vasculature
(DynaCirc); nicardipine (Cardene); and increased coronary blood flow are
secondary benefits of vasodilator therapy.
Adrenergic neuron blockers: guanadrel
Reduce arterial and venous constriction activity
(Hylorel); guanethidine (Ismelin); reserpine
at the sympathetic nerve endings.
(Serpalan);
Direct-acting oral vasodilators: hydralazine Action is to relax vascular smooth muscle,
(Apresoline); minoxidil (Loniten); thereby reducing vascular resistance.
Direct-acting parenteral
vasodilators:diazoxide (Hyperstat), These are given intravenously for management
nitroprusside (Nitropress); labetalol of hypertensive emergencies.
(Normodyne);
Angiotensin-converting enzyme (ACE)
The use of an additional sympathetic inhibitor
inhibitors: captopril (Capoten); enalapril
may be required for its cumulative effect when
(Vasotec); lisinopril (Zestril); fosinopril
other measures have failed to control BP or
(Monopril); ramipril (Altace). Angiotensin II
when congestive heart failure (CHF) or diabetes
blockers: valsartan (Diovan), guanethidine
is present.
(Ismelin).
These restrictions can help manage fluid
Implement dietary sodium, fat, and cholesterol
retention and, with associated hypertensive
restrictions as indicated.
response, decrease myocardial workload.
Prepare for surgery when indicated. When hypertension is due to
Nursing Interventions Rationale
pheochromocytoma, removal of the tumor will
correct condition.
