Nursing Care Plans – Hypertension by Ayo A. Ale-Finks 3 of 3
Hypertensive Emergency is severe hypertension with acute impairment of an organ and the
possibility of irreversible organ-damage. In case of a hypertensive emergency, the blood pressure
should be lowered aggressively over minutes to hours with an antihypertensive agent.
Nursing Priorities
1. Maintenance of client’s cardiovascular functions
2. Maintenance of organ functions
3. Prevent further disease progression
4. Enhance active client participation and involvement in treatment plan of condition
5. Provide information and/or patient education as it relates to condition, outcome, and treatment
Discharge Goals
1. Disease process/prognosis and demonstration of understanding/role in therapeutic regimen.
2. Lifestyle changes coping with change
3. Minimize/Prevent further complication
4. Demonstrate proficient self-care
5. Cardiovascular and systemic minimization/prevention of further complications
A. Decrease Cardiac OutputNursing Diagnosis
i. Cardiac Output, risk for decreased cardiac output
Risk factors
i. increased vascular/circulatory resistance and vasoconstriction
ii. ventricular rigidity
iii. myocardial ischemia
Nursing Interventions
i. Review clients at risk as noted in Related Factors as well as individuals with conditions
that stress the heart.
ii. Check/review lab data – CBC’s, ABG’s, BUN, electrolytes, cardiac enzymes, and creatine
nitrogen.
iii. Monitor/record blood pressure. Measurements are done in both arms and thighs 3x, 3 to 5
minutes apart while the client is at rest, sitting, then standing for the initial assessment.
iv. Monitor/record client’s presence and quality of central and peripheral pulses
v. Monitor/record and auscultation of heart tones and lung sounds
vi. Monitor/record capillary refill time, skin color, temperature, and moisture.
vii. Monitor/record any indication of edema
d. Rational
i. Clients with acute or chronic hypertension may compromise circulation and place
unnecessary excessive demands on the heart
ii. identification of contributing/compounding factors
iii. when comparing pressures on all extremities and across various positions and client
activities, this provides the clinician a more complete presentation of the client’s vascular
involvement and/or scope of challenges with disease process.
iv. Bounding pulses over the carotid, jugular, radial and femoral arteries may be observed
and palpated. Pulses over the feet and legs may be diminished, indicating the effects of
vasoconstriction and venous congestion.
v. The presence of an increased S4 heart sound is indicative of atrial forceful contraction in an
effort to overcome an abnormally hypertrophic ventricle.
vi. The presence of delayed capillary refill, pallor, cool moist clammy skin; may be
indicative of vasoconstriction or reflect cardiac decompensation and a decrease in output.
vii. Edema, if present, may be indicative of fluid overload, general heart failure, renal and/or
vascular impairment.
B. Imbalanced Nutrition
a. Nursing Diagnosis
i. Altered nutrition: less than Body Requirements
b. Risk factors
i. Hypertension exacerbation
c. Nursing Interventions
i. Explain dietary restrictions
ii. Implement dietary sodium, cholesterol and fat restrictions to diet
d. Rational
i. Inform client of contributing factors and need for dietary changes to prevent further disease
progression
ii. Restrictions should help maintain/reduce further disease progression. Management of fluid
retention and reduction in cardiac workload
C. Deficient Knowledge
a. Nursing Diagnosis
i. Misinterpretation of information, access to support group and unfamiliarity with resources
b. Risk factors
i. Inaccurate follow through of instructions, failure to return demonstration.
c. Nursing Interventions
i. assessment readiness and/or barriers to learning
ii. implementation of normal blood pressure limits, education of client about hypertension,
possible acute and long-term effects
d. Rational
i. the client’s long-term success in reduction control of hypertension depends on the client’s
willingness to change lifestyle and the elimination of barriers and misinformation about
