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  1. Hypertension, widely known as high blood pressure, has been seen to cause 7.5 million deaths or about 12.8% of total deaths according to World Health Organization. This also responsible for the 57 million disability adjusted life years which equates to 3.7% disability adjusted life years.

hypertension-nursing-care-planDefinition

  • Blood pressure greater than 140/90 mm hg and is classified according to the degree of severity.
  • Conceptual definition: the level of blood pressure in which the benefits of action exceeds the risk and costs of inaction.

Factors involved in the conceptual definition of hypertension

ActionBenefitsRisks and costs
Action
  • Reduce risk of cardiovascular disease, debility, and death.
  • Decrease monetary cost of catastrophic events.
  • Assume psychological burdens of “the hypertensive patient”.
  • Interfere with quality of life.
  • Require change in lifestyle.
  •  Add risk side effects from therapy.
  • Add monetary cost of health care.
Inaction  Preserve “non-patient” role

  •  Maintain current lifestyle and quality of life.
  • Avoid risk and side effects of therapy.
  • Avoid monetary costs of health care.
 

  • Increase risk of cardiovascular disease, debility, and death.
  • Increase monetary cost of catastrophic events.

Source: Kaplan, N. (2010). Kaplan’s clinical hypertension. Philadelphia, PA: Lippincott Williams & Wilkins.

Stages of hypertension

Normal: systolic ≤ 120 mmHg and diastolic ≤80 mmHg.

Prehypertension: systolic between 120 mmHg and 139 mmHg, or a diastolic between 80 mmHg to 89 mmHg.

Stage 1 (mild): systolic between 140 and 159 mm hg or diastolic 90 and 99 mm hg.

Stage 2 (moderate): systolic 160 mm hg and 179 mmHg or diastolic 100 mm hg or 109 mmHg.

Prevalence

  • There is a low incidence rate of hypertension in rural populations of China, Africa, South America, and Latin America.
  • There is a normal incidence rate of hypertension in a population in most of the industrialized areas such as Europe, Japan, and Caucasian groups in United States, which ranges from 15% to 30%.
  • There is a high incidence rate of hypertension in places such as Russian Federation, Poland, Finland, and among African Americans, which ranges from 30% to 40%.

Risk factors

Unmodifiable factors:

Age

Between birth and the age of 30Pre-high blood pressure stage. Occasional blood pressure could be high, but then, the elevation is not constant.
Usually between the ages of 30 to 40Frequent occurrence of high blood pressure, but the period of normal blood pressure still follow. This may last for 5 to 10 years.
As early as 30 years old, but is commonly at 50 years oldEssential hypertension, which is a sustained high blood pressure but its cause can’t be determined. These people are also highly susceptible to early heart attacks and brain attacks.
Past the age of 50This stage is believed to be more likely secondary (brought about by other causes) high blood pressure.

Sex – According to studies, boys are more likely to have higher systolic blood pressure than girls. In fact, starting at age 12 and every two years thereafter, high blood pressure increases by 19 percent among boys but still continue to remain unchanged among girls (study conducted by Circulation December 2006 with Canadian participants).  Among young adults aged 18 to 35 years old, men still have higher prevalence rate as compared to women. However, after women reach the age of 50, they appear to have higher prevalence of high blood pressure as compared to men. This sudden change is brought about by the loss of estrogen through menopause or removal of ovaries.

Ethnic background – More common among African Americans as compared to Caucasians (see Prevalence).

Family history/ Hereditary – High Blood pressure have a tendency to run in the family. However, researchers cannot still demarcate how and which part of the human genes re responsible for high blood pressure. In addition to this, heredity also affects one’s body weight, which implies that people who are closely related are likely to have similar degrees of obesity.

Modifiable factors: less active, overweight/ obese, consumption of salty foods, stressful lifestyle, smoking, and drinking.

Diagnostic studies

  1. Hematocrit: not diagnostic but assesses relationship of cells to fluid volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia.
  2. Blood urea nitrogen (bun)/creatinine: provides information about renal perfusion/function.
  3. Glucose: hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result from elevated catecholamine levels (increases hypertension).
  4. Serum potassium: hypokalemia may indicate the presence of primary aldosteronism (cause) or be a side effect of diuretic ­therapy.
  5. Serum calcium: imbalance may contribute to hypertension.
  6. Lipid panel (total lipids, high-density lipoprotein [hdl], low-density lipoprotein [ldl], cholesterol, triglycerides, phospholipids): elevated level may indicate predisposition for/presence of atheromatous plaquing.
  7. Thyroid studies: hyperthyroidism may lead or contribute to vasoconstriction and hypertension.
  8. Serum/urine aldosterone level: may be done to assess for primary aldosteronism (cause).
  9. Urinalysis: may show blood, protein, or white blood cells; or glucose suggests renal dysfunction and/or presence of diabetes.
  10. Creatinine clearance:may be reduced, reflecting renal damage.
  11. 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.
  12. Uric acid: hyperuricemia has been implicated as a risk factor for the development of hypertension.
  13. Renin: elevated in renovascular and malignant hypertension, salt-wasting disorders.
  14. Urine steroids: elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, cushing’s syndrome.
  15. Intravenous pyelogram (ivp): may identify cause of secondary hypertension, e.g., renal parenchymal disease, renal/ureteral ­calculi.
  16. Kidney and renography nuclear scan: evaluates renal status (tod).
  17. Excretory urography: may reveal renal atrophy, indicating chronic renal disease.
  18. Chest x-ray: may demonstrate obstructing calcification in valve areas; deposits in and/or notching of aorta; cardiac enlargement.
  19. Computed tomography (CT) scan: assesses for cerebral tumor, cva, or encephalopathy or to rule out pheochromocytoma.
  20. 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.

Treatment

Medications:

  • Thiazide diuretics – diuretics helps work by removing sodium and water, thus alleviating high blood pressure by reducing blood volume.
  • Beta blockers – reduce blood pressure by diminishing the hearts workload and open the vessels. This will make the heart beats slower and less forceful.  
  • Angiotensin-converting enzyme (ACE) inhibitors – this medication work by relaxing blood vessels through hindering the development of natural chemical which narrows blood vessels.
  • Angiotensin II receptor blockers (ARBs) – this medication work by also relaxing blood vessels through hindering the action, and not the development, of natural chemical which narrows blood vessels.
  • Calcium channel blockers – reduced blood pressure by relaxing the muscles of your blood vessels.
  • Renin inhibitors – renin is an enzyme released by kidneys which starts a chain of chemical steps that increases blood pressure, and this medication slows down its production.

Other Additional Medications:

  • Alpha blockers – reduce nerve impulses to blood vessels leading to diminish the effects of natural chemicals, thus narrowing blood vessels.
  • Alpha-beta blockers – slows down the heartbeat, lessening amount of blood that must be pumped through the vessels.
  • Central-acting agents – Acts by averting brain from signaling the nervous system to upsurge heart rate and narrow your blood vessels.
  • Aldosterone antagonists – halt the impact of a natural chemical that can lead to salt and fluid retention. Salt and fluid retention contribute to increase blood pressure.

Lifestyle Changes 

  • DASH Diet (healthier diet with less salt consumption)
  • Quit smoking and limit alcohol drinking
  • Exercise regularly
  • Maintain a healthy weight or start reducing weight of overweight or obese.

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.

Nursing Care Plans for Hypertension (Based on NANDA)

Nursing diagnosis: Risk for Decreased Cardiac Output

Risk factors may include

  • Increased vascular resistance, vasoconstriction
  • Myocardial ischemia
  • Ventricular hypertrophy/rigidity

Possibly evidenced by

  • not applicable; presence of signs and symptoms establishes an actual

Desired outcomes/evaluation criteria—patient will:

  • Participate in activities that reduce blood pressure/cardiac workload.
  • Maintain blood pressure within individually acceptable range.
  • Demonstrate stable cardiac rhythm and rate within patient’s normal range.
Nursing InterventionsRationale
Independent: Hemodynamic regulation
Monitor bp. Measure in both arms/thighs three times, 3–5 min apart while patient is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and accurate technique.
 

Comparison of pressures provides a more complete picture of vascular involvement/scope of problem. Severe hypertension is classified in the adult as a diastolic pressure elevation to 110 mm hg; progressive diastolic readings above 120 mm hg are considered first accelerated, then malignant (very severe). 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 pulses.Bounding carotid, jugular, radial, and femoral pulses may be observed/palpated. Pulses in the legs/feet may be diminished, reflecting effects of vasoconstriction increased systemic vascular resistance  and venous congestion.
Auscultate heart tones and breath sounds.S4 heart sound is common in severely hypertensive patients because of the presence of atrial hypertrophy (increased atrial volume/pressure). Development of s3 indicates ventricular hypertrophy and impaired functioning. Presence of crackles, wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure.
Observe skin color, moisture, temperature, and capillary refill time.Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/decreased output.
Note dependent/general edema.May indicate heart failure, renal or vascular impairment.
Provide calm, restful surroundings, minimize environmental activity/noise. Limit the number of visitors and length of stay.Helps reduce sympathetic stimulation; promotes relaxation.
Maintain activity restrictions, e.g., bedrest/chair rest; schedule periods of uninterrupted rest; assist patient with self-care activities as needed.Reduces physical stress and tension that affect blood pressure and the course of hypertension.
Provide comfort measures, e.g., back and neck massage, elevation of head.Decreases discomfort and may reduce sympathetic stimulation.
 

Instruct in relaxation techniques, guided imagery, distractions.

Can reduce stressful stimuli, produce calming effect, thereby reducing bp.
Nursing InterventionsRationale
 

Independent
Monitor response to medications to control blood pressure.

Response to drug therapy (usually consisting of several Drugs, including diuretics, angiotensin-converting enzyme [ace] inhibitors, vascular smooth muscle relaxants, beta and calcium 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.

Collaborative

Administer medications as indicated:

Thiazide diuretics, e.g., chlorothiazide (diuril); hydrochlorothiazide (esidrix/hydrodiuril); bendroflumethiazide (naturetin); indapamide (lozol); metolazone (diulo); quinethazone (hydromox);

Diuretics are considered first-line medications for uncomplicated stage i or ii hypertension and may be used alone or in association with other drugs (such as beta-blockers) to reduce bp in patients with relatively normal renal function. These diuretics potentiate the effects of other antihypertensive agents as well, by limiting fluid retention, and may reduce the incidence of strokes and heart failure.
Loop diuretics, e.g., furosemide (lasix); ethacrynic acid (edecrin); bumetanide (bumex), torsemide (demadex)These drugs produce marked diuresis by inhibiting resorption of sodium and chloride and are effective antihypertensives, especially in patients who are resistant to thiazides or have renal impairment.
Potassium-sparing diuretics, e.g., spironolactone (aldactone); triamterene (dyrenium); amiloride (midamor)May be given in combination with a thiazide diuretic to minimize potassium loss.
Alpha, beta, or centrally acting adrenergic antagonists, e.g., doxazosin (cardura); propranolol (inderal); acebutolol (sectral); metoprolol (lopressor), labetalol (normodyne); atenolol (tenormin); nadolol (corgard), carvedilol (coreg); methyldopa (aldomet); clonidine (catapres); prazosin (minipress); terazosin (hytrin); pindolol (visken)Beta-blockers may be ordered instead of diuretics for patients with ischemic heart disease; obese patients with cardiogenic hypertension; and patients with concurrent supraventricular arrhythmias, angina, or hypertensive cardiomyopathy. Specific actions of these drugs vary, but they generally reduce bp through the combined effect of decreased total peripheral resistance, reduced cardiac output, inhibited sympathetic activity, and suppression of 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, e.g., monotherapy with a diuretic.
Calcium channel antagonists, e.g., nifedipine (procardia); verapamil (calan); diltiazem (cardizem); amlodipine (norvasc); isradipine (dynacirc); nicardipine (cardene) 

May be necessary to treat severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control bp. Vasodilation of healthy cardiac vasculature and increased coronary blood flow are secondary benefits of vasodilator therapy.

 

 

 

Adrenergic neuron blockers: guanadrel (hylorel); guanethidine (ismelin); reserpine (serpalan);Reduce arterial and venous constriction activity at the sympathetic nerve endings.
Direct-acting oral vasodilators: hydralazine (apresoline); minoxidil (loniten)Action is to relax vascular smooth muscle, thereby reducing vascular resistance.
Direct-acting parenteral vasodilators: diazoxide (hyperstat), nitroprusside (nitropress); labetalol (normodyne)These are given intravenously for management of hypertensive emergencies.
Angiotensin-converting enzyme (ace) inhibitors, e.g., captopril (capoten); enalapril (vasotec); lisinopril (zestril); fosinopril (monopril); ramipril (altace). Angiotensin ii blockers, e.g., valsartan (diovan), guanethidine (ismelin).The use of an additional sympathetic inhibitor may be required for its cumulative effect when other measures have failed to control bp or when congestive heart failure (chf) or diabetes is present.
Implement dietary sodium, fat, and cholesterol restrictions as indicated.These restrictions can help manage fluid retention and, with associated hypertensive response, decrease myocardial workload.
 Prepare for surgery when indicated. When hypertension is due to pheochromocytoma, removal of the tumor will correct condition.

Nursing diagnosis: Activity Intolerance

May be related to

  • Generalized weakness
  • Imbalance between oxygen supply and demand

Possibly evidenced by

  • Verbal report of fatigue or weakness
  • Abnormal heart rate or bp response to activity
  • Exertional discomfort or dyspnea
  • Electrocardiogram (ecg) changes reflecting ischemia; dysrhythmias

Desired outcomes/evaluation criteria—patient will:

  • Participate in necessary/desired activities.
  • Report a measurable increase in activity tolerance.
  • Demonstrate a decrease in physiological signs of intolerance.
Nursing InterventionsRationale
Energy management

Independent

Assess the patient’s response to activity, noting pulse rate more than 20 beats/min faster than resting rate; marked increase in bp during/after activity (systolic pressure increase of 40 mm hg or diastolic pressure increase of 20 mm hg); dyspnea or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope.

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.

 

 

The stated parameters are helpful in assessing physiological responses to the stress of activity and, if present, are indicators of overexertion.

Energy-saving techniques reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand.

Encourage progressive activity/self-care when tolerated. Provide assistance as needed.Gradual activity progression prevents a sudden increase in cardiac workload. Providing assistance only as needed encourages independence in performing activities.

Nursing diagnosis: Acute Pain, Headache

May be related to

  • Increased cerebral vascular pressure

Possibly evidenced by

  • Reports of throbbing pain located in suboccipital region, present on awakening and disappearing spontaneously after being up and about
  • Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists
  • Reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting

Desired outcomes/evaluation criteria—patient will:

  • Report pain/discomfort is relieved/controlled.
  • Verbalize methods that provide relief.
  • Follow prescribed pharmacological regimen
Nursing InterventionsRationale
Pain management
IndependentDetermine specifics of pain, e.g., location, characteristics, intensity (0–10 scale), onset/duration. Note nonverbal cues.
 

Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.

Encourage/maintain bedrest during acute phase.Minimizes stimulation/promotes relaxation.
Provide/recommend nonpharmacological measures for relief of headache, e.g., cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques (guided imagery, distraction); and diversional activities.Measures that reduce cerebral vascular pressure and that slow/block sympathetic response are effective in relieving headache and associated complications.
Eliminate/minimize vasoconstricting activities that may aggravate headache, e.g., straining at stool, prolonged coughing, bending over.Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.
Assist patient with ambulation as needed.Dizziness and blurred vision frequently are associated with vascular headache. Patient may also experience episodes of postural hypotension, causing weakness when ambulating.
Provide liquids, soft foods, frequent mouth care if nosebleeds occur or nasal packing has been done to stop bleeding.Promotes general comfort. Nasal packing may interfere with swallowing or require mouth breathing, leading to stagnation of oral secretions and drying of mucous membranes.
Collaborative

Administer medications as indicated:

Analgesics;

Reduce/control pain and decrease stimulation of the sympathetic nervous system.
Antianxiety agents, e.g., lorazepam (ativan), alprazolam (xanax), diazepam (valium).May aid in the reduction of tension and discomfort that is intensified by stress.

Nursing diagnosis: Imbalanced Nutrition (more than body requirements)

May be related to

  • Excessive intake in relation to metabolic need
  • Sedentary lifestyle
  • Cultural preferences

Possibly evidenced by

  • Weight 10%–20% more than ideal for height and frame
  • Triceps skinfold more than 15 mm in men and 25 mm in women (maximum for age and sex)
  • Reported or observed dysfunctional eating patterns

Desired outcomes/evaluation criteria—patient will:

  • Identify correlation between hypertension and obesity.
  • Demonstrate change in eating patterns (e.g., food choices, quantity) to attain desirable body weight with optimal maintenance of health.
  • Initiate/maintain individually appropriate exercise program
Nursing InterventionsRationale
Weight reduction assistance

Independent

Assess patient understanding of direct relationship between hypertension and obesity.

Obesity is an added risk with high blood pressure because of  the disproportion between fixed aortic capacity and

Increased cardiac output associated with increased body

Mass. Reduction in weight may obviate the need for drug

Therapy or decrease the amount of medication needed for

Control of bp. Note: recent research suggests that bringing weight within 15% of ideal weight can result in a drop of 10 mm hg in both systolic and diastolic bp.

Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar as indicated.Faulty eating habits contribute to atherosclerosis and

Obesity, which predispose to hypertension and subsequent

Complications, e.g., stroke, kidney disease, heart failure.

Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate  hypertension. Note: one study showed that sodium reduction reduced the need for medication by 31%. Weight loss lowered the need for medication by 36% and the combination of the two by 53%.

Determine patient’s desire to lose weight.Motivation for weight reduction is internal. The individual must want to lose weight, or the program most likely will not succeed.
Review usual daily caloric intake and dietary choices.Identifies current strengths/weaknesses in dietary program. Aids in determining individual need for adjustment/teaching.
Establish a realistic weight reduction plan with the patient, e.g., 1 lb weight loss/wk.

 

Reducing caloric intake by 500 calories daily theoretically yields a weight loss of 1 lb/wk. Slow reduction in weight is therefore indicative of fat loss with muscle sparing and generally reflects a change in eating habits.
Encourage patient to maintain a diary of food intake, including when and where eating takes place and the circumstances and feelings around which the food was eaten.Provides a database for both the adequacy of nutrients eaten and the emotional conditions of eating. Helps focus attention on factors that patient has control over/can change.
Instruct and assist in appropriate food selections, such as a diet rich in fruits, vegetables, and low-fat dairy foods referred to as the dash dietary approaches to stop hypertension) diet and avoiding foods high in saturated fat (butter, cheese, eggs, ice cream, meat) and cholesterol (fatty meat, egg yolks, whole dairy products, shrimp, organ meats).Avoiding foods high in saturated fat and cholesterol is important in preventing progressing atherogenesis. Moderation and use of low-fat products in place of total abstinence from certain food items may prevent sense of deprivation and enhance cooperation with dietary regimen. The dash diet, in conjunction with exercise, weight loss, and limits on salt intake, may reduce or even eliminate the need for drug therapy.
Collaborative

Refer to dietitian as indicated.

Can provide additional counseling and assistance with meeting individual dietary needs.

Nursing diagnosis: Ineffective Coping

May be related to

  • Situational/maturational crisis; multiple life changes
  • Inadequate relaxation; little or no exercise, work overload
  • Inadequate support systems
  • Poor nutrition
  • Unmet expectations; unrealistic perceptions
  • Inadequate coping methods

Possibly evidenced by

  • Verbalization of inability to cope or ask for help
  • Inability to meet role expectations/basic needs or problem-solve
  • Destructive behavior toward self; overeating, lack of appetite; excessive smoking/drinking, proneness to alcohol abuse
  • Chronic fatigue/insomnia; muscular tension; frequent head/neck aches;
  • Chronic worry, irritability, anxiety, emotional tension, depression

Desired outcomes/evaluation criteria—patient will:

Coping 

  • Identify ineffective coping behaviors and consequences.
  • Verbalize awareness of own coping abilities/strengths.
  • Identify potential stressful situations and steps to avoid/modify them.
  • Demonstrate the use of effective coping skills/methods.
Nursing InterventionsRationale
Coping enhancement

Independent

Assess effectiveness of coping strategies by observing behaviors, e.g., ability to verbalize feelings and concerns, willingness to participate in the treatment plan.

Adaptive mechanisms are necessary to appropriately alter one’s lifestyle, deal with the chronicity of hypertension, and integrate prescribed therapies into daily living.
Note reports of sleep disturbances, increasing fatigue, impaired concentration, irritability, decreased tolerance of headache, inability to cope/problem-solve.Manifestations of maladaptive coping mechanisms may be indicators of repressed anger and have been found to be major determinants of diastolic bp.
Assist patient to identify specific stressors and possible strategies for coping with them.

Include patient in planning of care, and encourage maximum participation in treatment plan.

Recognition of stressors is the first step in altering one’s response to the stressor.

Involvement provides patient with an ongoing sense of control, improves coping skills, and can enhance cooperation with therapeutic regimen.

Encourage patient to evaluate life priorities/goals. Ask questions such as “is what you are doing getting you what you want?”Focuses patient’s attention on reality of present situation relative to patient’s view of what is wanted. Strong work ethic, need for “control,” and outward focus may have led to lack of attention to personal needs.
Assist patient to identify and begin planning for necessary lifestyle changes. Assist to adjust, rather than abandon, personal/family goals.Necessary changes should be realistically prioritized so patient can avoid being overwhelmed and feeling powerless.

Nursing diagnosis: Knowledge Deficit (learning need) regarding condition, treatment plan, self-care and discharge needs

May be related to

Lack of knowledge/recall

  • Information misinterpretation
  • Cognitive limitation
  • Denial of diagnosis

Possibly evidenced by

  • Verbalization of the problem
  • Request for information
  • Statement of misconception
  • Inaccurate follow-through of instructions; inadequate performance of procedures
  • Inappropriate or exaggerated behaviors, e.g., hostile, agitated, apathetic

Desired outcomes/evaluation criteria—patient will:

  • Verbalize understanding of disease process and treatment regimen.
  • Identify drug side effects and possible complications that necessitate medical attention.
  • Maintain bp within individually acceptable parameters.

Knowledge: treatment regimen

  • Describe reasons for therapeutic actions/treatment regimen.
Nursing InterventionsRationale
Teaching: disease process
Independent
Assess readiness and blocks to learning. Include significant other (so).
Misconceptions and denial of the diagnosis because of long-standing feelings of well-being may interfere with patient/so willingness to learn about disease, progression, and prognosis. If patient does not accept the reality of a life-threatening condition requiring continuing treatment, lifestyle/behavioral changes will not be initiated/sustained.
Define and state the limits of desired bp. Explain hypertension and its effects on the heart, blood vessels, kidneys, and brain.Provides basis for understanding elevations of bp, and clarifies frequently used medical terminology. Understanding that high bp can exist without symptoms is central to enabling patient to continue treatment, even when feeling well.
Avoid saying “normal” bp, and use the term “well-controlled” to describe patient’s bp within desired limits.Because treatment for hypertension is lifelong, conveying the idea of “control” helps patient understand the need for continued treatment/medication.
Nursing InterventionsRationale
Teaching: disease process

Independent

Assist patient in identifying modifiable risk factors, e.g., obesity; diet high in sodium, saturated fats, and cholesterol; sedentary lifestyle; smoking; alcohol intake (more than 2 oz/day on a regular basis); stressful lifestyle.

 

These risk factors have been shown to contribute to hypertension and cardiovascular and renal disease.

Problem-solve with patient to identify ways in which appropriate lifestyle changes can be made to reduce modifiable risk factors.Changing “comfortable/usual” behavior patterns can be very difficult and stressful. Support, guidance, and empathy can enhance patient’s success in accomplishing these tasks.
Discuss importance of eliminating smoking, and assist patient in formulating a plan to quit smoking.Nicotine increases catecholamine discharge, resulting in increased heart rate, bp, vasoconstriction, and myocardial workload, and reduces tissue oxygenation.
Reinforce the importance of adhering to treatment regimen and keeping follow-up appointments.Lack of cooperation is a common reason for failure of antihypertensive therapy. Therefore, ongoing evaluation for patient cooperation is critical to successful treatment.  Compliance usually improves when patient understands causative factors and consequences of inadequate intervention and health maintenance.
Instruct and demonstrate technique of bp self-monitoring. Evaluate patient’s hearing, visual acuity, manual dexterity, and coordination.Monitoring bp at home is reassuring to patient because it provides visual/positive reinforcement for efforts in following the medical regimen and promotes early detection of deleterious changes.
Help patient develop a simple, convenient schedule for taking medications.Individualizing medication schedule to fit patient’s personal habits/needs may facilitate cooperation with long-term regimen.
Explain prescribed medications along with their rationale, dosage, expected and adverse side effects, and idiosyncrasiesAdequate information and understanding that side effects (e.g., mood changes, initial weight gain, dry mouth) are common and often subside with time can enhance cooperation with treatment plan.
Diuretics: take daily doses (or larger dose) in the early morning;Scheduling minimizes nighttime urination.
Weigh self on a regular schedule and recordPrimary indicator of effectiveness of diuretic therapy.
Avoid/limit alcohol intakeThe combined vasodilating effect of alcohol and the volume-depleting effect of a diuretic greatly increase the risk of orthostatic hypotension.
Notify physician if unable to tolerate food or fluid Dehydration can develop rapidly if intake is poor and patient continues to take a diuretic.
Nursing InterventionsRationale
Teaching: disease process

Independent

Antihypertensives: take prescribed dose on a regular schedule; avoid skipping, altering, or making up doses; and do not discontinue without notifying the healthcare provider. Review potential side effects and/or drug interactions

Because patients often cannot feel the difference the medication is making in blood pressure, it is critical that there is understanding about the medications’ working and side effects. For example, abruptly discontinuing a drug may cause rebound hypertension leading to severe complications, or medication may need to be altered to reduce adverse effects.
Rise slowly from a lying to standing position, sitting for a few minutes before standing. Sleep with the head slightly elevated.Measures reduce severity of orthostatic hypotension associated with the use of vasodilators and diuretics.
Suggest frequent position changes, leg exercises when lying down.Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting/standing.
Recommend avoiding hot baths, steam rooms, and saunas, especially with concomitant use of alcoholic beverages.Prevents vasodilation with potential for dangerous side effects of syncope and hypotension.
Instruct patient to consult healthcare provider before taking other prescription or over-the-counter (otc) medications.Precaution is important in preventing potentially dangerous drug interactions. Any drug that contains a sympathetic nervous stimulant may increase bp or counteract antihypertensive effects.
Instruct patient about increasing intake of foods/fluids high in potassium, e.g., oranges, bananas, figs, dates, tomatoes, potatoes, raisins, apricots, gatorade, and fruit juices and foods/fluids high in calcium, e.g., low-fat milk, yogurt, or calcium supplements, as indicated.Diuretics can deplete potassium levels. Dietary replacement is more palatable than drug supplements and may be all that is needed to correct deficit. Some studies show that 400 mg of calcium/day can lower systolic and diastolic bp. Correcting mineral deficiencies can also affect bp.
Review signs/symptoms requiring notification of healthcare provider, e.g., headache present on awakening that does not abate; sudden and continued increase of bp; chest pain/shortness of breath; irregular/increased  pulse rate; significant weight gain (2 lb/day or 5 lb/wk) or peripheral/abdominal swelling; visual disturbances; frequent, uncontrollable nosebleeds; depression/emotional lability; severe dizziness or episodes of fainting; muscle weakness/cramping; nausea/vomiting; excessive thirst.Early detection of developing complications/decreased effectiveness of drug regimen or adverse reactions to it allows for timely intervention.

 

Explain rationale for prescribed dietary regimen (usually a diet low in sodium, saturated fat, and cholesterol).Excess saturated fats, cholesterol, sodium, alcohol, and calories have been defined as nutritional risks in hypertension. A diet low in fat and high in polyunsaturated fat reduces bp, possibly through prostaglandin balance in both normotensive and hypertensive people.
Nursing InterventionsRationale
Teaching: disease process 

Independent

Help patient identify sources of sodium intake (e.g., table salt, salty snacks, processed meats and cheeses, sauerkraut, sauces, canned soups and vegetables, baking soda, baking powder, monosodium glutamate). Stress the importance of reading ingredient labels of foods and otc drugs.

Two years on a moderate low-salt diet may be sufficient to control mild hypertension or reduce the amount of medication required.
Encourage patient to establish an individual exercise program incorporating aerobic exercise (walking, swimming) within patient’s capabilities. Stress the importance of avoiding isometric activity.Besides helping to lower bp, aerobic activity aids in toning the cardiovascular system. Isometric exercise can increase serum catecholamine levels, further elevating bp.
Demonstrate application of ice pack to the back of the neck and pressure over the distal third of nose, and recommend that patient lean the head forward, if nosebleed occurs.Nasal capillaries may rupture as a result of excessive vascular pressure. Cold and pressure constrict capillaries to slow or halt bleeding. Leaning forward reduces the amount of blood that is swallowed.
Provide information regarding community resources, and support patient in making lifestyle changes. Initiate referrals as indicated.Community resources such as the american heart association, “coronary clubs,” stop smoking clinics, alcohol (drug) rehabilitation, weight loss programs, stress management classes, and counseling services may be helpful in patient’s efforts to initiate and maintain lifestyle changes.

References

  • Kaplan, N. (2010). Kaplan’s clinical hypertension. Philadelphia, PA: Lippincott Williams & Wilkins.
  • Mayo Clinic Staff (2015). High blood pressure: Treatments and drugs. Mayo Clinic. Retrieved September 29, 2015 from http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/treatment/con-20019580
  • Rubin, A. (2007). High blood pressure for dummies. Hoboken, NJ: John Wiley & Sons.
  • World Health Organization. (2015). Raised blood pressure. World Health Organization. Retrieved September 29, 2015 from http://www.who.int/gho/ncd/risk_factors/blood_pressure_prevalence_text/en/
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Danica is a Registered Nurse in the Philippines who used to work as an Occupational Health Nurse in a pharmaceutical company. She opted to devote and exemplify her profession through writing. She is an Academic Writer for more than three years. A mother of adorable 5 year old girl and an entrepreneur who started designing and making customized and originally crafted bags.