Sunday, November 13, 2011

Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions

Hypertension Nursing Assessment

Assessment is the main basis of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, their families, the data obtained through interviews, observation and examination.

The data collected can be divided into two (Kelliat, Budi Ana., 1995) :

  1. Data base
  2. Specific data relating to the current situation of the client which can be determined by the nurse, client or family.
The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).

Hypertension Nursing Diagnosis

  1. Risk for Decreased Cardiac Output related to Increased afterload, vasoconstriction and myocardial ischemia.
  2. Acute pain related to increased cerebral vascular pressure.

Hypertension Nursing Intervention

Nursing Diagnosis :

Risk for Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary related to impaired circulation

Nursing Intervention for Hypertension

  • Maintain bed rest, elevate head of bed
  • Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if available
  • Maintain fluid and drugs.
  • Observe the sudden hypotension.
  • Measure inputs and expenditures
  • Monitor electrolytes, BUN, creatinine.
  • Ambulation according to ability; avoid fatigue

Risk for Decreased Cardiac Output related to Hypertension
Nursing Care Plan for Hypertension in Pregnancy

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