Severe Hypertension Nursing Diagnosis and Interventions
Hypertension
Degree of Severity
- Stage I (mild) – 140/90 to 159/99 mm Hg
- Stage II (moderate) – 160/100 mm Hg or greater
- Stage II (severe) – systolc pressure greater than 180 and diastolic pressure greater than 110
- Stage IV (very severe) – systolic pressure greater than 210 or greater with diastolic pressure greater than 120
Etiology
- Primary (essential), which accounts for approximately 85% to 95% of all cases, has no identifiable cause
- Secondary, which occurs as a result of an identifiable, sometimes correctable,pathological condition, such as kidney disorders, adrenal gland tumors, or primary aldosteronism, medications, drugs, or other chemicals
Statistics (NHLBI, 2006; Centers for Disease Control and Prevention [CDC], CDC, 2006b; 2007a)
a. Morbidity: 72 million Americans are hypertensive (nearly 1 in 3).
a. Morbidity: 72 million Americans are hypertensive (nearly 1 in 3).
- i. 23% of adults aged 20 to 75 are hypertensive.
- ii. 70% of adults over age 75 are hypertensive.
- iii. Approximately 20% are undiagnosed.
- iv. Prevalence: African Americans 32%, whites 23%, Hispanics 23%
c. Cost: $47.2 billion is spent per year.Nursing Priorities
- Maintain or enhance cardiovascular functioning.
- Prevent complications.
- Provide information about disease process, prognosis, and treatment regimen.
- Support active client control of condition.
Discharge Goals
- BP within acceptable limits for individual.
- Cardiovascular and systemic complications prevented or minimized.
- Disease process, prognosis, and therapeutic regimen understood.
- Necessary lifestyle or behavioral changes initiated.
- Plan in place to meet needs after discharge.
Nursing Diagnosis : Risk for Decreased Cardiac Output
Risk factors may include :
- Increased vascular resistance, vasoconstriction
- Myocardial ischemia
- Ventricular hypertrophy or rigidity
- Possibly evidenced by
- (Not applicable; presence of signs and symptoms establishes an actual diagnosis)
- Desired Outcomes/Evaluation Criteria—Client Will
- Circulation Status
- Participate in activities that reduce BP and cardiac workload.
- Maintain BP within individually acceptable range.
- Demonstrate stable cardiac rhythm and rate within normal range.
Hemodynamic Regulation
Independent
Measure BP in both arms or thighs. Take three readings, 3 to 5 minutes apart while client is at rest, then sitting, and then standing for initial evaluation. Use correct cuff size and accurate technique. Take note of elevations in systolic as
well as diastolic readings.
Measure BP in both arms or thighs. Take three readings, 3 to 5 minutes apart while client is at rest, then sitting, and then standing for initial evaluation. Use correct cuff size and accurate technique. Take note of elevations in systolic as
well as diastolic readings.
Auscultate heart tones and breath sounds.
Observe skin color, moisture, temperature, and capillary refill time.
Note dependent and generalized edema.
Provide calm, restful surroundings, minimize environmental activity and noise. Consider limiting the number of visitors or length of visitation.
Maintain activity restrictions during crisis situation such as bedrest or chair rest and schedule periods of uninterrupted rest; assist client with self-care activities as needed.
Provide comfort measures, such as back and neck massage or elevation of head.
Instruct in relaxation techniques, guided imagery, and distractions.
Monitor response to medications that control BP.
Collaborative
Administer medications, as indicated:
Implement dietary restrictions, as indicated, such as reducing calories and avoiding refined carbohydrates, sodium, fat, and cholesterol. (Refer to ND, imbalanced Nutrition.)
Prepare for surgery when indicated.
Observe skin color, moisture, temperature, and capillary refill time.
Note dependent and generalized edema.
Provide calm, restful surroundings, minimize environmental activity and noise. Consider limiting the number of visitors or length of visitation.
Maintain activity restrictions during crisis situation such as bedrest or chair rest and schedule periods of uninterrupted rest; assist client with self-care activities as needed.
Provide comfort measures, such as back and neck massage or elevation of head.
Instruct in relaxation techniques, guided imagery, and distractions.
Monitor response to medications that control BP.
Collaborative
Administer medications, as indicated:
Implement dietary restrictions, as indicated, such as reducing calories and avoiding refined carbohydrates, sodium, fat, and cholesterol. (Refer to ND, imbalanced Nutrition.)
Prepare for surgery when indicated.
RATIONALE
Serial measurements using correct equipment provide a more complete picture of vascular involvement and scope of
problem. 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 even when diastolic pressure is not elevated. In younger client with normal systolic readings, elevated diastolic numbers may indicate prehypertension.
Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be
diminished, reflecting effects of vasoconstriction and venous congestion.
S4 is commonly heard in severely hypertensive clients because of the presence of atrial hypertrophy. Development of S3 indicates ventricular hypertrophy and impaired cardiac functioning. Presence of crackles or wheezes may indicate
pulmonary congestion secondary to developing or chronic heart failure.
Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation and decreased output.
Indicates heart or kidney failure or vascular impairment.
Helps reduce sympathetic stimulation and promotes relaxation.
Reduces physical stress and tension that affect BP and the course of hypertension.
Decreases discomfort and may reduce sympathetic stimulation.
Can reduce stressful stimuli and produce calming effect, thereby reducing BP.
Response to drug therapy is dependent on both the individual drugs and their synergistic effects. Because of potential side effects and drug interactions, it is important to use the smallest number and lowest dosage of medications possible.
Diuretics are considered first-line medications for uncomplicated hypertension and may be used alone or in association with other drugs, such as beta blockers, to reduce BP in clients with relatively normal renal function. These diuretics also potentiate the effects of other antihypertensive agents by limiting fluid retention and may reduce the incidence of stroke and heart failure.
These drugs produce marked diuresis by inhibiting resorption of sodium and chloride and are effective antihypertensives, especially in clients who are resistant to thiazides or have renal impairment. May be given in combination with a thiazide diuretic to minimize potassium loss.
Beta blockers are recommended for BP control in clients with heart failure and cardiovascular disease. Cardioselective
beta blockers, such as acebutolol, atenolol, and metroprolol, primarily affect -1 receptors in the heart, slowing heart
rate and decreasing the heart’s workload. Nonselective beta blockers, such as propranolol and timolol, also decrease the heart’s workload and promote vasodilation, but they exert effects on the -2 receptors on the bronchioles as well, potentially increasing symptoms of reactive airway disease and chronic obstructive pulmonary disease.
Cardioselective beta blockers are safer choices for patients with pulmonary disorders (Woods & Moshang, 2006).
Calcium channel blockers are categorized into two types.
One group, such as amlodipine, diltiazem, and isradipine, primarily affects blood vessels and can be used to treat
severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP.
Action is to relax vascular smooth muscle, thereby reducing vascular resistance.
These are given intravenously (IV) for management of hypertensive emergencies.
ACE inhibitors are generally considered first-line drugs for clients with documented congestive heart failure (CHF), diabetes, and those at risk for renal failure.
ARBs block the action of angiotensin II. As a result, blood vessels dilate and BP is reduced.
Aldosterone antagonists block the effects of aldosterone on the kidneys, allowing the kidneys to excrete extra sodium
and water, thereby reducing BP.
Limiting sodium and sodium-rich processed foods can help manage fluid retention and, with associated hypertensive response, decrease myocardial workload. A diet rich in calcium, potassium, and magnesium may help lower BP.
When hypertension is due to pheochromocytoma, removing the tumor corrects the condition.
problem. 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 even when diastolic pressure is not elevated. In younger client with normal systolic readings, elevated diastolic numbers may indicate prehypertension.
Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be
diminished, reflecting effects of vasoconstriction and venous congestion.
S4 is commonly heard in severely hypertensive clients because of the presence of atrial hypertrophy. Development of S3 indicates ventricular hypertrophy and impaired cardiac functioning. Presence of crackles or wheezes may indicate
pulmonary congestion secondary to developing or chronic heart failure.
Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation and decreased output.
Indicates heart or kidney failure or vascular impairment.
Helps reduce sympathetic stimulation and promotes relaxation.
Reduces physical stress and tension that affect BP and the course of hypertension.
Decreases discomfort and may reduce sympathetic stimulation.
Can reduce stressful stimuli and produce calming effect, thereby reducing BP.
Response to drug therapy is dependent on both the individual drugs and their synergistic effects. Because of potential side effects and drug interactions, it is important to use the smallest number and lowest dosage of medications possible.
Diuretics are considered first-line medications for uncomplicated hypertension and may be used alone or in association with other drugs, such as beta blockers, to reduce BP in clients with relatively normal renal function. These diuretics also potentiate the effects of other antihypertensive agents by limiting fluid retention and may reduce the incidence of stroke and heart failure.
These drugs produce marked diuresis by inhibiting resorption of sodium and chloride and are effective antihypertensives, especially in clients who are resistant to thiazides or have renal impairment. May be given in combination with a thiazide diuretic to minimize potassium loss.
Beta blockers are recommended for BP control in clients with heart failure and cardiovascular disease. Cardioselective
beta blockers, such as acebutolol, atenolol, and metroprolol, primarily affect -1 receptors in the heart, slowing heart
rate and decreasing the heart’s workload. Nonselective beta blockers, such as propranolol and timolol, also decrease the heart’s workload and promote vasodilation, but they exert effects on the -2 receptors on the bronchioles as well, potentially increasing symptoms of reactive airway disease and chronic obstructive pulmonary disease.
Cardioselective beta blockers are safer choices for patients with pulmonary disorders (Woods & Moshang, 2006).
Calcium channel blockers are categorized into two types.
One group, such as amlodipine, diltiazem, and isradipine, primarily affects blood vessels and can be used to treat
severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP.
Action is to relax vascular smooth muscle, thereby reducing vascular resistance.
These are given intravenously (IV) for management of hypertensive emergencies.
ACE inhibitors are generally considered first-line drugs for clients with documented congestive heart failure (CHF), diabetes, and those at risk for renal failure.
ARBs block the action of angiotensin II. As a result, blood vessels dilate and BP is reduced.
Aldosterone antagonists block the effects of aldosterone on the kidneys, allowing the kidneys to excrete extra sodium
and water, thereby reducing BP.
Limiting sodium and sodium-rich processed foods can help manage fluid retention and, with associated hypertensive response, decrease myocardial workload. A diet rich in calcium, potassium, and magnesium may help lower BP.
When hypertension is due to pheochromocytoma, removing the tumor corrects the condition.
