- Decreased Cardiac Output related to Impaired cardiac muscle contraction and conditions that compromise blood flow as evidenced by Dysrhythmias and Intolerance in activities
- Deficient Knowledge related to lack of understanding of hypertension and its effect on the body as evidenced by Worsening blood pressure and Incorrect follow-through with diet or lifestyle recommendations
- Excess Fluid Volume related to chronic conditions: heart failure, kidney disease as evidenced by edema in extremities and High blood pressure
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbalizes Chest Pain and discomfort Objective data: -Decreased oxygen saturation -Chest pain (angina) -Presence of abnormal lung sounds upon auscultation -Difficulty breathing (dyspnea) Rapid breathing (tachypnea) -Intolerance in activities -Prolonged capillary refill time | Decreased Cardiac Output related to Impaired cardiac muscle contraction and conditions that compromise blood flow as evidenced by Dysrhythmias and Intolerance in activities | Patient will manifest blood pressure and pulses within acceptable limits. Patient will not develop complications from hypertension. Patient will adhere to lab testing, medications, and follow-up appointments for hypertension. | 1. Assist the patient in lifelong change. Since hypertension is a chronic disorder, it requires constant monitoring and management. Exercise, weight management, and limiting alcohol and smoking are crucial to minimizing cardiovascular risk. 2. Administer beta-blockers or calcium-channel blockers as prescribed. Beta-blockers and calcium channel blockers offer quick heart rate control at rest and during activity. They can be administered intravenously (IV) or orally. 3. Use CPAP or supplemental oxygen at night. Obstructive sleep apnea requires treatment to reduce sympathetic nervous system stimulation to reduce cardiac workload and blood pressure. 4. Monitor and increase activity as tolerated. Exercise is a necessity to strengthen the heart and lower blood pressure. Closely monitor the patient’s response to activity through their HR and BP. 5. Limit salt intake. Consuming excess salt raises the incidence of cardiovascular disease and hypertension. Hypertension results from increased salt absorption leading to increased volume, reduced renin-angiotensin-aldosterone system (RAAS) response, and increased sympathetic nervous system activity. | Patient manifested blood pressure and pulses within acceptable limits. Patient developed complications from hypertension. Patient adhered to lab testing, medications, and follow-up appointments for hypertension. |
| Subjective data: Verbalizes poor understanding Seeks additional information Denial of a need to learn Objective data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition | Deficient Knowledge related to lack of understanding of hypertension and its effect on the body as evidenced by Worsening blood pressure and Incorrect follow-through with diet or lifestyle recommendations | Patient will “teach-back” education provided to them regarding how to manage their blood pressure. Patient will state their personal risk factors for hypertension. Patient will explain the action of their blood pressure medications and the importance of not missing doses | 1. Help the patient identify their personal risk factors. Educate between modifiable (stress, diet, weight, tobacco use) vs. non-modifiable risk factors (age, family history, ethnicity). From there, patients can identify areas of improvement. 2. Teach the patient how to monitor blood pressure. Educate the patient on what their blood pressure number should be, and what is considered high or low. Have the patient bring in their own BP monitor to calibrate it and observe them using it to ensure accuracy of readings. 3. Provide positive reinforcement. Do not criticize a patient for mistakes or difficulty in implementing their treatment plan. Reinforce any attempt to learn more or even a slight improvement. 4. Review medications thoroughly. Patients may not understand the purpose of their medications and may skip or miss doses. Review the action, side effects, and rationale of each blood pressure medication as well as the frequency and interactions with other drugs. | Patient stated their personal risk factors for hypertension. Patient explained the action of their blood pressure medications and the importance of not missing doses |
| Subjective data: Difficulty breathing Anxiety Weight gain or swelling Objective data: -Adventitious breath sounds (rales or crackles) -High blood pressure -Restlessness -Decreased haemoglobin or haematocrit -Increased central venous pressure -Jugular vein distention -Oliguria -Tachycardia | Excess Fluid Volume related to chronic conditions: heart failure, kidney disease as evidenced by edema in extremities and High blood pressure | Patient will maintain stable fluid volume as evidenced by balanced intake and output, weight at baseline, and no signs of edema. Patient will verbalize the importance of reducing sodium intake. | 1. Educate on fluid and/or sodium restrictions. Patients with hypertension must be aware of their sodium and fluid intake. This is even more important when coupled with kidney disease or heart failure as this complicates the ability to regulate this balance. 2. Administer diuretics. Diuretics may be required to rid the body of extra fluid if the patient is displaying symptoms such as shortness of breath or extremely elevated blood pressure. 3. Elevate extremities. Edematous extremities should be elevated above the level of the heart in order to aid in circulation. Frequent positioning and use of pillows will also prevent skin breakdown. 4. Instruct on low-sodium options. Patients are often unaware of the amount of sodium in foods. Frozen dinners, canned food, and most restaurant entrees are overloaded with sodium. Educate patients on their daily recommended sodium intake and to limit processed foods and opt for low-sodium options. | Patient maintained stable fluid volume as evidenced by balanced intake and output, weight at baseline, and no signs of edema. Patient verbalized the importance of reducing sodium intake. |