Assessment: Objective Data: -Pale in color -Skin cool and moist to touch -Jugular vein can be easily seen

and bounding upon palpation -Blood pressure ranging from 140/90 to 150/100 mmHg, BP as of 6:00 A.M. 12:00 on the same day is 150/90 mmHg -has been admitted before because of hypertension Subjective data: -the patient verbalized when ask what does she felt before admission, nagluluya si hawak ko, nagpipiriot ang daghan

Nursing Diagnosis Risk for decreased cardiac output related to increased vascular vasoconstriction

Planning The patient will participate in activities that reduce cardiac workload after one day. The patient will maintain blood pressure within acceptable range after two days. The patient will demonstrate stable cardiac rhythm and rate within patients normal range after two days.

Nursing Interventions

Rationale Nursing Care Plan for Hypertension

Independent:

1. Monitor blood pressure periodically. Measure both arms three times; 3-5 mins apart while patient is at rest for initial evaluation. 2. Note presence of, quality of central and peripheral pulses. 3. Auscultate heart tones and breath sounds 4. Observe skin color, moisture, temperature and capillary refill time. 5. Note independent or general edema 6. Provide a calm environment; minimizing noise; limiting visitors and length of stay. 7. Maintain activity restrictions (bed

1. Bounding carotid, jugular, radial, femoral pulses may be observed/ palpated. Pulses in the leg may be diminished, implicating effects of vasoconstriction and venous congestion. 2. S3 and S4 heart sounds may indicate atrial and venous hypertrophy and impaired functioning. 3. Presence of adventitious breath sounds may indicate pulmonary congestion secondary to developing heart failure. 4. Presence of pallor; cool and moist skin and delayed capillary refill may be due to peripheral vasoconstriction or decreased cardiac

rest) and assist patient with selfcare activities. 8. Provide comfort measures, i.e. elevation of head 9. Encourage relaxation techniques like guided imagery and distractions 10. Monitor response to medications to control blood pressure
Depedent

11. Administer medications like diuretics, alpha and beta antagonists, calcium channel blockers, and vasodilators.
Collaborative

12. Instruct and implement to patient dietary restrictions in sodium, fat and

output. 5. It may indicate heart failure, vascular or renal impairment. 6. Promotes relaxation. 7. It reduces physical stress and stimuli that affect the blood pressure. 8. Decreases discomfort and may reduce sympathetic stimulation 9. It helps reduce stressful stimuli, thereby decreases blood pressure. 10. Response to drug is dependent on both the individual and the synergistic effect of the drug. It is also important to check for any untoward signs and symptoms of the medications. 11. These medications should be medically prescribed by the physician and dose and timing of medications should be followed. Checking BP prior to giving of medications

cholesterol

is always a must to prevent hypotension. 12. This restrictions help manage fluid retention and decrease myocardial workload.