Nursing Diagnosis Risk for decreased cardiac output related to increased vascular vasoconstriction Assessment: Subjective Data: I do not

really feel well, right now. My blood pressure is always high and I feel light headed when I suddenly move. as claimed by patient. Objective Data: -Pale in color -Skin cool and moist to touch -Jugular vein can be easily seen and bounding upon palpation -Verbalized light headedness on sudden change of position -Easy fatigability and occasional dyspnic occurrences upon exertion -Blood pressure ranging

Patient Outcomes Outcome Identification:

Nursing Interventions

Rationale Nursing Care Plan for Hypertension 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

Evaluation Please refer to the Patient Outcomes tab

The patient will Independent: participate in activities that 1. Monitor blood reduce cardiac pressure workload by periodically. 04/18/12. Measure both arms The patient will three times; 3-5 maintain blood mins apart while pressure within patient is at rest for acceptable range initial evaluation. by 04/19/12. 2. Note presence of, The patient will quality of central demonstrate stable and peripheral cardiac rhythm pulses. and rate within 3. Auscultate heart patients normal tones and breath range by 04/19/12. 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 rest) and assist patient with selfcare activities.

from 140/90 to 150/100 mmHg, BP as of 6:00 A.M. 04/17/12 is 150/90 mmHg -Pulse rate of 110 beats per minute as of 6:00 A.M. 04/17/12 -Capillary refill of 2-3 seconds

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 cholesterol

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decreased cardiac output. It may indicate heart failure, vascular or renal impairment. Promotes relaxation. It reduces physical stress and stimuli that affect the blood pressure. Decreases discomfort and may reduce sympathetic stimulation It helps reduce stressful stimuli, thereby decreases blood pressure. 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. 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 is always a must to prevent hypotension. 12. This restrictions help manage fluid retention and decrease myocardial workload.