HYPERTENSION: SEVERE
CARE SETTING
RELATED CONCERNS
Cerebrovascular accident/stroke
Myocardial infarction
Psychosocial aspects of care
Renal failure: acute
Renal failure: chronic
Patient Assessment Database
ACTIVITY/REST
May report:
Weakness, fatigue, shortness of breath, sedentary lifestyle
May exhibit:
Elevated heart rate
Change in heart rhythm
Tachypnea; shortness of breath with exertion
CIRCULATION
May report:
History of intermittent or sustained elevation of diastolic or systolic blood pressure; presence of atherosclerotic, valvular, or coronary artery heart disease (including myocardial infarction [MI], angina, heart failure [HF]) and cerebrovascular disease (reflecting TOD)
Episodes of palpitations, diaphoresis
May exhibit:
Elevated blood pressure (BP) (serial elevated measurements are necessary to confirm diagnosis) Note: Postural hypotension, when present, may be related to drug regimen or reflect dehydration or reduced ventricular function.
Pulse:
Bounding carotid, jugular, radial pulsations; pulse disparities, e.g., femoral delay as compared with radial or brachial pulsation; absence of/diminished popliteal, posterior tibial, pedal pulses
Apical pulse:
Point of maximal impulse (PMI) possibly displaced and/or forceful
Rate/rhythm:
Tachycardia, various dysrhythmias
Heart sounds:
Accentuated S2 at base; S3 (early HF); S4 (rigid left ventricle/left ventricular hypertrophy)
Murmurs of valvular stenosis
Vascular bruits audible over carotid, femoral, or epigastrium (artery stenosis); jugular venous distension (JVD) (venous congestion)
Extremities:
Discoloration of skin, cool temperature (peripheral vasoconstriction); capillary refill possibly slow/delayed (vasoconstriction)
Skin:
Pallor, cyanosis, and diaphoresis (congestion, hypoxemia); flushing (pheochromocytoma)
EGO INTEGRITY
May report:
History of personality changes, anxiety, depression, euphoria, or chronic anger (may cerebral impairment)
Multiple stress factors (relationship, financial, job-related)
May exhibit:
Mood swings, restlessness, irritability, narrowed attention span, outbursts of crying
Emphatic hand gestures, tense facial muscles (particularly around the eyes), quick physical movement, expiratory sighs, accelerated speech pattern
ELIMINATION
May report:
Past or present renal insult (e.g., infection/obstruction or past history of kidney disease)
FOOD/FLUID
May report:
Food preferences, which include high-salt, high-fat, high-cholesterol foods (e.g., fried foods, cheese, eggs); licorice; high caloric content; low dietary intake of potassium, calcium, and magnesium
Nausea, vomiting
Recent weight changes (gain/loss)
Current/history of diuretic use
May exhibit:
Normal weight or obesity
Presence of edema (may be generalized or dependent); venous congestion, JVD
Glycosuria (almost 10% of hypertensive patients are diabetic, reflecting TOD)
NEUROSENSORY
May report:
Fainting spells/dizziness
Throbbing, suboccipital headaches (present on awakening and disappearing spontaneously after several hours)
Episodes of numbness and/or weakness on one side of the body, brief periods of confusion or difficulty with speech (transient ischemic attack [TIA]); or history of cerebrovascular accident (CVA)
Visual disturbances (diplopia, blurred vision)
Episodes of epistaxis
May exhibit:
Mental status: changes in alertness, orientation, speech pattern/content, affect, thought process, or memory
Motor responses: decreased strength, hand grip, and/or deep tendon reflexes
Optic retinal changes: from mild sclerosis/arterial narrowing to marked retinal and sclerotic changes with edema or papilledema, exudates, hemorrhages, and arterial nicking, dependent on severity/duration of hypertension (TOD)
PAIN/DISCOMFORT
May report:
Angina (coronary artery disease/cardiac involvement)
Intermittent pain in legs/claudication (indicative of arteriosclerosis of lower extremity arteries)
Severe occipital headaches as previously noted
Abdominal pain/masses (pheochromocytoma)
RESPIRATION
(Generally associated with advanced cardiopulmonary effects of sustained/severe hypertension)
May report:
Dyspnea associated with activity/exertion
Tachypnea, orthopnea, paroxysmal nocturnal dyspnea
Cough with/without sputum production
Smoking history (major risk factor)
May exhibit:
Respiratory distress/use of accessory muscles
Adventitious breath sounds (crackles/wheezes)
Pallor or cyanosis
SAFETY
May report/exhibit:
Impaired coordination/gait
Transient episodes of numbness, unilateral paresthesias
Light-headedness with position changes
sexuality
May report:
Postmenopausal (major risk factor)
Erectile dysfunction (medication related)
TEACHING/LEARNING
May report:
Familial risk factors: hypertension, atherosclerosis, heart disease, diabetes mellitus, cerebrovascular/kidney disease
Ethnic/racial risk factors, e.g., more prevalent in African-American and Southeast Asian populations
Use of birth control pills or other hormones; drug/alcohol use
Discharge plan considerations:
DRG projected mean length of inpatient stay: 3.5 days
Assistance with self-monitoring of BP
Periodic evaluation of and alterations in medication therapy
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to fluid volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia.
Blood urea nitrogen (BUN)/creatinine: Provides information about renal perfusion/function.
Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result from elevated catecholamine levels (increases hypertension).
Serum potassium: Hypokalemia may indicate the presence of primary aldosteronism (cause) or be a side effect of diuretic therapy.
Serum calcium: Imbalance may contribute to hypertension.
Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL], cholesterol, triglycerides, phospholipids): Elevated level may indicate predisposition for/presence of atheromatous plaquing.
Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction and hypertension.
Serum/urine aldosterone level: May be done to assess for primary aldosteronism (cause).
Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal dysfunction and/or presence of diabetes.
Creatinine clearance: May be reduced, reflecting renal damage.
Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation may indicate presence of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of pheochromocytoma if hypertension is intermittent.
Uric acid: Hyperuricemia has been implicated as a risk factor for the development of hypertension.
Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, Cushing’s syndrome.
Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal parenchymal disease, renal/ureteral calculi.
Kidney and renography nuclear scan: Evaluates renal status (TOD).
Excretory urography: May reveal renal atrophy, indicating chronic renal disease.
Chest x-ray: May demonstrate obstructing calcification in valve areas; deposits in and/or notching of aorta; cardiac enlargement.
Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or encephalopathy or to rule out pheochromocytoma.
Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns, conduction disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive heart disease.
NURSING PRIORITIES
1. Maintain/enhance cardiovascular functioning.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment regimen.
4. Support active patient control of condition.
DISCHARGE GOALS
1. BP within acceptable limits for individual.
2. Cardiovascular and systemic complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Necessary lifestyle/behavioral changes initiated.
5. Plan in place to meet needs after discharge.
Full Nursing Care Plan Hypertension
Hypertension is defined by the 1992 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure as pressure greater than 140/90 mm Hg and is classified according to the degree of severity. Stage I (mild) is 140/90–159/99. Stage II (moderate) is 160/100–179/108. Stage III (severe) is present when systolic pressure is greater than 180 and diastolic pressure is greater than 110. Stage IV (very severe) occurs when systolic pressure is 210 or greater with diastolic pressure greater than 120. Hypertension is categorized as primary/essential (approximately 90% of all cases) or secondary, which occurs as a result of an identifiable, sometimes correctable pathological condition, such as renal disease or primary aldosteronism. The goal of treatment is to prevent the long-term sequelae of the disease (i.e., target organ disease [TOD]). African-Americans and the elderly are most prone to this disorder and its sequelae.
CARE SETTING
Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of complications/compromise may require inpatient care, especially when TOD is present. The majority of interventions included here can be used in either setting.
RELATED CONCERNS
Cerebrovascular accident/stroke
Myocardial infarction
Psychosocial aspects of care
Renal failure: acute
Renal failure: chronic
Patient Assessment Database
ACTIVITY/REST
May report:
Weakness, fatigue, shortness of breath, sedentary lifestyle
May exhibit:
Elevated heart rate
Change in heart rhythm
Tachypnea; shortness of breath with exertion
CIRCULATION
May report:
History of intermittent or sustained elevation of diastolic or systolic blood pressure; presence of atherosclerotic, valvular, or coronary artery heart disease (including myocardial infarction [MI], angina, heart failure [HF]) and cerebrovascular disease (reflecting TOD)
Episodes of palpitations, diaphoresis
May exhibit:
Elevated blood pressure (BP) (serial elevated measurements are necessary to confirm diagnosis) Note: Postural hypotension, when present, may be related to drug regimen or reflect dehydration or reduced ventricular function.
Pulse:
Bounding carotid, jugular, radial pulsations; pulse disparities, e.g., femoral delay as compared with radial or brachial pulsation; absence of/diminished popliteal, posterior tibial, pedal pulses
Apical pulse:
Point of maximal impulse (PMI) possibly displaced and/or forceful
Rate/rhythm:
Tachycardia, various dysrhythmias
Heart sounds:
Accentuated S2 at base; S3 (early HF); S4 (rigid left ventricle/left ventricular hypertrophy)
Murmurs of valvular stenosis
Vascular bruits audible over carotid, femoral, or epigastrium (artery stenosis); jugular venous distension (JVD) (venous congestion)
Extremities:
Discoloration of skin, cool temperature (peripheral vasoconstriction); capillary refill possibly slow/delayed (vasoconstriction)
Skin:
Pallor, cyanosis, and diaphoresis (congestion, hypoxemia); flushing (pheochromocytoma)
EGO INTEGRITY
May report:
History of personality changes, anxiety, depression, euphoria, or chronic anger (may cerebral impairment)
Multiple stress factors (relationship, financial, job-related)
May exhibit:
Mood swings, restlessness, irritability, narrowed attention span, outbursts of crying
Emphatic hand gestures, tense facial muscles (particularly around the eyes), quick physical movement, expiratory sighs, accelerated speech pattern
ELIMINATION
May report:
Past or present renal insult (e.g., infection/obstruction or past history of kidney disease)
FOOD/FLUID
May report:
Food preferences, which include high-salt, high-fat, high-cholesterol foods (e.g., fried foods, cheese, eggs); licorice; high caloric content; low dietary intake of potassium, calcium, and magnesium
Nausea, vomiting
Recent weight changes (gain/loss)
Current/history of diuretic use
May exhibit:
Normal weight or obesity
Presence of edema (may be generalized or dependent); venous congestion, JVD
Glycosuria (almost 10% of hypertensive patients are diabetic, reflecting TOD)
NEUROSENSORY
May report:
Fainting spells/dizziness
Throbbing, suboccipital headaches (present on awakening and disappearing spontaneously after several hours)
Episodes of numbness and/or weakness on one side of the body, brief periods of confusion or difficulty with speech (transient ischemic attack [TIA]); or history of cerebrovascular accident (CVA)
Visual disturbances (diplopia, blurred vision)
Episodes of epistaxis
May exhibit:
Mental status: changes in alertness, orientation, speech pattern/content, affect, thought process, or memory
Motor responses: decreased strength, hand grip, and/or deep tendon reflexes
Optic retinal changes: from mild sclerosis/arterial narrowing to marked retinal and sclerotic changes with edema or papilledema, exudates, hemorrhages, and arterial nicking, dependent on severity/duration of hypertension (TOD)
PAIN/DISCOMFORT
May report:
Angina (coronary artery disease/cardiac involvement)
Intermittent pain in legs/claudication (indicative of arteriosclerosis of lower extremity arteries)
Severe occipital headaches as previously noted
Abdominal pain/masses (pheochromocytoma)
RESPIRATION
(Generally associated with advanced cardiopulmonary effects of sustained/severe hypertension)
May report:
Dyspnea associated with activity/exertion
Tachypnea, orthopnea, paroxysmal nocturnal dyspnea
Cough with/without sputum production
Smoking history (major risk factor)
May exhibit:
Respiratory distress/use of accessory muscles
Adventitious breath sounds (crackles/wheezes)
Pallor or cyanosis
SAFETY
May report/exhibit:
Impaired coordination/gait
Transient episodes of numbness, unilateral paresthesias
Light-headedness with position changes
sexuality
May report:
Postmenopausal (major risk factor)
Erectile dysfunction (medication related)
TEACHING/LEARNING
May report:
Familial risk factors: hypertension, atherosclerosis, heart disease, diabetes mellitus, cerebrovascular/kidney disease
Ethnic/racial risk factors, e.g., more prevalent in African-American and Southeast Asian populations
Use of birth control pills or other hormones; drug/alcohol use
Discharge plan considerations:
DRG projected mean length of inpatient stay: 3.5 days
Assistance with self-monitoring of BP
Periodic evaluation of and alterations in medication therapy
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to fluid volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia.
Blood urea nitrogen (BUN)/creatinine: Provides information about renal perfusion/function.
Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result from elevated catecholamine levels (increases hypertension).
Serum potassium: Hypokalemia may indicate the presence of primary aldosteronism (cause) or be a side effect of diuretic therapy.
Serum calcium: Imbalance may contribute to hypertension.
Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL], cholesterol, triglycerides, phospholipids): Elevated level may indicate predisposition for/presence of atheromatous plaquing.
Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction and hypertension.
Serum/urine aldosterone level: May be done to assess for primary aldosteronism (cause).
Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal dysfunction and/or presence of diabetes.
Creatinine clearance: May be reduced, reflecting renal damage.
Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation may indicate presence of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of pheochromocytoma if hypertension is intermittent.
Uric acid: Hyperuricemia has been implicated as a risk factor for the development of hypertension.
Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary dysfunction, Cushing’s syndrome.
Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal parenchymal disease, renal/ureteral calculi.
Kidney and renography nuclear scan: Evaluates renal status (TOD).
Excretory urography: May reveal renal atrophy, indicating chronic renal disease.
Chest x-ray: May demonstrate obstructing calcification in valve areas; deposits in and/or notching of aorta; cardiac enlargement.
Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or encephalopathy or to rule out pheochromocytoma.
Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns, conduction disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive heart disease.
NURSING PRIORITIES
1. Maintain/enhance cardiovascular functioning.
2. Prevent complications.
3. Provide information about disease process/prognosis and treatment regimen.
4. Support active patient control of condition.
DISCHARGE GOALS
1. BP within acceptable limits for individual.
2. Cardiovascular and systemic complications prevented/minimized.
3. Disease process/prognosis and therapeutic regimen understood.
4. Necessary lifestyle/behavioral changes initiated.
5. Plan in place to meet needs after discharge.
Full Nursing Care Plan Hypertension
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