Nursing Care Plan Hypertension: Severe


I.Pathophysiology—malignant or cancerous tumor, starting
from the cells of the breast tissue and occurring primarily in
women, although men may also be affected.
b. Types (NCCN, 2007)
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A. Pathophysiology—malignant or cancerous tumor, starting
from the cells of the breast tissue and occurring primarily in
women, although men may also be affected.
b. Types (NCCN, 2007)
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iv. Adaptive: e.g., regulation of intracellular Na+ and Ca++
by cell membrane ion pumps
v. Neural: variety of complex nerve mechanisms
vi. Endocrine: pheochromocytoma, primary aldosteronism
vii. Humoral: varied agents that constrict and dilate blood
viii. Hemodynamic: blood volume or viscosity, intrarenal
II. Classification—2003 Guidelines National Heart, Lung, and
Blood Institute (NHLBI)
a. Normal blood pressure (BP)—less than 120/80 mm Hg
b. Prehypertension—120/80 to 139/89 mm Hg
c. Hypertension—greater than 140/90 mm Hg

III. Degree of Severity
a. Stage I (mild) - 140/90 to 159/99 mm Hg
b. Stage II (moderate) - 160/100 mm Hg or greater
c. Stage II (severe) - systolc pressure greater than 180 and diastolic pressure greater than 110
d. Stage IV (very severe) - systolic pressure greater than 210 or greater with diastolic pressure greater than 120

IV. Etiology
a. Primary (essential), which accounts for approximately 85% to 95% of all cases, has no identifiable cause
b. 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
V. Statistics (NHLBI, 2006; Centers for Disease Control and
Prevention [CDC], CDC, 2006b; 2007a)
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%
b. Mortality: There are more than 19,000 deaths per year.
c. Cost: $47.2 billion is spent per year.

Care Setting
Although hypertension is usually treated in a community setting,
management of stages III and IV with symptoms of complications
or compromise may require inpatient care, especially
when target organ disease (TOD) is present. The majority
of interventions included here can be used in either setting.

Nursing Priorities
1. Maintain or enhance cardiovascular functioning.
2. Prevent complications.
3. Provide information about disease process, prognosis,
and treatment regimen.
4. Support active client control of condition.

Discharge Goals
1. BP within acceptable limits for individual.
2. Cardiovascular and systemic complications prevented or
3. Disease process, prognosis, and therapeutic regimen
4. Necessary lifestyle or behavioral changes initiated.
5. 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
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
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
Monitor response to medications that control BP.
Administer medications, as indicated:
Diuretics, for example, thiazide, such as chlorothiazide
(Diuril), hydrochlorothiazide (Esidrix, HydroDIURIL),
hydrochlorothiazide with triamterene (Diazide, Maxide) or
amiloride (Modiuretic), bendroflumethiazide (Naturetin),
indapamide (Lozol), metolazone (Mykrox, Zaroxolyn); and
loop diuretics, such as furosemide (Lasix), bumetanide
(Bumex), and torsemide (Demadex)
Potassium-sparing diuretics, such as spironolactone
(Aldactone), triamterene (Dyrenium), and amiloride
Beta blockers, such as doxazosin (Cardura), acebutolol
(Sectral), metoprolol (Lopressor), labetalol (Normodyne),
atenolol (Tenormin), nadolol (Corgard), carvedilol
(Coreg), propranolol (Inderal), methyldopa (Aldomet),
clonidine (Catapres), prazosin (Minipress), terazosin
(Hytrin), pindolol (Visken), and timolol (Blocarden)
Calcium channel blockers, such as nifedipine (Adalat,
Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem
(Cardizem), amlodipine (Norvasc), isradipine (DynaCirc),
nicardipine (Cardene), and felodipine (Plendil)
Direct-acting oral vasodilators, such as hydralazine
(Apresoline) and minoxidil (Loniten)
Direct-acting parenteral vasodilators, such as diazoxide
(Hyperstat), nitroprusside (Nitropress), and labetalol
Angiotensin-converting enzyme (ACE) inhibitors, such as
captopril (Capoten), enalapril (Vasotec), benazepril
(Lotensin), lisinopril (Zestril), fosinopril (Monopril),
ramipril (Altace), moexipril (Univasc), and trandolapril
Angiotensin II receptor blockers (ARBs), such as candesartan
(Atacand), olmesartan (Benicar), valsartan (Diovan),
losartan (Cozaar), and irbesartan (Avapro)
Aldosterone blockers, such as eplerenone (Inspra) and
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.


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
Reduces physical stress and tension that affect BP and the
course of hypertension.
Decreases discomfort and may reduce sympathetic
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
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.