Nursing Diagnosis

Risk for decreased cardiac

output related to increased
vascular vasoconstriction

Patient Outcomes
Outcome Identification:

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 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.

The patient will

participate in
activities that reduce
cardiac workload by
04/18/12.
The patient will
maintain blood
pressure within
acceptable range by
04/19/12.
The patient will
demonstrate stable
cardiac rhythm and
rate within patients
normal range by
04/19/12.

Nursing Interventions

Rationale

Independent:

Nursing Care Plan for

Hypertension

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 rest)
and assist patient with
self- care activities.
8. Provide comfort
measures, i.e.
elevation of head
9. Encourage relaxation
techniques like guided
imagery and
distractions
10. Monitor response to

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
output.
5. It may indicate heart
failure, vascular or
renal impairment.
6. Promotes relaxation.
7. It reduces physical
stress and stimuli that

Evaluation
Please refer to the Patient
Outcomes tab

04/17/12
-Capillary refill of 2-3
seconds

medications to control
blood pressure
8.
Depedent
11. Administer
medications like
diuretics, alpha and
beta antagonists,
calcium channel
blockers, and
vasodilators.

9.

10.

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

11.

12.

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.
This restrictions help
manage fluid
retention and decrease
myocardial workload.