1. Risk for decreased cardiac output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy.
Purpose: afterload is not increased, there was no vasoconstriction, and myocardial ischemia does not occur.
- Maintaining blood pressure within an acceptable range.
- Showed stable cardiac rhythm and frequency.
- Participate in activities that lower blood pressure.
- Monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure.
- Auscultation of breath sounds and heart tone. Observe skin color, moisture, temperature and capillary refill time.
- Note the presence, quality of the central and peripheral pulses.
- Maintain restrictions on activities such as rest in bed or chair.
- Assist in performing self-care activities as needed.
- Provide a quiet environment, convenient, and therapeutic and reduce activity. Note the general edema.
- Monitor response to medication to control blood pressure. Give fluid and dietary sodium restriction as indicated.
- Medical collaboration in the provision of drugs as indicated.
2. Acute pain: headache related to increased cerebral vascular pressure.
Purpose: The pressure does not increase cerebral vascular
Expected Outcomes: Patients revealed the absence of headache and looked comfortable.
- Maintain bed rest, quiet neighborhood, a little light.
- Limit of patients in the activity.
- Minimize disruption and environmental stimuli.
- Give a fun action according to indications such as ice packs, the position of comfort, relaxation techniques, counseling imagination, avoid constipation.
- Medical collaboration in providing analgesic and sedative drugs.
Purpose: The circulation of the body is not impaired.
Expected outcomes :
- Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headache, dizziness, laboratory values within normal limits.
- Stable vital signs.
- Urine output 30 ml / min.
- Maintain bed rest, elevate the head position in bed patients.
- Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if it is available.
- Measure the input and discharge.
- Observe the sudden hypotension.
- Ambulation within your means and avoid fatigue in patients.
- Monitor electrolytes, creatinine according to medical advice.
- Maintain fluids and medications according to medical advice.
Purpose : patients are met in terms of information about hypertension.
Expected outcomes :
- Patients can express their knowledge and skills of the management of early treatment of hypertension.
- Reported the use of drugs according to medical advice.
- Describe the nature of the disease and the purpose of the procedure and the treatment of hypertension.
- Explain the importance of a peaceful environment and theraupetik, and management of stressors.
- Discuss the importance of maintaining a stable weight.
- Discuss the need for low-calorie diet, low in sodium to order.
- Discuss the importance of avoiding fatigue in the activity.
- Explain the need to avoid constipation in the bowel movement.
- Explain penetingnya maintain proper fluid intake, amount allowed, restrictions such as caffeinated coffee, tea and alcohol.
- Discuss the symptoms of relapse or progression of complications reported to the doctor: headache, dizziness, fainting, nausea and vomiting.
- Talk about drugs: the name, dosage, time of administration, purpose and side effects or toxic effects.
- Explain the need to avoid drug-free, without a doctor's examination.
Hypertension Nursing Care Plan : Assessment, Diagnosis and Interventions
Nursing Management of Hypertension
Pathophysiology of Hypertension
Nanda Nursing Diagnosis for Hypertension