Risk for decreased cardiacoutput related to increasedvascular vasoconstriction
Subjective Data: “I do not
really feel well, right now. Myblood pressure is always highand 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 easilyseen and bounding uponpalpation-Verbalized light headednesson sudden change of position-Easy fatigability andoccasional dyspnicoccurrences upon exertion-Blood pressure ranging from140/90 to 150/100 mmHg, BPas of 6:00 A.M. 04/17/12 is150/90 mmHg-Pulse rate of 110 beats perOutcome Identification:
The patient willparticipate inactivities that reducecardiac workload by04/18/12.
The patient willmaintain bloodpressure withinacceptable range by04/19/12.
The patient willdemonstrate stablecardiac rhythm and
rate within patient’s
normal range by04/19/12.
Monitor bloodpressure periodically.Measure both armsthree times; 3-5 minsapart while patient isat rest for initialevaluation.2.
Note presence of,quality of central andperipheral pulses.3.
Auscultate heart tonesand breath sounds4.
Observe skin color,moisture, temperatureand capillary refilltime.5.
Note independent orgeneral edema6.
Provide a calmenvironment;minimizing noise;limiting visitors andlength of stay.7.
Maintain activityrestrictions (bed rest)and assist patient withself- care activities.8.
Provide comfortmeasures, i.e.elevation of head9.
Encourage relaxationtechniques like guidedimagery anddistractions10.
Monitor response to
Nursing Care Plan forHypertension
Bounding carotid, jugular, radial,femoral pulses may beobserved/ palpated.Pulses in the leg maybe diminished,implicating effects of vasoconstriction andvenous congestion.2.
S3 and S4 heartsounds may indicateatrial and venoushypertrophy andimpaired functioning.3.
Presence of adventitious breathsounds may indicatepulmonary congestionsecondary todeveloping heartfailure.4.
Presence of pallor;cool and moist skinand delayed capillaryrefill may be due toperipheralvasoconstriction ordecreased cardiacoutput.5.
It may indicate heartfailure, vascular orrenal impairment.6.
It reduces physicalstress and stimuli thatPlease refer to the PatientOutcomes tab