Nursing Diagnosis
Risk for decreased cardiac
output related to increased
vascular vasoconstriction
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.
Patient Outcomes Nursing Interventions
Outcome Identification:
 The patient will Independent:
participate in
activities that reduce 1. Monitor blood
cardiac workload by pressure periodically.
04/18/12. Measure both arms
 The patient will three times; 3-5 mins
maintain blood apart while patient is
pressure within at rest for initial
acceptable range by evaluation.
04/19/12. 2. Note presence of,
 The patient will quality of central and
demonstrate stable peripheral pulses.
cardiac rhythm and 3. Auscultate heart tones
rate within patient’s and breath sounds
normal range by 4. Observe skin color,
04/19/12. 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
Rationale Evaluation
Please refer to the Patient
Nursing Care Plan for Outcomes tab
Hypertension
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
04/17/12 medications to control affect the blood
blood pressure pressure.
-Capillary refill of 2-3 8. Decreases discomfort
seconds Depedent and may reduce
sympathetic
11. Administer stimulation
medications like 9. It helps reduce
diuretics, alpha and stressful stimuli,
beta antagonists, thereby decreases
calcium channel blood pressure.
blockers, and 10. Response to drug is
vasodilators. dependent on both the
individual and the
Collaborative synergistic effect of
the drug. It is also
12. Instruct and important to check for
implement to patient any untoward signs
dietary restrictions in and symptoms of the
sodium, fat and medications.
cholesterol 11. 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.
12. This restrictions help
manage fluid
retention and decrease
myocardial workload.