Legend

Risk/Predisposing Factors
Risk Factors
•Age (47 yrs old)
•Stress
Pathophysiology
•Physical Inactivity (8 hours of work)

Signs and Symptoms

Nursing diagnosis,
goals, & interventions Defects in renal sodium homeostasis Functional, vasoconstriction Defects in vascular smooth muscle growth and structure

Medications
Inadequate sodium excretion
Diagnostic/Laboratory
Tests Sodium and Water retention

Increased Plasma and ECF volume Increased Vascular activity Increased Vascular Wall Thickness

Increased Cardiac
Output Increased Total Peripheral
Resistance
NURSING DIAGNOSIS
Nursing Diagnosis: Acute pain r/t increased BP as
Primary Hypertension evidenced by discomfort
Activity intolerance r/t
weakness as evidenced by
reports of dizziness Dizziness Discomfort: Headache and Nape Goals: The patient will participate in
and weakness of the body pain activities that reduce the pain.

Weakness of the body Acetaminophen, Naproxen

Goals: The patient will
participate in necessary sodium Nursing Interventions:
desired activities and the
Vestibular suppressant Laboratory/Diagnostic Tests: Acknowledge and accept
patient will use identified
drugs (Diazepam, • Urinalysis the client’s pain.
techniques to enhance
meclizine) Hypertensive Crisis • Blood Chemistry •Obtain client’s/SO’s
activity tolerance.
• 12-lead ECG assessment of pain to
• Creatinine Clearance include location,
Rapid increased vascular • Renin Levels characteristics, onset,
Nursing Interventions: resistance • 24-hour urine protein duration, frequency, quality,
Establish guidelines and goals of activity intensity.
with the patient •Provide comfort measures
Endothelial Damage Spontaneous natriuresis (e.g., touch, repositioning,
•Ascertain ability to move about and
degree of assistance necessary or use of use of heat or cold packs,
equipment to determine current status and nurse’s presence), quiet
Intravascular volume depletion
needs associated with participation in environment, and calm
needed activities. Increased Endothelial activities to promote
permeability nonpharmacological pain
•Increase exercise/activity levels gradually; Increased in vasoconstrictors
teach methods to conserve energy management.
•Plan care to carefully balance rest periods Dec. in vasodilators, nitric •Instruct in and encourage
with activities to reduce fatigue oxide, prostacyclin use of relaxation
•Provide positive atmosphere, while Further increase in blood techniques, such as focused
acknowledging the difficulty of the situation pressure breathing, imaging,
Platelet and fibrin intimal CDs/tapes (e.g., “white”
for the client. H proliferation
•Encourage client to maintain positive noise, music, instructional)
attitude; suggest use of relaxation to distract attention and
techniques, such as visualization or guided Severe blood pressure reduce tension.
imagery, as appropriate, to enhance sense elevation •Encourage diversional
of well-being. activities (e.g., TV/radio,
•Encourage participation in recreation, socialization with others).
social activities, and hobbies appropriate Elevated BP 220/150 mm Syncope •Establish collaborative
for situation. Hg approach for pain
management based on
Nursing Diagnosis: Altered Tissue client’s understanding about
Nursing Diagnosis: Decreased cardiac Perfusion r/t decrease in peripheral blood and acceptance of available
Beta blockers
output r/t altered contractility evidenced circulation AEB syncope and elevated BP. treatment options
(Metoprolol, Propranolol)
by elevated BP •Administer analgesics, as
Goals: The patient will show effective indicated
ACE inhibitors
Goals: The patient will maintain BP tissue perfusion by having a stable blood
(captopril, ramipril)
within individually acceptable range. pressure.
Angiotensin 2 receptor
blockers Nursing Interventions:
(Losartan, Valsartan) Nursing Interventions:
Check the blood pressure in the
morning before eating or taking any • Monitor changes suddenly or continuous
medication and in the evening mental disorders (anxiety, confusion,
•Keep client on bed rest in a position of lethargy).
comfort • Observation of pallor, cyanosis, striped, skin
•Administer oxygen via mask or cold / humid, record peripheral pulse
ventilator if needed strength.
•Provide a peaceful environment to • Assess Homan's sign (pain in the calf with
promote adequate rest dorsiflexion), erythema, edema.
•Encourage the patient to perform self- • Encourage leg exercises active / passive.
care activities • Monitor breathing.
•Collaborate with nutritionist for diet • Assess GI function, note; anorexia,
restrictions decreased bowel sounds, nausea /
3C3 – Subgroup 1 •Educate the patient about the s/s and vomiting, abdominal distension,
1. Florentino, Robelle report any changes constipation.
2. Gomez, Khallae May •Give information about positive signs of • Monitor input and changes in urine output.
3. Sia, Angel improvement, such as normal BP • Prevent injury (nonskid socks, doesn’t walk
4. Tabora, Kurt Raidel •Encourage the patient to engage in without assistance, bed in the lowest locked
5. Urayanza, Nikka Ira regular exercise position, necessary items within reach, call
6. Valdecantos, Enkeli S. bell within reach, side rails up x3)