NCP FOR HYPERTENSION

by group 3
 CINDY PUSPITA SARI
(PO713201211011)

GROUP FATIMAH AZZAHRA

NAME
(PO713201211019)

MARLINA
(PO713201211025)

VIRA MURTAFIAH
(PO713201211025)
 A . DEFINITION
Hypertension is an abnormal
increase in systolic pressure of 140
mmHg or more and diastolic
pressure of 120 mmHg (Sharon, L.
Rogen, 1996). Hypertension is the
increase in systolic blood pressure
over 140 mmHg and diastolic blood
pressure over 90 mmHg (Luckman
Sorensen, 1996). Hypertension is a
condition where an increase in
systolic blood pressure 140 mmHg
or more and diastolic blood pressure
90 mmHg or more. (Barbara
Hearrison 1997)
 The loss of elastic tissue in the elderly and
B . ETIOLOGI arteriosclerosis Based on the etiology
Hypertension is divided into 2 groups,
namely: 1. Essential Hypertension (Primary)
The cause is unknown but many factors that
influence such as genetics, environment,
hyperactivity, sympathetic nervous system,
In general, hypertension has no specific cause. angiotensin system rennin, the effect of
Hypertension occurs in response to increased excretion of Na, obesity, smoking and stress.
cardiac output or increased peripheral
pressure.
But there are several factors that influence the
occurrence
●
of hypertension:
Genetics: Response to stress or disorder
●
neurology.
Obesity: associated with high insulin levels
●
which increase blood resulting in pressure.
Environmental Stress.
 C. PATHOPHYSIOLOGY

The pathophysiology of hypertension involves

impaired renal pressure natriuresis, a feedback
system in which high blood pressure induces
increased excretion of sodium and air by the kidneys
which leads to a decrease in blood pressure.

Pressure natriuresis can result from impaired kidney

function, inappropriate activation of hormones that
regulate salt and water excretion by the kidneys
(such as in the renin-angiotensin-aldosterone
system), or overactivation of the sympathetic
nervous system.

D. ASSESSMENT

Severe headache Fatigue

Nauseous Confusion
Blurred and disturbed vision It's hard to breathe
Buzzing ears A pounding sensation in the neck, ears, or chest
Irregular heartbeat There are blood spots in the urine
chest pain It's easy to feel anxious
 5. NURSING DIAGNOSE

1. Decrease high risk for cardiac output associated with

increased after load, vasoconstriction, myocardial 3. Impaired sense of comfort:
ischemia, ventricular hypertrophy. pain (headache) is associated
Objective: The Increased after load is not, there is no with cerebral vascular increased
vasoconstriction, myocardial ischemia did not occur. pressure
Criteria: acceptable, showing stable norms and cardiac Objective: Cerebral vascular
frequency in the normal range pressure did not increase is.
2. Activity intolerance is related to general weakness, Criteria: The patient revealed the
imbalance between supply and demand absence of a headache and
Objective: Meet the clients need looked comfortable.

Criteria: Clients can participate in activities at the desired/

required, and reported an increase in tolerance activity can
be measured.
F .NURSING CARE PLAN (NCP)
DX.1 Decrease high risk for cardiac output associated
with increased after load, vasoconstriction,
myocardial ischemia, ventricular hypertrophy.
1) Monitor the blood pressure
● Rationale (ratio of pressure Gives a more complete
picture about the involvement / field of vascular
problems
2) Monitor the color, moisture, temperature, and
capillary refill time
● Rational (the pale, cool, moist skin and slow
capillary refill time Reflects as decreased cardiac
output).
3) The presence of fever, general / specific.
● Rationale: (may indicate heart failure, kidney
damage or vascular)
D4) Provide a comfortable, quiet
environment, reduce the
activity/fray circle, and limit the
number of visitors and length of
stay.
● Rationale: (helping to reduce
stimulation, increasing relaxation).
sympathetic
5) Encourage relaxation techniques, your imagination
and distraction
● Rationale: (Can lower the stimulus that causes
stress; create a calming effect, thereby decreasing
blood pressure).
6) Collaboration with doctors in hypertension
therapy,anti awards, diuretics.
●Rationale: (lowers blood pressure).
Dx. 2. Activity intolerance is related to general weakness,
imbalance between supply an and 02.
1) Assess the patient's to parameters: pulse frequer of breaks, increased blood pressure readings,dyspnea,or chest pain,severe
fatigue and weakness, sweating,or fainting.
● Rationale: (Parameter shows the stress of the patient's physiological responses, activities and indicators of the degree of
influence of the excess / heart).
2) Assess readiness to increase activity e.g. reduction of weakness/ fatigue, stable BP, heart rate, increased attention to activities
and self-care.
●Rational (resting physiological stability necessary to promote individual activity level).
3) Push to promote the activities / tolerance of self-care.
● Rationale: (Consumption of myokardia oxygen during various activities can increase the amount of available of oxygen
Progress to Prevent gradual increase in the activity of a sudden on the work of the heart.).

●
4) Provide assistance as needed and encourage the use of bath seats, brushing my teeth/ hair with sitting and so on.
Rationale: (energy saving techniques to lower energy use and thus help balance supply and demand of oxygen).
5) Encourage the patient to choose the period of participation in the activity.
●Rationale: (As the schedule increases the tolerance to withstand the progress of activities and weakness).
Dx. 3. Impaired sense of comfort: pain (headache) is associated with cerebral vascular increased pressure

1) Maintain bed rest during the acute phase.

● Rationale: (Minimize stimulation / increase of relaxation).
2).Give the non-pharmacological measures to relieve headaches, for example: a cold compress on the
forehead, neck and back massage and relaxation techniques.
● Rationale: (Actions that reduce the pressure with a cerebral vascular inhibit /block sympathetic
Aplikasi Dalam Penerup response, effective in relieving pain head and its complications).
3) Help Patients in ambulation as needed.
● Rationale: (Minimize the use of oxygen and excessive activity that aggravate the condition of the client)
4) Teach relaxation techniques and distraction
● Rationale: minimization pain
5) Collaboration with physicians in the delivery of analgesics, anti-anxiety, diazepam etc.
● Rationale: Analgesics reduce pain and Decrease sympathetic neuronal excitability.
 G. IMPLEMENTATION

In nursing implementation the nurses apply the

nursing care plan that have been planned to meet
the clients need. During the nursing
implementation phase is done, the nurses evaluate
the responses of the clients toward the nursing
care given. And what have done by the nurses
should be noted as nursing documentation off all
nursing care taken and its result.
 H. EVALUATION
In the evaluation phase the student would evaluate progressing toward attainment
of goals and outcomes based on the nursing diagnosis that have been formulated
before implementing the nursing care plan. During the evaluation phase takes
place, the students apply critical thinking to analyze the client’s condition,
reassessment data and determine if a client’s expected outcomes have been met,
partially met or not met by the time frames established. If outcomes are not met or
only partially met, the nursing care plan should be revised. Reassessment should
be done accurately by observing and discussing with the client as individually to
find a more accurate date to overcome the client’s problem as soon as possible.
Risk of cardiac decline does not occur, activity intolerance can be resolved , the
head pain is reduced and even disappears.
THANK YOU
muach