The pathophysiology of HTN is quite complex. Blood pressure is essentially the amount of blood the heart pumps, as well as the resistance to blood flow in the actual arteries. If there is more blood and/or smaller arteries, naturally the pressure will be higher. When someone has higher pressure for an extended period of time, it begins to cause problems. HTN is called the silent killer because it can begin to cause problems without any symptoms. Some don’t realize this is happening until end-organ damage occurs, like kidney failure. Many times it has been happening for years undetected. The way it is detected is with a simple blood pressure screening, hopefully done at an annual physical. However, if someone does not regularly visit a physician and get checkups, then this may go undetected for a long period of time.
There is primary and secondary HTN. Primary HTN is caused by a combination of genetic and environmental factors. Secondary HTN comes from an identifiable cause (for example, sleep apnea or hyperthyroidism).
Keep in mind, higher blood pressure for a short period of time is normal. Your blood pressure will naturally increase during times of stress or pain, but the HTN we are discussing is chronically elevated even during times of relaxation.
Primary HTN can be caused by many different factors. Certain ethnicities have a higher incidence of HTN (African Americans). The older a person is, the higher the likelihood of HTN. Family history, body weight, sedentary lifestyle, not enough of certain vitamins (like Vitamin D), not enough potassium, too much sodium, or excessive stress can all be a causative factor of primary HTN.
Secondary HTN arises from various conditions like kidney/adrenal/thyroid issues, congenital blood vessel defects, sleep apnea, various meds (decongestants are a big one!), street drugs (cocaine, methamphetamines), tobacco and excessive alcohol use, and more, can all cause secondary HTN.
Control blood pressure down to a safe level appropriately. Please note, if a patient has had chronically elevated blood pressure for years or is in a hypertensive crisis , they may need their blood pressure lowered slowly, as they can have symptoms of hypotension at even normal blood pressure levels. Make sure you’re following orders very specifically and not decreasing the blood pressure too quickly in these instances.
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Okay guys, I’m excited to work through an example, nursing care plan for you, for a patient with hypertension. Now here’s the thing, guys. The first step is always to gather all of your information, but in this case, we’re using a hypothetical patient. So let’s just think through this hypothetical patient with hypertension and think through some of the relevant subjective and objective data that we might see for this patient. So the biggest thing, the first thing that we’re going to see, they’re hypertensive. So their blood pressure is going to be up, right? So let’s just go hypothetical. Let’s say you’ve got a patient with a blood pressure of 160, over 88. Okay? So that’s my blood pressure. So objectively, I know that their blood pressure is high.
But here’s the reality. With your hypertensive patients, a lot of times they’re asymptomatic unless they’ve developed complications. So one of the biggest things we might see in terms of relevant symptoms in a hypertensive patient is signs of complications. The major, major complications we could see, is something like a hypertensive crisis or a hypertensive emergency. Uh, we could possibly see a stroke, especially those hemorrhagic strokes where the vessels are under so much pressure that they bleed. Or we could actually see them start to develop heart failure. So really any signs and symptoms of these things could indicate problems with hypertension. So examples, hypertensive crisis, they might report a headache or some vision changes, right? They might be dizzy. You might actually have straight up signs and symptoms of a stroke, right? What about heart failure? We might actually see some edema if they end up with that volume overload, right?
You might see some shortness of breath that they might report, right? So remember subjective is what the patient reports, objective is what you observe or what you have assessed. So it’s actual, measurable data. So again, with an actual patient, when you’re in this step, step one of gathering all data, you’re literally going to have all data. So you’re also going to have a heart rate and you’re also going to have bowel sounds and you’re also going to have urine output. You’re going to have all of these things as well. And so our goal with step one is literally just to kind of gather all of the information. And in step two we’re going to analyze, we’re actually going to pick out the important information. So in this case, like I said, because it’s a hypothetical patient, we’ve kind of already picked out the important information for you and we’re just going to ignore the rest of it.
So we get to step two, we want to analyze all the information we collected, and decide what is a problem, what could be improved, what do we need to do for this patient? So what’s a huge problem? Uh, this patient had a blood pressure of 160 over 88. That is definitely a problem. This elevated blood pressure is going to cause a lot of problems for them. Um, the other thing that we didn’t talk about is their lifestyle. So things that could be improved, maybe they’ve got diet and lifestyle changes that could be improved, could be changed, maybe they’re a smoker. So those are all things that could be improved, right? We didn’t talk about that in the first slide. That’s some data we could’ve collected as well. Um, and then also one of the big things here is remember this risk that they have for all these complications.
Because again, remember hypertensive patients tend to be relatively asymptomatic until they develop complications. Until they develop issues with perfusion to their organs. So big problem is this elevated blood pressure and risk for complications. And then of course we could consider possibly improving some of their lifestyle diet changes. And possibly, especially let’s say they’re a smoker, that’s a big thing. So what’s the biggest priority here? So if I wanted to just pick one priority for this patient to say, what do I need to make sure that I do? I mean, it’s clearly going to be the blood pressure, right? So I’m going to say blood pressure control is my priority for this hypertensive patient, right? So we get to the next step and the next step is – ask your how questions. So how did I know it was a problem? Well, this is where I start making links between my data.
So I say this data tells me this is a problem and this is how I know. And then I’m going to start looking at how I address it and how I know it gets better. That’s my implement and evaluate phase. So I’m gonna Plan my implementation, plan, my interventions, and then figure out how to evaluate them. So one of the big things, well I’ve got high blood pressure, right? So I’m going to assess that blood pressure and monitor it, right? Um, I might give some meds, some BP meds, right? Cause I really want to deal with that blood pressure, but I’ve got other problems too. I’ve got this risk for all these complications as well, right? So I’m probably gonna do like a heart and lung assessment to make sure that I’m not causing any heart failure issues. I’m probably going to monitor other things like their fluid status.
Maybe check for edema, check for pulses. So all these things that could possibly tell me that there’s complications. And then of course, if we’re talking about these diet and lifestyle changes, I’m going to educate, educate, educate. Right? So then this is when we come and we look at all these things and you go, well, how will I know if those problems that I came up with are any better? Well, number one, my blood pressure is going to be within range. And I say within range because some patients, we don’t necessarily want them to be normal, right? We don’t want to bring them from 160, over 88 all the way down to 118 over 68. Right? Um, so maybe the have a specific range like, hey, let’s get their systolic less than 140, so get their blood pressure within range.
Maybe we would say they didn’t develop any complications, right? No signs and symptoms of complications. That would be a way that I know this is working. Right? Um, and then education, anytime we educate patients, we want them to verbalize or demonstrate, verbalize or demonstrate. So either they’re going to say, this is what I’m gonna do, this is what I’m going to change. Or they’re going to physically show you that they know how to do it. So these are just ways to think through like what was going on, what would I do about it and how would I know if it’s working.
So again, step four is translate. So again, we translate this into the terms that we need to use so that we can concisely and simply communicate the issues. Here at NRSNG we prefer to use nursing concepts because we think they really give you the big picture priorities instead of forcing you to drill down to the super specific issue.
Now of course, whatever you are required to use, make sure that you’re translating it into those terms. So let’s think about this patient we just talked about, this hypothetical patient, we said our number one issue was blood pressure control. So what is the high level nursing concept for that? Well, perfusion, right? We had to make sure their perfusion is adequate and appropriate. Um, and we also said they have a really high risk for all these complications that we need to make sure we’re monitoring closely for. You know, the sooner we catch it sooner we can treat it. And so if I want to translate that concern that I have into a concept, I probably am going to say something like safety.
So safety, I want to protect them from complications, right? I want to decrease that risk. Okay, so it’s all about this risk. What about the third one we talked about their diet and lifestyle changes, right? So maybe we just say our third priority for this patient is patient education. There we go. So that’s step four, translate this into the high level terms that you need to use and then transcribe.
So this is the part where you, number one, put it on paper, get it written down, get it concisely communicated. But also the best part about this step is the ability to actually start linking your data with your priorities, with your interventions, your rationales for those interventions and your expected outcomes. So in other words, what’s wrong? How do I know? What am I going to do about it? Why and what should I expect to see?
So let’s look at these. So we said perfusion is our number one issue. Safety’s our number two and patient education is our number three. Now again, remember we’re looking at a hypothetical patient and we’re assuming that their isolated problem is hypertension. So really it might be that you have this patient that has hypertension but also has all these other issues. And so you are gonna want to prioritize your problems based on the holistic big picture of the patient. But in this case, we’re just looking at the hypertension specifically. So perfusion, how did I know there was a perfusion issue? Well, my blood pressure was super high, right? And maybe the patient has chest pain, especially if their blood pressure’s really high. If their heart’s beating really fast, if they have signs of complications, you’re going to see some chest pain probably with that hypertensive patient. So what am I going to do about it?
Well, I’m going to assess and monitor their blood pressure and I’m probably going to give them blood pressure meds depending on what’s ordered. Right? Um, remember anytime you put an intervention about medications, things like that, make sure you write as ordered as prescribed. Because obviously we don’t prescribe things, right? So why am I going to do this? Well, I need to monitor blood pressure so that I can know where I’m at. I need to be able to track whether or not my meds and my interventions are working and obviously this is going to help me actually get control of my blood pressure. So my expected outcome, again is just that that blood pressure would be in target range, whatever that range is for that patient. So let’s look at safety again. Remember we were talking about decreasing the risk for complications here, right? Preventing them from developing more problems.
So what was my subjective and objective data that would tell me maybe that they’re developing problems, maybe signs and symptoms of a stroke. Signs and symptoms of heart failure. A maybe a severe headache could tell me that they have some sort of hypertensive crisis, right? So my interventions at this point, a neuro assessment to make sure that I’m not developing signs of a stroke, heart and lung assessments to make sure I’m not developing that pulmonary edema or any murmurs, any issues with my heart. And of course, keeping a close eye on their fluid status, make sure they don’t get volume overloaded. Um, and of course monitoring their blood pressure is going to happen throughout, right? It’s always going to happen. So why do I want to do this? Well, early detection means early treatment. The sooner I noticed that there’s a problem, the sooner I can treat it and the less likely the patient is to experience bad things because of it.
So again, our expected outcome is that they develop no complications or that if they do have signs of complications that those signs are improved. Makes Sense. So really, I’m basically saying I didn’t develop it or if I’d had them, it’s better. So let’s look at patient education again. Diet choices, activity level, and smoking. Those are the main things that are going to be huge impactors of our blood pressure. So what are my interventions? Educate, educate, educate, educate, diet and lifestyle changes. You know, avoiding too much sodium. Maybe they need to be on a sodium or fluid restriction. And smoking cessation. Huge. So why? Well, we know that diet and lifestyle changes can improve control of blood pressure overall. And we know that smoking causes vasoconstriction, which causes increased blood pressure. So if we can help decrease their smoking, we can help decrease their blood pressure.
So again, expected outcomes. Anytime you have patient education, you’re talking about verbalizing or demonstrating. So maybe the patient verbalizes three changes they’re gonna make or maybe the patient quit smoking. And remember your goal should always be measurable. So maybe say patient quit smoking within two months, right? So it’s more of a long term goal, but that’s okay. So this is just a big picture. Again, hypothetical patient with an isolated problem of hypertension, how we pick out the data, how we decide what to do about it, and how we decide whether or not that thing would work.
So again, remember the five step process. You’re going to collect all information. This is your assessment data. And again, remember you’re going to have a lot of information. So the next step is analyze it. What’s important, what’s relevant, what tells me there’s a problem and what are my biggest priorities I need to focus on?
Then you’re gonna ask your how questions, how did I know it was a problem? How would I affect it or fix it? And how would I know whether or not that worked? And then translate it. Get your concise terms, whether it’s concepts needed, a nursing diagnoses, whatever you need. Put it into a broad picture, big picture terms, and then transcribe. Get it on paper. Use whatever form you prefer. All right guys, I hope that was helpful example for a hypertension care plan. Make sure you check out all the rest of the examples that we have in this course. Now go out and be your best self today. And as always, happy nursing.