A nurse is caring for a client who has hypertension and is afraid to take medication

Hypertension is high blood pressure. The guidelines were updated by the American College of Cardiology in 2017, and a blood pressure of less than 120/80 mmHg is now considered normal. Anything above this is considered elevated, and stage 1 hypertension is diagnosed at 130/80 mmHg. 

Hypertension is the most common preventable risk factor for cardiovascular disease and places unnecessary stress on the arteries increasing the risk for stroke, heart attack, and atherosclerosis.

The Nursing Process  

Almost 50% of adults in the United States have hypertension. As a nurse, it is one of the most common comorbidities that require management and treatment.  

Patients cannot change risk factors such as family history or ethnicity, but can change lifestyle behaviors. Nurses can assist patients in recognizing risk factors such as smoking, poor diet choices, and stress and educating on ways to reduce their risks. Controlling blood pressure prevents complications and poor health outcomes.

Nursing Care Plans Related to Hypertension

Sedentary Lifestyle Care Plan

A sedentary lifestyle is a risk factor for developing hypertension. Inactivity naturally contributes to a higher heart rate causing the heart to work harder. Those who exercise regularly normally have a lower heart rate, decreasing stress on the heart and arteries.

Nursing Diagnosis: Sedentary Lifestyle

• Lack of interest in physical activity 
• Inability to participate due to health or physical limitations 
• Lack of knowledge related to the benefit of exercise on blood pressure 

As evidenced by: 

• Deconditioned appearance 
• Overweight/obese or very frail 
• Activity intolerance
• Tachycardia at rest 
• Abnormal heart rate or BP response to activity 

Expected Outcomes: 

• Patient will participate in physical activity within their capabilities at least 3 times per week 
• Patient will report an improvement in their ability to exercise as evidenced by no shortness of breath with minimal exertion and heart rate within safe limits 
• Patient will report a decrease in their blood pressure after 1 month of exercising

Sedentary Lifestyle Assessment

1. Build a rapport.
Exercise can be a difficult subject to broach with patients. Those with a sedentary lifestyle may balk at changing their behavior. It’s important for the nurse to first form a therapeutic relationship with the patient in order to understand and overcome resistance.

2. Assess their history and interests.
Instead of simply telling the patient to move more, get to know what types of exercise or activities they’ve done in the past. Patients are more likely to create a habit when they enjoy what they’re doing.

3. Ensure the patient is safe for activity.
The provider will advise if exercise is unsafe for the patient, but most patients will benefit from some kind of movement. If the patient becomes very short of breath, fatigued, or dizzy from a certain exercise, it should be avoided or decreased.

Sedentary Lifestyle Interventions

1. Help with coaching and goal setting.
Depending on the patient’s activity level, strength, age, and health status, meet them where they are in their journey. Walking to the mailbox daily may be a great goal for some, while others may be able to handle more strenuous activity. Start slow and create attainable goals the patient will be excited to reach.

2. Keep track of progress.
Instruct the patient to keep a log of activity completed, time spent exercising, and improvement in physiological responses or weight loss. Along with this, the patient should be monitoring their BP as directed by their provider, and they may notice a decrease in their blood pressure along with regular exercise.

3. Refer to PT, cardiac rehab, or local programs.
Patients who require a more supervised approach may need PT evaluation for safety modifications. Cardiac rehab teaches exercise training specific to heart health. Patients may also find support from their local gym or programs that offer free or low-cost classes.

4. Educate on the benefits and necessity of exercise.
Exercise not only benefits the heart and circulation, but it also improves muscle strength, coordination and boosts mood. Patients should not be scared into exercising for fear of illness, but providing the positive aspects that are relevant to them (more time with grandkids, for example) will help them see the benefits.

Deficient Knowledge Care Plan

A lack of understanding of hypertension prevents the patient from making appropriate lifestyle choices and places them at risk for worsening health conditions.

Nursing Diagnosis: Deficient Knowledge

• Lack of understanding of hypertension and its effect on the body 
• Lack of knowledge of risk factors 
• Poor health literacy 
• Lack of interest or motivation 

As evidenced by: 

• Worsening blood pressure 
• Inability to recall information provided 
• Incorrect follow-through with diet or lifestyle recommendations 
• Development of a chronic condition due to uncontrolled hypertension 

Expected Outcomes: 

• Patient will “teach-back” education provided to them regarding how to manage their blood pressure 
• Patient will state their personal risk factors for hypertension 
• Patient will explain the action of their blood pressure medications and the importance of not missing doses 

Deficient Knowledge Assessment

1. Assess the patient’s understanding of hypertension.
Many patients do not understand the role high blood pressure plays in contributing to other conditions and placing them at risk for stroke or heart disease. Assess the patient’s knowledge deficit to fill in the gaps.

2. Assess barriers to learning.
Assess for cognitive, cultural, or language barriers. Perception of the problem and motivation for change is also important. If the patient is not yet ready to learn or does not perceive a reason to, learning will not take place.

3. Assess support systems.
Patients who have difficulty remembering to take medications, monitor their BP, limit salt intake, or follow-up with appointments may need support from family members or friends in order to manage their condition.

Deficient Knowledge Interventions

1. Help the patient identify their personal risk factors.
Educate between modifiable (stress, diet, weight, tobacco use) vs. non-modifiable risk factors (age, family history, ethnicity). From there, patients can identify areas of improvement.

2. Teach the patient how to monitor blood pressure.
Educate the patient on what their blood pressure number should be, and what is considered high or low. Have the patient bring in their own BP monitor to calibrate it and observe them using it to ensure accuracy of readings.

3. Provide positive reinforcement.
Do not criticize a patient for mistakes or difficulty in implementing their treatment plan. Reinforce any attempt to learn more or even a slight improvement.

4. Review medications thoroughly.
Patients may not understand the purpose of their medications and may skip or miss doses. Review the action, side effects, and rationale of each blood pressure medication as well as the frequency and interactions with other drugs.

Excess Fluid Volume Care Plan

An increase in the circulating blood volume will cause the heart to pump harder, increasing blood pressure.

Nursing Diagnosis: Excess Fluid Volume

• Chronic conditions: heart failure, kidney disease 
• Excess fluid intake 
• Excess sodium intake 

As evidenced by: 

• Weight gain 
• Edema in extremities 
• Jugular vein distention 
• High blood pressure 
• Tachycardia 

Expected Outcomes: 

• Patient will maintain stable fluid volume as evidenced by balanced intake and output, weight at baseline, and no signs of edema 
• Patient will verbalize the importance of reducing sodium intake

Excess Fluid Volume Assessment

1. Assess for peripheral edema and weight gain.
Excess fluid causes swelling to the extremities, usually the lower legs and feet/ankles. The patient may also notice a sudden weight gain.

2. Assess lab values.
Monitor electrolyte imbalances that are caused by fluid overload such as increased sodium levels or decreased potassium. Monitor renal values that show evidence of fluid retention: BUN, creatinine, urine specific gravity.

3. Assess diet and fluid intake.
An unbalanced diet with either a large amount of sodium or water intake can contribute to fluid overload and increase blood pressure.

Excess Fluid Volume Interventions

1. Educate on fluid and/or sodium restrictions.
Patients with hypertension must be aware of their sodium and fluid intake. This is even more important when coupled with kidney disease or heart failure as this complicates the ability to regulate this balance.

2. Administer diuretics.
Diuretics may be required to rid the body of extra fluid if the patient is displaying symptoms such as shortness of breath or extremely elevated blood pressure.

3. Elevate extremities.
Edematous extremities should be elevated above the level of the heart in order to aid in circulation. Frequent positioning and use of pillows will also prevent skin breakdown.

4. Instruct on low-sodium options.
Patients are often unaware of the amount of sodium in foods. Frozen dinners, canned food, and most restaurant entrees are overloaded with sodium. Educate patients on their daily recommended sodium intake and to limit processed foods and opt for low-sodium options.

References and Sources

1. Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2018). Prevention and Control of Hypertension: JACC Health Promotion Series. Journal of the American College of Cardiology, 72(11), 1278–1293. https://doi.org/10.1016/j.jacc.2018.07.008
2. Centers for Disease Control and Prevention. (2021, September 27). Facts About Hypertension | cdc.gov. CDC. Retrieved February 2, 2022, from https://www.cdc.gov/bloodpressure/facts.htm
3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
4. Exercise: A drug-free approach to lowering high blood pressure. (2021, May 18). Mayo Clinic. Retrieved February 2, 2022, from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20045206
5. Hür, E., Özişik, M., Ural, C., Yildiz, G., Mağden, K., Köse, S. B., Köktürk, F., Büyükuysal, Ç., Yildirim, I., Süleymanlar, G., Ateş, K., & Duman, S. (2014). Hypervolemia for hypertension pathophysiology: a population-based study. BioMed research international, 2014, 895401. https://doi.org/10.1155/2014/895401