Risk for Decrease Cardiac Output related to Hypertensive Heart Disease
Nursing Diagnosis : Risk for Decrease Cardiac Output related to increased afterload, vasoconstriction, myocardial ischemia, ventricular hypertrophy.
Goal : Want to participate in activities that lower blood pressure / cardiac workload.
Outcomes :
- Blood pressure within an acceptable range of individuals.
- Rhythm and heart rate stabilized in the normal range.
Interventions :
- Monitor vital signs.
- Note the presence, quality central and peripheral pulses.
- Heart tone auscultation, and breath sounds.
- Observe skin color, moisture, temperature, and capillary refill time.
- Note the general edema / certain.
- Provide a quiet and comfortable environment, reduce the activity / environment commotion, limit the number of visitors and length of stay.
- Maintain restrictions on activities such as rest in bed / chair ; schedule uninterrupted rest period ; help patients perform self-care as needed.
- Perform actions as comfortable as back and neck massage, tilt the head of the bed.
- Encourage relaxation techniques, imagination guide, transfer activity.
- Monitor response to medication to control blood pressure.
Rationale :
- Comparison of blood pressure gives a more complete picture of the involvement / field of vascular problems.
- Throbbing carotid, jugular, radial and femolaris probably observed / palpable. Pulse in the limbs may decrease, reflecting the effect of vasoconstriction (increased SVR) and venous congestion.
- S4 is commonly heard in patients with severe hypertension due to an increase in atrium volume / pressure. S3 shows the development of ventricular hypertrophy and malfunction, the presence of crackles, wheezes may indicate pulmonary congestion secondary to the onset or chronic renal failure.
- The presence of pale, cool, moist skin and slow capillary refill time may be related to vasoconstriction or reflect decompensation / decrease in cardiac output.
- May indicate heart failure, kidney or vascular damage.
- Helps to reduce sympathetic stimulation ; increase relaxation .
- Lowering stress and tension which affects blood pressure and hypertensive disease course.
- Reduce discomfort and can reduce sympathetic stimulation.
- Can reduce stressful stimuli, making a calming effect, thus reducing BP.
- Response to drug therapy "stepeed" (consisting of diuretics, sympathetic inhibitors and vasodilators) depends on the individual and synergistic effects of the drug, because of these side effects, it is important to use the drug in the fewest number and lowest doses.
Activity Intolerance related to Hypertensive Heart Disease
Nursing Diagnosis for Hypertensive Heart Disease : Activity Intolerance related to general weakness, imbalance between supply and demand of oxygen.
Goal : The client is able to perform the activity is tolerated.
Outcomes :
- Participate in activities desired / required.
- Reported an increase in tolerance activity can be measured.
- Showed a decrease in physiological signs of intolerance.
Interventions :
- Assess the client's response to the activity, attention pulse frequency more than 20 times per minute above the break frequency ; significant increase in BP during / after activity, dyspnea, chest pain ; excessive fatigue and weakness ; diaphoresis ; dizziness or fainting.
- Instructed the patient on energy saving techniques, eg ; using the bath seat, sit while combing hair or brushing teeth, doing activities slowly.
- Suggest to do the activity / self- phased treatment if tolerated, provide assistance as needed.
- Mention parameters help in assessing the physiological response to stress and activity when there is an indicator of excess work -related activity levels.
- Energy saving techniques also help reduce the presence of a balance between energy supply and oxygen demand.
- Activity progress gradually to prevent sudden increase in cardiac work, provide only limited assistance will need to encourage independence in performing activities.
Acute Pain related to Hypertensive Heart Disease
Nursing Diagnosis : Acute Pain : headache related to an increase in cerebral vascular pressure.
Goal : Pain is reduced
Outcomes :
- Client reported pain / discomfort disappeared / controlled.
Interventions :
- Maintaining bed rest during the acute phase.
- Give non-pharmacological measures to relieve headaches, for example; cold compress on the forehead, back and neck massage, a quiet, dim room light, relaxation techniques (imagination, distraction ) and leisure time activities.
- Eliminate / minimize vasoconstriction activity that can improve headaches, for example; straining during defecation, coughing and bending length.
- Assist patients in ambulation as needed.
- Give liquids, soft foods, regular oral care in case of nose bleeds or compress the nose has been done to stop the bleeding.
- Collaboration of drugs ; analgesic, anti- anxiety.
Rationale :
- Minimizing stimulation / increase relaxation.
- Actions that decreases cerebral vascular pressure and the slow / block the sympathetic response is effective in relieving headaches and complications.
- Activities that increase vasoconstriction cause headaches in an increase in cerebral vascular pressure.
- Dizziness and blurred vision often associated with headache, patients may also experience episodes of postural hypotension.
- Increase the general comfort, compress the nose may interfere with the ingestion or require breathing with the mouth, causing stagnation and drying oral secretions of mucous membranes.
- Lose / control pain and decrease the sympathetic nervous system stimulation.
- Can reduce tension and discomfort aggravated by stress.
Source : http://list-nanda-nursing-diagnosis.blogspot.com/2014/10/acute-pain-related-to-hypertensive.html