Hypertension Severe: Nursing Care Plan

Hypertension is the term used to describe high blood pressure. Hypertension is repeatedly elevated blood pressure exceeding 140 over 90 mmHg. It is categorized as primary or essential (approximately 90% of all cases) or secondary, which occurs as a result of an identifiable, sometimes correctable pathological condition, such as renal disease or primary aldosteronism.



  • Normal blood pressure (BP)—less than 120/80 mm Hg
  • Prehypertension—120/80 to 139/89 mm Hg
  • Hypertension—greater than 140/90 mm Hg

Care Setting

Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of complications or compromise may require inpatient care, especially when target organ disease (TOD) is present. The majority of interventions included here can be used in either setting.

Collect Client’s Assessment Data: Follow table. 


• Sedentary lifestyle, which is a major risk factor for
• Weakness, fatigue
• Shortness of breath

• Elevated heart rate
• Change in heart rhythm
• Tachypnea
• Dyspnea with exertion

• History of elevated BP over time
• Presence of TOD, such as atherosclerotic, valvular, or coronary
artery heart disease, including myocardial infarction
(MI), angina, heart failure (HF), and cerebrovascular disease
• Episodes of palpitations, diaphoresis

• Pulses: Bounding carotid, jugular, radial pulsations
• Pulse disparities, particularly femoral delay as compared with
radial or brachial pulsation and absence of or diminished
popliteal, posterior tibial, pedal pulses
• Apical pulse: Point of maximal impulse (PMI) possibly
displaced or forceful
• Heart rate and rhythm: Tachycardia, various dysrhythmias
• Heart sounds: Accentuated S2 at base; S3 in early HF; S4,
which reflects rigid left ventricle and left ventricular hypertrophy;
murmurs of valvular stenosis; vascular bruits audible
over carotid, femoral, or epigastrium
• Jugular vein distension (JVD)
• Extremities: Discoloration of skin, cool temperature indicating
peripheral vasoconstriction and slow or delayed capillary refill
indicating vasoconstriction
• Skin: Pallor, cyanosis, and diaphoresis, suggesting pulmonary
congestion and hypoxemia, or flushing, suggesting pheochromocytoma

• History of personality changes, anxiety, depression, euphoria,
or chronic anger that may indicate cerebral impairment
• Multiple stress factors, such as relationship, financial, or
job-related concerns

• Mood swings, restlessness, irritability
• Narrowed focus

• Past or present renal insult, such as kidney infection,
renovascular obstruction, or past history of kidney disease

• May have decreased urinary output, if kidney failure is present,
or increased output, if taking diuretics

• Food preferences that are high-calorie, high-salt, high-fat, and
high-cholesterol, such as fried foods, cheese, eggs, or licorice
• Low dietary intake of potassium, calcium, and magnesium
• Nausea, vomiting
• Recent weight changes
• Current or history of diuretic use

• Normal weight or obesity
• Presence of edema
• Venous congestion, JVD
• Glycosuria—almost 10% of hypertensive clients are
diabetic, reflecting renal TOD

• History of numbness or weakness on one side of the body;
TIA or stroke
• Fainting spells or dizziness
Throbbing, suboccipital headaches, usually present on awakening
and disappearing spontaneously after several hours
• Visual disturbances, such as diplopia and blurred vision
• Episodes of epistaxis

• Mental status: Changes in alertness, orientation, speech pattern
and content, affect, thought process, or memory
• Motor responses: Decreased strength, hand grip, and deep
tendon reflexes
• Optic retinal changes: From mild sclerosis and arterial
narrowing to marked retinal and sclerotic changes with edema
or papilledema, exudates, hemorrhages, and arterial nicking,
although dependent on severity and duration of hypertension
and resulting TOD

• Severe, throbbing occipital headaches located in suboccipital
region, present on awakening, and disappearing spontaneously
after several hours
• Stiffness of neck, dizziness, and blurred vision
• Abdominal pain or masses, suggesting pheochromocytoma

• Relu-ctance to move head, rubbing head, avoidance of bright
lights and noise, wrinkled brow, clenched fists; grimacing and
guarding behaviors

• Dyspnea associated with activity or exertion
• Tachypnea, orthopnea, paroxysmal nocturnal dyspnea
• Cough with or without sputum production
• Smoking history, which is a major risk factor

• Respiratory distress or use of accessory muscles
• Adventitious breath sounds, such as crackles or wheezes
• Pallor or cyanosis generally associated with advanced
cardiopulmonary effects of sustained or severe hypertension

• Transient episodes of numbness, unilateral paresthesias
• Light-headedness with position changes

• Impaired coordination or gait

• Postmenopausal, which is a major risk factor
• Erectile dysfunction (ED), which may be associated with
hypertension or antihypertensive medications

• Familial risk factors, including hypertension, atherosclerosis,
heart disease, diabetes mellitus, and cerebrovascular or
kidney disease
• Ethnic or racial risk factors, such as increased prevalence in
African American and Southeast Asian populations
• Use of birth control pills or other hormone replacement
• Drug and alcohol use
• Use of herbal supplements to manage BP, such as garlic,
hawthorn, black cohash, celery seed, coleus, and evening

• May require assistance with self-monitoring of BP as well as
periodic evaluation of and alterations in medication therapy

Nursing Priorities

  • Maintain or enhance cardiovascular functioning.
  • Prevent complications.
  • Provide information about disease process, prognosis,
  • and treatment regimen.
  • Support active client control of condition.

Diagnostic Studies follow table.


Hypertension: Diagnostic Studies


• Hemoglobin/hematocrit: Assesses relationship of red blood
cells (RBCs) to fluid volume or viscosity and may indicate
risk factors, such as anemia or hypercoagulability.

Hematocrit rises when the number of RBCs increases or when
the plasma volume is reduced, as in dehydration.
• Platelets: Platelets have an essential function in coagulation,
hemostasis, and thrombus formation. An elevated platelet
count can cause increased clotting.
May show abnormalities leading to clotting and increased risk
for heart attack or stroke, particularly in persons with diabetes.
• Blood urea nitrogen (BUN) and creatinine (Cr): BUN measures
the amount of urea nitrogen in the blood. Cr measures
the amount of creatinine in blood or urine.
Provides information about renal perfusion and function and can
reveal cause if hypertension is related to kidney dysfunction.
Glucose: Measures the amount of glucose in the blood right at
the time of sample collection.
Hyperglycemia may result from elevated catecholamine levels,
which increases BP, and use of thiazide diuretics. Also,
diabetes mellitus can be associated with hypertension.
• Serum potassium: Potassium is an electrolyte that helps
regulate the amount of fluid in the body, stimulate muscle contraction,
and maintain a stable acid-base balance.
Hypokalemia may indicate the presence of primary aldosteronism
as a possible cause of hypertension or it may be a side
effect of diuretic therapy.
Thyroid studies: Blood test and scan to evaluate thyroid function;
most commonly used laboratory test is the measurement
of thyroid-stimulating hormone (TSH).
Hypertension is present in approximately 3% of clients with
hypothyroidism and 20% to 30% in those with thyrotoxicosis
(Hix & Vidt, 2004).
Serum/urine aldosterone level: May be done to assess for
primary aldosteronism as cause of hypertension.
Elevated in primary aldosteronism.
• Urinalysis: Screening tool to determine effectiveness of kidney
function and to monitor fluid imbalances and treatment.
Presence of blood, protein, or white blood cells (WBCs) suggests
renal dysfunction; glucose suggests presence of diabetes.
Creatinine clearance: Determines extent of nephron damage
in known kidney disease.
Reduced in hypertensive patient with renal damage.
Uric acid: Measures end product of purine metabolism,
providing one index of renal function.
Hyperuricemia has been implicated as a risk factor for the
development of hypertension.
Computed tomography (CT) scan: Noninvasive procedure,
done with or without contrast media, to enhance certain
anatomic views of cerebral structures and locate abnormalities.
Assesses for cerebral tumor or stroke; also rules out pheochromocytoma
or encephalopathy as contributing factors for
Electrocardiogram (ECG): Record of the electrical activity
of the heart that can demonstrate conduction disturbances,
enlarged heart, and chamber strain patterns.
Broad, notched P wave is one of the earliest signs of hypertensive
heart disease.

Discharge Goals

  • BP within acceptable limits for individual.
  • Cardiovascular and systemic complications prevented or minimized.
  • Disease process, prognosis, and therapeutic regimen understood.
  • Necessary lifestyle or behavioral changes initiated.
  • Plan in place to meet needs after discharge.

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