Hypertension nursing care plan- HELP!

nurseprnRN, BSN, RN · Feb 4, 2015

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that. We hate it when instructors imply that nursing diagnosis is a consequence of medical diagnosis by making an assignment like this.

You don't "pick" or "choose" a nursing diagnosis. You MAKE a nursing diagnosis the same way a physician makes a medical diagnosis, from evaluating evidence and observable/measurable data.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. As physicians make medical diagnoses based on evidence, so do nurses make nursing diagnoses based on evidence.

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I'm making the nursing diagnosis of/I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2015-2017 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2015-2017, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. CONGRATULATIONS! You made a nursing diagnosis! :anpom: If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

Two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current NANDA-I 2015-2017 nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Now, as to your problem of the moment, you could go into your med/surg book and see what the long-term complications of high blood pressure are, what symptoms the patient might develop as a result, what side effects of medications, perhaps. YOu can also imagine people you know well who could receive a medical diagnosis of high blood pressure (BTW, the AHA doesn't call it "hypertension" anymore, because that misleads patients into thinking that laid-back people can't be at risk for ...) Then you can imagine what they might do. Do they have money for meds? Do they live where they can buy healthy food, or are they stuck with high-sodium, high-fat fast food..or prefer it? Is obesity in the picture? Is there adequate support for nutrition teaching, care provider follow up...?

If this is an imaginary patient, then you can say, "If he exhibits these symptoms or tells me thus and such or asks me these questions, then my assessment data would probably be X,Y,Z, which are defining characteristics for nursing diagnoses A, B, and maybe C." Then you take it from there.

If it's a real patient, then you have to dig deeper to find assessment data to see if there IS a nursing diagnosis in there, and HINT: it may have nothing at all to do with his BP.

almost.rn · Feb 4, 2015

Wow, thank you so much for your help. I have the nursing diagnosis handbook by Ackley and love it. For these care plans are instructor wants us to just do ONE nursing diagnosis, and she was trying to make it easier for our first time, so she chose a medical diagnosis for us to focus on for each of our patients (this is a real patient too). My patient had many MEDICAL diagnoses, so she said I want you to come up with a nursing diagnosis that is based around her medical diagnosis of hypertension. Now that is where I'm so confused. Her BPs seem fairly normal. he is 100+ and is very healthy for his age. I have a whole list of medications he takes including : albuterol sulfate neb, senokot, lexapro, tenormin, norvasc, lasix, aspirin, and levothyroxine. Patient is independent in everything, except for dressing and hygiene. Vitals are always good, except SaO2 is generally 90% RA. He is sometimes SOB if nebs not given QID. I have other nursing diagnoses i'd like to make, BUT would like to follow her assignment and do one that explains her hypertension. Any other suggestions?

Esme12, ASN, BSN, RN · Feb 5, 2015

Wow, thank you so much for your help. I have the nursing diagnosis handbook by Ackley and love it. For these care plans are instructor wants us to just do ONE nursing diagnosis, and she was trying to make it easier for our first time, so she chose a medical diagnosis for us to focus on for each of our patients (this is a real patient too). My patient had many MEDICAL diagnoses, so she said I want you to come up with a nursing diagnosis that is based around her medical diagnosis of hypertension. Now that is where I'm so confused. Her BPs seem fairly normal. he is 100+ and is very healthy for his age. I have a whole list of medications he takes including : albuterol sulfate neb, senokot, lexapro, tenormin, norvasc, lasix, aspirin, and levothyroxine. Patient is independent in everything, except for dressing and hygiene. Vitals are always good, except SaO2 is generally 90% RA. He is sometimes SOB if nebs not given QID. I have other nursing diagnoses i'd like to make, BUT would like to follow her assignment and do one that explains her hypertension. Any other suggestions?

Care plans are all about the patient assessment.

Here is my standard speech.....

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment
(collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis
(make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning
(write measurable goals/outcomes and nursing interventions)
Implementation
(initiate the care plan)
Evaluation
(determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Esme12, ASN, BSN, RN · Feb 5, 2015

Hi,
I'm a fairly new nursing student and need serious help with my care plan! Our instructor gives us a diagnosis to work on and I'm to do my nursing diagnosis on hypertension. His BP is controlled by medications and his BP is at 132/84, so fairly "normal". I initially had "Decreased cardiac output r/t altered afterload AEB increased vascular resistance." I'm not certain that this is okay because their BP is pretty normal. Any other suggestions. Please help!!

If your assignment is to make a diagnosis off HTN then this is OK I would say Risk for decreased cardiac output.....this may help you. Hypertension Nursing Care Plan

Bedside_Life RN · Feb 6, 2015

What Esme12 and GrnTea are getting at, is that you should be diagnosing this patient on their actual or potential risks and/or response to the related medical diagnosis. Pay attention to how they both have mentioned, in several obvious statements, of your subjective and objective data collection "During ASSESSMENT"***. What patient response(s) have you ASSESSED that could use attention? I feel like you are confusing medical Dx from Nursing Dx. Understanding this difference is imperative.

nurseprnRN, BSN, RN · Feb 6, 2015

There is no nursing diagnosis that "explains" her high blood pressure. Nursing diagnoses do not explain medical diagnoses.

The last Ackley edition does not include the current NANDA-I approved diagnoses (How do I know that? Because I got asked to contribute to the next one :)).

We understand that students have to try to make their instructors happy, really, we do, and we don't want to get you in Dutch with them. But the fact remains that you cannot make ANY nursing diagnosis without data, and your instructor telling you to pull some ND out of, um, the air because it looks like it has to do with a medical diagnosis is just plain wrong. Pull out your NANDA-I 2015-2017 (the real thing, not an out of date incomplete regurg in a secondary source) and show her what your question is.

You cannot find data that matches any of the stuff you listed above? Sit down with your patient and explore some of those other things. Is she at risk for losing her support systems? So she has her BP well-controlled c meds-- wonderful! Does she understand what to do if she runs low on them, or (god forbid) has to choose between meds and, oh, food? Does she have family or other support to maintain her health?

Esme12, ASN, BSN, RN · Feb 6, 2015

The current Ackley doesn't contain all the new diagnoses because there hasn't been one published since NANDA released new criteria. Didn't she just pass away?

nurseprnRN, BSN, RN · Feb 6, 2015

She did, and we are hoping it won't delay the next edition. They are taking into account the new NANDA-I 2015-2017 in it, is what they tell me.