I cannot find a nursing diagnosis for hypertension, help

lsm332 · Feb 3, 2009

it kind of depends on what else you have found in your assessment of your patient. why is the patient hypertensive?

you could try ineffective health maintainence, risk for noncompliance, decreased cardiac output... knowledge deficit would be good if they are newly diagnosed or if they need teaching about diet, exercise, smoking, other modifiable risk factors, etc

brandy1215 · Feb 3, 2009

Patient is in to r/o rhabdomyolsis and hypetension, newly diagnosed. Dont know how to include interventions on meds for hypertension and must redo careplan. Decreased cardiac output is good but wouldnt it be a risk for if just the b/p is high and no other signs and symptoms.

FUTURE_ER_RN · Feb 3, 2009

Did the patient have any other abnormal's with any of his labs? Is the patient older with any signs of atheroscerosis, high cholesterol, or higher hematocrit? These could all increase bp.

madwife2002, BSN, RN · Feb 3, 2009

The hypertension will be a result of what is happening in the Kidneys, and may not be an issue after the ARF has been treated.

Daytonite, BSN, RN · Feb 3, 2009

you must understand that a nursing care plan is a determination of a patient's nursing problems. hypertension is a medical diagnosis. there is no nursing diagnosis equivalent of hypertension. is this why the patient was hospitalized? so, how do you care plan for someone who has hypertension? you care plan for the patient's responses to their medical condition. what nursing problems does the patient have as a result of their medical disease or condition? that is what you must discover. that is why each care plan must be customized and unique. to do this you must use the nursing process to help you. the nursing process is a very helpful tool if used correctly. it consists of 5 steps. the first step consists of assessing the patient. for care planning this assessment is extremely important because the remainder of the care plan relies on what you discover during assessment. assessment consists of:

a health history (review of systems)
performing a physical exam
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming)
reviewing the pathophysiology, signs and symptoms and complications of their medical condition
reviewing the signs, symptoms and side effects of the medications they are taking

before you can do any diagnosing you must have the evidence, or proof, to support any diagnoses you will choose. diagnoses are not chosen from the thin air. there must be a reason for picking them and there must be evidence to support them. that evidence is found when you do your assessment of the patient. everything that is abnormal in the assessment are the signs and symptoms of your nursing diagnoses (nanda calls them defining characteristics). doctors go through the same process when they question and examine patients and finally diagnose them with a medical condition. what is different is that we nurses have a whole different book, if you will, of specific nursing diagnoses that we work from that really have no connection to medical diagnoses. we may break down medical diseases into their signs and symptoms and include them in our assessment data, but we never diagnose anyone with a medical diagnosis.

it was interesting that you listed all those diagnoses, but they mean nothing because you supplied absolutely no data about this patient. so, go back through the notes you took and what you can remember and think about the assessment you did on this patient and what you remember that was abnormal. just as a police detective cannot make an arrest without evidence that a suspect probably committed the crime, you cannot say that a patient has ineffective health maintenance without the proper facts and data to back it up.

with rhabdomyolysis and hypertension. . .did this patient fall or have some kind of injury?

you can see examples of other care planning on this thread in this forum: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans

NurseLoveJoy88, ASN, RN · Feb 3, 2009

Here are a couple NANDA approved nursing diagnosis of course you'll have to add your R/T and AEB.

1) Imbalanced Nutrition: More than body requirements. ( Does your patient consume more NA than what is required?)

2) Excess Fluid Volume

3) Ineffective Therapuetic Regimen Managment ( Is your patient exercising, or doing dieting ?)

I can list a few more, but is hard to give a full example with out me know the Hx of you patient.