Care Plan: Hypertensive Crisis

debbie2388 · Jul 19, 2009

The first intervention for your patient has to be safety. With this patients decrease in strength and mobility you want to make sure that assist this patient with toileting if there is no catheter in place, so one intervention could be placing this pt on the bedpan prn. Also since the pt is decreasing neurologically, then you want to implement frequent neuro checks throughout the shift. You also want to assess for the degree of weakness in the upper and lower extremities. This patient is an excellent candidate for a care plane because they are at risk for so many things like ineffective airway clearance, impaired physical mobility, disturbed sensory perception etc...Go to you care plan book for help. I used Mosbys and Gulanick/Meyers during my critical care med/surg clinicals, and they give all of the interventions along with the rationales. I truly hope this helps you...Try not to get too distressed..it will all be over soon...Good luck!

Daytonite, BSN, RN · Jul 19, 2009

i cannot tell if this is a real patient or this is a case scenario you were given to work on, but one thing is very clear. . .you are hung up on the medical diagnosis. a care plan is all about determining what the person's nursing problems (nursing diagnoses) are. to do that you have to assess the patient and isolate abnormal data. the only abnormal data you have posted is

bp 236/117
reduction in strength and mobility on the right side
drowsy and disoriented
answers "yes" to any questions

your task is to figure out what nursing diagnoses any of the above are signs and symptoms of. just a word. "risk for" in a nursing diagnostic statement means the nursing problem is anticipatory, or not yet existent. if the patient has abnormal assessment data then something is happening and the risk is over and the problem has arrived.

decreased cardiac output r/t increased contractility aeb bp 236/117
impaired physical mobility r/t neuromuscular impairment aeb reduced mobility on the right side [your description of mobility needs to be more specific
acute confusion r/t traumatic delirium aeb drowsiness, disorientation and answering "yes" to any questions.

i strongly suggest you look up "hypertension" and "hypertensive crisis" and read about them and their pathophysiology. also, look over this thread and how to do nursing diagnosis: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. the nursing interventions for each diagnosis are based upon the aeb items that support and are the evidence proving that the nursing problem exists. the aeb items are the signs and symptoms (abnormal data from your assessment of the patient) of the nursing problem that you will develop specific treatment (nursing interventions) for. the reason you are having difficulty finding nursing interventions for this care plan is because you have not clearly determined what the abnormal data is yet. follow the nursing process.

assess - collect all the data about the patient
determine the problem(s) - make a list of the abnormal data (as i did above), sort it, group it, determine what nursing problems you have and label them with nursing diagnoses. every nanda nursing diagnosis has a definition and a set of defining characteristics (signs and symptoms) and related factors (causes).
plan - set goals and how you will go about improving, stabilizing or supporting the patient's condition (your nursing interventions)
implement
evaluate

Daytonite, BSN, RN · Jul 19, 2009

risk for decreased cardiac output r/t increased vascular resistance secondary to hypertensive crisis

this is not a nanda diagnosis.

risk for ventricular hypertrophy r/t increased vascular resistance secondary to hypertensive crisis

this is not a nanda diagnosis. ventricular hypertrophy would be included with the nanda diagnosis of

decreased cardiac output

because with ventricular hypertrophy cardiac output would be affected.

risk for cerebrovascular accident/stroke (hemorrhagic) r/t to hypertensive crisis

this is not a nanda diagnosis. we can't use medical diagnoses in nursing diagnostic statements. the point of "risk for" diagnoses is to prevent those problems from happening. how can we nurses prevent a hemorrhagic stroke? doctors can't even stop a hemorrhagic stroke from happening. break cva into its component signs and symptoms that the patient is at risk for and some of those can become appropriate anticipated nursing problems.

risk for nutrition imbalance: less than body requirements r/t poor intake

this is not a nanda diagnosis.

risk for impaired skin integrity

risk factors are missing.

CanuckStudent · Jul 19, 2009

Daytonite has it correct. You are a nurse. Not an MD. Your main concern is how to provide care for the client and the risk factors that may affect or change that care. You are not diagnosing or treating any disease.

Also, think about your wording and what you are saying (aside from NANDA). Since you are not an MD, it would be incorrect to infer that your patient has 'vascular resistance secondary to Hypertensive Crisis'. How can you determine that? Are you assuming that he has hyperthyroidism and is in a thyroid storm/toxicosis and thus his increased (not decreased) cardiac output thus triggered reflex resistance? Vascular resistance is a cause of HTN, but it doesn't make any sense to say that the vascular resistance was *caused by the HTN crisis*. If you were making a medical inference, you could reason that your patient has increased cardiac output/stroke volume due to Grave's toxicosis (hormone triggered HTN that can cause sinus tachy), which caused vascular resistance, which combined started a cycle that lead to a Hypertensive Crisis.

I'm simplifying of course. And I'm just a stupid Practical Nursing student.

But my point is that I agree with Daytonite and that you need to focus on what *nurses* diagnose (nurses are not junior MDs), and the NANDA list and format.

Good luck!

P.S. Daytonite gave you a good link. From what I have seen, this isn't really a homework question forum (assuming this is what your question is), so your best bet is to talk with your instructor if you are really stuck with the NANDA system. It is confusing to many people, especially if you are coming to nursing from another healthcare background. Nursing is its own entity with its own rules. :)

cparr0623 · Jul 19, 2009

Thanks to each of you.... let's see if I can put this all back together...the right way.