Pulmonary Hypertension NCLEX Review Care Plans
Nursing Study Guide on Pulmonary Hypertension
Pulmonary hypertension is a medical condition where in the blood pressure in the arteries of the lungs and the right side of the heart becomes elevated.
The blood vessels of the lungs may experience blockage, narrowing, or damage – all of which can increase the blood pressure.
This adds workload to the heart. As the heart becomes force to work harder to pump blood in the pulmonary circulation, the cardiac muscles could be weakened.
Eventually, heart failure may occur.
Pulmonary hypertension can slowly progress and become fatal. This disorder is not curable; however, the treatment of pulmonary hypertension is aimed at the reduction of symptoms and the improvement of the patient’s quality of life and daily living.
Signs and Symptoms of Pulmonary Hypertension
- Shortness of breath (Dyspnea) during exercise, but may also be present while at rest eventually
- Chest pain that can be described as pressure-like
- Swelling (edema) in the lower extremities
- Swelling of the abdomen (ascites)
- Bluish discoloration of the mucosa, lips and skin (cyanosis)
- Chest palpitations and/or tachycardia
Causes of Pulmonary Hypertension
The right ventricle of the heart is responsible for pumping blood to the heart via the pulmonary artery.
The blood in the lungs picks up oxygen as it releases the carbon dioxide (waste). The blood normally goes back to the left side of the heart.
However, when the lining of the pulmonary arteries undergoes cellular changes, the arterial wall can become narrowed or stiff.
The blood would not be able to flow properly through the lungs and the blood pressure inside these narrowed arteries is increased, resulting to pulmonary hypertension.
Group 1 of this condition is called pulmonary arterial hypertension (PAH), which may have an unknown cause (idiopathic). It could also result from HIV infection, liver cirrhosis, or connective tissue disorders. In addition to these, PAH could also be due to an inherited genetic mutation running through the family.
Group 2 pulmonary hypertension can be caused by left-sided heart disease which may involve the aortic valve, mitral valve, and/or the left ventricle.
Group 3 can result from lung diseases such as COPD, pulmonary fibrosis, and obstructive sleep apnea may also cause pulmonary hypertension.
Group 4 Chronic blood clots and clotting disorders may cause group 4 pulmonary hypertension.
Group 5 pulmonary hypertension may be caused by other disorders such as tumors and blood disorders.
Risk Factors of Pulmonary Hypertension
The risk factors that may increase the likelihood of developing pulmonary hypertension include:
- Age – many cases of pulmonary hypertension involve people between age 30 and 60
- History of blood clotting disorders
- Asbestos exposure
- Family history of pulmonary hypertension or any genetic disorder
- Residing at a high altitude
- Some illegal drugs like cocaine
- Anti-depressive/ anxiolytic drugs – also known as selective serotonin reuptake inhibitors (SSRIs)
Complications of Pulmonary Hypertension
- Cardiac disorders. Heart failure or cardiomegaly (enlarged heart) may result from uncontrolled pulmonary hypertension. In particular, it can cause cor pulmonale, wherein the right ventricle of the heart is enlarged as it is forced to work harder by pumping blood through the blocked or narrowed pulmonary blood vessels.
- Arrhythmia and palpitations. Irregular heartbeats or arrhythmias may come from uncontrolled pulmonary hypertension.
- Clot formation or bleeding. The small arteries of the lungs may be blocked by formed clots due to persistent pulmonary hypertension. On the other hand, some blood vessels may have weaker walls, causing them to bleed. The blood may be coughed up, a sign known as hemoptysis.
- Complications in pregnancy. Pulmonary hypertension may be fatal for both the mother and her baby, as high rates of morbidity and mortality have been reported even with today’s modern medical management.
Diagnosis of Pulmonary Hypertension
- Vital signs – a loud pulmonic 2nd heart sound upon auscultation, which is usually a murmur or a gallop; tachycardia
- Blood tests – B-type Natriuretic Peptide (BNP), Basic Metabolic Panel (BMP), Complete Metabolic Panel (CMP), Liver Function Tests (LFTs) are all useful in diagnosing pulmonary hypertension
- Electrocardiogram (ECG) – to check for any irregularity in heartbeat
- Exercise stress test – use of ECG while the patient is on a treadmill or a stationary bike
- Chest X-ray – to check for any enlargement of the heart’s right ventricle
- Echocardiogram – utilizes sound waves to create images of the heart
- Cardiac catheterization (right-sided) and angiogram – to directly measure the pressure in the right ventricle and the pulmonary arteries
- Cardiac CT scan / MRI
- Pulmonary function test -a non-invasive test using a spirometer to measure how much air the lungs can hold
- Genetic test – if there is a suspected hereditary or genetic involvement
Treatment for Pulmonary Hypertension
Pulmonary hypertension cannot be cured, but it can be controlled, and its symptoms can be reduced by the following treatments:
- Medications. The following drugs may be used to manage pulmonary hypertension:
- Vasodilators – to relax the blood vessels, thereby opening the narrowed blood vessels and improve blood flow
- Guanylate cyclase (GSC) stimulators – to increase the level of nitric oxide which can relax the pulmonary arteries, thereby decreasing the pressure in them
- Endothelin receptor antagonists – to stop the endothelin from narrowing the arterial walls
- Calcium channel blockers – to relax the muscles in the arterial walls
- Digoxin – to help the heart pump more blood and treat arrythmias
- Anticoagulants (usually warfarin) – to reduce the formation of blood clots in the pulmonary arteries
- Diuretics – to reduce excess fluid in the body through urination, thereby decreasing cardiac workload
- Surgery. Surgical interventions are required if pulmonary hypertension is uncontrolled by medications. These surgeries include:
- Atrial septostomy – an open-heart surgery wherein an opening between the two atria of the heart is created, effectively relieving the pressure in the right ventricle of the heart
- Transplantation – this can be a lung or a heart-and-lung organ transplant that are done for people with idiopathic PAH.
- Lifestyle changes. A low cholesterol, low fat diet to control cholesterol and triglyceride levels is needed for a patient with pulmonary hypertension. Weight management, reduced alcohol intake, and smoking cessation are also important lifestyle changes. Increased physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle. Patients with pulmonary hypertension should avoid living or traveling at high altitude.
Nursing Care Plans for Pulmonary Hypertension
Nursing Care Plan 1
Decreased cardiac output related to arrhythmias secondary to pulmonary hypertension, as evidenced by palpitations, heart rate of 120 bpm (tachycardia), high blood pressure level of 190/100, fatigue, and inability to do ADLs as normal
Desired outcome: The patient will be able to maintain adequate cardiac output.
|Assess the patient’s vital signs and characteristics of heartbeat at least every 4 hours. Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Heart murmur or gallop upon auscultation could indicate pulmonary hypertension. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.|
|Administer prescribed medications for pulmonary hypertension.||Vasodilators – to relax the blood vessels, thereby opening the narrowed blood vessels and improve blood flowGuanylate cyclase (GSC) stimulators – to increase the level of nitric oxide which can relax the pulmonary arteries, thereby decreasing the pressure in themEndothelin receptor antagonists – to stop the endothelin from narrowing the arterial wallsCalcium channel blockers – to relax the muscles in the arterial wallsDigoxin – to help the heart pump more blood and treat arrythmiasAnticoagulants (usually warfarin) – to reduce the formation of blood clots in the pulmonary arteriesDiuretics – to reduce excess fluid in the body through urination, thereby decreasing cardiac workload|
|Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing stress is also an important aspect of dealing with fatigue.|
Nursing Care Plan 2
Nursing Diagnosis: Acute Pain related to increased strain in cardiac muscles secondary to pulmonary hypertension, as evidenced by pain score of 10 out of 10, verbalization of pressure-like chest pain, guarding sign on the chest, heart rate of 120 bpm, respiratory rate of 29 cpm, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Administer prescribed medications that alleviate the symptoms of pain.||Aspirin may be given to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates may be given to relax the blood vessels. Other medications that help treat chest include anti-cholesterol drugs (e.g. statins), and calcium channel blockers.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is within the target range, or as ordered by the physician.||To increase the oxygen level and achieve an SpO2 value within the target range.|
|Place the patient in complete bed rest when in severe pain. Educate patient on stress management, deep breathing exercises, and relaxation techniques.||Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase cardiac workload.|
Other nursing diagnoses:
- Risk for Bleeding
- Risk for Maternal/Fetal Injury
- Activity Intolerance
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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