Pulmonary Hypertension Nursing Care Plans Diagnosis and Interventions
Pulmonary Hypertension NCLEX Review and Nursing Care Plans
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 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.
Pulmonary Hypertension Nursing Diagnosis
Nursing Care Plan for Pulmonary Hypertension 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.
|Pulmonary Hypertension Nursing Interventions||Rationale|
|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 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
|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 for Pulmonary Hypertension 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.
|Pulmonary Hypertension Nursing Interventions||Rationale|
|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.|
Nursing Care Plan for Pulmonary Hypertension 3
Nursing Diagnosis: Ineffective Breathing Pattern related to pulmonary hypertension secondary to chronic obstructive pulmonary disorder (COPD) as evidenced by nasal flaring, pursed lip breathing, and use of accessory muscles.
- The patient will exhibit an effective breathing pattern, as evidenced by normal respiratory rate and depth.
- The patient will exhibit adequate perfusion as evidenced by normal oxygen saturation and blood gases.
- The patient will be able to perform breathing techniques to prevent episodes of respiratory distress.
Nursing Care Plan for Pulmonary Hypertension 4
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to altered myocardial contractility secondary to pulmonary hypertension.
- The patient will maintain adequate cardiac output while waiting for treatment as evidenced by stable vital signs.
- The patient will perform activities that reduce cardiac workload.
|Pulmonary Hypertension Nursing Interventions||Rationale|
|Assess and monitor heart rate through auscultation of apical pulse while the patient is asleep.||Use the apical pulse for a more accurate assessment of the heart rate. An early sign of reduced cardiac output is an increased heart rate even at rest.|
|Assess and monitor heart sounds through auscultation. Note any extra heart sounds, systolic murmur, or gallop rhythm.||S1 and S2 may be weak due to decreased pumping action. A pulmonary and tricuspid valve regurgitation murmur, along with pulmonic valve closure (P2) and S4 gallop is usually seen in patients with pulmonary hypertension.|
|Assess and monitor blood pressure when lying, sitting, and standing if possible.||Blood pressure is used as a basis for pharmacological interventions. A decrease in circulating blood volume and excessive peripheral vasodilation may cause hypotension in patients with pulmonary hypertension.|
|Monitor heart rhythm using ECG. Note for dysrhythmias, speed, and rhythm of the heart.||Right axis deviation, peaked P waves, and right ventricular strain pattern is due to right ventricular hypertrophy (RVH) and right atrial enlargement usually seen in patients with pulmonary hypertension.|
|Monitor oxygen saturation and ABGs.||Pulmonary hypertension can cause narrowing of pulmonary arteries decreasing the oxygenated blood. Decreased cardiac output causes metabolic acidosis while decreased pulmonary blood flow causes respiratory acidosis.|
|Assess the skin, peripheral pulses, capillary refill, and intake & output for signs of diminished perfusion.||Decreased cardiac output cause systemic hypoperfusion that may result in cyanosis, diminished peripheral pulses, delayed capillary refill, and decreased urine output.|
|Assist the patient in a high Fowler’s position. Reposition every two hours ensuring a comfortable position. Instruct the patient to avoid holding the breath or straining during position changes.||High Fowler’s promote maximum lung expansion and reduced diaphragmatic pressure, pulmonary congestion, and cardiac workload. Immobility causes decreased blood circulation leading to edema and pressure ulcers. Holding of breath or straining elicits vasovagal response causing hypoperfusion.|
|Provide a peaceful and quiet environment. Schedule rest periods in between activities.||An adequate physical and peaceful sleep allows the patient to conserve energy. Frequent rest periods between activities reduce oxygen demand and cardiac workload.|
|Elevate the lower extremities and place a pillow under the knees assuming a comfortable position. Routinely check the extremities for redness, swelling, tenderness, pallor, and diminished pulses.||Pulmonary hypertension is associated with platelet dysfunction and thrombus formation. Elevating the legs reduces the incidence of thrombus formation.|
|Assist the patient with activities of daily living. Encourage passive during bed rest and active ROM as tolerated. Avoid strenuous activities.||Prolonged immobility has its deconditioning effects and risk. Bed rest may be indicated during the acute phase. Otherwise, ADLs and active ROM should be done daily with continuous supervision from the nurse.|
|Provide a bedside commode and stool softeners as ordered. Instruct the patient to avoid straining during bowel movements.||A bedside commode saves energy from walking to the bathroom or struggling with putting a bedpan. Valsalva maneuver reduces cerebral blood flow and means arterial blood pressure causing hypoperfusion.|
|Educate the patient about limiting fluid intake to 2liters per day. Instruct the patient to list and measure the amount of all liquid intake from both food and drinks. Restrict sodium from the diet.||Fluid restrictions may change depending on the severity of the patient’s condition. Too much fluid will cause the heart to work harder to pump the extra fluids. Limiting sodium decreases fluid retention.|
|Administer supplemental oxygen as needed and discontinue once the target range was reached.||Continuous monitoring of oxygen saturation is needed to determine the need for oxygen.|
|Administer medications such as diuretics, vasodilators, ACE inhibitors, inotropic agents, morphine sulfate, anticoagulants, and sedatives as ordered.||Diuretics are the first line of choice in reducing blood volume and venous pressure. Vasodilators increased cardiac output by reducing circulating blood volume. ACE inhibitors improve hemodynamics. Inotropic agents increase myocardial contractility and vasodilation. Morphine sulfate reduces cardiac workload during pulmonary congestion. Anticoagulants prevent thrombus formation. Sedatives are used to calm the patient and reduce oxygen demand.|
|Educate the patient and significant others about the condition, signs and symptoms to watch out for, and the interventions needed.||Adequate information is vital to prevent the progression and deterioration of the patient’s condition. This also increases compliance with the treatment plan.|
Nursing Care Plan for Pulmonary Hypertension 5
Nursing Diagnosis: Impaired Physical Mobility related to edema of lower extremities secondary to pulmonary hypertension as evidenced by swelling and reports of pain with movement.
- The patient will display a decreased amount of swelling after 2days of nursing interventions.
- The patient will be able to perform activities of daily living without any pain and limitation of movement.
|Pulmonary Hypertension Nursing Interventions||Rationale|
|Assess the patient’s functional level of mobility using the Bedside Mobility Assessment Tool (BMAT) which includes: |
Level 1: Sit and shake includes repositioning, turning, and limb holding.
Level 2: Stretch includes extending the leg, straightening the knee, dorsiflexion, and plantar flexion.
Level 3: Stand. Ask the patient from a seated position to stand upright for up to 1 minute.
Level 4: Step includes marching in place and moving forward.
|BMAT is a simple functional assessment tool to determine the mobility status and select appropriate equipment to safely mobilize the patient.|
|Assess the patient’s ability to perform Activities of Daily Living (ADLs) safely and efficiently using the following scale: |
0 – Total independence
1 – Requires use of devices or equipment
2 – Requires assistance, instruction, and supervision
3 – Requires assistance of another person and/or equipment and device
4 – Dependent on others or does not engage in any activity
|Gauging the patient functional level to perform activities of daily living will help the nurse plan activities based on their strength and insufficiencies.|
|Assess and monitor the skin integrity of both lower extremities. Note for redness, degree of swelling, and ischemia, especially on the bony prominences.||Documenting the skin integrity for future comparison of progression or resolution of the condition. Bony prominences are more prone to pressure ulcers and routine inspection will facilitate early recognition and treatment.|
|Assess all joints in performing range of motions.||Joint involvement will guide the nurse on the extent of disability and the planning of appropriate activities.|
|Provide a safe environment by raising bedside rails, lowering the bed, and keeping important items within reach. Assess the patient’s surrounding for any blockage, obstacle, or hazards.||These measures reduce the risk of falls due to patients’ limited movement from edema. Ensuring the safety of the patient before performing any activities must be a priority to prevent accidents and injury.|
|Elevate the lower extremities and place a pillow under the knees assuming a comfortable position. Use anti-embolic stockings or compression devices. Routinely check the extremities for redness, swelling, tenderness, pallor, and diminished pulses.||Elevating the lower extremities promotes venous return and decreases swelling. This also reduces the incidence of thrombus formation associated with pulmonary hypertension.|
|Assist the patient in performing passive ROM exercises in all extremities. Gradually introduce active ROM as tolerated.||These exercises increased venous return relieving the edema. Immobility can cause muscle weakness and stiffness which can delay recovery.|
|Educate the patient about safety measures to keep the skin clean and dry, keeping the linens neat and free from folds, using of gel mattress, etc.||These measures prevent skin breakdown and prevent pressure ulcers.|
|Assist the patient in ambulation if possible. Instruct the patient to initially dangle the legs on the side of the bed and then sit on a chair before ambulating.||These movements allow the patient to adjust and gauge his/her ability to ambulate. Early ambulation increases self-esteem and independence.|
|Provide rest periods in between activities. Ensure adequate rest during the night.||Adequate rest especially at night helps the body regain adequate energy that will be needed during the day.|
|Assist the patient with activities of daily living as tolerated. Encourage independent activities without any deadline of accomplishment.||This will promote independence and confidence in finishing the task. Let the patient accomplish the task at his/her own pace.|
|Educate the patient about the use of mobility devices such as canes, walkers, crutches, etc. Educate significant others about transfer methods when moving the patient to bed, chair, or stretcher.||These devices aid in mobility and enhance activity while promoting safety and conserving energy. Same with the proper way of transferring.|
|Educate the patient about energy conservation techniques such as frequent position changes, pushing rather than pulling, sliding rather than lifting, and placing items within reach.||This helps conserve energy for the much more needed task that requires energy consumption, cardiac workload, and prolonged activities.|
|Assess the patient’s emotional response to activity limitations including verbal and non-verbal cues.||Let the patient understand and accept his/her limitations. Help the patient enhance abilities to avoid being dependent.|
|Provide support and positive reinforcement during activities.||Reassure the patient and boost his/her confidence with continued supervision until recovery is achieved.|
More Nursing Diagnosis for Pulmonary Hypertension
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. (2022). 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. (2020). 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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