Risk for Unstable Blood Pressure Nursing Diagnosis

Risk for Unstable Blood Pressure Nursing Diagnosis & Care Plans

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Risk for unstable blood pressure is a critical nursing diagnosis that focuses on identifying and managing patients at risk for dangerous fluctuations in blood pressure, whether hypertensive or hypotensive. This comprehensive care plan guides nurses in preventing complications and maintaining optimal blood pressure control.

Causes (Related to)

Blood pressure instability can be influenced by various factors affecting cardiovascular function:

  • Underlying Medical Conditions:
    • Cardiovascular disease
    • Endocrine disorders
    • Autonomic dysfunction
    • Renal disease
    • Neurological conditions
  • Medications:
  • Physiological Factors:
    • Advanced age
    • Pregnancy
    • Dehydration
    • Electrolyte imbalances
    • Fluid volume changes
  • Environmental/Lifestyle Factors:
    • Stress
    • Physical exertion
    • Poor diet
    • Excessive sodium intake
    • Sleep disorders

Signs and Symptoms (As evidenced by)

Subjective: (Patient reports)

  • Dizziness or lightheadedness
  • Headache
  • Visual disturbances
  • Fatigue
  • Chest pain
  • Shortness of breath
  • Anxiety about blood pressure readings
  • Palpitations

Objective: (Nurse assesses)

  • Fluctuating blood pressure readings
  • Changes in heart rate
  • Irregular pulse
  • Altered level of consciousness
  • Changes in skin color
  • Peripheral edema
  • Abnormal ECG findings
  • Changes in urinary output

Expected Outcomes

  • The patient will maintain blood pressure within the target range
  • The patient will demonstrate an understanding of blood pressure management
  • The patient will identify personal triggers for blood pressure fluctuations
  • The patient will adhere to the prescribed medication regimen
  • The patient will implement appropriate lifestyle modifications
  • The patient will recognize and report symptoms of blood pressure changes
  • The patient will maintain adequate perfusion to vital organs

Nursing Assessment

Monitor Vital Signs

  • Check blood pressure in both arms
  • Assess for orthostatic changes
  • Monitor heart rate and rhythm
  • Document blood pressure patterns
  • Note the timing of medications

Evaluate Risk Factors

  • Review medical history
  • Assess medication compliance
  • Check for lifestyle factors
  • Evaluate stress levels
  • Monitor dietary habits

Assess End-Organ Function

  • Monitor neurological status
  • Assess cardiovascular function
  • Check renal function
  • Evaluate respiratory status
  • Monitor for complications

Review Medications

  • Check for drug interactions
  • Assess the timing of medications
  • Monitor for side effects
  • Verify proper dosing
  • Document medication response

Environmental Assessment

  • Evaluate stress factors
  • Check activity levels
  • Assess dietary habits
  • Monitor fluid intake
  • Review sleep patterns

Nursing Care Plans

Nursing Care Plan 1: Risk for Decreased Cardiac Output

Nursing Diagnosis Statement:
Risk for decreased cardiac output related to unstable blood pressure as evidenced by fluctuating blood pressure readings and altered heart rate.

Related Factors:

  • Irregular blood pressure
  • Compromised cardiovascular function
  • Medication effects
  • Fluid volume changes

Nursing Interventions and Rationales:

  1. Monitor vital signs q2-4h
    Rationale: Enables early detection of cardiovascular changes
  2. Assess for signs of decreased perfusion
    Rationale: Identifies complications early
  3. Administer medications as prescribed
    Rationale: Maintains therapeutic blood pressure levels

Desired Outcomes:

  • The patient will maintain stable cardiac output
  • The patient will demonstrate adequate tissue perfusion
  • The patient will maintain blood pressure within the target range

Nursing Care Plan 2: Risk for Falls

Nursing Diagnosis Statement:
Risk for falls related to blood pressure fluctuations as evidenced by reports of dizziness and unsteady gait.

Related Factors:

  • Orthostatic hypotension
  • Medication side effects
  • Altered consciousness
  • Physical weakness

Nursing Interventions and Rationales:

  1. Implement fall precautions
    Rationale: Prevents injury from falls
  2. Assist with ambulation
    Rationale: Ensures patient safety during position changes
  3. Teach orthostatic hypotension prevention
    Rationale: Reduces risk of sudden blood pressure drops

Desired Outcomes:

  • The patient will remain free from falls
  • The patient will demonstrate safe mobility
  • The patient will use appropriate safety measures

Nursing Care Plan 3: Knowledge Deficit

Nursing Diagnosis Statement:
Knowledge deficit related to blood pressure management as evidenced by verbalized confusion about medications and lifestyle modifications.

Related Factors:

  • Complex medication regimen
  • Limited health literacy
  • Lack of exposure to information
  • Misconceptions about treatment

Nursing Interventions and Rationales:

  1. Provide education about blood pressure management
    Rationale: Increases patient understanding and compliance
  2. Teach medication administration
    Rationale: Ensures proper medication use
  3. Demonstrate blood pressure monitoring
    Rationale: Empowers patient in self-monitoring

Desired Outcomes:

  • The patient will verbalize understanding of blood pressure management
  • The patient will demonstrate proper medication administration
  • The patient will perform accurate blood pressure monitoring

Nursing Care Plan 4: Anxiety

Nursing Diagnosis Statement:
Anxiety related to unstable blood pressure as evidenced by expressed concerns and increased vital signs.

Related Factors:

  • Health uncertainty
  • Fear of complications
  • Lack of control
  • Symptom unpredictability

Nursing Interventions and Rationales:

  1. Provide emotional support
    Rationale: Reduces anxiety and promotes coping
  2. Teach relaxation techniques
    Rationale: Helps manage stress-induced blood pressure changes
  3. Encourage expression of concerns
    Rationale: Allows for addressing specific fears

Desired Outcomes:

  • The patient will demonstrate reduced anxiety
  • The patient will use effective coping strategies
  • The patient will report an improved sense of control

Nursing Care Plan 5: Ineffective Health Management

Nursing Diagnosis Statement:
Ineffective health management related to complex treatment regimen as evidenced by difficulty following prescribed interventions.

Related Factors:

  • Complex care requirements
  • Limited support system
  • Lifestyle challenges
  • Resource constraints

Nursing Interventions and Rationales:

  1. Develop an individualized management plan
    Rationale: Creates achievable health goals
  2. Connect with support resources
    Rationale: Enhances treatment adherence
  3. Monitor compliance with interventions
    Rationale: Identifies barriers to care

Desired Outcomes:

  • The patient will demonstrate improved adherence to treatment plan
  • The patient will utilize available resources effectively
  • The patient will maintain stable blood pressure readings

References

  1. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 
  2. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
  3. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
  4. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
  5. Kitt J, Fox R, Tucker KL, McManus RJ. New Approaches in Hypertension Management: a Review of Current and Developing Technologies and Their Potential Impact on Hypertension Care. Curr Hypertens Rep. 2019 Apr 25;21(6):44. doi: 10.1007/s11906-019-0949-4. PMID: 31025117; PMCID: PMC6483962.
  6. Ramdani S, Haddiya I. Updates in the management of hypertension. Ann Med Surg (Lond). 2024 Apr 23;86(6):3514-3521. doi: 10.1097/MS9.0000000000002052. PMID: 38846840; PMCID: PMC11152838.
  7. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 
  8. Weber MA, Schiffrin EL, White WB, Mann S, Lindholm LH, Kenerson JG, Flack JM, Carter BL, Materson BJ, Ram CV, Cohen DL, Cadet JC, Jean-Charles RR, Taler S, Kountz D, Townsend RR, Chalmers J, Ramirez AJ, Bakris GL, Wang J, Schutte AE, Bisognano JD, Touyz RM, Sica D, Harrap SB. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich). 2014 Jan;16(1):14-26. doi: 10.1111/jch.12237. Epub 2013 Dec 17. PMID: 24341872; PMCID: PMC8031779.
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Anna Curran. RN, BSN, PHN

Anna Curran. RN, BSN, PHN I am a Critical Care ER nurse. I have been in this field for over 30 years. I also began teaching BSN and LVN students and found that by writing additional study guides helped their knowledge base, especially when it was time to take the NCLEX examinations.
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