NANDA Nursing Diagnosis for Risk for Unstable Blood Pressure: Definition: Vulnerable to fluctuations in blood pressure that may compromise health.
Defining Characteristics of Risk for Unstable Blood Pressure:
- Patient reports a history of hypertension.
- Patient expresses concerns about blood pressure changes.
- Patient reports dizziness or lightheadedness.
- Elevated blood pressure readings.
- Signs of orthostatic hypotension (e.g., drop in blood pressure upon standing).
- Signs of autonomic dysfunction (e.g., excessive sweating, flushing).
- History of hypertension.
- Medication non-compliance.
- Presence of comorbidities (e.g., diabetes, renal disease).
- Sedentary lifestyle.
- Excessive sodium intake.
- Stress and anxiety.
- Family history of hypertension.
Individuals with a history of hypertension or other risk factors for unstable blood pressure.
- Increased risk of stroke or myocardial infarction.
- Risk of end-organ damage (e.g., renal dysfunction, retinopathy).
- Impaired tissue perfusion.
- Risk of falls due to orthostatic hypotension.
Suggestions for Use:
- Assess blood pressure regularly and document any fluctuations.
- Monitor for signs and symptoms of orthostatic hypotension.
- Educate the patient about lifestyle modifications and medication adherence to control blood pressure.
- Collaborate with the healthcare team to develop an individualized care plan.
Suggested Alternative NANDA Diagnoses:
- Risk for Falls
- Ineffective Tissue Perfusion
- Risk for Impaired Renal Function
- Ineffective Coping
- Risk for Impaired Vision
- Monitor blood pressure using appropriate techniques and devices.
- Provide education on dietary modifications (e.g., low-sodium diet) and regular exercise.
- Encourage medication compliance and regular follow-up appointments.
- Assess and manage stress and anxiety levels.
- Collaborate with the patient to set realistic goals for blood pressure management.
NOC Outcomes (Nursing Outcomes Classification):
- Blood Pressure Control
- Cardiovascular Status
- Tissue Perfusion: Peripheral
- Fall Prevention
- Knowledge: Blood Pressure Management
NOC Results (Example):
- Blood pressure within the normal range.
- Absence of signs of orthostatic hypotension.
- Adequate peripheral tissue perfusion.
- No falls or fall-related injuries.
- Demonstrates understanding of blood pressure management strategies.
NIC Interventions (Nursing Interventions Classification):
- Blood Pressure Management
- Fall Prevention
- Medication Management
- Health Education
- Stress Management
- Risk Identification
Nursing Care Plans
Unstable Blood Pressure Nursing Care Plan (Ineffective Tissue Perfusion)
Nursing Diagnosis: Ineffective Tissue Perfusion related to unstable blood pressure
- Fluctuating blood pressure levels
- Impaired blood flow due to vasoconstriction or vasodilation
- Medication non-compliance
- Presence of comorbidities (e.g., diabetes, renal disease)
- Sedentary lifestyle
- Excessive sodium intake
- Stress and anxiety
- Maintain stable blood pressure within the target range.
- Improve tissue perfusion to prevent complications.
- Minimize the risk of end-organ damage.
- Prevent falls or injuries related to orthostatic hypotension.
Nursing Interventions for Risk for Unstable Blood Pressure:
- Assess and Monitor:
- Monitor blood pressure regularly using appropriate techniques and devices.
- Assess peripheral pulses, capillary refill, and skin color for signs of impaired tissue perfusion.
- Observe for signs of orthostatic hypotension such as dizziness, lightheadedness, and changes in blood pressure upon standing.
- Medication Management:
- Ensure adherence to prescribed medications for blood pressure control.
- Educate the patient about the purpose, dosage, and side effects of their medications.
- Collaborate with the healthcare team to adjust medication regimen as needed.
- Lifestyle Modifications:
- Educate the patient about adopting a heart-healthy diet, including reducing sodium intake.
- Encourage regular physical activity within the patient’s abilities and limitations.
- Promote weight management and smoking cessation if applicable.
- Patient Education:
- Teach the patient about the importance of blood pressure control and its impact on tissue perfusion.
- Provide instructions on how to measure blood pressure at home and keep a record.
- Explain the signs and symptoms of orthostatic hypotension and fall prevention strategies.
- Stress Management:
- Identify stressors and assist the patient in developing effective coping mechanisms.
- Teach relaxation techniques such as deep breathing exercises or meditation.
- Encourage the patient to engage in activities that promote relaxation and reduce stress.
- Collaborative Care:
- Consult with the healthcare team to address underlying comorbidities and their impact on tissue perfusion.
- Coordinate referrals to specialists, such as a cardiologist or nephrologist, for further evaluation and management.
- Collaborate with the patient and their support system to develop a comprehensive care plan.
- Monitor blood pressure trends and note stability within the target range.
- Assess for improvements in tissue perfusion, such as normal peripheral pulses and skin color.
- Evaluate patient understanding and adherence to lifestyle modifications and medication regimen.
- Document any reductions in falls or fall-related injuries.
Risk for Unstable Blood Pressure Nursing Care Plan (Risk for Falls)
Nursing Diagnosis: Risk for Falls related to the risk of unstable blood pressure
- History of hypertension
- Fluctuating blood pressure levels
- Presence of orthostatic hypotension
- Medication side effects (e.g., dizziness)
- Impaired balance and coordination
- Muscle weakness or mobility limitations
- Environmental hazards (e.g., slippery floors, inadequate lighting)
- Age-related changes in sensory perception
- Prevent falls and fall-related injuries.
- Promote a safe and hazard-free environment.
- Optimize patient’s physical mobility and balance.
- Promote patient and caregiver education on fall prevention strategies.
Nursing Interventions for Risk for Unstable Blood Pressure:
- Assess Fall Risk:
- Conduct a comprehensive fall risk assessment, including the patient’s medical history, medication review, and assessment of balance and gait.
- Use validated fall risk assessment tools, such as the Morse Fall Scale or Hendrich II Fall Risk Model.
- Identify specific risk factors contributing to falls, such as orthostatic hypotension or muscle weakness.
- Environmental Modification:
- Conduct a thorough assessment of the patient’s environment to identify potential hazards.
- Remove or minimize tripping hazards, such as loose rugs or clutter.
- Ensure adequate lighting in all areas, especially at night.
- Install grab bars in the bathroom and handrails on staircases.
- Provide non-slip mats or surfaces in the bathroom and shower areas.
- Education and Collaboration:
- Educate the patient and caregivers about fall risks associated with unstable blood pressure.
- Teach the patient and caregivers about strategies to prevent falls, such as using assistive devices, taking precautions during position changes, and avoiding sudden movements.
- Collaborate with physical therapy and occupational therapy to assess and address any balance or mobility impairments.
- Involve the patient’s family and caregivers in fall prevention strategies and educate them about the patient’s specific needs.
- Medication Review and Management:
- Review the patient’s medications for potential side effects related to dizziness or orthostatic hypotension.
- Collaborate with the healthcare team to adjust medication regimens as appropriate to minimize fall risks.
- Educate the patient on the importance of medication compliance and reporting any adverse effects.
- Assistive Devices and Ambulation:
- Assess the patient’s need for assistive devices, such as canes or walkers, and ensure proper fit and training in their use.
- Encourage the patient to use handrails when climbing stairs or walking on uneven surfaces.
- Assist the patient with safe ambulation and provide support as needed.
- Encourage regular physical activity within the patient’s capabilities and limitations to improve strength and balance.
- Ongoing Assessment and Communication:
- Regularly reassess the patient’s fall risk, especially with changes in blood pressure levels.
- Communicate any changes or concerns related to falls to the healthcare team.
- Document all fall incidents, near falls, and interventions implemented.
- Monitor the patient’s fall incidents and near falls to assess the effectiveness of interventions.
- Document any improvements in fall risk factors or reduction in fall-related injuries.
- Evaluate patient and caregiver understanding and compliance with fall prevention strategies.
- Collaborate with the healthcare team to adjust the care plan based on the patient’s progress and changing needs.
Risk for Unstable Blood Pressure Nursing Test Questions
Question 1: A nursing student is caring for a patient who has a history of hypertension. Which action by the student demonstrates an understanding of the risk for unstable blood pressure?
A. Monitoring the patient’s blood pressure every 4 hours.
B. Encouraging the patient to consume a diet high in sodium.
C. Assisting the patient in engaging in regular physical activity.
D. Administering antihypertensive medications without consulting the healthcare provider.
Answer: C. Assisting the patient in engaging in regular physical activity.
Rationale: Regular physical activity is beneficial for managing blood pressure and promoting overall cardiovascular health. It helps improve circulation and can contribute to more stable blood pressure levels.
Monitoring blood pressure regularly (option A) is important but does not directly address the risk for unstable blood pressure.
Encouraging a diet high in sodium (option B) is contraindicated for hypertension management. Administering medications without consulting the healthcare provider (option D) can lead to adverse effects and is not within the nursing student’s scope of practice.
Question 2: A nursing student is caring for a patient at risk for unstable blood pressure. Which assessment finding requires immediate intervention?
A. Blood pressure reading of 130/80 mmHg.
B. Complaints of dizziness and lightheadedness.
C. Decreased urine output and increased thirst.
D. Absence of peripheral pulses in lower extremities.
Answer: D. Absence of peripheral pulses in lower extremities.
Rationale: The absence of peripheral pulses in the lower extremities indicates a severe impairment in blood flow and requires immediate intervention. This finding suggests a potential vascular emergency that could lead to tissue ischemia and damage.
While all other options require further assessment or intervention, they do not indicate an immediate threat to the patient’s circulation and tissue perfusion.
Question 3: A nursing student is providing education to a patient at risk for unstable blood pressure. Which statement by the student requires correction?
A. “You should limit your sodium intake to help control your blood pressure.”
B. “It is important to take your prescribed blood pressure medications as directed.”
C. “You should avoid physical activity to prevent fluctuations in your blood pressure.”
D. “Please report any dizziness or lightheadedness to your healthcare provider.”
Answer: C. “You should avoid physical activity to prevent fluctuations in your blood pressure.”
Rationale: This statement requires correction. Regular physical activity is beneficial for blood pressure control and overall cardiovascular health.
It helps strengthen the heart, improves circulation, and can contribute to stable blood pressure levels. The patient should engage in regular, moderate-intensity exercise unless otherwise advised by the healthcare provider.
The other options are correct and provide appropriate education related to sodium intake (option A), medication adherence (option B), and reporting symptoms (option D).
Question 4: A nursing student is caring for a patient with a risk for unstable blood pressure. Which intervention should the student implement to promote a safe environment?
A. Assistive devices should be readily available for the patient.
B. Encourage the patient to rise quickly from a sitting to a standing position.
C. Encourage the patient to drink large amounts of fluids throughout the day.
D. Encourage the patient to walk independently without supervision.
Answer: A. Assistive devices should be readily available for the patient.
Rationale: Providing assistive devices, such as canes or walkers, promotes safety and stability for patients at risk for unstable blood pressure. These devices assist with balance and reduce the risk of falls.
Encouraging the patient to rise quickly from a sitting to a standing position (option B) can exacerbate orthostatic hypotension and increase the risk of falls. Drinking large amounts of fluids (option C) may be contraindicated depending on the patient’s underlying condition and should be individualized based on their specific needs.
Encouraging the patient to walk independently without supervision (option D) may increase the risk of falls if the patient experiences sudden drops in blood pressure. Close supervision and assistance should be provided, especially during activities that may pose a fall risk.
Question 5: A nursing student is reviewing the medications of a patient at risk for unstable blood pressure. Which medication is commonly used to manage hypertension and promote blood pressure stability?
D. Narcotic analgesics
Answer: A. Beta-blockers
Rationale: Beta-blockers are commonly prescribed for the management of hypertension and can help promote blood pressure stability. They work by blocking the effects of adrenaline on the heart, reducing the heart rate and the force of contraction. T
his leads to a decrease in blood pressure. Anticoagulants (option B) are used to prevent blood clots but do not directly impact blood pressure. Antihistamines (option C) are used to manage allergies and do not have a primary effect on blood pressure.
Narcotic analgesics (option D) are used for pain management and do not directly influence blood pressure stability.
Note: Nursing students should always consult with their instructor or clinical preceptor and refer to specific medication references for accurate and up-to-date information on medication use and indications.
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.
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.
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.
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.
Best Nursing Books and Resources
These are the nursing books and resources that we recommend.
This is an excellent reference for nurses and nursing students. While it is a great resource for writing nursing care plans and nursing diagnoses, it also helps guide the nurse to match the nursing diagnosis to the patient assessment and diagnosis.
This handbook has been updated with NANDA-I approved Nursing Diagnoses that incorporates NOC and NIC taxonomies and evidenced based nursing interventions and much more.
All introductory chapters in this updated version of a ground-breaking text have been completely rewritten to give nurses the knowledge they require to appreciate assessment, its relationship to diagnosis and clinical reasoning, and the goal and use of taxonomic organization at the bedside.
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