Nanda - Nursing Care Plan

Showing posts with label Hypertensive Heart Disease. Show all posts
Showing posts with label Hypertensive Heart Disease. Show all posts

Nursing Assessment for Hypertensive Heart Disease

Hypertensive heart disease is heart disease caused by hypertension. Hypertension that is not controlled for a long time causing the left ventricle hypertrophy (LVH).

The main causes of hypertensive heart disease is chronic hypertension. Hypertension in adults is caused by several things including:
Essential hypertension occurred in 90% of cases of hypertension in adults.
Secondary hypertension 10% of cases of hypertension in adults is caused by abnormalities in the kidneys, endocrine disorders, increased ICT, etc.

In the early stages of hypertension, will appear the signs as a result of chronic sympathetic stimulation. Heart beat faster and stronger. Occurred hyper circulation that may result from increased activity and neurohumoral system accompanied by hipervolumia. At an advanced stage, there will be a compensation mechanism in the form of heart muscle hypertrophy of the left ventricle and increased peripheral vascular resistance. Will appear shortness of breath in patients by the presence of diastolic interference.

The assessment focused on the physical and psychological disorders caused by HHD. The existence of a long history of hypertension and a history of hypertension and heart disease in the family.

Data base assessment:

1. Activity / rest
Symptoms: There is weakness, fatigue, shortness of breath.
Signs: Heart rate increases, changes in heart rhythm, tachypnea.

2. Circulation
Symptoms: A history of hypertension, atherosclerosis, coronary heart disease and cerebrovascular disease.
Symptoms: Increased blood pressure, pulse clear the area of the carotid, jugular and radial. Femoral pulse slowed, while the pulse popliteal, tibial and dorsalis pedis becoming weaker.
Arising tachycardia and dysrhythmias, audible voice S4 atrial gallop.
Skin discoloration occurs in the extremities, cold temperatures, pale skin, cyanosis.

3. Ego integrity
Symptoms: The change of personality, anxiety, depression, anger, multiple stress factors.
Symptoms: Restlessness, narrowing the field of attention, crying, facial muscle tension, increased speech patterns, often sighed.

4. Elimination
Symptoms: The presence of disorders of the kidneys.

5. Food / liquids
Symptoms: The habit of eating foods high in salt, fat and cholesterol. Feelings of nausea and vomiting, weight changes, use of diuretics.
Signs: Normal weight or obese. Arising edema (general or specific).

6. Neuro sensory
Symptoms: The existence of complaints of dizziness, throbbing head, sub-occipital headache, weakness on one side of the body, impairments, and epistaxis may occur.

7. Pain / discomfort
Symptoms: There angina, intermittent pain in the legs as indications of arteriosclerosis, severe occipital headache, abdominal pain.

8. Breathing
Symptoms: dyspnoea associated with the activity, tachypnea, orthopnea, cough with or without sputum, a history of smoking.
Signs: The use of accessory respiratory muscles, the additional breath sounds, cyanosis.

9. Learning
Symptoms: Risk factors family history of hypertension, atherosclerosis, heart disease, diabetes, cerebrovascular disease / kidney. Race factor, the use of drugs / alcohol.

HHD Hypertensive Heart Disease - 5 Nursing Diagnosis Interventions

Hypertensive heart disease refers to heart problems that occur because of high blood pressure. These problems include:
  • Coronary artery disease and angina
  • Heart failure
  • Thickening of the heart muscle (called hypertrophy)

HHD can not only be caused by high blood pressure, but it can also lead to heart disease, stroke, thickened blood vessels, and heart attack. It can also cause sudden death.

Symptoms of HHD include:
  • Shortness of breath
  • Fatigue
  • Irregular pulse
  • Weight gain
  • Nausea
  • Bloating
  • Swelling of feet
  • Chest pain
  • Dizziness
  • Sweating


Nursing Diagnosis and Interventions for HHD Hypertensive Heart Disease

1. Acute Pain: Chest pain related to tissue ischemia due to decreased oxygen supply.

Goal:
  • Chest pain is gone.
  • Calm face expression.
  • Vital signs within normal limits.

Interventions :
  • Adjust the position of the patient semi-fowler
  • Collaboration with a physician for treatment
  • Give analgesics according to the medical program
  • Assess chest pain after a given action
  • Observation of vital signs


2. Ineffective Tissue Perfusion: cerebral related to decreased supply of oxygen and nutrients in the brain due to hypertension.

Goal:
  • The patient does not feel dizzy
  • The patient does not look uneasy
  • There is no sign of change in mental status are lacking.
  • Normal vital signs

Interventions :
  • Observation of vital signs
  • Assess history of hypertension
  • Observation of changes in sensory and motor
  • Instruct the patient to bedrest
  • Collaboration of anti-hypertensive therapy


3. Ineffective Breathing Pattern related to increased compensation body to increase oxygen supply to the tissues.

Goal:
  • Patient does not feel shortness of breath
  • Normal breathing frequency
  • Regular breathing rhythm
  • No increase in chest retraction

Interventions :
  • Assess the patient's level of anxiety
  • Observation of vital signs
  • Give oxygen as needed
  • Atue sitting with semi-Fowler position

4. Disturbed Sleep Pattern related to the feeling of dizziness.

Goal:
  • Patient can sleep as needed
  • Patient does not look lethargic
  • Normal vital signs
  • Normal blood pressure within 3 days of treatment

Interventions :
  • Assess the patient's ability to adapt to headache
  • Assess the patient's ability to rest and sleep needs
  • Teach relaxation techniques
  • Create a calm atmosphere
  • Limit visitors
  • Collaboration with physicians for the provision of medicines

5. Anxiety related to lack of knowledge about the disease, treatment program and maintenance actions to be performed and experienced.

Goal:
  • Patient look calm
  • Patients cooperative in care and treatment programs
  • Increase patients' knowledge about the disease, the signs and the conditions experienced, as well as the complications that may occur.

Interventions :
  • Assess the patient's anxiety
  • Provide an opportunity for patients to express anxiety
  • Provide a description of the information about: disease condition, food on abstinence and the reason, care and treatment programs will be carried out, break relations with the condition of the disease
  • Provide an opportunity for patients to explain the re-explanation.