Nursing Diagnosis
Risk for decreased cardiac
output related to increased
vascular vasoconstriction
Assessment:
Subjective Data: “I do not
really feel well, right now.
My blood pressure is
always high and I feel light
headed when I suddenly
move.” as claimed by
patient.
Objective Data:
-Pale in color
-Skin cool and moist to
touch
-Jugular vein can be easily
seen and bounding upon
palpation
-Verbalized light
headedness on sudden
change of position
-Easy fatigability and
occasional dyspnic
occurrences upon exertion
Patient Outcomes Nursing Interventions Nursing Interventions
Outcome Identification:
Nursing Care Plan for
 The patient will Independent: Hypertension
participate in
activities that 1. Monitor blood
reduce cardiac pressure
workload by periodically.
04/18/12. Measure both arms
 The patient will three times; 3-5
maintain blood mins apart while
pressure within patient is at rest for
acceptable range by initial evaluation.
04/19/12. 2. Note presence of,
 The patient will quality of central
demonstrate stable and peripheral
cardiac rhythm and pulses.
rate within patient’s 3. Auscultate heart
normal range by tones and breath
04/19/12. sounds
4. Observe skin color,
moisture,
temperature and
capillary refill time.
5. Note independent
or general edema
6. Provide a calm
environment;
minimizing noise;
limiting visitors and
length of stay.
7. Maintain activity
restrictions (bed
rest) and assist
patient with self-
care activities.
Nursing Interventions
Please refer to the Patient
Outcomes tab
1. Bounding carotid,
jugular, radial,
femoral pulses may
be observed/
palpated. Pulses in
the leg may be
diminished,
implicating effects
of vasoconstriction
and venous
congestion.
2. S3 and S4 heart
sounds may indicate
atrial and venous
hypertrophy and
impaired
functioning.
3. Presence of
adventitious breath
sounds may indicate
pulmonary
congestion
secondary to
developing heart
failure.
 8. Provide comfort 4. Presence of pallor;
measures, i.e. cool and moist skin
-Blood pressure ranging elevation of head and delayed
from 140/90 to 150/100 9. Encourage capillary refill may
mmHg, BP as of 6:00 relaxation be due to peripheral
A.M. 04/17/12 is 150/90 techniques like vasoconstriction or
mmHg guided imagery and decreased cardiac
distractions output.
10. Monitor response to 5. It may indicate
medications to heart failure,
control blood vascular or renal
pressure impairment.
-Pulse rate of 110 beats per 6. Promotes
minute as of 6:00 A.M. Depedent relaxation.
04/17/12 7. It reduces physical
11. Administer stress and stimuli
-Capillary refill of 2-3 medications like that affect the blood
seconds diuretics, alpha and pressure.
beta antagonists, 8. Decreases
calcium channel discomfort and may
blockers, and reduce sympathetic
vasodilators. stimulation
9. It helps reduce
Collaborative stressful stimuli,
thereby decreases
12. Instruct and blood pressure.
implement to
patient dietary
restrictions in
sodium, fat and
cholesterol
10. Response to drug is
dependent on both
the individual and
the synergistic
effect of the drug. It
is also important to
check for any
untoward signs and
symptoms of the
medications.
11. These medications
should be medically
prescribed by the
physician and dose
and timing of
medications should
be followed.
Checking BP prior
to giving of
medications is
always a must to
prevent
hypotension.
12. This restrictions
help manage fluid
retention and
decrease myocardial
workload.