Hypertension

Hypertension

Clinical Findings

Neuro: Dizziness, lightheadedness, vertigo, faintness, headache, anxiety, ALOC, restlessness, visual disturbances, seizures. Resp: Shortness of breath, hyperventilation. CV:Tachycardia, bradycardia, chest pain, palpitations, dysrhythmias, dependent edema, symptoms of CHF. Skin: Cool and moist, warm and flushed, tingling sensation. GI/GU: Nausea and vomiting. MS:Weakness, fatigue.

Nursing Interventions

■ Note: if SPB _220 or DPB _140 mm Hg, notify physician STAT. ■ Elevate Pt’s HOB to 30–45 degrees and offer reassurance. ■ Assess LOC and orientation. ■ Assess apical pulse for rate and rhythm. If Pt is monitored, assess ECG and manage dysrhythmias per ACLS protocol. ■ Assess for neuro deficits such as slurred speech, unequal pupils, facial droop, or weakness or numbness on one side of body and other associated findings such as chest pain; respiratory distress; rapid, thready pulse; or ALOC. ■ Administer supplemental oxygen titrated to SpO2 >90%. ■ Obtain and document baseline VS (HR, RR, BP, temp, SpO2), and obtain and record blood pressure readings in both arms. ■ Administer antihypertensive medication if ordered. ■ Review medical record (medication, recent labs, and treatments) for possible causes of rise in BP. ■ Notify physician of change in Pt status including pertinent assessment findings and interventions, if any implemented. ■ Consult physician about continued treatment, including ordering STAT 12-lead ECG, labs (BUN, creatinine, CBC, electrolytes, UA, and coagulation studies), chest x-ray, additional pharmacologic therapy (e.g., betablockers, ACE inhibitors, calcium channel blockers), or transfer to ICU. ■ Document assessments, any interventions, and outcome. ■ Note: If elevated BP is reasonably anticipated in relation to Pt’s clinical status, it is not immediately necessary to notify the physician, unless there exists a need to order (or clarify an order for) antihypertensive medications.