Nursing Diagnosis for Severe Hypertension | Acute Pain

Nursing Care Plan for Severe Hypertension

Nursing diagnosis: Acute pain may be related to increased cerebral vascular pressure

Possibly evidenced by

Reports of throbbing pain located in suboccipital region, present on awakening, and disappearing spontaneously after being up and about

Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists

Reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting

Desired Outcomes/Evaluation Criteria—Client Will

Pain Control

Report pain or discomfort is relieved or controlled.

Verbalize methods that provide relief.

Follow prescribed pharmacological regimen.

Nursing care plan intervention with rationale:

1.Determine specifics of pain, such as location, characteristics, intensity (on a 0 to 10 scale), onset, and duration. Note nonverbal cues.

Rationale: Facilitates diagnosis of problem and initiation of appropriate therapy. Helpful in evaluating effectiveness of therapy.

2. Encourage and maintain bedrest during acute phase, if indicated.

Rationale: Minimizes stimulation and promotes relaxation.

3. Provide or recommend nonpharmacological measures for relief of headache, such as placing a cool cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques, such as guided imagery and distraction; and diversional activities.

Rationale: Measures that reduce cerebral vascular pressure and that slow or block sympathetic response are effective in relieving headache and associated complications.

4. Eliminate or minimize vasoconstricting activities that may aggravate headache, such as straining at stool, prolonged coughing, and bending over.

Rationale: Activities that increase vasoconstriction accentuate the headache in the presence of increased cerebral vascular pressure.

5. Assist client with ambulation, as needed.

Rationale: Dizziness and blurred vision frequently are associated with vascular headache. Client may also experience episodes of postural hypotension, causing weakness when ambulating.

6. Provide liquids, soft foods, and frequent mouth care if nosebleeds occur or nasal packing has been done to stop bleeding.

Rationale: Promotes general comfort. Nasal packing may interfere with swallowing or require mouth breathing, leading to stagnation of oral secretions and drying of mucous membranes.

7. Administer analgesics, as indicated.

Rationale: Reduce or control pain and decrease stimulation of the sympathetic nervous system.

8. Administer anti-anxiety agents, such as lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium).

Rationale: May aid in the reduction of tension and discomfort that is intensified by stress.