Introduction for NANDA Nursing Diagnosis: Unstable Blood Pressure Risk
High-risk unstable blood pressure (HIBP) is defined as a sudden, severe fall or rise in blood pressure, either of which can cause grave consequences to a person’s health. To ensure prompt and effective interventions, it is essential that nurses are armed with knowledge of the signs and symptoms associated with HIBP diagnosis, as well as the interventions needed to manage it. The following article provides a brief overview of the nursing diagnosis related to HIBP and its management.
NANDA Nursing Diagnosis Definition
The NANDA-I approved nursing diagnosis for Unstable Blood Pressure Risk is: “Risk for Unstable Blood Pressure, initiated by sudden change in blood pressure”. The defining characteristics include:
- Fatigue or addition uneasiness
- Blurred vision
- Bona fide BP measurement (systolic / diastolic BP)
- Tachycardia / bradycardia
- Cool / clammy skin
Related Factors with Explanation
- Dehydration: Inadequate intake of fluids leads to decreased volume of intravascular fluid, resulting in decreased perfusion and blood pressure.
- Medication: Medications such as diuretics and nitrates used to maintain normal blood pressure can cause an unreceptive reaction resulting in dropping or growing of BP.
- Smoking: Environmental stimulation, such as smoking, can effect the constriction or enlargement of the blood vessels, which can lead to increasing or decreasing of BP.
Risk Population with Explanation
Patients at an increased risk of developing unsteady blood pressure include those with:
- Hypertension: High readings of systolic/diastolic pressure increase the risk of sudden changes in blood pressure.
- Hypoglycemia: Low glucose levels further decrease vasomotor constriction, resulting in sudden drops in blood pressure.
- Older adults: Elderly adults are sensitive to medications and environmental stimuli, which can even lead to dramatic fluctuation in blood pressure.
Associated Problems with Explanation
Uneven blood pressure is associated with many problems such as:
- Organ damage: Sudden rises and drops of the blood pressure will lead to inadequate oxygen and nutrition delivery to the vital organs.
- Neurological damage: Uneven blood pressure weakens the cerebral circulation, which can affect cognitive functioning.
- Cardiac events: Uneven and sudden changes in the heart rate and stroke volume can lead to significant cardiac events.
Suggestions of Use with Explanation
To prevent any untoward events due to uneven blood pressure, nurses should be aware of their patient’s blood pressure status. Hence, BP readings should be taken at least every 4 hours in high-risk patients. This is necessary to detect any changes in blood pressure that can result in an emergency situation. Moreover, it is important to create an intervention plan early on to prevent any harmful events.
Suggested Alternative NANDA Diagnosis with Explanation
Other than unstable blood pressure risk, there are other related nursing diagnoses that are commonly used. These include:
- Ineffective Tissue Perfusion, Cardiac: Inadequate delivery of oxygen and nutrition to the cardiac tissue results in poor organ functioning.
- Anxiety: Anxiety caused due to the fear of health deterioration may further exacerbate the problem.
- Ineffective Health Management: Not managing hypertension and other medical conditions by appropriate interventions may further add to the problem.
- Monitor important signs such as pulse rate and blood pressure regularly, particularly in high-risk patients.
- Patients suffering from HIBP should be closely monitored for indication of change in mental state, vision, and behavior.
- Encourage the patient to adhere to the treatment and lifestyle modifications suggested by the health care provider.
- Establish a network of support for the family members and the patient.
NOC Results with Explanation
Nursing interventions focused on unstable blood pressure can achieve the following expected outcomes, as prescribed by the NOC:
- Cardiac Output: Effective intravascular filling will improve cardiac output to normal limit.
- Blood Pressure: Appropriate management of fluid intake, medications, and other necessary interventions can maintain blood pressure within normal range.
- Neurological Status: Continuous monitoring of the neurological function can provide early detection and management of any variations.
- Health Maintenance: Education regarding health maintenance activities can assist the patient in controlling her condition.
NIC Interventions with Explanation
Involving evidence-based nursing interventions can than assist the patient reaching maximum outcome. Some of the commonly used NIC interventions that can promote effective management of the problem includes
- Fluid Therapy Management: Administration of IV Fluids as well as advice regarding oral intake can help in keeping the intravascular volume stable.
- Blood Pressure Monitoring: Measuring and recording of blood pressure is essential to detect any variation in the pressure readings.
- Medication Management: Administering protocol approved medications such as vasoactive agents is necessary to regulate the blood pressure.
- Infection Prevention and Control: Operative sterilization of all equipment used during incidents of HIBP is important to reduce the risk of infection.
- Environmental Management: Establishing a stress free environment and avoiding any sort of environmental stimulus is essential for regulation of blood pressure.
Effective management of unstable blood pressure requires vigilant monitoring, timely interventions, and adopting precautionary measures. The nurses should be aware of patient’s medical history, medications, and understand the nature of the problem. Further, utilizing evidence-based strategies, such as NAC/NIC interventions, is essential to providing quality care to the patient.
- What is high-risk unstable blood pressure? High-risk unstable blood pressure (HIBP) is defined as a sudden, severe fall or rise in blood pressure, either of which can cause grave consequences to a person’s health.
- Who are at risk for HIBP? Patients at an increased risk of developing unsteady blood pressure include those with hypertension, hypoglycemia, older adults, etc.
- What intervention strategies should be adopted for HIBP? To prevent any untoward events due to uneven blood pressure, nurses should be aware of their patient’s blood pressure status. Hence, BP readings should be taken at least every 4 hours in high-risk patients. Additionally, utilizing evidence-based strategies, such as NAC/NIC interventions, are essential to providing quality care to the patient.