A client has been diagnosed with hypertension. The nurse priority nursing diagnosis would be:
A. Ineffective health maintenance
B. Impaired skin integrity
C. Deficient fluid volume
D. Pain
Correct Answer: A. Ineffective health maintenance
Managing hypertension is the priority for the client with hypertension. Clients with hypertension frequently do not experience pain, deficient volume, or impaired skin integrity. It is the asymptomatic nature of hypertension that makes it so difficult to treat. Monitor and record BP. Measure both arms and thighs three times, 3–5 min apart while the patient is at rest, then sitting, then standing for initial evaluation. Use correct cuff size and accurate technique.
Option B: Impaired skin integrity is an inappropriate nursing diagnosis because there is no alteration in the skin in hypertension. Comparison of pressures provides a more complete picture of vascular involvement or scope of problem. Severe hypertension is classified in the adult as a diastolic pressure elevation to 110 mmHg; progressive diastolic readings above 120 mmHg are considered first accelerated, then malignant (very severe). Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease, when diastolic pressure is elevated.
Option C: The client with hypertension experiences no fluid deficit. Note presence, quality of central and peripheral pulses. Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be diminished, reflecting effects of vasoconstriction (increased systemic vascular resistance [SVR]) and venous congestion.
Option D: There is no pain experienced in hypertension. Auscultate heart tones and breath sounds. S4 heart sound is common in severely hypertensive patients because of the presence of atrial hypertrophy (increased atrial volume and pressure). Development of S3 indicates ventricular hypertrophy and impaired functioning. Presence of crackles, wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure.