For hypertension, prioritize: risk for decreased cardiac tissue perfusion → ineffective health management → deficient knowledge → imbalanced nutrition → risk for impaired renal function. Core interventions are correct BP technique (seated 5 min, correct cuff, two readings averaged), identifying the actual adherence barrier before adding a drug, validated home BP monitoring, DASH with a 1,500 mg sodium goal, guideline-directed therapy with K⁺/creatinine recheck at 2–4 weeks, and nurse-led follow-up. Target below 130/80 mmHg.
Assessment (subjective + objective)
Subjective: occipital morning headache, "I stopped my pills because they made me pee all night", no home BP monitor, adds salt at the table, sedentary, 12 pack-year smoking history, reports work stress and poor sleep.
Objective: BP 168/98 (repeat 164/96 after 5 min rest, correct cuff size), HR 84, BMI 33.4, waist 42 in, LDL 158, HbA1c 6.1%, urine albumin/creatinine 42 mg/g, retinal arteriolar narrowing, ECG with LVH voltage criteria.
Priority NANDA-I diagnoses
- Risk for decreased cardiac tissue perfusion AEB sustained BP 168/98, LVH on ECG, and LDL 158.
- Ineffective health management related to medication side effects and absent self-monitoring AEB self-discontinuation of antihypertensive therapy.
- Deficient knowledge regarding sodium intake, DASH pattern, and home BP technique.
- Imbalanced nutrition: more than body requirements AEB BMI 33.4, waist 42 in.
- Risk for impaired renal function AEB albumin/creatinine 42 mg/g.
NOC outcomes (SMART)
- Office BP < 130/80 within 12 weeks (per 2017 ACC/AHA target).
- Patient submits ≥ 12 home BP readings using correct technique before the 4-week visit.
- Patient states three high-sodium foods to avoid and the 1,500 mg/day sodium goal before discharge from clinic.
- Patient reports ≥ 150 min/week of moderate activity by week 8.
- Weight loss ≥ 5% of body weight by 6 months.
NIC interventions and rationale
- Measure BP with correct technique: seated 5 min, back supported, arm at heart level, correct cuff size, two readings averaged — improper technique routinely overestimates BP by 10–20 mmHg and drives unnecessary escalation.
- Elicit and address the actual adherence barrier before adding a drug — this patient stopped a diuretic for nocturia; morning dosing or a switch to an ACEi/CCB solves it without another prescription.
- Teach and validate home BP monitoring; give a written log or app — home readings predict cardiovascular outcomes better than office readings and improve adherence.
- DASH pattern with 1,500 mg sodium goal; review label reading and the top sodium sources (bread, deli meat, canned soup, pizza, sauces) — DASH plus sodium restriction lowers SBP 8–14 mmHg, comparable to a first-line drug.
- Reinforce guideline-directed pharmacotherapy (thiazide, ACEi/ARB, dihydropyridine CCB) and check K⁺/creatinine 2–4 weeks after any change.
- Screen for and treat sleep apnea, and assess alcohol, NSAID, and decongestant use — common reversible contributors to resistant hypertension.
- Teach hypertensive urgency warning signs: chest pain, focal weakness, vision change, severe headache, dyspnea.
- Schedule nurse-led follow-up at 2–4 weeks after any medication change — structured nurse-led titration clinics achieve control faster than usual care.
Evaluation
At week 12: office BP 128/78, 26 home readings logged with correct technique, patient names four high-sodium foods and reports 180 min/week walking, weight down 4.1 kg (4.6%). Outcomes 1–4 met; weight-loss outcome on track and continued to 6 months.
Frequently Asked Questions
Sources & Further Reading
- Whelton, P. K., et al.. 2017 ACC/AHA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Hypertension, 71(6), e13–e115.
- Appel, L. J., et al.. Effects on blood pressure of reduced dietary sodium and the DASH diet. New England Journal of Medicine, 344(1), 3–10.