Susceptible to fluctuating forces of blood flowing through arterial vessels, which may compromise health.
Risk Factors
Inconsistency with medication regimen; orthostasis
Associated Condition
Adverse effects of cocaine; adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs); adverse effects of steroids; cardiac dysrhythmia; Cushing Syndrome; electrolyte imbalance; fluid retention; fluid shifts; hormonal change; hyperosmolar solutions; hyperparathyroidism; hyperthyroidism; hypothyroidism; increased intracranial pressure; rapid absorption and distribution of anti-arrhythmia agent; rapid absorption and distribution of
diuretic agent; rapid absorption and distribution of vasodilator agents; sympathetic responses; use of antidepressant agents
NOC (Nursing Outcomes Classification) Suggested NOC Outcomes
Fatigue; Arrhythmia; Dizziness; Confusion; Blurred Vision; Circulation Status; Tissue Perfusion: Cardiac; Tissue Perfusion: Cellular; Vital Signs
E x a m p l e N O C O u t c o m e w i t h I n d i c a t o r s
Tissue Perfusion: Cardiac as evidenced by the following indicators: Heart rate/Arrhythmia/Profuse diaphoresis/Nausea/Vomiting. (Rate the outcome and indicators of Tissue Perfusion: Cardiac: 1 = severe, 2
= substantial, 3 = moderate, 4 = mild, 5 = none [see Section I].)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain vital signs within normal range
• Remain asymptomatic with cardiac rhythm (have absence of arrhythmias, tachycardia, or bradycardia)
• Be free from dizziness with changes in positions (lying to standing)
• Deny fatigue, nausea, vomiting
• Deny chest pain
NIC (Nursing Interventions Classification) Suggested NIC Interventions
Cardiac Care; Cardiac Precautions; Hypertension Management; Hypotension Management; Dysrhythmia Management; Vital Signs Monitoring
E x a m p l e N I C A c t i v i t y — Vi t a l S i g n s M o n i t o r i n g
Note trends and wide fluctuations in blood pressure; Monitor blood pressure while client is lying, sitting, and standing before and after position change as appropriate; Monitor blood pressure after patient has taken medications if possible; Monitor for central and peripheral cyanosis
Nursing Interventions and Rationales
▲ Hypertension (HTN) is a major risk factor for cardiovascular disease placing the client at increased risk of myocardial infarction and stroke (Whelton et al, 2017). EB:
The 2017 clinical practice guidelines for the management of adults with HTN now defines HTN as a blood pressure above 130/80 mm Hg for anyone at risk of a myocardial infarction or stroke. Significant emphasis is placed on ensuring the client understands the importance of lifestyle modifications to include regular exercise and dietary changes (Whelton et al, 2017).
• Provide client-specific education about the importance of a healthy lifestyle to reduce complications associated with HTN. EB: A heart-healthy diet with low-sodium content, maintaining a normal weight, limiting alcohol consumption, and a regular exercise program can lower the client's blood pressure and associated risk of cardiovascular disease (Whelton et al, 2017).
• Provide drug and client-specific education if medications are prescribed to manage
the client's HTN. Blood pressure medications may cause hypotension or secondary complications such as electrolyte imbalances, dehydration, and orthostasis (Whelton et al, 2017).
▲ Screen clients for secondary causes of HTN with abrupt onset or age <30 years. EB:
Secondary HTN should be explored so that the primary cause of the HTN is treated. The client should be evaluated for undetected renal disease, primary aldosteronism, obstructive sleep apnea (OSA), thyroid disease, and alcohol-induced HTN (Grossman & Messerli, 2012;
Whelton et al, 2017; Wolf et al, 2018).
▲ Review the client's past medical history. EB: Understanding the client's risk for secondary causes of HTN is important to establishing a proper plan of care and follow-up treatments (Wolf et al, 2018).
• Explore the client's subjective statements concerning poor sleep, report of snoring, and daytime fatigue. EB: OSA compromises cardiovascular health. Assessment of OSA can be easily incorporated into practice using valid and reliable assessment tools such as STOP Bang (Nagappa et al, 2015; Miller & Berger 2016). If OSA is assessed, the nurse should notify the provider for additional monitoring to address OSA and HTN management.
• Review the client's history of arrhythmias, especially a history of atrial fibrillation.
EB: Atrial fibrillation alters cardiac output and can cause hypotension and HTN episodes that result in client falls and/or altered mentation, or chest pain (Rapsomaniki et al, 2014).
• Review the client's current medications both prescribed and over the counter. EB:
Many medications and over-the-counter agents can cause HTN and interfere with antihypertension treatments (Grossman & Messerli, 2012).
• Steroid agents, administered at higher doses, (e.g., 80–200 mg/day) can trigger HTN (Grossman & Messerli, 2012). Teach the client to monitor blood pressure and report changes to their prescribing provider.
• Ask the client if they are prescribed antidepressant agents. Several antidepressant agents cause an elevation in blood pressure that may be progressively clinically significant if the diastolic blood pressure rises >90 mm Hg (Grossman & Messerli, 2012; Whelton et al, 2017).
• NSAIDs can induce HTN and/or interfere with antihypertensive therapy. EB: Ask the client if they use NSAIDS to include dose and frequency of consuming these over-the- counter drugs (Grossman & Messerli, 2012; Whelton et al, 2017).
• Over consumption of caffeine stimulates sympathetic activity, which causes a rise in blood pressure that can be followed by a decrease in blood pressure once the effects of the caffeine have worn off. EB: Ask the client to describe their caffeine consumption to include frequency, dose, and physical effects when consuming products containing caffeine (Grossman & Messerli, 2012; Turnbull et al, 2017).
• Licorice consumption may trigger HTN in some patients. EB: Licorice consumption can prolong cortisol metabolism associated with an 11β-hydroxysteroid dehydrogenase
deficiency leading to HTN. Ask the client about typical consumption of licorice (Ferrari, 2010;
Grossman & Messerli, 2012).
• Some herbal products may induce HTN and/or interfere with antihypertensive treatment. EB: Over-the counter herbal agents are poorly regulated; however, some agents such as arnica, bitter orange, blue-cohosh, dong quai, ephedra, ginkgo, ginseng, guarana, licorice, pennyroyal oil, Scotch broom, senna, southern bayberry, St. John’s wort, and yohimbine are known stimulants that may elevate blood pressure (Jalili et al, 2013). Ask the client about herbal agents to include dose, frequency, and reason for taking the herbal agent.
• Alcohol is known to elevate blood pressure and increases the client's risk of HTN.
EB: Inquire about the client’s typical alcohol consumption. Current recommendations suggest men should be limited to no more than two drinks per day and women to no more than one
standard alcohol drink per day (Whelton et al, 2017).
• Blood pressure may be unstable with substance abuse disorders (SUDs). Certain drugs have specific effects on the cardiovascular system. Clients may experience tachycardia along with severe hypotension or HTN with an overdose of opioid, cocaine, and synthetic cannabinoids (Akerele & Olupona, 2017).
• Cocaine use causes increased alertness and feelings of euphoria, along with dilated pupils, increased body temperature, tachycardia, and increased blood pressure.
Tachyarrhythmias and marked elevated blood pressure can be life-threatening.
Cocaine overdose can present as a myocardial infarction or arterial dissection (Hoffman, 2010;
Akerele & Olupona, 2017).
• Cocaine overdose is a medical emergency because of the risk of cardiac toxicity.
Treatment is focused on lowering body temperature with external cooling devices and antipyretic medications, administering sedation agents to treat hyperactivity, oxygen to address increased myocardial oxygen needs, and possible administration of antithrombotic agents if a myocardial infarction is suspected (Hoffman, 2010; Akerele & Olupona, 2017).
• Opioid intoxication results in changes in heart rate, slowed breathing, and decrease in blood pressure leading to loss of alertness. Opioid intoxication and overdose lead to primarily respiratory arrest with subsequent cardiovascular arrest (Jones et al, 2015; Akerele
& Olupona, 2017).
• Synthetic cannabinoids are man-made, mind-altering chemicals that may be added to foods or inhaled. There is a growing availability of these designer drugs in which adverse effects are not well known. EB: The primary effect of synthetic cannabinoid intoxication results in severe anxiety, paranoia, nausea, vomiting, and cardiovascular symptoms to include slurred speech, HTN, chest pain, skin pallor, muscle twitches, and hypokalemia that may lead to arrhythmias (Weaver, Hooper, & Gunderson, 2015; Akerele &
Olupona, 2017).
Critical Care
• Monitor the client for symptoms associated with chest pain, myocardial infarction, acute HTN, and hypotension. EB: Alterations in blood pressure, HTN, and hypotension adversely affect cardiac function and myocardial oxygen consumption that can result in myocardial muscle injury. Nursing interventions to monitor cardiac function and reduce oxygen needs should be implemented along with continuous cardiac function monitoring (Habib, 2018).
• Clients with hypertensive crisis will require close monitoring for signs and
symptoms consistent with acute renal failure, stroke, myocardial infarction, and acute heart failure. Many conditions may cause hypertensive crisis; however, uncontrolled HTN is the most common cause. Subjective symptoms include severe headache, shortness of breath, faintness, and severe anxiety (Habib, 2018).
• Myxedema coma is an acute emergency associated with hypothyroidism that manifests with severe hypotension, bradycardia, hypothermia, seizures, and coma.
Treatment focuses on supporting the client's blood pressure and restoring thyroid function by administering levothyroxine as prescribed, and supporting other organ systems (Njoku, 2013).
• Thyroid storm (thyrotoxicosis) is an acute, life-threatening, hypermetabolic state induced by excessive release of thyroid stimulating hormone (TSH). Symptoms are severe and include fever, tachycardia, HTN, congestive heart failure leading to hypotension and shock, profuse sweating, respiratory distress, nausea and vomiting, diarrhea, abdominal pain, jaundice, anxiety, seizures, and coma. EB: Nursing care focuses on symptom management to include reducing fever and cardiovascular support
(Njoku, 2013).
Pediatric
• HTN is an underrecognized disease in children. Current recommendations include annual blood pressure monitoring with more focused monitoring in high-risk
children. EB: Blood pressure monitoring should be initiated starting at age 3. Client risk factors that include obesity and inactivity should be addressed during well child visits to reduce the cardiovascular risks associated with childhood HTN (Dionne, 2017).
▲ Secondary causes of HTN should be explored in the absence of childhood obesity, known cardiovascular disease, family history. Kidney disease should be explored as a possible etiology of unexplained HTN (Dionne, 2017).
• Normal ranges for child and adolescent blood pressure measurements were recently updated to reflect age, gender, and weight considerations. Revisions to the blood pressure table are intended to facilitate earlier detection of abnormal blood pressure allowing for earlier intervention to reduce the risk of end-organ injury (Flynn et al, 2017).
Geriatric
• Risk of cardiac arrhythmias increases with advanced age placing the client at
increased risk of HTN and hypotension. EB: Ask the client about a history of arrhythmias, feeling his or heart “skip beats,” history of falls, and lightheadedness (Rapsomaniki et al, 2014).
• Comorbid cardiovascular disease risks increase with advanced age. EB: Clients, regardless of age, should be encouraged to engage in daily physical activity, consuming a heart-healthy diet, maintaining ideal body weight, and monitoring effects of prescribed cardiovascular medications (Whelton et al, 2017).
• Polypharmacy is a risk for both hypotension and HTN in older clients. Review the client’s medications frequently to include prescribed and over-the-counter medications and herbal agents.
Client/Family Teaching and Discharge Planning
• Nutritional education has been found to be an important variable in an individual maintaining cardiovascular health. EB: Assumptions have been made that individuals understand what a healthy diet means. Current guidelines suggest using props such as a plate and food types/portions along with practicing reading food labels are essential to client
nutritional education/learning (Allison, 2017).
• Teach the client to monitor blood pressure and to report changes in blood pressure to the provider and with each health care visit. EB: A recent systematic review and meta- analysis found that teaching the client to properly self-monitor blood pressure along with other cardiovascular treatments (i.e., diet, exercise, medications) has been found to clinically lower blood pressure for up to a year (Tucker et al, 2017).
References
Akerele E, Olupona T. Drugs of abuse. The Psychiatric Clinics of North America. 2017;40:501–517.
Allison RL. Back to basics: The effect of healthy diet and exercise on chronic disease management. South Dakota Medicine: The Journal of the South Dakota State Medical Association. 2017;5:10–18.
Dionne JM. Updated guideline may improve the recognition and diagnosis of hypertension in children and adolescents: Review of the 2017 AAP blood pressure clinical practice guideline. Current Hypertension Reports. 2017;19:84.
Ferrari P. The role of 11β-hydroxysteroid dehydrogenase type 2 in human hypertension. Biochimica et Biophysica Acta. 2010;1820(12):1178–1187.
Flynn JT, Kaelber DC, Baker-Smith CM. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904.
Grossman E, Messerli FH. Drug-induced hypertension: An unappreciated cause of secondary hypertension. The American Journal of Medicine. 2012;125:14–22.
Habib GB. Hypertension. Levine GN. Cardiology secrets. 5th ed. Elsevier: St. Louis; 2018:369–376.
Hoffman RS. Treatment of patients with cocaine-induced arrhythmias: Bringing the bench to the bedside.
British Journal of Clinical Pharmacology. 2010;69(5):448–457.
Jalili J, Askeroglu U, Alleyne B, et al. Herbal products that may contribute to hypertension. Plastic and Reconstructive Surgery. 2013;131(1):168–173.
Jones CM, Campopiano M, Baldwin G, et al. National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health. 2015;105(8):E55–E63.
Miller JN, Berger AM. Screening and assessment for obstructive sleep apnea in primary care. Sleep Medicine Reviews. 2016;29:41–51.
Nagappa M, Liao P, Wong J, et al. Validation of the STOP bang questionnaire as a screening tool for obstructive sleep apnea among different populations: A systematic review and meta-analysis. PLoS ONE.
2015;10(12):e014367; 10.1371/journal.pone.0143697.
Njoku MJ. Patients with chronic endocrine disease. The Medical Clinics of North America. 2013;97:1123–1137.
Rapsomaniki E, Timmis A, George J, et al. Blood pressure and incidence of twelve cardiovascular diseases:
Lifetime risks, healthy life-years lost, and age-specific associations in 1.25 million people. Lancet.
2014;383(9932):1899–1910.
Tucker KL, Sheppard JP, Stevens R, et al. Self-monitoring of blood pressure in hypertension: A systematic review and individual patient data meta-analysis. PLoS Medicine. 2017;14(9):e1002389;
10.1371/journal.pmed.1002389.
Turnbull D, Rodricks JV, Mariano GF, et al. Caffeine and cardiovascular health. Regulatory Toxicology and Pharmacology. 2017;89:165–185.
Weaver MF, Hooper JA, Gunderson EW. Designer drugs 2015: Assessment and management. Addiction Science & Clinical Practice. 2015;10(1):1–9.
Whelton PK, Carey RM, Aronow WS, et al.
ACC/AHA/AAPA/ABC/ACPM/AGS/APha/ASH/ASPC/NMA/PCNA guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Forces on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2017;71:e127–e248 [Retrieved from]
http://www.onlinejacc.org/content/71/19/e127?_ga=2.66372653.2004839219.1542569578- 506177100.1542569578.
Wolf M, Ewen S, Mahfoud F, et al. Hypertension: History and development of established and novel treatments. Clinical Research in Cardiology. 2018;107(Suppl. 2):S16–S29.
Disturbed Body Image
Gail B. Ladwig MSN, RN, Marsha McKenzie MA Ed, BSN, RN
NANDA-I Definition
Confusion in mental picture of one's physical self.
Defining Characteristics
Absence of body part; alteration in body function; alteration in body structure; alteration in view of one's body;
avoids looking at one's body; avoids touching one's body; behavior of acknowledging one's body; behavior of monitoring one's body; change in ability to estimate spatial relationship of body to environment; change in lifestyle; change in social involvement; depersonalization of body part by use of impersonal pronouns;
depersonalization of loss by use of impersonal pronouns; emphasis on remaining strengths; extension of body boundary; fear of reaction by others; focus on past appearance; focus on past function; focus on previous strength; heightened achievement; hiding of body part; negative feeling about body; nonverbal response to change in body; nonverbal response to perceived change in body; overexposure of body part; perceptions that
reflect an altered view of one's body appearance; personalization of body part by name; personalization of loss by name; preoccupation with change; preoccupation with loss; refusal to acknowledge change; trauma to nonfunctioning body part
Related Factors
Alteration in self-perception; cultural incongruence; spiritual incongruence
At-Risk Population
Developmental transition
Associated Condition
Alteration in body function; alteration in cognitive functioning; illness; impaired psychosocial functioning;
injury; surgical procedure; trauma; treatment regimen
NOC (Nursing Outcomes Classification) Suggested NOC Outcomes
Body Image; Self-Esteem; Acceptance Health Status: Coping, Personal Identity
E x a m p l e N O C O u t c o m e w i t h I n d i c a t o r s
Body Image as evidenced by the following indicators: Congruence between body reality, body ideal, and body presentation/Satisfaction with body appearance/Adjustment to changes in physical appearance. (Rate the outcome and indicators of Body Image: 1 = never positive, 2 = rarely positive, 3 = sometimes positive, 4 = often positive, 5 = consistently positive [see Section I].)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate adaptation to changes in physical appearance or body function as evidenced by adjustment to lifestyle change
• Identify and change irrational beliefs and expectations regarding body size or function
• Recognize health-destructive behaviors and demonstrate willingness to adhere to treatments or methods that will promote health
• Verbalize congruence between body reality and body perception
• Describe, touch, or observe affected body part
• Demonstrate social involvement rather than avoidance and use adaptive coping and/or social skills
• Use cognitive strategies or other coping skills to improve perception of body image and enhance functioning
• Use strategies to enhance appearance (e.g., wig, clothing)
NIC (Nursing Interventions Classification) Suggested NIC Interventions
Body Image Enhancement; Counseling; Eating Disorders Management; Referral; Self-Awareness Enhancement;
Self-Esteem Enhancement; Support Group; Therapy Group; Weight Gain Assistance
E x a m p l e N I C A c t i v i t i e s — B o d y I m a g e E n h a n c e m e n t
Determine client's body image expectations based on developmental stage; Assist client to identify actions that will enhance appearance
Nursing Interventions and Rationales
• Incorporate psychosocial questions related to body image as part of nursing assessment to identify clients at risk for body image disturbance.
• Maintain awareness of conditions or changes that are likely to cause a disturbed body image: removal of a body part or change/loss of body function such as
blindness or hearing loss, cancer survivors, clients with eating disorders, burns, skin disorders, or those with stomas or other disfiguring conditions, or a loss of perceived attractiveness such as hair loss.
• Be aware of the impact of treatments and surgeries that involve the face and neck and be prepared to address the client's psychosocial needs. EB: A cross-sectional survey of 150 patients with head and neck cancer demonstrated that radical neck surgery has a significant impact on their body image (Tsung-Min et al, 2017)
• Maintain understanding that age, gender, and other demographic identifiers may be associated with higher degrees of body image disturbance. EB: A study of body image disturbance in clients with stomas was demonstrated to be higher in males, younger adults, and overweight clients (Jayarajah & Samarasekera, 2017).
• Consideration should be given to providing counseling for women with breast cancer to assist with acceptance of the reality of the disease and to increase their resilience against breast surgery EB: Current research supports previous findings regarding the change in body image satisfaction following breast surgery (Mushtaq & Naz, 2017).
• Discuss treatment options and outcomes for women diagnosed with breast cancer.
Be prepared to explore options of lumpectomy versus mastectomy and the potential for reconstructive surgery. Include cosmetic and appliance options available to mitigate effects of mastectomy and/or chemotherapy, such as wigs and customized mastectomy bras. EB: Disturbance of body image has a relationship to the extent of the surgical procedure and the perceived ability to mitigate these body alterations (Rosenberg et al, 2013).
• Nurses and other health professionals should support clients with stomas in problem-focused coping strategies. EBN: It is also important for nurses to encourage patients to have contact with their friends and family, as well as stoma support groups (Burch, 2017).
Pediatric
• Many of the previously mentioned interventions are appropriate for the pediatric client.
• Educate parents on the role their own attitudes play in a child's body perception and acceptance. EB: A recent study confirms previous research demonstrating body
dissatisfaction is related to internalization of a socially acceptable body size and the pressure to change body shape among parents. There is an elevated risk that parents can model negative body attitudes to their children (Kościcka et al, 2016).
• When caring for teenagers, be aware of the impact of acne vulgaris on quality of life.
The impact was proportional to the severity of acne. Assess for symptoms of social