PATHOPHYSIOLOGY
Systemic arterial hypertension is becoming an increasingly common health problem in children and adolescents, although it is still more prevalent in adults.
Hypertension is usually defined as an elevation of the systolic and/or diastolic blood pressures above the acceptable range for a given age and sex. Blood pressure readings above the 95th percentile for age and sex on three separate occasions over a 6 to 12 month period is one criterion for diagnosing hypertension in children.
Hypertension can be either primary or secondary. Primary hypertension, also called essential hypertension, has no known cause, although genetic and environmental factors may play a role in its development.
This is the most common form of hypertension in the adult population and may at times have its origin in childhood. An increased incidence of primary hypertension has recently been noted in older children.
Identified environmental factors that may contribute to this condition include stress, increased sodium intake, and obesity. Secondary hypertension results from an existing pathological process, such as renal disease, endocrine disorders, and cardiovascular disease.
It can also occur as a side effect of steroid therapy for chronic illness and ingestion of over-the-counter medications (caffeine, ephedrine), prescription medications (oral contraceptives), and other agents (cocaine, tobacco).
Research has led to speculation that primary hypertension may be a result of both genetic and environmental factors. In younger children, however,
hypertension is most often due to secondary causes such as renal disease. When renal ischemia is present, renin is released. Renin in turn causes the eventual formation of angiotensin II, a pressor agent that constricts the arterioles, thus elevating blood pressure. Angiotensin II decreases the glomerular filtration rate by its vasoconstrictive action and causes the release of aldosterone from the adrenal cortex. Aldosterone promotes sodium and water retention, resulting in increased blood volume and increased blood pressure.
Children with primary hypertension may be asymptomatic. Blood pressure should be checked routinely for all children 3 years of age and older.
Primary Nursing Diagnosis: Decreased Cardiac Output
Definition: Decrease in the amount of blood that leaves the left ventricle
Possibly Related to:
• Increased systemic vascular resistance
• Fluid volume overload
• Underlying disease process (specify)
• Impaired elasticity of the vessels
Assessment/Defining Characteristics of Child and/or Family:
Objective Data:
• Tachycardia
• Tachypnea
• Hypertension
• Palpitations
• Bounding carotid and radial pulses
• Delayed femoral pulse compared to radial pulse
• Absent or diminished lower extremity pulses
Subjective Data:
• Flushing of skin
• Headache
• Visual disturbance
• Epistaxis
• Chest pain
• Fatigue
Expected Outcomes:
Child will have adequate cardiac output as evidenced by
• heart rate within acceptable range (state specific range)
• respiratory rate within acceptable range (state specific range)
• blood pressure within acceptable range (state specific range)
• strong and equal peripheral pulses
• absence of flushing, headache, epistaxis, visual disturbance, chest pain, and fatigue
• adequate urine output (state specific range; 1 to 2 ml/kg/hr)
• lack of signs/ symptoms of decreased cardiac output (such as those listed under Assessment)
| Nursing Interventions | Rationale | Evaluation |
|---|---|---|
| Assess and record HR, RR, BP, and any signs/symptoms of decreased cardiac output (such as those listed under Assessment) every 2 to 4 hours and PRN. | If child experiences decreased cardiac output (CO) the HR and RR will increase and BP will decrease. | Document range of HR, RR, and BP. Describe any signs/symptoms of decreased cardiac output noted. |
| Administer diuretics on schedule. Assess and record effectiveness and any side effects noted (e.g., hypokalemia, dehydration). | Diuretics are given to decrease excess intravascular fluid through increased urine output, which will decrease the workload on the heart. | Document whether diuretics were administered on schedule. Describe effectiveness and any side effects noted. |
| Administer antihypertensives on schedule. Assess and record effectiveness and any side effects noted (e.g., dizziness, hypotension, GI disturbance). | Antihypertensive drugs work in various ways to lower BP in order to reach the ultimate goal of decreasing workload on the heart. | Document whether antihypertensive drugs were administered on schedule. Describe effectiveness and any side effects noted. |
| Weigh child daily on same scale at same time each day. Record results and compare to previous weight. | Sudden increase in weight gain may indicate extravascular fluid overload and may result in decreased CO. | Document weight and determine if it was an increase or decrease from the previous weight. |
| Keep accurate record of intake and output. | Decreased output may indicate decreased CO possibly due to a shift of the intravascular fluid into the interstitial space. | Document intake and output. |
| Teach child/family about characteristics of decreased cardiac output. Assess and record results. | Increased knowledge will assist the child/ family in recognizing and reporting changes in the child’s condition. | Document whether teaching was done and describe results. |
| Teach child/family about care. Assess and record child’s/family’s knowledge of and participation in care regarding accurate procedure for obtaining blood pressure, etc. | Education of child/ family will allow for accurate care. | Document whether teaching was done and describe results. |
Nursing Diagnosis: Noncompliance
Definition: Inability or unwillingness of an individual or individual’s caregiver to adhere to therapeutic recommendations
Possibly Related to:
• Asymptomatic condition
• Side effects of medication
• Dietary restrictions
• Forgetfulness in taking medications
• Lack of family support
• Developmental stage of life
Assessment/Defining Characteristics of Child and/or Family:
Objective Data:
• Evidence of increase in or return of symptoms
• Hypertension
• Weight gain
• Edema
Subjective Data:
• Inability to attain set goals
• Verbalization of difficulty in maintaining set goals
• Failure to keep appointments
Expected Outcomes:
Child/family will comply with therapeutic recommendations as evidenced by
• blood pressure within acceptable range (state specific range)
• lack of sudden weight gain and edema
• evidence of weight loss, if appropriate
• taking prescribed medications on schedule
• ability to follow food plan (reduced sodium)
• keeping clinical appointment after discharge
• following exercise program (if indicated)
• lack of signs/ symptoms of noncompliance (such as those listed under Assessment)
| Nursing Interventions | Rationale | Evaluation |
|---|---|---|
| Assess and record BP and any signs/ symptoms of noncompliance (such as those listed under Assessment) every 2 to 4 hours and PRN. | If BP increases above the desired level, this will decrease cardiac output. Document range of BP. | Describe any characteristics of decreased compliance in taking BP on schedule. |
| Weigh child daily on same scale at same time each day. Record results and compare to previous weight. | Sudden increase in weight gain may indicate extravascular fluid overload and may result in increased blood pressur and decreased CO. | Document weight and determine if it was an increase or decrease from the previous weight. |
| Teach child/family about characteristics of noncompliant behavior. Assess and record results. | Increased knowledge will assist the child/ family in recognizing and reporting changes in the child’s condition. | Document whether teaching was done and describe any successful measures used to help child/family comply with therapeutic recommendations. |
| Teach child/family about care. Assess and record child’s/family’s knowledge of and participation in care regarding accurate procedure for obtaining blood pressure, etc. | Education of child/ family will allow for accurate care. | Document whether teaching was done and describe results. |
Related Nursing Diagnoses :
Deficient Knowledge (Child/Family): related to
a. disease process
b. continuing home management (including diet, exercise, medications)
Activity Intolerance related to
a. fatigue
b. side effects of medication
Acute Pain related to
a. headache
b. chest pain
Ineffective Tissue Perfusion: related to increased vascular resistance
Compromised Family Coping: related to needed changes in lifestyle
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