Nursing Assessment for Hypertension
Assessment is the main basis of the nursing process. Assessment is the first step in one of the nursing process (Gaffar, 1999). Activities undertaken in the assessment is gathering data and formulating priority issues. In the assessment - a careful collection of data about clients, their families, the data obtained through interviews, observation and examination.
The data collected can be divided into two (Kelliat, Budi Ana., 1995) :
Data base
Specific data relating to the current situation of the client which can be determined by the nurse, client or family.
The purpose of nursing assessment is to collect data, classify data and analyze the data. Thus concluded a nursing diagnosis (Gaffar, 1999).
Basic Nursing Assessment data by Doenges (1999) :
Activity / Rest
Symptoms: weakness, fatigue, shortness of breath, monotonous lifestyle.
Signs: The frequency of the heart increases, changes in heart rhythm, tachypnoea.
Circulation
Symptoms: History of hypertension, atherosclerosis, coronary heart disease / valve and cebrocaskuler disease, episodes of palpitations.
Signs: The increase in BP, pulse throbbing clear from the carotid, jugular, radial, tachycardia, valvular stenosis murmur, jugular venous distension, pale skin, cyanosis, cold temperature (peripheral vasoconstriction) filling the capillary may be slow / delayed.
Ego Integrity
Symptoms: History personality changes, anxiety, multiple stress factors (relationship, financial, work related).
Signs: Explosion mood, anxiety, continue narrowing of attention, tears burst, face muscles tense, breathing heaved, increased speech patterns.
Elimination
Symptoms: Impaired renal current or (such as obstruction or a history of kidney disease in the past).
Food / fluid
Symptoms: The preferred food that includes foods high in salt, fat and cholesterol, nausea, vomiting and changes in body weight lately (up / down) Historical use of diuretics.
Signs: normal weight or obese, the presence of edema, glikosuria.
Neuro Sensory
Genjala: Complaints of dizziness / headache, throbbing, headache, suboksipital (happens when you wake up and eliminate spontaneously after a few hours) Impaired vision (diplobia, blurred vision, epistaxis).
Signs: mental status, changes in waking, orientation, pattern / content of speech, effects, think the process, decreased hand grip strength.
Pain / discomfort
Symptoms: Angina (coronary artery disease / heart involvement), headache.
Respiratory
Symptoms: dyspnea related to the activities / work Tachypnoea, orthopnea, dyspnea, cough with or without the formation of sputum, history of smoking.
Signs: respiratory distress / respiratory accessory muscle use additional breath sounds (krakties / wheezing), cyanosis.
Security
Symptoms: Impaired coordination / gait, postural hypotension.
Nursing Assessment for Hypertension
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