Nursing Guide to Hypertension: Nursing Diagnosis, Interventions, & Care Plans

Hypertension General overview 

Hypertension is a chronic condition indicated by constant elevated arterial blood pressure. It is one of the most common noncommunicable diseases worldwide and a major modifiable risk factor for cardiovascular disease, stroke, heart failure, chronic kidney disease, and premature mortality. Because hypertension is often asymptomatic, it is frequently called the “silent killer.” Nurses help with screening, early identification, patient education, ongoing monitoring, and long-term management across inpatient, outpatient, and community settings. 

Blood pressure represents the force applied by circulating blood on the arterial walls. It is expressed as two values: systolic blood pressure, which is the pressure during cardiac contraction, and diastolic blood pressure, which is the pressure during cardiac relaxation. Hypertension is identified when blood pressure readings are steadily above established thresholds on more than one occasion, using proper technique and validated devices. 

International and national guidelines vary slightly, but in adults, hypertension is typically defined as systolic blood pressure at or above 130 to 140 mm Hg or diastolic blood pressure at or above 80 to 90 mm Hg, depending on the guideline and risk profile. Clinical decisions are based on the overall cardiovascular risk, not blood pressure alone. 

From a nursing perspective, hypertension care includes: 

• Accurate and reproducible blood pressure measurement
• Identification of symptoms and complications
• Assessment of lifestyle factors and social determinants of health
• Support for medication adherence and self management
• Early recognition of hypertensive urgency and emergency
• Education on risk reduction and when to seek medical attention 

Nurses are often the first healthcare professionals to detect elevated blood pressure in routine visits, emergency departments, workplaces, schools, and community screening events. High-quality nursing practice can significantly influence early diagnosis, treatment success, and long-term outcomes. 

Hypertension is a global problem and is defined as a sustained elevation of arterial blood pressure. The term high blood pressure is how most people refer to hypertension. 

According to the American Heart Association (2017), a person must fit into one of the following stages to receive a diagnosis of hypertensive: 

• Elevated systolic blood pressure (BP) 120 to 129 mmHg and a diastolic BP less than 80 mmHg
• Stage 1 hypertension: Systolic BP 130 to 139 mmHg or diastolic BP 80 to 89 mmHg
• Stage 2 hypertension: Systolic BP 140 mmHg or higher or diastolic BP 90 mmHg or higher
• Hypertensive crisis: Systolic BP ≥ 180 mmHg and/or diastolic BP ≥ 120 mmHg 

Etiology and epidemiology 

Etiology 

Hypertension can be categorized broadly into: 

• Primary (essential) hypertension
  • Accounts for approximately 90 to 95 percent of adult cases.
  • No single identifiable cause.
  • Results from a complex interaction of genetic predisposition, environmental influences, and lifestyle factors.
  • Contributing mechanisms include increased sympathetic nervous system activity, dysregulation of the renin angiotensin aldosterone system, impaired sodium excretion, vascular stiffness, and endothelial dysfunction.
• Secondary hypertension
  • Accounts for approximately five to 10 percent of cases.
  • Caused by an identifiable and potentially reversible condition.
  • Important causes include:
    • Chronic kidney disease and renovascular disease
    • Primary aldosteronism
    • Pheochromocytoma and other catecholamine secreting tumors
    • Cushing syndrome
    • Thyroid dysfunction (hypothyroidism or hyperthyroidism)
    • Obstructive sleep apnea
    • Coarctation of the aorta
    • Drug-induced hypertension, for example, from oral contraceptives, NSAIDs, corticosteroids, calcineurin inhibitors, some antidepressants, and illicit drugs such as cocaine and amphetamines 

Identification of secondary hypertension is critical because treatment of the underlying cause may improve or normalize blood pressure and reduce medication burden. 

Risk factors 

Risk factors for primary hypertension include: 

• Aging
• Positive family history of hypertension or cardiovascular disease
• Overweight and obesity, especially central adiposity
• High-sodium and low-potassium intake
• Excessive alcohol consumption
• Physical inactivity or sedentary lifestyle
• Smoking and exposure to tobacco products
• Chronic stress and exposure to traumatic events
• Race and ethnicity, with higher prevalence and complications in some populations 

These risk factors are often categorized as modifiable and non-modifiable, which help simplify prevention strategies. Many of the modifiable factors present opportunities for prevention and health promotion. 

Epidemiology 

Hypertension is highly prevalent worldwide and represents a leading cause of morbidity and mortality. 

Key points: 

• More than one billion adults globally are estimated to have hypertension.
• Prevalence increases with age. Many high-income countries report that more than 50 percent of adults older than 60 years are hypertensive.
• A large proportion of people with hypertension remain undiagnosed or inadequately treated.
• Among those treated, many do not achieve the goal blood pressure due to factors such as inadequate therapy, poor adherence, therapeutic inertia, and limited access to care.
• Hypertension contributes substantially to the global burden of ischemic heart disease, stroke, heart failure, peripheral arterial disease, chronic kidney disease, and dementia. 

These epidemiologic realities make hypertension detection and management a priority in nursing practice, public health initiatives, and health system planning. 

ICD 10 code 

Hypertension-related diagnoses are found primarily in the I10 to I15 blocks of ICD-10. 

Commonly used codes include: 

• I10
  • Essential (primary) hypertension
  • Used when there is no specified secondary cause or associated hypertensive heart or kidney disease documented.
• I11.0
  • Hypertensive heart disease with heart failure
• I11.9
  • Hypertensive heart disease without heart failure
• I12.0
  • Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease
• I12.9
  • Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease or unspecified chronic kidney disease
• I13.0 to I13.2
  • Hypertensive heart and chronic kidney disease, with or without heart failure, and with different stages of chronic kidney disease
• I15.x
  • Secondary hypertension, which includes codes such as:
    • I15.0 Renovascular hypertension
    • I15.1 Hypertension secondary to other renal disorders
    • I15.2 Hypertension secondary to endocrine disorders 

Nurses are usually not responsible for selecting ICD-10 codes, but accurate, specific clinical documentation of: 

• Blood pressure readings
• Underlying conditions such as chronic kidney disease, heart failure, or endocrine disorders
• Clinical symptoms and relevant findings 

Nursing documentation and reporting of symptoms or values supports coders and providers in choosing the correct codes and justifies treatment intensity. 

Typical sources for ICD-10 information include: 

• World Health Organization. International statistical classification of diseases and related health problems, 10th revision (ICD-10).
• Centers for Medicare and Medicaid Services. ICD-10-CM official guidelines for coding and reporting. 

Diagnosis 

Diagnosis of hypertension requires accurate, repeated blood pressure measurements and evaluation of cardiovascular risk and potential secondary causes. 

Blood pressure measurement 

Nurses have a key responsibility for proper measurement technique. Errors can significantly affect diagnosis and management. 

Preparation: 

• Ensure the patient has avoided smoking, caffeine, and vigorous exercise for at least 30 minutes before measurement.
• Ask the patient to empty their bladder if needed.
• Allow the patient to sit quietly for at least five minutes before the first reading. 

Positioning: 

• Seat the patient with their back supported, feet flat on the floor, and legs uncrossed.
• Support the arm at heart level.
• Use a properly sized cuff, with length 80 percent and width 40 percent of arm circumference. 

Technique: 

• Use a validated, calibrated device, either automated or manual.
• If manual, use standard auscultatory technique with a stethoscope over the brachial artery.
• Take at least two readings, separated by 1 to 2 minutes, and average them.
• If readings differ substantially, take additional measurements.
• Obtain blood pressure in both arms at the first visit, using the higher arm for future measurements. 

Office and out of office measurements 

Diagnosis should be based on more than one visit, except in clear cases of hypertension with very high readings or evidence of acute target organ damage. 

Additional approaches: 

• Home blood pressure monitoring (HBPM):
  • Patients use validated devices at home, often two readings morning and evening for several days.
  • It helps identify white coat hypertension and masked hypertension.
• Ambulatory blood pressure monitoring (ABPM):
  • A portable device measures blood pressure at regular intervals over 24 hours.
  • This is considered the gold standard in many guidelines for confirming diagnosis. 

Clinical evaluation 

Once elevated blood pressure is identified, a comprehensive evaluation is required to: 

• Confirm persistent hypertension.
• Assess for target organ damage.
• Estimate global cardiovascular risk.
• Screen for secondary causes. 

History: 

• Duration and pattern of elevated blood pressure
• Previous readings and treatments
• Symptoms such as headache, visual changes, chest pain, dyspnea, palpitations, neurologic symptoms, or claudication
• History of cardiovascular disease, stroke, kidney disease, diabetes, or sleep apnea
• Medication use, including over-the-counter and herbal products
• Alcohol, tobacco, and recreational substance use
• Dietary habits, especially sodium intake, and physical activity
• Family history of hypertension and premature cardiovascular disease 

Physical examination: 

• Accurate blood pressure in both arms, and in some cases, measurement in sitting and standing positions to evaluate for orthostatic changes
• Pulse rate and rhythm
• Body mass index and waist circumference
• Cardiac examination for murmurs, gallops, or displaced point of maximal impulse
• Lung examination for rales or wheezes
• Vascular examination for bruits, diminished peripheral pulses, or edema
• Neurologic screening for focal deficits
• Fundoscopic examination for hypertensive retinopathy when feasible 

Laboratory and diagnostic tests: 

Typical baseline investigations include: 

• Serum electrolytes, urea, and creatinine to assess kidney function and identify secondary causes such as hyperaldosteronism.
• Fasting glucose or HbA1c for diabetes screening
• Fasting lipid profile
• Urinalysis for proteinuria or hematuria
• Electrocardiogram to detect left ventricular hypertrophy, arrhythmias, or ischemic changes
• Additional tests in selected patients, such as echocardiography, renal ultrasound, screening for endocrine disorders, or sleep studies 

Hypertensive urgency and emergency 

Nurses must recognize signs that suggest severe acute hypertension: 

• Hypertensive urgency: markedly elevated blood pressure, usually systolic above 180 mm Hg or diastolic above 110 to 120 mm Hg, without acute target organ damage.
• Hypertensive emergency: severe elevation with evidence of acute end-organ damage, such as encephalopathy, stroke, myocardial infarction, acute heart failure, aortic dissection, or acute kidney injury. 

Symptoms of hypertensive emergency may be severe headaches, confusion, visual disturbances, chest pain, shortness of breath, seizures, or decreased urine output. These situations require immediate physician evaluation and often intensive care. 

Management 

Management of hypertension includes lifestyle modification for all patients and pharmacologic therapy for many. The goal is to reduce blood pressure to target levels and lower overall cardiovascular risk. 

Lifestyle modification 

Nurses are central in counseling, teaching, and reinforcing changes, including: 

• Dietary modification:
  • Reduction of sodium intake, often to less than 1500 to 2000 mg per day, depending on guidelines and patient factors.
  • Adoption of heart-healthy patterns such as the DASH diet, rich in fruits, vegetables, low-fat dairy products, whole grains, and lean proteins.
  • Limiting saturated and trans fats, refined carbohydrates, and added sugars.
• Weight management:
  • Encouragement of weight loss in individuals who are overweight and obese.
  • Even a five to 10 percent decrease in body weight can lead to clinically meaningful blood pressure reductions.
• Physical activity:
  • Promotion of regular aerobic exercise, such as brisk walking, for at least 150 minutes per week of moderate intensity or 75 minutes per week of vigorous intensity activity, plus muscle strengthening activities two or more days per week if medically appropriate.
• Alcohol moderation:
  • Limiting alcohol intake. Many guidelines recommend no more than one drink per day for female patients and two for male patients, and in some patients, less is preferable.
• Smoking cessation:
  • Counseling and referral to tobacco cessation programs, pharmacotherapy, and behavioral support. While smoking does not directly change blood pressure dramatically, it greatly increases cardiovascular risk.
• Stress management and sleep health:
  • Encouraging stress reduction techniques and adequate sleep, including assessment and treatment of sleep apnea when suspected. 

Pharmacologic therapy 

When lifestyle interventions alone are insufficient or when blood pressure is significantly elevated, or the patient has high cardiovascular risk, medication therapy is indicated. 

Common first-line classes include: 

• Thiazide or thiazide like diuretics
• Calcium channel blockers
• Angiotensin converting enzyme (ACE) inhibitors
• Angiotensin II receptor blockers (ARBs) 

Choice depends on age, race, or ethnicity patterns in local guidelines, comorbid conditions, and potential side effects. Beta blockers, mineralocorticoid receptor antagonists, and other agents are used in specific circumstances. 

General principles: 

• Many patients require two or more medications to achieve the target blood pressure.
• Fixed-dose combination pills can improve adherence.
• Dosing is adjusted based on response and tolerability.
• Careful monitoring is required, especially of electrolytes and kidney function, when using ACE inhibitors, ARBs, and diuretics. 

Nursing roles in medication management: 

• Reviewing medication lists for possible contributors to hypertension
• Assessing adherence, barriers such as cost or complexity, and side effects
• Encouraging use of pill organizers, reminder systems, and linking medication times with daily routines
• Monitoring blood pressure response and reporting changes to providers 

Nursing care plan 

A comprehensive nursing care plan for a patient with hypertension should address physiological, psychological, and educational needs. 

Priority problems 

• Ineffective health maintenance related to knowledge deficit, low health literacy, or cultural factors
• Risk for decreased cardiac output related to sustained elevated systemic vascular resistance
• Risk for nonadherence to therapeutic regimen related to complex medication schedule and lifestyle changes
• Risk for impaired tissue perfusion, cardiac, cerebral, or renal, related to chronic hypertension
• Anxiety related to new diagnosis or fear of complications 

Example goals 

Short-term goals: 

• Patient will verbalize understanding of hypertension, risk factors, and treatment plans before discharge or end of visit.
• Patient will demonstrate proper techniques for home blood pressure monitoring.
• Patient will identify at least two personal strategies to reduce dietary sodium. 

Long term goals: 

• Patient will maintain blood pressure within an individually determined target range.
• Patient will adhere to medication and follow-up appointments at least 90 percent of the time as reported or documented.
• Patient will report improvement in lifestyle behaviors such as increased physical activity or smoking cessation. 

Planning should incorporate patient preferences, cultural considerations, financial resources, social support, and comorbid conditions. 

Nursing considerations 

Hypertension management is an ongoing partnership between the patient and healthcare team. Key nursing considerations include: 

• Person-centered care: Tailor recommendations to the patient’s readiness to change, beliefs, cultural practices, and priorities.
• Health literacy: Use plain language, teach back techniques, and written materials at an appropriate reading level.
• Social determinants of health: Recognize that access to healthy food, safe places to exercise, transportation, and medication affordability significantly influence outcomes. Connect patients with community resources and social services when possible.
• Stigma and emotional response: Some patients experience denial, fear, or anxiety after diagnosis. Empathetic communication and supportive counseling are important.
• Comorbidities: Many patients have diabetes, chronic kidney disease, or other conditions that require coordination of care and adjustment of medications.
• Cultural dietary patterns: Help patients adapt traditional diets rather than simply replacing them, for example by lowering sodium in familiar dishes. 

In acute care settings, nurses monitor for signs of hypertensive urgency or emergency, promote early mobilization, ensure appropriate medication administration, and prepare patients for safe discharge with follow-up plans. 

Assessment 

Nursing assessment of a patient with hypertension includes: 

Subjective data 

• Complaints, such as headache, dizziness, blurred vision, chest pain, shortness of breath, palpitations, or fatigue
• History of elevated blood pressure, previous treatments, and responses
• Current medication regimen, including nonprescription and herbal supplements
• Diet, physical activity, smoking, alcohol use, and sleep patterns
• Psychosocial aspects, including stress, coping strategies, and social support
• Understanding of hypertension and perception of risk 

Objective data 

• Accurate blood pressure measurements, including orthostatic measurements when indicated
• Heart rate, respiratory rate, and temperature
• Height, weight, and body mass index
• Cardiac, pulmonary, and peripheral vascular examination findings
• Evidence of end-organ damage, such as edema, decreased urine output, or neurologic changes
• Review of laboratory results for electrolytes, kidney function, glucose, lipids, and urinalysis 

Assessment is ongoing and guides refinement of the care plan and patient education. 

Nursing diagnosis or risk for 

Common nursing diagnoses for patients with hypertension include: 

• Ineffective health maintenance related to knowledge deficit, complexity of therapeutic regimen, or low health literacy, as evidenced by inconsistent blood pressure monitoring or uncertainty about medications.
• Risk for decreased cardiac output related to increased afterload.
• Risk for impaired tissue perfusion (cerebral, cardiac, renal, peripheral) related to chronic elevated blood pressure.
• Noncompliance or risk for noncompliance related to side effects, cost of medications, or lack of perceived symptoms.
• Anxiety related to threat of disease progression or potential complications.
• Overweight or obesity related to imbalance between calorie intake and expenditure. 

These diagnoses help structure individualized interventions and expected outcomes. 

Interventions 

Nursing interventions aim to control blood pressure, prevent complications, and promote self-management. 

Blood pressure monitoring 

• Use proper measurement technique consistently.
• Schedule and perform regular blood pressure checks according to patient risk level and setting.
• Teach patients and caregivers how to use home blood pressure monitors accurately.
• Encourage keeping a blood pressure log to share with providers. 

Medication-related interventions 

• Verify medication list and reconcile on each encounter.
• Administer medications as prescribed in inpatient settings and monitor for side effects such as dizziness, cough, electrolyte abnormalities, or swelling.
• Educate patients on the purpose of each medication, dosing schedule, potential side effects, and what to do if a dose is missed.
• Encourage not to stop medications abruptly without consulting a provider.
• Collaborate with pharmacists when cost, side effects, or complex regimens are barriers. 

Lifestyle support 

• Provide individualized counseling on sodium reduction, for example, by reading food labels, limiting processed foods, and not adding salt at the table.
• Suggest realistic physical activity goals based on functional status.
• Offer referrals to dietitians, exercise programs, or smoking cessation resources.
• Use motivational interviewing techniques to support behavior change rather than simply instructing. 

Monitoring for complications 

• Assess for chest pain, shortness of breath, neurologic changes, or sudden severe headache, and respond according to emergency protocols.
• Monitor kidney function and urine output, especially in patients on ACE inhibitors, ARBs, or diuretics.
• Watch for orthostatic hypotension, particularly in older adults and those on multiple antihypertensive agents. 

Education and psychosocial interventions 

• Provide ongoing education, not just at diagnosis.
• Encourage involvement of family or caregivers when appropriate.
• Address myths such as, “If I feel fine, my blood pressure must be fine.”
• Support coping strategies that reduce stress and promote adherence. 

Expected outcomes 

With effective management and nursing support, expected outcomes for patients with hypertension may include: 

• Blood pressure maintained within individualized target range on most readings.
• Reduction in overall cardiovascular risk profile through improved lifestyle habits.
• No development or progression of major target organ damage, such as stroke, myocardial infarction, heart failure, or chronic kidney disease, during the period of care.
• Patient demonstrates accurate self-monitoring of blood pressure and understands when to seek medical help.
• Improved adherence to medication therapy and follow up appointments.
• Patient reports improved understanding of hypertension and confidence in managing the condition. 

In the inpatient setting, additional outcomes include stable blood pressure during hospitalization, avoidance of hypertensive crises, and safe transition to home or another care setting with clear instructions. 

Individual or caregiver education 

Education is a continuous process and should be reinforced at every contact. 

Key teaching points: 

• Nature of hypertension
  • Explain that hypertension is often asymptomatic but still damaging if uncontrolled.
  • Clarify that treatment aims to prevent future complications rather than simply relieve symptoms.
• Blood pressure targets
  • Discuss individual target blood pressure based on age, comorbidities, and provider recommendations.
  • Emphasize the importance of regular monitoring and recording measurements.
• Medication adherence
  • Stress taking medications exactly as prescribed.
  • Explain what to do if a dose is missed.
  • Review common side effects and when to contact a provider.
• Lifestyle changes
  • Provide specific, achievable steps for diet, activity, and smoking cessation.
  • Work with the patient to set short-term goals, for example, limiting sugary beverages or walking for 10 to 15 minutes most days.
• Recognition of warning signs
  • Educate on symptoms that require urgent evaluation, such as chest pain, severe shortness of breath, weakness or numbness on one side of the body, sudden difficulty speaking, sudden severe headache, or vision changes.
• Use of home devices
  • Demonstrate correct use of home blood pressure monitors.
  • Ensure the cuff size is appropriate.
  • Teach timing and frequency of home readings.
• Follow up care
  • Stress the importance of keeping follow-up appointments even if feeling well.
  • Encourage patients to bring their blood pressure logs and medication lists to visits. 

For caregivers, education focuses on: 

• Supporting the patient in taking medications and attending appointments
• Assisting with dietary changes and activity routines
• Recognizing symptoms that warrant urgent care
• Encouraging and reinforcing positive behavior change 

Resources 

Nurses can connect patients and families with a range of resources, which may include: 

• National heart and stroke foundations and cardiovascular societies that provide patient education materials
• Community-based hypertension education and screening programs
• Dietitian services, cardiac rehabilitation, and supervised exercise programs
• Smoking cessation clinics and quit lines
• Social work or case management for assistance with insurance, medication cost, and transportation
• Online tools and mobile applications for tracking blood pressure, medications, and lifestyle habits 

Local resources vary, so nurses should be familiar with the services available in their region. 

References 

• Centers for Medicare and Medicaid Services. (n.d.). ICD-10-CM official guidelines for coding and reporting. U.S. Department of Health and Human Services. https://www.cms.gov/medicare/coding-billing/icd-10-codes 
• Whelton, P. K., Carey, R. M., Aronow, W. S., & et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology, 71(19), e127–e248. https://doi.org/10.1016/j.jacc.2017.11.006 
• Williams, B., Mancia, G., Spiering, W., & et al. (2018). 2018 ESC/ESH guidelines for the management of arterial hypertension. European Heart Journal, 39(33), 3021–3104. https://doi.org/10.1093/eurheartj/ehy339 
• World Health Organization. (2019). International statistical classification of diseases and related health problems (10th rev.). https://icd.who.int/browse10/2019/en