Hypotension Nursing Care Plan: 2 Sample Plans and Interventions

Hypotension is blood pressure low enough that organs may not get the blood flow they need. Causes include fluid loss, bleeding, infection, heart problems, and medications. Your priorities are restoring perfusion, preventing falls, and finding the cause.

A · AssessmentD · DiagnosisP · PlanningI · InterventionE · Evaluation

Each care plan below follows the nursing process (ADPIE).

CARE PLAN 1 · NURSING DIAGNOSIS

Decreased Cardiac Output

Related to

Low circulating volume
Vasodilation from medications or infection
Weak heart pumping

As evidenced by

BP below 90/60 or MAP below 65
Tachycardia
Dizziness or lightheadedness
Cool, pale skin and urine output below 0.5 mL/kg/hr

PLANNING · EXPECTED OUTCOMES

Short-term goals

MAP of 65 or higher within the ordered time
Urine output of at least 0.5 mL/kg/hr

Long-term goals

Client maintains a BP within the ordered range without symptoms

ASSESSMENT

BP, MAP, and heart rate frequently
Mental status
Urine output
Skin color, temperature, and capillary refill

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Lay the client flat and raise the legs if allowed	This helps blood return to the heart and brain.
Give IV fluids as ordered	Fluid raises circulating volume and BP.
Hold or clarify BP-lowering medications when BP is low	Giving them can drop BP even further.
Report a MAP under 65 or new confusion right away	These are signs that organs are not getting enough blood.

EVALUATION

MAP stays at 65 or higher
Urine output meets the goal
Client is alert and oriented

CARE PLAN 2 · NURSING DIAGNOSIS

Risk for Falls

Risk factors

Orthostatic hypotension
Dizziness and weakness
Medications such as diuretics and antihypertensives

PLANNING · EXPECTED OUTCOMES

Short-term goals

Client remains free of falls during the hospital stay

Long-term goals

Client uses safe position changes at home and stays free of falls

ASSESSMENT

Orthostatic vital signs as ordered
Fall risk score every shift
Medication list for drugs that lower BP

INTERVENTIONS AND RATIONALES

INTERVENTION	RATIONALE
Teach the client to sit on the edge of the bed before standing	Slow position changes give the body time to adjust BP.
Assist with walking and keep the call light in reach	Help reduces the chance of a fall during a dizzy spell.
Encourage fluids unless restricted	Good hydration supports a stable BP.
Teach the client to sit or lie down if dizzy	This prevents fainting and injury.

EVALUATION

Client has no falls
Client demonstrates slow position changes
Client states what to do when dizzy

Practice this in Priority Care

Choose which client with a falling blood pressure needs you first.

Play Priority Care

Quick answers

What is the first action for a client with sudden hypotension?

Assess the client and lay them flat with legs raised if allowed, then notify the provider and prepare for fluids as ordered.

What MAP shows adequate organ perfusion?

A MAP of 65 or higher is the usual goal for perfusing the brain, heart, and kidneys.

For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.