Hypertension Nursing Care Plan Evaluation Form
Please complete this evaluation to assess the effectiveness of the hypertension nursing care plan.
Evaluator's Name
*
First Name
Last Name
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient's Age Group
*
Please Select
18-29
30-44
45-59
60 and above
Blood Pressure Monitoring Frequency
*
Daily
Weekly
Monthly
Not Monitored
Patient Understanding of Hypertension Management
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Adherence to Medication Regimen
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Lifestyle Modification Assessment
*
Rows
Not Addressed
Partially Addressed
Fully Addressed
Dietary Changes
1
2
3
Physical Activity
4
5
6
Smoking Cessation
7
8
9
Stress Management
10
11
12
Patient Education Provided
*
Yes
No
Overall Effectiveness of the Nursing Care Plan
*
1
2
3
4
5
Comments or Recommendations
Submit Evaluation
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