Persistent

elevation of

Systolic blood pressure 140 mm Hg or Diastolic blood pressure 90 mm Hg or Current use of antihypertensive medication(s)

Systolic

blood pressure:120139 mm Hg

Or
Diastolic

blood pressure:8089 mm Hg

Blood Pressure

Cardiac Output

Systemic Vascular Resistance

 Primary

hypertension

Also called idiopathic or essential Increased blood pressure without an identified cause Covers 90-95% of all cases of HTN

Secondary

hypertension

Increased blood pressure with a specific cause that can be identified and corrected

 Cirrhosis
Narrowing

of the aorta Endocrine disorders Medications Neurologic disorders Pregnancy induced HTN Renal disease Sleep apnea

Category
Normal
Prehypertension Stage 1 Stage 2

SBP (mm Hg)

< 120 and

DBP (mm Hg)

< 80

120139

or

8089

140159

or

9099

> 160

or

> 100

 For

persons over age 50, SBP is more important than DBP as a CVD risk factor who are normotensive at age 55 have a 90% lifetime risk for developing HTN

Persons

Age Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

 Referred

to as the silent killer because patients are frequently asymptomatic until target organ disease occurs

 Symptoms

are often secondary to target organ disease and can include

Fatigue, reduced activity tolerance Dizziness Palpitations, angina Dyspnea

Target

organ diseases occur most frequently in the

Heart Brain Peripheral vasculature Kidney Eyes

Hypertensive

heart

disease

Coronary artery disease Left ventricular hypertrophy Heart failure

Fig. 33-3: Top, normal heart; Bottom, left ventricular hypertrophy

 Cerebrovascular

disease

Stroke

Peripheral

vascular disease

Nephrosclerosis Retinal

damage

 History BP

and physical examination

measurement in both arms

Use arm with higher reading for subsequent measurements BP highest in early morning, lowest at night

Use auscultatory method with a properly calibrated instrument

Patient should be seated quietly for 5 min in a chair, feet on the floor, and arm supported at heart level

Appropriate-sized cuff is necessary to ensure accurate reading

At least two measurements should be obtained

The correct technique for blood pressure measurements includes a) Always taking the blood pressure in both arms b) Releasing the pressure in the cuff at a rate of 1 mm Hg per second c) Inflating the cuff 5 mm Hg higher than the expected systolic pressure d) Taking additional readings if the first two readings differ more than 10 mm Hg

 Urinalysis,

creatinine clearance Serum electrolytes, glucose BUN and serum creatinine Serum lipid profile ECG Echocardiogram

White coat phenomenon may

precipitate the need for ambulatory blood pressure monitoring (ABPM)

Uses a noninvasive, fully automated system that measures BP at preset intervals over a 24hour period

 Overall

goals

Control blood pressure Reduce CVD risk factors

Strategies

for adherence to regimens

Empathy increases patient trust, motivation, and adherence to therapy Consider patients cultural beliefs and individual attitudes in formulating treatment goals

Average Percent Reduction

Stroke incidence Myocardial infarction Heart failure 35%40% 20%25% 50%

 Lifestyle

modifications

Weight reduction:
Weight loss of 10 kg (22 lb) may decrease SBP by ~ 5 to 20 mm Hg

Dietary Approaches to Stop Hypertension (DASH) Diet

Low sodium

<2.4 g of sodium/day

Low fat Limited starchy foods Increased vegetable and fruit intake

 Lifestyle

modifications

Moderation of alcohol consumption:

Men: no more than 2 drinks/day Women: no more than 1 drink/day

Physical activity: Regular physical (aerobic) activity, at least 30 minutes, most days of the week
Avoidance of tobacco products Stress management

 Drug

therapy:

Primary actions of drugs to treat hypertension

Reduce SVR Reduce volume of circulating blood

Classifications of drugs used to treat HTN

Diuretics Adrenergic inhibitors Direct vasodilators Angiotensin inhibitors Calcium channel blockers

 Diuretics

Inhibit NaCl reabsorption in the tubules Increases excretion of Na and Cl Potassium-sparing diuretics reduce excretion of K+ Types:

Thiazide diuretics:

hydrochlorothiazide (HydroDiuril), metolazone (Zaroxolyn) bumetanide (Bumex) furosemide (Lasix), torsemide (Demadex) triamterene (Dyrenium) spironolactone (Aldactone)

Loop Diuretics:

Potassium-sparing diuretics:

Aldosterone Receptor Blockers:

 What

will you monitor in patients taking diuretics?

I&O Daily Weight Electrolyte abnormalities

Potassium Sodium Orthostatic hypotension

BP

Ototoxicity (Lasix) Dizziness, vertigo

 Adrenergic

inhibitors

Central-Acting -1 Adrenergic Antagonists

Reduce sympathetic outflow from CNS Reduces peripheral sympathetic tone, produces vasodilation, decreases SVR and BP Types: Clonidine (Catapress) Methyldopa (Aldomet)

 Adrenergic

inhibitors

-1 Adrenergic Blockers
Block -1 adrenergic effects, producing peripheral vasodilation (decreases SVR and BP) Types: Doxazosin (Cardura), Prozosin (Minipress), Terazosin (Hytrin)

-Adrenergic Blockers

Decrease CO and reduce vasoconstrictor tone Types: Atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal)

 What

will you monitor in patients taking Adrenergic-Blockers?

Dry mouth

Central-Acting -1 Adrenergic Antagonists Orthostatic hypotension -1 adrenergic blockers -Adrenergic Blockers -Adrenergic Blockers

BP

Retention of salt and water

Bronchospasm

Bradycardia

 Direct

vasodilators

Reduce SVR and BP by arterial vasodilation Types:

Hydralazine (Apresoline), nitroglycerin (Tridil), sodium nitroprusside (Nipride)

What

will you monitor for?

BP Tachycardia Flushing Palpitations Dizziness Angina Headache

Angiotensin inhibitors

Angiotensin-Converting Enzyme (ACE) Inhibitors

Reduce conversion of Angiotensin I to angiotensin II, prevent vasoconstriction Types: captopril (Capoten), enalapril (vasotec), lisinopril
(Prinivil)

Angiotensin II Receptor Blockers

Prevent action of angiotensin II and produce vasodilation and increased salt and water excretion Types: irbesartan (Avapro), valsartan (Diovan)

What will you monitor? Angiotensin-Converting Enzyme (ACE) Inhibitors

BP Dizziness Loss of taste Hyperkalemia ARF

Angiotensin II Receptor Blockers

Hyperkalemia Decreased RF

 Calcium

channel blockers

Block movement of extracellular calcium into cells, causing vasodilation and decreased HR, contractility, and SVR Types:

Amlodipine (Norvasc), diltiazem (Cardizem), nifedipine (Procardia), verapamil (Calan)

What will you monitor? BP Bradycardia Headache, dizziness, peripheral edema, flushing

 Drug

therapy and patient teaching

Identify, report, and minimize side effects

Orthostatic hypotension Sexual dysfunction Dry mouth Frequent urination

 Nursing

Assessment

Subjective data
Past health history

Medications

CV,

renal, thyroid disease, DM, obesity and OTC

Functional health patterns

Family history Diet Activity level Stress

Prescription

Objective data

Target organ damage

Peripheral

pulses, abnormal heart sounds, BP >140/90

 Nursing

Ineffective health maintenance r/t lack of knowledge Anxiety r/t management regimen or lifestyle changes Sexual dysfunction r/t medication side effects Ineffective therapeutic regimen management r/t lack of knowledge, side effects of medications, return of blood pressure to normal while on medications Ineffective tissue perfusion r/t complications of HTN (cerebral, CV, renal, retinal)

Diagnoses

 Collaborative
Potential

problems

complications:

Adverse effects from antihypertensive therapy (hypokalemia) Hypertensive crisis Stroke Coronary artery disease (CAD) Myocardial infarction

Severe, abrupt increase in DBP defined as DBP >140 mm Hg Rate of increase in BP is more important than the absolute value Often occurs in patients with a history of HTN who have failed to comply with medications or who have been undermedicated

Hypertensive Emergency
Develops within hours to days BP > 180/120 mm Hg Acute target organ damage May precipitate: Hypertensive encephalopathy, cerebral hemorrhage Acute renal failure Myocardial infarction Heart failure with pulmonary edema

Hyptertensive Urgency

Develops within days to weeks No clinical evidence of target organ damage

 Hypertensive

Emergency

Hypertensive encephalopathy
Sudden rise in BP associated with HA, N/V, seizures, confusion, coma May also have blurred vision and transient blindness Due to increased cerebral capillary permeability leading to cerebral edema and disruption in cerebral function

Renal insufficiency CV decompensation

Unstable angina MI Pulmonary edema

 Hospitalization

IV drug therapy

Sodium nitroprusside (Nipride) MOST EFFECTIVE Titrated to mean arterial pressure

MAP = (SBP + 2 DBP) 3

 Nursing

Interventions

Monitor BP and HR every 3-5 minutes Titrate med based on MAP DO NOT DECREASE BP TO QUICKLY may cause stroke, MI Continual ECG monitoring Hourly UO Strict BP Neurologic checks

LOC, pupil checks, movement and strength of extremities pulmonary edema, HF, angina

CV and Respiratory assessment

 Hypertensive

Urgency

Managed with oral medications

Difficult to regulate drugs Need follow-up within 24 hours

May not need hospitalization Nursing Interventions

Provide quiet environment Encourage patient to verbalize concerns Answer questions Eliminate stimuli Determine cause Education to avoid future crises

Planning: Patient will Achieve and maintain the individually determined goal BP

Understand, accept, and implement the therapeutic plan Experience minimal or no unpleasant side effects of therapy Be confident of ability to manage and cope with this condition

Nursing Implementation

Health Promotion

Individual patient evaluation

Risk

factors Routine BP Health assessment Weight patterns Family history

Blood pressure measurement Screening programs Cardiovascular risk factor modification Modifiable: HTN, DM, obesity, tobacco cessation, physical inactivity

Nursing Implementation
Ambulatory and Home Care
Patient and family teaching includes

Nutritional therapy Drug therapy Physical activity

30

minutes/day most days of week

Home monitoring of BP (if appropriate)

Rest

3-5 minutes prior to taking BP No smoking, exercise or caffeine 30 minutes prior Take daily and record in log

Tobacco cessation (if applicable)

Nursing Evaluation
Patient

will

Achieve and maintain goal BP as defined for the individual Understand, accept, and implement the therapeutic plan

Experience minimal or no unpleasant side effects of therapy

Isolated systolic hypertension (ISH) is the most common form of hypertension in individuals age >50 The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age >65) normotensive men and women Why?

Loss of elasticity, increased PVR, blunting of baroreceptors, decreased renal function, decreased renin production

Older adults are more likely to have white coat hypertension

Often a wide gap between the first Korotkoff sound and subsequent beats called the auscultatory gap Failure to inflate the cuff high enough may result in seriously underestimating the SBP

Assess disappearance of pulse upon inflation of cuff

Older adults have varying degrees of impaired baroreceptor reflex mechanisms

Consequently, orthostatic hypotension occurs often especially in patients with ISH

Most commonly associated with volume depletion or decreased renal or hepatic function

In general, treatment similar for all demographic and ethnic groups

Prevalence and severity of HTN increased in African Americans

Mexican Americans are less likely to receive treatment for hypertension than whites and African Americans
Mexican Americans and Native Americans have lower rates of BP pressure control than whites and African Americans