HYPERTENSION

FAMADOR ORGE GENALDO, RN, MD

11/22/15

Definition
A disease of vascular regulation
in which the mechanisms that
control arterial pressure within
normal range are altered
The basic explanation is that
blood pressure is elevated when
there is increased cardiac output
plus increased peripheral
vascular resistance

 Hypertension is defined as the

sustained elevation in systolic or
diastolic blood pressure.
It occurs as two major types:
primary and secondary
hypertension.
Over 50 million American have
this kind of disease, and this
may increase due to aging of the
population

Pathophysiology and
Etiology

The etiology of Primary

Hypertension is idiopathic.
Hypertension is classified as
secondary if it is related a
systemic disease that raises
peripheral vascular resistance.

 Primary or Essential
Hypertension
(Approximately 95% of patients
with hypertension)
When the diastolic pressure is
90 mm Hg or higher and other
causes of hypertension are
absent, the condition is said to
be primary hypertension.

 Causes of essential hypertension

is unknown
However there are several areas
of investigation:
- Hyperactivity of sympathetic
vasoconstricting nerves
- Presence of vasoactive
substance released from the
arterial endothelial cells that
acts on smooth muscles,
sensitizing it to vasoconstriction

- Increased cardiac output,

followed by arteriole constriction
- Excessive dietary sodium
intake, sodium retention, insulin
resistance, and hyperinsulinemia
play roles that are not clear
- Familial (genetic) tendency

 Systolic blood pressure elevation

in the absence of elevated
diastolic blood pressure is
termed as isolated systolic
hypertension and is treated in
the same manner

 Secondary Hypertension
Occurs approximately 5% of
patients with hypertension
secondary to pathology
Renal pathology
Congenital anomalies,
pyelonephritis, renal artery
obstruction, acute and chronic
glomerulonephritis

 Renal pathology
Reduced blood flow to kidney
causes release of renin.
Renin reacts with serum
protein in liver (a2-globulin) to
angiotensin I;
this plus angiotensinconverting enzyme (ACE) to
angiotensin II that leads to
increased blood pressure

 Coarctation of aorta (stenosis of

aorta)- blood flow to upper
extremities is greater than flow
to lower extremities
hypertension of upper part of
body.
Medications such as estrogens,
sympathomimetics, NSAIDs,
steroids, antidepressants.

 Endocrine disturbances
Pheochromocytoma a tumor
of the adrenal gland that
causes release of epinephrine
and norepinephrine and a rise
in blood pressure
Adrenal cortex tumors lead to
an increase in aldosterone
secretion (hyperaldosteronism)
and elevated blood pressure

Cushings Syndrome leads to

an increase in adrenocortical
steroids (causing sodium and
fluid retention) and
hypertension.

Excess
Sodium
Intake

Fewer
Nephrons

Renal
sodium
retentio
n

Fluid
volume

Decreased
filtration
surface

Sympatheti
c nervous
system
over
activity

Genetic
alteration

Reninangiotensi
n excess

Obesity

Cell
membrane
alteration

Endothelial
factors

Hypoinsu
linemia

Venous
constriction

Preload

Blood
Pressure
Hypertensio
n

Stress

Contractility

CARDIAC
OUTPUT
Increased CO

Functional
constriction

X
And/
or

Autoregulation

Structural
hypertroph
y

PERIPHERAL
RESISTANCE Increased
PR

PATHOPHYSIOLOGY
Changes in the arteriolar bed
causing increased resistance
Abnormally increased tone in
the sensory nervous system
that originates in the vasomotor
center, causing increased
peripheral vascular resistance
Increased blood volume
resulting from renal or
hormonal dysfunction

PATHOPHYSIOLOGY
An increase in arteriolar
thickening caused by genetic
factors, leading to increased
peripheral vascular resistance
Abnormal rennin release
resulting in the formation of
angiotensin II, which constricts
the arterioles and increased
blood volume

STAGES OF
HYPERTENSION

CLASSIFICATION AND MANAGEMENT OF BLOOD PRESSURE FOR ADULTS

Initial Drug Therapy
BP Classification

SBP
mmHg

DBP
mmHg

Lifestyle
Modificatio
n

Without
Compelling
Indication

With Compelling
Indication

Normal

<120

And <80

Encourage

Prehypertension

120-139

Or 80-89

Yes

No
antihypertensi
ve drug
indicated

Drug/s for
compelling
indications

Stage1
Hypertension

140-159

Or 90-99

Yes

Thiazide-type
diuretics for
most.
May consider
ACEI,ARB,BB,C
CB or
combination

Drug/s for the

compelling
indications.

Stage2
Hypertension

> 160

Or > 100

Yes

Two-drug
combination
for most.
(Usually
thiazide-type
diuretic and
ACEI or ARB or
BB or CCB

Other
antihypertensive
drugs (diuretics,
ACEI,ARB,BB,CCB
) as needed

Classification of
Hypertension
Essential/ Idiopathic/ Primary
Hypertension
Secondary Hypertension
Malignant Hypertension
Labile Hypertension
Resistant Hypertension
White Coat Hypertension
Hypertensive Crisis

SIGNS AND SYMPTOMS

Usually asymptomatic
Hypertension usually doesnt
produce signs and symptoms
until vascular changes in the
heart, brain, or kidneys occur.
May cause headache, dizziness,
blurred vision when greatly
elevated

 Severely elevated blood

pressure damages the intima of
small vessels resulting in fibrin
accumulation in the vessels,
local edema and possibly,
intravascular clotting.

RISK FACTORS
Modifiable Risk Factors :
Cigarette smoking
Diabetes mellitus
Elevated serum lipid levels
Sedentary lifestyle
Stress
Obesity
Alcohol Intake
Excessive intake of dietary fats,
carbohydrates and salt

RISK FACTORS
Non Modifiable Risk Factors :
Age
Male gender
Family history
Race

COMPLICATIONS

COMPLICATIONS
Cardiac complications include
CAD, angina, MI, heart failure,
arrhythmias and sudden death.
Neurologic complications
include stroke and hypertensive
encephalopathy.

 Hypertensive retinopathy can

cause blindness.
Renovascular hypertension can
lead to renal failure.

COMPLICATIONS

Brain
Cerebral
Perfusion

TIA
Thrombosis
Aneurysms
Hemorrhage

Cardiac output
Oxygen
Supply
High Blood
Pressure
(>140/90)
Peripheral
Vascular
Resistance

Heart
Myocardial
Workload

Ventricular
Hypertrophy
Ischemia
Angina
MI
Heart Failure

Myocardial
Oxygen
Consumption

Kidney
Blood
flow
Oxygen

Renin + aldosterone
secretion

Na and H2O
reabsorption
Blood Volume

GFR
Azotemia

Failure

DIAGNOSTIC PROCEDURES
Urinalysis:
May show protein, red blood
cells or white blood cells
suggesting renal disease;
Glucose suggesting diabetes
mellitus
Excretory urography:
May reveal renal atrophy,
indicating chronic renal disease.

 Serum potassium levels less

than 3.5 mEq/L
May indicate adrenal
dysfunction
Blood Urea Nitrogen levels that
are elevated to more than 20
mg:
Indicates kidney disease as a
cause or effect of hypertension
Chest x-ray:
May show cardiomegaly

 Blood chemistry (analysis of

sodium, potassium, creatinine,
fasting glucose, and total HDL
and LDL levels
12-L Electrocardiogram
to determine effects of
hypertension on the heart or
presence of underlying heart
disease

DIAGNOSTIC PROCEDURES

 Proteinuria, elevated serum

blood urea nitrogen (BUN), and
creatinine levels:
Indicate kidney disease as a
cause or effect of
hypertension;
First voided micro albumin is
the early sign

 Serum potassium:
Decreased in primary
hyperaldoteronism;
elevated in Cushings
syndrome both causes of
secondary hypertension

 Urine (24 hour) for

catecholamines:
Increased in
pheochromocytoma
Renal scan to detect renal
vascular diseases:
May include ingestion of
Captopril, an ACE inhibitor, to
detect its effect on renal blood
flow

PREVENTION
Primary prevention:
Moderation on sodium intake

PREVENTION
Decreased saturated fats diet

PREVENTION
Maintenance of IBW

PREVENTION
Maintenance of regular pattern
of exercise

PREVENTION
Cessation of cigarette smoking

PREVENTION
Stress reduction through
effective coping strategies

Medical Management
Lifestyle Modification
Lose weight if body mass index
(BMI) is greater than or equal to
27
Limit alcohol no more than 1
oz ethanol daily for men, 0.5 oz
for women
Get regular exercise equivalent
to 30 to 45 minutes of brisk
walking most days.

 Cut sodium intake to 2.4 g or

less per day
Dash Diet (Dietary Approaches
to Stop Hypertension) rich in
fruits, vegetables, low-fat dairy
products, and fiber
Stop smoking
Reduce dietary saturated fat and
cholesterol
Consider reducing coffee intake

 Despite lifestyle changes, the

blood pressure within normal
range remains or above 140/90
mm Hg over 3 to 6 months, drug
therapy should be initiated

 Drug therapy
Considerations in selecting
therapy include:
a. Race African Americans
respond well to diuretic therapy;
Caucasians responds well to ACE
inhibitors
b. Age some side effects may
not be tolerated well by elderly
persons.

 c. Concomitant diseases and

therapies
Some agents also treat
migraines, benign prostatic
hyperplasia, CHF;
Or have beneficial effects on
conditions such as renal
insufficiency;
Or have adverse effects on
conditions such as diabetes or
asthma.

 d. Quality of life impact

tolerance to side effects.
e. Economic considerations
newer agents are very
expensive.
f. Doses per day may be
compliance problem.

 Pharmacologic Agents:
Diuretics - lower blood pressure
by promoting urinary excretion
of water and sodium to lower
blood volume.
Loop diuretics:
Furosemide
K-sparing diuretics:
Spirolactone
Triamterene

 Beta Blockers - Beta-adrenergic

inhibitors that lower blood
pressure by slowing the heart
and reducing cardiac output as
well as release of renin from the
kidneys.
Metoprolol
Propranolol

 A-receptor Blockers- alphaadrenergic inhibitors that lower

pressure by dilating peripheral
blood vessels and lowering
peripheral vascular resistance.
Prazosin
Terazosin

 Central Alpha Antagonists- lower

blood pressure by diminishing
sympathetic outflow form the
brain, thereby lowering
peripheral resistance.
Clonidine
Methyldopa

 Peripheral Adrenergic Agentsinhibit peripheral adrenergic

release of vasoconstricting
catecholamines, such as
norepinephrine.
Reserpine

 Combined alpha and beta

blockers- adrenergic inhibitors
that works through both alpha
and beta receptors
Carvedilol
Labetalol

 Angiotensin Converting Enzyme

(ACE) Inhibitors- lower blood
pressure by blocking the enzymes
that converts angiotensin I to the
potent vasoconstrictor
angiotensin II.
These drugs also raise the
level of bradykinin, a potent
vasodilator, and lower
aldosterone levels.
Captopril, Enalapril, Ramipril

 Angiotensin II antagonistssimilar action to ACE inhibitors.

Candesartan
Irbesartan
Losartan
Valsartan

 Calcium Antagonists (Calcium

Channel Blockers)- stop the
movement of calcium into the
cells; relax smooth muscles,
which causes vasodilation; and
inhibit reabsorption of sodium in
the renal tubules.
Diltiazem
Nifedipine
Nicardipine
Felodipine

 Direct Vasodilators- direct

smooth muscle relaxants the
primarily dilate arteries and
arterioles.
Hydralazine HCl
Minoxidil

 If hypertension is not controlled

with the first drug within 1 to 3
months, three options can be
considered:
First: If the patient has faithfully
taken the drug and not
developed and side effects, the
dose of the drug may be
increased.

 Second: If the patient has had

adverse effects, another class of
drugs can be substituted.
Third: A second drug from
another class could be added.
If adding the second agent
lowers the pressure, the first
agent can be slowly withdrawn
Or, if necessary, combination
therapy will be continued.

 The best management of

hypertension is to use the
fewest drugs at the lowest doses
while encouraging the patient to
maintain lifestyle changes.
After blood pressure has been
under control for at least a year,
a slow, progressive decline in
drug therapy can be attempted.

 If the desired blood pressure is

still not achieved with the
addition of a second drug, a
third agent or a diuretic or both
(if not already prescribed) could
be added.

Drug

Trade Name

Usual Dose
Range in Total
mg/day
(frequency per
day)

Selected Adverse Effects

Central aAgonists
Clonidine

Catapres

0.2-1.2 (2-3)

Sedation, dry mouth,

bradycardia, withdrawal
hypertension

A-Blockers
Doxazosin
mesylate

Cardura

1-16 (1)

Postural hypertension

B-Blockers
Acebutolol

Sectral

200-800 (1)

Bronchospasm, bradycardia,
heart failure, may mask
insulin-induced
hypoglycemia; less serious;
impaired peripheral
circulation, insomia, fatigue,
decreased exercise
tolerance,
hypertriglyceridemia

Direct
Vasodilators
Hydralazine

Apresoline

50-300 (2)

Headaches, fluid retention,

tachycardia,

Calcium
Antagonists
Diltiazem HCl

Cardizem SR,
Cardizem CD,
Dilacor XR,
Tiazac

120-360 (2)

Conduction defects,
worsening of systolic
dysfunction, gingival
hyperplasia

AngiotenrinConverting

Capoten

25-150 (2-3)

Common: cough; rare:

angioedema, hyperkalemia,

Angiotensin II
Receptor Blockers
Irbersartan

Avapro

150-300 (1)

Angioedema (very
rare),
hyperkalemia

Diuretics
Hydrochlorothiazid
e (G)

HYdroDIURIL.
Microzide, Esidrix

12.5-50 (1)

Biochemical
abnormalities:
decreases
potassium,
sodium, and
magnesium levels,
increases uric acid
and calcium levels

Loop Diuretics
Furosimide (G)

Lasix

40-240 (2-3)

(Short duration of
action no
hypercalcemia)

Potassium-Sparing
Agents
Spironolactone (G)

Aldactone

25-100 (1)

(gynecomastia)

Adrenergic
Inhibitors
Peripheral Agents
Guanadrel

Hylorel

10-75 (2)

(Postural
hypotension,
diarrhea)

Combined a and BBlockers

Carvedilol

Coreg

12.5-50 (2)

Postural
hypotension,
bronchospasm

TREATMENT

Pharmacologic Management:
ACE Inhibitors
A II Receptor Blockers
Alpha-adrenergic Blockers
Beta-adrenergic Blockers
Calcium Antagonist
Diuretics

 Complications
Angina pectoris or MI due to
decreased coronary perfusion.
Left ventricular hypertrophy and
CHF due to consistently elevated
aortic pressure.
Renal failure due to thickening of
renal vessels and diminished
perfusion to the glomerulus.

 Transient due to cerebral

ischemia and arteriosclerosis.
Retinopathy
Accelerated hypertension

Brain
Cerebral
Perfusion

TIA
Thrombosis
Aneurysms
Hemorrhage

Cardiac output
Oxygen
Supply
High Blood
Pressure
(>140/90)

Peripheral
Vascular
Resistance

Heart
Myocardial
Workload

Ventricular
Hypertrophy
Ischemia
Angina
MI
Heart Failure

Myocardial
Oxygen
Consumption

Kidney
Blood flow

Oxygen

Renin + aldosterone
secretion

Na and H2O
reabsorption

Blood Volume

GFR
Azotemia

Failure

Nursing Assessment
Nursing History
Query the patient with regard to
the following:
Family history of high blood
pressure
Previous episodes of high blood
pressure
Dietary habits and salt intake

 Target organ disease or other

disease processes that may
place the client in a high-risk
group:
Diabetes, coronary artery
disease, kidney disease.

 Cigarette smoking
Medication that could elevate
blood pressure:
Oral contraceptives, steroids
NSAIDs
Nasal decongestants, appetite
suppressants, tricyclic
antidepressants

 Episodes of headache,
weakness, muscle cramps,
tingling, palpations, sweating,
visual disturbances
Other disease processes, such as
gout, migraines, asthma, heart
failure, and benign prostatic
hypertrophy, that may be helped
or worsened by particular
hypertension drugs.

NURSING CARE
PLAN:

Physical Assessment
Auscultate heart rate and
palpate peripheral pulses;
determine respirations.
If skilled in doing so, perform
funduscopic examination of the
eyes for the purpose of noting
vascular changes.
Look for edema, spasm, and
hemorrhage of the eye
vessels.

 Examine the heart for a shift of

the point of maximal impulse to
the left, which occurs in the
heart enlargement.
Auscultate for bruits over
peripheral arteries to determine
the presence of atherosclerosis,
which may be manifested as
obstructed blood flow.

 Determine mentation status by

asking patient about memory,
ability to concentrate, and ability
to perform simple mathematical
calculations.

NURSING CARE PLAN:

Assessment:
Assess blood pressure at
frequent intervals;
Know baseline level.
Note changes in pressure that
would require change in
medication
Note the apical and peripheral
pulse rate, rhythm and
character.

 Assess symptoms such as

nosebleeds; anginal pain,
shortness of breath; alterations
in vision, speech or balance
(vertigo); headache or nocturia.
Assess extent to which
hypertension has affected
patient personally, socially or
financially.

 Blood Pressure Determination

Measure the BP of the client
under the same conditions each
time
Avoid taking BP readings
immediately after stressful or
taxing situations
Wait 30 min after client has
smoked

 Place the client in a position of

comfort and have him or her
remain silent
Support the bared arm and
avoid constriction of arm by a
rolled sleeve
Be aware that falsely elevated
BP may be obtained with a cuff
that is too narrow
Falsely low readings maybe
obtained with a cuff that is too
wide

 Use a blood pressure cuff of the

correct size
The bladder within the cuff
should encircle at least 80% of
the clients arm
Many adults require a large
cuff
Two or more readings
separated by 2 minutes should
be averaged

 Be aware that falsely elevated

blood pressures may be
obtained with a cuff that is too
narrow;
Falsely low readings may be
obtained with a cuff that is too
wide.

 Auscultate and record precisely

the systolic and diastolic
pressures based on Korotkoff
sounds.
Systolic the pressure within
the cuff indicated by the clear
level of mercury column at the
moment when the first clear,
rhythmic pulsatile sound is
heard

 First diastolic:
The pressure within the cuff
indicated by the level of the
mercury column at the
moment when the sound
becomes muffed
Second diastolic:
The pressure within the cuff
at the moment the sound
disappears.

 Phases 2 and 3 are less

distinct sounds produce
between the systolic and first
diastolic and are not identified
clinically or recorded.

NURSING CARE
MANAGEMENT:
Nursing Diagnosis:
Deficient Knowledge regarding
the relationship of the treatment
regimen and control of the
disease process.
Ineffective Management of
Therapeutic Regimen related to
medication side effects and
difficult lifestyle adjustments

Goal:
The major goal include patients
understanding the disease
process and its treatment,
compliance with the self-care
program and absence of
complications

NURSING CARE PLAN:

Nursing Interventions:
Explain the meaning of high
blood pressure
Risk factors
And their influences on the
cardiovascular, cerebral, and
renal systems

 Stress that there can never be

total cure, only control, of the
essential hypertension;
Emphasize the consequences
of uncontrolled hypertension

NURSING CARE PLAN:

Emphasize the concept of
controlling hypertension (with
lifestyle changes and
medications) rather than curing
it.
Advise patient to limit alcohol
intake and avoid use of tobacco.

 Stress the fact that there may

be no correlation between high
blood pressure and symptoms;
The client cannot tell by the
way he or she feels whether
blood pressure is elevated or
not

 Have the client recognize that

hypertension is chronic and
requires persistent therapy and
periodic evaluation.
Effective treatment improves
life expectancy;
Therefore, follow-up health
care visits are mandatory

 Present a coordinated and

complementary plan of guidance
Inform the client of the
meaning of the various
diagnostic and therapeutic
activities to minimize anxiety
and to obtain cooperation.

Solicit the assistance of the

clients spouse/family/friend
Provide information
regarding the total
treatment plan.
Be aware of the dietary plan
developed for this particular
client.

 Explain the pharmacologic

control of hypertension.
Explain that the drugs used
for effective control of blood
pressure will likely produce
side effects

 Warn client of the possibility

that orthostatic hypotension
may occur initially with some
drug
Instruct the client to get up
slowly to offset the feeling of
dizziness
Encourage the client to sit or
lie down immediately if he or
she feels faint

 Alert the patient to expect

initial effects such as:
Anorexia,
Light-headedness, and
Fatigue with many
medications

 Inform that the goal of

treatment is to:
Control blood pressure,
Reduce the possibility of
complications, and
Use minimum number of
drugs with the lowest
dosage necessary to
accomplish this

 Educate client to be aware of

serious side effects and report
them immediately so that
adjustments can be made in
individual pharmacotherapy.
Note that dosages are
individualized; to predict
reactions.

 Warn the client on vasodilating

drugs to use with caution in
certain circumstances that
produce vasodilatation:
A hot bath, hot weather,
febrile illness, consumption of
alcohol may exacerbate blood
pressure reduction.

 Warn client that blood pressure

is often decreased when
circulating blood volume is
reduced-as in dehydration,
diarrhea, hemorrhage-so blood
pressure should be monitored
closely and treatment adjusted.

 Enlist the clients cooperation in

redirecting lifestyle in keeping
with the guidelines of therapy,
acknowledge the difficulty, and
provide support and
encouragement.

 Develop a plan of instruction for

medication self-management.
Plan the clients medication
schedule so that many
medications are given at
proper and convenient times;
Set up a daily checklist on
which the client can record the
medication taken.

 Be sure the client knows

regarding the generic and
brand names for all
medications and throws away
old medications and dosage so
they will not be mixed up with
current medications

 Instruct the client regarding

proper method of taking blood
pressure at home and at work if
health care provider so desires.
Inform client desired range
and the readings that are to
be reported.

 Determine recommended dietary

plans and provide dietary
education as appropriate.
Most clients have a basic
knowledge of nutrients and
minerals such as fats and
sodium and can be taught to
read labels

 Some clients may require

consultation with a dietician to
understand how diet may
affect blood pressure and
health.

 Support client and promote

adherence to therapy in a costeffective manner;
Collaborate with client to set
goals.
Support client in planning
lifestyle changes, including an
exercise program with regular
physical activity.

NURSING CARE PLAN:

Reinforce the importance of
taking medications as
prescribed, scheduling regular
follow-up appointments,
maintaining dietary restrictions
of sodium and fat, increasing
fruits and vegetables and
controlling weight.

NURSING CARE PLAN:

Encourage active participation in
the program, including selfmonitoring of blood pressure
and diet for increased
compliance.
Encourage client to abstain from
alcohol because alcohol may
have a synergistic effect with
medication.

 Discourage use of tobacco and

nicotine products.
Give client written information
regarding expected effects and
side effects of medications.
Teach client and family how to
measure blood pressure.

10 WAYS TO CONTROL YOUR HIGH

BLOOD PRESSURE
According to J.M. Black
1. Know your blood pressure.
Have it checked regularly
2. Know what your weight should
be.
Keep it at that level or below.
1. Do not use too much salt in
cooking or at meals.
Avoid salty foods.

4. Eat a low-fat diet!

5. Do not smoke cigarettes or use
tobacco products
6. Take your medicine exactly as
prescribed.
Do not run out of pills even
for a single day.
7. Keep appointments with the
doctor

10 WAYS TO CONTROL YOUR HIGH

BLOOD PRESSURE
8. Follow your doctors advice
about exercise.
9. Make certain that your parent,
brothers, sisters, and children
their blood pressure checked
regularly.
10. Live a normal life in every
other way

 Outcome-Based Evaluation
Demonstrates increased
knowledge about high blood
pressure, medication effects,
and prescribed therapeutic
activities
Takes medications, keeps followup appointments

 THE END