1 of 20

Unit 6, Chapter 31: Assessment �and Management of Patients With Hypertension

2 of 20

Hypertension (HTN)

High Blood Pressure
Defined as a systolic blood pressure (SBP) of 140 mmHg or higher or a diastolic blood pressure (DBP) of 90mmHg or higher.
Based on the average of two or more accurate blood pressure (BP) measurements taken 1 to 4 weeks apart by a health care provider.
BP= CO X PR (Peripheral Resistance), CO= HR X SV
Prolonged blood pressure elevation gradually damages blood vessels thought the body. Particularly in target organs such as: Heart, Kidneys, Brain & Eyes.

3 of 20

Classification of Blood Pressure for Adults Age 18 Years and Older

4 of 20

Hypertension— “The Silent Killer”

About 33% of the adult population of the U.S. has hypertension.
About 46% of adults with HTN do not have it under control.
Primary Hypertension: (Essential HTN): 95% of patients; unidentified cause.
Secondary Hypertension: 5% of patients
Causes of Secondary HTN: Chronic kidney disease, renal artery stenosis, hyperaldosteronism, pheochromocytoma, & sleep apnea, high BP can occur with pregnancy.

5 of 20

�Factors Involved in the Control of BP

BP= CO X PR, CO= HR X SV

6 of 20

Major Risk Factors

High BP can be viewed as a sign, as a risk factor or as a disease.
HTN accompanies other risk factors for Atherosclerotic heart disease:
Older age & Family history
Overweight/obesity
Physical inactivity
Dyslipidemia
Diabetes Mellitus (DM) & Metabolic syndrome
Possible Contributing Factors: Use of tobacco products (e.g., cigarettes, e-cigarettes), and secondhand smoke, Stress, Sleep apnea.

7 of 20

Manifestations of Hypertension

HTN called the silent killer- symptom free
Usually no symptoms other than elevated blood pressure
Symptoms seen related to organ damage are seen late and are serious:

Retinal changes: hemorrhages, exudates, arteriolar narrowing & papilledema (swelling of the optic disc).
Renal damage: increased BUN & Creatinine levels
CAD with angina & Myocardial Infarction (MI)
Left ventricular hypertrophy & heart failure
Stroke or transient ischemic attack (TIA)

8 of 20

Assessment & Diagnostic Findings

History and Physical Examination
Retinal exam
Laboratory Tests:

Urinalysis
Blood chemistry (Na, K, Creatinine, BUN, creatinine levels, fasting glucose)
Total and HDL cholesterol levels

ECG
Echocardiography: left ventricular hypertrophy

9 of 20

Medical Management

The goal of hypertension treatment is to prevent complications and death by maintaining the arterial blood pressure lower than 140/90 mm Hg.
Lifestyle Modifications:
Weight loss: normal BMI: 18.5-24.9kg/m²
DASH diet, fruits, vegetables, low fat dairy products
Decreased Na intake to ≤ 2400 mg/day
Physical Activity: Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day most days of the week).
Reduced Alcohol consumption
Stress management

10 of 20

Lifestyle Modifications

11 of 20

Lifestyle Modifications

TABLE 31-3 The DASH (Dietary Approaches to Stop Hypertension) Diet

12 of 20

Medical Management - Pharmacologic Therapy

Medication used to decrease peripheral resistance, blood volume, & decrease the strength and rate of heart contraction.
Diuretics, Beta-blockers, Alpha₁-blockers, combined alpha- & beta-blockers, Vasodilators, ACE inhibitors, Ca channel blockers, dihydropyridines, and direct Renin inhibitors.
Patients 60 years of age and older with stage I hypertension, the recommended initial medications include a calcium channel blocker or a thiazide diuretic.
Patients with stage I hypertension who are less than 60 years of age are typically prescribed either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker
Low doses are initiated, & the medication dosage is increased gradually if blood pressure does not reach target goal
Additional medications are added if needed.
Multiple medications may be needed to control blood pressure.

13 of 20

Medical Management

14 of 20

Nursing History and Assessment

History and risk factors
Assess potential symptoms of target organ damage:

Angina, shortness of breath, altered speech, altered vision, nosebleeds, headaches, dizziness, balance problems, nocturia
Cardiovascular assessment: apical and peripheral pulses

Deficient knowledge regarding the relation between treatment regimen & control of the disease process
Noncompliance with therapeutic regimen related to side effects of prescribed therapy

Nursing Diagnoses

15 of 20

Collaborative Problems and Potential Complications

Potential complications may include the following:
Left Ventricular Hypertrophy
Myocardial Infarction (MI)
Heart Failure (HF)
Transient Ischemic Attack (TIA)
Cerebrovascular Accident (CVA, Stroke, or Brain attack)
Renal Insufficiency and Failure
Retinal Hemorrhage (impaired vision)

16 of 20

Nursing Interventions

Patient education: Lifestyle Modifications
Support adherence to the treatment regimen
Consultation and collaboration
Follow-up care
Emphasize control rather than cure
Reinforce and support lifestyle changes
A lifelong process
Monitoring and managing potential complications

17 of 20

Evaluation

Reports knowledge of disease management:
Maintains BP at less than 140/90 mm Hg (less than 150/90 mm Hg for adults older than 60 years of age)
Demonstrate no symptoms of angina, palpitations, or vision changes; stable BUN & serum creatinine levels.
Adheres to the self-care program:

Reduces calorie, Na, & fat intake; exercises regularly; Has no complications
Takes medications as prescribed & reports side effects
Measures BP routinely
Abstains from tobacco & excessive alcohol intake
Keeps follow up appointments

18 of 20

Hypertensive Crises

Occur in patients whose HTN poorly controlled, undiagnosed, or in case of discontinued their medications.
Hypertensive Emergency

Blood pressure >180/120 mm Hg and must be lowered immediately to prevent damage to target organs.

Hypertensive Urgency

Blood pressure is very high but no evidence of immediate or progressive target organ damage.

19 of 20

Hypertensive Emergency

Reduce blood pressure 20% to 25% in first hour.
Reduce to 160/100 over 6 hours.
Then gradual reduction to normal over a period of days.
Exceptions are ischemic stroke and aortic dissection.
Medications:

IV Vasodilators: Sodium nitroprusside, Nicardipine, Fenoldopam mesylate, Enalaprilat, Nitroglycerin

Need very frequent monitoring of BP and cardiovascular status.

20 of 20

Hypertensive Urgency

Elevated BP associated with sever headaches, nosebleeds, or anxiety.
Patient requires close monitoring of blood pressure & cardiovascular status.
Assess for potential evidence of target organ damage.
Oral agents can be given with the goal of normalizing BP within 24 to 48 hours.
Medications

Fast-acting oral agents : Beta-adrenergic blocker— Labetalol; Angiotensin-converting enzyme inhibitor— Captopril; or Alpha₂-agonist—Clonidine.