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Grown Up... © Caring for Adolescents, Adults, and Aging Adults Volume 17, Issue 2 HYPERTENSION... ASSESSMENT & PATIENT EDUCATION February 2012 Editor-in-Chief: Mary Myers Dunlap, MAEd, RN BEHAVIORAL OBJECTIVES AFTER READING THIS NEWSLETTER THE LEARNER WILL BE ABLE TO: 1. Discuss primary hypertension, including six common risk factors. 2. Describe symptoms and assessment of hypertension, as well as patient education related to lifestyle modifications. With hypertension, the pressure of the blood pumping through the arteries is abnormally high. Blood pressure is determined by blood flow and peripheral vascular resistance. Blood flow is the volume of blood ejected from the left ventricle with each contraction of the heart and the heart rate. Peripheral vascular resistance refers to the size of the peripheral blood vessels. The more constricted the vessel, such as from atherosclerosis, build-up of plaque, the greater the resistance to flow and blood pressure becomes increased. Many other environmental factors can affect blood pressure, including volume of water in the body, salt content of the body, smoking, and obesity. TYPES OF HYPERTENSION & RISK FACTORS The prevalence of high blood pressure, or hypertension, is on the rise in the United States. Hypertension affects one in four adults, with the incidence increasing in the aging population. Only about 30% of people with high blood pressure are aware of it. About 50% of people who suffer a first MI and about 66% of people experiencing a first stroke have a blood pressure above 160/95 mm Hg. Of those who are aware, only 34% have their high blood pressure controlled. Because hypertension may not produce signs or symptoms initially, high blood pressure is often discovered during a routine screening or when another condition occurs. This newsletter will describe types and common risk factors of hypertension. Symptoms and assessment of hypertension, as well as patient education related to lifestyle modifications, will also be discussed. HYPERTENSION Normal blood pressure is defined as a systolic BP less than 120 mm Hg and diastolic BP less than 80 mm Hg. There are four classifications of BP CLASSIFICATION blood pressure Normal: Systolic <120 and diastolic <80 which are based Prehypertension: Systolic 120 to 139 or on the average of diastolic 80 to 89 two or more Stage 1 hypertension: Systolic 140 to 159 properly or diastolic 90 to 99 measured, Stage 2 hypertension: Systolic >/= 160 or seated diastolic >/= 100 measurements made on each of two or more office visits. Hypertension is a major risk factor for cardiovascular disease and renal disease, and studies suggest that untreated high blood pressure shortens life expectancy by approximately five years. Essential or primary hypertension has no identifiable cause and accounts for over 95% of all cases of hypertension. However, it may be linked to genetic factors and certain environmental factors. The following are factors believed to increase the risk of primary hypertension: Ø Genetic factors are thought to play a significant role in hypertension. Scientists believe that approximately 30% of high blood pressure cases are due, at least in part, to genetic factors. Individuals who have a parent with hypertension are twice as likely to develop hypertension as the rest of the population. Ø Race: Hypertension is twice as prevalent among African Americans and it is also usually more severe. Ø Gender: Hypertension is more common among men than women until after menopause, when the incidence in women increases. Ø Age: As people grow older, their blood pressure steadily rises. About 75% of women and almost 66% of men, aged 75 or older, have high blood pressure. One in four people between the ages of 20 and 74 have high blood pressure. Ø Obesity: High blood pressure occurs twice as often in people who are obese. Obesity is associated with increased intravascular volume. Ø Diet: Primary hypertension may occur in people who have an excess level of salt intake. Salt consumption is thought to be one of the most important factors contributing to high blood pressure. Salt increases fluid retention around cells and in the blood, thus causing more pressure on the walls of the arteries, causing the heart to work harder. Copyright © 2012 Growing Up With Us, Inc. All rights reserved. Page 1 of 4 Diets high in cholesterol also lead to hypertension. Cholesterol causes formation of plaque that narrows arteries and restricts blood flow, causing increased peripheral vascular resistance and workload on the heart, thus increasing blood pressure. Ø Chronic stress - stimulates the sympathetic nervous system, causing catecholamines, such as epinephrine and norepinephrine, to be released. These chemicals cause vasoconstriction. Ø Alcohol - consumption of three or more alcoholic beverages per day appears to increase blood pressure by increasing plasma catecholamines, causing vasoconstriction. Ø Cigarette smoking - nicotine constricts blood vessels. Secondary hypertension is high blood pressure that is caused by an unrelated condition in the body. Causes of secondary hypertension include prescription medications, such as corticosteroids, and over-the counter medications, including cold medications. Kidney disease or kidney surgery, as well as preeclampsia and eclampsia in pregnancy, can also cause secondary hypertension. SYMPTOMS OF HYPERTENSION Hypertension is often called the "silent killer" because symptoms of high blood pressure do not appear for years. Patients with hypertension may exhibit general signs, including headaches, dizziness, blurred vision and swollen extremities, such as the hands and fingers. The higher the blood pressure, the greater the patient’s risk of MI, heart failure, angina, stroke, atrial fibrillation, aneurysm, peripheral artery disease, and kidney damage. The risk of cardiovascular disease doubles with each 20 mm Hg incremental increase in systolic BP and/or 10 mm Hg incremental increase in diastolic BP. In younger people, elevated diastolic BP is associated with more cardiovascular disease risk than increased systolic BP. However, starting at age 50, systolic BP becomes the more important risk factor. ASSESSMENT A diagnosis of hypertension is made if two or more elevated blood pressure readings are obtained on at least two separate occasions. High blood pressure is often discovered during a routine assessment. “White-coat hypertension,” the tendency for blood pressure to rise when a patient is being assessed by a healthcare provider, can also result in imprecise readings. Measuring BP accurately is crucial to assessing hypertension. Following are tips, regardless of the equipment used, to accurately measure blood pressure, which are particularly important to follow when the initial measurement is high: § For 30 minutes before a patient’s BP is taken, he or she should avoid smoking or drinking beverages containing caffeine. Nicotine can cause temporary fluctuations in BP and after consuming caffeine, blood pressure increases briefly. § Have the patient rest quietly for at least 5 minutes before taking the patient’s BP to prevent a falsely high reading. § Apply the BP cuff to the patient's bare arm. The cuff should cover at least 2/3 of the upper arm and fit evenly and snuggly. The lower edge of the cuff should be about one inch above where the bell of the stethoscope will be placed over the brachial artery. § § § Palpate the patient's radial pulse. Inflate the cuff until a pulse is no longer felt and then inflate the cuff 30 mm Hg more. Having a BP checked should not be painful. For example, if a patient’s BP is 118/78, inflating the cuff to 220 mm Hg, will hurt. Inflating the cuff to 150 mm HG should be appropriate. The cuff should then be deflated slowly (about 2 to 3 mm Hg/second). When the first sound is heard that is the systolic measurement. When the sound fades, record the diastolic measurement. If the patient's BP is elevated, wait at least 2 minutes, then take it again in the other arm. Taking the patient’s BP sitting, as well as standing, may also provide pertinent information. If the patient is newly diagnosed with hypertension, routine studies are generally performed to establish a baseline to help determine the extent of hypertensive target-organ damage, as well as to identify other cardiovascular risk factors. Such studies may include an electrocardiogram, fasting blood glucose level, and cholesterol profile, including triglycerides. PATIENT EDUCATION Depending on the severity of the patient’s hypertension, before drug therapy is implemented, lifestyle modifications are often recommended. Patient education should focus on: Ø The DASH diet (Dietary Approaches to Stop Hypertension) is an eating plan that emphasizes fruits, vegetables, and low fat dairy foods. It is also low in saturated fat, total fat, and cholesterol. DASH includes whole grains, poultry, fish, and nuts and has reduced amounts of fats, red meats, sweets, and sugared beverages. Ø Weight reduction - a decrease in body weight will decrease the work of the heart, thus decreasing blood pressure. Ø Decreasing salt intake - strict sodium restriction is no longer recommended. Patients with hypertension should be instructed not to add salt at the table or when cooking. Foods high in salt, such as ham, bacon, sausage, sauerkraut, canned vegetables and soup and processed foods, such as hot dogs and luncheon meats, should be avoided. Ø Exercise - research shows that as little as 30 to 60 minutes of exercise per week can aid in weight reduction and can help reduce blood pressure. Ø Limit daily alcohol consumption. Ø Quit smoking. Smoking cessation programs, which may include medications, counseling and support groups, are helpful. Ø Utilize stress management, such as deep breathing and relaxation techniques. Hypertension has serious consequences, and, therefore, early detection is critical. Hypertension can be identified easily and treated effectively. If lifestyle modifications have not been successful after 3 to 6 months, pharmacologic intervention is appropriate, while lifestyle modifications are continued. Growing Up With Us, Inc. PO Box 481810 • Charlotte, NC • 28269 Phone: (919) 489-1238 Fax: (919) 321-0789 Editor-in-Chief: Mary M. Dunlap MAEd, RN E-mail: [email protected] Website: www.growingupwithus.com GUWU Testing Center www.growingupwithus.com/quiztaker/ Copyright © 2012 Growing Up With Us, Inc. All rights reserved. Page 2 of 4 Name:_____________________________________________________ Date:___________________________________ Employee ID#:____________________________________________ Unit:____________________________________ POPULATION/AGE-SPECIFIC EDUCATION POST TEST GROWN UP... Caring for Adolescents, Adults, and Aging Adults February 2012 Competency: Demonstrates Age-Specific Competency by correctly answering 9 out of 10 questions related to Hypertension...Assessment & Patient Education. HYPERTENSION... ASSESSMENT & PATIENT EDUCATION 1. Sally Ree, 58 years old, is seen in the clinic for a diabetes check-up. Her blood pressure is 151/98 today. One month ago, at the same clinic, her BP was 155/99. Sally would be classified as having: a. normal blood pressure. b. prehypertension. c. stage 1 hypertension. d. stage 2 hypertension. 2. Which statement is correct about essential hypertension? It is: a. also called secondary hypertension. b. the most common type. c. a type where the cause is clear. d. a new hypertension classification. 3. Hypertension is diagnosed by: a. any reading with a diastolic pressure over 90 mm Hg. b. two or more elevated blood pressure readings obtained on at least two separate occasions. c. a patient’s complaint of headache, dizziness and swollen fingers. d. a systolic pressure over 140 mm Hg or above. 4. All of the following can cause vasoconstriction leading to high blood pressure EXCEPT? a. Cigarette smoking b. Stress c. Alcohol abuse d. A diet high in potassium Copyright © 2012 Growing Up With Us, Inc. All rights reserved. Page 3 of 4 Name:_____________________________________________________ Date:___________________________________ Employee ID#:____________________________________________ Unit:____________________________________ POPULATION/AGE-SPECIFIC EDUCATION POST TEST GROWN UP... Caring For Adolescents, Adults, and Aging Adults HYPERTENSION... ASSESSMENT & PATIENT EDUCATION 5. Hypertension increases the risk of all of the following EXCEPT: a. an aneurysm. b. kidney damage. c. heart failure. d. asthma. 6. A patient’s blood pressure is initially 140/90. Before retaking it, the healthcare provider should: a. have the patient take a few deep breaths. b. realize the patient has “white coat” hypertension. c. have the patient rest quietly for at least 5 minutes. d. offer the patient a cup of coffee to relax. 7. With a diagnosis of hypertension, the patient should be taught to strictly limit salt intake. a. True b. False 8. Which of the following menus would be appropriate for the hypertensive patient? a. A deli ham sandwich, potato chips and pickles. b. Fried chicken, baked potato with butter and shortbread cookies. c. Broiled fish, broccoli and whole grain rice. d. Fried eggs, bacon and whole wheat toast. 9. The DASH diet has reduced amounts of which of the following? a. Red meats b. Fresh fruits c. Green vegetables d. Nuts 10. With aging, blood pressure normally increases. a. True b. False Copyright © 2012 Growing Up With Us, Inc. All rights reserved. Page 4 of 4