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Chapter 38
Hypertension
Hypertension/High Blood Pressure
• Persistent SBP >= 140 mmHg
• Persistent DBP >= 90 mmHg
• “the silent killer”
• Higher prevalence in African Americans
• Risk factors: obesity, family history
Classification & Risks
Risk Group A
Risk Group B
Risk Group C
No major risk factors
1+ risk factors (not
including diabetes)
May or may not have
risk factors
No target organ damage
No target organ damage
Target organ damage
No clinical
cardiovascular disease
No clinical
cardiovascular disease
Clinical cardiovascular
disease or diabetes
Classification
Systolic (SBP)
Diastolic (DBP)
Normal
90-119 mmHg
60-79 mmHg
Pre-hypertensive
120-139 mmHg
80-89 mmHg
Stage 1
140-159 mmHg
90-99 mmHg
Stage 2
>= 160 mmHg
>= 100 mmHg
Classification
• Primary (essential): identifiable factors
(increased sodium, obesity, diabetes, excessive
alcohol)
• Secondary: caused by an underlying condition
(kidney disease, pregnancy, arterial conditions)
Blood Pressure Factors
BP = CO x PVR
• Blood pressure = cardiac output X peripheral vascular resistance
• Cardiac output: volume of blood pumped by the heart in 1 minute
• PVR: force in the blood vessels that the LV must overcome to eject
blood from the heart
▫ Diameter of blood vessels
▫ Blood viscosity
▫ PVR increased when arteries or arterioles are narrow or there is
increased fluid volume
Age-Related Changes
• Reduced elasticity of arteries
• Decreased cardiac output, increased PVR
• Decreased ability of aorta to stretch
Primary (Essential) Hypertension
• Risk Factors: dyslipidemia, atherosclerosis, diabetes, tobacco use, 55+
men or 65+ women, family history, sedentary lifestyle, obesity, stress
• S/S: no symptoms; headaches; lightheadedness; epistaxis; impaired organ
function
• Complications: heart attack, heart failure, stroke, kidney disease,
blindness, organ damage
▫ Heart: CHD can cause angina, MI, or CHF; the LV has to work harder,
leading to hypertrophy & failure
▫ Kidneys: renal arteries narrow, decreasing renal function & leading to
renal failure; nocturia, azotemia, proteinuria, & hematuria may
indicate failure
▫ Brain: cerebral arteries constrict & are damaged, leading to risk for
TIAs & CVAs
▫ Eyes: narrowing of retinal arterioles, retinal hemorrhage, or
papilledema can lead to blindness
Diagnostic Tests & Procedures
• At home monitoring (ambulatory)
• Lifestyle data, cardiovascular risks, medical
diagnoses
• Lab studies
• EKG
• Chest radiograph
Treatment
• Gradually reduce PVR & BP to less than 140/90
mmHg
• Goal 130/80 mmHg if they have diabetes or
renal disease
• Optimal BP is less than 120/80 mmHg
• Treat underlying condition if secondary
• Nonpharmacologic tx first
• Drug therapy, if needed
Treatment: Lifestyle Modifications
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Weight reduction
Smoking cessation
Sodium/alcohol restriction
Exercise program
Relaxation
Treatment: Pharmacologic Therapy
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Indicated for 160/100 or greater
Individualized treatment
With diurectics, monitor fluids & electrolytes
Monitor s/s hypokalemia
Irritability,confusion
pg775
Treatment: Pharmacologic Therapy
1. Centrally Acting Agents (Alpha2-Agonists)
1.
Reduces peripheral resistance & lowers BP
2. Alpha-Adrenergic Receptor Blockers (Antagonist)
1.
2.
Reduces peripheral resistance
SE: orthostatic hypotension (lie down for 2 hours after taking first or increased dose);
dizziness, headache, drowsiness
3. Beta-Adrenergic Receptor Blockers (Beta Blockers)
1.
2.
3.
Lower HR; decrease cardiac constriction
Do not use in patients with asthma, COPD, or heart blocks
Monitor for bradycardia, hypotension, & hypoglycemia
4. Direct Vasodilators
1.
2.
Relaxes arteriolar smooth muscle
Sometimes used for emergency situations via IV fluids
Treatment: Pharmacologic Therapy
1. Calcium Channel Blockers (Calcium Antagonists)
1.
2.
Reduces HR, reduces cardiac contraction, dilates peripheral arteries
SE: flushing, dizziness, headache, hypotension, bradycardia, edema
2. Angiotensin-Converting Enzyme Inhibitors (ACE)
1.
2.
Decreased peripheral resistance, decreased fluid retention
SE: chronic cough, dizziness, headache, fatigue, angioedema, hyperkalemia, hypotension
3. Diuretics
1.
2.
Monitor for fluid/electrolyte imbalance; I/O; Signs of hypokalemia (especially in
geriatrics)
Potassium replacement, if needed
4. Angiotensin II Receptor Antagonists
1.
2.
Prevent vasoconstriction, reduces blood volume
SE: dizziness
Treatment: Nursing Implications
1.
2.
3.
4.
Be familiar with the drugs & side effects
Monitor the patient
Teach about their drug regimen & disease process
Carefully monitor geriatric patients due to reduce
liver/kidney functions & risk for orthostatic
hypotension (risk for falls)
Secondary Hypertension
• Causes: renal disease, excess secretion of adrenal hormones, narrowed
aorta, increased intracranial pressure, some drugs
Nursing Assessment
• Health History: previous hypertension; renal, cardiac, or endocrine disorders;
previous BP measurements; pregnancy/hormone replacement therapy; all
medications/OTC/herbal remedies; family history; review of systems for symptoms
(headache, epistaxis, dizziness, dyspnea, angina, nocturia); occupational history,
activity levels; sleep/rest/stress; nutrition
• Physical Exam: general appearance; signs of distress; height/weight/VS; BP in
both arms, if possible; RR rate & effort; extremities (edema/color); reassess BP 1-5
minutes later; notify MD immediately if DBP > 115 mmHg (risk for stroke!)
Pg778-779
Secondary Hypertension: Interventions
• Ineffective Self-Health Management: educate on therapy adherence and
disease process; listen & address concerns; include family or support system;
teach about medications & at-home monitoring; educate on diet therapy,
including weight loss & low-sodium diet
▫ Exercise: educate; encourage; start a program; discuss with physicians;
motivate
▫ Stress Management: identify stressors; discuss stress reduction strategies;
refer to counselor if needed
▫ Drug Therapy: educate about medications, timing, purpose, side effects;
advise not to stop or change drug therapies without talking to their doctor;
discuss OTC therapies that can cause high blood pressure
▫ DASH Diet (Dietary Approaches to Stop Hypertension)
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2000 calories a day
7-8 servings of grains/grain products
4-5 servings of vegetables
4-5 servings of fruits
2-3 servings of low-fat or fat-free dairy
2 or less lean meats, poultry, fish
4-5 per week of nuts, seeds, dry beans
2-3 fats & oils
5 per week of sweets
Secondary Hypertension: Interventions
• Risk for Injury: due to drug side effects; educate & monitor
▫ Orthostatic Hypotension: sudden drop in SBP (20 mmHg) when going
from lying/sitting to standing position; monitor for syncope,
lightheadedness, dizziness; encourage leg exercises & to rise slowly
▫ Sedation: take meds at nighttime (if ordered) to promote sleep; if
unavoidable, do not do activities (driving) during peak drug times
• Ineffective Coping: depression (drug side effect), consult MD; refer if
needed
• Sexual Dysfunction: (Rx side effect); ask about sexual abilities if
patient does not offer this information; advise MD
Older Patients
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Monitor drug therapy response
Watch for orthostatic hypotension & sedation
Monitor & assess for depression
Never assume they are not sexually active
pg782
Hypertensive Crisis
• Life-threatening medical emergency! Death can occur!
• S/S: severe headache, blurred vision, nausea, restlessness, confusion,
Elevated DBP (130 mmHg or more); tachycardia, tachypnea
• “Malignant hypertension:” type of hypertensive crisis with DBP > 140
mmHg; sudden onset; usually African-Americans aged 30-40.
• Diagnosis: elevated BP, HR, RR; retinal hemorrhage; papilledema; labs &
chest radiograph; direct BP monitoring through arterial catheter
• Treatment: rapidly reduce BP to nonlife-threatening level, then slowly to
normal range; diuretics & potent vasodilators
THIS CAN HAPPEN IF A PATIENT ABRUPTLY
STOPS THEIR HTN MEDICATIONS!
EDUCATE TO NEVER STOP TAKING THEIR MEDS WITHOUT
TALKING TO THEIR DOCTOR FIRST!!!
Hypertensive Crisis
Nursing Care
• Assessment: monitor closely, frequently check VS; record I/O; watch for N/V (early
signs of seizure or coma)
• Interventions: administer drugs; monitor VS; monitor cardiac/renal function;
continue IV therapy & oxygen; comfort patient; ensure safety if possible seizure
activity (raise/pad side rails, elevate HOB, ensure oral airway & suction equipment is
available); encourage & educate patient
Questions?