Download Hypertension - NurseCe4Less.com

HYPERTENSION:
AN OVERVIEW
Dana Bartlett, BSN, MSN, MA, CSPI
Dana Bartlett is a professional nurse and
author. His clinical experience includes 16
years of ICU and ER experience and over 20
years of as a poison control center
information specialist. Dana has published
numerous CE and journal articles, written
NCLEX material and textbook chapters, and
done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme.
He has written widely on the subject of toxicology and was recently named a
contributing editor, toxicology section, for Critical Care Nurse journal. He is currently
employed at the Connecticut Poison Control Center and is actively involved in
lecturing and mentoring nurses, emergency medical residents and pharmacy
students.
ABSTRACT
Primary hypertension, sometimes called essential hypertension, is far
more common than secondary hypertension. There are many distinct
and separate causes of secondary hypertension, which requires a more
thorough discussion than would be possible in a short study. Primary
hypertension is primarily discussed, as well as the topics of
hypertensive emergencies, isolated diastolic hypertension, and isolated
systolic hypertension is briefly highlighted.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
1
Accreditation Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses.
Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Pharmacology content is 0.5 hours (30 minutes).
Course Author & Planner Disclosure Policy Statements
It is the policy of NurseCe4Less.com to ensure objectivity,
transparency, and best practice in clinical education for all continuing
nursing education (CNE) activities. All authors and course planners
participating in the planning or implementation of a CNE activity are
expected to disclose to course participants any relevant conflict of
interest that may arise.
Statement of Learning Need
Nurses in various practice settings need to know the definitions and
statistics of hypertension, including the etiologies of primary and
secondary hypertension, risk factors of primary hypertension, as well
as the complications and treatments used for primary hypertension in
order to properly educate patients to prevent and to recognize
hypertension.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
2
Course Purpose
The provide nurses with knowledge about primary hypertension and
secondary hypertension, including the risk, prevention and treatment
of primary hypertension.
Target Audience
Advanced Practice Registered Nurses, Registered Nurses, Licensed
Practical Nurses and Nursing Associates
Course Author & Director Disclosures
Dana Bartlett, BSN, MA, MSN, CSPI, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC -all have
no disclosures.
Acknowledgement of Commercial Support: There is none.
PLEASE TAKE TIME TO COMPLETE A SELF-ASSESSMENT OF KNOWLEDGE, ON
PAGE 4, SAMPLE QUESTIONS BEFORE READING THE ARTICLE.
OPPORTUNITY TO COMPLETE A SELF-ASSESSMENT OF KNOWLEDGE
LEARNED WILL BE PROVIDED AT THE END OF THE COURSE.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
3
1. Elevated blood pressure that does not have an identifiable
cause is known as
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
systolic hypertension.
2. Elevated blood pressure that is caused by heart and lung
disease, or other illness, is known as
a.
b.
c.
d.
primary hypertension.
chronic hypertension.
secondary hypertension.
acute hypertension.
3. If only the diastolic blood pressure is elevated when
measured, then the patient is understood to have
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
systolic hypertension.
4. The majority of people who have hypertension have:
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
acute hypertension.
5. Primary hypertension is defined as:
a.
b.
c.
d.
SBP
SBP
SBP
SBP
> 110 mm Hg or DBP > 70 mm Hg.
≥ 160 mm Hg or DBP ≥ 110 mm Hg.
≥ 140 mm Hg or DBP ≥ 90 mm Hg.
120-139 mm Hg, DBP 80-89 mm Hg.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
4
Introduction
Hypertension, often referred to as high blood pressure, is one of the
most common chronic diseases. Approximately one in three adult
Americans has hypertension. This means that 66 to 78 million
Americans have the disease. Hypertension is typically and most
usefully classified as primary or secondary. Primary hypertension
accounts for the great majority of the cases of hypertension. The
terms primary hypertension and hypertension refer to the same
disease and they will be used interchangeably throughout this study.
Etiology Of Hypertension
The etiology of primary hypertension is not known. There is a genetic
component to the development of the disease, but age and lifestyle
factors contribute significantly to its development and progression.
Secondary hypertension is much less common than primary
hypertension, and in secondary hypertension there are identifiable
causes. The causes of secondary hypertension include, but are not
limited to:

endocrine, neurologic, renal, and vascular diseases

medical conditions, such as obstructive sleep apnea, rare
cancers, and rare genetic diseases

pregnancy

drugs such as alcohol, cocaine, non-steroidal antiinflammatories, and oral contraceptives
The majority of people who have hypertension (aside from secondary
hypertension) have no characteristic signs or symptoms except for an
elevated blood pressure, and this is one of the most harmful features
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
5
of the disease. Untreated, unrecognized hypertension slowly causes
progressive damage to the heart, the eyes, the kidneys, the
neurological system, and the vascular system and by the time the
patient is symptomatic, the damage is extensive and often irreversible.
The presence of hypertension
significantly increases the risk for
developing cardiovascular diseases
such as atrial fibrillation, coronary
artery disease, congestive heart
failure, myocardial infarction,
stroke, renal disease, and
retinopathy. Morbidity and mortality
are directly related to the duration
and severity of hypertension.
Hypertension cannot be cured but it
can be controlled with lifestyle
modifications and antihypertensive
drug therapy; however, initiating
and maintaining these lifestyle
modifications are very difficult and
patient compliance with antihypertensive drug therapy is often poor,
as well. The problem is worsened because a large number of people
who are at risk for developing hypertension are not screened for the
disease, and many people who have been diagnosed with hypertension
are not being adequately treated. As the population ages and as
obesity becomes more common, the incidence of hypertension will
grow.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
6
Definitions of Hypertension
The term hypertension refers to chronic increases in blood pressure.
These measured increases can be of both the systolic and diastolic
blood pressure, which is called primary hypertension. If only the
diastolic blood pressure is elevated when measured, then the patient is
understood to have isolated diastolic hypertension. If only the systolic
blood pressure is elevated when measured, then the patient is
understood to have isolated systolic hypertension.
Whether a patient has primary diastolic or systolic hypertension
depends on the particular level of blood pressure. Pre-hypertension is
present when the systolic blood pressure and/or diastolic blood
pressure are elevated, but not to a degree that is considered to fit the
criteria for primary hypertension. Primary Hypertension is also divided
into Stage I and Stage II, as seen below.1,2,5
Definitions of Hypertension
Pre-hypertension: SBP 120-139 mm Hg, DBP 80-89 mm Hg
Stage I hypertension: SBP ≥ 140-159 mm Hg or DBP ≥ 90-99 mm Hg
Stage II hypertension: SBP ≥ 160 mm Hg or DBP ≥ 100 mm Hg
Isolated diastolic hypertension: DBP ≥ 90 mm Hg and SBP < 160 mm Hg
Isolated systolic hypertension: SBP ≥ 140 mm HG and DBP < 90 mm Hg
Hypertensive Emergencies
Blood pressure measurements that require immediate medical care
and/or are causing significant signs and symptoms or organ damage
are considered to be diagnostic of hypertensive emergencies.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
7
Hypertensive emergencies are a spectrum of clinical presentations that
are usually characterized by a systolic blood pressure > 220 mm Hg or
a diastolic blood pressure > 120 mm Hg.4 The situation is considered
urgent (not necessarily an emergency) if the patient has no significant
signs and symptoms and no evidence of end-organ damage.
Patients in whom the blood pressure elevation is considered to be
urgent may be managed with initiation of antihypertensive therapy or
a change to the existing antihypertensive therapy and outpatient
follow up. Rapid control of blood pressure is typically not needed.6 If
the patient has significant signs and symptoms such as chest pain,
headache, or shortness of breath, or evidence of end-organ damage
such as aortic dissection, hypertensive encephalopathy, intracranial
hemorrhage, myocardial infarction, papilledema, or retinal
hemorrhages, hospitalization and rapid control of blood pressure would
be required.6,7
Scope of the Problem
One in three American adults or approximately 66-78 million
Americans have hypertension.1,2 It is one of the most common and
well-known public health problems in the U.S., but many people who
have hypertension are either unaware that they have hypertension,
are not receiving treatment, or are inadequately treated.1,2,4
The incidence of hypertension increases with age. Until age 45 men
are more likely than women to have hypertension.1 As discussed in the
next section, race is an important factor with hypertension. For
example, hypertension is much more common in African Americans.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
8
This population also suffers disproportionately from the complications
of hypertension.
Risk Factors And Pathogenesis Of Primary Hypertension
Primary hypertension accounts for approximately 80%-95% of all
cases of hypertension.4 It is a disease that is multifactorial in origin,
and it is caused by genetic and environmental factors. Many of the risk
factors that contribute to the development and progression of primary
hypertension are closely related and cannot be easily separated.
Genetics
The genetic contribution to the development of hypertension is
unclear. Studies that have controlled environmental factors have
estimated the heritability of blood pressure to be 15%-35%,4 and it
may be that susceptibility to end-organ damage from hypertension is
also influenced by genetics.4 But heritability measures phenotype
variability that is attributed to genetic variability; it does not mean
that a specific percentage of an individual’s phenotype is caused by
genetics.
Genetic abnormalities have been identified in people who have
hypertension but these have not been shown to be a primary cause of
the disease1 and because environmental factors clearly contribute to
the development of primary hypertension, genetic identification of
those at risk is not feasible at this time and may not be.8
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
9
Age
Hypertension should not be considered to be an inevitable part of
getting older, but the statistics of aging and hypertension are not
comforting. The likelihood of developing hypertension increases as an
individual ages and it has been estimated that the probability is 90%
of a middle-aged or elderly person developing hypertension in his or
her lifetime.1
The high prevalence of hypertension in the elderly can be explained by
a diet high in sodium, obesity, and a sedentary lifestyle.9 Hypertension
in this age group can also be explained by physiological factors that
occur during aging such as increased arterial stiffness, decreased
baroreceptor sensitivity, increased activity of the sympathetic nervous
system, and a decreased ability of the kidneys to excrete sodium.10
Race
The incidence and severity of hypertension is higher in African
Americans than in other ethnic groups in the U.S.11 African Americans
develop hypertension at an earlier age and the rate of progression
from pre-hypertension to hypertension is increased.11 In addition,
African Americans suffer disproportionately from the cardiovascular
and renal complications of hypertension11 and optimal control of blood
pressure is more difficult for African Americans, even when awareness
of the problem and the level of treatment are equivalent to other
ethnic groups.12
These disparities can be partially explained by socio-economic status,
suboptimal maternal nutrition that causes low birth weight, the
increased incidence of obesity in the African American community,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
10
diet, and differences in salt sensitivity. However, even when income,
body mass, and diet are considered, hypertension is a particular
problem for African Americans and the reasons for this are not clear.
Obesity
Obesity increases the risk of developing hypertension13,14 and weight
reduction can help reduce blood pressure, but the mechanisms by
which obesity contributes to the development of hypertension are not
clearly understood.14 Insulin resistance and obstructive sleep apnea
(OSA) are common in people who are obese, and there is some
evidence that these are contributory causes of hypertension.15
However, there appears to be significant inter-individual variation in
the degree to which insulin resistance, OSA, and obesity itself
contribute to the risk of developing hypertension.15 For example, not
all people who are obese develop high blood pressure. It may be the
distribution of body fat, not body weight per se, which is the factor
that determines who will or will not become hypertensive.13
Smoking
The relationship between cigarette smoking and hypertension is
complex. Cigarette smoking increases arterial stiffness,16 and the
incidence of hypertension is increased in people who smoke more than
15 cigarettes a day.17 Smoking increases the risk of developing
atherosclerosis and atherosclerosis and contributes to the development
of hypertension.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
11
Alcohol
Alcohol appears to be an independent risk factor for hypertension.
Moderate alcohol intake may have a protective effect;18 excessive
alcohol intake increases the risk of developing hypertension.18-20
Physical Inactivity
Physical inactivity and a sedentary lifestyle increase the risk for
developing hypertension,1,21,22 and a high level of fitness and physical
activity are inversely associated with the development of
hypertension.22
Sodium Intake
Dietary sodium intake is closely associated with hypertension. Excess
dietary sodium increases the risk of developing hypertension23 and
reducing salt intake will lower blood pressure.24
Other factors that may be risk factors for the development of primary
hypertension are Vitamin D deficiency,25-27 dyslipidemia,28 low dietary
intake of calcium and magnesium4 and fruits and vegetables,29 and
psycho-social variables such as depression, occupational stress,
personality type, sleep quality, and the individual’s level of isolation
and social support.30-33
All of the risk factors that were discussed are or may be contributing
causes to the development of hypertension. How much each one
influences the risk for hypertension and how they interact is not
known. It is clear however that many of these risk factors such as
obesity, smoking, and a sedentary lifestyle, regardless of their effect
on hypertension, are very unhealthy and they are primary causes of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
12
many other serious chronic diseases. Losing weight, smoking
cessation, physical exercise, and a healthy diet improve health, lower
blood pressure and may prevent hypertension, as well.
Screening And Initial Evaluation Of Hypertensive Patients
Screening for hypertension significantly reduces the incidence of
cardiovascular events and poses very little harm.34 Blood pressure can
be measured in a physician’s office, at home by the patient, or by
using ambulatory blood pressure monitoring (ABPM). The U.S.
Preventive Services Task Force (USPSTF) recommendations for blood
pressure screening are outlined below.34
1. Annual screening for everyone ≥ 40 years of age and for people
who have risk factors for the development of hypertension.
2. The USPSTF considers a high-normal blood pressure (130139/85-89 mm Hg), African American ethnicity, and obesity and
being overweight as risk factors.
3. Adults aged 18 to 39 years with normal blood pressure (<130/85
mm Hg) who do not have other risk factors should be rescreened
every 3 to 5 years.
4. The USPSTF recommends rescreening with properly measured
office blood pressure and, if blood pressure is elevated,
confirming the diagnosis of hypertension with ABPM.
Ambulatory Blood Pressure Monitoring
Ambulatory blood pressure monitoring is considered to be the most
accurate method for diagnosing hypertension, it is the preferred
technique for diagnosing hypertension,34-36 and it is especially helpful
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
13
at detecting masked hypertension.37 A portable blood pressure monitor
device is worn by the patient and the measurements are recorded at
fixed intervals for 24-48 hours, sometimes less.
Home Measurement
Home measurement of blood pressure with an automated device is an
acceptable method for detecting hypertension. The technique is the
same as off-based measurement (discussed below). It is
recommended that at least 12-14 measurements should be taken
during the day and the evening35 but there is no consensus about the
optimal schedule.38
Office-based Measurement
Office-based measurement of blood
pressure for hypertension screening
requires proper technique to obtain
accurate results. Close attention
must be paid to the following details
when performing office-based blood
pressure measures.35
Cuff Size
Incorrect cuff size can result in an inaccurate reading. The American
Heart Association (AHA) recommendations for cuff size are: 1) Upper
arm circumference 22-26 cm, small adult cuff/12 x 22 cm, 2) Upper
arm circumference 27-34 cm, adult cuff/16 x 30 cm, 3) Upper arm
circumference 35-44 cm, large adult cuff/16 x 36 cm, and 4) Upper
arm circumference 45-52 cm, adult thigh cuff/16 x 42 cm.39
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
14
Cuff Placement and Inflation/Deflation
The cuff bladder should be midline over the brachial artery and it
should not be placed over clothing. Place the cuff so that the
stethoscope does not touch the bladder; this will prevent noise from
cuff deflation from interfering with an accurate measurement.
When inflating and deflating the cuff, inflate the cuff 20 mmHg above
the systolic pressure; and, deflate the cuff 3 mmHg per second. Use
the disappearance of sound - the Korotkoff V phase - as the diastolic
pressure.
Device
The same device should be used for each measurement; different
devices will give different results.
Number of Measurements
At least three measurements should be taken. It is very important that
multiple readings should be taken and these readings must be
separated by the appropriate length of time. This will avoid white coat
hypertension, which is when a person experiences high blood pressure
only when he or she visits their medical provider’s office, or masked
hypertension, which is when a person’s blood pressure is normal when
being measured by a medical professional but otherwise abnormally
high.
Patient Position
The patient should be seated with the back supported, and the legs
should not be crossed. If the back is unsupported or the legs are
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
15
crossed the measurement will be falsely elevated. The patient’s arm
should be at the level of the heart; if the arm is below heart level the
reading will be elevated.
Time
Each measurement in the office should be done at the same time.
Other Variables
The patient should be sitting for at least five minutes before a
measurement is taken. There should be no smoking or ingestion of
caffeine prior to the measurement. Also, the room where the patient is
sitting should not be too cool, and the patient should not be talking
while blood pressure is being measured. If the above variables are not
observed, an elevated blood pressure could result.
When it has been confirmed that the patient has hypertension, the
patient should be assessed for secondary hypertension and he or she
should be evaluated for end-organ damage. Renal function should be
assessed, neurologic and ophthalmologic exams should be performed,
and an evaluation of the patient’s cardiovascular status should be
done.
Complications Of Hypertension
Primary hypertension is a progressive disease and the first stage in its
development is pre-hypertension. Pre-hypertension is a condition in
which the blood pressure is elevated above normal levels but not to
the measurements that define hypertension. In addition, the patient is
asymptomatic and he or she has not yet developed organ damage.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
16
Pre-hypertension greatly increases
the risk of developing hypertension40
and by itself it is a significant risk
factor for the development of
cardiovascular disease and
stroke.41,42 Pre-hypertension is
followed by early hypertension, and
by 30-50 years of age, primary
hypertension is well established.
If the patient who has primary hypertension is not diagnosed and
treated, he or she will eventually develop complicated hypertension
and, potentially, damage to the eyes, heart, kidneys, nervous system,
and central and peripheral vasculature.4 The chance of developing
complications increases as the level of blood pressure elevation
increases;4,43 the risk of developing heart disease doubles for every 20
mmHg increase in systolic pressure and every 10 mmHg increase in
diastolic pressure.4 Complications of primary hypertension include
those highlighted below.
Atherosclerosis
Hypertension greatly increases the risk for developing
atherosclerosis,44-47 and in younger adults, hypertension contributes
more to the development of atherosclerosis and cardiovascular disease
than diabetes, dyslipidemia, or smoking.48
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
17
Stroke
Hypertension and pre-hypertension are associated with a significant
increase in the risk for stroke.43,49 The incidence of stroke increases in
direct proportion to increases in blood pressure.4
Kidney Disease
Hypertension is a major risk factor for the development of chronic
kidney disease, and the risk of chronic kidney disease increases in
direct proportion to elevations in blood pressure.4
Heart Disease
Hypertension increases the risk of developing atrial fibrillation,
congestive heart failure, myocardial infarction, and other
cardiovascular and heart pathologies.4,10,45 Heart disease is the most
common cause of death in people who have hypertension.
Retinal Damage
The incidence of retinopathy in patients who have hypertension has
been reported to be as high as 66.3% to 80.3%,50,51 and the level of
systolic blood pressure and the duration of hypertension are significant
risk factors for developing retinal damage. The presence of diabetes in
many hypertensive patients and the particular methods used to detect
retinal damage may skew these figures but, even when these factors
are considered, hypertensive retinopathy is still a problem of
considerable magnitude.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
18
Isolated Diastolic And Isolated Systolic Hypertension
Hypertension refers to elevations of both systolic and diastolic blood
pressure, but elevations of diastolic pressure or systolic pressure alone
are well described and isolated systolic blood pressure is relatively
common.
Isolated diastolic blood pressure primarily affects adults and young
men who are obese, and it is the most common form of hypertension
in adults less than age 40.52,53 Isolated diastolic hypertension is
strongly related to increases in cardiovascular morbidity and
mortality52 and most people who have isolated diastolic hypertension
will develop hypertension.54 However, the importance of isolated
diastolic hypertension as a cause of hypertensive complications is not
completely understood52 nor are the best treatment options.53 Patients
who have isolated diastolic hypertension should be treated with
lifestyle modifications, and if they are considered to be at risk for
hypertensive complications and/or there is evidence of organ damage
they should be treated with antihypertensive medication.53
Isolated systolic hypertension is caused by reduced compliance and
elasticity of large arteries, and it is quite common in the elderly.52
Isolated systolic hypertension is considered to be a significant cause of
cardiovascular disease52 and patients who have isolated systolic
hypertension should be closely monitored and treated.
Treatment Of Primary Hypertension
The benefits of treating primary hypertension are clear and significant.
It has been estimated that lowering systolic blood pressure 10 mmHg
and diastolic blood pressure 5 mmHg will reduce the risk of congestive
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
19
heart failure by 50%, the risk of coronary heart disease and
myocardial infarction by 20%-25%, the risk of stroke by 35%-40%,
and overall mortality rate by 10%-20%.10,45
Recommendations for the treatment of patients who have
hypertension have changed and evolved. Given the complexity and
multifactorial nature of the disease it is not surprising that there is
some disagreement in the medical community as to who should be
treated, when treatment should be started, the best therapies and
medications, and what level of benefits treatment can provide.
However, the basic approach to treating hypertension is essentially the
same, regardless of the source of the recommendations.
This section will discuss the treatment recommendations published in
2014 by the Eighth National Joint Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure, an expert panel
appointed by the National Heart, Lung, and Blood Institute.55
Additionally, articles from the medical literature will be used that will
provide background information on these recommendations.
Once the diagnosis of hypertension has been confirmed and goal blood
pressure has been determined, treatment can begin and as with most
medical conditions, it is prudent to start with simple measures first.
The first step in treating hypertension is to establish a goal blood
pressure. The table below lists the goal blood pressures recommended
by the 2014 Eighth National Joint Committee.55
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
20
Setting Goals for Blood Pressure
General population: Age ≥ 60
↓
Systolic pressure < 150 mm Hg; diastolic pressure < 90 mm Hg
__________________________________________
General population, age < 60, and patients of any age who have chronic
kidney disease (CKD) and/or diabetes
↓
Systolic pressure < 140 mm Hg, diastolic pressure < 90 mm Hg
Lifestyle Modifications
Lifestyle modifications are the first intervention when treating and
controlling hypertension.56 these changes must be considered to be
life-long commitments. The use of antihypertensives can at times be
decreased but adherence to an exercise program, moderate use of
alcohol, salt restriction, smoking cessation, and maintaining optimal
body weight are essential for the successful treatment of hypertension.
If the risk factors are not eliminated or modified, then treating
hypertension will be an uphill battle.
Exercise
Aerobic exercise has been shown to reduce blood pressure for 24
hours post-exercise and to reduce resting blood pressure, as well.57
Patients who have hypertension should perform 30-40 minutes of
moderate to vigorous aerobic exercise four to seven days a week.58,59
Resistance exercise, i.e., weight lifting, is also recommended for
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
21
patients who have hypertension. However, the blood pressure lowering
effects of resistance training appear to be much less than for aerobic
exercise and the level of proof of its usefulness for lowering blood
pressure is not as robust as for aerobic exercise.58,60
Resistance training is still recommended for patients who have
hypertension and if it is determined that resistance training can be
done safely, it will not be harmful and patients should be encouraged
to start a weight lifting program. Before starting an exercise program,
patients should consult with a physician, especially if he or she is
greater than 40 years of age, has chest pain at rest or during activity,
bone or joint pain, a balance disorder, or is taking medications for
hypertension or a cardiac disorder. The American College of Sports
Medicine has published exercise program recommendations for people
who have hypertension.
Diet
Patients who have hypertension should be instructed to follow the
Dietary Approaches to Stop Hypertension (DASH) eating pattern.4 The
DASH program is a diet that stresses consumption of fruits,
vegetables, whole grains, and low-fat dairy products while reducing
intake of saturated fats and total fats and restricting sodium intake.
The DASH program has been shown to significantly reduce systolic and
diastolic blood pressure. The guidelines of the DASH diet 2000 calorie
and varied nutritional intake are outlined below.61
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
22
DASH Diet Guidelines, 2000 Calorie Daily Diet
Calcium: 1250 mg
Carbohydrates: 55% of daily calories
Cholesterol: 150 mg
Fiber: 30 grams
Magnesium: 500 mg
Potassium: 4700 mg
Protein: 18% of daily calories
Saturated fat: 6% of daily calories
Sodium: 2300 mg, 1500 mg in African American and older adults
Total fats: 27% of daily calories
Weight Loss
Obesity is strongly associated with hypertension, and weight loss has
been shown to produce significant reductions in blood pressure.62,63
Smoking Cessation
Smoking cessation has been shown to decrease blood pressure and
arterial stiffness.64-66
Decreased Alcohol Consumption
The association between alcohol consumption and hypertension is
strong and well established,67,68 and an alcohol consumption of more
than 30 grams a day (a drink of alcohol is 14 grams - this is the
amount of alcohol in 6 ounces of wine) is associated with an increased
risk for hypertension.67 The mechanism by which alcohol causes
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
23
hypertension is not known,67,68 but stopping or cutting down drinking
has been shown to be effective at lowering blood pressure.4,67
Antihypertensive Therapy
The following recommendations are from the 2014 report by the
Eighth National Joint Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure.55 The mechanism of action of
each class of drug will be discussed in the next section. Most patients
who have hypertension will eventually require more than one type of
drug in order to reach the blood pressure goal.
Non-black patients, no diabetes or diabetes present, no CKD:
Start therapy with a thiazide diuretic, angiotensin converting enzyme
inhibitor (ACEI), angiotensin II receptor blocker (ARB), or a calcium
channel blocker (CCB), alone or in combination. The ACEIs and ARBs
should not be used together.
Black patients, no diabetes or diabetes present, no CKD:
Start therapy with a thiazide diuretic or a CCB.
All races, CKD present:
Start therapy with an ACEI or an ARB, alone or with another antihypertensive. The ACEIs and ARBs should not be used together.
After the patient has been started on an antihypertensive, the
medications can be adjusted using one of the following strategies:55
1. maximize the first medication dose before adding a second
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
24
2. add a second medication before reaching the maximum dose of
the first medication
3. start with two medication classes separately or as fixed-dose
combination
If the blood pressure goal is not attained using this first approach, the
following extension to the above treatment recommendations should
be applied.
Reinforce Medication and Lifestyle Adherence
For strategies 1 and 2, add and titrate thiazide-type diuretic or ACEI or
ARB or CCB; use a medication not previously selected, and avoid the
combined use of an ACEI and an ARB. For strategy 3, titrate doses of
initial medications to the maximum. If the blood pressure goal is not
attained using this approach, the following medication changes may be
instituted:

Add and titrate thiazide-type diuretic or ACEI or ARB or CCB (use
a medication class previously selected, avoid combined use of an
ACEI and an ARB).

If the blood pressure goal is not attained using the above
approach, a medication from another class (i.e., β-blocker,
aldosterone antagonist, or others) and/or refer to medical
provider with expertise in hypertension management.
The drugs that are most commonly used to treat primary hypertension
are the ACEIs, ARBs, beta-blockers, CCBs, and the thiazide diuretics.
These medications are available as single drugs or in combination (i.e.,
Enalapril Maleate-Hydrochlorothiazide, which is a combination of
enalapril and hydrochlorothiazide). They are typically given orally but
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
25
intravenous preparations of some of them are available. Although
primarily used to treat hypertension, some of them have other labeled
uses, as well.
Angiotensin Converting Enzyme Inhibitors
The Angiotensin Converting Enzyme Inhibitors (ACEIs) currently
available in the U.S. are benazepril, captopril, enalapril, lisinopril,
moexipril, perindopril, quinapril, ramipril, and trandolapril. The ACEIs
lower blood pressure by their effect on the renin-angiotensin system,
one of the primary mechanisms of blood pressure homeostasis. These
drugs inhibit the activity of the angiotensin-converting enzyme (ACE).
Angiotensin converting enzyme inhibits the conversion of angiotensin I
to angiotensin II, and angiotensin II is a potent vasoconstrictor.
Common side effects of the ACEIs include cough, hyperkalemia,
hypersensitivity reactions, and skin rash. Angioedema is an uncommon
but potentially life-threatening side effect of these drugs that can
occur even after months and years of use of an ACEI. African
Americans do not generally respond well to monotherapy with an
ACEI.55
Angiotensin II Receptor Blockers
The Angiotensin II Receptor Blockers (ARBS) currently available in the
U.S. are azilsartan, candesartan, irbesartan, losartan, olmesartan,
telmisartan, and valsartan. The ARBs lower blood pressure by their
effect on the renin-angiotensin system, and they do so by
antagonizing the effect of angiotensin II at receptor sites on the blood
vessels resulting in vasodilation of the peripheral vasculature.
Common side effects of these drugs include dizziness, headache,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
26
lightheadedness, and nasal congestion. Cough and angioedema are
uncommon, unlike the ACEIs.
Beta-blockers
The beta-blockers currently available in the U.S. are acebutolol,
atenolol, betaxolol, bisoprolol, carvedilol, esmolol, labetalol,
metoprolol, nadolol, propranolol, nebivolol, and sotalol. The betablockers can be beta-selective, non-selective, some have intrinsic
sympathomimetic properties, and others have alpha blocking effects,
as well. The beta-blockers lower blood pressure by antagonizing the
effects of catecholamines at beta-receptors in the heart and the
peripheral vasculature, decreasing the force of myocardial contraction
and causing vasodilation.
Beta-blocker side effects include bradycardia, bronchospasm,
depression, dizziness, exercise intolerance, fatigue, hypotension, and
sexual dysfunction. These drugs must be used very cautiously in
patients who have asthma, diabetes, or peripheral vascular disease as
they can cause bronchospasm, blunt the signs and symptoms of
hypoglycemia, and aggravate and/or cause arterial insufficiency.
Calcium Channel Blockers
The calcium channel blockers currently available in the U.S. are
amlodipine, clevidipine, diltiazem, felodipine, nicardipine, nifedipine,
nisoldipine, and verapamil. Similar to the beta-blockers, the CCBs are
a diverse group of medications and there are slight differences in their
respective mechanisms of action. However, all of the CCBs lower blood
pressure by antagonizing the movement of calcium through calcium
ion channels in the conducting tissues and pathways of the heart, the
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
27
myocardium, and the peripheral vasculature, thus lowering the heart
rate, decreasing the force of myocardial contraction, and causing
vasodilation.
The common side effects include bradycardia, constipation, dizziness
headache, hypotension, edema, fatigue, and rash.
Diuretics
There are several classes of diuretics: aldosterone receptor
antagonists, carbonic anhydrase inhibitors, loop diuretics, osmotic
diuretics, potassium-sparing diuretics, and thiazide diuretics. Each of
these has a specific and distinct mechanism of action. The thiazide
diuretics are the first choice for the treatment of primary hypertension,
and those currently available in the U.S. include chlorothiazide,
hydrochlorothiazide, and methylchlothiazide.
The thiazide diuretics lower blood pressure by inhibiting sodium reabsorption in the distal tubules, causing increased sodium excretion
and diuresis. Common side effects of the thiazide diuretics include
blurred vision, dehydration, dizziness, hypokalemia, hyponatremia,
hypomagnesemia, hypotension, and orthostatic hypotension.
Other Antihypertensive Medication
There are a variety of other medications that may be used to treat
hypertension when other drugs have not worked or multi-drug therapy
is indicated. Alpha-1 blockers such as doxazosin and prazosin are
peripheral alpha-blockers that lower blood pressure by causing
dilatation of the peripheral blood vessels.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
28
The alpha-2 agonists clonidine, guanfacine, and methyldopa reduce
blood pressure by stimulating central alpha-2 receptors and decreasing
sympathetic outflow from the brain. Hydralazine and minoxidil lower
blood pressure by dilating arterioles. Aliskiren is a renin inhibitor that
lowers blood pressure by preventing the conversion of angiotensinogen
to angiotensin I.
Alternative Therapies
A wide variety of alternative and
complementary therapies have been
used to treat primary hypertension
including, but not limited to,
acupuncture, biofeedback, meditation,
and yoga.69-74 Evidence for the
effectiveness of these therapies is
weak and/or conflicting,69 but as they
are generally safe when done correctly
and they may have other health benefits aside from lowering blood
pressure, their use can be recommended.
Nursing Considerations
Approximately 52% of people who have hypertension have the
condition under control75 and one in five adults who have hypertension
are undiagnosed. There is a multitude of reasons why treatment of
hypertension is suboptimal; such as, inadequate screening, poor
patient compliance, incomplete patient education, unpleasant side
effects of the antihypertensive medication, lack of medical and patient
resources, lack of patient knowledge, and, the well documented
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
29
difficulty many people have in losing weight, stopping smoking, using
alcohol in moderation and adhering to an exercise regimen.
Nurses can and should have an
active role in the identification,
prevention and treatment of
hypertension. Patients who are at
risk for developing hypertension
should be encouraged to have
their blood pressure checked. The
nurse should assess these
patients to determine if there is a
family history of hypertension and
if the patient has lifestyle issues
such as poor diet, obesity,
sedentary lifestyle, or smoking
that increase the risk for
developing hypertension. If these or other risk factors are present, the
nurse should provide the patient with information about such
deleterious lifestyle choices and with the education, referrals,
resources, and support needed to make needed changes, such as
setting up an exercise program, making proper dietary changes, losing
weight, and smoking cessation.
If the patient has hypertension, he or she should be carefully assessed
for signs and symptoms of end-organ damage, i.e., blurred vision or
other ocular abnormalities, chest pain, dizziness, hematuria, numbness
or tingling in the extremities, or palpitations. These patients should
also be assessed for the presence of risk factors, for their level of
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
30
knowledge about how lifestyle factors can influence hypertension, and
how well they understand their role in self-care.
Nursing considerations appropriate for the patient with hypertension
address the following concerns: 1) deficient knowledge regarding the
relationship between the treatment regimen and control of the disease
process, 2) ineffective therapeutic regimen management related to
medication adverse effects and difficult lifestyle adjustments, 3)
ineffective coping, and 4) noncompliance with the therapeutic regimen.
The following table addresses key points for patient education.
Key Points for Patient Teaching
 Know the blood pressure goal – ideally less than 120/80 mmHg.
 Understand which lifestyle changes are helpful in treating and preventing
hypertension.
 Hypertension cannot be cured but it can be managed and patient involvement
and self-care are absolutely critical.
 Know how often to follow up with the health care provider; typically, monthly
until blood pressure is well controlled and every three to six months thereafter.
 Know which blood tests are important to monitor based on the medications
taken.
 Maintain a record of blood pressure readings.
 Contact the healthcare provider for signs/symptoms of end-organ damage.
 To change or stop medications, or for side effects difficult to tolerate, contact
the primary health care provider.
 Understand common side effects and report them to the health care provider.
 For a missed dose of medication, contact the primary health care provider, or
pharmacist. Do not take an extra dose to “catch up” as this could be dangerous.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
31
Summary
Hypertension significantly increases the risk for developing
cardiovascular diseases, which include atherosclerosis, cardiac
arrhythmias, congestive heart failure, myocardial infarction, stroke and
organ disease. Morbidity and mortality are directly related to the
duration and severity of hypertension. Hypertension is typically
classified as primary or secondary. Primary hypertension accounts for
the great majority of the cases of hypertension. Whereas, secondary
hypertension is much less common than primary hypertension, and
identifiable causes of secondary hypertension are multifactorial, such
as endocrine, neurologic, renal, and vascular diseases, medical
conditions (i.e., obstructive sleep apnea), pregnancy, and druginduced.
While there is no cure for hypertension, certain lifestyle modifications
and antihypertensive drug therapy can help to control it. Screening for
hypertension is key to identifying those individuals at risk for having
hypertension. Additionally, patient knowledge of and compliance with
hypertension drug therapy and the needed lifestyle changes are
important to successful treatment. Nurses have a fundamental role in
educating patients on the prevention and treatment of hypertension,
and in closing gaps in patient knowledge to obtain appropriate care.
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
32
1. Elevated blood pressure that does not have an identifiable
cause is known as
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
systolic hypertension.
2. Elevated blood pressure that is caused by heart and lung
disease, or other illness, is known as
a.
b.
c.
d.
primary hypertension.
chronic hypertension.
secondary hypertension.
acute hypertension.
3. If only the diastolic blood pressure is elevated when
measured, then the patient is understood to have
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
systolic hypertension.
4. The majority of people who have hypertension have:
a.
b.
c.
d.
primary hypertension.
isolated diastolic hypertension.
secondary hypertension.
acute hypertension.
5. Primary hypertension is defined as:
a.
b.
c.
d.
SBP
SBP
SBP
SBP
> 110 mm Hg or DBP > 70 mm Hg.
≥ 160 mm Hg or DBP ≥ 110 mm Hg.
≥ 140 mm Hg or DBP ≥ 90 mm Hg.
120-139 mm Hg, DBP 80-89 mm Hg.
6. In the beginning stages of hypertension
a.
b.
c.
d.
most
most
most
most
people experience chest pain and shortness of breath.
people are asymptomatic.
people have blurred vision and dizziness.
have mild and non-specific symptoms.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
33
7. True or False: African Americans suffer disproportionately
from hypertension.
a. True
b. False
8. Which of the following answers lists correctly the risk
factors for hypertension?
a. Age < 20 years, obesity, and diet high in fiber.
b. Heavy drinking, high level of physical activity, and age.
c. Family history, sedentary lifestyle, and abstinence from
tobacco.
d. Obesity, smoking, and excessive sodium intake.
9. Complications of primary hypertension include:
a.
b.
c.
d.
Hepatic and pulmonary damage.
Stroke and kidney damage.
Atherosclerosis and hypokalemia.
Thyroid disorders and retinopathy.
10. A diagnosis of hypertension is confirmed if the patient’s
blood pressure is elevated
a. and orthostatic changes are present.
b. and risk factors for hypertension are present.
c. on at least 3 separate occasions, separated by the
appropriate length of time.
d. with readings of SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.
11. Isolated systolic hypertension is very common in
a.
b.
c.
d.
the elderly.
African Americans
people < 40 years of age.
men.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
34
12. The first intervention when treating and controlling
hypertension is
a.
b.
c.
d.
aggressive diuresis with a thiazide diuretic.
starting therapy with an ACEI and a CCB.
starting therapy with low-dose aspirin and a beta-blocker.
lifestyle modifications.
13. The first-line drug(s) of choice for treating patients who
have hypertension is/are:
a.
b.
c.
d.
ACEIs and ARBs.
Thiazide diuretics.
Beta-blockers and loop diuretics.
Vasodilators and alpha1 blockers.
14. Hypertension can be ________ with lifestyle modifications
and anti-hypertensive drug therapy.
a.
b.
c.
d.
cured
controlled
diagnosed
eliminated
15. Which of the following defines pre-hypertension?
a.
b.
c.
d.
SBP
SBP
SBP
SBP
≥ 160 mm Hg or DBP ≥ 100 mm Hg
≥ 140 mm HG and DBP < 90 mm Hg
120-139 mm Hg, DBP 80-89 mm Hg
≥ 140 mm Hg or DBP ≥ 90 mm Hg
16. True or False: A patient who has elevated blood pressure is
considered to be in a hypertension emergency.
a. True
b. False
17. Patients in whom the blood pressure elevation is
considered to be urgent may be managed with
a.
b.
c.
d.
hospitalization and rapid control of blood pressure.
rapid control of blood pressure.
maintaining the same anti-hypertensive therapy.
initiation of anti-hypertensive therapy.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
35
18. Hospitalization and rapid control of blood pressure would
be required in cases where a patient has significant signs
and symptoms such as
a.
b.
c.
d.
chest pain.
evidence of end-organ damage such as aortic dissection.
hypertensive encephalopathy.
All of the above
19. The most important factor related to obesity, which
contributes to an increased risk of developing
hypertension, appears to be
a.
b.
c.
d.
body weight.
distribution of body fat.
insulin resistance.
obstructive sleep apnea.
20. The incidence of hypertension is increased in people who
smoke because smoking increases the risk of developing
a.
b.
c.
d.
atherosclerosis.
obesity.
encephalopathy.
decreased activity of the sympathetic nervous system.
21. The incidence of retinopathy in hypertension patients may
be skewed by the presence of
a.
b.
c.
d.
metabolic syndrome.
sympathetic nervous system abnormalities.
diabetes.
physical inactivity.
22. The high prevalence of hypertension in the elderly can be
explained physiological factors that occur during aging
such as
a.
b.
c.
d.
increased arterial stiffness.
decreased activity of the sympathetic nervous system.
a diet high in sodium.
obesity.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
36
23. Studies show that with the development of hypertension in
an individual, genetic
a.
b.
c.
d.
factors are primary causes of the disease.
factors play no role.
factors will predict hypertension in over half the cases.
identification of those at risk is not feasible at this time.
24. Hypertensive emergencies are a spectrum of clinical
presentations that are usually characterized by
a.
b.
c.
d.
SBP
SBP
SBP
SBP
≥
≥
>
≥
160
140
220
140
mm
mm
mm
mm
Hg or DBP ≥ 100 mm Hg
HG and DBP < 90 mm Hg
Hg or a DBP > 120 mm Hg
Hg or DBP ≥ 90 mm Hg
25. True or False: Until age 45 men are more likely than
women to have hypertension.
a. True
b. False
26. Other factors that have been identified as possible
independent contributors to the development of primary
hypertension include(s)
a.
b.
c.
d.
high-fiber diet.
Vitamin D deficiency.
decreased activity of the sympathetic nervous system.
All of the above
27. The incidence of retinopathy in patients who have
hypertension has been reported to be
a. due to Vitamin D deficiency.
b. statistically insignificant because retinopathy is usually caused
by diabetes.
c. below 20%.
d. as high as 66.3% to 80.3%.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
37
28. _________________________ is the most common form
of hypertension in adults less than age 40.
a.
b.
c.
d.
Isolated diastolic blood pressure
Isolated systolic blood pressure
Acute hypertension
Genetic hypertension
29. Isolated systolic hypertension is caused by
a.
b.
c.
d.
Vitamin D deficiency.
decreased sympathetic neural activity.
reduced compliance and elasticity of large arteries.
conforming nephron mass.
30. True or False: An alcohol consumption of more than 30
grams a day is associated with an increased risk for
hypertension.
a. True
b. False
31. Common side effects of Angiotensin Converting Enzyme
Inhibitors (ACEIs) include
a.
b.
c.
d.
cough.
hyperkalemia.
hypersensitivity reactions, and skin rash.
All of the above
32. The Angiotensin II Receptor Blockers (ARBs) lower blood
pressure by their effect on
a.
b.
c.
d.
the renin-angiotensin system.
sympathetic neural activity.
hypertensive encephalopathy
retinal hemorrhages.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
38
33. Common side effects of Angiotensin II Receptor Blockers
(ARBs) include
a.
b.
c.
d.
cough.
angioedema.
dizziness.
All of the above
34. The nurse should assess these patients to determine if
there is/are ________________________________ that
increase(s) the risk for developing hypertension.
a.
b.
c.
d.
a family history of hypertension
lifestyle issues such as obesity
lifestyle issues such as smoking
All of the above
35. True or False: Beta-blockers must be used very cautiously
in patients who have asthma, diabetes, or peripheral
vascular disease.
a. True
b. False
CORRECT ANSWERS:
1. Elevated blood pressure that does not have an identifiable
cause is known as
a. primary hypertension.
p. 5: “The etiology of primary hypertension is not known.
There is a genetic component to the development of the
disease, but age and lifestyle factors contribute significantly
to its development and progression. Secondary hypertension
is much less common than primary hypertension, and in
secondary hypertension there are identifiable causes.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
39
2. Elevated blood pressure that is caused by heart and lung
disease, or other illness, is known as
c. secondary hypertension.
p. 5: “The etiology of primary hypertension is not known.
There is a genetic component to the development of the
disease, but age and lifestyle factors contribute significantly
to its development and progression. Secondary hypertension
is much less common than primary hypertension, and in
secondary hypertension there are identifiable causes.”
3. If only the diastolic blood pressure is elevated when
measured, then the patient is understood to have
b. isolated diastolic hypertension.
p. 6: “If only the diastolic blood pressure is elevated when
measured, then the patient is understood to have isolated
diastolic hypertension.”
4. The majority of people who have hypertension have:
a. primary hypertension.
p. 5: “Primary hypertension accounts for the great majority of
the cases of hypertension.”
5. Primary hypertension is defined as:
c. SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg.
p. 7: “Stage I Hypertension: SBP ≥ 140 mm Hg or DBP ≥ 90
mm Hg.”
6. In the beginning stages of hypertension
b. most people are asymptomatic.
pp. 5-6: “The majority of people who have hypertension
(aside from secondary hypertension) have no characteristic
signs or symptoms except for an elevated blood pressure, and
this is one of the most harmful features of the disease.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
40
p. 16: “Pre-hypertension is a condition in which the blood
pressure is elevated above normal levels but not to the
measurements that define hypertension. In addition, the
patient is asymptomatic and he or she has not yet developed
organ damage.”
7. True or False: African Americans suffer disproportionately
from hypertension.
a. True
p. 10: “The incidence and severity of hypertension is higher in
African Americans than in other ethnic groups in the U.S.”
8. Which of the following answers correctly lists risk factors for
hypertension?
d. Obesity, smoking, and excessive sodium intake.
See discussion at pages 9-12.
9. Complications of primary hypertension include:
b. Stroke and kidney damage.
pp. 16-17: “Complications of primary hypertension include …
Kidney disease. Hypertension is a major risk factor for the
development of chronic kidney disease, and the risk of
chronic kidney disease increases in direct proportion to
elevations in blood pressure. Hypertension is the second
leading cause of kidney failure in the U.S.”
10. A diagnosis of hypertension is confirmed if the patient’s
blood pressure is elevated
c. on at least 3 separate occasions, separated by an
appropriate length of time.
p. 15: “At least three measurements should be taken. It is
very important that multiple readings should be taken and
these readings must be separated by the appropriate length
of time.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
41
11. Isolated systolic hypertension is very common:
a. in the elderly.
p. 18: “Isolated systolic hypertension is caused by reduced
compliance and elasticity of large arteries, and it is quite
common in the elderly.”
12. The first intervention when treating and controlling
hypertension is
d. lifestyle modifications.
p. 20: “Lifestyle modifications are the first intervention when
treating and controlling hypertension.”
13. The first-line drugs of choice for treating patients who
have hypertension are:
b. Thiazide diuretics.
p. 27: “The thiazide diuretics are the first choice for the
treatment of primary hypertension, and those currently
available in the U.S., include chlorothiazide,
hydrochlorothiazide, and methylchlothiazide.”
14. Hypertension can be ________ with lifestyle modifications
and anti-hypertensive drug therapy.
b. controlled
p. 6: “Hypertension cannot be cured but it can be controlled
with lifestyle modifications and anti-hypertensive drug
therapy.”
15. Which of the following defines pre-hypertension?
c. SBP 120-139 mm Hg, DBP 80-89 mm Hg
p. 7: “Pre-hypertension: SBP 120-139 mm Hg, DBP 80-89
mm Hg.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
42
16. True or False: A patient who has elevated blood pressure is
considered to be in a hypertension emergency.
b. False
p. 7: “Hypertensive emergencies are a spectrum of clinical
presentations that are usually characterized by a systolic
blood pressure > 220 mm Hg or a diastolic blood pressure >
120 mm Hg. The situation is considered urgent (not
necessarily an emergency) if the patient has no significant
signs and symptoms and no evidence of end-organ damage.”
17. Patients in whom the blood pressure elevation is
considered to be urgent may be managed with
d. initiation of anti-hypertensive therapy.
pp. 7-8: “Patients in whom the blood pressure elevation is
considered to be urgent may be managed with initiation of
anti-hypertensive therapy or a change to the existing antihypertensive therapy and outpatient follow up.”
18. Hospitalization and rapid control of blood pressure would
be required in cases where a patient has significant signs
and symptoms such as
a.
b.
c.
d.
chest pain.
evidence of end-organ damage such as aortic dissection.
hypertensive encephalopathy.
All of the above
p. 8: “If the patient has significant signs and symptoms such
as chest pain, headache, or shortness of breath, or evidence
of end-organ damage such as aortic dissection, hypertensive
encephalopathy, intracranial hemorrhage, myocardial
infarction, papilledema, or retinal hemorrhages,
hospitalization and rapid control of blood pressure would be
required.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
43
19. The most important factor related to obesity, which
contributes to an increased risk of developing
hypertension, appears to be
b. distribution of body fat.
p. 11: “It may be the distribution of body fat, not body
weight, which is the factor that determines who will or will not
become hypertensive.”
20. The incidence of hypertension is increased in people who
smoke because smoking increases the risk of developing
a. atherosclerosis.
p. 11: “Smoking increases the risk of developing
atherosclerosis and atherosclerosis contributes to the
development of hypertension.”
21. The incidence of retinopathy in hypertension patients may
be skewed by the presence of
c. diabetes.
pp. 17-18: “The incidence of retinopathy in patients who have
hypertension has been reported to be as high as 66.3% to
80.3%, and the level of systolic blood pressure and the
duration of hypertension are significant risk factors for
developing retinal damage. The presence of diabetes in many
hypertensive patients and the particular methods used to
detect retinal damage may skew these figures but, even when
these factors are considered, hypertensive retinopathy is still
a problem of considerable magnitude.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
44
22. The high prevalence of hypertension in the elderly can be
explained physiological factors that occur during aging
such as
a. increased arterial stiffness.
pp. 9-10: “The high prevalence of hypertension in the elderly
can be explained by a diet high in sodium, obesity, and a
sedentary lifestyle. Hypertension in this age group can also be
explained by physiological factors that occur during aging
such as increased arterial stiffness, decreased baroreceptor
sensitivity, increased activity of the sympathetic nervous
system, and a decreased ability of the kidneys to excrete
sodium.”
23. Studies show that with the development of hypertension in
an individual, genetic
d. identification of those at risk is not feasible at this time.
p. 9: “Genetic abnormalities have been identified in people
who have hypertension but these have not been shown to be
a primary cause of the disease and because environmental
factors clearly contribute to the development of primary
hypertension, genetic identification of those at risk is not
feasible at this time and may not be.”
24. Hypertensive emergencies are a spectrum of clinical
presentations that are usually characterized by
c. SBP > 220 mm Hg or a DBP > 120 mm Hg
p. 7: “Hypertensive emergencies are a spectrum of clinical
presentations that are usually characterized by a systolic
blood pressure > 220 mm Hg or a diastolic blood pressure >
120 mm Hg.”
25. True or False: Until age 45 men are more likely than
women to have hypertension.
a. True
p. 8: "Until age 45 men are more likely than women to have
hypertension.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
45
26. Other factors that have been identified as possible
independent contributors to the development of primary
hypertension include(s)
b. Vitamin D deficiency.
p. 12: “Other factors that may be risk factors for the
development of primary hypertension are Vitamin D
deficiency, dyslipidemia, low dietary intake of calcium and
magnesium and fruits and vegetables, and psycho-social
variables such as depression, occupational stress, personality
type, sleep quality, and the individual’s level of isolation and
social support.”
27. The incidence of retinopathy in patients who have
hypertension has been reported to be
d. as high as 66.3% to 80.3%.
pp. 17-18: “The incidence of retinopathy in patients who have
hypertension has been reported to be as high as 66.3% to
80.3%, and the level of systolic blood pressure and the
duration of hypertension are significant risk factors for
developing retinal damage. The presence of diabetes in many
hypertensive patients and the particular methods used to
detect retinal damage may skew these figures but, even when
these factors are considered, hypertensive retinopathy is still
a problem of considerable magnitude.”
28. _________________________ is the most common form
of hypertension in adults less than age 40.
a. Isolated diastolic blood pressure
p. 18: “Isolated diastolic blood pressure primarily affects
adults and young men who are obese, and it is the most
common form of hypertension in adults less than age 40.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
46
29. Isolated systolic hypertension is caused by
c. reduced compliance and elasticity of large arteries.
p. 18: “Isolated systolic hypertension is caused by reduced
compliance and elasticity of large arteries, and it is quite
common in the elderly.”
30. True or False: An alcohol consumption of more than 30
grams a day is associated with an increased risk for
hypertension.
a. True
p. 22: “The association between alcohol consumption and
hypertension is strong and well established, and an alcohol
consumption of more than 30 grams a day (a drink of alcohol
is 14 grams - this is the amount of alcohol in 6 ounces of
wine) is associated with an increased risk for hypertension.”
31. Common side effects of Angiotensin Converting Enzyme
Inhibitors (ACEIs) include
d. All of the above
p. 25: “Common side effects of the ACEIs include cough,
hyperkalemia, hypersensitivity reactions, and skin rash.”
32. The Angiotensin II Receptor Blockers (ARBs) lower blood
pressure by their effect on
a. the renin-angiotensin system.
p. 25: “The ARBs lower blood pressure by their effect on the
renin-angiotensin system.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
47
33. Common side effects of Angiotensin II Receptor Blockers
(ARBs) include
c. dizziness.
pp. 25-26: “The ARBs lower blood pressure by their effect on
the renin-angiotensin system, …. Common side effects of
these drugs include dizziness, headache, lightheadedness,
and nasal congestion. Cough and angioedema are uncommon,
unlike the ACEIs.”
34. The nurse should assess these patients to determine if
there is/are ________________________________ that
increase(s) the risk for developing hypertension.
d. All of the above
p. 29: “The nurse should assess these patients to determine if
there is a family history of hypertension and if the patient has
lifestyle issues such as poor diet, obesity, sedentary lifestyle,
or smoking that increase the risk for developing hypertension.
If these or other risk factors are present, the nurse should
provide the patient with information about such deleterious
lifestyle choices and with the education, referrals, resources,
and support needed to make needed changes, such as setting
up an exercise program, making proper dietary changes,
losing weight, and for smoking cessation.”
35. True or False: Beta-blockers must be used very cautiously
in patients who have asthma, diabetes, or peripheral
vascular disease.
a. True
p. 26: “Beta-blocker side effects include bradycardia,
bronchospasm, depression, dizziness, exercise intolerance,
fatigue, hypotension, and sexual dysfunction. These drugs
must be used very cautiously in patients who have asthma,
diabetes, or peripheral vascular disease as they can cause
bronchospasm, blunt the signs and symptoms of
hypoglycemia, and aggravate and/or cause arterial
insufficiency.”
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
48
References Section
The reference section of in-text citations includes published works
intended as helpful material for further reading. Unpublished works
and personal communications are not included in this section, although
may appear within the study text.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Basile J, Bloch MJ. Overview of hypertension in adults.
UpToDate. March 2, 2016. Retrieved September 23, 2016 from
http://www.uptodate.com/contents/overview-of-hypertensionin-adults.
Sutters M. Systemic hypertension. In: Papadakis MA, McPhee
SJ, Rabow MW, eds. Current Medical Diagnosis & Treatment
2016. 55rd ed. New York, NY: McGraw-Hill Education; 2016.
Online edition, retrieved September 23, 2016 from
www.UCHC.edu.
Kaplan NM. Prehypertension. UpToDate. July 2, 2014. Retrieved
September 19, 2014 from
http://www.uptodate.com/contents/prehypertension?source=se
arch_result&search=prehypertension&selectedTitle=1%7E29.
Kotchen TA. Hypertensive vascular disease. In: Longo DL, Fauci
AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds.
Harrison’s Principles of Internal Medicine. 19th ed. New York,
NY: McGraw-Hill; 2015. Online edition, retrieved September 23,
2016 from www.UCHC.edu.
Mann JFE, Hilgers KF. Hypertension: Who should be treated?
UpToDate. September 16, 2014. Retrieved September 19, 2014
from http://www.uptodate.com/contents/hypertension-whoshould-betreated?source=search_result&search=isolated+diastolic+hype
rtension&selectedTitle=1%7E4.
Cooper CM, Fenves AZ. Hypertensive urgencies and
emergencies in the hospital setting. Hosp Pract (1995).
2016;44(1):21-27.
Taylor DA. Hypertensive crisis: A review of pathophysiology and
treatment. Crit Care Nurs Clin North Am. 2015;27(4):439-447.
Natekar A, Olds RL, Lau MW, Min K, Imoto K, Slavin TP.
Elevated blood pressure: Our family’s fault? The genetics of
essential hypertension. World J Cardiol. 2014;26:327-337.
Syed Q, Messinger-Rapport. B Hypertension. In: Williams BA,
Chang A, Ahalt C, Chen H, Conant R, Landefeld CS, Ritchie C,
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
49
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Yukawa M, eds. Current Treatment & Diagnosis: Geriatrics, 2nd
ed. New York, NY: McGraw-Hill; 2014.
Supiano MA. Hypertension. In: Halter JB, Ouslander JG, Tinetti
ME, Studenski S, High KP, Asthana S, eds. Hazzard’s Geriatric
Medicine and Gerontology. 6th ed. New York, NY: McGraw-Hill;
2009. Online edition, retrieved September 18, 2014 from
www.UCHC.edu.
Kaplan NM. Hypertensive complications in blacks. UpToDate.
January 2, 2014. Retrieved September 20, 2014 from
http://www.uptodate.com/contents/hypertensivecomplications-inblacks?source=search_result&search=Hypertensive+complicati
ons+in+blacks&selectedTitle=1%7E150.
Lackland DT. Racial differences in hypertension: implications for
high blood pressure management. Am J Med Sci.
2014;348(2):135-138.
Chandraa A, Neeland IJ, Berry jd, ET AL. The relationship of
body mass and fat distribution with incident hypertension. J Am
Coll Cardiol. 2014;64(10):997-1002.
Kokubo Y. Prevention of hypertension and cardiovascular
diseases: A comparison of lifestyle factors in Westerners and
East Asians. Hypertension. 2014;63:655-660.
Kaplan NM. Obesity and weight reduction in hypertension.
UpToDate. June 30, 2014. Retrieved September 19, 2014 from
http://www.uptodate.com/contents/obesity-and-weightreduction-inhypertension?source=search_result&search=Obesity+and+wei
ght+reducton+in+hypertension&selectedTitle=1%7E150.
Yu-Jie W, Hui-Lang L, Lu, Z, Zhi-Geng J. Impact of smoking
and smoking cessation on arterial stiffness in healthy
participants. Angiology. 2013;64(4):273-280.
Kaplan NM. Smoking and hypertension. UpToDate. February 5,
2014. Retrieved September 19, 2014 from
http://www.uptodate.com/contents/smoking-andhypertension?source=search_result&search=smoking+and+hy
pertension&selectedTitle=1%7E150.
Mostofsky E, Mukamal KJ, Giovannucci EL, Stampfer MJ, Rimm
EB. Key findings on alcohol consumption and a variety of health
outcomes from the nurses' health study. Am J Public Health.
2016;106(9):1586-1591.
Tangney CC, Rosenson RS. Cardiovascular benefits and risks of
moderate alcohol consumption. UpToDate. July 8, 2015.
Lawlor DA, Nordestgaard BG, Benn M, Zuccolo L, TybjaergHansen A, Davey Smith G. Exploring causal associations
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
50
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
between alcohol and coronary heart disease risk factors:
findings from a Mendelian randomization study in the
Copenhagen General Population Study. Eur Heart J. 2013;
34(32):2519-2528.
Sharman JE, La Gerche A, Coombes JS. Exercise and
cardiovascular risk in patients with hypertension. Am J
Hypertens. 2015;28(2):147-158.
Christofaro DG, De Andrade SM, Cardoso JR, Mesas AE,
Codogno JS, Fernandes RA. High blood pressure and sedentary
behavior in adolescents are associated even after controlling for
confounding factors. Blood Press. 2015;24(5):317-323.
Leyvraz M, Taffé P, Chatelan A, et al. Sodium intake and blood
pressure in children and adolescents: protocol for a systematic
review and meta-analysis. BMJ Open. 2016 Sep
21;6(9):e012518. doi: 10.1136/bmjopen-2016-012518.
He FJ, Li J, Macgregor GA. Effect of longer term modest salt
reduction on blood pressure: Cochrane systematic review and
meta-analysis of randomised trials. BMJ. 2013 Apr
3;346:f1325. doi: 10.1136/bmj.f1325.
Van Ballegooijen A, Van Schoor N, Brouwer I, Visser M, Beulens
J. OS 06-09 THE Synergistic association between vitamin D and
vvitamin K with incident hypertension. J Hypertens. 2016;34
Suppl 1:e64
Tamez H, Kalim S, Thadhani RI. Does vitamin D modulate blood
pressure? Curr Opin Nephrol Hypertens. 2013;22(2):204-209.
Vimaleswaran KS, Cavadino A, Berry DJ, et al. Association of
vitamin D status with arterial blood pressure and hypertension
risk: a mendelian randomisation study. Lancet Diabetes
Endocrinol. 2014;2(9):719-729.
Otsuka T, Takada H, Nishiyama Y, et al. Dyslipidemia and the
risk of developing hypertension in a working-age male
population. J Am Heart Assoc. 2016 Mar 25;5(3):e003053. doi:
10.1161/JAHA.115.003053.
Wu L, Sun D, He Y. Fruit and vegetables consumption and
incident hypertension: dose-response meta-analysis of
prospective cohort studies. J Hum Hypertens.
2016;30(10):573-580.
Cuffee Y, Ogedegbe C, Williams NJ, Ogedegbe G, Schoenthaler
A. Psychosocial risk factors for hypertension: an update of the
literature. Curr Hypertens Report. 2014; 16:483. doi:
10.1007/s11906-014-0483-3.
Zambrana RE, López L, Dinwiddie GY, et al. Association of
baseline depressive symptoms with prevalent and incident prehypertension and hypertension in postmenopausal Hispanic
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
51
32.
33.
34.
35.
36.
37.
38.
39.
40.
women: Results from the Women's Health Initiative. PLoS One.
2016 Apr 28;11(4):e0152765. doi:
10.1371/journal.pone.0152765. eCollection 2016.
Jackson CA, Pathirana T, Gardiner PA. Depression, anxiety and
risk of hypertension in mid-aged women: a prospective
longitudinal study. J Hypertens. 2016;34(10):1959-1566.
Lin CL, Liu TC, Lin FH, Chung CH, Chien WC. Association
between sleep disorders and hypertension in Taiwan: a
nationwide population-based retrospective cohort study. J Hum
Hypertens. 2016 Aug 11. doi: 10.1038/jhh.2016.55. [Epub
ahead of print]
Siu AL; U.S. Preventive Services Task Force. Screening for high
blood pressure in adults: U.S. Preventive Services Task Force
recommendation statement. Ann Intern Med.
2015;163(10):778-786.
Kaplan NM, Thomas G, Pohl MA. Blood pressure measurement
in the diagnosis and management of hypertension in adults.
UpToDate. July 26, 2016.
https://www.uptodate.com/contents/blood-pressuremeasurement-in-the-diagnosis-and-management-ofhypertension-in-adults. Accessed September 25, 2016.
Piper MA, Evans CV, Burda BU, et al. Diagnostic and predictive
accuracy of blood pressure screening methods with
consideration of rescreening intervals: a systematic review for
the U.S. Preventive Services Task Force. Ann Intern Med.
2015;162(3):192-204.
Kang YY, Li Y, Huang QF, Song J, et al. Accuracy of home
versus ambulatory blood pressure monitoring in the diagnosis
of white-coat and masked hypertension. J Hypertens. 2015
Aug;33(8):1580-7. doi: 10.1097/HJH.0000000000000596.
Niiranen TJ, Johansson JK, Reunanen A, Jula AM. Optimal
schedule for home blood pressure measurement based on
prognostic data: the Finn-Home Study. Hypertension. 2011;
57(6):1081-1086.
Pickering TG, Hall JE, Appel LJ, et al. Recommendations for
blood pressure measurement in humans and experimental
animals: part 1: blood pressure measurement in humans: a
statement for professionals from the Subcommittee of
Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research.
Circulation. 2005; 111(5):697-716.
Gupta P, Nagaraju SP, Gupta A, Mandya Chikkalingaiah KB.
Prehypertension - time to act. Saudi J Kidney Dis Transpl.
2012; 23(2):223-233.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
52
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Sulayma Albarwani, Sultan Al-Siyabi, Musbah O Tanira.
Prehypertension: Underlying pathology and therapeutic options.
World J Cardiol. 2014; 26(8):728-743.
Huang Y, Cai X, Li Y, Su L, Mai W, Wang S, et al.
Prehypertension and the risk of stroke: a meta-analysis.
Neurology. 2014; 82:153-1161.
Rodriguez CJ, Swett K, Agarwal SK, Folsom AR, Fox ER, Loehr
LR, et al. Systolic blood pressure levels among adults with
hypertension and incident cardiovascular events: the
Atherosclerosis Risk in Communities Study. JAMA Inter Med.
2014; 174(8):1252-1261.
Ogedebge G, Pickering TG. Epidemiology of hypertension. In:
Fuster V, Walsh A, Harrington RA, eds. Hurst’s The Heart, 13th
ed. New York, NY: McGraw-Hill; 2011. Online edition, retrieved
September 26, 2016 from www.UCHC.edu.
Im TS, Chun EJ, Lee MS, Adla T, Kim JA, Choi SI. Graderesponse relationship between blood pressure and severity of
coronary atherosclerosis in asymptomatic adults: assessment
with coronary CT angiography. Int J Cardiovasc Imaging. 2014
Dec;30 Suppl 2:105-12. doi: 10.1007/s10554-014-0522-9.
Epub 2014 Sep 2.
Xie W, Liu J, Wang W, Wang M, Li Y, Sun J, et al. Five-year
change in systolic blood pressure is independently associated
with carotid atherosclerosis progression: a population-based
cohort study. Hypertens Res. 2014;37(10):960-965.
Gorgui J, Gorshkov M, Khan N, Daskalopoulou SS. Hypertension
as a risk factor for ischemic stroke in women. Can J Cardio.
2014; 30(7):774-782.
Carnethon MR, Evans NS, Church TS, et al. Joint associations of
physical activity and aerobic fitness on the development of
incident hypertension: coronary artery risk development in
young adults. Hypertension. 2010;56(1):49-55.
National Kidney and Urologic Diseases Information
Clearinghouse (NKUDIC). High blood pressure and kidney
disease. Retrieved September 22, 2014 from
http://kidney.niddk.nih.gov/kudiseases/pubs/highblood/.
Bakalli A, Koçinaj D, Bakalli A, Krasniqi A. Relationship of
hypertensive retinopathy to thoracic aortic atherosclerosis in
patients with severe arterial hypertension. Clin Expl Hypertens.
2011; 33(2):89-94.
Erden S. Bicaki B. Hypertensive retinopathy. Incidence, risk
factors, and co-morbidities. Clin Exp Hypertens.
2012;34(6):397-401.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
53
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
Mann JFE, Hilgers KF. Hypertension: Who should be treated?
UpToDate. September 16, 2014. Retrieved September 22, 2014
from http://www.uptodate.com/contents/hypertension-whoshould-betreated?source=search_result&search=Hypertension%3A+Who
+should+be+treated%3F&selectedTitle=1%7E150.
Franklin SS, Pio JR, Wong ND, et al. Predictors of new-onset
diastolic and systolic hypertension: the Framingham Heart
Study. Circulation. 2005;111(9):1121-1127.
Staessen JA, Gasowski J, Wang JG, Thijs L, Den Hond E, Boissel
JP, et al. Risks of untreated and treated isolated systolic
hypertension in the elderly: meta-analysis of outcome trials.
Lancet. 2000; 355(9207):865-872.
James PA, Oparil S, Carter BL, et al. 2014 evidence-based
guideline for the management of high blood pressure in adults:
report from the panel members appointed to the Eighth Joint
National Committee (JNC 8). JAMA. 311;(5) (2014), pp. 507520.
Millar PJ, Goodman JM. Exercise as medicine: Role in the
management of primary hypertension. Appl Physiol Nutr Metab.
2014; 39(7):856-858.
Brook RRD, Appel LJ, Rubenfire M, Ogedegbe G, Bisognano JD,
Elliot WJ, et al. Beyond medications and diet: alternative
approaches to lowering blood pressure: a scientific statement
from the American Heart Association. Hypertension. 2013;
61(6):1360-1383.
Eckell RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA,
et al. 2013 AHA/ACC Guideline on Life Style Management to
Reduce Cardiovascular Risk: a report of the American College
of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2014; 129(25 Suppl 2):576599.
Rossi AM, Moullec G, Lavoie KL, Gour-Provençal G, Bacon SL.
The evolution of the Canadian Hypertension Education Program
recommendation: The impact of resistance training on resting
blood pressure in adults as an example. Can J Cardiol. 2013;
29(5):622-627.
Saneei P, Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L.
Influence of Dietary Approaches to Stop Hypertension (DASH)
diet on blood pressure: A systematic review and meta-analysis
on randomized controlled trials. Nutr Metabol Cardiovasc Dis.
2014;24(12):1253-1261.
Chiu S, Bergeron N, Williams PT, Bray GA, Sutherland B, Krauss
RM. Comparison of the DASH (Dietary Approaches to Stop
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
54
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Hypertension) diet and a higher-fat DASH diet on blood
pressure and lipids and lipoproteins: a randomized controlled
trial. Am J Clin Nutr. 2016;103(2):341-347.
Ho AK, Bartels CM, Thorpe CT, Pandhi N, Smith MA, Johnson
HM. Achieving Weight Loss and Hypertension Control Among
Obese Adults: A US Multidisciplinary Group Practice
Observational Study. Am J Hypertens. 2016;29(8):984-991.
Poorolajal J, Hooshmand E, Bahrami M, Ameri P. How much
excess weight loss can reduce the risk of hypertension? J Public
Health (Oxf). 2016 Aug 13. [Epub ahead of print]
Oren S, Isakov I, Golzman B, et al. The influence of smoking
cessation on hemodynamics and arterial compliance. Angiology.
2006;57(5):564-568.
Takeshi Takami T, Saito Y. Effects of smoking cessation on
central blood pressure and arterial stiffness. Vasc Health Risk
Manag. 2011; 7:633-638.
Oncken CA, White WB, Cooney JL, Van Kirk JR, Ahluwalia JS,
Giacco S. Impact of smoking cessation on ambulatory blood
pressure and heart rate in postmenopausal women. Am J
Hypertens. 2001; 14(9 Pt 1):942-949.
Husain K, Ansari RA, Ferder L. Alcohol-induced hypertension:
Mechanism and prevention. World J Cardiol. 2014;6(5):245252.
Marchi KC Muniz JJ, Tirapelli CR. Hypertension and chronic
ethanol consumption: What do we know after a century of
study? World J Cardiol. 2014;6(5):283-294.
Eckell RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC Guideline on
Life Style Management to Reduce Cardiovascular Risk: A report
of the American College of Cardiology/American Heart
Association Task Force. Circulation. 2014 129:576-599.
Posadzki P, Cramer H, Kuzdzal A, Lee MS, Ernst E. Yoga for
hypertension: a systematic review of randomized clinical trials.
Complement Ther Med. 2014; 22(3):511-522.
Cramer H, Haller H, Lauche R, Steckhan N, Michalsen A, Dobos
G. A systematic review and meta-analysis of yoga for
hypertension. Am J Hypertens. 2014; 27(9):1146-1151.
Blom K, Baker B, How M, Dai M, Irvine J, Abbey S, et al.
Hypertension analysis of stress reduction using mindfulness
meditation and yoga: results from the HARMONY randomized
controlled trial. Am J Hypertens. 2014; 27(1):122-129.
Wang J, Xiong X, Liu W. Acupuncture for essential
hypertension. Int J Cardiol. 2013; 169(5):317-326.
Li DZ, Zhou Y, Yang YN, Ma YT, Li XM, Yu J, et al. Acupuncture
for ssential hypertension: a meta-analysis of randomized sham-
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
55
75.
controlled clinical trials. Evid Based Complement Alt Med. 2014;
279478. doi: 10.1155/2014/279478. Ep2014 Mar 4.
Centers for Disease Control and Prevention. High blood
pressure facts. February 19, 2015. Retrieved September 26,
2016 from http://www.cdc.gov/bloodpressure/facts.htm.
The information presented in this course is intended solely for the use of healthcare professionals taking
this course, for credit, from NurseCe4Less.com.
The information is designed to assist healthcare professionals, including nurses,
in addressing issues associated with healthcare.
The information provided in this course is general in nature, and is not designed to address any specific
situation. This publication in no way absolves facilities of their responsibility for the appropriate orientation
of healthcare professionals.
Hospitals or other organizations using this publication as a part of their own orientation processes should
review the contents of this publication to ensure accuracy and compliance before using this publication.
Hospitals and facilities that use this publication agree to defend and indemnify, and shall hold
NurseCe4Less.com, including its parent(s), subsidiaries, affiliates, officers/directors, and employees from
liability resulting from the use of this publication.
The contents of this publication may not be reproduced without written permission from
NurseCe4Less.com.
nursece4less.com nursece4less.com nursece4less.com nursece4less.com
56