Hypertension

George Ann Daniels MS, RN

What is Blood Pressure

• Components of B/P– Pressure of blood

against the walls of the arteries

– The elasticity of the artery walls

– The volume and thickness of the blood

• Systolic– Force while the heart pumps– Pressure as the heart pushes

the blood out to the body– Normal >130

• Diastolic– Force between heart pumps– Pressure as the heart begins

to fill with blood– Normal >85

• Systolic over diastolic• 120/80

What is Hypertension

• Is the result of persistent high arterial blood pressure which may cause damage to the vessels and arteries of the– Heart

– Brain

– Kidneys

– Eyes

• B/P > 140/90

Damage to arteries

• HTN arterial walls thicken– Narrowing the opening inside the artery and

reduces/block blood flow

• Persistent HTN arterial walls become rough– Easy for plaque is collect inside the artery– Decreased/blocked blood flow– Plaque can become mobile

• Fatty emboli

Classifications of Hypertension

• Primary– Essential HTN

• Slow onset

• Asymptomatic

– Malignant• Sudden onset

• Rapid development of symptoms

• Accelerated progression

Risk Factors R/T Primary Hypertension

• Age/Heredity• Sex• Race• Obesity• Stimulants• Sodium• Alcohol• Stress• Hyperlipidemia• Diabetes• Socioeconomic Status

Secondary Hypertension

• Underlying cause that impairs peripheral blood flow, alters cardiac output, or increases blood viscosity

• Most common – Renal failure

• Other causes– Endocrine, Coarctation, neurological, sleep apnea,

medications/stimulants, PIH

• Treat cause and hypertension resolves

Clinical Manifestation

• Persistent hypertension

• Fatigue• Reduced activity

tolerance,• Palpation• Angina• Dyspnea

Complications• Hypertensive Heart Disease

– Coronary Artery Disease• Hypertension is a major risk

factor for CAD• Left Ventricular Hypertrophy

(LVH)– Increased resistance in the

arteries» Stiffness and

narrowing of vessels» Left heart works

harder pumping against higher pressure

» Increases myocardial work and 02 consumption

• Heart Failure– Heart can no longer pump enough blood to

meet the metabolic needs of the body– Contractility depressed– Stroke volume and cardiac output decreases– C/O

• SOB on exertion, paroxysmal nocturnal dyspnea and fatigue

Complications Con’t• Cerebrovascular Disease

(CVA)– Most common cause

Atherosclerosis

– Portions of plaque or a blood clot (forms on plaque) breaks off

• Thromboembolism

• Travels to intracerebral vessels

– Stops the flow of blood to parts of the brain

– Aneurysms burst R/T increased pressure

» Hemorrhage

» Brain tissue damage

• Peripheral Vascular Disease (PVD)– Hypertension speeds up

Atherosclerosis in the peripheral blood vessels

• Aortic aneurysm

• Aortic dissection

• PVD

– C/O• Intermittent claudication

• Nephrosclerosis– End stage renal disease

– Renal dysfunction• Ischemia

– Narrowed intrarenal vessel

» Atrophy of tubules

» Destruction of glomeruli

» Death of nephron

– Earliest symptom• nocturia

• Retinal Damage– Red flag

• Damage to retinal vessels may indicate vessel damage in the heart, brain, and kidney

– C/O• Blurred vision

• Retinal hemorrhage

• Loss of vision

Nursing Assessment Data

• Subjective Data– Past medical history/Family

history– FHP 2 Nutrition

• Alcohol use, salt and fat intake, wt. gain/loss

– FHP 3 Elimination• Nocturia

– FHP 4 Activity/Exercise• Fatigue, Dyspnea on

exertion, palpitation, angina, chest pain, intermittent claudication, muscle cramps, smoking history, sedentary lifestyle

FHP 6 Cognitive/perception

Blurred visionparesthesia

FHP 9 Sexual/ReproImpotence

FHP 10 Coping/stressStressful life eventsNoncompliance

knowledge deficitfinancial

Objective Data

• Cardiovascular– Persisted elevated B/P

– Orthostatic change in B/P or pulse

– Retinal changes

– Abnormal heart sounds

– Diminished or absent peripheral pulses

– Carotid, renal, ischial or femoral bruits

– edema

• Musculoskeletal– Truncal obesity– Abnormal waist-hip

ratio

• Neurologic– Mental status changes,– Localized edema

Abnormal Diagnostic Test

• Lab– UA, BUN, serum

Creatinine• Renal involvement

– Serum electrolytes• Potassium

– Hyperaldosteronism

– Blood Glucose– Serum cholesterol and

triglycerides– Uric acid

• ECG– Left Ventricular

hypertrophy

• EEG– Ischemic heart disease

Medications

• Diuretics– Suppresses renal tubular re-

absorption of sodium• Diuril

– Loop diuretics• Bumex, Lasix, Demadex

– Potassium supplement

– Potassium sparing diuretic• Aldactone

• Beta Blockers– Blocks sympathetic

stimulation, decreases renin secretions, decreases cardiac output.

• Tenormin, Lopressor, Corgard, Inderal

• Alpha Inhibitors– Decreases peripheral vascular

resistance,

– Vasodilator• Catapres

• Central Inhibitors– Decreases cardiac output,

peripheral resistance, and heart rate

• Aldomet, Tenex

• Peripheral Inhibitors– Relaxes smooth muscle,

decreases peripheral resistance, decreases heart rate, and B/P

• Resperine

• Vasodilators– Relaxation of arteriolar

smooth muscle, vasodilatation, decreases cardiac output, decreases peripheral resistance

• Apresolilne, Nipride

• Calcium Channel Blockers– Inhibits calcium into

smooth muscle cells, vasodilatation, decreases peripheral resistance, increases cardiac output

• Norvasc, Cardizem, Plendil

• Angiotension-Converting Enzyme Inhibitors– Decreases peripheral

vascular resistance• Lotension, Captoen,

Vasotec, Prinivil, Accupril

Expected Outcomes

• Patient will achieve and maintain desired B/P

• Patient will understand, accept, and implement the therapeutic plan for B/P

• Patient will experience minimal or no side effects from therapy

• Patient will exhibit a confident ability to manage and cope with hypertension.

Plan of Care

• Health Promotion– Life style modifications

• Diet

• Regular physical activity

• Avoid smoking and chewing

• Relaxation techniques/stress management

• Drug Therapy

• Teaching– Hypertension

• Family/patient

– Correct technique for taking B/P

– ID Risk factors and S& S– Screening programs– Drug therapy

• Recommendations for follow-up– Box 31-13

Hypertensive Crisis

• Severe and abrupt elevation in B/P– Diastolic of 120-130

• Non-compliant patients

• Cocaine or crack users• PCP, LSD• Causes listed in table

31-15

Types of Hypertensive Crisis• Hypertensive Emergency

– Develops over hours to days

– Evidence of damage to acute target organ• CNS

– Hypertensive encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure with pulmonary edema, myocardial infarction, renal failure, and dissecting aortic aneurysm

• Hypertensive Urgency– Develops over days to weeks

– No evidence of target organ damage

Assessment data• Sudden rise in arterial pressure seen in Hypertensive

Encephalopathy – HA, Nausea, Vomiting, Seizures, Confusion, Stupor, Coma– Other common

• Blurred vision and transient blindness

• Renal insufficiency– Minor to complete renal shut down

• Rapid cardiac decomposition– Unstable angina to MI– Pulmonary edema

• Chest pain and dyspnea

• Neurological– Change in LOC

Diagnostic

• Mean arterial pressure (MAP)– DBP plus pulse pressure(SBP minus DBP)– MAP = DBP + 1/3 Pulse Pressure– Goal decrease MAP 10-20% in the first 1-2

hours– Patients with aortic dissection, unstable angina,

or sign of MI• Must have SBP lowered to l00-120 mm Hg asap

Medications

• IV Meds for Hypertensive Emergency– Vasodilators

• Nipride (most effective), Nitroglycerin, Hyperstat, Apresoline

– Alpha Inhibitors• Regitine, Normodyne, Brevibloc

– Ace Inhibitors• Vasotec

• Meds for Hypertensive Urgency– Oral agents

• Capoten, Catapres

Plan of Care

• Hypertensive Emergency– Administer IV meds with

rapid onset of action– B/P Q 2-3 minutes– Medication is titrated

according to B/P– Prevent hypotension

• Stroke, MI, visual changes

– Monitor ECG– Hourly output– Bedrest– Neurochecks

• Hypertensive Urgencies– Sit quietly for 20-30 minutes– Oral medications– Encourage patient to verbalize fears R/T

hypertension– Follow up in 24 hours

Pediatric Considerations

• Most common secondary to a structural abnormality or underlying pathologic process

• Manifestations– Adolescents/older children

• Frequent HA, dizziness, visual changes

– Infants/young children• Irritability, head

banging/head rubbing, wake up screaming at night

Treatment• Diagnosis of underlying cause• Surgery correction• Life style changes

– Low salt diet, wt loss, exercise, avoid stress, avoid smoking

– Avoidance of BCP

• Education– Orthostatic hypotension– Take drug as prescribed– Awarness of side effects and what to do– Avoid alcohol– Stay on diet

The End