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