HYPERTENSION

SIS: NILES-ALLEYNE
10/01/2024
 OBJECTIVE

At the end of this lesson, students will be able to:

 Define blood pressure and high blood pressure
 Identify risk factors for hypertension.
 Describe the treatment approach for hypertension, including
 Lifestyle changes and medication therapy.
 Use the nursing process as a framework for care of the patient with Hypertension.
 Describe the necessity for immediate treatment of hypertension
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INCIDENCE

 Hypertension is the most common public health concern affecting the adult
population.
 Prevalence of hypertension increases with age, with blacks more affected than white.
 A higher percentage of men than women have hypertension until age 45 years. From
45 to 54 Years. While women have a slightly higher percentage of hypertension than
men, After age 54 years,

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DEFINITION

 Hypertension is defined as a systolic

blood pressure greater than 140 mm Hg
and a diastolic pressure greater than 90
mmHg, based on two or more
measurements.
 According to the Seventh Joint National
Committee (JNC) on Prevention,
Detection, Evaluation, and Treatment of
High Blood Pressure, the individual
shouldn’t have diabetes mellitus (DM)
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CLASSIFICATION SYSTEM FOR BLOOD PRESSURE

Hypertension can be classified as follows:

 Normal: systolic less than 120 mm Hg; diastolic less than 80 mm Hg
 Prehypertension: systolic 120 to 139 mm Hg; diastolic 80 to 89 mm Hg
 Hypertension/Stage 1: systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg
 Severe Hypertension/Stage 2: systolic ≥160 mm Hg; diastolic ≥100 mm Hg

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 ETIOLOGY OF HYPERTENSION
 Hypertension can be essential (primary) or secondary.
 Essential/Primary hypertension is the most common classification (between 90%
and 95% ). Essential HTN has no identifiable medical cause (idiopathic hypertension) ;
and appears to be a multifactorial, polygenic condition.
 Genetic predisposition and conditions such as obesity , loss of elastic tissue and
arteriosclerosis of aorta and large arteries and even environmental stresses. The
sustained elevated BP in patients with essential hypertension results in damage to vital
organs by causing medial hyperplasia (thickening) of the arterioles.
 As the blood vessels thicken and perfusion decreases, body organs are damaged. These
changes can result in myocardial infarctions, strokes, peripheral vascular disease (PVD),
or renal failure.
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 Secondary hypertension is characterized by elevations in blood pressure with a specific
cause. Usually accounts for about 5-10% of the population affected by hypertension.
Conditions such as, renal parenchymal disease, hyperaldosteronism (mineralocorticoid
hypertension), certain medications, pregnancy, and coarctation of the aorta. Hypertension can
also be acute, a sign of an underlying condition that causes a change in peripheral resistance
or cardiac output.
 Malignant hypertension is a severe type of elevated blood pressure that rapidly
progresses. A person with this health problem usually has symptoms such as morning
headaches, blurred vision, and dyspnea and/or symptoms of uremia (accumulation in the
blood of substances ordinarily eliminated in the urine). Patients are often in their 30s, 40s,
or 50s with their systolic blood pressure greater than 200 mm Hg. The diastolic
blood pressure is greater than 150 mm Hg or greater than 130 mm Hg when there
are pre-existing complications.
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 RISK FACTORS FOR HYPERTENSION

 Age
 Gender
 Family History
 Ethnic group
 Stress
 Physical inactivity
 Obesity
 Conditions: DM
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CLINICAL MANIFESTATIONS

The early stage of hypertension usually is asymptomatic with only evidence of an

elevated blood pressure.
 Headaches
 Facial flushing (redness)
 Dizziness, or fainting as a result of the elevated blood pressure.
 Nosebleeds
 Shortness of breath
 Nausea and/or vomiting.
 Heart palpitations
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 DIAGNOSES
 The diagnosis of hypertension in adults is by:
 History identifies possible causes/risk factors.
 Physical examination (Two or more readings with
elevation may be taken at each visit (Obtain blood pressure
readings in both arms.), including retinal examination
(Funduscopic examination) of the eyes to observe vascular
changes in the retina.
 Laboratory studies supports detection of secondary
causes of hypertension. for organ damage, including
urinalysis& 24-hrs urine protein, blood chemistry (sodium,
potassium, creatinine, fasting glucose, total and high-density
lipoprotein).
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DIAGNOSES
NB: Kidney disease can be diagnosed by the presence of
protein, red blood cells, pus cells, and casts in the urine;
elevated levels of blood urea nitrogen (BUN); and
elevated serum creatinine levels.
The creatinine clearance test directly indicates the
glomerular filtration ability of the kidneys. The normal
value is 107 to 139 mL/min for men and 87 to 107
mL/min for women (Pagana & Pagana, 2010). Decreased
levels indicate kidney disease.
 Electrocardiogram(ECG); to assess left ventricular
hypertrophy, this the first ECG sign of heart disease
resulting from hypertension.
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 COMPLICATIONS

Hypertension is a major risk factor for atherosclerotic cardiovascular disease such as:
 Left ventricular hypertrophy
 Myocardial infarction
 Heart Failure
 Transient Ischemic Attack
 CVA/stroke
 Renal insufficiency and failure
 Retinal hemorrhage
 Death R. NILES-ALLEYNE-ADULT HEALTH NURSING
MEDICAL MANAGEMENT

 The goal is to prevent death and complications by achieving and maintaining an

arterial blood pressure at or below 140/90 mm Hg (130/80 mm Hg for people with
diabetes mellitus or chronic kidney disease).
 Nonpharmacologic approaches include lifestyle modifications such as weight
reduction; restriction of alcohol and sodium; regular exercise and relaxation.
 A DASH (Dietary Approaches to Stop Hypertension) diet high in fruits, vegetables,
and low-fat dairy products has been shown to lower elevated pressures.

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 PHARMACOLOGIC APPROACHES
 Antihypertensive and Lipid-Lowering treatment to prevent
Heart Attack Trial (ALLHAT). Hypertensive drugs used
reduces peripheral resistance, blood volume or the
strength and rate of myocardial contraction.
 Drug therapy is individualized for each patient, with
consideration given to culture, age, other existing illness,
severity of blood pressure elevation, and cost of drugs and
follow-up. Once-a-day drug therapy is best, especially for
the older adult.
 Antihypertensive drugs such as diuretics, Calcium
channel blockers, angiotensin-converting enzyme
(ACE) inhibitors, angiotensin II receptor
antagonists, and aldosterone receptor antagonists.
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 ANTIHYPERTENSIVE

First line medications include:

 Diuretic agents
 Beta blockers
Sometimes used together starting with low
doses and gradually increased to obtain
hypertension is controlled.
Does are reduced once 140/90mmhg
attained for 1 year.
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 PHARMACOLOGIC APPROACHES
 Diuretics are the first type of drugs for managing hypertension. R. NILES-ALLEYNE-ADULT HEALTH NURSING

 Three basic types of diuretics are used to decrease blood volume and lower blood pressure.
 Thiazide (low-ceiling) diuretics, such as hydrochlorothiazide, which inhibit sodium,
chloride, and water reabsorption in the distal tubules while promoting potassium, bicarbonate,
and magnesium excretion. They decrease calcium excretion, which helps prevent kidney stones
and bone loss.
 Loop (high-ceiling) diuretics, such as furosemide (Lasix, Furoside ) and torsemide
(Demadex), inhibit sodium, chloride, and water reabsorption in the ascending loop of Henle
and promote potassium excretion
 Potassium-sparing diuretics, such as spironolactone (Aldactone,), and amiloride (Midamor),
act on the distal renal tubule to inhibit reabsorption of sodium ions in exchange for potassium,
thereby retaining potassium in the body. When used, they are typically in combination with
another diuretic or antihypertensive drug to conserve potassium
 PHARMACOLOGIC APPROACHES
 Beta-adrenergic blockers, are categorized as cardioselective (working only
on the cardiovascular system) and non-cardioselective.
 Cardioselective beta blockers, affecting only beta-1 receptors, may be prescribed
to lower blood pressure by blocking beta receptothe heart and peripheral
vessels. By blocking these receptors, the drugs decrease heart rate and
myocardial contractility.
 Teach patients about common side effects of beta blockers, including fatigue,
weakness, depression, and sexual dysfunction. The potential for side effects
depends on the “selective” blocking effects of the drug
 Atenolol (Tenormin, ApoAtenol ), bisoprolol (Zebeta), and metoprolol
(Lopressor, Toprol, Toprol-XL, Betaloc ) are commonly used cardioselective beta
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blockers for hypertension.

 PHARMACOLOGIC APPROACHES
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 Calcium channel blockers such as verapamil hydrochloride lower blood

pressure by interfering with the transmembrane flux of calcium ions. This
results in vasodilation, which decreases blood pressure. These drugs also
block SA and AV node conduction, resulting in a decreased heart rate.
Calcium channel blockers are most effective in older adults and African
Americans.
 Angiotensin II receptor antagonists, also called angiotensin II receptor
blockers (ARBs) or the -sartan drugs, make up a group of drugs that
selectively block the binding of angiotensin II to receptor sites in the
vascular smooth muscle and adrenal tissues by competing directly with
angiotensin II but not inhibiting ACE. Examples of drugs in this group are
candesartan (Atacand), valsartan (Diovan), and losartan
 PHARMACOLOGIC APPROACHES
 Angiotensin-converting enzyme (ACE) inhibitors, also known R. NILES-ALLEYNE-ADULT HEALTH NURSING

as the “pril” drugs, are also used as single or combination agents in

the treatment of hypertension. These drugs block the action of the
angiotensin-converting enzyme as it attempts to convert angiotensin
I to angiotensin II, one of the most powerful vasoconstrictors in the
body. This action also decreases sodium and water retention and
lowers peripheral vascular resistance, both of which lower blood
pressure.
 ACE inhibitors include captopril (Capoten), lisinopril (Prinivil,
Zestril), and enalapril (Vasotec). The most common side effect of this
group of drugs is a nagging, dry cough. Teach patients to report this
problem to their health care provider as soon as possible. If a cough
develops, the drug is discontinued.
PHARMACOLOGIC APPROACHES

 Aldosterone receptor antagonists block the

hypertensive effect of the mineralocorticoid hormone
aldosterone.
 Aldosterone increases sodium reabsorption by the kidney
and is a significant contributor to hypertension, cardiac and
vascular remodeling, and heart failure. Eplerenone (Inspra)
lowers blood pressure by blocking aldosterone binding at
the mineralocorticoid receptor sites in the kidney, heart,
blood vessels, and brain.
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NURSING ASSESSMENT

 Assess for the following subjective and objective data:

 Adult BMI greater than 25 kg/m2
 Triceps skinfold more than 15 mm in men and 25 mm in women (maximum for age
and sex)
 Reported or observed dysfunctional eating patterns
 Sedentary lifestyle
 Verbal report of fatigue or weakness
 Abnormal heart rate or BP response to activity
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NURSING ASSESSMENT

 Verbal reports of throbbing pain

located in suboccipital region,
(Headache) present on awakening  Changes in appetite
and disappearing spontaneously after
being up and about  Exertional discomfort or dyspnea

 Reports of stiffness of neck,  Electrocardiogram (ECG) changes

dizziness, blurred vision, nausea and reflecting ischemia; dysrhythmias
vomiting
 Reluctance to move head, rubbing head,
avoidance of bright lights and noise,
wrinkled brow, clenched fists R. NILES-ALLEYNE-ADULT HEALTH NURSING
NURSING ASSESSMENT

Care givers should ensure they assess for factors related to the cause of hypertension:
 Increased vascular resistance, vasoconstriction
 Myocardial ischemia
 Myocardial damage
 Ventricular hypertrophy/rigidity
 Generalized weakness
 Sedentary lifestyle
 Imbalance between oxygen supply and demand
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NURSING PRIORITIES

The following are the nursing priorities for patients with hypertension:
 Prevent complications and death through aggressive hypertension
management.
 Weight reduction and lifestyle & dietary modifications.
 Promoting adherence to therapeutic regimen

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NURSING DIAGNOSES

Common nursing diagnosis for patients with hypertension

 Deficient knowledge regarding the relationship between the
treatment regimen and control of the disease process
 Noncompliance with therapeutic regimen related to side effects of
prescribed therapy

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PLANNING AND GOALS
Goals and expected outcomes may include: R. NILES-ALLEYNE-ADULT HEALTH NURSING

 Patient will actively engage in activities aimed at reducing blood pressure and cardiac
workload, maintain blood pressure within an individually acceptable range, exhibit
stable cardiac rhythm and rate within normal limits, and actively participate in stress
management activities and a balanced plan of activities and rest to prevent stress.
 The patient will demonstrate knowledge and understanding of the disease process,
treatment regimen, drug side effects, possible complications requiring medical
attention, acceptable blood pressure parameters, and the rationale behind
therapeutic actions and treatment regimen.
 Patient will effectively manage pain and discomfort, demonstrate knowledge of pain
relief methods, adhere to prescribed medication regimen, and utilize relaxation
techniques and diversional activities to promote comfort and well-being.
NURSING INTERVENTIONS

 Assist patient in identifying modifiable risk factors (obesity; a diet high in sodium,
saturated fats, and cholesterol; sedentary lifestyle; smoking; alcohol intake of more
than 2 oz per day regularly; stressful lifestyle). These risk factors have been shown to
contribute to hypertension and cardiovascular and renal disease.
 Advise patient to limit alcohol intake and avoid use of tobacco. Discuss the
importance of eliminating smoking, and assist the patient in formulating a plan to quit
smoking. Nicotine increases catecholamine discharge, resulting in increased heart
rate, BP, vasoconstriction, and myocardial workload, and reduces tissue oxygenation.
 Recommend support groups for weight control, smoking cessation, and stress
reduction, if necessary.
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 Reinforce the importance of adhering to treatment regimens and keeping follow-up
appointments. Lack of cooperation is a common reason for the failure of
antihypertensive therapy. Therefore, ongoing evaluation for patient cooperation is
critical to successful treatment. Compliance usually improves when the patient
understands the causative factors and consequences of inadequate intervention and
health maintenance.
 Explain prescribed medications along with their rationale, dosage, expected and
adverse side effects. Adequate information and understanding that side effects (mood
changes, initial weight gain, dry mouth) are common and often subside with time can
enhance cooperation with a treatment plan.
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 Instruct and demonstrate the technique of BP self-monitoring. Evaluate patient’s
hearing, visual acuity, manual dexterity, and coordination. Monitoring BP at home is
reassuring to patients because it provides visual and positive reinforcement for
following the medical regimen and promotes early deleterious changes.

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 Monitor and record BP. Measure in both arms and thighs three times, 3–5
min apart while the patient is at rest, then sitting, then standing for initial evaluation.
Use correct cuff size and accurate technique. Comparison of pressures provides a
complete picture of vascular involvement or the scope of the problem. Severe
hypertension is classified in adults as a diastolic pressure elevation of 110 mmHg;
progressive diastolic readings above 120 mmHg are considered first accelerated, then
malignant (very severe). Systolic hypertension is also an established risk factor for
cerebrovascular disease and ischemic heart disease when elevated diastolic
pressure. See updated guidelines for classifying hypertension above.
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 Provide calm, restful surroundings, and minimize environmental activity
and noise. Limit the number of visitors and length of stay.
It helps lessen sympathetic stimulation; promotes relaxation.
 Note dependent and general edema. May indicate heart failure, renal, or
vascular impairment.

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 Maintain activity restrictions (bedrest or chair rest); schedule
uninterrupted rest periods; assist patient with self-care activities as
needed. Lessens physical stress and tension that affect blood pressure and
the course of hypertension.
 Administer medications and monitor response to medications to control
blood pressure.
Response to drug therapy (usually consisting of several drugs, including diuretics,
angiotensin-converting enzyme [ACE] inhibitors, vascular smooth muscle relaxants,
and beta and calcium channel blockers) is dependent on both the individual and the
synergistic effects of the drugs. Because of side effects, drug interactions, and patient’s
motivation for taking antihypertensive medication, it is important to use the smallest
number and lowest dosage of medications. R. NILES-ALLEYNE-ADULT HEALTH NURSING
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 Evaluate client reports or evidence of extreme fatigue, intolerance for activity, sudden
or progressive weight gain, swelling of extremities, and progressive shortness of breath.
To assess for signs of poor ventricular function or impending cardiac failure.
 Assess the patient’s response to activity. Noting pulse rate more than 20 beats per
min faster than resting rate; marked increase in BP during and after activity (systolic
pressure increase of 40 mm Hg or diastolic pressure increase of 20 mm Hg); dyspnea
or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope. The
stated parameters help assess physiological responses to the stress of activity and, if
present, are indicators of overexertion.
 Determine specifics of pain (location, characteristics, intensity (0–10 scale),
onset, and duration). Note nonverbal cues. Facilitates diagnosis of problem and
initiation of appropriate therapy. Helpful in evaluating the effectiveness of therapy
 Encourage and maintain bed rest during the acute phase. Minimizes stimulation and promotes relaxation.
 Provide or recommend non pharmacological measures to relieve headache such as cool
cloth to forehead; back and neck rubs; quiet, dimly lit room; relaxation techniques (guided
imagery, distraction); and diversional activities. Measures that reduce cerebral vascular pressure
and slow or block sympathetic response effectively relieve headaches and associated complications.
 Assist patient with ambulation as needed. Dizziness and blurred vision frequently are associated
with vascular headaches. The patient may also experience episodes of postural hypotension, causing
weakness when ambulating.
 Assess the effectiveness of coping strategies by observing behaviors (ability to verbalize
feelings and concerns, willingness to participate in the treatment plan).
Adaptive mechanisms are necessary to appropriately alter one’s lifestyle, deal with the chronicity of
hypertension, and integrate prescribed therapies into daily living
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 Assist the patient in identifying and begin planning for necessary lifestyle changes. Assist in
adjusting, rather than abandon, personal/family goals.
Necessary changes should be realistically prioritized so patients can avoid being overwhelmed and
feeling powerless.
 Establish a realistic weight-reduction plan with the patient, such as 1 lb weight loss per wk.
Reducing caloric intake by 500 calories daily theoretically yields a weight loss of 1 lb per wk. Therefore,
a slow weight reduction indicates fat loss with muscle-sparing and generally reflects a change in eating
habits.
 Encourage the patient to maintain a diary of food intake, including when and where eating takes place
and the circumstances and feelings around which the food was eaten. Provides a database for both the
adequacy of nutrients eaten and the emotional conditions of eating. It helps focus attention on factors
that the patient has control over or can change.
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 R. NILES-ALLEYNE-ADULT HEALTH NURSING

 Instruct and assist in appropriate food selections, such as a diet rich in fruits,
vegetables, and low-fat dairy foods referred to as the DASH Dietary Approaches
to Stop Hypertension) diet and avoiding foods high in saturated fat (butter,
cheese, eggs, ice cream, meat) and cholesterol (fatty meat, egg yolks, whole dairy
products, shrimp, organ meats).
 Avoiding foods high in saturated fat and cholesterol is important in preventing
progressing atherogenesis.
 Moderation and use of low-fat products in place of total abstinence from certain
food items may prevent a sense of deprivation and enhance cooperation with
the dietary regimen. In conjunction with exercise, weight loss, and limits on salt
intake, the DASH diet may reduce or even eliminate the need for drug therapy.
 Monitoring and Managing Potential Complications
 Assess all body systems when patient returns for follow-up care to detect any
evidence of vascular damage.
 Question patient about blurred vision, spots, or diminished visual acuity.
 Report any significant findings promptly to determine whether additional studies or
changes in medications are required.

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CONTINUING CARE

 Reinforce importance of regular follow-up care.

 Obtain patient history and perform physical examination at each clinic visit.
 Assess for medication-related problems (orthostatic hypotension).
 Provide continued education and encouragement to enable patients to formulate an
acceptable plan that helps them live with their hypertension and adhere to the
treatment plan.
 Assist with behavior change by supporting patients in making small changes with each
visit that move them toward their goals.
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 HYPERTENSIVE CRISIS
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 A hypertensive, or high blood pressure, crisis is a potentially life-threatening

condition characterized by severe elevated blood pressure (180/120 millimeters of
mercury (mm Hg) or greater).
 Patients who do not adhere to antihypertensive treatment are at a high risk for target
organ damage and hypertensive urgency or crisis (causes organ damage, such as
kidney or heart [target organs]).
 Patients in hypertensive crisis are admitted to critical care units, where they receive IV
antihypertensive therapy such as hydralazine (apresolin), nicardipine (Cardene IV),
fenoldopam (Corlopam), or labetalol (Normodyne).
 These drugs act quickly as vasodilators to decrease blood pressure (BP). When the
patient’s blood pressure stabilizes, oral antihypertensive drugs are given
 SIGNS AND SYMPTOMS OF HYPERTENSIVE URGENCY OR CRISIS

Extremely high
blood pressure Dizziness
Severe
headache (BP)

Severe anxiety

Blurred vision Shortness of Epistaxis

breath (nosebleed)

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 MANAGEMENT
 Place patient in a semi-Fowler’s position. R. NILES-ALLEYNE-ADULT HEALTH NURSING

 Administer oxygen.
 Start IV of 0.9% normal saline (NS) solution slowly to prevent fluid overload (which
would increase blood pressure).
 Administer IV nitroprusside (Nitropress), nicardipine (Cardene IV), or other infusion
drug as prescribed (for nitroprusside, cover infusion bag to prevent drug breakdown by
light); when stable, switch to oral antihypertensive drug.
 Monitor BP every 5 to 15 minutes until the diastolic pressure is below 90 and not less
than 75; then monitor BP every 30 minutes to ensure that BP is not lowered too quickly.
 Observe for neurologic or cardiovascular complications, such as seizures; numbness,
weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of
target organ damage
MANAGEMENT

 Medication Vasodilators such as Hydralazine (apresoline) is often used in

hypertensive crisis . It has direct action on smooth muscles wall of the arterioles
causing arteriolar vasodilation and thus reducing the pressure.
 Patient may be receive a urethral catheter to promote rest and limit activities and
allow for accurate kidney function assessment.
 Nursing care activities will be clustered to ensure rest is promoted and blood
pressure decreases.

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 The End !
Any questions?
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