Hypertension

Hypertension
Introduction
• Blood pressure is the force exerted by
circulating blood against the walls of the
body’s arteries, the major blood vessels in
the body. Hypertension is when blood
pressure is too high.
Blood pressure is written as two numbers.

The first (systolic) number represents the
pressure in blood vessels when the heart
contracts or beats. The second (diastolic)
• number represents the pressure in the
vessels when the heart rests between beats.
Hypertension is diagnosed if, when it is

measured on two different days, the systolic
blood pressure readings on both days is
≥140 mmHg and/or the diastolic blood
pressure readings on both days is ≥90
mmHg.
Key facts of hypertension
• Hypertension - or elevated blood
pressure - is a serious medical condition
that significantly increases the risks of
heart, brain, kidney and other diseases.
• An estimated 1.13 billion people
worldwide have hypertension, most (two-
thirds) living in low- and middle-income
countries.
• In 2015, 1 in 4 men and 1 in 5 women had
hypertension.
• Fewer than 1 in 5 people with
hypertension have the problem under
control.
• Hypertension is a major cause of
premature death worldwide.
• One of the global targets for non
communicable diseases is to reduce the
Factors Influencing Blood Pressure
Blood Pressure = Cardiac Output x Systemic Vascular

Resistance
Hypertension
Definition
• Hypertension is sustained elevation of BP

– Systolic blood pressure  140 mm Hg
– Diastolic blood pressure  90 mm Hg
Blood Pressure Classification
BP Classification SBP mmHg DBP mmHg
Normal < 120 and < 80
Pre-hypertension* 120-139 or 80-89
Stage 1 Hypertension 140-159 or 90-99
Stage 2 Hypertension > 160 or > 100
*newly recognized, requiring

lifestyle modifications
Hypertension
• For persons over age 50, SBP is more
important than DBP as a CVD risk factor
• Starting at 115/75 mmHg, CVD risk

doubles with each increment of 20/10
mmHg throughout the BP range
Classification of Hypertension
• Primary (Essential) Hypertension

- Elevated BP with unknown cause
- 90% to 95% of all cases
• Secondary Hypertension
- Elevated BP with a specific cause
- 5% to 10% in adults
• Primary Hypertension
- Contributing factors:
•  SNS activity
• Diabetes mellitus
•  Sodium intake
• Excessive alcohol intake
• Secondary Hypertension
- Contributing factors:
• Coarctation of aorta
• Renal disease
• Endocrine disorders
• Neurologic disorders
- Rx: Treat underlying cause
Risk Factors for Primary
Hypertension
• Age (> 55 for men; > 65 for women)
• Alcohol
• Cigarette smoking
• Diabetes mellitus
• Elevated serum lipids
• Excess dietary sodium
• Gender
Risk Factors for Primary
Hypertension
• Family history
• Obesity (BMI > 30)
• Ethnicity (African Americans)
• Sedentary lifestyle
• Socioeconomic status
• Stress
Hypertension
Clinical Manifestations
• Frequently asymptomatic until severe
and target organ disease has occurred
– Fatigue, reduced activity tolerance
– Dizziness
– Palpitations, angina
– Dyspnea
Hypertension: Complications
• Complications are
primarily related to
development of
atherosclerosis
(“hardening of
arteries”), or fatty
deposits that harden
with age
Hypertension
Complications
The common complications are

target organ diseases occurring in the
Heart
Brain
Kidney
Eyes
Hypertension
Complications
 Hypertensive Heart Disease
• Coronary artery disease

• Left ventricular hypertrophy
• Heart failure
Left Ventricular Hypertrophy
Fig. 32-3
Hypertension
Complications
 Cerebrovascular Disease
• Stroke
 Peripheral Vascular Disease
 Nephrosclerosis
 Retinal Damage
Hypertension
Diagnosis
• Diagnosis requires several elevated

readings over several weeks (unless >
180/110)
• BP measurement in both arms
- Use arm with higher reading for
subsequent measurements
Hypertension
Diagnosis
• Ambulatory BP Monitoring
– For “white coat” phenomenon, hypotensive or
hypertensive episodes, apparent drug resistance
Hypertension
BP Measurement
 See Table 32-12 (p. 794)

Treatment Goals
• Goal is to reduce overall cardiovascular
risk factors and control BP by the least
intrusive means possible
– BP < 140/90
– In patients with diabetes or renal
disease, goal is < 130/80
Benefits of Lowering BP
Average Percent Reduction

Stroke incidence 35–40%
Myocardial infarction 20–25%
Heart failure 50%

Algorithm for Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)

(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling With Compelling

Indications Indications
Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and (diuretics, ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs

until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
Hypertension
Collaborative Care
• Lifestyle Modifications
- Weight reduction
- Dietary changes (DASH diet)
- Limitation of alcohol intake (< 2 drinks/day for men;
< 1/day for women)

- Regular physical activity
- Avoidance of tobacco use
- Stress management
Hypertension
Collaborative Care
• Nutritional Therapy: DASH Diet =
Dietary Approahes to Stop HTN
- Sodium restriction
- Rich in vegetables, fruit, and nonfat
dairy products
- Calorie restriction if overweight
Hypertension
Collaborative Care
• Drug Therapy
- Reduce SVR
- Decrease volume of circulating blood
Hypertension
Collaborative Care
• Drug Therapy
• Diuretics
• Adrenergic inhibitors
• β - Adrenergic blockers
• ACE Inhibitors
• Calcium channel blockers
Hypertension: Drug Therapy
• Thiazide-type Diuretics
– Inhibit NaCl reabsorption
– Side effects:
• Electrolyte imbalances: ↓ Na, ↓ Cl, ↓ K** (advise K
rich foods)
• Fluid volume depletion (monitor for orthostatic
hypotension)
• Impotence, decreased libido
• Adrenergic Inhibitors
– Reduce sympathetic effects that cause HTN by:
• Reducing sympathetic outflow
• Blocking effects of sympathetic activity on vessels
– Side effects
• Hypotension
• Varied, depending on specific drug
• β – adrenergic blockers (suffix “olol”)
– (metoprolol, propranolol)
– Block β – adrenergic receptors
• ↓ HR, ↓ inotropy, reduces sympathetic
vasoconstriction)
– Side effects
• Bradycardia, hypotension, heart failure, impotence
• ACE Inhibitors (suffix “pril)
– Enalapril, captopril
– Prevents conversion of angiotensin I to
angiotensin II, thereby preventing the
vasoconstriction associate with A II.
– Side effects
• Hypotension, cough
• Calcium Channel Blockers
– Block movement of calcium into cells, causing
vasodilation
– Side effects
• Brdaycardia, heart block
Hypertension
Collaborative Care
• Drug Therapy and Patient Teaching
- Identify, report, and minimize side effects
• Orthostatic hypotension
• Sexual dysfunction
• Dry mouth
• Frequent urination
Primary Hypertension
Nursing Management
Nursing Diagnoses
- Ineffective health maintenance
- Anxiety
- Sexual dysfunction
- Ineffective therapeutic regimen
management r/t
- lack of S/S of HTN, side effects of Rx,
cost of Rx, etc.
Primary Hypertension
Nursing Management
Nursing Implementation
Health Promotion
• Individual patient evaluation
• Screening programs
• Cardiovascular risk factor
modification
Hypertensive Crisis
• Severe, abrupt elevation in BP
• The rate of  in BP is more important than
the absolute value
• Most common in patients with a history of
HTN who have failed to comply with
medications or who have been under-
medicated
Hypertensive Crisis
Clinical Manifestations
- Hypertensive encephalopathy (H/A, N & V,

seizures, confusion, coma)
- Renal insufficiency
- Heart failure
- Pulmonary edema
Hypertensive Crisis
Nursing and Collaborative
Management
Hospitalization
- IV drug therapy
- Monitor cardiac and renal function
- Neurologic checks
- Determine cause
- Education to avoid future crises
Supporting Materials
 Website www.nhlbi.nih.gov
 For patients and the general public
• Facts About the DASH Eating Plan
• Your Guide to Lowering Blood Pressure
• For health professionals

• Reference Card

Hypertension

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Hypertension

Blood pressure is written as two numbers.

Hypertension is diagnosed if, when it is

Blood Pressure = Cardiac Output x Systemic Vascular

• Hypertension is sustained elevation of BP

Normal < 120 and < 80

Pre-hypertension* 120-139 or 80-89

Stage 1 Hypertension 140-159 or 90-99

Stage 2 Hypertension > 160 or > 100

*newly recognized, requiring

• Starting at 115/75 mmHg, CVD risk

• Primary (Essential) Hypertension

The common complications are

 Hypertensive Heart Disease

• Coronary artery disease

• Diagnosis requires several elevated

 See Table 32-12 (p. 794)

Average Percent Reduction

Myocardial infarction 20–25%

Heart failure 50%

Not at Goal Blood Pressure (<140/90 mmHg)

Initial Drug Choices

Without Compelling With Compelling

Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling

Optimize dosages or add additional drugs

< 1/day for women)

- Hypertensive encephalopathy (H/A, N & V,

• For health professionals

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