HYPERTENSION

(High blood pressure, HTN, HPN)

Definition

•Chronic elevation in BP > 140/90

•Etiology unknown in 90-95% of pts (“essential

hypertension”)

•Always consider a secondary correctable form of

hypertension, especially in pts under age 30 or those who
become hypertensive after 55.

•Isolated systolic hypertension (systolic > 160, diastolic <

90) most common in elderly pts, due to reduced vascular
compliance.

•Hypertension is the most important modifiable risk factor

for coronary heart disease, stroke, congestive heart
failure, ESRD, and peripheral vascular disease.
Classifications

Labile Hypertension
• Intermittently elevated BP
Persistent/Resistant hypertension
• Hypertension that does not respond to usual
treatment
• One of the risk factors for strokes, heart attacks,
heart failure and arterial aneurysm, and is a leading
cause of chronic renal failure.
• Even moderate elevation of blood pressure leads to
shortened life expectancy.
Malignant hypertension
• Is severe, rapidly progressive elevation in BP that
causes rapid onset of end organ complications
White coat hypertension
• Is elevation of BP only during clinic visits.
Hypertension can be classified either essential(primary)
or secondary

Essential hypertension indicates that no specific

medical cause can be found to explain a patient’s
condition.

Secondary hypertension indicates that the high blood

pressure is a result of another condition, such as
kidney disease or tumors (pheochromocytoma and
paraganglioma)
Etiologies of Secondary hypertension

Renal artery stenosis

•Due to either to atherosclerosis (older men) or
fibromuscular dysplasia (young women)

•Sudden onset of hypertension

•Refractory to usual antihypertensive therapy

•Abdominal bruit often audible

•Mild hypokalemia may be present due to activation

of the renin-angiotensin-aldosterone system
Renal Parenchymal Disease

•Elevated serum creatinine and abnormal

urinalysis, containing protein, cells

Coarctation of Aorta

•Presents in children or young adults

•Constriction is usually present in aorta at

origin of left subclavian artery

•Exam shows diminished, delayed femoral

pulsations

•Late systolic murmur loudest over the midback

Pheochromocytoma

•A catecholamine-secreting tumor, typically of the

adrenal medulla, that presents as paroxysmal or
sustained hypertension in young to middle-aged pts.

•Sudden episodes of headache, palpitations and profuse

diaphoresis are common.

Hyperaldosteronism

•Due to aldosterone-secreting adenoma or bilateral

adrenal hyperplasia

•Should be suspected when hypokalemia is present in a

hypertensive pt off diuretic
Hypertensive Crisis
There are two types:

Hypertensive emergencies
•Represent severe hypertension with acute impairment
of an organ system (eg. Central Nervous System,
Cadiovascular system, Renal system)
•In these conditions, the BP should be lowered
aggressively over minutes to hours

Hypertensive urgency
•Defined as a severe elevation of BP, without evidence
of progressive target organ dysfunction.
•These patients require BP control over several days to
weeks
Risk Factors

•Family History

•Age

•High salt-intake

•Low potassium intake

•Obesity

•Excess alcohol consumption

•Smoking

•Stress
Signs and Symptoms

•Headache (especially upon waking). This is the most

characteristic sign.
•Epistaxis
•Dizziness
•Tinnitus
•Unsteadiness
•Blurred vision
•Depression
•Nocturia
•Retinopathy, papilledema (on fundoscopy)
 Laboratory and
Diagnostic Procedures
Seventh Joint National Committee Classification:

III. Hypertension Category

Systolic (mmHg)
Diastolic(mmHG)

Normal < 120

and < 80
Pre-hypertension 120 – 139 or
80 – 89
Hypertension
Stage 1 (mild) 140 – 159
or 90 – 99
Stage 2 ≥ 160
or ≥ 100
(moderate-severe)
II. Recommendations for Follow-up Based on Initial Set
of Blood Pressure Measurements for Adults

Initial Blood Pressure Screening Follow-up

Recommended

Systolic Diastolic

< 120 and < 80 Recheck in 2 years.

120 – 139 or 80 – 89 Advice healthy

lifestyle and recheck
in 1 year.

140 – 159 or 90 – 99 Confirm hypertension in 2

months.

≥ 160 or ≥ 100 Evaluate or refer to

source of care within
1 month.
III. Recommended Laboratory
tests:

CBC, Urinalysis, Potassium, FBS,

Creatinine, Calcium,
Total Cholesterol, HDL, LDL,
Triglycerides,
ECG, arterial line BP monitoring,
CXR
CBC

•Hematocrit is the most significant finding that is

related to hypertension.

•Low hematocrit (< 36%) can be related to volume

overload after aggressive hydration causing dilution
and hypertension.

•High hematocrit (>46%) means that the patient is

dehydrated.
Urinalysis

•Specifically, the Specific gravity determines the

hemodynamic condition of the patient.

•Low specific gravity means more concentrated

therefore dehydrated.

•High specific gravity means more diluted therefore

overhydrated which is more prone to hypertension.
Potassium Level

•Because of the use of potassium wasting diuretics as

treatment to hypertension, we need to monitor the
Potassium level of the patient.

•Prompts for hyperaldosteronism or renal artery

stenosis

•Take note that when withdrawing blood specimen for

chem-labs, the nurse must withdraw blood slowly
from the patient to prevent hemolysis of RBCs.
Hemolysis results in the release of potassium into the
serum component making the reading falsely high.
Creatinine
•To monitor kidney function
•Renal parenchymal disease

Total Cholesterol
•>200 mg/dL is high and considered as high
risk for hypertension

HDL
•Normal is 30-60 mg/dL

LDL
•Normal is < 190 mg/dL

Tryglycerides
•Normal is <180 mg/dL
Arterial line

•It is used for patients receiving more than small

amounts of vasoactive drip to properly manage
blood pressure.

•It is also preferred in sick patients who are labile

and whose BP is unstable.

•Certain situations absolutely require an a-line for

BP monitoring: any use of any dose of nipride, for
example. This is a truly powerful drug – it works
very quickly, and your patient can rapidly get into all
sorts of trouble unless you’re monitoring BP
continuously.

•Also serves as a port for obtaining ABG for lab

testing.
Nursing Considerations (A-line):

Before the procedure

•Obtain informed consent.

•Assess the patient’s status:

Is he hypotensive?
Is he anticoagulated?
Which hand is the dominant hand of the
patient?
Is the patient agitated? Needs sedation?
•Allen’s test
After the procedure

•Assess every shift:

Capillary refill
Distal Pulse
Feel the warmth of the hand and note its
color

•Apply pressure and compress the site after

withdrawing specimen

•Watch out for complications:

Compartment Syndrome
Hematoma formation
Using a-line to monitor blood pressure

•Make sure the trasducer is in level with the heart (4th

intercostal space, mid – axillary line)

•Make sure that there is no air in the line before hooking

it up to the patient – use the flusher to clear the bubbles
out of the tubing.

•Zero the line to negate the pressure applied by the

heparinised flush.

•Correlation of pressure readings with blood pressure

cuff should be done periodically, if possible.
Medical Surgical Management

There is no known surgical treatment to essential

(primary) hypertension. Surgical treatment is only
applicable to secondary hypertension wherein the cause
of the hypertension can be managed surgically.
Some Surgical Procedures:

Renal artery stent placement

•Indicated for renal artery stenosis

which hemodynamically compromises
the patient.

o Hypertension that is
poorly controlled on
adequate (two or three
drugs) medical therapy.

o Renal insufficiency

o “flash” pulmonary edema

•Stents are superior to balloons for both procedural
success and long-term patency

•Not an absolute cure for hypertension. However,

most of the patients will benefit by improved blood
pressure control and the need for fewer medications

•The benefits of renal stent placement include

reperfusion of ischemic kidneys, resulting in a
reduction in the stimulus to renin production, which
decreases angiotensin and aldosterone production,
thereby decreasing peripheral arterial
vasoconstriction and intravascular volume.

•Improving renal perfusion enhances glomerular

filtration, thus natriuresis.
Resection and end-to-end anastomosis –
coarctation of aorta

Malignant pheochromocytomas are treated by

surgical incision of the tumor.

Total adrenalectomy is the procedure of choice

for pheochromocytomas.

Total adrenalectomy if the hyperaldosteronism

is caused by an adrenocortical adenoma.
Approach to treatment:

• Rule out correctable and secondary causes of

hypertension first.

These include drug-induced hypertension,

thyroid and parathyroid disease, chronic
kidney disease, renovascular disease,
coarctation of the aorta, primary
aldosteronism, chronic steroid therapy and
Cushing’s syndrome, pheochromocytoma.
B. Encourage Lifestyle Change for Essential
Hypetension

• Stop smoking

• Lose weight if overweight. Maintain body mass

index of 18.5 – 24.9 kg/m2. For every 10 kg of
weight loss, BP drops by approximately 5-20
mmHg.

• Reduce sodium intake (<2 grams of sodium or

approximately < 6 grams of sodium chloride).
• Healthy diet. Consume a diet rich in vegetables,
fruits and low fat dietary products. Reduce dietary
saturated fat and cholesterol intake for overall
cardiovascular health. Reducing fat intake also
helps reduce calorie intake, which is important for
control of weight in type II diabetes.

• Engage in regular aerobic exercise once BP is

controlled. At least 30 minutes per day, most days
of the week. Brisk walking is good exercise.
• Limit alcohol intake to less than 1 oz/day of
ethanol (24 oz beer, 8 oz wine, or 2 oz 80-proof
whiskey)

• Maintain adequate dietary potassium, calcium

and magnesium intake.
 Medical treatment:
Choice of antihypertensive drugs based on
Patient characteristics

4.Diabetic patients and those with chronic kidney

disease:
Use ACE-inhibitors or Angiotensin II
antagonists to delay diabetic nephropathy

7.Young patients:
Use beta-blockers unless contraindicated

10.Coronary Artery Disease (CAD) patients:

Use beta-blockers, calcium channel-blockers.
Avoid hydralazine(Apresoline) which is a
direct vasodilator
•Heart Failure Patients:
Use ACE-inhibitors and/or diuretics. Generally
avoid beta-blockers and calcium-antagonists.

•Athletes:
Avoid beta-blockers and diuretics

•Broncho-pulmonary disease patients:

Use verapamil and other calcium-antagonist.
Avoid beta-blockers.

•Peripheral Vascular Disease patients:

Use calcium-antagonist(nifedipine), vasodilators,
or ACE-inhibitors. Avoid beta-blockers.
 •Dyslipidemic patients:
Avoid beta-blockers and diuretics.

•End-stage Renal Disease (ESRD) patients:

Use calcium-antagonists, diuretics and
centrally-acting agents(clonidine, methyldopa).
Caution on ACE-inhibitors.

•For stroke patients:

Use ACE-inhibitors and/or diuretics.

•Elderly patients:
Use diuretics. Generally use lower dosages.
Be wary of pseudohypertension wherein the
elevated BP is due to brachial artery
atherosclerosis and not hypertension per se.
Treatment Goal and Guide:

3. For hypertensive patients with diabetes or renal

disease, the target BP is < 130/80 mmHg. For
other patients without cardiovascular risk
factors, the BP goal is < 140/90 mmHg.

5. JNC VII recommends the use of thiazide-type

diuretics as first line treatment unless with
contraindications. Hydrochlorothiazide 25 mg
tab is given at ½ tab per day or Aldazide at ½
tab per day. Giving lower doses of diuretics is
safer because it minimizes electrolyte
imbalance.
Management of Hypertensive Crisis

Hypertensive Emergency

•The patient should be hospitalized for IV access,

continous intra-arterial blood pressure monitoring, and
electrocardiographic monitoring.
•Volume status and urine output should be monitored
•Rapid, uncontrolled reduction of blood pressure
should be avoided because coma, stroke, MI, acute
renal failure or death may result.
•The goal of initial therapy is to terminate ongoing
target organ damage.
•The Mean arterial pressure (MAP) should be lowered
not more than 20 - 25%, or to a diastolic blood pressure
of 100 mmHg over 15 to 30 minutes.
•Blood pressure should be controlled over a few hours
Hypertensive Urgency

•The initial goal in patients with severe asymptomatic

hypertension should be a reduction in blood pressure to
160/110 over several hours with conventional oral
therapy.
•If the patient is not volume depleted, furosemide (Lasix)
is given in a dosage of 20 mg if renal function is normal,
and higher if renal insufficiency is present.
•A calcium channel blocker (isradipine [DynaCirc], 5 mg
or felodipine [Plendil], 5 mg) should be added. A dose of
captopril (Capoten)(12.5 mg) can be added if the
response is not adequate. This regimen should lower
the blood pressure to a safe level over three to six hours
and the patient can be discharged on a regimen of once-
a-day medications.
Parenteral antihypertensive agents

Nitroprusside (Nipride)
•Nitroprusside is the drug of choice in almost all
hypertensive emergencies (except myocardial ischemia or
renal impairment). It dilates both arteries and veins, and it
reduces afterload and preload. Onset of action is nearly
instantaneous, and the effects disappear 1-2 minutes after
discontinuation.
•The starting dosage is 0.25-0.5 mcg/kg/min by continuous
infusion with a range of 0.25-8.0 mcg/kg/min. Titrate dose to
gradually reduce blood pressure over minutes to hours.
•When treatment is prolonged or when renal insufficiency is
present, the risk of cyanide and thiocyanate toxicity is
increased. Signs of thiocyanate toxicity include
disorientation, fatigue, hallucinations, nausea, toxic
psychosis, and seizures.
Nitroglycerin

•Nitroglycerin is the drug of choice for hypertensive

emergencies with coronary ischemia. It should not be
used with hypertensive encephalopathy because it
increases intracranial pressure.
•Nitroglycerin increases venous capacitance, decreases
venous return and left ventricular filling pressure. It has a
rapid onset of action of 2-5 minutes. Tolerance may occur
within 24-48 hours.
•The starting dose is 15 mcg IV bolus, then 5-10 mcg/min
(50 mg in 250 mL D5W). Titrate by increasing the dose at
3- to 5-minute intervals.
•Generally doses >1.0 mcg/kg/min are required for
afterload reduction (max 2.0 mcg/kg/hr). Monitor for
methemoglobinemia.
Labetalol IV (Normodyne)

Labetalol is a good choice if BP elevation is associated

with hyperadrenergic activity, aortic dissection, an
aneurysm, or postoperative hypertension.

Labetalol is administered as 20 mg slow IV over 2 min.

Additional doses of 20-80 mg may be administered q5-
10min, then q3-4h prn or 0.5-2.0 mg/min IV infusion.

Labetalol is contraindicated in obstructive pulmonary

disease, CHF, or heart block greater than first degree.
Enalaprilat IV (Vasotec)

•Enalaprilat is an ACE-inhibitor with a rapid

onset of action (15 min) and long duration of
action (11 hours). It is ideal for patients with
heart failure or accelerated-malignant
hypertension.

•Initial dose, 1.25 mg IVP (over 2-5 min) q6h,

then increase up to 5 mg q6h. Reduce dose in
azotemic patients.

•Contraindicated in bilateral renal artery

stenosis.
Esmolol (Brevibloc)

•is a non-selective beta-blocker with a 1-2 min onset of

action and short duration of 10 min.
•The dose is 500 mcg/kg/min x 1 min, then 50
mcg/kg/min; max 300 mcg/kg/min IV infusion.

Hydralazine

•is a preload and afterload reducing agent.

•It is ideal in hypertension due to eclampsia.
•Reflex tachycardia is common. The dose is 20 mg
IV/IM q4-6h.
Nicardipine (Cardene IV)
•is a calcium channel blocker.
•It is contraindicated in presence of CHF.
•Tachycardia and headache are common.
•The onset of action is 10 min, and the duration is 2-4
hours. The dose is 5 mg/hr continuous infusion, up to 15
mg/hr.

Fenoldopam (Corlopam)
•is a vasodilator. It may cause reflex tachycardia and
headaches.
•The onset of action is 2-3 min, and the duration is 30
min.
•The dose is 0.01 mcg/kg/min IV infusion titrated, up to
0.3 mcg/kg/min.
Phentolamine (Regitine)

•is an intravenous alphaadrenergic antagonist used in

excess catecholamine states, such as
pheochromocytomas, rebound hypertension due to
withdrawal of clonidine, and drug ingestions.
•The dose is 2-5 mg IV every 5 to 10 minutes.

Trimethaphan (Arfonad)

•is a ganglionic-blocking agent. It is useful in

dissecting aortic aneurysm when beta-blockers are
contraindicated; however, it is rarely used because
most physicians are more familiar with nitroprusside.
•The dosage of trimethoprim is 0.3-3 mg/min IV
infusion.
Oral and sublingual antihypertensive drugs

Nifedipine
•Has a rapid onset of action, usually within 15 to 30
min.
•Initial dose should not exceed 10 mg to prevent
sudden drop in blood pressure.

Clonidine
•For urgent hypertension
•Use the clonidine loading regimen – initial dose of
0.2 mg
followed by 0.1 mg every hour, for up to 5 hours, until
diastolic blood pressure is reduced to below 110 mmHg
or a total dose of 0.7 mg is reached.
•Side effects of sedation, dry mouth, and orthostatic
hypotension
Nursing Interventions
•Patient Teaching/Counselling
o Teaching about hypertension
o Teaching about the risk factors
o Stress therapy
o Low sodium, low saturated fat diet
o Avoid stimulants (eg. Caffeine, alcohol,
cigarette)
o Regular pattern of exercise
o Weight reduction if obese
•Teaching about medication

oThe most common side effects of diuretics are

potassium depletion and orthostatic hypotension
oThe most common side effect of the different
antihypertensive drugs is orthostatic hypotension
oTake antihypertensive medications at regular
basis
oAssume sitting or lying position for few minutes
oChange position gradually
oAvoid very warm bath
oAvoid prolonged sitting or standing
oAvoid alcoholic beverages
•Lie down immediately if faintness, weakness, nausea
and vomiting occur; put feet higher than head; flex
thigh muscles and wiggle toes.

•Use caution when driving or operating heavy or

dangerous machinery

•Avoid cheese, beer, or wine when taking a Monoamine

oxidase inhibitor (e.g. pargyline). A severe reaction might
occur, with a possibility or cerebral hemorrhage.

•Should hypotensive crisis occur, wrap legs firmly with

ace bandages when ambulating. Ace bandage helps
promote venous return.
 oAvoid tyramine-rich foods (proteins) as
follows:
 Aged cheese
 Liver
 Beer
 Wine
 Chocolate
 Yogurt
 Pickle
 Sausage
 Soy sauce
*these may cause hypertensive
crisis
•Preventing Non-compliance

o Inform the client that absence of symptoms

does not indicate control of BP.

o Advise the client against abrupt withdrawal

of medication; rebound hypertension may
occur.

o Device ways to facilitate remembering of

taking medications(e.g. labeled containers)
Other Nursing Considerations

When giving medications measure the BP before and 5

min after drug administration.

Nitroprusside must be protected from light, and the

solution changed every 12 hours.
High dosages of Nitroprusside over several days require
monitoring of serum thiocyanate level.

Nitroprusside toxicity is treated by administration of

Hydroxocobalamin – a vit B12 derivative.

A special non absorbing infusion set is require to avoid

adherence of nitroglycerin to the plastic or polyvinyl
chloride contained in most IV lines.
Possible Nursing Diagnosis and interventions

Risk for decreased cardiac output

•Determine baseline vital signs/hemodynamic

parameters including peripheral pulses
•Provide quiet environment, cool room, decreased
sensory stimuli, soothing colors and soft music.
•Encourage patient to restrict activity and rest in bed
as much as possible
•Administer oxygen as necessary
•Administer antihypertensive medications as indicated
•Start an IV if symptoms of malignant hypertension
were present (encephalopathy, intracranial
hemorrhage, severe chest pain, acute pulmonary
edema)
Deficient knowledge regarding condition
(hypertension), therapeutic regimen and potential
complications

•Identify Significant others also requiring

information
•Discuss the condition of the client and how it can
be managed
•State objectives in learner’s term to meet the
learner’s need
•Discuss the side effects of the medications and its
considerations