LESSON PLAN ON

HYPERTENSIVE CRISIS

PRESENTED BY

MRS. PRADNYA BASANKAR

AIMS: At the end of this seminar, student will able to provide comprehensive nursing care to client with hypertensive crisis under
supervision.

Objectives: student will be to,

1. Reviews anatomy and physiology related to arterial blood pressure.

2. Define hypertensive crisis.
3. Identify types of hypertensive crisis.
4. Enlist etiological and risk factors of hypertensive crisis.
5. Describe pathophysiology of hypertensive crisis.
6. Discuss clinical manifestations of hypertensive crisis.
7. Perform assessment and diagnosis of hypertensive crisis.
8. Explain medical management of hypertensive crisis.
9. Describe nursing management of hypertensive crisis.
10. Explain discharge planning of hypertensive crisis.
SR.NO. TIME CONTRIBUTORY LEARNING CONTENT TEACHING LEARNING AV AIDS
OBJECTIVES ACTIVITIES

1. 2 min. Student introduces Student teacher introduces topic hypertensive Student teacher ask Blackboard
topic hypertensive crisis which is extreme rise in blood pressure question about what is
crisis. beyond limit 120/80 mmHg. hypertension?
And also ask if blood
A hypertensive (high blood pressure) crisis
pressure crosses limit
refers to abrupt acute and marked increase in
then what is
blood pressure from patient's baseline which
terminology?
leads to acute progressive end organ damage.
Student tell about
When blood pressure rises quickly and
hypertension. Teacher
severely with readings of 180/120 or greater. 
appreciate and then
make them sit. And write
the name of topic on
blackboard.
 
SR.NO. TIME CONTRIBUTORY LEARNING CONTENT TEACHING LEARNING AV AIDS
OBJECTIVES ACTIVITIES

2. 3 min Students reviews arterial blood pressure Student teacher reviews ppt
anatomy and 1. Systolic pressure: pressure at the height of anatomy and physiology
physiology related the pressure pulse. related to arterial blood
to arterial blood 2. Diastolic pressure: the lowest pressure pressure
pressure 3. Pulse pressure: the difference between
systolic and diastolic pressure
4. Mean arterial pressure: represents the
average pressure in the arterial system during
ventricular contraction and relaxation
5. arterial blood pressure Represents the
pressure of the blood as it moves through the
arterial system
6. Cardiac output = HR x SV
7. Vascular resistance
8.Mean arterial pressure = CO x VR
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OBJECTIVES ACTIVITIES

3. 2 min. Student defines  Extremely high blood pressure — a top Student teacher defines Transperency
hypertensive crisis. number (systolic pressure) of 180 millimeters hypertensive crisis by
of mercury (mm Hg) or higher or a bottom projecting transparency
number (diastolic pressure) of 120 mm Hg or and also repeat it from
higher — can damage blood vessels. The student and appreciate
blood vessels become inflamed and may leak that student and told
fluid or blood. As a result, the heart may not them to sit.
be able to pump blood effectively.

Definition of hypertensive crisis:

Severely elevated blood pressure (equal to or
greater than a systolic 180 or diastolic of 110
—sometimes termed malignant or accelerated
hypertension) is referred to as a "hypertensive
crisis"
.

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OBJECTIVES ACTIVITIES
4. 3 min. Student Identifies types of hypertensive crisis: Student teacher Flashcard
types of 1.hypertensive urgency differentiates between
hypertensive crisis. 2. hypertensive emergencies types of hypertensive
Hypertensive Hypertensive crisis by showing
urgency Emergencies flashcard.
1.blood pressure 1. blood pressure
is extremely is extremely
high, high,
2. not associated 2. associated
with acute or with damage to
progressive organs & life-
damage to threatening
target organs. complications.
(encephalopathy,
Acute LVF,
Pulmonary
edema)
 .

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OBJECTIVES ACTIVITIES
5. 2 min. Student enlist Causes of a hypertensive emergency include: Student teacher enlists Flannel board
causes of causes of hypertensive
 Forgetting to take your blood pressure
hypertensive crisis. crisis by showing chart.
medication

 Stroke

 Heart attack

 Heart failure

 Kidney failure

 Rupture of body's main artery (aorta)

 Interaction between medications

 Convulsions during pregnancy

(eclampsia)

Risk factors
 Male sex
 Black race.
 Cigarette smoking.
 Tobacco abuse.
  Oral contraceptive use.
 Low socioeco-nomic status.
Predisposing factors.
 Essential hypertension
 Reno vascular hypertension.
 Parenchymal renal diseases.
 Drug-induced causes.
 Head injuries.
 Central nervous system events.
 Vasculitis Collagen vascular disease.

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OBJECTIVES ACTIVITIES
6. 2 min. Student Describes pathophysiology of hypertensive crisis. Student teacher chart
pathophysiology of The exact mechanism of hypertensive crisis Describes
hypertensive crisis. is not known. pathophysiology of
The majority of patients have known hypertensive crisis
hypertension before the crisis, and the
sudden rise in BP is often related to the
underlying disease process

Sever hypertension due to endocrine

factors, pregnancy, drugs.

The pathophysiology humoral

vasoconstrictors

release systemic vascular resistance

increases

severe elevations of BP

endothelial injury, fibrinoid necrosis of the

arterioles
 deposition of platelets and fibrin,
a breakdown of the normal autoregulatory
function

ischemia

• RENIN ANGIOTENSIN
ALDOSTERON SYSTEM
• AUTOREGULAION
• SYMPATHETIC NERVOUS
SYSTEM
• ANTIDIURETIC HORMONE

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OBJECTIVES ACTIVITIES
7. 3 min. Students enlists clinical manifestations of hypertensive crisis: Student teacher enlists PPT
clinical Hypertensive crisis can be manifested by any the clinical
manifestations of of the following symptoms, depending on the manifestations of
hypertensive crisis. end-organ involved hypertensive crisis.
1.CNS compromise,
identified by headache, blurred vision
2. Change in mental status or coma
3. Chest pain.
4. shortness of breath.
5. Headache.
6. Blurred vision.
7.signs of altered mental status.
8. Focal neurologic signs.
9. Grade III or IV retinopathy.
10.– Pulse deficits.
11. Nausea & Vomiting
12.weight loss.
13. Anorexia.
14.Shortness of breath, chest pain.
15. Headache.
16.Blurred vision.
 17. Abdominal pain.
18. Patients with accelerated or malignant
hypertension often have oliguria.
se, identified
by the chest pain of an acute coronary
syndrome or aortic dissection

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SR.NO. TIME CONTRIBUTORY LEARNING CONTENT TEACHING LEARNING AV AIDS
OBJECTIVES ACTIVITIES

8. 4 min Students Performs Assessment and diagnosis of hypertensive Student teacher explain ppt
assessment and crisis. about assessment and
diagnosis of physical examination including diagnosis of hypertensive
hypertensive crisis.  assessment of bilateral blood crisis.
pressures,
 body mass index, and optic fundi;
 palpation and auscultation of carotid
arteries, femoral arteries, abdominal
aorta, thyroid, heart, lungs, abdomen
(for enlarged kidneys or distended
bladder), and extremities (for edema
and pulses);
 neurologic examination
Bedside investigation
 ECG
Lab investigation
 CBC
 RP
  Urine analysis
 Coag
 CE/ trop T
Radiological
 CXR
 CT scan (altered mental status)

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OBJECTIVES ACTIVITIES
8 5 min Students Explains Medical management of hypertensive crisis. Describe medical ppt
medical Goal of therapy is immediate, controlled management of
management of reduction in blood pressure. hypertensive crisis.
hypertensive crisis. Urgency : Out-patient
Oral medication
BP reduction 24-48 hours
Emergency : Patients are
treated in an ICU, where clinical
status and vital signs can
be constantly monitored with the aid of an
arterial line.
Intravenous
Immediate BP reduction < 25% within minutes
– 1 Hour 160/100 : 2-6 hours.
Attention is focused on the status of airway,
breathing, and circulation(ABCs).
Ancillary measures such as
intubation and dialysis are
instituted if necessary.
Medical therapy
A number of parenteral antihypertensive
medications are available to manage
Hypertensive emergencies.
Characteristics of an ideal agent
include
o Rapid onset.
o Cessation of action.
o A predictable dose-response
curve
o Minimal side effects.
Drugs used to treat hypertensive crisis:
1.Calcium channel blocker-
Clevidipine, nicardipine, nifedipine
Action.- They work by inhibiting movement of
calcium ion into cells of cardic and vascular
smooth muscles , which produces relaxation
of coronary muscles and dilates coronary
arteries slows SA & AV node conduction and
dilates peripheral arteries.

2. vasodilators
Nitoprusside, hydralazine
Action- it directly relaxes venous smooth
muscles resulting in reduction of cardiac
preload and afterload.
3. ACE (angiotensin converting enzyme)
inhibitors
Enalapril, ramipril
Action- It helps to dilate blood vessels to
improve amount of blood that heart pumps
and lowers blood pressure.
4. angiotensin II receptor blockers.
Omesartan, telmisarten
Action as like ACE inhibitors
5. diuretics
Furosemide
It helps to excrete the extra water and salts
through urine which ultimately lowering blood
pressure
SR.NO. TIME Contributory objectives LEARNING CONTENT TEACHING LEARNING AV AIDS
ACTIVITIES

6. beta-blockers
labetelol
Action- they block effect of sympathetic
nervous system on heart.

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OBJECTIVES ACTIVITIES
9 7 min. Student Describes goals Nursing management Student teacher Ppt
nursing - to lower BP to less than 140 mm Hg systolic describes nursing
management of and less than 90 mm Hg diastolic for most management.
hypertensive crisis. persons with hypertension (less than 130 mm
Hg systolic and less than 80 mm Hg diastolic
for those with diabetes mellitus and chronic
kidney disease).
 Obtain complete history to assess for
symptoms that indicate target organ
damage (whether other body systems
have been affected by the elevated
blood pressure).
 Ex: anginal pain; shortness of breath;
alterations in speech, vision, or
balance; nosebleeds; headaches;
dizziness; or nocturia. Pulse rate,
rhythm, and character of apical and
peripheral pulses.
 Lifestyle modifications are indicated
for all patients with prehypertension and
hypertension and include the following:
 Weight reduction. A weight loss
of 10 kg (22 lb) may decrease SBP by
approximately 5 to 20 mm Hg.
 Dietary Approaches to Stop
Hypertension (DASH) eating plan.
Involves eating several servings of
fish each week, eating plenty of
fruits and vegetables, increasing
fiber intake, and drinking a lot of
water. The DASH diet significantly
lowers BP.
 Restriction of dietary sodium to
less than 6 g of salt (NaCl) or less
than 2.4 g of sodium per day.
 This involves avoiding foods
known to be high in sodium (e.g.,
canned soups) and not adding salt in
the preparation of foods or at meals.
 Restriction of alcohol
 Regular aerobic physical
activity (e.g., brisk walking) at least
 30 minutes a day most days of the
week. Moderately intense activity
such as brisk walking, jogging, and
swimming can lower BP, promote
relaxation, and decrease or control
body weight.
 It is strongly recommended
that tobacco use be avoided.
 Stress can raise BP on a short-
term basis and has been implicated
in the development of hypertension.
Relaxation therapy, guided imagery,
and biofeedback may be useful in
helping patients manage stress, thus
decreasing BP.
Nursing Diagnosis:
1.Ineffective tissue perfusion related to
compromised blood flow secondary to severe
hypertension resulting in end-organ damage.
2. decreased cardiac output related to
increased vascular resistance and ventricular
hypertrophy.
3. activity intolerance related to generalized
weakness and imbalance between oxygen
demand and supply
4. acute pain related to increased cerebral
vascular pressure evidenced by headache.
SR.NO. TIME CONTRIBUTORY LEARNING CONTENT TEACHING LEARNING AV AIDS
OBJECTIVES ACTIVITIES
9 4 min Students Explains Health education Student teacher Explains ppt
discharge  Teaching about medications discharge instructions for
instructions for 1.Most common side effects of diuretics are client having
client having potassium depletion and orthostatic hypertensive crisis.
hypertensive crisis. hypotension.
2. The most common side-effects of different
antihypertensive drugs is orthostatic
hypotension
3. Take meds at regular basis
4. Assume sitting or lying position for few
minutes 5. Change position gradually
6. Avoid very warm bath, prolonged sitting or
standing .
8.Sit quietly for 5 minutes before the reading.
Sit comfortably with the forearm supported at
heart level on a firm surface, with both feet on
the ground; avoid talking during
measurement.
 Measuring and Monitor BP at home.
Assessment is based on the average of at least
two readings. (If two readings differ by more
 than 5 mm Hg, additional readings are taken
and an average reading is calculated from the
results.) Note: patients should be given a
written record of his or her blood pressure at
the screening.
Student explains COMPLICATIONS
complication of • SUBARACHNOID
hypertensive crisis HEMMORHAGE
• ARRYTHMIAS
• ANEURYSM
• STROKE
• HEART AND RENAL FAILURE
• DEATH

RESEARCH:

1.ACUTE HYPERTENSION: HYPERTENSIVE URGENCY AND HYPERTENSIVE EMERGENCY Bookmark this page 
Authors: Gregary D. Marhefka, MD
ABSTRACT: Acute hypertension—blood pressure greater than 180/120 mm Hg—can be classified as either hypertensive
urgency or hypertensive emergency. Hypertensive urgency has no associated target organ damage, whereas
hypertensive emergency can feature neurologic, aortic, cardiac, renal, hematologic, and/or pregnancy-related damage.
Little evidence-based research exists about treatment. Intravenous antihypertensive pharmacotherapy is indicated only for
hypertensive emergency, with the use of specific agents tailored to the type of organ damage. Several US and European
guidelines provide recommendations for the diagnosis and management of hypertensive urgency and hypertensive
emergency. This review summarizes what is known about managing hypertensive urgency and emergency, with an
emphasis on guideline-directed therapy.

2. Risk factors for hypertensive crisis: importance of out-patient blood pressure control
Author James E Tisdale Mike B Huang Steven Borzak, Published: 01 August 2004
Abstract
Objectives. The purpose of this study was to identify independent risk factors for development of hypertensive crisis.
Results. The average blood pressure during Emergency Department presentation in patients with hypertensive crisis was 197 ± 21/108
± 14 mmHg. Less successful out-patient systolic blood pressure control was an independent risk factor for hypertensive crisis [odds
ratio (OR) 1.30 (1.18–1.42), per 10 mmHg, P < 0.001]. Higher out-patient diastolic blood pressures [OR 1.21 (0.99–1.43 per 10
mmHg, P = 0.07] and history of heart failure [OR 3.48 (0.94–12.94), P = 0.06] trended towards independence as risk factors.
Conclusion. Less effective blood pressure control, based on out-patient systolic blood pressure measurements, is an independent risk
factor for an Emergency Department presentation due to hypertensive crisis.

3.Nursing management in hypertensive crises].

[Article in Spanish] Vázquez Robles M1.
Abstract

Arterial hypertension is the increase in systemic arterial pressure above the values considered normal according to the
age of the subject, referenced either to the systolic or diastolic pressure or to both. A diastolic arterial pressure above 120-
130 mmHg is called hypertensive crisis, and is classified for its therapeutic management in: Hypertensive emergency that
causes damage to target organs, i.e., brain, heart, and kidney, which require an immediate decrease in arterial pressure
through the use of i.v. applied medication, although not necessarily down to normal values, and Hypertensive urgency, in
which no acute damage is evidenced and treatment is focused on diminishing pressure values within the first 24 hours
using oral or sublingual medication. Both conditions require strict surveillance and nursing care starting with the correct
procedure to determine blood pressure.

4. Intravenous labetalol in the emergency treatment of hypertension. Vidt DG.

Abstract: Labetalol is a unique alpha- and beta-adrenergic-receptor blocking agent that has recently been approved for
the treatment of hypertensive emergencies and urgencies. This agent lowers peripheral vascular resistance by
vasodilatation with little or no effect on cardiac output. The method of administration of labetalol will be determined by the
particular hypertensive emergency. Rapid reduction in blood pressure within 5 minutes follows the administration of a
bolus injection of 1.0-2.0 mg/kg, whereas smaller minibolus injections of labetalol are associated with a more gradual
reduction in blood pressure.
5.Diagnostic and therapeutic approach to the hypertensive crisis.

[Article in English, Spanish] Arbe G1, Pastor I2, Franco J3.

Abstract : High blood pressure is a problem with elevated prevalence in the world population. The acute forms of
presentation are "hypertensive crises," which represent a frequent cause for emergency room and primary care
consultations. Hypertensive crises are divided into hypertensiveemergencies and hypertensive urgencies, depending on
whether or not there is acute damage to the target organ, respectively. Each situation has a different prognosis and
treatment. More specifically, hypertensive emergencies are potentially serious and usually require rapid reductions in blood
pressure, whereas hypertensive urgencies can be treated as outpatients by reducing blood pressure in hours or days. A
significant number of patients who consult medical professionals regarding a hypertensive crisis do not have a prior
diagnosis of hypertension; therefore, it is important to periodically monitor blood pressure levels in the community.
SR.NO. TIME CONTRIBUTORY LEARNING CONTENT TEACHING LEARNING AV AIDS
OBJECTIVES ACTIVITIES
1 3 min Summarization In this seminar, there is anatomy and Student teacher ppt
physiology related to arterial pressure, summarizes topic.
hypertensive crisis- definition, causes,
pathophysiology, clinical manifestations,
assessment, management in medical and
nursing areas and also health education.
2. 2 min Recapitulation All the drugs mentioned below are used in
hypertensive emergencies except:
A. Nitroprusside B. NTG C. Nifedipine D. Esmolol

3. 1 min Conclusion Here I m concluding the topic that will help all
in clinicals with achievement of estimated
objectives
1.Criteria to diagnose hypertension emergency
4. 4 min assignment
depends on all except:
A. Severity of BP
B. Organ damage
C. Rate of increase BP
D. All of the above

2. Hypertension urgencies require:

A. Admission to ICU
B. Management in ER
 C. BP reduction achieved gradually
D. Use of parenteral preparations

5. 1 min bibliography 1. Black J.M., 2009,medical surgical nursing,

8th edition, published by Elsevier.
2. Smeltzar s. c., Bare B.G. , Hinkle J. L.,
Cheever K.H. , 2010, Brunner and Suddharth's
medical surgical nursing, 12th edition,
published by wolter.
3. Roth S.K., 2013, 1ST edition, nursing drug
reference, published by elsvier
4.Sole; Moseley; 2012, introduction to critical
care nursing, 6th edition, published by elavier
health sciences.
5. Chulay M. Burns S., 2003, AACN Essentials
of critical care nursing, 2nd edition, published
by McCaan.
6. www.ncbi.nlm.nih
6. pubmed.in