Hypertension  Stress

 It is identified as the leading risk  Sleep apnea

factor for premature death, disability,
and overall disease burden Pathophysiology
worldwide because it may lead to Blood pressure is the product of cardiac output
cardiovascular disease (CVD), multiplied by peripheral resistance. Cardiac
stroke, and chronic kidney disease output is the product of the heart rate multiplied
(CKD) when not appropriately by the stroke volume. Each time the heart
treated contracts, pressure is transferred from the
 Hypertension is categorized as either contraction of the myocardium to the blood and
primary hypertension or secondary then pressure is exerted by the blood as it
hypertension. flows through the blood vessels. Hypertension
 Primary hypertension (also called can result from increases in cardiac output,
essential hypertension) is diagnosed increases in peripheral resistance (constriction
when there is no identifiable cause of the blood vessels), or both. Increases in
(Alexander, 2019). cardiac output are often related to an
 Secondary hypertension is defined expansion in vascular volume. Although no
as high blood pressure from an precise cause can be identified for most cases
identifiable underlying cause. of hypertension, it is understood that
Screening for secondary hypertension is a multifactorial condition.
hypertension is indicated for new- Because hypertension can be a sign, it is most
onset, poorly controlled likely to have many causes, just as fever has
hypertension, in hypertension many causes (Norris, 2019). For hypertension
resistant to treatment with three or to occur there must be a change in one or
more drugs, with hypertension of an more factors affecting peripheral resistance or
abrupt onset, or in patients younger cardiac output. In addition, there must also be
than 30 years of age a problem with the body’s control systems that
monitor or regulate pressure.
Risk factors
 Advancing adult age Common Causes of Secondary
 African American Hypertension
 Chronic kidney disease  Chronic kidney disease
 Diabetes Drinking too much alcohol (i.e.,  Coarctation of the aorta
more than two drinks per day for men  Cushing’s syndrome
and more than one drink per day for  Hyperaldosteronism (primary or
women) secondary)
 Family history  Hyperparathyroidism
 Gender-related:  Hypo- or hyperthyroidism
o Men have greater risk until 64 y  Medication abuse (nonsteroidal anti-
of age inflammatory drugs [NSAIDs]) or
o Women have greater risk at 65 y substance abuse disorder (alcohol,
of age and later cocaine, amphetamines)
 Hypercholesterolemia  Obstructive sleep apnea
 Overweight/obesity  Pheochromocytoma
 Poor diet habits, particularly if it includes  Preeclampsia
too much salt, as well as limited intake  Polycystic kidney disease
of vegetables, fiber, fish fats, and  Prostatism
potassium Sedentary lifestyle  Renal artery stenosis
 Use of tobacco and nicotine products
(e.g., cigarettes, e-cigarettes) and Clinical Manifestations
exposure to secondhand smoke
  Retinal changes such as hemorrhages,
exudates (fluid accumulation), arteriolar
narrowing, and cotton-wool spots (small
infarctions) may occur.
 In severe hypertension, papilledema
(swelling of the optic disc) may be seen
(Weber & Kelley, 2018).
 Coronary artery disease with angina and
myocardial infarction (MI) are common
consequences of hypertension.
 LVH occurs in response to the increased
workload placed on the ventricle as it
contracts against higher systemic
pressure.
 Pathologic changes in the kidneys
(indicated by 2387 increased blood urea
nitrogen [BUN] and serum creatinine
levels) may manifest as nocturia.
 Cerebrovascular involvement may lead
to a transient ischemic attack (TIA) or
stroke, manifested by alterations in
vision or speech, dizziness, weakness, a
sudden fall, or transient or permanent
hemiplegia (paralysis on one side).
 Cerebral infarctions account for most of
the strokes in patients with hypertension
(Norris, 2019).
Assessment and Diagnostic
Findings
 The first step of diagnosis is an
accurate blood pressure
measurement. It is important to use an
average of at least two blood pressure
readings on at least two occasions to
confirm the diagnosis of hypertension for
most patients. The notable exception is
when a patient’s average BP is greater
than or equal to 160/100 mm Hg,
confirmed by at least two accurate
readings on one occasion
Medical Management
 All patients who report lifestyle choices
that may put them at risk for
hypertension should be counseled to
adopt lifestyle changes, as
appropriate. These lifestyle changes
could include weight loss, dietary
changes, physical activity
modifications, decreased alcohol
consumption, and smoking
cessation. In particular, the Dietary
Approach to Stop Hypertension
(DASH) diet has been one of the most
effective diets in lowering BP; if used in
conjunction with weight loss, this diet
can lower SBP by 11 to 16 mm Hg
(Campbell, 2017) In addition to this
dietary advice, patients should be
counseled to incorporate a low sodium
(less than 2 g/day), high potassium
(3500 to 5000 mg/day) diet; this dietary
combination is more effective than
following either a lone low sodium or
high potassium diet (Perez & Chang,
2014). A high potassium diet must be
 The recommended treatment for
patients with elevated blood pressure
but who are not diagnosed with
hypertension is lifestyle changes, not
antihypertensive medications, with
follow-up in 3 to 6 months, as noted
previously, to not only reevaluate the
blood pressure but to see if it has
responded positively to lifestyle
modifications avoided in patients with
CKD, however.
 The primary provider is advised by the
ACC/AHA Guidelines (Whelton et al.,
2017) to screen the patient diagnosed
with Stage 1 hypertension for risk of
having adverse cardiac events (e.g.,
stroke, MI) within the next 10 years by
using the online ASCVD Risk
Estimator Plus. This tool is published
by the ACC and is free to use (links to
this tool are provided in the Resources
section at the end of this chapter). This
tool screens patients based on
factors that include blood pressure
readings, age, gender, lipid panel
results, use of medications, smoking
status, and whether or not they have
concomitant diabetes.
 progress or identify and treat any
complications of disease or therapy.

Pharmacologic Therapy
 Research findings have demonstrated
that appropriately prescribing
antihypertensive pharmacologic agents
lowers BP, and reduces the risk of CVD,
cerebrovascular disease, and death
(Whelton et al., 2017). Many classes of
medications are available for
hypertension management
 The medications that have been shown
to prevent CVD are recommended as
first line agents for most patients. This
first-line group includes thiazide or
thiazide type diuretics, angiotensin-
converting enzyme (ACE) inhibitors,
angiotensin receptor blockers (ARBs),
and calcium channel blockers (CCBs).

Nursing Management
 The objective of nursing care for
patients with hypertension focuses on
lowering and controlling the blood
pressure without adverse effects or
undue cost. To achieve these goals, the
nurse’s role is to support and educate
the patient about the treatment regimen,
including making lifestyle changes,
taking medications as prescribed, and
scheduling regular appointments with
the patient’s primary provider to monitor