Assessment and Management

of Patients With Hypertension

Adult Health Nursing 1
Blood Pressure
• Blood Pressure = Cardiac Output x Peripheral Resistance

• Cardiac Output = Heart Rate x Stroke Volume

Hypertension
• High blood pressure
• Defined by the Seventh Report of the Joint National Commission on
the Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (JNC 7) as a systolic pressure greater than 140 mm Hg and a
diastolic pressure greater than 90 mm Hg. based on the average of
two or more accurate blood pressure measurements taken during
two or more contacts with a health care provider
Classification of Blood Pressure for Adults Age
18 and Older
Incidence of Hypertension—
“The Silent Killer”
• Primary hypertension.
• Secondary hypertension.
• 28–31% of the adult population of the U.S. has
hypertension.
• 90–95% of this population with hypertension has
primary hypertension.
• In Jordan the prevalence is 33.8% among men and
29.4% among women
Primary: Essential Hypertension
• Cause of essential hypertension is unknown; however, there are
several areas of investigation:
• a. Hyperactivity of sympathetic vasoconstricting nerves.
• b. Presence of vasoactive substance released from the arterial
endothelial cells, which acts on smooth muscle, sensitizing it to
vasoconstriction.
• c. Increased cardiac output, followed by arteriole constriction.
• d. Excessive dietary sodium intake, sodium retention, insulin
resistance, and hyperinsulinemia play roles
Secondary hypertension
• 1- Renal pathology:
• a. Chronic kidney disease, congenital ,pyelonephritis, renal artery
stenosis, acute and chronic glomerulonephritis
• b. Reduced blood flow to kidney causes release of renin. Renin reacts
with a serum protein to form angiotensin I, which is converted to
angiotenin II through the action of angiotensin-converting enzyme in
the lungs, leading to vasoconstriction and increased salt and water
retention.
• 2. Stenosis of aorta—The kidneys release renin when they sense
hypotension.
3. Endocrine disturbances:
a. tumor of the adrenal gland that causes release of
epinephrine and norepinephrine and a rise in BP (extremely
rare).
b. Adrenal cortex tumors lead to an increase in aldosterone
secretion (hyperaldosteronism) and an elevated BP (rare).
c. Cushing’s syndrome leads to an increase in adrenocortical
steroids (causing sodium and fluid retention) and
hypertension.
d. Hyperthyroidism causes increased cardiac output.
4. Obstructive sleep apnea causes nocturnal
hypertension, which leads to sustained daytime
hypertension.
5. Prescription medications such as estrogens and
steroids (cause fluid retention), sympathomimetics
(cause vasoconstriction
Factors Involved in the Control of Blood
Pressure
Factors that Influence the Development of
Hypertension
• Increased sympathetic nervous system activity
• Increased reabsorption of sodium chloride and water by the
kidneys
• Increased activity of the rennin-angiotensin system
• Decreased vasodilatation
• Insulin resistance:(insulin has role in vessel wall decrease
relaxation by effect on secretion of nitric oxide)
Manifestations of Hypertension
• Usually NO symptoms other than elevated blood pressure
• Symptoms seen related to organ damage are seen late and
are serious
• Retinal and other eye changes
• Renal damage
• Myocardial infarction
• Cardiac hypertrophy
• Stroke
Major Risk Factors of Hypertension
• Smoking
• Obesity
• Physical inactivity
• High blood lipid
• Diabetes mellitus
• Microalbuminuria or GFR < 60
• Older age
• Family history
Patient Assessment
• History and Physical assessment
• Laboratory tests
• Urinalysis
• Blood chemistry: BUN, lipid, electrolytes
• ECG
Treatment
• Usually initial medication treatment is a thiazide diuretic.
• Low doses are initiated and the medication dosage is
increased gradually if blood pressure does not reach target
goal.
• Additional medications are added if needed.
• Multiple medications may be needed to control blood
pressure.
• Lifestyle changes initiated to control BP must be maintained.
Medications
• Diuretic and related drugs
• Thiazide diuretics
• Loop diuretics
• Potassium sparing diuretics
• Aldosterone receptors blockers
• Central alpha2-agonists and other centrally acting
drugs(inhibit norepinephrine)
• Beta-blockers
• Alpha and beta blockers
Medications
• Vasodilators
• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotenisin II antagonists
• Calcium channel blockers
Life style medication
• Weight loss
• Educed sodium intake
• Regular physical activity
• Diet: high in fruits, vegetables, and low-fat dairy
• DASH (dietary approach to stop hypertension) diet: is rich in
fruits, vegetables, whole grains, and low-fat dairy foods;
includes meat, fish, poultry, nuts and beans; and is limited in
sugar-sweetened foods and beverages, red meat, and added
fats
Complications of hypertension
Nursing History and Assessment
• History and risk factors
• Assess potential symptoms of target organ damage
• Angina, shortness of breath, altered speech, altered
vision, nosebleeds, headaches, dizziness, balance
problems, nocturia
• Cardiovascular assessment: apical and peripheral pulses
• Personal, social, and financial factors that will influence the
condition or its treatment
Nursing Diagnosis
• Knowledge deficit regarding the relation of the treatment
regimen and control of the disease process
• Noncompliance with therapeutic regimen related to side
effects of prescribed therapy
Nursing Planning
• Patient understanding of disease process
• Patient understanding of treatment regimen
• Patient participation in self-care
• Absence of complications
Nursing Intervenstions
• Patient teaching
• Support adherence to the treatment regimen
• Consultation/collaboration
• Follow-up care
• Emphasize control rather than cure
• Reinforce and support lifestyle changes
• A lifelong process
• Hypertensive emergency
• Blood pressure > 180/120 and must be lowered
immediately to prevent damage to target organs
Clinical manifestations
• Brain effects: a. Encephalopathy. b. Stroke. c. Progressive headache,
stupor, seizures.
• 2. Kidney effects: Decreased blood flow, vasoconstriction. Elevated
BUN. Increased plasma renin activity. Lowered urine-specific gravity.
Proteinuria. Renal failure.
• 3. Cardiac effects:
• a. Left-sided heart failure.
• b. Acute MI.
• c. Right-sided heart failure
Treatment
• Reduce BP 25% in first hour.
• Reduce to 160/100 over 6 hours.
• Then gradual reduction to normal over a period of days.
• Exceptions are ischemic stroke and aortic dissection.
• Medications
• IV vasodilators: sodium nitroprusside, nicardipine, fenodopam mesylate,
enalaprilat, nitrogylcerin
• Need very frequent monitoring of BP and cardiovascular status.