Chapter 27

Assessment and Management of Patients

with Hypertension

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Hypertension

• High blood pressure

• Most common chronic disease among U.S.
adults
• Defined by the American College of Cardiology
(ACC)/American Heart Association (AHA) as a
systolic blood pressure (SBP) of 130 mm Hg or
higher or a diastolic blood pressure (DBP) of 80
mm Hg or higher

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Classification of Blood Pressure
for Adults Age 18 Years and Older

• Normal Blood Pressure

• Systolic <120 mm Hg and Diastolic <80 mm Hg
• Elevated Blood Pressure
• Systolic 120–129 mm Hg and Diastolic <80 mm Hg
• Stage 1 hypertension
• Systolic 130–129 mm Hg or Diastolic 80–89 mm Hg
• Stage 2 hypertension
• Systolic >140 mm Hg or Diastolic >90 mm Hg

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Incidence of Hypertension—“The
Silent Killer”

• Primary hypertension: essential

• 90–95% of patients; unidentifiable cause
• Secondary hypertension
• 5–10% of patients; renal disease, sleep apnea,
pregnancy related
• About 33% of the adult population of the
United States has hypertension
• About 46% do not have it under control
• Highest prevalence in African Americans

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Manifestations of Hypertension

• Usually no symptoms other than elevated

blood pressure
• Symptoms related to organ damage are seen
late and are serious
• Retinal and other eye changes
• Renal damage
• Myocardial infarction
• Cardiac hypertrophy
• Stroke

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Pathophysiologic Processes

• BP= CO x Peripheral Resistance

• (CO= SV x HR)
• Can result from increases in cardiac output,
peripheral resistance, or both
• Must also be a problem with the body’s control system
• Dysfunction of the autonomic nervous system
• Increased renin–angiotensin–aldosterone system
• Resistance to insulin action
• Activation of the immune system

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Measuring Blood Pressure

• Correct arm cuff size

• Sit quietly with arm at the level of the heart
• Confirmation of diagnosis by average of two
blood pressure readings
• Do not cross legs

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Alternative Manifestations

• Masked hypertension
• Blood pressure that is suggestive of hypertension
that is paradoxically normal in health care settings
• White coat hypertension
• Hypertensive blood pressure readings in the health
care setting that is paradoxically normal ranges in
other settings

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Abnormal Physical Examination
Findings

• Absent or weak pulses

• Additional cardiac sounds
• Retinal hemorrhages
• Distended jugular veins
• Renal artery bruit

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Major Risk Factors

• Smoking
• Obesity
• Physical inactivity
• Dyslipidemia
• Diabetes mellitus
• Microalbuminuria or GFR <60 mL/min
• Older age
• Family history

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Patient Assessment

• History and physical examination

• Retinal exam
• Laboratory tests
• Urinalysis
• Blood chemistry
• ECG

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Medical Management #1

• Maintain blood pressure

• <130/80 mm Hg
• Lifestyle modifications
• Weight reduction
• DASH diet, decreased sodium intake
• Regular physical activity
• Reduced alcohol consumption
• Smoking cessation

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Medical Management #2

• Pharmacologic therapy
• Decrease peripheral resistance, blood volume
• Decrease strength and rate of myocardial
contraction
• Diuretics, beta-blockers, alpha1-blockers,
combined alpha- and beta-blockers,
vasodilators, ACE inhibitors, ARBs, calcium
channel blockers, dihydropyridines, and direct
renin inhibitors

Copyright © 2022 Wolters Kluwer · All Rights Reserved

First line antihypertensives
• Diuretics (Thiazide/ Thiazide type)
• Decreases fluid volume
• S/E- Dry mouth, orthostatic hypotension, electrolyte imbalance
• Ex.) Hydrochlorothiazide
• Ace Inhibitors
• Inhibits conversion of angiotensin I to angiotensin II
• S/E- Hyperkalemia, cough, angioedema
• Ex.) Lisinopril, captopril,benazepril
• ARBS
• Blocks effects of angiotensin II
• S/E- hyperkalemia
• Ex.) Losartan, valsartan, Olmesartan

Copyright © 2022 Wolters Kluwer · All Rights Reserved

First line antihypertensives

• Calcium channel blockers

• Dihydropyridines- Inhibits calcium influx,
vasodilation and decreases cardiac workload
• Nondihydropyridines- Inhibits calcium influx,
reduces cardiac afterload
• S/E- Edema, dizziness, cardiac complaints
• Ex.) Amlodipine, nifedipine (Dihydropyridines)
• Ex.) Diltiazem, verapamil (Nondihydropyridines)

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Second line antihypertensives

• Loop diuretics
• Blocks reabsorption of sodium and water
• S/E- Electrolyte depletion, hypokalemia
• Ex.) Furosemide, torsemide
• Potassium sparing diuretics
• Blocks reabsorption of sodium, but spares potassium
• S/E- Hyperkalemia, GI symptoms
• Ex.) amiloride, triamterene
• Aldosterone antagonist diuretics
• Inhibits aldosterone binding
• S/E- Lethargy, dizziness, Gi Symptoms
• Ex.) eplerenone, spironolactone

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Second line antihypertensives

• Beta Blockers
• Blocks Beta-1 adrenergic receptors of the sympathetic nervous
system
• Do not discontinue, contraindicated in asthma
• Ex.) Metoprolol. Timolol, carvedilol
• Direct Vasodilators
• Decreases peripheral resistance by direct vasodilation
• S/E- Sodium and fluid retention, tachycardia, flushing
• Ex.) Hydralazine, minoxidil
• Direct renin inhibitors
• Prevents renin conversion to angiotensin I
• S/E- Hyperkalemia, very long acting, multiple drug interactions
• Ex.) Aliskiren

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Question #1

A nurse explains that a patient must never take

more than one type of antihypertensive
medication at a time. Is this true or false?
A. True
B. False

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Answer to Question #1

B. False

Rationale: For patients with hypertension,

especially those with severe hypertension, there
will often be multiple antihypertensives
prescribed for maximum effect and could be
taken at similar times depending on the
medication. Be mindful for drug interactions and
contraindications of various specific
antihypertensives.

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Potential Complications

• Left ventricular hypertrophy

• Myocardial infarction
• Heart failure
• Transient ischemic attack (TIA)
• Cerebrovascular disease (CVA, stroke, or brain
attack)
• Renal insufficiency and chronic kidney disease
• Retinal hemorrhage

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Nursing diagnosis

• Decreased cardiac output related to increased vascular

resistance
• Risk for ineffective tissue perfusion related to
myocardial damage
• Lack of knowledge regarding the relation between the
treatment regimen and control of the disease process
• Impaired ability to manage regime as evidenced by
difficulty adhering to prescribed regimen (e.g., lifestyle
changes, antihypertensive medication prescriptions)

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Planning and Goals

• Understanding of the disease process and its

treatment
• Participation in a self-care program
• Absence of complications

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Interventions

• Support and educate the patient about the

treatment regimen
• Reinforce and support lifestyle changes
• Taking medications as prescribed
• Follow-up care
• Monitoring for potential complications

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Evaluation and Outcomes #1

• Reports knowledge of disease management

sufficient to maintain adequate tissue
perfusion
• Maintains blood pressure at less than 130/80 mm Hg
with lifestyle modifications, medications, or both
• Demonstrates no symptoms of angina, palpitations,
or vision changes
• Has stable BUN and serum creatinine levels
• Has palpable peripheral pulses

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Evaluation and Outcomes #2

• Effectively manages health program

• Adheres to the dietary regimen as prescribed:
reduces calorie, sodium, and fat intake; increases
fruit and vegetable intake
• Exercises regularly
• Takes medications as prescribed and reports side
effects
• Measures BP routinely
• Abstains from tobacco and excessive alcohol intake
• Keeps follow‐up appointments

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Evaluation and Outcomes #3

• Has no complications
• Reports no changes in vision; exhibits no retinal
damage on vision testing
• Maintains pulse rate and rhythm and respiratory
rate within normal ranges; reports no dyspnea or
edema
• Maintains urine output consistent with intake; has
renal function test results within normal range
• Demonstrates no motor, speech, or sensory deficits
• Reports no headaches, dizziness, weakness, changes
in gait, or falls

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Gerontologic Considerations

• Medication regimen can be difficult to remember

• Expense can be a challenge
• Monotherapy, if appropriate, may simplify the
medication regimen and make it less expensive
• Ensure that older adult patients understand the
regimen and can see and read instructions, open
medication containers, and get prescriptions
refilled
• Include family and caregivers in educational
program

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Question #2

The nurse is preparing an education plan for a patient

newly diagnosed with hypertension. Which of the
following should be included in the education plan?
A. Engage in regular aerobic physical activity such as
brisk walking (at least 30 min/day most days of the
week)
B. Eliminate alcoholic beverages from the diet
C. Reduce sodium intake to no more than 3500 mg daily
D. Maintain a normal body weight with BMI between 18
and 30 kg/m2

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Answer to Question #2

A. Engage in regular aerobic physical activity such as brisk

walking (at least 30 min/day most days of the week).

Rationale: The nurse assists the patient to develop and

adhere to an appropriate exercise regimen (as described
above), because regular activity is a significant factor in
reducing blood pressure. Alcoholic beverages can be
consumed in moderation. Sodium should be reduced to no
more than 2300 mg, and the patient should maintain a
normal body weight with a BMI between 18.5 and 24.9
kg/m2

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Hypertensive Crises

• Hypertensive emergency
• Blood pressure >180/120 mm Hg with evidence of
damage to target organs
• Hypertensive urgency
• Blood pressure >180/120 mm Hg but no evidence of
immediate or progressive target organ damage

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Hypertensive Emergency

• Reduce blood pressure by no more than 25% in first hour

• Reduce to 160/100 mm Hg within 2 to 6 hours
• Then gradual reduction to normal 24 to 48 hours of
treatment
• Exceptions are ischemic stroke and aortic dissection
• Medications
• IV vasodilators: sodium nitroprusside, nicardipine,
fenoldopam mesylate, enalaprilat, nitroglycerin
• Need very frequent monitoring of BP and cardiovascular
status
• Monitor patient and frequent assessments

Copyright © 2022 Wolters Kluwer · All Rights Reserved

Hypertensive Urgency

• Oral agents can be administered with the goal of

normalizing blood pressure within 24 to 48 hours
• Fast-acting oral agents:
• Beta-adrenergic blocker—labetalol
• Angiotensin-converting enzyme inhibitor—captopril
• Alpha2-agonist—clonidine
• Patient requires close monitoring of blood pressure
and cardiovascular status
• Assess for potential evidence of target organ
damage

Copyright © 2022 Wolters Kluwer · All Rights Reserved