View
218
Download
1
Category
Preview:
Citation preview
FOCUS ON HYPERTENSI
ON
HYPERTENSIONDEFINITION
Persistent elevation of Systolic blood pressure ≥140 mm Hg or Diastolic blood pressure ≥90 mm Hg or Current use of antihypertensive medication(s)
PREHYPERTENSIONDEFINITION
Systolic blood pressure:120–139 mm Hg
Or
Diastolic blood pressure:80–89 mm Hg
FACTORS INFLUENCING BLOOD PRESSURE (BP)
Blood Pressure
=
CardiacOutput
xSystemic VascularResistance
FACTORS INFLUENCING BP
HYPERTENSION CLASSIFICATIONS Primary hypertension
Also called idiopathic or essential Increased blood pressure without an
identified causeCovers 90-95% of all cases of HTN
Secondary hypertension Increased blood pressure with a specific
cause that can be identified and corrected
CAUSES OF SECONDARY HTN Cirrhosis Narrowing of the aorta Endocrine disorders Medications Neurologic disorders Pregnancy induced HTN Renal disease Sleep apnea
BLOOD PRESSURE CLASSIFICATION
Category SBP (mm Hg)
DBP (mm Hg)
Normal < 120 and < 80
Prehypertension 120–139 or 80–89
Stage 1 140–159 or 90–99
Stage 2 > 160 or > 100
HYPERTENSION For persons over age 50, SBP is more
important than DBP as a CVD risk factor
Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN
RISK FACTORS FOR PRIMARY HYPERTENSION
Age Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress
HYPERTENSIONCLINICAL MANIFESTATIONS
Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs
HYPERTENSIONCLINICAL MANIFESTATIONS
Symptoms are often secondary to target organ disease and can include Fatigue, reduced activity toleranceDizzinessPalpitations, anginaDyspnea
HYPERTENSIONCOMPLICATIONS
Target organ diseases occur most frequently in theHeartBrainPeripheral vasculature KidneyEyes
HYPERTENSIONCOMPLICATIONS Hypertensive
heart diseaseCoronary artery
diseaseLeft ventricular
hypertrophyHeart failure
Fig. 33-3: Top, normal heart; Bottom, left ventricular hypertrophy
HYPERTENSIONCOMPLICATIONS
Cerebrovascular diseaseStroke
Peripheral vascular disease
Nephrosclerosis
Retinal damage
HYPERTENSIONDIAGNOSTIC STUDIES
History and physical examination
BP measurement in both armsUse arm with higher reading for subsequent
measurementsBP highest in early morning, lowest at night
HYPERTENSIONOFFICE BP MEASUREMENT
Use auscultatory method with a properly calibrated instrument
Patient should be seated quietly for 5 min in a chair, feet on the floor, and arm supported at heart level
Appropriate-sized cuff is necessary to ensure accurate reading
At least two measurements should be obtained
The correct technique for blood pressure measurements includes
a) Always taking the blood pressure in both arms
b) Releasing the pressure in the cuff at a rate of 1 mm Hg per second
c) Inflating the cuff 5 mm Hg higher than the expected systolic pressure
d) Taking additional readings if the first two readings differ more than 10 mm Hg
HYPERTENSIONDIAGNOSTIC STUDIES
Urinalysis, creatinine clearance Serum electrolytes, glucose BUN and serum creatinine Serum lipid profile ECG Echocardiogram
HYPERTENSIONDIAGNOSTIC STUDIES
“White coat” phenomenon may precipitate the need for ambulatory blood pressure monitoring (ABPM)Uses a noninvasive, fully automated
system that measures BP at preset intervals over a 24-hour period
TREATMENT ALGORITHM FOR HYPERTENSION
HYPERTENSION COLLABORATIVE CARE Overall goals
Control blood pressureReduce CVD risk factors
Strategies for adherence to regimensEmpathy increases patient trust,
motivation, and adherence to therapyConsider patient’s cultural beliefs and
individual attitudes in formulating treatment goals
BENEFITS OF LOWERING BP
Average Percent Reduction
Stroke incidence 35%–40%Myocardial infarction 20%–25%Heart failure 50%
HYPERTENSIONCOLLABORATIVE CARE
Lifestyle modificationsWeight reduction:
Weight loss of 10 kg (22 lb) may decrease SBP by ~ 5 to 20 mm Hg
Dietary Approaches to Stop Hypertension (DASH) Diet Low sodium
<2.4 g of sodium/day Low fat Limited starchy foods Increased vegetable and fruit intake
HYPERTENSIONCOLLABORATIVE CARE
Lifestyle modificationsModeration of alcohol consumption:
Men: no more than 2 drinks/day Women: no more than 1 drink/day
Physical activity: Regular physical (aerobic) activity, at least
30 minutes, most days of the week
Avoidance of tobacco products
Stress management
HYPERTENSIONCOLLABORATIVE CARE Drug therapy:
Primary actions of drugs to treat hypertension Reduce SVR Reduce volume of circulating blood
Classifications of drugs used to treat HTN Diuretics Adrenergic inhibitors Direct vasodilators Angiotensin inhibitors Calcium channel blockers
HYPERTENSIONCOLLABORATIVE CARE
Diuretics Inhibit NaCl reabsorption in the tubules Increases excretion of Na and ClPotassium-sparing diuretics reduce excretion of
K+Types:
Thiazide diuretics: hydrochlorothiazide (HydroDiuril), metolazone (Zaroxolyn)
Loop Diuretics: bumetanide (Bumex) furosemide (Lasix), torsemide
(Demadex) Potassium-sparing diuretics:
triamterene (Dyrenium) Aldosterone Receptor Blockers:
spironolactone (Aldactone)
HYPERTENSIONCOLLABORATIVE CARE What will you monitor in patients taking
diuretics? I & ODaily WeightElectrolyte abnormalities
Potassium Sodium
BP Orthostatic hypotension
Ototoxicity (Lasix)Dizziness, vertigo
HYPERTENSIONCOLLABORATIVE CARE Adrenergic inhibitors
Central-Acting α-1 Adrenergic Antagonists Reduce sympathetic outflow from CNS Reduces peripheral sympathetic tone,
produces vasodilation, decreases SVR and BP Types:
Clonidine (Catapress)Methyldopa (Aldomet)
HYPERTENSIONCOLLABORATIVE CARE Adrenergic inhibitors
α-1 Adrenergic Blockers Block α-1 adrenergic effects, producing peripheral
vasodilation (decreases SVR and BP) Types:
Doxazosin (Cardura), Prozosin (Minipress), Terazosin (Hytrin)
β-Adrenergic Blockers Decrease CO and reduce vasoconstrictor tone Types:
Atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal)
HYPERTENSIONCOLLABORATIVE CARE What will you monitor in patients taking
Adrenergic-Blockers?Dry mouth
Central-Acting α-1 Adrenergic AntagonistsBP
Orthostatic hypotensionRetention of salt and water
α-1 adrenergic blockersBronchospasm
β-Adrenergic BlockersBradycardia
β-Adrenergic Blockers
HYPERTENSIONCOLLABORATIVE CARE
Direct vasodilators Reduce SVR and BP by arterial vasodilation Types:
Hydralazine (Apresoline), nitroglycerin (Tridil), sodium nitroprusside (Nipride)
What will you monitor for? BP Tachycardia Flushing Palpitations Dizziness Angina Headache
HYPERTENSIONCOLLABORATIVE CARE
Angiotensin inhibitors Angiotensin-Converting Enzyme (ACE)
Inhibitors Reduce conversion of Angiotensin I to
angiotensin II, prevent vasoconstriction Types: captopril (Capoten), enalapril (vasotec),
lisinopril (Prinivil)
Angiotensin II Receptor Blockers Prevent action of angiotensin II and produce
vasodilation and increased salt and water excretion Types: irbesartan (Avapro), valsartan (Diovan)
HYPERTENSIONCOLLABORATIVE CARE What will you monitor?
Angiotensin-Converting Enzyme (ACE) Inhibitors BP Dizziness Loss of taste Hyperkalemia ARF
Angiotensin II Receptor Blockers Hyperkalemia Decreased RF
HYPERTENSIONCOLLABORATIVE CARE
Calcium channel blockers Block movement of extracellular calcium into
cells, causing vasodilation and decreased HR, contractility, and SVR
Types: Amlodipine (Norvasc), diltiazem (Cardizem),
nifedipine (Procardia), verapamil (Calan)
What will you monitor?BPBradycardiaHeadache, dizziness, peripheral edema, flushing
HYPERTENSIONCOLLABORATIVE CARE
Drug therapy and patient teaching Identify, report, and minimize side effects
Orthostatic hypotension Sexual dysfunction Dry mouth Frequent urination
HYPERTENSIONNURSING MANAGEMENT
Nursing AssessmentSubjective data
Past health history CV, renal, thyroid disease, DM, obesity
Medications Prescription and OTC
Functional health patterns Family history Diet Activity level Stress
Objective data Target organ damage
Peripheral pulses, abnormal heart sounds, BP >140/90
HYPERTENSIONNURSING MANAGEMENT
Nursing Diagnoses Ineffective health maintenance r/t lack of
knowledge
Anxiety r/t management regimen or lifestyle changes
Sexual dysfunction r/t medication side effects
Ineffective therapeutic regimen management r/t lack of knowledge, side effects of medications, return of blood pressure to normal while on medications
Ineffective tissue perfusion r/t complications of HTN (cerebral, CV, renal, retinal)
HYPERTENSIONNURSING MANAGEMENT Collaborative problems
Potential complications: Adverse effects from antihypertensive
therapy (hypokalemia) Hypertensive crisis Stroke Coronary artery disease (CAD) Myocardial infarction
HYPERTENSIVE CRISIS Severe, abrupt increase in DBP
defined as DBP >140 mm Hg
Rate of increase in BP is more important than the absolute value
Often occurs in patients with a history of HTN who have failed to comply with medications or who have been undermedicated
HYPERTENSIVE CRISIS Hypertensive Emergency
Develops within hours to days BP > 180/120 mm Hg Acute target organ damage May precipitate:
Hypertensive encephalopathy, cerebral hemorrhage
Acute renal failure Myocardial infarction Heart failure with pulmonary edema
Hyptertensive Urgency Develops within days to weeks No clinical evidence of target organ damage
HYPERTENSIVE CRISISCLINICAL MANIFESTATIONS
Hypertensive EmergencyHypertensive encephalopathy
Sudden rise in BP associated with HA, N/V, seizures, confusion, coma
May also have blurred vision and transient blindness Due to increased cerebral capillary permeability
leading to cerebral edema and disruption in cerebral function
Renal insufficiency
CV decompensation Unstable angina MI Pulmonary edema
HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Hospitalization
IV drug therapy Sodium nitroprusside (Nipride) – MOST EFFECTIVE
Titrated to mean arterial pressure
MAP =(SBP + 2 DBP)
3
HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Nursing Interventions
Monitor BP and HR every 3-5 minutesTitrate med based on MAPDO NOT DECREASE BP TO QUICKLY – may
cause stroke, MIContinual ECG monitoringHourly UOStrict BPNeurologic checks
LOC, pupil checks, movement and strength of extremities
CV and Respiratory assessment pulmonary edema, HF, angina
HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Hypertensive Urgency
Managed with oral medications Difficult to regulate drugs Need follow-up within 24 hours
May not need hospitalizationNursing Interventions
Provide quiet environment Encourage patient to verbalize concerns Answer questions Eliminate stimuli Determine cause Education to avoid future crises
HYPERTENSIONNURSING MANAGEMENT Planning: Patient will
Achieve and maintain the individually determined goal BP
Understand, accept, and implement the therapeutic plan
Experience minimal or no unpleasant side effects of therapy
Be confident of ability to manage and cope with this condition
HYPERTENSIONNURSING MANAGEMENT
Nursing ImplementationHealth Promotion
Individual patient evaluation Risk factors Routine BP Health assessment Weight patterns Family history
Blood pressure measurement Screening programs Cardiovascular risk factor modification
Modifiable: HTN, DM, obesity, tobacco cessation, physical inactivity
HYPERTENSIONNURSING MANAGEMENT
Nursing ImplementationAmbulatory and Home Care Patient and family teaching includes
Nutritional therapy Drug therapy Physical activity
30 minutes/day most days of week Home monitoring of BP (if appropriate)
Rest 3-5 minutes prior to taking BP No smoking, exercise or caffeine 30 minutes prior Take daily and record in log
Tobacco cessation (if applicable)
HYPERTENSIONNURSING MANAGEMENT
Nursing Evaluation Patient will
Achieve and maintain goal BP as defined for the individual
Understand, accept, and implement the therapeutic plan
Experience minimal or no unpleasant side effects of therapy
HYPERTENSION IN OLDER PERSONS Isolated systolic hypertension (ISH) is the most
common form of hypertension in individuals age >50
The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age >65) normotensive men and women
Why? Loss of elasticity, increased PVR, blunting of
baroreceptors, decreased renal function, decreased renin production
HYPERTENSION IN OLDER PERSONS
Older adults are more likely to have “white coat” hypertension
Often a wide gap between the first Korotkoff sound and subsequent beats called the auscultatory gap
Failure to inflate the cuff high enough may result in seriously underestimating the SBP Assess disappearance of pulse upon inflation of cuff
HYPERTENSION IN OLDER PERSONS
Older adults have varying degrees of impaired baroreceptor reflex mechanisms
Consequently, orthostatic hypotension occurs often especially in patients with ISH Most commonly associated with volume depletion
or decreased renal or hepatic function
HYPERTENSIONCULTURAL AND ETHNIC DISPARITIES
In general, treatment similar for all demographic and ethnic groups
Prevalence and severity of HTN increased in African Americans
HYPERTENSIONCULTURAL AND ETHNIC DISPARITIES
Mexican Americans are less likely to receive treatment for hypertension than whites and African Americans
Mexican Americans and Native Americans have lower rates of BP pressure control than whites and African Americans
Recommended