Focus on Hypertension

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


Urinalysis, creatinine clearance Serum electrolytes, glucose BUN and serum creatinine Serum lipid profile ECG Echocardiogram


“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


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


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


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


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


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


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


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


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


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)


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

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Focus on Hypertension