Assessment and Management of Patients With Hypertension

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. Incidence is greater in southeastern U.S. and among African-Americans.

Factors Involved in the Control of Blood Pressure

Common Peripheral Vascular Primary Hypertension – Pathophysiologic causes Sympathetic nervous system overstimulation Alterations of the renin-angiotensin-aldosterone system Chemical mediators of vasomotor tone and blood volume Interaction between insulin resistance, hyperinsulinemia and endothelial function

Common Peripheral Vascular

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

Common Peripheral Vascular – Manifestations Initially asymptomatic Headache, confusion Nocturia Nausea and vomiting Visual disturbances – Complications Cardiovascular Neurologic Renal systems.

Common Peripheral Vascular Secondary Hypertension – Related to a specific underlying cause Kidney disease Coarctation of the aorta Endocrine disorders Neurologic disorders Drug use Pregnancy

Major Risk Factors Hypertension Smoking Obesity Physical inactivity Dyslipedemia Diabetes mellitus Microalbuminuria or GFR < 60 Older age Family history

Patient Assessment History and Physical Laboratory tests – Urinalysis – Blood chemistry – Cholesterol levels ECG

JNC 7 Treatment Algorithm Refer to fig. 32-2

JNC 7 Treatment Algorithm

Persons with diabetes mellitus or chronic renal disease as evidenced by a reduced GFR or an elevated serum creatinine have a lower goal pressure of 130/80 (JNC 7).

Lifestyle Modifications Weight loss Reduced alcohol intake Educed sodium intake Regular physical activity Diet: high in fruits, vegetables, and low-fat dairy DASH diet

Medication 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.

Medication Therapy for Hypertension Diuretic and related drugs – Thiazide diuretics – Loop diuretics – Potassium sparing diuretics – Aldosterone receptors blockers Central alpha 2 -agonists and other centrally acting drugs Beta-blockers Beta-blockers with intrinsic sympathomimetic activity Alpha and beta blockers

Medication Therapy for Hypertension (continued) Vasodilators Angiotensin-converting enzyme (ACE) inhibitors Angiotenisin II antagonists Calcium channel blockers

Recommendations for Follow-up Based on Initial Blood Pressure Readings

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

Goals: Patient understanding of disease process Patient understanding of treatment regimen Patient participation in self-care Absence of complications

Nursing Diagnoses 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

Interventions 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

Gerontologic Considerations Noncompliance Include family Understanding of therapeutic regimen – Reading instructions – Monotherapy

Hypertensive Crises Hypertensive emergency – Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs Hypertensive urgency – Blood pressure is very high but no evidence of immediate or progressive target organ damage

Hypertensive Emergency 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.

Hypertensive Urgency Patient requires close monitoring of blood pressure and cardiovascular status. Assess for potential evidence of target organ damage. Medications – Fast-acting oral agents: beta adrenergic blocker— labetalol; angiotensin-converting enzyme inhibitor— captopril; or alpha 2 -agonist—clonidine