Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. (Relates to Chapter 33, “Nursing Management: Hypertension,” in the textbook)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Persistent elevation of Systolic blood pressure ≥140 mm Hg or Diastolic blood pressure ≥90 mm Hg or Current use of antihypertensive medication(s)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Systolic blood pressure: mm Hg OR  Diastolic blood pressure: mm Hg

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Blood Pressure Cardiac Output Systemic Vascular Resistance =x

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 33-1

Cardiac Heart rateHeart rate Inotropic stateInotropic state NeuralNeural HumoralHumoralCardiac Heart rateHeart rate Inotropic stateInotropic state NeuralNeural HumoralHumoral Cardiac Output Renal Fluid Volume Control Renin–angiotensinRenin–angiotensin AldosteroneAldosterone Atrial natriuretic factorAtrial natriuretic factor

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Fig. 33-2

Sympathetic Nervous System  -Adrenergic receptors  -Adrenergic receptors (vasoconstriction) (vasoconstriction)  -Adrenergic receptors  -Adrenergic receptors (vasodilation) (vasodilation) LocalRegulation Vasodilators Vasodilators Prostaglandins Prostaglandins EDRF EDRF Vasoconstrictors Vasoconstrictors Endothelin Endothelin SystemicVascularResistance Humoral VasoconstrictorsVasoconstrictors Angiotensin Angiotensin Catecholamines Catecholamines Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

CategorySBP (mm Hg) DBP Normal <120 and <80 <80 Prehypertension 120–139 or 80–89 80–89 Stage 1 hypertension 140–159 or 90–99 90–99 Stage 2 hypertension >160 or >100 >100

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Subtypes Isolated systolic hypertension  SBP >140 mm Hg with DBP <90 mm Hg Pseudohypertension

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Primary (essential or idiopathic) hypertension Elevated BP without an identified cause 90% to 95% of all cases

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Primary (essential or idiopathic) hypertension Contributing factors  ↑ SNS activity  ↑ Sodium-retaining hormones and vasoconstrictors  Diabetes mellitus  >Ideal body weight  ↑ Sodium intake  Excessive alcohol intake

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Secondary hypertension Elevated BP with a specific cause 5% to 10% of adult cases

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Secondary hypertension Contributing factors  Coarctation of aorta  Renal disease  Endocrine disorders  Neurologic disorders  Cirrhosis  Sleep apnea

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  For persons over 50 years of age, SBP is more important than DBP as a CVD risk factor  Persons who are normotensive at 55 years of age have a 90% lifetime risk for developing HTN

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Age  Alcohol  Cigarette smoking  Diabetes mellitus  Elevated serum lipids  Excess dietary sodium  Gender

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Family history  Obesity  Ethnicity  Sedentary lifestyle  Socioeconomic status  Stress

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Heredity  In most cases, hypertension results from the interaction of Environmental factors Demographic factors Genetic factors

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Water and sodium retention High sodium intake may activate a number of pressor mechanisms resulting in water retention

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Water and sodium retention Certain demographics are associated with “salt sensitivity”  Obesity  Increasing age  African American ethnicity  People with diabetes, renal disease

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Stress and increased SNS activity Produces increased vasoconstriction ↑ HR ↑ Renin release

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Insulin resistance and hyperinsulinemia High insulin concentration stimulates SNS activity and impairs nitric oxide–mediated vasodilation

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Altered renin–angiotensin mechanism: high plasma renin activity  Endothelial cell dysfunction

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Symptoms are often secondary to target organ disease and can include Fatigue, reduced activity tolerance Dizziness Palpitations, angina Dyspnea

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Target organ diseases occur most frequently in the Heart Brain Peripheral vasculature Kidney Eyes

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Hypertensive heart disease Coronary artery disease Left ventricular hypertrophy Heart failure Fig. 33-3

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Cerebrovascular disease Stroke  Peripheral vascular disease  Nephrosclerosis  Retinal damage

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  History and physical examination  BP measurement in both arms Use arm with higher reading for subsequent measurements BP highest in early morning, lowest at night

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Appropriate-sized cuff is necessary to ensure accurate reading  At least two measurements should be obtained

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Urinalysis, creatinine clearance  Serum electrolytes, glucose  BUN and serum creatinine  Serum lipid profile  ECG  Echocardiogram

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  “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

Fig. 33-4

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Overall goals Control blood pressure Reduce CVD risk factors

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Strategies for adherence to regimens Empathy increases patient trust, motivation, and adherence to therapy Consider patient’s cultural beliefs and individual attitudes in formulating treatment goals

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Average Percent Reduction Stroke incidence 35%-40% Myocardial infarction 20%-25% Heart failure 50%

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Lifestyle modifications Weight reduction: Weight loss of 10 kg (22 lb) may decrease SBP by approx. 5 to 20 mm Hg

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Lifestyle modifications Dietary sodium reduction  <2.4 g of sodium/day Moderation of alcohol consumption:  Men: no more than 2 drinks/day  Women: no more than 1 drink/day

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Lifestyle modifications Physical activity: Regular physical (aerobic) activity, at least 30 min, most days of the week Avoidance of tobacco products Stress management

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Drug therapy: Primary actions of drugs to treat hypertension Reduce SVR Reduce volume of circulating blood

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Drug therapy: Classifications of drugs used to treat hypertension Diuretics Adrenergic inhibitors Direct vasodilators Angiotensin inhibitors Calcium channel blockers

Fig. 33-5

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Drug therapy and patient teaching Identify, report, and minimize side effects  Orthostatic hypotension  Sexual dysfunction  Dry mouth  Frequent urination

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nursing Assessment Subjective data  Past health history  Medications  Functional health patterns Objective data  Target organ damage

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nursing Diagnoses Ineffective health maintenance Anxiety Sexual dysfunction Ineffective therapeutic regimen management Disturbed body image Ineffective tissue perfusion

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Collaborative problems Potential complication: Adverse effects from antihypertensive therapy Potential complication: Hypertensive crisis Potential complication: Stroke Potential complication: Myocardial infarction

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nursing Implementation Health Promotion  Individual patient evaluation  Blood pressure measurement  Screening programs  Cardiovascular risk factor modification

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Nursing Implementation Ambulatory and home care  Patient and family teaching includes  Nutritional therapy  Drug therapy  Physical activity  Home monitoring of BP (if appropriate)  Tobacco cessation (if applicable)

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Isolated systolic hypertension (ISH) is the most common form of hypertension in individuals >50 years of age

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  The lifetime risk of developing hypertension is approximately 90% for middle-aged (55 to 65 years of age) and older (>65 years of age) normotensive men and women

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Older adults have varying degrees of impaired baroreceptor reflex mechanisms  Consequently, orthostatic hypotension occurs often, especially in patients with ISH

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  In general, treatment similar for all demographic and ethnic groups  Prevalence and severity of HTN increased in African Americans

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Severe, abrupt increase in DBP (defined as >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

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Hypertensive emergency = evidence of acute target organ damage: Hypertensive encephalopathy, cerebral hemorrhage Acute renal failure Myocardial infarction Heart failure with pulmonary edema

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Hospitalization IV drug therapy: Titrated to mean arterial pressure Monitor cardiac and renal function Neurologic checks Determine cause Education to avoid future crises

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Web site  For patients and the general public Facts about the DASH Eating Plan Your Guide to Lowering Blood Pressure My Blood Pressure Wallet Card  For health professionals Reference Card

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

 40-year-old male attends a community health screening  He is alert, coordinated, and cooperative

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  Clinical finding are Height 5 feet, 6 inches and weight 230 lbs Blood pressure 182/104 mm Hg Pulse 90 beats/min Respirations 24 breath/min Temperature 97.0° F

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.  He states He is a truck driver and eats a lot of fast foods It is hard to “eat healthy” on the road This is his first checkup in many years He smokes one pack of cigarettes per day, and this helps him stay calm

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 1. What risk factors for hypertension does he have? 2. As part of the health screening, what should you do next? 3. In what areas should you provide teaching?