1. Focus on Hypertension
(Relates to Chapter 33, “Nursing Management: Hypertension,” in the textbook)

2. Objectives:

3. Hypertension Definition
Persistent elevation of
Systolic blood pressure ≥140 mm Hg or
Diastolic blood pressure ≥90 mm Hg or
Current use of antihypertensive medication(s)

4. Prehypertension Definition
Systolic blood pressure: mm Hg Diastolic blood pressure: mm Hg

5. Factors Influencing Blood Pressure (BP)
Systemic Vascular Resistance
Blood Pressure
Cardiac Output = x

6. Factors Influencing BP (Cont’d)
Fig. 33-1

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

8. Blood Pressure Classification
Category
SBP
(mm Hg)
DBP
Normal
< and
<80
Prehypertension
120– or
80–89
Stage 1 hypertension
140– or
90–99
Stage 2 hypertension
> or
>100

9. Blood Pressure Classification (Cont’d)
Subtypes
Isolated systolic hypertension
SBP >140 mm Hg with DBP <90 mm Hg
Pseudohypertension

10. Etiology of Hypertension
Primary (essential or idiopathic) hypertension
Elevated BP without an identified cause
90% to 95% of all cases

11. Etiology of Hypertension (Cont’d)
Primary (essential or idiopathic) hypertension
Contributing factors
↑ SNS activity
↑ Sodium-retaining hormones and vasoconstrictors
Diabetes mellitus
>Ideal body weight
↑ Sodium intake
Excessive alcohol intake

12. Etiology of Hypertension (Cont’d)
Secondary hypertension
Elevated BP with a specific cause
5% to 10% of adult cases

13. Etiology of Hypertension (Cont’d)
Secondary hypertension
Contributing factors
Coarctation of aorta
Renal disease
Endocrine disorders
Neurologic disorders
Cirrhosis
Sleep apnea

14. Hypertension
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

15. Risk Factors for Primary Hypertension
Age
Alcohol
Cigarette smoking
Diabetes mellitus
Elevated serum lipids
Excess dietary sodium
Gender

16. Risk Factors for Primary Hypertension (Cont’d)
Family history
Obesity
Ethnicity
Sedentary lifestyle
Socioeconomic status
Stress

17. Pathophysiology of Primary Hypertension
Heredity
In most cases, hypertension results from the interaction of
Environmental factors
Demographic factors
Genetic factors

18. Pathophysiology of Primary Hypertension (Cont’d)
Water and sodium retention
High sodium intake may activate a number of pressor mechanisms resulting in water retention

19. Pathophysiology of Primary Hypertension (Cont’d)
Water and sodium retention
Certain demographics are associated with “salt sensitivity”
Obesity
Increasing age
African American ethnicity
People with diabetes, renal disease

20. Pathophysiology of Primary Hypertension (Cont’d)
Stress and increased SNS activity
Produces increased vasoconstriction
↑ HR
↑ Renin release

21. Pathophysiology of Primary Hypertension (Cont’d)
Insulin resistance and hyperinsulinemia
High insulin concentration stimulates SNS activity and impairs nitric oxide–mediated vasodilation

22. Pathophysiology of Primary Hypertension (Cont’d)
Altered renin–angiotensin mechanism: high plasma renin activity
Endothelial cell dysfunction

23. Hypertension Clinical Manifestations
Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs

24. Hypertension Clinical Manifestations (Cont’d)
Symptoms are often secondary to target organ disease and can include
Fatigue, reduced activity tolerance
Dizziness
Palpitations, angina
Dyspnea

25. Hypertension Complications
Target organ diseases occur most frequently in the
Heart
Brain
Peripheral vasculature
Kidney
Eyes

26. Hypertension Complications (Cont’d)
Hypertensive heart disease
Coronary artery disease
Left ventricular hypertrophy
Heart failure
Fig. 33-3

27. Hypertension Complications (Cont’d)
Cerebrovascular disease
Stroke
Peripheral vascular disease
Nephrosclerosis
Retinal damage

28. Hypertension Diagnostic Studies
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

29. Hypertension Office 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

30. Hypertension Office BP Measurement (Cont’d)
Appropriate-sized cuff is necessary to ensure accurate reading
At least two measurements should be obtained

31. Hypertension Diagnostic Studies
Urinalysis, creatinine clearance
Serum electrolytes, glucose
BUN and serum creatinine
Serum lipid profile
ECG
Echocardiogram

32. Hypertension Diagnostic Studies (Cont’d)
“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

33. Treatment Algorithm for Hypertension
Fig. 33-4
Fig. 33-4

34. Hypertension Collaborative Care
Overall goals
Control blood pressure
Reduce CVD risk factors

35. Hypertension Collaborative Care (Cont’d)
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

36. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence %-40%
Myocardial infarction %-25%
Heart failure %

37. Hypertension Collaborative Care (Cont’d)
Lifestyle modifications
Weight reduction: Weight loss of 10 kg (22 lb) may decrease SBP by approx. 5 to 20 mm Hg

38. Hypertension Collaborative Care (Cont’d)
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

39. Hypertension Collaborative Care (Cont’d)
Lifestyle modifications
Physical activity: Regular physical (aerobic) activity, at least 30 min, most days of the week
Avoidance of tobacco products
Stress management

40. Hypertension Collaborative Care (Cont’d)
Drug therapy: Primary actions of drugs to treat hypertension
Reduce SVR
Reduce volume of circulating blood

41. Hypertension Collaborative Care (Cont’d)
Drug therapy: Classifications of drugs used to treat hypertension
Diuretics
Adrenergic inhibitors
Direct vasodilators
Angiotensin inhibitors
Calcium channel blockers

42. Collaborative Care
Fig. 33-5

43. Hypertension Collaborative Care
Drug therapy and patient teaching
Identify, report, and minimize side effects
Orthostatic hypotension
Sexual dysfunction
Dry mouth
Frequent urination

44. Hypertension Nursing Management
Nursing Assessment
Subjective data
Past health history
Medications
Functional health patterns
Objective data
Target organ damage

45. Hypertension Nursing Management (Cont’d)
Nursing Diagnoses
Ineffective health maintenance
Anxiety
Sexual dysfunction
Ineffective therapeutic regimen management
Disturbed body image
Ineffective tissue perfusion

46. Hypertension Nursing Management (Cont’d)
Collaborative problems
Potential complication: Adverse effects from antihypertensive therapy
Potential complication: Hypertensive crisis
Potential complication: Stroke
Potential complication: Myocardial infarction

47. Hypertension Nursing Management (Cont’d)
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

48. Hypertension Nursing Management (Cont’d)
Nursing Implementation
Health Promotion
Individual patient evaluation
Blood pressure measurement
Screening programs
Cardiovascular risk factor modification

49. Hypertension Nursing Management (Cont’d)
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)

50. Hypertension Nursing Management (Cont’d)
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

51. Hypertension in Older Persons
Isolated systolic hypertension (ISH) is the most common form of hypertension in individuals >50 years of age

52. Hypertension in Older Persons (Cont’d)
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

53. Hypertension in Older Persons (Cont’d)
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

54. Hypertension in Older Persons (Cont’d)
Older adults have varying degrees of impaired baroreceptor reflex mechanisms
Consequently, orthostatic hypotension occurs often, especially in patients with ISH

55. Cultural and Ethnic Disparities
In general, treatment similar for all demographic and ethnic groups
Prevalence and severity of HTN increased in African Americans

56. Cultural and Ethnic Disparities (Cont’d)
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

57. Hypertensive Crisis
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

58. Hypertensive Crisis Clinical Manifestations
Hypertensive emergency = evidence of acute target organ damage:
Hypertensive encephalopathy, cerebral hemorrhage
Acute renal failure
Myocardial infarction
Heart failure with pulmonary edema

59. Hypertensive Crisis Nursing and Collaborative Management
Hospitalization
IV drug therapy: Titrated to mean arterial pressure
Monitor cardiac and renal function
Neurologic checks
Determine cause
Education to avoid future crises

60. Supporting Materials Web site www.nhlbi.nih.gov
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

61. Case Study

62. Case Study 40-year-old male attends a community health screening
He is alert, coordinated, and cooperative

63. Case Study (Cont’d) 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

64. Case Study (Cont’d) 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

65. Discussion Questions What risk factors for hypertension does he have?
As part of the health screening, what should you do next?
In what areas should you provide teaching?
2. Recheck the BP a second time, at least 1 minute after the initial screening. Check the BP in both arms. Inform him that his BP is elevated, and make arrangements for him to follow up with a health care provider. Obtain his phone number so the nurse can follow up on this referral.
3. Provide him with information on 1) BP management, 2) Weight loss, 3) Nutrition, 4) Smoking cessation, 5) Increasing physical activity, and 6) Stress management.