Chapter 27 Hypertension Flashcards
Hypertension (HTN)
A condition in which the force of the blood against the artery walls is too high
What are the parameters to diagnose hypertension?
Must be based on an average of 2+ accurate readings taken between 1-4 weeks apart
Blood Pressure (BP)
The pressure that the blood exerts against the walls of the arteries as it passes through them
Systolic BP (SBP)
Arterial pressure when the heart contracts
Diastolic Pressure (DBP)
Arterial pressure when the heart relaxes and fills with blood
Mean Arterial Pressure (MAP)
Average pressure w/in the artery during one full cardiac cycle
Ambulatory BPM
Assesses daytime & nighttime BP during routine daily activities typically, for one 24 hr period
Home BPM
Assesses BP at specific times during the day & night over a longer period while the patient is seated & resting
Normal BP Reading
Systolic: Less than 120 mmHg
Diastolic: Less than 80 mmHg
Elevated BP Reading
Systolic: 120-129 mmHg
and
Diastolic: Less than 80 mmHg
HTN Stage 1 BP Reading
Systolic: 130-139 mmHg
or
Diastolic: 80-89 mmHg
HTN Stage 2 BP Reading
Systolic: 140-159 mmHg
or
Diastolic: 90-99 mmHg
Hypertensive Crisis
Systolic: Higher than 180 mmHg
and/or
Diastolic: Higher than 120 mmHg
With which type of patients, would you see hypertensive crisis occur in?
Secondary HTN
Poorly controlled HTN
Undiagnosed HTN
Abrupt discontinuation or non adherence of med->rebound hypertension
Hypertensive Urgency
BP is severely elevated: SBP >180 mmHg or DBP >120 mmHg, in stable patient w/ NO EVIDENCE of impending target organ damage
Nursing Considerations for Hypertensive Urgency
Explore reason for nonadherence
* Finances, anxiety, misunderstandings, miscommunication, drug side
effects, or recreational drug use
* Use team approach and mobilize resources to prevent nonadherence
from continuing or recurring
Frequency of vital signs assessment based on clinical judgement
and varies with patient’s condition
* Every 5 mins with rapidly changing BP is appropriate
* Every 15 or 30mins in a more stable situation should be sufficient
Treatment for Hypertensive Urgency
Restart antihypertensive meds or increase dosages
Hypertensive Emergency
BP is extremely elevated >180/120 mm Hg with new or worsening target organ damage:
* Hypertensive encephalopathy
* Ischemic stroke
* Myocardial infarction
* Heart failure with pulmonary edema
* Dissecting aortic aneurysm
* Renal failure
Nursing Considerations for Hypertensive Emergency
Rapid, focused assessment needed to determine possible cause and target organ involvement:
* Aortic Dissection – goal is to reduce SBP to <120 mmHg within the first hour of treatment
* Severe Preeclampsia/Eclampsia or Pheochromocytoma Crisis – goal is to reduce SBP to <140 mm Hg with first hour of treatment
* Goal for other cases of HTN emergency
* Reduce SBP by no more than 25% in first hour of treatment
* If stable, reduce to 160/100 mm Hg within the next 2-6 hours
* End goal of normal, controlled BP within 24-48 hours of initial treatment
ICU admission required for frequent and continuous monitoring of BP and cardiovascular status
Antihypertensive medication of choice
* IV meds such as nicardipine, labetalol, esmolol, nitroglycerin, and nitroprusside
Hypertension Risk Factors
Advancing Adult Age
Ethnicity: African-American
Chronic kidney disease
Diabetes
Excess alcohol consumption
Family History
Gender:
-Men have greater risk until age of 64 yrs old
-Women have greater risk at 65 yrs old and up
Hypercholesterolemia
Obesity
Poor diet habits: Excess salt intake, limited intake of veggies, fiber, fish fats, & potassium
Sedentary lifestyle
Use of tobacco & nicotine prods & exposure to 2nd hand smoke
Sleep apnea
Stress
In which ethnic group, is hypertension most prevalent?
African Americans
Primary/Essential HTN
High BP due to an unknown cause, usually due to multitude of co-morbidities
Secondary Hypertension
High BP due to an identifiable cause
Indications for Secondary HTN Screening
New-onset of high BP
Poorly controlled HTN
HTN resistant to 3 or more drugs
Abrupt onset of HTN
Patients younger than 30 yrs old
Conditions Associated w/New Diagnosis of HTN
Excessive target organ damage
Cerebral Vascular Disease
Retinopathy
LT ventricular hypertrophy
HF w/preserved ejection fraction
Coronary artery disease
CKD
Peripheral arterial disease
Formula to Calculate BP
BP = CO (Cardiac Output) X R (Resistance)
Systemic Vascular Resistance
The pressure in the peripheral blood vessels that the heart must overcome to pump blood into the system
Formula to Calculate Cardiac Output (CO)
CO = HR (Hear rate) X SV (Stroke volume)
Cardiac Output (CO)
The amount of blood pumped by the heart per minute
Stroke Volume (SV)
The amount of blood pumped out of the heart with each contraction
How does increased venous return increase stroke volume?
More fluid in the vasculature
Factors that can Cause Hypertension
Increase in CO (usually rel to expansion in vascular volume)
Increase in peripheral resistance (constriction of blood vessels)
In order for hypertension to occur…
… there must be a change in 1 or more factors affecting peripheral resistance or cardiac output
Additionally, there must be a problem w/ the body’s monitoring/pressure regulation control system
Common Causes of Secondary HTN
CKD
Cushing’s syndrome
Hyperaldosteronism
Hyperparathyroidism
Hypo/Hyperthyroidism
NSAID/Substance abuse
Obstructive sleep apnea
Preeclampsyia
Polycystic kidney disease
Renal artery stenosis
Physiological Processes that can Lead to Hypertension
Increased SNS activity due to ANS dysfunction
Increased renal absorption of Na+, Cl-, & water due to genetic variation in pathways in how kidneys handle sodium
Increased RAAS system activity-> extracellular fluid volume expansion & increased systemic vascular resistance
Decreased vasodilation of the arterioles due to vascular endothelium dysfunction
Insulin resistance
Activation of the innate & adaptive components of the immune response that contribute to vascular inflammation & dysfunction
High levels of Insulin & HTN (Type II Diabetes & Metabolic Disease)
Lead to renal dysfunction & cause enhanced levels of Na+ retention-> RAAS dysfunction
Renin-angiotensin-aldosterone system (RAAS)
Compensatory process that leads to increased BP via increased fluid retention (increases preload) & vasoconstriction via angiotensin II
Aldosterone
Promotes Na+ and H2O retention by kidneys
increases blood volume & BP
If sodium is retained…
…H2O is also retained
Immunity/Inflammatory Response in HTN
Chronic low levels of immune mediators-> immunity cells can begin damaging endothelium
Prostaglandin Effect on Vasculature
Causes vasoconstriction
Gerontological Considerations for Hypertension
Increase in BP due to changes in heart, blood vessels, and kidneys:
-Accumulation of atherosclerotic plaque
-Fragmentation of arterial elastins
-Increased collagen deposits
-Impaired vasodilation
-Renal dysfunction
Decreased elasticity
Stiffening of major blood vessels (aorta)
Volume expansion
Isolated systolic HTN is predominant in older adults
Isolated Systolic Hypertension
A disorder most comm seen in older adults in which the systolic BP is greater than 140 mmHg & diastolic BP is less than 80 mmHg
Clinical Manifestations of Hypertension
Known as “the silent killer” since there are NO warning signs
-Usually most people do not know they have it
Fatigue
Reduced activity tolerance
Dizziness
Palpitations
Angina
Dyspnea
Target Organ Damage
Manifestations of pathophysiologic changes in various organs as a consequence of hypertension
Target Organ Damage: Eyes
Retina changes:
-Hemorrhages
-Exudate
-Arteriolar narrowing
-Cotton-wool spots (small infarctions)
Papilledema: Swelling of the optic disc
-Seen in severe HTN
Target Organ Damage: Heart
CAD w/angina & MI leads to left ventricular hypertrophy
LVH occurs in response to increased workload placed on the ventricle as it contracts against higher systemic pressure
-When heart damage is extensive, HF follows
LVH
Left Ventricular Hypertrophy
Thickening of the wall w/in LT ventricle
Target Organ Damage: Kidneys
Increased BUN & serum creatinine levels-> nocturia manifestation
Electrolyte imbalances
Target Organ Damage: Cerebrovascular Involvement
Transient ischemic attack (TI) or stroke
Alterations in vision or speech
Dizziness
Weakness
Sudden fall
Permanent or transient hemiplegia (paralysis on one side)
Nursing Considerations for Obtaining Accurate BP Reading
Equipment: BP cuff
Patient Instruction:
-Avoid eating, smoking, drinking caffeinated beverages, & physical activity 30 mins prior to BP measuring
-Empty bladder
-Sit quietly for 5 min before measurement
-Sit w/ back supported, arm at heart level on firm surface, w/ both feet on the ground
a) Avoid talking while measurement is being taken
Choose appropriately sized cuff: Width of at least 40% limb circumference & length of at least 80-100% limb circumference
Wrap cuff firmly around arm: Center cuff directly over brachial artery
Record BP results of both arms & take subsequent measurement from the arm w/higher reading
-Should vary no more than by 5 mmHg
-Take 2 readings between 1-2 mins apart & use average of measurements
-Document BP measurement site & position of the patient
Patient Assessment
Assess for s/s of target organ damage:
-CV assessment
- Neck assessment for bruits, distended veins, or enlarged thyroid gland
-Auscultate upper abdomen for kidney arterial stenosis
-Eyes
-Neuro assessment
Assess health history:
-Screen for primary or secondary HTN
-Review patient’s ambulatory or home BP measurement techniques and verify its accuracy
-Assess family history and cardiovascular risk factors
-Examine personal, social, or financial factors; health beliefs, depressive symptoms, social support, and concomitant comorbidities
Lab & Diagnostic Studies
* 12-lead EKG
* Echocardiogram
* Urinalysis: Look for albumin for kidney damage
* Blood chemistries
Masked Hypertension
BP that is typically suggestive of a diagnosis of HTN that is paradoxically normal in a healthcare setting
White Coat Hypertension
BP that increases to hypertensive readings in healthcare settings that is paradoxically w/in the normal ranges in other settings
Goal of Hypertension Treatment
Prevent complications (target organ damage) & death by maintaining a BP reading lower than 130/80 mmHg
Medical Management of a Patient w/out Prior Diagnosis of HTN w/ Elevated BP
BP Reading: SBP of 120-129 mmHg & DBP of <80 mmHg
Should be advised to follow up w/additional BP readings w/in 3-6 months
Medical Management of a Patient w/BP that could be consistent w/HTN
BP Readings: SBP > or equal to 130 mmHg or DBP of > or equal to 80 mmHg
Should follow-up w/ additional BP readings w/in 1 month’s time to confirm or rule out diagnosis
Patient’s w/suspected masked or white coat HTN: BP should be based on HPBM or ABPM
Medical Management of Patients w/BP Reading of > or equal to 160/100 mmHg
Diagnosed w/HTN & begin treatment w/antihypertensive meds
Lifestyle Changes for Hypertension
Weight loss, DASH diet, physical exercise, reduced NA+ intake, increased K+ intake, smoking cessation, & decreased alcohol intake
Dietary Approach to Stop Hypertension (DASH) Diet
Increase fruit, vegetables, and low-fat dairy prods w/ reduced content of saturated & total fat
-Restrict sweets
If DASH diet is used in conjunction w/weight loss…
…it can lower SBP by 11-16 mmHg
DASH Diet Recommended Servings of Grains & Grain Products
7 or 8 servings daily
DASH Diet Recommended Servings of Veggies
4 or 5 servings daily
DASH Diet Recommended Servings of Fruits
4 or 5 servings daily
DASH Diet Recommended Servings of Low-fat or Fat-Free Dairy Foods
2 or 3 servings daily
DASH Diet Recommended Servings of Lean Meat, Fish,
& Poultry
Less than or equal to 2 servings daily
DASH Diet Recommended Servings of Nuts, Seeds, & Dry Beans
4 or 5 servings weekly
Other Dietary Considerations for Hypertension
Incorporate low sodium, high potassium diet: less than 2g Na+/day, 3,500-5,000mg/day
-Aim for at least 1000 mg/day sodium reduction
-High potassium diet must be avoided in patients w/CKD
Limit alcohol consumption to 2 drinks or less per day in men
- 24 oz beer
- 10 oz wine
- 3 oz 80 proof whiskey
Limit alcohol consumption to 1 drink or less per day in women
Exercise & Weight Loss Interventions for Hypertension
Maintain normal body weight
-Ideal body weight is best goal but, aim for at least 1 kg (2.2 lbs) weight loss
-Expect ~1 mmHg SBP decrease for every 1 kg reduction in weight
Regular aerobic phys activity (brisk walking) for at least 90-150 mins weekly
Regular dynamic resistance training 90-150 mins weekly
Regular isometric resistance training at least 3X a week
First Line of Meds for Hypertension Management
Thiazide or thiazide-type diuretics
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin-receptor blockers (ARBs)
Calcium channel blockers (CCBs)
Thiazide or Thiazide-type Diuretics
Inhibit Na+ reabsorption in the distal convoluted tubule of the nephron
Side effects include: hyponatremia, hypokalemia, and metabolic alkalosis
Side Effects of Thiazide or Thiazide-Type Diuretics
Dry mouth
Thirst
Weakness
Drowsiness/lethargy
Muscle aches
Muscle fatigue
Fatigue
Tachycardia
GI disturbance
Nursing Considerations for Thiazide or Thiazide-Type Diuretics
Monitor for side effects
Orthostatic hypotension may be potentiated by alcohol, barbiturates, opioids, or hot weather
Cause loss of Na+, K+, & Magnesium w/ increase in uric acid & Ca+2: Monitor for electrolyte imbalances
Encourage intake of potassium-rich foods
Gerontological considerations: Risk for orthostatic hypotension (be weary of fall risk)
Angiotensin-converting enzyme (ACE) inhibitors
Block the conversion of angiotensin I to Angiotensin II
Side effects: Hyperkalemia, Angioedema, cough
Nursing Considerations for ACE inhibitors
Can cause hyperkalemia
Side effects can include cough
Gerontological Considerations: Req reduced dosages & addition of loop diuretics when renal dysfunction is present
May cause reuptake of ACE2 receptors-> Makes pts more susceptible to infection w/ SARS-CoV-2
Angiotensin-receptor Blockers (ARBs)
Block effects of angiotensin II at the receptor
-Reduces peripheral resistance
Side Effects: Hyperkalemia, angioedema, upregulation of ACE2 receptors
Calcium Channel Blockers (CCB)
Inhibit Ca+2 ion influx
-Vasodilation
Side effects: headache, dizziness, skin flushing, peripheral edema, hypotension
Clinical Manifestations of Hyponatremia
SALT LOSS
Seizures & Stupor
Abdominal cramping, attitude changes (confusion)
Lethargic
Tendon reflexes diminished, trouble concentrating (confused)
Loss of urine & appetite
Orthostatic hypotension, overactive bowel sounds
Shallow respirations (happens late due to skeletal muscle weakness)
Spasms of muscles
Clinical Manifestations of Hypokalemia
“Everything is going to be LOW & SLOW”
Weak pulses: Irregular and thready
Orthostatic Hypotension
Depression ST, flat or inverted T wave and prominent u-wave
Shallow respirations with diminished breath sounds….due to weakness of accessory muscle movement to breath
Confusion, weak
Flaccid paralysis
Decrease deep tendon reflexes
Decreased bowel sounds
The 7 L’s of Hypokalemia
1) Lethargy (confusion)
2) Low, shallow respirations (due to decreased ability to use accessory muscles for breathing)
3) Lethal cardiac dysrhythmias: ST depression, shallow T wave, projecting U wave
4) Lots of urine: frequent urination…kidneys unable to make the urine concentrated
5) Leg cramps
6) Limp muscles: Decrease deep tendon reflexes
7) Low BP & Heart
Clinical Manifestations of Hyperkalemia
“MURDER”
Muscle weakness
Urine production: Little or none (renal failure)
Respiratory failure due to the decreased ability to use breathing muscles or seizures develop
Decreased cardiac contractility: weak pulse, low blood pressure
Early signs of muscle twitches/cramps…late profound weakness, flaccid
Rhythm changes: Tall peaked T waves, flat p waves, Widened QRS and prolonged PR interval
First Line of Meds for Hypertension Management in African-American Patients
Without HF or CKD
Thiazide diuretic or calcium channel blocker
-NOT ACE inhibitors or ARBs
Special Considerations for Pharmacological Treatment of HTN
Patients are first prescribed low doses
-If pt’s BP does not fall to less than 130/80 mmHg: Dose is gradually increased additional meds are included as necessary to achieve control
Resistant Hypertension
High BP treated w/ 3+ antihypertensive medicine (1 must be a diuretic agent) of different classes
Risk Factors for Resistant Hypertension
Older Age
Ethnicity: African-American descent
Obesity
CKD
Diabetes
Nursing Considerations for Resistant Hypertension
Assess for patient adherence
- Ensure finances are not preventing them
- Check for pt understanding of med purpose
- Check that med side effects are tolerable
Patients should also be assessed for secondary hypertension
Older adults: Start low & go slow
Monotherapy, if appropriate, may simplify the med regimen & make it less expensive
Check for drug interactions w/ over-the-counter medication
Include family & caregivers in educational program
Target BP
<130/80 for all adults regardless of age
-Exception: Target SBP <140 mmHg in patient 60 yrs & older w/history of stroke or TIA, reducing reoccurrence or w/in clinical judgement of provider
Which med class is the biggest risk factor for falls?
Calcium channel blockers due to vasodilation
Match assessment finding or intervention to cause or disorder
Assessment Finding/Intervention
1) SBP 120-129 mmHg & DBP <80 mmHg
2) BP >180/120 mmHg w/out target organ damage
3) Screened for risk of adverse cardiac events
4) Treat underlying cause to obtain normal BP
5) BP >180/120 mmHg w/ target organ damage
6) Essential w/ unknown cause
7) HTN caused by sleep apnea
8) SBP more than or equal to 140 mmHg or DBP more than or equal to 90 mmHg
Cause/Potential Disorder
a) Primary HTN
b) Secondary HTN
c) Elevated HTN
d) Stage 1 HTN
e) Stage 2 HTN
f) Hypertensive Urgency
g) Hypertensive Emergency
1) c
2) f
3) d
4) b
5) g
6) a
7) b
8) e
