Chapter 32 Hypertension Flashcards
Hypertension
- Direct relationship between hypertension and?
- Affects __ of adults in U.S.
- Additional ___% have prehypertension
- High priority health concern identified in?
- cardiovascular disease
- Affects 33% of adults in U.S.
- Additional 30% have prehypertension
- High priority health concern identified in Healthy People 2020
Blood pressure (BP) is the force exerted by the blood against the walls of the blood vessel. It must be adequate to maintain tissue perfusion during activity and rest. The maintenance of normal BP and tissue perfusion requires the integration of both?
systemic factors and local peripheral vascular effects. BP is primarily a function of cardiac output (CO) and systemic vascular resistance (SVR)
CO is?
total blood flow through the systemic or pulmonary circulation per minute. It is described as the stroke volume (SV) or the amount of blood pumped out of the left ventricle per beat (approximately 70 mL) multiplied by the heart rate (HR).
Factors influencing BP: Sympathetic nervous system (SNS)
- Activation increases HR and cardiac contractility
- Vasoconstriction and renin release
- Increases CO and SVR
Systemic vascular resistance (SVR) is the force opposing the movement of blood within the blood vessels. The radius of the small arteries and arterioles is the principal factor determining SVR. As arteries narrow, resistance to blood flow increases. As arteries dilate, resistance to blood flow decreases. A small change in the radius of the arterioles creates a major change in the SVR. If SVR is increased and CO remains constant or increases, what happens?
arterial BP will increase
The mechanisms that regulate BP can affect either CO or SVR, or both. Regulation of BP is a complex process involving both short-term (seconds to hours) and long-term (days to weeks) mechanisms.
1) Short-term mechanisms, including?
2) Long-term mechanisms include?
1) sympathetic nervous system (SNS) and vascular endothelium, are active within a few seconds.
2) renal and hormonal processes that regulate arteriolar resistance and blood volume.
- In a healthy person these regulatory mechanisms function in response to the body’s demands.
Sympathetic Nervous System:
The nervous system, which reacts within seconds after a drop in BP, increases BP primarily by activating the SNS. Increased SNS activity increases?
HR and cardiac contractility, produces widespread vasoconstriction in the peripheral arterioles, and promotes the release of renin from the kidneys. The net effect of SNS activation is to increase BP by increasing both CO and SVR.
Sympathetic Nervous System: Specialized nerve cells called baroreceptors (pressoreceptors) are located in the carotid arteries and arch of the aorta.
1) These cells sense?
2) SNS efferent nerves innervate cardiac and vascular smooth muscle cells. Under normal conditions, a low level of continuous?
1) changes in BP and transmit this information to the vasomotor centers in the brainstem. The brainstem sends this information through complex networks of neurons that excite or inhibit efferent nerves.
2) SNS activity maintains vascular tone. BP may be reduced by withdrawal of SNS activity or by stimulation of the parasympathetic nervous system (PNS). The PNS decreases the HR (via the vagus nerve) and thereby decreases CO.
Sympathetic nervous system: The neurotransmitter norepinephrine (NE) is released from SNS nerve endings. 1) NE activates receptors located in the?
2) The response to NE depends on the type of receptors present. SNS receptors are classified as α1, α2, β1, and β2. The smooth muscle of the blood vessels has?
3) α-Adrenergic receptors located in the peripheral vasculature cause what when stimulated by NE?
4) β1-Adrenergic receptors in the heart respond to NE and epinephrine with?
5) β2-Adrenergic receptors are activated primarily by?
1) sinoatrial node, myocardium, and vascular smooth muscle.
2) α-adrenergic and β2-adrenergic receptors.
3) vasoconstriction when stimulated by NE.
4) increased HR (chronotropic), increased force of contraction (inotropic), and increased speed of conduction (dromotropic).
5) epinephrine released from the adrenal medulla and cause vasodilation
Sympathetic Nervous System Receptors Affecting BP
α1 Receptor:
-Location
-Response when activated
1)
- Location: Vascular smooth muscle
- Response when activated: Vasoconstriction
2)
- Location: Heart
- Response when activated: Increased contractility (positive inotropic effect)
Sympathetic Nervous System Receptors Affecting BP
α2 Receptor:
-Location
-Response when activated
1)
- Location: Presynaptic nerve terminals
- Response when activated: Inhibition of norepinephrine release
2)
- Location: Vascular smooth muscle
- Response when activated: Vasoconstriction
Sympathetic Nervous System Receptors Affecting BP
β1 Receptor:
-Location
-Response when activated
1)
- Location: Heart
- Response when activated:
* Increased contractility (positive inotropic effect)
* Increased heart rate (positive chronotropic effect)
* Increased conduction (positive dromotropic effect)
2)
- Location: Juxtaglomerular cells of the kidney
- Response when activated: Increased renin secretion
Sympathetic Nervous System Receptors Affecting BP
β2 Receptor:
-Location
-Response when activated
- Location: Smooth muscle of blood vessels in heart (e.g., coronary arteries), lungs (e.g., bronchi), and skeletal muscle
- Response when activated: Vasodilation
Sympathetic Nervous System Receptors Affecting BP
Dopamine Receptors:
-Location
-Response when activated
- Location: Primarily renal blood vessels
- Response when activated: Vasodilation
The sympathetic vasomotor center interacts with many areas of the brain to maintain normal BP under various conditions. It is activated during times of pain, stress, and exercise. The SNS response causes an appropriate increase in CO and BP to adjust to the body’s increased O2 demands.
- During postural change from lying to standing, there is a transient?
decrease in BP. The vasomotor center is stimulated, and the SNS response causes peripheral vasoconstriction and increased venous return to the heart. If this response did not occur, blood flow to the brain would be inadequate, resulting in dizziness or syncope.
Baroreceptors have an important role in the maintenance of BP stability during normal activities.
1) They are sensitive to stretching and, when stimulated by an increase in BP, they?
2) When a fall in BP is sensed by the baroreceptors, the?
1) send inhibitory impulses to the sympathetic vasomotor center. Inhibition of the SNS results in decreased HR, decreased force of contraction, and vasodilation in peripheral arterioles.
2) SNS is activated. The result is constriction of the peripheral arterioles, increased HR, and increased contractility of the heart. In long-standing hypertension, the baroreceptors become adjusted to elevated BP levels and recognize this level as their new “normal.”
- Sensitive to stretching
- Send impulses to sympathetic vasomotor center
Baroreceptors
The vascular endothelium is a single-cell layer that lines the blood vessels.
- Functions:
- Functions: platelet adhesion, coagulation regulation, immune function, and regulation of fluid control within the vessel and extravascular space. The endothelium can also cause adhesion and aggregation of neutrophils and stimulate smooth muscle growth.
- essential to the regulation and maintenance of the vasodilating and vasoconstricting substances.9 Endothelium-derived vasoactive substances include nitric oxide (NO) and prostacyclin, which are both vasodilators. Another product of the endothelium is endothelin (ET), which is a potent vasoconstrictor (Fig. 32-1). A disruption or dysfunction of arterial tone (either through excessive constriction or dilation) is an early warning signal of CVD.
Produces vasoactive substances to maintain low arterial tone
Vascular endothelium
- Control sodium excretion and ECF volume
- RAAS system
- Prostaglandins
Renal system
Renal System
- Control sodium excretion and ECF volume
The kidneys contribute to BP regulation by controlling sodium excretion and extracellular fluid (ECF) volume. Sodium retention results in water retention, which causes an increase in ECF volume. This increases the venous return to the heart and stroke volume. Together these increase CO and BP.
Renal System
- RAAS system
plays an important role in BP regulation.
- juxtaglomerular apparatus in the kidney secretes renin in response to SNS stimulation, decreased blood flow through the kidneys, or decreased serum sodium concentration.
- Renin (enzyme that converts angiotensinogen to angiotensin I) Angiotensin I is converted to angiotensin II (A-II) by angiotensin-converting enzyme (ACE).
- A-II increases BP by two different mechanisms. First, A-II is a potent vasoconstrictor and increases SVR. This results in an immediate increase in BP. Second, over a period of hours or days, A-II increases BP indirectly by stimulating the adrenal cortex to secrete aldosterone
- A-II also acts at a local level within the heart and blood vessels. These effects include vasoconstriction and tissue growth that result in remodeling of the vessel walls, which can be due to or caused by endothelial dysfunction. These changes are linked to the development of primary hypertension and also the long-term effects of hypertension (e.g., atherosclerosis, renal disease, cardiac hypertrophy)
Renal system
- Prostaglandins
Prostaglandins (PGE2 and PGI2) secreted by the renal medulla have a vasodilator effect on the systemic circulation. This results in decreased SVR and lowering of BP. The natriuretic peptides (atrial natriuretic peptide [ANP] and b-type natriuretic peptide [BNP]) are secreted by heart cells. They antagonize the effects of antidiuretic hormone (ADH) and aldosterone. This results in natriuresis (excretion of sodium in urine) and diuresis, resulting in reduced blood volume and BP.
Factors influencing BP: Endocrine system main points
- Epinephrine and norepinephrine from adrenal medulla
- Aldosterone from adrenal cortex
- ADH from posterior pituitary
Endocrine System
1) Stimulation of the SNS results in release of epinephrine along with a small fraction of NE by the adrenal medulla. Epinephrine increases the?
2) Epinephrine activates β2-adrenergic receptors in?
3) In peripheral arterioles with only α1-adrenergic receptors (skin and kidneys), epinephrine causes?
1) CO by increasing the HR and myocardial contractility.
2) peripheral arterioles of skeletal muscle, causing vasodilation.
3) vasoconstriction.
Endocrine System
- A-II stimulates the adrenal cortex to release aldosterone. Aldosterone stimulates the?
kidneys to retain sodium and water. This increases blood volume and CO
Endocrine System
- An increased blood sodium and osmolarity level stimulates the release of?
ADH from the posterior pituitary gland. ADH increases the ECF volume by promoting the reabsorption of water in the distal and collecting tubules of the kidneys. The resulting increase in blood volume causes an increase in CO and BP.
Hypertension is defined as a persistent?
systolic BP (SBP) of 140 mm Hg or more, diastolic BP (DBP) of 90 mm Hg or more, or current use of antihypertensive medication
Prehypertension is defined as?
SBP of 120 to 139 mm Hg or DBP of 80 to 89 mm Hg
Isolated systolic hypertension (ISH) is defined as an average
SBP of 140 mm Hg or more, coupled with an average DBP of less than 90 mm Hg.
- SBP increases with aging.
- DBP rises until approximately age 55 and then declines. - Control of ISH decreases the incidence of stroke, heart failure, and death.
Blood pressure classification:
Isolated systolic hypertension
Hypertension Stage 1
Hypertension Stage 2
- Isolated systolic hypertension SBP >140 mm Hg with DBP <90 mm Hg - Hypertension Stage 1 SBP 140–149 or DBP 90–99 - Hypertension Stage 2 SBP >160 or DBP >100
The nurse determines that the patient has stage 2 hypertension when the patient’s average blood pressure is
a. 155/88 mm Hg.
b. 172/92 mm Hg.
c. 160/110 mm Hg.
d. 182/106 mm Hg.
c. 160/110 mm Hg.
Primary hypertension main points
- Also called essential or idiopathic hypertension
- Elevated BP without an identified cause
- 90% to 95% of all cases
- Exact cause unknown but several contributing factors
Primary Hypertension (essential or idiopathic)
- elevated BP without an identified cause, and it accounts for 90% to 95% of all cases of HTN
- several contributing factors include changes in endothelial function related to either vasoconstricting or vasodilating agents, increased SNS activity, overproduction of sodium-retaining hormones, increased sodium intake, greater-than-ideal body weight, diabetes, tobacco use, and excessive alcohol intake.
Secondary hypertension is elevated BP with a specific cause that often can be identified and corrected. This type of hypertension accounts for 5% to 10% of hypertension in adults.
1) Secondary hypertension should be suspected in people who suddenly develop?
2) Clinical findings that suggest secondary hypertension relate to the?
1) high BP, especially if it is severe.
2) underlying cause. For example, an abdominal bruit heard over the renal arteries may indicate renal disease. Treatment of secondary hypertension is aimed at removing or treating the underlying cause. Secondary hypertension is a contributing factor to hypertensive crisis
Secondary hypertension main points
- Elevated BP with a specific cause
- 5% to 10% of adult cases
- Clinical findings relate to underlying cause
- Treatment aimed at removing or treating cause
Pathophysiology Primary Hypertension main points
- Persistently increased SVR
- Abnormalities in any mechanisms involved in
- maintenance of normal BP
Causes of Secondary Hypertension
- Cirrhosis
- Coarctation or congenital narrowing of the aorta
- Drug-related: estrogen replacement therapy, oral contraceptives, corticosteroids, nonsteroidal antiinflammatory drugs (e.g., cyclooxygenase-2 inhibitors), sympathetic stimulants (e.g., cocaine, monoamine oxidase)
- Endocrine disorders (e.g., pheochromocytoma, Cushing syndrome, thyroid disease)
- Neurologic disorders (e.g., brain tumors, quadriplegia, traumatic brain injury)
- Pregnancy-induced hypertension
- Renal disease (e.g., renal artery stenosis, glomerulonephritis)
- Sleep apnea
Pathophysiology of Primary Hypertension
- BP rises with any increase in?
- Increased CO is sometimes found in the person with?
- The hemodynamic hallmark of hypertension is?
- CO or SVR
- prehypertension. Later in the course of hypertension, the SVR rises and CO returns to normal.
- persistently increased SVR. This persistent elevation in SVR may occur in various ways.
Risk factor for primary hypertension: Alcohol
• Excessive alcohol intake is strongly associated with hypertension.
• Moderate intake of alcohol has cardioprotective properties; males with hypertension should limit their daily intake of alcohol? For females?
males with hypertension should limit their daily intake of alcohol to 2 drinks per day, and 1 drink per day for females with hypertension.
Risk factor for primary hypertension: Elevated serum lipids
- ↑ Levels of cholesterol and triglycerides are primary risk factors in atherosclerosis.
- Hyperlipidemia is more common in people with hypertension.
Risk factor for primary hypertension: Gender
- Hypertension is more prevalent in men in young adulthood and early middle age.
- After age 64, hypertension is more prevalent in women.
Risk factor for primary hypertension: Obesity
- Weight gain is associated with increased frequency of hypertension.
- Risk increases with central abdominal obesity.
Risk factor for primary hypertension: Ethnicity
• Incidence of hypertension is 2 times higher in African Americans than in whites.
Risk Factors for Primary Hypertension
- Age
- Alcohol
- Tobacco use
- Diabetes mellitus
- Elevated serum lipids
- Excess dietary sodium
- Gender
- Family history
- Obesity
- Ethnicity
- Sedentary lifestyle
- Socioeconomic status
- Stress
While performing blood pressure screening at a health fair, the nurse counsels which person as having the greatest risk for developing hypertension?
a. A 56-year-old man whose father died at age 62 from a stroke
b. A 30-year-old female advertising agent who is unmarried and lives alone
c. A 68-year-old man who uses herbal remedies to treat his enlarged prostate gland
d. A 43-year-old man who travels extensively with his job and exercises only on weekends
A 56-year-old man whose father died at age 62 from a stroke
HypertensionClinical Manifestations
- “Silent killer”
- Symptoms of severe hypertension
- Fatigue
- Dizziness
- Palpitations
- Angina
- Dyspnea
Clinical Manifestations
1) Hypertension is often called the “silent killer” because it is?
2) A patient with severe hypertension may experience a variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart. These secondary symptoms include?
3) In the past, symptoms of hypertension were thought to include headache and nosebleeds. Unless BP is very high, these symptoms are no more frequent in people with hypertension than in the general population. However, patients with?
1) frequently asymptomatic until it becomes severe and target organ disease occurs.
2) fatigue, dizziness, palpitations, angina, and dyspnea.
3) hypertensive crisis may experience severe headaches, dyspnea, anxiety, and nosebleeds
Hypertension Complications: Target organ diseases occur most frequently in the?
- Heart
- Brain
- Peripheral vascular disease
- Kidney
- Eyes
Hypertension Complications:
The most common complications of hypertension are target organ diseases occurring in the?
- heart (hypertensive heart disease)
- brain (cerebrovascular disease)
- peripheral vessels (peripheral vascular disease)
- kidneys (nephrosclerosis)
- eyes (retinal damage)
Manifestations of Target Organ Disease:
- Organ: Cardiac
- Manifestations:
- Manifestations:
• Clinical, electrocardiographic, or radiologic evidence of coronary artery disease (e.g., previous MI, coronary revascularization)
• Left ventricular hypertrophy by ECG or echocardiography
• Left ventricular dysfunction or heart failure
Manifestations of Target Organ Disease:
- Organ: Cerebrovascular
- Manifestations:
- Manifestations:
• Transient ischemic attack
• Stroke
Manifestations of Target Organ Disease:
- Organ: Peripheral vascular
- Manifestations:
- Manifestations: • One or more major pulses in the extremities (except for dorsalis pedis) faint or absent • Intermittent claudication • Abdominal or carotid bruits or thrills • Aneurysm
Manifestations of Target Organ Disease:
- Organ: Renal
- Manifestations:
- Serum creatinine ≥1.5 mg/dL (130 µmol/L)
- Proteinuria (≥1+)
- Microalbuminuria
Manifestations of Target Organ Disease:
- Organ: Retinopathy
- Manifestations:
- Generalized or focal narrowing of retinal arterioles
- Arteriovenous nicking
- Hemorrhages or exudates with or without papilledema
Hypertension Diagnostic Studies
- Urinalysis
- BUN and serum creatinine
- Creatinine clearance
- Serum electrolytes, glucose
- Serum lipid profile
- Uric acid levels
- ECG
- Echocardiogram
Hypertensive heart disease: Coronary Artery Disease.
Hypertension is a major risk factor for coronary artery disease (CAD). The mechanisms by which hypertension contributes to the development of atherosclerosis are not fully known. The “response-to-injury” theory of atherogenesis suggests that hypertension?
disrupts the coronary artery endothelium. This results in a stiff arterial wall with a narrowed lumen, and accounts for a high rate of CAD, angina, and MI.
Hypertensive heart disease: Left Ventricular Hypertrophy.
Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH). Initially, LVH is a compensatory mechanism that strengthens cardiac contraction and increases CO. However, increased contractility increases?
myocardial work and O2 demand. Progressive LVH, especially in the presence of CAD, is associated with the development of heart failure.
Hypertensive heart disease: Heart Failure.
Heart failure occurs when the heart’s compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body’s demands. Contractility is?
depressed, and stroke volume and CO are decreased. The patient may complain of shortness of breath on exertion, paroxysmal nocturnal dyspnea, and fatigue.
Cerebrovascular Disease.
Atherosclerosis is the most common cause of cerebrovascular disease. Hypertension is a major risk factor for cerebral atherosclerosis and stroke. Even in mildly hypertensive people, the risk of stroke is four times higher than in normotensive people. Adequate control of BP diminishes the risk of stroke.
1) Atherosclerotic plaques are commonly found at the?
2) Portions of the atherosclerotic plaque or the blood clot that forms with disruption of the plaque may break off and travel to cerebral vessels, producing a?
3) Hypertensive encephalopathy may occur after a marked rise in BP if the cerebral blood flow is not decreased by autoregulation. Autoregulation is a physiologic process that maintains?
1) bifurcation of the common carotid artery and in the internal and external carotid arteries.
2) thromboembolism. The patient may experience transient ischemic attacks or a stroke.
3) constant cerebral blood flow despite fluctuations in BP. Normally, as pressure in the cerebral blood vessels rises, the vessels constrict to maintain constant flow. When BP exceeds the body’s ability to autoregulate, the cerebral vessels suddenly dilate, capillary permeability increases, and cerebral edema develops. This produces a rise in intracranial pressure. If left untreated, patients can die quickly from brain damage.
Peripheral Vascular Disease.
Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels. This leads to the development of?
-Symptom of peripheral vascular disease
peripheral vascular disease, aortic aneurysm, and aortic dissection. Intermittent claudication (ischemic leg pain precipitated by activity and relieved with rest) is a classic symptom of peripheral vascular disease.
Nephrosclerosis.
Hypertension is one of the leading causes of chronic kidney disease, especially among African Americans. Some degree of renal disease is usually present in the hypertensive patient, even those with minimally elevated BP.
1) Renal disease results from ischemia caused by the narrowing of the renal blood vessels. This leads to?
2) Laboratory indications of renal disease are?
3) Manifestation of renal disease is?
1) atrophy of the tubules, destruction of the glomeruli, and eventual death of nephrons. Initially intact nephrons can compensate, but these changes may eventually lead to renal failure.
2) albuminuria, proteinuria, microscopic hematuria, and elevated serum creatinine and blood urea nitrogen (BUN) levels.
3) An early manifestation of renal disease is usually nocturia
Retinal Damage.
The appearance of the retina provides important information about the severity and duration of hypertension. The blood vessels of the retina can be directly visualized with an ophthalmoscope.
1) Damage to the retinal vessels provides an indication of?
2) Manifestations of severe retinal damage include?
1) related vessel damage in the heart, brain, and kidneys. 2) blurring of vision, retinal hemorrhage, and loss of vision.
Most hypertension is classified as primary hypertension and testing for secondary causes is not routinely done. Basic laboratory studies are performed to?
(1) identify or rule out causes of secondary hypertension (2) evaluate target organ disease
(3) determine overall cardiovascular risk
(4) establish baseline levels before initiating therapy
Diagnostics: Routine urinalysis, BUN, and serum creatinine levels are used to screen for?
- Creatinine clearance reflects the?
- used to screen for renal involvement and provide baseline information about kidney function.
- Creatinine clearance reflects the glomerular filtration rate. Decreases in creatinine clearance indicate renal insufficiency.
Diagnostic studies:
1) Measurement of serum electrolytes, especially potassium, is important to detect?
2) Blood glucose levels assist in the diagnosis of diabetes.
3) A lipid profile provides information about additional risk factors related to?
4) Uric acid levels establish a?
5) An electrocardiogram (ECG) provides baseline information about heart status. It can identify the presence of?
6) If the patient’s age, history, physical examination, or severity of hypertension points to a secondary cause, further?
1) hyperaldosteronism, a cause of secondary hypertension.
2) Blood glucose levels assist in the diagnosis of?
3) atherosclerosis and CVD.
4) baseline, since the levels often rise with diuretic therapy.
5) LVH, cardiac ischemia, or previous MI. If LVH is suspected, echocardiography is often performed.
6) diagnostic testing is indicated.
best method for diagnosing hypertension
Ambulatory BP monitoring (ABPM)
- It is a noninvasive, fully automated system that measures BP at preset intervals over a 12-24-hour period. The equipment includes a BP cuff and a microprocessing unit that fits into a pouch worn on a shoulder strap or belt. Tell patients to hold their arm still by their side when the device is taking a reading.
BP demonstrates diurnal variability expressed as sleep-wakefulness difference. For day-active people, BP is?
- The presence of diurnal variability is confirmed with?
- highest in the early morning, decreases during the day, and is lowest at night. BP at night (during sleep) usually drops by 10% or more from daytime (awake) BP.
- ABPM.
Lifestyle Modifications.
Lifestyle modifications are directed toward reducing the patient’s BP and overall cardiovascular risk. Modifications include?
(1) weight reduction
(2) Dietary Approaches to Stop Hypertension (DASH) eating plan
(3) dietary sodium reduction
(4) moderation of alcohol intake
(5) regular physical activity
(6) avoidance of tobacco use (smoking and chewing)
(7) management of psychosocial risk factors
DASH Eating Plan.
1) The DASH eating plan emphasizes?
2) Compared with the typical American diet, the plan contains?
3) The DASH eating plan significantly lowers BP, and these decreases compare with those achieved with BP-lowering medication. Additional benefits also include lowering of?
1) fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish, poultry, beans, seeds, and nuts.
2) less red meat, salt, sweets, added sugars, and sugar-containing beverages.
3) low-density lipoprotein (LDL) cholesterol
Hypertension Collaborative Care
Overall goals
- Control blood pressure
- Reduce CVD risk factors and target organ disease
Weight reduction
- Weight loss of 22 lb (10 kg ) may decrease SBP by approx. 5 to 20 mm Hg
- Calorie restriction and physical activity
Fruits, vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and nuts
DASH eating plan
Dietary Sodium Reduction.
1) Healthy adults should restrict sodium intake to less than or equal to?
2) African Americans; people middle aged and older; and those with hypertension, diabetes, or chronic kidney disease should restrict sodium to?
1) 2300 mg/day
2) less than or equal to 1500 mg/day.13 This involves avoiding foods known to be high in sodium (e.g., canned soups, frozen dinners) and not adding salt in the preparation of foods or at meals
Physical Activity.
1) A physically active lifestyle is essential to promote and maintain good health. The AHA and American College of Sports Medicine recommend that adults perform moderate-intensity aerobic physical activity for at least?
2) Exercise goals can be accomplished by performing shorter periods of exercise that last at least 10 minutes. Additionally, combinations of ?
1) 30 minutes most days (i.e., more than 5 days per week) with a goal of at least 150 minutes per week.
2) moderate and vigorous activity are acceptable (e.g., walking briskly for 30 minutes on 2 days of the week and jogging for 20 minutes on 2 other days)
Physical Activity:
All adults should perform muscle-strengthening activities using the major muscles of the body at least twice a week. This helps to maintain or increase muscle strength and endurance.
- Additionally, flexibility and balance exercises are recommended?
- Moderate-intensity activities can?
- at least twice a week for older adults, especially for those at risk for falls
- lower BP, promote relaxation, and decrease or control body weight. Regular activity of this type can reduce SBP by approximately 4 to 9 mm Hg
Physical activity main points
- Moderate-intensity aerobic activity, at least 30 minutes, most days of the week
- Vigorous-intensity aerobic activity at least 20 minutes, 3 days a week
- Muscle-strengthening activities at least 2 times a week
- Flexibility and balance exercises 2 times a week
Avoidance of Tobacco Products.
1) Nicotine contained in tobacco causes?
2) Smoking tobacco is also a major risk factor for CVD. The cardiovascular benefits of stopping tobacco use are seen when?
3) Strongly encourage everyone, especially patients with hypertension, to avoid tobacco use. Advise those who continue to use tobacco products to?
1) vasoconstriction and increases BP, especially in people with hypertension.
2) within 1 year in all age-groups.
3) monitor their BP during use.
Avoidance of tobacco products main points
- Nicotine causes vasoconstriction and elevated BP
- Smoking cessation reduces risk factors within 1 year
Psychosocial risk factors main points
- Low socioeconomic status, social isolation and lack of support, stress, negative emotions
- Activate SNS and stress hormones
Psychosocial risk factors have direct effects on the cardiovascular system by activating the SNS and stress hormones. This can cause a wide variety of pathophysiologic responses, including?
hypertension and tachycardia, inflammation, endothelial dysfunction, increased platelet aggregation, insulin resistance, and central obesity
Psychosocial risk factors can contribute to CVD indirectly as well, simply by their impact on lifestyle behaviors and choices. Screening for psychosocial risk factors is important. Make appropriate referrals (e.g., counseling), when indicated. Suggest behavioral interventions such as?
relaxation training, stress management courses, support groups, and exercise training for individuals who are not in acute psychologic distress
Drug therapy:
• In patients 60 years or over, start drug treatment for what BP?
• In patients less than 60 years, treatment initiation and goals should be?
- BP greater than or equal to 150 mm Hg systolic or greater than or equal to 90 mm Hg diastolic and treat to goal BP less than those thresholds.
- 140/90 mm Hg, the same threshold used in patients 18 years or older with either chronic kidney disease (CKD) or diabetes.
Drug therapy: The drugs currently available for treating hypertension have two main actions:
(1) decrease the volume of circulating blood
(2) reduce SVR
Drug therapy: Diuretics promote?
sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines.
Drug therapy: Adrenergic-inhibiting agents act by diminishing the?
SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels.
Drug therapy: Direct vasodilators decrease the BP by?
relaxing vascular smooth muscle and reducing SVR.
Drug therapy: Calcium channel blockers increase?
sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells.
Drug therapy: Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of?
angiotensin I to angiotensin II and reduce angiotensin II (A-II)–mediated vasoconstriction and sodium and water retention.
Drug therapy: A-II receptor blockers (ARBs) prevent?
angiotensin II from binding to its receptors in the walls of the blood vessels.
Drug therapy: Once antihypertensive therapy is started, patients should return for follow-up and adjustment of drugs at monthly intervals until the goal BP is reached.
1) More frequent visits are necessary for patients with?
2) After BP is at goal and stable, follow-up visits can usually be at?
3) Co-morbidities (e.g., heart failure), associated diseases (e.g., diabetes), and the need for ongoing monitoring (e.g., laboratory testing) influence the?
1) stage 2 hypertension or with co-morbidities.
2) 3- to 6-month intervals.
3) frequency of visits.
Hypertension Drug Therapy and Patient Teaching
Follow-up care – Are they taking the medications?
Identify, report, and minimize side effects
- Orthostatic hypotension
- Sexual dysfunction
- Dry mouth
- Frequent urination
- Time of day to take drug
Patient and Caregiver Teaching Related to Drug Therapy.
Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not adhere to the therapy. Patient and caregiver teaching related to drug therapy helps them to identify and minimize side effects. This may help the patient adhere to therapy.
- Side effects may be an initial response to a drug and may decrease over time. Telling the patient about side effects that may decrease with time may help the person to continue taking the drug. The number or severity of side effects may relate to the?
dose. It may be necessary to change the drug or decrease the dose. Advise the patient to report all side effects to the HCP.
A common side effect of several of the antihypertensive drugs is?
orthostatic hypotension. This condition results from an alteration of the autonomic nervous system’s mechanisms for regulating BP, which are needed for position changes. Consequently, the patient may feel dizzy and faint when assuming an upright position after sitting or lying down.
Sexual problems may occur with many of the antihypertensive drugs. This can be a major reason that patients do not adhere to the treatment plan.
1) Problems can range from?
2) Rather than discussing a sexual problem with an HCP, the patient may decide just to stop taking the drug. Approach the patient on this sensitive subject and encourage discussion of?
1) reduced libido to erectile dysfunction.
2) any sexual problem that may be experienced. The sexual problems may be easier for the patient to discuss once you explain that the drug may be the source of the problem.
Some unpleasant side effects of drugs result from their therapeutic effect, but these can be decreased. For example, diuretics cause?
dry mouth and frequent voiding. Sugarless gum or hard candy may help ease the dry mouth. Taking diuretics earlier in the day may limit frequent voiding during the night and preserve sleep.
Subjective Data
Important Health Information
Past health history:
Medications:
- Past health history: Known duration and past workup of high BP; cardiovascular, cerebrovascular, renal, or thyroid disease; diabetes mellitus; pituitary disorders; obesity; dyslipidemia; menopause or hormone replacement status
- Medications: Use of any prescription or over-the-counter, illicit, or herbal drugs or products; previous use of antihypertensive drug therapy
Subjective Data Functional Health Patterns Health perception–health management: Nutritional-metabolic: Elimination: Activity-exercise: Cognitive-perceptual: Sexual-reproductive: Coping–stress tolerance:
- Health perception–health management: Family history of hypertension or cardiovascular disease; tobacco use, alcohol use; sedentary lifestyle; health literacy; readiness for change
- Nutritional-metabolic: Usual salt and fat intake; weight gain or loss
- Elimination: Nocturia
- Activity-exercise: Fatigue; dyspnea on exertion, palpitations, exertional chest pain; intermittent claudication, muscle cramps; usual pattern and type of exercise
- Cognitive-perceptual: Dizziness; blurred vision; paresthesias
- Sexual-reproductive: Erectile dysfunction, decreased libido
- Coping–stress tolerance: Stressful life events
Objective Data: Cardiovascular
- SBP consistently
- DBP
- SBP consistently >140 mm Hg or DBP >90 mm Hg for patients <60 yr old or >150 mm Hg or DBP >90 mm Hg for patients >60 years old. Orthostatic changes in BP and HR; bilateral BPs significantly different; abnormal heart sounds; laterally displaced apical pulse; diminished or absent peripheral pulses; carotid, renal, or femoral bruits; peripheral edema
Nursing assessment subjective data
- Family history
- Salt and fat intake
- Weight gain or loss
- Nocturia
- Fatigue, dyspnea on exertion, palpitations, pain
- Dizziness, blurred vision
- Erectile dysfunction
- Stressful events
Nursing assessment objective data
Gastrointestinal
Obesity (BMI ≥30 kg/m2); abnormal waist-hip ratio
Nursing assessment objective data
Neurologic
Mental status changes
Nursing assessment objective data
Possible Diagnostic Findings
Abnormal serum electrolytes (especially potassium); ↑ BUN, creatinine, glucose, cholesterol, and triglyceride levels; proteinuria, albuminuria, microscopic hematuria; evidence of ischemic heart disease and left ventricular hypertrophy on ECG; evidence of structural heart disease and left ventricular hypertrophy on echocardiogram; evidence of arteriovenous nicking, retinal hemorrhages, and papilledema on funduscopic examination
Objective data main points
- Blood pressure readings
- Heart sounds
- Pulses
- Edema
- Body measurements
- Mental status changes
Nursing diagnoses and collaborative problems for the patient with hypertension include, but are not limited to, the following.
- Ineffective health management related to lack of knowledge of pathology, complications, and management of hypertension
- Anxiety related to complexity of management regimen
- Sexual dysfunction related to side effects of antihypertensive medication
- Risk for decreased cardiac tissue perfusion
- Risk for ineffective cerebral tissue perfusion
- Risk for ineffective renal perfusion
- Potential complication: stroke, MI
Planning
The overall goals for the patient with hypertension are that the patient will?
(1) achieve and maintain the goal BP
(2) follow the therapeutic plan, including appointments with the HCP
(3) experience minimal side effects of therapy
(4) manage and cope with this condition
Individual Patient Evaluation
Hypertension is usually identified through routine screening for insurance, preemployment, and military physical examinations. You are in an ideal position to assess for the presence of hypertension, identify the risk factors for hypertension and CAD, and teach patients about these conditions. In addition to BP measurement, a health assessment should include such factors as?
age, gender, and race; diet history (including salt and alcohol intake); weight patterns; tobacco use; and family history of CVD, stroke, renal disease, and diabetes. Note all drugs taken, both prescribed and over-the-counter. Last, ask the patient about a previous history of high BP and the results of treatment (if any)
Blood Pressure Measurement
BP can be measured using the oscillatory or auscultatory method.
1) First, take the BP in?
2) Atherosclerosis in the subclavian artery can cause a?
3) Use the arm with the?
1) both arms to note any differences.
2) falsely low reading on the side where the narrowing occurs.
3) highest BP and take at least two readings, a minimum of 1 minute apart. Waiting for at least 1 minute between readings allows the blood to drain from the arm and prevents inaccurate readings. Record the average pressure as the value for that visit.
Blood Pressure Measurement
Proper size and correct placement of the BP cuff are critical for accurate measurement.
1) Place the cuff snugly around the patient’s?
2) Place the patient’s arm at the level of the heart during BP measurement. For BP measurements taken in the sitting position? For measurements taken in a supine position?
1) bare upper arm with the midline of the bladder of the cuff (usually marked on the cuff by the manufacturer) placed in line with the brachial artery.
2) sitting position, raise and support the arm at the level of the heart. supine position, raise and support (e.g., with a small pillow) the arm at heart level. If the arm is resting on the bed, it will be below heart level.
Blood Pressure Measurement
If neither upper arm can be used to measure the BP (e.g., presence of IV lines, fistula), or if a maximum size BP cuff does not fit the upper arm, use the?
forearm. In this case, position the proper size cuff midway between the elbow and the wrist. Auscultate Korotkoff sounds over the radial artery or use a Doppler device to note SBP. Use of an oscillometric device on the forearm is acceptable. Forearm and upper arm BPs are not interchangeable
Blood Pressure Measurement
The patient should not have smoked, exercised, or ingested caffeine within 30 min before measurement.
1. Seat patient with legs?
2. Begin measurement after patient has rested quietly for
3. Measure and record BP in?
4. Select the appropriate cuff size, following instructions for?
5. Take the BP with a recently calibrated aneroid or mercury sphygmomanometer, or electronic oscillometric device. Accuracy of oscillometric devices may be limited if patients are?
6. For auscultatory measurement, estimate SBP by palpating the?
7. Deflate the cuff at a rate of?
8. Record the SBP and DBP. Note the SBP when the?
9. Average two or more?
10. Provide the patient (verbally and in writing) with the?
11. Clean BP cuffs when?
Blood Pressure Measurement
The patient should not have smoked, exercised, or ingested caffeine within 30 min before measurement.
1. uncrossed, feet on the floor, and back supported. Bare patient’s arm and support it at heart level.
2. 5 min. Ask patient to relax as much as possible and not to talk during the measurement.
3. both arms initially.
4. fit and placement according to manufacturer’s recommendations.
5. hypertensive, hypotensive, or have heart dysrhythmias (e.g., atrial fibrillation).
6. radial pulse and inflating the cuff until the pulse disappears. Inflate the cuff 20-30 mm Hg above this level.
7. 2-3 mm Hg/sec.
8. first of two or more Korotkoff sounds is heard and the DBP when sound disappears.
9. readings (taken at intervals of at least 1 min). Obtain additional readings if the first two readings differ by more than 5 mm Hg.
10. BP reading, BP goal, and recommendations for follow-up.
11. between patients according to agency policy.
Safety Alert
Blood Pressure Measurement
• If using the forearm for BP measurement, always?
• BP cuffs that are too small or too large will result in?
• If bilateral BP measurements are not equal, document?
- document the site.
- readings that are falsely high or low, respectively.
- this finding and use the arm with the highest BP for all future measurements.
Assess for orthostatic (or postural) changes in BP and HR in older adults, in people taking antihypertensive drugs, and in patients who report symptoms consistent with reduced BP on standing (e.g., light-headedness, dizziness, syncope). Measure serial BP and HR with the patient in the supine, sitting, and standing positions.
1) First, measure BP and HR with the patient in the?
2) Reposition the patient in the?
3) Last, reposition the patient to the?
4) Usually the SBP?
5) whereas the DBP and pulse?
6) Orthostatic hypotension occurs when a patient moves from a?
7) Common causes of orthostatic hypotension include?
1) supine position after at least 2 to 3 minutes of rest.
2) sitting position with legs dangling and measure BP and HR again within 1 to 2 minutes.
3) standing position and measure the BP and HR within 1 to 2 minutes.
4) decreases slightly (less than 10 mm Hg) on standing
5) DBP and pulse increase slightly.
6) supine to standing position, and there is a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in the HR of 20 beats/minute.
7) dehydration and inadequate vasoconstrictor mechanisms related to disease or drugs.
Blood Pressure: In acute care settings, BP measurement is usually done to evaluate vital signs, volume status, and effects of drugs, rather than to diagnose hypertension. Trends in BP are more important than a single value. Inform the HCP of any patient with a?
persistent elevated BP. These patients should be evaluated for hypertension before discharge, if appropriate, or after discharge
Hypertension Blood Pressure Measurement
- Can use forearm if needed
- Assess for orthostatic hypotension
- Can use forearm if needed
- Document site
- Assess for orthostatic hypotension
- BP and pulse supine, sitting, and standing
- Measure within 1 to 2 minutes of position change
- Positive if ↓ of 20 mm Hg or more in SBP, ↓10 mm Hg or more in DBP, or ↑ 20 beats/minute or more in heart rate
Hypertension Nursing Planning
- Patient will
- Achieve and maintain the goal BP
- Understand and follow the therapeutic plan
- Experience minimal or no unpleasant side effects of therapy
- Be confident of ability to manage and cope with this condition
Hypertension Nursing Implementation
- Health promotion
- Primary prevention via lifestyle modification
- Individual patient evaluation and education
- Screening programs
- Cardiovascular risk factor modification
Screening programs in the community are widely used to identify persons who have a high BP. At the time of the BP measurement, give each person a written, numeric value of the reading. Explain why further evaluation is needed.
Focus efforts on the following:
(1) controlling BP in persons already identified as having hypertension
(2) identifying and controlling BP in at-risk groups such as African Americans, obese people, and blood relatives of people with hypertension
(3) screening those with limited access to health care
(4) connecting persons with an HCP and/or health insurance
Role of Nursing Personnel
Registered Nurse (RN)
• Develop and conduct?
• Assess patients for?
• Teach patients about?
• Evaluate the effectiveness of?
• Teach about home BP monitoring, including the?
• Make appropriate referrals to other HCPs, such as?
• Monitor for complications of hypertension such as?
• Assess the patient with hypertensive crisis for evidence of?
• Manage the patient with hypertensive urgency or emergency, including?
- hypertension screening programs.
- hypertension risk factors and develop risk modification plans.
- lifestyle management and drug use.
- lifestyle management and drugs in decreasing BP to acceptable levels.
- correct use of automatic BP monitors. Check that the device selected by the patient meets the Association for the Advancement of Medical Instrumentation standards
- dietitians or stress management programs.
- coronary artery disease, heart failure, cerebrovascular disease, peripheral vascular disease, and renal disease.
- target organ disease (e.g., encephalopathy, renal insufficiency, cardiac decompensation).
- administration of drugs and evaluation for resolution of the crisis.
Role of Nursing personnel Licensed Practical/Vocational Nurse (LPN/LVN) • Give? • Monitor for? • Reinforce?
- Give antihypertensive drugs to stable patients.
- adverse effects of antihypertensive drugs.
- Reinforce teaching about drugs and lifestyle management.
Role of Nursing personnel Unlicensed Assistive Personnel (UAP) • Obtain? • Report? • Check for?
- Obtain accurate BP readings in outpatient and inpatient settings.
- Report high or low BP readings immediately to RN.
- Check for postural changes in BP as directed.
Role of Other Team Members Dietitian • Obtain a? • Teach the components of? • Provide instructions for?
- Obtain a diet history from the patient.
- Teach the components of the DASH diet.
- Provide instructions for dietary changes as needed.
Role of Other Team Members
Physical Therapist
- Assess patient’s current level of fitness.
* Develop an exercise plan with the patient.
Ambulatory and home care main points
- Evaluate therapeutic effectiveness
- Detect and report adverse effects
- Assess and enhance compliance
- Patient and caregiver teaching
Ambulatory Care.
Your primary roles in long-term management of hypertension are to assist the patient to reach the goal BP and adhere to the treatment plan. Your actions include?
evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing adherence, and patient and caregiver teaching
Patient and Caregiver Teaching
General Instructions
1. Provide the patient’s BP reading and explain what it means (e.g., high, low, goal, borderline). Encourage patient to monitor?
2. Hypertension is usually?
3. Hypertension means?
4. Long-term therapy and follow-up care are necessary to treat hypertension. Therapy involves?
5. Therapy will not?
6. Controlled hypertension usually results in an?
7. Explain the potential dangers of?
- BP at home and instruct the patient to call the HCP if BP exceeds high or low limits set by HCP.
- asymptomatic and symptoms (e.g., nosebleeds) do not reliably indicate BP levels.
- high BP and does not relate to a “hyper” personality.
- lifestyle changes (e.g., weight management, sodium reduction, smoking cessation, regular physical activity) and, in most cases, drugs.
- will not cure, but should control, hypertension.
- excellent prognosis and a normal lifestyle.
- uncontrolled hypertension (e.g., stroke, heart attack).
Reasons for noncompliance
- Inadequate teaching
- Side effects
- Return to normal BP
- Lack of motivation
- Financial
- Lack of trust
Measures to enhance compliance
- Individualize plan
- Active patient participation
- Select affordable drugs
- Involve caregivers
- Combination drugs
- Patient teaching
Patient and caregiver teaching includes:
- Nutritional therapy
- Drug therapy
- Physical activity
- Home BP monitoring (if appropriate)
- Tobacco cessation (if applicable)
Instructions Related to Medications
- Be specific about the?.
- Help the patient plan regular and convenient times for?
- Do not stop drugs abruptly because?
- Do not double up on?
- If BP increases or decreases, do not?
- Do not take any drugs belonging to?
- Supplement diet with foods high in potassium (e.g., citrus fruits, green leafy vegetables) if taking?
- Avoid hot baths, excessive amounts of alcohol, and strenuous exercise within?
- Many drugs cause orthostatic hypotension. Reduce the effects of orthostatic hypotension by?
- Some drugs cause sexual problems (e.g., erectile dysfunction, decreased libido). Consult with the HCP about?
- Some side effects of drug(s) may?
- Be careful about taking potentially high-risk over-the-counter drugs, such as?
- names, actions, dosages, and side effects of prescribed drugs.
- taking drugs and measuring BP.
- withdrawal may cause a severe hypertensive reaction.
- dose when a dose is missed.
- do not adjust the drug dose without consulting the HCP.
- someone else.
- potassium-wasting diuretics.
- 3 hours of taking drugs that promote vasodilation.
- rising slowly from bed, sitting on the side of the bed for a few minutes, standing slowly, and beginning to move if no symptoms develop (e.g., dizziness, light-headedness). Do not stand still for prolonged periods, do leg exercises to increase venous return, or sleep with the head of the bed raised. Do lie or sit down when dizziness occurs.
- changing drugs or dosages if sexual problems develop.
- decrease with time (e.g., fatigue, diarrhea).
- high-sodium antacids, NSAIDs, appetite suppressants, and cold and sinus medications. Read warning labels and consult with a pharmacist.
Home BP monitoring:
1) Tell the patient to measure BP in the?
2) Tell the patient to measure BP when?
3) Have the patient record?
4) For clinical decision making (e.g., changes in dosage, start of new drug), tell patients to take BP readings?
5) Stable, normotensive patients should measure?
1) nondominant arm, or arm with the higher BP if there is a known difference between arms.
2) first thing in the morning (if possible, before taking medications) and at night before going to bed.
3) all BP measurements and bring the record to office visits.
4) as described for 1 week.
5) morning and evening BP for at least 1 week every 3 months. Devices that have memory or printouts of the readings are recommended to ensure accurate reporting
A patient’s blood pressure has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is
- Progressive target organ damage.
- The possibility of drug interactions.
- The patient not adhering to therapy.
- The patient’s possible use of recreational drugs.
- The patient not adhering to therapy.
Hypertension in Older Persons Main Points
- Increased incidence with age
- Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50
- Older adults are more likely to have “white coat” hypertension
- Age-related physical changes contribute to HTN
- Altered drug absorption, metabolism, and excretion
- Often a wide gap between the first Korotkoff sound and subsequent beats is called the auscultatory gap
- ↑ risk for orthostatic hypotension
- Also postprandial hypotension
The pathophysiology of hypertension in the older adult involves the following age-related physical changes:
(1) loss of elasticity in large arteries from atherosclerosis (2) increased collagen content and stiffness of the myocardium
(3) increased peripheral vascular resistance
(4) decreased adrenergic receptor sensitivity
(5) blunting of baroreceptor reflexes
(6) decreased renal function
(7) decreased renin response to sodium and water depletion
In the older adult who is taking antihypertensive drugs, what are the changes?
absorption of some drugs may be altered as a result of decreased blood flow to the gut. Metabolism and excretion of drugs may also be prolonged.
Careful technique is important in assessing BP in older adults. Some older people have a wide gap between the?
first Korotkoff sound and subsequent beats. This is called the auscultatory gap. Failure to inflate the cuff high enough may result in underestimating SBP
Current recommendations for target BP goals in people older than 60 years of age are controversial and range from less than 120/80 mm Hg7 to less than 150/90 mm Hg. The preferred three first-line antihypertensive drugs are a?
thiazide diuretic, a calcium channel blocker, and an ACE inhibitor or ARB. A diuretic should always be the first or second drug ordered for most patients.
- Orthostatic hypotension often occurs in older adults because of varying degrees of impaired baroreceptor reflexes, especially in those with ISH. Orthostatic hypotension in this age group is often associated with?
- Additionally, older adults experience postprandial drops in BP. The greatest decrease occurs approximately?
- To reduce the likelihood of orthostatic hypotension, antihypertensive drugs should be started at?
- volume depletion or chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance.
- 1 hour after eating. BP returns to preprandial levels 3 to 4 hours after eating.
- low doses and increased slowly. Measure BP and HR in the supine, sitting, and standing positions at every visit.
After CVD, arthritis is the second most prevalent disease in older adults. The most frequently taken drugs by older adults are nonsteroidal antiinflammatory drugs (NSAIDs), both prescription and over-the-counter. Nonselective NSAIDs (e.g., ibuprofen [Advil]) and selective NSAIDs (e.g., celecoxib [Celebrex]) cause loss of BP control and heart failure. Additionally, there is the potential for?
Adverse renal effects and/or hyperkalemia when NSAIDs are used with ACE inhibitors, ARBs, or aldosterone antagonists
Hypertensive crisis is a term used to indicate either a hypertensive urgency or emergency.
1) Hypertensive crisis occurs at systolic BP?
2) BPs can often be greater than?
3) The difference between a hypertensive urgency and emergency is the?
1) systolic BP greater than 180 mm Hg and/or diastolic BP greater than 110 mm Hg.
2) 220/140 mm Hg.
3) absence or presence of target organ damage.
Hypertensive urgency develops when?
over hours to days and does not have clinical evidence of target organ disease. It may not require hospitalization to correct.
Hypertensive emergencies have target organ disease and most often require hospitalization for prompt, controlled reduction of BP. If prompt treatment is not obtained, a hypertensive emergency can produce severe problems. These include?
encephalopathy, intracranial or subarachnoid hemorrhage, heart failure, MI, renal failure, dissecting aortic aneurysm, and retinopathy
Hypertensive Crisis: The rate of increase of BP is more important than the absolute value in determining the need for emergency treatment.
- Patients with chronic hypertension can tolerate much higher BPs than normotensive people.
- Prompt recognition and management of a hypertensive crisis are essential to decrease the threat to organ function and life.
Hypertensive crisis occurs more often in patients with a history of hypertension who have not adhered to their drug regimens or who have been undermedicated.
- Rapidly increasing BP can cause?
shearing of the endothelial surface due to turbulent blood flow within the vessels. This can lead to further vascular damage and the release of additional vasoconstricting substances. A vicious cycle of BP elevation follows, leading to life-threatening damage to target organs.
Hypertensive crisis related to cocaine or crack use is a frequent problem. Other drugs, such as?
amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD), can also cause hypertensive crisis that may be complicated by drug-induced seizures, stroke, MI, or encephalopathy
Causes of Hypertensive Crisis
- Exacerbation of chronic hypertension
- Renovascular hypertension
- Preeclampsia, eclampsia
- Pheochromocytoma
- Drugs (cocaine, amphetamines)
- Monoamine oxidase inhibitors taken with tyramine-containing foods
- Rebound hypertension (from abrupt withdrawal of some antihypertensive drugs such as clonidine [Catapres] or β-blockers)
- Head injury
- Acute aortic dissection
Hypertensive Crisis:
- Hypertensive emergency
- Hypertensive urgency
- Rate of rise more important than absolute value
- Hypertensive emergency
- Occurs over hours to days
- BP >220/140 with target organ disease
- Hypertensive urgency
- Occurs over days to weeks
- BP >180/110 with no clinical evidence of target organ disease
Clinical Manifestations
1) A hypertensive emergency is often manifested as?
2) On retinal examination, what are found?
3) Renal insufficiency?
4) Rapid cardiac decompensation ranging from?
5) Patients can have?
6) Patient assessment is extremely important. Monitor for?
7) The neurologic changes are often similar to those related to a stroke. However, a hypertensive crisis does not show?
1) hypertensive encephalopathy, a syndrome in which a sudden rise in BP is associated with severe headache, nausea, vomiting, seizures, confusion, and coma. The manifestations of encephalopathy are the result of increased cerebral capillary permeability. This leads to cerebral edema and a disruption in cerebral function.
2) On retinal examination, exudates, hemorrhages, and/or papilledema are found
3) Ranging from minor injury to complete renal failure can occur.
4) unstable angina to MI and pulmonary edema is also possible.
5) chest pain and dyspnea. Aortic dissection can develop and will cause sudden, excruciating chest and back pain and possibly reduced or absent pulses in the extremities.
6) signs of neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure.
7) focal or lateralizing signs often seen with a stroke. (In a stroke, focal impairments affect a specific region of the body [e.g., weakness in the left arm, right leg]. Lateralizing signs are restricted to one side of the body [e.g., weakness of an arm or leg].)
Hypertensive Crisis Clinical Manifestations Main Points
- Hypertensive encephalopathy
- Headache, n/v, seizures, confusion, coma
- Renal insufficiency
- Cardiac decompensation
- MI, HF, pulmonary edema
- Aortic dissection
Hypertensive emergencies require hospitalization, IV administration of antihypertensive drugs, and intensive care monitoring.
1) BP level alone is a poor marker of the?
2) When treating hypertensive emergencies, the?
3) The initial goal is to decrease MAP by?
1) seriousness of the patient’s condition. It is not the major factor in deciding the treatment for a hypertensive crisis. The link between elevated BP and signs of new or progressive target organ disease determines the seriousness of the situation.
2) mean arterial pressure (MAP) is often used instead of BP readings to guide and evaluate drug therapy. MAP is calculated as follows: MAP = (SBP + 2 DBP)/3
3) decrease MAP by no more than 20% to 25%, or to decrease MAP to 110 to 115 mm Hg. If the patient is clinically stable, drugs can be titrated to gradually lower BP over the next 24 hours. Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could cause a stroke, MI, or renal failure.
Hypertensive Crisis:
- Special circumstances include patients with aortic dissection. These patients should have their SBP lowered to?
- Another exception is patients with acute ischemic stroke, in whom BP is?
- Last, an elevated BP in the immediate poststroke period may be a compensatory response to?
- aortic dissection= SBP lowered to less than 100 to 120 mm Hg as soon as possible (if tolerated).
- lowered to allow the use of thrombolytic agents.
- improve cerebral perfusion to ischemic brain tissue. There is no clear evidence supporting the use of antihypertensive drugs in these patients
IV drugs used for hypertensive emergencies include?
1) vasodilators (e.g., sodium nitroprusside, fenoldopam [Corlopam], nicardipine [Cardene])
2) adrenergic inhibitors (e.g., phentolamine [Regitine], labetalol, esmolol [Brevibloc])
3) calcium channel blocker clevidipine (Cleviprex).
- Sodium nitroprusside is the most effective IV drug to treat hypertensive emergencies.
- Oral agents may be given along with IV drugs to help make an earlier transition to long-term therapy.
Labetalol
• Instruct patient not to?
• Abrupt cessation may precipitate?
- Instruct patient not to discontinue drug abruptly.
* Abrupt cessation may precipitate angina or heart failure.
Antihypertensive drugs given IV have a rapid (within seconds to minutes) onset of action.
1) Assess the patient’s BP and HR every?
2) Use an?
3) Titrate the drug according to?
4) Monitor the ECG for?
5) Use extreme caution in treating the patient with?
6) Measure urine output?
7) Patients receiving IV antihypertensive drugs may be restricted to?
1) 2 to 3 minutes during the initial administration of these drugs.
2) arterial line or an automated, noninvasive BP machine to monitor the BP.
3) MAP or BP as ordered.
4) dysrhythmias and signs of ischemia or MI.
5) CAD or cerebrovascular disease.
6) hourly to assess renal perfusion.
7) bed. Getting up (e.g., to use the commode) may cause severe cerebral ischemia and fainting.
Hypertensive Crisis: Ongoing assessment is essential to evaluate the effectiveness of these drugs and the patient’s response to therapy.
1) Frequent neurologic checks, including?
2) Monitor cardiac, pulmonary, and renal systems for?
1) level of consciousness, pupillary size and reaction, and movement of extremities, help detect any changes in the patient’s condition.
2) decompensation caused by the severe elevation in BP (e.g., angina, pulmonary edema, renal failure).
Hypertensive urgencies usually do not require IV drugs but can be managed with oral agents. The patient with hypertensive urgency may not need hospitalization but will require follow-up. The oral drugs most frequently used for hypertensive urgencies are captopril, labetalol, clonidine (Catapres), and amlodipine (Norvasc). The disadvantage of oral drugs is the?
inability to regulate the dosage moment to moment, as can be done with IV drugs. If a patient with hypertensive urgency is not hospitalized, outpatient follow-up care should be arranged within 24 hours.
Hypertensive Crisis Nursing/Collaborative Management
Hospitalization
- IV drug therapy: titrated to MAP
- Monitor cardiac and renal function
- Neurologic checks
- Determine cause
- Education to avoid future crisis
The nurse takes blood pressures at a health fair. The nurse identifies which person as most at risk for developing hypertension?
- A 52-year-old male who smokes and has a parent with hypertension
- A 30-year-old female advertising agent who is unmarried and lives alone
- A 68-year-old male who uses herbal remedies to treat an enlarged prostate gland
- A 43-year-old female who travels extensively for work and exercises only on weekends
- A 52-year-old male who smokes and has a parent with hypertension
The nurse determines that which of the following blood pressures would meet the criteria for a diagnosis of stage 2 hypertension?
- 152/98 mm Hg
- 118/84 mm Hg
- 106/62 mm Hg
- 182/94 mm Hg
- 182/94 mm Hg
Which BP-regulating mechanism(s) can result in the development of hypertension if defective (select all that apply)?
a. Release of norepinephrine
b. Secretion of prostaglandins
c. Stimulation of the sympathetic nervous system
d. Stimulation of the parasympathetic nervous system
e. Activation of the renin-angiotensin-aldosterone system
a. Release of norepinephrine
c. Stimulation of the sympathetic nervous system
e. Activation of the renin-angiotensin-aldosterone system
Rationale: Norepinephrine (NE) is released from the sympathetic nervous system nerve endings and activates receptors located in the vascular smooth muscle. When the α-adrenergic receptors in smooth muscle of the blood vessels are stimulated by NE, vasoconstriction results. Increased sympathetic nervous system stimulation produces increased vasoconstriction and increased renin release. Increased renin levels activate the renin-angiotensin-aldosterone system, leading to elevation in BP.
While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is
a. a low-calcium diet.
b. excessive alcohol intake.
c. a family history of hypertension.
d. consumption of a high-protein diet.
b. excessive alcohol diet
Rationale: Alcohol intake is a modifiable risk factor for hypertension. Excessive alcohol intake is strongly associated with hypertension. Males with hypertension should limit their daily intake of alcohol to 2 drinks per day, and 1 drink per day for females with hypertension.
In teaching a patient with hypertension about controlling the illness, the nurse recognizes that
a. all patients with elevated BP require medication.
b. obese persons must achieve a normal weight to lower BP.
c. it is not necessary to limit salt in the diet if taking a diuretic.
d. lifestyle modifications are indicated for all persons with elevated BP.
d. lifestyle modifications are indicated for all persons with elevated BP
Rationale: Lifestyle modifications are indicated for all patients with prehypertension and hypertension.
A priority consideration in the management of the older adult with hypertension is to
a. prevent primary hypertension from converting to secondary hypertension.
b. recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult.
c. ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption.
d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.
d. use careful technique in assessing the BP of the patient because of the possible presence of an auscultatory gap
Rationale: Careful technique is important in assessing BP in older adults. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats; such a wide interval is called an auscultatory gap. Failure to inflate the cuff high enough may result in a serious underestimate of systolic BP.
A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient?
a. Medication will be required because the BP is still not at goal.
b. BP monitoring should continue for another 3 months to confirm a diagnosis of hypertension.
c. Lifestyle changes are less important, since they were not effective, and medications will be started.
d. More vigorous changes in the patient’s lifestyle are needed for a longer time before starting medications.
a. Medication will be required because the BP is still not at goal
Rationale: The patient has hypertension, stage 1. Lifestyle modifications will continue, but drug initiation of therapy is a priority. Reduction of BP can help to prevent serious complications related to hypertension.
A patient is admitted to the hospital in hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategy(ies) would be most appropriate for this patient (select all that apply)?
a. Measuring hourly urine output
b. Decreasing the MAP by 50% within the first hour
c. Continuous BP monitoring with an arterial line
d. Maintaining bed rest and providing tranquilizers to lower the BP
e. Assessing the patient for signs and symptoms of heart failure and changes in mental status
a. Measuring hourly urine output
c. Continuous BP monitoring with an arterial line
e. Assessing the patient for signs and symptoms of heart failure and changes in mental status
Rationale: Measure urine output hourly to assess renal perfusion. Patients treated with IV sodium nitroprusside should have continuous intraarterial BP monitoring. Hypertensive crisis can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure, myocardial infarction, renal failure, dissecting aortic aneurysm, and retinopathy. The initial treatment goal is to decrease the mean atrial pressure (MAP) by no more than 25% within minutes to 1 hour. Patients receiving IV antihypertensive drugs may be restricted to bed rest. Getting up (e.g., to use the toilet/commode) may cause severe cerebral ischemia and fainting.
The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching?
“I will avoid adding salt to my food during or after cooking.”
“If I lose weight, I might not need to continue taking medications.”
“I can lower my blood pressure by switching to smokeless tobacco.”
“Diet changes can be as effective as taking blood pressure medications.”
“I can lower my blood pressure by switching to smokeless tobacco.”
Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure–lowering medication.
The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene?
Waiting 2 minutes after position changes to take orthostatic pressures
Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second
Taking the blood pressure with the patient’s arm at the level of the heart
Taking a forearm blood pressure because the largest cuff will not fit the patient’s upper arm
Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second
The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.
A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing instruction, which statement by the patient indicates correct understanding?
“If I take this medication, I will not need to follow a special diet.”
“It is normal to have some swelling in my face while taking this medication.”
“I will need to eat foods such as bananas and potatoes that are high in potassium.”
“If I develop a dry cough while taking this medication, I should notify my doctor.”
“If I develop a dry cough while taking this medication, I should notify my doctor.”
Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.
A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After one hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority?
Start an infusion of 0.9% normal saline at 100 mL/hr.
Maintain the current administration rate of the nitroprusside.
Request insertion of an arterial line for accurate blood pressure monitoring.
Stop the nitroprusside infusion and assess the patient for potential complications.
Stop the nitroprusside infusion and assess the patient for potential complications.
Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be approximately 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.
The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism?
Hypertension promotes atherosclerosis and damage to the walls of the arteries.
Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue.
Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems.
Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.
Hypertension promotes atherosclerosis and damage to the walls of the arteries.
Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.
In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL
Serum creatinine of 2.6 mg/dL
The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.
When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast
Roasted duck
Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.
The nurse is caring for a patient admitted with a history of hypertension. The patient’s medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy?
Weight loss of 2 lb
BP 128/86 mm Hg
Absence of ankle edema
Output of 600 mL per 8 hours
BP 128/86 mm Hg
Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.
The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration?
O2 saturation 93%
Pulse 48 beats/min
Respirations 24 breaths/min
Blood pressure 118/74 mm Hg
Pulse 48 beats/min
Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.
The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next?
Repeat BP and HR in this position.
Record the BP and HR measurements.
Take BP and HR with patient standing.
Return the patient to the supine position
Take BP and HR with patient standing.
The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine positon. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.
A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority?
Is the patient pregnant?
Does the patient need to urinate?
Does the patient have a headache or confusion?
Is the patient taking antiseizure medications as prescribed?
Does the patient have a headache or confusion?
The nurse’s priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.
When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)?
Systolic blood pressure increases with aging.
Blood pressures should be maintained near 120/80 mm Hg.
White coat syndrome is prevalent in elderly patients.
Volume depletion contributes to orthostatic hypotension.
Blood pressure drops 1 hour postprandially in many older patients.
Older patients will require higher doses of antihypertensive medications.
Systolic blood pressure increases with aging.
White coat syndrome is prevalent in elderly patients.
Volume depletion contributes to orthostatic hypotension.
Blood pressure drops 1 hour postprandially in many older patients.
Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.
The nurse is teaching a women’s group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)?
Lose weight. Limit nuts and seeds. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days.
Limit sodium and fat intake.
Increase fruits and vegetables.
Exercise 30 minutes most days.
Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.
