Exam 2- Assessment & Management of Patients with Hypertension Flashcards
90-95% of patients; unidentifiable cause
Primary hypertension: essential
5-10% of patients; renal disease, sleep apnea, pregnancy related
Secondary hypertension
What % of adults in the US have HTN?
33%
Highest prevalence of HTN in what ethnicity?
African Americans
Symptoms r/t organ damage are seen early or late?
Late
HTN can result from…
Increases in cardiac output, peripheral resistance, or both
HTN is a dysfunction of what?
Autonomic nervous system
What system is increased with HTN?
Renin-angiotensin-aldosterone system
HTN has a resistance to…
Insulin action
HTN causes an activation of what system?
Immune system
Masked HTN
BP that is suggestive of HTN that is paradoxically normal in health care settings
White coat HTN
Hypertensive BP readings in the health care setting that is paradoxically normal ranges in other settings
Abnormal physical examination findings with HTN
- Absent or weak pulses
- Additional cardiac sounds: murmurs, rubs
- Retinal hemorrhages
- Distended jugular veins
- Renal artery bruit
Assessment of HTN
- History and risk factors
- Assess potential symptoms of target organ damage
- CV assessment (apical and peripheral pulses)
- Personal, social, and financial factors that will influence the condition or its treatment
Prevalence of HTN: Highest rate and what percentage
Greater than or equal to 65 years of age (69.7%)
Prevalence of HTN: Non-Hispanic blacks percentage
38.6%
Of those with HTN, prevalence with pharmacological treatment percentage
69.9%
Prevalence of Treatment: Lowest among what age group and what percentage?
18-39 years
37.4%
Prevalence of Treatment: Mexican Americans percentage
56.1%
Prevalence of Treatment: Those without a source of medical care
19.8%
Prevalence of Treatment: Those who had received medical care less than twice during previous year
33.8%
Prevalence of Treatment: Those without healthcare insurance
43.5%
HTN: Normal Systolic and Diastolic
Systolic: Less than 120
Diastolic: Less than 80
Prehypertensive Systolic and Diastolic
Systolic: 120-139
Diastolic: 80-89
Stage 1 HTN Systolic and Diastolic
Systolic: 140-159
Diastolic: 90-99
Stage 2 HTN Systolic and Diastolic
Systolic: Greater than or equal to 160
Diastolic: Greater than or equal to 100
Hypertensive Crisis: Systolic and Diastolic
What do you do?
Systolic: higher than 180
Diastolic: higher than 120
Consult your doctor immediately
HTN is based on what?
The average of two or more accurate BP measurements taken 1-4 weeks apart by a HC provider
Primary Hypertension
High blood pressure from an undetermined cause
Secondary Hypertension
High blood pressure with an identifiable cause
Examples of Secondary Hypertension (6)
- Renal parenchymal disease
- Hyperaldosteronism
- Medications (prednisone, epoetin)
- Coarctation of the aorta
- Pregnancy
- Sleep apnea
HTN Risk Factors (13)
- Ethnicity (especially African American)
- Obesity
- Age
- Genetics (family history)
- Diet
- Sedentary lifestyle
- ETOH Consumption
- Smoking (also increased for those with CV conditions, including HF, CAD, and HX of stroke)
- Obstructive Sleep Apnea
- Physical inactivity
- Dyslipidemia
- Diabetes mellitus
- Microalbuminuria or GFR <60 mL/min
HTN Clinical Manifestations: Symptomatic or Asymptomatic?
Asymptomatic (“silent killer”)
HTN Clinical Manifestations: When specific S/S occur, typically indicative of…
Vascular damage with manifestations related to organs served by involved vessels
HTN Clinical Manifestations Examples
- Retinal damage or other eye changes
- Renal damage
- MI
- Heart failure
- Cardiac hypertrophy (Left Ventricular)
- Stroke
- Peripheral arterial disease
Assessment & Diagnostics (5)
- History and physical examination
- Retinal exam
- Laboratory Studies (urinalysis and blood chemistry)
- 12 Lead ECG
- 2D Echo
- Risk Factor Assessment for CVD
What lab studies do we do for HTN?
- Blood Chemistry (NA, K, fasting glucose)
- BUN/CR
- Urinalysis
- Total and HDL cholesterol levels
Risk Factors for CVD in Patients with Hypertension (8)
- Smoking
- Obesity
- Diabetes
- Physical Inactivity
- Impaired Renal Function (GFR less than 60mL/min)
- Age (greater than 55 for men, greater than 65 or women)
- Family history of CVD
- Dyslipidemia (elevated LDL, or total cholesterol and/or low HDL)
Medical Management for HTN: Goal maintained BP
140/90 mmHg or lower
Medical Management for HTN: Goal maintained BP for patients older than 60
150/90 mmHg
What does a maintained goal BP allow for?
Clinical judgement and individual patient considerations
Medical Management HTN: Treatment
Optimal treatment plan is inexpensive, simple, and least disruptive
Medical Management for HTN: Lifestyle Modifications (4)
- Weight loss
- DASH diet
- Physical activity
- Moderate alcohol consumption
Medical Management for HTN
- Pharmacological Treatment
What is the Pharmacological Treatment used for?
To decrease peripheral resistance, blood volume, or the strength and rate of myocardial contraction
Initial medications (for those with uncomplicated HTN)
- ACE or ARB
- Diuretics
- Beta Blockers
- Combination
-Vasodilators
- Alpha1 blockers
- CCBs
- Dihydropyridines
- Direct renin inhibitors
How does dosing work for initial medications with HTN?
Doses increased gradually until target BP met
- Additional medications added as necessary to achieve control
Why is the simplest treatment schedule used for HTN?
To promote adherence (ideally one pill per day)
Controlling high BP may benefit from a ___, between HC systems, HC providers, and patients working together
Team-Based Approach
Nursing Care & Management for HTN. What does this include?
- History and physical assessment
Include: - Assessment of risk factors
- Accurate BP measurement
- Assessment of impact of HTN on body and other personal, social, or financial factors
Nursing Diagnoses for HTN (2)
- Deficient knowledge regarding the relation between the treatment regimen and control of the disease process
- Noncompliance with therapeutic regimen related to side effects of prescribed therapy
Collaborative Problems for HTN (7)
- Left ventricular hypertrophy
- Myocardial infarction
- TIA
- Heart failure
- Stroke
- Renal insufficiency or failure
- Retinal hemorrhage
Planning & Goals for HTN (3)
- Understanding disease process and treatment
- Participation in a self-care program
- Absence of complications
Nursing Interventions for HTN (5)
- Promotion of adherence to treatment regimen (compromises may be necessary, support pt’s making even small changes, and support groups)
- Education
- Taking medication as prescribed
- Consultation with collaborative team (Dietician)
- Follow up care
- Emphasis on life long process and changes
- Monitoring for potential complications
Evaluation for HTN
- Reports knowledge of disease management sufficient to maintain adequate tissue perfusion
- Adheres to the self-care program
- Absence of Complications
- Maintains BP at less than 130/80 mmHg with lifestyle modification, meds, or both
- Palpable peripheral pulses
- Stable BUN and serum creatinine levels
Gerontologic Considerations for HTN
- Medication regimen can be difficult to remember
- Expense can be a challenge
- Monotherapy
- Ensure that older adult patients understand the regimen and can see and read instructions, open medication containers, and get prescriptions refilled
- Include family and caregivers in educational program
Evaluation for HTN: Reports knowledge of disease management sufficient to maintain adequate tissue perfusion (examples)
- Maintains BP at less than 1430/80 mmHg with no symptoms of angina, palpitations, or vision changes
- Stable BUN and serum creatinine levels
- Palpable peripheral pulses
Evaluation for HTN: Adheres to the self-care program (examples)
- Reduces calorie, Na, and fat intake
- Exercises regularly
- Takes medications as prescribed and reports side effects
- Measures BP
- Abstains from tobacco and excessive alcohol intake
- Keeps appointments
Gerontologic Considerations for HTN: Monotherapy
If appropriate, may simplify the medication regimen and make it less expensive
Gerontologic Considerations for HTN: Medication regimen can be difficult to remember
- May predispose to orthostatic hypotension
- May also be more sensitive to volume depletion from diuretic therapy
Hypertension signs and symptoms: ABC
Achy head
Blurred vision (retinopathy)
Chest pain (angina)
BP over 180/120: BCDE
Immediate IV drugs
Beta blockers (B- blocks beats)
CCBs (C- calms the heart)
Dilators (Vasodilators) (Nitro = pillow)
HTN Causes: SODA
- Stress, Smoking, Seditary Lifestyle
- Obesity, Oral contraceptives (BC)
- Diet (High sodium & Cholesterol), Diseases (DR. HH) (DM, Renal Disease, HF, Hyperlipidemia)
- African men & Age (old)
HTN Treatments: DRESS
- Diet: low SCC (sodium, calories, cholesterol)
- Reduce alcohol & caffeine
- Exercise: Walking (30 min x 5 days/week)
- Stop smoking & alcohol
- Stress reduction
HTN Risk Factors that can’t be changed (3)
- increasing age
- male gender
- heredity (including race)
HTN Risk Factors that you CAN change (6) & Other Factors to consider
- tobacco smoke and vaping
- high blood cholesterol
- high BP
- physical inactivity
- obesity and being overweight
- diabetes
Other factors to consider:
Stress, sleep, alcohol, and diet/nutrition
For patients with uncomplicated, hypertension, and no specific indicators for another medication, what is the initial medication?
Thiazide diuretic, like hydrochlorothiazide
The nurse is preparing an education plan for a patient newly diagnosed with hypertension. What should be included in the education plan?
Engage in regular aerobic physical activity such as brisk walking (at least 30 mins/day most days of the week)
An 84 year old male newly diagnosed with primary hypertension, has just been started on a beta-blocker. Your nursing education for this patient should include, what?
Use of strategies to prevent falls stemming from postural hypotension
A nurse is providing dietary advice to a patient newly diagnoses with HTN. Which of the following meal options should the nurse recommend?
A) Fried chicken with mashed potatoes and carrots
B) Salmon with broccoli and brown rice
C) Pepperoni pizza with vegan cheese
D) Bacon cheeseburger with a side of chips
B) Salmon with broccoli and brown rice
Because all other options have a heavy intake of sodium, cholesterol, processed fods, red meat, and sugary beverages.
Stage 1 HTN medication treatment for African Americans and ppl over 60 years
- CCBs (-dipine)
- Thiazide diuretic (-thiazide)
Stage 1 HTN medication treatment for non-African Americans and ppl under 60 years
- ACE (-pril)
- ARB (-sartan)
Medication treatment for patients with uncomplicated HTN and no specific indications for another medication
Thiazide diuretic
Symptoms of HTN target organ damage
- Angina
- SOB
- Altered speech
- Altered vision
- Nose bleeds
- Headaches
- Dizziness
- Balance problems
- Nocturia
Collaborative problems and potential complications
- Left ventricular hypertrophy
- MI
- HF
- Transient ischemic attack (TIA)
- Cerebrovascular disease (CVA, stroke, or brain attack)
- Renal insufficiency and CKD
- Retinal hemorrhage
HTN outcomes (7)
Effectively manages health program
- Adheres to the dietary regimen as prescribed: reduces calorie, sodium, and fat intake; increases fruits and vegetable intake
- Exercises regularly
- Takes meds as prescribed and reports SE
- Measures BP routinely
- Abstains from tobacco and excessive alcohol intake
- Keeps follow-up appointments
Outcomes of HTN (vision)
Reports no changes in vision; exhibits no retinal damage on vision testing
Outcomes of HTN (HR and lungs)
Maintains pulse rate and rhythm and respiratory rate within normal ranges; reports no dyspnea or edema
Outcomes of HTN (renal)
Maintains urine output consistent with intake; has renal function test results within normal range
Outcomes of HTN (motor)
Demonstrates no motor, speech, or sensory deficits
Outcomes of HTN (s/s)
Reports no headaches, dizziness, weakness, changes in gait, or falls
Hypertensive emergency
BP >180/120 mmHg with signs of end-organ damage; must be lowered immediately to prevent further damage to target organs
Signs of end-organ damage
- Chest pain
- Vision changes
- AMS
- Reduced urine output
Hypertensive urgency
BP >180/120 mmHg but no evidence of immediate or progressive target organ damage
Which of the following is a priority nursing assessment when caring for the patient in a hypertensive crisis receiving intravenous vasodilators?
A) Pain
B) I&O
C) Vision
D) Family history
B) I&O
What to do in a hypertensive emergency?
- Reduce BP by no more than 25% in first hour
- Reduce to 60/100 mmHg within 2-6 hours
- Then gradual reduction to normal 24-48 hours of treatment
- Meds (IV vasodilators)
- Need very frequent monitoring of BP and CV status
Medications to take in a hypertensive emergency
IV Vasodilators:
sodium nitroprusside
nicardipine
fenoldopam mesylate
enalaprilat
nitroglycerin
What to do in a hypertensive urgency?
- Oral agents can be administered w he goal of normalizing BP within 24-48 hours
- Fast-acting oral agents
- Patient requires close monitoring of BP and CV status
- Assess for potential evidence of target organ damage
Medications to take in a hypertensive urgency
Fast-acting oral agents:
- Beta-adrenergic blocker: labetalol (-lol drugs)
- Angiotensin-converting enzyme inhibitor: captopril (-pril drugs)
- Alpha2-agonist: clonidine (-ine drugs)
Exceptions for hypertensive emergency
Ischemic stroke and aortic dissection
For confirmation of a BP diagnosis, how many readings do you need?
2
Which condition(s) indicates target organ damage from untreated/undertreated hypertension? Select all that apply.
Heart failure
Retinal damage
Diabetes
Hyperlipidemia
Stroke
Heart failure
Retinal damage
Stroke
The nurse is performing an assessment on a client to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.)
Heart rate
Respiratory rate
Heart rhythm
Character of apical and peripheral pulses
Lung sounds
Heart rate
Heart rhythm
Character of apical and peripheral pulses
Which describes a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage?
Hypertensive emergency
The nurse is teaching a client about chronic untreated hypertension. What complication will the nurse explain to the client?
Stroke
Management of hypertension includes three of the following four goals, depending on the primary and secondary causes. Select all that apply.
Impairing the synthesis of norepinephrine.
Modifying the rate of myocardial contraction.
Increasing the force of cardiac output to overcome peripheral resistance.
Decreasing renal absorption of sodium.
Impairing the synthesis of norepinephrine.
Modifying the rate of myocardial contraction.
Decreasing renal absorption of sodium.
