Hypertension

Question 1

Normal blood pressure

Answer 1

Less than 120/80

Question 2

Elevated blood pressure

Answer 2

120-129 / <80

Question 3

Hypertension stage 1

Answer 3

130-139 / 80-89

Question 4

Hypertension stage 2

Answer 4

> or equal to 140/ or equal 90

Question 5

Hypertensive crisis

Answer 5

> 180/ >120

Question 6

If someone’s systolic pressure was 125/ 82 what would be their blood pressure classification?

Answer 6

They would be in hypertensive crisis stage 1 because their diastolic pressure is between the 80-89 range.

Question 7

Correlate clinical manifestations of primary hypertension to pathological processes.

Answer 7

Primary hypertension is about 90% to 95% of adults with hypertension.

The cause with primary hypertension cannot be determined although probably result from environmental, lifestyles, and genetic factors.

Question 8

Correlate clinical manifestations of secondary hypertension to pathophysiological process’s.

Answer 8

Secondary hypertension is about 5% to 10% of all adults with hypertension.

Reason for secondary hypertension: kidney disease, thyroid disease, adrenal disease

Question 9

Hypertension is a silent killer because people who have it are often symptom free.
True or False

Answer 9

TRUE!

With prolonged high blood pressure, it damages the blood vessels (endothelium).
Inflammation in the endothelium causes atherosclerosis disease (dyslipidemia) which contributes to Myocardial Infarction, cerebrovascular accident and chronic kidney disease.

Question 10

One of the functions of the kidney is to regulate blood pressure by sending impulses to the RAAS.
True/ False

Answer 10

TRUE!

Activation of the RAAS increases blood pressure

Question 11

Aging with hypertension
1) Damage of the endothelium results in atherosclerosis

Answer 11

This makes it easier for fat deposits of cholesterol to stick in the endothelium, creating coronary artery disease and cerebrovascular disease.

This also increases the risk for aortic aneurysms.

Question 12

Aging with hypertension
2) Increased systolic blood pressure will also cause changes in the heart structure itself.

Answer 12

This can cause left ventricular hypertrophy because the heart has a harder, increased workload.
(It’s harder for the heart to pump the blood because of the stiffening (loss of elasticity) of the artery)

Question 13

Aging with hypertension
3) With hypertrophy there’s enlargement of the muscle, but a narrowing of the space that occupies the blood.

Answer 13

This results in a diastolic dysfunction and makes it harder for the heart to pump blood that is now systolic dysfunction and eventually leads to heart failure.

Question 14

Aging with hypertension
4) Decreased cardiac output minimizes the kidneys 25% of cardiac output.

Answer 14

Renal insufficiency occurs because the nephrons aren’t getting enough oxygen from the heart, less blood coming from the heart therefore the RAAS will be activated.

Question 15

Discuss the management of hypertension amongst older adults.

Elevated systolic blood pressure in isolation among older adults.

Answer 15

• Decreased elasticity and the accumulation of atherosclerotic plaque in the major blood vessels.
• Volume expansion associated with structural and functional changes in the kidney.
• Changes in the strength of cardiac contraction (left ventricular systolic dysfunction).

Question 16

Consider target blood pressure control to less than 130/80 in all adults including older adults with hypertension.

Answer 16

• Start low and go slow when starting antihypertensive medication among older adults
• As you grow older there will be an increase in systolic and diastolic blood pressure.
• Carefully monitor for orthostatic hypotension, falls, and reduced renal function.
• A less aggressive blood pressure target for older adults with multiple comorbidities, limited life expectancy, frequent falls and cognitive impairment; those who are 60 years or older with HX of stroke/ TIA, a target of systolic blood pressure of 140 is recommended to reduce the risk of recurrent stroke.

Question 17

What’s the usual blood pressure range for older adults?

Answer 17

Less than 130/80

Question 18

Risk factors of hypertension:

Answer 18

• Advancing adult age
• African American
• Chronic kidney disease-
• Diabetes
• Alcohol (more than 2 drink a day for men and more than 1 drink a day for women)
• Family history
• Gender: men have a greater risk until 64 yr of age. Women have a greater risk at age 65 and older.
• Hyperholesterolemia
• Overweight/obesity
• Poor diet habits, particularly if it includes or much salt, as well as limited intake of vegetables, fiber, fish fats, and potassium.
• Sedentary lifestyle
• Use of tobacco, nicotine products, and exposure to second hand smoke.
• Stress
• Sleep apnea

Question 19

Common causes of secondary hypertension:

Answer 19

• Chronic kidney disease
• Cushing syndrome
• Hyperaldosteronism
• Hypo - Hyperthyroidism
• Medical abuse (NSAIDs, alcohol, cocaine, amphetamines)
• Obstructive sleep apnea
• Pheochromocytoma
• Preeclampsia
• Renal artery stenosis
• Polycystic kidney disease

Question 20

Low blood pressure/ orthostatic hypotension maybe related to impaired cardiovascular reflexes secondary to diuretics and other medication interactions.
True/ False

Answer 20

TRUE!

With impaired CV reflexes it’s harder for older adults to compensate right away when there’s a drop in blood pressure

Question 21

Gerontological considerations

Answer 21

• Be aware of finances, poly pharmacy, and inability to remember treatment plan.
• Make sure older adults understand, see, and read medication instructions as well as being able to open their medication containers and get Rx refills. (Caregivers should be included in the plan of care to encourage older adults adherence to treatment plan).
• Ensure regular follow up visits are followed (remind them to bring BP log and machine)
• Ask about potential medication-related problems such as orthostatic hypotension (dizziness/lightheadedness)
• Counsel how to be safe and prevent falls.

Question 22

Increased cardiac output =

Answer 22

Increased blood pressure

• Increase in BP is related to increased cardiac output and constriction of the blood vessels.
• Increased cardiac output is associated with volume expansion.

Question 23

Clinical manifestations of hypertension

Answer 23

When specific signs and symptoms appear, they usually indicate vascular damage, with specific manifestations related to the organs served by the involved vessels. These specific manifestations of pathophysiologic changes in various organs as a consequence of hypertension are referred to as target organ damage.

Retinal changes such as hemorrhages, exudates (fluid accumulation), arteriolar narrowing, and cotton-wool spots (small infarctions) may occur. In severe hypertension, papilledema (swelling of the optic disc) may be seen.

Coronary artery disease with angina and myocardial infarction (MI) are common consequences of hypertension. LVH occurs in response to the increased workload placed on the ventricle as it contracts against higher systemic pressure. When heart damage is extensive, heart failure follows.

Pathologic changes in the kidneys (indicated by increased blood urea nitrogen [BUN] and serum creatinine levels) may manifest as nocturia. Cerebrovascular involvement may lead to a transient ischemic attack (TIA) or stroke, manifested by alterations in vision or speech, dizziness, weakness, a sudden fall, or transient or permanent hemiplegia (paralysis on one side). Cerebral infarctions account for most of the strokes in patients with hypertension

Question 24

Describe the lifestyle modifications for hypertension

Answer 24

These lifestyle changes could include weight loss, dietary changes, physical activity modifications, decreased alcohol consumption, and smoking cessation. In particular, the Dietary Approach to Stop Hypertension (DASH) diet has been one of the most effective diets in lowering BP; if used in conjunction with weight loss, this diet can lower SBP by 11 to 16 mm Hg.
In addition to this dietary advice, patients should be counseled to incorporate a low sodium (less than 2 g/day), high potassium (3500 to 5000 mg/day) diet; this dietary combination is more effective than following either a lone low sodium or high potassium diet.

A high potassium diet must be avoided in patients with chronic kidney disease

Question 25

Physical activity for lifestyle mods in hypertension:

Answer 25

Engage in:
Regular aerobic activity such as brisk walking 90-150 min weekly.
Regular dynamic resistance training 90-150 min weekly.
Regular isometric resistance training at least three times weekly.

Question 26

Describe the medication therapy for hypertension

Answer 26

The first line antihypertensives to prevent CV disease are Thiazide or thiazide-like diuretics, ACE inhibitors, ARBs, and calcium channel blockers.

Question 27

What meds do we give to African Americans without heart failure or chronic kidney disease?

Answer 27

Thiazide-like diuretics or calcium channel blocker as a first line hypertensive med.

NOT ACEs or ARBs because they have a low renin profile

Question 28

Gentorologic considerations of hypertensive medications

Answer 28

Thiazide/loop diuretics- have a high risk for orthostatic hypotension
ACE inhibitors- require reduced dosages and the addition of a loop diuretic when there is a renal dysfunction.

Question 29

Hypertensive urgency =

Answer 29

No evidence of target organ damage
Meaning no signs or symptoms

Ex: no chest pain, no headache, no double vision, no TIA, no kidney issues

We give a fast acting antihypertensive agent orally

Question 30

Hypertensive emergency =

Answer 30

Life-threatening blood pressure that requires immediate treatment to prevent target organ damage.
There is target organ damage.
Ex: Myocardial infarction, intracranial hemorrhage

Meds are given through IV

Question 31

In a hypertensive emergency why do we taper the blood pressure down slowly instead of brining it back to a normal BP immediately?

Answer 31

Use of intravenous vasodilators to gradually decrease SBP by no more than 25% within the 1st hour; 160/100mmHg within 2 to 6 hours; normal/controlled BP within 24-48 hours.

Because the body was used to the level of perfusion it was receiving with the high blood pressure. We don’t wan to drop it immediately to prevent injury and decreased tissue perfusion.

Question 32

What should hypertensive clients limit their daily sodium intake to?

Answer 32

No more than 2000 mg daily

Question 33

What are the lab values in kidney damage?

Answer 33

Creatinine in the blood = high
Creatinine in the urine = low
Protein in the blood = low
Protein in the urine = high

Indication of protein in the urine means kidney damage

Question 34

Assessment & diagnostic findings of hypertension

Answer 34

• The first step of diagnosing HTN is an accurate blood pressure measurement.
  It’s important to use an average of at least two blood pressure readings on at least two occasions to confirm the diagnosis

The exception is when a patients average BP is greater than or equal to 160/100mmHg, confirmed by at least two accurate readings

Question 35

Estrogen is thought to be a protective agent against cardiovascular disease in women
True/False

Answer 35

TRUE!

Women have a greater risk at 65 yrs or older for CV disease due to menopause.

Question 36

Pathophysiology of hypertension

Answer 36

1) Increased sympathetic nervous system activity (increase in epinephrine = increase in blood)
- Peripheral vascular disease

2) Increased renal reabsorption of sodium, chloride and water
- Cardiac output

3) Increased activity of the RAAS
- Peripheral vascular disease and cardiac output

4) Decreased vasodilation of the arterioles ( nitric oxide- natural substance in endothelium that vasodilators the blood vessels)
- Peripheral vascular disease

5) Resistance in insulin action (insulin resistance for diabetic patients with increased BP)
- Inflammatory

6) Activation of the innate and adaptive components of the immune response (constant stress/constant inflammation = increase in BP)
- Inflammatary

Question 37

Hypertension is a result of a complex interaction between behavioral-social-environmental risks and genetics.
True/False

Answer 37

TRUE!