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Focus on Hypertension

Focus on Hypertension. Hypertension Definition. Persistent elevation of Systolic blood pressure ≥140 mm Hg or Diastolic blood pressure ≥90 mm Hg or Current use of antihypertensive medication(s). Prehypertension Definition. Systolic blood pressure:120–139 mm Hg Or

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Focus on Hypertension

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  1. Focus on Hypertension

  2. HypertensionDefinition • Persistent elevation of • Systolic blood pressure ≥140 mm Hg or • Diastolic blood pressure ≥90 mm Hg or • Current use of antihypertensive medication(s)

  3. PrehypertensionDefinition • Systolic blood pressure:120–139 mm Hg Or • Diastolic blood pressure:80–89 mm Hg

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

  5. Factors Influencing BP

  6. Hypertension classifications • Primary hypertension • Also called idiopathic or essential • Increased blood pressure without an identified cause • Covers 90-95% of all cases of HTN • Secondary hypertension • Increased blood pressure with a specific cause that can be identified and corrected

  7. Causes of secondary hTN • Cirrhosis • Narrowing of the aorta • Endocrine disorders • Medications • Neurologic disorders • Pregnancy induced HTN • Renal disease • Sleep apnea

  8. Blood Pressure Classification

  9. Hypertension • For persons over age 50, SBP is more important than DBP as a CVD risk factor • Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN

  10. Risk Factors for Primary Hypertension • Age • Alcohol • Cigarette smoking • Diabetes mellitus • Elevated serum lipids • Excess dietary sodium • Gender • Family history • Obesity • Ethnicity • Sedentary lifestyle • Socioeconomic status • Stress

  11. HypertensionClinical Manifestations • Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs

  12. HypertensionClinicalManifestations • Symptoms are often secondary to target organ disease and can include • Fatigue, reduced activity tolerance • Dizziness • Palpitations, angina • Dyspnea

  13. HypertensionComplications • Target organ diseases occur most frequently in the • Heart • Brain • Peripheral vasculature • Kidney • Eyes

  14. HypertensionComplications • Hypertensive heart disease • Coronary artery disease • Left ventricular hypertrophy • Heart failure Fig. 33-3: Top, normal heart; Bottom, left ventricular hypertrophy

  15. HypertensionComplications • Cerebrovascular disease • Stroke • Peripheral vascular disease • Nephrosclerosis • Retinal damage

  16. HypertensionDiagnostic Studies • History and physical examination • BP measurement in both arms • Use arm with higher reading for subsequent measurements • BP highest in early morning, lowest at night

  17. HypertensionOffice BP Measurement • Use auscultatory method with a properly calibrated instrument • Patient should be seated quietly for 5 min in a chair, feet on the floor, and arm supported at heart level • Appropriate-sized cuff is necessary to ensure accurate reading • At least two measurements should be obtained

  18. The correct technique for blood pressure measurements includes • Always taking the blood pressure in both arms • Releasing the pressure in the cuff at a rate of 1 mm Hg per second • Inflating the cuff 5 mm Hg higher than the expected systolic pressure • Taking additional readings if the first two readings differ more than 10 mm Hg

  19. HypertensionDiagnosticStudies • Urinalysis, creatinine clearance • Serum electrolytes, glucose • BUN and serum creatinine • Serum lipid profile • ECG • Echocardiogram

  20. HypertensionDiagnosticStudies • “White coat” phenomenon may precipitate the need for ambulatory blood pressure monitoring (ABPM) • Uses a noninvasive, fully automated system that measures BP at preset intervals over a 24-hour period

  21. Treatment Algorithm for Hypertension

  22. Hypertension CollaborativeCare • Overall goals • Control blood pressure • Reduce CVD risk factors • Strategies for adherence to regimens • Empathy increases patient trust, motivation, and adherence to therapy • Consider patient’s cultural beliefs and individual attitudes in formulating treatment goals

  23. Benefits of Lowering BP

  24. HypertensionCollaborativeCare • Lifestyle modifications • Weight reduction: • Weight loss of 10 kg (22 lb) may decrease SBP by ~ 5 to 20 mm Hg • Dietary Approaches to Stop Hypertension (DASH) Diet • Low sodium • <2.4 g of sodium/day • Low fat • Limited starchy foods • Increased vegetable and fruit intake

  25. HypertensionCollaborativeCare • Lifestyle modifications • Moderation of alcohol consumption: • Men: no more than 2 drinks/day • Women: no more than 1 drink/day • Physical activity: • Regular physical (aerobic) activity, at least 30 minutes, most days of the week • Avoidance of tobacco products • Stress management

  26. HypertensionCollaborativeCare • Drug therapy: • Primary actions of drugs to treat hypertension • Reduce SVR • Reduce volume of circulating blood • Classifications of drugs used to treat HTN • Diuretics • Adrenergic inhibitors • Direct vasodilators • Angiotensin inhibitors • Calcium channel blockers

  27. HypertensionCollaborative Care • Diuretics • Inhibit NaCl reabsorption in the tubules • Increases excretion of Na and Cl • Potassium-sparing diuretics reduce excretion of K+ • Types: • Thiazide diuretics: • hydrochlorothiazide (HydroDiuril), metolazone (Zaroxolyn) • Loop Diuretics: • bumetanide (Bumex) furosemide (Lasix), torsemide (Demadex) • Potassium-sparing diuretics: • triamterene (Dyrenium) • Aldosterone Receptor Blockers: • spironolactone (Aldactone)

  28. HypertensionCollaborativeCare • What will you monitor in patients taking diuretics? • I & O • Daily Weight • Electrolyte abnormalities • Potassium • Sodium • BP • Orthostatic hypotension • Ototoxicity (Lasix) • Dizziness, vertigo

  29. HypertensionCollaborative Care • Adrenergic inhibitors • Central-Acting α-1 Adrenergic Antagonists • Reduce sympathetic outflow from CNS • Reduces peripheral sympathetic tone, produces vasodilation, decreases SVR and BP • Types: • Clonidine (Catapress) • Methyldopa (Aldomet)

  30. HypertensionCollaborativeCare • Adrenergic inhibitors • α-1 Adrenergic Blockers • Block α-1 adrenergic effects, producing peripheral vasodilation (decreases SVR and BP) • Types: • Doxazosin (Cardura), Prozosin (Minipress), Terazosin (Hytrin) • β-Adrenergic Blockers • Decrease CO and reduce vasoconstrictor tone • Types: • Atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal)

  31. HypertensionCollaborativeCare • What will you monitor in patients taking Adrenergic-Blockers? • Dry mouth • Central-Acting α-1 Adrenergic Antagonists • BP • Orthostatic hypotension • Retention of salt and water • α-1 adrenergic blockers • Bronchospasm • β-Adrenergic Blockers • Bradycardia • β-Adrenergic Blockers

  32. HypertensionCollaborative Care • Direct vasodilators • Reduce SVR and BP by arterial vasodilation • Types: • Hydralazine (Apresoline), nitroglycerin (Tridil), sodium nitroprusside (Nipride) • What will you monitor for? • BP • Tachycardia • Flushing • Palpitations • Dizziness • Angina • Headache

  33. HypertensionCollaborativeCare • Angiotensin inhibitors • Angiotensin-Converting Enzyme (ACE) Inhibitors • Reduce conversion of Angiotensin I to angiotensin II, prevent vasoconstriction • Types: captopril (Capoten), enalapril (vasotec), lisinopril (Prinivil) • Angiotensin II Receptor Blockers • Prevent action of angiotensin II and produce vasodilation and increased salt and water excretion • Types: irbesartan (Avapro), valsartan (Diovan)

  34. HypertensionCollaborative Care • What will you monitor? • Angiotensin-Converting Enzyme (ACE) Inhibitors • BP • Dizziness • Loss of taste • Hyperkalemia • ARF • Angiotensin II Receptor Blockers • Hyperkalemia • Decreased RF

  35. HypertensionCollaborative Care • Calcium channel blockers • Block movement of extracellular calcium into cells, causing vasodilation and decreased HR, contractility, and SVR • Types: • Amlodipine (Norvasc), diltiazem (Cardizem), nifedipine (Procardia), verapamil (Calan) • What will you monitor? • BP • Bradycardia • Headache, dizziness, peripheral edema, flushing

  36. HypertensionCollaborative Care • Drug therapy and patient teaching • Identify, report, and minimize side effects • Orthostatic hypotension • Sexual dysfunction • Dry mouth • Frequent urination

  37. HypertensionNursing Management • Nursing Assessment • Subjective data • Past health history • CV, renal, thyroid disease, DM, obesity • Medications • Prescription and OTC • Functional health patterns • Family history • Diet • Activity level • Stress • Objective data • Target organ damage • Peripheral pulses, abnormal heart sounds, BP >140/90

  38. HypertensionNursing Management • Nursing Diagnoses • Ineffective health maintenance r/t lack of knowledge • Anxiety r/t management regimen or lifestyle changes • Sexual dysfunction r/t medication side effects • Ineffective therapeutic regimen management r/t lack of knowledge, side effects of medications, return of blood pressure to normal while on medications • Ineffective tissue perfusion r/t complications of HTN (cerebral, CV, renal, retinal)

  39. HypertensionNursing Management • Collaborative problems • Potential complications: • Adverse effects from antihypertensive therapy (hypokalemia) • Hypertensive crisis • Stroke • Coronary artery disease (CAD) • Myocardial infarction

  40. Hypertensive Crisis • Severe, abrupt increase in DBP • defined as DBP >140 mm Hg • Rate of increase in BP is more important than the absolute value • Often occurs in patients with a history of HTN who have failed to comply with medications or who have been undermedicated

  41. Hypertensive Crisis • Hypertensive Emergency • Develops within hours to days • BP > 180/120 mm Hg • Acute target organ damage • May precipitate: • Hypertensive encephalopathy, cerebral hemorrhage • Acute renal failure • Myocardial infarction • Heart failure with pulmonary edema • Hyptertensive Urgency • Develops within days to weeks • No clinical evidence of target organ damage

  42. Hypertensive CrisisClinical Manifestations • Hypertensive Emergency • Hypertensive encephalopathy • Sudden rise in BP associated with HA, N/V, seizures, confusion, coma • May also have blurred vision and transient blindness • Due to increased cerebral capillary permeability leading to cerebral edema and disruption in cerebral function • Renal insufficiency • CV decompensation • Unstable angina • MI • Pulmonary edema

  43. Hypertensive CrisisNursing and Collaborative Management • Hospitalization • IV drug therapy • Sodium nitroprusside (Nipride) – MOST EFFECTIVE • Titrated to mean arterial pressure (SBP + 2 DBP) 3 MAP =

  44. Hypertensive CrisisNursing and Collaborative Management • Nursing Interventions • Monitor BP and HR every 3-5 minutes • Titrate med based on MAP • DO NOT DECREASE BP TO QUICKLY – may cause stroke, MI • Continual ECG monitoring • Hourly UO • Strict BP • Neurologic checks • LOC, pupil checks, movement and strength of extremities • CV and Respiratory assessment • pulmonary edema, HF, angina

  45. Hypertensive CrisisNursing and Collaborative Management • Hypertensive Urgency • Managed with oral medications • Difficult to regulate drugs • Need follow-up within 24 hours • May not need hospitalization • Nursing Interventions • Provide quiet environment • Encourage patient to verbalize concerns • Answer questions • Eliminate stimuli • Determine cause • Education to avoid future crises

  46. HypertensionNursing Management • Planning: Patient will • Achieve and maintain the individually determined goal BP • Understand, accept, and implement the therapeutic plan • Experience minimal or no unpleasant side effects of therapy • Be confident of ability to manage and cope with this condition

  47. HypertensionNursing Management Nursing Implementation • Health Promotion • Individual patient evaluation • Risk factors • Routine BP • Health assessment • Weight patterns • Family history • Blood pressure measurement • Screening programs • Cardiovascular risk factor modification • Modifiable: HTN, DM, obesity, tobacco cessation, physical inactivity

  48. HypertensionNursing Management Nursing Implementation Ambulatory and Home Care • Patient and family teaching includes • Nutritional therapy • Drug therapy • Physical activity • 30 minutes/day most days of week • Home monitoring of BP (if appropriate) • Rest 3-5 minutes prior to taking BP • No smoking, exercise or caffeine 30 minutes prior • Take daily and record in log • Tobacco cessation (if applicable)

  49. HypertensionNursing Management Nursing Evaluation • Patient will • Achieve and maintain goal BP as defined for the individual • Understand, accept, and implement the therapeutic plan • Experience minimal or no unpleasant side effects of therapy

  50. Hypertension in Older Persons • Isolated systolic hypertension (ISH) is the most common form of hypertension in individuals age >50 • The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age >65) normotensive men and women • Why? • Loss of elasticity, increased PVR, blunting of baroreceptors, decreased renal function, decreased renin production

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