Assessment and Management of Patients With Hypertension

1. Assessment and Management of Patients With Hypertension

2. Hypertension • High blood pressure • Defined by the Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg. based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider

3. Classification of Blood Pressure for Adults Age 18 and Older

4. Incidence of Hypertension— “The Silent Killer” • Primary hypertension. • Secondary hypertension. • 28–31% of the adult population of the U.S. has hypertension. • 90–95% of this population with hypertension has primary hypertension. • Incidence is greater in southeastern U.S. and among African-Americans.

5. Factors Involved in the Control of Blood Pressure

6. Common Peripheral Vascular • Primary Hypertension • Pathophysiologic causes • Sympathetic nervous system overstimulation • Alterations of the renin-angiotensin-aldosterone system • Chemical mediators of vasomotor tone and blood volume • Interaction between insulin resistance, hyperinsulinemia and endothelial function

7. Common Peripheral Vascular

8. Common Peripheral Vascular

9. Common Peripheral Vascular

10. Manifestations of Hypertension • Usually NO symptoms other than elevated blood pressure • Symptoms seen related to organ damage are seen late and are serious • Retinal and other eye changes • Renal damage • Myocardial infarction • Cardiac hypertrophy • Stroke

11. Common Peripheral Vascular • Manifestations • Initially asymptomatic • Headache, confusion • Nocturia • Nausea and vomiting • Visual disturbances • Complications • Cardiovascular • Neurologic • Renal systems.

12. Common Peripheral Vascular • Secondary Hypertension • Related to a specific underlying cause • Kidney disease • Coarctation of the aorta • Endocrine disorders • Neurologic disorders • Drug use • Pregnancy

13. Major Risk Factors • Hypertension • Smoking • Obesity • Physical inactivity • Dyslipedemia • Diabetes mellitus • Microalbuminuria or GFR < 60 • Older age • Family history

14. Patient Assessment • History and Physical • Laboratory tests • Urinalysis • Blood chemistry • Cholesterol levels • ECG

15. JNC 7 Treatment Algorithm Refer to fig. 32-2

16. JNC 7 Treatment Algorithm

17. Persons with diabetes mellitus or chronic renal disease as evidenced by a reduced GFR or an elevated serum creatinine have a lower goal pressure of 130/80 (JNC 7).

18. Lifestyle Modifications • Weight loss • Reduced alcohol intake • Educed sodium intake • Regular physical activity • Diet: high in fruits, vegetables, and low-fat dairy • DASH diet

20. Medication Treatment • Usually initial medication treatment is a thiazide diuretic. • Low doses are initiated and the medication dosage is increased gradually if blood pressure does not reach target goal. • Additional medications are added if needed. • Multiple medications may be needed to control blood pressure. • Lifestyle changes initiated to control BP must be maintained.

21. Medication Therapy for Hypertension • Diuretic and related drugs • Thiazide diuretics • Loop diuretics • Potassium sparing diuretics • Aldosterone receptors blockers • Central alpha2-agonists and other centrally acting drugs • Beta-blockers • Beta-blockers with intrinsic sympathomimetic activity • Alpha and beta blockers

22. Medication Therapy for Hypertension (continued) • Vasodilators • Angiotensin-converting enzyme (ACE) inhibitors • Angiotenisin II antagonists • Calcium channel blockers

23. Recommendations for Follow-up Based on Initial Blood Pressure Readings

24. Nursing History and Assessment • History and risk factors • Assess potential symptoms of target organ damage • Angina, shortness of breath, altered speech, altered vision, nosebleeds, headaches, dizziness, balance problems, nocturia • Cardiovascular assessment: apical and peripheral pulses • Personal, social, and financial factors that will influence the condition or its treatment

25. Goals: • Patient understanding of disease process • Patient understanding of treatment regimen • Patient participation in self-care • Absence of complications

26. Nursing Diagnoses • Knowledge deficit regarding the relation of the treatment regimen and control of the disease process • Noncompliance with therapeutic regimen related to side effects of prescribed therapy

27. Interventions • Patient teaching • Support adherence to the treatment regimen • Consultation/collaboration • Follow-up care • Emphasize control rather than cure • Reinforce and support lifestyle changes • A lifelong process

28. Gerontologic Considerations • Noncompliance • Include family • Understanding of therapeutic regimen • Reading instructions • Monotherapy

29. Hypertensive Crises • Hypertensive emergency • Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs • Hypertensive urgency • Blood pressure is very high but no evidence of immediate or progressive target organ damage

30. Hypertensive Emergency • Reduce BP 25% in first hour. • Reduce to 160/100 over 6 hours. • Then gradual reduction to normal over a period of days. • Exceptions are ischemic stroke and aortic dissection. • Medications • IV vasodilators: sodium nitroprusside, nicardipine, fenodopammesylate, enalaprilat, nitrogylcerin • Need very frequent monitoring of BP and cardiovascular status.

31. Hypertensive Urgency • Patient requires close monitoring of blood pressure and cardiovascular status. • Assess for potential evidence of target organ damage. • Medications • Fast-acting oral agents: beta adrenergic blocker— labetalol; angiotensin-converting enzyme inhibitor— captopril; or alpha2-agonist—clonidine