Hypertension refers to a state where a person’s blood pressure remains at an elevated level at all

times. This condition is formally known as arterial hypertension and is popularly called high blood
pressure.

Two types of hypertension:

Primary Hypertension – when a patient’s chronically elevated blood pressure does not have a
specific medical cause that can be identified
Secondary Hypertension – When high blood pressure is caused by other health conditions like
tumors of the adrenal gland, kidney disease of other problems.
Hypertension is a dangerous condition because it can lead to serious complications. Chronically
elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial
aneurysm and strokes. Many cases of chronic renal failure have been linked to high blood
pressure.

Signs and Symptoms:

Undiagnosed high blood pressure can lead to many physical problems including damage to major
organs over a period of time. The symptoms of hypertension, if ignored, can lead to deterioration
in kidney / liver function and cardiac problems. Hypertension can also damage vision, cause
strokes and more.

Here are some of the common hypertension symptoms to be aware of.

Recurrent / persistent headaches

Vision problems including blurring of vision
Giddiness
Convulsions
Tremors in the hands or other body parts
Walking difficulties (formally called ataxia)

INTRODUCTION

Hypertension is one of the most common worldwide diseases afflicting humans. Because of the
associated morbidity and mortality and the cost to society, hypertension is an important public
health challenge. Over the past several decades, extensive research, widespread patient
education, and a concerted effort on the part of health care professionals have led to decreased
mortality and morbidity rates from the multiple organ damage arising from years of untreated
hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease
(the leading cause of death in North America), stroke (the third leading cause), congestive heart
failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care
professionals must not only identify and treat patients with hypertension but also promote a
healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the
general population.

• Pre-hypertension – Systolic blood pressure (SBP) 120-139 or diastolic blood pressure(DBP)

80-89
• Stage I HTN – SBP 140-159 or DBP 90-99
• Stage II HTN – SBP >160 or DBP >100

Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled BPs

leads to progressive or impending target organ dysfunction (TOD). The clinical distinction
between hypertensive emergencies and hypertensive urgencies depends on the presence of
acute TOD and not on the absolute level of the BP.

Hypertensive emergencies represent severe HTN with acute impairment of an organ system (eg,
central nervous system [CNS], cardiovascular, renal). In these conditions, the BP should be
lowered aggressively over minutes to hours.

Hypertensive urgency is defined as a severe elevation of BP, without evidence of progressive

target organ dysfunction. These patients require BP control over several days to weeks.

Causes
The most common hypertensive urgency is a rapid unexplained rise in BP in a patient with
chronic essential HTN.

Other causes:

Renal parenchymal disease – Chronic pyelonephritis, primary glomerulonephritis, tubulointerstitial

nephritis (accounts for 80% of all secondary causes)
Systemic disorders with renal involvement – Systemic lupus erythematosus, systemic sclerosis,
vasculitides
Renovascular disease – Atherosclerotic disease, fibromuscular dysplasia, polyarteritis nodosa
Endocrine – Pheochromocytoma, Cushing syndrome, primary hyperaldosteronism
Drugs – Cocaine, amphetamines, cyclosporin, clonidine withdrawal, phencyclidine, diet pills, oral
contraceptive pills
Drug interactions – Monoamine oxidase inhibitors with tricyclic antidepressants, antihistamines,
or tyramine-containing food
CNS – CNS trauma or spinal cord disorders, such as Guillain-Barré syndrome
Coarctation of the aorta
Preeclampsia/eclampsia
Postoperative hypertension
Physical

Vitals

BP should be measured in both the supine position and the standing position (assess volume
depletion).
BP should also be measured in both arms (a significant difference suggests an aortic dissection).
ENT: The presence of new retinal hemorrhages, exudates, or papilledema suggests a
hypertensive urgency.

Cardiovascular – Evaluate for the presence of heart failure.

Jugular venous distension

Crackles
Peripheral edema
Abdomen – Abdominal masses or bruits
CNS

Level of consciousness
Visual fields
Focal neurologic signs
Takayasu arteritis is a granulomatous vasculitis of unknown etiology that commonly affects the
thoracic and abdominal aorta. It causes intimal fibroproliferation of the aorta, great vessels,
pulmonary arteries, and renal arteries and results in segmental stenosis, occlusion, dilatation, and
aneurysmal formation in these vessels. Takayasu arteritis is the only form of aortitis that causes
stenosis and occlusion of the aorta.

Takayasu disease has also been referred to as pulseless disease and aortic arch syndrome.
During the acute inflammatory stage, Takayasu disease causes a low-grade temperature,
tachycardia, pain adjacent to the inflamed arteries (eg, carotodynia), and easy fatigability in 50%
of patients. Carotid and clavicular bruits, asymmetric upper-extremity blood pressures,
hypertension, diminished or absent upper-extremity pulses, and ischemic symptoms can suggest
the diagnosis

ANATOMY & PHYSIOLOGY

Central Nervous System

Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the
spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in
consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and
blood vessel diameter.

Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary
gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body
temperature and regulates eating and drinking behavior. Helps maintain the waking state and
establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone.

Cardiovascular System

Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal carotid
arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular
center in the medulla oblongata to help regulate blood pressure. The two most important
baroreceptor reflexes are the carotid sinus reflex and the aortic reflex.

Chemoreceptors, sensory receptors that monitor the xhemical composition of blood, are located
close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called
carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood
level of O2, CO2, and H+.

Renal System

Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys
decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence,
renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active
hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent
vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it
stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by
the kidneys. The water reabsorption increases total blood volume, which increases blood
pressure.

Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior
pituitary in response to dehydration or decreased blood volume. Among other actions, ADH
causes vasoconstriction, which increases blood pressure.

Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure
by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces
blood volume.

NURSING ASSESSMENT

Present Health History

The present health history started 7 days prior to confinement at PCMC when the patient,
experienced general body weakness, vomiting and elevated blood pressure. She was admitted at
Duque’s Clinic for 3 days but no BP monitoring was done. After 3 days, she was transferred to
Cabiao General Hospital. Chest x-ray was done and the result implies cardiomegaly. She stayed
at the said institution for 2 days and was treated as a case of hypertension. The patient was
referred to Nueva Ecija Doctors last April 10, she had undergone ultrasound of her abdomen. She
was given furosemide, nifedipine, mefenamic acid and ranitidine as her medication. Last April 12,
2007 at 12:55am she was admitted at the Philippine Children’s Medical Center with a diagnosis of
Hypertensive Urgency secondary to Takayasu disease.

Past Health History

Prior to her hospitalization , she denies in having any record or medical history of being admitted
due to trauma, accident and disease. She also denies having allergies to food and drugs.

Family Health History

The patient has family health history of hypertension on her mother’s side.

Demographic Data/Physical Assessment & General Appearance

Review of Systems

? Psychosocial
Being the second among three children, she considers herself as an active individual who is fond
of interacting with other people. She considers herself as friendly even at home and at work. She
excels in her subjects especially in Mathematics.

? Elimination
Her elimination pattern has somehow deviated from her usual urine and stool elimination. Before
her confinement, she usually urinates for 7 times a day and defecates at least 2 times per day.
During her confinement, she now urinates 4 times a day and defecates once a day. According to
her the variation from her elimination pattern is due to change in appetite and setting.

? Rest & Activity

A typical day to her would be waking up at around 7:00 am to eat breakfast and play with her
siblings. She had is fond of playing in their neighborhood and running around their house. Her
usual sleeping hours is at 8:00 pm. During her confinement, she was not able to rest and have
enough sleep as well. During her leisure time before confinement, she loves to watch television.

? Safety
She usually stays at home and around their vicinity when playing. There is no physical threat for
her safety.

? Oxygenation
According to her, before and during her confinement she had no difficulty in breathing and
ventilation.

? Nutrition
According to her mother, she has a good appetite. She prefers to eat fish and vegetables rather
than meat. She also adds that her daughter prefers to drink water.

PATHOPHYSIOLOGY

LABORATORY DIAGNOSIS

MEDICAL & SURGICAL MANAGEMENT

There are three clinical indications for selecting a patient with a hemodynamically significant renal
artery stenosis (RAS) for treatment. The first is hypertension that is poorly controlled on adequate
(two or three drugs) medical therapy, or in a patient intolerant of hypertensive medications. The
second is renal insufficiency, and the third is a “cardiac disturbance” syndrome, such as “flash”
pulmonary edema.

The treating physician should have a high clinical suspicion that the target RAS is causally related
to the clinical symptoms. The procedural risks, potential benefits, and alternative therapies must
be considered for each patient. Generally, a RAS of <50% does not require revascularization,
while a symptomatic patient with a stenosis ?70% generally merits revascularization. Absolute
criteria for determining lesion severity have not been established; however, a systolic
translesional pressure gradient of ?20 mm Hg or a mean gradient of ?10 mm Hg is generally
accepted as representing significant renal artery obstruction in symptomatic patients.

Stents are superior to balloons for both procedural success and long-term patency, due to
scaffolding of the arterial lumen. The single, randomized, controlled trial comparing stents to
balloons in renovascular hypertension demonstrated procedural superiority, better patency rates,
and cost-effectiveness for primary stent placement.

Despite a uniformly high (?95%) technical success rate for renal artery stent placement, very few
patients will be cured of hypertension. However, the majority of hypertensive patients will benefit
by improved blood pressure control and/or the need for fewer medications. Patients with the
highest pretreatment systolic blood pressures have the greatest decrease in systolic pressure. A
multivariate logistic regression analysis demonstrated that bilateral RAS and mean arterial
pressure >110 mm Hg predicted a better blood pressure response following stent placement.

Studies comparing the results in elderly (?75 years) versus younger (<75 years) patients or in
females versus males have failed to show any difference in response to renal stent placement.
The suggestion that a high level of resistance in the segmental renal arteries (resistance index ?
80), determined by noninvasive Doppler measurement, predicted a poor response to
revascularization has been challenged by more recent data that suggested that patients with
increased resistance respond favorably to renal intervention.

The benefits of renal stent placement include reperfusion of the ischemic kidney(s), resulting in a
reduction in the stimulus to renin production, which decreases angiotensin and aldosterone
production, thereby decreasing peripheral arterial vasoconstriction and intravascular volume.
Improving renal perfusion enhances glomerular filtration, thus natriuresis. Finally, in patients with
a solitary kidney or bilateral RAS, the administration of angiotensin antagonists is facilitated by
revascularization.