Chapter - 033 HTN Class

Hypertension
Chapter 33
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Hypertension
Direct relationship
between hypertension and
cardiovascular disease
Affects 33% of adults in
U.S.
Additional 30% have
prehypertension
High priority health
concern identified in
Factors Influencing BP
Systemic
Blood
Cardiac
=
Vascular
Pressure
Output
Resistance
Sympathetic nervous
system (SNS)
Activation increases HR and
cardiac contractility
Vasoconstriction and renin
release
Increases CO and SVR
Baroreceptors
Sensitive to stretching
Send impulses to
sympathetic vasomotor
center
Vascular endothelium
Produces vasoactive
substances to maintain low
arterial tone
Renal system
Control sodium excretion and

ECF volume
RAAS system
Prostaglandins
Endocrine system
Epinephrine and
norepinephrine from adrenal
medulla
Aldosterone from adrenal
cortex
ADH from posterior pituitary
Hypertension
Definition
Persistent elevation of
Systolic blood pressure
140 mm Hg
OR
Diastolic blood pressure 90
mm Hg
OR
Current use of
antihypertensive drug(s)
Prehypertension
Definition
Systolic BP: 120 to 139

mm Hg
OR
Diastolic BP: 80 to 89 mm
Hg
Blood Pressure
Classification
Isolated systolic
hypertension
Hypertension Stage 1
SBP >140 mm Hg with DBP <90

mm Hg
SBP 140149 or DBP 9099
Hypertension Stage 2
SBP >160 or DBP >100
Audience Response Question

The nurse determines that the
patient has stage 2
hypertension when the
patients average blood
pressure is
a. 155/88 mm Hg.
b. 172/92 mm Hg.
c. 160/110 mm Hg.
d. 182/106 mm Hg.
Etiology of Hypertension
Primary hypertension
Also called essential or
idiopathic hypertension
Elevated BP without an
identified cause
90% to 95% of all cases
Exact cause unknown but
several contributing factors
Etiology of Hypertension
Secondary hypertension
Elevated BP with a specific
cause
5% to 10% of adult cases
Clinical findings relate to
underlying cause
Treatment aimed at
removing or treating cause
Pathophysiology
Primary Hypertension
Persistently increased SVR

Abnormalities in any
mechanisms involved in
maintenance of normal BP
Case Study
C.S. is a 4o-year-old male
who attends a community
health screening.
He states that he has not
seen a health care provider
in a really long time.
He is a truck driver who eats
mainly fast food while on the
road.
Fuse/Thinkstock
Case Study
He smokes a pack of
cigarettes a day just for
something to do during
the long hours of driving
and to keep me calm.
Fuse/Thinkstock
Case Study
C.S. is 5 ft, 9 in tall and
weighs 230 lb.
His BP is 182/104, heart
rate 90, respirations 24,
and temperature 97.0F
What risks factors for
hypertension does C.S.
have?
Fuse/Thinkstock
Risk Factors for Primary

Hypertension
Age
Alcohol
Tobacco use
Diabetes mellitus
Elevated serum lipids
Excess dietary sodium
Gender
Risk Factors for Primary

Hypertension
Family history
Obesity
Ethnicity
Sedentary lifestyle
Socioeconomic status
Stress

While performing blood pressure screening at
a health fair, the nurse counsels which person
as having the greatest risk for developing
hypertension?
a. A 56-year-old man whose father died at age
62 from a stroke
b. A 30-year-old female advertising agent who
is unmarried and lives alone
c. A 68-year-old man who uses herbal
remedies to treat his enlarged prostate
gland
d. A 43-year-old man who travels extensively
with his job and exercises only on weekends
Pathophysiology
Genetic links
Different sets of genes
regulate BP at different
times
Although known
contribution small, current
research ongoing
Pathophysiology
Water and sodium

retention
Only 1 in 3 people who
consume high sodium diet
develop hypertension
High sodium intake may
activate a number of
pressor mechanisms,
resulting in water retention
Pathophysiology
Stress and increased SNS

activity
Causes increased
vasoconstriction
HR
renin release
Pathophysiology
Altered renin-angiotensinaldosterone system

(RAAS)
Increased renin activates
RAAS
Renin levels do not decrease
in response to elevated BP
Pathophysiology
Insulin resistance and

hyperinsulinemia
High insulin concentration

stimulates SNS activity and
impairs nitric oxide
mediated vasodilation
Pathophysiology
Endothelium dysfunction
Impaired response to nitric
oxide vasodilation
Elevated endothelin
vasoconstriction
Case Study
Fuse/Thinkstock
What clinical
manifestations of
hypertension would you
assess for in C.S.?
Hypertension
Clinical Manifestations
Silent killer
Symptoms of severe
hypertension
Fatigue
Dizziness
Palpitations
Angina
Dyspnea
Case Study
Fuse/Thinkstock
What complications will

you assess C.S. for?
Hypertension
Complications
Target organ diseases

occur most frequently in
the
Heart
Brain
Peripheral vascular disease
Kidney
Eyes
Case Study
C.S. is referred to his
health care provider to
follow up on his high blood
pressure screening.
What diagnostic studies
might you expect the
health care provider to
order for C.S.?
Fuse/Thinkstock
Hypertension
Diagnostic Studies
Urinalysis
BUN and serum creatinine
Creatinine clearance
Serum electrolytes, glucose
Serum lipid profile
Uric acid levels
ECG
Echocardiogram
Hypertension
Diagnostic Studies
Ambulatory blood
pressure monitoring
(ABPM)
Noninvasive, fully
automated system that
measures BP at preset
intervals over 24-hour
period
Teach patient to hold arm
still and keep diary
Case Study
C.S.s blood pressure is
monitored for several visits and
remains elevated.
His serum cholesterol, BUN,
and creatinine levels are
elevated.
His creatinine clearance
(glomerular filtration rate) is
below normal, demonstrating
renal insufficiency.
Fuse/Thinkstock
Case Study
What type of lifestyle
modifications would you
recommend for C.S. to
control his blood
pressure?
Fuse/Thinkstock
Hypertension
Collaborative Care
Overall goals
Control blood pressure
Reduce CVD risk factors and
target organ disease
Hypertension
Lifestyle Modifications
Weight reduction
Weight loss of 22 lb (10 kg )
may decrease SBP by approx.
5 to 20 mm Hg
Calorie restriction and
physical activity
DASH eating plan
Fruits, vegetables, fat-free or

low-fat milk, whole grains,
Hypertension
Physical activity
Moderate-intensity aerobic
activity, at least 30 minutes, most
days of the week
Vigorous-intensity aerobic activity
at least 20 minutes, 3 days a week
Muscle-strengthening activities at
least 2 times a week
Flexibility and balance exercises 2
times a week
Hypertension
Avoidance of tobacco products
Nicotine causes vasoconstriction

and elevated BP
Smoking cessation reduces risk
factors within 1 year
Psychosocial risk factors
Low socioeconomic status, social

isolation and lack of support,
stress, negative emotions
Activate SNS and stress hormones
Case Study
In addition to lifestyle
modifications, C.S.s health
care provider prescribes
hydrochlorothiazide.
What would you teach C. S.
about this drug?
Fuse/Thinkstock
Drug Therapy
Hypertension
Drug Therapy and Patient Teaching
Follow-up care
Identify, report, and
minimize side effects
Orthostatic hypotension
Sexual dysfunction
Dry mouth
Frequent urination
Time of day to take drug

Hypertension
Nursing Assessment
Subjective data
Past health history

Hypertension
Cardiovascular, cerebrovascular,
renal, thyroid disease
Diabetes mellitus, pituitary
disorders, obesity, dyslipidemia
Menopause or hormone
replacement
Drugs
Hypertension
Nursing Assessment
Subjective data
Family history
Salt and fat intake
Weight gain or loss
Nocturia
Fatigue, dyspnea on exertion,
palpitations, pain
Dizziness, blurred vision
Erectile dysfunction
Stressful events
Hypertension
Nursing Assessment
Objective data
Blood pressure readings

Heart sounds
Pulses
Edema
Body measurements
Mental status changes
Hypertension
BP Measurement
Take in both arms initially

Proper size and placement
of cuff
From: Bonewit-West:, K Clinical Procedures for

Medical Assistants, ed 7, St. Louis, 2008, Saunders
Hypertension
BP Measurement
Can use forearm if needed
Document site
Assess for orthostatic hypotension
BP and pulse supine, sitting, and

standing
Measure within 1 to 2 minutes of
position change
Positive if of 20 mm Hg or more in
SBP, 10 mm Hg or more in DBP, or
20 beats/minute or more in heart rate
Hypertension
Nursing Diagnoses
Ineffective self-health
management
Anxiety
Sexual dysfunction
Risk for decreased cardiac
perfusion
Risk for ineffective cerebral and
renal perfusion
Potential complications: stroke,
MI
Hypertension
Nursing Planning
Patient will
Achieve and maintain the goal

BP
Understand and follow the
therapeutic plan
Experience minimal or no
unpleasant side effects of
therapy
Be confident of ability to manage
and cope with this condition
Hypertension
Nursing Implementation
Health promotion
Primary prevention via
lifestyle modification
Individual patient evaluation
and education
Screening programs
Cardiovascular risk factor
modification
Hypertension
Ambulatory and home care

Evaluate therapeutic
effectiveness
Detect and report adverse
effects
Assess and enhance
compliance
Patient and caregiver
teaching
Hypertension
Reasons for
noncompliance
Inadequate teaching
Side effects
Return to normal BP
Lack of motivation
Financial
Lack of trust
Case Study
What could you do to
increase C.S.s compliance
with his medication and
lifestyle changes?
Fuse/Thinkstock
Hypertension
Measures to enhance
compliance
Individualize plan
Active patient participation
Select affordable drugs
Involve caregivers
Combination drugs
Patient teaching
Hypertension
Patient and caregiver

teaching includes:
Nutritional therapy
Drug therapy
Physical activity
Home BP monitoring (if
appropriate)
Tobacco cessation (if
applicable)
Case Study
C.S. returns to the HCPs
office for a follow-up visit
3 months after starting on
hydrochlorothiazide.
How would you evaluate
the effectiveness of his
treatment strategies?
Fuse/Thinkstock
Hypertension
Nursing Management
Nursing evaluation
Patient will:
Achieve and maintain goal BP
Understand, accept, and
implement the therapeutic plan
Experience minimal or no
unpleasant side effects of
therapy

A patients blood pressure has not
responded consistently to
prescribed drugs for hypertension.
The first cause of this lack of
responsiveness the nurse should
explore is
1. Progressive target organ
damage.
2. The possibility of drug
interactions.
3. The patient not adhering to
therapy.
Hypertension in Older
Persons
Increased incidence with
age
Isolated systolic
hypertension (ISH): Most
common form of
hypertension in
individuals age >50
Older adults are more
likely to have white coat
Hypertension in Older
Persons
Altered drug absorption,

metabolism, and excretion
Often a wide gap between the
first Korotkoff sound and
subsequent beats is called
the auscultatory gap
risk for orthostatic
hypotension
Also postprandial hypotension
Hypertensive Crisis
Hypertensive emergency
Hypertensive urgency
Occurs over hours to days

BP >220/140 with target organ
disease
Occurs over days to weeks
BP >180/110 with no clinical
evidence of target organ disease
Rate of rise more important

than absolute value
Hypertensive Crisis
Clinical Manifestations
Hypertensive
encephalopathy
Headache, n/v, seizures,

confusion, coma
Renal insufficiency
Cardiac decompensation
MI, HF, pulmonary edema
Aortic dissection
Hypertensive Crisis
Nursing/Collaborative Management
Hospitalization
IV drug therapy: titrated to

MAP
Monitor cardiac and renal
function
Neurologic checks
Determine cause
Education to avoid future
crisis

The nurse takes blood pressures at a health fair.
The nurse identifies which person as most at risk
for developing hypertension?
1.A 52-year-old male who smokes and has a
parent with hypertension
2.A 30-year-old female advertising agent who is
unmarried and lives alone
3.A 68-year-old male who uses herbal remedies
to treat an enlarged prostate gland
4.A 43-year-old female who travels extensively
for work and exercises only on weekends

The nurse determines that which of the following
blood pressures would meet the criteria for a
diagnosis of stage 2 hypertension?
1.152/98 mm Hg
2.118/84 mm Hg
3.106/62 mm Hg
4.182/94 mm Hg

A patients blood pressure has not responded to
the prescribed drugs for hypertension. Which of
the following should the nurse assess first?
1.Progressive target organ damage
2.Potential for drug interactions
3.Patients adherence to drug therapy
4.Possible use of recreational drugs

Chapter - 033 HTN Class

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Chapter - 033 HTN Class

Transféré par

Droits d'auteur :

Formats disponibles

Hypertension

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Control sodium excretion and

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Systolic BP: 120 to 139

SBP >140 mm Hg with DBP <90

SBP >160 or DBP >100

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Persistently increased SVR

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors for Primary

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors for Primary

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Water and sodium

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Stress and increased SNS

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Altered renin-angiotensinaldosterone system

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Insulin resistance and

High insulin concentration

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

What complications will

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Target organ diseases

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

DASH eating plan

Fruits, vegetables, fat-free or

Avoidance of tobacco products

Nicotine causes vasoconstriction

Psychosocial risk factors

Low socioeconomic status, social

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Time of day to take drug

Past health history

Blood pressure readings

Take in both arms initially

From: Bonewit-West:, K Clinical Procedures for

Can use forearm if needed

Assess for orthostatic hypotension

BP and pulse supine, sitting, and

Copyright 2014 by Mosby, an imprint of Elsevier Inc.