Chapter 31 Hypertension

High blood pressure
systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg.

Normal blood pressure range
Systolic less 120
Diastolic less than 80

Prehypertensive
Systolic 129-139
Diastolic 80-89

Stage 1 hypertensive
Systolic 140-159
Diastolic 90-99

Stage 2 hypertension
Systolic greater 160
Diastolic greater than 100

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

Major Risk Factors
•Smoking
•Obesity
•Physical inactivity
•Dyslipidemia
•Diabetes mellitus
•Microalbuminuria or GFR <60 mL/min •Older age •Family history

Pt assessment
History and physical examination
•Laboratory tests
-Urinalysis
-Blood chemistry
-Cholesterol levels
•ECG

Lifestyle modifications
– Weight reduction
-DASH diet, decreased Na intake
-Physical activity
-Moderate alcohol consumption

Medication therapy
-Diuretics, beta-blockers, alpha1-blockers, combined alpha- and beta-blockers, vasodilators, ACE inhibitors, ARBs, Ca channel blockers, dihydropyridines, and direct renin inhibitors

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.

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

Dx
Deficient knowledge regarding the relation between the treatment regimen and control of the disease process
•Noncompliance with therapeutic regimen related to side effects of prescribed therapy

Collaborative Problems and Potential Complications
Left ventricular hypertrophy
•Myocardial infarction
•Heart failure
•Transient ischemic attack (TIA)
•Cerebrovascular accident (CVA, stroke, or brain attack)
•Renal insufficiency and failure
•Retinal hemorrhage

Planning and Goals
-Understanding of the disease process and its treatment
•Participation in a self-care program
•Absence of complications

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

Evaluating
Reports knowledge of disease management sufficient to maintain adequate tissue perfusion
-Maintains blood pressure at less than 140/90 mm Hg with no symptoms of angina, palpitations, or vision changes; stable BUN and serum creatinine levels; and palpable peripheral pulses
•Adheres to the self-care program
-Reduces calorie, Na, and fat intake; exercises regularly; takes medications as prescribed and reports side effects; measures BP; abstains from tobacco and excessive alcohol intake; keeps appointments

Gerontologic Considerations
Medication regimen can be difficult to remember
•Expense can be a challenge
•Monotherapy, if appropriate, may simplify the medication regimen and make it less expensive
•Ensure that older adult patients understand the regimen and can see and read instructions, open medication containers, and get prescriptions refilled.
•Include family and caregivers in educational program

Hypertensive emergency
-Blood pressure >180/120 mm Hg and must be lowered immediately to prevent damage to target organs

Hypertensive urgency define
Blood pressure is very high but no evidence of immediate or progressive target organ damage

Hypertensive Emergency define
Reduce blood pressure 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, fenoldopam mesylate, enalaprilat, nitroglycerin
•Need very frequent monitoring of BP and cardiovascular status.

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

Hypertensive Emergency
Reduce blood pressure 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, fenoldopam mesylate, enalaprilat, nitroglycerin
•Need very frequent monitoring of BP and cardiovascular status.

What is a priority nursing assessment when caring for the patient in a hypertensive crisis receiving intravenous vasodilators?
Assessing the individual’s fluid volume status is recommended because if there is volume depletion secondary to natriuresis caused by the elevated blood pressure, then volume replacement with normal saline can prevent large sudden drops in blood pressure when antihypertensive medications are administered.

How do diuretics work
are sometimes called ‘water tablets’ because they can cause you to pass more urine than usual. They work on your kidneys by increasing the amount of salt and water that comes out through your urine. Too much salt can cause extra fluid to build up in your blood vessels, raising your blood pressure.

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