Chapter 32 Assessment and Management of Patients With Hypertension

Question Is the following equation True or False? Cardiac Output = Heart Rate x Stroke Volume

Answer True Cardiac Output = Heart Rate x Stroke Volume

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

Classification of Blood Pressure for Adults Age 18 and Older

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.

Factors Involved in the Control of Blood Pressure

Factors that Influence the Development of Hypertension Increased sympathetic nervous system activity Increased reabsorption of sodium chloride and water by the kidneys Increased activity of the rennin-angiotensin system Decreased vasodilatation Insulin resistance

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 Hypertension Smoking Obesity Physical inactivity Dyslipedemia Diabetes mellitus Microalbuminuria or GFR < 60 Older age Family history

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

JNC 7 Treatment Algorithm Refer to fig. 32-2

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).

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

Question For patients with uncomplicated hypertension and no specific indications for another medication, what is the initial medication? Thiazide diuretic Calcium channel blockers Vasodilators Angiotensin converting enzyme inhibitors

Answer A For patients with uncomplicated hypertension and no specific indications for another medication, the recommended initial medication is thiazide diuretics for most patients. If blood pressure does not fall to less than 140/90 mm Hg, the dose is increased gradually and additional medications are included as necessary to achieve control.

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.

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

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

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

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

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

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

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

Question Is the following statement True or False? A hypertensive urgency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage.

Answer False A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. A hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage.

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

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, fenodopam mesylate, enalaprilat, nitrogylcerin 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