Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Hypertension A direct relationship has been observed between hypertension and cardiovascular disease (CVD), along with a proportionate increase in the risk of myocardial infarction (MI), heart failure, stroke, and renal disease with higher BP. One in three adults in the United States has high BP. An additional 38% are at high risk of developing 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 Healthy People 2020 Hypertension or high blood pressure (BP) is an important medical and public health problem. There is a direct relationship between hypertension and cardiovascular disease (CVD). As BP increases, so does the risk of myocardial infarction (MI), heart failure, stroke, and renal disease. One in three adults in the United States has hypertension. Additionally, 30% of adults have prehypertension, and approximately 8% have undiagnosed hypertension. Healthy People 2020 lists the number of adults with hypertension whose BP is under control as one of the 26 high-priority, leading health indicators for the coming decade. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Factors Influencing BP
Systemic Vascular Resistance Blood Pressure Cardiac Output = × Blood pressure (BP), the force exerted by the blood against the walls of the blood vessel, is primarily a function of cardiac output (CO) and systemic vascular resistance. CO is the total blood flow through the systemic or pulmonary circulation per minute. It is described as the stroke volume (amount of blood pumped out of the left ventricle per beat [approximately 70 mL]) multiplied by the heart rate (HR) for 1 minute. Systemic vascular resistance (SVR) is the force opposing the movement of blood within the blood vessels. The radius of the small arteries and arterioles is the principal factor determining vascular resistance. A small change in the radius of the arterioles creates a major change in the SVR. If SVR is increased and CO remains constant or increases, arterial BP will increase. BP must be adequate to maintain tissue perfusion during activity and rest. The maintenance of normal BP and tissue perfusion requires the integration of both systemic factors and local peripheral vascular effects. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

The mechanisms that regulate BP can affect either CO or SVR, or both. Regulation of BP is a complex process involving both short-term (seconds to hours) and long-term (days to weeks) mechanisms. Short-term mechanisms, including the sympathetic nervous system (SNS) and vascular endothelium, are active within a few seconds. Long-term mechanisms include renal and hormonal processes that regulate arteriolar resistance and blood volume. In a healthy person, these regulatory mechanisms function in response to the demands of the body. (Each mechanism is more fully described in the following slides.) Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Sympathetic nervous system (SNS) Activation increases HR and cardiac contractility Vasoconstriction and renin release Increases CO and SVR Sympathetic nervous system The nervous system, which reacts within seconds after a drop in BP, increases BP primarily by activating the SNS. Increased SNS activity increases HR and cardiac contractility, produces widespread vasoconstriction in the peripheral arterioles, and promotes the release of renin from the kidneys. The net effect of SNS activation is to increase BP by increasing both CO and SVR. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Baroreceptors Sensitive to stretching Send impulses to sympathetic vasomotor center Baroreceptors Specialized nerve cells called baroreceptors (pressoreceptors) are located in the carotid arteries and the arch of the aorta. Baroreceptors have an important role in the maintenance of BP stability during normal activities. They are sensitive to stretching and, when stimulated by an increase in BP, send inhibitory impulses to the sympathetic vasomotor center. Inhibition of the SNS results in decreased HR, decreased force of contraction, and vasodilation in peripheral arterioles. When a fall in BP is sensed by the baroreceptors, the SNS is activated. The result is constriction of the peripheral arterioles, increased HR, and increased contractility of the heart. In the presence of long-standing hypertension, the baroreceptors become adjusted to elevated levels of BP and recognize this level as “normal.” Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Vascular endothelium Produces vasoactive substances to maintain low arterial tone Renal system Control sodium excretion and ECF volume RAAS system Prostaglandins Vascular Endothelium The vascular endothelium is a single-cell layer that lines the blood vessels. It produces several vasoactive substances and growth factors. Nitric oxide and prostacyclin help maintain low arterial tone, inhibit growth of the smooth muscle layer, and inhibit platelet aggregation. Endothelin (ET) is an extremely potent vasoconstrictor. Renal System The kidneys contribute to BP regulation by controlling sodium excretion and extracellular fluid (ECF) volume. Sodium retention results in water retention, which causes an increased ECF volume. This increases the venous return to the heart and the stroke volume. Together, these increase CO and BP. The renin-angiotensin-aldosterone system (RAAS) also plays an important role in BP regulation. The kidney secretes renin in response to SNS stimulation, decreased blood flow through the kidneys, or decreased serum sodium concentration. Renin is an enzyme that converts angiotensinogen to angiotensin I. Angiotensin-converting enzyme (ACE) converts angiotensin I into angiotensin II (A-II). A-II increases BP. Prostaglandins (PGE2 and PGI2) secreted by the renal medulla have a vasodilator effect on the systemic circulation. This results in decreased SVR and lowering of BP. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Endocrine system Epinephrine and norepinephrine from adrenal medulla Aldosterone from adrenal cortex ADH from posterior pituitary Endocrine System Stimulation of the SNS results in release of epinephrine along with a small fraction of NE by the adrenal medulla. Epinephrine increases the CO by increasing the HR and myocardial contractility. Epinephrine activates β2-adrenergic receptors in peripheral arterioles of skeletal muscle, causing vasodilation. In peripheral arterioles with only α1-ardrenergic receptors (skin and kidneys), epinephrine causes vasoconstriction. A-II stimulates the adrenal cortex to release aldosterone. Aldosterone stimulates the kidneys to retain sodium and water. This increases blood volume and CO. An increased blood sodium and osmolarity level stimulates the release of ADH from the posterior pituitary gland. ADH increases the ECF volume by promoting the reabsorption of water in the distal and collecting tubules of the kidneys. The resulting increase in blood volume causes an increase in CO and BP. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Definition
Persistent elevation of Systolic blood pressure ≥140 mm Hg OR Diastolic blood pressure ≥90 mm Hg Current use of antihypertensive drug(s) Hypertension is defined as a persistent systolic BP (SBP) ≥140 mm Hg, diastolic BP (DBP) ≥90 mm Hg, or current use of antihypertensive drug. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Prehypertension Definition
Systolic BP: 120 to 139 mm Hg OR Diastolic BP: 80 to 89 mm Hg Prehypertension is defined as SBP 120 to 139 mm Hg or DBP 80 to 89 mm Hg. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Blood Pressure Classification
Isolated systolic hypertension SBP >140 mm Hg with DBP <90 mm Hg Hypertension Stage 1 SBP 140–149 or DBP 90–99 Hypertension Stage 2 SBP >160 or DBP >100 Isolated systolic hypertension (ISH) is defined as an average SBP ≥140 mm Hg coupled with an average DBP less than 90 mm Hg. SBP increases with aging. DBP rises until approximately age 55 and then declines. Control of ISH decreases the incidence of stroke, heart failure, and death. Hypertension is also subclassified as stage 1 or stage 2, dependent on severity of elevation. The classification of BP is based on the average of two or more properly measured BP readings on two or more office visits. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question
The nurse determines that the patient has stage 2 hypertension when the patient’s average blood pressure is 155/88 mm Hg. 172/92 mm Hg. 160/110 mm Hg. 182/106 mm Hg. Answer: b, c, & d Rationale: Stage 2 hypertension is diagnosed when systolic blood pressure is greater than or equal to 160 mm Hg, or diastolic blood pressure is greater than or equal to 100 mm Hg. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Primary (essential or idiopathic) hypertension is elevated BP without an identified cause, and it accounts for 90% to 95% of all cases of hypertension. Although the exact cause of primary hypertension is unknown, there are several contributing factors. These include increased SNS activity, overproduction of sodium-retaining hormones and vasoconstricting substances, increased sodium intake, greater than ideal body weight, diabetes mellitus, tobacco use, and excessive alcohol consumption Primary hypertension is the focus of this presentation because of its prevalence in clinical practice and impact on health. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Secondary hypertension is elevated BP with a specific cause that often can be identified and corrected. This type of hypertension accounts for 5% to 10% of hypertension in adults. Secondary hypertension should be suspected in people who suddenly develop high BP, especially if it is severe. Clinical findings that suggest secondary hypertension will relate to the underlying cause. For example, an abdominal bruit heard over the renal arteries may indicate renal disease. Treatment of secondary hypertension is aimed at removing or treating the underlying cause. Secondary hypertension is a contributing factor to hypertensive crisis. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Pathophysiology Primary Hypertension
Persistently increased SVR Abnormalities in any mechanisms involved in maintenance of normal BP BP rises with any increase in CO and/or SVR. Increased CO is sometimes found in the person with prehypertension. Later in the course of hypertension, the SVR rises and the CO returns to normal. The hemodynamic hallmark of hypertension is persistently increased SVR. This persistent elevation in SVR may occur in various ways. Abnormalities of any of the mechanisms involved in the maintenance of normal BP can result in the development of hypertension. There are several factors that relate to the development of primary hypertension or contribute to its consequences. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 97.0°F What risks factors for hypertension does C.S. have? Fuse/Thinkstock Obesity, tobacco use, stress, gender, excess dietary sodium, sedentary lifestyle Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors for Primary Hypertension
Age Alcohol Tobacco use Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Age SBP rises progressively with increasing age. After age 50, SBP >140 mm Hg is a more important cardiovascular risk factor than DBP. Alcohol Excessive alcohol intake is strongly associated with hypertension. Patients with hypertension should limit their daily intake to 1 oz of alcohol. Tobacco use Smoking tobacco greatly ↑ risk of cardiovascular disease. People with hypertension who smoke tobacco are at even greater risk for cardiovascular disease. Diabetes mellitus Hypertension is more common in diabetics. When hypertension and diabetes coexist, complications (e.g., target organ disease) are more severe. Elevated serum lipids ↑ levels of cholesterol and triglycerides are primary risk factors in atherosclerosis. Hyperlipidemia is more common in people with hypertension. Excess dietary sodium High sodium intake can contribute to hypertension in some patients. Decrease the effectiveness of certain antihypertensive drugs Gender Hypertension is more prevalent in men in young adulthood and early middle age (<55 yr of age). After age 64, hypertension is more prevalent in women. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Risk Factors for Primary Hypertension
Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress Family history History of a close blood relative (e.g., parents, sibling) with hypertension is associated with an ↑ risk for developing hypertension. Obesity Weight gain is associated with increased frequency of hypertension. The risk is greatest with central abdominal obesity. Ethnicity Incidence of hypertension is two times higher in African Americans than in whites. Sedentary lifestyle Regular physical activity can help control weight and reduce cardiovascular risk. Physical activity may ↓ BP. Socioeconomic status Hypertension is more prevalent in lower socioeconomic groups and among the less educated. Stress People exposed to repeated stress may develop hypertension more frequently than others. People who develop hypertension may respond differently to stress than those who do not develop hypertension. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question While performing blood pressure screening at a health fair, the nurse counsels which person as having the greatest risk for developing hypertension? A 56-year-old man whose father died at age 62 from a stroke A 30-year-old female advertising agent who is unmarried and lives alone A 68-year-old man who uses herbal remedies to treat his enlarged prostate gland A 43-year-old man who travels extensively with his job and exercises only on weekends Answer: a Rationale: History of a close blood relative (e.g., father to son) with hypertension is associated with an increased risk for developing hypertension; atherosclerosis is the most common cause of cerebrovascular disease. Hypertension is the major risk factor for cerebral atherosclerosis and stroke. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Primary Hypertension Pathophysiology
Genetic links Different sets of genes regulate BP at different times Although known contribution small, current research ongoing Genetic Links Different sets of genes may regulate BP at different times throughout the lifespan. Genetic abnormalities associated with a rare form of hypertension characterized by excess levels of potassium have been identified. To date, the known contribution of genetic factors to BP in the general population remains very small. The International Consortium for Blood Pressure Genome-Wide Association Studies is a network of researchers currently working to uncover genetic factors related to hypertension. In practice, you should screen children and siblings of persons with hypertension and strongly advise them to adopt healthy lifestyles to prevent hypertension. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Water and Sodium Retention Excessive sodium intake is linked to the start of hypertension. Although most people consume a high-sodium diet, only one in three will develop hypertension. A high sodium intake may activate a number of pressor mechanisms and cause water retention. In clinical practice, there is not an easy or simple test to identify individuals whose BP will rise with even a small increase in salt intake (salt sensitive) versus those who can ingest large amounts of sodium without much change in BP (salt resistant). In general, the effect of sodium on BP is greater in African Americans and in middle-aged and older adults. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Stress and increased SNS activity Causes increased vasoconstriction ↑ HR ↑ renin release Stress and Increased Sympathetic Nervous System Activity It has long been recognized that BP is influenced by factors such as anger, fear, and pain. Physiologic responses to stress, which are normally protective, may persist to a pathologic degree, resulting in a prolonged increase in SNS activity. Increased SNS stimulation produces increased vasoconstriction, increased HR, and increased renin release. Increased renin activates the RAAS leading to elevated BP. People exposed to high levels of repeated psychologic stress develop hypertension to a greater extent than those who do not experience as much stress. Increased renin activates the RAAS, leading to elevated BP. People exposed to high levels of repeated psychologic stress develop hypertension to a greater extent than do those who do not experience as much stress. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Altered renin-angiotensin- aldosterone system (RAAS) Increased renin activates RAAS Renin levels do not decrease in response to elevated BP Altered Renin-Angiotensin-Aldosterone System (RAAS) Increased renin activates the RAAS, leading to elevated BP. Elevated BP would normally inhibit release of renin; does not occur in the majority of patients with hypertension Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Insulin resistance and hyperinsulinemia High insulin concentration stimulates SNS activity and impairs nitric oxide–mediated vasodilation Insulin Resistance and Hyperinsulinemia Insulin resistance is a risk factor for the development of hypertension and CVD. High insulin levels stimulate SNS activity and impair nitric oxide–mediated vasodilation. Additional pressor effects of insulin include vascular hypertrophy and increased renal sodium reabsorption. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Endothelium dysfunction Impaired response to nitric oxide vasodilation Elevated endothelin → vasoconstriction Endothelium Dysfunction Endothelium dysfunction may contribute to atherosclerosis and primary hypertension. Some people with hypertension have a reduced vasodilator response to nitric oxide. Others have high levels of ET that produce a pronounced and prolonged vasoconstriction. The role of endothelium dysfunction in the pathogenesis and treatment of hypertension is an area of ongoing investigation. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study Fuse/Thinkstock What clinical manifestations of hypertension would you assess for in C.S.? Have students brainstorm and then discuss with next slide. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Clinical Manifestations
“Silent killer” Symptoms of severe hypertension Fatigue Dizziness Palpitations Angina Dyspnea Hypertension is often called the “silent killer” because it is frequently asymptomatic until it becomes severe and target organ disease occurs. A patient with severe hypertension may experience a variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart. These secondary symptoms include fatigue, dizziness, palpitations, angina, and dyspnea. In the past, symptoms of hypertension were thought to include headache and nosebleeds. Unless BP is very high, these symptoms are no more frequent in people with hypertension than in the general population. However, patients with hypertensive crisis may experience severe headaches, dyspnea, anxiety, and nosebleeds. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Complications
Target organ diseases occur most frequently in the Heart Brain Peripheral vascular disease Kidney Eyes The most common complications of hypertension are target organ diseases occurring in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vessels (peripheral vascular disease), kidneys (nephrosclerosis), and eyes (retinal damage). Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

The top picture of the heart demonstrates compensatory hypertrophy of the left ventricular muscle to pump against increased systemic vascular resistance caused by hypertension. Compare with normal thickness in bottom picture. This is an example of cellular adaptation to an increased cardiac workload. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Have students brainstorm and then discuss with next few slides. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Diagnostic Studies
Urinalysis BUN and serum creatinine Creatinine clearance Serum electrolytes, glucose Serum lipid profile Uric acid levels ECG Echocardiogram There is some controversy as to what the diagnostic workup should be in the initial assessment of a person with hypertension. Because most hypertension is classified as primary hypertension, testing for secondary causes is not routinely done. Basic laboratory studies are performed to (1) identify or rule out causes of secondary hypertension, (2) evaluate target organ disease, (3) determine overall cardiovascular risk, or (4) establish baseline levels before initiating therapy. Routine urinalysis, BUN, and serum creatinine levels are used to screen for renal involvement and to provide baseline information about kidney function. Creatinine clearance reflects the glomerular filtration rate. Decreases in creatinine clearance indicate renal insufficiency. Measurement of serum electrolytes, especially potassium, is important to detect hyperaldosteronism, a cause of secondary hypertension. Blood glucose levels assist in the diagnosis of diabetes mellitus. A lipid profile provides information about additional risk factors that lead to atherosclerosis and CVD. Uric acid levels establish a baseline, because the levels often rise with diuretic therapy. An ECG provides baseline information about cardiac status. It can identify the presence of LVH, cardiac ischemia, or previous MI. If LVH is suspected, echocardiography is often performed. If the patient’s age, history, physical examination, or severity of hypertension points to a secondary cause, further diagnostic testing is indicated. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Many applications for use ABPM is a noninvasive, fully automated system that measures BP at preset intervals over a 24-hour period. The equipment includes a BP cuff and a microprocessing unit that fits into a pouch worn on a shoulder strap or belt. Tell patients to hold their arm still by their side when the device is taking a reading. Also ask them to maintain a diary of activities that may affect BP. Useful for patients who have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. This phenomenon is referred to as “white coat” hypertension. Other potential applications for ABPM include suspected antihypertensive drug resistance, hypotensive symptoms with antihypertensive drugs, episodic hypertension, or SNS dysfunction. BP at night (during sleep) usually drops by 10% or more from daytime (awake) BP. Some patients with hypertension do not show a normal, nocturnal dip in BP and are referred to as “nondippers.” The absence of diurnal variability has been associated with more target organ disease and an increased risk for CVD. The presence or absence of diurnal variability can be determined by ABPM. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study What type of lifestyle modifications would you recommend for C.S. to control his blood pressure? Fuse/Thinkstock Have students brainstorm. Should include weight reduction, exercise, dietary changes, stress reduction, smoking cessation. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Collaborative Care
Overall goals Control blood pressure Reduce CVD risk factors and target organ disease Goals include achieving and maintaining goal BP, and reducing cardiovascular risk and target organ disease. Lifestyle modifications, directed toward reducing the patient’s BP and overall cardiovascular risk, are indicated for all patients with prehypertension and hypertension. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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, fish, poultry, beans, seeds, and nuts Weight Reduction Overweight persons have an increased incidence of hypertension and increased risk for CVD. Weight reduction has a significant effect on lowering BP in many people, and the effect is seen with even moderate weight loss. A weight loss of 22 lb (10 kg) may decrease SBP by approximately 5 to 20 mm Hg. When a person decreases caloric intake, sodium and fat intake are usually also reduced. Although reducing the fat content of the diet has not been shown to produce sustained benefits in BP control, it may slow the progress of atherosclerosis and reduce overall CVD risk. Weight reduction through a combination of calorie restriction and moderate physical activity is recommended for overweight patients with hypertension. DASH Eating Plan The DASH eating plan emphasizes fruits, vegetables, fat-free or low-fat milk and milk products, whole grains, fish, poultry, beans, seeds, and nuts. Compared with the typical American diet, the plan contains less red meat, salt, sweets, added sugars, and sugar-containing beverages. The DASH eating plan significantly lowers BP and these decreases compare with those achieved with BP-lowering drug. Additional benefits also include lowering of low-density lipoprotein (LDL) cholesterol. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Physical Activity A physically active lifestyle is essential to promote and maintain good health. The AHA and American College of Sports Medicine recommend that adults perform moderate-intensity aerobic physical activity for at least 30 minutes most days (i.e., more than 5) per week or vigorous-intensity aerobic activity for at least 20 minutes, 3 days a week. The 30-minute goal can be accomplished by performing shorter periods of exercise that last at least 10 minutes or more. Additionally, combinations of moderate and vigorous activity are acceptable (e.g., walking briskly for 30 minutes on 2 days of the week and jogging for 20 minutes on 2 other days). For adults age 18 to 65, walking briskly at a pace that noticeably increases the pulse defines moderate-intensity aerobic activity. Jogging at a pace that substantially increases the pulse and causes rapid breathing is an example of vigorous activity for this age group. All adults should perform muscle-strengthening activities using the major muscles of the body at least twice a week. This helps to maintain or increase muscle strength and endurance. Additionally, flexibility and balance exercises are recommended at least twice a week for older adults, especially for those at risk for falls. Generally, physical activity is more likely to be done if it is safe and enjoyable, fits easily into one’s daily schedule, and is inexpensive. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Avoidance of Tobacco Products Nicotine contained in tobacco causes vasoconstriction and increases BP, especially in people with hypertension. Smoking tobacco is also a major risk factor for CVD. The cardiovascular benefits of stopping tobacco use are seen within 1 year in all age groups. Strongly encourage everyone, especially patients with hypertension, to avoid tobacco use. Advise those who continue to use tobacco products to monitor their BP during use. Management of Psychosocial Risk Factors Psychosocial risk factors can contribute to the risk of developing CVD and to a poorer prognosis and clinical course in patients with CVD. These risk factors include low socioeconomic status, social isolation and lack of support, stress at work and in family life, and negative emotions such as depression and hostility. Frequently, these risk factors are clustered together. For example, there tends to be higher rates of depression in individuals who experience job stress. Psychosocial risk factors have direct effects on the cardiovascular system by activating the SNS and stress hormones. This can cause a wide variety of pathophysiologic responses, including hypertension Psychosocial risk factors can contribute to CVD indirectly as well, simply by their impact on lifestyle behaviors and choices. Screening for psychosocial risk factors is important. Make appropriate referrals (e.g., counseling), when indicated. Suggest behavioral interventions such as relaxation training, stress management courses, support groups, and exercise training for individuals who are not in acute psychologic distress. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Have students brainstorm. Should include the following: This drug is a diuretic that will increase the amount of water excreted as urine. Decreasing the amount of fluid circulating in your blood stream will work to decrease your blood pressure. Take in the morning to prevent nocturnal diuresis. Change positions slowly to prevent a sudden drop in blood pressure (orthostatic hypotension). Use sugarless gum or hard candy to help ease dry mouth that may occur. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Once antihypertensive therapy is started, patients should return for follow-up and adjustment of drugs at monthly intervals until the goal BP is reached. More frequent visits are necessary for patients with stage 2 hypertension or with co-morbidities. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals. Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not comply with therapy. Patient and caregiver teaching related to drug therapy may help the patient comply with therapy. Side effects may be an initial response to a drug and may decrease over time. Informing the patient about side effects that may decrease with time may enable the person to continue taking the drug. The number or severity of side effects may relate to the dosage. It may be necessary to change the drug or decrease the dosage. A common side effect of several of these drugs is orthostatic hypotension. This condition results from an alteration of the autonomic nervous system’s mechanisms for regulating BP, which are required for position changes. Consequently, the patient may feel dizzy and faint when assuming an upright position after sitting or lying down. Sexual problems may occur with many of the antihypertensive drugs and can be a major reason that patients do not comply with the treatment plan. Problems can range from reduced libido to erectile dysfunction. Rather than discussing a sexual problem with a health care provider, the patient may decide just to stop taking the drug. Diuretics cause dry mouth and frequent voiding. Sugarless gum or hard candy may help ease dry mouth. Taking diuretics earlier in the day may limit frequent voiding during the night and preserve sleep. Side effects of vasodilators and adrenergic inhibitors decrease if the drugs are taken in the evening. Because BP is lowest during the night and highest shortly after awakening, drugs with a 24-hour duration of action should be taken as early in the morning as possible (e.g., 4 or 5 am if the patient awakens to void). Advise the patient to report all side effects to the health care provider who prescribes the drug. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Obtain the following important health information from the patient: Past health history: Known duration and past workup of high BP; cardiovascular, cerebrovascular, renal, or thyroid disease; diabetes mellitus; pituitary disorders; obesity; dyslipidemia; menopause or hormone replacement status Drugs: Use of any prescription or over-the-counter, illicit, or herbal drugs or products; previous use of antihypertensive drug therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Also obtain the following important health information related to pertinent functional health patterns: Health perception–health management: Family history of hypertension or cardiovascular disease; tobacco use, alcohol use; sedentary lifestyle Nutritional-metabolic: Usual salt and fat intake; weight gain or loss Elimination: Nocturia Activity-exercise: Fatigue; dyspnea on exertion, palpitations, exertional chest pain; intermittent claudication, muscle cramps; usual pattern and type of exercise Cognitive-perceptual: Dizziness; blurred vision; paresthesia Sexual-reproductive: Erectile dysfunction, decreased libido Coping–stress tolerance: Stressful life events Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Objective data Blood pressure readings Heart sounds Pulses Edema Body measurements Mental status changes Perform a focused physical assessment for the following risk factors and/or clinical manifestations: Cardiovascular SBP consistently >140 mm Hg or DBP >90 mm Hg, orthostatic changes in BP and pulse; bilateral BPs significantly different; abnormal heart sounds; laterally displaced, apical pulse; diminished or absent peripheral pulses; carotid, renal, or femoral bruits; presence of peripheral edema Gastrointestinal Obesity (BMI >30 kg/m2); abnormal waist-hip ratio Neurologic Mental status changes Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension BP Measurement
Take in both arms initially Proper size and placement of cuff Initially, take the BP in both arms to note any differences. Atherosclerosis in the subclavian artery can cause a falsely low reading on the side where the narrowing occurs. Use the arm with the highest BP and take at least two readings, at least 1 minute apart. Waiting for at least 1 minute between readings allows the blood to drain from the arm and prevents inaccurate readings. Proper size and correct placement of the BP cuff are critical for accurate measurement. Place the cuff snugly around the patient’s bare upper arm with the midline of the bladder of the cuff (usually marked on the cuff by the manufacturer) placed above the brachial artery. Place the patient’s arm at the level of the heart during BP measurement. For BP measurements taken in the sitting position, raise and support the arm at the level of the heart. For measurements taken in a supine position, raise and support (e.g., with a small pillow) the arm at heart level. If the arm is resting on the bed, it will be below heart level. BP cuffs that are too small or too large will result in readings that are falsely high or low, respectively. From: Bonewit-West:, K Clinical Procedures for Medical Assistants, ed 7, St. Louis, 2008, Saunders Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 If neither upper arm can be used to measure BP (e.g., presence of IV lines, fistula), or if a maximum size BP cuff does not fit the upper arm, use the forearm. In this case, position the proper size cuff midway between the elbow and the wrist. Auscultate Korotkoff sounds over the radial artery or use a Doppler device to note systolic BP. Use of an oscillometric device on the forearm is acceptable. Forearm and upper arm BPs are not interchangeable. If using the forearm for BP measurement, always document the site. Assess for orthostatic (or postural) changes in BP and pulse in older adults, in people taking antihypertensive drugs, and in patients who report symptoms consistent with reduced BP on standing (e.g., light-headedness, dizziness, syncope). Measure serial BP and pulse with the patient in the supine, sitting, and standing positions. Initially, measure BP and pulse with the patient in the supine position after at least 2 to 3 minutes of rest. Reposition the patient in the sitting position with legs dangling and measure BP and pulse again within 1 to 2 minutes. Finally reposition the patient to the standing position and measure the BP and pulse within 1 to 2 minutes. Usually the SBP decreases slightly (less than 10 mm Hg) on standing, whereas the DBP and pulse increase slightly. A decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in the heart rate of ≥20 beats/min from supine to standing indicates orthostatic hypotension. Common causes of orthostatic hypotension include intravascular volume loss and inadequate vasoconstrictor mechanisms related to disease or drugs. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Ineffective self-health management related to lack of knowledge of pathology, complications, and management of hypertension Anxiety related to complexity of management regimen Sexual dysfunction related to side effects of an antihypertensive drug Risk for decreased cardiac tissue perfusion Risk for ineffective cerebral tissue perfusion Risk for ineffective renal perfusion Potential complication: stroke Potential complication: myocardial infarction Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 The overall goals for the patient with hypertension are that the patient will (1) achieve and maintain the goal BP; (2) understand and follow the therapeutic plan; (3) experience minimal or no unpleasant side effects of therapy; and (4) be confident of the ability to manage and cope with this condition. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension Nursing Implementation
Health promotion Primary prevention via lifestyle modification Individual patient evaluation and education Screening programs Cardiovascular risk factor modification Primary prevention of hypertension is a very cost-effective approach. Current recommendations for primary prevention include lifestyle modifications that prevent or delay the rise in BP in susceptible people. Following the DASH diet and reducing sodium can lower BP. This diet is recommended for primary prevention in the general population. Hypertension is usually identified through routine screening for insurance, preemployment, and military physical examinations. You are in an ideal position to assess for the presence of hypertension, identify the risk factors for hypertension and CAD, and teach the patient about these conditions. Screening programs in the community are widely used to check individuals for high BP. At the time of the BP measurement, give each person a written, numeric value of the reading. If necessary, explain why further evaluation is needed. Effort and resources should focus on the following: (1) controlling BP in persons already identified as having hypertension; (2) identifying and controlling BP in at-risk groups, such as African Americans, obese people, and blood relatives of people with hypertension; and (3) screening those with limited access to the health care system. Teaching regarding CVD risk factors is appropriate for all individuals and during targeted screening programs. Modifiable cardiovascular risk factors include hypertension, obesity, diabetes mellitus, tobacco use, and physical inactivity. Discuss lifestyle modifications based on identified risk factors. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Ambulatory and home care Evaluate therapeutic effectiveness Detect and report adverse effects Assess and enhance compliance Patient and caregiver teaching Your primary responsibilities for long-term management of hypertension are to assist the patient in reducing BP and complying with the treatment plan. Your nursing actions include evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing compliance, and patient and caregiver teaching. A major problem in the long-term management of the patient with hypertension is poor compliance with the prescribed treatment plan. The reasons are many and include inadequate patient teaching, unpleasant side effects of drugs, return of BP to normal range while on medication, lack of motivation, high cost of drugs, lack of insurance, and lack of a trusting relationship between the patient and the health care provider. Also assess the patient’s diet, activity level, and lifestyle as an additional indicator of compliance. Individually assess patients to determine the reasons why the patient is not complying with the treatment and develop a plan with the patient to improve compliance. The plan should be compatible with the patient’s personality, habits, and lifestyle. Active patient participation increases the likelihood of adherence to the treatment plan. Measures such as including the patient in the development of a drug schedule, selecting drugs that are affordable, and involving caregivers help increase patient compliance. Substituting combination drugs for multiple drugs once the BP is stable may also facilitate compliance. Combination drugs reduce the number of pills the patient has to take each day and may reduce costs. It is important to help the patient and caregiver understand that hypertension is a chronic illness that cannot be cured. Emphasize that it can be controlled with drug therapy, diet changes, physical activity, periodic follow-up, and other relevant lifestyle modifications. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Reasons for noncompliance Inadequate teaching Side effects Return to normal BP Lack of motivation Financial Lack of trust A major problem in the long-term management of the patient with hypertension is poor compliance with the prescribed treatment plan. The reasons are many and include inadequate patient teaching, unpleasant side effects of drugs, return of BP to normal range while on the drugs, lack of motivation, high cost of drugs, lack of insurance, and lack of a trusting relationship between the patient and the health care provider. Also assess the patient’s diet, activity level, and lifestyle as an additional indicator of compliance. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study What could you do to increase C.S.’s compliance with his medication and lifestyle changes? Fuse/Thinkstock Have student’s brainstorm and then discuss with next slide. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Measures to enhance compliance Individualize plan Active patient participation Select affordable drugs Involve caregivers Combination drugs Patient teaching Individually assess patients to determine the reasons why the patient is not complying with the treatment and develop a plan with the patient to improve compliance. The plan should be compatible with the patient’s personality, habits, and lifestyle. Active patient participation increases the likelihood of adherence to the treatment plan. Measures such as including the patient in the development of a drug schedule, selecting drugs that are affordable, and involving caregivers help increase patient compliance. Substituting combination drugs for multiple drugs once the BP is stable may also facilitate compliance. Combination drugs reduce the number of pills the patient has to take each day and may reduce costs. It is important to help the patient and caregiver understand that hypertension is a chronic illness that cannot be cured. Emphasize that it can be controlled with drug therapy, diet changes, physical activity, periodic follow-up, and other relevant lifestyle modifications. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Patient and caregiver teaching includes: Nutritional therapy Drug therapy Physical activity Home BP monitoring (if appropriate) Tobacco cessation (if applicable) Patients and caregivers need education regarding proper diet, drugs, and exercise. Most patients with known or suspected hypertension should monitor their BP at home. Patient teaching is critical to ensure accuracy. Tell patients to buy an oscillometric BP monitor that uses a cuff for the upper arm. The patient should bring the BP monitor to the office to verify proper cuff size, accuracy of the device, and the patient’s technique. Teach the patient to properly obtain a BP measurement. Tell the patient to measure BP in the nondominant arm, or arm with the higher BP if there is a known difference between arms. Advise the patient to measure BP first thing in the morning (if possible, before taking drugs) and at night before going to bed. Tell the patient to keep a log of all BP measurements and to bring the log to office visits. For clinical decision making (e.g., adjustments in dosage, start of new drug), instruct patients to take BP readings as described for 1 week. Stable, normotensive patients should measure morning and evening BP for at least 1 week every 3 months. Home BP readings may help achieve patient compliance by reinforcing the need to remain on therapy. However, some patients become overly concerned with the BP readings. Discourage too frequent checking of their BP. Generally, home BP monitoring should reassure the patient that the treatment is effective. If the patient is a smoker, tobacco cessation teaching should also be provided. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study C.S. returns to the HCP’s office for a follow-up visit 3 months after starting on hydrochlorothiazide. How would you evaluate the effectiveness of his treatment strategies? Fuse/Thinkstock Have students brainstorm and then discuss with next slide. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 The overall expected outcomes are that the patient with hypertension will: Achieve and maintain goal BP as defined for the individual Understand, accept, and implement the therapeutic plan Experience minimal or no unpleasant side effects of therapy Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question A patient’s 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. 4. The patient’s possible use of recreational drugs. Answer: 3 Rationale: Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not comply with therapy. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Age-related physical changes contribute to HTN The prevalence of hypertension increases with age. The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age over 65) normotensive men and women. Isolated systolic hypertension (ISH) is the most common form of hypertension in people over 50 years of age. Additionally, older adults are more likely to have white coat hypertension. The following age-related physical changes play a role in the pathophysiology of hypertension in the older adult: (1) loss of elasticity in large arteries from atherosclerosis; (2) increased collagen content and stiffness of the myocardium; (3) increased peripheral vascular resistance; (4) decreased adrenergic receptor sensitivity; (5) blunting of baroreceptor reflexes; (6) decreased renal function; and (7) decreased renin response to sodium and water depletion. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 In the older adult who is taking an antihypertensive drug, absorption of some drugs may be altered as a result of decreased blood flow to the gut. Metabolism and excretion of drugs may also be prolonged. Careful technique is important in assessing BP in older adults. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats. This is called the auscultatory gap. Failure to inflate the cuff high enough may result in underestimating SBP. Because of varying degrees of impaired baroreceptor reflexes, orthostatic hypotension often occurs in older adults, especially in those with ISH. Orthostatic hypotension in this age-group is often associated with volume depletion or chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance. To reduce the likelihood of orthostatic hypotension, antihypertensive drugs should be started at low doses and increased slowly. Measure BP and heart rate in the supine, sitting, and standing positions at every visit. Older adults experience postprandial drops in BP. The greatest decrease occurs approximately 1 hour after eating. BP returns to preprandial levels 3 to 4 hours after eating. Avoid giving vasoactive drugs with meals. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis Hypertensive emergency Occurs over hours to days BP >220/140 with target organ disease Hypertensive urgency 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 is a term used to indicate either a hypertensive urgency or emergency. This is determined by the degree of target organ disease and how quickly the BP must be lowered. A hypertensive emergency develops over hours to days. It is a situation in which a patient’s BP is severely elevated (often greater than 220/140 mm Hg) with clinical evidence of target organ disease. Hypertensive urgency develops over days to weeks. This is a situation in which a patient’s BP is severely elevated (usually above 180/110 mm Hg) but there is no clinical evidence of target organ disease. The rate of rise of BP is more important than the absolute value in determining the need for emergency treatment. Patients with chronic hypertension can tolerate much higher BPs than normotensive people. Prompt recognition and management of hypertensive crisis is essential to decrease the threat to organ function and life. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis Clinical Manifestations
Hypertensive encephalopathy Headache, n/v, seizures, confusion, coma Renal insufficiency Cardiac decompensation MI, HF, pulmonary edema Aortic dissection A hypertensive emergency is often manifested as hypertensive encephalopathy, a syndrome in which a sudden rise in BP is associated with severe headache, nausea, vomiting, seizures, confusion, and coma. The manifestations of encephalopathy are the result of increased cerebral capillary permeability. This leads to cerebral edema and a disruption in cerebral function. On retinal examination, exudates, hemorrhages, and/or papilledema are found. Renal insufficiency ranging from minor injury to complete renal failure can occur. Rapid cardiac decompensation ranging from unstable angina to MI and pulmonary edema is also possible. Patients can have chest pain and dyspnea. Aortic dissection can develop and will cause sudden, excruciating chest and back pain and possibly reduced or absent pulses in the extremities. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Hypertensive emergencies require hospitalization, IV administration of antihypertensive drugs, and intensive care monitoring. When treating hypertensive emergencies, the mean arterial pressure (MAP) is often used instead of BP readings to guide and evaluate drug therapy. The initial goal is to decrease MAP by no more than 20% to 25%, or to decrease MAP to 110 to 115 mm Hg. If the patient is clinically stable, drugs can be titrated to gradually lower BP over the next 24 hours. Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could precipitate a stroke, MI, or renal failure. Antihypertensive drugs administered IV have a rapid (within seconds to minutes) onset of action. Assess the patient’s BP and pulse every 2 to 3 minutes during the initial administration of these drugs. Use an intraarterial line or an automated, noninvasive BP machine to monitor BP. Titrate the drug according to MAP or BP as ordered. Monitor the ECG for cardiac dysrhythmias and signs of ischemia or MI. Measure urine output hourly to assess renal perfusion. Patients receiving IV antihypertensive drugs may be restricted to bed. Getting up (e.g., to use the commode) may cause severe cerebral ischemia and fainting. Ongoing assessment is essential to evaluate the effectiveness of these drugs and the patient’s response to therapy. Frequent neurologic checks, including level of consciousness, pupillary size and reaction, and movement of extremities, help detect any changes in the patient’s condition. Once the hypertensive crisis is resolved, it is important to determine the cause. The patient will need appropriate management and teaching to avoid future crises. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Answer: 1 Rationale: Hypertension is more prevalent in men who are less than 55 years of age. Smoking tobacco greatly increases the risk of cardiovascular disease. A history of a close blood relative (e.g., parents, sibling) with hypertension is associated with an increased risk for developing hypertension. Other risk factors would include increasing age, sedentary lifestyle, and stress. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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 Answer: 4 Rationale: Stage 2 hypertension is diagnosed when the systolic blood pressure is greater than or equal to 160 mm Hg or the diastolic blood pressure is greater than or equal to 100 mm Hg. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

A patient’s 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. Patient’s adherence to drug therapy 4. Possible use of recreational drugs Answer: 3 Rationale: Side effects of antihypertensive drugs are common and may be so severe or undesirable that the patient does not comply with therapy. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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