1. Chapter 37
Hypertension 1

2. Learning Objectives Define hypertension.
Explain the physiology of blood pressure regulation.
Discuss the risk factors, signs and symptoms, diagnosis,
treatment, and complications of hypertension.
Identify the nursing considerations when administering
selected antihypertensive drugs.
List the data to be collected for the nursing assessment
of a person with known or suspected hypertension.
Identify the nursing diagnoses, goals, and outcome criteria
for the patient with hypertension.
Describe the nursing interventions for the patient with
hypertension.

3. Definitions
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
Normal blood pressure
Systolic: <120 mm Hg; diastolic <80 mm Hg
Prehypertension
Systolic pressures between 120 and 139; diastolic pressures between 80 and 89
Stage 1 and stage 2 hypertension
See Table 37-1
What risks are included in each of the Risk Groups A, B, and C?
Some people have only occasional elevations in blood pressure and normal readings at other times; this is called isolated pressure elevations. 3

4. Types of Hypertension Primary hypertension Secondary hypertension
90% to 95% of all cases of hypertension
Its cause is unknown
Secondary hypertension
Caused by underlying factors, such as kidney disease, certain arterial conditions, some drugs, and occasionally pregnancy 4

5. Anatomy and Physiology of Blood Pressure Regulation
Cardiac output
The volume of blood pumped by the heart in a specific period (usually 1 minute)
Determined by strength, rate, and rhythm of the contraction of the left ventricle and the blood volume 5

6. Anatomy and Physiology of Blood Pressure Regulation
Peripheral vascular resistance
Force in the blood vessels that left ventricle must overcome to eject blood from the heart
Resistance to blood flow determined by diameter of the blood vessels and blood viscosity (thickness)
Increased peripheral vascular resistance: the most prominent characteristic of hypertension
Why does increased peripheral vascular resistance occur? 6

7. Anatomy and Physiology of Blood Pressure Regulation
Diameter of blood vessels regulated by the vasomotor center
Sympathetic nervous system tracts from the medulla extend down the spinal cord to the thoracic and abdominal regions
Stimulation of sympathetic nervous system causes release of the hormones norepinephrine and epinephrine 7

8. Anatomy and Physiology of Blood Pressure Regulation
Norepinephrine and epinephrine (catecholamines) are vasoconstrictors: cause blood vessels to constrict, making diameter smaller
By constricting blood vessels, norepinephrine increases peripheral vascular resistance and raises blood pressure
Epinephrine constricts blood vessels and increases the force of cardiac contraction, causing blood pressure to rise 8

9. Anatomy and Physiology of Blood Pressure Regulation
Vasoconstriction decreases blood flow to the kidneys, which then release renin
Renin leads to the formation of angiotensin, another potent vasoconstrictor
Angiotensin stimulates the adrenal cortex to secrete aldosterone, a hormone that promotes sodium and water retention
This results in an increased blood volume
Vasoconstriction, cardiac stimulation, and retention of fluid all contribute to hypertension 9

10. Figure 37-1 10

11. Age-Related Changes Affecting Blood Pressure
Atherosclerotic changes reduce the elasticity of the arteries, causing decrease in cardiac output and increase in peripheral vascular resistance
Pulse pressure (the difference between the systolic and diastolic pressures) widens in response to a decreased ability of the aorta to distend
After age 60 years, peripheral vascular resistance increases by approximately 1% per year.
Why does the systolic pressure rise in the older adult?
Because research has shown that older people do benefit from controlling hypertension, age is no longer considered a barrier to aggressive treatment. 11

12. Primary (Essential) Hypertension12

13. Risk Factors Dyslipidemia Atherosclerosis Diabetes mellitus
Tobacco use
Age >55 years for men or age >65 years for women
Family history
Father or brother with heart disease before age 55; mother or sister with heart disease before age 65
Sedentary lifestyle
Obesity
Other risk factors include stress, overstimulation, and a family history of obesity, hypertension, or dyslipidemia.
What stimulants may contribute to or aggravate hypertension? 13

14. Signs and Symptoms Occipital headaches that are more severe on arising
Lightheadedness
Epistaxis
If hypertension has damaged blood vessels in the heart, kidneys, eyes, or brain, patient may have symptoms of impaired function of those organs 14

15. Figure 37-2 15

16. Complications Heart Kidneys
Coronary artery disease develops in patients with hypertension two to three times more frequently than in people with normal blood pressures
Kidneys
Narrowing of the renal arteries may decrease renal function and lead to chronic renal failure
Coronary artery disease reduces blood supply to the myocardium, which can result in angina, myocardial infarction, and congestive heart failure.
What may cause the left ventricle to hypertrophy?
Initial indicators of renal failure are nocturia (need to urinate during the night) and azotemia (accumulation of nitrogen waste products in the blood). 16

17. Complications Brain Eyes
Prolonged hypertension constricts and damages cerebral arteries, putting patient at risk for transient ischemic attacks and cerebrovascular accidents
Eyes
Damage to eyes may include narrowing of the retinal arterioles, retinal hemorrhages, and papilledema; may lead to blindness
What is a transient ischemic attack?
People with hypertension have a sevenfold greater incidence of cerebrovascular accidents than those with normal blood pressures. 17

18. Diagnostic Tests and Procedures
Confirmed by repeated findings of average pressures equal to or greater than 140/90
Ambulatory blood pressure monitors
Physician collects data about patient’s lifestyle, other cardiovascular risk factors, and other medical diagnoses
Electrocardiogram
Blood studies include glucose, hematocrit, potassium, calcium, creatinine, and a lipid profile
Chest radiograph
Why would physicians feel there is no need to find the cause of a patient’s hypertension? 18

19. Medical Treatment Lifestyle modifications Weight reduction
Smoking cessation
Sodium and alcohol restriction
Exercise
Relaxation techniques
Reduction of weight can reduce blood pressure by reducing the cardiac workload.
Stopping smoking eliminates vasoconstriction caused by nicotine.
Reduction of sodium in the body reduces water retention and decreases the blood volume.
A planned program of exercise improves cardiac efficiency by increasing cardiac output and decreasing peripheral vascular resistance.
Relaxation therapy, biofeedback, and behavior modification techniques also may be used to reduce stress and lower blood pressure.
How much should alcohol intake be limited? 19

20. Medical Treatment Pharmacologic therapy
Specific antihypertensive drugs
Diuretics
Beta-adrenergic receptor blockers
Calcium antagonists
Angiotensin-converting enzyme (ACE) inhibitors (or ACEIs)
Angiotensin II receptor antagonists (ARBs)
Central adrenergic blockers
Alpha-adrenergic receptor blockers
Direct vasodilators
What is the goal of drug therapy? 20

21. Figure 37-3 21

22. Medical Treatment Pharmacologic therapy Nursing implications
Administering the drugs to inpatients
Monitoring for therapeutic and adverse effects
Teaching patients about their drugs
Older patients are at greater risk for adverse effects of medications because of reduced liver and kidney function.
Why do antihypertensive drugs cause older adults to be at risk for falls? 22

23. Secondary Hypertension
Has a specific known cause and is less common than primary hypertension
Causes
Renal disease
Excess secretion of adrenal hormones
Narrowing of the aorta
Increased intracranial pressure
Some drugs such as vasoconstrictors 23

24. Nursing Care of the Patient with Hypertension24

25. Assessment
Periodic blood pressure checks detect new or unknown hypertensive people; provide data to evaluate effect of therapy in hypertensive people
Complete history and physical examination by the registered nurse
The LVN may be involved in initial blood pressure screenings and monitoring, and provides important data to evaluate treatment effectiveness
What are the keys to blood pressure control? 25

26. Health History
Explore past medical for hypertension or renal, cardiac, or endocrine disorders
Date and readings of the last blood pressure measurement
Ask about pregnancy and about hormone replacement therapy
Current medications, including over-the-counter drugs 26

27. Health History
Family health history: hypertension, myocardial infarction, or cerebrovascular accidents
Body systems for signs and symptoms, particularly headaches, epistaxis, dizziness, visual disturbances, dyspnea, angina, nocturia
Data about the patient’s usual functioning may detect some risk factors for hypertension
Occupation, exercise and activity, sleep and rest, nutrition, interpersonal relationships, and stressors 27

28. Physical Examination General appearance; note obvious distress
Measure height and weight and vital signs
Patient should be seated in a chair with feet on the floor and arm resting at the level of the heart
The proper cuff size is essential
Multiple readings should be taken
Blood pressure assessed in both arms in the supine, sitting, and standing positions
The nurse may be the first to detect elevated pressure, so accurate measurement of blood pressure is very important.
What may cause a blood pressure reading to have a falsely high reading? A falsely low reading?
When screening persons for hypertension, if blood pressure is elevated initially, reassess it after 1 to 5 minutes; If the pressure remains elevated, refer the patient for medical evaluation. 28

29. Interventions: Ineffective Therapeutic Regimen Management
Diet therapy goals
Maintain ideal body weight; prevent fluid retention
Exercise
Walking is highly recommended: increases cardiovascular functioning, burns calories, relieves stress, and promotes a sense of well-being
A diet low in saturated fats with no more than 2 g of sodium is often prescribed.
What is the maximum daily intake of sodium recommended by the National Research Council?
If the patient is taking a potassium-wasting diuretic, dietary potassium intake may need to be increased or potassium supplements may be recommended.
The DASH (Dietary Approaches to Stop Hypertension) eating plan can not only help lower blood pressure in people with hypertension, but also decrease the risk of a person developing hypertension.
Advise patients to ask their physicians before beginning new exercise programs.
Instruct them to increase their activities gradually over a period of time. 29

30. Interventions: Ineffective Therapeutic Regimen Management
Stress management
Help patients identify stressors in their lives and explore ways to reduce them
Drug therapy
Review the name, dosage, purpose, and side effects of any prescribed medications
Patients need to be well informed about their medications.
What adverse effects may be caused by suddenly stopping antihypertensive drugs? 30

31. Interventions Risk for Injury Orthostatic hypotension Sedation
Sudden drop in systolic blood pressure, usually 20 mm Hg, when going from lying or sitting to a standing position
Monitor for lightheadedness, dizziness, syncope
Sedation
Advise if drowsiness is likely so activities requiring alertness can be avoided during times of peak drug effect
Taking medications at bedtime to promote sleep
How should patients who are prone to orthostatic hypotension be advised to prevent falling? 31

32. Interventions Ineffective Coping Sexual Dysfunction
If depression a side effect of an antihypertensive, consult physician to substitute another drug
Sexual Dysfunction
Decreased libido, inability to achieve an erection, or delayed ejaculation
Advise physician so an alternative medication or other intervention can be considered
What is the best way to introduce the subject of sexual dysfunction to a patient? 32

33. Older Patients
Response to drug therapy more difficult to predict; side effects are more common
Orthostatic hypotension and sedation problematic for the older person, who is prone to fall and suffer serious injuries
Depression also must be taken very seriously because it lowers motivation, impairs quality of life, and can lead to suicide
What effects can depression have on the older patient?
The older patient should be treated just like a younger patient in the assessment and management of distressing drug effects. 33

34. Hypertensive Emergencies
A life-threatening medical emergency
Severe headache, blurred vision, nausea, restlessness, and confusion
Elevated diastolic blood pressure (130 mm Hg or more); the heart and respiratory rates are increased
May result from having stopped taking antihypertensive drugs
Malignant hypertension is a specific type of hypertensive emergency in which the diastolic pressure exceeds 140 mm Hg.
In what population is hypertensive crisis most commonly seen? 34

35. Hypertensive Emergencies
Causes: malignant hypertension, hypertensive encephalopathy, eclampsia, pheochromocytoma (adrenal tumor), cerebrovascular accident
Without treatment, the patient in hypertensive crisis may incur cardiac and renal damage
Death may ensue as a result of a cerebrovascular accident, renal failure, or cardiac failure 35

36. Medical Diagnosis
Assessment in the ED reveals elevated blood pressure, pulse, and respiratory rate
Retinal hemorrhage or papilledema, or both, observed in fundus (back, interior portion) of eye
Physician may order blood drawn for arterial blood gases, CBC, electrolytes, blood urea nitrogen, creatinine, and cardiac enzymes
Chest radiograph may be requested
Direct blood pressure monitoring through an arterial catheter preferred 36

37. Medical Treatment
The goal of drug therapy is to rapidly reduce the pressure to a non–life-threatening level and then to bring it slowly within normal range
Diuretics and potent vasodilators
Fenoldopam
Nitroglycerin
Diazoxide
Hydralazine
Phentolamine
Labetalol
Nitroprusside 37

38. Medical Treatment
An intravenous line is usually established because many drugs are given by that route
Oral options for the management of hypertensive crisis include captopril, clonidine, and nifedipine
See Box 37-3, p. 728 38

39. Nursing Care of the Patient in Hypertensive Crisis39

40. Assessment
Frequently check blood pressure, pulse, respiration, and level of consciousness
Some drugs are given in intravenous fluids, requiring continuous monitoring and adjustment
Careful record of fluid intake and output
Nausea and vomiting may indicate an impending seizure or coma 40

41. Interventions Administer prescribed drugs
Vital signs before and after each dose
Monitor cardiac and renal function
Start and maintain intravenous therapy
Administer oxygen as ordered
Comfort the patient 41

42. Interventions
Take appropriate safety measures if the patient shows signs of seizure activity or a decreasing level of consciousness
Once patient’s condition improves, it is important to explain how to manage hypertension and prevent future crises
What safety measures should be taken for signs of seizure activity or decreased consciousness? 42