1. Chapter 32 Assessment and Management of Patients With Hypertension

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

3. Answer
True
Cardiac Output = Heart Rate x Stroke Volume

4. 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

5. Classification of Blood Pressure for Adults Age 18 and Older

6. 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.

7. Factors Involved in the Control of Blood Pressure

8. 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

9. 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

10. Major Risk Factors Hypertension Smoking Obesity Physical inactivity
Dyslipedemia
Diabetes mellitus
Microalbuminuria or GFR < 60
Older age
Family history

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

12. JNC 7 Treatment Algorithm
Refer to fig. 32-2

13. 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).

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

15. 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

16. 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.

17. 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.

18. 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

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

20. 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

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

22. 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

23. 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

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

25. 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.

26. 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.

27. 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

28. 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.

29. 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