Nursing Assessment and Management of Patients with Hypertension

					   Assessment and
Management of Patients
  with Hypertension

      Adult Health I
       NURS 400



                         1
What is Blood Pressure?
 Product of cardiac
 output x peripheral
 resistance




                          2
Hypertension
 Defined by Seventh Report on the Joint
 National Committee on Prevention,
 Detection, Evaluation and Treatment of
 High Blood Pressure (JNC 7) as:
 – systolic blood pressure = or >140mmHg and/or
   diastolic blood pressure = or > 90mmHg
 – Requires 2 or more readings on 2 or more
   occasions
 Affects 28% - 31% of adults in US

                                                  3
Classification of Hypertension
BP               Systolic BP   Diastolic BP
Classification
Normal           <120          <80

Pre-             120-139       80-89
hypertension
Stage 1          140-159       90-99
hypertension
Stage 2          ≥ 160         ≥ 100
hypertension
                                              4
Types of Hypertension
 Primary Hypertension
 – 90% - 95% of all hypertension
 – No known cause
 Secondary Hypertension
 – Remaining 5% - 10% of hypertension
 – HTN r/t other causes
 – Example: Pheochromocytoma


                                        5
Facts About Hypertension
 “The Silent Killer”
 Incidence is greater in southeastern U.S. and
 among African-Americans
 Other factors that influence HTN:
 – Increased sympathetic nervous system activity
 – Increased reabsorption of sodium, chloride and water
   by the kidneys
 – Increased activity of the renin-angiotensin system
 – Decreased vasodilatation
 – Insulin resistance


                                                          6
Recommendations for Follow-up
Based on Initial BP Readings
 Normal BP – recheck 2 years
 Pre-hypertension – recheck 1 year
 Stage 1 hypertension – confirm within 2
 months
 Stage 2 hypertension – evaluate or refer to
 source of care within 1 month
 – BP 180/100 or >, evaluate or refer for care
   within 1 week


                                                 7
Major Risk Factors
 Elevated BP readings
 Smoking
 Obesity
 Physical inactivity
 Dyslipidemia
 Diabetes mellitus
 Microalbuminuria or GFR <60
 Older age
 Family history


                               8
Signs and Symptoms
 Elevated bp readings
 If any sx are reported:
 –   Retinal changes
 –   Headache
 –   Dizziness
 –   Epistaxis
 Sx usually only reported in cases of
 hypertensive emergencies

                                        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
Lifestyle Modifications
 Weight loss
 Reduced alcohol intake
 Reduced sodium intake
 Regular physical activity
 DASH diet




                             11
DASH (Dietary Approaches to Stop
Hypertension) Diet

Food Group                  # Servings per Day
Grains                      7-8
Vegetables                  4-5
Fruits                      4-5
Low-fat or fat-free dairy   2-3
Meat, fish, poultry         2 or fewer
Nuts, seeds, dry beans      4-5 weekly

                                                 12
Advantages of Lifestyle Modification

 Weight loss of 10kg can reduce BP 5-
 20mmHg
 Sodium reduction (2.4g/day) can reduce BP
 2-8mmHg
 Physical activity can reduce BP 4-9mmHg
 Moderation of alcohol can reduce BP 2-
 4mmHg


                                         13
Medications
 Usually initial medication treatment is a diuretic, a
 beta blocker, or both
 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


                                                     14
Medication Therapy for
Hypertension
 Diuretic and related drugs
  –   Thiazide diuretics (HCTZ)
  –   Loop diuretics (Furosemide)
  –   Potassium-sparing diuretics (Triamterene)
  –   Aldosterone receptor blockers (Spironolactone)
 Central Alpha2-Agonists and other centrally
 acting drugs (Clonidine)
 Beta blockers (Atenolol)

                                                   15
Medication Therapy for
Hypertension
 Alpha and beta blockers (Carvidilol)
 Vasodilators (Nitroglycerine)
 Angiotensin-converting enzyme (ACE)
 inhibitors (Enalapril)
 Angiotensin II antagonists (Valsartan)
 Calcium channel blockers
  – Nondihydropyridines (Diltiazem)
  – Dihydropyridines (Amlodipine)

                                          16
Nursing 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



                                                         17
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




                                                 18
Patient Centered Goals
 Patient understanding of disease process
 Patient understanding of treatment regimen
 Patient participation in self-care
 Absence of complications




                                              19
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

                                              20
Gerontologic Considerations
 Noncompliance
 Include family
 Understanding of therapeutic regimen
 – Reading instructions
 – Monotherapy




                                        21
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.



                                                    22
Management of 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,
   fenoldopam mesylate, enalaprilat, nitroglycerin
 Need very frequent monitoring of BP and
 cardiovascular status

                                                         23
Management of 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 inhibitors: captopril or alpha2-agonists-
   clonidine

                                                  24
Case Study: MJ is a 73y WF with no hx of
HTN. She comes to the doctor’s office for a
flu vaccine

 Subjective data:
  –   Wt gain of 20lbs
  –   Doesn’t smoke or drink alcohol
  –   Meds: MVI 1 tab daily
  –   Eats a lot of canned foods
  –   Does not regularly exercise
 Objective data:
  –   Ht: 64”, wt: 170lbs
  –   BP: 170/82
  –   PE normal
  –   Serum K+ = 3.3
                                              25
Critical Thinking Questions
1. What are the contributing factors to her
   elevated BP?
2. What risk factors does she have?
3. What dietary changes would you
   recommend?
4. What teaching would you do?
5. If drug therapy becomes necessary, what
   type would be considered?

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