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HYPERTENSION

statistics
2005 & 2006 - 29% of all U.S. adults age 18 or older had hypertension
The percentage of those with hypertension increases with age, from 7% in those ages 18 to 39 to 67% in those
ages 60 or older (Ostchega et al., 2008)
The highest occurrence was in non-Hispanic blacks at 41%, then non- Hispanic whites at 28%, followed by
Mexican Americans at 22%
prevalence of hypertension remains high despite effective treatments

Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High
Blood Pressure (JNC 7)
(National Heart, Lung, and Blood Institute [NHLBI], 2004)
redefined normal and abnormal blood pressures for adults ages 18 and older and established treatment
guidelines for physicians, clinicians, nurses, and community programs to follow

BLOOD PRESSURE CATEGORIES AND MEASURES*

It is very important to take blood pressure readings correctly to prevent inaccurate readings
normal BP reading = systolic pressure is below 120 mm Hg and diastolic pressure is below 80 mm Hg with
the patient in a seated position and the arm supported at heart level
Prehypertension = systolic bloodpressure of 120 to 139 mm Hg or a diastolic blood pressure of 80 to 89
mm Hg
Hypertension, also known as high blood pressure, is a condition in which the average of at least two or more
readings on different dates is above prehypertension levels.

Taking Accurate Blood Pressure Measurements


Use auscultatory method with properly calibrated and validated blood pressure instrument.
Seat patient quietly for at least 5 minutes in a chair (not on examination table) with feet on the floor and arm
supported at heart level.
Use appropriate-sized cuff in which cuff bladder encircles at least 80% of arm.
Take at least two blood pressure measurements.
Systolic blood pressure first of two or more sounds heard.
Diastolic blood pressure disappearance of sounds.
Provide patients, verbally and in writing, their specific BP reading.
Source: Adapted from NHLBI, 2004.

SAFETY TIP
Research studies show that stethoscopes used by all types of health care providers, such as nurses, physicians,
paramedics, and emergency medical technicians, are contaminated with bacteria including methicillin-
resistant Staphylococcus aureus (MRSA).
With infection rates on the rise, keep your patients safe.
Clean your stethoscope between every patient!

PATHOPHYSIOLOGY
Normally the heart pumps blood through the body to meet the cells needs for oxygen and nutrients.
As it pumps, the heart forces blood through the blood vessels.
The pressure exerted by blood on the walls of the blood vessels is measured as blood pressure.

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Blood pressure is determined by
cardiac output (CO),
peripheral vascular resistance (PVR; the ability of the vessels to stretch),
the viscosity (thickness) of the blood, and
the amount of circulating blood volume.

Decreased stretching ability of blood vessels, increased blood viscosity, and/or increased fluid volume may
cause an increase in blood pressure.

Several processes infl uence blood pressure


nervous system regulation,
arterial baroreceptors and chemoreceptors,
the renin-angiotensin-aldosterone mechanism, and
the balance of body fluids.

Cardiac output
One way blood pressure is influenced is through adjustment of the CO, which is the amount of blood that the
heart pumps each minute
The heart rate rises to increase CO in response to physical or emotional activities that increase the need for
oxygen in the organs and tissues

Peripheral vascular resistance (PVR)


the opposition that blood encounters as it flows through vessels
Anything causing blood vessels to become narrower increases PVR
Any time PVR is increased, more pressure is needed to push the blood through the vessels, so blood pressure
increases as a result.
If PVR is decreased, less pressure is needed.
Increased arteriolar PVR is the main mechanism that elevates blood pressure in hypertension

Factors that impair normal regulation of blood pressure may lead to hypertension.
Many of these factors are not well understood.
Sympathetic nervous system overstimulation
which causes vasoconstriction, can contribute to hypertension
Alterations in baroreceptors and chemoreceptors may also influence the development of hypertension.
For example, baroreceptors may become less sensitive from prolonged increases in vessel pressure and
subsequently fail to stimulate vasodilation through vessel stretching.

Hormones
increases in hormones that cause sodium retention, such as aldosterone, lead to increased fluid retention
Changes in kidney function that alter the excretion of fluid also result in an increase in overall body fluid that
may contribute to hypertension

Cytomegalovirus
A study has shown that high blood pressure might be caused by the common virus cytomegalovirus (CMV)
(Cheng et al., 2009)
By age 40, most adults are infected with CMV, which is a herpes virus, although they remain asymptomatic
until a weakened immune system occurs
CMV increases renin, an enzyme associated with high blood pressure, as well as angiotensin 11, a protein
involved in high blood pressure.
A vaccine for CMV or the use of antiviral medications may reduce cardiovascular disease and hypertension
related to CMV infection

Classifications of hypertension
Primary Hypertension
or essential hypertension
the chronic elevation of blood pressure from an unknown cause
Secondary Hypertension
has a known cause
In other words, it is a sign of another problem, such as a kidney abnormality, a tumor of the adrenal gland, or
a congenital defect of the aorta
When the cause of secondary hypertension is treated before permanent structural changes occur, blood
pressure usually returns to normal
Isolated Systolic Hypertension (ISH)
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systolic pressure of 140 mm Hg or greater and a diastolic pressure of 90 mm Hg or less
occurs mainly in the elderly, although it can occur at any age
People with a systolic pressure higher than 140 mm Hg and a diastolic pressure under 90 mm Hg found on
two separate readings should be referred to a physician for further evaluation.
Treatment - recommended to decrease cardiovascular disease, especially heart failure episodes and risk of
stroke
Lifestyle modifications are usually tried first if the systolic elevation is not too severe
If lifestyle modifications fail to reduce the systolic pressure, antihypertensive medication is added.

GERONTOLOGICAL ISSUES
In the past, it was thought that diastolic pressure was the most important aspect of
blood pressure to control. However, it is now known that after age 55, diastolic pressure
falls while systolic pressure continues to rise with age. This means that it is important to
control systolic blood pressure, not just diastolic pressure, in older adults to prevent heart
disease and stroke. In fact, lowering diastolic blood pressure too much may be unhealthy.
Alcohol consumption in the elderly can aggravate age-related hypertension. Guided
relaxation has been shown effective in reducing high blood pressure in older adults.

SIGNS AND SYMPTOMS


no signs or symptoms other than elevated blood pressure readings
hypertension is referred to as the silent killer
often first diagnosed when seeking health care for reasons unrelated to hypertension
FEW - may report a headache, bloody nose, severe anxiety, or shortness of breath, although it is usually
impossible for a patient to correlate the absence or presence of symptoms with the degree of blood pressure
elevation

DIAGNOSIS
Health Hx - considers a patients risk factors for hypertension, a previous diagnosis of hypertension, presence
of signs and symptoms, history of kidney or heart disease, and current use of medications
When the average seated blood pressure is above prehypertensive levels of 120 to 139 systolic or 80 to 89
diastolic on two or more occasions, then hypertension is diagnosed
Home blood pressure measurements obtained by the patient tend to be lower than the readings in the health
care providers office
They also are closer to the measurements recorded by 24-hour ambulatory monitors, which best indicate
cardiovascular risk
JNC 7 recommends
undergo various routine tests to identify damage to organs or blood vessels before beginning therapy for high
blood pressure:
electrocardiogram (ECG),
blood glucose level,
hematocrit, serum potassium and calcium levels,
lipoprotein profile, high-density and low-density lipoprotein cholesterol (HDL-C and LDL-C,
respectively), and triglyceride level
RISK FACTORS
Nonmodifiable risk factorsthose that cannot be changedinclude a family history of hypertension, age,
ethnicity, and diabetes mellitus
Modifiable risk factorsthose that can be changedinclude blood glucose level, activity level, smoking, salt
and alcohol intake, and newly added insufficient sleep (less than 5 hours per night).

NONMODIFI ABLE RISK FACTORS


Family History of Hypertension
Hypertension is more common among people with a family history of hypertension. Indeed, people with a
family history have almost twice the risk of developing hypertension as those with no family history. People
with a family history of hypertension should be encouraged to have their blood pressure checked regularly.
Age
People age differently because of their genetic and environmental risk factors and lifestyle habits. Thus, the
results of the aging process may be refl ected in wide variations of blood pressure among elderly people. As a
person ages, plaque builds up in the arteries, and blood vessels become stiffer and less elastic, causing the heart
to work harder to force blood through the vessels. These vessel changes increase the amount of work required
by the heart to maintain blood fl ow into the circulation and, consequently, blood pressure increases.
Race and Ethnicity
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Hypertension continues to be the most serious health problem affecting African Americans in the United
States. These patients suffer higher mortality and morbidity rates related to hypertension and at an earlier age
than all other ethnic groups.
African Americans from lower socioeconomic backgrounds have higher blood pressure than African
Americans from higher socioeconomic backgrounds. Additionally, African Americans are three to four times
more likely to develop kidney failure related to hypertension than European Americans. Addressing obesity,
high sodium intake, low potassium intake, and lack of physical activity is especially important for
cardiovascular health in African Americans.
Hypertension among African Americans is usually caused by increased renin activity, resulting in greater
sodium and fluid retention. Thus, African Americans respond better to diuretics such as furosemide (Lasix)
and hydrochlorothiazide (HydroDIURIL) than to beta blockers such as propranolol (Inderal). Hypertension
among European Americans is more often caused by chemical imbalances; thus, they respond better to beta
blockers.
Chinese people are more sensitive than Caucasians to the effects of propranolol on heart rate and blood
pressure, requiring only half the blood level of European Americans to achieve a therapeutic effect. Propranolol
is eliminated from the bodies of many Chinese people at double the rate of European Americans. They are more
likely to suffer fatigue as a side effect. Thus, the nurse must carefully monitor the Chinese patient for
therapeutic and side effects.
Hypertension among Japanese Americans is primarily related to the high sodium content of the Japanese
diet, stress, and a high rate of cigarette smoking.
High rates of hypertension among Koreans and Filipinos are due to the stress of immigration, salt
preservatives in their foods, and the use of condiments high in sodium.
Diabetes Mellitus
Many adults who have diabetes mellitus also have hypertension. The risk of developing hypertension with a
family history of diabetes and obesity is greater than when there is no family history. Lifestyle modifi cations
and adherence to therapy are crucial to prevent the heart attacks, strokes, blindness, and kidney failure
associated with high blood glucose and blood pressure levels.

MODIFIABLE RISK FACTORS


The JNC 7 suggests advising patients with hypertension to make lifestyle modifi cations. These modifi cations
include weight reduction; adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan;
moderation of dietary sodium, caffeine, and alcohol intake; increased physical activity; and smoking cessation.
Lifestyle modifi cations are often used with antihypertensive drugs to control hypertension and enhance drug
effects
Weight Reduction
There is a strong relationship between excess body weight and increased blood pressure. Weight reduction is
one of the most important lifestyle modifi cations to lower blood pressure. The health care provider and dietitian
should be consulted to help the patient develop a weight-reduction plan.
Meal Planning
SALT. High blood pressure is associated with a diet high in salt. Patients whose blood pressure can be lowered
by restricting dietary sodium are called salt sensitive. This sensitivity is particularly common among African
Americans, elderly persons, and patients with diabetes and obesity.
Patients with hypertension should be instructed not to add salt while cooking and/or table salt to their food.
Processed foods and foods in which salt can be easily tasted (e.g., canned soups, ham, bacon, salted nuts) should
also be avoided.
CAFFEINE. Intake of caffeine should be limited because it can increase aortic stiffness. This raises the risk of
cardiovascular disease for those with high blood pressure.
POTASSIUM, MAGNESIUM, AND CALCIUM. The JNC 7 recommends a balanced diet that ensures
adequate intake of potassium, magnesium, and calcium. Low levels of these nutrients can contribute to
cardiovascular events. Foods rich in potassium include oranges, bananas, and broccoli. Magnesium is found in
green vegetables such as spinach, nuts, seeds, and some whole grains. Milk, yogurt, and spinach are rich in
calcium. Whenever possible, fresh or frozen foods should be selected rather than canned foods to increase
intake of these nutrients.

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Alcohol Consumption
The regular consumption of three or more drinks per day can increase the risk of hypertension and cause
resistance to antihypertensive therapy. The nurse should counsel hypertensive patients who drink alcohol to
consume no more than 1 oz of ethanol per day for men (two drinks) and no more than 1/2 oz per day for women
(one drink). One drink is defined as 1.5 oz of 80-proof liquor, 12 oz of beer, or 5 oz of wine (NHLBI, 2004).
Blood pressure may decrease or return to normal when alcohol consumption is modified.
Exercise
People with sedentary lifestyles have an increased risk of hypertension. Exercise helps prevent and control
hypertension by reducing weight, decreasing peripheral resistance, and decreasing body fat. Anyone who is able
should participate in regular aerobic physical activity, such as brisk walking, for at least 30 minutes daily on
most days of the week. Patients with hypertension should be evaluated by a health care provider before starting
an exercise program.
Smoking
Smoking is a major risk factor for cardiovascular disease. Blood pressure may increase because nicotine
constricts the blood vessels. Nurses should counsel patients with hypertension to quit smoking to reduce overall
cardiovascular risk. A referral to a smoking cessation program can be helpful in reaching this goal.
Activities that will help to decrease blood pressure
Smoking cessation;
reduced consumption of salt, caffeine, and alcohol;
weight reduction;
improved meal planning;
increased physical activity;
managing stress; and
getting adequate sleep
THERAPEUTIC MEASURES
JNC 7 provides guidelines for selecting therapy based on
the patients blood pressure,
severity of blood pressure risk factors, and
the presence of target-organ disease or cardiovascular disease
goal of therapeutic intervention
blood pressure lower than 140/90 mm Hg (lower than 130/80 mm Hg for those with diabetes, chronic kidney
disease, or proteinuria of more than 1 g/day)
no- or low-risk hypertensive patients therapy
begins with lifestyle modifications
If lifestyle modifications alone do not result in blood pressure reaching the target goal, then drug therapy is
recommended
severe hypertension, high-risk factors, or target-organ disease
drug therapy is started immediately along with lifestyle modifications
Safe administration of medications is important, especially for the older person

most patients with hypertension


initial drug therapy often involves thiazide-type diuretics
If the response is inadequate to achieve the blood pressure goal, the dosage may be increased or a second drug
from a different class may be added.
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Usually two, and sometimes three or four, medications for resistant hypertension are needed.
Combination forms of medications are available

a study was presented that showed aspirin reduces blood pressure if taken at night rather than in the morning
(American Society of Hypertensions Twenty-Third Annual Scientific Meeting and Exposition, [ASH}, 2008)
treatment plan
lifestyle modifications and medications is effective only when patients are motivated to accept the diagnosis
of hypertension and include lifelong treatment in their daily routine
Empathy and trust can increase patient motivation
Patients should be instructed that antihypertensive therapy usually must be continued for the rest of their lives
Patients should be reminded that although they may be feeling better with the modifications and medications,
the hypertension is still present even if it is well controlled.
Patients should be told not to stop taking their medications unless instructed to do so by their primary care
provider
GERONTOLOGICAL ISSUES - Managing Antihypertensive Therapy
For safety, teach older adults who take antihypertensive drugs to rise slowly to prevent the
effects of orthostatic hypotension. Dizziness may increase the risk of falling. Deficiencies
in fluid volume can be a common problem for older adults as well, and diuretics can
contribute to them. Careful monitoring of fl uid balance is important to prevent
dehydration. Older adults may be more sensitive to medications, so monitor them carefully
for adverse effects. Older patients may need lower dosages.
MEDICATIONS USED TO TREAT HYPERTENSION

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Medications side effects
Patients should be told what these side effects are and to report them if they occur, so that medications can be
altered if possible
Erectile dysfunction can be one of the side effects of these medications
Men may be reluctant to discuss this side effect and instead choose to stop the medication.
The nurse should be proactive and inform men about this side effect so they will understand that, if it occurs
and is reported, the primary care provider can make adjustments in the medication regimen
Other measures
Walking for 30 minutes is an effective way to lower blood pressure, as is listening to 30 minutes of classical,
Celtic, or raga music daily.
Transcendental meditation has also been shown to help control high blood pressure

LLimit salt, caffeine, and alcohol.


IInclude daily potassium and calcium.
FFight fat and cholesterol.
EExercise regularly (walking).
SStay on your blood pressure regimen.
TTry to quit smoking.
YYour medications are to be taken daily.
LLose weight.
EEnd-stage complications will be avoided!
COMPLICATIONS
Coronary artery disease,
atherosclerosis,
myocardial infarction (MI),
heart failure (HF),
stroke, and
kidney or eye damage

severity and duration of the increase in blood pressure determine the extent of the vascular changes causing
organ damage
High blood pressure levels may also increase the size of the left ventricle, referred to as hypertrophy
Over time elevated blood pressure damages the small vessels of the heart, brain, kidneys, and retina
The results are a progressive functional impairment of these organs, known as target-organ disease
SPECIAL CONSIDERATIONS
Blood pressure should be well controlled before the patient has any invasive procedure
Hypertensive patients are at greater risk for strokes, MI, HF, kidney failure, and pulmonary edema
These patients should be instructed to continue their blood pressure medications until the time of the
procedure, unless otherwise directed by their primary care provider.
Antihypertensive medications should be resumed as soon as possible after the procedure, as directed by the
provider
HYPERTENSIVE EMERGENCY

a severe type of hypertension characterized by elevations in systolic BP greater than 180 mm Hg and diastolic
BP greater than 120 mm Hg that are complicated by a risk for or progression of target-organ dysfunction
(examples include MI, HF, and dissecting aortic aneurysm)
RISK FACTORS

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Untreated HPN,
Noncompliance to antihypertensive therapy, or
stop their medication abruptly
Management plan
require immediate reduction of blood pressure to prevent or limit damage to target organs
Patients with hypertensive crises should be admitted to the critical care unit
In some cases, the blood pressure may need to be reduced by 25% within 1 hour to prevent organ damage
Management plan
If the patient is stable, blood pressure is then decreased to 160/100 to 110 mm Hg in the next 2 to 6 hours
Gradual reduction of blood pressure - to prevent decreased blood flow to the kidneys, heart, and/or brain
IV medication such as nitroprusside (Nipride) may be given to quickly reduce blood pressure during the crisis
HYPERTENSIVE URGENCY

when blood pressure is as elevated as in a hypertensive emergency but without progression of target-organ
dysfunction
Signs and symptoms
may have severe headaches, nosebleeds, shortness of breath, and severe anxiety
treatment
Usually can be treated with combination oral medication and scheduled for a follow-up visit within several
days

NURSING PROCESS - assessment


patients health history, blood pressure measurements, medications, and physical assessment
Determining what hypertensive patients and their families know about hypertension and associated risk
factors is essential for planning patient and family education and subsequent lifelong lifestyle modification
needs
Nursing dx
Defi cient Knowledge related to disease process and treatment regimen
Ineffective Self Health Management related to complexity of therapy, cost of medications, lack of symptoms,
side effects of medications, need to alter long-term lifestyle habits, normal blood pressure controlled by
therapy

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