HYPERTENSION

 Persistent elevation of the systolic blood pressure above 140 mmHg

and diastolic pressure above 90 mmHg
 Major risk factor for coronary, cerebral, renal and peripheral vascular
diseases
 Silent killer

Classification of Blood pressure

Category Systolic BP Diastolic BP Follow up

Optimal <120 <80
Normal <130 <85 In 2 years
High normal 130-139 85-89 Within 1 year
Hypertension
Stage 1 140-159 90-99 Confirm within 2 mos
Stage 2 160-179 100-109 Evaluate and refer in 1 mo
Stage 3 >180 >110 Evaluate & refer in 1wk or imme.

Types
1. Primary or Essential hypertension
No known etiology

2. secondary hypertension
occurs as a result of other disorders
renal stenosis
renal parenchymal diseases (pheochromocytoma)
hyperaldosteronism
medications
coarctation of aorta (congenital)

Pathophysiology

Multifactorial
Increased SNS stimulation
Increased reabsorption of Na, Cl, and water
Increased in RAAS activity
Decreased vasodilation of arteriole related to dysfunction of endothelium
Resistance to insulin action
Elderly: increased atherosclerotic plaque and decreased elasticity of blood
vessel
Clinical manifestations

 There may be no significant PE findings except for elevated BP

 Heart disease: anginal pain
 Stoke: Headache, weakness, dizziness, paralysis
 Nephropathy: nocturia
 Peripheral arterial disease: claudication
 Retinopathy: visual disturbance
 Others: epistaxis

Assessment and Diagnostic evaluation

History and PE
Lad test
ECG
Chest XRAY
2D Echo

Medical management:
 goal: prevent death and complication by maintaining a normal BP
o lifestyle modification
o pharmacologic therapy
 lifestyle modification
o loose weight if overweight
o limit alcohol intake
o increase aerobic physical activity
o reduce sodium intake to 2-4 grams/day
o maintain adequate intake of K, Ca, Mg
o stop smoking

 pharmacologic therapy
 diuretics
o Thiazide diuretics
 Hydrochlorothiazide
o Loop diuretics
 Furosemide, Bumetanide
o Potassium sparing diuretics
 Spironolactone, Amelioride, Triamterene

 Adrenergic agents
o Peripheral agents: Reserpine
o Central antagonist: Methyldopa (Aldomet), Clonidine (Catapres)

 Beta blockers: Propranolol, Metoprolol

 Vasodilators: Hydralazine (Apresoline), Minoxidil, Na Nitroprusside
  ACE inhibitors: Captopril, Ramipril
 Angiotensin II receptor blockers: Losartan, Valsartan, Candesartan
 Ca channel blockers: Diltiazem, Nifedipine, Amlodipine, Felodipine
HYPERTENSIVE CRISIS
 clinical condition requiring immediate reduction in blood pressure
 an acute and life-threatening condition
 emergency treatment is required since target organ damage can occur
quikly
 death can be caused by stroke, renal failure, or heart failure

Clinical Manifestation
Diastolic pressure above 120mmHg
Headache, drowsiness, confusion, change in neurologic status
Tachycardia, tachypnea, dyspnea
Cyanosis
Seizure

Intervention

Maintain patent airway, maintain in fowlers position

Administer IV antihypertensive medications
Monitor VS
Monitor for IV therapy and assess for fluid overload
Monitor I&O
Insert foley catheter

Long term management

Maintenance of ideal body weight
Dietary sodium restriction to 2 grams pr day as prescribed
Moderate intake of alcohol and caffeine containing products
Regular exercise program
Avoidance/ cessation of smoking

Step care approach

Step 1: a single medication is prescribed
Diuretic, Beta blocker, Ca channel blocker, ACE inhibitor
Step 2: evaluation of Step 1 after 1-3 mos
- If therapy is not adequate, compliance is evaluated
- dosage may be increased or new meds is prescribed, or a
2nd meds is added
Step 3: Step 2 is evaluated
- compliance is assessed
- if not adequate, a 2nd or 3rd mediation is added
Step 4: compliance is evaluated
- assess factors limiting antihypertensive response
- a 3rd or 4th medication may be added
heart failure

inability of the heart to pump sufficient blood to meet the needs of the
tissues for oxygen and nutrients

Etiology
1. CAD
2. cardiomyopathy
a. dilated cardiomyopathy
– causes systolic failure
- diffused necrosis results in decreased contractility

b. hypertrophic and restrictive cardiomyopathy

- decreased ventricular filling

3. Valvular heart disease

- difficulty of moving blood forward = increased cardiac workload
- diastolic failure

causative factors
↓↓
myocardial damage
↓↓
CHF

↓ CO
↑ Left ventricle,
↑ afterload diastolic pressure
↑ preload
compensatory mechanism
↑RAAS
↑ SNS
↑ vasoconstriction

Classification
Class I – ordinary physical activity does not cause symptoms
- no limitation of activity (climbs ≥2 flight of stairs with ease)
- good prognosis
Class II – no symptoms at rest but increase physical activity elicits Ssx
-slight limitation of activity (climbs stairs but with difficulty)
-good prognosis
Class III – comfortable at rest but less than ordinary activities cause ssx
-marked limitation of activity ( ≤1 flight of stairs)
- fair prognosis
Class IV – symptoms even at rest
- poor prognosis
Pathophysiology

Systolic Failure: Vicious cycle of HF

1. ↓↓ ventricular contraction
↓↓ Ventricular filling
↓↓
2. Stimulation of the SNS
(supports myocardium - ↑↑↑ CO, HR, BP, contractility, vasoconstriction)
↓↓
3. Down regulation or loss of beta 1-adrenergic receptor sites
(= further myocardial damage)
↓↓
4. ↑↑ renin level -- ↑↑angiotensin II and aldosterone --vasoconstriction, ↑BP
↓↓
5. ↑↑ preload, afterload = ↑↑↑ cardiac workload
↓↓
6. ↓↓ cardiac contractility --- ventricular dilation
↓↓
7. ↑↑↑ stress on the ventricular walls – hypertrophy
↓↓
8. ↑↑↑ O2 demand and coronary blood flow – ischemia/infarction
↓↓
9. SNS promotes coronary vasoconstriction – myocardial ischemia

Diastolic failure
Cardiac hypertrophy and ↓↓ contractility
↓↓
↓↓ ventricular filling
↓↓
↓↓CO

Assessment

a. Right-sided heart failure : evident in the systemic circulation

1. pitting, dependent edema in the feet, legs, sacrum, back, buttocks
2. ascites from portal hypertension
3. tenderness of right upper quadrant
4. distended neck veins
5. pulsus alternans
6. anorxia, nausea
7. fatigue
8. weight gain
9. nocturnal diuresis
b. Left-sided heart failure : evident in the pulmonary system
1. cough
2. dyspnea
3. orthopnea
4. paroxysmal nocturnal dyspnea
5. crackles or rales on auscultation
6. tachycardia
7. pulsus alternans
8. fatigue
9. pallor
10. cyanosis
11. confusion and disorientation

c. acute heart failure (pulmonary edema)

1. severe dyspnea and orthopnea
2. pallor
3. tachycardia
4. expectoration of blood tinge, frothy sputum
5. wheezing and rales
6. acute anxiety, apprehension and restlessness
7.cyanosis
8. nasal flaring
9. use of accessory respiratory muscles
10. tachypnea

Immediate management

1.place the client on high fowler with thelegs in the dependent position
2.administer O2 in high concentration
3.prepare for intubation and ventilator support
4.suction as needed
5.assess level of consciousness, VS
6.monitor progression of edema (weight, abdominal girth, pulses)
7.monitor I&O, insert foley catheter
8.avoid unnecessary IVF
9.administer medications as prescribed
morphine SO4 for sedation and vasodilation
diuretics to reduce preload and pulmonary congestion
digitalis to increase cardiac contractility increasing CO
inotropic meds to facilitate contractility
vasodilators to decrease afterload
10. ABG and electrolyte analysis
Following the acute episode

1. encourage verbalization of feelings about lifestyle changes

2. assess precipitating factors and ways to eliminate them
3. instruct client about prescribed medication
4. instruct client to avoid large amount of caffeine
5. diet: low sodium, low fat diet !!!!!!!!!!!!!!!!!!
6. fluid restriction as necessary
7. space activity and rest periods

Medical Management

eliminate or reduced contributing factors such as alcohol ingestion

↓ workload by ↓ preload and ↓ afterload
Na restriction and water limitation
O2 inhalation
Pharmacologic therapy

1. ACE inhibitors
`Vasodilation --- ↓↓ afterload
`Causes diuresis -- ↓↓ afterload

`Captopril, lisinopril, enalapril, quinapril, ramipril

`S/E: hypotension, hypovolemia hyponatremia, cough

2. Hydralazine and nitrates

` for patients who cannot tolerate ACE inhibitors

3. Beta blockers
`Metoprolol, Propranolol
`S/E dizziniess, hypotension, bradycardia
`C/I asthma, bradycardia, congestion

4. Diuretics
` increase UO, decrease edema, decrease preload
`Thiazide, loop and K+ sparing diuretics

5. Digitalis: Digoxin
`↑myocardial contraction and ↓↓conduction = ↑↑ CO and diuresis
`Digitalis toxicity: enhanced by hypokalemia
Fatigue, depression, malaise, anorexia, n/v,
headache, altered visual perception
changes in the rhthym
`N/I assess apical HR before administration (assess bradycardia)
monitor serum potassium
 6. Angiotensin II blockers
`Losartan, Telmisartan, Valsartan

7. Ca-channel blockers
` vasodilation for improvement of symptoms
` indicated for diastolic dysfunction
`Amlodipine, Felodipine
`Verapamil, Diltiazem and Nifedipne are C/I in HF

8. Anticoagulants
` Ibuprofen and decongestants are avoided

Nutritional therapy
Low Na diet
Avoid excessive fluid intake