Hypertension

Tuesday, January 17, 2012 10:44 AM

Recommendations for Follow-up Based on Initial Blood Pressure Readings

Definitions In normal circulation, pressure exerted by flow of blood through the heart and blood vessel High blood pressure can result from the changes in the cardiac output or changes in peripheral resistance Medication can use to treat HTN and decrease peripheral resistance Blood volume is the strength and rate of the myocardial contraction Blood Pressure = Cardiac Output x Peripheral Resistance Cardiac Output = Heart Rate x Stroke Volume Hypertension: AKA 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 Classification of Blood Pressure for Adults Age 18 and Older

Hypertension Treatment 1. Medication Treatment a. Usually initial medication treatment is a thiazide diuretic. b. Low doses are initiated and the medication dosage is increased gradually if blood pressure does not reach target goal. c. Additional medications are added if needed. d. Multiple medications may be needed to control blood pressure. e. Lifestyle changes initiated to control BP must be maintained. Lifestyle Modifications

Incidence of Hypertension- The Silent Killer 1. About 31% of the adult population of the U.S. have hypertension. 2. 90-95% of this population with hypertension have primary hypertension 3. Remaining 5-10% have secondary hypertension related to unidentifiable cause a. Such as narrowing of the arteries, hyperaldosteronism, certain medication can cause HTN 4. Incidence is greater in southeastern U.S. and among African-Americans (37%) Factors Involved in the Control of Blood Pressure 1. Increase sympathetic nervous system activity 2. Insulin resistance 3. Increase reabsorbtion of water, sodium, and chloride by the kidney 4. Increase activity in the renin-angiotensin system 5. Decrease vasodilatation Manifestations of Hypertension 1. Usually NO symptoms other than elevated blood pressure 2. Symptoms seen related to organ damage are seen late and are serious: a. Retinal and other eye changes b. Renal damage c. Myocardial infarction d. Cardiac hypertrophy e. Stroke Assessment & Diagnostic Evaluation 1. Major Risk Factors a. Smoking b. Obesity: BMI > 130 c. Physical inactivity d. Dyslipidemia e. Diabetes mellitus f. Microalbuminuria or GFR < 60 g. Older age: vessel gets narrow and lose elasticity h. Family history Patient Assessment 1. History and Physical 2. Laboratory tests a. Urinalysis b. Blood chemistry c. Cholesterol levels d. Liver Panel (BUN & Creatinine) 3. ECG (12 lead) 4. Echocardiogram

Medication Therapy for Hypertension 1. Diuretic and related drugs a. Thiazide diuretics b. Loop diuretics c. Potassium-sparing diuretics d. Aldosterone receptor blockers 2. Central Alpha2-Agonists and other centrally acting drugs 3. Beta blockers 4. Beta blockers with intrinsic sympathomimetic activity 5. Alpha and beta blockers a. Adverse effects: orthostatic hypotension, postural hypotension (get up slowly, use supportive device to prevent from falling) 6. Vasodilators 7. Angiotensin-converting enzyme (ACE) inhibitors 8. Angiotensin II antagonists 9. Calcium channel blockers a. Nondihydropyridines (cardizem) b. Dihydropyridines (Norvac)

Cardiovascular II Page 1

Nursing Process: Hypertension

Tuesday, January 17, 2012 11:24 PM

Nursing History and Assessment 1. History and risk factors 2. Assess potential symptoms of target organ damage a. Angina, shortness of breath, altered speech, altered vision, nosebleeds, headaches, dizziness, balance problems, nocturia b. Cardiovascular assessment: apical and peripheral pulses 3. Personal, social, and financial factors that will influence the condition or its treatment Nursing Diagnoses 1. Knowledge deficit regarding the relation of the treatment regimen and control of the disease process. 2. Noncompliance with therapeutic regimen related to side effects of prescribed therapy. Goals: 1. Patient understanding of disease process. 2. Patient understanding of treatment regimen. 3. Patient participation in self-care. 4. Absence of complications.

Interventions 1. Patient teaching 2. Support adherence to the treatment regimen 3. Consultation/collaboration 4. Follow-up care 5. Emphasize control rather than cure 6. Reinforce and support lifestyle changes 7. A lifelong process 8. Objective is to lower B/P without adverse effects
Gerontologic Considerations 1. Noncompliance 2. Include family 3. Understanding of therapeutic regimen a. Reading instructions b. Monotherapy: placed on one drugs instead of a bunch of drugs

Hypertensive Crises 1. Hypertensive emergency a. Blood pressure >180/120 and must be lowered immediately to prevent damage to target organs. i. Can cause angina because heart is pumping harder ii. Left ventricle works harder, can cause enlarged heart b. Conditions includes i. Pregnancy ii. Acute myocardial infarction iii. Dissecting aortic aneurysm iv. Intracranial hemorrhage c. Reduce BP 25% in first hour d. Reduce to 160/100 over 6 hours e. Then gradual reduction to normal over a period of days f. Exceptions are ischemic stroke and aortic dissection g. Medications i. IV vasodilators: sodium nitroprusside, nicardipine, fenoldopam mesylate, enalaprilat, nitroglycerin 1) Short acting drugs: takes minutes to 4 hours 2) May be used for initial treatment h. Need very frequent monitoring of BP and cardiovascular status 2. Hypertensive urgency a. Blood pressure is very high but no evidence of immediate or progressive target organ damage. b. Condition includes: i. Severe HA ii. Nosebleed iii. Anxious c. Patient requires close monitoring of blood pressure and cardiovascular status. d. Assess for potential evidence of target organ damage. e. Medications - Fast-acting oral agents: i. Beta-adrenergic blocker- labetalol ii. Angiotensin-converting enzyme inhibitors: captopril iii. Alpha2-agonists-clonidine Therapeutic goals are reduction of the mean blood pressure by up to 25% within 1st hour of treatment Further reduction of blood pressure is about 160/100 over a period of up to 6 hours Gradual reduction of blood pressure is over a period of days Exception of these goals are the treatment of ischemic stroke (ex. Aortic dissection) You dont want B/P to stay elevated for long because it could rupture or can cause a stroke

Cardiovascular II Page 2