Assessment and Management of Patients with Hypertension Adult Health 1

Assessment and Management of Patients with Hypertension Adult Health I


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

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

Classification of Hypertension
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


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


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


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


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


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


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


DASH (Dietary Approaches to Stop Hypertension) Diet

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

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

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)

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)

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

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

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

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

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

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.

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

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