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142 terms

hypertension

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What is considered a normal blood pressure in a healthy adult?
120/80
What is the classification of blood pressure for a prehypertensive pt?
(120-139)/(80-89)
What is the classification of blood pressure for stage ONE hypertension?
(140-159)/ (90-99)
What is the classification of blood pressure for Stage TWO hypertension?
greater than or equal to 160/100.
What is the blood pressure goal for diabetics and pts with renal disorders?
130/80

140/90 is considered normal as well
Why is hypertension called the "silent killer?"
HYPERTENSION CAUSES:
*Coronary artery disease
*TIA
*CVA, etc

*MAIN FACTOR IN HEART DISEASE*
What's a hypertensive crisis?
1.) Diastolic BP >110

2.) BP pressure of 200/150
If you increase cardiac output, you ______BP?
increase
If you incr. arterial elasticity, you ______BP?
decrease
If you increase peripheral resistance (vasoconstriction), you____BP?
increase
If you increase blood volume, you ______BP?
increase

-good example is when you have an abnormalilty in the transport of Na+ in the renal tubules, causes incr. blood volume due to excess Na+ and water levels in body.

(B&H, 1293)
If you decrease arterial O2 concentration or pH, you _____ BP?
increase

(B&H, 1293)
If you increase CO2 concentration, you ____BP?
decrease

(B&H, 1293)
If something happens to the kidneys, it will effect your BP.
...
What are the two main causes of primary hypertension?
1.) Overactive sympathetic nervous system

2.) Overactive Renin-angiotensin-aldosterone system.
What does it mean to have an overactive sympathetic nervous system?
1. You may have a genetic disposition, as well as environmental factors cause.
2. Problems w/ pressure detection by aortic and carotid baroreceptors
3. Problems w/ chemoreceptors detection of blood O2 and CO2.


***PRIMARY HYPERTENSION***
Sympathetic nervous system stimulation causes...(2)
1. incr. HR

2. Incr. vasoconstriction (peripheral resistance)

(B&H, 1293)
What is the primary medication used for hypertension caused by an overactive sympathetic nervous system?
beta blockers
What is an overactive-renin-angiotension-aldosterone system?
**PRIMARY HYPERTENSION**
1.) genetic predisposition and environmental factors may cause it.
2.) Problems w/ detection of serum osmolarity by atrium and kidneys.
3.) Stimulation of renin-angiotensin systems.
4.) Vasoconstriction and aldosterone secretions
5.) Pts on fluid restrictions

****IF YOU INCR. THE BLOOD VOLUME=INCR. BP

(B&H, 1293)
What is the age range that pts are normally dx with an overactive-renin-angiotension-aldosterone system?
30-50 yrs old
What medication is usually given for an overactive-renin-angiotension-aldosterone system that causes HTN?
diuretics.
What is a normal BP for an infant?
(65-115)/ (42-80)

very wide range
What is a normal BP for a child?
(87-117)/ (48-64)
What is the % of adults that have HTN?
35%
What is the % of geriatrics that have HTN?
90%
What is the natural BP cycle of person for 24 hrs?
1)BP dips the lowest at night between 12-3am.

2.) Rises suddenly upon awakening.

3.) Rises slowly all day long.

4. dips back down at sleep.

*FEWER S/E FROM HYPERTENSION IF PT HAS DIPS IN THIER BP**
What night time issues are assoc. w/ HTN?
SLEEP DISTURBANCE (nocturia, snoring, etc)
What are the contributing factors for primary HTN?
1. Age-BP naturally incr.
2. Stress
3. Ethnicity
4. Gender
5. Daily variation-lowest in the AM
6. Medications- OTC meds cause HTN
7. Lifestyle-activity, weight, diet
8. Smoking
What ethnicity has twice the amount of primary HTN and kidney failure, over caucasians?
African Americans
What other ethnicity also has a high prevalence of primary HTN?
Asians
When does the rate of primary HTN go up in males?
after puberty
When does the rate of prevalence go up with females with primary hypertension?
after menopause
What age range do males generally develop HTN?
30-50 yrs mostly

**COMMONLY PRIMARY HTN**
What age range do females generally develop HTN?
50+ yrs old
What are the priamry causes of ISOLATED SYSTOLIC HYPERTENSION? (4)
1. arteriosclerosis causes thickening and loss of elasticity in arterial walls, fibrous tissue replaces normal tissue.

2. Increase peripheral vascular resistance (constriction)

3. Normal blood volume is forced through rigid arterial walls, and systemic blood pressure increases.

4. Systolic pressure is more significantly elevated than diastolic.

*MOST COMMON IN MENOPAUSAL WOMEN, OR WOMEN >50*
What is the treatment for isolated systolic hypertension?
TREATMENT IS THE SAME AS PRIMARY
What does smoking do to cause HTN?
vasodilation at first (BP drops), and then vasoconstriction for several hours afterwards.
What is SECONDARY HYPERTENSION?
R/T COMORBIDITIES
What are the specific causes of SECONDARY HTN? (5)
1. renal disease

2. coarctation of aorta (narrowing) decrease elasticity= need for incr. force.

3. tumors

4. endocrine disease

5. neurological diseases

(B&H 1295)
How do you treat SECONDARY HYPERTENSION?
Treatment involves removing the original cause if possible, otherwise treated the same as primary.
What does exercise do for BP?
lowers blood pressure for several hrs after.
Which OTC meds cause HTN?
nasal decongestants, corticosteroids, nicotine.
WHAT CAUSES PEDIATRIC HYPERTENSION?
**Usually secondary HTN (comorbidities)**

-can be primary if they are overweight adolescents or African American children with a family hx.

**WARRANTS A FULL LOOK UP TO FIND ALL THE CAUSES**
What is a HYPERTENSIVE CRISIS?
**210/120 AVERAGE CRISIS BLOOD PRESSURE**
What causes a HYPERTENSIVE CRISIS?
**AUTONOMIC DYSFUNCTION IN NEUROLOGICAL DISORDERS**

1. Multiple factors including abrupt release of catecholamines.
2. Mechanical stress produces endothelial damage, inappropriate activation of the renin-angiotensin-aldosterone system and oxidative stress.
3. Overwhelms normal regulatios causing sudden significant increase in vascular resistance
4. Initiates inflammatory response.
What is MALIGNANT HYPERTENSION?
NEUROLOGICAL DISORDER THAT CAUSES A HTN CRISIS

Malignant hypertension is very high blood pressure that comes on suddenly and quickly. The lower (diastolic) blood pressure reading, which is normally around 80 mmHg, is often above 130 mmHg.
What are the causes of MALIGNANT HTN?
The disorder affects about 1% of people with high blood pressure, including both children and adults. It is more common in younger adults, especially African-American men.

IT ALSO OCCURS IN PEOPLE WITH:

-Collagen vascular disorders
-Kidney problems
-Toxemia of pregnancy
What are considered to be the large vessels of the body?
Aorta
Coronary arteries
basilar artery (brain)
peripheral vessels (limbs)
What are considered to be the small vessels of the body?
Tissues of the heart
Kidney
retina
brain
What happens is we have elevated BP to the large vessels of the body?
1. the vessels become sclerotic, tortulous, and weak.

2. Lumina narrows causing decreased blood flow to the heart, brain, and limbs.

3. Vessels can become occluded or hemorrhage, causing infarction (MI, stroke, and PVD)
What happens if we have elevated BP to the small vessels in the body?
1.Elevated DBP damages the
intimal lining of the small vessels
2. Fibrin accumulates, local edema
develops, intravascular clots
occur
3. Causes decreased blood supply to
tissues (heart, kidneys, retina &
brain)
4. Chronic ischemia causes
infarction of the tissues similar to
the large vessels
5. Causes progressive functional
impairment of these organs
What does HTN do to the heart?
Causes coronary artery disease and heart failure

**heart continually pumps against increased resistance, left ventricular hypertrophy develops and blood flow to the vital organs is decreased.
What does HTN do to the kidneys?
causes renal failure
What does HTN do to the brain?
CVA
What does HTN do to the eyes?
blindness
What are s/s of early stages of HTN?
There are none. They have only had it a short time.
How long should a pt rest before you take their blood pressure?
at least 5 mins
How many readings does it take to accurately dx HTN?
AT LEAST TWO READINGS OVER 140 SYSTOLIC.

It will be common to have pt come back in two months to reassess the BP, in order to make an accurate dx.

- if assessing twice in one office visit, do the readings at least 5 mins apart, and confirm elevated reading in contralateral arm.
When assessing a pt, you need to identify those at risk for HTN.
Those at risk are....
-family hx of HTN
-obesity
-tobacco use
-heavy alcohol use
-incr. Na+ uptake
-sedentary lifestyle
-exposure to stress
-diabetes mellitus
-older
-african american
-asian american
Review perry and potter pg 538 for how to accurately take a Blood pressure
...
What are later signs and symptoms of HTN?
*persistant HA
*fatigue
*dizziness
*palpitations
*flushing
*blurred or dbl vision
*epistaxis (nose bleed)
Compare all four limbs of a person's body. Why?
Variance of 10 or more points differene in any systolic # on any of the limbs, may indicate future heart disease
ABPM
Ambulatory BP Monitoring

-dx hypertension while "out and about"
-indicated for evaluation of "white coat HTN."
What does an EKG do?
Looks at the electrical activity of the heart
What is a chest x-ray used for in dx HTN?
looking for an enlarged heart
Why would they use a renal ultrasound in dx HTN?
TO assess renal fxn and blood flow.

*to assess end organ damage as well*
End organ damage is...
damage occurring in major organs fed by the circulatory system (heart, kidneys, brain, eyes, cap refill, periphery) which can sustain damage due to uncontrolled hypertension.
Why is a arteriography done to dx HTN?
shows atheroscerosis, and the elasticity of the BV's.
What are the labs that are used to dx HTN?
CBC
• BUN
• Creatinine
• Uric Acid
• Electrolytes
• Fasting Blood Glucose-diabetes
• Serum Cholesterol-atherosclerosis
• UA-renal fxn and glucose in urine
What are the TWO STEPS of the stepped approach in HTN management?
Step 1: lifestyle changes

Step 2: medications
Step one in controlling HTN: Lifestyle changes
Modify:
-diet
-exercise
-weight loss

*pt compliance is tough to get pts to do lifestyle changes*
Step two in controlling HTN: Medications
**IF STEP ONE DOES NOT WORK**

1. Thiazide diuretics
2. Beta blockers
3. Vasodilators

>>Meds have few side effects and get great results>>
**many times treatments start here, and then they get their lifestyle modifications under control**
What is the first type of medication usually given to control HTN?
Thiazide diuretics
What are some examples of THIAZIDE DIURETICS?
Furosemide (Lasix),
spironolactone (Aldactone),
metolazone,
polythiazide,
benzthiazide
Furosemide
Lasix
Spironolactone
Aldactone
How do diuretics lower blood pressure?
Lower blood pressure by reducing reabsorption of sodium and water by the kidneys, thus lowering circulating fluid volume

***LOWERS VASCULAR RESISTANCE***
What is the order for therapy for a pt without compelling indicators, and has Stage one hypertension?
1) Lifestyle modifications
2) Thiazide type diuretics for most
3) May consider using Ace inhibs, angiotensin receptors, beta blockers, calcium channel blockers, OR A COMBINATION OF ANY OF THEM.
What are compelling indicators?
Kidney failure, Heart failure, etc
What is the order for therapy for a pt without compelling indicators, and has STAGE TWO hypertension?
1) lifestyle modifications
2) TWO DRUG COMBINATION THERAPY FOR MOST
3) USUALLY A THIAZIDE DIURETIC AND Ace inhib, beta blockers, calcium channel blockers, or angiotensin receptors.
What do you NOT GIVE African Americans with hypertension?
THIAZIDE DIURETICS
Which type of medication is used to reduce the heart rate, and block sympathetic response?
Beta blockers
What are common beta blockers used for HTN?
1.Atenolol (Tenormin),
2.nadolol (Corgard),
3.propranolol (Inderal)
What do most beta blockers end in?
"olol"
Atenolol
(Tenormin)

BETA BLOCKER
Nadolol
Corgard

BETA BLOCKER
propanolol
Inderal
Which types of medications reduce stroke volume?
1. diuretics
2. Ace inhibitors
3. Angiotensin receptor blocker
Ace inhibitors
Reduce stroke volume, and vascular resistance

1.Captopril (Capoten)
2. enalapril (Vasotec)
3.lisinopril (Prinivil, Zestril)
4.benazepril (Lotensin)
What do most ace inhibitors end in?
"pril"
Captopril
(Capoten)

ACE INHIBITOR
enalapril
(Vasotec)

ACE INHIBITOR
lisinopril
(Prinivil, Zestril)

ACE INHIBITOR
benazepril
(Lotensin)

ACE INHIBITOR
Angiotensin receptor blockers
Reduce stroke volume, block binding of angiotensin and lower peripheral resistance.
What do most Angiotensin receptor blockers end in?
"tan"
What are the two most common angiotensin receptor blockers?
1. Losartan (Cozaar)
2.olmesartan (Cozaar)
Losartan
(Cozaar)

Angiotensin receptor blockers
Olmesartan
(Cozaar)

Angiotensin receptor blockers
What do calcium channel blockers do for HTN?
Relax arterial smooth muscles (vasodilation)

-otherwise known as reducing systemic vascular resistance
What do most calcium channel blockers end in ?
"pine"
What are the common calcium channel blockers used for HTN?
1.Diltiazem (Cardizem, Dilacor XR)
2.Verapamil hydrochloride (Calan SR)
3. nifedipine (Procardia),
4. nicardipine (Cardene)
Ditiazem
(Cardizem, Dilacor XR)

calcium channel blockers
Verapamil hydrochloride
Calan SR

calcium channel blockers
nifedipine
Procardia

calcium channel blockers
nicardipine
Cardene

calcium channel blockers
What do alpha blockers do for HTN?
cause vasodilation, and reduce systemic vascular resistance.
Whats the most common alpha blocker?
Doxazosin (Cardura)
Doxazosin
Cardura

ALPHA BLOCKER
Which medication is the pulse not an accurate indicator ovf body issues with ?
Beta blockers

-they modulate the HR
What are chronotherapies for HTN management?
1.bed time dosing to align more with
circadian rhythm
2.Control the steep increase with am
surge and following high values
3.Simple cost-free manipulation in the
timing of therapy
Nursing care for detection and dx
1.Facilitate early detection of hypertension
- Community screenings to prevent early complications

2.Utilize correct technique, appropriate cuff size, and
properly maintained/calibrated equipment when
assessing blood pressure

3.Be knowledgeable about the process of diagnosing
hypertension

4.Educate clients on HTN
Nursing care for lifestyle changes in pts with HTN
1.Work with clients to identify lifestyle factors
that may influence hypertension
management

2.Recognize potential areas for change

3. Create collaborative management plan to
assist in reaching client goals to prevent
secondary complications
Nursing Care for diet changes in pts with HTN
1, Diet, in collaboration with dieticians
-Assess for and educate clients about
dietary risk factors

2.Counsel clients to consume the DASH Diet

3. Counsel clients to limit dietary intake of
sodium.
What is the daily recommended intake of sodium?
2400 mg/ day
OR/

1500mg/day if on low na+ diet
What does DASH stand for?
(Dietary Approaches to Stop Hypertension)
What is the dash diet?
**DIET RICH IN MG, K+, CA+, PROTEIN, AND FIBER*
Dramatic results within 2 weeks, even
more so with restriction to 1500mg

• ↓sat fats, cholesterol and total fat
• ↑ fruits, vegetables and low-fat dairy
• ↑ whole grains, fish, poultry and nuts
• ↓ red meat, sweets, and sugar beverages
What are the ways to avoid high na+ in your diet?
1.Red Flag Words for Na+
-Pickled, cured, soy sauce, broth

2. More in ...
- Canned foods
- Frozen vegetables with sauces
- Processed cheese
- Ham
What are the female BMI restrictions that make it to where theyshould consider weight reduction?
>34 inch waist circumferance

BMI >25
What are the male BMI restrictions that make it to where theyshould consider weight reduction?
BMI > 25

> 40 in weight circumferance
How much moderate/ intense exercise should a person with HTN get?
30-60 mins most days.
If you have uncomplicated HTN should you restrict exercise
NO, it wil be good for these people.

Consult physician if you have complicatedHTN
How much alcohol can a woman drink if she is trying to avoid HTN?
1 drink/ day

OR/
9 drinks/week
How much alcohol can a man
drink if he is trying to avoid HTN?
2 drinks/ day

OR/

14 drinks/week
Teach pts how to deal with stress
...
How often will a doctor see a pt with uncomplicated HTN?
once a yr
How often will a doctor see a pt for complicated HTN?
twice a yr
How do youmake sure pts are adhering to their HTN interventions effectively?
Check to see if they are getting their prescriptions filled on time.

establish therapeutic relationships

assess adherence to treatment plan each visit.

educate
What are some ways to have more effective pt adherence to HTN management?
• Work with prescribers to simplify
dosing regimens

• Encourage routines and reminders
to facilitate adherence

• Ensure that clients who miss
appointments receive follow-up
telephone calls in order to keep
them in care
What is considered to be an URGENT hypertensive crisis?
DBP > 120
******NO SYMPTOMS*****

TREAT:
Reduce BP within a few
hours to 24 hours
• PO meds
What is an EMERGENT hypertensive crisis?
DBP> 120
End organ damage
--may have a HA and a bloody nose--
How do you treat an EMERGENT hypertensive crisis?
1.Reduce Mean Arterial
Pressure within 2 hours

2.Reduce BP to
over 2-6 hours

3.Patent airway

4. IV Meds
Hypertensive crisis end organ damage: NEURO
- Encephalopathy
- CVA
Hypertensive crisis end organ damage: CARDIAC
- Heart Failure with
pulmonary edema

- MI

- Aortic Dissection

- Hemolytic anemia
Hypertensive crisis end organ damage: RENAL
- Proteinuria

- Hematuria

- Casts

- Acute renal failure
Hypertensive crisis end organ damage: RETINOPATHY
- Blurred vision

- Reduced visual acuity

- Blindness
Hypertensive crisis: Mean Arterial Pressure:
MAP = [(2 x diastolic) + systolic]/3

Ex: BP of 140/96 = (2X96) +140/3 = 40.67
Why does diastole count for twice as much as systole in the mean arterial pressure?
Diastole counts twice as much as systole because
2/3 of cardiac cycle is spent in diastole
What is a normal MAP?
70-110
What is the minimum MAP that you need to perfuse the heart, brain, and kidneys?
60
What is orthostatic hypotension caused by?
The MAP not being enough to maintain orgain function.
What are the nursing treatments for HYPERTENSIVE CRISIS?
1. Monitor VS frequently (q 5-15 min)
2. Assess for hypotension
- SE of meds: cause coronary, cerebral or
renal ischemia
3. Code cart nearby
4. Maintain bedrest with HOB 45°
5. Monitor IV therapy
6. Assess I&O
7. Foley for accuracy