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NUR 195 Ch 13 Nursing Management: Patients With Hypertension
Terms in this set (16)
- Defines a BP < 120/80 mm Hg as normal, BP of 120 to 139/80 to 89 as prehypertension, & a BP of 140/90 mm Hg or higher as hypertension.
- HTN is further classified as stage 1 or 2 depending on its severity. Stage 1: systolic pressure is 140 to 159 mm Hg or greater and/or diastolic pressure is 90 to 99 mm Hg or greater. Stage 2: diastolic pressure is 160 mm Hg or higher, or diastolic pressure is 100 mm Hg or higher. If systolic & diastolic pressures are in separate categories, the higher classification is used.
- Elevation in BP from pre-hypertension through stages 1 & 2 is associated w/ increasing morbidity & mortality.
-Dx of HTN is based on average of 2 or more accurate BP measurements taken during 2 or more contacts w/ HCP
- BP: product of CO x by the peripheral resistance. CO: volume of blood being pumped by the heart per min & the product of the HR x by the SV (amount of blood pumped out from the ventricles per beat.)
- Peripheral vascular resistance (PVR) is r/t the diameter of the blood vessel & viscosity of the blood. The thicker the blood or smaller the radius of the blood vessel, the higher the resistance. The larger the diameter of the vessel or thinner the blood, the lower the PVR.
- For HTN to develop, there must be a change in 1 or more factors affecting PVR or CO. There must also be a problem w/ the body's control systems that monitor or regulate pressure.
- Management of HTN aims to decrease peripheral resistance, blood volume, or the strength, force, & rate of myocardial contraction.
- Of pts w/ HTN, 95% have primary hypertension (high BP from an unidentified cause)
- The remaining 5% have secondary HTN (high BP secondary to an identified cause). These causes include narrowing of the renal arteries or renal artery stenosis, renal disease, hyperaldosteronism (mineralocorticoid htn), meds, preg, & coarctation of the aorta
- Additional types of HTN not treated aggressively: 1) White-coat HTN has norm ambulatory BP readings but elevated pressures (>140/90) in a health care office. 2) Masked HTN presents as norm pressure readings in provider settings but elevated BPs at home or work. Nurse should suspect masked htn in men, those w/ diabetes, renal disease, & those w/ transiently elevated BPs. Those w/ masked htn have an increased prevalence of metabolic risk factors, left ventricular hypertrophy, & carotid plaque, demonstrating the impact of htn on organ function. When at-risk individual is identified, the nurse advocates for the use of home BP monitoring to confirm the dx & monitor treatment. Engaging pt in the process of self-care results in better outcomes
- Although no precise cause can be identified for most cases of htn, it is understood that htn is a multifactorial condition.
- Systolic htn is the most common form & is a major risk factor for cardiovascular disease. Diastolic htn is a more potent CV risk factor than an elevated systolic BP (SBP) until age 50; thereafter, SBP elevation is more important.
- HTN is more common in younger men than women, until the time of menopause.
- Obesity is one of the common risk factors for the development of htn.
- Hypertension, a risk factor for atheosclerotic heart disease, often coexists w/ dyslipidemia, DM, & a sedentary lifestyle.
- Metabolic syndrome or syndrome X occurs when 3 of the follow symptoms are present: BP elevation greater than 130/85, insulin resistance, dyslipidemia, and/or abdominal obesity. Metabolic syndrome place pt at risk for CV disease & diabetes. Risk for CV disease doubles w/ each increment of 20/10 mm Hg above 115/75 mm Hg.
- Incidence of htn is higher among African Americans, who have an earlier onset, higher prevalence, & a greater rate of stage 2 htn, leading to higher incidences of nonfatal stroke, death from heart disease, & end-stage renal disease. This increases when African Am individual is male, overweight, physically inactive, & diabetic.
- Oral contraceptive use causes a small increase in systolic & diastolic BP, which, when accompanied by smoking & obesity, results in htn 3x more than those w/o these risk factors. Cigarette smoking does not cause high BP; however, if a person w/ htn smokes, risk of dying from heart disease or related disorders increases significantly
- Factors contributing to htn may include increased SNS activity & increased renal reabsorption of Na, Cl, & water.
- Increased activity of the renin-angiotensin-aldosterone system, causing expansion of extracellular fluid volume & increased systemic vascular resistance, or dysfunction of the vascular endothelium contribute to htn.
- Resistance to insulin may be a common factor linking htn, type 2 DM, hypertriglyceridemia, obesity, & glucose intolerance.
- The prevalence of htn increases w/ aging; half of individuals aged 60 to 69 & 75% of individuals over 70 are affected.
- Aging causes structural & functional changes in heart & blood vessels, including atherosclerosis & decreased elasticity of the major blood vessels.
- B/c of increased wall stiffness, the arteries are less able to buffer the pressure created as blood is ejected from the left ventricle & unable to store the energy to exert diastolic pressure.
- Isolated systolic htn w/ widened pulse pressure is more common in older adults. This is associated w/ cardiovascular & cerebrovascular morbidity & mortality, as well as dementia
- To reduce cardiovascular & cerebrovascular risks, older adults should begin treatment w/ lifestyle modifications.
- If meds are needed to achieve BP goal of less than 140/90 mm Hg, the starting dose should be half that used in younger pts & increased slowly ("start low & go slow" w/ med regimens & geriatric population).
- Compliance may be more difficult for the elderly when memory impairment exists or due to the expense of treatment plans.
- Nurse should ensure that the pt understands the regimen, & can see/read instructions, open med container, & get the prescription refilled.
Clinical Manifestations and Assessment
- B/c there are typically no symptoms of htn, physical exam may be unremarkable, other than elevated BP.
- Nurse should assess for s/s of target organ damage by asking about anginal pain; shortness of breath; alterations in speech, vision, or balance; epistaxis; headaches; dizziness; or nocturia. Further assessment includes asking about personal, social, or financial factors, or unacceptable pharmaceutical side effects that may interfere w/ pts' ability to adhere to the med regimen.
- HTN may be asymptomatic & remain so for many yrs; however, when s/s appear, vascular damage r/t the organs served by the involved vessels has occurred.
- Coronary artery disease w/ angina or myocardial infarction is a common consequence of htn. Left ventricular hypertrophy occurs in response to the increased workload placed on the ventricle as it contracts against higher systemic pressure. When heart damage is extensive, heart failure follows; 90% of the time, htn precedes CHF.
- Pathologic changes in the kidneys, indicated by microalbuminuria, increased BUN & serum creatinine lvls, & nocturia result.
- Cerebrovascular involvement may lead to stroke or transient ischemic attack, manifested by alterations in vision or speech, dizziness, weakness, a sudden fall, or hemiplegia.
- Occasionally, retinal changes such as hemorrhages, exudates (fluid accumulation), arteriolar narrowing, & cotton-wool spots (small infarctions) occur. In severe htn, papilledema (swelling of optic disc) may be seen.
- A risk factor assessment is needed to classify & guide the treatment of hypertensive ppl at risk for cardiovascular damage. (Box 13-2)
- Routine lab tests include urinalysis, evaluation for microalbuminuria or proteinuria, blood chemistry (analysis of sodium, potassium, BUN & creatinine, fasting glucose, & total & high density lipoprotein [HDL] cholesterol lvls), & a 12-lead ECG. Left ventricular hypertrophy can be assessed by echocardiography.
- Additional studies (creatinine clearance, renin lvl, urine tests, & 24-hour urine protein) may be performed.
Medical and Nursing Management
- Treatment goal for individuals w/ htn & w/o complicating conditions is a BP of <140/90 mm Hg. The aim for individuals w/ prehypertension & no complicating conditions is to lower BP to normal.
- To prevent or delay progression to htn, JNC 7 urges HCP to encourage ppl w/ BPs in the pre-hypertension category to begin lifestyle modifications, such as dietary changes & exercise.
- JNC 7 recommends that ppl w/ stage 1 htn be treated w/ pharmacologic therapy & lifestyle changes. HCP should monitor these pts every month until BP goal is reached, & every 3 to 6 months thereafter.
- Ppl w/ stage 2 htn or w/ other complicating conditions need to be seen more freq. For individuals w/ diabetes or chronic kidney disease, JNC 7 specifies a target pressure of <130/80 mm Hg.
- The clinician uses the treatment algorithm (Fig. 13-2), risk factor assessment data, & pt's BP category to choose treatment plans for the pt.
- Nurse encourages self-management, which may include self BP monitoring, & education to initiate & maintain lifestyle changes. Important to assess the pt's beliefs about htn (Box 13-3).
- Nurse should routinely ask whether pts take herbal supplements or OTC meds that may increase BP. These include caffeine & ephedra, which are stimulants; licorice, which has an aldosterone-like effect; & oral contraceptives, acetaminophen & NSAIDs, which may lead to fluid retention.
- In addition, certain agents have been touted as BP lowering agents such as coenzyme Q10, garlic, vit C, & L-arginine. Pts should be cautioned that nutritional supplements are not regulated in the same manner as pharmaceuticals, & all products used should be reported to HCP.
Medical and Nursing Management: Lifestyle Changes (Table 13-2 & 13-3)
- Research findings demonstrate that smoking cessation, weight loss, reduced alcohol & sodium intake, & reg physical activity are effective lifestyle adaptations to reduce BP. Nurse should emphasize the concept of life-long BP control rather than cure.
- Specific info regarding lifestyle changes should include importance of achieving a waist circumference of <40 in. for a man & <35 in. for a woman & a BMI b/w 18.5 & 24.9 kg/m2.
- For pts not meeting that goal, modification involves caloric restriction & increased physical activity. A weight loss of only 10 pounds may result in a 5 to 20 mm Hg reduction in SBP.
- Nurse encourages the pt to formulate a plan for weight loss, consulting a dietician or using support groups if necessary. Bariatric pt may benefit from surgical intervention. A pedometer may assist the pt in increasing physical activity
- Adhering to the DASH approach (Dietary Approaches to Stop HTN) can decrease systolic BP by 8 to 14 mm Hg. DASH approach includes increasing fruits, vegetables, whole grains, fiber, nuts, legumes, & low-fat dairy products while limiting animal proteins & fats, esp saturated fats (Table 13-3). Specific info should be provided on reading labels for foods that contain < 400 mg of sodium per serving & for reducing intake of table salt to 1 tsp (2.4 g of sodium) daily
- Limiting daily alcohol to 24 oz of beer, 10 oz of wine, or 3 oz of whiskey for men, & half that for women is recommended. Smoking cessation may reduce systolic BP by 4 mm Hg & diastolic BP by 3 mm Hg.
Medical and Nursing Management: Alternate Therapies
- Evidence suggests that device-guided breathing can lower BP w/o adverse effects. Lower resp rates decrease sympathetic outflow, microvascular tone, & peripheral resistance, thereby lowering BP. RESPeRATE by InterCure, Inc. is approved by the FDA & has been shown to lower BP by 14/8 mm Hg.
- As w/ all BP-lowering interventions, consistent use is key.
- Complementary & alternative medicine therapies & mind-body interventions are potentially effective in reducing BP. Relaxation, meditation, guided imagery, hypnosis, & yoga are some examples of these therapies.
Medical and Nursing Management: BP Monitoring
- The nurse must ensure that follow-up is provided for any person identified as having an elevated BP lvl.
- Each person should be given a written record of his or her BP at the screening.
- Reductions in BP are greater when self-management education includes a written action plan, self-monitoring, & reg review
Medical and Nursing Management: Pharmacologic Therapy
- Nurse collaborates w/ the pt to support adherence to the med regimen b/c up to 50% of individuals prescribed antihypertensive meds do not continue for more than 1 yr
- For pts w/ uncomplicated htn, the recommended initial med is a thiazide diuretic. Thiazide are useful in the elderly & in pts w/ osteoporosis b/c they decrease bone breakdown & preserve bone integrity.
- The provider begins w/ low doses of med. If BP does not fall to less than 140/90 mm Hg, the dose may be increased gradually or additional meds added. Most pts requiring med need 2 drugs for effective treatment b/c htn is cause by multiple factors.
- For pts w/ documented diabetes, HF, or cardiovascular disease, an ACE inhibitor or angiotensin receptor blocker (ARB) is recommended. These drugs protect & preserve renal function & protect the vascular endothelium.
- Beta blockers are additional first-line agents; these are recommended for pts w/ heart CV heart disease & HF.
- Cardioselective beta blockers are indicated for pts w/ pulmonary diseases such as asthma or COPD. Calcium channel blockers, such as amlopidipine, exert their major effect on blood vessels & are recommended for treatment of htn, while meds that affect HR, such as diltiazem, are better suited to rhythm control. Alpha2 stimulating agents, alpha-beta blockers, & direct vasodilators are also used.
Medical and Nursing Management: Pharmacologic Therapy (Table 13-4)
- When BP is less than 140/90 mm Hg for at least 1 yr, gradual reduction of types & doses of med is indicated. To promote compliance, clinicians try to prescribe the simplest treatment schedule possible, ideally 1 pill a day.
- Nurse needs to emphasize & support both pharmacologic & nonpharmacologic strategies; contracting, goal setting, counseling, & referral to support groups are some of the strategies used.
- A pt may be dx w/ resistant htn, which is a failure to reach goal BP in pts who adhere to full doses of an appropriate 3-drug regimen that includes a diuretic.
- Nurse should include education when drug treatment for other risk factors is combined w/ antihypertensive therapy.
- There is evidence that depression is associated w/ poor adherence to med regimens & that PTSD is associated w/ htn, thus directing the nurse to develop further psychosocial interventions & reinforce collaborative pharmacologic interventions
- Nurse provides written info about the expected effects & side effects of antihypertensive meds, warning the pt not to abruptly stop meds b/c rebound htn may occur.
- Both female & male pts should be informed that certain meds, such as beta blockers, may cause sexual dysfunction or dissatisfaction & that other meds are available should this problem develop.
- Pts should be cautioned to avoid OTC meds, esp nasal decongestants containing vasoconstrictors, which can further elevate BP.
- Med compliance increases when pts actively participate in self-care, including self-monitoring of BP, diet, & exercise—possibly b/c pts receive immediate feedback & have a greater sense of control.
- Evidence demonstrates that compliance further increases when the provider takes time in counseling, takes into account cultural perspectives on causes & treatment of htn, & avoids viewing the pt as responsible for treatment failures.
- Prolonged BP elevation damages blood vessels, particularly in target organs such as heart, kidneys, brain, & eyes.
- The consequences of prolonged, uncontrolled htn are myocardial infarction, HF, left ventricular hypertrophy, renal failure, stroke, & impaired vision.
- An acute elevation in BP associated w/ end-organ damage is termed hypertensive crisis.
- Hypertensive crisis is defined as a systolic BP of >180 mm Hg or a diastolic BP of >120 mm Hg.
- Hypertensive crises occur in pts whose htn has been poorly controlled or in those who have discontinued their meds. These crises are more common in men, older adults, & African Americans.
- Other causes of hypertensive crises include head injury, pheochromocytoma, food-drug interactions (such as tyramine combined w/ a MAO inhibitors), eclampsia or preeclampsia, substance abuse (cocaine intoxication), & renal disease.
- Once crisis has been managed, nurse strategizes w/ the pt & provider to take control of his or her BP & prevent recurrence.
- 2 classes of hypertensive crisis that require immediate intervention: 1) hypertensive emergency & 2) hypertensive urgency.
Hypertensive Crises: Hypertensive Emergency
1) Hypertensive emergency: situation in which BP is higher than 180/120 mm Hg & must be lowered quickly to halt or prevent damage to the target organs.
- Conditions associated w/ hypertensive emergency include htn of pregnancy, acute MI, dissecting aortic aneurysm, & intracranial hemorrhage.
- Therapeutic goals are reduction of the mean BP by up to 25% within 1st hr of treatment, a further reduction to a goal pressure of about 160/100 mm Hg over a period of 2 to 6 hrs, & then a more gradual reduction in pressure to the target goal over a period of days.
- Important not to become over-eager & lower BP too quickly, thus reducing tissue perfusion & causing an MI or CVA.
- The exception is treatment of aortic dissection, in which the systolic pressure should be reduced to <100 mm Hg. This pt will most likely receive care in an ICU w/ BP measured every 5 mins while unstable. Nurse evaluates pt for a precipitous drop in BP, which requires immediate action to restore BP to normal lvls.
Hypertensive Crises: Hypertensive Urgency
2) Hypertensive urgency: situation in which BP is severely elevated, but there is no evidence of impending or progressive target organ damage.
- Elevated BPs associated w/ severe headache, epistaxis, or anxiety are classified as urgencies.
- Goal is to reduce BP to 160/110 over several hrs to several days. This can be accomplished by keeping the pt in the emergency dept for several hrs, followed by outpatient management using oral meds.
Hypertensive Crises: Pharmacologic Management of Hypertensive Crises
- Meds of choice in hypertensive emergencies are best managed w/ continuous IV infusion of a short-acting titratable antihypertensive agent.
- Nurse avoids sublingual & IM routes as their absorption/dynamics are unpredictable.
- Meds may include labetalol, nicardipine or clevidipine hydrochloride, fenoldopam mesylate, enalaprilat, esmolol, hydralazine, or nitroglycerin or sodium nitroprusside, which have immediate, short-lived actions. Nitroprusside is no longer recommended as first-line treatment due to thiocyanate toxicity, erratic responses, & risk for severe hypotension.
- Oral doses of fast-acting agents such as beta-adrenergic blocking agents, ACE inhibitors, or alpha2-agonists are recommended for the treatment of hypertensive urgencies.
- Nurse follows-up w/ teaching about the hypertensive crisis & encourages pt to take charge of managing htn.
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