PART I

PRELIMINARY

1.1 Background
Today the community is no stranger to hear the word Hypertension.
Hypertension is one of the diseases that are prevalent in the community,
and is a disease associated with the cardiovascular system.
Hypertension is not a contagious disease, but we can not consider it
trivial, should we must always be vigilant.
High Blood Pressure or Hipertesi and arterosclerosis (hardening of the
arteries) are two basic conditions that underlie many forms of
cardiovascular disease. Furthermore, it is not uncommon high blood
pressure also leads to kidney disease. Until now, efforts in both
preventing and treating hypertension has not been entirely successful, it
is because a lot of factors that influence such as lack of knowledge about
hypertension (definition, classification, signs and symptoms, causal,
complications) and also maintenance.
Currently, the number of deaths due to hypertension in Indonesia is very
high. Hypertension is the third leading cause of death after stroke and
tuberculosis, which reached 6.7% of the population of deaths in all age
groups in Indonesia. Hypertension is a disorder of the circulatory system
that cause a rise in blood pressure above normal, which is 140/90
mmHg. Health Research (Riskesdas) Balitbangkes 2007 shows the
prevalence of hypertension nationwide reached 31.7% (Ministry of
Health of the Republic of Indonesia).
Of that amount, 60% of hypertensive patients at stroke ends. While the
rest of the heart, kidney failure, and blindness. While in the West, just a
lot of hypertension cause renal failure, therefore there should be efforts
to reduce the number of peyakit hypertension, especially for patients
with hypertension need to be given proper care and treatment that is not
likely to cause more severe complications. Besides the importance of
nursing care in hypertensive patients is also very necessary to
implement the right in hypertensive patients.
It is expected by the making of a paper on nursing care clients with
hypertensive disorders can provide proper nursing care and the right
for people with hypertension and to reduce morbidity and mortality due
to hypertension in the community.
1.2 Purpose
The purpose of this paper is as follows:
a. General purpose
Students are able to understand the concept of nursing care in
patients with hypertension
 b. Special purpose
1) Describe the concept of hypertension which includes anatomy and
physiology of heart disease, the definition, classification, etiology,
clinical manifestations, pathophysiology, pathways, complications,
investigations, medical management, nursing and diet
2) Understand the nursing care in hypertensive patients with the correct
methodology of nursing care

CHAPTER II
LITERATURE REVIEW

2.1 Anatomy and Physiology Hypertension

a. Anatomy
1) Heart
Is about one fist and is located in the chest, the right is the limit on the
right of the sternum and apeksnya the fifth intercostal space left on linea
midclavikula.
Relationships heart is:
a) above: large blood vessels
b) below: diaphragm
c) each side: lung
d) back: dessendens aorta, oesopagus, columna vertebral
2) Artery
Is a tube through which the blood flow in tissues and organs. Artery
consists of the inner layer: a layer of slippery, the middle layer of tissue
elastin / muscle: the aorta and its branches was great having a middle
layer consisting of a network of elastin (to deliver blood to the organs),
smaller arteries have a middle layer of muscle (set number blood
delivered to an organ).
Increased blood pressure in the arteries can occur in several ways:
a) The heart pumps more powerful that drain more fluid on every second
b) large arteries lose elasticity and become rigid, so they can not inflate
when the heart pumps blood through the artery. Because the blood in
each heartbeat is forced to pass through narrow vessels than normal and
cause a rise in pressure. This is what happened in the elderly, where the
walls of arteries thickened and stiff due to atherosclerosis. In the same
way, the blood pressure was also increased in the event of
"vasoconstriction", ie if the small arteries (arterioles) to temporarily
shrink due to stimulation of nerves or hormones in the blood.
c) The increase in the circulation of fluid can cause increased blood
pressure. This occurs if there are abnormalities in kidney function that
can not afford to throw some salt and water from the body. The blood
volume in the body increases, so that the blood pressure has also
increased, by contrast, if:
a) reduced heart pumping activity,
b) arteries are widening,
c) a lot of fluid out of the circulation.
Then the blood pressure will decrease or become smaller.
Adjustments to these factors implemented by changes in renal function
and autonomic nervous system (part of the nervous system that regulates
many body functions automatically).
3) Changes in kidney function
Kidneys control blood pressure in several ways:
a) If your blood pressure rises, the kidneys will increase spending on
salt and water, which will cause a reduction in blood volume and blood
pressure returns to normal.
b) If the blood pressure falls, the kidneys will reduce the discharge of
salt and water, so that the blood volume increases and blood pressure
returns to normal
c) The kidneys also can increase blood pressure by producing an
enzyme called renin, which triggers the formation of the hormone
angiotensin, which in turn will trigger the release of the hormone
aldosterone.
Kidney is an important organ in controlling blood pressure, because of a
variety of diseases and disorders of the kidneys can lead to high blood
pressure. Eg narrowing of the arteries leading to one of the kidneys
(renal artery stenosis) can cause hypertension. Inflammation and injury
to one or both kidneys can also cause a rise in blood pressure.
4) arterioles
Are the blood vessels with smooth muscle walls are relatively thick.
Arteriolar wall muscle to contract. Kontriksi contraction causes the blood
vessel diameter. When kontriksi is local, the blood supply to the tissue /
organ is reduced. When there kontriksi general, blood pressure will
rise.
5) The major blood vessels and capillaries
The major blood vessels are thin-walled vessels that run directly from
the arterioles to venul. Capillary is a network of tiny blood vessels open
major blood vessels
6) Sinusoids
There spleen, liver, bone marrow and endocrine glands. Sinusoid three
to four times greater than the capillary and partially coated with reticulo-
endothelial system cells. In their place sinusoid, having direct contact
with the blood cells and the exchange does not occur through the
network space
7) Vena and venul
Venul is small veins that formed capillaries combined. Vena formed by
the confluence venul. Vena has three walls that are not adjacent to each
other perfectly.
b. Physiology
The heart's function as pumping oxygenated blood into the arterial
system, which was brought to the cell and the entire body to collect
deoxygenated blood (blood oxygen levels less) of the vein system
which is sent to the lungs for reoxygenation (Black, 2010).

2.2 Definitions
Hypertension is defined by the Joint National Committee on Detection,
Evaluation and Treatment of High Blood Pressure (JNC) as a pressure
higher than 140/90 mmHg and classified according to the degree of
severity, has a range of blood pressure (BP) high normal to malignant
hypertension. This condition is categorized as primary / essential
(almost 90% of all cases) or secondary, occurring as a result of
pathological conditions that can be identified, it can often be repaired
(Marilynn E. Doenges, et al, 1999).
Hypertension is a condition when the systolic blood pressure greater
than 120 mmHg and diastolic blood pressure over 80 mmHg.
Hypertension often causes changes in blood vessels that can lead to
increasing blood pressure (Arif Muttaqin, 2009).
According to Bruner and Suddarth (2001) hypertension can be defined
as persistent blood pressure where the systolic pressure above 140
mmHg and diastolic pressure above 90 mmHg. In an aging population,
hypertension is defined as systolic pressure above 160 mmHg and
diastolic blood pressure above 90 mmHg.
It concluded that hypertension is the increased pressure of at least 140
mmHg systolic and 90 mmHg diastolic least.

2.3 Classification
Classification of blood pressure according to JNC 7 (2003) can be
seen in the following table:
Classification Systolic Pressure (mmHg) Diastolic Pressure (mmHg)
Normal <120 <80
Prehypertension 120-139 80-89
Stage I hypertension 140-150 90-99
Stage II hypertension> 150> 100
(Arif Muttaqin, 2009).
Hypertension according to WHO classification:
Category Systole (mmHg) diastolic (mmHg)
Optimal <120 <80
Normal <130 <85
Level I (mild hypertension) 140-159 90-99
Sub-group: Border 140-149 90-94
Level 2 (Moderate Hypertension) 160-179 100-109
Level 3 (Hypertension weight)> 180> 110
Systole isolated hypertension> 140 <90
Sub-group: Border 140-149 <90
(Andy Sofyan, 2012)
Results Consensus Classification Hypertension Hypertension Association
Indonesia
Category Systole (mmHg) and / or diastolic (mmHg)
Normal <120 and <180
Pre Hypertension 120-139 or 80-89
Stage I Hypertension 140-159 or 90-99
Phase II Hypertension ≥160 or ≥100
Isolated Systole hypertension ≥140 and <90
(Andy Sofyan, 2012)

2.4 Etiology
a. Decreased elasticity of the aortic wall
b. Valvular heart to thicken and become stiffer
c. Loss of elasticity of the arteries and narrowing of the lumen of blood
vessels
The classification of hypertension according to the etiology:
a) Primary Hypertension: Consumption Na is too high, genetic,
psychological stress
b) Renal Hypertension: the state of ischemic kidneys
c) Hypertension hormonal
d) The form of hypertension as: medicine, cardiovascular, neurogenic
(Andy Sofyan, 2012)
2.5 Clinical Manifestations
most of the clinical manifestations of hypertension arise after many
years in the form of:
a. headache while awake, sometimes accompanied by nausea and
vomiting
b. blurred vision due to damage to the retina caused by hypertension
c. swing step unsteady because of damage to the central nervous
system
d. nocturia due to an increase in renal blood flow and glomerular
filtration
e. dependent edema and swelling due to increased capillary
pressure
(Elizabeth J. Corwin, 2000).
2.6 Pathophysiology
The mechanisms that control the constriction and relaxation of blood
vessels located in the vasomotor center, in the medulla of the brain. This
stems from the vasomotor center in the sympathetic nervous system,
which continues down to the spinal cord and out of the columns of the
spinal cord to the sympathetic ganglia in the thorax and abdomen.
Vasomotor center stimulation delivered in the form of an impulse that
moves downward through the sympathetic nervous system to the
sympathetic ganglia.
At this point, the preganglionic neurons release acetylcholine, which
stimulates nerve fibers after ganglion into a vein, where the release of
norepinephrine resulting in constriction of blood vessels. Various factors
such as anxiety and fear can affect the response of blood vessels to
vasoconstrictor stimuli. Individuals with hypertension are particularly
sensitive to norepinephrine, although it is not clear why this happened.
At the same time in which the sympathetic nervous system stimulates the
blood vessels in response to emotional stimuli. The adrenal glands are
also stimulated, resulting in additional vasoconstriction activity. The
adrenal medulla secretes epinephrine, which causes vasoconstriction.
Adrenal cortex to secrete cortisol and other streroid, which can
strengthen the response to vasoconstriction of blood vessels.
Vasoconstriction resulting in decreased blood flow to the kidneys,
causing release of renin. Renin stimulates the formation of angiotensin I
is then converted into angiotensin II, a potent vasokonstrikstriktor.
Which in turn stimulates aldosterone secretion by the adrenal cortex.
This hormone causes the retention of sodium and water by the kidney
tubules, causing an increase in intravascular volume. All of these factors
tend to trigger a state of hypertension.
Gerontologis consideration. Structure and functional changes in the
peripheral system is responsible for changes in blood pressure that
occurs in the elderly. These changes include atherosclerosis, elastisistas
loss of connective tissue, and a decrease in vascular smooth muscle
relaxation, which in turn reduce the ability distension and tensile
strength of blood vessels. Consequently, the aorta and large arteries
decreases its ability to accommodate the volume of blood pumped by
the heart (stroke volume), resulting in a decrease in cardiac output and
an increase in prisoners parifer (Bruner and Suddarth, 2001).

2.7 Pathway
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CHAPTER III
NURSING CARE

3.1 Physical Examination

Conducting assessments:
a. The patient's identity: name, age, gender, ethnicity, occupation
b. History
1) Family health history
2) Past medical history
3) History of present illness
4) The clinical manifestations of cardiovascular disease such as dyspnea,
angina
5) Daily habits: nutrition, rest, exercise
6) psychological and environmental factors: stes emotional eating
culture, and economic status
7) The risk factors
8) History of allergies
9) history of drug use: birth control pills, steroids, NSAIDs
c. Physical examination
1) Body weight and height.
2) Eyes: funduskopi examination for retinal arteriolar narrowing,
bleeding, exudates and edema papill
3) Neck: JVP, noisy carotid and thyroid enlargement
4) Lungs: respiratory (rhythm, frequency, type of breathing)
5) Heart: heart rate, heart sounds, heart murmurs. Blood pressure is
measured at least 2 times at an interval of 2 minutes of lying down or
sitting, and standing at least after 2 minutes. Measurements using
appropriate, and should be done on both sides of the arm, and if the
value is different then the highest value is taken
6) Abdomen: noisy, renal enlargement
7) Extremities: weakness or loss of pulse parifer, edema
8) Neurology: a sign of cerebral thrombosis and bleeding
d. Supporting investigation
1) ECG: left ventricular enlargement, left atrial enlargement, the
presence of coronary heart disease or arrhythmia
2) Hemoglobin / hematocrit: not diagnostic but reviewing hubngan of
cells to the volume of fluid (viscosity) and may indicate risk factors such
as hiperkogulabilitas, anemia
3) BUN / creatinine: provide information on perfusion / kidney function
4) Glucose: hyperglycemia (Millitus Diabetes is the originator of
hypertension) can be caused by elevated levels of catecholamines
(increase hypertension)
5) Serum potassium: hypokalemia can indicate their main aldosterone
(the cause) or be a side effect of diuretic therapy
6) Calcium serum: increased serum calcium levels can increase
hypertension
7) Cholesterol and triglyceride serum: increased levels may indicate the
originator's / the formation of atheromatous plaque (cardiovascular
effects)
8) Asamm veins: hyperuricaemia has been the implications as a risk
factor for hypertension
9) X-ray: enlarged heart, vascularization or dilated aorta
10) Echocardiogram: visible thickening of the left ventricular wall, may
also occur dilatation and impaired systolic and diastolic function
(Training PJT-RSCM, 2008).

3.2 Nursing Diagnosis

Nursing diagnosis for hypertension clients include:
a. The decrease in cardiac output associated with increased afterload,
vaskonstriksi, myocardial ischemia, ventricular hypertrophy
b. Pain (headaches) are associated with increased cerebral vascular
pressure
c. Activity intolerance related to imbalance between supply and oxygen
demand (Doenges, et al. 1999).
3.3 Interventions and Rational Measures
The nursing care plan for patients with hypertension are as follows:
a. The decrease in cardiac output associated with increased afterload,
vasoconstriction, myocardial ischemia, hypertrophy ventrikelar
Objective: after the act of nursing for 2x24 hours reduced cardiac output
is expected problem can be resolved with outcomes:
1) to maintain blood pressure in the range of individuals who can be
accepted
2) participate in activities that lower blood pressure or heart action
3) shows the rhythm and heart rate stabilized in the normal range of
patients
INTERVENTION RATIONAL
Monitor blood pressure. Measure on both arms / thighs for an initial
evaluation. Use the proper cuff size and accurate technique. Comparison
of pressure provides a more langkap about the involvement / field of
vascular problems. Severe hypertension in adults classified as an
increase in diastolic blood pressure to 130 mmHg, diastolic
measurement results above 130 mmHg considered as an increase in
first, then malignant. Sistolit Hypertension is also a risk factor that is
determined to cerebrovascular disease and ischemic heart disease
when the diastolic pressure 90-115
Please note the presence, quality and parifer central pulsation throbbing
carotid, jugular, radial and femoral probably observed / palpable.
Pulses in the limbs may be declining, reflecting the effects of
vasoconstriction (increased SVR) and venous congestion
Auscultation tone S4 heart and breath sounds commonly heard in
patients with severe hypertension due to atrial hypertrophy (increase in
volume / atrial pressure). Perkemba-
Ngan S3 show ventricular hypertrophy and dysfunction. Their krakles,
indicating pulmonary congestion secondary to the occurrence or
chronic heart failure.
Observe the color, moisture, temperature, and capillary refill time
presence of pale, cool, moist skin and slow capillary refill time may be
associated with vasoconstriction or reflect decompensation / decrease in
cardiac output.
Please note the general edema / particular to indicate heart failure,
kidney damage or vascular
Provide quiet environment, convenient, reduce the activity /
environment commotion. Limit the number of visitors and the length of
stay Helps reduce sympathetic stimulation increases the relaxation
Maintain restrictions on activities, such as: rest in bed / chair,
jadwalperiode uninterrupted rest, help patients perform self-care
activities as needed Reduce stress and tension that affects the blood and
travel peyakit tekanna hypertension
Perform actions that are comfortable, such as back and neck massage,
elevating the head of the bed Reduce discomfort and can reduce
sympathetic stimulation
Encourage relaxation techniques, imagination guide, transfer of
activities to decrease the stimuli that cause stress, create a calm effect,
thereby decreasing TD
Monitor response to medication to control blood takanan response to
drug therapy "stepped" (which consists of the top diuretics, sympathetic
inhibitors and vasodilators) depends on the individual and synergistic
effects of the drug. Because of these side effects, it is important to use the
drug in the fewest number and doses most rebdah
Collaboration:
Give medications as indicated, for example:
Tiazin diuretics, for example: corticosteroids (diuri),
hydrochlorothiazide (esidrix / hidroDIURIL), bendroflumentiazid
(Naturetin) thiazides may be used alone or mixed with other drugs for
reducing BP in patients with relatively normal renal function. This
diuretic memperkuan other antihypertensive agents by limiting fluid
retention.
Give fluid and dietary sodium restriction as indicated These restrictions
can handle fluid retention hypertensive response, thus lowering heart
work

b. Pain (headaches) are associated with increased cerebral vascular

press
Objective: after the act of nursing for 1x24 hours of pain problems
solved with the expected outcomes:
1) To report pain / discomfort controlled
2) Following the pharmacological regimen prescribed
INTERVENTION RATIONAL
Maintaining bed rest during the acute phase Minimizing stimulation /
increase relaxation
Give nonpharmacological measures to relieve headaches, eg: a cold
compress on the forehead, back and neck massage, quiet, dim room
light, relaxation techniques (imagination guide, distraction) and leisure
activities Measures pressure cerebral vascular
and that slow or block the sympathetic response is effective in relieving
headaches and complications
Eliminate / minimize vasoconstriction activity that can improve
headaches, for example, straining during defecation, coughing long,
bent Activities that increase vasoconstriction cause headaches in the
increased pressure vaskularserebral
Assist patients in ambulation as needed Dizziness and blurred vision are
often associated with headaches. Patients may also experience episodes
of postural hypotension
Give liquids, soft foods, oral care is organized if there is bleeding nose
or nasal pack has been done to stop the bleeding Increase the
convenience of the public. Compress the nose and interfere with
swallowing or need breathing with the mouth, causing stagnation and
stressed-out oral secretion of mucous membranes
Kilaborasi:
Give as indicated: analgesics Reduce / control pain and decrease the
stimulation of the sympathetic nervous system
Antiansieta, eg, lorazepam (Ativan), diazepam (Valium) to reduce
tension and discomfort exacerbated by stress

c. Activity intolerance related to imbalance between supply and oxygen

demand
Objective: after the act of nursing for 2x24 hours expected activity
intolerance problem resolved by outcomes:
1) The increase in tolerance activity can be measured
2) shows a decrease in signs of intolerance physiology
3) Participating in the activity of the desired / required
INTERVENTION RATIONAL
Assess the patient's response to the activity, note the pulse rate more
than 20 times per minute over the frequency of breaks, increased TD
tangible during / after activity (systolic blood pressure increase of 40
mmHg or diastolic blood pressure increase of 20 mmHg), dyspnea or
chest pain, fatigue and weakness excessive, diaphoresis, dizziness or
fainting Mention parameter assist in assessing the physiological
response to stress activity and when there is an indicator of excess work
associated with the level of activity
Instruct the patient about energy saving techniques, eg: using a bath
seat, sit down while combing the hair or brushing teeth, doing activities
with slowly Engineering saving energy reduces energy use, it also helps
the balance between supply and oxygen demand
Encourage daily activity / self-care to if tolerated. Provide assistance as
needed. Progress activity gradually to prevent an increase in sudden
cardiac work. Provide only limited assistance will need to encourage
independence in performing activities.
(Doenges, et al. 1999)

CHAPTER IV
COVER

4.1 Conclusions
Hypertension is the increased pressure of at least 140 mmHg
systolic and 90 mmHg diastolic least.
Hypertension is influenced by several factors: genetic factors,
age, emotional state of a person, Na consumption is too high, Drugs,
Hormonal, Neurologic, etc.
People who are exposed to hypertension Sugah can also
experience many suffered complications, including stroke, blindness,
angina pectoris, CHF, renal failure, myocardial infarction, etc.
4.2 Recommendations
To avoid the occurrence of hypertension, then we should as a
medical officer should give an example of the community to adopt
healthy behaviors and clean life, and also not to consume foods
carelessly untested health.