Hypertensive Crisis

NURS 3305
Hypertensive crisis (pp. 709-729);
Ch 36 Hypertension (pp. 409-415)

Copyright 2014 by Mosby, an

imprint of Elsevier Inc.

Factors Influencing BP
Systemic
Blood
Cardiac
=
Vascular
Pressure
Output
Resistance

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Factors Influencing BP

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Classification of Hypertension from JNC VII

Category

Systolic BP

Normal

<120

Diastolic
BP
<80

Prehypertensi
on
Hypertension

120-139

80-89

140-159

90-99

Stage II

>160

>100

Etiology of Hypertension
Primary hypertension
Also called essential or idiopathic
hypertension
Exact cause unknown but several
contributing factors
90% to 95% of all cases

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Etiology of Hypertension
Secondary hypertension
Elevated BP with a specific cause
Clinical findings relate to underlying
cause
Treatment aimed at removing or treating
cause
Is a contributing factor to hypertensive
crisis.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension
Complications
Target organ diseases occur most
frequently in the
Heart
Brain
Peripheral vascular disease
Kidney
Eyes

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Drug Therapy

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Case Study
C.S. is referred to his health care
provider to follow up on his high blood
pressure screening. His blood pressure
is 225 /141 mmHg when checked in the
physicians office.

Fuse/Thinkstock

What does this blood indicate? What

are the potential effects of this blood
pressure?
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis
Hypertensive Urgency

Hypertensive Emergency

Occurs over days to weeks

BP > 180/110
No evidences of target
organ disease

Develops over hours to

days
Severely elevated BP (often
>220/140 mmHg)
Evidence of target organ
disease
Cause target organ damage
Heart (AMI) Brain
(encephalopathy or
stroke[SAH]), kidney (renal
failure), Aorta (dissection),
Eyes (retinopathy)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis Etiology

Untreated or uncontrolled hypertension

Renal dysfunction
Pregnancy
Endocrine disorders
Acute aortic dissection
Postoperative complications after
surgery
Burns

Hypertensive Crisis
Clinical Manifestations/End organ damage

Hypertensive encephalopathy
Headache, n/v, seizures, confusion,
coma

Renal insufficiency
Cardiac decompensation
MI, HF, pulmonary edema

Aortic dissection

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension
Nursing Assessment
Cardiovascular
Vital signs BP in both arms initially, monitor
frequently, arterial line may be indicated
especially with IV vasodilators
Chest pain (AMI or Aortic dissection), dysrhythmias

Neurologic
Mental status changes, HA, blurred vision,
papilledema, stroke, coma

Renal
Sudden decrease/absence of UOP, renal failure

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertension
Nursing Assessment
Catecholamine excess
Pheochromocytoma
MAOI in combination with other drugs or foods
Abrupt withdrawal of of antihypertensive
agents

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis
Nursing/Collaborative Management
Hospitalization
IV drug therapy: titrated to MAP
Titrate IV meds to lower pressure cautiously
Initial goal: reduce by no more than 25% in first 26 hours
Ischemic stroke (BP lowered slowly by 15-20%
Aortic dissection (SBP < 100 mmHg)

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis
Nursing/Collaborative Management
IV drug therapy: IV Vasodilators
Nitrates
NTG vasodilation (venous > arterial) decreases
LVEDV (preload), decreases chest pain
Nitroprusside (Nipride) peripheral vasodilation
(arterial & venous smooth muscle), decreases
preload and afterload
Nursing considerations avoid long term use
due to cyanide toxicity

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis
Nursing/Collaborative Management
Other Drug Therapy
Ace Inhibitors enalapril
Diuretics furosemide
Beta blockers labetolol (alpha, beta
blockade effect), esmolol (short acting beta
blocker)
Calcium channel blockers nicardipine,
cardizem, verapamil
Dopamine receptor antagonist fenoldopam
Alpha blocker phentolamine
Hydralazine
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Hypertensive Crisis
Nursing/Collaborative Management
Monitor for possible complications
Monitor cardiac and renal function
Perform Neurologic checks

Determine cause of hypertensive crisis

after resolved
Education to avoid future crisis

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Discharge Teaching
Diet
Low sodium, low fat diet. Lower cholesterol levels to <
200 mg/dL total and LDL <100 mg/dL

Lifestyle modification
Smoking cessation, maintain ideal body weight,
exercise, adherence to antihypertensive medications.

Self-monitoring of BP at home
Goal of 140/90 or lower

Warning signs
MI, CVA, PAD

Medications
what they are for and the side effects
Signs & symptoms to report

Hypertension
Nursing Diagnoses
Risk for ineffective cerebral and renal
perfusion
Risk for decreased cardiac perfusion
Anxiety
Potential complications: stroke, MI

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

References
Burns, S. (2014) AACN essentials of critical care nursing. (3 rd
ed.) St Louis: Elsevier).
Lewis, S., et al, ( 2013). Medical surgical nursing Assessment
and management of clinical problems (9th) ed. St. Louis:
Mosby: Elsevier.
Sole, M., Klein, D., Mosley, M. (20130. Introduction to critical
care nursing. 6th ed. St. Louis: Elsevier.
Urden, L., Stacy, K. & Lough, M. (2010). Critical care nursing:
Diagnosis and management. (6th ed.). St. Louis: Mosby.