Chapter 22:

Nursing Care of
Patients with
Hypertension
Beth Campos MSN RN
Instructor

Learning Objectives
1. Explain the pathophysiology of hypertension
2. Identify causes and risk factors for
hypertension.
3. List signs and symptoms of hypertension.
4. Describe therapeutic measures for
hypertension.
5. Evaluate effectiveness of nursing
interventions.
6. Define classifications and treatment
recommendations for hypertension in adults.
7. Define hypertensive emergency.
8. List common complications of hypertension.
9. Plan nursing care for patients with
hypertension.

Hypertension
Commonly

called as high blood pressure

Medical condition in which the blood
pressure is chronically elevated in
which the average of at least two or
more readings on different dates is
above the prehypertension levels
Systolic pressure equal to or greater
than140mm Hg and a diastolic
pressure equal to or greater than
90mm Hg when taken at least twice and
averaged on two different occasions 2
weeks apart

Hypertension

The Seventh Report of the Joint National

Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood
Pressure definitions:
Normal blood pressure:
Systolic: below 120 mm Hg
Diastolic below 80 mm Hg
Prehypertension:
Systolic BP: 120- 139, Diastolic BP: 80-89
Stage 1 hypertension :
Systolic BP: 140- 159, Diastolic BP: 90-99
Stage 2 hypertension:
Systolic BP: 160 or higher, Diastolic BP: 100
or higher

Hypertension: Follow-Up Care

Normal BP:
2 Years
Pre-hypertension:
1 Year
Stage 1 Hypertension:
2 Months
Stage 2 Hypertension:
1 Month
>180/110 mm Hg: Immediate
Treatment

Types of Hypertension
Primary hypertension (Essential): 90% to 95% of
all cases of hypertension; no specific medical
cause to explain the patients condition, chronic
elevation of unknown cause
Secondary hypertension: cause is known, 5% of
all cases of hypertension; result of another disease or
condition
Caused by underlying factors such as:
kidney disease: pyelonephritis, nephrotic
syndrome, glomerulonephritis
certain arterial conditions: coarctation of aorta
endocrine problems: adrenal tumors
some drugs (estrogens), occasionally pregnancy
Isolated systolic hypertension (ISH): occurs
mainly in older adults. SBP >140mmHg, DBP
90mmHg

Hypertension

Persistent hypertension is one of the risk

factors for strokes, heart attacks, heart
failure, arterial aneurysm and is a leading
cause of chronic renal failure
Even moderate elevation of arterial blood
pressure leads to shortened life expectancy
Factors that determine BP:
1. Cardiac output
2. Peripheral vascular resistance
3. Viscosity of the blood
4. Amount of circulating blood

Hypertension

Blood Pressure Regulation

Cardiac output: the volume of blood pumped by the
heart in a specific period (usually 1 minute).
Determined by strength, rate, and rhythm of the
contraction of the left ventricle and the blood volume.
Cardiac output (CO) X peripheral vascular resistance
(PVC) = BP
Peripheral vascular resistance: force in the blood
vessels that left ventricle must overcome to eject
blood from the heart. Resistance to blood flow
determined by diameter of the blood vessels
(narrowing) and blood viscosity (thickness),
increased blood volume (sodium and water
retention)
Increased peripheral vascular resistance: the
most prominent characteristic of hypertension

Hypertension

Blood Pressure Regulation

Diameter of blood vessels regulated by
vasomotor center located in the medulla of
the brain
Arterial baroreceptors located in the carotid
sinus, aorta and left ventricle control BP by
altering heart rate causing vasoconstriction
or vasodilatation
Sympathetic Nervous System tracts from the
medulla extend down the spinal cord to the
thoracic and abdominal regions
Stimulation of Sympathetic Nervous System
causes release of the catecholamine
hormones norepinephrine and epinephrine

Hypertension
Blood

Pressure Regulation

Norepinephrine and epinephrine

(catecholamines) are vasoconstrictors:
cause blood vessels to constrict, making
diameter smaller
By constricting blood vessels, norepinephrine
increases peripheral vascular resistance
and raises blood pressure
Epinephrine constricts blood vessels and
increases the force of cardiac contraction,
causing blood pressure to rise

Hypertension
Blood

Pressure Regulation
Vasoconstriction decreases blood flow to the
kidneys, which then release Renin
Renin leads to the formation of
Angiotensin II, another potent
vasoconstrictor
Angiotensin II stimulates the adrenal
cortex to secrete aldosterone, a
hormone that promotes sodium and
water retention
This results in an increased blood volume
Vasoconstriction, cardiac stimulation,
and retention of fluid all contribute to
hypertension

Figure 37-1

Age-Related Changes Affecting

Blood Pressure
Atherosclerotic changes reduce
the elasticity of the arteries, causing
decrease in cardiac output and
increase in peripheral vascular
resistance
Pulse pressure (the difference
between the systolic and diastolic
pressures) widens in response to a
decreased ability of the aorta to
distend

Primary (Essential)
Risk Factors:
Hypertension

Non modifiable risk factors:

Genetic: Family history of hypertension: 2x
the risk, father or brother with heart disease
before age 55; mother or sister with heart
disease before age 65
Age: >55 years for men or age >65 years for
women, blood vessels stiff, less elastic, plaque
build up cause heart to work harder
Race and ethnicity: African-American descent
Non-Hispanic Blacks: 42.1%, Non-Hispanic
Whites: 28%, Mexican Americans: 26%
Family History of Diabetes Mellitus

Primary (Essential)
Hypertension
Modifiable Risk factors

( environmental)
Weight: obesity (central obesity)
Stress, inadequate sleep
Diet: Increase salt intake, decreased
intake of potassium, calcium, magnesium
Excess alcohol consumption
Sedentary lifestyle, Lack of exercise
Smoking: major risk factor
Dyslipidemia
Atherosclerosis
Diabetes mellitus: glucose levels

Hypertension

Manifestations:
Elevated BP measurement: No signs and
symptoms are Silent Killers
Rare: occipital headaches that are more
severe on arising, lightheadedness,
fainting, dizziness, blurry vision, fatigue,
epistaxis, facial flushing, tinnitus
Target Organ Disease signs and
symptoms: has damaged blood vessels in
the heart, kidneys, eyes, or brain. Patient
may have symptoms of impaired function
of those organs

Complications

Heart:

coronary artery disease develops in patients

with hypertension 2 to 3X more frequently than in
people with normal BP, MI, Atherosclerosis, heart
failure
Kidneys: Hypertensive nephropathy- narrowing of
renal arteries may decrease renal function and lead to
chronic renal failure
Brain: prolonged hypertension constricts and
damages cerebral arteries, putting patient at risk for
TIA and CVA
Eyes: Hypertensive retinopathy- damage to eyes may
include narrowing of retinal arterioles, retinal
hemorrhages, and papilledema; may lead to blindness
Progressive functional impairment of the target
organ/s

Figure 37-2

Diagnostic Tests and

History:
confirmed by repeated findings of
Procedures
average pressures equal to or greater than
140/90, previous diagnosis, family history,
medications
Signs and symptoms: Ambulatory blood
pressure monitors, data collection about
patients lifestyle, other cardiovascular risk
factors, and other medical diagnoses
Electrocardiogram
Blood studies include glucose, CBC
(hematocrit), urinalysis, BUN, creatinine,
sodium, chloride, potassium, calcium,
magnesium, lipid profile (cholesterol,
triglycerides)
Chest X-ray: cardiomegaly

Taking Blood Pressure (BP)

Use

Calibrated Instrument
Have Patient Sit Quietly for 5 Minutes in
Chair (Not Exam Table) with Feet on
Floor, Arm Supported at Heart Level
Use Cuff Bladder Encircling at Least 80%
of Arm
Take Two BP Measurements (Wait Inbetween)
Patient Centered Care: Inform Patient of
BP Reading

Management

No/low risk Hypertensive:

Lifestyle Changes

Goal of Hypertension Treatment

60 years or older: <150/90mmHg
3059 years old: < 90mmHg diastolic
Other adults: <140/90mmHg
Chronic kidney disease or diabetes:
<140/90mmHg

Management

Lifestyle modifications:
Diet: use DASH diet (Dietary
Approaches to Stop Hypertension)
decreased Na intake or Na restriction: 2
to 3 g/day (decrease BP by 60%), adequate
potassium and calcium. Monitor potassium
with some salt substitutes (may interfere
with medications). Caffeine can increase BP
but does not produce chronic HTN
Weight reduction: lose weight for obese
with low saturated fats and cholesterol.
Control alcohol intake (2 oz. liquor, 8 oz.
wine, 24 oz. beer/day)

Management

Lifestyle modifications:
Regular exercise: begin slowly and
gradually and advance with guidance of
the physician and physical therapist
Smoking cessation: not directly linked
with hypertension but with high
association with cardiovascular diseases
Stress reduction: relaxation techniques
such as yoga, massage, hypnosis,
behavior modification

Management

Anti hypertensive medications: start

immediately
Specific antihypertensive drugs: 8
categories
1. Diuretics
2. Beta-adrenergic receptor blockers
3. Calcium-channel blockers
4. Angiotensin-converting enzyme (ACE)
inhibitors (or ACEIs)
5. Angiotensin II receptor antagonists (ARBs)
6. Central adrenergic blockers
7. Alpha-adrenergic receptor blockers
8. Direct vasodilators

Anti-Hypertensive medications

Diuretics: first line of drugs

increases excretion of water and Na by inhibiting
reabsorption in the distal tubule.
Thiazide diuretics: prevent water and sodium
reabsorption and promote potassium excretion.
Side effects: hypokalemia
Examples: hydrochrothiazide (HCTZ),
chlorothiazide (Diuril), chlorthalidone (Hygroton)
Other diuretics used if not responsive to thiazide
diuretics
Loop diuretics such as furosemide (Lasix)
decrease sodium reabsorption and promote
potassium excretion. Monitor for hypokalemia
Potassium sparing diuretics: affect distal
tubule and prevent reabsorption of sodium in
exchange for potassium. Examples: spironolactone
(Aldactone) Monitor for hyperkalemia

Anti-Hypertensive medications

Calcium channel blockers:

inhibit transport of calcium into myocardial
and vascular smooth muscle producing
vasodilatation to decrease BP
Side effects: hypotension, bradycardia, CHF
Examples: nifenidine (Adalat), amlopidine
(Norvasc), diltiazem (Cardizem), Verapamil
Monitor BP and pulse, change position
slowly, encourage high fiber foods, use
sunscreen and protective clothings when
exposed to sun, avoid grapefruit juice
(potentiate medication effects: hypotension
and can cause toxicity)

Anti-Hypertensive
medications
Beta adrenergic blockers:

blocks stimulation of beta1 adrenergic

receptors to decrease BP and HR. indicated
for patients with unstable angina and MI
Side effects: bradycardia, hypotension,
fatigue, weakness, depression, sexual
dysfunction (impotence), may masks
hypoglycemia in diabetics
Examples: Atenolol (Tenormin), labetalol
(Normodyne), metoprolol (Lopressor, ToprolXL), propranolol (Inderal)
Monitor BP and pulse, change
positions slowly
Do not stop medication suddenly, may
cause rebound hypertension

Anti-Hypertensive medications

Angiotensin- converting enzymes (ACE)

inhibitors:
blocks action of converting Angiotensin 1 to
Angiotensin II to prevent vasoconstriction to lower
BP, and decrease fluid retention by decreasing
aldosterone production
Side effects: chronic cough, headache, fatigue,
dizziness, hypotension, taste disturbance,
impotence, neutropenia, hyperkalemia, angioedema
Examples: captopril (Capoten), enalapril (Vasotec),
fosinopril (Monopril), lisinopril (Zestril), quinapril
(Accupril), ramipril (Altace), benazepril (Lotensin
Monitor BP and pulse, change positions
slowly, report cough, signs of heart failure (edema)

Anti-Hypertensive medications

Angiotensin II receptor antagonists

(ARBs):

blocks vasoconstrictor and aldosterone producing

effects of Angiotensin II in vascular smooth
muscle and adrenals
Side effects: dizziness, fatigue, hypotension,
renal failure, hyperkalemia
Examples: irbesartan (Avapro), losartan
(Cozaar), valsartan (Diovan), candesartan
(Atacand), telmisartan (Micardis),
Good option for patient reporting cough. Do not
require dosage adjustments in older adults
Monitor BP and pulse, change positions
slowly, report signs of angioedema (swollen
lips or face) or heart failure (edema)

Anti-Hypertensive medications

Alpha adrenergic blockers: dilates arteries and veins

by blocking alpha adrenergic receptors to constrict
arterioles.
Side effects: dizziness, headache, orthostatic
hypotension (lie down 2 hours after taking or give at
bedtime). Use of these medication is limited
Examples: doxazosin (Cardura), prazosin (Minipress),
terazocin (Hytrin)
Central alpha agonists such as clonidine (Catapres)
and methyldolpa (Aldomet) prevents reuptake of
norepinephrine, which lowers perilpheral vascular
resistance and blood pressure. Not use as first line
management. Monitor BP and pulse, caution when
getting OOB, no driving or climbing if effects are not
known
Side effects: sedation, orthostatic hypotension, impotenc e

Anti-Hypertensive medications

Direct acting vasodilators

Relax smooth muscle of the blood vessels causing

vasodilatation to increase blood flow to the braim
and kidneys. It also causes the BP to drop. May
cause water and sodium retention leading to
peripheral edema. Diuretics can decrease edema
Side effects: hypotension, palpitations, edema,
headaches, nasal congestion
Examples: hydralazine (Apresoline), minoxidil
(Loniten), sodium nitroprusside (Nitropress),
nitroglycerin)
Monitor BP and pulse, excess hair growth with
minoxidil, kept in dark bag for Nitropress solution
(stable for 24 hours), discard if medication becomes
red, green or blue

Nursing Care of the Patient with

Hypertension

Assessment
Periodic blood pressure checks detect new or
unknown hypertensive people; provide data to
evaluate effect of therapy in hypertensive people
Complete history and physical examination by
the registered nurse
Blood pressure screenings and monitoring, and
provides important data to evaluate treatment
effectiveness
Home self-measurement and recordings is
a strong predictor of a long termcardiovascular events. Patients are taught to
take BP at home

Health History
Explore past medical for
hypertension or renal, cardiac, or
endocrine disorders
Date and readings of the last blood
pressure measurement
Ask about pregnancy and about
hormone replacement therapy
Current medications, including overthe-counter drugs

Health History

Family health history: hypertension,

myocardial infarction, or cerebrovascular
accidents
Body systems for signs and symptoms,
particularly headaches, epistaxis,
dizziness, visual disturbances, dyspnea,
angina, nocturia
Data about the patients usual functioning
may detect some risk factors for
hypertension
Occupation, exercise and activity, sleep
and rest, nutrition, interpersonal
relationships, and stressors

Physical Examination

General appearance; note obvious distress

Measure height and weight and vital signs
Patient should be seated in a chair with
feet on the floor and arm resting at the
level of the heart
The proper cuff size is essential
Multiple readings should be taken
Blood pressure assessed in both arms in
the supine, sitting, and standing positions

Nursing Diagnosis

Ineffective Therapeutic Regimen

Management
Diet therapy goals : Maintain ideal body
weight; prevent fluid retention
Exercise : Walking is highly recommended:
increases cardiovascular functioning, burns
calories, relieves stress, and promotes a sense
of well-being
Stress management : Help patients identify
stressors in their lives and explore ways to
reduce them
Drug therapy : Review the name, dosage,
purpose, and side effects of any prescribed
medications. Educate patient on medications

Nursing Diagnosis

Risk for Injury

Orthostatic hypotension
Sudden drop in systolic blood pressure,
usually 20 mm Hg, when going from lying
or sitting to a standing position
Monitor for lightheadedness, dizziness,
syncope
Sedation
Advise if drowsiness is likely so activities
requiring alertness can be avoided during
times of peak drug effect
Taking medications at bedtime to promote
sleep

Nursing Diagnosis

Ineffective Coping
If depression a side effect of an
antihypertensive, consult physician
to substitute another drug
Sexual Dysfunction
Decreased libido, inability to achieve
an erection, or delayed ejaculation
Advise physician so an alternative
medication or other intervention can
be considered

Hypertension
Older

Patients
Response to drug therapy more difficult to
predict; side effects are more common
Orthostatic hypotension and sedation
problematic for the older person, who is
prone to fall and suffer serious injuries
Depression also must be taken very
seriously because it lowers motivation,
impairs quality of life, and can lead to
suicide

Hypertensive Emergencies
A life-threatening medical emergency
Severe hypertension with acute

impairment of an organ system

especially CNS, CVS, renal system,
possibility of irreversible organ damage
May result from having stopped
taking antihypertensive drugs
Signs and Symptoms:

Severe headache, blurred vision, nausea,

dizziness, restlessness, and confusion,
disorientation
Elevated systolic BP of > 240 mmHg,
diastolic blood pressure of >130 mm Hg; the
heart and respiratory rates are increased

Hypertensive
Emergencies
Causes: malignant hypertension,
hypertensive encephalopathy,
eclampsia, pheochromocytoma (adrenal
tumor), cerebrovascular accident
BP should be lowered aggressively
Without treatment, the patient in
hypertensive crisis may incur cardiac
and renal damage
Death may ensue as a result of a
cerebrovascular accident, renal failure,
or cardiac failure

Hypertensive
Emergencies
Diagnosis
Assessment in the ED reveals elevated
blood pressure, pulse, and respiratory rate
Retinal hemorrhage or papilledema, or
both, observed in fundus (back, interior
portion) of eye
Physician may order blood drawn for
arterial blood gases, CBC, electrolytes,
blood urea nitrogen, creatinine, and
cardiac enzymes
Chest radiograph may be requested
Direct blood pressure monitoring through
an arterial catheter preferred

Hypertensive Emergencies

Management goal: Drug therapy is to

rapidly reduce the pressure to a nonlifethreatening level and then to bring it
slowly within normal range
Potent direct vasodilators: relax
arteriolar smooth muscle. Mostly given IV
Fenoldopam (Corlopam) - Nitroglycerin
Diazoxide (Hyperstat)
- Hydralazine
(Apresoline)
Phentolamine
- Labetalol
(Normodyne)
Nitroprusside (Nipride)

Hypertensive Emergencies
An

intravenous line is usually established

because many drugs are given by that route
Oral options for the management of hypertensive
crisis include captopril, clonidine, and nifedipine
Frequently check blood pressure, pulse,
respiration, and level of consciousness
Some drugs are given in intravenous fluids,
requiring continuous monitoring and adjustment
Monitor cardiac and renal function, careful record
of fluid intake and output
Nausea and vomiting may indicate an impending
seizure or coma

Hypertensive
Administer
Emergencies
oxygen as ordered

Assess patient and monitor closely

Take appropriate safety measures if

the patient shows signs of seizure

activity or a decreasing level of
consciousness
Once patients condition improves, it
is important to explain how to manage
hypertension and prevent future crises
Comfort the patient

Hypertensive Emergencies
Collaboration with health team
Patient education: home teachings:

lifestyle changes
Medication compliance
Meal planning: DASH diet (dietary
approach to stop HTN), low sodium
diet (avoid canned fruit and
vegetables), low cholesterol, read food
labels (potassium in salt substitutes)
Home exercise: 30-60min- 4-7x a week
lose weight
Stop smoking, alcohol moderation
Side effects of meds