NUR 342

Unit II

Assessment and Management

of Patients With Hypertension

Question
Is the following equation True or
False?
Blood Pressure = Heart Rate x
Stroke Volume

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Answer
False

Blood Pressure = Cardiac Output x

Peripheral Resistance

Cardiac Output = Heart Rate x

Stroke Volume
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Hypertension

AKA High blood pressure

Eighth Report (2014) of Joint National
Commission (JNC8) published Evidence-based
Guideline for the Management of High Blood
Pressure in Adults: Recommendation #1: In the
general population ages =/>60 years, initiate
pharmacologic treatment to lower BP at
SBP=/>150 mm Hg or DBP =/>90 mm HG and
treat to a goal SBP <150 mm Hg and goal DBP
< 90 mm Hg (Strong recommendation Grade
A) ; see other recommendations on Guidelines
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Hypertension

Primary or Essential Hypertension: no

specific reason
Secondary Hypertension: specific cause, e.g.
pheochromocytoma, Cushings, chronic
steroid use

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Incidence of HypertensionApproximately
30% of the adult
The
Silent Killer

population of the U.S. have

hypertension.
90-95% of this population with
hypertension have primary
hypertension.
Incidence is greater in southeastern
U.S. and among African-Americans.
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Pathophysiology

Increased SNS
Increased reabsorption of NA,CL,H20
Increased RAA system activity
Decreased vasodilation of arterioles
r/t vascular endothelial dysfunction
Resistance to Insulin action
Gerontological aspects
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Factors Involved in the

Control of Blood Pressure

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Manifestations of
Hypertension

Usually NO symptoms other than

elevated blood pressure
Symptoms seen related to organ
damage are seen late and are serious:

Retinal and other eye changes

Renal damage
Myocardial infarction
Cardiac hypertrophy
Stroke
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Major Risk Factors

Smoking
Obesity BMI =/>30kg/m2
Physical inactivity
Dyslipidemia
Diabetes mellitus
Microalbuminuria or GFR <60 ml/min
Older age
Family history
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Assessment and
Diagnostics

History
Physical Exam

Diagnostic Tests

Retinas
Blood Chemistry
U/A
Cholesterol levels

EKG
Echocardiography: Check Left Ventricular
Hypertrophy
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JNC 7 Recommendations vs
JNC 8 Evidence-based
New JNC8 Evidence-based
Guideline
guideline just published in
December 2013.

We will use the JNC7 for this

discussion but be aware that there
are new guidelines.
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Medical Management

Goal is to achieve BP 140/90 mm Hg. or

lower;goal of 130/80 mm Hg for patients with
diabetes or chronic renal disease.
Treatment algorithm issued in Seventh Report
of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High
Blood Pressure (2003)
Lifestyle changes: weight loss, diet (DASH),
dietary sodium restriction;physical activity;
moderation of alcohol consumption
Pharmacologic therapy: diuretics, ARBs, BBs,
ACE-I, Alpha blockers, Alpha/Beta blockers;
vasodilators, others
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Special Indications for BP Control

Persons with diabetes mellitus or

chronic renal disease as evidenced
by a reduced GFR or an elevated
serum creatinine have a lower goal
pressure of 130/80 (JNC 7).

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JNC 7 Treatment Algorithm

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Lifestyle Modifications

Weight loss
Reduced alcohol intake
Reduced sodium intake
Regular physical activity
Diet: high in fruits, vegetables, and
low-fat dairy
DASH diet
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DASH Diet

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Question
For patients with uncomplicated
hypertension and no specific indications
for another medication, what is the initial
medication?
A. Thiazide diuretic
B. Calcium channel blockers
C. Vasodilators
D. Angiotensin converting enzyme inhibitors
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Answer
A
For patients with uncomplicated
hypertension and no specific indications
for another medication, the
recommended initial medication is
thiazide diuretics for most patients. If
blood pressure does not fall to less than
140/90 mm Hg, the dose is increased
gradually and additional medications are
included as necessary to achieve control.
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Medication Treatment

Usually initial medication treatment is a

diuretic, a beta blocker, or both.
Low doses are initiated and the medication
dosage is increased gradually if blood
pressure does not reach target goal.
Additional medications are added if needed.
Multiple medications may be needed to
control blood pressure.
Lifestyle changes initiated to control BP
must be maintained.
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Medication Therapy for

Hypertension

Diuretic and related drugs

Thiazide diuretics
Loop diuretics
Potassium-sparing diuretics
Aldosterone receptor blockers

Central Alpha2-Agonists and other centrally

acting drugs
Beta blockers
Beta blockers with intrinsic sympathomimetic
activity
Alpha and beta blockers
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Medication Therapy for

Hypertension (continued)

Vasodilators
Angiotensin-converting enzyme
(ACE) inhibitors
Angiotensin II antagonists
Calcium channel blockers

Nondihydropyridines
Dihydropyridines
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Nursing History and

Assessment

History and risk factors

Assess potential symptoms of target organ
damage

Angina, shortness of breath, altered speech,

altered vision, nosebleeds, headaches,
dizziness, balance problems, nocturia
Cardiovascular assessment: apical and
peripheral pulses

Personal, social, and financial factors that

will influence the condition or its treatment
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Goals:

Patient understanding of disease

process.
Patient understanding of treatment
regimen.
Patient participation in self-care.
Absence of complications.

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Nursing Diagnoses

Knowledge deficit regarding the

relation of the treatment regimen
and control of the disease process.
Noncompliance with therapeutic
regimen related to side effects of
prescribed therapy.

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Interventions

Patient teaching
Support adherence to the treatment
regimen
Consultation/collaboration
Follow-up care
Emphasize control rather than cure
Reinforce and support lifestyle changes
A lifelong process
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Gerontologic
Considerations

Noncompliance
Include family
Understanding of therapeutic
regimen

Reading instructions
Monotherapy

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Recommendations for Follow-up

Based on
Initial Blood Pressure Readings

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Hypertensive Crises

Hypertensive emergency

Blood pressure >180/120 and must

be lowered immediately to prevent
damage to target organs.

Hypertensive urgency

Blood pressure is very high but no

evidence of immediate or progressive
target organ damage.
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Hypertensive Emergency

Reduce BP 25% in first hour

Reduce to 160/100 over 6 hours
Then gradual reduction to normal over a
period of days
Exceptions are ischemic stroke and aortic
dissection
Medications

IV vasodilators: sodium nitroprusside, nicardipine,

fenoldopam mesylate, enalaprilat, nitroglycerin

Need very frequent monitoring of BP and

cardiovascular status
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Hypertensive Urgency

Patient requires close monitoring of blood

pressure and cardiovascular status.
Assess for potential evidence of target
organ damage.
Medications

Fast-acting oral agents: beta-adrenergic

blocker- labetalol; angiotensin-converting
enzyme inhibitors: captopril or alpha2agonists-clonidine

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