Chapter 32 Assessment and Management of Patients With Hypertension Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following equation True or False? Cardiac Output = Heart Rate x Stroke Volume Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True • Cardiac Output = Heart Rate x Stroke Volume Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypertension • High blood pressure • Defined by the Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Joint National Committee-JNC 7) as a systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg. based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Classification of Blood Pressure for Adults Age 18 and Older Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Incidence of Hypertension— “The Silent Killer” • Primary hypertension. • Secondary hypertension. • 28–31% of the adult population of the U.S. has hypertension. • 90–95% of this population with hypertension has primary hypertension. • Incidence is greater in southeastern U.S. and among African-Americans. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Involved in the Control of Blood Pressure Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors that Influence the Development of Hypertension • Increased sympathetic nervous system activity • Increased reabsorption of sodium chloride and water by the kidneys • Increased activity of the rennin-angiotensin system • Decreased vasodilatation • Increased insulin resistance Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Major Risk Factors • Hypertension • Smoking • Obesity • Physical inactivity • Dyslipedemia • Diabetes mellitus • Microalbuminuria or GFR < 60 • Older age • Family history Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient Assessment • History and Physical examination • Laboratory tests – Urinalysis – Blood chemistry – Cholesterol levels • ECG Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins • 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). Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Lifestyle Modifications • Weight loss • Reduced alcohol intake • Educed sodium intake • Regular physical activity • Diet: high in fruits, vegetables, and low-fat dairy • DASH diet (eating more fruits, vegetables, and low fat dairy products, less saturated and total fat) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Medication Treatment • Usually initial medication treatment is a thiazide diuretic. (first line) • 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. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Key facts about diuretics: • Ease your heart’s workload. • Lower your blood pressure. • Can relieve shortness of breath. • Reduce swelling and bloating. • Make patients urinate more often. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Medication Therapy for Hypertension • Diuretic and related drugs – Thiazide diuretics – Loop diuretics – Potassium sparing diuretics – Aldosterone receptors blockers (water pill, retain potassium and decrease the function of aldosterone so retain fluid) -Central alpha2-agonists and other centrally acting drugs • stimulating alpha-receptors in the brain ((Catapres) which open peripheral arteries easing blood flow Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Patient education • make more urine. So you will need to use the bathroom more often. – taking medication at least six hours before bedtime. • Limit the amount of salt you consume. • Spironolactone can be taken with or without food (Aldosterone receptors blockers). • Spironolactone might make you drowsy (Aldosterone receptors blockers ) – Avoid driving until you know if you are affected. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of diuretics • Thiazide diuretics • Thiazides are the most commonly prescribed diuretics. They’re most often used to treat high blood pressure. These drugs not only decrease fluids, they also cause your blood vessels to relax. • Thiazides are sometimes taken with other medications used to lower blood pressure • chlorthalidone • hydrochlorothiazide (Microzide) • Metolazone, indapamide Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins • Loop diuretics • Loop diuretics are often used to treat heart failure. Examples of these drugs include: • torsemide (Demadex) • furosemide (Lasix) • bumetanide Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins • Potassium-sparing diuretics • Potassium-sparing diuretics reduce fluid levels in your body without causing you to lose potassium. Used with other types of diuretics to increase its effect on decreasing BP. • Examples of potassium-sparing diuretics include: • amiloride • triamterene (Dyrenium) • spironolactone (Aldactone) • eplerenone (Inspra) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Common side effect • too little potassium in the blood • too much potassium in the blood (for potassium-sparing diuretics) • low sodium levels, headache, dizziness • Thirst, increased blood sugar • muscle cramps, increased cholesterol • Diarrhea Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Medication Group 1: Adrenergic (epinephrine) antagonists (Beta-blocker and alpha blocker) are a group of drugs that inhibit the function of adrenergic receptors • Beta-blockers: Beta blockers lower blood pressure by acting directly on the heart • Beta-blockers with intrinsic sympathomimetic activity: • Beta blockers interfere with the binding to the receptor of epinephrine and other stress hormones, and weaken the effects of stress hormones. (sympathomimetic agents). Relaxing the heart muscle Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins • Alpha-beta blockers. In addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow the heartbeat to reduce the amount of blood that must be pumped through the vessels. • Alpha-beta blockers include carvedilol (Coreg) and labetalol (Trandate). Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Medication Therapy for Hypertension (continued) • ANGIOTENSIN II RECEPTOR BLOCKERS • Angiotensin is a hormone in the body that causes blood vessels to narrow. • The angiotensin-converting enzyme (ACE) inhibitors decrease the production of angiotensin and, in turn, that helps lower blood pressure. (widen the blood vessles) • Angiotensin-converting enzyme (ACE) inhibitors • Angiotenisin II antagonists Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins • Calcium channel blockers – Nondihydropyridines – Dihydropyridines • Calcium channel blockers lower blood pressure by relaxing blood vessels and reducing heart rate • The heart does not have to work hard Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Goals: • Patient understanding of disease process • Patient understanding of treatment regimen • Patient participation in self-care • Absence of complications Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Gerontologic Considerations • Noncompliance • Include family • Understanding of therapeutic regimen – Reading instructions – Monotherapy Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement True or False? A hypertensive urgency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False A hypertensive emergency is a situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage. A hypertensive urgency is a situation in which blood pressure is severely elevated but there is no evidence of actual or probable target organ damage. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypertensive Crises • Hypertensive emergency – Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs – Blood pressure is very high but no evidence of immediate or progressive target organ damage Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypertension emergency • Changes in mental status, such as confusion • Bleeding into the brain (stroke) • Heart failure • Chest pain (unstable angina) • Fluid in the lungs (pulmonary edema) • Heart attack • Aneurysm (aortic dissection ) • Eclampsia (occurs during pregnancy) Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of HTN emergency • Headache or blurred vision • Increasing confusion or level of consciousness • Seizure • Increasing chest pain • Increasing shortness of breath • Swelling or edema (fluid buildup in the tissues) • Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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, fenodopam mesylate, enalaprilat, nitrogylcerin • Need very frequent monitoring of BP and cardiovascular status. Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins 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 inhibitor— captopril; or alpha2-agonist—clonidine Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
