Chapter 27- assessment & Management of patients with hypertension
Table 27-1 Comparing BP Classification by key guidelines for adults age 18 and older
SBP
DBP
ACC/AHA
JNC
<120
And
<80
Normal
Normal
120-129
And
<80
Elevated
Prehypertensive
130-139
Or
80-89
Stage1 HTN
Prehypertension
140-159
Or
90-99
Stage 2 HTN
Stage 1 HTN
>160
Or
 100
Stage2 HTN
Stage 2 HTN
Chart 27-1 Risk Factors page 866
List the risk factors to develop hypertension
 Advancing adult age
 African American
 Chronic kidney disease
 Diabetes
 Too much alcohol
 Family history
 Gender related
o Men 64 age
o Women 65 age
 Hypercholesterolemia
 Overweight/obesity
 Poor diet
 Sedentary lifestyle
 Stress
 Tobacco and nicotine
 Sleep apnea
Define primary hypertension
 Diagnosed when there is no identifiable cause (essential hypertension)
 90% to 95% adults with hypertension have primary hypertension
Define secondary hypertension
 High bp from an identifiable underlying cause
 5% to 10% of adults
Chart 27-2 – common causes of secondary hypertension
 Chronic kidney disease
 coarctation of aorta
 Cushing syndrome
 Hyperaldosteronism
 Hyperparathyroidism
 Hypo or hyperthyroidism
 Medication abuse
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Chapter 27- assessment & Management of patients with hypertension

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



Obstructive sleep apnea
Pheochromocytoma
Preeclampsia
polycystic kidney disease
Prostatism
Renal artery stenosis
Clinical manifestations
 Physical exam may reveal no abnormalities other than elevated bp
 May be asymptomatic for many years
 Silent killer because no warning signs or symptoms
 Vascular damage when symptoms show
o Target organ damage
o Retinal changes- hemorrhages, exudates, arteriolar narrowing, cotton wool spots
o Papilledema (swelling of optic disc) in severe hypertension
o Coronary artery disease with angina and myocardial infarction
What should be included in assessment?
 Accurate blood pressure measurement
 Average of at least two bp readings on at least two occasions
What lab tests should be performed ?
 Urinalysis, blood chemistry, 12 lead electrocardiogram
 BUN, creatinine clearance, renin level, urine tests, 24-hour urine protein
Medical Management
What is the goal of HTN treatment ?
 Prevent complication and death by maintaining a blood pressure lower than 130/80 mm
Hg
Page 870
How is the diagnosed confirmed?
 Average of at least two bp readings on at least two occasions
Table 27-2 lifestyle modifications to prevent and manage HTN
Modification
Recommendation
Impact on SBP
reduction
Patient without HTN
Weight
reduction
Maintain normal body weight.
Ideal body weight is best goal
but aim for at least 1 kg weight
loss.
Expect – 1 mm Hg SBP decrease
-2-3 mm Hg
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Impact on SBP
reduction
Patients with
hypertension
-5 mm Hg
Chapter 27- assessment & Management of patients with hypertension
Adopt DASH
eating plan
(table 27-3 food
groups involved)
Dietary sodium
reduction
Dietary
potassium
increase
Physical activity
Moderation of
alcohol
consumption
per 1 kg reduction in weight.
Consume a diet rich in fruits,
vegetables, and low-fat dairy
products with a reduced
content of saturated and total
fat.
Sodium <2 g/day is optimal
goal: but aim for at least 1000
mg/day reduction. Check
sodium amount on food labels.
Preferred potassium intake is
3500-5000 mg/day. Choose
high potassium foods; check
amount on food labels
Regular aerobic physical activity
such as brisk walking 90-150
min weekly
Regular dynamic resistance
training 90-150 min weekly
Regular isometric resistance
training at least three times
weekly
Limit consumption to <2 drinks
per day in most men and to <1
per day in women
-3 mm Hg
-11 mm Hg
-2-3 mm Hg
-5-6 mm Hg
-2 mm Hg
-4-5 mm Hg
-2-4 mm Hg
-5-8 mm Hg
-2 mm Hg
-4 mm Hg
-4 mm Hg
-5 mm Hg
-3 mm Hg
-4 mm Hg
Pharmacologic Therapy
Page 871
Research findings demonstrated :
 Appropriately prescribing antihypertensive pharmacologic agents lowers bp, reduces risk
of CVD, cerebrovascular disease, and death
What are considered first line medications ?
 Prevent CVD
 Thiazide or thiazide type diuretics, angiotensin converting enzyme (ACE) inhibitors,
angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs)
How does therapy differ for African Americans?
 Should be prescribed either a thiazide diuretic or a CCB as first line agent
Dosing starts at the lowest then if BP does not fall below 130/80 mm Hg
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Chapter 27- assessment & Management of patients with hypertension
What happens?
 The dose is increased gradually, and additional medications are included as necessary to
achieve control
Define resistant hypertension
 Patient takes at least three antihypertensive medications from different classes
(including diuretic) and blood pressure is still not controlled
Table 27-4 page 872
Oral medications for hypertension
Medications
First line
antihypertensive
agents
Thiazide or thiazide
type diuretics
Major actions



Decrease of blood
volume, renal
blood flow,
cardiac output
Depletion of
extracellular fluid.
Negative sodium
balance, mild
hypokalemia.
Directly affect
vascular smooth
muscle
Advantages &
contraindications







Relatively
inexpensive
Effective orally
Effective during
long term
administration
Mild side effects
Enhance other
hypertensive
medications
Counter sodium
retention effects
of other
antihypertensive
medications
Contraindications:
gout, known
sensitivity to
sulfonamide
derived
medications,
severely impaired
kidney function,
history of
hyponatremia
ACE inhibitors
Angiotensin receptor
Blockers (ARBs)
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Effects & nursing
considerations


Side effects: dry
mouth, thirst,
weakness,
drowsiness,
lethargy, muscle
aches, muscle
fatigue,
tachycardia, GI
disturbance
Orthostatic
hypotension
Chapter 27- assessment & Management of patients with hypertension
Calcium channel
blockersdihydropyridines
Calcium channel
blockers –
nondihydropyridines
SECOND- LINE
ANTIHYPERTENSIVE
AGENTS
DIURETICS- LOOP
Diuretics- potassium
sparing
Diuretics Aldosterone
Antagonists
Beta-Blockers—
Cardioselective
Beta-Blockers—
Cardioselective and
Vasodilatory
Beta-Blockers—
Noncardioselective
Beta-Blockers—
Intrinsic
Sympathomimetic
Activity
Beta-Blockers—
Combined Alphaand Beta-Receptor
Blockers
Direct Renin Inhibitor
Alpha-1 Blockers
Central Alpha2Agonists and Other
Centrally Acting
Drugs
Direct Vasodilators
Table 27-5
Oral hypertensive medication for patients with select comorbid disease
Comorbid disease
First line hypertensive
Second line hypertensive
Stable CAD ( no HF)
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Chapter 27- assessment & Management of patients with hypertension
HF with reduced EF
HR with preserved EF
CKD
Diabetes
History of atrial fibrillation
COVID 19
PAGE 875
Which classification of medication could possibly protect the patient from COVID?
 ACE2 receptors
Interesting research …..
Gero considerations
This population should be carefully monitored for :
 Adverse effects of prescribed antihypertensive medications
o Falls, orthostatic hypertension, reduced renal function
Nursing Process page 876
Assessment :
 Bp assessment using equipment, instructions, interpretive guidelines, review patient’s
ambulatory or home blood pressure measurement/technique
 Complete history obtained to assess for sign/symptoms or organ damage
Potential problems/concerns
 Left ventricular hypertrophy
 Myocardial infarction
 Heart failure
 Cerebrovascular disease
 Chronic kidney disease/end stage renal disease
 Retinal hemorrhage
Nursing interventions
How can the nurse increase knowledge?
 Emphasize concept of controlling hypertension rather than curing it
 Encourage patient to consult a dietician to help develop a plan for improving nutrient
intake or for weight loss
 2-3 months for taste buds to adapt to changes in salt intake
 Limit alcohol intake, tobacco and nicotine should be avoided
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Chapter 27- assessment & Management of patients with hypertension
How can the nurse promote effective health management ?
 Nurse led wellness programs tailored to patients’ behaviors and eating and exercise
practices more effective than generic programs
 Continued education and encouragement needed to enable patients to formulate an
acceptable plan that helps them live with hypertension and adherence to plan
Why is adherence to the therapeutic program more difficult for the older adult?
 Medication regimen may be difficult to remember
 Expense can be a challenge
 simplification of medication regimen to treatment with single antihypertensive
medication if POSSIBLE
VERY IMPORTANT Quality and Safety Nursing Alert
The patient and caregivers should be cautioned that antihypertensive medications might cause
hypotension. Low blood pressure or orthostatic hypotension should be reported immediately.
Older adults have impaired cardiovascular reflexes and thus are more sensitive to the
extracellular volume depletion caused by diuretics and to the sympathetic inhibition caused by
adrenergic antagonists. The nurse educates patients to change positions slowly when moving
from a lying or sitting position to a standing position. The nurse also counsels older adult
patients to use supportive devices such as handrails and walkers as necessary to prevent falls
that could result from dizziness.
Monitoring & managing potential complications
 eye examination with an ophthalmoscope
 blurred vision, spots in front of eyes, diminished visual acuity
 heart, nervous system, kidneys
Page 879
Hypertensive crises
 two classes require immediate intervention: hypertensive emergency and hypertensive
urgency
o SBP exceeds 180 and DBP exceeds 120
o May occur in patients with secondary hypertension, poorly controlled
hypertension, undiagnosed
Hypertensive emergency
 Severe bp elevation (SBP greater than 180, DBP greater than 120) with new or
worsening target organ damage
 Target organ damage
o Hypertensive encephalopathy, ischemic stroke, MI, heart failure with pulmonary
edema
 Rapid and focused assessment necessary to determine possible causes and target organ
involvement
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Chapter 27- assessment & Management of patients with hypertension

Antihypertensive medication of choice
o Intravenous drugs: nicardipine, clevidipine, labetalol, esmolol, nitroglycerin,
nitroprusside
Hypertensive urgency
 Severe bp elevation (SBP greater than 180 or DBP greater than 120) in stable patients
without target organ damage as evidenced based on clinical examination and results of
lab studies
 Patients are nonadherent with antihypertensive therapy
 Extremely close monitoring of patient’s blood pressure and cardiovascular status is
required during treatment
 Taking vitals every 5 mins appropriate if bp is changing rapidly
o Vitals 15-30 mins if in more stable situation
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