Transcript Slide 1

(Relates to Chapter 33,
“Nursing Management: Hypertension,”
in the textbook)
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 Persistent
elevation of
• Systolic blood pressure ≥140 mm Hg or
• Diastolic blood pressure ≥90 mm Hg or
• Current use of antihypertensive
medication(s)
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 Systolic
blood pressure: 120-139 mm
Hg
OR
 Diastolic blood pressure: 80-89 mm Hg
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Systemic
Blood
Cardiac
=
x Vascular
Pressure
Output
Resistance
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Fig. 33-1
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Cardiac
•Heart rate
•Inotropic state
•Neural
•Humoral
Cardiac Output
Renal Fluid Volume Control
•Renin–angiotensin
•Aldosterone
•Atrial natriuretic factor
Fig. 33-2
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Sympathetic Nervous
System
• -Adrenergic receptors
(vasoconstriction)
• -Adrenergic receptors
(vasodilation)
Humoral
•Vasoconstrictors
Systemic
Vascular
Resistance
Local
Regulation
• Vasodilators
Prostaglandins
EDRF
• Vasoconstrictors
Endothelin
Angiotensin
Catecholamines
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Category
Normal
SBP
DBP
(mm Hg)
(mm Hg)
<120
and <80
Prehypertension
120–139 or
80–89
Stage 1 hypertension
140–159 or
90–99
Stage 2 hypertension
>160
>100
or
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 Subtypes
• Isolated systolic hypertension
 SBP >140 mm Hg with DBP <90 mm Hg
• Pseudohypertension
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 Primary
(essential or idiopathic)
hypertension
• Elevated BP without an identified cause
• 90% to 95% of all cases
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 Primary
(essential or idiopathic)
hypertension
• Contributing factors
 ↑ SNS activity
 ↑ Sodium-retaining hormones and
vasoconstrictors
 Diabetes mellitus
 >Ideal body weight
 ↑ Sodium intake
 Excessive alcohol intake
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 Secondary
hypertension
• Elevated BP with a specific cause
• 5% to 10% of adult cases
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 Secondary
hypertension
• Contributing factors
 Coarctation of aorta
 Renal disease
 Endocrine disorders
 Neurologic disorders
 Cirrhosis
 Sleep apnea
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 For
persons over 50 years of age, SBP
is more important than DBP as a CVD
risk factor
 Persons who are normotensive at 55
years of age have a 90% lifetime risk
for developing HTN
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 Age
 Alcohol
 Cigarette
smoking
 Diabetes mellitus
 Elevated serum lipids
 Excess dietary sodium
 Gender
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 Family
history
 Obesity
 Ethnicity
 Sedentary lifestyle
 Socioeconomic status
 Stress
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 Heredity
 In
most cases, hypertension results
from the interaction of
• Environmental factors
• Demographic factors
• Genetic factors
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 Water
and sodium retention
• High sodium intake may activate a
number of pressor mechanisms resulting
in water retention
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 Water
and sodium retention
• Certain demographics are associated with
“salt sensitivity”
 Obesity
 Increasing age
 African American ethnicity
 People with diabetes, renal disease
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 Stress
and increased SNS activity
• Produces increased vasoconstriction
• ↑ HR
• ↑ Renin release
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 Insulin
resistance and
hyperinsulinemia
• High insulin concentration stimulates SNS
activity and impairs nitric oxide–mediated
vasodilation
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 Altered
renin–angiotensin mechanism:
high plasma renin activity
 Endothelial cell dysfunction
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 Referred
to as the “silent killer”
because patients are frequently
asymptomatic until target organ
disease occurs
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 Symptoms are
often secondary to
target organ disease and can include
• Fatigue, reduced activity tolerance
• Dizziness
• Palpitations, angina
• Dyspnea
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 Target
organ diseases occur most
frequently in the
• Heart
• Brain
• Peripheral vasculature
• Kidney
• Eyes
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 Hypertensive
heart disease
• Coronary artery
disease
• Left ventricular
hypertrophy
• Heart failure
Fig. 33-3
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 Cerebrovascular
disease
• Stroke
 Peripheral
vascular disease
 Nephrosclerosis
 Retinal damage
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 History
and physical examination
 BP measurement in both arms
• Use arm with higher reading for
subsequent measurements
• BP highest in early morning, lowest at
night
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 Use
auscultatory method with a
properly calibrated instrument
 Patient should be seated quietly for 5
min in a chair, feet on the floor, and
arm supported at heart level
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 Appropriate-sized
cuff is necessary to
ensure accurate reading
 At least two measurements should be
obtained
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 Urinalysis,
creatinine clearance
 Serum electrolytes, glucose
 BUN and serum creatinine
 Serum lipid profile
 ECG
 Echocardiogram
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 “White coat”
phenomenon may
precipitate the need for ambulatory
blood pressure monitoring (ABPM)
• Uses a noninvasive, fully automated
system that measures BP at preset
intervals over a 24-hour period
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Fig. 33-4 Fig.
33-4
 Overall
goals
• Control blood pressure
• Reduce CVD risk factors
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 Strategies
for adherence to regimens
• Empathy increases patient trust,
motivation, and adherence to therapy
• Consider patient’s cultural beliefs and
individual attitudes in formulating
treatment goals
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Average Percent Reduction
Stroke incidence
35%-40%
Myocardial infarction
20%-25%
Heart failure
50%
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 Lifestyle
modifications
• Weight reduction: Weight loss of 10 kg (22
lb) may decrease SBP by approx. 5 to 20
mm Hg
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 Lifestyle
modifications
• Dietary sodium reduction
 <2.4 g of sodium/day
• Moderation of alcohol consumption:
 Men: no more than 2 drinks/day
 Women: no more than 1 drink/day
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 Lifestyle
modifications
• Physical activity: Regular physical
(aerobic) activity, at least 30 min, most
days of the week
• Avoidance of tobacco products
• Stress management
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 Drug
therapy: Primary actions of drugs
to treat hypertension
• Reduce SVR
• Reduce volume of circulating blood
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 Drug
therapy: Classifications of drugs
used to treat hypertension
• Diuretics
• Adrenergic inhibitors
• Direct vasodilators
• Angiotensin inhibitors
• Calcium channel blockers
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Fig. 33-5
 Drug
therapy and patient teaching
• Identify, report, and minimize side effects
 Orthostatic hypotension
 Sexual dysfunction
 Dry mouth
 Frequent urination
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 Nursing Assessment
• Subjective data
 Past health history
 Medications
 Functional health patterns
• Objective data
 Target organ damage
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 Nursing
Diagnoses
• Ineffective health maintenance
• Anxiety
• Sexual dysfunction
• Ineffective therapeutic regimen
management
• Disturbed body image
• Ineffective tissue perfusion
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 Collaborative
problems
• Potential complication: Adverse effects
from antihypertensive therapy
• Potential complication: Hypertensive
crisis
• Potential complication: Stroke
• Potential complication: Myocardial
infarction
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 Planning:
Patient will
• Achieve and maintain the individually
determined goal BP
• Understand, accept, and implement the
therapeutic plan
• Experience minimal or no unpleasant side
effects of therapy
• Be confident of ability to manage and
cope with this condition
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 Nursing
Implementation
• Health Promotion
 Individual patient evaluation
 Blood pressure measurement
 Screening programs
 Cardiovascular risk factor modification
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 Nursing
Implementation
• Ambulatory and home care
 Patient and family teaching includes





Nutritional therapy
Drug therapy
Physical activity
Home monitoring of BP (if appropriate)
Tobacco cessation (if applicable)
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 Nursing
Evaluation
• Patient will
 Achieve and maintain goal BP as defined for
the individual
 Understand, accept, and implement the
therapeutic plan
 Experience minimal or no unpleasant side
effects of therapy
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 Isolated systolic hypertension
(ISH) is
the most common form of
hypertension in individuals >50 years
of age
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 The
lifetime risk of developing
hypertension is approximately 90%
for middle-aged (55 to 65 years of age)
and older (>65 years of age)
normotensive men and women
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 Older
adults are more likely to have
“white coat” hypertension
 Often a wide gap between the first
Korotkoff sound and subsequent beats
called the auscultatory gap
 Failure to inflate the cuff high enough
may result in seriously
underestimating the SBP
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 Older
adults have varying degrees of
impaired baroreceptor reflex
mechanisms
 Consequently, orthostatic
hypotension occurs often, especially in
patients with ISH
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 In
general, treatment similar for all
demographic and ethnic groups
 Prevalence and severity of HTN
increased in African Americans
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 Mexican Americans
are less likely to
receive treatment for hypertension
than whites and African Americans
 Mexican Americans and Native
Americans have lower rates of BP
pressure control than whites and
African Americans
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 Severe,
abrupt increase in DBP
(defined as >140 mm Hg)
 Rate of increase in BP is more
important than the absolute value
 Often occurs in patients with a history
of HTN who have failed to comply with
medications or who have been
undermedicated
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 Hypertensive
emergency = evidence of
acute target organ damage:
• Hypertensive encephalopathy, cerebral
hemorrhage
• Acute renal failure
• Myocardial infarction
• Heart failure with pulmonary edema
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 Hospitalization
• IV drug therapy: Titrated to mean arterial
pressure
• Monitor cardiac and renal function
• Neurologic checks
• Determine cause
• Education to avoid future crises
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 Web
site www.nhlbi.nih.gov
 For patients and the general public
• Facts about the DASH Eating Plan
• Your Guide to Lowering Blood Pressure
• My Blood Pressure Wallet Card
 For
health professionals
• Reference Card
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 40-year-old
male attends a community
health screening
 He
is alert, coordinated, and
cooperative
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 Clinical
finding are
• Height 5 feet, 6 inches and weight 230 lbs
• Blood pressure 182/104 mm Hg
• Pulse 90 beats/min
• Respirations 24 breath/min
• Temperature 97.0° F
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 He
states
• He is a truck driver and eats a lot of fast
foods
• It is hard to “eat healthy” on the road
• This is his first checkup in many years
• He smokes one pack of cigarettes per day,
and this helps him stay calm
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1.
What risk factors for hypertension
does he have?
2.
As part of the health screening, what
should you do next?
3.
In what areas should you provide
teaching?
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