Jumarang, Kim Enrico M.

CITY

BSN401

STI GLOBAL

HYPERTENSION
High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is considered high. The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure reflects the lowest pressure to which the arteries are exposed. An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as endorgan damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications. It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk.

HOW TO MEASURE?
The blood pressure usually is measured with a small, portable instrument called a blood pressure cuff (sphygmomanometer). (Sphygmo is Greek for pulse, and a manometer measures pressure.) The blood pressure cuff consists of an air pump, a pressure gauge, and a rubber cuff. The instrument measures the blood pressure in units called millimeters of mercury (mm Hg). The cuff is placed around the upper arm and inflated with an air pump to a pressure that blocks the flow of blood in the main artery (brachial artery) that travels through the arm. The arm is then extended at the side of the body at the level of the heart, and the pressure of the cuff on the arm and artery is gradually released. As the pressure in the cuff decreases, a health practitioner listens with a stethoscope over the

artery at the front of the elbow. The pressure at which the practitioner first hears a pulsation from the artery is the systolic pressure (the top number). As the cuff pressure decreases further, the pressure at which the pulsation finally stops is the diastolic pressure (the bottom number).

SYMPTOMS
High blood pressure usually causes no symptoms and high blood pressure often is labeled "the silent killer." People who have high blood pressure typically don't know it until their blood pressure is measured. Sometimes people with markedly elevated blood pressure may develop: headache, dizziness, blurred vision, nausea and vomiting, and chest pain and shortness of breath.

People often do not seek medical care until they have symptoms arising from the organ damage caused by chronic (ongoing, long-term) high blood pressure. The following types of organ damage are commonly seen in chronic high blood pressure: Heart attack Heart failure Stroke or transient ischemic attack (TIA) Kidney failure Eye damage with progressive vision loss Peripheral arterial disease causing leg pain with walking (claudication) Outpouchings of the aorta, called aneurysms

About 1% of people with high blood pressure do not seek medical care until the high blood pressure is very severe, a condition known as malignant hypertension. In malignant hypertension, the diastolic blood pressure (the lower number) often exceeds 140 mm Hg. Malignant hypertension may be associated with headache, lightheadedness, nausea, vomiting, and stroke like symptoms Malignant hypertension requires emergency intervention and lowering of blood pressure to prevent brain hemorrhage or stroke. It is of utmost importance to realize that high blood pressure can be unrecognized for years, causing no symptoms but causing progressive damage to the heart, other organs, and blood vessels.

CAUSES

Two forms of high blood pressure have been described: essential (or primary) hypertension and secondary hypertension. Essential hypertension is a far more common condition and accounts for 95% of hypertension. The cause of essential hypertension is multifactorial, that is, there are several factors whose combined effects produce hypertension. In secondary hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. (Secondary hypertension is discussed further in a separate section later.) Salt intake may be a particularly important factor in relation to essential hypertension in several situations, and excess salt may be involved in the hypertension that is associated with advancing age, African American background, obesity, hereditary (genetic) susceptibility, and kidney failure (renal insufficiency). The Institute of Medicine of the National Academies recommends healthy 19 to 50-year-old adults consume only 3.8 grams of salt to replace the average amount lost daily through perspiration and to achieve a diet that provides sufficient amounts of other essential nutrients. Genetic factors are thought to play a prominent role in the development of essential hypertension. However, the genes for hypertension have not yet been identified. (Genes are tiny portions of chromosomes that produce the proteins that determine the characteristics of individuals.) The current research in this area is focused on the genetic factors that affect the renin-angiotensin-aldosterone system. This system helps to regulate blood pressure by controlling salt balance and the tone (state of elasticity) of the arteries. The vast majority of patients with essential hypertension have in common a particular abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in the tiny arteries that are most distant from the heart (peripheral arteries or arterioles). The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the body. The arterioles are connected by capillaries in the tissues to the veins (the venous system), which returns the blood to the heart and lungs. Just what makes the peripheral arteries become stiff is not known. Yet, this increased peripheral arteriolar stiffness is present in those individuals whose essential hypertension is associated with genetic factors, obesity, lack of exercise, overuse of salt, and aging. Inflammation also may play a role in hypertension since a predictor of the development of hypertension is the presence of an elevated C reactive protein level (a blood test marker of inflammation) in some individuals.

TREATMENT AND MEDICATION

Blood pressure control is a lifelong challenge. Hypertension can progress through the years, and treatments that worked earlier in life may need to be adjusted over time. Blood pressure control may involve a stepwise approach beginning with diet, weight loss, and lifestyle changes and eventually adding medications as required. In some situations, medications may be recommended immediately. As with many diseases, the health care practitioner and patient work together as a team to find the treatment plan that will work for that specific individual.

It may take trial and error to find the proper medication or combination of medications that will help control hypertension in each case. It is important to take the medications as prescribed and only discontinue them on the advice of your health care practitioner. Water Pills (diuretics) Diuretics are used very widely to control mildly high blood pressure, and are often used in combination with other medications. They increase sodium excretion and urine output and decrease blood volume. The sensitivity to the effect of other hormones in your body is decreased. One example of a diuretic is hydrochlorothiazide (HydroDIURIL) The most commonly used diuretics to treat hypertension include: o o o o Beta-Blockers Beta-blockers reduce heart rate and decrease the force of heart contraction by blocking the action of adrenaline receptors. Beta blockers are widely prescribed and effective but can cause increased fatigue and decreased exercise tolerance because they prevent an increased heart rate as a normal response to physical activity. They are also prescribed for people who have associated heart disease, angina, or history of a heart attack. Examples of beta blockers include, carvedilol (Coreg), metoprolol (Lopressor), atenolol (Tenormin) Calcium Channel Blockers (CCBs) Calcium channel blocking agents work by relaxing the muscle in artery walls and by therefore reducing the force of contraction of heart muscle. Example of calcium channel blockers include, nifedipine (Procardia), diltiazem (Cardizem), verapamil (Isoptin, Calan), nicardipine (Cardene), amlodipine (Norvasc), and felodipine (Plendil) Angiotensin-Converting Enzyme (ACE) Inhibitors ACE inhibitors stop the production in the body of a chemical called angiotensin II, which causes blood vessels to contract. Narrower blood vessels are associated with increased blood pressure. Relaxing artery walls leads to lower blood pressure. Examples of ACE inhibitors include Captopril (Capoten), enalapril (Vasotec), lisinopril (Zestril, Prinivil), quinapril (Accupril), and fosinopril (Monopril) Angiotensin Receptor Blockers (ARBs) ARBs work block angiotensin II receptors and prevent vasoconstriction, or narrowing of blood vessels. hydrochlorothiazide (HydroDIURIL), the loop diuretics furosemide (Lasix) and torsemide (Demadex), the combination of triamterene and hydrochlorothiazide (Dyazide), and metolazone (Zaroxolyn).

Examples of ARBs include losartan (Cozaar), valsartan (Diovan), candesartan (Atacand), and irbesartan (Avapro)

Blockers of Central Sympathetic (autonomic nervous) System These agents block messages from the brain's autonomic nervous system that contract blood vessels. The autonomic nervous system is the part of the unconscious nervous system of the body that controls heart rate, breathing rate, and other basic functions. These medications relax blood vessels, thus lowering blood pressure. An example is clonidine (Catapres)

Direct Vasodilators Direct vasodilators relax (dilate) the blood vessels to allow blood to flow under lower pressure. These medications are most often used in times of hypertensive crisis and are injected intravenously to quickly lower blood pressure readings. Examples include nitroprusside (Nitropress), and diazoxide (Hyperstat).

NURSING MANAGEMENT
Observation: Vital signs should be checked 2 hourly with emphasis on Blood pressure and pulse rate. Monitor patient's weight daily and keep proper record. This is to help detect edema or weight loss. Check for side effects of drugs e.g. orthostatic hypotension. 2. Rest: Patient should be advised to avoid stress and tension. He should therefore have physical and mental rest in order to conserve energy. Encourage moderate exercise e.g. walking if there is no dyspnea. Mild tranquilizers may be given to enable patient sleep. Should there be dizziness patient should be protected from falls and injury. 3. Diet: Restrict sodium intake to about 4grams daily. Give light, easily digestible diet. Fatty food and excessive carbohydrate that can increase weight and cholesterol should be avoided. Coffee, tea, kola nuts, alcohol should be avoided or minimized. 4. Physical care: Assist patient with physical care if patient is very weak. Where there is blurred vision patient may require the use of medicated eye glasses. If there is bleeding from the nose (epistaxis) apply ice pack to the bridge of the nose and back of the neck. When the ice pack cannot control bleeding the nose may be packed. The pack should however be removed within few days. Make sure patient does not lie on one side of his body for several days in bed. If he is to be admitted for days, his position should be changed every 2-4 hours to prevent pressure sore from developing. 5. Elimination: Constipation should be avoided because it makes the patient strain at defecation thereby further elevating the blood pressure. Food rich in fibre should be given to prevent constipation.

Other interventions include: Monitor blood pressure Note the central and peripheral pulse quality Auscultation of heart and breath sounds Observe skin color, moisture, temperature and capillary filling time Observe the general edema Provide quiet environment, comfortable Suggest to reduce activity. Maintain restrictions on activities such as recess ditemapt bed / chair Help perform self-care activities as needed Perform actions such as a comfortable back and neck massage Encourage relaxation techniques Give fluid restriction and sodium diet as indicated.