NURS 3101P

Care of Adult Population

Hypertension



Student Names: Emmanuella Iyo & Juan Ical
Lectures: Ms V.Jenkin & Mrs. L. Haylock
Due Date: March 10, 2014




Hypertension
By E. Iyo & J. Ical
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Table of Content
Over View.......................................................................................................................................1
Definition........................................................................................................................................1
Etiology...........................................................................................................................................1
Risk Factors for Hypertension........................................................................................................2
Pathophysiology.............................................................................................................................3
Signs and symptoms.......................................................................................................................4
Diagnostic Tests..............................................................................................................................5
Blood Pressure Measurement guideline..........................................................................................6
Nursing Management......................................................................................................................6
Medical Management......................................................................................................................7
Surgical Intervention.......................................................................................................................8
Lifestyle Modification.....................................................................................................................8
Complications and Prognosis..........................................................................................................9
Prevention......................................................................................................................................10
References......................................................................................................................................11
Appendix








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Hypertension
Overview
Hypertension or high blood pressure is an all too common condition in Belize. In fact,
hypertension has been one of the leading causes of death for Belizeans for several years
according to Cardiologist Dr John Gough on Channel 5 news. There is a protocol put in place to
manage hypertension as it has become critical in Belize as morbidity and mortality related to this
disease has shown significant increase over the past decade. The number of Caribbean people
with high blood pressure and diabetes is drastically increasing as elsewhere in both developed
and developing countries, a United Nations report has said.

WHO's World Health Statistics 2012 report, which includes data from 194 countries, said that
one in three adults worldwide has raised blood pressure and one in 10 suffers from diabetes.
Black people are more prone to hypertension than other ethnics groups according this study.

Definition: Is a chronic medical condition in which the blood pressure in the arteries is elevated
which is indicated by a systolic blood pressure greater than 140 mm/Hg and a diastolic blood
pressure of greater than 90mm/Hg based on the average of two or more accurate blood pressure
measurement taken. It is an increase in the amount of force that blood places on blood vessels as
it moves through the body. Some types include
Pregnancy Hypertension/ Gestational Hypertension/Transient Hypertension
White coat hypertension is hypertension brought about by presence of medical personnel
including hospitals,
Pulmonary Hypertension that is hypertension through lungs, pulmonary vessels or alveoli
capillaries
Perioperative hypertension like the name suggest comes on during or around operative
procedures
Arterial Hypertension common or essential hypertension
Episodic hypertension sporadic hypertension, various etiologic
Pseudo hypertension hypertensive readings caused from the difficulty of compression
the peripheral arteries
Etiology
Hypertension can be classified as either essential or secondary
Primary (Essential) hypertension- Indicates that no specific medical cause can be found to
explain a patients condition. About 90-95% of hypertension is essential hypertension
Secondary hypertension- When the high blood pressure is a result of another underlying
condition and a direct cause can be identified; the condition is described as a secondary
hypertension. These normally correct themselves once the secondary condition is corrected. The
narrowing of the arteries that supply the kidneys, other diseases of kidneys, abnormalities in the
endocrine system (such as overactive adrenal glands), transient conditions such as pregnancy for
certain women, are examples. Certain medications that can increase the risk of high blood
pressure, such as oral contraceptives or estrogen replacement therapy following menopause are
also secondary. The doctor will explore any of these potential underlying causes for hypertension
prior to making the diagnosis.

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Among the known causes of secondary hypertension, kidney disease ranks highest. Hypertension
can also be triggered by tumors or other abnormalities that cause the adrenal glands (small
glands that sit atop the kidneys) to secrete excess amounts of the hormones that elevate blood
pressure. Birth control pills specifically those containing estrogen and pregnancy can boost
blood pressure, as can medications that constrict blood vessels. Certain medications, such as
birth control pills, cold remedies, decongestants, over-the-counter pain relievers and some
prescription drugs. Also illegal drugs, such as cocaine and amphetamines have been implicated.

Several factors and conditions may play a role in its development, including:
Smoking tobacco
Diseases like Diabetes, chronic kidney disease
Obesity or high cholesterol elevated LDL or/low HDL etc
Lack of physical activity
Too much salt in the diet
Not enough potassium
Too much alcohol consumption (more than 1 to 2 drinks per day)
Stress
Older age >55 in men and > 65 for women
Genetics also play a part
Family history of high blood pressure and or diabetes
Chronic kidney disease: If the kidneys blood vessels are damaged, they may stop
removing wastes and extra fluid from the body. Extra fluid in the blood vessels may then
raise blood pressure even more, creating a dangerous cycle.
Adrenal and thyroid disorders like microalbuminuria,
Narrowing of the blood vessels.
Hyperaldosteronism etc
Pathophysiology
Hypertension is the product of Cardiac output(CO) x Peripheral Resistance (PR). CO is the
product of the heart rate multiplied by the stroke volume.
Blood pressure is the measure of the force of blood pushing against blood vessel walls. The heart
pumps blood into the arteries (blood vessels), which carry the blood throughout the body. High
blood pressure, also called hypertension, is dangerous because it makes the heart work harder to
pump blood to the body and contributes to hardening of the arteries, or atherosclerosis, and to the
development of heart failure.

The pathophysiology of essential hypertension remains an area of active research, with many
theories and different links to many risk factors. Hypertension can result from an increase in
cardiac output, an increase in peripheral resistance (constriction of the blood vessels), or both.
Although no precise cause can be identified for most cases of hypertension, it is understood that
hypertension is a multifactorial condition. For hypertension to occur there must be a change in
one or more factors affecting peripheral resistance or cardiac output. In addition, there must also
be a problem with the bodys control systems that monitor or regulate pressure.

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Factors that can increase the amount of force on blood vessels as it moves throughout the body
include higher blood volume due to extra fluid in the blood and blood vessels that are narrow,
stiff, or clogged. Increased systemic vascular resistance, increased vascular stiffness, and
increased vascular responsiveness to stimuli are central to the pathophysiology of hypertension.

Hypertension is a chronic elevation of blood pressure that, in the long-term, causes end-organ
damage and results in increased morbidity and mortality. Blood pressure is the product of cardiac
output and systemic vascular resistance. It follows that patients with arterial hypertension may
have an increase in cardiac output, an increase in systemic vascular resistance, or both. In the
younger age group, the cardiac output is often elevated, while in older patients increased
systemic vascular resistance and increased stiffness of the vasculature play a dominant role.

Vascular tone may be elevated because of increased -adrenoceptor stimulation or increased
release of peptides such as angiotensin or endothelins. The final pathway is an increase in
cytosolic calcium in vascular smooth muscle causing vasoconstriction. Several growth factors,
including angiotensin and endothelins, cause an increase in vascular smooth muscle mass termed
vascular remodelling. Both an increase in systemic vascular resistance and an increase in
vascular stiffness increase the load imposed on the left ventricle; this induces left ventricular
hypertrophy and left ventricular diastolic dysfunction.

In youth, the pulse pressure generated by the left ventricle is relatively low and the waves
reflected by the peripheral vasculature occur mainly after the end of systole, thus increasing
pressure during the early part of diastole and improving coronary perfusion. With ageing,
stiffening of the aorta and elastic arteries increases the pulse pressure. Reflected waves move
from early diastole to late systole. This results in an increase in left ventricular afterload, and
contributes to left ventricular hypertrophy. The widening of the pulse pressure with ageing is a
strong predictor of coronary heart disease.

The autonomic nervous system plays an important role in the control of blood pressure. In
hypertensive patients, both increased release of, and enhanced peripheral sensitivity to,
norepinephrine can be found. In addition, there is increased responsiveness to stressful stimuli.
Another feature of arterial hypertension is a resetting of the baroreflexes and decreased
baroreceptor sensitivity. The reninangiotensin system is involved at least in some forms of
hypertension (e.g. renovascular hypertension) and is suppressed in the presence of primary
hyperaldosteronism. Elderly or black patients tend to have low-renin hypertension. Others have
high-renin hypertension and these are more likely to develop myocardial infarction and other
cardiovascular complications.

In human essential hypertension, and experimental hypertension, volume regulation and the
relationship between blood pressure and sodium excretion (pressure natriuresis) are abnormal.
Considerable evidence indicates that resetting of pressure natriuresis plays a key role in causing
hypertension. In patients with essential hypertension, resetting of pressure natriuresis is
characterized either by a parallel shift to higher blood pressures and salt-insensitive
hypertension, or by a decreased slope of pressure natriuresis and salt-sensitive hypertension.
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Signs and symptoms
One of the most dangerous aspects of hypertension is that the person may not know that he/she
has it. In fact, nearly one-third of people who have high blood pressure do not know it. The only
way to know if your blood pressure is high is through regular checkups. This is especially
important if you have a close relative who has high blood pressure.
If the blood pressure is extremely high, there may be certain symptoms to look out for, including;
1. Severe headache
2. Nausea
3. Fatigue or confusion
4. Vision problems, dizziness
5. Trouble concentrating
6. Sleep problems
7. Chest pain
8. Retinopathy and other renal complications
9. Difficulty breathing
10. Irregular heartbeat
11. Left ventricular hypertrophy
12. Blood in the urine
13. Pounding in the chest, neck, or ears
Diagnostic tests
In adults aged 50 years and older, the 2010 Institute for Clinical Systems Improvement (ICSI)
guideline on the diagnosis and treatment of hypertension indicates that systolic blood pressure
(SBP) should be the major factor to detect, evaluate, and treat hypertension.

Blood pressure test
Blood pressure measurements fall into four general categories:
Normal blood pressure: Your blood pressure is normal if its below 120/80 mm Hg. However,
some doctors recommend 115/75 mm Hg as a better goal. Once blood pressure rises above
115/75 mm Hg, the risk of cardiovascular disease begins to increase.
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Prehypertension: Prehypertension is a systolic pressure ranging from 120 to 139 mm Hg or a
diastolic pressure ranging from 80 to 89 mm Hg. Prehypertension tends to get worse over time.
Stage 1 hypertension: Stage 1 hypertension is a systolic pressure ranging from 140 to 159 mm
Hg or a diastolic pressure ranging from 90 to 99 mm Hg.

Stage 2 hypertension: More severe hypertension, stage 2 hypertension is a systolic pressure of
160 mm Hg or higher or a diastolic pressure of 100 mm Hg or higher.
Besides taking your blood pressure, your doctor will do a physical exam and medical history
The doctor may also have the patient get other tests to find out whether high blood pressure has
damaged any organs or caused other problems. These tests may include:
Urine tests to check for kidney or liver disease.
Blood tests to check levels of potassium, sodium, and cholesterol.
A blood glucose test to check for diabetes.
Tests to measure kidney function.
An electrocardiogram (EKG, ECG) to find out whether there is any damage to the heart.


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Blood Pressure Measurement using CNA guidelines
Make sure the cuff is the right size.
The Patient is rested 5 minutes before you start
Make sure the arm is level with the heart the patients legs are not crossed.
No talking during measurement or movement, the dial may flicker but do not start here
.
Measure what you hear not what you see
Place the stethoscope at the brachial artery do not touch the cuff during measurement.
Listen for the first faint sound and the point at which the sound completely disappears.
No caffeine, smoking or alcohol for preceding 30 minutes before the measurement
Do not re inflate the cuff if you miss a beat. Wait 5 minutes and try again.
For irregular pulse or older patients take multiple measurements
Take a baseline measurement before you start to gage how much to inflate the cuff.
For diagnosis, obtain 2-3 reading in two office visit for diagnosis.
Home readings are often more accurate than office readings
Talk to your patient after the reading and address any concerns.
Multiple measurement are required for those with irregular pulse or older patients.
Nursing Management of Hypertension
Take complete detailed history to determine symptoms indicative of secondary
hypertension, renal disease, risk factors, eating habits, activities of daily living.
Use proper monitoring of BP, some suggest that Mercury spygmanometers give more
accurate reading.
Manage associated clinical conditions like DM 2 or chronic kidney disease
Assist in medical planning and interventions like fondoscopy
Educate patient to modify behavior r/t diet, weight, stress, tobacco smoking
Assist in diagnostic tests as ordered
Educate the patient on the target Bp and importance of maintaining target
Obtain detailed medical history(Prescribed, OTC, illicit drug use)
Know classes of medication that may be prescribed and the interactions between them
(Diuretics, ACE inhibitors, ARBs, Blockers and Calcium Channel Blockers)

Some research has shown that smoking cessation may even increase blood pressure, but the risk
of cardiovascular disease from smoking is greater than that from the increased blood pressure
after smoking cessation.
Medical Management
Many guidelines exist for the management of hypertension. Two of the most widely used
recommendations are those from the American Diabetes Association (ADA) and the Seventh
Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure (JNC 7). The Eighth Report of the JNC (JNC 8) was released in December
2013


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According to the JNC 8 recommendations
In patients aged 60 years or older, initiate therapy in those with systolic BP levels at 150 mm Hg
or greater or whose diastolic BP levels are 90 mm Hg or greater; treat to below those thresholds.

In patients younger than 60 years as well as those older than 18 years with either chronic kidney
disease (CKD) or diabetes, the BP treatment initiation and goals should be 140/90 mm Hg.
In nonblack hypertensive patients, begin treatment with either a thiazide-type diuretic, CCB,
ACE inhibitor, or ARB.

In hypertensive black patients, initiate therapy with a thiazide-type diuretic or CCB
Regardless of race or diabetes status, in patients 18 years or older with CKD, initial or add-on
therapy should consist of an ACE inhibitor or ARB

Do not use an ACE inhibitor in conjunction with an ARB in the same patient

The main aim here is identification of the target goal, then initiate and choose the best way to
attain this goal. Lifestyle modification is preferred after the initial thiazide type diuretic, which
reduces the volume of fluid thus cardiac output and BP.
Adrenergic inhibitors block the neural mechanism
Vasodilators like CCB, ACE inhibitors dilate the vessels to relieve pressure
Angiotensin receptor blockage decrease PVR

If a patients goal BP is not achieved within 1 month of treatment, increase the dose of the initial
agent or add an agent from another of the recommended drug classes; if 2-drug therapy is
unsuccessful for reaching the target BP, add a third agent from the recommended drug classes
In patients whose goal BP cannot be reached with 3 agents from the recommended drug classes,
use agents from other drug classes and/or refer the patients to a hypertension specialist.

Renin inhibitors act within the renin-angiotensin system (RAS), a hormone system important in
the regulation of blood pressure, electrolyte homeostasis, and vascular growth. Renin inhibitors
have an additive effect when used with diuretics. Avoid the use of these agents in pregnancy.
Mgmt of Hypertension and Diabetes
Hypertension is not only disproportionately high in diabetic individuals, but it also increases the
risk of diabetes 2.5 times within 5 years in hypertensive patients.

In addition, hypertension and
diabetes are both risk factors for cardiovascular disease, stroke, progression of renal disease, and
diabetic retinopathy.

The goal here is initiating treatment at systolic blood pressure (BP) levels of 140 mm Hg or
greater or at diastolic BP levels of 90 mm Hg or greater, and then treat to a goal BP below
140/90 mm Hg. Manage diabetes and Bp to balance out the ill effect of both on the patient. This
can be achieved through manipulation of medications for both condition in different levels.
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Surgical intervention
For renovascular hypertension (high blood pressure due to narrowing of the arteries that carry
blood to the kidneys renal artery angioplasty with stenting is performed.

Surgical resection is the treatment of choice for pheochromocytoma (Pheochromocytoma is a
rare tumor of adrenal gland tissue. It results in the release of too much epinephrine and
norepinephrine, hormones that control heart rate, metabolism, and blood pressure )

For patients with a unilateral solitary aldosterone-producing adenoma (adeno-, "gland" + -oma,
"tumor is a benign tumor of epithelial tissue ), because hypertension in this case is cured by
tumor resection.

In patients with fibromuscular renal disease, angioplasty has a 60-80% success rate for
improvement or cure of hypertension.
A promising therapy for resistant hypertension is renal denervation via a percutaneous approach.
This catheter-based intervention is currently in the clinical trial phase.
Lifestyle modification
Maintain adequate intake of dietary potassium (approximately 90 mmol/d)
Maintain adequate intake of dietary calcium and magnesium for general health
Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular
health

Intervention

Targeted Change

SBP/DBP
Sodium reduction

100 mmol or 1 tsp/day

5.8/-2.5
Dietary Patterns

D ASH diet

11.4/-5.5
Exercise*

3 times/week

-7.4/-5.8
Weight loss

4.5 kg

7.2/-5.9
Alcohol reduction

2.7 drinks/day

4.6/-2.3

Source: Miller ER et al. Results of aggregate and meta analysis of short term trials. J Clin Hyper
1999;3:191-8. * Exercise and Hypertension, Medicine and Science in Sports & Exercise
2004;36(3)

DASH Eating Plan Number of Servings for Calorie Levels
Food Group Servings/Day `1600 Calories/Day ``3100 Calories/Day
Grains and grain products 6 12-13
Vegetables 3-4 6
Fruits 4 6
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Lowfat or fat free dairy foods 2-3 3-4
Meat, poultry and fish 1-2 2-3
Nuts, seeds and dry beans 3/week 1
Fats and oils 2 4
Sweets 0 2
Complications associated with Hypertension/ Prognosis
Most individuals diagnosed with hypertension will have increasing blood pressure (BP) as they
age. Untreated hypertension is notorious for increasing the risk of mortality and is often
described as a silent killer. Mild to moderate hypertension, if left untreated, may be associated
with a risk of atherosclerotic disease in 30% of people and organ damage in 50% of people
within 8-10 years after onset.

Death from ischemic heart disease or stroke increases progressively as BP increases. For every
20 mm Hg systolic or 10 mm Hg diastolic increase in BP above 115/75 mm Hg, the mortality
rate for both ischemic heart disease and stroke doubles.

Hypertensive retinopathy was associated with an increased long-term risk of stroke, even in
patients with well-controlled BP, in a report of 2907 adults with hypertension participating in the
Atherosclerosis Risk in Communities (ARIC) study. Increasing severity of hypertensive
retinopathy was associated with an increased risk of stroke; the stroke risk was 1.35 in the mild
retinopathy group and 2.37 in the moderate/severe group.

The morbidity and mortality of hypertensive emergencies depend on the extent of end-organ
dysfunction on presentation and the degree to which BP is controlled subsequently. With BP
control and medication compliance, the 10-year survival rate of patients with hypertensive crises
approaches 70%.

Nephrosclerosis is one of the possible complications of long-standing hypertension. The risk of
hypertension-induced end-stage renal disease is higher in black patients, even when blood
pressure is under good control. Furthermore, patients with diabetic nephropathy who are
hypertensive are also at high risk for developing end-stage renal disease.
Prevention Interventions
Weight Control to reduce risk factors
Increased physical activity for better cardiovascular health
Moderate sodium and alcohol intake to protect the liver
Increased potassium intake that aids in muscle regeneration and better function
A balance diet rich in fruits and vegetables, low fat meats, fish and dairy products.
Monitor Bp frequently at home.
Know your family Medical History
Do yearly medical checkups


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References

Bolton Cindy (Date) Nursing Management of Hypertension Retrieved 04 March 2014.
http://apps.strokenetworkseo.ca/public/pdf_docs/Hypertension%20BPG.pdf

Madhur, M. S. (2014) Ed. Maron, D. J. Hypertension. Medscape Medical Reference.
Retrieved March 4, 2014 http://emedicine.medscape.com/article/241381-overview#showall

Bengtson, Ann. (2003) The Nurse's Role and Skills in Hypertension Care Retrieved March 4,
2014 http://www.medscape.com/viewarticle/463185_2

Foex. P, Sear JW (2014) hypertension and pathophysiology. retrieved March 31, 2014 from
http://ceaccp.oxfordjournals.org/content/4/3/71.full

Hockenberry, M. J.,Wilson, D.,(2011) Wongs Nursing Care Of Infants And
Children (9
th
edition) St Louis, MO: Mosby.

Smltzer, S. C., Hinkle, J. L., Bare, B. G., & Cheever, K. H.,(2010) Brunner & Suddarths
textbook of Medical Surgical Nursing (12
th
ed) Philadelphia, USA: Wolters Kluwer

WebMD (2013) hypertension/high blood pressure. Retrieved March 28, 2014
http://www.webmd.com/hypertension-high-blood-pressure/tc/high-blood-pressure-

NLUDIC (2014) High Blood Pressure and Kidney Disease. Retrieved April 1
st
, 2014 from
http://kidney.niddk.nih.gov/kudiseases/pubs/highblood/