Lewis: Medical-Surgical Nursing, 9th Edition

Chapter 33 Nursing Management: Hypertension KEY POINTS Normal Regulation of Blood Pressure Blood pressure (BP) is the force exerted by the blood against the walls of the blood vessel. It must be adequate to maintain tissue perfusion during activity and rest. Regulation of BP involves nervous, cardiovascular, endothelial, renal, and endocrine functions. HYPERTENSION Classification of Hypertension Hypertension, or high BP, is defined as a persistent systolic BP (SBP) 140 mm Hg, diastolic BP (DBP) 90 mm Hg, or current use of antihypertensive medication. Hypertension is classified as follows: o Prehypertension is BP 120 to 139 per 80 to 89 mm Hg. o Hypertension, Stage 1 is BP 140 to 159 per 90 to 99 mm Hg. o Hypertension, Stage 2 is systolic BP 160 or diastolic BP 100 mm Hg. o Isolated systolic hypertension (ISH) is average SBP 140 mm Hg coupled with an average DBP less than 90 mm Hg. ISH is more common in older adults. Control of ISH decreases the incidence of stroke, heart failure, cardiovascular mortality, and total mortality. Etiology Primary (essential or idiopathic) hypertension is elevated BP without an identified cause. It accounts for 90% to 95% of all cases of hypertension. Secondary hypertension is elevated BP with a specific cause. It accounts for 5% to 10% of hypertension in adults. Pathophysiology of Primary Hypertension The hemodynamic hallmark of hypertension is persistently increased SVR. This persistent elevation in SVR may occur in various ways. Abnormalities of any of the mechanisms involved in the maintenance of normal BP, including sodium intake, the renin-angiotensin-aldosterone mechanism, and sympathetic nervous system (SNS) stimulation, can result in the development of hypertension.

Abnormalities of glucose, insulin, and lipoprotein metabolism are common in primary hypertension. Contributing factors to the development of hypertension include cardiovascular risk factors combined with socioeconomic conditions and gender and ethnic differences.

Clinical Manifestations Often called the silent killer because it is frequently asymptomatic until it becomes severe and target organ disease occurs. Target organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vessels (peripheral vascular disease), kidney (nephrosclerosis), and eyes (retinopathy). o It is one of the leading causes of end-stage renal disease, especially in African Americans. o Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision. There is a direct relationship between hypertension and cardiovascular disease (CVD). Hypertension is a major risk factor for coronary artery disease (CAD), stroke, and cerebral atherosclerosis. Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failure. Diagnostic Studies Basic laboratory studies are performed to (1) identify or rule out causes of secondary hypertension, (2) evaluate target organ disease, (3) determine overall cardiovascular risk, or (4) establish baseline levels before initiating therapy. Routine urinalysis, BUN, serum creatinine, and creatinine clearance levels are used to screen for renal involvement and to provide baseline information about kidney function. Lipid profile provides information about additional risk factors that predispose to atherosclerosis and cardiovascular disease. ECG and echocardiography provide information about the cardiac status. Ambulatory BP monitoring (ABPM) may be used to measure BP at preset intervals over a 24-hour period. Collaborative Care The goal for treating primary hypertension is BP less than 140/90 mm Hg. A goal of less than 130/80 mm Hg is recommended for patients who are at high risk for CAD as well as for patients with preexisting CAD. Lifestyle modifications are indicated for all patients with prehypertension and hypertension. These include (1) reducing weight (if appropriate), (2) using the DASH eating plan, (3) restricting dietary sodium and alcohol intake, (4) avoiding tobacco products, (5) participating in physical activity, and (6) reducing psychosocial risk factors

that contribute to the risk of developing CVD. Drug Therapy Drugs currently available for treating hypertension work by (1) decreasing the volume of circulating blood and/or (2) reducing SVR. o Diuretics promote sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines. o Adrenergic-inhibiting agents act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels. o Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR. o Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. o Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)mediated vasoconstriction and sodium and water retention. o A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels. Most patients who are hypertensive will require two or more antihypertensive medications to achieve their BP goals. Side effects and adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy. Patient and caregiver teaching related to drug therapy is needed to identify and minimize side effects and to cope with therapeutic effects. Resistant hypertension is the failure to reach goal BP in patients who are adhering to full doses of an appropriate three-drug therapy regimen that includes a diuretic. NURSING MANAGEMENT: PRIMARY HYPERTENSION The primary nursing responsibilities for long-term management of hypertension are to assist the patient in reducing BP and complying with the treatment plan. Nursing actions include evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing compliance, and patient and caregiver teaching. Patient and caregiver teaching includes the following: (1) nutritional therapy, (2) drug therapy, (3) lifestyle modification, and (4) home monitoring of BP (if appropriate). Blood Pressure Measurement Accurate BP measurements are important. An important role of the nurse is to provide patient and caregiver teaching regarding measuring BP at home. Orthostatic hypotension is defined as a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase of 20 beats per min or more in pulse

from supine to standing. Orthostatic (or postural) changes in BP and pulse should be measured in older adults, in people taking antihypertensive drugs, and in patients who report symptoms consistent with reduced BP upon standing (e.g., light-headedness, dizziness, syncope).

GERONTOLOGIC CONSIDERATIONS: HYPERTENSION The prevalence of hypertension increases with age. The lifetime risk of developing hypertension is approximately 90% for middle age (age 55 to 65) and older (age older than 65) normotensive men and women. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats (auscultatory gap). Failure to inflate the cuff high enough may result in underestimating the SBP. A goal BP less than 140 per 90 mmHg for people 65 to 79 years of age and an SBP goal of 140 to 145 mmHg for those 80-years-old and older are recommended. Orthostatic hypotension often occurs in older adults because of impaired baroreceptor reflex mechanisms, volume depletion, and chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance. HYPERTENSIVE CRISIS Hypertensive crisis is a term used to indicate either a hypertensive urgency or emergency. This is determined by the degree of target organ disease and how quickly the BP must be lowered. Hypertensive urgency develops over days to weeks. The BP is severely elevated but there is no clinical evidence of target organ disease. o Hypertensive urgencies usually do not require IV medications but can be managed with oral agents. o If a patient with hypertensive urgency is not hospitalized, outpatient follow-up should be arranged within 24 hours. Hypertensive emergencies require hospitalization with intensive care monitoring and the IV administration of antihypertensive drugs, including vasodilators, adrenergic inhibitors, the ACE inhibitor enalaprilat, and the calcium channel blocker clevidipine (Cleviprex). Drugs are titrated based on MAP. Regular, ongoing assessment (e.g., ECG monitoring, vital signs, urinary output, level of consciousness, visual changes) is essential to evaluate the patient with severe hypertension.