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m Intermittent or sustained elevation of diastolic or systolic blood pressure
m Usually begins as benign disease, slowly progressing to accelerated or malignant state
m Two major types: essential (also called primary or idiopathic) hypertension and secondary hypertension, which results from
renal disease or another identifiable cause
m Malignant hypertension, a medical emergency, is a severe, fulminant form commonly arising from both types
Pathophysiology:
peveral theories:
m Vhanges in arteriolar bed cause increased peripheral vascular resistance.
m Abnormally increased tone in the sympathetic nervous system originates in the vasomotor system centers,mcausing
increased peripheral vascular resistance.
m Increased blood volume results from renal or hormonal dysfunction.
m Increase in arteriolar thickening is caused by genetic factors, leading to increased peripheral vascularmresistance.
m Abnormal renin release results in the formation of angiotensin II, which constricts the arterioles andmincreases blood volume.
Vauses:
m Unknown
isk factors:
m ëamily history
m Blacks in the United pates
m ptress
m Obesity
m High-sodium, high-saturated fat diet
m Use of tobacco
m Use of hormonal contraceptives
m Excessive alcohol intake
m pedentary lifestyle
m Aging
? cide ce:
m This disorder affects 15% to 20% of adults in the United ptates.
m Essential hypertension accounts for 90% to 95% of cases.
Vomplicatio s:
m Vardiac disease
m Renal failure
m Blindness
m ptroke
m
 

cistory:
m In many cases, no symptoms, and disorder revealed incidentally during evaluation for another disorder ormduring a routine
blood pressure screening program
m pymptoms that reflect the effect of hypertension on the organ systems
m Awakening with a headache in the occipital region, which subsides spontaneously after a few hours
m Dizziness, fatigue, and confusion
m Palpitations, chest pain, dyspnea
m Epistaxis
m Hematuria
 m Blurred vision
Physical fi di gs:
m Bounding pulse
m p
m Peripheral edema in late stages
m Hemorrhages, exudates, and papilledema of the eye in late stages if hypertensive retinopathy present
m Pulsating abdominal mass, suggesting an abdominal aneurysm
m Elevated blood pressure on at least two consecutive occasions after initial screenings
m Bruits over the abdominal aorta and femoral arteries or the carotids
m
        
¬aboratory:
m Urinalysis may show protein, RBVs, or WBVs, suggesting renal disease, or glucose,msuggesting diabetes mellitus.
m perum potassium levels less than 3.5 mEq/L may indicate adrenal dysfunction (primarymhyperaldosteronism).
m Blood urea nitrogen levels normal or elevated to more than 20 mg/dl and serum creatinine levels normal ormelevated to more
than 1.5 mg/dl suggest renal disease.
?magi g:
m Excretory urography reveals renal atrophy, indicating chronic renal disease; one kidney more than 5/8´m(1.6 cm) shorter
than the other suggests unilateral renal disease.
m Vhest X-rays demonstrate cardiomegaly.
m Renal arteriography shows renal artery stenosis.
iag ostic procedures:
m Electrocardiography may show left ventricular hypertrophy or ischemia.
m An oral captopril challenge may be done to test for renovascular hypertension.
m Ophthalmoscopy reveals arteriovenous nicking and, in hypertensive encephalopathy, edema.
m


e eral:
m Lifestyle modification, such as weight control, limiting alcohol, regular exercise, and smoking cessation
m ëor a patient with secondary hypertension, correction of the underlying cause and control of hypertensivemeffects
iet:
m Low-saturated fat and low-sodium
m Adequate calcium, magnesium, and potassium
ctivity:
m Regular exercise
edicatio s:
m Diuretics
m Beta-adrenergic blockers
m Valcium channel blockers
m Angiotensin-converting enzyme inhibitors
m Alpha-receptor antagonists
m Vasodilators
m Angiotensin-receptor blockers
m Aldosterone antagonist
m


     
Yursi g diag oses:
m ëatigue
m Ineffective coping
m Ineffective tissue perfusion: cardiopulmonary
m Noncompliance (therapeutic regimen)
m Risk for injury
Ê pected outcomes:
The patient will:
m Express feelings of increased energy
m Demonstrate adaptive coping behaviours
m Maintain adequate cardiac output and hemodynamic stability
m Vomply with the therapy regimen
m Remain free from complications
Yursi g i terve tio s:
m ive prescribed drugs.
m Encourage dietary changes, as appropriate.
m Help the patient identify risk factors and modify his lifestyle, as appropriate.
o itori g:
m Vital signs, especially blood pressure
m pigns and symptoms of target end-organ damage
m Vomplications
m Response to treatment
m Risk factor modification
m Adverse effects of antihypertensive agents
m

   
e eral:
Be sure to cover:
m The disorder, diagnosis and treatment
m How to use a self-monitoring blood pressure cuff and to record the reading in a journal for review by thempractitioner
m The importance of compliance with antihypertensive therapy and establishing a daily routine for takingmprescribed drugs
m The need to report adverse effects of drugs
m The need to avoid high sodium antacids and over-the-counter cold and sinus medications containingmharmful
vasoconstrictors
m Examining and modifying lifestyle, including diet
m The need for a routine exercise program, particularly aerobic walking
m Dietary restrictions
m The importance of follow-up care.
ischarge pla i g:
m Refer the patient to stress-reduction therapies or support groups, as needed.
m Refer the patient to weight-reduction or smoking-cessation groups, as needed.
m
m
m
Vocabulary:
Renin ± a proteolytic enzyme, produced by and stored in the juxtaglomerular apparatus that surrounds each arteriole as it enters a
glomerulus. The enzyme affects the blood pressure by catalyzing the change of angiotensinogen to angiotensin.

Angiotensin ± a polypeptide occurring in the blood causing vasoconstriction, increased blood pressure, and the release of the
aldosterone in the adrenal cortex. Angiotensin is formed by the action of renin on angiotensinogen, an alpha-2-globulin that is produced
in the liver and constantly circulates in the blood.

p ± the fourth heart sound in the cardiac cycle. It occurs late in diastole in contraction of the atria. Rarely heard in normal subjects, it
indicates an abnormally increased resistance to ventricular filling.

Papilledema ± swelling of the optic disc caused by increased intracranial pressure. The meningeal sheaths that surround the optic
nerves from the optic disc are continuous with the meninges of the brain; therefore, increased intracranial pressure is transmitted
forward from the brain to the optic disc in the eye to cause the swelling.

Hypertensive retinopathy ± damage to retina due to hypertension.

Bruit ± an unusual sound that blood makes when rushes past an obstruction (turbulent flow) in an artery when the sound is auscultated
with the bell portion of the stethoscope. Also called ³vascular murmur´.

Hyperaldosteronism ± excessive aldosterone is produced by the adrenal glands, which can lead to lowered potassium levels in the
blood.

Vardiomegaly ± hypertrophy or enlargement of the heart caused frequently by pulmonary hypertension.

Renal artery stenosis ± narrowing of the renal artery, most often caused by atherosclerosis or fibromuscular dysplasia. This narrowing
of the renal artery can impede blood flow to the target kidney. Hypertension and atrophy of the affected kidney may result from renal
artery stenosis, ultimately leading to renal failure if not treated.

Electrocardiography (EV) ± a device used for recording the electric activity of the myocardium to detect abnormal transmission of
cardiac impulse through the conductive tissues of the muscle. It allows diagnosis of specific cardiac abnormalities.

Left ventricular hypertrophy (LVH) ± the thickening of the myocardium of the left ventricle of the heart.

Ischemia ± a decreased blood supply, generally due to factors in the blood vessels, to a body organ or part. Often marked by pain and
organ or tissue dysfunction.

Vaptopril (Vapoten) ± an angiotensin-converting enzyme inhibitor (AVE inhibitor) used for the treatment of hypertension and some
types of congestive heart failure.

Renovascular hypertension (renal hypertension) ± a syndrome which consists of high blood pressure caused by narrowing of the
arteries supplying the kidneys (renal artery stenosis). It is a form of secondary hypertension ± a form of hypertension whose cause is
identifiable.

Ophthalmoscopy (ëunduscopy) ± a test that allow a health professional to see inside the fundus of the eye and other structures using
ophthalmoscope (funduscope). It is done as part of an eye examination and maybe done as part of a routine physical examination. It is
crucial for determining the health of the retina and vitreous humor.

Hypertensive encephalopathy ± a neurological dysfunction induced by malignant hypertension. It describes cerebral conditions,
typically reversible, caused by sudden and sustained elevation of systolic blood pressure (above 130 mm Hg). It occurs in eclampsia,
acute nephritis, and crises in essential hypertension. pymptoms of hypertensive encephalopathy include headache, restlessness,
nausea, disturbances of consciousness, seizures, retinal hemorrhage, and papilledema. ëocal brain lesions may be associated with
specific neurological symptoms. These neurological impairments may culminate in a coma. The condition is treated by drugs that
decrease blood pressure.

Diuretics ± any drug that elevates the rate of urination and thus provides a means of forced diuresis. There are several categories of
diuretics. All diuretics increased the excretion of water from bodies, although each class does so in a distinct way.

Beta-adrenergic blocker ± a class of drugs used for various indications, but particularly for the management of cardiac arrhythmias,
cardioprotection after myocardial infarction (heart attack), and hypertension. Beta blockers block the action of endogenous
catecholamines (epinephrine (adrenaline) and norepinephrine (noradrenaline) in particular), beta-adrenergic receptors, part of the
sympathetic nervous system which mediates the ³fight or flight´ response. Examples of beta blockers include: Acebutolol, Betaxolol,
Bisoprolol, Esmolol, Propanolol, Atenolol, Labetalol, Varvedilol, Metoprolol, and Nebivolol.

Valcium channel blocker ± prevent calcium from entering cells of the heart and blood vessel walls, resulting in lower blood pressure.
Valcium channel blockers, also called calcium antagonists, relax and widen blood vessels by affecting the muscle cells in the arterial
walls. pome of the medications of this class have the added benefit of slowing your heart rate which can further lower blood pressure,
relieve chest pain (angina), and control an irregular heartbeat. Examples of calcium channel blockers include: Amlodipine (Norvasc),
Diltiazem (Vardizem LA, Dilacor XR, Tiazac), ëelodipine (Plendil), Nicardipine (Vardene, Vardene pR), Nifedipine (Procardia,
Procardia XL, Adalat VV), Nisoldipine (pular), Verapamil (Valan Verelan, Vovera-Hp).

Angiotensin-converting enzyme (AVE) inhibitors ± help relax blood vessels. AVE inhibitors prevent an enzyme in your body from
producing angiotensin II, a substance in your body that affects your cardiovascular system by narrowing your blood vessels and
releasing hormones that can raise your blood pressure. This narrowing can cause high blood pressure and force your heart to work
harder. AVE inhibitors treat a variety of conditions such as hypertension, scleroderma, and migraines. Examples of AVE inhibitors
include: Benazepril (Lotensin), Vaptopril (Vapoten), Enalapril (Vasotec), ëosinopril (Monopril), Lisinopril (Prinivil, Zestril), Moexipril
(Univasc), Perindopril (Aceon), Quinapril (Accupril), Ramipril (Altace), Trandolapril (Mavik).

Vasodilators ± medications that open (dilate) blood vessels. They work directly on the muscle in the walls of your arteries, preventing
the muscles from tightening and the walls from narrowing. As a result, blood flows more easily through your arteries, your heart doesn¶t
have to pump as hard and your blood pressure is reduced. Examples of vasodilators include: Hydralazine, Minoxidil (in pill form).

Angiotensin-receptor blockers (ARBs) ± also known as angiotensin II receptor antagonists, or sartans. A group of medications which
modulate the renin-angiotensin-aldosterone system. Their main use is in hypertension, diabetic nephropathy (kidney damage due to
diabetes), and congestive heart failure.

Aldosterone antagonists ± refers to diuretic drugs which antagonize the action of aldosterone at mineralocorticoid receptors. This group
of drugs is often used as adjunctive therapy, in combination with other drugs, for the management of chronic heart failure.