1.

Anatomy and Fisiology

1. Heart
Measuring about one fist and located inside the chest, the right border is in the right
sternum and the apex in the fifth fifth intercostal space in the midclavicular line. The
heart connection is:
Above: large blood vessels
Bottom: diaphragm
Every side: lungs
Rear: descending aorta, esophagus, vertebral column -
2. Arteries
Is a tube through which blood is flowed to tissues and organs. The artery consists of
an inner layer: a slippery layer, a middle layer of elastin / muscle tissue: the aorta and
its large branches have a middle layer consisting of elastin tissue (to deliver blood to
organs), smaller arteries have a middle layer of muscle (regulating the amount blood
delivered to an organ).
3. Arteriol
It is a blood vessel with a relatively thick smooth muscle wall. The muscle of the
arteriole wall can contract. Contractions cause contraception of blood vessel diameter.
If the contours are local, the blood supply to the tissues / organs decreases. If there is
general controversy, blood pressure will increase.
4. Main blood vessels and capillaries
 The main blood vessels are thin-walled vessels that run directly from arterioles to
venules. Capillary is a network of small blood vessels that open the main blood
vessels.
5. Sinusoid
There are spleen, liver, bone marrow and endocrine glands. Sinusoid is three to four
times larger than capillaries and is partially coated with reticulo-endothelial system
cells. At the site of sinusoids, blood experiences direct contact with cells and
exchange does not occur through tissue space.
6. Veins and venules
Venul is a small vein formed by a combination of capillaries. Veins are formed by a
combination of venul. Veins have three walls that are not perfectly bordered with
each other (Gibson, John. Issue 2 of 2002, p. 110)
Blood pressure comes from the heart pump mechanism which drives a certain amount
of blood with high pressure so that blood reaches all organs of the body through blood
vessels.
Blood pressure is one parameter, hemodynamics that is simple and easy to measure.
Hemodynamics is a condition where blood pressure, blood flow can maintain perfusion or
exchange 02 in body tissues. The high blood pressure is determined by the amount of blood
pumped to the heart (bulk) and the diameter of the blood (peripheral resistance).
The mechanism by which the hypertension causes paralysis or death is directly related
to its effect on the heart and blood vessels. Increased systolic blood pressure increases
resistance to pumping blood from the left vertical as a result of too much heart material and a
dilated and poor heart. The heart is increasingly threatened by increasingly rupturing
coronary oleroclerosis, so myocardial oxygen supply decreases and the need for oxygen
myocardium increases due to ventricular hypertrophy and the workload of the heart increases
resulting in anging or infarction of the myocardium
2. Definition
Hypertension is a systolic pressure higher than 140 mmHg persistent or diastolic
pressure> 90 mmHg. The diagnosis is confirmed by measuring the average of two or more
blood pressure engravings at separate times (Engram, 1998).
Hypertension is persistent blood pressure where the systolic pressure is above 140
mmHg and the diastolic pressure is above 90 mmHg (Brunner and Suddarth, 2001).
Hypertension is an increase in systole, whose height depends on the age of the
individual affected. Blood pressure fluctuates within certain limits, depending on body
position, age and stress level experienced (Tamboyong, 2000).
3. Etiology
Based on the cause of hypertension is divided into two:
1. Essential hypertension.
Namely hypertension, which has no known cause and covers 90% of all patients with
hypertension, factors that affect, among others
a. Genetics
The role of genetic factors in essential hypertension is proven that the incidence
of hypertension is more common in patients with monozygotic twins than
heterozygotes, if one of them suffers from hypertension. In 70% of cases of
essential hypertension is a history of essential hypertension.
b. Age
The incidence of hypertension increases with increasing age. Hypertension in
those under 35 years of age clearly increases the incidence of coronary artery
disease and premature death.
c. Obesity
The accumulation of fat especially in blood vessels results in a decrease in
peripheral resistance which increases sympathetic nerve activity which results in
increased vasoconstriction and decreased vasodilation where it can stimulate the
adrenal medulla to secrete epinerpin and norepineprin which can cause
hypertension.
d. Hypercholesterol
Fat in various processes will cause the formation of plaque in blood vessels. This
development causes narrowing and hardening called atherosclerosis.
e. Sodium intake increases (sodium balance)
Damage to renal sodium excretion is the first change found in the process of HT.
Na + retention is followed by expansion of blood volume and then increased
cardiac output. Peripheral autoregulation increases peripheral vascular resistance
and ends with HT.
f. Cigarettes
Cigarette smoke contains nicotine which stimulates the release of adrenaline
which stimulates the heartbeat and blood pressure. Besides cigarette smoke
contains carbon monoxide which has a stronger ability than Hb in attracting
oxygen. So the network lacks oxygen including the heart.
g. Alcohol
Long-term use of alcohol or ethanol can cause an increase in lipogenesis
(hyperlipidemia occurs) synthesis of cholesterol from acetyl co enzyme A,
changes in seklerosis and fibrosis in small arteries.
h. Certain drugs or anti-pregnancy pills
Anti-pregnant pills contain the hormone estrogen which is also salt and water
retention, and can raise blood cholesterol and blood sugar.
i. Psychological stress
 Stress can trigger the release of high levels of the hormone adrenaline and
catecholamine, which aggravates the work of the coronary arteries so that the
supply of blood to the heart muscle is disrupted. Stress can activate sympathetic
nerves that can increase blood pressure intermittently.
2. Hipertensi sekunder
Caused by certain diseases, for example:
a. Kidney disease
Damage to the kidneys causes renin by juxtaglomerular cells to come out, resulting in
the release of angiostensin II which affects the secretion of aldosterone which can
retain Na and water.
b. Diabetes Mellitus
Caused by high sugar levels at the same time results in concentrated blood sugar and
deposition which results in atherosclerosis increasing blood pressure (Sjaifoellah
Noer, 2001)
4. Pathophysiology Or Pathway
Pathaway
Attached
The mechanism that controls the constriction and relaxation of blood vessels is located in
the vasomotor center, in the medulla in the brain. From this vasomotor center begins the
sympathetic nerve pathway, which continues downward to the spinal cord and exits the
column of the spinal cord to the sympathetic ganglia in the thorax and abdomen. Vasomotor
central stimuli are delivered in the form of impulses that move down through the sympathetic
nervous system to the sympathetic ganglia. At this point, preganglionic neurons release
acetylene, which stimulates post-ganglion nerve fibers to blood vessels, where the release of
norepinephrine results in blood vessel construction. Various factors such as anxiety and fear
can affect blood vessel response to stimulating vasoconstrictors. Individuals with
hypertension are very sensitive to noepinifrin, although it is not clear why this can occur. At
the same time, the sympathetic nervous system stimulates blood vessels in response to
emotional stimulation. The adrenal gland is also aroused, resulting in additional activation of
vasoconstriction. The adrenal cortex secretes cortisol and other steroids, which can
strengthen blood vessel vasoconstrictor responses. Vasoconstriction which results in reduced
blood flow to the kidneys, causes release of rennin. Rennin stimulates the formation of
angiotensin I, which is then converted to angiotensin II, a powerful vasoconstrictor, which in
turn stimulates aldosterone secretion by the adenal cortex. This hormone causes retention of
sodium and water by the kidney tubules, causing an increase in intravascular volume. All of
these factors trigger the state of hypertension. (Bruner & Suddhart, 2001, p. 898).
5. Classification
According to WHO's classification of hypertension, namely:
1. Normal blood pressure that is if systolic is less or equal to 140 mmHg and diastolic is less
or equal to 90 mmHg
2. Border blood pressure (broder line) that is if systolic 141-149 mmHg and diastolic 91-94
mmHgHigh blood pressure (hypertension) that is if the systolic is greater or equal to 160
mmHg and the diastolic is greater or equal to 95mmHg.
Classification according to the Joint National Committee on Detection and Treatment of
Hypertension, namely:
1. Diastolic
a. <85 mmHg: Normal blood pressure
b. 85 - 99 mmHg: Normal high blood pressure
c. 90 -104 mmHg: Mild hypertension
d. 105 - 114 mmHg: Moderate hypertension
e. > 115 mmHg: Severe hypertension
2. Systolic (with a diastolic pressure of 90 mmHg)
a. <140 mmHg: Normal blood pressure
140 - 159 mmHg: Isolated border systolic hypertension
b. > 160 mmHg: Isolated systolic hypertension
The hypertension crisis is a sudden increase in blood pressure (cystole 80180 mmHg
and / or diastole ≥120 mmHg), in patients with hypertension, who need immediate
response characterized by very high blood pressure with the possibility of occurrence
or target organ abnormalities ( brain, eyes (retina), kidneys, heart and blood vessels).
The high blood pressure varies, the most important is the rapid rise in blood pressure,
including:
1. Emergency Hypertension
Situations where immediate blood pressure reduction is required with parenteral
antihypertensive drugs due to the presence of acute target organ damage or
progressive acute or progressive targets. Sudden BP increase accompanied by
progressive target organ damage and immediate BP reduction in minutes / hours.
2. Urgency Hypertension
Situations where there is a significant increase in blood pressure in the absence of
severe symptoms or significant progressive target organ damage without severe
symptoms or progressive target organ damage and blood pressure need to be reduced
within a few hours. A reduction in BP should be carried out within 24-48 hours (a
decrease in blood pressure can be carried out more slowly (within hours to days).
Classification of Stage Hypertension According to Sjaifoellah Noer, (2001) consists of:
1. Stage 1 (light)
Systolic pressure between 140 - 159 mmHg. Diastolic pressure between 90-99 mmHg.
2. Stage 2 (medium)
 Systolic pressure between 160 - 179 mmHg. Diastolic pressure between 100 - 109
mmHg.
3. Stage 3 (heavy)
Systolic pressure between 180 - 209 mmHg. Diastolic pressure between 110 - 119
mmHg.
4. Stage 4 (very heavy)
Systolic pressure is more than or equal to 210 mmHg. Diastolic pressure between> 120
mmHg.
This classification is not for someone who is taking antihypertensive drugs and is not acutely
ill. If the systolic and diastolic pressures are in different categories. Then a high category
must be chosen to classify a person's blood pressure status.
6. Signs And Symptoms
According to Tambayong (2000) symptoms and signs can be characterized as follows:
1. Headache
2. Pain or heaviness in the nape of the neck
3. Difficulty sleeping
4. Easily tired and angry
5. Tinnitus
6. Eyes are dizzy
7. Epistaxis
8. Shaking
9. Pulse quickly after activity
10. Shortness of breath
11. Nausea, vomiting
7. Complications
Complications according to Tambayong (2000) that may occur in hypertension are as
follows:
1. Broken heart (heart failure)
2. Brain bleeding (stroke)
3. Malignant hypertension: retinal, renal and cerebral abnormalities
4. Hypertension encephalopathy: complications of malignant hypertension with brain
disorders.
5. Myocardial infarction
It can occur if an atherosclerotic coronary artery cannot supply enough chemiocardial
oxygen or if a thrombus is formed which blocks blood flow through the blood vessels.
6. Kidney failure
Because of progressive damage due to high pressure on the renal capillaries, the
glomerulus. With the destruction of the glomerulus blood will flow to the functional units
 of the kidney. Nephrons are disrupted and can continue to become hypoxia and
kemataian. With the breakdown of the glomerular membrane, protein will pass through
urine so that the plasma colloid osmotic pressure is reduced, causing edema, which is
often found in chronic hypertension.
8. Support Examination
Investigations that can be used to diagnose hypertension according to Doenges (2000)
include:
1. ECG: Left ventricular hypertrophy in advanced chronic conditions.
2. Potassium in serum: increases from the normal threshold.
3. Post prandial blood sugar examination if there is an indication of DM.
4. Urine:
a. Ureum, creatinine: increases in chronic conditions and continues from the normal
threshold.
b. Urine Protein: Positive
9. Management
According to Engram (1999), management includes:
1. Treatment of secondary hypertension prioritizes causal treatment.
2. Treatment of essential hypertension is intended to reduce blood pressure with
hypertension drugs.
3. Treatment of hypertension is a long-term treatment even for life.
4. Treatment using standard triple therapy (STT) consists of:
a. Diuretics, for example: thiazide, furosemide, hydrochlorothiazide.
b. Betablocker: methyldopa, reserpine.
c. Vasodilators: dioxid, pranosine, hydralacin.
d. Angiotensin, Converting Enzyme Inhibitors.
5. Modification of lifestyle, with:
a. Weight loss.
b. Reduction of alcoholic intake.
c. Regular physical activity.
d. Reducing sodium input.
e. Stop smoking.
10. Assessment
Basic data assessment (Doenges, 2000)
1. Activity : weakness, fatigue, lethargy, tachypnea, increased HR, changes in heart
rhythm.
2. Circulation : history of hypertension, palpitations, elevated BP changes in skin color,
cold temperature, pale, cyanosis, diaporesis.
 3. Ego integrity : anxiety, depression, anger, anxiety, tense facial muscles, increased
speech patterns.
4. Food / fluid : normal BB / obesity, edema.
5. Neurosensory : dizziness, headache, vision problems, epistaxis.
6. Pain : pain arises in the legs, headache, abdominal pain.
7. Respiratory : takipnea dyspnea, smoking history, additional breath sounds.
8. Elimination : current or past gunjal disturbances.
9. Security : coordination disorders, postural hypotension.
11. Nursing Diagnosis
1. High risk of decreased cardiac output releted to increased afterload, vasoconstriction,
ventricular hypertrophy / rigidity, ischemia myocardial.
2. Activity intolerance releted to weakness, imbalance in supply and oxygen demand.
3. Acute pain releted to increased cerebral vascular pressure
4. Anxiety releted to a secondary situational crisis of hypertension suffered by the client.
5. Lack of knowledge is related to a lack of information about the disease process
 NURSING PLAN
NO NURSING DIAGNOSIS
GOAL (NOC) INTERVENTION (NIC)
DX AND COLLABORATION
1 High risk of decreased NOC : NIC :
cardiac output is related to Cardiac Pump Effectiveness Cardiac Care
increased afterload, Circulation Status Evaluation of chest pain (intensity, location, duration)
vasoconstriction, ventricular Vital Sign Status Record the presence of cardiac dysrhythmias
hypertrophy / rigidity, Result Criteria: Note the signs and symptoms of decreased cardiac putput
myocardial ischemia Vital signs in the normal range (blood Monitor cardiovascular status
pressure, pulse, respiration) Monitor respiratory status which indicates heart failure
Can tolerate activity, there is no fatigue Monitor the abdomen as an indicator of decreased perfusion
There is no pulmonary, peripheral edema, Monitor fluid balance
and no ascites Monitor changes in blood pressure
There is no decrease in consciousness Monitor patient response to the effects of antiarrhythmic treatment
Set the period of exercise and rest to avoid fatigue
Monitor tolerance of patient activity
Monitor for dyspneu, fatigue, tekipneu and orthopneu
Advise to reduce stress

Vital Sign Monitoring

Monitor TD, pulse, temperature, and RR
Record blood pressure fluctuations
Monitor VS when the patient is lying down, sitting or standing
Auscultate BP in both arms and compare
Monitor TD, pulse, RR, before, during, and after activity
Monitor the quality of the pulse
Monitor the presence of pulsus paradoxus
Monitor the presence of pulsus alterans
Monitor the amount and rhythm of the heart
Monitor heart sounds
Monitor the frequency and rhythm of breathing
Monitor lung sounds
Monitor abnormal breathing patterns
Monitor skin temperature, color and moisture
Monitor peripheral cyanosis
Monitor the presence of cushing triad (widening pulse pressure,
bradycardia, increased systolic)
Identify the causes of vital sign changes
2 Activity intolerance releted to NOC :
with weakness, imbalance in Energy conservation
supply and oxygen demand. Self Care: ADLs
Result Criteria:
Participating in physical activity without
accompanied by an increase in blood
pressure, pulse and RR
Able to do daily activities (ADLs)
independently
NIC :
Energy Management
Observation of restrictions on clients in carrying out activities
Encourage the anal to express feelings towards limitations
Assess for factors that cause fatigue
Monitor nutrition and strong energy sources
Monitor patients for excessive physical and emotional fatigue
Monitor cardivascular responses to activity
Monitor sleep patterns and length of sleep / patient rest
Activity Therapy
Collaboration with Medical Rehabilitation Workers in planning the right
therapy program.
Help clients identify activities that are capable of being done
Help to choose consistent activities that are in accordance with physical,
psychological and social abilities
Help to identify and get the resources needed for the desired activity
Help to get activity aid tools such as wheelchairs, crutches
Help to identify preferred activities
Help clients to make training schedules in their spare time
Help patients / families to identify deficiencies in activities
Provide positive reinforcement for those who are active in activities
Help patients develop self motivation and reinforcement
 Monitor physical, emotional, social and spiritual responses

3 Acute pain releted to NOC : NIC :

increased cerebral vascular
pressure
Result Criteria:
Pain Level, Pain Management
Pain control, Perform a comprehensive pain assessment including location,
Comfort level characteristics, duration, frequency, quality and precipitation factors
Observation of nonverbal reactions from discomfort
Able to control pain (know the cause of Use therapeutic communication techniques to determine the patient's pain
pain, be able to use non-pharmacological experience
techniques to reduce pain, seek help) Assess culture that affects pain response
Report that pain is reduced by using pain Evaluation of past pain experiences
management Evaluation with patients and other health teams about the ineffectiveness of
Able to recognize pain (scale, intensity, past pain control
frequency and signs of pain) Help patients and families find and find support
Expressing comfort after the pain has Environmental controls that can affect pain such as room temperature,
diminished lighting and noise
Vital signs in the normal range Reduce the factor of precipitation pain
Choose and do pain management (pharmacology, non-pharmacology and
inter-personal)
Assess the type and source of pain to determine intervention
Teach about non-pharmacological techniques
Give analgesics to reduce pain
 Evaluate the effectiveness of pain control
Increase rest
Collaborate with a doctor if there are complaints and pain actions are not
successful
Monitor patient acceptance of pain management

Analgesic Administration
Determine the location, characteristics, quality, and degree of pain before
administration of the drug
Check the doctor's instructions about the type of drug, dosage, and
frequency
Check allergy history
Choose the analgesics needed or a combination of analgesics when giving
more than one
Determine analgesic choices depending on the type and severity of the pain
Determine choice analgesics, route of administration, and optimal dosage
Select IV administration route, IM for the treatment of pain regularly
Monitor vital signs before and after the first analgesic administration
Give analgesics on time, especially when pain is great
Evaluate the effectiveness of analgesics, signs and symptoms (side effects)
4 Anxiety releted to a After nursing actions for 3 x 24 hours, worry Anxiety Reduction
secondary situational crisis of about the patient's reduced criteria for Use a calming approach
hypertension suffered by the results: Clearly express expectations of the perpetrators of the patient
client Anxiety Control Describe all procedures and what is felt during the procedure
Coping Accompany patients to provide security and reduce fear
Vital Sign Status Give factual information about the diagnosis, prognosis
Showing techniques to control anxiety Encourage families to accompany children
deep breathing techniques Perform back / neck rub
The patient's posture relaxes and the Listen attentively
facial expressions are not tense Identify the level of anxiety
Expressing anxiety decreases Help patients recognize situations that cause anxiety
TTV dbn Encourage patients to express feelings, fears, perceptions
TD = 110-130 / 70-80 mmHg Instruct patients to use relaxation techniques
RR = 14-24 x / minute Share drugs to reduce anxiety
N = 60 -100 x / minute
S = 365 - 375 0C
5 Lack of knowledge is related NOC : NIC :
to a lack of information about Kowlwdge: disease process Teaching : disease Process
the disease process Kowledge: health Behavior Give an assessment of the level of patient knowledge about the specific
Result Criteria: disease process
Patients and families express an Describe the pathophysiology of the disease and how it relates to anatomy
understanding of the disease, conditions, and physiology, in the right way.
 prognosis and treatment program
Patients and families are able to carry out
the procedure correctly described
Patients and families are able to explain
again what the nurse / other health team
explained.
Describe the usual signs and symptoms in the disease, in the right way
Describe the disease process, in the right way
Identify possible causes, with the right way
Provide information to patients about the condition, in the right way
Avoid empty expectations
Provide the family or SO with information about the patient's progress in
the right way
Discuss lifestyle changes that may be needed to prevent future
complications and / or disease control processes
Discuss treatment or treatment options
Support patients to explore or get a second opinion in the right way or
indicated
Exploration of possible sources or support, in the right way
Refer patients to groups or agencies in the local community, in the right
way
Instruct patients about signs and symptoms to report to health care
providers, in the right way
 BIBLIOGRAPHY

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