Maria Carmela L. DomocmatInstructorSchool of NursingNorthern Luzon Adventist College
Systolic pressure: pressure at the height ofthe pressure pulseDiastolic pressure: the lowest pressurePulse pressure: the difference betweensystolic and diastolic pressureMean arterial pressure: represents theaverage pressure in the arterial system duringventricular contraction and relaxation
Represents the pressure of the blood as itmoves through the arterial systemCardiac output = HR x SVVascular resistanceMean arterial pressure = CO x VR
Short-term regulation: corrects temporaryimbalances in blood pressure Neural mechanisms Humoral mechanismsLong-term regulation: controls the daily,weekly, and monthly regulation of bloodpressure Renal mechanism
Systolic pressure The characteristics of the stroke volume being ejected from the heart The ability of the aorta to stretch and accommodate the stroke volumeDiastolic pressure The energy that is stored in the aorta as its elastic fibres are stretched during systole The resistance to the runoff of blood from the systemic blood vessels
Physical Blood volume and the elastic properties of the blood vesselsPhysiologic factors Cardiac output Systemic vascular resistance
Which of the following does not directly affect arterial blood pressure?a. Heart rateb. Vascular resistancec. Venous constrictiond. Blood volume
BP of › 140/90 in individuals who do not havediabetes. systolic blood pressure greater than or equal to 140 mm Hg and/or a diastolic blood pressure greater than or equal to 90 mm HgBP of ›130/85 in individuals with diabetesand/or renal impairment systolic blood pressure of 130 mm Hg and/or a diastolic blood pressure of 85 mm Hg or higher
affects 1.5 billion peopleworldwide1: 4 One in every four Filipino adults suffers from hypertension or high11: 100 least 11 in every 100 Filipinos have pre- hypertension5th leading causemortality & morbidity inthe Philippines
MORBIDITY: 10 Leading Causes, Number and Rate* 5-Year Average (2000-2004) & 2005 5-Year Average (1955-1959) 2005 Diseases Number Rate Number Rate1. Acute Lower Respiratory Tract Infection and 694,209 884.6 690,566 809.9Pneumonia**2. Bronchitis/Bronchiolitis 669,800 854.7 616,041 722.53. Acute watery diarrhea 726,211 928.3 603,287 707.64. Influenza 459,624 587.0 406,237 476.55. Hypertension 314,175 400.5 382,662 448.86. TB Respiratory 109,369 139.7 114,360 134.17. Diseases of the Heart 43,945 56.1 43,898 51.58. Malaria 35,970 46.1 36,090 42.39. Chicken Pox 79,236 41.1 30,063 36.310. Dengue fever 15,383 19.6 20,107 23.6* per 100,000 population** Does not include ALRI, Pneumonia cases only from 2000-2002 http://www.doh.gov.ph/kp/statistics/morbidity
MORBIDITY: 10 Leading Causes, Number and Rate* 5-Year Average (1999-2003) & 2004 5-Year Average (1999-2003) 2004 Diseases Number Rate Number Rate1. Acute Lower Respiratory Tract Infection and 677,563 875.8 776,562 929.4Pneumonia**2. Bronchitis/Bronchiolitis 669,246 866.4 719,982 861.63. Acute watery diarrhea 792,479 1027.0 577,518 690.74. Influenza 486,481 629.6 379,910 454.75. Hypertension 287,368 370.5 342,284 409.66. TB Respiratory 117,712 152.6 103,214 123.57. Chicken Pox 77,020 38.9 46,779 56.08. Diseases of the Heart 49,160 63.8 37,092 44.49. Malaria 45,622 59.3 19,894 23.810. Dengue fever 14,039 18.1 15,838 19.0* per 100,000 population** Pneumonia only from 1999-2002 http://www.doh.gov.ph/kp/statistics/morbidity
systolic blood pressure (SBP) › 140 mm Hgdiastolic blood pressure (DBP) › 90 mm Hgbased on the average of > 2 BPmeasurements taken on different occasionsthe higher the systolic or diastolic pressure,the greater the risk.
1. _____________ or __________________ Idiopathic cause reason for elevation BP is unknown most common (90 to 95%)2. _____________________________ With an identifiable cause e.g. pheochromocytoma, narrowing of the renal arteries, renal parenchymal disease, hyperaldosteronism (mineralocorticoid hypertension) certain medications, pregnancy, and coarctation of the aorta
3. ___________________________ severe type of elevated blood pressure that is rapidly progressive. morning headaches, blurred vision, and dyspnea and/or symptoms of uremia BP › 200/150 mm Hg
4 _____________________ - intermittently elevated BP5. _____________________ - does not respond to usual treatment6. _____________________ - elevation of BP only during clinic visits7. ______________________ - sudden elevation of Bp requiring immediate lowering to prevent complications
_______________________ Both the systolic and diastolic pressures are elevated_______________________ The diastolic pressure is selectively elevated________________________ The systolic pressure is selectively elevated
Renal failure results in Na+ and water retention. This results in hypertension. How would you classify this type of hypertension?a. Primary hypertensionb. Secondary hypertensionc. Malignant hypertensiond. Systolic hypertension
Same risk factors for atherosclerotic heartdiseasedyslipidemia (abnormal blood fat levels)diabetes mellitus.Race: African Americans.Cigarette smoking
Family historyAge-related changes in blood pressureInsulin resistance and metabolicabnormalitiesCircadian variationsLifestyle factors
High salt intakeObesityExcess alcohol consumptionDietary intake of potassium, calcium, andmagnesiumOral contraceptive drugsStress
As a Sign nurses and other health care professionals use BP to monitor a patient’s clinical status. Elevated pressure may indicate an excessive dose of vasoconstrictive medication or other problems.As a risk factor hypertension contributes to rate at which atherosclerotic plaque accumulates within arterial walls.As a disease hypertension is a major contributor to death from cardiac, renal, and peripheral vascular disease.
is the amount of forceon the walls of thearteries as the bloodcirculates around thebody.
High blood pressure/ Hypertension result from a change in cardiac output, a changein peripheral resistance, or both.
↑ ↑ _________ ___________ x = ↑ Blood Pressure
Multifactorial conditionCauses: change in one or more factors affecting peripheral resistance or cardiac output problem with control systems that monitor or regulate pressure. Single gene mutations or polygenic (mutations in more than one gene)
Stabilizing mechanisms exist in the body toexert an overall regulation of systemic arterialpressure and to prevent circu latory collapse.Four control systems play a major role inmaintaining blood pressure: the arterialbaroreceptor system, regulation of body fluidvolume, the renin-angiotensinaldosteronesystem, and vascular autoregulation.
found primarily in carotid sinus, also in aorta and wall ofleft ventricle.Monitor level of arterial pressurecounteracts rise in arterial pressure through vagallymediated cardiac slowing and vasodilation with decreasedsympathetic tone.Therefore reflex control of circulation elevates thesystemic arterial pressure when it falls and lowers it whenit rises.Why this control fails in hypertension is unknown. There isevidence for upward resetting of baroreceptor sensitivityso that pressure rises are inadequately sensed eventhough pressure decreases are not.
Changes in fluid volume also affect the systemicarterial pressure.excess of salt and water in a persons body, the bloodpressure rises through complex physiologicmechanisms that change the venous return to theheart, producing a rise in cardiac output.If the kidneys are functioning adequately, a rise insystemic arterial pressure produces diuresis and a fallin pressure.Pathologic conditions that change the pressurethreshold at which the kidneys excrete salt and wateralter the systemic arterial pressure.
Renin, angiotensin, and aldosterone alsoregulate blood pressurekidney produces renin an enzyme that acts on a plasma protein substrate to split off angiotensin I which is converted by an enzyme in the lung to form angiotensin II.
Angiotensin II strong vasoconstrictor is the controlling mechanism for aldosterone release. With Aldosterone inhibit sodium excretion, resulting in an elevation in blood pressure.Inappropriate secretion of renin may cause increasedperipheral vascular resistance in essential (primary)hypertension. In high blood pressure, renin levelsshould be expected to fall because the increased renalarteriolar pressure should inhibit renin secretion. Inmost people with essential hypertension, however,renin levels are normal.
The process of vascular autoregulation, whichkeeps perfusion of tissues in the bodyrelatively constant, appears to be importantin causing hypertension accompanying saltand water overload. This mechanism is poorlyunderstood.
• Increased SNS activity r/t dysfunction of ANS Increased renal reabsorption of Na, Cl, and H20 r/t genetic variation in pathways by which kidneys handle Na Increased activity of RAAS, resulting in expansion of extracellular fluid volume and increased systemic vascular resistance Decreased vasodilation of arterioles r/t dysfunction of vascular endothelium Resistance to insulin action which may be a common factor linking hypertension, type 2 diabetes mellitus, hypertriglyceridemia, obesity, and glucose intolerance
Modifiable and nonmodifiable risk factors Nonmodifiable risk factors ▪ Family history, gender, race, and age-related increases in blood pressure Modifiable risk factors ▪ Sedentary lifestyle, poor dietary habits, abdominal obesity, impaired glucose tolerance or diabetes mellitus, smoking, dyslipidemia, drug use, and stress
family history of In families withhypertension is a major risk hypertension, there mayfactor. be a defect in renal secretion of sodium or a heightened sympathetic nervous system response to stress.
Age More common in younger men than younger women More common in the elderlyRace The Ontario Survey of the prevalence and control of hypertension More common in blacks and South AsiansSocioeconomic group More common in lower socioeconomic group
ESSENTIAL (PRIMARY) SECONDARY Renal vascular and renal parenchymal No known cause disease Associated risk factors Primary aldosteronism Pheochromocytoma Family history of Cushings disease Coarctation of the aorta hypertension Brain tumors Encephalitis High sodium intake Psychiatric disturbances Excessive calorie Pregnancy Medications consumption Estrogen (e.g., oral contraceptives) Glucocorticoids Physical inactivity Mineralocorticoids Sympathomimetics Excessive alcohol intake estrogen-containing oral Low potassium intake contraceptives
Why is hypertensionsometimes called“the silent killer”?
Hypertension is sometimes called “the silentkiller” because people who have it are oftensymptom free.
AsymptomaticHigh blood pressureHeadache ( especially upon waking) Most characteristic signDizzinessChest painTinnitusEpistaxis
Visual disturbancesretinal changes hemorrhages, exudates (fluid accumulation), arteriolar narrowing, and cottonwool spots (small infarctions)Papilledema swelling of the optic disc For severe hypertensionpostural (orthostatic) changess/s of primary cause
thorough health history and physical examination arenecessary.Retinas examined (fundoscopy)laboratory studies Urinalysis blood chemistry (ie, Na, K, creatinine, FBS, lipid profile 12-lead ECG Echocardiography (Left ventricular hypertrophy) Renal damage may be suggested by elevations in BUN and creatinine levels or by microalbuminuria or macroalbuminuria. Additional studies, such as creatinine clearance, renin level, urine tests, and 24-hour urine protein, may be performed.
psychosocial stressorsJob-related, economic, and other lifestressorsclients response to these stressors.coping with the lifestyle changes needed tocontrol hypertension.Assess past coping strategies.
Prolonged BP elevation eventually damagesblood vessels throughout the body,particularly in target organs such as theheart, kidneys, brain, and eyes.
goal : prevent death and complications byachieving and maintaining the arterial bloodpressure at 140/90 mm Hg or lower.
Initial Drug Therapy Lifestyle Without Compelling With Compelling Modification Indication IndicationNormal BP Encourage N/A N/A Drugs for compellingPrehypertension Yes No meds indication (DM, heart failure, MI, renal failure) Thiazide- Thiazide-type diuretics,Stage I HPN Yes ACE inhibitors, ARBs, CCBs, Beta blockers Drugs for compelling indications + other antihypertensivesStage II HPN Yes Two-drug combinations Two-
Weight reduction if BMI is 27 or higherIncrease aerobic physical activity 30 to 45 minutes most days of the week brisk walking, running, cycling, swimming, or stair climbing, 30 to 45 minutes three to five times a week. Initiate gradually should stop and notify the physician if severe shortness of breath, fainting, or chest pain occurs. should avoid muscle-building isometric exercise (weight lifting, wrestling, rowing)
Sodium restriction no more than 2.4 g sodium or 6 g NaCl Explain it takes 2 to 3 months for the taste buds to adapt to changes in salt intake may help the patient adjust to reduced salt intake. avoid adding salt at the table avoid cooking with salt avoid adding seasonings that contain sodium limit consumption of canned, frozen, or other processed foods read labels on processed foods
Maintain adequate intake of dietary K(approximately 90 mmol per day).Maintain adequate intake of dietaryCa and Mg for general health.Reduce intake of dietary saturated fat andcholesterol
Stop smoking / Avoid tobaccoModeration of alcohol intakeSupport groups for weight control, smokingcessation, and stress reductionStress reduction
FOOD GROUP NO. SERVINGS PER DAYGrains 7–8Vegetables 4–5Fruits 4–5Low fat dairy foods 2–3Meat, fish, poultry 2 or lessNut, seeds, dry beans 4 – 5 weekly
diuretics, beta-blockers, or both uncomplicated hypertension and no specific indications for another medicationgradual reduction of types and doses ofmedication when BP less than 140/90 mm Hg for at least 1 year
DiureticsAdrenergic Agents (alpha and beta blockers)VasodilatorsACE InhibitorsARBsCCB
• Instruct to stay in bed for 3 to 4 hours If receiving for first time to avoid the severe hypotensive effect (Postural (orthostatic) hypotension) that can occur with initial use. Monitor BP q 15 min after first dose.
Or angiotensin II receptor antagonists losartan (Cozaar) irbesartan (Avapro) candesartan (Atacand) valsartan (Diovan) telmisartan (Micardis)excellent options for clients who complain of coughassociated with ACE inhibitors and for those withhyperkalemia
Caution patient and caregivers antihypertensivemedications can cause hypotension.Low blood pressure or postural hypotensionshould be reported immediately.change positions slowly when moving from alying or sitting position to a standing position.elderly : use supportive devices such as handrails and walkers when necessary to prevent fallsthat could result from dizziness.
Monitor BPObtain complete history to assess for symptoms that indicate target organ damage (whether other body systems have been affected by the elevated blood pressure). Ex: anginal pain; shortness of breath; alterations in speech, vision, or balance; nosebleeds; headaches; dizziness; or nocturia.Pulse rate, rhythm, and character of apical and peripheral pulses
Deficient knowledge regarding the relationbetween the treatment regimen and controlof the disease processNoncompliance with therapeutic regimenrelated to side effects of prescribed therapy
objective : lowering and controlling the bloodpressure without adverse effects and without unduecostsupport and teach the patient to adhere to treatmentregimen Implement necessary lifestyle changes Take medications as prescribed Schedule regular follow-up appointmentsTeach disease process and how lifestyle changes andmeds can control hypertension.emphasize concept of controlling hypertension ratherthan curing it
1. Most common side effects of diuretics are potassium depletion and orthostatic hypotension.2. The most common s/e of different antihypertensive drugs is orthostatic hypotension3. Take meds at regular basis4. Assume sitting or lying position for few minutes5. Change position gradually6. Avoid very warm bath, prolonged sitting or standing
Avoid smoking cigarettes or drinking caffeinefor 30 minutes before blood pressure ismeasured.Sit quietly for 5 minutes before the reading.Sit comfortably with the forearm supportedat heart level on a firm surface, with both feeton the ground; avoid talking duringmeasurement.
Assessment is based on the average of atleast two readings. (If two readings differ bymore than 5 mm Hg, additional readings aretaken and an average reading is calculatedfrom the results.)Note: patients should be given a writtenrecord of his or her blood pressure at thescreening.
Provide written information : expectedeffects and side effects of medications;report s/erebound hypertensionsexual dysfunction some medications, such as beta-blockers, may cause sexual dysfunction and that, if a problem with sexual function or satisfaction occurs, other medications are available.Monitor BP at home.
Gestational hypertensionChronic hypertensionPreeclampsia-eclampsiaPreeclampsia superimposed on chronichypertension
Early prenatal careRefraining from alcohol and tobacco useSalt restrictionBed restCarefully chosen antihypertensivemedications
Blood pressure norms for children are based on age,height, and gender-specific percentilesSecondary hypertension is the most common formof high blood pressure in infants and children Kidney abnormalities Coarctation of the aorta Pheochromocytoma and adrenal cortical disordersIn infants, associated most commonly with highumbilical catheterization and renal arteryobstruction caused by thrombosis
There are two hypertensive crises thatrequire nursing intervention: hypertensive emergency hypertensive urgency.Hypertensive emergencies and urgenciesmay occur in patients whose hypertensionhas been poorly controlled or in those whohave abruptly discontinued theirmedications.
is a situation in which blood pressure must belowered immediately (not necessarily to less than140/90 mm Hg) to halt or prevent damage to thetarget organs.Conditions associated acute myocardial infarction dissecting aortic aneurysm intracranial hemorrhageare acute, life threatening BP elevations that requireprompt treatment in an intensive care setting becauseof the serious target organ damage that may occur.
admitted to critical care units Intravenous vasodilators have an immediate action that is short lived minutes to 4 hours used as the initial treatment sodium nitroprusside (Nipride, Nitropress) nicardipine hydrochloride (Cardene) fenoldopam mesylate (Corlopam) enalaprilat (Vasotec I.V.) nitroglycerin (Nitro-Bid IV, Tridil) labetalol (Normodyne) diazoxide (Hyperstat IV)• sublingual nifedipine (Procardia, Adalat)
is a situation in which blood pressure must belowered within a few hours.Ex: severe perioperative hypertension
Extremely close hemodynamic monitoring ofthe patient’s blood pressure and cardiovascularstatus is required during treatment ofhypertensive emergencies and urgencies.VS every 5 minutes or 15 or 30 minutes intervalsif stable.A precipitous drop in blood pressure can occur,which would require immediate action to restoreblood pressure to an acceptable level.
An abnormal decrease in blood pressure onassumption of the upright position
Decrease in venous return to the heart due topooling of blood in lower part of bodyInadequate circulatory response to decreasedcardiac output and a decrease in bloodpressure
Conditions that decrease vascular volume DehydrationConditions that impair muscle pumpfunction Bed rest Spinal cord injury
Conditions that interfere withcardiovascular reflexes Medications Disorders of autonomic nervous system Effects of aging on baroreflex function
Excessive use of diureticsExcessive diaphoresisLoss of gastrointestinal fluids throughvomiting and diarrheaLoss of fluid volume associated withprolonged bed rest
DizzinessVisual changesHead and neck discomfortPoor concentration while standingPalpitationsTremor, anxietyPresyncope, and in some cases syncope
Increased vascular compliance may contribute to which condition?a. Systolic hypertensionb. Orthostatic hypotensionc. Orthostatic hypertensiond. Diastolic hypertension