2. Definition
• HTN = the presence of a BP elevation to a
level that places patients at increased risk
for target organ damage in several
vascular beds including the retina, brain,
heart, kidneys, and large conduit arteries.
2
9. Assessment
Risk Factors
Essential hypertension
• Positive family history
• Excessive sodium intake
• Physical inactivity
• Obesity
• High alcohol consumption
• African American
• Smoking
• Hyperlipidemia
• Stress
Risk Factors
• Secondary hypertension
• Kidney disease
• Cushing’s disease (excessive
glucocorticoid secretion)
• Primary aldosteronism (causes
hypertension and
hypokalemia)
• Pheochromocytoma
(excessive catecholamine
release)
• Brain tumors, encephalitis
• Medications such as estrogen,
steroids, sympathomimetics
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10. Assessment
Subjective Data
• Clients who have hypertension
can experience few or no
symptoms. The nurse should
• monitor for:
• Headaches, particularly in the
morning.
• Dizziness.
• Fainting.
• Retinal changes, visual
disturbances.
• Nocturia.
Objective Data
Physical Assessment Findings
• When a blood pressure
reading is elevated, take it
in both arms and with the
client sitting and standing.
• There are several levels of
hypertension, as defined by
the Joint National
Committee on Prevention,
Detection, Evaluation, and
Treatment of High Blood
Pressure.
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11. Assessment
Objective Data -cont
• Laboratory Tests
• No laboratory tests exist to
diagnose hypertension;
however, several laboratory
tests can identify the causes of
secondary hypertension and
target organ damage.
• BUN, creatinine – elevation is
indicative of kidney disease
• Elevated serum corticoids to
detect Cushing’s disease
• B.G and cholesterol studies can
identify contributing factors
related to blood vessel changes.
Objective Data -cont
• Diagnostic Procedures
• An ECG evaluates
cardiac function. Tall R-
waves are often seen
with left-ventricular
hypertrophy.
• A chest x-ray may show
cardiomegaly.
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14. Management
Lifestyle Modifications
• Lose weight if body mass index is
greater than or equal to 25.
• Stop drinking alcohol
• regular aerobic exercise 30 to 45
minutes daily
• Smoking cessation.
• Reduce dietary saturated fat and
cholesterol.
• Restricted sodium intake
• Consider reducing coffee intake
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15. Drug Therapy
• The best management of hypertension is
to use the fewest drugs at the lowest
doses while encouraging the patient to
maintain lifestyle changes.
• Most patients require two or more
antihypertensive medications to achieve
their BP goals.
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18. Pharmacological Treatment
• Aim is to reduce BP while controlling other
modifiable cardiovascular risk factors.
• Gradual reduction to avoid end organ
ischemia.
• Patient education:
– Life long treatment.
– Symptoms don’t reflect severity.
– Prognosis improves with proper management.
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19. Pharmacological Treatment
•Treatment determined by highest BP
category.
•Most patients are controlled with more
than one drug.
•Initial combined therapy should be used
cautiously in those at risk for orthostatic
hypotension.
•Compelling indications.
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20. Pharmacological Treatment
• Stage 1: thiaizide type diuretic if no
compelling indication.
• When BP is > 20/10 mmHg above goal:
add a 2nd drug (when the 1st drug used in
adequate dose).
• Stage 2 : usually 2-drug combination for
most: thiazide + ACE inhibitor, ARB, BB
or CCB.
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21. Thiazide diuretics
• Well-proven, 1st line therapy.
• Both low-dose and high-dose regimens
decrease rates of stroke and death.
• Low-dose regimens reduce CAD.
• Enhance antihypertensive efficacy of
multidrug regimens.
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24. Loop diuretics
• Diuretics promote sodium and water
excretion, reduce plasma volume, decrease
sodium in the arteriolar walls, and reduce
the vascular response to catecholamine.
• Loop diuretics- e.g. furosemide (Lasix)
• side effects
• Hyperuricemia, hyperglycemia, and
hypokalemia are common side effects
24
25. cont
• Nursing Considerations
• Monitor potassium levels and watch for
muscle weakness, irregular pulse, and
dehydration.
• Thiazide and loop diuretics can cause
hypokalemia, and potassium-sparing
diuretics can cause hyperkalemia.
25
26. cont
• Client Education
• Encourage the client to keep all
appointments with the provider to monitor
efficacy of pharmacological treatment and
possible electrolyte imbalance
(hyponatremia, hyperkalemia).
• If the client is taking a potassium-depleting
diuretic, encourage consumption of
potassium-rich foods, such as bananas.
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27. Beta-adrenergic blockers
• Act centrally on the vasomotor center and
peripherally to inhibit norepinephrine release
or to block the adrenergic receptors on
blood vessels.
• Cardioselective: atenolol, metoprolol.
• Non-selective: propranolol, timolol.
27
28. cont
• MOA:
– Competitive inhibition
of catecholamines.
– Decrease plasma
renin.
– Resetting of
baroreceptors.
– Release of vasodilator.
Side effect
Orthostatic hypotension
and sexual dysfunction
Bronchospasm,
bradycardia, fatigue.
28
29. cont
• Nursing Considerations
• Monitor blood pressure and pulse.
• These medications can mask
hypoglycemia in clients who have diabetes
mellitus.
29
30. cont
• Client Education
• Teach the client that these medications may cause
fatigue, weakness, depression, and sexual
dysfunction.
• Advise the client not to suddenly stop taking the
medication without consulting with the provider.
Stopping suddenly can cause rebound hypertension.
• Teach the client manifestations of hypoglycemia that
do not include tachycardia, which beta blockers
suppress.
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31. Calcium Channel Blockers
• MOA:
– Arteriolar
vasodilatation by
selective blockage of
calcium influx in
vascular smooth
muscle cells.
31
32. • All CCBs are metabolized in the liver.
• Nefidipine: 10 mg TDS, or nefidipineXL 30
mg O/D.
• Verapamil and diltiazem have negative
cardiac inotropic and chronotropic effects.
• CCBs should not be initiated immediately
after MI.
Calcium Channel Blockers
32
34. • Nursing Considerations
• Monitor blood pressure and pulse, and
change the client’s position slowly.
Hypotension is a common side effect.
• Use calcium-channel blockers cautiously
with clients who have heart failure.
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35. • Client Education
• Constipation can occur with verapamil
hydrochloride, so encourage intake of
foods that are high in fiber.
• A decrease or increase in heart rate and
atrioventricular (AV) block can occur. So,
teach the client how to take her pulse and
call the provider if it’s irregular or lower
than the established rate.
36. • Instruct the client to avoid grapefruit juice,
which potentiates the medication’s effects,
increases hypotensive effects, and
increases the risk of medication toxicity.
36
37. ACE Inhibitors
• Examples: lisinopril,
enalapril, captopril.
• MOA: block the
production of AII
resulting in:
– Arterial and venous
vasodilatation.
– Low aldosterone: mild
natriuresis with
decrease in K+
secretion
37
38. ACE Inhibitors
• Beneficial effects in patients with
concomitant heart failure or kidney
disease.
• Can reduce the metabolic effects of
diuretics.
38
39. • Increase the level of vasodilator
bradykinins.
• Side effects:
– Dry cough in up to 20% of patients.
– Angioneurotic oedema.
– Hypotension.
– Hyperkalaemia.
– Captopril: taste disturbance, leukopenia,
glomerulopathy with proteinuria.
ACE Inhibitors
39
40. • Nursing Considerations
• Monitor blood pressure and pulse.
Hypotension is a common adverse effect.
• Monitor for evidence of heart failure, such
as edema. This medication may cause
heart and kidney complications.
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41. • Client Education
• Teach the client to report a cough, which is a side
effect of ACE inhibitors. The client should notify
the provider of this adverse effect, as the
medication can be discontinued due to its
persistent nature and occasional relationship to
angioedema (swelling of the tissues in the throat
that can progress to a life-threatening obstruction).
41
42. ARBs
• these medications, such as candesartan
(Atacand), losartan (Cozaar), and
telmisartan (Micardis), are a good option
for clients taking ACE inhibitors who report
cough and those who have hyperkalemia.
Also, ARBs do not require a dosage
adjustment for older adult clients.
42
43. • Nursing Considerations
• Monitor for manifestations of angioedema
or heart failure. Angioedema is a serious,
but uncommon adverse effect, and heart
failure can result from taking this
medication.
43
44. • Client Education
• Teach the client to change positions slowly.
• Teach the client to report findings of
angioedema (swollen lips or face) or heart
failure (edema).
• Teach the client to avoid foods that are high in
potassium and to have serum potassium levels
monitored because ARBS can cause
hyperkalemia.
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46. • Nursing Considerations
• Monitor kidney function, triglycerides, sodium, and
potassium levels. The risk of adverse effects increases
with deteriorating kidney function. Hypertriglyceridemia,
hyponatremia,and hyperkalemia can occur as the dose
increases.
• Monitor potassium levels every 2 weeks for the first few
months and every 2 months thereafter. The client should
avoid taking potassium supplements or potassium-
sparing diuretics.
46
47. • Client Education
• Teach the client about potential food,
medication, and herbal interactions.
Grapefruit juice and St. John’s wort can
increase adverse effects.
• Instruct the client not to take salt
substitutes with potassium or other foods
that are rich in potassium.
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48. 48
Central-alpha agonists
Central-alpha agonists, such as clonidine
(Catapres), reduce peripheral vascular resistance
and decrease blood pressure by inhibiting the
reuptake of norepinephrine.
■Nursing Considerations
Monitor blood pressure and pulse.
This medication is not for first-line management of
hypertension.
Client Education
Teach the client that adverse effects include
sedation, orthostatic hypotension,
and impotence.
49. Alpha-adrenergic Antagonists
• Alpha-adrenergic antagonists, such as prazosin (Minipress),
reduce blood pressure by causing vasodilation.
• Nursing Considerations
• Start treatment with a low dose of the medication, usually given
at night.
• Monitor blood pressure for 2 hr after initiation of treatment.
• Client Education
• Advise the client to rise slowly to prevent postural hypotension.
Tell the client to use caution when driving until the effects of
the medication are known.
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50. • For primary prevention: 75mg aspirin is
recommended for hypertensive patients aged 50
years or more who have satisfactory control over
their blood pressure and either target organ
damage, diabetes or cardiovascular disease risk
> 20%.
• For primary prevention: statin therapy is
indicated when the 10-year cardiovascular
disease risk is >20%.
Aspirin… Statins
50
51. • For secondary prevention: statin therapy
and aspirin therapy are indicated when
there is evidence of cardiovascular
disease, that is, angina/MI, stroke, TIA,
peripheral vascular disease, etc.
Aspirin… Statins
51
52. Hypertensive Crisis
• Usually develop in pts with previous
history of elevated BP, but may arise in a
normotensive pt.
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53. Hypertensive Urgencies
• Substantial increase in BP usually with
DBP > 120 without evidence of end organ
damage.
• Occur in 1% of all hypertensive patients.
• Treatment: oral medications in outpatient
settings with close and frequent follow up.
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54. Hypertensive Emergencies
• Accelerated and malignant HTN.
• SBP > 210 and DBP > 130 with evidence
of end organ damage.
• Reduce the BP by < 25% within 2hrs and
to a level of 160/100 by 6 hrs.
• Avoid excessive reduction of BP
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55. Hypertensive Emergencies
• Treatment:
– Admission.
– I.V medications:
• Sodium nitroprusside: infusion, direct arterial and
venous vasodilator, rapid onset, easily titrable and
short-lived.
• Hydralazine: I.V bolus, direct smooth muscle
relaxant, 10mg I.V every 10---15 min. Maximum
dose 50 mg..
• Nitroglycerin infusion: alternative. Useful after
unstable angina, MI and LVH.
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57. Patient-Centered Care
• Nursing Care
Discuss factors with a client that increase the risk of
hypertension and how he can manage them.
• Medications
Medications are added to treat hypertension that is not
responsive to lifestyle changes alone. Diuretics are often
first-line medications. However, clients can require a
combination of medications to control hypertension.
Instruct clients who are taking antihypertensives to
change positions slowly, be careful when getting out of
bed, driving, and climbing stairs until the medication’s
effects are fully known.
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58. Care After Discharge
• Instruct client to report manifestations of
electrolyte imbalance (hyperkalemia,
hypokalemia,hyponatremia).
• Express to the client and family the
importance of adhering to the medication
regimen, even if the client is asymptomatic.
• Provide verbal and written education to the
client regarding medications and their
side/adverse effects.
58
59. cont
• Ensure that the client has the resources
necessary to pay for and obtain prescribed
antihypertensive medication.
• Encourage the client to schedule regular
provider appointments to monitor
hypertension and cardiovascular status.
• If the client has blood pressure that is difficult
to manage, teach him or a significant other
how to take blood pressure.
59
60. cont
• Encourage the client to report findings and
adverse effects, as they may be indicative
of additional problems. Medications can
often be changed to alleviate side or
adverse effects.
• Older adult clients are more likely to
experience medication interactions.
• Older adult clients are more likely to
experience orthostatic hypotension.
60
61. cont
Treatment involves the client making lifestyle
changes.
• Nutrition
• Monitor potassium with salt substitute use.
• Consume less than 2.3 g/day of sodium.
• Consume a diet low in fat, saturated fat, and
cholesterol.
• Control alcohol intake for men to 2 drinks per day
and for women to 1 drink per day. Intake of 1 drink
equals 12 oz beer, 4 oz wine, or 1 to 1.5 oz liquor.
61
62. cont
• Dietary approaches to stop hypertension
(DASH) have been proven to be effective
in the prevention and treatment of
hypertension.
• The DASH diet should be high in fruits,
vegetables, and low-fat dairy foods.
• Avoid foods high in sodium and fat.
• Consume foods rich in potassium,
calcium, and magnesium.
62
63. cont
• Weight reduction and maintenance.
• Exercise at least three times a week in a
manner that provides aerobic benefits.
63
64. cont
• Smoking cessation.
• Stress reduction Encourage the client to
try yoga, massage, hypnosis, or other
forms of relaxation.
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65. Complications
• Hypertensive Crisis
• Hypertensive crisis often occurs when clients do
not follow the medication therapy regimen.
• Nursing Actions
• Recognize clinical manifestations.
• Severe headache
• Extremely high blood pressure (generally, systolic
blood pressure greater than 240 mm Hg, diastolic
greater than 120 mm Hg)
• Blurred vision, dizziness, and disorientation
• Epistaxis
65
66. cont
• Administer IV antihypertensive therapies as
prescribed.
• Before, during, and after administration of IV
antihypertensive, monitor blood pressure
every 5 to 15 min.
• Assess neurological status such as pupils,
level of consciousness, and muscle strength,
to monitor for cerebrovascular change.
• Monitor the ECG to assess cardiac status.
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