HTN              Dr. Ram Sharan MehtaMedical-Surgical Nursing Department        Dr. RS Mehta, MSND, BPKIHS   1
Definition• Hypertension is a systolic blood pressure  greater than 140 mm Hg and a diastolic  pressure greater than 90 mm...
Dr. RS Mehta, MSND, BPKIHS   3
New FactsFor persons over age 50, SBP is a more important than DBP asCVD risk factor.Starting at 115/75 mmHg, CVD risk dou...
International Health Survey: HarrisonPrevalence of hypertension is 22% in Canada, ofwhich 16% is controlled; 26.3% in Egyp...
Dr. RS Mehta, MSND, BPKIHS   6
Dr. RS Mehta, MSND, BPKIHS   7
Classification of HIN1. Systolic HTN / Diastolic HTN- Systolic BP > 140/ Diastolic BP > 902. Primary [essential] HTN/Secon...
Classification of HTN according to      Type                          Cause/etiology           Degree of severity         ...
Benefits of Lowering BP            Average Percent ReductionStroke incidence                  35–40%Myocardial infarction ...
Dr. RS Mehta, MSND, BPKIHS   11
Use of holterDr. RS Mehta, MSND, BPKIHS                   12
Source:RS Mehta, MSND, BPKIHS     Dr. Bruner, May be western countries   13
Aetiology of Hypertension• Primary – 90-95% of cases: essential or idiopathic• Secondary – about 5% of cases  – Renal or r...
Dr. RS Mehta, MSND, BPKIHS   15
Risk Factors• Modifiable: weight/obesity, stress,  diet-cholesterole/ coffee/ salt,  alcohol, smoking, sedentary job,  Dia...
Dr. RS Mehta, MSND, BPKIHS   17
CVD Risk Factors  Hypertension (Major Risk Factor)  Cigarette smoking  Obesity* (BMI >30 kg/m2)  Physical inactivity  Dysl...
Dr. RS Mehta, MSND, BPKIHS   19
Pathophysiology• Primary HTN: the actual pathogenesis of  HTN remain unknown. Failure to maintain  Normal blood pressure.E...
Pathophysiology    Four control systems plays a major    role in maintaining BP. They are:•      arterial baroreceptor sys...
C/F: General•   Early stage of HTN is asymptomatic•   Morning occipital headache•   Fatigue•   Dizziness•   Palpitation•  ...
C/F• Mild to moderate: asymptomatic except  intermittent risk of BP• Moderate to severe: headache with  dizziness, flushin...
• Malignant HTN: retinopathy,  papilledema• HTN encephalopathy is manifested  by: restlessness, blurred vision,  dizziness...
Hypertensive crisis• It includes hypertensive urgencies and  emergencies:1. Hypertensive urgencies: DBP> 120-130, with  op...
Dx• BP: 2 separate visit, at least 2 weeks apart• CxR/ECG: LVH, Cardiomegaly, arrythmias• Blood chemistry: BUN (>20 mg %),...
Hypertensive Retinopathy         Grade I                          Grade II• Narrowing of arterioles         • Hemorrhages ...
Hypertensive Retinopathy          Grade III                         Grade IV• Extensive hemorrhages          • Exaggerated...
Hypertension: Reason to Treat• Reduce incidence of stroke:                35-40%• Reduce incidence of MI:                 ...
Dr. RS Mehta, MSND, BPKIHS   30
Dr. RS Mehta, MSND, BPKIHS   31
Management of HTNA. Non-pharmacological1.Salt restriction2.Relief of stress3.Weight reduction4.Avoid alcohol and cigarette...
B. Drug therapy   a. Beta-blockers   b. Calcium channel blockers   c. ACE (angiotensin converting enzyme) inhibitors   d. ...
Dr. RS Mehta, MSND, BPKIHS   34
• Beta-blockers: Atenolol 50-100 mg od/bd  Contraindications: COPD, Br. Asthma,  CCF, Heart block• Calcium channel channel...
ACE inhibitors: a. Catopril 25-50 mg tds b. Enalpril 5-20 mg OD c. Lisnopril 5-20 mg ODS/E: Sudden hypotension, neutropeni...
Angiotensin II receptor blockers1. Losartan 20-100 mg/day2. Valsartan 80mg/day3. Candesartan 8-16mg/dayS/E: angioedema, al...
Management of hypertensive crisisParenteral IV agents:1. Sodium nitropruside2. Nitroglycerine3. Esmolol4. etc             ...
Dr. RS Mehta, MSND, BPKIHS   39
Dr. RS Mehta, MSND, BPKIHS   40
Hypertensive crises• Abnormal elevated blood  pressure: 20% of emergency  department patients• Hypertensive crisis: 1%    ...
•History  • Duration of hypertension  • Duration of current symptoms  • Other medical problems –CNS manifestations –Cardio...
• Neurologic symptoms –Headache (85%) –New-onset blurred vision (60%) –Weight loss (75%) –Nausea and vomiting –Weakness an...
• Imaging studies –Chest x-ray   • Signs of CHF, pulmonary edema, or     coarctation of aorta –Head CT scan   • Abnormal n...
Dr. RS Mehta, MSND, BPKIHS   45
Dr. RS Mehta, MSND, BPKIHS   46
Dr. RS Mehta, MSND, BPKIHS   47
Hypertension and Diabetes• Hypertension co-exists with type II in about  40% at age 45 rising to 60% at age 75.• 70% of ty...
Follow-up• For patients with BP stabilised by  management, follow up should normally be  three monthly (interval should no...
Thank-You  Dr. RS Mehta, MSND, BPKIHS   50
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Hypertension

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Hypertension PPT Class Notes for Graduate and post-graduate nursing students.

Hypertension

  1. 1. HTN Dr. Ram Sharan MehtaMedical-Surgical Nursing Department Dr. RS Mehta, MSND, BPKIHS 1
  2. 2. Definition• Hypertension is a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more contacts with the health care provider after an initial screening. Dr. RS Mehta, MSND, BPKIHS 2
  3. 3. Dr. RS Mehta, MSND, BPKIHS 3
  4. 4. New FactsFor persons over age 50, SBP is a more important than DBP asCVD risk factor.Starting at 115/75 mmHg, CVD risk doubles with eachincrement of20/10 mmHg throughout the BP range.Persons who are normotensive at age 55 have a 90% lifetimerisk for developing HTN.Those with SBP 120–139 mmHg or DBP 80–89 mmHg shouldbe considered prehypertensive who require health-promotinglifestyle modifications Dr. RS Mehta, MSND, BPKIHS to prevent CVD. 4
  5. 5. International Health Survey: HarrisonPrevalence of hypertension is 22% in Canada, ofwhich 16% is controlled; 26.3% in Egypt, of which8% is controlled; and 13.6% in China, of which 3%is controlled. Hypertension is a worldwideepidemic; in many countries, 50% of thepopulation older than 60 years has hypertension.Overall, approximately 20% of the worlds adultsare estimated to have hypertension. The 20%prevalence is for hypertension defined as bloodpressure in excess of 140/90 mm Hg. Theprevalence dramatically increases in patientsolder than 60 years.RS Mehta, MSND, BPKIHS Dr. 5
  6. 6. Dr. RS Mehta, MSND, BPKIHS 6
  7. 7. Dr. RS Mehta, MSND, BPKIHS 7
  8. 8. Classification of HIN1. Systolic HTN / Diastolic HTN- Systolic BP > 140/ Diastolic BP > 902. Primary [essential] HTN/Secondary HTN- Majority idiopathic cause/cause known3. White coat HTN: Normotensive otherwise4. Malignant HTN: DBP > 120 mg, Retinal hemorrhage, papilledema, ARF, Rapid vascular deterioration Dr. RS Mehta, MSND, BPKIHS 8
  9. 9. Classification of HTN according to Type Cause/etiology Degree of severity • borderline/liable •White coatSystolic /Diastolic Primary/secondary •Benign •Malignant •accelerated Dr. RS Mehta, MSND, BPKIHS 9
  10. 10. Benefits of Lowering BP Average Percent ReductionStroke incidence 35–40%Myocardial infarction 20–25%Heart failure 50% Dr. RS Mehta, MSND, BPKIHS 10
  11. 11. Dr. RS Mehta, MSND, BPKIHS 11
  12. 12. Use of holterDr. RS Mehta, MSND, BPKIHS 12
  13. 13. Source:RS Mehta, MSND, BPKIHS Dr. Bruner, May be western countries 13
  14. 14. Aetiology of Hypertension• Primary – 90-95% of cases: essential or idiopathic• Secondary – about 5% of cases – Renal or renovascular disease – Endocrine disease • Cusings syndrome • Acromegaly • hypothyroidism – Coarctation of the aorta – Iatrogenic • Hormonal / oral contraceptive • NSAIDs Dr. RS Mehta, MSND, BPKIHS 14
  15. 15. Dr. RS Mehta, MSND, BPKIHS 15
  16. 16. Risk Factors• Modifiable: weight/obesity, stress, diet-cholesterole/ coffee/ salt, alcohol, smoking, sedentary job, Diabetes, Durgs-OCP.• Non-Modifiable: Hereditary, sex, age, race. Dr. RS Mehta, MSND, BPKIHS 16
  17. 17. Dr. RS Mehta, MSND, BPKIHS 17
  18. 18. CVD Risk Factors Hypertension (Major Risk Factor) Cigarette smoking Obesity* (BMI >30 kg/m2) Physical inactivity Dyslipidemia Diabetes mellitus Microalbuminuria or estimated GFR <60 ml/min Age (older than 55 for men, 65 for women) Family history of premature CVD (men under age 55 or women under age 65)*Components of the metabolic syndrome. Mehta, MSND, BPKIHS Dr. RS 18
  19. 19. Dr. RS Mehta, MSND, BPKIHS 19
  20. 20. Pathophysiology• Primary HTN: the actual pathogenesis of HTN remain unknown. Failure to maintain Normal blood pressure.Elderly: atherosclerosis, loss of connective tissue elasticity, decrease in relaxation of vascular smooth muscle, which reduce ability of vessels to distend and recoil. Dr. RS Mehta, MSND, BPKIHS 20
  21. 21. Pathophysiology Four control systems plays a major role in maintaining BP. They are:• arterial baroreceptor system• regulation of body fluid volume• renin angiotensin system• vascular autoregulation. Dr. RS Mehta, MSND, BPKIHS 21
  22. 22. C/F: General• Early stage of HTN is asymptomatic• Morning occipital headache• Fatigue• Dizziness• Palpitation• Flushing• Blurred vision gradually blindness occur• epistaxis Dr. RS Mehta, MSND, BPKIHS 22
  23. 23. C/F• Mild to moderate: asymptomatic except intermittent risk of BP• Moderate to severe: headache with dizziness, flushing, fatigue, vertigo, palpitations.• Severe: Morning-throbbing subocipital headache, blurred vision, epistaxis, hematuria, papilledema Dr. RS Mehta, MSND, BPKIHS 23
  24. 24. • Malignant HTN: retinopathy, papilledema• HTN encephalopathy is manifested by: restlessness, blurred vision, dizziness, headache, N/V.• Renal insufficiency manifested by: proteinuria, hematuria, hemolytic anemia, LVF, Pulmonary edema. Dr. RS Mehta, MSND, BPKIHS 24
  25. 25. Hypertensive crisis• It includes hypertensive urgencies and emergencies:1. Hypertensive urgencies: DBP> 120-130, with optic disc edema, end organ complication etc)2. Hypertensive emergencies:a. Accelerated HTN: SBP>210, DBP>130, with headache, blurred vision, focal neurological symptom and pailloedema.b. Malignant HNT: SBP>210, DBP>140 (130), with headache, blurred vision, papilloedema, arterial fibrisis, renal failre etc. Dr. RS Mehta, MSND, BPKIHS 25
  26. 26. Dx• BP: 2 separate visit, at least 2 weeks apart• CxR/ECG: LVH, Cardiomegaly, arrythmias• Blood chemistry: BUN (>20 mg %), Creatinin (>1.5%)• CBC, lipid profile, sugar profile• Urine analysis• Special examination: IVP, Fundoscopy Dr. RS Mehta, MSND, BPKIHS 26
  27. 27. Hypertensive Retinopathy Grade I Grade II• Narrowing of arterioles • Hemorrhages Dr. RS Mehta, MSND, BPKIHS 27
  28. 28. Hypertensive Retinopathy Grade III Grade IV• Extensive hemorrhages • Exaggerated changes of• Retinal exudates grade III• Cotton wool patchesRS Mehta, MSND,Disk edema (not Dr. • BPKIHS 28 papilledema)
  29. 29. Hypertension: Reason to Treat• Reduce incidence of stroke: 35-40%• Reduce incidence of MI: 20-25%• Reduce incidence of Heart failure: 50% Dr. RS Mehta, MSND, BPKIHS 29
  30. 30. Dr. RS Mehta, MSND, BPKIHS 30
  31. 31. Dr. RS Mehta, MSND, BPKIHS 31
  32. 32. Management of HTNA. Non-pharmacological1.Salt restriction2.Relief of stress3.Weight reduction4.Avoid alcohol and cigarette5.Dietary fat modification6. Exercises7.Caffeine restriction8.Relaxation technique BPKIHS Dr. RS Mehta, MSND, 32
  33. 33. B. Drug therapy a. Beta-blockers b. Calcium channel blockers c. ACE (angiotensin converting enzyme) inhibitors d. Angiotensin II receptors blockers e. Diuretics Stepped care approach/ Step down therapy/ Combination therapy Dr. RS Mehta, MSND, BPKIHS 33
  34. 34. Dr. RS Mehta, MSND, BPKIHS 34
  35. 35. • Beta-blockers: Atenolol 50-100 mg od/bd Contraindications: COPD, Br. Asthma, CCF, Heart block• Calcium channel channel blockers: Nifedipine 10-20 mg 8 hrly if diastolic BP more than 110 mm of Hg, may use S/L 5- 10 mg cap but not practice now a days. S/E: Palpitation, headache, flushing, pedal edema. Dr. RS Mehta, MSND, BPKIHS 35
  36. 36. ACE inhibitors: a. Catopril 25-50 mg tds b. Enalpril 5-20 mg OD c. Lisnopril 5-20 mg ODS/E: Sudden hypotension, neutropenia, albunninuriaNote: ACE inhibitor are more preferred when HTN is associated with heart failure, IHD, DM and renal disease with protenurea. Dr. RS Mehta, MSND, BPKIHS 36
  37. 37. Angiotensin II receptor blockers1. Losartan 20-100 mg/day2. Valsartan 80mg/day3. Candesartan 8-16mg/dayS/E: angioedema, allergic reaction, rashes Dr. RS Mehta, MSND, BPKIHS 37
  38. 38. Management of hypertensive crisisParenteral IV agents:1. Sodium nitropruside2. Nitroglycerine3. Esmolol4. etc Dr. RS Mehta, MSND, BPKIHS 38
  39. 39. Dr. RS Mehta, MSND, BPKIHS 39
  40. 40. Dr. RS Mehta, MSND, BPKIHS 40
  41. 41. Hypertensive crises• Abnormal elevated blood pressure: 20% of emergency department patients• Hypertensive crisis: 1% Dr. RS Mehta, MSND, BPKIHS 41
  42. 42. •History • Duration of hypertension • Duration of current symptoms • Other medical problems –CNS manifestations –Cardiovascular manifestations –Renal manifestations –Medications Dr. RS Mehta, MSND, BPKIHS 42
  43. 43. • Neurologic symptoms –Headache (85%) –New-onset blurred vision (60%) –Weight loss (75%) –Nausea and vomiting –Weakness and fatigue (30%) –Change in mental status Dr. RS Mehta, MSND, BPKIHS 43
  44. 44. • Imaging studies –Chest x-ray • Signs of CHF, pulmonary edema, or coarctation of aorta –Head CT scan • Abnormal neurologic exam intracranial bleeding, edema, or infarction Dr. RS Mehta, MSND, BPKIHS 44
  45. 45. Dr. RS Mehta, MSND, BPKIHS 45
  46. 46. Dr. RS Mehta, MSND, BPKIHS 46
  47. 47. Dr. RS Mehta, MSND, BPKIHS 47
  48. 48. Hypertension and Diabetes• Hypertension co-exists with type II in about 40% at age 45 rising to 60% at age 75.• 70% of type II patients die from cardio- vascular disease.• At least 60% of patients will require 2 or 3 antihypertensive agents to achieve tight control. Dr. RS Mehta, MSND, BPKIHS 48
  49. 49. Follow-up• For patients with BP stabilised by management, follow up should normally be three monthly (interval should not exceed 6 months), at which the following should be assessed by a trained nurse/Doctor: * Measurement of BP and weight * Reinforcement of non-pharmacological advice * General health and drug side-effects * Test urine for proteinuria (annually) Dr. RS Mehta, MSND, BPKIHS 49
  50. 50. Thank-You Dr. RS Mehta, MSND, BPKIHS 50

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