This document discusses hypertension (HTN), defining it as a persistent systolic blood pressure (SBP) of 130 mm Hg or more or diastolic blood pressure (DBP) of 80 mm Hg or more. Approximately 1.13 billion people worldwide have HTN, including 100-110 million people in India. HTN can lead to numerous complications affecting the heart, brain, kidneys and eyes if not properly managed. The document outlines assessment approaches for HTN, including medical history, physical examination, and lab tests to identify secondary causes and target organ damage from high blood pressure.

1. NIKHIL VAISHNAV
M.SC.(NURSING)
PARUL UNIVERSITY

2.  Introduction
 Definition

5. As per new 2017 ACC/AHA
definition
“ Hypertension is defined as a
persistent systolic BP(SBP) of
130 mm Hg or more, diastolic
BP(DBP) of 80 mm Hg or more” .

7. 1.13 billion people worldwide have
hypertension .
HTN is present in 25-30 % of urban & 10-20 % of
rural population.
Approx. 100-110 million persons have HTN in
India.
HTN is the attributable cause for 57 % of stroke
and 24.5 % of coronary heart disease in India.

9.  Malignant Hypertension.
 Hypertensive urgency.
 Hypertensive emergency.
 White coat HTN.
 Pseudohypertension.
 Transient HTN.
 Paradoxical HTN
 Hypertensive crisis.
 Isolated systolic HTN
 Accelerated HTN
 Masked HTN
 Resistant hypertension

10.  Extremely high blood pressure( >180/120
mm Hg) that develops rapidly .
 It should be treated as medical
emergency.
 S/S are changes in vision , kidney failure,
grade IV retinopathy(papillidema) etc.

11.  It is clinical situation where blood
pressure is elevated without
evidence of target organ damage.
 Blood pressure readings at 180/120
or higher .
 BP can be controlled safely within
a few hours with medications.

12. Condition where blood pressure is
elevated with evidence of target
organ damage.
 BP is > 180 / 120 mm Hg.
 Blood pressure must be reduced
immediately to prevent imminent
organ damage.

13.  White coat syndrome is a
phenomenon in which people exhibit
a blood pressure level above the
normal range, in a clinical setting.
 They do not exhibit it in other
settings.
 It may be due
to anxiety experienced during a
clinic visit

15.  It is an uncommon phenomenon
seen in elderly clients.
 Intra –arterial BP is lower than the
BP measured by sphygmomanometer.
 It is caused by stiff and non
compliant vessels due to thickened
wall of arteries with aging.

16. An increased BP for a particular
period of time and then droping
back to normal.
 It is seen in Acute stroke, Acute MI,
pregnancy, Acute
glomerulonephritis.

17.  Paroxysmal hypertension is episodic
and volatile high blood pressure,
which may be due to stress of any
sort, or from a pheochromocytoma.
 There is a sudden increase in BP
even on anti hypertensive drugs.

18.  A hypertensive crisis is a severe increase
in blood pressure that can lead to a
stroke.
 BP is 180 /120 mm of Hg.
 It is an umbrella term includes
hypertensive urgency & emergency.
 S/S are severe chest pain, severe
headache, confusion, Shortness of breath
etc.

19.  Systolic BP > 130 mm Hg , but
Diastolic BP < 80 mm of Hg.
 Common type of HTN in older
people.
 Caused by artery stiffness,
diabetes, and overactive thyroid.

21.  When blood pressure reading is normal at
the doctor's office but high at home—is
known as masked hypertension .

23.  Resistant hypertension is high blood pressure that
does not respond well to aggressive medical
treatment.
 Hypertension is considered resistant when all of the
following are true:
1) Someone is taking three* different blood pressure
medications at their maximally tolerated doses.
2) One of the blood pressure medications is
a diuretic (removes fluid and salt from the body).
3) Blood pressure remains above goal—(usually
130/80 mmHg) .
4) If hypertension requires four or more medications
to be controlled it is also called resistant
hypertension.

24.  Hypertension is defined as resistant when BP
remains > 160/100 mm Hg despite use of 3
different antihypertensive drugs with
complementary mechanisms of action (one of
which being a diuretic).

27. PRIMARY
HYPERTENSION
SECONDARY
HYPERTENSION

28.  Also referred to as essential or
idiopathic HTN.
 There is elevated BP without an
identified cause.
 Accounts for 90-95%. Of all cases of
HTN.
 Since primary HTN has unknown
cause, there are several contributing
factors.

29.  Increased SNS activity.
 Obesity.
 Diabetes mellitus.
 Insulin resistance.
 Stress
 Excessive alcohol consumption.
 Increased Sodium intake.
 Vasoconstriction(Endothelium).
 Tobacco use.
 Dysfunction in RAAS system.
 Dyslipidemia

30. ➢ Age
➢ Alcohol
➢ Tobacco use.
➢ Diabetes mellitus
➢ Elevated serum
lipids
➢ Excess dietary
sodium.
➢ Ethnicity
➢ Gender
➢ Family history.
➢ Obesity.
➢ Sedentary
lifestyle.
➢ Stress
➢ Socioeconomic
status

31.  SBP rises
progressively with
increasing age.
 DBP may decrease
with age.
 After age 50,
SBP>140 mm Hg is
more important
cardiovascular risk
factor than DBP.

32.  Excessive alcohol
intake is strongly
associated with HTN.
 Moderate intake of
alcohol has
cardioprotective
properties.
 Hypertensive males
should limit their
daily alcohol intake to
2 drinks.
 Hypertensive females
should limit 1 drink
per day .

33.  Smoking tobacco greatly increases
risk of cardiovascular disease.
 Hypertensive people who smoke
tobacco are at greater risk for
cardiovascular disease.

36.  HTN is more common in
patient with DM.
 When HTN and DM coexist,
complications such as target
organ disease are more severe.

38.  Increased level of
Cholesterol &
triglycerides are
primary risk factor
in atherosclerosis.
 Hyperlipidemia is
more common in
hypertensive
people

39.  High sodium
intake can lead to
HTN in salt
sensitive patients.
 Decreases the
effectiveness of
certain
antihypertensive
drugs.


40. 

41.  HTN is more prevalent in men in
young adulthood and early middle
age.
 After the age 64, HTN is more in
women.

42.  History of a close blood
relative(parents, sibling) with HTN is
associated with an increasing risk of
HTN.

43.  Regular physical activity can
control weight & reduce
cardiovascular risk.
 Physical activity may
decrease BP

44. HTN is more prevalent in lower
socioeconomic groups and among the
less educated.
Social isolation.
Lack of support.

45.  Repeated stress
may develop HTN
more frequently
than others.

47.  Weight gain is associated
with increased frequency of
HTN.
 Central abdominal obesity
has more risk .

50.  Secondary HTN is elevated BP with
a specific cause .
 It can be identified and corrected.
 It accounts for 5-10 % of HTN cases.
 Contributing factor to hypertensive
crisis.
 Treatment aimed at treating the
underlying cause.

51. ❑ Renal disease( renal artery stenosis,
glomerulonephritis, renal parenchymal
disease).
❑ Coarctation or congenital narrowing of
aorta.
❑ Cirrhosis of liver.
❑ Endocrine disorders(
pheochromocytoma, Cushing syndrome,
thyroid disease, primary
hyperaldosteronism) .

52. ❑ Pregnancy induced hypertension.
❑ Sleep apnea.
❑ Drugs: Oral contraceptives , estrogen
replacement therapy, NSAIDs, sympathetic
stimulants ( cocaine, monoamine oxidase) ,
corticosteroids.
❑ Neurologic disorders( brain tumors, head
injury, quadriplegia, GBS) .

53. Heredity.
water & sodium retention
Altered Renin –angiotensin –aldosterone mechanism.
Stress & Increased SNS activity.
Insulin resistance & Hyperinsulinemia
Endothelial dysfunction

56. . Hypertension is a complex multifactorial disorder
with genetic, environmental and demographic
factors contributing to its prevalence.
Several genetic variations influence the body’s
sensitivity to salt lead to HTN.
Endothelial surface proteins activated , stimulates
proinflammatory properties, impairs vasodilatory
effects leads to HTN.

58. Excessive sodium intake is linked to the
HTN development.
Only 1 in 3 develop HTN, Though most
people consume a high sodium diet.
Effect of sodium on BP has a strong
genetic component.
Effect of sodium is greater in middle
aged & older adults.

62. 

63. Impair nitrous
oxide mediated
vasodilatation
Stimulates SNS
activity
High insulin
level in blood

64. Insulin resistance is a risk factor
in the development of HTN &
CVD.
Additional effects of insulin
include vascular hypertrophy &
increased renal sodium
absorption.

65. It is recognized as a marker of CVD(
primary HTN)
Vasodilator( Nitric oxide) &
Vasoconstrictor( Endothelin) are
produced in endothelial cells.
Therefore endothelial dysfunction
affects BP.

66. High levels of
Endothelin
prolonged
vasoconstriction
HTN
Oxygen free
radicals
Impair the Nitrous
oxide availability
Altered
Vasodilation
HTN

67. Renal parenchymal disease
Renovascualar disease
Primary hyperaldosteronism.
Pheochromocytoma
Liver cirrhosis
Sleep apnea

68. Due to loss of nephrons .
Retention of salt & water.
Decreased release of nitric oxide.
Activation of renin angiotensin
mechanisms.

71. Renal artery stenosis
Renal ischemia
Release of renin from JG cells
RAAS process
increased blood pressure

74. ❑ Hyperaldosteronism is characterized by
excessive secretion of aldosterone.

75. Excessive aldosterone secretion
Retention of sodium , water &
chloride
Increased ECF
Increased venous return to
heart
CO increased thus BP increased

76. PCC is a rare tumor of
adrenal gland
Excessive release of
adrenaline & nor adrenaline
Increased HR, CO
Increased BP

78. 

80. Due to liver cirrhosis
Scarring in liver
Blockage of portal vein blood flow through
the liver.
Increased pressure in portal vein
Large veins( Varices) in esophagus
Varices bleed easily.

85. It is usually asymptomatic so called” silent
killer” .
When HTN becomes severe & target organ
disease occurs.
Severe hypertension effects blood vessels in
various organs & increases workload on heart.
So secondary symptoms include fatigue,
dizziness, palpitations, angina and dyspnea.

87. What are the complications
of Hypertension?

89. Hypertensive
heart disease
Cerebrovascular
disease
Peripheral
vascular disease
Nephrosclerosis
Eye disease
Sexual
dysfunction

90. Coronary
artery disease
Left
ventricular
hypertrophy
Heart
failure

92. Hypertension disrupts
coronary artery endothelium.
Atheroma formation
Stiffed arterial wall with a
narrowed lumen
CAD, MI & ANGINA

96. Sustained HTN
Increased cardiac workload
LVH to increase cardiac
output & cardiac contraction
Increased Myocardial
workload and oxygen demand
Progressive LVH with CAD
Heart failure

99. Due to increased preload &
After load
Heart compensatory
mechanism failed
Contractility diminished
CO diminished
Fatigue, dyspnoea, Shortness of
breath

102. Cerebral
atherosclerosis
Hypertensive
encephalopathy

103. Atherosclerosis is the most common cause of
Cerebrovascular disease.
HTN is a major risk factor for cerebral
atherosclerosis & stroke.
Plaque is found at the bifurcation of the common
carotid artery.
Portion of plaque or blood clot may break off and
travel to coronary vessels causes thromboembolism.

105. Hypertensive encephalopathy (HE) is general brain
dysfunction due to significantly high blood pressure.
Generally the blood pressure is greater than
200/130 mmHg
Symptoms may include headache, vomiting, trouble
with balance, and confusion.
It occurs after a marked rise in BP if cerebral
blood flow is not decreased by auto regulation.

107. Elevated Blood pressure
Autoregulation of cerebral flow
decreased
Cerebral blood vessels dilate
increased capillary
permeability
cerebral edema

108. Increased
intracranial pressure
Brain damage
Death

109. HTN speeds up the process of
atherosclerosis in PVD.
It leads to PVD, aortic
aneurysm, aortic dissection .
Intermittent claudication is a
classic symptom of PVD.

111.  Hypertension is the second
leading cause of kidney failure
 Some degree of renal disease is
usually present in hypertensive
patient.

112. Eventually renal failure.
Atrophy of renal tubules, glomeruli destruction & death of nephrons.
Renal ischemia
Narrowing of renal blood vessels
Uncontrolled HTN

114.  Eyes contain tiny blood vessels . Due to long
term effects of HTN, following conditions
occur:
1. Blood vessel damage (retinopathy).
2. Fluid buildup under the retina
(choroidopathy).
3. Nerve damage (optic neuropathy)

115.  Retinopathy: A lack of blood flow to the retina
leads to blurred vision or the complete loss of
sight.
 Fluid buildup under the retina
(choroidopathy) This buildup of fluid under the
retina, the light-sensitive layer of tissue at the
back of the eyeball, results in distorted vision or,
in some cases, scarring that impairs vision.
 Nerve damage (optic neuropathy): The result of
blocked blood flow that damages the optic
nerve, it can kill nerve cells in eyes, which may
cause temporary or permanent vision loss.

116. HTN damages blood vessels causes
reduced blood flow to the pelvis. It leads
to sexual dysfunction in both gender.
In Male it causes Erectile dysfunction.
In Women it leads to decreased libido &
less interest in sex.

117. ASSESSMENT

118. Known duration of HTN & previously recorded BP.
Any history or symptoms of coronary artery disease, heart
failure, sleep apnea or loud snoring .
History or symptoms of other relevant coexisting
disorders (eg, stroke, renal dysfunction, peripheral
arterial disease, dyslipidemia, diabetes, gout).
Family history .

119. Social history includes exercise
levels and use of tobacco, alcohol,
and stimulant drugs (prescribed
and illicit).
A dietary history focuses on intake
of salt and stimulants (eg, tea,
coffee, caffeine-containing sodas,
energy drinks).

120. Measurement of height, weight, and waist
circumference . ( Central obesity)
Funduscopic examination for retinopathy .
Auscultation for bruits in the neck and abdomen(
Renal artery stenosis) .
Abdomen palpation for kidney enlargement and
abdominal masses ( Polycystic kidney disease) .
A full cardiac, respiratory, and neurologic
examination.

121. Diminished or delayed femoral
pulses suggest aortic
Coarctation.
A unilateral renal artery bruit
may be heard in slim patients
with Renovascualar
hypertension.

122. Routine urinalysis & spot urine
albumin:creatinine ratio .
BUN , serum creatinine level , urinalysis to
screen for renal involvement .
Decreased Creatinine clearance indicates
renal insufficiency.
Serum electrolytes: potassium (Hypokalemia)
is important to detect hyperaldosteronism.

123. Blood glucose level to detect DM.
Chest X ray to detect cardiomegaly, Coarctation
of aorta.
Lipid profile to identify atherosclerosis and CVD.
ECG to identify Left ventricular hypertrophy(LVH)
, previous MI .
Thyroid function test : To rule out
hypothyroidism , hyperthyroidism.

124. Echocardiography to detect LVH .
Uric acid level : Rises with diuretic therapy.
Renal ultrasound : To detect possible renal
disease.
Renal angiography: To detect or confirm renal
artery stenosis.
Ambulatory BP recording : To assess white coat
HTN & masked HTN .

125. Plasma free metanephrines : To rule out
pheochromocytoma
Urinary cortisol test : To detect possible
cushing’s disease.
Plasma renin activity & aldosterone: To
detect primary aldosteronism .
Sleep study : people with sleep apnea.

126.  The goal of treatment includes achieve
and maintain goal BP, reduce
cardiovascular risk and target organ
disease.
 Primary hypertension has no cure, but
some causes of secondary hypertension
can be corrected.
 Treatment targets for the general
population, including all those with a
kidney disorder or diabetes: BP < 130/80
mm Hg regardless of age up to age 80.

127. Lifestyle
modifications
Medications
Devices & Physical
interventions

128. Weight reduction
DASH eating plan
Physical activity
Dietary sodium reduction
Avoidance of tobacco products
Moderation of alcohol intake
Management of Psychosocial risk factors

130. Weight reduction has a significant effect on
lowering Blood pressure.
For overweight hypertensive patinets a combination
of dietary calories restriction and moderate physical
activity is recommended to reduce weight .
A weight loss of 22 lb may decrease SBP by approx. 5
to 22 mm Hg

132. Dietary approaches to stop hypertension(
DASH) diet emphasizes fruits, vegetables ,
low fat milk , whole grains, fish , poultry ,
been , seeds & nuts .
DASH diet plan lowers BP and LDL
cholesterol.

136. AHA & ACSM recommended that all
adults perform regular physical activity
(brisk walking) at least 30 minutes per
day more than 5 days per week .
Moderate intense activity such as brisk
walking, jogging, swimming can lower
BP, control body weight.

140. Healthy adults should restrict sodium intake
to less than or equal to 2.3 gram/day.
Hypertensive person should limit sodium to
less than 1.5 gram/day.
Avoid foods known to high in sodium(
canned soups) .
Do not add salt in the preparation of foods
or at meals.

141. The patient , Family & person who
prepare meals should be taught about
sodium restricted diet.
Foods high in sodium should be identified
Sodium restriction may be enough to
control BP in some patients with HTN.

145. Nicotine causes vasoconstriction and
increases BP.
Smoking tobacco is a major risk
factor for CVD.
The benefits of tobacco cessation are
seen within 1 year in all age groups.

147. Drinking three or more alcoholic drinks daily
is a risk factor for CVD & Stroke.
Men should limit alcohol not more than 2
drinks per day.
Women and lighter weight men to no more
than 1 drink per day.
Liver cirrhosis due to excessive alcohol intake
is the frequent cause of secondary HTN.

150. Psychosocial risk factors have direct effects on CVS by
activating SNS and stress hormone.
It can lead to HTN , tachycardia etc.
Screening for Psychosocial risk factors should be done.
Relaxation therapy, guided imagery , biofeedback ,
support groups, exercise training may be useful in patient
with HTN.

153. 

157. Percutaneous
catheter-based
radiofrequency
ablation .
Carotid
baroreceptor
stimulation

158. Aka renal denervation .
Used to control Resistant Hypertension.
There is reduction of renal sympathetic activity by Percutaneous
catheter-based radiofrequency ablation via the renal arteries .
Renal sympathetic nerve signals are interrupted by radiofrequency
ablation.
It is approved in Europe and Australia for resistant hypertension.

170.  https://www.msdmanuals.com/en-
in/professional/cardiovascular-disorders/hypertension/overview-
of-hypertension
 Lewis medical surgical nursing 3rd edition .
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 https://www.heartandstroke.ca/heart/risk-and-
prevention/condition-risk-factors/high-blood-pressure
 https://www.acc.org/latest-in-
cardiology/articles/2017/11/08/11/47/mon-5pm-bp-guideline-
aha-2017
 Bhatt DL, Kandzari DE, O'Neill WW, et al, for the SYMPLICITY
HTN-3 Investigators: A controlled trial of renal denervation for
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10.1056/NEJMoa1402670.
 https://www.hopkinsmedicine.org/health/conditions-and-
diseases/high-blood-pressure-hypertension/resistant-
hypertension