for nurses

2. INTRODUCTION
 The English clergyman Stephen hales made the
first published measurement of blood pressure in
1733.
 Description of what would come to be called
hypertension came from among others, Thomas
Young in 1808 and especially Richard Bright in
1836.

3.  Reverend Stephen Hales is generally credited as
being the first person to measure arterial pressure,
direct intra-arterial pressure in the horse in 1733.
 Almost a century later, sphygmographic devices
were developed to measure blood pressure
noninvasively in humans.
 The early devices were cumbersome and relatively
insensitive. The introduction of the
sphygmomanometer into clinical medicine in the
late 1800s and early 1900s was accepted by some
practitioners as a valuable aid to diagnosis.

4. Hypertension is a serious medical condition and
can increase risk of heart, brain, kidney and other
disease
 Many people with hypertension do not notice
symptoms and may be unaware about the problem.
 Hypertension has often been described as the
silent killer.
 Hypertension can also cause strokes, kidney
damage.

5. Definition
 Hypertension is the persistent systolic blood
pressure equal or greater than 140mm of Hg or
diastolic blood pressure equal or greater than
90mm of Hg ( 2 or more reading ) by two
different doctor with different blood pressure
instrument i.e, mercury sphygmomanometer
and aneroid manometer.

6. INCIDENCE
 An estimated 1.28 billion people worldwide have
hypertension most(two-third)living in low-and
middle-income countries.
 In 2015,1in 4 men and 1 in 5 women had
hypertension.
 Hypertension is a major cause of premature death
worldwide.
 Fewer than 1 in 5people with hypertension have
the problem under control.

7.  Among South Asian countries, Nepal reported the
highest proportion of hypertensive people (33.8%).
 In Nepal, hypertension is prevalent in 17.0% of
women and 23.0% of men in age 15 and above. In
age group of 55-59 years, 32.0% of women and
36% of men have hypertension. It is most likely to
be hypertensive belong to the criteria of women
and men in urban areas, those living in the Hill
ecological zone, in the Western region.
(WHO, 2013)

8.  One of the global targets noncommunicable
disease is to reduce the prevalence of hypertension
by 33% between 2010 and 2030.
- World Health Organization

9. TYPES
Two board categories of hypertension
1. Primary (essential) hypertension
2. Secondary hypertension
3. Others
 White coat hypertension
 Isolated systolic hypertension
 Malignant hypertension

10. 1.Primary (essential) hypertension
 It is defined as high blood pressure with no
apparent cause.
 90-95% of all cases of hypertension are
primary hypertension.
 However, there are a number of factors
associated and hypertension development:
genetics, diet, weight and lifestyle.

11. 2.Secondary hypertension
It is defined as high blood pressure caused by a
pre-existing physical condition such as kidney
disease,thyroid condition,diabetes etc.
 5-10% of all cases of hypertension are
secondary hypertension.

12. OTHERS
White coat hypertension more commonly known
as white coat syndrome, is a phenomenon in which
people exhibit a blood pressure level above the
normal range, in a clinical setting, although they do
not exhibit it in other settings.
Systolic blood pressure is higher than 130 but
diastolic blood pressure is under 80,that’s called
isolated systolic hypertension.

13.  Malignant hypertension is extremely high
blood pressure that develops rapidly and
causes some type of organ damage.
–Blood pressure that’s typically above
180/120mm of hg.
–Malignant hypertension should be treated as
a medical emergency.

15. Risk factors
1. Non modifiable factors
• Advancing age; vascular system changes with
increasing age. Artery gets stiffer then leads to
increase in arterial pressure and causes
hypertension.
• Family history; blood relatives tend to have
many of the same gene and transfer from one
generation to next generation.

16. • Gender; Bp is higher in men than in women at
similar age. After menopause however ,BP
increases in women to levels even higher than in
men.
• Ethnicity; Black adults have more risk of having
hypertension than in white adults. (Shows by
research)
2. Modifiable factors
• Stress; body releases the surge of the hormones
then heart rates become more faster and leads to
narrow blood vessels that causes hypertension.

17. • Obesity; It includes sympathetic nervous system
over activation, stimulation of RASS , alteration in
adipose derived cytokines ,insulin resistance and
change in renal function that leads to hypertension.
• Physical inactivity; sedentary life style
contributes to artery hardening and plaque
formation in the arteries that leads to
hypertension.
• Nutrients; Blood pressures is positively
associated with higher sodium ,alcohol and
proteins intakes.

18. • Smoking; Nicotine-the main active ingredient in
cigarette smoke –stimulates the release of
epinephrine and norepinephrine , which are the
hormones that increases blood pressure.
• Cardiovascular disease; In atherosclerosis,
plaque collects in artery and get bigger as well as
narrower that leads to hypertension .
• Kidney disease; By the narrowing of arteries
that carry the blood to the kidney and cause
increase in hormones production i.e. Renin that
leads to hypertension.

19. • Diabetes ; It damages the small blood vessels in
the body and causing the walls of blood vessels to
stiffen that leads to raises in Bp.
• Substance abuse
• Corticosteroids; overstimulation of
mineralocorticoid receptor, resulting in sodium
retention in the kidney leads to raise in bp.
• Hypothyroidism; slows the heart rates and
makes the artery less elastic that leads to
hypertension.
• Hyperthyroidism; decreasing systemic vascular
resistance ,increasing HR and raising cardia output
and leads to HTN.

20. PATHOPHYSIOLOGY
Due to modifiable and non modifiable risk factors
Kidney release renin
Renin converts angiotensinogen into angiotensin I in
liver
Angiotensin I is converted to angiotensin II in the
lungs by an enzyme angiotensin converting enzyme

21. Angiotensin II causes arterial constriction and
aldosterone secretion in the kidney
Aldosterone causes sodium and water to be retained
in the system
Increase blood volume and arterial constriction
causes increase in vascular resistance
Increase cardiac output and peripheral resistance
ultimately cause hypertension.

22. Sign and Symptoms
• Headache,dizziness,irritability
• Chest pain
• Shortness of breath
• Flushing
• Anorexia
• Epistaxis
• Visual changes
• Palpitation
• seizures

24. Diagnosis
• History taking
-family history
-personal history
-lifestyles
-dietary history
-drug history

25. • Physical examination
-measurement of blood pressure
-skin changes
-edema;due to high sodium and water
reabsorbtion
-flushing;due to dilate of blood vessels
-neurological examination;look for evidence
of stroke
-visual changes

26. • Laboratory investigation
-proteinuria;reflect chronic kidney damage
-lipid profile;increased cholesterol
-blood sugar test;increased blood sugar
level
-elevated serum BUN(blood urea nitrogen)
-renal function test;elevated creatinine level
indicate damage to kidney
-urine analysis

27. • Chest x-ray
-cardiomegaly
• ECG
-LVH(left ventricular hypertrophy)
• ECHO
-enlargement of left side of heart
• USG
-if renal disease is suspected

28. • Renal Arteriography
-if there is evidence of renal artery stenosis
• 24hours urine catecholamine
-if history suggests phaeochromocytoma
• Angiography
-if COA(coarctation of aorta)is suspected

29. MANAGEMENT
1. Lifestyle modification
Weight reduction
• Mainatain normal body weight(body mass
index,18.4-24.9kg/m2) .
• A weight loss of 10 kg may decrease systolic
blood pressure by approximately 5 to 20 mm
of hg.

30. Dietary sodium reduction
• Reduce dietary sodium intake to no more than
1500mg / day.
• Average sodium intake is approximately
4200mg/day in men and 3300mg/day in women .
• Moderate sodium restriction lessens the risk of
hypokalemia associated with diuretic therapy.

31.  Physical activity
• Encourage to patient to engage in regular aerobic
physical activity (e.g. brisk walking) at least 30
minutes / day ,most of the week .
• Advise hypertensive client to initiate exercise
programs gradually , slowly increasing the
intensity and the duration of activity as the body
adjust .
• Lifting heavy weights can be harmful because
blood pressure rises , sometimes to high levels ,
with the vasovagal response that occurs during an
intense isometric muscle contraction .

32. Reducing the alcohol consumption
• Excessive alcohol intake is strongly
associated with hypertension .
• Consumption three or more alcoholic
drinks daily is also risk factor for cardio
vascular disease and stroke .

33.  Avoidance of tobacco products
• Nicotine contained in tobacco causes
vasoconstriction and increases blood pressure ,
especially in people with hypertension .
• Smoking tobacco is also a major risk factor for
cardiovascular disease.
• Strongly encourage everyone , especially patient
with hypertension , to avoid tobacco use .
• Advise those who continue to use tobacco
production to monitor their BP during use.

34.  Relaxation techniques
 Meditation
• Meditation activates our bodies “rest-and –
Digest” functions, Which counteracts our “
flight – or – fight “ responses .
• It increase the amount of nitric oxide in our body
, a compound that can widen blood vessels and
make it easier for blood to flow freely when the
heart is pumping .

35.  Yoga:- It poses involve breathing in certain
pattern which can control blood pressure as well
as relieve stress .
• It will also enhance the functioning of our heart ,
and also leaves a positive impact on our mind
and body .
• It is effective way to lower blood pressure
 Laughter therapy :-It is a type of therapy that
uses humor to help relieve pain and stress and
improve a person’s well – being .

36. 2. Adopt DASH ( Dietary Approaches To Stop
Hypertension) Diet
• Eating more fruits ,Vegetables , and low – fat
dairy foods .
• Cutting back on foods that are high in saturated
fat , Cholesterol , and trans fat .
• Eating more whole grains products , fish , poultry
, and nuts .
• Eating less red meat ( especially processed meats )
and sweats .
• Eating food that are rich in magnesium , potassium
, and calcium .

37. PYRAMID OF DASH DIET

38. Food Group Number of
serving / day
Grains And grains products 7 or 8
Vegetables 4 or 5
Fruits 4 or 5
Low – fat or fat – free dairy foods 2 or 3
Lean meats , fish , and poultry < 2
Nuts , seeds , and dry bean 4 or 5 weekly

39. 3. Anti – hypertensive Drugs
Diuretics
• Thiazides :- Hydrochlorothiazides
• High ceiling :- Furosemides
• K + sparing :- Spironolactone
• Mechanism of actions : - Acts on kidneys to
increase excretion of Na and H2O _ decrease in
peripheral resistance and blood volume .

40. Beta - adrenergic blockers:- Atenolol , Metoprolol
• Mechanism of action :- It reduces the workload of
the heart and blood vessel and causing the heart to
beat slowly and with less force .
 Alpha – adrenergic blockers:- Prazosin ,
Doxazosin
 Mechanism of action :- It causes the peripheral
vasodilation of blood vessels .

41.  Calcium Channel blockers :- Amlodipine ,
Nifedipine
 Mechanism of action :- It will block the
movement of extra cellular calcium into the cells
and causing vasodilation and decreased heart rate .
Angiotensin – Converting Enzyme (ACE)
Inhibitors:- Captopril , Ramipril ,Enalapril .
 Mechanism of action :-Inhibit synthesis of
Angiotensin || - decrease in peripheral resistance
and blood volume.

42.  Angiotensin receptor blockers : - Losartan ,
Candesartan , Telmisartan
 Mechanism of Action :- Blocking binding of
Angiotensin || to it’s receptors .
 Centrally acting :- Methyldopa
 Mechanism of Action :- Act on Central Alpha 2A
receptors to decrease sympathetic outflow – fall in
BP .

43.  Vasodilators:- Nitroglycerin , Nitroprusside .
 Mechanism of Action: -Acting directly on the
Muscles in the wall of arteries and preventing
the muscles from tightening and arteries from
narrowing .

44. Nursing Management
ASSESSMENT
• History taking : family history , personal
history(sedentary lifestyle, smoking and
alcohol habits, exercise, diet).
• Systemic assessment :assess the symptoms of
headache, dizziness, chest pain, nose bleed,
anginal pain, shortness of breath, alteration in
vision.
• Assess BP at frequent intervals and note the
changes that would require a change in
medication.

45.  Nursing diagnosis(Actual)
1. Decreased cardiac output related to conditions
that compromise blood flow as evidenced by
chest pain(angina).
2. Deficient knowledge related to lack of
knowledge of risk factors as evidenced by
worsening blood pressure.
3. Excess fluid volume related to excess sodium
intake as evidenced by high blood pressure.
4. Sedentary lifestyle related to lack of interest in
physical activity as evidenced by overweight.
 (Potential)
5.Non-compliance related to side effect of
prescribed therapy.

46.  Nursing intervention
1. Decrease cardiac output related to condition
that compromise blood flow
a) Auscultate the heart sounds
• The existence of an S4 heart sound indicates a
rigid left ventricle, causing left ventricular
hypertrophy and diastolic dysfunction. Both S3
and S4 sounds indicate heart failure.
b)Obtain ECG
• Patient with hypertension are given an
electrocardiogram to check for silent myocardial
infarction or left ventricular hypertrophy.

47. Continue……..
• Ecg is useful for assessing heart attacks and
thickening of the heart wall or muscle ,which
are effects of high blood pressure.
C) Assist the patient in lifelong change
• Exercise, weight management, and limiting
alcohol and smoking are crucial to minimizing
cardiovascular risk.

48. 2.Deficient knowledge related to lack
knowledge of risk factor
a) Assess the patient understanding of
hypertension
• Many patient do not understand the role of
high blood pressure plays in contributing to
other condition and placing them at risk for
stroke or heart disease.

49. B)Assess barriers to learning
• Assess for cognitive, cultural or language
barriers. perception of the problem and
motivation for change is also important.
C)Help the patient identify their personal risk
factors
• Educate between modifiable(stress, diet,
weight vs. non modifiable risk factors age,
family history).

50. 3)Excess fluid volume related to excess
sodium intake
a) Assess diet and fluid intake
• An unbalanced diet with large amount of
sodium or water intake can contribute to fluid
overload and increase blood pressure so patient
should be aware of sodium and fluid intake.

51. B)Administer diuretics
• Diuretics may be required to rid the extra body
fluid if the patient is displaying symptoms such
as shortness of breath or extremely elevated
blood pressure.

52. 4)Sedentary lifestyle related to lack of interest
in physical activity
A. Assess their history and interest
• Instead of simply telling the patient to move
more, get to know what types of exercise or
activities they have done in the past. patient
are more likely to create a habit when they
enjoy what they are doing.

53. B. Help with coaching and goal setting
• Depending on patient’s activity level ,strength,
age, and health status ,meet them where they are in
their journey.
C. Keep track of progress
• Instruct the patient to keep a log of activity
completed, time spent ,exercising, and
improvement in physiological response or weight
loss and monitor BP and they may notice a
decrease in their bp along with regular exercise.

54. Promoting compliance with self care
 Encourage active participation of patient in the
program for increased compliance.
 Encourage to avoid the use of alcohol.
 Discourage use of tobacco and nicotine
products.
 Provide information regarding expected effects
of medications.

55. • Teach patient and family how to measure
blood pressure
• Assess for medication related problems
(orthostatic hypertension).

56. Complications
Brain
Cerebro vascular accidents ( stroke)
 blood clot in the arteries block blood flow to
the brain potentially causing stroke.
Hypertensive encephalopathy
 Alter brain structure and function
–Confusion
–Headache
–convulsion

57. Eye
 Hypertensive retinopathy: vascular damage of
the retina.
Blood
 Elevated blood sugar: hypertension causes
insulin resistance resulting in impaired glucose
intake that leads to elevated blood glucose
level.

58. Heart
 Myocardial infarction: endothelial injury > blood
clot> artery become blocked> interrupt blood
flow> ischemia> death of cardiac muscle >
myocardial infarction.
 Hypertensive cardiomyopathy: left ventricular
hypertrophy
 Heart failure
 Arterial fibrillation: left ventricular hypertrophy>
diastolic dysfunction> arterial structure and
electrical remodelling > arterial fibrillation.
 Aortic aneurysm: due increased pressure in the
aorta

59. Kidneys
• Hypertensive nephropathy: damage to the
kidney function.
• Chronic renal failure: damage the nephron >
GFR alteration> decreased urine output,
proteinuria > CKD

62. Prognosis
 The prognosis depends on blood pressure
control and is favorable only if the blood
pressures attain adequate control;
however, complications may develop in some
patients as hypertension is a progressive
disease.
 Adequate control and lifestyle measures only
serve to delay the development and
progression of sequelae such as chronic kidney
disease and renal failure.

63.  Large scale metanalyses have also shown the
rising CVD and vascular disease risk with
a rise in systolic and diastolic blood pressures,
with almost doubling of risk of death from
heart disease and stroke with rising SBP of as
much as 20 and DBP of 10mmHg.
• National Center for
Biotechnology Information
(2021)

64. Prevention
 Reducing salt intake (to less than 5gm daily).
 Eating more fruits and vegetables.
 Being physically active on a regular basis.
 Avoiding use of tobacco.
 Reducing alcohol consumption.
 Limiting the intake of foods high in saturated
fats.
 Eliminating/reducing trans fats in diet.

65.  High blood pressure is to start using DASH
diet.
 Eat more fruits,vegetables,and low-fat dairy
foods.
 Cut back on food that are high in saturated
fat,cholesterol and trans fat.
 Eat more whole-grains foods,fish,poultry and
nuts.
 Limit sodium,sweets,sugary drinks and red
meats.