Hypertension, or high blood pressure, affects nearly 1 billion people worldwide. It is a leading cause of death and is poorly controlled in many countries. May 14th is recognized as World Hypertension Day to increase awareness. Hypertension is defined as a systolic blood pressure over 140 mmHg or a diastolic over 90 mmHg. Lifestyle modifications like weight loss, dietary changes, and increased physical activity can help control blood pressure but medication is often required. Treatment goals are to reduce blood pressure below 140/90 mmHg or 130/80 for those with diabetes or kidney disease to lower the risks of complications.

1. HYPERTENSION
HYPERTENSION

2. Hypertension
A World Wide Epidemic
Nearly 1 billion hypertensive in the world
Hypertension is poorly controlled, with less than 25%
controlled in developed countries and less than 10% in
developing countries.
Hypertension which is responsible for 3 million death
annually.
May 14th is World Hypertension Day

3. BLOOD PRESSURE ?

4. Factors Influencing
Blood Pressure (BP)
Cardiac output is total blood flow through systemic or pulmonary
circulation per min. CO =stroke volume (amt pumped out of
L ventricle per beat [70 ml]) times the HR for 1 min.
SVR + force opposing movement of blood in vessels;
determined primarily by radius of small arteries & arterioles
Blood
Pressure
Cardiac
Output
Systemic
Vascular
Resistance
= x
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

5. Normal regulation of blood pressure

6. Sympathetic Nervous System
 Baroreceptors
 Nerve cells in carotid artery & aortic arch
 Maintain BP during normal activities
 React to increases & decreases in BP
 elevated BP – impulse to brain to inhibit SNS; decrease HR &
force of contraction; vasodilation of arterioles
 decreased BP – activates SNS; vasoconstriction of arterioles;
increases HR & heart contractility

7. RENIN ANGIOTENSIN ALDOSTERONE
MECHANISM (RAAS)

8.  Produce vasoactive substances and growth factors
nitric oxide- decreases the vascular tone
endothelin- vasoconstrictor
Vascular endothelium

9.  Hypertension is a persistent systolic blood pressure
greater than 140 mm Hg and a diastolic pressure greater
than 90 mm Hg or current use of antihypertensive
medication
 (Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure [JNC
VI]
DEFINITION

10. JNC 7 Blood Pressure Classification
Category SBP
(mm Hg)
DBP
(mm Hg)
Normal < 120 < 80
Prehypertension 120–139 80–89
Stage 1 hypertension 140–159 90–99
Stage 2 hypertension > 160 or > 100
Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

11. Systolic blood pressure tends to rise and diastolic to fall.
When the average systolic blood pressure is 140 mm Hg
and diastolic blood pressure is <90 mm Hg, the patient is
classified as isolated systolic hypertensive.
COMMON IN OLDER ADULTS
Isolated Systolic Hypertension

12.  More commonly seen in some younger adults, the average systolic
pressure remains <140 mm Hg but the diastolic is 90 mm Hg. Although
diastolic pressure is generally thought to be the best predictor of risk
in patients younger than age 50 years
 Common in younger adults
Isolated Diastolic Hypertension

13.  Accelerated hypertension is defined as a recent significant increase
over baseline BP that is associated with target organ damage
Accelerated hypertension/malignant
hypertension

14.  Blood pressure may only be elevated persistently in the presence of a
health care worker, particularly a physician. When measured elsewhere,
including while at work, the blood pressure is not elevated. it is
referred to as white coat hypertension or isolated office hypertension
 The commonly used definition is a persistently elevated average office
blood pressure of >140/90 mm Hg and an average awake ambulatory
reading of <135/85 mm Hg.
White coat hypertension

15.  In some elderly patients the peripheral muscular arteries
become very rigid from advanced, and sometimes calcified,
arteriosclerosis. Consequently, the cuff has to be at a higher
pressure to compress them, so that a falsely high blood
pressure is recorded.
 It is difficult to detect clinically, so these patients may be
overdosed with antihypertensive medications resulting in
orthostatic hypotension and other side effects
Pseudohypertension

16.  Primary hypertension (essential or idiopathic) - 90% to 95% of allcases
 Secondary hypertension - 5-10%
Classification by Cause

17. Etiology of Hypertension
 Primary (essential or idiopathic) hypertension
 Contributing factors
↑ SNS activity
↑ Sodium retaining, hormones and vasoconstrictors
Diabetes mellitus
> Ideal body weight
↑ Sodium intake
Excessive alcohol intake

18. Risk Factors for - Primary Hypertension
 Age (>55)
 Alcohol
 Cigarette smoking
 Diabetes mellitus
 Elevated serum lipids
 Excess dietary sodium
 Gender
 Family history
 Obesity
 Ethnicity
 Sedentary lifestyle
 Stress

19. I. Renal
A. Renal parenchymal disease
 1. Acute glomerulonephritis
 2. Chronic nephritis
 3. Polycystic disease of kidney
 4. Diabetic nephropathy
B. Renovascular
 1. Renal artery stenosis
 2. Intrarenal vasculitis
C. Renin producing tumors
D. Primary sodium retention
Secondary Hypertension

20. II.Endocrine
A. Acromegaly
B. hyperthyroidism
C. Hyperparathyroidism
D. Adrenal
1. Cortical
• Cushing’s syndrome
• Primary hyperaldosteronism (Conn’s syndrome)
• Congenital adrenal hyperplasia
2. Medullary – pheochromocytoma

21. III. Vascular causes : Coarctation of aorta
IV. PREGNANCY INDUCED HYPERTENSION
V. NEUROLOGICAL DISORDERS
a. Increased intracranial pressure
• Brain tumours
• Encephalitis
b. Guillain-Barré syndrome

22. Clinical Manifestation
 Referred to as the “silent killer”
 Frequently asymptomatic until target
organ disease
 Occurs Or recognized on routine
screening
 Headache may occur when SBP rises
above 200mmHg or when blood
pressure is rapidly elevated.

23. Symptoms secondary to the effects on blood vessels in the various
organs and tissues or increased workload of the heart
Fatigue
Dizziness
Palpitations
Nosebleeds
Angina
Dyspnea etc..
Clinical Manifestation

24. Hypertension
Complications
Target organ diseases occur most frequently in:
 Heart
 Brain
 Peripheral vasculature
 Kidney
 Eyes

25. Complication of Hypertension
1. Cardiac :
LVH
LVF
•Systolic
•Diastolic
IHD
Arrhythmias
2. Vascular Peripheral arterial disease
•Aortic dissection
3. Cerebral
Stroke
TIA
Encephalopathy
4. Renal Nephropathy
Renal failure
5. Eye Retinopathy

26. Hypertension
Complications
 Hypertensive heart disease
 Coronary artery disease
 Left ventricular
hypertrophy
 Heart failure
Fig. 33-3: Top, normal heart;
Bottom, left ventricular
hypertrophy
Increased systemic vascular resistance causes left ventricle to work to hard; initially increases
in size as compensatory mechanism; eventually becomes too large and requires more oxygen
and energy; can’t keep up with demand and end up with heart failure

27. Hypertension
Diagnostic Studies
 History and physical examination
 BP measurement in both arms
 Use arm with higher reading for subsequent
measurements
 BP highest in early morning, lowest at night

28. Measuring Blood Pressure
 Patient seated quietly for at least 5minutes in a
chair, with feet on the floor and arm supported
at heart level
•An appropriate-sized cuff (cuff bladder encircling at least 80% of
the arm)
•At least 2 measurements
Continue…

29. Hypertension
Diagnostic Studies
 Urinalysis, creatinine clearance
 Serum electrolytes, glucose
 BUN and serum creatinine
 Serum lipid profile
 ECG
 Echocardiogram

30. MANAGEMENT

31. Goals of Therapy
Reduction of cardiovascular and renal morbidity and
mortality.
 The primary focus should be on achieving the systolic BP goal.
 Systolic BP and diastolic BP to targets < 140/90 mmHg = decrease
in CVD complications.
 In patients with hypertension with diabetes or renal disease, the BP
goal is < 130/80 mmHg

32. Benefits of Lowering BP
Average Percent Reduction
Stroke incidence 35%–40%
Myocardial infarction 20%–25%
Heart failure 50%

33. JNC VII Algorithm for Treatment of Hypertension
JNC - VII Report, JAMA , 2003;289:2560-2572
Lifestyle Modifications
Not at Goal BP
(< 140/90 mmHg or < 130/80 mmHg for Those
with Diabetes or Chronic Kidney Disease
Initial Drug Choices

34. Lifestyle Modification: 1
Socioeconomic condition in the world suggest that prevention through
Lifestyle Modifications is the universal “vaccine” against Hypertension
Weight Reduction
 Maintain normal body weight
 BMI: 18.5 – 24.9
 BP reduction: 5-20 mmHg/10 kg loss
DASH Eating Plan
 Dietary Approaches to Stop Hypertension
 Fruits, Vegetables, Low-fat dairy
 Reduce saturated and total fat
 8-14 mmHg BP reduction

36. Lifestyle Modification: 2
Dietary Sodium Reduction
2.4 grams Sodium or 6 grams Sodium Chloride
2-8 mmHg BP reduction
Physical Activity
–Regular aerobic physical activity
•4-9 mmHg BP reduction

37. Lifestyle Modification: 3
Smoking Cessation
Any independent chronic effect of smoking on BP is small
Smoking cessation does not decrease BP
BUT total cardiovascular risk is increased by smoking.
Therefore hypertensives who smoke should be
counselled on smoking cessation

38. Collaborative Care HTN
Drug Therapy
Primary actions
 Reduce SVR
 Reduce volume of circulating blood
 Review pharmacology and know drug classes & how they work to reduce BP; side
effects

39. CLASSIFICATIONS
 DIURETICS
LOOP DIURETICS
Eg- furosemide- 40 mg PO t.i.d
THIAZIDE DIURETICS
Eg- Hydrochlorothiazide -25–100 mg/d
POTASSIUM SPARING DIURETICS
Eg- Spirinolactone-50–100 mg/d PO

40. ADRENERGICinhibitors
 CENTRALLY ACTING α- ADRENERGIC ANTAGONISTS
Eg- Clonidine- 50-100 mcg TID
 PERIPHERALLY ACTING α- ADRENERGIC ANTAGONISTS
Eg- Reserpine- 100-250 mcg daily
 α- ADRENERGIC BLOCKERS
Eg-Prazocin- 500 mcg BID

41.  β- ADRENERGIC BLOCKERS
Eg- Atenelol-50-100 mg
 Calcium ChannelBlockers
Eg- Amlodipine
Nifidipine

42. ANGIOTENSIN INHIBITORS
 ANGIOTENSIN-CONVERTINGENZYME(ACE) INHIBITORS
Eg- Captopril, Enalapril
 Angiotensin II–Receptor Blockers
Eg- Losartan
Telmisartan-40–80 mg/d PO
 Vasodilators
Eg- Nitroglycerin-40-50 mg d

43.  DIRECT VASODILATORS
Eg- Nitroglycerin
Sodium nitroprusside-40-50 mg d

44. NURSING MANAGEMENT

45. Collaborative Care
Nursing Management
Assessment
 Subjective data
Past health history
Medications
Functional health patterns
 Objective data
Target organ damage

46. Collaborative Care
Nursing Management
Nursing Diagnoses
 Ineffective health maintenance R/T lack of knowledge of
pathology,complication and management
 Anxiety r/t complexity of mgmnt regimen, lifestyle changes
 Ineffective therapeutic regimen management r/t lack of
knwldge, unpleasent side effects, returns of bp to normal
while on medication, inconvenient schedule

47. Hypertensive Crisis
 Severe, abrupt increase in DBP
 Defined as >140 mm Hg
 Rate of increase in BP more important than absolute value
 Often occurs in patients with Hx of HTN who failed to comply with
medications or who have been undermedicated
 Monitor MAP mean arterial pressure: MAP = (SBP + 2DBP)
3