1. Introduction
Hypertension, also known as high blood pressure, affects approximately 74.5 million
people in the US that are over the age of 20 ("High blood pressure statistics," n.d., pars. 1). This
means that one out of every three adults has hypertension ("High blood pressure statistics," n.d.,
pars. 3). According to the American Heart Association, of the people diagnosed with high blood
pressure, only 67.9% were receiving treatment, and of those only 44.1% had it under control
("High blood pressure statistics," n.d., pars. 4). That leaves a whooping 55.9% that do not have
their blood pressure under control ("High blood pressure statistics," n.d., pars. 4).
The purpose of this paper is to answer the four main objectives outlined below. This was
copied directly from the syllabus provided by the instructor Jennifer Lillibridge. One, describe
the pathophysiology for one major common adult disease process, in this case hypertension, and
related nursing care. Two, describe scientific principles and concepts underlying nursing
interventions, including the basic nursing skills used in health maintenance and preventive care
for an individual. Three, describe physiological, psychological and cultural/spiritual factors that
can influence a person's health status with specific examples. Four, identify teaching, decision
making, and critical thinking theories as they pertain to care of the acutely ill adult patient using
a specific example. My nursing diagnosis is ineffective health maintenance related to lack of
knowledge of possible complications associated with hypertension and lifestyle changes needed
in order to manage disorder.
Objective I
In order to understand hypertension, it is important to understand exactly what blood
pressure is and how it is regulated. Blood pressure is really about the pressure of blood moving
through the heart during contraction and relaxation. Blood flows down a pressure gradient from

2. high pressure, found in the arterioles, to low pressure found in the venules (Porth, 2011, p. 378).
Blood pressure is, in a nutshell, cardiac output (CO) x systemic vascular resistance (SVR)
(Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 743). CO is the amount of blood
flow through the systemic or pulmonary circulation per minute (Lewis, Heitkemper, Dirksen,
O'Brien, & Bucher, 2007, p. 743). SVR is the amount of resistance or force opposing the
movement of blood (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 743). It stands to
reason that when either the CO or SVR is increased there will be a corresponding increase in BP
(Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 762).
Blood pressure consists of two numbers. The upper number is the systolic blood pressure
(SBP), and the lower number is the diastolic blood pressure (DBP). Per Lewis et al., “systolic
blood pressure (SBP) is the peak pressure exerted against the arteries when the heart contracts.”
(2007, p. 743). The residual pressure of the arterial system during ventricular relaxation is what
constitutes diastolic blood pressure (DBP) (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher,
2007, p. 743). Hypertension is defined as a SBP over 140 mm Hg, or a DBP over 90 mm Hg
(Porth, 2011, p. 427).
Currently there are two types of hypertension, primary and secondary. Primary
hypertension is what this paper will focus on, and is an elevated BP without an identifiable cause
(Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 765). Secondary hypertension
pertains to an elevated BP that is related to a specific cause (Lewis, Heitkemper, Dirksen,
O'Brien, & Bucher, 2007, p. 765). According to Lewis et al., “The hemodynamic hallmark of
hypertension is persistently increased SVR.” (2007, p. 765). Although, an elevated SVR may be
the hallmark of primary hypertension, the actual cause of primary hypertension remains largely
unknown (Porth, 2011, p. 428). Although the direct cause is unknown, there are several

3. identifiable factors that we will discuss here. One key factor that can contribute to hypertension
in some people is an excessive sodium intake (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher,
2007, p. 765). It has been found that populations whose diets consist of a low sodium intake
have lower BP’s. When these same populations adopt a diet higher in sodium, the incidence of
hypertension rises (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 765). Another key
factor is that some people may have an altered renin-angiotensin mechanism (Lewis,
Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 766). In some individuals there may be
increased levels of renin in the system. Renin is converted to angiotensinogen which converts to
angiotensin I and then to angiotensin II (Porth, 2011, p. 612). Angiotensin II is a potent
vasoconstrictor (Porth, 2011, p. 612), which obviously will increase SVR thereby increasing BP.
In addition, the angiotensin II stimulates the adrenal gland to produce aldosterone which results
in the kidneys retaining sodium and water (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher,
2007, p. 766). More sodium and water will increase cardiac output which will also increase BP.
The third factor that can cause increased blood pressure in individuals is an increase in the
activity of the sympathetic nervous system (SNS) (Lewis, Heitkemper, Dirksen, O'Brien, &
Bucher, 2007, p. 766). According to Lewis et al., “Increased SNS stimulation produces
increased vasoconstriction, increased HR, and increased renin release.” (2007, p. 766). Stress
can cause an increase in SNS stimulation thereby leading to an increase in BP. People exposed
to high levels of stress on a daily basis are much more prone to having an elevated BP then those
who are not (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 766). Regardless of the
cause of high blood pressure, basic management of the patient with hypertension is to control the
BP which will reduce further complications.

4. Basic nursing care will include frequent monitoring of vital signs, especially the BP, to
ensure that they are with in normal limits. Many medications will require that the BP be taken
before the medication is administered so it will be essential that the BP, and in some instances,
the heart rate, be taken before administering any of these medications. Any SBP over 180 or
DBP over 110 is a medical emergency known as hypertensive crisis, and a physician will need to
be notified immediately.
Objective II
So as nurses, what nursing interventions are appropriate for the patient with
hypertension? First and foremost, it is imperative to assess the patient’s knowledge of the
disorder (Gulanick & Myers, 2011, p. 270). The patient needs to understand that hypertension is
a chronic condition with long term complications. In order to prevent complications, the BP has
to be at a safe level. If the patient doesn’t know the risks and complications where’s the
incentive to try to manage the BP at all? If you don’t know where the patient’s level of
knowledge is at, then you don’t where teaching needs to begin. You also won’t know if the
patient has any misunderstandings in regards to the disorder. Another important intervention is
to encourage questions about the treatment prescribed (Gulanick & Myers, 2011, p. 270). For
most people the prescribed treatment will include medications as well as diet modifications.
Again, this is finding out what the patient knows. Give the patient plenty of time to ask
questions. A lot of patients have questions about lifestyle modifications. There’s so much to
remember! Recommend reading The DASH Diet Action Plan. This book provides proven ways
to lower blood pressure and cholesterol. The DASH diet, encourages an intake high in fruits,
vegetables, low fat dairy , and is also low in “total and saturated fats” (Gulanick & Myers, 2011,
p. 271). This diet is also contains a good mix of potassium, magnesium, and calcium which acts

5. as a diuretic to help the body excrete excess salt (Gulanick & Myers, 2011, p. 271). Make sure
to plan the teaching in stages so as not to overwhelm the patient, as this will also help promote
understanding (Gulanick & Myers, 2011, p. 271). Open communication is key to helping
patients keep their BP under control. If the patient is not complying with the treatment plan it is
important to find out why. Make sure to involve the patient in the treatment plan, the more
involved the patient is, the more likely that the treatment will be successful. It will also be very
important to stress the importance of keeping on track with the treatment. Hypertension is a
chronic condition; the goal is keep the BP at a safe level. Many patients have the
misunderstanding that if their BP is normal they can go off the plan. Make sure to help the
patient understand that the goal of treatment is to control the BP and that there is no cure
(Gulanick & Myers, 2011, p. 271). Bottom line, the more information the patient has the better
the chances of helping to keep the BP under control.
In addition to teaching, it will be important to administer the patient’s medications
exactly as prescribed. Some of the medications may have BP parameters that need to be
monitored, so it will be important to monitor the patient’s BP. Explain to the patient what
medication is being given and more importantly what it is for. The patient is more likely to
adhere to the medication regime if they know what they are taking and why they are taking it.
Objective III
There are several risk factors that are important to know when working with a patient
with hypertension. According to Lewis et al., SBP rises with increasing age, unfortunately
cardiovascular disease is associated with elevated SBP levels (2011, p, 766). You should make
sure to let your patient know that cigarette smoking and alcohol both have an adverse effect on
BP and should be avoided (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 766).

6. According to the American Heart Association the highest rates of hypertension were found
within the African-American community, and of those they were “more likely to be middle aged
or older, less educated, overweight or obese, physically inactive, and to have diabetes.” ("High
blood pressure statistics," n.d., pars. 8). Men under the age of 55 have a higher incidence of
hypertension than women of the same age; however after the age of 55, hypertension is more
prevalent in women (Lewis, Heitkemper, Dirksen, O'Brien, & Bucher, 2007, p. 766). It is
interesting to note that in 2006 the death rates per 100,000 were as follows: 15.6 for white
males, 51.1 for black males, 14.3 for white females and 37.7 for black females ("High blood
pressure statistics," n.d., pars. 9). It may be surprising to learn that people with a lower
socioeconomic status have a higher incidence of hypertension (Lewis, Heitkemper, Dirksen,
O'Brien, & Bucher, 2007, p. 766). There may be several reasons for this. Lack of insurance or
an inability to pay for medications needed could be a factor. Another factor is people with a
lower socioeconomic status might not have the means to have an annual exam; therefore they
may be unaware that there is even a problem. If you don’t know there is a problem, you don’t
know that it needs to be fixed. Also when there are financial worries, there is more stress.
We’ve already been able to identify that stress can play a role in high blood pressure.
Recently, I had the pleasure of taking care of Roger Langston (name has been changed).
Roger is a 53 year old African-American man with a history of uncontrolled high blood pressure.
He is 6’1” and weighs 250 lbs and is a smoker. He works as a manager of a car dealership, and
he usually works 50+ hours a week. Having little concern over his diet, it mostly consists of fast
food, he usually has a beer once a week. He is physically inactive, blaming his many hours at
work as the primary cause. Roger, for the most part has been non-compliant with his treatment
plan for hypertension. Roger has been admitted to the hospital with congestive heart failure

7. (CHF), a complication of hypertension. It has been explained to Roger that his uncontrolled
hypertension, is one of the reasons for the development of CHF. He has been informed by his
physician that he absolutely needs to adhere to the treatment plan, which consists of medication
and lifestyle changes. Roger has most of the risk factors identified with hypertension. He is a
male smoker. He is African-American. He has a high stress job. Roger also has a poor diet, he
is obese, with a low physical activity level. Although Roger has risk factors over which he has
no control. He has several lifestyle risk factors of which he has complete control. While in the
hospital, Roger’s hypertension has been controlled, but since he is close to discharge it’s
important to make sure he understand not only the medication regimen, but that lifestyle changes
need to be made to keep his BP at a safe level, and to prevent any further target organ damage.
Objective IV
According to Gulanick and Myers, the following teaching areas should be addressed:
definition of hypertension, common risk factors, strategies for weight reduction, rationale and
strategies for adopting the DASH diet and a low sodium diet (2011, p.271). I also believe that
Roger really needs to understand the complications of hypertension. Teaching is going to be key
in order to keep Roger’s BP under control. In order for his treatment to be successful, he needs
to understand the importance of lifestyle changes and ways to help implement them into his daily
life. Having been his nurse for the past few days, I have been able to ascertain that Roger is
receptive to teaching and this recent diagnosis of CHF has made him seem to take his
hypertension more seriously. As previously mentioned, teaching in smaller sessions is
important, as I want him to remember what we discuss. First, I want to go over the
complications of the disorder. Although, Roger is taking his treatment more seriously at this
time, knowing the complications can increase his success in effective management once he gets

8. home. The main complication of hypertension is target organ damage (Porth, 2011, p. 431).
Hypertension for the most part is asymptomatic, it will be important to stress this (Porth, 2011, p.
431). When symptoms do develop it is usually related to long term effects on target organs
(Porth, 2011, p. 431). These target organs include the kidneys, heart, eyes, and blood vessels
(Porth, 2011, p. 431). In Roger’s case, his heart is showing signs of damage. Hypertension is
considered a major risk factor for coronary artery disease, heart failure, stroke, and peripheral
artery disease (Porth, 2011, p. 431). Roger also needs to know what hypertension is. Explain
that hypertension is defined as a SBP over 140 mm Hg, or a DBP over 90 mm Hg (Porth, 2011,
p. 427). Explain that SBP is the upper number and DBP is the lower number. Advise him to
monitor his BP at home and that he should purchase equipment that is approved by his physician
(Gulanick & Myers, 2011, p. 270).
Lifestyle changes are hard for anyone, but it will be very important to arm Roger with the
tools he needs to make the necessary lifestyle changes. Roger needs to know that lifestyle
modification has been proven to reduce blood pressure and enhance the effects of drug therapy
(Porth, 2011, p. 431). Rogers needs to quit smoking, lose weight, modify his diet, and increase
his physical activity. Since Roger smokes this increases his risks for heart disease. Refer Roger
to www.smokefree.gov. This will give him the information he needs to quit for good. Weight
loss has been proven to lower BP (Gulanick & Myers, 2011, p. 271). Since Roger will be on a
weight loss plan, he can incorporate foods from the Dash diet and this in turn will help him
reduce his sodium intake. The Dash diet and a reduction of sodium intake have been proven to
not only be effective in lowering BP, but are especially effective in the African-American
population (Gulanick & Myers, 2011, p. 271). Since Roger mostly eats fast foods, we can help
him learn to choose healthy foods from fast food menus. In addition, physical activity has been

9. shown to have a positive effect on weight loss and on BP, so that needs to be implemented as
well. Roger has indicated that he didn’t have time for exercise. Studies show that aerobic
exercise has a positive effect on BP (Gulanick & Myers, 2011, p. 272). A brisk 30 minute walk
before or after work most days of the week, might work for him, or getting on a treadmill while
watching TV would be helpful. Refer Roger to dashdiet.org as well as The American Heart
Association website at www.heart.org/HEARTORG/. Both of these are recognized websites that
can help Roger meet his goals.
Conclusion
Hypertension is a common chronic disorder that is virtually asymptomatic. However it
has been shown, that with proper teaching and lifestyle modifications a patient can keep his/her
BP under control. When the patient has the right information about the disorder the patient can
feel empowered to make the right decisions to manage the disorder.

10. References
Gulanick, M., & Myers, J. L. (2011). Nursing care plans: diagnoses, interventions, and
outcomes (Seventh ed.). St. Louis, MO: Elsevier Mosby.
High blood pressure statistics. (n.d.). American Heart Association. Retrieved June 10, 2011,
from http://www.americanheart.org/presenter.jhtml?identifier=4621
Lewis, S., Heitkemper, M. M., Dirksen, S. R., O'Brien, P. G., & Bucher, L. (2007). Medical-
surgical nursing: assessment and management of clinical problems. (Seventh ed., pp.
743-783). St. Louis: Mosby Elsevier.
Porth, C. (2011). Essentials of pathophysiology: concepts of altered health states (Third ed.).
Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.