This document discusses hypertensive crisis, including its definition, causes, risk factors, clinical manifestations, diagnostic evaluation, and management. Hypertensive crisis is defined as a sudden severe elevation in blood pressure that can cause end organ damage if not promptly treated. The most common cause is poorly controlled essential hypertension. Clinical manifestations depend on the affected end organ and may include seizures, pulmonary edema, kidney injury, or retinal hemorrhage. Treatment involves rapidly lowering blood pressure by 20-25% using intravenous antihypertensive drugs to prevent further organ damage.

1. MRS.ROJARANI.K, RNM, M.SC(N),
MEDICAL SURGICAL NURSING
ASSISTANT PROFESSOR
GANGA COLLEGE OF NURSING
COIMBATORE

2. MEDICAL SURGICAL
NURSING
HYPERTENSIVE
CRISIS

3. LEARNING OBJECTIVES
At the end of the class, the students will be able to
➢ Review anatomy and physiology of blood vessel
 Define Hypertensive crisis
 State the incidence of hypertensive crisis
➢List down the causes & risk factors of Hypertensive crisis
 Describe the pathophysiology of hypertensive crisis
 Enlist the clinical manifestations of hypertensive crisis
 Enumerate the diagnostic evaluation of hypertensive crisis
➢Narrate the management of patients with hypertensive crisis
 Prevention of hypertensive crisis

4. REVIEW ANATOMY & PHYSIOLOGY OF BLOOD
VESSEL
 Blood vessel, a vessel in the human or animal body in which
blood circulates. The vessels that carry blood away from the
heart are called arteries, and their very small branches are
arterioles. Very small branches that collect the blood from the
various organs and parts are called venules, and they unite to
form veins, which return the blood to the heart. Capillaries are
minute thin-walled vessels that connect the arterioles and
venules; it is through the capillaries that nutrients and wastes
are exchanged between the blood and body tissues.

5. REVIEW ANATOMY & PHYSIOLOGY OF BLOOD
VESSEL CONT’
Arteries and veins are comprised of three distinct layers while
the much smaller capillaries are composed of a single layer.
Tunica intima- Inner layer (endothelial cells)
Tunica media- medial layer
Tunica Externa or tunica adventitia - outer layer

6. INTRODUCTION
Hypertension is one of the most common chronic
conditions that, on an average, affects 30% of the
population more than 20 years old.
Although chronic hypertension is an established risk
factor for cardiovascular, cerebrovascular, and renal
disease, even acute elevations in BP can result in
acute end-organ damage with significant morbidity.
Hypertensive crisis is commonly
encountered in the emergency rooms.

7. INTRODUCTION
• Prompt recognition, evaluation, and appropriate
treatment of this condition are crucial to prevent
permanent end-organ damage
• Any disorder that causes hypertension can give rise
to a hypertensive crisis, but the most common cause
is poorly controlled essential hypertension

8. INCIDENCDE
• Hypertensive emergencies are common and occur 1% to 2% of
hypertensive population.
• In South East Asia region 36% of adults have hypertension.
• In India, review of epidemiological studies suggest that the
prevalence of hypertension has increased in both urban and
rural subjects and presently 25% of the urban adults and 10 to
15% of rural adults are hypertensive.
• Among all Indian hypertensive 1 to 2 % present with
hypertensive crisis.

9. Terminologies
Hypertensive Crisis It is a clinical syndrome that is
associated abrupt, marked increase in blood pressure
“relative to the patient's baseline” causes acute or
rapidly progressing end-organ damage.
It includes two forms:
• Hypertensive Urgency
• Hypertensive Emergency

10. Terminologies CONT’...
Hypertensive Urgencies:
Is extreme elevation in BP (>180/120 mmHg) without
evidence of end organ damage
Hypertensive Emergencies:
It is a situation in which BP is extremely elevated
(more than 180/120 mm Hg) and must be lowered
immediately (not necessarily to less than 140/90 mm
Hg) to halt or prevent damage to the target organs

11. ETIOLOGY
Most common causes:
➢ Rapid unexplained rise in BP in pt with
chronic essential HT
➢ Most patients will have history of poor
treatment/compliance or an abrupt discontinuation of
their medicine
Other causes:
➢ Renal parenchymal disease (80% of sec.causes)
➢ Systemic disorders with renal involvement (SLE)

12. ETIOLOGY

13. ETIOLOGY cont’
➢ Renovascular disease (Atheroscleroses/fibromuscular
dysplasia)
➢ Endocrine disorders ( phaeochromocytoma/cushing
syndrome)
➢ Drugs (cocaine/amphetam/clonidine withdrawal)
➢ CNS (trauma or spinal cord disorders – Guillain-
Barre)
➢ Coarctation of the aorta
➢ Preeclampsia/Eclampsia
➢ Postop. HT

14. RISK FACTORS
 Female sex,
Higher grades of obesity,
The presence of a hypertensive or coronary heart
disease,
The presence of a somatoform disorder,
A higher number of antihypertensive drugs, and
 Nonadherence to medication.

15. PATHOPHYSIOLOGY
• Not well understood
• Failure of normal autoregulation + abrupt rise in SVR
Increase in SVR due to release of humoral
vasoconstrictors from the stressed vessel wall.
• Endothelium plays a central role in BP homeostasis
via substances as Nitric oxide and prostacyclin

16. PATHOPHYSIOLOGY CONT’
Increased pressure starts a cycle
of:
➢ Endothelial damage
➢ local activation of clotting cascade
➢ fibrinoid necrosis of small vessels
➢ release of more vasoconstrictors
Process leads to progressive
increase in resistance and further
endothelial dysfunction

17. PATHOPHYSIOLOGY CONT’
blood pressure
Auto Regulation Failure
Resistance
vasoconstriction
Endothelial Injury
ischemia
Target organ damage
Prothrombotic
state
RAAS
Activation

18. Common clinical manifestations of end organ
damage in hypertensive emergency

19. Types of End Organ Damage
End organ Damage type
Brain Seizure, ischemic attack, cerebral
infarction,intra cerebral or subarachnoid
bleed, hypertensive encephalopathy
Heart Acute pulmonary edema,acute CHF,ACS
Blood
vessels
Acute aortic dissection,microangiopathic
haemolytic anemia
Kidney Acute kidney injury
Retina Papilleedema,hemorrhage,retinal edema
uterus Eclampsia

20. Diagnostic Evaluation
1)Focus on presence of symptoms of end-organ
dysfunction
2)Any identifiable etiology
Hypertension history
last known normal BP
Prior diagnoses + treatment
Dietary and social factors
Medication
Steroid use
Estrogens
Sympathomimetics ▪ MAO
inhibitor
Social history
smoking, alcohol
illicit drugs (cocaine, stimulants)
Family history
Early HT in family members
cardiovascular and
cerebrovascular disease
Diabetes
Pheochromocytoma
Pregnancy

21. Diagnostic Evaluation cont’...
History (cont)
CVS Hx: Previous MI/angina/arrhythmias, chest
pain/SOB/claudication/flank or back pain
Neurologic Hx: Prior strokes, neuro dysfunction, visual
changes, blurriness, loss of visual fields, vomiting, change
in mental status
Renal Hx: Underlying renal disease (RF), Acute onset
changes in renal frequency (anuria/oliguria)

22. Diagnostic Evaluation cont’...
Endocrine Hx: Diabetes, thyroid dysfunction, Cushing’s
syndrome
Physical Examination:
 Confirm elevated BP
 Proper position, appropriate cuff size, Supine and standing and
both arms
 Perform Fundoscopy examination, CV examination, CNS
examination, respiratory Assessment, Renal assessment, and
Neck examination.

23. Diagnostic Evaluation cont’...

24. Diagnostic Evaluation cont’...
Lab studies:
❖Electrolytes, urea and creatinine
❖CBC and smear
❖Urinalysis – dipstix + microscopy
Imaging studies
❖CXR (chest pain or SOB)
❖Head CT/MRI brain (abn neurology)
❖Chest CT/TEE/Aortic angiogram
(Aortic dissection)

25. Diagnostic Evaluation cont’...
Other Tests
❖ECG
❖toxicology screen and
❖pregnancy test

26. Diagnostic Evaluation cont’...
Classification of Blood Pressure for Adults

27. Management of Hypertensive Crisis
GOAL : Reduce MAP by no more than 20-25%, DBP to
100-110mm Hg within few minutes to 2 hours.
➢More aggressive and rapid BP reduction(Acute
Pulmonary edema, Aortic dissection)
➢More slowly for acute cerebrovascular damages with
monitoring of neurological status.
➢ Constant infusion of intravenous agents required (no
intermittent IV boluses/oral/sublingual drugs- drastic BP
fall).

28. Pharmacological management
1. Sodium nitroprusside: Arterial and venous
vasodilator (Reduces preload and afterload)
2. Fenoldopam: A peripheral dopamine-1 receptor
antagonist(DA1)
3. Nicardipine: cerebral and coronary vasodilation
4. Clevipidine: calcium channel antagonist
5. Labetalol: Combined selective alpha1 adrenergic
and non selective β adrenergic receptor blocker
6. Esmolol: cardio selective beta blocking agents

31. Oral drugs for Hypertensive urgencies

32. Nursing Management
The primary nursing responsibilities for long-term
management of HT are to assist the patient in
➢ Reducing BP
➢ Complying with the treatment plan
Nursing actions:
It includes
✓ Monitor the blood pressure continuously
✓ Administer the recommended antihypertensive
medication

33. ✓ Provide absolute bed rest.
✓ Elevate the head end
✓ Monitor the strict intake and output chart Nursing
Management
✓ Patient and family teaching
✓ Detection and reporting of adverse treatment effects
✓ Compliance assessment and enhancement
✓ Evaluation of therapeutic effectiveness

34. Patient and Family teaching
1. Nutritional therapy
2. Drug therapy
3. Physical activity and rest
4. Home monitoring of BP
5. Tobacco cessation
( Teach the patient about weight loss, stress
management, low salt- low fat – low
cholesterol diet and compliance with the
treatment)

35. ✓ Provide absolute bed rest.
✓ Elevate the head end
✓ Monitor the strict intake and output chart Nursing
Management
✓ Patient and family teaching
✓ Detection and reporting of adverse treatment effects
✓ Compliance assessment and enhancement
✓ Evaluation of therapeutic effectiveness

36.  Some cases of hypertensive emergencies can be
prevented.
 To check your blood pressure regularly.
 To take all prescribed medications without missing any
doses.
 Try to also maintain a healthy lifestyle and
 Follow your doctor's advice.
PREVENTION

37. Reference
1. Aronow W. S. (2017). Treatment of hypertensive
emergencies. Annals of translational medicine, 5(Suppl 1),
S5. https://doi.org/10.21037/atm.2017.03.34.
2. Benken.KS.Hypertensive emergencies.medical issues in
the ICU. Retrieved from
https://www.accp.com/docs/bookstore/ccsap/ccsap20
18b1_sample.pdf •
Sharma.S.K.&Madhavi.S.(2018)Brunner and suddarth’s
text book of medical surgical nursing,
1 SA Edition, New delhi. WoltersKluwer India .

38. Reference cont’
WEB SOURCES
• https://en.wikipedia.org/wiki/Hypertensive_cri
sis
• www.mayoclinic.org/diseases-conditions/high-
blood-pressure/hypertensive-crisis