Hypertension treatment and crises

1. • HYPERTENTION

2. • Introduction
• Hypertension is a very common medical condition
globally. It is commonly known as high blood pressure
or arterial hypertension. Persistent hypertension is one
of the risk factors for strokes, heart attacks, heart
failure and arterial aneurisms. It is the leading cause of
chronic renal failure.
• In this write up, we are going to discuss hypertension
with regards to the definitions, etiology, types,
pathophysiology, clinical manifestations and
management.

3. • FACTORS THAT REGULATES BLOOD PRESSURE
• 1. SYMPATHETIC NERVOUS SYSTEM
• Sympathetic stimulation
• increase heart rate
• increases cardiac contractility
• causes vasoconstriction
• all of the above causes increased cardiac out
put.

4. • 2. NEURAL TRANSMITERS
• Neuro-transmmiters such as epinephrine cause vaso
constriction
• 3. VASCULAR ENDOTHELIN
• Endothelin is secreted by endotherial cells of the
endotheriam of capillaries. It is a potential vasoconstrictor.
• 4. ALDOSTERONE
• Promotes sodium and water retention there by raising the
blood pressure
• 5. ANTIDIURETIC HORMONE
• The hormone promote reabsorption of water and sodium
from the renal tubes thereby increasing the blood volume.

5. • 6. RENAL SYSTEM
• 7. SODIUM AND WATER RETENTION

6. • Definitions of hypertension
• “Hypertension is defined as a persistent elevation
of the systolic blood pressure at a level of 140
mmHg or higher and diastolic blood pressure at a
level of 90mmHg or higher (Black and Hawks,
2005).
• “Arterial hypertension is a persistent elevation of
the systolic blood pressure above 140mmHg and
of the diastolic blood pressure above 90mmHg
(Luckman, J, 1997).

7. • Epidemiology
• Hypertension is on the rise world wide.
• The prevelance increases with age.
• It is more common in blacks than whites.
• It is the disease of the affluent (the rich)

8. • CLASSIFICATION
• There are two major classifications of
hypertension: primary hypertension and
secondary hypertension.

9. 1. Primary Hypertension
• Primary hypertension is also known as essential or
idiopathic hypertension. There are characteristics
associated with primary hypertension as follows:
• Typically appears between the ages of 30 and 50 years.
• Affects 90% to 95% of all hypertensive cases
• Has a poorer prognosis and is considered to be the
most significant cause of coronary artery disease
• It is the leading cause of death and disability among
adults.

10. • Risk Factors Associated With Primary
Hypertension.

11. • A) Non modifiable factors
• Age-ages between 30 to 50 years and older
age
• family history of hypertension
• Ethnicity (black race)
• Gender-higher in men before the age of 55
and vise versa after the age of 74.

12. • B) Modifiable Factors
• Obesity
• High salt intake
• Tobacco smoking
• Alcoholism
• Stress
• Occupational, aircraft and roadway exposure to
noise
•

13. •
• 1. Secondary Hypertension
• Secondary hypertension is that type of
hypertension which results from other
diseases. Usually the cause is known and
accounts for 5% to 10% of the hypertensive
population. It may result from the following
conditions:
•

14. • Diseases of the cardiovascular system-
coarcutation of the aorta
• Diseases renal system -glomerulonephritis,
pyelonephritis, and congenital cystic disease.
• Diseases of the endocrine system-Cushing’s
syndrome, hyperthyroidism and
phaechromocytoma
• Secondary to pregnancy
• Secondary to certain drugs e.g. estrogen
containing contraceptive pills

15. • Other Classifications
• Regardless of the cause hypertension may be
classified as benign or malignant.
• I. Benign hypertension
• The rise of blood pressure is slow and over a long
period of time. M any patients with this type of
hypertension live active lives with few or no
symptoms and die of independent diseases.
Unless treated patients suffer disability and death
from heart failure

16. • II. Malignant hypertension
• Malignant hypertension is characterized by a
very high blood pressure. The onset is sudden,
and the patient finds it difficult to lead a
normal life. The patient will present with
many signs and symptoms including eye
changes such as retinal hemorrhages.

17. • III. “WHITE COAT HYPERTENSION”
• Hypertension in people who are actually
normotensive except when their blood
pressure is measured by a health care
professional. An intermittent vasovagal
response accounts for the transient elevation
in blood pressure

18. • Iv. Isolated Systolic Hypertension (ISH)
• This type of hypertension occurs when the
systolic blood pressure is 140mmhg or higher
but the diastolic blood pressure remains less
than 90 mmHg. It is thought to be related to
increased cardiac output or atherosclerosis. It
occurs primarily in older adults.
•
•

19. • PATHOPHYSIOLOGY
• Pathophysiology of Primary Hypertension
• The pathologic underpinnings of primary hypertension
remain to be established. However, any factor that
produces an alteration in peripheral vascular resistance,
heart rate or stroke volume affects systemic blood
pressure. Such factors are thought to act by producing a
disturbance in more than one of the four control systems
that play a major role in maintaining blood pressure: the
arterial baroreceptors and chemoreceptor systems,
regulation of blood volume, the rennin-angiotensin system
and the vascular auto regulation.

20. • The baroreceptors and stretch receptors found in the carotid sinus,
aorta and walls of the left ventricle monitor the level of arterial
blood pressure and counter act increases through vasodilation and
slowing of the heart rate via the vagus nerve. Chemoreceptors
located in the medulla and carotid and aortic bodies are sensitive to
changes in the oxygen (O2), carbondioxide (C02) and hydrogen ions
(Ph) concentrations in the blood. A decrease in O2 concentration
and pH causes a rise in blood pressure while a decrease in CO2
concentration causes a decrease in blood pressure. The
chemoreceptors may become desensitized following continued
resetting in sustained increase blood pressure and the
chemoreceptors auto regulation may be altered due to increases in
blood volume and sympathetic over stimulation.

21. • When sodium and water levels are excessive, total
blood volume increases thereby increasing blood
pressure. Pathologic changes that alter the pressure
threshold at which the kidneys excrete salt and water
alter systemic blood pressure. Inappropriate secretion
of rennin increases peripheral resistance. Rennin, an
enzyme produced by the kidneys catalyzes a plasma
protein substrate to split off angiotensin I to
angiotensin II and III. Angiotensin II and III act as
vasoconstrictors and also stimulate aldosterone
release. Therefore increases in rennin causes increased
peripheral vascular resistance.
•

22. • Pathophysiology of malignant Hypertension
• Many renal, vascular , neurologic and drug
induced problems that directly or indirectly
affect the kidneys can result in serious insults
in these organs that interfere with sodium
excretion, renal perfusion or the rennin
angiotensin-aldosterone mechanism leading
to an elevation in blood pressure over time.
•

23. • CLINICAL MANIFESTATIONS
• Hypertension has been called a “silent killer”
because in most cases the symptoms are
unnoticed. An elevation in blood pressure may
only be “caught” at routine screening. However
some people may present with the following:
• Persistent headache due to poor oxygen
perfusion to the brain
• Fatigue as a result of reduced tissue perfusion

24. • Dizziness due to reduced oxygen perfusion to the brain and
raised intracranial pressure
• Palpitations due to brain hypoxia
• Flushing due to brain hypoxia
• Blurred or double vision due to brain hypoxia
• Epistaxis due to rupture of small blood vessels in the nose
• Angina pectoris due to reduced blood supply to the heart
• restlesness and disorientation due to brain hypoxia
• excessive sweating due to increased metabolism
• vomiting due to increased intracranial pressure
• shortness of breath due to poor lung perfusion

25. • MANAGEMENT
• i) Assessment of a Client with Hypertension
• a) History taking
• The following points have to be noted when interviewing the
hypertensive client:
• Family history of hypertension, diabetes mellitus, cardiovascular
diseases or renal disease
• Previous documentation of raised blood pressure
• Prescribed drugs and over the counter drugs
• History of any disease or trauma to target organs
• History of recent weight gain, excessive sodium intake, fat intake,
alcohol use and smoking
• Chronic psychosocial and environmental stress.
•

26. • b) Physical examination
• Blood pressure should be taken in sitting, lying
and standing positions from both arms to
confirm an elevated reading.
• Physical examination from head to toe should
be done.
• Vital signs and weight are taken for baseline
data

27. • c) Investigations
• fundoscopy for assessment of retinopathy due raised blood
pressure
• full blood count
• urinalysis may review blood and protein, signs of kidney damage
due to hypertension
• serum potassium and sodium levels
• blood sugar tests to identify diabetes mellitus
• electrocardiogram may detect heart abnormalities
• chest x-ray may review enlargement of the heart
• blood urea usually raised
• creatinine to assess renal function
• blood cholesterol levels

28. •
• Medical Treatment
• 1. Beta blockers
• Propranol
• Dose: 80mg b.d
• Action: reduce cardiac output, alter baroreceptor
reflex sensitivity and block peripheral adrenal receptors
• Side effects: bradycardia, hypotension, heart failure,
bronchospasm and peripheral vasoconstriction
• 2. Diuretics

29. • Hydrochlorothiazide
• Dose: 25 to 100mg o.d
• Action: increases excretion of water, sodium,
potassium and chloride by blocking the
reabsorption of sodium and chloride
• Side effects: headache, dizziness, parasthesia,
dehydration, abdominal pains and dermatitis

30. • 3. calcium channel blockers
• Nifedipine
• Dose: retard-20mg b.d
• Action: relaxes vascular smooth muscle, and
dilates coronary and peripheral arteries
• Side effects: headache, flushing, dizziness,
tachycardia, palpitations and lethargy.

31. • 4. Angiotensin Converting Enzyme(ACE)
inhibitors
• Captopril
• Dose: 12.5 mg b.d
• Action: inhibit the conversion of angiotensin I to
angiotesin II
• Side effects: tachycardia, serum sickness, weight
loss, stomatitis, maculopapular rash, flushing and
acidosis.

32. • Vaso- dilators
• Hydralazine 25-50 mg bd po
• 20-40 mg iv or im
• action causes relaxation of vascular sooth muscles
leading to peripheral vaso dilatation hence reducing
blood pressure
• side effects-heart papitation, tachycardia, oedema,
angina pectoris, headache, peripheral neuritis,
lacrimation, anaemia.
• 5 Sedative
• Valium 5-10 mg tds

33. • NURSING CARE
• ENVIRONMENT
• The environment should be clean, quiet and well ventilated to promote comfort.
• Position
• The patient should be nursed in the most comfortable position.
• Nutrition
• Provide a well mixed nutritious diet.
• A low salt diet is recommended because salt causes water retention that can increase the blood
volume.
• Provide a low fat diet. In obese patient carolies may be restricted.
• Advice the patient to stop smoking and taking alcohol if they do.
• REST AND ACTIVITIES
• Ensure complete bed rest when the blood pressure is very high
• Put in place measure to achieved complete bed rest.
• As the patient's condition improves, mild exercise and can be encouraged
• These are important to prevent complications such as hypostatic pneumonia. Exercise also help to
burn out excess fat.
•

34. • OBSERVATION
• Check BP 2-3 Hourly to monitor thee patient's condition
• Check pulse 2-4 hourly to evaluate cardiac function
• Monitor respirations 2-4 hourly. Patient may be dyspnaeoic during periods of high blood pressure.
• Observe the mental status of the patient to rule out hypertensive encephalopathy.
• Observe signs of complications such as palarysis as in CVA
• Observe signs of intracranial heamorrhage such as dilatation of the pupil, altered level of conscousness
• Observe the general condition of the patient to detect any abnormalities early.
• PSYCHOLOGICAL CARE
• Encourage the patient to express his feelings about the disease.
• Explain the disease process, treatment and complication, in simple language and allow the patient to ask question to allay anxiety.
• Involve the relatives and significant others in the care to promote compliance to treatment
• Inform the patient that the medical team is doing everything possible to ensure his quick recovery
• Tell the patient that the condition may not be completely elimminated but can be controlled, that is allowing prolonging the periods without attacks.
• Inform the patient that he may be on drugs for a long period of time
• ELIMINATION
• Provide a high rauphage diet to prevent constipation as this can cause straining when opening bowels which can raise the BP
• Monitor urine out put to detect urinary complications early.
• MEDICATION
•
•
• COMPLICATIONS OF HYPERTENSION
• Cardiac disorders e.g. infarctions, congestive cardiac failure
• Hypertensive encelopathy
• Cerebral vascular accidents
• Retinal changes
• Renal failure