Hypertension

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Hypertension

• Terri Slifer Lynch, MSN, RN, BC
• Spring 2006

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Hypertension

• Systolic blood pressure gt 140 mmHg
• or
• Diastolic blood pressure gt 90 mmHg

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• According to the National Institutes of Health
  (NIH), if hypertension (HTN) is left untreated
• 1/2 of hypertensive clients will die of heart
  disease
• 1/3 of hypertensive clients will die of a stroke
• Rest of clients will die of renal failure

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Classifications of HTN

• Primary (essential) HTN
• Secondary HTN
• White coat HTN
• Malignant HTN

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Categories for Blood Pressure in Adults 18 Years
and Older from the Seventh Report From the Joint
National Committee (JNC)

• Normal systoliclt120 and diastoliclt80
• Prehypertension systolic 120-139 or diastolic
  80-89
• Hypertension
• Stage 1systolic 140-159 or diastolic 90-99
• Stage 2 systolic gt160 or diastolic gt100

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Risk Factors for Primary HTN

• Family history
• Age
• Gender
• Stress
• Obesity
• Substance abuse

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Pathophysiological Effects of HTN

• Lumen of vessels become narrowed SVR is
  increased
• Elevated pressure damages intima of vessels
• Ischemia occurs and infarction can follow
• Target organs of damage heart, brain, kidneys,
  eyes

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Clinical Manifestations of Hypertension

• HA, dizziness, double vision,
• Fatigue, red face, epistaxis
• Systolic pressure gt140 or diastolic pressure gt 90
• Retinal changes
• Papilledema
• Angina, MI, TIA, stroke, HF

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Assessment and Diagnostic Evaluation with HTN

• Thorough history
• Physical exam
• 12 lead ECG
• ECHO

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• Blood chemistry
• Urinalysis
• Additional studies to identify extent of renal
  damage
• Lipid profile

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Algorithm for Treatment of HTN

• Lifestyle modifications
• Weight loss
• Exercise
• Smoking cessation
• Decreased ETOH consumption
• Stress reduction
• Dietary modifications

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Pharmacologic Therapy

• Diuretics
• Increase Na and water excretion and reduce blood
  volume
• Side effects- hypotension, dehydration, lyte
  imbalance

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• Drugs
• Thiazide - Hydrochlorothiazide (HCTZ). Mild
  effects.
• Loop diuretic Furosemide (Lasix). Stronger
  effects.
• Potassium sparing Spironolactone (Aldactone).
  Competes with Aldosterone for receptor sites.
  Eplerenone (Inspra)- selective angiotensin
  receptor antagonist.

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• Angiotensin Converting Enzyme (ACE) Inhibitors
• Block enzyme that converts Angiotensin I to
  Angiotensin II
• Also decrease Aldosterone production
• Side effects- Renal damage, angioedema, dry
  cough, hypotension, hyperkalemia. Contraindicated
  in pregnancy.
• Drugs - captopril (Capoten), enalapril (Vasotec),
  ramipril (Altace), lisinopril (Zestril)

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• Angiotensin II Receptor Inhibitor/ Blockers (ARB
  II)
• Block Angiotensin II from its receptor sites.
  Decrease SVR.
• Side effects hypotension, less likely to cause
  hyperkalemia and cough. Contraindicated in
  pregnancy.
• Drugs - losartin (Cozaar), candesartin (Atacand),
  valsartin (Diovan)

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• Beta adrenergic blockers
• Prevent epinephrine and norepinephrine from
  receptor sites. Decrease heart rate,
  automaticity, contractility, myocardial oxygen
  demand
• Side effects hypotension, bradycardia,
  impotence, fatigue, bronchoconstriction, masks
  early signs of hypoglycemia
• Nonselective- block Beta1 Beta2 receptors.
  Propranolol (Inderal), nadolol (Corgard)
• Cardioselective block Beta1 receptors only.
  Metoprolol (Lopressor), atenolol (Tenormin)

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• Calcium channel blockers
• Block inflow of Ca into cells. Decrease
  contractility and conduction. Cause vasodilation
• Side effects hypotension, bradycardia,
  constipation, peripheral edema. Contraindicated
  with severe heart failure.
• Drugs - Diltiazem (Cardizem), verapamil (Calan),
  amlodipine (Norvasc)

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• Alpha2 agonists
• Alpha2 receptors in CNS decrease sympathetic
  nervous stimulation which prevents
  vasoconstriction
• Side effects hypotension, drowsiness,
  dizziness, dry mouth
• Drugs - methyldopa (Aldomet), clonidine
  (Catapress)

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• Alpha1 blockers
• Act directly on vessels and cause vasodilation
• Side effects postural hypotension, syncope,
  lack of energy, increase in SCD
• Drugs - Prazosin (Minipress), doxazosin (Cardura)

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• Vasodilators
• Act directly on smooth muscles of arterioles or
  veins to lower pressure
• Dilate arterioles - decrease SVR. Dilate veins
  decrease preload.
• Side effects hypotension, reflex tachycardia,
  flushing, headache
• Drugs - nitroglycerine (Nitrodur, Imdur),
  nitroprusside (Nipride), hydralazine (Apresoline)
  

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Nursing Diagnoses
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Nursing Interventions For The Hypertensive Client

• Increase knowledge
• Promote home care
• Stress importance of follow-up care
• Reinforce compliance

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Hypertensive Crisis

• Emergency situation where it is imperative to
  reduce pressure immediately to prevent or limit
  target organ damage.
• Goal reduce mean arterial pressure by no more
  than 25 within first 2 hrs. Then to 160/100
  over next 2-6 hrs.
• MAP systolic 2(diastolic)
• 3

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• Use vasodilators for immediate effect
• Nitroprusside (Nipride)
• NTG (Tridil)
• Hydralazine
• Labetolol
• Frequent and close monitoring of vital signs

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Expected Outcomes

• Maintain adequate tissue perfusion
• BP lt 140/90
• No symptoms of angina, stroke, vision changes
• Stable BUN, Cr
• Complies with self care program
• No complications