© 2022 Lippincott Advisor for Education - Diseases and Conditions Hypertension PDF

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Use for hypertension teaching project. Can be used in lab....

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1/30/22, 10:28 AM

© 2022 Lippincott Advisor for Education - Diseases and Conditions: Hypertension

Hypertension Revised: October 01, 2021

Overview Elevated blood pressure (BP), characterized by two or more BP measurements that are greater than 129/80 mm Hg and taken on two separate occasions using a reliable BP recording method; BP measurements may be obtained during a health care visit, at home, or using an ambulatory BP recording device Diagnosis and classification based on new BP categories established in 2017 by the American College of Cardiology/American Heart Association Task Force (see Classifying hypertension) Usually begins as a benign disease, slowly progressing to an accelerated or malignant state Two major types of hypertension Essential hypertension—primary or idiopathic hypertension Secondary hypertension—results from renal disease or another identifiable cause Other forms of hypertension White coat hypertension—elevated BP that occurs in nontreated individuals typically only during health care visits and not at other times; characterized by a systolic BP between 130 and 160 mm Hg May warrant screening with ambulatory or at-home BP monitoring May also warrant screening in adult patients who are on antihypertensive treatment and within 10 mm Hg of their systolic BP goal Masked hypertension—characterized by BP readings that are consistently at 120 to 129 mm Hg (systolic) and 75 to 79 mm Hg (diastolic) Requires ambulatory or at-home BP monitoring Warrants having the patient look for elevations in BP throughout the day, which would signal the need for treatment Hypertensive emergency—the most severe, fulminant form of hypertension characterized by end-organ dysfunction and an extremely high, rapidly developing BP that's typically greater than 180/120 mm Hg May arise from any type of hypertension and is considered a medical emergency Differs from hypertensive urgency (an extremely high blood pressure without end-organ dysfunction), which is treated differently

Classifying hypertension Blood pressure (BP) may be categorized as normal, elevated, stage 1 hypertension, or stage 2 hypertension based on current American College of Cardiology/American Heart Association guidelines. A diagnosis of hypertension is based on obtaining two separate BP readings that fall within the specific parameters listed below. Blood pressure category

Systolic BP*

Diastolic BP*

Normal BP

less than 120 mm Hg

AND

less than 80 mm Hg

Elevated BP

120 to 129 mm Hg

AND

less than 80 mm Hg

Stage 1 hypertension

130 to 139 mm Hg

OR

80 to 89 mm Hg

Stage 2 hypertension

at or above 140 mm Hg

OR

at or above 90 mm Hg

*Individuals

with a systolic BP and a diastolic BP in two categories should be marked in the higher

category. Adapted from: Whelton, P. K., et al. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Journal of the American College of Cardiology. https://doi.org/10.1161/HYP.0000000000000065

Pathophysiology https://advisor-edu.lww.com/lna/pages/printPage.jsp

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© 2022 Lippincott Advisor for Education - Diseases and Conditions: Hypertension

Several theories attempt to explain the pathophysiology of hypertension: Changes in the arteriolar bed cause increased peripheral vascular resistance. Abnormally increased tone in the sympathetic nervous system originates in the vasomotor system centers, causing increased peripheral vascular resistance. Increased blood volume results from renal or hormonal dysfunction. Arteriolar thickening is caused by genetic factors, leading to increased peripheral vascular resistance. Abnormal renin release results in the formation of angiotensin II, which constricts the arterioles and increases blood volume.

Causes Often unknown in primary hypertension Multiple interfering factors: genetic predisposition; obesity; poor diet, including increased sodium and fat intake and low potassium intake; environmental risk factors, including alcohol use and low physical activity level; childhood hypertension; premature birth; and low birthweight Secondary hypertension: renal disease, primary aldosteronism, obstructive sleep apnea, drug or alcohol use (including over-the-counter, prescription, and illicit drugs), and many other less common causes

Risk Factors Family history Black race Stress Obesity High-sodium, high-saturated fat diet Tobacco use Dyslipidemia Hormonal contraceptive use Excessive alcohol intake Sedentary lifestyle Age Diabetes Pregnancy or preeclampsia Renal artery stenosis Reduced nephron mass Depression Hypovitaminosis Chronic nonsteroidal anti-inflammatory drug use Systemic corticosteroid use Antidepressant and atypical antipsychotic drug use Weight loss medication use Stimulant use (amphetamines and caffeine) Illicit drug use (methamphetamines and cocaine) Herbal supplement use (including ma huang)

Incidence Incidence depends on the definition of hypertension used: Using the previous definition of a BP greater than or equal to 140/90 mm Hg, the incidence was approximately 32% of the adult U.S. population over age 20. Using the new definition of a BP greater than or equal to 130/80 mm Hg, the incidence is thought to be closer to 46% of the adult U.S. population. (This increase shouldn't lead to an increase in patients taking antihypertensives because lifestyle modification is the primary treatment for patients with elevated blood pressure or stage 1 hypertension with a low risk of atherosclerotic cardiovascular disease [ASCVD].) Secondary causes of hypertension are found in only about 10% of patients. Hypertension is more common and typically more severe in blacks than in whites, Asians, or Hispanics. https://advisor-edu.lww.com/lna/pages/printPage.jsp

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© 2022 Lippincott Advisor for Education - Diseases and Conditions: Hypertension

The incidence of hypertension increases with age. Generally, a nonhypertensive 45-year-old patient has an increased risk of developing hypertension within 40 years. The risk is 84% if the patient is Chinese, 86% if white, 92% if Hispanic, and 93% if black.

Complications Heart failure (systolic and diastolic) Left ventricular hypertrophy Myocardial infarction Chronic or end-stage kidney failure Blindness Transient ischemic attack or ischemic stroke Hypertensive crisis Neurologic deterioration Intracerebral hemorrhage

Assessment History Asymptomatic in many cases; disorder revealed incidentally during evaluation for another disorder or during routine BP screening Symptoms that reflect the effect of hypertension on organ systems: Awakening with a headache in the occipital region, which subsides spontaneously after a few hours Dizziness, fatigue, and confusion Palpitations, chest pain, and dyspnea Epistaxis Hematuria Blurred vision

Physical Findings Bounding pulse BP greater than 120/80 mm Hg S4 (fourth heart sound) Peripheral edema in late stages Hemorrhages, exudates, and papilledema of the eye in late stages, if hypertensive retinopathy is present Pulsating abdominal mass, suggesting an abdominal aneurysm Elevated BP on at least two consecutive occasions after initial screenings Bruits over the abdominal aorta and femoral arteries or the carotids

Diagnostic Test Results Blood Pressure Measurement The diagnosis of hypertension is contingent on two BP readings indicating pressures above normal. BP readings may be done in a health care setting or using a home-based or ambulatory BP measurement device. Each blood pressure assessment must be accurately performed using the proper technique to ensure consistent readings, especially across practitioners and devices. The patient should be prepared to have BP measured and should be informed of the readings after the assessment is completed. Measurements should be taken in both arms after estimated systolic BP is performed. Documentation should include listing the arm used and the patient's position when the reading was taken. Proper averaging of the readings helps ensure better accuracy. https://advisor-edu.lww.com/lna/pages/printPage.jsp

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Laboratory Urinalysis may show protein, red blood cells, or white blood cells, suggesting renal disease, or the test may show glucose, suggesting diabetes mellitus. High-density lipoprotein (HDL) and low-density lipoprotein (LDL) tests are abnormal. A potassium level (serum) less than 3.5 mEq/L may indicate adrenal dysfunction (primary hyperaldosteronism). A blood urea nitrogen level test (BUN) and creatinine level (serum) can help identify kidney disease. Thyroid-stimulating hormone level (serum) may indicate hyperthyroidism or hypothyroidism as an etiology. A fasting plasma glucose level test may indicate underlying diabetes mellitus. A complete blood count (CBC) with differential can help identify anemia. Sodium level (serum) and calcium level (serum and urine) should be assessed along with potassium, BUN, and creatinine as part of a basic metabolic panel.

Imaging Excretory urography reveals renal atrophy, indicating chronic kidney disease; one kidney that's more than 1.6 cm shorter than the other suggests unilateral kidney disease. Chest radiography demonstrates cardiomegaly. Renal arteriography shows renal artery stenosis.

Diagnostic Procedures Electrocardiography may show left ventricular hypertrophy or ischemia. Captopril radionuclide renal imaging may be done to test for renovascular hypertension. Ophthalmoscopy reveals arteriovenous nicking and, in hypertensive encephalopathy, edema. Echocardiography identifies left ventricular hypertrophy and possible end-organ damage.

Treatment General Lifestyle modification, such as weight reduction or control, dietary changes, limitation of alcohol, regular exercise, avoidance of illicit drugs such as cocaine, and smoking cessation For patient with secondary hypertension, correction of the underlying cause and control of hypertensive effects Relaxation exercises and biofeedback, if appropriate

Diet Low-saturated-fat and low-sodium diet Adequate intake of calcium, magnesium, and potassium DASH (Dietary Approaches to Stop Hypertension) diet (see Following the DASH diet)

Following the DASH diet The DASH (Dietary Approaches to Stop Hypertension) diet is a healthy way of eating developed to help treat or prevent hypertension. It is also recommended to prevent osteoporosis, cancer, heart disease, stroke, and diabetes. The DASH diet focuses on: vegetables fruits low-fat dairy products whole grains https://advisor-edu.lww.com/lna/pages/printPage.jsp

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fish poultry lean meats nuts. A low-sodium version of the DASH diet may be recommended when sodium restriction is prescribed. Other recommendations include minimal alcohol consumption (two or fewer drinks per day for men and one or fewer drinks per day for women). More information on the DASH diet is available at http://www.heart.org/HEARTORG/Conditions/HighB loodPressure/PreventionTreatmentofHighBloodPressure/Managing-Blood-Pressure-with-a-Heart-Healt hy-Diet_UCM_301879_Article.jsp

Activity Regular aerobic exercise (at least 30 minutes per day most days of the week, for a total of 120 to 150 minutes per week) Dynamic resistance exercise (90 to 150 minutes per week) Isometric resistance exercises

Medications First-line medications for the treatment of hypertension, including: angiotensin-converting enzyme inhibitors, such as enalapril maleate and lisinopril thiazide diuretics, such as hydroCHLOROthiazide and chlorthalidone-clonidine hydrochloride angiotensin II receptor blockers (ARBs), such as losartan potassium, eprosartan mesylate, valsartan, and irbesartan calcium channel blockers, such as amLODIPine besylate, and dilTIAZem hydrochloride beta-adrenergic blockers, such as atenolol and metoprolol succinate (occasionally first-line treatments in patients with coronary artery disease and heart failure with reduced ejection fraction) Possibly two medications (or a combination pill) as the initial treatment for a patient diagnosed with stage 2 hypertension whose blood pressure is more than 20/10 mm Hg higher than the target level; the two medications should have different actions and be from different classes

Follow-up Monitoring For patients with elevated BP or stage 1 hypertension and ASCVD risk greater than 10%, nonpharmacologic measures should be used, with follow up in 3 to 6 months. For patients with stage 1 hypertension and ASCVD risk greater than 10%, treatment should include nonpharmacologic measures and antihypertensive medication, with follow-up in 1 month. Patients with stage 2 hypertension should be referred to a primary care provider. Treatment should include nonpharmacologic measures and antihypertensive medication, sometimes requiring multiple medications in different classes. Follow-up is recommended in 1 month. For patients with very high average blood pressure (systolic BP greater than 180 mm Hg or diastolic BP greater than 110 mm Hg), evaluation and prompt antihypertensive treatment is encouraged. Follow-up is recommended in 1 month. For patients with normal blood pressure, annual monitoring is recommended.

Nursing Considerations Nursing Interventions Give prescribed drugs; anticipate the need for a multidrug regimen. Assist the patient in developing a schedule for administration if multiple drugs are ordered. https://advisor-edu.lww.com/lna/pages/printPage.jsp

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Before starting medication therapy, obtain baseline BP readings with the patient lying, sitting, and standing; after the patient has begun medication therapy, continue with continued assessment of BP lying, sitting, and standing, and report differences in readings of 10 mm Hg or greater. Urge the patient to change positions slowly. Advise waiting a few minutes before going from a sitting to a standing position to minimize the risk of orthostatic hypotension. Encourage dietary changes, as appropriate. Obtain a dietary recall, and determine the patient's likes and dislikes. Provide appropriate low-sodium, low-fat food choices, and enlist the aid of a dietitian to assist with meal planning and food selection. Help the patient identify risk factors and modify lifestyle, as appropriate. Help the patient incorporate lifestyle changes and medication therapy into a daily pattern to foster adherence. Encourage the patient to quit smoking, if appropriate. Urge the patient to engage in routine aerobic exercise. Ensure that the patient is comfortable before measuring BP to ensure accurate readings. Use a cuff of the appropriate size. If the patient smokes, wait 30 minutes after the patient has finished a cigarette before obtaining a reading. Institute safety precautions if the patient experiences orthostatic BP changes. Encourage the patient to change positions slowly and to sit at the end of the bed or chair before rising.

Monitoring Vital signs, especially BP (see Recommended BP goals)

Recommended BP goals Recommended blood pressure (BP) goals for selected adults are as follows: adults with confirmed hypertension and atherosclerotic cardiovascular disease (ASCVD) greater than 10%: below 130/80 mm Hg adults with confirmed hypertension and ASCVD less than 10%: below 130/80 mm Hg adults with stable ischemic heart disease and hypertension: below 130/80 mm Hg adults with increased risk of heart failure and hypertension: below 130/80 mm Hg adults with heart failure with reduced ejection fraction: below 130/80 mm Hg adults with heart failure with preserved ejection fraction: first treat fluid overload; then goal is below 130/80 mm Hg adults with chronic kidney disease: below 130/80 mm Hg adults after kidney transplant: below 130/80 mm Hg adults with a prior stroke treated for hypertension prior to stroke: below 130/80 mm Hg adults with a prior stroke not treated for hypertension prior to stroke: if BP is above 140/90 mm Hg, then goal is below 130/80 mm Hg; if BP is less than 140/90 mm Hg, then treatment might not be indicated adults with peripheral arterial disease (PAD) and hypertension: similar to those without PAD (below 130/80 mm Hg) adults with diabetes and hypertension: below 130/80 mm Hg community dwelling, ambulatory adults over age 65 with hypertension: systolic BP below 130 mm Hg institutionalized older adults over age 65 with high rates of comorbidity and limited life expectancy: team-based approach of balancing risks and benefits, clinical judgment, and patient preference Signs and symptoms of target end-organ damage Adherence to prescribed therapy Dietary intake Response to treatment Risk factor modification https://advisor-edu.lww.com/lna/pages/printPage.jsp

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Adverse effects of antihypertensive agents

Associated Nursing Procedures 12-lead electrocardiogram (ECG) Blood pressure measurement Cardiac monitoring Nutritional screening Oral drug administration Postural vital signs measurement Relaxation and stress management techniques Safe medication administration practices, general Urine specimen collection, random Weight measurement

Patient Teaching General Include the patient's family or caregiver in your teaching, when appropriate. Provide information according to their individual communication and learning needs. Be sure to cover: disorder, diagnostic testing, and treatment, including single versus combination drug therapy explanation that the cause of the disorder is usually unknown risk factors, including diet and lifestyle need to avoid over-the-counter cold and sinus medications that contain harmful vasoconstrictors and the need to check with the health care practitioner before using any over-the-counter products lifestyle examination and modification, including diet, activity level, smoking, stress, and alcohol intake DASH diet or dietary restrictions, including information about a low-salt, low-total-fat, low-saturatedfat diet and foods to include and avoid need for a routine exercise program, particularly aerobic walking for at least 30 minutes most days of the week use of a self-monitoring BP cuff and importance of recording the readings in a journal for review by a health care practitioner prescribed medication therapy, including drug names, dosages, rationales for use, and schedule of administration possible adverse effects of prescribed drugs, including orthostatic hypotension and sexual dysfunction, and the need to report adverse effects to the health care practitioner importance of changing positions slowly to prevent orthostatic hypotension danger signs and symptoms and the need to report them to a health care practitioner importance of adhering to antihypertensive therapy and establishing a daily routine for taking prescribed drugs importance of follow-up care, including frequent BP monitoring and evaluation of medication therapy effectiveness.

Discharge Planning Participate as part of a multidisciplinary team to coordinate discharge planning efforts. The team may include a bedside nurse, social worker, case manager, nutritionist, cardiologist, and primary care practitioner. Assess the patient's and family's understanding of the diagnosis, treatment, prognosis, follow-up, and warning signs for which to seek medical attention. Identify the patient'...