Nursing Care of Clients with Hypertension

1. Maria Carmela L. Domocmat
Instructor
School of Nursing
Northern Luzon Adventist College

3. Systolic pressure: pressure at the height of
the pressure pulse
Diastolic pressure: the lowest pressure
Pulse pressure: the difference between
systolic and diastolic pressure
Mean arterial pressure: represents the
average pressure in the arterial system during
ventricular contraction and relaxation

4. Represents the pressure of the blood as it
moves through the arterial system
Cardiac output = HR x SV
Vascular resistance
Mean arterial pressure = CO x VR

5. Short-term regulation: corrects temporary
imbalances in blood pressure
Neural mechanisms
Humoral mechanisms
Long-term regulation: controls the daily,
weekly, and monthly regulation of blood
pressure
Renal mechanism

6. Systolic pressure
The characteristics of the stroke volume being ejected
from the heart
The ability of the aorta to stretch and accommodate the
stroke volume
Diastolic pressure
The energy that is stored in the aorta as its elastic fibres
are stretched during systole
The resistance to the runoff of blood from the systemic
blood vessels

7. Physical
Blood volume and the elastic properties of the
blood vessels
Physiologic factors
Cardiac output
Systemic vascular resistance

8. Which of the following does not directly affect
arterial blood pressure?
a. Heart rate
b. Vascular resistance
c. Venous constriction
d. Blood volume

10. BP of › 140/90 in individuals who do not have
diabetes.
systolic blood pressure greater than or equal to
140 mm Hg and/or a diastolic blood pressure
greater than or equal to 90 mm Hg
BP of ›130/85 in individuals with diabetes
and/or renal impairment
systolic blood pressure of 130 mm Hg and/or a
diastolic blood pressure of 85 mm Hg or higher

11. affects 1.5 billion people
worldwide
1: 4
One in every four Filipino
adults suffers from
hypertension or high
11: 100
least 11 in every 100
Filipinos have pre-
hypertension
5th leading cause
mortality & morbidity in
the Philippines

12. MORBIDITY: 10 Leading Causes, Number and Rate*
5-Year Average (2000-2004) & 2005
5-Year Average (1955-1959) 2005
Diseases
Number Rate Number Rate
1. Acute Lower Respiratory Tract Infection and
694,209 884.6 690,566 809.9
Pneumonia**
2. Bronchitis/Bronchiolitis 669,800 854.7 616,041 722.5
3. Acute watery diarrhea 726,211 928.3 603,287 707.6
4. Influenza 459,624 587.0 406,237 476.5
5. Hypertension 314,175 400.5 382,662 448.8
6. TB Respiratory 109,369 139.7 114,360 134.1
7. Diseases of the Heart 43,945 56.1 43,898 51.5
8. Malaria 35,970 46.1 36,090 42.3
9. Chicken Pox 79,236 41.1 30,063 36.3
10. Dengue fever 15,383 19.6 20,107 23.6
* per 100,000 population
** Does not include ALRI, Pneumonia cases only from 2000-2002
http://www.doh.gov.ph/kp/statistics/morbidity

13. MORBIDITY: 10 Leading Causes, Number and Rate*
5-Year Average (1999-2003) & 2004
5-Year Average (1999-2003) 2004
Diseases
Number Rate Number Rate
1. Acute Lower Respiratory Tract Infection and
677,563 875.8 776,562 929.4
Pneumonia**
2. Bronchitis/Bronchiolitis 669,246 866.4 719,982 861.6
3. Acute watery diarrhea 792,479 1027.0 577,518 690.7
4. Influenza 486,481 629.6 379,910 454.7
5. Hypertension 287,368 370.5 342,284 409.6
6. TB Respiratory 117,712 152.6 103,214 123.5
7. Chicken Pox 77,020 38.9 46,779 56.0
8. Diseases of the Heart 49,160 63.8 37,092 44.4
9. Malaria 45,622 59.3 19,894 23.8
10. Dengue fever 14,039 18.1 15,838 19.0
* per 100,000 population
** Pneumonia only from 1999-2002
http://www.doh.gov.ph/kp/statistics/morbidity

14. systolic blood pressure (SBP) › 140 mm Hg
diastolic blood pressure (DBP) › 90 mm Hg
based on the average of > 2 BP
measurements taken on different occasions
the higher the systolic or diastolic pressure,
the greater the risk.

17. 1. _____________ or __________________
Idiopathic cause
reason for elevation BP is unknown
most common (90 to 95%)
2. _____________________________
With an identifiable cause
e.g. pheochromocytoma, narrowing of the renal
arteries, renal parenchymal disease,
hyperaldosteronism (mineralocorticoid
hypertension) certain medications, pregnancy, and
coarctation of the aorta

18. 3. ___________________________
severe type of elevated blood pressure that is
rapidly progressive.
morning headaches, blurred vision, and dyspnea
and/or symptoms of uremia
BP › 200/150 mm Hg

19. 4 _____________________
- intermittently elevated BP
5. _____________________
- does not respond to usual treatment
6. _____________________
- elevation of BP only during clinic visits
7. ______________________
- sudden elevation of Bp requiring immediate
lowering to prevent complications

20. _______________________
Both the systolic and diastolic pressures are
elevated
_______________________
The diastolic pressure is selectively elevated
________________________
The systolic pressure is selectively elevated

21. Renal failure results in Na+ and water retention.
This results in hypertension. How would you
classify this type of hypertension?
a. Primary hypertension
b. Secondary hypertension
c. Malignant hypertension
d. Systolic hypertension

23. Same risk factors for atherosclerotic heart
disease
dyslipidemia (abnormal blood fat levels)
diabetes mellitus.
Race: African Americans.
Cigarette smoking

24. Family history
Age-related changes in blood pressure
Insulin resistance and metabolic
abnormalities
Circadian variations
Lifestyle factors

25. High salt intake
Obesity
Excess alcohol consumption
Dietary intake of potassium, calcium, and
magnesium
Oral contraceptive drugs
Stress

26. As a Sign
nurses and other health care professionals use BP to
monitor a patient’s clinical status.
Elevated pressure may indicate an excessive dose of
vasoconstrictive medication or other problems.
As a risk factor
hypertension contributes to rate at which
atherosclerotic plaque accumulates within arterial
walls.
As a disease
hypertension is a major contributor to death from
cardiac, renal, and peripheral vascular disease.

28. is the amount of force
on the walls of the
arteries as the blood
circulates around the
body.

29. High blood pressure/ Hypertension result from a change in cardiac output, a change
in peripheral resistance, or both.

30. ↑ ↑
_________ ___________
x
=
↑ Blood Pressure

31. Multifactorial condition
Causes:
change in one or more factors affecting peripheral
resistance or cardiac output
problem with control systems that monitor or
regulate pressure.
Single gene mutations or polygenic (mutations in
more than one gene)

32. Stabilizing mechanisms exist in the body to
exert an overall regulation of systemic arterial
pressure and to prevent circu latory collapse.
Four control systems play a major role in
maintaining blood pressure: the arterial
baroreceptor system, regulation of body fluid
volume, the renin-angiotensinaldosterone
system, and vascular autoregulation.

33. found primarily in carotid sinus, also in aorta and wall of
left ventricle.
Monitor level of arterial pressure
counteracts rise in arterial pressure through vagally
mediated cardiac slowing and vasodilation with decreased
sympathetic tone.
Therefore reflex control of circulation elevates the
systemic arterial pressure when it falls and lowers it when
it rises.
Why this control fails in hypertension is unknown. There is
evidence for upward resetting of baroreceptor sensitivity
so that pressure rises are inadequately sensed even
though pressure decreases are not.

34. Changes in fluid volume also affect the systemic
arterial pressure.
excess of salt and water in a person's body, the blood
pressure rises through complex physiologic
mechanisms that change the venous return to the
heart, producing a rise in cardiac output.
If the kidneys are functioning adequately, a rise in
systemic arterial pressure produces diuresis and a fall
in pressure.
Pathologic conditions that change the pressure
threshold at which the kidneys excrete salt and water
alter the systemic arterial pressure.

35. Renin, angiotensin, and aldosterone also
regulate blood pressure
kidney produces renin
an enzyme that acts on a plasma protein
substrate to split off angiotensin I
which is converted by an enzyme in the lung to
form angiotensin II.

36. Angiotensin II
strong vasoconstrictor
is the controlling mechanism for aldosterone release.
With Aldosterone inhibit sodium excretion, resulting in an
elevation in blood pressure.
Inappropriate secretion of renin may cause increased
peripheral vascular resistance in essential (primary)
hypertension. In high blood pressure, renin levels
should be expected to fall because the increased renal
arteriolar pressure should inhibit renin secretion. In
most people with essential hypertension, however,
renin levels are normal.

37. The process of vascular autoregulation, which
keeps perfusion of tissues in the body
relatively constant, appears to be important
in causing hypertension accompanying salt
and water overload. This mechanism is poorly
understood.

39. • Increased SNS activity r/t dysfunction of ANS
Increased renal reabsorption of Na, Cl, and H20 r/t genetic
variation in pathways by which kidneys handle Na
Increased activity of RAAS, resulting in expansion of
extracellular fluid volume and increased systemic vascular
resistance
Decreased vasodilation of arterioles r/t dysfunction of
vascular endothelium
Resistance to insulin action
which may be a common factor linking hypertension, type 2 diabetes
mellitus, hypertriglyceridemia, obesity, and glucose intolerance

41. Modifiable and nonmodifiable risk factors
Nonmodifiable risk factors
▪ Family history, gender, race, and age-related increases
in blood pressure
Modifiable risk factors
▪ Sedentary lifestyle, poor dietary habits, abdominal
obesity, impaired glucose tolerance or diabetes mellitus,
smoking, dyslipidemia, drug use, and stress

42. family history of In families with
hypertension is a major risk hypertension, there may
factor. be a defect in renal
secretion of sodium or a
heightened sympathetic
nervous system response
to stress.

43. Age
More common in younger men than younger
women
More common in the elderly
Race
The Ontario Survey of the prevalence and control
of hypertension
More common in blacks and South Asians
Socioeconomic group
More common in lower socioeconomic group

44. ESSENTIAL (PRIMARY) SECONDARY
Renal vascular and renal parenchymal
No known cause disease
Associated risk factors Primary aldosteronism
Pheochromocytoma
Family history of Cushing's disease
Coarctation of the aorta
hypertension Brain tumors
Encephalitis
High sodium intake Psychiatric disturbances
Excessive calorie Pregnancy
Medications
consumption Estrogen (e.g., oral contraceptives)
Glucocorticoids
Physical inactivity Mineralocorticoids
Sympathomimetics
Excessive alcohol intake estrogen-containing oral
Low potassium intake contraceptives

45. Why is hypertension
sometimes called
“the silent killer”?

46. Hypertension is sometimes called “the silent
killer” because people who have it are often
symptom free.

47. Asymptomatic
High blood pressure
Headache ( especially upon waking)
Most characteristic sign
Dizziness
Chest pain
Tinnitus
Epistaxis

48. Visual disturbances
retinal changes
hemorrhages, exudates (fluid accumulation),
arteriolar narrowing, and cottonwool spots (small
infarctions)
Papilledema
swelling of the optic disc
For severe hypertension
postural (orthostatic) changes
s/s of primary cause

52. thorough health history and physical examination are
necessary.
Retinas examined (fundoscopy)
laboratory studies
Urinalysis
blood chemistry (ie, Na, K, creatinine, FBS, lipid profile
12-lead ECG
Echocardiography (Left ventricular hypertrophy)
Renal damage may be suggested by elevations in BUN and
creatinine levels or by microalbuminuria or
macroalbuminuria. Additional studies, such as creatinine
clearance, renin level, urine tests, and 24-hour urine
protein, may be performed.

53. psychosocial stressors
Job-related, economic, and other life
stressors
client's response to these stressors.
coping with the lifestyle changes needed to
control hypertension.
Assess past coping strategies.

55. Prolonged BP elevation eventually damages
blood vessels throughout the body,
particularly in target organs such as the
heart, kidneys, brain, and eyes.

56. Coronary artery disease (angina or MI)
Left ventricular hypertrophy
HF
Renal failure
Cerebrovascular involvement [stroke or
transient ischemic attack (TIA)]
Impaired vision

59. goal : prevent death and complications by
achieving and maintaining the arterial blood
pressure at 140/90 mm Hg or lower.

60. Initial Drug Therapy
Lifestyle Without Compelling With Compelling
Modification Indication Indication
Normal BP Encourage N/A N/A
Drugs for compelling
Prehypertension Yes No meds indication (DM, heart
failure, MI, renal failure)
Thiazide-
Thiazide-type diuretics,
Stage I HPN Yes ACE inhibitors, ARBs,
CCBs, Beta blockers Drugs for compelling
indications + other
antihypertensives
Stage II HPN Yes Two-drug combinations
Two-

62. Weight reduction if BMI is 27 or higher
Increase aerobic physical activity
30 to 45 minutes most days of the week
brisk walking, running, cycling, swimming, or stair
climbing, 30 to 45 minutes three to five times a week.
Initiate gradually
should stop and notify the physician if severe
shortness of breath, fainting, or chest pain occurs.
should avoid muscle-building isometric exercise
(weight lifting, wrestling, rowing)

63. Sodium restriction
no more than 2.4 g sodium or 6 g NaCl
Explain it takes 2 to 3 months for the taste buds to
adapt to changes in salt intake may help the patient
adjust to reduced salt intake.
avoid adding salt at the table
avoid cooking with salt
avoid adding seasonings that contain sodium
limit consumption of canned, frozen, or other
processed foods
read labels on processed foods

65. Maintain adequate intake of dietary K
(approximately 90 mmol per day).
Maintain adequate intake of dietary
Ca and Mg for general health.
Reduce intake of dietary saturated fat and
cholesterol

66. Stop smoking / Avoid tobacco
Moderation of alcohol intake
Support groups for weight control, smoking
cessation, and stress reduction
Stress reduction

67. FOOD GROUP NO. SERVINGS PER
DAY
Grains 7–8
Vegetables 4–5
Fruits 4–5
Low fat dairy foods 2–3
Meat, fish, poultry 2 or less
Nut, seeds, dry beans 4 – 5 weekly

69. Yoga
Massage
Biofeedback
Music therapy
Hypnosis

71. diuretics, beta-blockers, or both
uncomplicated hypertension and no specific
indications for another medication
gradual reduction of types and doses of
medication
when BP less than 140/90 mm Hg for at least 1
year

72. Diuretics
Adrenergic Agents (alpha and beta blockers)
Vasodilators
ACE Inhibitors
ARBs
CCB

73. Thiazide Diuretics
chlorthalidone (Hygroton)
quinethazone (Hydromox)
chlorothiazide (Diuril)
hydrochlorothiazide (Esidrix; HydroDIURIL)
Loop Diuretics
furosemide (Lasix)
bumetanide (Bumex)
Potassium-Sparing Diuretics
spironolactone (Aldactone)
triamterene (Dyrenium)

74. What electrolyte are you going to
monitor when a client is in loop or
thiazide diuretics?

77. Beta-Blockers
propranolol (Inderal)
metoprolol (Lopressor)
nadolol (Corgard)

79. Can you give Beta-Blockers to client with
hx of asthma? Why or why not?

80. Alpha Blocker/ Alpha-adrenergic receptor
agonists
prazosin hydrochloride (Minipress)
How do alpha blockers help lower
BP?

82. Combined Alpha and Beta Blocker
labetalol hydrochloride (Normodyne, Trandate)
Peripheral Agents
reserpine (Serpasil)

84. Central Alpha Agonists
methyldopa (Aldomet)
clonidine hydrochloride (Catapres)
▪ transdermal patch
▪ Provide control of BP for as long as 7 days.
s/e: sedation, postural hypotension, impotence

86. Nitroglycerin (Nitro-Bid)
hydralazine hydrochloride (Apresoline)
sodium nitroprusside (Nipride, Nitropress)
fenoldopam mesylate
Minoxidil (Loniten)
diazoxide (Hyperstat, NitroBid IV, Tridil)

88. captopril (Capoten)
enalapril (Vasotec)
lisinopril (Prinivil, Zestril)
benazepril (Lotensin)
enalaprilat (Vasotec IV)
ramipril (Altace)
trandolapril (Mavik)

89. • Instruct to stay in bed for 3 to 4 hours
If receiving for first time
to avoid the severe hypotensive effect (Postural
(orthostatic) hypotension) that can occur with
initial use.
Monitor BP q 15 min after first dose.

91. Or angiotensin II receptor antagonists
losartan (Cozaar)
irbesartan (Avapro)
candesartan (Atacand)
valsartan (Diovan)
telmisartan (Micardis)
excellent options for clients who complain of cough
associated with ACE inhibitors and for those with
hyperkalemia

92. Nondihydropyridines
diltiazem hydrochloride (Cardizem SR, Cardizem CD,
Dilacor XR, Tiazac)
verapamil (Isoptin SR Calan SR, Verelan, Covera HS)
Dihydropyridines
nifedipine (Procardia Adalat CC)
amlodipine (Norvasc)
felodipine (Plendil)
nicardipine (Cardene)
nisoldipine (Sular)

94. Caution patient and caregivers antihypertensive
medications can cause hypotension.
Low blood pressure or postural hypotension
should be reported immediately.
change positions slowly when moving from a
lying or sitting position to a standing position.
elderly : use supportive devices such as hand
rails and walkers when necessary to prevent falls
that could result from dizziness.

96. Monitor BP
Obtain complete history
to assess for symptoms that indicate target organ
damage (whether other body systems have been
affected by the elevated blood pressure).
Ex: anginal pain; shortness of breath; alterations in
speech, vision, or balance; nosebleeds; headaches;
dizziness; or nocturia.
Pulse
rate, rhythm, and character of apical and peripheral
pulses

97. Deficient knowledge regarding the relation
between the treatment regimen and control
of the disease process
Noncompliance with therapeutic regimen
related to side effects of prescribed therapy

98. objective : lowering and controlling the blood
pressure without adverse effects and without undue
cost
support and teach the patient to adhere to treatment
regimen
Implement necessary lifestyle changes
Take medications as prescribed
Schedule regular follow-up appointments
Teach disease process and how lifestyle changes and
meds can control hypertension.
emphasize concept of controlling hypertension rather
than curing it

99. 1. Most common side effects of diuretics are potassium
depletion and orthostatic hypotension.
2. The most common s/e of different antihypertensive
drugs is orthostatic hypotension
3. Take meds at regular basis
4. Assume sitting or lying position for few minutes
5. Change position gradually
6. Avoid very warm bath, prolonged sitting or standing

100. Avoid smoking cigarettes or drinking caffeine
for 30 minutes before blood pressure is
measured.
Sit quietly for 5 minutes before the reading.
Sit comfortably with the forearm supported
at heart level on a firm surface, with both feet
on the ground; avoid talking during
measurement.

101. Assessment is based on the average of at
least two readings. (If two readings differ by
more than 5 mm Hg, additional readings are
taken and an average reading is calculated
from the results.)
Note: patients should be given a written
record of his or her blood pressure at the
screening.

102. Provide written information : expected
effects and side effects of medications;
report s/e
rebound hypertension
sexual dysfunction
some medications, such as beta-blockers, may
cause sexual dysfunction and that, if a problem
with sexual function or satisfaction occurs, other
medications are available.
Monitor BP at home.

104. Gestational hypertension
Chronic hypertension
Preeclampsia-eclampsia
Preeclampsia superimposed on chronic
hypertension

105. Early prenatal care
Refraining from alcohol and tobacco use
Salt restriction
Bed rest
Carefully chosen antihypertensive
medications

106. Blood pressure norms for children are based on age,
height, and gender-specific percentiles
Secondary hypertension is the most common form
of high blood pressure in infants and children
Kidney abnormalities
Coarctation of the aorta
Pheochromocytoma and adrenal cortical
disorders
In infants, associated most commonly with high
umbilical catheterization and renal artery
obstruction caused by thrombosis

108. http://www.cardeneiv.com/acute_hypertension.html

109. http://www.cardeneiv.com/acute_hypertension.html

110. There are two hypertensive crises that
require nursing intervention:
hypertensive emergency
hypertensive urgency.
Hypertensive emergencies and urgencies
may occur in patients whose hypertension
has been poorly controlled or in those who
have abruptly discontinued their
medications.

112. is a situation in which blood pressure must be
lowered immediately (not necessarily to less than
140/90 mm Hg) to halt or prevent damage to the
target organs.
Conditions associated
acute myocardial infarction
dissecting aortic aneurysm
intracranial hemorrhage
are acute, life threatening BP elevations that require
prompt treatment in an intensive care setting because
of the serious target organ damage that may occur.

113. admitted to critical care units
Intravenous vasodilators
have an immediate action that is short lived minutes to 4 hours
used as the initial treatment
sodium nitroprusside (Nipride, Nitropress)
nicardipine hydrochloride (Cardene)
fenoldopam mesylate (Corlopam)
enalaprilat (Vasotec I.V.)
nitroglycerin (Nitro-Bid IV, Tridil)
labetalol (Normodyne)
diazoxide (Hyperstat IV)
• sublingual nifedipine (Procardia, Adalat)

115. is a situation in which blood pressure must be
lowered within a few hours.
Ex: severe perioperative hypertension

116. oral doses of fast-acting agents
loop diuretics (bumetanide [Bumex], furosemide
[Lasix])
beta-blockers propranolol (Inderal), metoprolol
(Lopressor), nadolol (Corgard)
angiotensin-converting enzyme inhibitors
(benazepril [Lotensin], captopril [Capoten], enalapril
[Vasotec]),
calcium antagonists (diltiazem [Cardizem], verapamil
[Isoptin SR, Calan SR, Covera HS])
alpha2-agonists, such as clonidine (Catapres) and
guanfacine (Tenex)

117. Extremely close hemodynamic monitoring of
the patient’s blood pressure and cardiovascular
status is required during treatment of
hypertensive emergencies and urgencies.
VS every 5 minutes or 15 or 30 minutes intervals
if stable.
A precipitous drop in blood pressure can occur,
which would require immediate action to restore
blood pressure to an acceptable level.

119. An abnormal decrease in blood pressure on
assumption of the upright position

120. Decrease in venous return to the heart due to
pooling of blood in lower part of body
Inadequate circulatory response to decreased
cardiac output and a decrease in blood
pressure

121. Conditions that decrease vascular volume
Dehydration
Conditions that impair muscle pump
function
Bed rest
Spinal cord injury

122. Conditions that interfere with
cardiovascular reflexes
Medications
Disorders of autonomic nervous system
Effects of aging on baroreflex function

123. Excessive use of diuretics
Excessive diaphoresis
Loss of gastrointestinal fluids through
vomiting and diarrhea
Loss of fluid volume associated with
prolonged bed rest

124. Dizziness
Visual changes
Head and neck discomfort
Poor concentration while standing
Palpitations
Tremor, anxiety
Presyncope, and in some cases syncope

125. Increased vascular compliance may contribute
to which condition?
a. Systolic hypertension
b. Orthostatic hypotension
c. Orthostatic hypertension
d. Diastolic hypertension

126. LWW ppt presentation. Chapter 23 Disorders
of Blood Pressure Regulation
Brunner
Ignatavicius