Chapter 32 Hypertension - Complex 2021 Unit 1 Cardiac

Systemic vascular resistance (SVR)

is the force opposing the movement of blood within the blood vessels -radius of the small arteries and arterioles is the principal factor determining SVR. -as arteries narrow, resistance to blood flow increases. --As arteries dilate, resistance to blood flow decreases. --A small change in the radius of the arterioles creates a significant change in the SVR. -If SVR is increased and CO stays constant or increases, arterial BP will increase. -mechanisms that regulate BP can affect either CO or SVR or both.

Coronary Artery Disease

mechanisms by which HTN contributes to the development of atherosclerosis are not fully known -"response-to-injury" theory of atherogenesis suggests that hypertension disrupts the coronary artery endothelium -results in a rigid arterial wall with a narrowed lumen -may account for the high rate of CAD angina MI.

β-Adrenergic Blockers - Non-Cardioselective Blockers

nadolol (Corgard) pindolol propranolol (Inderal) Block β1- and β2-adrenergic receptors Reduce BP by blocking β1- and β2-adrenergic effects Same as cardioselective, except may cause bronchospasm, especially in patients with a history of asthma

A patient with hypertension has been prescribed an antihypertensive medication. During a follow-up visit, the patient asks if the medication can be stopped because the BP is now within the normal range. Which response would the nurse provide? 1. "You may stop the medication now because your BP is normal." 2. "Begin taking half-doses of the medication because the BP has decreased." 3. "You may stop taking the medication only if you maintain a healthy lifestyle." 4. "Continue the medication unless your health care provider advises discontinuing it."

"Continue the medication unless your health care provider advises discontinuing it." Antihypertensive medications are effective at reducing BP; however, the medications should not be stopped abruptly because this can cause a severe hypertensive reaction. The medications should be discontinued only after consulting with the health care provider. The medication should not be stopped even if the BP measurements show normal readings. Medications should be taken regularly for sustained therapeutic effects. A reduction of the dosage may reduce the efficacy of the drug. Lifestyle modifications are necessary to reduce cardiovascular risks; however, antihypertensive medications should also be used for effective reduction of BP.

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? "I will avoid adding salt to my food during or after cooking." "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications."

"I can lower my blood pressure by switching to smokeless tobacco." Rationale: Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

A nurse provides education to a patient with hypertension related to lifestyle modifications to reduce overall cardiovascular risk. Which statement made by the patient indicates effective learning? Select all that apply. 1. "I should exercise for at least 30 minutes daily." 2. "I should achieve and maintain a healthy weight." 3. "I should limit my alcohol intake to five drinks per day." 4. "I should restrict my salt intake to less than or equal to 1500 mg/day." 5. "I can continue to smoke because nicotine does not affect BP."

"I should exercise for at least 30 minutes daily." "I should achieve and maintain a healthy weight." "I should restrict my salt intake to less than or equal to 1500 mg/day." Lifestyle modifications play a vital role in reducing BP and cardiovascular risk. Overweight people are at higher risk of cardiovascular disease. A weight loss of 22 lb may decrease systolic BP by approximately 5 to 20 mm Hg. Being physically active is essential to maintaining good health. It decreases the cardiovascular risk of hypertension. Sodium reduction helps to control BP. A patient with hypertension should lower salt intake to 1500 mg/day. The nicotine in tobacco causes vasoconstriction and increases BP. Therefore smokers who are hypertensive should stop smoking. Excessive alcohol consumption increases the risk of hypertension. Consuming three or more drinks per day increases the risk of cardiovascular disease and stroke.

The nurse provides education to a patient about the Dietary Approaches to Stop Hypertension (DASH) diet. Which statement made by the patient indicates an understanding of the teaching? 1. "I should drink no more than three glasses of whole milk per day." 2. "I should include four to five servings of fruits and vegetables daily." 3. "I should eat three servings of red meat, such as pork or beef, daily." 4. "I should consume whole-grain products no more than once per week."

"I should include four to five servings of fruits and vegetables daily." The DASH diet encourages the consumption of fruits and vegetables. Pork and beef are high in fat and therefore have to be restricted according to the DASH diet; poultry and fish have to be consumed instead of red meat. Fat-free or low-fat milk has to be used instead of whole milk according to the DASH recommendations. The DASH diet recommends a few servings of whole-grain products daily.

The nurse provides education to a patient about the Dietary Approaches to Stop Hypertension (DASH) diet. Which statement made by the patient indicates an understanding of the teaching? 1. "I should drink no more than three glasses of whole milk per day." 2. "I should include four to five servings of fruits and vegetables daily." 3. "I should eat three servings of red meat, such as pork or beef, daily." 4. "I should consume whole-grain products no more than once per week."

"I should include four to five servings of fruits and vegetables daily." The DASH diet encourages the consumption of fruits and vegetables. Pork and beef are high in fat and therefore have to be restricted according to the DASH diet; poultry and fish have to be consumed instead of red meat. Fat-free or low-fat milk has to be used instead of whole milk according to the DASH recommendations. The DASH diet recommends a few servings of whole-grain products daily.

A 44-yr-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After providing teaching, which statement by the patient indicates correct understanding? "If I take this medication, I will not need to follow a special diet." "It is normal to have some swelling in my face while taking this medication." "I will need to eat foods such as bananas and potatoes that are high in potassium." "If I develop a dry cough while taking this medication, I should notify my doctor."

"If I develop a dry cough while taking this medication, I should notify my doctor." Rationale: Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced sodium diet.

Which information would the nurse teach to a patient who has a new prescription for doxazosin? 1. "Monitor yourself for a fast heart rate, which is a common side effect." 2. "Make position changes slowly, especially from lying down to standing." 3. "The medication also improves breathing by decreasing chest congestion." 4. "It is common for patients who take this medication to experience nausea."

"Make position changes slowly, especially from lying down to standing." Doxazosin is an α-adrenergic blocker and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. It is recommended to take the medication at bedtime to reduce the risk of associated orthostatic hypotension. Tachycardia, respiratory effects, and nausea are not evident with the medication.

A patient with hypertension asks the nurse, "What can I do to decrease my BP?" Which information will the nurse provide? 1. "Reduce sodium intake to less than 3000 mg per day." 2. "Restrict alcohol consumption to no more than three drinks daily." 3. "Perform moderate-intensity aerobic physical activity for at least 30 minutes daily." 4. "Reduce weight by 10 pounds, which decreases BP by 20 to 30 mm Hg."

"Perform moderate-intensity aerobic physical activity for at least 30 minutes daily." Moderate physical activity, such as walking for at least 30 minutes, on at least five days per week is recommended to reduce BP. For those with hypertension, sodium should be restricted to less than or equal to 1500 mg per day. Alcohol consumption should be restricted to no more than one drink per day for women and no more than two drinks per day for men. Weight reduction by 20 lbs leads to a reduction in systolic BP of 5 to 20 mm Hg.

Drug Alert: Doxazosin (Cardura)

-Use caution when giving the first dose. It is best to give the first dose at bedtime to reduce the first dose BP drop. -Syncope occasionally occurs 30 to 90 min after the first dose, a too-rapid increase in dose, or addition of another antihypertensive agent to therapy. -Drug interactions (severe low BP) can occur with patients taking phosphodiesterase inhibitors, such as sildenafil (Viagra) or tadalafil (Cialis).

A patient receives a new prescription for doxazosin. Which information would the nurse include in the patient's medication education? 1. "Weigh yourself daily and report any weight loss to your prescriber." 2. "Increase your potassium intake by eating more bananas and apricots." 3. "Take this drug at bedtime because of the risk of orthostatic hypotension." 4. "The impaired taste associated with this medication usually goes away in two to three weeks."

"Take this drug at bedtime because of the risk of orthostatic hypotension." A patient who is starting doxazosin should take the first dose while lying down because there is a first-dose hypotensive effect with this medication. Taking the drug at bedtime reduces risks associated with orthostatic hypotension. It does not cause weight loss because it is not a diuretic. The patient does not need to increase potassium intake. Doxazosin does not cause impaired taste.

A patient is diagnosed with primary hypertension and asks the nurse what caused the condition. Which response would the nurse give? 1. "There is no identified cause." 2. "A decrease in plasma renin levels." 3. "Too much plaque in the blood vessels." 4. "Kidney disease is the most common cause."

"There is no identified cause." There is not one exact cause of primary hypertension; there are several contributing factors. Renal or kidney disease is a cause of secondary hypertension. An increase, not a decrease, in plasma renin levels is a contributing factor in the development of primary hypertension. Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels.

The nurse provides education to a 68-year-old patient who is experiencing orthostatic hypotension. Which statement made by the patient indicates the need for further teaching? 1. "I should change positions slowly so that I do not become light-headed." 2. "I should continue to limit my salt intake, which helps prevent high BP." 3. "This may be caused by dehydration, so perhaps I should increase my fluid intake." 4. "This may be caused by my BP medications, which I should stop taking."

"This may be caused by my BP medications, which I should stop taking." BP medications may contribute to orthostatic hypotension; however, medications should not be discontinued unless advised by the health care provider. Changing positions slowly and limitation of salt intake are both correct ways to promote cardiovascular health and safety associated with the hypotension. Dehydration is a common cause of orthostatic hypotension and should be addressed.

The nurse provides medication education to a patient with a new prescription for lisinopril. Which information would the nurse include in the teaching? 1. "Never take this medication on an empty stomach." 2. "You should not take this medication if you have asthma." 3. "You may develop a dry cough while taking this medication." 4. "Discontinue this medication if you develop a drop in your BP."

"You may develop a dry cough while taking this medication." Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor. A common side effect is a dry cough. This medication is safe for use with asthma, can be taken on an empty stomach, and should not be discontinued unless instructed to do so by a health care provider.

An adult patient with no medical history is being seen in a clinic for a routine physical exam. The patient's BP reading is 158/92. The patient asks the nurse: "Does this mean that I have hypertension?" Which response would the nurse provide? 1. "Do not worry. Everything is fine." 2. "It is a normal BP reading for an adult." 3. "Yes, you have hypertension because your BP is over 140/90." 5. "You need a follow-up BP check to make that determination.

"You need a follow-up BP check to make that determination." A diagnosis of hypertension will not be made based on one elevated BP reading. Considering the fact that the patient does not have any medical problems and that this reading is the first elevated BP reading, a follow-up office visit is required. Providing false reassurance to the patient is leading to misinformation. Normal BP is defined as a systolic BP (SBP) of less than 120 mm Hg and a diastolic BP (DBP) of less than 80 mm Hg, so a reading of 158/92 is not normal.

A patient is diagnosed with primary hypertension and asks the nurse what caused the condition. How should the nurse respond? 1. "There is no identified cause." 2. "Kidney disease is the most common cause." 3. "It is caused by a decrease in plasma renin levels." 4. "It is caused by too much plaque in the blood vessels.

1. "There is no identified cause." "There is not one exact cause of primary hypertension; there are several contributing factors. Renal or kidney disease is a cause of secondary hypertension. An increase, not a decrease, in plasma renin levels is a contributing factor in the development of primary hypertension. Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels.

A patient has not reached goal BP despite taking full dose of an appropriate three-drug therapy regimen, including a diuretic. Which finding in the patient history is the likely cause of resistant hypertension. 1. Increasing obesity. 2. Excess pepper intake. 3. Consumes peppermint. 4. Erectile dysfunction (ED) medication.

1. Increased obesity. An increase in obesity is one of the causes of resistant hypertension. Licorice (rather than peppermint), excess salt (rather than pepper) intake, and oral contraceptives (rather than ED medications) are also possible causes of resistant hypertension.

An elderly patient often experiences sudden dizziness when standing. In which order would the nurse perform the steps of an assessment for orthostatic hypotension? 1. Assist the patient to a sitting position with the legs dangling. 2. Assist the patient to stand and measure BP and heart rate (HR) within one to two minutes. 3. Measure BP and HR in the supine position after two to three minutes of rest. 4. Measure BP and HR again within one to two minutes after sitting. 5. Evaluate the findings.

1. Measure BP and HR in the supine position after two to three minutes of rest. 2.Assist the patient to a sitting position with the legs dangling. 3.Measure BP and HR again within one to two minutes after sitting. 4.Assist the patient to stand and measure BP and heart rate (HR) within one to two minutes. 5.Evaluate the findings. When assessing a patient for orthostatic or postural changes in BP and pulse, the nurse initially measures BP in the supine position after two to three minutes of rest. BP and pulse are then measured one to two minutes after assisting the patient to a sitting position with the legs dangling. Next, BP and pulse are assessed in the standing position after standing for one to two minutes. Finally, the findings should be evaluated to determine if orthostatic hypotension exists.

Which mechanism of hypertension causes target organ damage? 1. Promotion of atherosclerosis and damage to the walls of the arteries. 2. Thickening of the capillary membranes, leading to hypoxia of organs. 3. Direct pressure on organs that results in necrosis and replacement of cells with scar tissue. 4. Increased blood viscosity that contributes to intravascular coagulation and tissue necrosis.

1. Promotion of atherosclerosis and damage of the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of the arteries and reduces circulation to target organs and tissues. Hypertension does not thicken capillary membranes, cause direct pressure on organs, or increase blood viscosity.

Blood pressure measurement

1. Seat patient with legs uncrossed, feet on the floor, and back supported. Bare patient's arm and support it at heart level. 2. Begin measurement after the patient has rested quietly for 5 min. Ask patient to relax as much as possible and not to talk during the measurement. 3. Use the right cuff size, following instructions for fit and placement according to manufacturer's recommendations. 4. Measure and record BP in both arms initially and note any differences. There are conditions when an extremity should not be used for blood pressures. These exclusions include, but are not limited to, deep venous thrombosis, arteriovenous fistula or graft, peripherally inserted central line (PICC), lymphedema, and limb ischemia. Use the arm with the highest BP and verify the reference point is at the heart. 5. BP should preferably be taken with an oscillometric device, rather than manually. The accuracy of oscillometric devices may be limited if patients are hypertensive, hypotensive, or have heart dysrhythmias (e.g., atrial fibrillation). 6. Patients with atrial fibrillation may HR variations causing variations in BP, so it is recommended to take 3 different measurements over several minutes to confirm the BP. 7. For auscultatory measurement, estimate SBP by palpating the radial pulse and inflating the cuff until the pulse disappears. Inflate the cuff 20-30 mm Hg above this level. 8. Deflate the cuff at a rate of 2-3 mm Hg/sec. 9. Record the SBP and DBP. Note the SBP when the first of 2 or more Korotkoff sounds are heard and the DBP when sound disappears. 10. Provide the patient (verbally and in writing) with the BP reading, BP goal, and recommendations for follow-up. 11. Clean BP cuffs between patients according to the agencies policy for reusable medical equipment cleaning. Safety Alert • If using the forearm rather than the upper arm for BP measurement, document the site. • BP cuffs that are too small or too large will result in readings that are falsely high or low, respectively. • If bilateral BP measurements are not equal, record this finding and use the arm with the highest BP for all future measurements.

A patient is diagnosed with primary hypertension. Which factors in the patient's history likely contributed to the development of hypertension? Select all that apply. 1. Tobacco use. 2. Thyroid disease. 3. Diabetes mellitus. 4. Increased sodium intake. 5. Greater-than-ideal body weight. 6. Underproduction of sodium-retaining hormones.

1. Tobacco use. 3. Diabetes mellitus. 4. Increased sodium intake. 5. Greater-than-ideal body weight. Contributing factors to primary hypertension include tobacco, diabetes mellitus, increased sodium intake, and greater-than-ideal body weight. Thyroid disease is related to secondary hypertension. Overproduction (not underproduction) of sodium-retaining hormones contributes to primary hypertension.

A patient who has been taking clonidine for 10 years tells the nurse, "I decided to quit taking the medication a few days ago." For which manifestation would the nurse monitor this patient? 1. Tremors 2. Lethargy 3. Dysphagia 4. Bradycardia

1. Tremors Sudden discontinuation may cause withdrawal, including rebound hypertension, tachycardia, headache, tremors, apprehension, and sweating. Bradycardia, lethargy, and dysphagia are not indicators of the withdrawal syndrome.

Which systolic BP (SBP) measurement correlates with stage 1 hypertension? 1. 118 mm Hg 2. 129 mm Hg 3. 132 mm Hg 4. 142 mm Hg

132 mm Hg Stage 1 hypertension is defined as an SBP of 130 to 139 or a diastolic BP (DBP) of 80 to 89 mm Hg. Normal BP is defined as an SBP of less than 120 mm Hg and a DBP of less than 80 mm Hg. Elevated BP is defined as an SBP between 120 and 129 mm Hg and a DBP of less than 80 mm Hg. Hypertension (stage 1) is defined as an SBP between 130 and 139 mm Hg and a DBP between 80 and 89 mm Hg. Hypertension (stage 2) is defined as an SBP of greater than 140 mm Hg and a DBP of greater than 90 mm Hg. If either the SBP or DBP is outside of a range, the higher measurement determines the classification.

A patient admitted with a history of hypertension has been taking hydrochlorathiazide daily for the past 10 years. Which parameter would the nurse evaluate to indicate the effectiveness of this drug therapy? 1. Weight loss of 2 lb. 2. BP of 118/76. 3. Absence of angle edema. 4. Urine output of 600 mL per eight hours.

2. BP of 118/76. Because the patient has been taking this medication for 10 years, the most direct measurement of its long term intended effect would be normal BP. Hydrochlorathizide may be used alone with monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, so weight loss, absence of edema, and urine output would not be pertinent.

Which mechanism of action makes atenolol beneficial to a patient with hypertension? 1. Activates dopamine receptors. 2. Blocks Beta-adrenergic receptors. 3. Relaxes arterial and venous smooth muscles. 4. Reduces conversion of angiotensin I to angiotensin II.

2. Blocks Beta-adrenergic receptors. Atenolol is a cardioselective Beta-adrenergic receptor blockers (Beta-blockers) that reduces BP. It also reduces cardiac output and reduces sympathetic vasoconstrictor. It also decreases renin secretion by the kidneys. Fenoldopam, a direct vasodilator, activates dopamine receptors, resulting in systemic and renal vasodilation. Nitroglycerin is a direct vasodilator, which relaxes arterial and venous smooth muscle, reducing preload and systemic vascular resistance (SVR). Angiotensin-converting enzyme (ACE) inhibitors ACE, reducing the conversion of angiotensin I to angiotensin II.

Which medication should be used with caution in patients with diabetes because the drug may depress the tachycardia associated with hypoglycemia. 1. Diltiazem 2. Metoprolol 3. Prednisone 4. Hydromorphone

2. Metoprolol Metoprolol, a beta-adrenergic receptor blocker (b-blocker), slows the heart rate. Tachycardia is a classic symptom of hypoglycemia; therefore patients must be made aware of the failure of the heart rate to respond to decreased glucose levels and should be instructed for other signs of hypoglycemia. Diltiazem and hydromorphone will not affect blood sugars or signs/symptoms of hypoglycemia. Prednisone will increase, not decrease, blood sugar levels.

Which instruction is important for the nurse to provide to a patient about the management of stage 1 hypertension? 1. Restrict all caffeine 2. Restrict sodium intake 3. Increase protein intake 4. Use calcium supplements

2. Restrict sodium intake The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

Which laboratory test result indicates the presence of target organ damage in a patient with hypertension? 1. Serum uric acid of 3.8 mg/dL 2. Serum creatinine of 2.6 mg/dL 3. Serum potassium of 3.5 mEq/L 4. Blood urea nitrogen (BUN) of 15 mg/dL

2. Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. BUN of 15 mg/dL, serum uric acid of 3.8 mg/dL, and serum potassium of 3.5 mEq/L are within normal limits.

A patient receives instructions about monitoring BP levels at home. Which information would the nurse teach the patient about measuring the BP in a supine position? 1. Take the reading immediately after lying down. 2. Support the arm with a pillow during measurement. 3. Take at least two conservative readings one after another. 4. Use the arm with lower BP for all future measurements.

2. Support the arm with a pillow during measurement. When measuring BP in a supine position, the patient should support the arm with a small pillow to raise the position of the hand to the level of the heart. Record the average pressure by taking two consecutive readings at least one minute apart; this allows the blood to drain from the arm and prevent inaccurate readings. The first reading should be taken after two to three minutes of rest in a supine position. If bilateral BP measurements are not equal, the patient should use the arm with the highest BP for all future measurements.

A female patient with chronic hypertension is admitted to the emergency department with a sudden rise in BP. Which question is the priority for the nurse to ask the patient? 1. "Are you pregnant?" 2. "Do you need to urinate?" 3. "Do you have a headache or confusion?" 4. "Are you taking antiseizure medications?"

3. "Do you have a headache or confusion?" The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy, from increased cerebral capillary permeability leading to cerebral edema. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not indicate a hypertensive emergency.

Which systolic BP measurement correlates with stage 1 hypertension? 1. 118 mm Hg 2. 129 mm Hg 3. 132 mm Hg 4. 124 mm Hg

3. 132 mm Hg Stage 1 hypertension is defined as an SBP of 130 to 139 or a diastolic BP (DBP) of 80 to 89 mm Hg. Normal BP is defined as an SBP of less than 120 mm Hg and a DBP of less than 80 mm Hg. Elevated BP is defined as an SBP between 120 and 129 mm Hg and a DBP of less than 80 mm Hg. Hypertension (stage 1) is defined as an SBP between 130 and 139 mm Hg and a DBP between 80 and 89 mm Hg. Hypertension (stage 2) is defined as an SBP of greater than 140 mm Hg and a DBP of greater than 90 mm Hg. If either the SBP or DBP is outside of a range, the higher measurement determines the classification.

A patient is scheduled to begin prescribed doses of metoprolol. Which assessment finding would lead the nurse to withhold the medication and consult the health care provider? 1. Migraine headache. 2. Pitting edema of +1. 3. Blood sugar 217 mg/dL. 4. Pulse 112 beats/minute.

3. Blood sugar 217 mg/dL Metoprolol is a Beta-adrenergic-blocking agent that reduces BP. It should be used with caution in patients with diabetes because the drug may depress the tachycardia associated with hypoglycemia and may adversely affect glucose metabolism. Metoprolol will not worsen migraine, may help with decreasing edema, and will decrease the elevated pulse rate.

Which changes in vital signs indicate that a patient who has just stood up is experiencing postural hypotension? 1. Increased systolic BP and/or decreased heart rate (HR). 2. Increased diastolic BP and/or decreased HR. 3. Decreased systolic BP, decreased diastolic BP, and/or increased HR. 4. Decreased systolic BP, increased diastolic BP, and no change in HR.

3. Decreased systolic, BP, decreased diastolic BP, and/or increased HR. A decrease in both systolic and diastolic BP and increase in HR would be seen in a patient with postural hypotension. BP drops as the volume of circulating blood decreases when a patient abruptly stands from a lying or sitting position. The HR increases as the heart attempts to compensate by increasing the amount of circulating blood by increasing cardiac output. Increased systolic BP and decreased HR; increased diastolic BP and increased HR; and decreased systolic BP, increased diastolic BP, increased diastolic BP, and no change in HR are all incorrect.

A patient with hypertension receives a prescription for lisinopril. Which mechanism of action would the nurse expect from this medication? 1. Blocks a-adrenergic effects. 2. Relaxes arterial and venous smooth muscle. 3. Inhibits conversion of angiotensin I to angiotensin II 4. Reduces sympathetic outflow from the central nervous system (CNS)

3. Inhibits conversion of angiotensin I to angiotensin II Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta-adrenergic receptor blockers (b-blockers) result in vasodilation and a decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central-acting a-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased system vascular resistance (SVR) and BP.

The nurse provides discharge teaching to a female patient who was newly diagnosed with primary hypertension. Which instruction would be included? 1. Decrease the intake of omega-3 fatty acids. 2. Restrict sodium to less than or equal to 2300 mg/day. 3. Limit the intake of alcohol to no more than one drink per day. 4. Begin taking a calcium supplement to help lower BP.

3. Limit the intake of alcohol to no more than one drink per day. Excessive alcohol intake is strongly associated with hypertension. Women and lighter-weight men should limit their intake to no more than one drink per day. Calcium supplements are not recommended to lower BP. Increased levels of dietary omega-3 fatty acids are associated with lower BP. People with hypertension should restrict sodium to less than or equal to 1500 mg/day.

The nurse is teaching an older patient with hypertension about developing an exercise program. Which instructions should the nurse include? 1. Perform weightlifting on a daily basis. 2. Perform flexibility and balance exercises daily. 3. Perform muscle strengthening activities twice a week. 4. Perform high-intensity for 30 minutes on most days.

3. Perform muscle strengthening activities twice a week. All adults should perform muscle-strengthening activities using the major muscles of the body at least twice a week. Weightlifting is not recommended for a patient with hypertension because it may increase BP. Flexibility and balance exercises are recommended at least twice a week for older adults, especially those at risk for falls. It is recommended to perform moderate-intensity aerobic physical activity for at least 30 minutes on most days (i.e., more than 5 days a week).

The nurse is preparing to measure the blood pressure of a patient who is lying down on a bed. What technique should the nurse use? 1. Place the BP cuff on the forearm when measuring the BP. 2. Measure the BP in both arms and record the lowest reading. 3. Rest the patient's arm on a pillow during the BP measurement. 4. Measure the BP twice in a quick succession and average the readings.

3. Rest the patient's arm on a pillow during the BP measurement. For measurement taken in a supine position, raise and support (e.g., with a small pillow) the arm at the heart level. If the arm is resting on the bed, it will be below the heart level. This allows the blood to drain from the arm and prevents inaccurate readings. If the patient is in a lying-down position, the arm should be placed on a pillow so that it is at the heart level. The upper arm, not the forearm, is the preferred site of BP cuff placement because of its accuracy of recordings. Atherosclerosis in the subclavian artery may result in a falsely low BP in the affected side; therefore the arm that has the highest recording of the BP should be used for further measurements. The BP should be taken at least 1 minute apart.

A patient with hypertension has been prescribed an antihypertensive medication. During a follow-up visit, the patient asks if the medication can be stopped because the blood pressure (BP) is now within the normal range. Which nursing response is appropriate? 1. "You may stop the medication because your BP is normal." 2. "You may stop taking the medication if you maintain a healthy lifestyle." 3. "Begin taking half-doses of the medication because the BP has decreased." 4. "Continue the medication until your health care provider advises to discontinue it."

4. "Continue the medication until your health care provider advises to discontinue it." Antihypertensive medications are effective at reducing BP; however, the medications should not be stopped abruptly because this can cause a severe hypertensive reaction. The medications should be discontinued only after consulting with the primary health care provider. The medication should not be stopped even if the BP measurements show normal readings. Medications should be taken regularly for sustained therapeutic effects. A reduction of the dosage may reduce the efficacy of the drug. Lifestyle modifications are necessary to reduce cardiovascular risks; however, antihypertensive medications should also be used for effective reduction of BP.

The nurse is assessing a patient for orthostatic hypotension. First, the nurse measured the BP and heart rate (HR) with the patient in supine position. 1. Repeat BP and HR in the supine position. 2. Ask the patient to sit or stand and then measure the BP and HR within 15 minutes. 3. Move the patient to a standing position and immediately measure the BP and HR. 4. Move the patient to a sitting position and measure the BP and HR again within 2 minutes. When assessing for orthostatic changes, after measuring the BP and HR in the supine position, the patient then is placed in a sitting position and the BP and HR are measured within one to two minutes. The patient is then repositioned to the standing position with BP and HR measured again, within one to two minutes. The results then are recorded with a decrease of 20 mm Hg or more in systolic blood pressure (SBP), a decrease of 10 mm Hg or more in diastolic blood pressure (DBP), or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing, indicating orthostatic hypotension.

4. Move the patient to a sitting position and measure the BP and HR again within 2 minutes. When assessing for orthostatic changes, after measuring the BP and HR in the supine position, the patient then is placed in a sitting position and the BP and HR are measured within one to two minutes. The patient is then repositioned to the standing position with BP and HR measured again, within one to two minutes. The results then are recorded with a decrease of 20 mm Hg or more in systolic blood pressure (SBP), a decrease of 10 mm Hg or more in diastolic blood pressure (DBP), or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing, indicating orthostatic hypotension.

Propranolol (Inderal) is prescribed for a patient diagnosed with hypertension. The nurse should consult with the health care provider before giving this drug when the patient reveals a history of: a. asthma. b. daily alcohol use. c. peptic ulcer disease. d. myocardial infarction (MI).

A Nonselective beta-blockers block beta 1- and beta 2-adrenergic receptors and can cause bronchospasm, especially in patients with a history of asthma. beta-Blockers will have no effect on the patient's peptic ulcer disease or alcohol use. beta-Blocker therapy is recommended after MI.

The nurse on the intermediate care unit received change-of-shift report on four patients with hypertension. Which patient should the nurse assess first? a. 48-yr-old with a blood pressure of 160/92 mm Hg who reports chest pain b. 52-yr-old with a blood pressure of 198/90 mm Hg who has intermittent claudication c. 50-yr-old with a blood pressure of 190/104 mm Hg who has a creatinine of 1.7 mg/dL d. 43-yr-old with a blood pressure of 172/98 mm Hg whose urine shows icroalbuminuria.

ANS: A The patient with chest pain may be experiencing acute myocardial infarction and rapid assessment and intervention are needed. Intermittent claudication, elevated creatinine, and microalbuminuria show target organ damage but do not indicate acute processes.

Which patient at a wellness clinic has the highest risk for developing primary hypertension? 1. A 65-year-old black patient who has a body mass index (BMI) of 35 2. A 45-year-old patient who has chronic pain caused by cancer 3. A 65-year-old retired white patient with a BMI of 15 4. A 45-year-old factory worker who smokes one pack of cigarettes per day

A 65-year-old black patient who has a body mass index (BMI) of 35 The 65-year-old black patient has three risk factors for primary hypertension: advanced age, black race, and morbid obesity with a BMI of 35. All of the other patients have fewer risk factors for primary hypertension. In the 45-year-old, smoking is the only risk factor. In the 45-year-old with cancer, pain is the only risk factor. In the 65-year-old retiree, the only risk factor is advanced age.

The nurse reviews the medical records of several patients. Which patients are at high risk of developing hypertension? Select all that apply. 1. A 65-year-old black woman 2. An older adult man who smokes 3. A 35-year-old man who is obese 4. A female teenager with a fractured humerus 5. A 50-year-old man whose parent had hypertension

A 65-year-old black woman An older adult man who smokes A 35-year-old man who is obese A 50-year-old man whose parent had hypertension Blacks have an increased risk of developing hypertension compared with their white counterparts. In addition, the woman is 65 years old; in females, the risk of hypertension increases after 50 years of age. An elderly man is at risk of hypertension because of his age. In addition, smoking increases the risk of developing hypertension. Obesity increases the risk of hypertension. A person who has a family history of hypertension is at increased risk of developing hypertension. A female teenager with a fracture is not at risk because of her young age and female gender.

The nurse receives information about the assigned patients during shift report. Which patient would the nurse assess first? 1. A patient who reports a severe headache and has begun vomiting 2. A patient who reports dizziness with a BP of 150/92 mm Hg 3. A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale 4. A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue

A patient who reports a severe headache and has begun vomiting Rationale: Severe headache and vomiting are signs of a hypertensive crisis, which is an emergency situation; therefore the nurse must assess this patient first. Dizziness is one of the symptoms of hypertension, and the patient has an elevated BP, but it is not an emergency situation. A pain level of 2 on a scale of 1 to 10 is mild pain, and therefore this patient is not a priority. Fatigue is one of the symptoms of hypertension, but the patient just received an antihypertensive medication.

physical activity

AHA and American College of Sports Medicine recommend that adults perform a moderate-intensity aerobic physical activity for at least 30 minutes most days (i.e., more than 5 days per week) with a goal of at least 150 minutes per week. -shorter periods of exercise that last at least 10 minutes, several times during a day -combinations of moderate and vigorous activity are acceptable (e.g., walking briskly for 30 minutes on 2 days of the week and jogging for 20 minutes on 2 other days) For adults ages 18 to 65, walking briskly at a pace that noticeably increases the pulse defines moderate-intensity aerobic activity. Jogging at a pace that substantially increases the pulse and causes rapid breathing is an example of vigorous activity for this age group. All adults should perform muscle-strengthening activities using the major muscles of the body at least twice a week. This helps to maintain or increase muscle strength and endurance. Flexibility and balance exercises are recommended at least twice a week for older adults, especially for those at risk for falls. Moderate-intensity activities can lower BP, promote relaxation, and decrease or control body weight. Regular activity of this type can reduce SBP by 4 to 9 mm Hg. Physical activity is more likely to become a habit if it is: -safe and enjoyable =fits easily into one's daily schedule -inexpensive Many shopping malls open early in the morning, offering a warm, safe, flat area for walking Some health clubs offer special "off-peak" rates to encourage physical activity among older adults. Some health insurance carriers offer health club discounts as a benefit to encourage member fitness. Cardiac rehabilitation programs offer supervised exercise and education about cardiovascular risk factor reduction.

The nurse obtains a blood pressure of 172/82 mm Hg for a patient. What is the patient's mean arterial pressure (MAP)?

ANS: 112 mm Hg MAP = (SBP + 2 DBP)/3

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider? a. Serum creatinine of 2.8 mg/dL b. Serum potassium of 4.5 mEq/L c. Serum hemoglobin of 14.7 g/dL d. Blood glucose level of 96 mg/dL

ANS: A The elevated serum creatinine indicates renal damage caused by the hypertension. The other laboratory results are normal.

Which action should the nurse take first to assist a patient with newly diagnosed stage 1 hypertension in making needed dietary changes? a. Collect a detailed diet history. b. Provide a list of low-sodium foods. c. Help the patient make an appointment with a dietitian. d. Teach the patient about foods that are high in potassium.

ANS: A The initial nursing action should be assessment of the patient's baseline dietary intake through a thorough diet history. The other actions may be appropriate, but assessment of the patient's baseline should occur first.

Complications of HTN

CAD Left ventricular hypertrophy Heart failure Cerebral vascular disease Peripheral vascular disease Nephrosclerosis Retinal damage

The nurse is caring for a 70-yr-old patient who takes hydrochlorothiazide and enalapril (Norvasc). The patient's blood pressure (BP) continues to be high. Which patient information may indicate a need for a change? a. Patient takes a daily multivitamin tablet. b. Patient uses ibuprofen to treat osteoarthritis. c. Patient checks BP daily just after getting up. d. Patient drinks wine three to four times a week.

ANS: B Because use of nonsteroidal antiinflammatory drugs (NSAIDs) can prevent adequate BP control, the patient may need to avoid the use of ibuprofen. A multivitamin tablet will help supply vitamin D, which may help lower BP. BP decreases while sleeping, so self-monitoring early in the morning will result in obtaining pressures that are at their lowest. The patient's alcohol intake is not excessive.

Which assessment finding for a patient receiving IV furosemide (Lasix) to treat stage 2 hypertension is most important to report to the health care provider? a. Blood glucose level of 175 mg/dL b. Serum potassium level of 3.0 mEq/L c. Orthostatic systolic BP decrease of 12 mm Hg d. Current blood pressure (BP) reading of 168/94 mm Hg

ANS: B Hypokalemia is a frequent adverse effect of the loop diuretics and can cause life-threatening dysrhythmias. The health care provider should be notified of the potassium level immediately and administration of potassium supplements initiated. The elevated blood glucose and BP also need collaborative intervention but will not require action as urgently as the hypokalemia. An orthostatic drop of 12 mm Hg will require intervention only if the patient is symptomatic.

An older patient has been diagnosed with possible white coat hypertension. Which planned action by the nurse addresses that suspected cause of the hypertension? a. Instruct the patient about the need to decrease stress levels. b. Teach the patient how to self-monitor and record BPs at home. c. Tell the patient and caregiver that major dietary changes are needed. d. Schedule the patient for regular blood pressure (BP) checks in the clinic.

ANS: B In the phenomenon of "white coat" hypertension, patients have elevated BP readings in a clinical setting and normal readings when BP is measured elsewhere. Having the patient self-monitor BPs at home will provide a reliable indication about whether the patient has hypertension. Regular BP checks in the clinic are likely to be high in a patient with white coat hypertension. There is no evidence that this patient has elevated stress levels or a poor diet, and those factors do not cause white coat hypertension.

A patient with a history of hypertension treated with a diuretic and an angiotensin-converting enzyme (ACE) inhibitor arrives in the emergency department. The patient reports a severe headache and nausea and has a blood pressure (BP) of 238/118 mm Hg. Which question should the nurse ask to follow up on these findings? a. "Have you recently taken any antihistamines?" b. "Have you consistently taken your medications?" c. "Did you take any acetaminophen (Tylenol) today?" d. "Have there been recent stressful events in your life?"

ANS: B Sudden withdrawal of antihypertensive medications can cause rebound hypertension and hypertensive crisis. Although many over-the-counter medications can cause hypertension, antihistamines and acetaminophen do not increase BP. Stressful events will increase BP but not usually to the level seen in this patient.

Which blood pressure (BP) finding by the nurse indicates that no changes in therapy are needed for a 48-yr-old patient with newly diagnosed hypertension? a. 98/56 mm Hg b. 128/76 mm Hg c. 128/92 mm Hg d. 142/78 mm Hg

ANS: B The 8th Joint National Committee's recommended goal for antihypertensive therapy for a 30-to 59-yr-old patient with hypertension is a BP below 130/80 mm Hg. The BP of 98/56 mm Hg may indicate overtreatment of the hypertension and an increased risk for adverse drug effects. The other two blood pressures indicate a need for modifications in the patient's treatment.

The charge nurse observes a new registered nurse (RN) doing discharge teaching for a patient with hypertension who has a new prescription for enalapril (Vasotec). Which statement by the new nurse to the patient would require the charge nurse's intervention? a. "Make an appointment with the dietitian for teaching." b. "Increase your dietary intake of high-potassium foods." c. "Check your blood pressure at home at least once a day." d. "Move slowly when moving from lying to sitting to standing."

ANS: B The ACE inhibitors cause retention of potassium by the kidney, so hyperkalemia is a possible adverse effect. The other teaching by the new RN is appropriate for a patient with newly diagnosed hypertension who has just started therapy with enalapril.

The nurse is assessing a patient who has been admitted to the intensive care unit (ICU) with a hypertensive emergency. Which finding is most important to report to the health care provider? a. Urine output over 8 hours is 250 mL less than the fluid intake. b. The patient cannot move the left arm and leg when asked to do so. c. Tremors are noted in the fingers when the patient extends the arms. d. The patient reports a headache with pain at level 7 of 10 (0 to 10 scale).

ANS: B The patient's inability to move the left arm and leg indicates that a stroke may be occurring and will require immediate action to prevent further neurologic damage. The other clinical manifestations are also likely caused by the hypertension and will require rapid nursing actions, but they do not require action as urgently as the neurologic changes.

A patient with hypertension who has just started taking atenolol (Tenormin) returns to the health clinic after 2 weeks for a follow-up visit. The blood pressure (BP) is unchanged from the previous visit. Which action should the nurse take first? a. Tell the patient why a change in drug dosage is needed. b. Ask the patient if the medication is being taken as prescribed. c. Review with the patient any lifestyle changes made to help control BP. d. Teach the patient that multiple drugs are often needed to treat hypertension.

ANS: B Because nonadherence with antihypertensive therapy is common, the nurse's initial action should be to determine whether the patient is taking the atenolol as prescribed. The other actions also may be implemented, but these would be done after assessing patient adherence with the prescribed therapy.

Which information is most important for the nurse to include when teaching a patient newly diagnosed with hypertension? a. Most people are able to control BP through dietary changes. b. Annual BP checks are needed to monitor treatment effectiveness. c. Hypertension is usually asymptomatic until target organ damage occurs. d. Increasing physical activity controls blood pressure (BP) for most people.

ANS: C Hypertension is usually asymptomatic until target organ damage has occurred. Lifestyle changes (e.g., physical activity, dietary changes) are used to help manage BP, but drugs are needed for most patients. Home BP monitoring should be taught to the patient and findings checked by the health care provider frequently when starting treatment for hypertension and then every 3 months when stable.

During change-of-shift report, the nurse obtains the following information about a hypertensive patient who received the first dose of nadolol (Corgard) during the previous shift. Which information indicates that the patient needs immediate intervention? a. The patient's pulse has dropped from 68 to 57 beats/min. b. The patient reports that the fingers and toes feel quite cold. c. The patient has developed wheezes throughout the lung fields. d. The patient's blood pressure (BP) reading is now 158/92 mm Hg.

ANS: C The most urgent concern for this patient is the wheezes, which indicate that bronchospasm (a common adverse effect of the non-cardioselective beta-blockers) is occurring. The nurse should immediately obtain an O2 saturation measurement, apply supplemental O2, and notify the health care provider. The mild decrease in heart rate and cold fingers and toes are associated with beta-receptor blockade but do not require any change in therapy. The BP reading may indicate that a change in medication type or dose may be indicated. However, this is not as urgently needed as addressing the bronchospasm.

The registered nurse (RN) is caring for a patient with a hypertensive crisis who is receiving sodium nitroprusside. Which nursing action can the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)? a. Evaluate effectiveness of nitroprusside therapy on blood pressure (BP). b. Assess the patient's environment for adverse stimuli that might increase BP. c. Titrate nitroprusside to decrease mean arterial pressure (MAP) to 115 mm Hg. d. Set up the automatic noninvasive BP machine to take readings every 15 minutes.

ANS: D LPN/VN education and scope of practice include the correct use of common equipment such as automatic noninvasive blood pressure machines. Assessment, evaluation, and medication titration require advanced nursing judgment and education, and should be done by RNs.

Causes of hypertensive crisis

Acute aortic dissection Exacerbation of chronic hypertension Head injury Monoamine oxidase inhibitors are taken with tyramine-containing foods Pheochromocytoma Preeclampsia, eclampsia Rebound hypertension (from abrupt withdrawal of some antihypertensive drugs, such as clonidine or β-blockers) Recreational drug use (cocaine, amphetamines) Renovascular hypertension

Risk factors for primary HTN

Age -Systolic BP rises progressively with -After age 50, SBP >140 mm Hg is a more important cardiovascular risk factor than diastolic BP Alcohol • Excess alcohol intake is strongly associated with hypertension • Moderate intake of alcohol has cardioprotective properties; males should limit their daily intake of alcohol to 2 drinks per day, and 1 drink per day for females Diabetes • Hypertension is more common in patients with diabetes • When hypertension and diabetes coexist, complications (e.g., target organ disease) are more severe Elevated serum lipids • ↑ Levels of cholesterol and triglycerides are primary risk factors for atherosclerosis • Hyperlipidemia is more common in people with hypertension Ethnicity • The incidence of hypertension is 2 times higher in blacks than in whites Excess dietary sodium • High sodium intake can • Contribute to hypertension in salt-sensitive patients • Decrease the effectiveness of certain antihypertensive drugs Family history • History of a close blood relative (e.g., parents, sibling) with hypertension is associated with an ↑ risk for developing hypertension Gender • Hypertension is more prevalent in men in young adulthood and early middle age • After age 64, hypertension is more prevalent in women Obesity • Weight gain is associated with ↑ frequency of hypertension • Risk increases with central abdominal obesity Sedentary lifestyle • Regular physical activity can help control weight and reduce cardiovascular risk • Physical activity may ↓ BP Socioeconomic status • Hypertension is more prevalent in lower socioeconomic groups and among the less educated Stress • People exposed to repeated stress may develop hypertension more often than others • People who develop hypertension may respond differently to stress than those who do not develop hypertension Tobacco use • Smoking tobacco greatly ↑ risk for CVD • People with hypertension who smoke tobacco are at even greater risk for CVD

Which factors in a patient's health history are nonmodifiable risk factors for primary hypertension? Select all that apply. 1. Age 65 years 2. Black ethnicity 3. Dietary sodium 4. Alcohol consumption 5. Family history of hypertension

Age 65 years Black ethnicity Family history of hypertension Nonmodifiable risk factors for hypertension include increasing age, black ethnicity, and a family history of hypertension. Consumption of excessive dietary sodium and alcohol are considered modifiable risk factors.

Renin Inhibitors

Aliskiren hemifumarate (Tekturna) Directly inhibits renin, thus reducing the conversion of angiotensinogen to angiotensin I May cause angioedema of the face, extremities, lips, tongue, glottis, and/or larynx Not to be used in pregnancy

Which manifestations are related to target organ disease from hypertension? Select all that apply. 1. Anemia 2. Aneurysm 3. Proteinuria 4. Pneumonia 5. Transient ischemic attack

Aneurysm Proteinuria Transient ischemic attack Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to aneurysms. Hypertension affects the kidneys; a manifestation of renal disease is proteinuria. Adequate control of BP reduces the risk of transient ischemic attack. Pneumonia and anemia are not manifestations of target organ disease.

A patient asks the nurse, "How can I use my smart phone to help control my hypertension?" Which smart-phone functions will the nurse recommend to help manage the patient's BP? Select all that apply. 1. Appointment tracking 2. Maintaining a drug history 3. Generating a report for the patient's health care provider 4. Tracking variables, including time of day and medications taken 5. Contacting emergency services automatically for a high BP reading

Appointment tracking Maintaining a drug history Generating a report for the patient's health care provider Tracking variables, including time of day and medications taken A smart phone can be used to help a patient with hypertension manage his or her care by tracking clinical appointments, generating reports, maintaining a drug history, and allowing the patient to enter variables. A smart phone does not correlate critical BP readings to the need to contact emergency services.

Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mm Hg. What should the nurse do next? Assess his adherence to therapy. Ask him to make an exercise plan. Teach him to follow the DASH diet. Request a prescription for a thiazide diuretic.

Assess his adherence to therapy. Rationale: A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance and arterial blood pressure and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to begin by assessing adherence to therapy.

A male patient who takes nifedipine to treat hypertension continues to have BP readings over 140/90 mm Hg. Which action would the nurse take first? 1. Assess the patient's adherence to therapy. 2. Request a prescription for a thiazide diuretic. 3. Assist the patient in creating an exercise plan. 4. Instruct the patient about dietary modifications.

Assess the patient's adherence to therapy. A major problem in the long-term management of the patient with hypertension is poor adherence with the treatment plan. The nurse needs to assess the patient's adherence to therapy. A long-acting calcium channel blocker, such as nifedipine, causes vascular smooth muscle relaxation, resulting in decreased systemic vascular resistance (SVR) and arterial BP and related side effects. The patient's BP is still elevated and must be addressed. It is not necessary to request another medication without assessing if the patient actually is taking the medication prescribed. Asking the patient to make an exercise plan or use a different diet is not addressing the BP, but these aspects may be reinforced based on an assessment of the patient's adherence to medications and other therapy.

A patient receives a prescription for nadolol 50 mg by mouth (PO) daily. Which medical diagnosis in the patient's health record would lead the nurse to question the prescription? 1. Asthma 2. Hypertension 3. Diabetes mellitus 4. Renal insufficiency

Asthma Nadolol is a nonselective β1- and β2-adrenergic-blocking agent that reduces BP. Nonselective agents may cause bronchospasm, especially in patients with asthma. Nadolol will treat, not worsen, hypertension. Nadolol will not worsen renal insufficiency and diabetes.

Cerebrovascular disease

Atherosclerosis is the most common cause of cerebrovascular disease. Even in mildly hypertensive people, the risk for stroke is 4 times higher than in normotensive people. Adequate BP control decreases the risk for stroke. Atherosclerotic plaques are often found at the bifurcation of the common carotid artery and in the internal and external carotid arteries. Portions of the atherosclerotic plaque or the blood clot that forms with disruption of the plaque may break off and travel to cerebral vessels, producing a thromboembolism. The patient may have transient ischemic attacks or a stroke. Hypertensive encephalopathy may occur after a marked rise in BP if autoregulation does not decrease the cerebral blood flow. Autoregulation is a physiologic process that keeps cerebral blood flow constant despite fluctuations in BP. Typically, as pressure in the cerebral blood vessels rises, the vessels constrict to maintain constant flow. When BP exceeds the body's ability to autoregulate, the cerebral vessels suddenly dilate, capillary permeability increases, and cerebral edema develops. This produces a rise in intracranial pressure. If left untreated, patients can die quickly from brain damage.

The nurse has just finished teaching a hypertensive patient about a newly prescribed drug, ramipril (Altace). Which patient statement indicates that more teaching is needed? a. "The medication may not work well if I take aspirin." b. "I can expect some swelling around my lips and face." c. "The doctor may order a blood potassium level occasionally." d. "I will call the doctor if I notice that I have a frequent cough."

B Angioedema occurring with angiotensin-converting enzyme (ACE) inhibitor therapy is an indication that the ACE inhibitor should be discontinued. The patient should be taught that if any swelling of the face or oral mucosa occurs, the health care provider should be immediately notified because this could be life threatening. The other patient statements indicate that the patient has an accurate understanding of ACE inhibitor therapy.

Which action should the nurse in the hypertension clinic take to obtain an accurate baseline blood pressure (BP) for a new patient? a. Deflate the BP cuff at a rate of 5 to 10 mm Hg per second. b. Have the patient sit in a chair with the feet flat on the floor. c. Assist the patient to the supine position for BP measurements. d. Obtain two BP readings in the dominant arm and average the results.

B The patient should be seated with the feet flat on the floor. The BP is obtained in both arms, and the results of the two arms are not averaged. The patient does not need to be in the supine position. The cuff should be deflated at 2 to 3 mm Hg per second.

The nurse obtains the following information from a patient newly diagnosed with elevated blood pressure. Which finding is most important to address with the patient? a. Low dietary fiber intake b. No regular physical exercise c. Drinks a beer with dinner every night d. Weight is 5 pounds above ideal weight

B The recommendations for preventing hypertension include exercising aerobically for 30 minutes most days of the week. A weight that is 5 pounds over the ideal body weight is not a risk factor for hypertension. The Dietary Approaches to Stop Hypertension (DASH) diet is high in fiber but increasing fiber alone will not prevent hypertension from developing. The patient's alcohol intake is within guidelines and will not increase the hypertension risk.

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? BP 128/78 mm Hg Weight loss of 2 lb Absence of ankle edema Output of 600 mL per 8 hours

BP 128/78 mm Hg Rationale: Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

A patient admitted with a history of hypertension has been taking hydrochlorothiazide daily for the past 10 years. Which parameter would the nurse evaluate to indicate the effectiveness of this drug therapy? 1. Weight loss of 2 lb 2. BP of 118/76 3. Absence of ankle edema 4. Urine output of 600 mL per eight hours

BP of 118/76 Because the patient has been taking this medication for 10 years, the most direct measurement of its long-term intended effect would be normal BP. Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, so weight loss, absence of edema, and urine output would not be as pertinent.

A patient who is black is hospitalized for the treatment of hypertension. Which type of medication has been shown to provide better control for black individuals? 1. β-Adrenergic receptor blockers (β-blockers) 2. Calcium channel blockers 3. Peripheral adrenergic inhibitors 4. Angiotensin-converting enzyme inhibitors

Calcium channel blockers Calcium channel blockers provide better control for black individuals than other classes of antihypertensives, including β-blockers and peripheral adrenergic inhibitors. Blacks have a higher risk of angioedema with angiotensin-converting enzyme inhibitors than whites.

A patient is newly diagnosed with hypertension. Which information would the nurse provide about the reasons for prescribed diagnostic studies? Select all that apply. 1. Echocardiography to provide baseline information about electrical conduction 2. Electrocardiogram (ECG) to evaluate the degree of left ventricular hypertrophy 3. Uric acid level to establish a baseline because the levels often decrease with diuretic therapy 4. Blood urea nitrogen (BUN) and serum creatinine levels to provide information about renal function 5. Lipid profile to provide information about risk factors related to atherosclerosis and cardiovascular disease

Blood urea nitrogen (BUN) and serum creatinine levels to provide information about renal function Lipid profile to provide information about risk factors related to atherosclerosis and cardiovascular disease BUN, creatinine, and urinalysis provide information about baseline renal function and help to identify renal damage caused by hypertension. An elevated lipid profile is an additional risk factor for hypertension because having elevated blood lipids leads to the development of atherosclerosis. Echocardiography evaluates the degree of ventricular hypertrophy. An ECG can identify the presence but not the degree of ventricular hypertrophy and is used to assess baseline cardiac conduction. Diuretic therapy used for hypertensive treatment frequently leads to an increase in uric acid.

The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for given the patient's health history? Hypocapnia Tachycardia Bronchospasm Nausea and vomiting

Bronchospasm Rationale: Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.

The nurse admits a 73-yr-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication? Clonidine (Catapres) Bumetanide (Bumex) Amiloride (Midamor) Spironolactone (Aldactone)

Bumetanide (Bumex) Rationale: Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.

A 62-yr-old patient who has no history of hypertension or other health problems suddenly develops a blood pressure (BP) of 198/110 mm Hg. After reconfirming the BP, it is appropriate for the nurse to tell the patient that: a. a BP recheck should be scheduled in a few weeks. b. dietary sodium and fat content should be decreased. c. diagnosis, treatment, and monitoring will be needed. d. there is danger of a stroke, requiring hospitalization.

C A sudden increase in BP in a patient older than age 50 years with no hypertension history or risk factors indicates that the hypertension may be secondary to some other problem. The BP will need treatment and ongoing monitoring. If the patient has no other risk factors, a stroke in the immediate future is unlikely. There is no indication that dietary salt or fat intake have contributed to this sudden increase in BP. Reducing intake of salt and fat alone will not be adequate to reduce this BP to an acceptable level.

After the nurse teaches the patient with stage 1 hypertension about diet modifications, which diet choice indicates that the teaching has been most effective? a. The patient avoids eating nuts or nut butters. b. The patient restricts intake of chicken and fish. c. The patient drinks low-fat milk with each meal. d. The patient has two cups of coffee in the morning.

C For the prevention of hypertension, the Dietary Approaches to Stop Hypertension (DASH) recommendations include increasing the intake of calcium-rich foods. Caffeine restriction and decreased protein intake are not part of the recommendations. Nuts are high in beneficial nutrients and 4 to 5 servings weekly are recommended in the DASH diet.

A patient diagnosed with hypertension has been prescribed captopril. Which information is most important to teach the patient about this drug? a. Include high-potassium foods such as bananas in the diet. b. Increase fluid intake if dryness of the mouth is a problem. c. Change position slowly to help prevent dizziness and falls. d. Check the blood pressure in both arms before taking the drug.

C The angiotensin-converting enzyme (ACE) inhibitors often cause orthostatic hypotension, and patients should be taught to change position slowly to allow the vascular system time to compensate for the position change. Increasing fluid intake may counteract the effect of the drug. The patient is taught to use gum or hard candy to relieve dry mouth. The BP should be taken in the nondominant arm by newly diagnosed patients in the morning, before taking the drug, and in the evening. Because ACE inhibitors cause potassium retention, increased intake of high-potassium foods is inappropriate.

The registered nurse on a medical inpatient unit reviews the patient assignments. Which activities could the nurse delegate to assistive personnel? Select all that apply. 1. Check for postural changes in BP. 2. Make appropriate referrals to other health care professionals. 3. Teach patients about lifestyle management and medication use. 4. Report high or low BP readings to the registered nurse. 5. Assess patients for hypertension risk factors and develop risk modification plans.

Check for postural changes in BP. Report high or low BP readings to the registered nurse. Reporting high or low BP readings and checking for postural changes in BP are repetitive activities and do not require nursing judgment. Therefore these activities can be delegated to assistive personnel. Making appropriate referrals requires an understanding of the collaborative care and judgment regarding the requirement of the referrals; this activity cannot be delegated and is the role of a registered nurse. Patient education about lifestyle management and medication use requires sound knowledge; therefore this activity should be performed by the nurse. Assessment and development of risk modification plans requires assessment and planning skills; this activity should not be delegated and should be performed by the nurse.

A patient who is prescribed lisinopril asks about the side effects of this medication. Which side effects would the nurse describe? Select all that apply. 1. Cough 2. Edema 3. Impotence 4. Hypotension 5. Muscle stiffness

Cough Hypotension Cough and hypotension are side effects of angiotensin-converting enzyme (ACE) inhibitors. Peripheral edema is a side effect of calcium channel blockers. Impotence is a side effect of thiazide diuretics, aldosterone receptor blockers, central-acting α-adrenergic antagonists, peripheral-acting α-adrenergic antagonists, β-adrenergic blockers, and mixed α1- and β1-blockers. Muscle stiffness is not associated with an ACE inhibitor.

Which action will be included in the plan of care for a patient who is receiving nicardipine (Cardene) to treat a hypertensive emergency? a. Keep the patient NPO to prevent aspiration caused by nausea and possible vomiting. b. Organize nursing activities so that the patient has 8 hours of undisturbed sleep at night. c. Assist the patient up in the chair for meals to avoid complications associated with immobility. d. Use an automated noninvasive blood pressure machine to obtain frequent measurements.

D Frequent monitoring of BP is needed when the patient is receiving rapid-acting IV antihypertensive medications. This can be most easily accomplished with an automated BP machine or arterial line. The patient will require frequent assessments, so allowing 8 hours of undisturbed sleep is not reasonable. When patients are receiving IV vasodilators, bed rest is maintained to prevent decreased cerebral perfusion and fainting. There is no indication that this patient is nauseated or at risk for aspiration, so an NPO status is unnecessary.

Which action should the nurse take when giving the first dose of oral labetalol to a patient with hypertension? a. Encourage the use of hard candy to prevent dry mouth. b. Teach the patient that headaches often occur with this drug. c. Instruct the patient to call for help if heart palpitations occur. d. Ask the patient to request assistance before getting out of bed.

D Labetalol decreases sympathetic nervous system activity by blocking both a- and b-adrenergic receptors, leading to vasodilation and a decrease in heart rate, which can cause severe orthostatic hypotension. Heart palpitations, dry mouth, dehydration, and headaches are possible side effects of other antihypertensives.

DASH eating plan

DASH (Dietary Approaches to Stop Hypertension) -fruits -vegetables -fat-free or low-fat milk and milk products -whole grains -fish -poultry -beans -seeds -nuts DASH eating plan significantly lowers BP and reduces low-density lipoprotein (LDL) cholesterol

Insulin Resistance and Hyperinsulinemia

Defects in glucose, insulin, and lipoprotein metabolism are common in primary hypertension. -defects are not present in secondary hypertension and do not improve when primary hypertension is treated -Insulin resistance is a risk factor in the development of hypertension and CVD -High insulin levels stimulate SNS activity and impair nitrous oxide-mediated vasodilation. -Other pressor effects of insulin include vascular hypertrophy and increased renal sodium reabsorption.

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of an obese patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec Waiting 2 minutes after position changes to take orthostatic pressures Taking the blood pressure with the patient's arm at the level of the heart Taking a forearm blood pressure if the largest cuff will not fit the patient's upper arm

Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg/sec Rationale: The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

A patient has been prescribed atenolol. Which condition should the nurse question the patient about before administering the drug? 1. Asthma 2. Dry cough 3. Depression 4. Diabetes mellitus

Diabetes mellitus Atenolol is a cardioselective β-1 blocker that reduces BP by blocking β-adrenergic effects. It should be used with caution in patients with diabetes mellitus because it depresses the tachycardia associated with hypoglycemia and may hinder diagnosing hypoglycemia. A history of asthma, dry cough, or depression does not affect the administration of the drug. Noncardioselective β-adrenergic receptor blockers (β-blockers) should not be used in patients with asthma because of the risk of bronchospasm, but this is not the case with atenolol because it is cardioselective. Angiotensin-converting enzymes may cause a dry cough. Reserpine should not be administered in patients with depression because this may cause the condition to worsen.

Which instruction would the nurse include in the patient's discharge teaching plan regarding prescribed propranolol for hypertension? 1. Do not stop taking the medication abruptly. 2. Increase your intake of green leafy vegetables. 3. Take the medication with orange juice to prevent hypokalemia. 4. Take a hot bath within one hour of the medication to promote vasodilation

Do not stop taking the medication abruptly. Patients should not stop taking this medication abruptly because this may cause rebound hypertension. β-Adrenergic receptor blockers (β-blockers) are not potassium wasting, so it is not necessary to increase the intake of potassium-rich foods such as green leafy vegetables or to take them with orange juice. The patient should be instructed to avoid hot baths within three hours of taking drugs that promote vasodilation; excessive hypotension may occur.

A patient with a history of chronic hypertension is being evaluated in the emergency department for a blood pressure of 200/140 mm Hg. Which patient assessment question is the priority? Is the patient pregnant? Does the patient need to urinate? Does the patient have a headache or confusion? Is the patient taking antiseizure medications as prescribed?

Does the patient have a headache or confusion? Rationale: The nurse's priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. In addition, headache or confusion could represent signs and symptoms of a hemorrhagic stroke. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.

Moderate alcohol intake

Drinking 3 or more alcoholic drinks a day is a risk factor for CVD and stroke. Men should limit their intake of alcohol -no more than 2 drinks per day Women and lighter weight men -no more than 1 drink per day 1 drink is defined as: -12 oz of regular beer -5 oz of wine (12% alcohol) -1.5 oz of 80-proof distilled spirits Excess alcohol intake that results in cirrhosis is a frequent cause of secondary hypertension.

A patient whose BP is 200/120 mm Hg receives a prescription for clonidine. Which side effect requires the patient to avoid hazardous activities? 1. Drowsiness 2. Orthostatic hypotension 3. Rapid decrease in BP 4. Rebound hypertension

Drowsiness Clonidine is an adrenergic inhibitor that reduces sympathetic outflow from the central nervous system. It lowers BP by reducing peripheral sympathetic tone, dilating the blood vessels, and decreasing the systemic vascular resistance. Drowsiness is a side effect of the drug, and the patient is advised to avoid engaging in hazardous activities because this can increase the risk of injury. The drug also causes orthostatic hypotension, so the patient is advised to change position slowly. The drug does not cause a rapid decrease in BP. The drug can cause rebound hypertension if discontinued abruptly.

Endothelial Dysfunction

Endothelial dysfunction is a marker for CVD, including primary hypertension. Hypertension can manifest as a prolonged vasoconstriction response or as a reduced vasodilator response. High levels of ET may cause prolonged vasoconstriction. Vasodilation effects can be altered by oxygen free radicals, which impair the bioavailability of Nitric Oxide. This leads to cellular dysfunction and an imbalance of the vasodilation and vasoconstriction mechanisms in the endothelium.

A nurse provides discharge education to a patient about the care and management of hypertension. Which information would the teaching plan include? Select all that apply. 1. Explain the meaning of the BP values. 2. Remind the patient to supplement the diet with foods high in sodium. 3. Explain the potential dangers of uncontrolled hypertension. 4. Assure the patient that short-term therapy will cure hypertension. 5. Exercise after taking the medication prescribed for hypertension. 6. Do not alter medication dosage without consulting the health care provider.

Explain the meaning of the BP values. Explain the potential dangers of uncontrolled hypertension Do not alter medication dosage without consulting the health care provider. The nurse should explain the meaning of the systolic BP (SBP) and diastolic BP (DBP) values. The nurse should also explain the potential dangers of uncontrolled hypertension and the dangers of altering the dosage without consulting the health care provider. The nurse should inform the patient that long-term therapy and follow-up care are essential to treat hypertension and that therapy will not cure but should control hypertension. The patient should avoid foods high in sodium; instead, supplement the diet with foods high in potassium. The patient should avoid strenuous exercise, hot baths, and excessive amounts of alcohol within three hours of taking the medication prescribed for hypertension.

The nurse provides education to a patient about the symptoms of uncontrolled hypertension. Which symptoms would the nurse include? Select all that apply. 1. Fatigue 2. Dizziness 3. Palpitations 4. Cluster headaches 5. Shortness of breath

Fatigue Dizziness Palpitations Shortness of breath A patient with severe hypertension may have a variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart. These secondary symptoms include fatigue, dizziness, palpitations, angina, and dyspnea. Cluster headaches do not occur with uncontrolled hypertension.

Heart Failure

HF occurs when the heart's compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body's demands Contractility is depressed, and SV and CO are decreased. The patient may have: -SOB on exertion -paroxysmal nocturnal dyspnea -fatigue.

Clinical manifestations

HTN is often called the "silent killer" -is often asymptomatic -until it is severe and target organ disease occurs. -severe HTN may have a variety of symptoms secondary to the effects on blood vessels in the various organs and tissues or to the increased workload of the heart Secondary symptoms -fatigue -dizziness -palpitations -angina -dyspnea In the past, we thought headaches and nosebleeds were symptoms of hypertension. Unless BP is very high, these symptoms are no more frequent in people with HTN than in the general population. hypertensive crisis may have: -severe headaches -dyspnea -anxiety -nosebleeds

Nephrosclerosis

HTN is one of the leading causes of chronic kidney disease (CKD), especially among blacks. Renal disease results from ischemia caused by the narrowing of the renal blood vessels. Leads to: -atrophy of the tubules -destruction of the glomeruli -eventual death of nephrons Laboratory signs of renal disease -albuminuria -proteinuria -microscopic hematuria -high serum creatinine and blood urea nitrogen (BUN) Nocturia is an early symptom of renal disease

Dietary sodium reduction

Healthy adults should restrict sodium intake to 2300 mg/day or less. Blacks, people middle aged and older, and those with hypertension, diabetes, or CKD should restrict sodium to 1500 mg/day or less. Avoiding foods high in sodium: -"Salty Six." -recommend not adding salt -reducing intake of: bread products lunch meat and cured meats pizza soup sandwiches poultry Average sodium intake: -4200 mg/day in men -3300 mg/day in women Teaching: -reading labels of over-the-counter (OTC) drugs -prepared and packaged foods -health products (e.g., toothpaste containing baking soda) Increased levels of dietary potassium and calcium are associated with lower BP People with hypertension should receive adequate intake of these from food sources. Calcium supplements are not recommended to lower BP. General Principles: -Do not add salt or seasonings containing sodium when preparing foods. -Do not use salt at the table -1 tsp of salt equals 2.3 g of sodium -Avoid high-sodium foods *canned soups *processed meats *cheese *frozen meals -Limit milk products to 2 cups daily

Stress and Increased Sympathetic Nervous System Activity

High plasma renin activity (PRA) increases the conversion of angiotensinogen to angiotensin I -change in the RAAS may contribute to the development of hypertension -any rise in BP inhibits the release of renin from the renal juxtaglomerular cells

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which causes intravascular coagulation and tissue necrosis distal to occlusions.

Hypertension promotes atherosclerosis and damage to the walls of the arteries. Rationale: Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

Peripheral Vascular Disease (PVD)

Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels. -leads to peripheral vascular disease (PVD), aortic aneurysm, and aortic dissection Intermittent claudication (ischemic leg pain precipitated by activity and relieved by rest) is a classic symptom of PVD.

A patient's BP reading is 142/91 mm Hg. How should the nurse classify the BP? 1. Normal 2. Prehypertension 3. Hypertension, stage 1 4. Hypertension, stage 2

Hypertension, stage 2 Normal BP is defined as a systolic BP (SBP) of less than 120 mm Hg and a diastolic BP (DBP) of less than 80 mm Hg. Elevated BP is defined as an SBP between 120 and 129 mm Hg and a DBP of less than 80 mm Hg. Hypertension (stage 1) is defined as an SBP between 130 and 139 mm Hg and a DBP between 80 and 89 mm Hg. Hypertension (stage 2) is defined as an SBP of greater than 140 mm Hg and a DBP of greater than 90 mm Hg. If either the SBP or DBP is outside of a range, the higher measurement determines the classification.

The nurse provides information to a group of nursing students about measuring BP in older patients. Which information would the nurse include in the teaching? 1. Measure the patient's BP one hour after eating. 2. Peripheral vascular resistance decreases with aging. 3. Older adults are less likely to have postural hypotension. 4. Inflate the cuff 20 to 30 mm Hg after the radial pulse disappears

Inflate the cuff 20 to 30 mm Hg after the radial pulse disappears. When measuring BP, the nurse should inflate the cuff 20 to 30 mm Hg after the radial pulse disappears. Elderly patients experience a postprandial drop in BP; the greatest drop occurs approximately one hour after eating. The BP returns to preprandial levels three to four hours after eating. An age-related change is increased peripheral vascular resistance. Care should be taken to assess for orthostatic hypotension and acute kidney injury in patients over 65 years old.

The nurse provides information to a group of nursing students about measuring BP in older patients. Which information would the nurse include in the teaching? 1. Measure the patient's BP one hour after eating. 2. Peripheral vascular resistance decreases with aging. 3. Older adults are less likely to have postural hypotension. 4. Inflate the cuff 20 to 30 mm Hg after the radial pulse disappears.

Inflate the cuff 20 to 30 mm Hg after the radial pulse disappears. When measuring BP, the nurse should inflate the cuff 20 to 30 mm Hg after the radial pulse disappears. Elderly patients experience a postprandial drop in BP; the greatest drop occurs approximately one hour after eating. The BP returns to preprandial levels three to four hours after eating. An age-related change is increased peripheral vascular resistance. Care should be taken to assess for orthostatic hypotension and acute kidney injury in patients over 65 years old.

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse explain? Blocks β-adrenergic effects. Relaxes arterial and venous smooth muscle. Inhibits conversion of angiotensin I to angiotensin II. Reduces sympathetic outflow from central nervous system.

Inhibits conversion of angiotensin I to angiotensin II. Rationale: Lisinopril is an angiotensin-converting enzyme inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. β-Blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central-acting α-adrenergic antagonists reduce sympathetic outflow from the central nervous system to produce vasodilation and decreased systemic vascular resistance and blood pressure.

A patient presents to the emergency department with a sudden rise in BP and a severe headache. Which precaution will the nurse take while administering the prescribed IV labetalol? 1. Keeping the patient supine 2. Monitoring for tachycardia 3. Maintaining seizure precautions 4. Taking the BP every five minutes

Keeping the patient supine The patient is experiencing a hypertensive crisis. Labetalol is an α- and β-adrenergic blocker and reduces BP by causing vasodilation and a decrease in heart rate. Patients must be kept supine during IV administration because of the severe orthostatic hypotension that occurs with the medication. The medication will decrease, not increase, the heart rate. The BP should be assessed every two to three minutes during the initial administration of the drug. Seizure activity is not an adverse effect of the medication.

Which instructions would the nurse include in the discharge teaching for a patient with orthostatic hypotension from carvedilol? Select all that apply. 1. Lie down or sit if dizziness occurs. 2. Avoid sleeping with the head elevated. 3. Do not stand still for prolonged periods. 4. Rise slowly from a supine to a sitting position. 5. Perform leg exercises to increase venous return

Lie down or sit if dizziness occurs. Do not stand still for prolonged periods. Rise slowly from a supine to a sitting position. Perform leg exercises to increase venous return Orthostatic hypotension is a condition in which there is a decrease in BP upon rising to a standing position from a lying down or sitting position. Carvedilol causes peripheral vasodilation and decreased heart rate, leading to the potential for orthostatic hypotension. The patient should sit or lie down if there is dizziness. This decreases the risk of falling. Standing still for prolonged periods may cause venous stasis and worsen hypotension. The patient should be instructed to rise slowly from the sitting and lying-down positions and to move only when no dizziness occurs. Doing leg exercises helps to increase venous return to the heart and lowers BP. Sleeping with the head elevated helps to keep the blood flow to the brain uniform and prevents orthostatic hypotension, so it does not need to be avoided.

Lifestyle changes

Lifestyle modifications Weight reduction DASH eating plan Dietary sodium reduction Moderate alcohol intake Physical activity Avoiding tobacco products Managing risk factors Drug therapy

The nurse is teaching a women's group about ways to prevent hypertension. What information should the nurse include? (Select all that apply.) Lose weight. Limit beef consumption. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days.

Limit beef consumption. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days. Rationale: Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Beef includes saturated fats, which should be limited. Weight loss may or may not be necessary, depending on the person.

The nurse provides education to a group of women about preventing hypertension. Which information would the nurse include? Select all that apply. 1. Lose weight. 2. Limit nuts and seeds. 3. Limit sodium and fat intake. 4. Drink fat-free or low-fat milk. 5. Perform moderate physical activity for at least 30 minutes on most days.

Limit sodium and fat intake. Drink fat-free or low-fat milk. Perform moderate physical activity for at least 30 minutes on most days. The primary prevention of hypertension involves making lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the Dietary Approaches to Stop Hypertension (DASH) eating plan is a healthy way to lower BP by limiting sodium and fat intake and drinking fat-free or low-fat milk. Weight loss may or may not be necessary for the individuals within the community group. Nuts and seeds and dried beans are excellent sources of protein and are included in the DASH eating plan.

A patient diagnosed with acute ischemic stroke is receiving IV antihypertensive drugs. Which interventions would the nurse perform for this patient? Select all that apply. 1. Measure hourly urine output. 2. Perform frequent neurologic checks. 3. Ambulate the patient with a one-person assist. 4. Assess BP and heart rate (HR) every 30 minutes. 5. Titrate drug according to mean arterial pressure (MAP) or BP as prescribed.

Measure hourly urine output. Perform frequent neurologic checks. Titrate drug according to mean arterial pressure (MAP) or BP as prescribed Drugs should be titrated according to MAP or BP as prescribed. The nurse should measure hourly urine output to assess renal perfusion and should perform frequent neurologic checks. Antihypertensive IV drugs have a rapid onset of action; hence, BP and pulse should be assessed every two to three minutes using a noninvasive BP machine. The patient should be restricted to bed; severe cerebral ischemia or fainting may result if the patient tries to get up.

Loop diuretics

bumetanide (Bumex) furosemide (Lasix) torsemide (Demadex) Inhibit NaCl reabsorption in the ascending limb of the loop of Henle Increase excretion of Na+ and Cl− More potent diuretic effect than thiazides, but shorter duration of action Monitor for orthostatic hypotension and electrolyte abnormalities Remain effective despite renal insufficiency Diuretic effect increases at higher doses Less effective for hypertension

The nurse presents information to a group of nursing students about cultural and ethnic health disparities related to hypertension. Which information would the nurse include about the comparison of Mexican Americans to white and black populations? 1. Mexican Americans have higher rates of good BP control. 2. Mexican Americans are more likely to receive treatment for hypertension. 3. Mexican Americans have the highest prevalence of hypertension in the world. 4. Mexican Americans have lower levels of awareness of hypertension and its treatment

Mexican Americans have lower levels of awareness of hypertension and its treatment. Mexican Americans have lower levels of awareness of hypertension and its treatment than do whites and blacks. Mexican Americans have lower rates of BP control, and they are less likely to receive treatment for hypertension. Blacks have the highest prevalence of hypertension in the world.

The nurse is caring for a patient admitted to the hospital with hypertension who is taking prazosin. Which action would the nurse include in the patient's plan of care? 1. Monitor for orthostatic hypotension. 2. Observe for cardiac dysrhythmias. 3. Do not give the medication with grapefruit juice. 4. Hold the medication if the patient is unable to void

Monitor for orthostatic hypotension. Low BP or postural hypotension can cause a fall from dizziness. The direct vasodilator minoxidil may cause electrocardiogram (ECG) changes of flattened and inverted T waves. Administering grapefruit juice with certain calcium channel blockers may increase the serum concentrations, resulting in toxicity. The medication can reduce resistance to outflow of urine in patients with benign prostatic hyperplasia (BPH), so it may facilitate voiding.

The nurse is caring for a patient admitted to the hospital with hypertension who is taking prazosin. Which action would the nurse include in the patient's plan of care? 1. Monitor for orthostatic hypotension. 2. Observe for cardiac dysrhythmias. 3. Do not give the medication with grapefruit juice. 4. Hold the medication if the patient is unable to void.

Monitor for orthostatic hypotension. Low BP or postural hypotension can cause a fall from dizziness. The direct vasodilator minoxidil may cause electrocardiogram (ECG) changes of flattened and inverted T waves. Administering grapefruit juice with certain calcium channel blockers may increase the serum concentrations, resulting in toxicity. The medication can reduce resistance to outflow of urine in patients with benign prostatic hyperplasia (BPH), so it may facilitate voiding.

Avoiding tobacco products

Nicotine contained in tobacco causes vasoconstriction and increases BP, especially in people with hypertension. benefits of stopping tobacco use are seen within a year in all age-groups

A patient with hypertension receives a prescription for chlorothiazide. Which item would the nurse instruct the patient to limit? 1. Nonsteroidal antiinflammatory drugs (NSAIDs) 2. Ginkgo biloba 3. Grapefruit juice 4. Potassium-rich foods

Nonsteroidal antiinflammatory drugs (NSAIDs) Chlorothiazide is a diuretic, which inhibits NaCl reabsorption in the distal convoluted tubule. It increases the excretion of sodium and chloride. NSAIDs can decrease the diuretic and antihypertensive effects of thiazide diuretics and potentially cause renal impairment. Ginkgo biloba and grapefruit juice will not decrease the effectiveness of chlorothiazide. Chlorothiazide can cause hypokalemia; patients are advised to supplement with potassium-rich foods.

A patient is hospitalized with uncontrolled hypertension. Which diagnostic study will the nurse expect to be prescribed? 1. Cardiac MRI 2. Thyroid function tests 3. Ophthalmic examination 4. CT scan of the head

Ophthalmic examination An ophthalmic exam is performed to assess the appearance of the retina and identify target organ damage. It can provide important information about the severity and duration of hypertension. A cardiac MRI, a CT of the head, or thyroid function tests will not provide useful information about hypertension.

The nurse notes that there is a difference in a patient's BP and heart rate (HR) when the patient changes position from supine to standing. The differences are a decrease of 20 mm Hg in systolic BP, a decrease of 10 mm Hg in diastolic BP, and an increase in the HR of 20 beats/minute. Which interpretation would the nurse make about the patient's condition? 1. Hypertensive crisis 2. An auscultatory gap 3. Resistant hypertension 4. Orthostatic hypotension

Orthostatic hypotension A decrease in BP with a change of position indicates orthostatic hypotension. It may manifest as light-headedness, dizziness, or syncope. Intravascular volume loss and inadequate vasoconstrictor mechanisms related to disease or medications are common causes. A hypertensive crisis is characterized by severely elevated BP with or without the presence of target organ damage. An auscultatory gap is commonly seen in elderly patients as a wide gap between the first Korotkoff sound and subsequent beats. Resistant hypertension is a condition in which the patient fails to reach BP goals despite an effective treatment regimen.

The nurse is teaching an older patient with hypertension about developing an exercise program. Which instructions would the nurse include? 1. Perform weightlifting on a daily basis. 2. Perform flexibility and balance exercises daily. 3. Perform muscle-strengthening activities twice a week. 4. Perform high-intensity activity for 30 minutes on most days.

Perform muscle-strengthening activities twice a week. All adults should perform muscle-strengthening activities using the major muscles of the body at least twice a week. Weightlifting is not recommended for a patient with hypertension because it may increase BP. Flexibility and balance exercises are recommended at least twice a week for older adults, especially those at risk for falls. It is recommended to perform moderate-intensity aerobic physical activity for at least 30 minutes on most days (i.e., more than five days a week).

Which actions of a diuretic medication help to control BP? Select all that apply. 1. Vasodilation 2. Reduces plasma volume 3. Promotes sodium and water excretion 4. Reduces vascular response to catecholamines 5. Prevents extracellular calcium from moving into the cells

Reduces plasma volume Promotes sodium and water excretion Reduces vascular response to catecholamines Diuretics are an important component of BP treatment. Diuretics tend to reduce the plasma volume by promoting the excretion of sodium and water. The net result is a reduction in the circulating volume, which causes a decrease in the BP. Diuretics also reduce the vascular response to catecholamines. The blood vessels do not constrict in response to catecholamines; as a result, the BP is reduced. Diuretics do not cause vasodilation or prevent the movement of extracellular calcium into the cells; these effects are brought about by calcium channel blockers.

A patient with a history of pheochromocytoma presents to the emergency department with a BP of 246/144 mm Hg. The health care provider prescribes an antihypertensive medication by continuous IV infusion. Which interventions will the nurse plan? Select all that apply. 1. Place the patient on bed rest. 2. Monitor the urine output hourly. 3. Monitor the electrocardiogram (ECG) for dysrhythmias. 4. Assess the BP and heart rate (HR) every 15 minutes during the initial administration. 5. Titrate the infusion according to mean arterial pressure (MAP) or BP as prescribed.

Place the patient on bed rest. Monitor the urine output hourly. Monitor the electrocardiogram (ECG) for dysrhythmias. Titrate the infusion according to mean arterial pressure (MAP) or BP as prescribed. Measure urine output hourly to assess renal perfusion. Patients are placed on bed rest; getting up may cause severe cerebral ischemia and fainting. The drug is titrated according to MAP or BP as prescribed. The nurse should monitor the ECG for dysrhythmias and signs of ischemia or myocardial infarction (MI). Lowering the BP too quickly or too much may decrease cerebral, coronary, or renal perfusion. This could precipitate a stroke, MI, or renal failure. Antihypertensive medications given through an IV have a rapid (within seconds to minutes) onset of action. The patient's BP and HR should be assessed every two to three minutes during the initial administration of these drugs.

The nurse is caring for a patient with hypertension. Which vital sign taken just before the scheduled administration of esmolol would lead the nurse to withhold the dose and consult the prescribing health care provider? 1. Pulse 48 2. Respirations 24 3. BP 118/74 4. Oxygen saturation 93%

Pulse 48 Because esmolol is a β1-adrenergic-blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse-rate limits. Respirations, BP, and oxygen saturation are not a source of concern in this case.

The nurse is caring for a patient with hypertension who is scheduled to receive a dose of metoprolol (Lopressor). The nurse should withhold the dose and consult the prescribing provider for which vital sign taken just before administration? O2 saturation 93% Pulse 48 beats/min Respirations 24 breaths/min Blood pressure 118/74 mm Hg

Pulse 48 beats/min Rationale: Because metoprolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.

Which foods would the nurse suggest that a patient with hypertension should limit? Select all that apply. 1. Nuts 2. Poultry 3. Red meat 4. Canned soup 5. Frozen dinners

Red meat Canned soup Frozen dinners Foods high in fat and sodium, including canned soup, red meat, and frozen dinners, should be avoided by the patient with hypertension. Nuts and poultry are included in the Dietary Approaches to Stop Hypertension (DASH) eating plan.

A 22-year-old healthy adult with a family history of hypertension asks the nurse about how to reduce the risk of developing high BP. Which recommendations would the nurse give? Select all that apply. 1. Restrict sodium intake to less than or equal to 2300 mg/day. 2. Limit alcohol intake; one drink is defined as 24 oz of regular beer. 3. Eat fish, such as salmon and catfish, at least two times per week. 4. Perform moderate-intensity activity for 20 minutes a day, three days a week. 5. Jog at a pace that substantially increases the pulse for moderate physical activity.

Restrict sodium intake to less than or equal to 2300 mg/day. Eat fish, such as salmon and catfish, at least two times per week. Healthy adults should restrict sodium intake to less than or equal to 2300 mg/day. For healthy adults with no history of heart disease, the American Heart Association recommends eating fish at least two times per week; fatty fish such as catfish and salmon are recommended. One drink is defined as 12 oz of regular beer. Moderate-intensity aerobic physical activity should be performed for 30 minutes a day, at least five days a week. Jogging at a pace that substantially increases the pulse is considered to be vigorous activity.

When teaching a patient about dietary management of stage 1 hypertension, which instruction is appropriate? Increase water intake. Restrict sodium intake. Increase protein intake. Use calcium supplements.

Restrict sodium intake. Rationale: The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

When providing dietary teaching to a patient with hypertension, the nurse would teach the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast

Roasted duck Rationale: Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL

Serum creatinine of 2.6 mg/dL Rationale: The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

Which laboratory test result indicates the presence of target organ damage in a patient with hypertension? 1. Serum uric acid of 3.8 mg/dL 2. Serum creatinine of 2.6 mg/dL 3. Serum potassium of 3.5 mEq/L 4. Blood urea nitrogen (BUN) of 15 mg/dL

Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level of 2.6 mg/dL indicates target organ damage to the kidneys. BUN of 15 mg/dL, serum uric acid of 3.8 mg/dL, and serum potassium of 3.5 mEq/L are within normal limits.

The nurse is teaching a patient about the common side effects of antihypertensive medications. Which information would the nurse include? Select all that apply. 1. Sexual problems 2. Resistant hypertension 3. Orthostatic hypotension 4. Frequent voiding and dry mouth from diuretics 5. Rebound hypotension if the drug is stopped abruptly

Sexual problems Orthostatic hypotension Frequent voiding and dry mouth from diuretics Reduced libido or erectile dysfunction are examples of sexual problems as a side effect of antihypertensive medications. Alteration of the autonomic nervous system mechanism by antihypertensive medications leads to orthostatic hypotension. Diuretics are one class of medications for the treatment of hypertension that cause frequent urination and dry mouth. "Resistant hypertension" is a term used to describe a failure to reach the desired BP in the patient who takes multiple antihypertensive medications. Rebound hypertension results from an abrupt stopping of antihypertensive medication use.

Which common side effects of antihypertensive medications would the nurse explain to a patient with a new diagnosis of hypertension? Select all that apply. 1. Constipation 2. Sexual problems 3 Impaired memory 4 Orthostatic hypotension 5 Urge urinary incontinence

Sexual problems Orthostatic hypotension Sexual problems may occur with many of the antihypertensive drugs. Problems can range from reduced libido to erectile dysfunction. A common side effect of several of the antihypertensive drugs is orthostatic hypotension. This condition results from an alteration of the autonomic nervous system's mechanisms for regulating BP, which are needed for position changes. Constipation, impaired memory, and urge urinary incontinence are not common side effects of antihypertensive drugs.

A 67-yr-old woman with hypertension is admitted to the emergency department with a blood pressure of 234/148 mm Hg and was started on nitroprusside (Nitropress). After 1 hour of treatment, the mean arterial blood pressure (MAP) is 55 mm Hg. Which nursing action is a priority? Start an infusion of 0.9% normal saline at 100 mL/hr. Maintain the current administration rate of the nitroprusside. Request insertion of an arterial line for accurate blood pressure monitoring. Stop the nitroprusside infusion and assess the patient for potential complications.

Stop the nitroprusside infusion and assess the patient for potential complications. Rationale: Nitroprusside is a potent vasodilator medication. A blood pressure of 234/118 mm Hg would have a calculated MAP of 177 mm Hg. Subtracting 25% (or 44 mm Hg) = 133 mm Hg. The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. For this patient, the goal MAP would be around 133 mm Hg. Minimal MAP required to perfuse organs is around 60 to 65 mm Hg. Lowering the blood pressure too rapidly may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. The priority is to stop the nitroprusside infusion and then use fluids only if necessary to support restoration of MAP.

As treatment for hypertensive crisis, a patient has received sodium nitroprusside for three days. For which reason would the nurse plan to monitor the patient's thiocyanate levels? 1. The medication has a long half-life. 2. The medication is metabolized to cyanide, then thiocyanate. 3. An increased level indicates interactions with other drugs the patient is taking. 4. An increased level indicates adverse effects on target organs caused by the medication

The medication is metabolized to cyanide, then thiocyanate Sodium nitroprusside causes arterial vasodilation and reduces systemic vascular resistance. This, in turn, decreases the BP. Sodium nitroprusside is metabolized to cyanide and then to thiocyanate, which can reach lethal levels. Therefore thiocyanate levels should be monitored in patients receiving the drug for more than three days or at doses greater than or equal to 4 mcg/kg/min. An increased level does not indicate adverse effects on target organs. It does not indicate interactions with other medications. The cause of concern and the need to assess the thiocyanate level do not relate to the medication's half-life.

The nurse is preparing a presentation related to the complications of hypertension. Which information will the nurse include? Select all that apply. 1. Stroke as a result of atherosclerosis 2. Heart failure as a result of increased heart contractility 3. Blurring of vision or loss of vision secondary to retinal damage 4. Right ventricular hypertrophy as a result of increased workload 5. Coronary artery disease caused by an increase in the elasticity of arterial walls

Stroke as a result of atherosclerosis Blurring of vision or loss of vision secondary to retinal damage Hypertension is a significant risk factor for cerebral atherosclerosis and stroke. Even in mildly hypertensive people, the risk for stroke is 4 times higher than in normotensive people. Adequate BP control decreases the risk of stroke. Embolic stroke may be a result of cerebral blood flow obstruction by a portion of atherosclerotic plaque or a blood clot formed in the carotid arteries. Hypertension leads to retinal damage that is manifested by blurred vision or loss of vision and retinal hemorrhage. Heart failure is a result of decreased heart contractility along with decreased stroke volume and cardiac output. Hypertension leads to an increased cardiac workload that causes left ventricular hypertrophy. Coronary artery disease is caused by decreased elasticity of the arterial walls and narrowing of the lumen.

The nurse is preparing a presentation related to the complications of hypertension. Which information will the nurse include? Select all that apply. 1. Stroke as a result of atherosclerosis 2. Heart failure as a result of increased heart contractility 3. Blurring of vision or loss of vision secondary to retinal damage 4. Right ventricular hypertrophy as a result of increased workload 5. Coronary artery disease caused by an increase in the elasticity of arterial walls

Stroke as a result of atherosclerosis Blurring of vision or loss of vision secondary to retinal damage Hypertension is a significant risk factor for cerebral atherosclerosis and stroke. Even in mildly hypertensive people, the risk for stroke is 4 times higher than in normotensive people. Adequate BP control decreases the risk of stroke. Embolic stroke may be a result of cerebral blood flow obstruction by a portion of atherosclerotic plaque or a blood clot formed in the carotid arteries. Hypertension leads to retinal damage that is manifested by blurred vision or loss of vision and retinal hemorrhage. Heart failure is a result of decreased heart contractility along with decreased stroke volume and cardiac output. Hypertension leads to an increased cardiac workload that causes left ventricular hypertrophy. Coronary artery disease is caused by decreased elasticity of the arterial walls and narrowing of the lumen.

A patient receives instructions about monitoring BP levels at home. Which information would the nurse teach the patient about measuring the BP in a supine position? 1. Take the reading immediately after lying down. 2. Support the arm with a pillow during measurement. 3. Take at least two consecutive readings one after another. 4. Use the arm with the lower BP for all future measurements

Support the arm with a pillow during measurement. When measuring BP in a supine position, the patient should support the arm with a small pillow to raise the position of the hand to the level of the heart. Record the average pressure by taking two consecutive readings at least one minute apart; this allows the blood to drain from the arm and prevents inaccurate readings. The first reading should be taken after two to three minutes of rest in a supine position. If bilateral BP measurements are not equal, the patient should use the arm with the highest BP for all future measurements.

Which actions would the nurse take when obtaining a routine BP measurement? Select all that apply. 1. Support the patient's arm at the heart level. 2. Deflate the cuff at a rate of 5 to 10 mm Hg/sec. 3. Take two or more readings in rapid succession. 4. Ensure the patient has not exercised in the past 30 minutes. 5. Take the measurement immediately after the patient is seated

Support the patient's arm at the heart level. Ensure the patient has not exercised in the past 30 minutes. The patient's arm should be supported at the heart level. The nurse should ensure that the patient has not exercised, smoked, or ingested caffeine within 30 minutes before measurement. The nurse should begin measurement only after the patient has rested quietly for five minutes after sitting. The cuff should be deflated at a rate of 2 to 3 mm Hg/sec. Additional BP readings should be taken at intervals of at least one minute.

Left Ventricular Hypertrophy (LVH)

Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH) Initially, LVH is a compensatory mechanism that strengthens cardiac contraction and increases CO. However, increased contractility increases myocardial work and O2 demand. Progressive LVH, especially in the presence of CAD, is associated with the development of HF.

Which information should the nurse consider when planning care for older adult patients with hypertension? (Select all that apply.) Systolic blood pressure increases with aging. White coat syndrome is prevalent in older patients. Volume depletion contributes to orthostatic hypotension. Blood pressures should be maintained near 120/80 mm Hg. Blood pressure drops 1 hour after eating in many older patients. Older patients require higher doses of antihypertensive medications.

Systolic blood pressure increases with aging. White coat syndrome is prevalent in older patients. Volume depletion contributes to orthostatic hypotension. Blood pressures should be maintained near 120/80 mm Hg. Blood pressure drops 1 hour after eating in many older patients. Rationale: Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older adults are more likely to have elevated blood pressure when taken by health care providers (white coat syndrome). Older patients have orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients have a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? Repeat BP and HR in this position. Record the BP and HR measurements. Take BP and HR with patient standing. Return the patient to the supine position.

Take BP and HR with patient standing. Rationale: The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine position. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.

Drug Alert: Labetalol

Teach patient not to stop the drug abruptly. Abrupt cessation may precipitate angina or HF.

Drug Alert: Clonidine (Catapres)

Teach patient to change positions slowly to limit orthostatic hypotension. Avoid hazardous activities since the drug may cause drowsiness. Do not stop abruptly as this may cause rebound hypertension.

A patient arrives at a medical clinic for a routine physical exam. The patient's BP is 150/94 mm Hg. All other assessment findings are within normal limits, and there is no previous history of elevated BP. Which situation may have falsely elevated the BP reading? 1. The BP cuff was too small for the size of the patient. 2. There is atherosclerosis present in the subclavian artery. 3. The patient smoked the day before the BP measurement. 4. The patient engaged in strenuous exercises the day before.

The BP cuff was too small for the size of the patient. BP measurements should be performed using proper technique to get an accurate reading. BP measurements may be falsely high if the BP cuff is too small because it puts undue pressure on the artery. If the subclavian artery has atherosclerosis, the BP measurement would be falsely low. Smoking and engaging in strenuous exercise should be avoided 30 minutes before the BP measurement because they can alter the measurement. Smoking or engaging in strenuous exercise one day before a BP measurement will not affect the readings.

The nurse observes another health care provider taking the BP of an older patient. The cuff is inflated to 180 mm Hg. The care provider records the systolic BP (SBP) as 180 mm Hg. For which reason is the BP measurement likely to be inaccurate? 1. An older patient's SBP is typically at or below 140 mm Hg. 2. An older patient is prone to anxiety, which can alter the reading. 3. The SBP could be underestimated if an auscultatory gap is present. 4. The patient's arm was level with the patient's heart during the reading

The SBP could be underestimated if an auscultatory gap is present Careful technique is important in assessing BP in older adults. Some older people have a wide gap between the first Korotkoff sound and subsequent beats. This is called the auscultatory gap. Failure to inflate the cuff high enough may result in underestimating SBP. Changes in the older population often place the patient at risk for hypertension. Taking the reading with the arm at heart level is the correct technique. There is no information provided that the patient was anxious.

Retinal Damage

The appearance of the retina gives essential information about the severity and duration of hypertension. We can directly see the blood vessels of the retina with an ophthalmoscope. Damage to the retinal vessels indicates related vessel damage in the heart, brain, and kidneys. Manifestations of severe retinal damage include: -blurring of vision -retinal hemorrhage -vision loss

For which reason would the nurse instruct an elderly patient to avoid taking enalapril with meals? 1. The drug may worsen postprandial hypotension. 2. Drugs may reach toxic levels in elderly patients. 3. Drugs may cause nausea and vomiting if taken with meals. 4. Antihypertensives cause orthostatic hypotension in elderly patients.

The drug may worsen postprandial hypotension. Elderly people experience postprandial drops in BP. BP drops to its lowest level about one hour after eating and returns to normal within three to four hours. Vasoactive drugs taken with meals may worsen the hypotension and cause dangerously low levels of BP; therefore vasoactive drugs should not be taken with meals. Orthostatic hypotension is a side effect of antihypertensive drugs but is not related to food. As with all drugs, vasoactive drugs may reach toxic levels in elderly patients if the dosage is not titrated; however, taking the drug with meals or without meals does not affect this. Nausea and vomiting are common side effects of drugs; however, avoiding the drug with meals does not prevent the side effects.

Sympatheric Nervous System (SNS)

The nervous system -reacts within seconds after a drop in BP -increases BP by activating the SNS -Increased SNS activity increases HR, and cardiac contractility produces widespread vasoconstriction in the peripheral arterioles and promotes the release of renin from the kidneys Net effect of SNS activation is to increase BP by increasing both CO and SVR. Specialized nerve cells called baroreceptors are found in the carotid arteries and arch of the aorta. -cells sense changes in BP and send this information to the vasomotor centers in the brainstem. -brainstem sends this information through complex networks of neurons that excite or inhibit efferent nerves. -SNS efferent nerves innervate cardiac and vascular smooth muscle cells. BP may be reduced by the withdrawal of SNS activity or by stimulation of the parasympathetic nervous system (PNS). -PNS decreases the HR (via the vagus nerve) and thereby decreases CO. -neurotransmitter norepinephrine (NE) is released from SNS nerve endings. -activates receptors in the sinoatrial node, myocardium, and vascular smooth muscle -response to NE depends on the type of receptors present. -SNS receptors are classified as α1, α2, β1, and β2 -smooth muscle of the blood vessels has α-adrenergic and β2-adrenergic receptors. α-Adrenergic receptors -found in the peripheral vasculature -cause vasoconstriction when stimulated by NE. β1-Adrenergic receptors -in the heart respond to NE and epinephrine with increased HR (chronotropic) increased force of contraction (inotropic) increased speed of conduction (dromotropic) β2-Adrenergic receptors are activated mainly by epinephrine released from the adrenal medulla and cause vasodilation

A patient reports feeling dizzy after moving from a supine position to a standing position. Which is the probable reason for the dizziness? 1. The peripheral arteries were constricted. 2. The venous return to the heart increased. 3. The force of contraction of the heart increased. 4. The sympathetic nervous system (SNS) did not respond

The sympathetic nervous system (SNS) did not respond. During any change in position, the vasomotor center is activated and stimulates the SNS response. The SNS response ensures that cerebral blood flow is maintained by causing peripheral vasoconstriction and by increasing venous return. If the patient feels dizzy when changing positions, it means that the SNS response did not occur. If the peripheral arteries constrict and the venous return to the heart is increased, the blood flow to the heart is maintained, preventing dizziness in the patient. If the force of contraction is increased, the patient will not experience dizziness; the blood flow to the brain would be maintained.

A patient who has been taking clonidine for 10 years tells the nurse, "I decided to quit taking the medication a few days ago." For which manifestation would the nurse monitor this patient? 1. Tremors 2. Lethargy 3. Dysphasia 4. Bradycardia

Tremors Sudden discontinuation may cause withdrawal syndrome, including rebound hypertension, tachycardia, headache, tremors, apprehension, and sweating, Bradycardia, lethargy, and dysphasia are not indicators of withdrawal syndrome.

Pathophysiology of Hypertension

Water and sodium Retention Stress and increased SNS activity Altered Renin-Angiotensin-Aldosterone System (RAAS) Insulin resistance and hyper-insulinemia Endothelial dysfunction

Water and sodium retention

When sodium is restricted in people with HTN, their BP usually falls -suggests that some degree of sodium sensitivity may exist for high sodium intake to trigger the development of HTN

A patient with newly discovered high BP has an average reading of 158/98 mm Hg after 3 months of exercise and diet modifications. Which management strategy will be a priority for this patient? a. Drug therapy will be needed because the BP is still not at goal. b. BP monitoring should continue for 3 months to confirm a diagnosis of hypertension. c. Lifestyle changes are less important since they were not effective, and drugs will be started. d. More changes in the patient's lifestyle are needed for a longer time before starting drug therapy.

a Rationale: The patient has hypertension, stage 1. Lifestyle modifications will continue, but starting drug therapy is a priority. Reducing BP can help to prevent serious complications related to hypertension.

Hypertensive crisis

a term used to indicate either a hypertensive urgency or emergency. -occurs at systolic BP greater than 180 mm Hg and/or diastolic BP greater than 120 mm Hg. -can be greater than 220/140 mm Hg. occurs more often in patients with a history of hypertension who have not adhered to their medication regimens or who have been undermedicated. Hypertensive emergencies -have evidence of target organ disease. -most often requires hospitalization for immediate, controlled reduction of BP. Without prompt treatment can produce: encephalopathy intracranial or subarachnoid hemorrhage HF MI renal failure dissecting aortic aneurysm retinopathy Untreated, has a 1-year mortality rate of more than 79%, Hypertensive urgency -has no clinical evidence of target organ disease. -Hospitalization may not be needed to correct the BP. -more common than hypertensive emergency Associated with: chronic, stable complications such as stable angina chronic HF prior MI or cerebrovascular accident Rapidly increasing BP can cause shearing of the endothelial surface due to turbulent blood flow within the vessels leading to further vascular damage and the release of more vasoconstricting substances. A vicious cycle of BP elevation follows, leading to life-threatening damage to target organs. Hypertensive crisis related to cocaine or crack use is a frequent problem. Other drugs that can cause hypertensive crisis: amphetamines phencyclidine (PCP) lysergic acid diethylamide (LSD) -be complicated by drug-induced: seizures stroke MI encephalopathy

A patient is admitted to the hospital in a hypertensive emergency (BP 244/142 mm Hg). Sodium nitroprusside is started to treat the elevated BP. Which management strategies would be most appropriate for this patient? (select all that apply) a. Measuring hourly urine output b. Continuous BP monitoring with an arterial line c. Decreasing the MAP by 50% within the first hour d. Maintaining bed rest and giving tranquilizers to lower the BP e. Assessing the patient for signs and symptoms of heart failure and changes in mental status

a, b, e Rationale: Measure urine output hourly to assess renal perfusion. Patients treated with IV sodium nitroprusside should have continuous intraarterial BP monitoring. Hypertensive crisis can cause encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure, MI, renal failure, dissecting aortic aneurysm, and retinopathy. The initial treatment goal is to decrease the mean arterial pressure (MAP) by no more than 25% within minutes to 1 hour. Patients receiving IV antihypertensive drugs may be restricted to bed rest. Getting up (e.g., to use the toilet/commode) may cause severe cerebral ischemia and fainting

Mixed α- and β-Blockers

carvedilol (Coreg) labetalol α1-, β1-, and β2-adrenergic blocking properties producing peripheral vasodilation and decreased heart rate Reduce CO, SVR, and BP Same as β-blockers IV form is available for hypertensive crisis in hospitalized patients Keep patient supine during IV administration Assess patient tolerance of upright position (severe orthostatic hypotension) before allowing upright activities (e.g., commode)

Which BP-regulating mechanism(s) can result in the development of hypertension if defective? (select all that apply) a. Release of norepinephrine b. Secretion of prostaglandins c. Stimulation of the sympathetic nervous system d. Stimulation of the parasympathetic nervous system e. Activation of the renin-angiotensin-aldosterone system

a, c, e Rationale: Norepinephrine (NE) is released from the sympathetic nervous system nerve endings and activates receptors found in the vascular smooth muscle. When the α-adrenergic receptors in smooth muscle of the blood vessels are stimulated by NE, vasoconstriction results. Increased sympathetic nervous system stimulation produces increased vasoconstriction and increased renin release. Increased renin levels activate the renin-angiotensin-aldosterone system, leading to an elevation in BP.

β-Adrenergic Blockers - Cardioselective Blockers

acebutolol (Sectral) atenolol (Tenormin) betaxolol bisoprolol esmolol (Brevibloc) metoprolol (Lopressor) Block β1-adrenergic receptors Reduce BP by blocking β-adrenergic effects Decrease CO and reduce sympathetic vasoconstrictor tone Decrease renin secretion by kidneys Monitor pulse and BP regularly Use with caution in patients with diabetes because may depress the tachycardia associated with hypoglycemia and adversely affect glucose metabolism Drug of choice for patients with a history of an MI or HF Less effective BP reduction in black patients Esmolol is for IV use only Lose cardioselectivity at higher doses

Adrenergic-inhibiting agents

act by decreasing the SNS effects that increase BP. -work centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels.

Potassium-Sparing Diuretics

amiloride (Midamor) triamterene (Dyrenium) Reduce K+ and Na+ exchange in the distal and collecting tubules Reduce excretion of K+, H+, Ca++, and Mg++ Monitor for orthostatic hypotension and hyperkalemia Contraindicated in patients with renal failure Use with caution in patients on ACE inhibitors or angiotensin II blockers Avoid potassium supplements

Calcium Channel Blockers - Dihydropyridines

amlodipine (Norvasc) clevidipine (Cleviprex) felodipine isradipine nicardipine sustained release nifedipine long acting (Procardia XL) nisoldipine (Sular) Cause vascular smooth muscle relaxation resulting in decreased SVR and arterial BP More potent peripheral vasodilators Clevidipine is for IV use only; solution must be changed every 12 hrs Use of sublingual short-acting nifedipine in hypertensive emergencies is unsafe and not effective Serious adverse events (e.g., stroke, acute MI) have occurred IV nicardipine is available for hypertensive crisis in hospitalized patients; change peripheral IV infusion sites every 12 hrs

Lifestyle modifications

are directed toward reducing the patient's BP and overall cardiovascular risk. AHA's "Life's Simple 7" steps support (1) manage blood pressure (2) control cholesterol (3) reduce blood sugar (4) get active (5) eat better (6) lose weight (7) stop smoking Other modifications: sodium restrictions alcohol intake

Baroreceptors

are sensitive to stretching and, when stimulated by an increase in BP, send inhibitory impulses to the sympathetic vasomotor center. SNS inhibition results in -decreased HR -decreased force of contraction -vasodilation in peripheral arterioles When baroreceptors sense a fall in BP, the SNS is activated. Result is: -constriction of the peripheral arterioles -increased HR -increased contractility of the heart In long-standing hypertension, the baroreceptors become adjusted to elevated BP levels and recognize this level as their new "normal."

Angiotensin II Receptor Blockers (ARBs)

azilsartan (Edarbi) candesartan (Atacand) eprosartan (Teveten) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar) telmisartan (Micardis) valsartan (Diovan) Prevent action of A-II and produce vasodilation and increased Na+ and water excretion Full effect on BP may not be seen for 3-6 wk Do not affect bradykinin levels, therefore an acceptable alternative to ACE inhibitors in people who develop a dry cough In patients with kidney disease, ACE inhibitors and ARBs should not be used together due to adverse renal effects

While obtaining subjective assessment data from a patient with hypertension, the nurse recognizes that a modifiable risk factor for the development of hypertension is a. A low-calcium diet. b. Excess alcohol intake. c. A family history of hypertension. d. Consumption of a high-protein diet.

b Rationale: Alcohol intake is a modifiable risk factor for hypertension. Excessive alcohol intake is strongly associated with hypertension. Males with hypertension should limit their daily intake of alcohol to 2 drinks per day, and one drink per day for females with hypertension.

Angiotensin-Converting Enzyme (ACE) Inhibitors

benazepril (Lotensin) captopril enalapril (Vasotec) fosinopril lisinopril (Zestril) moexipril perindopril quinapril (Accupril) ramipril (Altace) trandolapril (Mavik) Inhibit ACE, reduce conversion of angiotensin I to angiotensin II (A-II) Inhibit A-II-mediated vasoconstriction Aspirin and NSAIDs may reduce effectiveness Adding a diuretic enhances effect, but should not be used with potassium-sparing diuretics Can cause an increase in serum creatinine Inhibit breakdown of bradykinin, which may cause a dry, hacking cough that can occur at any point during treatment, even years later Captopril may be given orally for hypertensive crisis

Thiazide and Related Diuretics

chlorothiazide hlorthalidone hydrochlorothiazide indapamide metolazone (Zaroxolyn) Inhibit NaCl reabsorption in the distal convoluted tubule Increase excretion of Na+ and Cl− Initial decrease in ECF Sustained decrease in SVR Lower BP moderately in 2-4 wk Monitor for orthostatic hypotension, hypokalemia, and alkalosis May potentiate cardiotoxicity of digoxin by producing hypokalemia Dietary sodium restriction reduces the risk for hypokalemia NSAIDs can decrease diuretic and antihypertensive effect and potentially cause renal impairment Teach patient to supplement with potassium-rich foods

Central-Acting α-Adrenergic Agonist

clonidine (Catapres) clonidine patch (Catapres-TTS) Reduce sympathetic outflow from CNS Reduce peripheral sympathetic tone, produces vasodilation, decreases SVR and BP Nurse consideration: Sudden discontinuation may cause withdrawal syndrome, including -rebound hypertension -tachycardia -headache -tremors -apprehension -sweating Chewing gum or hard candy may relieve dry mouth Alcohol and sedatives increase sedation Transdermal patch may be related to fewer side effects and better adherence guanabenz guanfacine (Tenex) -not available in the transdermal formulation methyldopa Teach patient about daytime sedation and avoiding hazardous activities Taking a single daily dose at bedtime minimizes the sedative effect

A priority consideration in the management of the older adult with hypertension is to a. Prevent primary hypertension from converting to secondary hypertension. b. Recognize that the older adult is less likely to adhere to the drug therapy regimen than a younger adult. c. Ensure that the patient receives larger initial doses of antihypertensive drugs because of impaired absorption. d. Use precise technique in assessing the BP of the patient because of the possible presence of an auscultatory gap.

d Rationale: Careful technique is important in assessing BP in older adults. In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats. This wide interval is called an auscultatory gap. Failure to inflate the cuff high enough may result in an inaccurate systolic BP, one that is too low for the patient.

In teaching a patient with hypertension about controlling the illness, the nurse recognizes that a. All patients with elevated BP need drug therapy. b. Obese persons must achieve a normal weight to lower BP. c. It is not necessary to limit salt in the diet if taking a diuretic. d. Lifestyle modifications are needed for all persons with elevated BP.

d Rationale: Lifestyle modifications are needed for all patients with prehypertension and hypertension.

Direct vasodilators

decrease the BP by relaxing the vascular smooth muscle and reducing SVR.

Calcium Channel Blockers - Non-Dihydropyridines

diltiazem extended release (Cardizem LA) verapamil intermediate release (Calan) verapamil timed-release (Verelan PM) Inhibit movement of Ca++ across cell membrane, resulting in vasodilation Cardioselective resulting in a decrease in heart rate and slowing of AV conduction Use with caution in patients with HF Grapefruit juice may increase serum concentrations and toxicity of certain calcium channel blockers; avoid concurrent use Used for supraventricular tachydysrhythmias Avoid in patients with second- or third-degree AV block or left ventricular systolic dysfunction

α1-Adrenergic Blockers

doxazosin (Cardura) prazosin (Minipress) terazosin Block α1-adrenergic effects, producing peripheral vasodilation (decreases SVR and BP) Beneficial effects on lipid profile Reduced resistance to the outflow of urine in benign prostatic hyperplasia Take at bedtime to reduce risk associated with orthostatic hypotension phentolamine Blocks α1-adrenergic receptors, resulting in peripheral vasodilation (decreases SVR and BP) Used in the short-term management of pheochromocytoma Used locally to prevent necrosis of skin and subcutaneous tissue after extravasation of adrenergic drug No oral formulation

Secondary hypertension

elevated BP with a specific cause that often can be identified and corrected -can become resistant, causing cardiovascular complications -5% to 10% of hypertension in adults -suspected in people who suddenly develop high BP, especially if it is severe Treatment is aimed at removing or treating the underlying cause. Common causes: Cirrhosis Coarctation or congenital narrowing of the aorta Drug-related: -estrogen replacement therapy -oral contraceptives -corticosteroids -nonsteroidal antiinflammatory drugs *cyclooxygenase-2 inhibitors -SNS stimulants *cocaine *monoamine oxidase -Endocrine disorders *pheochromocytoma *Cushing syndrome *thyroid disease -Neurologic disorders *brain tumors *quadriplegia *traumatic brain injury -Pregnancy-induced hypertension -Renal disease *renal artery stenosis *glomerulonephritis -Sleep apnea

Primary hypertension (essential or idiopathic)

elevated BP without an identified cause. -90% to 95% of all cases Multiple contributing factors: -changes in endothelial function related to either vasoconstricting or vasodilating agents -increased SNS activity -overproduction of sodium-retaining hormones -increased sodium intake -greater than ideal body weight -age -family history -ethnicity -diabetes -tobacco use -excess alcohol intake.

Resistant Hypertension

failure to reach goal BP in patients who are taking full doses of an appropriate three-drug therapy regimen that includes a diuretic carries a 2- to 6-fold increase in complications including MI and stroke over other hypertensive patients. Causes of pseudoresistant HTN: • Improper BP measurements (i.e., inappropriate BP cuff size) • Inadequate drug doses • Inappropriate drug therapy • Poor adherence to drug regimen (e.g., due to side effects, finances) • White coat syndrome Volume overload • Excess salt intake • Volume retention from kidney disease • Inadequate diuretic therapy • Drug-induced • Corticosteroids • Cyclosporine and tacrolimus (Prograf) • Erythropoietin • Illegal drugs (e.g., cocaine, amphetamines) • Licorice • Nonsteroidal antiinflammatory drugs • Oral contraceptives • OTC dietary or herbal supplements and drugs (e.g., ma huang, bitter orange) • Sympathomimetics (e.g., decongestants, diet pills) Associated conditions • Excess alcohol intake • Increasing obesity

Direct Vasodilators

fenoldopam (Corlopam) Activates dopamine receptors, resulting in systemic and renal vasodilation IV use only for hypertensive crisis in hospitalized patients Use cautiously in patients with glaucoma Patient should remain flat for 1 hr after administration hydralazine Reduces SVR and BP by direct arterial vasodilation IV use for hypertensive crisis in hospitalized patients Twice-daily oral dosage Not used as monotherapy because of side effects Contraindicated in patients with CAD minoxidil Reduces SVR and BP by direct arterial vasodilation Reserved for treatment of severe hypertension associated with renal failure and resistant to other therapy Once- or twice-daily dosage nitroglycerin Relaxes arterial and venous smooth muscle, reducing preload and SVR At a low dose, venous dilation predominates; at a higher dose, arterial dilation is present IV use for hypertensive crisis in hospitalized patients with myocardial ischemia Given by continuous IV infusion with pump or control device sodium nitroprusside Direct arterial vasodilation reduces SVR and BP IV use for hypertensive crisis in hospitalized patients Given by continuous IV infusion with pump or control device Arterial BP monitoring BP recommended Wrap IV solutions with an opaque material to protect from light Stable for 24 hrs then metabolized to cyanide, then thiocyanate Monitor thiocyanate levels with prolonged use (>3 days) or doses ≥4 mcg/kg/min

Weight reduction

has a significant effect on lowering BP -effect is seen with even moderate weight loss -for every 1 kg of weight lost, BP will decrease by 1 mm Hg. When a person decreases caloric intake, sodium and fat intake are usually also reduced. Although reducing the fat content of the diet has not shown any sustained benefits in BP control, it may slow the progress of atherosclerosis and reduce overall CVD risk. Weight reduction through a combination of calorie restriction and moderate physical activity is recommended

Hypertension

high blood pressure most important modifiable risk factor for development of CVD Differences in Ethnicity: Blacks -have the highest prevalence of HTN in the world -more likely to have resistant hypertension -develop HTN at a younger age than other ethnicities with higher average blood pressure -higher incidence of HTN among women -have more nocturnal non-dipping BP than whites, which is associated with an increase in CVD -HTN is more aggressive /results in more severe end-organ damage -highest death rate resulting from HTN -make less renin and do not respond well to renin-inhibiting drugs -better BP control with calcium channel blockers and diuretics, especially with monotherapy -higher risk for angioedema with ACE inhibitors than whites Hispanics -less likely to receive treatment for HTN -lower rates of BP control than -lower levels of awareness of HTN and its treatment Gender differences: Men -Before early middle age, HTN is more common in men Women -HTN is 2 to 3 times more common in women who take oral contraceptives than in women who do not. - history of preeclampsia may be an early sign of risk for CVD. -After age 64, HTN is more common in women. -part of the rise in BP in women is attributed to menopause-related factors: estrogen withdrawal overproduction of pituitary hormones weight gain -harder to control HTN in older women (ages 70 to 79) than in women ages 50 to 69, despite having similar rates of treatment.

Calcium channel blockers (CCB)

increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells.

Elevated blood pressure

is defined as an SBP between 120 -129 mm Hg and a DBP < 80 mm Hg. Normal blood pressure: -SBP < 120 -DBP < 80 Hypertension (stage 1): -SBP between 130-139 mm Hg -DBP between 80-89 mm Hg Hypertension (stage 2) -SBP > 140 mm Hg -DBP > 90 mm Hg If either the SBP or DBP is outside of a range, the higher measurement determines the classification. Example: 115/86 would be classified as hypertension stage 1 even though the SBP is within normal limits. SBP increases with age. DBP rises until around 55 years old and then declines. BP classification is based on 2 or more readings, accurately performed on both arms, on 2 separate occasions.

Blood pressure (BP)

is the force exerted by the blood against the walls of the blood vessel. It must be adequate to maintain tissue perfusion during activity and rest. BP is mainly a function of cardiac output (CO) and systemic vascular resistance

Orthostatic hypotension

occurs when a patient moves from a supine to standing position, and there is a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in the HR of 20 beats/min. Document any lightheadedness or dizziness during the procedure, which is considered an abnormal finding. Common causes: dehydration inadequate vasoconstrictor mechanisms related to disease or drug therapy Measure serial BP and HR with the patient: -supine -sitting -standing 1. have the patient lie down for 5 minutes then measure BP and HR. 2. help the patient to a standing position and measure the BP and HR both 1 minute and 3 minutes after standing. 3. Record all 3 measurements, noting the patient's position and corresponding measurement. Usually, the SBP decreases slightly (less than 10 mm Hg) on standing, while the DBP and pulse increase slightly.

A-II receptor blockers (ARBs)

prevent angiotensin II from binding to its receptors in the walls of the blood vessels.

Angiotensin-converting enzyme (ACE) inhibitors

prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)-mediated vasoconstriction and sodium and water retention.

Diuretics

promote sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines.

Aldosterone Receptor Blockers

spironolactone (Aldactone) eplerenone (Inspra) Inhibit the Na+-retaining and K+-excreting effects of aldosterone in the distal and collecting tubules Monitor for orthostatic hypotension and hyperkalemia Do not combine with potassium-sparing diuretics or potassium supplements Use with caution in patients on ACE inhibitors or angiotensin II blockers Classified as potassium-sparing diuretics

Drug Therapy

• In patients 65 years or older with an average SBP of more than 130 mm Hg who are ambulatory and living in a community setting, rather than living in a care facility, treatment goals should be to obtain an SBP < 130 mmHg. • In patients 65 years or older with an average SBP of more than 130 mm Hg who live in a care facility, and/or have multiple comorbidities or limited life expectancy, treatment should be based on patient preference, clinical experiences, and team input. • In patients over 18 years old with hypertension, known CVD or other risk factors, a BP of 130/80 mm Hg is the goal of treatment. • In all other patients without CVD or other risk factors, a BP of less than 130/80 mm Hg may be reasonable.