Ch 31: Patients w/ HTN

Classification of Blood Pressure for Adults Age 18 Years and Older (not children)

"The Silent Killer" Diastolic is an excellent indicator on how much fluid we have (tx: diuretics)

Gerontologic Considerations

-Medication regimen can be difficult to remember -Expense can be a challenge -*Monotherapy,* (the use of a single drug to treat a disease or condition) if appropriate, may simplify the medication regimen and make it less expensive -Ensure that older adult patients understand the regimen and can see and read instructions, open medication containers, and get prescriptions refilled. -Include family and caregivers in educational program

HTN statistics

-Primary hypertension. (no known cause) -Secondary hypertension. (Due to other dz states, renal dz, or SE of meds) - 28-31% of the adult population of the U.S. has hypertension. - 90-95% of this population with hypertension has primary hypertension. - About 54% of adults with HTN do not have it under control -Incidence is *greater in southeastern U.S. and among African-Americans.*

Factors that Influence the Development of Hypertension

-Increased sympathetic nervous system activity (arterial barorecptors) ex: sleep apnea -Increased reabsorption of sodium chloride and water by the kidneys (properly functioning kidneys) -Increased activity of the rennin-angiotensin system (RAAS) -Decreased vasodilatation (age related changes) -Insulin resistance *Hyperinsulinemia can be caused by insulin resistance, which creates elevated glucose levels due to glucose intolerance. The pancreas tries to correct this by massively increasing insulin production, which leaves high levels of serum insulin that are not utilized. One of the many effects of this over production is the increased re-absorption of sodium by the kidneys.This causes increased extracellular fluid volume, which will demand greater cardiac output and raise blood pressure. There are also several other pathways in which sustained elevated levels of insulin can stimulate the sympathetic nervous system and increase peripheral vascular resistance and raise blood pressure.*

For patients with uncomplicated hypertension and no specific indications for another medication, what is the initial medication? A) Thiazide diuretic B) Calcium channel blockers C) Vasodilators D) Angiotensin converting enzyme inhibitors Think about BP = CO X PVR and CO = HR X SV

A For patients with uncomplicated hypertension and no specific indications for another medication, the recommended initial medication is thiazide diuretics for most patients. If blood pressure does not fall to less than 140/90 mm Hg, the dose is increased gradually and additional medications are included as necessary to achieve control. ^use thiazide first because less ae^ ^works by decreasing fluids which decreases SV and CO

A nurse is caring for a client who is diagnosed with HTN and is prescribed spironolactone (Aldactone) 25mg/day. Which of the following statements by the client indicates a need for further teaching? A) "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B) "I will report any changes in HR or rhythm." C) "I should use a salt substitute that is low in potassium." D) "I will continue to take this medication even if I am feeling better."

A. " I should eat a lot of fruits and vegetables, especially bananas and potatoes." Potatoes and bananas are high in potassium, and Aldactone is a potassium-sparing diuretic. Consuming these food can lead to hyperkalemia. The client should report any changes in HR or rhythm, use salt substitutes that are low in potassium to prevent hyperkalemia, and know to continue taking the medication even if he is symptom free.

*Hypertensive emergency*

Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs Reduce BP 25% in first hour. Reduce to 160/100 over 6 hours. *(SLOWLY*) Then gradual reduction to normal over a period of days. Exceptions are ischemic stroke and aortic dissection. *Medications* IV vasodilators: sodium nitroprusside, nicardipine, fenodopam mesylate, enalaprilat, nitrogylcerin Need very frequent monitoring of BP and cardiovascular status.

*Hypertensive urgency*

Blood pressure is very high but no evidence of immediate or progressive target organ damage Patient requires close monitoring of blood pressure and cardiovascular status. Assess for potential evidence of target organ damage. *Medications* Fast-acting oral agents: beta adrenergic blocker— labetalol; angiotensin-converting enzyme inhibitor— captopril; or alpha2-agonist—clonidine

Nursing History and Assessment

History and risk factors Assess potential symptoms of target organ damage: -Angina, shortness of breath, altered speech, altered vision, nosebleeds, headaches, dizziness, balance problems, nocturia Cardiovascular assessment: apical and peripheral pulses. Personal, social, and financial factors that will influence the condition or its treatment (ex: don't like the way it makes them feel)

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147. The client reports a HA and states that she is seeing double. The client states that she ran out of her Cardizem 3 days ago, and she has not been able to purchase more. Which of the following nursing interventions should the nurse expect to perform first? A) Administer Tylenol for HA B) Provide teaching in regard to the importance of not abruptly stopping an antihypertensive. C) Obtain IV access and prepare to administer an IV antihypertensive. D) Call social services for a referral for financial assistance in obtaining prescribed medication.

C. Obtain IV access and prepare to administer an IV antihypertensive. The greatest risk to the client is injury due to a BP of 266/147, which can be life-threatening. The highest priority is to decrease the client's BP as quickly as possible. An IV should be started for IV access. Medications given by the IV route will be absorbed and distributed much faster than by the oral route. Administering Tylenol for HA, providing teaching regarding medication administration, and obtaining financial assistance is important, but not the priority at this time.

Major risk factors

Hypertension Smoking Obesity Physical inactivity Dyslipedemia Diabetes mellitus *Microalbuminuria* (small protein in the urine bc it got pushed through the fine mesh in kidneys: scream of a dying kidney) or GFR < 60 Older age Family history

HTN

Defined by the Seventh Report of the Joint National Commission on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) as a *systolic pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg. * -Based on the average of *two or more accurate blood pressure measurements taken during two or more contacts* with a health care provider.

The nurse is preparing an education plan for a patient newly diagnosed with hypertension. What should be included in the education plan? A) Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day most days of the week). B) Eliminate alcoholic beverages from the diet. C) Reduce sodium intake to no more than 200 mmol/day. D) Maintain a normal body weight with BMI between 18 and 30 kg/m2.

Engage in regular aerobic physical activity such as brisk walking (at least 30 min/day most days of the week). Rationale: Exercise is recommended as above. Alcoholic beverages can be consumed in moderation. Sodium should be reduced to no more than 100 mmol/day, and the patient should maintain a normal body weight with a BMI between 18.5 and 24.9 kg/m2.

Patient assessment

History and Physical Laboratory tests (to ID causes of secondary HTN or target organ damage) -Urinalysis -Blood chemistry -Cholesterol levels -Serum corticoids to detect Cushing's disease ECG (tall R waves often seen in LVH) CXR (cardiomegally)

What is a priority nursing assessment when caring for the patient in a hypertensive crisis receiving intravenous vasodilators? a)Pain b) I&O c) Vision d) Family history

I&O Rationale: Assessing the individual's fluid volume status is recommended because if there is volume depletion secondary to natriuresis caused by the elevated blood pressure, then volume replacement with normal saline can prevent large sudden drops in blood pressure when antihypertensive medications are administered.

Collaborative Problems and Potential Complications

Left ventricular hypertrophy Myocardial infarction Heart failure Transient ischemic attack (TIA) Cerebrovascular accident (CVA, stroke, or brain attack) Renal insufficiency and failure Retinal hemorrhage

S&S of HTN

Most ppl who have HTN don't have S/S other than high blood pressure (except pregnant women) Symptoms seen related to organ damage are seen late and are serious *-h/a (esp in am), dizziness, fainting, retinal changes, visual disturbances, nocturia* -Retinal and other eye changes -Renal damage -Myocardial infarction (MI) -Cardiac hypertrophy -Stroke

Hypertensive Crises

Often occurs when clients do not follow the medication therapy regimen *S/SX* severe HA, blurred vision, dizziness, disorientation, epistaxis *Hypertensive emergency* AND *Hypertensive urgency*

Goals and Interventions

Patient understanding of disease process Patient understanding of treatment regimen Patient participation in self-care (*when to take, when to call*) Absence of complications *ADHEREANCE TO THERAPUTIC REGIMEN* ^teach pt how to take BP *Interventions:* Patient education Support adherence to the treatment regimen Consultation/collaboration Follow-up care Emphasize control rather than cure Reinforce and support lifestyle changes **A lifelong process**

Evaluation

Reports knowledge of disease management sufficient to maintain adequate tissue perfusion -Maintains blood pressure at less than 140/90 mm Hg with no symptoms of angina, palpitations, or vision changes; stable BUN and serum creatinine levels; and palpable peripheral pulses Adheres to the self-care program -Reduces calorie, Na, and fat intake; exercises regularly; takes medications as prescribed and reports side effects; measures BP; abstains from tobacco and excessive alcohol intake; keeps appointments Has no complications -Reports no changes in vision; exhibits no retinal damage on vision testing -Maintains pulse rate and rhythm and respiratory rate within normal ranges; reports no dyspnea or edema -Maintains urine output consistent with intake; has renal function test results within normal range -Demonstrates no motor, speech, or sensory deficits -Reports no headaches, dizziness, weakness, changes in gait, or falls

Medication treatment

Usually initial medication treatment is a* thiazide diuretic.* -Low doses are initiated and the medication dosage is increased gradually if blood pressure does not reach target goal. +Additional medications are added if needed. (Multiple medications may be needed to control blood pressure). -Lifestyle changes initiated to control BP must be maintained. *Diuretic and related drugs* Thiazide diuretics Loop diuretics Potassium sparing diuretics Aldosterone receptors blockers -Central alpha2-agonists and other centrally acting drugs -Beta-blockers -Beta-blockers with intrinsic sympathomimetic activity -Alpha and beta blockers -Vasodilators -Angiotensin-converting enzyme (ACE) inhibitors: *DONT AFFECT HR!1* (prevents constriction, doesn't promote dilation) -Angiotenisin II antagonists (ARB) -Direct renin inhibitors (Tekturna) -Calcium channel blockers (don't give if heart rate is below 60) Nondihydropyridines Dihydropyridines ^which one blocks conversion of angiotensinogen to angiotensin by renin?

Lifestyle modifications

Weight loss Reduced alcohol intake (alcohol = sugar) Educed sodium intake Regular physical activity Diet: high in fruits, vegetables, and low-fat dairy DASH diet (dietary approaches to stop HTN) Moderation of alcohol consumption

Blood pressure=

cardiac output x peripheral resistance (PVR)