Adult Health Nursing 1 Blood Pressure • Blood Pressure = Cardiac Output x Peripheral Resistance
• Cardiac Output = Heart Rate x Stroke Volume
Hypertension • High blood pressure • 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 Classification of Blood Pressure for Adults Age 18 and Older Incidence of Hypertension— “The Silent Killer” • Primary hypertension. • Secondary hypertension. • 28–31% of the adult population of the U.S. has hypertension. • 90–95% of this population with hypertension has primary hypertension. • In Jordan the prevalence is 33.8% among men and 29.4% among women Primary: Essential Hypertension • Cause of essential hypertension is unknown; however, there are several areas of investigation: • a. Hyperactivity of sympathetic vasoconstricting nerves. • b. Presence of vasoactive substance released from the arterial endothelial cells, which acts on smooth muscle, sensitizing it to vasoconstriction. • c. Increased cardiac output, followed by arteriole constriction. • d. Excessive dietary sodium intake, sodium retention, insulin resistance, and hyperinsulinemia play roles Secondary hypertension • 1- Renal pathology: • a. Chronic kidney disease, congenital ,pyelonephritis, renal artery stenosis, acute and chronic glomerulonephritis • b. Reduced blood flow to kidney causes release of renin. Renin reacts with a serum protein to form angiotensin I, which is converted to angiotenin II through the action of angiotensin-converting enzyme in the lungs, leading to vasoconstriction and increased salt and water retention. • 2. Stenosis of aorta—The kidneys release renin when they sense hypotension. 3. Endocrine disturbances: a. tumor of the adrenal gland that causes release of epinephrine and norepinephrine and a rise in BP (extremely rare). b. Adrenal cortex tumors lead to an increase in aldosterone secretion (hyperaldosteronism) and an elevated BP (rare). c. Cushing’s syndrome leads to an increase in adrenocortical steroids (causing sodium and fluid retention) and hypertension. d. Hyperthyroidism causes increased cardiac output. 4. Obstructive sleep apnea causes nocturnal hypertension, which leads to sustained daytime hypertension. 5. Prescription medications such as estrogens and steroids (cause fluid retention), sympathomimetics (cause vasoconstriction Factors Involved in the Control of Blood Pressure Factors that Influence the Development of Hypertension • Increased sympathetic nervous system activity • Increased reabsorption of sodium chloride and water by the kidneys • Increased activity of the rennin-angiotensin system • Decreased vasodilatation • Insulin resistance:(insulin has role in vessel wall decrease relaxation by effect on secretion of nitric oxide) Manifestations of Hypertension • Usually NO symptoms other than elevated blood pressure • Symptoms seen related to organ damage are seen late and are serious • Retinal and other eye changes • Renal damage • Myocardial infarction • Cardiac hypertrophy • Stroke Major Risk Factors of Hypertension • Smoking • Obesity • Physical inactivity • High blood lipid • Diabetes mellitus • Microalbuminuria or GFR < 60 • Older age • Family history Patient Assessment • History and Physical assessment • Laboratory tests • Urinalysis • Blood chemistry: BUN, lipid, electrolytes • ECG 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. Medications • Diuretic and related drugs • Thiazide diuretics • Loop diuretics • Potassium sparing diuretics • Aldosterone receptors blockers • Central alpha2-agonists and other centrally acting drugs(inhibit norepinephrine) • Beta-blockers • Alpha and beta blockers Medications • Vasodilators • Angiotensin-converting enzyme (ACE) inhibitors • Angiotenisin II antagonists • Calcium channel blockers Life style medication • Weight loss • Educed sodium intake • Regular physical activity • Diet: high in fruits, vegetables, and low-fat dairy • DASH (dietary approach to stop hypertension) diet: is rich in fruits, vegetables, whole grains, and low-fat dairy foods; includes meat, fish, poultry, nuts and beans; and is limited in sugar-sweetened foods and beverages, red meat, and added fats Complications of hypertension 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 Nursing Diagnosis • Knowledge deficit regarding the relation of the treatment regimen and control of the disease process • Noncompliance with therapeutic regimen related to side effects of prescribed therapy Nursing Planning • Patient understanding of disease process • Patient understanding of treatment regimen • Patient participation in self-care • Absence of complications Nursing Intervenstions • Patient teaching • Support adherence to the treatment regimen • Consultation/collaboration • Follow-up care • Emphasize control rather than cure • Reinforce and support lifestyle changes • A lifelong process • Hypertensive emergency • Blood pressure > 180/120 and must be lowered immediately to prevent damage to target organs Clinical manifestations • Brain effects: a. Encephalopathy. b. Stroke. c. Progressive headache, stupor, seizures. • 2. Kidney effects: Decreased blood flow, vasoconstriction. Elevated BUN. Increased plasma renin activity. Lowered urine-specific gravity. Proteinuria. Renal failure. • 3. Cardiac effects: • a. Left-sided heart failure. • b. Acute MI. • c. Right-sided heart failure Treatment • Reduce BP 25% in first hour. • Reduce to 160/100 over 6 hours. • 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.