Hypertension: Causes, Risks, and Management

Hypertension Overview

• Primary hypertension has no single identifiable cause.
• Secondary hypertension is associated with cirrhosis, adrenal tumors, pregnancy, and drug use, characterized by sudden development.
• Hypertension is often asymptomatic, earning it the name "silent killer," but symptoms can include fatigue, dizziness, and palpitations.

Hypertension Complications

• Target organ diseases are most common in the heart, leading to coronary artery disease, atherosclerosis, and heart failure (HF), and in the brain, causing cerebrovascular disease, transient ischemic attacks (TIA), stroke, and peripheral vascular disease.

Assessing and Managing Risk Factors

• Non-modifiable risk factors encompasses genetic factors, age (women over 65, men over 55), gender (men and post-menopausal women), ethnicity (Hispanic, African-American), and family history.
• Modifiable risk factors are diabetes, stress, obesity, poor nutrition, high sodium intake, low calcium, potassium, magnesium, substance abuse, cigarette smoking/tobacco use, cocaine, ETOH, and caffeine.

Diagnostic Studies

• Diagnostic studies includes measurement of BP Labs to identify or rule out secondary HTN, evaluate target organ disease, determine CV risk, and establish baselines prior to starting therapy.
• Key tests are renal function, U/A, BMP, CBC, serum lipid profile, uric acid, ECG, ophthalmic exam, Echo, LFTs, TSH as well as ambulatory blood pressure monitoring (ABPM).
• Ambulatory blood pressure monitoring (ABPM) involves a noninvasive, fully automated system, ensuring that patients are taught to hold their arm still and keep a diary of activities.

Nursing Interventions and Patient Education

• Interprofessional care & patient education ensures the achievement & maintenance of goal BP and reduction of CV risk factors & target organ disease.
• Lifestyle modifications include the AHA Life's Simple 7.
• Self-management includes managing blood glucose (BG) with home BP monitoring, controlling cholesterol, reducing blood sugar, engaging in physical activity (30 minutes at least 5 days/week), and adopting better eating habits.
• Dietary advice includes following the DASH diet, which restricts sodium, fat, alcohol, and caffeine, and focusing on weight reduction also smoking cessation following https://smokefree.gov/
• Always prioritize lifestyle modifications first to normalize B/P and reduce the risk of organ damage.

Pharmacotherapy for Hypertension

• Pharmacotherapy involves decreasing circulating blood volume, decreasing systemic vascular resistance, and using adrenergic inhibiting agents.
• Key medications include ACE Inhibitors ("pril" like Lisinopril), Calcium Channel Blockers (Cardizem), ARBs (Cozaar), Diuretics (Lasix), Beta Blockers “olol” (Atenolol), Alpha & Beta Adrenergic blockers, and direct vasodilators.

Important Considerations for Drug Therapy

• Follow-up care involves identifying, reporting, & minimizing side effects for orthostatic hypotension, sexual problems (decreased libido or erectile dysfunction), dry mouth (use sugarless gum or candy), and frequent urination (take diuretic early in the day).
• Resistant hypertension means failure to reach goal BP, thus further monitoring/treatment will be required.

Blood Pressure Measurement Protocol

• Patients should avoid smoking, exercise, or caffeine for 30 minutes before measurement and rest quietly for 5 minutes without talking.
• Take readings in both arms initially with proper cuff size & placement.
• Note that the forearm is an acceptable alternative site, and the measurement site should be documented.
• Assess for orthostatic hypotension by measuring BP & HR supine, sitting, & standing, measuring within 1 to 2 minutes of position change.

Orthostatic Hypotension

• A positive finding indicative of orthostatic hypotension is a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, or an increase of 20 beats/minute or more in heart rate.

Nursing Implementation

• Give BP reading in writing; explain need for further evaluation & focus is on control for those with HTN; identify at-risk groups/CV risk modification.
• Address lifestyle modifications, screen for those with limited access to care; connect to HCP or insurance if needed in ambulatory care-long-term management.
• Evaluate therapeutic effectiveness, detect & report adverse effects, and assess & enhance adherence by individualizing plan and actively involving the patient.
• Patient participation also involves patient and caregiver teaching and providing nutritional and drug therapy.

Hypertensive Crisis

• A hypertensive crisis is when SBP >180 mmHg &/or DBP >120 mmHg.
• Hypertensive crisis has hypertensive emergency, hypertensive urgency, and hypertensive crisis manifestations.
• Hypertensive encephalopathy (headache, N/V, seizures, confusion, coma, retinal changes), renal insufficiency, cardiac decompensation (MI, HF, pulmonary edema) and aortic dissection are also other manifestations to be aware of.

Hypertensive Crisis Treatment

• Treatment for hypertensive crisis: Hospitalization—HTN emergency involves treatment related to BP & evidence of target organ disease via IV drugs which require slow titration.
• Administer vasodilators such as sodium nitroprusside and adrenergic inhibitors, calcium channel blockers.
• Rapid onset drugs necessitate monitoring HR & BP every 2 to 3 minutes, cardiac & renal function, neurologic checks on patient under bed rest.
• Always determine the cause to educate patient to avoid future crisis.

Coronary Vascular Disorders: Clinical Treatment

• Coronary vascular disorders includes coronary artery disease, coronary atherosclerosis, & angina pectoris, with primary manifestation being coronary atherosclerosis from fatty deposits.

Risk Factors and Management Strategies

• The main non-modifiable risk is age and this must be considered.
• Hyperlipidemia and hypertension are modifiable risk factors.
• High levels raises ones risk of atherosclerosis & CAD.
• High-density lipoproteins (HDL) <40 mg/dL in men, <50 mg/dL (1.3 mmol/L) in women, require health interventions.
• High levels prevent lipid accumulation in arteries and keep Triglycerides >150 mg/dL.
• High levels indicate risk for CAD
• Treatment guidelines: high LDL are based on 10-year & lifetime risk score for having heart disease or stroke that data considered are: Age, gender, race, tobacco use, diabetes, systolic BP, diastolic BP, use of BP drugs, total cholesterol level & HDL level and use http://www.cvriskcalculator.com

Health Promotion

• Health goals may be to focus on identifying high-risk person and management through smoking cessation and diabetes control.
• Emphasize the need to quit smoking and maintain control over diabetes.

Physical Intervention

• Follow FITT formula
• 30 min./day + wt. training 2 days/wk is ideal to improve physical strength.

Nutritional Intervention

• Reduce ones intake of saturated fats, cholesterol, red meat, egg yolks, & whole milk.
• Increase ones intake of complex carbs & fiber and omega-3 fatty acids.

Drug Treatment

• Common drugs are HMG-CoA Reductase Inhibitors like Atorvastatin (Lipitor), Rosuvastatin (Crestor) and Niacin, Fibric Acid Derivatives like Gemribrozil (Lopid), Bile Acid Sequestrants, Proprotein Convertase Subtilisin/Kexin Inhibitors, and Ezetimibe (Zetia).

Angina Pectoris

• CAD is a chronic & progressive disease with asymptomatic pts maybe prone to chronic chest pain, this increases O2 demand and decreases the supply leading to myocardial ischemia.
• Angina has stable, unstable, intractable, variant and silent ischemia types.

Assessments with Angina

• Angina is identified through patient description which are tightness, choking, or a heavy sensation, usually retrosternal radiating to neck, jaw, shoulders, back or arms (usually left).
• Anxiety frequently accompanies the pain.
• Other symptoms may occur dyspnea or shortness of breath, dizziness, nausea, & vomiting.
• Typical angina pain subsides w/rest or NTG.
• Unstable angina is characterized by increased frequency & severity & is not relieved by rest & NTG, and requires medical intervention!

Chronic Stable Angina

• Chronic stable angina onset is related to physical exertion, stress, or emotional upset Accurate assessment is extremely important.
• Patients will experience pressure, heaviness, or discomfort in chest; along with dyspnea or fatigue lasting a couple of minutes, normally subsiding with precipitating factor.
• Treatment involve rest, calm down, while administering sublingual nitroglycerin (SL NTG), which is normally predictable & controlled w/ drugs

Clinical Interventions for Angina

• Aspirin, along with short-acting nitrates such as dilation of peripheral & coronary arteries & collateral vessels is crucial.
• Nitroglycerin (SL NTG) or translingual spray: give 1 tablet or 1 to 2 metered sprays, with relief in 5 minutes lasting 30 to 40 minutes.
• If symptoms unchanged after administering dose, immediately contact EMS, patient must also keep proper use & storage.
• Contraindicated conditions are severe bradycardia, acute decompensated HF and must be used cautiously for patients with asthma, diabetes or under treatment with Calcium channel blockers (CCBs) or lipid-lowering drugs.

Peripheral Arterial Disease (PAD)

• PAD is identified with Thickening & narrowing of arteries in extremities.

Risk Factors for PAD

• Risk factors: smoking, DM, HTN, increasing cholesterol, aged 60
• Intermittent claudication is reproducible, resolves in 10 min. or less w/rest
• Paresthesia- numbness or tingling, burning or shooting pain Diminished or absent peripheral pulses
• Absence of hair, shiny skin, taut, pallor
• Dependent = reactive hyperemia (rubor/redness), elevated=pallor Pain at rest-worse at night & w/elevation
• Critical Limb Ischemia (CLI) has chronic ischemic rest pain lasting longer than 2 weeks causing atrophy of skin & muscles.
• Delayed healing, wound infection, tissue necrosis, ulcers Gangrene- resulting in amputation

Diagnostics

• Diagnostics comprise of doppler ultrasound Duplex imaging Ankle-Brachial Index, this can be calculated when the ankle systolic value is divided by by the brachial systolic result.
• Angiography is effective as a diagnostic tool.

PAD Interventions

• Interventions encompass risk factor modification while controlling BP reduce sodium in take and DASH diet, smoking cessation, Hemo A1C levels lowered to <7.0% diabetics aggressive to control hyperlipidemia.
• Drug therapy, involves administering ACE inhibitors & statins, providing antiplatelet agents like ASA, Clopidogrel (Plavix) as intermittent claudication- Cilostazol (Pletal), Pentoxifylline (Trental).
• Exercise therapy is administered to manage pain while walking patient for up to 30-45 min 3x a week.
• Nutritional adjustments include weight loss with DASH Care with Leg CLI Protect from trauma, and prevent/control infection Interventional Radiologic Procedures: PTA, stent, atherectomy, cryoplasty Surgery or Graft, endarterectomy, patch graft, amputation. Recommend modification of cholesterol, sat. fat, & refined sugar diet and instruct on foot care & avoidance of injuries.

Nursing Management

• Monitor skin color & temp, cap refill, peripheral pulses distal to site for sensation & monitor extremity movement as these are key indicators.
• After recovery, monitor circulatory assessment for complications, avoid knee-flexed positions & prolonged sitting, turn & position frequently, OOB, ambulate, graduate compression stockings.
• Management include promotion of risk factors such as smoking cessation, long-term antiplatelet/ASA therapy under supervised exercise training and meticulous foot care instructions.
• Instruction for daily inspection, comfortable shoes, rounded toes, lightly laced will provide more comfort.
• Cap refill and instruct patient check there skin and teach the same for the caregiver to monitor temperature, Cap. Refill, and palpate pulses.

Acute Arterial Ischemic Disorders

• Sudden interruption in arterial blood supply is associated with Embolism, thrombosis, or trauma thrombus from infective endocarditis, valve disease, atrial fibrillation, cardiomyopathies, aneurysms, plaque, endovascular procedures, and venous thrombi.
• Early diagnosis & treatment are critical and may comprise of anticoagulant administrations like IV unfractionated heparin to restore blood flow.
• Amputation may be required.
• Interprofessional care is essential

Raynaud's Syndrome

• Cold, nicotine, caffeine, and stress can precipitate an attack.
• Manifestations includes white, blue, red, coldness, numbness followed by throbbing, aching, burning pain, tingling, & swelling with episodes lasting minutes to hours.
• Prolonged or frequent attacks = thick skin, brittle nails, lesions, & gangrenous ulcers
• Prevent through keeping hands/feet warm & dry- wear mittens, reduce Smoking & caffeine intake.
• No vasoconstrictor medications Medications like calcium channel blockers to promote vasodilation and seek medical care for any ulceration.

Venous Thromboembolism

• Consist of superficial vein thrombosis, deep vein thrombosis (DVT), and venous thromboembolism (VTE), DVT can lead to pulmonary embolism (PE)
• Key risk factors are being above the age of 40, and Atrial fibrillation Surgery, Venous stasis, Heart attack/disease Pregnancy trauma, Oral contraceptives Malignancy and obesity..
• Other factors include genetics such as a family history, coagulation disorders, prolonged immobility such as extended sitting, and smoking

Superficial Vein Thrombosis

• Superficial leg veins are most commonly inflicted with clinical manifestations that can be identified by having palpable, firm, cordlike vein, itchy, painful, red, & warm skin.
• Diagnosis is through Ultrasound of clot
• It is treated when clots are smaller than 5 cm & not near saphenousfemoral junction can be administered with oral or topical NSAIDs Graduated compression stockings Warm compresses, elevated limb above heart with some mild exercise.

Venous Thromboembolism (VTE)

• VTE affects deep veins of arms or legs, pelvis, vena cava, a& pulmonary system
• Lower extremity manifestation includes Unilateral edema, pain, tenderness w/ palpation Dilated superficial veins Full sensation in thigh or calf, paresthesias Red, warm, fever.
• Diagnostics may be through ACT, aPTT, INR, bleeding time, Hgb, Hct, platelet count, D- dimer, fibrin monomer complex.
• The VTE prophylaxis measures, from The Joint Commission (TJC), advocate for and maintain core measures as a health value.
• Early & Progressive ambulation
• If on bed rest, reposition every 2 hours and flex & extend feet, knees, & hips every 2-4 hourly, while patient is awake.
• Transfer to OOB to chair, to walk every day, and graduated compression stockings

Compression Interventions

• Note as compression interventions stockings should be fit properly but are Not recommended if VTE already exists.
• Intermittent pneumatic compression is also encouraged along with stockings.
• Do not use w/active VTE = risk of PE, and always promote Interprofessional Care.

Drug Interventions

• Review VTE risk factors, drug doses like anticoagulants (table 26-2) Warfarin, heparin & LMWH, factor Xa inhibitors- as well as the side effects & routine blood tests;
• Use caution and administer drugs while wearing medic- alert ID
• The dietary considerations are intake of Vitamin K & Warfarin.
• Monitor for the need to avoid falls & trauma and apply pressure to bleeding sites for 10-15 minutes.
• Report/call EMS for Bleeding (urine, stool, vomit, nose, gums, skin) and Severe headache, stomach pain, chest pain, palpitations, dyspnea, and also report is there is any change in LOC and inform all HCP & dentist of anticoagulation

Chronic Venous Insufficiency (CVI)

• Lower leg is brown, leathery, edematous, with itchy & scratching Venous ulcers, is linked to infections especially on pain with dependent positions
• Healing is through Compression such as stockings, bandages, IPCs, wraps.
• Teach proper fit & application and assess for PAD prior to compression, and teach activities and limb positions. Interprofessional care is also essential
• Balanced diets high in protein, vit. A & C, zinc can improve glucose control.
• Interprofessional care should also involve wound care & dressings to maintain a moist environment.

Nursing Diagnoses

Monitor CVI leg ulcers for infection, debridement, excision, and administer antibiotics.

• Moisturize skin after shower or bath with lotion with eczema without alcohol due to itching Watch for contact dermatitis.
• Drug interventions are administration of pentoxifylline or micronized flavonoid fraction and the administration of skin replacements.

Varicose Veins

• Varicose veins need Avoid activities that cause venous stasis (wearing socks that are too tight at the top or that leave marks on the skin, crossing the legs at the thighs, & sitting or standing for long periods) Elevate the legs 3- 6 in. than average level
• Encourage patient to walk 30 minutes and wear graduated compression stockings under the overweight weight reduction plans.

Cellutitis

• S&S include localized swelling or redness, fever, chills, sweating Treat with oral or IV antibiotics based on severity Nursing. Instructions are to elevate affected area to remain 3-6 in high with warm and moist site every 2-4 hours. Educate on how to prevent recurrence in the care of their skin and foot.