Hypertension - Zarqa University PDF

Chapter 32 Hypertension Dr/ Manal Omer Associate prof. In Critical care & Emergency Nursing Outline Intended Learning Outcomes ILO’s After completing this chapter, the students will be able to:- G.H.E. 1: Discuss the prevalence and incidence of Hypertension. H.P.M.2: E...

Chapter 32 Hypertension Dr/ Manal Omer Associate prof. In Critical care & Emergency Nursing Outline Intended Learning Outcomes ILO’s After completing this chapter, the students will be able to:- G.H.E. 1: Discuss the prevalence and incidence of Hypertension. H.P.M.2: Explain the pathophysiology, risk factors, manifestations, and complications Hypertension. PH.I.1: Relate the pathophysiology of acute and chronic complications of hypertension to the clinical manifestations. H.P.M.1: Perform comprehensive assessments using validated tools and techniques, and develop skills in making accurate nursing diagnoses of adult patients with Hypertension. PH.I.1: Apply knowledge of normal anatomy, physiology, and assessments when providing nursing care for patients with Hypertension. PH.I.1: Relate the pathophysiologic mechanisms associated with primary hypertension to the clinical manifestations and complications. 3 Intended Learning Outcomes ILO’s After completing this chapter, the students will be able to:- H.P.M.2: Choose appropriate strategies for the prevention of primary hypertension. PH.I.1: Interpret results of the diagnostic laboratory tests to evaluate and diagnose adult with Hypertension. PH.I.1: Use the nursing process as a framework for providing individualized care to patients with Hypertension. PH.I.1: Provide individualized nursing interventions that address priorities and needs of patients with Hypertension. P.S.I.1: Integrate psychosocial nursing interventions aiming to provide emotional support to patients with hypertensionand its complications P.S.I.2: Explain the nursing implications for antihypertensive medications prescribed to treat hypertension and it’s complications. 4 Intended Learning Outcomes ILO’s After completing this chapter, the students will be able to:- PH.I.1: Describe the interprofessional care for primary hypertension, including drug therapy and lifestyle modifications. PH.I.1: Explain the interprofessional care of the older adult with primary hypertension. PH.I.1: Describe the nursing and interprofessional care of a patient with a hypertensive crisis. 5 Blood Pressure What is blood pressure? What is hypertension ? Blood Pressure BP Sign: monitor patient’s clinical status. Risk factor ( atherosclerotic cardiovascular disease) Disease (high) Blood Pressure BP = Cardiac Output x Peripheral Resistance High BP from : Any change in CO , PR or both CO = HR x SV The cardiac output is usually expressed in liters/minute Classification of Blood Pressure for Adults Age 18 and Older  Primary (essential or idiopathic) hypertension Elevated BP without an identified cause 90%- 95% of all cases Secondary hypertension Elevated BP with a specific cause 5% to 10% of adult cases more than 80% of HTN in children  DM Dyslipidemia : Elevated serum lipids Obesity Family history/ Heredity Ethnicity Sedentary lifestyle Socioeconomic status Stress  Secondary hypertension Contributing factors congenital narrowing of aorta Renal disease Endocrine disorders [Pheochromocytoma] Neurologic disorders Cirrhosis Medications e.g. (NSAIDs) Pregnancy induced hypertension Hypertension Hypertension means Heart is working harder than normal Heart and blood vessels under strain Direct Relationship between HTN and CVD Renal CVA Factors Involved in Control of BP Pathophysiology Hypertension is a multifactorial condition Factors that Influence Development of Hypertension ↑ sympathetic nervous system activity related to dysfunction of autonomic nervous system [DM] ↑ reabsorption of sodium chloride and water by kidneys related to a genetic variation ↑ activity of the rennin-angiotensin system resulting in expansion of extracellular fluid volume and increased systemic vascular resistance ↓vasodilatation of the arterioles related to dysfunction of the vascular endothelium Insulin resistance (DM)[autonomic dysfunction]. Manifestations of Hypertension Referred to as “silent killer”: Patient frequently asymptomatic until target organ disease occurs Usually NO symptoms other than elevated BP Symptoms seen related to organ damage are seen late and are serious Retinal and other eye changes Renal damage MI or angina Cardiac hypertrophy Stroke or [transient ischemic attack [TIA] Manifestations of Hypertension Symptoms often secondary to target organ disease and can include Fatigue, reduced activity tolerance Dizziness Palpitations, angina Dyspnea Hypertension complications Prolonged BP eventually damages blood vessels throughout body, particularly in target organs Target organ diseases occur most frequently in Heart (CAD, MI, HF, Left ventricular hypertrophy) Brain (STROK) Peripheral vascular systems Kidney RF Eyes impaired vision Major Risk Factors for Cardiovascular Problems in Hypertensive Patients Smoking Obesity Physical inactivity Dyslipedemia DM Microalbuminuria or GFR < 60 [A value above 30 mg/day suggests that albumin excretion is high and therefore MA is present]. MA should be checked annually in everyone, and every 6 months within the first year of treatment to assess the impact in patients started on antihypertensive therapy and its presence is the earliest clinical sign of diabetic nephropathy ]. Older age Family history Patient Assessment History and Physical examination Laboratory tests Urinalysis Blood chemistry Cholesterol levels ECG Echocardiogram Medical Management Goals of treatment Control BP Reduce cardiovascular risk prevent complications and death Medical Management Treatment goals for most people with HTN maintaining arterial blood pressure at 140/90 mm Hg or lower. Treatment goals for people with DM or chronic kidney disease, 130/80 mm Hg Medical Management Management options for hypertension summarized in treatment algorithm issued by Joint National Committee (JNC 7 (Fig. 32-2). Table 32-2 summarizes recommended lifestyle modifications. The Physician use algorithm with risk factor assessment data and Patient BP to choose initial and subsequent treatment plans for Patient Treatment begins with lifestyle modifications and continues with various medication regimens  Lifestyle Weight reduction Modifications Reduce alcohol intake Reduce sodium intake: Dietary sodium reduction Less than 2.4 g of sodium/day or 6 g sodium chloride. Adopt DASH (Dietary Approaches to Stop Hypertension) eating Diet: high in fruits, vegetables, and low-fat dairy OR fat-free dairy foods Avoid tobacco products Medical Management Regular physical activity at least 30 min such as brisk walking, most days of week. Pharmacologic Therapy Drug therapy: Primary actions of drugs to treat hypertension Reduce SVR (Systemic Vascular Resistance) Reduce volume of circulating blood Medication Treatment For patients with uncomplicated hypertension and no specific indications for another medication usually initial medication treatment is a thiazide diuretic, beta-blockers, or both. Start with Low doses Medication dosage increased gradually if BP not reach target goal. Additional medications added if needed. Multiple medications may be needed to control BP. When BP is less than 140/90 mm Hg for at least 1 year, gradual reduction of types and doses of medication is indicated. Lifestyle changes initiated to control BP must be maintained. Medication Treatment Drug therapy: Classifications of drugs used to treat hypertension Diuretics Adrenergic inhibitors:inhibit the action of catecholamines at the adrenergic receptors. Vasodilators Angiotensin-converting enzyme (ACE) inhibitors E.G captopril (Capoten) Calcium channel blockers[Hypercalcemia has a positive chronotropic effect (increase in heart rate), and a positive inotropic effect (increase incontractility, [used to alter heart rate, CCBs are particularly effective against large vessel stiffness , CCBs can directly influence the biosynthesis of aldosterone in adrenocortical cells Amlodipine (Norvasc) Table 32-4 describes various pharmacologic agents that are recommended for treatment of hypertension. Medication Therapy for Hypertension Diuretic Thiazide diuretics e.g chlorothiazide (Diuril) Loop diuretics e.g furosemide (Lasix) Potassium sparing diuretics E.G amiloride (Midamor) Aldosterone receptors blockers E.G spironolactone (Aldactone) Central alpha2-agonists E.G methyldopa (Aldomet) [sympathomimetic agents] Beta-blockers E.G atenolol (Tenormin) Beta-blockers with intrinsic sympathomimetic activity Alpha1-Blockers E.G doxazosin (Cardura) block α1-adrenergic receptors in arteries, smooth muscles, andcentral nervous system tissues. [vasoconstriction] Combined Alpha and beta blockers Diuretics Medication Therapy for Hypertension Angiotenisin II antagonists Nursing process :Patient with HTN 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 process :Patient with HTN Goals Patient understanding of disease process Patient understanding of treatment regimen Patient participation in self-care Absence of complications  Nursing Diagnoses Knowledge deficit in relation to the treatment regimen and control of disease process Noncompliance with therapeutic regimen related to side effects of prescribed therapy Interventions Patient teaching Support adherence to treatment regimen Follow-up care Emphasize control rather than cure Reinforce and support lifestyle changes Lifelong process Nursing Alert Patient and family should be cautioned that antihypertensive medications can cause hypotension. Low BP or postural hypotension should be reported immediately. Nurse teach Patient to change positions slowly when move from a lying or sitting position to a standing position. Elderly Patient use supportive devices such as hand rails and walkers as necessary to prevent falls that could result from dizziness. Hypertensive Crises 2 types of crises Hypertensive emergency Hypertensive urgency may occur in patients whose hypertension has been poorly controlled or in those who have suddenly discontinued their medications. Hypertensive Crises Hypertensive emergency BP > 180/120 acute, life-threatening BP elevations BP must be lowered immediately (not necessarily to less than 140/90 mm Hg) to prevent damage to target organs Hypertensive Emergency Conditions associated with hypertensive emergency include Hypertension of pregnancy Acute MI Intracranial hemorrhage. Hypertensive Emergency Therapeutic goals Reduce BP 25% in first hour of RX. Reduce to 160/100 over 6 hours. Then gradual reduction to normal over a period of days. Medications IV vasodilators: sodium nitroprusside [potent vasodilating], nicardipine , fenodopam mesylate, enalaprilat [ACE inhibitor], nitrogylcerin [nitrates (relaxing and widening blood vessels so blood can flow more easily to the heart). For more information about these medications, see Table 32-4. Need very frequent monitoring of BP and cardiovascular status. Hypertensive urgency Elevated BP no evidence of immediate or progressive target organ damage Associated with severe headaches, nosebleeds, or anxiety Hypertensive Urgency Patient needs close monitoring of BP 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 (see Table 32-4).