Hypertension (Fall 2024) Lecture Notes PDF

Hypertension Janelle Thomas MSN, RN-BC, CEN Learning Objectives 1. Describe the pathophysiology and etiology of hypertension. 2. Identify risk factors for hypertension. 3. Compare and contrast primary and secondary hypertension. 4. Compare and contrast hypertension urgency and hypertension...

Hypertension Janelle Thomas MSN, RN-BC, CEN Learning Objectives 1. Describe the pathophysiology and etiology of hypertension. 2. Identify risk factors for hypertension. 3. Compare and contrast primary and secondary hypertension. 4. Compare and contrast hypertension urgency and hypertension crisis. 5. Describe normal and abnormal laboratory and physical assessment findings related to hypertension. 6. List the criterion pressure values identified in the Classification of Blood Pressure for Adults. 7. Discuss evidenced-based lifestyle management and dietary education recommendations for a patient with hypertension. 8. Discuss and compare the various medications used in the pharmacologic management of hypertension. Exemplars of Perfusion Congenital Congenital Cardiomyopathy Cardiomyopathy Heart Heart Stroke Stroke Defects Defects Shock Shock Coronary Coronary Artery ArteryDisease Disease Pulmonary Pulmonary Deep DeepVein Vein Embolism Embolism Thrombosis Thrombus PERFUSIN PERFUSION Pregnancy-In Pregnancy-In Disseminated Disseminated duced duced Intravascular Intravascular Hypertension Hypertension Coagulation Coagulation Life Life Peripheral Peripheral -Threatening -Threatening Heart Heart Hypertension Hypertension Vascular Vascular Failure Failure Dysrhythmias Dysrhythmias Disease Disease REGULATING BLOOD PRESSURE Blood Pressure Blood Pressure = CO × SVR – CO = cardiac output 4-6 L/min. Average – SVR = systemic vascular resistance Determined by blood viscosity, length of vessel & diameter of vessel Mean Arterial Pressure – Average pressure in the arterial circulation through the cardiac cycle Blood Pressure Systolic pressure – The peak pressure exerted against arterial walls as ventricles contract and eject blood Diastolic pressure – The minimum pressure exerted against arterial walls, between contracts when the heart is a rest Regulating Blood Pressure Pearson. p. 1249 Regulating Blood Pressure Autonomic Nervous System Sympathetic Nervous System Parasympathetic Nervous System Controls energy expenditure Helps conserve energy (especially stressful situation) Releases acetylcholine (a Releases norepinephrine cholinergic neurohormone) (an adrenergic catecholamine) “Rest and Digest” System “Fight or Flight” System ↓ Heart Rate ↑ Heart Rate ↓ Blood Pressure ↑ cardiac conduction Vasodilation ↑ Blood Pressure Bronchoconstriction Vasoconstriction Pupil Constriction Bronchodilation Pupil Dilation HYPERTENSION Hypertension = High Blood Pressure Based on the average of 2 or more readings taken on separate occasions – Systolic BP = 130 mmHg or higher – Diastolic BP = 80 mmHg or higher No obvious symptoms “Silent Killer” Leads to irreparable end organ damage Major risk factor for causing: – Coronary artery disease - Stroke – Heart failure - Renal failure – Peripheral vascular disease - Retinopathy Classification of Blood Pressure Classification Systolic Diastolic (mmHg) (mmHg) Normal < 120 And < 80 Elevated 120 – 129 And < 80 Hypertension ** Stage I HTN 130 - 139 Or 80 - 89 Stage II HTN >/= 140 Or >/= 90 Hypertensive > 180 And/ >120 Crisis Or Primary Hypertension AKA Essential Hypertension Persistently elevated systemic blood pressure No Known Cause Accounts for 90-95% of all cases Possible Causes of Primary Hypertension Interaction between: – Overstimulation of alpha-and beta-adrenergic receptors – Altered function of renin-angiotensin-aldosterone system – Sodium Intake – Insulin resistance, hyperinsulinemia – Environmental and genetic factors Secondary Hypertension Elevated blood pressure resulting from an identifiable underlying process Accounts for only 2-5% of identified cases Pattern of secondary hypertension varies depending the cause Treatment focused on correcting or controlling the underlying disease process  Identifiable Causes of Secondary Hypertension Kidney disease – Renal artery stenosis Medications/Drugs – Glomerulonephritis or – Estrogen Pyelonephritis – Oral Contraceptives – Polycystic kidney disease – Corticosteroids (prednisone) – Renal failure – Stimulants (Ritalin, Adderall) Coarctation of aorta – Decongestants (Sudafed) Endocrine disorders Pregnancy – Cushing’s Disease Hypothyroidism – Primary Aldosteronism Obstructive sleep apnea – Myxedema – Pheochromocytoma Hypertensive Urgency vs Emergency SBP >180 mmHg and/or DBP > 120 mmHg Hypertensive Urgency No symptoms of organ damage Monitor and treat Hypertensive Emergency/Crisis Rapid onset / life threatening Associated with ischemic organ damage Symptoms of target organ damage – Blurred vision, papilledema (swelling of optic nerve) – Chest pain, back pain, shortness of breath – Severe headache, confusion, difficulty speaking – Motor & sensory deficits – numbness, weakness Requires treatment within 1 hour to: – Prevent cardiac, renal, and vascular damage – Decrease morbidity & mortality Treatment of Hypertensive Emergency/Crisis Stroke Emergency/Crisis – Administer medications IV Nitroprusside Labetalol Nicardipine – Decrease BP gradually – Monitor BP continuously (every 5-15 min) – Assess neurological status – Continuous ECG monitoring Risk Factors for Hypertension Modifiable Non-Modifiable Mineral intake Genetic Factors – Excessive sodium intake Age – Low potassium, calcium, and Sex magnesium intake – Men Low vitamin D levels – Women after menopause Physical inactivity Family history Obesity Race Insulin resistance – African American Excess alcohol consumption Smoking Hyperlipidemia Stress /Depression Possible Clinical Manifestations May have few or no symptoms (Silent Killer) – Seen most with extremely high BP Vague symptoms – Headaches, particularly in the morning – Fatigue, dizziness, fainting – Facial flushing Symptoms targeting specific organ damage – Nocturia – Confusion – N/V – Chest pain – Shortness of breath – Visual disturbances – blurred vision – Retinal changes Labs and Diagnostic Testing No specific labs or diagnostic tests are used to diagnose HTN; however, they can be used to diagnose: – Underlying cause(s) of HTN – CV risk factors – Presence/absence of target organ damage Labs and Diagnostic Testing Tests may include: ECG Vit D & Ca levels Urine Analysis Cholesterol panel Blood Glucose GFR, Creatinine Clearance Serum creatinine LIFESTYLE AND DIETARY MODIFICATIONS Lifestyle Modifications – Patient Education Weight reduction and maintenance Engage in Exercise – Aim for 30 minutes most days of the week (5–6 days/week) Limit alcohol – Women:1 serving/day; Men: 2 servings/day Smoking cessation Stress reduction – Meditation, relaxation, deep breathing, yoga Dietary Modifications – Patient Education Eat a diet rich in fruits, vegetables, and low-fat dairy products Reduce sodium intake Reduce intake of total and saturated fats Increase potassium, calcium, magnesium intake High fiber diet Limit caffeine intake DASH Diet (Dietary Approach to Stop Hypertension) DASH Diet Recommendations Based on Grains: 6-8 servings/day 2000 calories/day Vegetables: 4-5 servings/day Fruits: 4-5 servings/day Meats, poultry, & fish: 6 or fewer servings/day (1 oz each) Fat-free or low-fat dairy products: 2-3 servings/day Fats & oils: 2-3 servings/day Sodium: 1500-2300 mg/day Nuts, seeds, & dry beans: 4-5 servings/week Sweets/added sugars (low fat): 5 or fewer servings/week PHARMACOLOGICAL THERAPY Site of Antihypertensive Drug Therapy Pearson, p.1254 Alpha-Adrenergic Blockers (-osin) doxazosin (Cardura) Alpha-Adrenergic Blockers (-osin) Mechanism of Action – Blocks alpha receptors in vascular smooth muscle – Decreases vasomotor tone and vasoconstriction – Cause venous and arterial dilation Assess apical pulse & BP Adverse effects – Bradycardia – Hypotension – First dose syncope (administer at bedtime) – Impotence Beta Adrenergic Blockers (-olol) Cardioselective: B1 (affects heart only) – metoprolol (Lopressor) Beta Adrenergic Blockers (-olol) Cardioselective: B1 (affects heart only) Mechanism of Action – Block sympathetic nervous system – Blocks the beta-receptor stimulation in heart, resulting in decreased heart rate & cardiac output Assess BP and apical pulse Adverse Effects – Bradycardia, hypotension, decrease cardiac output – Mask symptoms of hypoglycemia and tachycardia Beta Adrenergic Blockers (-olol) Nonselective: B1 & B2 (affects heart & lungs) – propranolol (Inderal) Mechanism of Action – Blocks the Beta1 & Beta2 receptor stimulation in heart and lungs, resulting in decreased heart rate & cardiac output Assess BP and apical pulse Adverse Effects – Bradycardia, hypotension, decrease cardiac output – Mask symptoms of hypoglycemia and tachycardia – Bronchospasm (shortness of breath) Beta Adrenergic Blockers (-olol) Dual Acting Alpha, Beta Blockers (A1, B1, B2 Blocked) – carvedilol (Coreg) – labetalol (Normodyne) Beta Adrenergic Blockers (-olol) Dual Acting Alpha, Beta Blockers Mechanism of Action – Reduce BP by blocking Beta1 Beta2 and Alpha receptor – Receptors in the heart, lungs, and causes vasodilation Assess BP and apical pulse Adverse Effects – Bradycardia, hypotension, decrease cardiac output – Bronchospasm (shortness of breath) – Fatigue, weakness, depression, & impotence – Mask symptoms of hypoglycemia (tachycardia) – Rebound hypertension if stopped abruptly Angiotensin Converting Enzyme Inhibitors (-pril) ACE Inhibitors lisinopril (Prinivil, Zestril) benazepril (Lotensin) ACE Inhibitors (-pril) Mechanism of Action – Lower BP by preventing conversion of angiotensin I to angiotensin II – Causes vasodilation and excretion of sodium and water Assess blood pressure Adverse Effects – First dose orthostatic hypotension – Hyperkalemia – Angioedema – Persistent cough (very common) Angiotensin II Receptor Blockers (-sartan) ARBs losartan (Cozaar) valsartan (Diovan) Angiotensin II Receptor Blockers (-sartan) Mechanism of Action – Blocks effects of angiotensin II – Decreases peripheral resistance – Decreases release of aldosterone (increased excretion of sodium & water) – Blocks vasoconstriction and promote relaxation of blood vessels (vasodilation) Assess BP Adverse Effects – Orthostatic hypotension – Hyperkalemia (less than ACE Inhibitors) – Angioedema (swelling lips or face) Calcium Channel Blockers (- dipine) amlodipine (Norvasc) diltiazem (Cardizem) Calcium Channel Blockers (- dipine) Mechanism of Action – Inhibit flow of calcium ions across the cell membrane of vascular tissue and cardiac cells – Relax arterial smooth muscle, lowering peripheral resistance through vasodilation Assess BP & apical pulse (rate & rhythm) Adverse Effects – Hypotension (common) – Bradycardia or tachycardia – Orthostatic hypotension – Peripheral edema Thiazide Diuretics hydrochlorothiazide Thiazide Diuretics hydrochlorothiazide Mechanism of Action – Prevent tubular reabsorption of sodium – Prevents water reabsorption (increased urine output) – Reduce systemic vascular resistance Assess BP & serum K+ Adverse Effects – Hypokalemia, hyponatremia, hypochloremia – Hyperglycemia Loop Diuretics (- ide) furosemide (Lasix) bumetanide (Bumex) Mechanism of Action – Inhibits sodium, chloride reabsorption & reabsorption of water. Causes extensive diuresis. Assess BP & serum K+ Monitor daily weights and I & O Adverse Effects – Dehydration, hyponatremia, hypochloremia, hypokalemia – Hypotension - Ototoxicity (IV route) Potassium Sparing Diuretics Spironolactone (Aldactone) Mechanism of Action – Block action of aldosterone (sodium & water retention), resulting in potassium retention and excretion of sodium & water Used as an add on drug to treat heart failure and hypertension Avoid using with ACE inhibitors, ARBs, and potassium supplements Assess Serum K+ and blood pressure Adverse Effects – Hyperkalemia Vasodilators Vasodilators hydralazine (Apresoline) – Direct acting peripheral arteriolar vasodilator nitroprusside (Nipride) – IV route used to treat hypertensive emergency – Causes rapid lowering of BP Mechanism of Action – Cause dilation of blood vessel Adverse Effects – hypotension Class Activity (NCLEX) NCLEX Questions A 66-year old client has his blood pressure checked at a health fair. The BP is 168/98. Which action should the nurse implement first? A. Recommend the client have their BP checked in a month. B. Instruct the client to see their health-care provider as soon as possible. C. Discuss the importance of eating a low-salt, low-fat, and a low-cholesterol diet. D. Explain that the BP is within the normal range for an elderly person. NCLEX Questions The nurse is obtaining a blood pressure for a client with primary hypertension. The nurse ensures accuracy of the blood pressure by avoiding which of the following? A. Placing the arm in a supportive position, bare-armed, and at the level of the heart B. Measuring the blood pressure after the client has rested for 5 minutes C. Using a cuff that covers 80% of the limb D. Taking the blood pressure within 10 minutes of the client ingesting caffeine  NCLEX Questions Identify the patient assessments the nurse will monitor when furosemide is prescribed. (Select All That Apply.) A. Apical pulse B. Blood pressure C. Hemoglobin and Hematocrit D. Intake and Output E. Sodium, potassium, and magnesium levels NCLEX Questions A nurse is caring for a patient admitted with hypertension who has been prescribed losartan, furosemide, and doxazosin. The client’s current blood pressure is 162/86 with a heart rate of 64. Serum potassium level is 3.2 mEq. Which of the following is the best action by the nurse? A. BP is elevated, administer all medications to assist in lower BP. B. Administer the losartan and the furosemide, hold the doxazosin, and notify the prescriber. C. Hold all medications and notify the prescriber. D. Administer doxazosin and losartan, hold furosemide and notify prescriber. NCLEX Questions Identify blood pressures that fall in the elevated blood pressure classification. (Select All That Apply.) A. 118/70 B. 120/72 C. 130/ 82 D. 146/88 E. 128/68 F. 124/76 G. 122/58 H. 129/78 NCLEX Questions An angiotensin-converting enzyme (ACE) inhibitor for a patient with hypertension. Which statement is the most appropriate rationale for administering this medication? A. ACE inhibitors prevent beta receptor stimulation in the heart. B. This medication blocks the alpha receptors in the vascular smooth muscle. C. This medication prevents vasoconstriction, and sodium and water retention. D. ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle. NCLEX Questions A nurse is preparing to administer medications for a patient admitted with essential hypertension, who has a history of hypercholesterolemia and atrial fibrillation. Assessment data includes apical pulse 68, BP 118/64, and serum potassium 4.5 mEq. Which of the prescribed medications will the nurse administer? (Select All That Apply.) A. valsartan B. hydrochlorothiazide C. digoxin D. diltiazem E. atorvastatin  NCLEX Questions The nurse is administering metoprolol to a patient diagnosed with essential hypertension. Which intervention should the nurse implement? A. Notify the health-care provider if the potassium level is less than 3.8 mEq. B. Question administering the medication if the BP is 94/56. C. Do not administer the medication if the patient’s heart rate is greater than 100. D. Monitor the patient’s BP while lying, sitting, and standing. NCLEX Questions Identify the medication that causes water and sodium excretion from the kidneys but does not deplete potassium? A. Furosemide B. Angiotensin II Receptor Blockers C. Spironolactone D. Hydrochlorothiazide E. Angiotensin-Converting Enzyme Inhibitors NCLEX Questions The nurse caring for a diabetic client with chronic renal failure classifies the hypertension as: A. Malignant B. Secondary C. Primary D. Genetic NCLEX Questions A nurse is teaching a family with several members at risk for hypertension about measures that can be taken to help prevent hypertension. The nurse includes which of the following in the teaching? (Select All That Apply.) A. Eat a diet rich in fruits and vegetables. B. Increase sodium intake. C. Reduce cholesterol intake. D. Stop smoking. E. Engage in isometric exercises. NCLEX Questions Hyperkalemia is a side effect of which medications? (Select All That Apply.) A. diltiazem B. captopril C. valsartan D. metoprolol E. doxazosin