MS CH 22 Nursing Care of Patients With Hypertension.pdf

4068_Ch22_417-431 15/11/14 1:37 PM Page 417 Nursing Care of Patients With Hypertension LINDA S. WILLIAMS LEARNING OUTCOMES 1. 2. 3. 4. 5. 6. 7. 8. 9. Explain the pathophysiology of hypertension. Identify causes and risk factors for hypertension. List signs and symptoms of hypertension. Describe th...

4068_Ch22_417-431 15/11/14 1:37 PM Page 417 Nursing Care of Patients With Hypertension LINDA S. WILLIAMS LEARNING OUTCOMES 1. 2. 3. 4. 5. 6. 7. 8. 9. Explain the pathophysiology of hypertension. Identify causes and risk factors for hypertension. List signs and symptoms of hypertension. Describe therapeutic measures for hypertension. Define classifications and treatment recommendations for hypertension in adults. Define hypertensive emergency. List common complications of hypertension. Plan nursing care for patients with hypertension. Evaluate effectiveness of nursing interventions. 22 KEY TERMS cardiac output (KAR-dee-yak OWT-put) diastolic blood pressure (dy-uh-STAH-lik BLUHD PREH-shure) essential hypertension (ee-SEN-shul HY-per-TEN-shun) hypertension (HY-per-TEN-shun) hypertensive emergency (HY-per-TEN-siv ee-MURgehn-see) hypertensive urgency (HY-per-TEN-siv UR-gehn-see) hypertrophy (hy-PER-truh-fee) normotensive (nor-moe-TEN-siv) peripheral vascular resistance (puh-RIFF-uh-ruhl VASkyoo-lar ree-ZIS-tense) plaque (PLAK) primary hypertension (PRY-mare-ee HY-per-TEN-shun) secondary hypertension (SEK-un-DAR-ee HY-per-TENshun) systolic blood pressure (siss-TALL-ik BLUHD PREHshure) viscosity (vis-KAW-sih-tee) 417 4068_Ch22_417-431 15/11/14 1:37 PM Page 418 418 UNIT FIVE Understanding the Cardiovascular System During 2011–2012, 29.9% of U.S. adults aged 18 or older had hypertension. The prevalence of those with hypertension increases with age, from 7.3% in those aged 18 to 39 to 65% in those ages 60 or older (Nwankwo, Yoon, Burt, & Gu, 2013). The highest occurrence was in non-Hispanic blacks at 42.1%, then non-Hispanic whites at 28%, follo wed by Hispanics at 26%. The prevalence of hypertension remains high despite effective treatments. The 2014 Evidence-Based Guideline for the Management of High BP in Adults by the Eighth Joint National Committee (JNC 8; James et al, 2014) takes a different approach than the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High BP (JNC 7; National Heart, Lung, and Blood Institute, 2004). JNC 8 does not define hypertension, as JNC 7 did, but rather defines pharmacologic treatment thresholds, recommends drug therap y, and supports the 2013 American Heart Association/American College of Cardiology (AHA/A CC) lifestyle modifications guidelines (James et al, 2014). The lifestyle interventions to reduce cardiovascular risk are identified in the 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. In general, the guidelines recommend restricting sugary foods and be verages, trans and saturated f ats, and sodium; following a Dietary Approaches to Stop Hypertension (D ASH)-type (see “Nutrition Notes”) or Mediterranean or diet with fruits, vegetables, whole grains, nuts, lo w fat dairy, poultry, fish and nontropical vegetable oils; and participating in 40 minutes of moderate to vigorous aerobic activity three to four times weekly (Eckel et al, 2013). Follow-up studies involving overweight or obese persons with above-normal BP found the D ASH diet alone reduced BP by 11.2/7.5 mm Hg but the addition of exercise and weight loss to the DASH diet resulted in reductions of 16.1/9.9 mm Hg. Even the control group consuming their usual diet recorded 3.4/3.8 mm Hg reductions in the 4-month program (Blumenthal et al, 2010). In this same group, greater adher ence to the DASH diet was associated with larger BP reductions independent of weight loss. African Americans were less likely to adhere to the D ASH dietary eating plan compared with whites, suggesting that culturally sensitive dietary strategies might be needed to improve adherence to the DASH diet (Epstein et al, 2012). The JNC 7 redefined normal and abnormal BPs for adults aged 18 and older (Table 22.1) www.nhlbi.nih.gov/guidelines /hypertension/express.pdf). Because they were not addressed nor eliminated by JNC 8, they remain included here. BP MEASUREMENT It is essential to tak e BP readings correctly for accurate readings. A normal BP reading is one in which systolic pressure is belo w 120 mm Hg and diastolic pressure is below 80 mm Hg with the patient in a seated position and the arm supported at heart le vel (see Chapter 21). Prehy pertension is a systolic BP of 120 to 139 mm Hg or a diastolic BP of 80 to 89 mm Hg. Hypertension, also known Nutrition Notes Reducing BP With Diet The original DASH diet reduced blood pressure (BP) significantly in normotensive people and produced e ven greater reductions in hypertensive people in an 8-week feeding trial that was designed to maintain the subjects’starting weight. Rather than emphasizing food restriction, the DASH diet increases the intake of certain commonly available, not specialty, foods. On a 2,000-calorie diet, a person following the DASH diet would consume the following: Number of Example of Food Group Servings One Serving 7–8 Grains • 1 slice of bread • 1/2 cup cooked cereal or pasta Vegetables 4–5 • 1 cup raw leafy • 1/2 cup cooked, nonstarchy Fruits 4–5 • 1 medium fresh • 1/2 cup canned or frozen • 1/4 cup dried Low-fat or nonfat dairy 2–3 • 8 ounces of milk • 1 1/2 ounces of cheese Lean meat, poultry, or fish 2 or fewer • 3 ounces cooked Fats and oils, preferably monounsaturated (canola, olive, peanut) 2 1/2 • 1 teaspoonful Nuts, seeds, legumes 4–5 weekly • 1/3 cup of nuts • 2 tablespoonfuls of seeds • 1/2 cup cooked beans as high BP, is a condition in which the a verage of at least two or more readings on different dates is above prehypertension levels. For more information on hypertension, visit www.americanheart.org. • WORD • BUILDING • systolic: systole—concentration diastolic: diastole—expansion hypertension: hyper—excessive + tensio—tension 4068_Ch22_417-431 15/11/14 1:37 PM Page 419 Chapter 22 Nursing Care of Patients With Hypertension 419 TABLE 22.1 BLOOD PRESSURE (BP) CATEGORIES AND MEASURES* BP Category Normal Systolic BP (mm Hg) Less than 120 Diastolic BP (mm Hg) Less than 80 Recommended Follow-Up 2 years Lifestyle Modification Encourage Pre-hypertension 120–139 80–89 1 year Yes Stage 1 hypertension 140–159 90–99 2 months Yes Stage 2 hypertension 160 or higher 100 or higher 1 month For BP over 180/110 mm Hg, evaluate and seek treatment immediately; then 1 week as needed. Yes Note. Adapted from National Heart, Lung, and Blood Institute (2004) and James et al (2014). *Treatment is based on highest BP category. BE SAFE! Research studies show that stethoscopes used by all types of health care providers (HCPs), such as nurses, physicians, paramedics, and emergency medical technicians, are contaminated with bacteria. With infection rates on the rise, reduce the transmission of organisms to help keep your patients safe. Clean your stethoscope between every patient! (See “Evidence-Based Practice.”) EVIDENCE-BASED PRACTICE Clinical Question Are stethoscopes contaminated, and what is the best way to decontaminate them? Evidence An observational study of 100 nurses and their stethoscopes found high stethoscope contamination rates in the emergency department, with a low prevalence of Staphylococcus aureus or methicillin-resistant S. aureus (MRSA) and that only 8% of nurses cleaned their stethoscopes (Tang, Worster, Srigley, & Main, 2011). In a study comparing an ethanol-based cleanser (EBC) with isopropyl alcohol pads in reducing bacterial contamination of stethoscope diaphragms, 99 stethoscopes were cultured, and all were positive for bacterial growth (Lecat, Cropp, McCord, & Haller, 2009). The use of either EBC or isopropyl alcohol reduced the bacteria count significantly. Implications for Nursing Practice Stethoscopes become contaminated with use. To protect patients from potential organism transmission and reduce infection, stethoscopes must be cleaned between every patient by all HCPs. Stethoscopes should be cleaned as often as hands are washed using either EBC or isopropyl alcohol pads. REFERENCES Lecat, P., Cropp, E., McCord, G., & Haller, N. (2009). Ethanol-based cleanser versus isopropyl alcohol to decontaminate stethoscopes. American Journal of Infection Control, 37, 241–243. Tang, P. H. P., Worster, A., Srigley, J. A., & Main, C. L. (2011). Examination of staphylococcal stethoscope contamination in the emergency department (pilot) study (EXSSCITED pilot study). Canadian Journal of Emergency Medicine, 13, 239–244. PATHOPHYSIOLOGY OF HYPERTENSION Normally the heart pumps blood through the body to meet the cells’ needs for oxygen and nutrients. As it pumps, the heart forces blood through the blood v essels. The pressure exerted by blood on the walls of the blood vessels is measured as BP. BP is determined by cardiac output (CO), peripheral vascular resistance (PVR; the ability of the vessels to stretch), the viscosity (thickness) of the blood, and the amount of circulating blood v olume. Decreased stretching ability of blood vessels, increased blood viscosity, and/or increased fluid volume may cause an increase in BP. • WORD • BUILDING • viscosity: viscous—sticky 4068_Ch22_417-431 15/11/14 1:37 PM Page 420 420 UNIT FIVE Understanding the Cardiovascular System Several processes influence BP. These include nervous system regulation, arterial baroreceptors and chemoreceptors, the renin-angiotensin-aldosterone mechanism, and the balance of body fluids. One way BP is influenced is through adjustment of the CO, which is the amount of blood that the heart pumps each minute. The heart rate rises to increase CO in response to physical or emotional acti vities that increase the need for oxygen in the or gans and tissues. PVR also influences BP; it is the opposition that blood encounters as it flows through vessels. Anything causing blood vessels to become narrower increases PVR. Any time PVR is increased, more pressure is needed to push the blood through the vessels, so BP increases as a result. If PVR is decreased, less pressure is needed. Increased arteriolar PVR is the main mechanism that elevates BP in hypertension. Factors that impair normal regulation of BP may lead to hypertension. Many of these factors are not well understood. Sympathetic nervous system overstimulation, which causes vasoconstriction, can contribute to hypertension. Alterations in baroreceptors and chemoreceptors may also influence the development of hypertension. F or example, baroreceptors may become less sensitive from prolonged increases in vessel pressure, and subsequently fail to stimulate vasodilation through vessel stretching. Additionally, increases in hor mones that cause sodium retention, such as aldosterone, lead to increased fluid retention. Changes in kidney function that alter the excretion of fluid also result in an increase in overall body fluid that may contribute to hypertension. Types of Hypertension Primary Hypertension Primary, or essential, hypertension is chronic elevation of BP from an unknown cause. Secondary Hypertension Secondary hypertension has a known cause. In other words, it is a sign of another problem, such as a kidney abnormality, a tumor of the adrenal gland, or a congenital defect of the aorta. When the cause of secondary hypertension is treated before permanent structural changes occur, BP usually returns to normal. Isolated Systolic Hypertension (ISH) ISH is a systolic pressure of 140 mm Hg or greater and a diastolic pressure of 90 mm Hg or less.This type of hypertension occurs mainly in the older adult, although it can occur at any age (“Gerontological Issues”). People with a systolic pressure higher than 140 mm Hg and a diastolic pressure less than 90 mm Hg found on tw o separate readings should be further evaluated. Treatment of ISH is recommended to decrease cardio vascular disease, especially heart failure episodes and risk of stroke. Lifestyle modifications are usually tried first if the systolic elevation is not too severe. If lifestyle modifications fail to reduce the systolic pressure, antihypertensive medication is added. Alcohol consumption in the older adult can aggravate agerelated hypertension. Guided relaxation has been sho wn effective in reducing high BP in older adults. Gerontological Issues It is now known that after age 55, diastolic pressure falls while systolic pressure continues to rise with age. This means that it is important to control systolic BP, not just diastolic pressure, in older adults to prevent heart disease and stroke. In fact, lowering diastolic BP too much may be unhealthy. SIGNS AND SYMPTOMS OF HYPERTENSION Have you known someone with high BP? Did that person have signs and symptoms of hypertension? If not, it is because hypertension often causes no signs or symptoms other than elevated BP readings. As a result, hypertension is referred to as the “silent killer.” Patients with hypertension are often first diagnosed when seeking health care for reasons unrelated to hypertension. In a small number of cases, a patient with hypertension may report a headache, bloody nose, se vere anxiety, or shortness of breath, although it is usually impossible for a patient to correlate the absence or presence of symptoms with the degree of BP elevation (Table 22.2). DIAGNOSIS OF HYPERTENSION Diagnosis of hypertension considers a patient’ s risk factors for hypertension, a previous diagnosis of hypertension, presence of signs and symptoms, history of kidne y or heart disease, and current use of medications. When the a verage seated BP is above prehypertensive levels of 120 to 139 systolic or 80 to 89 diastolic on two or more occasions, then hypertension is diagnosed (see Table 22.1). The JNC 7 recommends that patients undergo various routine tests to identify damage to organs or blood vessels before beginning therapy for high BP. Tests recommended by JNC 7 include electrocardiogram (ECG), blood glucose le vel, hematocrit, serum potassium and calcium levels, lipoprotein profile, high-density and low-density lipoprotein cholesterol (HDL-C and LDL-C, respecti vely), and triglyceride le vel. These tests help determine if tar get-organ damage has been caused by elevated BP. An example of this is testing for kidney damage with a urinalysis or serum creatinine level. RISK FACTORS FOR HYPERTENSION A combination of genetic (nonmodifiable) and environmental (modifiable) risk factors is thought to be responsible for the development of hypertension, although the cause remains unknown. Nonmodifiable risk f actors—those that cannot be changed—include a family history of hypertension, age, 4068_Ch22_417-431 15/11/14 1:37 PM Page 421 Chapter 22 Nursing Care of Patients With Hypertension 421 TABLE 22.2 HYPERTENSION SUMMARY Signs and Symptoms Often none Increased BP Headache, bloody nose, severe anxiety, or shortness of breath Diagnosis Prehypertension is greater than systolic of 120 mm Hg and diastolic of 80 mm Hg. Hypertension is an average BP, using two or more readings on different dates, greater than a systolic of 139 mm Hg and diastolic of 89 mm Hg. Therapeutic Measures Lifestyle modification Medications Complications Heart failure, myocardial infarction, stroke, renal failure Priority Nursing Diagnoses Deficient Knowledge Ineffective Self Health Management ethnicity, and diabetes mellitus. Modif iable risk factors— those that can be changed—include blood glucose level, activity level, smoking, salt and alcohol intake, and insufficient sleep (less than 5 hours per night). Managing these risk factors can help to decrease BP. Nonmodifiable Risk Factors Family History of Hypertension Hypertension is more common among people with a family history of hypertension. Indeed, people with a f amily history have almost twice the risk of developing hypertension as those with no family history. People with a family history of hypertension should be encouraged to ha ve their BP checked regularly. Age People age differently because of their genetic and environmental risk factors and lifestyle habits. Thus, the results of the aging process may be reflected in wide v ariations of BP among older adults. As a person ages, plaque builds up in the arteries, and blood vessels become stiffer and less elastic, causing the heart to w ork harder to force blood through the vessels. These vessel changes increase the amount of w ork required by the heart to maintain blood flow into the circulation and, consequently, BP increases. Race and Ethnicity “Cultural Considerations” discusses hypertension among various ethnic groups. Cultural Considerations African Americans Hypertension continues to be the most serious health problem affecting African Americans in the United States. This population suffers higher mortality and morbidity rates related to hypertension and at an earlier age than all other ethnic groups. African Americans from lower socioeconomic backgrounds have higher BP than African Americans from higher socioeconomic backgrounds. Additionally, African Americans are three to four times more likely to develop kidney failure related to hypertension than European Americans. Addressing obesity, high sodium intake, low potassium intake, and lack of physical activity is especially important for cardiovascular health in African Americans. Hypertension among African Americans is usually caused by increased renin activity, resulting in greater sodium and fluid retention. Thus, African Americans respond better to diuretics such as furosemide (Lasix) and hydrochlorothiazide (HydroDIURIL) than to beta blockers such as propranolol (Inderal). Hypertension among European Americans is more often caused by chemical imbalances; thus, they respond better to beta blockers. Chinese Americans Chinese people are more sensitive than Caucasians to the effects of propranolol on heart rate and BP, requiring only half the blood level of European Americans to achieve a therapeutic effect. Propranolol is eliminated from the bodies of many Chinese people at double the rate of European Americans. They are more likely to suffer fatigue as a side effect. Thus, the nurse must carefully monitor the Chinese patient for therapeutic and side effects. Continued 4068_Ch22_417-431 15/11/14 1:37 PM Page 422 422 UNIT FIVE Understanding the Cardiovascular System Cultural Considerations—cont’d Japanese Americans Hypertension among Japanese Americans is primarily related to the high sodium content of the Japanese diet, stress, and a high rate of cigarette smoking. Korean Americans and Filipino Americans High rates of hypertension among Koreans and Filipinos are due to the stress of immigration, salt preservatives in their foods, and the use of condiments high in sodium. Diabetes Mellitus Many adults who have diabetes mellitus also ha ve hypertension. The risk of developing hypertension with a family history of diabetes and obesity is greater than when there is no family history. Lifestyle modifications and adherence to therap y are crucial to prevent the heart attacks, strokes, blindness, and kidney failure associated with high blood glucose and BP levels. Modifiable Risk Factors: Lifestyle JNC 8 supports patients with hypertension making lifestyle modifications. These modifications include adoption of the DASH or Mediterranean diet, reduction of dietary sodium, and increased physical activity (see “Nutrition Notes”; Eckel et al, 2013). The HCP and dietitian should be consulted to help the patient develop a healthy diet plan. Lifestyle modifications are used along with antihypertensive drugs to control hypertension. CRITICAL THINKING Ms. Miller ■ Ms. Miller, age 54, visits a health clinic because she has a headache every morning. The nurse collects data on Ms. Miller and f inds that she is an of fice manager, smokes a pack of cigarettes a day , eats f ast food for lunch at her desk, has two adult children, is recently divorced, and has tw o to three alcoholic drinks e very evening. Ms. Miller has been in good health and tak es two aspirin tablets for her headaches daily. 1. What are Ms. Miller’s risk factors for hypertension? 2. What is the most significant patient information identified? Why? 3. Why is hypertension referred to as the “silent killer”? 4. Why should Ms. Miller be told of the need for lifelong therapy if she is diagnosed with hypertension? Suggested answers are at the end of the chapter. THERAPEUTIC MEASURES FOR HYPERTENSION JCN 8 recommends therap y to achie ve a BP less than 150/90 mm Hg for those 60 and older; for those aged 30 to 59, the goal is a diastolic BP less than 90 mm Hg; and a goal BP less than 140/90 mm Hg for other adults.Treatment may begin with lifestyle modifications and then consideration of drug therapy. For initial drug therapy, a thiazide diuretic, angiotensin-converting enzyme (A CE) inhibitor, angiotensin receptor blocker (ARB), or calcium channel blocker (CCB) is recommended. African Americans should receive a CCB or thiazide diuretic (if chronic kidney disease with proteinuria ACE inhibitor or ARB), and anyone with chronic kidney disease an ACE inhibitor or ARB. For those with chronic kidney disease or diabetes, the goal BP is less than 140/90. If the response does not achie ve the BP goal, dosage may be increased or a second drug from a different class may be added. See Table 22.3 for e xamples of medications used to treat hypertension. Safe administration of medications is important, especially for older patients (“Gerontological Issues”). Gerontological Issues Managing Antihypertensive Therapy • For safety, teach older adults who take antihypertensive drugs to rise slowly to prevent the effects of orthostatic hypotension. Dizziness may increase the risk of falling. • Deficiencies in fluid volume can be a common problem for older adults as well, and diuretics can contribute to them. Careful monitoring of fluid balance is important to prevent dehydration. • Older adults may be more sensitive to medications, so monitor them carefully for adverse effects. Older patients may need lower dosages. 4068_Ch22_417-431 15/11/14 1:38 PM Page 423 Chapter 22 Nursing Care of Patients With Hypertension 423 TABLE 22.3 MEDICATIONS USED TO TREAT HYPERTENSION Medication Class/Action Examples Diuretics Increase urine output by inhibiting sodium and water reabsorption by the kidney. Several types. Nursing Implications Take with food to prevent GI upset. Monitor I&O and weight to determine fluid loss. Assess for improvement of edema in patients with HF, and reduced BP in hypertension. Electrolyte imbalances may occur quickly. Teach patient to take during waking hours to prevent excessive urination during sleeping hours. Thiazide and Thiazide-Like Diuretics Increase urine output by promoting sodium, chloride, and water excretion. Causes loss of potassium, sodium, magnesium. Calcium saved. No immediate effect. Most effective in normal renal function. Thiazide: hydrochlorothiazide (HydroDIURIL) chlorothiazide (Diuril) Thiazide-like: chlorthalidone (Hygroton) indapamide (Lozol) metolazone (Zaroxolyn) Monitor potassium level for hypokalemia. Blood glucose may increase in diabetics. Teach patient to wear sunscreen and protective clothing to prevent photosensitivity. Hypercalcemia could be hazardous to patient on digoxin. Loop Diuretics Act on ascending loop of Henle in kidney to cause sodium and water loss. Also causes loss of potassium, magnesium, and calcium. bumetanide (Bumex) furosemide (Lasix) torsemide (Demadex) Monitor potassium level for hypokalemia. Contraindicated if allergic to sulfonamides. Teach patient to use sunscreen to prevent photosensitivity. Take with food or milk to prevent GI upset. amiloride (Midamor) spironolactone (Aldactone) Check potassium level for hyperkalemia. Check BP before administration. Avoid foods rich in potassium such as oranges, bananas, salt substitutes, dried fruits. Triamterene: Take after meals for GI upset; may turn urine blue. atenolol (Tenormin) metoprolol (Lopressor) metoprolol, extended release (Toprol XL) nadolol (Corgard) propranolol (Inderal) propranolol, long acting (Inderal LA) Check heart rate and BP before administration as causes bradycardia and orthostatic hypotension. Daily I&O and weight. Monitor for bronchospasm. Teaching: Rise slowly. Do not stop drug abruptly to avoid rebound hypertension, angina, or dysrhythmias. Potassium-Sparing Diuretics Mild diuretic. Can be used as combination therapy. Promote sodium and water excretion and potassium retention by the kidney. Sympatholytics Beta Blockers Decrease sympathetic nervous system response, resulting in decreased BP, heart rate, contractility, cardiac output, and renin activity. Continued 4068_Ch22_417-431 15/11/14 1:38 PM Page 424 424 UNIT FIVE Understanding the Cardiovascular System TABLE 22.3 MEDICATIONS USED TO TREAT HYPERTENSION—cont’d Medication Class/Action Alpha1 Blockers Block effects of sympathetic nervous system on smooth muscle of blood vessels, resulting in vasodilation and decreased BP. Combined Alpha and Beta Blockers Block alpha-adrenergic receptors, causing vasodilation and reduced BP. Decrease sympathetic nervous system response, resulting in decreased heart rate and contractility. Central-Acting Alpha2 Agonists Block effects of sympathetic nervous system centrally. Angiotensin-Converting Enzyme (ACE) Inhibitors Blocks production of angiotensin II, a potent vasoconstrictor. Reduces peripheral arterial resistance and BP. Angiotensin II Receptor Antagonists (ARB) Block angiotensin II receptors, causing vasodilation and reduction in BP. Examples Nursing Implications HIGH ALERT: IV vasoactive medications are inherently dangerous. Oral and parenteral doses of propranolol are not interchangeable; IV dose is 1/10 the oral dose. Patient harm or fatalities have occurred when switching from oral to IV route. prazosin (Minipress) terazosin (Hytrin) Check heart rate and BP before administration; causes hypotension and tachycardia. Teaching: Rise slowly. carvedilol (Coreg) labetalol (Normodyne) Daily I&O and weight. Check heart rate and BP before administration as causes bradycardia and hypotension. Monitor edema, neck vein distention, lung sounds. Teaching: Rise slowly. Do not stop drug abruptly to avoid rebound hypertension, angina, or dysrhythmias. clonidine (Catapres) guanfacine HCl (Tenex) Check for decreased BP and edema. Suggest gum or hard candy for dry mouth. Teaching: Rise slowly. Do not stop drug abruptly to avoid rebound hypertension, angina, or dysrhythmias. benazepril HCl (Lotensin) captopril (Capoten) enalapril (Vasotec) fosinopril (Monopril) lisinopril (Prinivil, Zestril) moexipril (Univasc) perindopril (Aceon) quinapril (Accupril) ramipril (Altace) trandolapril (Mavik) Monitor patient for edema with HF, decreased BP with hypertension and new-onset cough. Teaching: Rise slowly. Tell to report new-onset cough. Use sunscreen to prevent photosensitivity. Do not stop drug abruptly to avoid rebound hypertension, angina, or dysrhythmias candesartan (Atacand) eprosartan (Teveten) irbesartan (Avapro) losartan (Cozaar) olmesartan (Benicar) telmisartan (Micardis) valsartan (Diovan) Monitor patient for edema with HF and decreased BP with hypertension. Teaching: Tell to report new-onset cough. Use sunscreen to prevent photosensitivity. 4068_Ch22_417-431 15/11/14 1:38 PM Page 425 Chapter 22 Nursing Care of Patients With Hypertension 425 TABLE 22.3 MEDICATIONS USED TO TREAT HYPERTENSION—cont’d Medication Class/Action Aldosterone Receptor Antagonist Blocks binding of aldosterone at receptor site to reduce sodium reabsorption and then BP. Calcium Channel Blockers Prevent movement of extracellular calcium into the cell which vasodilates. Direct Vasodilators Relax smooth muscles of blood vessels, causing vasodilation and decreased BP. Combination Agents See individual agent for action. Examples Nursing Implications eplerenone (Inspra) Monitor potassium for hyperkalemia before and during therapy. amlodipine (Norvasc) diltiazem (Cardizem) felodipine (Plendil) isradipine (DynaCirc) nicardipine HCl (Cardene, Cardene SR) nifedipine (Procardia) nisoldipine (Sular) verapamil (Calan SR, Isoptin SR) Take pulse before administration. Check BP for hypotension, heart rate, dysrhythmias, angina. May increase blood levels of digoxin. hydralazine (Apresoline) minoxidil (Loniten) Monitor BP for hypotension/hypertension and increasing heart rate. Treat headache with acetaminophen. Often given with diuretic to reduce edema resulting from water and sodium retention. Hyzaar = Cozaar + HCTZ, Micardis HCT = Micardis + HCTZ Note. GI, gastrointestinal; HF = heart failure; I&O = input and output; PO = oral; IV = intravenous. BE SAFE! Clonidine, an alpha-adrenergic agonist, and clonazepam, a benzodiazepine, have lookalike and sound-alike drug names. Be aware of drug names that look alike and sound alike to prevent errors involving these drugs. The treatment plan of lifestyle modifications and medications is effective only when patients are moti vated to accept the diagnosis of hypertension and include lifelong treatment in their daily routine. Empathy and trust can increase patient motivation. Patients should be instructed that antihypertensive therapy usually must be continued for the rest of their lives. Patients should be reminded that although they may be feeling better with the modifications and medications, the hypertension is still present e ven if it is well controlled. Patients should be told not to stop taking their medications unless instructed to do so by their HCP. Antihypertensive medications can have unpleasant side effects. Patients should be told what these side ef fects are and to report them if they occur, so that medications can be altered if possible. Erectile dysfunction can be one of the side effects of these medications. Men may be reluctant to discuss this side effect and instead choose to stop the medication. The nurse should be proacti ve and inform men about this side effect so they will understand that, if it occurs and is reported, the HCP can make medication changes. COMPLICATIONS OF HYPERTENSION Common complications of hypertension include coronary artery disease, atherosclerosis, myocardial infarction (MI), heart failure (HF), stroke, and kidney or eye damage. The severity and duration of the increase in BP determine the extent of the vascular changes causing organ damage. High BP levels may also increase the size of the left ventricle, referred to as hypertrophy. Over time elevated BP damages the small vessels of the heart, brain, kidneys, and retina. The results are a progressi ve functional impairment of these organs, known as target-organ disease. 4068_Ch22_417-431 15/11/14 1:38 PM Page 426 426 UNIT FIVE Understanding the Cardiovascular System LEARNING TIP Walking for 30 minutes is an effective way to lower BP, as is listening to 30 minutes of classical, Celtic, or raga music with slow abdominal breathing daily. Transcendental meditation also helps control high BP. Here are additional, important lifestyle modifications arranged in an easy-to-remember mnemonic: L—Limit salt, caffeine, and alcohol. I—Include daily potassium and calcium. F—Fight fat and cholesterol. E—Exercise regularly (walking). S—Stay on your BP regimen. T—Try to quit smoking. Y—Your medications are to be taken daily. L—Lose weight. E—End-stage complications will be avoided! SPECIAL CONSIDERATIONS BP should be well controlled before the patient has an invasive procedure. Hypertensive patients are at greater risk for strokes, MI, HF, kidney failure, and pulmonary edema. These patients should be instructed to continue their BP medications until the time of the procedure, unless other wise directed by their HCP. Antihypertensive medications should be resumed as soon as possible after the procedure, as directed by the HCP. CRITICAL THINKING Mrs. Bell Mrs. Bell, 80 years old, is seen in her physician’ s office. She lives a sedentary lifestyle alone in her own home with a bathroom do wn the hall from the bedroom. Mrs. Bell’s son lives in the same city and visits her often. She has wood floors with throw rugs in the hall and a tile floor in the bathroom. She wears glasses and has a cataract. She has an unsteady gait and nocturia. She is 40 pounds overweight and has a 10-year history of hypertension for which she is taking chlorothiazide (Diuril) and propranolol (Inderal) when she remembers them. ■ 1. What are Mrs. Bell’s modifiable and nonmodifiable risk factors for hypertension? 2. Why is Mrs. Bell taking chlorothiazide and propranolol to treat her hypertension? 3. What teaching methods could be used to help ensure that Mrs. Bell will understand and follow her treatment plan? 4. Why should patient safety needs be addressed in the nursing care plan? 5. What patient-centered safety interventions should the patient and family be taught? 6. Inderal 20 mg by mouth (PO) is ordered now because Mrs. Bell forgot to take her medication. The nurse has on hand Inderal 10-mg tablets. How many tablets should the nurse give? Suggested answers are at the end of the chapter. HYPERTENSIVE EMERGENCY How would you know if a patient’s BP was in the dangerous range? Hypertensive emergency is a severe type of hypertension characterized by elevations in systolic BP greater than 180 mm Hg and diastolic BP greater than 120 mm Hg that are complicated by a risk for or progression of tar get-organ dysfunction (examples include MI, HF, and dissecting aortic aneurysm). Patients who are untreated, fail to adhere to antihypertensive therapy, or stop their medications abruptly are at risk for hypertensive emergency. These patients require immediate reduction of BP to prevent or limit damage to target organs. Patients with hypertensive crises should be admitted to the critical care unit. In some cases, the BP may need to be reduced by 25% within 1 hour to prevent organ damage. If the patient is stable, BP is then decreased to 160/100 to 110 mm Hg in the next 2 to 6 hours. Gradual reduction of BP is desired to prevent decreased blood flo w to the kidne ys, heart, and/or brain. An intravenous (IV) medication such as nitroprusside (Nipride) may be gi ven to quickly reduce BP during the crisis. HYPERTENSIVE URGENCY The JNC7 considers hypertensive urgency to occur in situations when BP is as elevated as in a hypertensive emergency but without progression of target-organ dysfunction. A patient with hypertensive urgency may have severe headaches, nosebleeds, shortness of breath, and severe anxiety. Patients with hypertensive urgency usually can be treated with combination oral medication and scheduled for a follo w-up visit within several days. NURSING PROCESS FOR THE PATIENT WITH HYPERTENSION Data Collection Data collection for a patient with hypertension includes the patient’s health history, BP measurements, medications, and 4068_Ch22_417-431 15/11/14 1:38 PM Page 427 Chapter 22 Nursing Care of Patients With Hypertension 427 physical assessment (Fig. 22.1). Determining what hypertensive patients and their families know about hypertension and associated risk factors is essential for planning patient and family education and subsequent lifelong lifestyle modification needs. Nursing Diagnoses, Planning, Interventions, and Evaluation Possible nursing diagnoses, planning, interv entions, and evaluation must be agreed on by the patient and the health care team. See the Nursing Care Plan for the Patient With Hypertension. FIGURE 22.1 Nurse obtaining BP measurement. Correct size cuff use is essential for accurate reading. NURSING CARE PLAN for the Patient With Hypertension Nursing Diagnosis: Deficient Knowledge related to disease process and treatment regimen Expected Outcome: The patient will verbalize knowledge of disease process and treatment regimen. Evaluation of Outcome: Is patient able to discuss and explain hypertension disease process, including its risk factors, complications, and treatment regimen? Intervention Identify patient’s readiness and ability to learn. Rationale Patient must accept the hypertension diagnosis and be able to receive and understand information given. Determine patient’s preferred method of learning. Evaluation Does patient verbalize acceptance of hypertension diagnosis? Does patient demonstrate ability to read, write, and retain information? Intervention Provide patient with information concerning disease process including risk factors, complications, and treatment regimen. Rationale Patient will be more willing to participate in treatment regimen when able to understand need for changes in behavior. Evaluation Is patient able to participate in discussion concerning hypertension disease process including risk factors, complications, and treatment regimen? Nursing Diagnosis: Ineffective Self Health Management related to complexity of therapy, cost of medications, lack of symptoms, side effects of medications, need to alter long-term lifestyle habits, normal BP controlled by therapy Expected Outcome: The patient will verbalize ability and willingness to adhere to treatment. Evaluation of Outcome: Is patient able to state how lifestyle will include therapy? Does patient identify and problem solve barriers for therapy? Intervention Identify patient’s modifiable risk factors and lifestyle modification needs. Rationale Identifying risk factors is the first step in planning therapy. Patient must understand the relationship of these risk factors with hypertension and complication development. Evaluation Can patient state rationale for modifying risk factors to prevent development of complications? Continued 4068_Ch22_417-431 15/11/14 1:38 PM Page 428 428 UNIT FIVE Understanding the Cardiovascular System NURSING CARE PLAN for the Patient With Hypertension—cont’d Intervention Identify factors that are barriers to patient adhering to therapy. Rationale Factors such as finances, transportation, aging changes, patient motivation, habits, and reading and educational level can be barriers for therapy. Evaluation Are barriers present for patient? Intervention Develop plan to overcome barriers. Make referrals as needed. Rationale Identified barriers can be overcome with planning and intervention, such as referral to support groups or for financial assistance or prescription delivery service, and instructions provided at level of patient’s learning ability. Evaluation Have barriers been eliminated? Is patient willing to use referrals? Intervention Assess ability to take medications daily: financially, obtaining refills, understanding directions. Rationale Older adult patients may be on a fixed income, lack transportation, or lack ability to take several medications several times a day. Simplifying this process, to one medication if possible, can increase adherence to medication treatment. Evaluation Is patient able to obtain medications? Can patient self-administer medications accurately on daily basis? Intervention Teach patient to take medications as prescribed and not to skip dosages. Rationale Older patients may skip dosages to save money, reduce side effects, or reduce need to void. Evaluation Does patient take dosages as prescribed? Does patient express concern over cost, side effects, or frequent voiding? Intervention Teach patient to change positions slowly to prevent falls. Rationale Antihypertensive medications can cause hypotension, resulting in dizziness and weakness and possibly leading to falls. Evaluation Does patient understand how to change positions slowly? Does patient experience dizziness or weakness? Home Health Hints • Discuss medication usage with the patient and count the number of remaining pills in the patient’s pill bottles, if needed, to assess compliance. Remind the patient to get refills and keep medical appointments by writing them on a calendar. • Monitor carefully for symptoms of congestive HF if the patient takes a beta blocker. This is a side effect that needs to be caught early and reported to the HCP. • Instruct patients to take medication as prescribed even if they are feeling well or if side effects, which they should report, are present. Medication compliance can be a challenge for the older adult patient with hypertension. If medicines are too expensive for the patient, check with the HCP and pharmacist for less expensive alternatives. • Encourage the patient to obtain a home BP monitoring device. Instruct the patient or caregiver on proper use and logging the date, time, and reading obtained. The home health nurse should review the log on each visit. • Teach the patient or caregiver to take the patient’s pulse and to call the nurse if it is below 60 beats per minute or the parameters defined by the HCP. Many antihypertensive medicines can cause bradycardia. • Instruct patients to weigh themselves every morning after voiding, to wear the same amount of clothing each time, and to keep a log for the nurse to review. • Advise patients who are leaving home for the weekend or holidays to refill medicines ahead of time to make sure they do not run out. The HCP can write a prescription for the patient to have for emergency refills. • Discuss with the registered nurse if the DASH eating plan would be appropriate for the patient (see www .nhlbi.nih.gov/health/public/heart/hbp/dash/new _dash.pdf). • Instruct patients and caregivers to avoid frozen dinners and deli meats because many are high in sodium. • Teach patient to consult HCP about use of salt substitutes, which often contain potassium, because medication and electrolyte interactions can occur. • Teach patients how to read food labels for fat and salt content. If patients are on a 2- to 3-g sodium diet, instruct them about eating breads or cereals that contain 200 mg or less of sodium per serving 4068_Ch22_417-431 15/11/14 1:38 PM Page 429 Chapter 22 or canned vegetables that contain 150 mg of sodium per serving. Fresh vegetables are better, but cost and storage must be considered. Providing written suggestions for the caregiver who does the grocery shopping increases adherence to diet therapy. • Provide the following suggestions to help a patient decrease or stop smoking: use cinnamon mouthwash on arising; put away all ashtrays but one, and keep it in a place not normally used for Nursing Care of Patients With Hypertension 429 smoking; find ways to keep hands busy at times when usually holding a cigarette, such as when drinking coffee or alcohol. • Encourage patients to put “No Smoking” signs on their door to avoid passive smoking. • Promote home exercise if cleared by HCP. Weights for exercising can be improvised using canned goods and bags of sugar. The amount of weight being used is easily identified for documentation by the labeling on the food item. SUGGESTED ANSWERS TO CRITICAL THINKING ■ Ms. Miller 1. Risk factors include gender; age; smoking; a diet high in fat, salt, and calories; consumption of two to three alcoholic drinks per evening; and possibly her morning headaches. 2. Morning headaches. Ms. Miller may be experiencing an episode of hypertensive urgency and should be evaluated immediately by an HCP. 3. “Silent killer” refers to the fact that there are often no signs or symptoms associated with hypertension. 4. Lifelong therapy is required because there is no cure for hypertension, and complications need to be prevented. ■ Mrs. Bell 1. Nonmodifiable risk factors include age, gender, and history of hypertension. Modifiable risk factors include weight and adherence to antihypertensive therapy. 2. Thiazide diuretics are first-line drugs. Diuretics remove excess salt and water to decrease blood volume and lower BP. Beta blockers stop the beta receptors from receiving the message from the brain for the heart to work harder. Therefore, the heart rate and BP decrease. 3. Identify patient’s reading level and primary language. Provide patient with written instructions in large letters about medications. Include family members and enlist their support in reinforcing the importance of adhering to the treatment plan. 4. Patient is 80 years old, makes frequent trips to the bathroom related to diuretics, has vision problems, and a side effect of propranolol is weakness and fatigue. 5. Make arrangements for a bedside commode to reduce the distance and urgency to get to the bathroom. Encourage the patient and family to place nightlights in the bedroom, hall, and bathroom. Explain that throw rugs increase the risk of falling and that wood or tile floors can be slippery when wet and hard if a fall occurs. Encourage removal of throw rugs, and suggest carpeting these areas if possible. Suggest the use of safety bars in the hall and bathroom for support or other walking aids as needed. If incontinence is a concern, suggest wearing an adult brief to prevent a wet, slippery floor. Suggest discussing with the physician an exercise program to increase strength, such as lifting small, lightweight objects (e.g., soup can), squeezing a rubber ball, or riding an exercise bike if able. These exercises can be done while sitting so they are not a fall-risk activity. 6. Unit analysis method: 20 mg 1 tablet 10 mg = 2 tablets 4068_Ch22_417-431 15/11/14 1:38 PM Page 430 430 UNIT FIVE Understanding the Cardiovascular System REVIEW QUESTIONS 1. The nurse provides a teaching session for a newly diagnosed patient with hypertension. Which of the following statements if made by the patient would indicate the need for further teaching about the cause of primary hypertension? Select all that apply. 1. It is caused by a tumor of the adrenal gland. 2. There are no tests that can identify the cause. 3. An arteriogram can show why hypertension is occurring. 4. The cause is unknown. 5. The cause can be identified with magnetic resonance imaging (MRI). 2. Which of the following would the nurse reinforce after a teaching session as the most important lifestyle modification for the patient who is age 59, 5'11", weighs 280 pounds, and is hypertensive? 1. Reduce weight. 2. Restrict salt intake. 3. Increase potassium intake. 4. Decrease alcohol intake. 3. The nurse is reinforcing teaching on hypertension for a patient. Which of the following statements if made by the patient after a teaching session would indicate understanding of what is often the only sign of hypertension? 1. Sacral edema 2. Elevated BP 3. Tachycardia 4. Jugular venous distention 4. The nurse is participating in a teaching session on diet for a patient with hypertension. Which of the following statements if made by the patient would indicate understanding of the teaching? Select all that apply. 1. “Canned fruit and vegetables are best to eat.” 2. “Add salt to food during cooking.” 3. “Increase foods high in saturated fat.” 4. “Choose fresh or frozen fruits and vegetables.” 5. “Read food labels.” 6. “Watch for potassium in salt substitutes.” 5. The nurse is obtaining BP readings for patients during a clinic visit. For which of the following BP readings should a 1-year follow-up visit be recommended in the patient’s teaching plan? 1. 108/66 mm Hg 2. 116/76 mm Hg 3. 138/84 mm Hg 4. 142/90 mm Hg 6. During a health screening, a patient’s BP is confirmed by two nurses to be 210/120 mm Hg. Which of the following actions should the nurse recommend to the patient? 1. Take off work for the rest of the day and rest. 2. Sit quietly while we call 911 to request an ambulance. 3. The patient should take two doses of BP medication right now. 4. The patient may return to work and have BP rechecked in 2 days. 7. The nurse is collecting data for a patient experiencing the complication of heart failure from hypertension. Which of the following findings would the nurse expect for this patient? Select all that apply. 1. Abnormal hair growth pattern on face 2. Distended jugular veins in semi-Fowler’s position 3. Pain in the right hand when writing 4. Depression from taking BP medication 5. Bilateral ankle edema 8. The nurse is reinforcing medication teaching for a patient. The nurse would include which of the following instructions to a patient receiving a diuretic? 1. Change positions slowly. 2. Eliminate salt in your diet. 3. Take your medication before bed. 4. Empty your bladder after taking the first dose. 9. The nurse is collecting data at a follow-up visit for a patient with hypertension. Which of the following data would best indicate to the nurse that the patient’s BP therapy has been successful? 1. Weight decreased by 3 pounds. 2. Diary of dietary intake is within suggested diet. 3. BP is less than 120/80 mm Hg. 4. Patient reports walking 30 to 40 minutes daily. Answers can be found in Appendix C. 4068_Ch22_417-431 15/11/14 1:38 PM Page 431 Chapter 22 References Blumenthal, J. A., Babyak, M. A., Hinderliter, A., Watkins, L. L., Craighead, L., Lin, P. H., . . . Sherwood, A. (2010). Effects of the DASH diet alone and in combination with exercise and weight loss on BP and cardiovascular biomarkers in men and women with high BP: The ENCORE study. Arch Intern Med, 170, 126–135. Eckel, R. H, Jakicic, J. M., Ard, J. D., Hubbard, V. S., de Jesus, J. M., . . . Yanovski, S. Z. (2013, November 12). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published online]. Circulation. Retrieved April 5, 2014, at http://circ .ahajournals.org/content/early/2013/11/11/01.cir.0000437740 .48606.d1.citation Epstein, D. E., Sherwood, A., Smith, P. J., Craighead, L., Caccia, C., Lin, P. H. . . . Blumenthal, J. A. (2012). Determinants and consequences of adherence to the dietary approaches to stop hypertension diet in African-American and white adults with high BP: Results from the ENCORE trial. Journal of the Academy of Nutrition and Dietetics, 112, 1763–1773. Nursing Care of Patients With Hypertension 431 James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., . . . Ortiz, E. (2014). 2014 Evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association, 311, 507–520. National Heart, Lung, and Blood Institute. (2004). The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP. Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health. Retrieved February 17, 2014, from www.nhlbi .nih.gov/guidelines/hypertension/jnc7full.htm Nwankwo, T., Yoon, S. S., Burt, V., & Gu, Q. (2013). Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011–2012 (NCHS Data Brief No. 133). Hyattsville, MD: National Center for Health Statistics. Retrieved February 17, 2014, from www.cdc.gov /nchs/data/databriefs/db133.htm For additional resources and information visit davispl.us/medsurg5