HYPERTENSION

HYPERTENSION



Introduction



High blood
pressure is a common condition in which the long-term force of the blood
against your artery walls is high enough that it may eventually cause health
problems, such as heart disease.





Blood
pressure is determined both by the amount of blood your heart pumps and the
amount of resistance to blood flow in your arteries. The more blood your heart
pumps and the narrower your arteries, the higher your blood pressure.



You can
have high blood pressure (hypertension) for years without any symptoms. Even
without symptoms, damage to blood vessels and your heart continues and can be
detected. Uncontrolled high blood pressure increases your risk of serious
health problems, including heart attack and stroke.



High blood
pressure generally develops over many years, and it affects nearly everyone
eventually. Fortunately, high blood pressure can be easily detected. And once
you know you have high blood pressure, you can work with your doctor to control
it.



Definition








Hypertension
is defined as a repeatedly elevated blood pressure exceeding 140 over 90
mmHg and systolic pressure above 140 or a diastolic pressure. 



Classifications of Blood Pressure





Blood pressure measurements
fall into four general categories:



Normal  blood  pressure. Your blood pressure is normal if it's below 120/80 mm Hg.



Pre hypertension 
.  Pre hypertension is a systolic
pressure ranging from 120 to 139 mm Hg or a diastolic pressure ranging from 80
to 89 mm Hg. Prehypertension tends to get worse over time.



Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 140 to
159 mm Hg or a diastolic pressure ranging from 90 to 99 mm Hg.



Stage 2  hypertension. More severe hypertension, stage 2 hypertension
is a systolic pressure of 160 mm Hg or higher or a diastolic pressure of 100 mm
Hg or higher. 



Epidemiology



v  Nearly
1 billion hypertensive in the world



v  Hypertension
is poorly controlled, with less than 25% controlled in developed countries and
less than 10% in developing countries.



v  Hypertension
which is responsible for 3 million death annually.



Prevalence of Hypertension












Etiology 



For most
adults, there's no identifiable cause of high blood pressure. This type of high
blood pressure, called primary (essential) hypertension, tends to develop
gradually over many years.



Secondary
hypertension



Some people
have high blood pressure caused by an underlying condition. This type of high
blood pressure, called secondary hypertension, tends to appear suddenly and
cause higher blood pressure than does primary hypertension. 



Various
conditions and medications can lead to secondary hypertension, including:



•       Obstructive sleep apnea 



•       Kidney problems



•       Adrenal gland tumors 



•       Thyroid problems



•       Certain defects in blood vessels
you're born with (congenital)



•       Certain medications, such as birth
control pills, cold remedies, decongestants, over-the-counter pain relievers
and some prescription drugs



•       Illegal drugs, such as cocaine and
amphetamines



•       Alcohol abuse or chronic alcohol use



Risk Factors



•       Age-
Blood pressure rises with increasing age.



•       Alcohol-
Excessive alcohol intake is associated with Hypertension



•       Cigarette
smoking- Smoking increases your risk for Cardiovascular disease.  If you have hypertension & smoke and/or
take Oral contraceptives you have a greater risk for Cardiovascular disease and
blood clots.



•       Diabetes
Mellitus- Hypertension is more common in Diabetics



•       Elevated
Cholesterol & Triglycerides-  High
levels of cholesterol & triglycerides are primary risk factors for
atherosclerosis (plaque build up in your blood vessels).



•       Too
much salt in your diet- High sodium intake contributes to high blood
pressure and causes water retention.



•       Gender-
Hypertension is more common in young adulthood men & middle aged men
(<55 yr of age). After the age off 55 Hypertension is more common in women.



•       Family
history- Having a close blood relative 
( parents or sibling) with hypertension increases your risk of
developing hypertension.



•       Obesity-
Weight gain is  highly associated with
increased  frequency of hypertension,
especially with central abdominal obesity.



•       Ethnicity-
The incidence of hypertension is twice as high in African Americans as they are
in whites.



•       Sedentary
lifestyle- Inactivity and weight gain are associated with high blood
pressure & increases the risk for heart disease.



•       Stress-
People exposed to repeated stress may develop hypertension more frequently than
others.



Pathophysiology










Clinical
Manifestations



•      
Hypertension
is often called the “Silent killer” because it is frequently asymptomatic-
meaning “without symptoms” until it has become severe and damage to  organs have occurred



A person with severe
hypertension may have symptoms caused by the effects on the blood vessels which
my be:



•      
Fatigue



•      
Reduced
activity tolerance



•      
Dizziness



•      
Palpitations



•      
Angina
(chest pain)



•      
And difficulty
breathing



•      
According
to the American Heart Association There's a common misconception that people
with high blood pressure will experience symptoms such as nervousness,
sweating, difficulty sleeping or facial flushing. The truth is that HBP (high
blood pressure) is largely a symptomless condition. If you ignore your blood
pressure because you think symptoms will alert you to the problem, you are
taking a dangerous chance with your life. Everybody needs to know their blood
pressure numbers, and everyone needs to prevent high blood pressure from
developing.



•      
There
are also myths of headaches/nosebleeds believed to be related to HBP. According
to the AHA studies have shown that people with higher systolic (top number)
blood pressure were up to 40% less likely to have headaches ( except in the
cases of Hypertensive crisis SBP ≥180mmHg and DSP ≥110mmHg)



•      
It is
important to know that nosebleeds can be associated with other factors,. Most
common reasons for nosebleeds are dry air especially in hot climates like the
desert Southwest (Arizona). Other causes may be allergies, sinusitis or
anticoagulants such as Warfarin or aspirin.

Diagnostic
Evaluation



Diagnosis of hypertension is made by measuring blood pressure over a
number of clinic visits, using a sphygmomanometer. 



An isolated high reading is not taken as proof of hypertension. Rather,
diagnosis can be made after elevated readings are taken on at least three
separate days.



Measurements may be taken at the doctor's office while a patient is
seated and after standing; this helps the doctor to look for orthostatic or
postural hypotension.



An exception to this is those with very high blood pressure readings
especially when there is poor organ function. Initial assessment
of the hypertensive people should include a
complete history and physical examination.  



Laboratory tests can also be performed to identify possible causes of
secondary hypertension, and to determine whether hypertension has caused damage
to the heart, eyes, and kidneys. Additional tests for diabetes and high
cholesterol levels are usually performed because these conditions are
additional risk factors for the development of heart disease and may
require treatment



•      
Serum creatinine is measured to assess for
the presence of kidney disease, which can be either the cause or the result of
hypertension.



•      
 Electrocardiogram testing is done to
check for evidence that the heart is under strain from high blood pressure. It
may also show whether there is thickening of the heart muscle (left ventricular
hypertrophy) or whether the heart has experienced a prior minor disturbance
such as a silent heart attack. A chest X-ray or
an echocardiogram may also be performed to look for signs of heart
enlargement or damage to the heart.



Management



Lifestyle changes are important for both treatment and prevention of high
blood pressure, and they can be as effective as a drug treatment. These
lifestyle changes can also have wider benefits for heart health and overall
health.



•      
Salt restriction - typical salt intake is
between 9 and 12 g a day and modest blood pressure reductions can be achieved
even in people with normal levels by lowering salt to around 5 g a day - the
greatest effects are seen in people with hypertension



•      
Moderation of alcohol consumption - expert
guidelines say moving from moderate to excessive drinking is "associated
both with raised blood pressure and with an increased risk of stroke“



•      
High consumption of vegetables and fruits and
low-fat - people with, or at risk of, high blood pressure are advised to
minimize intake of saturated fat and total fat and to eat whole-grain,
high-fibre foods, at least 300 g of fruit and vegetables a day, beans, pulses,
and nuts, and omega-3-rich fish twice a week



•      
Reducing weight and maintaining it -
hypertension is closely correlated with excess body weight, and weight
reduction is followed by a fall in blood pressure



•      
Regular physical exercise - guidelines say
"hypertensive patients should participate in at least 30 min of
moderate-intensity dynamic aerobic exercise (walking, jogging, cycling or
swimming) on 5 to 7 days a week“



•      
Stress reduction - avoiding sources of stress,
where possible, and developing healthy coping strategies for managing
unavoidable stress can help with blood pressure control, especially as many
people turn to alcohol, drugs, smoking and unhealthy foods or overeating to
cope with stress.



•      
Smoking can also raise blood pressure, and because
of its wider effects on heart health and the rest of the body, giving up
smoking is highly recommended for people with high blood pressure.



The DASH diet



The US National Heart Lung and Blood Institute recommends the DASH diet
for people with high blood pressure.



 It

 is a flexible and balanced eating plan based on research studies
sponsored by the institute, which says the diet 



•      
Lowers high blood pressure



•      
Improves levels of blood lipids (fats in the
bloodstream)



•      
Reduces the risk of developing cardiovascular
disease.





Pharmacological
Management



Drugs
are usually started as monotherapy (just one drug) and at a low
dose. Side-effects associated with antihypertensive drugs are usually
minor.



Thiazide
diuretics



 Diuretics,
sometimes called water pills, are medications that act on your kidneys to help
your body eliminate sodium and water, reducing blood volume.



Thiazide
diuretics are often the first, but not the only, choice in high blood pressure
medications. Thiazide diuretics include hydrochlorothiazide
(Microzide), chlorthalidone and others.



Beta
blockers 



These
medications reduce the workload on your heart and open your blood vessels,
causing your heart to beat slower and with less force. Beta blockers include acebutolol (Sectral), atenolol (Tenormin ) and
others.



When
prescribed alone, beta blockers don't work as well, especially in older adults,
but may be effective when combined with other blood pressure medications.



Angiotensin-converting enzyme (ACE) inhibitors 



These
medications —
such as lisinopril (Zestril), benazepril
(Lotensin), captopril (Capoten) and others — help relax blood vessels by
blocking the formation of a natural chemical that narrows blood vessels. People
with chronic kidney disease may benefit from having an ACE inhibitor as one of
their medications.



Angiotensin
II receptor blockers (ARBs)



 These
medications help relax blood vessels by blocking the action, not the formation,
of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others.
People with chronic kidney disease may benefit from having an ARB as one of
their medications.



•       Calcium channel blockers



These
medications — including amlodipine (Norvasc),
diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles
of your blood vessels. Some slow your heart rate. Calcium channel blockers may
work better for older people  than do ACE
inhibitors alone.



Renin
inhibitors. Aliskiren
(Tekturna) slows down the production of renin, an enzyme produced by your
kidneys that starts a chain of chemical steps that increases blood pressure.



Additional
medications sometimes used to treat high blood pressure



Alpha
blockers



These
medications reduce nerve impulses to blood vessels, reducing the effects of
natural chemicals that narrow blood vessels. Alpha blockers include doxazosin (Cardura), prazosin (Minipress) and others.



Alpha-beta
blockers. In
addition to reducing nerve impulses to blood vessels, alpha-beta blockers slow
the heartbeat to reduce the amount of blood that must be pumped through the
vessels. Alpha-beta blockers include carvedilol
(Coreg) and labetalol (Trandate).



Central-acting
agents. These
medications prevent your brain from signaling your nervous system to increase
your heart rate and narrow your blood vessels. Examples include clonidine (Catapres, Kapvay), guanfacine (Intuniv, Tenex)
and methyldopa.



•      
Vasodilators. These medications, including hydralazine
and minoxidil, work directly on the muscles in the walls of your
arteries, preventing the muscles from tightening and your arteries from
narrowing.



•      
Aldosterone antagonists. Examples are spironolactone
(Aldactone) and eplerenone (Inspra). These drugs block the effect of a
natural chemical that can lead to salt and fluid retention, which can
contribute to high blood pressure.



HOW TO DO 



High
blood pressure isn't a problem that you can treat and then ignore. It's a
condition you need to manage for the rest of your life. To keep your blood
pressure under control:



•      
Take your medications properly. If side effects or costs pose
problems, don't stop taking your medications. Ask your doctor about other
options.



•      
Schedule regular doctor visits. It takes a team effort to treat
high blood pressure successfully. Your doctor can't do it alone, and neither
can you. Work with your doctor to bring your blood pressure to a safe level,
and keep it there.



•      
Adopt healthy habits. Eat healthy foods, lose excess weight and get
regular physical activity. Limit alcohol. If you smoke, quit.



•      
Manage stress. Say no to extra tasks, release negative thoughts,
maintain good relationships, and remain patient and optimistic.



Nursing Management



Nursing Diagnosis



Decreased
Cardiac Output related to Increased vascular resistance,
vasoconstriction/Myocardial ischemia/Ventricular
hypertrophy/rigidity



Interventions 



•      
Review clients at risk as noted in Related Factors as well as
individuals with conditions that stress the heart.



•      
Check laboratory data (cardiac markers, complete blood ell count,
electrolytes, ABGs, blood urea nitrogen and creatinine, cardiac enzymes, and
cultures, such as blood, wound or secretions).



•      
Monitor and record BP. Measure in both arms and thighs three times, 3–5
min apart while patient is at rest, then sitting, then standing for initial
evaluation.



•      
Auscultate heart tones and breath sounds.



•      
Provide calm, restful surroundings, minimize environmental activity and
noise. Limit the number of visitors and length of stay.



•      
Administer medications as indicated 



Nursing Diagnosis



Activity
intolerance  related to Generalized
weakness/Sedentary lifestyle/Imbalance between oxygen supply and demand



Interventions 



•      
Note presence of factors contributing to fatigue (age, frail, acute or
chronic illness, heart failure, hypothyroidism, cancer and cancer therapies).



•      
Assess the patient’s response to activity, noting pulse rate more than
20 beats per min faster than resting rate; marked increase in BP during and
after activity



•      
Encourage progressive activity and self-care when tolerated. Provide
assistance as needed.



•      
Assess emotional and psychological factors affecting the current
situation.



•      
Instruct patient in energy-conserving techniques, e.g., using chair when
showering, sitting to brush teeth or comb hair, carrying
out activities at a slower pace.



Nursing Diagnosis



 Acute
pain related to increased cerebral vascular pressure.



•      
Maintain bed rest, quiet neighbourhood, a little light.



•      
Limit of patients in the activity.



•      
Minimize disruption and environmental stimuli.



•      
Give a fun action according to indications such as ice packs, the
position of comfort, relaxation techniques, counselling imagination, avoid
constipation.



•      
Medical collaboration in providing analgesic and sedative drugs.



Nursing Diagnosis



Ineffective
Tissue Perfusion (cerebral, renal, cardiac) related to impaired
circulation



Interventions



•      
Maintain bed rest, elevate the head position in bed patients.



•      
Assess blood pressure at admission in both arms, sleeping, sitting with
arterial pressure monitoring if it is available.



•      
Measure the input and discharge.



•      
Observe the sudden hypotension.



•      
Ambulation within your means and avoid fatigue in patients.



•      
Monitor electrolytes, creatinine according to medical advice.



•      
Maintain fluids and medications according to medical advice.



Nursing Diagnosis



Knowledge
deficit related to lack of information about the disease process and self-care.



Interventions



•      
Describe the nature of the disease and the purpose of the
procedure and the treatment of hypertension.



•      
Explain the importance of a peaceful environment and therapeutic, and
management of stressors.



•      
Discuss the importance of maintaining a stable weight.



•      
Discuss the need for low-calorie diet, low in sodium to order.



•      
Discuss the importance of avoiding fatigue in the activity.



•      
Explain the need to avoid constipation in the bowel movement.



•      
Explain patient to maintain proper fluid intake, amount allowed,
restrictions such as caffeinated coffee, tea and alcohol.



•      
Discuss the symptoms of relapse or progression of complications reported
to the doctor: headache, dizziness, fainting, nausea and vomiting.



•      
Talk about drugs: the name, dosage, time of administration, purpose and
side effects or toxic effects.



•      
Explain the need to avoid drug-free, without a doctor's examination.



Nursing Diagnosis



Knowledge
deficit related to lack of information about the disease process and self-care.



Interventions



•      
Describe the nature of the disease and the purpose of the
procedure and the treatment of hypertension.



•      
Explain the importance of a peaceful environment and therapeutic, and
management of stressors.



•      
Discuss the importance of maintaining a stable weight.



•      
Discuss the need for low-calorie diet, low in sodium to order.



•      
Discuss the importance of avoiding fatigue in the activity.



•      
Explain the need to avoid constipation in the bowel movement.



•      
Explain patient to maintain proper fluid intake, amount allowed,
restrictions such as caffeinated coffee, tea and alcohol.



•      
Discuss the symptoms of relapse or progression of complications reported
to the doctor: headache, dizziness, fainting, nausea and vomiting.



•      
Talk about drugs: the name, dosage, time of administration, purpose and
side effects or toxic effects.



•      
Explain the need to avoid drug-free, without a doctor's examination.



Nursing Diagnosis



Imbalanced
nutrition more than body requirements related to



•      
Excessive intake in relation to metabolic need



•      
Sedentary activity level



•      
Cultural preferences



Interventions



•      
Assess risk or presence of conditions associated with obesity



•      
Assess patient understanding of direct relationship between hypertension
and obesity.



•      
Discuss necessity for decreased caloric intake and limited intake of
fats, salt, and sugar as indicated.



•      
Establish a realistic weight reduction plan with the patient such as 1
lb weight loss per wk.



•      
Encourage patient to maintain a diary of food intake, including when and
where eating takes place and the circumstances and feelings around which the
food was eaten.



•      
Instruct and assist in appropriate food selections, such as a diet rich
in fruits, vegetables, and low-fat dairy foods referred to as the DASH Dietary
Approaches to Stop Hypertension)