NURSING CARE PLAN / HYPERTENSION

[justify]Hypertension

Hypertension (high blood pressure) is a disease of vascular regulation in which the mechanisms that control arterial pressure within the normal range are altered. Predominant mechanisms of control are the central nervous system (CNS), the renal pressor system (renin-angiotensin-aldosterone system), and extracellular fluid volume. Why these mechanisms fail is not known. The basic explanation is that blood pressure is elevated when there is increased cardiac output plus increased peripheral vascular resistance.
Pathophysiology/Etiology
A. Primary or Essential Hypertension
(Approximately 90% of patients with hypertension)
1. When the diastolic pressure is 90 mm Hg or higher and other causes of hypertension are absent, the condition is said to be primary hypertension. More specifically, an individual is considered hypertensive when the average of three or more blood pressure readings taken at rest several days apart exceeds the upper limits of the following table:
2. Cause of essential hypertension is unknown; however, there are several areas of investigation:
a. Hyperactivity of sympathetic vasoconstricting nerves
b. Presence of blood component containing a vasoconstrictor that acts on smooth muscle, sensitizing it to constrictor substances
c. Increased cardiac output, followed by arteriole constriction
d. Prostaglandins affect regulatory mechanisms, which include the renin-angiotensin system, renal sodium and water excretion, and vascular smooth muscle tone.
e. Familial (genetic) tendency
3. Terminology to describe hypertension:
a. Labile—intermittently elevated blood pressure
b. Accelerated—sudden and severe escalation in arterial pressure, producing many symptoms and vascular damage
c. Resistant—hypertension that is not responsive to usual treatment
See Table 12-4
B. Secondary Hypertension
(Occurs in approximately 5% to 10% of patients with hypertension)
1. Follows other pathology
2. Renal pathology—may lead to hypertension
a. Congenital anomalies, pyelonephritis, renal artery obstruction, acute and chronic glomerulonephritis
b. Reduced blood flow to kidney (such as atherosclerotic plaque)—release of renin. Renin reacts with serum protein in liver (a2-globulin) angiotensin I; this plus angiotensin-converting enzyme (ACE) angiotensin II leads to increased blood pressure.
3. Coarctation of aorta (stenosis of aorta)—blood flow to upper extremities is greater than flow to lower extremities—hypertension of upper part of body.
4. Endocrine disturbances
a. Pheochromocytoma—a tumor of the adrenal gland that causes release of epinephrine and norepinephrine and a rise in blood pressure
b. Adrenal cortex tumors lead to an increase in aldosterone secretion and an elevated blood pressure.
c. Cushing's syndrome leads to an increase in adrenocortical steroids and hypertension.
d. Hyperthyroidism
C. Accelerated Hypertension—A Hypertensive Crisis
Blood pressure elevates very rapidly, threatening one or more of the target organs: brain, kidney, heart (see Accelerated Hypertension).
Prevalence and Risk Factors
1. Hypertension is one of the most prevalent chronic diseases for which treatment is available; however, most patients with hypertension are untreated.
2. There are no symptoms; thus, it is termed "the silent killer."
3. Increase in incidence is associated with the following risk factors:
a. Age—between 30 and 70
b. Race—African American
c. Birth control pills
d. Overweight
e. Family history
f. Smoking
g. Sedentary lifestyle
h. Stress
i. Diabetes mellitus
Clinical Manifestations
1. Usually asymptomatic
2. May cause headache, dizziness, blurred vision when greatly elevated
3. Blood pressure readings as stated in table, above
Diagnostic Evaluation
1. ECG—to determine effects of hypertension on the heart (left ventricular hypertrophy, ischemia) or presence of underlying heart disease
2. Chest x-ray—may show cardiomegaly
3. Proteinuria, elevated serum blood urea nitrogen (BUN) and creatinine levels—indicate kidney disease as a cause or effect of hypertension
4. Serum potassium—decreased in primary hyperaldosteronism; elevated in Cushing's syndrome, both causes of secondary hypertension
5. Urine for catecholamines—increased in pheo-chromocytoma
6. Renal scan to detect renal vascular diseases
Management
A. Lifestyle Modifications
1. Lose weight, if more than 10% above ideal weight.
2. Limit alcohol, no more than 1 oz ethanol daily
3. Get regular aerobic exercise 3 times per week.
4. Cut sodium intake to less than 2 g per day
5. Include recommended daily allowances of potassium, calcium and magnesium in diet.
6. Stop smoking.
7. Reduce dietary saturated fat and cholesterol.
8. If, despite lifestyle changes, the blood pressure remains at or above 140/90 mm Hg over 3 to 6 months, drug therapy should be initiated.
B. Drug Therapy .
1. Considerations in selecting therapy include:
a. Race—African Americans respond well to diuretic therapy; whites respond well to ACE inhibitors.
b. Age—some side effects may not be tolerated well by elderly persons.
c. Concommitant diseases and therapies—some agents also treat migraines, benign prostatic hyperplasia, CHF.
d. Quality of life impact—tolerance of side effects
e. Economic considerations—newer agents very expensive
f. Doses per day—may be compliance problem
2. Agents include:
a. Diuretics—lower blood pressure by promoting urinary excretion of water and sodium to lower blood volume
b. b Blockers—adrenergic inhibitors that lower blood pressure by slowing the heart and reducing cardiac output as well as release of renin from the kidneys
c. a-Receptor blockers—lower blood pressure by dilating peripheral blood vessels and lowering peripheral vascular resistance
d. Angiotensin—converting enzyme (ACE) inhibitors—lower blood pressure by blocking the enzyme that converts angiotensin I to the potent vasoconstrictor angiotensin II. These drugs also raise the level of bradykinin, a potent vasodilator and lower aldosterone levels.
e. Calcium antagonists (calcium channel blockers)—stop the movement of calcium into the cells; relax smooth muscle, which causes vasodilation; and inhibit reabsorption of sodium in the renal tubules
3. If hypertension is not controlled with the first drug within 1 to 3 months, three options can be considered:
a. If the patient has faithfully taken the drug and not developed any side effects, the dose of the drug may be increased.
b. If the patient has had adverse effects, another class of drugs can be substituted.
c. A second drug from another class could be added. If adding the second agent lowers the pressure, the first agent can be slowly withdrawn.
4. The best management of hypertension is to use the fewest drugs at the lowest doses while encouraging the patient to maintain lifestyle changes. After blood pressure has been under control for at least a year, a slow progressive decline in drug therapy can be attempted.
5. If the desired blood pressure is still not achieved with the addition of a second drug, a third agent or a diuretic or both (if not already prescribed) could be added. These supplemental agents include:
a. Centrally acting a2-agonists—lower blood pressure by diminishing sympathetic outflow from the brain thereby lowering peripheral resistance.
b. Peripheral adrenergic antagonists—inhibit peripheral adrenergic release of vasoconstricting catecholamines, such as norepinephrine.
c. Direct vasodilators—direct smooth muscle relaxants that primarily dilate arteries and arterioles
Complications
See Figure 12-10.
1. Angina pectoris or MI due to decreased coronary perfusion
2. Left ventricular hypertrophy and CHF due to consistently elevated aortic pressure
3. Renal failure due to thickening of renal vessels and diminished perfusion to the glomerulus
4. Stroke or cerebral hemorrhage due to cerebral ischemia and arteriosclerosis
5. Retinopathy
6. Accelerated Hypertension.
Nursing Assessment
A. Nursing History
Query the patient with regard to the following:
1. Family history of high blood pressure
2. Previous episodes of high blood pressure
3. Excessive salt intake
4. Lipid abnormalities
5. Smoking (cigarette)
6. Episodes of headache, weakness, muscle cramp, tingling, palpitations, sweating, visual disturbances
7. Medication that could elevate blood pressure:
a. Oral contraceptives, steroids
b. NSAIDs
c. Nasal decongestants, appetite suppressants, tricyclic antidepressants
8. Other disease processes such as gout or diabetes, asthma, peptic ulcer
B. Physical Examination
1. Auscultate heart rate and palpate peripheral pulses; determine respirations.
2. If skilled in doing so, perform funduscopic examination of the eyes for the purpose of noting vascular changes. Look for edema, spasm, and hemorrhage of the eye vessels.
3. Examine the heart for a shift of the point of maximal impulse to the left, which occurs in heart enlargement.
4. Auscultate for bruits over peripheral arteries to determine the presence of atherosclerosis, which may be manifested as obstructed blood flow.
5. Determine mentation status by asking patient about memory, ability to concentrate, and ability to perform simple mathematic calculations.
C. Blood Pressure Determination
1. Measure the blood pressure of the patient under the same conditions each time.
2. Avoid taking blood pressure readings immediately after stressful or taxing situations.
3. Place the patient in a position of comfort.
4. Support the bared arm; avoid constriction of arm by a rolled sleeve.
5. Use a blood pressure cuff of the correct size (Table 12-3).
a. It is recommended that the width of the cuff be 20% greater than the width of the measured extremity.
b. The length should be sufficient to encircle the measured extremity.
c. The average dimensions for an adult cuff are 13 cm wide by 24 cm long.
6. Be aware that falsely elevated blood pressures may be obtained with a cuff that is too narrow; falsely low readings may be obtained with a cuff that is too wide.
7. Auscultate and record precisely the systolic and diastolic pressures based on Korotkoff sounds.
a. Systolic—the pressure within the cuff indicated by the level of the mercury column at the moment when the first clear, rhythmic pulsatile sound is heard (phase 1)
b. First diastolic—the pressure within the cuff indicated by the level of the mercury column at the moment when the sound becomes muffled (phase 4)
c. Second diastolic—the pressure within the cuff at the moment the sound disappears, that is, the onset of silence (phase 5)
d. Phases 2 and 3 are less distinct sounds produced between systolic and first diastolic and are not identified clinically nor recorded.
NURSING ALERT:
The finding of an isolated elevated blood pressure does not necessarily indicate hypertension. However, the patient should be regarded at risk for high blood pressure until further assessment through history taking and diagnostic testing either confirms or denies the diagnosis.
Nursing Diagnoses
A. Knowledge Deficit regarding the relationship between the treatment regimen and control of the disease process
B. Ineffective Management of Therapeutic Regimen related to medication side effects and difficult lifestyle adjustments
Nursing Interventions/Patient Education
A. Providing Basic Education
1. Explain the meaning of high blood pressure, risk factors, and their influences on the cardiovascular, cerebral, and renal systems.
2. Stress that there can never be total cure, only control of essential hypertension; emphasize the consequences of uncontrolled hypertension.
3. Stress the fact that there may be no correlation between high blood pressure and symptoms; the patient cannot tell by the way he or she feels whether blood pressure is normal or elevated.
4. Have the patient recognize that hypertension is chronic and requires persistent therapy and periodic evaluation; effective treatment improves life expectancy; therefore, follow-up health care visits are mandatory.
5. Present a coordinated and complementary plan of guidance.
a. Inform the patient of the meaning of the various diagnostic and therapeutic activities to minimize anxiety and to obtain cooperation.
b. Solicit the assistance of the patient's spouse/ family/friend—provide information regarding the total treatment plan.
c. Be aware of the dietary plan developed for this particular patient.
6. Explain the pharmacologic control of hypertension.
a. Explain that the drugs used for effective control of elevated blood pressure will likely produce side effects.
b. Warn the patient of the possibility that hypotension may occur after the intake of certain drugs.
(1) Instruct the patient to get up slowly to offset the feeling of dizziness.
(2) Encourage the patient to lie down immediately if feels faint.
c. Alert the patient to expect effects such as nasal congestion, asthenia (loss of strength), anorexia (loss of appetite), and orthostatic hypotension (dizziness on changing position).
d. Inform the patient that the goal of treatment is to control blood pressure, reduce the possibility of complications, and use the minimum number of drugs with lowest dosage necessary to accomplish this.
7. Educate the patient to be aware of toxic manifestations and report them so that adjustments can be made in individual pharmacotherapy.
a. Note that dosages are individualized; therefore, they may need to be adjusted because it is often impossible to predict reactions.
b. Remember that certain circumstances produce vasodilation—a hot bath, hot weather, febrile illness, consumption of alcohol.
c. Be aware that blood pressure is decreased when circulating blood volume is reduced—dehydration, diarrhea, hemorrhage.
d. Consider the presence of edema as a reportable symptom, particularly when guanethidine is taken; these medications are less effective in the presence of edema.
GERONTOLOGIC ALERT:
The multiple drugs required to control blood pressure may be difficult for the elderly patient to comprehend. The names of drugs are frequently difficult for the patient to pronounce. Color coding of medication bottles with an accompanying color-coded time of administration chart is one way to assist the patient in remembering when to take medications. Elderly patients are also more sensitive to therapeutic levels of drugs and may demonstrate side effects while on an otherwise average dosage. They may be more sensitive to postural hypotension and should be cautioned to change positions with great care.
B. Encouraging Self-Management
1. Enlist the patient's cooperation in redirecting lifestyle in keeping with the guidelines of therapy.
a. Present a written instructional program to fit individual requirements.
b. Reassure the patient when encouragement is needed; the modifications required must appear meaningful.
c. Encourage patient in adapting and adjusting activities in line with the prescribed therapeutic regimen.
2. Develop a plan of instruction to be practiced by the patient at home.
a. Instruct the patient regarding proper method of taking blood pressure at home and at work if health care provider so desires. Inform patient of the readings that are to be reported.
b. Plan the patient's medication schedule so that the many medications are given at proper and convenient times; set up a daily checklist on which the patient can record the medication taken.
c. Determine recommended dietary plans.
Evaluation
A. Demonstrates increased knowledge about high blood pressure, medication effects, and prescribed therapeutic activities
B. Adheres to therapeutic regimen by limiting sodium intake, exercising, conscientiously taking medications, and keeping follow-up appointments[/justify]

NURSING CARE PLAN / HYPERTENSION

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