Chapter 27

Assessment and
Management of Patients
with Hypertension
Hypertension

❖High blood pressure

❖Most common chronic disease among U.S. adults
❖Defined by the American College of Cardiology
(ACC)/American Heart Association (AHA) as a
systolic blood pressure (SBP) of 130 mm Hg or
higher or a diastolic blood pressure (DBP) of 80 mm
Hg or higher

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Classification of Blood Pressure for Adults
Age 18 Years and Older

❖Normal Blood Pressure

o Systolic <120 mm Hg and Diastolic <80 mm Hg
❖Elevated Blood Pressure
o Systolic 120–129 mm Hg and Diastolic <80 mm
Hg
❖Stage 1 hypertension
o Systolic 130–129 mm Hg or Diastolic 80–89 mm
Hg
❖Stage 2 hypertension
o Systolic >140 mm Hg or Diastolic >90 mm Hg
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Incidence of Hypertension—“The Silent
Killer”

❖Primary hypertension: essential

o 90–95% of patients; unidentifiable cause
❖Secondary hypertension
o 5–10% of patients; renal disease, sleep apnea,
pregnancy related
❖About 33% of the adult population of the United
States has hypertension
❖About 46% do not have it under control
❖Highest prevalence in African Americans

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Manifestations of Hypertension

❖Usually no symptoms other than elevated blood

pressure
❖Symptoms related to organ damage are seen late
and are serious
o Retinal and other eye changes
o Renal damage
o Myocardial infarction
o Cardiac hypertrophy
o Stroke

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Pathophysiologic Processes

❖Can result from increases in cardiac output,

peripheral resistance, or both
❖Must also be a problem with the body’s control
system
❖Dysfunction of the autonomic nervous system
❖Increased renin–angiotensin–aldosterone system
❖Resistance to insulin action
❖Activation of the immune system

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Measuring Blood Pressure

❖Correct arm cuff size

❖Sit quietly with arm at the level of the heart
❖Confirmation of diagnosis by average of two blood
pressure readings
❖Can also evaluate lifestyle modifications and success
of prescription medications

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Alternative Manifestations

❖Masked hypertension
o Blood pressure that is suggestive of
hypertension that is paradoxically normal in
health care settings
❖White coat hypertension
o Hypertensive blood pressure readings in the
health care setting that is paradoxically normal
ranges in other settings

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Abnormal Physical Examination Findings

❖Absent or weak pulses

❖Additional cardiac sounds
❖Retinal hemorrhages
❖Distended jugular veins
❖Renal artery bruit

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Major Risk Factors

❖Hypertension
❖Smoking
❖Obesity
❖Physical inactivity
❖Dyslipidemia
❖Diabetes mellitus
❖Microalbuminuria or GFR <60 mL/min
❖Older age
❖Family history
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Patient Assessment

❖History and physical examination

o Retinal exam
❖Laboratory tests
o Urinalysis
o Blood chemistry
❖ECG

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Medical Management #1

❖Maintain blood pressure

o <130/80 mm Hg
❖Lifestyle modifications
o Weight reduction
o DASH diet, decreased sodium intake
o Regular physical activity
o Reduced alcohol consumption

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Medical Management #2

❖Pharmacologic therapy
o Decrease peripheral resistance, blood volume
o Decrease strength and rate of myocardial
contraction
❖Diuretics, beta-blockers, alpha1-blockers, combined
alpha- and beta-blockers, vasodilators, ACE
inhibitors, ARBs, calcium channel blockers,
dihydropyridines, and direct renin inhibitors

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Medication Treatment

❖Stage I hypertension:
o African American and patients >60 years:
calcium channel blocker or thiazide diuretic
o Non African American and patients <60 years:
ACE-I or ARB
❖Low doses are initiated, and the medication dosage
is increased gradually if blood pressure does not
reach target goal
❖Multiple medications may be needed to control blood
pressure

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Question #1

For patients with uncomplicated hypertension and no

specific indications for another medication, what is the
recommended initial medication?
A. Thiazide diuretic
B. Calcium channel blockers
C. Vasodilators
D. Angiotensin-converting enzyme (ACE) inhibitors

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Answer to Question #1

A. Thiazide diuretic

Rationale: For patients with uncomplicated

hypertension and no specific indications for another
medication, the recommended initial medication is
thiazide diuretics for most patients. If blood pressure
does not fall to less than 140/90 mm Hg, the dose is
increased gradually, and additional medications are
included as necessary to achieve control.

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Assessment

❖History and risk factors

❖Assess potential symptoms of target organ damage
o Angina, shortness of breath, altered speech,
altered vision, nosebleeds, headaches, dizziness,
balance problems, nocturia
o Cardiovascular assessment: apical and
peripheral pulses
❖Personal, social, and financial factors that will
influence the condition or its treatment

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Collaborative Problems and Potential
Complications

❖Left ventricular hypertrophy

❖Myocardial infarction
❖Heart failure
❖Transient ischemic attack (TIA)
❖Cerebrovascular disease (CVA, stroke, or brain
attack)
❖Renal insufficiency and chronic kidney disease
❖Retinal hemorrhage

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Planning and Goals

❖Understanding of the disease process and its

treatment
❖Participation in a self-care program
❖Absence of complications

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Interventions

❖Support and educate the patient about the

treatment regimen
❖Reinforce and support lifestyle changes
❖Taking medications as prescribed
❖Follow-up care
❖Monitoring for potential complications

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Evaluation and Outcomes #1

❖Reports knowledge of disease management

sufficient to maintain adequate tissue perfusion
o Maintains blood pressure at less than 130/80
mm Hg with lifestyle modifications, medications,
or both
o Demonstrates no symptoms of angina,
palpitations, or vision changes
o Has stable BUN and serum creatinine levels
o Has palpable peripheral pulses

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Evaluation and Outcomes #2

❖Effectively manages health program

o Adheres to the dietary regimen as prescribed:
reduces calorie, sodium, and fat intake;
increases fruit and vegetable intake
o Exercises regularly
o Takes medications as prescribed and reports
side effects
o Measures BP routinely
o Abstains from tobacco and excessive alcohol
intake
o Keeps follow‐up appointments
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Evaluation and Outcomes #3

❖ Has no complications
o Reports no changes in vision; exhibits no retinal
damage on vision testing
o Maintains pulse rate and rhythm and respiratory rate
within normal ranges; reports no dyspnea or edema
o Maintains urine output consistent with intake; has
renal function test results within normal range
o Demonstrates no motor, speech, or sensory deficits
o Reports no headaches, dizziness, weakness, changes
in gait, or falls

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Gerontologic Considerations

❖Medication regimen can be difficult to remember

❖Expense can be a challenge
❖Monotherapy, if appropriate, may simplify the
medication regimen and make it less expensive
❖Ensure that older adult patients understand the
regimen and can see and read instructions, open
medication containers, and get prescriptions refilled
❖Include family and caregivers in educational
program

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Question #2

The nurse is preparing an education plan for a patient

newly diagnosed with hypertension. Which of the
following should be included in the education plan?
A. Engage in regular aerobic physical activity such as
brisk walking (at least 30 min/day most days of the
week)
B. Eliminate alcoholic beverages from the diet
C. Reduce sodium intake to no more than 200
mmol/day
D. Maintain a normal body weight with BMI between
18 and 30 kg/m2

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Answer to Question #2

A. Engage in regular aerobic physical activity such as

brisk walking (at least 30 min/day most days of the
week).

Rationale: The nurse assists the patient to develop

and adhere to an appropriate exercise regimen (as
described above), because regular activity is a
significant factor in reducing blood pressure. Alcoholic
beverages can be consumed in moderation. Sodium
should be reduced to no more than 100 mmol/day,
and the patient should maintain a normal body weight
with a BMI between 18.5 and 24.9 kg/m2

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Hypertensive Crises

❖Hypertensive emergency
o Blood pressure >180/120 mm Hg and must be
lowered immediately to prevent further damage
to target organs
❖Hypertensive urgency
o Blood pressure >180/120 mm Hg but no
evidence of immediate or progressive target
organ damage

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Hypertensive Emergency

❖ Reduce blood pressure by no more than 25% in first hour

❖ Reduce to 160/100 mm Hg within 2 to 6 hours
❖ Then gradual reduction to normal 24 to 48 hours of
treatment
❖ Exceptions are ischemic stroke and aortic dissection
❖ Medications
o IV vasodilators: sodium nitroprusside, nicardipine,
fenoldopam mesylate, enalaprilat, nitroglycerin
❖ Need very frequent monitoring of BP and cardiovascular
status

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Hypertensive Urgency

❖Oral agents can be administered with the goal of

normalizing blood pressure within 24 to 48 hours
❖Fast-acting oral agents:
o Beta-adrenergic blocker—labetalol
o Angiotensin-converting enzyme inhibitor—
captopril
o Alpha2-agonist—clonidine
❖Patient requires close monitoring of blood pressure
and cardiovascular status
❖Assess for potential evidence of target organ
damage
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Question #3

Which of the following is a priority nursing assessment

when caring for the patient in a hypertensive crisis
receiving intravenous vasodilators?
A. Pain
B. I&O
C. Vision
D. Family history

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Answer to Question #3

B. I&O

Rationale: Assessing the individual’s fluid volume

status is recommended because if there is volume
depletion secondary to natriuresis caused by the
elevated blood pressure, then volume replacement
with normal saline can prevent large sudden drops in
blood pressure when antihypertensive medications are
administered.

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