HYPERTENSION
NURSING CARE MANAGEMENT
ARIF SETYO UPOYO
LEARNING OBJECTIVE
Student explain :
• What is Hypertension?
• Classification
• Causes
• Pathophysiology
• Clinical Manifestations
• Prevention
• Complications
• Assessment and Diagnostic Findings
• Medical Management
• Nursing Management
• Evidanced based research in hypertension
Key fact ( WHO, 2021 )
• Hypertension ̶ or elevated blood pressure ̶ is a serious medical condition that
significantly increases the risks of heart, brain, kidney and other diseases.
• An estimated 1.28 billion adults aged 30-79 years worldwide have hypertension,
most (two-thirds) living in low- and middle-income countries
• An estimated 46% of adults with hypertension are unaware that they have the
condition.
• Less than half of adults (42%) with hypertension are diagnosed and treated.
• Approximately 1 in 5 adults (21%) with hypertension have it under control.
• Hypertension is a major cause of premature death worldwide.
• One of the global targets for noncommunicable diseases is to reduce the
prevalence of hypertension by 33% between 2010 and 2030.
INDONESIA
• Based on Riskesdas 2018, the prevalence of hypertension based on measurement results
in the population aged 18 years was 34.1%, the highest was in South Kalimantan (44.1%),
while the lowest was in Papua (22.2%). Hypertension occurs in the age group 31-44
years (31.6%), age 45-54 years (45.3%), age 55-64 years (55.2%).
• From the prevalence of hypertension of 34.1%, it was known that 8.8% were diagnosed
with hypertension and 13.3% of people diagnosed with hypertension did not take
medication and 32.3% did not take medication regularly. This shows that most people
with hypertension do not know that they are hypertension so they do not get treatment.
• The reasons people with hypertension do not take medication are because people with
hypertension feel healthy (59.8%), irregular visits to health facilities (31.3%), taking
traditional medicine (14.5%), using other therapies (12.5%) ), forgetting to take medicine
(11.5%), unable to buy medicine (8.1%), drug side effects (4.5%), and hypertension
medicine is not available at HEALTH SERVICE FACILITY (2%).
What is Hypertension?
• Blood pressure is the force exerted by circulating blood against the walls
of the body’s arteries, the major blood vessels in the body. Hypertension is
when blood pressure is too high.
Blood pressure is written as two numbers. The first (systolic) number
represents the pressure in blood vessels when the heart contracts or
beats. The second (diastolic) number represents the pressure in the
vessels when the heart rests between beats.
Hypertension is diagnosed if, when it is measured on two different days,
the systolic blood pressure readings on both days is ≥140 mmHg and/or
the diastolic blood pressure readings on both days is ≥90 mmHg.
Classification
Types of hypertension
• Essential hypertension
• 95%
• No underlying cause
• Secondary hypertension
• Underlying cause
Causes
The factors that are implicated as causes of hypertension are:
• Increased sympathetic nervous system activity. Sympathetic nervous system activity
increases because there is dysfunction in the autonomic nervous system.
• Increase renal reabsorption. There is an increase reabsorption of sodium, chloride, and
water which is related to a genetic variation in the pathways by which the kidneys
handle sodium.
• Increased RAAS activity. The renin-angiotensin-aldosterone system increases its activity
leading to the expansion of extracellular fluid volume and increased systemic vascular
resistance.
• Decreased vasodilation of the arterioles. The vascular
endothelium is damaged because of the decrease in the vasodilation of the arterioles.
RISK FACTORS
• Modifiable risk factors • Non-modifiable risk
include unhealthy diets factors include a
(excessive salt family history of
consumption, a diet high hypertension, age over
in saturated fat and trans 65 years and co-
fats, low intake of fruits existing diseases such
and vegetables), physical as diabetes or kidney
inactivity, consumption of disease.
tobacco and alcohol, and
being overweight or
obese.
Pathophysiology
In a normal circulation, pressure is transferred from the heart muscle to the
blood each time the heart contracts and then pressure is exerted by the
blood as it flows through the blood vessels. The pathophysiology of
hypertension follows.
• Hypertension is a multifactorial
• When there is excess sodium intake, renal sodium retention occurs,
which increases fluid volume resulting in increased preload and increase
in contractility.
• Obesity is also a factor in hypertension because hyperinsulinemia
develops and structural hypertrophy results leading to increased
peripheral vascular resistance.
• Genetic alteration also plays a role in the development of hypertension
because when there is cell membrane alteration, functional constriction
may follow and also results in increased peripheral vascular resistance.
PHISIOLOGY
•BLOOD PRESSURE = CO X PR
•CO = STROKE VOLUME X HR
Haemodynamic Pattern in Hypertension
Young : BP = CO X TPR
Elderly : BP = CO X TPR
Clinical Manifestations
Many people who have hypertension are asymptomatic at first. Physical
examination may reveal no abnormalities except for an elevated blood
pressure, so one must be prepared to recognize hypertension at its earliest.
• Headache. The red blood cells carrying oxygen is having a hard time
reaching the brain because of constricted vessels, causing headache.
• Dizziness occurs due to the low concentration of oxygen that reaches
the brain.
• Chest pain. Chest pain occurs also due to decreased oxygen levels.
• Blurred vision. Blurred vision may occur later on because of too much
constriction in the blood vessels of the eye that red blood cells carrying
oxygen cannot pass through.
Prevention of hypertension
Mainly relies on a healthy lifestyle and self-discipline.
• Weight reduction. Maintenance of normal body weight can help prevent
hypertension.
• Adopt DASH. DASH or the Dietary Approaches to Stop Hypertension
includes consummation of a diet rich in fruits, vegetable, and low-fat dairy.
• Dietary sodium retention. Sodium contributes to an elevated blood
pressure, so reducing the dietary intake to no more than 2.4 g sodium per
day can be really helpful.
• Physical activity. Engage in regular aerobic physical activity for 30 minutes
thrice every week.
• Moderation of alcohol consumption. Limit alcohol consumption to no
more than 2 drinks per day in men and one drink for women and people
who are lighter in weight.
Complications
If hypertension is left untreated, it could progress to complications of
the different body organs.
• Heart failure. With increased blood pressure, the heart pumps
blood faster than normal until the heart muscle goes weak from
too much exertion.
• Myocardial infarction. Decreased oxygen due to constriction of
blood vessels may lead to MI.
• Stroke
• Impaired vision. Ineffective peripheral perfusion affects the eye,
causing problems in vision because of decreased oxygen.
• Renal failure. Blood carrying oxygen and nutrients could not reach
the renal system because of the constricted blood vessels.
Assessment
• Assess the patient’s health history
• Perform physical examination as appropriate.
• The retinas are examined to assess possible
organ damage.
• Laboratory tests are also taken to check target
organ damage.
Diagnostic Tests
• Urinalysis is performed to check the concentration of sodium in the urine though the
specific gravity.
• Blood chemistry (e.g. analysis of sodium, potassium, creatinine, fasting glucose, and
total and high density lipoprotein cholesterol levels). These tests are done to determine
the level of sodium and fat in the body.
• 12-lead ECG. ECG needs to be performed to rule presence of cardiovascular damage.
• Echocardiography. Echocardiography assesses the presence of left ventricular
hypertrophy.
• Creatinine clearance. Creatinine clearance is performed to check for the level of BUN
and creatinine that can determine if there is renal damage or not.
• Renin level. Renin level should be assessed to determine how RAAS is coping.
• Hemoglobin/hematocrit: Not diagnostic but assesses relationship of cells to fluid
volume (viscosity) and may indicate risk factors such as hypercoagulability, anemia.
• Blood urea nitrogen (BUN)/creatinine: Provides information about renal
perfusion/function.
• Glucose: Hyperglycemia (diabetes mellitus is a precipitator of hypertension) may result
from elevated catecholamine levels (increases hypertension).
Diagnostic Tests
• Serum potassium: Hypokalemia may indicate the presence of primary aldosteronism (cause) or be
a side effect of diuretic therapy.
• Serum calcium: Imbalance may contribute to hypertension.
• Lipid panel (total lipids, high-density lipoprotein [HDL], low-density lipoprotein [LDL],
cholesterol, triglycerides, phospholipids): Elevated level may indicate predisposition for/presence
of atheromatous plaques.
• Thyroid studies: Hyperthyroidism may lead or contribute to vasoconstriction and hypertension.
• Serum/urine aldosterone level: May be done to assess for primary aldosteronism (cause).
• Urinalysis: May show blood, protein, or white blood cells; or glucose suggests renal dysfunction
and/or presence of diabetes.
• Creatinine clearance: May be reduced, reflecting renal damage.
• Urine vanillylmandelic acid (VMA) (catecholamine metabolite): Elevation may indicate presence
of pheochromocytoma (cause); 24-hour urine VMA may be done for assessment of
pheochromocytoma if hypertension is intermittent.
Diagnostic Tests
• Uric acid: Hyperuricemia has been implicated as a risk factor for the development of
hypertension.
• Renin: Elevated in renovascular and malignant hypertension, salt-wasting disorders.
• Urine steroids: Elevation may indicate hyperadrenalism, pheochromocytoma, pituitary
dysfunction, Cushing’s syndrome.
• Intravenous pyelogram (IVP): May identify cause of secondary hypertension, e.g., renal
parenchymal disease, renal/ureteral calculi.
• Kidney and renography nuclear scan: Evaluates renal status (TOD).
• Excretory urography: May reveal renal atrophy, indicating chronic renal disease.
• Chest x-ray: May demonstrate obstructing calcification in valve areas; deposits in and/or
notching of aorta; cardiac enlargement.
• Computed tomography (CT) scan: Assesses for cerebral tumor, CVA, or
encephalopathy or to rule out pheochromocytoma.
• Electrocardiogram (ECG): May demonstrate enlarged heart, strain patterns, conduction
disturbances. Note: Broad, notched P wave is one of the earliest signs of hypertensive
heart disease.
Pharmacologic Therapy
• The medications used for treating hypertension decrease peripheral resistance, blood
volume, or the strength and rate of myocardial contraction.
• For uncomplicated hypertension, the initial medications recommended are diuretics and
beta blockers.
• Only low doses are given, but if blood pressure still exceeds 140/90 mmHg, the dose is
increased gradually.
• Thiazide diuretics decrease blood volume, renal blood flow, and cardiac output.
• ARBs are competitive inhibitors of aldosterone binding.
• Beta blockers block the sympathetic nervous system to produce a slower heart rate
and a lower blood pressure.
• ACE inhibitors inhibit the conversion of angiotensin I to angiotensin II and lowers
peripheral resistance.
Goals of Therapy
▪Reduce Cardiac and renal morbidity and mortality.
▪ Treat to BP <140/90 mmHg or BP <130/80 mmHg in
patients with diabetes or chronic kidney disease.
Non pharmacological
Treatment of hypertension
DASH
diet
Regular exercise
Loose weight , if obese
Reduce salt and high fat diets
Avoid harmful habits ,smoking ,alcohal
Life style modifications
• Lose weight, if overweight
• Increase physical activity
• Reduce salt intake
• Stop smoking
• Limit intake of foods rich in fats and cholesterol
• increase consumption of fruits and vegetables
• Limit alcohol intake
Lifestyle Modification
Modification Approximate SBP reduction
(range)
Weight reduction 5–20 mmHg / 10 kg weight loss
Adopt DASH eating 8–14 mmHg
plan
Dietary sodium 2–8 mmHg
reduction
Physical activity 4–9 mmHg
Moderation of alcohol 2–4 mmHg
consumption
Antihypertensive
Drugs
AT1 receptor
ARB Continue….
Algorithm for
Treatment of Hypertension
Lifestyle Modifications
Not at Goal Blood Pressure (<140/90 mmHg)
(<130/80 mmHg for those with diabetes or chronic kidney disease)
Initial Drug Choices
Without Compelling With Compelling
Indications Indications
Stage 1 Hypertension Stage 2 Hypertension Drug(s) for the compelling
(SBP 140–159 or DBP 90–99 mmHg) (SBP >160 or DBP >100 mmHg) indications
Thiazide-type diuretics for most. 2-drug combination for most (usually Other antihypertensive drugs (diuretics,
May consider ACEI, ARB, BB, CCB, thiazide-type diuretic and ACEI, ARB, BB, CCB)
or combination. ACEI, or ARB, or BB, or CCB) as needed.
Not at Goal
Blood Pressure
Optimize dosages or add additional drugs
until goal blood pressure is achieved.
Consider consultation with hypertension specialist.
• Stage 1 Hypertension
• Thiazide diuretic is recommended for most and angiotensin-
converting enzyme-1, aldosterone receptor blocker, beta
blocker, or calcium channel blocker is considered.
• Stage 2 Hypertension
• Two-drug combination is followed, usually including thiazide
diuretic and angiotensin-converting enzyme-1, or beta-blocker,
or calcium channel blocker.
Nursing Assessment
Nursing assessment must involve careful monitoring of the blood
pressure at frequent and routinely scheduled intervals.
• If patient is on antihypertensive medications, blood pressure is
assessed to determine the effectiveness and detect
changes in the blood pressure.
• Complete history should be obtained to assess for signs and
symptoms that indicate target organ damage.
• Pay attention to the rate, rhythm, and character of the apical
and peripheral pulses.
NURSING DIAGNOSIS
• Deficient knowledge regarding the relation between the
treatment regimen and control of the disease process.
• Noncompliance with the therapeutic regimen related to side
effects of the prescribed therapy.
• Risk for activity intolerance related to imbalance between
oxygen supply and demand.
• Risk for Decreased Cardiac Output
• Acute Pain
• Ineffective Coping
NURSING GOALS
• Understanding of the disease process and its treatment.
• Participation in a self-care program.
• Absence of complications.
• BP within acceptable limits for individual.
• Cardiovascular and systemic complications
prevented/minimized.
• Disease process/prognosis and therapeutic regimen
understood.
• Necessary lifestyle/behavioral changes initiated.
• Plan in place to meet needs after discharge.
Nursing Interventions
The objective of nursing care focuses on lowering and controlling the blood pressure without adverse
effects and without undue cost.
• Encourage the patient to consult a dietitian to help develop a plan for improving nutrient intake or
for weight loss.
• Encourage restriction of sodium and fat
• Emphasize increase intake of fruits and vegetables.
• Implement regular physical activity.
• Advise patient to limit alcohol consumption and avoidance of tobacco.
• Assist the patient to develop and adhere to an appropriate exercise regimen.
• Reducing and managing stress.
• Regularly checking blood pressure.
• Treating high blood pressure (MAKE SURE MEDICINE IS TAKEN ACCORDING TO THE
DOCTOR'S PRECISION)
• MONITOR other medical conditions.
Evaluation
At the end of the treatment regimen, the following are expected to be achieved:
• Maintain blood pressure at less than 140/90 mmHg with lifestyle
modifications, medications, or both.
• Demonstrate no symptoms of angina, palpitations, or visual changes.
• Has stable BUN and serum creatinine levels.
• Has palpable peripheral pulses.
• Adheres to the dietary regimen as prescribed.
• Exercises regularly.
• Takes medications as prescribed and reports side effects.
• Measures blood pressure routinely.
• Abstains from tobacco and alcohol intake.
• Exhibits no complications.
Discharge and Home Care Guidelines
Following discharge, the nurse should promote self-care and independence
of the patient.
• The nurse can help the patient achieve blood pressure control
through education about managing blood pressure.
• Assist the patient in setting goal blood pressures.
• Provide assistance with social support.
• Encourage the involvement of family members in the education
program to support the patient’s efforts to control hypertension.
• Provide written information about expected effects and side effects.
• Encourage and teach patients to measure their blood pressures at home.
• Emphasize strict compliance of follow-up check up.
Self-Measurement of BP
▪ Provides information on:
1. Response to antihypertensive therapy
2. Improving adherence with therapy
3. Evaluating white-coat HTN
▪ Home measurement of >135/85 mmHg is generally
considered to be hypertensive.
▪ Home measurement devices should be checked
regularly.
Measuring Blood Pressure
• Patient seated quietly for at least 5minutes in a
chair, with feet on the floor and arm supported at
heart level
•An appropriate-sized cuff (cuff bladder
encircling at least 80% of the arm)
•At least 2 measurements
Continue…
Measuring Blood Pressure
• Systolic Blood Pressure is the point at which
the first of 2 or more sounds is heard
• Diastolic Blood Pressure is the point of
disappearance of the sounds (Korotkoff 5th)
Continue…