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FOCUS ON HYPERTENSION

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Page 1: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

FOCUS ON HYPERTENSI

ON

Page 2: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONDEFINITION

Persistent elevation of Systolic blood pressure ≥140 mm Hg or Diastolic blood pressure ≥90 mm Hg or Current use of antihypertensive medication(s)

Page 3: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

PREHYPERTENSIONDEFINITION

Systolic blood pressure:120–139 mm Hg

Or

Diastolic blood pressure:80–89 mm Hg

Page 4: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

FACTORS INFLUENCING BLOOD PRESSURE (BP)

Blood Pressure

=

CardiacOutput

xSystemic VascularResistance

Page 5: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

FACTORS INFLUENCING BP

Page 6: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION CLASSIFICATIONS Primary hypertension

Also called idiopathic or essential Increased blood pressure without an

identified causeCovers 90-95% of all cases of HTN

Secondary hypertension Increased blood pressure with a specific

cause that can be identified and corrected

Page 7: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

CAUSES OF SECONDARY HTN Cirrhosis Narrowing of the aorta Endocrine disorders Medications Neurologic disorders Pregnancy induced HTN Renal disease Sleep apnea

Page 8: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

BLOOD PRESSURE CLASSIFICATION

Category SBP (mm Hg)

DBP (mm Hg)

Normal < 120 and < 80

Prehypertension 120–139 or 80–89

Stage 1 140–159 or 90–99

Stage 2 > 160 or > 100

Page 9: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION For persons over age 50, SBP is more

important than DBP as a CVD risk factor

Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN

Page 10: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

RISK FACTORS FOR PRIMARY HYPERTENSION

Age Alcohol Cigarette smoking Diabetes mellitus Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

Page 11: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCLINICAL MANIFESTATIONS

Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs

Page 12: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCLINICAL MANIFESTATIONS

Symptoms are often secondary to target organ disease and can include Fatigue, reduced activity toleranceDizzinessPalpitations, anginaDyspnea

Page 13: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOMPLICATIONS

Target organ diseases occur most frequently in theHeartBrainPeripheral vasculature KidneyEyes

Page 14: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOMPLICATIONS Hypertensive

heart diseaseCoronary artery

diseaseLeft ventricular

hypertrophyHeart failure

Fig. 33-3: Top, normal heart; Bottom, left ventricular hypertrophy

Page 15: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOMPLICATIONS

Cerebrovascular diseaseStroke

Peripheral vascular disease

Nephrosclerosis

Retinal damage

Page 16: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONDIAGNOSTIC STUDIES

History and physical examination

BP measurement in both armsUse arm with higher reading for subsequent

measurementsBP highest in early morning, lowest at night

Page 17: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONOFFICE BP MEASUREMENT

Use auscultatory method with a properly calibrated instrument

Patient should be seated quietly for 5 min in a chair, feet on the floor, and arm supported at heart level

Appropriate-sized cuff is necessary to ensure accurate reading

At least two measurements should be obtained

Page 18: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

The correct technique for blood pressure measurements includes

a) Always taking the blood pressure in both arms

b) Releasing the pressure in the cuff at a rate of 1 mm Hg per second

c) Inflating the cuff 5 mm Hg higher than the expected systolic pressure

d) Taking additional readings if the first two readings differ more than 10 mm Hg

Page 19: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONDIAGNOSTIC STUDIES

Urinalysis, creatinine clearance Serum electrolytes, glucose BUN and serum creatinine Serum lipid profile ECG Echocardiogram

Page 20: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONDIAGNOSTIC STUDIES

“White coat” phenomenon may precipitate the need for ambulatory blood pressure monitoring (ABPM)Uses a noninvasive, fully automated

system that measures BP at preset intervals over a 24-hour period

Page 21: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

TREATMENT ALGORITHM FOR HYPERTENSION

Page 22: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION COLLABORATIVE CARE Overall goals

Control blood pressureReduce CVD risk factors

Strategies for adherence to regimensEmpathy increases patient trust,

motivation, and adherence to therapyConsider patient’s cultural beliefs and

individual attitudes in formulating treatment goals

Page 23: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

BENEFITS OF LOWERING BP

Average Percent Reduction

Stroke incidence 35%–40%Myocardial infarction 20%–25%Heart failure 50%

Page 24: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Lifestyle modificationsWeight reduction:

Weight loss of 10 kg (22 lb) may decrease SBP by ~ 5 to 20 mm Hg

Dietary Approaches to Stop Hypertension (DASH) Diet Low sodium

<2.4 g of sodium/day Low fat Limited starchy foods Increased vegetable and fruit intake

Page 25: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Lifestyle modificationsModeration of alcohol consumption:

Men: no more than 2 drinks/day Women: no more than 1 drink/day

Physical activity: Regular physical (aerobic) activity, at least

30 minutes, most days of the week

Avoidance of tobacco products

Stress management

Page 26: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE Drug therapy:

Primary actions of drugs to treat hypertension Reduce SVR Reduce volume of circulating blood

Classifications of drugs used to treat HTN Diuretics Adrenergic inhibitors Direct vasodilators Angiotensin inhibitors Calcium channel blockers

Page 27: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Diuretics Inhibit NaCl reabsorption in the tubules Increases excretion of Na and ClPotassium-sparing diuretics reduce excretion of

K+Types:

Thiazide diuretics: hydrochlorothiazide (HydroDiuril), metolazone (Zaroxolyn)

Loop Diuretics: bumetanide (Bumex) furosemide (Lasix), torsemide

(Demadex) Potassium-sparing diuretics:

triamterene (Dyrenium) Aldosterone Receptor Blockers:

spironolactone (Aldactone)

Page 28: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE What will you monitor in patients taking

diuretics? I & ODaily WeightElectrolyte abnormalities

Potassium Sodium

BP Orthostatic hypotension

Ototoxicity (Lasix)Dizziness, vertigo

Page 29: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE Adrenergic inhibitors

Central-Acting α-1 Adrenergic Antagonists Reduce sympathetic outflow from CNS Reduces peripheral sympathetic tone,

produces vasodilation, decreases SVR and BP Types:

Clonidine (Catapress)Methyldopa (Aldomet)

Page 30: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE Adrenergic inhibitors

α-1 Adrenergic Blockers Block α-1 adrenergic effects, producing peripheral

vasodilation (decreases SVR and BP) Types:

Doxazosin (Cardura), Prozosin (Minipress), Terazosin (Hytrin)

β-Adrenergic Blockers Decrease CO and reduce vasoconstrictor tone Types:

Atenolol (Tenormin), metoprolol (Lopressor), propranolol (Inderal)

Page 31: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE What will you monitor in patients taking

Adrenergic-Blockers?Dry mouth

Central-Acting α-1 Adrenergic AntagonistsBP

Orthostatic hypotensionRetention of salt and water

α-1 adrenergic blockersBronchospasm

β-Adrenergic BlockersBradycardia

β-Adrenergic Blockers

Page 32: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Direct vasodilators Reduce SVR and BP by arterial vasodilation Types:

Hydralazine (Apresoline), nitroglycerin (Tridil), sodium nitroprusside (Nipride)

What will you monitor for? BP Tachycardia Flushing Palpitations Dizziness Angina Headache

Page 33: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Angiotensin inhibitors Angiotensin-Converting Enzyme (ACE)

Inhibitors Reduce conversion of Angiotensin I to

angiotensin II, prevent vasoconstriction Types: captopril (Capoten), enalapril (vasotec),

lisinopril (Prinivil)

Angiotensin II Receptor Blockers Prevent action of angiotensin II and produce

vasodilation and increased salt and water excretion Types: irbesartan (Avapro), valsartan (Diovan)

Page 34: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE What will you monitor?

Angiotensin-Converting Enzyme (ACE) Inhibitors BP Dizziness Loss of taste Hyperkalemia ARF

Angiotensin II Receptor Blockers Hyperkalemia Decreased RF

Page 35: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Calcium channel blockers Block movement of extracellular calcium into

cells, causing vasodilation and decreased HR, contractility, and SVR

Types: Amlodipine (Norvasc), diltiazem (Cardizem),

nifedipine (Procardia), verapamil (Calan)

What will you monitor?BPBradycardiaHeadache, dizziness, peripheral edema, flushing

Page 36: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCOLLABORATIVE CARE

Drug therapy and patient teaching Identify, report, and minimize side effects

Orthostatic hypotension Sexual dysfunction Dry mouth Frequent urination

Page 37: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT

Nursing AssessmentSubjective data

Past health history CV, renal, thyroid disease, DM, obesity

Medications Prescription and OTC

Functional health patterns Family history Diet Activity level Stress

Objective data Target organ damage

Peripheral pulses, abnormal heart sounds, BP >140/90

Page 38: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT

Nursing Diagnoses Ineffective health maintenance r/t lack of

knowledge

Anxiety r/t management regimen or lifestyle changes

Sexual dysfunction r/t medication side effects

Ineffective therapeutic regimen management r/t lack of knowledge, side effects of medications, return of blood pressure to normal while on medications

Ineffective tissue perfusion r/t complications of HTN (cerebral, CV, renal, retinal)

Page 39: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT Collaborative problems

Potential complications: Adverse effects from antihypertensive

therapy (hypokalemia) Hypertensive crisis Stroke Coronary artery disease (CAD) Myocardial infarction

Page 40: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISIS Severe, abrupt increase in DBP

defined as DBP >140 mm Hg

Rate of increase in BP is more important than the absolute value

Often occurs in patients with a history of HTN who have failed to comply with medications or who have been undermedicated

Page 41: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISIS Hypertensive Emergency

Develops within hours to days BP > 180/120 mm Hg Acute target organ damage May precipitate:

Hypertensive encephalopathy, cerebral hemorrhage

Acute renal failure Myocardial infarction Heart failure with pulmonary edema

Hyptertensive Urgency Develops within days to weeks No clinical evidence of target organ damage

Page 42: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISISCLINICAL MANIFESTATIONS

Hypertensive EmergencyHypertensive encephalopathy

Sudden rise in BP associated with HA, N/V, seizures, confusion, coma

May also have blurred vision and transient blindness Due to increased cerebral capillary permeability

leading to cerebral edema and disruption in cerebral function

Renal insufficiency

CV decompensation Unstable angina MI Pulmonary edema

Page 43: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Hospitalization

IV drug therapy Sodium nitroprusside (Nipride) – MOST EFFECTIVE

Titrated to mean arterial pressure

MAP =(SBP + 2 DBP)

3

Page 44: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Nursing Interventions

Monitor BP and HR every 3-5 minutesTitrate med based on MAPDO NOT DECREASE BP TO QUICKLY – may

cause stroke, MIContinual ECG monitoringHourly UOStrict BPNeurologic checks

LOC, pupil checks, movement and strength of extremities

CV and Respiratory assessment pulmonary edema, HF, angina

Page 45: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIVE CRISISNURSING AND COLLABORATIVE MANAGEMENT Hypertensive Urgency

Managed with oral medications Difficult to regulate drugs Need follow-up within 24 hours

May not need hospitalizationNursing Interventions

Provide quiet environment Encourage patient to verbalize concerns Answer questions Eliminate stimuli Determine cause Education to avoid future crises

Page 46: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT Planning: Patient will

Achieve and maintain the individually determined goal BP

Understand, accept, and implement the therapeutic plan

Experience minimal or no unpleasant side effects of therapy

Be confident of ability to manage and cope with this condition

Page 47: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT

Nursing ImplementationHealth Promotion

Individual patient evaluation Risk factors Routine BP Health assessment Weight patterns Family history

Blood pressure measurement Screening programs Cardiovascular risk factor modification

Modifiable: HTN, DM, obesity, tobacco cessation, physical inactivity

Page 48: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT

Nursing ImplementationAmbulatory and Home Care Patient and family teaching includes

Nutritional therapy Drug therapy Physical activity

30 minutes/day most days of week Home monitoring of BP (if appropriate)

Rest 3-5 minutes prior to taking BP No smoking, exercise or caffeine 30 minutes prior Take daily and record in log

Tobacco cessation (if applicable)

Page 49: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONNURSING MANAGEMENT

Nursing Evaluation Patient will

Achieve and maintain goal BP as defined for the individual

Understand, accept, and implement the therapeutic plan

Experience minimal or no unpleasant side effects of therapy

Page 50: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION IN OLDER PERSONS Isolated systolic hypertension (ISH) is the most

common form of hypertension in individuals age >50

The lifetime risk of developing hypertension is approximately 90% for middle-aged (age 55 to 65) and older (age >65) normotensive men and women

Why? Loss of elasticity, increased PVR, blunting of

baroreceptors, decreased renal function, decreased renin production

Page 51: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION IN OLDER PERSONS

Older adults are more likely to have “white coat” hypertension

Often a wide gap between the first Korotkoff sound and subsequent beats called the auscultatory gap

Failure to inflate the cuff high enough may result in seriously underestimating the SBP Assess disappearance of pulse upon inflation of cuff

Page 52: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSION IN OLDER PERSONS

Older adults have varying degrees of impaired baroreceptor reflex mechanisms

Consequently, orthostatic hypotension occurs often especially in patients with ISH Most commonly associated with volume depletion

or decreased renal or hepatic function

Page 53: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCULTURAL AND ETHNIC DISPARITIES

In general, treatment similar for all demographic and ethnic groups

Prevalence and severity of HTN increased in African Americans

Page 54: Persistent elevation of  Systolic blood pressure ≥140 mm Hg or  Diastolic blood pressure ≥90 mm Hg or  Current use of antihypertensive medication(s)

HYPERTENSIONCULTURAL AND ETHNIC DISPARITIES

Mexican Americans are less likely to receive treatment for hypertension than whites and African Americans

Mexican Americans and Native Americans have lower rates of BP pressure control than whites and African Americans