Concept of Hypertension | CHAPTER-13 | Medical and Surgical Nursing

Concept of Hypertension – This course is designed to understand the concept of community health nursing: nurses’ roles and interventions in family health, school health, occupational health, environmental health, elderly health care, gender issues, disaster management and principles and terminology of epidemiology. The aim of the course is to acquire knowledge and skills in community health nursing.

Concept of Hypertension

Definition of Hypertension

It is the level of blood pressure at which the institution of therapy reduce BP related morbidity & mortality.

(Ref: Harison-2047/18th)

Or,

When arterial pressure (diastolic) rises above its normal level (90 mm of Hg) in the resting supine subject. Then this condition is called hypertension. Hypertension Systolic BP>120 mm of Hg and diastolic BP>80 mm of Hg.

Types/Grading Of Hypertension

(Ref by: Davidson’s 234/607 Box No-18.85)

Causes of Hypertension

A. Primary or essential hypertension

a) Genetic factors. (40-60%)

b) Environmental factors

• Obesity
• Alcohol intake
• Salt intake

c) Humoral factors

• Catecholamines
• Renin angiotensin system
• Atrial natriuretic peptide

B. Secondary hypertension

a) Alcohol

b) Obesity

c) Pregnancy (Pre-eclampsia)

d) Renal causes

• Renal vascular disease – Renal artery stenosis.
• Parenchymal renal disease: – Glomerulonephritis.
• Polycystic kidney disease.

e) Endocrine causes

• Phaeochromocytoma
• Cushing’s syndrome
• Primary hyper-aldosteronism (Conn’s syndrome)
• Adrenal hyperplasia
• Acromegaly
• Hyper-parathyroidism
• Primary hypothyroidism
• Thyrotoxicosis
• Congenital adrenal hyperplasia due to 11 -beta hydroxylase or 17 hydroxylase deficiency.
• Liddle’s syndrome
• 11-beta hydroxysteriod dehydrogenase deficiency.

f) Drugs

• Oral contraceptive pill containing oestrogens.
• Anabolic steroids
• NSAIDs
• Carbenoxolone
• Corticosteriod.
• Sympathomimetic agents

g) Coarctation of the aorta

h) Obstructive sleep apnea.

(Ref by: Davidson’s 23rd/607 Box No-18.86)

Pathophysiological Condition of Hypertension

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.

1. Hypertension is a multifactorial

2. When there is excess sodium intake, renal sodium retention occurs, which increases fluid volume resulting in increased preload and increase in contractility.

3. Obesity is also a factor in hypertension because hyperinsulinemia develops and structural hypertrophy results leading to increased peripheral vascular resistance.

4. 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

Or,

Increase vasoconstriction or increase circulatory blood volume

↓

Hypertrophy and hyperplasia of arterial muscle

↓

Permanent narrowing of the lumen

↓

Injury of the vascular endothelium

↓

Inflammation release mediators

↓

Na, Ca, Water, Plasma, Protein enter into vessel walls

↓

Causing further thickening

↓

Hypertension

Preventive Measure/ Advice to Prevent Hypertension

A. Developing a healthy diet: A heart-healthy diet is vital for helping reduce high blood pressure. It’s also important for managing hypertension that is under control, and reducing the risk of complications. These complications include heart disease, stroke, and heart attack. A heart-healthy diet emphasizes foods that include:

• Fruits
• Vegetables
• Whole grains
• Lean proteins like fish

B. Increasing physical activity: Reaching a healthy weight should include being more physically active. In addition to helping you shed pounds, exercise can help reduce stress, lower blood pressure naturally, and strengthen your cardiovascular system. Aim to get 150 minutes of moderate physical activity each week. That’s about 30 minutes five times per week.

C. Reaching a healthy weight: If you are overweight or obese, losing weight can help lower your blood pressure.

D. Managing stress: Exercise is a great way to manage stress. Other activities can also be helpful. These include:

• Meditation
• Deep breathing
• Massage
• Muscle relaxation

These are all proven stress-reducing techniques. Getting adequate sleep can also help reduce stress levels.

E. Adopting a cleaner lifestyle: If you’re a smoker, try to quit. Tobacco damages and hardens blood vessel walls. If you regularly consume too much alcohol or have an alcohol dependency, seek help to reduce the amount you drink or stop altogether. Alcohol can raise blood pressure.

Classification of Anti-Hypertensive Drug

Anti-hypertensive drug are medicines that help lower blood pressure

History

• Family history
• History
• Lifestyle (exercise, salt intake, smoking habit)
• Drug or alcohol intake
• Secondary hypertension

Clinical Features of Hypertension

A. Symptoms

1. Mostly Asymptomatic

2. Angina pain

3. Breathlessness due to LVF

4. Blurring of vision

5. Headache

6. Vertigo

7. Palpitation

8. Polyurea

9. Dizziness

10. Aching pain in the back of neck (if BP is severe)

B. Sign’s

1. Persistent rise of blood pressure (hypertension)

2. Left ventricular hypertrophy – Apical heave, downwards and outwards displacement of apex beat.

3. Accentuation of the aortic component of the second heart sound, and a fourth heart sound.

4. Signs of complication, eg, hypertensive retinopathy

5. Signs of etiological factors:

• Coarctation of aorta – Radio-femoral delay
• Polycystic kidney disease – Palpable both kidneys
• Renal artery stenosis – Renal bruit
• Cushing syndrome – Characteristic facies and habitus.

Investigation

For all patients

• Urine analysis: Protein, glucose, haematuria
• Chest X-ray: Cardiomegaly, heart failure, rib notching (in coarctation)
• ECG: LVH, ischemia
• Plasma lipid profile:
• Plasma urea or creatinine
• Plasma electrolytes: Hypokalaemic alkalosis (hyper aldosteronism)

For high risk patient

• Chest X-ray
• Ambulatroy BP recording
• Echocardiogram
• Renal ultrasound
• Renal angiography
• Urinary catecholamines
• Urinary cortisol and dexamethasone suppression test
• Plasma rennin activity and aldosterone

(Ref by-Davidson/22/608)

Management of Hypertension

General management

1. Diet

• Restriction of salt, Avoid fatty and spicy food
• Reduce heavy alcohol consumption
• Add potassium and oily fish

2. Stop smoking

3. Regular exercise

4. Weight reduction

5. Relaxation like praying, Meditation

Antihypertensive drugs therapy

1. Diuretics

a) Thiazide diuretics

• Bendrofluazide 2.5 mg daily, or
• Cyclopenthiazide 0.5 mg daily

b) Loop diuretics:

• Frusemide 40 mg daily, or
• Bumetanide 1-2 mg daily (it is helpful in patients with renal or cardiac impairment and in combination with ACE inhibitors.

c) ẞ-adrenoceptor antagonists:

d) Cardio selective drugs (ẞ1 antagonist):

• Atenolol 50-100 mg daily, or
• Metoprolol 100-200 mg daily, or

e) Non-cardio selective drugs:

• Propranolol 40-120 mg orally 3 time a day, or
• Pindolol 15-30 mg daily, or
• Oxprenolol 160-320 mg daily

f) Labetalol (Combined a & ẞ adrenoceptor antagonist) 100-200 mg twice daily.

g) Angiotensin converting enzyme (ACE) inhibitors: (ACE inhibitor is the drug of choice in diabetes)

h) Captopril 25-75 mg 12 hourly, or

i) Enalapril 20 mg daily, or

j) Lisinopril 10mg daily

k) Calcium antagonists:

i) Diltiazem 60 mg 8 hourly, or

m) Amlodipine 5-10 mg daily, or

n) Nifedipine 20 mg twice daily

o) Other drugs:

p) Prazosin 0.5-20 mg daily in divided doses

q) Indoramin 25-100 mg 12 hourly

r) Doxazosin 1-16 mg daily.

(Ref by-Davidson/234/609)

Complication of Hypertension

A. Central nervous system

• Stroke
• Transient ischemic attack (TIA)
• Carotid atheroma
• Sub-arachnoid hemorrhage
• Hypertensive encephalopathy

B. Eye

• Hypertensive retinopathy
• Central retinal vein thrombosis

C. Heart

• Left ventricular hypertrophy (LVH) leading to LVF.
• Left heart failure
• Angina, myocardial ischemia and infarction
• Atrial fibrillation

D. Blood vessels

• The vessels dilate and become tortuous and their walls become less compliant.
• Aortic aneurysm
• Aortic dissection
• Wide spread atheroma

E. Kidney

• Proteinuria
• Progressive renal failure (in long standing hypertension)

Nursing Management of Hypertension

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.

Diagnosis

Based on the assessment data, nursing diagnoses may include the following:

• 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-prone health behavior related to condition requiring change in lifestyle.

Nursing Care Plan and Goals

• The major goals for a patient with hypertension are as follows:
• 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 Priorities

• Maintain/enhance cardiovascular functioning.
• Prevent complications.
• Provide information about disease process/prognosis and treatment regimen.
• Support active patient control of condition.

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.

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 checkup.

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