Care of the Patient with Hypertension

Prepared By:
Fatima Aryan, RN, MSN, CNS
How body control the blood pressure
 Blood pressure
• is the amount of force on the
• walls of the arteries as the blood
• circulates around the body.
 Hypertension according to AHA
• is defined as a persistent systolic BP (SBP) of 140 mm Hg or more, diastolic BP (DBP) of 90 mm Hg or
more, or current use of antihypertensive medication.
• Prehypertension is defined as SBP of 120 to 139 mm Hg or DBP of 80 to 89 mm Hg.
• BP of ›130/85 in individuals with diabetes and/or renal impairment
systolic blood pressure of 130 mm Hg and/or a diastolic blood pressure of 85 mm Hg or higher
• Hypertension mean that the heart is working harder than both the heart and the blood vessel under stair.
• There is direct relationship between hypertension and cardiovascular disease
• It is the major cause of heart failure, stroke, and renal failure, and its called the silent killer because
people with HTN are often symptom free, asymptomatic until it becomes severe and target organ disease
occurs.
 Hypertension
• Incidence:
20% of the population develops hypertension, more than 90% of them have (essential) primary HTN with
no indefinable medical cause, the reminder develops secondary HTN.

Etiology
• The etiology of hypertension can be classified as either primary or secondary.
• Primary Hypertension
• Primary (essential or idiopathic) hypertension is elevated BP without an identified cause .

• Accounts for 90% to 95% of all cases of hypertension.

• Although the exact cause of primary hypertension is unknown.

 Secondary Hypertension.
• Is elevated BP with a specific cause that often can be identified and corrected.

• This type of hypertension accounts for 5% to 10% of hypertension in adults and more than 80% of
hypertension in children.

• If a person below age 20 or over age 50 suddenly develops hypertension.

 Risk factors
Non-Modifiable and Modifiable
 Risk factors
Age and gender
▪ More common in younger men than younger women
▪ More common in the elderly
Race
▪ More common in blacks and South Asians
Socioeconomic group
▪ More common in lower socioeconomic group
• The most common complications of hypertension are target organ
• diseases occurring in the heart (hypertensive heart disease), brain (cerebrovascular disease),
peripheral vessels (peripheral vascular disease), kidneys (nephrosclerosis), and eyes (retinal damage).
• Coronary artery disease (angina or MI)
• Left ventricular hypertrophy
• HF
• Renal failure
• Cerebrovascular involvement [stroke or transient ischemic attack (TIA)]
• Impaired vision
 Management
• Objective: to prevent associated morbidity and mortality by achieving and
maintaining an arterial blood pressure below 140/90mmhg whenever possible.

• Non- pharmacological
• Pharmacological
 Non- pharmacological
Life style modification
• Lose weight if you’re overweight or obese
• Increase aerobic physical activity 30 to 45 minutes most days of the week ( brisk walking ‫ مشي س يرع‬, running,
cycling, swimming, or
• stair climbing, 30 to 45 minutes three to five times a week Initiate gradually
▪ should stop and notify the physician if severe shortness of breath, fainting, or chest pain occurs.
▪ should avoid muscle-building isometric exercise (weight lifting, wrestling, rowing ‫)تجديف‬
• Sodium restriction no more than 2.4 g sodium or 6 g NaCl
• Explain it takes 2 to 3 months for the taste buds to adapt to changes in salt intake may help the patient adjust
to reduced salt intake.
▪ avoid adding salt at the table
▪ avoid cooking with salt
▪ avoid adding seasonings ‫ يوابل‬that contain sodium
▪ limit consumption of canned, frozen, or other processed foods
▪ read labels on processed foods
• Stop smoking
• Stop alcohol intake
 Pharmacological treatment

• Diuretics
• Adrenergic Agents (alpha and beta blockers)
• Vasodilators
• ACE Inhibitors
• CCB (calcium channel blocker
 Teaching about medication

• The most common s/e of different antihypertensive drugs is orthostatic hypotension

• Take meds. at regular basis
• Assume sitting or lying position for few minutes
• Change position gradually
• Avoid very warm bath, prolonged sitting or standing
• Most common side effects of diuretics are potassium depletion and orthostatic hypotension
• Avoid hot baths, excessive alcohol, and strenuous exercise within 3 hours after taking
medications that promote vasodilation
 CARE OF PATIENT WITH CORONARY VASCULARDISORDERS
• Arteriosclerosis
• Angina Pectoris
• Myocardial Infarction
 ARTERIOSCLEROSIS
• Narrowing and hardening of the arteries.
• Atherosclerosis (fatty deposits called plaque on inner lining of vessel walls),
• leads to changes in arterial structure and function and reduction of blood flow to the myocardium.
Etiology and Pathophysiology
 Atherosclerosis
Clinical Manifestations:
• Signs and symptoms depend on the degree of narrowing:
The decreased blood flow to myocardium produce ischemia with the major manifestation of
chest pain.
ECG changes
Dysrhythmias
sudden death.
 Complications

• Angina
• Heart failure
• TIA(transient ischemic attack)
• Stroke
• Aneurysm
• Peripheral artery disease
• Chronic kidney disease
 ANGINA PECTORIS
• A syndrome characterized by episodes of paroxysmal (suden) pain or pressure in the
anterior chest caused by insufficient coronary blood flow

• Physical exertion or emotional stress increases myocardial oxygen demand, and the
coronary vessels are unable to supply sufficient blood flow to meet the oxygen
demand.
 Precipitating Factors of Angina
Temperature Extremes
• Increase workload of the heart.
• Blood vessels constrict in response to a cold stimulus.
• Blood vessels dilate and blood pools in the skin in response to a hot stimulus.
Physical exertion
by increase myocardial demands.

Exposure to cold
which cause vasoconstriction then increase oxygen demand.
 Extra Factors that can lead to angina pain

Eating heavy meals which increase the blood flow to the mesenteric area for digestion then
reduce the available blood supply to the heart.

Stress or emotional situation which increase the release of adrenaline and increase blood
pressure then increase heart rate leads to increase myocardial work load.
 ASSESSMENT
• Subjective data:
• PAIN
• Type: squeezing, pressing, burning
• Location: retrosternal, substernal, left of sternum, radiates to left arm
• Duration: short; usually 3-5 mins,
• Dyspnea
• Palpitations
• Dizziness; faintness
• Epigastric distress, indigestion
• Objective data:
• Tachycardia
• Pallor
• Diaphoresis
• ECG changes during attack
• NURSING DIAGNOSES
• Altered cardiopulmonary tissue perfusion related to insufficient blood flow
• Pain related to myocardial ischemia
• Activity intolerance related to onset of pain
• Anxiety
• Knowledge deficit
 Management
Objectives:
1-To decrease the oxygen demand of the myocardium.
2-To increase the oxygen supply.

The objectives are met medically by drugs and control of risk factors.
The objectives are met surgically by revascularization that restore blood supply to
the myocardium through coronary artery bypass surgery or percutaneous
transluminal coronary angioplasty (PTCA).
 Management/pharmacologicl
Nitroglycerin
It acts as vasoactive agent which dilate both veins and arteries, then it reduce myocardial
oxygen consumption which decreases ischemia and relieves angina pain.

 It is given sublingually and alleviates the pain of ischemia within 3 minutes (Isordil).

 Topical nitroglycerin ointment which applied on the skin and has the effect of up to 24hr.
 2- Beta – adrenergic blockers.

 Propranolol hydrochloride (inderal) remains the medication of choice

 reduce myocardial oxygen consumption by blocking the sympathetic impulses to the heart and
result in reduction in heart rate, blood pressure and myocardial contractility

Blood pressure drops, a vasopressor may be needed

if severe bradycardia occurs, atropine is the medication of choice.

 3- Calcium ion antagonists / channel blockers.
• It increases myocardial oxygen supply by dilating the smooth muscle wall of the coronary artery
• And decrease myocardial oxygen demands by reducing systemic arterial pressure
• Thus the workload of the ventricle is reduced.
• Nifedipine (procardia) verapamil (isoptin) diltiazem (the most commonly used).

• Side effects: may includes constipation, gastric distress, and dizziness

•
 Nursing Process
3- With acute angina assess the level of pain and its characteristics.
- Put the patient in semi fowler's position.
- Take vital signs.
- Obtain ECG.
- Chest X-Ray.
- O2 Administration.
- Give nitroglycerin as prescribe
 Myocardial Infarction (MI)
Myocardial Infarction (MI) refers to the occlusion of a coronary artery (damage from occlusion
of 1 or more coronary arteries), caused by atherosclerosis or embolus resulting in a necrotic area
in the myocardium.

Is the term used to describe irreversible myocardial necrosis (cell death) that results from an
abrupt decrease or total cessation of coronary blood flow to a specific area of the myocardium
It is the most life- threatening of acute coronary syndromes
Anterior wall of left ventricle near apex: This is the commonest site.
DIAGNOSIS
• 3.Coronary Angiography
• to evaluate the extent of the disease and to determine the most appropriate
therapeutic modality.

• 4.other Measures.
• Exercise stress testing and echocardiograms may be used when a patient has an
abnormal but non-diagnostic baseline ECG.
 Clinical Manifestations:
• Pain : Severe, immobilizing chest pain not relieved by rest, position change, or nitrate administration is
the hallmark of an MI,
• Common locations are substernal, retrosternal, or epigastric areas.
• The pain may radiate to the neck, jaw, and arms or to the back.
• It may occur while the patient is active or at rest, or asleep or awake.
• However, it commonly occurs in the early morning hours.
• It usually lasts for 20 minutes or more and is described as more severe than usual anginal pain
Sudden chest pain over the lower sternal region and abdomen is the presenting symptoms.

Pain increased to reach the level of heavy, risk like pain, which may radiate to the shoulders and down
the arms (usually left arm).

The pain begins spontaneously not after effort and not respond or relieved by rest or nitroglycerin.

The pain is accompanied by S.O.B, pallor, diaphoresis, dizziness, light headedness, nausea and
vomiting.

The patient with diabetes mellitus may not experience severe pain with myocardial infarction
 Clinical Manifestations:
2.Sympathetic Nervous System Stimulation.
During the initial phase of MI, catecholamine (norepinephrine and epinephrine) are released from the
ischemic myocardial jells that normally contain varying quantities of these substances.

The increased sympathetic nervous system stimulation results in release of glycogen, diaphoresis, and
vasoconstriction of peripheral blood vessels.

On physical examination, the patient's skin may be ashen, clammy, and cool to touch.
 Cardiovascular Manifestations.
• In response to the release of catecholamine, the BP and HR may be elevated initially.
• Later, the BP may drop because of decreased cardiac output (CO).
• If severe enough, this may result in decreased renal perfusion and urine output.
• " Crackles may be noted in the lungs, persisting for several hours to several days, suggesting left
ventricular dysfunction.
• Jugular venous distention, hepatic engorgement, and peripheral edema may indicate right ventricular
dysfunction.
• Cardiac examination may reveal abnormal heart sounds that may seem distant.
4.Nausea and Vomiting.
• The patient may be nauseated and vomit.
• Nausea and vomiting an result from reflex stimulation of the vomiting center by the severe pain

5- Fever.
• The temperature may increase within the first 24 hours up to (38° C) and occasionally to the
temperature elevation may last for as long as week
 Medical management:
1- Pharmacotherapy (used to increase oxygen supply, Vasodilators, Anticoagulants , Thrombolytic)
2- Oxygen therapy
3- Analgesics
4- Urgent PTCA

• Thrombolytic: which used to dissolve any thrombus that may have in a coronary artery
• . e.g. streptokinase &&tissue – type plasminogen activator, METALYSE .
• Those medication are effective if administered within 4-6 hours of the onset of chest pain before
transnural tissue necrosis occurs.
 Drug Therapy
IV nitroglycerin, aspirin, B-adrenergic blockers, and systemic anticoagulation
1.-IV Nitroglycerin : The goal of therapy is to reduce pain and improve coronary blood flow.
2.Morphine Sulfate. Morphine sulfate is given for chest pain that is unrelieved by nitroglycerin, administered
I.V. in doses of 1 to 2 mg
• There are a therapeutic benefits of administering morphine because it reduce the pre-load and after load and
relaxes bronchioles to enhance oxygenation.

3.B-Adrenergic Blockers: B- Adrenergic blockers are used to decrease myocardial oxygen demand by reducing
HR, BP, and contractility.
4.Angiotensin Converting Enzyme Inhibitors: ACE inhibitors (e.g., captopril [Capoten]) are recommended
 Drug Therapy
5.Anti-dysrhythmia Drugs: Dysrhythmias are the most common complications after an MI
6-Anticoagulants:
• Heparin is the anticoagulant of choice
• It prolongs the clotting time of the blood, thus reducing the probability of thrombus formation and the
subsequent diminished blood flow

7- Cholesterol-Lowering Drugs: A fasting lipid panel should be obtained on all patients admitted with MI
8- Stool Softeners
9- Nutritional Therapy: Initially, patients may be NPO (nothing by mouth) except for sips of water until stable
(e.g., pain free, nausea resolved). Diet is advanced as tolerated to a low-salt, low-saturated-fat, and low-cholesterol
diet