HYPERTENSION

Blood pressure
• Blood pressure is the force exerted by the
blood against the walls of the blood vessels

Arterial blood pressure = cardiac out put X

systemic vascular resistance
 Definition
• Hypertension is persistently high blood
pressure that results from abnormalities in
regulatory mechanisms. It is usually defined as
a systolic pressure above 140 mm Hg or a
diastolic pressure above 90 mm Hg on
multiple blood pressure measurements.
Classification of hypertension

Category Systolic (mm) Hg Diastolic (mm)Hg

Normal <120 <80

Prehypertension 120 -139 80-89

Stage I hypertension 140-159 90-99

Stage >160 >100

 Subtype of hypertension

• Isolated systolic hypertension : it is defined as

an average SBP>140 mm Hg coupled with an
average DBP<90 mm Hg
• Psudohypertension : or false hypertension ,
can occur with advanced arteriosclerosis .
 Etiology can be classified based on

Secondary causes
Primary causes •Coarction of aorta or congenital
•Unknown narrowing of aorta
• Increasing Age •Renal disease such as renal artery
stenosis and parenchymal disease
•Alcohol •Endocrine disorder such as
•Cigarette smoking pheochromocytoma , cushing syndrome
•Diabetes mellitus and hyperaldosteronism
•Neurologic disorder such as brain
•Elevated serum lipids tumours , tetraplegia , and head injury
•Excess dietary sodium •Sleep apnoea
•Gender –male more •Medications such as sympathetic
stimulants such as monoamine oxidase
prevalent inhibitors taken with tyramine –
•Obesity containing foods , estorgen replacement
•Obesity therapy , oral contraceptive pills ,
NSAIDs drugs
•Ethnicity – twice as high •Cirrhosis
in African American as in •Pregenacy induced hypertension
whites
•Stress
•Sedentary life style
•Socioeconomic status
Due to increased intake of sodium
Excess sodium intake

Retention of water

Increased intra vascular

volume

Hypertension

Complication
Due to stress cause hypertension

Stress

Increased sympathetic nerves system

activation

Increased SNS stimulation

Increased vasoconstriction

Increased HR & increased

rennin release

Increased rennin activates the

angiotension mechanism
Increased rennin activates the
angiotension mechanism

Increase aldosterone secretion

Elevated BP
 Clinical manifestation
• Hypertension is often called the silent killer
because it is frequently asympathetic until
become severe target organ
• Secondary hypertension symptoms are
fatigue , reduced activity tolerance , dizziness ,
palpitation , angina and dyspnea
• Decreased urine output -
• Change in LOC; one-sided weakness cerebral
vascular accident (CVA) -
• Neurological changes related to cerebral
hemorrhage - High pressures in the arterioles
in the brain may cause them to rupture
• chest pain from a myocardia infarction
• Pulsatile back pain from an aortic aneurysm
 Diagnostic evaluation
• Test for suspected underlying cause.
• Blood pressure monitoring.
• 24-hour blood pressure monitor: confirms consistent hypertension.
• Serum BUN: elevated.
• Serum creatinine: elevated.
• Urinalysis: positive for blood cells and albumin.
• Auscultation: check for abdominal bruit, irregular heart sounds.
• Eye examination with ophthalmoscope: views arterioles of retina is
an
• Indication that other blood vessels in the body are damaged.
• Electrocardiography (ECG): detects enlargement of the heart.
 Drug management
• Classification
• 1. Diuretics.
• 2. Beta adrenergic blockers.
• 3. Calcium channel blockers.
• 4. Angiotensin converting enzyme inhibitors.
• 5. Angiotensin receptor blockers.
• 6. Sympatholytics and adrenergic blockers.
• 7. Direct arterial vasodilators.
• Diuretics
• Types
• • Thiazides and related diuretics.
• • Loop diuretics.
• • Potassium sparing diuretics.
 Conti..
• Mechanism of Action
• • Initial effects: through reduction of plasma
volume and cardiac output.
• • Long term effect: through decrease in total
peripheral vascular resistance.
 Conti..
• Beta - Adrenergic Blocking Agents
• Mechanisms of Action
• • Initial decrease in cardiac output, foll owed
by reduction in peripheral vascular resistance.
• • Other actions include decrease plasma
renin activity, resetting of baroreceptors,
release of vasodilator prostaglandins, and
blockade of pre-junctional beta-receptors
 Conti..
• Angiotensin Converting Enzyme Inhibitors
• Types
• • Class I: captopril
• • Class II (prodrug) : e.g., ramipril, enalapril, perindopril
• • Class III ( water soluble) : lisinopril.
• Mechanism of Action
• • Inhibition of circulating and tissue angiotensin-
converting enzyme.
• • Increased formation of bradykinin and vasodilatory
prostaglandins.
• • Decreased secretion of aldosterone; help sodium
excretion
• Angiotensin Receptor Blockers
• Mechanism of action
• They act by blocking type I angiotensin II
receptors generally, producing more blockade
of the renin - angiotensin - aldosterone axis.
 Conti..
• Calcium channel blockers
• Types
• • Dihydropyridine: nifedipine, amlodipine, felodipine, nicardipine,
lacidipine.
• • Non dihydropyridine :
• - Phenylalkylamine: verapamil.
• - Benzothiazepine: diltiazem.
• Mechanisms of action
• • Decrease in the concentration of free intracellular calcium ions
results in decreased contraction and vasodilation.
• • Diuretic effect through increase in renal blood flow and
glomerular filtration rate.
• • Inhibition of aldosterone secretion
•Life style modification in your client with hypertension

Avoiding tobacco or
smoking
Weight reduction

Regular Life style

aerobic modification
exercise for DASH diet
hypertension

Moderation of alcohol
intake consumption Dietary sodium
restriction
• Weight reduction : it has significant effect on lowering BP in many
people , and effect it seen with even moderate weight loss
• DASH (Dietary Approach For Stop Hypertension ) diet : this diet
involves eating several serving of fish week , eating plenty of fruits
and vegetables, increasing fiber intake and drinking a lot of water .
the dash diet significant effect on lowering BP
• Dietary sodium restriction: the adult average intake of salt
15g/day . in adult restricted salt intake to less than 6g/day . the
patient and family , especially the members who appears the meals
, should be taught about sodium restricted diet. Instruction should
be includes reading labels of over the counter drugs, packed foods
and health products . sodium restriction may be enough to control
BP in some patient with hypertension
• Moderate of alcohol consumption : men should limit
their intake of alcohol to no more than 2 drinks per day
and women and lighter men to no more than one drink
per day
• Physical activity : it is recommended that all adults
have regular aerobic activity at least 30 minutes per
day most of day the week .moderated intense activity
such as brisk walking , jogging and swimming can lower
BP
• Avoidance of tobacco products : nicotine contained
tobacco causes vasoconstriction and increase BP
•
• Nutritional management
• Restriction of sodium
• Reduce weight
• Restricted cholesterol and statured fats
• Maintain adequate intake of potassium
• Maintain adequate intake of calcium and magnesium
• Other management
• Regular , moderate exercise
• Cessation of smoking
• Moderate of alcohol consumption
• Stress management
 Complications

• Coronary artery disease

• Left ventricular hypertrophy
• heart failure
• Cerebrovascular disease
• Peripheral vascular disease
• Rental damage
• Nephrosclerosis
 Hypertensive crisis

• It is a severe and abrupt elevation in BP ,

arbitrarily defined as a DBP > 140 mm Hg .
The rate of rise of BP is more important than
the absolute value in determine the need for
emergency treatment.
• Causes
• History of hypertension
 Types

Hypertensive Hypertensive urgency

emergency
 Hypertensive emergency
• : it develops over hours to days , is a situation
in which a patients BP is severely elevated ( >
180 /120 mm Hg ) with evidence of acute
target damage , especially to the central
nervous system
 Hypertensive urgency
• : which develops over a days to weeks , is a
situation in which a patients BP is severely
elevated but there is no clinical evidenced of
target organ damage
 Hypertension emergency

Endothelia damage in
arteries

Rupture of artery due to continuous elevation of

BP

Especially in CNS

Intracranial haemorrhage
Death
 Clinical manifestation
• Hypertensive emergency
• Hypertensive encephalopathy , a syndrome in which rise in BP is
associated with headache , nausea, vomiting , seizures , confusion , stupor
and coma
• Blurred vision
• Papiledema
• Retinopathy
• Renal insufficiency
• Chest pain
• Dyspnea
• Back pain
• Diaphrosis and loss of pulse
•
 Diagnostic evaluation

• History collection
• Physical examination
• BP measurement
• CT scan to find any complication
 Management

Hypertensive emergency
• IV vasodilators e.g sodim nitroprusside ,
nitroglycrine
• Adrenergic inhibitors e.g phenolamine
Hypertensive urgency
• IV medications but can be managed with oral
drugs such as captopril , labetalol
 Nursing management

• Continuous monitoring of BP with the help of

non-invasive monitoring
• Monitoring fluid and urinary out put
• Monitor vital signs and ECG
• Assessment of neurological status
• Monitor any organ dysfunction
 List of nursing diagnosis
• Acute pain: headache related to increased cerebral vascular
pressure.
. Ineffective Tissue Perfusion: cerebral, renal, cardiac related to
impaired circulation.
Risk for decreased cardiac output related to increased afterload,
vasoconstriction, myocardial ischemia, ventricular hypertrophy.
Knowledge deficit related to lack of information about the disease
process and self-care.
Activity Intolerance related to mismatch in oxygen supply and
demand
• Imbalance nutritional more than body requirement related to
disease process