HYPERTENSIVE
CRISIS
Group (C)
:Under Supervision of
.Dr/ Hamada Abdelhamid
OUTLINE
p C
• Introduction (Anatomy) • Situation.
ro u
• Definition
• Causes.
• Q&A
G
• Pathophysiology.
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations
• Management (Medical and Nusring)
OUTLINE
• Introduction (Anatomy).
• Definition. ANATOMY
r o u p C
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
• Definition. DEFINITION
r o u p C
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
Definition
• Hypertensive crises refer to clinical situations in which the blood pressure is elevated and there
is either acute (hypertensive emergencies) or impending end-organ damage* (hypertensive
urgencies).
• Examples of impending end-organ damage include papilledema, shortness of breath,and pedal
edema.
• Historically, hypertensive urgencies have been defined as diastolic blood pressures 120 mm Hg.
• It is important to remember, however, that the absolute blood pressure is not as critical as the
degree and rate of increase from baseline blood pressure in
determining what is or is not a hypertensive urgency.
OUTLINE
• Introduction (Anatomy).
• Definition. EITOLOGY
r o u p C
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
• Definition. CAUSES
r o u p C
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
CAUSES
• Changes in mental status, such as confusion
• Bleeding into the brain (stroke)
• Heart failure
• Chest pain (unstable angina)
• Fluid in the lungs (pulmonary edema)
• Heart attack
• Aneurysm (aortic dissection)
• Eclampsia (occurs during pregnancy)
• alcohol withdrawal. Stroke, heart attack, kidney trauma,
• cocaine abuse, and an overactive or underactive thyroid
OUTLINE
• Introduction (Anatomy). PATHOPHYSIOLOGYC
• Definition.
u p
r o
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
• Definition. TYPES
r o u p C
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
HYPERTENSIVE EMERGENCY HYPERTENSIVE URGENCY
.Severly elevated BP with evidence of target organ injury Severty elevated BP with no current avidence of secondary
organ damage, although if left untreated, target organ injury
.may result imminently
BP > 180/120 .BP > 180/120 mmHg
.Decrease BP immediately .Decrease BP Soon
.Target Organs / CNS & Heart & Kidney & Eye Occurs on chronic stable complications
: Examples
Encephalopacy, Intracranial Hemorrhage, unstable
.angina,dissecting aortic aneurysm
OUTLINE
• Introduction (Anatomy). SIGNS & SYMPTOMS
C
• Definition.
u p
r o
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
Symptoms of a hypertensive emergency include:
• Headache or blurred vision
• Increasing confusion
• Seizure
• Increasing chest pain
• Increasing shortness of breath
• Swelling or edema (fluid buildup in the tissues)
OUTLINE
• Introduction (Anatomy).
COMPLICATIONS
p C
• Definition.
r o u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
DIAGNOSIS p C
• Definition.
r o u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
• The diagnosis of hypertensive emergency is made when a patient presents with elevated
blood pressure and acute end-organ Damage.
Although commonly the diastolic blood pressure is >120 mm Hg, the degree of blood
pressure elevation is not uniformly above a certain level, nor should it be defined by it.
• It is more important to establish the presence of acute end organ damage in the setting of
elevated blood pressure.
• In determining the acuity of organ damage, it becomes important to know historical data on
patients before arriving at the diagnosis of hypertensive emergency.
• For example, if a patient presents with a diastolic blood pressure of 140 mm Hg
and a creatinine of 3.0 mg/dL, but 6 months ago had a creatinine of 2.8 mg/dL,
this finding alone is not a hypertensive emergency, but could rather be considered
indicative of a hypertensive urgency or uncontrolled severe hypertension.
• Regular monitoring of blood pressure
• Eye exam to look for swelling and bleeding
• Blood and urine testing
OUTLINE
• Introduction (Anatomy).
C
LAB INVESTIGATIONS
p
• Definition.
ro u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
C
MANAGMENT
p
• Definition.
ro u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
C
MEDICAL MANAGMENT
p
• Definition.
ro u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
OUTLINE
• Introduction (Anatomy).
C
NURSING MANAGMENT
p
• Definition.
ro u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
History and assessment hints
.(CASE)
• The ED nurse obtains a health history from Mr. Jones. He states he was
diagnosed with hypertension 10 years ago and takes metoprolol 25 mg/day to
treat it. But he admits he doesn’t take it every day because of the cost. He
says his headache began early this morning and got worse throughout the
day. When his vision started getting blurry, he asked a neighbor to take him to
the ED. He also reports a 30-year history of smoking.
• The ED nurse observes that he’s overweight—a risk factor for hypertension. She
also notes other risk factors: male, African-American, older than age 55, history of
smoking, and nonadherence with his BP medication regimen. Based on Mr. Jones’
history and physical findings, the nurse suspects he’s having a hypertensive crisis—
an umbrella term that includes hypertensive urgency and hypertensive emergency.
Blood pressure and diagnostic results distinguish the two conditions.
• In hypertensive urgency, BP is 180/110 or higher but no associated
damage to target organs (heart, lung, brain, or kidney) occurs.
• In hypertensive emergency, systolic pressure exceeds 190 mm Hg or
diastolic pressure exceeds 120 mm Hg, and organ damage occurs.
• Mr. Jones’ extremely elevated BP, blurred vision, and worsening headache
suggest a hypertensive emergency with brain damage from an impending stroke.
To evaluate for possible stroke, the nurse asks Mr. Jones to smile so she can
check for unilateral facial droop. She asks him to recite a simple sentence to
evaluate his short-term memory and check for speech difficulty, and to raise both
arms to check for unilateral limb weakness.
Call for help
• The nurse alerts the physician, who orders a computed tomography scan of
the brain to check for stroke; a urinalysis to rule out renal disease; serum
potassium, cre-atinine, and hematocrit tests to help detect secondary causes
of hypertension; and an electrocardiogram (ECG) to check for left ventricular
hypertrophy.
On the scene
• The physician orders I.V. nicardipine, starting at 5 mg/hour and increasing 2.5
mg/hour every 5 minutes up to 30 mg/hour, adjusted as needed. Mr. Jones is
admitted to the intensive care unit.
• Based on his BP response to the drug, the nicardipine dosage may be titrated
downward 3 mg/hour as tolerated.
• The goal is to reduce his BP by 15% to 25% in the first hour. He requires careful
monitoring, because reducing BP more than 25% per hour can cause organ
damage.
• Nursing staff monitor him for adverse reactions linked to vasodilation, such as
headache, nausea, vomiting, and tachycardia.
• His laboratory test results are unremarkable, and his ECG is normal.
Outcome
• Nursing care goals are to monitor I.V. drug administration and Mr. Jones’ response to
treatment. When he’s stable, his medication may be titrated to further lower his BP.
• On his second hospital day, Mr. Jones’ BP decreases to 140/85 mm Hg and his
nifedipine is switched to the oral route.
Education and follow-up
• The nurse teaches Mr. Jones about his new medication regimen and stresses
the importance of taking the drugs as prescribed.
• He is transferred to a step-down unit for 1 more day of monitoring.
• At discharge, the nurse provides referrals for possible financial assistance with
his medications, home health visits for short-term BP monitoring to ensure
stability, nutritional services for counseling on weight reduction and dietary
restrictions, and smoking-cessation education and counseling.
• , when do the effects of hypertension require a visit to the emergency room
• Extremely high blood pressure can cause severe life-threatening issues
including stroke, aneurysms, heart attacks, and heart failure.
OUTLINE
• Introduction (Anatomy).
SITUATION p C
• Definition.
r o u
• Causes.
• Pathophysiology. G
• Types.
• Sign & Symptoms.
• Complications.
• Diagnosis.
• Lab Investigations.
• Prevention.
• Management ( Medical & Nursing )
Situations that can cause hypertensive
:emergencies include
• Forgetting to take your blood pressure medication .
• Worsening kidney failure.
• An interaction between medications or supplements that you are taking.
* Complications related to pregnancy
• Certain endocrine diseases such as thyroid storm or pheochromocytoma.
• Recreational drug use .
• When your high blood pressure is extremely high, it has a potential to damage your
organs and blood vessels.
• If you deal with high blood pressure and notice any of the following signs or
symptoms, a trip to an emergency medical facility is an absolute necessity.
• Severe chest pain
• A severe headache, especially when accompanied by confusion or vision changes
• Nausea and vomiting
• Extreme levels of anxiety
• Shortness of breath
• Seizures or tremors
Q&A
1- What blood pressure is required for a hypertensive
crisis to occur?
A) Systolic pressure over 180 or diastolic pressure over 110
B) Systolic pressure over 160 or diastolic pressure over 90
C) Systolic pressure over 170 or diastolic pressure over 100
D) Systolic pressure over 150 or diastolic pressure over 80
2. What is hypertensive urgency?
A) A hypertensive crisis with no organ damage
B) Low blood pressure with no organ damage
C) A hypertensive crisis with organ damage
D) Low blood pressure with organ damage
3. What is a hypertensive emergency?
A) A hypertensive crisis with no organ damage
B) Low blood pressure with organ damage
C) A hypertensive crisis with organ damage
D) Low blood pressure with no organ damage
4- Which of the following is the most common type of end-organ
damage associated with hypertensive emergencies?
A) Cerebral hemorrhage
B) Hypertensive encephalopathy
C) Aortic dissection
D) Cerebral infarction
5- Of the following intravenous drugs used in the
management of hypertensive crises, which has the
longest half-life?
A) Labetalol
B) Nicardipine
C) Nitroglycerin
D) Phentolamine
6- Of the following intravenous drugs used in the
management of hypertensive crises, which has the
shortest onset of action?
A) Nitroglycerin
B) Nitroprusside
C) Esmolol
D) Urapidil
7-Which of the following conditions is a contraindication
for using nicardipine to control a hypertensive crisis?
A) Renal failure
B) Liver failure
C) Second degree AV block
D) Tachyarrhythmia
Mohamed
Ismail Elblat
