5.5 Hypertension

Overview

Normal blood pressure is defined as less than 120/80 mm Hg in adults. Hypertension refers to chronically elevated blood pressure greater than 120/80 mm Hg. Hypertension is very common, affecting millions of individuals worldwide. See Figure 5.26^[1] for an image of a health care professional obtaining a blood pressure reading.

There are several classifications of blood pressure based on the systolic and diastolic readings. See Table 5.5 for classifications of hypertension according to the American Heart Association.^[2]

Table 5.5. Blood Pressure Classifications^[3]

Causes of Hypertension

Hypertension can be due to a primary cause or as a secondary cause. Primary hypertension is the most common type of hypertension and has no identifiable cause. It typically develops gradually over time and is influenced by various risk factors such as genetics, age, race, diet, lifestyle, and stress.

Secondary hypertension is the result of an underlying medical condition or medication. Conditions such as kidney disease, hormonal disorders, or the use of medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), pseudoephedrine or phenylephrine, and estrogen-containing birth control pills can contribute to secondary hypertension. Additionally, medical conditions like diabetes, kidney disease, and sleep apnea can increase one’s risk of developing hypertension.

Risk factors for developing hypertension include age, family history, and lifestyle factors. Individuals with obesity, diets high in sodium, excessive alcohol intake, chronic stress, and limited physical activity are at higher risk for developing hypertension.^[4] For this reason, health teaching about lifestyle modifications is essential for nurses to provide to clients experiencing prehypertension or hypertension.

Assessment

Many individuals with hypertension have no symptoms and are unaware of the condition until they have an elevated blood pressure reading collected. If individuals have an elevated blood pressure reading, providers will typically repeat the reading at another appointment before making a diagnosis and beginning treatment. They may ask the individual to collect blood pressures at various dates/times at home or when out in the community and keep a tracking log. Many individuals with hypertension are asymptomatic although some develop symptoms as a result of hypertension, such as a headache, dizziness, or fainting.^[5] Untreated hypertension can lead to significant health complications such as myocardial infarction (heart attack), heart failure, cerebrovascular accident (stroke), vision loss, kidney damage.

Diagnostic Testing

Diagnostic testing for hypertension involves recording blood pressures on at least two separate occasions. Blood pressure should be measured in both arms while a client is seated and relaxed. Many providers who suspect hypertension will also evaluate for signs of organ damage as a result of sustained elevated blood pressures. These evaluations may include an echocardiogram to examine for left ventricular hypertrophy (enlargement), fundoscopic examination of retinal blood vessels within the eyes, and kidney function tests to evaluate for elevated levels of serum creatinine or decreased glomerular filtration rate (GFR).^[6],[7] Review normal reference ranges for common diagnostic tests in “Appendix A – Normal Reference Ranges.”

Nursing Diagnoses

Nursing priorities for clients diagnosed with hypertension include managing blood pressure levels, promoting healthy lifestyle modifications, and providing health teaching. Common nursing diagnoses for clients with hypertension are as follows^[8]:

• Risk for Decreased Cardiac Output
• Risk for Unstable Blood Pressure
• Readiness for Enhanced Health Self-Management

Outcome Identification

Outcome identification involves setting short- and long-term goals and creating expected outcome statements tailored to the client’s specific needs. These outcomes should be measurable and responsive to nursing interventions.

These are some sample expected outcomes for common nursing diagnoses related to hypertension:

• The client will demonstrate improved knowledge of hypertension management by verbalizing three lifestyle modifications.
• The client will maintain blood pressure within the recommended target range of SBP between 100-119 mm Hg and DBP less than 80 mm Hg.
• The client will actively engage in self-monitoring blood pressure and maintain a record of readings to bring to the next appointment.
• The client will verbalize three symptoms of reduced tissue perfusion to promptly report to the health care provider.

Interventions

Medical Interventions

Medical interventions play an important role in managing hypertension. These interventions are important for minimizing impact on other organs and potential complications like heart failure, kidney disease, and vision loss.

Lifestyle Modifications

Lifestyle changes are often the first step in hypertension management and can be effective in lowering blood pressure. Recommendations may include the following:

• Dietary Changes: Reducing sodium intake, following a heart-healthy diet (such as the DASH or Mediterranean diets), and limiting alcohol intake.
• Regular Physical Activity: Engaging in regular aerobic exercise, such as brisk walking or swimming, as recommended by a health care provider.
• Weight Management: Achieving and maintaining a healthy weight through diet and exercise.
• Smoking Cessation: Encouraging smoking cessation and providing resources when the client is ready to quit.

Medication Management

Antihypertensive medications are prescribed to control blood pressure, especially if lifestyle modifications alone are insufficient. Classes of medications used to treat hypertension include the following^[9],[10]:

• Diuretics: Eliminate excess sodium and fluid, thus reducing blood volume and blood pressure.
• Beta-Blockers: Block beta-receptors, causing decreased heart rate and force of heart contractions, thus lowering blood pressure. Select beta-blockers may appear to also cause vasodilation through the alpha-1 receptor blockade.
• Angiotensin-converting enzyme (ACE) Inhibitors: Block the conversion of Angiotensin I to Angiotensin II in the renin-angiotensin-aldosterone system, leading to vasodilation and sodium and water excretion, thus lowering blood pressure.
• Angiotensin II Receptor Blockers (ARBs): Block the effects of Angiotensin II, a hormone that causes vasoconstriction, thus lowering blood pressure.
• Calcium Channel Blockers: Relax blood vessels by blocking calcium, thus causing vasodilation and decreased blood pressure.
• Alpha-Agonists: Stimulate alpha-receptors, promoting vasodilation and reducing blood pressure.
• Direct Vasodilators: Directly relax vascular smooth muscle, causing vasodilation and reducing blood pressure.

Nursing Interventions

Nursing interventions for hypertension management are essential in helping clients maintain healthy blood pressure levels and prevent complications due to damage to other organs such as the heart, kidneys, brain, and eyes.

Blood Pressure Monitoring

Nurses teach clients how to accurately measure their blood pressure at home and record blood pressure readings in a log. They encourage clients to share home blood pressure logs during follow-up appointments with their health care provider.

Medication Management

Nurses safely administer antihypertensive medications and provide health teaching about their role in blood pressure management, potential side effects, and when to notify the provider. They teach clients about the importance of adhering to their prescribed drug treatment regimen and to consult with their provider before making any changes.

Health Teaching

Health teaching focuses on empowering clients to make healthy lifestyle changes to maintain normal blood pressure.

Lifestyle Modification

Nurses teach clients about the importance of blood pressure control to prevent damage to other organs. They also teach about recommended dietary changes (such as a low-sodium diet), regular exercise, and smoking cessation to promote heart health.

Stress Management

Nurses teach relaxation techniques and stress management strategies, such as deep breathing exercises, progressive muscle relaxation, or guided imagery. They promote healthy coping mechanisms and encourage clients to seek counseling if needed.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.