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Hypertension: Pathophysiology, Physical Assessment, Pharmacology Study Notes, Summaries of Pharmacology

A summary of pathophysiology, physical assessment, nursing care and management, and pharmacology of hypertension for nursing students.

Typology: Summaries

2023/2024

Available from 11/11/2024

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Hypertension: Pathophysiology, Physical Assessment, Pharmacology
Study Notes
A. Definition
Hypertension, or high blood pressure, is a condition where the force of the blood against
the artery walls is too high, often defined as blood pressure above 140/90 mmHg, and
considered severe if the pressure is above 180/120 mmHg.
B. Classification
Normal: Systolic <120 mm Hg and Diastolic <80 mm Hg
Reassess in 1 year.
Elevated: Systolic 120-129 mm Hg and Diastolic <80 mm Hg
Reassess in 3–6 months.
Nonpharmacological management.
Hypertension Stage 1: Systolic 130-139 mm Hg or Diastolic 80-89 mm Hg
Nonpharmacological management and reassess in 3–6 months.
If the patient has heart disease or risk factors, start antihypertensive medication.
Reassess in 1 month
Hypertension Stage 2: Systolic ≥140 mm Hg or Diastolic ≥90 mm Hg
Start antihypertensive medication along with nonpharmacological management.
Reassess in 1 month.
Hypertensive Crisis: Systolic >180 mm Hg and/or Diastolic >120 mm Hg
Requires emergent intervention.
C. Risk Factors
Nonmodifiable: Age, family history, race (higher in African Americans), gender (more
common in men until age 64, then more common in women).
Modifiable: Obesity, sedentary lifestyle, smoking, high salt intake, excessive alcohol
consumption, stress, chronic conditions (e.g., kidney disease, diabetes).
D. Pathophysiology
Involves several key mechanisms:
1. Genetic Factors: Genetic predisposition plays a significant role, with specific genes
influencing blood pressure regulation through pathways such as the
renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), and
renal function.
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Hypertension: Pathophysiology, Physical Assessment, Pharmacology

Study Notes

A. Definition ● Hypertension, or high blood pressure, is a condition where the force of the blood against the artery walls is too high, often defined as blood pressure above 140/90 mmHg, and considered severe if the pressure is above 180/120 mmHg. B. ClassificationNormal : Systolic <120 mm Hg and Diastolic <80 mm Hg ○ Reassess in 1 year. ● Elevated : Systolic 120-129 mm Hg and Diastolic <80 mm Hg ○ Reassess in 3–6 months. ○ Nonpharmacological management. ● Hypertension Stage 1 : Systolic 130-139 mm Hg or Diastolic 80-89 mm Hg ○ Nonpharmacological management and reassess in 3–6 months. ○ If the patient has heart disease or risk factors, start antihypertensive medication. Reassess in 1 month ● Hypertension Stage 2 : Systolic ≥140 mm Hg or Diastolic ≥90 mm Hg ○ Start antihypertensive medication along with nonpharmacological management. Reassess in 1 month. ● Hypertensive Crisis : Systolic >180 mm Hg and/or Diastolic >120 mm Hg ○ Requires emergent intervention. C. Risk FactorsNonmodifiable : Age, family history, race (higher in African Americans), gender (more common in men until age 64, then more common in women). ● Modifiable : Obesity, sedentary lifestyle, smoking, high salt intake, excessive alcohol consumption, stress, chronic conditions (e.g., kidney disease, diabetes). D. Pathophysiology Involves several key mechanisms:

  1. Genetic Factors : Genetic predisposition plays a significant role, with specific genes influencing blood pressure regulation through pathways such as the renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), and renal function.
  1. Renin-Angiotensin-Aldosterone System (RAAS) : This hormonal system regulates blood pressure and fluid balance. Overactivity of RAAS can lead to increased blood volume and vasoconstriction, raising blood pressure. Angiotensin II, a potent vasoconstrictor, and aldosterone, which promotes sodium and water retention, are key components.
  2. Sympathetic Nervous System (SNS) Overactivity : Increased SNS activity can lead to vasoconstriction, increased heart rate, and higher cardiac output, all of which elevate blood pressure. Chronic stress and certain lifestyle factors can enhance SNS activity.
  3. Endothelial Dysfunction : The endothelium (inner lining of blood vessels) plays a crucial role in vascular tone regulation by releasing vasodilators like nitric oxide. Dysfunction of the endothelium can lead to reduced production of vasodilators and increased production of vasoconstrictors, contributing to hypertension.
  4. Kidney Function : The kidneys regulate blood pressure by controlling fluid and electrolyte balance. Impaired kidney function can lead to sodium and water retention, increasing blood volume and pressure.
  5. Vascular Remodeling : Chronic hypertension can cause structural changes in blood vessels, such as thickening of the arterial walls (arteriosclerosis) and reduced elasticity, which increase peripheral resistance and further elevate blood pressure.
  6. Lifestyle Factors : Diet high in sodium, obesity, physical inactivity, excessive alcohol consumption, and smoking are significant contributors to hypertension. These factors can influence the aforementioned mechanisms, exacerbating the condition.
  7. Hormonal Factors : Hormones like aldosterone, cortisol, insulin, and thyroid hormones can affect blood pressure regulation by influencing sodium retention, vascular tone, and SNS activity. E. Symptoms ● Often asymptomatic. ● Severe hypertension may cause headaches, shortness of breath, nosebleeds, or other symptoms. F. Complications ● Heart attack or stroke. ● Aneurysm. ● Heart failure. ● Weakened and narrowed blood vessels in the kidneys. ● Thickened, narrowed, or torn blood vessels in the eyes. ● Metabolic syndrome.

Jugular Venous Pressure (JVP) : Assess JVP for signs of heart failure or volume overload. ○ Edema : Check for peripheral edema, which may indicate heart failure or renal dysfunction.

5. Respiratory Examination:Lungs : Auscultate for breath sounds, crackles, or wheezes that may indicate heart failure or other respiratory conditions. 6. Abdominal Examination:Auscultation : Listen for abdominal bruits, which may suggest renal artery stenosis. ○ Palpation : Check for an enlarged liver or spleen, which may indicate congestive heart failure or other systemic conditions. 7. Neurological Examination: ○ Assess for any neurological deficits that may suggest complications such as stroke or transient ischemic attacks (TIAs). 8. Ophthalmic Examination:Fundoscopy : Examine the retina for signs of hypertensive retinopathy, such as arteriovenous nicking, hemorrhages, exudates, or papilledema. 9. Laboratory and Diagnostic Tests:Blood Tests : Evaluate serum electrolytes, renal function (creatinine, BUN), lipid profile, fasting glucose, and thyroid function. ○ Urinalysis : Check for proteinuria, hematuria, or other abnormalities that may indicate kidney damage. ○ Electrocardiogram (ECG) : Assess for signs of left ventricular hypertrophy, ischemia, or arrhythmias. ○ Echocardiogram : Evaluate cardiac structure and function, particularly if there are signs of heart failure or left ventricular hypertrophy. ○ Imaging : Consider renal ultrasound or other imaging studies if secondary causes of hypertension are suspected. I. Management Lifestyle ModificationsDiet : DASH diet (Dietary Approaches to Stop Hypertension), reduce salt intake and increase potassium intake. ○ Eat more: ■ Fruits, vegetables, and low-fat dairy foods ■ Whole grain products, fish, poultry, and nuts ■ Foods rich in magnesium, potassium, and calcium

○ Eat less: ■ Fatty foods (i.e., saturated fats, cholesterol) ■ Red meat ■ Sweets and simple sugars ● Exercise : Regular physical activity (150 minutes of moderate-intensity exercise per week). ● Weight loss : Achieve and maintain a healthy weight. ● Limit alcohol : No more than one drink per day for women and two for men. ● Quit smoking : Smoking cessation. ● Stress management : Meditation, yoga, or deep breathing exercises. Nonpharmacological Management Because lifestyle modifications can be highly helpful in lowering blood pressure, nonpharmacological approaches may be used before medication, depending on the type of blood pressure and the presence of additional cardiac risk factors. ● Safe and Effective Nursing Care for Manual BP: ○ Manual BP is indicated when:

  1. Patient requires a cuff size not available with electronic measurement.
  2. Clinician questions the accuracy of electronic BP readings.
  3. Calibration and confirmation of electronic measurement devices for patient’s home use are needed. ● Safe and Effective Nursing Care for Patients Taking: ○ ACEIs and ARBs:
  4. Monitor BP daily 1 hour after dose when the medication is initiated for a week and also daily for a week when the dose is changed.
  5. Assess for any changes in voice or swelling of the tongue (signs of angioedema) with the first dose and report to the prescriber.
  6. The prescriber will monitor lab values frequently (renal function for ACEIs and ARBs; liver function for ARBs). ○ Beta Blockers:
  7. If you have diabetes, this medication may affect the signs and symptoms of hypoglycemia, so you need to check your blood glucose level if you suspect a problem.
  8. Do not abruptly stop taking this medication; it will need to be weaned slowly by the prescriber.
  9. Report wheezing or difficulty breathing immediately.

SEs - side effects BP - blood pressure HF - heart failure ARDS - acute respiratory distress syndrome CHF - congestive heart failure Gi - gastrointestinal CNS - central nervous system ECG - electrocardiogram HR - heart rate 1 & O - intake and output; SVT - supraventricular tachycardia SR - sustained release CD - controlled delivery XR - extended release Medications Affecting Blood Pressure CLASS EXAMPLE ACTION DOSAGE SENC Adrenergic agonists Dopamine Activates sympathomimetic response (alpha and beta). Treatment of shock that has not been responsive to fluid replacement Renal: IV: 0.5-3 mcg/kg/min Cardiac: IV: 2-10 mcg/kg/min (SEs): Arrhythmias, hypotension, headache, mydriasis (high doses), vasoconstriction of peripheral circulation, extravasation. Close monitoring of cardiac rhythm, BP, urine output and IV site; administer in large veins to decrease risk of extravasation. Alpha, - and beta,-(nonselective) adrenergic blocking agents Secondary agent Labetalol Vasodilation, decreased heart rate, and cardiac contractility. Oral: 100 mg bid; max 2.4 g/day HTN crisis: IV: 20 mg slowly over 2 min SEs: Fatigue, weakness, dizziness, bronchospasm, bradycardia, HF, pulmonary edema, orthostatic hypotension. Assess apical pulse prior to administration; assess for ortho static hypotension, daily weights; assess for fluid overload. Amiodarone Vasodilation; slows sinus rate; increases PR and QT. Oral: maintenance (ventricular) 400 mg/day SEs: Dizziness, malaise, fatigue, ARDS, CHF, bradycardia, hypotension, Gl upset,

Hypertension; ventricular arrhythmias; SVT. IV: 150 mg over 10 min, then drip photosensitivity, ataxia, and other CNS effects. Continuous ECG monitoring in IV therapy; assess lung sounds, has long half-life; monitor thyroid and liver function. Carvedilol Decreases heart rate; improves cardiac output. Slows progression of heart failure. Oral: 6.25 mg bid initial; max 25 mg bid ER: 29 mg daily; max 80 mg daily SEs: Fatigue, weakness, dizziness, diarrhea, erectile dysfunction, hyperglycemia. Associated with hepatic failure. Assess apical pulse prior to administration. Assess BP, HR, 1&0, and daily weights; teach patients not to abruptly stop drug; food slows absorption. Nonselective beta-adrenergic blocking agents Secondary agent Propranolol Vascular tone is decreased by blocking of beta, receptors in heart. Oral: 40 mg bid or 80 mg SR daily SEs: Fatigue, weakness, bradycardia, arrhythmias, pulmonary edema, erectile dysfunction; masks hypo- and hyperglycemia. Assess HR and BP, blood glucose levels; take with meals or just after meals to enhance absorption. Beta, selective adrenergic blocking agents Secondary agent Atenolol Reduce HR and BP by blocking beta, receptors in the heart. Oral: 50 mg-100 mg daily Fatigue, weakness, HF, bradycardia, pulmonary edema, erectile dysfunction. Masks hypo- and hyperglycemia. Pulse will not increase with exercise.

flutter, atrial fibrillation with rapid ventricular rates. with simvastatin (10 mg/day) Interacts with grapefruit juice. Take pulse before administration; assess for HF, assess for rash intermittently during therapy; monitor serum K+. SR has fewer side effects. Vasodilators Secondary agent Hydralazine Vasodilation by acting directly on peripheral arteries. Lowers BP and decreases afterload in HF. Oral: maximum dose 300 mg/day IV: 5-40 mg may repeat as needed SEs: Tachycardia, sodium retention, drug-induced lupus syndrome, dizziness, headache, drowsiness. Monitor BP and pulse carefully when starting therapy. Increased risk for toxicity in patients of Chinese, Alaska Native, and Japanese ethnicity.

J. Monitoring and Follow-Up ● Regular blood pressure checks. ● Monitoring for side effects of medications. ● Regular follow-up appointments with healthcare provider. K. Patient Education ● Importance of adherence to medication and lifestyle changes. ● How to properly measure blood pressure at home. ● Recognizing symptoms of hypertensive crisis and when to seek emergency care. L. Summary Hypertension is a common but serious condition that requires a combination of lifestyle changes and medication to manage effectively. Early detection and consistent management are key to preventing complications and improving quality of life. Reference: Best, J., Buttriss, G. and Hines, A. (2022) ‘Chapter 1: Hypertension’, in Pathophysiology, Physical Assessment, & Pharmacology: Advanced Integrative Clinical Concepts. Philadelphia, Pennsylvania: F.A. Davis Company, pp. 9–21.