Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of hypertension
- Describe the diagnostics and laboratory values in the disease of hypertension
- Apply nursing concepts and plan associated nursing care for the patient with hypertension
- Evaluate the efficacy of nursing care for the patient with hypertension
- Describe the medical therapies that apply to the care of hypertension and the Joint National Committee (JNC 8) guidelines for the treatment of hypertension
The Centers for Disease Control (2022) notes that almost half of individuals in the United States are afflicted with hypertension (HTN). According to the American Heart Association (2023), HTN costs the United States between $131 and $198 billion each year. Men (50%), Blacks (56%), non-Hispanic White adults (48%), non-Hispanic Asian adults (46%), and Hispanic (39%) adults are more likely to have HTN (CDC, 2022). Age, gender, and ethnic and racial disposition are nonmodifiable risk factors. Modifiable risk factors for HTN include diabetes, a diet high in sodium and low in potassium, physical inactivity, obesity, excessive alcohol use, and tobacco use. Uncontrolled blood pressure can result in stroke, heart disease (coronary heart disease, congestive heart disease), arrhythmia, and kidney disease.
Pathophysiology
There are two types of HTN. Though the cause for these types varies, the manifestations and sequelae do not. The two classifications are primary or essential hypertension and secondary hypertension. Often multi-factorial, primary hypertension does not have one distinct cause, while secondary hypertension is caused by another medical condition, such as thyroid issues or adrenal or kidney disease.
In the early stages of HTN, increased cardiac output creates high blood velocity to counteract the tightened arterioles. Activation of the renin-angiotensin hormonal system is highly correlated with renal endocrine function. When perfusion is decreased in the kidneys, renin is released and converts angiotensin I to angiotensin II (released from the kidneys), which increases blood pressure. Also, physiological influences from the autonomic nervous system (sympathetic nervous system) activation influence arteriolar constriction and dilation. Other factors that contribute to the pathophysiology of HTN include hypercoagulability, in which viscous blood is created from endothelial dysfunction and results in increased pressure. Peripheral resistance is increased from tight endothelial intimal thickening in small arterioles (Gallo et al., 2021). Hemodynamic cutoff parameters with systolic pressures ≥ 140 mm Hg/diastolic ≥ 90 mm Hg are consistently elevated in hypertensive patients (World Health Organization, 2023).
Clinical Manifestations
Blood pressure will periodically rise during moments of stress, anxiety, or physical activity. While there are transient rises in blood pressure during these moments, readings do not remain consistently high. Consistent high blood pressure may not cause any symptoms. Often referred to as the “silent killer,” elevated readings may be discovered during routine physical exams. Symptomatic hypertension may cause headaches, nose bleeds, fatigue, nausea, chest pain, and shortness of breath. In severe cases, patients with hypertensive urgency may report chest pain, shortness of breath, blurred vision, and headaches (resulting from elevated intracranial pressure), but do not exhibit target organ damage (American Heart Association, 2024). In contrast, patients with malignant hypertension will exhibit similar symptoms with target organ damage, such as kidney failure or pulmonary edema (Naranjo et al., 2023).
The American Heart Association (2022) notes blood pressure readings may rise as high as 180/120 mm Hg to be considered a hypertensive urgency or emergency; however, some patients will experience severe symptoms with readings 160/90 mm Hg or greater. It is prudent for nurses to recommend patients proceed to an inpatient facility for treatment and evaluation. Table 12.4 demonstrates the progression of high blood pressure based on systolic readings.
| Classification | Criteria |
|---|---|
| Normal blood pressure | 120-129/80 mm Hg |
| Stage I hypertension | 130-139/80-90 mm Hg |
| Stage II hypertension | 140/90 mm Hg or higher |
| Hypertensive urgency | 160/90 mm Hg or higher |
Diagnostics and Laboratory Values
Assessment begins with a thorough medical history inquiring about genetics, comorbid conditions (elevated lipids, diabetes, obesity), and lifestyle practices. The nurse assessing the blood pressure must take two blood pressure readings on two different occasions, using a properly sized cuff (Figure 12.21). The patient should be positioned in a comfortable environment and should be instructed to sit with legs uncrossed. They should abstain from eating and smoking a minimum of 30 to 45 minutes prior to testing. If the patient demonstrates anxiety, permit rest first, as being in medical facilities may cause elevated readings. This is also known as “white coat syndrome.” Hypertension is diagnosed for patients with high blood pressure that is seen in two separate clinic visits at least two weeks apart, and on both visits.
Manual blood pressure readings are always the best practice; therefore, if automated noninvasive blood pressure monitoring yields elevated measurements, the nurse should follow up with a manual reading.
Other diagnostic tests include a 12-lead electrocardiogram (EKG). Twelve lead EKGs may demonstrate ischemia, heart failure, or dysrhythmia to explain organic causes of HTN. The provider may order laboratory values such as a basic metabolic panel, lipid profile, fasting blood sugar, and urine test (protein) (Unger et al., 2020). The clinical work up of other chronic comorbidities is considered when there is a new diagnosis of HTN. It is of utmost importance that the blood pressure readings are taken correctly and in a consistent manner. The nurse must also note if the patient is demonstrating any symptoms of elevated blood pressure, which may include headache, chest pain, blurred vision, shortness of breath, fatigue, or dizziness. Patient presentation is paramount to consider the effects of the elevated blood pressure, not the abnormal value in isolation.
Clinical Safety and Procedures (QSEN)
Evidence-Based Practice: The Correct Technique for Taking a Blood Pressure
- The patient must refrain from eating or smoking for 30-45 minutes.
- Seat the patient in a comfortable environment with both feet on the ground and arm resting on a table or on the lap.
- Ask patients if there are limb restrictions due to mastectomy or lymph node removal from a history of breast cancer.
- Ensure the patient’s blood pressure is taken with a correctly sized cuff.
Nursing Care of the Patient with Hypertension
In the medical-surgical inpatient setting, nurses will be treating chronic HTN or acute HTN. The accessibility and ease of recognizing trends of hemodynamic changes is to the benefit of the inpatient nurse. Although most of the current nursing literature centers around diagnosing HTN in the outpatient setting, more streamlined practices are in development to accurately diagnose HTN in the acute care setting (Armitage et al., 2019).
Recognizing Cues and Analyzing Cues
The nurse begins the physical assessment by taking a proper BP assessment, noting the position and size of the cuff. The nurse must perform a thorough heart and lung assessment, noting any extra heart sounds, gallops, murmurs, irregularities, or crackles. Note the patient’s pulse and assess for edema. Patients with uncontrolled HTN may retain fluid and have an underlying diagnosis of congestive heart failure. Have the patient keep a journal of blood pressure readings to self-monitor medication effects; the nurse should analyze the readings and determine if they are consistently high or low. Note if the patient has any associated symptoms with elevated blood pressure such as headache, chest pain, blurred vision, or shortness of breath.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
First-line interventions with newly diagnosed HTN aim to reduce modifiable risk factors and should be tailored to the individual. If appropriate, encourage the patient to abstain from alcohol and quit smoking. Chronic alcohol use will elevate blood pressure and interfere with pharmacotherapeutics. Nicotine is a vasoconstrictor and contributes to elevated readings. Provide education to the patient on long-term effects from these modifiable risk factors. Patients may have to reduce or eliminate caffeine as needed to avert elevated blood pressure readings.
Educate the patient on physical activity recommendations. The American Heart Association recommends at least 150 minutes of physical activity per week. Sodium reduction in the diet is recommended, as excess sodium leads to fluid retention and will result in elevated readings. Diets high in saturated fats and sugar are linked with endothelial intimal dysfunction. Patients may benefit from interprofessional referral to a registered nutritionist or physical trainer to assist with goal development in aerobic activity.
Lastly, the patient must be made aware of the symptoms of symptomatic hypertensive readings. If the nurse suspects that the patient is having an acute hypertensive event, assess the patient’s blood pressure and document symptoms and onset. Therapies will be initiated inpatient per the provider’s order (intravenous hydralazine, intravenous beta-blockers), labs to assess for target organ damage, and telemetry to monitor for serial blood pressures and rhythm. Oftentimes, patients trivialize symptoms with elevated blood pressure measurements; nurses can assist patients with safe triage and access to care. When planning goals for patients with HTN, they must align with the patient’s preferences and intended clinical responses. Goals may include a demonstration of knowledge of symptoms of hypertensive crisis, adherence to medication therapy, increase in physical activity, alteration in modifiable risk factors, and normalization of blood pressure readings. The nurse must understand goals may have to be adjusted based on the patient’s condition.
Evaluation of Nursing Care of the Patient with Hypertension
In most cases with acute presentations of HTN, goal creation will focus on secondary and tertiary prevention of complications. Goals will have to be tailored to the degree of symptom burden and risk factors.
Evaluating Outcomes
With HTN, patient goals center around SMART concepts. The following outcomes are measurable and can be adjusted to reflect short-term or long-term outcomes.
- The patient’s blood pressure should be reduced below 120/80 mm Hg with medication adherence.
- The patient will comply with the therapy and efforts to modify lifestyle choices that are risk factors.
- The patient will demonstrate knowledge of sodium discretion and make appropriate menu choices that are low-fat and low-glycemic.
- The patient will participate in a moderate exercise program for 30 minutes (five times a week).
- The patient will maintain a healthy BMI (target < 30%, anything over 30% is obese).
Collectively, patient empowerment through education and adherence to medical therapy will yield the desired responses. Patients may struggle to accept the disease and restrictions; however, patient-centered care with realistic goals will prove effective.
Medical Therapies and Related Care
Recently released guidelines endorsed by the Joint National Committee updated guidelines for the pharmacological therapies for patients with HTN (Cifu & Davis, 2017), which will be referred to as the JNC 8 in this text. For the non-Black population (with or without diabetes), initial therapy should include thiazide diuretics, CCBs, ACE inhibitors, or ARBs. In contrast, the Black population (with or without diabetes) should be started on thiazide diuretics or CCBs. Current guidelines encourage ACE inhibitor/ARB therapy for Black individuals with HTN to reduce the risk of stroke. Upward titration of medications should occur with proper assessment of blood pressure response. If these initial therapies do not achieve a therapeutic response, the addition of CCBs, ACE inhibitors, or ARBs will be considered. Other agents to consider are beta-blockers or aldosterone agents. While nurses are not responsible for the prescribing of the medication, they must consider whether their patients are at high risk of heart-related complications such as HF, heart attack, and stroke. The most recent developments endorse closer outpatient monitoring of blood pressure, adding potassium supplementation, and adhering to lifestyle recommendations. New recent guidelines endorse the implementation of sodium-close cotransporter-2 inhibitors (SGLT-2) for patients with HF and HTN. Nursing responsibilities include monitoring hemodynamic response, monitoring for side effects, and teaching correct techniques for at-home self-monitoring of antihypertensive therapies. Hemodynamic monitoring may be conducted by the nurse, or the patient will be educated on home monitoring. With the integration of sophisticated technology, current software permits telemonitoring and the use of smartwatches or tablets to assist patients with monitoring therapies.