Chapter 36, Hypertension: p. 809-813
Nursing Management: Primary Hypertension
Assessment
Subjective and objective data to obtain from a patient with hypertension.
Clinical Problems
Clinical problems for the patient with hypertension include:
Altered blood pressure
Body weight problem
Difficulty coping
Health maintenance alteration
Impaired cardiac function
Impaired sexual function
Inadequate tissue perfusion
Nutritionally compromised
Planning
Nursing care focuses on the priority problems of maintaining BP at a level that decreases complications and supporting the patient to manage a complicated drug regimen with many side effects.
The overall goals for the patient with hypertension are that the patient will:
Achieve and maintain the goal BP.
Experience minimal side effects of therapy.
Manage and cope with the condition.
Nursing Management: Primary Hypertension
Assessment
Subjective and objective data to obtain from a patient with hypertension.
Clinical Problems
Clinical problems for the patient with hypertension include:
Altered blood pressure
Body weight problem
Difficulty coping
Health maintenance alteration
Impaired cardiac function
Impaired sexual function
Inadequate tissue perfusion
Nutritionally compromised
Planning
Nursing care focuses on the priority problems of maintaining BP at a level that decreases complications and supporting the patient to manage a complicated drug regimen with many side effects.
The overall goals for the patient with hypertension are that the patient will:
Achieve and maintain the goal BP.
Experience minimal side effects of therapy.
Manage and cope with the condition.
Blood Pressure Measurement
Proper Cuff Size and Placement
Proper size and correct placement of the BP cuff are critical for accurate measurement (see Table 36.11).
Place the cuff snugly around the patient’s bare upper arm with the midline of the bladder of the cuff (usually marked) in line with the brachial artery.
Position the patient’s arm at heart level during BP measurement:
For sitting position: raise and support the arm at heart level.
For supine position: raise and support the arm (e.g., with a small pillow).
Measurement Method
BP can be measured using the auscultatory (oscillatory) method.
Note any differences in measurements between each arm. Falsely low readings can occur in the presence of atherosclerosis in the subclavian artery.
Alternative Measurement Sites
If neither upper arm can be used for BP measurement due to IV lines, fistulas, or if the BP cuff is too large, use the forearm:
Position the cuff midway between the elbow and wrist.
Auscultate Korotkoff sounds over the radial artery or use a Doppler device to note SBP.
Use of an oscillometric device on the forearm is acceptable.
Note that forearm and upper arm BPs are not interchangeable.
Antihypertensive Drugs
An illustration describes the sites and methods of action of various antihypertensive drugs and their effects on the cardiovascular system including the brain, heart, blood vessels, and kidneys, detailing their mechanisms of action (as referenced from JNC 7, 2003).
Blood Pressure Measurement
Proper Cuff Size and Placement
Proper size and correct placement of the BP cuff are critical for accurate measurement (see Table 36.11).
Place the cuff snugly around the patient’s bare upper arm with the midline of the bladder of the cuff (usually marked) in line with the brachial artery.
Position the patient’s arm at heart level during BP measurement:
For sitting position: raise and support the arm at heart level.
For supine position: raise and support the arm (e.g., with a small pillow).
Measurement Method
BP can be measured using the auscultatory (oscillatory) method.
Note any differences in measurements between each arm. Falsely low readings can occur in the presence of atherosclerosis in the subclavian artery.
Alternative Measurement Sites
If neither upper arm can be used for BP measurement due to IV lines, fistulas, or if the BP cuff is too large, use the forearm:
Position the cuff midway between the elbow and wrist.
Auscultate Korotkoff sounds over the radial artery or use a Doppler device to note SBP.
Use of an oscillometric device on the forearm is acceptable.
Note that forearm and upper arm BPs are not interchangeable.
Antihypertensive Drugs
An illustration describes the sites and methods of action of various antihypertensive drugs and their effects on the cardiovascular system including the brain, heart, blood vessels, and kidneys, detailing their mechanisms of action (as referenced from JNC 7, 2003).
Orthostatic Changes in Blood Pressure and Heart Rate Assessment
Assessment Process:
Assess for orthostatic changes in BP and HR in:
Older adults
People taking antihypertensive drugs
Patients reporting symptoms consistent with reduced BP on standing (e.g., lightheadedness, dizziness, syncope).
Have the person rest in the supine position for 3 minutes.
Take baseline readings for BP and pulse.
Have the patient sit and repeat BP and pulse measurements.
Have the patient stand and assess BP and pulse again after 3 minutes of standing.
Normal Findings:
Typically, the SBP decreases slightly (less than 10 mm Hg) upon standing, while DBP and pulse increase slightly.
Orthostatic Hypotension Criteria:
Occurs when there is:
A decrease of 20 mm Hg or more in SBP
A decrease of 10 mm Hg or more in DBP
An increase in HR of 20 beats/min or more
Note any symptoms such as lightheadedness or dizziness during the assessment as this is considered abnormal.
Common Causes:
Dehydration
Inadequate vasoconstrictor mechanisms due to disease or drug therapy.
Auscultatory Gap:
A gap between the first Korotkoff sound and subsequent beats may indicate an auscultatory gap. Failing to inflate the cuff high enough can result in an inaccurate SBP reading, typically lower than the patient's actual BP.
Evaluation of BP Trends:
Trends in BP measurements are more significant than a single value. In acute care settings, BP readings commonly assess volume status and effects of drugs rather than diagnosing hypertension. Inform the Healthcare Provider (HCP) of any patient with a persistently elevated BP; they should be evaluated for hypertension.
Blood Pressure Monitoring at Home
Verifying how blood pressure (BP) is obtained at home is essential when assessing for potential hypertension.
Ensure that:
The home BP machine has been validated for accuracy.
The patient records measurements at the same time of day for consistency.
Confirming office BP readings with home BP readings can help determine the average BP.
Causes of Resistant Hypertension
Causes of Pseudoresistant Hypertension
Improper BP measurements (i.e., inappropriate BP cuff size)
Inadequate drug doses
Inappropriate drug therapy
Poor adherence to drug regimen (e.g., due to side effects, finances)
White coat syndrome
Volume Overload
Drug-induced
Corticosteroids
Cyclosporine and tacrolimus (Prograf)
Erythropoietin
Nonsteroidal antiinflammatory drugs
Oral contraceptives
Sympathomimetics (e.g., decongestants, diet pills)
Excess salt intake
Herbal supplements (e.g., ma huang, bitter orange)
Inadequate diuretic therapy
Illegal drugs (e.g., cocaine, amphetamines)
Licorice
Volume retention from kidney disease
Associated Conditions
Excess alcohol use
Increasing obesity
Obstructive sleep apnea
Screening Programs
Screening programs in the community are widely used to identify persons who have high BP.
At the time of the BP measurement, provide each person with a written, numeric value of the reading, and explain why further evaluation is needed.
Ambulatory Care
Your primary role in the long-term management of hypertension is to assist the patient in reaching the goal BP and adhering to the treatment plan (see Table 36.12).
Actions include:
Evaluating therapeutic effectiveness
Detecting and reporting any adverse treatment effects
Assessing and enhancing adherence
Teaching patients and caregivers.
Cardiovascular Risk Factor Modification
Teaching about CVD risk factors is appropriate for all persons.
Modifiable CVD risk factors include:
Hypertension
Obesity
Diabetes
Tobacco use
Physical inactivity
Discuss lifestyle modifications based on identified risk factors.
Table 36.13 contains general information and health-promoting behaviors for patients with hypertension.
Teaching Related to Drug Therapy
Side effects of antihypertensive therapy are common and may be severe or undesirable, impacting adherence.
Informing the patient about side effects that may reduce over time can encourage continued therapy.
The number or severity of side effects can relate to the dose; it may be necessary to adjust the drug or dose accordingly.
Teach the patient to report all side effects to the healthcare provider (HCP).
A common side effect of several antihypertensive drugs is orthostatic hypotension, which results from changes in the autonomic nervous system's mechanisms for regulating BP during position changes.
Patients may feel dizzy and faint when transitioning to an upright position after sitting or lying down.
Table 36.13 presents specific measures to help the patient manage or decrease orthostatic hypotension.
Sexual problems may occur with many antihypertensive drugs, significantly impacting treatment adherence. Issues can range from reduced libido to erectile dysfunction.
Patients may hesitate to discuss sexual issues with their HCP and might stop therapy instead.
Approach the topic sensitively and encourage open communication; explaining that the medication may be the cause can help facilitate this discussion.
Changing to another antihypertensive drug can help alleviate or reduce these side effects, and patients should be encouraged to discuss these issues with their HCP. Offer to alert the HCP about the patient’s side effects if necessary.
Many options exist for treating hypertension, and the goal should be to find a management plan that is acceptable to the patient.
Some unpleasant side effects result from a drug's therapeutic action but can be managed. For example, diuretics may cause dry mouth and frequent urination:
Suggest using sugarless gum or hard candy to relieve dry mouth.
Advise taking diuretics earlier in the day to limit nighttime voiding and improve sleep.
Home Blood Pressure Monitoring
Most patients with known or suspected hypertension should monitor their BP at home.
Readings taken at home are often lower than those in an office setting and are a better predictor of cardiovascular disease (CVD) risk.
Home BP readings can help improve adherence by reinforcing the need for ongoing therapy.
However, some patients may become overly concerned with their BP readings. It's important to provide information about their target BP and its significance.
Patient teaching is critical to ensure accuracy:
Advise patients to purchase an oscillometric BP monitor that uses a cuff for the upper arm or wrist.
Instruct patients to bring their BP monitor to the office to verify proper cuff size, accuracy of the device, and technique.
Teach the patient to obtain BP as per the steps in Table 36.11.
Measure BP in the nondominant arm or the arm with the higher BP if there is a known difference.
Encourage measuring BP first thing in the morning (ideally before taking any medications) and at night before bed.
Instruct the patient to record all BP measurements and bring the record to office visits.
For clinical decision-making (e.g., changes in dosage or starting new medication):
Patients should take BP readings as outlined for 1 week.
Stable, normotensive patients should measure morning and evening BP for at least 1 week every 3 months.
Devices that have memory or printouts of the readings are convenient for reporting.
Patient Adherence
A significant problem in the long-term management of hypertension is poor adherence to the treatment plan.
Reasons for nonadherence can include:
Inadequate patient teaching
Low health literacy
Unpleasant drug side effects
BP returning to normal range with therapy
High cost of drugs
Lack of insurance
It is important to determine the reasons for nonadherence:
Assess the patient’s diet, activity level, and lifestyle as indicators of adherence.
Develop a plan with the patient and caregiver to improve adherence:
The plan should be compatible with the patient’s habits, cultural beliefs, and lifestyle.
Active participation increases adherence.
Involve the patient in choosing affordable drugs.
Engage caregivers to help increase adherence.
Substituting combination drugs for multiple drugs once the BP is stable may promote adherence:
Combination drugs reduce the number of pills per day and may lower costs.
Help the patient and caregiver understand:
Primary hypertension is a chronic illness that cannot be cured but can be controlled with:
Drug therapy
Diet changes
Physical activity
Periodic follow-up
Other relevant lifestyle modifications.