Chapter 33 Hypertension

Question 1

What are the rules for taking a proper BP?

Answer 1

BP is generally higher in the am. Make sure the cuff is the proper size and the arm is at the level of the heart. measure both arms, use arm with higher BP for reading in the future. PTs shouldnt smoke, exercise, or drink caffeine 30 minutes before. they should sit quietly and rest 5 minutes with arm supported at heart level. Both feet should be flat on the floor, and the back supported. Take BP first thing in the morning (before meds) and at night before bed. Take 2 readings, wait 1 minute b/t each. Single value isnt as important as a series of values.

Question 2

Modifiable risk factors for hypertension

Answer 2

Age, alcohol, cigarette smoking, diabetes mellitus, high lipids, high sodium

Question 3

Nonmodifiable risk factors for hypertension

Answer 3

Gender, family history, obesity, ethnicity, sedentary lifestyle, stress

Question 4

Hypertension

Answer 4

persistant SBP of 140 or more, diastolic BP of 90 or more, or current use of hypertensive meds

Question 5

Prehypertension

Answer 5

SBP of 120-139 or DBP of 80-89

Question 6

Isolated systolic hypertension

Answer 6

average SBP of 140 or more, coupled with average DBP of less than 90. SBP increases with aging. BP rises with aging, DBP rises until age 55, then declines. Control of ISH decreases incodence of stroke, heart failure, and death

Question 7

White coat hypertension

Answer 7

BP rises when they’re at the docs office, will need to monitor BP at home

Question 8

Pseudohypertension

Answer 8

False HTN that occurs when person has severe atherosclerosis. Arteries dont collapse when cuff is inflated so pressure is falsely elevated. The only way we know they have this is if their arteries feel rigid and they have no other organ changes from the HTN. The only way to get accurate BP is via arterial line

Question 9

What are the signs/symptoms of HTN?

Answer 9

•	“Silent killer”
•	No s/s until organ disease occurs
•	Fatigue
•	Activity intolerance
•	Dizziness
•	Palpitations
Angina
•	Dyspnea
•	Hyptertensive crisis causes severe headache, nosebleeds – not typical HTN

Question 10

What are we most concerned about when we give the initial dose of a beta-blocker?

Answer 10

• Beta blockers - BB makes me LOL “lols”- Used for HTN, angina, dysrhythmias, post-MI (prevents another MI); not recommended for heart failure or asthmatics—
• Propranolol
• Atenolol
• Metoprolol

Question 11

What are we most concerned about when we give the initial dose of an ACE inhibitor?

Answer 11

• Angiotensin-Converting Enzyme (ACE) inhibitors – ACE is a real “Pril” “prils”
• Side effects – dry cough, low BP, high potassium, angioedema (swelling of the lips and face - must stop the drug if they have this side effect)
• Benzepril
• Captopril
• Enalapril
• Lisinopril

Question 12

What are the diet recommendations with DASH?

Answer 12

• DASH Eating Plan
– Emphasizes fruits, veggies, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, nuts
– Decreased red meat, salt, sweets, added sugars, sugared beverages
– No restrictions on caffeine or protein
• Sodium restriction
–

Question 13

Diuretics?

Answer 13

• Diuretics
– Lasix, hydrochlorothiazide, spironolactone (K+ sparing)
– Used for HTN, fluid overload
– Decreases preload by decreasing fluid buildup
– Side effects – low potassium (except for spironalactone), low magnesium, dehydration (remember if potassium is low, digoxin toxicity is a higher risk)
– Take in the morning (so they aren’t up all night)
– No drugs for prehypertension unless diabetic or chronic kidney disease
– Many people require 2 or more BP meds from different classes
– Diuretics are often given as first line treatment even though they aren’t actually anti-hypertensives

Question 14

Beta blockers?

Answer 14

• Beta blockers - BB makes me LOL “lols”
– Used for HTN, angina, dysrhythmias, post-MI (prevents another MI); not recommended for heart failure or asthmatics
– Blocks the effects of epinephrine (sympathetic nervous system), decreases HR, lowers BP, lowers cardiac output, vasodilates, decreases contractility (pumping strength)
– Side effects – fatigue, impotence, wheezing or shortness of breath (that’s why we don’t use it in asthmatics)

Question 15

Angiotensin-Converting Enzyme (ACE) inhibitors?

Answer 15

ACE is a real “Pril” “prils”
– Used for HTN, heart failure, diabetes (to protect the kidneys); can prevent heart attack and stroke
– Lowers levels of angiotensin II, lowers BP, vasodilates (decreases afterload)
– Side effects – dry cough, low BP, high potassium, angioedema (swelling of the lips and face - must stop the drug if they have this side effect)
– Don’t take with ASA or NSAIDs, Need diuretic

Question 16

Angiotensin II Receptor Blockers (ARB) “sartans”?

Answer 16

– Used for HTN, heart failure; give if unable to tolerate an ACE
– Blocks angiotensin II from having any effect, lowers BP, vasodilates (decreases afterload)
– Side effects – high potassium, decreased kidney function
– Can take awhile to work so don’t use it as first line treatment for BP, can use for those on an ACE bothered by cough
– ARBs are used when patients can’t tolerate ACEs, action is very similar
– Losartan
– Valsartan
– Irbesartan

Question 17

Calcium channel blockers – CC is such a DIP “dip” (amlodipine) or “pine”, also Diltiazem, Verapamil

Answer 17

– Used for angina, HTN, dysrhythmias; do not use after MI or with heart failure; not used as first line treatment for BP
– Interrupts the movement of calcium into the cells of the heart, vasodilates (decreases afterload), decreases contractility (pumping strength)
– Side effects – bradycardia, low BP, headache, dizziness, nausea
– Do not give with grapefruit juice
– CC is such a DIP (amlodipine), Van-Diesel (calcium channel blockers – verapamil, amlodipine, nifedipine, diltiazem)
– These drugs are not used as first-line treatment

Question 18

Alpha adrenergic blockers

Answer 18

– Clonidine, Hytrin, Cardura
– Used for HTN, BPH (benign prostatic hypertrophy)
– Vasodilates, lowers BP, lowers cardiac output
– Side effects – dry mouth, sedation, fatigue, impotence, low BP-Don’t take with alcohol or sedatives, may need to take at bedtime
-Alpha adrenergic blockers are often used for prostate issues instead of as an anti-hypertensive

Question 19

Vasodilators

Answer 19

– Nitrates
– Used for angina, HTN (for those who can’t take an ACE), MI, heart failure
– Vasodilates (decreases afterload), decreases preload
– Side effects – headache, low BP, dizziness
– Must monitor BP (needs to be above 100 to give), repeat every 5 minutes for 3 times, keep in dark area, must ask if they have taken any erectile dysfunction drugs prior to giving vasodilators
– Rarely used as a primary tx for HTN, usu. used for angina

Question 20

What symptoms would make you think of secondary HTN? What do we do differently in the workup for secondary versus primary HTN? Why?

Answer 20

If someone suddenly develops a high BP very quickly- hypertensive crisis
We would look at BUN/crea. Treatment is aimed at removing or treating the underlying cause. Secondary hypertension is a contributing factor to hypertensive crisis

Question 21

What is the side effect of IV Nipride? What is the required nursing care?

Answer 21

SE= orthostatic hypotension.
Nursing care: Monitor ECG for dysrhythmias. Admin by continuous IV infusion with pump. Intraarterial monitoring of BP recommended. Wrap IV solutions with an opaque material to protect from light. Stable for 24 hr. Metabolized to cyanide, then thiocyanate. Monitor thiocyanate levels with prolonged use (>3days) or doses (>4 mcg/kg/min).
*Check BP q 2-3 mins

Question 22

What are the complications of HTN? Which ones are most concerning?

Answer 22

• Hypertensive Heart Disease
– CAD, left ventricular hypertrophy, heart failure
• Cerebrovascular Disease
– Atherosclerosis, stroke, HTN encepalopathy
• Peripheral Vascular Disease
– PVD, aortic aneurysm, aortic dissection
• Nephrosclerosis
– End-stage renal disease, renal dysfunction
• Retinal Damage
– Blurred vision, retinal hemorrhage, blindness
• PVD – intermittent claudication is common symptom (pain with walking/exercise, subsides with rest – c/b too little blood flow during exercise)
• Nephrosclerosis – nocturia is common symptom
• Retinal damage tells us the severity and duration of HTN
• HTN= #1 cause of stroke

Question 23

What is the most common reason for a patient prescribed anti-hypertensives to have continued high blood pressure?

Answer 23

Noncompliance d/t:
• Many common side effects, can be severe enough pts won’t take the medications
– Orthostatic hypotension
• Check HR (>50) and BP (>100) before giving, use caution with first dose, get up slowly, safety
– Sexual dysfunction
• Change to another drug
– Potassium
• Most make it low, but ACE or ARB can make it high
– Dry mouth: Gum or candy
– Nocturia: Take early in the day

Question 24

What are the complications of a hypertensive crisis? Which are most concerning?

Answer 24

• Can develop over hours or days
• Rate of rise, not actual BP, is most important (MAP is also more important than actual BP)
• Most common cause is failure to take routine BP medications
• Another cause is cocaine/crack use
• S/S – severe headache, n/v, seizures, confusion, coma, papilledema, tremors, decreased urine output
• Most common cause of hypertensive crisis is failure to take their meds causing rebound hypertension (not stress or cold medications)
• Looks a lot like a stroke but no focal or lateralizing symptoms of stroke
• Complications include angina, MI, pulmonary edema (chest pain, dyspnea), aortic dissection (sudden, excruciating chest/back pain, reduced/absent pulses in the extremities), stroke

Question 25

What is a common side effect of Lasix? How does that side effect affect Digoxin?

Answer 25

– Side effects – low potassium (except for spironalactone), low magnesium, dehydration (remember if potassium is low, digoxin toxicity is a higher risk)