Question

System Disorder for HTN 1. Alterations in health( Diagnoses) 2. Patho related to the pts problem 3. Health Promotion and Disease Prevention 4. Risk Factors and Expected Findings 5. Laboratory Testing 6. Diagnostic and therapeutic procedures 7. Nursing Care 8. Client Education 9. Medications 10. Complications 11. Interprofessional care

Answer 1

STAGE 1 HYPERTENSION

                        Stage 1 hypertension is a systolic pressure ranging from 130 to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.

Diastolic (bottom) 380 Diagnosis Normal Prehypertension Stage 1 Hypertension Stage 2 Hypertension Hypertensive Emergency Systolic (top) <120 120-139 140-159 >160 80-89 90-99 >100 >180 >120

System disorders of stage 1 Hypertension

Retina of eye Hypertensive Retinopathy Brain Cerebrovascular accident (strokes) Hypertensive encephalopathy: confusion, headache and convulsion Heart: Myocardial infarction (heart attack) ► Hypertensive cardiomyopathy: heart failure Blood Elevated sugar levels Kidneys : Hypertensive nephropathy: chronic renal failure

Pathophysiology of Stage 1 Hypertension

Persistent psychological stress Hypothalamic-pituitary-adrenal and sympathetic-adrenomedullar axes Stress hormones: corticosteroids, catecholamines Recruitment of pro-inflammatory cells Acute phase proteins (CRP, fibrinogen, protein S, -protease inhibitor, etc.) Oxidative stress Pro- inflammatory cytokines Low-grade vascular inflammation Endothelial damage Hypertension Endothelial dysfunction

Hypertension is a chronic elevation of blood pressure that, in the long-term, causes end-organ damage and results in increased morbidity and mortality. Blood pressure is the product of cardiac output and systemic vascular resistance. It follows that patients with arterial hypertension may have an increase in cardiac output, an increase in systemic vascular resistance, or both. Vascular tone may be elevated because of increased α-adrenoceptor stimulation or increased release of peptides such as angiotensin or endothelins. The final pathway is an increase in cytosolic calcium in vascular smooth muscle causing vasoconstriction. Both an increase in systemic vascular resistance and an increase in vascular stiffness augment the load imposed on the left ventricle; this induces left ventricular hypertrophy and left ventricular diastolic dysfunction.

                          The autonomic nervous system plays an important role in the control of blood pressure. In hypertensive patients, both increased release of, and enhanced peripheral sensitivity to, norepinephrine can be found. The renin–angiotensin system is involved at least in some forms of hypertension (e.g. renovascular hypertension) and is suppressed in the presence of primary hyperaldosteronism. Elderly or black patients tend to have low-renin hypertension. Others have high-renin hypertension and these are more likely to develop myocardial infarction and other cardiovascular complications.

Health promotion and disease prevention for hypertension

                         More work is needed to understand barriers to achieving better control and to develop evidence-based interventions. Community and health systems interventions tailored to the populations they serve are recommended as important strategies for attaining better blood pressure control among more people. Sixteen objectives in the HDS Topic Area focus on blood pressure. The federal partners who oversee these HDS objectives support research, data analysis, public health initiatives, and public education activities that will facilitate use of evidence-based strategies to prevent and control hypertension.

         Effectiveness and implementation trials also provide key information. The goal of these trials is to determine effective strategies for delivering proven effective interventions in routine clinical settings. An example of this type of NHLBI sponsored research include the Home Blood Pressure Telemonitoring and Case Management to Control Hypertension study which promotes community efforts to achieve blood pressure control through in-home blood pressure monitoring with the collaboration of pharmacists and primary care physicians. This study plans to evaluate the long term feasibility, and critical factors for translating this intervention into practice.

Risk factors of Hypertension

Risk factors for high blood pressure include:

1. Being overweight or obese
2. Too much salt (sodium) in the diet
3. Too little potassium in the diet
4. Not being physically active
5. Drinking too much alcohol
6. Stress
7. Non-steroidal Anti-inflammatory Drugs (NSAIDs)
8. Cough and Cold Medications (Sudafed and other brands that contain pseudoephedrine and phenylephrine)
9. Certain chronic conditions(DM, Kidney disease)
10. A diet low in vitamin D

Laboratory testing for Hypertension

Tests may be done for several reasons:

• To screen for and diagnose high blood pressure
• To determine whether the cause is an underlying medical condition that can possibly be resolved or controlled
• To evaluate the status of body organs, such as the kidneys, and get a baseline of organ health prior to the start of drug therapies
• To monitor hypertension control and organ status over time

Laboratory tests:

• Urinalysis, urine protein – to help assess kidney function
• Urinary albumin (microalbumin), BUN (blood urea nitrogen), creatinine, estimated glomerular filtration rate (eGFR) – to detect and monitor kidney dysfunction or to monitor the effect of medications on the kidneys
• Potassium – as part of the electrolyte panel, which also includes sodium, chloride, and carbon dioxide (CO2); to evaluate and monitor the balance of the body's electrolytes.
• Fasting glucose, A1c – to help diagnose diabetes and to monitor glucose control over time in people with diabetes
• Calcium – to determine how much total calcium or ionized calcium is circulating in the blood; increased activity of the parathyroid glands, which produces an increase in serum calcium, is associated with hypertension.
• TSH (thyroid stimulating hormone) and T4 – to detect and monitor thyroid dysfunction
• Lipid profile – to evaluate levels of total cholesterol, HDL cholesterol, LDL cholesterol and triglycerides and assess the risk of developing atherosclerosis
• The basic metabolic panel (BMP) includes several of the tests listed above, so it may be ordered instead of the individual tests

Diagnostic and therapeutic procedures for hypertension

To measure your blood pressure, your doctor or a specialist will usually place an inflatable arm cuff around your arm and measure your blood pressure using a pressure-measuring gauge. Doctor will likely take two to three blood pressure readings each at three or more separate appointments before diagnosing you with high blood pressure. This is because blood pressure normally varies throughout the day, and it may be elevated during visits to the doctor (white coat hypertension).

            Doctor may ask to record your blood pressure at home to provide additional information and confirm if you have high blood pressure.Doctor may recommend a 24-hour blood pressure monitoring test called ambulatory blood pressure monitoring to confirm high blood pressure. The device used for this test measures blood pressure at regular intervals over a 24-hour period and provides a more accurate picture of blood pressure changes over an average day and night.

Treatment:

Changing the lifestyle can go a long way toward controlling high blood pressure. Lifestyle changes including:

· Eating a heart-healthy diet with less salt

· Getting regular physical activity

· Maintaining a healthy weight or losing weight if overweight or obese

· Limiting the amount of alcohol drink

But sometimes lifestyle changes aren't enough. In addition to diet and exercise, doctor may recommend medication to lower the blood pressure.

Blood pressure treatment goal depends on how healthy the patient is.

Blood pressure treatment goal should be less than 130/80 mm Hg if:

· Healthy adult age 65 or older

· Healthy adult younger than age 65 with a 10 percent or higher risk of developing cardiovascular disease in the next 10 years

· Have chronic kidney disease, diabetes or coronary artery disease

Although 120/80 mm Hg or lower is the ideal blood pressure goal, doctors are unsure if need treatment (medications) to reach that level.

Nursing Care in Hypertension

The major goals for a patient with hypertension are as follows:

· Understanding of the disease process and its treatment.

· Participation in a self-care program.

· Absence of complications.

· BP within acceptable limits for individual.

· Cardiovascular and systemic complications prevented/minimized.

· Disease process/prognosis and therapeutic regimen understood.

· Necessary lifestyle/behavioral changes initiated.

· Plan in place to meet needs after discharge.

• Maintain/enhance cardiovascular functioning.
• Prevent complications.
• Provide information about disease process/prognosis and treatment regimen.
• Support active patient control of condition.

Client Education in Hypertension

START WITH LIFESTYLE CHANGES IMPROVE YOUR DIET Get physically active Don't smoke Reduce salt (sodium) More vegetables Low fat dairy products Control your weight L85 Whole grains Reduce stress Lean meat, fish and poultry Limit alcohol Women should drink no more than 9 standard drinks per week and men no more than 14 Avoid fast food, canned and prepared foods high in salt and sugar Talk to me or a pharmacist if you eat food or supplements rich in potassium Reduce caffeine Replace shortening, palm oil, coconut oil and lard with healthy fats like olive oil or safflower oil Tell me if you take vitamins or supplements or natural products VITAMINS Copyright NexJ Systems Inc. All Rights Reserved

Medications to treat high blood pressure

· Thiazide diuretics. Diuretics, sometimes called water pills, are medications that act on your kidneys to help your body eliminate sodium and water, reducing blood volume.

Thiazide diuretics are often the first, but not the only, choice in high blood pressure medications. Thiazide diuretics include chlorthalidone, hydrochlorothiazide (Microzide) and others.

· Angiotensin-converting enzyme (ACE) inhibitors. These medications — such as lisinopril (Zestril), benazepril (Lotensin), captopril (Capoten) and others — help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels. People with chronic kidney disease may benefit from having an ACE inhibitor as one of their medications.

· Angiotensin II receptor blockers (ARBs). These medications help relax blood vessels by blocking the action, not the formation, of a natural chemical that narrows blood vessels. ARBs include candesartan (Atacand), losartan (Cozaar) and others. People with chronic kidney disease may benefit from having an ARB as one of their medications.

· Calcium channel blockers. These medications — including amlodipine (Norvasc), diltiazem (Cardizem, Tiazac, others) and others — help relax the muscles of your blood vessels. Some slow your heart rate. Calcium channel blockers may work better for older people and people of African heritage than do ACE inhibitors alone.

Complications of Hypertension

Atherosclerosis Aneurysms Aortic dissections Haematuria Uraemia Proteinemia Chronic kidney disease Complications of Hypertension Pulmonary oedema Myocardial infarction Left ventricular hypertrophy Cardiac failure Haemorrhage / infarction Seizures Vascular dementia Stroke / TIA Haemorrhages Exudates A-V nipping Papilloedema Blindness

Interprofessional care in Hypertension

                      The Team-Based Care for improving Hypertension management (TBC-HTA) study aims to evaluate the effect of a team based care (TBC) interprofessional intervention, involving nurses, community pharmacists and physicians, on BP control of hypertensive outpatients compared to usual care in routine clinical practice.

Improving the management of chronic disease such as hypertension requires a change in health model of care. Interprofessional education can help sharing skills and knowledge among future healthcare professionals. It also helps building a team-based care culture.