The goal of nursing management of hypertension is to lower blood pressure and assist patients in making lifestyle changes to prevent a recurrence.

• Let’s first understand what hypertension is, its causes, how it occurs, and its clinical symptoms before diving into the specifics of nursing care management for hypertension.
• A blood pressure rise that is greater than the normal limit is called hypertension. The normal blood pressure, according to the Centers for Disease Control and Prevention (CDC), is 130/90 mmHg. Hypertension stage 1 occurs when blood pressure rises above this limit.
• Stage-2 hypertension occurs when blood pressure is 140/90 or higher. Blood pressure greater than 180/120 is considered to be a hypertension crisis.

Epidemiology

The prevalence of hypertension as a lifestyle disorder has increased.

According to data from the World Health Organization (2020), hypertension affects 1.13 billion people worldwide. About one billion people in the aging population have uncontrolled hypertension. More Africans (>40%) than Americans (>35%) are affected.

Hypertension affects about 1.28 billion adults between the ages of 30 and 79. They come from low- or middle-income countries for two-thirds of them.

The irony of having high blood pressure is that 46% of adults do not know they have it. As a result, hypertension is referred to as a “silent killer.”

The following was discovered by a CDC survey from 2017 to 2019:

• Hypertension increases with an increase in age of 22.4% (aged 18–39), 54.5% (40–59), and 74.5% (60 and over).
• The prevalence of hypertension is higher among non-Hispanic blacks (57.1%) than non-Hispanic whites (43.6%) or Hispanic (43.7%) adults.

In 2018, the American Heart Association reported that 103 million adults in the United States had high blood pressure. In the United States of America, the death rate from hypertension increased to 11% between 2015 and 2017.

Hypertension classification

Americal College of Cardiology (ACC)/American Heart Association (AHA) hypertension classification is as follows:

• Normal <120mmHg systolic <80mmHg diastolic
• Stage -1 hypertension- (130–139 systolic or 80–89 mm Hg diastolic)
• stage 2 hypertension (≥140 systolic or ≥90 mm Hg diastolic).

Two or more readings should be taken at different times to classify a patient into one of the aforementioned categories.

Hypertension signs and symptoms

The following are hypertension-related symptoms:

• Severe headache
• Chest pain
• Blurring vision
• Bleeding from nose
• Difficulty in breathing
• Hematuria
• Irregular heartbeat
• Confusion
• Seizure
• Nausea and vomiting
• Pain in neck and back
• Flushing
• Feeling hot
• Lightheadedness
• Dizziness

Diagnostic tests for hypertension

Most cases of primary hypertension are asymptomatic. The most effective method for diagnosing hypertension is an increase in blood pressure following repeated measurements at a different interval.

Diagnostics for secondary hypertension

Causes	Physical examination	Laboratory findings	Tests
Renal parenchymal disease	Mass in abdomen	Presence of protein, erythrocytes, or leucocytes in the urine Decreased Glomerular Filtration Rate	Renal ultrasound All kidney-related laboratory tests
Renal artery stenosis	Abnormal sound (bruit) in the abdomen	Difference of >1.5 cm in length between the two kidneys Decrease in renal function	Renal doppler ultrasound, Magnetic resonance angiography, Spiral computed tomography
Primary aldosteronism	Arrhythmias	Hypokalemia, the presence of adrenal masses	Estimation of aldosterone and renin ratio, oral sodium loading, Captopril tests, Adrenal CT scan.
Pheochromocytoma	Skin stigmata of neurofibromatosis	presence of adrenal or extra-adrenal masses	CT or MRI of the pelvis, Genetic screening for pathogenic mutations
Cushing syndrome	central obesity, moon-face, buffalo hump, red striae, hirsutism	Hyperglycaemia	24-hr urinary cortisol excretion, Dexamethasone-suppression test

Other laboratory investigations for hypertension

• Haemoglobin
• Fasting blood glucose
• Cholesterol profile
• Fasting serum triglycerides
• Kidney function tests
• Estimated glomerular filtration rate
• Urine analysis test
• 12 lead EKG
• Hemoglobin A1c
• Quantitative proteinuria
• ECG
• Holter monitoring
• Carotid ultrasound
• Pulse wave velocity
• Ankle-brachial index
• Ambulatory BP monitoring

Complications of hypertension

Complications such as these can occur if hypertension is not treated:

• Ventricular hypertrophy
• Heart failure
• Atherosclerosis
• Cerebrovascular disease
• Stroke
• Renal failure
• Retinopathy
• Chronic disease
• Inability to comprehend and recall information
• Dementia
• Metabolic syndrome

Management of hypertension

Blood pressure treatment targets

Antihypertensive pharmacotherapy

The morbidity and mortality associated with cardiovascular disease (CVD) are being reduced as antihypertensive medications evolve. First-line antihypertensive medication can be administered alone or in combination with other medications.

• ACE inhibitors, angiotensin II receptor blockers, dihydropyridine calcium channel blockers, and thiazide diuretics are the first-line antihypertensive medications. Additionally, first-line antihypertensive drugs contain beta-blockers. Patients with heart failure and decreased ventricular ejection use it.
• Patients’ efficacy and tolerability should guide the selection of first-line medications. For instance, medications like labetalol or alpha-methyldopa are preferable for gestational hypertension.
• Due to their potential risk of renal teratogenicity, angiotensin II receptor blockers and ACE inhibitors are sometimes contraindicated.
• When antihypertensives are administered in divided doses, adherence is frequently disrupted; consequently, this practice ought to be avoided whenever at all possible.
• A single medication cannot control blood pressure in patients with severe hypertension. Therefore, the patient’s comorbidities and side effects of combining therapies should be taken into consideration.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

• First-line antihypertensives are angiotensin II blockers and ACE inhibitors.
• The effectiveness of ACE inhibitors and angiotensin II receptor blockers is supported by numerous studies. In patients with heart failure and decreased ventricular ejection, these medications are the most frequently prescribed option.
• When compared to other drugs, ACE inhibitors and angiotensin II receptor blockers lower the risk of cardiovascular disease. Patients with type-2 diabetes who are younger also prefer these medications. They improve cough, hyperkalemia, and kidney function.
• One daily dose of ACE inhibitors can be taken.

Dihydropyridine calcium channel blockers

• Calcium channel blockers made of dihydropyridine obstruct calcium channels in smooth muscle. As a result, it has a vasodilatory effect.
  Numerous clinical trials have tested them.
  It can be administered alongside other first-line antihypertensive medications.
  It may cause peripheral edema, decrease cardiac contractility, and slow down the heart rate.
  Constipation is a sign of aging.

Thiazide-type and thiazide-like diuretics

• Sodium absorption is reduced by thiazide diuretics. Urination increased the amount of fluid lost. Plasma and extracellular fluid both shrink as a result. As a result, blood pressure drops, cardiac output decreases, and venous return decreases.
• Diabetes mellitus can result from taking thiazides. Additionally, it causes hypokalemia, hyponatremia, cardiac arrhythmias, muscle weakness, confusion, a seizure, and a coma as side effects.

Beta-adrenoreceptor blockers

• Beta-adrenoreceptor blockers lower blood pressure via lowering heart rate, cardiac output, and renin release. These drugs are beneficial for people with acute myocardial infarction.
  It negatively impacts body weight. Patients with asthma shouldn’t use it because it causes bronchus constriction.

Combining beta-blockers with calcium channel blockers other than those containing dihydropyridine is not advised. Atrioventricular conduction is decreased by this combination.

Newer pharmacological agents for hypertension

• New antihypertensive drugs are constantly being created through research studies. A mixture of recently authorized medications includes:
• Neprilysin and angiotensin II receptor inhibitors (for heart failure)
• medicines that modulate soluble guanylyl cyclase (for erectile dysfunction)
• Inhibitors of sodium-glucose cotransporter 2 (SGLT2) (for type 2 diabetes mellitus)
• Some more recent medications have demonstrated success in treating resistant hypertension.

Treatment of resistant hypertension

• When two or more antihypertensive medications, including diuretics, have been used to treat the problem, the blood pressure remains above 140/90 mmHg.
  Ineffective medication adherence is the primary cause of resistant hypertension. To manage blood pressure, the treatment program needs to be supplemented with one or two additional medications.
  The PATHWAY trial involved patients with resistant hypertension. It was more efficient to add two medications in sequence: a loop diuretic and a mineralocorticoid receptor antagonist.
• Antagonism of the mineralocorticoid receptor was discovered to be an effective medication for resistant hypertension. The danger of hyperkalemia in the patient using this group of medicine calls for routine monitoring of serum potassium levels.

Non-pharmacological management of hypertension

The best treatment for high blood pressure is preventative action. All hypertension patients should modify their lifestyles.

The following list of lifestyle adjustment recommendations:

Reduced salt intake:

• Take salt equal to the amount that is lost in a day.
• WHO recommended <5 g of salt in a day.
• American Society of Hypertension has recommended 3.8 g of salt use in a day.
• Currently, an average of 9 g-12 g of salt is used in most countries.

The authors of a paper entitled “Effect of modest salt reduction on blood pressure: a meta-analysis of randomized trials” are F J He and G A MacGregor. consequences for public health They discovered a link between lower sodium intake and lower blood pressure.

Increased potassium intake: 

• The recommended daily intake of potassium for healthy individuals is 4.7 g. Lower blood pressure has been linked to an increase in potassium intake.
• Increasing your intake of fruits and vegetables is the most effective method for getting more potassium into your body.

Moderate alcohol consumption

A daily alcohol intake of no more than two drinks for males and one drink for women also lowers blood pressure by 2-4 mmHg.

Physical activity

• Doing some physical activities daily also reduces blood pressure.
• Endurance training is also effective for hypertensive patients.
• According to a recent clinical experiment, frequent medium- to high-intensity aerobic exercise lowered blood pressure by an average of 11/5 mmHg.

Weight loss

Blood pressure rises when there is too much fat tissue in the body. Obese patients need more antihypertensive medication to keep their blood pressure under control, according to research.

Nursing management on hypertension

Nursing Assessment for hypertension

Collect data from patients regarding the following:

• Family history of having high blood pressure
• Previous episodes of blood pressure
• Dietary habits and amount of salt intake
• Cigarette smoking
• if the patient is taking steroids, hormonal contraceptives, NSAIDS, nasal decongestants, antidepressants, etc.
  If the patient suffers from certain conditions like asthma, gout, migraine, heart failure, or benign prostatic hyperplasia.

Physical examinations for Hypertension

• Assess your heart sound and pulse rate.
  Do a fundoscopic examination of the eyes if you can to look for any changes in the vascular system. Look at the heart to see if the point of maximum impulse has shifted to the left. It mostly happens when the heart gets bigger.
  To determine whether atherosclerosis is present, listen for noises in the peripheral arteries.
  Do a mental status check to see if your memory, concentration, or ability to do simple math calculations has changed.

Measures to be followed while taking blood pressure

• The same conditions should be used each time to measure blood pressure.
  After stressful situations, do not take your blood pressure.
  After smoking, allow 30 minutes for a blood pressure measurement.
  Make the patient feel at ease and ask him to remain silent while you take his blood pressure.
  Use a BP cuff that is the right size.
  After encircling, the cuff inside the BP cuff must cover 80% of the patient’s hand.
  If you must read consecutively, leave at least two minutes between each reading.