A clinical presentation on hypertension and it's complications and management

This is a presentation on hypertension,it's clinical features , etiology, sign and symptoms and management

1. HYPERTENSION

2. Peripheral Vascular Diseases Medical surgical Nursing-MSN II NURS 304 Lecturer :Salihu A. Kombo, -RN, MSc.

3. HYPERTENSION

4. OBJECTIVES Paticipants will be able to: 1. Define and classify hypertension. 2. Demonstrate adequate knowledge of the causes, pathophysiology and management of patients with hypertension and related problems. 3. Utilize nursing process approach in the care of patients with hypertension and related problems

5. Definition of Hypertension Hypertension The term hypertension is used to describe a level of blood pressure that, taking all other cardiovascular risk factors into account, would benefit the patient if reduced. It is therefore not possible to have a definitive blood pressure value that is classified as ‘hypertension’, but measurements above 140/90 mmHg are considered higher than ‘normal’ . Hypertension may be defined as a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg, based on two or more measurements. Hypertension : Is a sustained elevation of arterial blood pressure above average or normal range, considering the sex, age and race of the individual.

6. This disease is usually asymptomatic until the damaging effects of hypertension (such as stroke, myocardial infarction, renal dysfunction, visual problems, etc.) are observed. Hypertension is a major risk factor for coronary artery disease, myocardial infarction ("heart attacks") and stroke.

7. The care of people with hypertension needs a significant amount of nursing skills and resources. This condition remains one of the highest causes of morbidity and mortality among adults and the aged in Nigeria. 

8. The condition is chronic rather than curable and requires a lot of skillful nursing care. The patient and family need a lot of education on the care and management of the condition. The cause of hypertension in majority of cases is unknown. 

9. Impact of Hypertension Hypertension is a major risk factor for atherosclerotic cardiovascular disease, HF, stroke, and kidney failure. Hypertension carries the risk for premature morbidity or mortality, which increases as systolic and diastolic pressures rise. Prolonged blood pressure elevation damages blood vessels in target organs (heart, kidneys, brain, and eyes).

10. Classification of Hypertension Classified as follows: • Normal: systolic less than 120 mm Hg; diastolic less than 80 mm Hg • Prehypertension : systolic 120 to 139 mm Hg; diastolic 80 to 89 mm Hg •Stage 1: systolic 140 to 159 mm Hg; diastolic 90 to 99 mm Hg •Stage 2: systolic ≥160 mm Hg; diastolic ≥100 mm Hg

11. FACTORS THAT MAINTAIN BLOOD PRESSURE Blood pressure is determined by cardiac output and peripheral resistance. Change in either of these parameters tends to alter systemic blood pressure, although the body’s compensatory mechanisms usually adjust for any significant change.

12. A. Cardiac output Cardiac output: amount of blood ejected per contraction, which is determined by the stroke volume ( The stroke volume is determined by the volume of blood in the ventricles immediately before they contract, i.e. the ventricular end-diastolic volume (VEDV), sometimes called preload. In turn, preload depends on the amount of blood returning to the heart through the superior and inferior venae cavae (the venous return) .

13. heart rate the rate at which the heart beats Average normal adult_ Child_ The main factors affecting heart rate Gender Autonomic (sympathetic and parasympathetic) nerve activity Age Circulating hormones, e.g. adrenaline (epinephrine), thyroxine Activity and exercise Temperature The baroreceptor reflex Emotional states

14. Factors that affect the heart rate and stroke volume are described above, and they may increase or decrease cardiac output and, in turn, blood pressure. An increase in cardiac output raises both systolic and diastolic pressures. An increase in stroke volume increases systolic pressure more than it does diastolic pressure.

15. B. Peripheral or arteriolar resistance Arterioles are the smallest arteries and they have a tunica media composed almost entirely of smooth muscle, which responds to nerve and chemical stimulation. Constriction and dilation of the arterioles are the main determinants of peripheral resistance. Vasoconstriction causes blood pressure to rise and vasodilation causes it to fall. When elastic tissue in the tunica media is replaced by inelastic fibrous tissue as part of the ageing process, blood pressure rises.

16. Control of blood pressure (BP) Blood pressure is controlled in two ways: short-term control , on a moment-to-moment basis, which mainly involves the baroreceptor reflex, discussed below, and also chemoreceptors and circulating hormones long-term control , which involves regulation of blood volume by the kidneys and the renin–angiotensin – aldosterone system.

17. Short-term blood pressure regulation The cardiovascular centre (CVC) is a collection of interconnected neurones in the medulla and pons of the brain stem. The CVC receives, integrates and coordinates inputs from: baroreceptors (pressure receptors) chemoreceptors higher centres in the brain. The CVC sends autonomic nerves (both sympathetic and parasympathetic) to the heart and blood vessels. It controls BP by slowing down or speeding up the heart rate and by dilating or constricting blood vessels. Activity in these fibres is essential for control of blood pressure. The two divisions of the autonomic nervous system, the sympathetic and the parasympathetic divisions

18. Long-term blood pressure regulation Long-term blood pressure control is mainly exerted by the renin – angiotensin–aldosterone system (RAAS, and the action of antidiuretic hormone (ADH,). Both of these systems regulate blood volume, thus influencing blood pressure. In addition, atrial natriuretic peptide (ANP,), a hormone released by the heart itself, causes sodium and water loss from the kidney and reduces blood pressure, opposing the activities of both ADH and the RAAS.

19. CLASSIFICATION OF HYPERTENSION (Based on Cause) Primary/essential/idiopathic:- It is mostly of unknown cause, found among the elderly, bussiness men and highly excitable people. Secondary/non essential/pathological- this results from other disease conditions that tend to directly or indirectly affect the blood vessels or have an impact on the central nervous sytem that controls the activity of blood veessels.

20. CAUSES Approximately 90% of people with hypertension have primary, essential hypertension; the remaining 10% have secondary hypertension.   PRIMARY Unknown/ Idiopathic Hereditary - Lifestyle/ habits Chronic anxiety /Excitability Excessive smoking

21. Aging process Obesity SECONDARY Drugs .- Renal disorders e.g. Sclerotic changes, chronic nephritis, nephrotic syndrome etc. Circulatory disorders Metabolic and endocrine causes Pregnancy induced. Endocrine disosers e.g. Tumor of adrenal cortex,cushion syndrome, diabettes mellitus, thyroidtoxicosis etc.

22. CONT. Circulatory causes: eg. Atheroclerisis,arteriosclerosis, coartation of the aorta etc. Medication causes: eg. Oral contraceptives. Miscelleneous causes: eg. Pregnancy.

23. PATHOPHYSIOLOGY OF HYPERTENSION 1. As a result of arteriosclerosis ( hardening,shrinking or narrowing of the artery) due to old age or the under aged possessing decompositionof fatty substanses within the lumen of arteries (atherosclerosis) the heart on attempt to supply sufficient blood increases its action to force enough blood to the target area, the volume of blood increases within the narrowed lumen thus bringing about

24. increasd pressure (hypertension) 2.On renal diseases , any condition that reduces blood flow to the kidney or destroys the renal functional tissue causes hypertension. Conditions like sclerotic changes, stenosis of renal artery, nephritis e.t.c The ischaemic kidney reacts by secreting a proteolytic enzyme called renin. The renin acts upon a plasma protein to produce angiotensin I which is also converted to angiotensin II by another enzyme.

25. The angiotensin II causes vasoconstriction of the arterioles and increases peripheral resistance leading to an elevation of arterial blood pressure. Angiotensin II is also alleged to increase secretion of aldesterone by adrenal gland which causes increase blood pressure through its influence on sodium and water retention.

26. CONT. 3.On endocrine disrders where there’s existance of tumour of the adrenal medula which may be single or multiple the tumour cells secret adrenaline in the same way as normal medullary cells which produce vasoconstriction and increase cardiac out put with a corresponding elevationin artrial blood pressure. It is only the removal of the tumour(s) that can restore the individual to a normal blood pressure.

27. An increased output of aldosterone by the cortex of the adrenal glands may also be responsible for hypertension as aldosterone increases the reabsorption of sodium by the kidney leading to water retention and expansion of intra vascular volume thereby increasing the arterial blood pressure.Aldosterone also have direct vasoconstricting effect

28. 4.On medications e.g women taking contraceptives develop hypertension as it is thought that the oestrogen component of pills may be responsible by stimulating hepatic synthesis of angiotensinogen which leads to increased amount of angiotensin. In this case its only when the contraceptives agents are discontinued(which may last for six months) before blood pressure returns to normal.

29. MANIFESTATIONS OF HYPERTENSION - Throbbing occipital headache or migraine due to elevated blood pressure or vascular damage -Palpitations and easy fatigability as result of over activity of the heart and loss of nutrients -Epistasis,haematuria,blurring of vission due to vascular damage/disease -Weakness or dizziness due to transient cerebral ischaemia. -

30. Angina pectoris, dyspnoea are due to cardiac failure. -Pain due to dissection of the aorta -Secondary hypertension causes polyuria, polydipsia, and muscle weakness due to interference with the kidney or nephron of the kidney -Memory lapses and personality changes due to cerebral vascular damage -Heart, kidney and brain damage due to persistent hypertension

31. DIAGNOSTIC PROCEDURES Hypertension should not be considered on the basis of just a single blood pressure measurement. 1.Initial elevated reading should be confirmed on 2 subsequent occasions with average levels of diastolic pressure above 90mmHg or systolic pressure of above 140mmHg 2.Investigate several systems to identify the cause e.g existence of renal problems e.t.c

32. History and physical examination, including retinal examination; laboratory studies for organ damage, including urinalysis, blood chemistry (sodium, potassium, creatinine, fasting glucose, total and high-density lipoprotein); ECG; and echocardiography to assess left ventricular hypertrophy. •Additional studies, such as creatinine clearance, renin level, urinalysis and 24-hour urine protein, may be performed.

33. Medical Mgt Medical Management The goal of any treatment program is to prevent death and complications by achieving and maintaining an arterial blood pressure at or below 140/90 mm Hg (130/80 mm Hg for people with diabetes mellitus or chronic kidney disease), whenever possible. • Nonpharmacologic approaches include weight reduction; restriction of alcohol and sodium; regular exercise and relaxation. A DASH (Dietary Approaches to Stop Hypertension) diet high in fruits, vegetables, and low-fat dairy products has been shown to lower elevated pressures. •Select a drug class that has the greatest effectiveness, fewest side effects, and best chance of acceptance by patient. Two classes of drugs are available as first -line therapy: diuretics and beta-blockers. •Promote compliance by avoiding complicated drug schedules

34. MANAGEMENT MEDICAL ANTI-HYPERTENSIVE DRUGS- examples Beta adrenergic blocking agents. Vasodilators- Aldomet , Apresoline . Arterial vasodilators- Guanithedine Angiotensin converting enzyme inhibitor- captopril Calcium antagonist- Nifedipine Rauwolfia Alkaloids- Reserpine.

35. DIURETICS Frusemide Spironolactone SEDATIVES SURGERY Surgical intervention if it is due to conditions like wilm’s tumour or Phaeochromocytoma . 

36. NURSING CARE- USING NURSING PROCESS APPROACH ASSESSMENT Asses the patient’s blood pressure Assess patient for anxiety, palpitation, headache and dizziness. Assess patient’s needs for rest, dietary regulation and exercise. Asses patient’s intake of drugs Asses patient if there is renal or cardiovascular disorders 

37. IDENTIFIED NURSING DIAGNOSES  . Nursing Diagnoses • Deficient knowledge regarding the relationship between the treatment regimen and control of the disease process • Noncompliance with therapeutic regimen related to side effects of prescribed therapy Activity intolerance related to tiredness, dizziness and blurred vision. Pain related to increased intracranial pressure.

38. Nursing Diagnosis Nursing Objectives Nursing Intervention Scientific Rationale Evaluation

39. PLANNING Develop a nursing care plan based on the identified nursing diagnoses. IMPLEMENTATION Implement patient’s care with emphasis on: Encouraging adequate rest. Relieving anxiety. Relieving headache, chest pain and other pains. Regulating dietary intake which should be low salt/salt free etc. Monitoring patient’s blood pressure.

40. EVALUATION Expected outcomes may include: Relieving patient’s anxiety. Encouraging rest and sleep. Relieving headache, dizziness, blurred vision, etc. Reducing blood pressure to normal range. 

41. COMPLICATIONS 1.Cardiac failure 2.Cerebrovascular accident 3.Retinopathy 4.Renal failure 5.Hypertensive encephalopathy 6.Uraemia 7Cardiac asthma 8.Coronary thrombosis 9.Angina pectoris

42. PREVENTION Regular Blood Pressure Check Maintain a healthy weight Reduce salt intake Increase potassium intake Limit Alcohol intake Regular exercise Avoid stress Stop Smoking

43. CONCLUSION Good cardiovascular function depends on a healthy heart, adequate blood volume and flow to the tissues. A lot of energy is required of patients with hypertension to adhere to lifestyles diet, and activity restrictions and to take regularly prescribed medications. Much supervision, education, and encouragement are often needed by hypertensive persons to arrive at an acceptable plan for living with the disease and treatment regimen. .

44. Compromises may have to be made on some aspects of the therapy to achieve success in higher priority areas. A thorough understanding of the disease process as well as the impact of medication and health habits is important. The concept of hypertension control rather than cure is important to explain