Risk factors may include
a. Increased vascular resistance, vasoconstriction
b. Myocardial ischemia
c. Ventricular hypertrophy or rigidity
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
a. Participate in activities that reduce BP and cardiac workload.
b. Maintain BP within individually acceptable range.
c. Demonstrate stable cardiac rhythm and rate within normal range.
Independent Nursing Intervention
1. Measure BP in both arms or thighs. Take three readings, 3 to 5 minutes apart while client is at rest, then sitting, and then standing for initial evaluation. Use correct cuff size and accurate technique. Take note of elevations in systolic as well as diastolic readings.
Rationale: Serial measurements using correct equipment provide a more complete picture of vascular involvement and scope of problem. Progressive diastolic readings above 120 mm Hg are considered first accelerated, then malignant (very severe). Systolic hypertension also is an established risk factor for cerebrovascular disease and ischemic heart disease even when diastolic pressure is not elevated. In younger client with normal systolic readings, elevated diastolic numbers may indicate prehypertension.
2. Note presence and quality of central and peripheral pulses.
Rationale: Bounding carotid, jugular, radial, and femoral pulses may be observed and palpated. Pulses in the legs and feet may be diminished, reflecting effects of vasoconstriction and venous congestion.
3. Auscultate heart tones and breath sounds.
Rationale: S4 is commonly heard in severely hypertensive clients because of the presence of atrial hypertrophy. Development of S3 indicates ventricular hypertrophy and impaired cardiac functioning. Presence of crackles or wheezes may indicate pulmonary congestion secondary to developing or chronic heart failure.
4. Observe skin color, moisture, temperature, and capillary refill time.
Rationale: Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation and decreased output.
5. Note dependent and generalized edema.
Rationale: Indicates heart or kidney failure or vascular impairment.
6. Provide calm, restful surroundings, minimize environmental activity and noise. Consider limiting the number of visitors or length of visitation.
Rationale: Helps reduce sympathetic stimulation and promotes relaxation.
7. Maintain activity restrictions during crisis situation such as bedrest or chair rest and schedule periods of uninterrupted rest; assist client with self-care activities as needed.
Rationale: Reduces physical stress and tension that affect BP and the course of hypertension.
8. Provide comfort measures, such as back and neck massage or elevation of head.
Rationale: Decreases discomfort and may reduce sympathetic stimulation.
9. Instruct in relaxation techniques, guided imagery, and distractions.
Rationale: Can reduce stressful stimuli and produce calming effect, thereby reducing BP.
10. Monitor response to medications that control BP.
Rationale: Response to drug therapy is dependent on both the individual drugs and their synergistic effects. Because of potential side effects and drug interactions, it is important to use the smallest number and lowest dosage of medications possible.
Collaborative Nursing Intervention
1. Administer medications, as indicated: Diuretics, for example, thiazide, such as chlorothiazide (Diuril), hydrochlorothiazide (Esidrix, HydroDIURIL), hydrochlorothiazide with triamterene (Diazide, Maxide) or amiloride (Modiuretic), bendroflumethiazide (Naturetin), indapamide (Lozol), metolazone (Mykrox, Zaroxolyn); and loop diuretics, such as furosemide (Lasix), bumetanide (Bumex), and torsemide (Demadex).
Rationale: Diuretics are considered first-line medications for uncomplicated hypertension and may be used alone or in association with other drugs, such as beta blockers, to reduce BP in clients with relatively normal renal function. These diuretics also potentiate the effects of other antihypertensive agents by limiting fluid retention and may reduce the incidence of stroke and heart failure.
2. Potassium-sparing diuretics, such as spironolactone (Aldactone), triamterene (Dyrenium), and amiloride (Midamor).
Rationale: These drugs produce marked diuresis by inhibiting resorption of sodium and chloride and are effective antihypertensives, especially in clients who are resistant to thiazides or have renal impairment. May be given in combination with a thiazide diuretic to minimize potassium loss.
3. Beta blockers, such as doxazosin (Cardura), acebutolol (Sectral), metoprolol (Lopressor), labetalol (Normodyne), atenolol (Tenormin), nadolol (Corgard), carvedilol (Coreg), propranolol (Inderal), methyldopa (Aldomet), clonidine (Catapres), prazosin (Minipress), terazosin (Hytrin), pindolol (Visken), and timolol (Blocarden).
Rationale: Beta blockers are recommended for BP control in clients with heart failure and cardiovascular disease. Cardioselective beta blockers, such as acebutolol, atenolol, and metroprolol, primarily affect -1 receptors in the heart, slowing heart rate and decreasing the heart’s workload. Nonselective beta blockers, such as propranolol and timolol, also decrease the heart’s workload and promote vasodilation, but they exert effects on the -2 receptors on the bronchioles as well, potentially increasing symptoms of reactive airway disease and chronic obstructive pulmonary disease. Cardioselective beta blockers are safer choices for patients with pulmonary disorders (Woods & Moshang, 2006).
4. Calcium channel blockers, such as nifedipine (Adalat, Procardia), verapamil (Calan, Isoptin, Verelan), diltiazem (Cardizem), amlodipine (Norvasc), isradipine (DynaCirc), nicardipine (Cardene), and felodipine (Plendil).
Rationale: Calcium channel blockers are categorized into two types. One group, such as amlodipine, diltiazem, and isradipine, primarily affects blood vessels and can be used to treat severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP.
5. Direct-acting oral vasodilators, such as hydralazine (Apresoline) and minoxidil (Loniten).
Rationale: Action is to relax vascular smooth muscle, thereby reducing vascular resistance.
6. Direct-acting parenteral vasodilators, such as diazoxide (Hyperstat), nitroprusside (Nitropress), and labetalol (Normodyne).
Rationale: These are given intravenously (IV) for management of hypertensive emergencies.
7. Angiotensin-converting enzyme (ACE) inhibitors, such as captopril (Capoten), enalapril (Vasotec), benazepril (Lotensin), lisinopril (Zestril), fosinopril (Monopril), ramipril (Altace), moexipril (Univasc), and trandolapril (Mavik).
Rationale: ACE inhibitors are generally considered first-line drugs for clients with documented congestive heart failure (CHF), diabetes, and those at risk for renal failure.
8. Angiotensin II receptor blockers (ARBs), such as candesartan (Atacand), olmesartan (Benicar), valsartan (Diovan), losartan (Cozaar), and irbesartan (Avapro).
Rationale: ARBs block the action of angiotensin II. As a result, blood vessels dilate and BP is reduced.
9. Aldosterone blockers, such as eplerenone (Inspra) and spironolactone.
Rationale: Aldosterone antagonists block the effects of aldosterone on the kidneys, allowing the kidneys to excrete extra sodium and water, thereby reducing BP.
10. Implement dietary restrictions, as indicated, such as reducing calories and avoiding refined carbohydrates, sodium, fat, and cholesterol. (Refer to ND, imbalanced Nutrition.)
Rationale: Limiting sodium and sodium-rich processed foods can help manage fluid retention and, with associated hypertensive response, decrease myocardial workload. A diet rich in calcium, potassium, and magnesium may help lower BP.
11. Prepare for surgery when indicated.
Rationale: When hypertension is due to pheochromocytoma, removing the tumor corrects the condition.