HTN

Question 1

Hypertension

Answer 1

Types of HTN:
1. PRIMARY (90-95%) – Cause is unknown

2. SECONDARY (5-10%) – i.e. Tumor
3. MALIGNANT: >180/120 mmHg – depending on the cause, treatment will vary in attempt to gradually reduce to normal

BP category:

1. Normal: <120 SBP and <80 DBP
2. Elevated: 120-129 SBP and <80 DBP
3. HTN (stage 1): 130-139 SBP and 80-90 DBP
4. HTN (stage 2): >140 SBP and >90 DBP

**Classified on 2 or more visits

Question 2

Pathophysiology of primary HTN

Answer 2

Factors affecting BP:

1. Cardiac output – Ability to pump blood (SV x HR)
2. Vascular resistance – Peripheral resistance, water and sodium retention, RAAS

Factors affecting HTN:

1. SNS – Stimulated = Increased BP and HR
2. Vascular volume (water and sodium retention) – High Na intake
3. RAAS – Low blood volume stimulates secretion of renin that converts angiotensinogen to angiotensin I, which further converts to angiotensin II (a powerful vasoconstrictor)

**Angiotensin II stimulates the secretion of aldosterone from the adrenal cortex which increases sodium and water resorption, increasing circulating volume and BP

Question 3

Clinical manifestations of primary HTN

Answer 3

Clinical manifestations
1. Increased BP – No symptoms; Severe HTN: May experience painful HA, confusion, hallucination, vision problems, nosebleeds, N/V (increased ICP)

2. Vascular damage due to HTN – Heart disease (CAD, HF), peripheral vascular disease (atherosclerosis), cerebrovascular disease (stroke), nephrosclerosis (elevated BUN, Cr., proteinuria, hematuria), retinal damage (blurred vision, retinal hemorrhage, vision loss)

Question 4

Risk factors

Answer 4

HTN risk factors:
1. Age

2. Alcohol and tobacco use
3. DM
4. Elevated serum lipids
5. Na intake
6. Gender (men)
7. FHX
8. Obesity – especially truncal
9. Sedentary lifestyle
10. Socioeconomic status
11. Stress

Question 5

Modifiable vs. fixed risk factors

Answer 5

MODIFIABLE risk factors:

1. Current cigarette smoking, secondhand smoking
2. DM
3. DLP
4. Hypercholesterolemia
5. Overweight/obesity
6. Physical inactivity
7. Unhealthy diet

FIXED risk factors:

1. CKD
2. FHX
3. Increased age
4. Low socioeconomic/education status
5. Gender (male)
6. Obstructive sleep apnea
7. Psychosocial stress

Question 6

Diagnostics

Answer 6

Tests:
1. BP – Sitting with back supported, no ingestion of caffeine/exercise/smoke within 30min. of reading, appropriate size cuff

2. Rule out secondary cause
3. Evaluate end organ disease
4. Determine CV risk – EKG, lipid profile
5. Establish baseline levels (prior to therapy)
6. Labwork – CBC, chem panel (BUN, Cr., calcium), lipid profile (LDL, HDL, trigs.), serum uric acid, FBG
7. 24 hr. Cr. clearance
8. LFTs
9. Serum thyroid stimulating hormone
10. Eye exam
11. Urinalysis
12. EKG

Question 7

Medical management

Answer 7

Non-pharmacologic:
Lifestyle changes – Diet, exercise, decrease stress, weight loss

Medication management:
1. ACE inhibitors (angiotensin converting enzyme inhibitors)

2. ARBs (angiotensin II receptor blockers)
3. Calcium channel blockers
4. Thiazide diuretics (retain calcium, excrete potassium)

Question 8

Nursing management

Answer 8

1. Assessment
2. Monitor for end organ damage
3. Non-pharmacologic intervention – Diet, exercise, weight loss, smoking cessation
4. Medication management – BP prior to meds., monitor electrolytes, I&Os, decrease pill burden, drug teaching, BP monitoring at home, daily weight

Question 9

Complications & end organ damage

Answer 9

Neuro – CVA, HTN encephalopathy (confusion, HA, convulsion)

Heart – MI, HTN cardiomyopathy (HF)

Lungs

GU – HTN nephropathy (CKF)

Periphery – HTN neuropathy (elevated BG)

Vision – HTN retinopathy

Question 10

Diet

Answer 10

DASH (Dietary Approaches to Stop HTN):
1. Potassium (3,500-5,000mg/day)

2. Low sodium (<1,500mg/day) – Hidden sources: Condiments, cheese/dairy, canned soup/vegetables, breakfast cereals, baked goods, deli meat, “low salt”/”heart healthy”, salty sweets
3. Limit alcohol intake – <2 drinks/day (men) and <1 drink/day (women)

Question 11

Exercise

Answer 11

1. Aerobic (90-150 min./week)
2. Dynamic resistance (90-150 min/week)
3. Isometric resistance

Question 12

Decrease in HTN per intervention

Answer 12

Intervention:
1. DASH diet – 11 mmHg

2. Reduction of sodium – 5-6 mmHg
3. Potassium-rich diet – 4-5 mmHg
4. Moderation of alcohol – 4 mmHg
5. Weight loss – 1 mmHg/kg lost
6. Aerobic exercise – 5-8 mmHg

Question 13

Pt education

Answer 13

Promote:
1. Prevention of complications

2. Identifying risk factors – Pt and family assessment (comprehensive dietary recall, lifestyle log, daily habits), resources
3. Enabling self-care – daily BP, dangerous S/S, follow up PCP once/month