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Hypertension Nursing Guide

The content for this course was created by Kathleen Koopmann, RN, BSN, PCCN.

Hypertension Overview

This course is intended as a Quick Reference for hypertension and will cover an overview as well as nursing considerations utilizing the nursing process. 

Hypertension Etiology and Epidemiology 

Hypertension is a global problem and is defined as a sustained elevation of arterial blood pressure. The term high blood pressure is how most people refer to hypertension. 

According to the American Heart Association (2017), a person must fit into one of the following stages to receive a diagnosis of hypertensive: 

  • Elevated systolic blood pressure (BP) 120 to 129 mmHg and a diastolic BP less than 80 mmHg 
  • Stage 1 hypertension: Systolic BP 130 to 139 mmHg or diastolic BP 80 to 89 mmHg 
  • Stage 2 hypertension: Systolic BP 140 mmHg or higher or diastolic BP 90 mmHg or higher 
  • Hypertensive crisis: Systolic BP ≥ 180 mmHg and/or diastolic BP ≥ 120 mmHg 

Hypertension is considered a standalone heart disease that leads to hypertensive heart disease. There are two categories of hypertension, essential and secondary. 

The cause of essential hypertension is idiopathic and accounts for approximately 95% of all hypertension diagnoses. 

The cause of secondary hypertension is other pathology and accounts for about 5% of all hypertension diagnoses. 

More than one billion people globally have hypertension (Iqbal & Jamal, 2021). There is an increased prevalence of hypertension that is consistent across all socio-economic statuses. 

Hypertension prevalence increases with age affecting close to 60% of adults over the age of 65. It is the leading cause of disability and death across the globe. Hypertension accounts for more cardiovascular disease-related deaths in the U. S. than any other modifiable risk factor. 

Some risk factors for hypertension are modifiable and others are not. Modifiable risk factors for developing hypertension include: 

  • Cigarette smoking or second-hand smoke exposure 
  • Diabetes 
  • Being overweight 
  • High cholesterol 
  • Unhealthy diet, such as diets high in sodium or excess of alcohol consumption 
  • Physical inactivity 
  • High stress level 

The risk factors for hypertension that are either not modifiable or difficult to control include: 

  • Obstructive sleep apnea 
  • Chronic kidney disease 
  • Male gender 
  • Increasing age 
  • Race/ethnicity 
  • Family history of hypertension 
  • Elevated blood pressure during medical treatment (white coat syndrome) 

Hypertension has been referred to as the silent killer and often occurs without symptoms. Approximately one-third of individuals with hypertension in the U. S. are not aware of their condition (DynaMed, 2018). The chief complaint for those suffering from hypertension is a headache. 

Other symptoms of hypertension include: 

  • Headaches upon rising 
  • Nose bleeds 
  • Irregular heart rhythms 
  • Visual changes 
  • Buzzing or ringing in the ears 

The symptoms of more severe hypertension can include: 

  • Chest pain 
  • Confusion 
  • Nausea 
  • Vomiting 
  • Muscle tremors 
  • Fatigue 
  • Anxiety 

Over time, hypertension leads to other complications, which include: 

  • Stroke 
  • Heart attack 
  • Damage to the kidneys, retinas, and peripheral nervous system 

Hypertension Diagnosis 

The best way to detect hypertension is through regular blood pressure screening. The routine screen should be done annually during visits to a healthcare provider, who will evaluate the individuals for risks or associated conditions. Home blood pressure monitoring can also be done in between routine healthcare visits. 

The recommendation from the American Heart Association (2017) is that anyone over the age of 20 receives blood pressure screenings annually. Generally, a healthcare provider will take at least two blood pressure readings on at least two visits before diagnosing hypertension. Blood pressure should be taken in a relaxed position with the arm elevated to the heart level. 

Once hypertension is diagnosed, other studies can be done to determine its effects on the body. These studies include (Nettina, 2019): 

 Electrocardiogram (ECG) to determine effects on the heart 

  • Chest X-ray to look for cardiomegaly, aortic dilation, or widened mediastinum 
  • Laboratory studies such as urine protein, serum blood urea nitrogen, and creatine to check for kidney damage 
  • Renal ultrasound if indicated 
  • Routine ambulatory blood pressure checks 
  • Other tests to rule out secondary causes of hypertension 

Hypertension Management 

Treatment of hypertension includes nonpharmacological or pharmacological therapy or both (Iqbal & Jamal, 2021). 

 Nonpharmacological management is recommended for all individuals with hypertension regardless of gender, age, risks, or comorbidities. 

Nonpharmacological treatment includes lifestyle changes such as: 

  • Educating regarding risk factors for hypertension 
  • Controlling weight 
  • Lowering sodium in diet 
  • Smoking cessation 
  • Controlling diabetes 
  • Eliminating stress 
  • Increasing physical activity 
  • Managing sleep apnea 

Pharmacological therapy consists of single or combination medications to control blood pressure, such as: 

  • Angiotensin receptor blockers: Valsartan (Diovan®) or candesartan (Atacand®) 
  • Thiazide diuretics: Hydrochlorothiazide (HydroDiuril®) or metolazone (Zaroxolyn®) 
  • Calcium channel blockers: Amlodipine (Norvasc®) or nifedipine (Procardia®) 
  • Beta-blockers: Atenolol (Tenormin®) or metoprolol (Lopressor®) 

Age, race, and comorbidities should be taken into consideration when choosing pharmacologic therapy. 

There are three different organizations that each have established their own recommendations for treating hypertension (Iqbal & Jamal, 2021). Many healthcare providers follow the guidance set by one of these organizations. 

 The Joint National Committee (JNC-8) start pharmacologic therapy for: 

  • High-risk individuals with conditions such as diabetes, heart disease, or chronic kidney disease. 
  • Individuals over 60 years old with BP ≥ 150/90 
  • Individuals 18 to 59 years old with systolic BP ≥ 140 mmHg 
  • A general goal of BP ≤ 140/90 mmHg 

American College of Cardiology (ACC) start pharmacologic therapy for: 

  • Consider 10-year atherosclerotic cardiovascular disease risk 
  • BP readings consistently ≥ 140/90 mmHg 
  • High-risk individuals with conditions such as diabetes, heart disease, or chronic kidney disease. 
  • A general goal of BP ≤ 130/80 mmHg 

European Society of Cardiology and European Society of Hypertension (ESC/ ESH) start pharmacologic therapy for: 

  • Treat according to a grade of hypertension 
    • Grade 1: Systolic blood pressure 140 to 159mmHg and/or diastolic BP 90 to 99mmHg 
    • Grade 2: Systolic blood pressure 160 to 179mmHg and/or diastolic BP 100 to 109mmHg 
    • Grade 3: Systolic blood pressure ≥180mmHg and/or diastolic BP ≥110mmHg 
  • Grade 2 or 3 hypertension 
  • Grade 1 hypertension if there is organ damage 
  • Individuals over 80 years old with BP ≥160/90 mmHg 
  • Individuals 18 to 79 years old if BP ≥ 140/90 mmHg 

Hypertension Nursing Care Plan

Nursing Considerations 

Use the nursing process to develop a plan of care for individuals. The nursing assessment (with common findings listed), diagnoses, interventions, expected outcomes, and education for hypertension are listed below. 

Assessment 

Assess signs and symptoms, such as: 

  • Vital signs 
  • Blood pressure in both arms 
  • Adventitious heart sounds 
  • Bruit over aorta 
  • Mental status 
  • Family history of high BP 
  • Dietary habits/sodium intake 
  • Skin color, temperature, and moisture 
  • Capillary refill time 
  • General or dependent edema 
  • Concurrent organ disease such as diabetes, chronic kidney disease, or coronary artery disease 
  • Tobacco use 
  • Symptoms of hypertension: 
    • Headaches 
    • Weakness 
    • Muscle cramps
    • Palpitations 
    • Sweating 
    • Visual disturbances 
    • Use of medications that cause elevated BP: 
    • Hormone replacement therapy 
    • Corticosteroids 
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) 
    • Nasal decongestants 
    • Appetite suppressants 
    • Tricyclic antidepressants 
  • Overweight 
  • Physical activity level 
  • Response to activity 
  • Stress level 
  • Sleep apnea 

Nursing Diagnosis/Risk For 

  • Risk for decreased cardiac output related to hypertension, as evidenced by (Phelps, 2021a): 
    • Hypertension 
    • Increased peripheral resistance 
  • Deficient knowledge related to modifiable risk factors for hypertension as evidenced by (Phelps, 2021b): 
    • Lack of knowledge of disease process 
    • Modifiable risk factors present 
  • Decreased activity tolerance related to fatigue as evidenced by (Phelps, 2021c): 
    • Generalized weakness 
    • Sedentary lifestyle 

Interventions 

  • Provide a calm, restful atmosphere 
  • Monitor vital signs 
  • Report increases in BP to the healthcare provider 
  • Maintain activity restrictions 
  • Provide comfort measures 
  • Administer intravenous or oral antihypertensive medications as ordered 
  • Monitor for side effects of medications 
  • Monitor output 
  • Monitor serum electrolytes 
  • Observe for central nervous system complications: 
    • Confusion 
    • Irritability 
    • Lethargy 
    • Disorientation
  • Monitor cardiac rhythm until BP is stable 
  • Explain risk factors for hypertension 
  • Reinforce the importance of following treatment regimens and follow up appointments 
  • Encourage regular activity through an individualized exercise program 
  • Provide a low sodium or no added salt diet 

Expected Outcomes 

  • Participates in activities to reduce BP 
  • Maintains BP within a specified range 
  • Verbalizes understanding of disease process and treatment regimen 
  • Understands side effects of medications 

Individual/Caregiver Education 

  • Condition, treatment, and expected outcomes 
  • Notify healthcare provider or seek immediate medical care for: 
    • o BP ≤ 90/60 
    • Dizziness or lightheadedness 
    • Syncope 
    • Palpitations or racing heart 
    • BP ≥ 150/90 
    • Increasing or returning symptoms of hypertension: 
      • Headaches 
      • Weakness 
      • Muscle cramps 
      • Palpitations 
      • Sweating 
      • Visual disturbances 
    • If BP ≥ 180 systolic or ≥ 120 diastolic, notify 911 
  • Side effects of medications 
  • Lifestyle modifications: 
    • Salt restricted diet 
    • Regular activity 
    • Smoking cessation 
    • Weight control 
    • Stress reduction 
  • Blood pressure self-monitoring daily and when symptomatic 
  • Importance of taking antihypertensives as ordered: 
    • Avoid skipping doses 
    • Do not alter the dose or take a make-up dose if missed 
    • Do not discontinue without notifying the healthcare provider 
    • Do not take with over the counter medications without consulting a healthcare provider 

Treatments for Hypertension

To assist the healthcare team in keeping up to date with antihypertension medications, including those used in combination for antihypertensive emergencies.

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Additional Information

Content Release Date

4/1/2022

Content Expiration

12/31/2025

Course Contributor 

The content for this course was created by Kathleen Koopmann, RN, BSN, PCCN. Kathleen earned her Associate Degree in nursing in 1987 at Mid-Michigan Community College and her Bachelor of Science in nursing in 2018 from Western Governor’s University. She has training from the North Carolina Statewide Program for Infection Control and Epidemiology through NCDHHS and the University of North Carolina. Kathleen has worked in long-term care, outpatient care, acute care, and nursing education. She has hospital experience in Med-Surg, OR/PACU, Critical Care, Telemetry, and outpatient experience in Occupational Health. Kathleen has experience as a clinical instructor for the LPN program at Susquehanna County Career and Technical Center in Pennsylvania. Most recently, she worked in long-term care as a Staff Development Coordinator and Infection Control Practitioner. 

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References 

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