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Monitor blood pressure periodically. Measure
both arms three times; 3-5 minutes apart while
patient is at rest, then sitting, then standing for
initial evaluation. Use correct cuff size and
accurate technique.


Comparison of pressures provides a more

complete picture of vascular involvement or
scope of problem. Severe hypertension is
classified in the adult as a diastolic pressure
elevation to 110 mmHg; progressive diastolic
readings above 120 mmHg are considered first
accelerated, then malignant (very severe).
Systolic hypertension also is an established
risk factor for cerebrovascular disease and
ischemic heart disease, when diastolic pressure
is elevated.

Note presence of, quality of central and

peripheral pulses.

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 (increased systemic
vascular resistance [SVR]) and venous

Auscultate heart tones and breath sounds.

S4 heart sound is common in severely

hypertensive patients because of the presence
of atrial hypertrophy (increased atrial volume
and pressure). Development of S3 indicates
ventricular hypertrophy and impaired
functioning. Presence of crackles, wheezes
may indicate pulmonary congestion secondary
to developing or chronic heart failure.

Observe skin color, moisture, temperature and

capillary refill time.

Presence of pallor; cool and moist skin and

delayed capillary refill may be due to
peripheral vasoconstriction or decreased
cardiac output.


Maintain activity restrictions (bed rest) and

assist patient with self- care activities.

It reduces physical stress and stimuli that affect

the blood pressure.

Provide calm, restful surroundings, minimize

environmental activity and noise.

Helps lessen sympathetic stimulation;

promotes relaxation.

Provide comfort measures (back and neck

massage, elevation of head).

Decreases discomfort and may reduce

sympathetic stimulation.

Instruct in relaxation techniques, guided

imagery, distractions

Can reduce stressful stimuli, produce calming

effect, thereby reducing BP.


The use of a mental picture or an imagined

event that involves use of the five senses to
distract oneself from stressful stimuli.

Distraction techniques such as

talking with the patient,
watching and listening to

Heightening one's concentration upon non

painful stimuli to decrease one's awareness and
experience of pain and stress. Some methods
are breathing modifications and nerve

a. Music therapy

Relaxation exercises

Deep breathing exercises

Functions as a distracter from hospital noise

thereby reducing emotional anxiety and pain.
(Gardner et al, 2009)
Techniques used to bring about a state of
physical and mental awareness and tranquility.
The goal of these techniques is to reduce
tensions, subsequently reducing pain. Also
helps reduce skeletal muscle tension, which
will reduce intensity of pain.

By voluntarily changing the rate, depth, and

pattern of breathing, we can change the
messages being sent from the bodys
respiratory system to the brain. In this way,
breathing techniques provide a portal to the
autonomic communication network through
which we can, by changing our breathing

patterns, send specific messages to the brain

using the language of the body, a language the
brain understands and to which it responds.
Messages from the respiratory system have
rapid, powerful effects on major brain centers
involved in thought, emotion, and behavior.

Dependent: Administer medications as indicated:

Thiazide diuretics: chlorothiazide (Diuril);
hydrochlorothiazide (Esidrix/HydroDIURIL);
bendroflumethiazide (Naturetin); indapamide
(Lozol); metolazone (Diulo); quinethazone

Diuretics are considered first-line medications

for uncomplicated stage I or II hypertension
and may be used alone or in association with
other drugs (such as beta-blockers) to reduce
BP in patients with relatively normal renal
function. These diuretics potentiate the effects
of other antihypertensive agents as well, by
limiting fluid retention, and may reduce the
incidence of strokes and heart failure.

Loop diuretics: furosemide (Lasix);

ethacrynic acid (Edecrin); bumetanide
(Bumex), torsemide (Demadex);

These drugs produce marked diuresis by

inhibiting resorption of sodium and chloride
and are effective antihypertensives, especially
in patients who are resistant to thiazides or
have renal impairment.

Potassium-sparing diuretics:spironolactone
(Aldactone); triamterene (Dyrenium);
amiloride (Midamor);

May be given in combination with a thiazide

diuretic to minimize potassium loss.

Alpha, beta, or centrally acting adrenergic

antagonists: doxazosin (Cardura); propranolol
(Inderal); acebutolol (Sectral); metoprolol
(Lopressor), labetalol (Normodyne); atenolol
(Tenormin); nadolol (Corgard), carvedilol
(Coreg); methyldopa (Aldomet); clonidine
(Catapres); prazosin (Minipress); terazosin
(Hytrin); pindolol (Visken);

Beta-Blockers may be ordered instead of

diuretics for patients with ischemic heart
disease; obese patients with cardiogenic
hypertension; and patients with concurrent
supraventricular arrhythmias, angina, or
hypertensive cardiomyopathy. Specific actions
of these drugs vary, but they generally reduce
BP through the combined effect of decreased
total peripheral resistance, reduced cardiac
output, inhibited sympathetic activity, and
suppression of renin release. Note: Patients

with diabetes should use Corgard and Visken

with caution because they can prolong and
mask the hypoglycemic effects of insulin. The
elderly may require smaller doses because of
the potential for bradycardia and hypotension.
African-American patients tend to be less
responsive to beta-blockers in general and may
require increased dosage or use of another drug
(monotherapy with a diuretic).
Calcium channel antagonists: nifedipine
(Procardia); verapamil (Calan); diltiazem
(Cardizem); amlodipine (Norvasc); isradipine
(DynaCirc); nicardipine (Cardene)

May be necessary to treat severe hypertension

when a combination of a diuretic and a
sympathetic inhibitor does not sufficiently
control BP. Vasodilation of healthy cardiac
vasculature and increased coronary blood flow
are secondary benefits of vasodilator therapy.

Adrenergic neuron blockers: guanadrel

(Hylorel); guanethidine (Ismelin); reserpine
Direct-acting oral vasodilators:hydralazine
(Apresoline); minoxidil (Loniten);

Reduce arterial and venous constriction

activity at the sympathetic nerve endings.

Direct-acting parenteral
vasodilators:diazoxide (Hyperstat),
nitroprusside (Nitropress); labetalol

These are given intravenously for management

of hypertensive emergencies.

Angiotensin-converting enzyme (ACE)

inhibitors: captopril (Capoten); enalapril
(Vasotec); lisinopril (Zestril); fosinopril
(Monopril); ramipril (Altace). Angiotensin II
blockers: valsartan (Diovan), guanethidine

The use of an additional sympathetic inhibitor

may be required for its cumulative effect when
other measures have failed to control BP or
when congestive heart failure (CHF) or
diabetes is present.

Action is to relax vascular smooth muscle,

thereby reducing vascular resistance.

A high salt intake has been shown to increase BP (He et al 2013). The
recommended daily intake of salt is no more than 6g (one teaspoon)
per day, however many people are unaware they may be consuming
9g of salt or more per day as a result of the high quantity in processed

food, including ready-meals and takeaways. Reducing salt intake to 6g

or less daily will help to lower BP (He et al 2013).
Nurses can help patients by explaining food labels to enable them to
avoid foods high in fat, saturated fat, salt and sugar and by describing
what one portion of fruit or vegetables constitutes so they can increase
their consumption. Fruit juices and smoothies are popular, but only one
glass of fruit juice per day can be included in the portion count (150mL
of unsweetened 100% fruit juice). Smoothies need to contain the
correct amount of fruit or vegetables to be included in the portion
count (NHS Choices 2013).

Exercising for at least 30 minutes per day five times each week can
lower BP, and patients require support to develop and maintain a
routine appropriate for their age and physical ability (NHS choices
2014b). The link between alcohol intake and hypertension is well
documented (Taylor et al 2009), however over 10 million adults exceed
the recommended alcohol limits (National Audit Office 2008), which is
14 units per week for women and 21 units for men (NICE 2011a).
Assisting patients to calculate their alcohol intake and stay within the
recommended limits can help to reduce BP.

The different classes of drug available to treat primary hypertension

are angiotensin-converting enzyme (ACE) inhibitors, angiotensin
receptor blockers (ARB), calcium channel blockers, thiazide-like
diuretics, aldosterone antagonists, alpha-blockers and beta-blockers.
The average BP reduction with any one drug at the standard dose is
about 10/5mmHg and adding another drug class lowers BP further
(Wald et al 2009). Most patients need two or more classes of medicines
to achieve BP control (Chobanian et al 2003). Where possible, drugs
taken once daily should be prescribed to promote adherence. For each
major class of antihypertensive drug, there will be indications and
contraindications for use in specific patient groups (Williams et al
Angiotensin-converting enzyme inhibitors or angiotensin
receptor blockers
An ACE inhibitor or ARB is the recommended first-line treatment
for people under 55 years with primary hypertension (NICE
2011a). Examples of ACE inhibitors include ramipril, lisinopril and
perindopril. ARBs include losartan, candesartan and irbesartan.

Both classes of drug are well tolerated, but ACE inhibitors may
induce a dry cough, which is not dose-related, and angioedema
particularly in people of African-Caribbean origin, and an ARB is
generally preferred (NICE 2011a). ACE inhibitors and ARBs cause
increased serum potassium, which if severe (hyperkalaemia), can
lead to cardiac arrhythmias and cardiac arrest (Williams et al
2004). This is a particular risk if the patient has renal
impairment, and renal function can decline rapidly in bilateral
renal artery stenosis. This occurs when there is clinically relevant
occlusion (generally atherosclerotic) of both renal arteries
(Williams et al 2004). Renal function should be checked before
and within two weeks of commencing treatment (BHS 2012b).
Calcium channel blockers
Calcium channel blockers are more effective in lowering BP in
those aged over 55 and black people of African-Caribbean origin
and are, therefore, recommended as first-line treatment for these
patients (NICE 2011a). This class of drugs can be divided into
dihydropyridines, which include amlodipine, felodipine and
nifedipine, and rate-limiting drugs, which include verapamil and
diltiazem. The adverse effects of dihydropyridines include
headaches and flushing as a result of peripheral vasodilation and
dose-related swelling of the ankles, the risk of which is reduced
by combined use with an ACE inhibitor or ARB (Fogari et al 2007).
Palpitations and gum hypertrophy can also occur (BNF 2013).
Rate-limiting calcium channel blockers cause less ankle oedema,
but can cause bradycardia and verapamil can cause constipation
(BNF 2013). Rate-limiting calcium channel blockers are
contraindicated for anyone with heart block or heart failure and
patients taking beta-blockers because there is an increased risk
of heart block and heart failure (BHS 2012b). When combining
simvastatin with a calcium channel blocker the recommended
maximum dose is 20mg as higher doses increase the risk of
myopathy and/or rhabdomyolysis (BNF 2013).
Thiazide-like diuretics
Thiazide-like diuretics include chlortalidone and indapamide. If
BP remains above target levels despite maximally tolerated
doses of an ACE inhibitor or ARB and calcium channel blocker,
adding a thiazide-like diuretic is recommended (NICE 2011a). A
thiazide-like diuretic is also recommended as first-line therapy if

a calcium channel blocker is not tolerated or the person has

oedema, evidence of heart failure or a high risk of heart failure
(NICE 2011a). Thiazide diuretics bendroflumethiazide and
hydrochlorothiazide are no longer recommended because there
is more evidence for the efficacy of thiazide-like diuretics (NICE
2011a). However, if the patients BP is controlled using a thiazide
diuretic then there is no need to change this regimen. Adverse
effects such as a marked fall in serum potassium may indicate
primary hyperaldosteronism, which occurs when the adrenal
gland produces too much aldosterone causing hypertension, and
it is recommended that the patient undergoes further
investigations such as a blood test to measure renin and
aldosterone levels (Beevers et al 2007). Other adverse effects
include raised uric acid increasing the risk of gout and raised
glucose levels increasing the risk of new onset diabetes (BHS
A biphasic relationship between alcohol and blood pressure has been
observed. Small amounts of alcohol are associated with vasodilatation and a
slight fall in blood pressure. As alcohol consumption increases, blood
pressure rises, presumably because of the effect on sympathetic nervous
system (SNS) activity and cardiac output. Habitual consumption of >1 oz of
pure alcohol/day (representing 2 oz of 100-proof spirits, 8 oz of wine, or 24
oz of beer) is often associated with elevated blood pressure. Reduction in
alcohol intake in such individuals usually lowers blood pressure and, in some
cases, may be all that is required to achieve normal blood-pressure levels.
Asking the patient about his or her alcohol consumption is an important part
of the medical history and may suggest a simple approach to treatment of
Sedentary lifestyle is associated with obesity, elevated blood pressure, and
an increased risk for CVD. Regular exercise is useful in maintaining ideal
body weight, or weight loss in the obese, and also increases cardiovascular
fitness. Few studies have examined the effects of exercise on blood pressure
with controls for the confounding effect of weight loss that typically occurs
when sedentary individuals begin a regular exercise program. Depending on
the type, intensity, and duration of exercise, blood pressure may increase,

stay the same, or decrease during exercise. For example, weightlifting is

associated with marked elevation of blood pressure, with some of the highest
measurements ever recorded in normal subjects. Other forms of vigorous
exercise (ie, running, stair-stepping, vigorous bicycling) are also known to
raise blood pressure. During the cooling-off period, assuming substantial
effort expenditure, vasodilatation and fluid loss from perspiration are usually
associated with a reduction in blood pressure below basal values. When the
presence of vascular disease does not preclude regular exercise, an effort
should be made to pursue a gradual program of exercise progressing to 30
minutes at least 5 days/week of whatever activity is best suited for the
individual. This activity may range from brisk walking to rapid running, stairstepping, cycling, or engaging in vigorous sports. This degree of activity is
shown to have beneficial cardiovascular effects and to raise high-density
lipoprotein (HDL) levels. The key is to select a program that the patient
enjoys and is likely to maintain, and to begin the program gradually, building
up to effective levels over weeks or months.