NSG 6440 Week 3 Assignment 2 Hypertension: Recent

NSG 6440 Week 3 Assignment 2 Hypertension: Recent

NSG 6440 Week 3 Assignment 2 Hypertension: Recent

Explained the diagnostic criteria to differentiate three types of hypertension.
Identified and explained one classification of hypertension and provided its management and treatment plan.
Used correct spelling, grammar, and professional vocabulary. Cited all sources using APA format.

A Sample Answer For the Assignment: NSG 6440 Week 3 Assignment 2 Hypertension: Recent

Hypertension Management Topics

Hypertension is

• the most common risk factor for MI and stroke
• Strong contributor to heart disease, CHF, and Kidney disease
• Modifiable risk factor for premature cardiac disease
• Smoking
• Dyslipidemia
• DM

Notes:

According to Mills et al. (2020), hypertension, or high blood pressure, is when the pressure inside an individual’s blood vessels exceeds 140/90 mmHg. Hypertension serves as a fundamental danger factor for the development of cardiovascular ailments, including conditions such as stroke, myocardial infarction, cardiac insufficiency, and aneurysm. Managing blood pressure is paramount in maintaining overall health and mitigating the potential hazards of these dangerous diseases.

Blood pressure is

• the primary determinant in the reduction of CV risk

Notes:

Blood pressure is the force the heart exerts to circulate blood throughout the body (Flack & Adekola, 2020). Systolic pressure refers to the pressure exerted by the heart when it propels blood into the arteries. Diastolic pressure refers to the pressure exerted on the arterial walls during the resting phase of the heart, occurring between beats.

The optimal blood pressure range is typically defined as 90/60mmHg to 120/80mmHg. High blood pressure is having a systolic blood pressure of 140 mmHg or higher or a diastolic blood pressure of 90 mmHg or higher. Hypotension is defined as having a blood pressure reading below 90/60mmHg.

Complications associated with hypertension are

• LVH
• HF
• Stroke- ischemic and hemorrhagic
• Ischemic heart disease
• MI
• CKD

Notes:

According to Craciun et al. (2022), most cases involving high blood pressure result in gradual damage over time. If left undetected or untamed, hypertension can result in arterial damage, which can cause blockages that impede blood flow to the cardiac muscle, resulting in a heart attack. High blood pressure can lead to the blockage or rupture of blood vessels that provide blood and oxygen to the brain, resulting in a stroke.

 Heart failure occurs when the heart enlarges and cannot adequately supply blood to the body due to the increased workload caused by high blood pressure. Hypertension can also damage the renal artery and impair the kidneys’ filtration function, resulting in kidney disease or failure.

HTN Stats (CDC, 2016)

• Approximately 1 in 3 adults in America (70 million people) have hypertension.
• 54% of those have their blood pressure under control.
• High blood pressure costs the nation $48.6 billion each year.
• 5% of adults are affected by high blood pressure, half of them have it under control

Notes:

In 2021, hypertension accounted for 691,095 deaths in the United States (Centers for Disease Control and Prevention, 2021). Approximately 48.1% of adults, or 119.9 million individuals, have hypertension. This is characterized by having a systolic blood pressure exceeding 130 mmHg, a diastolic blood pressure exceeding 80 mmHg, or being under medication for hypertension. Approximately 25% of adults diagnosed with hypertension effectively manage their condition.

Approximately 45% of adults with uncontrolled hypertension exhibit a blood pressure reading of 140/90 mmHg or above. This figure encompasses a total of 37 million adults in the United States. Approximately 34 million adults who have been advised to take medication may require a prescription and initiation of treatment. Approximately 19 million individuals, constituting nearly two-thirds of this group, exhibit a blood pressure reading equal to or exceeding 140/90 mmHg.

Hypertension prevalence

SOURCE: https://www.healthypeople.gov/2020/topics-objectives/topic/heart-disease-and-stroke

Notes:

The map illustrates that the counties with the highest prevalence of hypertension, specifically those in the top quintile, are primarily in Mississippi, Louisiana, Arkansas, Oklahoma, Texas, Kentucky, Tennessee, Alabama, Georgia, South Carolina, North Carolina, Virginia, Maine, and Michigan. High-rate counties were also identified in Florida, New Mexico, Arizona, Nevada, and Missouri.

 SOURCE: https://bit.ly/3MDX6y0

Healthy People 2020

• Visit the HP 2020 progress review
• Present your critical thoughts after reviewing slides 6, 7, and 24 – 31.

Key thoughts:

The data on slide 6 indicates a rising economic and health burden associated with heart disease. Heart disease is the primary cause of mortality in the United States. As a result of the findings on slide 7, implementing interventions based on the identified risk factors can potentially lead to a 50% reduction in the prevalence of high blood pressure among adults, as projected.

Slides 24-31 present a comprehensive analysis of hypertension prevalence across various states in the United States, examining different age groups and individuals from diverse ethnic backgrounds. Black individuals experience the highest level of impact (Healthy People 2020 Progress Review, n.d.).

AHA 2017 guidelines for hypertension

• Look at the US Preventative Task Force for who, when, and how often you should be screening for HTN.
• USPSTF
• Annual screening: Adults over the age of 40
• High risk
• 130-139/80-8
• Obese
• African American

Notes:

According to the 2017 guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA), hypertension is diagnosed when blood pressure (BP) reaches or exceeds 130/80 mmHg. The recommended treatment goal for hypertension is to achieve a BP below 130/80 mmHg (Mahato et al., 2021).

The USPSTF recommends annual screening for adults aged 40 and older and individuals with a higher risk of developing high blood pressure. Furthermore, the United States Preventive Services Task Force (USPSTF) advises obtaining blood pressure measurements in non-clinical settings to verify the diagnosis of hypertension prior to initiating treatment.

Risk factors for primary HTN

• Age
• Obesity
• Family Hx (2x as familiar with hypertensive parent)
• Race – African American
• High sodium diet
• Excessive ETOH
• DM
• Dyslipidemia

Notes:

Certain risk factors, such as lousy living choices, provide the potential for modification (Mahato et al., 2021). Certain risk factors, such as advanced age, familial predisposition and genetic makeup, racial and cultural background, and biological sex, are immutable and beyond modification. Engaging in a healthy lifestyle can potentially mitigate the likelihood of acquiring hypertension.

Contributing factors for secondary HTN

●       Prescription/ OTC medications: Oral contraceptives Chronic NSAID use TCA, SSRI Glucocorticoids Decongestants –  pseudoephedrine ●       Weight loss medications ●       Stimulants or illicit drugs ●       Renal Disease ●       Renal artery stenosis ●       CKD

●       Hyperaldosteronism ●       Hypertension ●       Unexplained hypokalemia ●       Metabolic alkalosis ●       Obstructive sleep apnea ●       Pheochromocytoma – paroxysmal HTN ●       Cushing’s syndrome ●       Thyroid disorders ●       Pregnancy ●       Coarctation of the aorta

 

According to the findings of Almeida et al. (2020), secondary hypertension, which constitutes about 10% of all instances of hypertension, manifests when elevated blood pressure arises as a result of an underlying medical condition or the administration of medicines intended for the management of other health conditions.

Several prevalent risk factors for secondary hypertension include the utilization of oral contraceptives or corticosteroids, complications related to the adrenal or thyroid glands, hormonal disorders or pregnancy, the presence of a congenital disability known as coarctation in the aorta of the heart, kidney disease, insufficient blood flow to the kidneys caused by arterial blockage, as well as alcohol abuse or sleep apnea.

Be familiar with the complications of HTN

●       LVH ●       CHF ●       CAD ●       MI ●       Sudden Death ●       Aortic Dissection ●       CVD

●       Proteinuria ●       Renal Insufficiency ●       Atherosclerosis ●       Retinopathy ●       Decline in function- Vascular Dementia, Alzheimer’s Dx

As stated by Almeida et al. (2020), the clinical consequences of chronically elevated blood pressure, often referred to as hypertension, include a range of complications, including erectile dysfunction, cardiovascular disease, atherosclerosis, kidney disease, diabetes, metabolic syndrome, preeclampsia, and eye disease.

Think about the clinical presentation of HTN.

• Often initially not noticed- Preventative Screening is imperative
• Symptoms usually occur as consequences of end-organ damage – stroke, renal dx, retinopathy, aortic dissection, sequelae of LVF
• 2nd HTN – usually present with s/s consistent with the underlying cause

Notes:

Based on the findings of Di Palo and Barone (2020), it is observed that the majority of people with high blood pressure do not exhibit any apparent symptoms. Numerous symptoms, such as headaches, poor vision, chest pain, and other related manifestations, may be brought on by elevated blood pressure levels. The most effective method for determining the presence of high blood pressure is monitoring one’s blood pressure.

Understand the following HTN information

• Identify target organ damage
• Identify signs of secondary HTN
• Identify reversible exacerbating factors
• Develop a baseline to document the progression

Notes:

According to Di Palo and Barone (2020), hypertension is associated with target organ damage affecting several bodily systems, including the vasculature, heart, brain, and kidneys. Secondary hypertension symptoms may exhibit variability contingent upon the specific ailment or disease that coexists with elevated blood pressure. Several illnesses may present with symptoms, such as pheochromocytoma, Cushing’s syndrome, thyroid disorders, Conn’s syndrome, and obstructive sleep apnea.

However, certain risk factors may be reversed by various interventions, including smoking cessation, stress management, adoption of a better diet low in sodium, engagement in regular physical activity, and weight loss. The utilization of pulse wave velocity as a predictive measure has been seen in the context of monitoring the advancement of blood pressure and the emergence of hypertension among individuals in the young adult population.

Your assessment should include, at a minimum

●       Aggravating factors: ●       Medications ●       ETOH ●       Diet ●       Duration: ●       Last known normal blood pressure ●       Previous attempts at treatment ●       Medications ●       Presence of risk factors for CV disease

●       Smoking ●       DM ●       Dyslipidemia ●       Physical inactivity ●       Family History ●       Sleep Apnea ●       Snoring ●       Daytime somnolence ●       Psychosocial Factors

 

Di Palo and Barone (2020) state that the comprehensive assessment of a patient with hypertension requires more than just identifying increased blood pressure. The comprehensive evaluation should include an assessment of cardiovascular disease (CVD) risk, target organ damage, and concurrent clinical diseases that may impact blood pressure (BP) or associated target organ damage.

Additionally, it is essential to recognize any indications that may imply secondary hypertension. Specific investigations are considered regular and are essential for all patients, while others are only required for select patient groups based on their medical history, clinical examination, and standard testing. The pathophysiology of hypertension in some hereditary types is attributed to a solitary genetic mutation.

Look for signs / Sx of target organ damage

• Heart: Chest pain, palpitations, activity intolerance, etc.
• Brain: dizziness, confusion, transient loss of function
• Kidneys: history of renal disease
• Peripheral arterial disease: intermittent claudication
• Retinopathy: visual disturbances

Notes:

Following the research conducted by Di Palo and Barone (2020), it is recommended that auscultation of the heart, renal arteries, and carotid arteries be performed on all patients. In that order, identifying murmurs, which can be heard using the stethoscope, should prompt further examinations, including carotid ultrasonography, echocardiography, and renal ultrasound.

The presence of an irregular pulse often suggests the presence of atrial fibrillation, a condition that should be verified by the use of an electrocardiogram (EKG). Laboratory analyses are used to identify supplementary risk variables, ascertain or eliminate the presence of secondary hypertension, identify clinical or subclinical harm to target organs and evaluate the overall risk of cardiovascular disease.

Review Metabolic Syndrome

• three or more of the following:
  • Abdominal obesity: Waist circumference >40” men >35” women
  • Glucose intolerance: Fasting glucose >110
  • High Triglycerides: >150
  • HTN : >130/85
  • Low HDL: <40

Notes:

Based on Sorrentino’s (2019) findings, a robust correlation exists between hypertension and metabolic syndrome, which may be attributed to the pathophysiological mechanisms involving fat. The recommended first laboratory investigations for individuals suspected of having metabolic syndrome should include routine biochemical analyses to evaluate hyperglycemia and renal impairment and lipid examinations to examine hypertriglyceridemia or low high-density lipoprotein (HDL) levels.

Essential aspects of the PE

• Accurate BP – 2 readings
• Height/Weight/BMI
• Vascular Effects:
  • Retinal exam: Arterial narrowing, AV nicking, exudate, hemorrhage, papilledema
  • Auscultate for carotid, femoral, renal artery, and bruits
• Thyromegaly, nodules

Notes:

The measurement of blood pressure (BP) is vital in evaluating an individual’s cardiovascular well-being, as emphasized by Sorrentino (2019), in the context of patient education. It is advisable to get two successive blood pressure measures to ensure precision. The factors under consideration in this study include height, weight, and body mass index (BMI).

Comprehensive lifestyle change and pharmaceutical treatment education are crucial for optimal blood pressure management and mitigating potential consequences. Implementing weight management techniques, engaging in regular physical exercise, and adopting measures to restrict the consumption of alcohol, tobacco, and smoking are essential strategies for reducing the risk of cardiovascular disease.

Target organ damage secondary causes of HTN

• Derm: Signs of Cushing’s –

            Cause of secondary HTN (striae and hirsutism)

Notes:

The occurrence of hypertension in Cushing’s syndrome is strongly associated with the length of time an individual experiences excessive cortisol levels. The intricate interplay of many pathophysiological systems that control plasma volume, peripheral resistance, and cardiac output—all of which are increased in this condition—leads to this occurrence (Sorrentino, 2019).

• Cardio-Resp: Signs of Heart Failure, Aortic insufficiency
  • Rales, murmurs, tachycardia, S3, S4, lifts, heaves, displaced PMI, edema
  • Abd: masses, bruits, pulsation

Notes:

As a consequence of decreased blood and oxygen flow to the heart caused by impaired arterial elasticity, high blood pressure has the potential to accelerate the onset of cardiovascular disease. Additionally, a decrease in blood flow to the heart muscle may cause the development of chest pain, known medically as angina (Sorrentino, 2019).

• Neuro: focal deficits, h/o TIA or past stroke, cognitive impairment, visual field cuts
• Peripheral Vascular
  • Femoral bruits
  • Femoral pulses (Delayed or absent in aortic coarctation)
  • Symmetrical pulses
  • Lower extremity shin hair loss (shiny)
  • LE edema

Notes:

Elevated blood pressure has the potential to induce the formation of blood clots inside the cerebral arteries, impeding the average circulation of blood and possibly precipitating a cerebrovascular accident (Sorrentino, 2019). Hypertension, often known as high blood pressure, has the potential to inflict damage on arterial structures. Additionally, it exposes individuals to the potential development of peripheral arterial disease (PAD). Peripheral artery disease (PAD) is a pathological condition affecting the arterial system in the lower extremities, resulting in compromised blood circulation.

HEENT

• • Retinal Exam – Arteriole narrowing, AV nicking, exudate, hemorrhage, papilledema
  • Oral Exam – Sleep Apnea
  • Palpate Thyroid
  • Carotid Bruits
  • Neck vein distension

Notes:

Hypertension can result in various detrimental effects on the eye, including retinopathy, optic neuropathy, and choroidopathy (Sorrentino, 2019). The pathophysiological connections between hypertension (HTN) and obstructive sleep apnea (OSA) include activation of the renin-angiotensin-aldosterone system, hypoxemia, nocturnal flow shift, increased sympathetic tone with reduced parasympathetic tone, poor sleep quality.

Thyroid disease affects blood pressure across its entire range. Hyperthyroidism leads to physiological changes, such as heightened cardiac output, increased contractility, tachycardia, widened pulse pressure, reduced systemic vascular resistance, and elevated basal metabolic rate.

Reference images

Go to Uptodate and search on ocular effects of hypertension to find an article with the following images:

• Cotton wool spots ocular effects of hypertension–view images
• Hypertensive retinopathy

Notes:

Hypertensive retinal changes commonly include flame-shaped hemorrhages in the superficial retinal layers and cotton-wool patches resulting from occlusion of the precapillary arterioles, leading to ischemic infarction of the inner retina. (UpToDate, no date). Hypertensive retinopathy encompasses retinal microvascular changes commonly observed in individuals with hypertension. Traditionally, the features are categorized into four degrees, and their morphological classification has been extensively employed.

Diagnostics to understand when treating hypertension

• Electrolytes
• Creatinine
• Fasting glucose
• Urinalysis
• Lipid profile
• Abnormal EKG (LVH)
• Echocardiogram (ejection fraction)

Notes:

The potential of ambulatory blood pressure monitoring (ABPM) or home blood pressure monitoring (HBPM) to validate newly diagnosed cases of hypertension offers a promising solution to address the problem of excessive diagnoses and the resulting negative consequences.

These consequences include unnecessary treatments, adverse treatment effects, and misclassifying individuals as having chronic illnesses (Mills et al., 2020). However, the availability of ABPM within the community may be limited. Clinicians use HBPM as a diagnostic instrument. However, there is a lack of regular adherence to specified criteria.

Pregnant Women

• ACE-I/ARB are contraindicated
• Treatment of HTN    
• Methyldopa
• Beta-blockers
• Vasodilators

Notes:

IV labetalol and hydralazine are commonly used as initial treatments for acute-onset, arterial severe hypertension in pregnant and postpartum women. According to Mandras et al. (2020), oral nifedipine may be a viable option for initial treatment.

African Americans

• Prevalence and severity of HTN is elevated
• Generally respond best to Thiazide and CCB rather than ACE-I; monotherapy recommended for improved response to treatment
• Angioedema with ACE-I occurs 2-4x more frequently

Notes:

Lifestyle modifications, including regular physical activity, adherence to a nutritious diet, and maintaining a healthy body weight, have effectively reduced blood pressure levels. The preferred initial choices for Black adults requiring medication are usually a  calcium channel blocker or thiazide diuretic (Mandras et al., 2020).

Lifestyle Modifications

• Review Dash diet
• Weight Loss: ca 1 mm Hg for every 1 pound
• Decrease ETOH
  • Women – 1 drink/day women
  • Men – 2 drinks/day
• Aerobic Exercise-30 min most days
• Smoking Cessation
• Stress Reduction
  • Yoga or meditation
  • Muscle relaxation

Notes:

Effective lifestyle changes for improving health include smoking cessation, stress reduction, alcohol moderation, and regular exercise. The DASH diet recommends consuming foods high in potassium, calcium, and magnesium for individuals with hypertension. The DASH diet emphasizes consuming vegetables, fruits, and whole grains. 

These lifestyle changes are effective individually, but their combined use often yields the most significant benefits. Given the typically modest impact of lifestyle modifications, individuals with hypertension often need to supplement these changes with medication to attain their target blood pressure levels (Mandras et al., 2020).

Treatment goals

Review when you should initiate treatment and what your goals are.

• Non-black population (including diabetics):
  • Thiazide, CCB, ACE or ARB
• Black population (including diabetics)
  • Thiazide or CCB
• Age >18 years w/CKD
  • ACE or ARB

Notes:

Treating hypertension aims to reduce elevated blood pressure levels and safeguard vital organs, such as the brain, heart, and kidneys, against potential harm (Mandras et al., 2020). Pharmacological treatment for hypertension (HTN) should be initiated within four weeks of diagnosis of HTN. The initial treatment options for blood pressure medication are thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin II receptor blockers (ARBs), particularly for individuals with kidney disease and heart failure.

Thiazide diuretics

• Act by decreasing blood volume/cardiac output
• Decrease peripheral resistance during chronic therapy
• No added benefit of increasing HCTZ higher than 25mg daily – add the second agent
• Drug of choice for pts with no comorbidities, African Americans, obese individuals, and elderly

Notes:

The mechanism of action (MOA) of thiazide diuretics involves the reduction of sodium reabsorption, leading to a subsequent decrease in fluid reabsorption. Consequently, this process directly results in lower levels of circulating sodium (Mandras et al., 2020).

Side Effects/Precautions

• Hypokalemia
• Hyponatremia
• Hyperglycemia
• Hyperuricemia
• Hyperlipidemia
• Not safe in renal and hepatic insuff
• Favorable – Osteoporosis

Notes:

Hypokalemia is the primary adverse effect of thiazide diuretics (Mandras et al., 2020).As previously mentioned, hypokalemia occurs due to the actions of the Na/K pump in the CT, which are mediated by aldosterone. Thiazide diuretics reduce sodium reabsorption, leading to a decrease in fluid reabsorption. Consequently, this results in reduced levels of circulating sodium, which can cause hyponatremia. Thiazide diuretic use can lead to hypokalemic metabolic alkalosis in patients. This is caused by the enhanced excretion of potassium and hydrogen ions in the intercalated cells of the cortical collecting tubule, mediated by aldosterone.

Ang