Calcium channel blockers are an alternative for elderly patients and patients with diabetes who can't tolerate other drug types. These agents cause arterial dilatation and a decrease in cardiac output. Because they have long half-lives, calcium channel blockers are useful for once-a-day dosing. Patients shouldn't suddenly change brands because each formulation is very specific. Adverse reactions include palpitations, flushing, headache, and lower extremity edema.
Because most hypertensive patients have primary hypertension, in which the sympathetic and renin-angiotensin-aldosterone systems are hyperactive, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) can help reduce the vasoconstrictive action of angiotensin II. ACE inhibitors and ARBs are preferred for patients with diabetes, as they delay renal-heart disease. However, ACE inhibitors take 4 to 6 weeks to lower BP after treatment has begun. ARBs have been demonstrated to have 24-hour efficacy in treatment. Aldosterone receptor blockers may also be used.
Helping patients stay on track
Deviation from the therapeutic program is a significant problem for patients with hypertension. An estimated 50% of patients discontinue their medications within 1 year of beginning to take them. BP control is achieved by only 34% of hypertensive patients. Patient noncompliance is often due to adverse reactions of medications and lack of knowledge about the consequences of sustained hypertension. Patients complain about the cost of BP medications and the need to take them continuously, and often believe that the medications aren't really working. Other areas of concern are the low palatability of a low-sodium diet. Compliance increases when patients actively participate in self-care, including self-monitoring of BP and diet. Continued education and encouragement are usually needed to enable patients to formulate an acceptable plan that helps them live with their hypertension and adhere to the treatment plan. Compromises may have to be made about some aspects of therapy to achieve higher-priority goals.
The objective of nursing care for hypertensive patients focuses on lowering and controlling BP without adverse reactions and undue cost. To achieve these goals, you must support and teach your patient to adhere to the treatment regimen by implementing necessary lifestyle changes, taking medications as prescribed, and scheduling regular follow-up appointments with his healthcare provider to monitor progress or identify and treat any complications of disease or therapy. Your patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. Emphasize the concept of controlling hypertension rather than curing it.
Encourage your patient to consult a dietitian to help develop a plan for weight loss if indicated. Explaining that it takes 2 to 3 months for the taste buds to adapt to changes in salt intake may help your patient adjust to reduced salt in his diet. Advise him to limit alcohol intake and avoid tobacco use. Support groups for weight control, smoking cessation, and stress reduction may be beneficial for some patients. Assist your patient to develop and adhere to an appropriate exercise regimen because regular physical activity is a significant factor in weight reduction and lowering BP. Also encourage your patient to monitor BP at home and teach him how to do so. Patients need to know that BP varies continuously and that the range within which their pressure varies should be monitored.
The American Heart Association and the National Heart, Lung, and Blood Institute provide printed and electronic patient education materials. Providing written information about the expected effects and adverse reactions of medications is important. Inform your patient that rebound hypertension can occur if antihypertensive medications are suddenly stopped. Also inform both female and male patients that some medications, such as beta-blockers, may cause sexual dysfunction; other medications are available if problems with sexual function or satisfaction occur.
Regular follow-up care is imperative so that the disease process can be assessed and treated. A history and physical exam should be completed at each clinic visit. The history should include all data pertaining to any potential problem, specifically medication-related problems such as postural hypotension.
The beat goes on
The pressure's on to reverse the global epidemic of this preventable condition. The bedside nurse is in the ideal position to encourage patients to adopt necessary lifestyle changes and to follow their prescribed medication regimen.
Diabetes and hypertension
No discussion of hypertension is complete without consideration of diabetes. One-half of patients with insulin-dependent diabetes also have hypertension, and only 10% of diabetic patients achieve adequate control of BP. Hypertension in patients with diabetes should be treated aggressively, with a BP goal of lower than 130/80 mm Hg. If renal disease is also present, the BP goal should be lower than 125/75 mm Hg to prevent further organ damage. Treatment goals for patients with diabetes and hypertension include regular self-monitoring of blood glucose levels and BP, taking medications as prescribed, reporting adverse reactions to the healthcare provider, and implementing strategies for stress reduction. With adequate control of BP, regression of left ventricular remodeling can be achieved in these patients.
Risk factors for cardiovascular problems in hypertensive patients
Major risk factors (in addition to hypertension)
- Dyslipidemia (elevated LDL [total] cholesterol and/or low HDL cholesterol)
- Diabetes mellitus
- Impaired renal function (glomerular filtration rate of less than 60 mL/minute and/or microalbuminuria)
- Obesity (body mass index higher than or equal to 30 kg/m2)
- Physical inactivity
- Age (older than age 55 for men, age 65 for women)
- Family history of cardiovascular disease (in a female relative younger than age 65 or male relative younger than age 55)
Target organ damage or clinical cardiovascular disease
- Heart disease (left ventricular hypertrophy, angina or previous MI, previous coronary revascularization, heart failure)
- Stroke or transient ischemic attack
- Chronic kidney disease
- Peripheral arterial disease
Source: National Heart, Lung, and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure—Complete Report. http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf.
did you know?
According to a new Institute of Medicine report, public health policies should support healthier eating, reduced sodium consumption, and increased physical activity to curb the high rate of hypertension in the United States. Read the report at http://www.iom.edu/Reports/2010/A-Population-Based-Policy-and-Systems-Change-Approach-to-Prevent-and-Control-Hypertension.aspx.
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