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Hypertension: facts and forecasts.

Hypertension affects one in three adults over the age of 18. It is the most common chronic condition seen in primary care. Deaths due to hypertension are about 18.8 per thousand people per year (Caboral-Stevens & Rosario-Sim, 2014) . The definition of hypertension was not changed by the Eighth Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC8) and remains a systolic blood pressure over 140 or a diastolic blood pressure over 90 (James et al., 2013).The Centers for Disease Control and Prevention (CDC) describes hypertension as the silent killer as there are usually no warning signs or symptoms. The incidence of hypertension varies with age, sex, race, and ethnic groups. For example, more men than women have high blood pressure in those younger than age 45. However, for those over age 65, more women than men have high blood pressure. Differences in the diagnosis of high blood pressure between men and women are described in Tables I and 2 (CDC, 2015). Based on race and ethnicity, African Americans develop high blood pressure more often and at an earlier age than Caucasians and Mexican Americans. More African American women than African American men have high blood pressure (see Table 2) (CDC, 2015). High blood pressure may result from a number of risk factors, some of which are controllable (see Table 3).The cost of health care, medications, and missed days of work is about $47.5 billion a year in the United States for the hypertensive population (CDC, 2015).

Etiology

There are several risk factors for hypertension that cannot be controlled, including age, sex, race, ethnicity, and family history.The risk factors that are controllable are diet, obesity, tobacco use, sedentary lifestyle, alcohol use, and cigarette smoking. The incidence of heart disease, cerebrovascular accidents, and chronic kidney disease may be reduced with adequate blood pressure control. Lifestyle changes for those with hypertension may decrease the need for medications (Caboral-Stevens & Rosario-Sim, 2014; James et al., 2013). Blood pressure increases as people age due to decreasing elasticity of the arteries, resulting in stiffness (Potts, 2014). Hypertension may be initially asymptomatic, and the physical damage from hypertension may not be evident for years (Dreisbach & Batuman, 2015).

Hypertension may also be a symptom of other conditions, including renal artery stenosis, coarctation of the aorta, aldosteronism, thyroid disorders, pheochromocytoma, or Cushing syndrome. Hypertension may result from use of illicit drugs, oral contraceptives, herbal supplements, nonsteroidal anti-inflammatory medications, some psychiatric medications, steroids, or sympathomimetic drugs like diet pills or decongestants (Vera & Neutze, 2010). These potentially correctable forms of hypertension are classified as secondary hypertension. There are studies that may prove a connection between hypertension and rheumatoid arthritis or psoriasis (American Society of Hypertension [ASH], 2014b). The current recommendations are to consider hypertension as one of several concurrent diseases due to the high incidence of hypertension occurring in the presence of kidney disease, diabetes, obesity, and other co-morbidities (ASH, 2014a). The diagnosis of hypertension is not always easily identified, and additional tests may be needed.

Diagnosis and Effects

Hypertension is defined as an increase in either the systolic or diastolic pressure or both readings. A systolic reading of 140 millimeters of mercury (mmHg) or diastolic of 90 mmHg are considered Stage I hypertension (Davis, 2013; James et al., 2013; Potts, 2014). Stage I hypertension is defined as a systolic BP of 140-159 mmHg or a diastolic BP of 90-99 mmHg. Stage 2, or severe, hypertension is a systolic BP of 160 mmHg or higher or a diastolic BP of 100 mmHg or higher (Columbia University Medical Center, 2015).

The diagnosis of hypertension is dependent on an accurate measurement (Caboral-Stevens & Rosario-Sim, 2014). The technique used when taking blood pressures is crucial to getting accurate readings. Health care personnel should be audited to assure that they are aware of the implications of errors in blood pressure readings. Patients could receive unneeded treatment, and those who require treatment would not get it based on erroneous readings. The appropriate cuff size, a cuff at the level of the heart, a relaxed sitting position, a supported arm, uncrossed legs, and support for the patient's back may all affect blood pressure readings. The diaphragm of the stethoscope has been shown to be more reliable when taking blood pressures than the bell (Handler, 2009). Blood pressures taken with an automatic machine are often lower than with a manual method. Blood pressures taken on the forearm or wrist are not recommended. Falsely high or low blood pressures may be the result of doctor-related white coat effect, engaging the patient in conversation during blood pressure readings, or rounding readings up or down (Handler, 2009). Blood pressure readings may be classified as normal, at risk, or high. The readings for each level are noted in Table 4 (CDC, 2014b; Davis, 2013).

Some of the most commons signs and symptoms of hypertension, if there are any, are mild to severe headache, fatigue, confusion, dizziness, vision problems, chest pain, difficulty breathing, irregular heartbeat, nosebleed, and pounding in the chest, neck, or ears. These symptoms may occur at any time during the course of the disease or not at all until a catastrophic event (Mayo Clinic, 2015).

High blood pressure affects the major organs including heart, brain, and kidneys. The stiffness of the aorta decreases the blood flow to the heart, which leads to cardiovascular disease. Uncontrolled blood pressure increases an individual's risk of stroke, artery damage and narrowing, myocardial infarction, enlarged left heart, aneurysm, heart failure, coronary artery disease, transient ischemic attack, dementia, cognitive impairment, kidney failure, and kidney scarring. Chronic kidney disease is a possible result of high blood pressure and diabetes. Twenty percent of adults with high blood pressure and 33% of adults with diabetes have chronic kidney disease. Control of high blood pressure decreases the risk of major organ deterioration (CDC, 2015; Mayo Clinic, 2014).

Treatment

Dietary changes, including decreases in fried foods and foods high in saturated fats, and decreased sodium intake, as well as daily exercise, are recommended to prevent hypertension and may decrease blood pressure and the need for medication. "The new guidelines for preventing heart disease and strokes, from The American Heart Association and The American College of Cardiology, recommend the DASH diet, which lemphasize[s] fruits, vegetables, whole grains, low-fat dairy products, poultry, fish, and nuts'" (The DASH Diet, 2015). Aerobic exercise helps increase the strength of the heart muscle, which can result in more efficient pumping.

Life's emotional stressors, although there is no direct effect on blood pressure, may result in behaviors that contribute to hypertension. Behaviors like overeating, drinking alcohol, and poor sleeping habits contribute to increases in blood pressure. Blood pressure is positively affected by increasing fruits, vegetables, and whole grains in the diet and decreasing sodium intake. Exercising at least three to four times a week is recommended by physicians, along with weight loss, smoking cessation, medication adherence, and a healthy diet. A reduction in blood pressure decreases or prevents damage to blood vessels (Mayo Clinic, 2014; Potts, 2014).

Medications such as antihypertensives and diuretics may be used to maintain a goal blood pressure. The JNC8 (James et al., 2013) published nine recommendations related to age groups, ethnicity, and blood pressure levels, outlining the recommended treatment including medications. Medications are recommended in many specific populations when presenting with hypertension alone or in combination with another disease already in the process. The recommendations of JNC8 outline blood pressure goals for all age groups and include specifics of best practice treatment for those who have chronic kidney disease, diabetes, or any combination of those risk factors (James et al., 2013). Recommended practice incorporates from one to three medications given alone or in combination. These drugs have side effects and adverse reactions that may necessitate changes in medications until the right combination is achieved. Ongoing assessments (a requirement for all patients) as patients age may necessitate medication changes to keep hypertension controlled (Caboral-Stevens & Rosario-Sim, 2014). Patients with hypertension must be followed on a regular basis by a health care professional.

Nurses, nurse practitioners, and nurse prescribers have opportunities to educate and positively influence patients and families to incorporate the lifestyle changes that help patients reach their goals (Carter, Bosworth, & Green, 201 I). Follow-up medical visits and maintenance of lifestyle changes should be emphasized and reinforced (Madhur & Maron, 2014).The purpose, side effects, dosages, and dosing times of medications prescribed for hypertension control should be explained to patients verbally, and there should be written instructions provided. Information about taking medications with or without food and what to do if a dose is missed is important for ongoing adherence with pharmacologic treatment. A cost-effectiveness analysis by Moran and colleagues (2015) showed that implementation of the 2014 hypertension guidelines for adults in the United States between the ages of 35 and 74 could prevent about 56,000 cardiovascular accidents and 13,000 deaths annually while saving costs. Nurses have a responsibility and the opportunities to impact lives in clinics, hospitals, social groups, and family gatherings with relevant information about optimal lifestyles.

Conclusion

Hypertension may not be the result of aging. A change in the environment, dietary precautions, exercise, and a decrease in stress may lower the risk and prevent hypertension and its negative health care outcomes. Public health education should include early education, diet modification, regular monitoring of blood pressures, and exercise that may decrease the occurrence of the multiple disease processes related to hypertension (Whelton, 2004). In a prevalence study, Tu, Chen, and Lipscombe (2008) concluded that the prevalence of hypertension will increase by 24% by the year 2025, and practices to manage it are needed.

References

American Heart Association (AHA). (2014). Understand your risk for high blood pressure. Retrieved May 25, 2016, from www.heart.org/ HEARTORG/Conditions/HighBloodPressure/UnderstandYourRisk forHighBloodPressure/Understand-Your-Risk-for-High-BloodPressure_UCM_002052_Article.jsp

American Society of Hypertension (ASH). (2014a). Preventing and treating hypertension and its consequences. Retrieved from http://www.ash-us.org/

American Society of Hypertension (ASH). (2014b). ASH wire. Retrieved from http://us I .campaign-archive2.com/?u=5376333d Ia39071 c6d 9505873&id=273e 132750&e=483339c 15d

Caboral-Stevens, M., & Rosario-Sim, M. (2014). Review of the joint national committee's recommendations in the management of hypertension. Journal of Nurse Practitioners, 10(5), 32S-330.

Carter, B., Bosworth, H., & Green, B. (201 I). The hypertension team: The role of the pharmacist, nurse, and teamwork in hypertension therapy. The Journal of Clinical Hypertension, / 4(1), 51-65.

Centers for Disease Control and Prevention (CDC). (2014a). High blood pressure risk factors. Retrieved May 25, 2016, from www.cdc.gov/bloodpressure/risk_factors.htm

Centers for Disease Control and Prevention (CDC). (2014b). Measuring high blood pressure. Retrieved May 25, 2016, from http://www.cdc.gov/bloodpressure/measure.htm Centers for Disease Control and Prevention (CDC). (2015). High blood pressure facts. Retrieved May 25, 2016, from http://www.cdc.gov/ bloodpressure/facts.htm

Columbia University Medical Center. (2015). New hypertension guidelines could save lives and money. Retrieved from http://newsroom.cumc. columbia.edu/blog/20l 5/0 l/28/new-hypertension-guidelines-savelives-money/

DASH Diet, The. (2015). The DASH diet eating plan. Retrieved from http://dashdiet.org/

Davis, L. (2013). Using the latest evidence to manage hypertension. Journal of Nurse Practitioners, 9( 10), 621-627.

Dreisbach. A., & Batuman. V. (2015). Pathogenesis of essential hypertension. Medscape. Retrieved from http://emedicine.medscape.com/ article/1937383-overview

Handler, J. (2009).The importance of accurate blood pressure measurement. The Permanente Journal, I3(3), 51-54.

James, P, Oparil, S., Carter, B., Cushman, W., Dennison-Himmelfarb, C., Handler, J., ... Ortiz, E. (2013). 2014 evidence-based guideline for the management of high blood pressure in adults. Journal of the American Medical Association, 311 (5), 507-520.

Madhur, M., & Maron, D. (2014). Hypertension. Medscape. Retrieved from http://emedicine.medscape.com/article/241381--overview

Mayo Clinic. (2014). High blood pressure dangers: Hypertension's effects on your body. Retrieved from http://www.mayoclinic.org/diseasesconditions/high-blood-pressure/in-depth/high-blood- pressure/art-20045868

Mayo Clinic. (2015). High blood pressure (hypertension) symptoms. Retrieved May 25, 2016,from http://www.mayoclinic.org/diseasesconditions/high-blood-pressure/basics/symptoms/con- 20019580

Moran, A., Odden, M., Thanataveerat, A., Tzong, K., Rasmuxxen, R, Guzman, D.,... Goldman, L. (2015). Cost-effectiveness of hypertension therapy according to 2014 guidelines. New England Journal of Medicine, 372, 447-455. Retrieved from http://www.nejm.org/ doi/full/10.1056/NEJMsa 1406751

Potts, K. (2014). Hypertension in older people: Assessment and management. Clinical Review, 16(3), 146-149.

Terrie. Y. C. (2013). Selection of blood pressure monitors: An essential tool for at-home monitoring. Retrieved from http://www.pharmacytimes. com/publications/issue/2013/december2013/selection-of-bloodpressure-monitors-an-essential-tool-for-at-home-monitoring

Tu, K., Chen, Z., & Lipscombe, L. (2008). Prevalence and incidence of hypertension from 1995 to 2005: A population-based study. Research, 178(11), 1429-1435.

Vera, A., & Neutze, D. (2010). Diagnosis of secondary hypertension: An age-based approach American Academy of Family Physicians, 82( 12), 1471-1478. Retrieved from http://www.aafp.org/afp/20IO/ 1215/p 1471.pdf

Whelton, P. (2004). Epidemiology and the prevention of hypertension. Medscape Nurses. Retrieved from http://www.medscape.com/ viewarticle/494336

Karen E. Elmore, MSN, RN, NE-BC, is Nurse Manager, UT Southwestern Medical Center, Dallas, TX.

Instructions for Continuing Nursing Education Contact Hours

Hypertension:

Facts and Forecasts

Deadline for Submission:

June 30, 2018

MSNNI603

To Obtain CNE Contact Hours

1. For those wishing to obtain CNE contact hours, you must read the article and complete the evaluation through the AMSN Online Library. Complete your evaluation online and print your CNE certificate immediately, or later. Simply go to www.amsn.org/library

2. Evaluations must be completed online by June 30, 2018. Upon completion of the evaluation, a certificate for 1.0 contact hour(s) may be printed.

Fees

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Learning Outcome

After completing this learning activity, the learner will be able to describe the etiology, diagnosis, effects, and treatment of hypertension.

The author(s), editor, editorial committee, content reviewers, and education director reported no actual or potential conflict of interest in relation to this continuing nursing education article.

This educational activity is jointly provided by Anthony J. Jannetti, Inc. and the Academy of Medical-Surgical Nurses (AMSN).

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Anthony J. Jannetti, Inc. is a provider approved by the California Board of Registered Nursing, provider number CEP 5387. Licensees in the state of California must retain this certificate for four years after the CNE activity is completed.

This article was reviewed and formatted for contact hour credit by Rosemarie Marmion, MSN, RN-BC, NE-BC, AMSN Education Director.
Table 1.
Blood Pressure Levels Vary by Age

Age            Men (%)   Women (%)

20-34           1l.l        6.8
35-44           25.1       19.0
45-54           37.1       35.2
55-64           54.0       53.3
65-74           64.0       69.3
75 and older    66.7       78.5
All             34.1       32.7

Source: Adapted from CDC, 2015.

Table 2.
Blood Pressure Levels Vary by Race and Ethnicity

Race of Ethnic Group   Men (%)   Women (%)

African Americans       43.0       45.7
Mexican Americans       27.8       28.9
Whites                  33.9       31.3
All                     34.1       32.7

Source: Adapted from CDC, 2015.

Table 3.
Risk Factors for Hypertension

                   Hypertension Risk Factors

 Nonmodifiable Risk Factors        Modifiable Risk Factors

Ethnicity (African Americans    Being overweight or obese
are at greater risk)

Increased age (over 35 years)   History of smoking

Having a familial history       High intake of dietary sodium
of hypertension
                                Excessive use of alcohol

                                Sedentary lifestyle

                                High level of stress

                                Poorly controlled diabetes

Source: Adapted from AHA, 2014; CDC, 2014a; Terrie, 2013.

Table 4.
Blood Pressure Levels

     Classification                    Range

Normal                      systolic: less than 120 mmHg
                            diastolic: less than 80mmHg

At risk (prehypertension)   systolic: 120-139 mmHg
                            diastolic: 80-89 mmHg

High                        systolic: 140 mmHg or higher
                            diastolic: 90 mmHg or higher

Source: Adapted from CDC, 2014b.
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Author:Elmore, Karen E.
Publication:MedSurg Nursing
Article Type:Disease/Disorder overview
Date:May 1, 2016
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