Blood pressure increase
Blood pressure increase: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
Elevated blood pressure — an intermittent or sustained increase in blood pressure exceeding 140/90 mm Hg — strikes more men than women. By itself, this common sign is easily ignored by the patient; after all, he can’t see or feel it. However, its causes can be life-threatening.
CULTURAL CUE:Blacks have a higher incidence of hypertension than Whites. In addition, hypertension occurs at an earlier age, is more severe, and has a higher mortality in Blacks than in Whites.
Elevated blood pressure may develop suddenly or gradually. A sudden, severe rise in pressure (exceeding 180/110 mm Hg) may indicate life-threatening hypertensive crisis. However, even a less dramatic rise may be equally significant if it heralds a dissecting aortic aneurysm, increased intracranial pressure, myocardial infarction, eclampsia, or thyrotoxicosis. (See Associated disorder: Hypertension, page 90.)
Usually associated with essential hypertension, elevated blood pressure may also result from a renal or endocrine disorder, a treatment that affects fluid status such as dialysis, or a drug’s adverse effect. Ingestion of large amounts of certain foods, such as black licorice and cheddar cheese, may temporarily elevate blood pressure. (See Understanding blood pressure regulation, page 91.)
Emergency Actions
Elevated blood pressure can signal various life-threatening disorders. However, if pressure exceeds 180/110 mm Hg, the patient may be experiencing hypertensive crisis and may require prompt treatment. Maintain a patent airway in case the patient vomits, and institute seizure precautions. Prepare to administer an I.V. antihypertensive and diuretic. You’ll also need to insert an indwelling urinary catheter to accurately monitor urine output.
History
After ruling out life-threatening causes, complete a more leisurely patient history. Determine if the patient has a history of cardiovascular or cerebrovascular disease, diabetes, or renal disease. Ask about a family history of high blood pressure — a likely finding with essential hypertension, pheochromocytoma, or polycystic kidney disease. Then ask about its onset. Did high blood pressure appear abruptly? Ask the patient’s age. Sudden onset of high blood pressure in middle-aged or elderly patients suggests renovascular stenosis. Although essential hypertension may begin in childhood, it typically isn’t diagnosed until near age 35. Pheochromocytoma and primary aldosteronism usually occur between ages 40 and 60. If you suspect either, check for orthostatic hypotension. Take the patient’s blood pressure with him lying down, sitting, and then standing. Normally, systolic pressure falls and diastolic pressure rises on standing. With orthostatic hypotension, both pressures fall.
Note headache, palpitations, blurred vision, and sweating. Ask about wine-colored urine and decreased urine output; these signs suggest glomerulonephritis, which can cause elevated blood pressure.
Obtain a drug history, including past and present prescriptions, herbal preparations, and over-the-counter drugs (especially decongestants). If the patient is taking an antihypertensive, determine how well he complies with the regimen. Ask about his perception of elevated blood pressure. How serious does he believe it is? Does he expect drug therapy to help? Explore psychosocial or environmental factors that may impact blood pressure control.
Physical assessment
Follow up the history with a thorough physical assessment. Using a funduscope, check for intraocular hemorrhage, exudate, and papilledema, which characterize severe hypertension. Perform a thorough cardiovascular assessment. Check for carotid bruits and jugular vein distention. Assess skin color, temperature, and turgor. Palpate peripheral pulses. Auscultate for abnormal heart sounds (gallops, louder second sound, murmurs), rate (bradycardia, tachycardia), or rhythm. Then auscultate for abnormal breath sounds (crackles, wheezing), rate (bradypnea, tachypnea), or rhythm.
Palpate the abdomen for tenderness, masses, or liver enlargement. Auscultate for abdominal bruits. Renal artery stenosis produces bruits over the upper abdomen or in the costovertebral angles. Easily palpable, enlarged kidneys and a large, tender liver suggest polycystic kidney disease. Obtain a urine specimen to check for microscopic hematuria.
Medical causes
Anemia
Elevated systolic pressure in anemia is accompanied by pulsations in the capillary beds, bounding pulse, tachycardia, systolic ejection murmur, pale mucous membranes and, in patients with sickle cell anemia, ventricular gallop and crackles.
Aortic aneurysm (dissecting)
Initially, dissecting aortic aneurysm causes a sudden rise in systolic pressure (which may be the precipitating event) but causes no change in diastolic pressure. However, this increase is brief. The body’s ability to compensate fails, resulting in hypotension.
Other signs and symptoms of this life-threatening disorder vary, depending on the type of aortic aneurysm. An abdominal aneurysm may cause persistent abdominal and back pain, weakness, sweating, tachycardia, dyspnea, a pulsating abdominal mass, restlessness, confusion, and cool, clammy skin. A thoracic aneurysm may cause a ripping or tearing sensation in the chest, which may radiate to the neck, shoulders, lower back, or abdomen; pallor; syncope; blindness; loss of consciousness; sweating; dyspnea; tachycardia; cyanosis; leg weakness; murmur; and absent radial and femoral pulses.
Atherosclerosis
With atherosclerosis, systolic pressure rises, whereas diastolic pressure commonly remains normal or slightly elevated. The patient may show no other signs, or he may have a weak pulse, flushed skin, tachycardia, angina, and claudication.
Cushing’s syndrome
Twice as common in females as in males, Cushing’s syndrome causes elevated blood pressure and widened pulse pressure as well as truncal obesity, moon face, and other cushingoid signs. It’s usually caused by corticosteroid use.
Hypertension
Essential hypertension develops insidiously and is characterized by a gradual increase in blood pressure from decade to decade. Except for this high blood pressure, the patient may be asymptomatic or (rarely) may complain of suboccipital headache, light-headedness, tinnitus, and fatigue.
With malignant hypertension, diastolic pressure abruptly rises above 120 mm Hg, and systolic pressure may exceed 200 mm Hg. Typically, the patient has pulmonary edema marked by jugular vein distention, dyspnea, tachypnea, tachycardia, and coughing of pink, frothy sputum. Other characteristic signs and symptoms include severe headache, confusion, blurred vision, tinnitus, epistaxis, muscle twitching, chest pain, nausea, and vomiting.
Increased intracranial pressure
Increased intracranial pressure (ICP) causes an increased respiratory rate initially, followed by increased systolic pressure and widened pulse pressure. It affects heart rate last, causing bradycardia (Cushing’s reflex). Associated signs and symptoms of increased ICP include headache, projectile vomiting, decreased level of consciousness, and fixed or dilated pupils.
Myocardial infarction
Myocardial infarction is a life-threatening disorder that can cause high or low blood pressure. Common findings include crushing chest pain that may radiate to the jaw, shoulder, arm, or epigastrium. Other findings include dyspnea, anxiety, nausea, vomiting, weakness, diaphoresis, atrial gallop, and murmurs.
Pheochromocytoma
Paroxysmal or sustained elevated blood pressure characterizes pheochromocytoma and may be accompanied by orthostatic hypotension. Associated signs and symptoms include anxiety, diaphoresis, palpitations, tremors, pallor, nausea, weight loss, and headache.
In advanced stages, this disease may cause concurrent hematuria, life-threatening retroperitoneal bleeding, resulting from cyst rupture, proteinuria, and colicky abdominal pain from the ureteral passage of clots of calculi.
Preeclampsia and eclampsia
Potentially life-threatening to the patient and her fetus, preeclampsia and eclampsia characteristically increase blood pressure. They’re defined as a reading of 140/90 mm Hg or more in the first trimester, a reading of 130/80 mm Hg or more in the second or third trimester, an increase of 30 mm Hg above the patient’s baseline systolic pressure, or an increase of 15 mm Hg above the patient’s baseline diastolic pressure. Accompanying elevated blood pressure are generalized edema, sudden weight gain of 3 lb (1.4 kg) or more per week during the second or third trimester, severe frontal headache, blurred or double vision, decreased urine output, proteinuria, midabdominal pain, neuromuscular irritability, nausea and, possibly, seizures (eclampsia).
Renovascular stenosis
Renovascular stenosis produces abruptly elevated systolic and diastolic pressures. Other characteristic signs and symptoms include bruits over the upper abdomen or in the costovertebral angles, hematuria, and acute flank pain.
Thyrotoxicosis
A potentially life-threatening disorder, thyrotoxicosis is accompanied by elevated systolic pressure, widened pulse pressure, tachycardia, bounding pulse, pulsations in the capillary nail beds, palpitations, weight loss, exophthalmos, an enlarged thyroid gland, weakness, diarrhea, fever over 100° F (37.8° C), and warm, moist skin. The patient may appear nervous and emotionally unstable, displaying occasional outbursts or even psychotic behavior. Heat intolerance, exertional dyspnea and, in females, decreased or absent menses may also occur.
Other causes
Drugs
Central nervous system stimulants (such as amphetamines), sympathomimetics, corticosteroids, nonsteroidal anti-inflammatories, hormonal contraceptives, monoamine oxidase inhibitors, and over-the-counter cold remedies can increase blood pressure, as can cocaine abuse.
Treatments
Kidney dialysis and transplantation cause transient elevation of blood pressure.
Special considerations
If routine screening detects elevated blood pressure, stress to the patient the need for follow-up diagnostic tests. Then prepare him for routine blood tests and urinalysis. Depending on the suspected cause of the increased blood pressure, radiographic studies, especially of the kidneys, may be necessary.
Pediatric pointers
Normally, blood pressure in children is lower than it is in adults, an essential point to recognize when assessing a patient for elevated blood pressure. (See Normal pediatric blood pressure, page 88.)
Elevated blood pressure in children may result from lead or mercury poisoning, essential hypertension, renovascular stenosis, chronic pyelonephritis, coarctation of the aorta, patent ductus arteriosus, glomerulonephritis, adrenogenital syndrome, or neuroblastoma. Treatment typically begins with drug therapy. Surgery may then follow in patients with patent ductus arteriosus, coarctation of the aorta, neuroblastoma, and some cases of renovascular stenosis. Diuretics and antibiotics are used to treat glomerulonephritis and chronic pyelonephritis; hormonal therapy, to treat adrenogenital syndrome.
Geriatric pointers
Atherosclerosis commonly produces isolated systolic hypertension in elderly patients. Treatment is warranted to prevent long-term complications.
Patient counseling
Encourage the patient to lose weight, if necessary, and to restrict sodium intake. Suggest that he participate in an exercise or stress management program as well. In addition, other risk factors for coronary artery disease, such as smoking and elevated cholesterol levels, need to be addressed. Then teach the patient how to monitor his blood pressure so that he can evaluate the effectiveness of drug therapy and lifestyle changes. Have him record blood pressure readings and symptoms, and ask him to share this information on his return visits.
If the patient has essential hypertension, explain the importance of long-term control of elevated blood pressure and the purpose, dosage, schedule, route, and adverse effects of prescribed antihypertensives. Reassure him that there are other drugs he can take if the one he’s taking isn’t effective or causes intolerable adverse reactions. Encourage him to report adverse reactions; the drug dosage or schedule may simply need adjustment.
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Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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