Diagnostic Tests

Computed tomography (CT) and magnetic resonance imaging help rule out other causes of your patient’s severe headache, such as a CVA. Imaging may reveal areas of hemorrhage ranging in size from pinpoint to massive.

A lumbar puncture is contraindicated because of the patient’s high ICP. Introducing a needle into the central canal of his spinal cord would cause cerebrospinal fluid (CSF) to gush, and the sudden and dramatic decrease in CSF could force delicate brain tissue to herniate into the spinal canal, resulting in immediate death

Usually, a physician prescribes an antihypertensive drug to rapidly reduce ICP and arterial blood pressure and to maintain diastolic blood pressure at about 100 mm Hg. The drugs used to treat hypertensive encephalopathy include vasodilators, beta-blockers, and osmotic diuretics. Most commonly, a physician prescribes the vasodilator nitroprusside. Vasodilators relax vascular smooth muscle, which reduces peripheral artery and vein dilation. Beta-blockers may be used to reduce vascular resistance.

The physician may prescribe mannitol, an osmotic diuretic, if the patient already shows signs and symptoms of cerebral edema. Although osmotic diuretics reduce ICP, they’re contraindicated in patients with active cerebral bleeding. The adverse effects of osmotic diuretics-confusion, convulsions, dizziness, disorientation, headache, rebound increased ICP, and syncope-can mimic a worsening neurologic condition .

Although rapidly reducing your patient’s blood pressure will dramatically improve the symptoms of hypertensive encephalopathy, he’ll require continued close monitoring in an ICU.

In helping a hypertensive patient control his weight, your primary responsibilities include educating him about his prescribed diet and monitoring his weight reduction. You’ll also need to regularly measure his blood pressure.Review the elements of the weight-reduction diet with your patient. If appropriate, obtain a referral for a dietitian to assist him and his family with planning appropriate meals. Provide him with suggestions to help him comply with the prescribed diet, keeping in mind his food preferences and ethnic background. Also, recommend alternative food choices for patients with poor dentition, food intolerances, and limited physical mobility. And stress the importance of reducing weight to reduce blood pressure.

When teaching your patient, tell him to eat regularly planned meals and to not skip meals. Teach him to measure his foods to determine the correct portions. Also, tell him to avoid foods that are high in fat and sugars and to reduce the amount of fat he uses in cooking. Suggest baking, broiling, or steaming food as a way to eliminate all fried foods from his diet. Also, recommend he reduce fat by removing the skin on poultry before cooking and have him increase his daily intake of fruits and vegetables. And warn your patient to avoid fad and crash diets, which reduce weight only temporarily. Monitor the success of your patient’s weight reduction by recording weekly weights. Don’t measure daily weights because they reflect the body’s fluid status and don’t usually indicate total body weight reduction.

Use ongoing blood pressure measurement to evaluate his body’s response to weight reduction. Blood pressure readings don’t immediately show dramatic decrease. However, some reduction in blood pressure may occur with a weight loss of as little as 10 pounds. Reinforce the success of weight and blood pressure reductions with your patient to encourage ongoing compliance with the prescribed regimen.

When your hypertensive patient begins an exercise program, teach him about the prescribed exercise. Monitor his exercise tolerance and continue to regularly measure his blood pressure.During your patient teaching, tell him to exercise at the same time every day. Instruct him to wear loose-fitting clothing and to wear shoes that properly support his feet. If his exercise consists of walking, tell him to walk at a comfortable pace on level ground. Also, urge him to carry identification and a list of the drugs he’s taking.

Hypertensive patients with other health problems may need special devices, such as braces or splints, to assist them in an exercise program. Assess your patient’s overall physical status and consult with a physical therapist or cardiac rehabilitation specialist for exercise suggestions.

To help your patient adapt his exercise program to his needs and tolerance level, advise him to measure his pulse rate before and immediately after he exercises. He can use his pulse as a guide to increasing or decreasing his activity. Also, tell him to assess himself after 5 minutes of exercise. He should feel warm, not hot and sweating.

Until the patient knows his exercise tolerance, he should exercise with someone else. Instruct him to stop exercising if he becomes extremely tired, short of breath, dizzy, or light-headed. If he develops chest pain, palpitations, or tingling, numbness, or pain in his arms or legs, he should stop exercising and contact his physician. Tell him to seek emergency care if any of these symptoms persists for more than 15 minutes after the exercise activity is stopped.

Review the key elements of the exercise program with your patient. Provide suggestions to help him comply with the plan and stress the importance of exercise for managing his hypertension. Encourage him to do exercises that he enjoys so that he’ll be more likely to do them regularly.

Advise your patient to set realistic goals and advance his exercise program at his own pace. To ensure compliance, suggest that he join a walking group such as one that walks in malls.

Monitor the success of your patient’s exercise program by checking his blood pressure and resting heart rate weekly. If his blood pressure decreases, emphasize the success of the exercise program to encourage continued compliance.

Alcohol

When obtaining your patient’s health history, ask him how much alcohol he drinks. If appropriate, advise him to reduce his intake to less than 1 ounce per day.

The exact mechanism by which alcohol raises blood pressure isn’t known, but alcohol may increase renin or aldosterone release. Chronic alcohol abuse

can also increase blood cortisol levels, which can aggravate hypertension.

Alcohol consumption also affects weight reduction. Alcohol provides empty calories. Plus, one or two drinks a day can slow a person’s metabolism by as much as 25%. Drinking three or more alcoholic drinks a day also increases a person’s risk of hypertension.

Caffeine

By constricting the peripheral blood vessels, caffeine increases the heart rate and blood pressure. Therefore, you should encourage your hypertensive patient to reduce his intake of caffeinated beverages. Tell him that most drinks such as coffee, tea, and soda are now available in caffeine-free preparations. Also, teach him that many other products contain caffeine, including foods such as chocolate and over-the-counter (OTC) drugs used for the treatment of headaches.

Sodium

You should advise your patient to limit his sodium intake, especially if he’s sodium sensitive. Restricting sodium intake may reduce extracellular fluid and total circulating blood volume, thus decreasing the heart’s workload.

Sodium may interfere with the effectiveness of certain antihypertensive drugs. Thus, by limiting his sodium intake, the patient may be able to control his blood pressure with lower doses of antihypertensive drugs. And by using lower dosages, he will have less risk of developing adverse effects from the drugs.

Usually, sodium is restricted to 2 grams of sodium or 5 grams of salt per day. A patient can achieve this restriction by not adding table salt to food and by avoiding foods that are high in sodium.

Regular isotonic exercise-such as walking, jogging, and swimming-can help control blood pressure. Generally, hypertensive patients should participate in a moderate amount of exercise at regular intervals, rather than vigorous exercise at irregular intervals.The short-term benefits of exercise include stress reduction and appetite suppression. Over time, exercise promotes effective blood flow, increases oxygen consumption, and strengthens the cardiac muscle. With stronger muscle, the heart beats more efficiently. Also, blood flows more easily through the vessels and at a lower pressure, thereby reducing systolic blood pressure.

Isotonic exercises, which are recommended for hypertensive patients, don’t put unnecessary strain on the heart. However, isometric exercises such as weight lifting significantly raise blood pressure. And participating in isometric exercises increases a hypertensive patient’s risk of sustaining an acute myocardial infarction (MI) or cerebrovascular accident.

Isometric exercises are not recommended because they also increase muscle tension and demand more oxygen. In hypertensive patients, the heart contracts with greater force than normal, so blood flows through the vessels with greater force. Hypertension also causes the arterioles and capillaries to be rigid. Therefore, blood flow through these vessels to the muscles may not meet the increased oxygen demands of isometric exercise. As exercise tolerance decreases, the muscles cramp, and a hypertensive patient may faint from lack of oxygen to the tissues.

Exercise Plan

Patients with known cardiac disease or other health problems need a thorough examination, including stress testing monitored by electrocardiography (ECG) , before beginning an exercise plan. Also, the patient’s physician should approve the program.

Walking is the ideal exercise for the hypertensive patient. The amount of walking should be increased gradually to establish exercise tolerance and to reduce the effects of overexercise .

You can estimate the daily caloric intake your patient needs for normal body functioning and weight control by multiplying his ideal body weight by 10. Thus, a patient whose ideal body weight is 180 pounds should have a daily caloric intake of 1,800 calories.Although some weight-reduction diets severely limit the total daily caloric intake to as little as 800 calories or less, low-calorie diets usually range from 1,000 to 1,500 calories per day. A diet that’s lower than 1,000 calories per day may cause muscle loss instead of fat loss. The body also compensates for large reductions in caloric intake by decreasing the metabolic rate.

After you’ve estimated your patient’s total daily caloric intake, you can develop his nutrition plan. Talk with him about his goals for weight reduction or control and make sure they’re realistic. Develop these goals with the patient to improve his compliance. Also, teach the family members who are responsible for meal preparation or who will support your patient in his efforts.

Recommended Foods

To control or reduce his weight, your patient may need to change his eating habits. His diet should include appropriate portions of low-fat foods. He should also avoid high-fat snacks and reduce his total daily caloric intake.

The American Heart Association Healthy Heart diet identifies foods to avoid and foods to include to achieve weight control or reduction.

Hypertensive Patients Should Avoid These Foods:

• animal products-large portions of meat (beef, lamb, pork, or veal), liver or organ meats, bacon, sausage, and luncheon meats
• dairy products-egg yolks, whole milk, ice cream, cheese, and butter
• oil products-beef lard, salad dressings, cream sauces, and gravies
• simple carbohydrates-sweets, candy, sugar, cake, cookies, and jellies.
• Hypertensive patients should include daily allowances of the following:
• protein-4 to 6 ounces of fish, skinless poultry, or lean red meat with all visible fat removed
• grains and starches-a minimum of four servings of whole-grain, high-fiber cereals, breads, potatoes, rice, or starchy vegetables
• vegetables-a minimum of two servings of deep green or orange vegetables
• fruit and juice-a minimum of two servings, one of which is citrus
• dairy-a minimum of two servings of skim or low-fat milk, skim cheese, nonfat yogurt, or ice milk.

Improving your Patient’s Compliance

To prevent life-threatening, chronic complications, your hypertensive patient must comply with his prescribed treatment plan. Unfortunately, many hypertensive patients don’t comply. If your patient isn’t following his treatment plan, identify the reasons and then take corrective action. Here are some common causes of noncompliance, along with proven intervention strategies.

Patient Isn’t Involved in Decision Making

Many times, the health care team makes the mistake of deciding what’s best for the patient and then telling him what to do. But patients who aren’t involved in the planning tend to not get involved in the plan. So be sure to include the patient in discussions about his treatment.

Encourage him to identify problems he might have in complying with the options under discussion. Remember, he’ll be more likely to comply with a treatment plan he feels he can realistically follow.

Patient Thinks his Blood Pressure is Normal

Patients who feel well may assume that their blood pressure isn’t a problem. Teach your patient how to measure his own blood pressure at home and advise him to record how he feels at the time he takes each measurement. Doing so will help him realize that regardless of how he feels, his blood pressure will begin to climb if he forgets to take his antihypertensive drug, cheats on his diet, or fails to reduce his stress.

Patient Doesn’t Integrate Treatment Into Everyday Life

The complexity of treatment is inversely related to the degree of patient compliance. This poses a major problem in managing hypertension because several treatments-lifestyle changes and drugs-are usually needed to maintain normal blood pressure.

Anything you can suggest to simplify your patient’s treatment plan may help foster compliance. For example, if your patient must take a drug several times a day, ask his physician to substitute one that requires less frequent dosing. Or if the patient must take several different drugs, ask the physician to prescribe a combination product to simplify the patient’s drug regimen.

Patient Can’t Afford Drugs and Foods

Many patients with limited incomes are embarrassed to reveal that they have difficulty purchasing the drugs and foods required for their treatment. To identify this problem early on, explore your patient’s ability to pay when you discuss the treatment plan with him. If you identify a problem, call the social worker to make alternative arrangements for your patient.