Hypertension Blog

The effects of cerebrovascular disease on your patient and his family can be devastating. A tremendous amount of education and support is needed for optimum recovery.

During the acute phase of a CVA, orient the patient and his family to the unit, to the procedures being performed and the equipment used, and to the treatment plan. Explain the need for rehabilitative therapy after the acute phase has passed.

Once the patient’s condition has stabilized and the amount of cerebral tissue damage has been determined, explain the disease, his deficits, and the planned rehabilitation. If necessary, ensure that each rehabilitation team member explains his or her specialty so that the patient and his family fully understand the rehabilitation process.

Teach the patient the signs and symptoms of a CVA and stress the importance of seeking treatment immediately if any of the following occur:

• sudden onset of weakness, numbness, or paralysis of the face, arm, or leg, usually on one side of the body
• sudden blurring or loss of vision in one or both eyes
• loss of speech or trouble talking or understanding speech
• sudden severe headache
• unexplained dizziness or loss of balance, especially if combined with other signs and symptoms.

If the physician prescribes an antihypertensive, anticoagulation, or anti platelet aggregation drug, teach your patient the name of the drug, its dosage, and its therapeutic and adverse effects. If he must take an anticoagulant, also teach him the signs and symptoms of bleeding that he should report .

If the physician has prescribed warfarin, tell your patient which drugs interact with it. Instruct him to maintain a diet that provides moderate amounts of vitamin K. Explain that extreme variations in vitamin K intake can cause wide fluctuations in the anticoagulant level. Tell the patient to avoid trauma and to wear a medical alert tag or bracelet at all times. Inform him that he’ll need frequent blood tests for his physician to adjust the warfarin dose.

Depending on the amount of cerebral damage, your patient may be transferred to a rehabilitation facility or a skilled nursing facility for further treatment. If he requires a wheelchair or walker, tell him that a home care nurse or other health provider should visit his home to identify physical barriers that would limit their use.

Explain that the home care nurse will monitor his vital signs, check his compliance with antihypertensive drug therapy, and assess his response to the drug. She’ll evaluate his bowel and bladder function and provide retraining, if necessary. She’ll also assess his response to rehabilitation, determining which assistive devices might be useful to him.

Systolic hypertension is more common in elderly patients. Elevated systolic blood pressure readings are usually caused by increased CO, systemic vascular resistance, or both. The main vascular cause of systolic hypertension is rigidity of the aorta, which develops from arteriosclerosis and increases total peripheral vascular resistance. Normally, the elastic aorta stretches as blood is pumped from the heart, but with decreased elasticity and compliance, systolic pressure increases significantly.

Aging also causes hyaline degeneration of the tunica media of arterioles, reducing lumen size. Further, decreased baroreceptor sensitivity may contribute to increased sympathetic nervous system activity and elevated levels of norepinephrine.

About 45% of the elderly in the United States have systolic blood pressures of 160 mm Hg or higher and diastolic pressures of less than 90 mm Hg-a condition known as isolated systolic hypertension. Generally, this condition reflects a disease process resulting in lost elasticity of the aorta and its large branches. Other than advanced age, this condition is the greatest risk factor of endocrine disease in elderly patients.

Endocrine Disorders

Pheochromocytoma, an abnormal growth of new tissue on the adrenal medulla, produces excessive catecholamines, causing hypertension. These tumors occur most commonly in patients ages 40 to 60, and about 90% of them are benign.

A patient with pheochromocytoma may experience severe headaches, profuse sweating, palpitations, and pronounced pallor caused by a sudden release of catecholamines resulting in a hypertensive crisis. These attacks can be triggered by physical activity, postural changes, emotional distress, hypoglycemia, and surgical trauma. An attack may also be provoked when the tumor is palpated.

If left untreated, a patient with pheochromocytoma can develop diabetes, cardiomyopathy, and hypertension, any of which can result in death. The usual treatment is surgical removal of the tumor, which relieves hypertension in about 75% of patients. The remaining 25% can usually manage their hypertension with antihypertensive drug therapy.

Caused by excessive aldosterone secretion of the adrenal gland, primary hyperaldosteronism is another endocrine disorder that causes hypertension. This condition is more common in women ages 20 to 50. Suspect it in hypertensive patients who have hypokalemia and don’t take diuretics.

The three causes of primary hyperaldosteronism are unilateral adrenocortical adenoma, adenomatous hyperplasia, and adrenocortical carcinoma. Unilateral adrenocortical adenoma alone causes 80% to 85% of the cases of primary hyperaldosteronism.

Physicians typically treat primary hyperaldosteronism by surgically removing the tumor. Unfortunately, surgery generally doesn’t cure hypertension resulting from adenomatous hyperplasia.

Cushing’s syndrome, another cause of hypertension, results from either prolonged treatment with large doses of glucocorticoids or excess cortisol production by the adrenal cortex, which is most commonly caused by a pituitary tumor. In either case, hypertension results from the mineralocorticoid effects of the hyperfunctioning adrenal tissue. When a pituitary tumor causes Cushing’s syndrome, the usual treatment consists of surgical removal. Hypertension can also be caused by acromegaly-a chronic metabolic condition resulting from excessive production of growth hormone in the anterior pituitary. The condition is characterized by enlargement and elongation of the bones of the face, jaw, and extremities. Although one­third of patients with acromegaly have hypertension, it’s usually not severe, and the treatment of acromegaly-surgery, radiation, and drugs-usually alleviates the hypertension.

Hypertension is sometimes called the “silent killer” because many people don’t know they have it. If left untreated, chronic systolic and diastolic hypertension damages the walls of systemic blood vessels and organs such as the heart, brain, kidneys, and retina. Eventually, this organ damage can result in coronary artery disease (CAD), CVA, renal failure, and blindness .

Coronary Artery Disease

Hypertension is the main risk factor for developing CAD from atherosclerosis. With hypertension, atherosclerotic plaque forms in the inner lining of the artery at an accelerated rate. As the artery narrows, more force is needed to pump blood through it, creating an even further elevation in blood pressure.

Cerebrovascular Accident

Hypertension is also a serious risk factor of CVA. In fact, hypertension is a leading cause of transient ischemic attacks and CVAs resulting from cerebral thrombosis, intracerebral hemorrhage, and emboli.

Cerebral arterial hemorrhage can occur when progressive atherosclerotic changes take place and blood pressure increases in the affected vessels. Eventually, smooth blood vessel tissue is replaced with fibrous tissue, causing vessel walls to become thicker and more rigid. But the vessels also weaken because of intense constriction of the cerebral arterioles and arteries, resulting in the development of microaneurysms that tend to rupture easily.

Renal Disease

Hypertension also leads to end-stage renal disease. During the early stage of hypertension, the capillary basement membrane of the glomeruli becomes thickened by atherosclerosis. Hypertension then causes a gradual destruction of the glomeruli, tubules, and nephrons. At first, a patient’s glomerular filtration rate may remain normal, but scarring eventually occurs, causing renal failure. Although most hypertensive patients have some degree of renal dysfunction, African-American hypertensive patients have the greatest risk of developing end-stage renal disease.

Retinopathy

Hypertension can also cause retinopathy. The resulting retinal changes are categorized in four stages of increasingly severe vessel damage.

Usually, the early stages go undetected because the patient has no significant signs or symptoms to report and no apparent reason to seek medical attention. However, if his hypertension is left untreated and his condition progresses into the later stages of retinopathy, he may develop retinal lesions, which can cause blurred vision, or papilledema and retinal hemorrhaging, which can result in blindness.