HYPERTENSION

                                                                              

I. DEFINITION

Hypertension can be defined as persistent blood pressure where the systolic pressure above 140 mmHg and diastolic pressure above 90 mmHg (Smith Tom, 1995). According to WHO, hypertension disease is an increase in systolic pressure greater than or equal to 160 mmHg and or diastolic pressure equal to or greater 95 mmHg (Kodim Nasrin, 2003). Hypertension is mild categorized when diastolic pressure is between 95 - 104 mmHg, moderate hypertension if diastolic pressure between 105 and 114 mmHg, and severe hypertension when diastolic pressure is 115 mmHg or more. This division is based on an increase in diastolic pressure because it is considered more serious than a systolic increase (Smith Tom, 1995).

 

  

  Table 1

Blood Pressure Category

It is important to remember that one's blood pressure with one another varies depending on age, occupation, or other specific things that can affect it.

 

Table 2

Normal Value Blood Pressure

II. CAUSE

Hypertension based on the cause can be divided into 2 major groups namely: (Lany Gunawan, 2001)

1. Essential hypertension (primary hypertension) that is unknown cause hypertension

2. Secondary hypertension is hypertension caused by other diseases

Primary hypertension is present in more than 90% of hypertensive patients, while the remaining 10% is due to secondary hypertension. Although primary hypertension is not known for certain causes, research data have found several factors that often lead to hypertension. The factors are as follows:

1. Hereditary factors

From statistical data proved that a person will have greater possibility to get hypertension if her parents are hypertension sufferers

a) Individual characteristics

Individual traits that affect the onset of hypertension are age (if age increases TD increases), gender (male is higher than female) and race (more black race than white)

b) Habits of life

Habits that often cause hypertension are high salt intake (over 30 grams), overweight or overeating, stress and other influences such as smoking, drinking alcohol, taking medication (ephedrine, prednisone, epineprin)

III. PATHOPHYSIOLOGY

The mechanism that controls constriction and relaxation of blood vessels lies at the center of the vasomotor, in the medulla in the brain. From this vasomotor center begins the sympathetic nerve pathway, which continues downward into the spinal cord and exits from the spinal column of the sympathetic ganglia of the thorax and abdomen. Vasomotor center stimulation is delivered in the form of an impulse that moves downward through the sympathetic nervous system to the sympathetic ganglia. At this point, the preganglion neuron releases acetylcholine, which will stimulate the post-ganglion nerve fibers into the blood vessels, which with the release of noreepineprin results in constriction of blood vessels. Various factors such as anxiety and fear can affect the vascular response to vasoconstriction stimuli. Individuals with hypertension are very sensitive to norepinephrine, although it is not clear why this is possible.

At the same time that the sympathetic nervous system stimulates the blood vessels in response to emotional stimulation, the adrenal glands are also aroused, resulting in additional vasoconstriction activity. Adrenal medulla secretes epinephrine, which causes vasoconstriction. The adrenal cortex secretes cortisol and other steroids, which can strengthen the vasoconstrictor response of the blood vessels. Vasoconstriction resulting in decreased flow to the kidneys, leading to rennin release. Rennin stimulates the formation of angiotensin I which is then converted to angiotensin II, a powerful vasoconstrictor, which in turn stimulates aldosterone secretion by the adrenal cortex. This hormone causes sodium and water retention by the renal tubules, leading to an increase in intra vascular volume. All these factors tend to trigger the state of hypertension.

For consideration gerontology. Structural and functional changes in the peripheral vessel system are responsible for changes in blood pressure that occur in old age. These changes include atherosclerosis, loss of elasticity of connective tissue and decrease in relaxation of smooth muscle of the blood vessels, which in turn decreases the ability of distention and tensile strength of blood vessels. Consequently, large aorta and arteries decrease their ability to accommodate the volume of blood pumped by the heart (stroke volume), resulting in a decrease in the heart's cheating and increased peripheral resistance (Brunner & Suddarth, 2002).

IV. SIGNS AND SYMPTOMS

Signs and symptoms of hypertension are divided into: (Edward K Chung, 1995)

1. No symptoms

There are no specific symptoms that can be associated with an increase in blood pressure, in addition to determining arterial pressure by the examining physician. This means arterial hypertension will never be diagnosed if arterial pressure is not measurable.

2. Common symptoms

Signs and symptoms that can arise by hypertension disease are as follows:

a)    Headache

b)    Pain or nape is heavy

c)     Difficulty sleeping

d)   Easily tired and emotional

e)    Trembling

f)      Fast pulse after activity

g)    Sometimes also dissertation nausea, vomiting, spasms to epistaksis

.

V. SUPPORTING INVESTIGATION

a)    History and physical examination as a whole

b)    Retinal examination

c)     Laboratory tests to find out organ damage such as kidney and heart

d)   ECG to know left ventricle hypertrophy

e)    Urinalysis to find proteins in urine, blood, glucose

f)      Examination: renogram, renal arteriogram intravenous pyelogram, examination of separated renal function and determination of urine levels.

g)    Photo chest and CT scan

VI. ASSESSMENT

1.     Activity / rest

Symptoms: weakness, fatigue, shortness of breath, monotonous lifestyle

Signs: increased heart frequency, heart rhythm changes, tachypnoea

2.     Circulation

Symptoms: History of hypertension, atherosclerosis, coronary heart disease, cerebrovascular disease

Signs: Increase in TD, postural hypotension, tachycardia, discoloration, cold temperature

3.     Ego Integrity

Symptoms: History of personality changes, anxiety, depression, euphoria, multiple stress factors

Signs: Mood swings, anxiety, continuous narrowing of attention, bursting cries, tense facial muscles, breathing drag, improving speech patterns

4.     Elimination

Symptoms: current or past renal impairment

5.     Food / Liquids

Symptoms: Preferable foods that can include foods high in salt, fat and cholesterol

Signs: BB normal or obese, the presence of edema

6.     Neurosensory

Symptoms: dizziness / dizziness, headache, throbbing headache, throbbing, visual impairment, episode episode

Signs: orientation changes, decreased grip strength, optical retinal changes

7.     Pain / discomfort

Symptoms: Angina, pain relief on the legs, severe occipital headache, abdominal pain

8.     Breathing

Symptoms: activity-related dyspnoea, tachypnoea, orthopnea, proximal nocturnal dyspnea, cough with or without sputum, smoking history

Signs: respiratory distress / use of muscle respiratory accessories, additional breath sounds, cyanosis

9.     Security

Symptoms: Disturbance of coordination, way of way

Signs: episodes of transient unilateral paresthesias, psotural hypotension

10.Learning / Counseling

Symptoms: family risk factors, hypertension, atherosclerosis, heart disease, DM, kidney disease, ethnic risk factors, use of birth control pills or hormones

VIII. MANAGEMENT

Management of hypertension aims to prevent morbidity and mortality due to cardiovascular complications associated with achievement and maintenance of blood pressure below 140/90 mmHg Principles of hypertensive disease management include:

1. Therapy without Drugs

Non-drug therapy is used as an action for mild hypertension and as a supportive measure of moderate and severe hypertension. Non-drug therapy includes:

a)    Diet

The recommended diet for people with hypertension is:

1)    Restriction of salt moderately from 10 gr / hr to 5 gr / hr

2)    Diets low in cholesterol and low in saturated fatty acids

3)    Weight loss

4)    Decrease in ethanol intake

5)    Stop smoking

6)    Diet high potassium

b)    Physical Exercise

Physical exercise or regular and focused exercise is recommended for people with hypertension is a sport that has four principles, namely:

1)     Kind of exercise is isotonic and dynamic such as running, jogging, cycling, swimming and others.

2)     Good exercise intensity between 60-80% of aerobic capacity or 72-87% of maximal pulse called exercise zone. Maximum pulse rate can be determined with the 220-age formula

3)     The duration of exercise ranges from 20 to 25 minutes in the training zone

4)     Frequency of exercise should be 3 x weekly and best 5 x week

c)     Psychological Education

Provision of psychological education for people with hypertension include:

1)     Biofeedback Technique

Biofeedback is a technique used to show on the subject of signs about the state of the body that the subject consciously considers abnormal.

Application of biofeedback is mainly used to treat somatic disorders such as headache and migraine, as well as for psychological disorders such as anxiety and tension.

2)     Relaxation Technique

Relaxation is a procedure or technique that aims to reduce tension or anxiety, by training the patient to be able to learn to make the muscles in the body to relax

d)   Changing Lifestyle

Management that needs to be done next is to change the lifestyle as below so that hypertension can be controlled and prevented, among others:

1)    Lose weight

2)    Reduce alcohol consumption

3)    Activities on a regular basis

4)    Reduces excessive sodium intake

5)    Reduce or even quit smoking

2. Therapy with Drugs

The goal of hypertension treatment not only lowers blood pressure alone but also reduces and prevents complications due to hypertension in order for the patient to grow stronger. Treatment of hypertension generally needs to be done for the lifetime of the patient. The standard treatment recommended by the Hypertension Expert Committee (JOINT NATIONAL COMMITTEE ON DETECTION, EVALUATION AND TREATMENT OF HIGH BLOOD PRESSURE, USA, 1988) concluded that diuretic drugs, beta-blockers, calcium antagonists, or ACE inhibitors may be used as the first single drug with regard to The state of the patient and other diseases that exist in the patient.

Treatment includes:

a)    Step 1: First-choice drugs: diuretics, beta blockers, Ca antagonists, ACE inhibitors

b)    Step 2: Alternatives that can be given

1)    The first drug dose is increased

2)    Replaced another type of drug of choice first

3)    Plus the other 2 types of drugs, can be diuretics, beta blockers, Ca antagonists, Alpa blockers, clonidin, reserphin, vasodilator

c)     Step 3: alternatives that can be taken

a)    The 2nd drug is replaced

b)    Plus 3rd drug of another kind

d)   Step 4: alternative drug delivery

1)    Plus drugs 3rd and 4th

2)    Re-evaluation and consultation

3. Follow Up to maintain therapy

To maintain long-term therapy requires good interaction and communication between patients and health workers (nurses, doctors) by means of health education. Matters that must be considered in the interaction of patients with health care workers are as follows:

a)     Each time the patient checks, the patient is notified of the results of his blood pressure measurement

b)    Talk to the sufferer the goal to be achieved about his blood pressure

c)     Discuss with the patient that hypertension can not be cured, but can be controlled to reduce morbidity and mortality

d)    Reassure the patient that the patient can not say the high blood pressure on what basis he feels, the blood pressure can only be determined by measuring using a tensimeter

e)     Patients should not stop the drug without being discussed first

f)      As far as possible the therapeutic measures are included in the patient's way of life

g)     Include the patient's family in the therapeutic process

h)    In certain patients it may be beneficial if the patient or family can measure their blood pressure at home

i)       Make it as simple as possible use of anti-hypertensive drugs eg 1 x daily or 2 x daily

j)       Discuss with the patient about anti-hypertensive medications, side effects and possible problems

k)    Reassure the patient the possibility of modifying the dose or substituting the drug to achieve minimal side effects and maximum effectiveness

l)       Keep therapeutic costs to a minimum

m) For patients who are less obedient, try to visit more often

n)    Call the patient immediately, if not arriving at the specified time.

Seeing the importance of patient compliance in the treatment is very necessary once the knowledge and attitude of patients about understanding and implementation of hypertension treatment.

IX. NURSING DIAGNOSES

1.     Acute pain associated with biological injury agents

2.     Anxiety relates to situational crisis

3.     Activity intolerance relates to physical disability

X. INTERVENTION OF NURSING HYPERTENSION

Diagnosis 1: Acute pain associated with biological injury agents

Goal and yield criteria (NOC)

After patient care is given:

a)     Shows pain-seeking, as evidenced by the following indicator:

1.     Never

2.     rarely

3.     sometimes

4.     often

5.     always

Indicator	1	2	3	4	5
Recognizing onset of pain
Use precautions
Reporting the pain can be tied

b)    Showing the level of pain, as evidenced by the following indicator:

1.     very heavy

2.     heavy

3.     medium

4.     light

5.     Nothing

Indicator	1	2	3	4	5
Expression of pain on the face
Restlessness or muscle tension
Duration of pain episodes
Whimper and cry
Anxious

c)     show an effective individual relaxation technique to achieve comfort

d)    maintain pain on .... Or less (on a scale of 0-10)

e)     report on physical and psychological well-being

f)      identify the cause factor and use the action to modify the factor

g)     reporting pain to health care workers

h)    reporting good sleep patterns

Nursing Intervention (NIC)

Assessment

a)    Use the patient's own report as the first option for collecting assessment information

b)    Ask the patient to assess pain on a scale of 0-10.

c)     Use the pain chart to relieve analgesic pain relief and possible side effects

d)   Assess the impact of religion, culture and belief, and the environment on pain and patient response

e)    In assessing the pain of the patient, use words appropriate to the age and level of patient development

Pain management:

a)    Perform a comprehensive pain assessment including location, characteristics, onset and duration, frequency, quality, intensity or severity of pain and precipitation factors

b)    Observation of nonverbal cues of discomfort, especially in those unable to communicate effectively

Counseling for patient / family

a)    Include in the instructions for the return of the patient specific drug to be taken, the frequency, the frequency of administration, possible side effects, possible drug interactions, special precautions when taking the drug and the name of the person to contact in case of stubborn pain.

b)    Instruct the patient to inform the nurse if pain relief can not be achieved

c)     Inform patients about procedures that can improve pain and offer coping strategies offered

d)   Correct misperceptions about narcotic or oploid analgesics (risk of dependence or overdose)

Pain management:

a)    Provide information about the pain, such as the cause of the pain, how long it will last, and anticipate the discomfort due to the procedure

b)    Teach the use of nonpharmacology techniques (relaxation, distraction, therapy)

Collaborative activities

a)    Manage early postoperative pain with scheduled opiates (eg, every 4 hours for 36 hours) or PCA

b)    Pain management:

c)     Use pain control measures before the pain becomes more severe

d)   Report to the doctor if the action is not successful or if the current complaint is a meaningful change from past patient pain experience

Treatment at home

a)    The above interventions can be customized for home care

b)    Teach clients and families to take advantage of the technology needed in drug delivery

Diagnosis 2: Anxiety associated with situational crisis

Goal and yield criteria (NOC)

Once given the client care will show:

a)    Anxiety is reduced, evidenced by the level of mild to moderate anxiety and selau showing self-control of anxiety, self, coping.

b)    Demonstrate self-control of anxiety; As evidenced by the following indicators:

1.     Never

2.     rarely

3.     sometimes

4.     often

5.     always

Indicator	1	2	3	4	5
Plan coping strategies for stressful situations
Maintain role performance
Monitoring perception distortion
Monitoring manifestations of anxiety behavior
Using relaxation techniques to relieve anxiety

NIC Nursing Intervention

Assessment

a.      review and document the patient's anxiety level, including any physical reactions ...... ..

b.     review for the cultural factors that cause anxiety

c.      digging with patients on successful techniques and failing to reduce anxiety in the past

d.     reduction of anxiety (NIC); Determine the patient's decision-making ability

Counseling for patients and families

a)    make an extension plan with realistic goals, including the need for repetition, support and praise of the tasks that have been learned

b)    provide information on available community resources, such as friends, neighbors, self-help groups, places of worship, volunteer institutions and recreation centers

c)     inform about anxiety symptoms

d)   teach family members how to distinguish between panic attacks and symptoms of physical illness

e)    reduction of anxiety (NIC);

f)      provide factual information regarding diagnosis, therapy and prognosis

g)    instruct the patient on the use of relaxation techniques

h)   explain all procedures, including the sensations normally experienced during the procedure

Collaborative activities

a)    reduction of anxiety (NIC); Give medications to lower anxiety if necessary

Other activities

a)    at the time of severe anxiety, accompany the patient, speak calmly, and give calm and comfort

b)    give dorngan to the patient to express verbally the thoughts and feelings to externalize anxiety

c)     assist the patient to focus on the current situation, as a way of identifying the coping mechanism needed to reduce anxiety

d)   provide diversion through television, radio, games and occupational therapy to reduce anxiety and expand focus

e)    try techniques such as bombing imagination and progressive relaxation

f)      encourage the patient to express anger and irritation, and allow the patient to cry

g)    reassure patients through touch, and empathic attitudes verbally and nonverbally in turn

h)   provide a quiet environment and limit contact with others

i)      suggest alternative therapies to reduce anxiety acceptable to the patient

j)      get rid of anxiety sources if possible

reduction of anxiety (NIC);

l)      use a calm and convincing approach

m) state clearly about expectations of patient behavior

n)   damping patients to improve safety and reduce fear

o)    provide a back massage, neck massage if necessary

p)   keep the maintenance equipment away from view

q)    help patients to identify situations that trigger anxiety

Diagnosis 3: Activity intolerance relates to physical disability

Goal and yield criteria (NOC)

After being given patient care will show:

a)    Tolerate ongoing activity, as evidenced by activity tolerance, resilience, energy savings, physical fitness, psychomotor energy, and self-care, ADL.

b)    Demonstrate the activity tolerance, as evidenced by the following indicator:

1.     Exterminal disorders

2.     heavy

3.     medium

4.     light

5.     No interruption

Indicator	1	2	3	4	5
Oxygen saturation during activity
Respiratory frequency during activity
Ability to speak during physical activity

c)     Demonstrate energy savings, as evidenced by the following indicators:

1.     Never

2.     rarely

3.     sometimes

4.     often

5.     always

Indicator	1	2	3	4	5
Recognizing the limitations of energy
Balancing activity and rest
Organize an activity schedule to save energy

Nursing Intervention (NIC)

Assessment

a)    Assess the patient's ability to move from bed, stand up, ambulate, and perform ADL

b)    Assess emotional, social and spiritual responses to activities

c)     Evaluation of motivation and desire of the patient to increase activity

Energy management (NIC):

a)    Determine the cause of fatigue

b)    Monitor the cardiorespiratory response to the activity

c)     Monitor the patient's oxygen response to activity

d)   Monitor the nutritional response to ensure adequate energy sources

e)    Monitor and document patient sleep patterns and duration of sleep within hours

Counseling for patients and families

a)    Instruct patient and family to:

b)    Use of controlled breathing techniques during activity, if necessary

c)     Recognize signs and symptoms of activity intolerance, including conditions that need to be reported to a doctor

d)   The importance of good nutrition

e)    Use of equipment such as oxygen during activity

f)      Use of relaxation techniques during activity

g)    Impact of activity intolerance on family role responsibilities

h)   Action to save energy

Energy management (NIC):

a)      Teach to patients and people closest to self-care techniques that will minimize oxygen consumption

b)     Teach about setting activity and time management techniques to prevent fatigue

Collaborative activities

a)      Give pain treatment before the activity, if pain is one cause

b)     Collaborate with occupational, physical or recreational therapists to plan and monitor activity programs, if necessary.

c)      For patients with mental illness, refer mental health services at home

d)     Refer the home health care provider to get home care assistance services, if necessary

e)      Refer patients with nutrition for diet planning

f)       Refer the patient to a cardiac rehabilitation center if fatigue is associated with heart disease

Other activities

a)    Avoid scheduling maintenance activities during rest periods

b)    Help the patient to change positions periodically, if necessary

c)     Monitor vital signs before, during and after activity

d)   Plan scheduled joint patient activities between rest and exercise

Energy management (NIC);

a)    Help the patient to identify the choice of activity

b)    Plan activity in the period when the patient has the most energy

c)     Assist the patient for regular physical activity

d)   Help environmental stimulation for relaxation

e)    Help the patient to perform independent monitoring by creating and using written documentation to record caloric and energy intake

Treatment at home

a)    Evaluation of home conditions that may lead to activity intolerance

b)    Assess the need for tools, oxygen and other sebagainga home

BIBLIOGRAPHY

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Judith M. Wilkinson dan Nancy R. Ahern. Buku Saku DIAGNOSIS KEPERAWATAN Diagnosis NANDA, Intervensi NIC, Kriteria hasil NOC Edisi 9. Alih Bahasa Ns. Esti Wahuningsih, S.Kep dan Ns. Dwi Widiarti, S,Kep. EGC. Jakarta