Running head: HYPERTENSION

Hypertension
By
Ellenor Chance
Coppin State University
Nurs 660: Professor Setlow and Bell-Hawkins

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Hypertension

Introductory Statement
Hypertension has been defined by determining the level of blood pressure that causes end
organ damage as arterial flow is delivered. Hypertension occurs when the force of blood against
the artery walls increases and remains high due to malfunctioning feedback loops that normally
maintain homeostasis. Hypertension may be primary having no known cause or secondary, in
which it results from a structural, circulatory, or chemical abnormality. 95% of all known causes
of hypertension are primary while only 5% are due to secondary causes ( Buttaro, 2013, p. 556).
The JNC 7 (2004), a guideline published by the national heart, lung, and blood institute, to guide
the prevention, detection, evaluation, and treatment of hypertension classifies hypertension in
stages. They conquer that normal blood pressure readings are a systolic blood pressure (SBP)
less than 120 and diastolic blood pressure (DBP) less than 80. Pre-hypertension is defined as
SBP between 120 and 139 and DBP between 80 and 90. Stage 1 hypertension is SBP range of
140 through 159 and DBP of range 90 through 99. Stage2 hypertension is SBP greater than or
equal to160 and DBP greater than or equal to 100 (JNC 7, 2004). Health care providers use
these blood pressure parameters to guide the treatment and management of individuals with
hypertension.
There are many causal factors that increase the risk of developing hypertension.
Hypertension in itself is a risk factor for acquiring significant diseases such as heart disease,
stroke, renal failure, retinopathy, and peripheral vascular disease (Buttaro, 2013, p. 550). For
educational purposes, this paper will review the problems concerning hypertension, discuss the
prevalence of hypertension in the general population, and identify agencies that have taken
initiatives to address hypertension in the general public, review the current literature on the issue,

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and discuss the implications for the nurse practitioner in the diagnosis and management of those
affected by the hypertension.
Statement Concerning the Health Problem
The prevention and management of hypertension are major public health challenges for
the United States because it affects millions of American annually, increasing the risk of
developing co morbidities such as heart disease, chronic kidney failure, and stroke (CDC, 2013).
In addition, treatment of hypertension is costly and places greater strain on an already burdened
health care system. $47.5 billion dollars are spent annually in direct medical expenses in the
management of this disease and 3.5 billion each year in lost productivity due hypertension (CDC,
2013). The prevalence of hypertension increases with age, affecting more than half of individuals
over the age of 60 (JNC 7, 2004, p. 7). Obesity, sedentary lifestyle, high sodium diet, excessive
alcohol intake, and inadequate intake of fruits, vegetables, and potassium are risk factors for
developing hypertension (JNC 7, 2004, p.7). Adding to the challenge of managing hypertension
is the high prevalence of these characteristic in the general population, at least 122 million
American are overweight or obese, mean sodium intake is almost double the recommended daily
allowance for some Americans and 75% comes from processed foods. Less than 20% of
Americans engage in regular physical activity and less that 25% consume five or more fruits and
vegetables per day (JNC7, 2004, p. 17).
Hypertension is a disease that often yields no symptoms, until significant end organ
damage has occurred. Research has shown that early detection and treatment of hypertension
significantly decrease morbidity and mortality in those affected (Buttaro, 2013, p. 550). It also
decreases health care cost associated with treating chronic disease states that are an end result of
untreated hypertension (JNC 7, 2004). It is important for health care providers to perform

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regular blood pressure screenings during every patient encounter to early detect and treat
hypertension before the aforementioned occurs. Primary prevention measures are aimed at
reducing risk factors associated with the development of hypertension in the general population
(JNC 7, 2004). However, many Americans do not receive routine primary care and hypertension
goes undiagnosed (Scott, Cummings, & Newburn-Cook, 2010).
Prevalence of Hypertension
In the U.S, one out of every three adults has high blood pressure (CDC, 2013). Of those
diagnoses with hypertension 81.5% are aware they have it, 74.9% are under current treatment,
52.5% have their hypertension controlled, and 47.5% do not have it controlled (American Heart
Association, 2013). African American (AA) women have with highest incident of hypertension
47.0% among adults age 20 or older in the U.S, with AA men following at 42.6%. African
Americans have a higher incidence of cardiovascular, stroke, and renal complications related to
hypertension. Overall, AA have higher mortality rate related to hypertension than any other
ethnic background (Buttaro, 2013, p. 557). Non-Hispanic Whites are second with rates of 33.4%
of men and 30.7% of women. Mexican Americans follow close behind with 30.1% of men and
28.8% of women affected by disease (American Heart Association, 2013). There is higher
incidence of hypertension in men until age 45 (American Heart Association, 2013). After
menopause women have higher incidence of hypertension. By age 65 women have higher overall
prevalence of hypertension than men (Buttaro, 2013, p. 556). In addition, individuals of lower
socioeconomic status have a higher prevalence of hypertension. Increased prevalence in this
population may be related to poor diet, stress, and poor access to health care (Buttaro, 2013, p.
557).

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High blood pressure was listed as the primary cause of death for more than 61,000 American in
2009. It was the primary contributing cause of death in about 348,102 of the more than 2.4
million U.S. deaths in 2009. The overall death rate from hypertension was 18.5 per 100,000, of
these 17.0 where white males, 14.4 white females, 51.6 black males, and 38.3 black females
(American Heart Association, 2013).
Resources
There are several public health programs both nationally and locally that have taken
initiatives to address the growing concern of hypertension in the general public. The National
Heart Disease and Stroke Prevention program coordinates programs and research aimed at
preventing heart disease and stroke, with strong emphasis on blood pressure control (CDC,
2013). Healthy People 2020s goal is to improve cardiovascular health by reducing the incidence
of modifiable risk factors such as hypertension. Healthy people 2020 state that heart disease
would be decreased if major improvements were made in diet, physical activity, control of high
blood pressure and cholesterol (Healthy People 2020, 2012). The National Institute of health and
the National heart, lung, and blood institute released its seventh national report on the
prevention, detection, evaluation, and treatment of hypertension. These guidelines are used
widely by providers in the diagnosis and management of those with hypertension (JNC 7, 2004).
In addition, they promote the Dietary Approaches to Stop Hypertension (DASH) diet. The
DASH diet promotes consumption of a diet rich in fruit, vegetables, whole grains, and low-fat
dairy products, all of which are clinically proven to prevent and control hypertension (JNC 7,
2004).
Locally, the Baltimore City health Department released a comprehensive health policy
agenda coined Healthy Baltimore 2015. This agenda articulates priority areas and indicators for

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action to improve the health of Baltimore City residents. Health promotion through improving
cardiovascular disease and decreasing incidence of high blood pressure, physical inactivity, and
smoking cessation are amongst the priorities on the list to improve overall health of
Baltimoreans. This agenda promotes a tobacco free environment with efforts to decrease the
amounts of adults and teens that smoke by 20%; prevent obesity by redesigning communities to
decrease inequities in supermarket access by 15%, reduce the percent of adults who are obese by
15%; decrease the rate of premature deaths from major cardiovascular disease by 10% and
increase the percent of adults being treated for hypertension by 10% (Baltimorehealth.org, 2013).
Barriers that Impede Care
There are several patient-related barriers to the attainment of blood pressure control in
those diagnosed with hypertension. These barriers include cultural norms, poor medication
adherence, and attitudes and beliefs about the importance of medications (JNC 7, 2004). Cultural
norms are amongst one of the biggest barriers to overcome. In todays society, it is culturally
acceptable to consume diets high in fat and sodium. Food industries serve large servings of these
types of food in restaurants therefore; individuals consume larger portions than recommended
(JNC7, 2004). Poor medication adherence may be related to advanced age which is associated
with decline in cognitive ability in the elderly population (Fitzgerald, 2010). In addition, many
patients lack sufficient knowledge about the importance of medications and blood pressure
control, which often leads to non compliance with the prescribed regimen. If a patient does not
believe in the drug therapy, then he or she may be less inclined to comply (Fitzgerald, 2010).
Often, patients will be non compliant with medications because of the side effects associated
with the drug or drug to drug interactions. For example, sexual dysfunction is a side effect of

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many antihypertensive agents and it is known to affect patients adherence to this class of
medications (Fitzgerald, 2010).
Provider related factors are related to insufficient attention to health education by health
care providers and therapeutic inertia, which occurs when the provider fails to adequately
intensify treatment in those with poor blood pressure control (JNC7, 2004; Fitzgerald, 2010).
Providers are encouraged to manage hypertension according to JNC 7 guidelines to ensure that
optimal blood pressure control is achieved (JNC7, 2004). It is also recommended that providers
provide comprehensive patient education in those diagnosed and at risk for hypertension
(Fitzgerald, 2010). This includes lifestyle modification and medication management. Providers
must make patients aware of the importance of blood pressure control to avoid the macrovascular
and microvascular complications associated with uncontrolled blood pressure (Bengalore et al.,
2007). Societal barriers to the prevention of hypertension includes lack of availability of healthy
food choices, increased cost of foods low in sodium and fat content and lack of adequate
supportive services to increase physical activities in communities (JNC 7, 2004).
Literature Review
Hypertension is a major risk factor for cardiovascular disease and an important public
health problem worldwide (Morgado et al., 2011). It affects one in three adults in the United
States and is estimated to cost $73.4 billion for direct and indirect cost annually (Llyod-Jones et
al., 2007). The risk for cardiovascular morbidity and mortality is significantly increased with
uncontrolled hypertension. Randomized clinical trials demonstrate that controlling high blood
pressure with medications can substantially reduce the risk of stroke by 34%-40% and
myocardial infarction by 20-25% (Morgadi et al., 2011). However, in the United States, only
66% of patients with hypertension are aware of their diagnosis, and of these only 54% are treated

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(Ong et al., 2007). Furthermore, individuals without health insurance are more likely to be
poorly controlled and have higher incidence of stroke and myocardial infarction (Scholoman,
Virgin, Schmitke, & Patros, 2010).
Hypertension is also a major risk factor in the occurrence and prevalence of chronic
kidney disease. It is recognized as the second leading cause in the progression of kidney disease
(Lingerfelt & Hodnicki, 2012). Hypertension in those clients receiving hemodialysis is
associated with increased cardiovascular complications and is an independent risk factor for
mortality in this population (Lingerfelt & Hodnicki, 2012). Therefore, hypertension management
in this client population is important to decrease further kidney damage and development of
additional end organ damage (Lingerfelt & Hodnicki, 2012).
Hypertension is now accepted as a major risk factor for macrovascular and microvascular
complications in those with diabetes as well as a contributor to early death in this population
(Williams, 2008). Modest blood pressure reduction with the use of blood pressure lowering
combination therapy is associated with 9% risk reduction in major macrovascular and
microvascular events, an 18% reduction in cardiovascular death and a 14% reduction in all-cause
mortality (Williams, 2008). Sullivan and Dinneen (2008) found that the benefits of tight blood
pressure control in preventing diabetes related complications were helpful; however, the
benefits only lasted up to eight years after the intervention stopped. The only benefit that
remained was a decreased in the occurrence of peripheral vascular disease. They also found that
death was higher in the angiotensin converting enzyme inhibitor group than in the beta blocker
group (Sullivan & Dinneen, 2008).
Rigsby (2011) found that African Americans are disproportionately affected by
hypertension when compared to other races. They suffer from onset of hypertension at an earlier

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age; increased incidence and prevalence of hypertension; and, high hypertension-related

morbidity and mortality rates (Rigsby, 2011). Poor disease management in African Americans is
related to one aspect of the problem of increased incidence in this population. Heckler, Lambert,
Leventhal, Jahn, and Contrada (2008) conducted a study that examined illness beliefs, behaviors,
and hypertension control among 102 African American outpatients. They found that African
Americans have varying beliefs as it relates to hypertension. One group conformed more to the
biomedical and lifestyle related factors such as genetics, high sodium diet, controlled by
exercise, diet, and medications, which are accepted in the medical community (Hecklet et al.,
2008). Others conformed to the folk- disease concept of hyper-tension where disease is
primarily related to stress (Heckler et al., 2008). Those who conformed more to biomedical
beliefs of hypertension were more likely to engage in lifestyle modification behaviors, whereas
others were more likely to reduce their stress level (Heckler et al., 2008). Lifestyle modifications
but not necessarily stress-reducing behaviors were more effective at managing hypertension
(Heckler et al., 2008).
Although benefits of treating hypertension are well documented hypertension remains
inadequately managed worldwide (Morgadi et al., 2011). The JNC 7 (2004) introduced
prehypertension, defined as blood pressure values of 120-139/80-89 to identify at-risk
individuals. This designation is to signal need for increased primary prevention and provide a
stimulus for health care providers to act on prevention of hypertension as a major public health
challenge (Hernandez & Anderson, 2010). JNC 7(2004) stresses lifestyle modifications as the
primary source to decrease the incidence of prehypertension. These modifications include weight
reduction, adoption of the DASH eating plan, increase physical activity, and moderation of
alcohol consumption. Individuals diagnosed with stage one or stage two hypertension will

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require pharmacologic treatment in addition to lifestyle modifications. Thiazide diuretics are

considered a first line therapy but they may be used in combination with angioconverting
enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), beta blockers (BBs), and
calcium channel blockers (CCBs) (JNC 7, 2004). Most patients who are hypertensive will
require two or more antihypertensive medications to achieve optimal blood pressure control and
addition of a second drug from a different class should be initiated when use of a single drug in
adequate doses fails to achieve goal blood pressure (JNC 7, 2004).
Conclusion
In conclusion, the deleterious effects of hypertension are well documented. It increases
risk of cardiovascular disease, stroke, kidney disease, retinopathy, and peripheral vascular
disease (Buttaro, 2013, p. 550). In addition it increases morbidity and mortality in those with co
morbidities such as diabetes and renal failure (Lingerfelt & Hodnicki, 2012; Williams, 2008).
Hypertension disproportionately affects African Americans and those of lower soci-economic
status and is costly to manage and treat once complications arise (Rigsby, 2011). Hypertension is
a condition that is often undetected and inadequately managed in individuals already diagnosed
(JNC 7, 2004). These implications require the nurse practitioner to keep these factors to the
forefront when caring for individuals with hypertension in the primary care setting. Those
identified as having pre-hypertension should be monitored closely to prevent disease
progression. Thorough patient education regarding lifestyle modification, DASH eating plan,
medication adherence, and complications of uncontrolled hypertension should be provided using
resources such as the JNC 7 guidelines. The nurse practitioner should avoid therapeutic inertia by
failing to add a second medication when blood pressures are uncontrolled using mono-therapy. In
addition, drug combination pills should be prescribed when possible to prevent decreased

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medication adherence due to multiple drug therapy (Fitzgerald, 2010). Additional screening,
management, and patient education should be provided to those disproportionately affected by
hypertension in the form in community outreach (Rigsby, 2011). Moreover, referrals to specialist
and community resources should be utilized when appropriate, to ensure comprehensive client
care.

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References

American Heart Association. (2013). Statistical fact sheet. Retrieved from:

http://www.heart.org/idc/groups/heartpublic/@wcm/@sop/@smd/documents/downloadab
le/ucm_319587.pdf
Bakris, G., Black,H., Cushman, W., Green,L., Izzo, J., Materson, B., Oparil, S. (2004). The
seventh report of the joint national committee on the prevention, detection, evaluation,
and treatment of high blood pressure. Retrieved from:
http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf
Baltimore City Health Department. (2013). Healthy Baltimore 2015. Retrieved from:
http://www.baltimorehealth.org/info/Healthy_Baltimore_2015/HealthyBaltimore2015_Fi
nal_Web.pdf
Bangalore, S., Wild, D., Parkar, S., Kukin, M., & Messerli, F. H. (2008).
Beta-blockers for primary prevention of heart failure in patients with
hypertension insights from a meta-analysis. Journal of the American College of
Cardiology, 52(13), 10621072.
Buttaro, T. M, Trybulski, J., Bailey, P.P., & Sandberg-Cook. (2013). Hypertension. Primary care
a collaborative practice (4th ed.). (p. 556-571). St. Louis Missouri: Mosby Elsevier
Center for Disease Control and Prevention. (2013). High blood pressure. Retrieved from:
http://www.cdc.gov/bloodpressure/
Center for Disease Control and Prevention. (2013). High blood pressure risk factors. Retrieved
from: http://www.cdc.gov/bloodpressure/facts.htm

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Fitzgerald, M. A. (2011). Hypertension treatment update: Focus on direct renin

inhibition. Journal Of The American Academy Of Nurse Practitioners, 23(5), 239-248.
doi:10.1111/j.1745-7599.2010.00589.x
Healthy People 2020. (2012). Heart disease and stroke. Retrieved from:
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=21
Hekler, E. B., Lambert, J., Leventhal, E., Leventhal, H., Jahn, E., & Contrada, R. J. (2008).
Commonsense illness beliefs, adherence behaviors, and hypertension control among
African Americans. Journal Of Behavioral Medicine, 31(5), 391-400.
doi:10.1007/s10865-008-9165-4
Hernandez, J., & Anderson, S. (2012). Prehypertension: A literature-documented public health
concern. Journal Of The American Academy Of Nurse Practitioners, 24(1), 3-10.
doi:10.1111/j.1745-7599.2011.00684.x
Lingerfelt, K., & Hodnicki, D. (2012). Hypertension Management in Patients Receiving
Hemodialysis: The Benefits Of Home Blood Pressure Monitoring. Nephrology Nursing
Journal, 39(1), 31-37.
Lloyd-Jones, D., Adams, R., Carnethon, M., De Simone, G., Ferguson, T. B.,
Flegal, K., et al. (2008). Heart disease and stroke statistics2009 update.
A Report from the American Heart Association Statistics Committee and
Stroke Statistics Subcommittee. Circulation.
Morgado, M. P., Morgado, S. R., Mendes, L. C., Pereira, L. J., & Castelo-Branco, M. (2011).
Pharmacist interventions to enhance blood pressure control and adherence to
antihypertensive therapy: Review and meta-analysis. American Journal Of Health-System
Pharmacy, 68(3), 241-253. doi:10.2146/ajhp090656

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Ong, K. L., Cheung, B. M., Man, Y. B., Lau, C. P., & Lam, K. S. (2007).
Prevalence, awareness, treatment, and control of hypertension among
United States adults 19992004. Hypertension, 49(1), 6975.
Rigsby, B. D. (2011). Hypertension Improvement through Healthy Lifestyle Modifications.
ABNF Journal, 22(2), 41-43.
Schlomann, P., Virgin, S., Schmitke, J., & Patros, S. (2011). Hypertension among the uninsured:
Tensions and challenges. Journal Of The American Academy Of Nurse Practitioners,
23(6), 305-313. doi:10.1111/j.1745-7599.2011.00616.x
Scott, R. L., Cummings, G. E., & Newburn-Cook, C. (2011). The feasibility and effectiveness of
emergency department based hypertension screening: A systematic review. Journal Of
The American Academy Of Nurse Practitioners, 23(9), 493-500. doi:10.1111/j.17457599.2011.00636.x
Sullivan, E. P., & Dinneen, S. F. (2008). Benefits of tight blood pressure control to prevent
diabetes complications were not sustained.ACP Journal Club, 149(6), 3.
Williams, B. B. (2008). The Hypertension in Diabetes Study (HDS): a catalyst for
change. Diabetic Medicine, 2513-19. doi:10.1111/j.1464-5491.2008.02506.x

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