Hypertensive Emergency is severe hypertension (high blood pressure) with acute impairment of an organ system (especially the central nervous system, cardiovascular system and/or the renal system) and the possibility of irreversible organ-damage. In case of a hypertensive emergency, the blood pressure should be lowered aggressively over minutes to hours with an antihypertensive agent.
Several classes of antihypertensive agents are recommended and the choice for the antihypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated blood pressure and the patient’s usual blood pressure before the hypertensive crisis. In most cases, the administration of an intravenous sodium nitroprusside injection which has an almost immediate antihypertensive effect is suitable but in many cases not readily available. In less urgent cases, oral agents like captopril, clonidine, labetalol, prazosin, which all have a delayed onset of action by several minutes compared to sodium nitroprusside, can also be used.
Nursing Care Plan
Below are nursing care plans for hypertensive emergency.
Decreased Cardiac Output
Hypertension is defined as a condition wherein there is an increase in BP beyond the normal range. Hypertensive emergency is used for BPs above 160/100mmHg. With hypertension, the blood vessels constrict. When blood vessels are constricted, there is a decrease in blood volume, decrease in cardiac output and increase in BP as blood passes through the narrowed lumen of the vessels.
- Decreased cardiac output r/t altered stroke volume secondary to hypertensive emergency
Possibly evidenced by:
- Increase in blood pressure
- Prolonged capillary refill
- Cold clammy skin
- Variations in BP
- Patient will manifest hemodynamic stability.
- Verbalize understanding of risk factors.
|Establish rapport||To gain patient’s trust|
|Monitor vital signs||To obtain baseline data|
|History taking||The history and the physical examination determine the nature, severity, and management of the hypertensive event. The history should focus on the presence of end-organ dysfunction, the circumstances surrounding the hypertension, and any identifiable etiology.|
|Explain dietary restrictions||To inform patient of contributing factors|
|Determine whether patient is pregnant.||In pregnant patients, acute hypertensive crisis usually results from severe preeclampsia and can lead to maternal stroke, cardiopulmonary decompensation, fetal decompensation caused by reduced uterine perfusion, abruption, and stillbirth.|
|Carefully assess patient’s complaint of symptoms.||Patients may complain of specific symptoms that suggest end-organ dysfunction may be present. Chest pain may indicate myocardial ischemia or infarction, back pain may denote aortic dissection; and dyspnea may suggest pulmonary edema or congestive heart failure. The presence of neurologic symptoms may include seizures, visual disturbances, and altered level of consciousness and may be indicative of hypertensive encephalopathy.|
|Administer antihypertensive medications:|
|Sodium nitroprusside||Sodium nitroprusside is a commonly used medication. It is a short-acting agent, and the BP response can be titrated from minute to minute. However, patients must have constant monitoring in an intensive care unit. The potential exists for thiocyanate and cyanide toxicity with prolonged use or if the patient has renal or hepatic failure.|
|Labetalol||Labetalol, an alpha- and beta-blocking agent, has proven to be quite beneficial in the treatment of patients with hypertensive emergencies. Labetalol is particularly preferred in patients with acute dissection and patients with end-stage renal disease. Boluses of 10-20 mg may be administered, or the drug may be infused at 1 mg/min until the desired BP is obtained. Once an adequate BP level is obtained, oral antihypertensive therapy should be initiated, and patients are gradually weaned from parenteral agents.|
|Fenoldopam||Fenoldopam, a peripheral dopamine-1-receptor agonist is given as initial IV dose of 0.1 µg/kg/min titrated every 15 minutes.|