Hypertensive Emergency (Nursing) (2024)

Learning Outcome

Recall the cause of hypertensive emergencies
Describe the presentation of hypertensive emergencies
Summarize the management of hypertensive emergencies
List the nursing management of a patient with a hypertensive emergency

Introduction

A hypertensive emergency is an acute, marked elevation in blood pressure that is associated with signs of target-organ damage. These can include pulmonary edema, cardiac ischemia, neurologic deficits, acute renal failure, aortic dissection, and eclampsia.[1][2][3]

Nursing Diagnosis

Headache
Visual blurring
Dyspnea
Chest pain
Dizzy
Anxiety
Sense of doom

Causes

Variousinciting events can cause hypertensive emergencies. The majority of hypertensive emergencies occur in patients already diagnosed with chronic hypertension. Noncompliance with antihypertensive medications and use of sympathomimetics are two of the more common causes. These leading to a rapid rise in blood pressure beyond the body's innate autoregulation capacity.

The levels of hypertension that constitute a hypertensive emergency, while often quoted, are not universally established and are arbitrary. The rate of rising above baseline is likely a more important contributor and explains why patients without chronic hypertension may show signs of hypertensive emergency at much lower levels, while patients with longstanding hypertension may tolerate exceedingly high blood pressure without developing acute organ dysfunction.[4][5]

Risk Factors

It is estimated that about 30% of adults in America have hypertension. Of these, 1% to 2% will have a hypertensive crisis, a term inclusive of hypertensive emergency and hypertensive urgency. Acute pulmonary edema, cardiac ischemia, and neurologic emergencies are the most common types of acute target organ dysfunction.[6]

Assessment

In patients who present with markedly elevated blood pressure, a careful history and exam are necessary to determine which of these patients is having a true hypertensive emergency. Symptoms such as a headache, dizziness, altered mental status, shortness of breath, chest pain, decreased urine output, vomiting, or changes in vision warrant further evaluation. The source of the abrupt onset of hypertension should also be investigated to direct treatment.

Evaluation

The evaluation for hypertensive emergencies also depends on the symptoms and signs present. Once it is determined that a true hypertensive emergency is present or likely, labs such as metabolic panels, urinalysis, B-natriuretic peptide, and cardiac enzymes may be useful. An ECG is recommended in any patient suspected of having cardiac ischemia. Head computed tomography (CT) is recommended in patients with acute neurologic complaints or signs on an exam. A chest x-ray may prove to beuseful in patients with shortness of breath. A chest x-ray may also show widening of the mediastinum in the setting or aortic dissection, but this is a relatively insensitive marker, and CT angiography of the chest and abdomen should be obtained to rule out or confirm a dissection and to determine the extent of the intimal tear.[7]

Medical Management

While the specific target organ that is affected may dictate somespecifics of treatment, rapid lowering of blood pressure is the mainstay of therapy for hypertensive emergencies. The goal would be to lower the mean arterial pressure by 20% to 25% within the first 1 to 2 hours. Several agents can be used, but the unifying characteristics are that they are rapidly acting and easily titratable. For this reason, oral medications, such as clonidine and nifedipine, play no role in the immediate management of a hypertensive emergency. Intravenous vasoactive drips such as labetalol, esmolol, nicardipine, and nitroglycerin are typically effective options.[5][8]

Nursing Management

Monitor blood pressure frequently. Know the target set by the physician
Administer antihypertensive medications as prescribed
Have two large-bore IVs
Provide oxygen f the saturations are low (less than 94%)
Limit fluid intake if the patient is in heart failure
Assess ECG to ensure the patient is not having a heart attack
Check report of the chest x-ray to ensure the patient is not in heart failure
Listen to the heart for murmurs and lungs for rales and crackles
Check if the patient has edema
Check renal function and electrolyte levels
Encourage rest and provide a quiet room
Educate the patient on how to lower stress
Educate patient on a low salt diet, exercise, and healthy eating
Educate the patient on the importance of taking antihypertensive medications
See Also
One exercise decreases blood pressure as well as medicine, study shows

When To Seek Help

If altered LOC
Unresponsive
High BP (more than 200/100) despite treatment

Outcome Identification

There are many case series indicating that in the short term management of hypertensive emergency has good outcomes but the long-term results remain unknown. Part of the problem is that patients are lost to follow up, and the medication regimen is frequently changed. Many studies indicate that untreated hypertensive emergencies have very high morbidity and mortality and unless healthcare providers make a determined effort to educate the patient on the seriousness of hypertension, this trend is likely to continue. [1](Level V)

Coordination of Care

Hypertensive emergency is not an uncommon presentation to the ER. Despite awareness of its high morbidity and mortality, at least 50% of patients with hypertension do not remain compliant with their medications. The problem is exacerbated when the only access for these patients is the emergency room. There are countless guidelines by national agencies and organizations on blood pressure control, but many patients do not seem to appreciate the seriousness of hypertension. An interprofessional approach to the management of hypertension is recommended beginning with the primary caregiver. The treatment of hypertension is best done as an outpatient; the few minutes spent with a cardiologist in a hospital veryrarely makes any difference.

The pharmacist, nurse, and the primary practitioner have a vital role to play in the education of patients with hypertension. The need to regularly measure the blood pressure and follow up with the healthcare provider cannot be overemphasized. Patients need to be told to change their lifestyle, eat healthy, exercise, discontinue smoking, and remain medication compliant. Sadly, evidence-based guidelines have not translated in reducing the number of people still presenting to the ER with hypertensive emergencies.[9][10][11] (Level V)

Outcomes

There are many case series indicating that in the short term management of hypertensive emergency has good outcomes but the long-term results remain unknown. Part of the problem is that patients are lost to follow up, and the medication regimen is frequently changed. Many studies indicate that untreated hypertensive emergencies have a very high morbidity and mortality and unless healthcare providers make a determined effort to educate the patient on the seriousness of hypertension, this trend is likely to continue. [1](Level V)

Health Teaching and Health Promotion

The best way to prevent a hypertensive emergency is to remain compliant with antihypertensive medications. While routine hypertension can be managed by the primary health care provider, consultation from a cardiologist is recommended when the patient is on more than 3 antihypertensives and the blood pressure stillremains elevated.

Discharge Planning

Hypertensive emergency is not an uncommon presentation to the ER. Despite awareness of its high morbidity and mortality, at least 50% of patients with hypertension do not remain compliant with their medications. The problem is exacerbated when the only access for these patients is the emergency room. There are countless guidelines by national agencies and organizations on blood pressure control, but many patients do not seem to appreciate the seriousness of hypertension. An interprofessional approach to the management of hypertension is recommended beginning with the primary caregiver. Patients need to be educated about the importance of antihypertensive medications by the pharmacist, discharge nurse, and primary care provider. The treatment of hypertension is best done as an outpatient; the few minutes spent with a cardiologist in a hospital veryrarely makes any difference.

The pharmacist, nurse, and the primary practitioner have a vital role to play in the education of patients with hypertension. The need to regularly measure the blood pressure and follow up with the healthcare provider cannot be overemphasized. Patients need to be told to change their lifestyle, eat healthy, exercise, discontinue smoking and remain medication compliant. At every clinic visit, the blood pressure should be monitored. A social worker should be involved in the care to ensure that the patient's financial status is not limiting the ability to buy the medications.

Sadly, evidence-based guidelines have not translated in reducing the number of people still presenting to the ER with hypertensive emergencies.[9][10][11] (Level V)

Pearls and Other issues

Markedly elevated blood pressure is common with acute ischemic stroke and requires a specialized approach. Per AHA/ASA guidelines, patients eligible for thrombolysis should have blood pressure lowered to SBPlower than185 mmHg and DBP lower than 110 mmHg and maintained at SBPlowerthan 180 mmHg and DBPlowerthan 105 mmHg for the first 24 hours. For those not receiving thrombolytics, only levels SBP higher than 220 mmHg or DBP higher than 120mmHg should be lowered as hypertension in acute stroke is usually transient and may be protective. A reasonable goal is about 15% decrease in mean arterial pressure.

In an acute hemorrhagic stroke, the reduction of SBP to lower than 140 mmHg may improve functional outcomes. This requires an aggressive approach with rapidly titrated intravenous antihypertensives, and extreme vigilance is necessary to prevent hypotension, which causes decreased cerebral perfusion pressure and adds to the ischemic insult. Easily titratable medications with rapid onset and short duration of action, such as nicardipine, are recommended.

Aortic dissection also deviates in the degree ofblood pressure-lowering that is recommended. Traditional teaching is to lower the blood pressure to as low as organs will allow, with close monitoring of the patient’s mental status as a guide. Intravenous beta-blockers, most commonly esmolol, are first-line treatments due to their ability to lower blood pressure while avoiding reflex tachycardia and increased shear stress to the aortic wall. Classically, nitroprusside has been used asan adjunct to beta-blockers in the treatment of aortic dissection, but this has become an infrequent practice due to its association with rapid and profound hypotension, tachyphylaxis, as well as the potential for cyanide toxicity. Nicardipine with the addition of a beta-blocker would also be a reasonable choice.

Preeclampsia is a particularly troubling and difficult to manage hypertensive emergency since there are two patients to consider. The first-line therapy is magnesium sulfate, administered as a 4 g to 6 g loading dose followed by 1 g to 2 g/hour infusion. Care must be taken to monitor urine output, deep tendon reflexes, and respiratory status. If further antihypertensives are needed, beta-blockers can be used, but only to treat SBP higher than 160 mmHg. Hydralazine was once touted as the preferred agent in pregnant patients; however, its delayed onset of action, prolonged duration, and unpredictable hypotensive effects make it a less than ideal choice. Regardless of the agent, the patient is likely to need close monitoring in a critical care setting.

Review Questions

References

1.: Froehlich RJ, Maggio L, Has P, Vrees R, Hughes BL. Improving Obstetric Hypertensive Emergency Treatment in a Tertiary Care Women's Emergency Department. Obstet Gynecol. 2018 Oct;132(4):850-858. [PubMed: 30130350]
2.: Shao PJ, Sawe HR, Murray BL, Mfinanga JA, Mwafongo V, Runyon MS. Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania. BMC Cardiovasc Disord. 2018 Aug 02;18(1):158. [PMC free article: PMC6090910] [PubMed: 30068315]
3.: Tocci G, Figliuzzi I, Presta V, Miceli F, Citoni B, Coluccia R, Musumeci MB, Ferrucci A, Volpe M. Therapeutic Approach to Hypertension Urgencies and Emergencies During Acute Coronary Syndrome. High Blood Press Cardiovasc Prev. 2018 Sep;25(3):253-259. [PubMed: 30066227]
4.: Paini A, Aggiusti C, Bertacchini F, Agabiti Rosei C, Maruelli G, Arnoldi C, Cappellini S, Muiesan ML, Salvetti M. Definitions and Epidemiological Aspects of Hypertensive Urgencies and Emergencies. High Blood Press Cardiovasc Prev. 2018 Sep;25(3):241-244. [PubMed: 29916180]
5.: Watson K, Broscious R, Devabhakthuni S, Noel ZR. Focused Update on Pharmacologic Management of Hypertensive Emergencies. Curr Hypertens Rep. 2018 Jun 08;20(7):56. [PubMed: 29884955]
6.: Viera AJ. Hypertension Update: Hypertensive Emergency and Asymptomatic Severe Hypertension. FP Essent. 2018 Jun;469:16-19. [PubMed: 29863318]
7.: Arbe G, Pastor I, Franco J. Diagnostic and therapeutic approach to the hypertensive crisis. Med Clin (Barc). 2018 Apr 23;150(8):317-322. [PubMed: 29174704]
8.: Salvetti M, Paini A, Bertacchini F, Stassaldi D, Aggiusti C, Agabiti Rosei C, Muiesan ML. Acute blood pressure elevation: Therapeutic approach. Pharmacol Res. 2018 Apr;130:180-190. [PubMed: 29481963]
9.: Martínez-Díaz AM, Palazón-Bru A, Folgado-de la Rosa DM, Ramírez-Prado D, Navarro-Juan M, Pérez-Ramírez N, Gil-Guillén VF. A one-year risk score to predict all-cause mortality in hypertensive inpatients. Eur J Intern Med. 2019 Jan;59:77-83. [PubMed: 30007839]
10.: Georgiopoulos G, Kollia Z, Katsi V, Oikonomou D, Tsioufis C, Tousoulis D. Nurse's Contribution to Alleviate Non-adherence to Hypertension Treatment. Curr Hypertens Rep. 2018 Jun 15;20(8):65. [PubMed: 29904903]
11.: Chim C, Dimitropoulos E, Ginzburg R. Implementing a Policy and Protocol on Managing Patients With Hypertensive Urgencies. Ann Pharmacother. 2016 Jul;50(7):548-54. [PubMed: 27083919]
12.: Cazarim Mde S, de Freitas O, Penaforte TR, Achcar A, Pereira LR. Impact Assessment of Pharmaceutical Care in the Management of Hypertension and Coronary Risk Factors after Discharge. PLoS One. 2016;11(6):e0155204. [PMC free article: PMC4909302] [PubMed: 27304922]

: Disclosure: William Alley declares no relevant financial relationships with ineligible companies.
: Disclosure: Michael Schick declares no relevant financial relationships with ineligible companies.
: Disclosure: Chaddie Doerr declares no relevant financial relationships with ineligible companies.