Hypertension
Meet the Client: George Thomas
A group of nursing students is conducting blood pressure and cholesterol screenings outside a local
home improvement store on Saturday morning for its community service project. George Thomas, a
52-year-old Caucasian male stops by the booth to have his blood pressure and cholesterol checked.
He tells the students that he is a construction foreman.
Assessment:
George’s blood pressure is 189/110. His LDL Cholesterol is 200 mg/dL. He asks the student nurse if his
blood pressure is something he should be concerned about
1. How should the student respond?
A. Your blood pressure is very high. You need to see your healthcare provider today.
B. You have hypertension. You need to start making some lifestyle changes.
C. Please sit quietly for a few minutes. I need to recheck your blood pressure.
D. I need you to remain seated. I am going to call for the emergency squad.
*I chose C because you always want to recheck the BP if it’s running high, and it could’ve also been
elevated to George being stressed or some recent physical activity.
The student nurse asks George about his health history. George is 6 feet tall (182.88cm) and his weight
is 190 pounds (86.18 kgs). George states that he has lost a lot of weight recently. He also reports feeling
a lot of stress at work and that he often goes out with the crew after work to have several beers. He
reports that his mother who had Diabetes Mellitus passed away recently which has also contributed to
his emotional health. He believes his mom also had hypertension. George smokes a pack of cigarettes a
day and drinks 4 to 5 cups of coffee a day too.
2. What significant risk factors for hypertension does the nursing student identify for George
according to his reported health history? SELECT ALL THAT APPLY
A. Family history of Diabetes
B. Alcohol Consumption
C. Smoking
D. Stress
E. Caffeine consumption
*I chose alcohol consumption, smoking, and stress because these are all risk factors for hypertension. A
family history of diabetes isn’t important in this scenario, and caffeine is not a risk factor for
hypertension.
The student retakes George’s blood pressure now that George has been sitting quietly for a few minutes.
His blood pressure is 180/106 mmHg.
3. According to the assessment of this client, which recommendation is most important for the
student nurse to provide George?
, A. See your Healthcare Provider as soon as possible within the next week for a blood pressure
check.
B. Limit his salt intake and start a weight loss program.
C. Attend a stress reduction seminar offered in his community.
D. Learn about high fiber foods and add more fiber to his diet.
*I chose to have his BP rechecked because the previous two were taken in the same day, and taking
another BP in a few days would be a better and accurate indicator of George having hypertension.
The student nurse continues to talk to George about his blood pressure results. He states that he feels
great physically and does not see why he needs to see his Doctor.
4. Which is the best response the student nurse can give to George about the urgent need to see a
Healthcare Provider (HCP)?
A. Your blood pressure is dangerously elevated. You could have a heart attack or stroke at any
time.
B. While often there are no symptoms, high blood pressure can damage many organs.
C. Hypertension is called the silent killer. I am sure you do not want to die at your young age.
D. It is always better to treat high blood pressure before you start having symptoms.
*Hypertension could cause major organ damage to an individual, before they start to experience
symptoms, so it is important for us to diagnose asap.
A week later, George has an appointment with his HCP. After the exam the HCP explains to George that
he has stage 2, primary, (essential) hypertension.
5. Which information obtained during the assessment supports this diagnosis?
A. Blood Pressure of 184/98 mmHg
B. Family history of Hypertension
C. Irregular pulse rate of 110 beats/min.
D. A auscultated heart murmur
*Stage 2 hypertension is classified as a systolic reading of 140 or higher, and a diastolic reading of 90 or
higher, so Georges reading helps us further understand that he has stage 2 hypertension.
The HCP informs George that he needs to be on a low salt diet, stop smoking, limit his alcohol intake,
decrease his stress level, and start taking Chlorothiazide (Diuril) and Atenolol (Tenormin). The nurse
enters the room to give George his prescriptions and spends some time teaching him about his care and
medications. When speaking with the nurse, George expresses some concern that the HCP did not
prescribe any additional tests. He asks, “Shouldn’t the HCP find out why I have hypertension?
Hypertension
Assessment of the Client with Hypertension
History
Note the following points when interviewing the hypertensive client:
, Family history of hypertension, diabetes mellitus, cardiovascular disease,
hyperlipidemia, or renal disease; smoking; stress; obesity; or sedentary lifestyle
Previous documentation of high blood pressure, including age at onset, level of
elevation, and currently prescribed medical regimen
History of all prescribed and over-the-counter medications and the client's exact
compliance with taking the medications. NOTE: Medications that may either raise
blood pressure or interfere with the effectiveness of antihypertensive medications
include oral contraceptives, steroids, nonsteroidal anti-inflammatory drugs, nasal
decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants,
monoamine oxidase inhibitors, and erythropoietin
History of any disease or trauma to target organs
Results and side effects of previous antihypertensive therapy
Clinical manifestations of cardiovascular disorders, such as angina, dyspnea, or
claudication
History of or recent weight gain, exercise activities, sodium intake, fat intake, alcohol
use, and smoking
Psychosocial and environmental factors (e.g., emotional stress, cultural food
practices, economic status) that may influence blood pressure control
Physical Examination
Physical assessment should include an accurate determination of blood pressure as well as
an evaluation of target organs:
Vital signs and weight
Blood pressure—because blood pressure is variable and can be affected by multiple
factors, it should be measured so that readings are representative of the client's
usual level; the following techniques are strongly recommended: The client should
be seated with the arm bared, supported, and positioned at heart level. The client
should not have smoked tobacco or ingested caffeine within the previous 30
minutes. Measurement should begin after at least 5 minutes of quiet rest. The
client's back should be supported, and both feet should be flat on the floor with the
legs uncrossed. The client should not speak while the blood pressure is being
monitored.
Use of the appropriate cuff size will ensure an accurate measurement. The rubber bladder
should encircle at least 80% of the limb being measured. The bladder's width should be one-
third to one-half the circumference of the limb. Several sizes of cuffs (e.g., child, adult, large
adult) should be available.
Measurements should be taken with a mercury sphygmomanometer, a recently
calibrated aneroid manometer, or a validated electronic device.
Postural blood pressures should be measured and recorded according to position and
arm used, including lying, sitting, and standing measurements from both arms.
Both systolic and diastolic blood pressures should be recorded. The disappearance of
sound (phase V) should be used for the diastolic reading. Two or more readings
should be averaged. If the first two readings differ by more than 5 mm Hg, additional
readings should be obtained.
Funduscopic examination for retinal arteriolar narrowing, hemorrhages, exudates,
and papilledema
Examination of the neck for distended veins, carotid bruits, and enlarged thyroid
Auscultation of the heart for increased heart rate, dysrhythmias, enlargement,
precordial impulses, murmurs, and S3 and S4 heart sounds
Meet the Client: George Thomas
A group of nursing students is conducting blood pressure and cholesterol screenings outside a local
home improvement store on Saturday morning for its community service project. George Thomas, a
52-year-old Caucasian male stops by the booth to have his blood pressure and cholesterol checked.
He tells the students that he is a construction foreman.
Assessment:
George’s blood pressure is 189/110. His LDL Cholesterol is 200 mg/dL. He asks the student nurse if his
blood pressure is something he should be concerned about
1. How should the student respond?
A. Your blood pressure is very high. You need to see your healthcare provider today.
B. You have hypertension. You need to start making some lifestyle changes.
C. Please sit quietly for a few minutes. I need to recheck your blood pressure.
D. I need you to remain seated. I am going to call for the emergency squad.
*I chose C because you always want to recheck the BP if it’s running high, and it could’ve also been
elevated to George being stressed or some recent physical activity.
The student nurse asks George about his health history. George is 6 feet tall (182.88cm) and his weight
is 190 pounds (86.18 kgs). George states that he has lost a lot of weight recently. He also reports feeling
a lot of stress at work and that he often goes out with the crew after work to have several beers. He
reports that his mother who had Diabetes Mellitus passed away recently which has also contributed to
his emotional health. He believes his mom also had hypertension. George smokes a pack of cigarettes a
day and drinks 4 to 5 cups of coffee a day too.
2. What significant risk factors for hypertension does the nursing student identify for George
according to his reported health history? SELECT ALL THAT APPLY
A. Family history of Diabetes
B. Alcohol Consumption
C. Smoking
D. Stress
E. Caffeine consumption
*I chose alcohol consumption, smoking, and stress because these are all risk factors for hypertension. A
family history of diabetes isn’t important in this scenario, and caffeine is not a risk factor for
hypertension.
The student retakes George’s blood pressure now that George has been sitting quietly for a few minutes.
His blood pressure is 180/106 mmHg.
3. According to the assessment of this client, which recommendation is most important for the
student nurse to provide George?
, A. See your Healthcare Provider as soon as possible within the next week for a blood pressure
check.
B. Limit his salt intake and start a weight loss program.
C. Attend a stress reduction seminar offered in his community.
D. Learn about high fiber foods and add more fiber to his diet.
*I chose to have his BP rechecked because the previous two were taken in the same day, and taking
another BP in a few days would be a better and accurate indicator of George having hypertension.
The student nurse continues to talk to George about his blood pressure results. He states that he feels
great physically and does not see why he needs to see his Doctor.
4. Which is the best response the student nurse can give to George about the urgent need to see a
Healthcare Provider (HCP)?
A. Your blood pressure is dangerously elevated. You could have a heart attack or stroke at any
time.
B. While often there are no symptoms, high blood pressure can damage many organs.
C. Hypertension is called the silent killer. I am sure you do not want to die at your young age.
D. It is always better to treat high blood pressure before you start having symptoms.
*Hypertension could cause major organ damage to an individual, before they start to experience
symptoms, so it is important for us to diagnose asap.
A week later, George has an appointment with his HCP. After the exam the HCP explains to George that
he has stage 2, primary, (essential) hypertension.
5. Which information obtained during the assessment supports this diagnosis?
A. Blood Pressure of 184/98 mmHg
B. Family history of Hypertension
C. Irregular pulse rate of 110 beats/min.
D. A auscultated heart murmur
*Stage 2 hypertension is classified as a systolic reading of 140 or higher, and a diastolic reading of 90 or
higher, so Georges reading helps us further understand that he has stage 2 hypertension.
The HCP informs George that he needs to be on a low salt diet, stop smoking, limit his alcohol intake,
decrease his stress level, and start taking Chlorothiazide (Diuril) and Atenolol (Tenormin). The nurse
enters the room to give George his prescriptions and spends some time teaching him about his care and
medications. When speaking with the nurse, George expresses some concern that the HCP did not
prescribe any additional tests. He asks, “Shouldn’t the HCP find out why I have hypertension?
Hypertension
Assessment of the Client with Hypertension
History
Note the following points when interviewing the hypertensive client:
, Family history of hypertension, diabetes mellitus, cardiovascular disease,
hyperlipidemia, or renal disease; smoking; stress; obesity; or sedentary lifestyle
Previous documentation of high blood pressure, including age at onset, level of
elevation, and currently prescribed medical regimen
History of all prescribed and over-the-counter medications and the client's exact
compliance with taking the medications. NOTE: Medications that may either raise
blood pressure or interfere with the effectiveness of antihypertensive medications
include oral contraceptives, steroids, nonsteroidal anti-inflammatory drugs, nasal
decongestants, appetite suppressants, cyclosporine, tricyclic antidepressants,
monoamine oxidase inhibitors, and erythropoietin
History of any disease or trauma to target organs
Results and side effects of previous antihypertensive therapy
Clinical manifestations of cardiovascular disorders, such as angina, dyspnea, or
claudication
History of or recent weight gain, exercise activities, sodium intake, fat intake, alcohol
use, and smoking
Psychosocial and environmental factors (e.g., emotional stress, cultural food
practices, economic status) that may influence blood pressure control
Physical Examination
Physical assessment should include an accurate determination of blood pressure as well as
an evaluation of target organs:
Vital signs and weight
Blood pressure—because blood pressure is variable and can be affected by multiple
factors, it should be measured so that readings are representative of the client's
usual level; the following techniques are strongly recommended: The client should
be seated with the arm bared, supported, and positioned at heart level. The client
should not have smoked tobacco or ingested caffeine within the previous 30
minutes. Measurement should begin after at least 5 minutes of quiet rest. The
client's back should be supported, and both feet should be flat on the floor with the
legs uncrossed. The client should not speak while the blood pressure is being
monitored.
Use of the appropriate cuff size will ensure an accurate measurement. The rubber bladder
should encircle at least 80% of the limb being measured. The bladder's width should be one-
third to one-half the circumference of the limb. Several sizes of cuffs (e.g., child, adult, large
adult) should be available.
Measurements should be taken with a mercury sphygmomanometer, a recently
calibrated aneroid manometer, or a validated electronic device.
Postural blood pressures should be measured and recorded according to position and
arm used, including lying, sitting, and standing measurements from both arms.
Both systolic and diastolic blood pressures should be recorded. The disappearance of
sound (phase V) should be used for the diastolic reading. Two or more readings
should be averaged. If the first two readings differ by more than 5 mm Hg, additional
readings should be obtained.
Funduscopic examination for retinal arteriolar narrowing, hemorrhages, exudates,
and papilledema
Examination of the neck for distended veins, carotid bruits, and enlarged thyroid
Auscultation of the heart for increased heart rate, dysrhythmias, enlargement,
precordial impulses, murmurs, and S3 and S4 heart sounds
