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Mar.09.2020

Hypertension Acute (Adult ED)

Clinical Description

  • Care of the emergency department patient seeking treatment for acute blood pressure elevation.

Key Information

  • Hypertensive emergency is severely elevated blood pressure (systolic blood pressure greater than 180 mmHg, diastolic blood pressure greater than 120 mmHg or both) with symptoms of target-organ dysfunction or damage.
  • Hypertensive urgency is severely elevated blood pressure (systolic blood pressure greater than 180 mmHg or diastolic blood pressure greater than 110 to 120 mmHg) without symptoms of target-organ dysfunction. This is usually managed with oral agents over a period of days.
  • Target organs include heart, brain, kidneys, peripheral arteries and eyes. Dysfunction or damage to these organs is an emergent condition.
  • During hypertensive emergency, blood pressure should be gradually decreased to prevent or limit further organ damage. Clinical situation determines the speed and extent of blood pressure decrease.
  • An appropriately sized blood pressure cuff is required to obtain accurate readings.

Threats to Life, Limb or Function

  • acute stroke
  • heart failure
  • hemorrhage secondary to aortic dissection
  • hypertensive encephalopathy
  • myocardial infarction
  • progressive target-organ damage, such as heart, brain, kidneys, peripheral vascular system, eyes
  • pulmonary edema

Clinical Goals

By transition of care

A. The patient will achieve the following goals:
  • Goal: Acute Signs/Symptoms are Managed

  • Goal: Acceptable Pain Level Achieved

    Correlate Health Status

    • Correlate health status to:

      • history, comorbidity
      • age, developmental level
      • sex, gender identity
      • baseline assessment data
      • physiologic status
      • response to medication and interventions
      • psychosocial status, social determinants of health
      • barriers to accessing care and services
      • health literacy
      • cultural and spiritual preferences
      • safety risks
      • family interaction
      • plan for transition of care

    Hypertension Acute

    Associated Documentation

    • Hypertension, Acute Management

    Presentation

    • blood pressure acutely increased
    • chest pain
    • dizziness
    • fatigue
    • headache
    • level of consciousness altered
    • nausea and vomiting
    • shortness of breath

    Associated Signs/Symptoms

    • abdominal pain
    • anxiety
    • back pain
    • epistaxis
    • visual disturbance

    Potential Causes

    • acute coronary syndrome
    • adverse drug effect
    • aortic dissection
    • burn
    • cardiogenic pulmonary edema
    • endocrine disorder
    • essential hypertension
    • medication noncompliance
    • pain
    • renal artery stenosis
    • renal parenchymal disease
    • stroke
    • subarachnoid hemorrhage

    Initial Assessment

    • airway and respiratory status
    • blood pressure
    • cardiovascular status
    • fluid status
    • hemodynamic status
    • neurologic status
    • symptoms of end-organ damage (chest pain, back pain, increased work of breathing, signs of stroke or encephalopathy)

    History

    • allergies
    • comorbidities
    • immunization status
    • last menstrual period (females of childbearing age)
    • medications
    • aggravating conditions
    • family history of primary hypertension, cardiac disease or endocrine disease
    • onset of symptoms
    • substance use

    Laboratory Studies

    • blood glucose level
    • BUN (blood urea nitrogen)
    • CBC (complete blood count) with differential
    • serum creatinine
    • serum electrolytes
    • urinalysis

    Diagnostics

    • 12-lead ECG (electrocardiogram)
    • chest x-ray

    Potential Additional Testing

    • 2D echocardiogram (assess left ventricular mass and function)
    • BNP (B-type natriuretic peptide)
    • cardiac biomarkers
    • catecholamine level (blood, urine)
    • CT (computed tomography) scan
    • eGFR (estimated glomerular filtration rate)
    • pregnancy test (for females of childbearing age)
    • renal ultrasound
    • thyroid function tests
    • ultrasound for optic nerve sheath diameter measurement
    • uric acid
    • urine culture
    • urine toxicology screen

    Problem Intervention

    Provide Hemodynamic Support

    • Monitor cardiovascular status.
    • Observe for and address cardiac dysrhythmia.
    • Position to support perfusion.
    • Evaluate fluid status; provide fluid therapy to improve blood flow, perfusion and tissue oxygenation.
    • Anticipate urgent intervention in the presence of hemodynamic instability.

    Problem Intervention

    Provide Respiratory Support

    • Assess and monitor airway, breathing and circulation for effective oxygenation and ventilation; maintain close surveillance for deterioration.
    • Maintain open and patent airway.
    • Position to minimize the risk of aspiration, ventilation/perfusion mismatch and breathlessness.
    • Minimize oxygen consumption and demand.
    • Provide oxygen therapy judiciously; titrate to prevent hyperoxemia.
    • Implement noninvasive or invasive positive pressure ventilation to support oxygenation and ventilation, as well as relieve respiratory distress.

    Problem Intervention

    Monitor and Manage Blood Pressure

    • Treat aggravating conditions, such as pain or underlying cause (if identified), such as pulmonary edema.
    • Verify blood pressure reading before beginning treatment.
    • Lower blood pressure via pharmacologic method if evidence of target organ damage. With hypertensive emergency, clinical situation and comorbidity should be considered to establish blood pressure goal and guide careful reduction.
    • Monitor for drug-induced side effects of antihypertensive therapy, such as reflex tachycardia or rebound hypertension.

    Problem Intervention

    Promote Comfort and Manage Pain

    • Use a consistent pain assessment tool; evaluate pain and treatment response at regular intervals.
    • Involve patient and family/caregiver in the management plan.
    • Consider pharmacologic measures, such as an analgesic or anxiolytic agent.
    • Provide nonpharmacologic strategies, such as a quiet, calm environment and relaxation techniques.
    • Evaluate risk for opioid use.

    Problem Intervention

    Initiate Consult or Referral

    • Facilitate contact, such as intensivist or personal physician.

    Education

    General Emergency Education

    Teaching Focus

    • symptom/problem overview

    • risk factors/triggers

    • self-management

    • assistive device

    • diagnostic test

    • diet modification

    • medical device/equipment use

    • medication administration

    • opioid medication management

    • orthopaedic device

    • safe medication disposal

    • smoking cessation

    • wound care

    Population-Specific Considerations

    Forensics and Legal

    • Utilize local, state/province, federal requirements and hospital policy and protocols to manage patient care involving forensics, protective services, workman’s compensation and mandatory reportable events and illness.

    Human Trafficking

    • Human trafficking victims most frequently seek healthcare services from Emergency Departments. Healthcare professionals, alert to signs of trafficking, can guide supportive care for victims.
    • Trafficked individuals may be male or female and engaged in sex work or other forced labor. High-risk signs requiring more direct questioning about exploitation include, among others, current employment in a high-risk industry, prior sexually transmitted infections, recent immigration, undocumented immigrant status and other vulnerable and minority populations.

    Geriatric

    • Neurologic changes from baseline, such as agitation, lethargy and confusion, are often an indicator of illness versus ”old age”.
    • Older adults may require stronger stimuli and longer response time with neurologic evaluation.
    • Signs of increased intracranial pressure may be subtle in the geriatric population.
    • Older adults have an increased sensitivity to medication and toxins. There is also a decrease in renal function and cardiovascular resilience, as well as ability to react to volume and electrolyte changes.

    References

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    Clinical Practice Guidelines represent a consistent/standardized approach to the care of patients with specific diagnoses. Care should always be individualized by adding patient specific information to the Plan of Care.