Nurse Practitioner Protocols                                                                                   Cardiovascular - Chapter 6 - Page  A

HYPERTENSION

 ADULTS,  INITIAL VISIT

EVALUATION/DIAGNOSTIC PROTOCOL

SUBJECTIVE

History.  General medical history and family history.  Note that hypertension is usually asymptomatic.  Has there been any recent use of medications, prescription or non-prescription, illicit?

OBJECTIVE                 NOTE:  JNC Sixth Report 11/97 defines optimal blood pressure as systolic <120 and diastolic <80.  Normal is 130-139 systolic and 85-89 diastolic.

Physical Examination.  General appearance, vital signs, retinal, chest, and cardiovascular exam.  Be certain your blood pressure reading is not artifactual.  If time permits, a more thorough complete physical examination should be performed; otherwise, it should be scheduled.  If hypertension confirmed by review of old records, otherwise confirm by serial readings every ______ day(s).

Lab.  Consider establishing complete health data base to include chemistry profile, CBC, thyroid profile, lipid profile, EKG, chest x-ray.

ASSESSMENT                                                  Systolic^*                                   Diastolic*

Normal                                                                          <130                                         <85

High Normal                                                                  130-139                                    85-89

Hypertension                                                    

Stage 1                                                 140-159                                    90-99

Stage 2                                                 160-179                                    100-109

Stage 3/Severe                                      180-209                                    110-119

Stage 4/Very Severe                                          >209                                         >119

Differential Diagnosis is directed at etiology, with over 90% being idiopathic (better known as "essential") hypertension, which needs to be differentiated from secondary causes.

Complications include accelerated coronary arterial disease, cardiomyopathy, congestive heart failure, aneurysm, cerebro­vascular disease, renal vascular disease, retinopathy. 

PLAN/MANAGEMENT PROTOCOL

General Measures.  Explain hypertension and its direct relation to shortened life span as well as potential complications if untreated.  Provide reinforcing educational materials.  Begin appropriate habit modification instruction (involve significant family members):  weight reduction, sodium restriction, aerobic exercise for 30-45 minute daily if not contraindicated , discontinuing smoking.  Outline a program for regular blood pressure monitoring.

Specific Measures.  The authors recognize that practice circumstances and patient population may necessitate formulary variation.

Consider initially a diuretic e.g., HCTZ   25-50 mg or triamterene/HCTZ 37.5/25                                                                          ^**(_IS),

                                                                                          or

A beta blocker e.g., atenolol 25, 50, or 100 qd or split bid                                                                                           *(_IS),                                        

Consider calcium antagonist   e.g., verapamil 240 mg SR qd                                                                                     * (_IS),

An ACE inhibitor   e.g., lisinopril 5, 10, or 20 mg qd or bid                                                                                          * (_IS),

                                                                                or (but not both)

An AIIR blocker                                                                                                                                                         * (_IS),

                                                                                          or

Other antihypertensive per J.N.C. Sixth Report 11/97                                                                                                * (_IS).

Physician Consultation.  Consider on all newly diagnosed patients, in particular those in Stage 2 or Stage 3 hypertensive range.  Consult immediately on any with evidence of target organ involvement.

Referral.

Immediate Transfer.  Usually not necessary.

Follow-up Plan.  Recheck for those only on habit modification every          week(s).  Recheck blood pressure every          day(s) as pharmacotherapy instituted.  ­Other­wise, recheck every           week(s) until normotensive.