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HYPERTENSION: SEVERE Hypertension is defined by the 1992 Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure as pressure greater than 140/90 mm Hg and is classified according to the degree of severity. Stage I (mild) is 140/90–159/99. Stage II (moderate) is 160/100–179/108. Stage III (severe) is present when systolic pressure is greater than 180 and diastolic pressure is greater than 110. Stage IV (very severe) occurs when systolic pressure is 210 or greater with diastolic pressure greater than 120. Hypertension is categorized as primary/essential (approximately 90% of all cases) or secondary, which occurs as a result of an identifiable, sometimes correctable pathological condition, such as renal disease or primary aldosteronism. The goal of treatment is to prevent the long-term sequelae of the disease (i.e., target organ disease [TOD]). African-Americans and the elderly are most prone to this disorder and its sequelae. CARE SETTING Although hypertension is usually treated in a community setting, management of stages III and IV with symptoms of complications/compromise may require inpatient care, especially when TOD is present. The majority of interventions included here can be used in either setting. RELATED CONCERNS Cerebrovascular accident/stroke Myocardial infarction Psychosocial aspects of care Renal failure: acute Renal failure: chronic Patient Assessment Database ACTIVITY/REST May report: Weakness, fatigue, shortness of breath, sedentary lifestyle May exhibit: Elevated heart rate Change in heart rhythm Tachypnea; shortness of breath with exertion CIRCULATION May report: History of intermittent or sustained elevation of diastolic or systolic blood pressure; presence of atherosclerotic, valvular, or coronary artery heart disease (including myocardial infarction [MI], angina, heart failure [HF]) and cerebrovascular disease (reflecting TOD) Episodes of palpitations, diaphoresis May exhibit: Elevated blood pressure (BP) (serial elevated measurements are necessary to confirm diagnosis) Note: Postural hypotension, when present, may be related to drug regimen or reflect dehydration or reduced ventricular function. Pulse: Bounding carotid, jugular, radial pulsations; pulse disparities, e.g., femoral delay as compared with radial or brachial pulsation; absence of/diminished popliteal, posterior tibial, pedal pulses Apical pulse: Point of maximal impulse (PMI) possibly displaced and/or forceful Rate/rhythm: Tachycardia, various dysrhythmias Heart sounds: Accentuated S 2 at base; S 3 (early HF); S 4 (rigid left ventricle/left ventricular hypertrophy) Murmurs of valvular stenosis Vascular bruits audible over carotid, femoral, or epigastrium (artery stenosis); jugular venous distension (JVD) (venous congestion) Extremities: Discoloration of skin, cool temperature (peripheral vasoconstriction); capillary refill possibly slow/delayed (vasoconstriction)
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