 Hi and welcome to Nursing School at Explained and this video on Hypertensive Crisis that is sometimes also known as a Hypertensive Urgency or Emergency. So clearly we really have to act quickly when this happens. And the Hypertensive Crisis or Urgency or Emergency is defined as a systolic blood pressure of greater than 180 and or a diastolic blood pressure of greater than 120. So these are significantly higher than the blood pressure readings from the current guidelines of a blood pressure of less than 120 over 80. So just think about if you had all the blood pressure, all the vessels in your body under extreme pressure because the pressure is just really high putting a lot of pressure on the blood vessels themselves as well as the organs then stand under a lot of pressure. All of the signs and symptoms and possible complications would be kind of logical to come from there. So whenever there is a Hypertensive Crisis with a really high blood pressure the patient might have signs and symptoms of a headache, dizziness or nausea vomiting because all the cerebral arteries are just pounding and the patient might feel that. It might also lead to confusion and altered level of consciousness can lead as far as coma or the patient might complain of chest pain or shortness of breath because also the heart and the lungs are under this immense pressure. It can lead to seizures because of encephalopathy or it can lead to intracranial hemorrhages or subarachnoid hemorrhages when the blood vessels in the brain just kind of burst because they're under so much pressure and that would be a hemorrhagic stroke here for example. It can also have signs and symptoms of heart failure or pulmonary edema because again that pressure is putting a lot of pressure on the heart that then can't really pump and the blood is backing up the fluid is backing up into the lungs causing pulmonary edema. It can also lead to aortic dissection so the aorta the main blood vessel can basically peel away from the inside because it's all so under so much pressure that the blood that the inner lining of the blood vessel just kind of starts to peel away and give out and eventually it can it can rupture. But it can also put the kidneys under a lot of pressure and the patient might exhibit signs and symptoms of renal failure as well as MI heart attack and retinopathy. So definitely visual disturbances are also very common with a hypertensive crisis. Now what leads to hypertensive crisis unfortunately the most common one is a patient with a history of hypertension who is non adherent to the medication regimen. So they forget there are other circumstances and they just don't take their anti-hypertensives and then the blood pressure gets out of control. Keep in mind that hypertension is also called the silent killer. So if somebody has blood pressure that has been creeping up over the years and getting increasingly higher the patient might just have vague signs and symptoms that we've just discussed and not really know that now the blood pressure is above the certain threshold and then have you know significant complications from that. Usually also drug abuse causes hypertensive crises and drugs that are known to amp up the blood pressure are all the things that kind of cause everything to speed up which is cocaine, crack, PCP and LSD so all the drugs that make the patient extra hyper. But also in the OB setting preeclampsia can lead to a hypertensive crisis and then also drugs called MAO inhibitors that are usually used in the mental health setting. They don't really get along with thyramine containing foods and so if a patient is on these MAO, MOA inhibitors and eats thyramine containing foods then it can lead to hypertensive crisis which can be life threatening. Any kind of head injury of course because now the cerebral auto regulation is off and the body might respond by trying to perfuse the brain with more blood and increasing the blood pressure and then the patient will have hypertensive crisis as well as an acute aortic dissection and we already discussed this and I do have a separate video about aortic dissection. Now what's the treatment? The patient will need to be hospitalized for IV medications. Many times single dose or two, three single doses won't really do the trick. The patient will have to be hospitalized and be on medications that need to be titrated meaning adjusted to a certain level of blood pressure and these medications will look about in a moment here and typically the medications are titrated to the mean arterial pressure and this is important to know because the orders will typically not give you a reading of systolic and diastolic blood pressure. They will typically give you a map which is systolic blood pressure plus two times the diastolic blood pressure and all that in the denominator and the numerator divided by three and certainly the patient will need to be on telemetry monitoring or the cardiac monitor if they require ICU hospitalization and the level of the hypertension as well as the ability of the hospital department to care for a patient that requires titration of drugs will depend on where the patient goes whether that's the regular celly floor or maybe the progressive care unit, the stepped on unit or even the intensive care unit. And then medications used in the treatment of hypertension are vasodilators. If we dilate the blood vessel the pressure will go down and typically we use here nitroprosyde as well as nitroglycerin and keep in mind that nitroglycerin is available sublingual as well as topical but in this case it would be an IV infusion titrated to the go map. Also beta blockers such as labedalol and calcium channel blockers such as necardipine can be effective here sometimes maybe even a combination of these medications is needed to bring the blood pressure down. As for nursing care you can imagine because we have a crisis urgency or emergency these patients are pretty sick so they are going to require frequent monitoring of blood pressures as well as heart rates so every 5 to 15 minutes and because it is so frequent many times they will have an arterial line because it takes a lot of toll on the arm plus it might not be super accurate to check the blood pressure that frequently the regular way on an arm so an arterial line an invasive line might be much more reliable and actually easier to manage with the nurse as well as easier on the patient because it's not going to squeeze the arm yes it is an invasive line but it's just much more accurate whenever we're titrating vasoactive drugs and the goal usually for the titration of any of these medications is to decrease that mean arterial pressure which is talked about by 20 to 25% gradually over 24 hours so we don't want to drop that blood pressure that's 200 over 130 all the way down to 120 over 80 really quickly because the body might not respond well and all the rasp and all the mechanisms that typically kick in when we drop our blood pressure will kick in and then we have kind of like this rebound hypertension so it typically is done gradually because otherwise there are risk for cerebral coronary and renal perfusion problems because all these organs we know are super important and they might not get the blood flow that they need to stay functioning properly the only exception here for the goal of lowering the blood pressure is if the patient has an aortic dissection because that is an emergency because if the dissection if the blood vessel is basically just dilated there's a high risk that it might rupture and then the patient might bleed out internally so that's the only exception to when we really want to get that systolic blood pressure low and the goal here is between 100 and 120 pretty quickly to take the pressure off the aorta otherwise it might burst and other nursing measures so certainly we'll check an EKG and keep the patient on the cardiac monitor we'll monitor closely for urine output and eyes and nose to check there see how the kidneys are doing the patient will need to be on bed rest because any activity might exacerbate their hypertension and certainly will need neural checks frequently because we talk about all those neural symptoms that the patient can have all the way leading up to encephalopathy or intracranial hemorrhage basically hemorrhagic stroke so thank you for watching this video on hypertensive crisis please also watch my other videos in the critical care playlist also the ones on aortic aortic dissection and aortic aneurysm as well as the basic explanations of hypertension and the guidelines for blood pressure control as to what we should aim for always in the outpatient setting so that the patient does not even get to the part where to the point where they have this hypertensive crisis thanks for watching nursing school explain see you soon