2 Hypertension

Understanding and classifying hypertension

Hypertension is persistently elevated arterial blood pressure and often causes no symptoms. Because it may be silent while increasing the risk of damage to the heart, brain, kidneys, eyes, and blood vessels, accurate measurement and follow-up are essential. A diagnosis should rely on properly obtained readings and clinical evaluation, not on a single routine measurement.

Blood pressure categories

For nonpregnant adults, the 2025 AHA/ACC guideline classifies blood pressure using systolic and diastolic readings. A reading in either the systolic or diastolic range may determine the category.

• Normal: systolic below $120$ mm Hg and diastolic below $80$ mm Hg.

• Elevated: systolic from $120$ to $129$ mm Hg and diastolic below $80$ mm Hg.

• Stage 1 hypertension: systolic from $130$ to $139$ mm Hg or diastolic from $80$ to $89$ mm Hg.

• Stage 2 hypertension: systolic at least $140$ mm Hg or diastolic at least $90$ mm Hg.

The general treatment goal is below $130/80$ mm Hg, with individual considerations for some patients. Confirming elevated readings outside the clinic may help identify White-coat hypertension or Masked hypertension.

Obtaining accurate readings

Prepare for a reliable reading by having the patient avoid smoking, exercise, and caffeine for $30$ minutes beforehand and empty their bladder. The patient should sit quietly for at least $5$ minutes, with the back supported, feet flat, and legs uncrossed. Place a correctly sized cuff on a bare upper arm, rest the arm at heart level, and have the patient remain quiet during measurement.

For home monitoring, teach patients to take at least two readings $1$–$2$ minutes apart, record the readings, and share the log with the care team. A reading such as $136/84$ mm Hg falls in stage 1 hypertension because either the systolic value of $130$–$139$ mm Hg or the diastolic value of $80$–$89$ mm Hg meets that category.

Nursing assessment and monitoring

Nursing assessment includes reviewing blood pressure trends, medication use, and barriers to adherence. Screen for symptoms or signs of target-organ injury, and monitor relevant laboratory results, such as kidney function and electrolytes, when indicated by the patient's condition or medications.

After treatment changes, assess dizziness or orthostatic symptoms. If a patient reports dizziness after a medication change, assess symptoms and blood pressure, including positional readings when appropriate, and report the findings. Reinforce follow-up rather than advising unsupervised medication changes.

Complications and urgent response

Long-term uncontrolled hypertension can injure the heart, brain, kidneys, retina, and arteries. Possible outcomes include myocardial infarction, heart failure, stroke, chronic kidney disease, vision loss, and peripheral arterial disease. New chest pain, shortness of breath, weakness, numbness, confusion, difficulty speaking, or acute vision changes require urgent assessment.

A repeated blood pressure above $180/120$ mm Hg needs prompt attention. If this severe reading is accompanied by concerning symptoms such as chest pain, shortness of breath, weakness, vision change, or difficulty speaking, call emergency services. For example, a repeat reading of $184/122$ mm Hg with sudden weakness and difficulty speaking calls for emergency services.

If the repeat reading remains above $180/120$ mm Hg without symptoms, contact a health professional promptly for assessment and treatment guidance. Do not independently take extra doses or attempt rapid lowering.

Treatment decisions

Treatment combines lifestyle measures and, when indicated, medication. The 2025 guideline recommends medication for adults with an average blood pressure of at least $140/90$ mm Hg, and for selected adults at or above $130/80$ mm Hg based on cardiovascular disease, prior stroke, diabetes, chronic kidney disease, or estimated cardiovascular risk.

For lower-risk adults with stage 1 hypertension, medication is recommended if blood pressure remains at or above $130/80$ mm Hg after an initial lifestyle trial of $3$–$6$ months. For stage 2 hypertension, starting two first-line medicines from different classes is preferred; these are often provided in one combination pill. The treatment plan and goal should be individualized.

Lifestyle and medication education

Lifestyle teaching includes following a heart-healthy eating pattern such as DASH, reducing sodium, pursuing a healthy weight, engaging in regular physical activity, avoiding tobacco, managing stress, and limiting or avoiding alcohol.

Patients should take medicines as prescribed and continue them even when they feel well. They should consult their clinician before stopping a medicine or changing a dose. Because hypertension is commonly symptom-free, feeling normal is not a reason to stop treatment without clinical advice.

Medication groups and safe use

Common medication groups include thiazide-type diuretics, ACE inhibitors, angiotensin-receptor blockers (ARBs), and calcium-channel blockers. The choice depends on the patient's health conditions, response, adverse effects, and laboratory findings. Nurses reinforce the medication plan, assess adherence and side effects, and encourage follow-up and home monitoring.

Patients should ask a clinician or pharmacist before using over-the-counter medicines or supplements. Some products, including certain decongestants and NSAIDs, can raise blood pressure or interact with treatment.