Hypertension

I. UNDERSTANDING 
Hypertension can be defined as persistent blood pressure where pressure sistoliknya above 140 mmHg and diastolic above 90 mmHg. In the elderly population, hypertension is defined as a systolic pressure of 160 mmHg and diastolic pressure of 90 mmHg. (Smeltzer, 2001)According to WHO (1978), blood pressure equal to or above 160/95 mmHg expressed as hypertension.

II. CLASSIFICATION 
Hypertension in the elderly be divided into: (Darmojo, 1999)a. Hypertension in which systolic pressure equal to or greater than 140 mmHg and / or diastolic pressure equal to or greater than 90 mmHgb. Isolated systolic hypertension in which systolic pressure greater than 160 mmHg and diastolic pressure lower than 90 mmHg.
Clinically the degree of hypertension can be classified in accordance with recommendations from "The Sixth Report of the Join National Committee, Prevention, Detection and Treatment of High Blood Pressure" (JNC - VI, 1997) as follows:
No Category Systolic (mmHg) Diastolic (mmHg)1. Optimal <120 <802. Normal 120-129 80-843. High Normal 130-139 85-894. HypertensionGrade 1 (mild) 140-159 90-99Grade 2 (medium) 160 - 179100-109Grade 3 (severe) 180 - 209100-119Grade 4 (very severe)> 210> 120
Calcification based on the cause of hypertension can be differentiated into 2 major categories namely:a. Essential hypertension (hypertension), namely hypertension of unknown causeb. Secondary hypertension is hypertension that is caused by other diseases.

III. Etiology 
The cause of hypertension in people with advanced age is the change - change in:a. Decreased elasticity of the aortic wallb. Valvular heart to thicken and become stiffc. Decreases the heart's ability to pump blood1% every year after age 20 years decreases the heart's ability to pump blood causing decreased contraction and volume. Loss of elasticity of blood vesselsThis happens karenakurangnya effectiveness of peripheral blood vessels for oxygenatione. Increased peripheral vascular resistance.
Although essential hypertension is not known with certainty the cause, the data of studies have found several factors that often lead to hypertension.  
These factors are as follows: 
a. Heredity 
From the statistical data proved that a person will have a greater chance to get hypertension if their parents are hypertensive 
b. Individual Characteristics
Individual characteristics that affect the incidence of hypertension is:
 Age (if age increases, the TD increases) 
 Type of sex (male greater than female) 
 Race (blacks more than whites) 
c. Living habits 
Living habits that often lead to hypertension are:
 high salt consumption (in excess of 30 g) 
 Overweight or overeating 
 Stress Smoking 
 Drinking alcohol 
 Drinking drugs (ephedrine, prednisone, epineprin)

While the causes of secondary hypertension are: 
a. Kidney 
 Glomerulonephritis 
 Pyelonephritis 
 acute tubular necrosis
 Tumors
 b. Vascular 
 Atherosclerosis
 hyperplasia 
 Thrombosis 
 Aneurysms
  cholesterol embolism 
 Vasculitis 
c. Endocrine disorders 
 DM 
 Hyperthyroidism
  Hypothyroidism 
d. Nerve 
 Stroke 
 encephalitis 
 Abuse 
e. Drugs - drugs
 Oral contraceptives 
 Corticosteroids

IV. Pathophysiology / Pathway 
The mechanisms that control the constriction and relaxation of blood vessels located in the center vasomotor, the medulla brain. From the central vasomotor sympathetic nerve jaras begins, which continues downward to the spinal cord and spinal cord out of the column in the thoracic sympathetic ganglia and abdomen. 
 Vasomotor center stimulation delivered in the form of an impulse that moves downward through the sympathetic nervous system into sympathetic ganglia. At this point, preganglionic neurons release acetylcholine, which will stimulate post-ganglion nerve fibers to blood vessels, where with the release of noreepineprin cause constriction of blood vessels. Various factors such as anxiety and fear can affect blood vessels respond to stimuli vasoconstriction. Individuals with hypertension are very sensitive to norepinephrine, although it is not clear why it can happen.At the same time stimulate the sympathetic nervous system in which blood vessels in response to emotional stimuli, the adrenal glands are also stimulated, resulting in additional vasoconstriction activity. Adrenal medulla to secrete epinephrine, which causes vasoconstriction. Adrenal cortex to secrete cortisol and other steroids, which can strengthen the vasoconstrictor response of blood vessels. Vasoconstriction resulting in decreased flow to the kidneys, causing release of renin. Renin stimulates the formation of angiotensin I is then converted into angiotensin II, a powerful vasoconstrictor, which in turn stimulates the secretion of aldosterone by the adrenal cortex. This hormone causes retention of sodium and water by kidney tubules, causing increased intra-vascular volume. All these factors tend to trigger a state of hypertension.As consideration gerontologis where structural and functional changes in peripheral vascular system are responsible for blood pressure changes that occur in the elderly. These changes include atherosclerosis, loss of elasticity of the connective tissue and a decrease in vascular smooth muscle relaxation, which in turn reduce the ability to stretch resources distension and blood vessels. Consequently, the aorta and large arteries decreases its ability to accommodate the volume of blood pumped by the heart (sekuncup volume) resulted in a decrease cheating heart and increased peripheral resistance (Smeltzer, 2001).In old age to consider the possibility of "false hypertension" due to brachial artery stiffness that is not compressed by a cuff sphygmomanometer (Darmojo, 1999).
 
V. SIGNS AND SYMPTOMS 
Signs and symptoms of hypertension can be divided into: 
a. No symptoms 
There are no specific symptoms that can be associated with increased blood pressure, in addition to the determination of arterial pressure by the examining physician. This means that arterial hypertension will never be diagnosed if arterial pressure was not measurable.
b. Symptoms commonly 
Terlazim often said that the symptoms that accompany hypertension include headache and fatigue. In fact this is a symptom of terlazim that most patients who seek medical help.
According Rokhaeni (2001), clinical manifestations some patients who suffer from hypertension, namely:a. Complained of headaches, dizzinessb. Weakness, fatiguec. Blownd. Nervouse. Nauseaf. Throw upg. Epistaxish. Decreased consciousness

VI. EXAMINATION SUPPORTa. Hemoglobin / hematocritTo assess the relationship of the cell - the cell to the volume of fluid (viscosity) and to indicate factors - risk factors such as hypercoagulability, anemia.b. BUN: to provide information on renal perfusionc. GlucoseHyperglycemia (diabetes mellitus is the originator of hypertension) may be caused by increased catecholamines (increased hypertension)d. Serum potassiumHypokalemia can megindikasikan the main aldosterone (cause) or be a side effect of diuretic therapy.e. Serum calciumIncreased serum calcium levels can cause hypertensionf. Serum cholesterol and triglyceridesElevated levels can indicate the originator for / presence of plaque formation ateromatosa (cardiovascular effects)g. Thyroid Examination Hyperthyroidism can cause vasoconstriction and hypertensionh. Aldosterone levels of urine / serumTo assess the primary aldosteronism (cause)i. UrinalisaBlood, protein, glucose and / or renal dysfunction suggests the existence of diabetes.j. Uric acidHiperurisemia has become the implications of hypertension risk factorsk. Urinary SteroidsKenaiakn may indicate hiperadrenalismel. IVP Hieprtensiseperti can identify the cause of renal parenchymal disease, kidney stones / ureterm. Photo chest
      Showed calcification in the area of valvular obstruction, enlarged heartn. CT scanTo study the cerebral tumor, encephalopathyo. ECGCan indicate an enlarged heart, strain patterns, conduction disorders, elevation of the P wave is one early sign of hypertensive heart disease

VII. MANAGEMENT 
Management of hypertension to prevent morbidity and mortality due to cardiovascular complications associated with the achievement and maintenance of blood pressure below 140/90 mmHg.
Hypertension disease management principles include: 
a. Therapy without Medication 
Without drug therapy are used as measures for mild hypertension and as a supportive action in moderate and severe hypertension. Without drug therapy include:
1. Diet 
The recommended diet for people with hypertension are:- Restrictions in a moderate salt of 10 g / hr to 5 g / hr- Diets low in cholesterol and low in saturated fatty acids
- Weight loss 
- Decrease in ethanol intake 
- Stop smoking 
2. Physical Exercise 
Physical exercise or sports are organized and directed that recommended for patients with hypertension is a sport that has four principles:- A variety of sporting and dynamic isotonis like running, jogging, biking, swimming etc.- The intensity of exercise between 60-80% of aerobic capacity or 72-87% of maximal heart rate training zone is called.- The length of training ranges from 20-25 minutes in the exercise zone- The frequency of exercise should be 3 times a week and the best 5 x per week 
3. Psychological Education
 Provision of psychological education for patients with hypertension include:- Biofeedback TechniquesBiofeedback is a technique used to show on the subject of signs about the state body is consciously by the subjects considered normal.Application of biofeedback is mainly used to cope with somatic disorders such as headache and migraine, also for psychological disorders such as anxiety and tension.- Relaxation techniquesRelaxation is a procedure or technique that aims to reduce tension or anxiety, a way to train people to be able to learn to make the muscles in the body become relaxed 
4. Health Education (Counseling) 
The purpose of health education is to improve patient knowledge about hypertension and its management so that patients can maintain life and prevent further complications.
 
b. Therapy with Drugs 
 The aim of treatment of hypertension is not only lowers blood pressure but also reduce and prevent complications from hypertension for patients to grow stronger. Treatment of hypertension is generally needed lifelong sufferer. The standard treatment recommended by the Physicians Committee of Experts Hypertension (JOINT NATIONAL COMMITTEE ON DETECTION, Evaluation and Treatment OF HIGH Blood Pressure, USA, 1988) concluded that the diuretic drugs, beta insulation, calcium antagonists, or ACE inhibitors can be used as single drug first with regard state of patients and other diseases that exist in people.Treatment includes: 
• Step 1 
The first choice medicine: diuretics, beta blockers, calcium antagonists, ACE inhibitors
• Step 2 
An alternative that can be given: 
- The first drug dose was increased
- Replace other kind of drugs the first choice
- Plus other types of drugs to 
-2, can be either diuretics, beta blockers, calcium antagonist, Alpha blocker, clonidin, reserphin, vasodilator• Step 3: The alternatives could be 
- Drugs to be replaced-2- Plus-3 drugs to other types• 
Step 4: Alternative medicine administration 
- Plus the drugs into the 3rd and 4th- Re-evaluation and consultationc. Follow Up to retain therapy

To maintain long-term therapy requires a good interaction and communication between patients and health workers (nurses, doctors) by providing health education.Things that should be considered in patient interaction with health workers is as follows: 
1. Each time patients check out, the patient was told his blood pressure measurements 
2. Talk to people with goals to be reached regarding his blood pressure 
3. Discuss with patients that hypertension can not be cured, but can be controlled in order to reduce morbidity and mortilitas 
4. Reassure the patient that the patient can not say high blood pressure based on what she feels, blood pressure can only be known by measuring the tool wear tensimeter
5. Patients should not discontinue medication without prior discussion 
6. Wherever possible therapeutic measures included in the way of living patients 
7. Ikutsertakan the patient's family in the process of therapy
8. In certain patients may benefit if the patient or family can measure blood pressure at home 
9. Keep it simple use of antihypertensive drugs eg 1 x daily or 2 times daily 
10. Discuss with patients on anti-hypertensive medications, side effects and problems that may occur 
11. Reassure the patient the possibility of the need to modify the dosage or change medications to achieve minimal side effects and maximum effectiveness 
12. Keep costs to a minimum therapy 
13. For the less compliant patients, try to visit more often 
14. Contact the patient immediately, if not come at the appointed time.Seeing the importance of patient adherence in the treatment so it will need all the knowledge and attitudes of patients about the understanding and implementation of treatment of hypertension.