Some of the evidence may show an accelerated HPN in association with chronic headaches, somnolence, confusion state, visual disturbances, and nausea with vomiting (i.e., hypertensive encephalopathy). Also, note the retinas sometimes appear effected with narrowing of arterial diameter to less than 50% of venous diameter, copper and/or silver wire appearance, exudates, hemorrhages, or papilledema.11 Some signs and symptoms are important among infants and neo-nates such as ‘failure to thrive,’ associated with seizure, irritability or lethargy, and respiratory distress.12 Also, in children (6-16 years of age), HPN may manifest itself through strong headaches, chronic fatigue, intermittent blurred vision, epistaxis, i.e. nosebleed, and through bell-palsy disorder.13
 

  Another important clue, sign and/or symptom for the practitioner to investigate would be a secondary medical cause of chronic (i.e., 12 weeks or longer) HPN, such as centripetal obesity, “buffalo hump,” and/or wide purple abnormal striae and maybe a recent onset of diabetes could suggest glucocorticoid excess due to either Cushing’s syndrome or other causes. Cushing’s syndrome, hits young to middle-age adults ages 20-50, with signs such as wasting of muscles, thinning of the skin, severe fatigue, high B/P, hyperglycemia (high blood sugar), and weakened bones.14 Also, HPN has been associated with other secondary endocrine diseases such as hyperthyroidism, hypothyroidism, or growth hormone excess shows symptoms specific to these disease such as in hyperthyroidism there may be weight loss, tremor disorder, tachycardia, or atrial arrhythmia, palmar erythema (i.e., reddening of the palms) plus, 30% of patients with rheumatoid arthritis show signs. In addition, an onset of persistent sweating may accrue.15 
  The registered nurse should note with high B/P by asking if the patient has or is having angina or augmenting acute pulmonary edema. This could be a doll or quick sharp pain from the neck, down through one or both arms. The onset could last just a few moments and have no lasting effects. When B/P is markedly elevated in the chronic state, untreated could lead to left ventricular hypertrophy (i.e., LVH), which can present with exertional and paroxysmal nocturnal dyspnea.16 LVH is a major risk factor for cardiovascular morbidity in HTN patients. The effects of diuretics on LVH have raised controversies, but recent studies suggest that diuretics are able to reduce LVH in hypertensive patients, mainly through a reduction in ventricular diameter.17 Also, note with chronic HPN the possibility of cerebral involvement could cause stroke (i.e., CVA), due to thrombosis or hemorrhage from microaneurysms of small penetrating intracranial arteries. HTN encephalopathy could cause an acute capillary congestion and exudation with cerebral edema, which is reversible.18 

Initial Observation- 
  Please understand that as a practicing nurse, you should never be lulled into believing that all patients are the same. Therefore, ‘a blanket approach’ to HTN management, may be used. Below, are some guidelines to help you get started with developing your own initial assessments for uses in hospitals and/or clinic setting:

Baseline approach: Systolic B/P of >160 mmHg

Baseline approach: Diastolic B/P of <100 mmHg

Enquiries-
Background symptoms suggestive of secondary causes of HPN, (e.g., renal stenosis)…
Check for family history of Cardio activities, i.e. unstable angina, palpitations, chest discomfort, heart disease, or valvular stenosis…
Past history of cerebrovascular trauma, or accident, (i.e., head injury, fall, and swelling in extremities’), car or mechanical devise indent…
Diabetes Mellitus Type 2, (i.e., adult onset)…
Hyperlipidaemia, (i.e., group of abnormal elevated levels of lipids (fats) in the blood)…
Smoking status and how much…
Drug history, (e.g., oral contraceptives), cyclosporine (immunosuppressant) given with kidney disease, Crohn disease, and aplastic anemia (shortages of red & white blood cells)…
Lifestyle: salt and fat intakes…

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