Hypertensive Urgency vs. Emergency: What Nurse Practitioners Need to Know

High blood pressure is one of the most common issues in primary care. But sometimes numbers come back very high— and as a new nurse practitioner, it can be hard to know when to panic and when to manage in clinic. The key: distinguishing hypertensive urgency from hypertensive emergency.

Definitions at a Glance

• Hypertensive Urgency

  • BP ≥180/≥120 mmHg

  • No acute target-organ damage (no chest pain, neuro deficits, renal failure, etc.)

  • Usually chronic uncontrolled HTN that needs outpatient medication adjustment.

• Hypertensive Emergency

  • BP ≥180/≥120 mmHg

  • With acute target-organ damage (encephalopathy, stroke, ACS, aortic dissection, AKI, retinopathy, pulmonary edema).

  • Requires immediate ED referral and IV therapy.

Quick Bedside Assessment (2-Minute NP Checklist)

1. Symptoms? Headache, vision changes, chest pain, SOB, neuro changes, confusion.

2. Neuro exam: Focal deficits, mental status.

3. Cardiac/pulm: Chest pain, dyspnea, rales, JVD.

4. Renal: Oliguria, elevated creatinine.

5. Fundoscopy (if possible): Papilledema, retinal hemorrhage.

👉 If any end-organ damage → Emergency. If not → Urgency.

Management in Primary Care

Hypertensive Urgency (Outpatient Management)

• Do not drop BP too fast. Goal: gradual reduction over 24–48 hrs.

• Start or adjust oral antihypertensives:

  • Captopril, clonidine, or labetalol are commonly used if rapid oral reduction needed.

  • Otherwise adjust chronic regimen (ACE/ARB, thiazide, CCB, beta-blocker).

• Close follow-up: Recheck in 24–72 hrs.

• Address adherence & lifestyle: missed meds, high sodium intake, stress.

Hypertensive Emergency (ED/ICU Management)

• Immediate referral to ED — these patients need IV therapy and monitoring.

• Common IV meds: nitroprusside, labetalol, nicardipine, clevidipine.

• Goal: reduce mean arterial pressure by ~25% in the first hour, then gradually.

Clinical Pearls for New NPs

• Always repeat the BP — make sure it’s accurate, correct cuff size, patient seated/resting.

• Don’t label urgency vs. emergency by numbers alone — symptoms and organ damage are the differentiator.

• Avoid overly aggressive outpatient BP lowering; risk of ischemia.

• Document clearly: patient’s symptoms, exam, plan, and follow-up.

• Consider secondary causes if young or resistant: renal artery stenosis, pheochromocytoma, thyroid disorders.

Takeaway for Primary Care Nurse Practitioners

Hypertensive urgency is common in clinic — it usually means med adjustments and close follow-up. Hypertensive emergency is rare but critical — recognize red flags and send to the ED immediately. With a structured approach, you’ll feel more confident managing high BP in practice.

✉️ Have a tricky HTN case? Email me at [email protected] .
📌 Want more plug-and-play hypertension workflows? Explore my HTN Management Course for new NPs — practical, CE-approved, and designed for real-world primary care.