Hypertension, commonly known as high blood pressure, is a pervasive health issue affecting nearly half of adults in the United States. Updated guidelines from the American College of Cardiology in 2017 redefined normal blood pressure as less than 120/80 mmHg. Elevated blood pressure is anything exceeding this, with stage 1 hypertension diagnosed at 130/80 mmHg. Conversely, blood pressure below 90/60 mmHg is classified as hypotension.
Hypertension stands as the most prevalent modifiable risk factor for cardiovascular disease. It places undue strain on arteries, significantly elevating the risk of serious conditions such as stroke, heart attack, and atherosclerosis. Effective management of hypertension is crucial in mitigating these risks and promoting overall health. Nurses play a vital role in identifying, managing, and educating patients about hypertension and its associated risks through comprehensive care planning and targeted interventions. Understanding Nurses Diagnosis For Hypertension is paramount for delivering effective patient care and improving health outcomes.
Understanding Hypertension and Nursing’s Role
Almost 50% of adults in the United States are diagnosed with hypertension, making it a frequently encountered comorbidity requiring meticulous nursing management and treatment. While certain risk factors like family history and ethnicity are beyond patient control, lifestyle behaviors are modifiable. Nurses are instrumental in guiding patients to recognize and address modifiable risk factors such as smoking, unhealthy dietary choices, and stress. Educating patients on risk reduction strategies and the importance of blood pressure control is a cornerstone of nursing practice. Effective blood pressure management is key to preventing complications and ensuring positive health trajectories. This underscores the critical importance of accurate nurses diagnosis for hypertension in initiating appropriate care strategies.
Common Nursing Diagnoses for Hypertension
Once a nurse establishes nursing diagnoses for hypertension, it becomes possible to develop structured nursing care plans. These plans are essential for prioritizing assessments and interventions, setting both short-term and long-term care objectives. The following sections will detail examples of nursing care plans tailored for hypertension, outlining specific diagnoses and corresponding interventions. By utilizing nurses diagnosis for hypertension as a foundation, nurses can create individualized care plans that address the unique needs of each patient, leading to more effective management of this chronic condition.
Decreased Cardiac Output related to Hypertension
Chronic hypertension and the resultant vasoconstriction and increased vessel resistance can significantly impair cardiac function, leading to Decreased Cardiac Output. This diagnosis focuses on the heart’s reduced ability to pump sufficient blood to meet the body’s metabolic needs due to the strain imposed by hypertension.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Impaired cardiac muscle contraction due to prolonged hypertension
- Conditions that compromise blood flow, such as atherosclerosis
- Structural impairment of the heart from hypertrophy
- Increased workload on the heart muscle due to elevated blood pressure
- Alteration in stroke volume secondary to reduced ventricular filling
- Plaque formation in coronary arteries
- High blood viscosity increasing afterload
- Atherosclerosis reducing arterial elasticity
- Sedentary lifestyle contributing to cardiovascular deconditioning
As evidenced by:
- Increased central venous pressure (CVP) indicating fluid overload and poor cardiac function
- Increased pulmonary artery pressure (PAP) reflecting left ventricular dysfunction
- Tachycardia as the heart attempts to compensate for reduced output
- Dysrhythmias resulting from myocardial stress and electrical instability
- Ejection fraction less than 40% indicating systolic heart failure
- Decreased oxygen saturation due to inadequate tissue perfusion
- Presence of abnormal S3, S4 heart sounds upon auscultation, indicative of ventricular dysfunction and increased filling pressures
- Chest pain (angina) due to myocardial ischemia
- Presence of abnormal lung sounds upon auscultation (crackles, wheezes) suggesting pulmonary congestion
- Difficulty breathing (dyspnea) and shortness of breath on exertion or at rest
- Rapid breathing (tachypnea) as a compensatory mechanism for hypoxia
- Restlessness and anxiety due to decreased cerebral perfusion
- Fatigue and generalized weakness related to reduced oxygen transport
- Intolerance in activities due to insufficient cardiac reserve
- Prolonged capillary refill time indicating poor peripheral circulation
- Significant weight gain from fluid retention
- Edema in dependent areas reflecting fluid volume excess and venous congestion
Expected outcomes:
- Patient will achieve and maintain blood pressure and pulses within acceptable parameters as individually defined.
- Patient will demonstrate no signs or symptoms of complications arising from decreased cardiac output secondary to hypertension.
- Patient will actively engage in recommended lab testing, medication regimens, and follow-up appointments for hypertension management.
Assessment:
1. Auscultate the heart sounds. The presence of an S4 heart sound is a significant indicator of a stiff, noncompliant left ventricle, often associated with left ventricular hypertrophy and diastolic dysfunction caused by chronic hypertension. Both S3 and S4 heart sounds are clinical signs suggestive of heart failure.
2. Obtain ECG. Electrocardiography is a crucial diagnostic tool for patients with hypertension. It is used to detect silent myocardial infarction or left ventricular hypertrophy, both potential consequences of long-standing hypertension. ECG findings are invaluable in assessing for heart attacks and identifying thickening or enlargement (hypertrophy) of the heart wall or muscle, which are structural changes induced by persistently high blood pressure.
3. Determine the patient’s risk factors for hypertension. To identify potential underlying causes of hypertension and guide treatment strategies, a comprehensive assessment of risk factors and diagnostic tests are necessary:
- Electrolyte levels: To rule out electrolyte imbalances that can contribute to hypertension.
- Blood urea nitrogen (BUN) and creatinine levels: To assess renal function and detect renal failure, a secondary cause of hypertension.
- Lipid profile for cholesterol levels: To evaluate cardiovascular risk factors, as hyperlipidemia often coexists with hypertension.
- Hormone (adrenal gland or thyroid gland) levels: To screen for endocrine disorders such as hyperaldosteronism or thyroid dysfunction, which can cause secondary hypertension.
- Urine tests: To assess for proteinuria or other renal abnormalities.
- Imaging scans, such as kidney ultrasound and CT scan of the abdomen: To evaluate the kidneys and adrenal glands for structural abnormalities or tumors.
4. Assess for signs and symptoms of organ damage. Hypertension is often asymptomatic, earning it the moniker “silent killer.” Diagnosis frequently occurs incidentally during routine blood pressure measurement. However, chronic hypertension can lead to significant organ damage. Assess for signs and symptoms indicative of end-organ damage:
- Stroke: Neurological deficits, weakness, speech difficulties.
- Hypertensive encephalopathy: Severe headache, altered mental status, seizures.
- Chest pain: Angina pectoris due to coronary artery disease.
- Shortness of breath: Dyspnea from heart failure or pulmonary edema.
- Heart failure: Fatigue, edema, persistent cough.
- Kidney problems: Changes in urine output, edema, electrolyte imbalances.
- Vision changes: Blurred vision, vision loss due to retinopathy.
Interventions:
1. Assist the patient in adopting lifelong lifestyle modifications. Hypertension is a chronic condition requiring continuous monitoring and long-term management. Educate and support the patient in making sustainable lifestyle changes. Emphasize the importance of regular exercise, weight management, and abstinence from smoking and excessive alcohol consumption as crucial components in minimizing cardiovascular risk and managing hypertension effectively.
2. Administer beta-blockers or calcium-channel blockers as prescribed. Beta-blockers and calcium channel blockers are commonly prescribed antihypertensive medications that effectively control heart rate and blood pressure, both at rest and during physical activity. These medications can be administered intravenously (IV) for rapid control in acute situations or orally for chronic management.
3. Use CPAP or supplemental oxygen at night if indicated. Obstructive sleep apnea (OSA) is a significant secondary cause of hypertension. If OSA is diagnosed or suspected, treatment with Continuous Positive Airway Pressure (CPAP) or supplemental oxygen during sleep is essential. Addressing OSA reduces sympathetic nervous system stimulation, thereby decreasing cardiac workload and blood pressure during sleep and throughout the day.
4. Monitor and progressively increase activity as tolerated. Regular exercise is vital for strengthening the heart muscle and lowering blood pressure. Encourage and facilitate a gradual increase in physical activity tailored to the patient’s capabilities. Closely monitor the patient’s physiological response to activity by assessing heart rate (HR) and blood pressure (BP) before, during, and after exercise to ensure safety and effectiveness.
5. Limit sodium intake in the diet. Excessive sodium consumption is directly linked to an increased incidence of cardiovascular disease and hypertension. High sodium intake leads to increased fluid retention, which elevates blood volume and consequently, blood pressure. Furthermore, it can blunt the renin-angiotensin-aldosterone system (RAAS) response and increase sympathetic nervous system activity, both contributing to hypertension. Educate patients on low-sodium dietary choices and strategies.
Deficient Knowledge related to Hypertension Management
Deficient Knowledge regarding hypertension and its management is a significant barrier to effective self-care. Patients lacking understanding of their condition are less likely to adhere to treatment plans and lifestyle modifications, placing them at increased risk for adverse health outcomes.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of understanding of hypertension, its pathophysiology, and its effects on the body
- Insufficient knowledge of personal risk factors for hypertension
- Poor health literacy hindering comprehension of health information
- Lack of perceived relevance, interest, or motivation to learn about hypertension management
As evidenced by:
- Worsening blood pressure control despite medical interventions
- Inability to recall or accurately reiterate information provided about hypertension
- Incorrect or inconsistent follow-through with recommended dietary modifications or lifestyle changes
- Development or progression of chronic conditions due to uncontrolled hypertension
Expected outcomes:
- Patient will effectively “teach-back” essential information provided regarding hypertension management, demonstrating comprehension.
- Patient will accurately state their personal risk factors for hypertension, indicating understanding of their susceptibility.
- Patient will clearly explain the purpose and action of their blood pressure medications and articulate the critical importance of medication adherence and avoiding missed doses.
Assessment:
1. Assess the patient’s current understanding of hypertension. Many patients lack a comprehensive understanding of the significant role high blood pressure plays in contributing to serious health conditions such as stroke and heart disease. A thorough assessment of the patient’s existing knowledge base is essential to identify specific knowledge deficits and tailor education to fill these gaps effectively.
2. Assess potential barriers to learning. Identify any cognitive, cultural, or language barriers that may impede the patient’s ability to learn and understand health information. Evaluate the patient’s perception of the problem and their intrinsic motivation for behavior change. If the patient does not recognize the severity of hypertension or is not motivated to make changes, education efforts will be less effective. Readiness to learn is a crucial factor in patient education.
3. Assess the availability of support systems. Effective hypertension management often requires consistent lifestyle changes and medication adherence. Patients who experience challenges in remembering to take medications, regularly monitor their blood pressure, adhere to dietary restrictions, or keep follow-up appointments may benefit significantly from support from family members or friends. Assessing and mobilizing support systems can enhance patient adherence and improve outcomes.
Interventions:
1. Help the patient identify their personal risk factors for hypertension. Educate the patient about the distinction between modifiable risk factors (e.g., stress, diet, weight, tobacco use) and non-modifiable risk factors (e.g., age, family history, ethnicity). By understanding their individual risk profile, patients can better identify areas where lifestyle modifications can have the most significant impact on their health.
2. Teach the patient how to accurately monitor blood pressure at home. Provide comprehensive education on the correct technique for home blood pressure monitoring. Instruct the patient on what their target blood pressure range should be and how to interpret readings as high, low, or within normal limits. If the patient has a home BP monitor, have them bring it to an appointment to calibrate it for accuracy and observe them using it to ensure they are employing proper technique and obtaining reliable readings.
3. Provide consistent positive reinforcement and encouragement. Avoid criticizing or scolding patients for mistakes or difficulties encountered in implementing their hypertension treatment plan. Instead, offer positive reinforcement for any effort to learn more about their condition or even for small improvements made in their self-management practices. Positive feedback fosters motivation and encourages continued engagement in their care.
4. Review all medications thoroughly with the patient. Patients may not fully understand the purpose of their prescribed medications, leading to unintentional non-adherence, such as skipping or missing doses. Conduct a detailed review of each blood pressure medication, explaining its action, potential side effects, and the specific rationale for its prescription in their treatment plan. Also, discuss the importance of consistent medication timing, frequency, and potential interactions with other drugs or supplements they may be taking.
Excess Fluid Volume related to Hypertension
Excess Fluid Volume contributes directly to hypertension by increasing the circulating blood volume. This increased volume forces the heart to work harder to pump blood, consequently elevating blood pressure. This diagnosis addresses fluid overload as a direct contributor to hypertension.
Nursing Diagnosis: Excess Fluid Volume
Related to:
- Chronic conditions predisposing to fluid retention: heart failure, kidney disease
- Excessive fluid intake relative to output
- Excessive sodium intake promoting fluid retention
As evidenced by:
- Rapid weight gain over a short period
- Edema in extremities, particularly in the lower legs, ankles, and feet
- Jugular vein distention (JVD) indicating increased venous pressure
- Elevated blood pressure readings
- Tachycardia as the heart attempts to manage increased fluid volume
Expected outcomes:
- Patient will demonstrate stable fluid volume balance, evidenced by balanced fluid intake and output, maintenance of weight at baseline, and absence of edema.
- Patient will verbalize understanding of the importance of reducing sodium intake in managing fluid volume and blood pressure.
Assessment:
1. Assess for peripheral edema and monitor for weight gain. Excess fluid accumulation often manifests as peripheral edema, particularly in dependent extremities like the lower legs and feet/ankles. Regularly assess for edema and its severity. Also, monitor the patient’s weight for sudden increases, as weight gain can be an early indicator of fluid retention.
2. Assess relevant lab values. Monitor laboratory values for evidence of fluid overload and associated electrolyte imbalances. Pay close attention to:
- Electrolyte imbalances: Specifically, monitor for dilutional hyponatremia (low sodium levels) or changes in potassium levels that can occur with fluid shifts.
- Renal function values: Assess Blood Urea Nitrogen (BUN), creatinine, and urine specific gravity. Elevated BUN and creatinine, along with decreased urine specific gravity, can indicate impaired renal function and fluid retention.
3. Assess dietary habits, particularly sodium and fluid intake. An imbalanced diet high in sodium or excessive fluid intake can directly contribute to fluid overload and exacerbate hypertension. Thoroughly assess the patient’s dietary patterns, focusing on sodium content in their diet and their daily fluid intake to identify potential contributing factors.
Interventions:
1. Educate the patient on fluid and/or sodium restrictions as prescribed. For patients with hypertension, particularly those with coexisting kidney disease or heart failure, adherence to prescribed fluid and sodium restrictions is crucial. Provide detailed education on recommended daily sodium and fluid intake limits. Emphasize the importance of these restrictions in managing fluid balance and blood pressure, especially when coupled with conditions that compromise fluid regulation.
2. Administer diuretics as prescribed by the physician. Diuretics are often necessary to facilitate the removal of excess fluid from the body, especially when patients present with overt symptoms of fluid overload such as shortness of breath or significantly elevated blood pressure. Administer prescribed diuretics as ordered and monitor the patient’s response, including urine output, electrolyte levels, and blood pressure.
3. Elevate edematous extremities. In patients with peripheral edema, elevating the affected extremities above the level of the heart can aid in promoting venous return and reducing edema. Encourage frequent repositioning and the use of pillows to elevate legs when sitting or lying down. Elevating extremities also helps prevent skin breakdown in edematous areas by improving circulation.
4. Instruct the patient on low-sodium dietary options and strategies. Many patients are unaware of the high sodium content in processed and restaurant foods. Educate patients about hidden sources of sodium in their diet. Provide practical guidance on identifying low-sodium food options, reading food labels for sodium content, and preparing meals using fresh, unprocessed ingredients. Highlight that frozen dinners, canned foods, and most restaurant entrees are often excessively high in sodium. Encourage opting for low-sodium alternatives and limiting processed foods.
Risk for Unstable Blood Pressure
Risk for Unstable Blood Pressure is a pertinent nursing diagnosis for patients with hypertension, as various medical conditions and pharmacological agents can lead to fluctuations and elevations in blood pressure, increasing the risk of hypertensive crises and end-organ damage.
Nursing Diagnosis: Risk for Unstable Blood Pressure
Related to:
- Structural impairment of the heart affecting hemodynamic stability
- Difficulty of the heart muscle to pump effectively
- Increased exertion in workload on the heart
- Cardiac dysrhythmias disrupting normal heart rhythm and blood pressure regulation
- Electrolyte imbalances interfering with cardiovascular function
- Excess fluid volume contributing to blood pressure elevations
- Adverse effects of medications that can impact blood pressure
As evidenced by:
A risk diagnosis is characterized by the absence of current signs and symptoms, as the problem has not yet occurred. Nursing interventions are primarily focused on prevention.
Expected outcomes:
- Patient will maintain blood pressure within individually defined normal limits consistently.
- Patient will remain asymptomatic despite potential fluctuations in blood pressure.
- Patient will demonstrate consistent adherence to their antihypertensive medication regimen to prevent episodes of unstable blood pressure.
Assessment:
1. Regularly measure the patient’s blood pressure. Hypertension is frequently asymptomatic, and many individuals are unaware they have it until complications arise. Regular blood pressure monitoring is essential for both detecting new-onset hypertension and for ongoing management of diagnosed hypertension. Routine measurements are crucial in preventing or promptly identifying and addressing unstable blood pressure.
2. Screen for secondary causes of hypertension. In some cases, hypertension is secondary to other underlying medical conditions. Screen for potential secondary causes such as renal disease, obstructive sleep apnea, thyroid disorders, and alcohol-induced hypertension. Identifying and managing secondary causes is critical for effective blood pressure control. These conditions often require specific management strategies in addition to standard antihypertensive therapy.
3. Assess caffeine consumption habits. High caffeine intake can stimulate the sympathetic nervous system, leading to transient increases in blood pressure and potentially contributing to instability in blood pressure control. Assess the patient’s daily caffeine consumption from beverages like coffee, tea, energy drinks, and soda to identify a modifiable factor contributing to blood pressure fluctuations.
4. Review the patient’s complete medication list and supplement use. Numerous prescription and over-the-counter drugs, as well as nutritional supplements, can potentially elevate blood pressure or interact with antihypertensive medications. A thorough review of the patient’s medication list is essential. Examples of medications that can raise blood pressure include:
- NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
- Decongestants
- Antidepressants
- Birth control pills
- Excessive aspirin use
- Certain herbal remedies
Identify potential drug-induced causes of hypertension or drug interactions that may contribute to unstable blood pressure.
Interventions:
1. Educate on lifestyle factors that increase risk. Ensure the patient is thoroughly informed about substances and lifestyle choices that significantly increase the risk of cardiovascular events and hypertension. This includes educating them about the risks associated with:
- Cocaine and synthetic cannabinoids
- Cigarette smoking and tobacco use
- Excessive alcohol consumption
Provide guidance on avoiding these risk factors to promote cardiovascular health and blood pressure stability.
2. Emphasize the importance of treatment adherence. Patient education should strongly emphasize the critical importance of adhering to prescribed blood pressure medication regimens. Non-adherence is a leading cause of uncontrolled hypertension and significantly increases the risk of hypertensive crises, defined as a blood pressure reading of 180/120 mmHg or higher, which is a medical emergency requiring immediate intervention.
3. Remind the patient to report all medications, over-the-counter drugs, and herbal remedies to healthcare providers. Advise the patient to maintain an updated and comprehensive list of all medications they are taking, including prescription drugs, over-the-counter medications, and herbal supplements. Encourage them to bring this list to all healthcare appointments. This practice facilitates medication reconciliation by nurses and pharmacists, allowing for the identification and management of potential drug interactions or medications that may be contributing to unstable blood pressure.
4. Advise the patient to maintain home blood pressure logs. Instruct the patient on keeping a log of their home blood pressure readings, including the date, time, and readings. These logs should be regularly reviewed, ideally at least every three months, by healthcare providers to monitor the effectiveness of the treatment plan and make necessary adjustments. Home BP logs provide valuable data for managing hypertension effectively.
Sedentary Lifestyle related to Hypertension
A Sedentary Lifestyle is a well-established risk factor for developing hypertension. Physical inactivity contributes to a higher resting heart rate and reduced cardiovascular fitness, causing the heart to work harder even at rest. Conversely, regular physical activity typically results in a lower resting heart rate, decreasing stress on the heart and arteries and improving blood pressure control.
Nursing Diagnosis: Sedentary Lifestyle
Related to:
- Lack of interest or perceived enjoyment in physical activity
- Inability to participate in physical activity due to health issues or physical limitations
- Insufficient knowledge regarding the benefits of regular exercise on blood pressure and overall health
As evidenced by:
- Reported or observed deconditioned physical appearance
- Overweight/obese or conversely, very frail physical condition
- Activity intolerance reported or observed during minimal exertion
- Tachycardia at rest, indicating poor cardiovascular conditioning
- Abnormal heart rate or blood pressure response to even mild physical activity
Expected outcomes:
- Patient will actively participate in physical activity within their individual capabilities at least 3 times per week.
- Patient will report a subjective improvement in their ability to exercise, evidenced by reduced shortness of breath with minimal exertion and heart rate remaining within safe limits during activity.
- Patient will report a measurable decrease in their average blood pressure readings after one month of consistently engaging in regular exercise.
Assessment:
1. Build a rapport and therapeutic relationship with the patient. Addressing sedentary lifestyle and promoting exercise can be a sensitive topic for patients. Individuals with a sedentary lifestyle may exhibit resistance to change or feel defensive. Establishing a strong therapeutic relationship based on trust and empathy is crucial. Prioritize building rapport with the patient before addressing exercise habits to facilitate open communication and collaboration.
2. Assess the patient’s exercise history, preferences, and interests. Instead of simply advising the patient to “move more,” take a patient-centered approach. Explore the patient’s past experiences with exercise, identify activities they have enjoyed in the past, and explore their current interests. Patients are more likely to adopt and maintain an exercise routine when they engage in activities they find enjoyable and personally meaningful.
3. Ensure the patient is medically safe to engage in physical activity. While healthcare providers will ultimately determine exercise safety, nurses play a role in initial assessment and education. Generally, most patients, even those with chronic conditions, can benefit from some form of physical activity. However, it’s essential to advise patients to start slowly and monitor their responses. If a patient experiences significant shortness of breath, excessive fatigue, chest pain, or dizziness during exercise, the activity should be stopped or reduced in intensity, and the healthcare provider should be notified.
Interventions:
1. Provide coaching and assist with realistic goal setting. Tailor exercise recommendations to the patient’s current activity level, physical strength, age, health status, and personal preferences. Meet the patient where they are in their journey toward increased activity. For a very sedentary individual, a realistic initial goal might be simply walking to the mailbox daily. For someone more active, the goal could be more strenuous activities. Start with small, attainable goals that the patient feels confident in achieving to build motivation and momentum.
2. Encourage tracking of progress and provide positive feedback. Instruct the patient to keep a simple log of their physical activity, including the type of activity, duration of exercise sessions, and any improvements they notice in their physiological responses, such as decreased shortness of breath or weight loss. Advise them to monitor their blood pressure regularly as directed by their healthcare provider and record these readings in their log. Patients may observe a positive correlation between regular exercise and a decrease in their blood pressure, which can be highly motivating. Provide positive feedback and encouragement as they make progress.
3. Refer to physical therapy, cardiac rehabilitation, or local community programs as appropriate. Patients who require more structured and supervised exercise programs, particularly those with significant health limitations or safety concerns, may benefit from a referral to physical therapy (PT) for individualized exercise evaluation and guidance. Cardiac rehabilitation programs are specifically designed for patients with heart conditions and provide supervised exercise training tailored to improve cardiovascular health. Additionally, explore local community programs such as YMCA classes or senior centers that offer free or low-cost exercise classes and supportive group environments.
4. Educate on the multifaceted benefits and necessity of exercise. Emphasize that the benefits of regular exercise extend far beyond just heart health and blood pressure control. Educate patients about the wide range of positive impacts of physical activity, including:
- Improved muscle strength and endurance
- Enhanced coordination and balance
- Mood elevation and stress reduction
- Increased energy levels
- Weight management
- Reduced risk of other chronic diseases
Frame exercise in a positive light, focusing on the benefits that are most relevant and motivating to the individual patient, such as improved quality of life, increased independence, or the ability to engage more fully in activities they enjoy, like spending time with grandchildren. Avoid using fear-based tactics that focus solely on the negative consequences of inactivity.
Conclusion: Empowering Nurses in Hypertension Management
Understanding and applying nurses diagnosis for hypertension is crucial for effective patient care. Nurses are at the forefront of hypertension management, playing a pivotal role in assessment, education, and intervention. By utilizing these nursing diagnoses and developing tailored care plans, nurses empower patients to actively participate in managing their hypertension, reducing their risk of cardiovascular complications, and improving their overall quality of life. Continuous professional development and a commitment to patient-centered care are essential for nurses to remain effective in addressing this prevalent and significant health challenge.
