Hypertension and Preventive Care

Hypertension is a chronic disease and is a precursor to many serious adverse events such as stroke, heart failure, and myocardial infract. Supportive care and preventative care models can treat and minimize the potential adverse effects of hypertension. The purpose of this paper is to describe changes that can be made by nurses and organizations to move from supportive care to preventative care. Utilizing insights, theories, concepts, and strategies this paper aims to identify education and preventative measures that can be applied to patients with the chronic illness diagnosis of hypertension. Hypertension Overview

According to the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 to 2008 an estimated 29 to 31 percent of adults in the United States have hypertension which translates to 58 to 65 million individuals (Basile, J. N., & Bloch, 2012). The prevalence of patients diagnosed with hypertension is expected to increase with many individuals with uncontrolled hypertension. Primary and specialty care healthcare professionals will see an increasing population of those with obesity over the age of 65 and older. Screening should occur every two years for patients with blood pressure within normal limits up to 120/80 mmHg and annually for patients with pressure up to 139/ 89 mmHg. Hypertension is often symptomatically silent causing no sign of an abnormality or discomfort. Primary hypertension is a the most common type with no known cause.

Secondary hypertension may be due to underlying conditions such as primary renal disease or endocrine disorders. Risk factors include African American ethnicity, parental history, high sodium intake, excessive alcohol intake, physical inactivity and obesity. To best determine if treatment should be implemented a patient’s blood pressure should be persistently elevated after three to six encounters over several months including Additionally, diagnosis may include serum and urine tests, and an electrocardiogram. Patients should be evaluated and trialed on nonpharmacological modifications prior to implementing medications when appropriate.

Patient education should include identifying consistent and proper measurement. Patient compliance aids in diagnosing and managing chronic disease such as hypertension. A normal blood pressure is systolic 100mmHg. Patients can have an isolated episode of a hypertensive crises or malignant hypertension associated with a diastolic pressure above 120 mmHg. Malignant hypertension is also associated with hemorrhage and encephalopathy. Supportive Care vs. Preventative Care

Supportive care for patients who have a diagnosis of hypertension includes lifestyle modifications and the use of several types of medications. Patients may not respond well to certain medications and an alternative classifications of medications can be considered. Many medications have side effects such as dizziness or lightheadedness that may resolve with continued use. Some medications such as angiotensin-converting enzyme (ACE) inhibitors which allow blood vessels to widen have been known to cause persistent dry cough that is reversible when discontinued. Supportive care includes the healthcare team to be aware of the possibility of the most common side effects. Certain pre existing comorbities may preclude or exclude certain classification of antihypertensive medication.

For example, beta blockers which block the effects of the sympathetic nervous system decrease the force of which the heart pumps blood and may not be appropriate for patients with diabetes who are already at risk for peripheral vascular disease. Supportive care for the patient with primary hypertension is often complicated by the coexistence of other medical conditions such as diabetes or coronary artery disease. The successful treatment of hypertension requires carefull monitoring and reevaluation requiring provider vigilance and patient compliance. Only 25% of patients are reported as to have their hypertension well controlled. Nursing should educate patients to recognize the symptoms that may be related to a hypertensive emergency including vision changes, headache, confusion, lower back pain and chest pain. Preventative Care Nursing Action Plan

The usage of nursing case managers has been shown to play a pivotal roll in the success of preventative care management programs. Nurse care managers can assess patients for lifestyle modifications which may reduce hypertension. Studies by DuBusk (1999) demonstrate that e-mails reminders and phone contact for wellness checks are useful in engaging patients to manage and comply with their care. The nurse care manger should also frequently assess the efficacy of patient medications. Identifying the root cause of patient noncompliance is important to the success of subsequent treatment strategies. Implementing a weight loss plan and dietary changes may be sufficient is treating mild hypertension. It is recommended that patients increase their consumption of fresh fruits and vegetables, fish, and fiber in addition to regular exercise.

The Nurse-Family Partnership (NFP) case management model uses an evidence based approach to address identifiable community needs focusing on preventive care(Cohen & Cesta, 2007). A preventative nursing action plan may include assessment and education related to the relationship that family history, dietary habits, and exercise have on the management of hypertension. The nurse manager or navigator of a chronic disease management program should be a disease specific expert. They should have specialized knowledgeable regarding preexisting or external factors that may effective treatment. For example, a nurse expert may recognize the correlation between a patient who has started using oral contraceptives and the onset of an unusually high blood pressure reading.

Or the nurse may correlate a patient’s chronic cough with the use of Lisinopril and suggest discontinuing the medication. The nurse may propose trialing one medication at a time in order to identify each ones effects. Often a physician will prescribe a combination of medication to treat hypertension in order to obtain desired results. Successful management of patients diagnosed with hypertension requires coordinated care which may include other specialists, departments and ancillary staff. The ideal nurse would have a strong sense of autonomy as well as proficiency with working in a multidisciplinary setting. One of the most important aspects of skilled coordination is clear communication. Though at times difficult to achieve, patient involvement is another key attribute recognized in many case management models. Summary

The benefits of controlling a patient’s blood pressure include reducing the risk of potentially life threatening adverse events. A successful preventative care model would encourage patients to make lifestyle changes such as dietary adjustments and provide education related to medication usage and compliance. Frequent communication with patients has shown to increase compliance. This can be achieved through automated electronic reminders, e-mails and telephone contact. Supportive care provides a frame work or treatment whereas preventative care models aid in reducing incidence, early intervention, incorporating patient education and engagement. Many preventative nursing care models can be applied to aid in successfully controlling patients diagnosed with hypertension

References
Basile, J. N., & Bloch, M. J. (2012). NHANES Data Highlight the Clinical Characteristics of Those With Poorly Controlled Hypertension. The Journal of Clinical Hypertension, 14(4), 267-268. doi 10.1111/j.1751-7176.2012.00596.x. Cohen, E., & Cesta, T. (2005). p.230Nursing case management: From essentials to advanced practice applications. St. Louis, MO: Elsevier Mosby. DeBusk, R., West, J., Miller, N., & Taylor, C. (1999). Chronic disease management: Treating the patient with disease(s) vs. treating disease(s) in the patient. Archives of Internal Medicine, 159(22), 2739-2742. Joint National Committee (2003). Prevention, detectection, evaluation and treatment of high blood pressure. Retrived from :http://www.nhlbi.nih.gov/ guidelines/hypertension/ phycard.pdf on June 12, 2013. Roumie, C., Elasy T., Greevy R., et al. (2006). Improving blood Pressure control through provider education, provider alters, and patient education: a cluster randomized trial. Ann Intern Med. 2006;145(3):165-175. doi:10.7326/0003-4819-145-3-200608010-00004.