Hypertension: Nursing guide to this cardiac pressure cooker

Note:

The publications in Advanstar Communications' Life Sciences Group and its Web portal,

http://ModernMedicine.com

are collaborating in a coordinated, interdisciplinary initiative to address this major public health issue: cardiometabolic disorders and weight. To read the joint introductory articles in this series, visit the following links:

Cardiometabolic Disorders and Weight: Action for Outcomes

A complex constellation of interrelated conditions

FRAN IS 62 YEARS OF AGE

and works full time as a cashier at a local grocery store. She receives health benefits. A year ago, she completed treatment for stage 3 breast cancer, having undergone chemotherapy, a right mastectomy, and radiation. She has been feeling well and enjoying life despite having to wear a Job’s sleeve for lymphedema on her right arm. Just prior to her cancer diagnosis, Fran had been diagnosed with essential hypertension (HTN).

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Identifiable risk factors were her age, family history of HTN in her deceased father, and a reportedly high intake of sodium.

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A review of her medical records indicates a thiazide diuretic had been prescribed along with lifestyle modifications to facilitate meeting the treatment goals.1 You also note a work-up had not revealed any hypertensive cardiovascular disease (CVD), or neurological, retinal, or kidney end organ damage.

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Fran arrives today for a routine follow-up visit with her new primary care physician. You note that on her last three visits with the oncologist, her systolic blood pressure (BP) was between 146 mm Hg and 154 mm Hg. Her diastolic BP was within normal limits (WNL). You ask Fran if she’s been taking the diuretic for her hypertension and she replies, “When all the cancer treatment was going on I never even thought about my blood pressure, and since I’ve been feeling so well and no one’s mentioned it, I figured it wasn’t a problem anymore.” Further discussion reveals that Fran continues to eat a diet rather high in sodium and calories, but she is walking 30 minutes three days per week, weather permitting, a behavior she initiated after her cancer treatment was over. She denies any shortness of breath with this or other moderately exertional activities. She also drinks a glass or two of wine each evening to celebrate life. She reports a good relationship with her daughter and husband, especially after the cancer. When asked if Fran understands the risks of untreated HTN, she replies, “Sort of, but it can’t be as dangerous as having cancer.”

Your physical findings upon arriving in the exam room reveal the following: a body mass index (BMI) of 25.0 and an apical heart rate of 82 beats per minute and regular. After Fran has been seated for five minutes in a chair, feet on the floor and arms supported at heart level, her BP measures 152/82 mm Hg on the right.

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Today’s blood lab results reveal that her glucose, hematocrit, potassium, creatinine, calcium, and urine studies were all WNL and a fasting lipid profile was pending.

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Her clinician conducts an examination including auscultation for carotid, abdominal, and femoral bruits; palpation of the thyroid gland; listens to her heart and lungs; palpates her abdomen for the presence of masses and aortic pulsation; examines the lower extremities for edema; and concludes with a neurological assessment.1,2 He performs an electrocardiogram, which is normal, and inspects her retinas, which do not reveal changes consistent with HTN. He rewrites a prescription for the diuretic and tells Fran that if this and prescribed lifestyle modifications do not bring her BP to goal, he would likely have to add a second medication.1,5 Before she leaves, the clinician asks you to meet with Fran to make sure she understands the treatment plan and goals of therapy.

NURSING DIAGNOSIS

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• Deficient knowledge related to diagnosis and disease management.
• Risk for imbalanced nutrition: more than body requirements related to excess calorie and sodium intake.
• Risk for ineffective therapeutic regimen related to multifactorial treatment plan; lymphedema; lifestyle habits contributing to HTN.
• Risk for noncompliance related to lack of physical symptoms and failure to perceive seriousness or chronic nature of HTN.

DESIRED OUTCOMES/EVALUATION CRITERIA

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• Verbalize her risk factors for and complications associated with uncontrolled HTN.
• Verbalize treatment goals and how these are met.
• Initiate recommended lifestyle modifications:
• Achieve/maintain weight loss so measured BMI remains less than 25.
• Adopt an eating plan based on the Dietary Approach to Stop Hypertension (DASH), reducing saturated fat and cholesterol to less than 30% of dietary intake.
• Reduce dietary sodium intake to no more than 2,400 mg of sodium per day.
• Engage in regular/brisk exercise of 30 to 45 minutes three to seven days per week.
• Limit alcohol to one drink per day; 12 oz beer or 5 oz wine.
• Ensure diet includes daily allowance of calcium, potassium, and magnesium.
• Demonstrate ability to measure BP at home.
• Explain action, dosage, and side effects of prescribed medication(s); take as directed.
• Identify contraindicated over-the-counter medications-those high in sodium, those known to elevate BP.
• Develop strategy for home BP measurement.
• Verbalize consequences of noncompliance with prescribed treatment regimen.
• Identify sources of support for assisting with compliance.
• Keep scheduled follow-up appointments.

PLANNING AND IMPLEMENTATION

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• Using terminology Fran understands, review and discuss BP concepts; treatment goals and how these are met; discuss effects uncontrolled HTN has on cardiovascular system, brain, kidneys, and eyes; facilitate information with written and visual take-home aides.
• Explain concept of “control vs. cure” as HTN is a chronic disease state; reinforce efficacy of treatment plan if adhered to, and consequences of ignoring this silent danger.
• Provide reassurance and confidence in Fran’s ability to meet treatment goals, emphasizing her ability to have control over long-term outcomes especially in light of her recent show of strength undergoing treatment for breast cancer.
• Teach spouse how to measure Fran’s BP at home and instruct them to keep a log.
• Discuss lifestyle modifications that can reduce HTN and, in some cases, minimize the need for multiple medications.
• Refer to registered dietician to facilitate formulation of acceptable dietary plan in accordance with the Joint National Committee Seventh Report recommendations, as well as for weight loss and maintenance.
• Recommend Fran increase walking to a minimum of 30 to 45 minutes five to seven days a week; explore options for maintaining structured activity during inclement weather.
• Provide guidelines for prescribed medication including dosage, action, side effects, and precautions.
• Provide list of contraindicated over-the-counter medications (

http://www.webmd.com/hypertension-high-blood-pressure/guide/medications-cause

) and advise Fran to check with clinician before taking any new medication.
• Explain importance of and need for regular follow-up appointments to monitor response to treatment and make changes as needed
• Include spouse in all discussions.

EVALUATION

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Fran, along with her husband, returns to the clinic in approximately one month. Her average BP has been 140/86 mm Hg, and today it is 142/86 mm Hg. She has lost a pound, and has followed your recommendation that she walk a little longer and more frequently. She and her husband also have checked out the walking program at the local indoor mall, something that had been put on hold when she was diagnosed with cancer. After visiting with the dietician, Fran has managed to reduce some of the salt in her diet and increase her intake of fruits and vegetables. She’s obtained some low-sodium recipes and is excited about learning to cook with other spices. She admits that this is the most difficult challenge as she loves salt, but she adds that having had cancer was scary enough and she doesn’t want to “now get sick from high blood pressure when I don’t need to.” She’s taking her medication and overall feeling well, “but I never felt sick with the high blood pressure anyway.” You praise Fran for making these important lifestyle changes and explore with her where she might tweak more salt out of her diet. You reiterate you’d like to see her attain the BP goal of less than 140/90 mm Hg by next visit in a month or so. Both Fran and her husband leave thanking you for your kindness and expertise along with a promise that next time, Fran’s BP will be at goal.

RN

REFERENCES

1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

JAMA

. 2003;289(19):2560–2572.

2. Domino FJ, Kaplan NM. UpToDate Web site. Overview of hypertension in adults.

http://www.uptodate.com/patients/content/topic.do?topicKey=~an7a7QILOHLo3/a

. Updated 2009. Accessed August 27, 2009.

3. Ignatavicius DD, Workman ML. Care of patients with vascular problems.

Medical-Surgical Nursing

: Patient-Centered Collaborative Care. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010.

4. World Health Organization. Obesity and overweight. Fact sheet No. 311.

http://www.who.int/mediacentre/factsheets/fs311/en/

. September 2006. Accessed August 27, 2009.

5. Kaplan NM, Rose BD. UpToDate Web site. Choice of therapy in essential hypertension: Recommendations.

http://www.uptodate.com/patients/content/topic.do?topicKey=~MMUHEpy46yILPM

. Updated 2009. Accessed August 27, 2009.

6. Doenges ME, Moorhouse MF, Murr AC.

Nurse’s Pocket Guide. Diagnoses, Prioritized Interventions

, and Rationales. 11th ed. Philadelphia, PA: FA Davis Company; 2008.

7. Carpenito-Moyet LJ.

Nursing Care Plans and Documentation

. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.

Risk Factors

The etiology for developing essential hypertension (HTN) is still poorly understood, but there are several identified risk factors associated with its onset.

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Three major nonmodifiable risk factors

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• Age - less than 60 years
• Family history - HTN in one or both parents is independently associated with developing HTN in adult life
• Race - HTN tends to be more common and more severe in the black population.

Identified modifiable risk factors include the following and their presence in association with essential HTN may affect an individual’s prognosis:
• Cigarette smoking
• Obesity (body mass index greater than or equal to 30 kg/m

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)
• Physical inactivity
• Dyslipidemia
• Diabetes
• Excessive alcohol intake
• High sodium intake (average intake less than 2,300 mg of sodium per day)

The risks of ignoring the need for HTN treatment and addressing any modifiable risk factors are somewhat staggering in consideration of the following:
• Complying with HTN treatment and addressing modifiable risk factors may prevent many chronic diseases.

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• HTN is the most common risk factor, leading smoking, dyslipidemia, and diabetes for premature cardiovascular disease.
• HTN commonly leads to left ventricular hypertrophy and heart failure. HTN is the most important and common risk factor for stroke.
• HTN is an identified cause of end-stage renal disease.
• Acute and marked elevations in blood pressure can result in death.

References

1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

JAMA

. 2003;289(19):2560–2572.

2. Ignatavicius DD, Workman ML. Care of patients with vascular problems. Medical-Surgical Nursing:

Patient-Centered Collaborative Care

. 6th ed. Philadelphia, PA: Elsevier Saunders; 2010.

3. Kaplan NM, Rose BD. Choice of therapy in essential hypertension: Recommendations.

http://www.uptodate.com/patients/content/topic.do?topicKey=~MMUHEpy46yILPM

. Updated 2009. Accessed August 27, 2009.

4. Domino FJ, Kaplan NM. UpToDate Web site. Overview of hypertension in adults.

http://www.uptodate.com/patients/content/topic.do?topicKey=~an7a7QILOHLo3/a

. Updated 2009. Accessed August 27, 2009.

Goals of therapy

The ultimate goal of hypertension (HTN) treatment is to reduce cardiovascular (CV) and renal morbidity and mortality. Clinical trials have demonstrated that appropriate anti-HTN therapy is associated with significant reductions in the incidence of major CV events, i.e., stroke, heart failure, and myocardial infarction.

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To gain these benefits, the following therapeutic goals have been established:
• Systolic blood pressure (SBP) less than 140 mm Hg
• Diastolic blood pressure (DBP) less than 90 mm Hg (but no less then 65 mm Hg in elderly patients)
• In hypertensive patients with diabetes or renal disease, the goal is less than 130/80 mm Hg.

These BP goals are met by a combination of nonpharmacologic lifestyle modifications and drug therapy, a complete summary of which can be found at

http://www.nhlbi.nih.gov/guidelines/hypertension

and

http://www.uptodate.com/online/content/topic.do?topicKey=hyperten/23203&review

Nonpharmacologic therapy includes restricting dietary sodium, reducing weight if needed, avoiding excess alcohol, and performing regular aerobic exercise. In mildly hypertensive individuals, nonpharmacologic therapy alone may bring the BP to goal and should be prescribed for all individuals with HTN.

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However, most will, in addition, require at least one or a combination of drugs to meet their treatment goal. The three main classes of drugs used for initial treatment are the thiazide diuretics, long-acting calcium channel blockers, and angiotensin modifiers such as converting enzyme (ACE) inhibitors or angiotensin II receptor blockers. Each of these agents offers roughly the same degree of effectiveness in lowering the BP, producing an acceptable antihypertensive response in 30% to 50% of patients. Initiating a combination of two drugs is appropriate when the BP is greater than or equal to 20/10 mm Hg above goal.

Once therapy is initiated, it is recommended that most patients return for follow-up and adjustments if needed every four to six weeks until the BP goal is met. Once BP is at goal and stable, follow-up visits can occur at three- to six-month intervals, pending presence of comorbidities and other health needs.

References

1. Chobanian AV, Bakris GL, Black HR, et al. National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report.

JAMA

. 2003;289(19):2560–2572.

2. Domino FJ, Kaplan NM. UpToDate Web site. Overview of hypertension in adults.

http://www.uptodate.com/patients/content/topic.do?topicKey=~an7a7QILOHLo3/a

. Updated 2009. Accessed August 27, 2009.

3. Kaplan NM, Rose BD. UpToDate Web site. Choice of therapy in essential hypertension: Recommendations.

http://www.uptodate.com/patients/content/topic.do?topicKey=~MMUHEpy46yILPM

. Updated 2009. Accessed August 27, 2009.

The most common reason surveyed for outpatient office visits for adults in the United States is the treatment of essential hypertension (HTN)-HTN unrelated to another underlying condition, such as pheochromocytoma, primary aldosteronism, or renovascular disease. The number of patients with HTN continues to grow as the population ages, occurring in more than half of persons over 65 years of age.

The Seventh Report of the Joint National Committee (JNC 7) defines normal blood pressure (BP) as systolic less than 120 mm Hg and diastolic less than 80 mm Hg.

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Beyond that, the following classification for HTN has been established and is based on the average of two or more properly measured readings on each of two or more office visits.

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Prehypertension:
Systolic 120 mm Hg to 139 mm Hg or diastolic 80 mm Hg to 90 mm Hg (those in this category are at increased risk for developing HTN)

Hypertension:
Stage 1 HTN: Systolic 140 mm Hg to 159 mm Hg or diastolic 90 mm Hg to 99 mm Hg

Stage 2 HTN: Systolic greater than or equal to 160 mm Hg or diastolic greater than or equal to 100 mm Hg

The higher value of either the systolic or diastolic component determines the severity of HTN. In persons less than 65 years of age, the systolic BP is a greater predictor of risk for a heart attack, heart failure, stroke, and kidney disease. This risk is continuous, consistent, and increases for each increment in systolic BP than for an equivalent increase in diastolic BP, independently of other risk factors. Each incremental rise in systolic BP of 20 mm Hg, or 10 mm Hg in diastolic BP, doubles the risk for coronary artery disease (CVD) from a range of 115/75 mm Hg to 185/115 mm Hg. On the other hand, in persons over 65 years of age, an increased pulse pressure is the defining criterion associated with an adverse event.

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SALLY BEATTIE

is a clinical manager at the University of Missouri Hospital and Clinics, Columbia, MO. She is also a member of the

RN

editorial board.