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Nursing Management of Hypertension
Cindy BoltonTeam Leader, Development Panel
• Partnership: Heart and Stroke Foundation of Ontario and the Registered Nurses Association of Ontario
• Funding: Ministry of Health and Long-Term Care, Primary Health Care Transition Fund
• AIM Initiative: Improving the management of high blood pressure by doctors, nurses and pharmacists
Guideline Development• Cindy Bolton, RN, BNSc, MBA• Armi Armesto, RN, BScN, MHSM• Linda Belford, RN, MN, CCN(c), ENC(c)• Anna Bluvol, RN, MScN• Heather DeWagner, RN, BScN• Elaine Edwards, RN, BScN• BettyAnn Flogen, RN, BScN, MEd, ACNP• Elizabeth Hill, RN, MN, ACNP, GNC(c)• Hazelynn Kinney, RN, BScN, MN• Charmaine Martin, RN, BScN, MSc(T), ACNP• Cheryl Mayer, RN, MScN• Connie McCallum, RN(EC), BScN• Heather McConnell, RN, BScN, MA(Ed)• Mary Ellen Miller, RN, BScN• Susan Oates, RN, MScN• Tracy Saarinen, RN, BScN• Debbie Selkirk, RN(EC), BScN, ENC(c)
WHAT ARE GUIDELINES?
“Systematically developed statements to assist practitioners and patient decisions about appropriate health care for specific clinical (practice) circumstances.” Field and Lohr, 1990
Best Practice Guidelines are developed using the best available evidence.
Development
Planning
Evaluation
Revision
Dissemination
The guideline Nursing Management of Hypertension has been endorsed by the Canadian Hypertension Education Program.
Hypertension…
Is the most important modifiable risk factor for stroke.
♥ High blood pressure increases the risk of ischemic heart disease by 3-4 fold
♥ The incidence of stroke increases approximately 8 fold in persons with definite hypertension
♥ It has been estimated that 40% of cases of acute MI or stroke are attributable to hypertension
Classification of Hypertension: WHO/ISH*Category Systolic DiastolicOptimalNormalHigh Normal
< 120<130130-139
<80<8585-89
Grade 1 (mild hypertension)- Subgroup: borderline
140-159140-149
90-9990-94
Grade 2 (moderate hypertension) 160-179 100-109
Grade 3 (severe Hypertension) ≥ 180 ≥110
Isolated Systolic Hypertension (ISH)- Subgroup (borderline)
≥140140-149
<90<90
*Reproduced with permission * World Health Organization –ISH International Society of Hypertension
National Institutes of Health ClassificationCategory Systolic DiastolicOptimal < 120 <80
Pre-hypertensive 120-139 80-89
Hypertensive ≥140 ≥90
Stage 1 140-159 90-99
Stage 2 ≥160 ≥100
National Institutes of Health 2003
PracticeRecommendations
Detection and Diagnosis
Nurses will…• Take every appropriate opportunity to assess BP of
adults to facilitate early detection of hypertension• Utilize correct technique, appropriate cuff size and
properly maintained/calibrated equipment• Be knowledgeable regarding the process involved in
diagnosis• Educate clients on their target BP and importance of
achieving and maintaining target
Identify 5 (or More) Measurement Errors
With permission: Vanasse A. Module d'autoformation # 17, l'Hypertension.
Which of the following is the correct position?
Cuff sizeinappropriate cuff size is the most frequent error in clinic-based BP assessment
Arm circumference (cm) Size of Cuff (cm)
From 18 to 26 9 x 18 (child)
From 26 to 33 12 x 23 (standard adult model)
From 33 to 41 15 x 33 (large, obese)
More than 41 18 x 36 (extra large, obese)
Blood Pressure Assessment:Patient preparation and posture
Standardized technique:
The patient should be calmly seated for at least 5 minutes, with his or her back well supported and arm supported at the level of the heart. His or her feet should touch the floor and legs should not be crossed.
The patient should be instructed not to talk prior and during the procedure.
Recommended Technique for Measuring Blood PressureStandardized technique:
• Use a mercury manometer or a recently calibrated aneroid or a validated electronic device.
• Aneroid devices should only be used if there is an established calibration check every 6-12 months.
Diagnostic algorithmElevated Out of the
Office BP measurement
Elevated Out of the Office BP
measurement
Elevated Random Office BP
Measurement
Elevated Random Office BP
Measurement
Hypertension Visit 1BP Measurement,
History and Physical examination
Hypertension Visit 1BP Measurement,
History and Physical examination
Hypertension Visit 2within 1 month
YesTarget organ damage
or Diabetesor Chronic Kidney Disease
or BP ≥ 180/110?
Target organ damageor Diabetes
or Chronic Kidney Diseaseor BP ≥ 180/110?
Diagnostic tests orderingat visit 1 or 2
Diagnostic tests orderingat visit 1 or 2
HypertensiveUrgency /
Emergency
HypertensiveUrgency /
Emergency
Diagnosisof HTN
Diagnosisof HTN
BP: 140-179 / 90-109BP: 140-179 / 90-109
No
Diagnostic algorithmBP: 140-179 / 90-109BP: 140-179 / 90-109
24-h ABPM (If available)24-h ABPM (If available)Clinic BPClinic BP S/H BPM (If available)S/H BPM (If available)
Diagnosisof HTN
Awake BP≥ 135 SBP or≥ 85 DBP or
24-hour≥ 130 SBP or
≥ 80 DBP
Awake BP≥ 135 SBP or≥ 85 DBP or
24-hour≥ 130 SBP or
≥ 80 DBP
Awake BP< 135/85 or
24-hour< 130/80
Awake BP< 135/85 or
24-hour< 130/80
Continue to follow-up
Diagnosisof HTN
Hypertension visit 3 ≥ 160 SBP or ≥ 100 DBP
≥ 140 SBP or≥ 90 DBP
< 140 / 90
Diagnosisof HTN
Continue to follow-up
< 160 / 100
Hypertension visit 4-5
ABPM or S/H BPM if availableor
≥ 135/85≥ 135/85< 135/85< 135/85
Diagnosisof HTN
Continue to follow-up
or
Acute Care• Diagnosis can be made
– During first visit if hypertensive emergency (see Appendix G)
– During second visit if TOD (retinopathy, renal disease, stroke/TIA, MI), diabetes
• Diagnosis of uncomplicated hypertension may be difficult in hospital because of physiological response to pain, illness & surgery
Threshold for Initiation of Treatment and Target Values
Condition Initiation of PharmacotherapySBP/DBP mmHg
TargetSBP/DBP
Diastolic ± systolic hypertension
≥140/90
≥160
≥130/80
≥130/80
≥125/75
Isolated systolic hypertension
<140/90
<140
<130/80
<130/80
Diabetes
Renal disease
Proteinuria >1 g/day <125/75
Source: 2005 Canadian Hypertension Education Program Recommendations
Assessment and Development of a Lifestyle Treatment Plan
Recommendations to address:• All lifestyle factors that influence hypertension• Dietary risk factors and specific diet
recommendations (DASH)• Dietary sodium• Weight, BMI and WC• Physical activity• Alcohol use• Smoking cessation• Managing stress
Summary Lifestyle Changes in Hypertensive Adults :
Intervention TargetSodium reduction 65-100 mmol/day
Diet DASH diet
Exercise 30-60 minutes at least 4x/week Weight lossWaist circumference
BMI <25 kg/m2
Men ≤102 cm (40 in) & women ≤ 88 cm (35 in)
Alcohol reduction <2 drinks/day
Smoking Smoke free environment
.
Source: Adapted from CHEP 2005 Recommendations
Impact of Lifestyle Therapies on BP in Hypertensive Adults
Intervention Targeted Change SBP/DBPSodium reduction 100 mmol or 1
tsp/day↓5.8/-2.5
Dietary Patterns DASH diet ↓ 11.4/-5.5
Exercise* 3 times/week ↓ -7.4/-5.8
Weight loss ↓ 4.5 kg ↓ 7.2/-5.9Alcohol reduction ↓ 2.7 drinks/day ↓ 4.6/-2.3
Source: Miller ER et al. Results of aggregate and meta analysis of short term trials.J Clin Hyper 1999;3:191-8.* Exercise and Hypertension, Medicine and Science in Sports & Exercise 2004;36(3).
Monitoring and Follow upNurses will:• Advocate that clients who are on anti-hypertensive
treatment receive appropriate follow up in collaboration with the health care team
MedicationsNurses will:• Obtain clients’ medication history (prescribed, OTC, herbal and
illicit drug use)
• Be knowledgeable about the classes of medications that maybe prescribed for clients diagnosed with hypertension
(Diuretics, ACE inhibitors, ARBs, β Blockers and Calcium Channel Blockers)
• Appendix O (Summary of classes of medications) helpful review of 5 classes of antihypertensive meds
• Provide education regarding pharmacological management (in collaboration with physicians and pharmacists)
AdherenceAdherence is the extent to which a client’s behaviour(taking medication, following a diet, modifying habits or attending clinic visits) coincides with health care advice.
Adherence is the single most important modifiable risk factor that compromises treatment outcome (WHO, 2003, Haynes et al., 2003)
Assessment of AdherenceNurses will:• Endeavour to establish a therapeutic relationship
with clients
• Explore clients’ expectations and beliefs regarding hypertension management
• Assess adherence to treatment plan at every appropriate visit
Promotion of AdherenceNurses will:• Provide information needed for clients with hypertension to
make educated choices related to treatment plan
• Work with prescribers to simplify clients’ dosing regimens (Level 1a)
• Encourage routine and reminders to facilitate adherence (Level 1a)
• Ensure that all clients who miss appointments receive follow up telephone calls in order to keep them in care
DocumentationNurses will:• Document and share comprehensive information
regarding hypertension management with the client and health care team.
Appendices• Glossary• Medication costs and programs• Stages of change model• Motivational interviewing• Client education for home BPM• Hypertensive urgencies/emergencies• DASH diet, reducing sodium and the DASH diet, recording food
habits and DASH• Canadian Body Weight classification system• Assessing alcohol consumption• Smoking Cessation – Brief intervention• “How vulnerable are you to stress?”• Summary of medication classes prescribed for hypertension• BP follow up algorithm• Educational resources and web sites
To download the guideline, visit the RNAO website at:
www.rnao.org/bestpractices
A limited number are available free from HSFO
csor@hsf.on.ca
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