Nursing Management of Hypertension Cindy Bolton Team 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.
Planning Development Evaluation Dissemination Revision
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 Diastolic Optimal Normal High Normal Grade 1 (mild hypertension) - Subgroup: borderline < 120 <130 130-139 140-159 140-149 <80 <85 85-89 90-99 90-94 Grade 2 (moderate hypertension) 160-179 100-109 Grade 3 (severe Hypertension) 180 110 Isolated Systolic Hypertension (ISH) - Subgroup (borderline) 140 140-149 <90 <90 *Reproduced with permission * World Health Organization ISH International Society of Hypertension
National Institutes of Health Classification Category Systolic Diastolic Optimal < 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
Practice Recommendations
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 size inappropriate cuff size is the most frequent error in clinic-based BP assessment Arm circumference (cm) Size of Cuff (cm) From 18 to 26 From 26 to 33 9 x 18 (child) 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 Pressure Standardized 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 algorithm Elevated Out of the Office BP measurement Hypertension Visit 2 within 1 month Hypertension Visit 1 BP Measurement, History and Physical examination Diagnostic tests ordering at visit 1 or 2 Elevated Random Office BP Measurement Hypertensive Urgency / Emergency Target organ damage or Diabetes or Chronic Kidney Disease or BP 180/110? Yes Diagnosis of HTN No BP: 140-179 / 90-109
Diagnostic algorithm BP: 140-179 / 90-109 Clinic BP Hypertension visit 3 160 SBP or 100 DBP < 160 / 100 or Hypertension visit 4-5 Diagnosis of HTN ABPM or S/H BPM if available Awake BP < 135/85 or 24-hour < 130/80 24-h ABPM (If available) Awake BP 135 SBP or 85 DBP or 24-hour 130 SBP or 80 DBP S/H BPM (If available) < 135/85 or 135/85 140 SBP or 90 DBP Diagnosis of HTN Continue to follow-up Diagnosis of HTN Continue to follow-up Diagnosis of HTN < 140 / 90 Continue to follow-up
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 Diastolic ± systolic hypertension Isolated systolic hypertension Diabetes Initiation of Pharmacotherapy SBP/DBP mmhg 140/90 160 130/80 Target SBP/DBP <140/90 <140 <130/80 Renal disease 130/80 <130/80 Proteinuria >1 g/day 125/75 <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 Sodium reduction Diet Exercise Weight loss Waist circumference Alcohol reduction Smoking Target 65-100 mmol/day DASH diet 30-60 minutes at least 4x/week BMI <25 kg/m 2 Men 102 cm (40 in) & women 88 cm (35 in) <2 drinks/day Smoke free environment Source: Adapted from CHEP 2005 Recommendations
Impact of Lifestyle Therapies on BP in Hypertensive Adults Intervention Targeted Change SBP/DBP Sodium 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/-5.9 Alcohol 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).
Nurses will: Monitoring and Follow up Advocate that clients who are on anti-hypertensive treatment receive appropriate follow up in collaboration with the health care team
Medications Nurses will: Obtain clients medication history (prescribed, OTC, herbal and illicit drug use) Be knowledgeable about the classes of medications that may be 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)
Adherence Adherence 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 Adherence Nurses 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 Adherence Nurses 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
Nurses will: Documentation 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