Nursing Care for Hypertension
Whats Is Hypertension
Hypertension is the term applied to sustained and elevated levels of systolic and/or diastolic blood pressure.
The exact level at which hypertension poses a health risk has been arbitrarily and continually redefined; however, the importance of hypertension is based on a rational association between sustained, elevated levels of arterial pressure and the probability of increased risk for morbidity and mortality from cardiovascular disease.
The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defined hypertension as systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg or taking antihypertensive medication (Chobani an et al., 2003) .
The committee classified blood pressure into three categories and
introduced the prehypertensive category for use in medical diagnosis,
evaluation, and treatment.
Primary Hypertension According Kaplan
Sustained and elevated systolic blood pressure is now considered to be as crucial a measure as the diastolic level in evaluating the risks for cardiovascular disease. Elevated systolic blood pressure accompanied by normal diastolic levels, known as isolated systolic hypertension, is common in older populations.
Primary hypertension, formerly known as essential hypertension,
occurs in as many as 95% of all individuals with high blood pressure, as
opposed to secondary hypertension, which is due to an identifiable and usually
treatable cause (Kaplan, NM, 1994).
Hypertension as a Health Issue
Hypertension affects approximately 50 million Americans, a major portion of the US adult population. In the 1999-2000 National Health and Nutrition Examination Survey (NHANES III), 33.5% of non-Hispanic Blacks, 28.9% of non Hispanic Whites, and 20.7% of Mexican Americans had hyper-tension (Hajjar & Kotchen, 2003 ).
Two thirds of hypertensive individuals were aware of their condition, and 58.4% reported being on drug therapy.
Among Mexican Americans, 40.3% of the hypertensive individuals were under treatment, but only 17.7% of all Mexican-American hypertensive individuals had controlled blood pressures, compared to 28.1% and 33.4% of the non-Hispanic Black and White populations, respectively , with controlled blood pressures.
Given equal access to therapy,
Black Americans, who are among the most affected population group, achieve less
blood pressure reductions.
Causes or Risk Factors Contributes to Hypertension
Hypertension increases with age, is more common in Blacks, and is more prevalent among lower socioeconomic populations. Hypertension has a higher prevalence in men throughout young adulthood to middle age.
Thereafter, the prevalence in women
rises above that of men. The highest rates among women are found in
non-Hispanic Black women and among men in non-Hispanic Black men.
In the 2003 report, the Joint National Committee (JNC) on Prevention, Detection, and Evaluation of High Blood Pressure amended the standards for clinical classification of adult patients with high blood pressure. The new classification differs in several ways from that published in 1997.
A new clinical category has been added: pre- hypertension which is not a disease category; also, there are now two instead of three stages in the hypertension category.
Other Pathological Issues and Hypertension
Hypertension seldom exists in isolation but most often occurs with other risk factors that increase the probability of cardiovascular disease. Factors commonly associated with hypertension that are nonmodifiable include low birth weight, older age, family history of high blood pressure, and history of diabetes mellitus, coronary heart disease, stroke, or end stage renal disease.
Modifiable confounders include smoking, alcohol consumption, high saturated dietary fats, excess dietary sodium, adiposity, and a sedentary lifestyle, as well as recreational and over the counter drugs. In addition, psychosocial and environmental factors create life stressors that may influence hypertension as well as care and management.
Target-organ disease as a consequence of sustained, uncontrolled elevated blood pressure includes arteriosclerosis, heart failure, transient ischemic attacks (TIA), stroke, peripheral vascular disease, aneurysm, and end-stage renal disease.
Currently, researchers have identified
several emerging cardiovascular risk markers such as high-sensitivity
C-reactive protein (Blake, Rifai, Buring, & Ridker, 2003) and homocysteine
(Lim & Cassano,2002).
Hypertension is a major independent risk factor for coronary artery disease and stroke, the first and third causes of mortality in the United States, respectively, yet its importance is not emphasized satisfactorily in research and practice.
The individuals hardest to reach and at the highest risk are often not in care or are uninsured. Medical and behavioral intervention approaches lack cohesiveness and cultural relevance, therefore failing to achieve the strength of their impact as a combined intervention.
Additional research is required to evaluate multidisciplinary strategies with a team approach to increase entry into care, remaining in care, and long-term compliance with prevention and treatment recommendations.
Research also is needed to increase understanding of cost benefit of interventions and the effects of self monitoring and titration, including pharmacological vacations.
Identifying markers for early detection continues to be a challenge, and research should focus on exploring biochemical and genotypic methods to define and classify the population at risk.
Goals and Outcomes of Treatment
The ultimate goal for treatment is to prevent morbidity and mortality by the least intrusive means. The treatment regimen is determined by evaluating the severity of the blood pressure elevation, the presence of target-organ disease, and the effects of other coexisting risk factors.
The inability to adhere to treatment recommendations is a major barrier in attaining and maintaining goal blood pressure levels in long-term management, evidencing the need for planned patient education programs. Traditional treatment strategies targeted to the general population lack cultural sensitivity, neglect active involvement of the patient in decision making, and fail to motivate and keep the patient in care.
More individually oriented treatment methodologies that address the patients' concerns, including their social support system, employment status, health insurance, and barriers in daily life to meeting compliance goals, are required.
Nursing can provide the training, education, and support to design
planned health programs to increase the efficacy of interventions and improve
overall compliance.
Non Pharmacological or Nursing Therapies
Lifestyle modification, formerly termed nonpharmacological therapy, includes interventions targeted toward healthier lifestyles and reducing the risks for cardiovascular complications at the family, community, and population levels.
Lifestyle modifications for blood pressure control include reduction in weight, adoption of the Dietary Approaches to Stop Hypertension (DASH) catting plan, adequate physical activity, dietary decreases in sodium, and moderation of alcohol consumption.
Smoking, although not directly related to hypertension, is
a major cardiovascular risk and should be avoided.
Health People Strategies and Objective
Nonpharmacological therapy for treatment of hypertension is an evolving strategy in line with the objectives of Healthy People 2010 (Healthy People 2010). It represents a prevention area ideally suited for nursing practice and research.
Public health prevention strategies focusing on lifestyle modification at the community and practice setting will help achieve an overall downward shift in the distribution of blood pressure levels in the general population. Interventions should target high dietary sodium, fats, alcohol, and low intake of potassium, as well as physical inactivity.
Although these intervention strategies show promise in prevention of high blood pressure, societal barriers, such as the lack of satisfactory food substitutes, lack of access to care, and absence of economic resources, constrain compliance and achievement of intervention goals.
Moreover, further research should focus on patient-oriented outcomes that
affect patients' well being such as sexual functioning, ability to sustain
family and social tasks, and ability to carry out activity of daily livings.
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