1. Introduction Hypertension, also known as high blood pressure, affects approximately 74.5 millionpeople in the US that are over the age of 20 ("High blood pressure statistics," n.d., pars. 1). Thismeans that one out of every three adults has hypertension ("High blood pressure statistics," n.d.,pars. 3). According to the American Heart Association, of the people diagnosed with high bloodpressure, only 67.9% were receiving treatment, and of those only 44.1% had it under control("High blood pressure statistics," n.d., pars. 4). That leaves a whooping 55.9% that do not havetheir blood pressure under control ("High blood pressure statistics," n.d., pars. 4). The purpose of this paper is to answer the four main objectives outlined below. This wascopied directly from the syllabus provided by the instructor Jennifer Lillibridge. One, describethe pathophysiology for one major common adult disease process, in this case hypertension, andrelated nursing care. Two, describe scientific principles and concepts underlying nursinginterventions, including the basic nursing skills used in health maintenance and preventive carefor an individual. Three, describe physiological, psychological and cultural/spiritual factors thatcan influence a persons health status with specific examples. Four, identify teaching, decisionmaking, and critical thinking theories as they pertain to care of the acutely ill adult patient usinga specific example. My nursing diagnosis is ineffective health maintenance related to lack ofknowledge of possible complications associated with hypertension and lifestyle changes neededin order to manage disorder. Objective I In order to understand hypertension, it is important to understand exactly what bloodpressure is and how it is regulated. Blood pressure is really about the pressure of blood movingthrough the heart during contraction and relaxation. Blood flows down a pressure gradient from
2. high pressure, found in the arterioles, to low pressure found in the venules (Porth, 2011, p. 378).Blood pressure is, in a nutshell, cardiac output (CO) x systemic vascular resistance (SVR)(Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 743). CO is the amount of bloodflow through the systemic or pulmonary circulation per minute (Lewis, Heitkemper, Dirksen,OBrien, & Bucher, 2007, p. 743). SVR is the amount of resistance or force opposing themovement of blood (Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 743). It stands toreason that when either the CO or SVR is increased there will be a corresponding increase in BP(Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 762). Blood pressure consists of two numbers. The upper number is the systolic blood pressure(SBP), and the lower number is the diastolic blood pressure (DBP). Per Lewis et al., “systolicblood pressure (SBP) is the peak pressure exerted against the arteries when the heart contracts.”(2007, p. 743). The residual pressure of the arterial system during ventricular relaxation is whatconstitutes diastolic blood pressure (DBP) (Lewis, Heitkemper, Dirksen, OBrien, & Bucher,2007, p. 743). Hypertension is defined as a SBP over 140 mm Hg, or a DBP over 90 mm Hg(Porth, 2011, p. 427). Currently there are two types of hypertension, primary and secondary. Primaryhypertension is what this paper will focus on, and is an elevated BP without an identifiable cause(Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 765). Secondary hypertensionpertains to an elevated BP that is related to a specific cause (Lewis, Heitkemper, Dirksen,OBrien, & Bucher, 2007, p. 765). According to Lewis et al., “The hemodynamic hallmark ofhypertension is persistently increased SVR.” (2007, p. 765). Although, an elevated SVR may bethe hallmark of primary hypertension, the actual cause of primary hypertension remains largelyunknown (Porth, 2011, p. 428). Although the direct cause is unknown, there are several
3. identifiable factors that we will discuss here. One key factor that can contribute to hypertensionin some people is an excessive sodium intake (Lewis, Heitkemper, Dirksen, OBrien, & Bucher,2007, p. 765). It has been found that populations whose diets consist of a low sodium intakehave lower BP’s. When these same populations adopt a diet higher in sodium, the incidence ofhypertension rises (Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 765). Another keyfactor is that some people may have an altered renin-angiotensin mechanism (Lewis,Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 766). In some individuals there may beincreased levels of renin in the system. Renin is converted to angiotensinogen which converts toangiotensin I and then to angiotensin II (Porth, 2011, p. 612). Angiotensin II is a potentvasoconstrictor (Porth, 2011, p. 612), which obviously will increase SVR thereby increasing BP.In addition, the angiotensin II stimulates the adrenal gland to produce aldosterone which resultsin the kidneys retaining sodium and water (Lewis, Heitkemper, Dirksen, OBrien, & Bucher,2007, p. 766). More sodium and water will increase cardiac output which will also increase BP.The third factor that can cause increased blood pressure in individuals is an increase in theactivity of the sympathetic nervous system (SNS) (Lewis, Heitkemper, Dirksen, OBrien, &Bucher, 2007, p. 766). According to Lewis et al., “Increased SNS stimulation producesincreased vasoconstriction, increased HR, and increased renin release.” (2007, p. 766). Stresscan cause an increase in SNS stimulation thereby leading to an increase in BP. People exposedto high levels of stress on a daily basis are much more prone to having an elevated BP then thosewho are not (Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 766). Regardless of thecause of high blood pressure, basic management of the patient with hypertension is to control theBP which will reduce further complications.
4. Basic nursing care will include frequent monitoring of vital signs, especially the BP, toensure that they are with in normal limits. Many medications will require that the BP be takenbefore the medication is administered so it will be essential that the BP, and in some instances,the heart rate, be taken before administering any of these medications. Any SBP over 180 orDBP over 110 is a medical emergency known as hypertensive crisis, and a physician will need tobe notified immediately. Objective II So as nurses, what nursing interventions are appropriate for the patient withhypertension? First and foremost, it is imperative to assess the patient’s knowledge of thedisorder (Gulanick & Myers, 2011, p. 270). The patient needs to understand that hypertension isa chronic condition with long term complications. In order to prevent complications, the BP hasto be at a safe level. If the patient doesn’t know the risks and complications where’s theincentive to try to manage the BP at all? If you don’t know where the patient’s level ofknowledge is at, then you don’t where teaching needs to begin. You also won’t know if thepatient has any misunderstandings in regards to the disorder. Another important intervention isto encourage questions about the treatment prescribed (Gulanick & Myers, 2011, p. 270). Formost people the prescribed treatment will include medications as well as diet modifications.Again, this is finding out what the patient knows. Give the patient plenty of time to askquestions. A lot of patients have questions about lifestyle modifications. There’s so much toremember! Recommend reading The DASH Diet Action Plan. This book provides proven waysto lower blood pressure and cholesterol. The DASH diet, encourages an intake high in fruits,vegetables, low fat dairy , and is also low in “total and saturated fats” (Gulanick & Myers, 2011,p. 271). This diet is also contains a good mix of potassium, magnesium, and calcium which acts
5. as a diuretic to help the body excrete excess salt (Gulanick & Myers, 2011, p. 271). Make sureto plan the teaching in stages so as not to overwhelm the patient, as this will also help promoteunderstanding (Gulanick & Myers, 2011, p. 271). Open communication is key to helpingpatients keep their BP under control. If the patient is not complying with the treatment plan it isimportant to find out why. Make sure to involve the patient in the treatment plan, the moreinvolved the patient is, the more likely that the treatment will be successful. It will also be veryimportant to stress the importance of keeping on track with the treatment. Hypertension is achronic condition; the goal is keep the BP at a safe level. Many patients have themisunderstanding that if their BP is normal they can go off the plan. Make sure to help thepatient understand that the goal of treatment is to control the BP and that there is no cure(Gulanick & Myers, 2011, p. 271). Bottom line, the more information the patient has the betterthe chances of helping to keep the BP under control. In addition to teaching, it will be important to administer the patient’s medicationsexactly as prescribed. Some of the medications may have BP parameters that need to bemonitored, so it will be important to monitor the patient’s BP. Explain to the patient whatmedication is being given and more importantly what it is for. The patient is more likely toadhere to the medication regime if they know what they are taking and why they are taking it. Objective III There are several risk factors that are important to know when working with a patientwith hypertension. According to Lewis et al., SBP rises with increasing age, unfortunatelycardiovascular disease is associated with elevated SBP levels (2011, p, 766). You should makesure to let your patient know that cigarette smoking and alcohol both have an adverse effect onBP and should be avoided (Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 766).
6. According to the American Heart Association the highest rates of hypertension were foundwithin the African-American community, and of those they were “more likely to be middle agedor older, less educated, overweight or obese, physically inactive, and to have diabetes.” ("Highblood pressure statistics," n.d., pars. 8). Men under the age of 55 have a higher incidence ofhypertension than women of the same age; however after the age of 55, hypertension is moreprevalent in women (Lewis, Heitkemper, Dirksen, OBrien, & Bucher, 2007, p. 766). It isinteresting to note that in 2006 the death rates per 100,000 were as follows: 15.6 for whitemales, 51.1 for black males, 14.3 for white females and 37.7 for black females ("High bloodpressure statistics," n.d., pars. 9). It may be surprising to learn that people with a lowersocioeconomic status have a higher incidence of hypertension (Lewis, Heitkemper, Dirksen,OBrien, & Bucher, 2007, p. 766). There may be several reasons for this. Lack of insurance oran inability to pay for medications needed could be a factor. Another factor is people with alower socioeconomic status might not have the means to have an annual exam; therefore theymay be unaware that there is even a problem. If you don’t know there is a problem, you don’tknow that it needs to be fixed. Also when there are financial worries, there is more stress.We’ve already been able to identify that stress can play a role in high blood pressure. Recently, I had the pleasure of taking care of Roger Langston (name has been changed).Roger is a 53 year old African-American man with a history of uncontrolled high blood pressure.He is 6’1” and weighs 250 lbs and is a smoker. He works as a manager of a car dealership, andhe usually works 50+ hours a week. Having little concern over his diet, it mostly consists of fastfood, he usually has a beer once a week. He is physically inactive, blaming his many hours atwork as the primary cause. Roger, for the most part has been non-compliant with his treatmentplan for hypertension. Roger has been admitted to the hospital with congestive heart failure
7. (CHF), a complication of hypertension. It has been explained to Roger that his uncontrolledhypertension, is one of the reasons for the development of CHF. He has been informed by hisphysician that he absolutely needs to adhere to the treatment plan, which consists of medicationand lifestyle changes. Roger has most of the risk factors identified with hypertension. He is amale smoker. He is African-American. He has a high stress job. Roger also has a poor diet, heis obese, with a low physical activity level. Although Roger has risk factors over which he hasno control. He has several lifestyle risk factors of which he has complete control. While in thehospital, Roger’s hypertension has been controlled, but since he is close to discharge it’simportant to make sure he understand not only the medication regimen, but that lifestyle changesneed to be made to keep his BP at a safe level, and to prevent any further target organ damage. Objective IV According to Gulanick and Myers, the following teaching areas should be addressed:definition of hypertension, common risk factors, strategies for weight reduction, rationale andstrategies for adopting the DASH diet and a low sodium diet (2011, p.271). I also believe thatRoger really needs to understand the complications of hypertension. Teaching is going to be keyin order to keep Roger’s BP under control. In order for his treatment to be successful, he needsto understand the importance of lifestyle changes and ways to help implement them into his dailylife. Having been his nurse for the past few days, I have been able to ascertain that Roger isreceptive to teaching and this recent diagnosis of CHF has made him seem to take hishypertension more seriously. As previously mentioned, teaching in smaller sessions isimportant, as I want him to remember what we discuss. First, I want to go over thecomplications of the disorder. Although, Roger is taking his treatment more seriously at thistime, knowing the complications can increase his success in effective management once he gets
8. home. The main complication of hypertension is target organ damage (Porth, 2011, p. 431).Hypertension for the most part is asymptomatic, it will be important to stress this (Porth, 2011, p.431). When symptoms do develop it is usually related to long term effects on target organs(Porth, 2011, p. 431). These target organs include the kidneys, heart, eyes, and blood vessels(Porth, 2011, p. 431). In Roger’s case, his heart is showing signs of damage. Hypertension isconsidered a major risk factor for coronary artery disease, heart failure, stroke, and peripheralartery disease (Porth, 2011, p. 431). Roger also needs to know what hypertension is. Explainthat hypertension is defined as a SBP over 140 mm Hg, or a DBP over 90 mm Hg (Porth, 2011,p. 427). Explain that SBP is the upper number and DBP is the lower number. Advise him tomonitor his BP at home and that he should purchase equipment that is approved by his physician(Gulanick & Myers, 2011, p. 270). Lifestyle changes are hard for anyone, but it will be very important to arm Roger with thetools he needs to make the necessary lifestyle changes. Roger needs to know that lifestylemodification has been proven to reduce blood pressure and enhance the effects of drug therapy(Porth, 2011, p. 431). Rogers needs to quit smoking, lose weight, modify his diet, and increasehis physical activity. Since Roger smokes this increases his risks for heart disease. Refer Rogerto www.smokefree.gov. This will give him the information he needs to quit for good. Weightloss has been proven to lower BP (Gulanick & Myers, 2011, p. 271). Since Roger will be on aweight loss plan, he can incorporate foods from the Dash diet and this in turn will help himreduce his sodium intake. The Dash diet and a reduction of sodium intake have been proven tonot only be effective in lowering BP, but are especially effective in the African-Americanpopulation (Gulanick & Myers, 2011, p. 271). Since Roger mostly eats fast foods, we can helphim learn to choose healthy foods from fast food menus. In addition, physical activity has been
9. shown to have a positive effect on weight loss and on BP, so that needs to be implemented aswell. Roger has indicated that he didn’t have time for exercise. Studies show that aerobicexercise has a positive effect on BP (Gulanick & Myers, 2011, p. 272). A brisk 30 minute walkbefore or after work most days of the week, might work for him, or getting on a treadmill whilewatching TV would be helpful. Refer Roger to dashdiet.org as well as The American HeartAssociation website at www.heart.org/HEARTORG/. Both of these are recognized websites thatcan help Roger meet his goals. Conclusion Hypertension is a common chronic disorder that is virtually asymptomatic. However ithas been shown, that with proper teaching and lifestyle modifications a patient can keep his/herBP under control. When the patient has the right information about the disorder the patient canfeel empowered to make the right decisions to manage the disorder.
10. ReferencesGulanick, M., & Myers, J. L. (2011). Nursing care plans: diagnoses, interventions, and outcomes (Seventh ed.). St. Louis, MO: Elsevier Mosby.High blood pressure statistics. (n.d.). American Heart Association. Retrieved June 10, 2011, from http://www.americanheart.org/presenter.jhtml?identifier=4621Lewis, S., Heitkemper, M. M., Dirksen, S. R., OBrien, P. G., & Bucher, L. (2007). Medical- surgical nursing: assessment and management of clinical problems. (Seventh ed., pp. 743-783). St. Louis: Mosby Elsevier.Porth, C. (2011). Essentials of pathophysiology: concepts of altered health states (Third ed.). Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins.