NURSING PROCESS:THE PATIENT WITH HYPERTENSION
When hypertension is initially detected, nursing assessment involves carefully monitoring the blood pressure at frequent intervals and then, after diagnosis, at routinely scheduled intervals. The Ameri-can Heart Association and the American Society of Hypertension have defined the standards for blood pressure measurement, in cluding conditions required before measurements are made, equip-ment specifications, and techniques for measuring blood pressure to obtain accurate and reliable readings (Chart 32-3) (American Soci-ety of Hypertension, 1992; Perloff et al., 1993) When the patient begins an antihypertensive treatment regimen, blood pressure as-sessments are needed to determine the effectiveness of medication therapy and to detect any changes in blood pressure that indicate the need for a change in the treatment plan.
A complete history is obtained to assess for symptoms that in-dicate target organ damage (whether other body systems have been affected by the elevated blood pressure). Such symptoms may in-clude anginal pain; shortness of breath; alterations in speech, vision, or balance; nosebleeds; headaches; dizziness; or nocturia.
During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the api-cal and peripheral pulses to detect effects of hypertension on the heart and blood vessels. A thorough assessment can yield valu-able information about the extent to which the hypertension has affected the body and about any other personal, social, or financial factors related to the condition.
Based on the assessment data, nursing diagnoses for the patient may include the following:
· Deficient knowledge regarding the relation between the treatment regimen and control of the disease process
· Noncompliance with therapeutic regimen related to side effects of prescribed therapy
Based on the assessment data, potential complications that may develop include the following:
· Left ventricular hypertrophy
· Myocardial infarction
· Heart failure
· Cerebrovascular accident (stroke or brain attack)
• Renal insufficiency and failure
• Retinal hemorrhage
The major goals for the patient include understanding of the dis-ease process and its treatment, participation in a self-care pro-gram, and absence of complications.
The objective of nursing care for hypertensive patients focuses on lowering and controlling the blood pressure without adverse effects and without undue cost. To achieve these goals, the nurse must support and teach the patient to adhere to the treatment regimen by implementing necessary lifestyle changes, taking medications as prescribed, and scheduling regular follow-up appointments with the health care provider to monitor progress or identify and treat any complications of disease or therapy.
The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. The nurse needs to emphasize the concept of controlling hypertension rather than curing it. The nurse can encourage the patient to con-sult a dietitian to help develop a plan for weight loss. The program usually consists of restricting sodium and fat intake, increasing intake of fruits and vegetables, and implementing regular physical activity. Explaining that it takes 2 to 3 months for the taste buds to adapt to changes in salt intake may help the patient adjust to re-duced salt intake.
The patient should be advised to limit alcohol intake (see Chart 32-2 for specific recommendations), and tobacco should be avoided—not because smoking is related to hyper-tension, but because anyone with high blood pressure is already at increased risk for heart disease, and smoking amplifies this risk. Support groups for weight control, smoking cessation, and stress reduction may be beneficial for some patients; others can benefit from the support of family and friends. The nurse assists the pa-tient to develop and adhere to an appropriate exercise regimen, because regular activity is a significant factor in weight reduction and a blood pressure–reducing intervention in the absence of any loss in weight (Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, 1997).
Blood pressure screenings with the sole purpose of case finding are not recommended by the National High Blood Pressure Education Program because approximately 70% of persons with hypertension are already aware of their blood pressure levels (JNC VI, 1997). If asked to participate in a blood pressure screening, the nurse should be sure that proper blood pressure measurement tech-nique is being used (see Chart 32-3), that the manometers used are calibrated (Perloff et al., 1993), and that provision has been made to provide follow-up for any person identified as having an elevated blood pressure. Adequate time should also be allowed to teach people what the blood pressure numbers mean. Each person should be given a written record of his or her blood pressure at the screening.
The therapeutic regimen is the responsibility of the patient in collaboration with the health care provider. Education about high blood pressure and how to manage it, including medica-tions, lifestyle changes of diet, weight control, and exercise (see Table 32-2), setting goal blood pressures, and assistance with social support, can help the patient achieve blood pressure con-trol. Involving family members in education programs enables them to support the patient’s efforts to control hypertension. The American Heart Association and the National Heart Lung and Blood Institute provide printed and electronic patient education materials.
Written information about the expected effects and side effects of medications is important. When side effects occur, patients need to understand the importance of reporting them and to whom they should be reported. Patients need to be informed that reboundhypertension can occur if antihypertensive medications are sud-denly stopped. Female and male patients should be informed that some medications, such as beta-blockers, may cause sexual dys-function and that, if a problem with sexual function or satisfaction occurs, other medications are available. The nurse can encourage and teach patients to measure their blood pressure at home. This practice involves patients in their own care and emphasizes the fact that failing to take medications may result in an identifiable rise in blood pressure. Patients need to know that blood pressure varies continuously and that the range within which their pressure varies should be monitored.
Regular follow-up care is imperative so that the disease process can be assessed and treated, depending on whether control or progression is found. A history and physical examination should be completed at each clinic visit. The history should include all data that pertain to any potential problem, specifically medication-related problems such as postural (orthostatic) hypotension (experienced as dizziness or lightheadedness).
Deviation from the therapeutic program is a significant prob-lem for people with hypertension and other chronic conditions requiring lifetime management. It is estimated that 50% dis-continue their medications within 1 year of beginning to take them. Blood pressure control is achieved by only 27% (JNC VI, 1997). However, when patients actively participate in self-care, including self-monitoring of blood pressure and diet, compliance increases— possibly because patients receive immediate feedback and have a greater sense of control.
Considerable effort is required by patients with hypertension to adhere to recommended lifestyle modifications and to take reg-ularly prescribed medications. The effort needed to follow the therapeutic plan may seem unreasonable to some, particularly when they have no symptoms without medications but do have side effects with medications. The recommended lifestyle changes are listed in Chart 32-2. Continued education and encourage-ment are usually needed to enable patients to formulate an ac-ceptable plan that helps them live with their hypertension and adhere to the treatment plan. Compromises may have to be made about some aspects of therapy to achieve success in higher-priority goals. The nurse can assist with behavior change by supporting patients in making small changes with each visit that move them toward their goals. Another important factor is following up at each visit to see how the patient has progressed with the plansmade at the prior visit. If the patient has had difficulty with a par-ticular aspect of the plan, the patient and nurse can work together to develop an alternative or modification to the plan that the patient believes will be more successful.
Symptoms suggesting that hypertension is progressing to the extent that target organ damage is occurring must be detected early so that appropriate treatment can be initiated accordingly. When the pa-tient returns for follow-up care, all body systems must be assessed to detect any evidence of vascular damage. Examining the eyes with an ophthalmoscope is particularly important because retinal blood ves-sel damage indicates similar damage elsewhere in the vascular sys-tem. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed and examined. Any signifi-cant findings are promptly reported to determine whether addi-tional diagnostic studies are required. Based on the findings, medications may be changed to improve blood pressure control.
Compliance with the therapeutic program may be more difficult for elderly people. The medication regimen can be difficult to remember, and the expense can be a problem. Monotherapy (treatment with a single agent), if appropriate, may simplify the medication regimen and make it less expensive. Special care must be taken to ensure that the elderly patient understands the regi-men and can see and read instructions, open the medication con-tainer, and get the prescription refilled. The elderly person’s family or caregivers should be included in the teaching program so that they can understand the patient’s needs, encourage ad-herence to the treatment plan, and know when and whom to call if problems arise or information is needed.
Expected patient outcomes may include the following:
1) Maintains adequate tissue perfusion
a) Maintains blood pressure at less than 140/90 mm Hg (or less than 130/85 mm Hg for persons with diabetes mellitus or proteinuria greater than 1 g per 24 hours) with lifestyle modifications, medications, or both
b) Demonstrates no symptoms of angina, palpitations, or vision changes
c) Has stable BUN and serum creatinine levels
d) Has palpable peripheral pulses
2) Complies with the self-care program
a) Adheres to the dietary regimen as prescribed: reduces calo-rie, sodium, and fat intake; increases fruit and vegetable intake
b) Exercises regularly
c) Takes medications as prescribed and reports any side effects
d) Measures blood pressure routinely
e) Abstains from tobacco and excessive alcohol intake
f) Keeps follow-up appointments
3) Has no complications
a) Reports no changes in vision
b) Exhibits no retinal damage on vision testing
c) Maintains pulse rate and rhythm and respiratory rate within normal ranges
d) Reports no dyspnea or edema
e) Maintains urine output consistent with intake
f) Has renal function test results within normal range
g) Demonstrates no motor, speech, or sensory deficits
h) Reports no headaches, dizziness, weakness, changes in gait, or falls