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