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Nursing Management of Hypertension Cindy Bolton Team Leader, Development Panel

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  • 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

  • National Institutes of Health ClassificationCategory Systolic DiastolicOptimal < 120
  • 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

  • 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

  • Impact of Lifestyle Therapies on BP in Hypertensive Adults

    Intervention Targeted Change SBP/DBPSodium reduction 100 mmol or 1

    tsp/day5.8/-2.5

    Dietary Patterns DASH diet 11.4/-5.5Exercise* 3 times/week -7.4/-5.8Weight 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, 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 clients 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

    [email protected]

    Nursing Management of HypertensionGuideline DevelopmentHypertensionClassification of Hypertension: WHO/ISH*National Institutes of Health ClassificationDetection and DiagnosisIdentify 5 (or More) Measurement ErrorsWhich of the following is the correct position?Cuff sizeBlood Pressure Assessment:Patient preparation and postureRecommended Technique for Measuring Blood PressureDiagnostic algorithmDiagnostic algorithmAcute CareThreshold for Initiation of Treatment and Target ValuesAssessment and Development of a Lifestyle Treatment PlanSummary Lifestyle Changes in Hypertensive Adults :Impact of Lifestyle Therapies on BP in Hypertensive AdultsMonitoring and Follow upMedicationsAdherenceAssessment of AdherencePromotion of AdherenceDocumentationAppendices