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.