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Oct.30.2019

Hypertension Management (Ambulatory) - CE

ALERT

Blood pressure (BP) measurements with an electronic BP device may be affected by excessive movement, such as what might occur with seizures, tremors, or shivering, and irregular heart rates.

Untreated or poorly controlled hypertension can lead to hypertensive emergencies and result in organ damage (i.e., myocardial infarction, pulmonary edema, acute renal failure, hypertensive encephalopathy, intracerebral hemorrhage). Patients with BP readings greater than 180/120 mm Hg and who have signs and symptoms of organ damage require immediate emergency treatment.undefined#ref4">4

OVERVIEW

Hypertension is when the force of blood pumping through the arteries is too strong. The arteries are the blood vessels that carry blood from the heart throughout the body. Hypertension forces the heart to work harder to pump blood and may cause arteries to become narrow or stiff, making them more susceptible to plaque buildup. Having untreated or uncontrolled hypertension can cause heart attacks, strokes, kidney disease, and other problems.

A number of risk factors are strongly associated with developing hypertension, including age, obesity, family history, race, high-sodium diet, excessive alcohol consumption, and physical inactivity.4 In 2017, the American College of Cardiology and American Heart Association updated the guidelines recommending using a lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) to define hypertension. As a result, this translated into 46% of adults 20 years old and older in the United States classified as having hypertension (defined either as taking antihypertensive medication, or having an SBP greater than 130 mm Hg, a DBP greater than 80 mm Hg, or both).3 Among nonpregnant adults in the United States, hypertension is the most common reason patients need care and chronic prescription medications.3

BP can be categorized in four ways (Table 1)Table 1:4

  • Normal BP: SBP less than 120 mm Hg and DBP less than 80 mm Hg
  • Elevated BP: SBP of 120 to 129 mm Hg and DBP less than 80 mm Hg
  • Hypertension:
    • Stage 1: SBP of 130 to 139 mm Hg or DBP 80 to 89 mm Hg
    • Stage 2: SBP at least 140 mm Hg or DBP at least 90 mm Hg
  • Hypertensive emergency: SBP greater than 180 mm Hg or DBP greater than 120 (or both) and signs of organ damage

If there is a disparity in category between the SBP and DBP, the higher value determines the stage.4

White coat hypertension occurs when BP readings taken at a health care facility are higher than readings obtained elsewhere. White coat hypertension impacts approximately 13% to 35% of adults.4 The prevalence of white coat hypertension increases with age and requires periodic monitoring because it increases the patient’s risk for developing hypertension.4

Treatment of high BP should involve nonpharmacologic interventions, including lifestyle modifications (e.g., salt restriction, dietary changes, weight loss, exercise, limiting alcohol intake). Not all patients diagnosed with hypertension require pharmacologic treatment. A specific plan of care for hypertension management should reflect an understanding of the modifiable and nonmodifiable determinants of health behaviors, including health literacy and access to health insurance and medication assistance.4

EDUCATION

  • Teach the patient the signs and symptoms of high BP (e.g., headache, numbness, weakness, visual changes, shortness of breath, nosebleed, nausea and vomiting, back pain, severe chest pain, seizures) and instruct him or her on when to seek additional care.
  • Teach the patient about risk factors for high BP (e.g., smoking, obesity, excessive alcohol use, or having too much fat, sugar, or sodium or too many calories in the diet).
  • Teach the patient about nonpharmacologic measures to manage and control hypertension, including a Dietary Approaches to Stop Hypertension (DASH) diet, tobacco cessation, weight loss, moderation in alcohol intake, increased physical activity, and reduced sodium intake.
  • Teach the patient about potassium-rich foods. Potassium lessens the BP-raising effects of sodium.4
  • Teach the patient to take BP medications as prescribed and to not skip doses.
  • Teach the patient to monitor his or her BP daily and to perform measurements in a quiet room after 5 minutes of rest and in the seated position with the back and arm supported and legs uncrossed.
  • Teach the patient to maintain a BP journal and to record readings taken over time.
  • Teach the patient about ambulatory BP threshold guidelines. In adults, normal BP is less than 120/80 mm Hg.4
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings are communicated to the clinical team leader per the organization’s practice.
  6. Obtain the patient’s medical history including history of hypertension, cardiovascular disease, renal disease, diabetes, and other factors that influence BP (e.g., weight, smoking, medications).
  7. Review the patient’s family history of hypertension, cardiovascular disease, diabetes, and dyslipidemia.
  8. Obtain a diet intake (sodium, cholesterol, fruits and vegetables, whole grains) and physical activity history.
  9. Obtain a social history including a review of smoking and tobacco use, substance abuse, and frequency and amount of alcohol consumed.
  10. Evaluate the patient for signs and symptoms of elevated BP.
    1. Headache (usually occipital)
    2. Visual disturbances
    3. Facial flushing
    4. Nosebleed
    5. Fatigue
    6. Numbness
    7. Weakness
    8. Nausea and vomiting
    9. Back pain
    10. Severe chest pain
    11. Seizures
  11. Evaluate the patient’s cardiovascular, pulmonary, and neurologic status and be prepared to follow the organization’s practice for emergency response, if necessary.
  12. Obtain the patient’s BP and other vital signs, including oxygen saturation. Ensure the accuracy of the BP reading.
  13. Rationale: BP measurements may be taken incorrectly if the cuff is too large or too small, leading to abnormally low or high BP readings respectively.
  14. If the patient is exhibiting signs and symptoms of a hypertensive emergency (BP greater than 180/120 mm Hg) and has evidence of organ damage,4 activate the emergency response system per the organization’s practice.
  15. Rationale: Hypertensive emergencies require an immediate reduction of BP to prevent further organ damage. Examples of organ damage include acute ischemic stroke, myocardial infarction, pulmonary edema, dissecting aortic aneurysm, and acute renal failure.
  16. Obtain the patient’s actual weight in kilograms.2 Stated, estimated, or historical weight should not be used.2
  17. Administer a BP-lowering medication, if ordered.
  18. Monitor the patient for adverse and allergic reactions to the prescribed medication. Recognize and immediately treat dyspnea, wheezing, and circulatory collapse, which are signs of a severe anaphylactic reaction. Follow the organization’s practice for emergency response.
  19. Discard supplies, remove gloves, and perform hand hygiene.
  20. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient is able to teach-back education about hypertension.
  • Patient is able to effectively monitor his or her BP at home.

UNEXPECTED OUTCOMES

  • Hypertensive emergency
  • Hypotension
  • Patient unable to teach-back education about hypertension
  • Patient unable to effectively monitor own BP

DOCUMENTATION

  • Patient education
  • BP readings before and after treatment
  • Interventions completed to address elevated BP
  • Medications administered
  • Unexpected outcomes and related interventions
  • Evaluation findings communicated to the clinical team leader per the organization’s practice
  • Plans for preventing further episodes of hypertension

PEDIATRIC CONSIDERATIONS

  • About 3.5% of all children and adolescents in the United States have high BP; however, it is often undetected and untreated.1
  • Children with conditions, such as obesity, chronic kidney disease, born preterm, genetic conditions, and sleep disturbances (e.g., obstructive sleep apnea) are at increased risk for developing hypertension.1
  • Diagnosing hypertension in children is difficult because BP is affected by many factors, including height, age, and sex, and high BP in children is almost always asymptomatic.1
  • The American Academy of Pediatrics and the National Heart, Lung, and Blood Institute both recommend that BP is measured at annual well-child visits beginning at 3 years old.1
  • There is no target BP reading for children.1

OLDER ADULT CONSIDERATIONS

  • Hypertension is the leading cause of preventable mortality and morbidity and is a major contributor to premature disability and admission to long-term–care facilities in older adults.4
  • The use of BP medications does not increase the risk for falls with injury in community-dwelling older adults.4
  • Older adult patients who have poor vision may have trouble monitoring BP at home.
  • Polypharmacy should be avoided as much as possible with older adults to reduce confusion and overdosing or underdosing of medications.

REFERENCES

  1. Flynn, J.T. and others. (2017). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics, 140(3), e20171904. doi:10.1542/peds.2017-1904 (Level VII)
  2. Institute for Safe Medication Practices (ISMP). (2017). 2018-2019 Targeted medication safety best practice for hospitals. Retrieved September 13, 2019, from https://www.ismp.org/sites/default/files/attachments/2017-12/TMSBP-for-Hospitalsv2.pdf (Level VII)
  3. Munter, P. and others. (2018). Potential U.S. population impact of the 2017 American College of Cardiology/American Heart Association high BP guideline (2018). Circulation, 137(2), 109-118. doi:10.1161/CIRCULATIONAHA.117.032582 (Level IV)
  4. Whelton, P.K. and others. (2017). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 138(17), e426-e483. doi:10.1161/CIR.0000000000000597 (Level VII)

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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