Hypertension

Goal: To improve the clinical management skills of NP students in managing hypertension effectively; familiarize yourself with the use of experiential learning techniques as to how new ideas area formed through observation, experimentation, and reflection .

Introduction

Heart disease and stroke are the leading causes of death and hospitalization in Canada. Research has proven that hypertension significantly increases risk for stroke, ischemic heart disease, peripheral vascular disease and heart failure.It is estimated that the lifetime risk for developing hypertension among adults aged 55 to 65 years with normal blood pressure is 90%. Similarly, almost 30% of hypertension can be attributed to excess dietary sodium. In 2007, hypertension was noted to be the chief most reason for doctor’s visit (Government of Canada, 2015). According to a statistics Canada report (2015), hypertension is prevalent among 24% Canadians between the age group of 20-79 years. Obesity was noted to be the major risk factors of hypertension with a prevalence rate of 30% among Canadian adults who were identified as being overweight or obese, compared with 12% of those who were normal weight. The above reports support the need for timely assessment and management of hypertension with pertinent strategies in place for reducing morbidity, mortality, and medical expenditure, induced by hypertension.

Hypertension Pathophysiology

Application of Experiential Learning Model- Step-1

Now, as nurses with proven experience in clinical settings, you are aware of BP targets, BP measuring technique, complications of hypertension, what are the signs of complications etc. However, in your current role as advanced practice nurses, you are taking your basic skills to next level in which you will learn to interpret the readings and offer pharmaceutical/ nonpharmaceutical management, screening for complications, arranging referral etc. Let us analyze this learning transition through the experiential learning cycle, as illustrated below.

Application of Experiential Leraning Model- Active Experimentation - Step-2

Are you ready to move on to step 2? - Active experimentation

HTN Diagnosis

Reference: Hypertension Canada (2018)

Investigations

• All patients with confirmed cases of HTN, should undergo physical examination, laboratory investigations, and screening for target organ damage.
• Lab investigations include: urinalysis, electrolytes, fasting blood glucose, creatinine, ECG.
• Physical exam should include target organ damage screening for the following: retinal, renal, cerebrovascular, cardiac screening, peripheral arterial screening.
• Refer to the following link to learn more about screening for target organ damage and to rule out other secondary causes of HTN such as renovascular HTN, and endocrine HTN https://guidelines.hypertension.ca/diagnosis-assessment/

Non-pharmacological management

• Recommend 30-60 minutes of moderate intensity dynamic exercise (e.g., walking, jogging, cycling, or swimming) 4-7 days per week in addition to the routine activities of daily living
• Maintain healthy body weight (body mass index of 18.5 to 24.9 kg/m2, and waist circumference <102 cm for men and <88 cm for women). As per Framingham Study, for each 4.5 kg of weight gain, there was an associated increase in SBP of 4 mm Hg in both men and women.
• Reduce alcohol consumption to ≤ 2 drinks per day, and consumption should not exceed 14 drinks/ week.
• Recommend DASH diet
• Consider reducing sodium intake toward 2000 mg per day
• In patients not at risk of hyperkalemia, increase dietary potassium intake to reduce BP
• Stress management

Indications for pharmacological management

• Initiate pharmacological management for DBP measurements of ≥100 mmHg or average SBP measurements of ≥160 mmHg, in patients without macrovascular target organ damage or other cardiovascular risk factors.
• Antihypertensive therapy should be strongly considered for average 140/90mmhg patients with known history of macrovascular target organ damage or at risk of cardiovascular diseases
• There are no definite recommendations made by CHEP in terms of initiating medications in patients with BP 140–159/90–99 mm Hg and no cardiovascular disease or risk factors; Do an individual global risk assessment in such patients when considering medications.(Hypertension Canada, 2018).

Pharmacological management

Are You ready to move on to stage 3 of ELT? - Concrete Experimentation

SOAP Note (by creating your soap notes, you have created a concrete concept on HTN management)

S

• h/o head ache x 3 days
• Past h/o HTN
• No c/o chest pain, palpitations, syncope
• No neurological deficits, constitutional symptoms
• Currently on ACEI, Coversyl at 4 mg
• No h/o substance abuse, trauma, vision changes, sob, pedal edema

O

• BP: 160/100mmhg
• PEARL, fundi-normal, no s/o conjunctival hemorrhage
• CVS- S1S2-wnl, no murmurs, no ehs
• JVP- wnl, no pedal edema
• Abd- soft, no renal bruits, masses
• Neuro
Neuro: perrla, cn 2-12 grossly n, eom n, strength 5/5, muscle tone grossly n, sens/coord/ref grossly n, no tremor/rigidity/bradykinesia, gait n, no nuchal rigidity

A

• Essential HTN

P

• Coversyl dose increased to 8mg po OD
• Lab as directed:lytes,creatinine
• f/u in 2 weeks to r/a BP
• Encouraged DASH diet
• Weight loss goal
• Physical activity

Clinical Pearl

Hypokalemia is one of the common side effects of diuretic therapy; similarly, ACEI may cause dry cough in some patients. Often initiation of Norvasc may produce ankle edema. Be mindful regarding ruling out secondary causes of HTN in patients with resistant HTN

Prescribe renal dose based on creatinine clearance rate, as required. https://www.kidney.org/professionals/KDOQI/gfr_calculatorCoc

Familiarize yourself with cardiovascular risk assessment tool, when planning antihypertensives, statin, ASA therapy etc. https://myhealth.alberta.ca/Alberta/Pages/Heart-Disease-Risk-Calculator.aspx