Nursing diagnosis and hypertension

Dear Mom,

I know you have another appointment with the doctor regarding your high blood pressure. So I wanted to mention some areas that the nurse might want to discuss with you. There are several things that are important to monitor when one has high blood pressure. These are choices and habits that will effect your blood pressure, and consequently, your health. So it is really important that you think about how you handle these situations and be ready to discuss them with the nurse.

The nurse will ask you about your diet and whether you are able to maintain a healthy weight through eating a balanced diet, including vegetables and fruits. Also, she/he will want to answer any questions you might have about your understanding of what makes a healthy diet for management of blood pressure.(1)  She/he would like to know if you understand the steps that you need to take to manage your blood pressure and why this is important for your long term health.(1)  Your medications, how you take them and whether any side effects are making it hard to stay on schedule should be discussed.(1)  The nurse will also ask if you have had any shortness of breath, pain in your chest, episodes of feeling lightheaded or dizzy.(2) 

I understand from that you and Dad like to go out to restaurants several times a week and you are wondering how that will work with following a American Heart Association diet. So I hope you bring up these issues when you meet with the nurse. I am sure she would be happy to talk with you about your concerns.

Take care Mom, and I will be seeing you soon,

Your daughter, Mary




Following is some more info that can help you as the nurse for this patient:

Hopper, Student workbook for Understanding medical surgical nursing.

1 Ackley, B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis, Mo.: Mosby Elsevier.

2 Nanda Nursing Interventions. (n.d.). Retrieved February 28, 2015, from http://nandanursinginterventions.blogspot.com/2012/05/4-nursing-diagnosis-interventions-for.html

3 Hopper, P., & Williams, L. (2007). Student workbook for Understanding medical surgical nursing (3rd ed., p. 428). Philadelphia: F.A. Davis.

How nurses support patients with high blood pressure

(1)Bengtson, RNT PhD, A., & Drevenhorn, MA, RN, E. (2003, January 1). The Nurse's Role and Skills in Hypertension Care. Retrieved February 20, 2015, from http://www.medscape.com/viewarticle/463185_5

The journal article, The Nurse's Role and Skills in Hypertension Care, offered a comprehensive view of how important the nurse's care can be to patient's that have hypertension.  I had not considered the advantages nurses have such as time, educational role and lack of "white coat syndrome".  Reading this article strengthened my conviction to become a nurse! 

The Nurse's Role and Skills in Hypertension Care

Hypertensive Medications Unravelled

Dear Mom,

In my nursing classes we are learning about all of the different approaches that might be used to help treat a person's high blood pressure.  I know that you have told me in the past that your doctor keeps changing your blood pressure medications and you were wondering why.  As a child, you taught me that everyone is different.  And this principle applies to how we respond to medicine as well.  The doctors know approximately how people will respond to blood pressure medications.  So they start with the general type or types of medication that will work for your specific issues.  Such as a person with high blood pressure alone would have different medication options than a person with high blood pressure and kidney disease.

Once the doctor has selected a medication(s) for the person, they then follow how the patient is doing on the medication(s).  Do the medications work -- is their blood pressure coming down?  How does the patient feel on the medication -- are they having undesirable side effects?  Then they do fine tuning for each patient based upon their response.  You can click on the link below to check out how your drugs help manage your high blood pressure and the following list of side effects of two of the more common drugs.

As always, give me a call if you have any questions on this information.  I hope it answers your questions, but let me know if I have just added a bunch of new questions to your list!

Mary


Types of Blood Pressure Medications and what they do in our bodies

Blood-Pressure Medications Chart

***********************************************************************

Two of the main therapies of treating hypertension are diuretics such as Lasix (Furosemide) and ACE Inhibitors such as Lisinopril and Vasotec.1  Side effects that people normally see are:

Lasix (common side effects)2

• High uric acid or low magnesium
• Loss of appetite
• Spasm of the bladder

Lasix (serious side effects)2

• Blood pressure that changes dramatically when you sit or stand up
• Drug hypersensitivity syndrome, Erythema multiforme, Erythroderma, Stevens-Johnson syndrome, Toxic epidermal necrolysis due to drug
• Inflammation of the Pancreas
• Agranulocytosis, Aplastic anemia, Thrombocytopenia
• Anaphylactoid reaction, Anaphylaxis

Lisinopril (common side effects)2

• Chest pain, Low blood pressure (up to 11% ), dizziness (5% to 7% )
• Dizziness (12% to 19% ), Headache
• Cough

Lisinopril (serious side effects)2

• Low blood pressure (Severe) (9% )
• Stevens-Johnson syndrome (1% or more ), Toxic epidermal necrolysis (1% or more )
• High potassium levels (2.2% to 6% )
• Intestinal swelling
• Allergic reaction due to insect stings or Dialysis
• Acute kidney failure, Kidney impairment (2.4% )
• Painful swelling of the Head and Neck

1 Madhur, MD, PhD, M. (2014, September 30). Hypertension Medication (D. Maron, MD, FACC, FAHA, Ed.). Retrieved February 14, 2015, from http://emedicine.medscape.com/article/241381-medication#2

2 Retrieved from  http://www.micromedexsolutions.com.offcampus.lib.washington.edu/micromedex2/librarian/PFDefaultActionId/evidencexpert.DoIntegratedSearch

• 
  

High Blood Pressure -- Signs and Symptoms

Dear Mom,

Yes, Mom, it is not uncommon for patients to be surprised when they hear they have high blood pressure (or hypertension as the doctors like to call it!).  The reason is that high blood pressure rarely has any recognizable symptoms. (1)  Most people walk around this earth feeling just fine, and then one year they have their annual checkup and learn their blood pressure is high.  This is so common!  

Of course there is the rare case when an individual develops a severe headache, severe anxiety, nosebleed or just can't catch their breath because of high blood pressure.  These people are usually in a hypertensive crisis and someone needs to call 911 right away.  Either the difference between their systolic pressure and their diastolic pressure is high or the systolic is above 180 or the diastolic is above 110.(1) Remember systolic is when the heart muscle pushes the blood out of the heart on its journey through the body and diastolic is when your heart muscle takes a break between pumps.

This is why high blood pressure is often called "The Silent Killer", because it is rarely felt by the person.

I can't emphasize enough how important it is for people to have their annual check-up with their health care provider.  I know you and dad are very faithful about seeing your doctor at least annually.  Please encourage your friends to do so as well.  If they can't see a doctor for some reason, encourage them to go to a pharmacy that has a blood pressure machine.  Most are free and if their blood pressure is different than 120/80, they can talk to the pharmacist about what to do.

And remember, even when people have not been diagnosed with high blood pressure, it is a good idea for them to take their blood pressure monthly -- again the machine at the pharmacy is a good place to go.  The reason I say this is because, our blood pressure can sometimes increase just because of a stressful day.  When a person takes their blood pressure regularly, they get to know their blood pressure range -- this is an important step in taking care of ourselves!

So Mom, when you went to the doctor, he measured different aspects of your body and the fluids in your body to look for signs of high blood pressure.  With this disease, signs are more telling than symptoms!  Here is a list of exams or tests that your doctor might have done to look for signs of (diagnosing) your high blood pressure:

-- Physical exam including your blood pressure and an eye exam

--Urinalysis

--Blood tests (BMP, CBC, Serum lipid profile, serum uric acid)

-- 12-lead ECG (measuring the impulses of your heart) (2)

Mom, I hope this helps and let me know what other questions you may have about hypertension:)

Mary

(1)  Understand Your Risk for High Blood Pressure. (n.d.). Retrieved February 7, 2015, from http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp

(2)  Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Harding, M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed., p. 715). St. Louis: Elsevier Mosby.

The mystery of blood pressure monitors!

Dear Mom,

An important part of good health care is keeping an eye on our blood pressure.  What I mean is that each of us has a responsibility to take care of ourselves.  This is especially important if we have been diagnosed with high blood pressure by our primary health care provider.  Since your doctor said you have hypertension, that means that your blood pressure is above 140/90 mm Hg.(1)  The reason this should be of concern to you is that high blood pressure can lead to heart disease if it remains high.  

Please take good care of yourself  -- take your blood pressure every morning  before breakfast and then again in the evening.  Measuring blood pressure with a monitor is part science and part art.  The science is how the cuff of the blood pressure monitor can feel the change in blood flow that is happening inside your arm when the cuff is inflated and deflated.  The art is in positioning and inflating the cuff, as well as controlling the pressure as it is deflated to get an accurate reading.  If you are interested in more detailed information, click on this site from the Mayo Clinic Advice on taking your own blood pressure

In general how it works is this:  the blood pressure cuff goes on your upper arm and then air is pumped into the cuff.  As the cuff squeezes your arm, the blood temporarily stops flowing through a large artery in your arm.  When the cuff is slowly deflated, the blood begins moving through the artery again.  This is your systolic pressure--basically, the pressure your heart exerts to send your blood on its way through your body.  We continue listening until we can't hear the blood moving through the artery any longer.  This is the diastolic pressure--the measure of pressure in your artery when your heart is taking a break between beats. 

A doctor or nurse will place a stethoscope on your arm over the artery in order to hear when the blood stops and restarts.  Your home blood pressure monitor does this automatically for you. 

Here is a picture that shows how the inflation of the cuff stops the flow of the artery.  Then how the first sound heard is the systolic pressure and the last sound heard is the diastolic pressure reading.

http://www.mootah-medical.com/en/images/30-08.gif

Mom, I just wanted to let you know that one of the best things you could do each day is get a little exercise and then relax and smell the roses :)

Love you,  Mary

(1)  Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Harding, M. (2014). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (9th ed., p. 715). St. Louis: Elsevier Mosby.

What causes high blood pressure?

Dear Mom,

Dad said you had a doctor's appointment for your high blood pressure today.  He mentioned that you still had questions about what you could do to lower your blood pressure.  That is such a great question!  In nursing school, we are learning about how important it is for each person to take responsibility for their health and many times, just by changing a few things we do each day, we can see great changes in our health.  While some people's blood pressure numbers can be difficult to bring down to healthy levels, USUALLY there are many things people can do to improve their blood pressure.  I am very thankful that you are interested in making the effort to try out some lifestyle changes that could make you feel better!

So Mom, it is first important to understand that there are 2 different types of hypertension.  (Remember, hypertension is just another word for high blood pressure!)  Most people (90-95%) have what is called Primary or Essential Hypertension.  This is what the doctors think you have.  Primary Hypertension develops slowly over many years and we don't really know the exact cause.  Yet we do know there are many risk factors that increase your chances of developing Primary Hypertension.  I added a list of these risk factors, because they can help guide you in understanding what changes you can make to lower your blood pressure.  Of course, I am sure the doctor mentioned, the most important thing is for you to faithfully take your blood pressure medicine every day as directed.

The second type of high blood pressure is called Secondary Hypertension -- yes, you could also call this Secondary High Blood Pressure, just as well!  This type develops suddenly, and usually people with this type have higher blood pressure numbers than people with Primary Hypertension.  It is called Secondary because there is something wrong in this person's body that is causing their blood pressure to rise.  As an example, they could be having problems with their kidneys, which in turn is causing their blood pressure to go up.  These problems usually have to do with the kidneys, blood vessels, or hormones.  If you are interested, I added a list of potential causes for Secondary Hypertension --you might have friends with this and its good to understand that treatment and medications are aimed at the problem causing the hypertension and not necessarily the hypertension itself.

Mom, I hope this information helps.  After you have had a chance to look over the Primary Hypertension Risk Factors, give me a call and we can brainstorm on day-to-day little changes you can make that could help lower your blood pressure! Also, if you have any questions about how to take the prescriptions that your doctor has ordered for you, please let me know.  I am happy to help sort through your medication schedule with you, though I am sure your doctor or his nurse or medical assistant would also be willing to answer your questions too.

It was a sunny day here in Seattle!  Hope your weather has been allowing you to get outside and rake up all of those oak tree leaves!

Love, your daughter,

Mary

**********************************************************************************************************************************

Risk factors for developing high blood pressure, also called hypertension:

• Family history
  Height, hair and eye color runs in families --- so can high blood pressure. If your parents or close blood relatives have had HBP, you are more likely to develop it, too. You might also pass that risk factor on to your children. That's why it's important for children as well as adults to have regular blood pressure checks. You can't control heredity, but you can take steps to live a healthy life and lower your other risk factors. Lifestyle choices have allowed many people with a strong family history of HBP to avoid it themselves. Learn about lifestyle changes you can make to prevent HBP.
  
  
   
• Advanced age
  As we age, we all develop higher risk for high blood pressure and cardiovascular disease. Blood vessels lose flexibility with age which can contribute to increasing pressure throughout the system.
• Gender-related risk patterns
  A higher percentage of men than women have HBP until 45 years of age. From ages 45 to 54 and 55 to 64, the percentages of men and women with HBP are similar. After that, a much higher percentage of women have HBP than men.
• Lack of physical activity
  Physical activity is good for your heart and circulatory system. An inactive lifestyle increases the chance of high blood pressure, heart disease, blood vessel disease and stroke. Inactivity also makes it easier to become overweight or obese. Give yourself the gift of improved health and lower blood pressure with regular, moderate-to-vigorous physical activity.
• Poor diet, especially one that includes too much salt
  To care for our bodies, we all need good nutrition from a variety of food sources. A diet that's high in calories, fats and sugars and low in essential nutrients contributes directly to poor health as well as to obesity. In addition, there are some problems that can happen from eating too much salt. Some people are "salt sensitive," meaning a high-salt (sodium) diet raises their high blood pressure. Salt keeps excess fluid in the body that can add to the burden on the heart. While too much salt can be dangerous, healthy food choices can actually lower blood pressure. Learn about enjoying a heart-healthy diet.
  
  
   
• Overweight and obesity
  Being overweight increases your chances of developing high blood pressure. A body mass index between 25 and 30 is considered overweight. A body mass index over 30 is considered obese. About two-thirds of U.S. adults are overweight or obese. About one in three U.S. children ages 2 to 19 are overweight or obese. Excess weight increases the strain on the heart, raises blood cholesterol and triglyceride levels, and lowers HDL (good) cholesterol levels. It can also make diabetes more likely to develop. Losing as little as 10 to 20 pounds can help lower your blood pressure and your heart disease risk. To successfully and healthfully lose weight—and keep it off—most people need to subtract about 500 calories per day from their diet to lose about 1 pound per week. Calculate your body mass index and learn how to manage your weight.
• Drinking too much alcohol
  Heavy and regular use of alcohol can increase blood pressure dramatically. It can also cause heart failure, lead to stroke and produce irregular heartbeats. Too much alcohol can contribute to high triglycerides, cancer and other diseases, obesity, alcoholism, suicide and accidents. If you drink alcohol, do so in moderation.  If you drink, limit your alcohol consumption to no more than two drinks per day for men and one drink per day for women.  One drink equals a 12-ounce beer, a 4-ounce glass of wine, 1.5 ounces of 80-proof liquor, or one ounce of hard liquor (100-proof). If you drink in excess, find out about curbing alcohol intake.
  
  

  Possible contributing factors

  There is some connection between blood pressure and these factors but science has not proven that they actually cause high blood pressure.
• Stress
  Being in a stressful situation can temporarily increase your blood pressure, but science has not proven that stress causes high blood pressure. Some scientists have noted a relationship between coronary heart disease risk and stress in a person's life, health behaviors and socioeconomic status. How you deal with stress may affect other, established risk factors for high blood pressure or heart disease. For example, people under stress may overeat or eat a less healthy diet, put off physical activity, drink, smoke or misuse drugs. Find ways to reduce stress.
• Smoking and second-hand smoke
  Smoking temporarily raises blood pressure and increases your risk of damaged arteries. The use of tobacco can be devastating to your health, especially if you're already at risk for high blood pressure. Secondhand smoke --- exposure to other people's smoke --- increases the risk of heart disease for nonsmokers. Learn how to kick the habit.
• Sleep Apnea
  Some 12 million Americans have sleep apnea, according to National Heart, Lung, and Blood Institute estimates. Sleep Apnea is a potentially life-threatening sleep disorder in which tissues in the throat collapse and block the airway. The brain forces the sleeper awake enough to cough or gulp air and open the trachea up again. But then, the whole cycle starts all over again. Pauses in breathing can contribute to severe fatigue during the day, increase your safety risks, and make it difficult to perform tasks that require alertness.  Sleep apnea is also a risk factor for such medical problems as high blood pressure, heart failure, diabetes and stroke. Learn more about sleep apnea.

**********************************************************************************************************************************

Secondary hypertension: HBP caused by a pre-existing problem

In 5-10 percent of high blood pressure cases, the HBP is caused by a pre-existing problem. This type of HBP is called secondary hypertension because another problem was present first.

Factors that may lead to secondary hypertension include:

• Kidney abnormality, including a tumor on the adrenal gland, which is located on top of the kidneys
• A structural abnormality of the aorta (the large blood vessel leaving the heart) that has existed since birth
• Narrowing of certain arteries

**********************************************************************************************************************************

Understand Your Risk for High Blood Pressure. (n.d.). Retrieved January 25, 2015, from http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp

• 
  

Who is at risk for high blood pressure?

Blood Pressure Levels Vary by Race and Ethnicity

Blacks develop high blood pressure more often, and at an earlier age, than whites and Hispanics do. More black women than men have high blood pressure.(1)

Race of Ethnic Group	Men (%)	Women (%)
African Americans	43.0	45.7
Mexican Americans	27.8	28.9
Whites	33.9	31.3
All	34.1	32.7

Blood Pressure Levels Vary by Age

Women are about as likely as men to develop high blood pressure during their lifetimes. However, for people younger than 45 years old, the condition affects more men than women. For people 65 years old or older, high blood pressure affects more women than men.(1)

Age	Men (%)	Women (%)
20-34	11.1	6.8
35-44	25.1	19.0
45-54	37.1	35.2
55-64	54.0	53.3
65-74	64.0	69.3
75 and older	66.7	78.5
All	34.1	32.7

Want to read more blood pressure facts from the Center for Disease Control http://www.cdc.gov/bloodpressure/facts.htm

(1)  Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; on behalf of the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013; 127:e6-e245.