MS3.pdf

10/17/23, 4:06 PM Realizeit for Student The Patient With Hypertension Assessment Nurse-led hypertension management has demonstrated greater rates of blood pressure control than when nurses are not leading these management efforts (Himmelfarb, Commodore-Mensah, & Hill, 2016). In many health care se...

10/17/23, 4:06 PM Realizeit for Student The Patient With Hypertension Assessment Nurse-led hypertension management has demonstrated greater rates of blood pressure control than when nurses are not leading these management efforts (Himmelfarb, Commodore-Mensah, & Hill, 2016). In many health care settings, nurses provide the BP assessment, the education, and the counseling while actively engaging the patient to promote adherence to the treatment plan (Himmelfarb et al., 2016). A complete history is obtained to assess for other cardiovascular risk factors and for signs and symptoms that indicate target organ damage (i.e., whether specific tissues are damaged by the elevated blood pressure). Manifestations of target organ damage may include angina; shortness of breath; alterations in speech, vision, or balance; nosebleeds; headaches; dizziness; or nocturia. The patient’s partner may be helpful in identifying whether the patient may be experiencing obstructive sleep apnea (OSA), if the patient does not report being diagnosed or treated for OSA. During the physical examination, the nurse must also pay specific attention to the rate, rhythm, and character of the apical and peripheral pulses to detect the effects of hypertension on the heart and blood vessels. A thorough assessment can yield valuable information about the extent to which the hypertension has affected the body and any other personal, social, or financial factors. For example, a patient’s ability to adhere to an antihypertensive medication regimen may be influenced by the patient’s financial resources to buy the medication and also by limited health insurance. Findings from research suggest that health beliefs, the presence of depressive symptoms, social support, and the presence of concomitant comorbidities might be associated with adherence to antihypertensive medication prescriptions (Spikes et al., 2019). Diagnosis NURSING DIAGNOSES Based on the assessment data, nursing diagnoses may include the following: Lack of knowledge regarding the relation between the treatment regimen and control of the disease process Impaired ability to manage regime as evidenced by difficulty adhering to prescribed regimen (e.g., lifestyle changes, antihypertensive medication prescriptions) COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS Potential complications may include the following: Left ventricular hypertrophy Myocardial infarction Heart failure https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IWsgl87YCND5MlxcaDR%2bIXwVK92JaTnVop0r%2bp7eT… 1/5 10/17/23, 4:06 PM Realizeit for Student Cerebrovascular disease (TIA or stroke) Chronic kidney disease/end-stage renal disease Retinal hemorrhage Planning and Goals The major goals for the patient include understanding of the disease process and its treatment, participation in a self-care program, and absence of complications. Nursing Interventions The objective of nursing care for patients with hypertension focuses on lowering and controlling the blood pressure without adverse effects or undue cost. To achieve these goals, the nurse’s role is to support and educate the patient about the treatment regimen, including making lifestyle changes, taking medications as prescribed, and scheduling regular follow-up appointments with the patient’s primary provider to monitor progress or identify and treat any complications of disease or therapy. INCREASING KNOWLEDGE The patient needs to understand the disease process and how lifestyle changes and medications can control hypertension. The nurse needs to emphasize the concept of controlling hypertension rather than curing it. The nurse can encourage the patient to consult a dietitian to help develop a plan for improving nutrient intake or for weight loss. Explaining that it takes 2–3 mo for the taste buds to adapt to changes in salt intake may help the patient adjust to reduced salt intake and consider herbs and seasonings that add flavor without adding salt. The patient should be advised to limit alcohol intake, and tobacco and nicotine should be avoided because anyone with high blood pressure is already at risk for heart disease, and use of cigarettes and electronic nicotine delivery systems (ENDS) including e-cigarettes, e-pens, e-pipes, e-hookah, and e-cigars, amplifies this risk. PROMOTING EFFECTIVE HEALTH MANAGEMENT https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IWsgl87YCND5MlxcaDR%2bIXwVK92JaTnVop0r%2bp7eT… 2/5 10/17/23, 4:06 PM Realizeit for Student Deviating from the therapeutic health management program is a significant problem for people with hypertension and other chronic conditions requiring lifetime management. Blood pressure control is achieved by only 54% of patients (Whelton et al., 2017). Rates of blood pressure control are lowest among Mexican American men, at only 39% overall (Himmelfarb et al., 2016). Effective health management is more likely, however, when patients actively participate in selfcare, including self-monitoring of blood pressure and diet, possibly because patients receive immediate feedback and have a greater sense of control. Nurse-led wellness programs that are tailored to the patients’ behaviors and eating and exercise practices are more effective than generic programs. Patients with hypertension must make considerable effort to adhere to recommended lifestyle modifications (see Table 27-2) and to take regularly prescribed medications. The effort needed to follow the therapeutic plan may seem unreasonable to some, particularly when they have no symptoms without medications but do have side effects with medications. Continued education and encouragement are usually needed to enable patients to formulate an acceptable plan that helps them live with their hypertension and adhere to the treatment plans. Compromises may have to be made about some aspects of therapy to achieve higher-priority goals. The nurse can assist with behavior change by supporting patients in making small changes with each visit that moves them toward their goals. Another important factor is following up at each visit to see how the patient has progressed with the plans made at the prior visit. If the patient has had difficulty with the plan, the patient and nurse should work together to develop an alternative or modification that the patient believes will be more successful. Support groups for weight control, smoking cessation, and stress reduction may be beneficial for some patients; others can benefit from the support of family and friends. The nurse assists the patient to develop and adhere to an appropriate exercise regimen, because regular activity is a significant factor in reducing blood pressure (Himmelfarb et al., 2016). Educating Patients About Self-Care. The therapeutic regimen is the responsibility of the patient in collaboration with the primary provider. The nurse can help the patient achieve blood pressure control through education about managing blood pressure (see earlier discussion), setting goal blood pressures, and providing assistance with social support. Involving family members in education programs https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IWsgl87YCND5MlxcaDR%2bIXwVK92JaTnVop0r%2bp7eT… 3/5 10/17/23, 4:06 PM Realizeit for Student enables them to support the patient’s efforts to control hypertension. The American Heart Association and the National Heart, Lung, and Blood Institute both provide printed and electronic patient education materials. Providing written information about the expected effects and side effects of medications is important. When side effects occur, patients need to understand the importance of reporting them and to whom they should be reported. Patients need to be informed that rebound hypertension can occur. This phenomenon is characterized by a pathologically high blood pressure exhibited by patients who suddenly stop taking prescribed antihypertensive medications. Thus, patients should be advised to have an adequate supply of medication, particularly when traveling and in case of emergencies such as natural disasters. If traveling by airplane, patients should pack the medication in their carry-on luggage. All patients should be informed that some medications, such as beta-blockers, might cause sexual dysfunction and that other medications are available if problems with sexual function or satisfaction occur. The nurse can encourage and educate patients to measure their blood pressure at home. This practice involves patients in their own care and emphasizes that failing to take medications may result in an identifiable rise in blood pressure. Patients need to know that blood pressure varies continuously and that the range within which their pressure varies should be monitored. Gerontologic Considerations Adherence to the therapeutic program may be more difficult for the older adult. The medication regimen may be difficult to remember, and the expense can be a challenge. Simplification of the medication regimen to treatment with a single antihypertensive medication, if possible, is helpful. Many older adults are taking other prescription and over-the-counter medications, and verifying that there are no medication interactions is important. As noted previously, communitydwelling, ambulatory older adults should be carefully monitored for adverse effects of prescribed antihypertensive medications, which can include falls, orthostatic hypotension, and reduced renal function (e.g., the nurse should assess patient’s urinary output and weight for changes from baseline). Special care must be taken to ensure the older patient understands the medication regimen, can see and read the instructions, open the medication container, and can get the prescription refilled. The older adult’s family or caregivers should be included in the educational program so that they understand the patient’s needs, can encourage adherence to the treatment plan, and know when and whom to call if problems arise or further information is needed. Continuing and Transitional Care. Regular follow-up care is imperative so that blood pressure control can be achieved. A history and physical examination should be completed at each clinic visit. The history should include all data pertaining to any potential problem, specifically https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IWsgl87YCND5MlxcaDR%2bIXwVK92JaTnVop0r%2bp7eT… 4/5 10/17/23, 4:06 PM Realizeit for Student medication-related problems such as orthostatic hypotension (experienced as dizziness or lightheadedness on standing). The patient should also bring a home blood pressure log and their own home blood pressure machine to verify accuracy and technique of home blood pressure monitor use. Patients and caregivers should also be given updated information at each visit on blood pressure medication, side effects, and important side effects to report immediately, such as low blood pressure or orthostatic hypotension. Low blood pressure readings can be due to impaired cardiovascular reflexes brought on by diuretics and other medication interactions. MONITORING AND MANAGING POTENTIAL COMPLICATIONS Target organ damage is a potential adverse effect of long standing or poorly controlled hypertension. When the patient returns for follow-up care, all body systems must be assessed to detect any evidence of vascular damage. An eye examination with an ophthalmoscope is particularly important because retinal blood vessel damage indicates similar damage elsewhere in the vascular system. The patient is questioned about blurred vision, spots in front of the eyes, and diminished visual acuity. The heart, nervous system, and kidneys are also carefully assessed. Any significant findings are promptly reported to determine whether additional diagnostic studies are required. Based on the findings, medications may be changed to improve blood pressure control. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IWsgl87YCND5MlxcaDR%2bIXwVK92JaTnVop0r%2bp7eT… 5/5