Ms. Profitt: Health Education for Hypertension

This is an educational curriculum for the patient with Hypertension. It may be given in one encounter, but would be better with multiple sessions so that patient comprehension can be monitored, and topics can be reinforced. The content in this post is based upon The Correctional Nurse Educator class entitled Chronic Care Patient Education: Hypertension in Corrections.

Today Ms. Profitt, a 50 year old female, arrives to your Nurse Sick Call for patient education for her new diagnosis of Hypertension. She told the nurse practitioner that she didn’t know anything about high blood pressure, except that she thought it was related to eating salty foods. She also has never taken medication every day. She is a little anxious today, stating that she is afraid she will not remember everything.

HYPERTENSION

Hypertension is also called high blood pressure.  Most people with hypertension feel fine and may not even know that they have high blood pressure.  High blood pressure has been called “The Silent Killer,” since it may be life threatening if left untreated.  However, with proper care, hypertension can be adequately treated in most patients.  Most people with high blood pressure (about 95%) have essential hypertension, meaning the cause is not known. The other five  percent have secondary hypertension, which means a specific cause can be identified.

DIAGNOSIS

Blood pressure measurement is simply measuring the pressure required to force blood through blood vessels.

Systolic blood pressure, the top number, measures the force while the heart pumps.  A normal, healthy systolic blood pressure is 120 or below.

Diastolic blood pressure, the bottom number, measures the force at rest – that is, in between heart pumps.  A normal, healthy diastolic blood pressure is 80 or below.

While the diastolic blood pressure stays at about the same level all the time, systolic blood pressure changes frequently depending on day-to-day activities and stress.  An occasional elevated number may not indicate high blood pressure.  It takes several repeatedly elevated pressures to diagnose hypertension.  When blood pressure is too high (either systolic or diastolic or both) and remains high, blood cannot flow freely through the arteries and the heart has to pump harder.

STAGES

 **It is important to note that the JNC8 guidelines from 2014 are different, but since the Centers for Disease Prevention and Control use the 2017 guidelines, this education session will as well. The guidelines used at your facility may be different.

In 2017, the American College of Cardiology and the American Heart Association published new guidelines for hypertension management and defined high hypertension as a blood pressure at or above 130/80 mmHg. Stage 2 hypertension is defined as a blood pressure at or above 140/90 mmHg.  

“Normal” or “good” blood pressure is below 120 mm Hg systolic and below 80 mm Hg diastolic.  This may also be called “optimal” blood pressure.

“Prehypertension” blood pressure is a systolic between 120 mm Hg and 129 mm Hg and a diastolic less than 80 mm Hg.

“Stage 1 Hypertension” is a systolic of 130 mm Hg to 139 mm Hg OR a diastolic of 80 mm Hg to 89 mm Hg.

“Stage 2 Hypertension” is a systolic greater than or equal to 140 mm Hg OR a diastolic greater than or equal to 90 mm Hg

CONSEQUENCES OF UNCONTROLLED HYPERTENSION

The most severe consequences of hypertension are stroke, kidney failure, congestive heart failure, heart attack and blindness.

Stroke occurs when the arteries in the brain become blocked. Without blood, and the oxygen and nutrients carried by the blood, brain tissue dies and the functions controlled by that part of the brain are lost. A stroke can also occur from too much pressure in blood vessels that burst and bleed into the brain. The consequences, or long-term effects of a stroke can range from paralysis on one side of the body, including the face, eyes and mouth; difficulty talking, eating, or doing simple daily activities to total paralysis, difficulty breathing, and death.

Kidney failure occurs when tiny vessels in the kidneys become blocked. Because the kidneys shrink and become irregular, they can no longer remove the waste products of the body. As kidney failure worsens, the body is slowly poisoned and dialysis or kidney transplant may be necessary.

Congestive heart failure (CHF) occurs when the body is not getting rid of enough fluid and the excess fluid ends up in the lungs and around the heart. Several things happen: the heart has to work extra hard and the person becomes short of breath, sometimes with a cough. When the heart continues to over-work, it becomes enlarged and works less efficiently. Fluid is retained around the ankles and the person may become weak. If the patient does not receive treatment, the heart will stop working. The heart muscle slowly loses its elasticity and the heart enlarges and becomes weaker.

Heart attack, also called myocardial infarction (MI), occurs when the blood vessels that supply the heart muscle itself with blood and oxygen become blocked. Often the heart gives warning that something is going wrong by producing angina (or chest pain). Nitroglycerin is taken by mouth to control the chest pain. If chest pain occurs and blood pressure is not controlled, there is a risk of heart attack and death.

TREATMENT: LIFESTYLE CHANGES

Lifestyle changes are the first line of treatment for hypertension and include the following:

Weight reduction:  Losing weight may lower blood pressure to a normal level or may allow a reduction or elimination of medication by a doctor.  In fact, being overweight may even make it more difficult for blood pressure medication to work.  Check with a health care provider to determine an ideal body weight.

Aerobic exercise makes the heart and blood vessels function more effectively and can assist in weight reduction.  Walking or stationary bicycling for at least 30 minutes three to five times a week are good aerobic choices.  Avoid muscle building exercises, such as weight lifting, which may increase blood pressure. Check with a health care provider before starting any exercise program.  Begin exercise slowly and increase the level of exercise gradually – don’t overdo it.

Restrict sodium intake to between 3 and 4 grams per day (that’s about 1.5 to 2 teaspoons of salt) including both the salt added to food and the salt already present in food.  Commercially prepared food (processed meat, flavored rice mixes, and instant pasta mixes) contain a large amount of salt.  Eliminating added salt from the diet is an important way to lower blood pressure.

Restrict dietary fat:  Eating too much fat leads to weight gain.  Some fats, particularly animal fats, contain cholesterol which can lead to plaque buildup inside blood vessels which can lead to high blood pressure and other serious conditions.

Stop smoking:  Smoking damages and constricts blood vessels and is, by itself, a risk factor for stroke and heart disease.  In fact, smoking a cigarette within 20 minutes before a blood pressure is taken can actually cause a higher reading.

Avoid extra caffeine:  Drinking more than 2 or 3 cups of coffee or other caffeinated beverage each day may raise blood pressure.  Caffeine can quickly raise blood pressure, but it generally does not keep it elevated.  Try substituting decaffeinated coffee, tea, or soda.

Consult with a health care provider on how to plan and proceed with these lifestyle changes that will not only help lower your blood pressure, but will improve your overall well-being.

TREATMENT: MEDICATION

Your provider may prescribe medications if lifestyle changes alone do not control your blood pressure or if your blood pressure is exceptionally high.  The healthcare provider will explain the medication, including side effects, and will closely monitor how well it controls blood pressure.  Most people have few side effects after beginning medications; however, if different or worse symptoms appear after taking the medication, tell a health care provider right away.  High blood pressure medication only works when it’s taken as directed.  So follow the instructions and take medication at the same time every day.  Never stop taking a medication without a doctor’s consent.

Suddenly stopping high blood pressure medication can cause a sudden, life-threatening increase in blood pressure. The medication selected will be based on factors which make it more likely that the medication will work to lower the blood pressure.  These factors include race, sex, age, and the presence of other medical conditions.

There are several major groups of high blood pressure medications:

Diuretics or “water pills” such as Hydrochlorothiazide remove excess fluid from the body, thus requiring less work by the heart.  Diuretics also remove salts from the body. While it is helpful to remove excess sodium, some diuretics can also remove potassium. In order to avoid losing too much potassium, adequate fruits and vegetables should be consumed.  Diuretics are often the first medication used to treat hypertension, and can be extremely effective.

Beta-Blockers such as Metoprolol are also frequently used as early treatment for high blood pressure. Beta blockers help your heart beat slower and with less force. As a result, your heart pumps less blood through your blood vessels. This causes your blood pressure to go down.  Some beta blockers are used to treat high blood pressure when there are other problems present such as angina, heart beat irregularities and palpitations, or after a heart attack. Some beta-blockers are avoided in the presence of asthma because they may worsen wheezing and breathing problems. It is important to check your pulse before administering a beta blocker, and if it is below 60, you should not take the medication and let your healthcare provider know.

Angiotensin Converting Enzyme Inhibitors (ACE inhibitors) such as Lisinopril are particularly effective when used in diabetics to help slow the progression of kidney damage.  ACE inhibitors keep your body from making a hormone called angiotensin II. This hormone normally causes blood vessels to narrow. ACE inhibitors prevent this, so your blood pressure goes down.  ACE inhibitors are also used with congestive heart failure and to decrease the development of heart failure.

Angiotensin II Receptor Blockers (ARB) are newer blood pressure medicines that protect your blood vessels from the angiotensin II hormone. As a result, blood vessels relax and widen, and your blood pressure goes down. An example of an ARB is valsartan.

Calcium Channel Blockers such as Amlodipine are often used in the presence of angina, rapid heart rate, and erratic heart rate.  Calcium channel blockers keep calcium from entering the muscle cells of your heart and blood vessels. This allows blood vessels to relax, and your blood pressure goes down.

MEDICATION INTERACTIONS

Certain medications can affect blood pressure.  These include:

Decongestants or cold preparations containing pseudoephedrine or phenylpropanolamine.

Certain pain and anti-inflammatory medications can cause you to retain water, creating kidney problems and increasing your blood pressure. Examples include Indomethacin (Indocin, others), Acetaminophen (Tylenol, others), Aspirin, naproxen sodium (Aleve, Anaprox) and Ibuprofen (Advil, Motrin IB, others), and Piroxicam (Feldene).

Antidepressants work by changing your body’s response to brain chemicals, including serotonin, norepinephrine and dopamine, which affect your mood. They can also cause an increase in blood pressure. Examples include:
• Venlafaxine (Effexor XR)
• Monoamine oxidase inhibitors
• Tricyclic antidepressants
• Fluoxetine (Prozac, Sarafem, others)

Almost all birth control pills, patches and vaginal rings include warnings that high blood pressure may be a side effect. This occurs because the hormones cause a narrowing of the smaller blood vessels. The risk of high blood pressure is greater if you’re older than age 35, overweight or a smoker.

Immunosuppressant medications can raise the blood pressure mainly because of their affect on the kidneys. Both cyclosporine (Neoral, Sandimmune, Gengraf) and Tacrolimus (Prograf, Envarsus XR, Astagraf) may increase your blood pressure.

Stimulants like methylphenidate (Ritalin, Concerta) can cause your heart to beat faster or irregularly, which may raise your blood pressure.

Caffeine blocks a hormone that keeps your blood vessels open, allowing blood to easily pass through. This may temporarily increase blood pressure. This may occur with the ingestion of 200 to 300 milligrams of caffeine. Caffeine may also cause you to produce more cortisol and adrenaline, which speeds up blood flow, and can cause a a sharp increase in blood pressure. However, there isn’t enough evidence to prove that caffeine raises your blood pressure long term. Examples of caffeine-containing medications and products include caffeine pills like Vivarin; coffee; and Energy Drinks like Red Bull.

It is important to tell healthcare staff if you are taking any herbal supplements because some can raise your blood pressure or interact with your blood pressure medication. Remember that although herbal supplements are “natural”, they may not always be safe. Examples of herbal supplements that can affect your blood pressure or blood pressure medications include:

• Arnica (Arnica montana)
• Bitter orange (Citrus aurantium)
• Ephedra (ma-huang)
• Ginseng (Panax quinquefolius and Panax ginseng)
• Guarana (Paullinia cupana)
• Licorice (Glycyrrhiza glabra)
• St. John’s wort (Hypericum perforatum)

Be sure to take breaks often and question the patient about the content just reviewed to verify learning. If the content is provided in multiple learning sessions, verify learning from past sessions has been retained at the beginning of the session. Use principles of adult learning, like those found in The Correctional Nurse Educator Class entitled Patient Education for the Correctional Nurse.

Be sure to read our patient education posts at CorrectionalNurse.Net