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Hypertension
Cindy Bolton
Team Leader, Development Panel
Guideline Development
Planning
Development
Evaluation
Dissemination
Revision
Hypertension
Is the most important modifiable risk factor for stroke.
High blood pressure increases the risk of ischemic
heart disease by 3-4 fold
The incidence of stroke increases approximately 8
fold in persons with definite hypertension
It has been estimated that 40% of cases of acute MI
or stroke are attributable to hypertension
Classification of Hypertension:
WHO/ISH*
Category
Systolic
Diastolic
Optimal
Normal
High Normal
< 120
<130
130-139
<80
<85
85-89
140-159
140-149
90-99
90-94
160-179
100-109
180
110
140
140-149
<90
<90
Systolic
< 120
Diastolic
<80
Pre-hypertensive
120-139
80-89
Hypertensive
140
90
Stage 1
140-159
90-99
Stage 2
160
100
Practice
Recommendations
Cuff size
inappropriate cuff size is the most
frequent error in clinic-based
BP assessment
From 18 to 26
9 x 18 (child)
From 26 to 33
12 x 23 (standard adult
model)
From 33 to 41
15 x 33 (large, obese)
More than 41
18 x 36 (extra large,
obese)
Recommended Technique
for Measuring Blood Pressure
Standardized technique:
Diagnostic algorithm
Elevated
Elevated Out
Out of
of the
the
Office
Office BP
BP
measurement
measurement
Elevated
Elevated Random
Random
Office
Office BP
BP
Measurement
Measurement
Hypertension
Hypertension Visit
Visit 11
Hypertensive
Hypertensive
Urgency
Urgency //
Emergency
Emergency
BP
BP Measurement,
Measurement,
History
and
History and Physical
Physical examination
examination
Diagnostic
Diagnostic tests
tests ordering
ordering
at
at visit
visit 11 or
or 22
Hypertension Visit 2
within 1 month
Target
Target organ
organ damage
damage
or
or Diabetes
Diabetes
or
Chronic
or Chronic Kidney
Kidney Disease
Disease
or
or BP
BP 180/110?
180/110?
No
BP:
BP: 140-179
140-179 // 90-109
90-109
Yes
Diagnosis
Diagnosis
of
of HTN
HTN
Diagnostic algorithm
BP:
BP: 140-179
140-179 // 90-109
90-109
24-h
24-h ABPM
ABPM (If
(If available)
available)
Clinic
Clinic BP
BP
S/H
S/H BPM
BPM (If
(If available)
available)
Hypertension visit 3
160 SBP or
100 DBP
< 160 / 100
Diagnosis
of HTN
or
ABPM or S/H
BPM if available
Awake
Awake BP
BP
<< 135/85
135/85 or
or
24-hour
24-hour
<< 130/80
130/80
Awake
Awake BP
BP
135
135 SBP
SBP or
or
85
85 DBP
DBP or
or
24-hour
24-hour
130
130 SBP
SBP or
or
80
DBP
80 DBP
Continue to
follow-up
Diagnosis
of HTN
< 140 / 90
Diagnosis
of HTN
Continue to
follow-up
<< 135/85
135/85
135/85
135/85
or
Continue to
follow-up
Diagnosis
of HTN
Acute Care
Diagnosis can be made
During first visit if hypertensive emergency (see
Appendix G)
During second visit if TOD (retinopathy, renal
disease, stroke/TIA, MI), diabetes
Initiation of
Pharmacotherapy
SBP/DBP mmHg
140/90
Target
SBP/DBP
160
<140
Diabetes
130/80
<130/80
Renal disease
130/80
<130/80
125/75
<125/75
Diastolic systolic
hypertension
Isolated systolic
hypertension
<140/90
Intervention
Target
Sodium reduction
65-100 mmol/day
Diet
DASH diet
Exercise
Weight loss
Waist
circumference
Alcohol reduction
Smoking
Targeted Change
SBP/DBP
Sodium reduction
100 mmol or 1
tsp/day
5.8/-2.5
Dietary Patterns
DASH diet
11.4/-5.5
Exercise*
3 times/week
-7.4/-5.8
Weight loss
4.5 kg
7.2/-5.9
Alcohol reduction
2.7 drinks/day
4.6/-2.3
Source: Miller ER et al. Results of aggregate and meta analysis of short term trials.
J Clin Hyper 1999;3:191-8.
* Exercise and Hypertension, Medicine and Science in Sports & Exercise 2004;36(3).
Medications
Nurses will:
Obtain clients medication history (prescribed, OTC, herbal and
illicit drug use)
Adherence
Adherence is the extent to which a clients behaviour
(taking medication, following a diet, modifying habits
or attending clinic visits) coincides with health care
advice.
Adherence is the single most important modifiable
risk factor that compromises treatment outcome
(WHO, 2003, Haynes et al., 2003)
Assessment of Adherence
Nurses will:
Endeavour to establish a therapeutic relationship
with clients
Explore clients expectations and beliefs regarding
hypertension management
Assess adherence to treatment plan at every
appropriate visit
Promotion of Adherence
Nurses will:
Documentation
Nurses will:
Document and share comprehensive information
regarding hypertension management with the client
and health care team.
Appendices
Glossary
Medication costs and programs
Stages of change model
Motivational interviewing
Client education for home BPM
Hypertensive urgencies/emergencies
DASH diet, reducing sodium and the DASH diet, recording food
habits and DASH
Canadian Body Weight classification system
Assessing alcohol consumption
Smoking Cessation Brief intervention
How vulnerable are you to stress?
Summary of medication classes prescribed for hypertension
BP follow up algorithm
Educational resources and web sites
www.rnao.org/bestpractices
A limited number are available free from
HSFO
csor@hsf.on.ca