Objectives

The patient with risk factors for hypertension will be able to:
Identify personal risk factors that increase the likelihood of developing (or worsening) hypertension
as evidenced by completion of a personal inventory survey and interview with healthcare provider.
Define the essential components of lifestyle modifications to reduce risk of developing (worsening)
hypertension based on risk factors identified in the personal survey as evidenced by discussion
with healthcare provider.
Develop a personal plan to achieve lifestyle modification goals based on risk factors identified in
personal survey as evidenced by setting of achievable mutually agreed upon goals that will be
assessed with each visit .
Teaching Plan
Essential to the success of any treatment plan is an understanding of the process you are hoping to
interrupt, reasons why it is important to avoid or reduce the disease and the effectiveness of the
suggested strategies. Essential to the success of your teaching is the patients readiness, willingness and
ability to learn (Patient Teaching, 2002). To achieve the desired learning outcome you will most likely need
to prioritize the topics around the patients needs and readiness.
Outline of the Teaching Plan
1. Overview of hypertension
1. Risk factors modifiable vs non modifiable.
2. Disease progression complications
3. Effective non-pharmacologic interventions
4. When pharmacologic intervention becomes necessary
2. Identification of personal risk factors
1. Assessment questions that focus on risk factor identification
2. Review of results with provider
3. Planning interventions
1. Achievable goals
2. Timeline for follow-up
Implementation
Depending on your setting one of two approaches may be taken. Individual counseling and teaching is
probably the most reasonable approach in most practice settings, however it is also very possible to hold a
general seminar for patients in the practice to provide the basic information on hypertension and risk
factors with the follow up in the office being the personal assessment of risk and plan. Funding for the
latter approach can be sought from drug company representatives who can sponsor light refreshments,
heart healthy of course, in a central location with easy access.
For individual counseling I would ask the patient to complete a questionnaire prior to the visit that answers
questions regarding risk factors, similar to the way we ask patients to complete a health history form. A
one on one review of their responses would form the basis of the teaching plan and evaluation. Because of
time constraints in individual counseling and private practice you will most likely have to provide the
teaching over a series of visits, so the initial visit would have to focus on prioritizing the list of controllable
risk factors. In place of a questionnaire the assessment questions presented in the teaching plan can be
asked as part of a health history interview during the visit.
Printed material to assist your teaching is available through American Heart Association. These patient
information flyers are generally one page with simple explanations of the topic and room for the patient to
write questions or personal information. It can be copied for individual patient use.
Overview of hypertension
To be successful in reducing hypertension patients should understand what high blood pressure is and the
effects of untreated high blood pressure on overall health and well-being. It is also important to
demonstrate the relationship that high blood pressure has with the development of other disease.
Providing simple explanation through one-on-one discussion with examples is important. Define the values
that constitute hypertension . Be specific that the diagnosis is not based on one reading Explain the
patients own blood pressure recording and advise the patient of the need for follow-up according to the
American Heart Associations recommendations for follow-up based on initial blood pressure measurements
for adults. Patients with systolic pressure 130-139 and diastolic pressure 85-89 with other cardiovascular
risk factors or target organ disease should be followed closely. If there is no known cardiovascular disease
or target organ disease present the patient should begin with lifestyle modifications. Providing the patient
with the American Heart Association handout- What is high blood pressure? ( AHA, 2000) or another
equivalent handout.
At the initial visit provide information on specific risk factors. Using the American Heart Association
handout What are Risk factors for Heart Disease and Stroke? (AHA, 2000), separate for the patient what
risk factors can be changed versus what there is no control over. Age and genetics are not something that
you can change but smoking, physical inactivity, high cholesterol, overweight are things you can control.
Individual discussion should help them to focus on what is realistic to change. Be sure to include that
lifestyle modification alone can be successful but that it may be necessary to couple lifestyle modification
with drug therapy (JNC VI, 1997). Most often this is related to the combination of risk factors for each

individual patient. Be clear that what works for one patient may not work for another because of the
combination of identified risk factors. It is also important for patients to understand that blood pressure
elevations are not inevitable consequences of aging. Through healthy lifestyle even with identified risk
factors onset of the disease may be delayed. Research has indicated that even modest salt reduction and
weight loss has enabled a large number of older adults to discontinue their antihypertensive medicine
(Whelton, 1998). Studies have also demonstrated that a nutritional program of weight loss, sodium
restriction and alcohol restriction achieved a 39 % success rate in reducing blood pressure without drugs
( Stamler, 1987).
As an integral part of the education visit should provide information through discussion on the results of
untreated high blood pressure. Onset of cardiovascular disease, stroke, diabetes, hyperlipedemia are all a
greater risk when coupled with hypertension. Give the patient handouts specific to their risk factors, to
reinforce this information.
Non pharmacologic therapy or lifestyle modifications is the initial approach for many young patients with
identified risk factors. It involves regular aerobic activity, diet, weight reduction, stress management,
reduction of sodium intake, and avoidance of excessive alcohol. After the discussion about what
hypertension is and its consequences when left untreated, review with the patient the results of their
personal inventory. You can then discuss lifestyle modification topics based on prioritization of personal
risk factors, and lifestyle assessment. It is important to set the patient up for success, i.e. if he is going to
be traveling for the next month it might not be the best time to start a diet, but could be reasonable to
increase physical activity.
Weight Loss
Assessment question: Do you know your ideal body weight?
Help the patient determine their ideal body weight by checking body mass index (BMI) and waist
circumference. At the visit the patients height and weight can be measured, as part of the assessment you
can identify what the patients BMI is and show them via a chart where they are in the classifications. BMI
is determined by multiplying weight in pounds by 703 the dividing by height in inches. There are programs
available for downloading onto a PDA (personal digital assistant) that have the automatic calculator and
the classification tables to make this easier and take up less time in the process. BMI alone does not
identify risk because weight from muscle or from water retention may overestimate body fat. Normal BMI
should be between 18.5 and 24.9.
Measure the patients waist circumference as part of the visit and document it in the record. Waist
circumference is also a good measure of need for weight loss. Too much body fat in the abdomen
increases risk of cardiovascular disease. For women a waist circumference of more than 35 inches and
men greater than 40 inches is considered high. Weight loss of just ten pounds can lower blood pressure
(Lowering Blood Pressure, 2003).
If the patient falls into the overweight range stress the importance of losing weight slowly. Encourage
patient to lose no more than to 2 pounds per week and a reasonable goal is 10 % of their current
weight. One pound equals 3,500 calories so to lose one pound per week the patient will need to eat 500
calories less per day or burn 500 calories per day. Provide a handout the gives meal plan examples to aid
the patients decision making. The best approach would be to eat less and be more physically active. Be
careful to stress that serving sizes/amount is as important as what is eaten.
Physical Activity
Assessment question: On a daily basis how much physical activity do you do?
Moderate level physical activity on a daily basis will not only help with weight loss but can reduce blood
pressure and the risk of cardiovascular disease. Moderate level activity thirty minutes a day for most days
of the week is recommended. To start the patient can even divide the thirty minutes into three ten-minute
periods. Discuss with the patient simple things to try in the beginning ,use the stairs instead of the
elevator, park you car at the far end of the parking lot in the morning. Give the patient the American Heart
Association pamphlet Just Get Moving. (AHA, 2000). At a follow up visit discuss other examples of
moderate level physical activity including: walking briskly, mowing the lawn, golf- walking to course,
swimming with moderate effort, cycling at moderate speed of 10 miles per hour, general cleaning, home
repair such as painting (Lowering Blood Pressure ,2003). Together with the patient, develop a plan for
them to incorporate moderate activity into their daily routine so they gradually increase the time spent in
physical activity to 60 minutes per day, everyday (Control your Risks, 2003). Give them a log to keep to
document the activity and ask them to bring it to subsequent visits.
Avoid Excessive Alcohol
Assessment question: What is your routine alcohol intake?
Many studies suggest that small amounts of alcohol intake can reduce risks of cardiovascular disease.
Drinking too much alcohol can raise blood pressure. Some studies say that drinking more than 3-4 ounces
per day of 80 proof alcohol will raise blood pressure (Control your risk, 2003). Alcohol consumption should
be limited to no more than 1-2 drinks per day. Remind the patient that if he/she is dieting alcohol is high in
calories. Define for the patient what constitutes a drink: 12 ounces of beer (150 calories), 5 ounces of wine
(100 calories), 1 ounces of 80 proof whiskey (100 calories ) ( Lowering Blood Pressure, 2003). Help the
patient fit their alcohol intake into their diet plan.
Eat Heart Healthy
Assessment questions: What is your sodium intake? Do you know what foods you eat regularly are high in
sodium?
Research shows that a healthy eating plan can not only help reduce weight but can lower the risk of

developing high blood pressure and reduce already elevated pressure (Control your risk factors, 2003). A
key to healthy eating is reducing sodium intake. In general we eat more sodium than we need on a daily
basis. 2.4 grams of sodium is the most we should ingest in a day. That equals approximately one teaspoon
of salt daily (Control your risk factors ,2003).
Because sodium is found naturally in many products an important part of patient education is teaching the
patient and family how to read labels to make good choices regarding the foods they include in their diet.
Look for labels that indicate: sodium free, low sodium, light sodium, reduced sodium. Teach comparing
labels, a good choice to use is frozen versus canned vegetables. Have the patient identify which is the
better choice.
To help the patient plan an overall better diet. Consider teaching the DASH diet. Dietary Approches to Stop
Hypertension (DASH) is from a clinical study that looked at the effects of nutrients in food on blood
pressure. This study found that blood pressure was reduced by focusing on low saturated fat, total fat and
cholesterol and adding foods rich in fruits, vegetables and low fat dairy products (Control your risk factors,
2003).
Through discussion and example teach the patient that because the DASH diet is higher in fruits,
vegetables and grain it is normal as you begin to have some bloating and diarrhea. A good way to avoid or
minimize that would be to change gradually, i.e. add a vegetable or fruit serving at lunch or dinner. Spread
out the servings throughout the day and add fruits as snacks. Treat meats as one part of the meal, try for
two or more meatless meals per week (Lowering blood pressure, 2003).
Provide the patient with information on calories, food substitutions, and foods that are rich in certain
nutrients. There are many good dietary handouts that can reinforce this information. As the nurse you can
choose one that meets the needs of your population. Being successful with dietary changes means an
understanding of what it is you eat each day, so you can make the needed changes. Initially ask the
patient to keep a diary of what they eat each day. This can provide a starting point for simple but
successful dietary changes and can aid in the evaluation of their success.
The caloric intake on the DASH plan can be easily altered so that the overall diet becomes more focused
on healthy eating, but reduced caloric intake. An example that can be easily shared with patients can be
found on http://www.nhlbi.nih.gov.
Other Risk factor Adjustments
Assessment questions: Are you a smoker? Have you ever been a smoker? How much do you/did you
smoke? When did you quit?
Smoking is a key risk factor for the development of heart attack and stroke. Most studies suggest smoking
cessation quickly lowers your risk factors within a year after stopping (Jekel, 2001). If the patient is a
smoker explore alternatives for smoking cessation. Look for strategies that will work for the individual, ask
the patient about personal preferences needs, related to strategies.
Stressors
Assessment question: Are you under presently under stress?
Recognizing the stressors in your everyday activities is extremely important to minimizing the effects that
stress has on your blood pressure management. Discuss with the patient the importance of relaxing for
short periods throughout the day. Demonstrate relaxation techniques. Have the patient return
demonstrate for you these techniques. Many patients will have to be taught to focus on relaxation
techniques, and how to incorporate them into their daily routines. Have the patient identify for you their
daily routine. Show them where they might fit in some relaxation time. Again as you teach for the
information to be useful you need to focus on what is realistic for the patient and what will make them
most successful (Patient Teaching, 2002).
Other medications
Explore with the patient what over the counter medications (OTC) they might routinely use. There are
many preparations that will increase blood pressure or that will interfere with medications used to treat
high blood pressure. Classes of drugs to be aware of include, steroids, NSAIDS, nasal decongestants, cold
remedies, diet pills, tricyclic antidepressants, and MAO inhibitors. Make sure the patient understands the
importance of care when adding OTC medications. An important point to make in addition is the sodium
content of many OTC drugs (Herfindal, 2000). They should be encouraged to contact their primary care
provider before starting any OTC preparations. Another strategy to reduce the potential adverse side
effects for patients with hypertension risk is to provide a list of acceptable OTC remedies for common
ailments.
Patient Compliance
Success to your teaching plan is measured by patient compliance to the prescribed treatment plan. Your
teaching should be set up with goals that will enhance compliance. You need to make the assessment with
the patient and family to focus on maximum compliance. Each visit should incorporate a review of the
goals that were set and examples of how the patient is meeting or not meeting those goals. When you are
following up during your visit to assess the success, if the patient has not followed the plan ask for the
patients help to identify what is preventing him from being successful and revise the plan based on
revised goals (Solomon, 2000). If the patient has even had small successes it is important to congratulate
them and focus on those positives as you reformulate goals.
Provide the patient with resources to help support his plan. Remember that there are many references out
there in the internet. Some are not so accurate, that may have just the opposite effect you and the patient
are trying to achieve. By providing the patient with a take home list of resources you can be sure the
information is the right information for the patient.

Websites for the Patient

http://www.nhlbi.nih.gov - provides many pamphlets for consumers on blood pressure management.
http://www.kidney.org - provides basic information on blood pressure management and end organ
disease.
http://www.stroke.org - provides basic hypertension information and how untreated HTN leads to other
diseases
http://www.4women.org - provides hypertension related information female specific.
After you begin your teaching plan it is important for compliance and success to evaluate where you are.
This allows you and the patient to reset goals and stay on target. It will ensure greater success (Patient
Teaching, 2001). Evaluation of lifestyle changes should be part of each visit to help the patient stay on
track. Follow-up visits are planned based on patient needs. For example if you have a patient with
elevated blood pressure and you are using lifestyle modification as an initial treatment plan you may want
an every two week follow-up. For many patients a more realistic follow up is monthly. Evaluation and
revision of the teaching plan is part of every visit.
References
American Heart Association (2000), Selected Patient Education References, Dallas Texas:
http://www.americanheart.org
Buttaro, T. M., Trybulski, J., Bailey, P. P., & Sandberg-Cook, J., Primary Care A Collaborative Practice.
(1999) St Louis Missouri: Mosby.
Duluth, J. (2003). Prevention of HTN necessary and feasible with lifestyle modifications. Geriatrics, 58(1),
20-23.
Facts about lowering blood pressure (2003) [Data file]. National Heart Lung and Blood Institute, National
Institutes of health. Available from http://www.nhlbi.nih.gov.
Herfindal, E. T., & Gourley, D. R.. Textbook of Therapeutics Drug and disease Management (7th ed.)
(2000) Philadelphia, Pa: Lippincott Williams and Wilkins.
Manson, J. E., & Bassuk, S. S..(2003) Obesity in the United States: A fresh look at it's high toll. The
Journal of the American Medical Association, 289(2), 229-233.
Murray, C. J., Lauer, J. A., Hutubessy, R. C., & Niessen, L. (2003). Effectiveness and Costs of interventions
to lower systolic blood pressure and cholesterol: A global and regional analysis on reduction of
cardiovascular disease risk. The Lancet, 361(9359), 717-731.
Patient Teaching Reference Manual (2002). Springhouse, Pa: Springhouse Corp.
Reaven, G. M..(2003). Importance of identifying the overweight patient who will benefit the most by
losing weight. Annuals of Internal Medicine, 138(5), 420-427.
Solomon, J. R. M. (2000). Promoting Compliance Tips for the Healthcare Professional. In Hypertension
Disease Management Guide (pp. 501-504). Montvale N.J.: Medical Economics Company.
The Sixth Report of the Joint National Committee on Prevention, Detection , evaluation and treatment of
High Blood Pressure (JNC VI) (1997). Retrieved February 23, 2003, from National Heart Lung and Blood
Institute National Institute of Health: http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm