Clinical Cases in High Blood Pressure - Case Study Example

Hypertension Hypertension Introduction High blood pressure or what is called hypertension is a medical in which narrowed arterial vessels increase resistance to the flow of blood, thereby stimulating the blood to exert excessive pressure against the blood vessel walls. Consequently, the heart must pump harder to deliver the blood through the constricted arteries. If the condition becomes longstanding, a likely damage to the cardiovascular system is to happen, which increases the risk of an individual for cerebrovascular accident, heart failure, and renal failure. It is usually called the silent killer because it does not present any symptoms until it reaches a serious and life-threatening stage (Microsoft Encarta Encyclopedia, 2003). The Joint National Committee on Prevention, Detection, Evaluation, and Treatment if High Blood Pressure has identified the classification of hypertension in adults older than 18 years are prehypertension, if systolic pressure is 120-139 mmHg and diastolic pressure is 80-89 mmHg; stage 1 hypertension is systolic pressure ranges 140-159 mmHg and diastolic pressure ranges 90-99 mmHg; and stage 2 hypertension if systolic pressure is 160 mmHg or more and diastolic pressure is 100 mmHg or higher (Bickley & Szilagyi, 2009). Essential or idiopathic hypertension is the term given to high blood pressures with no identifiable causes (Microsoft Encarta Encyclopedia, 2003). Hypertension has been also categorized in two classes. Primary hypertension happens when the sympathetic nervous system as well as the renin-angiotensin-aldosterone system is hyperactive thereby causing vasoconstriction and endothelial dysfunction, its mechanism however is still not known. Secondary hypertension on the other hand is caused by high intake with estrogen therapy, polycystic kidney disease, renal artery vasoconstriction, primary hyperaldosteronism, Cushing’s disease, hyperthyroidism, and pheochromocytoma (Woods, 2006). Individuals having a family history of hypertension and cardiovascular diseases are at greater risk of developing heart-related illnesses. Also included in the high risk group are those who are smoking cigarettes, living a sedentary lifestyle, or having a body mass index of 30 kg/m2 or more. Furthermore, patients with past medical history of dyslipidemia, diabetes mellitus, or presence of albumin in the urine are more predisposed to developing hypertension and heart diseases. Regarding to age, males older than 55 years and females older than 65 years and postmenopausal are at greater risk of acquiring hypertensive and cardiovascular diseases. In addition, individuals who are regularly taking non-steroidal anti-inflammatory drugs or women who are taking estrogen-containing contraceptives are also more predisposed to acquiring heart diseases (Woods, 2006). The survey on monitoring prevalence rate of cardiovascular diseases by the World Health Organization was conducted to 22 countries. Conclusions based on the data gathered are as follows: Hypertension prevalence is high in all countries with a scope of 20% to nearly 50%. Generally, industrialized countries have a greater prevalence than United States, excluding Canada, (Wolf-Maier, 2003). In one country, higher prevalence rate is observed in the urban areas than in rural areas (Gupta, 2004; Ibrahim, 1996, Ragoobirsingh, et. al., 2002). On the whole, the worldwide burden of hypertensive disease in 2000 was approximated to be 972 million individuals or 26.4% of the adult population; 333 million are in developed countries and 639 million are in developing countries. By the year 2025, approximately 1.56 billion persons will be afflicted with hypertension, a projection of 60% from year 2000 (Kearney, 2005).Several studies were also conducted according to age and race and it was found out that the frequency of hypertension is high in the United States, increases with age, and is greater in African Americans than in whites (Hajjar, 2006). The incidence and susceptibility to complications brought about by hypertension grow with increasing age. Complications include cardiomegaly and heart failure or hypertensive heart disease, multi-infarct dementia, aortic dissection and kidney failure. If this medical condition is not well managed, almost 50% of patients with hypertension die of ischemic heart disease, congestive heart failure, or cerebrovascular accident or stroke. Prophylactic blood pressure control and reduction dramatically decreases the prevalence of complications and death rates from all types of hypertension-related pathology (Kumar, et al., 2010). There is a need therefore for health promotion especially to individuals with increased risk of developing hypertension in order to prevent them from acquiring this condition and save them from suffering any of its complications and also to those persons who are already afflicted with hypertension so as to maximize their well being and prevent the disease from progressing to a more serious stage. Discussion The goal of prevention and intervention of hypertension is to prolong life, reduce high blood pressure-related signs, symptoms and other comorbidities, and prevent progression of complications such as stroke or kidney failure. Primary prevention aims to change the modifiable risk elements for hypertension which are lifestyle and dietary habits. The JNC 7, National High Blood Pressure Education Program, and the AHA promote a series of documented successful lifestyle modifications and risk management to keep away from hypertension. A high risk individual should have an optimal weight or body mass index ranging from 18-5 to 24.9 kg/m2 (Whelton, et al., 2002). For every 10 kg or 22 lbs of weight lost, blood pressure is reduced from 5 to 20 mmHg (Woods, 2006). Salt intake should be less than 6 grams of sodium chloride or 2.4 grams of sodium per day (Whelton, et al., 2002). Diet containing excessive sodium can cause fluid retention and increase blood pressure. Generally, older adults and African-Americans are sensitive to salt. A diet with low sodium content can decrease blood pressure by 2 to 8 mmHg (Woods, 2006). He/she must engage in a regular aerobic physical activities for instance brisk walking for at least 30 minutes daily, most days of the week (Whelton, et al., 2002). To reduce the risk of coronary heart diseases, it is significant to counsel high risk individuals to engage in aerobic physical activities, or exercises which lead to increase muscle oxygen uptake. Health practitioners could encourage their patients to be motivated by stressing the immediate gains to his/her health and well-being. Also, activities such as deep breathing, sweating in cool temperatures and pulse rates greater than 60% of the maximum normal age-adjusted cardiac rate, that is 220 minus the person’s age, are characteristic of the onset of aerobic metabolism (Bickley, 2009). Regular physical activity can drop the blood pressure by 4 to 9 mm Hg (Woods, 2006). There should only be a moderate intake of alcohol per day with 2 drinks or less for men and 1 drink or less for women. One drink is equivalent to 1 ounce ethanol, 12 ounce beer, 5 ounce wine, or 1-1.5 ounce of whiskey. Also, a dietary intake of potassium of not less than 3500 mg is recommended for high risk individuals. Furthermore, diet containing fruits, vegetables, and low-fat dairy products with minimal content of saturated and total fat are more preferable over high fat diet (Whelton, et al., 2002). The principle of healthy dietary habits is that individuals consuming high fat diet have a higher chance to accumulate body fat than individuals consuming foods rich in protein and carbohydrate. Healthy eating involves less consumption of cholesterol and total fat, particularly lower saturated and trans fat. Beware of these unhealthy fats that have high cholesterol content: dairy products, egg yolk, liver, organ meats, and high-fat meat and poultry. Also, foods with high saturated fat are integrated in high fat dairy products such as cream, cheese, ice cream, whole and 2% milk, butter, sour cream, bacon, chocolate, coconut oil, lard, and gravy from meat drippings; and high fat meats such as ground beef, bologna, hotdog, and sausage. Furthermore, food rich in trans fats are included in snacks and baked goods with hydrogenated or partially hydrogenated oil, stick margarines, shortening, and french fries. Meanwhile, the recommended foods containing healthy fats are foods with monounsaturated fats which can be seen in almonds, pecans, peanuts, sesame seeds, avocado, canola oil, olive and peanut oil; foods with polyunsaturated fats such as in corn, safflower, cottonseed, and soybean oil, walnuts, pumpkin, sunflower seeds, soft margarine, mayonnaise, and salad dressings; and foods with high omega-3 fatty acid contents such as in fish oils of albacore tuna, herring, mackerel, rainbow trout, salmon, and sardines. These healthy fats aid in lowering blood cholesterol levels (Bickley, 2009). In addition, smoking cigarettes should be stopped. Cigarette smoking is not just the primary cause of cancer of the lung but it is also the main cause of cardiovascular illnesses (Woods, 2006). Health education is a vital process in primary prevention. For the procedures and goals to be attained, it is important that the patient is able to understand the risks and predisposition to the condition, benefits from prophylactic management, and complications if intervention has not been successful. If despite these interventions, hypertension is still not lowered, secondary prevention is employed wherein antihypertensive drugs are used. Due to the increasing prevalence of the condition, continuing researches are conducted to come up with effective pharmacologic agents that could correct hypertension. Diuretics are antihypertensive drugs which help in extra salt and water elimination, reducing then the volume of fluid in the circulation and alleviating high pressure on walls of blood vessels. Beta blockers are also pharmacologic agents that lower down cardiac rate and the volume of blood that the heart pumps. Angiotensin-converting enzyme inhibitors prevent the stenosis of arterial blood vessel walls to control blood pressure. Also, calcium channel blockers decrease cardiac rate and dilate blood vessels to ease the flow of blood (Microsoft Encarta Encyclopedia, 2003). Calcium channel blockers are utilized not only for hypertension but also for angina pectoris or supraventricular tachyarrhythmias. Examples of these drugs that are available in the market are verapamil, amlodipine, nifedipine, felodipine, and diltiazem. These drugs are more efficient than other pharmacologic agents in older adults and African Americans (Kloner, 2004). Their action is to block peripheral blood vessels causing vasodilation to reduce blood vessel pressure, block cardiac arteries heart to increase cardiac perfusion, block at the level of sinoatrial node to reduce heart rate and block at the level of atrioventricular node to reduce AV node conduction, and block in cardiac muscles to reduce the strength of contractions (Lehne, 2007). Diuretics are the preferred first line of drugs for hypertension. They are effective for individuals who retain sodium. These drugs are generally well-tolerated and cheap. Also, documents state these drugs decrease associated incidence of morbidity and mortality (Holman, 2007). Diuretics act several parts of the kidney tubules to aid in eliminating sodium and water. The reduced peripheral resistance contributes to lowering of blood pressure (Aschenbrenner & Venable, 2009). Most of the time, these drugs are taken together in order to potentiate the effectiveness of the therapy. Also, several of these drugs are in synthesized in combined forms in one tablet or pill so as to increase patient compliance or facilitate easy drug administration. Thiazide diuretics are commonly the first line of drug. But for patients with comorbidities such as diabetes mellitus, cardiac failure or renal failure, an angiotensin-converting enzyme inhibitor is utilized as the drug of choice. Usually, ACE inhibitor is taken with diuretics. ACE inhibitors and angiotensin receptor blockers are effective in preserving the kidney function. Beta blocker or calcium channel blocker is prescribed to patients suffering from hypertension and stable angina. Beta blockers and ACE inhibitors are given with acute coronary syndromes. ACE inhibitors, diuretics, aldosterone antagonists, and beta-blockers are prescribed with heart failure (Woods, 2006). A nurse must always have the knowledge of how a drug acts to the body. This understanding will aid the nurse practitioner in explaining and justifying the goal of pharmacologic therapy as well as the possible adverse effects of the drug to the patient (Cranwell-Bruce, 2008). A need for lifelong awareness to manage high blood pressure should be undertaken to promote a relatively better prognosis of the disease. Secondary prevention also sees to it that the condition does not progress to its terminal stage thus preventing the patient to suffer its complications. Tertiary prevention is aimed at maximizing the well being of patients who have been afflicted with the complications of hypertension, i.e. myocardial ischemia, cardiovascular accident, or ruptured aneurysm. This intervention is not only directed with the involved person’s state of wellbeing but must also take into consideration his/her support groups and the promotion to perform his/her activities independent of others. Social groups are also established for their emotional support as they experience the chronicity and morbidity of the illness. Case Study A sample case study is HN who is 50 years old with a history of hypertension for the past several years. She has been prescribed maintenance and is regularly taking atenolol 50 mg and losartan 50 mg. She presents at the emergency room due to shortness of breath. Present medical condition started when patient had developed easy fatigability and shortness of breath on exertion. She is also dyspneic when lying down and walking several steps. Past medical history states that has not experienced chest pain, palpitations, or syncope. Family history is positive for hypertension. Personal and social history revealed that she is a nonsmoker. On clinical examination, ECG revealed a moderate to severe left ventricular hypertrophy with normal ventricular volumes and function, X-ray showed signs of pulmonary edema, and physical examinations revealed cold extremities and lateral and downward displacement of apex beat (Donnelly & Akram, n.d.). This patient has already developed a hypertensive disease which has been stated in her past medical history and as evidenced by her taking of antihypertensive drugs. Therefore, treatment that would best suit her condition would include pharmacologic therapy employing secondary prevention in addition to lifestyle and dietary modifications. A short term goal would be to relieve the shortness of breath at the emergency room by administration of oxygen for good tissue perfusion, infusion of intravenous diuretics to promote water elimination and nitrates to promote vasodilatation (Donnelly & Akram, n.d.). Long term goal of the therapy is to prevent progression of her condition to debilitating complications brought about by ineffective therapy or noncompliance to drug regimen of the patient. Thus it is essential that her blood pressure be monitored regularly to control any deviations from the normal values. Understanding the disease etiology and progression of the illness if hypertension is not controlled could aid the patient to comply with the drug therapy. In addition individualized physical activities are promoted by physicians along with low fat and low salt diet. Conclusion There are documented several reasons why there is yet increasing numbers with incidence of hypertension. Cultural norms, inadequate attention to health teachings and lack of health education especially in areas of nutrition education by health care practitioners, public health, and school systems, insufficient referral to dietitians, and economic disincentives to healthy lifestyles. To promote a healthy well being particularly those who are predisposed to hypertension include a blend of exercise, moderation in alcohol consumption, and healthy dietary plan with low sodium and fat content and high in fruits and vegetables. In addition reinforcement of public health education by health care givers can increase awareness of the people to a healthy lifestyle. We are at advantage, because of the chronicity of this condition, we have ample time to adjust our lifestyle. The combined efforts of the national government and its people with the health care providers can still improve and reinforce early spotting of high risk individuals and monitoring and controlling the condition by pharmacologic and non pharmacologic managements. References Aschenbrenner, D.S., & Venable, S.J. 2009. Drug therapy in nursing 3rd ed. Philadelphia: Wolters Kluwer. Bickley, L. & Szilagyi, P. 2009. Bates’ Guide to Physical Examination and History Taking 10th ed. Wolters Kluwer Health, Lippincot Williams & Wilkins Cranwell-Bruce, L. 2008. Antihypertensives. MedSurg Nursing Vol. 17/No. 5 Donnelly, R. & Akram, J. n.d. Clinical Cases in Hypertension: Difficult-to-control Hypertension. Book 26. Gupta R. 2004. Trends in hypertension epidemiology in India. J. Hum. Hypertens. 18:73–78 Hajjar, I., Kotchen, J. & Kotchen, T. 2006 Hypertension: Trends in Prevalence, Incidence, and Control. Annu. Rev. Public Health. 27:465–90 Holman, J.R. 2007. How to control BP in older patients. The Clinical Advisor, 10(2), 44-52. Ibrahim MM. 1996. The Egyptian National Hypertension Project (NHP): preliminary results. J. Hum. Hypertens. 10 (Suppl. 1):S39–41 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. 2005. Global burden of hypertension: analysis of worldwide data. Lancet 365:217–23 Kloner, R.A. 2004. Successfully diagnosing and preventing the “silent” disease. The Clinical Advisor, 7(10, Suppl. 1), 3-15. Kumar, V. et al., 2010 Robbins and Cotran Pathologic Basis of Disease 8th ed. Saunders Elsevier Lehne, R.A. 2007. Pharmacology for nursing care 6th ed. Philadelphia: Elsevier. Microsoft Encarta Encyclopedia, 2003 Ragoobirsingh D, McGrowder D, Morrison EY, Johnson P, Lewis-Fuller E, Fray J. 2002. The Jamaican hypertension prevalence study. J. Natl. Med. Assoc. 94:561–65 US Department of Helath and Human Services, National Institutes of Health, and National Heart, Lung, and Blood Institute. 2002. Primary Prevention of Hypertension: Clinical and Public Health Advisory from the National High Blood Pressure Education Program. NIH Publication NO. 02-5076 Whelton, P., He, J., Appel, L., et al. 2002. Primary Prevention of Hypertension. Clinical and Public Health Advisory from the National High Blood Pressure Education Program. JAMA 288(15): 1882-1888. Wolf-Maier K, Cooper RS, Banegas JR, Giampaoli S, Hense HW, et al. 2003. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA 289:2363–69 Woods, A. 2006. Advances in hypertension management: Follow the latest guidelines to identify patients at risk for high blood pressure and help them protect their health. Cardiac Insider. Read More