HYPERTENSION MANAGEMENT

APN Elizabeth Ho Moon LiangMN (Singapore), BSc Nur (Australia)

29/ 1 Jan 200820 November 2008

Chronic Diseases Management Course for Health Educators by

Primary Care Academy

At the end of the session you will:

Understand the overview of nursing management for Hypertension patients

List the side effects of common anti-hypertensive medications

Know the different BP monitoring devices

Know the application of hypertension self management plans

Objectives

Overview of Patient Education

ExerciseHealthy Eating

Medications Self Monitoring

Exercise

Healthy Eating

Meds

Overview of Patient Self Management

Home

Self Monitoring

Money

Moods

Work

Medications and their Classes

Activity

Medications Side Effects

Thiazides• Contradicted in Gout• Glucose intolerance• Hypokalemia, Hyponatraemia

BetaBlockers

• Bronchospasm• Erectile Dysfunction• Lethargy• Bradycardia

Calcium ChannelBlockers

• Flushing• Headache• Pedal edema

ACE Inhibitors

• Dry cough• Pedal edema• Renal impairment• Initial postural hypotension

• Well tolerated

ARB

Blood Pressure Monitoring, Devices and Self Care

HBPM should We Encourage?

In conclusion, the available evidence strongly supports HBPM as a valid tool for prognostic assessment.

Areas that need further research include the prognostic significance of other parameters derived from HBPM, such as heart rate or pulse pressure, and the relation of HBPM

with individual outcomes [e.g. coronary artery disease (CAD)]. More prospective studies in Western populations

appear to be needed.

Parati, G. et al. (2008). European Society of Hypertension guidelines for blood pressure monitroing at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. Journal of Hypertension, 26(8), 1505-1530

Which arm?The issue as to which arm should be used for blood

pressure measurement has been controversial … The fact that … differences between arms …and differences between

sequential arm blood pressure measurements …However, a recent study has shown significant differences in inter-arm differences for systolic and diastolic blood pressure, leading to the recommendation that bilateral measurement should be made on first consultation and, if reproducible

differences greater than 20 mmHg for systolic or 10 mmHg for diastolic pressure are present on consecutive readings,

the patient should be referred to a cardiovascular centre for further evaluation with simultaneous bilateral measurement

and the exclusion of arterial disease.

Lane, D. et al. (2002) Interarm differences in blood pressure: when are they clinically significant? Journal of Hypertension, 20:1089–1095.

Left arm or Right arm?

In individuals with a consistent and significant between-arm difference (e.g. >10mmHg systolic

and/or >5mmHg diastolic) on repeated measurements, the arm with the higher BP should be selected for future measurements. During HBPM, measurements should be

performed sequentially always on the same arm.

Parati, G. et al. (2008). European Society of Hypertension guidelines for blood pressure monitroing at home: a summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. Journal of Hypertension, 26(8), 1505-1530

Wrist devices are subject to errors that are not presently evaluated in the available validation

protocols. The most important source of error with wrist devices is the position of the arm in relation to

the heart. A wrist device may fulfill the accuracy criteria of a validation protocol when strict attention is paid to

having the wrist at heart level but in home use this may not happen and as a consequence the measurements

can become inaccurate. For this reason validated upper arm devices are recommended in preference to wrist devices.

Upper arm or Wrist devices?

http://www.bhsoc.org/bp_monitors/automatic_wrist.stm

Upper arm or Wrist devices?

Measurement with wrist devices is heavily influenced by not only the level at which the wrist is

held but also its flexion and hyperextension. Furthermore, wrist devices are inherently less

accurate…, as there are two arteries contributing to the oscillometric signal. As a result, there continue to be strong reservations about the use of wrist

devices for routine clinical practice. However, additional studies have been advocated to explore

the role of wrist measuring devices in special populations, such as obese or elderly individuals, in whom HBPM using the upper arm is more difficult

to perform.

Omron M5-I(elderly)

Microlife BP A100(pregnant)

http://www.bhsoc.org/bp_monitors/automatic.stm

British Hypertension Society

Fore-care SE 9400

British Hypertension Society

Omron R6 Omron R7

http://www.bhsoc.org/bp_monitors/automatic_wrist.stm

German Hypertension Society

boso-medicus prestige boso-medicus uno

Singapore Heart Foundation

Omron IW1 Omron IW2

Omron SEM1 Omron HEM7080

Hypertension Management Plan

Green Zone Green Zone means:

Blood Pressure < 140/90 mmHg Your blood pressure is under controlContinue taking your medication as orderedContinue routine blood pressure monitoring once a weekFollow healthy eating habitsKeep all Dr’s appointments

Yellow Zone Yellow Zone means:

Blood Pressure > 140/90 mmHg Your blood pressure levels may indicate that you need to adjust

your medicationsContinue routine blood pressure monitoring 2X a weekIf BP >140/90 & < 150/90 mmHg measures BP 2X a week If BP >150/95 mmHg, measures your BP every day, call

CM if BP >150/95 mmHg for a 3 days

Red Zone Red Zone means:

Blood Pressure > 160/100 mmHg Repeat measurement after resting ½ hourTo consult Dr if:1. BP >160/100 mmHg x3 times at ½ hour interval2. BP(diastolic) >120 mmHg with symptoms of chest

pain, breathless, weakness, headache, mental confusion, visual disturbances, nausea & vomitting

Recommendations for taking HBP

Use the following procedures when recording BP:

Allow the patient to sit or lie down for several minutes before measuring the BP Patient should refrain from smoking or ingesting caffeine during the 30 minutes preceding the measurement. Use a cuff with a bladder that is 12-13 cm x 35 cm in size, with a larger bladder for fat arms.

The bladder within the cuff should encircle at least 80% of the arm.

Recommendations for taking HBP

Use the disappearance of phase V Korotkoff sounds to measure the diastolic BP.

Measure the BP in both arms at the first visit.

Take 2 or more readings separated by 2 minutes. Average these 2 values. If the first 2 readings differ by more than 5 mmHg, additional readings should be obtained and averaged.

Measure the BP in both the standing and supine position for elderly subjects and diabetic patients. Place the sphygmomanometer cuff at heart level, whatever the position of the patient

1) Sit Upright. Don’t cross legs

3) Cuff height should be same height as your heart

2) Cuff should be closely attached to your arm.

Recommendations

Correct POSTURE

Correct CUFF

Correct HEIGHT

http://www.bhsoc.org/Blood_pressure_Publications.stm

http://www.moh.gov.sg/mohcorp/publications.aspx?id=16334http://www.nhgp.com.sg/contentview.aspx?article_id=645

Resources