HYPERTENSION

MANAGEMENT

APN Elizabeth Ho Moon Liang

MN (Singapore), BSc Nur (Australia)

29/ 1 Jan 2008

20 November 2008
Chronic Diseases Management
Course for Health Educators by
Primary Care Academy
Objectives

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
 Knowthe application of hypertension self
management plans
Overview of Patient Education

Healthy Exercise
Eating

Medications Self
Monitoring
 Overview of Patient Self Management

Self
Monitoring Moods

Exercise Money

Healthy
Eating Work

Meds Home
Medications and their Classes

Activity
 Medications Side Effects
• Contradicted in Gout
Thiazides • Glucose intolerance
• Hypokalemia, Hyponatraemia

• Bronchospasm
Beta • Erectile Dysfunction ARB
Blockers • Lethargy • Well tolerated
• Bradycardia

Calcium Channel ACE Inhibitors

Blockers
• Dry cough
• Flushing • Pedal edema
• Headache • Renal impairment
• Pedal edema • Initial postural hypotension
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
 Upper arm or Wrist devices?

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.

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.
 British Hypertension Society

Omron M5-I Fore-care SE 9400

(elderly)

Microlife BP A100
(pregnant)

http://www.bhsoc.org/bp_monitors/automatic.stm
 British Hypertension Society

Omron R6 Omron R7

http://www.bhsoc.org/bp_monitors/automatic_wrist.stm
German Hypertension Society

boso-medicus uno boso-medicus prestige

Singapore Heart Foundation

Omron SEM1 Omron HEM7080

Omron IW1 Omron IW2

 Hypertension Management Plan
Green Zone
Blood Pressure < 140/90 mmHg
Yellow Zone
Blood Pressure > 140/90 mmHg
Red Zone
Blood Pressure > 160/100 mmHg
Green Zone means:
Your blood pressure is under control
Continue taking your medication as ordered
Continue routine blood pressure monitoring once a week
Follow healthy eating habits
Keep all Dr’s appointments
Yellow Zone means:
Your blood pressure levels may indicate that you need to
adjust
your medications
Continue routine blood pressure monitoring 2X a week
If 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 mmHgRed for a Zone
3 daysmeans:
Repeat measurement after resting ½ hour
To consult Dr if:
• BP >160/100 mmHg x3 times at ½ hour interval
• 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
Recommendations

1) Sit Upright. Don’t cross legs

Correct
Correct CUFF
POSTURE 2) Cuff should be
closely attached to
your arm.

Correct
HEIGHT
3) Cuff height should be same
height as your heart
Resources

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