Hypertension

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Hypertension
Classification and external resources

Automated arm blood pressure meter showing arterial hypertension (shown a systolic blood pressure 158 mmHg, diastolic blood pressure 99 mmHg and heart rate of 80 beats per minute).

ICD-9

401.x

OMIM

145500

DiseasesDB

6330

MedlinePlus

000468

eMedicine

med/1106 ped/1097 emerg/267

MeSH

[1]

Hypertension is a chronic medical condition in which the blood pressure is elevated. It is also referred to as high blood pressure or shortened to HT, HTN or HPN. The word "hypertension", by itself, normally refers to systemic, arterial hypertension.[1] Hypertension can be classified as either essential (primary) or secondary. Essential or primary hypertension means that no medical cause can be found to explain the raised blood pressure. It is common. About 90-95% of hypertension is essential hypertension.[2][3][4][5] Secondary hypertension indicates that the high blood pressure is a result of (i.e., secondary to) another condition, such as kidney disease or tumours (adrenal adenoma or pheochromocytoma). Persistent hypertension is one of the risk factors for strokes, heart attacks, heart failure and arterial aneurysm, and is a leading cause of chronic renal failure.[6] Even moderate elevation of arterial blood pressure leads to shortened life expectancy. At severely high pressures, defined as mean arterial pressures 50% or more above average, a person can expect to live no more than a few years unless appropriately treated.[7] Beginning at a systolic pressure (which is peak pressure in the arteries, which occurs near the end of the cardiac cycle when the ventricles are contracting) of 115 mmHg and diastolic pressure (which is minimum pressure in the arteries, which occurs near the beginning of the cardiac cycle when the ventricles are filled with blood) of 75 mmHg (commonly written as 115/75 mmHg), cardiovascular disease (CVD) risk doubles for each increment of 20/10 mmHg.[8]

Contents
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1 Classification 2 Signs and symptoms 3 Causes o 3.1 Essential hypertension o 3.2 Secondary hypertension 3.2.1 Adrenal 3.2.2 Kidney 3.2.3 Medications 3.2.4 Pregnancy 3.2.5 Sleep disturbances 4 Pathophysiology 5 Diagnosis o 5.1 Measuring blood pressure o 5.2 Laboratory tests 6 Prevention 7 Treatment o 7.1 Lifestyle modifications o 7.2 Biofeedback o 7.3 Medications 7.3.1 Choice of initial medication 8 Prognosis

o 8.1 Complications 9 Epidemiology o 9.1 Children and adolescents 10 History 11 Society and culture o 11.1 Economics o 11.2 Awareness 12 References 13 Further reading 14 External links o 14.1 Major studies

[edit] Classification

The variation in pressure in the left ventricle (blue line) and the aorta (red line) over two cardiac cycles ("heart beats"), showing the definitions of systolic and diastolic pressure. A recent classification recommends blood pressure criteria for defining normal blood pressure, prehypertension, hypertension (stages I and II), and isolated systolic hypertension, which is a common occurrence among the elderly. These readings are based on the average of seated blood pressure readings that were properly measured during 2 or more office visits. In individuals older than 50 years, hypertension is considered to be present when a person's blood pressure is consistently at least 140 mmHg systolic or 90 mmHg diastolic. Patients with blood pressures over 130/80 mmHg along with Type 1 or Type 2 diabetes, or kidney disease require further treatment.[8]

Systolic pressure Classification

Diastolic pressure

mmHg kPa (kN/m2) mmHg kPa (kN/m2)

Normal

90119 1215.9

6079 8.010.5

Prehypertension 120139 16.018.5

8089 10.711.9

Stage 1

140159 18.721.2

9099 12.013.2

Stage 2

160

21.3

100

13.3

Isolated systolic 140 hypertension

18.7

<90

<12.0

Source: American Heart Association (2003).[8]

Resistant hypertension is defined as the failure to reduce blood pressure to the appropriate level after taking a three-drug regimen (include thiazide diuretic).[8] Guidelines for treating resistant hypertension have been published in the UK,[9] and US.[10] Excessive elevation in blood pressure during exercise is called exercise hypertension.[11][12][13] The upper normal systolic values during exercise reach levels between 200 and 230 mm Hg.[14] Exercise hypertension may be regarded as a precursor to established hypertension at rest.[13][14]

[edit] Signs and symptoms

Mild to moderate essential hypertension is greatly asymptomatic.[15][16][17][18][19] Accelerated hypertension is associated with headache, somnolence, confusion, visual disturbances, and nausea and vomiting (hypertensive encephalopathy). Retinas are affected with narrowing of arterial diameter to less than 50% of venous diameter, copper or silver wire appearance, exudates, hemorrhages, or papilledema.[20] Some signs and symptoms are especially important in infants and neonates such as failure to thrive, seizure, irritability or lethargy, and respiratory distress.[21] While in children hypertension may cause headache, fatigue, blurred vision, epistaxis, and bell palsy.[21]

Image showing patient with growth hormone excess Some signs and symptoms are especially important in suggesting a secondary medical cause of chronic hypertension, such as centripetal obesity, "buffalo hump," and/or wide purple abdominal striae and maybe a recent onset of diabetes suggest glucocorticoid excess either due to Cushing's

syndrome or other causes. Hypertension due to other secondary endocrine diseases such as hyperthyroidism, hypothyroidism, or growth hormone excess show symptoms specific to these disease such as in hyperthyrodism there may be weight loss, tremor, tachycardia or atrial arrhythmia, palmar erythema and sweating.[22] Signs and symptoms associated with growth hormone excess such as coarsening of facial features, prognathism, macroglossia,[23] hypertrichosis, hyperpigmentation, and hyperhidrosis may occur in these patients.[24]:499. Other endocrine causes such as hyperaldosteronism may cause less specific symptoms such as numbness, polyuria, polydipsia, hypernatraemia, and metabolic alkalosis.[25] A systolic bruit heard over the abdomen or in the flanks suggests renal artery stenosis. Also radiofemoral delay or diminished pulses in lower versus upper extremities suggests coarctation of the aorta. Hypertension in patients with pheochromocytomas is usually sustained but may be episodic. The typical attack lasts from minutes to hours and is associated with headache, anxiety, palpitation, profuse perspiration, pallor, tremor, and nausea and vomiting. Blood pressure is markedly elevated, and angina or acute pulmonary edema may occur. In primary aldosteronism, patients may have muscular weakness, polyuria, and nocturia due to hypokalemia. Chronic hypertension often leads to left ventricular hypertrophy, which can present with exertional and paroxysmal nocturnal dyspnea. Cerebral involvement causes stroke due to thrombosis or hemorrhage from microaneurysms of small penetrating intracranial arteries. Hypertensive encephalopathy is probably caused by acute capillary congestion and exudation with cerebral edema, which is reversible.[20] Signs and symptoms associated with pre-eclampsia and eclampsia, can be proteinuria, edema, and hallmark of eclampsia which is convulsions, Other cerebral signs may precede the convulsion such as nausea, vomiting, headaches, and blindness.[26]

[edit] Causes
[edit] Essential hypertension
Main article: Essential hypertension Hypertension is one of the most common complex disorders. The etiology of hypertension differs widely amongst individuals within a large population.[27] Essential hypertension is the form of hypertension that by definition, has no identifiable cause. It is the more common type and affects 90-95% of hypertensive patients,[2][3][4][5] and even though there are no direct causes, there are many risk factors such as sedentary lifestyle,[28] obesity[29][30][31][32][33] (more than 85% of cases occur in those with a body mass index greater than 25),[33] salt (sodium) sensitivity,[34][35][36][37] alcohol intake,[38][39] and vitamin D deficiency.[40][41][42] It is also related to aging[43] and to some inherited genetic mutations.[27][44][45][46][47][48] Family history increases the risk of developing hypertension.[49][50] Renin elevation is another risk factor, Renin is an enzyme secreted by the juxtaglomerular apparatus of the kidney and linked with aldosterone in a negative feedback loop.[30][51] Also sympathetic overactivity is implicated.[32][52][53][54][55] Insulin resistance which is a component of syndrome X, or the metabolic syndrome is also thought to cause hypertension.[30][52][56] Recently low birth weight has been questioned as a risk factor for adult essential hypertension.[31][57]

[edit] Secondary hypertension

Main article: Secondary hypertension On the other hand, secondary hypertension by definition results from an identifiable cause. This type is important to recognize since its treated differently than essential type by treating the underlying cause. Many secondary cause can cause hypertension, some are common and well recognized secondary causes such as Cushing's syndrome,[58] which is a condition where both adrenal glands can overproduce the hormone cortisol. Hypertension results from the interplay of several pathophysiological mechanisms regulating plasma volume, peripheral vascular resistance and cardiac output, all of which may be increased. More than 80% of patients with Cushing's syndrome have hypertension.[58] Another important cause is the congenital abnormality coarctation of the aorta. [edit] Adrenal A variety of adrenal cortical abnormalities can cause hypertension, In primary aldosteronism there is a clear relationship between the aldosterone-induced sodium retention and the hypertension.[59] Another related disorder that causes hypertension is apparent mineralocorticoid excess syndrome which is an autosomal recessive disorder results from mutations in gene encoding 11-hydroxysteroid dehydrogenase which normal patient inactivates circulating cortisol to the less-active metabolite cortisone.[60] Cortisol at high concentrations can cross-react and activate the mineralocorticoid receptor, leading to aldosterone-like effects in the kidney, causing hypertension.[61] This effect can also be produced by prolonged ingestion of liquorice(which can be of potent strength in liquorice candy), can result in inhibition of the 11hydroxysteroid dehydrogenase enzyme and cause secondary apparent mineralocorticoid excess syndrome.[62][63][64] Frequently, if liquorice is the cause of the high blood pressure, a low blood level of potassium will also be present.[63] Yet another related disorder causing hypertension is glucocorticoid remediable aldosteronism, which is an autosomal dominant disorder in which the increase in aldosterone secretion produced by ACTH is no longer transient, causing of primary hyperaldosteronism, the Gene mutated will result in an aldosterone synthase that is ACTHsensitive, which is normally not.[65][66][67][68][69] GRA appears to be the most common monogenic form of human hypertension.[70] Compare these effects to those seen in Conn's disease, an adrenocortical tumor which causes excess release of aldosterone,[71] that leads to hypertension.[72][73][74] Another adrenal related cause is Cushing's syndrome which is a disorder caused by high levels of cortisol. Cortisol is a hormone secreted by the cortex of the adrenal glands. Cushing's syndrome can be caused by taking glucocorticoid drugs, or by tumors that produce cortisol or adrenocorticotropic hormone (ACTH).[75] More than 80% of patients with Cushing's syndrome develop hypertension.[58], which is accompanied by distinct symptoms of the syndrome, such as central obesity, buffalo hump, moon face, sweating, hirsutism and anxiety.[76] [edit] Kidney

Other well known causes include diseases of the kidney. This includes diseases such as polycystic kidney disease which is a cystic genetic disorder of the kidneys, PKD is characterized by the presence of multiple cysts (hence, "polycystic") in both kidneys, can also damage the liver, pancreas, and rarely, the heart and brain.[77][78][79][80] It can be autosomal dominant or autosomal recessive, with the autosomal dominant form being more common and characterized by progressive cyst development and bilaterally enlarged kidneys with multiple cysts, with concurrent development of hypertension, renal insufficiency and renal pain.[81] Or chronic glomerulonephritis which is a disease characterized by inflammation of the glomeruli, or small blood vessels in the kidneys.[82][83][84] Hypertension can also be produced by diseases of the renal arteries supplying the kidney. This is known as renovascular hypertension; it is thought that decreased perfusion of renal tissue due to stenosis of a main or branch renal artery activates the renin-angiotensin system.[85][86][87] also some renal tumors can cause hypertension. The differential diagnosis of a renal tumor in a young patient with hypertension includes Juxtaglomerular cell tumor, Wilms' tumor, and renal cell carcinoma, all of which may produce renin.[88] Neuroendocrine tumors are also a well known cause of secondary hypertension. Pheochromocytoma[89] (most often located in the adrenal medulla) increases secretion of catecholamines such as epinephrine and norepinephrine, causing excessive stimulation of adrenergic receptors, which results in peripheral vasoconstriction and cardiac stimulation. This diagnosis is confirmed by demonstrating increased urinary excretion of epinephrine and norepinephrine and/or their metabolites (vanillylmandelic acid). [edit] Medications Certain medications, especially NSAIDs (Motrin/Ibuprofen) and steroids can cause hypertension.[90][91][92][93][94] High blood pressure that is associated with the sudden withdrawal of various antihypertensive medications is called Rebound Hypertension.[95][96][97][98][99][100][101] The increases in blood pressure may result in blood pressures greater than when the medication was initiated. Depending on the severity of the increase in blood pressure, rebound hypertension may result in a hypertensive emergency. Rebound hypertension is avoided by gradually reducing the dose (also known as "dose tapering"), thereby giving the body enough time to adjust to reduction in dose. Medications commonly associated with rebound hypertension include centrally
GUIDELINE TITLE Nursing management of hypertension. BIBLIOGRAPHIC SOURCE(S)

Heart and Stroke Foundation of Ontario, Registered Nurses Association of Ontario (RNAO). Nursing management of hypertension. Toronto (ON): Heart and Stroke Foundation of Ontario and Registered Nurses Association of Ontario (RNAO); 2005 Oct. 136 p. [155 references]

GUIDELINE STATUS This is the current release of the guideline.

COMPLETE SUMMARY CONTENT

SCOPE METHODOLOGY - including Rating Scheme and Cost Analysis RECOMMENDATIONS EVIDENCE SUPPORTING THE RECOMMENDATIONS BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS CONTRAINDICATIONS QUALIFYING STATEMENTS IMPLEMENTATION OF THE GUIDELINE INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES IDENTIFYING INFORMATION AND AVAILABILITY DISCLAIMER

SCOPE
DISEASE/CONDITION(S) Hypertension GUIDELINE CATEGORY Diagnosis Evaluation Management Treatment CLINICAL SPECIALTY Cardiology Family Practice Internal Medicine Nursing INTENDED USERS Advanced Practice Nurses Nurses GUIDELINE OBJECTIVE(S) To provide nurses with recommendations, based on the best available evidence, related to nursing interventions for high blood pressure detection, client assessment, and development of a collaborative treatment plan, promotion of adherence, and ongoing follow-up TARGET POPULATION Adults 18 years of age and older (including the older adult over 80) This is not meant to exclude the pediatric client, but children have special assessment needs related to developmental stages that are beyond the scope of this guideline. This guideline also does not address hypertension in adults related to pregnancy, transient hypertension, pulmonary hypertension, endocrine hypertension, or hypertension related to secondary causes (i.e., renal disease).

INTERVENTIONS AND PRACTICES CONSIDERED Diagnosis/Assessment 1. 2. Regular, accurate blood pressure measurement using a calibrated monitor Patient education regarding self/home blood pressure monitoring including community-based self monitoring devices and ambulatory blood pressure monitoring

Evaluation/Management/Treatment 1. Lifestyle interventions/modifications

Assessment of dietary risk factors, weight, body mass index (BMI), waist circumference, physical activity level, alcohol use status, tobacco use status Diet modifications including DASH (Dietary Approaches to Stop Hypertension) and limitations on sodium intake

2. 3. 4.

Weight reduction strategies Increased exercise Maximum alcohol consumption amounts Brief Tobacco Interventions Nicotine replacement therapies Stress management strategies Obtain medication history and provide patient education regarding medication Assessment and promotion of adherence to treatment plan Follow-up and documentation of management

MAJOR OUTCOMES CONSIDERED

Accurate diagnosis of hypertension Prevalence of hypertension Rates of hypertension-associated complications including cardiovascular and cerebrovascular disease
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METHODOLOGY
METHODS USED TO COLLECT/SELECT EVIDENCE Hand-searches of Published Literature (Primary Sources) Searches of Electronic Databases Searches of Unpublished Data DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE A database search for existing evidence related to hypertension management was conducted by a university health sciences library. An initial search of the MEDLINE, Embase, and CINAHL databases for guidelines and studies published from 1995 to 2004 was conducted in November 2004. This search was structured to answer the following questions:

How can nurses accurately detect symptoms of hypertension in the adult population? What effective treatment interventions can nurses utilize in practice to decrease blood pressure?

Detailed search strings developed to address these questions are available on the Registered Nurses Association of Ontario (RNAO) Web site at www.rnao.org/bestpractices.

One individual searched an established list of Web sites for content related to the topic area in September 2004. This list of sites, reviewed and updated in May 2004, was compiled based on existing knowledge of evidence-based practice Web sites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched as well as date searched. The Web sites at times did not house guidelines, but directed to another Web site or source for guideline retrieval. Guidelines were either downloaded if full versions were available or were ordered by phone/email. In addition, a Web site search for existing practice guidelines on hypertension management was conducted via the search engine "Google," using key search terms. One individual conducted this search, noting the results of the search, the Web sites reviewed, date, and a summary of the results. The search results were further reviewed by a second individual who identified guidelines and literature not previously retrieved. Panel members were asked to review personal archives to identify guidelines not previously found through the above search strategy. The search strategy described above resulted in the retrieval of 708 abstracts on the topic of hypertension. These abstracts were then screened by a research assistant in order to identify duplications and assess for inclusion/exclusion criteria. The resulting abstracts were included on a short list for article retrieval, quality appraisal, and data summary. In addition, 12 clinical practice guidelines were identified that met the screening criteria and were critically appraised using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001) instrument. NUMBER OF SOURCE DOCUMENTS Not stated METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE Weighting According to a Rating Scheme (Scheme Given) RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE Levels of Evidence Ia Evidence obtained from meta-analysis of randomized controlled trials Ib Evidence obtained from at least one randomized controlled trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities METHODS USED TO ANALYZE THE EVIDENCE Review of Published Meta-Analyses Systematic Review DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated METHODS USED TO FORMULATE THE RECOMMENDATIONS Expert Consensus DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS In October of 2004, a panel of nurses with expertise in hypertension management from a range of practice settings was convened under the auspices of the Heart and Stroke Foundation of Ontario (HSFO) and the Registered Nurses Association of Ontario (RNAO). The panel discussed the purpose of their work and came to consensus on the scope of the best practice guideline. The panel members divided into subgroups to undergo specific activities using the short listed guidelines, evidence summaries, studies, and other literature for the purpose of drafting recommendations for nursing interventions. This process resulted in the development of practice, education and organization, and policy recommendations. The panel members as a whole reviewed the first draft of recommendations, discussed gaps, reviewed the evidence, and came to consensus on a final set of recommendations. RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS Not applicable COST ANALYSIS A formal cost analysis was not performed and published cost analyses were not reviewed. METHOD OF GUIDELINE VALIDATION External Peer Review Internal Peer Review DESCRIPTION OF METHOD OF GUIDELINE VALIDATION This draft was submitted to a set of external stakeholders for review and feedback--an acknowledgement of these reviewers is provided at the front of this document. Stakeholders represented various healthcare professional groups, clients, and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions. Subsequent to stakeholder review, the Canadian Hypertension Education Program (CHEP) Executive Committee reviewed the guideline and endorsed the recommendations.
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RECOMMENDATIONS
MAJOR RECOMMENDATIONS The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. Practice Recommendations Detection and Diagnosis Recommendation 1.1

Nurses will take every appropriate opportunity to assess the blood pressure of adults in order to facilitate early detection of hypertension. (Level of Evidence = IV) Recommendation 1.2 Nurses will utilize correct technique, appropriate cuff size, and properly maintained/calibrated equipment when assessing clients' blood pressure. (Level of Evidence = IV) Recommendation 1.3 Nurses will be knowledgeable regarding the process involved in the diagnosis of hypertension. (Level of Evidence = IV) Recommendation 1.4 Nurses will educate clients about self/home blood pressure monitoring techniques and appropriate equipment to assist in potential diagnosis and the monitoring of hypertension. (Level of Evidence = IV) Recommendation 1.5 Nurses will educate clients on their target blood pressure and the importance of achieving and maintaining this target. (Level of Evidence = IV) Assessment and Development of a Treatment Plan Lifestyle Interventions Recommendation 2.1 Nurses will work with clients to identify lifestyle factors that may influence hypertension management, recognize potential areas for change, and create a collaborative management plan to assist in reaching client goals, which may prevent secondary complications. (Level of Evidence = IV) Diet Recommendation 2.2 Nurses will assess for and educate clients about dietary risk factors as part of management of hypertension, in collaboration with dietitians and other members of the healthcare team. (Level of Evidence = IV) Recommendation 2.3 Nurses will counsel clients with hypertension to consume the DASH Diet (Dietary Approaches to Stop Hypertension), in collaboration with dietitians and other members of the healthcare team.

(Level of Evidence = Ib) Recommendation 2.4 Nurses will counsel clients with hypertension to limit their dietary intake of sodium to the recommended quantity of 65 to 100 mmol/day, in collaboration with dietitians and other members of the healthcare team. (Level of Evidence = Ia) Healthy Weight Recommendation 2.5 Nurses will assess clients' weight, body mass index (BMI), and waist circumference. (Level of Evidence = IV) Recommendation 2.6 Nurses will advocate that clients with a BMI greater than or equal to 25 and a waist circumference over 102 cm (men) and 88 cm (women) consider weight reduction strategies. (Level of Evidence = IV) Exercise Recommendation 2.7 Nurses will assess clients' current physical activity level. (Level of Evidence = IV) Recommendation 2.8 Nurses will counsel clients, in collaboration with the healthcare team, to engage in moderate intensity dynamic exercise to be carried out for 30 to 60 minutes, 4 to 7 times a week. (Level of Evidence = Ia) Alcohol Recommendation 2.9 Nurses will assess clients' use of alcohol, including quantity and frequency, using a validated tool. (Level of Evidence = Ib) Recommendation 2.10 Nurses will routinely discuss alcohol consumption with clients and recommend limiting alcohol use, as appropriate, to a maximum of:

Two standard drinks per day or 14 drinks per week for men One standard drink per day or 9 drinks per week for women and lighter weight men

(Level of Evidence = III) Smoking

Recommendation 2.11 Nurses will be knowledgeable about the relationship between smoking and the risk of cardiovascular disease. (Level of Evidence = IV) Recommendation 2.12 Nurses will establish clients' tobacco use status and implement Brief Tobacco Interventions at each appropriate visit, in order to facilitate smoking cessation. (Level of Evidence = Ia) Stress Recommendation 2.13 Nurses will assist clients diagnosed with hypertension to understand how they react to stressful events and to learn how to cope with and manage stress effectively. (Level of Evidence = IV) Medications Recommendation 3.1 Nurses will obtain clients' medication history, which will include prescribed, over-the-counter, herbal, and illicit drug use. (Level of Evidence = IV) Recommendation 3.2 Nurses will be knowledgeable about the classes of medications that may be prescribed for clients diagnosed with hypertension. (Level of Evidence = IV) Recommendation 3.3 Nurses will provide education regarding the pharmacological management of hypertension, in collaboration with physicians and pharmacists. (Level of Evidence = IV) Assessment of Adherence Recommendation 4.1 Nurses will endeavour to establish therapeutic relationships with clients. (Level of Evidence = IV) Recommendation 4.2 Nurses will explore clients' expectations and beliefs regarding their hypertension management. (Level of Evidence = III)

Recommendation 4.3 Nurses will assess clients' adherence to the treatment plan at each appropriate visit. (Level of Evidence = III) Promotion of Adherence Recommendation 4.4 Nurses will provide the information needed for clients with hypertension to make educated choices related to their treatment plan. (Level of Evidence = III) Recommendation 4.5 Nurses will work with prescribers to simplify clients' dosing regimens. (Level of Evidence = Ia) Recommendation 4.6 Nurses will encourage routine and reminders to facilitate adherence. (Level of Evidence = Ia) Recommendation 4.7 Nurses will ensure that clients who miss appointments receive follow-up telephone calls in order to keep them in care. (Level of Evidence = IV) Monitoring and Follow-up Recommendation 5.1 Nurses will advocate that clients who are on antihypertensive treatment receive appropriate follow-up, in collaboration with the healthcare team. (Level of Evidence = IV) Documentation Recommendation 6.1 Nurses will document and share comprehensive information regarding hypertension management with the client and healthcare team. (Level of Evidence = IV) Education Recommendation Recommendation 7.1 Nurses working with adults with hypertension must have the appropriate knowledge and skills acquired through basic nursing education curriculum, ongoing professional development opportunities, and orientation to new work places. Knowledge and skills should include, at minimum:

Pathophysiology of hypertension Maximizing opportunities for detection Facilitating diagnosis Assessing and monitoring clients with hypertension Providing appropriate client/family education Supporting lifestyle changes Promoting the empowerment of the individual Documentation and communication with the client and other members of the healthcare team

(Level of Evidence = IV) Organization & Policy Recommendations Recommendation 8.1 Healthcare organizations will promote a collaborative practice model within the interdisciplinary team to enhance hypertension care and promote the nurses' role in hypertension management. (Level of Evidence = IV) Recommendation 8.2 Healthcare organizations will establish care delivery systems that allow for training in adherence management, as well as a means of accurately assessing adherence and those factors that contribute to it. (Level of Evidence = IV) Recommendation 8.3 Healthcare organizations will develop key indicators and outcome measurements that will allow them to monitor:

The implementation of the guidelines The impact of these guidelines on optimizing quality client care Efficiencies, or cost effectiveness achieved

(Level of Evidence = IV) Recommendation 8.4 Nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

An assessment of organizational readiness and barriers to education Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process Dedication of a qualified individual to provide the support needed for the education and implementation process Ongoing opportunities for discussion and education to reinforce the importance of best practices Opportunities for reflection on personal and organizational experience in implementing guidelines

(Level of Evidence = IV)

Definitions: Levels of Evidence Ia Evidence obtained from meta-analysis of randomized controlled trials Ib Evidence obtained from at least one randomized controlled trial IIa Evidence obtained from at least one well-designed controlled study without randomization IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies, and case studies IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities CLINICAL ALGORITHM(S) Algorithms are provided in the original guideline document for:

The Expedited Assessment and Diagnosis of Patient with Hypertension Brief Tobacco Intervention Follow-up
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EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS The type of evidence is identified and graded for each recommendation (see "Major Recommendations").
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BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

POTENTIAL BENEFITS

Accurate detection and treatment of hypertension may result in the prevention of target organ damage and the prevention of other debilitating complications Nurses, other health care professionals, and administrators who are leading and facilitating practice changes will find this document valuable for the development of policies, procedures, protocols, educational programs, assessments, and documentation tools.

POTENTIAL HARMS

Nicotine replacement therapies (NRT) should be used with caution with clients in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with serious or worsening angina. Adverse effects of pharmacological agents. Common side effects are listed in Appendix O in the original guideline document.
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CONTRAINDICATIONS
CONTRAINDICATIONS Contraindications of Pharmacological Agents Contraindications are listed in Appendix O in the original guideline document.
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QUALIFYING STATEMENTS
QUALIFYING STATEMENTS

This nursing best practice guideline is a comprehensive document providing resources necessary for the support of evidence based nursing practice. The document needs to be reviewed and applied, based on the specific needs of the organization or practice setting/environment, as well as the needs and wishes of the client. Guidelines should not be applied in a "cookbook" fashion but used as a tool to assist in decision making for individualized client care, as well as ensuring that appropriate structures and supports are in place to provide the best possible care. These best practice guidelines are related only to nursing practice and not intended to take into account fiscal efficiencies. These guidelines are not binding for nurses and their use should be flexible to accommodate client/family wishes and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Heart and Stroke Foundation of Ontario (HSFO) or Registered Nurses Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work. The views expressed in this guideline do not necessarily reflect those of the Ministry of Health and Long-Term Care. Any reference throughout the document to specific pharmaceutical products as examples does not imply endorsement of any of these products. It is acknowledged that effective healthcare depends on a coordinated interdisciplinary approach incorporating ongoing communication between health professionals and clients/families. It is acknowledged that the individual competencies of nurses varies between nurses and across categories of nursing professionals and are based on knowledge, skills, attitudes, critical analysis and decision making which are enhanced over time by experience and education. It is expected that individual nurses will perform only those aspects of hypertension management for which they have received appropriate education and experience and that they will seek appropriate consultation in instances where the client's care needs surpass their ability to act independently.
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IMPLEMENTATION OF THE GUIDELINE

DESCRIPTION OF IMPLEMENTATION STRATEGY Best practice guidelines can only be successfully implemented if there are: adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. In this light, Registered Nurses Association of Ontario (RNAO), through a panel of nurses, researchers, and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives, and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating, and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline: 1. 2. 3. 4. 5. 6. Identifying a well-developed, evidence-based clinical practice guideline. Identification, assessment, and engagement of stakeholders. Assessment of environmental readiness for guideline implementation. Identifying and planning evidence-based implementation strategies. Planning and implementing evaluation. Identifying and securing required resources for implementation.

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process. Evaluation and Monitoring Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on a framework outlined in the Registered Nurses Association of Ontario Toolkit: Implementation of Clinical Practice Guidelines (2002c), illustrates some specific indicators for monitoring and evaluation of the guideline Nursing Management of Hypertension. Implementation Strategies The Registered Nurses Association of Ontario and the guideline development panel have compiled a list of implementation strategies to assist healthcare organizations or healthcare disciplines who are interested in implementing this guideline. See the original guideline document for a summary of strategies. IMPLEMENTATION TOOLS Chart Documentation/Checklists/Forms Clinical Algorithm Patient Resources Quick Reference Guides/Physician Guides Resources Tool Kits
For information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.

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INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

IOM CARE NEED Getting Better Staying Healthy IOM DOMAIN Effectiveness Patient-centeredness
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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

Heart and Stroke Foundation of Ontario, Registered Nurses Association of Ontario (RNAO). Nursing management of hypertension. Toronto (ON): Heart and Stroke Foundation of Ontario and Registered Nurses Association of Ontario (RNAO); 2005 Oct. 136 p. [155 references]

ADAPTATION Not applicable: The guideline was not adapted from another source. DATE RELEASED 2005 Oct GUIDELINE DEVELOPER(S) Heart and Stroke Foundation of Ontario - Medical Specialty Society Registered Nurses' Association of Ontario - Professional Association SOURCE(S) OF FUNDING Funding was provided by the Ontario Ministry of Health and Long Term Care-Primary Health Care Transition Fund. GUIDELINE COMMITTEE Not stated COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE Development Panel Members Cindy Bolton, RN, BNSc, MBA Team Leader Telestroke Project Leader Kingston General Hospital Kingston, Ontario Armi Armesto, RN, BScN, MHSM Clinical Nurse Specialist Sunnybrook and Women's Regional Stroke Centre, North and East Toronto, Ontario Linda Belford, RN, MN, CCN(c), ENC(c) Acute Care Nurse Practitioner University Health Network Toronto, Ontario Anna Bluvol, RN, MScN Nurse Clinician, Stroke Rehabilitation St. Joseph's Health Care

Parkwood Site London, Ontario Heather DeWagner, RN, BScN Nurse Clinician -- Stroke Strategy Chatham-Kent Health Alliance Stroke Secondary Prevention Clinic Chatham, Ontario Elaine Edwards, RN, BScN Clinical Stroke Nurse Thunder Bay Regional Health Sciences Centre Thunder Bay, Ontario BettyAnn Flogen, RN, BScN, MEd, ACNP Clinical Nurse Specialist Brain Health Centre Interim Nurse Clinician Stroke and Cognition Clinic Baycrest Centre for Geriatric Care Toronto, Ontario Elizabeth Hill, RN, MN, ACNP, GNC(c) Acute Care Nurse Practitioner Chronic Obstructive Pulmonary Disease Kingston General Hospital Kingston, Ontario Hazelynn Kinney, RN, BScN, MN Clinical Nurse Specialist South East Toronto Regional Stroke Network St. Michael's Hospital Toronto, Ontario Charmaine Martin, RN, BScN, MSc(T), ACNP Clinical Nurse Specialist/Acute Care Nurse Practitioner, Stroke Hamilton Health Sciences Centre Hamilton General Site Hamilton, Ontario Cheryl Mayer, RN, MScN Clinical Nurse Specialist/Secondary Prevention Stroke London Health Sciences Centre--University Campus London, Ontario Connie McCallum, RN(EC), BScN Nurse Practitioner Stroke Prevention Clinic Niagara Falls, Ontario

Heather McConnell, RN, BScN, MA(Ed) Facilitator -- Program Manager Nursing Best Practice Guidelines Program Registered Nurses Association of Ontario Toronto, Ontario Mary Ellen Miller, RN, BScN Nurse Specialist District Stroke Centre Royal Victoria Hospital Barrie, Ontario Susan Oates, RN, MScN Advanced Practice Nurse -- Rehabilitation West Park Healthcare Centre Toronto, Ontario Tracy Saarinen, RN, BScN Secondary Stroke Prevention Nurse Thunder Bay Regional Health Sciences Centre