Managing Hypertension: 4 Strategies to Improve Blood Pressure Control

Allison Dillon PhD RN

Hypertension, or high blood pressure, is a condition that affects almost half of the adult population in the United States. According to the CDC, only 1 out of every 4 adults with hypertension has adequate blood pressure control. As nurses, we know poorly controlled blood pressure can contribute to an increase in the incidence of heart attack and stroke which are the 2 leading causes of death in the United States. Given these statistics, it's clear that many hypertensive patients need to improve their blood pressure control to reduce their risk of heart attack, stroke, congestive heart failure, vision, renal disease or failure, and sexual dysfunction. What can we do as nurses to help our patients improve control over their blood pressure? We can begin by using the four strategies discussed below.

Strategy 1: Ensure Accurate Measurement of Blood Pressure

Ensuring accurate measurement of blood pressure applies both in the physician's office and at home. Measuring blood pressure in a clinic setting is simple and quick but can be error-prone. To achieve the best reading use a device that has been validated and calibrated. Select the proper sized cuff and support the patient's arm. Ensure the patient is sitting with feet on the floor for more than 5 minutes, has voided prior to measurement, has not smoked, exercised, or had caffeine within the last 30 minutes, both patient and examiner are quiet, and that clothing is not obstructing the blood pressure cuff. An automated blood pressure cuff can be extremely helpful for patients who experience the "white-coat" phenomenon since the patient can be left alone. If this is the patient's first visit, measure blood pressure in each arm and record the higher reading and the arm it was measured from for pressures to be taken later. Document the systolic and diastolic readings and the time, if applicable, the last blood pressure medicine was taken. If multiple readings are necessary, separate each reading by 1-3 minutes. Ideally, take 2 readings on 2 different visits or 2 different times during one visit and average these readings to estimate a patient's "true" blood pressure.

While measuring blood pressure outside of the clinic is helpful to confirm hypertension and for medication management, there are more factors that can contribute to erroneous readings. In order to reduce the potential for error with home readings, educate and supervise patients regarding the selection of blood pressure equipment, that readings can fluctuate significantly and what the readings mean for them. Instruct and have the patient demonstrate the proper position and technique for measuring their blood pressure. Remind the patient not to smoke, consume caffeine or exercise 30 minutes prior to taking their blood pressure. Advise the patient to take 2 readings a minute apart prior to taking the morning medicine and again prior to their evening meal and have them record these measurements to bring to clinic appointments.

Strategy 2: Get to Know Your Patient

Understanding who makes up the hypertensive population you treat is an important contributing factor to helping patients set and achieve their blood pressure goals. Ensure you understand your patient's cultural and social backgrounds since these can affect their views on how their blood pressure is managed. For example, some patients may believe having a family history of hypertension means they have little control over developing or managing their blood pressure. Other patients may believe since they don't feel "sick" or have no symptoms that nothing is wrong with them. Assess your patient's health literacy and educate them on what high blood pressure means, what happens if it's not treated, lifestyle modifications they can make, and medicines they can take to manage their condition. Help your patients set goals by listening to and addressing their concerns about hypertension management and potential barriers they may face; incorporate these into developing a specific treatment plan for them.

Strategy 3: Improve Medication Adherence

Changes in lifestyle and behavior can be difficult for many patients for various reasons. Among patients with hypertension, non-compliance with treatment is an important contributing factor to poor blood pressure control. In fact, approximately 20% of patients with hypertension successfully achieve the benefits of significantly reducing the morbidity and mortality associated with cardiovascular disease. There are a few things we can do to help our patients improve their medication adherence. One useful tool is a medication adherence scale which is helpful for identifying any barriers a patient may have with medication adherence. Since hypertension often has no symptoms it is important to frequently remind our patients about the potential for other chronic diseases related to hypertension as this will help to reinforce the "why" for medication compliance. We also need to tell our patients about the side effects of the medications and emphasize the importance of contacting their primary care team if they have any side effects. They need to be aware of the dangers of suddenly stopping their medications such as rebound hypertension, hospitalization from a hypertensive crisis and the potential for stroke. A complex, multi-dose, multi-time medication regimen may be difficult for patients to follow and stick to. When possible, use fixed-dose combination medications and medications that can be taken once a day. Help patients develop a routine for taking their medication by incorporating it with an activity of daily living. Pillboxes can be helpful if multiple daily doses are needed. Many patients now have smartphones and setting medication reminders can also be useful for adhering to their medication regimen.

Strategy 4: Use HIT to Identify Untreated and Undertreated Patients

Health Information Technology can be an extremely useful tool for hypertension management. The electronic health record (EHR) often contains a data tool that allows for simple data mining. While these built-in data tools are helpful for broad queries and reports they often don't allow us to perform the more detailed data mining we may need. HIT departments within the healthcare system can be an invaluable resource for mining detailed clinical data. For example, questions (queries) can be run using algorithms to identify not only patients with hypertension who may be undertreated but also those who are untreated or at risk for hypertension. Furthermore, queries can provide clinicians with information on which patients need to have blood pressure measurements taken, the last time a patient was seen for a blood pressure-related event (e.g., medication adjustment, abnormal readings, labs, etc.), medication refill status (may indicate potential barriers), frequently prescribed medications and dosages and for areas for quality improvement projects.

Successfully treating hypertension involves developing a collaborative plan with our patients to help them achieve blood pressure control. As members of the healthcare team or as providers ourselves we need to ensure we are accurately measuring patient blood pressures and using HIT to improve and provide the best care for our patients. We also need to learn about our patients and what factors may influence their daily lives. We need to identify potential barriers and help our patients understand how the long-term effects of uncontrolled hypertension will affect their quality of life. By doing this we can foster the need for medication adherence and other healthy habits. Helping our patients reach their blood pressure goal is critical for managing their hypertension.

References/Resources

CDC: Facts about Hypertension

American Heart Association: The Facts About High Blood Pressure

AHA High Blood Pressure Toolkit

AHA: Health Threats from High Blood Pressure

AHA Journals: Hypertension

AHA: Common High Blood Pressure Myths