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2.

1 Definition
High blood pressure is a common disorder in which blood pressure remains
abnormally high (a reading of 140/90 mm Hg or greater) (Princeton, 2009).
According to the nurses dictionary, high blood pressure is elevation of the
arterial blood pressure that is, the rise of the arterial blood pressure above the
normal range expected in a particular age group. It may be of unknown origin
(essential hypertension) or from disease (secondary hypertension).

2.2 Why Is High Blood Pressure a clinical concern?


High blood pressure is dangerous because it causes the heart to work too hard,
making the walls of the arteries also hard. High blood pressure increases the risk
for heart disease and stroke, the first and third leading causes of death for
Americans and Singaporeans. High blood pressure can also cause other
problems, such as heart failure, kidney disease, and blindness. (Kannel WB,
1996).
2.3 Causes and Predisposing Factors
Blood pressure measurements are the result of the force of the blood produced
by the heart and the size and condition of the arteries. Many factors can affect
blood pressure, including:

• How much water and salt you have in your body


• The condition of your kidneys, nervous system, or blood vessels
• The levels of different body hormones

High blood pressure can affect all types of people. There is a higher risk of
high blood pressure if there is a family history of the disease. High blood
pressure is more common in African Americans than Caucasians. Smoking,
obesity, and diabetes are all risk factors for hypertension. When no cause is
identified, it is called ‘Essential hypertension’ (Williams B et al, 2004).
High blood pressure that results from a specific condition, habit, or medication
is called ‘Secondary hypertension’. Too much salt in your diet can lead to high
blood pressure. Secondary hypertension may also be due to: adrenal gland
tumor, alcohol abuse, anxiety and stress, arteriosclerosis, birth control pills,
Cocaine use, cushing syndrome, diabetes, kidney disease, ( glomerulonephritis
inflammation of kidneys), kidney failure, renal artery stenosis, renal vascular
obstruction or narrowing), medications ,appetite suppressants, Certain cold
medications, corticosteroids, migraine medications, hemolytic-uremic
syndrome, henoch-schonlein purpura, obesity, pain, periarteritis nodosa,
pheochromocytoma, pregnancy (called gestational hypertension), primary
hyperaldosteronism, renal artery stenosis, retroperitoneal fibrosis, wilms' tumor.
( Williams B et al, 2004).

2.4 Categorizing High blood pressure

Category Systolic Diastolic


Optimal < 120 and < 80
Normal 120 - 129 and/or 80 - 84
High Normal 130 - 139 and/or 85 - 89
Grade 1 hypertension 140 - 159 and/or 90 - 99
Grade 2 hypertension 160 - 179 and/or 100 - 109
Grade 3 hypertension ≥ 180 and/or ≥ 110
Isolated systolic hypertension ≥ 140 and < 90
(ESH-2007 guidelines – 2007 guidelines for hypertension)

2.5 Effect of high blood pressure


Brain: High blood pressure is the most important risk factor for stroke. Very
high pressure can cause a rupture in a blood vessel within the brain, which
could cause a stroke. If a blood clot occludes one of the narrowed arteries, it can
also cause a stroke (S Ross, et al 2004).
Eyes: High blood pressure can eventually cause blood vessels in the eye to
rupture. Vision may become blurred or otherwise impaired and can result in
blindness (S Ross, et al 2004).
.
Arteries: As people get older, arteries throughout the body "harden," especially
those in the heart, brain, and kidneys. High blood pressure is associated with
these “stiffer” arteries. This, in turn causes the heart and kidneys to work harder
(S Ross, et al 2004).
Kidneys: The kidneys act as filters, getting rid of the body’s wastes. Over time,
high blood pressure can narrow and thicken the blood vessels of the kidneys. In
which case, the kidneys filter less fluid and waste builds up in the blood and
eventually the kidneys may fail. When this happens, medical treatment
(dialysis) or a kidney transplant may be needed (S Ross, et al 2004).
.
Heart Attack: High blood pressure is a major risk factor for heart attack. The
arteries bring oxygen-carrying blood to the heart’s muscle. If the heart cannot
get enough oxygen, chest pain, also known as "angina," can occur. If the flow of
blood is blocked, a heart attacks results (S Ross, et al 2004).

Congestive Heart Failure: High blood pressure is the number one risk factor
for congestive heart failure (CHF). CHF is a serious condition in which the
heart is unable to pump enough blood to supply the body's needs. In most cases,
these emergencies arise because high blood pressure has not been adequately
controlled. (S Ross, et al 2004).

2.5.1 Other possible dangers of high blood pressure


Evidence is mounting about the fact that high blood pressure can also affect
other areas of the body, leading to such problems as:
i) Sexual dysfunction: Although the inability to have and maintain an
erection (erectile dysfunction) becomes increasingly common in men as
they reach age 50, it is even more likely to occur if they have high blood
pressure, too. Evidence linking high blood pressure to sexual dysfunction
in women is not conclusive (S Ross, et al 2004).
ii) Bone loss: High blood pressure can increase the amount of calcium that
is in your urine. The excessive elimination of calcium may lead to loss of
bone density (osteoporosis), which in turn can lead to broken bones. The
risk is especially increased in older women (S Ross, et al 2004).
iii) Sleep disorders: Obstructive sleep apnea (a condition where your throat
muscles relax causing you to snore loudly) occurs in more than half of
those with high blood pressure. It is now thought that high blood pressure
itself may help trigger sleep apnea. Also, sleep deprivation resulting from
sleep apnea can raise patients’ blood pressure (S Ross,et al 2004).

2.6 Diet and Hypertension

Hypertension cannot be cured, but it can be controlled through lifestyle changes


and prescriptive medication. While medications to treat hypertension are
available, research has shown that modest lifestyle and dietary changes can help
treat and often delay or prevent high blood pressure. People trying to control
hypertension often are advised to decrease sodium, increase potassium, watch
their calories, and maintain a reasonable weight.

For sodium-sensitive people, reducing sodium is a prudent approach to reducing


the risk of hypertension. The recommendation for daily sodium intake is 1,500
to 2,300 mg a day. According to Midgley, dietary Na restriction for older
hypertensive individuals might be considered, but the evidence in the
normotensive population does not support current recommendations for
universal dietary sodium restriction”

The amount of potassium in the diet is also important. Potassium works with
sodium to regulate the body’s water balance. Research has shown that the more
potassium and less sodium a person has in his/her diet, the greater the likelihood
that the person will maintain normal blood pressure. However, the evidence
does not suggest that people with high blood pressure should take potassium
supplements. Instead, potassium rich foods should be eaten everyday (Midgley
et al, 1996).

A newer area of interest is the relationship between calcium and high blood
pressure. People with a low calcium intake seem to be at increased risk for
hypertension. Everyone should meet the Dietary Reference Intake (DRI) for
calcium every day. For adults, this is 1,000 mg per day. For adults over 50,
1,200 mg is recommended ( J. Anderson, L. Young and E. Long, 2009).

2.6.1 The DASH Diet (Dietary Approaches to Stop Hypertension)

Recommended by the American Heart Association and the National Cancer


Institute, the DASH diet is an overall eating plan that focuses on what people
should eat, rather than what not to eat. The DASH Diet is rich in fruits,
vegetables, complex carbohydrates and low-fat dairy products, the DASH diet is
lower in fat, saturated fat, cholesterol, and sodium, and higher in potassium,
magnesium, and calcium than the typical American diet. The high levels of
potassium, magnesium, and calcium in the DASH diet are thought to be at least
partially responsible for its results. (New England Journal of Medicine, 1997).
The table below represents a summary of the DASH Diet

Significance to the DASH


Food Group Diet
Grains and grain
Carbohydrates and fibre
products
Potassium, magnesium and
Vegetables
fibre
Potassium, magnesium and
Fruits
fibre
Low-fat or fat free milk Calcium, protein, potassium
or milk products and magnesium
Meats, poultry and fish Protein and magnesium
Magnesium, potassium,
Nuts, seeds and beans
protein and fibre
( New England Journal of Medicine, 1997).

2.7 Noncompliance to hypertensive treatment


2.7.1 A global view
According to the Canadian Hypertension Society (Canadian Hypertension
Education Program, 2008), hypertension remains a significant health problem
that is projected to become a greater global burden in the next 20 years.
Internationally, the estimated total number of adults with hypertension in the
year 2000 was 972 million; 333 million in economically developed countries.
Current trends suggest that the number of adults with hypertension will increase
by about 60% to a total of 1.56 billion by the year 2025. Despite the availability
of effective treatment, more than half of patients treated for hypertension drop
out of care entirely within a year of diagnosis. Fifty per cent of patients who
remain under medical supervision take only 80% of their prescribed
medications. As a result, 75% of patients with a diagnosis of hypertension do
not achieve optimum blood pressure control due to poor adherence to anti-
hypertensive treatment. Nurses represent a formidable force in improving
adherence and care outcomes by understanding the dynamics of compliance,
and employing techniques in assessing and monitoring the problems of non
adherence. Nurses are well positioned to effectively use sustained strategies to
improve adherence, thereby decreasing the global burden of hypertension
(Jayasinghe J, 2009).
According to Haynes RB, Taylor DW,and Sackett, noncompliance with
treatment has long been the plague of national and international health-
care systems. Each year it is estimated that noncompliance with
medication, costs the UK economy billions of pounds, as a result of
preventable hospital admissions and loss of productivity due to illness. In
addition, noncompliance has been identified as the predominant reason
for the failure of medical therapy and disease progression. Compliance
has been defined as the extent to which a person's behaviour coincides
with medical care or advice. In the management of hypertension, figures
from the United States suggest that noncompliance with medication may
be as high as 50–80%, with compliance decreasing rapidly over time.
Based on the current definition of hypertension (blood pressure (BP) of
140/90 mm Hg), the 1998 Health Survey for England revealed that 42%
and 33% of adult ( 16 years) men and women, respectively, were
hypertensive. Fewer than 10% of hypertensive patients in the western
world currently achieve the recommended target BP of <140/90 mmHg. A
recent study, based on a meta-analysis of 61 prospective BP studies,
calculated that if all hypertensive patients in the UK reduced their systolic
BP to <140 mmHg, approximately 21,400 stroke deaths, 41,400 ischaemic
heart disease (IHD) deaths, and 125,600 events (nonfatal stroke or IHD)
could be prevented each year. In the face of such overwhelming evidence
of the benefits of BP reduction, less than one in 10 people in the UK
achieve adequate control of their BP? (G Thrall, et al 2004).

2.7.2 The situation in Africa


Hypertension is the commonest cardiovascular disease in Africans occurring in
more than 15% of the adult population in some studies. It occurs in the
lower as much as in the higher socio-economic groups. Recent studies have
confirmed earlier findings that essential hypertension in Africans is
characterised by volume loading, low plasma renin activity, high salt taste
threshold, high urinary sodium and low potassium excretion and high
plasma aldosterone. The commonest complication of hypertension in
Africans is congestive cardiac failure followed by cerebrovascular
accidents. Coronary heart disease is usually a rare case. Even in the absence
of overt heart failure and compounding factors like obesity, alcoholism,
cigarette smoking, diabetes mellitus and myocarditis, evidence of abnormal
left ventricular morphology and function is often present in newly
diagnosed patients with moderate or severe hypertension. Cost of drugs is
the most important determinant of compliance with drug treatment and
consequently the likelihood of progression of the diseases to more severe
forms in long term follow-up. Non compliance could also result from
cultural beliefs where the use of traditional medication is preferred to
medically prescribed drugs. (Salako LA ,1993),

According to Nuria Homedes and Antonio Ugalde, very little is known about
compliance to hypertensive treatment in the third world but there is generally
low levels of adherence to prescribed therapy. This has raise questions about
the quality of care provided to hypertensive patients. Nurse-patient relationship
is an important component in ensuring compliance of hypertensive patients to
prescribed therapy. In the African setting there is a strain in this relationship
which is also an important factor of noncompliance to therapy. In Africa there is
insufficiency of specialised nurses in hypertensive care. This has led to an
increased rate of heart attack, stroke and other adverse effects of the disease in
Africa.
2.7.3 The situation in Cameroon
2.8 Reasons for non-compliance to drug prescribed therapy
Various explanations have been proffered to explain why such a large
percentage of patients have resistant hypertension, including secondary
hypertension and endogenous resistance to treatment. However, the main reason
for inadequate control of BP is poor compliance with the treatment regimen,
both pharmacological and behavioural (e.g, weight reduction, sodium intake
restriction, and exercise). Understanding the reasons for patient noncompliance
with antihypertensive medication is essential if BP is to be more effectively
managed.( Johnson R,1993).
Much of the earlier research focused on identifying patient characteristics of
noncompliant individuals and the complexity of the medication regimen. BP
control typically requires more than one antihypertensive medication and the
frequency of dosing may vary. The complexity of the drug regimen effects
compliance; compliance among hypertensive patients improves considerably
when drugs are prescribed just once a day. In addition, many patients
experience unpleasant side effects from their medication that may be
unacceptable in a largely asymptomatic disease. This is often reported as one of
the main reasons for non or partial compliance. However, more recent studies
have focused on patient's decisions and the complex relationship between the
patient and physician as possible mediating factors for compliance.
Psychological and emotional factors of the patient may also play an important
role in determining compliance with medication. In this issue the Ross et al
examine the psychological and emotional effect of illness perceptions and
treatment beliefs on patient compliance to antihypertensive medication. Patients
who believed in the necessity of the medication were more likely to be
compliant with antihypertensive therapy than those who felt it was unnecessary.
This interesting study also demonstrates that patients who have a higher
emotional response to illness and believe they have lower personal control over
the disease are less likely to be compliant.

2.9 Non-compliance: A Problem for Patients and Nurses


Noncompliance is a serious healthcare problem with far-reaching consequences
for patients, nurses and doctors. Today’s patients are better informed about their
health than ever before. Or, at least, they think they are. That may be why some
of them don’t follow directions.
The significance of the problem is indicated in statistics showing that up to half
of all patients fail to follow their prescribed drug regimens, with 5% to 20% of
prescriptions never even being filled ( Barbara Worsley,2008 )
“Non-compliance often has very practical reasons behind it,” says Judy Z. Segal
PhD, an associate professor at the University of British Columbia, Vancouver.
“People can be confused about dosing schedules or cannot tolerate side effects.
But I think most often nurses and doctors have failed to persuade patients that
complying is in their own best interest. The idea is that people need good
reasons, sometimes very specific reasons, for following their medical advice.”
Nurses and physicians must always keep in mind that patients are experts about
their own lives and experience, but their patients don’t have the same
knowledge as they do.
Segal suggests that one reason patient compliance is not improving may be that
nurses don’t believe it’s an issue among their own patients. It is a fact that many
times nurses and physicians don’t know if a patient is noncompliant or just
nonresponsive. Patients must trust nurses to the point that they feel comfortable
revealing personal compliance issues. Nurses probably think their patients
already trust them.
Many nurses feel there is a certain level of responsibility for patients to follow
through and take care of themselves. But how patients feel about the message
and the messenger (nurse) is a decisive factor in their compliance. And, on
some level, noncompliant patients may not be buying into what nurses tell them.
The biggest motivator for patients today is still the nurse. Compliance generally
increases if patients are given clear and understandable information about their
condition and progress in a sincere and responsive way. To the nurse it makes
perfect sense to say to the patient, “the therapy has been recommended because,
if left untreated, your hypertension could increase your risk of renal failure,
myocardial infarction, and cerebral haemorrhage.” However, it would make
absolutely no sense at all to many patients, leaving them more puzzled than
motivated to comply with the providers’ recommendations.(Barbara
Worsley,2009)

2.10 Achieving compliance to prescribed therapy


One of the most effective ways to enhance compliance is for the nurse to
simplify the patient’s instructions or treatment regimen as much as possible.
Changing medications to suit patients work schedule e.g. Changing a patient’s
medication to one that can be taken once a day in the case of a shift worker
could help the patient be more compliant with his or her treatment regimen. The
nurse can also boost patient compliance regarding preventive care and check-
ups by having systems in place to cause patient appointment reminders. Patients
should always get the sense that their nurse cares about them and their health.
Compliance also increases if the nurse listens and respects patients’ concerns.
Finding out patients’ attitudes and past experiences can deeply affect
compliance and save time and problems later. Patients who do not adhere to
physician instructions or recommended follow-up treatment plans are not only
difficult to manage, they often present significant risk management concerns for
the nurse.( Svensson et al, 2000).

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