Nursing Management of

Hypertension

Cindy Bolton
Team Leader, Development Panel

 Partnership: Heart and

Stroke Foundation of Ontario
and the Registered Nurses
Association of Ontario
Funding: Ministry of Health
and Long-Term Care,
Primary Health Care
Transition Fund
AIM Initiative: Improving
the management of high
blood pressure by doctors,
nurses and pharmacists

Guideline Development

Cindy Bolton, RN, BNSc, MBA

Armi Armesto, RN, BScN, MHSM
Linda Belford, RN, MN, CCN(c), ENC(c)
Anna Bluvol, RN, MScN
Heather DeWagner, RN, BScN
Elaine Edwards, RN, BScN
BettyAnn Flogen, RN, BScN, MEd, ACNP
Elizabeth Hill, RN, MN, ACNP, GNC(c)
Hazelynn Kinney, RN, BScN, MN
Charmaine Martin, RN, BScN, MSc(T), ACNP
Cheryl Mayer, RN, MScN
Connie McCallum, RN(EC), BScN
Heather McConnell, RN, BScN, MA(Ed)
Mary Ellen Miller, RN, BScN
Susan Oates, RN, MScN
Tracy Saarinen, RN, BScN
Debbie Selkirk, RN(EC), BScN, ENC(c)

WHAT ARE GUIDELINES?

Systematically developed statements
to assist practitioners and patient
decisions about appropriate health
care for specific clinical (practice)
circumstances.
Field and Lohr, 1990
Best Practice Guidelines are
developed using the best
available evidence.

Planning
Development
Evaluation
Dissemination
Revision

The guideline Nursing Management of

Hypertension has been endorsed by the
Canadian Hypertension Education
Program.

Hypertension
Is the most important modifiable risk factor for stroke.
High blood pressure increases the risk of ischemic
heart disease by 3-4 fold
The incidence of stroke increases approximately 8
fold in persons with definite hypertension
It has been estimated that 40% of cases of acute MI
or stroke are attributable to hypertension

Classification of Hypertension:
WHO/ISH*
Category

Systolic

Diastolic

Optimal
Normal
High Normal

< 120
<130
130-139

<80
<85
85-89

Grade 1 (mild hypertension)

- Subgroup: borderline

140-159
140-149

90-99
90-94

Grade 2 (moderate hypertension)

160-179

100-109

Grade 3 (severe Hypertension)

180

110

Isolated Systolic Hypertension (ISH)

- Subgroup (borderline)

140
140-149

<90
<90

*Reproduced with permission * World Health Organization

ISH International Society of Hypertension

National Institutes of Health

Classification
Category
Optimal

Systolic
< 120

Diastolic
<80

Pre-hypertensive

120-139

80-89

Hypertensive

140

90

Stage 1

140-159

90-99

Stage 2

160

100

National Institutes of Health 2003

Practice
Recommendations

Detection and Diagnosis

Nurses will
Take every appropriate opportunity to assess BP of
adults to facilitate early detection of hypertension
Utilize correct technique, appropriate cuff size and
properly maintained/calibrated equipment
Be knowledgeable regarding the process involved in
diagnosis
Educate clients on their target BP and importance of
achieving and maintaining target

Identify 5 (or More) Measurement Errors

With permission: Vanasse A. Module d'autoformation # 17, l'Hypertension.

Which of the following is the

correct position?

Cuff size
inappropriate cuff size is the most
frequent error in clinic-based
BP assessment

Arm circumference (cm)

Size of Cuff (cm)

From 18 to 26

9 x 18 (child)

From 26 to 33

12 x 23 (standard adult
model)

From 33 to 41

15 x 33 (large, obese)

More than 41

18 x 36 (extra large,
obese)

Blood Pressure Assessment:

Patient preparation and posture
Standardized technique:
The patient should be calmly seated
for at least 5 minutes, with his or her
back well supported and arm
supported at the level of the heart.
His or her feet should touch the floor
and legs should not be crossed.
The patient should be instructed not
to talk prior and during the
procedure.

Recommended Technique
for Measuring Blood Pressure
Standardized technique:

Use a mercury manometer or a

recently calibrated aneroid or a
validated electronic device.

Aneroid devices should only be

used if there is an established
calibration check every 6-12
months.

Diagnostic algorithm
Elevated
Elevated Out
Out of
of the
the
Office
Office BP
BP
measurement
measurement

Elevated
Elevated Random
Random
Office
Office BP
BP
Measurement
Measurement

Hypertension
Hypertension Visit
Visit 11

Hypertensive
Hypertensive
Urgency
Urgency //
Emergency
Emergency

BP
BP Measurement,
Measurement,
History
and
History and Physical
Physical examination
examination
Diagnostic
Diagnostic tests
tests ordering
ordering
at
at visit
visit 11 or
or 22

Hypertension Visit 2
within 1 month
Target
Target organ
organ damage
damage
or
or Diabetes
Diabetes
or
Chronic
or Chronic Kidney
Kidney Disease
Disease
or
or BP
BP 180/110?
180/110?

No

BP:
BP: 140-179
140-179 // 90-109
90-109

Yes

Diagnosis
Diagnosis
of
of HTN
HTN

Diagnostic algorithm
BP:
BP: 140-179
140-179 // 90-109
90-109

24-h
24-h ABPM
ABPM (If
(If available)
available)

Clinic
Clinic BP
BP

S/H
S/H BPM
BPM (If
(If available)
available)

Hypertension visit 3
160 SBP or
100 DBP
< 160 / 100

Diagnosis
of HTN

or

ABPM or S/H
BPM if available

Awake
Awake BP
BP
<< 135/85
135/85 or
or
24-hour
24-hour
<< 130/80
130/80

Awake
Awake BP
BP
135
135 SBP
SBP or
or
85
85 DBP
DBP or
or
24-hour
24-hour
130
130 SBP
SBP or
or
80
DBP
80 DBP

Continue to
follow-up

Diagnosis
of HTN

Hypertension visit 4-5

140 SBP or
90 DBP

< 140 / 90

Diagnosis
of HTN

Continue to
follow-up

<< 135/85
135/85

135/85
135/85

or

Continue to
follow-up

Diagnosis
of HTN

Acute Care
Diagnosis can be made
During first visit if hypertensive emergency (see
Appendix G)
During second visit if TOD (retinopathy, renal
disease, stroke/TIA, MI), diabetes

Diagnosis of uncomplicated hypertension

may be difficult in hospital because of
physiological response to pain, illness &
surgery

Threshold for Initiation of Treatment

and Target Values
Condition

Initiation of
Pharmacotherapy
SBP/DBP mmHg
140/90

Target
SBP/DBP

160

<140

Diabetes

130/80

<130/80

Renal disease

130/80

<130/80

Proteinuria >1 g/day

125/75

<125/75

Diastolic systolic
hypertension
Isolated systolic
hypertension

<140/90

Source: 2005 Canadian Hypertension Education Program Recommendations

Assessment and Development of

a Lifestyle Treatment Plan
Recommendations to address:
All lifestyle factors that influence hypertension
Dietary risk factors and specific diet
recommendations (DASH)
Dietary sodium
Weight, BMI and WC
Physical activity
Alcohol use
Smoking cessation
Managing stress

Summary Lifestyle Changes in

Hypertensive Adults :

Intervention

Target

Sodium reduction

65-100 mmol/day

Diet

DASH diet

Exercise
Weight loss
Waist
circumference
Alcohol reduction

30-60 minutes at least 4x/week

BMI <25 kg/m2
Men 102 cm (40 in) & women 88
cm (35 in)
<2 drinks/day

Smoking

Smoke free environment

Source: Adapted from CHEP 2005 Recommendations

Impact of Lifestyle Therapies on

BP in Hypertensive Adults
Intervention

Targeted Change

SBP/DBP

Sodium reduction

100 mmol or 1
tsp/day

5.8/-2.5

Dietary Patterns

DASH diet

11.4/-5.5

Exercise*

3 times/week

-7.4/-5.8

Weight loss

4.5 kg

7.2/-5.9

Alcohol reduction

2.7 drinks/day

4.6/-2.3

Source: Miller ER et al. Results of aggregate and meta analysis of short term trials.
J Clin Hyper 1999;3:191-8.
* Exercise and Hypertension, Medicine and Science in Sports & Exercise 2004;36(3).

Monitoring and Follow up

Nurses will:
Advocate that clients who are on anti-hypertensive
treatment receive appropriate follow up in
collaboration with the health care team

Medications
Nurses will:
Obtain clients medication history (prescribed, OTC, herbal and
illicit drug use)

Be knowledgeable about the classes of medications that may

be prescribed for clients diagnosed with hypertension
(Diuretics, ACE inhibitors, ARBs, Blockers and Calcium
Channel Blockers)

Appendix O (Summary of classes of medications) helpful review

of 5 classes of antihypertensive meds

Provide education regarding pharmacological management (in

collaboration with physicians and pharmacists)

Adherence
Adherence is the extent to which a clients behaviour
(taking medication, following a diet, modifying habits
or attending clinic visits) coincides with health care
advice.
Adherence is the single most important modifiable
risk factor that compromises treatment outcome
(WHO, 2003, Haynes et al., 2003)

Assessment of Adherence
Nurses will:
Endeavour to establish a therapeutic relationship
with clients
Explore clients expectations and beliefs regarding
hypertension management
Assess adherence to treatment plan at every
appropriate visit

Promotion of Adherence
Nurses will:

Provide information needed for clients with hypertension to

make educated choices related to treatment plan

Work with prescribers to simplify clients dosing regimens

(Level 1a)

Encourage routine and reminders to facilitate adherence

(Level 1a)

Ensure that all clients who miss appointments receive follow up

telephone calls in order to keep them in care

Documentation
Nurses will:
Document and share comprehensive information
regarding hypertension management with the client
and health care team.

Appendices

Glossary
Medication costs and programs
Stages of change model
Motivational interviewing
Client education for home BPM
Hypertensive urgencies/emergencies
DASH diet, reducing sodium and the DASH diet, recording food
habits and DASH
Canadian Body Weight classification system
Assessing alcohol consumption
Smoking Cessation Brief intervention
How vulnerable are you to stress?
Summary of medication classes prescribed for hypertension
BP follow up algorithm
Educational resources and web sites

To download the guideline, visit the RNAO

website at:

www.rnao.org/bestpractices
A limited number are available free from
HSFO

csor@hsf.on.ca