POLSKI
Introduction
Arterial hypertension is a discrete disease that can develop secretly, unnoticed for many years, without giving any clear symptoms [1]. The first symptoms may include: deterioration of well-being, weakness, dizziness, headaches - especially in the occipital region, anxiety, palpitations, excessive sweating, decreased mental and physical fitness. Sometimes, however, there is a sudden increase in blood pressure, which manifests itself in nausea, a feeling of tightness in the chest, visual disturbances, a feeling of lack of air, and even neurological symptoms, e.g. speech disorders [2]. The diagnosis of hypertension itself seems to be a relatively simple task. Making a diagnosis is based on blood pressure measurements at intervals, exclusion of blood pressure distortions resulting from, for example, white coat syndrome or masked hypertension, and the correctness and repeatability of blood pressure measurements [3]. The diagnosis of hypertension is based on the performance of 3 types of tests:
The first one is the traditional office blood pressure measurement, it is performed in a doctor’s office. A very important element is the selection of the blood pressure cuff, it is also important to prepare the patient so that there is no clothing on the arm, the measurement should be performed after a 5-minute rest, the patient should not smoke cigarettes before the test, should not drink coffee, the arm should be placed at the level of the heart, stably supported on a table or desk. The first time the blood pressure measurement should be performed on both upper limbs, then subsequent measurements should be performed on the limb with the higher blood pressure value. Another method is to measure blood pressure at home, here the measurements are performed independently by the patient twice a day, preferably in the morning and in the evening, for several or a dozen days [4].
Another method of blood pressure monitoring is monitoring using a special portable device called Holter for 24 or 48 hours. The device turns on automatically every 1 hour, and during the night every 2 hours. It allows for recording blood pressure during daytime activities as well as during sleep at night. The most common reasons for setting up and recording blood pressure are: blood pressure variability during the day, suspicion of white coat or masked hypertension, suspicion of hypertension at night or no drop in blood pressure at night [5]. The diagnosis of hypertension should be confirmed after several visits to the doctor’s office, after measurements taken at home and after analysis of blood pressure with a 24-hour Holter device.
Causes of primary (essential) hypertension
The cause of hypertension is seen in primary factors, which affect 90-95% of cases and is more difficult to treat due to its complexity and cause. Another cause of hypertension is seen in secondary factors, which affect 5-10% of cases and here the cause is easier to identify and treat [6]. Many factors that support each other, including genetic and environmental conditions, may contribute to the development of primary hypertension. The most common increase in hypertension is observed with age. Additionally, there is a constant migration of people to larger cities in search of work. In addition, there is enormous progress and economic development, which increases consumerism and goes hand in hand with a poor diet and low physical activity [7].
Dietary errors are one of the most common causes of high blood pressure. As a result of excessive salt consumption, the volume of body fluids increases and the cardiac output increases. Sodium chloride also affects kidney function.
Alcohol is another factor contributing to hypertension. It has been proven that consuming at least 30 g of ethanol daily increases the risk of developing hypertension three times.
Overweight and obesity are important causes contributing to the development of hypertension. It has been scientifically proven that every 5 kg of excess weight increases systolic blood pressure parameters by about 4.5 mmHg, in both men and women.
Low physical activity contributes to the occurrence of hypertension. It is known that with age, the activity and physical fitness of every person decreases, and a passive, inactive lifestyle increases the likelihood of developing hypertension.
Stress can affect the development of hypertension. A short stressful situation increases blood pressure, but this is transient and there is no confirmation that short-term stress is the cause of HT. However, during long-term mental stress, the body releases two hormones, adrenaline and cortisol, which cause blood vessels to constrict and the heart to beat faster, which in turn leads to an increase in blood pressure [8].
Genetic conditions have a major impact on the pathogenesis of hypertension. It is highly probable that if one of the parents suffered from hypertension, there is an increased risk of hypertension in the offspring. This applies to 45-85% of cases.
Causes of secondary hypertension (so-called symptomatic)
Obstructive sleep apnea is a disease in which breathing stops or becomes shallow during sleep. Recurrent apneas cause numerous consequences, including hypertension.
Renal diseases that disrupt the functioning of electrolytes and fluids, which can result in fluid retention and increased blood volume, which leads to increased blood pressure parameters.
Drugs such as nSaiDs, steroids, contraceptives, antidiabetic drugs (including DPP-4 inhibitors, thiazolidinediones, insulin) - chronic use of these substances may cause hypertension in the future.
Renovascular hypertension is caused by hormonal consequences caused by renal artery stenosis. It is one of the most common forms of secondary hypertension [9].
Adrenal diseases, including Cushing’s syndrome, which is characterized by an increased concentration of glycosteroids, these are hormones produced by the adrenal glands and controlled by the pituitary gland, responsible for the release, stimulation of cortisol secretion. Too high a concentration of cortisol is unfavorable for humans, water and sodium retention occurs in the body.
Thyroid dysfunction, hypothyroidism and hyperthyroidism, adversely affect metabolism and the quality of blood vessels, disturbing their elasticity and capacity, which is the cause of increased blood pressure.
Parathyroid gland disorders, which are responsible for regulating calcium levels. Too much parathyroid gland activity causes increased calcium concentration in the blood, changes appear in the blood vessels, and is also the cause of increased blood pressure.
Congenital heart defects such as coarctation of the aorta, consist in narrowing the lumen of the aorta, which in turn affects blood flow, increasing vascular resistance and raising blood pressure in the place above its narrowing [10].
Treatment
Arterial hypertension requires multi-level treatment, but its primary goal is to reduce the risk of cardiovascular complications such as heart and kidney failure and stroke. Each therapeutic procedure is individually tailored to the given case. Treatment of arterial hypertension includes pharmacological and non-pharmacological actions [11].
Pharmacological treatment is based on the use of antihypertensive drugs. There are five basic groups of drugs for arterial hypertension [12].
Thiazide diuretics are designed to stimulate urine secretion. These are drugs used in patients who have water retention in the body, through their diuretic action they lead to a reduction in blood pressure and thus reduce the load on the heart. These drugs are designed to block sodium reabsorption, maintain potassium in the body, and inhibit the absorption of sodium ions.
Beta-adrenergic blockers are drugs that block beta-adrenergic receptors. These drugs slow down the heart rate, reduce the cardiac output, inhibit renin secretion, and release noradrenaline from nerve endings. Their effect is to reduce blood flow to arteries, dilate blood vessels, and cause a drop in blood pressure.
Calcium channel blockers – their role is to inhibit calcium flow to muscle cells, cause relaxation of the smooth muscles of the vascular walls, dilate blood vessels, which leads to a decrease in blood pressure parameters.
Angiotensin-converting enzyme inhibitors – they reduce the production of angiotensin II. This is one of the strongest physiological vasoconstrictor factors. Inhibitors also inhibit the breakdown of bradykinin. They also lead to humoral, metabolic, and hemodynamic changes, which in turn lead to lower blood pressure.
Angiotensin receptor inhibitors are a group of drugs that block receptors for angiotensin II, as a result of which this substance cannot produce its effects. This leads to vasodilation and a reduction in excess sodium, which leads to hypertension [13].
In the case of pharmacological treatment, monotherapy or combined treatment also can be used. Monotherapy is a form of treatment used in stage I hypertension and low cardiovascular risk, it consists of recommending a single antihypertensive drug. Monotherapy treatment and the effect of this treatment may depend on many factors, such as the degree of hypertension, the presence of other diseases, the patient’s age or the patient’s response to drugs. This form of treatment includes, above all, the abovementioned groups of drugs, i.e.: angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, thiazide diuretics, beta-blockers and calcium channel blockers.[14]
Combined treatment is called a combined form of treatment of hypertension consisting of the simultaneous use of two or more antihypertensive drugs in order to achieve and maintain appropriate blood pressure values. Combined treatment is usually implemented when monotherapy is not sufficient. To achieve a better therapeutic effect, it is usually recommended to administer a drug from the diuretic group. Other drug combinations are also recommended, such as: an angiotensin-converting enzyme inhibitor and a calcium antagonist, a thiazide/thiazide-like diuretic and an angiotensin-converting enzyme inhibitor, angiotensin II receptor blocker and a thiazide diuretic, a calcium channel blocker and angiotensin II receptor blocker, a calcium channel blocker and a thiazide diuretic, a calcium channel blocker and a beta-blocker [15, 16].
Non-pharmacological methods of dealing with hypertension are a very important therapeutic aspect. Changing lifestyle is very important because it is not burdened with any side effects or costs, and undoubtedly has a huge impact on the quality and length of life [17]. For example, cigarette smoking is associated with an increase in comorbidities and complications. Therefore, non-pharmacological treatment should be used throughout life, regardless of the blood pressure value and regardless of whether the patient is treated with pills or not. [18] Another important aspect is a healthy, rational diet. People with hypertension are recommended to follow the DASH diet, which is based on 5-6 healthy, unprocessed meals a day, dominated by products rich in protein, vegetables and fruits rich in fiber. In this diet, it is very important to eliminate salt, which increases blood pressure, and limit saturated fats and alcohol [19,20]. Another element of non-pharmacological treatment is systematic physical exercise performed for about 30 minutes, which will help to lower blood pressure and reduce body weight in overweight people. An important aspect of preventing hypertension is stress management. These can be relaxation techniques or other forms aimed at maintaining mental balance [21,22]. Limiting alcohol consumption can have a positive effect on blood pressure and reduce cardiovascular risk. Alcohol taken regularly, even in small doses, can cause an increase in blood pressure. It is similar with smoking tobacco, both active and passive smoking are harmful to health, increase blood pressure values, increase cardiovascular risk [23,24]. Sleep is very important in non-pharmacological treatment, its deficiency, chronic sleep deprivation have a negative impact on the general health condition and are the cause of increased blood pressure values, and contribute to the development of many diseases [25,26].
It should be remembered that monitoring blood pressure parameters in a systematic way also contributes to the prevention of hypertension. It allows for control of the effectiveness of treatment, allows for a quick response and limits the development of changes. Non-pharmacological treatment of hypertension should be used as the first line of defense. It can be effective both independently and as a supplement to pharmacotherapy.
The aim of the study was to present the nursing problems and the care plan of a patient struggling with hypertension. Material and methods: The study used the individual case method (case study). The subject of the study was a 41-year-old patient who has been treated for hypertension for 20 years. The techniques used in the study included a nursing interview, observation, analysis of medical records and measurements. The research tool was an interview questionnaire. Organization and course of the study: The observation was conducted for a week during spontaneous and planned visits to the patient’s home environment after obtaining the consent of the patient and her family. Case description: The study included a 45-year-old woman. The patient lives with her family in a block of flats in the city. The patient has a university degree but is currently unemployed, takes care of two children and the house. Her husband is the sole breadwinner in the family.
The patient has been suffering from hypertension for a dozen or so years. During the first years of the disease, she sporadically attended doctor’s visits and took medications irregularly. Blood pressure fluctuations in the early years of the disease oscillated around 150/100 mm Hg.
She has been regularly seeing a cardiologist for 15 years. In 2012, during her first pregnancy, she took medication (Dopegyt). She was also hospitalized during pregnancy due to fluctuations in blood pressure, at that time the dose of the medication was increased. The delivery was terminated by caesarean section one month earlier than the due date due to hypertension. After the pregnancy, the patient returned to taking her previous medication (Co - Prestarium 5 mg + 5 mg). Five years later, the patient became pregnant for the second time. During pregnancy, she took medication (Dopegyt) due to persistently high blood pressure. Additionally, the pregnant woman had gestational diabetes. There was no need to take insulin. The delivery took place in the 36th week of pregnancy due to the threat to the child’s life due to abnormal umbilical cord flows. After delivery, the patient did not continue the treatment of hypertension in the cardiology clinic.
In 2020, during the Covid-19 Sars Cov 2 infection. The patient experienced spikes/fluctuations in blood pressure, shortness of breath, chest discomfort, dizziness and headaches, sleep disorders, palpitations, facial flushing, sweating, weakness and fatigue. After a year, she returned to cardiology treatment, currently attends regular visits, cardiology tests, takes medications. She took medications: Bibloc0.0025g and Primacor 0.01g. Over the past year, she lost 30kg and since September 2022, she has been taking only Bibloc 0.0025g.
Patient’s care problems As a result of the interview, personal observations and medical records of the patient and the measurements taken, the following patient’s care problems were identified.
Problem 1:
Improper health behaviors resulting from lack of awareness and knowledge about regular medication Goal:
Modification of health behaviors, mobilization to visit a doctor and encouragement to take medications regularly, as well as lifestyle changes
Nursing activities:
informing the patient about the nature and consequences of untreated hypertension
solving health problems by visiting a specialist
discussing the benefits of pharmacological and non-pharmacological treatment
explaining the relationship between the risk of developing complications
in the course of hypertension and the patient’s improper health behaviors
indicating factors that make it difficult or possible to change improper health behaviors, developing appropriate methods of treatment
using all aids that will help the patient to take medications regularly
providing the patient with educational materials on hypertension
Implementation of activities:
informing the patient about the nature and consequences of untreated hypertension (organ complications, increased risk of stroke, hemorrhage, myocardial infarction)
the benefits of pharmacological and non-pharmacological treatment were discussed with the patient
the relationship between the risk of developing complications in the course of hypertension and the patient’s inappropriate behaviors was explained
the patient was scheduled for a visit to a specialist
factors that make it difficult or possible to change inappropriate health behaviors were indicated (change in eating habits, physical activity, limiting stimulants)
the patient uses reminders in the phone application to remind her
of the need to take a pill and bought special organizers for medications
the patient was provided with educational materials on hypertension
Assessment:
After visiting the doctor, the patient is aware of the consequences of untreated hypertension, knows how important it is to take medications regularly. She takes medications regularly, and is slowly starting to change her eating habits.
Problem 2:
Risk of discontinuing antihypertensive therapy due to the belief that asymptomatic hypertension does not require pharmacological treatment.
Action objective:
Increasing awareness of the importance of continuous pharmacotherapy.
Nursing actions:
identifying factors that increase discontinuation of treatment,
assessing the patient’s attitude towards the disease
emphasizing the risks of irregular use of pharmacotherapy
discussing the potential side effects of antihypertensive drugs and explaining the need to report adverse effects
Action implementation:
explaining the patient’s concerns about discontinuing treatment
the patient has a positive attitude towards the disease
emphasizing the risks of irregular use of pharmacotherapy
discussing the potential side effects of antihypertensive drugs and explaining the need to report adverse effects
Assessment: The patient is eager to cooperate with the treatment, takes the drugs regularly.
Problem 3:
Overweight caused by poor eating habits and lack of physical activity.
Objective:
Changing eating habits, reducing body weight, introducing physical activity
Nursing activities:
explaining the effect of diet on blood pressure values
providing information on proper dietary management
motivating the patient to prepare dietary meals on her own
making the patient aware of the need to reduce salt intake in her daily diet
encouraging the patient to engage in daily physical activity
recommending that she measure her body weight at least once a week
suggesting a visit to a dietician to select an appropriate diet
suggesting a meeting with a physiotherapist to select appropriate exercises
Implementation:
explaining how a properly selected diet affects the reduction of blood pressure values
motivating the introduction of the DASH diet, which consists of vegetables, fruits, healthy fats, good sources of protein, limiting salt intake, giving up stimulants and heavily processed food
observing the patient to prepare meals on her own
making her aware of limiting salt, which increases blood pressure
the patient was encouraged to engage in daily physical activity, e.g. walking
the patient was advised to measure her weight once a week and record the results
a visit to a dietician was suggested
the physiotherapist selected appropriate exercises and motivated the patient
Assessment:
The patient is highly motivated to change, she feels that she has control over the entire process of change, e.g. by planning meals. She has met with a physiotherapist and is implementing physical activity into her daily schedule.
Problem 4:
Constipation due to low physical activity.
Goal:
Regulation of bowel movements.
Nursing activities:
Assessment of hydration and recommendation to drink about 2 liters of water per day
recommendation to eat more products with high fiber content and fruits and vegetables
control of the number of bowel movements
encouragement to increase physical activity, which will have a positive effect on metabolism
rotational massage of abdominal muscles
Implementation:
recommendation to drink about 2 liters of water per day
assessment of the patient’s eating habits, encouragement to eat more high-fiber products (fruit, vegetables, whole grain bread, bran, kefir)
control of the number of bowel movements
walks and Nordic walking were suggested
the patient was suggested to perform rotational massage of the abdomen in a clockwise direction
Assessment:
As a result of the implemented physical activity and appropriately selected diet, bowel movements have become regular.
Problem 5:
Feeling of mental and physical discomfort due to disturbed sleep. Goal: Reduce discomfort, improve sleep quality. Nursing activities:
determining what factors cause difficulty falling asleep
ensuring proper sleep conditions
recommending the patient to perform relaxing and soothing exercises before going to bed
limiting the consumption of strong coffee or tea in the afternoon
informing the patient about giving up naps during the day
encouraging her to drink warm milk before going to bed
discussing the impact of a proper diet on the quality of sleep
Implementation:
making the patient aware of what factors may affect difficulty falling asleep (naps during the day, inappropriate microclimate, inappropriate nightwear, stressful situations)
ensuring proper sleep conditions (airing the bedroom, appropriate nightwear, breathing and relaxation exercises)
recommending the patient to perform breathing and soothing exercises
explaining the role of caffeine in the afternoon
convincing the patient to give up naps during the day day
assured about the effectiveness of drinking warm milk, lemon balm
discussed the influence of a proper diet on the quality of sleep, easily digestible dinner
Assessment:
The quality and length of the patient’s sleep have improved. The patient has given up napping and does not overeat in the evening, she has limited herself to one coffee a day, thanks to which she goes to bed earlier and has no problem getting up in the morning.
Problem 6:
Depressed mood caused by illness.
Goal:
Improve mood, ensure peace
Nursing actions:
provide support, ensure the patient’s physical and mental peace
provide care for the patient in peace, create a friendly atmosphere
and interest, listen to the patient, clarify doubts, show patience
provide conditions for peaceful rest
Achievement:
ensure physical and mental peace
provide care for the patient by creating a friendly atmosphere and showing interest
listen to the patient, show patience, use simple and explanatory answers
reduce the patient’s fear and anxiety
Assessment:
After the actions taken, the patient is calm, mood has improved significantly.
Conclusions
One of the most important activities in the care of a patient with arterial hypertension staying in the home environment is health education aimed at providing knowledge about proper conservative treatment, the need to take medications regularly, raising awareness of possible complications and motivating to implement changes in one’s lifestyle.
Thanks to an individual and professional approach, emotional and psychological support was provided, which contributed to ensuring the patient’s safety and comfort and also influenced the improvement of her health condition.
