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The Crucial Role of Nurses in Blood Pressure Management

Introduction

The rationale of choosing BP (BP) as a clinical skill:

The accurate readings of BP give a prominent indication about the health of a patient especially about the risk of suffering from hypertension followed by a stroke. Therefore, in nursing practice, this application of this clinical skill is very important to improve the condition of “hypertension control”, which has expanded within the last 50 years. There are several roles of nurses and nurse practitioners for the improvement of hypertension management program are: a) detection of patient followed by referral and eventual follow up’ b) management involving accurate diagnosis and prescribing of medicines, c) educating the patient about BP, skill-building tasks and counselling, d) providing care to patient, e) management of both office and clinic, f) management of health of the population, g) improvement of quality by assessing performance. Nurses also play a role in conducting research involving both lead clinic and community to develop the quality gap in the field of hypertension control due to cultural disparities between social, behavioural, and economic factors of hypertension. The concern about high BP is increasing as it is being considered as a public health issue of the global problem, impacting about 1.5 billion people worldwide within 2025 and will contribute to about 50% of the total heart disease risk cases and 75% of total stroke risk cases. Therefore accuracy is required in this clinical skill with updated knowledge and assigned as the key role of nurse’s job in their everyday practice (McManus, 2014; Williams, 2004; Himmelfarb, et al, 2016)

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Blood Pressure (BP)

“BP” is the force exerted by blood on the walls of the blood vessels (arteries). BP is expressed with two numbers namely the systolic pressure, the pressure occurs due to the contraction of the heart and the diastolic pressure, the pressure observed during the relaxation of the heart. It is expressed by recording the systolic pressure above and the diastolic pressure below. It is very important to have a normal range of BP to work effectively and with no problems. Just a little bit of fluctuation between BPs can change the behaviour of a person in many ways (Pickering, et al, 2013). The normal BP ranges from 80 to 120, in which a person performs effectively his all daily life routines. When the BP is high, it ranges from 120 above and when it is low, is it below 80. (Emdin, et al, 2015) When the BP is normal, it means that the rate of the heartbeat is normal and the person is having a perfectly balanced diet and should stick with the same routine. There are many phases of BP from normal to the lowest and from normal to the highest (American heart association, 2017). BP is the most commonly known nursing skill and many people prefer to understand and know about this skill because this problem is growing and is mostly found in adults and old people who can hardly give time for regular follow-ups and also cannot avail check-up most of the time at the hospital (Odell, 2015). But assistant practitioners can check and also recommend the precautions that the patient should take, at home. Sometimes, when the BP goes high, they prefer that the patient should be hospitalized so that he can be analyzed further by the nurses or assistant practitioners and the professionals.

Need for the measurement of BP

The importance of BP is now known to everybody as high BP can result in several fatal diseases such as strokes, heart diseases and also kidney diseases. If any pregnant women suffer from high BP and her BP is not properly monitored then the condition can become fatal to both women and baby. Therefore to get notified about high BP early, nurses should monitor BP regularly in the health care set up (Williams, 2004; Himmelfarb, et al, 2016)

Factors to be checked while measuring BP:

Certain factors need to be taken care by nursing staff during the measurement of the BP of a patient to avoid any false reading such as the cuff of the BP instrument should not be very small in length and should not be placed over clothing; whether the patient has practised any exercise recently, whether the patient needs to visit toilet or not, whether the patient has consumed any alcohol or caffeine products within 30 minutes before the reading, the patient should not be in a stressful condition and should not talk during the process (Williams, 2004; Himmelfarb, et al, 2016).

Problems associated with BP:

The most appropriate method of monitoring of BP is 24-Hour ambulatory BP monitoring as it can addresses some major issues such as accurate diagnosis of nocturnal Hypertension (the period during the day when BP mostly indicates about adverse cardiovascular result), or masked hypertension is a scenario which has affected 15% of the whole populations and posses risks equivalent to HT, hypotension. The above-mentioned process is also cost-effective. Certain practices have been linked with high BP such as alcohol abuse. Other severe factors may include myocardial infarction, shock, and haemorrhage factors that result in low BP as because they effectively reduce the cardiac output. Patients who are consuming oral contraceptives will be at higher risk of hypertension (UK Essays, 2018).

A case study:

This aspect of the professional skill of an assistant practitioner induced me to take up the skill and most importantly the practice is considered as an act of humanity in this field; During the process, the assistant practitioners treat the patients in such a manner so that they feel homely. Therefore the skill of checking BP will become more vivid and easy through the learning and working practice experience in the field. The constant rise in the population is occurring at an exponential rate, showing a direct effect upon the demand for this skill. Being an Assistant Practitioner, I was asked to do the admission process by my mentor. I welcomed the patient and offered her some drinks which she declined due to lack of appetite. I asked the lady if she prefers female or male staff to do the admission process. I asked her whether she needs to visit the toilet before the process and then allowed her to rest for at least 5 minutes before I start the procedure. She was a middle-aged lady. When I checked her BP, it was too high around 236/12. I completed the admission test during preadmission time or during arrival time at the ward. As an assistant practitioner, I have to note down all the necessary information in the progress notes of the patient (Giddens, 2017). Moreover, patient’s privacy was given topmost priority. All the necessary information such as the history about any current injury/illness, current admission, social history, family, implants, immunization history, medications, allergies and history were all recorded by the staff nurses. Complete physical examination of the patient allowed the assistant practitioners to get the complete assessment.

Sphygmomanometer Fig

Fig 1: Sphygmomanometer Fig 2 & 3: Steps to measure BP (Source: Hartle, et al, 2016)

Assessment

These questions can easily help in determining the reasons behind high BP, because a person who suffers from high BP usually have a heart problem at some point in their life, or is usually weak because he is not getting enough diet (Yusuf, et al, 2016) or in case the patient is an adult, female she may have just given birth to a child. We also need to observe them that are if they are looking obese or too weak; their weight can also help in determining the reason behind their problem. (Xie, et al, 2016).

A assistant practitioner should ask the patient about their smoking habits which helps in identifying that the true cause of BP (Nursing Practice, 2019). In the hospital, I asked the lady patients whether they are having enough sleep and proper diet. Whether the patient is taking any medicines, whether she is having some symptoms like headache, stressed, anxiety, fatigue. There were some other questions which also need to be enquired about from the lady such as how much salt do you take in your food daily? When a person takes too much salt it can result in high BP so if the patient replies positively then the problem is easily identified. BP is also a genetic disorder (Ehret, et al, 2016) It should be asked to a patient that whether anyone from his family is also a patient of BP problem too? If the member is said to be in blood relation then it is sure that the disease is adopted through the genes. Several other questions that help in correct assessment are: 1) Do the patient suffers from any heart problems? Whether the patient generally suffers from dehydration? (Interview, 2019)What type of diet does the patient consume daily? In the case of a lady patient, whether she has given birth to a child recently? Whether the patient takes enough sleep? What are the medications the patient has consumed before? Whether the patient is suffering from any type of infection? Other notable symptoms such as headache, anxiety, fatigue, urine dipstick have to be checked. Regular monitoring of health conditions will be done for a speedy recovery.

Plan

If the outcome of the checkup turns out that the patient was not getting enough diet and was smoking a lot then it would be advisable to maintain a chart beside the bedside of the patient and the nutrient level of his blood would be monitored after consumption of each meal. The patient would not be allowed to smoke any cigarette and his heart rate would also be monitored after each day. After following these practices, his heart rate should be within the normal range after each day. The routine checkup of the patient would be done in the evening time which would update the status of the patient. The BP would be checked four times a day.

Implementation

Every hospital staff should follow the given chart patterns for treatment. Sometimes, the patient was not able to understand the given questions and so could not answer in details. Moreover, the patient’s grandmother was also a patient of high BP but the subject had no knowledge about the issue. Hence as an assistant practitioner, I reviewed the case and other team members were also there to deal with any major issues.

Evaluation

When the patient is under assessment and is being provided with all the necessary things to make his BP normal then the symptoms should get better. It was analyzed that the fluctuations of his BP were found to be due to smoking and lack of nutrients. Therefore, when everything was planned then his heart rate should show improvement day by day. So all the nurses and the staff were ordered to keep an eye on the patient’s diet and smoking habit (he was not allowed to smoke at all). The patient revealed improvement after few healthy meals but it also demonstrated that there was something else too as a reason of high BP, due to which he would be questioned again to analyze about the other major problems.

Reflective practices help in thorough understanding and comprehending the experiences which someone just faced and the effectiveness can be observed when they are used in the medical fields by an assistant practitioner (Redmond, 2017). It increases the effectiveness of their work and to become more proficient in their field. These reflective models help nurses or practitioners in understanding the case of a patient and the whole process from which a patient goes through. By using the Gibbs Reflective Cycle, we will analyze the whole experience of high BP which is a step by step procedure and will help us to comprehend and understand the situation in a better way (Husebo, et al, 2015). The model of reflection was developed by Graham Gibbs in 1988 to create a structured learning experience. It allows you to learn and eventually plan from things that either gave good results or didn’t respond well. Now BP was considered to measure because it is a critical physiological parameter and indicates about the well being of the patient (Gibbs, 1988). Through Gibbs reflective cycle, the first step was to see what had happened to the lady patient and how we gave attention and comprehended the whole situation about her suffering from high BP (Tawansongsri and Phenwan, 2019). We came to know that she has smoking habits by asking her several questions. The second step was to take care that how she was feeling (Li and Peng, 2018). After analyzing the whole situation, being an assistant practitioner I observed, that the patient was looking too weak as compared to a normal person, this weakness showcased that the patient was not getting healthy diet that is why she appears to be too weak. The third step was to evaluate how the experience was overall and how you differentiated between the good and the bad effects which were found in the patient. In the above case, the patient had smoking habits for a long time and was not taking any healthy diet. In the fourth step, we had to analyze what further actions can be taken during the assessment of the patient. When we felt the need to check the patient again, it was observed that the patient also inherited this disease. After complete evaluation, the good things were that the major reasons were prominent to understand and the bad experience was that she was unable to clarify that this disease was inherited to her from her grandmother, genetically in origin. Then, the fifth step was to conclude that in what way we have assessed the patient and what else we could have done further for the whole assessment process. In our case, we came up to the conclusion that the patient can also be treated with those medicines specific to her inherited diseases. The last step was to plan an action in which we can comprehend and make future planning that what should be done in case the problem recurs. In our case, the problem could only enter into the danger zone if the patient starts to smoke or consumes an unhealthy diet again. These were the factors identified in our case that could make the BP shoot from normal to high. With the repercussion of the same problem, the patient will go through the same process again but during the next time assessment, she will have to be dealt with more medicines as the disease would have entered into the danger zone.

In another case a patient was not feeling well and used to get tired in every few minutes of walk, his heart rate was found fluctuating from normal to high. Being an assistant practitioner, I emphasized on the point that the patient needs to be assessed all the time because even after admission his heart rate was fluctuating and sometimes during the late-night, he needed oxygen as he was unable to breathe. The assigned tasks were to do a checkup of the patient after every thirty minutes. The skill of time management was important for that patient as he was alone and if the checkup was not on time then there were chances that he could collapse. Every nurse was informed strictly about the problem. A chart was placed on her side and the assistant practitioner checked her up last time to keep the BP normal.

I completed the admission test on preadmission or arrival to the ward. Being a responsible assistant practitioner, I added all the necessary information in the progress notes of the patient (Giddens, 2017). Above all, patient privacy was taken into consideration as the topmost priority. The nursing staff discussed about the current injury/illness history such as current admission social history, family, implants, immunization history, medications, allergies and history. Physical examination of the patient was also completed to have a complete assessment of the patient. Percussion, auscultation, observation, palpation, and inspection are known techniques used to collect information. Based on clinical judgment, decision about the extent of assessment was confirmed. The following informations were collected such as about the assessment of focused systems, principal assessments about circulation, disability, breathing and airway. All the information related to every assessment was widely specified in the section known as ‘shift assessment’.

This plan was so effective because when the new nurse used to come, she could easily analyze if the heart rate has increased or decreased and what is the time duration in which the patient showed changes. The chart helps in determining the past update of the patient and in analyzing what kind of progress he is most likely to show in the near time. The time was managed by all the nurses. This means that any nurse could check the status of the patient as soon as the other nurse left. This helped the nurse to easily track the last time the patient was checked was just a minute ago. After analyzing the patient timely, the final result showed that the patient’s heart rate collapses when he intakes any food or any nutrient; or even just when he intakes water. The analysis showed that the patient was unable to digest the food and that is why he was facing some problems in breathing. The actions showed that the patient was also suffering from high BP. (American Heart Association, 2017). The proposed actions were that the patient’s BP would be checked and he would also be given medicines that would help in keeping his BP normal.

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Conclusion:

At last, it can be concluded that my skill of recording BP is considered to be an important role for the nurse, as relying on electronic equipment is always not possible. I also learned that under different situations the BP reading can fluctuate, therefore proper questioning and assessment is essential. The skill becomes easier with daily practice. All patients are not same therefore the factors contributing to abnormalities in their BP are different. I have gained a lot of confidence in myself in the above-mentioned skill process.

References

McManus, R.J., 2014. Why are doctors still measuring BP?.

Williams, B., Poulter, N.R., Brown, M.J., Davis, M., McInnes, G.T., Potter, J.F., Sever, P.S. and Thom, S.M., 2004. British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. Bmj, 328(7440), pp.634-640.

Himmelfarb, C.R.D., Commodore-Mensah, Y. and Hill, M.N., 2016. Expanding the role of nurses to improve hypertension care and control globally. Annals of Global health, 82(2), pp.243-253.

American Heart Association, 2017. What is high BP?. South Carolina State Documents Depository.

American Heart Association, 2017. What is high BP?. South Carolina State Documents Depository.

Ehret, G.B., Ferreira, T., Chasman, D.I., Jackson, A.U., Schmidt, E.M., Johnson, T., Thorleifsson, G., Luan, J.A., Donnelly, L.A., Kanoni, S. and Petersen, A.K., 2016. The genetics of BP regulation and its target organs from association studies in 342,415 individuals. Nature genetics, 48(10), p.1171.

Emdin, C.A., Rahimi, K., Neal, B., Callender, T., Perkovic, V. and Patel, A., 2015. BP lowering in type 2 diabetes: a systematic review and meta-analysis. Jama, 313(6), pp.603-615.

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Giddens, J., 2017. Concepts for nursing practice. St. Louis, MO: Elsevier.

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Odell, M., 2015. Detection and management of the deteriorating ward patient: an evaluation of nursing practice. Journal of clinical nursing, 24(1-2), pp.173-182.

Redmond, B., 2017. Reflection in action: Developing reflective practice in health and social services. Routledge.

Stevens, S.L., Wood, S., Koshiaris, C., Law, K., Glasziou, P., Stevens, R.J. and McManus, R.J., 2016. BP variability and cardiovascular disease: systematic review and meta-analysis. bmj, 354, p.i4098.

Tawanwongsri, W. and Phenwan, T., 2019. Reflective and feedback performances on Thai medical students’ patient history-taking skills. BMC medical education, 19(1), p.141.

Xie, X., Atkins, E., Lv, J., Bennett, A., Neal, B., Ninomiya, T., Woodward, M., MacMahon, S., Turnbull, F., Hillis, G.S. and Chalmers, J., 2016. Effects of intensive BP lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis. The Lancet, 387(10017), pp.435-443.

Yusuf, S., Lonn, E., Pais, P., Bosch, J., López-Jaramillo, P., Zhu, J., Xavier, D., Avezum, A., Leiter, L.A., Piegas, L.S. and Parkhomenko, A., 2016. Blood-pressure and cholesterol lowering in persons without cardiovascular disease. New England Journal of Medicine, 374(21), pp.2032-2043.

Hartle, A., McCormack, T., Carlisle, J., Anderson, S., Pichel, A., Beckett, N., Woodcock, T. and Heagerty, A., 2016. The measurement of adult BP and management of hypertension before elective surgery: Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society. Anaesthesia, 71(3), pp.326-337.

Pickering, D. and Stevens, S., 2013. How to measure and record BP. Community eye health, 26(84), p.76.

Gibbs, G (1988). Learning by Doing: A guide to teaching and learning methods. Further Education Unit. Oxford Polytechnic: Oxford.

UKEssays. November 2018. The Fundamental Caring skill of BP recording. [online]. Available from:

https://www.ukessays.com/essays/nursing/the-fundamental-caring-skill-of-blood-pressure-recording-nursing-essay.php?vref=1 [Accessed 22 January 2020].

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