Hypertension nursing consultation opinions

It is not recommended to adjust the existing triple antihypertensive regimen of valsartan amlodipine + indapamide. Priority is given to improving 24-hour ambulatory blood pressure monitoring to detect hidden blood pressure fluctuations, and simultaneously correcting the three core intervenable problems of patients with long-term high sodium and low potassium diet, obstructive sleep apnea without intervention, and poor matching of antihypertensive drug taking time. Follow up after 4 weeks to evaluate the antihypertensive effect. If the standard is not met, the medication plan will be adjusted in collaboration with a physician.

In fact, there were disagreements at the beginning of this consultation. A nurse from the cardiology clinic pointed out that the patient's blood pressure in the clinic for three consecutive outpatient follow-up visits exceeded 160/90 mmHg, which met the preliminary criteria for refractory hypertension. It was more efficient to directly recommend that doctors add Class IV antihypertensive drugs, which is also in line with the recommended path of some guidelines. But several of us specialist nurses who have been in charge of wards for a long time think that we should not be impatient. To be honest, after almost ten years of working in this field, we have seen too many "pseudo-refractory hypertension". The root cause is not wrong medicine at all, but the daily nursing-related factors are not taken care of correctly.

Let’s just talk about this patient. She is from the Northeast. She has been eating pickled sauerkraut and soybean curd all her life. When I asked her if she ate a lot of salt, she felt aggrieved and said that I even skipped a spoonful of salt when cooking. Little did she know that there is more invisible salt in these pickled foods than in stir-fry dishes. The blood potassium test on admission was only 3.4mmol/L, which was just in line with the typical symptoms of a high-sodium and low-potassium diet. 70% of patients with hypertension in our country are salt-sensitive. This is recognized by the academic community. However, when it comes to the control standards for daily salt intake, the recommendations of different specialties are also different: cardiovascular guidelines recommend that the daily salt intake of ordinary hypertensive patients should not exceed 5g. Nephrology departments also require that for patients with CKD stage 3 If it drops below 3g, some scholars believe that there is no need to get too stuck to avoid hyponatremia in the elderly. Therefore, our advice to patients is to stop all pickled foods first and eat potassium-rich mushrooms and bananas 2-3 times a week. There is no need to deliberately eat low sodium salt (after all, high potassium needs to be prevented in patients with CKD). Adjust it for one month before looking at it.

Oh, by the way, there is also the issue of medication time that many people ignore. The patient used to take medicine after breakfast at 7 a.m., and her blood pressure at home only measured the value 1 hour after taking the medicine. Every time, it was 130/80mmHg. She felt that it was well controlled. She had no idea that her blood pressure would peak between 2 and 4 a.m., and could reach as high as 175/95mmHg. This is why she always said she felt dizzy when she woke up in the morning. There is a lot of debate about the timing of taking antihypertensive drugs. Some studies say that more than 60% of patients with non-dipper hypertension take the medicine before going to bed, which has a better blood pressure lowering effect. There are also concerns that low blood pressure in the elderly at night may easily cause cerebral infarction, so we did not directly ask her to change the timing of taking the medicine. We first asked her to measure her blood pressure at fixed points in the morning, noon, evening, before going to bed, and early morning for three consecutive days to find out her own fluctuation pattern before adjusting. It is always better to be more stable.

There is another point that is easily missed. The patient's wife said that she has been snoring for more than 20 years, and sometimes she can wake up while sleeping. According to our evaluation, we highly suspected obstructive sleep apnea hypopnea syndrome (OSAHS), which is also a common cause of secondary hypertension. There is no unified statement on the intervention plan for this problem. People with mild symptoms can improve it by sleeping on their sides and losing weight, while those with moderate symptoms and above need to wear a continuous positive pressure ventilation ventilator. There are also many patients who find sleeping with a ventilator too uncomfortable and would rather take half an extra antihypertensive pill. So our advice is to do a sleep monitoring to assess the severity first, and then choose an intervention method that is acceptable to you. After all, compliance is the first priority.

I met a 42-year-old male patient before. After taking triple antihypertensive drugs for half a year, his blood pressure was hovering at 150/95mmHg. After checking again and again, I finally found that he drank 2 taels of white wine with dinner every day. After persuading him to quit, within a month, his blood pressure stabilized at 120/80mmHg without changing the medicine. This is not to say that adjusting medication is not important, but that many times the nursing problem is not solved, and adding more medication will result in half the result with half the effort.

Of course, not all blood pressure substandards can be solved by adjusting lifestyle. If the blood pressure still has not dropped to the target value of 130/80mmHg after 4 weeks of follow-up, we will definitely work with the doctor to adjust the medication plan as soon as possible. After all, everyone’s physique and underlying diseases are different and cannot be generalized. Oh, yes, one last thing to mention. The patient used to measure blood pressure at home with a wrist-type sphygmomanometer, and the numerical error was quite large. She has been advised to switch to an upper-arm sphygmomanometer, and sit for 5 minutes without talking before taking the test. If these small details are not paid attention to, the blood pressure value will be inaccurate, and no matter how you adjust the plan, it will be in vain.