Critical thinking issues in hypertension care

The core of critical thinking in hypertension care is to break away from the inertial reliance on standardized care processes. On the basis of evidence-based medicine, we can dynamically adjust care decisions based on the patient's individual situation, life scenes, and subjective wishes. At the same time, we dare to question common clinical care misunderstandings, balance the contradiction between professional requirements and patients' actual compliance, and ultimately achieve individualized blood pressure management goals.

Last week I met a 62-year-old Aunt Zhang at a community health service station. She has grade 3 essential hypertension. According to the guideline, the regimen is amlodipine combined with valsartan. Her blood pressure has been hovering around 150/90mmHg for three consecutive months. The nurse who was in charge of her always said that she was disobedient and must have secretly eaten pickles and forgotten to take her medicine. I happened to be free that day, so I chatted with her for ten more minutes before I found out that she had to walk 20 minutes every morning to send her grandson to school. Her feet were always swollen after taking amlodipine, and she couldn't even climb the stairs when she was in pain. She secretly cut the amlodipine in half for fear of delaying her delivery of the child. Later, we discussed with the doctor and changed her plan to valsartan plus low-dose hydrochlorothiazide. The edema problem was solved, and her blood pressure stabilized at 135/85mmHg in less than a month.

In fact, this kind of situation of "following the guidelines but having no effect" is too common in clinical and community care. Now there are two different opinions on the evaluation standards of hypertension care in the industry. One school is a strict evidence-based school, which believes that all nursing actions must fully comply with the requirements of the "China Guidelines for the Prevention and Treatment of Hypertension", and there must be no loosening of blood pressure goals, medication specifications, and lifestyle interventions. For example, patients with diabetes must lower their blood pressure to below 130/80mmHg, and salt intake must be strictly controlled within 5g per day. The advantage of this view is that it has a low error tolerance and is not prone to principled errors, but it often ignores the actual implementation difficulty for patients. The other group is the individual adaptation group, which believes that the guidelines are only reference standards and should leave enough flexibility for patients. For example, elderly people over 80 years old with insufficient blood supply to the brain will easily get dizzy and fall if their blood pressure is lowered to below 130mmHg. It is better to relax to 150/90mmHg. As long as there is no discomfort, there will be no problem. This idea is more humane, but it requires extremely high professional skills of nursing staff. If you are not careful, you can easily slip into the misunderstanding of "random adjustment".

To be honest, I made the mistake of following the guide when I first started working. I managed a 78-year-old man whose blood pressure was always stable at 160/90mmHg. I chased him every day to lecture him, telling him to eat less salty food and to take medicine on time. Later, his wife secretly told me that the old man loved to eat porridge with pickles all his life, but now he can't even eat to lower his blood pressure. He has lost almost 10 pounds in three months, but he always feels weak all over. We later discussed with the doctor and slightly increased his antihypertensive medication and allowed him to eat a small piece of finger-sized pickles every day. The old man was happy and his food tasted delicious. On the contrary, one month later, his blood pressure stabilized at 140/85mmHg, and his energy level was much better than before.

Many people think that critical thinking is about going against the guidelines, which is not the case at all. Last winter I met a 29-year-old delivery boy. His physical examination showed that his blood pressure was 145/95mmHg, which is grade 1 hypertension. He immediately became anxious when he heard that he needed to take medicine. He said that taking antihypertensive medicine would make him sleepy, and he would be slow to react when running orders. His family was still waiting for him to make money, and he refused to take anything. We did not force him to take medicine, but gave him a less "standard" plan: don't buy iced Coke every time he goes out to order, bring a thermos cup with warm tea, walk briskly around the neighborhood for 15 minutes after work every day, and add less chili sauce when adding rice. He followed it for two months and then tested again. His blood pressure had dropped to 135/85mmHg, which was better than many people who took medicine obediently. But on the other hand, if you encounter a patient who secretly stops taking his medication after believing that "health supplements can cure high blood pressure," you cannot follow his wishes. You must be able to accurately distinguish between "reasonable flexible adjustments" and "wrong cognitive biases." This is the core of critical thinking.

I met an aunt before. She heard from her neighbor that she should not eat eggs if she has high blood pressure. She hadn’t touched eggs for half a year. As a result, her albumin was low and she kept catching colds. When she came, she asked us if it was a blood pressure problem. We corrected her for a long time and said that one egg a day would not affect blood pressure at all. She went back to try it with some doubts. She came back for a review a month later. Her blood pressure did not rise, but her immunity improved a lot. You see, many "nursing common sense" that has been circulated for a long time has no basis at all. Critical thinking also includes the courage to question these inertial misunderstandings. You cannot just follow what others say.

To put it bluntly, after working as a high blood pressure nurse for so many years, I feel that critical thinking is not a high-level academic concept at all. It means that you ask three more "whys": Why does his blood pressure still remain high after taking medicine according to the guidelines? Why doesn't he do what we say? Why is this standard inappropriate for him? Asking these three questions more often will be more useful than memorizing the guide ten times. Of course, the premise of all adjustments is that you have to solidify your professional knowledge. Otherwise, it is not called critical thinking, it is called chaos, and it will harm the patient.