High blood pressure nursing training summary

First, the blood pressure lowering target for elderly patients over 65 years old needs to be individually adjusted based on underlying diseases, and there is no need to impose a universal standard of 140/90mmHg.； Second, the priority of home nursing guidance is much higher than that of a single antihypertensive intervention during hospitalization. ； Third, there are currently two clinical views on folic acid supplementation dosage for patients with H-type hypertension, and patients need to be informed of the benefits and risks simultaneously.

Speaking of this training, what struck me the most was that the teacher from Xuanwu Hospital who taught the class used an adverse event reported by our department last month as a case at the beginning - 78-year-old Grandma Zhang had carotid artery plaque and her blood pressure was maintained at around 150/85mmHg. Her family members always felt that it was not safe if it did not drop to the "standard line". We did not remind her before. The doctor in charge of the bedside gave her half a tablet of antihypertensive medication. As a result, she fell dizzy when she got up the next day, and had to be transferred to the orthopedics department for surgery for her hip fracture. At that time, our department was still reviewing whether antihypertensive drugs were adjusted too hastily. This time, I learned that the industry has been arguing about the target of hypertension in the elderly for several years: the evidence-based group used the latest large sample data and said that as long as there are no contraindications, the long-term risk of stroke and myocardial infarction can be reduced by more than 30% if it is lowered to 130/80mmHg for those under 65 years old and 140/90mmHg for those 65-79 years old. ； However, pragmatists who have been in clinical practice all year round directly criticized it, saying that many elderly people have carotid artery stenosis of more than 50%, blood pressure drops too much and insufficient cerebral perfusion, which can cause dizziness and falls in mild cases, or directly induce ischemic stroke in severe cases, which is not worth the gain. In the end, the compromise plan given by the teacher was also very practical: first conduct a carotid artery ultrasound + daily activity assessment for the elderly. Those who can buy and cook their own food and have no obvious blood vessel stenosis should stick to the standard value. If they stagger when walking and have half of their blood vessels blocked, 150/90mmHg is completely acceptable. Don’t make the patient suffer just to make up the numbers.

In the past, when we did patient education, we always felt that we were "completing the task". We took the printed manual and read out "Daily salt intake should not exceed 5g, quit smoking and limit alcohol, and exercise for 150 minutes a week." Even if we talked too much, we would feel weak. I was particularly impressed by the example shared by the nurse from the community during this training: There was a 62-year-old Chen in their jurisdiction with level 3 hypertension. He had to drink two taels of white wine every day. Even after half a year of persuasion, it was to no avail. His blood pressure fluctuated around 160/100mmHg when measured. Later, they did not force him to quit drinking. They first asked him to find out that his drinking time was fixed at dinner, and then asked the doctor to adjust his medication plan: take half an extra tablet of amlodipine on the day of drinking (to eliminate the risk of orthostatic hypotension in advance). At the same time, he drank one less day a week and replaced it with alcohol-free beer. Now, three months later, Lao Chen's alcohol consumption has dropped to one or two drinks every two days, and his blood pressure has stabilized at 135/80mmHg, which is much stronger than before. There are also many details that we usually ignore: for example, many patients like to roll up their sleeves to the tightest part of their upper arm when measuring blood pressure. The blood pressure can be 10-15mmHg higher. ； There is also the Laohuo Jing soup that patients in the south love to drink. After two hours of cooking, the salt and purine levels exceed the standard. It is simply unrealistic to prevent him from drinking it. It is better to teach him to add half the salt when making soup, drink it twice a week, and slowly adjust his habits.

Regarding the folic acid supplementation program for H-type hypertension, this training did not give a "standard answer" and directly presented the research results of two groups: One group believes that daily supplementation of 0.8 mg of folic acid is enough to reduce homocysteine ​​levels, while supplementing a large dose of 5 mg may increase the risk of prostate cancer in men and cognitive impairment in the elderly.； The other group believes that the MTHFR gene polymorphism of Chinese people is different from that of Westerners. The dose of 0.8 mg is not enough at all, and 5 mg is needed to effectively reduce the incidence of stroke. The final instructions given to our nurses are also very clear: we don’t have to make up our own minds for the patients. We should inform the bedside doctor simultaneously of the benefits and potential risks of the two options. When communicating with the patients, we should also clearly explain the controversies of the existing research. Let the patients choose based on their family history and financial situation. There is no need to say which one is right.

To be honest, I always felt that hypertension care was the least "technical" in the past. It was nothing more than measuring blood pressure, dispensing medicines, and reading education manuals. After this training, I realized that what we hold in our hands is never a set of cold numerical standards, but the real life of each patient. After returning home, I plan to change Corey's missionary manual first, replacing the "must" and "strictly prohibited" words with small suggestions that ordinary people can implement, and then add a column for carotid artery condition and daily activity ability to the blood pressure assessment form for elderly patients. I can't let things like Grandma Zhang happen again.