Video Case Study - Care of the Patient with Hypertension

Nurse Kendra works in a family practice office and is caring for Peter, a 60-year-old male who presents for a follow-up appointment for elevated blood pressure readings and mild fatigue.

After settling Peter in his room, Nurse Kendra goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Peter’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.First, Nurse Kendra recognizes important cues, including Peter’s vital signs, which are temperature 99.0 F or 37.2 C, heart rate 90 beats per minute, respirations 16 breaths per minute, and blood pressure 156/96 mmHg taken manually five minutes apart and averaged over two readings.

Peter’s oxygen saturation is 98 percent on room air, and his pain rating is zero out of 10. Next, Nurse Kendra measures Peter’s height and weight and calculates his body mass index, or BMI, at 32 kg/m2.Nurse Kendra asks Peter about his health history.

She learns that he doesn’t take any medications, but says his father has high blood pressure and is taking medication for it.

He reports smoking a few cigarettes after work daily and denies drinking alcohol. He also tells Nurse Kendra that his job requires him to sit at a desk most of the day.Then, Nurse Kendra analyzes these cues.

She reviews the electronic health record, or EHR, and notes Peter’s blood pressure at his last two appointments was above 140/90 mmHg, and his ECG and cardiac labs were normal.

Nurse Kendra reports her assessment findings to the health care provider who diagnoses Peter with primary hypertension, and prescribes the oral antihypertensive medication, lisinopril, along with lifestyle modifications.

Nurse Kendra realizes Peter needs effective health maintenance.Now, using the information she’s gathered along with Peter’s history, Nurse Kendra chooses a priority hypothesis of inadequate health maintenance.

Then, she generates solutions that include pharmacologic and nonpharmacologic interventions and establishes the expected outcome that, after intervening, Peter will demonstrate one lifestyle change he’s made to lower his blood pressure by his next follow-up appointment.Nurse Kendra then takes action to implement these solutions.

Nurse Kendra: Your health care provider prescribed a medication called lisinopril to help lower your blood pressure. Peter: Do I have to start on medication?

I really don’t want to. Nurse Kendra: I know starting a new medication can feel intimidating.

But it'll help lower your blood pressure and decrease your risk of complications, like a heart attack or stroke. Peter: Okay, I’ll start it if I have to.Nurse Kendra: That’s great.

It’s important to take it exactly as prescribed and to not stop it suddenly. Until your body gets used to the medication you could get dizzy when making position changes like when you get up out of a chair or when you’re getting out of bed in the morning.

So, remember to make these position changes slowly. And please let us know if you have any other side effects, like a cough.

Peter: Okay.Nurse Kendra: Now, there are other ways to help lower your blood pressure too, like eating a healthy diet. Could you tell me about your typical eating habits?

Peter: For breakfast I have a pre-packaged pastry, for lunch I usually bring a turkey sandwich, and for dinner, my partner makes a casserole, if we aren’t going out to eat.

During work, I’ll snack on potato chips. Nurse Kendra: So, decreasing the amount of sodium, or salt, you eat can help lower your blood pressure.

That means having less pre-packaged or processed foods and eating at home more often than restaurants. For example, instead of lunchmeat, try having grilled chicken for lunch or instead of potato chips, try snacking on fresh fruit and vegetables.

I’ll have our dietitian talk to you to give you more details. Also, smoking can increase your blood pressure, so it’s important to quit.

Peter: Wow, that’s a lot of stuff I need to change.Nurse Kendra: I understand it can be overwhelming, but even small changes make a difference.

Exercise also helps lower your blood pressure. Try to get 30 minutes of exercise every day.

Peter: My partner always wants me to walk with them, sounds like I should start saying yes. Nurse Kendra: Great idea!Next, Nurse Kendra gives Peter information on smoking cessation and how to obtain a home blood pressure machine.

She then teaches him to measure and record his blood pressure readings daily. She also informs him of blood pressure readings that warrant a call to the health care provider and confirms his follow-up appointment is scheduled.Four weeks later, Peter arrives for his follow-up appointment and Nurse Kendra evaluates the outcome of her care.

She measures Peter’s blood pressure, which is 130/76 mmHg. Peter also shows her his blood pressure readings from home which average around 128/70 mmHg.

Next, Nurse Kendra asks Peter about his lifestyle modifications. Peter states he’s been eating whole grain cereal for breakfast, having salads with grilled chicken for lunch, and has been taking a daily walk with his partner.

He reports that he’s cut down on his smoking and is hoping to quit altogether in the coming months.Alright, as a quick recap… Nurse Kendra recognized and analyzed cues related to Peter’s ineffective health maintenance, prioritized hypotheses and generated solutions to address this problem.

Nurse Kendra then implemented pharmacologic and nonpharmacologic measures to address Peter’s hypertension, and evaluated Peter’s outcomes, comparing them to the expected outcome.

Since Peter demonstrated lifestyle changes to lower his blood pressure, Nurse Kendra determined that the plan of care was successful.

Kendra then implemented pharmacologic and nonpharmacologic measures to address Peter's hypertension and evaluated Peters outcomes Comparing them to the expected outcome Patients Peter patient demonstrated lifestyle changes to lower his BP Nurse Kendra determined that the plan of care was