Video Case Study - Caring for Patients With Hypertension

Nurse Tom works at a primary care clinic and is caring for Mahlik, a 62-year-old who is being seen for a wellness check.

In collaboration with the registered nurse, RN Jenny, Nurse Tom goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Mahlik’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Tom recognizes important cues, including temperature 99.4 F or 37.5 C, pulse 75 beats per minute, respirations 16 breaths per minute, blood pressure of 156/89 mmHg, and oxygen saturation 97% on room air.

Next, Nurse Tom asks Mahlik about his history. Nurse Tom: Do you usually have high blood pressure?

Do any of your family members have high blood pressure? Mahlik: My dad and older brother do.

My job is stressful, so maybe that’s contributing to it. I’ve checked my blood pressure at the drug store, and it’s been around 150/90, but with work, I haven’t had time to come in and have it checked.

Nurse Tom: Stress can contribute to high blood pressure, and having family members with high blood pressure can increase your likelihood of having it too.

What foods do you usually eat? Mahlik: I mostly eat fast food because I’m always on the go.

Nurse Tom: Can you tell me about how often you smoke, drink alcohol, and exercise? Mahlik: I don’t smoke, never have.

I drink maybe 1 to 2 beers a week on average, and honestly, I don’t exercise as much as I should. I’m just so busy with work.

Nurse Tom analyzes these cues. He reviews the electronic health record, or EHR, and notes Mahlik’s body mass index, or BMI, is 28 kg/m2.

Nurse Tom knows that blood pressure is determined by factors like peripheral vascular resistance, or the force the heart needs to overcome to pump blood into circulation, and the total volume of blood circulating in the body; and he knows if these increase, blood pressure can also increase.

Nurse Tom also understands Mahlik’s blood pressure could be affected by stress hormones like catecholamines, that can cause vasoconstriction and increase peripheral vascular resistance; and by Mahlik’s fast-food diet, which is likely high sodium, that can lead to fluid retention and increased blood volume.

Nurse Tom also identifies Mahlik’s other risk factors for hypertension, including a family history of hypertension, an increased BMI, and sedentary lifestyle.

Nurse Tom realizes Mahlik needs effective blood pressure management. Then, Nurse Tom alerts the health care provider and RN Jenny to Mahlik’s blood pressure and history.

The health care provider diagnoses Mahlik with stage 1 primary hypertension and prescribes an oral antihypertensive medication.

Next, Nurse Tom and RN Jenny choose a priority hypothesis of elevated blood pressure. Then, they generate solutions to address Mahlik’s blood pressure, and they establish the expected outcome that after intervening, Mahlik’s blood pressure will be 130/80 mmHg or below at his next follow-up appointment.

Then, Nurse Tom and RN Jenny take action to implement these solutions. RN Jenny teaches Mahlik about hypertension and the prescribed antihypertensive medication.

Nurse Tom then enters Mahlik’s room to go over his after-visit summary. Nurse Tom: Hi, Mahlik.

I have a printout of everything RN Jenny and your health care provider discussed with you today. Mahlik: Okay.

I remember they said I should pick up a medication called losartan from my pharmacy, which will help lower my blood pressure.

But there was a lot of other information. Can you remind me what else I’m supposed to do to help lower my blood pressure?

Nurse Tom: Sure. You should try to get at least two and a half hours a week of moderate exercise, like walking.

You don’t drink alcohol very much, so continue with alcohol in moderation, though eliminating it can be more helpful. Also, try to avoid foods high in sodium, like fast food.

If you do go out to eat, try selecting other options like a salad with low fat dressing or fruit. Mahlik: Okay.

I’ll also try packing my lunch to take to work, but if I run out of time, I’ll look for healthier fast-food options. And I can start by going for a walk a few times a week.

Nurse Tom: Those are great ideas! Next, Nurse Tom obtains a home blood pressure machine for Mahlik and reviews how Mahlik can measure his blood pressure at home.

Nurse Tom then makes an appointment for Mahlik to return to the clinic in three weeks. Three weeks later, Mahlik returns for his follow-up appointment, and Nurse Tom evaluates the outcome of his actions.

He measures Mahlik’s blood pressure, which is 128/76 mmHg. Alright, as a quick recap…Nurse Tom recognized and analyzed cues related to Mahlik’s newly diagnosed hypertension and,