Hypertension Management In Newly Diagnosed Patients

The management of hypertension in patients can improve their overall health and reduce the risk of other comorbidities that can arise from being untreated, especially those newly diagnosed. Orem's theory poses the concept of self-care and the abilities that patients have to improve their self-care. An individual’s ability to perform self-care is defined as the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health, and well-being. This can include the use of self-blood pressure checks/logs, managing diet and exercise, and following their directed medication regimen. Nurses may need to interfere in the utilization of this self-care when the patient is unable to perform continuous self-care. Her theory strongly correlates to health promotion and can easily be applied to this topic. The application of the Orem self-care model can improve blood pressure control through the use of management techniques that increase self-agency and will be described within this paper.

Dorothea Orem Theory of Self- care deficit, a grand theory, focuses on each individual’s ability to elicit self-care on their own in order to maintain health and well-being. This theory becomes activated when a patient is incapable of meeting the demands of their own self-care within their health. The assumptions of Dorothea Orem’s Self-Care Theory are in order to stay alive and remain functional, humans must remain in constant communication within their environment. Human agency is discovered through developing other ways to identify needs for, and make inputs into, self and others. Her self-care theory was a conceptualized framework surrounded around the deficit within the patient. Surrounding that were self-care agency, nurse agency, and self-care demands. Nurses must have their own self-care agency in order to meet the demands of the patient, our job is to increase their awareness of self-care and assist them on the path to gaining that.

Denyes et al. (2001) state that “from this theoretical view, it is essential that nurses have substantive knowledge about self-care and understand that human beings are both the focus of their own actions and the agents of their actions”. The major relational statement that will be discussed with application to her theory is 'inadequate management of blood pressure/non-adherence to the treatment plan can increase the risk of comorbidities and alter the quality of life among patients that are poorly treating their new diagnosis. We can also look at how when an individual is unable to meet the self-care requisites (universal, developmental, or health deviation), a self-care deficit can occur. The assumption is that the patient is alert and oriented and has a willingness to participate in care. The nurse is expected to manage these educational interventions and assist in increasing self-care agency as mentioned. Orem suggested that patients had a stronger outcome when they were able to become managers over their own self-care.

The applicability of Orem theory to newly diagnosed hypertension patients who have an apparent lack of self-care is evident. We can provide these patients with educational interventions that can improve those self-care capabilities and create operational definitions within the theory. We can instruct them on the use of a blood pressure journal log, they must monitor their BP every 2-3 days during the week and track their systolic and diastolic quantities. They must learn to evaluate the concerning values that may appear and when to reach out to their health care providers when those values are out of range for themselves. This will allow us to operationalize and track progress towards self-care, this gives them a sense they are in control of their health care goals. Another intervention is in relation to medication if that patient is requiring drug therapy for their new diagnosis. We of course know this is dependent on how advanced their hypertension has become, and presenting new medication treatment into their lifestyle may be overwhelming for the patient. As APRN, we must assist in education on the drug itself, as well as the importance of adhering to the directed dosage and timing of the prescription. This exemplifies the use of self-care by proving that the patient has the ability to manage their own condition through following the directed regimen. It indicates that they have a willingness to abide by directed therapy and maintain wellness. The last operationalized intervention is one of the most challenging ones for patients, that is the adjustment of their diet and increasing their exercise. This can become problematic for those who lead a busier lifestyle, work full time, or have children and household requirements to meet as well. This is where we can truly see where nurse agency may be obligatory. We must provide them with feasible weekly exercise routines that can easily be incorporated into their lives and potentially discuss the addition of a dietitian to follow with. Together the APRN and patient will discuss the means to achieve therapeutic self-care demands to reach the directed goal of hypertension reduction. This is done in order to reduce co-morbidities, such as heart attack and stroke, that can arise from high blood pressure, not to mention improve quality of life.

The University of Cincinnati Health Sciences Library Summon online, CINAHL, and inclusion criteria internet searches were used to conduct a literature review pertaining to this theory and topic. Search terms such as “Orem theory of self-care”, “Orem theory related to hypertension”, and “hypertension management” in relation to drugs and diet/exercise. Criteria that had to be met were research conducted within the last five years, primary research, and full-text online articles. Meta-analyses and systematic reviews were excluded. Four articles will be summarized and applied to the theory of self-care within these newly diagnosed patients in an effort to rationalize the importance of self-care amongst our patient populations.

Khademian, Kazemi Ara, & Gholamzadeh (2020), conducted a quasi-experimental study that aimed to determine the effect of Orem theory in relation to the quality of life and self-efficacy of patients with hypertension. This was a strong illustration of a research study that applied this theory to real people through the use of convenient sampling and randomization. 40 patients in the control and 40 in the experimental group completed the study. Sample sizing was stopped at 88 people due to a predicted potential for a 10% attrition rate. Patients completed the Quality of Life of Cardiac Patients questionnaire in order to assess the effects of cardiac disease and the patient's physical, emotional, and communal activities in order to determine their ability for self-care requisites.

Each question had a 7-point Likert scale and the scores ranged from 27-189, with higher scores indicating a stronger quality of life. Internal consistencies were confirmed by a Cronbach alpha coefficient of 0.95 for social and emotional dimensions, and 0.93 for physical measurement; this indicates strong validity and internal consistency within the study and that this measurement tool was effective. The experimental group also completed an educational intervention consisting of different classes based on Orem nursing theory with self-care requisites incorporated. The control group was still evaluated through blood pressure checks and monthly visits by a physician. Khademian et al determined that “According to the findings of this study, designing and implementing Orem self-care educational program based on the needs of patients with hypertension along with follow-ups can be effective in improving the quality of life of these patients”. There was a statistical significance found that this intervention does work and the importance of the nurse being available to answer any questions the patient may have. One of the limitations of this study was the concern that it wasn’t followed over a long enough period of time so that the effects of self-efficacy could be studied more longitudinally. According to the Facchiano & Synder (2012) scale, this article was considered a Level II due to the nature of the RCT study design. Participants were placed into groups based on simple randomization. Another limitation of the study mentioned was the process of blinding towards the researchers and participants. It was also determined that the questionnaire was given, although applied to patients with hypertension was more than likely suited for patients post MI rather. This study was still applicable in ways to Orem theory and does allow for independence in individuals and their functional participation in self-care.

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Another article that was found during research guides us with the intervention previously revealed, the importance of adhering to a diet regimen in order to recover poor blood pressure management. This devotion to an improved diet should also coincide with an exercise routine. If a patient can maintain follow through with this it can enhance their ability to provide self-care and allow us to operationalize success by tracking weight loss in relation to a reduction in BP. A diet in itself was created to improve the management of hypertension referred to as the DASH diet (Dietary Approach to Stop Hypertension). A randomized control trial was conducted in patients diagnosed with new grade I hypertension. Subjects were either provided the standard education or usual care, whereas the intervention group was given that usual care plus the DASH education delivered by a dietician. There were concerns that true evidence existed up to this point on whether the DASH diet could actually improve in reducing long-term cardiovascular risk. Subjects had to be Chinese patients that were aged 40-70, newly diagnosed with grade I hypertension, and not currently receiving antihypertensive agents. Wong et al stated that “the individualized DASH diet goals were recommended with respect to high consumption of fruits (4–5 serves/day) and vegetables (4–5 serves/day), low-fat dairy products (2–3 serves/day), lean meats, poultry, and fish (≤ 6 serves/day), and nuts, seeds, and legumes (4–5 serves/week).

No significant between-arm blood pressure differences were found between groups, besides that the intervention group reported marginally higher consumption of vegetables and dairy at the 12-month mark. Regression analysis and odds ratio were conducted to determine the results of the study and their usefulness. The estimated ten-year CV risk diminished considerably in both groups, yet the DASH recommendation produced no additional benefits. The ten-year risk does play part in some of the limitations of the study though, there was concern that the use of the ten-year risk rather than actual CV events causes a higher retention rate. The use of the DASH diet, despite the limitations of the study, still does prove primary prevention for furthered cardiac threat. This article was classified as a level II as well, being that it was a randomized control trial. This type of study attempts to reduce bias and allows for comparison among groups. This study was compared to other analyses of this diet conducted in similarity with this one, the researchers attempted many comparisons of their research with others. The only discussion of validity was a general critique with respect to how closely the predicted outcomes agree with the actual outcomes. They did make mention of the strict adherence to baseline guidelines to become part of the testing, as well as adherence to the protocols to ensure a reliable study.

Another intervention related to self-care that can be considered is the use of a blood pressure log. A retrospective cohort study was performed amongst men and women with hypertension to identify the efficiency of self-measured blood pressure. Participants who frequently checked their BP readings compared to those who didn’t have a greater reduction in hypertension. After modifying for sex, race, and ethnicity, the chances of blood pressure decline was 4.88 times greater for applicants who checked their BP readings frequently, compared to those who did not frequently check their BP readings (Swaminathan et al., 2020). There was no apparent IRB approval or informed consent openly mentioned, thus creating a considered limitation to this study. This would be classified as a level IV study on the evidence scale due to the nature of the cohort study, all shared the defining characteristic of hypertension.

The fourth article that was found was in relation to the adherence to a drug regimen if necessary, for patients with hypertension. There is a constant debate over which medications should be provided dependent on patient status and severity of hypertension. There is also an argument over whether to start a patient on combination or monotherapy with their drug routine. A 1-year, double-blind, randomized control trial was conducted to evaluate the effects of this concept, different phases of medication introduction were performed along with altered combinations of medication. Inclusion and exclusion criteria for the study was listed, patients aged 18-79 were selected and must have a systolic BP of Summary of the State of Evidence

All four articles coincide with the discussion of Orem's theory of self-care in relation to hypertension management, especially those newly diagnosed. We had considered the different operationalized interventions that can be put into place for these patients and the use of these different research studies, can offer assistance towards proving their usefulness. With the use of randomized control trials and cohort studies, it was apparent that the researchers utilized non-biased, outcome-driven research. A majority of the studies discoursed were at a level II for evidence, considered one of the higher stages of evidence.

The validity and reliability weren’t always revealed but it was mentioned by Wong et al (2016) that, “our study, in contrast, was performed in the real clinical setting wherein the dietary counseling practices are often delivered to grade 1 hypertensive patient on a one-off basis without follow-up prompts”. There is also unmentioned reliability in the use of questionnaires that were utilized within certain studies, it is presumed that people would answer honestly for themselves. All of the findings within each study were strongly applicable to those suffering from hypertension, it remained constant across all analyses.

Within this theory and clinical concern of poorly managed hypertension in those newly diagnosed, two APRN-led interventions will be evaluated. The first is the use of a blood pressure journal to monitor adherence to treatment and to show an improvement in SBP/DBP values. The client will be instructed to purchase an at-home blood pressure monitor device and to log values throughout the week. For this example, we can state that they must monitor their BP every 2-3 days twice daily. We don’t want them to develop an obsession with constantly checking these values, as it can end up falsely increasing their statistics if they are incessantly examining their vital signs. The utilization of such intervention can provide the patient with the ability to perform self-care and shows their willingness to increase their health and wellness. They will soon realize their unmet self-care needs or deficit of uncontrolled hypertension. This may be related to poor diet, lack of knowledge or resources, and an inability to be aware of the pending symptoms of high blood pressure. An important step in Orem's self-care theory is the APRN selecting methods that assist the client to compensate for those deficits, we can do so with the education of a blood pressure log. The log can also allow for measurable outcomes directly within itself, we can chart and trend progress, or determine if other modalities need to be supplemented if success isn’t being met. The applicants who monitored their BP readings frequently using a self-management plan at home have improved blood pressure control (Swaminathan et al., 2020).

A second intervention that can be related to this theory and applied is the adjustment in diet that must be made to improve blood pressure. The success of the DASH diet was demonstrated in detail and it has been shown to greatly enhance the lifestyle and welfare of hypertensive patients. In relation to Orem theory, the APN must create an environment yet again of supportive education with actions that are directed by nursing diagnosis. The patient must become aware of the importance of adherence to improved nutrition and thus creating a sense of self-care demand for the patient. We can measure the outcomes of an improved diet through weight loss and cholesterol levels; classified as precursors that can affect hypertension. We can also monitor a reduction in the actual blood pressure values of the patient that can be seen when these lifestyle modifications are potentially made.