Analysis of Protocol for Management of Hypertension in Adults - Research Paper Example

? "Analysis Of Protocol For Management Of Hypertension In Adults" Protocol Overview Hypertension is emerging as one of the fastest progressing fieldsin medical science. The condition is emerging as a challenge across the world due to its high rate of prevalence and affiliated hazards of cardiovascular and renal diseases (Whelton, 1997). High blood pressure is a trait as opposed to a specific disease and represents a quantitative rather than a qualitative deviation from the norm. Taking into deliberation the importance of Blood pressure, National Health and Nutrition Examination Survey, (NHANES, 2009) considered blood pressure measurement as a major health concern. A decision to embark upon antihypertensive therapy effectively commits the patient to life-long treatment, hence it is vital that blood pressure (BP) monitoring and management be taken seriously by pursuing the set norms and protocols to safeguard individuals from numerous predicaments (High Blood Pressure). The present article is an analysis of the Protocol For Management Of Hypertension in Adults to have a deeper understanding for hypertension measurement. Blood Pressure Measurement "Protocol For Management Of Hypertension In Adults" is based on the guidelines of National Institute of Clinical Excellence (NICE) for the hypertension management in adults in primary care. The protocol lays emphasis on the accuracy and precision of the blood pressure management, appropriate training of the health care provider and periodic review of the individual suspected or confirmed with the condition of hypertension. This holds true because precision is imperative in measurement of blood pressure. Any inaccuracy in the measurement of blood pressure may turn out to be overwhelming. Measurement of blood pressure is the most prevalent assessment in clinics, interpretation or analysis of the results or outcomes procured are responsible for future implications, an imperative step for the individual whose BP is measured. Any error in the reading or ignorance in taking the exact reading or taking a low reading than actual, may deprive the individual from taking medication at the right time and thereby enhances the susceptibility of the person for stroke or heart attack. Alternatively, if the person is normal and the measurement of the blood pressure is taken high the individual may be exposed to the BP lowering medication without any basis. These may result in serious implications, therefore, it is highly imperative to get an accurate measurement of blood pressure (O’Brien, et al, 2010; Hypertensive Crises: Recognition and Management). The current protocol emphasizes on the appropriate servicing and calibration of the equipment. As blood pressure is a hemodynamic variable, to get an accurate reading of blood pressure it is highly essential to have a validated measuring device in clinical settings in order to prevent erroneous outcomes. As per the protocol routine blood pressure measurement must be performed at least every 5 years until the age of 80 years, under normal circumstances, every individual who is around 40 years of age or above must get the BP checkup as a routine in 5 years to avert morbidity and mortality caused due to hypertension (National Institute for Health and Clinical Excellence, 2011). However, the current protocol does not mention that treatment and care should consider individual requirement, i.e. care should be person-centred care, which is well explained in the protocol of National Institute for Health and Clinical Excellence, (2011). The current protocol does not lay emphasis on development of excellent communication skill, which is essential for better compliance and prognosis and is also encouraged by evidence- based research studies. The protocol provided by National Institute for Health and Clinical Excellence, (2011) on the other hand, facilitates individuals to accomplish learned decisions about their care all. The current protocol further emphasize the fact that individuals with above normal values with the range of 135-139/85-89 mmHg should get their BP checkup annually. However, as per the new NCGC (National Clinical Guideline Center) guidelines which are developed in collaboration with British Hypertension Society (BHS), 2006 and 2011; individuals with clinic blood pressure as 140/90 mmHg or higher are categorized as stage 1 hypertension and therefore regular monitoring is required (National Institute for Health and Clinical Excellence, 2011). The current protocol does not indicate the number of readings to be taken and also the time interval, it has highlighted only day time pressure and night time pressure but the guidelines set by National Institute for Health and Clinical Excellence, (2011) highlight the time interval i.e. between 0800 hrs and 2200 hrs, when the person is awake and also mentions the average should be of at least 14 readings to conclude the case of hypertension. The protocol requires standardization of the environment and the patient must be relaxed. However, this is imperative because any noise in the vicinity may augment the BP and provide erroneous outcomes. Additionally, the requirement encompasses a comfortable environment, in terms of temperature, noise and other sources of commotion including telephone and cell phones. The equipment, mercury sphygmomanometers should be checked and verified prior to the study. The individual must be within 1 m of the range from the observer to read the menisci at the eye level between 40- 180 mm Hg. Bladder should be available, accompanied by nonelectronic stethoscope with appropriate fitting of the earpiece (O’Brien, et al, 2010). The current protocol does not mention the specification of the device needed to measure the blood pressure. However, emphasis is laid on the fact that, it is essential to use BHS validated device only encompassing mercury or oscillometric device, still, an anaeroid device is not recommended (Validated Blood Pressure Monitors: British Hypertensive Society). The current protocol does not specify the importance of appropriate cuff, especially for the obese individuals, to measure the blood pressure accurately. This is imperative as inappropriate cuff size may generate erroneous results. Conversely, this is highlighted in the Guidelines for the Management of Hypertension (2009). Use Of Ambulatory Blood Pressure Monitoring The current protocol does not rely on the routine examination of ABP monitoring as the values vary unusually. However, recent guidelines indicate monitoring treatment and blood pressure targets to consider ABPM (Ambulatory Blood Pressure Monitoring) or HBPM (Blood Pressure Monitoring) as an add-on to clinic blood pressure(National Institute for Health and Clinical Excellence, 2011). The current protocol suggested diagnostic thresholds for 24 hours ambulatory blood pressure as daytime pressure for normotensive 140/90 are considered definitely hypertensive. On the contrary, National Institute for Health and Clinical Excellence, 2011, considers 135/85 as stage 1 hypertension. The current protocol does not weigh the importance of ABPM or HBPM, but the National Institute for Health and Clinical Excellence, (2011) guidelines highlight the significance of ABPM and HBPM as two successive measurements must be taken in one minute interval at seated position, emphasis is given on twice recording, in morning and evening for 4-7 days. Average should be taken after discarding the first day measurement. Such importance to readings is not given in the current protocol. Evaluation The current protocol mentions the need for prevention of cardiovascular condition in primary care which is essential and could be helpful in safeguarding the individual provided the individual keeps a check on blood pressure and performs appropriate monitoring to commence the treatment and intervention at the very early stage. The current protocol has made it very clear that under controlled condition, no investigation is required but continuation of elevated blood pressure (observed through regular monitoring) are at potential risk of cardiovascular condition and therefore investigations become necessary encompassing urine examination for the occurrence of protein, blood examination for assessment of plasma, electrolyte, creatinine, serum-fasting cholesterol as well as HDL cholesterol. Emphasis is also given to issues related with resistance to treatment, drug intolerance, contraindications and non-compliance of the patient with the therapy, poor patient participation, inconsistency in blood pressure, isolated clinic hypertension, hypertension in pregnancy. The current protocol mentions these as special situation and therefore such conditions require necessary measures. Calculating Cardiovascular Risk The motive of monitoring hypertension is to reduce the incidence of adverse cardiovascular events, particularly coronary heart disease, stroke and heart failure; essentially, a formal estimate of absolute cardiovascular risk may help to determine whether the likely benefit of therapy will outweigh its costs and hazards. Most of the morbidity and mortality associated with hypertension is attributed to coronary heart disease and many treatment guidelines are therefore based on the estimates of 10 year coronary heart disease risk. The current protocol considers emergency attention of a specialist under following conditions where accelerated or malignant hypertension onsets or cases with severe hypertension such as cases with BP >220/120 mmHg and impending complications which are imperative and need to be included in the protocol to enhance its significance. Guidelines laid by National Institute for Health and Clinical Excellence, (2011) mentions similar criterion as mentioned in the current protocol, with an additional feature of the fundi check up for the occurrence of hypertensive retinopathy, which is not mentioned in current protocol. Guidelines laid by National Institute for Health and Clinical Excellence, (2011) also emphasize that individual diagnosed with Stage 1 hypertension, must seek the physician's advice to rule out the secondary cause of hypertension in order to prevent target organ damage. Considering the role played by various environmental factors play in modulating blood pressure of the individual 10 year cardiovascular risk assessment is a long time and needs to be revised in order to prevent jeopardy. Interventions (Pharmaceutical) The current protocol emphasize that the drug therapy should be offered to those who have constant blood pressure measurement as >160/100 mmHg, patients with elevated CVD (cardiovascular disease) jeopardy of 10 years or more and danger of >20% or active CVD or target organ injury or diabetic with unrelenting blood pressure of >140/90 mmHg. In certain cases a combination of drugs are used to keep the BP as 160 mmHg) should be offered the same treatment as the patients with both raised and diastolic blood pressure. Further, very elderly patients (over 80 years of age) are offered with the same treatment as younger patients having taken account of any comorbidity and their existing burden of drug use. The current protocol mentions the combination of drugs which was specified in guidelines laid by National Institute for Health and Clinical Excellence, (2011) that ACE (Angiotensin-Converting Enzyme) inhibitors with angiotensin II receptor blocker (ARB) should not be combined. Guidelines laid by NIHCE, (2011), also mentions management of pregnancy and breastfeeding with chronic hypertension. Interventions (Nonpharmaceutical) The current protocol offers suitable guidance to written or audiovisual objects to endorse lifestyle modification with the five A's model of effecting behavioral alterations- ask the patient about current status, advise the patient about the advantages and jeopardy of current actions, assesses motivation to modification, arranging review for the patient, assisting through advice etc. Similar interventions are also mentioned in guidelines laid by National Institute for Health and Clinical Excellence, (2011). However, the guidelines laid by National Institute for Health and Clinical Excellence, (2011) also mentions the diet and exercise patterns of the patient together with low salt intake, discouraging excessive consumption of coffee and other caffeine products. Similar interventions are also mentioned in the Guidelines for the Management of Hypertension (2009), which laid emphasis on the consumption of fruits and vegetables and very low fat consumption is recommended. The current protocol emphasize on encouraging individuals to stop smoking, the thought is also supported by other protocols. The current protocol discourages individuals to consume calcium, magnesium and potassium supplements in order to keep a check on BP as they are found to reduce negative implication on the arteries. The guidelines laid by National Institute for Health and Clinical Excellence, (2011) gives emphasis on relaxation therapies to reduce BP. Such interventions are also mentioned in the current protocol. However, current protocol also mentions the importance of stress management, cognitive therapies, minimize fat consumption and weight reduction which was not stated in guidelines laid by National Institute for Health and Clinical Excellence, (2011). Moreover, the current protocol mentions limit for alcohol consumption for men 140/90 mmHg) with the regimen, should incorporate beta-blocker. Patients with regimen and controlled BP (135/85 mmHg should be considered as hypertensive. Decrease in blood pressure and ACE inhibitors diminish the rate of turn down in renal failure. Multi- therapy should be anticipated as per the current protocol. Type 2 Diabetes Antihypertensive drug threshold for type 2 diabetes is >140/80 mmHg. Patient should be medicated to bring down BP Read More