Last week we posted a case example followed by eight questions designed to test knowledge of the most recent guidelines for management of hypertension as well as the unique challenges managing this disease in the correctional setting. Each of the test questions are listed below with the correct answer underlined followed by an explanation of the correct answer. The references are listed at the end of the post so you can access the material that was used to prepare this quiz.
Case example: The case example involved an inmate being seen in nurse sick call for complaints of nasal allergies and a recent back strain. His blood pressure is 148/90 mm Hg. At intake, a month ago, his blood pressure was 154/92 mm Hg.
1. Based upon the reading today, this patient is at what stage of hypertension?
- Stage 1 hypertension
- Stage 2 hypertension
- Hypertensive crisis
Explanation: Hypertension stages are unchanged from the JNC 7 report. These stages are defined as:
||Systolic blood pressure
||Diastolic blood pressure
||120 to 139 mm Hg
||80 to 89 mm Hg
|Stage 1 hypertension
||140 to 159 mm Hg
||90 to 99 mm Hg
|Stage 2 hypertension
||Equal or higher than 160 mm Hg
||100 mm Hg or higher
||Above 120 mm Hg
2. Which of the following is not a risk factor for hypertension?
- Family history
- Sexual orientation
- Alcohol use
Explanation: Gender is a risk factor but not sexual orientation. Men are more likely than women to have high blood pressure until about age 45. The rates of disease are similar between men and women from age 45 to 64 but after that women are at much higher risk (American Heart Association). Subgroups within an incarcerated population at higher risk of hypertension include youth, African American men and young women (Arries & Maposa 2013).
3. What lifestyle changes will you suggest to the patient?
- Weight loss
- Reduce salt
- Increase activity
- All of the above
Explanation: Lifestyle changes are a first line recommendation in the treatment of hypertension. Systolic blood pressure reduces 1 mm Hg for every pound of weight loss, reducing sodium intake to 1,500 – 2,300 mg/day decreases blood pressure by as much as 8 mm Hg, and 30 minutes of activity five days a week reduces systolic blood pressure by as much as 9 mm Hg (Townsend & Anderson 2015). Educating patients about the contribution of these lifestyle changes to reducing blood pressure, giving them the tools to account for these changes and the opportunity to see the change in blood pressure is a powerful means to engage patients in their own care. Several studies have shown that lifestyle change interventions are effective with incarcerated populations (Arries & Maposa 2013).
4. A patient with hypertension should be seen monthly until…
- Blood pressure reaches the target goal
- Lab work is within normal limits
- Blood pressure readings stabilize
- The provider determines another interval
Explanation: An important feature of the JNC recommendations are the target goals for blood pressure. A significant change in the JNC 8 was to ease the target goals for patients with diabetes and chronic kidney disease (James, Oparil, Carter et al 2014). The main purpose of hypertension treatment is to achieve and maintain blood pressure within the target range listed in the table below.
||Goal for systolic BP
||Goal for diastolic BP
|Aged 60 years or older
||150 mm Hg and below
||90 mm Hg and below
|All others including diabetics and chronic kidney disease
||140 mm Hg and below
||90 mm Hg and below
When a patient does not meet the target, treatment needs modification by increasing dosages, adding another medication or both until the goal is achieved (Townsend & Anderson 2015, Mahajan 2014). The interval between provider visits can be increased once the goal is achieved. Treatment adherence can be compromised by the patients’ experience of drug side effects, lack of motivation and insufficient knowledge. Nurse led clinics to coach and monitor adherence is a keystone in managing inmate/patients who are being treated for hypertension (Voermans 2013, Arries & Maposa 2013).
5. If lifestyle changes are not sufficient to lower this patient’s blood pressure, medication should be considered unless he…
- Is a diabetic
- Has liver disease
- Is over 60 years of age
- Has blurry vision
Explanation: The patient in the case example has a blood pressure of 148/90 mm Hg. A previous blood pressure reading was 154/92 mm Hg. According to the JNC 8 guidelines a target blood pressure of 150/90 mm Hg is recommended for persons 60 and older, without diabetes or chronic kidney disease (James, Oparil, Carter et al 2014). If he is 60 years of age or older he should still be followed so that he can be referred for drug treatment when his blood pressure exceeds 150/90 mm Hg. In the meantime continued assessment and coaching about lifestyle changes is recommended.
6. Initial medication orders for treatment of hypertension are likely to include any of the following except…
- ACE inhibitors
- Beta blockers
- Calcium channel blockers
- Thiazide type diuretic
Explanation: The JNC 8 guidelines expanded the number of medications that can be considered as first line therapy to include calcium channel blockers, ACE inhibitors and ARBs. The previous guidelines (JNC 7) gave preference to thiazide type diuretics for initial therapy. The JNC 8 also include specific recommendations for medications for African Americans based upon the evidence for prevention of other cardiovascular conditions (James, Oparil, Carter et al 2014, The Pharmacists Letter 2014).
7. The patient is placed on a low dose of lisinopril and hydrochlorothiazide. What lab work should be ordered to monitor this patient?
- BUN & GFR
- Albumin & bilirubin
- HgA1c & LDL
- Creatinine & potassium
Explanation: Lisinopril is an ACE inhibitor. ACE inhibitors frequently cause an elevation in creatinine which can give rise to hyperkalemia. Both of these should monitored and dosage adjusted or drug regime changed if levels rise (Townsend & Anderson 2015). Nurses can counsel patients about what side effects to expect, how to care of various side effects and what conditions should cause the patient to request health care attention. Nurses should always consider the medications a patient is taking during a sick call encounter. The problem being experienced may be a side effect that can be addressed so that adherence with prescribed treatment continues or it may be an adverse effect that needs prompt medical attention (Smith 2013).
8. What lifestyle change will be most difficult to accomplish while incarcerated?
- Increased exercise
- Lower sodium intake
- Smoking cessation
- Limiting alcohol use
Explanation: Incarceration for the most part limits access to alcohol. Smoking cessation is a fait accompli in those facilities which are smoke free. Aerobic exercise does not require any special equipment and blood pressure reduction can be accomplished as simply as brisk walking for 40 minutes three or four days a week (American Heart Association 2014). What inmates have the least control over are meals, both the calories and sodium content. Foods high in sodium which are frequently on the menu in correctional facilities are processed meat, baked goods, and processed cheese. When inmates try to obtain a healthier diet (medical diets or religious diets) the alternatives served are often monotonous and unpalatable. Inmates often supplement institution meals with food purchased from the canteen which also is likely to be high in calories and sodium. For this reason lowering sodium intake is the most difficult lifestyle change for patients to accomplish while incarcerated. Some facilities have found that by adopting a “heart healthy” diet as endorsed by the American Heart Association and offering a selection of healthier snacks through the canteen has been cost effective because most medical diets and waste from uneaten special meals are eliminated (Voermans 2013).
For more on the correctional nurses’ role managing patients with chronic conditions like hypertension, cardiovascular disease, asthma, arthritis, diabetes, and seizure disorders see Chapter 6 of our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!
American Heart Association (2014) Understand your risk for high blood pressure. Retrieved July 1, 2015 at http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp
Arries, E. J. & Maposa, S. (2013). Cardiovascular risk factors among prisoners. Journal of Forensic Nursing 9 (1): 52
Binswanger I.A., Krueger, P.M., & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health 63 (11): 912
James, P.A., Oparil, S., Carter, B.L., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311 (17): 1809
Mahajan, R. (2014). Joint National Committee 8 report: How it differs from JNC 7. International Journal of Applied Basic Medical Research 4 (2): 61
Noonan, M. E. & Ginder, S. (2014) Mortality in Local Jails and State Prisons, 2000-2012- Statistical Tables. Bureau of Justice Statistics. Retrieved July 1 at http://www.bjs.gov/content/pub/pdf/mljsp0012st.pdf
The Pharmacists Letter (2014) Treatment of hypertension: JNC 8 and more. Therapeutic Research Center. PL Detail – Document #300201. Retrieved July 1 at www.PharmacistsLetter.com
Smith, S. (2013) Sick Call. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.
Townsend, T., & Anderson, P. (2015). What goes up must come down: Hypertension and the JNC-8 guidelines. American Nurse Today 10 (6)
Voermans, P. (2013) Chronic Conditions. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. Springer. NY.
Wang, E.A., Pletcher, M., Lin, F., et al. (2009). Incarceration, incident hypertension, and access to health care. Archives of Internal Medicine 169 (7): 687
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