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Hypertension in All Age? Research Paper Example

Pages: 32

Words: 8935

Research Paper


Purpose/objectives:- The purpose of this study was to explore hypertension among all age groups with the major objective of emphasizing the role of the advanced nurse in collaborate management competency of the experience as a healthcare practitioner in the twenty-first century

Description of the project:- .A literary interpretation of hypertension affecting all age groups was given along with a full description of  the disease, epidemiology, treatment and current  trends in diagnosis and treatment were explained.

Interpretation/Conclusion: – Compliance with medication management and life style changes is at a crisis level. Patients in the older age group develop strong resistance to medication and are at higher risk of serious morbidities due to the condition


 This research is aimed at exploring hypertension occurring in all age groups. The condition can be defined as a chronic illness affecting persons at any age. Hypertension is also known as high blood pressure from a lay man’s perspective. This condition is diagnosed when a consistent reading above 140/90 mm Hg occurs. The national Institute of clinical excellence recommends three consecutive readings at monthly intervals of systolic pressure over 140 and diastolic above 90 before a diagnosis is made. According to current epidemiological data 34% of the world’s population is affected by hypertension. There have been marked increases among children and adolescents within the past 20 years (Luma, Spiotta & Spiotta, 2006).

In-depth description of the problem

Symptoms and classifications

 Hypertension is referred to by health care experts as the silent killer.  Blood pressure is evaluated by calculating two measurements, systolic and diastolic pressures. These two features assess both a maximum and minimum scale within the arterial system. Systolic pressure is revealed when the left ventricle contracts whereas diastolic pressure is recorded as  the left ventricle becomes most relaxed between contractions.  The range of normal blood pressure when the ventricles are at rest has been 100–140 mmHg systolic and 60–90 mmHg diastolic.  When a persistence of 140/90 millimeters mercury (mmHg) and above occurs in most adults hypertension is diagnosed. Blood pressure in children is evaluated using different criteria (Kotchen, 2011).

Hypertension can be symptomless. Rarely do individuals suffering from hypertension display any symptoms other than a high blood pressure reading. This makes the condition very unique because it can go unnoticed for many years without any symptoms, but insidiously affects the individuals’ health. For this reason routine blood pressure readings have become mandatory in every health care setting. However, while symptoms are not usually observed the different types and levels of hypertensive disease show some symptoms as the disorder progresses. Importantly, when  some clients report symptoms they could be related to anxiety. Consequently, even with a persistent reading of levels higher than normal other investigations are mandatory before active treatment of the disease actually begins. For example, when clients complain of headaches, dizziness, blurred vision, light headedness and vertigo they could be related to anxiety (Lawrence, Williams & Sanchez, 2013).

Primary hypertension     

Currently, hypertension among all age groups is classified as primary and secondary.  These two categories are further subdivided into several other sections for health care management convenience. Primary hypertension is also known as essential hypertension. While the condition is considered idiopathic experts have reviewed studies and concluded that several common genetic variants have impacts on the occurrence of high blood pressure. Consequently, the development of high blood pressure among many ethnic groups could have both genetic and environmental influences. Despite these  assumptions into determining an etiology for primary hypertension, that affects such great portion of the population, the condition is poorly understood within medical science (Lawrence, 2013).

Research shows that a person’s blood pressure naturally rises with age. As such, age could be a risk facto. Also, studies show where many environmental elements impact an elevated blood pressure level.  For example, some people are sensitive to high salt intake, which creates elevation in the blood pressure. Stress, lack of exercise, and obesity are some environmental elements that impact hypertension. More recently, depression was identified as a significant factor in creating hypertensive disease (Calhoun, Jones, & Textor, 2008).

Other factors such as caffeine consumption and vitamin D deficiency are still being researched. A syndrome X component, which is linked to insulin resistance in obese clients have been related to hypertension development also. It is known as the metabolic syndrome. Further research shows where conditions such as low birth weight, maternal drug abuse, inadequate breast feeding, smoking among other undisclosed elements are still being researched. However, the causes as well as signs and symptoms of primary hypertension still remain a medical mystery (Vaidya & Forman, 2010).

Secondary hypertension

 Secondary hypertension originates form a secondary known disease entity. One of the leading secondary etiologies is kidney disease. Other disease conditions responsible for the development of secondary hypertension include hypothyroidism, Conn’s diseases, hyperthyroid, Cushing syndrome, acromegaly, pheochromocytoma among many other endocrine conditions. Diabetes mellitus, obesity, pregnancy, coarcataion of the aorta, sleep apnea, herbal remedies, prescription medications liquorice consumption are identified as factors causing with secondary hypertension (Vaidya & Forman, 2010).

Renovascular hypertension

This is blockage of the arteries that supply blood to the kidneys. When the kidneys are depleted of blood supply the response is as if the blood pressure is low thereby releasing hormones that cause the blood pressure to rise. These hormones hold on to salt increasing fluid in the body. While this condition is responsible for causing high blood pressure high blood pressure could create kidney damage blocking blood vessels, too. Patients with renal disease without any hypertension diagnosis will develop hypertension ultimately (Liao, Sung, Hung,  Wu,  Lu, 2012).

Hypertension during pregnancy (preeclampsia)

 Many hormonal changes occur during pregnancy, which impact changes in the cardiovascular system and initiate an increase in blood pressure. Hypertension during pregnancy, however, is a very serious complication requiring careful management throughout the pre/intra and post-natal periods. Apart from the pregnancy and hormonal changes periods there is no known cause of the condition referred to as pre –eclampsia. It begins about the 29th week of pregnancy (Dadelszen, Duvekot & Pijnenborg, 2010).

Hypertension in children and adolescents

 Hypertension in children and adolescents is becoming a concern among health care professionals. Normal blood pressure in children is evaluated by using age, sex and height criteria. These can be captured on standardized tables. Pre-hypertension in children and adolescents is measured at 90th percentile, but less than 95th . The age, sex and height standards are usually 120/90 mm Hg or higher. Once the percentile is higher than 95th the client is considered hypertensive. Often hypertension in children and adolescents has a secondary etiology, which must be researched thoroughly. Essentially, it is associated with parenchymal or renovascular disease. Over weight and obesity is strongly related to hypertension in children (Riley& Bluhm, 2010).

The target organ damage for children with symptomatic hypertension includes eyes, left ventricular failure and kidneys, predominantly. The diagnosis is made in only 26% of all children since blood pressure evaluations are not done routinely as in adults. Children diagnosed with primary hypertension show risk factors linked to cardiovascular disease (CVD), diabetes and hyperlipidemia. However, normal blood pressure in children varies with age and geographic location (Riley & Bluhm, 2010).

The African American primary hypertension phenomenon

 As in many other diseases African Americans have been labeled as having a peculiar and high incidence of primary hypertension. Theories have been that due to their higher risk of obesity and diabetes they have become most vulnerable to hypertension. Other assumptions have been that all black Africans have a predisposition to hypertensive disease, which was proven false since samples of black West African evaluated showed no signs of hypertension. Further, theories have suggested that diet and poverty are the causes of primary hypertension prevalence among  black African descendants living in the United States of America (Fuchs, 2011).

Distinct studies show where the mechanisms relating biological differences of blood pressure control among African Americans and other races/Africans could be environmental as well as habits. Remarkably the hypertension phenomenon among blacks in America was confirmed by further studies that blacks in Africa and the Caribbean were not at risk of hypertension as those living in United States of America. More importantly, another study revealed that blacks migrating from the Caribbean seldom show signs of developing the disease within the first three to four years living in the country. However, after this period they become just as vulnerable as the average African American (Fuchs, 2011).

Consequently, this hypertension phenomenon among blacks living in the United States of America as against those residing in Africa and other parts of the world leaves scientists to conclude that  the dominant causes for this development is environmental and behavioral. There are characteristics within the society that initiate blood pressure increase mechanisms not found in other societies where blacks live across the globe (Fuchs, 2011).

Hypertensive crisis

This is also known as hypertensive crisis or emergency whereby retinal hemorrhage  may be observed or exudates flow from the eyes.  For a diagnosis to be made there must be evidence of papilledema.  Simultaneously, an increased intracranial pressure  must exist and manifestations of vomiting, headache, as well as subarachnoid/ cerebral hemorrhage. These symptoms are usually accompanied by left ventricular dysfunction.  Kidney dysfunction is also evident and sings of proteinuria, haematura, heart and acute renal failure are manifested. In screening these signs and symptoms are evaluated differently because they could gimmick complications of hypertension, but the presence of papilledema rules out other disease complications. Some clinicians may even relate the presence of papilledema to hypertensive retinopathy making an incorrect diagnosis (Thomas, 2011).

Again as in essential/primary hypertension the cause of an emergency hypertension or hypertensive crisis is unknown and the etiology has not been exclusively recognized. Often the blood pressure persists at a level of 200+/ 130+ mmHg. Patients often complain of tremors and are every anxious.  Characteristics of this condition are assessed as a serious urgent situation of elevated blood pressure that persists for more than an hour. In patients with anxiety attacks could display similar symptoms, but they subside independently without any treatment. It muat be noted that while anxiety could play a major role in an apparent hypertensive emergency or crisis patients must be observed for other serious complications of high blood pressure such as stroke or heart attack (Thomas, 2011).

Description of clinical setting for APNP

 The clinical setting for application of resolutions to the hypertensive epidemic facing this nation is twofold. First she/he functions as an educator in the field of primary care intervention. Secondly, the Advanced Nurse Practitioner functions as an interventionist adapting an appropriate model of care for persons affected by hypertension. The distinct clinical setting is the community; clinics and health care environments where education and treatment is required for control and addressing hypertension directly.

The Advanced Practice Nurse Practitioner (APNP) or Advanced Registered Nurse Practitioner (APRN) plays a unique role and has specific responsibilities within the health care setting. Importantly, he/she is trained to utilize extended skills in resolving health issues across a population of clients seeking care. He/she has knowledge to develop expertise in planning, assessment, diagnosis, implementing adequate treatment as well as evaluating care offered to clients within his/her scope of practice. These nurses are prepared to function at a postgraduate level and could specialize in any desired area of interest (Newhouse, Stanik-Hutt & White, 2011).

Criteria that allow Advance Practice nurses to perform at a much higher level than registered nurses pertain, to their knowledge base, skills, expertise developed through experience and practice and the patient/ client relationship training.  As such, in this era where healthcare delivery is very costly, the Advance Nurse has become the middle ground resource where millions of uninsured sick people across the nation can access more affordable health care. The critical analysis qualities obtained by advanced nurses from their training along with problem solving and evidence based decision making application make them a valuable compliment to any health care setting  in the twenty-first century (Newhouse, 2011).


 More people are being diagnosed with hypertension daily and its management is a huge health care cost. Statistical brief of hypertension health care costs reveal that in 2010, $42.9 billion was spent on hypertension treatment. $20.4 billion went towards prescription medications. This accounts for treatment of clients 18 years and older. Subsequently, the annual average expenditure for treatment was calculated at $733 per adult in 2010. Further, statistics show where the mean treatment expenditure per person was relatively higher in Hispanics ($887). Non-Hispanic blacks ($981) for non-Hispanic whites ($679). Non-Hispanics and others accounted for ($661). Treatment of hypertension is mandatory because it is the leading cause of stoke, kidney disease and heart failure, which all contribute to higher health care costs (Davis, 2013) (See Figure 1/6 and table 1).

Table 1: Total medical expenditures for hypertension, by type of service:

Adults age 18 and older, 2010

Total Prescription and medication Ambulatory      Other

        $42.9 billion                  $ 20.4 billion                  $13.0 billion                      $9.5 billion

Other costs include hospital stays, emergency room and home health (Davis, 2013).

 Significance of study

 Based on the estimated expenditure of treating uncomplicated hypertension it is essential that health care expend money on research to explore more appropriate measures for addressing this condition within the society. More evidence-based practice models are required. This research project could initiate such models from data collected by examining relevant literature.

Statistical evidence of hypertension prevalence

According to the Center for Disease Control an estimated 70 million American adults are affected by hypertension. This accounts for 29% of all adults or 1 in every 3. Of this percentage just 52% have their blood pressure under control. Blood pressure varies with age and gender. The specific percentage can be viewed on Table 2.

In the United States of America 81% of adults were aware of the condition. However, only 76.4% reported that they are on prescribed medication to control hypertension. This was observed during 2009 – 2010.  Importantly, the percentage of persons with controlled hypertension increased from 48% in 2008 to 53% in 2013. Further data shows where in 2013 approximately 360,000 deaths occurred due to hypertension and its complications. This is a rate of 1,000 persons per day. Besides, 7 out of every 10 with their first heart attack are hypertensive; 8 out of 10 people with their first stroke are hypertensive. Kidney disease is prevalent among persons with hypertension (Centers for Disease Control, 2014) (See Figure 2).

 From World Health Organization estimates in 2000 almost one billion of the world’s adult population (26%) had hypertension. In developed countries however, there is a marked increased number of 333 million. In undeveloped nations the amount is almost doubled at 639 million.  Regions across the world vary in the amount of people affected. Some countries have reported rates as low as 3.4% in men and 6.8% women, respectively (rural India). Meanwhile, in Poland the rates are as high as 68.9% in men and 72.5% in women. Thirty to forty five (30-54%) percent of people in Europe were hypertensive in 2013 (Centers for Disease, 2014).

Justification of Study

After reviewing the complexity of hypertension with regards to its epidemiology, especially, with an estimated death toll of 1,000 per day there is immense justification for more studies because this death rate is a disaster in itself. During disasters that claim the lives of so many people immediately strategies are designed to salvage victims from its danger. Apart from the extreme health care cost of an estimated $46 billion annually there are additional expenditures towards treating its complications,which is a huge financial undertaking. The leading cause of death in America is heart disease. Seven ( 7 ) out of every  ten (10) patients who get a heart attack subsequently, developing heart disease are hypertensive. Therefore, hypertension is the predisposing element to the heart attack. These factors justify further studies in hypertension since the etiology is unknown and many ethnic groups are at high risks due to environmental and behavioral circumstances.

Review of Literature

 This literature review will explore research studies with relevant data pertaining to screening and diagnosis, treatment intervention and current disease trends.

 Screening and diagnosis

In a conscientious effort to control spread of the hypertension epidemic in America, a systemic evidence review for the US preventative task force was commissioned. The review focused on blood pressure screening in adults. The research question, what is the shortest interval clinically significant diagnosed hypertension could develop’ was the focus of this review. Findings were less than six (6) years from a sample of 115,736 participants. The most frequently used diagnostic threshold was 140/90 mm Hg. Characteristics defining the best diagnostic accuracy for hypertension from a single test included resting time before measurement, body positions, intervals between measurements, number of measurements and the setting (Piper, 2014).

Meanwhile, resistant hypertension is creating many concerns among researchers with regards to its screening and diagnosis. In resolving this diagnostic dilemma researchers evaluated studies pertaining to resistant hypertension and the criteria used to ultimately conclude that the condition is unresponsive to treatment.   In ALLHAT, 34% of participants continued to be uncontrolled on an average of 2 medications after about 5 years follow up. When the study was completed 27% of the sample was taking at least three (3) medications. A more precise evaluation revealed that 49% of the ALLHAT participants used 1 or 2 medications, to control their blood pressure (Calhoun, Jones & Texter, 2008).

This meant that about 50% of participants were expected to take at least 3 or more blood pressure medications to lower the blood pressure hypertension. Researchers, however, explained that this disclosed percentage may be underestimated with regards to the extent to which patients’ resistance to medication  was diagnosed or their screening evaluation processed. Further, it was discovered that in screening difficult-to-treat hypertensive cases,  there were patients  who required more than two medications to achieve a blood pressure reading of <160/100 mm Hg. Eventually, they were screened separately  and removed from the ALLHAT study (Calhoun, 2008).

Ultimately, in this screening evaluation, the combined use of any 2 classes of medications mentioned in the classification below was not recommended. They included ‘thiazide-type diuretics, angiotensin-converting enzyme (ACE) inhibitors, calcium channel blockers, and ? adrenergic receptor antagonists’ (Calhoun, et. al, 2008, p 22).   Presently, these combinations are used as treatment protocols administered by health care providers to patients diagnosed with hypertension, which is controlled. In concluding the screening diagnostic evaluation of resistant hypertension researchers could not determine whether there was a significant difference in the prognosis of patients with resistant/ uncontrolled hypertension and those whose blood pressure is controlled. Besides, resistance to medication was observed  to be more among older patients 75 years and older (Calhoun, et. al, 2008).

Treatment interventions  

Gradman, Parkise, Lefebvre, Farley & Lafeuille (2013) conducted a study, which revealed that ‘Initial Combination Therapy Reduces the Risk of Cardiovascular Events in Hypertensive Patients. Data was retrieved from ‘A Matched Cohort Study.’ Researchers assessed the impact of initial versus delayed treatment drug combinations on blood pressure (BP) control as well as cardiovascular (CV) risk events in patients with hypertension. Clinical trials offered data indicative of the time factor administration of regime protocols’ influence on BP control. This intervention determined successful outcomes in the long-term even though there is insufficient evidence supportive of this assumption (Gradman, Parkise, Lefebvre, Farley & Lafeuille, 2013)

Electronic medical charts from 2005-2009 were reviewed. 17262 adult profiles of patients adapting the initial therapeutic intervention protocols were matched retrospectively comparing them to patients with initiating monotherapy. Later they were switched to the combination therapy. Many variables relating stroke events were evaluated among  the cohort studies reviewed. The initial therapy was linked to a marked reduction in cardiovascular risks events and after six (6) months normal blood pressure levels were achieved using the initial drug therapy (Gradman,, 2013).

Whittle (2014) reviewedImplementing Programs to Improve Hypertension Management in Typical Practice Settings concluding that it is. ‘Not as Easy as It Sounds.’ The expert contends that despite extensive application of evidence – based intervention programs 40% of American patients still do not maintain a blood pressure below 140/90 mm Hg. The concern after reviewing evidence from randomized control trials is that while life style changes do improve blood pressure control, there is no guarantee that patients will adapt to these measures on a daily basis. During the trials pharmacological interventions proved successful. However, due to the serious side effects of these drugs patients many not take them as prescribed. The conclusion was that no problem existed with the evidence obtained from these trials, but effective implementation was the real concern (Whittle, 2014).

 Current disease/ intervention trends

Rahmouni (2014) offered insights into ‘Obesity-Associated Hypertension Recent Progress in Deciphering the Pathogenesis.’  This researcher observed that excessive sympathetic nerve activity was associated with the development of hypertension. It was explained that when the sympathetic nervous system is activated, obesity occurs. This nervous system functions are responsible to a great extent for the maintenance of normal blood pressure levels. Importantly, the sympathetic overdrive functions are related to subclinical cardiovascular as well as renal alternations even when these obese patients have not been diagnosed with hypertension (Rahmouni, 2014).

Sharman (2015) studied ‘Exercise and Cardiovascular Risk in Patients with Hypertension.’  The expert discovered that people with hypertension tend to be less active than those who are not.  Further, it was clarified that exercise was not responsible for cardiovascular events in hypertensive patients as some theories advanced. Instead, exercise could prevent those situations termed cardiovascular events. Therefore, the benefits of exercise outweigh the risks. Currently, there has been profound evidence supporting the mandatory exercise intervention in preventing cardiovascular events and controlled high blood pressure (Sharman, 2015).

Niiranen (2014) and colleagues argue that there is ‘Lack of Impact of a Comprehensive Intervention on Hypertension in the Primary Care Setting.’ The team contends that  there is evidence supportive  of lifestyle changes, blood pressure (BP) monitoring at home, and optimizing antihypertensive drug therapy, significantly lowers blood pressure levels in controlled settings. However, this strategy/protocol was not used in primary health care settings. In concluding the study the researchers advanced that lack of motivation and incentives among  staff could be responsible for primary healthcare inadequate outcomes in treating the condition. Consequently, more attention should be given to education in primary care settings regarding adherence to evidence-based protocols in treating hypertension (Niiranen, 2014).


 Three major themes were highlighted in this literature review. They encompassed screening and diagnosis, treatment interventions and current trends in intervention and course of the disease. Two types of diagnostic and screening issues posed concerns for researchers. They pertained to first time hypertension discoveries and an emerging population of resistant to medication hypertensive clients. It was a matter of concern that while screening and treatment measures were evidence-based, people still displayed signs and symptoms. Usually, scientists have confirmed that the symptoms expressed by the sample reviewed were profound in their description. Therefore, it is not accurate to say hypertension is without signs and symptoms.

The argument about treatment interventions centered between the effects of delayed and initial approaches to medication management was clarified. Apart from acknowledging that the initial protocol adherence was more effective than delayed, there were special situations where the delayed was also effective. Clinicians were required to use their judgment in arriving at the most appropriate decision in relation to patients’ culture and age.

As more research is conducted in hypertension, daily scientists have been analyzing possible causes for the disease. There is profound evidence supporting the genetic theory. Researchers are also discovering that resistance to hypertension treatment protocols is not due to lack of evidence, but effective implementation strategies along with firm collaborative efforts among health care providers.

Various databases including PubMed and Google Scholar were explored in finding appropriate literature for this study. A total of 30 articles were retrieved. Twenty- six (26) were used in the study due to  their relevance of the topic hypertension.  Four were not directly related to hypertension because they discussed complications rather than the disease itself. Eight (8) were used as valuable resources for the review of literature. The inclusion criteria for all articles were studies pertaining to hypertension conducted during the years 2005 -2015. Articles unrelated to hypertension were excluded and if those written outside the 2005 – 2015 timeframe. Key words predicting inclusion exclusion criteria were hypertension and high blood pressure.

Conceptual model and mid-range theory

 The particular conceptual model selected for this study relates to the four metaparadigms of nursing namely nursing, person, environment and health.  A thorough exploration of the medical problem, hypertension, in all age groups require a conceptual framework/model, which is compatible with the individual, intervention, health care community through which care is expected to be executed.

 Nursing is the academic discipline though which individuals affected by hypertension disease can access care. Precisely, nursing is the art and science of holistic health care. This care consists of empowering values whereby persons affected by hypertension can take control of their lives in adapting the appropriate measures to live with the disease.  Hypertension is a chronic condition requiring lifelong treatment. Daily intervention is needed to maintain a high quality of life and postpone complications. Therefore, the nursing adaptations require choices by the health care provider and guided responsibilities. Nursing science allows knowledge transference and evidence-based implementation of treatment measures (Masters, 2012).

The benefit of nursing practice to hypertension management is the actualized therapeutic interventions executed by the advance nurse practitioner who is equipped with creativity to administer care way above the level of a trained registered nurse. Essentially, nurses apply critical thinking  skills along with clinical judgment in arriving at the most adequate response to the person’s individual need for management of a client suffering with hypertension. Ultimately, nursing as a scientific intervention in hypertensive disease reaches families of the affected person and in some cases the community since hypertension could be environmental in its etiology (Masters, 2012).

Human beings in this setting are persons diagnosed with hypertension. Each client is perceived as an open energy field through which experiences of life flow to promote resolution of any hypertensive episode in their awareness. These energy fields combine to support the holistic nature of the human or the human organism. The activities produced by combining human energy fields are unpredictable. However, as a holistic entity the human organism/person expresses dynamism, creativity, sentiment and is capable of demonstration many cognitive functions necessary for participating in restoration of wholeness. Importantly, the person is multidimensional very much capable of abstract reasoning, which could hinder or accelerate effectiveness of treatment interventions (Masters, 2012).

Understanding the human being as the person in the health care, nursing environment is essential because language expressions, empathy and love, are abstract communication patterns defining the person’s individuality. This aspect of the personality could become very complex when relating the disease issue to the person affect by hypertension. A very high level of competence is required by the health care provider. The person while an individual has many components of the self, which emerges under pressure receiving a hypertension diagnosis (Masters, 2012).

The landscape and geography where human social experiences are encountered is the environment reference in the metaparadigms of nursing conceptual model chosen to guide this study (Figure 3). It includes the physical space in which everyday life activities are conducted. Time spent in this space and quality of surroundings impact outcomes expected in the environment as well as   the person’s life. A personal, national, social, and global feature of individuals’ character is shaped by the environment. Values, societal beliefs, expectations, and culture are all influenced the environment.  More importantly, the environment is an energy force in itself, which combines with human energy to shape circumstances in the lives of persons within that geographic location. Therefore, when experts explain that hypertension in African Americans is closely related to the environment and behaviors this metaparadigms concept is amplified (Masters, 2012).

The goal of this health care system is to reduce the 1,000 death toll per day of people across America  affected with hypertension and its complications. It is a program of health restoration and maintenance. Health is a lived experience whereby congruence is established between the possibilities and realities of the client’s diagnosis. Caring targets the wellness of the person affected by the Illness. In situations where there is loss of normal function dysfunction mediated caring relationships are established. This conceptualization requires that every client be empowered to address stress through appropriate coping strategies. Ultimately, the health expression derived from this health concept is possible through interactions between/among the environment and human entities (Masters, 2012).

Middle Range Theory of Spiritual Well Being in Illness

The Middle Range Theory of Spiritual Well being in illness is effective for nurses applying holistic care concepts related to the metaparadigms in nursing. It is pays attention to the requirements for wholeness in the body, spirit and mind. Mid-range theories have less assumption for implementation than grand theories. They serve as an effective resource filling gaps between grand range and actual nursing practice. This middle rang theory of Spiritual Well being in illness could be very effective in addressing hypertension because the disease itself produces fear of sudden premature death along with numerous complications. Besides, medication therapies do not always work favorable with hypertensive patients because the condition in some cases becomes resistant to the drug (White, Peters & Schim, 2011).

Consequently, combining a spiritual well being perceptive in the holistic approach toward high blood pressure control can be very effective. The core component of this theory is finding spiritual expression in the presence of a chronic life-long illness challenge as hypertension. It is the influence of religion and spirituality on mental illness than other health conditions. The researcher offered eight reasons why it was important to integrate spirituality in health care. Patients have spiritual needs that are related to mental health. These needs are not adequately addressed. Secondly, Religion and spirituality help patients to cope with the illness. Thirdly, beliefs affect patients’ medical decisions and could conflict with their treatment outcome (Koenig, 2012).

Fourth, health care providers’ own religion and spirituality influence medical decisions. Fifth, religion and spirituality awareness affect physical and mental health thereby influencing the illness outcome health care providers ought to be aware of this factor. Six, spirituality affects the care and support patients receive at home. Seventh, research shows that failure to address patient’s religion and spirituality increases health care costs. Eight and finally it is a mandate of the Joint Commission for the Accreditation of Hospital Organizations (JCAHO) and by Medicare (in the US) that the spirituality and religion of clients/patients be respected and addressed while care is being administered (Koenig, 2012).

Issues related to the hypertension phenomenon


Cultural issues pertaining to hypertension are related main y to the dietary factory implied in hypertension disease. Some analysts have advanced that for groups in which hypertension is prevalent they have a food cultural predisposition that encourages development of the disease. Besides hypertension showing ethnic and gender variations, there are also geographic factors influencing emergence of the disease. For example, the theory that salt consumption is related to development and control of hypertension among people of African descent was challenged by some researchers who evaluated a sample of Africans residing in West Africa who ate more than the average amount of salt consumed by African Americans. It was found that these people did not show any signs of hypertension throughout the age groups with prevalence in developed nations across the globe (Fletcher, Hartmann- Boyce & McManus, 2014).

Consequently, the salt eating theory of hypertension predisposition is not applicable to all populations where African descendants reside. While food/diet contributes to the emergency of many diseases other than hypertension, it must be acknowledged that the type of foods consumed by people all over the world is strongly associated with their quality of health. The culture of fast food is associated with obesity among many cultures including the American society. Obesity is linked to hypertension and diabetes. More American adolescents, children and adults are obese and overweight in the twenty-first century than before. In the same way as  where there is an increase in obesity an associated rise in hypertension occurs. Dietary management and weight control are some key features in the management of this disease. Hypertension does have its cultural disposition, but it is not a cultural disease because it affects all age groups across cultures worldwide (Fletcher, 2009).

Anthropologists William Dressler (2009) speaking about ‘Hypertension and Culture Change: Acculturation and Disease in the West Indies’ explained that there is very little data internationally available to validate any suspicions about hypertension and culture, among  the affected groups across the world. His arguments pertain to the medical anthropology of disease whereby the ecological and cultural implications were evaluated. The author drew inferences of how religion, political ideologies such as colonialism and capitalism influence the cultural behavior including selection of food and social activities. In some cultures the consumption of alcohol in social settings is mandatory for enjoyment of the activity. He even mentioned the impact of slavery along with immigration on changes of native culture and the development of diseases such as hypertension (Dressler, 2009).

Health beliefs

All beliefs pertaining to any disease is cultural as well as socio- economic/political in origin. For example, research shows that some native Americas do not trust modern medicine in their diagnosis as well as treatment modalities. They do not respond to modern interventions such as vaccines and diet to promote health. These beliefs originate from history. Findings of the misleading Tuskegee study recruiting black males from Alabama in the syphilis research left a major portion of the African America population fearful of modern medicine strategies used in hypertension as well as many  other disease. More recently there have been rumors that the highest cause of death in America is not heart disease according to Center for Disease and Control publications, but incorrectly prescribed medication taken by patient for various diseases (Wexler, Elton, Pleister & Feldman, 2009).

Against this background of personal health beliefs and socio- political implications that the advanced nurse practitioner has to face a population of patients/ clients affected with hypertension. More importantly, due to the situation whereby minorities are neglected as health care recipients along with the health care rationing system in America, patients and clients are often unaccepting of hypertensions diagnoses. They view the diagnoses as political strategies to further incapacitate and limit participation in the social structure. The health belief is when people are ill they cannot work, provide effectively for their families and their socio-economic status remains at the bottom of the social ladder. These diagnoses are brain washing techniques to make them feel inadequate and threaten quality of life (Wexler et. al. 2009).

Jolles, Padwal, Clark & Braam (2013) conducted a ‘Qualitative Study of Patient Perspectives about Hypertension.’ The research panel sought to find patients belief systems about hypertension and its treatment. Major concerns initiating this study emerged from three observations. First even though more cases of hypertension are being diagnosed yet most patients being treated their hypertension is uncontrolled. Second it was discovered that medication and life style adherence remained very low. Thirdly, non – pharmacological interventions to control hypertension remains very complicated ( Jolles, Padwal, Clark & Braam, 2013).

The above researchers reported  findings  about patients that were recruited from two hypertensive clinics. The majority mentioned that health care providers were very intimidating, driving fear into them regarding life style and medication adherence. Often providers would tell them that they will develop a stroke, die from  a heart attack or end up disabled if they did not comply with the regiment even if there were serious side effects from the medication.   Another group explained that pharmacists were more accommodating to their needs than healthcare providers. Hence, these experiences shaped their belief systems about the disease and treatment health care providers forced on them (Jolles, 2013).

Even though hypertension is perceived “silent” and asymptomatic, 69% of participants sampled in this study expressed symptoms, which were linked to elevated BP levels. As such, in this study personal feelings and/or beliefs impacted hypertension management. Physical manifestations like ‘headaches (38%), energy loss, weakness/tiredness (27%), dizziness and light-headedness (19%), water retention (19%), and numbness (8%)’ (Jolles, 2013, p 12). It was believed that the symptoms expressed were associated with fluctuations in blood pressure (Jolles, 2013).

Therefore, while healthcare providers are still communicating with the public that hypertension has no symptoms 31% of the sample challenged this as being inaccurate. Symptoms were used to indicate whether there was an elevation in the blood pressure and when checked were found to be correct. Consequently, the sample became motivated to control their blood pressure merely for reduction of symptoms. Besides they owned BP monitoring system and checked their blood pressure regularly (Jolles, 2013).

Ethical/ Spiritual issues

 Irene Kretchy (2013) and other researchers ask the question, ‘Spiritual and religious beliefs: do they matter in the medication adherence behavior in hypertensive patients.’ The study results showed where 93% of patients sampled poorly adhered to medication management. They were high spiritually motivated individuals. However, while being religious it was not their religion that motivated non- compliance, but spirituality. The researchers concluded that while these patients were aware of their hypertension diagnosis they relied on divine intervention for its resolution rather than medication and advice of health care providers (Kretchy, 2013).

Medical scientists and researchers always seek to establish a relationship among religion, spirituality, and medication. These researchers explored a relationship as it pertained to hypertensive medication. It could be concluded that the high percentage of non-adherence among certain ethic groups is highly linked to their spirituality. Perhaps, the high incidence of its prevalence might be associated with their spirituality also. There are, however, insufficient data to support this assumption.

Pathological factors

The pathological factors associated with hypertension are related to its complications and commodities resulting from the condition. Hypertension is a chronic disease whereby there is a high tension process when blood is pumped from the heart through blood vessels. This tension can results in several alterations in bodily functions and associating organs. Since the disease condition implicates blood vessel function ultimately, damages occur in the structures of various organs such as the heart, kidney, eyes and brain ((Fletcher, 2014) (See Figure 4 diagram).

Mutations of singe gene could initiate Mendelian forms of high blood pressure. There have been ten genes linked to this pathology. These genes influence blood pressure levels by altering renal salt processing.  Similarities in blood pressure readings have been identified in families, especially, with shared environmental situations ((Fletcher, 2014).

Elements needed for effective interventions

Identification and management of medical crises associated with hypertension

Hypertension crises can occur and must be managed efficiently.  To prevent crises frequent screening for indications of possible emerging complications is mandatory. Cholesterol evaluation in hypertension is significant since high cholesterol levels do predispose to heart disease. Many patients refuse high cholesterol medications either due to belief systems or mere side effects intolerance. However, those clients must be educated regarding foods to avoid that will take cholesterol levels to go up. Also, blood glucose levels are significant. Even though hypertension does not cause diabetes, it is important to consider blood glucose level screening in hypertensive patients. Cardiac enzymes evaluation in patients with hypertensive disease cannot be over emphasized. Coronary heart disease is a serious complication of hypertension. To prevent its emergence then frequent screening is mandatory (Fletcher, 2014).

Hypertension management is often through education first and attempts to modify life styles. Life style modifications encompass encouraging exercise if the individual is pursuing a sedentary life style. Next are dietary interventions. If the client is obese weight control could greatly reduce hypertension crises controlling the blood pressure through natural means. Many patients do not respond to these measures, especially, if hypertension is a secondary condition. .Consequently, there are a group of medications doctors use to manage the condition medically. High blood pressure must be managed applying strategies used to contain complications of any chronic disorder (Fletcher, 2014).

Symptoms control strategies

Controlling hypertension symptoms is important even though they may be insidious. The main symptom in high blood pressure is an increase in systolic and diastolic levels above  normal. There are distinct danger zones requiring immediate intervention. They include a blood pressure of 200 or more systolic and 100 or more diastolic. This could be considered a medical emergency. Therefore, health care providers ought to educate clients concerning reading when the take blood pressure tests at home. Some medications are prescribed only as crisis interventions and this must be carefully communicated to the patient by their health care provider. Patients must be taught how to address a crisis in chronic illness when no health care provider is present (Fletcher, 2009).

Medication compliance programs

In health care there is always an issue of the non-compliant patients/clients. Culture plays an important role regarding whether patients take prescribed medications or follow advice offered by health care professionals. African Americans have been known to be seriously affected by this when compared to other ethnic groups. However, research shows where hypertension is not an African disease because blacks coming from the Caribbean and Africa do not have the same predisposition (Peters, Arorian, & Flack, 2006).

As such, while Hispanics are also affected noncompliance seems to be dominant among blacks. One researcher  reported that African Americans have a food culture, which hinders compliance. They engage in a sedentary life style and seldom take their medications due to the adverse effects. Many people in this ethnic group complain that they feel better when not taking the medication. However all chronic illnesses require compliance with a particular regime. It is the health care provider’s responsibility to devise strategies that would encourage compliance rather than force and threaten clients into carrying out prescribed regimes (Fletcher, 2009).

Social isolation prevention programs

In the quest to prevent people living in social isolation who are affected by chronic illness advocates recommend that relatives become participants in their care to garner an understanding of the chronic illness and how it affects their personality. They will be exposed to interpreting the changes occurring consequently. There have been arguments that especially in the American society elderly people are abused by children, siblings and friends when they encounter difficulties in their health. As such, many states have provided housing in safe residences called assisted living facilities where the older and old-old adults could live in congregate communities with peers (Whittle, 2014).

Younger adults may still have their spouses alive or many caring friends. Engaging is social activities is essential to preventing social isolation. Once the chronic illness does not create enormous disabilities individuals can still be employed either in the same capacity as when they were younger or one that is less stressful. Minimizing stress is essential towards blood pressure control. Importantly, social isolation is a form of stress and every effort should be made by health care providers to engage the services of a social worker in eliminating the occurrence of social isolation when it appears to be imminent (Whittle, 2014).

Commodity adjustment programs/strategies

Hypertension control requires many adjustments to changes. First it requires modifying life style to reflect more activity in daily routine. Walking is encouraged above driving when it is possible. Laughing more is a natural medicine for relieving stress. Hence, changes towards how one reacts to life’s challenges will have to be learned. Spiritual counseling could be effective if the person has that resource available. Changes in diet cannot be overemphasized because some clients’ blood pressure are controlled by diet alone (Whittle,  2014).

Educating for normalcy in daily living

Normalizing is a strategy whereby the focus is placed on facilitating normalcy in living standards despite evidence of chronic illness. For persons suffering from hypertension normalcy in daily activities is easily maintained except if there are underlying disease conditions. One of the greatest challenges faced by high blood pressure sufferers is controlling their eating preferences. In the United States where fast food takes precedence above green vegetables the tendency to go with the crowd is strong. These eating habits may have a cultural impact as it relates to normalcy.

Patients/clients will have to understand that the occasional eating fast foods must be replaced by more wholesome foods including fresh green vegetables. Importantly, a new normal will have to be adapted for better cardiovascular health. Daily activities such as working and conducting household chores are seldom affected when patients comply with the prescribed regime.

Acquiring adequate funding

Funding for the management of chronic diseases is often the responsibility of each client.  Persons with health insurances their providers often cover the cost partially or entirely. People without health insurance, are reliant on health agencies to fund at affordable costs.

Addressing Key psychosocial issues facing individuals affected by hypertension

A key psychological issue facing individuals affected by high blood pressure include the fear instilled by providers of patients who develop a stroke, heart/ kidney failure, go blind or experience a number of complications, which may never occur. A very unprofessional way of addressing hypertension if a client appears with an elevated blood pressure level is to tell them that they will get a stroke. This will not help the client, but fear and anxiety may even raise the blood pressure further and can cause a stroke. Some health care providers are guilty of this strategy. The individual already may have a stressed life that is creating elevated blood pressure levels and when being told this unpleasant news about their health it does not lower the blood pressure neither  does it help the client in any way to get better.

Most recent evidence based practice intervention

Most recent evidence-based practice intervention embraces adapting a model relevant to the  needs of the population affected or being serviced with treatment. A model mostly adapted from recent research is a goal of 150/90mm Hg  for persons older than 6o years of age and less than 140/90 mm Hg for persons younger. The initial pharmacological intervention encompasses a ‘angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or thiazide-typ diuretic’ (James, 2014, p 12) for non-black populations and those with diabetes. Blacks often receive a  calcium channel blocker or thiazide-type diuretic (James, 2014).

APN role and specific skills required for intervention with interdisciplinary collaboration

According to the American Nurses Association, advance practice nursing signals a new age in healthcare delivery across the globe. Consequently, while the roles of an advanced nurse practitioner in managing disease conditions may still be in its evolutionary stages they are accountable for performing tasks of improving healthcare quality (American Nurses Association, 2015).


 Administering Treatment

The advanced nurse practitioner is equipped with skills and tools to treat hypertension applying primary techniques as well as secondary interventions. At the primary level the role focuses on prevention of hypertension through health promotion programs/strategies that educate/sensitize the public regarding incidences and possible measures that can be taken to reduce its prevalence. At the secondary forum, the advanced nurse practitioner is expected to use knowledge and expertise acquired during training to manage hypertension effectively reducing the incidences of complications. They must be articulate in  improving compliance with management through participation in the patient’s  their care.

Expert coaching and guidance

While self-management limits the healthcare provider’s participation in the patient’s care at home and community, the advanced nurse practitioner is responsible for guiding the patient with hypertension into feeling confident in medication as well as life style management when the healthcare provider/specialist is not present in the environment.

In the secondary management stages of hypertension, the advanced nurse practitioner is expected to design a care plan with the client/patient that ensures compliance with life style changes and medication. In cases where complications have begun the goal should be educating patients/clients to cope with them and continue enjoying life.


Outcomes are inevitable once the advanced nurse begins an interaction with the client/patient. However, in executing care management the healthcare provider’s responsibility in the capacity of the advanced nurse practitioner is to establish techniques that would ensure favorable outcomes. These techniques describe the leadership potential of the advanced nurse initiating cooperation for desired outcomes to be achieved. These include adherence to medication management; discussion with client concerning adverse medication reactions. It means communicating with clients in a way to build confidence and not scare them to death; listening with apathy and not apprehension.


Prophylaxis from the advanced nurse’s perspective means hypertension prevention as well as the associated complications, which uncontrolled hypertension produces. This can only be achieved through collaboration with other health care and non-healthcare agencies in management of patients.

From the primary level paradigm it is assuming the role of a heath promoter, which may necessitate communicating with the client/patient as a nursing educator/teacher. It is also conducting the necessary screening to diagnose risks of the disease condition itself. Even though essential hypertension has no cure, early detection is vital in controlling outcomes. Consequently, collaborating with health promotion agencies such as public health where nutrition programs for preventing obesity and weight loss are conducted, would be valuable in sharing skills as an educator.

As a collaborator at the secondary level the advanced nurse practitioner is expected to treat hypertension by ensuring that compliance with diet, weight loss, exercise and life style changes to help reduce blood pressure levels until medication intervention becomes necessary. Here collaborating with pharmacists is valuable in explaining to patients side effects of many medications they cannot tolerate. All patients do not respond the same way to medications used in control of hypertension. It is the advanced nurse practitioner’s role to be cautious in prescribing medications and follow up with clients/patients regularly to evaluate for adverse effects. Besides, patients should be told of some complications and side effects of the drugs they take and make choices of whether they want to take them or select alternatives. A patient’s choice of medication should be honored without prejudice.


This research was focused on exploring hypertension occurring in all age groups.  The condition was defined as a chronic illness affecting persons at any age. Internationally, an estimated 54% of the world’s population is affected by the disease. More incidences occur among developing nations. Currently, in United States of America there is an alarming death toll of 1,000 deaths per day (360,000 per year). The cost of treating hypertension amounts to an estimated $46 billion US annually.

An extensive literature revealed that while more measures are being taken to prevent and treat the condition patients/ clients remain resistant to life style changes and medication. Consequently, the cases of uncontrolled hypertension are increasing and health care providers have to apply additional therapies in regulating high blood pressure in  most patients/clients. It was discovered also that culture, religion/ spirituality along with lack of confidence in the health care system, played a major role in compliance with medication and life style changes in management t of the disease.

Implications for practice

The implication, therefore, for intervention from the advanced nurse practitioner’s competences’ level, is careful implementation of a conceptual model relevant to ensuring that the four metaparadigms of nursing are fully employed in daily innovations. These innovations should distinctively be aimed at encouraging compliance with established management protocols. Importantly, more appropriate collaboration with organizations in the community geared towards understanding the cultural, socio-economic and spiritual implications that hinder regime compliance is mandatory for the advanced practice nurse’s consideration in the future.


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