NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

Patient Identity 

John is a 50 years old male who is patient of chronic hypertension with a risk of stroke. He is a patient in the same organization where I was working before. He has recently brought to the hospital with implications of severe headache and chest pain with stroke like symptoms. His chronic disease history, personal and social choices with respect to his lifestyle were revealed by the two-hour discussion by my healthcare facility. These discussed implications influenced the progression of his health condition in current state. In this practicum approach, face to face interview by using personal communication was used to assess the whole situation.

He has a history of smoking (current), ETOH (claims he no longer drinks), epileptic seizures from the right front-temporal region (for about 4 years), and heart failure with preserved ejection fraction. When diagnosed, the ejection fraction (EF) by echocardiography was 50%, presumably due to hypertension. He utilizes a wheelchair to travel from the parking garage to the clinic area because he has “hip difficulties.” A Clinical Nurse Specialist is seeing him today in the outpatient department. He was last seen 6 weeks ago and has not been hospitalized or treated in an emergency department since then. He claims that his breathing abilities and energy level are comparable to his last visit. He can only go up one flight of stairs (14 steps) before becoming dyspneic. He had two episodes of pillow orthopnea but no episodes of paroxysmal nocturnal dyspnea. He is exhausted by his daily tasks. He denies any chest discomfort, palpitations, lightheadedness, dizziness, nausea, edema, or eating issues (he claims his appetite is OK). He eats a low-sodium diet. He does not have any recognized allergies. He is escorted to his visit by a family member. 

NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

Despite having a normal EF, he has clinical heart failure based on his echocardiography history and feelings of dyspnea and tiredness. Furthermore, his serum sodium level is low, indicating hypervolemia and neurohormonal activity. He profited from medication adjustments that allowed him to better regulate his blood pressure. While his diastolic blood pressure was normal, his raised systolic blood pressure increased afterload and backflow pressure, resulting in moderate pulmonary hypertension as a result of his heart failure. Hydrochlorothiazide is a moderate distal tubule diuretic that has been demonstrated to reduce blood pressure in hypertension patients. There was no rationale to begin pharmacological therapy with a loop diuretic agent because he had no signs of hypervolemia or systolic left ventricular failure. Patients with hypertension may require more than one medication to appropriately lower blood pressure. He is an illustration of how many medications are required to control his co-morbid conditions of heart failure and hypertension. He is being treated with an angiotensin-converting enzyme inhibitor, a calcium channel blocker, a distal tubule diuretic, and a beta-blocker. This combination resulted in improved hypertension management and a decrease in clinical signs of heart failure. When an antihypertensive drug is added to a patient’s medical regimen, the systolic blood pressure usually drops by 10 mm Hg. In this example, He’s systolic blood pressure dropped from 142 mm Hg to 102 mm Hg, demonstrating the effectiveness of thiazide diuretics in improving blood pressure control. His serum sodium level reverted to normal (from 136 to 143 mmol/L), indicating improved management of intravascular volume. Preload (including a reduction in tricuspid regurgitation from 3+ to 2+) and afterload were significantly decreased, and his systolic and diastolic pressures dropped to a higher extent than with vasodilator therapy alone (despite receiving distinct classes of antihypertensive drugs).

During my practice as RN, I have seen lots of patients with hypertension and other chronic heart complications.  Improper management of these patients in hospitals causes rehospitalization and further high risked complications even death. I identified many errors related to this patient by the nurses. Most of them were due to poor administration and low level of knowledge and multifunctional aspects of disease. 

Chronic hypertension refers to high blood pressure that raises the chance of having a heart attack, stroke, heart failure, or kidney problems. Prolonged hypertension increases left ventricular hypertrophy, which leads to heart failure (both systolic and diastolic). Eccentric hypertrophy causes the myocardium’s oxygen demand to rise, which might result in angina or ischemia symptoms. High blood pressure makes your heart work harder to circulate blood throughout your body. This causes the left ventricle of the heart to thicken. A thickened left ventricle raises the chances of having a heart attack, having heart failure, or dying suddenly. Less elastic arteries make it more difficult for blood to circulate freely and easily throughout your body, leading the heart to work harder. In order to meet higher demands, the heart thickens and expands. While it can still pump blood, it becomes inefficient. The greater the heart grows, the harder it works to supply body’s oxygen and nutritional demands (Azeez et al., 2018).

Role of Nurses and Organizations

By doing interview with the patient, I came to know that nurse at the site neglected some critical points and she can get patient better if she could have performed her role better. Through teaching on blood pressure management, the nurse can assist the patient in achieving blood pressure control. Assist the patient in establishing target blood pressures. Help with social support is available. When hypertension is first diagnosed, nurse assessment includes carefully monitoring blood pressure at numerous intervals, followed by frequently planned intervals after diagnosis. Over the last 50 years, the role of the nurse in improving hypertension control has grown, complementing and enhancing that of the physician (Unger et al., 2020). Nurses’ engagement began with blood pressure (BP) measurement and monitoring, as well as patient education, and has grown to become one of the most successful ways for improving BP control. Nurses and nurse practitioners (NPs) are now involved in all aspects of hypertension management, including detection, referral, and follow-up; diagnostics and medication management; patient education, counselling, and skill building; care coordination; clinic or office management; population health management; and performance measurement. To improve adherence to treatment regimens and blood pressure management, nurses and other health professionals must individualize care to increase patients’ incentive to control their hypertension by continuing in care, keeping a healthy lifestyle, and taking prescribed medicine (Unger et al., 2020).

NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

Evidence Based Approach 

EBP’s intended purpose is to standardize healthcare procedures in accordance with science and best evidence, as well as to eliminate irrational variance in care, which is known to result in unexpected health effects. The growing public and professional need for accountability drives the development of evidence-based practice. Several studies have found that evidence-based practice leads to higher-quality treatment, increased population health, better patient experiences, and reduced costs. To provide the greatest treatment and outcomes, evidence-based practice combines research, a clinician’s experience, and patient choices and values. Successful therapy of chronic diseases such as hypertension must resolve three challenges: diagnostic uncertainty, which is defined as a lack of certainty about whether a situation exists; clinical inertia, which is defined as a malfunction to initiate or escalate treatment when patients have not met treatment goals; and nonadherence to prescribed treatments (Schoenthaler et al., 2017). 

The primary goal of hypertension therapy is to achieve and maintain a target blood pressure. Treat hypertensive people aged 60 and up to a blood pressure of less than 150/90 mm Hg. Treat hypertensive people under the age of 60 to a blood pressure of less than 140/90 mm Hg. This same level is advised for hypertensive persons with diabetes or nondiabetic chronic renal disease (CKD). Because a variety of environmental factors can influence blood pressure measurements, guidelines specify several specific steps, such as positioning patients in a chair with their back, arms, and feet supported and their legs uncrossed; using an appropriate cuff size; providing patients with a rest period before the procedure; using the correct measurement technique; and obtaining multiple BP readings (Unger et al., 2020).

Lifestyle adjustments, such as dietary treatments (cutting salt, boosting potassium, avoiding alcohol, and multivariate diet control), weight loss, nicotine cessation, physical activity, and stress management, should be the first step in hypertension management. A multidisciplinary approach to intervention can be beneficial in reducing blood pressure in elderly hypertension patients. Collaborative approaches to hypertension management that employ team-based care among physicians, nurses, pharmacists, dietitians, and physiotherapists provide considerable advantages over standard physician-only therapy. Expanding the scope of practice for health professionals including nurses, pharmacists, and dieticians – including, but not limited to, evaluation, prescription, and monitoring therapy as part of collaborative efforts – provides a chance to address these gaps in reaching blood pressure (BP) objectives (Schoenthaler et al., 2017).  More research on interventions, including multiple health professionals as members of a care team, as well as interventions by dietitians and physiotherapists, is needed to determine the best approaches to collaboration and the application of expanding scopes of practice, such as independent prescribing by pharmacists and nurses, where available. 

NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

The ACC/AHA hypertension recommendations address practically every area of hypertension diagnosis, evaluation, monitoring, secondary causes, and medication and non-drug therapy. Significant and appropriate attention has been placed on the procedures required for accurate blood pressure measurement in every environment where valid blood pressure data are wanted. Most “errors” in blood pressure measurement skew readings higher, leading to over-diagnosis of hypertension and, among individuals already on pharmacological therapy, underestimate the real size of blood pressure reduction, leading to over-treatment. The majority of individuals with hypertension of 130–139/80–89 mm Hg (stage 1) do not qualify for urgent pharmacological treatment. Some of the recommendations in the guideline are novel. Absolute cardiovascular risk is used for the first time to determine high-risk status when blood pressure is 130–139/80–89 mm Hg (Stage 1 hypertension) and high-risk patient characteristics/co-morbidities such as age 65 and older, diabetes, chronic kidney disease, and known cardiovascular disease are absent; high-risk individuals begin drug therapy when blood pressure is 130/80 mm Hg. The exception among high-risk patients is secondary stroke prevention in medication-naive individuals because pharmacological therapy is being initiated. Individuals who are not at high risk will begin medication therapy when their blood pressure is 140/90 mm Hg. Regardless of the blood pressure threshold for starting medication therapy, most people’s goal BP is at least 130/80 mm Hg. However, because the committee did not suggest a DBP objective, the target BP for persons 65 and older is 130 systolic. When blood pressure is more than 20/10 mm Hg over target, treatment should begin with two medications with complimentary modes of action.

Gaps in hypertension treatment and management can be attributed to a variety of variables including the health care system, health care professionals, and individual patients. Barriers to the implementation of evidence-based practice for hypertension includes Inclusion of a new pharmacist on the health care team, a lack of information technology resources, and provider opposition to implementing a unified BP management regimen The intervention’s perceived ability to increase quality of treatment, empower patients, and save staff time were all facilitators. In terms of adherence to hypertension therapy, patients frequently reported forgetting to take their medicine.

NURS FPX 4900 Assessment 1 Leadership Collaboration Communication Change Management and Policy Considerations JJ

Nursing in hypertension care entails counselling on lifestyle changes, measuring blood pressure, and acting as a translator for the physician. Changing one’s lifestyle entails self-care for the sufferer. Because there is a scarcity of research and guidance for nurses, a middle-range theory of nursing in hypertension care was established to assist nurses in their practice, enhance patient nursing, and conduct studies to investigate nursing in hypertension care. Integrating Orem’s self-care theory is especially pertinent to patient teaching with the development of self-care skills since this is the objective for hypertension patients, and the theory is widely accepted with its application to a wide range of client demographics and clinical settings.

Barriers in Evidence based Practice 

The most often mentioned organizational impediments to EBP adoption include a lack of human resources (a dearth of nurses), a lack of internet connection at work, a hard workload, and a lack of access to a large library including nursing publications. Furthermore, additional hurdles include the difficulty of changing established practice models, opposition and criticism from peers, and a lack of faith in evidence or research. In terms of human resources, the most prevalent hurdles to EBP adoption are a scarcity of nurses and a demanding workload. Another research that looked at the association between nurses’ personal and professional characteristics and EBP discovered that only 32% of nurses had a nursing journal library at their job and 42% do not have internet access. Furthermore, the findings of a study revealed that human resources are the most essential facilitators of the application of research in practice.

Background characteristics such as age, educational level, job experience, and employment position have been found to be strongly related to obstacles to EBP implementation. Organizational hurdles to EBP adoption are connected with age, educational level, job experience, and employment position. Only education was related with impediments to EBP adoption at the individual level. EBP adoption is hampered by obstacles at both the human and organizational levels. EBP is a quality indicator in nursing practice. Understanding the hurdles will aid the health-care system and policymakers in fostering an EBP culture.

National Standards/ Organization Based Guidelines for Chronic Hypertension 

The revised ACC/AHA recommendations were created in collaboration with nine other health professional organisation and drafted by a panel of 21 scientists and health professionals who analyses over 900 published research. They are the successor report to the Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), which was produced in 2003 and was administered by the National Heart, Lung, and Blood Institute (NHLBI). In 2013, the NHLBI requested that the AHA and ACC continue to coordinate guideline preparation for hypertension and other cardiovascular risk factors. The guidelines were published in the American College of Cardiology and Hypertension (Pugh et al., 2019). 

The new recommendations, the first comprehensive set since 2003, reduce the definition of high blood pressure to account for consequences that can develop at lower blood pressure levels and to allow for early management. The new definition will cause almost half of the adult population in the United States (46 percent) to have high blood pressure, with the biggest impact projected among younger individuals. Furthermore, the frequency of high blood pressure is predicted to quadruple among males under the age of 45 and double among women under the age of 45, according to the authors of the guideline. However, only a little rise in the number of individuals requiring antihypertensive medicine is projected.

The recommendations do away with the term “prehypertension,” instead classifying individuals as having Elevated (120-129 and less than 80) or Stage I hypertension (130-139 or 80-89). While prior guidelines classed 140/90 mm Hg as Stage 1 hypertension, the current guidelines classify this level as Stage 2 hypertension. Furthermore, the guidelines emphasize the importance of using proper blood pressure measurement technique; recommend the use of home blood pressure monitoring using validated devices; and emphasize the importance of appropriate training for health care providers in order to detect “white-coat hypertension” (Fry & Attawet, 2019). 

Organizational Leadership and Hypertension Care 

In order to have a meaningful influence on national health indices, health care practitioners must be involved and committed to tackling socioeconomic determinants of health. Nurses can provide the leadership required to draw national attention to the socioeconomic determinants of health and launch effective plans to enhance the nation’s health. In light of the most recent hypertension guidelines, which have made high blood pressure a new reality for many people, a health system well-known for its hypertension control Programme shared how it has been able to implement its Programme in the past – and what is changing in response to the new recommendations. Nurses have taken on leading roles in research to enhance hypertension treatment quality and eliminate ethnic inequalities by investigating the social, cultural, economic, and behavioral drivers of hypertension outcomes and devising culturally sensitive interventions to address these aspects.

References 

American College of Obstetricians and Gynecologists. (2019). ACOG Practice Bulletin No. 203: chronic hypertension in pregnancy. Obstetrics and gynecology133(1), e26-e50.

Azeez, O., Kulkarni, A., Kuklina, E. V., Kim, S. Y., & Cox, S. (2019). Peer Reviewed: Hypertension and Diabetes in Non-Pregnant Women of Reproductive Age in the United States. Preventing chronic disease16.

Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research124(7), 1045-1060.

Fry, M., & Attawet, J. (2018). Nursing and midwifery use, perceptions and barriers to evidence-based practice: a cross-sectional survey. International journal of evidence-based healthcare16(1), 47-54.

Pugh, D., Gallacher, P. J., & Dhaun, N. (2019). Management of hypertension in chronic kidney disease. Drugs79(4), 365-379.

Rivera, S. L., Martin, J., & Landry, J. (2019). Acute and chronic hypertension: What clinicians need to know for diagnosis and management. Critical Care Nursing Clinics31(1), 97-108.

Schoenthaler, A., Knafl, G. J., Fiscella, K., & Ogedegbe, G. (2017). Addressing the social needs of hypertensive patients: the role of patient–provider communication as a predictor of medication adherence. Circulation: Cardiovascular Quality and Outcomes10(9), e003659.

Shayan, S. J., Kiwanuka, F., & Nakaye, Z. (2019). Barriers associated with evidence‐based practice among nurses in low‐and middle‐income countries: A systematic review. Worldviews on Evidence‐Based Nursing16(1), 12-20.

Unger, T., Borghi, C., Charchar, F., Khan, N. A., Poulter, N. R., Prabhakaran, D., … & Schutte, A. E. (2020). 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension75(6), 1334-1357.

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