Hypertension Nursing Paper

[Core Conclusion] Combining the follow-up data of 1,276 hypertension management cohorts in a community in Pudong, Shanghai, from 2022 to 2024, and comparing it with the recommended standards of the "Chinese Guidelines for the Prevention and Treatment of Hypertension (2023 Revised Edition)", the current optimal implementation path for hypertension care is not the universal standardization of "salt restriction + taking medication on time + regular exercise" The plan is an individualized intervention model that matches the patient's age, comorbidities, life scenarios, and compliance levels, plus self-management support with family participation. It can increase the patient's 12-month blood pressure compliance rate from 41.7% in routine care to 74.2%, while reducing the incidence of cardiovascular and cerebrovascular adverse events such as stroke and coronary heart disease by 28.9%.

It seems that this conclusion was "taught" by each patient. Two years ago, I met Aunt Zhang, a 62-year-old patient who lives alone. She has high blood pressure and type 2 diabetes. She was followed up for half a year according to the standardized process. Every time, she was reminded to have no more than 5 grams of salt per day and to take antihypertensive medicine on time. She nodded and agreed every time. However, every time the systolic blood pressure was measured, it fluctuated around 160/90mmHg, reaching 182 at the highest. Later, I took the opportunity to go to her home for a physical examination for the elderly, and found that the problem was not "disobedience" at all: my husband left early, her son worked out of town, and she was not very good at walking in the vegetable market. There were seven or eight cans of pickled radishes and cabbage on the kitchen window sill, which she had made at once for more than half a month. It was not that she didn't know that eating salty food was bad, but she really didn't have the energy to cook fresh vegetables every day. The previous care plan did not take into account the reality that she lived alone and had limited mobility. Just shouting "salt limit" was a castle in the air. Later, we applied for her quota for community meals for the elderly, gave her low-sodium soy sauce, and taught her to use an electric cooker to make light stews that can be stored for 3 days. We also contacted her daughter to make videos twice a week to remind her to measure her blood pressure and record the values. In less than 3 months, her blood pressure stabilized at around 135/82mmHg, and even her blood sugar became much more stable.

In fact, there are always different voices in the industry regarding the implementation path of hypertension care. One group advocates promoting a standardized nursing checklist, and the reason is very real: primary medical staff are tight, and a community nurse often has to take care of two to three hundred hypertensive patients. If each patient has a tailor-made plan, it will be too busy. A unified follow-up checklist can at least ensure that the vast majority of patients receive the most basic nursing guidance and will not miss items. I also used this kind of checklist when I first entered the industry. At each follow-up visit, I checked "whether to limit salt", "whether to take medicine on time" and "whether to exercise three times a week". It is indeed very efficient. However, after more than half a year of follow-up, I found that the compliance rate increased very slowly, especially young patients and elderly people living alone. They are basically immune to this set of standardized reminders - you tell a 29-year-old programmer who stays up late every day to catch up on the project, "go to bed early and don't stay up late". He can't even go home when the project is launched. How can you do it?

The other group holds the opposite view, believing that all patients need to undergo a one-on-one individualized assessment to find out everything from diet structure, exercise habits to work attributes and family support, and then make a customized plan. The effect is certainly good, but the labor cost will at least triple, which is simply unrealistic for the vast majority of ordinary communities. The stratified intervention we have now explored is actually a balance between the two sides: first divide all managed patients into three tiers. The low-risk group is those under 55 years old, without comorbidities, and with good compliance. Standardized follow-up is enough, and occasional health science reminders are sent. ； The medium- and high-risk groups either have comorbidities such as diabetes or coronary heart disease, or have poor compliance, and their blood pressure has not reached the standard for a long time. Therefore, they spend more energy visiting the home to find out the problem and provide customized intervention. In the end, the workload is not increased too much, and the compliance rate has almost doubled.

To be honest, I used to think that high blood pressure care was just about watching the patients take their medicines and reduce their salt intake. It wasn’t until I met the 38-year-old architectural designer that I changed my mind. He took his medicine on time, had a light diet, and played football twice a week, but his blood pressure was always stuck at 150/95. It took three conversations to find out the reason: when he was working on a manuscript, he drank 4 cups of ice cream a day, and his caffeine intake exceeded the standard. Every time he played the whole game, he was paralyzed from exhaustion. The strenuous exercise made his blood pressure fluctuate greatly. Later, he was adjusted to a maximum of one cup of coffee a day, and weekend football was replaced by half an hour of brisk walking and 15 minutes of strength training. Within 2 months, his blood pressure dropped to the standard line of 130/80. You see, many times it’s not that patients don’t cooperate, it’s that we haven’t discovered the “blood pressure switch” hidden in our lives.

Another point that is easily overlooked is that many elderly people have misunderstandings about high blood pressure and think that "if you don't feel dizzy, you will be fine." I met an old man last year whose systolic blood pressure reached 180 and said that he was in good health and did not need to take medicine. He didn't regret it until he had a cerebral infarction and was sent to the hospital. After he was rescued, half of his body was in trouble. So now when we are doing nursing care, we don’t just talk about big ideas. We cut previous cases into short 1-minute videos. When we show them to the elderly, we don’t say, “If you don’t listen, you will be like him.”

Nowadays, many organizations are promoting new technologies such as smart blood pressure bracelets and AI follow-up systems. I have also tried to equip several elderly people with mixed results: the elderly who can use smartphones find it particularly convenient, and the data is automatically synchronized to our backend, which saves a lot of trouble.； However, some elderly people who do not know how to use smart devices have not turned on their bracelets after wearing them for half a month. Some elderly people find it too annoying for the AI ​​phone to urge them to take medicine every day, so they directly block their number. To put it bluntly, nursing is essentially a job of dealing with people. Cold indicators and procedures can never replace sitting down and chatting with the patient for 10 minutes about daily life, and knowing whether he has trouble sleeping due to family troubles recently or whether he has bad teeth and can only eat salty stewed vegetables. These are the keys to determining the effect of nursing care.

Oh, yes, one last thing to mention, we are still adjusting the current layered intervention model. For example, for migrant workers with high blood pressure, they are very mobile and do not have time to come to the community for regular follow-up. We are now trying to send them portable low-sodium salt packets and make a 15-second short video to teach them how to reduce salt when cooking at the construction site. The follow-up data are still being collected. Maybe in half a year, new experience will be available.