Hypertension diagnosis and management in a Puerto Rican patient

Hypertension

"in the United States

71% of adults with hypertension don't have their blood pressure under control"

(Medications for…, 2007 Fast fact section).

PATIENT PROFILE

Ethnicity and Age

"My mother died from a stroke 18 months ago. She was 64," Juan Valdez, a 47-year-old Puerto Rican native, who has lived in the South Bronx of New York City, for the past 22 years, told the attending physician, Dr., Peters. This day, he said, he was feeling dizzy and experiencing a headache that would not go away. Juan and his family had moved to the United States from Isabela, Puerto Rico 20 years earlier. Isabela, "known as 'El Jardin del Noroeste' (garden of the northwest) and 'El Pueblo de los Quesitos de Hoja'" (Isabela, 2009, p. 1). The hardest thing for Juan to get used to, he told the doctor was the frigid temperature in New York during the balmy winters. "The average temperature in Isabela is 84 degrees year round," he said. Five years ago, Juan, an only child lost his father, a heavy smoker, who at the age of 62, died shortly after experiencing a massive heart attack.

Due to financial constraints and a distrust of doctors, neither of Juan's parents had gone for regular health care screenings. Juan admitted that he also had a lingering distrust of doctors. Juan's wife, Celia, a lifelong resident of New York, told the doctor that she was concerned for Juan's health because of his family history. Juan had finally agreed to go with Celia to their family doctor, Dr. Peters, for his first check-up in over 12 years. After the examination, Dr. Peters presented her diagnosis to Juan: Hypertension, or high blood pressure (BP). Usually, Dr. Peters would not make this diagnosis until after measuring a patient's blood pressure on at least three separate occasions. Juan's three extreme blood pressure measurements during the hour he was at Dr. Peter's office convinced Dr. Peter's that Juan's need for medication was immediate. Toni Rizzo, Teresa G. Odle and Angela M. Costello (2006), all of the Cleveland Clinic Heart Center, contend in the journal publication, "Hypertension," that hypertension is high blood pressure. "Blood pressure is the force of blood pushing against the walls of arteries. Arteries are the blood vessels that carry oxygenated blood from the heart to the body's tissues" (Rizzo, Odle & Costello, 2006, ¶ 1). Along with prescribing medication to decrease Juan's blood pressure, Dr. Peters gave Juan a list of lifestyle tips; identified later during this paper. .

In the journal publication, "Hypertension: Just the facts," Kathy Sharp (2006), an oncology nurse practitioner at Blue Ridge Medical Specialists in Bristol, Tennessee, points out that the National Institutes of Health defines the various stages of blood pressure for individuals aged 18 years old and older. Figure 1 lists the normal blood pressure range, along with the next two stages and including the most dangerous stage of hypertension.

Figure 1: NIH Definitions of Hypertension (adapted from Sharp, 2006, ¶ 2).

Socioeconomic Status

Juan and Celia have owned and solely operated a successful hot dog stand in the Bronx for 12 years. Juan previously worked long hours as a city cab driver to save enough money to establish the family business. Due to limited finances, he and Celia purchased the least expensive medical insurance policy they could find. The policy with high deductibles and co-pays for all medical visits and procedures contributed to Juan not having regular checkups. Juan and his family have rented and lived in the same modest three-bedroom apartment for more than 16 years. Juan, a heavy smoker, occasionally drinks beer. He admits to being a perfectionist who works hard and frequently becomes stressed. He earns approximately $42,000.00 a year.

Culture and Food

Juan, approximately 20 pounds overweight, is a devout Catholic. One "sin" he admits to is that he often eats more than he knows he should. He jokes and claims that he is sometimes his own best customer at the family hot dog stand. Celia, a Caucasian, regularly prepares Juan's favorite Puerto Rican meals, particularly Fied Chapin (Trunkfish), a fish high in fat. Juan and his family also frequently eat black beans and tortillas, usually with mounds of cheese, typical Hispanic foods. Juan typically eats 3-4 of "Juan's dogs" six days a week.

Family History

Juan's paternal grandfather, also died of a heart attack at the age of 49. In Puerto Rico, regular health care visits and screenings were not readily available for Juan's family. The lack of health care information on Juan's family makes it difficult for Dr. Peters to assess whether or not hypertension was prevalent in Juan's family. Consequently, Dr. Peters had to make that assessment from the information Juan provides. This information includes factors such as: The age of death for family members and their health habits, including smoking and stress, factors that definitely constitute risk factors for hypertension.

Gender Roles and Religion

As devout Catholics, Juan and his family attend mass on Sunday. Like most Hispanics, the man, considered the head of the household, solely manages the finances. He also makes all relevant business decisions for the family hot dog stand business. Juan claims that he typically manages his stress well, but then also admits that occasionally when things do not go his way, he loses his temper.

Beliefs about Medicine/Nursing

Growing up in Puerto Rico, Juan, as his mother and father, did not have regular access to health care or doctor visits. In turn, he developed a distrust of most doctors and nurses. He states that he has never taken medication on a daily basis. Dr. Cunegundo Vergara, Director of Ambulatory Education and Assistant Clinical Director, Department of Medicine, Hartford Hospital, Fei Wang, Assistant Clinical Professor, University of Connecticut College of Pharmacy and Valori Banfi (2008), Clinical Librarian, Health Science Library, Conklin Building, Hartford Hospital, note that Puerto Ricans comprise the second largest Hispanic group in the United States with 75% of Puerto Ricans living in three states: Connecticut, New Jersey, and New York. In the journal publication, "Hypertension in Puerto Ricans in the Continental United States," Vergara, Wang and Banfi assert that as published data is limited about certain medical conditions including prevalent diseases like hypertension in the Hispanic community, little data exists for individuals such as Juan. This study did find, albeit: "The prevalence of hypertension for Puerto Ricans, as well as for the other Hispanic sub-groups, increased with older age. Men had higher age-adjusted prevalence for hypertension than women" (Vergara, Wang and Banfi, the HANES survey section, ¶ 1). .

When Dr. Peters relates this information to Juan, he agrees to follow through with the recommended testing to control his hypertension.

Medical or Nursing Therapies

No cure currently exists for primary hypertension, however, the correct treatment can almost always blood pressure be lowered. In treating hypertension, the physician attempts to "lower blood pressure to levels that will prevent heart disease and other complications of hypertension that could manifest in adulthood. In secondary hypertension, the disease that is responsible for the hypertension is treated in addition to the hypertension itself" (Rizzo, Odle & Costello, 2006, Treatment section, ¶ 1). When the underlying disorder is successfully treated, the secondary hypertension may simultaneously be cured.

Some treatments for hypertension considered alternative and complementary therapy, may include approaches not considered as mainstream of traditional health care. Acupuncture and biofeedback training, as well as yoga, tai chi, meditation, guided imagery, and relaxation training denote a few techniques to induce relaxation and reduce stress, and as a result may prove helpful in controlling blood pressure. "Dietary supplements, including garlic, fish oil (omega-3 fatty acids), L-arginine, soy, coenzyme Q10, phytosterols, and chelation therapy may be beneficial, but the exact nature of their effects on blood pressure is unknown" (Rizzo, Odle & Costello, 2006, Alternative Treatment section, ¶ 3). Little scientific evidence, albeit, exists to confirm that these type therapies do in fact lower blood pressure and/or prevent complications that accompany high blood pressure

Commonly Prescribed Medication

Diuretics, the oldest, least expensive class of drugs used to treat hypertension, "water pills," help the kidneys eliminate sodium and water from the body, the article, "Medications for treating hypertension," (2007) explains. When one cannot control his blood pressure by adopting healthier habits, "such as limiting salt, increasing exercise, and quitting smoking - then it's time for medications" (Medications for & #8230;2007). No one particular medication, however, suits each individual. The Mayo Clinic staff (2009) reports that a physician may initially prescribe a diuretic to treat hypertension as these medications flush excess water and sodium from the body; in turn lowering blood pressure. Along with lifestyle changes, this may control the individual's blood pressure.

Typical Dose

Vergara, Wang and Banfi (2008) report that the Joint National Committee (JNC) on Detection, Evaluation and Treatment of High Blood Pressure asserts that for various ethnic groups other than African-Americans, such as Puerto Ricans, a death of information exists regarding the response to antihypertensive medications of. In fact, few studies have been conducted with Puerto Rican participants. "Preliminary results of a double-blind, placebo controlled trial on hypertension in Hispanic-Americans support the efficacy of thiazide diuretics, such as Dyazide" (Vergara, Wang & Banfi, 2008, Treatment section, ¶ 2). Due to the increased predisposition for Hispanics to develop insulin resistance, diabetes mellitus, dyslipidemia and syndrome X, the National High Blood Pressure Education Program Working Group recommends that initially for the treatment of hypertension, the physician prescribes the lowest possible dose of thiazide diuretics or beta-blockers.

Dr. Peters prescribed Dyazide for Juan's high blood pressure. When Juan attended a follow-up checkup, after taking Dyazide for over a month, he reported he had not experienced any side effects. At this checkup, Juan's blood pressure measured within the normal range.

Common Side Effects

As treating the patient with Dyazide decreases blood volume, the person's heart has less blood to pump with each beat. Consequently, this lowers blood pressure.

Loop diuretics, which act on the part of the kidney tubules called the loop of Henle, block sodium and chloride from being reabsorbed from the tubule into the bloodstream. Thiazide diuretics act on another portion of the kidney tubules to stop sodium from re-entering circulation. Some common side effects of these medication can be weakness, confusion, potassium depletion, gout, fatigue, thirst, frequent urination, lightheadedness, muscle cramps, diarrhea or constipation, increased sensitivity to sunlight, allergic reaction in people allergic to sulfa drugs, impotence. (Medications for…2007, p. 1)

The individual taking Dyazide would need to report any significant side effects to his physician immediately.

Purpose and Common Interactions/Symptoms

Noreen Kassem (2009), a physician in training from Vancouver, Canada, stresses that medications are needed when diet and lifestyle changes alone do not control hypertension or when hypertension advances to dangerous stages. In the journal publication, "Medications for high blood pressure," Kassem explains that four main classes of drugs lower blood pressure. Frequently, the physician may prescribe combinations of the different classes of drugs together. Kassem explains:

Diuretics: Increase sodium and water loss through increased urination, which results in a reduction of blood volume and in turn, less pressure.

Beta blockers: Block receptors on blood vessel walls, which cause the arteries to relax and reduces the force of heart contraction.

Calcium channel blockers: Block passage of calcium into cell walls, which hinders constriction of the blood vessels.

Angiotensin-converting enzyme (ACE) inhibitors: Prevent the development of angiotensin, a substance which increases blood volume and restricts blood vessels (Kassem, 2009, p. 1).

Life Style Changes

Health promotion/Appropriate Activities

Rizzo, Odle & Costello (2006) explain that dietary guidelines are individualized, depending on the age and lifestyle of the patient. Healthcare providers regularly recommend the following low-fat dietary guidelines:

Total fat intake should be limited to 30% or less of total calories the person consumes daily.

Calories consumed as saturated fat should not exceed 8 to 10% of total calories the person consumes per day.

Total cholesterol intake should be limited to less than 300 mg/dl each day.

Elevated blood pressure may also be reduced by a diet that accentuates fruits, vegetables, and low-fat dairy foods, also low in saturated fat, total fat, and cholesterol. "The DASH diet is recommended for patients with hypertension and includes whole grains, poultry, fish, and nuts. Fats, red meats, sodium, sweets, and sugar-sweetened beverages are limited. Sodium should also be reduced to no more than 1,500 milligrams per day" (Rizzo, Odle & Costello, 2006, Nutritional Concerns section, ¶ 1-3). Dr. Peters provided a copy of the DASH diet to Juan and recommended he decrease his intake of hot dogs, as well as consider the ingredients and calories of the hot dogs he ate.

Along with changing his diet, Juan and Celia have started walking a minimum of two miles, five days each week, in the evening after their dinner. Juan also asked Celia to help him more in the management aspect of their family hot dog business. Celia's help in this area has, in turn lowered Juan's stress level. Juan, in line with the DASH diet, reduced his intake of fatty foods. Now, instead of eating his favorite, "Juan's Dogs," he eats, "Juan's Healthy Heart Dogs." He continues to smoke but has cut down from two packs to 1/2 pack of cigarettes a day. He is scheduled to attend a Stop Smoking Clinic during the next month. Juan has also learned to trust and respect Dr. Peters, his family physician. Juan knows that controlling his blood pressure will help ensure that his children will one day be able tell their physician: "My father has hypertension -- but he regularly attends appointments with his physician for regular check-ups to help ensure he keeps his hypertension manageable."