High blood pressure (HBP) is a health problem of concern that most nurses encounter in their daily practice. This care coordination plan analyzes high blood pressure and the best practices for improving the health of high blood pressure patients. It also establishes specific goals to address high blood pressure as well as physical, cultural, and psychosocial considerations made when dealing with high blood pressure patients. It further identifies and lists the available community resources to support a safe and effective continuum of care for high blood pressure.
The major risk factors for HBP include age, a family history of HBP, being overweight and obese, and a sedentary lifestyle combined with a high intake of alcohol, smoking, and high-sodium foods (World Health Organization, 2023). HBP is also a common comorbid disease with other chronic diseases such as diabetes and kidney issues. HBP progresses in stages. Readings of 120-129 systolic and less than 80 mm Hg diastolic indicate elevated blood pressure; 130-139 systolic or 80-89 mm Hg diastolic indicates hypertension stage one, while 140/90 mmHg indicates hypertension stage two (American Heart Association, n.d.). Readings above 180/120 mmHg lead to a hypertensive crisis. HBP is a health problem of concern as it increases the development of other chronic diseases. For instance, people with high blood pressure have an increased risk of developing cardiovascular diseases (CVD) and possible organ damage (Fuchs & Whelton, 2020). HBP also increases the costs of care and reduces an individual’s level of productivity as well as quality of life. According to the WHO data on hypertension, 1.28 billion adults aged 30-79 years live with HBP, and the condition affects an estimated one in every four American adults (World Health Organization, 2023). There are notable disparities in the prevalence of HBP as it is mostly in the elderly, with a majority of the problem experienced among individuals of African American backgrounds (World Health Organization, 2023).
There are multiple best practices for improving the health of patients with high blood pressure. The major best practice for health improvement for an HBP patient is a total lifestyle change. This includes a change in eating and activity habits. The WHO recommends avoiding fast foods and substituting such foods with healthy alternatives such as vegetables, home-cooked organic foods, and increasing physical activity (World Health Organization, 2023). The lifestyle changes further focus on losing extra weight and engaging in lifestyles that help maintain healthy body weight. There is also a need to support the patient to quit smoking and limit the amount or total elimination of alcohol in the patient’s life.
A high number of people with HBP are not yet diagnosed (World Health Organization, 2023), which makes HBP further an issue of concern. A best practice for improving the health of HBP patients is to improve the rate of people checking their blood pressure status. It is also important to keep track of blood pressure readings. As a best practice, providing HBP patients with tools and education help monitor their blood pressure at home. A combination of regular screening and monitoring of HBP can help detect blood pressure fluctuations and support early management to reduce the risk of complications. Educating the patient on the benefits of adhering to their medication plans is also important.
The analysis of HBP to support the development of this care coordination plan is based on available data. However, there are underlying assumptions and points of uncertainty that can affect its effectiveness in delivering well-coordinated care to patients. For instance, due to factors such as income level, education, and access to healthcare services, some elements of the plan may not be generalizable across the general population. Additionally, due to differences in stages of hypertension, the plan will require to be individualized to fit specific patient needs.
The goals established to address the problem of HBP are guided by the SMART (specific, measurable, achievable, relevant, and time-bound) goal-setting process. There are five SMART goals set for this care coordination plan for HBP.
The specific goal of the care coordination plan is to improve the patient’s HBP outcomes and overall well-being. The measurable goal for addressing HBP is to increase the level of awareness of HBP, risk factors, and associated risks and improve the rate of screening and monitoring for blood pressure among the patients and th
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