Nursing Research and Evidence Based Practice Sample

Evidence-based practice in nursing has been proven to result in quality patient care. The goal of nursing research, on the other hand, is to enable nurses to apply their education to discover new advancements and promote evidence-based practice. Acquisition of knowledge and interventions for evidence-based practice is an elemental skill required by nurse practitioners in any clinical encounter. The evidence-based practice further requires that a health practitioner possess boundless background information about diseases and potential interventions along with the necessary experience to properly examine specific foreground information vital in making clinical decisions. In this piece of writing, I will extensively examine hypertension as a risk factor for stroke using the PICOT format and leveraging extensive literature search.

 The PICOT Question

In elderly hypertensive patients, how does well control of hypertension compared to poor control of hypertension affect the incidence of stroke? Hypertension defined as blood pressure> 120/80mmHg (Wajngarten & Silva, 2019) despite being the identified clinical health problem also provides an opportunity for improvement of health outcomes since it is a modifiable risk factor. The role of hypertension as an independent risk factor for stroke has vividly been elaborated in literature (Wajngarten & Silva, 2019). In addition, hypertension is also a risk factor for various health problems among them renal impairment and myocardial infarction (Benetos et al., 2019). Benetos et al. (2019) in the journal of Circulation Research further states that long-term management of hypertension is critical for the reduction in mortality and morbidity. Hypertension further is a problem as its incidence rises with aging as a result of arteriole stiffening that comes with aging. Poorly controlled hypertension can be a consequence of a multitude of factors including non-adherence to antihypertensive, inadequate therapy, inappropriate therapy, resistant hypertension, drugs, obesity, and diet (Wajngarten & Silva, 2019). Nevertheless, well-controlled hypertension reduces the risk of stroke which is the second and third cause of mortality and disability worldwide respectively (Wajngarten & Silva, 2019). Therefore, this clinical problem when controlled through antihypertensives and lifestyle modification in conjunction with patient education contributes to an overall enhancement of health.

Literature Search

A literature search is an elemental skill that all nurse practitioners need to have. For my literature search, I used keywords including elderly, stroke, uncontrolled hypertension, controlled hypertension, and elderly to search databases such as Google, Google Scholar, CINAHL, MEDLINE, Trip, PubMed, and ProQuest. I specifically looked for peer-reviewed articles that were closely related to my PICOT question that had been published within the last five years. Subsequently, a total of five articles discussed below were selected.

Sarfo et al. (2020) in the Journal of the Neurological Sciences did research to assess the association between lower BP target and incident stroke risk in geriatric Ghanaians with hypertension. This retrospective evaluation of prospectively collected data of 1365 hypertensive patients over 18 months was analyzed using multivariable logistic regression models and the finds showed that 45.8% had uncontrolled hypertension. The incident of stroke was 0 stroke events/100py for BP < 120/80 mmHg, 1.98 for BP between 120 and 159/80-99 mmHg, and 2.46 events/100py at BP > 160/100 mmHg. Ultimately, a conclusion of the low incidence of stroke with well-controlled hypertension was made.

Han et al. (2017), concerned with the greatest burden of stroke in China, carried out research to assess the impact of suboptimal controls of hypertension on the incidence of stroke. In this population-based 10-year prospective cohort study, out of 1646 participants with hypertension, 55.4% were previously undetected, 7.0% detected but not treated, 27.5% treated but not controlled while only 7.7% were controlled. An incidence of 211 cases of stroke was recorded. Compared to normotensive cohorts and those with controlled hypertension, the multivariate-adjusted health risk for stroke increased by 1.63 in the undetected, 2.21 in the untreated, and 3.34 in the uncontrolled. This research concluded that a substantial number of people could be saved with the appropriate management of hypertension.

Lee et al. (2017) on the other hand researched to investigate the effect of adherence to antihypertensive medication on stroke incidence. This population-based retrospective cohort study using Poisson regression analysis by generalized estimating equation models found that among 38 520 patients with hypertension, the incidence of stroke was 957 (2.5%). Non-adherence to medication was significantly associated with a higher risk of stroke (intermediate adherence: adjusted relative risk (aRR)=1.13 to 1.21; poor adherence: aRR=1.27, to 1.38). This study concluded non-adherence to antihypertensives contributes significantly to the incidence of stroke and encouraged healthcare providers to adopt strategies to enhance patient adherence to medications.

Ishii et al. (2017) in the American Journal of Hypertension, conducted research to look into the relationship of hypertension and systolic blood pressure (SBP) with the risk of stroke or bleeding in atrial fibrillation patients. This community based prospective survey found out that hypertensive high blood pressure group (n=305) SBP > 150mmHg was associated with increased risk of stroke (hazard ratio =1.74) and major bleeding (hazard ratio= 2.01) compared to the hypertensive low blood pressure group (SBP<150 mmHg) and the control normotensive group. This research concluded that the incidence of stroke is higher in hypertensive individuals with SBP>150 mmHg.

Li et al. (2017) also conducted a study to investigate the optimal blood pressure trajectories for risk prediction of both intracerebral hemorrhage and cerebral infarction. This large prospective cohort study in China after statistical analysis documented 1034 incident cases of cerebral infarction and 187 cases of intracerebral hemorrhage out of 79 385. In addition, Individuals in stage 2 hypertension-stable systolic BP trajectory (175–179 mm Hg) had the highest risk of intracerebral hemorrhage (adjusted hazard ratio of 12.4) and cerebral infarction (adjusted hazard ratio of 5.07), relative to the normotensive-stable group. This study concluded that BP trajectories were associated with an increased risk of stroke.

The article that best supports nursing interventions for hypertension is the article by Han et al. (2017) which assesses the impact of suboptimal control of hypertension on the incidence of stroke. Han et al. (2017) urge the healthcare providers particularly the nurses to detect hypertension early through screening. Furthermore, emphasis on the treatment of already diagnosed hypertension is unquestionably elaborated in this article. The article further encourages nurses to adequately treat hypertension through various interventions to ensure that it is well controlled to reduce the incidence of adverse events such as stroke.  In contrast, the article by Lee et al. (2017) only stresses the need to adhere to antihypertensives to prevent stroke while the articles by Sarfo et al. (2020), Li et al. (2017), and Ishii et al. (2017) all concentrate on demonstrating the impact and overwhelming evidence of the significant contribution of uncontrolled hypertension to development of stroke.

Conclusion

A literature search is a vital skill in clinical practice. Existing literature undoubtedly associates uncontrolled hypertension with an increased incidence of stroke. Nurses play an indispensable role in reducing the burden of hypertension through early detection, adequate treatment of established cases, and patient education. All these along with strategies to facilitate adherence to antihypertensive medications reduce the incidence of stroke and its associated morbidity and mortality.

References

  • Benetos, A., Petrovic, M., & Strandberg, T. (2019). Hypertension management in older and frail older patients. Circulation Research, 124(7), 1045–1060. https://doi.org/10.1161/CIRCRESAHA.118.313236
  • Han, T. S., Wang, H. H.-X., Wei, L., Pan, Y., Ma, Y., Wang, Y., Wang, J., Hu, Z., Sharma, P., & Chen, R. (2017). Impacts of undetected and inadequately treated hypertension on incident stroke in China. BMJ Open, 7(10), e016581. https://doi.org/10.1136/bmjopen-2017-016581
  • Ishii, M., Ogawa, H., Unoki, T., An, Y., Iguchi, M., Masunaga, N., Esato, M., Chun, Y.-H., Tsuji, H., Wada, H., Hasegawa, K., Abe, M., & Akao, M. (2017). Relationship of hypertension and systolic blood pressure with the risk of stroke or bleeding in patients with atrial fibrillation: The Fushimi AF registry. American Journal of Hypertension, 30(11), 1073–1082. https://doi.org/10.1093/ajh/hpx094
  • Lee, H. J., Jang, S.-I., & Park, E.-C. (2017). Effect of adherence to antihypertensive medication on stroke incidence in patients with hypertension: a population-based retrospective cohort study. BMJ Open, 7(6), e014486. https://doi.org/10.1136/bmjopen-2016-014486
  • Li, W., Jin, C., Vaidya, A., Wu, Y., Rexrode, K., Zheng, X., Gurol, M. E., Ma, C., Wu, S., & Gao, X. (2017). Blood pressure trajectories and the risk of intracerebral hemorrhage and cerebral infarction: A prospective study. Hypertension, 70(3), 508–514. https://doi.org/10.1161/HYPERTENSIONAHA.117.09479
  • Sarfo, F. S., Mobula, L. M., Adade, T., Commodore-Mensah, Y., Agyei, M., Kokuro, C., Adu-Gyamfi, R., Duah, C., & Ovbiagele, B. (2020). Low blood pressure levels & incident stroke risk among elderly Ghanaians with hypertension. Journal of the Neurological Sciences, 413(116770), 116770. https://doi.org/10.1016/j.jns.2020.116770
  • Wajngarten, M., & Silva, G. S. (2019). Hypertension and stroke: Update on treatment. European Cardiology, 14(2), 111–115. https://doi.org/10.15420/ecr.2019.11.1