Introduction
Hypertension is a cardiovascular condition continuously on the rise due to many modifiable and nonmodifiable risk factors. The effects of this condition are manageable yet can also lead to rapid decline. According to recent studies, hypertension (or high blood pressure) is the primary contributor to cardiovascular disease and is the leading cause of morbidity and mortality worldwide (Mohamed et al., 2018, p. 9). Jones, Forouhi, Khaw, Wareham, and Monsivais (2018) go on to say, “Cardiovascular disease (CVD) is the most common cause of death in the world and was estimated to account for 32% of all deaths in 2013 (p.235).” Sanuade, Boatemaa, & Kushitor (2018) studied hypertension prevalence, awareness, treatment and control in Ghanaian population and globally stating, “Recent evidence shows that between 1990 and 2015, there has been an increase in hypertension incidence, prevalence, and deaths globally [2]” (p.1).

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As a result of these statistics, lifestyle modifications were researched to learn how patients diagnosed with hypertension can control their condition and reduce their risk for health decline. Dietary management and its effect on hypertension were the focal points during research. The interventions of interest are shown by studies done to assess the effect and correlation of dietary management on symptoms of hypertension. 
The PICO question guiding this paper is, in patients with hypertension, how does dietary management compared to no dietary management affect the symptoms of this chronic illness? The intent of this paper is to address the effects of dietary management and no dietary management in patients who have hypertension. This issue will be addressed through evidence presented in research studies expanding on dietary management resulting in weight loss, decreased obesity, and decreased symptoms of hypertension. Nurses play an important role in the lives of patients diagnosed with hypertension because they encounter them every day.
Nurses, as health care professionals, are responsible for educating their patients. Patients with hypertension should be educated on the effects of poor dietary management with this condition and the benefits that proper nutrition can yield. This paper provides evidencbout the management of hypertension to provide nurses with additional knowledge, so they are more equipped to educate their patients.
Literature Review
The articles discussed provide evidence on the effects of dietary management compared to no dietary management in patients with hypertension. Three topics were identified while reading the evidenced based research. The first topic involved foods to be avoided in patients with hypertension and foods that should be consumed to decrease the risk of progression into cardiovascular disease. The second topic was how weight loss can benefit someone diagnosed with hypertension and the third expanded on how exercise effects patients with hypertension.  Therefore, all articles researched discuss the effects, benefits, and importance of dietary management and other aspects regarding hypertension.
Diet
According to the article written by Jones et. al (2018), prioritizing a healthy diet significantly benefits someone diagnosed with hypertension (p.325). In this study, two trials were done to test the effects of dietary management. In this article Jones et. al (2018) states,
A diet based around nutrient targets – specifically reduced fat intake – was found to be less effective at reducing risk of CVD events than a dietary pattern based around changing the consumption of fruit, vegetables, whole grains, fish, nuts, dairy products and vegetable oils, and reduced consumption of processed meats, sugars, desserts, alcohol, and fats (p. 236).
Most patients who have hypertension see a decline in their health due to poor dietary management. Neglected nutrition can cause a buildup of lipids which results in an elevation of blood pressure. This can further lead to an increased risk for cardiovascular disease. Foods that cause this decline include processed meats, sugars, desserts, alcohol, fats, and red meats (Jones et. al, 2018, p. 235). Conversely, Jones et al. (2018) states consuming a diet of fruit, vegetables, legumes, whole grains, and low-fat dairy as opposed to fatty alternatives, significantly lowers the risk for decline with hypertension (p. 235). However, when regarding dietary management, education and compliance are priority. One risk for gathering self-reported data is that the patient may withhold their entire daily intake, causing error in dietary regiment. This results in possible increased blood pressure and risk for cardiovascular disease. Thus, emphasizing the importance of dietary management for prevention of chronic disease. 
Weight Loss
Poorolajal, Hooshmand, Bahrami, and Amen (2017) reviewed the next topic found, being the association between weight loss and incidence rate of hypertension (p, 95). Hypertension is a condition not only associated with overweight or obese individuals, but in comparison to normal weight, overweight can increase the risk of hypertension (Poorolajal et. al, 2017, p. 95). Poorolajal et. al (2017) expands on this statistic in his article by stating, “Raised blood pressure is a major risk factor for cardiovascular disease and stroke (p. 95). Evidence has shown that raised blood pressure happens in individuals of all body sizes, ranging from lean to obese. However, people who are overweight or obese are greater risk of developing high blood pressure” (Poorolajal et. al, 2017, p. 95). Due to this risk factor, the purpose of this article was specifically to provide evidence on if weight loss is a beneficial method of controlling hypertension and decreasing risk for cardiovascular disease. This research specifically expanded on “the effect of overweight and obesity on the risk of raised blood pressure and estimated the amount of relative reduction in the incidence of hypertension that may occur if excess body weight is controlled” (Poorolajal et. al, 2017, p. 95). The eligibility criteria were clearly stated, including explanations as to what overweight and obesity are defined as.
The exposure of interest was overweight and obesity. Overweight refers to a BMI between 25 and 29.9 kg/m squared. Obesity refers to a BMI equal to or >30 kg/m squared. The outcome of interest was high blood pressure so called hypertension. Hypertension refers to a mean systolic/diastolic blood pressure at or above 140/90 mmHg (Poorolajial et. al, 2017, p. 95)
One measure utilized was Attributable Risk Fraction (AFR), which indicates how much of the relative prevalence of raised blood pressure will reduce per specified weight loss. Researchers determined the evidence presented by gathering a variety of data from studies and data extracted from other research articles, comparing weight loss to the effects on overweight and obese patients with hypertension. Through comparing data, researchers found that the effect of weight loss had a positive correlation on the reduction of incidence rate in hypertension and decreased risk for future cardiovascular disease. According to the results and statistics, the article’s conclusion was that weight loss can effectively reduce the incidence rate of hypertension, therefore, excess weight loss is a vital strategy for controlling hypertension and is sufficient for achieving the global target relative reduction in the incidence of raised blood pressure (Poorolajial et. al, 2017, p. 95).
Exercise
An article written by Pescatello, McDonald, Lamberti, and Johnson (2015, p. 87) specifically expands upon the topic of the effects of exercise on hypertension. Through a series of randomized controlled trials, researchers were able to administer a variety of amounts of exercise including acute and chronic aerobic, dynamic resistance, and concurrent exercise ranging from 30-60 minutes each day on patients who were diagnosed with hypertension. After these exercises were administered, blood pressure was taken and recorded.
Numerous randomized controlled trials (RTCs) have been conducted investigating the antihypertensive effects of exercise…These meta-analyses concluded that aerobic exercise training lowers blood pressure (BP) 5-7 mmHg, while dynamic resistance training lowers BP 2-3 mmHg among adults with hypertension. The magnitude of these BP reductions rivals the magnitude of those obtained with first-line antihypertensive medications and lower CVD risk by 20-30% (Pescatello, et. al, 2015, p. 87).
Based on the results of the study, it was concluded that practicing regular exercise significantly reduces blood pressure. Therefore, making exercise a key modifiable determinant of hypertension that should be prioritized to reduce the significance of hypertension and its effects to those who are diagnosed with this condition (Pescatello et. al, 2015, p. 87). 
The biopsychosocial aspects related to hypertension include obesity, depression, and cardiovascular disease. Most individuals who are diagnosed with hypertension often lack diet management and exercise, which results in overweight or obesity. Obesity becomes psychosocially problematic when body image and self-esteem significantly decline, which can lead to depression. In addition to the biological aspect of obesity, untreated hypertension or noncompliance to a treatment plan leads to an increased risk for cardiovascular disease. If untreated, hypertension can cause an overall decline, frequently leading to obesity, depression, and cardiovascular disease.
Discussion
A.D., a 73-year-old male diagnosed with hypertension about two years ago was the subject interviewed throughout this process. Research found suggested that to decrease symptoms of hypertension and prevent further decline, patients diagnosed should practice diet management, prioritize weight loss, and exercise frequently. If compliant to these lifestyle modifications, research proposes a decrease in blood pressure and risk for future cardiovascular disease.
Nursing interventions suggested in the literature include engaging in a healthy lifestyle including diet management, weight control, and exercise. As stated before, diet management regarding patients diagnosed with hypertension is crucial for preventing further decline. A.D. has been practicing diet management for the previous two years and currently states that he “tries to cut down on sodium and consume foods that promote healthy blood pressure”. From the time of being diagnosed with hypertension to now, A.D. has lost 30 pounds from diet management and exercise. A.D. currently weighs 228 pounds and is 6’1”, giving him a BMI of 30.1, which is obese. Although he is considered obese, A.D. plans to lose more weight in the future through the same type of healthy lifestyle. In addition to diet management and weight loss, A.D. regularly goes to the gym about three times a week. His current gym regimen involves him doing cardio and weights every time he attends. A.D stated, “I try to incorporate cardiovascular and weight training exercises into my workout”. Cardio either being the bike machine or treadmill, and weights involving body weight exercises or free weights. A.D. also stated that he plans to continue his exercise routine throughout the future to promote losing weight and preventing further decline.
Direct nursing care measures and patient teaching which have been utilized with A.D. was educating on exactly how to engage in a healthy lifestyle required to prevent further decline of hypertension. Instilling different types of diet management and emphasizing the importance of prioritizing diet management are essential for patient competence. This may include describing different dieting plans or explaining specifically what foods to avoid and what foods to prioritize in a diet geared towards those who are diagnosed with hypertension. The importance of weight loss in addition to diet management is essential to educate the patient on, due to its positive effects on lowering blood pressure and therefore reducing the risk of worsening hypertension. Further education on integrating exercise into someone’s life is also important when teaching a patient how to engage in a healthy lifestyle. Explaining outlets for working out and the variety of at home exercises is important regarding a patient who may be overwhelmed with the idea of working out in general. As well as explaining how to engage in a healthy lifestyle, it is crucial to educate the patient on how hypertension has the potential to turn into serious cardiovascular disease. This may prompt the patient to prioritize preventative measures more seriously. Literature suggests that with diet management, weight loss, and regular exercise, a patient’s blood pressure is likely to decrease, reducing the potential of their hypertension to turn into serious cardiovascular disease.
A.D. is receiving the best practice based on the evidence that literature indicated, yet more education on specific diet management could be given. Further education would be given to confirm that he is getting the nutrients that he needs while only ingesting foods that promote cardiovascular function.
Developing a teaching plan for this patient would include mapping out a specific diet management plan and weekly exercise regimen. As stated before, A.D. currently “tries to cut down on sodium and only eat foods that promote healthy blood pressure”. Although this statement indicates that A.D. prioritizes a heart healthy diet, providing a specific diet plan would be beneficial in creating structure and therefore increasing compliance. Proper nutrition should include a diet high in fruit, vegetables, legumes, whole grains, and low-fat dairy. This will ensure that A.D. gets the appropriate vitamins and minerals needed, yet also promoting healthy blood pressure. A key exercise regimen would include cardio and weight bearing exercises for a period of 30-60 minutes three times a week. Cardio would involve biking or running, and weight bearing exercises may include either body weight, or utilizing free weights. These dynamic range of aerobic, dynamic resistance, and concurrent exercises will allow the burning of fat in the body, which lowers blood pressure, in addition to strengthening muscles. The limitations of this teaching plan would be noncompliance from the patient. As healthcare workers, educating the patient is vital in preventing decline, yet it is ultimately up to the patient whether or not they choose to comply with the teaching plan. Appropriate related nursing diagnoses would include knowledge deficit related to lack of specific diet plan. Due to not being prescribed a strict diet plan, this results in lack of in dept knowledge of which foods to avoid and prioritize for proper nutrition.
To evaluate the effectiveness of this teaching plan, A.D. stated that he plans to check his weight every day at the same time each day and monitor his blood pressure to assess any changes. A.D. agreed to prioritize a structured diet regimen and frequent exercise to continue to lower his blood pressure. In the future regarding nutrition, A.D. plans to discontinue red meats, alcohol, and sugar from his diet. He also states that he will incorporate cardiovascular promoting exercises that specifically burn fat into his exercise plan. The effects of these strategies will therefore be monitored through the evaluation of his body weight and blood pressure. Strengths to this teaching plan include that A.D. was educated on exactly how to engage in a healthy lifestyle involving proper nutrition, promotion of weight loss, and exercise. He was also educated on the importance of prevention of further cardiovascular disease. Another strength is that he was given structured diet and exercise plans in attempts to increase compliance.
Some suggestions in the literature that can be used, as a nursing student, to change practice would be to familiarize yourself with proper nutrition and exercises regarding patients diagnosed with hypertension. Understanding what foods inhibit the promotion of healthy blood pressure and which foods and exercises benefit those with high blood pressure is crucial when educating about controlling blood pressure. 
The patient’s preferences, with regard to the care given, are to continue with his diet and exercise plan. A.D. states “I want to continue to avoid sodium and only eat foods that promote healthy blood pressure. I also want to continue to workout three times a week and keep up the exercises I do at the gym.” The patient has been improving his compliance to following the teaching plan given and continues to show improvement in his blood pressure and weight loss.
Summary Conclusion
Nursing responsibilities in caring for patients affected by hypertension involves providing the best holistic personalized care while educating the patient. Holistic care entails more than solely dealing with the physical aspect of hypertension. To help patients appropriately cope and manage this condition, nursing responsibilities include taking into consideration the psychological, social, and spiritual aspects that the patient may be dealing with. Patients diagnosed with hypertension also need individualized care, which impacts wellness and promotes the best outcome for their situation. This means providing education on specific diet and exercise plans available to the patient and encouraging compliance with those plans. Education and encouragement are vital factors that contribute to impacting patient compliance. As nurses, offering these attributes to care endorses an overall well experience when patients are working through a chronic illness or condition.
References
Jones, N. R. V., Forouhi, N. G., Khaw, K.-T., Wareham, N. J., & Monsivais, P. (2018). Accordance to the Dietary approaches to stop hypertension diet pattern and cardiovascular disease in a British, population-based cohort. European Journal of Epidemiology, 33(2), 235–244. doi: 10.1007/s10654-017-0354-8
Mohamed, S. F., Mutua M. K., Wamai R., Wekesah F., Haregu T., Juma P., … Ogola E., (2018). Prevalence, awareness, treatment and control of hypertension and their determinants: results from a national survey in kenya. BMC Public Health, 18(3), 9–19. doi:10.1186/s12889-018-6052-y.
Pescatello, L. S., MacDonald, H. V., Lamberti, L., Johnson, B.T. (2015). Exercise for hypertension: a prescription update integrating existing recommendations with emerging research. Current Hypertension Reports, 17(11), 1–10. 2015. doi:10.1007/s11906-015-0600-y.
Poorolajal, J., Hooshmand, E., Bahrami, M., Ameri, P. (2017). How much excess weight loss can reduce the risk of hypertension? 95–103. Journal of Public Health, 2016. doi:10.1093/pubmed/fdw077.
Sanuade, O. A., Boatemaa, S., Kushitor, M. M., (2018). Hypertension prevalence, awareness, treatment and control in ghanaian population: evidence from the ghana demographic and health survey. Plos One, 13(11), 1–19. doi: 10.1371/journal.pone.0205985.