Clinical Reflections: Managing Uncontrolled Hypertension in an Elderly Male Patient

Patient Overview and Context

A 70-year-old male presented with persistently elevated blood pressure despite ongoing antihypertensive therapy. His medical history included type 2 diabetes mellitus, hyperlipidemia, and a sedentary lifestyle. He reported frequent headaches, mild dizziness, and shortness of breath on exertion. The blood pressure reading was 174/96 mmHg, taken on two different occasions, confirming uncontrolled hypertension. The patient admitted poor medication adherence, citing forgetfulness and mild fatigue as reasons for noncompliance. He consumed processed foods high in sodium and did not monitor his blood pressure regularly at home. His case reflected the intersection of clinical complexity and lifestyle inertia typical of older adults struggling with chronic cardiovascular conditions.

Clinical Assessment and Findings

The physical examination revealed a body mass index (BMI) of 31.4 kg/m², indicating obesity. Cardiovascular assessment demonstrated an audible S4 heart sound, mild pedal edema, and reduced peripheral pulses. Laboratory findings included fasting glucose of 142 mg/dL, LDL cholesterol of 168 mg/dL, and a serum creatinine of 1.4 mg/dL. Electrocardiogram showed left ventricular hypertrophy consistent with chronic pressure overload. These findings suggested target organ involvement and reinforced the diagnosis of uncontrolled hypertension. The patient’s condition was evaluated using the American College of Cardiology (ACC) and American Heart Association (AHA) hypertension management guidelines, which emphasize confirming adherence, evaluating secondary causes, and optimizing pharmacologic and nonpharmacologic therapy (Whelton et al., 2018).

Differential Diagnoses and Rationales

Three differential diagnoses were considered. The first was secondary hypertension due to chronic kidney disease. The mildly elevated creatinine and reduced renal clearance supported this possibility, although the absence of significant proteinuria made it less likely. The second differential was medication-induced hypertension. The patient had been intermittently using nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritis pain, known to raise blood pressure and blunt antihypertensive drug effects. The third was obstructive sleep apnea (OSA), supported by his obesity, loud snoring, and daytime somnolence, a common comorbidity in older hypertensive patients. According to Pedrosa et al. (2021), OSA significantly contributes to resistant hypertension, and screening in this population improves outcomes when continuous positive airway pressure (CPAP) therapy is used alongside medication.

Plan of Care and Intervention Strategy

The plan of care focused on both pharmacologic optimization and behavioral modification. Pharmacologically, the patient’s regimen was adjusted to include a combination of a thiazide diuretic and an angiotensin receptor blocker (ARB), targeting synergistic blood pressure control. The choice was supported by current evidence favoring combination therapy in resistant hypertension (Carey et al., 2021). A low-dose calcium channel blocker was added for additional vasodilation. Nonpharmacologic interventions emphasized dietary sodium reduction, weight loss, and improved medication adherence. A pillbox and phone reminder system were introduced to address forgetfulness. Nutritional counseling followed the DASH (Dietary Approaches to Stop Hypertension) plan, supported by research demonstrating significant systolic and diastolic reductions in elderly hypertensive patients (Siervo et al., 2020).

Health Promotion and Patient Education

Health promotion interventions targeted lifestyle change sustainability and self-management competence. The patient received structured education on home blood pressure monitoring, emphasizing daily readings at consistent times to identify fluctuations and enhance awareness. He was referred to a local hypertension support group, where adherence and peer accountability are encouraged. Education on the interaction between sodium intake and vascular stiffness was delivered in plain terms to foster understanding rather than compliance by authority. Exercise recommendations included low-impact aerobic activity, such as walking for 30 minutes five times weekly. Additionally, motivational interviewing techniques were employed to identify personal barriers to adherence and build intrinsic motivation for change. Consistent with the findings of Bosworth et al. (2020), motivational approaches in hypertension management increase adherence and sustain blood pressure control in older adults.

Challenges and Successes During the Week

The main challenge involved improving the patient’s engagement with his medication schedule and self-care regimen. Cognitive decline and low health literacy interfered with adherence despite good intentions. Adjusting communication style from technical explanations to practical instructions yielded measurable improvement. By the end of the week, the patient reported consistent medication use and had purchased a home blood pressure monitor. His systolic readings decreased slightly, suggesting early benefit from combined efforts. Another success was securing his commitment to reduce processed food consumption. The conversation shifted from vague dietary advice to specific, achievable actions, such as replacing canned soups with fresh vegetables and monitoring sodium labels. Progress in behavioral change required patience, repetition, and empathy, not clinical authority.

Reflections and Professional Learning

The experience reinforced the importance of comprehensive, patient-centered management in chronic disease care. Managing uncontrolled hypertension extends beyond prescribing more drugs; it demands understanding the social, psychological, and environmental context shaping adherence. For an advanced practice nurse, this case underscored the value of motivational interviewing and follow-up continuity. It also highlighted that patient education succeeds only when it aligns with the patient’s cognitive and emotional capacity. The integration of clinical guidelines with real-world adaptability defined the success of care delivery. Evidence-based frameworks such as the AHA hypertension guidelines are essential, but translating them into meaningful, lived interventions remains the art of advanced practice. Moreover, consistent documentation and reassessment of blood pressure response are necessary to evaluate progress and adjust therapy promptly.

Evidence-Based Rationale and Guideline Alignment

The treatment plan adhered to the 2017 ACC/AHA guidelines, which recommend initiating combination therapy when blood pressure exceeds 160/100 mmHg or remains uncontrolled on monotherapy. Lifestyle modifications remain central to management, with sodium restriction, physical activity, and weight reduction offering measurable benefits. The use of ARBs and thiazides is supported by evidence indicating improved cardiovascular outcomes and renal protection, especially in elderly diabetic populations (Carey et al., 2021). Integrating sleep apnea screening and addressing polypharmacy also align with best practices for resistant hypertension management. Education and follow-up form the cornerstone of chronic care improvement, as validated by multiple clinical trials emphasizing continuity and engagement as determinants of long-term control. Thus, the experience illustrated how evidence, empathy, and clinical reasoning converge to restore stability in a complex hypertensive patient.

Conclusion

The clinical week provided a comprehensive learning experience in managing complex hypertension in older adults. Beyond the physiological parameters, the case revealed the human dimension of chronic illness—forgetfulness, fatigue, resistance, and the need for encouragement grounded in understanding rather than instruction. The success lay not in immediate normalization of blood pressure but in establishing the patient’s trust and gradual behavioral shifts. For the advanced practice nurse, such encounters strengthen diagnostic reasoning, enhance communication skills, and reinforce the role of evidence-based decision-making. Uncontrolled hypertension demands precision and patience, and the balance between pharmacology and psychosocial intervention remains the heart of effective nursing practice.

References

Bosworth, H. B., Olsen, M. K., Grubber, J. M., Neary, A. M., Orr, M. M., Powers, B. J., & Oddone, E. Z. (2020). Two self-management interventions to improve hypertension control: A randomized trial. *Annals of Internal Medicine, 172*(6), 355–366. https://doi.org/10.7326/M19-3250

Carey, R. M., Muntner, P., Bosworth, H. B., & Whelton, P. K. (2021). Prevention and control of hypertension: JACC Health Promotion Series. *Journal of the American College of Cardiology, 77*(12), 1576–1594. https://doi.org/10.1016/j.jacc.2021.01.021

Pedrosa, R. P., Drager, L. F., Gonzaga, C. C., Amaro, A. C., Carvalho, L. L., & Lorenzi-Filho, G. (2021). Obstructive sleep apnea: The most common secondary cause of hypertension associated with resistant hypertension. *Hypertension, 78*(5), 1211–1220. https://doi.org/10.1161/HYPERTENSIONAHA.121.17256

Siervo, M., Lara, J., Chowdhury, S., Ashor, A., Oggioni, C., & Mathers, J. C. (2020). Effects of the DASH diet on blood pressure in hypertensive and normotensive subjects: A meta-analysis. *British Journal of Nutrition, 123*(9), 1012–1020. https://doi.org/10.1017/S0007114520000313

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Himmelfarb, C. D., & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. *Journal of the American College of Cardiology, 71*(19), e127–e248. https://doi.org/10.1016/j.jacc.2017.11.006

Weekly Clinical Experience 2

Describe your clinical experience for this week for a 70-year-old male patient with uncontrolled hypertension

• Did you face any challenges, any success? If so, what were they?
• Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.
• Mention the health promotion intervention for this patient.
• What did you learn from this week’s clinical experience that can beneficial for you as an advanced practice nurse?
• Support your plan of care with the current peer-reviewed research guideline.
• Discuss the weekly clinical experience of treating an elderly hypertensive patient, integrating guideline-based management and reflective learning.

Submission Instructions:

• Your initial post should be at least 500 words, formatted and cited in current APA style with support from at least 2 academic sources

 

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