NURS FPX 4905 Assessment 4 - Capella BSN .pdf

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1. NURS FPX 4905 Assessment 4: Patient, Family, or Population Health
Problem Solution
Student Name
Capella University
NHS-FPX 4905
Professor Name
Submission Date







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2. Introduction
Chronic illnesses continue to be among the most pressing challenges in contemporary healthcare,
with hypertension ranking as one of the most prevalent and modifiable risk factors for poor
outcomes. Despite the availability of effective treatments, millions of adults in the United States
live with uncontrolled high blood pressure, leading to significant burdens such as cardiovascular
complications, stroke, and kidney disease. The challenge becomes even more severe in
underserved populations, where barriers to care, socioeconomic limitations, and low health
literacy amplify health disparities.
This paper proposes an innovative, nurse-driven solution to improve hypertension control in
underserved adult populations. The model integrates digital health tools, culturally responsive
community engagement, and interprofessional teamwork, aiming not only to reduce blood
pressure but also to empower patients in achieving long-term self-management.
Identification of the Health Problem
Hypertension, often called the “silent killer,” affects nearly 48% of U.S. adults, yet only about
25% maintain their blood pressure within target ranges (CDC, 2022). For low-income
communities, inadequate healthcare access, limited medication adherence, and poor awareness
about the risks of uncontrolled hypertension worsen the situation. These disparities perpetuate
cycles of poor outcomes and higher healthcare utilization, creating an urgent need for
sustainable, community-oriented interventions.
Proposed Intervention
The recommended solution is a comprehensive nurse-led hypertension management
initiative consisting of three interconnected strategies:
1. Remote Blood Pressure Monitoring with Smart Devices
Patients will be equipped with user-friendly, Wi-Fi or Bluetooth-enabled monitors. Data
will automatically sync to a secure platform, enabling healthcare providers to track
progress in real time.
2. Culturally Tailored Education and Lifestyle Coaching
Nurses will conduct monthly interactive workshops and home visits focused on nutrition,
exercise, stress reduction, and medication adherence. Teaching methods will emphasize
visual aids, group discussions, and culturally relevant dietary examples.
3. Interprofessional Collaborative Care Model
Nurses will serve as care coordinators, linking primary care providers, dietitians,
pharmacists, and community health workers. This approach ensures continuity,
medication management, and timely intervention if blood pressure remains uncontrolled.

3. This model creates a blend of individualized monitoring and community-level engagement,
reinforcing both accountability and empowerment
Evidence Base for the Solution
Current literature strongly supports digital health integration and team-based care for
hypertension management. Omboni et al. (2020) reported that remote monitoring programs
improved blood pressure outcomes significantly compared to standard office-based care.
Similarly, Whelton et al. (2018) emphasized that structured lifestyle modifications remain
critical for long-term success.
Community engagement has also demonstrated effectiveness. A systematic review by
Viswanathan et al. (2019) concluded that interventions led by community health workers reduce
disparities in chronic disease outcomes by building trust and enhancing patient engagement.
When these evidence-based practices are combined, the synergy creates a robust model for
addressing hypertension in resource-limited populations.
Anticipated Barriers and Mitigation Strategies
Implementing such a program will inevitably face obstacles. Key barriers include:
• Limited Access to Technology: Some patients may lack smartphones or internet access.
Clinics can provide devices on loan or set up community kiosks for data uploads.
• Health Literacy Concerns: Nurses will adapt educational materials using plain
language, translated resources, and visual tools to accommodate varying literacy levels.
• Sustainability and Funding: Start-up costs for equipment may be high. Partnerships
with local health systems, public health agencies, and nonprofit organizations will ensure
long-term financial viability.
• Behavioral Resistance: Patients may be hesitant to adopt lifestyle changes. Motivational
interviewing, peer support groups, and positive reinforcement will increase adherence.
Role of Nursing in Implementation
Nurses are pivotal to the program’s success. Their role will extend beyond education to include:
• Technology facilitation: Teaching patients to use digital monitors and troubleshooting
device issues.
• Continuous monitoring: Reviewing daily blood pressure data and identifying trends that
require provider intervention.
• Advocacy and equity promotion: Ensuring vulnerable populations gain access to
affordable medications, dietary resources, and stress management services.
• Care coordination: Leading interprofessional meetings to align care plans and adjust
interventions as needed.

4. By leveraging their holistic approach, nurses ensure patients receive not only medical guidance
but also psychosocial and cultural support.
Expected Outcomes
With effective implementation, this program is expected to:
• Increase the percentage of patients achieving guideline-recommended blood pressure
targets.
• Enhance patient confidence and self-efficacy in managing hypertension.
• Decrease hospital admissions and emergency visits related to hypertensive crises.
• Improve collaboration between healthcare professionals and community stakeholders.
• Contribute to narrowing health disparities, particularly in underserved adult populations.
Conclusion
Hypertension management demands more than prescribing medications—it requires culturally
informed strategies, patient empowerment, and integrated healthcare delivery. This nurse-led,
technology-supported, and community-based model directly addresses the multifaceted barriers
contributing to uncontrolled hypertension. By focusing on evidence-based practices and
leveraging the leadership of nurses, the initiative holds strong potential to transform hypertension
outcomes, improve equity, and reduce the long-term burden of chronic disease within vulnerable
populations.
References
Centers for Disease Control and Prevention. (2022). Facts about hypertension.
https://www.cdc.gov/bloodpressure/facts.htm
Omboni, S., McManus, R. J., Bosworth, H. B., Chappell, L. C., Green, B. B., Kario, K., ... &
Parati, G. (2020). Evidence and recommendations on the use of telemedicine for the management
of arterial hypertension. Hypertension, 76(5), 1368–1383.
https://doi.org/10.1161/HYPERTENSIONAHA.120.15873
Viswanathan, M., Kraschnewski, J. L., Nishikawa, B., Morgan, L. C., Thieda, P., Lohr, K. N., &
Whitener, L. (2019). Outcomes and costs of community health worker interventions: A
systematic review. Medical Care, 58(6), 539–549.
https://doi.org/10.1097/MLR.0000000000001319
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison
Himmelfarb, C., ... & 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

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