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Effectiveness of Aerobic Exercise on Ambulatory Blood Pressure in Hypertensive Patients

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Effectiveness of Aerobic Exercise on Ambulatory Blood Pressure in Hypertensive Patients

Submitted by

Chinyere Christiana Pamugo

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

January 11, 2023

© by Chinyere Christiana Pamugo, 2023

All rights reserved.


Effectiveness of Aerobic Exercise on Ambulatory Blood Pressure in Hypertensive Patients

Chinyere Christiana Pamugo

has been approved

January 11, 2023


Dawn Robinson DNP, MSN, RN, LNHA, DPI Project Chairperson

Khoa Don Nguyen, MD., DPI Project Mentor



Lisa Smith, Ph.D., RN, CNE

Dean and Professor, College of Nursing and Health Care Professions




Physical exercise may improve hypertension and minimize cardiac complications. At the project site there were no standardized guidelines for hypertensive patients utilizing aerobic exercise as a blood pressure (BP) management mechanism, so an evidence based solution was sought. The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the translation of Saco-Ledo et al.’s research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks. Dorothy Orem’s self-care deficit theory and Kurt Lewin’s change model provided the scientific underpinnings for the project. Data were retrieved from the clinic’s electronic medical records on adult hypertensive patients ( N=10) and compared at baseline and four weeks post implementation. A paired-sample t-test showed a statistically and clinically significant improvement in systolic BP from baseline ( M = 152.60, SD = 14.42) to four weeks post implementation ( M = 126.10, SD = 19.93), t (9) = 6.35, p = .001. A paired-sample t-test also showed a statistically and clinically significant decrease in the mean diastolic BP level from baseline ( M = 87.30, SD = 11.19) to four weeks post implementation ( M = 78.10, SD = 8.45) , t (9) = 2.56, p = .031. Based on the results, the translation of Saco-Ledo et al.’s research on aerobic exercise may impact blood pressures in this population. Recommendations include sustaining the project and disseminating the results.

Keywords: aerobic exercise, ambulatory blood pressure, Saco-Ledo et al.’s research on aerobic exercise, Dorothy Orem’s self-care deficit theory, hypertension, hypertension-related conditions, Kurt Lewin’s change model, evidence based practice.


I dedicate this project to God, my life's author and finisher. Irrespective of the unsurmountable challenges and moments of despair, your mercy, grace, and love lead me through. Without your divine wisdom, Almighty father, I would not have been here this day. To my beloved families here and abroad, my mum, siblings, cousins, and spouse Engr. G. O. Pamugo, I achieved this goal because of your fervent prayers, support, and encouragement that fortified my strength, endurance, perseverance, and resilience not to quit to frustrations and fears. Even with my poor health, I struggled and still made it to this day because you all held my weak parts as I journeyed and ran the race to success. Thank you for believing in me and investing in my success. God bless you all. To my dad-late Chief M.E. Chukwu, I did accomplish your dreams on me, and I know wherever your soul is at this time, it is full of joy; rest in peace, daddy, until we meet again.

To my elder brother in the Lord, Rev. Fr. C. Iwuagwu, words cannot express the magnitude of gratitude I owe you for your fatherly and brotherly love, belief in my abilities, countless hours of encouragement, enormous -uplifts, and renewed determination. You are a blessing and gift to our family; remain blessed.


The fruitful journey of the Doctor of Nursing program (DNP) was made possible by the unconditional support of extraordinary and cherished individuals, such as Dr. Khoa and Don Nguyen, MD, for serving as my preceptor/mentor throughout the stages of my direct immersion project. I want to thank Dr. Dawn Robinson (Faculty /Chair), for her unshaken patience, quick feedback, and radiant positive energy, together with Dr. Sandi McDermott and faculty in course level review, reading countless revisions and providing knowledgeably expert guidance to the end of this course.

To my colleagues, Jeffrey Souza, Tresa Antony, Mercy Daniel, Lisa Johnson, Marissa Rafael, and Skyler Meyer, thank you for your unfading support. Countless times, I felt like the world has collapsed upon me, desperately seeking the way out in the darkness; lo and behold, your torchlights point through the doors of escape. I recognized each day we journeyed that the race was worth it because you all were there pointing your lights to the proper outlet.

To my supportive friends, Sr. Onyinyechukwu Uba, Ms. Euphemia, Ms. Amaka, Dr. Bashiru, Calista, Sylvia, Vincent, and Ogunbayode. Thank you for your support, encouragement, love, and understanding, especially in moments of desolation, sequestration, and poor communication from me due to loads of assignments on my table.

To my preceptees, Vivian, Michael, Adaeze, Jane, Kate, Esther, Marybeth, Florence, Ubong, Nkele, and others, your understanding when I transferred my frustrations to you humbled me most in my relationship with you as a preceptor. Looking upon the "role model thing" was the driving force that propelled me to this finishing point. You are more than welcome anytime for more guidance in the future in your further studies.

During this program, I also worked on my post-graduate certification program in the psychiatric mental health nurse practitioner program, and this is where I thank Dr. Ghislaine Mogo, my preceptor, for her tremendous patience and support. To my spiritual family, the Daughters of Charity of the Most Precious Blood, God gave me the best opportunity to be among you. Mother Ofelia Marzocca, see what I have become this day because of your decisions in the most challenging moments of my life and humble expression of an arduous journey that would benefit all. Thank you all, and may God reward us according to our deeds.

Table of Contents Chapter 1: Introduction to the Project 1 Background of the Project 2 Problem Statement 3 Purpose of the Project 4 Clinical Question 7 Advancing Scientific Knowledge 7 Significance of the Project 10 Rationale for the Methodology 11 Nature of the Project Design 12 Definition of Terms 13 Assumptions, Limitations, Delimitations 15 Summary and Organization of the Remainder of the Project 17 Chapter 2: Literature Review 19 Theoretical Foundations 22 Review of the Literature 25 Prevalence of Hypertension 26 Aerobic Exercise Health Intervention 31 Effect of Exercise on Blood Pressure 34 Summary 39 Chapter 3: Methodology 41 Statement of the Problem 42 Clinical Question 43 Project Methodology 44 Project Design 45 Population and Sample Selection 47 Instrumentation and Sources of Data 48 Validity 49 Reliability 50 Data Collection Procedures 50 Data Analysis Procedures 52 Potential Bias and Mitigation 53 Ethical Considerations 54 Limitations 55 Summary 55 Chapter 4: Data Analysis and Results 58 Descriptive Data 59 Data Analysis Procedures 60 Results 61 Summary 63 Chapter 5: Summary, Conclusions, and Recommendations 65 Summary of Findings and Conclusion 68 Implications 70 Theoretical Implications 70 Practical Implications 72 Future Implications 73 Recommendations 73 Recommendations for Future Projects 74 Recommendations for Practice 75 References 77 Appendix A 93 Grand Canyon University Institutional Review Board Outcome Letter 93 Appendix B 94 Saco-Ledo et al.’s Research Article 94 Appendix C 95 Permission to Use Saco-Ledo et al.’s Research Article 95

List of Tables

Table 1. Descriptive Data for Age 5 9

Table 2. Descriptive Data for Gender and Race 60

Table 3. Paired t Test results for Systolic Blood Pressure Levels 6 2

Table 4. Paired t Test results for Diastolic Blood Pressure Levels 6 2

Chapter 1: Introduction to the Project

Hypertension (HTN) is a medical condition associated with higher blood pressure, whereby the arteries that transport blood become damaged. Despite the availability of treatment strategies, less than one in five individuals have their blood pressure under control (Ghatage et al., 2021). Currently, in the United States (U.S.), the disease poses a significant problem that affects over half of the adult population (37 million individuals) (Centers for Disease Control and Prevention [CDC], 2021; Krist et al., 2021). Complications of the condition include myocardial infarction, heart failure, chronic renal disease, and stroke (Ghatage et al., 2021).

The increase in the cases of hypertension prompted the American Heart Association Task Force (AHA, 2022) to publish new guidelines to help manage the rise in hypertension among American adults (Wang et al., 2019). One critical change within the AHA guideline is the improvised reference and definition of hypertension values. The American College of Cardiology and the American Heart Association guidelines for hypertension management and definition of HTN defines it as having blood pressure at or above 130/80 mmHg (The American College of Cardiology (2022); American Heart Association, 2022). At the same time, stage 2 HTN is blood pressure at or above 140/90mmHg (CDC., 2021). Improved blood pressure (BP) among hypertensive patients has been associated with positive health outcomes (Severin et al., 2020), and early detection and control of BP have significantly impacted morbidity and mortality rates in the healthcare delivery system (CDC, 2021; Severin et al., 2020).

At the project site, the project manager collaborated with the Medical Director and clinical manager regarding the increasing ambulatory blood pressures seen within the past three months. Although the site provided patients with medication management for their disease, it was suggested that another strategy be employed to help reduce blood pressure. The conversation concluded with the project manager translating and implementing Saco-Ledo et al.’s (2020) research on aerobic exercise to impact the blood pressure of hypertensive patients.

The project was worth conducting because it helped to increase HTN patients’ knowledge levels and assist in helping them change their behaviors to combat this “silent killer” (Centers for Disease Control and Prevention [CDC], 2019). Unfortunately, many individuals are unaware of the symptoms, which makes the situation dire. This project promoted decreasing the fifth leading cause of death (CDC, 2019). Other areas the project impacted were improving their quality of life, reducing their chances of stroke, protecting their kidneys, and decreasing healthcare costs (CDC, 2019).

Chapter 1 introduced the topic of hypertension and the use of daily physical activity to combat the disease. Other sections of the chapter included the problem statement, purpose statement, and clinical question. Other chapter areas encompassed advancing scientific knowledge related to the theoretical underpinnings, quantitative methodology, and quasi-experimental design. The chapter's last segments comprised the definition of terms, assumptions, limitations, and delimitations with a preview of Chapter 2.

Background of the Project

The prevalence of hypertension among the adult population in the United States (U.S.) increased rapidly between 1988 to 2010, accounting for half of all fatalities from stroke and end-stage renal disease (ESRD) (Million Hearts, 2021). According to Muntner et al. (2020) trend analysis, the estimated proportion of the U.S. adult population suffering from hypertension between 1999 and 2000 was 31.8 %. The adult population affected by hypertension increased from 31.8 % in 1999-2000 to 48.5 % in 2007 and 2008 (Muntner et al., 2020). The number of affected U.S. adults has been on the rise ever since, and between 2013 and 2014, which was 53.8 % (Muntner et al., 2020). The percentage dropped slightly from 53.8% to 43.7% between 2017 and 2018, but the value is still relatively high (Muntner et al., 2020). This data imply that the American population is considerably affected by hypertension at an alarming rate.

The current hypertensive population impacted by increased ambulatory blood pressure is 43.7%, according to a recent study by Adams and Wright (2020). Currently, there are no standardized guidelines for educating hypertensive patients regarding incorporating exercise (daily physical activity) as a blood pressure management mechanism at the project site. The standard treatments include medications such as diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and calcium channel blockers (Mayo Clinic, 2021). After collaborating with the medical director and nursing staff, the decision was to implement Saco-Ledo et al.’s (2020) research on aerobic exercise to help lower systolic and diastolic blood pressures among this clinic’s adult hypertensive population.

Problem Statement

It was not known if or to what degree the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients. At the clinical site, there were no standardized guidelines for clinicians to educate hypertensive patients regarding implementing daily physical activity as a blood pressure management mechanism. Collaboration with the medical director and some nursing staff showed an increase of 37.1% in diagnosed HTN patients within the past six months. The clinic’s findings corresponded with the health statistics from the Texas Health and Human Services Commission (2022), as the county ranks 22 in the States with diagnosed hypertensive patients. The data, in combination with current literature by the Centers for Disease Prevention and Control [CDC] (2021), emphasizes that hypertension affects approximately 45% of American adults.

The project contributes to the current body of literature, such as Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al. (2020), regarding aerobic exercise being included in hypertension management. The CDC (2020) states that regular physical activity is essential for general wellness, weight loss, and well-being. Other areas impacted are the reduced symptoms of depression and anxiety (CDC, 2020). The project validated that using aerobic exercise, as stated by Saco-Ledo et al. (2020), decreased one’s systolic blood pressure by approximately 2 to 4 mm Hg in normotensive and 5 to 8 mm Hg in hypertension adult patients.

Purpose of the Project

The purpose of this quantitative, quasi-experimental quality improvement project was to determine if the translation of Saco-Ledo et al.’s research on aerobic exercise would impact systolic and diastolic blood pressures when compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas over four weeks. The independent variable for the project was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variable was blood pressure measurements. Convenience sampling was used to choose the patients during office visits. The project was conducted within four weeks using a quasi-experimental design and quantitative methodology. Six healthcare providers were educated to offer aerobic exercise using a translation of Saco-Ledo et al.’s research on aerobic exercise. The impact was measured using an Oscar 2 blood pressure monitoring device for HTN patients. The primary investigation carried out the implementation and comparison of data during the project using ambulatory blood pressure collected baseline and postimplementation. Patient blood pressures measured by the Oscar-2 were automatically imported into the patient’s medical record. Data were retrieved from the clinic’s electronic medical record and inputted into a Microsoft Excel spreadsheet. A statistician not associated with the primary investigator or project analyzed the data. A paired sample t-test was used to analyze the statistical significance of the variables using the Statistical Package for the Social Sciences (SPSS-28).

The inclusion criteria for the patients were 18 and older, diagnosed with HTN, current clinic patients, and able to participate in aerobic activity. The exclusion criteria are patients with musculoskeletal disabilities, mental disorders, and individuals with comorbidities that could bias the project findings. The patients engaged in aerobic exercise for 30 minutes in 24 hours, three days a week, for the four weeks of the project duration. The postimplementation outcome was a reduction in ambulatory blood pressure reading of the recommended BP below 140/80mmHg. The average decrease in SBP with aerobic exercise is approximately 2 to 4 mm Hg in normotensive patients and 5 to 8 mm Hg in adult hypertension patients (Saco-Ledo et al., 2020).

The individuals who implemented the intervention were one physician, two nurse practitioners, two registered nurses, and one medical assistant. All healthcare providers were educated to include aerobic exercise within office visits with HTN patients. Aerobic exercise was offered as translated from Saco-Ledo et al.’s (2020) research on aerobic exercise. The use of Oscar 2 Device for measuring ambulatory blood pressure. The clinicians demonstrated understanding via the teach-back method to the project manager to safeguard all the patients were taught the same way. They currently work full-time at the clinic for over one year and have access to the documentation software.

The project site’s geographic location is in southwest Texas, the most populous county and the third most populous county in the United States (U.S. Census Bureau, 2020). The affected population was patients diagnosed with HTN. The demographics show a diverse population of White (28.9 %), White-Hispanic (36.72%), Blacks (18.5%), Asians (6.9 %), and Latinos (8.98. %) (U.S. Census Bureau, 2020). Many residents over the age of 60 have chronic diseases such as (chronic obstructive pulmonary disease, heart disease, and diabetes) (UT Health Science Center at Houston, 2020). The age groups in the county 18 to 34 (20,586), 35 to 54 (46,513), and 55 to 64 reflect the patients in the project.

The project contributed to the nursing field by offering an evidence-based strategy and evaluating how aerobic exercises such as walking improve ambulatory blood pressure. The project provided vital information that could be shared with other nursing staff or healthcare providers at other primary care clinics, minority communities, or populations in similar diverse populations. The project also preferred an avenue for helping individuals and families to understand the relationship between the disease process and its management.

Clinical Question

Saco-Ledo et al. (2020) conducted a systematic review and meta-analysis. The authors claimed that ambulatory blood pressure (ABP) better predicts cardiovascular disease and mortality in adult hypertensive populations. Aerobic exercise played a significant role in lowering blood pressure and was beneficial in lowering ambulatory blood pressure in HTN patients. The following clinical question guided this quantitative project: To what degree does the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise impact systolic and diastolic blood pressures compared to current practice among adult hypertensive patients in a primary care clinic in southwest Texas? The independent variable was the translation of Saco-Ledo et al.’s (2020) research on aerobic exercise, and the dependent variable was ambulatory blood pressure.

Advancing Scientific Knowledge

Implementing an aerobic exercise education program to lower ambulatory blood pressure improved population health outcomes for hypertensive individuals (Saco-Ledo et al., 2020). Completing this quality improvement project advanced the understanding of ambulatory blood pressure in hypertensive patients to reduce or manage ambulatory blood pressure. The overall goals of aerobic exercise walking in controlling blood pressure in hypertensive patients were to decrease morbidity and increase the population's wellness, happiness, and vitality. Physical activities include walking, running, swimming, and biking, which improves symptoms, quality of life, and functional status, and reduces hospitalizations (CDC, 2021).

In clinical practice, management of cardiovascular diseases entailed resolving cardiovascular etiologies such as coronary heart disease and related conditions such as diabetes, preventative care, follow-up monitoring of cardiac status, care coordination and case management, educating and su

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