**3. Home blood pressure measurement**

Blood pressure self-monitoring has been proposed as a strategy to improve hypertension control. Although the results of previous clinical trials on blood pressure measurement in the adjustment of hypertensive therapy and in the control of hypertension are inconsistent, the results of TASMINH4 demonstrated that 90% of eligible participants revealed that they wanted to take an active role in selfmonitoring of blood pressure [24].

However, the importance of new studies in this area is highlighted, mainly studies involving risk groups, including patients with CKD in the advanced stage of the disease [25].

Hypertension is common in CKD patients, with a prevalence of around 60% to 90%, depending on the stage and cause of the disease, and is responsible for high cardiovascular morbidity and mortality. In this context, blood pressure control is a key measure [10].

HBPM is easier than ambulatory blood pressure measurement and, therefore, can be an important tool for blood pressure control in combination with other measures.

In this regard, Sanghavi, & Vassalotti emphasize that measuring blood pressure at home is a mean of reducing the burden of medication in individuals with "white coat hypertension", that is defined as the increase in blood pressure in the clinical context and maintenance of normal values at home. And, therefore, a means of improving the therapeutic compliance of hypertensive patients [26].

The authors also add that HBPM offers the patient a means to monitor the effectiveness of the medication and acts as a positive reinforcement, as shown by a study carried out in Spain. Of the 250 participants, 92% of the individuals in the experimental group (home blood pressure measurement) adhered to the antihypertensive regime, against 74% in the control group.

They concluded that HBPM is simple and not expensive. Besides, it offers more information to the practitioner, allowing more informed clinical decisions. It also promotes the involvement of the patient and the commitment of the health team, including nurses.

The evidence that shows the benefits of HBPM compared to measuring blood pressure in the clinical setting. Namely in improving blood pressure control, in reducing "white coat hypertension" events and in cardiovascular risk prediction [27–29].

The diagnosis of "white coat hypertension" is important because one of the consequences of this situation is overtreatment [30].

CKD patients with "white coat hypertension" have a lower cumulative risk of progressing to ESRD, so home blood pressure monitoring is essential. On the other side, renal patients have a high prevalence of masked hypertension, defined as normal blood pressure values in the clinical setting and high blood pressure values at home or ambulatory. This situation puts them at risk of organ damage, cardiovascular events and tends to evolve to ESRD [31].

#### *Self-Management of Blood Pressure Control at Home in Chronic Kidney Disease… DOI: http://dx.doi.org/10.5772/intechopen.96416*

HBPM allows a complementary assessment of daytime blood pressure variation, commonly seen in chronic kidney patients [32, 33].

Self-measurement of blood pressure at home is therefore an alternative for measuring blood pressure. Besides providing a more accurate assessment of blood pressure, it offers the possibility of having regular measurements in conditions closer to the patients' daily lives [34].

It is recognized by the scientific community that the measurement of blood pressure in the clinical context does not accurately reflect the blood pressure of each individual (due to changes in circadian rhythm and in the environment). It is thus necessary to create alternative methods whose main goal is to enable a closer assessment of the patient's values, because it takes place in a natural context, in the patient's natural environment [35].

Therefore, the self-monitoring of blood pressure at home becomes a tool to be incorporated into the self-care of CKD patients, through which the person has control over the process. This action makes the patient co-responsible for their health. This is a simple and important measure in preventing progression to ESRD, but it is nevertheless a complement to blood pressure measurement in the clinical context [36].

The negative individual, social, and economic consequences of not controlling blood pressure are evident. But these effects can be positive when enhanced by the self-management of hypertension.

The main negative effects resulting from the lack of blood pressure control in CKD patients call for the development of self-care interventions that result in behavior modification and optimization of hypertension control.

This issue is evident in the study by Humpherys et al., which, through a multifaceted intervention approach, optimized blood pressure values in proteinuric CKD patients and unproteinuric CKD patients. For that, the authors run 4 projects, which occurred in different practices, established chronologically in different periods of time. The percentage of patients with self-care behaviors for blood pressure management within the recommended target values increased from 34% to 74% in project 1, from 60% to 83% in project 2, from 68% to 71% in project 3 and 63% to 76% in project 4. Both groups (proteinuric and unproteinuric CKD patients) were able to reach the recommended target blood pressure values. The group of unproteinuric patients achieved blood pressure values below 140/90 mmHg and the group of proteinuric patients reached values of blood pressure below 130/80 mmHg. In this context, the authors concluded that this type of intervention proves to be an asset in reducing long-term complications resulting from suboptimization of blood pressure control [22].

The analysis of the systematic literature review carried out by Gallagher, et al. shows us the positive effects of educational interventions in reducing high blood pressure. The benefits of health education interventions in lowering blood pressure in chronic kidney patients were confirmed. As well as their potential in reducing cardiovascular events and delaying the progression of the disease [37].

Given that nurses have a pivotal role in promoting self-care behaviors in all aspects of care, including (1) problem identification, (2) diagnosis, (3) intervention, (4) evaluation and (5) follow-up, it is essential to highlight the interventions developed in the context of high blood pressure control in chronic kidney patients.

According to the literature, the possible causes of blood pressure control in this target group are associated with a reduction in self-care behaviors in relation to the consumption of salt, the practice of physical exercise and the adherence to medication. The overlook of these behaviors leads to hypertension. In this context, non-pharmacological interventions are relevant, along with pharmacological measures [38].
