Nursing follow-up in chronic-disease programmes: hypertension and diabetes in primary care
- Safe practice
In primary care the nurse follows people with high blood pressure or diabetes: measures, teaches, checks feet and adherence, and refers in time.
What it is
Hypertension and diabetes are long-term conditions that are mostly managed in primary care by a team. Hypertension usually causes no symptoms and is diagnosed when blood pressure is 140/90 mmHg or higher on two different days; diabetes can damage the eyes, kidneys, nerves, heart and feet, and foot ulcers can lead to amputation. Within the team, and under the institution's protocols, the nurse measures blood pressure and other parameters, counsels on diet, physical activity, tobacco and alcohol, supports adherence, examines and teaches foot care, and refers people who meet the referral criteria. Treatment decisions belong to the prescriber and follow the programme's protocol.
What it requires
- Training in correct blood-pressure measurement and a validated, calibrated device, preferably with digital reading.
- The programme's standard protocol, with clear referral criteria.
- Time for counselling, and educational material in plain language.
- A follow-up and recall system for people who miss appointments.
Components
- Ask: symptoms, known heart, kidney or cerebrovascular disease, tobacco, alcohol, physical activity, medicines and how they are taken.
- Assess: blood pressure, weight and waist, and in diabetes the feet; review results as the protocol sets.
- Decide: referral criteria present or absent.
- Counsel and agree on goals; schedule the next follow-up.
How it is applied (and why)
- Greet the person and ask about new symptoms and how they take their medicines — finds problems and non-adherence early.
- Measure blood pressure with the correct technique and record it — treatment decisions depend on accurate readings.
- Measure weight and waist circumference — they track risk and the effect of lifestyle changes.
- In diabetes, examine both feet: skin, nails, deformities, sensation, pulses, ulcers and shoes — finds feet at risk before an ulcer.
- Check the referral criteria at every visit — some findings need same-day or urgent attention.
- Counsel on low-salt healthy diet, physical activity, quitting tobacco and limiting alcohol — lifestyle is part of treatment.
- Teach daily foot care and what to do if there is a wound — self-care prevents ulcers and amputation.
- Explore barriers to adherence and agree on one achievable goal — small goals build self-efficacy.
- Record findings and agreements and schedule the next follow-up — continuity is the core of a chronic-care programme.
When to refer from primary care (examples from WHO PEN protocols)
| Finding | Action |
|---|---|
| Blood pressure above 200/120 mmHg | Urgent referral |
| Diabetes with severe infection or a foot ulcer | Urgent referral |
| New chest pain, worsening angina, or symptoms of stroke or transient ischaemic attack | Refer for medical assessment |
| Blood pressure 140/90 mmHg or higher in a person under 40 years | Refer to rule out secondary hypertension |
| Diabetes with recent loss of vision, or no eye examination in two years | Refer for eye assessment |
In nursing practice
- Foot-care teaching: never walk barefoot, wash feet in lukewarm water and dry well between the toes, look at the feet every day.
- Do not cut calluses or corns at home or use chemical products on them; report any wound to the health team.
- People on glucose-lowering medicines that can cause low blood glucose learn its signs and carry a source of sugar, as the team teaches.
- People with diabetes need regular eye examinations, as their programme schedules.
- Most people with hypertension feel well: explain that feeling well is not a reason to stop treatment.
Common mistakes
- Measuring blood pressure with a poor technique or an uncalibrated device.
- Skipping the foot examination because the person has no symptoms: absence of symptoms does not exclude foot problems.
- Giving long lists of advice instead of agreeing on one achievable goal.
- Not acting on a referral criterion found during the visit.
- Changing or suggesting medicine doses outside the prescriber's order.
Test yourself
Think of the answer, then tap the question to see it.
Which parts of the foot examination does the nurse check in a person with diabetes?
Skin and nails, deformities, sensation, foot pulses, ulcers and footwear.
Which blood-pressure reading calls for urgent referral in the WHO PEN protocol?
Blood pressure above 200/120 mmHg.
What are three foot-care messages for a person with diabetes?
Any three of: do not walk barefoot, wash and dry the feet well between the toes, look at them every day, do not cut calluses or corns, and report any wound to the team.
How is hypertension diagnosed according to WHO?
When blood pressure is 140/90 mmHg or higher on two different days.
Elsewhere in DurgiPedia
- Physiology of hypertension
- Physiology of diabetes and ketoacidosis
- Blood pressure measurement
- How to improve adherence
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Implementation tools: Package of Essential Noncommunicable (PEN) disease interventions for primary health care in low-resource settings (World Health Organization, 2013); Hypertension (fact sheet) (World Health Organization, 2025); Diabetes (fact sheet) (World Health Organization, 2026).
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Representative model, for educational purposes only.