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Victor Appau, Telana Fairchild, Bonnie Fitzgerald, Susan Hernandez, Abigail Mathews, Holly Shumard,...

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Stress, Diabetes and Hypertension Victor Appau, Telana Fairchild, Bonnie Fitzgerald, Susan Hernandez, Abigail Mathews, Holly Shumard, Sophie Stec, Reasmey Taing NP Students UMass - Worcester, Graduate School of Nursing N/NG 603A, Fall 2012
Transcript
  • Slide 1
  • Slide 2
  • Victor Appau, Telana Fairchild, Bonnie Fitzgerald, Susan Hernandez, Abigail Mathews, Holly Shumard, Sophie Stec, Reasmey Taing NP Students UMass - Worcester, Graduate School of Nursing N/NG 603A, Fall 2012
  • Slide 3
  • Discuss each section as it relates to Healthy People 2020, Health Determinants, and other sources Review our case study patients The use of the 5 As model Poster session with 5 As model applied to case study patients Video with Walter and use of MI Community resources NP role HIPPA Dhalgren and Whitehead, 1991.
  • Slide 4
  • Work-place stress may develop as a result of work environment Other Sources: o Unmanaged stress is a risk factor for multiple chronic diseases o A combination of primary, secondary, and tertiary methods are effective in stress management (USDHHS 2012). (CDC, 2012). (Richardson and Rothstein, 2008).
  • Slide 5
  • Goals: o Reduce new cases of DM Target: Move from 8 new cases/1,000 people to 7.2 new cases/1,000 people aged 18-84 o Reduce DM death rate Target: Move from 73.1/100,000 deaths to 65.8/100,000 o Bi-annual HbA1c for adults with diabetes Target: Move from 64.6% to 71.1% adults diagnosed with DM who have 2 HbA1c in 12 months
  • Slide 6
  • Experience delays in getting care they need Less likely routine screening and preventive care Not engage in fitness activities Use tobacco Be overweight Have high blood pressure Experience symptoms of psychological stress Receive less social-emotional support Have lower employment rates
  • Slide 7
  • Goals: o Reduce number of adults with disabilities living in congregate care residences Current: 57,462 Target: decrease to 31,604 o Increase participation in social, spiritual, recreational, community, and civic activities to the degree that they wish o Reduce delays in receiving primary care due to specific barriers, and delays in obtaining assistive devices, service animals, and technology services
  • Slide 8
  • A group of disorders affecting a persons ability to move and maintain balance or posture Caused by abnormal development of the brain or damage to the developing brain early in life Estimated 1/300 children in US have CP (CDC, 2012)
  • Slide 9
  • Skin breakdown Falls Social isolation Depression Decrease independence Self-care Deficit Premature aging: o Extra Stress o Organ system not to full capacity Pain: o Common sites o Chronic and Acute (CDC, 2012) (NINDS, 2012)
  • Slide 10
  • No Standard Therapy We need more research on adults with CP. Individual plan of care Interprofessional disease management (NINDS, 2012)
  • Slide 11
  • Goals: o Increase cholesterol checks within the preceiding 5 years Estimated 74.6% US adults in 2008 Target: increase by 10%, to 82.1% o Reduce high total blood cholesterol levels 15.0% of adults in the US fell into this category from 2005-2008 Target: Reduce this statistic to 13.5%, a 10% reduction o Reduce the mean total blood cholesterol levels The mean total blood cholesterol levels in 2005-2008 time period was 197.7 mg/dL Target: Decrease by 10%, mean total blood cholesterol level 177.9 mg/dL
  • Slide 12
  • Goals: o Reduce adults with hypertension 29.9% of adults aged 18+ y/o had high blood pressure/hypertension in 200508 Target: 26.9 percent o Reduce adolescents with hypertension 3.5% of children and adolescents aged 8 - 17 y/o had high blood pressure/ hypertension in 200508 Target: 3.2 percent
  • Slide 13
  • 43 y/o AA/NA male w/ hx of CP powered wheelchair Senior VP of Finances o maybe when I have my nervous breakdown, I can get workmen's comp o Concern for job security Runs late, HIGH stress level Partner of 5 years & has a personal care assistant C/O: Anxious, stressed, trouble sleeping EtOH- martini lunches & nightly cognacs Gourmet Parisian diet *Yelled during appointment*
  • Slide 14
  • 54 y/o Italian female Divorced mother of 3 children, lives in own mothers home New Assoc. VP of HR o Concern for job security Social EtOH, smoker wicked bad temper Depressed, denies SI Low self-esteem o Former Miss Teen MA *Overheard other pt exam*
  • Slide 15
  • Originally Developed US Department of Health and Human Services Counseling smokers Adopted and supported USPTF Behavior change in obese patients http://www.uspreventiveservicestaskforce.org/3rduspstf/b ehavior/behsum2.htm http://www.uspreventiveservicestaskforce.org/3rduspstf/b ehavior/behsum2.htm Recommended USPTF Clinicians to counsel tobacco cessation http://www.uspreventiveservicestaskforce.org/uspstf09/to bacco/tobaccors2.htm http://www.uspreventiveservicestaskforce.org/uspstf09/to bacco/tobaccors2.htm Evidence in support Jay et al. (2010).
  • Slide 16
  • 43 y/o AA/NA male w/ hx of CP powered wheelchair Runs late, HIGH stress level Partner of 5 years & has a personal care assistant C/O: Anxious, stressed, trouble sleeping EtOH- martini lunches & nightly cognacs B/P: 165/110 FBS: 130 Total Cholesterol: 354mg/dL HDL 20mg/dL LDL: 200mg/dL 54 y/o Italian female Divorced mother of 3 children, lives in own mothers home New Assoc. VP of HR o Concern for job security Social EtOH, smoker wicked bad temper Depressed, denies SI B/P 120/80 FBS: 110 HbA1C: 6.3% Total Cholesterol: 115mg/dL
  • Slide 17
  • Transtheoretical Model: stages of change - o Pre-contemplation: lacking intent to change, no interest in changing behavior, resistance o Technique: explore the balance of changing vs not changing; what's good and what's not good Readiness to change and confidence in ability to change Motivational Interviewing: Partnership between provider and patient Explore ambivalence Change comes from patient Suggestion: Self-monitoring Keep a journal Support and follow-up
  • Slide 18
  • Cerebral Palsy MA http://www.masscp.org/cpma/cpma_frameset. htm Diabetes Center for Excellence http://www.umassmemorial.org/our- care/diabetes-center-of-excellence Stress Reduction http://umassmed.edu/content.aspx?id=41254
  • Slide 19
  • Definition: o Level of Education o License o Holistic and preventative care o Culture relativism Massachusetts o Advanced skills o Collaboration o Inside expertise o Practice guidelines Mass.Gov.Health and Human Services. (2012). http://www.mass.gov/eohhs/provider/licensing) Rosenthal, L. D., & Guerrasio, J. (2010). Acute care nurse practitioner as hospitalist: role description. Critical Care Nurse, 21-26.
  • Slide 20
  • The purpose of 244 CMR 4.00 is to establish the conditions under which registered nurses licensed by the Board of Registration in Nursing may practice in an expanded role. 244 CMR 4.00 also establishes principles of supervision, responsibility, and discipline to which nurses practicing in the expanded role are subject Responsible for own practice Employment of advanced skills o Evaluation o Diagnoses o Treatment Mass.Gov.Health and Human Services. (2012). http://www.mass.gov/eohhs/provider/licensing)
  • Slide 21
  • Diagnosing, treating, evaluation Medical histories Physical examinations Diagnostic studies Prevention and prescribing Primary and specialty care services Acute and critical care settings Surgeries and procedures Counseling and educating Rosenthal, L. D., & Guerrasio, J. (2010). Acute care nurse practitioner as hospitalist: role description. Critical Care Nurse, 21-26.
  • Slide 22
  • Community clinics, health centers, urgent care centers Health maintenance organizations (HMOs) Hospitals and hospital clinics Nursing homes Physicians offices Public health departments Nurse practitioner practices/ offices Rosenthal, L. D., & Guerrasio, J. (2010). Acute care nurse practitioner as hospitalist: role description. Critical Care Nurse, 21-26.
  • Slide 23
  • Increase access to health care programs o Stress management o Nutritional counseling o Fitness programs o Smoking cessation o Family counseling Rosenthal, L. D., & Guerrasio, J. (2010). Acute care nurse practitioner as hospitalist: role description. Critical Care Nurse, 21-26.
  • Slide 24
  • Audrey over heard Walters appointment Definition: o 1996 o National standards o Protection of healthcare information Paper Electronic o Organization required to develop polices and procedures Failure to comply> penalties File complaint with OCR: http://www.hhs.gov/ocr/privacy/hipaa/complaints/i ndex.html. http://www.hhs.gov/ocr/privacy/hipaa/complaints/i ndex.html $1.5 million US Department of Health and Human Services. (2012). HHS.gov
  • Slide 25
  • Best practice: o Ensure compliance o Physical and technical safeguards o Risk assessment o IT audit o Breach notification plan US Department of Health and Human Services. (2012). HHS.gov/ocr/privcay
  • Slide 26
  • Inform Walter Discuss with Audrey o HIPPA law o Role Report to HMO Mandatory training for ALL employees Designee http://www.hhs.gov/ocr/privacy/ http://www.hhs.gov/ocr/privacy/ US Department of Health and Human Services. (2012). HHS.gov/ocr/privacy/
  • Slide 27
  • Slide 28
  • References Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2008). Practice guideline for the treatment of patients with acute stress disorder and posttraumatic stress disorder. Retrieved from http://guideline.gov/content.aspx?id=5954&search=acute+stress Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and weight management. Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2011). Management of overweight and obesity in the adult. Retrieved from http://guideline.gov/content.aspx?id=33134 Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and weight management. Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2012). Tobacco treatment. Retrieved from http://guideline.gov/content.aspx?id=36845 Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and weight management.
  • Slide 29
  • American Diabetes Association (ADA). (n.d.). Stress. Retrieved from http://www.diabetes.org/livingwith-diabetes/complications/stress.html American Diabetes Association is a web based site that pertains to the prevention, treatment, and cure for diabetes. Their objective is to help those who are affected by diabetes and provide them with valid information for their understanding of the disease. This site is a reputable and highly quoted site for those in the diabetic world. There are guidelines for treatment and research to support the data at this site. For our purposes this site aids in our understanding of diabetes, how it relates to patients, and information for us as providers in diagnosing and treating patients. We are able to link why stress might have an effect on developing or worsen the symptoms of diabetes. American Heart Association. (2011, November). Target Heart Rates. Retrieved from http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/Target-Heart- Rates_UCM_434341_Article.jsp American Heart Association is well known association that focuses on cardiovascular health in relation to heart disease and stroke. This association provides the medical field with standards of care for cardiovascular disease and stroke. They are a well trusted association among medical professionals, lets face it they provide the education and approval certification for practitioners to give CPR, ACLS, etc. For this particular information gained was to aid us in prescribing exercise prescriptions to our two case study patients and give them the information for understanding target heart rates and how to calculate heart rates. American Heart Association. (2012, April). About high blood pressure. Retrieved from http://www.heart.org/heartorg/conditions/highbloodpressure/high-blood-pressure-or- hypertension_ucm_002020_subhomepage.jsp The American Heart Association is a non-profit organization that advocates for the United States public through cardiovascular research, education, community programs through fund-raising which support continued growth. It gives a clear, organized breakdown of information and current research for the general public. The reference also gives further information on risk factors and prevention for patients.
  • Slide 30
  • American Heart Association. (2012). What your cholesterol levels mean. Retrieved from http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-Levels- Mean_UCM_305562_Article.jsp American Heart Association is well known association that focuses on cardiovascular health in relation to heart disease and stroke. This association provides the medical field with standards of care for cardiovascular disease and stroke. They are a well trusted association among medical professionals, lets face it they provide the education and approval certification for practitioners to give CPR, ACLS, etc. This particular website found on their site was to aid us in describing cholesterol levels to patients and what is means if they high. Also, gives the providers insight about knowing when their patients are at risk for development of certain diseases. American Society of Hypertension. (2010). La presin arterial y su salud. Blood Pressure Health. Retrieved from http://www.ash-us.org/documents/BloodPressureHealthSpanish.pdf The ASH produced an informational booklet through which Spanish-speaking patients can learn basic concepts of blood pressure, information about high blood pressure, and how to lower and control high blood pressure. The document underlines clear methods and guidelines as well as provide an interactive diary with outlined questions for provider follow- up. The resource also provides illustrations and photos for further visual learning methods. Barter, P.J. (2011). The causes and consequences of low levels of high density lipoproteins in patients with diabetes. Diabetes and Metabolism Journal, 35, 101-106. doi: 10.4093/dmj.2011.35.2.101 This review summarizes the relationship between pre-diabetes or diabetes and low HDL levels, low HDL levels with high triglyceride levels, HDL as a compound and pancreatic beta cells, and HDL levels with insulin resistance. The review illustrates how the progression of diabetes can be stopped or reversed through increasing and managing HDL levels. The document also describes the effect of niacin and other forms of pharmaceutical treatment to increase HDL levels. This is a reliable review of data analysis for the provider. Centers for Disease Control and Prevention. (2011). Physical Activity. Retrieved from http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html According to the CDC, adults need 150 minutes of moderate intensity cardiovascular exercise per week to achieve cardiovascular benefits. This recommendation allows patients to break their minutes into manageable segments of at least 10 minutes in duration. Patients working at moderate intensity should be able to talk during their workout, but not sing.
  • Slide 31
  • Centers for Disease Control and Prevention. (2012). Cerebral Palsy (CP). Retrieved from http://www.cdc.gov/NCBDDD/cp/facts.html The Centers for Disease Control and Prevention (CDC) is a government agency focusing on public health. The topic of cerebral palsy is addressed on the CDC website. The website provides background information about the disease, including basic facts, statistics, information about screening and diagnosis, and links to research and articles. This resource was a place for me to access general background information about CP and the health problems people with CP face. Centers for Disease Control and Prevention. (2012). Selected Preventative Screening Recommendations. Retrieved from http://www.cdc.gov/nccdphp/dnpao/hwi/resources/preventative_screening.htm Centers for Disease Control and Prevention outlines recommended preventative health screenings and intervals for adults, as established by U.S. Preventive Services Task Force (USPSTF). The list serves as a tool to identify potential valuable screening, with the risks and benefits to be weighed and individualized based on patient needs. Center for Mindfulness in Medicine, Health Care, and Society. (n.d.). Stress Reduction Program. University of Massachusetts Medical School. Retrieved from http://www.umassmed.edu/Content.aspx?id=41254 Center for Mindfulness in Medicine, Health Care, and Society is part of the University of Massachusetts Medical Department. At the center, they aid clients through an eight week Stress Reduction Program developed in 1979 by Dr. Jon Kabat-Zinn. Due to Dr. Kabat-Zinn evidence based research and studies in stress reduction, the program seem trustworthy and applicable. Other professionals have adapted his techniques imbedded in this program to help with several different patients and for many different reasons and it seems successful based on the research and testimonies. For our purposes this provided us with a program we could inform providers about in order to get their patients involved. Both Audrey and Walter could benefit from stress reduction. Chobanian, A.V., Bakris, G.L., Black, H.R., Cushman, W.C., Green, L.A., Izzo, J. L.,... Materson, B.J. (2003). The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure. The Journal of the American Medical Association, 289, 2560-2571. The Seventh Report of the Joint National Committee (JNC 7) is an excellent reference and guide for the treatment of hypertension. The guide contains recommendations that are based on evidence from a rigorous systematic reviews and synthesis of the published medical literature. The purpose of JNC report is to provide an evidence-based approach to prevention and management of hypertension.
  • Slide 32
  • Dagogo-Jack, S., Egbuonu, N., Edeoga, C. (2009). Principles and practice of nonpharmacological interventions to reduce cardiometabolic risk. Medical Principle Practice, 2010(19), 167-175. doi:10.1159/000285280 This article reviews landmark studies that demonstrate the principles of nonpharmacological approaches to the reduction of the components of the metabolic syndrome, including pre-diabetes, prehypertension and dyslipidemia. Lifestyle interventions have been shown to ameliorate and prevent the progression of individual components of the metabolic syndrome. Dahlgren, G. and Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm Institute for Future Studies Department of Veteran Affairs. (n.d.). [Chart for pulse rates per minute defined by age groups for moderate activity and vigorous activity]. MOVE! Retrieved from http://www.move.va.gov/download/NewHandouts/PhysicalActivity/P09_HowToTakeYourHeartRate.pdf Department of Veteran Affairs is another US government association that is provided and held to standards of our government. The validity of the source is based on the fact it is a government association and this particular information is from the MOVE program from the NCP. This particular information came from a handout they are providing to their client as part of the MOVE program. This was great source for the table provided and giving informative, simple instruction on how to check your pulse for patient or providers to use as a tool for educating patients. Fessler, M.B., Massing, M.W., Spruell, B., Jaramillo, R., Draper, D., Madenspacher, J.H., Zeldin, D.Z. (2009). Novel relationship of serum cholesterol with asthma and wheeze in the United States. Journal of Allergy and Clinical Immunology, 124(5), 967-974. doi: 10.1016/j.jaci.2009.08.005 This data analysis utilizes the Centers for Disease Control and Prevention 2006 survey National Health and Nutrition Examination Survey provided by the CDC National Center for Health Statistics. The study describes an inverse relationship of serum total cholesterol and non-high density lipoproteins with asthma and/or clinical wheeze, with a strong relationship specifically with the Mexican-American population.
  • Slide 33
  • Fitday. (n.d.). How to Calculate Your Serum Cholesterol Level. Retrieved from http://www.fitday.com/fitness- articles/nutrition/fats/how-to-calculate-your-serum-cholesterol-level.html This is simply an online journal for those try to lose weight and help keep a record of progress. After exhausting all the well-known sites for an exact equation for calculating the total cholesterol I had to use what I could find and this site gave insight. However, the are no listing of references or dates to know the validity of this site, but seems these days AHA, CDC, etc. use a lipid panel for testing and there is no need for this calculation anymore. If anything this would be a good website to tell patients about that is free of cost to help them track their healthy lives. Frost, S. (2011, June 25). Exercise Plan for Busy Moms. Livingstrong.com. Retrieved from http://www.livestrong.com/article/478805-exercise-plan-for-busy-moms/?utm_source=RELARTICLES_R1 Livestrong is the website that Lance Armstrong is a founder. They claim to post only information that is expert based and reviewed. This particular article is from 2011 and was reviewed at that time. LiveStrong used other sources and allowed experts to write articles that are then reviewed by peers increasing the level of confidence in the information found on this site. This website, having used it previously for Walter, is useful and knowledgeable about exercise for all different people. With Audrey we face the issue of her being a busy mom. This particular article referenced four other sites for busy moms and how they can find a way to fit exercise in their busy schedule. Hart, Jacqueline A. (2003, June 3). High blood pressure (hypertension) guide. Penn Cardiac Care. Penn Medicine. Retrieved from http://www.pennmedicine.org/health_info/hbp/index.html These University of Pennsylvania Medical School resources give accurate and detailed information on hypertension, symptomology, and information on the DASH diet to which patients can refer. These two references highlight the importance of blood pressure monitoring and severity of the condition. It supports blood pressure screening and lifestyle changes that the patient can further read in detail. Hart, Jacqueline A. (2004, March 29). High blood pressure is silent. Penn Cardiac Care. Penn Medicine. Retrieved from http://www.pennmedicine.org/health_info/hbp/hbp_step5.html These University of Pennsylvania Medical School resources give accurate and detailed information on hypertension, symptomology, and information on the DASH diet to which patients can refer. These two references highlight the importance of blood pressure monitoring and severity of the condition. It supports blood pressure screening and lifestyle changes that the patient can further read in detail.
  • Slide 34
  • Health Indicators Warehouse. (2008). Smoking cessation success (percent). Retrieved from http://www.healthindicators.gov/Indicators/Smokingcessationsuccess-6monthsto1yearago (adults18yearsandolder)_1555/Profile/Data The Health Indicators Warehouse, as cited by Healthy People 2020, provides a resource of current national statistics on smoking cessation adjusted by a variety of indices (age range, sex, etc.). Healthy People 2020. (2012). Disability and Health. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=9 Healthy People 2020 covers the topic of Disability and Health in order to explore the disparity of health care among people with disabilities. The report aims to promote the health and well-being of this population. This report was useful in looking at disability in relation to goals for Walters care. Healthy People 2020. (2012). Heart Disease and Stroke. Retrieved from http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=21 Healthy People 2020 covers the topic of cardiovascular disease. The webpage served to provide basic info on cardiovascular disease and its risk factors. Heisler, M., Resnicow, K. (2008). Helping patients make and sustain healthy changes: a brief introduction to motivational interview in clinical diabetes care. Clinical Diabetes, 26(4). Retrieved from http://diabetes.niddk.nih.gov This article focused on a major aspect of using Motivational Interviewing (MI) to help patients undertake and sustain the necessary behaviors to manage their conditions. MI requires practice and considerable training. Improving our ability as health care providers to listen, to understand and empathize with the patients struggles during difficult lifestyle changes. Working with the collaboration of the patients is the underlying philosophy. Horsman, M., Suto, M., Dudgeon, B., Harris, S. (2010). Aging with cerebral palsy: Psychosocial issues. Age and Aging. 39, 294-299. doi: 10.1093/ageing/afq018 This article described a narrative review of nine prior studies which aimed to address the psychosocial issues challenging adults with CP. McMaster Universitys Guidelines for Critical Review was used to evaluate both quantitative and qualitative studies. This article was useful in identifying areas of need for psychosocial support in an aging patient with CP. The discussion included the detrimental influence of physiological impairments on the psychosocial taxing effects of the disease.
  • Slide 35
  • Isometric Exercises. (n.d.). Isometric Exercises- History and Benefits. Retrieved from: http://www.isometricexercises.net This is a commercial based website used to get more information about isometrics Dr. Rimmer mentioned in his article. Due to having to make a prescription exercise plan for Walter I need examples of Isometric exercise and an idea if he could perform these exercises. The website was helpful and gave insight; however, confidence in the site is low due to lack of explanation of references used and dates the data are pulled. Based on the other sites found during searching this one was the easiest to follow and gave the most information for this project. Jay, M., Gillespie, C., Shlair, S., Sherman, S., Kalet, A. (2010). Physician's use of the 5as in counseling obese patients: is the quality of counseling associated with patients' motivation and intention to lose weight. BMC Health Services Research,10, 159. Retrieved from http://www.biomedcentral.com/1472-6963/10/159 Jay, M et al. explained the quality of physicians use of the 5as model of behavior change in counseling and investigated the relationship or associations between the quality of counseling and patients enthusiasm to lose weight. The results of this research were pertinent to Audrey and Walters cases because it was found that physicians use of the 5as model was associated with higher likelihood of patients desire to lose weight, eat healthy and exercise. This study provided us with a recent evidence based corroboration of the effectiveness of the 5as model being used to affect behavior change in Audrey and Walter. Kodama, S., Tanaka, S., Saito, K., Shu, M., Sone, Y., Onitake, F.,... Sone, H. (2007). Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol: a meta-analysis. Archives of Internal Medicine, 167(10), 999-1008. doi:10.1001/archinte.167.10.999 This is the meta-analysis describing the relationship of exercise amount, exercise intensity, and cholesterol levels. The article outlines criteria for increasing HDL with lifestyle changes and exercise through increased intensity and duration more than the national recommendations.
  • Slide 36
  • Lind, B.K., Lafferty, W.E., Tyree, P.T., Diehr, P.K. (2010). The Journal of Alternative and Complementary Medicine. 16(4), 411-417. The authors research the insurance expenditures of patients who use CAM versus those using only conventional medicine. This study indicated that patients using CAM have higher outpatient expenditure, but this expenditure is off-set by costly impatient imaging studies of non-CAM patients. The research suggests there is a cost benefit for insurance companies to cover CAM modalities in order to reduce expenditure per patient. Matthews, K.A., Katholi, C.R., McCreath, H., Whooley, M.A., Williams, D.R., Zhu, S., Markovitz, J.H. (2004, July, 6). Blood pressure reactivity to psychological stress predicts hypertension in the CARDIA study. Circulation, 110(1),74- 78. doi:10.1161/01.CIR.0000133415.37578.E4 This article is found in the Circulation Journal. The study is based on a large sample size of participants enrolled in the CARDIA Study. The research for this article was to show if there is a relationship between stress and hypertension. We do have to keep in mind that this is an article with many strengths and weaknesses. As mentioned before the sample size was very large and included both black and white men and women from 18 years of age to 30. The researchers followed the participants over a thirteen year period using standardize measurements and protocols. Even though, they had a large sample size there were lost follow up with some of the participants. Also, in one particular measurement of blood pressure to a stressor used in the study only one blood pressure measurement was used instead of taking an average. Their review of literature was very weak; more sources would have added more support to their theory. There is also no conclusive details on the nature of the association of stress to blood pressure found during the study and there is a need for more research. For our purposes, we used to show that yet there is no understanding and great data to represent a direct relationship of stress to hypertension; we learn again that stressors do increase blood pressure measurements done on a wide, multiple range of individuals. Mayo Clinic Staff at the Mayo Foundation for Medical Education and Research (MFMER). (2010, August 5). Stress and high blood pressure: What's the connection? Retrieved from http://www.mayoclinic.com/health/stress-and-high-blood-pressure/HI00092 Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to provide the best patient care by using information from research to educate and practice. They receive funding and do their own research using their patient population and their clinical staff. There may be slight bias in their studies; however, they base their outcomes on patients are first. For the particular data provided for this information was a website based on seven references, one of which was the AHA and citation within the last six years. For our purposes, they provided studies that aided in our understanding about stress and high blood pressure.
  • Slide 37
  • Mayo Clinic Staff at Mayo Foundation for Medical Education and Research (MFMER). (2010, December 8). Exercise: When to check with your doctor first. Retrieved from http://www.mayoclinic.com/health/exercise/SM00059 Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to provide the best patient care by using information from research to educate and practice. They receive funding and do their own research using their patient population and their clinical staff. There may be slight bias in their studies; however, they base their outcomes on patients are first. For the particular data provided for this information was a web site based on three references, two which are reputable sources (CDC and ACMS) within the last two years. However, one reference used was a expert opinion from someone in the clinical staff. For our purposes, this information aided us in developing information to give to patients so they know when they should consult with their provider before exercising. As providers and gave us information on which patient population we should evaluate before allowing them to do exercising. Mayo Clinic. (2007). Fitness: Tool: Target heart rate calculator. Retrieved from http://ww.mayoclinic.com/health/target-heart-rate/SM00083 Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to provide the best patient care by using information from research to educate and practice. They receive funding and do their own research using their patient population and their clinical staff. There may be slight bias in their studies; however, they base their outcomes on patients are first. For the particular website it is simply a tool providers or patients can use to calculate target heart rates in a simple, easy way. This tool is based on the CDC and adapted by MFMER in 2007. CDC is a reliable source that the MFMER recognizes as giving factual information and created this tool based on their standardization of care for patients. Michigan Quality Improvement Consortium. (2004). Communication Guidelines to Promote Behavior Change. Retrieved from http://www.mqic.org/pdf/Communication_Guidelines_to_Promote_Health_Behavior_Change_176076_7.pdf The Michigan Quality Improvement Consortium is a resource for clinical practice guidelines based on current research evidence. This communication guideline is pertinent to Walter and Audrey's cases because it underscores motivational interviewing and patient centered behavior change which we implemented to effect behavior change in Audrey and Walter.
  • Slide 38
  • Mortensen, A.M. (2011, July 22). Desk Exercises for Stress Relief and Health. Livestrong.com. Retrieved from http://www.livestrong.com/article/499013-desk-exercises-for-stress-relief-and-health/. Livestrong is the website that Lance Armstrong is a founder. They claim to post only information that is expert based and reviewed. This particular article is from 2011 and was reviewed at that time. LiveStrong used other sources and allowed experts to write articles that are then reviewed by peers increasing the level of confidence in the information found on this site. This website gave a lot of information for those with busy work schedules. Using more than one of them was to strengthen each other, providing the same information from two different authors and two different reviewers. As mentioned, with Audrey we face the issue of her being a busy mom. This particular article referenced three other sites and how they can find a way to fit exercise in their busy schedule even at the office desk. Mosca, L., Appel, L.J., Benjamin, E. J., Berra, K., Chandra-Strobos, N., Fabunmi, R.P., Grady, D. (2004). Evidence based guidelines for cardiovascular disease prevention in women. Journal of the American College of Cardiology, 43, 900-921. National Center for Health Statistics. Center for Disease Control and Prevention. (2011). NHANES Survey 2009-2010. National Health and Nutrition Examination Survey. Retrieved from http://www.cdc.gov/nchs/nhanes/nhanes2009-2010/nhanes09_10.htm This journal article articulates a data analysis of the Centers for Disease Control and Prevention 2009 survey National Health and Nutrition Examination Survey provided by the CDC National Center for Health Statistics. The National Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and physical examinations (CDC, 2012). The data analysis revealed a correlation of low HDL cholesterol levels and major depression in women, and illustrated a correlation of high LDL cholesterol levels and major depression in men. National Institutes of Health. (2011, August). Relaxation Techniques for Health: An Introduction. National Center for Complementary and Alternative Medicine. Retrieved from http://nccam.nih.gov/health/stress/relaxation.htm The National Institutes of Health is a part of the US Department of Health and Human Services. This is our nations agency for research in the medical field. The website gives links to its research and development and sets standards based on congressional decisions and policy. For these reasons, the NIH is a very renowned website and highly trustworthy to all of those involved in the medical world. It is also the largest fund providing agency to research and development leading to state of the art and the most up to date research projects. For our purposes this site gave us the opposite response to the flight or fight, which as we learned is how the body relaxes and decrease blood pressure and decreases the release of hormones that affect glucose levels in our body.
  • Slide 39
  • National Institute of Neurological Disorders and Stroke. (2012). Cerebral Palsy: Hope Through Research. Retrieved from: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#211453104 National Institute of Neurological Disorders and Stroke (NINDS) is a subset of the National Institutes of Health. NINDS aims to to reduce the burden of neurological disease. NINDS dedicates a Disorders page to CP. The webpage offers background information about the disease, as well as risk factors, treatment options, management, and research. The information on the NINDS website was used to generate nursing diagnoses for Walter and to supply general information about the treatment for adults with CP. Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W., Rossi, S. (1994). Stages of change and decisional balance for 12 problem behavior. Health Psychology, 13(1), 39-46. This article was used for further exploration in the Transtheoretical Model of Change in order to write the script for Walters Motivational Interview and Stages of Change video. Richardson, K. M., Rothstein, H. R. (2008). Effects of Occupational Stress Management Intervention Programs: A Meta-Analysis. Journal of Occupational Health Psychology, 13 (1), 69-93. A meta-analysis exploring the effectiveness of occupational stress management interventions represented 55 types of interventions and included 2,847 studies. The studies were then coded as cognitive behavioral, relaxation, organizational, multimodal, and alternative. Psychological outcomes were measure in most studies, versus physiological outcomes. The most commonly used intervention was relaxation technique. The authors used a selection process for inclusion of studies, requiring randomization of subjects, as control group, employed subjects, studies published in English after 1975, and exclusion of subjects diagnosed with major psychiatric disorders. Most interventions ranged from 8-12 weeks, and many were self-taught via audio tapes. Cognitive-behavioral interventions had the greatest outcomes, while relaxation was the most utilized intervention. Its worth noting that combining many stress reducing techniques in an intervention will reduce positive outcomes. Research indicated that two techniques per intervention produce the best outcomes. Understanding the effectiveness of occupational stress management will enable the provider to create an evidence-based intervention, like to improve patient outcomes.
  • Slide 40
  • Rimmer, J.H. (2012). Resistance Training for Persons with Physical Disabilities. National Center on Health, Physical Activity, and Disability. Retrieved from http://www.ncpad.org/94/699/Resistance~Training~for~Persons~with~Physical~Disabilities The National Center on Health, Physical Activity, and Disability is known for thirteen years of work with disabled clients keeping them on track with health and fitness. Dr. J.H. Rimmer is 25 year veteran working on health promotions with those who are disabled. He is well-known in his field through publishing in many resources and his position in two federal organizations. Due to his long time in the field of study and peer-reviewed publications this document has some validity to it. He is the only author and there are no statements of when or if reviewed so there could be some biasness from him. From the details; however, the description and the knowledge used gives confidence that the article holds truth. Walter has CP and due to this he has found it difficult to stay in shape, so this article gives insight to things specifically for CP clients. Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E.J., Berry, J. D., Borden, W.B., Turner, M. B. (2012). Heart disease and stroke statistics-2012 update: a report from the american heart association. Circulation, 125, 2-220. doi: 10.1161/CIR.0b013e31825e7519 This report gives current and thorough statistical information for individual prevalence of hypertension, coronary artery disease, heart failure, and other cardiovascular diseases in each state as well as the United States as a whole. The report also provides mortality and morbidity rates for the United States. The document provides information on risk assessment as well as nutritional data in regard to cardiovascular diseases providing a complete resource of information for a provider or researcher. Sandmaier, M. (2005 December). Your guide to a healthy heart. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, National Institutes of Health. National Heart, Lung, and Blood Institute, NIH Publication No. 06-5269. Retrieved from http://www.nhlbi.nih.gov/health/public/heart/other/your_guide/healthyheart.pdf The National Institutes of Health is a part of the US Department of Health and Human Services. This is our nations agency for research in the medical field. The website gives links to its research and development and sets standards based on congressional decisions and policy. For these reasons, the NIH is a very renowned website and highly trustworthy to all of those involved in the medical world. It is also the largest fund providing agency to research and development leading to state of the art and the most up to date research projects. For our purposes this site has lead us to the discovery of many articles to provide us with information on stress, hypertension and diabetes. Along with that, the site gives us insight of future research.
  • Slide 41
  • Shelby, J., McCance, K.L. (2004). Understanding Pathophysiology. S.E. Huether, K.L. McCance (Eds.). St. Louis, Missouri: Mosby. This is a text book from undergraduate nursing studies. The text book is about the pathophysiology of the human body. In this particular chapter the author is describing what stress is, how your body reacts to stress, the benefits and risk and how this relates to disease. The reference was very useful to aide in describing stress in relation to why it affects the body and understanding how it may lead to hypertension and diabetes. The information is highly reliable because it purpose is to provide facts so that health care professional will understand the pathophysiology of the human body. Due to its being a text book, the information is reliable and bias is minimal to obsolete. This text book helped us be able to understand and explain how stress is related to increase blood pressure and increase glucose levels. Being able to explain this will help support our other resources in describing the link of stress to hypertension and diabetes. Slaman, J., Roebroeck, M., van Meeteren, J., van der Slot, W., Reinders-Messelink, H., Lindeman, E., van den Berg-Emons, R. (2010). Learn 2 Move 16-24: effectiveness of an intervention to stimulate physical activity and improve physical fitness of adolescents and young adults with spastic cerebral palsy: a randomized controlled trial. BMC Pediatrics, 10(79), 1-8. This article described a randomized, controlled study, designed to evaluate the effectiveness of intervention to increase physical activity and improve fitness in adolescents and young adults with spastic CP. While the results of this trial have not yet been published, the article offered explanation and research detailing the reason for methods used and design of the interventions to stimulate physical activity and fitness in people with CP. Tedders, S. H., Fokong, K. D., McKenzie, L. E., Wesley, C., Yu, L.,Zhang, L. (2011). Low cholesterol is associated with depression among US household population. Journal ofAffective Disorders, 135, 115-121.doi:10.1016/j.jad.2011.06.045 This study compares HDL and LDL levels among men and women with the propensity toward major depressive disorder. The findings illustrate clinically significant differences between men and women. Thorpe, D. (2009). The role of fitness in health and disease: status of adults with cerebral palsy. Developmental Medicine and Child Neurology, 51(4), 52-58.doi: 10.1111/j.1469-8749.2009.03433.x This article reviewed quantitative research on physical activity and fitness and its relationship to health in adults with CP. The author identified a need for greater research on this topic and aimed the article at presenting possibilities for future research. United States Department of Health and Human Services. (2012). Healthy People 2020 Topics and Objectives: Heart Disease and Stroke Washington, D.C. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=21 This is a comprehensive report on the objectives and goals of the Department of Health and Human Services as they pertain to the cardiovascular health of the American population. The report is based on extensive health statistics describing the current state of health of the American people and provides measurable goals for which to strive. The report also outlines means to obtain these goals, including tips on behavior modification and methods for patient motivation.
  • Slide 42
  • United States Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute. (2002). Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III), final report (NIH Publication No. 02-5215). Retrieved fromhttp://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf This report is the result of the NCEP panels expert research on the management of dyslipidemia. It gives a basic description of lipids and primary targets of LDL, HDL, and total cholesterol management. It presents methods of assessing and predicting an individuals risk of adverse cardiovascular events based on current disease states and the presence of certain risk factors. The report also outlines guidelines for detection and evaluation of dyslipidemia and, finally, guidelines for treating dyslipidemia through both therapeutic lifestyle changes and drug therapy. United States Department of Health and Human Services, National Diabetes Education Program: A joint program of the National Institute of Health and the Center for Disease Control and Prevention. (2003). Small steps big rewards prevent type 2 diabetes. NIH Publication No. 03-5334 Retrieved from http://www.ndep.nih.gov This program designed to help health care providers and with the collaboration of the patients with the key components of and effective diabetes prevention regimen in the GAME plan: Goals, Accountability, Monitoring, and Effectiveness. This prevention is obtained through a lifestyle of activity and nutrition. van der Slot, W., Nieuwenhuijsen, C., van den Berg-Emons, R., Bergen, M., Hilberink, S., Stam, H., Roebroeck, M. (2012). Chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy. Developmental Medicine and Child Neurology, 54, 836-842. doi: 10.1111/j.1469-8749.2012.04371.x This article describes a study aiming to examine the co-occurrence of chronic pain, fatigue and depression in adults with spastic CP. Adults with CP were interviewed and self-report instruments were used for data collection and quantification of symptoms. This article clarified the link between pain, fatigue, and depression, and pointed towards the needs of adults with CP in addressing these issues. The article also addressed a gap in the literature regarding the clinical effects of these symptoms and identified a need for preventative measures and interventions. Wang, D. (2011, May 26). ROM Exercises for the Wheelchair Bound. Livestrong.com. Retrieved from http://www.livestrong.com/article/338602-rom-exercises-for-the-wheelchair-bound LiveStrong is the website that Lance Armstrong is a founder. They claim to post only information that is expert based and reviewed. This particular article is from 2011 and was reviewed at that time. This website offered the most informative information for helping a patient in a wheelchair exercise. Again, this is focused for Walter, having CP and being confined to a wheelchair is his excuse for not being physical. However, this website seemed to relate very well to clients who are wheelchair-bound and sensitive to their needs. Dr. Rimmers article gave a general idea about how people with CP could exercise but lacked specific exercise. Needing an exercise plan for Walter, I referred to LiveStrong for assistance with some good examples of exercise he can begin using daily.

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