Home Care Chronic Disease Prevention Program

1. Home Care Chronic DiseasePrevention Program Melanie S. Bunn RN,MS A collaboration of Duke University, Division of Community Health and University of South Carolina, School of Medicine

2. Homework review • What did you do? • What happened as you did that? • Why do you think that happened? • Here’s what might have happened. • How does this impact the next time you try this?

3. Chronic Disease Management Module 1:Health/Illness, Vital Signs, Exercise, Nutrition Module 2: Motivational Interviewing Module 3: End of Life Module 4: Heart Attack Module 5: COPD Module 6: Stroke Module 7: Hypertension Module 8: Diabetes Module 9: Congestive Heart Failure

4. Module: 7Hypertension

5. Objectives Define HTN and its impact on health Describe healthy lifestyle choices for the person with HTN Demonstrate use of motivational interviewing with the person with HTN

6. Hypertension • Also known as high blood pressure • Sometimes called “high blood” • Abbreviated “HTN” • About one in three older Americans have high blood pressure

7. What is blood pressure? • Blood is pumped from the heart to all parts of the body via arteries • The blood pressure is the force of the blood pumped against the arteries • The BP reading is represented as two numbers • The systolic pressure is the pressure when the heart pumps (top number) • The diastolic pressure is the pressure when the heart rests (bottom number)

8. Blood pressure • Blood pressure changes during the day • It can rise with stress and emotion • It is typically lowest during sleep

9. What is normal? • Blood pressure is always reported as a systolic and a diastolic number and both are important • Below 120/80 is normal • Pre-hypertension is 120-139/ 80-89 • Stage one : 140-159/ 90-99 • Stage two: greater than 160/100

10. How is it measured? • Sphygmomanometer • Do not drink coffee or smoke cigarettes 30 minutes before • Sit for 5-15 minutes before the test • Sit with back supported and feet flat • Arm should be at the level of the heart • The right size cuff must be used

11. EtiologyWhat causes it? • Majority of cases are essential (unknown etiology) • Some cases are due to other causes • Medications • Drugs • Primary kidney disease • Tumors

12. Who is at risk? • African Americans • Persons who are overweight • Persons who smoke • Persons who have a family history of high blood pressure • Men

13. Signs and symptoms • Often, NONE!!! • Typically silent, no symptoms • Headache, blurred vision, chest pain, shortness of breath, kidney damage

14. Complications • Heart can get larger from the work overload leading to heart failure • Blood vessels in the kidney narrow leading to kidney failure • Arteries throughout the body narrow leading to heart attacks, strokes, amputations • Bulges can form in blood vessels (aneurysm) and they can burst (hemorrhage)

15. Prevention • Healthy weight • Exercise • DASH diet • Quit smoking • Limit alcohol • Limit sodium

16. Treatment • Medications • Healthy diet • Exercise and weight loss • Quit smoking • Limit alcohol intake

17. Medications • Diuretics (“water pills”)- decrease the excess salt and water in the body to decrease the blood pressure • Beta blockers- cause the heart to beat slower and decreases the pressure • Ace inhibitors- decrease the level of an enzyme that narrows blood vessels • Calcium channel blockers- relaxes blood vessels

18. DASH diet • Diet low in saturated fat, cholesterol, total fat, red meat and sugared beverages • Diet high in fruits, vegetables, low fat dairy, whole grain, fish, poultry, and nuts • Lowers cholesterol

19. Food groups • 2,000 kcal diet • 7-8 servings of grains and grain products • 4-5 servings of vegetables • 4-5 servings of fruits • 2-3 servings of low fat dairy • 2 or less (3 ounces cooked) of meat, poultry, or fish • 1 serving of nuts/seeds • 2-3 servings of fats, oils

20. Sodium • Less than 2,400 mg • One teaspoon • Processed foods are high in salt • Rinse canned foods

21. Living with HTN • Keep track of measurements • Take medications as prescribed by your doctor • Report symptoms and side effects of medications • Chose healthier lifestyle choices • Women and HTN • Pregnancy • Oral contraceptives • Post menopausal hormone therapy

22. Warning symptoms • Shortness of breath • Chest pain • Headache • Visual changes

23. Warning signs *ALL vital parameters are determined by RN supervisor and are patient specific • Decreased blood pressure (less than 90/60) • Increased blood pressure ( greater than 160/100) • Increased pulse (greater than 100) • Decreased pulse (less than 60) • Other warnings: not taking medications

24. Case study • 69 year old female with hypertension • Tells you that her blood pressure is poorly controlled but that she feels fine • She goes on to tell you that she rarely takes her medications because she feels so good • What worries you about her behavior? • What are possible complications of her hypertension?

25. Case study • Her blood pressures usually run • Systolic 160-170 • Diastolic 96-118 • What is her stage of hypertension? • Stage I 140-159/ 90-99 • Stage II 160+/ 100 +

26. Case study • What worries you about her behavior? • What are possible complications if she doesn’t better manage her hypertension?

27. Case study • What worries you about her behavior? • She does not take her medications • She is not worried about the effects of hypertension • What are possible complications of hypertension? • Heart failure • Kidney failure • Stroke, heart attack • Blood vessels bulge and burst

28. Motivational interviewing • What could you do to assist her with her medication compliance? • Now that you’ve gained her trust you can start asking questions that will begin the change talk.

29. Starting the Change Talk • What questions can we ask that could start her thinking about taking her medications? • Tell me about your medications. • What do you think about not taking your medications?

30. WILLING, ABLE, READY • In the next few slides, put yourself in this client’s shoes. Try to write down answers to the questions from her point of view.

31. Find Out How WILLING She is to Change • Ask open ended questions so she can: • State her reasons for not taking her meds properly • State the reasons she has for taking her meds properly • Have her write down her answers to these questions in the next several slides

32. What are Her Reasons for Not Taking Her Meds? – 2 Good Questions to Ask

33. Here are Some Sample Reasons for Not Taking Meds

34. Explore Her Reasons Fully • Ask her how not taking her meds affects all the various aspects of her life: • Health • Lifestyle • Emotions • Relationships • Coping abilities (stress, for example) • Work • Social life • Spiritual life

35. Next, What Reasons Does She Have for Taking Her Meds?

36. Here are Some Sample Reasons for Exercising

37. Explore Her Reasons Fully • Ask her how taking her meds could affect all the various aspects of her life: • Health • Lifestyle • Emotions • Relationships • Coping abilities (stress, for example) • Work • Social life • Spiritual life

38. Next, How Important is It for Her to Change? • Ask her to compare her reasons for not changing with her reasons for changing • Have her assign a number to the Ruler of Change in the next slide. • This will show how important it is for her to change

39. How Important is It for You to Change? • On a scale of 0 to 10, how important is it to you to take your medications? The “Ruler of Change”

40. WILLING • This number on the Ruler of Change will show how WILLING she is to change • It will show how willing she is to take her medications per the doctor’s instructions

41. Willing (continued) • If her Ruler of Change number is below 3 or 4: • She is not willing to consider change. • She has lots of resistance to change • Her reasons for not taking her meds are STONGER THAN her reasons for changing.

42. Sample Question to Help Decrease Resistance • What would have to change to decrease the importance you give for your reasons for not taking your meds?

43. Questions to Decrease Resistance • A low number on the ruler of change says she does not think that taking her medications is important and she does not want to change • But, look at her number on the Ruler of Change • If she’s not at zero, she must have at least a small interest in change.

44. Decreasing Resistance • If this is the case, Ask: • Why are you at ___ and not zero? • What would it take for you to go from__ to__ ? • Her answers might get her to start thinking that change might be a good thing

45. Willing (continued) • If the number the client gives for the importance of changing is around 5: • She is “on the fence.” • She is split between wanting to take action and not being able to take the first step. • In this condition, she can’t change.

46. Sample Question to Help Increase Motivation • What would have to change to increase the importance of the reasons you have for taking your meds?

47. Willing (continued) • If the number she gives for the importance of change is greater than 6 or 7: • She is not resistant to change • She is not “on the fence” • She is ready to take some action

48. Next, Find out if She is ABLE • Measure her Confidence and Ability to Take her meds properly • Use the Confidence and Ability “Rulers of Change”

49. Assessing Confidence and Ability to Make a Change • Score your confidence to take your meds properly. • Score your ability to take your meds properly. Handout

50. For Scores of About 6 and Below • Ask, “What would it take to increase your confidence to take your meds properly?” • What encourages you to believe that you can achieve your goals for change? • Ask, “What would it take to increase your ability to take your meds properly?”