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Hypertension among African-Americans
Nursing Process and Health Promotion of Groups and Community Theory
Hypertension is very rampant in African-Americans, and health providers link it with three major chronic diseases, which include; stroke, kidney and heart diseases. This paper examines the incidence of hypertension in African-Americans in the five subsystems of the SDS Assessment Categories. African-Americans suffer high risks of organ damage as well as stroke and heart diseases, caused by hypertension. Health providers, especially nurses, ought to be very practical in identifying hypertension in African-Americans and increase their aggressiveness in regulating and treating person(s). In addition, health providers should focus in providing health education in order to reduce and prevent mortality and morbidity rate in the African-Americans suffering from hypertension.
Hypertension is an example of a chronic disease that causes major health problems to numerous Americans and a key issue to almost every racial group residing in the United…
American Fact Finder, (2013). Retrieved March 2013. From U.S. Census. gov.
Blixen, C.E., Singh, A., & Thacker, H. (2006). Values and beliefs about obesity and weight reduction among African-Americans and Caucasian women. Journal of Transcultural
Nursing, 17(3), 290-297.
One of the major health problems that the American society and the whole world experience is the prevalence of hypertension or high- blood pressure- caused illnesses or deaths in many people today. A special report made by the website Lifeclinic.com stated that almost 50 million Americans have hypertension, "1 in every 4 adults" (2002). This statistic illustrates the increasing number of people who are gradually suffering and eventually dying due to hypertension. Hypertension, or high blood pressure, is defined to be the "condition which can result when the arterial diameter is reduced... And increased pressure caused by reduced diameter of the arteries plays a greater role in hypertension" (Varona 1999 46). To comprehend the concept of hypertension, a definition of blood pressure is needed. lood pressure is defined as "the pressure of the blood flowing through the blood vessels against the vessel walls." In effect, if a high blood…
Basic Facts about High Blood Pressure. Retrieved 28 October 2002, from Lifeclinic.com. Web site: http://www.lifeclinic.com/focus/blood/whatisit.asp
Laragh, John H. (1991). Hypertension. In World Book Encyclopedia (Vol. 9,-page 460). USA: World Book Inc.
McCann, Dervilla M. (2001). The History of Hypertension: Not a Modern Day Phenomenon. Retrieved 28 October 2002, from Dr. Donnica.com. Web site: http://www.drdonnica.com/guests/00002086.htm
Varona, Blecenda. (1999). Healing Wonders of Diet: Effective Guide to Diet Therapy. Manila: Philippine Publishing House.
M., 2009, p. 1474).
IMPACT on the FAMILY:
Although hypertension is one of the most prevalent of all disorders in the United States, it does not affect nor impact the family of a person with this disorder as much as other diseases, such as heart disease, stroke, Alzheimer's and other disorders associated with the central nervous system. Overall, hypertension does affect a person's family in one important way, being the build-up of stress within the family unit which then impacts the person with hypertension, making him/her more prone to a heart attack, a stroke or higher levels of blood pressure which can lead to an entire host of related life-threatening disorders.
For example, a family member with hypertension might be faced with a number of family-related problems which only increase the symptoms of the disorder, such as constant worry about a son's or daughter's conduct at school or their activities…
Appel, L.J. (2009). Another major role for dietary sodium reduction: Improving blood pressure control in patients with resistant hypertension. Hypertension, 54(3), 444-446.
Baggish, a.L., Weiner, R.B., et al. (2009). Impact of family hypertension history on exercise-induced cardiac remodeling. American Journal of Cardiology, 104(1), 101-106.
Chummun, H. (2009). Hypertension: A contemporary approach to nursing care. British Journal of Nursing, 18(13), 784-789.
Forman, J.P., Stampfer, M.J., et al. (2008). Diet and lifestyle risk factors associated with incident hypertension in women. Journal of the American Medical Association, 302(4), 401-411.
Other factors include a history of alcohol and tobacco use, and dietary assessment including saturated fat and caffeine. Also certain prescribed and over-the-counter medications, herbal remedies, and illicit drugs may be factors, as well as psychosocial and environmental factors such as family situation, employment status, working conditions, and educational levels (Guidelines).
Aside from routine physical examinations, laboratory tests, such as urinalysis, blood cell count and blood chemistry may be used in diagnostic procedure (Guidelines).
Hypertension may be treated with drugs including diuretics, such as thiazide derivatives; vasodilators, such as hydralazine and prazosin; sympathetic nervous system depressants, such as rauwolfia alkaloids; sympathetic nervous system inhibitors such as guanethidine and methyldopa and ganglionic blocking agents, such as clonidine and propranolol (Hypertension). Individuals with high blood pressure should exercise regularly, follow a low-sodium, low-saturated fat diet, avoid stress, get adequate rest, and lower calorie intake to control obesity (Hypertension).
Nutritional management of hypertension…
Gay, Christopher. "New developments in the management of hypertension."
American Family Physician. September 1, 2003. Retrieved November 16, 2006 from HighBeam Research Library.
Hypertension." The Mosby Medical Encyclopedia.1996. Retrieved November 16, 2006 from HighBeam Research Library.
Selected Guidelines: Featured CME Topic: Hypertension." Southern Medical Journal.
In this text, I concern myself with hypertension. In so doing, I will amongst other things discuss its causes and possible complications. Further, I will also highlight treatment and control options with a particular emphasis on lifestyle changes, exercises, etc.
Hypertension could either be secondary or essential (Toth and Cannon, 2010). Unlike secondary hypertension, essential hypertension has no clear or exact cause. For this reason, this category of hypertension is often associated with a sedentary lifestyle, stress, excessive intake of alcohol, smoking, etc. On the other hand, secondary hypertension according to Toth and Cannon (2010) results from an identifiable mechanism or cause, i.e. A specific disorder.
Underlying Diseases Which Could be Caused by Hypertension
According to the American College of Sports Medicine -- ACSM (2010), underlying diseases which could be caused by hypertension include but they are not limited to chronic kidney disease, heart failure, CVD, etc. Other…
American College of Sports Medicine. (2010). ACSM'S Guidelines for Exercises Testing and Prescription (8th ed.). New York: Lippincott Williams & Wilkins.
Dunford, (Ed.). (2006). Sports Nutrition: A Practice for Professionals (4th ed.). New York: American Dietetic Association.
Harvey, R.A. & Champe, P.C. (2009). Pharmacology (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Toth, P.P. & Cannon, C.P. (Eds.) (2010). Comprehensive Cardiovascular Medicine in the Primary Care Setting. New York: Springer.
Diabetes is a disease in which the body does not properly use or produce insulin. A hormone, insulin converts sugar, starches, and other food into energy needed for daily life. The exact cause of diabetes remains a mystery. Experts agree that both genetics and environmental factors such as obesity and lack of exercise appear to contribute to the disease.
Over 17 million people in the United States, or slightly more than 6% of the population, have diabetes. Although an estimated 11 million Americans have been diagnosed, 6 million people (or the equivalent of one-third with the disease) are unaware that they have diabetes.
There are three major types of diabetes. They are:
Type 1 diabetes - The condition results from the body's inability to produce insulin, the hormone that "unlocks" or "opens" the cells of the body, allowing glucose to enter and fuel them. etween 5-10% of Americans…
National Diabetes Fact Sheet Brochure, issued and published by the American Diabetes Association. Downloaded from www.ada.orgon April 11, 2003.
Fuller JH, Stevens LK, Wang SL. Epidemiology of Hypertension in Diabetic Patients. The WHO Multinational Study of Vascular Disease in Diabetic patients. Journal of Cardiovascular Pharmacology 1996; 28(Suppl.4): SI-S5.
American Diabetes Association: Standards of medical care for patients with diabetes mellitus. Diabetes Care 22(Suppl 1):S32-S41, 1999.
The Diabetes Control and Complications Trial Research Group: The Effect of Intensive Treatment of Diabetes on the Development and Progression of Long-Term Complications in Insulin-Dependent Diabetes Mellitus. N Eng J. Med 329:977-986, 1993.
Figure 2 lists a number of risk factors that a person may change to reduce his/her risk of developing hypertension and/or to lower his/her blood pressure.
Figure 2: isk Factors for Hypertension (adapted from izzo, Odle & Costello, 2006, isk Factors section, ¶ 1).
Sharp (2006), purports that the four goals of evaluation for hypertension include:
1. Identifying lifestyle factors that contribute to elevated blood pressure and increased risk for cardiovascular disease,
2. assessing linking modifiable cardiovascular risk factors,
3. assessing for target organ disease, and
4. determining whether a secondary root exists for the elevation of the person's blood pressure (Sharp, 2006).
The instrument for measuring blood pressure, a sphygmomanometer, consists of a cloth-covered rubber cuff, which is wrapped around the upper arm and inflated. izzo, Odle and Costello (2006) explain the process:
When the cuff is inflated, an artery in the arm is squeezed to momentarily…
Isabela. (2009). Magaly Rivera. Retrieved October 16, 2009 from http://welcome.topuertorico.org/city/isabela.shtml
Kassem, N. (2009). Medications for high blood pressure. Suite101.com. Retrieved October 16,
2009 from http://heartdiseasediabetes.suite101.com/article.cfm/medications_that_reduce_high_blo
HYPETENSION IN African-AmericanS
The questions regarding all aspects of life of African-Americans is a matter of curiosity and resultant scientific interest within the people of America, and there is a resultant interest in their health on that account. This is probably the major reason behind the study of hypertension among them, and the latest reasons that are shown may reflect some of the causes of this hypertension at the door of the other section of Americans.
There has been research conduced recently at Stanford University School of Medicine, Loyola University Medical Center and Washington University School of Medicine in St. Louis along with others, who conducted a study on hypertension among African-Americans. This was the first in its line application of a new statistical method of analysis and it has identified regions on chromosomes 6 and 21 in their DNA which are likely to contain genes that result in the…
Bakris, George L; Ferdinand, Keith C; Douglas, Janice G; Sowers, James R. (October, 2002)
'Optimal treatment of hypertension in African-Americans" Postgraduate Medicine. Vol: 112; No: 4. Retrieved from http://www.postgradmed.com/issues/2002/10_02/bakris3.htm Accessed 7 November, 2005
Douglas, Janice G; Ferdinand, Keith C; Bakris, George L; Sowers, James R. (October, 2002)
'Barriers to blood pressure control in African-Americans" Postgraduate Medicine. Vol: 112; No: 4. Retrieved from http://www.postgradmed.com/issues/2002/10_02/douglas2.htm
Losing weight not only reduces the likelihood of complications due to high blood pressure; losing weight usually entails dietary changes that will also reduce hypertension. For example, eating fewer processed foods will both help a person lose weight and reduce sodium intake. Eating plenty of fruits and vegetables and no trans-fats ensures good overall health. Therefore, the first step towards reducing high blood pressure is learning how to identify foods that are healthy. eading product labels is one way to keep track of sodium intake. In general, persons with high blood pressure should avoid all processed and fast foods, which contain exorbitant amounts of salt.
In addition to paying attention to their sodium intake, individuals with high blood pressure or who are prone to it need to pay attention to their calcium intake. Low calcium intake is linked to high blood pressure (Anderson et al. 2008). Therefore, persons with high…
Anderson, J., Young, L. & Long, E. (2008). Diet and hypertension. Colorado State University. Retrieved online: http://www.ext.colostate.edu/pubs/foodnut/09318.html
MayoClinic (2010). High blood pressure (hypertension). Retrieved online: http://www.mayoclinic.com/health/high-blood-pressure/DS00100/DSECTION=lifestyle%2Dand%2Dhome%2Dremedies
Zieve, D. & Eltz, D.R. (2011). Hypertension. PubMed. Retrieved online: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/
This is closely related to atherosclerosis, as mentioned above. A plaque or rupture in a coronary vessel results in a significant reduction of blood supply to a critical portion of the myocardium.
Although not causing the condition directly, essential hypertension could be a significant contributing factor to the condition. Hypertension in such patients is also associated with elevated catecholamine levels, which in turn are caused by anxiety, pain, or other medical factors.
In addition to treatments for essential hypertension, Garas (2010) suggests that the condition can be treated by means of restoring the myocardial perfusion either by medical means or by surgery. Surgery might be administered either by percutaneous coronary intervention or coronary artery bypass grafting. Other suggested treatments include the restoration of balance between oxygen supply and demand to the myocardium; pain relief, or prevention and treatment measures for complications. Survival rates are reported to increase with Thrombolytic therapy,…
Alexander, R.W. (1995). Hypertension and the Pathogenesis of Atherosclerosis. Hypertension. Vol. 25. Retrieved from http://hyper.ahajournals.org/cgi/content/full/25/2/155#SEC6
Carretero, O.A. And Oparil, S. (2000). Essential Hypertension. Circulation. Retrieved from http://circ.ahajournals.org/cgi/content/full/circulationaha;101/3/329
Fenton, D.E. (2010, May 18). Myocardial Infarction. Emedicine. Retrieved from http://emedicine.medscape.com/article/759321-overview
Garas, S. (2010, Jan 22). Myocardial Infarction: Treatment & Medication. Emedicine. http://emedicine.medscape.com/article/155919-treatment
Cardiovascular System Disorder Case Study
System Disorder Case Study
Hypertension is a primary cause of cardiovascular diseases. Causes of hypertension are largely unknown or disputable. The application of other molecular biologic tools is likely to serve through better delineation of the basic mechanisms of primary hypertension. Other secondary causes account for 10% of hypertension. The ingredients include renal disorders like renin-producing tumors, renal renovascular disease, sodium retention, and primary parenchymal disease. Endocrinologic disturbances resulting in hypertension are inclusive of exogenous hormones, carcinoid, adrenal disorders, and thyroid disease (Lilly, 2012). Other causes include aortic coarctation, pregnancy complications (pre-eclampsia), acute stress, neurologic causes, alcohol ingestion, increased intravascular volume, nicotine use, and the drug use such as tacrolimus or cyclosporine.
The lymphatic and cardiovascular systems' diseases affect various systems due to their infectious agents that are easily disseminated by lymph and blood. Although blood remains sterile, moderate numbers of microorganisms are not harmful…
Labarthe, D. (2011). Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge. New York: Jones & Bartlett Learning.
Lilly, L.S. (2012). Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. New York: Elsevier Health Sciences.
Montezano, A.C. & Touyz, R.M. (2012). Reactive Oxygen Species and the Cardiovascular System. New York: Morgan & Claypool Publishers.
Vlodaver, Z., Wilson, R.F. & Garry, D.J. (2012). Coronary Heart Disease: Clinical, Pathological, Imaging, and Molecular Profiles. New York: Springer Science & Business Media.
Hypertension is defined as systolic BP of at least 140 mm HG and diastolic BP of at least 90 mm Hg, self-reported use of antihypertensive medications, or both. (Ostchega, 2005-2006)
Hypertension, according to the joint national committee 6 and 7, is classified into the following stages:
Classification of Blood Pressure for Adults Aged ? 18 Years: JNC 7 versus JNC
JNC 7 Blood
JNC 6 Blood
SBP (mm Hg)
DBP (mm Hg)
(Linda Brookes, Msc, 2003)
Hypertension is a progressive and multi-factorial disease, increasing in incidence with age, affecting twenty five percent of the population in the United States, with a predisposition amongst the African-American population.
Based on etiology, it is divided into idiopathic (or essential), occurring ninety five percent of the time,…
Ostchega, Y; Yoon, S.S; Hughes, J; Tatiana, L (2005-2006).Hypertension Awareness, Treatment, and Control -- Continued Disparities in Adults: United States. Retrieved from: http://www.cdc.gov/nchs/data/databriefs/db03.pdf
Linda Brookes, MSc. New Classification of Hypertension -- Introducing Pre-hypertension (2003): retrieved from: http://www.medscape.com/viewarticle/455849_2
Kumar Abbas, Fausto Mitchel. Robbins Basic Pathology (2007).India: Elsevier.
Healthy people website.Healthy people objective Development (2020).Retrieved from: http://www.healthypeople.gov/2020/about/objectiveDevelopment.aspx .
Hypertension, or elevated blood pressure, is the excessive amount of pressure generated as a result of blood flowing against the arterial wall. High blood pressure can be created when there is a great volume of blood passing through the arteries, or when there is narrowing of the arterial lumen, or both. A common analogy is that of a garden hose: when there is more water passing through the hose or when the nozzle is tightened, high hose pressure is generated. This is similar to what goes on in our blood vessels. (Wood Stephen, M.D, 1997)
When the systolic blood pressure (pressure with which the heart beats, while pumping) is 140 or greater, and the diastolic blood pressure (pressure when the heart is at rest, between beats) is 90 or greater, the person is said to be hypertensive. (National Heart Lung and Blood Institute)
There are various determinants of hypertension although…
Wood Stephen, M.D, Griffith Bert, P.A. Conquering High Blood Pressure (1997). Cambridge, MA: Perseus Publishing.
National Heart Lung and Blood Institute. High Blood Pressure: What Is High Blood Presssure (April, 2011). Retrieved from: http://www.nhlbi.nih.gov /health/dci/Diseases/Hbp/HBP_WhatIs.html.
CDC. High Blood Pressure. Retrieved from: http://www.cdc.gov/bloodpressure/sodium.htm .
National Heart Lung and Blood Institute. High Blood Pressure: What Are the Signs and Symptoms of High Blood Pressure (April, 2011). Retrieved from:
Hypertension / High Blood Pressure
hat are the symptoms of hypertension and what are the reasons that people get hypertension? hat ethnicities are most prone to hypertension? The answer is that African-Americans are most prone to hypertension -- in particular male African-Americans over the age of 60. hat is the best treatment for hypertension for those older African-American males? This paper discusses these issues using available literature.
Hypertension is a problem with people worldwide and is found in all populations "except some primitive communities that live in cultural isolation" (Nadar, 2015). Hypertension is caused by "abnormally elevated blood pressures" and is often called the "silent killer" because people don't always know they have hypertension, Nadar writes on page 3 of his book. About 6% of adult deaths in the whole world result from hypertension, and the first signs of hypertension often are diagnosed when a person suffers a "myocardial…
Flack, J.M., Nasser, S.A., and Levy, P.D. (2011). Therapy of Hypertension in African
Americans. American Journal of Cardiovascular Drugs, 11(2), 83-92.
Gulledge, J., and Beard, S. (1999). Hypertension Management: Clinical Pathways,
Guidelines, and Patient Education. Burlington, MA: Jones & Bartlett Learning.
Based on Mike's history and exam, what tests would you consider and why?
His doctor orders a straightforward metabolic panel. On top of that other things to be utilized are the electrocardiogram (EKG) in order to check the heart, along with a measurement of hemoglobin A1C (A1C). this is important because if a hemoglobin test exposes that your hemoglobin level is lesser than normal, it means that Mike may have a low red blood cell count (anemia). Furthermore, there needs to a urinalysis, urine protein / creatinine ratio, aldosterone, and a lipid panel.
What are the different types of hypertension and its pathophysiology.
The pathogenesis of essential hypertension is multifactorial and highly complex (Tong, 2015). Multiple factors moderate the blood pressure (BP) for suitable tissue perfusion and consist of humoral mediators, vascular reactivity, vascular caliber, mingling blood volume, blood vessel elasticity blood viscosity, cardiac output, and neural inspiration (King,…
King, C. (2015). Hypertension. Journal of the American College of Cardiology, 13(9), 3-27.
Tong, X. (2015). Hypertension Screening in Children and Adolescents -- National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and Medical Expenditure Panel Survey, United States, 2007-2010. CDC, 23(12).
Treatment of hypertension and the price to pay; adverse events and discontinuation from randomized treatment in clinical trials. (2016). Journal of Hypertension:, 34, 1489-1491.
Diabetes, Hypertension and Obesity
Diabetes Hypertension and Obesity:
Causes and Management
Diabetes Hypertension and Obesity: Causes and Management
The world as we know it today is a fast world and people are continuously adapting to the fast way in which things are done. In the process of doing this, the lifestyle and habits of many a people have greatly changed. This in turn has seen an upsurge in the occurrence of some specific types of diseases like diabetes, hypertension and obesity. Some of the causes of these diseases are quite obvious but others are vague therefore this paper will investigate the causes of these illnesses. As we will find out, some of these diseases are interrelated.
Obesity is defined better by the world health organization (2000) as the condition in which excess body fat affects the body. This means that the body fat has risen to a level more than…
Ann (2008, June 3). Screening for type 2 diabetes mellitus in adults. U.S. Preventive Services Task Force recommendation statement. Pub Med. pp. 846-54.
Benson, Herbert. (1975). The Relaxation Response, New York: Morrow
Dodt C., Wellhoner J.P., Schutt, M. & Sayk, F. (2009, January) Glucocorticoids and hypertension" Der Internist 50 (1): 36 -- 41.
Sjostrom L, Narbro K, Sjostrom CD, et al. (2007, August). Effects of bariatric surgery on mortality in Swedish obese subjects. N. Engl. J. Med., pp. 741 -- 52.
Obviously, the articles were created for different audiences, and for different purposes. The Ebony article assumes the reader has a basic knowledge of hypertension, while the AAFP article understands the physician has the knowledge, which is why it goes into much greater detail to help the healthcare professional solve problems. It does not need to educate, it needs to create solutions to problems physicians face every day.
Finally, both these articles are quite useful to the people they were geared to help. The AAFP article is quite helpful for anyone in the healthcare profession, and gives concrete information the physician, nurse, and clinician can use in their day-to-day interaction with patients, especially if they serve a large portion of the black community. While the information is geared to the black community, there are similarities in the disease in anyone who suffers from hypertension, and so the information applies to just…
Hall, W. Dallas, M.D. (July 1999). A Rational Approach to the Treatment of Hypertension in Special Populations. Retrieved from the American Academy of Family Physicians Web site: http://www.aafp.org/afp/990700ap/156.html1 June 2005.
Hypertension. (2003, July). Ebony, 58, 64.
Some of the drugs used
to treat hypertension include diuretics, vasodilators, certain depressants,
SNS inhibitors and specific blocking agents.
The prevention of hypertension includes many different methods, but
the most common are linked to changes in a person's lifestyle. These
include weight loss if a person is overweight or obese, regular exercise,
eating a healthy diet low in fat and sodium and high in fruits, vegetables
and fiber, avoiding smoking, and most importantly, controlling diabetes by
keeping one's blood sugar levels under strict control ("Hypertension: lood
Pressure asics," Internet). Of course, a person with hypertension should
always consult a physician before attempting to control or alter this
serious disorder which affects millions of Americans often without any kind
Cunha, John P. "High lood Pressure." Medicinenet.com. Internet. 2007.
"Hypertension." MedlinePlus. Internet. 2007. Retrieved from
"Hypertension: lood Pressure asics." WebMD. Internet. 2007. Retrieved
Cunha, John P. "High Blood Pressure." Medicinenet.com. Internet. 2007.
"Hypertension." MedlinePlus. Internet. 2007. Retrieved from
hen this takes place the cause is believed to be a vasculature that is abnormally remodeled and that develops incorrectly in utero, generally in response to pulmonary hypertension, hypoxia, or prolonged fetal stress. In these cases peripheral and excessive muscularization of many of the pulmonary arterioles is often seen. PPHN has also been commonly associated with hypoplasia of the lungs, which is seen generally in congenital diaphragmatic hernias. The underlying causes of this are quite different structurally and generally functional differences are also seen. These differences are generally witnessed in response to the inhalation of nitric oxide or other vasodilators. Learning more about the biological alterations that take place with PPHN is very important in expanding the options that are available to newborns therapeutically (neonatal.peds.washington.edu, 2000).
As for treatment for PPHN, there are several different treatments that are available and that are seen in clinical consensus and relevant literature from…
Works Cited neonatal.peds.washington.edu. (2000). Retrieved 8 February 2005 at http://neonatal.peds.washington.edu/NICU-WEB/pphn.stm.
A www.emedicine.com.(2004). Pulmonary Hypertension, Persistent-Newborn. Retrieved 8 February 2005 at http://www.emedicine.com/ped/topic2530.htm .
In the case of hypertension, the degree of hypertension will be placed into relevant categories. Stress levels will be divided into high stress and low stress.
Operationalization of Variables: The two key variables in this study will require different methods of measurement. Hypertension will be assessed through measurement with a blood pressure cuff by doctor's office personnel trained to do so. Stress will be measured through a scale developed by the researcher. There are a number of scales found, but many of them focused on life changes or acute stress. None were found that focused on chronic stress. The scale will be devised so that Likert-type answers can be added together to develop a "stress number." This number will be used to assign a numerical value to the person's stress level.
Qualitative esearch: This will be strictly a quantitative study.
eliability and validity: Measurement of hypertension is a standard medical…
Dobrian, a., Schriber, S., Khraibi, a., & Prewitt, R. (2004). Pioglitazone Prevents Hypertension and Reduces Oxidative Stress in Diet-Induced Obesity. Hypertension. 43: 48.
Grossman, E. (2008). Does Increased Oxidative Stress Cause Hypertension?
Diabetes Care, February 1, 2008; 31(Supplement_2): S185 - S189.
Guyton & Hall, (2005). Textbook of Medical Physiology (7th Ed. ed.). Elsevier-Saunders. Retrieved March 27, 2009 at http://www.mfi.ku.dk/ppaulev/chapter8/Chapter8.htm
Hypertension is the chronic elevation of blood pressure that can lead to organ failure and even mortality. Cardiac output creates blood pressure but in patients with hypertension, cardiac output is increased. The autonomic nervous system helps to regulate blood pressure but in patients with hypertension, no repinephrine is existent and stress is felt especially acutely.
Phenotype and Genotype
It is unknown what genes cause hypertension. Moreover, as Korner (2010) points out, “their identification is unlikely to be realized with current genetic approaches, because of ambiguities in the genotype-phenotype relationships in these polygenic disorders” (p. 841). Korner (2010) also notes that in the case of hypertension, the phenotype is “not just an aggregate of traits, but needs to be related to specific components of the circulatory control system at different stages” of hypertension (p. 841). Korner (2010) does show that some studies are underway to better understand the genotype-phenotype relationship…
Dickson, M., Sigmund, C. (2006). Genetic basis of hypertension. Hypertension, 48, 14-20.
Foex, P., Phil, D., Sear, J. (2004). Hypertension: Pathophysiology and treatment. Continuing Education in Anaesthesia Critical Care & Pain, 4(3), 71-75.
Geller, D. (2004). A genetic predisposition to hypertension? Hypertension, 44, 27-28.
Hamrahian, S. (2017). Pathophysiology of hypertension. Retrieved from https://emedicine.medscape.com/article/1937383-overview
Inoue I, Rohrwasser A, Helin C, Jeunemaitre X, Crain P, Bohlender J, Lifton RP, Corvol P, Ward K, Lalouel J-M. (1995). A mutation of angiotensinogen in a patient with preeclampsia leads to altered kinetics of the renin-angiotensin system. J Biol Chem., 270, 11430–11436.
Korner, P. (2010). The phenotypic patterns of essential hypertension are the key to identifying “high blood pressure” genes. Physiological Research, 59(6), 841-857.
Qibin, Q., Forman, J., Jensen, M. et al. (2012). Genetic predisposition to high blood pressure associates with cardiovascular complications among patients with type 2 diabetes. Diabetes, 61(11), 3026-3032.
Health disparities refer to avoidable dissimilarities existing in the occurrence of violence, disease and injury or in the opportunities for enjoying peak health which is faced by minority and social disadvantaged ethnic and racial populations and communities. Health differences are present across every age group, even in the older adults. Even though general health and life expectancy have both gotten better of recent, the Centres for Disease Control and Prevention knows that not every senior adult is enjoying these benefits equally as a result of factors like race, economic status and gender. The CDC realises that this issue is slowly becoming a huge concern and it is integrating it into our duties (Centers for Disease Control and Prevention, 2015).
Hypertension, commonly called High Blood Pressure, refers to a medical condition where blood flows in its vessels with a higher-than-normal force. When the heart beats, it drives blood through the…
Centers for Disease Control and Prevention. (2015, September 01). Adolescent and School Health. Retrieved August 02, 2017, from https://www.cdc.gov/healthyyouth/disparities/
Ephraim, P. L., Hill-Briggs, F., Roter, D., Bone, L., Wolff, J., Lewis-Boyer, L., … Boulware, L. E. (2014). Improving Urban African Americans’ Blood Pressure Control through Multi-level Interventions in the Achieving Blood Pressure Control Together (ACT) Study: A Randomized Clinical Trial. Contemporary Clinical Trials, 38(2), 370–382. http://doi.org/10.1016/j.cct.2014.06.009
Ferdinand, K. C. (2015). Hypertension in High Risk African Americans Current Concepts, Evidence-based Therapeutics and Future Considerations. New York, NY: Springer New York.
Harman, J., Walker, E. R., Charbonneau, V., Akylbekova, E. L., Nelson, C., & Wyatt, S. B. (2013). Treatment of hypertension among African Americans: the Jackson Heart Study. Journal of Clinical Hypertension (Greenwich, Conn.), 15(6), 367–374. http://doi.org/10.1111/jch.12088
Institute of Medicine (U.S.). (2010). A population-based policy and systems change approach to prevent and control hypertension. Washington, DC: National Academies Press.
Lackland, D. T. (2014). Racial Differences in Hypertension: Implications for High Blood Pressure Management. The American Journal of the Medical Sciences, 348(2), 135–138. http://doi.org/10.1097/MAJ.0000000000000308
Sharma, A., Colvin-Adams, M., & Yancy, C. W. (2014). Heart failure in African Americans: disparities can be overcome. Cleve Clin J Med, 81(5), 301-311.
Pcori. (2013, December 4). Clinical Interventions to Address Hypertension Disparities Workgroup: Topic Briefs. Retrieved August 2, 2017, from https://www.pcori.org/assets/2013/12/PCORI-Hypertension-Workgroup-Topic-Briefs-120413.pdf
Hypertension is also known as high blood pressure, which refers to an elevated pressure of the blood in the arteries. There are two major factors that cause hypertension and they can be present independently or together. These factors are the heart pumps blood with excessive force or the body's smaller blood vessels narrow, forcing the flow of blood to cause more pressure against the vessels' walls. The body is able to tolerate increased blood pressure for years, but eventually, the heart might enlarge and this might result in heart failure. The high blood pressure might also injure the blood vessels in the kidneys, heart, the eyes, and the brain (van der Giet & Tölle, 2015). Systolic and diastolic pressure are the numbers used to describe blood pressure. Systolic pressure is the first and higher number and indicates the force that blood exerts on the artery walls when the heart contracts…
Campbell, N. R., & Niebylski, M. L. (2014). Prevention and control of hypertension: developing a global agenda. Current opinion in cardiology, 29(4), 324-330.
Petriz, B. A., & Franco, O. L. (2014). Effects of hypertension and exercise on cardiac proteome remodelling. BioMed Research International, 2014.
van der Giet, M., & Tölle, M. (2015). New Hypertension Guidelines: Progression or a Step Backwards in Hypertension? Current hypertension reports, 17(7), 1-7.
Dietary approaches to stop hypertension
Hypertension has become a rampant disease in the contemporary generation. It is no longer a disease of the rich or the fact or the old, but a problem that people of all ages, from the young to the elderly face. There have been efforts to reduce the incidences of hypotension within the American society especially among the teenagers most of whom are school going students. The most important aspect to look at as proposed by dieticians and doctors is the diet of an individual. What one eats and avoids eating is key to stopping and avoiding hypertension. It is important to have diet low in fat and sodium. Pickles, canned chicken noodle soup, French fries, bacon, whole milk, frozen pot pies, donuts, ramen noodles, margarine, sugar, alcohol, red meat and table salt are all foods and indulgences that Americans often have in their meals but…
Mayo Clinic, (2018). 10 ways to control high blood pressure without medication. Retrieved April 15, 2018 from https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/in-depth/high-blood-pressure/art-20046974
The first step to help the patient reduce his blood pressure would be to help him quit smoking. Since the patient is currently smoking two packs of cigarettes a day, he knows he is a very heavy smoker, which is taking a physical and economic toll. No doubt, he is aware of different available options that can facilitate quitting smoking—such as patches and gum—but I would recommend that he switch to vaping, which can deliver a throat hit that is comparable to the act of smoking a real cigarette as well as the nicotine high found in cigarettes. For a heavy smoker, vaping e-liquids with a nicotine content of at least 12 would be appropriate to help him quit his habit. Polosa, Caponnetto, Cibella and Le-Houezec (2015) have found that vaping e-juices can be an effective way to quit cigarettes.
The second step would be to exercise more…
A Urate Lowering Intervention
Hypertension speaks to a noteworthy general medical issue. Around the world, roughly one-fourth of the grown-up populace has hypertension. Epidemiological and trial studies propose a linkage between Hyperuricemia and hypertension. Hyperuricemia influences 30?45 % of patients with untreated hypertension. A much lower commonness has been accounted for in normotensives or the overall public. “Be that as it may, in the case of bringing down serum uric Acid (SUA) may lower pulse or blood pressure is an unanswered inquiry.” (Hussar, 2010, p.70). High serum urate focus is a settled causative factor for the improvement of gouty joint inflammation. There is developing enthusiasm for a job for serum urate as a contributing component for the improvement or compounding of vascular, heart, and renal illness. The relationship between serum urate levels and Blood pressure (BP) has been depicted for a long time. Proof from creature studies gives solid help…
In the Kingdom of Saudi Arabia, there is a wide prevalence of a red meat and carbohydrate-intensive diet among Saudis. As diet high in fats and sugars has been shown to be linked to hypercholesterolemia (Torpy, Burke & Glass, 2009; Hruby & Hu, 2015) and the increase in triglycerides in the blood (leading to arteriosclerosis and hypertension in adults aged 30-40 years old), this study aims to investigate the relationship between hypertension and type 2 diabetes in Saudi Arabia.
In Saudi Arabia obesity is an emerging problem and hypertension is on the increase (Al Othaimeen, Al Nozha & Osman, 2007; Al-Nozha, Abdullah, Arafah et al., 2007). Investigating the dietary habits of Saudis and the onset of hypertension and diabetes type 2 among adults aged 25-40 will be helpful in establishing a preventive medicine approach that can be implemented by health care practitioners in the KSA to help reduce the spread…
blended study, both qualitative and quantitative in nature. The blend between numbers-based data and analysis and more abstract and conceptual work is necessary because of the totality of what is being looked at and how the research will be done (Lund, 2012).
ationale for Study Type Selection
While the before and after results of hypertension of patients in this case will be strictly numerical and statistical in scope, the formulation and tracking of the interventions, education and so forth that will form the control for the experiment will certainly be based more on concepts, evidence-based practice and the ostensibly proper ways to enforce and impose interventions on patients (McDonald & Blackwell, 2006). After all, the behaviors and changes under way are not something more detached and simple like whether a medication is take or not or whether a therapy is administered. The people involved will be instructed on what to…
Hanley, J. A. (2017). Correction of Selection Bias in Survey Data: Is the Statistical Cure Worse
Than the Bias?. American Journal of Public Health, 107(4), 503-505.
Lund, T. (2012). Combining Qualitative and Quantitative Approaches: Some Arguments for Mixed Methods Research. Scandinavian Journal Of Educational Research, 56(2), 155-
2009). The interventions used in this research study proved to be ineffective, however, and it has been suggested that more culturally relevant study leading to the development of more highly-culturally-specific practices is needed in this regard (Pekmezi et al. 2009).
Certain studies have also demonstrated a reduced efficacy of certain blood-pressure regulating pharmaceuticals in the African-American community, with certain individuals responsive to one type of medication but not others (Lackland 2004). This is significant in the area of hypertension prevention in the African-American community for several reasons, not the least of which is the fact that it is evidence of certain mechanisms at work that are still not fully understood or even necessarily identified in the medical literature (Lackland 2004). In addition, this suggests that there are certain predispositions that both affect hypertension and interrupt the mechanisms of drugs proven efficacious in other communities, which could provide greater insight into…
Douglas, J., Bakris, G., Epstein, M., Ferdinand, K., Ferrario, C., Flack, J…. & Vidt, D. (2003). Management of High Blood Pressure in African-Americans: Consensus Statement of the Hypertension in African-Americans Working Group of the International Society on Hypertension in Blacks. Archives of Internal Medicine 163(5): 525-41.
Glover, M., Greenlund, K., Ayala, C. & Croft, J. (2005). Racial/Ethnic Disparities in Prevalence, Treatment, and Control of Hypertension -- United States, 1999-2002. JAMA 293(8): 923-5.
Harvard. (2003). High blood pressure isn't color-blind. Harvard heart letter 13(10):1.
He, J., Klag, M., Caballero, B., Appel, L., Charleston, J. & Whelton, P. (1999). Plasma insulin levels and incidence of hypertension in African-Americans and Whites. Archives of internal medicine 159(5): 498-503.
Essential hypertension or primary hypertension is a highly complex disorder. There are various factors modulating BP or blood pressure in order for adequate tissue perfusion to occur. These include:
Circulating blood volume
Blood vessel elasticity
History of high blood pressure in family
Aside from these factors, the natural course of primary hypertension is progression from infrequent or occasional to established or frequent hypertension. There is a long, asymptomatic, and invariable period when the persistent hypertension then progresses into complicated hypertension. This means there will be target organ damage to the small arteries and aorta, retina, heart, kidneys, and central nervous system.
The journey to primary hypertension begins with prehypertension from ages 10-30 years. The transition to early hypertension occurs from ages 20-40 years. During this phase peripheral resistance is noticeable. After this stage is established…
Bolivar, J. (2013). Essential Hypertension: An Approach to Its Etiology and Neurogenic Pathophysiology. International Journal Of Hypertension, 2013, 1-11. http://dx.doi.org/10.1155/2013/547809
MacGregor, G., & Kaplan, N. (2010). Hypertension. Abingdon: Health Press.
Mayo Clinic,. (2016). Overview - Creatinine test - Mayo Clinic. Mayoclinic.org. Retrieved 29 February 2016, from http://www.mayoclinic.org/tests-procedures/creatinine-test/home/ovc-20179389
Podzolkov, A., & Fadeyev, V. (2009). Hypothyroidism, Subclinical Hypothyroidism, High-normal TSH-level. Clinical And Experimental Thyroidology, 5(2), 4. http://dx.doi.org/10.14341/ket2009524-16
precarious world of hypertension (HTN) as it relates to a specific and substantial segment of the American population. The study sought to determine whether an intervention with African-American students between the ages of 14 -- 17 would be efficacious. The problem is that there is a higher incidence of HTN in African-Americans than in almost any other demographic. This is a problem because of the many health risks associated with this disease.
The purpose of the study was to determine whether education and learning on how to combat HTN would be beneficial to the study participants, and through extrapolation be beneficial to the African-American members of society as well. Specifically, "the purpose of the study was to determine the efficacy of a school-based health promotion intervention" (Covelli, 2006, p. 173).
The objectives of the study included; increasing knowledge of health promotion and daily exercise, increasing the intake of fruits and…
And Li, (2006). These researchers took previous findings regarding the efficacy of ACE inhibitors (Fosinopril, in particular) and applied them to children of different racial populations. Moreover, Menon et al. (2006) investigated whether the evidenced differences in effectiveness of ACE inhibitors among adults of different racial groups transferred to children of different racial groups. The results of the study indicated that Fosinopril was effective in treating hypertension in all racial groups, but Black children in the study required a higher dosage of the anti-hypertensive medication in order to experience the beneficial results. Furthermore, the differences in ACE inhibitor efficacy observed among adults of different races exist also in children of various races (Menon et al., 2006).
The demonstrated fact that African-Americans with hypertension are not as responsive to certain anti-hypertensive medications than non-African-Americans has opened the door for further research. Papademetriou, Narayan, and Kokkinos (2004) studied the effectiveness of ACE…
Brewster, L.M., van Montfrans, G.A., Kleijnen, J. (2004). Systematic Review: antihypertensive drug therapy in black patients. Annals of Internal Medicine, 141(8), 614-27.
Ferdinand, K.C., Saunders, E. (2006). Hypertension-related morbidity and mortality in African-Americans - why we need to do better. Journal of Clinical Hypertension, 8 (Suppl. 1), 21-30.
Flack, J.M., and Hamaty, M. (1999). Difficult to treat hypertensive populations: focus on African- Americans and people with type 2 diabetes. Journal of Hypertension. Supplement, 17(1), S19-24.
McDowell, S.E., Coleman, J.J., Ferner, R.E. (2006). Systematic review and meta-analysis of ethnic differences in risks of adverse reactions to drugs used in cardiovascular medicine. British Medical Journal, 332, 1177-81.
The "pain" caused to the heart due to tissue damage can be misplaced in the body due to these nerve pathways and connections; heart attacks are often felt in the left arm and elsewhere on that side of the body between the heart and brain.
Diuretics would encourage the elimination of sodium and a lessened fluid retention, easing the pressure in his arteries.
The increased acidity in J.M.'s blood indicates reduced heart functionality and creatine phosphokinase levels are elevated which indicates muscle damage; low-normal lactate dehydrogenase suggest no recent prior infarctions, however, and without further tests this particular measure is not especially edifying.
The drug relaxes blood vessels, allowing easier passage of blood reducing chest pain (which elevates stress and blood pressure) and easing the underlying problem, as well
Aspirin inhibits the collection of platelets at the site of a plaque rupture, preventing a full blockage…
The patient should drink less, participate in more physical activity and should eat a better diet. The blood pressure and cholesterol both need to come down immediately.
The patient needs to take the recommendations in question 5 or he likely has a very dim future if his BP and cholesterol is not lowered a lot. Blood pressure should be measured after the patient has rested for at least five minutes. He should be instructed in advance of the appointment what not to eat or drink so that the test result is not improperly influenced (e.g. drinking caffeine).
There is no advancement or progression in symptoms but blood pressure is still entirely too high. It needs to drop by at least 30 points to be within a non-hypertension range. Needs to be made clear to patient that while he is feeling fine for now, that will change…
Its use on those with acute PAH should be performed with caution. The complication rate was observed at 2%
in patients with acute PAH. The use of the procedure was deemed relatively safe for chronic pulmonary arterial hypertension. Severely ill patients should be subjected to non-invasive imaging method exhaustively before resorting to pulmonary angiography (Hofman et al.).#
Albert, Nancy M. Caring for Patients with Pulmonary Hypertension. Nursing:
Springhouse Corporation, May 1999. Retrieved on April 25, 2009 from http://findarticles.com/p/articles/mi_qa3689/is_199905/ai_n8846566/?tag=content;col1
adesch, David, et al. Medical Therapy for Pulmonary Arterial Hypertension.
131 (6). Chest: American College of Chest Physicians, July 20, 2007. Retrieved on April 25, 2009 from http://www.medscape.com/viewarticle/560041
Flattery, Maureen P. And Kathy M. aker. Evidence for Racial Disparity in Cardiac
Transplantation Survival Rates. Journal of Cultural Diversity: Tucker Publications,
March 22, 2004. Retrieved on April 26, 2009 from http://findarticles.com/p/articles/mi_m)MJU/is_1_11/ai_n6183827/?tag=content;col1
Hofman, Lawrence V., et al. Safety and Hemodynamic Effects of Pulmonary…
Albert, Nancy M. Caring for Patients with Pulmonary Hypertension. Nursing:
Springhouse Corporation, May 1999. Retrieved on April 25, 2009 from http://findarticles.com/p/articles/mi_qa3689/is_199905/ai_n8846566/?tag=content;col1
Badesch, David, et al. Medical Therapy for Pulmonary Arterial Hypertension.
131 (6). Chest: American College of Chest Physicians, July 20, 2007. Retrieved on April 25, 2009 from http://www.medscape.com/viewarticle/560041
Furthermore, one of the pillars of collaborative care that will need to be firmly established is the fostering of clear dialogue and a means for strong communication within the care management planning. For instance, there needs to be a clear decision and communication of all tests ordered and when the test results will be available. One of the most important aspects of this collaborative care will be the nursing interventions which can have significant impact on the patient's health and stabilization (Allen, 2010). In fact, strategic nursing care can even minimize readmission rates of Margaret and other patients with comparable conditions (Chen et al., 2012).
Prioritize the Nursing Care Needs of Margaret
The prioritization of nursing interventions is essential, and the way in which a nurse determines this priority is going to be something unique and distinct. "Trials reviewed demonstrated a beneficial impact of nursing interventions for secondary prevention in…
Adler, H.M. (n.d.). Toward a biopsychosocial understanding of the patient -- physician relationship: An emerging dialogue. (2007). J Gen Intern Med,22(2), 280 -- 285.
Afilala, J. (n.d.). Frailty in patients with cardiovascular disease: Why, when, and how to measure. (2011). Curr Cardiovasc Risk Rep, 5(5), 467 -- 472.
Allen, J.K. (2010). Randomized trials of nursing interventions for secondary prevention in patients with coronary artery disease and heart failure: Systematic review.
Journal of Cardiovascular Nursing,25(3), 207-220.
The health of the person usually starts declining with every passing day after 65 years of age and as Mrs. Smith is 82 years old, she is also suffering from some problems. She is in mid stage of dementia because of which she suffers from recent memory impairment, hypertension and mental confusion. Due to dementia, she has already been in problems several times. Like, once she left the pan over the stove and also fallen number of times due to syncope. Moreover, she forgets to take her medicines on time. So, she needs an attended that takes care of her medication, diet and exercises and must not be left alone or unattended at home.
In an old age, a person is in need of company more than any medication. Healthy routine and happiness is the best treatment for various diseases. However, Mrs. Smith lives alone at home during…
AHRQ. (n.d.). Choosing Long-term Care. Retrieved from Agency of Healthcare Research and Quality: http://archive.ahrq.gov/consumer/qnt/qntltc.htm
Brodaty, H. (1988). 'Minimal brain damage in the Adult II: Early dementia'. Patient Management, August, 127-150.
Better Health Channel. (2011). Dementia -- Support Services are available. Retrieved from Better Health Channel: http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Dementia_support_services_are_available-open
Shea, D.E. & Reilly, M.S. (1999). An Action Plan for Dementia. Dublin 2: National Council on Ageing and Older People.
Health Promotion Lesson Plan
The concept of health promotion is thought of as "the science and art of helping people change their lifestyle to move toward a state of optimal health" (Dunphy et al., 2011, p 25). Serious heart conditions can be prevented, which is why it is so important to utilize community education techniques in order to help try to warn community members of the complications before they occur. This current lesson plan works to create three separate community lesson plans, based on specific age ranges. The age 18-29 focuses primarily on the use of social media and health advocacy efforts in association with the American Heart Association. For ages 30-49, there is also a focus on these two, combined with more community oriented issues, and for 50-60, there is much more of a focus on financial training along with community organized workshops.
Prevention has become a major issue…
References McLeod, Saul. (2010). Erik Erikson. Developmental Psychology. Simply Psychology. Web. http://www.simplypsychology.org/Erik-Erikson.html
Expressive functioning is related to communication such as emotional, verbal, and nonverbal communication, problem solving and roles within the family. Beliefs within the family are also a part of expressive functioning.
For the purpose of the Calgary Family Assessment Model, a family is defined as who they say they are. It is very important that the clinician performing the assessment not assign their own beliefs upon what he or she believes a family is, and take into account what the patient feels about family as to the patient is may mean not only the people who actually live within the household but can also address past, present and future emotional attachments.
Calgary Family Intervention Model:
The immediate family is composed of Mr. Herbert Schelley (the patient), Mrs. Annette Schelley (his wife), and their son Thomas Schelley. The extended family consists of the Schelley's two married daughters, their husbands and their…
Brownwald H. ed. (2003) Harrison's Textbook of Internal Medicine, 15th edition,
McGraw-Hill, New York
Clement S. (2004) Guidelines for glycemic control. Clin Cornerstone. 6(2):31-9
Echeverry D.M., Dike M.R., Washington C., Davidson M.B.. (1995). The impact of using a low-literacy patient education tool on process measures of diabetes care in a minority population J. Natl Med Assoc. (11):1074-81
nature of hypertension, as well as methods of treatment using both drugs and alternative approaches. Ceral et al. (2011) focus on whether antihypertensive drugs are effective or if patients are simply not using them. hey find that patients must adhere to recommended therapy in order for effects to be accurately measured. Inui et al. (1976) point out the importance of receiving and following physician tutorials. Green et al. (1975) likewise identify education for hypertensive patients as critical to effective therapy outcomes. Omran et al. (2015) discuss the treatment of hypertensive patients with diabetes co-morbidity and find antihypertensive medication to be an effective medication management tool to a limited degree.
Step 2: Briefly summarize the history and purpose of your research question.
he history and purpose of the research question is whether hypertensive medications or more effective than holistic approaches to hypertension in helping patients to alleviate symptoms and reduce hypertension…
There is a gap in the existing literature comparing pharmaceutical treatment of hypertension with holistic treatment, such as Chinese traditional medicine, which utilizes foods, spices, soups, etc. in the treatment of physical ailments. There is literature regarding holistic treatment of hypertension: Xiong, Yan, Liu et al. (2013) discuss Chinese herbal formulas for treating hypertension in traditional Chinese medicine. Comparing holistic treatment of hypertension and pharmaceutical treatment could help fill this gap in the literature.
Part IV: Identify the influence of empiricism on quantitative research methodology. Discuss its applicability to evidenced-based practice projects.
The influence of empiricism on quantitative research methodology is seen in the demand for quantifiable data and tangible results. Objective processes that can be duplicated in research, methods that are clear and supported by research, and analysis that is based on observation is key to conducting research in sciences today. The applicability to evidence-based practice projects is that empirical analysis helps to provide clear, objective findings that can be tested by other researchers.
health promotion strategies that can be implemented upon the predictive characteristics of the family.
My health promotion strategy program will center around a Cuban-American family called the Garcias whose primary health issues center on hypertension, and the need for greater information about the importance of establishing a healthy lifestyle. This includes the importance of screening, exercise, establishing healthy habits, and monitoring one's lifestyle. Several members of the family indicate stress and hypertension whilst the grandmother also has cardiac disease and osteoarthritis, but is resilient to receiving information on how to alleviate her symptoms. In a similar way, Angelo, an addicted smoker, refuses to stop smoking and to deal with his chronic cough and mild chest pain, stating that, as man of the family, he has to continue working his overwhelming hours. Gerardo, the son, being active homosexually, seems to be vulnerable to AIDS; it is unclear whether or not he…
Boswell, T.D. & Curtis, J.R. (1984) The Cuban-American Experience. Culture, Images and Perspectives. NJ: Rowman & Allanheld Publishers
Cuban Americans http://www.everyculture.com/multi/Bu-Dr./Cuban-Americans.html
Those who are the vulnerable will have specific genes they inherit from their relatives, who were impacted by the condition. This increases their chances of having similar complications when they become older. (Kolata, 2010)
Congestive Heart Failure and Hypertension
Congestive heart failure and hypertension are interconnected with each other. According to a study conducted by the University of Texas, they found that there are 660 thousand new cases reported each year. This is accounting for 7% of all deaths associated with cardio vascular disease. One of the biggest factors that will determine if someone is at risk is hypertension. As this is used in 75% of all cases, to predict if someone will be impacted by congestive heart failure and the long-term effects it will have on them. (Merla, 2009)
Hypertension can lead to complications by increasing the chances of ventricle or systolic dysfunction taking place. This improves the chances…
Heart Disease Fact. (2013). CDC. Retrieved from: http://www.cdc.gov/heartdisease/facts.htm
Heart Disease and Stroke. (2012). Lasker Foundation. Retrieved from:
Heart Failure. (2013). Mayo Clinic. Retrieved from: http://www.mayoclinic.com/health/heart-failure/DS00061
Constipation, Hypertension, Seizure
This is the infrequent or difficult bowel evacuation (Mayo Clinic Staff, 2012). While there are no strict standard for bowel elimination, it is generally believed that fewer than thrice a week constitutes constipation. Stools are usually hard and dry. Other common symptoms associated constipation include excessive straining during bowel evacuation, a sense of rectal blockage, a sense of incomplete evacuation and the need to perform manual measures to evacuate the bowels. Constipation may be the consequence of insufficient fluid intake or dehydration, inadequate fiber in the diet, foregoing elimination, irritable bowel syndrome, lack of physical activity, illness, abuse of laxatives and certain medical conditions. Those more likely to develop constipation are older adults, those who are sedentary, confined in bed, dehydrated, on low-fiber diet, on certain medications and undergoing chemotherapy. It is more common in women and children. Causes for alarm include fewer…
Makoff, D. (2012). High blood pressure. MedicineNet: MedicineNet.com. Retrieved on March 7, 2012 from http://www.medicinenet.com/high_blood_pressure/page
Mayo Clinic Staff (2012). Constipation. Mayo Clinic: Mayo Foundation for Medical
Education and Research. Retrieved on March 7, 2012 from http://www.mayoclinic.com/health/constipation.DS0063/METHOD=print&DSECTION=all
PubMed Health (2011). Seizures. ADAM Medical Encyclopedia: ADAM, Inc. Retrieved
Obesity is a serious social problem in America. The effects of obesity in childhood are well documented in both the social science literature and medical journals. During the last 30 years, the percentage of obese children between the ages of 6 and 11 has risen 200% while the percentage of obese children between 12 and 19 has tripled (CDC, Preventing Childhood Obesity, 2010). Obesity in the nited States has increased among all cohorts and ethnicities, spans across generations, and is not limited to income or educational levels. However, the incidence of obesity among African-American women is of particular concern given the prevalence and severity of the issue in America.
Public health issue
More than two-thirds of Americans are now obese or overweight (Ogden et al., 2010).
Rates of adult obesity now exceed 20% in 49 states and D.C and 25% in 40 states. By way of comparison, in 1991, rates…
U.S. Centers for Disease Control and Prevention (2011). Morbidity and Mortality Weekly Report. Vital Signs: Prevalence, Treatment, and Control of Hypertension -- United States, 1999 -- 2002 and 2005 -- 2008
Ward, S., Gray, A., Paranjape, A. (2008). African-Americans' perceptions of physician attempts to address obesity in the primary care setting. The Journal of General Internal Medicine, 24(5), 579-584.
Coenen, K.R., Hasty, A.H. (2007). Obesity potentiates development of fatty liver and insulin resistance, but not atherosclerosis, in high-fat diet-fed agouti LDLR-deficient mice. Retrieved from: http://ajpendo.physiology.org/content/293/2/E492.short
Risk Factors for Mr. Jablonski
CHD: Mr. J is a classic case for a potential Coronary Heart Disease (CHD) patient. His history shows several risk factors, which can be divided into uncontrollable and controllable risk factors. The uncontrollable factors are his age (48 years old) -- older people are more susceptible to CHD, his sex (male) -- men are more likely to get CHD, and his family history. The controllable risk factors are his obesity, his smoking habit, lack of physical activity, high blood pressure, and his high LDL cholesterol.
Hypertension: The risk factors for Mr. J are his age, gender, obesity, excessive salt intake, and his inactive lifestyle.
The risk factors described as 'controllable' can be mitigated by dietary control and medication. If his condition remains untreated Mr. J is a potential candidate for a severe heart disease and possible stroke.
In order to lower his high…
Biology -- Patient Scenario
What are the components of physical examination? Describe each component.
Physical examination consists of 5 basic components after obtaining a patient's description of the history of his/her systems. First, the provider observes the patient for physical signs of disease and evaluates such factors as mobility, posture, facial expression, alertness, responsiveness to stimuli and changes in skin color (Jarvis, 2011, pp. 33, 127-9). Secondly, one must take a patient's vital signs, including blood pressure, heart rate, breathing rate and temperature, and compare the patient's results with the reference ranges (Jarvis, 2011, pp. 136-150). Third, one must perform auscultation, using a stethoscope to listen to the patient's lungs, heart and bowel (Jarvis, 2011, p. 118). Fourth, one performs percussion by tapping on the patient's chest and abdomen to listen for sounds indicating normal conditions, fluid, excess air, size of the lungs and size of the affected area (Jarvis,…
Reference values) for each laboratory tests in the table above from the second set of tests.
The second round of Mr. Smith's tests, when compared with the normal ranges, indicate that: his blood potassium level is below the normal range; his
Metabolic syndrome is significant for our patient for several reasons. As we have noted, the syndrome is associated with a higher risk of cardiovascular disease. Those patients who have metabolic syndrome tend to develop coronary atherosclerosis at a higher rate than those who have coronary risk factors alone. Obesity increases the risk of metabolic syndrome but so does pre-obesity, or BMI ranging from 25-30. Women who have been diagnosed with polycystic ovarian syndrome are noted to be at increased risk of hypertension, dylipidemia, insulin resistance, impaired glucose tolerance and Type II diabetes. Because of all these comorbidities, women with PCOS also tend to be at greater risk for patients with subclinical carotid atherosclerosis, especially in the premenopausal population (Talbot, et al., 2000). For these same reasons, women diagnosed with PCOS have a 5 fold increased risk for the development of complications of coronary and cerebrovascular atherosclerosis.
Mrs. Stiller has many…
Reaven G. (2002) Metabolic syndrome. Pathophysiology and implications for management of cardiovascular disease. Circulation.106:286-288
Manson JE, Willet WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE, et al. (2005) Body weight and mortality among women. N Eng J. Med 333:677-85
Juahan-Vague I, Alessi MC. (1997) PAI-1, obesity, insulin resistance and risk of cardiovascular events. Thromb Haemost 78:656-60
Wilson PW. (2004) Estimating cardiovascular disease risk and the metabolic syndrome: a Framingham view. Endocrinol Metab Clin N. Am. 33:467-81
There are remedies (albeit not easy ones for the individuals involved), as suggested by the research. However, and this is very important, the current public health approaches that the Saudi government has taken, as Mabrey et al. (2010) note, have focused fairly narrowly on medical approaches. This focus includes research that has been conducted on metabolic syndrome (which is caused primarily by being overweight). This is caused by clear-cut factors and has a number of possible poor consequences.
Mabrey et al. (2010) note that metabolic syndrome is on average 10 to 15% higher in the GCC states than in the rest of world and that females are disproportionately affected by metabolic syndrome. These researchers are among those who note that a strictly medical approach to such medical problems is far from sufficient. For while metabolic syndrome itself can be identified and described in purely medical terms, such an approach does…
Abraham, S. & Nordsieck, M. (1960). Relationship of excess weight in children and adults. Public Health 75: 263-273.
Alghamdi, K.M. (2010). The use of topical bleaching agents among women: A cross-sectional study of knowledge, attitude and practices. Journal of the European Academy of Dermatology and Venereology, 24(10): 1214-1219.
Al-Qahtani, D.A., Imtiaz, M.L., Saad, O.S., & Hussein, N.M. (2006). A comparison of the prevalence of metabolic syndrome in Saudi adult females using two definitions. Metabolic Syndrome and Related Disorders, 4(3): 204-214.
Al Qauhiz, N.M. (2010). Obesity among Saudi Female University Students: Dietary Habits and Health Behaviors. Journal of the Egyptian Public Health Association 85(1-2):45-59.
Community resources must be identified and brought together to meet needs. Actions can be developed to prevent poor health outcomes by: appropriately identifying, collecting, and reporting racial/ethnic group-specific data; identifying where data are lacking and developing appropriate tools to collect those data; and linking poor health status indicators to social conditions and influences, as well as personal behaviors and genetics.
As indicated by other counties, the populations experiencing these disparities have many strengths and traditions to draw upon for solutions. In the African-American communities, churches provide connections and leadership on community issues. Other models have provided the use of community engagement principles encouraged throughout any state and local processes addressing eliminating health disparities, whether funded by this initiative or not. Such community engagement principles include fostering openness and participation in the planning process, ensuring that those representing a specific community truly represent that community's values, norms, and behaviors, and using…
Alpha.org. "Racial / Ethnic Disparities." Fact Sheets. 2004. 17 May 2005. www.apha.org/NPHW/facts/RaceEth-PHW04_Facts.pdf.
Fenwick, E. et.al. "Improving the Efficiency and Relevance of Health Technology
Assessment: The Role of Iterative Decision Analytic Modeling." 2003. Che
Discussion Paper. 17 May 2005. http://www.york.ac.uk/inst/che/DP179.pdf .
Studies conducted over decades have concluded that there is a significant link between diabetes mellitus and cardiovascular disease. For instance, the most common form of diabetes is type 2 diabetes, which involves both the impairment in insulin resistance and the defective secretion of insulin by the pancreas. The development of diabetes often comes with a number of cardiovascular complications including "coronary heart disease (CDC), stroke, peripheral arterial disease, nephropathy, retinopathy, and possibly neuropathy and cardiomyopathy." (Grundy 1999)
Specifically both diabetes type 1 and type 2 are considered to be risk factors for atherosclerotic coronary heart disease. "Moreover, myocardial ischemeal due to coronary atherosclerosis commonly occurs without symptoms in patients with diabetes." (Grundy 1999) In other words, patients with diabetes are more likely to be stricken with congestive heart failure. But it is not only the risk of heart failure that diabetes sufferers are at risk from, another…
"eGFR." Lab Tests Online, Available from http://labtestsonline.org/understanding/analytes/gfr/tab/test
"Glomerular Filtration Rate (GFR)" National Kidney Foundation Available from http://www.kidney.org/kidneydisease/ckd/knowgfr.cfm
Grundy, Scott. Et al 1999, "Diabetes and Heart Disease: A Statement for Healthcare
Professionals from the American Heart Association" AHA Scientific Statement.
Nursing - Discharge planning
Discharge Planning in Nursing
Mr. Trosack's Case
The three main health issues include movement hindrance where by Mr. Trosack will move with the help of a walker. Mr. Trosack diabetic condition is main health issue. Mr. Trosack is depressed and lonely and requires a special care and assistance. Mr. Trosack lives in a crowded apartment located at a second floor in a 3-storey building. The building does not have an elevator and thus Mr. Trosack has to use the stairs to reach to his apartment. The house has furniture and personal valuables and thus making it hard for him to use his walker once inside the room. e takes the garbage by himself since he lives alone because his wife died two years ago. e fears climbing up the stairs because of pain that emanate from the strain. is family works for 60 hours a week…
Hip fracture is a main health issue that happens in the United States. This study uses the baseline (1993) and data collected in 2006 in order to evaluate the aftermath of hip placement discharge. Patient discharge depends on the status code from the Medicare inpatient claim. They categorize discharge status depending on the condition of the patient. Mr. Trosack would fall for nursing facility because he would not get the required professional assistance from his family. In this study, most of the hip fracture patients went to a nursing facility.
An evaluation in this study reveals that at the time of placement, the patients had gone home for 90 days, and 180 days for patients discharged at a nursing facility. The evaluation of the care of hip placement patients needs consideration when choosing a discharge placement for them. Mr. Trosack, in addition to the surgery, is diagnosed with diabetes, hypertension, and obesity. The family, despite knowing all this, does not provide or hire a medical officer for a regular check up on him.
In order for Mr. Trosack to get well, it is crucial to refer him to a nursing facility. In this study, the home and rehabilitation discharge seems to decline while many people opt for the nursing placement, which increased. In these nursing facilities, patients are not likely to report any health issue compared to those placed at their homes. In addition, these nursing facilities offer functional needs to patients and may reduce hip fractures in elderly people.
Home health visits can be a useful method of identifying potential and actual health issues. Visiting the patient's home may provide the opportunity to identify issues which may not be readily apparent at a medical office. The home health visit is meant to assist in the promotion of the patient's health maintenance; limit further disability, and increase baseline health.
The visiting nurse will gain the ability to build a caring, professional, trusting, patient focused relationship. The home health nurse will be able to assist the patient by identifying, procuring and providing education for interventional items. The nurse will also know how to facilitate the communication of identified patient needs, in the home, to interdisciplinary members of the health care team (Liebel, Powers, Friedman, & Watson, 2012, p. 80).
The patient has been prescribed oxygen for home use by her physician. The patient states the she has not…
fever and palpable cervical nodes indicates an infection. Jennifer appears to have bacterial tonsillitis. However, in order to confirm, a throat culture must be taken. Although mononucleosis is uncommon in toddlers, it is a possible diagnosis and typically comes from contact in daycares (Yokoyama et al., 2013). To confirm the mononucleosis diagnosis, serology is needed. While the clinical manifestation points to possible mononucleosis diagnosis, younger children do not have as pronounced symptoms.
Bacterial or viral infections as well as other immunologic factors lead to development of tonsillitis. The majority of acute tonsillitis may be caused by viruses such as Herpes simplex virus (Babakurban, Erbek, Terzi, Arslan, & Sahin, 2014). Although because the symptoms are so pronounced, it could be caused by mononucleosis. This making the origins bacterial.
A possible treatment option is Augmentin. It is a broad spectrum penicillin antibiotic that has a combination of clauvulanate potassium and amoxicillin. However,…
Babakurban, S., Erbek, S., Terzi, Y., Arslan, F., & Sahin, F. (2014). Fractalkine receptor polymorphism and chronic tonsillitis. Eur Arch Otorhinolaryngol, 271(7), 2045-2048. http://dx.doi.org/10.1007/s00405-014-2908-7
HASLER, G. (2010). PATHOPHYSIOLOGY OF DEPRESSION: DO WE HAVE ANY SOLID EVIDENCEOF INTEREST TO CLINICIANS?. World Psychiatry, 9(3), 155. http://dx.doi.org/10.1002/%28ISSN%292051-5545
Schindler, M., Drozdenko, G., Kuhl, A., & Worm, M. (2014). Immunomodulation in Patients with Chronic Hand Eczema Treated with Oral Alitretinoin. Int Arch Allergy Immunol, 165(1), 18-26. http://dx.doi.org/10.1159/000365659
Soost, S., Abdollahnia, M., Kostev, K., & Worm, M. (2012). Topical therapy of hand eczema - analysis of the prescription profile from dermatologists in private practice. JDDG: Journal Der Deutschen Dermatologischen Gesellschaft, 10(3), 180-184. http://dx.doi.org/10.1111/j.1610-0387.2011.07787.x
A level of 126 mg/dL or above, confirmed by repeating the test on another day, means that you have diabetes.
An oral glucose tolerance test measures your blood glucose after you have gone at least 8 hours without eating and 2 hours after you drink a glucose-containing beverage. This test can be used to diagnose diabetes or pre-diabetes. OGTT is more sensitive than the FPG test for diagnosing pre-diabetes, but it is less convenient to administer. The OGTT requires you to fast for at least 8 hours before the test. Your plasma glucose is measured immediately before and 2 hours after you drink a liquid containing 75 grams of glucose dissolved in water.
If your blood glucose level is between 140 and 199 mg/dL 2 hours after drinking the liquid, you have a form of pre-diabetes called impaired glucose tolerance or IGT, meaning that you are more likely to develop…
Braunald, Eugene., Fauci, Anthony S., Kasper, Dennis L., Hauser, Stephen L., Longo, Dan L., Jameson, J. Larry. 2001. Harrison's Principle of Internal Medicine, 15th ed. New York: McGraw-Hill Medical Publishing Division.
The Merck Manual (16th ed.). (1995). Portland, Oregon: Merck & Co., Inc.
These different elements are important, because they are indicating that Ms. Lee needs to seek out regular treatment. As a result, some kind of consistent assessment must take place, in order to ensure that she is not subject to having a serious fall. This is because, of the overt signs that she is exhibiting from the side effects of the medication and her age. (Henrich, 2007, pp. 50 -- 57)
ased on the fact that Ms. Lee does not want to have an extensive diagnostic evaluation at the hospital, how would one approach her care?
The most logical approach is to have Ms. Lee go through a series of evaluations inside her home with health care professionals. This could be accomplished by having the doctor visit her apartment at least once per week. At the same time, select caregivers could begin to work with Ms. Lee on a regular basis.…
Hydrodiuri. (2011). EMEDTV. Retrieved from: http://hypertension.emedtv.com/hydrodiuril/hydrodiuril.html
Lopressor. (2011). EMEDTV. Retrieved from: http://blood-pressure.emedtv.com/lopressor/lopressor-side-effects.html
Henrich, A. (2007). How to Try This. American Journal of Nursing, 107(11), 50 -- 58.
Mark, J. (2011). Zolft. Medicinenet. Retrieved from: http://www.medicinenet.com/sertraline/article.htm
Nurse Speech to Group of esidents in a Large Independent Living Facility
The information addressed today in this speech are those involving the body's regulation of the correct numbers and ratios of blood cells and how blood pressure homeostasis is achieved as well as age-related changes to the heart including coronary artery disease, congestive heart failure and myocardial infarction.
Homeostatis and the Body's Balancing Act
The work of Vikrant and Tiwan (nd) report that studies on the population indicate that blood pressure is a continuous variable and there is really not a line that divides normal and abnormal values. However, there is a point of balance also called internal equilibrium and this is known as homeostasis. This state of balance describes how the human body reacts to certain changes. This can be viewed by picturing a set of scales in which coins are poured in unevenly with one side heavier…
Vikrant, S. And Tiwan, SC (nd) Essential Hypertension -- Pathogenesis and Path physiology. Retrieved from: http://medind.nic.in/jac/t01/i3/jact01i3p140.pdf
elationship of high cholesterol levels to the development of cardiovascular disease
Diabetes, heart disease, and high cholesterol are all strongly correlated. Even when diabetes is being well-managed, the patient's risks factors increase for comorbidity with these disorders. "High blood pressure has long been recognized as a major risk factor for cardiovascular disease. Studies report a positive association between hypertension and insulin resistance. When patients have both hypertension and diabetes, which is a common combination, their risk for cardiovascular disease doubles" (Cardiovascular disease and diabetes, 2014, AHA). Also, in the case of Ms. X, because of her uncontrolled diabetes, her risk for high cholesterol is higher than average even in the absence of obesity and inactivity. "This triad of poor lipid counts often occurs in patients with premature coronary heart disease. It is also characteristic of a lipid disorder associated with insulin resistance called atherogenic dyslipidemia, or diabetic dyslipidemia…
Burden, M. (2003). Diabetes: Treatment and complications. Nursing Times, 99(2) 30/
Cardiovascular disease and diabetes. (2012). American Heart Association. Retrieved from:
DIAGNOSIS AND TREATMENT PLAN
Diagnosis and Disease Processes
Using an appropriate patient assessment form (Sample Forms, 2013), D.M. has been found to have uncontrolled Type 2 diabetes, hypercholesterolemia, uncontrolled hypertension, chronic anemia, and probable hypothyroidism (Sample Forms).
Diabetes Type 2
is most probably on a poorly controlled diet of high cholesterol and high simple sugars. Diabetes mellitus type 2 is a metabolic disease wherein the body is not able to properly use ingested food because of insulin resistance. If more simple or refined sugars are consumed, the less the body is able to process them as nutrients. These tend to stay and float in the blood stream, un-used, and in this condition, they cause trouble in the different parts of the body. These include the end organs, such as the brain, the eyes, the kidneys, the heart, and even the feet. A poorly controlled diet and the lack…
Glasgow, R.E., et al. (2005). Development and validation of the patient assessment of chronic illness care. Vol. 43 # 5, Medical Care: PuMed. Retrieved on October 15,
2014 from http://www.ncbi.nlm.nih.gov/pubmed/15838407
Sample Forms (2013). Patient assessment form. Sample Forms.org. Retrieved on October 15, 2014 from http://www.sampleforms.org/patient-assessmentform.html
predicaments associated with the modern way of life unfortunately consist of many different natures. ut perhaps the most pressing genre is that of deteriorating health conditions. People are generally susceptible to a number of hazardous medical conditions and the prime reason for that is the type of diet that everyone adopts. According to the research conducted by Young and Nestle, "Overweight and obesity have increased sharply since the early 1980s in the United States and worldwide." (Young and Nestle 1) This is a source of major concern since weight problems simultaneously give rise to chronic conditions such as diabetes, hypertension and coronary heart disease, thereby reducing general level of life expectancy.
Due to the rapid augmentation of such concerns, the government of the United States has brought forward certain regulations that control portion sizes offered in restaurants. The implementation and reception of such a decree are open to debate, but…
Condrasky, Marge, Ledikwe, J.H., Flood, J.E. And Rolls, B.J. "Chef's Opinion of Restaurant Portion Sizes." Obesity Vol. 15 (2007): n. pag. Web.
Raats, Monique M., and Wills, J.M. Food Consumer Behavior and Health. Proc. Of Consumer Response to Portion Information on Food and Drink Packaging. N.p.: n.p., n.d. 1-23. Print.
Thomas, Lionel, Jr., and Mills, J.E. "Consumer Knowledge and Expectations of Restaurant Menus and Their Governing Legislation: A Qualitative Assessment."Department of Hospitality and Tourism Management (006): n. pag. Web.
Young, Lisa R., and Nestle, M. "Portion Sizes and Obesity: Responses of Fast-Food Companies." Journal of Public Health Policy (2007): 238-48. Web.
Sallie Mae Fisher
Ms. Fisher is an 82-year-old female with a history of chronic congestive heart failure (CHF), atrial fibrillation, and hypertension. With her age, and such an acute medical condition, she may undergo substantial changes in function and living standards.
Ms. Fisher has been hospitalized four times for exacerbation of her CHF in the last 6 months. One of her primary problems is most likely to be decline in function in activities of daily living (ADLs). During Post hospitalization, older patients experience changes in functional status, Mary seems not to recover well after hospitalization revealed by her frequent hospitalizations.
In addition, Ms. Fisher seems to gain weight fast an indication that her body is retaining extra fluid. This is a common complication associated with CHF. It appears that Ms. Fisher is not strict with her diet or in not monitoring her diet well to eliminate salt (De Lorgeril, Salen,…
De Lorgeril, M., Salen, P., & Defaye, P. (2005). Importance of nutrition in chronic heart failure patients. European Heart Journal, 2215-2217.
Mahoney, J.E., Eisner, J., Havighurst, T., Gray, S., & Palta, M. (2000). Problems of Older Adults Living Alone After Hospitalization. Journal Gen Intern Med, 611 -- 619.