Category: Blood pressure

Normal blood pressure is critical for people’s well-being because alterations in it are likely to cause a wide range of issues that affect health conditions. Generally, it is perceived as the force made by blood on the walls of blood vessels and belongs to the vital signs that indicate the state of the life-sustaining functions. Depending on the intensity of the pressure, professionals recognize hypotension, normal blood pressure, and hypertension. In order to find out one’s condition, a person should have his/her blood pressure measured. The results will be defined in two numbers that reveal systolic and diastolic blood pressures. The first one shows how much pressure is exerting when the heartbeats, while the second one focuses on the time when the heart rests.

A lot of people today suffer from high blood pressure nowadays. Weber et al. (2014) indicate that “about one-third of adults in most communities in the developed and developing the world have hypertension” (p. 1). It is the most common chronic health condition that affects the global population. This issue is widely recognized that is why not only primary care professionals but also other practitioners deal with it. This paper will synthesize relevant to the topic information obtained from the current literature to develop and justify various approaches and define the best treatment option.

Professionals indicate that it is critical to pay enormous attention to the patient’s blood pressure levels because they are tightly connected with other health-related issues. For example, because of hypertension, individuals can face cardiovascular problems, strokes, and kidney disease. Those who have a blood pressure of around 115/75 mm Hg are the least likely to deal with the mentioned complications. Increased rates of hypertension are currently observed because of two causes. The first one is the increased age of the individuals, which makes them more vulnerable.

As a rule, it happens with those people who are more than 50-60 years old. It is significant to consult a doctor regularly because this problem can face regardless of other factors. Moreover, diastolic pressure starts to decrease very often, which makes people think that they are fine however systolic pressure may increase during the rest of their life. The second reason is obesity that is among the most critical issues in the USA and other countries. Salt intake can also be a trigger of increases in high pressure that is why it is significant for the patients to pay attention to their diet.

To diagnose hypertension, professionals refer to clinical guidelines such as Clinical Practice Guidelines for the Management of Hypertension in the Community (Weber at al., 2014). According to it, they need to conduct a repeated examination, during which a person’s blood pressure is to be ≥140/90 mm Hg for adults between 18-80 years. For those who are older, systolic blood pressure up to 150 mm Hg is normal. When the issue is revealed, physicians indicate the necessity of treatment, which presupposes various interventions aimed at the reduction of blood pressure.

Professionals state that according to the research studies the best results are 115/75 mm Hg. However, they believe that it is not obligatory to reduce the high blood pressure to these numbers. What is more, there is no evidence that can justify a particular level to which hypertension should be treated. One more drawback deals with the fact that the adult population is considered as a whole while those who are 18-55 years old and those who are older may have more benefit when defining hypertension at different levels and receiving various treatments as their health conditions tend to have lots of discrepancies. For example, Weber et al. (2014) notice that some recent studies recommend addressing hypertension with 130/80 mm Hg for “patients with diabetes or chronic kidney disease” (p. 2). However, no changes in the general guideline were made.

Hypertension is classified into several categories. 120/80 – 139/89 mm Hg is a prehypertension stage that does not require any pharmacological treatment and can be addressed with lifestyle changes. Stage 1 is diagnosed with 140/90 – 159/99 mm Hg, and stage 2 with ≥160/100 mm Hg. Healthcare professionals differentiate primary (essential) and secondary hypertension. The first type of condition is defined in 95% of all cases. Its causes are still unknown, but the situation can be affected by genetic and environmental factors (Revanasiddappaa & Bhadauria, 2013).

In this way, attention should be paid to salt intake, obesity, diet, stiffening of the aorta with age, or high activity of the sympathetic nervous. Secondary hypertension is rarely observed, but its cause can be found so that the possibility to treat the condition exists. As a rule, it deals with chronic kidney disease, pheochromocytoma, “sleep apnea, renal artery stenosis, and hyperaldosteronism” (Börgel et al., 2010, p. 500). Gladding, Patrick, Manley, Mash, and Shepherd (2015) state that hypertension may be inherited in about 65% of all cases. Moreover, a research study was conducted by scientists to identify “a number of genes and single nucleotide polymorphisms… such as ATP2B1 and CYP17A1” (p. 299). Still, the results proved that they affect people’s blood pressure only on 1 mm Hg, which is not critical.

It is impossible to make a diagnosis of hypertension without blood pressure measurement. Healthcare professionals can refer to a conventional sphygmomanometer or by an electronic device. In fact, it is believed that the electronic device is preferable because it reduces the influence of technique variations and observer’s biases. If it is not available, arm cuffs should be used instead of the finger and wrist one’s because they are more accurate. Initially, the pressure should be measured in both arms to obtain the most reliable results. If it differs, the highest results are to be considered.

The measurement should be conducted when the clients emptied their bladders and are sitting in the uncrossed position. The arm used for the measurement should be on the same level as the heart. In addition to that, it is better to maintain two readings after 1-3 minutes. The second one can be done when a patient stands to consider postural changes in the elderly. The diagnosis can be confirmed at the next patient visit in 1-4 weeks. The results obtained during it should also confirm hypertension. Only if the results were initially very high, the diagnosis could be made on the first visit and treatment offered. Of course, these procedures can be maintained only by those professionals who have already received the required treatment and are able to work with related techniques.

It is significant for healthcare professionals to pay attention to the client’s behavior because one can have white-coat hypertension. It deals with the fear and stress people face when they are in the clinic. If this condition is suspected, professionals recommend home readings. What is more, home measurement provides an opportunity to consider changes in blood pressure in relation to treatment and different biases so that more useful treatment approaches can be provided.

Diagnosis procedures should include several elements. Patient evaluation focuses on:

• Personal history: previous cardiovascular events, including strokes, chronic kidney disease, diabetes, sleep apnea, etc.
• Physical examination: measurement of blood pressure, pulse, body mass index calculation, waist circumference, signs of heart failure, neurologic examination, and eyes.
• Selective testing: blood or urine sample, electrocardiography.

Students and professionals can obtain this information from the peer-reviewed articles that can be found online or in a printed version. For this paper, a literature search focused on such databases as ProQuest, PubMed, ScienceDirect, and GoogleScholar. The articles were reached using such key words and phrases as hypertension, high blood pressure, adult population, diagnosis, treatment, genetics, guidelines, losartan, and drug treatment.

All in all, healthcare professionals are expected to manage hypertension and deal with the most critical risk factors for cardiovascular disease. They are targeted at the reduction of blood pressure until it is <140/90 mm Hg for general patients. Some scientists also recommend to reach <130/80 mm Hg for those individuals who have related complications, but this claim is not well-grounded and is rarely considered because of the lack of reliable evidence. To reach positive health outcomes, it is significant to make the patients realize that their treatment is a life-long process that should not be terminated. As a rule, it includes both non-pharmacological and pharmacological approaches. Regardless of the severity of hypertension, healthcare professionals recommend their patients to implement lifestyle interventions. What is more, they are to keep to them constantly because only in this way this issue and other cardiovascular risk factors can be treated.

For example, those individuals who have stage 1 hypertension or less can see improvement in 6-12 months of a new lifestyle. They can even omit taking medicines, which is preferable. However, if patients have more critical issues and it is clear from the very beginning that their blood pressure does not correspond to the lifestyle or there are some other complications (health issues or inability to make regular clinic visits), it is better to start taking medicines earlier. All in all, non-pharmacological treatment is usually used as a complement to pharmacological one. Usually, professionals recommend such lifestyle changes as: Weight loss. Overweight and obesity are those risk factors that increase chances of having hypertension. Reducing their weight, patients are likely to cope with this problem. In addition to that, it can be helpful with diabetes and lipid disorders.

Even modest changes can bring positive results. Still, patients can face difficulties if they receive no support from people around them. It is recommended to eat fresh fruits and vegetables, which can be relatively expensive and inconvenient for patients, unfortunately (Ghezelbash & Ghorbani, 2012). Salt reduction. Many people often eat salty food, which increases their chances to have high blood pressure. What is more critical, many of them even do not realize that they have large amounts of salt every day because it is included in bread, canned products, and other products in which people do not put salt directly. In the same way, their food often lacks potassium. Thus, they need to be educated regarding the appropriate dietary.

Exercise. A regular structured aerobic exercise regimen can help patients to cope with hypertension. Unfortunately, it is not always available, so professionals encourage their clients to integrate physical activities into routines, walk more, use stairs, etc. Alcohol consumption. Males should have up to 2 drinks a day, and females should have 1 drink a day to reduce blood pressure and prevent other cardiovascular events. Greater amounts of alcohol will have the negative impact on their health condition. Stopping smoking. Even though cigarette smoking does not affect blood pressure directly, it is the main cardiovascular risk factor. People should try to discontinue it to enhance their condition. Still, there is a possibility to gain weight, and patients should be aware of it.

If changes in lifestyle turn out to be ineffective and a patient’s blood pressure is >140/90 mm Hg, healthcare professional should start drug treatment. Still, the initial state of hypertension and absence of abnormal risk factors can be used as a reason to delay pharmacological treatment for several months. A 2-drug combination is needed to treat patients with stage 2 hypertension. Individuals who are more than 80 years old and have the blood pressure of ≥150/90 mm Hg should also be treated with medicaments. The effectiveness of the selected treatment can be perceived in 1-8 weeks that is why a change in the dosage or usage of additional drugs is usually maintained in 2-3 weeks after the initial prescription. If the patient’s blood pressure is 20/10 mm Hg higher than needed, professionals recommend using 2 drugs simultaneously (Makridakis & DiNicolantonio, 2014).

Drugs are selected on the basis of various factors. Thus, professionals consider age, other clinical characteristics, and related health conditions. Doses depend on the drugs that they can be long-acting and short-acting. Their availability and affordability are to be discussed because the patient should be able to obtain prescribed medicine. Drugs of several classes can be used to treat hypertension:

• Angiotensin-Converting Enzyme Inhibitors. They block the renin-angiotensin system, which affects blood pressure. They are well tolerated and can be used by the majority of patients. Still, it rarely leads to angioedema (e.g. captopril).
• Angiotensin Receptor Blockers. They affect the renin-angiotensin system and are well tolerated. Being available, they are often preferred over the angiotensin-converting enzyme inhibitors but cannot be used along with them. They also cannot be used during pregnancy (e.g. losartan).
• Diuretics: They can be thiazide and thiazide-like. They reduce blood pressure increasing excretion of sodium. Still, they can have metabolic side effects. They can be combined with other medicines (e.g. hydrochlorothiazide).
• Calcium Channel Blockers. These drugs block the inward flow of calcium. They can sometimes lead to peripheral edema. To avoid it, professionals tend to combine them with other drugs (e.g. verapamil).
• β-Blockers. They reduce cardiac output and are often prescribed to patients who had myocardial infarction or heart failure even though an ordinary patient is likely to notice a less significant improvement (e.g. propranolol).
• α-Blockers. They block arterial α -adrenergic receptors and are rarely used as first-step agents. They are often combined with other drugs, especially diuretics. They are good for men with prostatic hypertrophy (e.g. prazosin).
• Centrally Acting Agents. They reduce sympathetic outflow and allow to each positive effects in most patient groups. They can lead to drowsiness and dry mouth but are widely used to reduce blood pressure in pregnancy (e.g. clonidine).
• Direct Vasodilators. They are used as fourth-line treatment as a rule because can cause fluid retention and tachycardia (e.g. hydralazine).
• Mineralocorticoid Receptor Antagonists. They are usually used in a low dose in treatment-resistant patients and often lead to gynecomastia and sexual dysfunction (e.g. spironolactone).

Of course, different treatment options can be recommended to cope with hypertension, but this paper will focus on the usage of angiotensin receptor blockers, losartan, in particular. This drug prevents blood vessels from narrowing, which allows to improve patient’s condition. What is more critical, this medicine can be used to prevent strokes. Unfortunately, it cannot be used during pregnancy, but an ordinary patient is likely to benefit from such treatment (Meredith, Murray, & McInnes, 2010).

Losartan, just like the majority of other drugs is prescribed by a healthcare professional after a thorough examination. The dose depends on individual’s condition but generally it equals 25-100 mg (Siyad, 2011). For the blood pressure to reduce, a patient should take it for 3-6 weeks. If a dose is missed, no extra one is needed. Professionals recommend taking another dose according to the schedule. Losartan is likely to bring more positive outcomes when being combined with amlodipine. Hong, Park, Kim, Yoon, and Yoon (2012) recommend a “fixed-dose amlodipine/losartan 5 mg /100 mg” (p. 194). Park, Youn, Chae, Yang, and Kim (2012) conducted research that proved that better outcomes are obtained with not with monotherapy but with a combination of camsylate and losartan “5 mg/50 mg, 5 mg/100 mg and 10 mg/50 mg” (p. 46). Thus, it can be claimed that losartan is an appropriate drug for treating hypertension, but it is better to combine it with other medicine to achieve more significant results.

High blood pressure is a critical issue that affects people’s health adversely. To diagnose hypertension, professionals should refer to clinical guideline and assess patient’s condition, paying attention to both systolic and diastolic blood pressure results. However, more emphasis is often made on systolic blood pressure because it is the main factor that can be used to identify cardiovascular diseases and hypertension. The risk of hypertension may increase because of other conditions.

As a rule, it is observed along with lipid issues, diabetes, obesity, cardiovascular diseases, and smoking. Considering the fact that lots of people are affected by this condition, professionals develop numerous diagnosis and treatment approaches that can be used to improve the overall health of the population. To define the most appropriate blood pressure treatment (non-pharmacological or pharmacological one), different factors should be considered including age, other diseases, pregnancy, etc. This paper, for example, recommends a combination of losartan with other drugs.

Healthcare professionals and scientists should pay attention to those diagnosis and treatment approaches that were discussed in this paper because they define what will be advantageous for the patients. They should address those gaps that were identified and try to fill them to improve the knowledge in the sphere and provide others with evidence. A research study should be maintained to consider differences in treatment of young adults and those who are older than 80 years. In addition to that, a particular level to which hypertension should be treated is to be identified. For now, this paper can be used as a basis when examining a patient and developing a diagnosis. Finally, it can help professionals select the most appropriate treatment option.

References

Börgel, J., Springer, S., Ghafoor, J., Arndt, D., Duchna, H., Barthel, A.,… Mugge, A. (2010). Unrecognized secondary causes of hypertension in patients with hypertensive urgency/emergency: prevalence and co-prevalence. Clinical Research in Cardiology, 99(8), 499-506.

Ghezelbash, S., & Ghorbani, A. (2012). Lifestyle modification and hypertension prevention. ARYA Atherosclerosis, 8, S202-S207.

Gladding, P.,Patrick, A., Manley, P., Mash, L., & Shepherd, P. (2015). Personalized hypertension management in practice. Personalized Medicine, 12(3), 297-311.

Hong, B., Park, G., Kim, S., Yoon, H., & Yoon, J. (2012). Comparison of the efficacy and safety of fixed-dose amlodipine/losartan and losartan in hypertensive patients inadequately controlled with losartan. American Journal of Cardiovascular Drugs, 12(3), 189-95.

Makridakis, S., & DiNicolantonio, J. (2014). Hypertension: empirical evidence and implications in 2014. Open Heart, 1(1), 1-8.

Meredith, P., Murray, S., & McInnes, T. (2010). Comparison of the efficacy of candesartan and losartan: a meta-analysis of trials in the treatment of hypertension. Journal of Human Hypertension, 24(8), 525-31.

Park, G., Youn, H., Chae, C., Yang, J., & Kim, H. (2012). Evaluation of the dose-response relationship of amlodipine and losartan combination in patients with essential hypertension. American Journal of Cardiovascular Drugs, 12(1), 35-47.

Revanasiddappaa, M., & Bhadauria, D. (2013). The role of genetics in hypertension. Clinical Queries: Nephrology, 2(3), 120-125.

Siyad, A. (2011). Hypertension. HYGEIA: Journal for Drugs and Medicines, 3(1), 1-16.

Weber, M., Schiffrin., E., White., W., Mann, S., Lindholm, L., Kenerson., J.,…Harrap, S. (2014). Clinical practice guidelines for the management of hypertension in the community a statement by the American society of hypertension and the international society of hypertension. The Journal of Clinical Hypertension, 1, 1-13.

Introduction

One important lesson in medical education is how to measure the vital signs of life such as blood pressure. For one to understand how to perform this accurately, it requires attention to detail, correct technique and careful listening (Kier, Wise and Krebs, 2003). The term blood pressure is taken from the fluctuating pressure that blood applies against arterial walls as the heart alternately expands and contracts.

This pressure is useful in that it can be used to assess the condition of the heart, amount of blood forced out of the heart at contraction, condition of the arteries and to some extent the viscosity and volume of the blood (Kier, Wise and Krebs, 2003). The blood pressure of an individual is measured in the brachial artery of the arm at the antecubital space (See Figure I).

Initially measurement should be performed on both hands as there is normally a 5-10mm difference (Kier, Wise and Krebs, 2003). After this subsequent readings should be continued on the arm with higher pressure. The maintenance of blood pressure is mainly the result of two related factors. The first being the heart which is responsible for pumping blood round the human body.

The human heart reportedly contracts almost 100,000 times daily forcing blood through the aorta and the entire range of blood vessels (Kier, Wise and Krebs, 2003). A strong pump is essential to make sure that the blood flows and the pressure does not drop.

In this report a discussion will be presented on how to provide a computer mediated lesson to teach how to measure blood pressure to a group of students. In addition to this a suitable method of evaluation will be selected to assist the instructor assess how well the learners understood the topic. Also to be discussed in the report is the role and effectiveness of one authoring tools that will be used in presenting the learning material to the learner’s.

Method of Evaluation

The purpose of evaluation of a learner is to establish whether what was taught has been understood (Reeves & Hedberg, 2003). It is reported that the most important function of evaluation is review of what has been presented to the learner. It is hoped that through reviewing the highlights of what was learnt the learner can recap and develop a sound understanding of the concepts taught (Reeves & Hedberg, 2003).

Prior to taking an evaluation it is important that the learner review the text or the material that was used in instruction. Another crucial but sometimes underutilized function of evaluation is needs assessment (Reeves & Hedberg, 2003). In the case of taking blood pressure it may be crucial that a needs assessment form part of the evaluation process depending on at which stage the learners are in the course.

In this case a practical needs assessment evaluation may need to be undertaken to ensure the learner is fully conversant with what is required to successfully carry out the blood pressure test. This would is sometimes known as a formative evaluation. A more detailed test may require a learner to carry out the actual tests and record results. Such an evaluation is more rigorous and may be classified as a formative evaluation.

As indicated above the evaluation methods used can either be formative or summative. In the case where formative evaluation is used the goal of the teacher is to establish the progression of students towards meeting the learning goals. In this case this suggests progress in the class towards learning how to complete the test and its relevance (Oermann and Gaberson, 2009).

On the other hand where summative evaluation is used the goal of the teacher will be to establish the student has completed the set of goals required within the rotation such as a term or semester (Oermann and Gaberson, 2009). This position shows clearly that the assessment will depend on the duration for which this task will be covered and whether it will be part of a set of tasks that are completed within a length of time.

However, if the task is a one off affair a formative evaluation will be appropriate. This may include a brief set of questions to ascertain whether the learners were paying attention during the lecture. Some questions on what materials are required and the main points of how to take a blood pressure reading could form the evaluation.

Instructional techniques

In the selection of an appropriate instructional technique it is important to know when a specific instructional technique is best applied. Given that that this lesson will be computer mediated it appears a lecture will be the most suitable technique for providing the lesson or lessons. This is because lectures are best applicable to a lesson when the instructor intends to give an overview of a greater issue (Sharma, 2007).

The lecture can be taken to e appropriate as it allows the instructor a longer time to discuss the issue at hand. As with the case of taking blood pressure a lecture or series of lectures is important as it will help put the issue into its correct perspective. As with any illness it is necessary to understand causes and possible circumstances to avoid.

A lengthy discussion such as this would require ample time. In addition to time to speak the instructor can make use of the computer or information technology to make the lecture more interesting (Sharma, 2007). This is because a lecture is also useful when the instructor wants to aid or supplement student reading.

In such cases an instructor can ask the class to read on a specific topic and later prepare a brief lecture or series of lectures to expand on the materials that the learners covered in their individual reading. A lecture is also useful when the instructor needs to provide the learner with background information on the topic. In such cases the learner will then be able to go about the study of the topic more intelligently (Sharma, 2007).

Without an appropriate introduction it is sometimes impossible for a learner to determine how deep and wide to study the desired subject. However, for introductory purposes a lecture can be very appropriate. Another reason why the lecture may be an appropriate mode of instruction is because the instructor may want to allow the students more time for in depth study or assignments or other tasks (Sharma, 2007).

Given that this task was to be accomplished in a semester of a nursing course it is likely that the student would be required to handle some assignments after completing the lesson. It is not uncommon for learners to be given tasks such as assignments to assist them gain deeper understanding (Sharma, 2007). In such a case therefore a lecture will be useful in acting as a suitable eye opener and providing descriptive boundaries to consider when doing further reading.

A lecture can also be very useful when the instructor wants to arouse interest in the learner. Introducing a new and perhaps complex article is likely to be difficult and complicated. However, with the use of an interesting well arranged and presented lecture a student can be aroused and enticed to enjoy an otherwise difficult or complex topic (Sharma, 2007).

In addition to the above the instructor may want to use the opportunity of a lecture to teach terms associated with the topic or clarify common misconceptions. Such occasions are best dealt with when the instructor opts to give an audible explanation. In addition to providing information this also acts as an opportunity to allow learners to ask questions about the topic.

Learner Activities

Since the subject matter in this case is related to medical studies we will use some information from medical studies to guide us in selection of learner activities. It has been reported that medical studies are best learnt when the learner s are motivated (Distlehorst, Dunnington and Folse, 2000).

It has bee suggested that an interesting activity that may captivate the learner’s upon completion of the lecture is a practical opportunity to attempt to take the blood pressure and listen in on the different phases. Blood pressure phases are identical to the phases of the pulse and an opportunity to physically perform the examination should be fairly exciting to most of the students (Kier, Wise and Krebs, 2003).

In addition to that another activity that the learner’s can participate in where the course is being offered near a clinic is an arrangement to walk in at scheduled times and assist the nurses in performing the examination. This activity is thought to be useful as learning is thought to be efficient when there is feedback to the learner (Distlehorst, Dunnington and Folse, 2000).

Such an opportunity is bound to be efficient as there is immediate feedback each time the student does something the right or wrong way. In addition to the above two the normal activities such as assignments may also be used to follow up on learning and even for evaluation of learning.

Computer Mediated Learning Authoring Tool

For the purposes of preparing a lecture or series of lectures on how to take blood pressure measurement a multimedia authoring tool such as PowerPoint may be used. Such tools allow the user to bring together various multimedia components to bring together a powerful presentation (See Figure I). For example on may incorporate pictures, audio and tables or charts and even video to make the presentation of a lecture very interesting (Stroman, Wilson & Wauson, 2008).

PowerPoint is typically called a slide show program and its main feature is it allows the preparation of a presentation one slide at a time or in a linear fashion. Each slide can allow the presenter to attach any of the multimedia content earlier mentioned and may allow some degree of branching (Stroman, Wilson & Wauson, 2008). The software was selected because it is readily available and fairly easy to learn.

References

Distlehorst, L. H., Dunnington, G., & Folse, J. R. (2000). Teaching and learning in medical and surgical education. Mahwah, NJ: Lawrence Erlbaum Associated Inc.

Keir, L., Wise, B. A., & Krebs, C. (2003). Medical Assisting: Essentials of Administrative and Clinical Competencies. Ontario: Delmar Learning.

Oermann, M. H., & Gaberson, K. B. (2009). Evaluation and Testing in nursing education. New York: Springer Publishing Company, LLC.

Reeves, T. C., & Hedberg, J. G. (2003). Interactive Learning Systems Evaluation. Engelwood Cliffs, NJ: Educational Technology Publications, Inc.

Sharma, T. C. (2007). Modern Methods of Teaching Social Studies. New Delhi: Sarup & Sons.

Stroman, J., Wilson, K., & Wauson, J. (2008). Administrative Assistants and Secretary’s Handbook. New York. Amacom.

Welcome Page

There are set processes in which storyboards are created for instance for films and animations either for study or for educational purposes. Being skeletons that give a step-by-step view of what is expected for any given procedure; storyboards become centrally important tools that assist the understanding of complex procedures that would otherwise be reserved for professionals and academicians alone.

For this assignment, the concept of storyboards is used as a lesson for how to take blood pressure and in doing so, the paper will discuss details of the importance of consistent taking of readings of one’s blood pressure as well as discussing some of the equipment that are used in the process of taking and checking blood pressure. This means that this storyboard will be a lesson dubbed: Taking Blood Pressure.

Introduction Page

Before delving into the processes that were arrived at in the making of the storyboard fort taking blood pressure, it is appropriate first of all to briefly describe what exactly is meant by storyboarding process. The creation of this storyboard is created in a number of steps so as to come up with a creative and useful thing.

The history of storyboards has been that they can be created either by hand or other designers have used digitized computer programs to draw and design them (Struijk, Mathews & Loupas, 2008). For the case that the storyboard is created by hand, the practice has been that the first step is to get a template which may either be downloaded or drawn manually.

For cases where the designers and producers require details in their designs that are of greater content, storyboard artists usually prepare the storyboards either by a way of hand or by using special programs that are used to draw storyboards in two dimensions (Struijk, Mathews & Loupas, 2008).

There are other software that may be used to create superior storyboards that contain greater details that express the exact intentions of the story as presented by the producer and director of the film or animation. After properly preparing these storyboards, they are usually presented to the given project management which forwards to its cinematographer who sees that what has been created achieves the vision and intentions of the director (Struijk, Mathews & Loupas, 2008).

Having briefly discussed what storyboards are and how they are created, the next important area of discussion is the subject of the storyboard taken for this paper and this is Taking Blood Pressure. First of all, blood pressure is a human condition which medically is generally described as the pressure that builds in the blood vessels due to the blood circulating in them after being pumped by the heart.

The heart usually pumps in two basic ways that creates moments of highest pressure called the systolic pressure and one that creates moments of the lowest pressure called the diastolic pressure in the blood vessels (Booth, 2007). This pressure is highest in the blood vessels that are closest to the heart and continually decreases slowly as the blood flows further from the heart. This decrease is caused by the resistance of the walls of these blood vessels such as arteries as the blood flows in them.

The body vessels that carry blood around the body usually decrease in size systematically as they approach specific organs where the blood is to deliver its products of respiration and these final blood vessels are usually tiny and therefore when blood enters them, its pressure reduces substantially such that by the time the blood is circulating back to the heart through the veins, its pressure barely moves it back to the heart for the process to begin again.

Valves are features of veins which prevent back flow of blood when a person is standing upright since the pressure in these veins is usually significantly low (Booth, 2007).

It is observable from the foregoing explanation that when there is a problem with the blood pressure, it may lead to catastrophic problems for someone since this pressure is imperative to be sufficient to carry the blood around the body but again not too much to injure (and at times burst) the arterial walls.

It is common practice to take the blood pressure of a person from the brachial artery which is usually located on the inside of the elbow since this is among the most sensitive parts of a human body that reflects the most accurate arterial pressure of a person. This pressure is usually expressed as a fraction of the systolic pressure over the diastolic pressure in millimeters of mercury (mmHg) such as 138/87.

It is very important to ensure that one’s blood pressure is regularly checked to ensure that it is within the medically safe region since when it is not put in check, it may lead to hypertension which is a condition where the arterial blood pressure is too high that it risks causing heart diseases and other related diseases that may lead to abrupt death.

According to Booth (2007), the generally accepted blood pressure reading that are considered normal in the medical world usually range around 120 over 80 where the first number is the systolic reading and the second number is the diastolic reading written as a fraction as earlier on indicated (Booth, 2007).

It is generally considered that pre-hypertensive states are observed when one’s pressure is anywhere between 120 and 139 over anywhere between 80 and 89 and high blood pressure (hypertension) is considered when one’s reading clocks anywhere between 140 and 159 over anywhere between 90 and 99 (Booth, 2007).

There are critical phases of hypertension where patients record readings as high as 160 and above over 100 and above and usually these stages are so critical that death may occur very easily through heart attacks and related conditions.

It is however appropriate to mention that merely having elevated blood pressure readings does not necessary mean that one has hypertension since there are other factors that may lead to elevated blood pressure readings and this factors include times where the immune system is low caused by illness or an infection or even due to stress (Booth, 2007).

This notwithstanding, it is very important to keep close track of one’s blood pressure since there are basically no known symptoms that can distinctively be said to the signs of high blood pressure or other related blood pressure conditions. Known symptoms at time as usually as mild as simply having difficult in sleeping, dry mouth or even emotional upsets.

The commonest symptom however that is observed in all blood pressure patients is having headaches and even this is not a final pointer of hypertension as there are just as many who experience excruciating headaches and yet do not suffer from hypertension (Booth, 2007). This means that it is imperative to get medical advice whenever there is something that is feared to be blood pressure related rather than merely speculating about it.

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There are different parts of a human body that are generally prone to blood pressure related problems which makes it very important to be careful with how this pressure is observed and monitored. The two commonest conditions that result in blood pressure are high blood pressure (hypertension) and low blood pressure (hypotension) conditions.

This notwithstanding, any pressure resisting blood flow in the arteries strains the arterial walls and that only has its potential risks that cannot be overlooked. High pressure against the blood flow usually increases the rate at which the heart has to work to meet the same demand of body organs of the supply of blood and this usually leads to unhealthy tissues called atheroma to grow within the walls of the arteries.

Continued increased blood pressure causes the heart muscles to overgrow with additional tissues that make it generally weak and this becomes a prime recipe for strokes, heart failures, heart attacks and what is called arterial aneurysms; a major cause of chronic renal failure (Booth, 2007).

On the contrary, hypotension is not usually a big medical bother unless it reaches critical levels that cause dizziness and/or fainting (Booth, 2007). This happens when the arterial pressure reduces so much to a critical level where the perfusion of the brain is changed to become extremely decreased which means that there is insufficient supply of blood to it.

This should however not be confused by orthostatic hypotension which is a condition where gravity in some cases reduces blood pressure significantly when someone stands up from a sitting position and in the process may experience dizziness as a result of reduced cardiac output due to reduced stroke volume. Other causes of hypotension include sepsis, blood loss, eating disorders like anorexia nervosa, and hormonal abnormalities like the case of Addison’s disease and among others (Booth, 2007).

There are different ways that are used in taking blood pressure and this can be either at home (for personal regular checkups) or in a hospital (in the event that there is real concern to warrant medical attention).

All of these procedures, taking of the readings is usually simply done by using special equipment that when strapped to different parts of the body (especially the inner side of an arm around the elbow point or on the tip of a finger) show the readings of the blood displayed as a fraction with the systolic reading presented over the diastolic reading (Booth, 2007).

Some of the common equipment that are used include the aneroid monitor which has a dial gauge that shows reading via a pointer and the other common one is the digital blood pressure monitor which can either have automatic or manual cuffs and usually has an in-built stethoscope that helps it to flash its reading on a digital screen (Booth, 2007).

Another equipment that is used in hospitals is the sphygmomanometer which uses the height of a mercury column to indicate its readings that are given in millimeters of mercury (mmHg). The figure below shows some of these equipments.

Figure 1. Types of Equipment that are used to measure blood pressure

Enabling Objectives

The following are the enabling objectives for lesson on taking Blood Pressure.

• Simplicity – it was desirable to ensure that the lesson that is presented is simple to follow and understand for ease of design and production.
• Cost effectiveness – this is an objective that required that the storyboard’s cost as compared to its quality and usage measures up to a given margin that is meaningful and rational.
• Relevance – this was an objective that required that the storyboard is relevant for the purpose for which it is designed which was to work as a lesson for taking blood pressure readings.
• Social interactiveness – this objective was to ensure that the lesson was acceptable in the cases of its diverse audience were critical about it. It was intended to identify with the social networks of the persons that would be reached by it.

Instructional Unit

The following are four core questions that are presented to gauge the understanding of this lesson to anyone who partakes in it. They are true of false questions.

1. Blood Pressure is a condition that is difficult to observe and one that does not have distinct symptoms.
   1. True
   2. False
2. The process of taking blood pressure requires professional training and therefore people with such knowledge cannot take blood pressure readings.
   1. True
   2. False
3. Anytime there is a slight deviation in the blood pressure taken is an indication that there is either hypertension or hypotension and therefore one needs get serious medical attention.
   1. True
   2. False
4. Blood pressure is a condition that when left to get to critical levels can become lethal and even cause death through strokes, heat failures and heart attacks.
   1. True
   2. False

References

Booth, J. (2007). A Short History of Blood Pressure Measurement. Proceedings of the Royal Society of Medicine, 70(11), 793–799.

Struijk, P., Mathews, V.J., & Loupas, T. (2008). Blood Pressure Estimation in the Human Fetal Descending Aorta. Ultrasound Obstet Gynecol 32(5), 673–681.

Introduction

The force that the heart exerts on the body’s arteries when pumping blood determines an individual’s systolic blood pressure. On the other hand, diastolic pressure is recorded when the heart relaxes. In a case where the general practitioner records the figures such as 115/85, the upper number indicates an individual’s systolic pressure while the lower one denotes his or her diastolic pressure.

Using the example of Mr. Joe, this study presents the fundamental physiological mechanisms that help in regulating one’s blood pressure, including a detailed discussion of why accuracy is crucial when recording blood pressure levels. It will also confirm that indeed Mr. Joe’s elevated blood pressure has the potential of causing stroke and even death if left unchecked. Hence, the general practitioner may recommend several measures such as the need for a thorough exercise and proper diet in addition to regular prescriptions to lower the patient’s blood pressure.

Physiological Processes

A healthy human body is designed in a manner that allows it to automatically maintain the required blood pressure and flow levels (Khan Academy 2018). In other words, it has a mechanism that detects pressure levels in blood vessels. This information is relayed to the heart and kidneys among other components such as veins that adjust their operations to decrease or raise the respective person’s blood pressure. The entire pressure regulation process may involve varying the capacity of blood that the heart directs to arteries or changing the level of blood in one’s veins. The body may also respond by altering the general blood volume. For instance, to raise pressure levels, the rate of heart pumping or contraction may go up to allow more blood to be distributed to the respective arteries and systems.

In addition, veins help to raise or lower the blood pressure by increasing or decreasing their diameters. For instance, when they inflate, they hold a larger volume of blood, thereby barring the amount that goes back to the heart for distribution to an individual’s arteries. In this case, since the volume it releases is low, blood pressure also goes down. Consequently, when they deflate, they hold a smaller volume to the extent that more blood finds its way to the heart for pumping, a situation that raises pressure in the arteries.

Kidneys also play a key role in regulating blood pressure in the body. It is crucial to point out that these body organs help to eliminate unnecessary fluids such as urine from the blood. In other words, when kidneys take high volumes of urine from the blood, arteries and veins are left with a lower blood capacity flowing through them, implying a reduction in the underlying blood pressure. However, since the elimination of urine from the blood takes time, it is necessary to point out kidneys’ blood pressure regulation is not as effective as the other discussed mechanisms.

As an illustration, a person may bleed excessively after being involved in an accident. Such a situation lowers his or her blood pressure. To restore the pressure to the required levels, the body may react by raising the speed of heart pumping. In this case, the heart contracts at a higher rate to distribute more blood to all vessels. In addition, the diameter of veins reduces to allow more blood to the heart for distribution. Moreover, the amount of blood to the kidneys goes down to lower the rate of urine formation, consequently retaining most of the blood in the vessels to maintain the pressure high. Such responses take place based on an individual’s blood pressure requirements in the body.

Blood Pressure

Accurate Blood Pressure Measurement

According to NICE (2011), accurate blood pressure figures help to get the correct number of obese people in a country, hence facilitating the establishment of the correct measures, including the manufacturing of adequate anti-hypertension prescriptions (NICE 2011). For instance, in case inaccurate figures are recorded following an erroneous additional 5 mm Hg, a huge number of people wrongly identified as obese may be subjected to medication, a situation that may ultimately interfere with their health.

In addition, a country will end up spending excess funds handling such cases. In other words, accurate blood pressure records not only ensure that only hypertensive patients are treated but also pave the way for countries to allocate the appropriate amount of finances to address obesity or hypertension cases.

Very few patients question the accuracy of blood pressure figures presented to them. In addition, nurses do not take time to prepare patients in a manner that they (patients) can facilitate the achievement of accurate blood pressure results (NICE 2011). Figure 1 below shows various areas that nurses can check with patients when assessing their blood pressure to get accurate results.

Incorrect diagnosis may lead to the prescription of the wrong drugs, a situation that subjects patients to undesirable health complications such as stroke (Abete et al. 2018). From the above information, nurses who end up recording inaccurate blood pressure figures expose the concerned patients who they classify as hypertensive to unnecessary pills that are counterproductive to their health. Such misdiagnosed patients may suffer mental complications and extra expenses, which could have been avoided if the respective general practitioners were keen to take the right blood pressure readings.

Impact of Mr. Joe’s Blood Pressure on His Health

Any patient whose systolic blood pressure figure reads above 120 is considered at risk of experiencing hypertension. Specifically, a systolic figure above 130 indicates that a patient has high blood pressure. Mr. Joe has a systolic figure of 160, meaning that he is already obese as the general practitioner observes. Although the patient engages in regular exercise, his continued consumption of fatty foods seems to have contributed significantly to the elevated blood pressure. Figure 2 below shows the impact of high blood pressure on a person’s health.

Abete et al. (2018) assert that patients with high blood pressure may experience stroke following an insufficient blood supply to their brains. Such a situation occurs when vessels that take blood to the brain are gradually weakened following the constant elevated pressure. Moreover, it is crucial to point out that Mr. Joe may suffer from heart failure, especially when it (heart) is exhausted after an extensive period of forceful pumping of blood.

According to Balije et al. (2016), high blood pressure levels have led to the death of many patients. In other words, Mr. Joe risks succumbing if he fails to eliminate the fatty foods he takes on a regular basis. In addition, since kidneys contribute to the regulation of blood pressure, Mr. Joe may experience kidney breakdown since proper functioning of this organ goes hand in hand with healthy blood vessels within or outside this body component.

The General Practitioner’s Recommendations

Once the doctor takes the reading, which depicts Mr. Joe as hypertensive, he or she may recommend various measures, including the need to redo the blood pressure measurement to confirm that the figures are indeed accurate. After ascertaining the accuracy of the readings, the health practitioner may recommend a change of diet for Mr. Joe. For instance, the doctor may propose the need for including more fruits and vegetables in the patient’s diet (British and Irish Hypertension Society 2018).

He or she may advise Mr. Joe to consume plenty of whole-grain diets, including fish and nuts. If the medical officer realises that Mr. Joe’s driving job is stressful to him, he may recommend a leave for him to concentrate on exercising, regular medication, and checking his daily diet. When properly implemented, such recommendations will facilitate the patient’s healing process.

Conclusion

The human heart plays a central role of ensuring that blood is pumped to all body parts to facilitate their operation. It achieves this goal by beating consistently to press and push blood to the intended destinations through various blood vessels. The need for taking accurate blood pressure figures has also been presented as vital in ensuring that patients who are given anti-hypertension prescriptions are indeed obese.

Inaccurate figures not only lead to health complications but also the allocation of excessive and unnecessary funds to manage cases of hypertension. Mr. Joe’s high blood pressure may subject him to health issues such as stroke, heart and kidney failure, and even death if it remains unchecked. However, the general practitioner can recommend the appropriate diet that is free of fats or sugars and thorough exercise to deal with the effects of high blood pressure.

Reference List

Abete, I, Zulet, M, Goyenechea, E, Blazquez, V, de Arce Borda, A, Lopez de Munain, A & Martinez, J 2018, ‘Association of lifestyle, inflammatory factors, and dietary patterns with the risk of suffering a stroke: a case-control study’, Nutritional Neuroscience, vol. 21, no. 1, pp. 70-78.

Balije, S, Kumar, A, Bhawani, G, Murthy, K & Kumari, N 2016, ‘Effect of hypertension at presentation on prognosis in patients with dilated cardiomyopathy presenting with normal renal angiogram’, Indian Journal of Medical Research, vol. 144, no. 2, pp. 281-287.

British and Irish Hypertension Society 2018, Annual scientific meeting. Web.

Khan Academy 2018, online video, what is blood pressure, California. Web.

NICE 2011, Hypertension in adults: diagnosis and management. Web.

Writer, S 2014, ‘How to get the most accurate blood pressure measurement’, AMA Wire. Web.

The provided case study describes HealthPartners’ Medical Group’s transition to using electronic health records (EHR) and its impact on the organization’s compliance with HEDIS Controlling High Blood Pressure measure. The transition was completed in 2005, showing a significant increase in the measure. However, there were challenges associated with the development, as well. This essay will examine the case study’s background and assess HealthPartners’ transition to EHR.

Background

Over the course of implementing EHR, the HEDIS measures for controlling high blood pressure increased significantly. Specifically, patients who are 46-85 years old and have had an outpatient encounter with a case of essential hypertension are included in the measure. They are considered to have their blood pressure under control if its reading is at most 140/90. The HEDIS band, ultimately, is derived from the percentage of eligible patients with hypertension that have their blood pressure under control.

Over the seven years of the study, HealthPartners’ blood pressure measure and HEDIS band saw a significant improvement. 56.8% of the patients had their blood pressure under control in 2000, and by 2006, the number increased to 67.4% (Fowles et al., 2008, p.11). Consequently, the HEDIS National Band performance improved from 3 to 2 (Fowles et al., 2008). The percentage peaked at 75.4% in 2005 and subsequently fell to its latest value due to a change in HEDIS guidelines (Fowles et al., 2008). This peak suggests a higher potential improvement caused by the EHR system.

Initial implementations of EHR had issues with verification and required to be manually checked until errors in logic were uncovered. Furthermore, difficulties arose from a lack of familiarity with the system, necessitating more manual reviews. Nonetheless, transitioning EHR ultimately reduced the need for manual review of patient medical records, which reduced costs. Although the case study presents these issues as temporary and typical for a newly-implemented system, they still warrant examination.

Assessment

Two issues in implementation are apparent in the case study. One of those issues is technological, allowing for inconsistencies in the system’s logic. Although said inconsistencies were amended, it is not clear whether the underlying error was resolved, which is essential because “a lack of preventive or root-cause analysis will cause repeated failures” (Balgrosky, 2015, p. 206). A possible inference is that the processes involved in its implementation were insufficiently structured. Based on this inference, one can recommend that HealthPartners adopt an information technology governance (ITG) framework, or review their adherence to the chosen one.

The second issue in HealthPartners’ transfer fell within the sphere of leadership, as evidenced by the lack of familiarity. It is possible that the employees received insufficient training in the new database tools or were otherwise unprepared to use it. The study by Stevens, Mailes, Goad, Longhurst, & Pantaleoni (2015) stresses the importance of end-user training since failed or insufficient training can “result in patient safety, quality, and efficiency issues” (p. 87). Therefore, if a recommendation is to be made, HealthPartners should improve their teaching for the current system. In the future, they should ensure that implementations of HIT measures allow sufficient time for providers to be trained in the use of said measures.

Conclusion

HealthPartners’ case study demonstrates a significant improvement in the HEDIS Controlling High Blood Pressure Measures following their transition to an EHR system. Based on these improvements, one can conclude that HealthPartners’ initiative was a success. However, issues that arose in the project can be inferred to have been caused by poor end-user-training and lack of rigor in the technology of the implementation. Based on these inferences, recommendations can be made to improve those aspects.

References

Balgrosky, J. A. (2015). Essentials of Health Information Systems and Technology. Burlington, MA: Jones & Bartlett Learning.

Fowles, J. B., Kind, E. A., Awwad, S., Weiner, J. P., Chan, K. S., Coon, P., & Selna, M. (2008). Performance measures using electronic health records: five case studies. The Commonwealth Fund.

Stevens, L. A., Mailes, E. S., Goad, B. A., Longhurst, C. A., & Pantaleoni, J. L. (2015). Successful Physician Training Program for Large Scale EMR Implementation. Applied Clinical Informatics, 06(01), 80–95. Web.

Community Health Initiative for Nurses

Free blood pressure screening for customers is an amazing initiative that can be effective in blood pressure control. Unfortunately, many people avoid seeing the doctor until they have a serious health problem (Office of Disease Prevention and Health Promotion, 2016). The atmosphere in a barbershop is friendlier and less tense, as compared with that in a hospital. Thus, people may feel safe discussing their health concerns or asking some questions. I believe that some people have known about their high blood pressure only thanks to this initiative, which makes it even more important.

Free blood pressure screening is a community health initiative for nurses as it engages them around improving health in the areas of safety and quality of life. Nurses are thus enabled to maximize their contribution to enhancing the community health, educating people about the importance of regularly monitoring their blood pressure, and addressing healthcare disparities (Harkness & DeMarco, 2016). This initiative not only encourages nurses to support the health sector but also recognizes their role in leading change.

Nurses’ Role in Health Policy

Nurses have a rich preparation in knowledge to participate in health policy decision making. One particular way they can influence health policy is by conducting research and considering the policy implications of their work (Arabi, Rafii, Cheraghi, & Ghiyasvandian, 2014). New protocols elaborated and tested by nurses, as well as evidence-based practices, may be further used as a basis for policy alternatives and modifications (World Health Organization, 2019). For example, Linda Aiken’s research on nurse staffing entailed the creation of regulations for staffing criteria (Harkness & DeMarco, 2016). Since nurses have basic vital evidence, they can make an impact on healthcare.

I would consider becoming a member of a healthcare organization and getting involved in agenda-setting. I will participate in the practice problems identification and the determination of tools and methods to deal with them. I think it is a good way to take part in health policy decision making because many nursing organizations, such as ANA, help their members become a part of governing boards in each state.

References

Arabi, A., Rafii, F., Cheraghi, M. A., & Ghiyasvandian, S. (2014). Nurses’ policy influence: A concept analysis. Iranian Journal of Nursing and Midwifery Research, 19(3), 315-322.

Harkness, G. A., & DeMarco, R. F. (2016). Community and public health nursing: Evidence for practice (2nd ed.). Philadelphia, PA: Lippincott Williams and Wilkins.

Office of Disease Prevention and Health Promotion. (2016). Heart disease and stroke.Web.

World Health Organization. (2019). Nursing staff are vital for making progress towards universal health.Web.

In the present article, Nguyen, Tran, and Duoos (2016) briefly describe the results of the research they conducted to study the influence of magnesium in comparison with potassium supplementation on SBP during aerobic-cycling exercise. They point to the gap in the studies concerning potassium and magnesium supplementation and address the effects of the new approach without emphasizing the expected outcomes.

The study was carried out objectively: magnesium and potassium capsules were distributed blindly and randomly, and the control and experiment groups were present (Nguyen et al., 2016). In the process of the research, heart rates at rest, posttest, and recovery were measured and recorded. However, the fact that the subjects themselves were responsible for registering their potassium and magnesium taking gives ground to be more careful in the assessment of the results.

The researchers describe the method and point out that a two-sampled t-test was done to compare pretest and posttest results within each supplementation group (Nguyen et al., 2016). According to the authors, a considerable difference between the two groups was registered via a one-way analysis of variance. The researchers conclude that potassium supplementation proves to lower exercise BP to a large extent in contrast with the pretest and posttest rates.

The article is laconic and, to some extent, lacks details. Although the main points are covered, one still needs more explanation of the key points. The theoretical part also seems necessary. It was probably the volume of the article that imposed some limitations. In this regard, the article may be considered satisfactory for those who need concise information about the usage of magnesium and potassium. Besides, this article may be used to understand the current trends in potassium supplementation and blood pressure research.

References

Nguyen, T. M., Tran, A., & Duoos, B. A. (2016). Exercise blood pressure response to magnesium versus potassium supplementation. Research Quarterly for Exercise and Sport, 87(S2), A9-A10.

Abstract

Hypertension is one of the most frequently diagnosed diseases and a major cause of premature death worldwide (World Health Organization [WHO], 2019). Consequently, the treatment and prevention of this disease is a global objective. Blood pressure measurements are used to diagnose and treat hypertension and evaluate the effectiveness of a doctor’s performance. Nevertheless, patient adherence to therapy also has a significant role in disease control. Various methods are used to increase compliance, including self-blood pressure monitoring. It is a simple and demonstrative method for maintaining a proper level of the patient’s consciousness and awareness regarding his disease. This paper examines the impact of daily home blood pressure monitoring on compliance with medication regimens for hypertension in adults diagnosed with hypertension.

Introduction

Hypertension is a medical condition in which blood pressure in the arteries is constantly elevated. This disease increases the risk of developing cardiovascular, brain, kidney, and other serious diseases. As mentioned by World Health Organization (WHO, 2019), in 2015, 1 in 4 men and 1 in 5 women had hypertension, and fewer than 1 in 5 people have the problem under control. In conjunction with this, proper treatment, monitoring, and surveillance are vital factors in reducing morbidity and mortality.

Treatment of hypertension is a complex process requiring attention and consistency, and therefore not all patients can remain compliant with it. Blood pressure measurement is the most affordable, quickest, and convenient way of assessing the treatment impact. If there is no blood pressure control, the probability of complications and death increases, and in this regard, its constant monitoring becomes a capable tool in disease management (WHO, 2019). This paper investigates the influence of daily self-blood pressure measurement on compliance with antihypertensive medication intake since it is one of the most prospective and accessible methods for the patient. In advanced nursing practice, the problem is of great practical importance due to the prevalence of the disease in everyday work.

Methods

Most of the sources relating to the paper topic were found using Google Scholar and the National Center for Biotechnology Information (NCBI). All sources listed were selected according to the criteria of conformity and concordance with the issue. The keywords used for the search were: self-blood pressure monitoring, home blood pressure monitoring, compliance, and adherence. About 50 articles were related to the issue in a given period from 2015 to 2020. However, this is not enough to reliably and distinctly answer the question posed by the problem. Most of the available materials are intended for research based on blood tests or new biotechnologies. For example, in addition to home blood pressure monitoring, it was possible to find studies related to other methods of compliance control, such as electronic monitoring of the medication intake. The sources chosen for this paper are selected due to their relevance and significance to the problem.

Review of Selected Literature

The Largest Study in Recent Years

Jo, S. H. et al. (2019) investigated whether self‐blood pressure monitoring (SBPM) can improve the control rate of blood pressure (BP), adherence to antihypertensive medications, and the awareness of the importance of BP control. A total of 7751 Korean patients (aged 18‐90 years old) participated in the study. They were given automatic electronic BP monitors and were recommended to measure their BP daily at home for 3 months. Changes in office BP, attainment of target BP, adherence to taking antihypertensive drugs, and awareness of BP were compared before and after SBPM (Jo et al., 2019).

The investigation was a nationwide single‐arm prospective observational study (Level VI evidence). Authors assessed drug adherence by the self‐reported questionnaire, which was well‐validated and is widely used in clinical practice despite some shortcomings regarding the ease of distortion by the patient and susceptible errors by visit time interval (Jo et al., 2019). Self‐BP was recommended to be measured twice a day, in the morning, 5‐10 minutes after waking up, and just before going to sleep.

The main findings of the study are that SBPM for 3 months is associated with improved patient awareness, drug adherence, and BP control. As a result, drug non‐adherence, defined as the number of days per week in which medication was skipped or lessened, decreased significantly after SBPM from an average of “0.86 to 0.53 days per week” (as cited in Jo et al., 2019, p. 1300). Drug adherence improved as the self-blood pressure monitoring rate increased.

The fact that it is not a randomized controlled trial is a limitation of the study. The accuracy of patients’ measurement of BP at home also was not examined. There could be recall errors or intended untruthful replies (Jo et al., 2019). The long‐term benefits of SBPM cannot be determined since the trial was only performed for 3 months. 20% of patients of the study participants were already using SBPM before the investigation (Jo et al., 2019). These patients could have been more diligent, which could have biased the results.

Improved Adherence in Specific Treatment Regimen

Spirk, D. et al. (2018), in their work, aimed to evaluate the influence of home blood pressure monitoring (HBPM) on patients’ awareness and attainment of BP value goals. The authors conducted a study using antihypertensive treatment with irbesartan alone or in combination with hydrochlorothiazide. 1,268 patients over 18 years of age with newly diagnosed or previously treated uncontrolled arterial hypertension were enrolled in the Factors Influencing Results in antihypertenSive Treatment (FIRST) study (Spirk et al., 2018) (Level IV evidence). It was performed by 348 general practitioners and internal medicine specialists across Switzerland. 60% of patients were instructed to use the devices for HBPM.

The study purposes included estimating a patient’s awareness and attainment of BP goals, and the efficacy and tolerability of antihypertensive treatment after three months (Spirk et al., 2018). General practitioners and internal medicine specialists were invited to screen and enroll up to 5 patients per physician for 10 months. At the baseline visit, an individual BP goal according to the current BP and the individual risk profile was defined, and a suitable antihypertensive medication and the use of HBPM were then chosen at the discretion of treating doctors (Spirk et al., 2018). The study results, including a large population of hypertensive patients living in Switzerland, show that promoting HBPM leads to better disease awareness and compliance with therapy. Even if antihypertensive drugs were well balanced in both groups, a better blood pressure control was observed in the group using HBPM as compared to the group without instructions for the HBPM use (Spirk et al., 2018). The study’s limitations include the non-randomized observational short-term character of the investigation, subjective selection of treatment chosen, and geographical constraint.

Compliance as an Advantage from the Use of BP Home-Devices

The aim of Zalloum, N. A., Farha, R. A., Ruqa’a, A. M. A., Khdair, A., & Basheti, I. A (2015) in their study was to investigate the effect of home monitoring of blood pressure on adherence to antihypertensive medications and control of the disease among patients attending a tertiary health facility. This is a cross-sectional correlation investigation conducted at the cardiovascular clinics of Jordan University Hospital (Level IV evidence). The authors used a questionnaire investigating participants’ disease level of control, disease duration, frequency of HMBP use, type of measuring devices used, the effect of HMBP on adherence to antihypertensive medications, and lifestyle changes (Zalloum et al., 2015). 205 hypertensive patients who practice HMBP were recruited into the study, 60% of them were aged 50-69 years. Almost 50% of the patients have been using digital devices for blood pressure monitoring. The mean rate of HMBP was 15 times per month, but almost 80 % of the patients did not document their blood pressure values (Zalloum et al., 2015).

As for the result, patients with higher levels of education, as well as patients with lower BP values, showed significantly higher adherence to their antihypertensive medications. Consequently, it supports the fact that compliance with antihypertensive medications is one of the advantages resulting from the use of BP home devices (Zalloum et al., 2015). The authors note that the role of the pharmacist should have been investigated in this study to give a clear, complete picture of the result. Since the pharmacist is the last specialist seen before the BP self-measuring device use, they can affect the accuracy of measurements by selecting a specific device for each patient. Another limitation concerns non-stringent conclusions made due to the specifics of the data gathered.

Hypertension in Pregnancy

Since arterial hypertension during pregnancy is a no less important problem, the OPTIMUM-BP study on this topic was conducted. Pealing et al. (2019) assessed the feasibility of a blood pressure self-monitoring intervention for managing pregnancy hypertension. It was an unmasked randomized controlled trial comparing a self-monitoring of blood pressure (SMBP) intervention versus usual care (Level II evidence). 86 women with chronic and 72 women with gestational hypertension from 4 UK centers were randomized (2:1) intervention to control (Pealing et al., 2019). In this case, self-monitoring involved daily home blood pressure measurements with recording via study diary or telemonitoring. Participants persisted with the intervention for 80% or more of their time from enrolment until delivery in 86% and 76% of those with chronic and gestational hypertension, respectively (Pealing et al., 2019).

As a consequence, medication adherence and beliefs about medication scores were at a high level but showed no difference between study groups. The research briefly concerns the chosen topic but still provides the necessary results. The trial outcome is limited by the inability to mask the participants or clinicians to the randomization group due to the nature of the intervention (Pealing et al., 2019). The inaccuracy of reported BP measurements also may take place.

Medication Adherence in Malaysia

Muhammad, J., Jamial, M. M., & Ishak, A. (2019), in their study, evaluated HMBP influence on office blood pressure control and treatment compliance among hypertensive patients. The investigation was conducted as a randomized, non-blinded two-arm parallel controlled trial performed in a primary care clinic in Malaysia (Level II evidence). 88 patients of stage I and stage II hypertension aged above 18 years were recruited. Patients were divided into the intervention and control groups. Each patient was seen at baseline and after 2 months. Medication adherence was measured using a novel validated Medication Adherence Scale (MAS) questionnaire (Muhammad et al., 2019). The automatic BP monitor Omron model HEM-7120 (Omron Healthcare Co. Ltd.) was used for the measurement of home BP, and the automatic BP monitor Omron model HEM-7203 – for the office BP. Both groups showed a significant improvement in the mean Medication Adherence Scale (from baseline to 2 months), and the intervention group showed a slightly greater change compared to the control group. However, there was no significant change in the mean difference in the Medication Adherence Scale between both groups at the end of the 2-month study period (Muhammad et al., 2019).

The reported outcomes resulting from HBPM in medication adherence differ among previous studies since there is a higher compliance rate at the baseline. Most of the patients had been followed up before and were highly motivated to control their hypertension (Muhammad et al., 2019). Authors also state that the study is limited since, according to Marquez-Contreras et al. (2006), the self-report is poorly predictive of non-compliance compared to the pill-count approach (Muhammad et al., 2019).

Racial Diversity

The study conducted by Abel, W. M., Joyner, J. S., Cornelius, J. B., & Greer, D. B (2017) investigates self-care management strategies used by Black women in the USA and their consistent adherence to antihypertensive medication-taking. There are no known research studies considering predominantly Black women’s behavior while they have the highest prevalence rate of hypertension (HTN), contributing to a higher risk of organ damage and death (Abel et al., 2017). The authors used a qualitative descriptive design (Level VI evidence) since it “allows a straightforward description of study participant experiences in their own language without the interpretation of existing theories” (Abel et al., 2017, “Methods”).

Four focus groups with a total of 20 Black women aged 25-71 years were formed, each woman was audiotaped. Transcripts were analyzed using qualitative content analysis. Participants were included in the study if they scored perfect adherence on the medication subscale of the Hill–Bone Compliance to High Blood Pressure Therapy Scale (Abel et al., 2017). For each of the four focus groups, the investigator served as a moderator with one or two female research assistants (registered nurses with master’s degree preparation and trained to serve as observers and note-takers). The investigator used semistructured, open-ended questions developed from the literature and framed around the tenets of Orem’s Self-Care Deficit Theory (Abel et al., 2017).

The majority of participants owned a BP device, measured their BP once per day or several times per week, and kept a log to report their BP numbers to the healthcare provider by email or during office appointments. As for the result concerning the paper’s problem, home BP monitoring is mentioned as beneficial in terms of reduced BP, improved BP control, and adherence to antihypertensive medication (Abel et al., 2017). Limitations of the study include small sample size, the discrepancy between general population characteristics, and the subjective nature of the Hill–Bone Compliance to High Blood Pressure Therapy Scale.

Conclusions and Recommendations

In summary, it should be noted that adherence to medication in the case of hypertension is an extremely relevant topic for discussion in the scientific community. Many studies in this direction were conducted in the early 21st century, and over time, the question is still raised in the course of medicine development. In recent years, more attention has been paid to the implementation of mobile applications and automatic electronic systems in the process of forming compliance.

However, measuring blood pressure at home remains one of the most convenient, reliable, and affordable ways for patients all over the world. Thus, Jo et al. (2019) proved that self‐blood pressure monitoring is effective in the elimination of drug non‐adherence. Results of studies conducted by Spirk et al. (2018) and Zalloum et al. (2015) also confirm that promoting HBPM leads to better disease awareness and compliance with therapy. Other studies with smaller samples have similar conclusions. Upscale guidelines on hypertension based on the presented studies and earlier research promote home blood pressure monitoring as a simple but reliable and easily accessible way to monitor the course of the disease and treatment (Williams et al., 2018). Such manuals are used by specialists to help millions of patients every year.

Users of these guides include advanced practice nurses as well. The data contained in these is of high value for nurses’ work since they use expanded skills and knowledge in assessment, planning, implementing diagnostics, and providing necessary medical care. The basis of the nurse’s work is evidence-based and verified decision making, so studies considered in the paper can help to improve the quality of applied treatment. For example, a nurse can conduct lectures and training for patients and colleagues explaining the need for home blood pressure control. Advanced practice nurses are prospective specialists for the future of the US healthcare system. With the available knowledge about the topic, they will be able to reduce the load on general practitioners in primary care while improving patients’ quality of life and satisfaction. Self-blood pressure monitoring by the patient reduces the level of supervision by the medical professional, at the same time patient himself pays more attention to his condition and its maintenance. This allows achieving automatism and autonomy, owing to which the effectiveness of treatment is reached.

References

Abel, W. M., Joyner, J. S., Cornelius, J. B., & Greer, D. B. (2017). Self-care management strategies used by Black women who self-report consistent adherence to antihypertensive medication. Patient Preference and Adherence, 11, 1401.

Jo, S. H., Kim, S. A., Park, K. H., Kim, H. S., Han, S. J., & Park, W. J. (2019). Self‐blood pressure monitoring is associated with improved awareness, adherence, and attainment of target blood pressure goals: Prospective observational study of 7751 patients. The Journal of Clinical Hypertension, 21(9), 1298-1304.

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Introduction

High blood pressure is an extremely severe condition that can cause the heart to fail in its functioning. In addition, this condition can lead to heart diseases and other complicated health problems within the human body. Behaviors such as smoking and consumption of large amounts of alcohol make individuals susceptible to this condition. Appropriate care can assist individuals suffering from these conditions to live better and more fulfilling life. Sadly, people from rural areas tend to have less quality health care services as compared to their urban counterparts. With regard to this, there arose a need for carrying out research to determine the impact of poverty plus rustic habitation on measures to alleviate high blood pressure in the US. This paper seeks to analyze the research that was performed to determine the impact of poverty plus rustic habitation on measures to alleviate high blood pressure in the US. Furthermore, the paper analyses the research on tendencies of Hypertension occurrence awareness and management from adults in the US using data from the National Health and Nutrition Examination Survey 1988 to 2004 (Ellis, Grubaugh, and Egede, 2010).

The Effect of Minority Status and Rural Residence on Actions to Control Blood Pressure in the US

The objective of the study was to determine the measures to regulate HBP and recommendations from doctors for the regulation of blood pressure amongst mature persons on the basis of their race and residence. A lot of efforts have been recognized by the United States government to help in the creation of awareness among all the residents so that steps can be undertaken to assist the people to escape the HBP condition. One of the organizations in the US whose efforts have been noticed to help in the alleviation of the tragedy is the US Department of Health and Human Services. This is a national institute that is concerned with the health of humans. The study to determine the impact of poverty, as well as the rustic habitation on the measures to limit high blood pressure, has its aim to save the lives of people and regulate the disease. Conversely, nursing is an occupation that concentrates on the care in terms of health for persons as well as societies so that they could retain, or recuperate to their normal health states. Therefore this research problem is highly related to nursing thus nursing research.

During the study, the quantitative method of data collection was found appropriate to be used. This was because the research was totally focusing on figures rather than words. In determining the impact of poverty and rural dwelling on the measures to regulate HBP, facts from 45,024 experiencing HBP were scrutinized in the the2007 National Health and Nutrition Examination Survey. As it is cited in, “the multiple logistic regression analyses were employed in the assessment of the sovereign alliance between contemporary measures to regulate HBP and commendations health-care contributor for management of blood pressure basing on the race and habitation after accounting for confounders” (p.34). In the second investigation, quantitative methods of data collection were employed. For instance: measurement. The study thus entailed a lot of figures.

During the examination of the measures to regulate HBP as well as commendations from health concerned nurses for the control of blood pressure amongst mature individuals by metropolitan/rustic habitation, it was found out that the blacks in spite of their habitation; had a high probability of accounting for their plummeting in the consumption of salt and alcoholic drinks, changing their habits of eating and following the doctors prescription than the whites. On the other side, blacks were probable to be guided to limit the dangerous vices such as high alcohol consumption that could lead to HBP. The mature blacks in rural areas were furthermore expected to account for the advice from health care nurses on drug consumption than whites from town centers. However, the whites in rural were less probable to be counseled to exercise than the adult whites from town places.

This study proved that racism and habitation have a discrepancy impact on measures to regulate HBP and nurses counsel to regulate HBP. The measures to be taken that dominated during the research are to a larger extent related to the spotlight of the Evidence-Based Practice (EBP). Most of the recommendations were highly correlated. For instance, people are recommended not to drink much alcohol and take the advice from their health care nurses seriously. This is similar to the recommendations from the EBP. “Over time, heavy drinking can damage your heart as raises your blood pressure, as it may cause your body to release hormones that increase your blood flow and heart rate” (p. 27)

Conclusion

This first research implies that clinically, people should avoid smoking and general use of tobacco as it may cause linings on the walls of the arteries leading to an increase in blood pressure. A lot of salt in one’s diet cause fluids to be retained thus blood pressure increase. Limit the amount of alcohol for much of it may lead to an increase in heart rate. The participation in exercises by an individual helps in reduction of fats in the body thus no either blood pressure or heart diseases. The alteration in eating habits and diet may help in reduction in the amount of potassium intake thus limiting the causes of HBP. This study focuses on adults, kids, drunkards as well as individuals who are obese. The findings of this research are perfect. There is a need for them to be followed so that the tragic state of HBP is escaped. They are in a form of rules thus should be pursued.

Reference

Ellis, C., Grubaugh, A. and Egede, L. (2010) The Effect of Minority Status and Rural Residence on Actions to Control Blood Pressure in the US. Public Health Reports. Vol. 125.

Case Summary

Douglas Adams is a 51 male patient with type 1 diabetes and hypertension. In order to manage his problem, he was taking medication, insulin. He was found unconscious by a friend who called the ambulance to bring him in. This report is a brief assessment of his health including physical assessment and other relevant tests.

Data Information

Subjective Data

Apparently, the patient lives alone in a single unit house and this could cause loneliness to him. Besides he is a heavy smoker even though he does not drink, Dunning, (2010, p. 45). The complications that come as a result of the pathophysiological development of diabetes are numerous and they are all detrimental sometimes leading to death American Diabetes Association, 2006, p. 5). DA was admitted after diagnosis of disorientation and confusion after he was found by a friend.

DA was taking insulin in the form of Humalog Mix 25: 26 units Mane Nocte, Perindopril: 4 mg mane and Aspirin 100 mg per day. He does not drink but he is a heavy smoker (one packet per day) and lives alone.

Objective Data

Douglas’s Glasgow coma score was 14/15 in the Emergency Room. He had vital signs as follows; HR-82 bpm, BP-110/87 mmHg, RR-18 and T-36.8. The doctor planned a CT scan on him later in the day. He was also having QID and 4/24 neurological observations as recorded in the morning. In the morning, his blood sugar level was 5.2 mmol/L and the nurses administered his medication. Before seeing the doctor, he was sweaty and a little shaky. He ate part of his breakfast and claimed he wasn’t hungry. He was found to be pale and spoke with a slightly slurred speech. The vital signs are HR – 88 bpm, BP – 105/80 mmHg, RR-18, T – 36.5.

When there is no enough insulin, the body is unable to utilise the blood sugar hence causing hyperglycaemia. It therefore requires daily injections of insulin (Rossetti, 2008, p. 118). However, sometimes the insulin treatment often reduces glucose much lower than the normal range hence hypoglycaemia (Zarowitz et al., 2006, p. 236).

Hypothesis

Douglas Adams suffered hypoglycaemic reaction caused as a result of very low blood glucose. When diabetes patients are on insulin medication and also taking drugs to manage hypertension they can suffer hypoglycaemia because the drugs could cause too much utilization of glucose (Zarowitz et al., 2006, p. 236). However, the insulin shock could still have been caused by causes like CAD or accelerated hypertension.

Discussion of the Hypothesis

The causes of hypoglycaemia are forgetting to eat, eat very little food, the patient drunk alcohol, exercised too much or did not adhered to insulin regime (Ali, 2007, p. 49). The hypoglycaemic effects come as a result of side effects especially the oral or some specific types of insulin drugs (Zrebiec, 2006, p. 213: ADA, 2006, p. 5). This causes hypoglycaemia when the blood glucose falls below 70mg/dL. The symptoms of hypoglycaemia ensue;

1. Hypoglycaemia reduces the level of consciousness of the patient. Essentially, glucose is needed for energy, maintenance of body cells and for growth (ADA, 2007, p. 15) especially the brain Brands, 2005, p. 728). When blood glucose gets low, the brain cannot function well. Cognitive function is affected and the patient suffered confusion and disorientation (ADA, 2007, p. 15). The patient also becomes very weak and aggressive. In such a state, the patient does not have energy even to move and even if he is able to move, he may not know direction (Zrebiec, 2006, p. 213). To determine this I would ask his name and if he knows where he was at the moment.
2. The patient could suffer coma. Insufficient glucose to the brain could be severe that the loss of consciousness exacerbate to seizures and then to total unconsciousness (Briscoe, & Davis, 2006, p. 115). This is diabetic coma. Hypoglycaemia is commonly experienced at night when the patient is asleep (ADA, 2008, p. 51). This could be probably the reason why Douglas was found disoriented in the morning. The patient can be seen to be sweating, hungry, trembling and with a very fast heart rate (Johnson, 2008, p. 154). When the patient regains consciousness, I would ask whether he took normal doses as prescribed by the physician or was it excess.
3. Hypoglycaemia may cause anxiety for the patient. Many patient of type 1 diabetes suffer hypoglycaemia episodically (Johnson, 2008, p. 154: Patton et al., 2008, p. 252). This can happen anytime and it is often very dangerous during the night. The risk of experiencing seizures, coma and possible death causes anxiety (Johnson, 2008, p. 155). Many patients panic when they experience such attacks since they need to frequently check their blood glucose levels (Briscoe, & Davis, 2006, p. 115: Brands, 2005, p. 728). At this point I would ask the patient whether he understood what could happen and if he was scared.
4. The mood of the patient may be aggressive. in a hypoglycaemic state the feeling is nasty and as a result, the patient tends to be moody (Daneman, 2006, p. 847). This is because, when cognitive function of brain is affected and the patient is undergoing confusion, nausea, light headedness, fatigue, restlessness and possible dizziness they will tend to get have sudden moodiness and clumsy behavior (Wang, et al., 2008, p. 169). When I see such behavior and ask the patient whether he was angry.

Discussion Of The Patient Interview

There are some vital physical assessments that I would conduct to help in making proper diagnosis.

1. General Appearance: Tired-looking adult male
2. Vital signs: HR-82 bpm, BP-110/87 mmHg, RR-18 and T-36.8.
3. Pulse: Regular heart rate and rhythm, the heart sounds normal
4. Head, Eyes, Ears, Nose, Throat – HEENT: Non-contributory
5. Skin: smooth, warm, and sweaty; better turgidity; non edematous
6. Chest/lungs: should be clear
7. Neurologic: confused and disoriented
8. Peripheral vascular: arterial Pulse 4+ bilaterally (bounding pulse), warm, no edema

Essentially, diabetes mellitus is the problem that faces a person when he or she is unable to manage blood glucose properly. When the problem is left unmanaged, it can exacerbate and cause complications (Winkler 2007, p. 1543). Patients suffering from diabetes are called diabetics and in order for them to maintain their blood sugar at a normal level, they have to watch their diet, do regular exercises, take oral medications and/or insulin to attain normal sugar level (Rossetti, 2008, p. 117). When blood sugar levels are very low, the patient can suffer what is called ‘Hypoglycaemic reaction’ and this is also called insulin reaction, low blood sugar reaction or insulin shock (Briscoe & Davis, 2006, p. 117). This happens when blood sugar get too low that the patient suffers confusion and disorientation (Johnson, 2008, p. 152: Ali, 2007, 39). The symptoms of this are confusion, disorientation, vomiting and slurred speech (Donnelly et al., (2005, p. 752). The general appearance test helps to ascertain this.

Vital signs like heart rate blood pressure and respiratory rate on the other hand play a crucial role in determining the contribution of hypertension to the problem the patient was suffering. Fortunately all this fell in the normal range when the patient had been assessed and have to be ruled out. The skin assessment is important because hypoglycaemia is accompanied by pale and sweaty skin because of the osmotic pressure characteristics of glucose. Neurologic tests confirm the impact of low glucose on the CNS leading to confusion (Donnelly et al., (2005, p. 752).

Reference List

Ali, R., (2007), Management of Diabetes in Older Adults, American Journal of the Medical Sciences, Vol. 333, Issue 1, pp. 35-47.

American Diabetes Association, (2007), Clinical Practice Recommendations, Diabetes Care; 30 (Suppl 1): S1- S103. Web.

American Diabetes Association, (2008), Standards of Medical Care in Diabetes [Position Statement], Diabetes Care 31 (Suppl. 1): S12 -S54.

American Diabetes Association, ADA (2006), ‘Standards of Medical Care In Diabetes,’ Diabetes Care, 29, S4 – S42.

Brands, A.M.A. (2005), ‘The Effects of Type 1 Diabetes on Cognitive Performance, A Meta-Analysis,’ Diabetes Care, Vol. 28 No. 3, p. 726-735.

Briscoe, V. J., & Davis, S. N. (2006), ‘Hypoglycaemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management,’ Clin. Diabet., 24 , 115–121.

Daneman, D., (2006), Type 1 Diabetes, The Lancet, Vol. 367, Issue 9513, Pp. 847-858.

Donnelly, L.A., et al., (2005), ‘Frequency and Predictors of Hypoglycaemia in Type 1 and Insulin-Treated Type 2 Diabetes: A Population-Based Study,’ Diabet Med, 22, pp. 749-755.

Dunning, T., (2010), Nursing Care Of Older People With Diabetes, Dunning, Oxford, Wiley Blackwell.

Johnson, E., (2008), ‘Treatment of Diabetes in Long-Term Care Facilities: A Primary Care Approach,’ Clinical Diabetes, Vol. 26, No. 4 pp. 152-156.

Patton, S.R., et al., (2008) ‘Fear Of Hypoglycemia In Parents Of Young Children With Type 1 Diabetes,’ Journal Of Clinical Psychology In Medical Setting, Vol. 15, No. 5, Pp. 252-259.

Rossetti, P., (2008), ‘Prevention Of Hypoglycaemia While Achieving Good Glycemic Control In Type 1 Diabetes: The Role Of Insulin Analogs,’ Diabetes Care, Vol. 31 No. Supplement 2, S113 – S120.

Wang, Z.H., Kihl-Selstam, E., & Eriksson, J.W., (2008), Ketoacidosis Occurs In Both Type 1and Type 2 Diabetes – A Population-Based Study From Northern Sweden, Diabetic medicine; 25: 867–70.

Winkler G. (2007), Complications of Diabetes Mellitus, In the Basics Of Internal Medicine, Budapest. , Pp. 1541–1569.

Zarowitz, B.J., et al., (2006), ‘Application of Evidence-Based Principles of Care in Older Persons: Issue 3: Management of Diabetes Mellitus,’ J Am Med Direct Assoc 7: pp. 234-240.

Zrebiec, J., (2006), ‘Case Study: Cognitive Impairment, Depression, and Severe Hypoglycemia,’ Diabetes Spectrum, 19, pp. 212-215.