Hypertension Education in an Outpatient Setting, Research Paper Example

In this paper I will review in detail the results of an outpatient treatment plan for a middle-aged African-American couple who recently had been diagnosed with hypertension. I designed the plan in conjunction with NAME, M.D (the responsible party for this project) and implemented it as part of my college coursework. It lasted from 9/15/2013 to 10/14/2013.

Background

William and Gail Green, an African-American couple in their late fifties, were newly enrolled patients at the medical offices of NAME, M.D., where I am employed as a nurse- practitioner student. Initially Mr. Green presented with two classic symptoms of hypertension: headache and changes to his vision (HPB, 2012). These complaints had forced Mr. Green to quit driving and as a result, his wife drove him to us. After the initial diagnosis of hypertension was made for Mr. Green, his wife decided to have a check-up as well, although she presented with no symptoms of hypertension nor any other immediate complaints. After a thorough physical examination by Dr. NAME a week later, a diagnosis of hypertension was made for Gail Green as well. Dr. NAME suggested to me that I might try to get the Greens’ permission to be enrolled in the hypertension outpatient-program I was planning. The Greens, alarmed by their test results, showed great interest in being a part of it, and agreed to participate in full.

Instructions for the Paper

1. Identify an area of needed improvement that would involve teaching/learning in a clinical setting. The area of improvement was the patient’s management of hypertension and the way such management techniques are taught. As a nurse-practitioner student, I had to restrict my program to among the ten classic non-pharmaceutical measures to combat hypertension: weight loss; exercise; diet; sodium reduction; alcohol reduction; smoking cessation; caffeine reduction; stress reduction; home blood-pressure monitoring; and social support (Mayo Clinic). With Dr. NAME overseeing this project, we were both confident that the measures I would undertake would be fully compatible with the Thiazide-type diuretics prescribed to the Greens.
2. Identify source of information for needed change. The source of personal and medical information about the Greens was the initial questionnaire that all patients fill out when first coming under a new doctor’s care. The questions are extensive and detailed enough to give the physician an overall picture of the health of the new patient. In personal interviews in their home, I was able to gather another critical piece of information, given below.
3. Describe the specific group for the project, including demographics, ages, gender, cultural, ethnic, spiritual, developmental stages, knowledge deficits, and learning needs. As noted above, the Greens are a middle-aged African American married couple. (I decided to use the Greens’ demographic base because they might be tracked into their post-65 years as they begin to collect their Social Security pensions.) The Greens have been married for thirty-two years; it is the second marriage for Mr. Green. They identify as middle-class, and although neither of the Greens is a college graduate, Mr. Green has successfully passed college extension courses in accounting and once published a review article on accounting software; and Mrs. Green attended college as an undergraduate before marrying Mr. Green. He earns $65,000 per year as a middle-manager for a large plastics manufacturer. He has worked there twenty-five years, having begun as a vacation-replacement clerk in the bookkeeping department. Mrs. Green works as a homemaker, having primarily raised their three children, two daughters and a son. One daughter and the son are grown and married. The youngest daughter was killed in an automobile accident in high school. Not wearing her seat belt as she was taught to do, she was the sole fatality. Mr. Green believes his hypertension began then, although I suspect that it was actually congenital and was simply made worse by Mr. Green’s gradually increased drinking and smoking. (See table below.) The Greens identify as Baptists and have attended their neighborhood church regularly for years. They have no obvious developmental issues or knowledge deficits or learning needs. Both are informed as to world events, subscribe to the Atlanta-Journal Constitution, are computer-literate, travel regularly to Boston to visit family, and have visited Europe twice. But, true to their culture and upbringing, aside from golf neither William nor Gail exercise regularly, and both follow a typical African-American “soul food” diet, rich in salt, fat, red meat, fried chicken, and cheese. At 190 lbs. and 165 lbs respectively, William and Gale BMI-scale as overweight, not obese.
4. Develop a teaching plan to meet the identified needs. The lesson plan I developed for the Greens centered first on their most pressing problems: smoking; Mr. Green’s drinking; their diet; and their lack of exercise. That was the content of my first lesson. My strategy was to use exercise to reduce smoking naturally and to break up Mr. Green’s daily routine (followed for years), which consisted of him arising in the morning in time for a shower, shave, breakfast, and commute. His afternoon routine was to come home from work (his wife had been driving him both ways for several months), turn on the TV news, and begin the first of six or seven drinks, alternating between various domestic beers with mid-priced red wine. (His wife preferred gin and tonics.) Household and yard chores were reserved for weekends. Since Mr. Green was the biggest offender against his health, the program was at first centered on him. It was my expectation (partially fulfilled) that to the extent Mr. Green progressed, his wife would follow suit. To get things started, I met them at their home one workday evening after their dinner. Mr. Green had had a few drinks but was not outwardly inebriated. Neither smoked in my presence, although there were a couple packs of their cigarettes on various tables. The house itself looked clean and well-ordered. (I was glad to see they had made no special effort to spruce things up for my benefit.) From one corner, a large and shaggy dog placidly watched me.

William Green’s Program

I began by asking Mr. Green to begin arising a half-hour earlier than usual for the sole purpose of taking a brisk walk. Although I didn’t say so, my goal was to delay his morning cigarettes, as well as transition him to an earlier bedtime to reduce his drinking. After a week, I asked him how he would feel about arising an hour earlier. He agreed immediately. Within another week he was walking and tentatively jogging for forty-five minutes on Atlanta’s Eastside Beltline Trail, which counts as Mr. Green’s community resource for this program. He no longer smoked before lunch. I then arranged for Mr. Green to get a nicotine patch to use for the rest of the day. This was only partially successful. When its failure seemed assured, I used that to up the ante: I asked Mr. Green if he would consider taking all his vacation time as soon as possible in order to begin a rigorous day-long walking program. My goal for him was to walk continually during his regular working hours. This would further reduce his smoking naturally while burning calories. I knew that if he stuck to it, he would lose at least five pounds and possibly more. That is when Mr. Green informed me he was on medical leave from work. From this I learned an important lesson never to forget: patients can and will hold back vital information in more formal clinical settings. I asked him to begin the expanded walking-program immediately. He agreed to.

Gail Green’s Program

I asked Mrs. Green, who was not yet interested in joining her husband in his walking and jogging regimen, to watch a PBS documentary called Soul Food Junkies (Hurt, 2012). After seeing it online, she agreed to start taking some classes on healthy cooking at the Atlanta Botanical Garden’s Edible Garden & Outdoor Kitchen, and that counts as her community resource for this program. I then suggested to Gail and William that she might start making him a brown-bag lunch to take on his walks, based on what she learned from her classes. They agreed, Mr. Green’s sole proviso being that his wife should be sure to make enough. I agreed with him that deliberate calorie-cutting was not on the schedule. It was my expectation that his exercise, in conjunction with healthier eating, would naturally moderate his appetite. It was also my expectation that the results of Mr. Green’s expanded exercise might spur her interest.

Both William and Gail required no urgent or ongoing coordination with other healthcare professionals beyond their stepped-up physician checkups. I did visit the Greens each week and monitored their blood-pressure, cholesterol, and weight; and Mr. Green understood that he was not to strenuously overexert himself until his BMI and cholesterol were clinically normal. Self-evaluation, being essentially self-regulation, was necessarily a big part of this program, and I initially was going to provide William and Gail with their own individual evaluation forms. But then I realized it was unnecessary. Instead, I asked William use a pedometer application on his smartphone to measure his walks. For Gail, I asked her to just copy her new recipes and note if they liked them, telling her frankly that I might try them myself if they were any good. Then as a teaching device I asked them to just save their empty cigarette packs and beer, wine, and gin bottles. I provided them with a couple of large and thick plastic trash-bags for that purpose.

5. Implement the plan following approval of faculty and other appropriate professionals and/or officials. This plan was fulfilled under the guidance of NAME, M.D.

The following demographic data is listed in accordance with Instruction #6 of the rubric:

Race: African-American. Age range: 56 (William) – 53 (Gail). Two grown children. Income range: middle class. Education: high school and some college. Physical disabilities: none. Diagnosed for hypertension. Mr. Green is the sole breadwinner. They are homeowners.

 Before 30-Day Outpatient Program

After 30-Day Outpatient Program

Outcomes

* To be used in conjunction with Adult Treatment Panel III Guidelines (Adult Treatment Panel III, 2002).

**To be used in conjunction with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (Lenfant, 2003).

 Conclusion

Sustained exercise provided the crucial outcome. Mr. Green improved his metrics across the board, Mrs. Green much less, although the new menu helped. The projected results of this improvement project are for Mr. Green to return to work within two months. However, this will be dependent on how well he can maintain his exercise and healthier diet. I anticipate no further improvement for Mrs. Green unless she is willing to begin regular and sustained exercise.

References

Adult Treatment Panel III. (2002, September). Retrieved from NIH: http://www.nhlbi.nih.gov/guidelines/cholesterol HBP. (2012, June 23). Retrieved from PubMedHealth: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001502/#adam_000468.disease.symptoms

Hurt, B. (Director). (2012). Soul Food Junkies [Motion Picture]. Viewable on Amazon.com

Lenfant, C. M. (2003, December). Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Retrieved from NIH.gov: http://www.nhlbi.nih.gov/guidelines/hypertension/express.pdf

Mayo Clinic. (n.d.). Hypertension. Retrieved from Mayo Clinic: http://www.mayoclinic.com/health/high-blood-pressure/HI00027/NSECTIONGROUP=1

[1] Mr. Green does not meet the overall criteria for alcoholism.