Victor Appau, Telana Fairchild, Bonnie Fitzgerald,
Susan Hernandez, Abigail Mathews, Holly
Shumard, Sophie Stec, Reasmey Taing
NP Students
UMass - Worcester,
Graduate School of Nursing
N/NG 603A, Fall 2012








Discuss each section as it relates to Healthy
People 2020, Health Determinants, and other
sources
Review our case study patients
The use of the 5 A’s model
Poster session with 5 A’s model applied to
case study patients
Video with Walter and use of MI
Community resources
NP role
HIPPA
Dhalgren and Whitehead, 1991.
Work-place stress may develop as
a result of work environment
 Other Sources:

o Unmanaged stress is a risk factor for
multiple chronic diseases
o A combination of primary, secondary,
and tertiary methods are effective in
stress management
(USDHHS 2012).
(CDC, 2012).
(Richardson and Rothstein,
2008).
 Goals:
oReduce new cases of DM
 Target: Move from 8 new cases/1,000 people
to 7.2 new cases/1,000 people aged 18-84
oReduce DM death rate
 Target: Move from 73.1/100,000 deaths to
65.8/100,000
oBi-annual HbA1c for adults with diabetes
 Target: Move from 64.6% to 71.1% adults
diagnosed with DM who have 2 HbA1c in 12
months









Experience delays in getting care they need
Less likely routine screening and preventive care
Not engage in fitness activities
Use tobacco
Be overweight
Have high blood pressure
Experience symptoms of psychological stress
Receive less social-emotional support
Have lower employment rates

Goals:
o Reduce number of adults with disabilities living in
congregate care residences


Current: 57,462
Target: decrease to 31,604
o Increase participation in social, spiritual,
recreational, community, and civic activities to the
degree that they wish
o Reduce delays in receiving primary care due to
specific barriers, and delays in obtaining assistive
devices, service animals, and technology services



A group of disorders affecting a
person’s ability to move and maintain
balance or posture
Caused by abnormal development of
the brain or damage to the
developing brain early in life
Estimated 1/300 children in US have
CP
(CDC, 2012)








Skin breakdown
Falls
Social isolation
Depression
Decrease independence
Self-care Deficit
Premature aging:
o Extra Stress
o Organ system not to full capacity
Pain:
o Common sites
o Chronic and Acute
(CDC, 2012)
(NINDS, 2012)




No Standard Therapy
“We need more research on adults
with CP.”
Individual plan of care
Interprofessional disease
management
(NINDS, 2012)

Goals:
o Increase cholesterol checks within the preceiding 5
years
 Estimated 74.6% US adults in 2008
 Target: increase by 10%, to 82.1%
o Reduce high total blood cholesterol levels
 15.0% of adults in the US fell into this category from
2005-2008
 Target: Reduce this statistic to 13.5%, a 10% reduction
o Reduce the mean total blood cholesterol levels
 The mean total blood cholesterol levels in 2005-2008
time period was 197.7 mg/dL
 Target: Decrease by 10%, mean total blood cholesterol
level 177.9 mg/dL

Goals:
o Reduce adults with hypertension


29.9% of adults aged 18+ y/o had high blood
pressure/hypertension in 2005–08
Target: 26.9 percent
o Reduce adolescents with hypertension


3.5% of children and adolescents aged 8 - 17
y/o had high blood pressure/ hypertension in
2005–08
Target: 3.2 percent








43 y/o AA/NA male w/ hx of CP powered
wheelchair
Senior VP of Finances
o “maybe when I have my nervous breakdown, I
can get workmen's comp”
o Concern for job security
Runs late, HIGH stress level
Partner of 5 years & has a personal care assistant
C/O: Anxious, stressed, trouble sleeping
EtOH- martini lunches & nightly cognacs
Gourmet Parisian diet
*Yelled during appointment*








54 y/o Italian female
Divorced mother of 3 children, lives in own
mother’s home
New Assoc. VP of HR
o Concern for job security
Social EtOH, smoker
“wicked bad temper”
Depressed, denies SI
Low self-esteem
o Former Miss Teen MA
*Overheard other pt exam*

Originally Developed

Adopted and supported

Recommended

Evidence in support
◦ US Department of Health and Human Services
◦ Counseling smokers
◦ USPTF
◦ Behavior change in obese patients
◦ http://www.uspreventiveservicestaskforce.org/3rduspstf/b
ehavior/behsum2.htm
◦ USPTF
◦ Clinicians to counsel tobacco cessation
◦ http://www.uspreventiveservicestaskforce.org/uspstf09/to
bacco/tobaccors2.htm
◦ Jay et al. (2010).










43 y/o AA/NA male w/ hx of
CP powered wheelchair
Runs late, HIGH stress level
Partner of 5 years & has a
personal care assistant
C/O: Anxious, stressed,
trouble sleeping
EtOH- martini lunches &
nightly cognacs
B/P: 165/110
FBS: 130
Total Cholesterol: 354mg/dL
HDL 20mg/dL
LDL: 200mg/dL










54 y/o Italian female
Divorced mother of 3
children, lives in own
mother’s home
New Assoc. VP of HR
o Concern for job
security
Social EtOH, smoker
“wicked bad temper”
Depressed, denies SI
B/P 120/80
FBS: 110
HbA1C: 6.3%
Total Cholesterol:
115mg/dL

Transtheoretical Model: stages of change-
o Pre-contemplation: lacking intent to change, no interest in
changing behavior, resistance
o Technique: explore the balance of changing vs not
changing; what's good and what's not good


Readiness to change and confidence in ability to change
Motivational Interviewing:
◦ Partnership between provider and patient
◦ Explore ambivalence
◦ Change comes from patient

Suggestion:
◦ Self-monitoring
◦ Keep a journal
◦ Support and follow-up
Cerebral Palsy MA
http://www.masscp.org/cpma/cpma_frameset.
htm
 Diabetes Center for Excellence
http://www.umassmemorial.org/ourcare/diabetes-center-of-excellence

Stress Reduction
http://umassmed.edu/content.aspx?id=41254


Definition:
o Level of Education
o License
o Holistic and preventative care
o Culture relativism

Massachusetts
o Advanced skills
o Collaboration
o Inside expertise
o Practice guidelines
Mass.Gov.Health and Human Services. (2012).
http://www.mass.gov/eohhs/provider/licensing)
Rosenthal, L. D., & Guerrasio, J. (2010). Acute care
nurse practitioner as hospitalist: role description. Critical
Care Nurse, 21-26.
The purpose of 244 CMR 4.00 is to establish
the conditions under which registered nurses
licensed by the Board of Registration in Nursing
may practice in an expanded role. 244 CMR
4.00 also establishes principles of supervision,
responsibility, and discipline to which nurses
practicing in the expanded role are subject
 Responsible for own practice
 Employment of advanced skills

o Evaluation
o Diagnoses
o Treatment
Mass.Gov.Health and Human Services. (2012).
http://www.mass.gov/eohhs/provider/licensing)
Diagnosing, treating, evaluation
 Medical histories
 Physical examinations
 Diagnostic studies
 Prevention and prescribing
 Primary and specialty care services
 Acute and critical care settings
 Surgeries and procedures
 Counseling and educating

Rosenthal, L. D., & Guerrasio, J. (2010). Acute care
nurse practitioner as hospitalist: role description. Critical
Care Nurse, 21-26.
 Community
clinics, health centers,
urgent care centers
 Health maintenance organizations
(HMOs)
 Hospitals and hospital clinics
 Nursing homes
 Physicians offices
 Public health departments
 Nurse practitioner practices/ offices
Rosenthal, L. D., & Guerrasio, J. (2010). Acute care
nurse practitioner as hospitalist: role description. Critical
Care Nurse, 21-26.

Increase access to health care
programs
oStress management
oNutritional counseling
oFitness programs
oSmoking cessation
oFamily counseling
Rosenthal, L. D., & Guerrasio, J. (2010). Acute care
nurse practitioner as hospitalist: role description. Critical
Care Nurse, 21-26.
Audrey over heard Walter’s appointment
 Definition:

o 1996
o National standards
o Protection of healthcare information
 Paper
 Electronic
o Organization required to develop polices and
procedures
 Failure to comply> penalties
File complaint with OCR:
http://www.hhs.gov/ocr/privacy/hipaa/complaints/i
ndex.html.
$1.5 million
US Department of Health and Human
Services. (2012). HHS.gov

Best practice:
oEnsure compliance
oPhysical and technical
safeguards
oRisk assessment
oIT audit
oBreach notification plan
US Department of Health and Human
Services. (2012). HHS.gov/ocr/privcay
 Inform
Walter
 Discuss with Audrey
oHIPPA law
oRole
 Report
to HMO
 Mandatory training for ALL employees
 Designee
 http://www.hhs.gov/ocr/privacy/
US Department of Health and Human Services. (2012).
HHS.gov/ocr/privacy/
References
Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2008). Practice guideline for the treatment
of patients with acute stress disorder and
posttraumatic stress disorder. Retrieved from
http://guideline.gov/content.aspx?id=5954&search=acute+stress
Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of
evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These
guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides
practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and
weight management.
Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2011). Management of overweight and
obesity in the adult. Retrieved from
http://guideline.gov/content.aspx?id=33134
Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of
evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These
guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides
practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and
weight management.
Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2012). Tobacco treatment. Retrieved from
http://guideline.gov/content.aspx?id=36845
Initiative by The Agency of Healthcare Research and Quality, The National Guidelines Clearinghouse provides a database of
evidence based treatment guidelines addressing several health areas (Overweight and obesity, Tobacco, Acute Stress). These
guidelines are useful in identifying and addressing the goals of behavior change for Walter and Audrey. It also provides
practitioners with evidence based treatment resources to address Walter and Audrey's problems such as smoking, stress and
weight management.
American Diabetes Association (ADA). (n.d.). Stress. Retrieved from
http://www.diabetes.org/livingwith-diabetes/complications/stress.html
American Diabetes Association is a web based site that pertains to the prevention, treatment, and cure for
diabetes. Their objective is to help those who are affected by diabetes and provide them with valid information for
their understanding of the disease. This site is a reputable and highly quoted site for those in the diabetic
world. There are guidelines for treatment and research to support the data at this site. For our purposes this site
aids in our understanding of diabetes, how it relates to patients, and information for us as providers in diagnosing
and treating patients. We are able to link why stress might have an effect on developing or worsen the symptoms of
diabetes.
American Heart Association. (2011, November). Target Heart Rates. Retrieved from
http://www.heart.org/HEARTORG/GettingHealthy/PhysicalActivity/Target-HeartRates_UCM_434341_Article.jsp
American Heart Association is well known association that focuses on cardiovascular health in relation to heart
disease and stroke. This association provides the medical field with standards of care for cardiovascular disease and
stroke. They are a well trusted association among medical professionals, let’s face it they provide the education and
approval certification for practitioners to give CPR, ACLS, etc. For this particular information gained was to aid us in
prescribing exercise prescriptions to our two case study patients and give them the information for understanding
target heart rates and how to calculate heart rates.
American Heart Association. (2012, April). About high blood pressure. Retrieved from
http://www.heart.org/heartorg/conditions/highbloodpressure/high-blood-pressure-orhypertension_ucm_002020_subhomepage.jsp
The American Heart Association is a non-profit organization that advocates for the United States public through
cardiovascular research, education, community programs through fund-raising which support continued growth. It
gives a clear, organized breakdown of information and current research for the general public. The reference also
gives further information on risk factors and prevention for patients.
American Heart Association. (2012). What your cholesterol levels mean. Retrieved from
http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-LevelsMean_UCM_305562_Article.jsp
American Heart Association is well known association that focuses on cardiovascular health in relation to heart disease and
stroke. This association provides the medical field with standards of care for cardiovascular disease and stroke. They are a
well trusted association among medical professionals, let’s face it they provide the education and approval certification for
practitioners to give CPR, ACLS, etc. This particular website found on their site was to aid us in describing cholesterol levels
to patients and what is means if they high. Also, gives the providers insight about knowing when their patients are at risk for
development of certain diseases.
American Society of Hypertension. (2010). La presión arterial y su salud. Blood Pressure Health. Retrieved from
http://www.ash-us.org/documents/BloodPressureHealthSpanish.pdf
The ASH produced an informational booklet through which Spanish-speaking patients can learn basic concepts of blood
pressure, information about high blood pressure, and how to lower and control high blood pressure. The document
underlines clear methods and guidelines as well as provide an interactive diary with outlined questions for provider followup. The resource also provides illustrations and photos for further visual learning methods.
Barter, P.J. (2011). The causes and consequences of low levels of high density lipoproteins in patients with diabetes. Diabetes
and Metabolism Journal, 35, 101-106.
doi: 10.4093/dmj.2011.35.2.101
This review summarizes the relationship between pre-diabetes or diabetes and low HDL levels, low HDL levels with high
triglyceride levels, HDL as a compound and pancreatic beta cells, and HDL levels with insulin resistance. The review
illustrates how the progression of diabetes can be stopped or reversed through increasing and managing HDL levels. The
document also describes the effect of niacin and other forms of pharmaceutical treatment to increase HDL levels. This is a
reliable review of data analysis for the provider.
Centers for Disease Control and Prevention. (2011). Physical Activity. Retrieved from
http://www.cdc.gov/physicalactivity/everyone/guidelines/adults.html
According to the CDC, adults need 150 minutes of moderate intensity cardiovascular exercise per week to achieve
cardiovascular benefits. This recommendation allows patients to break their minutes into manageable segments of at least 10
minutes in duration. Patients working at moderate intensity should be able to talk during their workout, but not sing.
Centers for Disease Control and Prevention. (2012). Cerebral Palsy (CP). Retrieved from
http://www.cdc.gov/NCBDDD/cp/facts.html
The Centers for Disease Control and Prevention (CDC) is a government agency focusing on public health. The topic of
cerebral palsy is addressed on the CDC website. The website provides background information about the disease, including
basic facts, statistics, information about screening and diagnosis, and links to research and articles. This resource was a
place for me to access general background information about CP and the health problems people with CP face.
Centers for Disease Control and Prevention. (2012). Selected Preventative Screening Recommendations. Retrieved from
http://www.cdc.gov/nccdphp/dnpao/hwi/resources/preventative_screening.htm
Centers for Disease Control and Prevention outlines recommended preventative health
screenings and intervals for
adults, as established by U.S. Preventive Services Task Force
(USPSTF). The list serves as a tool to identify potential
valuable screening, with the risks and benefits to be weighed and individualized based on patient needs.
Center for Mindfulness in Medicine, Health Care, and Society. (n.d.). Stress Reduction Program. University of Massachusetts
Medical School. Retrieved from
http://www.umassmed.edu/Content.aspx?id=41254
Center for Mindfulness in Medicine, Health Care, and Society is part of the University of Massachusetts Medical
Department. At the center, they aid clients through an eight week “Stress Reduction Program” developed in 1979 by Dr. Jon
Kabat-Zinn. Due to Dr. Kabat-Zinn evidence based research and studies in stress reduction, the program seem trustworthy
and applicable. Other professionals have adapted his techniques imbedded in this program to help with several different
patients and for many different reasons and it seems successful based on the research and testimonies. For our purposes
this provided us with a program we could inform providers about in order to get their patients involved. Both Audrey and
Walter could benefit from stress reduction.
Chobanian, A.V., Bakris, G.L., Black, H.R., Cushman, W.C., Green, L.A., Izzo, J. L.,... Materson, B.J. (2003). The seventh report
of the joint national committee on
prevention, detection, evaluation, and treatment of high blood pressure. The Journal
of the American Medical Association, 289, 2560-2571.
The Seventh Report of the Joint National Committee (JNC 7) is an excellent reference and guide for the treatment of
hypertension. The guide contains recommendations that are based on evidence from a rigorous systematic reviews and
synthesis of the published medical literature. The purpose of JNC report is to provide an evidence-based approach to
prevention and management of hypertension.
Dagogo-Jack, S., Egbuonu, N., Edeoga, C. (2009). Principles and practice of nonpharmacological interventions to
reduce cardiometabolic risk. Medical Principle Practice, 2010(19), 167-175. doi:10.1159/000285280
This article reviews landmark studies that demonstrate the principles of nonpharmacological approaches to the
reduction of the components of the metabolic syndrome, including pre-diabetes, prehypertension and dyslipidemia.
Lifestyle interventions have been shown to ameliorate and prevent the progression of individual components of the
metabolic syndrome.
Dahlgren, G. and Whitehead, M. (1991). Policies and strategies to promote social equity in health. Stockholm
Institute for Future Studies
Department of Veteran Affairs. (n.d.). [Chart for pulse rates per minute defined by age groups for moderate activity
and vigorous activity]. MOVE! Retrieved from
http://www.move.va.gov/download/NewHandouts/PhysicalActivity/P09_HowToTakeYourHeartRate.pdf
Department of Veteran Affairs is another US government association that is provided and held to standards of our
government. The validity of the source is based on the fact it is a government association and this particular
information is from the MOVE© program from the NCP. This particular information came from a handout they are
providing to their client as part of the MOVE© program. This was great source for the table provided and giving
informative, simple instruction on how to check your pulse for patient or providers to use as a tool for educating
patients.
Fessler, M.B., Massing, M.W., Spruell, B., Jaramillo, R., Draper, D., Madenspacher, J.H., Zeldin, D.Z. (2009). Novel
relationship of serum cholesterol with asthma and wheeze in the United States. Journal of Allergy and Clinical
Immunology, 124(5), 967-974. doi: 10.1016/j.jaci.2009.08.005
This data analysis utilizes the Centers for Disease Control and Prevention 2006 survey National Health and Nutrition
Examination Survey provided by the CDC National Center for Health Statistics. The study describes an inverse
relationship of serum total cholesterol and non-high density lipoproteins with asthma and/or clinical wheeze, with a
strong relationship specifically with the Mexican-American population.
Fitday. (n.d.). How to Calculate Your Serum Cholesterol Level. Retrieved from http://www.fitday.com/fitnessarticles/nutrition/fats/how-to-calculate-your-serum-cholesterol-level.html
This is simply an online journal for those try to lose weight and help keep a record of progress. After exhausting all
the well-known sites for an exact equation for calculating the total cholesterol I had to use what I could find and this
site gave insight. However, the are no listing of references or dates to know the validity of this site, but seems these
days AHA, CDC, etc. use a lipid panel for testing and there is no need for this calculation anymore. If anything this
would be a good website to tell patients about that is free of cost to help them track their healthy lives.
Frost, S. (2011, June 25). Exercise Plan for Busy Moms. Livingstrong.com. Retrieved from
http://www.livestrong.com/article/478805-exercise-plan-for-busy-moms/?utm_source=RELARTICLES_R1
Livestrong© is the website that Lance Armstrong is a founder. They claim to post only information that is expert
based and reviewed. This particular article is from 2011 and was reviewed at that time. LiveStrong© used other
sources and allowed experts to write articles that are then reviewed by peers increasing the level of confidence in the
information found on this site. This website, having used it previously for Walter, is useful and knowledgeable about
exercise for all different people. With Audrey we face the issue of her being a busy mom. This particular article
referenced four other sites for busy moms and how they can find a way to fit exercise in their busy schedule.
Hart, Jacqueline A. (2003, June 3). High blood pressure (hypertension) guide. Penn Cardiac Care. Penn Medicine.
Retrieved from
http://www.pennmedicine.org/health_info/hbp/index.html
These University of Pennsylvania Medical School resources give accurate and detailed information on hypertension,
symptomology, and information on the DASH diet to which patients can refer. These two references highlight the
importance of blood pressure monitoring and severity of the condition. It supports blood pressure screening and
lifestyle changes that the patient can further read in detail.
Hart, Jacqueline A. (2004, March 29). High blood pressure is “silent”. Penn Cardiac Care. Penn Medicine. Retrieved
from
http://www.pennmedicine.org/health_info/hbp/hbp_step5.html
These University of Pennsylvania Medical School resources give accurate and detailed information on hypertension,
symptomology, and information on the DASH diet to which patients can refer. These two references highlight the
importance of blood pressure monitoring and severity of the condition. It supports blood pressure screening and
lifestyle changes that the patient can further read in detail.
Health Indicators Warehouse. (2008). Smoking cessation success (percent). Retrieved from
http://www.healthindicators.gov/Indicators/Smokingcessationsuccess-6monthsto1yearago
(adults18yearsandolder)_1555/Profile/Data
The Health Indicators Warehouse, as cited by Healthy People 2020, provides a resource of current national statistics on
smoking cessation adjusted by a variety of indices (age range, sex, etc.).
Healthy People 2020. (2012). Disability and Health. Retrieved from
http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=9
Healthy People 2020 covers the topic of Disability and Health in order to explore the disparity of health care among people
with disabilities. The report aims to promote the health and well-being of this population. This report was useful in looking at
disability in relation to goals for Walter’s care.
Healthy People 2020. (2012). Heart Disease and Stroke. Retrieved from
http://healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=21
Healthy People 2020 covers the topic of cardiovascular disease. The webpage served to provide basic info on cardiovascular
disease and its risk factors.
Heisler, M., Resnicow, K. (2008). Helping patients make and sustain healthy changes: a brief introduction to motivational
interview in clinical diabetes care. Clinical Diabetes, 26(4). Retrieved from
http://diabetes.niddk.nih.gov
This article focused on a major aspect of using Motivational Interviewing (MI) to help patients undertake and sustain the
necessary behaviors to manage their conditions. MI requires practice and considerable training. Improving our ability as
health care providers to listen, to understand and empathize with the patients’ struggles during difficult lifestyle changes.
Working with the collaboration of the patients is the underlying philosophy.
Horsman, M., Suto, M., Dudgeon, B., Harris, S. (2010). Aging with cerebral palsy: Psychosocial issues. Age and Aging. 39,
294-299.
doi: 10.1093/ageing/afq018
This article described a narrative review of nine prior studies which aimed to address the psychosocial issues challenging
adults with CP. McMaster University’s Guidelines for Critical Review was used to evaluate both quantitative and qualitative
studies. This article was useful in identifying areas of need for psychosocial support in an aging patient with CP. The
discussion included the detrimental influence of physiological impairments on the psychosocial taxing effects of the disease.
Isometric Exercises. (n.d.). Isometric Exercises- History and Benefits. Retrieved from:
http://www.isometricexercises.net
This is a commercial based website used to get more information about isometrics Dr. Rimmer mentioned in his
article. Due to having to make a prescription exercise plan for Walter I need examples of Isometric exercise and an
idea if he could perform these exercises. The website was helpful and gave insight; however, confidence in the site is
low due to lack of explanation of references used and dates the data are pulled. Based on the other sites found
during searching this one was the easiest to follow and gave the most information for this project.
Jay, M., Gillespie, C., Shlair, S., Sherman, S., Kalet, A. (2010). Physician's use of the 5as in counseling obese patients:
is the quality of counseling associated with patients' motivation and intention to lose weight. BMC Health Services
Research,10, 159. Retrieved from
http://www.biomedcentral.com/1472-6963/10/159
Jay, M et al. explained the quality of physicians’ use of the 5a’s model of behavior change in counseling and
investigated the relationship or associations between the quality of counseling and patients’ enthusiasm to lose
weight. The results of this research were pertinent to Audrey and Walter’s cases because it was found that physician’s
use of the 5a’s model was associated with higher likelihood of patients desire to lose weight, eat healthy and
exercise. This study provided us with a recent evidence based corroboration of the effectiveness of the 5a’s model
being used to affect behavior change in Audrey and Walter.
Kodama, S., Tanaka, S., Saito, K., Shu, M., Sone, Y., Onitake, F.,... Sone, H. (2007). Effect of aerobic exercise training
on serum levels of high-density lipoprotein cholesterol: a
meta-analysis. Archives of Internal Medicine, 167(10), 999-1008.
doi:10.1001/archinte.167.10.999
This is the meta-analysis describing the relationship of exercise amount, exercise intensity, and cholesterol levels.
The article outlines criteria for increasing HDL with lifestyle changes and exercise through increased intensity and
duration more than the national recommendations.
Lind, B.K., Lafferty, W.E., Tyree, P.T., Diehr, P.K. (2010). The Journal of Alternative and Complementary Medicine. 16(4),
411-417.
The authors research the insurance expenditures of patients who use CAM versus those using only conventional medicine.
This study indicated that patients using CAM have higher outpatient expenditure, but this expenditure is off-set by costly
impatient imaging studies of non-CAM patients. The research suggests there is a cost benefit for insurance companies to
cover CAM modalities in order to reduce expenditure per patient.
Matthews, K.A., Katholi, C.R., McCreath, H., Whooley, M.A., Williams, D.R., Zhu, S., Markovitz, J.H. (2004, July, 6). Blood
pressure reactivity to psychological stress
predicts hypertension in the CARDIA study. Circulation, 110(1),7478.
doi:10.1161/01.CIR.0000133415.37578.E4
This article is found in the Circulation Journal. The study is based on a large sample size of participants enrolled in the
CARDIA Study. The research for this article was to show if there is a relationship between stress and hypertension. We do
have to keep in mind that this is an article with many strengths and weaknesses. As mentioned before the sample size
was very large and included both black and white men and women from 18 years of age to 30. The researchers followed
the participants over a thirteen year period using standardize measurements and protocols. Even though, they had a large
sample size there were lost follow up with some of the participants. Also, in one particular measurement of blood
pressure to a stressor used in the study only one blood pressure measurement was used instead of taking an
average. Their review of literature was very weak; more sources would have added more support to their theory. There is
also no conclusive details on the nature of the association of stress to blood pressure found during the study and there is
a need for more research. For our purposes, we used to show that yet there is no understanding and great data to
represent a direct relationship of stress to hypertension; we learn again that stressors do increase blood pressure
measurements done on a wide, multiple range of individuals.
Mayo Clinic Staff at the Mayo Foundation for Medical Education and Research (MFMER). (2010, August 5). Stress and high
blood pressure: What's the connection? Retrieved
from
http://www.mayoclinic.com/health/stress-and-high-blood-pressure/HI00092
Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to
provide the best patient care by using information from research to educate and practice. They receive funding and do
their own research using their patient population and their clinical staff. There may be slight bias in their studies;
however, they base their outcomes on patients are first. For the particular data provided for this information was a
website based on seven references, one of which was the AHA and citation within the last six years. For our purposes,
they provided studies that aided in our understanding about stress and high blood pressure.
Mayo Clinic Staff at Mayo Foundation for Medical Education and Research (MFMER). (2010, December 8). Exercise:
When to check with your doctor first. Retrieved from http://www.mayoclinic.com/health/exercise/SM00059
Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to
provide the best patient care by using information from research to educate and practice. They receive funding and
do their own research using their patient population and their clinical staff. There may be slight bias in their studies;
however, they base their outcomes on patients are first. For the particular data provided for this information was a
web site based on three references, two which are reputable sources (CDC and ACMS) within the last two
years. However, one reference used was a expert opinion from someone in the clinical staff. For our purposes, this
information aided us in developing information to give to patients so they know when they should consult with their
provider before exercising. As providers and gave us information on which patient population we should evaluate
before allowing them to do exercising.
Mayo Clinic. (2007). Fitness: Tool: Target heart rate calculator. Retrieved from
http://ww.mayoclinic.com/health/target-heart-rate/SM00083
Mayo Foundation for Medical Education and Research is part of the Mayo Clinic Network. Their goal as a network is to
provide the best patient care by using information from research to educate and practice. They receive funding and
do their own research using their patient population and their clinical staff. There may be slight bias in their studies;
however, they base their outcomes on patients are first. For the particular website it is simply a tool providers or
patients can use to calculate target heart rates in a simple, easy way. This tool is based on the CDC and adapted by
MFMER in 2007. CDC is a reliable source that the MFMER recognizes as giving factual information and created this
tool based on their standardization of care for patients.
Michigan Quality Improvement Consortium. (2004). Communication Guidelines to Promote Behavior Change.
Retrieved from
http://www.mqic.org/pdf/Communication_Guidelines_to_Promote_Health_Behavior_Change_176076_7.pdf
The Michigan Quality Improvement Consortium is a resource for clinical practice guidelines based on current research
evidence. This communication guideline is pertinent to Walter and Audrey's cases because it underscores motivational
interviewing and patient centered behavior change which we implemented to effect behavior change in Audrey and
Walter.
Mortensen, A.M. (2011, July 22). Desk Exercises for Stress Relief and Health. Livestrong.com. Retrieved from
http://www.livestrong.com/article/499013-desk-exercises-for-stress-relief-and-health/.
Livestrong© is the website that Lance Armstrong is a founder. They claim to post only information that is expert
based and reviewed. This particular article is from 2011 and was reviewed at that time. LiveStrong© used other
sources and allowed experts to write articles that are then reviewed by peers increasing the level of confidence in the
information found on this site. This website gave a lot of information for those with busy work schedules. Using
more than one of them was to strengthen each other, providing the same information from two different authors and
two different reviewers. As mentioned, with Audrey we face the issue of her being a busy mom. This particular
article referenced three other sites and how they can find a way to fit exercise in their busy schedule even at the office
desk.
Mosca, L., Appel, L.J., Benjamin, E. J., Berra, K., Chandra-Strobos, N., Fabunmi, R.P., … Grady, D. (2004). Evidence
based guidelines for cardiovascular disease prevention
in women. Journal of the American College of
Cardiology, 43, 900-921.
National Center for Health Statistics. Center for Disease Control and Prevention. (2011). NHANES Survey 2009-2010.
National Health and Nutrition Examination Survey.
Retrieved from
http://www.cdc.gov/nchs/nhanes/nhanes2009-2010/nhanes09_10.htm
This journal article articulates a data analysis of the Centers for Disease Control and Prevention 2009 survey National
Health and Nutrition Examination Survey provided by the CDC National Center for Health Statistics. “The National
Health and Nutrition Examination Survey (NHANES) is a program of studies designed to assess the health and
nutritional status of adults and children in the United States. The survey is unique in that it combines interviews and
physical examinations” (CDC, 2012). The data analysis revealed a correlation of low HDL cholesterol levels and major
depression in women, and illustrated a correlation of high LDL cholesterol levels and major depression in men.
National Institutes of Health. (2011, August). Relaxation Techniques for Health: An Introduction. National Center for
Complementary and Alternative Medicine. Retrieved from http://nccam.nih.gov/health/stress/relaxation.htm
The National Institutes of Health is a part of the US Department of Health and Human Services. This is our nation’s
agency for research in the medical field. The website gives links to its research and development and sets standards
based on congressional decisions and policy. For these reasons, the NIH is a very renowned website and highly
trustworthy to all of those involved in the medical world. It is also the largest fund providing agency to research and
development leading to state of the art and the most up to date research projects. For our purposes this site gave us
the opposite response to the flight or fight, which as we learned is how the body relaxes and decrease blood pressure
and decreases the release of hormones that affect glucose levels in our body.
National Institute of Neurological Disorders and Stroke. (2012). Cerebral Palsy: Hope Through Research. Retrieved
from: http://www.ninds.nih.gov/disorders/cerebral_palsy/detail_cerebral_palsy.htm#211453104
National Institute of Neurological Disorders and Stroke (NINDS) is a subset of the National Institutes of Health. NINDS
aims to to reduce the burden of neurological disease. NINDS dedicates a ‘Disorders’ page to CP. The webpage offers
background information about the disease, as well as risk factors, treatment options, management, and research. The
information on the NINDS website was used to generate nursing diagnoses for Walter and to supply general
information about the treatment for adults with CP.
Prochaska, J., Velicer, W., Rossi, J., Goldstein, M., Marcus, B., Rakowski, W.,… Rossi, S. (1994). Stages of change and
decisional balance for 12 problem behavior. Health Psychology, 13(1), 39-46.
This article was used for further exploration in the Transtheoretical Model of Change in order to write the script for
Walter’s Motivational Interview and Stages of Change video.
Richardson, K. M., Rothstein, H. R. (2008). Effects of Occupational Stress Management
Meta-Analysis. Journal of Occupational Health
Psychology, 13 (1), 69-93.
Intervention Programs: A
A meta-analysis exploring the effectiveness of occupational stress management interventions represented 55 types of
interventions and included 2,847 studies. The studies were then coded as cognitive– behavioral, relaxation,
organizational, multimodal, and alternative. Psychological outcomes were measure in most studies, versus
physiological outcomes. The most commonly used intervention was relaxation technique.
The authors used a selection process for inclusion of studies, requiring randomization of subjects, as control group,
employed subjects, studies published in English after 1975, and exclusion of subjects diagnosed with major
psychiatric disorders. Most interventions ranged from 8-12 weeks, and many were self-taught via audio tapes.
Cognitive-behavioral interventions had the greatest outcomes, while relaxation was the most utilized intervention.
It’s worth noting that combining many stress reducing techniques in an intervention will reduce positive outcomes.
Research indicated that two techniques per intervention produce the best outcomes. Understanding the effectiveness
of occupational stress management will enable the provider to create an evidence-based intervention, like to improve
patient outcomes.
Rimmer, J.H. (2012). Resistance Training for Persons with Physical Disabilities. National Center on Health, Physical Activity,
and Disability. Retrieved from http://www.ncpad.org/94/699/Resistance~Training~for~Persons~with~Physical~Disabilities
The National Center on Health, Physical Activity, and Disability is known for thirteen years of work with disabled clients
keeping them on track with health and fitness. Dr. J.H. Rimmer is 25 year veteran working on health promotions with those
who are disabled. He is well-known in his field through publishing in many resources and his position in two federal
organizations. Due to his long time in the field of study and peer-reviewed publications this document has some validity
to it. He is the only author and there are no statements of when or if reviewed so there could be some biasness from
him. From the details; however, the description and the knowledge used gives confidence that the article holds
truth. Walter has CP and due to this he has found it difficult to stay in shape, so this article gives insight to things
specifically for CP clients.
Roger, V. L., Go, A. S., Lloyd-Jones, D. M., Benjamin, E.J., Berry, J. D., Borden, W.B., Turner, M. B. (2012). Heart disease and
stroke statistics-2012 update: a report from the american heart association. Circulation, 125, 2-220. doi:
10.1161/CIR.0b013e31825e7519
This report gives current and thorough statistical information for individual prevalence of hypertension, coronary artery
disease, heart failure, and other cardiovascular diseases in each state as well as the United States as a whole. The report
also provides mortality and morbidity rates for the United States. The document provides information on risk assessment
as well as nutritional data in regard to cardiovascular diseases providing a complete resource of information for a provider
or researcher.
Sandmaier, M. (2005 December). Your guide to a healthy heart. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
National Institutes of Health. National Heart, Lung, and Blood Institute, NIH Publication No. 06-5269. Retrieved from
http://www.nhlbi.nih.gov/health/public/heart/other/your_guide/healthyheart.pdf
The National Institutes of Health is a part of the US Department of Health and Human Services. This is our nation’s agency
for research in the medical field. The website gives links to its research and development and sets standards based on
congressional decisions and policy. For these reasons, the NIH is a very renowned website and highly trustworthy to all of
those involved in the medical world. It is also the largest fund providing agency to research and development leading to
state of the art and the most up to date research projects. For our purposes this site has lead us to the discovery of many
articles to provide us with information on stress, hypertension and diabetes. Along with that, the site gives us insight of
future research.
Shelby, J., McCance, K.L. (2004). Understanding Pathophysiology. S.E. Huether, K.L. McCance (Eds.). St. Louis, Missouri:
Mosby.
This is a text book from undergraduate nursing studies. The text book is about the pathophysiology of the human body. In
this particular chapter the author is describing what stress is, how your body reacts to stress, the benefits and risk and how
this relates to disease. The reference was very useful to aide in describing stress in relation to why it affects the body and
understanding how it may lead to hypertension and diabetes. The information is highly reliable because it purpose is to
provide facts so that health care professional will understand the pathophysiology of the human body. Due to it’s being a
text book, the information is reliable and bias is minimal to obsolete. This text book helped us be able to understand and
explain how stress is related to increase blood pressure and increase glucose levels. Being able to explain this will help
support our other resources in describing the link of stress to hypertension and diabetes.
Slaman, J., Roebroeck, M., van Meeteren, J., van der Slot, W., Reinders-Messelink, H., Lindeman, E., … van den Berg-Emons,
R. (2010). Learn 2 Move 16-24: effectiveness of an intervention to stimulate physical activity and improve physical fitness of
adolescents and young adults with spastic cerebral palsy: a randomized controlled trial. BMC Pediatrics, 10(79), 1-8.
This article described a randomized, controlled study, designed to evaluate the effectiveness of intervention to increase
physical activity and improve fitness in adolescents and young adults with spastic CP. While the results of this trial have not
yet been published, the article offered explanation and research detailing the reason for methods used and design of the
interventions to stimulate physical activity and fitness in people with CP.
Tedders, S. H., Fokong, K. D., McKenzie, L. E., Wesley, C., Yu, L.,Zhang, L. (2011). Low cholesterol is associated with
depression among US household population. Journal ofAffective Disorders, 135, 115-121.doi:10.1016/j.jad.2011.06.045
This study compares HDL and LDL levels among men and women with the propensity toward major depressive disorder. The
findings illustrate clinically significant differences between men and women.
Thorpe, D. (2009). The role of fitness in health and disease: status of adults with cerebral palsy. Developmental Medicine
and Child Neurology, 51(4), 52-58.doi: 10.1111/j.1469-8749.2009.03433.x
This article reviewed quantitative research on physical activity and fitness and its relationship to health in adults with CP.
The author identified a need for greater research on this topic and aimed the article at presenting possibilities for future
research.
United States Department of Health and Human Services. (2012). Healthy People 2020 Topics and Objectives: Heart Disease
and Stroke Washington, D.C. Retrieved from
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=21
This is a comprehensive report on the objectives and goals of the Department of Health and Human Services as they pertain
to the cardiovascular health of the American population. The report is based on extensive health statistics describing the
current state of health of the American people and provides measurable goals for which to strive. The report also outlines
means to obtain these goals, including tips on behavior modification and methods for patient motivation.
United States Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood
Institute. (2002). Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation,
and treatment of high blood cholesterol in adults (adult treatment panel III), final report (NIH Publication No. 02-5215).
Retrieved fromhttp://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf
This report is the result of the NCEP panel’s expert research on the management of dyslipidemia. It gives a basic
description of lipids and primary targets of LDL, HDL, and total cholesterol management. It presents methods of assessing
and predicting an individual’s risk of adverse cardiovascular events based on current disease states and the presence of
certain risk factors. The report also outlines guidelines for detection and evaluation of dyslipidemia and, finally, guidelines
for treating dyslipidemia through both therapeutic lifestyle changes and drug therapy.
United States Department of Health and Human Services, National Diabetes Education Program: A joint program of the
National Institute of Health and the Center for Disease Control and Prevention. (2003). Small steps big rewards prevent type
2 diabetes. NIH Publication No. 03-5334 Retrieved from http://www.ndep.nih.gov
This program designed to help health care providers and with the collaboration of the patients with the key components of
and effective diabetes prevention regimen in the GAME plan: Goals, Accountability, Monitoring, and Effectiveness. This
prevention is obtained through a lifestyle of activity and nutrition.
van der Slot, W., Nieuwenhuijsen, C., van den Berg-Emons, R., Bergen, M., Hilberink, S., Stam, H., Roebroeck, M. (2012).
Chronic pain, fatigue, and depressive symptoms in
adults with spastic bilateral cerebral palsy. Developmental Medicine
and Child Neurology, 54, 836-842. doi: 10.1111/j.1469-8749.2012.04371.x
This article describes a study aiming to examine the co-occurrence of chronic pain, fatigue and depression in adults with
spastic CP. Adults with CP were interviewed and self-report instruments were used for data collection and quantification of
symptoms. This article clarified the link between pain, fatigue, and depression, and pointed towards the needs of adults
with CP in addressing these issues. The article also addressed a gap in the literature regarding the clinical effects of these
symptoms and identified a need for preventative measures and interventions.
Wang, D. (2011, May 26). ROM Exercises for the Wheelchair Bound. Livestrong.com. Retrieved from
http://www.livestrong.com/article/338602-rom-exercises-for-the-wheelchair-bound
LiveStrong© is the website that Lance Armstrong is a founder. They claim to post only information that is expert based
and reviewed. This particular article is from 2011 and was reviewed at that time. This website offered the most
informative information for helping a patient in a wheelchair exercise. Again, this is focused for Walter, having CP and
being confined to a wheelchair is his excuse for not being physical. However, this website seemed to relate very well to
clients who are wheelchair-bound and sensitive to their needs. Dr. Rimmer’s article gave a general idea about how people
with CP could exercise but lacked specific exercise. Needing an exercise plan for Walter, I referred to LiveStrong ©for
assistance with some good examples of exercise he can begin using daily.