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Diabetes
Mellitus
 Atherosclerosis
is correlated with the glucose intolerance associated with diabetes. This
occurs partly because of alterations in carbohydrate and fat metabolism.
This may result in direct damage to vessel basement membrane with the
elevated blood glucose. The incidence of atherosclerosis is higher among
those with diabetes mellitus than the general population. Individuals
with diabetes mellitus are also more likely to have other risk factors
such as obesity, hypertension and elevated serum lipids. These risk factors
appear to act in synchrony to increase plaque formation.
Obesity
Obesity
is defined as an excessive accumulation of fat on the body. When one is
20% - 30% over average for height, weight, and body structure, this creates
a problem with respiration and circulation. Abdominally distributed obesity
seems to be especially highly correlated with atherosclerosis. Closely
associated with obesity are hypertension, hypercholesterolemia, elevated
triglycerides, increased blood glucose levels, reduced carbohydrate tolerance,
sedentary lifestyle, and reduced HDL levels.
As
you can see, reducing weight may bring other modifiable factors under
control as well. The added strain on the work of the heart requires increased
circulation to the coronary arteries. As a result, the heart receives
two insults from obesity: increased work and blocked arteries.
Diet
High in Saturated Fat
Another
factor related to cholesterol and obesity is a diet high in saturated
fat. Saturated fat is dietary fat derived primarily from animals. It is
present in meats, dairy products, coconut oil, palm oil, chocolate, nondairy
whipped toppings and coffee creamer. Saturated fat contributes significantly
to increasing the LDL levels of the blood cholesterol.
Elevated
Serum Triglycerides
Even
though elevated levels of triglycerides in the blood are not an independent
risk factor in CAD, there is an indirect association of triglycerides
with atherosclerosis. It is thought that a diet high in saturated fats,
sugar, and alcohol contributes to elevated triglycerides. Again, obesity
is an interacting modifiable factor. Triglycerides are divided into two
categories: Type IV and Type V. Type IV triglycerides are manufactured
by the body; Type V are triglycerides consumed in the diet, and include
those manufactured by the body by conversion of fat.
Lack
of Exercise
Effects
of immobility are well known to the nurse caring for the sick person.
The circulatory, respiratory, endocrine, and gastrointestinal systems
are especially affected. If these same consequences are transferred to
a person already having risk factors for CAD, the problems are enhanced
greatly. Obese, smoking, and inactive persons are at greatest risk. Physical
inactivity may decrease HDL levels, collateral circulation, and vessel
size. It will also increase total cholesterol levels, glucose intolerance,
body weight, and blood pressure. Even a small gradual increase of exercise
will benefit the biological systems greatly by reversing these changes.
Oral
Contraceptives
In
some women, oral contraceptives will increase blood pressure and thrombus
formation. These factors need to be considered when determining the use
of these drugs, especially for women who have a history of thrombophlebitis.
Women who smoke are at higher risk when taking oral contraceptives. The
doses of estrogen have been reduced in the current formulations of these
products; therefore, the risk might have been reduced slightly. However,
there are no recent prospective studies to determine the current risks.
Stress
Stress
and personality factors, such as "Type A" behavior, have received considerable
public and professional attention for the past twenty years. Even though
early studies showed a higher incidence of death due to myocardial infarction
in "Type A individuals," more recent studies showed a lower rate than
in those not considered to be "Type A." Type "A" behavior is characterized
by aggressiveness, ambitiousness, hostility, competitiveness, and a sense
of urgency. Because the characteristics are multiple, it is often difficult
to measure these objectively. Anger and hostility may play a greater role
for clients at risk for CAD. Stress results in the release of endogenous
catecholamines that contribute to the workload of the heart and the entire
cardiovascular system. The rushed, stressed person may also not be inclined
to exercise and eat well. Many stressed people tend to smoke and are hypertensive.
For more information on this subject, order course #478
"Anger Kills."
Strategies
for Effective Patient Education
The
goal of health promotion is to encourage individuals to take responsibility
to improve their health. A high level of wellness can be achieved by all
ages, the chronically ill, and the disabled, as well as everyone else.
The nurse needs to keep this in mind as she develops the most effective
strategy for her area-based client population.
The
public is increasingly more aware of health promotion as seen in the media,
schools and community programs. This should have a positive effect on
individuals taking charge of their own health. Unfortunately, even with
all the information, this is not true for many. The nurse is continually
challenged by persons difficult to motivate to achieve goals mutually
set. The client, too, is challenged by the different, and sometimes conflicting,
information from the media. The news will often include a report of a
study just completed that refutes information reported earlier. Studies
on the effect of cholesterol and sodium in the diet are often conflicting.
Sometimes these reports are from a small study and have not been reviewed
by other experts or the American Heart Association. The damage may already
be done as the client believes the news report. The nurse will need to
keep aware of the new reports and help the client with sorting through
this information as it affects him. The AHA consensus panel of experts
is a good source of information for the nurse.
Although
client education is the best place to start, simply providing information
is not the only solution. The education you provide must also include
strategies for motivation and materials the client may use at home. Today,
nurses have access to video materials, excellent written materials, and
information about community-based programs. With these resources, the
nurse may plan accordingly.
Utilizing
the nursing process, the framework will include: assessment of need for
education; assessment of readiness; planning and developing an individualized
program; implementation of the program; and documentation and evaluation
of the patient education. Probably the assessment of readiness is the
most difficult for the nurse. All the great programs in the world will
not be effective if the patient is not ready to learn. The assessment
includes:
(1)
awareness of risk factors and/or diagnosis
(2)
previous knowledge and experience
(3)
intellectual level
(4)
motivational level
(5)
physical condition
(6)
psychological state
(7)
perceived need to learn.
All
factors take time to assess. Therefore, a one time interview and plan
probably will not be effective. The time the nurse spends with the patient
over the long term will greatly influence the success of the educational
plan.
The
Adult and Elderly Learner
Working
with the adult learner is usually characterized by focusing on developing
the individual's own goals. Adults want to know why they need to learn
something new and often will enjoy the learning sessions. However, they
come to the situation with a great deal of life experience, set habits
of tastes, some amount of pride, many preoccupations (i.e., work, family,
worries), and a desire to learn things they can use now. Adults have the
ability to change, but sometimes find it difficult. The nurse who is sensitive
to these characteristics will be the most effective.
Generally,
adults learn better in small groups or a workshop environment. The nurse
who sees herself as a facilitator, and utilizes the participant as a co-teacher
and co-learner, will be the most effective. As the nurse asks the client
for suggestions and effective strategies used by the client to make lifestyle
changes, the adult will become a more eager participant. Effective strategies
for specific risk factors will be discussed later in this study.
Working
with the elderly client may present other challenges. However, it is important
to take into account the changes of aging that will affect the learning
of your client. Some of the physiological changes will impact the ability
to participate in classes. Older clients will fatigue more easily than
younger ones. Providing frequent breaks will help compensate for this.
Because of the decrease of lean muscle mass, and increase in subcutaneous
fat with aging, sitting in uncomfortable chairs will become painful. Your
older clients will be more comfortable in padded chairs with armrests.
If
you are working with the older client on an exercise program, you need
to take into consideration the changes in cardiovascular and respiratory
changes of aging. Slowing heart rate, decreased stroke volume and decline
in cardiac output are normal changes of aging. Decreased function also
occurs in the respiratory system. Vital capacity is lost, and lung tissue
loses its elasticity. These changes affect the client's energy level,
strength, and speed. As a result, endurance will be affected. Although
many older adults have remarkable endurance, this needs to be taken into
consideration. If the client is too fatigued after these exercise sessions,
motivation may be lost and the client discouraged about continuing the
program. Other considerations regarding the elderly are sensory changes.
Vision changes include loss of the lens' ability to accommodate as it
becomes less elastic, larger, and more dense. Loss of visual acuity is
common. Glare is a serious problem, and loss of peripheral vision may
affect many. It is important then to use teaching materials that have
large print and good color contrasts. Check the lighting in your classroom
to minimize glare. A sheer curtain over the outside windows may help reduce
glare, and incandescent lighting is better than fluorescent lighting.
The loss of peripheral vision may impact your client's ability to interact
with others in the group, as they may not be aware of the persons sitting
next to them.
Hearing
loss is very common. High pitched sounds go first, but with aging, the
sounds in the middle and lower ranges are lost as well. Word sounds are
distorted, especially if there is background noise. Clients with presbycusis
will need more time to process the information. It is important for the
nurse to speak slowly and distinctly and face the client directly. Speaking
with a lower pitch will also help your client.
It
is important to take a holistic approach to assessing changes associated
with the aging of your client. In addition to assessing the physiological
changes previously discussed, psychological, sociological and cultural
dimensions must be assessed. Research is conflicting on the cognitive
changes of aging, but some elderly do have problems with short-term memory.
With this problem comes fear and anxiety that they are "losing their minds."
The resulting anxiety may impact their ability to learn more than the
actual lost of memory. The important concept is the attitude of both the
client and the nurse. It is easy to get discouraged. However, if the appropriate
pace and teaching strategy are used, this problem is not insurmountable.
Using written materials, lists, and calendars for appointments are all
good ways to assist the client. The important variable is interest. Most
of us remember what is important to us. Meaningless trivia is soon forgotten.
The good news is that more complex intellectual abilities increase with
age, and this should be emphasized.
Cultural
aspects will impact strategies used by the nurse. It is important to assess
these differences. The nurse needs to be sensitive to these differences
when assessing nutritional needs, exercise and other aspects of lifestyles.
Attempting to change activities in ways contrary to tradition will probably
be unsuccessful and can influence other aspects of the plan. Working with,
and not to, the client is the key word.
Principles
of Teaching/Learning
The
principle, "learning takes place when behavior is changed" may help guide
you when planning, implementing and evaluating your teaching plan. However,
it is important to understand the learning process. It is multifaceted
and sometimes complicated.
Learning
can be categorized into three broad types: cognitive, affective,
and psychomotor. The cognitive part is the body of knowledge
that the learner is grasping. The affective is the emotional response
to the learning situation. The psychomotor includes the skills
or actions the person takes with new knowledge. Therefore, it is important
that the nurse plan and evaluate all aspects of the teaching session to
be clear that the person has internalized the information, has accepted
it, and has followed it with a change.
The
categories of learning must be used as the nurse and the client establish
short- and long-term goals. The goals are used by the nurse to evaluate
the effectiveness of the plan. If the goals address only the cognitive
aspects of learning, the effect on attitudes and action will not be known.
As
you work with the client, you should see evidence that the client is problem
solving by using critical thinking regarding improvement of their health.
The nurse who models the strategies she is teaching will be the most effective.
As the client sees you using creative and critical thinking skills, he
will gain the ability to use them, too. Social learning theory is a model
of behavioral change most commonly cited as an effective strategy for
CAD clients. It utilizes behavioral, cognitive, and environmental factors
in the plan.
Social
learning theory emphasizes the importance of self-efficacy as the focus
of behavior change. Self-efficacy is a "person's assessment of his or
her ability to organize and execute a course of action to attain a designated
type of performance." This relates to the person's confidence that they
will succeed.
Self-efficacy
is influenced by four factors:
(1)
information and persuasion
(2)
observation of others
(3)
successful performance of the behavior
(4)
physiological feedback
Information
and persuasion from the health care professional that the person respects
will have the strongest influence. The professional will need to help
the person focus on the most important aspects of the learning that needs
to take place. The expectations of the health care professional will strongly
influence the behavior of the client.
The
observation of others with similar risks can have a strong social effect
on the client. Cardiac rehabilitation classes have already served as a
support group for persons participating in the classes. Those who have
been in the program and have benefited by the results will encourage the
newcomer. The new person in the cardiac risk classes will look to the
others who have succeeded as role models.
Unfortunately,
many look to past failures at losing weight or quitting smoking as an
obstacle for future success. The nurse will need to focus on different
ways that the client can succeed with the new behavior. Ask the client
to review what they did previously that was unsuccessful, and help him
develop a different plan.
There
is nothing like objective, concrete laboratory work to encourage a patient.
As the person sees changes in cholesterol level, lower blood pressure,
or better treadmill exercise test results, the motivation to continue
the program will be enhanced.
The
components of successful programs noted in clinical research and the experience
of those engaging in these programs are:
- positive, accurate expectations about results
- precisely defined behavior change
- realistic goals
- contracting
- prevention of lapse and relapse
- modeling
- prompting
- feedback
- problem solving
- rewards
- social support
Each
of these components will be discussed later in this study with strategies
for risk management.
Motivation
for Lifestyle Changes
Hans
Selye, known as the father of stress, once stated that if you can laugh
fifteen times a day it will relieve stress. Having a positive outlook
and a good sense of humor will help the nurse and the client achieve the
goals set for reducing the risk of heart disease. Achieving the motivation
and maintaining it to make significant life-style changes are probably
the hardest tasks that individuals have.
It
is known that a habit begins with small thread but forms a cable impossible
to break. A person will not work on breaking that cable unless they can
see the benefits. Therefore, the first step is personal motivation. The
clients should be encouraged to view themselves and the necessary changes
in a positive light.
The
nurse needs to develop a plan, following her assessment of the client,
that is individualized and hopefully effective for that person. First,
the nurse needs to seek to understand what the patient wants. This can
be done by using open-ended questions. Ask the patient to describe the
goals or anticipated outcomes of the lifestyle changes. After these goals
are elicited, the nurse will need to show personal interest in the client
and continue to offer encouragement. Even during times of failure, the
nurse can be a great support in helping the person to put the failure
behind them and move forward.
Another
positive approach to motivation is the warmth and good feelings that the
client gets from the nurse. If the client views the nurse as a problem-solver
and a resource, these feelings will continue.
Finally,
the nurse will need to get a commitment from the client to pursue the
goals set. You may need to ask the client, "Why not?" - just to get them
thinking about this commitment. As the old habits are replaced by the
new healthy habits, the person will begin to feel better and move toward
the goals.
Ultimately,
motivation lies solely with the client. The nurse plays a strong role
in encouragement, but the motivation must come from within. Some strategies
to share with the client include: meditation, vivid guided imagery, positive
self-talk, and a sense of humor.
Daily
meditation, or reflection, gives the individual a chance to get hold of
his thoughts. Meditation can take the form of just sitting comfortably
in a quiet place, away from distractions for at least 10 minutes. It is
a time to clear the mind and try to dispel any worrisome thoughts. The
person will need to remind himself to remove these stressful thoughts
using statements such as, "I'll worry about that later." - and channel
these thoughts into a problem solving method. Some find that reading Scripture
or meditation materials can help with the reflective process. Since many
of your clients are probably stressed, they may find meditation difficult.
Encourage them to give it at least a three-week trial.
Vivid
guided imagery is another technique that may help the person with motivation.
This involves the person visualizing himself as he will be later, after
successfully meeting his goals. Sometimes, the imagery needs to be very
vivid such as the person imagining the grease dripping from the fried
chicken he had planned to eat.
Another
strategy is positive self-talk. Encourage the person to use language.
"I am healthy, I enjoy my life, I want to feel good" are examples of ways
for the person to speak to himself.
Again,
a sense of humor will be the strongest asset you and your client will
have. Norman Cousins demonstrated well the power of laughter in restoring
one's health.
Effective
Programs to Promote Wellness
The
most effective health promotion programs include both educational and
personal counseling. These programs provide individual and group support
for the client at risk of CAD. The participants work with a variety of
health professionals in a team approach to gain control of the health
problems that lead to atherosclerosis. This team consists of the physician,
nurse, dietitian, psychologist, and exercise specialist. A nurse practitioner
who specializes in cholesterol management is often utilized. A structured
program is usually necessary to accomplish these changes.
An
example of one such program is HeartAction, sponsored by the Heart Institute
of Spokane, Washington. This program begins with an individual session
with a nurse to measure and discuss each risk for heart disease. A personal
action plan is then designed to change those risk factors. Laboratory
tests and medical histories are included. During the fourteen weeks of
support the following occur:
- Communication between the program nurses and primary physician to
determine the right approach for each person's needs
- Personal coaching by a nurse over the period of the program to create
a high likelihood of reaching personal goals
- Heart healthy nutrition classes by a registered dietitian
- Help with smoking cessation through a personal plan or referral to
a special class
- Stress management classes to support a healthy new lifestyle
- Exercise program provided by a cardiac rehabilitation program, or
a home exercise prescription, and
- Physician-guided management of related conditions such as diabetes,
high blood pressure and cholesterol disorders.
The
clients are referred to the program by their primary health care provider
who remains in control of all aspects of the patient's care. Eligibility
is determined by the risk factors the patient exhibits. The guidelines
for referral include:
(1)
person with total cholesterol > 240, or
(2)
HDL < 35, or
(3)
total cholesterol 200-239 with two or more risk factors,
(4)
have lipoprotein analysis and
(5)
further evaluation.
The
program serves patients with, and without, coronary artery disease. Persons
without a diagnosis of CAD should have two or more risk factors and LDL
< 130.
After
a person has completed the yearlong program, he is referred to other community
resources to assist with maintaining the lifestyle changes. The lipid
disorder management continues after the fourteen-week course is completed.
Please see Table 3 for the HeartAction flow chart to summarize this program.
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National Center
of Continuing Education
Nurses
can help their clients develop increased awareness of potentially modifiable
factors that increase the risk of developing heart disease by having them
calculate their own level of risk. The American Heart Association's RISKO
scale, which is based on data collected in the long-term Framingham Heart
Study, is a popular tool for this purpose. It has been most useful for education
of healthy individuals who are currently free of heart disease but may be
at risk of developing heart disease in the next few years.
