Embed Size (px)
Citation preview
Grambling State University
School of Graduate Studies
A COMPARISON OF BEFORE AND AFTER BLOOD PRESSURE IN
HYPERTENSIVE PATIENTS LIVING IN A SOUTH CENTRAL
STATE THAT HAVE BEEN TAUGHT THE DASH DIET
A Thesis
Submitted to the Faculty
of the School of Graduate Studies
in Partial Fulfillment
of the Requirements for the Degree of
Master of Nursing
September, 2009
Grambling State University
School of Graduate Studies
Department of Nursing
Proposal for a Thesis
A COMPARISON OF BEFORE AND AFTER BLOOD PRESSURE IN
HYPERTENSIVE PATIENTS LIVING IN NORTHEAST LOUISIANA
THAT HAVE BEEN TAUGHT THE DASH DIET
May, 2009
Approved:
__________________________ _________________________ Major Professor Committee Member _________________________ _________________________ Committee Member Program Director _________________________ _________________________ Committee Member Graduate School Dean
Grambling State University
School of Graduate Studies
This master’s thesis, written under the direction of the major professor/chair of the student’s major advisor and the student’s graduate committee and approved by all members of the committee and by the director of the graduate program in the student’s discipline, has been presented to and accepted by the Faculty of the School of Graduate Studies in partial fulfillment of the requirements for the degree of Master of Science in Nursing. Date____________________________________ ________________________________________ Dean Graduate Committee ______________________________ Major Advisor ______________________________ ______________________________ ______________________________ Department Head
TABLE OF CONTENTS PROPOSAL PAGE……………………………………………………………………….ii APPROVAL PAGE………………………………………………………………………iii ABSTRACT……………………………………………………………………………...iv ACKNOWLEDGEMENTS……………………………………………………………….v CHAPTER
I. INTRODUCTION………………………………………………………...1 Purpose…………………………………………………………………….3 Significance to Practice…………………………………………………...3 Theoretical Framework……………………………………………………5 Hypothesis………………………………………………………………...7 Definition of Terms……………………………………………………….8 Assumptions…………………………………………………………….....9 Limitations………………………………………………………………...9
II. REVIEW OF LITERATURE……………………………………………11 Hypertension Risk Factors……………………………………………….11 Dietary Approaches to Stopping Hypertension (DASH) Diet……….......14 DASH Diet and Hypertension…………………………………………...15 Nola Pender’s Health Promotion Model…………………………………16 Summary…………………………………………………………………18
III. CHAPTER 3……………………………………………………………..19
Methodology……………………………………………………………..19 Design of Study…………………………………………………………..19 Population/Sample……………………………………………………….20 Protection of Human Rights……………………………………………...20 Instrumentation…………………………………………………………..21 Data Collection…………………………………………………………..21 Data Analysis…………………………………………………………….23
REFERENCES…………………………………………………………………………..25
APPENDICES
A. INFORMED CONSENT………………………………………………...28
B. PERMISSION LETTER TO RANDY MORRIS………………………..30
C. COMMUNITY BULLETIN FLYER……………………………………32
D. PARTICIPANT’S CHECKLIST FOR PARTICIPATION……………...34
E. TEACHING PLAN………………………………………………………36
F. BROCHURE……………………………………………………………..39
G. DASH DIET FOOD PLANS AND RECIPES…………………………..40
H. DATA COLLECTION FORM…………………………………………..41
I. EQUIPMENT INSPECTION CHECKLIST…………………………….43
CHAPTER I
Introduction
The life expectancy for persons in the United States has increased from 68.2 years
for persons born in 1950 to 77.8 for persons born in 2005(Centers for Disease and
Control, 2008). As the lifespan of persons in the United States increases, the incidence of
chronic illnesses has become more prevalent. Hypertension is one illness which has
increased in incidence during this time period. As one ages, the risk of developing
hypertension increases dramatically. According to the Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure (2004), over 50% of people age 60-69 years old and over 75% of persons 75
years old or older will develop hypertension. This is significant because the risk for
ischemic heart disease, stroke, and chronic kidney disease increase as the blood pressure
increases. (Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure, 2004).
In the National Health and Nutrition Examination Survey, the researchers found
that between the years of 1976 and 1980 only 31% of hypertensive patients received
treatment. This number increased to 59% for the years 1999 through 2000. Of the patients
with hypertension during 1976 to 1980, only 10% had adequate control of their
hypertension. This number increased to only 34% for the years 1999 to 2000. Modifiable
factors that place people at higher risk for developing hypertension are excess body
weight, excess dietary intake of sodium, decreased physical activity, inadequate intake of
fruits and vegetables, and excess alcohol intake. According to the Seventh Report of the
Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure (JNC 7), less than 25% of Americans eat five or more servings of fruit
and vegetables daily. The average daily dietary intake of sodium in Americans is 4,100
grams which is more than the recommended daily allowance of sodium which is 2.3
grams daily. The Dietary Approach to Stopping Hypertension (DASH) Diet has been
developed to provide guidance in eating a diet that is high in fruits and vegetables and
lower in sodium. This diet plan is a healthy alternative for most Americans’ regular diet,
and it has been shown to lower systolic blood pressure 8-14 mm Hg (JNC 7, 2004).
According to the Harvard Heart Letter (2008), the use of the DASH diet or similar diets
high in fruits and vegetables was down 27% compared to its use in 1998. Hypertension
continues to be inadequately controlled in many patients, and diet is one factor that can
be modified by patients to improve control of their blood pressure.
According to the JNC 7, hypertension is defined as a systolic blood pressure
greater than 140 mm Hg or a diastolic blood pressure greater than 90 mm Hg. For a
patient to be diagnosed with hypertension, there should be two blood pressure recordings
of systolic blood pressure greater than or equal to 140 mm Hg or a diastolic blood
pressure greater than or equal to 90 mm Hg. In persons with diabetes the parameters for
systolic blood pressure should not exceed 130 mm Hg systolic or 80 mm Hg diastolic.
According to the 2005 National Medical Ambulatory Care Survey the percent of office
visits for hypertension had increased from 19.9% in 1995 to 28.1% in 2005. Regardless
of the increase in office visits, hypertension continues to be a growing epidemic not only
in the United States but worldwide. In the United States, 28% of adults were diagnosed
with prehypertension, and 29% of adults were diagnosed with hypertension . Although
there have been improvements in medical care, knowledge regarding hypertension and
the long term effects associated with it, and development of different hypertensive
medications, the incidence of hypertension in the United States has not changed between
1999 and 2006. Also, the percentage of patients diagnosed with hypertension that are
receiving treatment but continue to have inadequately controlled hypertension is 36%
(Ostchega, Yoon, Hughes, & Louis, 2008).
Purpose
The purpose of this study is to determine the effect of the DASH diet on blood
pressure levels in hypertensive clients living in a south central state.
Significance to Practice
According to Hyman and Pavlik, the majority of patients with undiagnosed
hypertension and those with known but inadequately controlled hypertension had access
to healthcare, but their physicians were not treating their blood pressure within
recommended guidelines of less than 140 mm Hg systolic and 90 mm Hg diastolic. As a
nurse practitioner, it is imperative that one recognizes hypertension and knows the
recommended guidelines for treatment. As stated previously, elevated blood pressure
places patients at risk for numerous co-morbidities. Modification of diet is one factor that
patients can perform as a means of improving blood pressure control. The nurse
practitioner should be cognizant of recommended treatment regimens that are conducive
to blood pressure control. Improved control of blood pressure by lifestyle modification
and proper medication management will reduce incidence of co morbidities associated
with uncontrolled hypertension.
Hypertension is a known risk factor for the development of cardiovascular
disease, cerebrovascular disease, chronic kidney disease, and retinopathy. For every 20
mm Hg increase in systolic blood pressure over 115 mm/Hg and 15 mm Hg increase in
diastolic blood pressure over 75 mm Hg, the risk for cardiovascular disease doubles (JNC
7, 2004). According to the World Health Organization, systolic blood pressure greater
than 115 mm Hg is to blame for 49% of ischemic heart disease and 62% cerebrovascular
disease. The National Kidney Foundation reports hypertension and diabetes as the
underlying cause for 66.7% of the cases of chronic kidney disease. Once a hypertensive
patient develops chronic kidney disease, the patient’s hypertension becomes more
difficult to control because chronic kidney disease in and of itself causes hypertension
(National Kidney Foundation, 2009). Hypertensive retinopathy has been established as an
effect of elevated blood pressure on the vascular system in the eyes. Retinopathy can also
serve as an indicator for increased risk in the development of cerebrovascular accident.
According to Wong, et al., 2002, the degree of damage to the vessels of the eye could be
correlated to blood pressure readings obtained 8 years earlier.
According to the National Vital Statistics Report, heart disease was the leading
cause of death in the United States for 2006. Cerebrovascular disease and stroke was the
third leading cause of death. Essential hypertension and hypertensive renal disease were
listed as the 13th cause of death.
The estimated direct and indirect costs of care in 2009 for hypertension and
associated co morbidities are as follows: hypertension-$73.4 billion, stroke-$68.9 billion,
cardiovascular disease-$475.3 billion, heart failure-$37.2 billion (Lloyd-Jones, et al,
2009). These numbers are staggering especially in the face of a national healthcare crisis.
Considering that 36% of persons with a diagnosis of hypertension do not have their blood
pressure under control, these numbers will certainly continue to increase as the
population ages and the risks for development of long-term side effects of hypertension
increases.
The physiological effects of hypertension in addition to the medications for
treatment can cause symptoms that negatively affect a person’s quality of life (Erickson,
Williams, & Gruppen, 2004). There has been reported a decrease in the quality of life in
persons with history of cerebrovascular accident secondary to the physical complications
associated with stroke as well as the psychological effects caused by stroke (Busco,
2008).
Theoretical Framework
Nola J. Pender’s Revised Health Promotion Model will serve as the theoretical
framework for this study. Dr. Pender’s theory focuses on three different aspects of an
individual and the relationship between the three: individual experiences and
characteristics, behavior-specific cognitions and affect, and behavioral outcomes.
(Pender, Murdaugh, & Parsons, 2006).
The individual experiences and characteristics encompass the areas of prior
related behavior and personal factors such as biological, psychological, and sociocultural.
Biological personal factors would include age, gender, body mass index, and physical
capabilities. Psychological factors include self-esteem, self-motivation, personal
competence, perceived health status, and one’s definition of health. Sociocultural factors
include race, ethnicity, education, and economic status (Tomey & Alligood, 2002).
The importance of these factors is they tend to predict behavior and can determine
the target behavior that is being considered for health promotion. This was proven in 75%
of studies evaluated by the Penders, Murdaugh, and Parsons (2006). The authors also
reported the effect of the person’s characteristics is also dependent on the behavior to be
targeted. One health promoting behavior may be instituted by a person, but another
behavior may be disregarded. Certain populations may embrace certain health promoting
behaviors whereas other populations may disregard the same behavior as unimportant.
According to Pender, one’s individual characteristics and experiences affects the
behavior-specific cognitions and affect which in turn influence behavioral outcome as
evidenced to commitment to a plan of action which leads to health-promotion behavior.
The characteristics of behavior-specific cognitions include perceived benefits of action
and perceived barriers to action. Perceived barriers to action are determined by perceived
self-efficacy which is influenced by activity-related affect. Activity-related affect is the
feelings that occur in regards to behavior, whether before, during, or after, which are
based on the properties of the behavior’s stimulus. If the person perceives the behavior in
a more positive manner, then the person’s sense of efficacy will be improved. Seventy-
nine percent of the studies evaluated by Pender, et al. supported the fact that if a person
perceives a factor to be a barrier then the person would be less likely to initiate the
behavior. If there are a large number of perceived barriers and the participant has little
willingness to participate in a health-promoting behavior, the behavior is very unlikely to
occur regardless of the actual benefits that could be received as a result of the behavior. If
there are very little perceived barriers and the participant is very willing to participate, the
behavior will more than likely be initiated.
Pender’s Health Promotion Theory is appropriate for this study. The purpose of
this study is to implement an action (adherence to the DASH diet) that is known to have a
positive effect on reducing blood pressure. In order for the DASH diet to be effective,
patients must be willing to make certain lifestyle modifications in regard to their diet.
This theory explores different components of persons’ experiences and how their
experiences and perceptions affect their actions and outcomes. The end goal is to develop
behavior that promotes health. One must first identify not only factors that may make
patients more receptive to implementing changes but to barriers as well. By doing this,
the teaching provided will be more effective and likely to cause desired behavioral
changes.
Hypothesis
Patients with hypertension who adhere to the DASH diet will lower their systolic
blood pressure levels more than patients with hypertension who do not adhere to the
DASH diet.
Definition of Terms
Patients with Hypertension
Theoretical definition: A person whose systolic blood pressure is greater than 140 mm
Hg and a diastolic blood pressure greater than 90 mm Hg for 2 consecutive readings.
(JNC 7, 2004)
Operational definition: Blood pressure is measured using an appropriately sized blood
pressure cuff, sphygmomanometer, and stethoscope. Normal blood pressure is a systolic
blood pressure <120 mmHg and a diastolic blood pressure <80 mm Hg. Hypertension is
defined as a systolic reading >140 mm Hg and a diastolic reading >90 mm Hg. In persons
with a co morbid condition of diabetes mellitus, a systolic blood pressure >130 mm Hg
and a diastolic blood pressure >80 mm Hg is considered hypertension (JNC 7, 2004).
Subject’s diagnosis of hypertension will be validated by subject’s self report of known
diagnosis of hypertension.
Systolic Blood Pressure
Theoretical definition: The pressure exerted on the blood vessels as the ventricles of the
heart contract.
Operational definition: This number is determined by the first audible beat noted upon
taking a person’s blood pressure using a blood pressure cuff, sphygmomanometer, and
stethoscope.
Dietary Approaches to Stopping Hypertension (DASH) Diet
Theoretical definition: A dietary plan that places emphasis on consuming a diet that is
low in saturated fat, total fat, and cholesterol and high in fruits, vegetables, and fat-free or
low-fat milk and dairy products. (National Heart, Lung, and Blood Institute, 2006)
Operational definition: A diet in which one eats 7-8 servings of grains, 4-5 servings of
fruit, 4-5 servings of vegetables, 2-3 servings of low-fat dairy, less than 2 servings lean
meat, fish, or poultry per day; 4-5 servings of nuts weekly. These serving suggestions are
based on a 2000 calorie diet. (The DASH Diet Plan).
Assumptions
1. Persons with hypertension want to gain better control of their blood pressure.
2. The person being taught about the DASH diet has the mental capabilities to
understand and retain the teaching.
3. The patient or their caregiver is physically able to buy and prepare meals in
accordance with DASH diet guidelines.
4. Individuals are willing to make changes in their diet if it will improve their health.
Limitations
1. The family of persons diagnosed with hypertension may not be receptive to diet
changes; therefore, the patient or caregiver may be less likely to prepare food in
accordance with DASH diet guidelines.
2. Persons with specialized diets may be unable to adhere to the recommended food
intakes specified by the DASH diet, such as patients with diabetes and/or severe
renal disease.
3. The perceived extra cost of buying fruits and vegetables may prevent persons
from attempting to adhere to the DASH diet.
4. The persons in the study may not “like” the types of food recommended in the
diet and therefore will not be compliant.
CHAPTER II
Review of Related Literature
The purpose of this study is to compare the difference in blood pressure in
persons before they are taught the DASH diet to their blood pressure after they have
adhered to the DASH diet for one week.This chapter documents the current literature
available regarding hypertension and the DASH diet. Each variable of the thesis will be
explored in a systematic and organized manner in order to provide the reader with
knowledge of the variables and the implications for practice in today’s world of health
care. Nola Pender’s Health Promotion Model, which serves as the theoretical basis for
this study, will also be discussed.
Hypertension Risk Factors
Hypertension is a topic of great concern in today’s health care. It is the leading
reason for office visits in the United States, and the improvement in management of
hypertension has not significantly improved since 1995. There are numerous risk factors
associated with hypertension. A study conducted by Stewart et al. demonstrated a
relationship between lower socioeconomic status and cardiovascular deaths in persons
with hypertension. This study indicated the more socioeconomic deprivation a person
experienced the higher the incidence of alcohol abuse, smoking, and increased body mass
index, which are risk factors associated with hypertension would occur. This is
significant in that according to the United States Census Bureau the percent of the
and 38.6% of the population in East Carroll parish was below poverty level for the year
2007. These two parishes will be the site for the majority of the data collection.
Hypertension places persons at increased risk for developing numerous
morbidities such as coronary heart disease, stroke, heart failure, renal failure, and
peripheral arterial disease. The Antihypertensive and Lipid-lowering Treatment to
Prevent Heart Attack Trial (ALLHAT, 2002) was a randomized, double-blind, active-
controlled clinical trial conducted over 8 years to determine what class of
antihypertensive medication was more effective in lowering the incidence of coronary
heart disease or cardiovascular disease. This study included over 33,000 participants.
Over the course of the trial, there was a decrease of at least 10 mm Hg in systolic blood
pressure among all groups and a decrease of at least 8 mm Hg in diastolic blood pressure.
Within seven years each group studied had occurrences reported of combined coronary
heart disease, combined coronary artery disease, stroke, and heart failure.
Hyman and Pavlik (2001) studied the characteristics of persons with uncontrolled
hypertension in the United States. It was interesting to note that in this study the majority
of patients with undiagnosed hypertension and those with diagnosed but uncontrolled
hypertension were under the care of a health care system. The greatest incidence of this
occurred in the elderly population. Males were also found to be at higher risk for having
uncontrolled hypertension. Access to medical care of medical insurance did not have a
significant impact on control of hypertension. The SUDAAN package was used for data
analysis in this study. Descriptive statistics and logistic-regression analysis were used to
describe the characteristics and variables of the participants in the study.
Lifestyle modification is indicated in all types of hypertension according to the
guidelines set forth by the JNC 7(2004). These interventions are inexpensive and can be
done safely in persons with hypertension. (August, 2003). Lifestyle modifications consist
of weight reduction to maintain a normal body mass index, adherence to the DASH diet,
restriction of dietary sodium to 2.4 grams daily, participation in 30 minutes of aerobic
exercise most days of the week, and limiting alcohol consumption to 2 or less drinks
daily for men and one drink daily for women.
Elmer et al. (2006) conducted a study that was published in the American College
of Physicians comparing the effects of multicomponent behavioral interventions to advice
only and the resulting effects on hypertension status, lifestyle changes, and blood
pressure. At the end of the study there was evidence that persons with prehypertension
and stage 1 hypertension were capable of maintaining lifestyle modifications congruent
with the recommendations for persons with hypertension.
Even though research has demonstrated that persons were capable of maintaining
lifestyle modifications that would prove therapeutic for persons with hypertension,
Mellen, et al. (2008) reported that adherence to the DASH diet has not been widely
accepted among hypertensive patients. Instead, their research indicated that person’s with
hypertension tended to maintain a diet that included saturated fats and a low amount of
nutrients. This was believed to be due in part to the lack of teaching by the health care
providers regarding dietary changes. According to Mellen, et al. (2004), only one third of
office visits for hypertensive patients include teaching on dietary management of
hypertension.
Dietary Approach to Stopping Hypertension (DASH) Diet
Appel et al. (1997) conducted a study using the DASH diet to identify its benefits
compared to a fruits and vegetables only diet and a control. The DASH diet showed the
greatest improvement in control of hypertension with an average decrease in systolic
blood pressure by 5.5 mm Hg and a decrease in the diastolic blood pressure by 3.0 mm
Hg. Reductions in blood pressure were reported in both sexes and in minority and
nonminority groups.
Sacks et al. (2001) conducted a study comparing the effects of the DASH diet to
reduced dietary sodium intake and the DASH diet. They reported that the addition of
lowering sodium intake further reduced both systolic and diastolic blood pressure. This
study consisted of a random sample of participants that were placed in 3 different groups
assigned to eat diets with varying levels of salt. Two of the diets were similar to the
standard diet many Americans eat; the third was the DASH diet. The participants had to
be at least 22 years of age and have an average systolic blood pressure between 120-159
mm Hg.
The ALLHAT study also noted the effects of lowering blood pressure by
adherence to the DASH diet. (Journal of the American Medical Association, 2002) The
ALLHAT study was a large randomized, double-blind, active-controlled clinical trial
conducted over 8 years. The purpose was to compare morbidity and mortality in
hypertensive persons taking angiotensin-converting enzyme inhibitors or calcium channel
blockers to persons taking diuretics.
DASH Diet and Hypertension
Svetkey, et al. conducted a randomized, controlled feeding study on persons over
22 years of age that had untreated hypertension with a systolic blood pressure less than
160 mm Hg and a diastolic blood pressure between 80 and 95 mm Hg. The participants
were placed in groups and fed one of three diets: a control diet that was representative of
the typical American diet, a fruit and vegetable diet that had a high concentration of fruits
and vegetables but was otherwise similar to the control diet and the DASH diet. The
DASH diet has shown to be beneficial in significantly lowering systolic blood pressure in
all groups studied by Svetkey, et al. (1999) and significantly lowering diastolic blood
pressure in all but 2 groups. The greatest decreases in blood pressure were seen in
African-American hypertensive patients. The results with the DASH diet surpassed the
improvement in both systolic and diastolic blood pressure compared to the remaining 2
diets implemented in this study.
Azadbackht, Mirmiran, Esmaillzadeh, Azizi, and Azizi (2005) conducted a
randomized controlled outpatient trial on persons with metabolic syndrome. The results
of the research demonstrated improvement in systolic blood pressure as evidenced in a
decrease of 11-12 mm Hg and a decrease in diastolic blood pressure of 6-7 mm Hg. In
addition to the benefits to the participants’ blood pressure, improvement was seen in the
participants’ high-density lipoprotein, low-density lipoprotein, weight and glucose
control.
Nola Pender’s Health Promotion Model
Dr. Pender’s Health Promotion Model has provided the basis for many studies in
which the development and/or implementation of health promoting behaviors have been
initiated in order to provide an outcome conducive to the improvement of one’s health.
As noted in the above information given, lifestyle modification is an important factor in
controlling hypertension.
In 2005, Hensley, et al. conducted a study on Louisiana residents diagnosed with
type 2 diabetes and hypertension that were under the care of nurse practitioners and
physicians using Dr. Pender’s Health Promotion Model as the theoretical framework for
their study. The purpose was to identify the outcomes of these patients as evidenced by
measurement of their body mass index, blood pressure, glycosylated hemoglobin, fasting
glucose, and total cholesterol levels over one year. The results of this study indicated
there was a significant improvement in the above listed criteria related to the amount of
visits the patients had with their healthcare provider, diabetic education, home glucose
monitoring, and taking the appropriate prescribed medications.
Conway, McClune, and Nosel (2007) used Pender’s Health Promotion Model to
conduct a study concerning agricultural related accidents in children in northwest
Pennsylvania. The goal was to determine the incidence of care provided to children
involved in farm related accidents, explore barriers in the provision of farm safety
material by primary health care providers, and identify the proportion of primary health
care providers that provide anticipatory guidance for farm safety. A significant number of
farm-related accidents for which persons sought treatment were reported. The authors
recommended rural health care providers should be given additional health promotion
material related to farm safety to give their patients for prevention of farm-related
accidents.
A study to determine the health promoting behaviors and to identify barriers to
health promoting behavior of elderly Chinese persons living in Hong Kong was
conducted by Kwong and Kwan (2006) by using Pender’s Health Promotion Model as a
guide. This study focused on physical activity, healthy dietary practices, and stress
management among this population. The results showed a relationship between perceived
self-efficacy, perceived benefits, and gender in 38.4% of the health-promoting behavior
noted in the subjects.
Pender’s Health Promotion Model served as the theoretical framework for a study
conducted by Mendias and Paar (2007) to explore the learning needs related to health and
self-care, barriers to learning, and the preferred modalities to learning in patients
diagnosed with HIV. The study dealt with education regarding treatment, management,
and the signs and symptoms of HIV/AIDS as well as information associated with chronic
illness in general. Participants showed a considerable amount of interest in health
promotion as well as symptom management, how to communicate with their health care
provider, current health state, and “living with HIV.” More than half of the participants
listed “not feeling well enough” as a barrier to their participation in receiving education.
The use of technology and the internet were listed as widely used modalities for receiving
education.
Wilson (2005) used Pender’s Health Promotion Model as the theoretical
framework for her research of the health practices of homeless women living in shelters.
The subjects participated in an assortment of health promoting behaviors, but there was a
deficit in receiving dental or eye examinations as recommended. The level of health
promotion behavior in this group of women was similar to the levels of health promoting
behavior of low-income women. These results supported the appropriateness of Pender’s
Health Promotion Model as the theoretical framework for the project.
Pender’s Health Promotion Model has been used in a variety of research studies
regarding various aspects of health promotion and factors that affect health promotion.
The diversity of the research based on this model demonstrates flexibility and potential
for continued use in a variety of areas regarding health care and promotion.
Summary
There is a large amount of research available regarding hypertension. There are
consistent results in the literature regarding diet as a modifiable factor of hypertension.
Diets low in total and saturated fat and cholesterol and high in fruits and vegetables, and
low-fat or fat-free dairy products have been shown to lower blood pressure. Pender’s
Health Promotion Model has been used frequently in research that focuses on health
promotion as a reliable theoretical framework.
CHAPTER III
Methodology
The purpose of this study is to compare the blood pressure of hypertensive
patients living in a south central state before they are taught the DASH diet to their blood
pressure after one week of adherence to the DASH diet to determine the significance of
the impact the DASH diet has on one’s blood pressure. The following information will be
examined and discussed in this chapter: the design of the study, population/sample,
protection of human rights, instrumentation, data collection, and data analysis. Each of
these topics will be discussed independently.
Design of Study
The study to be conducted is quasi-experimental, comparative study which will
measure and compare the blood pressure of the participants before the intervention of
implementing the DASH diet and one week after adherence to the DASH diet. Quasi-
experimental studies are ones in which an intervention or subjects are not randomly
assigned, but the researcher maintains certain controls in order to improve the study’s
internal validity (Polit & Beck, 2004). Comparative studies are ones in which the
researcher compares information obtained from participants before to information
obtained after an intervention is implemented (Polit & Beck, 2004). The collection of the
data will occur in multiple settings including participants’ homes, medical offices, and
local hospitals. Comparison will be made among the subjects.
Population/Sample
The participants included in this study will be persons greater than 18 years of age
that have been diagnosed with hypertension. The persons will be residents of a south
central state. The majority of the participants will be residents of Louisiana including but
not be limited to persons living in West Carroll and East Carroll Parishes. The persons
will be asked to participate by the varying means. Persons with a known history of
hypertension will be asked to participate in this study. Also, flyers will be placed on
community bulletin boards in public domains for volunteer participation.
The participants will include females and males and persons from various ethnic
backgrounds. The target number of participants will be 50 initially with at least 30
persons completing the requirements of blood pressure monitoring and adherence to the
DASH diet for final data analysis.
Protection of Human Rights
Before the data collection is initiated, the thesis proposal will be presented to the
Grambling State University Committee for the Protection of Human Subjects for
approval.
Participant confidentiality will be maintained. A brief overview will be presented
to the potential participant. An informed consent will be given to each person that
participates to read and sign. The measuring of the blood pressure and teaching of the
DASH diet will be done at a setting in which the participant and researcher are
comfortable.
The researcher will start the research with at least 50 participants. This will allow
for the gathering of sufficient data if some participants are unable to complete the study.
The participants may withdraw from the study at any time he or she wishes. The
researcher’s goal is to have at least 30 participants at the completion of the study.
Instrumentation
The teaching will be done in a neutral environment in a manner that is
nonthreatening to each participant. Teaching will be done according to the teaching plan
in appendix E. Each participant will receive a brochure defining hypertension and the
long term effects of uncontrolled hypertension as presented in appendix F. Participants
will be provided with 7 days worth of meal plans for breakfast, lunch, dinner, and one
snack as shown in appendix G. The participants are not required to follow the meal plans.
The instruments to be used to collect the blood pressure data will be a Welch-
Allyn blood pressure cuff appropriately sized for each patient, sphygmomanometer and
Welch-Allyn stethoscope. To decrease potential variances, blood pressure data will be
collected only by the study director. The blood pressures will be collected in rooms free
of excessive noise to allow for adequate hearing of the blood pressure. The figures
obtained will be recorded on the form in appendix H.
Data Collection
Each participant will fill out an information packet prior to initiating the teaching
of the DASH diet. The information requested will be the patient’s age, race, gender, and a
list of their antihypertensive medications. Once the information is collected, the person’s
blood pressure will be measured using the Korotkoff’s sound technique in one bare arm.
The participant will be in a sitting position with their legs uncrossed, back supported, and
the arm being used for blood pressure measurement supported at the level of the
participant’s heart. The arm used will be recorded so the blood pressure can be repeated
on the same arm and in the same position at the completion of the week of adherence to
the DASH diet. The participants’ blood pressure will be measured at the same time of the
day for each reading. Refer to appendix H for chart that will used to collect information
for the participants. If more than one blood pressure reading is taken, the researcher will
record both blood pressure readings and average the systolic and diastolic blood pressures
separately and record the average as the blood pressure to be used for the evaluation.
According to the American Heart Association guidelines, a closed system should
be used in measuring blood pressure. The equipment’s tubing and release valve should be
inspected routinely. Equipment to be used will be inspected on a weekly basis (Smith,
2005).
The blood pressure cuffs and sphygmomanometer used are a Welch-Allyn
DuraShock handheld, pocket, and integrated aneroid sphygmomanometer. According to
the product insert, the blood pressure measurements obtained by the equipment meet the
requirements of the American National Standard. The readings obtained are accurate
from +/- 3 mm Hg. In order to check the calibration of the sphygmomanometer, the
researcher will ensure the needle is within the oval at the bottom of the dial with the bulb
at zero-pressure gradient. The manufacturer recommends full calibration every 2 years to
ensure accuracy. The sphygmomanometer to be used was purchased in August, 2008, so
it is within the required 2 years recommended by the manufacturer.
The stethoscope to be used in auscultating the blood pressure is a Welch-Allyn
Harvey DLX double head stethoscope. The stethoscope will be inspected weekly to
determine integrity of the ear pieces, diaphragm, and tubing. The stethoscope will be
cleaned with alcohol between patients to prevent the possibility of spreading infection.
The diaphragm head of the stethoscope will be used to measure blood pressure. The
weekly examinations of the equipment will be recorded on the form in appendix I.
The measurement of blood pressure is considered a ratio measurement. The
values obtained can be used in all of the basic mathematical functions-adding,
subtracting, multiplying, and dividing-because there is a “rational, meaningful zero”
associated with blood pressure. (Polit, & Beck, 2004). The differences in the participants’
blood pressure before and after the initiation of the DASH diet are considered ratio
measurements, also.
Data Analysis
The data collected will be analyzed using the paired t-test method. The t-statistic
will be computed using the blood pressure readings obtained before and after the
initiation of the DASH diet. The inferential statistic that will be used to test the
hypothesis of this study is the paired t test. The assumptions for the paired t test are the
variables are categorical and have one mutually exclusive group of subjects; there is a
normal distribution of the independent variable; and the variances of the dependent
variable for the group is similar (Polit & Beck, 2004). An alpha level of 0.5 has been
chosen to determine statistical significance. Cronbach’s alpha will be used to determine
reliability of the instrument.
REFERENCES
Appel, L., Moore, T., Obarzanek, E., Vollmer, W., Svetkey, L., Sacks, F., et al. A clinical trial of the effects of dietary patterns on blood pressure. New England Journal of Medicine, 336(16), 1117-1124. Retrieved on February 10, 2009, from the New England Journal of Medicine Database.
August, A. (2001). Initial treatment of hypertension. New England Journal of Medicine,
348(7), 610-617. Retrieved February 10, 2009, from the New England Journal of Medicine Database.
Busko, M. (2008). Psychological symptoms decrease long-term quality of life after
stroke. Medscape medical news. Retrieved July 26, 2009, from http://www.medscape.com/viewarticle/585865
Centers for Disease Control and Prevention. (2008). Health,United States, 2008, with
special feature on the health of young adults. Retrieved September 6, 2009, from http://www.cdc.gov/nchs/data/hus/hus08.pdf#026
Conway, A., McClune, A., & Nosel. (2007). Down on the farm: Preventing farm
accidents in children. Pediatric Nursing, 33(1), 45-48. Retrieved April 16, 2009, from EBSCOHOST.
DASH diet ignored. (August, 2008). Harvard Heart Letter. Retrieved February 9, 2009
from www.health.harvard.edu Elmer, P., Obarzanek, E., Vollmer, W., Simons-Morton, D., Stevens, V., Young, D.,
Champagne, C., et al. (2006). Effects of comprehensive lifestyle modification of diet, weight, physical fitness, andblood pressure control: 18-month results of a randomized trial. Annals of Internal Medicine, 144(7), 485-495. Retrieved April 10, 2009, from EBSCOHOST.
Erickson, S., Williams, B., & Gruppen, L. (2004). Relationships between symptoms and
health-related quality of life in patients treated for hypertension. Pharmacotherapy, 24(3). Retrieved July 26, 2009, from http://www.medscape. com/viewarticle/470909
Hensley, R., Jones, A., Williams, A., Willsher, L., & Cain, P. (2005). One-year clinical
outcomes for Louisiana residents diagnosed with type 2 diabetes and hypertension. Journal of the American Academy of Nurse Practitioners, 17(9), 363-369.
Heron, M., Hoyert, D.,Murphy, S., Xu, J., Kochanek, K., & Tejada-Vera, J. (2009).
Deaths: Final data for 2006. National Vital Statistics Report, 57(14), 1-80.
Retrieved July 25, 2009, from http://www.cdc.gov/nchs/data/nvsr/ nvsr57/nvsr57_14.pdf
Hyman, D., & Pavilk, V. (August, 2001). Characteristics of patients with uncontrolled
hypertension in the United States. New England Journal of Medicine, 345, 470-487. Retrieved February 10, 2009, from the New England Journal of Medicine database.
Kwong, E., & Kwan, A. (2006). Participation in health-promoting behaviour: Influences
on community-dwelling older Chinese people. Journal of Advanced Nursing,57(5), 522-534. Retrieved April 16, 2009, from EBSCOHOST.
Lloyd-Jones, D., Adams, R., Carnethon, M., Simone, G., Ferguson, B.,Flegal, K., et al.
(2009). Heart Disease and Stroke Updates-2009. Circulation, 119, 21-181. Retrieved July 25, 2009, from http://circ.ahajournals.org/cgi/content/full/119/2 /e21#SEC116
Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting
enzyme inhibitor or calcium channel blocker vs. diuretic: The antihypertensive and lipid-lowering treatment ot prevent heart attack trial (ALLHAT). Journal of the American Medical Association, 288(23), 2981-2997. Retrieved April 13, 2009, from http://jama.ama-assn.org/cgi/content/full/288/23/2981
Mendias, E., & Paar, D. (2007) Perceptions of health and self-care learning needs of
outpatients with HIV/AIDS. Journal of Community Health Nursing, 24(1), 49-64. Retrieved April 16, 2009, from EBSCOHOST.
National Center for Health Statistics: Physician Office Visit Data. Retrieved April 10,
2009 from http://www.cdc.gov/nchs/about/major/ahcd/officevisitcharts.htm National Heart, Lung, and Blood Institute. (2006). Your guide to lowering your blood
pressure using DASH. Retrieved April 20, 2009, from http://www.nhlbi.nih.gov/ health/public/heart/hbp/dash/new_dash.pdf
National Kidney Foundation. (2009). Chronic kidney disease. Retrieved July 25, 2009,
from http://www.kidney.org/kidneydisease/ckd/index.cfm Pender, N., Murdaugh, C., Parsons, M. (2006). Health promotion in nursing practice (5th
ed.). Upper Saddle River, New Jersey: Pearson Prentice Hall. Polit, D., & Beck, C. (2004). Nursing Research: Principles and Methods. Philadelphia:
Lippincott, Williams, & Wilkins
Soukhanov, A., & Ellis, K. (Eds.) (1984). Webster’s II new Riverside University dictionary. Boston: Houghton Mifflin Company.
Smith, L. (2005). Practice guidelines: New AHA recommendation for blood pressure
measurement. American Family Physician. Retrieved September 6, 2009, from http://www.aafp.org/afp/20051001/practice.html
Stewart, L., McInnes, G., Murray, L., Sloan, B., Walters, M., Morton, R., Padmanaghan,
S., Reid, J., & Morrision, D. (2008). Risks of socioeconomic deprivation of mortality in hypertensive patients. Journal of Hypertension. Retrived March 30, 2009, from http://ovidsp.tx.ovid.com/spb/ovidweb.cgi?&S=KABJFPNNJKDDCN CNCGLDHCKE
The DASH diet eating plan. ( 2009). Retrieved February 9, 2009, from
http://dashdiet.org The seventh report of the joint national committee on prevention, detection, evaluation,
and treatment of high blood pressure. (2004, August). Retrieved February 9, 2009, from http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm
Tomey, A., & Alligood, M. (2002) Nursing theorists and their work. St. Louis: Mosby. Wilson, M. (2005). Health-promoting behaviors of sheltered homeless women. Family
and Community Health, 28(1), 51-63. Retrieved April 16, 2009, from EBSCOHOST.
Wong, T., Hubbard, L., Klein, R., Marino, E., Kronmal, R., Sharrett, A., Siscovick, D., et
al., Retinal microvascular abnormalities and blood pressure in older people: The cardiovascular study. British Journal of Ophthalmology, 86, 1007-1013. Retrieved July 25, 2009, from http://bjo.bmj.com/cgi/content/full/86/9/1007
World Health Organization.(2002). World health report 2002-reducing risks, promoting
healthly life. Retrieved July 25, 2009, from United States Census Bureau: State and County Quick Facts. Retrieved April 10, 2009
from http://quickfacts.census.gov/qfd/states/22/22035.html
APPENDIX A
Informed Consent
INFORMED CONSENT I understand that I am being asked to participate in a research study conducted by Carla Costello, a graduate family nurse practitioner student at Grambling State University. The purpose of this study is to evaluate the effect of adherence to the Dietary Approach to Stop Hypertension (DASH) diet in persons with high blood pressure. If I agree to participate in this study, I will be required to participate in a teaching session that will last approximately 15 minutes regarding the DASH diet. I agree to have my blood pressure taken before the implementation of the DASH diet and after one week of adherence to the DASH diet. There will be no use of identifying information included in the study. The information gathered will be kept confidential by the researcher. I understand that participation is strictly voluntary, and I may withdraw from the study at any time. There will be no monetary reimbursement for participation. I realize I will not be able to participate in the study if I am under 18 years of age. I realize I will not be able to participate in the study if I have a diagnosis of diabetes. If I need additional information regarding the study, I can contact Carla Costello any time during the study. The study has been explained to me. I have read and understand this consent form, all of my questions have been answered to my satisfaction, and I agree to participate. I will receive a copy of this consent form if I so desire. __________________________________________ ___________________ Signature of Subject Date __________________________________________ ___________________ Signature of Witness Date __________________________________________ ___________________ Signature of Researcher Date
APPENDIX B
Permission Letter to Randy Morris
Date to be added upon mailing. 307 McGaha Rd. Oak Grove, LA 71263 [email protected] Randy Morris 706 Ross St. Oak Grove, LA 71263 Dear Mr. Morris, As you know, I am enrolled in the Family Nurse Practitioner Program at Grambling State University. As part of my education requirements, I am writing a thesis and conducting research on the effects of diet on hypertension. The purpose of my thesis is to determine if the Dietary Approaches to Stopping Hypertension Diet causes a decrease in hypertensive patients’ blood pressure. I would like to have at least 50 participants enrolled at the beginning of my research. I am writing this letter to ask permission to place a flyer on the community bulletin boards at West Carroll Memorial Hospital, Community Medical Clinic, Lake Providence Medical Clinic, Oak Grove Medical Clinic, and West Carroll Medical Clinic. I have enclosed a copy of the flyer. If you have any questions, please contact me at the following phone number: (318)-669-0381. Thank you for your consideration in this matter. Sincerely,
APPENDIX C
Community Bulletin Flyer
HELP WANTED!
I am conducting a research project
regarding hypertension (high blood
pressure) and how what we eat affects
our blood pressure.
If anyone is interested in participating
in this research project, please
contact Carla Costello, RN, at 318-669-
0381.
APPENDIX D
Participant’s Checklist for Participation
PARTICIPANT CHECKLIST FOR PARTICIPATION IN DASH DIET THESIS RESEARCH
Informed Consent Obtained
and Signed
Participant’s Name
Participant’s Age
Participant’s Sex
Teaching Completed Regarding Hypertension
Teaching Completed Regarding the DASH Diet
BLOOD PRESSURE BEFORE INITIATION OF DASH DIET Blood Pressure Reading
Arm Blood Pressure Obtained In
Time Blood Pressure Recorded
BLOOD PRESSURE AFTER INITIATION OF DASH DIET
Blood Pressure Reading
Arm Blood Pressure Obtained In
Time Blood Pressure Recorded
APPENDIX E
Teaching Plan
TEACHING PLAN INTRODUCTION Personal Information:
• Carla Costello • RN for eleven years and is currently working on obtaining master’s degree and
nurse practitioner certification from Grambling State University. • The research being done is required for completion of master’s degree.
Goal of Research
• Increase hypertensive patient’s knowledge of their disease process. • Teach the DASH diet. • Measure blood pressure before and after one week’s adherence to DASH diet to
evaluate for any changes. HYPERTENSION (Brochure will be presented and read to pt.)
• What is blood pressure? o The pressure inside the arteries, the vessels that carry blood to the body. o The top number is the pressure inside the arteries when the heart beats o The bottom number is the pressure inside the arteries when the heart
relaxes between beats. • What is hypertension?
o An increase in blood pressure higher than the recommended number of 140 mm Hg systolic (top number) and/or 90 mm Hg diastolic (bottom number). For diabetics, an increase >130 mm Hg systolic and/or >80 mm Hg diastolic.
• What problems are associated with hypertension? o Stroke o Retinopathy which can lead to blindness o Kidney disease which can lead to kidney failure and dialysis o Heart disease which can lead to a heart attack. o Peripheral vascular disease.
• What can be done to control hypertension: o Take medicines as prescribed by your care provider. o Keep weight within a normal BMI range. o Exercise for 30 minutes most days of the week o Limit salt intake.
o Adhere to the DASH diet. DASH Diet
• Diet in which the patient eats 7-8 servings of grains, 4-5 servings of fruit, 4-5 servings of vegetables, 2-3 servings of low-fat dairy, and less than 2 servings of lean meat, fish, or poultry daily; 4-5 servings of nuts weekly.
• Presentation of diet plans that provides examples of what defines a serving of each listed food group.
RESEARCH REQUIREMENTS
• Participant will allow researcher to take blood pressure before adherence to DASH diet.
• Participant will agree to adhere to the DASH diet for one week. • At the completion of the week, the participant will allow the researcher to recheck
blood pressure. • Participant may discontinue participation in the study at any time.
*If participant agrees to participate in the research, an informed consent will be signed and witnessed. Data collection location, dates and times will be scheduled with the participant for the blood pressure readings. *If the participant does not want to participate, he/she will be thanked for their time and dismissed.
APPENDIX F
Brochure
APPENDIX G
DASH Diet Food Plans and Recipes
APPENDIX H
Data Collection Form
COMPILED DATA COLLECTION
Participant’sName Age Gender 1stBloodPressure 2ndBloodPressure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Participant’sName Age Gender 1stBloodPressure 2ndBloodPressure
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
Participant’sName Age Gender 1stBloodPressure 2ndBloodPressure
44.
45.
46.
47.
48.
49.
50.
APPENDIX I
Equipment Inspection Checklist
Equipment Inspection Checklist
DateChecked
BloodPressureCuff
Sphymomanometer
Stethoscope
DateChecked
BloodPressureCuff
Sphymomanometer
Stethoscope
