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A Family Case Study Presented To the College of Nursing

In Partial fulfillment of the Requirement in Community Organizing Participatory Action Research Family Case Study

Submitted to: Ms. Arlene D. Layupan, RN Mr. Henrries Dan Tulas, RN Mr. Ronald Allan Ramo, RN

Submitted by: Celedonio, Precy abe .

September !" !#"$

TA

!" OF CONT"NTS

%.T%TL& PA'&....................................................................................................." %%.TA L& () C(NT&NTS................................................................................! %%%.AC*N(+L&D'&M&NT...............................................................................$ %,.%NTR(D-CT%(N................................................................................................ ,.( /&CT%,&S o0 t1e CAS&.........................................................................2 ,%. %D&NT%)%CAT%(N () TH& CAS&....................................................................3 ,%%.)AM%L4 AC*'R(-ND............................................................................5 ,%%%.S(C%(6 &C(N(M%C AC*'R(-ND............................................................7 %8.)AM%L4 M&D%CAL and H&ALTH H%ST(R4...................................................9 8.'&N('RAM...................................................................................................."#6"" 8%.)AM%L4 AP'AR........................................................................................"! 8%%%.)AM%L4C(P%N' %ND&8..............................................................................."$6"5 8%,.N-RS%N'TH&(R4......................................................................................"76"9 8,. MANA'&M&NT A.M&D%CAL MANA'&M&NT....................................................................................................!#6!. .N-RS%N' MANA'&M&NT ." Problem List :Maslo;<s Hierarc1y=.....................................................!26!5 .! Problem %denti0ication :Healt1 T1reat> De0icit> )oreseeable Crisis=...!76!9 .$)amily Nursin? Care Plan....................................................................$#6$$ ..Healt1 Teac1in?s :T1ree Le@els o0 Pre@ention=..................................$.6$2 8,%.%MPL%CAT%(N................................................................................................$36$5 8,%%%.H&ALTH -PDAT&S.............................................................................................................$76.# 8%8.R&)&R&NC&S................................................................................................"

AC#NO$!"%&"'"NT

%, ;ould liAe to eBpress t1e 1eart0elt ?ratitude to t1e 0ollo;in? people 0or t1eir pro0essional direction. To Mr. Ronald Allan Ramo, RN, Mr. Henrries Dan Tulas RNC Miss Analyn Salamero RNC and Miss Arlene Layupan, RN and 0or t1eir @aluable ?uidance and 1elp durin? t1e entire community eBposure. To Dean (0elia C. Larie?o , RN, MANC 0or allo;in? us to 1a@e our eBposure and ?i@in? us t1e c1ance to impro@e our Ano;led?e and sAills in Community Healt1 Nursin?. To my belo@ed 0amily, ;1o al;ays t1ere to support me in any problems. )or t1e 0inancial support t1at t1ey ?a@e to me in order to attend sc1ool and duties. T1e 0ourt1 year SN students ;ould liAe to eBtend t1eir sincere appreciation

to t1eir indi@idual 0amily 0or t1eir unstoppable 0inancial support and 0or unendin? prayers to Aeep us sa0e durin? t1e community eBposure. To t1e r?y. Captain Robert (lanolan, 0or permittin? us to conduct t1e

community eBposure. To all residents ;1o ;illin?ly cooperated in all our acti@ities. And 0inally, % ;ould liAe to t1anA our Almi?1ty 'od 0or His ?uidance and protection durin? our acti@ities and di00iculties in ?oin? to t1e community.

INTRO%(CTION

Hypertension, also re0erred to as 1i?1 blood pressure, is a condition in ;1ic1 t1e arteries 1a@e persistently ele@ated blood pressure. &@ery time t1e 1uman 1eart beats, it pumps blood to t1e ;1ole body t1rou?1 t1e arteries. Hypertension is considered as t1e bi??est sin?le risA 0actor 0or deat1s ;orld;ide. Accordin? to t1e +orld Healt1 (r?aniDation !#"!, 1ypertension causes 5 million deat1s e@ery year ;1ile ".2 billion people su00er due to its complications. +e c1ose Ms. 84<s case because 1er case is one o0 t1e most common disease ;orld;ide a00lictin? 1umans, ;1ic1 is 1ypertension or 1i?1 blood pressure. %t is Ano;n as silent Ailler because in t1e initial sta?e it presents no symptoms. %t is only a0ter an or?an in t1e body is irritated or dama?ed, t1at t1e conseEuences o0 1i?1 blood pressure are realiDed. Li0estyle no;adays is one o0 t1e maFor precipitatin? 0actors o0 t1e condition. T1ese li0estyle 0actors include 1i?1 sodium intaAe, eBcessi@e calorie intaAe, and obesity, p1ysical inacti@ity and eBcessi@e alco1ol consumption.

O )"CTI*"S

A0ter "! days o0 span o0 nursin? care: Determine t1e le@el o0 co?nition in t1e determination and prioritiDation o0 problems t1at eBist in t1e community. De@elop t1e sAill o0 inter@ention prompt to t1e social 1ealt1 care problem in accordance ;it1 its appropriateness and e00ecti@eness. Pro@ide ser@ices and 0acilitate 0or t1e better and appropriate solutions present in a particular community. SP"CIFIC O )"CTI*"S+ A0ter "! days o0 span o0 nursin? care: ". Apply Ano;led?e and sAills on 1o; to ?i@e 1ealt1 education to t1e community in relation to t1eir identi0ied problemC !. Discuss brie0ly and eBplain t1e etiolo?y o0 prioritiDed problem, its causes and e00ects and ;ays on 1o; to eradicate itC $. Determine t1e 0amilies Ap?ar score and 0amily copin? indeB in assessin? t1e 0unctionin? and potential areas o0 0amily stren?t1 and resources. .. &stablis1ed a nursin? care plan ;1ic1 ;ould be bene0icial to t1e 0amily, as ;ell as to t1e communityC 2. )ormulate a clear and speci0ied plan o0 action to ?i@e solutions to t1e eBistin? 1ealt1 problems identi0ied ;it1in t1e community 3. Present data and proo0 about t1e common 1ealt1 problem o0 t1e community residentsC 5. Relate eBistin? 1ealt1 problems ;it1 di00erent nursin? t1eoriesC and 7. &@aluate t1e e00ecti@eness o0 t1e plan o0 action and t1e entire pro?ram per0ormed in t1e communityC 9. 'i@e summary, e@aluation and implicationC

I%"NTIFICATION OF T," CAS"

Code Name: Mrs. 84 Nationality: Reli?ion: Address: A?e: (ccupation: Ci@il Status: Menarc1e: Parity: 'ra@ida: Abortion: )ilipino Roman Cat1olic aran?ay 536A, ucana, Da@ao City .5 years old House;i0e, carpenter Married ". years old 2 2 # %rre?ular usually 1er menstrual cycle inter@al is !6$ mont1s Hypertension :!##9= Au?ust $#, !#"$ September !", !#"$

Menstrual Cycle: Dia?nosis: Date study e?un: Date study &nded:

%n0ormants:

Dau?1ter

FA'I!-

AC#&RO(N%

T1e 84 0amily, an eBtended type o0 0amily is t1e c1osen to be t1e subFect o0 my case study. T1ey are currently residin? at aran?ay 536A, PuroA 36A, ucana,

Da@ao City. Mrs. is .5 years old, a colle?e under?raduate, a 1ouse;i0e but sometimes ;orAs as a carpenter in ucana earnin? not less t1an $### a mont1 but

lately eBperiencin? DiDDiness. S1e is also t1e one maAin? t1e decision in terms o0 t1eir 0inancial bud?et. Her 1usband Mr. 84 is .7 years old, an elementary ?raduate, and ;orAs as a trisiAad dri@er in ucana ;as dia?nosed ;it1 1ypertension last

!#"".Mr. 84 is t1e one maAin? t1e decision in relation to 1ealt1, problems in t1e 0amily and sometimes t1e one ;1o bud?et ;it1 re?ards to 0inancial. T1ey 1a@e 2 c1ildren but only ! are still dependent and li@in? ;it1 t1em. T1eir eldest c1ild is !9 years old, a 1i?1 sc1ool ?raduate, married ;it1 . c1ildren and ;orA as a domestic 1elper at *u;ait. T1eir !nd c1ild is !3 years old, also a 1i?1 sc1ool ?raduate, sin?le and ;orAin? as a construction ;orAer. T1en, t1eir $ rd c1ild is !2 years old, married and ;orAs as a 0armer at ucana. T1eir . t1 c1ild is !$ years old sin?le and ;orAs as a saleslady at Lac1mi San Pedro street, Da@ao City. Lastly, t1eir 2t1 c1ild is "5 years old, still student and studyin? at *apitan Tomas. T1eir 0amily 1as o;ned t1eir 1ouse t1at is made o0 li?1t ;ood and cement ;it1 ! rooms. T1ey 1a@e no enou?1 0urniture. T1ey 1a@e one Tele@ision, D,D, internet, telep1one, AaraoAe and an insu00icient li?1tin? 0acility. T1ey also 1a@e a public ;ater supply, a ;ater sealed type o0 toilet 0acility near t1eir Aitc1en, 1as also

an open draina?e system. T1ey are also compostin? t1eir ?arba?e and uses 0ire;ood in cooAin?

SOCIO."CONO'IC

AC#&RO(N%

Mrs. 84 is .5 years old, and is married to Mr. 84 ;1o is a TrisiAad Dri@er in aran?ay 536A, ucana. S1e is a 1ouseAeeper and a lo@in? mot1er to 1er

0i@e :2= c1ildren. T1e eldest c1ild ;orAs as a domestic 1elper at *u;ait. T1eir !nd c1ild is ;orAin? as a construction ;orAer. T1e t1ird c1ild ;orAs as a 0armer at ucana. T1e 0ourt1 c1ild ;orAs as a saleslady at Lac1mi San Pedro Street, Da@ao City. T1eir 2t1 c1ild is "5 years old, still a student and studyin? at *apitan Tomas. Accordin? to 1er, t1ey 1a@e a ?ood 0amily relations1ipC t1ey are close to eac1 ot1er. Mrs. 84 is a colle?e under?raduate. S1e ;orAs in 1er place as a carepenter, and s1e also 1a@e small business% T1ey earned P.### to P2### per mont1 to?et1er ;it1 1er 1usband. T1ey ate $ times meal in a day. Accordin? to 84 ;1en t1ere are 1ealt1 emer?encies, 1er t;o :!= c1ildren ?i@e a small amount as 0inancial support. %0 t1ere is no support comin? 0rom 1er c1ildren, Mrs. 8 ;ill borro; money 0rom t1eir nei?1bor ;it1 an interest. T1e structure o0 t1eir 1ouse is made o0 ;ood and cement. %t 1as t;o rooms 0or 1er c1ildren and t1ey 1a@e a com0ort room. T1e location o0 t1eir 1ouse is near to sta?nant ;ater. T1e settin? o0 t1e 1ouses is muc1 closed and t1ey are prone to 0ire cases.

FA'I!- '"%ICA! and ,"A!T, ,ISTOR-

T1e 84 0amily is residin? at

aran?ay 536A, ucana, Da@ao City is compose

o0 5 membersC Mr. and Mrs. 84 ;it1 t1eir 0i@e c1ildren. T1e eldest and t1e ! nd c1ild are Ano;n smoAers and occasional alco1ol drinAers. T1e t1ird, 0ourt1 c1ild and t1e youn?est 1a@e no Ano;n disease or illness. T1ey eBperience common colds and cou?1 especially durin? rainy season, t1ey usually sel06medicate and t1ey do not 1a@e any re?ular c1ecA6up. Mrs. 84, .5 years old, ;1o eBperience diDDiness especially ;1en s1e<s o@er;orAed. S1e is not interested to ?o 0or c1ecA6up due to lacA o0 0inancial resources and at t1e same time 1er perceptions o0 ser@ices deli@ered by t1e 1ealt1 care pro@ider in t1eir 1ealt1 center is not appropriate, accordin? to 1er, t1e ser@ices are not complete and sometimes t1ey don<t prioritiDed people. A .7 year old 0emale client, Mr. 84 ;as dia?nosed ;it1 1ypertension last !#"" in a medical mission ;it1in t1eir community. %nitial blood pressure ;as taAen ;it1 a readin? o0 ".#>"## mmH?. S1e ;as t1en prescribed ;it1 Captopril 2# m? (D G HS as maintenance medication but 1e 1ad poor compliance due to lacA o0 0inancial resources.

A medical c1ecA6up ;as conducted a?ain last Au?ust $#, !#"$ and s1e 1ad 1er !nd c1ecA6up and 1ad t1e same 0indin?s ;it1 a blood pressure o0 "!#>"## and same dru? ;as prescribed.

10

&"NO&RA'

!"&"N%S+ Deceased )emale Deceased Male Male Married

%denti0ied Client %denti0ied Client<s 1usband )emale

11

Interpretation

T1is 'eno?ram s1o;s t1e 0amily dia?ram o0 t1e 84 )amily 0rom t1e "st ?eneration to t1e $rd ?eneration. %ncluded in t1is dia?ram are t1e diseases t1at ;ere eBperienced by t1e selected members o0 t1e 0amily. Mrs. 84 can still recall t1e a?e o0 1er parents ;1o already died. Accordin? to Mrs. 84 1er mot1er died due to 1ypertension at t1e a?e o0 5! ;1ile 1er 0at1er also died due to 1ypertension ;it1 t1e a?e o0 5.. Mr. 84<s parent<s bot1 died last !##5. His parent<s died due to 1ypertension. Accordin? to Mr. 84, one o0 1er sister died due to cyst in t1e breast ;1ile 1is ot1er siblin?<s most common illness is 1ypertension. T1e second c1ild complaints also o0 di00iculty in breat1in? but accordin? to Mrs. 84 t1ey Fust let 1is son to 1a@e rest and eat plenty. +1ile t1ere 2t1 c1ild 1as 1istory o0 ast1ma since 1e ;as 2 years old. ut it Fust tri??ers ;1en 1is c1ild is eBposed to dust.

12

Family Apgar Scoring+ Adaptation ! Total score: ot1 parents 1elp eac1 ot1er in terms o0 0inancial and 1ealt1 problems. T1ey 1a@e a ?ood relations1ip ;1en it comes to decision maAin? suc1 as 0inancial concerns. T1e couple discussed it to?et1er ;it1 t1eir c1ildren. %n terms in decision maAin? to 1ealt1, t1e 0at1er is t1e one ;1o decides and plan 0or a ?ood 1ealt1. T1e mot1er stated t1at t1ere ;ere no @ices are practiced in t1e 0amily. ut 1er 1usband drinAs occasionally and so ;it1 1er siblin?s. T1ey can eat . times a day to?et1er ;it1 snacA. T1e 0amily al;ays 1as time to bond ;it1 eac1 ot1er by doin? recreational acti@ities suc1 ;atc1in? mo@ies and @ideoAe. T1e 0amily 1as no enou?1 time especially in problems ;it1 t1eir c1ildren. T1e 0amily Ap?ar result is 9 ;1ic1 mean t1at t1eir 0amily is 1i?1ly 0unctional. %t s1o;s t1at t1eir 0amily is able to communicate ;ell and use t1e proper resource present in t1e community. #6$ H se@erely

Partners1ip

'ro;t1

A00ection

Resol@e Total

! "#

# point H IHardly e@erJ dys0unctional 0amily " point H ISome o0 t1e timeJ 0amily ! points H IAlmost al;aysJ

.63 H moderately dys0unctional

56"# H 1i?1ly 0unctional 0amily

13

FA'I!- COPIN& IN%"/

Family+ )amily 84 Address+ aran?ay 536A, ucana,Da@ao City

%ate+ Au?ust $#,!#"$

Family Coping Areas 1 PH4S%CAL %ND&P&ND&NC& TH&RAP&-T%C C(MP&T&NC& *N(+L&D'& () H&ALTH C(ND%T%(NS APPL%CAT%(N () PR%NC%PL&S () '&N&RAL H4'%&N& H&ALTH ATT%T-D&S

Point scales 2 3 4 5 8 8

Assessed Pro0lems

)ustification T1e 0amily is capable o0 doin? t1eir acti@ities o0 daily li@in? independently Mrs. 84 1as lacA o0 maintenance in medication because accordin? to 1er s1e don<t practiced taAin? medications because it 1as no cure bein? ?i@en and it is eBpensi@e. Mrs. 84 @erbaliDed t1at s1e lessen 1er intaAe o0 s;eets but s1e is not a;are o0 increased in salt can contribute to bad 1ealt1. S1e also does eBercise in t1e mornin?. T1e 0amily 1a@e improper disposal o0 ?arba?e and t1e sta?nant ;ater is near t1eir 1ouse. As ;e can see t1e mosEuitos are breedin? to t1e sta?nant ;ater. Mrs. 8 once @erbaliDed t1at t1ey don<t 1a@e enou?1 money to buy medications especially to t1eir ?randc1ildren.

None LacA o0 0inancial resources to a@ail maintenance medication Not enou?1 Ano;led?e in 1ealt1 conditions. . LacA o0 action in cleanin? t1eir surroundin?s. T1ey don<t 1a@e 0irst aid Ait and t1ey do not 1a@e re?ular c1ecA6 up. T1ey don<t trust t1e ser@ices ?i@en by t1e 1ealt1

14

center. &M(T%(NAL C(MP&T&NC& 8 None Mrs. 84 @erbaliDed t1at ;1ene@er t1ey 1a@e problems in t1e 0amily, t1ey Fust talA about it. Sometimes t1ey asA 0or 1elp t1rou?1 t1eir nei?1bors i0 it<s already bi? problems.

)AM%L4 L%,%N'

T1e 0amily 1as enou?1 resources because t1ey also 1a@e small business.

Mrs. 84 @erbaliDed t1at t1ey can still eat $B a day and can buy stu00s to t1eir c1ildren because t1eir c1ildren ?a@e money also 0rom t1eir Fob. Mrs. 84<s sister ;1o is in abroad and ?a@e enou?1 money 0or t1eir 0amily.

PH4S%CAL &N,%R(NM&NT

T1eir 1ouse is made o0 ;ood and cement. Sta?nant ;ater is near to t1eir 1ouse.

T1eir 1ouse is near in sta?nant ;ater and t1ere ;ould be possibility t1at mosEuito ;ill li@e t1ere and ;ill attacA to c1ildren causin? den?ue.

15

-S&S () C(MM-N%T4 R&S(-RC&S

%nability to taAe action to a@ail Mrs. 8 @erbaliDed IDili man Aaau mi na?a adto u? 1ealt1 t1e ser@ices in t1e center Aay dili nila ma1ata?an tanan na nan?ina1an?lan u? 1eal1 center. dili Aa ma1ata?an u? tambal.J

Scalin?+ 1. no competence6 3. moderate competence6 5. complete competence

16

Family Coping Inde7 T1e score 0or P1ysical %ndependence is 2 because t1e 0amily is capable o0 doin? all o0 t1eir daily li@in? acti@ities independently. T1e T1erapeutic Competence scored . because Mrs. 84 1as no enou?1 maintenance in 1er medication. S1e is not used and practiced to taAe any dru?s. *no;led?e o0 Healt1 &ducation is scored $ because Mrs. 84 used to eat 1i?1 in salt 0oods, s1e is not a;are ;1at ;ould it contribute to bad 1ealt1. S1e also does eBercise in t1e mornin?. )or t1e Application o0 Principles o0 ?eneral 1y?iene ;e scored $ t1e 0amily 1a@e improper disposal o0 ?arba?e and t1e sta?nant ;ater is near t1eir 1ouse. As ;e can see t1e mosEuitoes are breedin? to t1e sta?nant ;ater %n Healt1 attitudes ;e scored $ because Mrs. 84 once @erbaliDed t1at t1ey don<t 1a@e enou?1 money to buy medications especially to t1eir ?randc1ildren. )or &motional Competence ;e scored 2 because Mrs. 84 @erbaliDed t1at ;1ene@er t1ey 1a@e problems in t1e 0amily, t1ey Fust talA about it. Sometimes t1ey asA 0or 1elp t1rou?1 t1eir nei?1bors i0 it<s already a bi? problem. )or )amily li@in? ;e scored . because Mrs. 84 @erbaliDed t1at t1ey can still eat $B a day and can buy stu00s to t1eir c1ildren because t1eir c1ildren ?a@e money also 0rom t1eir Fob. Mrs. 84<s sister ;1o is in abroad and ?a@e enou?1 money 0or t1eir 0amily. %n P1ysical &n@ironment ;e scored $ because t1eir 1ouse is near in sta?nant ;ater and t1ere ;ould be possibility t1at mosEuito ;ill li@e t1ere and ;ill attacA to c1ildren causin? den?ue.

17

)or t1e use o0 Community Resources ;e scored ! because Mrs. 8 @erbaliDed IDili man Aaau mi na?a adto u? 1ealt1 center Aay dili nila ma1ata?an tanan na nan?ina1an?lan u? dili Aa ma1ata?an u? tambal.J

18

Nursing Theory

Florence Nightingale8s 9"n:ironmental Theory; )lorence ni?1tin?ale<s t1eory talAs about 1o; important en@ironment is to our 1ealt1. LiAe t1e @entilation and ;armt1, li?1t, cleanliness, 1ealt1 o0 1ouses, noise, bed and beddin?s, personal cleanliness, @ariety, c1atterin? 1opes and ad@ices, taAin? 0oods, petty mana?ement and obser@ation o0 t1e sicA. )lorence Ni?1tin?ale<s can be applied to my 0amily case study because t1e @entilation o0 our client<s 1ouse is not really ?ood, because t1ey don<t 1a@e enou?1 ;indo;s and t1e li?1t o0 t1eir 1ouse is insu00icient. Cleanliness is 0air, but t1ey are risA o0 1a@in? diseases due to t1e sta?nant ;ater near to t1eir 1ouse. . T1e location o0 t1e 1ouse is prone to 0ire cases because t1e settin? o0 t1e 1ouses are too near and many stocA ;ater near to it. Mrs. 84 cannot 1a@e dia?nostic test because o0 t1e 0inancial constraints.

*irginia ,enderson 914 0asic ,uman Needs; Henderson conceptualiDed t1e ". )undamental Needs o0 Humans, ;1ic1 are: /reat#ing normally, eating and drin0ing ade1uately, eliminating /ody 2astes, moving and maintaining desira/le position, sleeping and resting, sele-ting suita/le -lot#es, maintaining normal /ody temperature /y ad3usting -lot#ing and modifying t#e environment, 0eeping t#e /ody -lean and 2ell groomed to promote integument, avoiding dangers in t#e environment and avoid in3uring ot#ers, -ommuni-ating 2it# ot#ers in expressing emotions, needs, fears, or opinions and 2ors#ipping a--ording to fait#% S1e belie@es t1at Healt1 is a Euality o0 li0e and a basic 0or a person to

19

0unction 0ully. %t is important 0or a 1ealt1y indi@idual to control t1e en@ironment but as illness occurs, t1is ability is diminis1ed or a00ected in carin? 0or t1e sicA. ,ir?inia Henderson<s t1eory in relation to my 0amily t1at % c1ose to study is essential in0ormation because t1is 0amily 1as insu00icient 0inancial resources t1at sometimes t1ey can not e@en buy medicine i0 someone is ill. T1e 0amily doesn<t 1a@e any access to t1e ser@ices ?i@en by t1e 1ealt1 center. %n times ;1en t1ere is problems suc1 as 1ealt1 concerns, t1ey Fust let t1e member o0 t1e 0amily ;1o is sicA subsides 1is or 1er illness but i0 it ?et ;orst t1ey easily taAe t1e sicA c1ild to t1e 1ospital. ase on Henderson<s t1eory t1is 0amily really 1as an alteration in t1eir ". )undamental Needs o0 Humans.

20

'edical 'anagement for ,ypertension Overview of Hypertension Hypertension or Hi?1 lood Pressure, medical condition in ;1ic1 constricted

arterial blood @essels increase t1e resistance to blood 0lo;, causin? an increase in blood pressure a?ainst @essel ;alls. T1e 1eart must ;orA 1arder to pump blood t1rou?1 t1e narro;ed arteries. %0 t1e condition persists, dama?e to t1e 1eart and blood @essels is liAely, increasin? t1e risA 0or stroAe, 1eart attacA, and Aidney or 1eart 0ailure. (0ten called t1e Isilent Ailler,J 1ypertension usually causes no symptoms until it reac1es a li0e6t1reatenin? sta?e. Hypertension is a maFor risA 0actor

0or cardio:ascular disease :C,D= 6 cere0ro:ascular e:ent :C,&= and ischemic heart disease :%HD= and, as suc1, is one o0 t1e most important pre@entable causes o0 premature morbidity and mortality in de@eloped and de@elopin? countries. 4et studies still s1o; t1at 1ypertension remains under dia?nosed, undertreated and poorly controlled. T1e bene0its o0 anti1ypertensi@e t1erapy in reducin? t1e incidence o0 C,D depend lar?ely on blood pressure : P= lo;erin? 6 so ac1ie@in? stated tar?ets is important. Ideal 'edical 'anagement P1ysicians recommend t1at people ;it1 pre1ypertension under?o diet and li0estyle c1an?es, suc1 as losin? ;ei?1t and Euittin? smoAin?, in order to pre@ent a rise in blood pressure. Some patients can lo;er t1eir blood pressure by limitin? salt in t1eir diet. %ncreasin? p1ysical acti@ity and reducin? alco1ol consumption to less t1an t;o drinAs per day 0or men and one drinA per day 0or ;omen may also lo;er blood pressure. )or t1ose ;it1 sta?e " and sta?e ! 1ypertension, a p1ysician may prescribe diet and li0estyle c1an?es, as ;ell as one or more dru?s Ano;n as anti1ypertensi@e. Diuretics are anti1ypertensi@e t1at promote eBcess salt and ;ater eBcretion, reducin? 21 P

t1e amount o0 0luid in t1e bloodstream and relie@in? pressure on blood @essel ;alls. eta blocAers reduce 1eart rate and t1e amount o0 blood t1e 1eart pumps. AC& in1ibitors pre@ent t1e narro;in? o0 blood @essel ;alls to control blood pressure. Calcium c1annel blocAers slo; 1eart rate and relaB blood @essels. Studies s1o; t1at t;o dru?s are more e00ecti@e t1an one dru? at lo;erin? blood pressure to less t1an ".#>9# mm H?. Laboratory and diagnostic test for hypertension esides taAin? your blood pressure, your doctor ;ill do a p1ysical eBam and asA you Euestions about your medical 1istory. 4our doctor may also 1a@e you ?et ot1er tests to 0ind out ;1et1er 1i?1 blood pressure 1as dama?ed any or?ans or caused ot1er problems. T1ese tests may include:

-rine tests to c1ecA 0or Aidney or li@er disease. lood tests to c1ecA your le@els o0 potassium, sodium, and c1olesterol. A blood ?lucose test to c1ecA 0or diabetes. Tests to measure Aidney 0unction. An electrocardio?ram :&*', &C'= to 0ind out ;1et1er t1ere is any dama?e to t1e 1eart. 4our doctor may also c1ecA your risA o0 coronary artery disease. %n some cases, you may be asAed to c1ecA your blood pressure at 1ome and

Aeep a record o0 t1e readin?s. %0 you canKt do t1is, you may need ambulatory blood pressure monitorin?. T1is means ;earin? a special de@ice 0or !. to .7 1ours. T1e de@ice automatically taAes your blood pressure t1rou?1out t1e day.

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Actual 'edical 'anagement Mrs. 84 tell us t1at s1e ;as dia?nosed ;it1 1ypertension by a doctor last !##9.T1e doctor prescribed 1er ;it1 anti1ypertensi@e dru? ;1ic1 is Captopril 2# m?. " tab per day. Aside 0rom t1at, s1e also practices traditional medicine ;1ic1 isJpinaAuluan? ?uyabanoJ as an alternati@e i0 s1e cannot buy Captopril. S1e also practices eatin? less salty and 0atty 0oods as ad@ised by t1e doctor.

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%rug Study rand Name+ Captopril &eneric Name+ Capoten %rug Classification+ Anti61ypertensi@e dru?, cardio@ascular a?ent Indications+ HypertensionC in conFunction ;it1 di?italis and diuretics in CH), diabetic nep1opat1y Contraindications+ Pre?nancy, lactation. Sa0e use in c1ildren not establis1ed. 'echanism of action+ Lo;ers blood pressure by speci0ic in1ibition o0 t1e an?iotensin6con@ertin? enDyme. T1is interrupts con@ersion seEuences initiated by renin t1at lead to 0ormation o0 an?iotensin %%, a potent endo?enous @asoconstrictor. %osage+ S1e tooA " tab Captopril 2# m?. Adult %s P( 3.!26!2 m? T%D may increase to 2# m? T%D. Side effects+ HyperAalemia, pruritus, aDotemia, nep1rotic syndrome, urticarial, diDDiness, p1otosensiti@ity Nursing responsi0ilities+ ". Monitor P closely 0ollo;in? t1e 0irst dose. A sudden eBa??erated

1ypotensi@e response may occur "6$ o0 0irst dose especially t1ose ;it1 1i?1 P. !. Ad@ise bed rest and dose. $. Monitor t1erapeutic e00ecti@eness at least ! ;eeAs o0 t1erapy may be reEuired be0ore 0ull t1erapeutic e00ects are ac1ie@ed. .. Consult p1ysician promptly i0 @omitin? or diarr1ea occurs. P monitorin? 0or t1e 0irst $ 1ours a0ter t1e initial

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2. Report darAenin? or crumblin? o0 nail beds :re@ersible ;it1 dosa?e reaction= 3. -se (TC medications only ;it1 appro@al o0 t1e p1ysician. 5. &mp1asiDe t1e importance o0 routine 0ollo; up eBams or c1ecA6ups.

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MASL(+<S H%&RARCH4 () N&&DS

An interpretation o0 Maslo;Ks 1ierarc1y o0 needs, represented as a pyramid ;it1 t1e more basic needs at t1e bottom. As one mo@es to 1i?1er le@els o0 t1e pyramid t1e needs become more compleB. Maslo;<s Hierarc1y o0 Needs Physiologic Needs )ood

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T1e client 1as inadeEuate intaAe o0 nutritious 0ood suc1 as 0ruits and @e?etables due to socioeconomic 0actor suc1 as lo; 0inancial income and s1e lacAs supply in t1e bacAyard.

Homeostasis T1e client usually su00ers 0rom 1eadac1e ;1en s1e lacAs sleep and ele@ated blood pressure, t1us unable to continue all t1e 1ouse1old c1ores in t1e remainin? 1ours o0 t1e day. S1elter Mrs. 8<s 1ouse is made up o0 ;ood and some cement, as ;e @isit t1eir 1ouse ;e obser@ed t1at t1e materials used ;ere already old and brittle. Safety and Security Prone to 0ire and den?ue Settin? o0 t1e 1ouse is not ideal 0or li@in?. T1eir 1ouse is built near t1e sta?nant ;ater ;1ere mosEuitoes can li@e. T1e settin? o0 t1e 1ouse is too close to eac1 ot1er, causin? 0ire. Mrs. 84 is .5 years old. Last !##9 s1e ;as dia?nosed ;it1 1ypertension by a doctor and ;as prescribed ;it1 anti1ypertensi@e dru? ;1ic1 is Captopril 2#m?. T1is is t1e cause ;1y sometimes s1e su00er 1eadac1e ;1en per0ormin? di00erent 1ouse1old c1ores, lacAs sleep, and ele@ated blood pressure. +1en ;e tooA 1er last @ital si?ns ;e noticed t1at 1er blood pressure is 1i?1 ".#>9#mmH?. S1e also told us t1at ;1en 1er 1eadac1e occurs, s1e tooA Captopril and a0ter 1o; many minutes s1e ;as relie@ed. )inancial security 27

T1e client is a simple 1ouse;i0e. S1e cooAs one set o0 @iand and sells it 0or a li@in?. Her 1usband is a trisiAad dri@er t1at earns a mont1ly income t1at ran?es 0rom P!###6$### per mont1. !o:e and elongingness )amily Closely Anit relations1ip ;it1 t1e 0amily but ;it1 readily con0lict bet;een members. Self.esteem Sel06esteem is lo; +1en ;e conduct our inter@ie; to 1er s1e is Euite s1y t1ou?1 s1e ;elcomed us ;armly. S1e is Euite conscious about t1e condition o0 t1eir 1ouse. And ;e obser@ed t1at s1e lacAs con0idence to 1ersel0. Self.actualization (n6?oin? process to reac1 t1is sta?e.

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PRO !"' I%"NTIFICATION 9Health Threat, Health Deficit, Foreseeable Crisis; ,ealth Threats T1e 1ouse is made o0 ;ood and cement. T1e 1ouses settin? is too near to eac1 ot1er and t1ey are prone 0or 0ire cases. T1e location o0 t1e 1ouse is prone o0 diseases because t1ey are near in sta?nant ;ater. T1ey do not 1a@e proper stora?e o0 0ood liAe re0ri?erator or 0ood cabinets, t1us, t1eir 0ood is prone to contact ;it1 0lies or ot1er pests ;1ic1 mi?1t cause disease. T1eir toilet 0acility is near t1eir Aitc1en, t1ere is possibility t1at 0lies 0rom t1e toilet ;ill come in contact ;it1 t1eir 0ood ;1en t1ey are Fust preparin? or cooAin? 0or t1eir meal. T1e 0at1er and son are occasional alco1ol drinAers.

,ealth %eficits Hypertension :mot1er o0 t1e 0amily is dia?nosed last !##9= T1e 0at1er also 1as 1ypertension and ;as dia?noses last !#""

Foreseea0le Crisis )at1er<s occupation is unstable and does IpadyaAJ 0or a li@in?C mont1ly income ran?es 0rom 2##6",### pesos

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Mot1er 1as toAen business and a carpenter. +it1 a mont1ly income o0 !,###6 $### pesos.

!AC# OF FINANCIA! R"SO(RC"S Nature o0 t1e problem Modi0iability o0 t1e problem Pre@enti@e Potential Salience T(TAL SC(R& 2<==

INT"RPR"TATION )oreseeable crisis H " Partially modi0iable H " Moderate H ! Needin? immediate attention H !

FOR'(!A Score>$ B " Score>! B ! Score>! B ! Score>! B "

SCOR" ">$ B " H #.$$ LB!H" !>$ B " H #.33.. !>! B " H "

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,"A!T, PRO !"' Hypertension

FA'I!N(RSIN& PRO !"' %nability to reco?niDe t1e presence o0 1ealt1 problem due to: A. LacA o0 or inadeE uate Ano;led? e. . %nability to maAe decision ;it1 respect taAin? appropriat e 1ealt1 actions

&OA! OF CAR" A0ter nursin? inter@ention t1e 0amily ;ill maAe necessary measures to properly mana?e, control, and lessen t1e risA 0actors o0 1ypertension

O )"CTI*"S OF N(RSIN& CAR" A0ter nursin? inter@ention t1e 0amily ;ill be able to: A. Ha@e adeEuate Ano;led?e, a ?ood proper nutrition t1at reduces 1ypertension, pre@ents t1e occurrence o0 relati@e complications in t1e 0uture. . e able to determine t1e risA 0actor t1at contribute 1ypertension suc1 as 0amily 1istory, and a?e, salt and alco1ol intaAe, and obesity Practice proper li0estyle ;it1 re?ards to nutrition and p1ysical 0itness

N(RSIN& INT"R*"NTIONS Assess t1e 0amily le@el o0 understandin? re?ardin? t1e 1ealt1 problem Discuss ;it1 t1e 0amily t1e nature si?ns and symptoms and complication t1at mi?1t arise due to 1ypertension Discuss ;it1 t1e 0amily>client t1e risA 0actors o0 1ypertension suc1 as 0amily 1istory, a?e, salt and alco1ol intaAe and obesity. Promote 1ealt1y li0estyle suc1 as a.&ncoura?e prop er 0ood intaAe liAe reduce salty and 0atty 0oods and include DASH diet plan. Pre@ent obesity t1rou?1 proper nut rition and eBercise. c. SmoAin? cessation. Pro@ide in0ormation re?ardin? community resourcesC support t1e patient in maAin? li0estyle c1an?es and initiate re0errals

'"T,O%S OF N(RIN& FA'I!CONTACT Home @isit and Clinic @isit

R"SO(RC"S R">(IR"% Material resources: ,isual aid )NAT,NAT )CS 0ormat Human resources: Time and e00ort o0 t1e student nurse and 0amily>client. )inancial resources: Transportation eBpenses o0 t1e student nurse to conduct 1ome @isit.

"*A!(ATION

Partially Met A0ter t1e nursin? inter@ention: t1e client @erbaliDed understandin? o0 dieases process and treatment. As e@idence by Mrs. 84 @erbaliDation IDili naAo ma?Aaon u? m?a ba;al na pa?Aaon, m?a taba u? m?a parat. I

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,"A!T, PRO !"'

FA'I!- N(RSIN& PRO !"'

&OA! OF CAR"

O )"CTI*"S OF N(RSIN& CAR"

N(RSIN& INT"R*"NTIONS

%nsu00icient income to pro@ide all t1e needs o0 e@ery member in t1e 0amily

%nability to pro@ide a 1ome en@ironment conduci@e to 1ealt1 maintenance and personal de@elopment due to: a. %nadeEuate 0amily resources, specially: )inancial resources P1ysical 0acilities, i.e. li@in? space and ;ater Healt1 maintenance

T1e 0amily ;ill decide on appropriat e action:s= and alternati@e solution to properly mana?e t1e problem related to inadeEuat e 0amily income.

A0ter t1e nursin? inter@ention t1e 0amily ;ill be able to: a. &numerate t1e @arious ;ays o0 li@eli1ood plan. b. &Bplain t1e importance o0 1a@in? 1ealt1 action ;it1 t1e readily a@ailable resources. c. Plan a bud?et 0or t1eir 1ealt1 maintenanc e.

Discuss t1e implication o0 insu00icient income in t1e 0amily. R: A;areness on t1e e00ect o0 not 1a@in? a bud?et 0or t1eir 1ealt1. &ncoura?e attendance at appropriate educational pro?ram, i.e. pan?Aabu1 ayan and ot1er li@eli1ood pro?rams.

'"T,O% S OF N(RIN& FA'I!CONTAC T Home @isit and Clinic @isit

R"SO(RC"S R">(IR"%

"*A!(ATIO N

. Material resources: ,isual aid )NAT,NAT )CS 0ormat Human resources: Time and e00ort o0 t1e student nurse and 0amily>client. )inancial resources: Transportation eBpenses o0 t1e student nurse to conduct 1ome @isit.

T1e patient ;as able to @erbaliDe understandin ? o0 t1e disease process and treatment re?imen.

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R: ot1er sources o0 income Discus ;it1 t1e 0amily t1e courses o0 action t1at t1ey 1a@e identi0ied. R: Lead into a success0ul plannin?. Discus t1e conseEuen ces o0 0ailure to taAe appropriate action to t1e problem. R: LacA o0 Ano;led?e lead to 1eat1 de0icit.

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,"A!T, T"AC,IN&S %iet &ncoura?e t1e 0amily members to eat a ;ell6balanced diet, minimiDin? t1e intaAe o0 0atty, oily and salty 0oods. &Bplain t1e risA 0actors and causes o0 1ypertension. &mp1asiDe to t1e client t1e importance o0 reducin? sodium intaAe or to 1a@e a lo; salt diet, in any case, salt s1ould not eBceed more t1an t1ree ?rams or about 1al0 a teaspoon per day.

"7ercise

&mp1asiDe t1e 0amily members t1e importance o0 increasin? aerobic p1ysical acti@ity :$#6.2 minutes most days o0 t1e ;eeA= liAe brisA ;alAin? ;1ic1 promotes proper blood circulation. Re?ular eBercise 1as been s1o;n to be a po;er0ul tool in t1e pre@ention o0 1ypertension. (nhealthy ,a0its

&ducate t1e 0amily members on t1e disad@anta?es o0 smoAin? and intaAe o0 alco1ol and its e00ect to t1e body.

Sleep?Rest Pattern

&mp1asiDe to t1e0amily memberst1at eac1 o0 t1em must 1a@e an adeEuate rest or sleep e@eryday ;1ic1 is @ery important to pre@ent 0ati?ue, eB1austion and stress t1at can be a predisposin? 0actor to some diseases liAe 1ypertension.

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&n@ironmental Sanitation

". Teac1 t1e 0amily members t1e importance o0 proper 1and ;as1in? and its bene0it to our 1ealt1. !. &mp1asiDe t1e importance o0 eBposin? t1e pillo;s and 0oams to t1e sunli?1t. $. Teac1 t1e 0amily members t1e importance o0 proper ;aste disposal or 1a@in? a proper toilet 0acility. .. Teac1 t1e 0amily members about oral care and proper ?roomin?. 2. Tell client to co@er t1e ;ater containers as ;ell as to co@er t1eir ?arba?e containers.

&ncoura?e t1e client to ?et 1er ;1ole 0amily in@ol@ed in 1er care plan as ;ell as to remind t1e ot1er 0amily members 1o; important it is to be sensiti@e to client<s present situation

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I'P!ICATION OF T," ST(%-

N-RS%N' &D-CAT%(N T1e nursin? 0amily case study enli?1tens us to t1e real scenario in t1e

community. %t also ?a@e us t1e opportunity to Ano; t1at community 1ealt1 nursin? is important so t1at nursin? students ;ould be able to eBperience 1o; it ;orAs.T1e a@ailability o0 1ealt1 ser@ices is necessary in t1e community. %t ?a@e us t1e @ie; t1at e@ery community must 1a@e t;o public 1ealt1 nurses to accommodate eac1 0amily. T1e maintenance o0 t1e ability o0 bot1 public 1ealt1 a?encies and pri@ate pro@ides to mana?e day to day operations and t1e capacity to respond immediately to t1e community s1ould al;ays be accessible. T1rou?1 nursin? 0amily case study ;e ;ere able to assess t1e 1ealt1 needs o0 t1e 0amily, plan, implement, and e@aluate t1e impact o0 1ealt1 ser@ices in t1e community. %t ?a@e us t1e basic Ano;led?e and sAills in community 1ealt1 nursin? t1at one t1at 0ormulate policies and de@elops on nursin? aspect o0 speci0ic pro?ram suc1 as 1ealt1 teac1in? o0 1ypertension. N-RS%N' PR()&SS%(N

%n t1e nurse pro0ession, competence, credibility, commitment and Ano;led?e are needed in t1e pro0ession. T1e dedication o0 a nurse to ser@e in t1e community is remarAable and outstandin?. Ho;e@er, nurses must continuously en1ance t1eir Ano;led?e and sAills to eBplore t1e capability to be used in t1e community.

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T1e nurse and t1e community must collaborate in order to ac1ie@e t1e nursin? inter@ention ;1en dealin? ;it1 diseases liAe 1ypertension and smoAin? 1abits. T1is nursin? case study ;ill ?i@e t1e public 1ealt1 nurse t1e a;areness o0 1o; t1e community does t1e 1ome mana?ement in t1eir disease. )or a Nurse s1ould en1anced t1e Ano;led?e liAe political science 1elps t1e nurses to understand t1e 1ealt1 care deli@ery system 0or t1em to better respond to clients and use academic principles liAe sociolo?y and psyc1olo?y to Ano; better on 1o; to understand t1e community. N-RS%N' R&S&ARCH Hypertension is one o0 t1e most common ;orld;ide diseasesC "5." million deat1s per year are caused by 1ypertension. T1e maFor causes o0 1ypertension are p1ysical inacti@ity, an un1ealt1y diet and t1rou?1 0amily 1istory. P1ilippines reported t1at around "!.3 million o0 )ilipinos 1a@e 1ypertension. T1is researc1 0ound out t1at t1e people in t1e community resol@e to deal ;it1 1ypertension on t1eir o;n rat1er t1an seeAin? medical 1elp. T1is is because o0 t1eir lacA o0 Ano;led?e, i?norance and po@erty. T1e researc1es t1ere0ore recommend t1at 0uture studies in 1ypertension cases in community s1ould 0ocus on determinin? tan?ible ;ays to educate t1e people about t1e disease and t1e @alue o0 medical treatment in ?eneral.

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,ealth (pdates (ncontrolled ,ypertension Is Common6 0ut (ntreated6 $orld@ide 4ep% 3, !0.3 M A ?lobal study 1as 0ound t1at many patients donKt Ano; t1ey 1a@e 1ypertension and, e@en i0 t1ey do, too 0e; are recei@in? adeEuate dru? t1erapy 0or t1eir 1ypertension. T1is is true in 1i?1 income countries, liAe Canada, as ;ell as middle and lo; income countries, say an international team o0 researc1ers led by t1e Population Healt1 Researc1 %nstitute :PHR%= o0 McMaster -ni@ersity and Hamilton Healt1 Sciences . T1e report, ;1ic1 ;as publis1ed today by 56M6, t1e Fournal o0 t1e American Medical Association, is part o0 t1e P-R& :Prospecti@e -rban Rural &pidemiolo?ical= study. N(ur study indicates o@er 1al0 o0 people ;it1 1ypertension are una;are o0 t1eir condition and, amon?st t1ose identi0ied, @ery 0e; are taAin? enou?1 treatment to control t1eir blood pressure,N said Dr. Clara C1o;, lead aut1or, a member o0 PHR% and an associate pro0essor o0 medicine o0 Sydney -ni@ersity and t1e 'eor?e %nstitute 0or 'lobal Healt1 in Australia. Dr. Salim 4usu0, senior aut1or and pro0essor o0 medicine o0 McMaster -ni@ersityKs Mic1ael '. De'roote Sc1ool o0 Medicine, added t1at dru? treatments t1at ;orA to control 1ypertension are ;ell Ano;n, 1o;e@er t1is study 0ound only about a t1ird o0 patients ;1o are a;are o0 t1eir condition ;ere ac1ie@in? tar?et blood pressure control. N lood pressure lo;erin? dru?s are ?enerally ineBpensi@e and commonly a@ailable treatments,N said 4usu0. NHo;e@er only a t1ird o0 patients commenced on treatment are on enou?1 treatment to control t1eir blood pressure. T1is is ;orst in lo; income countries, but si?ni0icant in 1i?1 and middle income countries too.N T1is is important because 1ypertension or 1i?1 blood pressure is t1e leadin? cause o0 cardio@ascular disease, ;1ic1 is associated ;it1 at least 5.3 million deat1s per year ;orld;ide. Participants in t1e P-R& study included "2.,### adults bet;een $2 and 5# years old, ;it1 and ;it1out a 1istory o0 1eart disease or stroAe, 0rom "5 1i?1, middle and lo;6 income countries. &ac1 participant 1ad t1eir blood pressure measured and medication use recorded, alon? ;it1 in0ormation about t1eir a?e, ?ender, education, and Aey risA 0actors, includin? ;1et1er t1ey Ane; t1ey 1ad 1ypertension. T1e study 0ound .3.2O o0 t1ose ;it1 1ypertension ;ere a;are o0 t1e dia?nosis, ;1ile blood pressure ;as controlled amon? $!.2O o0 t1ose bein? treated. T1e aut1ors could only ?uess at potential solutions 0or t1e poor detection and inadeEuate treatment o0 1ypertension. NT1e 0indin?s are disturbin? and indicate a need 0or systematic e00orts to better detect t1ose ;it1 1i?1 blood pressure,N said 4usu0. N&arly use o0 combination t1erapies, t1at is, 38

t;o or more types o0 blood pressure6lo;erin? treatments taAen to?et1er, may be reEuired.N 4usu0 is t1e eBecuti@e director o0 t1e PHR% ;1ic1 initiated t1e P-R& study, t1e only multi6country study o0 its Aind. T1e study ;as 0unded by more t1an !2 or?aniDations includin? t1e Canadian %nstitutes 0or Healt1 Researc1, t1e Heart and StroAe )oundation o0 (ntario, similar or?aniDations in se@eral countries and by unrestricted ?rants 0rom se@eral p1armaceutical companies.

39

R"ACTION T1is article s1o;s t1e uncontrolled 1ypertension is common, but untreated, ;orld;ide. T1e study s1o;s t1at t1e ?lobal study 1as 0ound t1at many patients did not Ano; t1ey 1a@e 1ypertension and e@en i0 t1ey do, too 0e; are recei@in? adeEuate dru? t1erapy. As ;e Ano; t1at 1ypertension is a silent Ailler type o0 disease, so it is @ery dan?erous 0or us to sel0 medication. T1at<s ;1y it is necessary 0or us to consult a p1ysician i0 si?ns and symptoms occur. T1is ;ill 0acilitate us to Ano; t1e recommended medication, diet and li0estyle. As a 1ealt1 care pro@ider, ;e Ano; t1at pre@ention is better t1an cure. As muc1 as possible. 'i@e 1ealt1 teac1in? to t1e people you may encounter especially i0 t1ey are at risA o0 1a@in? 1ypertension. Healt1 teac1in? to t1em includes, lo; salt and lo; 0at diet, proper eBercises, treatment re?imen and also ?ood sleep may 1elp. (ur teac1in? is already a bi? 1elp to t1em so t1at t1ey can ;orA on t1rou?1 t1eir li0estyle and c1an?e it 0or t1e ?ood o0 t1eir 1ealt1.

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References MendeD6 C1acon et al :!##7, Au?ust 2=.)actors associated ;it1 1ypertension pre@alence, una;areness and treatment amon? Costa Rican elderly. MC Public Healt1, 7C!52. io Med Central Ltd. 1ttp:>>sciencedaily.com McMaster -ni@ersity :!#"$, September $=. -ncontrolled 1ypertension is common, but untreated, ;orld;ide. 4-ien-e Daily. Retrie@ed September !#, !#"$, 0rom 1ttp:>>;;;.sciencedaily.com >releases>!#"$>#9>"$#9#$"9$32".1tm

41