Rajiv Gandhi University of Health Sciences, Bangaluru, Karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALURU, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS

1. / NAME OF THE CANDIDATE AND ADDRESS / MR. VARA PRASAD.P
1 YR.MSc NURSING STUDENT
SRI CHANNEGOWDA COLLEGE OF NURSING, NH-4.BYPASS, NEAR RAILWAY GATE, KOGILAHALLI, KOLAR
KARNATAKA
PIN-563101
2. / NAME OF THE INSTITUTION / SRI CHANNEGOWDA COLLEGE OF NURSING, KOLAR
3. / COURSE OF STUDY AND SUBJECT / MASTER OF SCIENCE IN
MEDICAL AND SURGICAL NURSING
4. / DATE OF
ADMISSION TO COURSE / 10/07/2013
5. / TITLE OF THE
TOPIC / A STUDY TO ASSESS EFFECTIVENESS OF PLANNED TEACHING PROGRAMME ON KNOWLEDGE REGARDING IMPORTANCE OF MAINTAINING BODY CHOLESTEROL LEVEL AMONG HYPERTENSION PATIENT IN PREVENTING COMPLICATIONS AT SELECTED HOSPITAL AT KOLAR.

FOR DISSERTATION

6. BRIEF RESUME OF THE INTENTED WORK

INTRODUCTION

“Health promoting behavior is an expression of human actualizing tendency that is directed towards optimal well-being, personal fulfillment and productive living.”

-- Pender 2004

Everyone should lead a conscious life style that prevents diseases as, individual life style is central to the development of chronic diseases. Living healthy life style means taking responsibility for own health and well-being, it is the next step forward in our destiny and the advancement of human kind. Among the diseases Hypertension has become an epidemic and chronic causing increasing number of deaths among the younger age group affecting the productivity of economy.1

Hypertension orhigh blood pressureis acardiacchronicmedical conditionin which the systemic arterialblood pressureis elevated. What that means is that the heart has to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and diastolic. Normal blood pressure is 120/80mm/Hg. Hypertension is classified as either primary (essential) hypertension or secondary hypertension; about 90–95% of cases are categorized as "primary hypertension," which means high blood pressure with no obvious medical cause.The remaining 5–10% of cases (Secondary hypertension) are caused by other conditions that affect all other system.2

High blood pressure also causes other complications, such as heart disease and stroke. Patients can die of heart attacks and stroke even when their kidney disease is still in its early stages. So treatment of hypertension is essential not only to slow the progression of kidney disease, but to prevent cardiovascular complications and perhaps early death.2

High blood pressure is nicknamed “the silent killer” because there are often no symptoms. While some people experience headaches or dizziness, the majority of people with high blood pressure feel just fine. The only way to know for sure if blood pressure is elevated is to measure it! A home blood pressure cuff is a very useful tool for people with CKD.3

Cholesterolis a waxysteroidof fat that is produced in the liver or intestines. It is used to produce hormones and cell membranes and is transported in theblood plasmaof all mammals.It is an essential structural component of mammalian cell membranes and is required to establish propermembrane permeabilityandfluidity. In addition, cholesterol is an important component for themanufactureofbile acids,steroid hormones, andvitamin D. Cholesterol is the principalsterolsynthesized by animals; however, small quantities can be synthesized in othereukaryotessuch asplantsandfungi. It is almost completely absent among prokaryotesincluding bacteria.Although cholesterol is important and necessary for mammals, high levels of cholesterol in the blood have been linked to damage to arteries and are potentially linked to diseases such as those associated with the cardiovascular system (heart disease).4

High cholesterol can cause atherosclerosis, a dangerous accumulation of cholesterol and other deposits on the walls of your arteries. These deposits — called plaques — can reduce blood flow through your arteries, which can cause complications, such as: Chest painif the arteries that supply your heart with blood (coronary arteries) are affected, you may have chest pain (angina) and other symptoms of coronary artery disease. Heart attack.If plaques tear or rupture, a blood clot may form at the plaque-rupture site blocking the flow of blood or breaking free and plugging an artery downstream. If blood flow to part of your heart stops, you'll have a heart attack. StrokeSimilar to a heart attack, if blood flow to part of your brain is blocked by a blood clot, a stroke occurs.5

Compliance is the extent to which a patient follows their treatment schedule as prescribed by their health care provider. WHO defined compliance as “the extent to which a person’s behavior i.e. taking medication, following a diet, executing lifestyle change and corresponds with agreed recommendations from a health care provider”.18 Every hypertensive patient needs to adhere with the treatment schedule as recommended by their health care providers in achieving controlled blood pressure and reducing the life threatening complications such as cerebro vascular accident (stroke), myocardial infarction (heart attack), hypertensive cardiomyopathy (heart failure), hypertensive retinopathy, hypertensive nephropathy and hypertensive encephalopathy etc.19 The World Health Organization describes poor adherence as the most important cause of uncontrolled blood pressure and estimates that 50-70% of people do not take their antihypertensive medication as prescribed. Studies worldwide indicate that despite the availability of effective medical therapy over half of all hypertensive patients do not take any treatment. More than half of those on treatment have blood pressure over 140/90 mm Hg.7 Several recent studies have highlighted the importance of adherence to treatment for decreasing the cardiovascular risk.6

Hypertension is a latent disorder in many people as it has a long asymptomatic phase and it is the most common cardiovascular disease affecting large proportion of adults and a leading cause of death throughout the world.6 WHO in its Expert Committee report (1978) has arbitrarily defined hypertension in adults as “a systolic pressure equal to or greater than 160 mm Hg/or a diastolic pressure equal to or greater than 95 mm”. According to the Joint National Committee – V, Systolic pressure more than 140 mm Hg or a diastolic pressure equal to or greater than 90 mm Hg is taken as the diagnostic criteria of Hypertension.7

6.1. NEED FOR THE STUDY

Health awareness is the central issue in the control of hypertension and prevention of its complications. In India awareness of hypertension, its risk factors and complications is very poor which decreases the adherence to the treatment. It is believed that 20-30% of hypertension goes undiagnosed and untreated for a long time which increases the mortality and the risk for developing complications.8Therefore, treatment of hypertension and prevention of target organ diseases remain an important public health challenge.

The liver manufactures and secretes LDL cholesterol into the blood. It also removes LDL cholesterol from the blood by active LDL receptors on the surface of its cells. A decrease number of liver cell LDL receptors is associated with high LDL cholesterol blood levels. Diets that are high in saturated fats and cholesterol raise the levels of LDL cholesterol in the blood. Fats are classified as saturated or unsaturated (according to their chemical structure). The benefits of lowering LDL cholesterol are 1. Reducing or stopping the formation of new cholesterol plaques on the artery walls 2. Reducing existing cholesterol plaques on the artery walls and widening the arteries 3.Preventing the rupture of cholesterol plaques, which initiatesblood clot formationand blocks blood vessels. 4. Decreasing the risk of heart attacks 5. Decreasing the risk of strokes 6. Decreasing the risk of peripheral artery disease.9

Hypertension is the leading cause of cardiovascular disease worldwide. Prior to 1990, population data suggest that hypertension prevalence was decreasing; however, recent data suggest that it is again on the rise. In 1999–2002, 28.6% of the U.S. population had hypertension. Hypertension prevalence has also been increasing in other countries, and an estimated 972 million people in the world are suffering from this problem. Incidence rates of hypertension range between 3% and 18%, depending on the age, gender, ethnicity, and body size of the population studied. Despite advances in hypertension treatment, control rates continue to be suboptimal. Only about one third of all hypertensives are controlled in the United States. Programs that improve hypertension control rates and prevent hypertension are urgently needed.10

Cardiovascular diseases cause 2.3 million deaths in India in the year 1990; this is projected to double by the year 2020. Hypertension is directly responsible for 57% of all stroke deaths and 24% of all coronary heart disease deaths in India. Indian urban population studies in the mid-1950s used older WHO guidelines for diagnosis (BP >160 and/or 95mmHg) and reported hypertension prevalence of 1.2–4.0%. Subsequent studies report steadily increasing prevalence from 5% in 1960s to 12–15% in 1990s. Hypertension prevalence is lower in the rural Indian population, although there has been a steady increase over time here as well. Recent studies using revised criteria (BP140 and/or 90mmHg) have shown a high prevalence of hypertension among urban adults: men 30%, women 33% in Jaipur (1995), men 44%, women 45% in Mumbai (1999), men 31%, women 36% in Thiruvananthapuram (2000), 14% in Chennai (2001), and men 36%, women 37% in Jaipur (2002). Among the rural populations, hypertension prevalence is men 24%, women 17% in Rajasthan (1994). Hypertension diagnosed by multiple examinations has been reported in 27% male and 28% female executives in Mumbai (2000) and 4.5% rural subjects in Haryana (1999). There is a strong correlation between changing lifestyle factors and increase in hypertension in India. . Pooling of epidemiological studies shows that hypertension is present in 25% urban and 10% rural subjects in India. At an underestimate, there are 31.5 million hypertensives in rural and 34 million in urban populations. Population-based cost-effective hypertension control strategies should be developed.11

In India, there has been a significant increase in hypertension prevalence since the year 1950.16 World Health Organization (1999) reports that one out of three deaths in India is due to heart diseases. Hypertension is related to increased morbidity and mortality from cardiovascular, cerebro vascular, peripheral vascular and renal vascular complications.17 Hypertension is directly responsible for stroke deaths and 24% of all coronary heart disease deaths in India. Hypertension related cardiovascular diseases cause 2.3 million deaths in India in the year 1990 and it is projected to double by the year 2020.11

According to the seventh report of Joint National Committee on hypertension, there are approximately 50 million hypertensive individuals in the United States and one billion in the world wide. Even though, the burden of hypertension is currently centered in economically developed countries (37.3%), the developing countries will experience a greater impact due to their larger population. It is estimated that up to three quarters of the world’s hypertension population will be in economically developing countries by the year 2025.12

In addition, the investigator while working with patients has come across many hypertensive patients who come to hospital with uncontrolled cholesterol level which leading to several complications at least end up with death of the hypertension patient. From this point of view, the investigator felt that the hypertension patient who is mindful of barriers to compliance can motivate, teach and support the patients in taking the prescribed antihypertensive medications and how to maintain cholesterol level in normal limits, follow up by developing the new guidelines which addresses on how to comply with the treatment routine.

6.2.REVIEW OF LITERATURE

The review of literature for the study has been organized under the following headings:

1. Review of literature related to prevalence of hypertension
2. Review of literature related to importance of cholesterol in human body
3. Review of literature related to complication of hypertension and elevated cholesterol level in body.
4. Review of literature related to effectiveness of planned teaching programme

Review of literature related to prevalence of hypertension

A cross-sectional survey of total of 1609 respondents out of 1662 individuals in study to find out the prevalence pattern of hypertension in developing countries is different from that in the developed countries. In India, prevalence of hypertension has increased by about 30 times among urban dwellers and by about 10 times among the rural inhabitants. Various factors might have contributed to this rising trend and among others, consequences of urbanization such as change in life style pattern, diet and stress, increased population and shrinking employment have been implicated. with the aim of identifying the risk factors and suggesting intervention strategies. The observed prevalence of hypertension in this study and other studies suggest the need for a comprehensive national policy to control hypertension in India, and, in other similar developing countries.13

A cross-sectional survey to determine the age-specific blood pressure levels and prevalence of hypertension in an urban Indian population in six randomly selected municipal blocks in Jaipur city, India.There were 2122 subjects (1415 male, 797 female) aged 20 years or more. Results of the study showed the prevalence of hypertension according to the JNC-V criteria was 30% in men and 33% in women; by WHO criteria it was 11% in men and 12% in women and increased with age in all subjects. In the JNC-V hypertensive group borderline isolated systolic hypertension was present in 13% of men and 17% of women. The study was concluded by saying A high prevalence of hypertension was found in an Indian urban population. Significant determinants of hypertension were age, smoking and body mass index.14

In a article it as stated that recent studies among Indians have shown a high prevalence ofhypertension. To determine changing trends inhypertensionprevalence, in mean blood pressure (BP) levels and to study urban and rural differences we performed meta-analysis of all available Indian studies. The first such study was reported by Chopra in 1942. Since then many studies (n = 33) in urban and rural areas of India have been performed. In urban populations earlier studies of Dotto (1949), Dubey (1954) and Sathe (1959) showed prevalence ofhypertensionof 1.24 +/- 0.2, 4.24 +/- 0.4 and 3.03 +/- 0.3% in populations of Calcutta, Kanpur and Bombay respectively. Studies since 1959 used World Health Organization (WHO) guidelines and have shown increasing trend inhypertensionprevalence. It is concluded that in Indiahypertensionis emerging as a major health problem more so in urban than in rural subjects.15

A population-based survey was carried out in seven rural and non-industrialized villages around Raipur Rani block in the state of Haryana, India, to determine the prevalence of hypertension and Its associated risk factors. A total of 2559 individuals (86% of the eligible population) in the 16 to 70-year age group were interviewed using a pre-tested structured questionnaire to find out the lifestyle characteristics. Three blood pressure (BP) readings were recorded with a random zero sphygmomanometer at three different times. One hundred and fourteen individuals (4.5%) were found to be hypertensive according to JNC V criteria (BP of ≥ 140190 mm Hg). Analysis showed that advancing age, sedentary lifestyle, higher alcohol consumption and higher body mass index are the risk factors for hypertension in the rural un-industrialized population of India.16

The prevalence pattern of hypertension in developing countries is different from that in the developed countries. In India, a very large, populous and typical developing country, community surveys have documented that between three and six decades, prevalence of hypertension has increased by about 30 times among urban dwellers and by about 10 times among the rural inhabitants. Various factors might have contributed to this rising trend and among others, consequences of urbanization such as change in life style pattern, diet and stress, increased population and shrinking employment have been implicated. The observed prevalence of hypertension in this study and other studies suggest the need for a comprehensive national policy to control hypertension in India, and, in other similar developing countries.17

Review of literature related to importance of cholesterol in human body

The importance of dietary cholesterol in man has been reevaluated, using the formula diet technique. A prompt, significant increase in the serum cholesterol concentration occurred in all of 8 patients as the result of the feeding of a cholesterol formula diet. The discrepancies between this and previous studies is probably related to the administration of cholesterol in a form that facilitates its absorption. Substitution of corn oil for olive oil in the cholesterol containing formula diet failed to prevent but did limit the increase in the level of serum cholesterol. Oral neomycin was found to prevent the increase in serum cholesterol resulting from the cholesterol-olive oil formula diet. It would seem pertinent that studies having to do with the prevention of coronary heart disease by diet give cognizance to the importance of dietary cholesterol.18

In article it as stated that the liver X receptor (LXR) α and -β has been found to play a central role in maintaining cellular cholesterol homeostasis. This correlated with gene expression analyses that clearly indicated that LXRβ was the dominant transcript in the testis. Although Leydig cells did not accumulate excessive cholesterol, declining serum and intratesticular androgen levels with age suggested that these cells were in fact less functional. Ordinarily increased levels of cholesterol activate intracellular sensors to decrease these levels; however, the increasing amount of cholesterol in the Sertoli cells indicates improper control of cholesterol metabolism when LXRβ is absent. Although the precise molecular mechanism at this time remains unclear, our study highlights the crucial role for LXRβ in retaining cholesterol homeostasis in Sertoli cells.19

Cholesterolis of vitalimportancefor thehuman body. It is a constituent for most biological membranes, it is needed for the formation of bile salts, and it is the precursor for steroid hormones and vitamin D. However, the presence of excess cholesterolin cells, and in particular in macrophages in the arterial vessel wall, might be harmful. The accumulation of cholesterolin arteries can lead to atherosclerosis, and in turn, to other cardiovascular diseases. The route that is primarily thought to be responsible for the disposal ofcholesterolis called reversecholesteroltransport (RCT). Therefore, RCT is seen as an interesting target for the development of drugs aimed at the prevention of atherosclerosis. Research on RCT has taken off in recent years. In this review, the classical concepts about RCT are discussed, together with new insights about this topic.20

A study to compare measures of cumulative exposure with remote and recent values for each of total cholesterol(TC), systolic (SBP) and diastolic (DBP) blood pressure in terms of ability to quantify risk of atherosclerotic CAD in patientswith SLE. Here were 991patientswith mean [plus/minus] SD of 19 [plus/minus] 19 TC measurements perpatient. Over a follow-up of 6.7[plus/minus] 6.4 years, there were 86 CAD events. While remote TC was not significantly predictive of CAD, mean and AM TC were more strongly predictive (hazard ratio [HR] 2.07, P=0.003) than recent TC (HR 1.86, P=0.001). AUC TC was not predictive of CAD. A similar pattern was seen for DBP and SBP. Study concluded This is an important consideration in future studies of dynamic risk factors for CAD in a chronic relapsing-remitting disease such as SLE. Our findings also underpin theimportanceof adequate control of SLE disease activity while minimizing corticosteroid use, and highlight the cardio protective effect of antimalarials.21