What is health? According to the World Health Organization (WHO), health is ‘a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources as well as physical capacities’ (WHO). Decades ago governmental officials of the world, agreed to come together, despite of whatever conflicts, or political disagreements, to attain health for all the people of the world by the year 2000.
They wanted citizens of the world to all have access to basic, essential health care.
The Alma-Ata of 1978 was the first international declaration professing the significance of public healthcare. The Alma-Ata commences by stating that health, ‘which is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal” (WHO) The countries of the world, worked towards their goal but unfortunately did not achieve it by their targeted date.
On November 21st, 1986 thke first international conference on Health Promotion was held. Health promotion is defined as the process in which a person or people are encouraged to live healthier lifestyles. This promotion is expected to be holistic-physically, mentally and socially, so that everyone’s basic needs can be satisfied. A person cannot function in this world if he doesn’t know where his next meal is coming from. How can he focus on his health, if he has no home? An unemployed man’s last thought is to get his annual physical done. Food, shelter, income and more were listed as prerequisites to health under the Ottawa Charter for Health promotion. Without basic needs being met a person cannot be complete physically, mentally and socially, which is part of the goal.
According to the Department of Health and Human Services (DHHS) there are seven principles of health promotion, which are as follows:
i. Evidence informed practice
ii. Determinants of health
v. Action across the continuum
vi. Cultural change
vii. Supportive environments
viii. Community participation (DHHS, 2012).
Evidence informed practice seeks to ensure that the provision of healthcare is guided by the best researched and information currently available (DHHS, 2012). Purveyors of healthcare should understand the presenting problems and based on evidence, know what has been used to successfully treat the problem, Finally, the provider must know how to adopt the solutions to the current situation(DHHS, 2012) In health promotion, the evidence used, must be of excellent quality and be derived from a reliable source. It should take into account that cultural, moral, ethical and spiritual values have a direct influence on what we do to improve health both as clients and as practitioners (DHHS, 2012). Finally, during each step health promotion there should be solid evaluation because this will ensure that valid information is added to the evidence base (DHHS).
Determinants of health are about the factors that affect health. Typically, it involves looking at how and where people live and play as well as examining their work environment, and evaluating how these factors affect their health and behavior (DHHS, 2012).
Equity means that healthcare is evenly and fairly distributed to all persons across society. This is a mean of ensuring that the vulnerable and ‘at risk’ groups ‘ minorities – in society will also have access to modalities that can be life -saving (DHHS, 2012).
Partnership in healthcare means working with different people or organization to improve the health and well- being in individuals as well as communities (DHHS, 2006). One such partnership is the nurse-client relationship in healthcare.
Action across the continuum adopts a myriad of strategies to create change in how healthcare is offered. Changes can start with the individual, then progress to the community and eventually changes in public policies. According to the DHHS, ‘action across the continuum is about looking for opportunities to develop a comprehensive approach to promoting health and well- being in our communities’ (DHHS, 2006).
Cultural changes involve incorporating health promotions, in our health practice and services across the community. Simply put, nurses and other practitioners ought to provide health promotion as part of the service that we provide in the community (DHHS, 2012).
Supportive environments seek to ensure that patients and indeed the society in general are provided with healthy choices, for example fresh fruits and vegetables, so the consumer has options with regards to things that can increase his well-being (DHHS, 2012).
Community participation require healthcare workers to have a good understanding of the communities, groups and individuals with whom they work so that they can foster acceptance and participation of the health promotion principles( DHHS, 2012).
PENDER’S HEALTH PROMOTION THEORY
Nola J. Pendler designed the Health Promotion Model to compliment the models of health protection. Health promotion is directed at increasing a patient’s level of well-being. The health promotion model describes the multi-dimensional nature of persons as they interact within their environment to pursue health. Her model focuses on individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. Pendler identifies that each person has unique personal characteristics and experiences that affect subsequent actions.
Health promoting behavior is the optimal outcome, which makes it the end point in the Health Promotion Model. These positive behaviors should result in improved health, which strengthens functional potential and improves quality of life in all stages of development. The Health promotion Model makes four assumptions:
1. Individuals seek to actively regulate their own behavior.
2. Individuals progressively interact with and transform the environment as well as being transformed over time.
3. Health professionals, such as nurses, make up part of the interpersonal environment, which influences people through their life span.
4. Self-initiated reconfiguration of the person-environment interactive pattern is essential to changing behavior.
Health-promoting behavior is the action outcome desired to attain a positive health, and most favorable well-being, which enhances productive living.
Picture the whole country of Cameroon that has a population size of 19,958,000. Based on the Center of Disease Control, that and more people in the United States have Chronic Kidney Disease (CKD). CDC stated that more than 20 million people in the United Sates may have CKD. That is about ten percent of the U.S. population. So, what is Chronic Kidney Disease? Chronic Kidney Disease is a condition in which your kidneys can not perform its normal function to the best of its ability. The kidneys have many functions but one of its main roles is to filter the waste or toxins from the blood that passes through it. Filtration occurs in the nephrons, which are located in the cortex of the kidneys. There are millions of nephrons in each kidney to facilitate the process. The waste that is filtered out of the system is then excreted from the body in the form of urine. Without the filtration process wastes from the bloodstream stays and accumulates in the body and can be very hazardous to the individual’s health. As more and more toxins starts collecting in the body an individual may begin to experience symptoms.
Chronic Kidney Disease is diagnosed by the results of blood and urine samples. The blood tests checks the GFR (glomerular filtration rate) and the urine test checks for albumin or protein. The GFR tells how well your kidneys are filtering. Your GFR should be 60mL ?? min’1 per 1.73 m2 or higher for normal function. If the GFR is below 60mL ?? min’1 per 1.73 m2 it means that the person has kidney disease. A GFR of 15mL ?? min’1 per 1.73 m2 or less means kidney failure. Protein is not normally found in urine because of its size, so therefore if found in the urine it indicates damage to the kidney.
It is of great importance to have urine and blood test done annually. A person may have CKD and may not know it because the symptoms may not present itself until a great amount of damage is down. CKD can progress to Kidney Failure if left untreated. Kidney Failure is when the kidneys stop working. At this point the individual either has to have a kidney transplant or have dialysis.
There are numerous risk factors of CKD and some of them are genetics, high blood pressure, obesity, high cholesterol, kidney stone, kidney infection and many more. The two main risk factors for CKD are hypertension and diabetes and will be discussed in this paper. African Americans, Hispanics and American Indians are the populations at highest risk for CKD and those two risk factors are prevalent amongst these cultural groups. It is said that CKD occurs in African Americans four times as much as in Caucasians. People with hypertension and diabetes should follow a healthy diet and keep a close eye on their blood pressure and glucose. Uncontrolled diabetes and hypertension causes damage to organs in the body including the kidneys. It is said that 1 in 3 people with diabetes develop CKD and 1 in 5 with hypertension develops it (http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm). Their foods should be low in sodium and sugar. They should have lots of fruits and vegetables.
Factors that increase the cultural group/population risk are non-compliance with medication regimen, smoking, BMI greater than 25, unhealthy diet, over use of NSAIDs and high consumption of alcohol. Factors that decrease the risk for CKD are exercise, smoking cessation, constant monitoring of blood pressure and glucose, a diet low in sodium and sugary foods and following medication regimen. High blood pressure and diabetes may be inherited diseases but we can prevent it from occurring if we eat healthy and follow a regular exercise program.
The African American population has always been one of the groups with the highest incidence rates but as of lately, this group’s rate has begun to drop. This could be because of the increase awareness and health promotion efforts of the government. CKD is un-bias to age, it occurs in the elderlies above age 60 but it also occurs in the younger population, mainly due to uncontrolled diabetes and hypertension. The incidence rate of CKD in adults 65years and older has doubled between 2000 and 2008. In the adults between ages 20 and 64, the incidence rate is less than 0.5 percent. The prevalence of CKD in adults 60 years and older went from 18.8 to 24.5 between 1988-1994 surveys and 2003-2006 surveys. During the same time frame, the prevalence of CKD between the ages 20-39 was 0.5 (http://kidney.niddk.nih.gov/). As stated above, CKD leads to kidney failure and according to CDC’s fact-sheet, in 2011 forty-four percent of new cases had a primary diagnosis of diabetes. Twenty-eight percent of the new cases had a primary diagnosis of hypertension (http://www.cdc.gov/diabetes/pubs/factsheets/kidney.htm).
One of the objectives, listed on Healthy People 2020 for CKD is to reduce the proportion of the U.S. population with chronic kidney disease. The baseline they have is 15.1 of the population for the years 1999-2004. They are aiming to have this number reduced by 10%, which will be 13.6 of the population.
Pathophysiology of Risk Factors for CKD
Chronic Kidney Disease has multiple risk factors, but we will be focusing on Diabetes and Hypertension. Hypertension is a major cause of morbidity and mortality because of its association with coronary heart disease, cerebrovascular disease and renal disease. The blood pressure level which treatment is indicated is now 140/90 mm Hg. Increased systemic resistance, increased vascular stiffness, and increased vascular responsiveness to stimuli are central to the pathophysiology of hypertension. Morbidity and mortality attributable to hypertension result from target organ involvement. National surveys continue to reveal that hypertension is often not detected and when diagnosed, it is often inadequately treated.
Blood pressure is the combination of cardiac output and systemic vascular resistance. Cardiac output is usually elevated in younger people and decreases with age. This is due to increased systemic vascular resistance and increased stiffness of the vasculature. Stiffening of the aorta and elastic arteries increases the pulse pressure, this result in an increase in left ventricular afterload, and contributes to left ventricular hypertrophy. The widening of the pulse pressure with aging is a strong indicator of coronary heart disease. (Frey & Wexler, 2013).
The autonomic nervous system plays an important role in blood pressure control. (Leach, 2013) Increased release and enhanced peripheral sensitivity to norepinephrine can be found in hypertensive patients, and also increased responsiveness to stressful stimuli. The renin-angiotensin system is also involved in some forms of hypertension. Elderly or black patients usually have low ‘renin hypertension. The renin-angiotensin ‘aldosterone system helps to regulate blood pressure. When blood pressure falls, the kidneys release the enzyme renin into the blood stream. Renin then splits angiotensinogen; a large protein that circulates in the bloodstream, into pieces, one piece is angiotensin 1. Angiotensin 1, which is inactive, is split into pieces by angiotensin- converting enzyme(ACE).One piece is angiotensin 11, a hormone , which is very active. Angiotensin 11 causes the muscular walls of small arteries to constrict, increasing blood pressure. Angiotensin 11 also triggers the release of the hormone aldosterone from the adrenal glands and antidiuretic hormone from the pituitary gland. Aldosterone and antidiuretic hormone cause the kidneys to retain salt. Aldosterone also causes the kidneys to excrete potassium. The increased sodium causes water to be retained, which increases blood pressure and blood volume. Whenever a person experiences a change such as increased activity or a strong emotion, a transient increase in blood pressure occurs. One of the body’s compensatory mechanisms is triggered to counteract the change and keep the blood pressure at normal levels. An increase in the amount of blood pumped out by the heart increases blood pressure, which causes dilation of blood vessels and an increase in the kidney’s excretion of salt and water which decreases blood pressure. Renal disease may progress slowly and becomes evident in later year. Diabetes mellitus is a disorder in which the blood sugar is elevated because the body cannot produce enough insulin to meet its needs. Diabetes damages blood vessels, which increases the risk of strokes, heart attack and kidney failure.
Impaired insulin secretion and insulin resistance contribute to the development of pathophysiological conditions. Impaired insulin secretion is a decrease in glucose responsiveness, which occurs before the clinical onset of the disease. Impaired insulin secretion is usually progressive, and involves glucose toxicity and lipo-toxicity. The progression of the impairment of pancreatic B cell production affects the long term control of blood glucose. Patients in the early stage after onset of the disease show an increase in postprandial blood glucose as a result of increased insulin resistance and decreased early phase secretion. This in turn causes permanent elevation of blood glucose (Kaku, 2010).
Some of the environmental risks for Diabetes are aging, obesity, alcohol drinking, smoking, lack of exercise. Decreased activity is accompanied by a decrease in muscle mass, induces insulin resistance, and is associated with the rapid increase in the number of middle age and elderly patients. The changes in diet such as increased fat intake, and consumption of simple sugars, and decrease of dietary fiber promotes obesity, and cause deterioration of glucose tolerance. Diabetes may cause many long term complications as a result of the effect it has on blood vessels, which cause narrowing of the blood vessels, which in turn reduces the flow of blood to many parts of the body. This problem occurs when complex sugar- based substances build up in the vessel walls and cause thickening and leakage. Fatty substances in the blood also rise as a result of poor glucose control, and the vessels accumulate plaque, leading to Atherosclerosis, which is high risk factor for strokes and heart attacks. Over time, uncontrolled blood glucose and inadequate circulation can affect the brain, legs, eyes kidneys, and nerves. (Kaku, 2010). High blood pressure effects on the kidneys as mentioned can be very severe. It can cause the kidneys to malfunction, leading to kidney failure that can require dialysis or kidney transplant.
Chronic kidney disease (CKD) has several risk factors including, but not limited to diabetes, high blood pressure (HTN), age 65 and older and obesity (Ernst, 2010). Diabetes and HTN accounts for almost 70% of CDK incidence (Ernst, 2010). Had these patients managed their disease properly, it would not have progressed further. An important element in disease management is knowledge and this is where the nurse’s role as a teacher becomes important in the prevention and management of CKD (Ernst, 2010). There is an old saying that, ‘Prevention is better than cure’ and this is absolutely true with regards to CKD. To successfully prevent the occurrence of CKD, patients need to know the cause of the disease, the modes of transmission and the identified risk factors (Levey et al, 2008). Nurses as primary care givers have the enviable task of teaching primary, secondary and tertiary methods of prevention (Ernst, 2010).
The World Health Organization (WHO) defines health as a process of enabling people to increase control and improvement in their health (WHO, 1996). This definition apply aptly describes the nurse’s interventions in the primary prevention of CKD. Diabetes and HTN are the primary risk factors associated with CKD, and as such nurses has a key role in providing information to clients affected by these chronic illnesses, as well as to the public in general(Levey et al, 2008). Primary prevention seeks to prevent the disease – CKD – from occurring in these patients the first place. Nurses should teach all their patients ‘ with HTN and diabetes ‘ about the impact of mismanagement of these diseases. They must be encouraging them to take their medication in a timely manner as well as adopt a healthy lifestyle ‘ diet and exercise. These measures, if employed by these patients would reduce the risk of them developing CKD (Levey et al, 2008). A further strategy that can be employed is screening. Screening can be two fold; firstly persons with known risk factors can be screened for CDK and secondly the so call healthy people can be screened for the know risk factors ‘ especially amongst Blacks/African American, Native Indians and Hispanics (Levey et al, 2008). Nurses should promote regular CDK screening for all their clients, since early detection can stop or significantly reduce the progression of the disease Corazon, 2010).
Another intervention in primary prevention could include health fairs in targeted communities ‘ blacks/African American, Native Indians and Hispanics – where the disease is most devastating. Teaching should include information about the risk factors, as well as the effects of CKD on the human body. Participants should also be screened for the known/modifiable risk factors ‘ diabetes and HTN – because early detection means early intervention and prevention of CKD (Levey et al, 2008). Nurses can also use the internet to self-educate themselves about risk factors and ways to reduce them; so that they can answer particular queries by clients and point them to reputable website for information (Levey et al, 2008). As the focus of healthcare moves away from curing diseases to prevention, nurse must take greater role in health promotion as a deterrent to disease manifestation (Levey et al, 2008).
Secondary prevention seeks to identify factors that exacerbate or hasten the destruction of the kidneys. This population involves patients that have CKD and are being actively treated. Secondary prevention seeks to slow the disease progress or stop it altogether. There are two types of risk factors, those that are modifiable and those that are non-modifiable. Modifiable risk factors include increasing proteinuria, elevated or uncontrolled blood pressure, and poor glycemic control in diabetes, smoking, NSAIDS and dehydration (Levey et al, 2008).
Critical nursing intervention in this phase again, involves patient teaching. Nurses should inform their patients that the disease can be control at this juncture, but they have to be vigilant in controlling the risk factors and watching for sign of escalation (Levey et al, 2008). One of the most significant intervention, is regular screening for proteinuria- protein in the urine ‘ as this is a tell tale sign of disease progression (Levey et al, 2008). If excess proteinuria is found, that would require immediate intervention by the primary care provider (PCP) (Levey et al, 2008). Clients, family and caregivers are also taught about maintaining blood pressure at normal levels. Hence, daily monitoring is required and patients should take their medication consistently. Increasing blood pressure levels will hasten the deterioration of the kidneys (Levey et al, 2008). Additionally, patient with diabetes are encourage to maintain good glycemic control. Medication must be taken regularly and PCP instructions followed. Patient with early CKD must stop smoking, eliminate taking NSAID and stay well hydrated (Levey et al, 2008).
Also important in patient teaching is diet and exercise. Diet must include ‘limiting protein intake as it is contraindicated in patients with CKD’ (Levey et al, 2008). Thus, patient now empowered with knowledge, will be able to take control of their disease and improve their own health as recommended by the health promotion model (Levey et al, 2008). They will know the warning signs of escalation and know the corrective actions to take, whether it be calling the PCP or doing a simple blood test (Levey et al, 2008).
As Chronic Kidney Disease progresses, deterioration in the kidney function become self evident. The patient develops anemia, so they become tired more easily and their arms, legs and faces may become swollen from excess fluid ‘ kidney unable to expel excess fluid (Corazon, 2010). Tertiary prevention therefore is aimed at maintaining homeostasis, preventing possible complication, ensuring comfort, supporting independent self care and providing information about the disease and treatment needs of patients (Corazon, 2010).
A person suffering from kidney failure is most likely to retain excess body fluid which is manifested in swollen arms, legs and face. Nursing intervention for such a client is focus on maintaining homeostasis in the body and hence specific intervention may include monitoring the client’s vitals, heats sounds, lungs sound, pulse, blood pressure, pain, temperature, mentation and ability to respond (Corazon, 2010). It is important that these vitals be monitored to detect any sudden changes in the client’s internal environment or signs of complications (Corazon, 2010). It is indeed extremely serious if any changes occur, particularly with regards to fluid shifts, because this could signal the worsening of the person’s condition which can lead to heart failure (Corazon, 2010).
People who suffer from kidney failure are generally very weak and get tired easily because they do not have enough have enough oxygen flowing throughout the body (Corazon, 2010). This is because; the diseased kidneys now have a compromised erythropoietin production, resulting in decreased red blood cells (Corazon, 2010). Nursing intervention is geared towards ensuring the comfort of the patient; therefore the nurse should note reports of client weakness and fatigue as well as observe and also note signs of anemia and difficulty in breathing (Corazon, 2010). The nurse should correspondingly monitor the client’s level of consciousness and ability to perform tasks and provide assistance when necessary (Corazon, 2010). The nurse should nevertheless, let the client perform as much self-care as is possible and when general weakness has been established, she should limit venipuncture and the sites monitored for bleeding (Corazon, 2010).
Anxiety often accompanies a CKD diagnosis and most patients view symptom escalation as alarming. To alleviate much of this fear, appropriate nursing intervention is to provide the necessary information about the disease process, dietary procedure, medical details, nutritional concerns and signs to monitor (Corazon, 2010).
Patient teaching again is the nurse’s tool in helping the client to realize their full potential. Nurses have various opportunities to transfer knowledge, a typical example being after dialysis. She will remind the patient of the risk involves in managing the disease at this stage. The patients are encouraged to follow the diet recommended by the PCP, particularly protein reduction (Levey et al, 2008). Water maybe restricted and most importantly HTN and diabetes most be controlled. Nurses could also introduce the patient to the nutritionist, who could help with nutritious meal that is CKD compliant. She encourages the patent to join the American CKD Association, where they could get support and encouragement from people with similar condition (Levey et al, 2008). Dialysis nurses and nurses in general can have forums in the communities, which aims to provide information about ways to control the disease and necessary steps to take in improving quality of life (Levey et al, 2008). These health teaching should be designed to help patient, in taking greater interest in their healthcare and wellbeing, as well as providing the necessary information to help them to have a good quality of life when faced with this challenging disease (Corazon, 2010).
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