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The Reality Regarding Pediatric HypertensionAntoinette McNeil, RN, BSN, CCRNWashington Adventist UniversityPopulation-Based Nursing ConsiderationsNUED 555Adebisi Ayeodele, CNS, CRNPApril 23, 2012TABLE OF CONTENTSABSTRACT3INTRODUCTION4LITERATURE REVIEW6STRATEGIES8IMPLEMENTATION PLAN10CONCLUSION11REFERENCE LIST12AbstractThis paper is looking at the reality that children from the ages of 3 years to 18 years do suffer from hypertension. Diagnosing them has not been easy and many have been misdiagnosed. Hypertension in children has increased within the past 40 years. There are many factors that contribute to the development of hypertension in children. Studies have been done looking at why children developed hypertension and what can be done to prevent them from developing organ damage. Just as adults have to make lifestyle changes so do the children. This paper will refer to those of age 3-18 years old as children. Also will be addressed are the issues to care and what an Advance Practice Nurse can do regarding this issue.The Reality Regarding Pediatric HypertensionIntroductionHypertension affects more than 65 million people in the United States based on the data from the National Health and Nutrition Examination Survey (NHANES), 1999-2000 (Pickering et al., 2008). The prevalence of hypertension in children and adolescents has increased over the years and with it the incidence of atherosclerosis. Death and cardiovascular disability does not occur in hypertensive children and adolescents, intermediate markers of target organ damage such as thickening of the carotid vessel wall, retinal vascular changes and cognitive changes are detected in children and adolescents with high blood pressure (Falkner, 2010). Early diagnosing and treatment of hypertension in children will lead to a reduction in complications in adulthood as it relates to high blood pressure.Many children ages 3 years to 18 years old with hypertension are undiagnosed due to the difficulty some have in recognizing high blood pressure in this age group. As to the reason why identifying high blood pressure in children is so difficult is due, in part, that normal and abnormal values exist and differentiating abnormal values depends on the child’s gender, age and height percentile (Kaelber & Pickett, 2009). What is normal blood pressure in children? Normal is a systolic and diastolic blood pressure that is < the 90th percentile for the height, age, and sex (The Fourth Report, 2005). What is the definition of hypertension in children? Hypertension in children is defined as a sustained systolic and/or diastolic blood pressure that is ≥ 95th percentile for age, gender, and height (Flynn & Tullus, 2009). Pre-hypertension is systolic and or diastolic blood pressure that is >90th percentile and ≤95th percentile for height, gender, and age (Falkner, 2010). Stage 1 hypertension is systolic and or diastolic blood pressure that is ≥ 95th percentile and ≤ 99th percentile plus 5 mmHg. Stage 2 hypertension is systolic and or diastolic blood pressure > 99th percentile plus 5 mmHg (Flynn & Tullus, 2009).Why are children not being diagnosed properly regarding hypertension? The wrong size cuff is used, some have white coat syndrome, and the arm is not at the level of the heart. When taking a child’s blood pressure one must ensure that the cuff is of the right size. The blood pressure should be taken in the right arm and supported at the level of the heart (Riley & Bluhm, 2012). White coat syndrome is blood pressure levels that are ≥ 95th percentile when taken in a physician’s office but is normal outside the clinical setting (Urbina et al., 2008). Ambulatory BP monitoring is the preferred monitoring due to it distinguishes changes in blood pressure (BP) throughout daily activities (Urbina et al., 2008).The American Academy of Pediatrics recommend that children’s BP be taken at every office visit starting at the age of 3 years old. To prevent over-diagnosing a child with hypertension by one elevated BP reading, three separate clinical visits for BP readings are recommended, with an average BP ≥95th percentile is required before diagnosing a child with hypertension (Falkner, 2010). Many children do not have a health care provider due to parents not having insurance and or they are immigrants. Often a child is seen in the emergency room for their care which could be done in a health clinic setting. By using the emergency room as their health clinic setting it is causing a strain on the healthcare system.Many families are either unemployed or they are classified as the working poor who does not have medical insurance. The economy is bad thus many will spend money on foods that are high in fat, sodium and has empty calories. Money is spent electronic devices for pleasure thus children are not getting physical exercise due to a sedentary life which has led to obesity. Family history of hypertension and cardiovascular disease also has played into children having the propensity for developing hypertension.There are different services that are available to provide care to the indigent and those who are the working poor that cannot afford medical insurance, but many are unaware of these services. Racial discrimination is still present in the United States, thus immigrants who are illegal and those who bring family member to this country for care are finding it hard to find a facility that will care for them. Bias of healthcare providers, the response to the bias from the patient, or the patient’s own biases could prevent the patient or family from seeking medical care or lower adherence to a physician’s recommendation (Dovidio & Fiske, 2012). Ethnic minorities receive inferior quality health care than Whites in the United States (Dovidio & Fiske, 2012).Literature Review Epidemiological study was done by National Health and Nutrition Examination Surveys (NHANES). NHANES III (1988-1994) was compared to the recent survey of (1999-2000) and it revealed that the increase in BP in children in the United States (US) is attributed to an increase in being overweight (Hayman et al., 2007). Normal weight for a child is the BMI is in the >5th percentile and < 85th percentile. A child at risk for being overweight the BMI is in the ≥ 85th percentile and ≤95th percentile. A child who is classified as overweight the BMI is ≥95th percentile. When a child’s BMI is ≥95th percentile the Institute of Medicine classifies the child as obese (Hayman et al., 2007).A retrospective study was done on children who were new-onset hypertensive at the Texas Children Hospital Hypertensive Clinic. The children complaints were headaches, insomnia, fatigue, abdominal pain, and chest pain. The study noted that children with essential hypertension BMI was greater and the children were older than those with secondary hypertension. The symptoms decreased after 4-6 months of anti-hypertensive treatment (Croix & Feig, 2006).A study was done looking at the prevalence of behavioral and physiological risk factors of hypertension in a sample of African American adolescents from the ages of 14-17 years old. The risk factors that were looked at were the following: family history, diet, exercise, being pre-hypertensive, sympathetic hyper-responsiveness, cortisol levels, and stress and genetics. The finding resulted the following: 65% of the participants had a strong family history of hypertension, fruit and vegetables were very low on the plate but intake of fast foods were very high. Exercise was low with the females but high with the males due to playing basketball. There were 48 participants who completed the study and there were 14 students who were pre-hypertensive. The cortisol levels were elevated due to stress was found with these students. The finding revealed that 94% of the participants had ≥4 risk factors in which increase their probability to developing hypertension (Covelli, 2007). The Fourth Report has come out with these findings regarding dealing with children and adolescents with hypertension. Weight control results in lower BP’s, decreases sensitivity to salt and leads to reduction in other cardiovascular risk factors. Engaging the family in physical activities together will help to combat a sedentary lifestyle thus leading to lower blood pressure. Despite the fact that there is no concrete evidence that dietary changes in children and adolescents will lower BP’s, it is recommended that a diet of fresh fruit and vegetables, fiber, nonfat dairy and sodium reduction will help in lowering of elevated blood pressure in children (The Fourth Report, 2005).A randomized study known as the Special Turku Coronary Risk Factor Intervention Project (STRIP) study looked at the effects of a saturated-fat diet compared to a low saturated-fat diet in children since 7 months old. The families that were in the study were counseled on the intake of fat and saturated fats. Parents were counseled on breastfeeding their infants and when the child turned 1 years old give them skim milk instead of whole milk. They were encouraged to give their children fruits and vegetables. The controlled group was given just the basic information on health education (Niinikoski et al., 2009). The results of the study were the children of the intervention group intake of fat and saturated fat was lower than the controlled group (Niinikoski et al., 2009). The systolic and diastolic blood pressures in the intervention group were lower that the controlled group (Niinikoski et al., 2009). The STRIP study revealed that BP increased in age as the sodium intake increased and by the time a child was 8-10 years old reached the adult BP levels of low-sodium cultures (Niinikoski et al., 2009).StrategiesEducation regarding diet, exercise, medication, and weight controlled is paramount. The goal I have is that the prevalence of hypertension in children ages 3-18 years old will be greatly decreased by the year 2022. Incorporating the family as a unit to help the child who is hypertensive is beneficial for the whole family. Promoting the family to exercise together by taking walks, riding bicycles, basketball, volleyball, soccer, baseball, jumping rope will also help with knowing each other. Instruction in how to prepare a meal or how to choose a meal when out is something that many youths does not know how to do and sometimes their parents also. Fine tune the diet to foods that the child likes and promote nutrition.Not all children have access to health care thus they do receive regular physical examinations or have well-child care visits outside of what they receive from the school (Hayman et al., 2007). Many families have barriers to going to health care provider due to the biases that they encounter. Adults recognize when they are mistreated by their physician, children also recognize when they are mistreated by their physician. The economy does not lend itself for individuals to provide for their families ensuring that they are eating properly and are being seen by a physician. Community clinics are overcrowded and their hours are not convenient for those who are working and cannot afford to take off from work to attend to the needs of their child. The intake of Vitamin D to supplement the children’s diet due to not being outdoors to take in natural Vitamin D from the sun needs to be promoted.The school nurses are able to institute the some of these objectives that have been mentioned. The Advance Practice nurse can advocate and conduct evidence-based, age appropriate heart health education. They can implement age-appropriate and cultural sensitive curriculum in regard to changing students thought process regarding dietary intake, physical exercise and the need to not smoke. Performing health screening in schools and referring students who are at risk for cardiovascular disease to the community based program or center that can help them. The Advance Practice nurse can have ties to the community and network with other resources to promote heart healthy children (Hayman et al., 2007).Collaborate with churches when they are having health emphasis to promote education regarding prevention of cardiovascular disease in children. Advocate for change in school policies regarding for a need to implement age-appropriate heart health education, increasing physical education in schools and having nutritious meals served in schools (Hayman et al., 2007). Talking with one’s state representative and making recommendations that supporting policies that promote heart health programs for children and to ensure that children have access to health care no matter who or where they are from.Implementation PlanThe theory I will use to implement my plan is the community base theory. What defines a community? A community is people have a sense of belonging to and sharing common goals with other members in the community (Nilsen, 2006). A key element of the community base approach is that the members of the community must be involved in defining the health problem and coming up with a solution (Nilsen, 2006). Families and patients must have buy in being responsible for their own health care needs. The World Health Organization stated that people must be actively involved in promoting and protecting their health and the health of their family (Nilsen, 2006).I would collaborate with a church to start a program with a focus on hypertension prevention or cardiovascular disease prevention for children and adolescents. Many in are ignorant of the fact that hypertension and its effect does occur in children. I would apply for a grant to pay for the program and the materials that are needed. The measuring of blood pressure readings of children would be done biweekly. Obtain a fitness trainer to come show children and their family’s different exercises they can do to help promote weight loss. Have nutritionist come and explain why healthy meals are important. Have a hands-on class in how to prepare a nutritious meal or snack. Promote a sense of trust with the children and their families.Families must know that one cares and is looking out for them and have their best interest at heart. When needed partner with different organizations that and utilize the resources that are available to you. Go to supermarkets speak to the manager and formulate a plan to provide fresher produce for the community and promote wellness for their community in which they serve.In order to see how well the program is well the monitoring of blood pressures in children and seeing that the blood pressures are decreasing and that their BMI is decreasing also where they are either near or in the range for a healthy BMI. When there is more involvement in the program by families and the children are recognizing that they are feeling better is a good indicator that the program is going well. Have evaluation form for based on the Likert scale to evaluate the program after 6 months and then a year later and whenever necessary.ConclusionHypertension in children and adolescents is problem especially when they are misdiagnosed. Promotion of a health education program that engages children and their families is important for success in promoting a healthy child. A lifestyle change is effective when the focus is family-centered instead of patient oriented (Luma & Spiotta, 2006). The benefit of clinical and public health, identification, examination, and treatment of children who are at risk for hypertension is important to decrease the burden of cardiovascular disease (Falkner, 2010). We must remember that if a child’s hypertension is not dealt with when it is treatable it will lead to an adult with hypertension and cardiovascular disease. ReferencesAdams, M. H., Carter, T. M., Lammon, C. B., Judd, A. H., Leeper, J., & Wheat, J. R. (2008, September-October). Obesity and Blood Pressure Trends in Rural Adolescents over a Decade. Pediatric Nursing, 34(5), 381-394.Covelli, M. M. (2007, July-August). Prevelance of Behavioral and Physiological Risk Factors of Hypertension in African American Adolescents. Pediatric Nursing, 33(4), 323-332.Croix, B., & Feig, D. I. (2006). Childhood hypertension is not a silent disease. Pediatric Nephrology, 21(), 527-532.Dovidio, J. F., & Fiske, S. T. (2012, May). Under the Radar: How Unexamined Biases in Decision-Making Processes in Clinical Interactions Can Contribute to Health Care Disparities. American Journal of Public Health, 102(5), 945-952.Falkner, B. (2010). Hypertension in children and adolescents: epidemiology and natural history. Pediatric Nephology, 25(), 1219-1224.Flynn, J. T., & Tullus, K. (2009). Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatric Nephrology, 24(), 1101-1112.Hayman, L. L., Meininger, J. C., Daniels, S. R., McCrindle, B. W., Helden, L., Ross, J.,...Williams, C. L. (2007, July 17). Primary Prevention of Cardiovascular Disease in Nursing Practice: Focus on Children and Youth: A Scientific Statement From the American Heart Association Committee on Atherosclerosis, Hypertension, and Obesity in Youth of the Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on Nutrition, Physical Activity, and Metabolism. Circulation, 116(), 344-357.Holick, M. F., & Chen, T. C. (2008). Vitamin D deficiency: a worldwide problem with health consequences. American Journal of Clinical Nutrition, 1080-1086.Kaelber, D. C., & Pickett, F. (2009, June). Simple Table to Identify Children and Adolescents Needing Further Evaluation of Blood Pressure. PEDIATRICS, 123(6), 972-974.Lu, Q., Ma, C., Yin, F., Liu, B., Lou, D., & Liu, X. (2011). How to simplify the diagnostic criteria of hypertension in adolescents. Journal of Human Hypertension, 25(), 159-163.Luma, G. B., & Spiotta, R. T. (2006, May 1). Hypertension in Children and Adolescents. American Family Physician, 73(9), 1558-1568.Niinikoski, H., Jula, A., Viikari, J., Ronnemaa, T., Heino, P., Lagstrom, H.,...Simell, O. (2009, ). June. Hypertension, 53(), 918-924.Nilsen, P. (2006). The theory of community based health and safety programs: a critical examination. Injury Prevention, 12(), 140-145.Pickering, T. G., Miller, N. H., Ogedegbe, G., Krakoff, L. R., Artinian, N. T., & Goff, D. (2008, July/August). Call to Action on Use and Reimbursement for Home Blood Pressure Monitoring. Journal of Cardiovascular Nursing, 23(4), 299-323.Reis, J. P., Von Muhlen, D., Miller III, E. R., Michos, E. D., & Appel, L. J. (2009, September). Vitamin D Status and Cardiometabolic Risk Factors in the United States Adolescent Population. PEDIATRICS, 124(3), 371-379.Riley, M., & Bluhm, B. (2012, April 1). High Blood Pressure in Children and Adolescents. American Family Physician, 85(7), 693-700.The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. (2005). Rockville, MD: U.S. Department of Health and Human Services.Urbina, E., Alpert, B., Flynn, J., Hayman, L., Harshfield, G. A., Jacobson, M.,...Daniels, S. (2008, September). Ambulatory Blood Pressure Monitoring in Children and Adolescents: Recommendations for Standard Assessment: A Scientific Statement From the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young and the Council for High Blood Pressure Research. Hypertension, 52(), 433-451. ................
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