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Hypertension among female
Table of content
Content
Introduction
Goals and objectives
Target population, location and time
Plan
Materials and tools
Referral
Health care team involved
Evaluation
Documentation
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This past decade has seen a virtual explosion of epidemics, and
remarkably, most of these epidemics involve medical disorders that have
nothing to do with infectious diseases. For instance, we've seen a heart
attack epidemic, an obesity epidemic, an autism epidemic, a metabolic
syndrome epidemic and a hypertension epidemic. Amazingly, these
epidemics have occurred despite the fact that the actual incidence of the
disease in question, in most cases at least, has not changed very much.
Hypertension is an established major risk factor underlying the epidemic
of coronary and cardiovascular diseases in most developed countries,
and it has been shown to be a public health problem in many developing
countries since the 1970s.
In a series of risk factors, hypertension almost competes with elevated
plasma cholesterol for the first place. Communicable diseases are
becoming less common in developing countries. However, the dramatic
changes in lifestyle and food consumption patterns have led to the
emergence of non-communicable disease, such as hypertension, as a
public health problem in the Kingdom of Saudi Arabia. Several studies
indicate that hypertension and its related clinical events, such as
myocardial infarction and stroke, appear to be increasing, although at a
lower rate than in other parts of the world.
A study conducted on 13,000 Saudi subjects revealed that among the
age group between 40 and 75 years, the percentage of systolic
hypertensive females (15.7%) was significantly higher than males
(11.0%). (Mansour M. Al-Nozha,1997)
Hypertension is a chronic medical condition in which the blood pressure
is elevated. It is also referred to as high blood pressure or shortened to
HT, HTN or HPN. The word "hypertension", by itself, normally refers to
systemic, arterial hypertension.
Hypertension can be classified as either essential (primary) or
secondary. Essential or primary hypertension means that no medical
cause can be found to explain the raised blood pressure. It is common.
About 90-95% of hypertension is essential hypertension. Secondary
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hypertension indicates that the high blood pressure is a result of (i.e.,
secondary to) another condition, such as kidney disease or tumours
(adrenal adenoma or pheochromocytoma).
Persistent hypertension is one of the risk factors for strokes, heart
attacks, heart failure and arterial aneurysm, and is a leading cause of
chronic renal failure. Even moderate elevation of arterial blood pressure
leads to shortened life expectancy. At severely high pressures, defined
as mean arterial pressures 50% or more above average, a person can
expect to live no more than a few years unless appropriately treated.
Beginning at a systolic pressure (which is peak pressure in the arteries,
which occurs near the end of the cardiac cycle when the ventricles are
contracting) of 115 mmHg and diastolic pressure (which is minimum
pressure in the arteries, which occurs near the beginning of the cardiac
cycle when the ventricles are filled with blood) of 75 mmHg (commonly
written as 115/75 mmHg), cardiovascular disease (CVD) risk doubles for
each increment of 20/10 mmHg.
Essential hypertension
Hypertension is one of the most common complex disorders. The
etiology of hypertension differs widely amongst individuals within a
large population. Essential hypertension is the form of hypertension that
by definition, has no identifiable cause. It is the more common type and
affects 90-95% of hypertensive patients, and even though there are no
direct causes, there are many risk factors such as sedentary lifestyle,
obesity (more than 85% of cases occur in those with a body mass index
greater than 25), salt (sodium) sensitivity, alcohol intake, and vitamin D
deficiency. It is also related to aging and to some inherited genetic
mutations. Family history increases the risk of developing hypertension.
Renin elevation is another risk factor, Renin is an enzyme secreted by
the juxtaglomerular apparatus of the kidney and linked with aldosterone
in a negative feedback loop. Also sympathetic overactivity is implicated.
Insulin resistance which is a component of syndrome X, or the metabolic
syndrome is also thought to cause hypertension. Recently low birth
weight has been questioned as a risk factor for adult essential
hypertension.
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Secondary hypertension
Secondary hypertension by definition results from an identifiable cause.
This type is important to recognize since its treated differently than
essential type by treating the underlying cause.
Many secondary cause can cause hypertension, some are common and
well recognized secondary causes such as Cushing's syndrome, which is a
condition where both adrenal glands can overproduce the hormone
cortisol. Hypertension results from the interplay of several
pathophysiological mechanisms regulating plasma volume, peripheral
vascular resistance and cardiac output, all of which may be increased.
More than 80% of patients with Cushing's syndrome have hypertension.
Another important cause is the congenital abnormality coarctation of
the aorta.
Adrenal
A variety of adrenal cortical abnormalities can cause hypertension, In
primary aldosteronism there is a clear relationship between the
aldosterone-induced sodium retention and the hypertension. Another
related disorder that causes hypertension is apparent mineralocorticoid
excess syndrome which is an autosomal recessive disorder results from
mutations in gene encoding 11β-hydroxysteroid dehydrogenase which
normal patient inactivates circulating cortisol to the less-active
metabolite cortisone. Cortisol at high concentrations can cross-react and
activate the mineralocorticoid receptor, leading to aldosterone-like
effects in the kidney, causing hypertension. This effect can also be
produced by prolonged ingestion of liquorice(which can be of potent
strength in liquorice candy), can result in inhibition of the 11βhydroxysteroid dehydrogenase enzyme and cause secondary apparent
mineralocorticoid excess syndrome. Frequently, if liquorice is the cause
of the high blood pressure, a low blood level of potassium will also be
present. Yet another related disorder causing hypertension is
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glucocorticoid remediable aldosteronism, which is an autosomal
dominant disorder in which the increase in aldosterone secretion
produced by ACTH is no longer transient, causing of primary
hyperaldosteronism, the Gene mutated will result in an aldosterone
synthase that is ACTH-sensitive, which is normally not. GRA appears to
be the most common monogenic form of human hypertension. Compare
these effects to those seen in Conn's disease, an adrenocortical tumor
which causes excess release of aldosterone, that leads to hypertension.
Another adrenal related cause is Cushing's syndrome which is a disorder
caused by high levels of cortisol. Cortisol is a hormone secreted by the
cortex of the adrenal glands. Cushing's syndrome can be caused by
taking glucocorticoid drugs, or by tumors that produce cortisol or
adrenocorticotropic hormone (ACTH). More than 80% of patients with
Cushing's syndrome develop hypertension., which is accompanied by
distinct symptoms of the syndrome, such as central obesity, buffalo
hump, moon face, sweating, hirsutism and anxiety.
Kidney
Other well known causes include diseases of the kidney. This includes
diseases such as polycystic kidney disease which is a cystic genetic
disorder of the kidneys, PKD is characterized by the presence of multiple
cysts (hence, "polycystic") in both kidneys, can also damage the liver,
pancreas, and rarely, the heart and brain. It can be autosomal dominant
or autosomal recessive, with the autosomal dominant form being more
common and characterized by progressive cyst development and
bilaterally enlarged kidneys with multiple cysts, with concurrent
development of hypertension, renal insufficiency and renal pain. Or
chronic glomerulonephritis which is a disease characterized by
inflammation of the glomeruli, or small blood vessels in the kidneys.
Hypertension can also be produced by diseases of the renal arteries
supplying the kidney. This is known as renovascular hypertension; it is
thought that decreased perfusion of renal tissue due to stenosis of a
main or branch renal artery activates the renin-angiotensin system. also
some renal tumors can cause hypertension. The differential diagnosis of
a renal tumor in a young patient with hypertension includes
Juxtaglomerular cell tumor, Wilms' tumor, and renal cell carcinoma, all
of which may produce renin.
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Neuroendocrine tumors are also a well known cause of secondary
hypertension. Pheochromocytoma (most often located in the adrenal
medulla) increases secretion of catecholamines such as epinephrine and
norepinephrine, causing excessive stimulation of adrenergic receptors,
which results in peripheral vasoconstriction and cardiac stimulation. This
diagnosis is confirmed by demonstrating increased urinary excretion of
epinephrine and norepinephrine and/or their metabolites
(vanillylmandelic acid).
Medication side effects
Certain medications, especially NSAIDs (Motrin/Ibuprofen) and steroids
can cause hypertension. High blood pressure that is associated with the
sudden withdrawal of various antihypertensive medications is called
Rebound Hypertension. The increases in blood pressure may result in
blood pressures greater than when the medication was initiated.
Depending on the severity of the increase in blood pressure, rebound
hypertension may result in a hypertensive emergency. Rebound
hypertension is avoided by gradually reducing the dose (also known as
"dose tapering"), thereby giving the body enough time to adjust to
reduction in dose. Medications commonly associated with rebound
hypertension include centrally-acting antihypertensive agents, such as
clonidine and beta-blockers.
Pregnancy
Few women of childbearing age have high blood pressure, up to 11%
develop hypertension of pregnancy. While generally benign, it may
herald three complications of pregnancy: pre-eclampsia, HELLP
syndrome and eclampsia. Follow-up and control with medication is
therefore often necessary.
Sleep disturbances
Another common and under-recognized cause of hypertension is sleep
apnea, which is often best treated with nocturnal nasal continuous
positive airway pressure (CPAP), but other approaches include the
Mandibular advancement splint (MAS), UPPP, tonsillectomy,
adenoidectomy, septoplasty, or weight loss. Another cause is an
exceptionally rare neurological disease called Binswanger's disease,
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causing dementia; it is a rare form of multi-infarct dementia, and is one
of the neurological syndromes associated with hypertension.
Pathophysiology
Most of the mechanisms associated with secondary hypertension are
generally fully understood. However, those associated with essential
(primary) hypertension are far less understood. What is known is that
cardiac output is raised early in the disease course, with total peripheral
resistance (TPR) normal; over time cardiac output drops to normal levels
but TPR is increased. Three theories have been proposed to explain this:



Inability of the kidneys to excrete sodium, resulting in natriuretic
factors such as Atrial Natriuretic Factor being secreted to promote
salt excretion with the side effect of raising total peripheral
resistance.
An overactive Renin-angiotensin system leads to vasoconstriction
and retention of sodium and water. The increase in blood volume
leads to hypertension.
An overactive sympathetic nervous system, leading to increased
stress responses.
It is also known that hypertension is highly heritable and polygenic
(caused by more than one gene) and a few candidate genes have been
postulated in the etiology of this condition.
Diagnosis
Initial assessment of the hypertensive patient should include a complete
history and physical examination to confirm a diagnosis of hypertension.
Most patients with hypertension have no specific symptoms referable to
their blood pressure elevation. Although popularly considered a
symptom of elevated arterial pressure, headache generally occurs only
in patients with severe hypertension. Characteristically, a "hypertensive
headache" occurs in the morning and is localized to the occipital region.
Other nonspecific symptoms that may be related to elevated blood
pressure include dizziness, palpitations, easy fatiguability, and
impotence.
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Prognosis
It is based upon several factors including genetics, dietary habits, and
overall lifestyle choices. If individuals conscious of their condition take
the necessary preventive measures to lower their blood pressure, they
are more likely to have a much better outcome than those who does
not.
Complications
Hypertension is a risk factor for all clinical manifestations of
atherosclerosis since it is a risk factor for atherosclerosis itself. It is an
independent predisposing factor for heart failure, coronary artery
disease, stroke, renal disease, and peripheral arterial disease. it is the
most important risk factor for cardiovascular morbidity and mortality, in
industrialized countries. The risk is increased for:







Cerebrovascular accident (CVAs or strokes)
Myocardial infarction (heart attack)
Hypertensive cardiomyopathy (heart failure due to chronically
high blood pressure)
Left ventricular hypertrophy - thickening of the myocardium
(muscle) of the left ventricle of the heart.
Hypertensive retinopathy - damage to the retina
Hypertensive nephropathy - chronic renal failure due to
chronically high blood pressure "benign nephrosclerosis".
Hypertensive encephalopathy - confusion, headahe, convulsion
due to vasogenic edema in brain due to high blood pressure.
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Food/Diet Therapy for Hypertension
Research has shown that following a healthy eating plan can both reduce
the risk of developing high blood pressure and lower an already elevated
blood pressure.
Vegetarian Diet
Vegetarians, in general, have lower blood pressure levels and a lower
incidence of hypertension and other cardiovascular diseases. Experts
postulate that a typical vegetarian's diet contains more potassium,
complex carbohydrates, polyunsaturated fat, fiber, calcium, magnesium,
vitamin C and vitamin A, all of which may have a favorable influence on
blood pressure.
Fiber
A high-fiber diet has been shown to be effective in preventing and
treating many forms of cardiovascular disease, including hypertension.
The types of dietary fiber is important. Of the greatest benefit to
hypertension are the water soluble gel-forming fibers such as oat bran,
apple pectin, psyllium seeds, and guar gum. These fibers, in addition to
be of benefit against hypertension, are also useful to reduce cholesterol
levels, promote weight loss, chelate out heavy metals, etc.
Taking one to three tablespoons of herbal bulking formula containing
such things as oat fiber, guar gum, apple pectin, gum karaya, psyllium
seed, dandelion root powder, ginger root powder, fenugreek seed
powder and fennel seed powder.
Sugar
Sucrose, common table sugar, elevates blood pressure. Underlying
mechanism is not clearly understood. It is possible that sugar increases
the production of adrenaline, which in turn, increases blood vessel
constriction and sodium retention.
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Taking a diet that is rich in high potassium foods (vegetables and fruits)
and essential fatty acids. Daily intake of potassium should total 7 grams
per day. The diet should be low in saturated fat, sugar and salt. In
general, a whole food diet emphasizing vegetables and members of the
garlic/onion family should be consumed.
In an NIH sponsored research called "Dietary Approaches to Stop
Hypertension (DASH)," researchers tested the effects of nutrients in food
on blood pressure. The results showed that elevated blood pressures
were reduced by an eating plan that emphasized fruits, vegetables, and
low-fat dairy foods and was low in saturated fat, total fat, and
cholesterol. The DASH diet included whole grains, poultry, fish, and nuts.
It employed reduced amounts of fats, red meats, sweets, and sugared
beverages.
Reduce Salt and Sodium in Diet
A key to healthy eating is choosing foods lower in salt and sodium.
Before the widespread availability of medication to control high blood
pressure, people with serious hypertension had only one treatment
option, a drastically salt-reduced, low-calorie "rice diet." Some people
can significantly lower their blood pressure by avoiding salt.
Studies show that people in countries that use a great deal of salt in
their cooking tend to have higher blood pressures than people in
countries that use little salt. For example, the Japanese, whose cuisine is
among the saltiest in the world, also have the highest blood pressure;
and so do Americans. Americans take it for granted that blood pressure
will rise as we age. But in countries with low per-capita salt intake, blood
pressure does not rise significantly after puberty. For example, blacks in
Africa, who typically eat a low-salt, high-fiber diet, have relatively low
blood pressure, but for African-Americans, just the opposite is true.
Nearly 50 percent of all African-Americans have high blood pressure,
often beginning early in life.
Excessive consumption of dietary sodium chloride (salt), coupled with
diminished dietary potassium, induces an increase in fluid volume and
an impairment of blood pressure regulating mechanisms. This results in
hypertension in susceptible individuals.
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A high potassium-low sodium diet reduces the rise in blood pressure
during mental stress by reducing the blood vessel constricting effect of
adrenaline. Sodium restriction alone does not improve blood pressure
control; it must be accompanied by a high potassium intake.
Most of us consume more salt than we need. NIH recommends limiting
the sodium consumption to less than 2.4 grams (2,400 milligrams [mg] )
of sodium a day. That equals 6 grams (about 1 teaspoon) of table salt a
day. The 6 grams include ALL salt and sodium consumed, including that
used in cooking and at the table. Recent research has shown that people
consuming diets of 1,500 mg of sodium had even better blood pressure
lowering benefits. So, your doctor may advise eating less salt and sodium
if you are suffering from high blood pressure. The lower-sodium diets
also can keep blood pressure from rising and help blood pressure
medicines work better.
In a clinical study, researchers looked at the effect of a reduced dietary
sodium intake on blood pressure as people followed either the DASH
diet or a typical American diet. Results showed that reducing dietary
sodium lowered blood pressure for both the DASH diet and the typical
American diet. The biggest blood pressure-lowering benefits were for
those eating the DASH diet at the lowest sodium level (1,500 milligrams
per day). This study showed the importance of lowering sodium intake in
your diet.
The patient should watch what he/she eat. They should not add
additional salt to your food. If they have high blood pressure, they
should avoid eating certain highly processed, overly salted foods, such as
frozen pizza, canned salted vegetables, meals from fast-food
restaurants, and the like.
Beneficial Vegetables and Spices for Hypertension
A number of common vegetables and spices have beneficial effects in
controlling hypertension. Incorporate these into your cooking.
Alternately, you can make a tea or a vegetable soup.
Celery (Apium graveolens). Oriental Medicine practitioners have long
used celery for lowering high blood pressure. There are some
experimental evidence that shows that celery is useful for this. In one
animal study, laboratory animals injected with celery extract showed
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lowered blood pressure. Eating as few as four celery stalks was found to
be beneficial in lowering blood pressure in human beings.
Garlic (Allium sativum). Garlic is a wonder drug for heart. It has
beneficial effects in all cardiovascular system including blood pressure.
In a study, when people with high blood pressure were given one clove
of garlic a day for 12 weeks, their diastolic blood pressure and
cholesterol levels were significantly reduced. Eating quantities as small
as one clove of garlic a day was found to have beneficial effects on
managing hypertension. Using garlic in cooking, salad, soup, pickles, etc.
It is very versatile.
Onion (Allium cepa). Onions are useful in hypertension. What is best is
the onion essential oil. Two to three tablespoons of onion essential oil a
day was found to lower the systolic levels by an average of 25 points and
the diastolic levels by 15 points in hypertension subjects. This should not
be surprising because onion is a cousin of garlic.
Tomato (Lycopersicon lycopersicum). Tomatoes are high in gammaamino butyric acid (GABA), a compound that can help bring down blood
pressure.
Broccoli (Brassica oleracea). This vegetable contains several active
ingredients that reduce blood pressure.
Carrot (Daucus carota). Carrots also contain several compounds that
lower blood pressure.
Saffron (Crocus sativus). Saffron contains a chemical called crocetin that
lowers the blood pressure. They can use saffron in cooking. (It is a very
popular spice in Arabic cooking.) They can also make a tea with it. Many
Indians add a pinch of saffron in the brewed tea to give a heavenly
flavor. Unfortunately, it is very expensive.
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Goal:
To decrease the prevalence of HT among female pt in cardiac unit of
KFSH by 20% in 2013.
Objectives:
By the end of the program the Pt will be able to:
 Explain the effect of HT on the body.
 Explain how do diet treat HT.
 Demonstrate the HT diet.
Target group:
Female patients
Location:
Out Pt /nutritionist clinic of the cardiac unit first floor room number 5.
Waiting area of the cardiac unit first floor .
Time:
The program will start in a April of 2010 until April of 2013.
Plan:
I will implement my plan through individual teaching and group
teaching.
Individual teaching
Objectives:
By the end of the program the Pt will be able to:
 Explain how HT effect the heart.(p.7-8)
 Explain how HT effect other parts of the body eg. Kidney. (p.8)
 Explain how decreasing the intake of salt lower BP level. (p.10)
 Explain how increasing the intake of fibre and some types of
vegetables lower BP level.(p. 9-12)
Tools:
Computer, paper, file, wt and ht scale and food models.
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Material:
Hypertension the epidemic proshor.
Hypertension and diet statistics proshor.
How to plan a healthy meal proshor.
Hypertension and food proshor.
Hypertension and functional food proshor.
Hypertension complications proshor.
Evaluation :
Laboratory test.
Questioner.
Documentation :
Progress note in the Pt file.
Session plan:
Each Pt will receive 6 sessions during 3 months.
Session No. Duration
Location
Start
1
45 min Pt room/dietician clinic
First session
2
45 min Pt room/dietician clinic One week later
3
45 min Pt room/dietician clinic Tow weeks later
4
30 min Pt room/dietician clinic 3 weeks later
5
30 min Pt room/dietician clinic One month later
6
30 min Pt room/dietician clinic 3 months later
Session 1:
 Welcoming the Pt.
 Introduce myself.
 Ask the Pt:
 How is he doing?
 what he suffering from?
 what do he know about his illness?
 what do he know about HT?
 Teach him about HT ( statistics, definition, causes and
complication).
 Motivate him to change his diet.
 Focusing on reducing salt intake.
 Provide evidence that diet effect HT.
Tools
Computer, paper, file, wt and ht scale and food models.
Material
Hypertension the epidemic proshor.
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Hypertension and diet statistics proshor.
Evaluation
Laboratory test
Questioner.
Documentation
Progress note in the Pt file.
Session 2:
 Welcoming the Pt.
 Ask him how is he doing.
 Ask him about his adaptation to reducing salt intake.
 Teach him how to plan a healthy diet( salt , sugar, and fiber)
 Motivate him to change.
 Assess the Pt progression and adaptation.
 Revision HT knowledge, make sure that the Pt understand the
seriousness of his condition.
 Weight reduction if he is obese or over weight.
 Assess the Pt.
Tools
Computer, paper, file, wt and ht scale and food models.
Material
Weight reduction proshor.(if needed)
Hypertension complications proshor.
Evaluation
Laboratory test.
Documentation
Progress note in the Pt file.
Session 3:
 Welcoming the Pt.
 Ask him how is he doing.
 Ask him about his adaptation to the new diet.
 Teach him how to plan a healthy diet( salt , sugar, fiber,
vegetables and fruits)
 Motivate him.
 Assess the Pt.
Tools
Computer, paper, file, wt and ht scale and food models.
Material
How to plan a healthy meal proshor.
15
Evaluation
Laboratory test
Documentation
Progress note in the Pt file.
Session 4:
 Welcoming the Pt.
 Ask him how is he doing.
 Ask him about his adaptation to the new diet.
 Motivate the Pt to change his behavior.
 Assess the Pt
Tools
Computer, paper, file, wt and ht scale and food models.
Material
Hypertension and food proshor.
Evaluation
Laboratory test.
Documentation
Progress note in the Pt file.
Session 5:
 Welcoming the Pt.
 Ask him how is he doing.
 Ask him about his adaptation to the new diet.
 Motivate the Pt to change his behavior.
 Assess the Pt.
 Introduce the Pt to a new concept which is Functional food.
Tools
Computer, paper, file, wt and ht scale and food models.
Material
Hypertension and functional food proshor.
Evaluation
Laboratory test
Documentation
Progress note in the Pt file.
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F/U Session 6:
 Welcoming the Pt.
 Ask him how is he doing.
 Ask him about his adaptation to the new diet.
 Prevent collapse.
 Assess the Pt.
Tools
Computer, paper, file, wt and ht scale and food models.
Evaluation
Laboratory test
Documentation
Progress note in the Pt file.
Group teaching:
Objectives:
By the end of the program the Pt will be able to:
 Define HT.(p.3)
 Explain the complications of HT. (p.8)
 Explain the proper diet for hypertensive Pt.(p.9-12)
Tools:
Computer, screen, papers, note books, pins, file, foundo and food
models.
Material:
Hypertension and diet statistics proshor.
How to plan a healthy meal proshor.
Hypertension and food proshor.
Hypertension and functional food proshor.
Hypertension the epidemic proshor.
Hypertension complications proshor.
Evaluation :
Questioner.
Documentation :
17
Attendants sheet.
Classes plan:
Provide 2 classes at the first Friday of each month from 4-7 pm in prince
Salman auditorium.
First class:
From 4-5:30 pm
 Welcoming the patients.
 Introduce myself.
 Ask the Pts :
 How are they doing?
 what do they know about HT?
 Teach hem about HT ( statistics, definition, causes and
complication).
 Assess the patients.
Tools
Computer, screen, papers, note books, pins, and files.
Material
Hypertension the epidemic proshor.
Hypertension complications proshor.
Evaluation
Questioner.
Documentation
Attendants sheet.
Sacend class:
From 6-7 pm.
 Welcoming the patients.
 Introduce myself.
 Assess the patients.
 Motivate them to change their diet.
 Provide evidence that diet effect HT.
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 Teach them how to plan a healthy diet( salt , sugar, fiber,
vegetables and fruits)
 Introduce the Pts to a new concept which is Functional food.
Tools
Computer, screen, papers, note books, pins, file, foundo and food
models.
Material
Hypertension and diet statistics proshor.
How to plan a healthy meal proshor.
Hypertension and food proshor.
Hypertension and functional food proshor.
Evaluation
Questioner.
Documentation
Attendants sheet.
Material:
Krause’s food, nutrition and diet therapy book
www.mayoclinic.com
Tools:
Computer, screen, papers, note books, pins, file, BP monitor, foundo
and food models.
Referral:
Lamia al-Nasserallah
0555488181
Health care team involved:
Physician, nurse, health educator , and other dieticians.
Evaluation:
Laboratory test
Questioner.
Documentation:
Published report.
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Hypertension
Among
Female
By: Lamia Al-naserallah
Supervised by:
20
‫‪Mrs. Iffat Elbarazi‬‬
‫ً‬
‫معا‬
‫ضدًارتفاع‬
‫ضغطًالدم‬
‫‪21‬‬