Transcript Stage 1 HPN

Creating Lasting Change
Through Health Coaching
Becky Hampl RN Marathon Health Coach
[email protected]
Cell Phone: 1-802-3708
Session Agenda
Briefly Review Basic:
 Lifestyle modifications to
prevent or manage HPN
 Medical Guidelines for
1. HPN: Stage 1 and Stage 2
2. Diabetes
Agenda Continued:
 Motivational
 What
Interviewing:
is it?
 How does it work?
 How can I use it in my
everyday practice?
Lifestyle Modifications for
Treating HPN

Lose 10% of body weight in 1 yr.

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Teach client about DASH( Dietary Approaches to
Stop Hypertension) Diet:
The DASH diet focuses on foods that are high
in calcium, potassium, and magnesium:
(nutrients that can help lower blood pressure).
Less than 1
Teaspoon/Day
Hypertension
Medical Guidelines for treating
Hypertension: Stage 1 and Stage 2
 Stage 1: HPN: Moderate Risk
140 -159
90 – 99
 Stage 2: HPN: High Risk
Systolic > 160
Diastolic > 100
Common Treatment of Stage 1
HPN
Monotherapy using:

Thiazide Diuretic Medication
OR



Angiotensin Converting Enzyme (ACE)
Inhibitors
Calcium Channel Blockers
Angiotensin Receptor Blockers
Variances in Rx for Stage 1 HPN
 Beta
Blockers used initially only if
there is also specific indicators for
their use: Angina, MVP, Tachycardia,
Cardiac Arrhythmia
 Alpha
Blockers are not recommended
as first line of defense for HPN: may
actually cardiac related problems
Stage 1 HPN: 140 – 159
90 - 99

Single agent therapy does control
blood pressure for some patients but
not for others at time of diagnosis.

And over time an increasing proportion
of patients who were initially controlled
with monotherapy are found to be no
longer controlled.
Stage 2 HPN
Systolic > 160
Diastolic > 100
Two-Drug combination:
Usually a thiazide-type diuretic and:
 ACE Inhibitor OR
 Angiotensin Receptor Blocker (ARB) OR
 CCB
OR
 Beta Blocker
OR
 Sometimes takes more than 2 drug combo
HPN and Diabetes Rx
 All
individuals with HPN & DM
should be treated with a regimen
that includes either
 ACE Inhibitor
Or
 Angiotensin Receptor Blocker
HPN And Stable Angina Rx
 A Beta
Blocker is appropriate unless
otherwise contraindicated
 If Beta Blocker is contraindicated or if
BP is not managed on a beta blocker
alone:
 Then Calcium Channel Blockers can
be substituted or added
HPN and CHF Rx
 ACE
Inhibitor & Beta Blockers
used unless contraindicated
 For
those intolerant of ACE
Inhibitors, ARB’s may be used.
HPN and Kidney Disease Rx
For these individuals:
Most should receive an:
ACE Inhibitor or an ARB
Diuretic
Medical Guidelines advise
that patients with HPN be
assessed at least annually
Medical Guidelines for
Diabetes
 Pneumovax:
at least once in a
lifetime for all diabetic patients > 2
years of age
 A 1x
re-vaccination By CDC guidelines,
once vaccinated, you will likely never need
a revaccination. However, this remains a
controversial area.
Yearly Rx/Testing for DM


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Influenza: for individuals more than 50
and/or have a chronic illness
Foot Exam: A Podiatrist/ Neurologist Exam
Eye Exam: Dilated eye exam with
Ophthalmologist or Optometrist
Basic Metabolic Panel is indicated 1x – 2x
per year if on medications: Diuretics, ACEI,
etc. (Glucose, Na, Ca, K, Cl, CO2, BUN,
Creatinine)
More Frequent Exam / Testing for
DM


1.
2.

Foot Exam: every visit to identify
risk factors predictive of ulcers and
amputations, including pedal pulse.
Self Glucose monitoring:
Type 1: typically test 4x/day
Type 2: prn to meet treatment goals
A1C @ least every 6 months
DM: Risk Factors for Developing CAD

> 40 years old
Have HPN
+ Smoker
Dyslipidemia
Albuminuria
Family Hx of CAD

Rx with: Daily Aspirin Therapy





Statin Therapy is for DM:
 Regardless
of baseline lipid levels
for those with CAD
And
 For those w/o CAD but are over 40
and have 1 or more other CAD risk
factors.
•DM and Hx of MI
Rx with Beta Blockers

DM and Pregnant Patients Rx with:
+ Micro or Macro Albuminuria: Rx with
1. ACEI Therapy
Or
2. ARB Therapy
Monitoring of Serum Creatinine and
Potassium Levels
Traditional Medical Profession:
Many modalities to provide client education:
 Handouts on diagnosis
 Internet website references
 Books, Booklets, Pamphlets…
 Info on various Associations and Groups
 Medical Personnel ask investigative
questions; often closed ended; answer
“yes” or “no”
And the doctor said:
 “Good
morning Brian. I see you are
here for a follow up on your
hypertension.”
 “Yes.”
 “Are you taking the medication I gave
you?”
 “Yes.”
 “Good.
Any side effects?”
 “No.”
 “Do
you feel it’s helping?”
 “Well, I’m not as hyper. I don’t
know about the other part.”
“I am less hyper,
The conversation you
just read;
Actually Took Place!
This patient
was
a man
who
could not
read.
Health Literacy:

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
Only 12 percent of adults have Proficient
health literacy.
Nearly 9 out of 10 adults may lack the skills
needed to manage their health and prevent
disease.
http://www.health.gov/communication/lit
eracy
Flesch Kincaid Grade Level: 5.6
In the Medical Profession we have:

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Bench marks
Technology
Medical Guidelines for health risks
Clinical Trials
Medical Research
New Medications being developed
…
But what if our client or patient
says:

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

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“I have the medication but don’t take it.”
“I’d like to try natural supplements.”
“I can control my drinking.”
“I don’t agree with what my doctor
says.”
“I know what I need to do, but I just
don’t do it.”
“I’m not worried about it.”
Traditionally Labels/Blame were Applied
Non-Compliant
In Denial
Defensive
Closed Minded
The Correct Way to Weigh
Time to Think
Motivational Interviewing (MI)
James Porcheska
and
Carlo DiClemente
Journal of Consulting and Clinical Psychology, Vol
51(3), Jun 1983, 390-395.
 Developed
a trans-theoretical model
of progressive stages of change with
the idea that therapeutic interventions
should be matched to a client’s level
of readiness.
“If you tell people where to go,
but not how to get there,
be amazed atat
thethe
results.--Gen.
George Patton
you'll you'll
be amazed
results.”
Gen. George Patten
What is MI?

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Brief intervention designed to mobilize
client’s internal resources for change by
enhancing intrinsic motivation
A style of being with people, not just a set
of teachings
Considers non-directive and directive
approach
Goal of MI


Assist person to clarify values
Amplify discrepancies
Principles:
Express
Empathy
Avoid Argumentation
Roll with Resistance
Support Self-efficacy
Rolling with Resistance
Remember that both sides of the argument
are already present in them.


If you have arguments with client: and
yours is pro-change; they will argue for
staying status quo = NO CHANGE
If you reflect what they are saying in a nonjudgmental way, they lean towards change
talk
1) Pre-Contemplation

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Client/patient is not considering change
Not perceiving a problem
Not perceiving need to change
“My Doctor told me I needed to curb my appetite.”
2) Contemplation

Sea-saw ambivalently between changing
and staying the same.
Fed up with how her diet is going, Charlene takes a more
serious aim at her target weight.
3) Preparation: person is clear that a
change is needed
They are considering what to do.
“My Doctor told me to start my exercise
program very gradually. Today I drove past a
store that sells sweat pants.”
4) Action:
Client has identified 1 or more steps
to take & begins implementation
Maintenance: person sustains change
RELAPSE
Normal part of change process
 Most people do not maintain change on the
first try
 May cycle through the stages several times
before achieving stable change.

Consider MI in 2 Stages:
Ambivalence/Action
Having only 2 stages takes failure
out of the equation.
“Relapse” has a social stigma of
shame attached to it.
We’re all fighting 2 sides to ourselves

To be ambivalent is normal.
Run a
Rainbow
of
emotions
Ambivalence:
Must be
Engaged
Rather
Than
Overridden
Fix it Impulse
MI is not just
treating the
symptoms;
it is about
uncovering
what lies
underneath
Are you Ready?
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“My step-son committed murder.”
“My daughter was murdered in CO.”
“My husband is having an affair.”
“My grand daughter was born without an
important piece of her brain.”
“My husband had a really big stroke last
week. He may never talk again.”
“My son died in his sleep and the autopsy
found no reason. He was 21.”
OARS
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O = Open ended questions
A = Affirm: strengths, explore options
R = Reflect: change talk, motivators,
values, difficulties, ambivalence
S = Summarize in roughly 5 – 10 minute
blocks of time
Reflective Listening using OARS
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“Explain further about…..”
“You feel the desire to quit smoking and yet
you find yourself turning to cigarettes to
relieve the stress in your life.”
“Tell me about a time when you were
successful.”
“You mentioned….”
“I hear you struggle…”
“For you it feels like…”
Goal Setting and PDSA:
Once a goal is set: “I want to…”
 Plan = How will they get from here to there
with the least amount of wear and tear?
 Do = How will they carry out the plan?
 Study = How is the plan working?
 Act = Plan working: continue/add on
Plan not working: make a new plan

“Many of life’s failures
are people
who did not realize
how close they were to
success
when they gave up.”
Thomas Edison
Health Coaching Is:
Empowering: Accepting: Teaching