Hypertension can be defined as sustained elevation of systemic blood pressure more than 140/90 mm Hg. Reduced capacitance of the venous system and increased arteriolar resistance due to increased peripheral vascular smooth muscle tone can leading causes for the hypertension. The risk associated with hypertension dependent upon the combination risk factors in the specific individual. They are Age, Gender (males>female), Ethnic group (black>white), diet, smoking, family history, blood cholesterol, diabetes mellitus, & preexisting vascular diseases. Chronic hypertension can lead to strokes (cerebral thrombosis, cerebral hemorrhage), congestive heart failure, and myocardial infarction, and renal failure, malignant hypertension, peripheral vascular disease. If hypertension is diagnosed early and is properly treated the prevalence of morbidity and mortality.

One method of classification blood pressure is,

* Normal blood pressure: < 120/80

* Prehypertension: 120-139/80-89

* Hypertension: > 140/90

* Stage 1 Hypertension: 140-159/90-99

* Stage 2 Hypertension: 160 or greater/100.

Hypertension can be classified as essential hypertension and secondary hypertension. Essential hypertension has no identifiable cause. The majority (80-90%) of patients with hypertension have primary elevation of blood pressure, Essential hypertension has a multifactorial etiology such as Genetic factors, fetal factors(low birth weight),environment factors( obesity, sodium intake,alcohole intake, stress),Humoral mechanism, Insulin resistance.

Secondary hypertension is where blood pressure elevation is the result of a specific and potentially treatable cause. As examples renal diseases, alcohol, pregnancy, endocrine causes, congenital cardiovascular causes and drugs induced, autoimmune diseases.

When considering the complications of hypertension the Cerebrovascular disease and coronary artery disease are the most common causes of death, although hypertensive patients are also prone to renal failure and peripheral vascular disease

Hypertensives have a six fold increase in stroke (both hemorrhagic and atherothrombotic). There is a threefold increase in cardiac death (due either to coronary events or to cardiac failure). Furthermore, peripheral arterial disease is twice as common.

Malignant hypertension

Malignant or accelerated hypertension occurs when blood pressure rises rapidly and is considered with severe hypertension (diastolic blood pressure>120 mmHg). Necrotic arterial lesions, Pappiloedema, Cerebral symptoms, progressive renal failure and retinopathy are some features of malignant hypertension.

Arterial blood pressure mainly depend on the peripheral vascular resistance and cardiac output . These depending factors are controlled mainly by two overlapping control mechanisms: They are baroreflexes, and the renin-angiotensin-aldosterone system .Most antihypertensive drugs lower blood pressure by decreasing peripheral resistance and reducing cardiac output .

• Baroreceptors and the sympathetic nervous system

Baroreceptors are involving the sympathetic nerves system. These are responsible for regulation blood pressure. Baroreceptors are placed on aortic arch and carotid sinus. When blood pressure falls baroreceptors send impulses to cardiovascular centers. Then the CV center prompts reflex responses of decreased parasympathetic and increased sympathetic output.This causes vasoconstriction and increase cardiac output.This causes to compensatory rise in blood pressure.

• Renin-angiotensin-aldosterone system

The kidney arrange for the long-term control of blood pressure. It alters the blood volume. When arterial pressure reduced kidney releases the enzyme called as Renin.mot only that Low sodium intake and greater sodium loss also can increase releasing renin.. This enzyme converts angiotensinogen to angiotensin I,when angiotensin-converting enzyme (ACE) is present, angiotensin I is converted in turn to angiotensin II. Angiotensin II is a vasoconstrictor, it constricts both arterioles and veins,as a result blood pressure is increased. Angiotensin II also, increase glomerular filtration. Additionally, angiotensin II can stimulate aldosterone secretion.Aldosterone increases blood volume due to increase renal sodium reabsorption.. These effects of angiotensin II are mediated by stimulation of angiotensin I(AT1) receptors.

Treatment of Hypertension

The target of hypertension treatment is to lower high blood pressure and protect important organs, like the brain, heart, and kidneys from damage. Treatment for hypertension has been associated with reductions in stroke, heart attack, and heart failure. There is continuous interconnection between blood pressure and the risk of a cardiovascular event. So it is necessary for diminishing blood pressure in the general population by education and implementation of blood pressure lowering manners. Single drug can control mild hypertension. Current references are to initiate therapy with a thiazide diuretic unless there are convincing reasons to employ other drug classes.

Although the choice of first-line drug therapy may exert some effects on different long-term cardiovascular endpoints, randomized clinical trials and meta-analyses demonstrated that blood pressure reduction per se is the primary determinant in primary and secondary prevention. Hypertension is non-curable. But can reduce the consequences of disease or disease progression.so treatments can be mainly identified as pharmacological and non-pharmacological. Pharmacologically antihypertensive drugs can be used. They can be mainly classified as Diuretics, Beta blockers, ACE inhibitors, Angiotensin II receptors antagonists, Renin inhibitors, alpha blockers, Ca2+ channel blockers and others.

Diuretics.

These are called water pills and they are medications that act on the kidneys to help body eliminate sodium and water, reducing blood volume

Examples: – Eplerenone, furosemide, Hydrochlorothiazide, Spironolactone

Thiazide diuretics

Most effective method of the treatment of hypertension is using oral diuretic drugs. Thiazide drug is most commonly used. Thiazide diuretics are often the first – but not the only – choice in high blood pressure medications. Thiazide diuretics, such as hydrochlorothiazide, increase sodium and water defecation. Then they lower blood pressure and decrease in extracellular volume, increasing cardiac output and renal blood flow. With long-term management, plasma volume becomes a normal value, but peripheral resistance declines. These drugs can decrease blood pressure in both the supine and standing positions; these agents respond the sodium and water retention observed with other agents used in the treatment of hypertension. Potassium-sparing diuretics are commonly used joined with thiazides. In combination therapy, Thiazide can be used with a variety of other antihypertensive agents, such as ACE inhibitors, beta-blockers and angiotensin-receptor blockers. In the treatment of black or elderly patients, Thiazide drug especially useful. They are not effective in patients with inadequate kidney function. Loop diuretics may be required in these patients. Absorption and elimination rates vary considerably, although no clear advantage is present for one agent over another. All thiazides are ligands for the organic acid secretory system of the nephron, and as such, they may compete with uric acid for elimination. Thiazide diuretics induce hypokalemia and hyperuricemia in 70 percent of patients and hyperglycemia in 10 percent of patients. Hypomagnesaemia may also occur. Serum potassium levels should be monitored closely in patients who are predisposed to cardiac arrhythmias (particularly individuals with left ventricular hypertrophy, ischemic heart disease, or chronic heart failure) and who are concurrently being treated with both thiazide diuretics and digoxin.

Loop diuretics

The loop diuretics act promptly, even in patients with poor renal function or who have not responded to thiazides or other diuretics. Loop diuretics can decrease renal vascular resistance and increased renal blood flow. Loop diuretics increase the Ca2+ content of urine, When thiazide diuretics decrease the Ca2+ amount of urine, loop diuretics can decrease it.

Potassium-sparing diuretics.

Amiloride and triamterene (inhibitors of epithelial sodium transport at the late distal and collecting ducts) as well as spironolactone and eplerenone (aldosterone-receptor antagonists) reduce potassium loss in the urine. Spironolactone has the additional benefit of diminishing the cardiac remodeling that occurs in heart failure.

Beta blockers.

These medications reduce the workload on the heart and open blood vessels, this cause to heart to beat slower. Here it uses less force. Beta blockers don’t work as well in older adults, the effectiveness of Beta blockers increases when they combine with a thiazide diuretic. These are administered orally. Beta Blockers are considered as first-line drug therapy for hypertension. Primarily Beta blockers decrease cardiac output and as a result blood pressure reduces. Also Beta blockers decrease sympathetic outflow and decrease the formation of angiotensin II due to inhibition the release of renin. And the secretion of aldosterone. It will take few weeks to develop their full effects. The Beta-blockers are more effective for treating hypertension in white than in black patients and in young compared to elderly patients. , severe chronic obstructive lung disease, chronic congestive heart failure, or severe symptomatic occlusive peripheral vascular disease are Conditions that discourage the use of Beta blockers more commonly found in the elderly and in diabetics. The Beta-blockers are useful in treating conditions that may coexist with hypertension, such as supraventricular tachyarrhythmia, previous myocardial infarction, angina pectoris, chronic heart failure, and migraine headache. Bradycardia and CNS side effects such as, lethargy, fatigue hallucinations and insomnia can be occurring due to Beta blockers. Lipid metabolism may be disturbed by Beta blockers because they can increase plasma triacylglycerol and decrease cholesterol, high-density lipoprotein. Abrupt withdrawal of this drug may induce myocardial infarction, sudden death due to ischemic heart disease and angina may be induced by withdrawal of Beta blockers. Hence the doses of these drugs must be carefully managed with hypertension and ischemic heart disease.

Example:-Atenolol, Carvidilol, Nadolol, Timolol

Angiotensin-converting enzyme (ACE) inhibitors.

These medications help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.

.The ACE inhibitors reduce blood pressure by decreasing peripheral vascular resistance. It doesn’t increase heart rate, cardiac output, contractility of the heart. ACE is blocked by this drug interfering the cleavage of angiotensin I to form the angiotensin II. Angiotensin II is an effective vasoconstrictor. And also angeotensin converting enzyme is accountable for the breakdown of bradykinin.so due to ACE inhibitors, it increases bradykinin levels and decrease angiotensin II.Bradykinin is a vasodilator. So Vasodilation occurs due to the collective effects of low level of angiotensin II and the increased Brdykinin level. By reducing circulating angiotensin II levels, ACE inhibitors also reduce the level of aldosterone. This kind of drugs is most effective in younger hypertensive patients. However, when used in combination with a diuretic, the effectiveness of ACE inhibitors is similar in white and black patients with hypertension. Management of patients with chronic heart failure is also effectively managed by ACE inhibitors. The dry cough, which occurs in about 10 percent of patients, is thought to be due to increased levels of bradykinin in the pulmonary tree. Potassium levels must be monitored, and potassium supplements (or a high potassium diets) or potassium-sparing diuretics are contraindicated. Because of increased levels of bradykinin, angioedema may occur. It is rare incident. But it may have a life threatening reaction ACE inhibitors should be introduced at first time with the close observation of the physician. Because of the risk of angioedema and first-dose syncope. These are fetotoxic drug. Therefore it shouldn’t be used for the pregnant women.

Example:-Losartan, Valsartan, Olmesartan

Example:-Benazepril, Captopril, Lisinopril, Moexipril

Calcium channel blockers.

These medications help relax the muscles of your blood vessels.Calcium channel blockers may work better for older adults than ACE inhibitors or beta blockers alone. A word of caution for grapefruit lovers, though. Grapefruit juice interacts with some calcium channel blockers, increasing blood levels of the treatment and putting you at higher risk of side effects. When first line agents are ineffective, this method is used. Ca2+ blockers more commonly use in diabetes patients and angina patients. High doses of short-acting calcium-channel blockers should be avoided because of increased risk of myocardial infarction due to excessive vasodilation and marked reflex cardiac stimulation. The calcium-channel blockers are divided into three chemical classes, each with different pharmacokinetic properties and clinical indications.

Diphenylalkylamines:

this class has only one member. It is Verapamil. It has imperative effects on vascular smooth muscles and cardiac muscle cells. Treatments of, supraventricular tachyarrhythmias, angina and migraine headaches Verapamil is used commonly.

Benzodiazepines:

Diltiazem is the only member of this class that is currently approved in the United States. Has verapamil like action. Diltiazam has negative inotropic action. It has a satisfactory side-effect profile also.

Dihydropyridines:

This rapidly expanding class of calcium-channel blockers includes the first-generation nifedipine and it takes only a diminutive time for treating hypertension. Amlodipine, felodipine, isradipine, nicardipine and nisoldipine. These second-generation calcium-channel blockers differ in pharmacokinetics, approved uses, and drug interactions. Vascular calcium channels are often taken the high affinity of the dihydropyradines than calcium channels in the heart. So they are predominantly attractive in treating hypertension.

Example: – Amlodipine, Feladifine, Nicardipine, Nifedifine

Renin inhibition

Renin is a hormone secreted by the juxtaglomerular cells of the kidney and linked with aldosterone in a negative feedback loop.These slow down the manufacture of renin, an enzyme produced by kidneys that starts a chain of chemical steps that increases blood pressure and works by reducing the ability of renin to begin this process. Due to a risk of serious complications. A selective renin inhibitor, aliskiren has been released for the treatment of hypertension. Renin can be directly inhibited by aliskiren. So it, works on the renin-angiotensin-aldosterone system quicker than ACE inhibitors or ARBs. It lowers blood pressure about as effectively as ARBs, ACE inhibitors, and thiazides. It can also be combined other antihypertensive, such diuretics, ACE inhibitors, ARBs, or calcium-channel blocker. During the pregnancy this drug is contraindicated. The combination of maximum doses of aliskiren and valsartan decreased blood pressure more than maximum doses of either agent alone but not more than would be expected with dual therapy consisting of agents of different classes. Calcium concentration of the cell acts an main role in upholding the tone of smooth muscle and in the myocardium contraction. Ca2+ pass in to the muscle cells via special voltage-sensitive calcium channels. This initiates Release of Ca2+ from the sarcoplasmic reticulum and mitochondria are initiated by these drugs, which further upsurges the cytosolic level of calcium. the inward movement of calcium is blocked by Calcium-channel antagonists by binding to L-type calcium channels in the heart. and peripheral vasculature. This causes dilating arterioles.

These drugs have an intrinsic natriuretic effect. So they do not usually require the addition of a diuretic. These agents are very useful when treating the patients with angina,diadetes peripheral vascular disease and asthma. Black hypertension patients respond well to calcium-channel blockers.

Most of these agents have short half-lives following an oral dose. Treatment is required three times a day to maintain good control of hypertension. Sustained-release preparations are available and permit less frequent dosing. Amlodipine does not require a sustained-release preparation and. . has a very long half-life.

.Example:- Aliskiren (Tekturna)

Other drugs

Centrally acting adrenergic drugs.

Clonidine

Clonidine is a drug that acts on Alpha agonist hypotensive agents. This can be used with another Diuretic also.It decreases the adrenergic outflow. But glomerular filteration and renal blood flow are not reduced by Clonidine.So it is very important in complicated hypertensive due to renal diseases. This is administered orally and easily excreted with urine.this drug helps to sodium and water retention of the body.

Vasodilators

The direct-acting smooth muscle relaxants, such as hydralazine and minoxidil, have traditionally not been used as primary drugs to treat hypertension. Vasodilators act by producing relaxation of vascular smooth muscle, which decreases resistance and, therefore, blood pressure. These agents produce reflex stimulation of the heart, resulting in the competing reflexes of increased myocardial contractility, heart rate, and oxygen consumption. These actions may prompt angina pectoris, myocardial infarction, or cardiac failure in predisposed individuals. Vasodilators also increase plasma renin concentration, resulting in sodium and water retention. These undesirable side effects can be blocked by concomitant use of a diuretic and a Beta-blocker.

Hydralazine

This drug acts on arteries and arterioles decreasing vasodialation. It decreases the pheripheral resisrance. Use to control hypertension in pregnancy.

Minoxidil

This drug is orally administered.Severe sodium ,water retention occur. Beta blockers and loop diuretics are used combine with this.

. Hypertensive Emergency

This is a rare condition. But this can create a life threatening situations in which SBP/ DBP is greater than 210/150 mm Hg. Otherwise healthy person with preexisting complications, such as cerebral hemorrhage, encephalopathy aortic stenosis or left ventricular failure. Here it is emergency to reduce blood pressure rapidly by treatments.

Sodium nitroprusside

Nitroprusside can reduce blood pressure of all types of hypertension patients.This is intravenously administered causesing vasodilation. The drug can act on both on arterial and venous smooth muscle. It can diminish cardiac preload. Nitroprusside is metabolized rapidly and requires unremitting infusion to maintain its hypotensive action.

Labetalol

Labetalol can use in hypertensive emergencies and can give intravenously. effects of these drugs are on non-selective Beta blockers. Also it does cause tachycardia.Having the longer half life is the major restriction.

Fenoldopam

This drug is especially useful for patients with renal ineffectuality. Fenoldopam can be administered as an intravenous infusion. Unlike other parenteral antihypertensive agents, fenoldopam sustains or rises renal perfusion while it drops blood pressure. All hypertensive predicaments use this as a safely method. patients with glaucoma contraindicated this drug.

Nicardipine

This drug acts as a calcium-channel blocker. intravenous infusion can be used to administered . The primary dose is 5 mg/h and it can be increased to a maximum of 15 mg/h. The chief restriction of nicardipine in treating is having a long half time.

Use of non-pharmacological therapy in all hypertensive and borderline hypertensive people can be shown as follow

weight reduction

Overweight people have high concentration and activation of renin-angiotensin system. And also activity of sympathetic nerves system is also high.so they maintain a high arterial pressure. So hypertensive patients can decrease their calorie intake and maintain their body’s BMI below 25kg/m2.

low-sodium diet –

Reducing sodium (salt) diet is proven very effective: it decreases blood pressure in about 60% of people..It should maintain less than 6 g sodium chloride per day

limited alcohol consumption -( ≤ 21 units/week for menand ≤ 14 units/week for women)

Discontinuing tobacco smoking and alcohol drinking has been shown to lower blood pressure. The exact mechanisms are not fully understood, but blood pressure (especially systolic) always transiently increases following alcohol and/or nicotine consumption.

dynamic exercise

it decrease the activity of plasma renin. Regular aerobic exercises are recommended.Jogging,swimming and cycling helps to decrease peripheral resistence. Regular mild exercise improves blood flow and helps to reduce resting heart rate and blood pressure.Regular exercise should be done at least 30 minutes brisk walk perday

low-fat and saturated fat diet

increased fruit and vegetable consumption

Additional dietary changes beneficial to reducing blood pressure includes the DASH diet (Dietary Approaches to Stop Hypertension), which is rich in fruits and vegetables and low fat or fat-free dairy foods. In addition, an increase in daily calcium intake has also been shown to be highly effective in reducing blood pressure. Fruits, vegetables, and nuts have the added benefit of increasing dietary potassium, which theoretically can offset the effect of sodium and act on the kidney to decrease blood pressure.

reduce cardiovascular risk by stopping smoking and increasing oily fish consumption.

.

Relaxation therapy, such as meditation, that reduces environmental stress, high sound levels and over-illumination can be an additional method of ameliorating hypertension. Biofeedback is also used particularly device guided paced breathing. Obviously, the effectiveness of relaxation therapy relies on the patient’s attitude and compliance.

INTRODUCTION

Human development and health is greatly influenced by the environment in which they live in (Centre for Disease Control, 2009). Solid waste constitutes a major source of environmental hazard. Environmental hazards accounts for an estimated 25 % of the total burden of disease worldwide and nearly 35 % of ill-health in sub Saharan Africa is caused by environmental hazards (WHO, 2009). This dissertation is a report of a qualitative study done to find out the perceptions of Warri South Local Authority staff on solid waste and its disposal in Warri municipal. According to Beede and Bloom (2003), the perception and attitude of people towards waste can affect the way it is managed; hence it is essential to gain an insight and knowledge about the perception of Warri South Local Authority staff on solid waste and its disposal in Warri since they play a major role in the planning and running of Warri municipal. If they do not perceive waste disposal in Warri as a priority, little or no attention will be given to it. This first chapter starts by offering a background for the study. It will highlight the problem of municipal solid waste and depict its importance and public health consequences. The purpose of study, methodology adopted and potential benefits of this study are also discussed briefly. Overview of other chapters will also be discussed.

BACKGROUND FOR THE STUDY

The World Health Organization (WHO) constitution of 1964, defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (Naidoo and Williams, 2000). A clean environment is one of the prerequisite of a good health because there is a close relationship between the environment and people’s health. A high quality environment allow people to live longer in good and positive health (ref) Solid waste constitutes a major source of environmental hazard if not properly managed. The activities of humans and animals produce waste and the way these wastes are handled, stored, collected and disposed of, can pose risks to the environment and to public health (Tchobanoglous et al, 1993; Baritone, 1995; Ofomata, 2001, Da Zhu et al, 2008).

Municipal solid waste (MSW) refers to non-air and non-sewage emissions created within and disposed of by a municipality this includes household garbage, commercial refuse, construction and demolition debris, dead animals, and abandoned vehicles (Cointreau, 1982; Walling et al., 2004). There are several classification of solid waste based on their origin, characteristics and risk potentials (Ofomata and Eze, 2001). They are broadly classified by their characteristic as biodegradable and non-biodegradable. This classification is based on the quality of solid waste generated from different sources. According to Department of Environment, Food and Rural Affairs (DEFRA, 2007), biodegradable waste consists of all organic wastes that decay naturally as the result of the action of micro organisms into useful or less polluting products. Non-biodegradable wastes consist of wastes that do not breakdown naturally and must be recycled, burnt or buried; a common example is the plastic shopping bag (Williams, 2005).

In the beginning of civilization, disposal of waste was not a significant problem because population was small and land available for assimilation of waste was abundant (Tchobanoglous et al, 1993; Ahmed and Ali, 2004). Solid waste generated by the traditional society were little and simple, mostly containing organic matter while those generated by today’s technological societies are large and complex. Problems of waste disposal started from the time people began to assemble in clans, villages, and communities and the build up of waste became a consequence of life (Tchobanoglous et al, 1993) The rapid developments of cities across the globe have led to an increase in the amount of waste produced from human activities; this has posed a challenge of disposal to both developed and less developing nations (WHO, 2009).

According to United Nations Development Programme survey report of one hundred and fifty one mayors of different cities from around the world, inadequate solid waste disposal is the second most pressing problem facing city residents after unemployment (Da Zhu et al, 2008). This problem is further compounded as many nations continue to urbanize rapidly and to increase in population, making it difficult for most municipal authorities to provide most of the basic services (Ogbonna et al, 2002, Ayotamuno and Gobo, 2004). According to United Nation Statistic Division (UNSD, 2009) Nigeria has a population of about 140 million with an annual urban growth of 3.8%. It is a developing country that has persistent solid waste management problems in addition to her growing population (Walling et al, 2004). An average Nigerian generates about 0.49 kg of solid waste per day with households and commercial centres contributing almost 90% of total urban waste burden (Uguwh, 2009)

Developing countries spend as much as 20 to 40% of their municipal revenues on waste management (Thomas-Hope 1998, Schübeler 1996, Bartone 2000); yet they are often unable to solve the problem as one to two-thirds of the solid waste generated is not collected, while the uncollected waste is dumped on the land in a more or less uncontrolled manner (Onwurah et al, 2003, Da Zhu et al, 2008). Even the collected waste is often disposed in an uncontrolled dump site or burnt, contributing to water and air pollution (Da Zhu et al, 2008).

Indiscriminate disposal and dumping of waste has become a common practice in Nigerian cities. Municipal solid waste heaps are found in several parts of major Nigerian cities like Warri, often blocking roads, alleys, and pavements (Ayotamuno and Gobo, 2004). Most of the waste dumps are located close to residential areas, Markets, farms, roadsides, and creeks; with many human activities close to the dump sites, there is an increase threat to public health (Ogbonna et al, 2002). Generally, the uncollected solid wastes are left to decay, and this produces foul odour thereby constituting a source of environmental nuisance (Ofomata and Eze, 2001). Uncontrolled burning, another common method of disposing waste in Nigeria and this have often led to fire outbreaks. Smoke arising from such fires can reduce visibility, and have been known to cause fatal vehicular accidents (Ofomata and Eze, 2001). Warri is a major oil city located in Delta state Nigeria, with a population of over a million. Its population is rapidly growing due to urbanization and oil exploration activities; the total waste load for Warri is about 66 721 tonnes per year (Ajao and Anurigwo , 2002).

Municipal Solid Waste and Public Health Implication

The management of municipal solid waste is becoming a major public health and environmental concern in urban areas of many developing countries (Harris, 2004). The improper management of solid wastes represents a source of environmental pollution, and poses risks to human health (Puri et al., 2008). Municipal waste in most cities contain human excreta, animal excreta, hazardous chemical pollutants and sharps which can facilitate the spread of diseases and injury particularly among children playing near waste dumpsites and employees in waste management sector (Da Zhu et al, 2008). Poor disposal of solid waste is associated with spread of vector borne-diseases like malaria and dengue fever (McKenzie et al., 2004; Puri et al., 2008). Infrequently disposed refuse tend to become breeding sites for mosquitoes, as pools of rain water collect in discarded cans, bottles and car tires (Ofomata and Eze, 2001) Mosquitoes are responsible for the transmission of malaria-a life threatening disease through their bites (Human Protection Agency, 2009). Malaria accounts for an estimated 300-500 million cases globally; which is an endemic disease in sub-Saharan Africa. It accounts for about 1.5-2.5 million deaths yearly, most of them among children under five years (WHO, 2009). Decomposing organic materials can become breeding sites for pests, rats, flies and vermin that enhance the likelihood of disease transmission like diarrhoea and Lassa fever (Simon, 2008). Lassa fever is a haemorrhagic fever common in four African countries: Guinea, Liberia, Nigeria and Sierra Leone. It is transmitted to humans from contacts with food or household items contaminated with rodent excreta (HPA, 2009; WHO, 2009).

Uncollected waste left to accumulate or dumped in the streets can block water drains and channels which can cause flooding, posing significant environmental and public health risks (Whiteman et al, 2008). Ground or surface water pollution can occur when rain water combines with decomposing waste and seep through permeable soil, finally contaminating surface and ground water with both lethal materials and pathogenic organisms (Ofomata and Eze, 2001); this is extremely dangerous as ground water is the main source of drinking water for most cities in the developing world (Oluwasola, 2007). Incineration of municipal solid waste contributes to air pollution by the release of noxious materials into the air, which may cause ill-health (Ofomata and Eze, 2001). Uncontrolled incineration of solid waste can also cause fire outbreaks in nearby homes and farms. Other impacts of poor Municipal Solid Waste disposal include disgusting odour, unsightliness and general degradation of the environment (Dolk, 2002).

PURPOSE OF THE RESEARH

Many studies have been done on waste disposal and management in Nigeria but none has been done to explore the views of Warri south local authority staff. The aim of this research is to explore the views of the staff of Warri south local authority on municipal solid waste disposal system, and its public health implication in Warri.

RESEARCH QUESTION

The research question for this study is – What are the perceptions of Warri South Local Authority senior staff on municipal solid waste disposal in Warri? This will encompass the issues and problems of solid waste management in the municipal.

WHY PERCEPTION?

According to Collins school dictionary (2000) perception is your understanding of something or someone. Perception refers to the image or feelings formed in one’s mind about some perceived phenomenon or object (Okot- Uma et al, 2002). Perceptions vary from person to person, as they perceive different things about the same situation. Perception is influenced by perceiver’s value, beliefs, social economic circumstance and expectations (Okot- Uma et al, 2002). People’s perception of issue influence the way they act, behave or respond to them. Decision makers working in any environment

base their decision on the environment as they see it and not as it is. The action resulting from their decision on the other hand is played out in the real environment (ref).

If the general perception of people who play a major role in the running of warri municipal on solid waste disposal in Warri is that it is of little importance, little or no attention will be given to it.

METHODOLOGY.

The study will adopt a qualitative research methodology because it aims to gain an insight and knowledge about peoples’ perception on waste. Qualitative research concentrates on people’s attitudes, experiences, beliefs and their perceptions of a situation (Polit et al., 2001). It aims to generate an understanding of what is going on in everyday setting and it can also be used to describe a point of view, illustrate meaning, sensitize readers or try to understand phenomena (Green and Britten, 1998). Hence qualitative research is the most appropriate approach that should be used for this study.

BENEFIT OF THE RESEARCH

The study will be beneficial, as it will provide an insight on how the staff in charge of daily planning of services in Warri south view waste disposal in the community. It may also help Warri south local authority in modifying and improving waste disposal strategies and systems. I intend to publish the findings and recommendations of this study in a local paper. It will also contribute to the existing body of knowledge of waste management in Nigeria.

SYNOPSIS OF CHAPTERS

This chapter has presented an overview of municipal solid waste disposal problems and its public health implications as an introduction to the study. Chapter two will presents a review of current significant literature on waste disposal in Nigeria and other developing countries. A brief note on how the literature search was carried out will also be stated. Following the literature review chapter, will be the methodology of the research reported in chapter three; where different research methodologies and the justification for the method chosen are discussed. The research method, which includes; sampling method, data collection, data management/analysis and ethical issues also form sections of the methodology chapter. The findings of the study and discussion are reported in chapters four and five respectively. At the end of the dissertation, the recommendations based on the research findings are stated in chapter six.

Review of literature is an essential step in the development of a research project. The primary purpose is to gain abroad background or understanding of the information that is related to the research problem.

Review of literature of the present study was arranged in the following heading:

Review related to polycystic ovarian syndrome.

Review related to prevalence

Review related to Quality of life

Review related to risk factors.

Review related to treatment.

Review related to poly cystic ovarian syndrome.

Polycystic ovary syndrome (PCOS), also known as Stein Leventhal Syndrome, was first described in 1935. PCOS, which may also be referred to as polycystic ovary disease (PCOD) is the most common hormonal disorder found in premenopausal women. PCOS affects 7% of women from all races and nationalities.

Typically, PCOS symptoms first appear in adolescence, normally around the state of menstruation. Occasionally, some women do not develop PCOS symptoms until their early to mid-20s. One of the most common symptoms of PCOS is irregular periods. Polycystic ovary syndrome (PCOS) becomes symptomatic during adolescence and affects at least 5% of reproductive-age women. PCOS is a heterogeneous syndrome of unexplained chronic hyperandrogenism and oligo-anovulation, with a polycystic ovary being an alternative diagnostic criterion. About half of cases lack some of the classic Stein-Leventhal syndrome features of menstrual irregularity, hirsutism, obesity, and polycystic ovaries. Whether the syndrome can be diagnosed in the absence of hyperandrogenism is controversial, and the documentation of hyperandrogenemia can be problematic. The broad spectrum of the disorder seems to encompass atypical cases of hyperandrogenemia with central obesity and features of insulin resistance instead of hirsutism or anovulation.

Functional ovarian hyperandrogenism (FOH) is usually the source of the androgen excess. It is characterized by 17-hydroxyprogesterone (17PROG) hyperresponsiveness to the gonadotropin stimulation of GnRH agonist or human chorionic gonadotropin testing and subnormal suppressibility of plasma testosterone upon adrenal suppression by glucocorticoid. It is often accompanied by functional adrenal hyperandrogenism, characterized by 17-hydroxypregnenolone or dehydroepiandrosterone (DHEA) hyperresponsiveness to ACTH; in atypical PCOS, the sole source of androgen excess may be functional adrenal hyperandrogenism. The underlying defect seems to be a constitutive dysreglulaton of steroidogenic cells (9). Intrinsic granulosa cell dysfunction is also present. LH excess appears to contribute to 50-75% of cases. Evidence is accumulating that it arises from androgen interfering with the progesterone negative-feedback effect on LH secretion. However, the possibility of primary central mechanisms for LH excess remains, particularly in adolescent PCOS .

Increasing evidence suggests that PCOS arises as a complex trait with contributions from both heritable and nonheritable factors. Polygenic influences appear to account for about 70% of the variance in pathogenesis. Nearly half of sisters of women with PCOS have an elevated plasma testosterone level, although only half of them are symptomatic. Polycystic ovaries appear to be transmitted as a dominant trait, usually asymptomatic but often accompanied by a subclinical PCOS type of ovarian dysfunction. Central obesity and insulin resistance seem to play important roles in PCOS, perhaps by accentuating steroidogenic dysregulation but perhaps more fundamentally because PCOS is closely related to these features in parents. Gestational factors have also been incriminated; the syndrome has been associated with high birth weight in heavy mothers and can arise from fetal programming by androgen excess. In view of these indications for congenital origins of the syndrome, it is not surprising that there is increasing recognition of risk factors for PCOS in childhood

Minerva Pediatr (2010) Polycystic Ovary syndrome (PCOS) is a complex disorder, involving primarily ovarian hyperandrogenism in females and linked with insulin resistance in the majority of cases. Clinical features are widely variable and include a combination of menstrual irregularities, acne, hirsutism, and alopecia. Although it typically presents around puberty, several risk factors during childhood may help raise a high index of suspicion for the development of PCOS in adolescents. The pathophysiology of PCOS still remains unknown and likely includes a combination of genetic factors, insulin resistance and environmental factors. A thorough diagnostic work up is required in suspected cases and several management modalities have been suggested. Since various long term complications and comorbidities are associated with PCOS early diagnosis and therapeutic intervention is warranted in these cases.

Review Related To Prevalence

Pembe AB, Abeid MS (2009). The aim of this study was to determine prevalence of polycystic ovaries (PCO) and associated clinical and biochemical features among women with infertility attending gynaecological outpatients department (GOPD) at Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. All women with infertility attending the GOPD from 11th September 2006 to 15th February 2007 were recruited to the study. Information on socio-demographic, obstetric and menstrual characteristics was collected. Anthropometric measurement, clinical examination of acne and hirsutism, vaginal ultrasonography for PCO and biochemical analysis of luteinizing hormone (LH), follicle stimulating hormone (FSH) and testosterone were performed all 102 women who attended the GOPD during the study period due to infertilityw ere recruited. Two women were excluded after diagnosis of pregnancy made by hormonal assay and ultrasonography thus remaining with 100 women for analysis. Oligomenorrhoea and acne were significantly higher in a group of women with PCO than among women with normal ovaries. The mean hirsutism score though was not significant, was higher in women with PCO than in women with normal ovaries (5.1 +/-2.7 vs 4+/-2.4, P<0.057). Using the Rotterdam criteria 32 (32%) women were diagnosed to have polycystic ovary syndrome (PCOS). Among these women 25 (78.1%) had PCO, 24 (75%) had signs and oligoanovulation, and 18 (56.3%) had hirsutism. Among 68 women with no PCOS, 7 (10.3%) had polycystic ovaries, 15 (22.1%) had signs and oligoanovulation and 6 *8.8%) had hirsutism. In conclusion, polycystic ovaries are common among women with infertility, however are not necessarily associated with polycystic ovary syndrome.

Koivunen R. (1999) conducted study about prevalence of polycystic ovaries in healthy women. The prevalence of polycystic ovaries varies with age. The findings are more common in women aged 35 years or younger than in those aged 36 years or older. It remains unclear of women with polycystic ovaries will later develop fall-blown polycystic ovary syndrome; however, the hormonal parameters and clinical findings among women with polycystic ovaries mimized those will polycystic ovarian syndrome.

Enhrman DA, Cavagham MK, Barnes RB, (1999) prevalence of impaired glucose tolerance and diabetes in women with polycystic ovary syndrome obese women with polycystic ovary syndrome have the highest risk of glucose intolerance. Among women with polycystic ovary syndrome, 35% will have impaired glucose tolerance and 10% will be diabetic before age 40. Hyperandrogenemia may have a role in the development of glucose intolerance or be a marker of insulin resistance. Conversion from impaired glucose tolerance to NIDDM appears to be accelerated in women with polycystic ovary syndrome.

Review related to quality of life

Moran L, el.a.l (2010) conducted a observational, cross – sectional study in young woman. He assess the psychological features in young women with and without PCOS. Women with PCOS demonstrated worsened quality of life (p=0.033 ) and greater anxiety (p= 0.01)and depression (p=0.023) than women without PCOS related to BMI status. Women with PCOS were more likely to perceive themselves as at risk of obesity (p=0.012) and infertility (p=0.0001), and perceived greater importance in reducing future risk of prediabetes (p=0.027), gestationl diabetes (p=0.039),type2 diabetes (p= 0.01) , heart disease (p=0.005),obesity(p=0.0007),and infertility(p=0.023) than women without PCOS. Women with PCOS were more likely to have fears about future health related to weight gain (p=0.045 ), loss of femininity (p =0.035) , loss of sexuality (p =0.003) and infertility (p=0.019) than women without PCOS. Worsened quality of life, anxiety and depression in young women with PCOS is related to BMI. Risk perception is appropriately high in PCOS, yet perceived risk of future metabolic complications are less common than those related to weight gain and infertility.

Judy Griffin Mc Cook, et al conducted on a cross – sectional, regarding quality of life in women with polycystic ovarian syndrome. The results of this study indicate that women with PCOS have the greatest concern in the area of weight, followed by menstrual problems and infertility. These concerns are directely reflected in their objective life experiences. Women with PCOS clearly need education and support regarding the effect of their quality of life.

Sigrid elsenbruch el.al They conducted a survey method the sample was collected from out patients clinics of the devision of endocrinology ,department of medicine at the university of essen, based on referrals from gynecologists in the surrounding area or patients attracted by the clinic’s home page. They concluded that the pronounced psychological and psychosocial problems affecting health related to quality of life of patients with PCOS. Although an effective medical treatment aimed at improving PCOS – related symptoms will also reduce psychological distress and improve sexual self – worth , consideration of both the medical and psychological situation with the availability of an additional help group are likely to further improve life satisfaction and coping of affected women.

Maria E el. al conducted a cross sectional study of female adolescents and to determine whether clinically observed or self -perceived severity of illness attect their HRQL (Health related quality life) they concluded that adolescents with PCOS experience lower HRQL compared with healthy adolescents. Polycystic ovarian syndrome and perceived severity of illness negatively affect HRQL in adolescents. This study suggests a need to develop interventions to reduce the distress that patients with PCOS may face to adolescents and young adult.

Susanne Hahn, el. al A Comparative study was conducted in out patient clinic of The Department Of Medicine, university of Duisburg – Essen, Germany. The result of the study was PCOS patients showed significant reductions in quality of life, increased psychological disturbances, and decreased sexual satisfaction when healthy controls. BMI and hirsutism scores, but not the presence of acne , were associated with physical aspect of quality – of – life and sexual satisfaction. No clear effect of androgens or insulin resistance on psychosocial variables was detected. Similarly, the type of menstrual cycle disturbances or infertility had no impact on psychological well – being.

Review related to risk factors

Robert L. Rosenfield et al 2007 in this study state that risk factors for PCOS can be recognized in childhood. This study concluded that premature pubarche patients appear to carry about a 15 -20 % risk of developing PCOS. It seems likely that the risk is relatively high in those with exaggerated adrenarche and relatively low in those with ordinary premature adrenarche or idiopathic premature pubarche. PCOS is a complex trait with a large hereditary component. There fore, the presence of PCOS, or central obesity, diabetes, or other insulin resistant features in a parent should heighten the concern about risk for PCOS if the child presents other risk factors.

Bulent O. Yildiz, et.al (2005) The study was conducted at a tertiary care center. Population prevalence of PCOS according to body mass index (BMI) and change in BMI of PCOS patients over time were measured. The results suggest that the risk of PCOS is only minimally increased with obesity, although the degree of obesity of PCOS patients has increased, similar to that observed in the general population. These data indicate that obesity in PCOS reflects environmental factors to a great extent.

Meher un Nisal (2009) A cross – sectional analytical study was conducted in Qassim University Clinic, in the year of 2007 -2009 . They concluded that obesity plays an important role in the genesis and maintenance of polycystic ovarian disease. PCOD is the leading cause of anovultory infertility in females and affects 1 in 10 women of reproductive age. PCOD is strongly associated with obesity.

Angela Kerchner, B.A., el .al (2009) coducted a prospective longitudinal study cocluded that there is a significant risk mood disorders in women with polycystic ovarian syndrome. The persistent high rate of depression and other mood disorders are presents in young women with PCOS.

Rosenfield RL. The University of Chicago Pritzker School of Medicine, Department of Pediatrics (2007) conducted a study on polycystic ovary syndrome (PCOS) appears to arise as a complex trait with contributions from both heritable and nonheritable factors. Polygenic influences appear to account for about 70% of the variance in pathogenesis. In view of this evidence for congenital contributions to the syndrome, childhood manifestations may be expected. The objective has been to review the evidence that risk factors for PCOS can be recognized in childhood. Congenital virilizing disorder are average or low birth weight for gestation age; premature adrenarche, particularly exaggerated adrenarche; atypical sexual precocity; or intractable obesity with acanthosis nigricans, metabolic syndrome, and pseudo-cushing syndrome or pseudo-acromegaly in early childhood have been identified as independent prepubertal risk factors for the development of PCOS. During adolescence, PCOS may masquerade as physiological adolescent anovulation. Asymptomatic adolescents with a polycystic ovary occasionally (8%) have subclinical PCOS but often (42%) have a subclinical PCOS type of ovarian dysfunction, the prognosis for which is unclear. Identifying children at risk for PCOS offers the prospect of eventually preventing some of the long-term complications associated with this syndrome once our understanding of the basis of the disorder improves.

Fertile steril (2009) conducted a prospective longitudinal study in university they state that there is a significant risk for mood disorders in women with polycystic ovarian syndrome. They found that a high conversion risk for depression over a 1 to 2 year period under scores the importance of routine screening and aggressive treatment of mental health disorders in this population.

Duleba AJ, Ahmed IM (2010) observational study to evaluate urinary albumin excretion (UAE) in normotensive and non diabetic women with polycystic ovary syndrome in relation to their clinical, endocrine, and metabolic motiles. They concluded urinary albumin exenetion in women with pcos correlates well with other cordiovcescular events is continuous, evaluation of UAE in the presence of information and may aid in selecting appropriate patients for move aggressive treatment of likely aggravation factors, such as hyperonsulinemia or borderline hypertension.

Want Y, et.al says that the family history of diabetes mellitus has the most effect on the clinical phenotype in women with PCOS. The family history of other diseases such as menstrual disorder, premature balding and hypertension play less significant roles. A family history of positive coronary heart disease does not affect the clinical phenotype of such patients. A survey of the polycystic ovary syndrome in the Greek island of Lesbos: hormonal and metabolic profile.

Review related to Treatment

Moran LJ, Pasquali R, (2009) state that the lifestyle management should be used as the primary therapy in overweight and obese women with PCOS for the treatment of metabolic complications.

Jeans YM, et.al (2009) they conducted a experimental study on dietary management of women with PCOS. They concluded that 73% of overweight women were not following a diet to promote weight loss.

Humphreys L, costarelli V (2008). They concluded that in spite of the fact that weight loss and weight maintenance are absolutely vital in the treatment the PCOS. In their study bees shown that the support given to PCOS patients to help reduce and control their weight is inadequate and needs to be improved.

Hector F Escobar et.al. (2008). They done a case control study including 40 PCOS patients matched with 40 non hyperandrogenic women for age and body mass index. They concluded that serum OPG (Osteoprotegerin) concentrations are reduced in PCOS patients independently of obesity.

Unlu C. Atabe koglu CS. (2006). They suggest that the metformin has gained popularity as first line management in clomiphone citrate resistant women with polycystic ovarian syndrome. It ovulation does not occur within several months offer treatment with metformin, affer the evaluation of all PCOS and cons related to each treatment. Laparoscopic ovarian drilling or gonadotropins may be considered as an effective option according to patients choice.

Glueck CJ, et. Al. (2009 Sep) conduct a study: in 20 adolescents age, or = 17(16+/- 1 yr) with polycystic ovary syndrome (PCOS), endocrinopathy and coronary heart disease (CHD) risk factors. Median weight fell from 85.5 to 78.4 kg(p=0.004), waist circumference from 91 to 84 cm (p= 0.017), triglyceride form 108 to 71 mg/dl (p=0.026), and testosterone from 45.5 to 31.5ng/dl (p=0.03). The percentage of cycles with normal menses rose from a pre-treatment median of 8% to 100 %, p<0.0001. In adolescents (

Genazzani AD, Ricchieri F, Lanzoni C conducted a study in metformin is quite an old drug, but it is optimal for the control of glycemia in type 2 diabetes. It was reported, 15 years ago, that insulin resistance was abnormally high in most polycystic ovary syndrome (PCOS) patients. Starting disorder over 2 years after menarche, a higher incidence of obesity, marked hyperandrogenism and insulin resistance and disorderly gonadotropine secretion in comparison with control subjects. Hyperandrogenism and insulin resistance are much more severe in obese adolescent PCOS.

Beata Banasjewska MD Ph.D., Antoni J Duleba MD, Robert Z. Spacjynski, “Lipids in polycystic ovarian syndrome Role of hyperinsulinemia and effects of metformin”.Use of metformin in hyperinsulinemia women with PCOS is associated with a significant improvement of lipid profile; these findings support the notion that metformin use may be considered prophylactic therapy aimed at lowering cardiovascular risk factors.

Jeans YM et al (2009) conducted a study related to dietary management of women with polycystic ovary syndrome. Advice provided by dietitians focused on a reduction in energy intake (78%) and dietary glycaemic index (77%) often in combination. Of the women with poly cystic ovarian syndrome who were following a diet specifically for their poly cystic ovarian syndrome (57%) regimes included a low glycaemic index (34%), weight loss diets (16%) or a combination (26%). Of interest, 73% of overweight women were not following a diet with only 15% of women having seen a dietitian. Eighty-four percent of women with poly cystic ovarian syndrome who had increased physical activity (48%) self-reported an improvement in their symptoms. They concluded that women with poly cystic ovarian syndrome recognize the importance of diet, but few received dietary advice from a registered dietitian. The dietary information women with poly cystic ovarian syndrome received was often from an unregulated source. A consensus statement of evidence-based dietary advice for women with poly cystic ovarian syndrome is needed and would be a useful resource for dietitians.

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Introduction

Health promotion can lower morbidity and liabilities cost in health care today. In our practice, nurse take care of and deal with illness that patients has upon our interaction.  It is part of nurse’s duty to their patients to promote their health and wellness.  This is an essential piece of nurses practice to help prevent health risks factors and promote healthy patient outcomes.  Health promotion in nursing is how to empower patients to manage their health and control over their lives by focusing on their health and to recognized that health and illness has many dimensions. The purpose of this paper is to apply health promotion model to help nurse to understand the health behaviors and promote healthy lifestyles.

Health promotion and healthy living are an important part of reduction chronic disease. Lifestyle choices such as lack of exercise, poor dietary habits, tobacco and alcohol, are main leading cause of  chronic illness and disease. The problem of differing lifestyle lead to disease and premature deaths.  According to Van Sickle (2019), 467,00 deaths are related to high blood pressure, and tobacco use with obesity, lack of exercise results in 1 in 10 deaths. Education begins in the community to adapt healthier living choices. Healthy People 2020 and Control and Prevention (CDC) has concentrated efferent to educate in public health dept, schools, primary providers (Van Sickle,2019). In the nursing profession, nurses advocate for their patient in wellness and prevention, and educating the individual, families on healthy living will promote a reduction in disease such as hypertension, heart disease and lung disease.

The client of this paper (PE)  is a 55 year old Caucasian female that is married with three children that are in their 20’s. In her health history assessment and genogram, was identified medical issues to  (2)address in PE health and well being as well as her children was prevention of diabetes, hypertension and coronary artery disease. She has a medical history of spinal meningitis, lymes, borderline diabetic hypertension, rheumatoid arthritis and obesity.  She has trying to control these disease conditions with diet, exercise and medications.  She identifies herself as being happy with her life and considers herself religious but doesn’t rely on that when making medical decisions. Her strengths come from her family and has significant stress that occurs with work (as manager of store), she feels that it is handle well with activities like Girls Scout’s (crafts) and boating with her husband. In today’s society, both parents are working to provide financial stability to take care of their family’s basic needs for food, healthcare, and housing.

PE genogram showed that she had many family members on both her mother and father side that develop coronary artery disease, had stents and even heart attacks.  On her mother side there was 2 family members with diabetes and with PE being overweight she has diagnosed as pre- diabetic. Her grandmother was type 2 diabetic and one other aunt. PE was very anxious and terrified during the interview after she saw her health risks for heart attacks and being obese can cause more medical issues( Jarl et,.al, 2014).  She realized her risks for developing type 2 diabetes like many of her maternal relatives as it is linked to obesity and her lifestyle factors. Strengths in her self-care are getting a regular mammogram, PAP smear, seeing her primary physician for her hypertriton and pre-diabetes. She has not had a yearly eye exam and dental. She states she only performs occasional breast-self exams. The does take her medication for hypertension, but it is challenging to take it twice a day.

She will be focusing on her promoting health prevention of diabetes and well-being for today and in the future. However, positive life style changes and various treatments can reduce these risks. She reported in her health assessment that she has been overweight since she was a teenage and the last year, she has put on 40 lbs. She realizes that eating out a lot, fast foods, fried foods and lack of exercise resulted  weight gain, hypertension and now pre diabetes.  She admits a poor diet of high carbohydrate diet and drinks a lot of soda. She has family history of hypertension (genetics), fatigue, stress from work and lack of exercise which may be resulted in her having hypertension, diabetes and being overweight.

PE has been diagnosed with hypertension, as a result of information in her health history/genogram, the following health promotion/disease prevention were identified and most important to PE :  1. Healthier lifestyle eating healthy diet, reduce sodium and following DASH diet, maintaining healthy weight and increase her physical exercised. She doesn’t smoke or drink alcohol.

PE has been diagnosed as pre-diabetic. As a result of information in her health history/genogram, the following health promotion/disease prevention were identified and are most important to PE:  1. Over weight-lose weight. 2.work with coach/nutritionist to eat healthy. 3 manage her stress and stay motivated.

PE has been diagnosed with high Bmi , overweight and risk for coronary artery disease. As results of information in her health/genogram, the following health promotion/disease prevention were identified and are important to her: 1. Better management of her hypertension with reduction in blood pressure, weight loss goal of 40 lbs. 3. Start an exercise program with a coach.

3.Section 2 – Health promotion plan:

In developing a holistic integrated health promotion plan a range of health and wellbeing issues were acknowledged and identify to improve the health of PE. According to Burk(2019), “ bio-psycho-social-spiritual person is in the state of constant dynamic interaction with the environment; changes occurring in any of these aspects create change in all the other aspects of the person and the environment within which the client. When interview PE for her health history and genogram, she discovered that she had health risks based on genetics, ages, lifestyle. Her health issues, pre-diabetic, obesity and hypertension are putting her at risk for her family genetic history of heart attacks, cardiovascular disease and diabetes. She realizes there are some factors that can’t be change such as genetics, healthy aging, gender or ethnicity. Even though she sees her primary doctor on routine checks and sick, she realizes her understanding of disease and health practices limited. She started working with interprofessional team of her primary doctor, nurse, pharmacist, physician assistant, nutritionist about her diet and Health coaches for physical exercise program.

In healthcare today, nurses play a role in the multidisciplinary team. Working with the team can ensure better communication for the patient and providers. The team approach enhances patient-physician relationship with creating efficient, comprehensive and tailored healthcare plan and improving better patient outcomes (Nester,2016). The focus of the team is to ensure the social well being of the patient and improve coping mechanism. The physician can evaluate the patient for genetic assessment for risks. The nurse is responsible for ensuring the overall wellbeing coping of the patient on daily challenges.

In my nursing experience, team-base care approach improved in patient outcome and patient satisfactions. Collaborating with team about patient medical needs helped improved their care during their admission and when they were discharged. Having this experience will help with collaboration with her team of doctors, coaches and dietitian to make sure she is able to keep on track with her plan, goals and ensure she is able to obtained her weight loss to reduce her disease of hypertension and pre diabetes. . She realizes that she will need to meet every 2 -4 weeks with the team to achieve her weight loss goal of 40 lbs and maintain a healthy lifestyle

In healthcare, it is essential that nurse understand the different cultural beliefs, values of patient that they view on health, wellness and death.  If there is a language barrier, having an interpreter there or language line will help ensure that they understand their medical needs are address and incorrupt into plan of care. In taking care of patients, it is important to show respect, responsibility, and compassionate good care.  Nurses have to have critical thinking and problem-solvers when taking care of their patients, integrate information, outcomes and experience into plans and solutions for patients.

In healthcare effective communication is important on the quality of patient outcomes, satisfaction and decrease adverse outcomes.  Communication tools with use of white board/goal sheets share information about patient goals, concerns and plans. Team rounds with the doctors, nurses and social workers are performed at the facility where I work every day. According to Turin (2015), collaboration with professionals in the community resources, agency and program for patients to access improve patient outcomes.

The following planning steps are meant to be a guide for developing a health plan for PE;  her goal: to improved  cardiovascular disease and quality of life through detection, prevention and treatment of risk factors for heart attack and with reduction in her hypertension. Identifying her risk factor for disease or disorder that can be decrease or eliminated with modified health behavior is part of plan. Risk factors are related to poor life style choices, poor dietary habits, less than five portions of fruits and vegetables a day and motivation. Having a body mass more than 25%-(her 35.8). According to Mortin (2013),that there are health promotions that work together for patients to be successful: education, medical, behavior modification societal change and client-center.

Disease prevention priority issues

1. The risk for coronary artery disease related to obesity, poor manage hypertension, as evidence by secondary lifestyle, obesity poor diet, missed dose of antihypertension medicine.

2. The risk for diabetes type 2 related to her obese, pre- diabetic, hypertension, weight gain as evidence by poor diet, poor administration of antihypertensive medications.

3. The risk for hypertension related to her genetic predisposition by paternal uncles diagnose with hypertension, cardiac stents, being overweight, her age and poor diet.

NIC

1. Cardiac Risk Management 4050 (NIC)

1. Instructed the patient and families on strategies for healthy-heart diet with the use of a dietician incorporating the patient culture and personal experience.

2Instruct the patient on the need to achieve exercise goals in incremental periods of 10 minutes multiple times daily, if tolerant to sustained 30-minute activities in collaboration with an exercise physiologist.

3. Instruct the patient on patient and family on therapies to reduce cardiac risks to include medication regimens with the collaboration of her employer health coach program that provides phone apps that remind patient to take their medications.

• Goal Example: Pt reduce her blood pressure down to 130/80 at recheck in 4 weeks.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnic/cardiac_risk_management_4050/0

2. Health Screening 6520 (NIC, 2013)

1. Instruct on the rationale and purpose of health screening and self-monitoring in collaboration with an optometrist and nutritionist.

2. Provide appropriate self-monitoring information during screening in collaboration with the health coach monitoring labs, weight, and blood pressure readings with positive reinforcement.

• Goal Example: Pt will have followed up blood work, blood pressure reading in 4 weeks.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnic/health_screening_6520/0

3. Nutritional Counseling 5246(NIC,2013)

1..Determine patient’s food intake and eating habits

Establish realistic short-term and long-term goals for change in the nutritional status Discuss nutritional requirements and patient’s perceptions of the prescribed/ recommended diet

2.Discuss nutritional requirements and patient’s perceptions of the prescribed/ recommended diet

• Goal Example- Pt will meet with dietician in 4 weeks to review diet, and weight loss plan.
  
  https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnic/weight_management_1260/0
  

NOC

1.     Risk Control: Cardiovascular Disease 1914 (NOC, 2013).

1. The patient will return in 4 weeks to be weighed again with 4-8  pound weight loss and adherence to her twice a day antihypertensive medications after making contact with her health coach, exercise physiologist and dietician. The patient will use technology apps to help remind her to take her medications.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnoc/risk_control_cardiovascular_disease_1914/0

2. Risk Control : weight Loss Behavior 1627 (NOC,2013) – assisted with healthy eating plan, and control food portions. She needs to establish an exercise routine. Patient will follow up with dietician and health coach in 3 weeks with weekly log of weigh loss.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnoc/weight_loss_behavior_1627/0

3.  Exercise Participation 1633 (NOC, 2013)- to maintain adequate physical activity.  Since she hardly performs any kind of exercise, we set some goals that can tie into his schedule. Patient will keep a log of how much weight loss each week (3 lbs), then follow up with physical coach.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnoc/exercise_participation_1633/0

4. Knowledge: Healthy Diet1854 (NOC,2013)- to assist with making better food choices.  This is to make sure that she knows what is healthy, and how she can enjoy what she wants with some healthier adjustments. Pt will work with dietician on DASH diet to reduce her hypertension, and low carbohydrate diet with follow up visit in 2 week.

https://search-credoreference-com.vlib.excelsior.edu/content/entry/ehsnoc/knowledge_healthy_diet_1854/0

Evaluation of the Health Promotion Plan

PE will return in 4 weeks to be re-weight with a weight loss of 4-8 lbs. She will present a daily food, exercise and weight log that twill demonstrate well balance meals and progressing towards healthy body weight and BMI.  She will verbalize the utilization of a support group and dietician. She will be weighing and calculate new BMI. She will return in one month to determine if she is meeting targets and goals, what strategies she is finding success with, and if there is anything still hindering her.  She will have her daily log of her blood pressure with goal from 150/90 down to 120/80. She will have rechecked of blood work and check of her blood sugar to ensure that she is down to 70-110 range.

Client feedback questionnaires after undergoing the interventions in a month will be influential in evaluating the effectiveness of the health promotion plan. The sessions will be conducted twice a week for four weeks, and the questionnaires will be filled in the fourth week. An analysis of client feedback will help to understand whether they have benefited from the health promotion program and continually analyze the effectiveness intervention as needed

Section 4: Research Integration:

One of the highest risk factors for cardiovascular disease is hypertension. Obesity and hypertension are often link in adults and 53.5 percent that have hypertension are poorly controlled ( Jarl et.al.,2014).  Obesity in U.S. is more than 30 % and Healthy 2020 object is to decrease to 15 % in adults. (p.499). Addressing these health issues in primary care setting, healthcare professional have opportunity to promote healthy life styles through diet, weight control, and physical activities. They working towards improving hypertension and cardiovascular disease prevention in clinical setting. According to Jarl, et.al(2014), Nurse Practitioners(NP) focus on interventions on counseling on  diet, lifestyle that had a measurable impact on group that had hypertension and were overweight. Interventions on education of low sodium diet ( DASH-Dietary Approaches to Stop Hypertension),and lifestyle changes over 2 months.  The patients had 45 minutes counseling in group classes and two 20 minutes phone consult lead by NP.  Patients that used the DASH diet had weight and BMI reduction. There was weight loss of 3.6 lbs over 8 weeks period. The study used measure outcomes that included REAP and PIH. Another health issues that my client family history had was Cardiovascular disease (CVD).Risk factors that people can’t change is genetic, age, gender. Modified-risk factor that people can change is smoking, weight, blood pressure and high lipid protein levels.  According to Imes, & Lewis.(2014), 32.8 % of deaths are from CVD and perceived risks important to change healthy behavior. Its important that they know how the risks affect them and health related behaviors reduce their risks. According to Turin( 2015), in adults with health issues, there is a decrease in physical activity. Intervention with counseling and education to with understanding of patient circumstance to develop a exercise prescription. Methods they used were internet guide to physical activity and NP were motivators/ facilitators to their program. They were able to collaborate and found community resource for their physical plan. Brisk walking 20 minutes, 5 times a week in am before work, 2 day a week in evening and weekends. Health promotion with lifestyle changes, strategies to prevent disease and improve patient outcomes. Education and diet along with attaining healthy lifestyle, can reduce risk of hypertensions and obesity. The articles give strategies and plans that can help improve nurses knowledge and

Conclusion

It’s important to maintain a healthy life style to reduce the risk for heart attack. By exercising regularly, monitoring cholesterol level, hypertension and reduce fatty foods can reduce risk to getting the disease.  While healthy habits should be encouraged despite the risk factors, understanding what is genetic in your family give you the heads-up screening/lifestyle habits and possibility to prevent the disease.

References

• Burke, A.(2019. Health Promotion and Disease Prevention: Nclex RN. Registered Nursing. August 8, 2019. Retrieved from: https://www.registerednursing.org/nclex/health-promotion-disease-prevention/
• CdC. (2018).  The CDC Guide to Strategies to Increase Physical Activity in the Community. May 8, 2018. Retrieved from:
  
  https://www.cdc.gov/obesity/resources/strategies-guidelines.html
  
• Healthy 2020. (2019). Nutritional and Weight status. ODPHP. Retrieved from:  Health.gov
• Nester, J. (2016). The Importance of Interprofessional Practice and Education in the Era of Accountable Care. North Carolina Medical Journal. March-April, 2016. 77, 128-132. Retreived from:
  
  https://ncmedicaljournal.com
  
• Imes, C. C., & Lewis, F. M. (2014). Family History of Cardiovascular Disease, Perceived Cardiovascular Disease Risk, and Health-Related Behavior.
  
  Journal of Cardiovascular Nursing
  
  ,
  
  29
  
  (2), 108. Retrieved from:
  
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