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Blood pressures plus
Blood Pressures Ru: LENORE WEINSTEIN On prominent display at College Court, a subsidized high-rise apartment complex for the elderly, is this motto, " Y o u t h is a gift of nature but age is a work of a r t . " Nursing students who have been taking part in a blood pressure screening program at this facility have come to appreciate the truth of that saying. So, too, have the residents come to appreciate the presence of these students and the services they offer. Within its 251 apartments, College Court houses 264 elderly men and women. Eligibility for residence is based on age, disabilities, income, and savings. T h e blood pressure program began in 1974, when t h e residents asked their landlord, the Milwaukee Housing Authority, for such a program. The authority contracted with Marquette University for this service, which the school of nursing was glad to provide because it represented an additional community health experience for senior graduate students. T h e advantages of such an experience for both the client and the nurse, have already been d o c u m e n t e d ( I - 4 ) . The blood pressure screening clinics are held once a week, from 1:00 to 4:00 P.M., in the College Court lounge. Some 85 persons are seen each time; later, the students visit those residents who, because of health, mobility, or personal problems, cannot come to the lounge. Each semester, before the program begins, the students are given an orientation tour, and the differ-
W h e n this article was written, Lenore Weinstein, R.N., M.A., was a clinical instructor at M a r q u e t t e University College of N u r s i n g , Milwaukee, Wis., a n d was responsible for the s t u d e n t s taking part in the prog r a m described here. S h e is now in Israel, on leave of absence.
188 Geriatric Nursing May/June 1981
A Marquette University student nurse takes the blood pressure of one of the 85 high-rise apartment dwellers who attend the weekly screening clinic.
In the privacy of her own apartment, a College Court resident tells a student the outcome of a recent referral for further studies.
ences between this facility and a care-giving facility such as a nursing home are discussed. At College Court the residents are independent and self-sufficient, with such amenities as pull cords in the bedrooms and bathrooms, grab bars in tub and showers, and light
switches low on the wall for those in wheelchairs. As part of a monitoring system, residents have " I ' m O k a y " cards, which they hang on the outside of their doors when they retire and remove the next morning. Bulletin 13oards call their attention to educa-
Yes, the students check blood pressure for the elderly, but they also counsel, teach and grow through the experience.
tional opportunities, health and screening clinics, nutrition programs, and other community resources available to older adults. T h e students also meet with a nurse from the health department, to exchange information about resi-
I'M
(D dents who are being seen by the public health nurse and to establish procedures to follow if there is a need for collaboration or referral.
Ready and Waiting M a n y residents are already on hand when the students arrive for each clinic session. Each student takes a table and the residents seat themselves around it. The students talk with them individually, take their pulse and blood pressure, and record the findings for each person on a separate 5 x 7 index card. Often the residents ask the students to record the results on their own personal records. T h e average visit takes about five minutes, but the students spend more time with residents coming to the clinic for the first time, so they can take a more detailed health history. Referrals for the residents whom the students visit in their apartments come from m a n a g e m e n t
staff, other residents, social workers, community aides, or friends. Students also visit those who recently had increased blood pressure or other problems, but priority is given to the referrals and to those who have recently returned from the hospital. Lastly, they visit those residents who have not been seen for a long time. After each home visit, the students review the situation with the instructor. Usually this is not done in the clinic sessions; the instructor is consulted only if the student or resident is experiencing some special difficulty. T h e instructor does not herself provide nursing service, except in a crisis. H e r primary function is to guide, assist, and counsel the student. Some residents have been attending these screening clinics for several years. As more or less typical examples, the monthly blood pressure readings for three of them have been graphed, accompanied by observations from the students' notes recorded at the time of specified pressure readings (see following pages).
Students Feel "Needed" Heiler and Walsh have reported that " . . . a program of study requiring that nursing students have frequent contacts and planned experiences with essentially 'well' older people in visiting and activities is effective in inducing change in attitudes towards old people and preferences for working with old people"(5). Our students have almost unanimously confirmed that observation. Most of them said that it had been a " g o o d " experience. T h e y were able, for instance, to talk to the well elderly, to see the difference between life-styles in a highrise a p a r t m e n t and a single family house or nursing home, and to note the varying activity levels of the residents, ranging from those who
were homebound to those who were active participants in the community, volunteering their time to help others. Two students who had visited older, bedridden clients at home during their experience with a visiting nurses association were impressed by the differences between these "sick" persons and the "well" elderly in the high-rise. Students were also impressed by how friendly and receptive the residents were, their motivation to attend the clinic, and their interest in their blood pressure. Students enjoyed the experiences for other reasons as well. It was a complete c h a n g e from previous clinical encounters; they had a chance to meet many different types of people; they felt physically protected and secure; and they became actively involved with health promotion and preventive health measures. This setting, the students said, enabled them to accomplish many of the course objectives related to health teaching, case-finding, collaboration, referrals, and use of community resources. Most students saw the experience as a way to become involved in the community, making them aware of an aspect of community health that they previously did not realize existed. One student said the experience "sharpened up" her interviewing techniques, because she had to gather much information in a short time. Problems and Concerns But there were also frustrations and problems. All the students, for instance, were distressed by the large numbers of clients waiting at each clinic session. Most residents are finished with lunch a little after 12 o'clock and must then wait almost an hour until the clinic opens~.They all want to be seen as quickly as possible and
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m a n y want to be seen "first." T h e students try to handle the situation as tactfully as possible, but they often feel " r u s h e d and hassled" and say it prevents t h e m from spending as m u c h time as they believe is necessary with each person. Students complain, too, that the 5 x 7 index cards hold only minim u m information. T h e y believe that a m o r e complete history would be helpful, and they must be reminded that this is only a screening clinic, not a diagnostic center, and that detailed records are therefore not necessary. A n o t h e r problem reported by the students is their difficulty in persuading some of the residents to keep their regular physicians' appointments even though they are attending the clinics and their findings are within normal range. In addition, when the students m a k e referrals for one service or another, some residents either i m m e d i a t e l y decline the referral or do nothing a b o u t it. W e have to remind the students that it is the individual client's right to accept or refuse the referral. This also holds true for residents who refuse to have their pressure checked or will not permit a home visit. On several occasions, for in-
190 Geriatric Nursing May/June 1981
2/80
Diabetic on oral meds. Having dental work at Marquette University clinic, Has new dentures. Adjusting quite well. Complaining of sharp pain in right leg, but states he has this frequently in the winter months. Has a "miserable" cold Referred to doctor. Blood sugar 136. (Accepted referral). Appointment made at clinic. Taking blood pressure reeds daily. No complaints. Trying to watch diet because of diabetes_ Wife was placed in nursing home. Encouraged to call doctor to report increased blood pressure. Talked to primary nurse and reported last two blood pressures. New prescription started--hydrochlorothiazide. Feeling good. Diabetes under control. Appointment at clinic to have toenails cut. Takes "water pills" t.i.d. Taking hypoglycemics. Feels g o o d - - n o complaints.
stance, m a n a g e m e n t staff, the public health nurse, and the students have all referred Ms. N. for homem a k i n g services. Ms. N. reluctantly agrees but, when the h o m e m a k e r arrives, she refuses to let her in. Everyone gets f r u s t r a t e d and annoyed, but the students continue to see her each week. S o m e students question whether the clinics are needed every week or whether the s a m e residents (if they do not have high blood pressure) should be permitted to come each time. W e encourage the students to consider the p r o g r a m ' s other benef i t s - f o r example, socialization and diversion. Students are distressed, of course, when a resident's condition deteriorates to the point where he or she m u s t be moved to a m o r e protected environment, or when one of t h e m dies. As the instructor for these students, I, too, have formed relationships with some of the residents; it seems to help when the students know I share their distress or grief, and we work it out together. Residents' Reactions A f t e r five years of hearing the residents c o m m e n t informally that they appreciated this service, we
asked t h e m to fill out a questionnaire about the p r o g r a m . It was not intended as a research t o o l - - i n fact, it couldn't be used for that purpose, as m a n y residents did not answer all the questions. But we hoped it would elicit some specific information and suggestions. Residents were asked a b o u t their attendance at the clinics, the services provided by the students, and w h a t they liked or did not like about the p r o g r a m (or students). Over half of the 96 residents responding reported attending the clinic at least once or twice a month; m o r e than half had been coming for over a year. Only about one-third had high blood pressure, and f e w had a history of heart disease, yet they kept coming and m a n y kept records of their blood pressures. T h e y were unanimously enthusiastic a b o u t the students' services. While they perceived these as primarily a m a t t e r of blood pressure and pulse checks, they also added such c o m m e n t s as the students are " e a g e r to be helpful" and they " c o m f o r t and share withPyou." Those visited in their a p a r t m e n t s seemed particularly appreciative. In fact, m a n y were concerned that the questionnaire m e a n t that con-
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sideration was being given to terminating the program. W e reassured them that this was not the case. Overall Evaluation
T h e initial inducement for the school of nursing to make this arrangement was the opportunity to establish blood pressure screening clinics. Public education has successfully promoted the campaign against high blood pressure. People flock to get their blood pressures taken, as is evidenced by the attendance at College Court. (Imagine what other aspects of health promotion could be achieved if the media and the health professional pushed the issue.) In reality, the students spend less than half their time in such activities, also teaching the residents informally about nutrition, diet, medications, (how to take or not take them as well as side effects of specific drugs), blood pressure, skin care, and the like. Yet blood pressure and pulse checks represent a "hands on" experience, a tangible activity that the residents see as a needed service. As an educational experience, however, these screening clinics offer considerably more. T h e students are involved in both primary
9/79 2/80
No medications except eye drops. Wears hearing aid. Bladder infection--on antibiotics. Takes pain pill every night for arthritis. Up about three times a night to urinate. Saw doctor this week. Feels well aside from having a cold. Takes 2 arthritis pills daily. Complaining of sore t h r o a t - - h a s laryngitis. On arthritis med PRN. Doctor aware of blood pressure levels. Takes pain reeds for arthritis of the spine. As busy and active as ever. No complaints Sinus problems. Complaining of back pain; has new pills for this but they are causing constipation. Takes castor oil for this. Complaining a b o u t b a c k pain from arthritis. Is in touch with doctor. New pills for arthritis are helping much. Takes pills for arthritis. Uses Bengay.
and secondary prevention---each of them significant to this age group. Recently, we have expanded the program to enable students to hold formal group teaching sessions about health promotion with well older adults. Secondary prevention involves screening, case-finding, and early detection of disease. W e have several examples to document our success here. T h e students also teach about specific disease processes, such as hypertension, arthritis, heart disease, and other chronic illnesses c o m m o n among this age group. In doing so, they meet m a n y of the c o m m u n i t y health nursing course objectives. T h e y use the nursing process, do health teaching, health promotion, and counseling; refer clients; and learn to use c o m m u n i t y resources as well to be active participants themselves within a community setting. W h a t ' s more, the students perceive themselves as doing so! A setting like this is a potential powerhouse from a nursing education perspective. It can be used to achieve objectives for all levels of nursing, ranging from the beginning s t u d e n t s - - w h o can improve their technical skills (taking blood
pressure and pulse), communication, and interviewing t e c h n i q u e s - to the senior student, who can take detailed health histories, do physical and health assessments, and apply the nursing process to its fullest extent. This has been a satisfying experience for all concerned. T h e residents receive the services they desire and need; the students have a positive and enjoyable learning experience; and the educator's objectives are accomplished. References 1. Francis, M. B. Need community clinical experiences? Ask the senior citizens. N u r s e Educ. 3:22-24, Mar.-Apr. 1978, 2. Sullivan, J. A., and Armignacco, Felice. Effectiveness of a comprehensive health program for the well-elderly by community health nurses. Nurse.Res. 28: 70-75, Mar.-Apr. 1979. 3. Benson, E. R., and McDevitt, J. Q. Know your community resources: nursing service and nursing education: coaction to meet the health needs of the elderly. J.GerontoI.Nurs. 4:20-24, May-June 1978. 4. Figgins, Paula. Community nursing: t screen now--benefit later. N u r s . M t r for 149:24-25, Aug.30, 1979. 5. Heller, B. R., and Walsh, F. J. Changing nursing students' attitudes towards the aged: an - experimental study. J.Nurs.Educ. 15:9-'17, Jan. 1976.
Geriatric Nursing May/June 1981 191
W h e n this article was written, Lenore Weinstein, R.N., M.A., was a clinical instructor at M a r q u e t t e University College of N u r s i n g , Milwaukee, Wis., a n d was responsible for the s t u d e n t s taking part in the prog r a m described here. S h e is now in Israel, on leave of absence.
188 Geriatric Nursing May/June 1981
A Marquette University student nurse takes the blood pressure of one of the 85 high-rise apartment dwellers who attend the weekly screening clinic.
In the privacy of her own apartment, a College Court resident tells a student the outcome of a recent referral for further studies.
ences between this facility and a care-giving facility such as a nursing home are discussed. At College Court the residents are independent and self-sufficient, with such amenities as pull cords in the bedrooms and bathrooms, grab bars in tub and showers, and light
switches low on the wall for those in wheelchairs. As part of a monitoring system, residents have " I ' m O k a y " cards, which they hang on the outside of their doors when they retire and remove the next morning. Bulletin 13oards call their attention to educa-
Yes, the students check blood pressure for the elderly, but they also counsel, teach and grow through the experience.
tional opportunities, health and screening clinics, nutrition programs, and other community resources available to older adults. T h e students also meet with a nurse from the health department, to exchange information about resi-
I'M
(D dents who are being seen by the public health nurse and to establish procedures to follow if there is a need for collaboration or referral.
Ready and Waiting M a n y residents are already on hand when the students arrive for each clinic session. Each student takes a table and the residents seat themselves around it. The students talk with them individually, take their pulse and blood pressure, and record the findings for each person on a separate 5 x 7 index card. Often the residents ask the students to record the results on their own personal records. T h e average visit takes about five minutes, but the students spend more time with residents coming to the clinic for the first time, so they can take a more detailed health history. Referrals for the residents whom the students visit in their apartments come from m a n a g e m e n t
staff, other residents, social workers, community aides, or friends. Students also visit those who recently had increased blood pressure or other problems, but priority is given to the referrals and to those who have recently returned from the hospital. Lastly, they visit those residents who have not been seen for a long time. After each home visit, the students review the situation with the instructor. Usually this is not done in the clinic sessions; the instructor is consulted only if the student or resident is experiencing some special difficulty. T h e instructor does not herself provide nursing service, except in a crisis. H e r primary function is to guide, assist, and counsel the student. Some residents have been attending these screening clinics for several years. As more or less typical examples, the monthly blood pressure readings for three of them have been graphed, accompanied by observations from the students' notes recorded at the time of specified pressure readings (see following pages).
Students Feel "Needed" Heiler and Walsh have reported that " . . . a program of study requiring that nursing students have frequent contacts and planned experiences with essentially 'well' older people in visiting and activities is effective in inducing change in attitudes towards old people and preferences for working with old people"(5). Our students have almost unanimously confirmed that observation. Most of them said that it had been a " g o o d " experience. T h e y were able, for instance, to talk to the well elderly, to see the difference between life-styles in a highrise a p a r t m e n t and a single family house or nursing home, and to note the varying activity levels of the residents, ranging from those who
were homebound to those who were active participants in the community, volunteering their time to help others. Two students who had visited older, bedridden clients at home during their experience with a visiting nurses association were impressed by the differences between these "sick" persons and the "well" elderly in the high-rise. Students were also impressed by how friendly and receptive the residents were, their motivation to attend the clinic, and their interest in their blood pressure. Students enjoyed the experiences for other reasons as well. It was a complete c h a n g e from previous clinical encounters; they had a chance to meet many different types of people; they felt physically protected and secure; and they became actively involved with health promotion and preventive health measures. This setting, the students said, enabled them to accomplish many of the course objectives related to health teaching, case-finding, collaboration, referrals, and use of community resources. Most students saw the experience as a way to become involved in the community, making them aware of an aspect of community health that they previously did not realize existed. One student said the experience "sharpened up" her interviewing techniques, because she had to gather much information in a short time. Problems and Concerns But there were also frustrations and problems. All the students, for instance, were distressed by the large numbers of clients waiting at each clinic session. Most residents are finished with lunch a little after 12 o'clock and must then wait almost an hour until the clinic opens~.They all want to be seen as quickly as possible and
M~ W~,. ;~1. who la~L.~~ m ~ a_~1~I(~1 th~ blqod~preesuce ~.~eening clinic ~r~xr 19"15~~ _v~y~smgr162 a~lt~-rr lrae~nur~~IUI~QIS:tBf_~i'r~ l h l m ' l O / l ~ f t n l ~ ~ l ~ e~ali~ltB 'tlir of
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m a n y want to be seen "first." T h e students try to handle the situation as tactfully as possible, but they often feel " r u s h e d and hassled" and say it prevents t h e m from spending as m u c h time as they believe is necessary with each person. Students complain, too, that the 5 x 7 index cards hold only minim u m information. T h e y believe that a m o r e complete history would be helpful, and they must be reminded that this is only a screening clinic, not a diagnostic center, and that detailed records are therefore not necessary. A n o t h e r problem reported by the students is their difficulty in persuading some of the residents to keep their regular physicians' appointments even though they are attending the clinics and their findings are within normal range. In addition, when the students m a k e referrals for one service or another, some residents either i m m e d i a t e l y decline the referral or do nothing a b o u t it. W e have to remind the students that it is the individual client's right to accept or refuse the referral. This also holds true for residents who refuse to have their pressure checked or will not permit a home visit. On several occasions, for in-
190 Geriatric Nursing May/June 1981
2/80
Diabetic on oral meds. Having dental work at Marquette University clinic, Has new dentures. Adjusting quite well. Complaining of sharp pain in right leg, but states he has this frequently in the winter months. Has a "miserable" cold Referred to doctor. Blood sugar 136. (Accepted referral). Appointment made at clinic. Taking blood pressure reeds daily. No complaints. Trying to watch diet because of diabetes_ Wife was placed in nursing home. Encouraged to call doctor to report increased blood pressure. Talked to primary nurse and reported last two blood pressures. New prescription started--hydrochlorothiazide. Feeling good. Diabetes under control. Appointment at clinic to have toenails cut. Takes "water pills" t.i.d. Taking hypoglycemics. Feels g o o d - - n o complaints.
stance, m a n a g e m e n t staff, the public health nurse, and the students have all referred Ms. N. for homem a k i n g services. Ms. N. reluctantly agrees but, when the h o m e m a k e r arrives, she refuses to let her in. Everyone gets f r u s t r a t e d and annoyed, but the students continue to see her each week. S o m e students question whether the clinics are needed every week or whether the s a m e residents (if they do not have high blood pressure) should be permitted to come each time. W e encourage the students to consider the p r o g r a m ' s other benef i t s - f o r example, socialization and diversion. Students are distressed, of course, when a resident's condition deteriorates to the point where he or she m u s t be moved to a m o r e protected environment, or when one of t h e m dies. As the instructor for these students, I, too, have formed relationships with some of the residents; it seems to help when the students know I share their distress or grief, and we work it out together. Residents' Reactions A f t e r five years of hearing the residents c o m m e n t informally that they appreciated this service, we
asked t h e m to fill out a questionnaire about the p r o g r a m . It was not intended as a research t o o l - - i n fact, it couldn't be used for that purpose, as m a n y residents did not answer all the questions. But we hoped it would elicit some specific information and suggestions. Residents were asked a b o u t their attendance at the clinics, the services provided by the students, and w h a t they liked or did not like about the p r o g r a m (or students). Over half of the 96 residents responding reported attending the clinic at least once or twice a month; m o r e than half had been coming for over a year. Only about one-third had high blood pressure, and f e w had a history of heart disease, yet they kept coming and m a n y kept records of their blood pressures. T h e y were unanimously enthusiastic a b o u t the students' services. While they perceived these as primarily a m a t t e r of blood pressure and pulse checks, they also added such c o m m e n t s as the students are " e a g e r to be helpful" and they " c o m f o r t and share withPyou." Those visited in their a p a r t m e n t s seemed particularly appreciative. In fact, m a n y were concerned that the questionnaire m e a n t that con-
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sideration was being given to terminating the program. W e reassured them that this was not the case. Overall Evaluation
T h e initial inducement for the school of nursing to make this arrangement was the opportunity to establish blood pressure screening clinics. Public education has successfully promoted the campaign against high blood pressure. People flock to get their blood pressures taken, as is evidenced by the attendance at College Court. (Imagine what other aspects of health promotion could be achieved if the media and the health professional pushed the issue.) In reality, the students spend less than half their time in such activities, also teaching the residents informally about nutrition, diet, medications, (how to take or not take them as well as side effects of specific drugs), blood pressure, skin care, and the like. Yet blood pressure and pulse checks represent a "hands on" experience, a tangible activity that the residents see as a needed service. As an educational experience, however, these screening clinics offer considerably more. T h e students are involved in both primary
9/79 2/80
No medications except eye drops. Wears hearing aid. Bladder infection--on antibiotics. Takes pain pill every night for arthritis. Up about three times a night to urinate. Saw doctor this week. Feels well aside from having a cold. Takes 2 arthritis pills daily. Complaining of sore t h r o a t - - h a s laryngitis. On arthritis med PRN. Doctor aware of blood pressure levels. Takes pain reeds for arthritis of the spine. As busy and active as ever. No complaints Sinus problems. Complaining of back pain; has new pills for this but they are causing constipation. Takes castor oil for this. Complaining a b o u t b a c k pain from arthritis. Is in touch with doctor. New pills for arthritis are helping much. Takes pills for arthritis. Uses Bengay.
and secondary prevention---each of them significant to this age group. Recently, we have expanded the program to enable students to hold formal group teaching sessions about health promotion with well older adults. Secondary prevention involves screening, case-finding, and early detection of disease. W e have several examples to document our success here. T h e students also teach about specific disease processes, such as hypertension, arthritis, heart disease, and other chronic illnesses c o m m o n among this age group. In doing so, they meet m a n y of the c o m m u n i t y health nursing course objectives. T h e y use the nursing process, do health teaching, health promotion, and counseling; refer clients; and learn to use c o m m u n i t y resources as well to be active participants themselves within a community setting. W h a t ' s more, the students perceive themselves as doing so! A setting like this is a potential powerhouse from a nursing education perspective. It can be used to achieve objectives for all levels of nursing, ranging from the beginning s t u d e n t s - - w h o can improve their technical skills (taking blood
pressure and pulse), communication, and interviewing t e c h n i q u e s - to the senior student, who can take detailed health histories, do physical and health assessments, and apply the nursing process to its fullest extent. This has been a satisfying experience for all concerned. T h e residents receive the services they desire and need; the students have a positive and enjoyable learning experience; and the educator's objectives are accomplished. References 1. Francis, M. B. Need community clinical experiences? Ask the senior citizens. N u r s e Educ. 3:22-24, Mar.-Apr. 1978, 2. Sullivan, J. A., and Armignacco, Felice. Effectiveness of a comprehensive health program for the well-elderly by community health nurses. Nurse.Res. 28: 70-75, Mar.-Apr. 1979. 3. Benson, E. R., and McDevitt, J. Q. Know your community resources: nursing service and nursing education: coaction to meet the health needs of the elderly. J.GerontoI.Nurs. 4:20-24, May-June 1978. 4. Figgins, Paula. Community nursing: t screen now--benefit later. N u r s . M t r for 149:24-25, Aug.30, 1979. 5. Heller, B. R., and Walsh, F. J. Changing nursing students' attitudes towards the aged: an - experimental study. J.Nurs.Educ. 15:9-'17, Jan. 1976.
Geriatric Nursing May/June 1981 191