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Factors contributing to a nursing protocol on hypertensive patients with essential and secondary hypertension
hl. J. Nun. Stud. Vol. 16, pp. 329-336 0 Pergamon Press Ltd., 1979. hinted
in Great Britain
Factors contributing to a nursing protocol on hypertensivepatients with essentialand secondary hypertension RITA F. STEIN, Ph.D., CAROL L. MILLER, Ed.D. and CLARENCE E. GRIM, M.D. Nursing Research Department, Indiana University School of Nursing, Room 318, 1100 West Michigan Street, Indianapolis, Indiana 46202, U.S.A.
Nursing protocols are currently being used to guide practitioners in the care of clients in their use for the collection of data and recommendations for specific actions. Starting with a medical complaint, each step within the protocol is dependent on preceding responses or physical findings. What historical and physical information the nurse is to collect and what action the nurse is to take are generally based on two considerations: one is the frequency of a condition or a diagnosis sought; the other is the importance or value placed on making the diagnosis or defining the condition. The authors’ concern in this article is for the development of possible steps in a nursing protocol for the hypertensive patient with essential and secondary hypertension. The distribution of hypertensive patients’ medical complaints should serve as an index for a nursing protocol. There has been much confusion in the study of hypertension, involving many factors for consideration in the etiology of this disease. Various factors such as age, diet, race, sex, disease, obesity and heredity have been reported to be associated with elevated blood pressure (Henry and Cassel, 1969). Hypertensive patients may have symptoms related to their disease or its treatment. The objectives of this study are (1) to identify factors associated with physical and psychological symptoms of a group of heterogeneous hypertensive patients and (2) to determine which, if any, physical and psychological symptoms are of value in discriminating the essential from the secondary hypertensive patient. The distribution of the hypertensive patients’ complaints could serve as a means for the development of a nursing protocol from the following index. The Cornell Medical Index (CMI), a health questionnaire, was selected to examine the patient’s symptom complexes and the function of their symptoms in discriminating the essential from the secondary forms of hypertension. Hypertension has often been called the “silent disease”. During the silent period of this disease, hypertension is a symptomless, but dangerous disease (Genest, Koiw and Kuchel, 329
330
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
1977; Page, 1972). Clinical studies indicate that symptoms are unusual in the patient with mild or moderately severe essential hypertension (Kirkendall and Nottebohm, 1977). Kirkendall et al. (1977) described studies of headache, breathlessness, epistaxis, tinnitus, dizziness and migraine where the relationship of these symptoms to hypertension was not settled. Dollery and Bulpitt (1977) and Peart (1977) described the relevant long-term effect symptoms to be asked about hypertensive complications as follows: angina, intermittent depression, dyspnea on exertion, nocturia, paroxysmal nocturnal dyspnea, dysuria, ankle edema, hematuria, transient paresis, weakness in limbs, cerebrovascular accident, migraine, unsteadiness on standing in the morning, headache, epistaxis, cramps in feet and calves. Page (1972) recognized that no one would deny that the long-term effects of elevated blood pressure on the heart and blood vessels are manifested eventually in signs and symptoms of stroke, myocardial infarction and cardiac and renal failure. Grim, Weinberger, Higgins and Kramer (1977) concentrated on an efficient way for the medical practitioner to examine and accurately diagnose the hypertensive patient for renal artery stenosis and primary aldosteronism. They concluded that of the 236 hypertensive patients evaluated, their comprehensive protocol permitted identification of patients with renal artery stenosis, with primary aldosteronism, with high renin, with normal renin, and with low renin essential hypertension. Many of these hypertensive patients are subjects in the present study. Greenfield (Bullough, 1975) described the nursing protocol as having one of three outcomes for a final decision about the individual patient. One outcome was to refer the patient to the physician because of complexity of health care management; another outcome was that the physician reviews the outcome data and assumes the examination of one or more of the physical findings; and the third outcome was the recommendation that the patient may be sent home without seeing the physician. Greenfield (Bullough, 1975) stated, “If the nurses using a protocol are as effective as physicians in a well-controlled trial, we would say that the protocol administered by a nurse is an adequate mode of delivery of care.”
Sampling
All patients were previously hospitalized for investigation of the cause of their hypertension. At that time the diagnostic protocol was used, as developed by Grim et al. (1977). The hypertensive subjects consisted of each sex (male, N= 109, and female, N= 127) and race (black, N= 38, and white, N= 198). The study group was composed of essential and labile hypertensive patients, N= 187, primary aldosteronism, N= 22, and renovascular hypertensive patients, N=27. The essential hypertension group was also composed of high, N= 31, normal, N= 85, and low renin, N= 50. Age ranged from 18 to 78 yr. & Cornell Medical Index The CM1 Health Questionnaire was devised as an instrument suitable for collecting a body of medical and psychiatric data. The authors stated that this can serve as a standardized instrument to meet the needs of a medical history. It has been found useful in medical and psychological research to investigate incidence of symptoms in medical disorders with a reproducibility of 0.83 (Brodman, Erdmann and Wolff, 1949). The CM1 contains 195 questions in informal language which can be understood by per-
NURSING PROTOCOL ON PATIENTS WITH ESSENTIAL AND SECONDARY HYPERTENSION
331
sons with a reading knowledge of simple English. After each question a “yes” or “no” answer is given by circling one or the other. Questions are of four kinds: those relating to body symptom, those to past illnesses, family history and behavior, mood and feeling. Patients answer this questionnaire in lo-30 minutes. Male and female forms were used by the appropriate sex. Questions correspond to those asked in a detailed and comprehensive medical examination. The wordings that yielded answers in oral interview were included on the form. The questions were tested on several groups of patients at New York Hospital (Brodman et al., 1949). These responses were compared to those on the hospital patients’ records. They corresponded closely with those questions asked in oral interview. The CM1 collected data recorded in the hospital record and, in addition, a body of data omitted from patients’ oral histories (Brodman et al., 1949). Method The CM1 was administered to 236 hypertensive patients for factor analysis of the collected data on physical and psychological symptoms and for discriminant analysis of essential and secondary hypertensive patients with their recognized symptoms. The CM1 forms were mailed to 386 patients at their most recent home address. A postcard reminder was sent three weeks later. A total of 236 completed questionnaires were returned.
Factor analysis and discriminant
analysis
Factor analysis is a method of analyzing a set of observations from their intercorrelations to determine whether the variations represented can be accounted for adequately by a smaller number of basic categories. Thus data obtained by a large number of measures may be explained by a smaller number of reference variables. The role of factor analysis is to determine whether a classification system can be verified with empirical data for specific populations. Principle-component analysis with Varimax rotation is a relatively straightforward method of transforming a group of variables into a set of composite variables or principal components that are orthogonal to each other. No particular assumptions of underlying structure of variables are required. The discriminant analysis is a method of maximally separating members of a group to reveal to which group each member probably belongs. The role of stepwise discriminant analysis is to add, at each step, one variable until an optimum level with a set of variables predict group membership. Efforts were made to determine whether differences in variables ocurred among groups of primary and secondary forms of hypertension,
Results
Of the 195 questions answered on the CM1 by the respondents, only those questions which showed at least 75% “yes” responses to a sign or symptom were selected for factor analysis. The accepted frequencies ranged from 59 to 128 “yes” answers. Factor analysis was run on only 51 items which met this criterion. The computer format for the analyses performed has been described (Nie, Bent and Hull, 1975). A chi-square test was run on every question to confirm the factor analytic method of analyzing the data. For the chi-square analysis the number of “yes” responses was calculated to form the total score. The top scores were compared to the bottom 25% total scores
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
332
by analyzing the frequency count for each item. All 51 questions, as used in the factor analysis, discriminated the high-scoring patients from the low-scoring patients significantly at the P < 0.01 level. Fifteen factors were extracted and subjected to the Varimax rotation and Kaiser normalization (Nie et al., 1975). Analysis revealed eight factors that were chosen by the investigators as meaningful for interpretation and nursing protocol development. Table 1. Percentages of variance accounted for by the factors in hypertensive patients, and percentages of “yes” responses on the CM1 items. N=236 Factors
Loading
I. Exhaustion Complex Does every little effort wear you out? Does working tire you out completely? Do you often get spells of complete exhaustion or fatigue? Do you usually get up tired and exhausted in the morning? Do you get out of breath long before anyone else? Do your muscles and joints constantly feel stiff?
38.2 28.0 43.2 53.8 39.8 45.3 26.7
0.761 0.748 0.603 0.487 0.409 0.309
II. Cardiovascular Complex Does your heart often race like mad? Are you often bothered by thumping of the heart? Do you often have spells of severe dizziness? Do you have pains in heart or chest? Do you get out of breath long before anyone else? Do you suffer from frequent cramps in your legs? III.Headaches Does pressure or pain in head often make life miserable? Do you suffer badly from severe headaches?
31.4 31.8 28.0 38.1 45.3 34.7
0.772 0.719 0.438 0.359 0.314 0.302
29.2 29.2
0.835 0.735
IV. History of ‘Nervousness’ Does nervousness run in your family? Does worrying run in your family?
34.7 36.0
0.782 0.711
33.5 30.5 39.8 26.7
0.750 0.706 0.325 0.311
V. Exaggerated Physical Reaction Do you have to clear your throat frequently? Do you sweat a gteat deal even in cold weather? Do you have hot or cold spells? Do your muscles and joints constantly feel stiff? VI. Irritability Do little annoyances get on your nerves and make you angry? Are you easily upset or irritated? Does criticism always upset you? Are your feelings easily hurt? Are you considered a nervous person? Do people often annoy and irritate you? Do you become scared of sudden movements or noises at night? Do sudden noises make you jump or shake badly? VII. Pattern of Rest and Exercise Do you find it impossible to take a regular rest period each day? Do you find it impossible to take regular daily exercise? VIII. Gastric Syndrome Do you usually feel bloated after eating? Do you suffer from indigestion?
_ *The percentage represents subjects who responded “Yes”.
Variance (olo)
9.4
7.2
5.9
5.3
5.2 44.9 37.3 27.5 41.5 35.2 28.4 26.7 31.8
0.646 0.634 0.559 0.538 0.504 0.457 0.338 0.323
45.2 42.8
0.729 0.456
43.2 26.2
0.394 0.380
4.3
4.0
% Total variance
79.5
NURSING
PROTOCOL
ON PATIENTS
WITH ESSENTIAL
AND SECONDARY
HYPERTENSION
333
When all hypertensives were considered together, the first and dominant group of factors was termed by the investigators the Exhaustion Complex factor. The questions comprising this factor are shown in Table 1. The second factor the investigators have termed the Cardiovascular Complex. The third factor was related to Headaches. The fourth factor was related to a Family History of ‘Nervousness’. The questions comprising the fifth factor, as shown in the table, comprised a group of symptoms which are termed Exaggerated Physical Reaction. The sixth factor was named Irritability. The seventh factor was identified as Pattern of Rest and Exercise and the eighth factor as Gastric Syndrome. Discriminant analysis was run to separate the essential from the secondary hypertensive patients. For the discriminant analysis, 30 different questions which defined a category by a factor were used. These items together did not aid in separating these hypertensive patients. A stepwise discriminant analysis was then run, and six of the 30 questions were found significant. Wilks lambda was 0.914. This value was significant, F(6,229) = 3.58, P-C0.002). Table 2. Question discriminators related to hypertensive patients Items in CM1
Listed in order of entry
49 109 140 65 52 7s
Do you usually feel bloated after eating? Does working tire you out completely? Do you find it impossible to take a regular rest period each day? Do your muscles and joints constantly feel stiff? Do you suffer from indigestion? Do you sweat a great deal even in cold weather?
Cardiac symptoms were predominate in these people’s lives. They had pains in the chest, racing and thumping of the heart. They suffered from cramps in their legs. Dizziness can be a side effect of hypertension treatment. Factor II is related to Factor I, since cardiac illnesss and symptoms complex lead to feelings of exhaustion. They suffered from severe headaches and pressure in the head which made them feel miserable. Factor III could be related to the exhaustion and cardiovascular complex factors, since they become exhausted with effort and arise exhausted in the morning. Hypertension and cardiovascular symptoms promulgated headaches since the patients in this sample were all hypertensive. According to Weiss, headaches were a more common symptom among those aware of their hypertension than in those who were unaware of it (Weiss, 1972). These patients acknowledge that nervousness and worrying run in their families in Factor IV. In Miller, Stein and Grim’s study (1979) the 16 Personality Factor Index revealed tendencies for Factor 0 and Factor Q4 to be evident in the hypertensive group (P< 0.10). These factors revealed that the patients tended to be apprehensive and worried, tense and frustrated. Such factors may be due to environmental pressures exhibited within the family or the result of diagnosis and treatment. Factor V loads high in clearing the throat frequently as well as on severe sweats and on experiencing hot and cold spells. These exaggerated physical patterns perhaps may be due to older age, or could occur under emotional tension. The muscle and joint stiffness can be explained as a physical symptom of an aging subject. The mean age of “yes” responses to this item was 50.5 yr. As the physical symptoms increase, this lends itself also to an increase in emotional problems; Factor VI describes irritability. On the other hand, an increase in emotional problems could cause an exacerbation of elevated blood pressure.
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
334
Factor VI is called Irritability because of emotional annoyances and signs of emotional disturbance. Complaints of being easily hurt, easily upset, annoyed at small episodes and jumping at sudden noises, portrayed these individuals as tense, hyperactive, emotional and distraught. This is in agreement with the 16 Personality Factor description of the hypertensive group in a previous study (Miller et al., 1979). Here the hypertensive group was described as being easily led, docile, easily upset, sober and serious. There are tendencies for Factor 0 and Factor Q4 to be operating. These factors described the patients as apprehensive and worrying types with tension and frustrations evident in their personality. In Factor VII, even though people have periods of rest and have regular exercise, it is impossible for them to do these every day. More is to be known about the precise role of lack of regular exercise and periods of rest in elevated blood pressure. Since this cause plays a role after more than likely decades of abuse of the body, self-care in the form of wiser living emerges. It is a criterion of health education in preventive medicine. Factor VIII, the gastric syndrome, reflects eating patterns of the hypertensive patient. They usually felt bloated after eating and suffered from indigestion. This could be a sign of irritability. Some people take comfort out of ingesting food to excess, causing bodily discomfort. Six among the 30 questions were able to discriminate in a stepwise fashion a response set (P < 0.002) that the respondent chose to express common recognized symptoms (see Table 2). Discussion
The purpose of this study was to identify factors associated with physical and psychological symptoms of a group of heterogeneous hypertensive patients and secondly to determine which physical and psychological symptoms are of value in discriminating the essential from the secondary hypertensive patient. From factor analysis results previously described, the nurse could develop steps for a nursing protocol such as a schematic drawing which was presented by Greenfield (Bullough, 1975) (see Fig. 1). ,
Nurse-protocol
All patients ( random) \
IPhy,stcian
-
Physrcian treatment
Blind comparison of data collection
I
I
Comparison Of outcome
I
Physician --rNurse-protocoI-Nurse-protocoI treatment
I
Fig. 1. Random design model for process and outcome.
In the analysis the investigators identified eight existing factors associated with these hypertensive patients. The exhaustion complex, cardiovascular complex and headaches predominated as the first three factors. These were followed by history of “nervousness”, exaggerated physical reaction, irritability, pattern of rest and exercise and gastric syndrome. Stiffness in muscles and joints also emerged, indicating a phenomena of older groups in this sample. The fact that these patients get out of breath in the two first factors may be related to the exhaustion and cardiovascular complexes.
NURSING PROTOCOL
ON PATIENTS
WITH ESSENTIAL
AND SECONDARY
HYPERTENSION
335
Factor I loads on the Exhaustion Complex. Work and effort tired these people out completely. They often got spells of complete exhaustion. Exhaustion lends itself to getting out of breath and to constantly feeling stiff in the muscles and joints. This exhaustion may be associated with the cardiovascular complex in as much as these people get out of breath before anyone else. Six among the 30 questions within Factors I-VIII yielded qualitative differences separating the essential from the secondary hypertensive patients. The function of the analysis maximally discriminated the members of the group and could tell the practitioner to which group each patient probably belongs for better self-care. The question discriminators were listed. In addition, another study might separate more descriptively the essential hypertensive patients from the secondary hypertensive ones by examining each of the 6 questions. For example, one could ask the patient what caused him to feel the need to work until he was completely tired. Maybe the patient needed recognition; maybe his boss expected more work than usual; or maybe more than one reason is causing this frequent exhaustion complex. Perhaps from this process one might learn that there are different causes for the essential than the secondary hypertensive patient, based on symptomatology. More is to be known about the precise role these causes play in elevated blood pressure because they can be moderated or eliminated by self-care in the form of wiser living. The perspective from this study can give new depth to the control and even prevention of emotional blights of hypertension. It can point out new ways to break with the static conceptions of hypertension. It can point out ways to promote health by teaching people constructive methods to cope with life so that hypertension is decreased and people are happier in assuming their life style. Perhaps experimental designs can be initiated for a nursing protocol whereby both physician and nurse could set up their protocols, neither one knowing the other’s findings, to compare the delivery of health care for hypertensive patients. On the protocol form the nurse and the physician could record their histories and physical findings for a diagnosis and plan of action. In fact Greenfield (Bullough, 1975) speculated that concordance was similar between the nurse and the physician. Summary
The results from the current study are relevant to examining the symptomatology of the factors on long-term effects of hypertensive patients. The dimensions of medical and psychiatric data from the CM1 were identified from factor analysis of the item data. In spite of the sophisticated interview tool and well characterized patients, the results from the stepwise discriminant analysis suggest that a discrete pattern of six symptoms separate the essential hypertensives from the secondary ones. One could argue that the analysis allowed the researchers to separate the essential from the secondary hypertensive, but there is no physical reason why these responses would do so. The medically supervised hypertensive group gave evidence of undergoing exhaustion with cardiovascular symptoms and headaches. They felt exhausted and worn out by weak stimuli. They acknowledged that nervousness and worrying ran in the family. It was surmised that exaggerated physical reactions of various kinds such as clearing of throat, having hot or cold spells, sweating in cold weather, and stiffness of muscles and joints were related to irritability. They gave evidence of undergoing irritability; acknowledging nervousness, annoyances and emotional upsets to the point that sudden noises or sudden
336
RITA F. STEIN,
CAROL L. MILLER AND CLARENCE
E. GRIM
movements made them scared and jumpy. It was felt that this could be a psychosomatic process whereby hypertension and irritability aggravate each other. Establishing regular rest and exercise patterns on a daily basis was not possible for the majority of patients in this study. These long-term effect symptoms agreed with those of Dollery et al. (1977) and to those of Peart (1977). This study was in agreement with their statement on exertion (Factor I), but the researchers’ subjects became exhausted with many other symptoms spelling out an exhaustive complex. In their work they listed depression as a symptom of hypertension, while in this study, Factor VI reveals irritability unspecified. They mentioned cramps in feet and calves, while respondents recognized leg cramps. They listed headaches, which are also a predominant factor (III) in the present work. Chest pains in general were a predominate factor in this study which Dollery et al. (1977) have broken down to a specified pain of angina. The reader is referred to Dollery et al. (1977) for an added array of symptoms not presented here. Along with the findings in this study, there are programs attempting to medically control elevated blood pressure. The article in the Journal of the American Medical Association was paraphrased by an article in the Wail Street Journal. This article placed a strong link between hypertension and obesity. In agreement with this article, better nutritional and exercise habits are recommended. These recommendations coincide with the recommendations of the authors. Yet obesity and the above named problems continue to exist, although they can be controlled by health teaching and self-care. Like standing orders, the protocol must constantly be changed and revised according to discoveries in medical science. The nurse protocol should always represent the intellectual processes of the nurse which are expected to be kept up to date. Without the above considerations the protocol could not be used as a safe and reliable instrument. Protocols can ensure a minimum standard of quality nursing care based on current day standards of nursing practice. References
Brodman, K., Erdmann, A. J., Jr. and Wolff, H. G. (1949). Manualfor Cornell Medical Index: Health Questionnaire. Cornell University Medical College, New York. Dollery, C. and Bulpitt, C. J. (1977). Management of hypertension. In Hypertension. J. Genest, E. Koiw and 0. Kuchel (Eds.). Chapter 31.1. McGraw-Hill, New York. Genest, J., Koiw, E. and Kuchel, 0. (1977). Hypertension. Chapters 5 and 16. McGraw-Hill, New York. Greenfield, S. (1975). Protocols as analogs to standing orders. In The Law & the Expanding Nursing Role. B. Bullough (Ed.). Chapter 6. Appleton-Century-Crofts, New York. Grim, C. E., Weinberger, M. H., Higgins, J. T. and Kramer, N. H. (1977). Diagnosis of secondary forms of hypertension. J. Am. med. Ass. 237, 1331-1335. Henry, J. P. and Cassel, J. C. (1969). Psychosocial factors in essential hypertension: recent epidemiologic and animal experimental evidence. Am. J. Epidem. 90, 171-188. Kirkendall, W. M. and Nottebohm, G. A. (1977). Essential hypertension. In Hypertension. J. Genest, E. Kiow and 0. Kuchel (Eds.). Chapter 17. McGraw-Hill, New York. Miller, C., Stein, R. and Grim, C. (1979). Personality factors of the hypertensive patient. lnf. J. Nurs. Stud. 16, 235-251. Nie, N. H., Bent, D. H. and Hull, C. H. (1975). SPSS Statistical Package for the Social Sciences, 2nd edn. McGraw-Hill, New York. Page, I. H. (1972). Hypertension: A symptomless but dangerous disease. New Engl. J. Med. 287, 665-666. Peart, W. S. (1977). Generalities of hypertension. In Hypertension. J. Genest, E. Koiw and 0. Kuchel (Eds.). Chapter 1. McGraw-Hill, New York. Wall Street J. (1978). High blood pressure linked to weight, researchers confirm. Oct. 3, p.15. Weiss, N. S. (1972). Relation of high blood pressure to headache, epistaxis, and selected other symptoms. New Engl. J. Med. 287, 63 l-633. (Received I6 January
1979: accepted for publication 6 July 1979)
in Great Britain
Factors contributing to a nursing protocol on hypertensivepatients with essentialand secondary hypertension RITA F. STEIN, Ph.D., CAROL L. MILLER, Ed.D. and CLARENCE E. GRIM, M.D. Nursing Research Department, Indiana University School of Nursing, Room 318, 1100 West Michigan Street, Indianapolis, Indiana 46202, U.S.A.
Nursing protocols are currently being used to guide practitioners in the care of clients in their use for the collection of data and recommendations for specific actions. Starting with a medical complaint, each step within the protocol is dependent on preceding responses or physical findings. What historical and physical information the nurse is to collect and what action the nurse is to take are generally based on two considerations: one is the frequency of a condition or a diagnosis sought; the other is the importance or value placed on making the diagnosis or defining the condition. The authors’ concern in this article is for the development of possible steps in a nursing protocol for the hypertensive patient with essential and secondary hypertension. The distribution of hypertensive patients’ medical complaints should serve as an index for a nursing protocol. There has been much confusion in the study of hypertension, involving many factors for consideration in the etiology of this disease. Various factors such as age, diet, race, sex, disease, obesity and heredity have been reported to be associated with elevated blood pressure (Henry and Cassel, 1969). Hypertensive patients may have symptoms related to their disease or its treatment. The objectives of this study are (1) to identify factors associated with physical and psychological symptoms of a group of heterogeneous hypertensive patients and (2) to determine which, if any, physical and psychological symptoms are of value in discriminating the essential from the secondary hypertensive patient. The distribution of the hypertensive patients’ complaints could serve as a means for the development of a nursing protocol from the following index. The Cornell Medical Index (CMI), a health questionnaire, was selected to examine the patient’s symptom complexes and the function of their symptoms in discriminating the essential from the secondary forms of hypertension. Hypertension has often been called the “silent disease”. During the silent period of this disease, hypertension is a symptomless, but dangerous disease (Genest, Koiw and Kuchel, 329
330
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
1977; Page, 1972). Clinical studies indicate that symptoms are unusual in the patient with mild or moderately severe essential hypertension (Kirkendall and Nottebohm, 1977). Kirkendall et al. (1977) described studies of headache, breathlessness, epistaxis, tinnitus, dizziness and migraine where the relationship of these symptoms to hypertension was not settled. Dollery and Bulpitt (1977) and Peart (1977) described the relevant long-term effect symptoms to be asked about hypertensive complications as follows: angina, intermittent depression, dyspnea on exertion, nocturia, paroxysmal nocturnal dyspnea, dysuria, ankle edema, hematuria, transient paresis, weakness in limbs, cerebrovascular accident, migraine, unsteadiness on standing in the morning, headache, epistaxis, cramps in feet and calves. Page (1972) recognized that no one would deny that the long-term effects of elevated blood pressure on the heart and blood vessels are manifested eventually in signs and symptoms of stroke, myocardial infarction and cardiac and renal failure. Grim, Weinberger, Higgins and Kramer (1977) concentrated on an efficient way for the medical practitioner to examine and accurately diagnose the hypertensive patient for renal artery stenosis and primary aldosteronism. They concluded that of the 236 hypertensive patients evaluated, their comprehensive protocol permitted identification of patients with renal artery stenosis, with primary aldosteronism, with high renin, with normal renin, and with low renin essential hypertension. Many of these hypertensive patients are subjects in the present study. Greenfield (Bullough, 1975) described the nursing protocol as having one of three outcomes for a final decision about the individual patient. One outcome was to refer the patient to the physician because of complexity of health care management; another outcome was that the physician reviews the outcome data and assumes the examination of one or more of the physical findings; and the third outcome was the recommendation that the patient may be sent home without seeing the physician. Greenfield (Bullough, 1975) stated, “If the nurses using a protocol are as effective as physicians in a well-controlled trial, we would say that the protocol administered by a nurse is an adequate mode of delivery of care.”
Sampling
All patients were previously hospitalized for investigation of the cause of their hypertension. At that time the diagnostic protocol was used, as developed by Grim et al. (1977). The hypertensive subjects consisted of each sex (male, N= 109, and female, N= 127) and race (black, N= 38, and white, N= 198). The study group was composed of essential and labile hypertensive patients, N= 187, primary aldosteronism, N= 22, and renovascular hypertensive patients, N=27. The essential hypertension group was also composed of high, N= 31, normal, N= 85, and low renin, N= 50. Age ranged from 18 to 78 yr. & Cornell Medical Index The CM1 Health Questionnaire was devised as an instrument suitable for collecting a body of medical and psychiatric data. The authors stated that this can serve as a standardized instrument to meet the needs of a medical history. It has been found useful in medical and psychological research to investigate incidence of symptoms in medical disorders with a reproducibility of 0.83 (Brodman, Erdmann and Wolff, 1949). The CM1 contains 195 questions in informal language which can be understood by per-
NURSING PROTOCOL ON PATIENTS WITH ESSENTIAL AND SECONDARY HYPERTENSION
331
sons with a reading knowledge of simple English. After each question a “yes” or “no” answer is given by circling one or the other. Questions are of four kinds: those relating to body symptom, those to past illnesses, family history and behavior, mood and feeling. Patients answer this questionnaire in lo-30 minutes. Male and female forms were used by the appropriate sex. Questions correspond to those asked in a detailed and comprehensive medical examination. The wordings that yielded answers in oral interview were included on the form. The questions were tested on several groups of patients at New York Hospital (Brodman et al., 1949). These responses were compared to those on the hospital patients’ records. They corresponded closely with those questions asked in oral interview. The CM1 collected data recorded in the hospital record and, in addition, a body of data omitted from patients’ oral histories (Brodman et al., 1949). Method The CM1 was administered to 236 hypertensive patients for factor analysis of the collected data on physical and psychological symptoms and for discriminant analysis of essential and secondary hypertensive patients with their recognized symptoms. The CM1 forms were mailed to 386 patients at their most recent home address. A postcard reminder was sent three weeks later. A total of 236 completed questionnaires were returned.
Factor analysis and discriminant
analysis
Factor analysis is a method of analyzing a set of observations from their intercorrelations to determine whether the variations represented can be accounted for adequately by a smaller number of basic categories. Thus data obtained by a large number of measures may be explained by a smaller number of reference variables. The role of factor analysis is to determine whether a classification system can be verified with empirical data for specific populations. Principle-component analysis with Varimax rotation is a relatively straightforward method of transforming a group of variables into a set of composite variables or principal components that are orthogonal to each other. No particular assumptions of underlying structure of variables are required. The discriminant analysis is a method of maximally separating members of a group to reveal to which group each member probably belongs. The role of stepwise discriminant analysis is to add, at each step, one variable until an optimum level with a set of variables predict group membership. Efforts were made to determine whether differences in variables ocurred among groups of primary and secondary forms of hypertension,
Results
Of the 195 questions answered on the CM1 by the respondents, only those questions which showed at least 75% “yes” responses to a sign or symptom were selected for factor analysis. The accepted frequencies ranged from 59 to 128 “yes” answers. Factor analysis was run on only 51 items which met this criterion. The computer format for the analyses performed has been described (Nie, Bent and Hull, 1975). A chi-square test was run on every question to confirm the factor analytic method of analyzing the data. For the chi-square analysis the number of “yes” responses was calculated to form the total score. The top scores were compared to the bottom 25% total scores
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
332
by analyzing the frequency count for each item. All 51 questions, as used in the factor analysis, discriminated the high-scoring patients from the low-scoring patients significantly at the P < 0.01 level. Fifteen factors were extracted and subjected to the Varimax rotation and Kaiser normalization (Nie et al., 1975). Analysis revealed eight factors that were chosen by the investigators as meaningful for interpretation and nursing protocol development. Table 1. Percentages of variance accounted for by the factors in hypertensive patients, and percentages of “yes” responses on the CM1 items. N=236 Factors
Loading
I. Exhaustion Complex Does every little effort wear you out? Does working tire you out completely? Do you often get spells of complete exhaustion or fatigue? Do you usually get up tired and exhausted in the morning? Do you get out of breath long before anyone else? Do your muscles and joints constantly feel stiff?
38.2 28.0 43.2 53.8 39.8 45.3 26.7
0.761 0.748 0.603 0.487 0.409 0.309
II. Cardiovascular Complex Does your heart often race like mad? Are you often bothered by thumping of the heart? Do you often have spells of severe dizziness? Do you have pains in heart or chest? Do you get out of breath long before anyone else? Do you suffer from frequent cramps in your legs? III.Headaches Does pressure or pain in head often make life miserable? Do you suffer badly from severe headaches?
31.4 31.8 28.0 38.1 45.3 34.7
0.772 0.719 0.438 0.359 0.314 0.302
29.2 29.2
0.835 0.735
IV. History of ‘Nervousness’ Does nervousness run in your family? Does worrying run in your family?
34.7 36.0
0.782 0.711
33.5 30.5 39.8 26.7
0.750 0.706 0.325 0.311
V. Exaggerated Physical Reaction Do you have to clear your throat frequently? Do you sweat a gteat deal even in cold weather? Do you have hot or cold spells? Do your muscles and joints constantly feel stiff? VI. Irritability Do little annoyances get on your nerves and make you angry? Are you easily upset or irritated? Does criticism always upset you? Are your feelings easily hurt? Are you considered a nervous person? Do people often annoy and irritate you? Do you become scared of sudden movements or noises at night? Do sudden noises make you jump or shake badly? VII. Pattern of Rest and Exercise Do you find it impossible to take a regular rest period each day? Do you find it impossible to take regular daily exercise? VIII. Gastric Syndrome Do you usually feel bloated after eating? Do you suffer from indigestion?
_ *The percentage represents subjects who responded “Yes”.
Variance (olo)
9.4
7.2
5.9
5.3
5.2 44.9 37.3 27.5 41.5 35.2 28.4 26.7 31.8
0.646 0.634 0.559 0.538 0.504 0.457 0.338 0.323
45.2 42.8
0.729 0.456
43.2 26.2
0.394 0.380
4.3
4.0
% Total variance
79.5
NURSING
PROTOCOL
ON PATIENTS
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When all hypertensives were considered together, the first and dominant group of factors was termed by the investigators the Exhaustion Complex factor. The questions comprising this factor are shown in Table 1. The second factor the investigators have termed the Cardiovascular Complex. The third factor was related to Headaches. The fourth factor was related to a Family History of ‘Nervousness’. The questions comprising the fifth factor, as shown in the table, comprised a group of symptoms which are termed Exaggerated Physical Reaction. The sixth factor was named Irritability. The seventh factor was identified as Pattern of Rest and Exercise and the eighth factor as Gastric Syndrome. Discriminant analysis was run to separate the essential from the secondary hypertensive patients. For the discriminant analysis, 30 different questions which defined a category by a factor were used. These items together did not aid in separating these hypertensive patients. A stepwise discriminant analysis was then run, and six of the 30 questions were found significant. Wilks lambda was 0.914. This value was significant, F(6,229) = 3.58, P-C0.002). Table 2. Question discriminators related to hypertensive patients Items in CM1
Listed in order of entry
49 109 140 65 52 7s
Do you usually feel bloated after eating? Does working tire you out completely? Do you find it impossible to take a regular rest period each day? Do your muscles and joints constantly feel stiff? Do you suffer from indigestion? Do you sweat a great deal even in cold weather?
Cardiac symptoms were predominate in these people’s lives. They had pains in the chest, racing and thumping of the heart. They suffered from cramps in their legs. Dizziness can be a side effect of hypertension treatment. Factor II is related to Factor I, since cardiac illnesss and symptoms complex lead to feelings of exhaustion. They suffered from severe headaches and pressure in the head which made them feel miserable. Factor III could be related to the exhaustion and cardiovascular complex factors, since they become exhausted with effort and arise exhausted in the morning. Hypertension and cardiovascular symptoms promulgated headaches since the patients in this sample were all hypertensive. According to Weiss, headaches were a more common symptom among those aware of their hypertension than in those who were unaware of it (Weiss, 1972). These patients acknowledge that nervousness and worrying run in their families in Factor IV. In Miller, Stein and Grim’s study (1979) the 16 Personality Factor Index revealed tendencies for Factor 0 and Factor Q4 to be evident in the hypertensive group (P< 0.10). These factors revealed that the patients tended to be apprehensive and worried, tense and frustrated. Such factors may be due to environmental pressures exhibited within the family or the result of diagnosis and treatment. Factor V loads high in clearing the throat frequently as well as on severe sweats and on experiencing hot and cold spells. These exaggerated physical patterns perhaps may be due to older age, or could occur under emotional tension. The muscle and joint stiffness can be explained as a physical symptom of an aging subject. The mean age of “yes” responses to this item was 50.5 yr. As the physical symptoms increase, this lends itself also to an increase in emotional problems; Factor VI describes irritability. On the other hand, an increase in emotional problems could cause an exacerbation of elevated blood pressure.
RITA F. STEIN, CAROL L. MILLER AND CLARENCE E. GRIM
334
Factor VI is called Irritability because of emotional annoyances and signs of emotional disturbance. Complaints of being easily hurt, easily upset, annoyed at small episodes and jumping at sudden noises, portrayed these individuals as tense, hyperactive, emotional and distraught. This is in agreement with the 16 Personality Factor description of the hypertensive group in a previous study (Miller et al., 1979). Here the hypertensive group was described as being easily led, docile, easily upset, sober and serious. There are tendencies for Factor 0 and Factor Q4 to be operating. These factors described the patients as apprehensive and worrying types with tension and frustrations evident in their personality. In Factor VII, even though people have periods of rest and have regular exercise, it is impossible for them to do these every day. More is to be known about the precise role of lack of regular exercise and periods of rest in elevated blood pressure. Since this cause plays a role after more than likely decades of abuse of the body, self-care in the form of wiser living emerges. It is a criterion of health education in preventive medicine. Factor VIII, the gastric syndrome, reflects eating patterns of the hypertensive patient. They usually felt bloated after eating and suffered from indigestion. This could be a sign of irritability. Some people take comfort out of ingesting food to excess, causing bodily discomfort. Six among the 30 questions were able to discriminate in a stepwise fashion a response set (P < 0.002) that the respondent chose to express common recognized symptoms (see Table 2). Discussion
The purpose of this study was to identify factors associated with physical and psychological symptoms of a group of heterogeneous hypertensive patients and secondly to determine which physical and psychological symptoms are of value in discriminating the essential from the secondary hypertensive patient. From factor analysis results previously described, the nurse could develop steps for a nursing protocol such as a schematic drawing which was presented by Greenfield (Bullough, 1975) (see Fig. 1). ,
Nurse-protocol
All patients ( random) \
IPhy,stcian
-
Physrcian treatment
Blind comparison of data collection
I
I
Comparison Of outcome
I
Physician --rNurse-protocoI-Nurse-protocoI treatment
I
Fig. 1. Random design model for process and outcome.
In the analysis the investigators identified eight existing factors associated with these hypertensive patients. The exhaustion complex, cardiovascular complex and headaches predominated as the first three factors. These were followed by history of “nervousness”, exaggerated physical reaction, irritability, pattern of rest and exercise and gastric syndrome. Stiffness in muscles and joints also emerged, indicating a phenomena of older groups in this sample. The fact that these patients get out of breath in the two first factors may be related to the exhaustion and cardiovascular complexes.
NURSING PROTOCOL
ON PATIENTS
WITH ESSENTIAL
AND SECONDARY
HYPERTENSION
335
Factor I loads on the Exhaustion Complex. Work and effort tired these people out completely. They often got spells of complete exhaustion. Exhaustion lends itself to getting out of breath and to constantly feeling stiff in the muscles and joints. This exhaustion may be associated with the cardiovascular complex in as much as these people get out of breath before anyone else. Six among the 30 questions within Factors I-VIII yielded qualitative differences separating the essential from the secondary hypertensive patients. The function of the analysis maximally discriminated the members of the group and could tell the practitioner to which group each patient probably belongs for better self-care. The question discriminators were listed. In addition, another study might separate more descriptively the essential hypertensive patients from the secondary hypertensive ones by examining each of the 6 questions. For example, one could ask the patient what caused him to feel the need to work until he was completely tired. Maybe the patient needed recognition; maybe his boss expected more work than usual; or maybe more than one reason is causing this frequent exhaustion complex. Perhaps from this process one might learn that there are different causes for the essential than the secondary hypertensive patient, based on symptomatology. More is to be known about the precise role these causes play in elevated blood pressure because they can be moderated or eliminated by self-care in the form of wiser living. The perspective from this study can give new depth to the control and even prevention of emotional blights of hypertension. It can point out new ways to break with the static conceptions of hypertension. It can point out ways to promote health by teaching people constructive methods to cope with life so that hypertension is decreased and people are happier in assuming their life style. Perhaps experimental designs can be initiated for a nursing protocol whereby both physician and nurse could set up their protocols, neither one knowing the other’s findings, to compare the delivery of health care for hypertensive patients. On the protocol form the nurse and the physician could record their histories and physical findings for a diagnosis and plan of action. In fact Greenfield (Bullough, 1975) speculated that concordance was similar between the nurse and the physician. Summary
The results from the current study are relevant to examining the symptomatology of the factors on long-term effects of hypertensive patients. The dimensions of medical and psychiatric data from the CM1 were identified from factor analysis of the item data. In spite of the sophisticated interview tool and well characterized patients, the results from the stepwise discriminant analysis suggest that a discrete pattern of six symptoms separate the essential hypertensives from the secondary ones. One could argue that the analysis allowed the researchers to separate the essential from the secondary hypertensive, but there is no physical reason why these responses would do so. The medically supervised hypertensive group gave evidence of undergoing exhaustion with cardiovascular symptoms and headaches. They felt exhausted and worn out by weak stimuli. They acknowledged that nervousness and worrying ran in the family. It was surmised that exaggerated physical reactions of various kinds such as clearing of throat, having hot or cold spells, sweating in cold weather, and stiffness of muscles and joints were related to irritability. They gave evidence of undergoing irritability; acknowledging nervousness, annoyances and emotional upsets to the point that sudden noises or sudden
336
RITA F. STEIN,
CAROL L. MILLER AND CLARENCE
E. GRIM
movements made them scared and jumpy. It was felt that this could be a psychosomatic process whereby hypertension and irritability aggravate each other. Establishing regular rest and exercise patterns on a daily basis was not possible for the majority of patients in this study. These long-term effect symptoms agreed with those of Dollery et al. (1977) and to those of Peart (1977). This study was in agreement with their statement on exertion (Factor I), but the researchers’ subjects became exhausted with many other symptoms spelling out an exhaustive complex. In their work they listed depression as a symptom of hypertension, while in this study, Factor VI reveals irritability unspecified. They mentioned cramps in feet and calves, while respondents recognized leg cramps. They listed headaches, which are also a predominant factor (III) in the present work. Chest pains in general were a predominate factor in this study which Dollery et al. (1977) have broken down to a specified pain of angina. The reader is referred to Dollery et al. (1977) for an added array of symptoms not presented here. Along with the findings in this study, there are programs attempting to medically control elevated blood pressure. The article in the Journal of the American Medical Association was paraphrased by an article in the Wail Street Journal. This article placed a strong link between hypertension and obesity. In agreement with this article, better nutritional and exercise habits are recommended. These recommendations coincide with the recommendations of the authors. Yet obesity and the above named problems continue to exist, although they can be controlled by health teaching and self-care. Like standing orders, the protocol must constantly be changed and revised according to discoveries in medical science. The nurse protocol should always represent the intellectual processes of the nurse which are expected to be kept up to date. Without the above considerations the protocol could not be used as a safe and reliable instrument. Protocols can ensure a minimum standard of quality nursing care based on current day standards of nursing practice. References
Brodman, K., Erdmann, A. J., Jr. and Wolff, H. G. (1949). Manualfor Cornell Medical Index: Health Questionnaire. Cornell University Medical College, New York. Dollery, C. and Bulpitt, C. J. (1977). Management of hypertension. In Hypertension. J. Genest, E. Koiw and 0. Kuchel (Eds.). Chapter 31.1. McGraw-Hill, New York. Genest, J., Koiw, E. and Kuchel, 0. (1977). Hypertension. Chapters 5 and 16. McGraw-Hill, New York. Greenfield, S. (1975). Protocols as analogs to standing orders. In The Law & the Expanding Nursing Role. B. Bullough (Ed.). Chapter 6. Appleton-Century-Crofts, New York. Grim, C. E., Weinberger, M. H., Higgins, J. T. and Kramer, N. H. (1977). Diagnosis of secondary forms of hypertension. J. Am. med. Ass. 237, 1331-1335. Henry, J. P. and Cassel, J. C. (1969). Psychosocial factors in essential hypertension: recent epidemiologic and animal experimental evidence. Am. J. Epidem. 90, 171-188. Kirkendall, W. M. and Nottebohm, G. A. (1977). Essential hypertension. In Hypertension. J. Genest, E. Kiow and 0. Kuchel (Eds.). Chapter 17. McGraw-Hill, New York. Miller, C., Stein, R. and Grim, C. (1979). Personality factors of the hypertensive patient. lnf. J. Nurs. Stud. 16, 235-251. Nie, N. H., Bent, D. H. and Hull, C. H. (1975). SPSS Statistical Package for the Social Sciences, 2nd edn. McGraw-Hill, New York. Page, I. H. (1972). Hypertension: A symptomless but dangerous disease. New Engl. J. Med. 287, 665-666. Peart, W. S. (1977). Generalities of hypertension. In Hypertension. J. Genest, E. Koiw and 0. Kuchel (Eds.). Chapter 1. McGraw-Hill, New York. Wall Street J. (1978). High blood pressure linked to weight, researchers confirm. Oct. 3, p.15. Weiss, N. S. (1972). Relation of high blood pressure to headache, epistaxis, and selected other symptoms. New Engl. J. Med. 287, 63 l-633. (Received I6 January
1979: accepted for publication 6 July 1979)