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Denise S. Morris, Ed.D, MSN, RN Guest Editor
Denise S. Morris, Ed.D, MSN, RN received her Doctorate in Education from Wilmington University, her Masters in Nursing from Wesley College and her primary nursing diploma from Beebe School of Nursing. She is currently teaching g r a d u a t e n u r s i n g courses at Wesley College, Dover, DE. A strong advocate for inquiry based education and active participatory learning, she involves students in research and evidence based practice in a variety of community and small group settings focused upon health promotion and wellness. Her professional experiences include critical care, home care nursing, nursing administration and nursing education. Dr. Morris can be reached via email at [email protected]
While special populations are sometimes clearly visible to us, more often they are hidden in plain sight. Special populations inhabit the margins of our society, and are imbedded deeply within our healthcare system. Sub groups like children, illegal immigrants, adolescents, caregivers, and pregnant ethic minorities face complex and unique challenges as they attempt
Constituent member of ANA The mission of the Delaware Nurses Association is to advocate for the interest of professional nurses in the state of Delaware. The Delaware Nurses
Association is dedicated to serving its membership by defining, developing, promoting and advancing the profession of nursing as an art and science.Quarterly publication direct mailed to approximately 12,000 RNs and LPNs in Delaware.
Volume 40 • Issue 3 August, September, October 2015
Inside DNA REPORTER
Reporter The Official Publication of the Delaware Nurses Association
Special Populations: The Care Givers
Page 5
current resident or
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Princeton, MN55371 Executive Director’s Column. . . . . . . . . . . . . .1
President’s Message . . . . . . . . . . . . . . . . . . . .3Pregnant Latina Illegal Immigrants: A Special Population in Need of Care . . . . . .4Special Populations: The Caregivers . . . . . . . .5Homeless Immigrant Children: A School Nurse’s Perspective . . . . . . . . . . . . . . . . . 6-7
Adolescent Health: A Brief Review of the Literature . . . . . . . . . . . . . . . . . . . . . 8-9Welcome New and Reinstated Members . . . .10Delaware Today Magazine Top Nurses Gala 2015 . . . . . . . . . . . . . . . . . . . . . . . . .11
Denise Morris
Executive Director’s Column
Sarah Carmody
Guest Editor
to navigate the healthcare advantages that others may more easily enjoy. Recent healthcare and economic changes have resulted in a sharp increase in a variety of special populations. Each group, without the economic stability or healthcare resources necessary in today’s society, is thus placed at a higher risk for adversity. Further, the influx of illegal immigrants and the federal mandates for education and healthcare have created a population with vast needs beyond healthcare alone, yet it is often the healthcare provider who becomes the gateway to care and case management.
Nurses are critical to the care of special populations, and are often the primary advocate for these groups. The authors of these 4 articles have explored some of the special populations at risk and highlighted the needs and concerns of these groups from the perspectives of nursing practice. As you read their articles, you will become familiar with the current literature and experiences of these nurses. I am convinced some, if not all of you, will emulate with their experiences and will recognize the familiarity of their practice challenges. Further, you will be encouraged to embrace your broad nursing roles for action and future research in special populations. As nurses you can shine the light on the hidden places within our healthcare system, advocate for the special populations and affect the lives of the disenfranchised. In the words of Margaret Mead (2005) “Never believe that a few caring people can’t change the world. For indeed that is all who ever have.” (p.242).
ReferencesMead, M. (2005). The world ahead: An anthologist
anticipates the future. New York. NY: Berghahn Book.
Special Populations Sarah J. Carmody, MBA
The word ‘politics’ most frequently invokes negative thoughts or conversations depending on the activities within a state or federal government. However, as much as one might try not to be drawn into ‘politics’, laws passed by legislators can have a direct impact on our lives. Legislators are called to evaluate and judge pieces of legislation that may be outside their knowledge base, yet their votes will bind individuals to their decisions. For this reason, it is imperative that nurses express their opinions and share their expertise with legislators when it comes to nursing and the health of communities and patients.
Get involved with the legislative process! Registration is now open for the September 8th Fifth Annual DC Bus Trip. This trip will provide nurses with the opportunity to meet and hear from the ANA Government Affairs staff and talk with our national legislators about issues important to nursing and patient care. Space is limited!
Thank you to Delaware Today magazine for another great gala spotlighting this year’s Top
Executive Director continued on page 2
Delaware Today Magazine Top Nurses Gala2 0 1 5
Page 11
Page 2 • DNA Reporter August, September, October 2015
Vision: The Delaware Nurses Association is dedicated to serving its membership by defining, developing, promoting and advancing the profession of nursing as an art and science.
Mission: The Delaware Nurses Association advocates for the interest of professionalnurses in the state of Delaware.
Goals: The Delaware Nurses Association will work to:1. Promote high standards of nursing
practice, nursing education, and nursing research.
2. Strengthen the voice of nursing through membership and affiliate organizations.
3. Promote educational opportunities for nurses.
4. Establish collaborative relationships with consumers, health professionals and other advocacy organizations.
5. Safeguard the interests of health care consumers and nurses in the legislative, regulatory, and political arena.
6. Increase consumer understanding of the nursing profession.
7. Serves as an ambassador for the nursing profession.
8. Represent the voice of Delaware nurses in the national arena.
OFFICIAL PUBLICATIONof the
Delaware Nurses Association
4765 Ogletown-Stanton Road, Suite L10Newark, DE 19713
Phone: 302-733-5880Web: http://www.denurses.org
The DNA Reporter, (ISSN-0418-5412) is published quarterly every February, May, August and November by the Arthur L. Davis Publishing Agency, Inc., for the Delaware Nurses Association, a constituent member association of the American Nurses Association.
EXECUTIVE COMMITTEE
President TreasurerKaren Panunto, Bonnie Osgood, Ed.D, RN, APN MSN, RN-BC, NE-BC
Immediate Past President SecretaryLeslie Verucci, Alana King, MSN, RN MSN, APRN-BC
COMMITTEE CHAIRS
Continuing Education Advanced PracticeTerry Towne, MSN, RN-BC-NE-BC Allen Prettyman, Kathy Davidson, MSN, RN-BC, SDS PhD, FNP-BCCo-Chairs
Committee on Nomination Professional Development Jane Kurz, PhD, RN May Oboryshko, MSN, RNChair
Vacant Legislative Melanie Marshall, RN
Vacant
Environmental Ad-Hoc CommunicationsVacant William T. Campbell, Ed.D, RN Jennifer Hargreaves, BA, RN
Executive Director
Sarah J. Carmody, MBA
CE Coordiator
Karen Andrea, MS, RN, BC
Subscription to the DNA Reporter may be purchased for $20 per year, $30 per year for foreign addresses.
For advertising rates and information, please contact Arthur L. Davis Publishing Agency, Inc., 517 Washington Street, PO Box 216, Cedar Falls, Iowa 50613, (800) 626-4081, [email protected]. DNA and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.
Acceptance of advertising does not imply endorsement or approval by the Delaware Nurses Association of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. DNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of DNA or those of the national or local associations.
Managing EditorsWilliam T. Campbell, Ed.D, RNJennifer Hargreaves, BA, RN
The DNA Reporter welcomes unsolicited manuscripts by DNA members. Articles are submitted for the exclusive use of The DNA Reporter. All submitted articles must be original, not having been published before, and not under consideration for publication elsewhere. Submissions will be acknowledged by e-mail or a self-addressed stamped envelope provided by the author. All articles require a cover letter requesting consideration for publication. Articles can be submitted electronically by e-mail to Sarah J. Carmody, MBA @ [email protected].
Each article should be prefaced with the title, author(s) names, educational degrees, certification or other licenses, current position, and how the position or personal experiences relate to the topic of the article. Include affiliations. Manuscripts should not exceed five (5) typewritten pages and include APA format. Also include the author’s mailing address, telephone number where messages may be left, and fax number. Authors are responsible for obtaining permission to use any copyrighted material; in the case of an institution, permission must be obtained from the administrator in writing before publication. All articles will be peer-reviewed and edited as necessary for content, style, clarity, grammar and spelling. While student submissions are greatly sought and appreciated, no articles will be accepted for the sole purpose of fulfilling any course requirements. It is the policy of DNA Reporter not to provide monetary compensation for articles.
Reporter
Published by:Arthur L. Davis
Publishing Agency, Inc.
http://www.denurses.org
Did you know the DNA Reporter goes
to all registered nurses in
Delaware for free?
Arthur L. Davis Publishing does a great job of contacting advertisers, who support the publication of our newsletter. Without Arthur L. Davis Publishing and advertising support, DNA would not be able to provide the newsletter to all the nurses in Delaware.
Now that you know that, did you know receiving the DNA Reporter does not automatically provide
membership to the Delaware Nurses Association?
DNA needs you! The Delaware Nurses Association works for the nursing profession as a whole in Delaware. Without the financial and volunteer support of our members, our work would not be possible. Even if you cannot give your time, your membership dollars work for you and your profession both at the state and national levels. The DNA works hard to bring the voice of nursing to Legislative Hall, advocate for the profession on regulatory committees, protect the nurse practice act, and provide educational programs that support your required continuing nursing education.
At the national level, the American Nurses Association lobbies, advocates and educates about the nursing profession to national legislators/regulators, supports continuing education and provides a unified nationwide network for the voice of nurses.
Now is the time! Now is the time to join your
state nurses association! Visit www.denurses.org to join or
call (302) 733-5880.
Nurses. The Top Nurses recognition program is a very easy way for nurses to be recognized. No application to fill out! Just insert a name (must be a DNA member) into a category of your choice. That’s it! The names will be tallied for the number of times they appear in a category. Final winners will be determined by Delaware Today. Voting will take place for the 2016 Top Nurses in the first quarter of next year.
Lastly, DNA could not achieve its mission without the help of its volunteers. If you are interested in sharing your time and expertise with DNA, please let us know! Openings are available on all of the DNA committees. Call (302) 733-5880. Thank you for all you do!
Executive Director continued from page 1
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August, September, October 2015 DNA Reporter • Page 3
President’s Message
Karen L. Panunto
Welcome to the August-September-October edition of the DNA Reporter publication. Articles written by our nursing peers for this issue are focused on the topic of “Special Populations.” I want to extend a special thank you to Denise Morris, EdD, MSN, RN for her willingness to serve as the current Guest Editor in highlighting the many health disparities and health care needs of the special populations presented in this edition, as well as the pivotal role nurses provide in meeting their needs in the community settings.
DNA participated at the national level: From July 23 through July 25, Leslie Veruci (Past-president), Sarah Carmody (Executive Director), and I attended the 2015 American Nurses Association (ANA) Membership Assembly. During this Membership Assembly we participated in discussions related to nursing practice at the national level, voted for nurses to fill positions on the ANA Board of Directors, and participated in hearings/voted on proposed amendments to ANA’s bylaws. The ANA Membership Assembly was also a great opportunity to network and connect with other constituent members/organizations.
Delaware “Top Nurses” Recognized: On May 27th a gala was hosted by Delaware Today Magazine in honor of those nurses recognized by their professional peers to be “Top Nurses” in the state of Delaware. Via an online poll, nurses were selected by their peers to receive this recognition. What higher praise can you receive then that which is given to you by the individuals you work with every day, or those whom you have made an impact somewhere along their career path? Both the gala and May edition of the Delaware Today Magazine were a tribute to all nurses who authenticate the traits of “Ethical Practice. Quality Care” (American Nurses Association’s Nurses Week theme) everyday through their strong commitment, compassion, and care they display in their practice and profession. It was extremely rewarding to have nurses recognized for their leadership, dedication, and contribution to the
profession and to share with the public the vital role nurses have in the care of patients.
New Forum for General Membership Meeting: I want to thank those members who attended the DNA’s General Membership Meeting that was held on Tuesday, May 25th. In the past, the General Membership meeting has been held immediately following the lunch break during the fall and spring conferences. After much discussion with members of the Board of Directors, it was decided to explore holding the meeting on a separate date and time to allow for more thorough discussions on key issues affecting the organization and the profession. We were excited to have an ample turnout of members for the first meeting and look forward to the next meeting this fall (date TBD). Discussions were focused on the organization’s policies, as well as current legislative issues affecting nursing practice. It was refreshing to hear opinions, comments, and concerns from our members. We welcome all members to attend the next meeting!
DNA Bus Trip to our Nation’s Capital: The Delaware Nurses Association Bus Trip to the U.S. Capital will be held on Tuesday, September 8th. Please plan to join us as we travel to Washington D.C. to discuss health care concerns with our state legislators. It is always an enjoyable event and a chance to network with other nurses within our state.
Delaware Excellence in Nursing Practice Awards: The Delaware Organization of Nurse Leaders will hold the Delaware Excellence in Nursing Practice Awards event on September 24th. Information related to the program can be found on the DONL website at www.DelawareONE.org/Excellence_awards.html Please plan to attend this event to celebrate nursing excellence!
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Page 4 • DNA Reporter August, September, October 2015
Pregnant Latina Illegal Immigrants: A Special Population in Need of Care
Jennifer Santini, BSN, RN
Jennifer Santini, B S N , R N e a r n e d h e r A D N f r o m Delaware Technical & Community College in Georgetown, DE, a BS in Behavioral Science f r o m W i l m i n g t o n Universit y, a BSN equivalent from Walden University, and is currently completing her MSN in Nursing Education. Jennifer started her nursing career in 1999, working with severely disabled adults and children at Harbor Healthcare in Lewes. She later worked as a staff nurse in Med-Surg, Pediatrics, and Oncology at Beebe Healthcare, Lewes, DE. She is currently teaching at Delaware Technical & Community College in Georgetown, DE. Jennifer can be reached by email at [email protected]
According to 2011 U.S. Census Bureau population estimates, there are roughly 52.0 million Hispanics living in the United States representing approximately 16.7% of the U.S. total population with an expected jump to 30% by 2050 (Centers for Disease Control [CDC], 2013). In Delaware, the Hispanic population currently makes up approximately 8.2% of the total population, and in Georgetown, Delaware, Hispanics make up 48% of the total population (City-Data-Advameg, Inc., 2014; Delaware Health and Social Services [DHSS], 2005; Ruggiano, 2008). This growing population raises awareness of the healthcare needs of this special group. The Hispanic population in the U.S. face many health disparities, one of which is receiving late, or no, prenatal care.
Late prenatal care is defined as prenatal care started in the third trimester, or months 7-9 (U.S. Department of Health and Social Services [DHSS], 2012a). Mothers who receive late or no prenatal care are more likely to have babies with health problems, three times more likely to give birth to a low-birth-weight baby, and five times more likely to have their baby die (U.S. Department of Health and Social Services, 2012). Additionally, Latina women have a 1.5 to 3 times higher risk of having a child with a neural tube defect, higher rates of gestational diabetes, and higher rates of food-borne disease morbidity and mortality (Torres, Smithwick, Luchok, & Rodman-Rice, 2012). Perinatal diseases were the tenth most common cause of death for Hispanics (Ruggiano, 2008). In Delaware, 9.1% of Hispanic mothers received late or no prenatal care (Delaware Health and Social Services [DHSS], 2005). Among subgroups, 21.2% of mothers in the Central/South American subgroup received late or no prenatal care, 7% of mothers in the Mexican subgroup received late or no prenatal care, and 3.9% of mothers in the Puerto Rican subgroup received late or no prenatal care (DHSS, 2005).
Early prenatal care is crucial to the health of both mother and baby; however, only 60% of Hispanic women initiate prenatal care in the first trimester compared to 80% of white women (Valdez, 1999). Knowing that Latina women are at higher risk for complications, it is imperative to increase access to healthcare for this group of women (Torres et al., 2012). The literature highlighted that one significant factor to Latina women not receiving prenatal care is due to a lack of insurance. Hispanics have the highest uninsured rates of any racial or ethnic group within the United States (U.S. DHSS, 2014). It is estimated that 11.1 million immigrants are here illegally, with more than half being of Hispanic descent, meaning that they have little or no access to healthcare (Pew Research, 2013). Since the children who are born here are legal citizens, it is important that they are born as healthy as possible.
Granting any kind of access to health care for immigrants is becoming a focal point of Congressional debate under the 1996 Welfare Reform Act. Undocumented pregnant women are ineligible for federally-funded prenatal care, but due to regulation changes in 2002, states now have the option to provide prenatal care to undocumented immigrant women by extending Children’s Health Insurance Program (CHIP) coverage to the unborn child, known as the unborn child policy (Catholic Legal Immigration Network, Inc., 2013). Currently there are eighteen states that offer this prenatal care; however, Delaware is not one of them even though the Hispanic population has increased by over 50% in the past ten years (Ruggiano, 2008). Without a change to the existing law in Delaware, undocumented immigrant women will continue to go without needed prenatal care simply because many lack the resources to receive prenatal care and many times lack the knowledge to understand the importance.
With immigration reform and illegal immigration currently being a hot topic in the United States, many obstacles can be anticipated. Although as illegal immigrants the mothers are not eligible for federal benefits of any kind, their babies will be citizens by birth, meaning that the children are eligible for Medicaid as soon as they are born. Many states are currently fighting the same battle and the judges of the Second Circuit of the United States Court of Appeals ruled that illegal immigrant mothers are not entitled to anything before birth (Sengupta, 2001). Additional arguments are that illegal immigrants are being given preferential treatment while taxes are increased on citizens (O’Hanlan, 2013). However, preventing immigrants from getting prenatal health benefits is financially irresponsible and will only raise health care spending and contribute to a less healthy U.S. population (Mukherjee, 2013). In a study done in 2000 comparing initial and long-term costs and outcomes for California undocumented immigrant women and their children, with and without prenatal care, it was found that for every dollar not spent on prenatal care, there would be an additional cost of $3.33 for postnatal care and $4.63 in incremental long-term cost (American Public Health Association (APHA), 2013). Furthermore, hospitals cannot turn away patients based on ability to pay, known as the Emergency Medical Treatment and Active Labor Act (EMTALA). Therefore the state and federal governments, as well as the hospital end up paying for the care, in turn raising health care rates (Mukherjee, 2013). Mukherjee (2013) also reported soon after EMTALA’s passage, lawmakers authorized a special Medicaid fund that partially subsidizes emergency treatments for undocumented immigrants, costing approximately $2 billion per year, much of which is used on delivering babies for pregnant, undocumented women arriving to the emergency room.
There is no easy answer to this problem, however, in order to protect public health and provide the best start for the infants who will be citizens, it is imperative to provide care. It can also be argued that health care is a basic human right and that not providing prenatal health care may have an undesirable effect on the health of the nation. In order to reduce barriers to prenatal health care, culturally appropriate health promotion, intervention, and advocacy programs are needed.
Although many of these patients are here illegally, it does not change their need for health care. Providing early prenatal care can be cost effective for the United States as the children we are providing care for are our future citizens (McCurdy, 2013). Being an advocate for this program does not mean that one necessarily believes in the actions this population has made; it does, however, hold the belief that health care is a basic human right. By educating the public on the social and economic impacts of lack of access to prenatal healthcare services, positive change can be made.
ReferencesAmerican Public Health Association. (2013). Opposing
the exclusion of undocumented immigrants from health care reform. Retrieved from http://w w w. a p h a .o r g / N R /r d o n l y r e s/1C D 5 F 616 -E 0 7 F - 4 8 E 8 - B E 6 8 - C 1 8 6 A B 3 4 E 5 2 F/ 0 /A3UndocumentedImmigrantsandHealthReform.pdf
Catholic Legal Immigration Network, Inc. (2013). Eighteen states offer prenatal care to undocumented immigrant women (Nov. 2013). Retrieved from https://cliniclegal.org/resources/articles-clinic/eighteen-states-offer-prenatal-care-undocumented-immigrant-women-nov-2013
Centers for Disease Control. (2013). Hispanic or Latino populations. Retrieved from http://www.cdc.gov/minorityhealth/populations/REMP/hispanic.html
City-Data-Advameg, Inc. (n.d.). Retrieved from http://www.city-data.com/city/Georgetown-Delaware.html
Delaware Health and Social Services. (2005). Hispanic births in Delaware. Retrieved from ht tp://dhss.delaware.gov/dph/hp/files/hispanics.pdf
McCurdy, C. (2013). Advocates celebrate prenatal care expansion. The Lund Report. Retrieved from https://www.thelundreport.org/content/advocates-celebrate-prenatal-care-expansion
Mukherjee, S. (2013). Why Undocumented Immigrants Should Have Access To Taxpayer-Funded Health Care. Retrieved from http://thinkprogress.org/health/2013/05/24/2060541/undocumented-immigrants-taxpayer-funded-health-care/
O’Hanlon, K. (2013). Janssen goes after prenatal care for illegal immigrants. Journal Star. Retrieved from http://journalstar.com/legislature/janssen-goes-after-prenatal-care-for-illegal-immigrants/article_8e35cc13-39d7-5745-927a-bba3433cd122.html
Pew Research. (2013). A nation of immigrants. Retrieved from http://www.pewhispanic.org/2013/01/29/a-nation-of-immigrants/
Ruggiano, N. (2008). The health status of the Hispanic community in Delaware. Retrieved from http://arshtcannonfund.org/wp-content/uploads/2011/06/Health-Brief-final.pdf
Sengupta, S. (2001). Appeal pending, immigrant mothers-to-be crowd prenatal clinic. The New York Times. Retrieved from http://www.nytimes.com/2001/07/21/ny reg ion/appea l-pend ing-immigrant-mothers-to-be-crowd-prenatal-clinic.html
Torres, M. E., Smithwick, J., Luchok, K.J., & Rodman-Rice, G. (2012). Reducing maternal and child health disparities among Latino immigrants in South Carolina through a tailored, culturally appropriate and participant–driven initiative. Californian Journal of Health Promotion, 10, 1-14.
U.S. Department of Health and Social Services. (2012a). Child Health USA 2012. Retrieved from http://mchb.hrsa.gov/chusa12/hsfu/pages/pc.html
U.S. Department of Health and Social Services. (2012b). Prenatal care fact sheet. Retrieved from http://womenshealth.gov/publications/our-publications/fact-sheet/prenatal-care.html
U.S. Department of Health and Social Services. (2014). Hispanic/Latino profile. Retrieved from http://m i nor i t yhea l t h .h hs.gov/templates/browse.aspx?lvl=2&lvlID=54
Valdez, K. (1999). Hispanics and prenatal care. Retrieved from http://njms.rutgers.edu/genesweb2/topics/ob_gyn/hispanics.cfm
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August, September, October 2015 DNA Reporter • Page 5
Karen M. Mika, MSN, RN, CMSRN
Karen M. Mika, MSN, RN, CMSRN earned her bachelor’s degree in nursing at Wesley College, Dover, Delaware. She g raduated in May f rom t he Masters P r o g r a m a l s o a t Wesley College with a focus on community health promotion and wellness. Karen works on 2 West, a medical surgical telemetry unit at Milford Memorial Hospital, Bayhealth Medical Center. She is also a clinical instructor at Polytech Adult Education for the certified nursing assistant program. Karen is a member of the Academy of Medical Surgical Nurses and Sigma Theta Tau International. Prior to her nursing career, Karen served for 21 ½ years in the United States Air Force from 1985-2007. She worked in the air transportation career field and retired as a Senior Master Sergeant. Karen can be reached by email at [email protected]
As of 2012, the National Alliance for Caregiving and AARP reported that there were 65.7 million caregivers that made up 29% of the population in the United States. The caregiver services provided were valued at $450 billion per year in 2011. According to Healthy People 2020, older adults born between 1946 and 1964 are among the fastest growing age groups and manage more than one chronic condition (Healthy People 2020). By 2030, 1 out of every 5 adults in the United States will be over the age of 65 years old, and a large percentage will have debilitating conditions that will require around-the-clock caregiving (Mast, Swain & Pentaleo, 2012). Today, it is estimated that one in every five households in the United States provides support to elderly or disabled family members for 18 or more hours per week. Caregiving can be defined as providing unpaid assistance for the physical and emotional needs of another person (University of California, San Francisco, Human Resources Department [UCSF], 2015). A caregiver often helps with basic tasks and activities of daily living. Tasks which include grocery shopping, meal preparation, bathing, dressing, obtaining and taking medications, transportation to appointments, shopping, and managing their health ailments. These caregivers are often aging spouses who are frail and have comorbidities that make it difficult to provide adequate care for their loved ones (Mast et al., 2012).
When the caregiver is an adult child, they are responsible for trying to juggle their own careers and family responsibilities in addition to caring for the elderly family member. These caregivers rarely find time to relax and care for themselves in an effort to help manage the emotional and physical burdens of caregiving (Mast et al, 2012). This puts the caregiver at higher risk for depression and other related conditions. Many caregivers lack adequate finances, social resources, and skills needed to properly care for the home and health needs of their elderly family members (Mast et al., 2012).
The Stress and Strain of CaregivingCaregivers are constantly placed in overwhelming
situations that leave them feeling burdened and distressed, often affecting their physical and mental health (Pierce, Thompson, Govoni & Stiener, 2012). As the condition of the patient declines, the amount of caregiving increases. A wave of emotions and circumstances may cause conflict and confusion for the caregiver and in turn, may affect the care provided (Pierce et al., 2012). A majority of caregivers do not have proper education and training on how to care for the person needing care. In The Home Alone study – a study of family caregivers who provided complex care – the researchers found that almost half the caregivers interviewed provided medical and nursing duties (Family Caregiver Alliance: National Center on Caregiving, n.d.). When asked about which clinical tasks were more difficult for them to perform, the most common tasks mentioned were handling incontinence equipment, administering enemas, providing wound care, treating pressure ulcers, and
Karen Mika
managing medications (Reinhard & Levine, 2012). These factors increase stress and strain and are factors in the development of depression, isolation, and poor quality of life for the caregiver (Pierce et al, 2012).
As an example, for patients receiving cancer treatment, caregivers may be required to provide primary care at home when a person is receiving aggressive treatment that causes debility or if, and/or when, the treatment is transitioned into palliative or comfort care (Tamayo, Broxson, Munsell, & Cohen, 2010). Age, gender, cultural background, socio-economic status, education level, personal health, and family dynamics are factors that can determine the caregiver’s reaction to the demanding role (Tamayo et al., 2010). Family caregivers often reported a deficit in knowledge of how to properly care for their loved one receiving cancer treatment, lack of assistance from healthcare professionals and social services, and increased stress due to the person’s advancing cancer posed increased demands on the caregiver (Tamayo et al., 2010). Caregivers identified a knowledge deficit on proper medication administration and how to manage the side effects caused by chemotherapy (Tamayo et al., 2010). Common themes in the literature were identified as being worried, running on empty and losing self (Pierce et al, 2012).
Nursing Diagnosis Related to Caregiving Nursing diagnosis that pertain to the caregivers
are ineffective health maintenance, fatigue, impaired knowledge deficit, risk for powerlessness, risk for loneliness, risk for caregiver role strain, anticipatory grieving and ineffective coping (Tamayo et al., 2010). The role of the Clinical Nurse Specialist (CNS) in the community is to identify and provide guidance and assistance to caregivers so they can effectively care for their loved one. In the caregiver role, coping refers to the things that people do to resolve stressful situations. These mediating processes of nurse guidance and assistance were found to help with depression and anxiety among family caregivers of elders with chronic illnesses. Evidence of positive coping was also directly linked to improved caregiver health and wellness (Bacon et al., 2012).
ResourcesThere are many resources available in the
community for caregivers that include Senior Centers, adult day care programs, caregiver support groups, public transportation, meals on wheels, and many more. According to findings from the National Alliance for Caregiving and AARP [NACA], Caregiving in the U.S: National Alliance for Caregiving, and Washington, DC: AARP (n.d.), 49% of caregivers stated that they used one of three specific types of assistance to help them care for their care recipient. The most commonly used was public or outside transportation services (29%), resources for financial assistance (28%), and respite services (12%). Only 19% of caregivers reported receiving training, while 78% reported needing more training and assistance with at least 14 topics related to caregiving (NACA, n.d.). According to the National Alzheimer’s Association (2011), caregivers benefited from interventions such as individual/group therapy, education/training and support, and home visits by community nurses.
Additional research needs to be conducted that focuses on ways to improve the quality of life for caregivers. Possible improvement efforts mentioned in the studies reviewed were to improve interventions of delivering new information and education to caregivers. One area of concern could be a lack of knowledge or modern technology. This may help to provide better nurse-caregiver communication and education especially in the areas of medication administration and symptom management. Caregivers can also access online support groups without having to leave their homes and provide them the opportunity to network with other caregivers.
Conclusion In examining the literature on the special
population of caregivers, it was clear that the goal of the caregiver is to keep his or her loved one at home while being able to provide safe and effective care. Problems occur when the patient’s condition declines and there are not enough support services to allow the patient to remain at home with a caregiver. One of the prevention objectives listed in Healthy People 2020 is to reduce the number of caregivers who report an unmet need for caregiver support services. The goal as
healthcare providers in the community is to support caregivers in order for them to properly care for their loved ones and keep them home as long as possible and out of the hospital and institutions such as nursing homes. The role of the CNS in the community is to monitor the care of the person requiring care as well as the caregiver. The CNS is in the position to watch for signs of caregiver strain, provide education and resources, and refer as needed to other agencies for additional assistance in support of this special population.
ReferencesBacon, E., Milne, D., Sheikh, A. & Freestone, M. (2012).
Positive experiences in caregivers: An exploratory case series. Behavioral and Cognitive Psychotherapy, 37:95-114. DOI: .10.1017/s1352465808005055.
Mast, M., Swain, E., & Pentaleo, K., (2012). Life of a caregiver simulation: Teaching students about frail older adults and their family caregivers. Journal of Nursing Education. 50(7): 396-397. doi: 10.3928/01484834-20120427-02.
Pierce, L., Thompson, T., Govoni, A., & Stiener, V. (2012). Caregiver’ incongruence; emotional strain in caring for persons with stroke. Rehabilitative Nursing. 37(5) 258-266. Retrieved from ProQuest Central URL: http://search.proquest.com.wesley.idm.oclc.org/pqcentral/docview/1040422075/abstract/465522E1B0C74E4BPQ/1?accountid=45950
Reinhard, S. & Levine, (2012). Home Alone: Family caregivers providing complex and chronic care. American Association of Retired Persons, Retrieved from http://www.aarp.org/home-family/caregiving/in fo-10-2012/home-a lone-fami ly-ca reg ivers-providing-complex-chronic-care.print.html
Tamayo, G., Broxson, A., Munsell, M., & Cohen, M. (2010). Caring for the Caregiver. Oncology Nursing Forum. 37(1): E50-E57. DOI: 10.1188/10.ONF.E50-E57.
Healthy People 2020, retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/older-adults
National Alliance for Caregiving and AARP (n.d), Caregiving in the U.S: National Alliance for Caregiving, Washington, DC: AARP. Retrieved from http://www.caregiving.org
National Alzheimer’s Association, (2011) Alzheimer’s’ Disease Facts and Figures, Alzheimer’s And Dementia, Vol. 7(2) retrieved from http://www.alz.org/alzheimers_disease_facts_figures.asp
Family Caregiver Alliance: National Center on Caregiving (2012). Caregiver Statistics 2012 Retrieved from https://caregiver.org/selevted-caregiver-statistics on 1/23/2015
University of California, San Francisco (n.d.). Elderly Caregiving: Choices, Challenges and Resources for the Family 2015. Retrieved from http://ucsfhr.ucsf.edu/index.php/assist/article/Elderly-caregiving-choices-challenges-and-resources-for -the-family
Special Populations: The Caregivers
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Page 6 • DNA Reporter August, September, October 2015
Gene McMillen, Ed.D, MSN, RN
Gene McMillen, Ed.D, MSN, RN earned his BSN from Keuka College, his MSN and his Ed.D, from Wilmington University. Dr. McMillen began his health care career in the U.S. Coast Guard as a Corpsman, became a combat Medic, and graduated from the U.S. Army Officers Candidate School. He has practiced clinically in Pediatrics, Psychiatric nursing and Medical-Surgical nursing. He taught nursing as an Associate Professor of Nursing in Maryland before re-entering clinical practice as a Certified School Nurse with pre-K through 12 children with special needs program in the Indian River School District, Sussex County, Delaware. In addition, Dr. McMillen has received numerous awards for educational excellence in nursing. Dr. McMillen can be reached by email at [email protected]
The newest infusions of school-aged students in Delaware are children from south of the North American land borders. Most of these children are from the impoverished regions of Guatemala. Speaking little English and having only a first to third grade education, these children have endured great hardships to pave a path to the American dream (Starkey, 2014). Many of these children were sent alone to America by their parents and families knowing that their children will not be sent back. It is a risk they take to avoid such poor living conditions, and out of desperation even an American refugee camp is a lifestyle improvement. By United States policy any child (under age 18) who comes to this country unaccompanied by a parent is considered abandoned or homeless and will be retained (Starkey, 2014). Due to our compulsory education laws, these children with limited language and educational deficits are absorbed into our education system. In order to meet their specialized language and acculturation needs, Melissa Oates, School Administrator, developed the Accelerated Preliterate English Language Learners (APELL) program for the Indian River School District. Lead Teacher, Lori Ott, presents the APELL curriculum in a conventional classroom environment which develops the students academically as well as teaching them American traditions and culture.
Often the age range places these children into our middle schools and high schools, but their history of educational shortfalls has them performing at the
Gene McMillen
elementary school level (L. Ott, personal communication, March 18, 2015). The APELL scholastic program fast-tracks them into learning enough English to begin instruction in school to meet American educational standards.
Arrival and Health DocumentationThere is a method of movement for the
APELL children when coming into the United States that teacher Lori Ott likened to the famous underground railroad of over one-hundred and fifty years ago (L. Ott, personal communication, March 18, 2015). One professional educator told me that, essentially, “the kids cross the U.S. border in darkness via river or land, make their way to Texas, than go left to California, straight to Chicago, or right to Delaware” (L. Ott, personal communication, March 18, 2015). Rarely do any education or health records follow them. When these records are present, they are typically received from the public health camps in Texas and Arizona and will have only evidence of a physical, chest x-ray, and some immunizations.
Nursing Challenges
Health and Wellness This APELL population has a myriad of health and wellness challenges.
To begin with, the priorities of daily life in their home country are based on survival, making the #1 priority the earning of money. Health needs and education are the 2nd and 3rd priorities, respectively, but as the APELL students come from an area of the world with little to no health care provisions, they do not understand the emphasis Americans place on health. In fact, school nurses are most likely the APELL students’ first contact with a health care professional (M. Oates, personal communication, February 12, 2015). For example, most APELL students are not immunized due to the lack of public provisions in their native country. It is not until school nurses send them for immunization updates via the Delaware Public Health system that the APELL students receive their first series of inoculations. In the APELL students’ world, they believe they have received all needed shots. The follow-up for the 2nd and 3rd inoculations is difficult for APELL students to understand. Cultural perceptions that one only seeks healthcare when ill, coupled with limited transportation and no insurance, can make this basic practice become a logistics nightmare.
Another major health concern in this population is Tuberculosis. These children are coming from areas that the U.S. Department of Health and Human Services Centers for Disease Control and Prevention (CDC) has identified as “Foreign-born persons from high-prevalence areas, such as Asia, Africa, and Latin America” (CDC, 2009). Even if they have had an x-ray, Delaware requires these high-risk children to have the Mantoux PPD skin test. In my school alone, the prevalence of positive (greater than 10mm) PPD’s is forty percent. Next, Public Health initiates treatment which entails witnessed 76 doses of Isoniazid 300mg PO (INH) (Delaware Health and Social Services, Division of Public Health, 2015). This takes about 9 months to accomplish. Bear in mind the general health belief of this population is that, if I am not sick, why do I need to take medicine? This results in medication compliance concerns. On a positive note, at the completion of the regimen, the Department of Public Health issues a certificate of completion validation that shows evidence of treatment
Homeless Immigrant Children: A School Nurse’s Perspective
Homeless Immigrant Children continued on page 7
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August, September, October 2015 DNA Reporter • Page 7
compliance. As school nurses this accomplishment serves as a vehicle for positive reinforcement of students’ engagement in healthcare treatments.
Dietary Issues While the APELL students are defined by our
standards as “healthy” many of them are plagued with wellness issues. For example, in their native country, cow’s milk is expensive, so the milk they are used to is mixed with coffee or fruit juice to stretch it, and is usually served warm (L. Ott, personal communication, March 18, 2015). Furthermore, a less expensive product made with vegetable oils and flavoring is fluid and sold as milk (Euromonitor International, 2014). In U.S. schools, milk is served ice-cold at meals. Subsequently, this temperature difference may cause minor gastric cramping for many of the APELL students. Also, their body releases the same chemicals to digest our processed milk as it did to digest the raw milk which can contain higher natural bacteria counts. As a result, children may suffer additional gastric symptoms. Unlike the organic and raw nature of their native foods, the processed foods served in schools may cause similar gastro-intestinal effects such as diarrhea and abdominal pain and eventually constipation (Euromonitor International, 2014). These symptoms are related to the higher colonization of digestive microbiota initially seen in this population (Euromonitor International, 2014).
Psychological Many of these children have had horrific
experiences in their native country, such as escaping murder, prostitution, and drug-cartel slavery. Often they traverse hundreds of miles on foot getting to the Rio Grande. Furthermore, a child might be faced with the need to swim deep waters and swift currents to cross the border into the U.S. eventually arriving in a refugee camp only to give birth to a baby, or collapse in sheer exhaustion (Loughlin & Gliha, 2015). Often they are so impressed with the healthcare received that they want to become nurses or doctors to give back to others in their community.
Many times it is the behaviors in school that signal the existence of these past traumas. The collaboration of the school nurse, the school psychologist, and the school administration is often necessary to manage events such as head traumas with residual psychological and physical manifestations. These children may have been severely injured but received no health care because they were poor and hospitals were too far away. Traumatic Brain Injury (TBI) is rare, but left untreated following the trauma, TBI can have considerably worse lifelong neurological issues.
ConclusionThe experiences of this special population can
result in physical and psychological scars. Despite these experiences and health concerns, the children are polite, caring, and passionate about their integration into our society. They have endured vast prejudice being here and placed added pressure on our already-strained educational budgets (Loughlin & Gliha, 2015). Caring for these children offers opportunities where nurses can make a difference in the lives of disenfranchised children.
ReferencesDelaware Health and Social Services, Division of Public
Health (2015). Tuberculosis elimination program services. Available from http://dhss.delaware.gov/dhss/dph/dpc/tbservices.html
Euromonitor International (2014). Drinking milk products in Guatemala. (September, 2014). Available from http://www.euromonitor.com/drinking-milk-products-in-guatemala/report
Loughlin, R. & Gliha, L. (2015). Rural school grapples with influx of migrant students [Al Jazeera March 16, 2015 video news segment]. Available from http://america.aljazeera.com/watch/shows/america-tonight/2015/3/rural-school-grapples-with-influx- of-migrant-students.html
Starkey, J. (2014). Children who illegally immigrated alone into the U.S. were placed with families in Delaware. Available from http://www.delawareonline.com/story/news/local/2014/07/24/immigrant-children-put-families-Delaware/13136711/
U.S. Department of Health and Human Services Centers for Disease Control and Prevention. (2009). Issued October 1, 2009. Available from http://www.cdc.gov/immigrantrefugeehealth/pdf/tuberculosis-ti-2009.pdf
Homeless Immigrant Children continued from page 6
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Brian A. Hoover, BSN, RN
Brian A. Hoover, BSN, RN, received his ADN from Delaware Technical & Community College and his BSN f r o m W i l m i n g t o n University. He currently lives in New York City and has worked in home care, pain m a n a gement , a nd breast and endocrine oncology surgery. Brian spent most of his time volunteering at Mt. Sinai Beth Israel’s Pediatrics clinic during his clinical experience towards his BSN degree. Brian can be reached via email at [email protected]
Adolescents experience a wide range of changes throughout their stages of development that influences their lifestyle habit formation and decision-making processes into adulthood. These changes can potentially influence decision making in regards to eating, participating in physical activity, and engaging in risk taking behaviors (violence, substance abuse, sexual practices, etc.). As a result, adolescent health is becoming an important local and global health issue requiring attention. Areas of concern include physical health such as obesity, psychological health that includes depression, suicidal ideation, physical dating violence (PDV), and safety related and risk-taking behaviors such as sexual activity and substance abuse.
According to the Centers for Disease Control and Prevention’s (CDC) Youth Behavior Risk Surveillance (YBRS) of 2013, 13.7% of school students are considered obese, and 16.6% are considered overweight (Kann et al., 2014). The rate of overweight children in the United States has almost doubled in the last ten years to 45% (Power, Bindler, Goetz, & Daratha, 2010). In a cross-sectional study performed in Canada, the rate of obese children between the ages of 6 years and 17 years has doubled to 8.6% (Morin, Turcotte, & Perreault, 2013). In terms of physical health, adolescents and teens preferred
Brian Hoover
Adolescent Health: A Brief Review of the Literaturehigh calorie and less healthy snacks to fruits and vegetables (Power et al., 2010). Further, they participated in fewer physical activities and spent more time engaged in sedentary activities such as computer use and gaming. According to Kann et al. (2014), 41.3% of adolescents and teens spent three hours or more playing video games or sitting in front of a computer, and 32.5% spent three hours or more watching television.
In addition to nutrition and activity concerns, adolescents suffer an alarmingly high incidence of psychological health symptoms. These psychological symptoms were reported as: 30% feeling sad or hopeless for at least two weeks or longer, and 17% had considered attempting taking their own lives, almost 14% made an actual plan, and 8% made an actual attempt (Kann et al., 2014). In the area of safety approximately 10% experienced PDV or sexual dating violence, and less than 9% engaged in safe sex practices among the almost 47% of adolescents and teens who declared being sexually active (Kann et al., 2014).
Contributing Factors Social factors such as busy schedules can
contribute to poor physical health and often present as barriers to proper nutrition and exercise. Despite school lunch programs based upon USDA standards and education for students and parents, adolescents and busy parents frequently rely upon packaged and fast foods to save time from cooking and results in a culture of blame (Child Nutrition, 2010). According to Power et al. (2010), teachers often blamed parents for not teaching their children good eating habits, while the parents blamed the schools for not providing the necessary education and healthy school lunch programs for their children, and the children blamed their parents for not providing the right food to eat and for not being able to provide transportation to and from after school physical activities. While factors like neighborhood safety, affordability of equipment, and high cost of school activities create barriers for student’s exercise, student’s limitations of exercise are directly related to a lack of interest and lack of time (Morin et al., 2013).
Social factors affecting psychological and safety concerns among adolescents are associated with living in poverty stricken areas, and being evicted from their homes by their parents, often leading to depression, substance use, and violent activity. A primary influencing factor was a lack of an adult mentor for social guidance and support (Seil, Desai,
& Smith, 2014). According to the CDC (2012), suicide among adolescents and teens is the third leading cause of death for this age group. Further, Healthy People 2020 indicated that mental health is a leading health indicator and if left untreated can lead to high risk behaviors, such as substance abuse, violence, self-harm, and suicide (Healthy People 2020). Depression among adolescents and teens is difficult to recognize and identify making it equally difficult to address and potentially prevent it. Depression can lead to risk taking behaviors, such as substance abuse, physical dating violence (PDV), physical violence in general, and suicide. In the U.S. more anti-bullying programs have been put in place in schools to reduce teen depression and eventual suicide. Depression, suicidal ideation, and suicide attempts are hard to identify and detect in order to prevent adolescents or teens from attempting to take their own lives. The World Health Organization (WHO) published its first report on suicide as being a global phenomenon that is preventable (World Health Organization [WHO], 2014). For a national response to be effective, the WHO suggested that a governmental and non-governmental response is required. These responses need to involve communities and encourage the media for responsible reporting of suicide. They also need to be created to increase surveillance in communities in an effort to increase preventative measures before any suicide occurs.
Adolescent Health continued on page 9
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ConclusionPhysical health is a concern for adolescents in
regards to a lack of healthy foods, physical activity, with an increased risk for obesity leading to greater complications into adulthood. Physical activities are less available to adolescents and teens living in impoverished or dangerous neighborhoods, making it harder for them to commute by walking, or be able to participate in afterschool programs due to lack of sufficient transportation. Mental health and safety are continuing concerns in regards to violence, depression, substance abuse, and suicide with minimal resources available or known to adolescents and teens. School programs are focusing more on the importance of physical health and wellbeing compared to mental health needs. Suicide is a widespread phenomenon in the U.S. and has garnered the attention of The World Health Organization to publish a report to address its global impact.
Nurses acting as advocates, educators, and promoters of self-care and self-efficacy will provide the necessary assistance for adolescents to perform more adult functions independently. Nursing interventions that take into account physical, psychological, safety, and social aspects of adolescent and teen health should be emphasized. If one or more of these aspects were out of balance, then the others would begin to decline as well. The literature found more interventions focused on physical activity and nutrition rather than mental health, while none of the literature reviewed had any described mental health interventions to be used by nurses.
Future nursing research should be directed towards mental health initiatives that encompass depression screening, depression treatment methods such as counseling, suicide assistance resources
and identification, violence prevention, and sexual education with a focus on primary interventions, and substance abuse counseling.
ReferencesCenters for Disease Control & Prevention, Adolescent and
School Health, National Organizations. Retrieved from: http://www.cdc.gov/healthyyouth/partners/ngo/index.htm
Centers for Disease Control & Prevention. (2012). Suicide: Facts at a glance. Injury Prevention and Control: Division of Violence Prevention. Retrieved from: http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
Healthy People 2020, Educational and Community-Based Programs, ECBP-10, ECBP-10.1, ECBP-10.2, ECBP-10.3, ECBP-10.4, ECBP-10.5, ECBP-10.7, & ECBP-10.8. Retrieved from: http://www.healthypeople.gov/2020/topics-objectives/topic/educational-and- community -based-programs
Kann, L., Kinchen, S., Shanklin, S.L., Flint, K.H., Hawkins, J., Harris, W.A., Lowry, R., O’Malley Olson, E., McManus, T., Chyen, D., Whittle, L., Taylor, E., Demissie, Z., Brener, N., Thornton, J., Moore, J., Zaza, S. (June 13, 2014). Youth risk behavior surveillance-United States, 2013. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report (MMWR), 63(4). Retrieved f rom: http://w w w.researchgate.net/prof i le/
Adolescent Health continued from page 8
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Lloyd_Kolbe/publication/15458703_Youth_risk_behav ior_sur vei l lance--United_States_1993/links/00b495152f17f44462000000.pdf
Morin, P., Turcotte, S., Perreault, G. (September, 2013). Relationship between eating behaviors and physical activity among primary and secondary school students: Results of a cross-sectional study. Journal of School Health, 83(9), 597-604. DOI: 10.1111/josh.12071
Power, T.G., Bindler, R.C., Goetz, S., Daratha, K.B. (January, 2012). Obesity prevention in early adolescence: Student, parent, and teacher views. Journal of School Health, 80(1), 13-19. DOI: 10.1111/j.1746-1561.2009.00461.x
Seil, K., Desai, M., Smith, M. (October, 2014). Sexual orientation, adult connectedness, substance use, and mental health outcomes among adolescents: Findings from the 2009 New York City youth risk behavior survey. American Journal of Public Health, 104(10), 1950-1955. https://apha.confex.com/apha/141am/webprogram/Paper283547.html
The White House, Office of the Press Secretary. (December 13, 2010). Child nutrition reauthorization healthy, hunger-free kids act of 2010. Read the Fact Sheet. Retrieved from: http://www.whitehouse.gov/sites/default/files/Child_Nutrition_Fact_Sheet_12_10_10.pdf
World Health Organization. (2014). Preventing suicide: A global imperative. Geneva, Switzerland: WHO Press. Retrieved from: http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
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FREE ON-LINE EDUCATION FOR DELAWARE HEALTH CARE PROFESSIONALS
NATIONAL FOCUS ON DIABETES AND HYPERTENSIONAt its 2015 Annual Meeting the American Medical Association announced three major initiatives for the coming year. One of these initiatives is to target hypertension and diabetes in order to help Americans lead healthier and happier lives. The two conditions cost Americans a half trillion dollars in health care expenditures each year.
The Medical Society of Delaware, through a grant from the Delaware Division of Public Health and assistance by our educational partner Million Hearts Delaware, has created free web-based continuing medical education activities focused on hypertension and pre-diabetes, with Delaware-specific resources. Primary care physicians and specialists, nurses, pharmacists and other health care professionals are strongly encouraged to participate in these free educational offerings.
These activities have been approved for AMA PRA Category 1 Credit.TM
Learn the answers to your questions about identifying and managing hypertensive and pre-diabetic patients with free web-based continuing medical education activities.
Meet the patient, Ms. Jones, and follow her course of treatment to control her hypertension. It is recommended that the Hypertension modules be taken in order.
HYPERTENSION Module 1“Early Intervention, Identification, & Screening for Hypertension”http://doiop.com/hypertension-1
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What are the best ways to
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