Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK TD2 Behavioral, Neurologic, And Digestive Disorders Discussion Part Two

Exam (elaborations) NR 507 PATHOPHYSIOLOGY WEEK TD2 Behavioral, Neurologic, And Digestive Disorders Discussion Part Two Discussion Part Two (graded) Responses Lorna Durfee 6/13/2016 2:50:10 PM Discussion Part Two Your patient is a 77-year-old woman who has been more socially withdrawn lately and told her daughter she had not been feeling well. Her daughter has noticed a stepwise decline. While shopping for groceries with her daughter, she became separated from daughter in the aisles. She became confused and angry when store employees and others tried to assist her. Her current medications are Hydrochlorothiazide, Lisinopril, and Atorvastatin. • What is your differential diagnosis based on the information you now have? • What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) • How would you treat this patient and discuss why you give each medication or therapy you give. Doctor Brown: This patient appears to be exhibiting signs of loss of memory and having difficulty finding her way. She also demonstrates some agitation. From her symptoms and signs, she is exhibiting forgetfulness along with confusion and irritability; this could be the start of Alzheimer’s or dementia. When evaluating this patient consideration of current medications are vital. There can be drug interactions and toxic effects of certain medications. This patient may be exhibiting signs of toxic drug reaction. As we age, our body does not filter out medications as easily as when we were at a younger age. There could be a side effect or interaction occurring with her medications. As for her medications, The American Geriatrics Society, and Beers Criteria recommends that in patients over 65 years of age to use caution when prescribing diuretics. There is a risk of the syndrome of inappropriate antidiuresis, or hyponatremia when using Hydrochlorothiazide (Dynamed, 2016). This patient could be exhibiting the beginning of potassium depletion or hyponatremia. There is no indication of what her fluid consumption has been or what her electrolyte levels are. There can be adverse effects with an excessive reduction in blood pressure such as with orthostatic hypotension with the use of Hydrochlorothiazide. Confusion can be a symptom of adverse effects from the drug (Dynamed, 2016). Lisinopril – This is an ACE inhibitor and antihypertensive medication. This medication, when used in the geriatric population, needs to be used with caution. Another thing to consider, when using this medication, is decreased hepatic, renal and cardiac function. This medication can also cause hypotension (Dynamed, 2016). Atorvastatin - An HMG-CoA Reductase Inhibitor. This medication can be a factor for myopathy in the geriatric population. Before the use of this medication the adverse effects, drug interactions, and patient preferences should be reviewed. It is also an antilipemic agent. As a side effect from this medication, the patient may also be experiencing hyperglycemia effects. The side effect of cognitive impairment is rarely reported with use of this medication. Because there is a component of cognitive impairment in this patient, the National Lipid Association (NLA) statin safety assessment task force recommends evaluating this patient for a statin. They also recommend evaluation for non-statin causes, such as other medications, systemic or neuropsychiatric causes (Dynamed, 2016). What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) When asking this patient questions we could begin by asking her if she is feeling confused and overwhelmed. We could use a very calm demeanor. We would ask about her eating, sleeping, bowel movements, and do a system review. If she cannot answer those questions, the caregiver who accompanies her can help with this. We would also need to do a physical exam. Then we would need to do a mini-mental exam. We could use the Folstein mini-mental questionnaire. We could ask her if she knows where she is. We could also ask if she knows the date, the time, the President, and her name. We could have her spell a “WORLD” backward. We must assess her mental status and review her medications. The family members that accompany this visit could fill us in on details of what they have observed and give a detailed history. We could run some further blood tests to determine if there is any metabolic condition underlying this change. What is your differential diagnosis based on the information you now have? I think that this patient shows signs of mild cognitive impairment and possible onset of dementia. The Alzheimer’s Association explains that dementia is not a specific disease but an overall term that outlines a range of symptoms that appear with a decline in memory or thinking. Dementia limits the person’s ability to perform activities of daily living. Alzheimer’s accounts for 60 to 80 percent of the cases of dementia, however, vascular dementia is the second most common type worse (Alzheimer's Association, 2016). There are other conditions such as thyroid or vitamin deficiencies that can cause problems. The Alzheimer’s Association lists some of the conditions under what is considered dementia. If patients have dementia at least two core mental functions must be impaired. The core mental functions are; memory, communication, and language, ability to focus and pay attention, reasoning and judgment and visual perception. There can be problems with short-term memory, paying bills, preparing meals and traveling into unknown and recognized areas. Dementias are progressive, and the symptoms can start slowly and then get worse (Alzheimer's Association, 2016). There are other problems that cause memory issues, such as; depression, medication side effects, excessive use of alcohol, thyroid and vitamin deficiencies (Alzheimer's Association, 2016). Mild cognitive impairment is a symptom first seen in the progression of Alzheimer’s Disease. There is mild memory loss for recent and new information in early stage Alzheimer’s Disease. In other words, there is short-term memory loss, difficulty with planning and disorientation to location. There is also possible depression and mild anxiety. There is also mild instrumental activities of daily living (McCance, Huether, & Brashers, 2014, p. 550). How would you treat this patient and discuss why you give each medication or therapy you give? Establishing the cause for this dementing process may be very complicated. However, patients should be evaluated with laboratory and neuropsychologic testing and brain imaging. The use of neuroleptic medications could be considered. If there is depression the use of antidepressants can be appropriate (McCance, Huether, & Brashers, 2014, p. 546). Moyer ( 2014) and The United States Preventative Task Force state that older aged people are a known risk factor for cognitive impairment. There are other risk factors such as diabetes, tobacco use, hypercholesterolemia, and hypertension. A history of head trauma, depression, and physical frailty. Also, the lack of a proper support system. The screening tests suggested are for cognitive impairment, and that includes tasks that require attention, memory, language and visual-spatial abilities. The most used method is the Mini-Mental State Examination. There is also the clock drawing test, 7-minute screen, and questionnaire on cognitive decline in the elderly. The recommended treatment with pharmacologic agents includes acetylcholinesterase inhibitors and memantine. They also recommend cognitive training, lifestyle modifications and behavioral, exercise, education and multidisciplinary care (Moyer, 2014, p. 792). The National Institute on Aging (2016) tell us that there are medications that are approved by the United States Food and Drug Administration to treat the symptoms of Alzheimer’s Disease. They are; Donepezil (Aricept), rivastigmine for mild to moderate Alzheimer’s. Aricept and Memantine (Namenda) can be used to treat severe Alzheimer’s. Behavioral and cognitive training can help as well. Research is being undertaken in clinical trials to include; immunization therapy, drug therapies, treatments used for cardiovascular disease and diabetes (National Institute on Aging, 2016). This patient must undergo further testing and examination with possible referral to a specialist to determine whether or not she has underlying pathology is in indeed related to dementia. Her metabolic function or side effects from medications and other considerations will be dealt with through blood testing. A simple mini mental exam can help determine if this is cognitive impairment. Confirmation of dementia would be accomplished by a collaborative process and multidisciplinary approach. References Alzheimer's Association. (2016). Dementia – Signs, Symptoms, Causes, Tests, Treatment, Care. Retrieved from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Atorvastatin. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Hydrochlorothiazide. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from American Society of Health System Pharmacists, Inc. Dynamed . (2016 Feb 24). Lisinopril. Ipswich, MA: EBSCO. Retrieved June 13, 2016, from Boss, B. J. (2014). Alterations of Cognitive Systems, Cerebral Hemodynamics, and Motor Function. In McCance, K. L., Huether, S. E., Brashers, V. L. (Eds.), Pathophysiology: The biologic basis for disease in adults and children (7th ed., p. 550). St. Louis, MO: Mosby. Moyer, V. A. (2014). Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 160(11), 791-797. National Institute on Aging. (2016). About Alzheimer's Disease: Treatment. Retrieved June 13, 2016, from Rechel DelAntar reply to Lorna Durfee 6/15/2016 7:22:23 PM RE: Discussion Part Two Hello Lorna, Great post. Medications are an important part to consider in cause of diseases. Different people react to medication differently and age plays a part on its effects. The cause of Alzheimer's is not yet well defined but is constantly being researched upon. One of the studies on Alzheimers was done by John Hopkins and published in 2013 in the journal Neurology, suggested that High blood pressure is one the of the causes of Alzheimer's Disease. That’s the intriguing finding from a Johns Hopkins analysis of previously gathered data, which found that people who took commonly prescribed blood pressure medications were half as likely to develop Alzheimer’s as those who didn’t. High blood pressure can damage small blood vessels in the brain, affecting parts of the brain responsible for thinking and memory. Researchers found that the use of potassium-sparing diuretics reduced the risk of Alzheimer’s nearly 75 percent, while people who took any type of antihypertensive medication lowered their risk by about a third (John Hopkins Medicine, 2013). This interesting because in this case, the patient is taking 2 anti-hypertensive meds, Lipitor and hydrochlorthiazide and should be a low risk to develop Alzheimer’s. However, it is an unknow if she has had a history of high blood pressure in the past and for how long. The patient may still has uncontrolled hypertension at this time despite medications at this time. Or is one of her medications causing her to have Azlheimer’s as you have pointed. It is a very interesting subject with different possibilities as to causation. At this point efforts are into treatment until there is a definitive answer to the cause of Alzheimer’s. Reference: John Hopkins Medicine. (2013). Blood Pressure and Alzheimer’s Risk: What’s the Connection. Retrieved from healthy_aging/healthy_body/blood-pressure-and-alzheimers-risk-whats-theconnection. Rechel DelAntar 6/14/2016 9:16:46 PM Differential Diagnosis Hello professor and Class, Differential Diagnosis This is a case of a 77 year old that has been observed by the daughter to be increasingly withdrawn. Patient is only taking hypertensive meds, hydrochlorthiazide, lisinopril and atorvastatin. The daughter expresses a steep decline and verbalizes that while doing grocery shopping, the patient became confused and angry with store employees who were trying to assist her. A possible differential diagnosis for this patient would be: Dementia of Alzheimer’s Type = Dementia is a general term for a decline in mental ability severe enough to interfere with daily life. Dementia is not a disease but a group of symptoms and can be caused by a variety of conditions, the most common of which is Alzheimer's disease. Alzheimer’s disease is the leading cause of dementia and one of the most common causes of severe cognitive dysfunction in older adults. Nonhereditary, or sporadic or late onset type is the most prevalent form (70%) (McCance, K.L., et. al., 2013). The most common early symptom is short-term memory loss. As a person's condition declines, they often withdraw from family and society. As the disease advances, symptoms can include problems with language, disorientation, mood swings, loss of motivation, not managing self care, and behavioral issues. The cause of Alzheimer's disease is not well understood. About 70% of the risk is believed to be genetic. Other risk factors include a history of head injuries, depression, or hypertension since the disease process is associated with plaques and neurofibrillary tangles (National Institute on Aging, 2011). Gathering accurate historical data as well as testing is important in order to be able to provide an accurate diagnosis. As primary care giver, is important to perform early cognitive screening among our elderly. Cognitive impairment in older adults has a variety of causes, including medication side effects, metabolic and/or endocrine imbalance, delirium due to illness, depression, and dementia, with Alzheimer’s dementia being most common. Some causes, like medication side effects and depression, can be reversed with treatment. Others, such as Alzheimer’s disease, cannot be reversed, but symptoms can be treated for a period of time and families can be prepared for predictable changes. Questions to ask the patient: 1. What is her current and past medical history? 2. What medications is she taking? 3. What is family’s medical history including dementia? 4. Ask her about her dietary intake? Ask about current or history of alcohol intake or abuse as well as substance abuse. 5. Ask her about her current mental and emotional state? Does she feel depressed, confused, agitated, angry and why? 6. A mini-cog test can also be performed to assess patient’s cognitive status. Complex questions to assess functional status are best done alone with the patient so family or companions cannot prompt the patient (National Institute on Aging, 2016). Questions for the family? 1. What behavior changes have you noticed and when did it start? 2. Allow family to voice concerns and give specific examples. 3. Confirm with family medications patient is supposed to be taking. 4. Ask about medical family history including dementia. 5. Ask if the patient has had a history of alcohol or substance abuse past and present. The Alzheimer’s organization has developed and Alzheimer’s Identification tool, which is a questionnaire designed specifically for family members, which is used in conjunction with the patient’s mini-cog test and assessment can determine dementia among the elderly (Alzheimer’s Association, 2016). Treatment to Alzheimer’s involves different modalities. Trigger identification and behavior modification decreases anxiety, agitation and depression. Events of changes trigger behavioral symptoms. Change can be stressful for anyone and can be especially difficult for a person with Alzheimer's disease. It can increase the fear and fatigue of trying to make sense out of an increasingly confusing world. Identifying triggers can help in modifying the situation or environment as well as develop approaches to a situation before symptoms occur. Coping modalities by care givers such as monitoring comfort, avoiding confrontational behavior, redirecting attention, providing a quiet and clam environment, allow adequate rest, acknowledge request, explore other alternatives and not taking the behavior personally are helpful in caring for these patients. If non-drug approaches fail, medications may be appropriate for the patient. Medications used for this disease are Antidepressants (for mood), Anxiolytics (for anxiety/restlessness), Antipsychotic medications (for hallucinations) (Alzheimer’s Association, 2016). Reference: Alzheimer’s Association. (2016). Treatment for Behavior. Retrieved from Alzheimer’s Association. (2016). What is Dementia. Retrieved from National Institute on Aging. (2013). About Alzheimer’s Disease: Symptoms. Retrieved from National Institute on Aging. (2016). Assessing Cognitive Impairment in Older Patients: A Quick Guide for Primary Care Physicians. Retrieved from cognitive-impairment-older-patients#instruments. McCance, K.L., Huether, S.E., Brashers, V.L. and Rote, N.S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7 ed.). St. Louis,MO: Mosby. th Jennifer Roth reply to Rechel DelAntar 6/17/2016 7:38:03 AM RE: Differential Diagnosis Hi Rechel, I agree with you in that Alzheimer's disease/Dementia is the primary diagnosis. However, a UTI could also potentially be an option depending on the patient's history, medications, and symptoms. UTI's in the elderly are quite common and may be symptomatic or asymptomatic. A decline in mental or functional status may be seen in the elderly client with a UTI (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Toxicity from infection can cause an altered mental status (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Deterioration of mental status in a population with a high degree of cognitive impairment makes judging this indication of a UTI difficult (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Even so, research has shown that an altered mental state was the second most common indicator of bacteremia in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). A decline in general status has been described as an indication and sometimes the only indication of a UTI in the elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). This symptom may signal the subtle physical, mental, or functional changes that are present but difficult to describe in many elderly (Hsaio, Yang, Hsaio, Hung, & Wang, 2015). Reference Hsaio, C.Y., Yang, H.Y., Hsaio, M.C., Hung, P.H., & Wang, M.C. (2015). Risk Factors for Development of Acute Kidney Injury in Patients with Urinary Tract Infection: e. PLoS One, 10(7). doi: 10.1371/. Lanre Abawonse 6/15/2016 12:10:13 AM Discussion Part Two What is your differential diagnosis based on the information you now have? Alzheimer Disease Alzheimer’s disease (AD) is a degenerative disorder of the brain that is manifested by dementia and progressive physiological impairment. It is the most common cause of dementia in the elderly but is not a normal part of aging. Age and family history are the biggest risk factors however, this patient has other risks factors such as being female, estrogen deficit after menopause, having hypertension and hyperlipidemia (McCance, Huether, Brashers, & Rote, 2013). Dementia Dementia is not a specific disease but rather a syndrome associated with pathological processes in which the generic term is characterized by cognitive and behavioral disorder. The behavior seen is progressive deterioration and continuing decline of memory and other cognitive changes. A sudden change is behavior may be an indication that it is not dementia, as dementia progresses slowly (Somes, Donatelli, & Barrett, 2010). Personality and behavior changes accompany the cognitive deterioration. Judgement, abstract thinking and complex task performance are all affected. Many demented patients have agnosia or lack of insight into their cognitive deficiencies. Drug induced psychosis Drugs such atorvastatin have been labeled to have unwanted effect in some patients. In some of my clinical experience, a patient was admitted to the hospital where I work for violent and aggressive behavior. According to family members, this patient exhibited symptoms of aggressiveness after taking atorvastatin. Some findings have claimed that one in four Americans could experience aggressive behavior after taking atorvastatin. Is it possible to for us to ever know if this is the case? Gauthier and Massicotte (2015) stated that drug induced psychosis is characterized by hallucinations, delusions, memory loss, and confusion. There is an ongoing investigation about the incidence of psychosis induced by atorvastatin. What other questions would you like to ask her now? (Questions can be asked of patient first, and then of reliable historian separately.) One of the basic ways of finding out the true illness of a patient is the ability to question the patient, with the hope that a correct picture will be accounted for during assessment history. In many cases, the family members are the most useful resources in getting the information. In light of this, Thornbory (2013) suggested to establish what investigations and treatment were given and what the person had been told by their primary physician or specialist. It would be vital to ask the patient and the family member who take care of the patient daily what prior event leads to this outburst. Has there been any stress (loss, financial, or family stressor), any recent sickness, has she had medication changes, are there any prescription medicine she is taken, if so how and when? Does she live alone or does she have someone to take care of her? Does she uses any recreational drugs (weed, cocaine, meth, etc)? Has she had and previous changes in mental status? How would you treat this patient and discuss why you give each medication or therapy you give. Since Alzheimer’s disease (AD) is a severe chronic neurodegenerative disease characterized by progressive cognitive impairment, functional decline and neuropsychiatric symptoms, one of the recommended treatments is the use of cholinesterase. Spalletta et. al., (2014) stated that cholinesterase inhibitors (ChEIs) are the most effective drugs available at present for treatment of mild to moderate AD, can stabilize cognitive symptoms for a one to three year period, but they are not able to modify the progression of the disease. There is also preliminary evidence that they may improve some neuropsychiatric symptoms. Unfortunately, the therapeutic response to ChEIs is less satisfying in the long-term period and some patients adhere to prescribed treatment for only a short time. Using Aricept 5mg a day can help in modifying the disease. This can be increased to 10mg a day after one month. Reference Gauthier, J. M., & Massicotte, A. (2015). Statins and their effect on cognition: Let’s clear up the confusion. Canadian Pharmacists Journal (Sage Publications Inc.), 148(3), 150. doi:10.1177/ Grimes, J. A. (2016). Alzheimer disease. In F. J. Domino (Ed.), The 5-minute clinical consult 2016 (24th ed., pp. 36-37). Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins. Hort, J., O’Brien, J. T., Gainotti, G., Pirttila, T., Popescu, B. O., Rektorova, I.,& ... Scheltens, P. (2010). EFNS guidelines for the diagnosis and management of Alzheimer’s disease. European Journal of Neurology, 17(10), . doi:10.1111/j..2010.03040. McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby. Somes, J., Donatelli, N. S., & Barrett, J. (2010). Sudden confusion and agitation: causes to investigate! Delirium, dementia, depression. Journal of Emergency Nursing: JEN: Official Publication Of The Emergency Department Nurses Association, 36(5), 486-488. doi:10.1016/.2010.06.010 Spalletta, G., Caltagirone, C., Padovani, A., Sorbi, S., Attar, M., Colombo, D., & Cravello, L. (2014). Cognitive and Affective Changes in Mild to Moderate Alzheimer’s Disease Patients Undergoing Switch of Cholinesterase Inhibitors: A 6-Month Observational Study. Plos ONE, 9(2), 1-9. doi:10.1371/. Thornbory, G. (2013). Taking a history and making a functional assessment. Occupational Health, 65(3), 27-30. Sarah Boulware 6/15/2016 12:47:50 PM Part Two Dr. Brown and Class, 1. Drug Induced intoxication related to Atorvastatin Atorvastatin is a medication that lowers cholesterol levels by lowering low-density lipoprotein (LDL) levels and raising high-density lipoprotein (HDL) levels. It is a statin that works by slowing the production of cholesterol in the body to decrease the amount of cholesterol that may build up on the walls of the arteries and block blood flow to the heart, brain, and other parts of the body. Side effects include forgetfulness or memory loss, confusion, lack of energy, extreme tiredness, weakness, and loss of appetite. The patient seems to be experiencing some of these side effects (U.S. National Library of Medicine, 2016). 2. Dementia related to Alzheimer’s Dementia is a disorder of cognition that interferes with daily functioning and results in loss of independence. The majorities of dementias are of a gradual onset, are progressive in course, and occur in people with previously normal cognition. Dementia is a culmination of dysfunction in the cerebral hemispheres. Diseases that cause dementia do so by affecting particular parts of the cerebra cortex, subcortical muscle, or the underlying white matter pathways that link different cortical regions. Neuropsychiatric symptoms are common. They include apathy, loss of initiative, depression, anxiety, and irritability. Anterograde amnesia is typically the first symptom present. The patient has experienced a gradual progression of her symptoms. (Knopman, 2012). 3. Depression Depression and anxiety are the most common psychiatric diseases among the elderly and often remain undiagnosed or untreated. Symptoms of depression include feelings of sadness, or feeling low, loss of interest and reduction of participation in daily life, negative talk, poor concentration, sleep disturbance, general appearance of looking sad or unkempt (Hardy, 2011). Questions I would first ask the patient and her daughter about her medications. When is the last time she took Atorvastatin? Has she missed any doses and tried to double up on doses? Has she had any alcohol with the medication? I would ask her these questions because alcohol can increase the risk of severe side effects or she may have been taking extra doses without realizing it due to her confusion. I full mental status exam is necessary as well. If her symptoms don’t appear to be from her medications I would suspect dementia as my primary diagnosis (U.S. National Library of Medicine, 2016). Treatment Alzheimer’s disease is the most common form of dementia and is a degenerative, incurable and terminal illness. Patients exhibit progressive cognitive failure and a decline in reasoning. There is no drug that can cure Alzheimer’s. Treatment to delay symptoms works best if initiated in the early stages. The choice of drug is determined by the stage of the disease. Cholinesterase inhibitors, like donepezil hydrochloride, rivastigmine, and galantamine, inhibit the enzyme acetylcholinesterase from breaking down the neurotransmitter acetycholine, which is essential for communication (Shan, 2013). References Hardy, S. (2011). Depression in the elderly: ways to offer support. Practice Nursing, 22(10), 520-525. Knopman, D. (2012). Alzheimer’s disease and other dementias. Goldman’s Cecil Medicine, 2, . Shan, Y. (2013). Treatment of Alzheimer’s disease. Primary Health Care, 23(6), 32-38. U.S. National Library of Medicine. (2016). Atorvastatin. Retrieved from Instructor Brown reply to Sarah Boulware 6/17/2016 8:45:45 AM RE: Part Two I see how the medication Atorvastatin works. How would this cause the intoxication? How would it cause the S/E of memory loss, confusion? Sarah Boulware reply to Instructor Brown 6/19/2016 3:17:04 PM RE: Part Two Dr. Brown, Ford (2013) found that in general statins are well tolerated. Side effects include altered liver function, gastrointestinal effects such as flatulence, abdominal pain, diarrhea, nausea, and vomiting, and muscle aches. Muscle damage can progress to rhabdomyolosis. Less well known side effects include sleep disturbances, memory loss, and sexual dysfunction. The cause of these side effects is unclear. It is important to take into account patient reports of side affects and acknowledge that concordance with therapy may be influenced by individuals’ perceptions of side effects. Hepatotoxicity has been associated with atorvastatin. The cause is unknown but the drug is mostly metabolized in the liver and excreted in the bile. The Food and Drug Administration examined the complaints of memory loss, forgetfulness, and confusion for patients taking Atorvastatin. The cause for this side effect is still undetermined. References Ford, H. (2013). Use of statins to reduce the risk of cardiovascular disease in adults. Nursing Standard, 27(39), 48-56.