TUGAS KEPERAWATAN
KELUARGA
ANALISIS JURNAL
HOME CARE
Nama
: Hikmah Musthofiatun
NIM
: 04.09.2274
Kelas
: C/KP/VII
STIKES
SURYA GLOBAL YK
Dosen
: Arita Murwani s.Kep, M.Kep
HOME BLOOD PRESSURE
MONITORING IN DIABETES
Caroline
Gompels, Denis Savage
Abstract
Forty
three children with diabetes were recruited to evaluate home blood pressure
monitoring using an electronic oscillometric
sphygmomanometer
(Philips HP5330). This device was found to be simple to use and reliable. It
fulfilled the accuracy criteria of the American Association for the Advancement
of Medical Instrumentation for both systolic and diastolic blood pressure and
those of the British Hypertension Society for systolic blood pressure. Thirty
eight children successfully measured their own blood pressure at home and
taught other family members to do the same. The results indicate that home
blood pressure monitoring is of value in the management of diabetic children.
these factors and to assess the potential value of home blood pressure
monitoring.
Patients and methods
Forty
three (26 male, 17 female) children and teenagers with insulin dependent
diabetes were
recruited
randomly from the clinic over a six month period. Their mean age was 15-0 years
(range 8-819-3 years) and mean duration of diabetes 6-7 years (range 0-2-17-3
years). The home monitor used was the Philips HP5330 which measures systolic
and phase V diastolic blood pressure by the oscillometric method and displays
the results digitally. The study initially validated the home monitor, and then
examined the results of home blood pressure monitoring in these patients and
some of their families. Diabetic nephropathy is the major life threatening complication
of juvenile onset diabetes.' Preceding the nephropathy by as much as 10 years
there may be a small but significant rise in blood pressure, usually together
with microalbuminuria. 2 Antihypertensive therapy at this normotensive stage
(according to the criteria of the World Health Organisation (WHO)3) can prevent
the progressive decline in renal function and associated rise in blood
pressure.4 Blood pressure then, should be measured as accurately as possible in
young diabetic patients. When measured in outpatient clinics, blood pressure is
often raised.5 In adults, a series of pressure measurements at home is helpful
in distinguishing patients with sustained hypertension from those with 'office
hypertension'.6 Home recordings using an electronic sphygmomanometer correlate
closely with ambulatory measurements,7 which have been shown to be of greater
predictive value than office measurements. 8 The accurate assessment of blood
pressure in young diabetics should therefore probably include a representative
home series before appropriate diagnostic and therapeutic decisions can be
made. As familial hypertension may be a risk factor for nephropathy,9 the blood
pressure of parents and siblings should also be assessed; home monitoring would
provide a practical means of doing this. To our knowledge, home blood pressure monitoring
in diabetic children and their families has not previously been evaluated. As
the usefulness of such a technique depends primarily on the reliability and
accuracy of the equipment when used in the population under review and on the
abilities of those performing the home monitoring, this study was designed to
examine.
VALIDATION OF THE HOME
MONITOR
The
validation procedure included the criteria of the American Association for the
Advancement of Medical Instrumentation (AAMI)'° and the British Hypertension
Society (BHS) protocol. " Pressure indicator accuracy and interdevice variability
Calibration was checked by connecting the monitor to a standard mercury column
with a Y connector. The pressure recorded on the monitor was then compared with
that indicated on the mercury column. This was done for pressures of 0, 50,
100, and 150 mm Hg before use and on return from each family for all of the eight
monitors purchased for the study. The AAMI protocol requires 95% of
measurements to be within 3 mm Hg of the reference standard. Interdevice
variability was assessed by analysis of variance.
Device validation
The
subjects rested in a sitting position for at least five minutes before their
blood pressure was measured on the right arm using an adult cuff (bladder size
12x22 cm). No child was admitted to the study in whom this cuff size would have
been inappropriate. 12 The bloodpressure was measured simultaneously with the monitor
and a random zero sphygmomanometer by using a Y connector. Two or three pairs
of readings were recorded at two minute
intervals. Systolic and diastolic (phase V) pressures were recorded by
auscultation to the nearest 2 mm Hg. The AAMI protocol requires the mean
difference to be <5 mm Hg and the standard deviation (SD) to be <8 mm Hg
for both systolic and diastolic pressures. The BHS protocol grades the monitor
on the cumulative percentage of measurements differing from the reference sphygmomanometer
by 5, 10, and 15 mm Hg. Acceptability for home use The patients were taught to
use the home monitor and were asked to record their own blood pressure at home
three times between 1730 and 2100 hours for three days. They were asked to rest
in a sitting position for at least five minutes before starting and to leave at
least two minutes between readings. The importance of correct positioning of
the cuff around the right arm, correct inflation procedure,'3 a steady deflation
rate of 2-3 mm Hg/second, and keeping the arm and tubing still during the
measurements (as oscillometric devices can give inaccurate results with
excessive movement) were all explained and reiterated in an instruction leaflet
given out with the monitor. A chart was provided for recording the results with
space for comments on the monitor. The patients were
asked
to teach the rest of the family how to use the device and record the results at
home in a
similar
manner. The monitor was collected from the home a week later. The participating
family members were weighed and measured, asked details of illnesses,
medication, and whether they had encountered any problems in using the monitor.
The mean value for systolic and diastolic pressures was calculated for each
diabetic child and their natural mother, father, and eldest sibling (aged
>10 years). Any measurement where either the systolic or the diastolic
pressure was >30 mm Hg from the mean was rejected as invalid and the mean
computed again from the remaining measurements. Any occasions on which it had
been recorded that the monitor had failed to function were also noted as were
any other comments written or verbal about the monitor. Unless at least three
valid measurements were available the blood pressure series was not used for
further analysis.
EVALUATION OF HOME
BLOOD PRESSURE
MONITORING
The
mean of each diabetic child's blood pressure measurements that had been recorded
using the home monitor in the clinic (when validating it against the random
zero sphygmomanometer) was calculated and compared with the mean home blood
pressure obtained with the same home monitor. The mean home blood pressure of
the diabetic children and siblings was compared with the blood pressure
centiles for height based on the data of Andre et all4 as suggested by the
BHS.'2 The mean home blood pressure of each parent was graded according to WHO criteria:
normal (<140/90), borderline (between 140/90 and 160/85), and high
(>160/85).3
RESULTS
VALIDATION
OF THE HOME MONITOR
Pressure
indicator accuracy and interdevice variability. At all pressures compared (0,
50, 100, and 150 mm Hg), 100% monitor measurements were within 3 mm Hg of those
indicated on the mercury column. Each monitor was used by between four and
eight families and there was no deterioration in accuracy over the course of the
study. Analysis of variance revealed no significant interdevice variability. Device
validation A total of 124 paired measurements were recorded in 43 patients
(three pairs of readings in 38 patients and two pairs in five patients). The
range of systolic pressures in the 43 diabetic children was 75-157 mm Hg and
the range of diastolic pressures was 43-98 mm Hg. The home monitor's systolic
pressures fulfil the AAMI standard for accuracy (mean (SD) difference 1-7 (5 1)
mm Hg) and achieve BHS grade B. The monitor's diastolic pressures fulfil the AAMI
criteria (mean (SD) difference 4-9 (5 8) mm Hg), and achieve a BHS grade D.
There was no statistical evidence of terminal digit preference in the random
zero sphygmomanometer readings. Acceptability for home use None of the 43
patients invited to participate declined at the start of the study and 38 completed
the home monitoring satisfactorily. Five failed to complete the home blood
pressure series, but when asked to demonstrate whether they could use the
monitor correctly, all were able to do so. A total of 69 natural parents (33 fathers,
36 mothers) and 27 eldest siblings (15 male, 12 female) also participated. Rejected
readings occurred in <2% of over
1100
home blood pressure measurements. These were usually very high systolic
readings which tended to occur as a result of excessive movement during the
procedure. Five participants noted when the monitor either failed to record (usually
when the cuff deflation was too slow) or recorded 'error' (usually when cuff
deflation was too fast). A total of 61% of participants produced nine
measurements each, while the others produced between three and eight. Although
most of these stated that they had not had sufficient time to do all three
readings for three evenings as requested, some of these missing readings may
have resulted from machine failures or faulty technique. A few subjects
complained that the cuff was uncomfortable. There were otherwise no reports of
any significant problems and the majority of diabetic children and their
families said that they had enjoyed participating in the study.
EVALUATION OF HOME
BLOOD PRESSURE
MONITORING
Only
the results for systolic pressure were used in reviewing the blood pressure of
the diabetics and their families. Of the 38 diabetic children who completed the
study, 66% had a mean home systolicpressure within 10 mm Hg of their mean clinic
systolic pressure (fig 1). Three children had a clinic blood pressure more than
10 mm Hg 637 Gompels, Savage.
Mean
of readings at home (mm Hg) Figure 1 Comparison between the mean systolic blood
pressure measured by the home monitor in the clinic and the mean systolic blood
pressure at home. above their mean home blood pressure, one differing by 35 mm
Hg. Ten children had a home blood pressure more than 10 mm Hg higher than their
clinic pressure. One 17 year old diabetic boy had a mean systolic pressure of
145 mm Hg both in the clinic and at home; this was above the 90th centile for
his height. His mother is a diabetic and her mean home systolic blood pressure
was 134 mm Hg on antihypertensive treatment. One diabetic girl whose home blood
pressure was on the 90th centile has a brother whose blood pressure was on the
97th centile and a father, aged 56 and non-obese, whose home systolic pressure
was 168 mm Hg. The blood pressure of all the other diabetic children and their
siblings was unremarkable (figs 2A and 2B). Three fathers had a borderline
raised systolicpressure (between 140 and 160 mm Hg) but the other members of
their families were normotensive.
Discussion
This study successfully validated the use of the Philips
HP5330 home sphygmomanometer in
diabetic children and demonstrated the feasibility of
home blood pressure monitoring in this
group and their families. Electronic sphygmomanometers
designed for use in adults may not be sufficiently simple to use, reliable and
accurate for use in children and teenagers. Some devices designed for self measurement
of blood pressure fall far short of basic standards and some of the validation
tests to which they have been subjected are also questionable.' 0 " The detailed
protocols of the AAMI and BHS address these problems and it is hoped that, in
the future, home sphygmomanometers will be subjected to more rigorous validation
procedures by the manufacturers before being put on the market. Meanwhile, by adapting
a combination of those stringent tests to a paediatric setting, we have
provided a model for further studies and have validated one home monitor for
more regular use by the diabetics attending our clinic. The home monitor was
shown to be reliable in that all eight monitors maintained a high degree of
pressure indicator accuracy throughout the study and did not significantly vary
from each other. It passed the validation criteria for the AMI protocol and
achieved a BHS grade B for systolic pressure (grade A has proved unobtainable
by any device so far9), but performed less well for diastolic pressures.
However, this does not invalidate its use, as measurement of diastolic pressure
in children is notoriously difficult, inaccurate, and inconsistent. 14 '5 The
random zero sphygmomanometer was used as the reference standard in preference to
a standard mercury sphygmomanometer, although it was known that it slightly
underestimates both systolic and diastolic pressures. 6 This was done to minimise
observer bias and prevent digit preference since there was by necessity a
single observer (CG). Important features of the home monitor were that it was
simple to use and seldom malfunctioned. Even those who failed to complete the
home blood pressure monitoring had understood after one demonstration how to
use it correctly but were not sufficiently motivated to continue with the
study. The majority of the diabetic children participated enthusiastically and
also enlisted their families into the study with excellent results. The
participants were asked to measure their blood pressure in the evenings rather
than throughout the day to improve the acceptability of the study. As this is a
time of day when blood pressure is relatively stable,'7 the home series was
still felt to be representative of their day to day blood pressure. The numbers
of diabetic children, parents, and siblings involved in this study were small
as it was a validation and feasibility exercise. However, the results clearly
demonstrate the potential value of home blood pressure monitoring. It appears
to distinguish office hypertension from sustained hypertension: the boy with a
persistent systolic pressure of 145 mm Hg has since been further investigated
and treated, whereas the girl with a clinic pressure of 150 mm Hg and a home
pressure of 115 mm Hg has avoided unnecessary intervention. The home monitor
provides a profile of the family's blood pressure, so that diabetic children who
are possibly at risk of hypertension can be followed more closely. Whether
familial hypertension is an important risk factor in diabetic nephropathy
requires further research. As many diabetic teenagers attend clinics
unaccompanied, home monitoring is a practical method of assessing the blood
pressure of their families and probably of more relevance than an occasional
clinic measurement. It may also provide useful information for the general practitioner
in the surveillance of families with a tendency to hypertension (the father
with hypertension is now being treated). In fact, such family blood pressure
studies should perhaps be done in conjunction with general practitioners,
possibly using the diabetic liaison health visitor to teach and supervise the
home monitoring. It was surprising that 10 children had a home blood pressure
higher than their clinic pressure. Although none of these was above the 90th centile,
these home readings may be of greaterprognostic significance than their clinic
blood pressure, as has been demonstrated in adults.8 Large prospective studies
would be needed to answer this question.
We did not use a
control group of nondiabetic families in this study but instead compared the
blood pressure of the diabetic children and their siblings with centile charts which
relate pressure to height. These are particularly useful in diabetic children
in whom blood pressure and height are measured regularly. In any child whose
blood pressure is in the upper centiles or whose pressure appears to be crossing
centiles, a home series and family blood pressure profile may be appropriate.
In summary, the
management of diabetic children includes the prevention of complications. Careful
assessment of blood pressure is part of that surveillance and this study
demonstrates that home monitoring is feasible and accurate. We believe it has
great potential value in the management of diabetic children, particularly in
distinguishing sustained from office hypertension, and in providing a blood
pressure profile of a diabetic child's family.
DAFTAR PUSTAKA
1.
Deckert T, Poulsen JE, Larsen M. Prognosis of diabetics with diabetes onset
before the age of thirty one: survival, causes of death and complications.
Diabetologia 1978;14: 363-70.
2.
Jensen J, Borch-Johnsen K, Deckert T. Changes in blood pressure and renal
function in patients with type I (insulindependent) diabetes mellitus prior to
clinical diabetic nephropathy. Diabetes Res 1987;4:159-62.
3.
World Health Organisation. Arterial hypertension. Report of a WHO expert
committee on hypertension. WHO Tech Rep Ser 1979:628.
4.
Marre M, Chatellier G, Leblanc H, Guyene TT, Menard J Passa P. Prevention
of diabetic nephropathy with enalapril in normotensive diabetes with
microalbuminuria. BMJ 1988;297: 1092-5.
5.
Mancia G, Grassi G, Pomidossi G, et al. Effects of blood pressure
measurement by the doctor on patient's blood pressure and heart rate. Lancet
1983;ii:695-8.
6.
Hall CL, Higgs CMB, Notarianni L for the Bath District Hypertension Study
Group. Value of patient-recorded home blood pressure series in distinguishing
sustained from office hypertension: effects on diagnosis and treatment of mild
hypertension. J Hum Hypertens 1990;4 Suppl 2:9-13.
7.
Kleinert HD, Harshfield GA, Pickering TG, et al. What is the value of home
blood pressure measurement in patients with mild hypertension? Hypertension
1984;6:574-8.
8.
Perloff D, Sokolow M, Cowan R. The prognostic value ofambulatory blood
pressure. 7AMA 1983;249:2792-9.
9.
Krolewski AS, Canessa M, Warram JH, et al. Predisposition to hypertension
and susceptibility to renal disease in insulin-dependent diabetes mellitus. N
Engl J Med 1988; 318:140-5. Association for the Advancement of Medical
Instrumentation American national standard for electronic or automated
sphygmomanometers. Washington DC: AAMI, 1987
10.
O'Brien E, Petrie J, Littler W, et al. The British Hypertension Society
protocol for the evaluation of automated and semiautomated blood pressure
measuring devices with special reference to ambulatory systems. J Hypertens
1990;8: 607-19.
11.
de Swiet M, Dillon MJ, Littler W, O'Brien E, Padfield PL, Petre JC.
Measurement of blood pressure in children. Recommendations of a working party
of the British Hypertension Society. BMJ 1989;299:497.
12.
Veerman DP, Van Montfrans GA, Wieling W. Effects of cuff inflation on
self-recorded blood pressure. Lancet 1990;335: 45 1-3.
13.
Andre JL, Deschamps JP, Gueguen R. La tension arterielle chez l'enfant et
l'adolescent. Valeurs rapportees a l'age et a la tailHe chez 17,067 suiets.
Arch Fr Pediatr 1980;37:477-82. National Heart, Lung and Blood Institute,
Bethesda, Maryland Report of the second task force on blood pressure control in
children-1987. Pediatrics 1987;79:1-25.
14.
O'Brien E, Mee F, Atkins N, O'Malley K. Inaccuracy of the Hawksley random
zero sphygmomanometer. Lancet 1990; 336:1465-8. Millar-Craig MW, BishopCN,
Raftery EB. Circadian variation of blood pressure. Lancet 1978;i:795-7.
ANALISA
PERTANYAAN 5W+1H
- (Where) Dimana penelitian mengenai Pengukuran Tekanan Darah di Rumah Pemantauan Diabetes dilakukan?
Jawab : Penelitian
dilakukan di Asosiasi Amerika dan British Hypertension Society
- (When) Kapan waktu yang bagi pasien melakukan pengukuran tekanan darah di rumah?
Jawab : Pasien dilakukan pengukuran tekanan darah antara
17.30 dan 21.00 jam selama tiga hari yang sebelumnya pasien diajarkan untuk
menggunakan monitor rumah dan diminta untuk mencatat tekanan darah mereka
sendiri di rumah.
- (Who) Siapa yang menjadi Subjek penelitian dalam jurnal tersebut?
Jawab :
Anak-anak dengan diabetes melitus
- (Why) mengapa dalam penelitian tersebut peserta diminta untuk mengukur tekanan darah mereka di malam hari ?
Jawab : Dalam
penelitian tersebut peserta diminta untuk mengukur tekanan darah mereka di
malam hari daripada
sepanjang hari untuk meningkatkan penerimaan dari penelitian. Karena ini adalah
waktu hari ketika tekanan darah relatif stabil
- (What) apa alat yang digunakan untuk mengevaluasi tekana darah pada penelitian tersebut?
Jawab : Alat
yang digunakan untuk mengevaluasi tekana darah pada penelitian tersebut
oscillometric elektronik sphygmomanometer (Philips HP5330) yang mengukur
sistolik dan fase tekanan darah diastolik V dengan metode oscillometric dan
menampilkan hasilnya digital.
- (How) Bagaimana , manajemen anak-anak dengan diabetes ?
Jawab : Manajemen
anak-anak dengan diabetes meliputi pencegahan komplikasi. Penilaian hati-hati
tekanan darah merupakan bagian dari pengawasan itu dan studi ini menunjukkan
bahwa pemantauan rumah layak dan akurat. Peneliti percaya itu memiliki nilai
potensi besar dalam pengelolaan diabetes anak-anak, terutama dalam membedakan
berkelanjutan dari hipertensi kantor, dan dalam menyediakan profil tekanan
darah keluarga anak diabetes.
