BEHAVIORAL ASSESSMENT
The evaluation system commonly used has been the mere distinction between normotension and hypertension, but this assessment assumes that the regulatory processes that are acting are homogeneous, but within the normotensive we can find both people with high-normal pressure and in hypertension we can find, in turn, different degrees of development. By contrast, establishing a greater number of qualifying entities more complex evaluation process. More complex
This assessment provides a much more accurate information and allows a true assessment against the mere behavioral distinction levels above or below the hypertension values, which are the result, most of the time, a measurement "asituacional" or "causal." Measurements "causal" or asituacionales made in the clinical setting are usually higher than those in the patient's natural environment.
addition to assessing the hemodynamic factors necessary to assess psychosocial factors and facilitates.
Evaluation of hemodynamic factors
The existence of different moments in the development of essential hypertension, require a precise psychophysiological assessment the current state of disorder in every person, for the proper selection of techniques and objectives to consider treatment. To carry out such an assessment will gather information from blood pressure, both systolic and diastolic blood pressure and cardiac output or heart rate, the latter commonly being used as an estimate of the previous one, because it is easier measurement.
The conditions under which the measurement should be made to understand, first, a baseline measurement that serves as a baseline reference for the implementation of which can use a period between 10 and 20 minutes of relaxation and other hand, a measurement under influences mainly beta and alpha-adrenergic, for which conditions may be employed active and passive coping respectively. In such conditions the psychophysiological patterns that appear, will determine the components involved in the elevation of blood pressure and hemodynamics phase in which the person is.
The differentiation between normal pressure and a reactive or high-normal we can do it by comparing the results in systolic pressure and heart rate, for the conditions of active and passive coping. The heart rate will rise between 10% and 12% in both conditions in the case of normal pressure and condition passive coping in the case of reactive pressure, and between 20% and 25% in the condition of active coping in reaction pressure. The systolic pressure presented a similar profile, rising between 5% and 8% at normal pressure and passive coping in the reactive rise between 8% and 13% in active coping reagents.
In all cases, reagents recover faster and stay longer borderline elevations. For the passive coping, the present boundary elevations in diastolic pressure slightly higher than the reactants.
Finally, the more similar the pressure elevations systolic and diastolic, or lower in the latter differences between active and passive coping, the more elevated peripheral resistance and, therefore, greater chronicity of the disorder.
Assessment of psychosocial factors
Depending on the degree of establishment of the disorder (high-normal pressure, borderline hypertension and hypertension grade 1 or grade 2 and 3), we must pay greater attention evaluation in one or another type of psychosocial factors.
In general, we must detect if changes have occurred in situations or lifestyles, and it should be evaluated in stressful environments and, in a special way, the work-related stress and family, social skills, coping styles, self-control, the ability to solve problems and, finally, the factors personality.
Of these factors, which have a way of more specific and operational assessment of personality factors are reflected in the behavior pattern Type-A. This pattern of behavior in certain situations is presented as a valid measure of reactivity and hypertension risk. Factors of the type-A are: overloading, impatience, competitive hostility, social dependence, loss of control, etc. Best instrument for this assessment is the Structured Interview own Friedman and Rosenman, the versions in the form of questionnaires and inventories have not proven valid as predictors of hypertensive disorders.
The limits of stressful situations and how the subject responds to them, is another major points of evaluation and, more specifically, in the face of training for handling such situations.
Evaluation of facilitating factors
The evaluation of eating habits and the number of cigarettes smoked daily was carried out through self-observation techniques, which will be used for self-registration cards to be entered in each of the behaviors under observation. For example, in the case of food habits indicates the type of food, containing sodium, fat content and caloric value. This self-registration will be maintained during the treatment process, during which it is inserted in all, a section to record the purpose or goal to achieve.
Pressure Recording
addition to the above points of evaluation, it is advisable to make a continuous recording of blood pressure levels, both during the evaluation period, and during treatment. It is necessary that the subject himself made in two or three times a day, measurements of systolic and diastolic pressures, and record their values \u200b\u200bin a record book along with the condition and emotional state were performed. Also it is desirable to perform several steps until stable values, given the reactive effects of measurement itself. The information provided by this log pressure control is very useful as a therapeutic process.
TREATMENT TECHNIQUES
With the information obtained from the evaluation it is possible to estimate the hemodynamic pattern that presents the person and thus know the main mechanisms involved in the disorder (heart, vasculature, kidney, etc.).. for the treatment of these mechanisms should be used much more specific technical terms are more specific and phasic and / or the more general techniques tonics. In regard to psychosocial factors and facilitators, their treatment depends on the risk factor involved and the impact they have on maintaining the current stage of development of the disorder.
A special case is that of pressures of the normal-high, which has not yet produced the disorder being treated. However, it would be possible preventive treatment.
Techniques for control of hemodynamic factors
Techniques for the control of various hemodynamic factors involved in hypertension are numerous, can be classified in terms of attempting to establish control so specific direct or indirect, acting more global and nonspecific.
Direct Control Direct methods of control of factors hemodynamics have been based on feedback techniques to reduce the pressure on herself, or to act on it through other activities, or activities specifically relevant indices in the regulation of pressure.
The feedback systolic and diastolic have amply demonstrated its validity as a therapeutic techniques. However, a noninvasive measurement of blood pressure presents such problems for use in training feedback, it has been necessary to create specific detection systems that meet technology, among these systems include cycle systems fast, double cuff systems, systems oscillometric constant pressure systems or pinch with tracking systems.
Despite many attempts to put measurement systems noninvasive pressure for use in feedback, the solution has emerged from the use of indices of such activity, so the speed of the pulse wave is used as an index diastolic pressure and / or measure, and pulse transit time is used as an index of systolic pressure. These alternatives are currently the most widely used and its effectiveness is widely proven.
addition to blood pressure and indices, interest in the control of activities specifically related with myocardial performance, has made to develop other feedback techniques, such as T-wave amplitude of ECG, dP / dt, the pre-ejection period infarction, or pulse transit time between wave Q ECG and peripheral blood flow. All these techniques are intended to be an index of myocardial contractility and its use would be particularly suitable for controlling high-normal pressure or borderline hypertension, but its use is restricted by the multiple methodological problems that arise, being replaced by heart rate as an index of myocardial activity but much less problematic imprecise, reflecting both adrenergic and cholinergic effects.
A final type of feedback has tried to serve as a control on myocardial metabolism, using a composite feedback systolic pressure and heart rate, and the results are inconclusive and their use is severely restricted.
In summary, direct technical changes intended to pursue specific hemodynamic activity, besides being susceptible to its use to reductions in both tonic and phasic, and consequently may be used at any stage of development of hypertension, although some, such as feedback diastolic pressure, no sense in the early stages, and others, such as myocardial contractility, did not have a high chronic.
The feedback systolic and diastolic have amply demonstrated its validity as a therapeutic techniques. However, a noninvasive measurement of blood pressure presents such problems for use in training feedback, it has been necessary to create specific detection systems that meet technology, among these systems include cycle systems fast, double cuff systems, systems oscillometric constant pressure systems or pinch with tracking systems.
Despite many attempts to put measurement systems noninvasive pressure for use in feedback, the solution has emerged from the use of indices of such activity, so the speed of the pulse wave is used as an index diastolic pressure and / or measure, and pulse transit time is used as an index of systolic pressure. These alternatives are currently the most widely used and its effectiveness is widely proven.
addition to blood pressure and indices, interest in the control of activities specifically related with myocardial performance, has made to develop other feedback techniques, such as T-wave amplitude of ECG, dP / dt, the pre-ejection period infarction, or pulse transit time between wave Q ECG and peripheral blood flow. All these techniques are intended to be an index of myocardial contractility and its use would be particularly suitable for controlling high-normal pressure or borderline hypertension, but its use is restricted by the multiple methodological problems that arise, being replaced by heart rate as an index of myocardial activity but much less problematic imprecise, reflecting both adrenergic and cholinergic effects.
A final type of feedback has tried to serve as a control on myocardial metabolism, using a composite feedback systolic pressure and heart rate, and the results are inconclusive and their use is severely restricted.
In summary, direct technical changes intended to pursue specific hemodynamic activity, besides being susceptible to its use to reductions in both tonic and phasic, and consequently may be used at any stage of development of hypertension, although some, such as feedback diastolic pressure, no sense in the early stages, and others, such as myocardial contractility, did not have a high chronic.
Indirect control
indirect methods used to control blood pressure corresponds historically with the first attempts in this field. The type of techniques used include, from relaxation and meditation to feedback training.
relaxation techniques that have proven effective in reducing tonic levels of pressure include progressive relaxation, and variants thereof, as the metronome conditioned relaxation, autogenic training and hypnotic relaxation.
meditation techniques, Transcendental Meditation, the relaxation response and psychological relaxation can be beneficial, but not for all the people, their utility is restricted to the early stages of establishment, and is even contraindicated in stages chronicity.
The use of feedback training in response fisiolótgicas indirectly related to the regulation of pressure has been reduced to EMG feedback, mainly from the frontal muscle, electrodermal activity and skin temperature, the use of this training has been always accompanied by other techniques larger therapeutic packet, so time can not tell what was their contribution to overall results, in any way, the effectiveness shown by the above packages are presented as one of the most useful methods from those available.
A final indirect technique, is the REST (Restricted Environmental Stimulation Therapy), used in some cases in conjunction with progressive relaxation. The lack of work controlled and short time of existence, does not allow any conclusions about its effectiveness.
In short, all indirect techniques, despite their diversity, share a common ground among themselves; all seek a reduction in activity, especially muscular tension, and focus all attention to a point, whether internal or external. The use of these techniques is particularly felt by their lower instrumental requirements, its use is often done in conjunction with other techniques and there are few references to their use alone.
indirect methods used to control blood pressure corresponds historically with the first attempts in this field. The type of techniques used include, from relaxation and meditation to feedback training.
relaxation techniques that have proven effective in reducing tonic levels of pressure include progressive relaxation, and variants thereof, as the metronome conditioned relaxation, autogenic training and hypnotic relaxation.
meditation techniques, Transcendental Meditation, the relaxation response and psychological relaxation can be beneficial, but not for all the people, their utility is restricted to the early stages of establishment, and is even contraindicated in stages chronicity.
The use of feedback training in response fisiolótgicas indirectly related to the regulation of pressure has been reduced to EMG feedback, mainly from the frontal muscle, electrodermal activity and skin temperature, the use of this training has been always accompanied by other techniques larger therapeutic packet, so time can not tell what was their contribution to overall results, in any way, the effectiveness shown by the above packages are presented as one of the most useful methods from those available.
A final indirect technique, is the REST (Restricted Environmental Stimulation Therapy), used in some cases in conjunction with progressive relaxation. The lack of work controlled and short time of existence, does not allow any conclusions about its effectiveness.
In short, all indirect techniques, despite their diversity, share a common ground among themselves; all seek a reduction in activity, especially muscular tension, and focus all attention to a point, whether internal or external. The use of these techniques is particularly felt by their lower instrumental requirements, its use is often done in conjunction with other techniques and there are few references to their use alone.
control techniques of psychosocial factors
cover practically the whole range of existing techniques in behavior modification, however, programs for management of anxiety and stress are those with a higher incidence also to be one of the therapeutic approaches that tend to have better results. Although there
different programs of this type, Chandra Patel program which has been most widespread. Comprising:
- weld
- relaxation training, training
- electrodermal activity feedback,
- information about the disorder,
- training in problem solving, and
- instructions to apply learning to program in confronting the real-life situations. Based
In any regard to factors related to the pattern of Type-A behavior, cognitive techniques, and more specifically the Rational Emotive Therapy, have proved effective in reducing these factors.
control techniques of facilitating factors
Since most facilitating factors from improper eating habits, the techniques employed will be focused on controlling the intake of both alcohol, coffee, sodium or fat, such as diet, in general, to maintain a normal weight and stabilized. Also, will control the use of snuff and any drug. Another important point is the amount of physical activity, should be enough, should be complemented with a training exercise.
All these interventions will be undertaken through self-management techniques, with particular emphasis on providing information on the effects of these facilitators, since for relatively long periods it takes to make effects, not always easy to achieve compliance with this part of the program.
intervention design
therapeutic intervention program should be designed specifically for each person and must take into account the impact of different types of factors involved in the disorder. The partial action on some of the factors, even if you change the pressure levels will not ensure the success of the intervention.
An additional problem is the possible medications you are taking the person for treatment of hypertensive disorder itself. When drugs are of type diuretic, or no influence on the hemodynamic assessment or treatment. By contrast, beta-blocker drugs affect both the evaluation and treatment.
GUIDE FOR PSYCHOLOGICAL INTERVENTION
Like any psychological intervention, it must start with an initial interview in which to define the problem, its history and if the pressure missing or not controlled at that time. Special attention should be paid to another set of conditions, primarily pharmacological, which can lead to increases in pressure, such as nonsteroidal anti-inflammatory, oral contraceptives and, occasionally, hormone replacement treatments, cocaine and licorice.
Psychological intervention should be carried out following a series of steps that are defining different objectives and methods of operation:
First step .- Situational assessment of blood pressure
Typically, the detection and diagnosis of hypertension was made in a medical context, where the determinations of the pressure levels for diagnosis have been performed on a asituacional or "causal", ie without controlling the conditions under which they are producing such pressure levels. Such a form of pressure measurement, tends to provide higher levels than the "real", especially in the case of systolic pressure. Faced with such diagnoses
we take special care, since some of those diagnosed as hypertensive people are actually reactive to the conditions of measurement. That is, these measures reflect not their usual values \u200b\u200bof pressure, but much higher values, so that the estimates used for diagnosis are altered to falsely high.
To handle these situations it is desirable to measure blood pressure that allows us to see if they are giving such emotional triggers (reactivity) or alternatively take the measurement conditions to a different context of the clinician.
Verification of emotional arousal, can be done simultaneously using another index of emotional arousal, while we make the pressure measurement. Thus, we can use a tool that allows us to make a continuous recording of skin conductance or heart rate, thus we can determine whether this index is significantly altered from the time they inform the patient that we will proceed measure your blood pressure so far we end this procedure and, therefore, detect the presence or absence of reactivity to the measurement procedure.
Another alternative is the use of a measuring ambulatory blood pressure over 24 hours. If there is no ambulatory measurement equipment, will train the patient in the use of an automatic sphygmomanometer reading, so you can complete a self-registration, over a week, during different times of day and various conditions.
reactivity measure is the cause of what is known in clinical settings mo the "white coat hypertension, ie hypertension who are misdiagnosed, because blood pressure is elevated during the measurement process as a result of an emotional response. The first action to be executed in case of detecting such a reactivity measure is the response with DS. Whether
found no evidence of reactivity of measurement, whether the results of the DS do not lead to obtaining normotensive values, will require further intervention, as reflected in the next step.
Typically, the detection and diagnosis of hypertension was made in a medical context, where the determinations of the pressure levels for diagnosis have been performed on a asituacional or "causal", ie without controlling the conditions under which they are producing such pressure levels. Such a form of pressure measurement, tends to provide higher levels than the "real", especially in the case of systolic pressure. Faced with such diagnoses
we take special care, since some of those diagnosed as hypertensive people are actually reactive to the conditions of measurement. That is, these measures reflect not their usual values \u200b\u200bof pressure, but much higher values, so that the estimates used for diagnosis are altered to falsely high.
To handle these situations it is desirable to measure blood pressure that allows us to see if they are giving such emotional triggers (reactivity) or alternatively take the measurement conditions to a different context of the clinician.
Verification of emotional arousal, can be done simultaneously using another index of emotional arousal, while we make the pressure measurement. Thus, we can use a tool that allows us to make a continuous recording of skin conductance or heart rate, thus we can determine whether this index is significantly altered from the time they inform the patient that we will proceed measure your blood pressure so far we end this procedure and, therefore, detect the presence or absence of reactivity to the measurement procedure.
Another alternative is the use of a measuring ambulatory blood pressure over 24 hours. If there is no ambulatory measurement equipment, will train the patient in the use of an automatic sphygmomanometer reading, so you can complete a self-registration, over a week, during different times of day and various conditions.
reactivity measure is the cause of what is known in clinical settings mo the "white coat hypertension, ie hypertension who are misdiagnosed, because blood pressure is elevated during the measurement process as a result of an emotional response. The first action to be executed in case of detecting such a reactivity measure is the response with DS. Whether
found no evidence of reactivity of measurement, whether the results of the DS do not lead to obtaining normotensive values, will require further intervention, as reflected in the next step.
Step .- Verify the confluence of coronary risk factors.
aims to verify if co-occur with hypertension or other risk factors, which will, if so, the treatment of hypertension can not focus exclusively on this point, but should address the treatment from a broader perspective of prevention of cardiovascular risk factors.
As well as hypertension are other risk factors the predicted risk of cardiovascular accident is low, when hypertension coincides with one or two risk factors is considered average when it coincides with three or four is considered high risk and when hypertension is accompanied by more than 4 risk factors is very high.
It is therefore critical assessment of other risk factors that forces us to expand the therapeutic objective intervention, the sole reduction of blood pressure levels, the prevention of stroke, by reducing all risk factors that present the subject.
Step .- Primary Intervention Program, standardized.
For the reduction of hypertension is the therapeutic goal of the intervention, both as the only significant risk factor presented by the patient as a whole broader intervention, the third step will be concrete in the production of a hypertension intervention, based on a standardized program to be carried out for any general practice.
This approach of non-pharmacological treatment of hypertension, is based on an intervention in two sequential steps in time: a first phase of primary intervention by non-specialist staff and resources and, if necessary, a second phase of intervention school, conducted by staff and the media.
The primary intervention approach and standard is supported by resource constraints arising in the implementation of assessment processes and specialized treatment as well as the excellent cost-effectiveness has shown this type of intervention. So the package
therapeutic use in this first stage of the intervention will consist of a technique based on indirect methods to control blood pressure. The goal of most of these techniques is to achieve a reduction in sympathetic activity and muscle tone. Its use seems to be most effective when used in conjunction with other techniques of support and not their own.
indirect techniques include, from relaxation and meditation to biofeedback training. All relaxation techniques have proven effective in reducing tonic levels of blood pressure, meditation techniques seems effective in the early stages and finally the use of EMG biofeedback training in electrodermal activity and skin temperature, has shown its effectiveness in the work, both experimental and clinical, in which it has been used in conjunction with other techniques .
The package will have also therapeutic techniques for controlling and facilitating psychosocial factors that impact on hypertension. In this field, training in problem solving and emotional self-control techniques are the procedures most frequently included in programs for management of anxiety and stress used for the treatment of hypertension. They must also join the technical intervention aimed at controlling food intake, in order to modify inappropriate eating habits.
As we have seen, any therapeutic intervention program should be designed specifically for each person and should take into account the impact of different types of factors that intervene in the disorder. However, the complexity and cost of such treatment in this field, make your production is not possible in a non-specialist or primary care and therefore have to be reserved for specialized treatment, conducted in centers, in turn, highly specialized.
By contrast, a program treatment in its early stages, should be done following a standardized treatment program that is implemented by procedures that do not require the completion of a complex evaluation and which consist of techniques that are likely to be implemented even in groups, to optimize the ratio costs / benefits. The review of work on psychological intervention controlled hypertension, shows that the best results in reducing blood pressure levels are obtained by combination packages.
A possible therapeutic package for this first stage of primary prevention should be established only a short baseline of one week of their own blood pressure levels and maintain this evaluation throughout the treatment and control of its effects.
The therapeutic package itself, which would apply in a standardized manner to all patients, would consist of an indirect reduction of pressure, for example, through a progressive relaxation training, techniques of performance on psychological factors ( eg problem solving) and, with regard to enabling factors, a program for the control of food intake and physical activity, compared to the latter, performing moderate aerobic exercise can be very beneficial, whereas, by contrast, isometric exercise has the opposite effect and, therefore, should be avoided.
If once the application of this package, the patient has no improvement, proceed to the second stage of treatment, which should take place in a specialized center that would create a specific and personalized interventions for each patient. The primary intervention will not have been by no means a waste of time because the patient has learned a number of skills that will be prepared and facilitate the implementation of the intervention itself espcializada.
Thus, once this first phase must be re-evaluated the levels of pressure and, if the reductions have not been enough to get to keep normotensive values, will require the implementation of the second phase of specialist treatment, which must begin with the realization of specific assessment to establish the degree of chronicity of hypertension in the patient. Step Four
.- Specific evaluation of hemodynamic factors and other factors may be involved.
It aims at conducting a specialized evaluation of hemodynamic factors to establish the degree of chronicity, and the evaluation of other factors.
Thus, the realization of the behavioral assessment of essential hypertension, means, in turn, two distinct parts: first, a psychophysiological assessment of hemodynamic factors and, secondly, the assessment of psychological factors and partners may be affecting the maintenance of pressure elevation. Also, it is advisable to make a daily record of blood pressure and heart rate. Step Five
specific intervention program .-
is a specialized treatment, established on the basis of information evaluation obtained by following the instructions in the previous step. Step Six
.- Monitoring of the operation and maintenance
It aims to monitor and control the effects of the intervention as well as performing maintenance sessions. This monitoring should take place not only after the completion of specialized intervention outlined in steps 4 and 5, but also, and almost in a more special, when treatment has been terminated in step 3 after a successful intervention with the standardized program .
is of special importance, control and reminder sessions with a frequency between 6 and 8 months during the two years following completion of treatment.
pharmacologically controlled hypertension
aims to verify if co-occur with hypertension or other risk factors, which will, if so, the treatment of hypertension can not focus exclusively on this point, but should address the treatment from a broader perspective of prevention of cardiovascular risk factors.
As well as hypertension are other risk factors the predicted risk of cardiovascular accident is low, when hypertension coincides with one or two risk factors is considered average when it coincides with three or four is considered high risk and when hypertension is accompanied by more than 4 risk factors is very high.
It is therefore critical assessment of other risk factors that forces us to expand the therapeutic objective intervention, the sole reduction of blood pressure levels, the prevention of stroke, by reducing all risk factors that present the subject.
Step .- Primary Intervention Program, standardized.
For the reduction of hypertension is the therapeutic goal of the intervention, both as the only significant risk factor presented by the patient as a whole broader intervention, the third step will be concrete in the production of a hypertension intervention, based on a standardized program to be carried out for any general practice.
This approach of non-pharmacological treatment of hypertension, is based on an intervention in two sequential steps in time: a first phase of primary intervention by non-specialist staff and resources and, if necessary, a second phase of intervention school, conducted by staff and the media.
The primary intervention approach and standard is supported by resource constraints arising in the implementation of assessment processes and specialized treatment as well as the excellent cost-effectiveness has shown this type of intervention. So the package
therapeutic use in this first stage of the intervention will consist of a technique based on indirect methods to control blood pressure. The goal of most of these techniques is to achieve a reduction in sympathetic activity and muscle tone. Its use seems to be most effective when used in conjunction with other techniques of support and not their own.
indirect techniques include, from relaxation and meditation to biofeedback training. All relaxation techniques have proven effective in reducing tonic levels of blood pressure, meditation techniques seems effective in the early stages and finally the use of EMG biofeedback training in electrodermal activity and skin temperature, has shown its effectiveness in the work, both experimental and clinical, in which it has been used in conjunction with other techniques .
The package will have also therapeutic techniques for controlling and facilitating psychosocial factors that impact on hypertension. In this field, training in problem solving and emotional self-control techniques are the procedures most frequently included in programs for management of anxiety and stress used for the treatment of hypertension. They must also join the technical intervention aimed at controlling food intake, in order to modify inappropriate eating habits.
As we have seen, any therapeutic intervention program should be designed specifically for each person and should take into account the impact of different types of factors that intervene in the disorder. However, the complexity and cost of such treatment in this field, make your production is not possible in a non-specialist or primary care and therefore have to be reserved for specialized treatment, conducted in centers, in turn, highly specialized.
By contrast, a program treatment in its early stages, should be done following a standardized treatment program that is implemented by procedures that do not require the completion of a complex evaluation and which consist of techniques that are likely to be implemented even in groups, to optimize the ratio costs / benefits. The review of work on psychological intervention controlled hypertension, shows that the best results in reducing blood pressure levels are obtained by combination packages.
A possible therapeutic package for this first stage of primary prevention should be established only a short baseline of one week of their own blood pressure levels and maintain this evaluation throughout the treatment and control of its effects.
The therapeutic package itself, which would apply in a standardized manner to all patients, would consist of an indirect reduction of pressure, for example, through a progressive relaxation training, techniques of performance on psychological factors ( eg problem solving) and, with regard to enabling factors, a program for the control of food intake and physical activity, compared to the latter, performing moderate aerobic exercise can be very beneficial, whereas, by contrast, isometric exercise has the opposite effect and, therefore, should be avoided.
If once the application of this package, the patient has no improvement, proceed to the second stage of treatment, which should take place in a specialized center that would create a specific and personalized interventions for each patient. The primary intervention will not have been by no means a waste of time because the patient has learned a number of skills that will be prepared and facilitate the implementation of the intervention itself espcializada.
Thus, once this first phase must be re-evaluated the levels of pressure and, if the reductions have not been enough to get to keep normotensive values, will require the implementation of the second phase of specialist treatment, which must begin with the realization of specific assessment to establish the degree of chronicity of hypertension in the patient. Step Four
.- Specific evaluation of hemodynamic factors and other factors may be involved.
It aims at conducting a specialized evaluation of hemodynamic factors to establish the degree of chronicity, and the evaluation of other factors.
Thus, the realization of the behavioral assessment of essential hypertension, means, in turn, two distinct parts: first, a psychophysiological assessment of hemodynamic factors and, secondly, the assessment of psychological factors and partners may be affecting the maintenance of pressure elevation. Also, it is advisable to make a daily record of blood pressure and heart rate. Step Five
specific intervention program .-
is a specialized treatment, established on the basis of information evaluation obtained by following the instructions in the previous step. Step Six
.- Monitoring of the operation and maintenance
It aims to monitor and control the effects of the intervention as well as performing maintenance sessions. This monitoring should take place not only after the completion of specialized intervention outlined in steps 4 and 5, but also, and almost in a more special, when treatment has been terminated in step 3 after a successful intervention with the standardized program .
is of special importance, control and reminder sessions with a frequency between 6 and 8 months during the two years following completion of treatment.
pharmacologically controlled hypertension
A different situation is the case of hypertension drug is under control. In such situations the possible therapeutic targets are two:
- Increased adherence to medical treatment
- reduction of medication, in the case of hypertension successfully controlled with medication, but that either the control has been established with two or more families of drugs and / or drug treatment severely alters the patient's welfare, the objective of the intervention is to reduce the dose of a drug or delete one if several used, maintaining blood pressure control. In such cases, training in peripheral temperature biofeedback is the type of intervention that has provided better results in this field.
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