Une REL fantastique

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Une REL fantastique 

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Pour essayer l'outil

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Muriel Weidenhammer, 4 months ago

Team Performance

Instructional Summary
This module exposes the learner to the challenges of leading a project team. It explores a multitude of personal and interpersonal skills as well as team motivation theory and strategy, and the all-important topic of how to create highly motivated self-managing project teams.
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Introduction

This module exposes the learner to the challenges of leading a project team. It explores a multitude of personal and interpersonal skills as well as team motivation theory and strategy, and the all-important topic of how to create highly motivated self-managing project teams.

role of the project manager and challenges of managing project teams and engaging stakeholders effectively

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My Indigenous Vocabulary: Algonquin Words

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Statue of Keewakwa Abenaki Keenahbeh in Opechee Park in Laconia, New Hampshire (standing at 36 ft.)

Statue of Keewakwa Abenaki Keenahbeh in Opechee Park in Laconia, New Hampshire (standing at 36 ft.). Sources: Sculptor: Peter Wolf Toth / Photo by: Niranjan Arminius - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=51375010

The Abenaki (Abnaki, Abinaki, Alnôbak) are a Native American tribe and First Nation. They are one of the Algonquian-speaking peoples of northeastern North America. The Abenaki originated in a region called Wabanahkik in the Eastern Algonquian languages (meaning "Dawn Land"), a territory now including parts of Quebec and the Maritimes of Canada and northern sections of the New England region of the United States. The Abenaki are one of the five members of the Wabanaki Confederacy.

The Abenaki language is closely related to the Panawahpskek (Penobscot) language. Other neighboring Wabanaki tribes, the Pestomuhkati (Passamaquoddy), Wolastoqiyik (Maliseet), and Miꞌkmaq, and other Eastern Algonquian languages share many linguistic similarities. It has come close to extinction as a spoken language. Tribal members are working to revive the Abenaki language at Odanak (means "in the village"), a First Nations Abenaki reserve near Pierreville, Quebec, and throughout New Hampshire, Vermont and New York state.

Twenty Basic Words in Algonquin

Abenaki is an Algonquian language, related to other languages like Lenape and Ojibwe. We have included twenty basic Algonquin words here.

Algonquin Word Set

English (Français) Algonquin Words
One (Un) Pejig
Two (Deux) Nìj
Three (Trois) Niswi
Four (Quatre) New
Five (Cinq) Nànan
Man (Homme) Ininì
Woman (Femme) Ikwe
Dog (Chien) Animosh
Sun (Soleil) Kìzis
Moon (Lune) Tibik-kìzis
Water (Eau) Nibì
White (Blanc) Wàbà
Yellow (Jaune) Ozàwà
Red (Rouge) Miskwà
Black (Noir) Makadewà
Eat (Manger) Mìdjin
See (Voir) Wàbi
Hear (Entendre) Nòndam
Sing (Chanter) Nigamo
Leave (Partir) Màdjà or Nagadàn

Test your memory

Please note: the content on this page, sourced from http://www.native-languages.org/algonquin_words.htm, is meant for demonstration purposes only.

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Abenaki is an Algonquian language, related to other languages like Lenape and Ojibwe. We have included twenty basic Algonquin words here.

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Remix of Introduction to DSGN 8230

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Welcome to Week 1 of DSGN 820!

In this first week we have a number of topics to cover, including:

  • Introduction to the course
  • Introduction to your eTextbook
  • Getting started with Visual Studio
  • History of the Internet
  • Introduction to HTML5 and CSS

Required Preparations

Please ensure that you have prepared the following prior to our second class in week 1:

  • Make sure you can access your eText
  • Make sure you can access our course in BrightSpace
  • Make sure you have Visual Studio install on your laptop
  • Make sure you can access your School OneDrive
  • Read Chapter 1 in your eText
  • Complete the "Getting to know you" Survey
Illustration displaying numerous symbols and web design tools/languages.

So you want to be a Web Developer?

The History of the Internet

As you might expect for a technology so expansive and ever-changing, it is impossible to credit the invention of the internet to a single person. The internet was the work of dozens of pioneering scientists, programmers and engineers who each developed new features and technologies that eventually merged to become the “information superhighway” we know today.

Long before the technology existed to actually build the internet, many scientists had already anticipated the existence of worldwide networks of information. Nikola Tesla toyed with the idea of a “world wireless system” in the early 1900s, and visionary thinkers like Paul Otlet and Vannevar Bush conceived of mechanized, searchable storage systems of books and media in the 1930s and 1940s. 

Still, the first practical schematics for the internet would not arrive until the early 1960s, when MIT’s J.C.R. Licklider popularized the idea of an “Intergalactic Network” of computers. Shortly thereafter, computer scientists developed the concept of “packet switching,” a method for effectively transmitting electronic data that would later become one of the major building blocks of the internet.

The first workable prototype of the Internet came in the late 1960s with the creation of ARPANET, or the Advanced Research Projects Agency Network. Originally funded by the U.S. Department of Defense, ARPANET used packet switching to allow multiple computers to communicate on a single network. 

On October 29, 1969, ARPAnet delivered its first message: a “node-to-node” communication from one computer to another. (The first computer was located in a research lab at UCLA and the second was at Stanford; each one was the size of a small house.) The message—“LOGIN”—was short and simple, but it crashed the fledgling ARPA network anyway: The Stanford computer only received the note’s first two letters.

Symbolic representation of the Arpanet as of September 1974.

Symbolic representation of the Arpanet as of September 1974.

Encapsulation of application data descending through the layered IP architecture

Encapsulation of application data descending through the layers described in RFC 1122

The technology continued to grow in the 1970s after scientists Robert Kahn and Vinton Cerf developed Transmission Control Protocol and Internet Protocol, or TCP/IP, a communications model that set standards for how data could be transmitted between multiple networks. 

ARPANET adopted TCP/IP on January 1, 1983, and from there researchers began to assemble the “network of networks” that became the modern Internet. The online world then took on a more recognizable form in 1990, when computer scientist Tim Berners-Lee invented the World Wide Web. While it’s often confused with the internet itself, the web is actually just the most common means of accessing data online in the form of websites and hyperlinks. 

The web helped popularize the internet among the public, and served as a crucial step in developing the vast trove of information that most of us now access on a daily basis.

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1.2.2 Balance Sheet and Statement of Cash Flows

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The Balance Sheet

The balance sheet is also called the statement of financial position.

The balance sheet reports a company’s financial position as at a specific date (e.g., last day of a monthly, quarterly, or annual reporting period).  Since it is presented as at a specific date, you can think of the balance as a snapshot of the company’s financial position at a particular point in time.

Note: the other 3 statements cover a period of time.

From the balance sheet above, note the Accounting Equation (Assets = Liabilities + Shareholders’ Equity):
Total Assets = $90,973 which equals the Total Liabilities and Shareholders’ Equity = $90,973.

Balance Sheet Has Three Main Elements:

  1. Assets: Economic resources controlled by the entity as a result of past business events from which future economic benefits may be obtained.
    1. Current assets: Expected to be converted to cash, sold, or consumed during the next 12 months or within the business’ operating cycle, whichever is longer, and include:
      1. Cash and cash equivalents
      2. Short-term investments
      3. Accounts and notes receivable
      4. Inventory
      5. Prepaid expenses
    2. Non-current assets: Will be held longer than one year and include:
      1. Property and equipment
      2. Land
      3. Buildings
      4. Computers
      5. Equipment
      6. Intangibles
      7. Long-term investments
  2. Liabilities: Debts the entity owes as a result of a past event, and which it expects to pay off in the future using some of its assets.
    1. Current liabilities: Debts payable in the next 12 months or within the business’ operating cycle, whichever is longer, and include:
      1. Accounts payable
      2. Income taxes payable
      3. Accrued expenses payable
      4. Current maturities of long-term debt
    2. Non-current liabilities: Debts payable more than one year from the balance sheet date and include:
      1. Long-term notes payable
      2. Bonds payable
  3. Shareholders’ equity: Owners’ remaining interest in the assets of the company after deducting all its liabilities (i.e., owners’ claim on the company’s assets net of company’s liabilities, hence, called net assets), consisting of two components:
    1. Share capital: capital (usually in the form of cash) received from its owners in exchange for shares of the company. Also called common shares.
    2. Retained earnings: the cumulative net income earned by the company over its lifetime, less its cumulative net losses and dividends. 
      Note: a portion of net income is typically distributed to shareholders in the form of dividends and the remainder is retained by the business that is called retained earnings.
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Dividing net income into dividends (distributed to shareholders) and retained earnings (retained by the business).

The balance sheet takes its name from the fact that the assets (A) must always equal (be in balance with) the sum of the liabilities (L) and the shareholders' equity (SE).

A = L + SE

(Assets) = (Liabilities) + (Shareholders' Equity)

Assets refer to the economic resources of the company.

Companies can finance the economic resources in two ways:

  1. Liabilities: Financing provided by creditors
  2. Shareholders' equity: Financing provided by shareholders

Typical Account Titles

Assets Liabilities Shareholders’ Equity
Cash Trade Payables Share Capital
(or Common Shares)
Short-Term Investment Short-term Borrowing Retained Earnings
Trade Receivable Long-term Borrowing  
Notes Receivable Provisions  
Inventory (to be sold) Other Liabilities  
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Remix of Functions and Function Notation

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Learning Objectives

In this section, you will:

  • Determine whether a relation represents a function.
  • Find the value of a function.
  • Determine whether a function is one-to-one.
  • Use the vertical line test to identify functions.
  • Graph the functions listed in the library of functions.

A jetliner changes altitude as its distance from the starting point of a flight increases. The weight of a growing child increases with time. In each case, one quantity depends on another. There is a relationship between the two quantities that we can describe, analyze, and use to make predictions. In this section, we will analyze such relationships.

Determining Whether a Relation Represents a Function

A relation is a set of ordered pairs. The set consisting of the first components of each ordered pair is called the domain and the set consisting of the second components of each ordered pair is called the range. Consider the following set of ordered pairs. The first numbers in each pair are the first five natural numbers. The second number in each pair is twice that of the first.

$$\{(1,\text{ }2),\text{ }(2,\text{ }4),\text{ }(3,\text{ }6),\text{ }(4,\text{ }8),\text{ }(5,\text{ }10)\}$$

The domain is \(\{1,\text{ }2,\text{ }3,\text{ }4,\text{ }5\}\). The range is \(\{2,\text{ }4,\text{ }6,\text{ }8,\text{ }10\}\).

Note that each value in the domain is also known as an input value, or independent variable, and is often labeled with the lowercase letter \(x\). Each value in the range is also known as an output value, or dependent variable, and is often labeled lowercase letter \(y\).

A function \(f\) is a relation that assigns a single value in the range to each value in the domain. In other words, no x-values are repeated. For our example that relates the first five natural numbers to numbers double their values, this relation is a function because each element in the domain, \(\{1, 2, 3, 4, 5\}\), is paired with exactly one element in the range, \(\{2, 4, 6, 8, 10\}\).

Now let’s consider the set of ordered pairs that relates the terms “even” and “odd” to the first five natural numbers. It would appear as

$$\{{(\text{odd},\text{ }1),\text{ }(\text{even},\text{ }2),\text{ }(\text{odd},\text{ }3),\text{ }(\text{even},\text{ }4),\text{ }(\text{odd},\text{ }5)}\}$$

Notice that each element in the domain, \(\{even, odd\}\) is not paired with exactly one element in the range, \(\{1, 2, 3, 4, 5\}\). For example, the term “odd” corresponds to three values from the range, \(\{1, 3, 5\}\) and the term “even” corresponds to two values from the range, \(\{2, 4\}\). This violates the definition of a function, so this relation is not a function.

Figure 1 compares relations that are functions and not functions.

Three relations that demonstrate what constitute a function.

Figure 1 (a) This relationship is a function because each input is associated with a single output. Note that input  q  and  r  both give output  n.  (b) This relationship is also a function. In this case, each input is associated with a single output.

Functions

function is a relation in which each possible input value leads to exactly one output value. We say “the output is a function of the input.”

The input values make up the domain, and the output values make up the range.

Examples

Given a relationship between two quantities, determine whether the relationship is a function.

Using Function Notation

Once we determine that a relationship is a function, we need to display and define the functional relationships so that we can understand and use them, and sometimes also so that we can program them into computers. There are various ways of representing functions. A standard function notation is one representation that facilitates working with functions.

To represent “height is a function of age,” we start by identifying the descriptive variables \(h\) for height and \(a\) for age. The letters \(f\), \(g\), and \(h\) are often used to represent functions just as we use \(x, y\), and \(z\) to represent numbers and \(A, B\), and \(C\) to represent sets.

$$ \begin{array}{lcccc}h\text{ is }f\text{ of }a&&&&\text{We name the function }f;\text{ height is a function of age}.\\h=f(a)&&&&\text{We use parentheses to indicate the function input}\text{. }\\f(a)&&&&\text{We name the function }f;\text{ the expression is read as “}f\text{ of }a\text{.”}\end{array} $$

Remember, we can use any letter to name the function; the notation \(h(a)\) shows us that \(h\) depends on \(a\). The value a  a must be put into the function \(h\) to get a result. The parentheses indicate that age is input into the function; they do not indicate multiplication.

We can also give an algebraic expression as the input to a function. For example \(f(a+b)\) means "first add a and b, and the result is the input for the function f." The operations must be performed in this order to obtain the correct result.

Function Notation

The notation \(y=f(x)\) defines a function named \(f\). This is read as "\(y is a function of x\)". The letter \(x\) represents the input value, or independent variable. The letter \(y\), or \(f(x)\), represents the output value, or dependent variable.

Practice Quiz

Content for this page has been sourced from OpenStax - Access for free at https://openstax.org/books/algebra-and-trigonometry/pages/1-introduction-to-prerequisites

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A demonstration of the MathJax authoring capabilities. Content for this page has been sourced from OpenStax - Access for free at https://openstax.org/books/algebra-and-trigonometry/pages/1-introduction-to-prerequisites

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1.1 Accounting: The Language of Business

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Understanding the Role of Accounting

Accounting is an information system that measures and records business activities. The role of accounting is to identify, record, and measure the transactions or activities in a business to be able to evaluate its performance and assess its financial health

- (Harrison et al., 2018, p. 3)

This information is communicated to stakeholders using financial statements that contain useful information to help them make rational economic decisions. Financial statements are prepared based on a set of accounting rules, such as Generally Accepted Accounting Principles (GAAP) or International Financial Reporting Standards (IFRS); these help standardize accounting across businesses. Review the flow of accounting information diagram below.  

Graphic illustration displaying the 3 steps of the flow of information in accounting

The Flow of Accounting Information. People make decisions, business transactions occur, companies report their results. The process is cyclical.

This diagram illustrates the flow of accounting information and helps illustrate accounting’s role in business. The accounting process begins and ends with people making decisions.

Let’s apply the flow of accounting information to a real business: Apple Inc.

In this diagram, it begins with production. Apple Inc. produces a new annual line up of its iPhone. Then, it moves to purchasing. Customers make purchases at the store. From there is reporting. Revenues from the product and expenses from operating the store are reported in Apple’s quarterly and annual reports. These financial results inform managers’ decisions regarding product line, stocking, etc. This brings us back to production.

The Four Financial Statements

The flow of accounting results in transactions that are recorded and presented using four important financial statements to report the results to various stakeholders. We will explore these four financial statements further in the next topic.

Note: The order is important! The first is income statements, then statement of retained earnings, balance sheet, and lastly statement of cash flow. 

Users of Financial Information

These financial statements are used by different stakeholders. So, who are the users of financial information?

Managers: set goals, evaluate those goals, and take corrective action.

  • Most companies hire managers to oversee the day-to-day operations of the business (i.e., operating activities).

  • Managers make many business decisions using accounting info:

    • Should they build a new product line?
    • Should they open a regional sales office?
    • Should they acquire a competitor?
    • Should they extend credit to their major customers?

Investors: decide whether to invest in a business or evaluate an investment.

  • Investors are individuals/groups who provide capital to finance a business’s activities by purchasing ownership interest. They own shares of the business and are called shareholders.

  • Investors look for two sources of possible gain:

    • Sell ownership interest in the future for more than they paid.
    • Receive a portion of the company’s earnings in cash (dividends).
  • Investors (shareholders) use accounting information to find out how much income they can expect to earn on their investment and where to invest their money.

  • You too are an investor if you buy stocks, debt, or real estate! Financial information can help you decide where to invest your money.

Creditors: evaluate a borrower’s ability to make required payments.

  • Creditors provide capital to finance a business’s activities by lending money. Unlike investors, creditors do not own a share of the company.

  • For example, a bank lends funds to a company in the form of a loan that must be repaid by the company in the future along with interest.

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Banks loan companies funds, but must be repaid with interest.

Government and regulatory bodies such as Canada Revenue Agency (CRA): ensure organizations pay the correct amount of taxes.

  • Government and regulatory bodies use accounting information for taxation and regulation of the stock markets. 

  • For example, the CRA uses financial information to compute the sales and business taxes owed by a business and the Ontario Securities Commission requires periodic financial information from companies that are stock listed on the Toronto Stock Exchange (TSX).

Individuals: make investment decisions and/or manage a bank account.

  • Individuals like you and me use financial information to make daily purchasing decisions.

  • Do you budget your annual, monthly, or weekly spending? Even high-level budgeting of your tuition, rent, food, and transportation is, in a way, using financial information to determine your financial needs.

Not-for-profit organizations: use accounting information in virtually the same way as for-profit organizations.

  • Like for-profit companies, not-for-profit organizations use financial information to make decisions about their operations and investments, and to report financial information to their users.

  • Users of financial information for a not-for-profit organization include board members, managers, and the CRA.

  • The CRA has a designated non-taxable business status for approved not-for-profit organizations. These designated organizations need to comply with reporting requirements and do not have to pay regular business taxes like for-profit companies.

Financial vs. Management Accounting

Since different users have different reporting needs and underlying reasons for financial information, there are two types of accounting information:

Financial Accounting

Financial accounting provides information for different internal and external users:

  • Internal users
    • Managers

    • Investors

  • External users
    • Creditors

    • Government

    • Public

Financial accounting is the focus of our course!

Management Accounting

Management accounting provides the following information for internal users only:

  • Budgets

  • Forecasts

  • Projections

  • Detailed product level/department level information

This is most likely your next accounting course!

Types of Business Organizations

There are three main forms of business organizations: proprietorship, partnership, and corporation.

 

  Proprietorship Partnership Corporation
Owner(s) Single owner known as the proprietor Generally two or more partners are co-owners

Owned by shareholders and legally formed under federal or provincial law:

  • Public company: many shareholders (i.e. Apple)

  • Private company: small number of shareholders (i.e. a small business)

Personal liability of owner(s) for business debts Proprietor is personally liable Partners are usually personally liable Shareholders are not personally liable
Life of entity Limited by owner’s choice or death Limited by owner’s choice or death Indefinite (owned by shareholders)
Tax structure Included in personal taxes of the proprietor Doesn’t pay taxes as income flows through to individual partners and is taxed at their personal tax rate Corporation pays taxes and any dividends paid to shareholders are taxed at their personal tax rate
Examples

Common business structure for self-employed, small retail stores, or professional service providers:

  • Lawyers

  • Accountants

The Big Four accounting companies are all partnerships:

  • PwC LLP

  • KPMG LLP

  • Deloitte LLP
  • EY LLP

Public companies:

  • Apple Inc.
  • Alphabet Inc.
  • Amazon Inc.
  • Wal-Mart Inc.

Private companies:

  • IKEA
  • Koch Industries
  • Bechtel
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Remix of HYPERTENSION

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VIDEO: HTN Basics

Clinical Manifestations AKA Symptoms

  • HTN is a lanthanic or silent disease because it is frequently asymptomatic until it becomes severe and target-organ disease occurs.

  • Target-organ diseases occur in the heart (hypertensive heart disease), brain (cerebrovascular disease), peripheral vasculature (peripheral vascular disease), kidney (nephron-sclerosis), and eyes (retinal damage).

VIDEO: Hypertension Signs & Symptoms

Possible Complications & Risk Factors

  • Hypertension is a major risk factor for coronary artery disease (CAD).

  • Sustained high BP increases the cardiac workload and produces left ventricular hypertrophy (LVH). Progressive LVH, especially in association with CAD, is associated with the development of heart failure.

  • Hypertension is a major risk factor for cerebral atherosclerosis and stroke.

  • Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection.

  • Intermittent claudication (ischemic muscle pain precipitated by activity and relieved with rest) is a classic symptom of peripheral vascular disease involving the arteries.

  • Hypertension is one of the leading causes of end-stage renal disease. The earliest manifestation of renal dysfunction is usually nocturia.

  • The retina provides important information about the severity and duration of hypertension. Damage to retinal vessels provides an indication of concurrent vessel damage in the heart, brain, and kidney. Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision.

Lab Tests & Diagnostic Tests

  • The diagnosis of hypertension is not based on a single elevated reading (if <80/110 mm Hg) but requires several elevated readings over several weeks.

  • Routine urinalysis and serum creatinine levels are used to screen for renal involvement and to provide baseline information about kidney function.

  • Measurement of serum electrolytes, especially potassium levels, is done to detect hyperaldosteronism, a cause of secondary hypertension.

  • Blood glucose levels assist in the diagnosis of diabetes mellitus.

  • Lipid profile provides information about additional risk factors that predispose to atherosclerosis and cardiovascular disease.

  • ECG and echocardiography provide information about cardiac status.

  • Ambulatory blood pressure monitoring is a noninvasive, fully automated system that measures BP at preset intervals over a 24-hour period.

    • Some patients with hypertension do not show a normal, nocturnal dip in BP and are referred to as “nondippers.”

    • The absence of diurnal variability has been associated with more target-organ damage and an increased risk for cardiovascular events. The presence or absence of diurnal variability can be determined by continuous ambulatory BP monitoring.

Collaborative Care Treatment Goals

  • Treatment goals are to lower BP to less than 140 mm Hg systolic and less than 90 mm Hg diastolic for most persons with hypertension (less than 130 mm Hg systolic and less than 80 mm Hg diastolic for those with diabetes mellitus and chronic kidney disease).   

  • Hypertension Canada has identified a number of key recommendations for the treatment of hypertension and updates them annually.  

  • Lifestyle modifications are indicated for all patients with hypertension, and include the following:

    • Dietary changes: The Dietary Approaches to Stop Hypertension (DASH) eating plan emphasizes fruits, vegetables, and low-fat dairy products; dietary and soluble fibre; and whole grains and protein from plant sources and that is reduced in saturated fat and cholesterol. The DASH diet significantly lowers BP. Dietary management also includes restriction of sodium, maintenance of potassium, calcium, and magnesium.

    • Weight reduction: Height, weight, and waist circumference should be measured and body mass index (BMI) calculated for all adults. Maintenance of a healthy body weight is recommended for individuals who are normotensive to prevent HTN and for Canadians with HTN to reduce BP. All overweight hypertensive individuals should be advised to lose weight.

    • Limitation of alcohol intake to no more than two drinks per day. o    Regular aerobic physical activity (e.g., brisk walking) of 30-60 minutes a day, 4–7 days per week. Moderately intense activity such as brisk walking, jogging, and swimming can lower BP, promote relaxation, and decrease or control body weight.

    • Avoid tobacco use (smoking and chewing).

    • Stress management

Drug Therapy

  • The general goal of drug therapy is to achieve a BP of less than 140/90 mm Hg. For patients with chronic kidney disease or diabetes, target BP is less than 130/80 mm Hg.
  • Drugs currently available for treating hypertension work by (1) decreasing the volume of circulating blood, and/or (2) reducing SVR.
  • Diuretics promote sodium and water excretion, reduce plasma volume, decrease sodium in the arteriolar walls, and reduce the vascular response to catecholamines.
  • Adrenergic-inhibiting drugs act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor centre and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels.
  • Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR.
  • Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells. o    Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)–mediated vasoconstriction and sodium and water retention. A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels.
  • Thiazide-type diuretics are used as initial therapy for most patients with hypertension, either alone or in combination with one of the other classes.
  • If the BP is not controlled, the dosage of the first-line drug can be increased. A second drug from a different class can be substituted or added if the initial drug was ineffective or there were adverse effects to the initial drug. Most patients who are hypertensive will require two or more antihypertensive medications (taken in a single-pill format) to achieve their BP goals.
  • A new drug has been authorized for use in Canada: Aliskiren fumarate (Rasilez) is an oral direct renin inhibitor (DRI).

Adverse Effects

Adverse effects of antihypertensive drugs may be so severe or undesirable that the patient does not comply with therapy.

  • Hyperuricemia, hyperglycemia, and hypokalemia are common adverse effects with both thiazide and loop diuretics.
  • ACE inhibitors lead to high levels of bradykinin, which can cause coughing. An individual who develops a cough with the use of ACE inhibitors may be switched to an ARB.
  • Hyperkalemia can be a serious adverse effect of the potassium-sparing diuretics and ACE inhibitors.
  • Impotence may occur with some of the diuretics.
  • Orthostatic hypotension and sexual dysfunction are two undesirable effects of adrenergic-inhibiting agents.
  • Tachycardia and orthostatic hypotension are potential adverse effects of both vasodilators and angiotensin inhibitors.
  • Patient and caregiver teaching related to drug therapy is needed to identify and minimize adverse effects and to cope with therapeutic effects. Adverse effects may be an initial response to a drug and may decrease with continued use of the drug.

NURSING MANAGEMENT

  • The primary nursing responsibilities for long-term management of hypertension are to assist the patient in reducing BP and adhering to the treatment plan.

  • Nursing actions include evaluating therapeutic effectiveness, detecting and reporting any adverse treatment effects, assessing and enhancing adherence, and patient and caregiver teaching.

  • Patient and caregiver teaching includes the following:

    1. nutritional therapy

    2. drug therapy

    3. lifestyle modification

    4. home monitoring of BP (if appropriate).

Age Related Considerations

  • The prevalence of hypertension increases with age. HTN is common in people 60 years of age and older in industrialized countries. The SBP rises throughout the lifespan and DBP rises until age 55 or 60 years and then levels off.

  • A number of age-related physical changes contribute to the pathophysiology of hypertension in the older adult.

  • In some older people, there is a wide gap between the first Korotkoff sound and subsequent beats (auscultatory gap). Failure to inflate the cuff enough may result in underestimating the SBP.

  • Older adults are sensitive to BP changes. Reducing SBP to less than 120 mm Hg in a person with long-standing hypertension could lead to inadequate cerebral blood flow.

  • Older adults produce less renin and are more resistant to the effects of ACE inhibitors and A-II receptor blockers.

  • Orthostatic hypotension often occurs in older adults because of impaired baroreceptor reflex mechanisms, volume depletion, and chronic disease states, such as decreased renal and hepatic function or electrolyte imbalance.

  • To reduce the likelihood of orthostatic hypotension, antihypertensive drugs should be started at low doses and increased cautiously.

HYPERTENSIVE EMERGENCIES

HYPERTENSIVE CRISIS

  • Hypertensive crisis is a severe and abrupt elevation in BP, arbitrarily defined as a DBP above 120 to 130 mm Hg.

  • Hypertensive crisis occurs most often in patients with a history of hypertension who have failed to adhere to their prescribed medications or who have been undermedicated.

  • Hypertensive crisis related to cocaine or crack use is becoming a more frequent problem. Other drugs such as amphetamines, phencyclidine (PCP), and lysergic acid diethylamide (LSD) may also precipitate hypertensive crisis that may be complicated by drug-induced seizures, stroke, MI, or encephalopathy.

HYPERTENSIVE EMERGENCY

  • Hypertensive emergency develops over hours to days, and is defined as BP that is severely elevated with evidence of acute target-organ damage.

  • Hypertensive emergencies can precipitate encephalopathy, intracranial or subarachnoid hemorrhage, acute left ventricular failure with pulmonary edema, MI, renal failure, and dissecting aortic aneurysm.

  • Hypertensive emergencies require hospitalization, parenteral administration of antihypertensive drugs, and intensive care monitoring.

HYPERTENSIVE URGENCY

  • Hypertensive urgency develops over days to weeks, and is defined as a BP that is severely elevated but with no clinical evidence of target organ damage.

  • Hypertensive urgencies usually do not require IV medications but can be managed with oral agents.

  • If a patient with hypertensive urgency is not hospitalized, outpatient follow-up should be arranged within 24 hours.

NURSING & COLLABORATIVE MANAGEMENT

  • The initial treatment goal is to decrease mean arterial pressure (MAP) 10% to 20% in the first one to two hours with further gradual reduction over the next 24 hours.

  • Lowering BP excessively may decrease cerebral perfusion and could precipitate a stroke.

  • A patient who has aortic dissection, unstable angina, or signs of MI must have the SBP lowered to 100 to 120 mm Hg as quickly as possible.

  • Antihypertensive drugs include vasodilators, adrenergic inhibitors, esmolol hydrochloride, and the ACE inhibitor enalaprilat sodium (Vasotec). Sodium nitroprusside is the most effective parenteral drug for the treatment of hypertensive emergencies.

  • Regular, ongoing assessment (e.g., ECG monitoring, vital signs, urinary output, level of consciousness, visual changes) is essential to evaluate the patient with severe hypertension.

  • Once the hypertensive crisis is resolved, it is important to determine the cause. The patient will need appropriate management and extensive education to avoid future crises.

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ADPIE of Hypertension

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