Running Head: Pepper Family Case Study 1 Pepper Family Case Study 15 Pepper Family Case Study Instructor Name Course Date Client's demographical information Olivia Pepper is a 30-year-old African American woman who is married with three children (ages 2, 6, and 8). Olivia is a Baptist and is receiving several financial need scholarships which allows her to attend school without working. She has two residential treatments, once as an adolescent for alcohol use and the second when she was 24 for depression and alcohol use. She has had two DUI's, one at 16 and the second at 22. Olivia has previously taken Zoloft and Wellbutrin, and has gone to family counseling as a teenager. Olivia is currently pursuing her Master’s degree and has a 3.8 overall GPA. She has been referred to the University Counseling Center from her professor for erratic behaviors, which include failing two classes and having a sporadic attendance, being late, and smelling of alcohol on more than one occasion. Olivia's peers have reported that she wants to meet at the local bar and is never engaged in learning. Olivia grew up with loving parents who worked hard. Her mother left when she was 14 and that is when she started to drink. She has been in a “funk” on and off her whole life and reports that most days she just doesn’t want to get out of bed and face the day. She is overwhelmed and sleeps 10-12 hours a day, isolates herself from her family, and avoids going to school. She has attempted suicide once with a drug overdose on Wellbutrin with alcohol. Olivia is currently attending AA meetings regularly and reports that church and AA help her get out of bed in the morning. She has started to drink again and sneaks drinks into her lemonade so that her family does not know. Her husband is angry and wants her to quit school, and Olivia is concerned for her 8-year-old daughter who is exhibiting similar behaviors as her. Olivia's demographic information paints a vivid picture of her life. She has faced many challenges in her life, from her mother leaving when she was 14 to her father passing away two years ago from drinking. She is under a lot of stress with having to care for her three children and still trying to pursue her degree. She has dealt with depression and alcohol use, attempted suicide, and has had two, (DUI's Shenoy,2019). Olivia has had to find different coping mechanisms to get her through her day, and while church and AA have been helpful, she has resorted to drinking again, which is causing her to struggle in her classes. Her family dynamics are strained with her husband wanting her to quit school and her 8-year-old daughter exhibiting similar behaviors. It is clear that Olivia is in need of support and guidance to help her get through the current struggles that she is facing. Analysis of the Client's presenting problem Olivia is struggling with depression and alcohol misuse. .

1. Running Head: Pepper Family Case Study 1
Pepper Family Case Study 15
Pepper Family Case Study
Instructor Name
Course
Date
Client's demographical information
Olivia Pepper is a 30-year-old African American woman
who is married with three children (ages 2, 6, and 8). Olivia is a
Baptist and is receiving several financial need scholarships
which allows her to attend school without working. She has two
residential treatments, once as an adolescent for alcohol use and
the second when she was 24 for depression and alcohol use. She
has had two DUI's, one at 16 and the second at 22. Olivia has
previously taken Zoloft and Wellbutrin, and has gone to family
counseling as a teenager. Olivia is currently pursuing her
Master’s degree and has a 3.8 overall GPA. She has been
referred to the University Counseling Center from her professor

2. for erratic behaviors, which include failing two classes and
having a sporadic attendance, being late, and smelling of
alcohol on more than one occasion. Olivia's peers have reported
that she wants to meet at the local bar and is never engaged in
learning.
Olivia grew up with loving parents who worked hard.
Her mother left when she was 14 and that is when she started to
drink. She has been in a “funk” on and off her whole life and
reports that most days she just doesn’t want to get out of bed
and face the day. She is overwhelmed and sleeps 10-12 hours a
day, isolates herself from her family, and avoids going to
school. She has attempted suicide once with a drug overdose on
Wellbutrin with alcohol. Olivia is currently attending AA
meetings regularly and reports that church and AA help her get
out of bed in the morning. She has started to drink again and
sneaks drinks into her lemonade so that her family does not
know. Her husband is angry and wants her to quit school, and
Olivia is concerned for her 8-year-old daughter who is
exhibiting similar behaviors as her.
Olivia's demographic information paints a vivid
picture of her life. She has faced many challenges in her life,
from her mother leaving when she was 14 to her father passing
away two years ago from drinking. She is under a lot of stress
with having to care for her three children and still trying to
pursue her degree. She has dealt with depression and alcohol
use, attempted suicide, and has had two, (DUI's Shenoy,2019).
Olivia has had to find different coping mechanisms to get her
through her day, and while church and AA have been helpful,
she has resorted to drinking again, which is causing her to
struggle in her classes. Her family dynamics are strained with
her husband wanting her to quit school and her 8-year-old
daughter exhibiting similar behaviors. It is clear that Olivia is
in need of support and guidance to help her get through the
current struggles that she is facing.
Analysis of the Client's presenting problem
Olivia is struggling with depression and alcohol

3. misuse. She is currently failing two of her courses and her
attendance has been sporadic. According to her professor, she
has been smelling of alcohol after lunch and is not engaged in
learning, and instead is more interested in what is next to drink.
Her intake paperwork reveals that she has a history of alcohol
misuse, two residential treatments for alcohol use and
depression, and two DUI's.
Olivia has reported that she feels overwhelmed and
exhausted all the time, and has difficulty getting out of bed and
facing her day. She is sleeping 10-12 hours a day and is
isolating herself from her family. She also reports that her
husband was recently fired from his job, which has caused a
great deal of stress in the home and has led to him asking her to
quit school and work until he finds a new job. She has reported
that she has been in a "funk" her entire life and has experienced
feelings of worthlessness. She has a history of alcohol misuse,
which she began engaging in as a coping mechanism after her
mother left when she was 14. She has also attempted suicide in
the past due to her depression and alcohol misuse, which has
caused her to seek help in the form of attending AA meetings.
Olivia is currently exhibiting a number of signs and
symptoms of depression, including feelings of worthlessness,
difficulty getting out of bed and facing her day, sleeping 10-12
hours a day, and isolating herself from her family. She has also
reported that she is struggling with alcohol misuse, which is
likely a maladaptive coping mechanism to deal with her
depression. Her two DUI's and two residential treatments for
alcohol use and depression are further evidence of her struggles
with alcohol. Additionally, her husband's recent job loss has
likely exacerbated her depression and alcohol misuse, leading to
her current difficulty with her studies.
Overall, Olivia is presenting with depression and
alcohol misuse. Her current symptoms of depression and alcohol
misuse are likely a result of her past experiences, her current
situation, and her maladaptive coping strategies which she has
employed to deal with her symptoms. Additionally, her

4. husband's recent job loss and the resulting stress it has caused is
likely further exacerbating her symptoms.
Client's diagnoses using the DSM-5-TR
Olivia presents with a constellation of symptoms that are
consistent with a diagnosis of Major Depressive Disorder,
Recurrent, Moderate. According to the DSM-5-TR, this is a
mental disorder characterized by five or more of the following
symptoms, present during the same two-week period and reflect
a change from previous functioning; at least one of the
symptoms must be either; depressed mood or loss of interest or
pleasure: depressed mood most of the day, nearly every day,
markedly diminished interest or pleasure in all, or almost all
activities most of the day, nearly every day, significant weight
loss when not dieting, or weight gain, or decrease or increase in
appetite nearly every day, insomnia or hypersomnia nearly
every day, psychomotor agitation or retardation nearly every
day, fatigue or loss of energy nearly every day, feelings of
worthlessness or excessive or inappropriate guilt nearly every
day, diminished ability to think or concentrate, or
indecisiveness, nearly every day, recurrent thoughts of death,
recurrent suicidal ideation without a specific plan, or a suicide
attempt or a specific plan for committing suicide, (Himes,2020).
In addition, Olivia meets criteria for Alcohol Use
Disorder, Moderate. According to the DSM-5-TR, this is a
pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by at least two of the
following, occurring within a 12-month period: Alcohol is often
taken in larger amounts or over a longer period than was
intended, there is a persistent desire or unsuccessful efforts to
cut down or control alcohol use. A great deal of time is spent in
activities necessary to obtain alcohol, use alcohol, or recover
from its effects. Craving, or a strong desire or urge to use
alcohol. Recurrent alcohol use resulting in a failure to fulfill
major role obligations at work, school, or home. Continued
alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of

5. alcohol (Himes,2020). Important social, occupational, or
recreational activities are given up or reduced because of
alcohol use. Recurrent alcohol uses in situations in which it is
physically hazardous. Alcohol use is continued despite
knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or
exacerbated by alcohol.
Olivia also meets criteria for Post-Traumatic Stress Disorder,
Mild. According to the DSM-5-TR, this is a mental disorder that
can occur in people who have experienced or witnessed a
traumatic event. It is characterized by avoidance of stimuli
associated with the trauma, increased arousal, and negative
alterations in cognitions and mood. Symptoms include the
following: exposure to traumatic event involving actual or
threatened death, serious injury, or sexual violence, persistent
re-experiencing of the traumatic event, such as flashbacks or
nightmares, avoidance of reminders of the trauma, such as
people, places, conversations, or activities, persistent negative
alterations in cognitions and mood, such as negative beliefs
about oneself or the world, or persistent inability to experience
positive emotions, increased arousal, such as difficulty
sleeping, hypervigilance, exaggerated startle response, or
problems with concentration, (Borlaug,2020).
Assessments used to approach the diagnosis
The first assessment that should be used to approach
the diagnosis of Olivia is the Patient Health Questionnaire-9
(PHQ-9). The PHQ-9 is a depression scale that evaluates the
severity of depression and can help diagnose major depressive
disorder. It is a nine-item self-report that asks questions about
the frequency of symptoms experienced over the past two
weeks. The score from the PHQ-9 can range from 0-27 and can
help to determine the severity of depression, (Borlaug,2020).
The second assessment is the Alcohol Use Disorders
Identification Test (AUDIT). This is a 10-item self-report

6. questionnaire that evaluates the severity of alcohol
consumption. The AUDIT assesses the quantity and frequency
of alcohol consumption, the problems associated with alcohol
use, and the alcohol related consequences. The score from the
AUDIT can range from 0-40 and can help to diagnose any level
of alcohol use disorder (Raskin,2022).
The third assessment is the Attention Deficit
Hyperactivity Disorder (ADHD) scale. This is a seven-item self-
report questionnaire that evaluates the presence of symptoms
associated with ADHD. The score from the ADHD scale can
range from 0-14 and can help to diagnose any level of ADHD
(Raskin,2022).
In addition to the assessments listed above, it is also
important to obtain a thorough family history, a mental status
exam, and any other relevant information that can help to
provide a better understanding of Olivia's situation. It is also
important to note any co-occurring diagnoses such as anxiety or
substance use disorders.
The assessments listed above can help to identify any
issues Olivia may be facing and can provide a better
understanding of her current mental health. It is important to
use a combination of assessments to gain a comprehensive
understanding of Olivia's situation and to provide the best
treatment possible, (Bradley,2022).
Mental health theory application
In this case, cognitive theory is one of the mental
health theories that could be applied to Olivia’s situation.
Cognitive theory focuses on the individual’s thoughts and
beliefs and how they affect behavior. According to cognitive
theory, Olivia’s thoughts and beliefs about herself, her life, and
her abilities are impacting her behavior in a negative way. She
believes that she is not capable of completing her degree and is
overwhelmed by her current life situation. This is leading her to
make poor decisions, such as drinking and isolating herself
from family and friends. (Bradley,2022)
The cognitive theory suggests that by changing her

7. thought patterns, Olivia can change her behavior. To do this,
she needs to identify her negative thought patterns and replace
them with more positive, realistic thoughts. For example,
instead of believing that she is incapable of completing her
degree, she can focus on her past successes and the progress she
has made. She can also focus on the positive aspects of her life,
such as her loving family, and create concrete plans to help her
achieve her goals.
By using cognitive theory, Olivia can begin to challenge
her negative thoughts and develop more positive, healthier
beliefs. This will help her to make better decisions and move
forward with her life in a more positive direction. With the help
of her therapist and other supportive individuals, Olivia can
take the steps necessary to make positive changes in her life and
move towards her future goals, (Torous,2018).
Treatment interventions
The treatment intervention in this case would be a
Cognitive Behavioral Therapy (CBT) approach with a focus on
self-regulatory strategies. This approach is designed to help the
client identify and modify maladaptive thoughts and behaviors
that are associated with her current struggles. The client's
strengths include her intelligence, drive, and dedication to her
studies. She also has a strong interest in helping those in similar
circumstances to her own. Her weaknesses include her self-
regulatory abilities, her tendency to isolate herself, and her high
stress levels. Her social support systems include her husband,
her children, her faith, and her peers at school.
The long-term goal of the treatment intervention is for
Olivia to increase her self-regulation skills and to have better
control over her emotions and behaviors so that she can
successfully complete her studies and achieve her goals.
Additionally, she should be able to manage her stress levels and
find healthier coping strategies for her negative emotions
The short-term goals and treatment objectives are to
identify and modify Olivia's maladaptive thoughts and
behaviors that are associated with her current struggles,

8. (Torous,2018). This includes identifying her triggers and
helping her develop better coping strategies when faced with
them. Additionally, she should learn how to manage her stress
levels, control her emotions, and become more engaged in her
studies. She should also learn to recognize and regulate her
alcohol use. Finally, she should become more social and
develop healthier relationships with her peers and family.
(Torous,2018)
Treatment Timeline
Time
Description
Week 1.
Intake assessment
Psychoeducation on substance use, depression, anxiety and
stress
Cognitive Behavioral Therapy to address irrational thoughts
Psychoeducation on the importance of sleep hygiene
Education on the importance of self-care
Week 2
Group therapy for substance use
Individual therapy to address depression and anxiety
Couples therapy to address marital issues
Family therapy to address parenting and family dynamics
Week 3
Stress management skills
Mindfulness training
Relaxation training
Assertiveness training
Week 4
Continuing individual therapy
Continuing couple’s therapy
Continuing family therapy
Continuing group therapy
Week 5
Continuing individual therapy
Continuing couple’s therapy

9. Continuing family therapy
Continuing group therapy
Exploring relapse prevention strategies
Week 6
Continuing individual therapy
Continuing couple’s therapy
Continuing family therapy
Continuing group therapy
Exploring relapse prevention strategies
Discharge planning
Systems theory perspective
At the micro level, Olivia’s family systems theory
includes her husband and children. The primary focus of the
treatment should be on the dynamics of the family system and
how each member’s role and behavior affects the entire family.
Treatment should address the family’s stressors, such as the
husband’s unemployment, Olivia’s depression and alcohol use,
and the children’s emotional and academic needs (Raskin,2022).
At the mezzo level, Olivia’s extended family and
community should be considered. Treatment should include
communication between family members, and possibly family
therapy. Additionally, the family should be connected to
community resources, such as AA, financial assistance, and
educational support.
At the macro level, Olivia’s social environment should
be considered. Treatment should focus on the larger social
issues that may be impacting her and her family, such as
poverty, racism, and lack of social support. Additionally,
Olivia’s access to health care and mental health services should
be addressed.
Ethical Dilemmas
One potential ethical dilemma in Olivia's case is the
issue of her husband wanting her to quit school and work
instead. According to the NASW Code of Ethics, social workers

10. should “promote the right of clients to self-determination and
assist clients in their efforts to identify and clarify their goals”
(2018). By encouraging Olivia to pursue her educational goals,
social workers should strive to empower her and help her reach
her goals. In addition, social workers should strive to provide a
safe and supportive environment for her in which to discuss her
goals and make decisions about her future. Finally, social
workers should be mindful of the potential power imbalance
between Olivia and her husband, and strive to ensure that all
decisions are made in Olivia's best interests.
Client’s Diversity Needs
Olivia and her family come from a diverse background
that should be taken into consideration when providing
treatment. As an African American woman married with three
children, Olivia has the additional stress of being a single
parent with financial need scholarships and no job. In addition,
her religious affiliation is Baptist, which can also impact how
she perceives her life and her relationship with her family and
community. Olivia's two residential treatments for alcohol use,
two DUIs, and previous mental health issues should also be
taken into account when providing treatment (Kelly,2019).
When addressing the diversity needs of Olivia and her
family, it is important to use a culturally sensitive and trauma-
informed approach. This includes using language that is
respectful and understanding of her cultural background and
experiences. It is also important to recognize that Olivia and her
family may have faced racism, microaggressions, and other
forms of oppression (Kelly,2019). The counselor should also be
aware of the potential for the family to have experienced
generational trauma and should use culturally sensitive
approaches when exploring this topic. Finally, the counselor
should take into consideration the family's religious background
and how this may impact their views on alcohol use and other
issues.
Evaluation of the Client’s Progress

11. When evaluating Olivia's progress, I will use a
variety of approaches. I will use a combination of both
qualitative and quantitative measures, such as self-report
questionnaires, interviews, and observations. I will also use
standardized assessments, such as the Beck Depression
Inventory, to help measure her progress. Additionally, I will use
qualitative measures, such as interviews and observations, to
gain a deeper understanding of her progress. I will also use
measures such as her academic performance, attendance, and
her alcohol use. By using a combination of both qualitative and
quantitative measures I will be able to get a more
comprehensive picture of Olivia's progress. Furthermore, I will
also use self-report questionnaires to more accurately measure
her progress. This will allow me to get more detailed feedback
from her, which will be invaluable in helping her make
progress. Additionally, I will also use family interviews and
assessments to gain a better understanding of her family
dynamics and how this may be impacting her progress. By using
a combination of measures and approaches, I will be able to
accurately measure Olivia's progress and make the necessary
changes to help her succeed.
References
Shenoy, E. S., Macy, E., Rowe, T., & Blumenthal, K. G. (2019).
Evaluation and management of penicillin allergy: a review.
Jama,
321(2), 188-199.

12. Himes, C. P., Ganesh, R., Wight, E. C., Simha, V., & Liebow,
M. (2020, December). Perioperative evaluation and management
of endocrine disorders. In
Mayo Clinic Proceedings (Vol. 95, No. 12, pp. 2760-
2774). Elsevier.
Borlaug, B. A. (2020). Evaluation and management of heart
failure with preserved ejection fraction.
Nature Reviews Cardiology,
17(9), 559-573.
Bradley, L., Noble, N., & Hendricks, B. (2022). DSM-5-TR:
Salient Changes.
The Family Journal, 10664807221123558.
Raskin, J. D., Maynard, D., & Gayle, M. C. (2022).
Psychologist attitudes toward DSM-5 and its alternatives.
Professional Psychology: Research and Practice.
Bernet, W., & Baker, A. J. Proposal for Parental Alienation
Relational Problem to be Included in “Other Conditions That
May Be a Focus of Clinical Attention” in DSM-5-TR.
Torous, J., Nicholas, J., Larsen, M. E., Firth, J., & Christensen,
H. (2018). Clinical review of user engagement with mental
health smartphone apps: evidence, theory and improvements.
Evidence-based mental health,
21(3), 116-119.
Kelly, M., & Coughlan, B. (2019). A theory of youth mental
health recovery from a parental perspective.
Child and Adolescent Mental Health,
24(2), 161-169.
Levis, B., Benedetti, A., & Thombs, B. D. (2019). Accuracy of
Patient Health Questionnaire-9 (PHQ-9) for screening to detect
major depression: individual participant data meta-analysis.

13. bmj,
365.
Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E.,
Costanza, A., Serafini, G., ... & Amerio, A. (2021). Screening
for depression in primary care with Patient Health
Questionnaire-9 (PHQ-9): A systematic review.
Journal of affective disorders,
279, 473-483.
Effectiveness of Aerobic Exercise on Ambulatory Blood
Pressure in Hypertensive Patients
Presented by
Chinyere Christiana Pamugo

14. 1
DNP 965: Final Oral Presentation
December 13, 2022
A Direct Practice Improvement Project Presented in Partial
Fulfillment
of the Requirements for the Degree
Doctor of Nursing Practice
2
Investigator’s background
Registered Nurse for XXX years

15. 3
Topic’s background
Many individuals are unaware of the symptoms for
hypertension, which makes it a top priority to educate patients
and their families.
In the United States, over 37 million individuals are affected
(Centers for Disease Control and Prevention [CDC], 2021; Krist
et al., 2021).
The American College of Cardiology and the American Heart
Association guidelines for hypertension management and
definition of HTN defines it as having a blood pressure at or
above 130/80 mmHg (The American College of Cardiology
Foundation and the American Heart Association, 2018). At the
same time, stage 2 HTN is blood pressure at or above
140/90mmHg (CDC., 2021).
4
Topic’s background
Complications of the condition include myocardial infarction,

16. heart failure, chronic renal disease, and stroke (Ghatage et al.,
2021).
American Heart Association Task Force (AHA) published new
guidelines to help manage the increase of the disease (Wang et
al., 2019).
Purpose statement
The purpose of this quantitative, quasi-experimental project was
to determine if or to what degree the translation of Saco-Ledo et
al.’s research on aerobic exercise would impact ambulatory
blood pressure when compared to current practice among adult
hypertensive patients in a primary care clinic in southwest
Texas over four weeks
6
problem statement
It was not known if or to what degree the translation of Saco-
Ledo et al.’s research on aerobic exercise would impact
ambulatory blood pressure when compared to current practice
among adult hypertensive patients

17. 7
Identified problem
At the clinical site, there were no standardized guidelines for
clinicians to educate hypertensive patients regarding
implementing daily physical activity as a blood pressure
management mechanism.
Collaboration with the medical director and some of the nursing
staff showed an increase of 37.1% in diagnosed HTN patients
within the past six months. The clinic’s findings corresponded
with the health statistics from the Texas Department of State
Health Services (2022), as the county ranks 22 in the States
with diagnosed hypertensive patients
8
Significance of the project
Implementing a recommended evidence-based strategy by the
AHA guideline regarding aerobic exercise
Commodore-Mensah et al. (2018) state that the financial prices
are significant, approximately $131-198 billion annually
This project could help decrease the financial costs associated
with the disease
Hypertensive persons incur an extra $2000 yearly in healthcare
expenditures compared to non-hypertensive persons
(Commodore-Mensah et al., 2018).
9

18. Clinical question
To what degree does the translation of Saco-Ledo et al.’s
research on aerobic exercise would impact blood pressure when
compared to current practice among adult hypertensive patients
in a primary care clinic in southwest Texas?
The independent variable was the translation of Saco-Ledo et
al.’s research regarding aerobic exercise, and the dependent
variable is blood pressure
10
Theoretical underpinnings
Dorothy Orem’s self-care deficit theory (Orem, 1995).
Kurt Lewin’s change model (Lewin, 1947).
Unfreezing
Change or Movement
Refreezing
Based on the theory, self-care is that patients must engage in to
maintain and improve their quality of health (Orem, 1995).
Utilizing this theory, the nurses do not see their patients as
inactive or receiving health services; instead, they consider
them strong and reliable to participate in daily activities and
decision-making processes (Orem, 1995). Three nursing systems
are defined in Orem’s nursing theory; they include wholly
compensatory, partially compensatory, and supportive-educative
strategies (Khademian et al., 2020).
The chosen change is Lewin’s change model. It was selected
because it is a way to describe the process change versus
guiding the activities that will be conducted.

19. 11
review of the Literature
Prevention of Hypertension
Systolic Blood Pressure Management
Diastolic Blood Pressure Management
Ambulatory Blood Pressure Management
Aerobic Exercise Health Intervention
Pre-Aerobic State
Post-Aerobic State
Ambulatory Blood Pressure Management
Effect of Exercise on Blood Pressure
Health Literacy Level
Self-Efficacy
Lifestyle Modification
12
clinical Question
To what degree does the implementation of American Heart
Association guideline aerobic exercise would impact blood
pressure when compared to current practice among adult
hypertensive patients in a primary care clinic in southwest
Texas?
The independent variable is the American Heart Association
guideline regarding aerobic exercise, and the dependent variable
is blood pressures.

20. 13
Methodology
Quantitative methodology
Using numerical data
It is objective, systematic, and focused data analysis strategies
(Guetterman & Fetters, 2018).
Data can be replicated (Creswell & Creswell, 2018).
In this project, the project manager will evaluate the AHA
guidelines and its impact on the blood pressures of HTN
patients. The dependent variable will be measured four weeks
before and post project intervention. This methodology is the
most appropriate because other investigators can replicate the
data (Creswell & Creswell, 2018).
A qualitative methodology was not selected because this method
is often thematic and subjective, and findings are produced
using the participants' words verbatim (Creswell & Creswell,
2018). In this project, the project manager will not seek to
understand the participants' behaviors, feelings, or lived
experiences (Creswell & Creswell, 2018
14
Project design
Quasi-experimental design
Determines the effect that the independent variable has on the
dependent variable (Creswell & Creswell, 2018).
Participants are not randomly assigned (Creswell & Creswell,

21. 2018).
Project manager will manipulate the independent variable
For this project, the dependent variable (blood pressure) will be
measured at two different times (once before the intervention
and one after the intervention (Creswell & Creswell, 2018). A
correlational design was not the most appropriate for this
project. It is a non-experimental design where the independent
and dependent variables are measured and assessed for their
correlation relationship (Creswell & Creswell, 2018).
15
Instrumentation
Data source: ABPM log retrieved from the Oscar 2 device
Electronic ABP data retrieved from the electronic medical
record
Before starting the ABP project, it was imperative to ensure that
the device operated as required and was installed correctly on
the patient (Nwankwo et al., 2020).
The electronic ABP data on the device was retrieved from a
computer via a USB cable
16
Data collection
Data collected four weeks pre/post implementation
Oscar 2 device
Participants walked at home three to five times weekly for 20

22. minutes
They were instructed to continue taking their antihypertensive
medications
Tracked their process in a logbook (Mon, Wed, Fri)
Participants were re-evaluated at the clinic week four
The healthcare providers took the 24-hour ABP measurements at
two-time points: baseline without aerobic exercise in week one
and week four after the workout
In week four, the participants returned to the clinic to retake
their ABP using Oscar 2 device. Participants ambulated around
the clinic for 20 minutes wearing the Oscar 2 device. They were
monitored for their walking, whether it was intense or moderate.
The ABP measurements were taken after a 20-minute rest period
by the staff.
17
Data analysis
Descriptive data (such as age, gender, and ethnicity)
Paired Sample t-Test.
Descriptive data (such as age, gender, and ethnicity) will be
collected via the clinic’s electronic medical records (evaluated
using frequency counts and percentages)
The independent variable is nominal, and the dependent variable
is an interval level variable (Schober & Vetter, 2019). This t-
test examines the mean scores taken from the same participants
(Schober & Vetter, 2019).

23. The level of statistical significance was set to .05 to indicate
that a p-value of less than .05 will be considered statistically
significant.
18
resultsVariableDescriptive DataMSDAge56.507.92
Table 1
Descriptive Data for Age
Table 2
Descriptive Data for Gender and RaceVariableDescriptive
Datan%Gender Male330.0 Female770.0Race African
American880.0 Hispanic110.0 Caucasian110.0
Note. M = mean; SD =standard deviation
Note. n =count; % = percentage
results
VariablePre
Post
t (9)
pMSDMSDSystolic BP
(mm/Hg)152.6014.42126.1019.936.35.001
Chi-square test results showed a decrease in the mean systolic
BP level from pre (M = 152.60, SD = 14.42) to post (M =
126.10, SD = 19.93), t (9) = 6.35, p = .001. The p-value is less
than .05 which indicates that the decrease in mean systolic BP
was statistically significant. Clinical significance was supported
by the 26.50 mean decline in the systolic mean levels after the
intervention.
Table 3

24. Paired t-Test Results for Systolic Blood Pressure Levels
Note. M = mean; SD =standard deviation
results
VariablePre
Post
t (9)
pMSDMSDDiastolic BP (mm/Hg)87.3011.1978.108.452.56.031
Chi-square test results showed a decrease in the mean diastolic
BP level from pre (M = 87.30, SD = 11.19) to post (M = 78.10,
SD = 8.45), t (9) = 2.56, p = .031. The p-value is less than .05
which indicates that the decrease in mean diastolic BP was
statistically significant. Clinical significance was supported by
the 9.20-point mean decline in the systolic mean levels after the
intervention.
Table 4
Paired t-Test Results for Diastolic Blood Pressure Levels
Note. M = mean; SD =standard deviation
limitations
Small sample size
Limited time frame to conduct project (four-weeks)
Data analysis being conducted by outside statistician

25. First limitation: Small sample size
Second limitation: Limited time (four-weeks) a longitudinal
project three or more months
Third limitation: Due to the project manager’s limited
knowledge and time in conducting statistical analysis, an
outside statistician not affiliated with the project or manager
will perform the data analysis.
22
discussion
Clinical significance was demonstrated by the 26.50 mean
decline in the systolic mean and 9.20 in the diastolic mean and
9.20 in the diastolic mean levels
Based on the results, the translation of Saco-Ledo et al.’s on
aerobic exercise may improve blood pressure. One
recommendation for future projects is to conduct the project in
other medical settings, such as medical-surgical units, women’s
health, and dialysis patients.
Recommendations
The project findings showed that an educational program in
combination with aerobic exercise about hypertension can result
in systolic and diastolic blood pressure changes
Reproduce the intervention in other healthcare settings
Conduct longitudinal project (one year or longer)
For nurse managers to pay attention to the HTN risk in their
older employees (age 40 and above)
Evaluate the patient’s health stressors that can contribute to
hypertension

26. references
Centers for Disease Control and Prevention, (2021). Facts about
hypertension in the United States.
https://www.cdc.gov/bloodpressure/facts.htm
Commodore-Mensah, Y., Selvin, E., Aboagye, J., Turkson-
Ocran, R., Li, X., Himmelfarb, C., Ahima, R., & Cooper, L. A.
(2018). Hypertension, overweight/obesity, and diabetes among
immigrants in the United States: An analysis of the 2010–2016
national health interview survey. BMC Public Health, 18(1), 1-
8. https://doi.org/10.1186/s12889-018-5683-3
Creswell, J.W., & Creswell, J. D. (2018). Research design:
Qualitative, quantitative, and mixed methods approaches
(5thed.). Sage Publications.
references
Ghatage, T., Goyal, S., Dhar, A., & Bhat, A. (2021). Novel
therapeutics for the treatment of hypertension and its associated
complications: Peptide- and nonpeptide-based
strategies. Hypertension Research, 44(7), 740-755.
https://doi.org/10.1038/s41440-021-00643-z
Guetterman, T., & Fetters, M. (2018). Two methodological
approaches to the integration of mixed methods and case study
designs: A systematic review. American Behavioral Scientist,
62, 900-918.
https://doi.org/10.1177/0002764218772641
Krist, A., Davidson, K., Mangione, C., Cabana, M.,

27. Caughey, A., Davis, E., Donahue, K., Doubeni, C., Kubik, M.,
Li, L., Ogedegbe, G., Pbert, L., Silverstein, M., Stevermer, J.,
Tseng, C., & Wong, J. (2021). Screening for hypertension in
adults. JAMA, 325(16), 1650-
1656. https://doi.org/10.1001/jama.2021.4987
references
Lewin, K. (1947). Frontiers in group dynamics: concept,
method, and reality in social science; social equilibria and
social change. Human Relations, 1, 5–41.
https://doi.org/10.1177/001872674700100103
Nwankwo, T., Coleman King, S. M., Ostchega, Y., Zhang, G.,
Loustalot, F., Gillespie, C., & Merritt, R. (2020). Comparison
of 3 devices for 24-hour ambulatory blood pressure monitoring
in a nonclinical environment through a randomized trial.
American Journal of Hypertension, 33(11), 1021-
1029.https://doi.org/10.1093/ajh/hpaa117
Orem, D. E. (1991). Nursing: Concepts of practice (4th ed.).
Mosby.
Schober, P., & Vetter, T. (2019). Descriptive statistics in
medical research. Anesthesia & Analgesia, 129(6), 1445-1447.
https://doi.org/10.1213/ane.0000000000004480
Wang, D., Hatahet, M., Wang, Y., Liang, H., Bazikian, Y., &
Bray, C. (2019). Multivariate analysis of hypertension in
general US adults based on the 2017 ACC/AHA guideline: data
from the national health and nutrition examination survey 1999
to 2016. Blood Pressure, 28(3), 191-198. doi:
10.1080/08037051.2019.1593042

28. Effectiveness of Aerobic Exercise on Ambulatory Blood
Pressure in Hypertensive Patients
By Chinyere Christiana Pamugo
Grand Canyon University, Phoenix Arizona
Introduction and Problem
Variables
Descriptive Data
Results
Results (cont.)
Clinical Question(s)
Discussion
Project Limitations
Recommendations for Future Projects and Practice
Purpose of the Project
Data Analysis
The project site is a primary care clinic in urban Texas. A
convenience sample of n= 10 adult patients with HTN were
enrolled in the project. Descriptive data were collected for age,
gender, and race.
Table 1 displays the descriptive data for age. The mean age was
56.50 (SD = 7.92) ranging from 43 to 71.
References
The independent variable was the translation of Saco-Ledo et
al.’s research regarding aerobic exercise, and the dependent
variable is ambulatory blood pressure.

29. .
.
Centers for Disease Control and Prevention (CDC). (2021).
Facts about hypertension in the United States.
https://www.cdc.gov/bloodpressure/facts.htm
Krist, A., Davidson, K., Mangione, C., Cabana, M., Caughey,
A., Davis, E., Donahue, K., Doubeni, C., Kubik, M., Li, L.,
Ogedegbe, G., Pbert, L., Silverstein, M., Stevermer, J., Tseng,
C., & Wong, J. (2021). Screening for hypertension in adults.
Journal of the American Medical Association, 325(16), 1650-
1656. https://doi.org/10.1001/jama.2021.4987
Leedy, P., & Ormrod, J. (2020). Practical research: Planning
and design. Pearson Publications.
Saco-Ledo, G., Valenzuela, P., Ruiz-Hurtado, G., Ruilope, L., &
Lucia, A. (2020). Exercise reduces ambulatory blood pressure in
patients with hypertension: A systematic review and meta-
analysis of randomized controlled trials. Journal of American
Heart Association, 15(9), 1-18. doi: 10.1161/JAHA.120.018487.
Many individuals are unaware of the symptoms for
hypertension, which makes it a top priority to educate patients
and their families.
In the United States, over 37 million individuals are affected
(Centers for Disease Control and Prevention [CDC], 2021; Krist

30. et al., 2021).
Using the translation of Saco-Ledo et al.’s research on aerobic
exercise would impact ambulatory blood pressures.
At the clinical site, there were no standardized guidelines for
clinicians to educate hypertensive patients regarding
implementing daily physical activity as a blood pressure
management mechanism
It was not known if or to what degree the translation of Saco-
Ledo et al.’s research on aerobic exercise would impact
ambulatory blood pressure when compared to current practice
among adult hypertensive patients
Chi-square test results showed a decrease in the mean systolic
BP level from pre (M = 152.60, SD = 14.42) to post (M =
126.10, SD = 19.93), t (9) = 6.35, p = .001. The p-value is less
than .05 which indicates that the decrease in mean systolic BP
was statistically significant. Clinical significance was supported
by the 26.50 mean decline in the systolic mean levels after the
intervention. The results are displayed in Table 3.
The results are presented to address the clinical question related
to the impact of the AHA guidelines for aerobic exercise on
systolic and diastolic blood pressure. A paired t-test was
conducted on systolic and diastolic blood pressure at pre-and
post-implementation.. The goal was to reduce ambulatory blood
pressure after the intervention. Results are displayed in
narrative and table format.
The purpose of this quantitative, quasi-experimental project was
to determine if or to what degree the translation of Saco-Ledo et
al.’s research on aerobic exercise would impact ambulatory
blood pressure when compared to current practice among adult

31. hypertensive patients in a primary care clinic in southwest
Texas over four weeks
To what degree does the translation of Saco-Ledo et al.’s
research on aerobic exercise would impact blood pressure when
compared to current practice among adult hypertensive patients
in a primary care clinic in southwest Texas
Clinical significance was demonstrated by the 26.50 mean
decline in the systolic mean and 9.20 in the diastolic mean and
9.20 in the diastolic mean levels
Based on the results, the translation of Saco-Ledo et al.’s on
aerobic exercise may improve blood pressure. One
recommendation for future projects is to conduct the project in
other medical settings, such as medical-surgical units, women’s
health, and dialysis patients.
The first limitation was the restricted time to conduct the
project (four weeks). A longitudinal project allows one to
evaluate the trends and changes over time (Leedy & Ormrod,
2020).
The second limitation was the small sample size. The primary
problem with a small sample size was interpreting the results,
mainly related to the confidence intervals and p-values (Leedy
& Ormrod, 2020).
The project findings showed that an educational program in
combination with aerobic exercise about hypertension can result
in systolic and diastolic blood pressure changes
Reproduce the intervention in other healthcare settings
Conduct longitudinal project (one year or longer)
Nurse managers to pay attention to the HTN risk in their older
employees (age 40 and above)
Evaluate the patient’s health stressors that can contribute to
hypertension
Descriptive data (such as age, gender, and ethnicity) including

32. mean and standard deviation for age and frequencies and
percentage for gender and ethnicity.
To examine systolic and diastolic blood pressure at pre- and
post-implementation, paired sample t-tests were conducted in
IBM SPSS version 28 using a level of significance of .05.
Table 1
Descriptive Data for Age
Table 2
Descriptive Data for Gender and Race
Gender and race are displayed in Table 2. There were three
males (30.0%) and females made up 70.0% (n = 7). Race was
80.0% (n = 8) African American, 10.0% (n = 1) Hispanic, and
10.0% (n = 1) Caucasian.
Table 3
Paired t-Test Results for Systolic Blood Pressure Levels
Chi-square test results showed a decrease in the mean diastolic
BP level from pre (M = 87.30, SD = 11.19) to post (M = 78.10,
SD = 8.45), t (9) = 2.56, p = .031. The p-value is less than .05
which indicates that the decrease in mean diastolic BP was
statistically significant. Clinical significance was supported by
the 9.20-point mean decline in the systolic mean levels after the
intervention.
Table 4
Paired t-Test Results for Diastolic Blood Pressure Levels
Note. M = mean; SD =standard deviation
Note. M = mean; SD =standard deviation
Note. n =count; % = percentage
Note. M = mean; SD =standard deviation

33. TEMPLATE DESIGN © 2008
www.PosterPresentations.com
28
Statistics show that as at the end of 2010, an estimated 31.1% of
adults (1.39 Billion) worldwide had hypertension, with many
people unaware of its symptoms. This makes my projects unique
as it is designed for educating patients and their families. As
indicated above, complications from this health condition may
include myocardial infarction, heart failure, chronic renal
disease, and stroke (Ghatage et al., 2021).
Purpose of Study: My quantitative, quasi-experimental project
determines if or to what degree the translation of Saco-Ledo et
al.’s research on aerobic exercise can impact ambulatory blood
pressure when compared to current practice among adult
hypertensive patients in a primary care clinic in southwest
Texas over four weeks. The problem came from the fact that at
the clinical site, there was no standardized guidelines for
clinicians to educate hypertensive patients regarding
implementing daily physical activity as a blood pressure
management mechanism. It created a problem statement that “it
was not known if or to what degree the translation of Saco-Ledo
et al.’s research on aerobic exercise would impact ambulatory
blood pressure when compared to current practice among adult
hypertensive patients.”
The significance of this project stems from the fact there is the
need to implement an evidence-based strategy such as the ones
recommended by the AHA guideline regarding aerobic exercise
as well as the recommendation of Commodore-Mensah et al.

34. (2018), in which it states that spending on prices are significant
and is approximately $131-198 billion annually. This project
potentially helps in decreasing the financial costs associated
with the disease when Dorothy Orem’s self-care deficit theory
(Orem, 1995) and Kurt Lewin’s change model (Lewin, 1947)’s
Unfreezing, Change or Movement and Refreezing are used.
Recommendations: The discovery in this projects proved that an
educational program in combination with aerobic exercise about
hypertension results in systolic and diastolic blood pressure
changes. Other recommendations include:
Reproduce the intervention in other healthcare settings
Conduct longitudinal project (one year or longer)
For nurse managers to pay attention to the HTN risk in their
older employees (age 40 and above)
Evaluate the patient’s health stressors that can contribute to
hypertension
29
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image4.png
image5.jpeg

35. image6.png
image7.png
image8.png
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1
EffectivenessofAerobicExerciseonAmbulatoryBloodPressureinH
ypertensivePatients
Submitted by
Chinyere Christiana Pamugo
A Direct Practice Improvement Project Presented in Partial
Fulfillment
Of the Requirements for the Degree
Doctor of Nursing Practice
Grand Canyon University
Phoenix, Arizona
December 7th, 2022

36. ©byChinyereChristianaPamugo,2022
All rights reserved.
GRANDCANYONUNIVERSITY
EffectivenessofAerobicExerciseonAmbulatoryBloodPressureinH
ypertensivePatients
Chinyere Christiana Pamugo
Has been approved
December 7th, 2022
APPROVED:
Dawn Robinson DNP, MSN, RN, LNHA, DPI Project
Chairperson
Khoa Don Nguyen, MD.,DPI Project Mentor

37. ACCEPTEDANDSIGNED:
________________________________________
Lisa Smith, Ph.D., RN, CNE
Dean and Professor, College of Nursing and HealthCare
Professions
_________________________________________
Date
Abstract
Hypertensionisaprevalentdiseaseaffectingmillionsofindividualsi
ntheUnitedStates.Attheprojectsite,therewerenostandardizedguide
linesforeducatinghypertensivepatientsregardingincorporatingexe
rcise(dailyphysicalactivity)asabloodpressure
(BP)managementmechanism.Thepurposeofthisquantitative,quasi
-experimentalprojectwas to determine if or to what degree the
implementation of
“theAmericanHeartAssociation’s”guidelineonaerobicexercisewo
uldimpactambulatory
bloodpressurewhencomparedtocurrentpracticeamongadulthypert
ensivepatientsinaprimarycareclinicinsouthwestTexasoverfourwe
eks.DorothyOrem’sself-
caredeficittheoryandLewin’schangemodelwere the scientific
underpinnings.Datawereretrievedfromtheclinic’selectronicmedic
alrecords of adult hypertensive patients.(
n-10) and compared at baseline and four weeks post-
implementation of the American Herat Association’s guideline
on aerobic exercise. A paired-sample
t-test showed a statistically and clinically significant
improvement in the systolic blood pressure. Based on the
results, the American Herat Association’s guideline on aerobic
exercise may improve blood
pressure.Onerecommendationforfutureprojectsistoconductthepro
jectinothermedicalsettingssuchasmedical-
surgicalunits,women’shealth,anddialysispatients.
Keywords:aerobicexercise,AmericanHeartAssociationguideline,
DorothyOrem’sself-

38. caredeficittheory,hypertension,hypertension-
relatedconditions,KurtLewin’changemodel.
Dedication
I dedicate this project to God, my life's author, and finisher.
Irrespective of the unsurmountable challenges and moments of
despair, your mercy, grace, and love lead me through. Without
your divine wisdom, Almighty father, I would not have been
here this day.
To my Beloved families here and abroad, my mum, siblings,
cousins, and spouse Engr. G. O. Pamugo, I achieved this goal
because of your fervent prayers, support, and encouragement
that fortified my strength, endurance, perseverance, and
resilience not to quit to frustrations and fears. Even with my
poor health, I struggled and still made it to this day because you
all held my weak parts as I journeyed and ran the race to
success. Thank you for believing in me and investing in my
success. God bless you all. To my dad-late Chief M.E. Chukwu,
I did accomplish your dreams on me, and I know wherever your
soul is at this time, it is full of joy; rest in peace, daddy, until
we meet again.
To my elder brother in the Lord, Rev. Fr. C. Iwuagwu, words
cannot express the magnitude of gratitude I owe you for your
fatherly and brotherly love, belief in my abilities, countless
hours of encouragement, enormous -uplifts, and renewed
determination. You are a blessing and gift to our family; remain
blessed.
Acknowledgments
The fruitful journey of my Doctor of Nursing program (DNP)
was made possible by the unconditional support of
extraordinary and cherished individuals, such as Dr. Khoa and
Don Nguyen, MD, for serving as my preceptor/mentor
throughout the stages of my direct immersion project. Dr. Dawn
Robinson, my Faculty /Chair, for her unshaken patience, quick

39. feedback, and radiant positive energy, together with Dr.
Katherine McDermott and faculty in course level review,
reading countless revisions and providing knowledgeably expert
guidance to the end of this course.
To my colleagues, Jeffrey Souza, Tresa Antony, Mercy Daniel,
Lisa Johnson, Marissa Rafael, and Skyler Meyer, thank you for
your unfading support. Countless times, I felt like the world has
collapsed upon me, desperately seeking the way out in the
darkness, lo and behold, your torchlights point through the
doors of escape. I recognized each day we journeyed that the
race was worth it because you all were there pointing your
lights to the proper outlet.
To my supportive friends, Sr. Onyinyechukwu Uba, Ms.
Euphemia, Ms. Amaka, Dr. Bashiru, Calista, Sylvia, Vincent,
and Ogunbayode. Thank you for your support, encouragement,
love, and understanding, especially in moments of desolation,
sequestration, and poor communication from me due to loads of
assignments on my table.
To my preceptees, Vivian, Michael, Adaeze, Jane, Kate, Esther,
Marybeth, Florence, Ebong, Nkele, and others, your
understanding when I transfer my frustrations to you humbled
me most in my relationship with you as a preceptor. Looking
upon the "role model thing" was the driving force that propelled
me to this finishing point. You are more than welcome anytime
for more guidance in the future in your further studies.
I was also working on my post-graduate certification program in
the psychiatric mental health nurse practitioner program, and
this is where I thank Dr. Ghislaine Mogo, my preceptor, for her
tremendous patience and support.
To my spiritual family, the Daughters of Charity of the Most
Precious Blood, God gave me the best opportunity to be among
you. Mother Ofelia Marzocca, see what I have become this day
because of your decisions in the most challenging moments of
my life and humble expression of an arduous journey that would
benefit all. Thank you all, and may God reward us according to
our deeds.

40. Table of Contents
Statement of the Problemvii
Chapter1:IntroductiontotheProject1
BackgroundoftheProject2
ProblemStatement3
PurposeoftheProject4
ClinicalQuestion6
AdvancingScientificKnowledge7
SignificanceoftheProject9
RationalefortheMethodology11
NatureoftheProjectDesign11
DefinitionofTerms13
Assumptions,Limitations,Delimitations15
SummaryandOrganizationoftheRemainderoftheProject17
Chapter2:LiteratureReview19
TheoreticalFoundations22
ReviewoftheLiterature25
PrevalenceofHypertension26
AerobicExerciseHealthIntervention32
EffectofExerciseonBloodPressure34
Summary39
Chapter3:Methodology40
StatementoftheProblem41
ClinicalQuestion42
ProjectMethodology44
ProjectDesign44
PopulationandSampleSelection46
InstrumentationandSourcesofData48

41. Validity49
Reliability49
DataCollectionProcedures50
DataAnalysisProcedures52
PotentialBiasandMitigation53
EthicalConsiderations53
Limitations54
Summary55
Chapter4:DataAnalysisandResults57
Chapter 4 summarizes the collected data and how it was
analyzed. Other chapter segments include the problem
statement, clinical question, and methodology. The results are
presented in narrative form along with figures, tables. The last
section of the chapter provided a preview of Chapter 5 and its
contents.58
Descriptive Data58
Data Analysis Procedures59
Results60
Chapter5:Summary,Conclusions,andRecommendations64
At the clinical site, the project manager, Medical Director, and
clinic manager collaborated regarding the increased ambulatory
blood pressures noted within the past three months. The
standard of care at the site is through medication management
for their condition. Hence, a unanimous decision was made to
utilize a new strategy, implementing the American Heart
Association's guidelines on aerobic exercise to influence
hypertensive patients.64
Chapter 5 reintroduced the project’s topic and summarized the
project. Other chapter segments included a summary of the
project’s findings and conclusion, theoretical, practical, and
future implications. The last portion of the chapter offered
recommendations for future quality improvement projects and
clinical practices.64
Summary of theProject65
Thisquality improvement project was conducted utilizing a
quantitative methodology and quasi-experimental design in four

42. weeks. Chapter 1 presented studies such as Adam and Wright
(2020), Aung and Htay (2021), Krist et al. (2021), and Saco-
Ledo et al. (2020) related to incorporating aerobic exercise to
be included in an individual’s HTN management plan.The
project contributed to the current body of literature, such as
Aung and Htay (2021), Krist et al. (2021), and Saco-Ledo et al.
(2020), regarding aerobic exercise being included in
hypertension management. The impacted population was adults
diagnosed with hypertension in a primary care clinic. The
county’s demographics revealed that roughly 60,000 seniors 65
and older comprise the county’s populace (Data USA, 2019). In
Texas, the incidence of HTN is at 35.1%, which validates
findings from the CDC (2021) and Million Hearts (2021).65
Chapter 2 discussed Orem’s self-care deficit theory and Lewin’s
change model are the theoretical underpinnings for this quality
improvement project. Orem’s self-care theory was chosen
because it focused on the reciprocal relationship between
humans and their environment (Orem, 1995). The theory
highlighted that a human could provide self-care, and the
primary goal of the healthcare provider should assist them in
achieving an optimal level of independence (Orem, 1995). The
nursing theory comprises five constructs: universal self-care
requisites, normalcy, developmental self-care requisites, and
health deviation self-care requisite (Orem, 1995). Implementing
this theory permitted the project manager to guide the clinicians
regarding their responsibilities in providing the patient with a
transparent plan of care. This helped the HTN patients to
sustain an appropriate level of self-care (Orem, 1995).65
Lewin’s change model was selected for this quality
improvement project. It was chosen because it emphasized the
need for change for clinicians and HTN patients impacted by
restraining forces (Lewin, 1947). The change model consists of
three phases: unfreezing, change (movement), and refreezing
(Lewin, 1947). The first phase, unfreezing, began when the
project manager collaborated with the nursing manager, medical
director, and a few nursing staff to detect the increase in

43. ambulatory blood pressures in HTN patients within the past
three months. The second phase, changing (movement), began
when the project manager educated the staff to use the
implementation of the American Heart Association (AHA)
guidelines related to aerobic exercise. During the phase, the
patients were educated by the staff, clinicians were trained, and
the project was monitored. The last stage, refreezing, began
when the discussion about the AHA guidelines became infused
into the organizational culture and a daily habit in the
healthcare providers' clinical practice (Lewin, 1947).66
The project was implemented once approval was received from
Grand Canyon University IRB and the project site. It was
implemented in four weeks to examine the impact of AHA
guidelines related to aerobic exercise on ambulatory blood
pressures. The project came after collaboration with the medical
director and some nursing staff showed an increase of 37.1% in
diagnosed HTN patients within the past six months. The project
contributed to the current body of literature regarding the
impact of aerobic exercise on decreasing one’s hypertension
(Aung &Htay, 2021; Krist et al., 2021; Saco-Ledo et al., 2020).
Other areas affected by regular aerobic exercise are weight loss,
improved well-being, and decreased symptoms of depression
and anxiety (CDC, 2022).66
SummaryofFindingsandConclusion67
Implications69
The nursing field is a discipline that requires research, which
concentrates on issues that affect the nursing practice (Polit &
Beck, 2021). Nursing implications are essential in considering
when to begin a new medication, intervention, or procedure
(Polit & Beck, 2021). Healthcare providers who understand the
potential impact they could have on the clinical practice,
nursing care, and the patient allows them to provide the best
quality care (Polit & Beck, 2021). The implications discussed in
the following sections were developed on the project
findings.69
Theoretical Implications69

44. PracticalImplications71
The third implication is for clinicians to use an interactive
pictorial wheel to improve self-management in HTN patients.
This educational style using pictures can help patients discuss
their personalized approach to managing HTN without feeling
belittled or embarrassed. Furthermore, this method has been
adapted for other diseases such as asthma, heart failure, and
stroke (Gan et al., 2022). This communication style would be
beneficial for individuals with low health literacy levels. The
communication wheel would be based on medication, exercise,
weight management, diet, and complications72
Future Implications72
Recommendations72
Recommendations for Future Projects73
The “next step” in forwarding this project is for the healthcare
providers to deliver patient care using culturally competent care
for this populace. Unfortunately, many of the patients seen at
the clinic are from Black and Brown communities. As
mentioned in Chapter 1, the project site’s demographics show a
high population of Hispanics (36.72%) and Blacks (18.5%).
This confirms the statistics found by the Centers for Disease
Control and Prevention (2022), Hispanics (39%), and Blacks
(56%).73
RecommendationsforPractice74
References76
AppendixA90
GrandCanyonUniversityInstitutionalReviewBoardOutcomeDeter
minationLetter90
AppendixB91
AmericanHeartAssociationPhysicalActivityGuidelines91
AppendixC92
Permission to Use the American Heart Association Physical
Activity Guidelines92
List of Tables

45. Table1.DescriptiveDataforAge58
Table2.DescriptiveDataforGenderandRace59
Table3.Pairedt-TestResultsforSystolicBloodPressureLevels60
Table4.Pairedt-TestResultsforDiastolicBloodPressureLevels61
Chapter1:IntroductiontotheProject
Hypertension(HTN)isamedicalconditionassociatedwithhigherblo
odpressure,wherebythearteriesthattransportbloodbecomedamage
d.Despitetheavailabilityoftreatmentstrategies,lessthanoneinfivei
ndividualshavetheirbloodpressureundercontrol(Ghatageetal.,202
1).Currently,intheUnitedStates(U.S.),thediseaseposesasignifican
tproblemthataffectsoverhalfoftheadultpopulation(37millionindiv
iduals)(CentersforDiseaseControlandPrevention[CDC],2021;Kri
stetal.,2021).Complicationsoftheconditionincludemyocardialinfa
rction,heartfailure,chronicrenaldisease,andstroke(Ghatageetal.,2
021).
TheincreaseinthecasesofhypertensionpromptedtheAmericanHear
tAssociationTaskForce(AHA)topublishnewguidelinestohelpmana
getheriseinhypertensionamongAmericanadults(Wangetal.,2019).
OnecriticalchangewithintheAHAguidelineistheimprovisedrefere
nceanddefinitionofhypertensionvalues.TheAmericanCollegeofCa
rdiologyandtheAmericanHeartAssociationguidelinesforhyperten
sionmanagementanddefinitionofHTNdefinesitashavingbloodpres
sureatorabove130/80mmHg(TheAmericanCollegeofCardiology(2
022);AmericanHeartAssociation,2022).Atthesametime,stage2HT
Nisbloodpressureatorabove140/90mmHg(CDC.,2021).Improved
bloodpressure(BP)amonghypertensivepatientshasbeenassociated
withpositivehealthoutcomes(Severinetal.,2020),andearlydetectio
nandcontrolofBPhavesignificantlyimpactedmorbidityandmortalit
yratesinthehealthcaredeliverysystem(CDC,2021;Severinetal.,202
0).

46. Attheprojectsite,theprojectmanagercollaboratedwiththeMedicalD
irectorandclinicalmanagerregardingtheincreasingambulatorybloo
dpressuresseenwithinthepastthreemonths.Althoughthesiteprovid
epatientswithmedicationmanagementfortheirdisease,itwassugges
tedthatanotherstrategybeemployedtohelpreducebloodpressure.Th
econversationconcludedwiththeprojectmanagerimplementingthe
AmericanHeartAssociation'sguidelinesonaerobicexercisetoinflue
ncehypertensivepatients.
The project was worth conducting because it helped
toincreaseHTNpatients’knowledgelevelsandassistinhelpingthem
changetheirbehaviorstocombatthis“silentkiller”(CDC,2019).Unf
ortunately,manyindividualsareunawareofthesymptoms,whichmak
esthesituationdire.Thisprojectpromotedecreasingthefifthleadingc
auseofdeath(CDC,2019).Otherareastheprojectimpactsone’simpro
vementoftheirqualityoflife,reducingtheirchancesofstroke,protect
ingtheirkidneys,anddecreasinghealthcarecosts(CDC,2019).
Chapter1introducesthetopicofhypertensionandtheuseofdailyphys
icalactivitytocombatthedisease.Othersectionsofthechapterinclud
etheproblemstatement,purposestatement,andclinicalquestion.Oth
erareasofthechapterinvolveadvancingscientificknowledgerelated
tothetheoreticalunderpinnings,quantitativemethodology,andquas
i-
experimentaldesign.Thechapter'slastsegmentscomprisethedefinit
ionofterms,assumptions,limitations,anddelimitationswithaprevie
wofChapter2.
Background of the Project
TheprevalenceofhypertensionamongtheadultpopulationintheUnit
edStatesincreasedrapidlybetween1988to2010,accountingforhalfo
fallfatalitiesfromstroke,end-
stagerenaldisease(ESRD),andstroke(MillionHearts,2021).Accord
ingtoMuntneretal.(2020)trendanalysis,theestimatedproportionoft
heU.S.adultpopulationsufferingfromhypertensionbetween1999an
d2000was31.8%.Theadultpopulationaffectedbyhypertensionincre
asedfrom31.8%in1999-

47. 2000to48.5%in2007and2008(Muntneretal.,2020).Thenumberofaf
fectedU.S.adultshasbeenontheriseeversince,andbetween2013and
2014,whichwas53.8%(Muntneretal.,2020).Thepercentagedroppe
dslightlyfrom53.8%to43.7%between2017and2018,butthevalueiss
tillrelativelyhigh(Muntneretal.,2020).ThisdataimplythattheAmer
icanpopulationisconsiderablyaffectedbyhypertensionatanalarmin
grate.
Thecurrenthypertensivepopulationimpactedbyambulatorybloodpr
essureis43.7%,accordingtoarecentstudybyAdamsandWright(2020
).Currently,atthefacility,therearenostandardizedguidelinesforedu
catinghypertensivepatientsregardingincorporatingexercise(daily
physicalactivity)asabloodpressuremanagementmechanism.Thesta
ndardtreatmentsincludemedicationssuchasdiuretics,angiotensin-
convertingenzyme(ACE)inhibitors,angiotensinIIreceptorblocker
s(ARBs),andcalciumchannelblockers(MayoClinic,2021).Aftercol
laboratingwiththemedicaldirectorandnursingstaff,thedecisionwas
toimplementtheAHArecommendationforaerobicexercisetohelplo
werambulatorybloodpressureamongthisclinic’sadulthypertensive
population.
Problem Statement
ItwasnotknownifortowhatdegreetheimplementationoftheAmerica
nHeartAssociation’sguidelineonaerobicexercisewouldimpactamb
ulatory
bloodpressurewhencomparedtocurrentpracticeamongadulthypert
ensivepatients.Attheclinicalsite,therearenostandardizedguideline
sforclinicianstoeducatehypertensivepatientsregardingimplementi
ngdailyphysicalactivityasabloodpressuremanagementmechanism.
Collaborationwiththemedicaldirectorandsomeofthenursingstaffs
howedanincreaseof37.1%indiagnosedHTNpatientswithinthepasts
ixmonths.Theclinic’sfindingscorrespondedwiththehealthstatistic
sfromtheTexasDepartmentofStateHealthServices(2022),asthecou
ntyranks22intheStateswithdiagnosedhypertensivepatients.Thedat
a,incombinationwithcurrentliteraturebytheCentersforDiseasePre
ventionandControl[CDC](2021),emphasizesthathypertensionaffe
ctsapproximately45%ofAmericanadults.

48. Theprojectcontributestothecurrentbodyofliterature,suchasAunga
ndHtay(2021),Kristetal.(2021),andSaco-
Ledoetal.(2020),regardingaerobicexercisebeingincludedinhypert
ensionmanagement.TheCDC(2020)statesthatregularphysicalactiv
ityisessentialforgeneralwellness,weightloss,andwell-
being.Otherareasimpactedarethereducedsymptomsofdepressiona
ndanxiety(CDC,2020).Theprojectvalidatesthatusingaerobicexerc
ise,asstatedbySaco-
Ledoetal.(2020),decreasesone’ssystolicbloodpressurebyapproxi
mately2to4mmHginnormotensiveand5to8mmHginhypertensionad
ultpatients.
Purpose of the Project
The purpose of this quantitative, quasi-experimental project was
to determine if or to what degree the implementation of the
American Heart Association’s guideline on aerobic exercise
would impact ambulatory blood pressure when compared to
current practice among adult hypertensive patients in a primary
care clinic in southwest Texas over four week-
period.TheindependentvariablefortheprojectistheAmericanHeart
Association’s
guidelines,andthedependentvariableisbloodpressuremeasurement
s.Conveniencesamplingwillbeusedtochoosetheparticipants.Thepr
ojectwas conductedwithinfourweeksusingaquasi-
experimentaldesignandquantitativemethodology.Sixhealthcarepr
oviderswillbeeducatedusingtheAmericanHeartAssociation’sguid
elinesforaerobicexercise(walking and blood pressure
measurement using Oscar 2 Device) for HTN patients. The
primary investigation carried out implementation and
comparison of data during the project using ambulatory blood
pressure baseline and post-implementation
data.Datawasretrievedfromtheclinic’selectronicmedicalrecordan
dinputintoaMicrosoftExcelspreadsheet.An outside statistician
not associated with the primary investigator or project analyzed
the data.Apairedsamplet-

49. testwasusedtoanalyzethestatisticalsignificanceofthevariablesusin
gtheStatisticalPackagefortheSocialSciences(SPSS-28).
Theinclusioncriteriafortheparticipantswere18andolder,diagnosed
withHTN,currentclinicpatients,andabletoparticipateinaerobicacti
vity.Theexclusioncriteriaarepatientswithmusculoskeletaldisabilit
ies,mentaldisorders,andindividualswithcomorbiditiesthatcouldbi
astheprojectfindings.Theparticipantsengagedinaerobicexercisefo
r30minutesin24hours,threedaysaweek,forthefourweeksoftheproje
ct duration. The outcome post-intervention was a reduction in
ambulatory
bloodpressurereadingoftherecommendedBPbelow140/80mmHg.T
heaveragedecreaseinSBPwithaerobicexerciseisapproximately2to
4mmHginnormotensivepatientsand5to8mmHginadulthypertensio
npatients(Saco-Ledoetal.,2020).
Thepersonswhoimplementedtheinterventionwereonephysician,tw
onursepractitioners,tworegisterednurses,andonemedicalassistant.
Allhealthcareproviderswereeducatedregarding“theAmericanHear
tAssociation’s”guidelinetoincludeexerciseinHTNpatients’diseas
emanagement.The use of Oscar2 Device for measuring
ambulatory blood pressure. The clinicians demonstrated vibrant
understandingviatheteach-
backmethodtotheprojectmanagertosafeguardalltheparticipantswe
re
taughtthesameway.Theindividualscurrentlyworkfulltimeattheclin
icforoveroneyearandhaveaccesstothedocumentationsoftware.
Theprojectsite’sgeographiclocationisinsouthwestTexas,themostp
opulouscountyandthethirdmostpopulouscountyintheUnitedStates
(U.S.CensusBureau,2020).Theaffectedpopulationwaspatientsdia
gnosedwithHTN.ThedemographicsshowadiversepopulationofWh
ite(28.9%),White-
Hispanic(36.72%),Blacks(18.5%),Asians(6.9%),andLatinos(8.98
.%)(U.S.CensusBureau,2020).Manyresidentsovertheageof60have
chronicdiseasessuchas(chronicobstructivepulmonarydisease,hear
tdisease,anddiabetes)(UTHealthScienceCenteratHouston,2020).
Theagegroupsinthecounty18to34(20,586),35to54(46,513),and55t
o64reflecttheparticipantsintheproject.

50. Theprojectcontributestothenursingfieldbyofferinganevidence-
basedstrategyandevaluatinghowaerobicexercisessuchaswalkingi
mprovedambulatorybloodpressure.Theprojectprovidedvitalinfor
mationthatcouldbesharedwithothernursingstafforhealthcareprovi
dersatotherprimarycareclinics,minoritycommunities,orpopulatio
nsinsimilardiversepopulations.The project also preferred an
avenue for helping individuals and families to understand the
relationship between the disease process and its management.
Clinical Question
Saco-Ledoetal.(2020)conductedasystematicreviewandmeta-
analysis.Theauthorsclaimedthatambulatorybloodpressure(ABP)b
etterpredictscardiovasculardiseaseandmortalityinadulthypertensi
vepopulations.Aerobicexerciseplayedasignificantroleinlowering
bloodpressure,anditwasbeneficialinloweringambulatorybloodpre
ssureinHTNpatients.Thefollowingclinicalquestionthatguidedthis
quantitativeproject:Towhatdegreedidtheimplementationof“theA
mericanHeartAssociation’s”guidelineonaerobicexerciseimpacta
mbulatory
bloodpressurewhencomparedtocurrentpracticeamongadulthypert
ensivepatientsinaprimarycareclinicinsouthwestTexas?
Theindependentvariableis“theAmericanHeartAssociation’s”guid
elineregardingaerobicexercise,andthedependentvariableisambula
tory blood pressure.
Advancing Scientific Knowledge
Implementinganaerobicexerciseeducationprogramtolowerambula
torybloodpressurebyfollowingAHAguidelines,theinitiativeimpro
vedpopulationhealthoutcomesforhypertensiveindividuals.Compl
etingthisqualityimprovementprojectadvancedourunderstandingof
ambulatorybloodpressureinhypertensivepatientstoreduceormana
geambulatorybloodpressure.Theoverallgoalsofaerobicexercisewa
lkingincontrollingbloodpressureinhypertensivepatientsweretodec
reasemorbidityandincreasethepopulation'swellness, happiness
and

51. vitality.Physicalactivitiessuchaswalking,running,swimming,and
bikingimprovesymptoms,qualityoflife,functionalstatus,andreduc
eshospitalizations(CDC,2021).
Inclinicalpractice,managementofcardiovasculardiseasesentailedr
esolvingcardiovascularetiologiessuchascoronaryheartdiseaseand
relatedconditionssuchasdiabetes,preventativecare,follow-
upmonitoringofcardiacstatus,carecoordinationandcasemanageme
nt,educatingandsupportingpatientsforself-
management,rehabilitationofheartfunction,andhealthpromotion,a
mongothers(Jiang&Wang,2021).Thepharmacologicaltreatmentof
cardiovasculardiseaseshasimprovedwiththedevelopmentofnewth
erapiesandunderstandingitspathophysiology.Despitedevelopingn
ovelpharmacologicalinterventionsforpatientswithHTN,congestiv
eheartfailureexistingtreatmentshavenotyieldedsignificantmortali
tybenefitsforHFpatientswithheartfailurewithreducedejectionfract
ion(HFpEF).Instead,thedrugtreatmentstrytocontrolsymptoms,tre
atcomorbidities,andriskfactorsthatthecausethroughmeasuressuch
asaerobicexercise,dietandweightcontrol,bloodpressureself-
monitoring,andlowsodiumintake,amongothers(CDC,2021).
Theidentifiedgapistheelevatedambulatorybloodpressureamongth
ehypertensivegroupbasedontheavailableresearch(Blumenthaletal.
,2018;Saco-
Ledoetal.,2020).Educationalprogramsonaerobicexercisetodecrea
seandmanageambulatorybloodpressureshouldbuildonthefindings(
Blumenthaletal.,2018).Otherfactorsthatinfluencebloodpressurear
ethepresenceofcomorbiditiesandriskybehaviorssuchassmoking,p
atients’educationlevel,caregiverpresence,andin-
patientHTNeducation.As the patients became more aware of the
aerobic exercise in lowering blood pressure through the
educational program, individuals showed less comorbidities that
reduced risk to hypertensive complications and frequent
hospitalizations (Saco-Ledo, 2020).
TheinitiativefilledthegaporneedbyutilizingtheAHAguidelinesfor
aerobicexerciseeducationprogramstolowerambulatorybloodpress
ureforpatientswithhypertension.
Theselectedtheoreticalframeworkforthisqualityimprovementproj

52. ectwasDorothyOrem’sself-
caredeficittheory.Basedonthetheory,patientsmustengageinself-
caretomaintainandimprovetheirqualityofhealth(Orem,1995).Utili
zingthistheory,thenursesdidnotseetheirpatientsasinactiveorreceiv
inghealthservices;instead,theyconsiderthemstrongandreliabletop
articipateindailyactivitiesanddecision-
makingprocesses(Orem,1995).Threenursingsystemsaredefinedin
Orem’snursingtheory;theyincludewhollycompensatory,partiallyc
ompensatory,andsupportive-
educativestrategies(Khademianetal.,2020).Forthisproject,thefoc
usisonthelastsystem(supportiveeducationalsystem).Theclinicians
assessedthepatient’sreadinesstolearnsomethingnewbutneedassist
anceandguidance.Patientswithchronicillnessesrequiremotivation
andtheskillstoconductthebehaviorsneededtomaintainandimprovet
heirhealth(Khademianetal.,2020).Hence, the patient gained the
capability to learn disease processes and perform activities
independently, overcoming seen and unseen limitations.
Lewin’schangemodelwaschosentoworkincombinationwithOrem’s
self-
caredeficittheory.Itwasselectedbecauseitwasawaytodescribethep
rocesschangeversusguidingtheactivitiesthatwere
conducted.ThetheoryworkedwellwithOrem’snursingtheoryinimpr
ovingthepatient’sself-
efficacyandmanagementofhypertension.Furthermore,thismodelal
lowedtheprojectmanagertoactivelyexaminetheclinicsiteandclinic
ians'changeprocessandprogression(Harrisonetal.,2021).Themode
lconsistedofthreestages:unfreezing,changing(movement),andrefr
eezing(Lewin,1947).Thefirststage,unfreezing,allowedtheproject
manager,medicaldirector,andafewnursingstaffmemberstoidentify
theproblem,developanevidence-
basedstrategy,andconsenttochange(Lewin,1947).Thesecondstage
,movement,happenedwhentheinterventionwasimplemented.Theh
ealthcareprovidersprovidedatimelinewithaclearplanthat were
followed for the project(Lewin,1947).The last stage, refreezing,
occurred
whentheinterventionbecameadailyparttheclinicalpracticeandconv

53. ersationwithhypertensivepatients(Lewin,1947).
Significance of the Project
The significance of the quality improvement project
wasimplementingarecommendedevidencebasedstrategyby“theAH
A’sguideline”regardingaerobicexercise.Implementingtheprojecth
elpeddecreasethehealthcarecostsassociatedwithHTNintheUnited
States.Commodore-
Mensahetal.(2018)statethatthefinancialpricesaresignificant,appr
oximately$131-
198billionannually.Hypertensivepersonsincuranextra$2,000yearl
yinhealthcareexpenditurescomparedtonon-
hypertensivepersons(Commodore-
Mensahetal.,2018).Furthermore,HTNisacrucialriskfactorinvariou
sdiseases,includingmyocardialinfarction,heartfailure,stroke,andc
hronicrenaldisease(Commodore-Mensahetal.,2018).
OnenursingimplicationrelatestoLewin’schangemodelincreatinga
ndsustainingchange.Amulti-systematicapproachmustbe
drawnfromthemodeltosupporttheimplementationoftheAmericanH
eartAssociationguidelinesregardingaerobicexerciseforhypertensi
vepatients.Themodelhighlightedtheprinciplesrelatingtopeoplech
angingfromtheonset,discussingtheirfeelingsregardingthechange,
andsupportingtheprocessviacommunicationandcollaboration(Har
risonetal.,2021).
The second nursing implication relates to the participants’
management of their disease process (hypertension). The
participants were taught the importance of including aerobic
exercise and walking (30 minutes, three times a week) in their
private daily
schedules.Theprojectmanagerevaluatedtherespondents'understan
dingandreceptivenesstonewinformationandsafetymeasuresrelated
toexercising.Rationale for the Methodology
Thequantitativemethodologywasusedtoprovideinformationthatus
esnumericaldata(Statistical

54. Solution
s,2019).Thismethodbestansweredtheclinicalquestionandaddressi
ngtheproblemstatementforthisprojectbecauseitallowedanin-
depthcomparisonoftherelationshipbetweenpre- andpost-
interventionresults(Guetterman&Fetters,2018).Itwasusedbecause
itofferedobjective,systematic,andfocuseddataanalysisstrategies(
Guetterman&Fetters,2018).Inthisproject,theprojectmanagerevalu
ated“theAHA’sguidelines”anditsimpactonthebloodpressureofHT
Npatients.Thedependentvariableweremeasuredfourweeksbeforea
ndafterimproving
theintervention.Thismethodologywasthemostappropriatebecause
otherinvestigatorscouldreplicatethedata(Creswell&Creswell,201
8).
Aqualitativemethodologywasconsideredbutdeemedinappropriate
forthisproject.Itfocusedondescribingthecharacteristicsorqualities
ofaphenomenon(Creswell&Creswell,2018).Thismethodisoftenthe
maticandsubjective,andfindingsareproducedusingtheparticipants'
wordsverbatim(Creswell&Creswell,2018).Inthisproject,theproje
ctmanagerdidnotseektounderstandtheparticipants'behaviors,feeli
ngs,orlivedexperiences(Creswell&Creswell,2018).Thedatawasan
alyzedusingacodingmethodthatexploresthemesandpatterns(Cres
well&Creswell,2018).Theresultswerepresentedverbatimintwotot

55. hreecolumnsusingtherespondent'swords.
Nature of the Project Design
Aquasi-
experimentaldesignwasusedinthisqualityimprovementproject.Th
erationalebehindselectingtheproject,asmentionedabove,wasthatit
allowedforcomparingthedependent(bloodpressure)andindepende
ntvariables(implementationstrategyaerobicexerciseeducationgui
deline.Thedesignwassuitableforscrutinizingtheproject’svariables
anddeterminingtheindependentvariable'seffectonthedependentva
riable(Creswell&Creswell,2018).Furthermore,thedesigndidnotall
owtheparticipantstoberandomlyassigned(Creswell&Creswell,201
8).Forthisproject,thedependentvariable(ambulatory
bloodpressure)weremeasuredattwodifferenttimes(oncebeforethei
nterventionandonceaftertheintervention(Creswell&Creswell,201
8).
Acorrelationaldesignwasnotselectedforthisqualityimprovementpr
oject.Itwasnotchosenbecauseitisanon-
experimentaldesignwherethevariablesaremeasuredandevaluatedf
ortheirrelationship(correlation)(Creswell&Creswell,2018).Theva
riablescannotbecontrolled(Creswell&Creswell,2018).Tworationa
lesfor
notusingthistypeofdesignareevaluatingthecausalstatisticalrelatio
nshipsbetweenthevariablesandnotmanipulatingtheindependentva
riable(Creswell&Creswell,2018).

56. The project sample
exploredwasadultpatientsdiagnosedwithHTN.Theindividualswer
e18orolder,spokeEnglish,andwereabletoparticipateinaerobicexer
cise.Theexclusioncriteriaincluderespondentswithmentalchalleng
es,musculoskeletaldisabilities,andcomorbiditiesthatcouldbiasthe
projectresults.ThesamplesizewascalculatedusingG*Powersoftwa
re,version3.1.9.2,withanalphameasureof0.05,aneffectsizeof0.5,a
ndapowerof80%.Theminimumnumberofparticipantssuggestedfort
heprojectwasN=34.
The data collection process was began after receiving
theapprovaltoconducttheprojectfromGrandCanyonUniversityInst
itutionalReviewBoardandtheclinicalsite.Thedatacollectionproce
duresincludededucatingthesixhealthcareprovidersforonehourusin
gtheAHAguideline(aerobicexercise)andslidepresentation.Theclin
icians demonstratedtheproceduresviatheteach-
backmethods.Allpotentialparticipantswereeducatedregardingthe
minimalrisksandbenefitsofpartakingintheproject.Thedemographi
cdatawas
retrievedfromtheclinic’selectronicmedicalrecords(age,gender,rac
e,maritalstatus,andeducation).
Definition of Terms
Aqualityimprovementprojectmustofferthereaderanunderstanding
oftheterms,concepts,andvariablesused(GrandCanyonUniversity,2
021).Newknowledgeiscriticaltosuccessfulsolutions(Polit&Beck,

57. 2018).Beloware the words used intermittently throughout the
project
Ambulatory Blood Pressure Monitoring(ABPM)
Ambulatorybloodpressuremonitoringwasintroducedintheearly19
60sandwas usedtoassessone’sbloodpressureinreal-
time(Shackelford,2022).Ahealthcareprovidertypically
evaluatedthebloodpressureduringroutineactivitiessuchasworking
,sleeping,ordoingchores(Shackelford,2022).
The American College of Cardiology Foundation
The American College of Cardiology Foundationisanon-
profitmedicalorganizationdedicatedtoimprovingthelivesofcardio
vascularpatients(AmericanCollegeofCardiology,2022).Thiswasd
oneviacontinuousqualityimprovementmonitoring,patient-
carestrategies,paymentinnovation,andprofessionalism(American
CollegeofCardiology,2022).
American Heart Association
TheAmericanHeartAssociationwasformedin1924toestablishscien
tificresearchthatcouldofferhealthcareprovidersandpatientsmetho
dstotreatcardiacdiseaseandprevention(AmericanHeartAssociatio
n,2022).
Aerobic Exercise
Aerobicexercisereferstoanyactivityinvolvingcardiovascularcondi
tioningandpertainstorunning,briskwalking,swimming,orevencycl
ing.Thisprojectwillapplyaerobicexercisetohelphypertensivepatie

58. ntsreducetheirambulatorybloodpressure(Sealsetal.,2019).
High Blood Pressure
Highbloodpressurereferstothescenarioinwhichanadult’sbloodpre
ssureisabovetheoptimumlevel,whichisusuallyat130/80mmHgfora
dultpatients.Whenapatient'sbloodpressureexceedstheoptimumsho
wnabove,theyareexposedtotheriskofchronicheartfailure,stroke,m
yocardialinfarction,andinextremecircumstances,death(Fuchs&W
helton,2020).
Hypertensive Patients
Hypertensivepatientsreferstothepatientsdiagnosedwithhypertensi
onsincehypertensionhasbeenshowntobeacausativefactorforotherd
iseasessuchaschronicheartfailure,stroke,andevenmyocardialinfar
ction(Schwingshackletal.,2019).Assumptions, Limitations,
Delimitations
GrandCanyonUniversity(2021)statedthatanassumptionisanindisp
utablefact.Thefirstassumptionwasthatthisqualityimprovementpro
jectwasbasedontheAHAguidelineonaerobicexerciseeducationpro
gramwillenhancetheself-
efficacyofadulthypertensivepatientsbyhelpingthemkeeptheirbloo
dpressureatoptimumlevels.Inturn,theAHAguidelineontheaerobic
exerciseeducationprograminterventionwouldplayapivotalroleinli
festyleimprovementandskilldevelopmentwhichwere

59. requiredtoencourageimprovedhealthoutcomesandadaptivehealth-
relatedbehavior(Cameronetal.,2018).Thesecondassumptionwasth
atallparticipants
answeredthequestionshonestly.Tomaintainhonestyfromthepartici
pantsduringtheproject,theprojectmanagerdidnotinfluencetheparti
cipantsanswers.Tomaintainobjectivityandreducethepossibilityoft
hedatabeingskewed,theinvestigator
hiredanoutsidestatisticiantoconductthedataanalysis(Statistical