Health promotion and disease prevention are important components of a healthy cardiovascular system. To determine appropriate interventions, you must carefully consider all available subjective and objective data. Part of your subjective data collection will include inquiring about risk factors, social determinants, and other considerations.

The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific patient.

Smoking

First-hand, second-hand, and third-hand smoke are major risk factors that negatively affect the cardiovascular system. The chemicals in smoke cause inflammation of the blood vessels and contribute to plaque buildup and narrowing of the blood vessels.

Probing questions related to smoking include:

• Do you smoke cigarettes or any tobacco-related products? If the client’s answer is affirmative, ask probing questions: How much do you smoke? How many packages of cigarettes do you smoke a day? How many years have you smoked? Can you tell me about the reasons that you started smoking?
• If you do not currently smoke, have you ever smoked? If the client’s answer is affirmative, ask similar probing questions as above, including the reason that they quit.
• Have you ever tried quitting? If the client’s answer is affirmative, ask probing questions: Tell me about what made you want to quit? How long did you quit? Did you use any strategies to help you quit?
• Have you ever thought of quitting? If the client’s answer is negative, make a non-judgemental comment like: “If you ever want to discuss quitting, let me know, there are many resources to help you.”

The effectiveness of health promotion is influenced by client interest and collaborative intervention because these factors are important in producing a successful outcome in smoking cessation. Each intervention must be tailored to the client, and could include counselling, cognitive-behavioural therapy, pharmacology treatments (e.g., nicotine replacement therapy), smart-phone applications, and short text message services. Sometimes a brief discussion about risks and a recommendation to quit smoking is sufficient. You might also choose to be involved in developing public health educational campaigns and resources about how smoking affects health as a population-based prevention strategy.

Contextualizing health promotion related to smoking from a sociocultural perspective will help you understand who might be more vulnerable or at risk. For example, the prevalence of smoking is higher among individuals with lower socio-economic status and lower education attainment, and those experiencing racial and ethnic discrimination (Wang & Wu, 2020). These populations are less likely to have access to resources pertaining to smoking cessation, so it is important to consider interventions as they relate to the social determinants of health, rather than using a one-size-fits all approach (Brady, 2020).

Diet

An unhealthy diet is a risk factor that contributes to cardiovascular disease, such as a diet high in saturated and trans fats, cholesterol, sodium, and alcohol. It is best for clients to choose water and reduce caffeine and alcohol intake. Clients with heart failure are sometimes recommended to limit all types of fluids.

Probing questions related to diet include:

• Tell me about your usual diet?
• What have you eaten in the last 24 hours? Is that your usual diet?
• Have you had any recent changes in your life that have affected your diet?
• Do you add sugar and salt to your food?
• How much fluid do you typically drink in a day? What fluids (e.g., water, caffeinated beverages, alcohol)?

You may want to assess a client’s familiarity with Health Canada’s (2019) Food Guide and discuss with them how to use it: https://food-guide.canada.ca/en/. This new food guide still has a Eurocentric bias, so you should collaborate with the client about its relevance in the context of their cultural food practices. It is now offered in dozens of languages that you can refer clients to: https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/snapshot/languages.html and many resources are available about food safety for Indigenous People: https://www.sac-isc.gc.ca/eng/1581522106156/1581522147811

Some key elements of Canada’s Food Guide are:

• Be mindful of eating patterns.
• Choose water as the drink of choice.
• A dinner plate should be one-half vegetables/fruit, one-quarter protein, and one-quarter whole grains.
• Make time to enjoy eating meals with others.
• Cook when possible, as opposed to eating processed meals and purchasing fast foods.
• Reduce sodium, saturated and trans fats, and sugar, and monitor portion sizes.

Canada’s guidelines now suggest that there are health risks associated with any level of alcohol consumption, although negligible with two drinks or less weekly (Paradis et al., 2022). Although some previous research had suggested some positive benefits to alcohol, this is now being disputed indicating that drinking alcohol of any kind does not decrease risks of heart disease, and high levels of consumption increase risk for coronary artery disease, myocardial infarction, heart failure, hypertension, and stroke (Paradis et al., 2022).

Many types of diets can be heart healthy, but some research points especially to the benefits of the Mediterranean diet and DASH diet. The American Heart Association (2020) recommends the Mediterranean diet as heart healthy: it includes plenty of fruits and vegetables, grains, potatoes, legumes, nuts, and seeds, olive oil, along with small amounts of dairy, eggs, fish, and poultry. The Heart and Stroke Foundation of Canada (n.d.) recommends the DASH (Dietary Approaches to Stopping Hypertension) diet as heart healthy and helpful to lower blood pressure: it is rich in vegetables, fruit and low-fat dairy foods and lower in saturated fat, total fat and cholesterol. The two diets are very similar and may be used in combination; the Mediterranean diet typically emphasizes more fish and less dairy products than the DASH diet.

Healthy eating involves behavioural actions but also relational and structural actions. First, an individual needs access to healthy food and the financial capacity to purchase it; this is referred to as food security. The rising cost of food globally has made this a challenge, and in many remote regions of Canada’s North, access to nutritious food is limited in terms of availability; even when available, the costs are excessive.

Socioeconomic status is known to affect food purchasing: individuals from socioeconomically disadvantaged communities – those with lower household income and lower levels of education – purchase fewer healthy foods like fruits and vegetables (Turrell et al., 2002). Therefore, health promotion efforts should focus on narrowing socioeconomic differences in food purchasing. Nurses can work in partnership with disadvantaged individuals and tailor a health promotion approach to their particular needs and attend to structural and economic barriers (Turrell et al., 2002). For example, you could direct clients to organizations that partner with vulnerable communities to support access to healthy foods, skill development, and capacity-building in terms of community-led initiatives (Turrell et al., 2002). You could also advocate on behalf of these communities for more effective social policy to address food insecurity (Turrell et al., 2002).

Activity

A sedentary lifestyle with limited activity/exercise is another risk factor that contributes to cardiovascular disease. Guidelines vary based on age and health, but individuals should generally participate in about 30 to 60 minutes of aerobic activity five to seven times per week.

Probing questions related to activity are:

• Do you have any concerns about your level of activity or exercise?
• Tell me about your daily pattern of activity? What activity are you involved in?
• What exercise do you engage in? How long do you do this type of exercise? How many days a week do you exercise? If a client plays sports, ask about their use of protective equipment.

You can collaborate with clients to create an activity/exercise care plan that is specific to their needs and goals. Start at a realistic and attainable level, depending on physical capability and energy level, then slowly increase the timing and level of activity. Many interventions are also available to support clients to achieve their activity goals: community walking groups, fitness apps, local gyms, and group activities. The participACTION website is a helpful resource for activity guidelines: https://www.participaction.com/en-ca

Nurses should use a relational health promotion approach when addressing activity. A community of support can promote activity, so you should assess the client’s access to support (e.g., friends, family, acquaintances) who may have similar activity interests or goals. A structural approach to health promotion can also help address and eliminate inequities. For example, some clients may not be able to afford gym memberships or sports registration fees. Additionally, those in urban areas may have more access to specific activities or rehabilitation programs than those living in rural or remote regions, including in the North. You will need to consider these factors and tailor activity programming to each client. You could also advocate for policies to address these inequities.

Sleep

Adequate sleep is important for restoration of the body and mind: 6–8 hours is usually considered adequate sleep. Pulse and blood pressure lower during deep sleep, known as non-rapid eye movement, which is important for cardiovascular health. Lack of sleep quality and quantity has been linked to cardiovascular-related illnesses such as hypertension, obesity, myocardial infarction, and stroke.

Probing questions related to sleep include:

• How much sleep do you get each day/night? How many hours? Do you rest during the day?
• Do you have any concerns about your sleep?
• Tell me about your sleep routine? What do you do before you go to bed? Do you take any medications to help you sleep?
• Do you wake up during the night? If so, why? Are you able to fall back to sleep?
• Do you feel rested when you wake up?

One behavioural intervention is a sleep journal. Ask the client to record how much sleep they get. If less than recommended, address potential triggers that may be disrupting the client’s sleep, such as stress or pain. Limiting screen time two hours prior to bedtime can also be helpful. Additionally, you may want to discuss with the client the potential for naps.

The physical and social environment affects sleep. Siengsukon (2020) describes that sleep may be affected by the following:

• Living in an unsafe or noisy neighbourhood.
• Not having access to private transportation and needing to get up early to commute via public transportation.
• Living in congregate or multigenerational housing might mean that clients share bedrooms or beds.
• Being a caregiver for a spouse or parent can also interfere with sleep, as does living with someone who works long hours or shift work.

It is important to note that many of these physical and social factors influencing sleep are associated with race, ethnicity, and socioeconomic status (Siengsukon, 2020).

Stress

Stress is subjective and can have emotional, physical, mental, social, and financial effects; it is a risk factor for cardiovascular-related illnesses. Stress is usually caused by a combination of multiple stressors. How a person may talk about themselves, their life and their situation can indicate potential concerns and areas that need further assessment.

Probing questions related to stress could include:

• Tell me about the stress in your life?
• Have you experienced stress recently? Physically? Emotionally?
• Have you had any recent changes in your life? (tell me more).
• How does stress affect you?
• How do you handle this stress?
• Tell me about the coping strategies you use?

Stress management and coping strategies may include:

• Regular physical activity.
• Getting adequate sleep.
• Spending time with family and friends.
• Taking time for personal interests and hobbies.
• Practicing relaxation techniques such as meditation, deep breathing exercises, and tai chi.

From a relational and structural health promotion perspective, it is important to be aware that stress does not exist in a vacuum: how it is experienced, perceived, and managed is affected by relationships with others. All clients experience stress sometimes, but structural factors influence whether a client is more at risk for stress or able to manage stress. For example, racism is a major determinant that can lead to highly stressful experiences. You can use an anti-racist approach to stress and stress management to understand how the client is being influenced by racism and how best to support them. Socioeconomic status can also influence a person’s access to resources to cope with stress. When collaborating with clients to develop stress management techniques, you must be aware of these larger structural influences.

Weight and blood pressure 

Obesity and high blood pressure are linked to cardiovascular-related illnesses, so clients should monitor their weight and blood pressure.

Probing questions may include:

• Are there any recent changes in your life that may have affected your weight or blood pressure?
• Have you had any recent changes in your weight?
• Do you have any concerns about your weight?
• When was the last time you had your blood pressure taken?
• Do you know what your blood pressure normally is?

In collaboration with the client, discuss any disruptions in daily patterns and explore possible ways to address these – and facilitate weight loss and lowering of blood pressure if relevant. Many interventions related to diet, activity/exercise, and stress will help with weight and blood pressure. Nurses can also advocate on behalf of clients and take actions to develop and advance equitable healthy public policies.

References

American Heart Association (2020). What is the Mediterranean diet? https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet

Brady, K. T. (2020). Social determinants of health and smoking cessation: A challenge. The American Journal of Psychiatry, 177(11), 1029-1030. https://doi.org/10.1176/appi.ajp.2020.20091374

CAN-ADAPTT. (2011). Canadian Smoking Cessation Clinical Practice Guideline. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, Centre for Addiction and Mental Health. https://www.nicotinedependenceclinic.com/en/canadaptt/PublishingImages/Pages/CAN-ADAPTT-Guidelines/CAN-ADAPTT%20Canadian%20Smoking%20Cessation%20Guideline_website.pdf

Health Canada (2109). Canada’s Dietary Guidelines for health professionals and policymakers. https://food-guide.canada.ca/en/guidelines/

Heart & Stroke Foundation of Canada (n.d.). The DASH diet to lower high blood pressure. https://www.heartandstroke.ca/healthy-living/healthy-eating/dash-diet

Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2022). Update of Canada’s Low-Risk Alcohol Drinking Guidelines: Final Report for Public Consultation. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.

Siengsukon, C. F. (2020). The link between social determinants of health, sleep, and cardiovascular disease. Cardiopulmonary Physical Therapy Journal, 31(1), 5-10. https://doi.org/10.1097/CPT.0000000000000130

Turrell, G., Hewitt, B., Patterson, C., Oldenburg, B., & Gould, T. (2002). Socioeconomic differences in food purchasing behaviour and suggested implications for diet-related health promotion. Journal of Human Nutrition and Dietetics, 15(5), 355-364. https://doi.org/10.1046/j.1365-277X.2002.00384.x

Wang, G., & Wu, L. (2020). Healthy people 2020: Social determinants of cigarette smoking and electronic cigarette smoking among youth in the United States 2010-2018. International Journal of Environmental Research and Public Health, 17(20), 7503. https://doi.org/10.3390/ijerph17207503