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Cardiovascular Dysfunction
Part one: HYPERTENSION
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What is hypertension?
Sustained systolic pressure greaterthan 140mm Hg and diastolic
pressure greater than 90mm Hg
Based on more than one bloodpressure measurement taken at
different times.
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Classification of HTN
JNC VII report now redefines bloodpressure stages
Refer to handout regarding
classifications
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Types of Hypertension
Primary or essential hypertension-thereason for the increased blood
pressure cannot be identified
Secondary-elevated blood pressurefrom an identified cause
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Is HTN always a disease?
Elevated BP may be-a vital sign that is routinely monitored as part of
clinical status
Risk factor for atherosclerosis(plaques accumulate on arterial walls
also called hardening of the arteries)
Disease that contributes to death fromcardiac, renal and peripheral vascular
disease
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Pathophysiology
Blood pressure (BP) equals cardiacoutput (CO) times peripheral
resistance (PR)
BP= CO X PR Hypertension equals increased CO
and/or increased PR (figure 32-1,
page 857)
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What is cardiac output?
CO is the volume of blood flowingthrough either the systemic or the
pulmonary circuit per minute. This
blood flow exerts pressure on thewalls of arteries.
It is effected by sodium intake, fluid
volume, venous constriction andstress
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Peripheral resistance
Resistance to blood flow within thearteries and arterioles.
The smaller the diameter of the
vessel, the greater the resistance.The larger the diameter the less the
resistance.
It is influenced by obesity,sympatheticnervous system activity, hormonal
substances and other factors (p.819)
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Preload and Afterload
Preload determined by the volume ofthe blood within the ventricle at the
end of diastole. It is the degree of
stretch by the cardiac fibers at theend of diastole.
Afterload is the amount of resistance
to ejection of blood from the ventricle(SVR)
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Aging and blood pressure
Isolated systolic hypertension iscommon in the elderly.
Problems associated with aging
cause a decrease in the elasticity ofmajor blood vessels.
Force of the blood that would have
caused the vessels to stretch, nowraises the blood pressure.
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May be asymtomatic-silent killer Retinal changes-cotton wool spots,
papilledema
Target organ damage-heart, kidneysand cerebrovascular system
Symptoms anyone?
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What is target organ damage?
Major vessels affected byhypertension:
Heart-CAD (angina, MI, heart failure)
Kidneys- renal failure (nocturia)
Cerebrovascular- TIAs, stroke
Peripheral vascular disease
Eyes-retinopathy
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Diagnosing hypertension
Health history and physical exam Eye exam-particularly the retinas
Risk factor assessment
Laboratory studies
-urinalysis and blood chemistry (Na,
K, creatinine, fasting glucose,
cholesterol, LDL, HDL)-12 lead EKG
-Echocardiogram
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Routine lab work is a base line andmay indicate a problem for further
study -elevated LDL in
atherosclerosis Renal damage is assessed by protein
in urine and elevated BUN and
creatinine levels Echocardiogram can diagnose
ventricular hypertrophy
Lab data
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Goal of treatment
To achieve and maintain the patientsBP below 140/90 in order to prevent
complications and death.
To provide care that is inexpensive,simple and causes the least possible
disruption in the patients life.
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Treatment recommendations
Lifestyle modifications-weight loss
-reduce alcohol and sodium intake
-regular physical activity
-diet high in fruits and vegetables-stop smoking
-reduce saturated fat and cholesterol
-maintain adequate intake of K, Ca,
and Mag
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If lifestyle change isnt
enough, then what?
Medications to reduce the bloodpressure are then ordered. There are
several types which function
differently. -diuretics-Andrenergic Inhibitors-Beta-blockers
-Alpha- blockers
-vasodilators
-Angiotension-
converting enzyme inhibitors
-Angiotensin II receptor blockers-
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Medications cont
Calcium channel blockers Peripheral vasodilators
H d di i k
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How do diuretics work to
lower the blood pressure?
Primary action is in the kidney-decrease blood volume
-decrease the reabsorption of Na and water
-decrease cardiac output
-increase renal blood flow
May be one of three types
-thiazide
-loop-potassium sparing
Ad i i hibit
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Adrenergic inhibitors vs.
diuretics
Adrenergic inhibitors work onnorephinephrine (increases the BP)
-impairs synthesis and reuptake of
norephinephrine -prevents release of
norephinephrine -decreases stores
of norephinephrine
Includes Catapres, Aldomet, Serpasil
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A&Bs of blockers
Beta-blockers-block sympatheticnervous system (beta-adrenergic
receptors) Inderal and Lopressor- slower heart rate-lower blood pressure
Alpha-blockers-peripheral
vasodilation directly to blood vessel
(Minipress) - lowers blood pressure
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Vasodilators for control?
Vasodilators-work on smooth muscleof arterial vessels
- decrease peripheral resistance
- reduces systolic and diastolic blood
pressure - peripheral vasodilation
Includes Apresoline, nitroglycerin, Nitropres
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Angiotensin
Angiotensin is a polypeptide in theblood that causes BP to elevate.
- angiotensin-converting enzyme inhibitors
prevent converion of angiotensin I to angiotensin II
(Capoten and Vasotec)
- angiotensin II receptor blockers-
block effects of angiotensin II at the receptor
(Cozaar and Diovan)
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Anticholinergic effects Effects on electrolytes
GI symptoms
Postural hypotension
Sexual dysfunction
Mental depression-see medication handoutfor hypertension
Side effects of meds
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BP checks
Screening- routine monitoring of all patients (may be
asymtomatic)
Initial Detection- regular intervals
Monitor effects of treatment regimen
- routinely scheduled intervals to determine if
treatment is working and to determine if changes
need to be made in treatment
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Assessment
Nurse also needs to assess- complete history (especially symptoms that
may indicate target organ damage)
- physical exam (rate, rhythm and character
of apical and peripheral pulses)
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Nursing diagnoses
Knowledge deficit regarding therelation between treatment regimen
and control of the disease process.
Noncompliance with the therapeuticregimen related to side effects of
prescribed therapy
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Other problems?
Collaborative Problems/potentialcomplications
- left ventricular hypertrophy
- myocardial infarction
- heart failure
- TIAs
- Stroke
- Renal insufficiency and retinal
hemorrhage
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Major nursing goals
Major goals/outcomes- patient will develop an
understanding of the disease process and its
treatment - patient will
participate in a self-care program - patientwill be free from complications of hypertension
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Interventions
1. Increase patients knowledge- explain what hypertension is
- explain how hypertension is treated (lifestyle
modifications and medication regimen)
- explain physician and nurses role- explain patients role
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Interventions continued
2. Teach and support Self-Care- lifestyle modifications are
- weight loss
- reduce alcohol consumption
- quit smoking- support groups for weight,
smoking and stress - exercise regimen
- stress management
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Nursing Interventions
2. Teach and support self-care cont- medications
- what, when, how
- expected results, side effects
- Self monitoring of BP- Follow-up with health care
professional
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Nursing Interventions
3. Monitor clinical status- routinely check BP and vital signs
- routinely check lab data
- administer prescribed medications (client
response and adverse reactions)- monitor for target organ problems
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Evaluation of Outcome #1
Knows normal & abnormal values ofBP
Knows the need to modify diet, take
medications, routinely exercise, quitsmoking, decrease alcohol intake
Knows that doctor/nurse will-inquire
about lifestyle modifications, monitor response tomeds, assess for complications of hypertension,
adjust/add medications as needed
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Evaluation of Outcome #1
Knows importance of compliance- lifestyle changes
- medication regimen
- follow-up visits
- reporting effects/side effects
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Evaluation of Outcome #2
Knows which lifestyle changes areneeded
- adheres to dietary regimen
- exercise regularly
- quit smoking
- reduce use of alcohol
- attend support groups for weight,
smoking, and stress
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Evaluation of Outcome #2
Know what medication she/he istaking - can name them
- knows the expected side effects
- knows when to take, how to take
- knows what side effects to reportto physician - knows not to stop them without
consulting with physician first
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Evaluation of Outcome #2
Knows how to take own bloodpressure of knows resources for BP
checks
Has follow-up appointment withphysician
Knows importance of keeping
appointments
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Evaluation of Outcome #3
Patient has no complications ofhypertension
- maintains BP and vital signs in normal range
- reports no changes in vision
- exhibits no retinal damage on vision
testing - reports no dyspnea or
edema - results of
renal function tests are normal
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Evaluation of Outcome #3
Demonstrates no motor, speech, orsensory deficits
Reports no headache, dizziness,
weakness, changes in gait or falls
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Geriatric treatment
Single medication once a day ifpossible
Schedules to help them remember
when and how to take medications Expense is considered
Involve family
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Noncompliance problems
Acute, life-threatening blood pressureelevations that require prompt
treatment in an intensive care setting
Hypertensive emergency-meds wouldbe by IV-vasodilators that have an
immediate action
Hypertensive urgency
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Hypertensive crisis continued
Hypertensive emergency-BP must belowered immediately to halt or prevent
damage to target organs such as
acute MI, dissecting aortic aneurysmand intracranial hemmorhage
Hypertensive urgency-BP must be
lowered within several hours
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Geriatric considerations
Incidence: Affects 35-45% of elderlyover 65, women>men
Control harder to achieve due to
comorbidities Drug therapy-dosages started low
and increased slowly
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Conclusion
Hypertension-the silent killer-is treatable,but not curable-can sometimes be controlled with
change in lifestyle alone-meds are prescribed from
ones with fewest side effects, least expensive and
reduces BP