Download Jana`s HTN

Hypertension
Blood pressure: force exerted by the blood against the inner walls of vessels.
Factors Affecting BP
• Blood pressure is affected by:
• Baroreceptors: sensitive to changes in pressure***
• Activate the nervous system
• Blood volume: BP proportional to volume of blood in the body
• Heart action: cardiac output & stroke volume
• Peripheral resistance: changes in arterioles
The efficiency and effectiveness of your heart is going to effect BP
Where salt goes, water follows
• Stress: SNS
• Obesity:
• Diet: Na+ intake
• Kidney: Regulatory
• Age:
Hypertension: Silent Killer
• Between 28% and 31% of US adults have hypertension; often symptom free
• 90% to 95% of this group have primary hypertension
• 5% to 10% have secondary hypertension
Seventh Report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
(AKA JNC 7)
Defines Htn as: systolic bp > 140mm/Hg
and diastolic bp > 90 mm/Hg on 2
or more contacts with HCP
Primary: etiology unknown, unidentified cause; previously as essential hypertension; 90%to 95% of clients with HTN
have primary hypertension
Secondary hypertension: cause is known, related to underlying pathology or condition:
• chronic renal disease
• renovascular disease
• oral contraceptives induced
• coarctation of the aorta
• primary aldosteronism
• Cushings syndrome
• Pheochromocytoma
• sleep apnea
• thyroid or parathyroid disease
JNC7 HTN Classifications
Normal
Pre-HTN
Stage 1 HTN
Stage 2 HTN
HTN
• Considered as:
Systolic
< 120
120-139
140-159
> or = 160
Diastolic
< 80
80-89
90-99
> or = 100
• Sign: indicator of underlying problem
• Risk factor: atherosclerotic plaque
• Disease: contributing factor in many diseases and comorbidities
Patho of HTN
Multifactorial:
• Genetic component: gene mutations
• Peripheral resistance change
• Cardiac output change
• Dysfunction in autonomic nervous system
Renin angiotensin aldosterone mechanism
Assessment and Diagnosis
• Thorough health history: family history, patient history, lifestyle history
• Complete physical examination: head to toe assessment with vital signs
Diagnostic Labs
• Done to assess organ damage.
• Urinalysis/24 hour creatinine clearance
• Chemistry: electrolytes, BUN, creatinine
• Lipid panel: cholesterol, HDL, LDL, triglycerides
• ECG: 12 lead
Risk Factors
• If the client is hypertensive they are at significantly > risk for heart disease.
• HTN with:
• Smoking
• Diabetes
• Dyslipidemia
• kidney disease
• Obesity
• physical inactivity
• Age
• family history of heart disease
• > risk if a female family member was diagnoses under 65 y/o and males under 55 y/o
Organ Damage
• Prolonged or uncontrolled HTN leads to:
• Heart disease
• Stroke
• Chronic kidney disease
• Peripheral artery disease
• Retinopathy
Treatment Modalities
• Lifestyle changes: exercise, diet, control of weight, reduction of stress, low Na+ diet
• Medications: diuretics, sympathetic inhibitors, MANY drugs for HTN
Goals of Treatment
Lifestyle Changes
Modification
Weight reduction
DASH diet
Reduced Na+
Exercise
Alcohol
Goal of SBP Reduction
5-20 mm/Hg per 10 kg
8-14 mm/Hg
2-8 mm/Hg
4-9 mm/Hg
2-4 mm/Hg
Medical Management
• Diuretics and related drugs:
• Thiazide diuretics
• Loop diuretics
• Potassium sparing diuretics
• Beta blockers
• Alpha blockers
• Combination alpha and beta blockers
• Vasodilators/Arterial dilators
• ACE inhibitors:
• angiotensin converting enzyme inhibitors
• Angiotensin II receptor blockers
• Calcium channel blockers:
• Nondihydropyridines
• dihydroyridines
Nursing Process for the Client with HTN
• Assess:
• knowledge base
• subjective data
• objective data
• health history
• Planning:
• r/t lifestyle changes
• r/t medication mgmt
• Implementation: action taken by nurse
• Evaluation: outcome of interventions
Hypertensive Crisis
• Hypertensive emergency: extremely elevated BP (>180/120 mm Hg) and must be lowered to prevent or halt
organ damage
• Hypertensive urgency: very elevated BP without any indication of organ damage
Orthostatic Hypotension
• Position change; drop BP
• S/S
• Normal postural changes
• Postural changes
• Nursing Action- pt education, get up slowly (1-3 min)
Vascular Disorders
Vascular System
• Arteries and arterioles- difference is wall thickness
• Capillaries
• Veins and venules
• Lymphatic system- compliments the vascular sys, transports lymph to intersititial tissues
Function of the Vascular System
• Supplies oxygen to tissues
• Supplies nourishment to tissues
• Removes waste from tissues
A&P Review
Arteries: carry oxygenated blood
 thick walled: makes up 25% of diameter in most
 three layers:
• intima or inner layer made up of endothelial cells
• media or middle layer made up of smooth muscle and elastic tissue
• adventitia or outer layer made up of connective tissue
Veins: carry deoxygenated blood
 Thin walled: makes up 10% of diameter
 Have one way bicuspid valves, to prevent backflow
 Also three layers, but less defined
Lymphatic vessels: collects lymphatic fluid from vessels and transports to venous circulation, permeable to proteins
 Right lymphatic duct: right side of head, neck, thorax, and upper arms
 Thoracic duct: rest of body
 Regional lymph nodes: lymph passes thru regional nodes before entering venous system
Circulation
• Unidirectional: one way!!
• Systemic circulation: throughout the body
• Pulmonary circulation: throughout the lungs
Peripheral Vascular Assessment
• Physical exam: pulses, thorough skin assessment
• Health history: any risk factors, previous problems, medication history
• Diagnostic testing: Doppler studies, exercise study, CT scan, MRI, angiography, lymphoscintigraphy,
lymphangiography, contrast phlebography, air plethysmography
Cellulitis
• Infectious process
• Etiology: bacteria enter skin via open entry area and bacteria releases toxins
Signs and Symptoms
• Swelling
• Localized redness
• Pain
• Fever
• Chills
• Sweating
Treatment
• Mild cases: oral antibiotics
• Severe cases: IV antibiotics for 7-10 days
• Elevate affected area above level of heart
• Warm, moist packs to site
• Pain management
Lymphedema
• Condition of the lymphatic system where lymph does not drain into the venous circulation, but collects in the
tissues
Patho
• Primary: congenital malformation
• Secondary: acquired
• surgery
• obesity
• parasites
• varicose veins
Elephantiasis, Lymphangitis and Lymphadenitis
• Elephantiasis: occurs after chronic lymphedema, thickening of the subQ tissue, chronic fibrosis
• Lymphangitis: acute inflammation of the lymphatic channels, focal, from hemolytic strep
• Lymphadenitis: acute or suppurative, acute stage- large and tender
Treatment
• Goal: to reduce and ctrl edema and prevent infection
• active and passive exercises
• compression
• manual drainage
• pneumatic pumps
• pharmacologic therapy- diuretics, pain meds, antibiotics if indicated
• surgical management
Venous Disorders
• Venous thrombosis: aggregates of platelets
• Deep vein thrombosis: found in deep veins
• Thrombophlebitis: inflammation of vein wall
• Phlebothrombosis: thrombus w/o inflammation
Virchow’s Triad
• Stasis of blood: not moving normally
• Obesity, heart failure, shock, hx of veroscities, over age 65, have had anesthesia
• Vessel wall injury: endothelial damage
• Trauma, surgery, pacing wires, central venous catheters, dialysis caths, local vein damage (IV sites),
repetitive competative injury
• Altered blood coagulation: abnormal clotting
• PG, BCP, clotting factors, septicemia
Deep vs Superficial Thrombus
• Superficial vein:
• s/s: pain, tenderness, redness, warmth
• typically resolves spontaneously
• treated with BR, elevation, analgesics, and anti-inflammatory meds
• Deep veins:
• s/s: edema, swelling of extremity, heat, tenderness at later stage
• treatment: usually requires medical mgmt and may include medication and surgery
Phlegmasia Cerulea Dolens
• involves entire extremity
• s/s: massive swelling, tense, painful, cool
• aka: massive iliofemoral venous thrombus
Diagnostics
• Physical exam with history
• Pulse checks
• Doppler studies
• Arteriography
• Venography
DVT Treatment
• Best option: prevention!!!
• elastic compression
• intermittent pneumatic compression devices (SCD’s)
• Positioning
• Exercise
• Mobilization
• Usually to prevent growth of thrombus and from fragmenting and forming pulmonary embolism
• Medications:
• Heparins
• Fibrinolytics
• factor XA inhibitor
• oral anticoagulants
Heparins
• Unfractionated heparin: SQ or IV
• tx x 5 to 7 days
• IV may be intermittent or continuous
• may be given w/ oral anticoagulants
• labs: aPTT, INR, and platelet cts
• Low molecular weight heparin: SQ
• longer half life than unfractionated
• med adjusted for weight
• fewer complications than unfractionated heparins
Thrombolytic Therapy
• Fibrinolytics: or thrombolytics
• lyses thrombi in 50% of clients
• given within three days of formation
• 3x greater risk of bleeding than heparin
• examples: staphlokinase, urokinase, streptokinase, Altepase, Activase, reteplase, tenecteplase
Additional meds
• Fondaparinus (Arixtra):
• inhibits factor Xa, ½ life of 17 hrs, used as prophylaxis for ortho surgeries, given SQ
• Oral agents:
• Warfarin (Coumadin)
• vit K antagonist,
• used for extended therapy,
• labs to monitor are PT,
• limit diet of Vit K rich foods
• Sometimes FFP
Nursing Care for DVT
• Monitor for bleeding
• Monitor labs for thrombocytopenia
• Bedrest with affected limb elevated
• Compression of affected extremity
• Pain control
• Monitor for PE
• S/Sx of PE: chest pain, SOB, increased respiratory rate, sputum, decrease in BP
Chronic Venous Insufficiency
• Etiology: obstruction of venous valves reflux r/t incompetent valves
• s/s: pain “aching” / “heaviness”
• Postthrobotic syndrome: chronic venous stasis = edema, pain, altered pigmentation, stasis dermatitis
Venous Stasis Ulcers***
• Stasis ulcers: approx 75% of all stasis ulcers are from venous insufficiency
• Patho: open inflamed sore develop 20 to poor venous return, results in necrosis
• Appearance: large, superficial, and exudative, usually at medial or lateral malleolus
• Treatment: wound care, elevation, pain control, compression hose
• Avoid prolonged sitting and don’t wear constrictive clothing such as tight socks around the ankles
Varicose Veins
• Varicosities: dilated, tortuous, superficial veins
• Path: incompetent valves
• Treatment: ligation, thermal ablation, & sclerotherapy
• Other options: wear compression hose, legs elevated, weight control
Arterial Disorders
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•
•
•
Arteriosclerosis: “hardening of arteries”
Atherosclerosis: plaque or atheromas
Peripheral arterial occlusive disease: arterial insufficiency
Raynaud’s disease: arterial vasoconstriction in digits
Arteriosclerosis
• Most common disease of arteries
• Patho: muscle fibers/endothelial lining of arteries become thick
• not isolated to single vessel, diffuse throughout body
• occurs with atherosclerosis
Atherosclerosis
• Patho: plaque builds up in lumen, causing decreased diameter thru which blood can flow
• Fatty streaks: typically no clinical symptoms, not age related
• Fibrous plaques: progressive & irreversible
• s/s: intermittent claudication, labs, TIAs, stroke
• Risk factors:
• modifiable: nicotine, diet, HTN, ctrl of diabetes, obesity, stress, sedentary lifestyle, elevated c-reactive
protein, hyperhomocysteinemia
• nonmodifiable: age, gender, genetics
• Complications from atheroslcerosis: atheroma (plaque mass on arterial wall)….hemorrhage, ulceration
calcification, and thrombosis
• May result in: myocardial infarction, stroke, and gangrene
• Treatment options: best tx is preventative measures
• Surgery:
• inflow & outflow
• grafting
• Radiologic: angioplasty (PTCA), stent placement
Peripheral Artery Disease
• Aka: peripheral arterial insufficiency of the extremities
• s/s: claudication pain, resting pain in forefoot, pallor, rubor, or cyanosis, weak or absent peripheral pulses, altered
skin integrity
• Treatment: exercise, positioning medication, indirect heat, pain mgmt, appropriate protective clothing (shoes,
warm clothing), good nutrition, maintain skin integrity
Arterial Ulcers
• Patho: caused by ischemia & pressure
• Appearance: small, deep, circular; usually on toe tips or web spaces of toes
• Treatment: keep clean and dry
Reynaud’s Disease
 Definition: form of intermittent arteriolar vasoconstriction
 Etiology: unknown, often related with immunological disorders
 Symptoms: coldness, pain, and pallor of toes and fingertips
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Vasoconstriction leads to cyanosis as deoxygenated blood pools in affected digit. When vasospasm stops, blood
returns rapidly.
White to blue to red; bilateral and symmetric.
Treatment:
o Minimize exposure to cold
o Stop smoking
o Pharmacological intervention
o Sympathectomy
Reminders:
o V = venous, position higher than heart
 “legs” of V are UP
o A= arterial, position lower than heart
 “legs” of A are DOWN