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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 • • • • 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 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