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NURS3313 Adult Health > Chapter 27 Hypertension > Flashcards

Chapter 27 Hypertension Flashcards

1
Q

Hypertension (HTN)

A

A condition in which the force of the blood against the artery walls is too high

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2
Q

What are the parameters to diagnose hypertension?

A

Must be based on an average of 2+ accurate readings taken between 1-4 weeks apart

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3
Q

Blood Pressure (BP)

A

The pressure that the blood exerts against the walls of the arteries as it passes through them

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4
Q

Systolic BP (SBP)

A

Arterial pressure when the heart contracts

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5
Q

Diastolic Pressure (DBP)

A

Arterial pressure when the heart relaxes and fills with blood

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6
Q

Mean Arterial Pressure (MAP)

A

Average pressure w/in the artery during one full cardiac cycle

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7
Q

Ambulatory BPM

A

Assesses daytime & nighttime BP during routine daily activities typically, for one 24 hr period

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8
Q

Home BPM

A

Assesses BP at specific times during the day & night over a longer period while the patient is seated & resting

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9
Q

Normal BP Reading

A

Systolic: Less than 120 mmHg

Diastolic: Less than 80 mmHg

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10
Q

Elevated BP Reading

A

Systolic: 120-129 mmHg
and
Diastolic: Less than 80 mmHg

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11
Q

HTN Stage 1 BP Reading

A

Systolic: 130-139 mmHg
or
Diastolic: 80-89 mmHg

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12
Q

HTN Stage 2 BP Reading

A

Systolic: 140-159 mmHg
or
Diastolic: 90-99 mmHg

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13
Q

Hypertensive Crisis

A

Systolic: Higher than 180 mmHg
and/or
Diastolic: Higher than 120 mmHg

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14
Q

With which type of patients, would you see hypertensive crisis occur in?

A

Secondary HTN

Poorly controlled HTN

Undiagnosed HTN

Abrupt discontinuation or non adherence of med->rebound hypertension

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15
Q

Hypertensive Urgency

A

BP is severely elevated: SBP >180 mmHg or DBP >120 mmHg, in stable patient w/ NO EVIDENCE of impending target organ damage

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16
Q

Nursing Considerations for Hypertensive Urgency

A

Explore reason for nonadherence
* Finances, anxiety, misunderstandings, miscommunication, drug side
effects, or recreational drug use
* Use team approach and mobilize resources to prevent nonadherence
from continuing or recurring

Frequency of vital signs assessment based on clinical judgement
and varies with patient’s condition
* Every 5 mins with rapidly changing BP is appropriate
* Every 15 or 30mins in a more stable situation should be sufficient

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17
Q

Treatment for Hypertensive Urgency

A

Restart antihypertensive meds or increase dosages

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18
Q

Hypertensive Emergency

A

BP is extremely elevated >180/120 mm Hg with new or worsening target organ damage:
* Hypertensive encephalopathy
* Ischemic stroke
* Myocardial infarction
* Heart failure with pulmonary edema
* Dissecting aortic aneurysm
* Renal failure

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19
Q

Nursing Considerations for Hypertensive Emergency

A

Rapid, focused assessment needed to determine possible cause and target organ involvement:
* Aortic Dissection – goal is to reduce SBP to <120 mmHg within the first hour of treatment
* Severe Preeclampsia/Eclampsia or Pheochromocytoma Crisis – goal is to reduce SBP to <140 mm Hg with first hour of treatment
* Goal for other cases of HTN emergency
* Reduce SBP by no more than 25% in first hour of treatment
* If stable, reduce to 160/100 mm Hg within the next 2-6 hours
* End goal of normal, controlled BP within 24-48 hours of initial treatment

ICU admission required for frequent and continuous monitoring of BP and cardiovascular status

Antihypertensive medication of choice
* IV meds such as nicardipine, labetalol, esmolol, nitroglycerin, and nitroprusside

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20
Q

Hypertension Risk Factors

A

Advancing Adult Age

Ethnicity: African-American

Chronic kidney disease

Diabetes

Excess alcohol consumption

Family History

Gender:
-Men have greater risk until age of 64 yrs old
-Women have greater risk at 65 yrs old and up

Hypercholesterolemia

Obesity

Poor diet habits: Excess salt intake, limited intake of veggies, fiber, fish fats, & potassium

Sedentary lifestyle

Use of tobacco & nicotine prods & exposure to 2nd hand smoke

Sleep apnea

Stress

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21
Q

In which ethnic group, is hypertension most prevalent?

A

African Americans

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22
Q

Primary/Essential HTN

A

High BP due to an unknown cause, usually due to multitude of co-morbidities

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23
Q

Secondary Hypertension

A

High BP due to an identifiable cause

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24
Q

Indications for Secondary HTN Screening

A

New-onset of high BP

Poorly controlled HTN

HTN resistant to 3 or more drugs

Abrupt onset of HTN

Patients younger than 30 yrs old

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25
Conditions Associated w/New Diagnosis of HTN
Excessive target organ damage Cerebral Vascular Disease Retinopathy LT ventricular hypertrophy HF w/preserved ejection fraction Coronary artery disease CKD Peripheral arterial disease
26
Formula to Calculate BP
BP = CO (Cardiac Output) X R (Resistance)
27
Systemic Vascular Resistance
The pressure in the peripheral blood vessels that the heart must overcome to pump blood into the system
28
Formula to Calculate Cardiac Output (CO)
CO = HR (Hear rate) X SV (Stroke volume)
29
Cardiac Output (CO)
The amount of blood pumped by the heart per minute
30
Stroke Volume (SV)
The amount of blood pumped out of the heart with each contraction
31
How does increased venous return increase stroke volume?
More fluid in the vasculature
32
Factors that can Cause Hypertension
Increase in CO (usually rel to expansion in vascular volume) Increase in peripheral resistance (constriction of blood vessels)
33
In order for hypertension to occur...
... there must be a change in 1 or more factors affecting peripheral resistance or cardiac output Additionally, there must be a problem w/ the body's monitoring/pressure regulation control system
34
Common Causes of Secondary HTN
CKD Cushing's syndrome Hyperaldosteronism Hyperparathyroidism Hypo/Hyperthyroidism NSAID/Substance abuse Obstructive sleep apnea Preeclampsyia Polycystic kidney disease Renal artery stenosis
35
Physiological Processes that can Lead to Hypertension
Increased SNS activity due to ANS dysfunction Increased renal absorption of Na+, Cl-, & water due to genetic variation in pathways in how kidneys handle sodium Increased RAAS system activity-> extracellular fluid volume expansion & increased systemic vascular resistance Decreased vasodilation of the arterioles due to vascular endothelium dysfunction Insulin resistance Activation of the innate & adaptive components of the immune response that contribute to vascular inflammation & dysfunction
36
High levels of Insulin & HTN (Type II Diabetes & Metabolic Disease)
Lead to renal dysfunction & cause enhanced levels of Na+ retention-> RAAS dysfunction
37
Renin-angiotensin-aldosterone system (RAAS)
Compensatory process that leads to increased BP via increased fluid retention (increases preload) & vasoconstriction via angiotensin II
38
Aldosterone
Promotes Na+ and H2O retention by kidneys increases blood volume & BP
39
If sodium is retained...
...H2O is also retained
40
Immunity/Inflammatory Response in HTN
Chronic low levels of immune mediators-> immunity cells can begin damaging endothelium
41
Prostaglandin Effect on Vasculature
Causes vasoconstriction
42
Gerontological Considerations for Hypertension
Increase in BP due to changes in heart, blood vessels, and kidneys: -Accumulation of atherosclerotic plaque -Fragmentation of arterial elastins -Increased collagen deposits -Impaired vasodilation -Renal dysfunction Decreased elasticity Stiffening of major blood vessels (aorta) Volume expansion Isolated systolic HTN is predominant in older adults
43
Isolated Systolic Hypertension
A disorder most comm seen in older adults in which the systolic BP is greater than 140 mmHg & diastolic BP is less than 80 mmHg
44
Clinical Manifestations of Hypertension
Known as "the silent killer" since there are NO warning signs -Usually most people do not know they have it Fatigue Reduced activity tolerance Dizziness Palpitations Angina Dyspnea
45
Target Organ Damage
Manifestations of pathophysiologic changes in various organs as a consequence of hypertension
46
Target Organ Damage: Eyes
Retina changes: -Hemorrhages -Exudate -Arteriolar narrowing -Cotton-wool spots (small infarctions) Papilledema: Swelling of the optic disc -Seen in severe HTN
47
Target Organ Damage: Heart
CAD w/angina & MI leads to left ventricular hypertrophy LVH occurs in response to increased workload placed on the ventricle as it contracts against higher systemic pressure -When heart damage is extensive, HF follows
48
LVH
Left Ventricular Hypertrophy Thickening of the wall w/in LT ventricle
49
Target Organ Damage: Kidneys
Increased BUN & serum creatinine levels-> nocturia manifestation Electrolyte imbalances
50
Target Organ Damage: Cerebrovascular Involvement
Transient ischemic attack (TI) or stroke Alterations in vision or speech Dizziness Weakness Sudden fall Permanent or transient hemiplegia (paralysis on one side)
51
Nursing Considerations for Obtaining Accurate BP Reading
Equipment: BP cuff Patient Instruction: -Avoid eating, smoking, drinking caffeinated beverages, & physical activity 30 mins prior to BP measuring -Empty bladder -Sit quietly for 5 min before measurement -Sit w/ back supported, arm at heart level on firm surface, w/ both feet on the ground a) Avoid talking while measurement is being taken Choose appropriately sized cuff: Width of at least 40% limb circumference & length of at least 80-100% limb circumference Wrap cuff firmly around arm: Center cuff directly over brachial artery Record BP results of both arms & take subsequent measurement from the arm w/higher reading -Should vary no more than by 5 mmHg -Take 2 readings between 1-2 mins apart & use average of measurements -Document BP measurement site & position of the patient
52
Patient Assessment
Assess for s/s of target organ damage: -CV assessment - Neck assessment for bruits, distended veins, or enlarged thyroid gland -Auscultate upper abdomen for kidney arterial stenosis -Eyes -Neuro assessment Assess health history: -Screen for primary or secondary HTN -Review patient’s ambulatory or home BP measurement techniques and verify its accuracy -Assess family history and cardiovascular risk factors -Examine personal, social, or financial factors; health beliefs, depressive symptoms, social support, and concomitant comorbidities Lab & Diagnostic Studies * 12-lead EKG * Echocardiogram * Urinalysis: Look for albumin for kidney damage * Blood chemistries
53
Masked Hypertension
BP that is typically suggestive of a diagnosis of HTN that is paradoxically normal in a healthcare setting
54
White Coat Hypertension
BP that increases to hypertensive readings in healthcare settings that is paradoxically w/in the normal ranges in other settings
55
Goal of Hypertension Treatment
Prevent complications (target organ damage) & death by maintaining a BP reading lower than 130/80 mmHg
56
Medical Management of a Patient w/out Prior Diagnosis of HTN w/ Elevated BP
BP Reading: SBP of 120-129 mmHg & DBP of <80 mmHg Should be advised to follow up w/additional BP readings w/in 3-6 months
57
Medical Management of a Patient w/BP that could be consistent w/HTN
BP Readings: SBP > or equal to 130 mmHg or DBP of > or equal to 80 mmHg Should follow-up w/ additional BP readings w/in 1 month's time to confirm or rule out diagnosis Patient's w/suspected masked or white coat HTN: BP should be based on HPBM or ABPM
58
Medical Management of Patients w/BP Reading of > or equal to 160/100 mmHg
Diagnosed w/HTN & begin treatment w/antihypertensive meds
59
Lifestyle Changes for Hypertension
Weight loss, DASH diet, physical exercise, reduced NA+ intake, increased K+ intake, smoking cessation, & decreased alcohol intake
60
Dietary Approach to Stop Hypertension (DASH) Diet
Increase fruit, vegetables, and low-fat dairy prods w/ reduced content of saturated & total fat -Restrict sweets
61
If DASH diet is used in conjunction w/weight loss...
...it can lower SBP by 11-16 mmHg
62
DASH Diet Recommended Servings of Grains & Grain Products
7 or 8 servings daily
63
DASH Diet Recommended Servings of Veggies
4 or 5 servings daily
64
DASH Diet Recommended Servings of Fruits
4 or 5 servings daily
65
DASH Diet Recommended Servings of Low-fat or Fat-Free Dairy Foods
2 or 3 servings daily
66
DASH Diet Recommended Servings of Lean Meat, Fish, & Poultry
Less than or equal to 2 servings daily
67
DASH Diet Recommended Servings of Nuts, Seeds, & Dry Beans
4 or 5 servings weekly
68
Other Dietary Considerations for Hypertension
Incorporate low sodium, high potassium diet: less than 2g Na+/day, 3,500-5,000mg/day -Aim for at least 1000 mg/day sodium reduction -High potassium diet must be avoided in patients w/CKD Limit alcohol consumption to 2 drinks or less per day in men - 24 oz beer - 10 oz wine - 3 oz 80 proof whiskey Limit alcohol consumption to 1 drink or less per day in women
69
Exercise & Weight Loss Interventions for Hypertension
Maintain normal body weight -Ideal body weight is best goal but, aim for at least 1 kg (2.2 lbs) weight loss -Expect ~1 mmHg SBP decrease for every 1 kg reduction in weight Regular aerobic phys activity (brisk walking) for at least 90-150 mins weekly Regular dynamic resistance training 90-150 mins weekly Regular isometric resistance training at least 3X a week
70
First Line of Meds for Hypertension Management
Thiazide or thiazide-type diuretics Angiotensin-converting enzyme (ACE) inhibitors Angiotensin-receptor blockers (ARBs) Calcium channel blockers (CCBs)
71
Thiazide or Thiazide-type Diuretics
Inhibit Na+ reabsorption in the distal convoluted tubule of the nephron Side effects include: hyponatremia, hypokalemia, and metabolic alkalosis
72
Side Effects of Thiazide or Thiazide-Type Diuretics
Dry mouth Thirst Weakness Drowsiness/lethargy Muscle aches Muscle fatigue Fatigue Tachycardia GI disturbance
73
Nursing Considerations for Thiazide or Thiazide-Type Diuretics
Monitor for side effects Orthostatic hypotension may be potentiated by alcohol, barbiturates, opioids, or hot weather Cause loss of Na+, K+, & Magnesium w/ increase in uric acid & Ca+2: Monitor for electrolyte imbalances Encourage intake of potassium-rich foods Gerontological considerations: Risk for orthostatic hypotension (be weary of fall risk)
74
Angiotensin-converting enzyme (ACE) inhibitors
Block the conversion of angiotensin I to Angiotensin II Side effects: Hyperkalemia, Angioedema, cough
75
Nursing Considerations for ACE inhibitors
Can cause hyperkalemia Side effects can include cough Gerontological Considerations: Req reduced dosages & addition of loop diuretics when renal dysfunction is present May cause reuptake of ACE2 receptors-> Makes pts more susceptible to infection w/ SARS-CoV-2
76
Angiotensin-receptor Blockers (ARBs)
Block effects of angiotensin II at the receptor -Reduces peripheral resistance Side Effects: Hyperkalemia, angioedema, upregulation of ACE2 receptors
77
Calcium Channel Blockers (CCB)
Inhibit Ca+2 ion influx -Vasodilation Side effects: headache, dizziness, skin flushing, peripheral edema, hypotension
78
Clinical Manifestations of Hyponatremia
SALT LOSS Seizures & Stupor Abdominal cramping, attitude changes (confusion) Lethargic Tendon reflexes diminished, trouble concentrating (confused) Loss of urine & appetite Orthostatic hypotension, overactive bowel sounds Shallow respirations (happens late due to skeletal muscle weakness) Spasms of muscles
79
Clinical Manifestations of Hypokalemia
"Everything is going to be LOW & SLOW" Weak pulses: Irregular and thready Orthostatic Hypotension Depression ST, flat or inverted T wave and prominent u-wave Shallow respirations with diminished breath sounds….due to weakness of accessory muscle movement to breath Confusion, weak Flaccid paralysis Decrease deep tendon reflexes Decreased bowel sounds
80
The 7 L's of Hypokalemia
1) Lethargy (confusion) 2) Low, shallow respirations (due to decreased ability to use accessory muscles for breathing) 3) Lethal cardiac dysrhythmias: ST depression, shallow T wave, projecting U wave 4) Lots of urine: frequent urination…kidneys unable to make the urine concentrated 5) Leg cramps 6) Limp muscles: Decrease deep tendon reflexes 7) Low BP & Heart
81
Clinical Manifestations of Hyperkalemia
"MURDER" Muscle weakness Urine production: Little or none (renal failure) Respiratory failure due to the decreased ability to use breathing muscles or seizures develop Decreased cardiac contractility: weak pulse, low blood pressure Early signs of muscle twitches/cramps…late profound weakness, flaccid Rhythm changes: Tall peaked T waves, flat p waves, Widened QRS and prolonged PR interval
82
First Line of Meds for Hypertension Management in African-American Patients
Without HF or CKD Thiazide diuretic or calcium channel blocker -NOT ACE inhibitors or ARBs
83
Special Considerations for Pharmacological Treatment of HTN
Patients are first prescribed low doses -If pt's BP does not fall to less than 130/80 mmHg: Dose is gradually increased additional meds are included as necessary to achieve control
84
Resistant Hypertension
High BP treated w/ 3+ antihypertensive medicine (1 must be a diuretic agent) of different classes
85
Risk Factors for Resistant Hypertension
Older Age Ethnicity: African-American descent Obesity CKD Diabetes
86
Nursing Considerations for Resistant Hypertension
Assess for patient adherence - Ensure finances are not preventing them - Check for pt understanding of med purpose - Check that med side effects are tolerable Patients should also be assessed for secondary hypertension Older adults: Start low & go slow Monotherapy, if appropriate, may simplify the med regimen & make it less expensive Check for drug interactions w/ over-the-counter medication Include family & caregivers in educational program
87
Target BP
<130/80 for all adults regardless of age -Exception: Target SBP <140 mmHg in patient 60 yrs & older w/history of stroke or TIA, reducing reoccurrence or w/in clinical judgement of provider
88
Which med class is the biggest risk factor for falls?
Calcium channel blockers due to vasodilation
89
Match assessment finding or intervention to cause or disorder Assessment Finding/Intervention 1) SBP 120-129 mmHg & DBP <80 mmHg 2) BP >180/120 mmHg w/out target organ damage 3) Screened for risk of adverse cardiac events 4) Treat underlying cause to obtain normal BP 5) BP >180/120 mmHg w/ target organ damage 6) Essential w/ unknown cause 7) HTN caused by sleep apnea 8) SBP more than or equal to 140 mmHg or DBP more than or equal to 90 mmHg Cause/Potential Disorder a) Primary HTN b) Secondary HTN c) Elevated HTN d) Stage 1 HTN e) Stage 2 HTN f) Hypertensive Urgency g) Hypertensive Emergency
1) c 2) f 3) d 4) b 5) g 6) a 7) b 8) e

NURS3313 Adult Health (27 decks)

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