Hypertension and Heart Failure Flashcards
what are the classifications of hypertension and what do they consist of
Primary HTN- this is a primary diagnosis
-usually caused by genetics, obesity, poor diet and other modifiable factors like smoking and excersize
Secondary HTN- HTN that is cased by other conditions like pregnancy or stress. Another example is when strep infection attacks the kidneys and since those control the BP. Pain can also cause this
Emergent HTN- this is crisis. happens bc of strokes, running out of BP meds and not having access to healthcare
what is normal BP
less than 120 systolic and less than 80 diastolic
what is elevated BP
120-129 systolic and less than 80
what is considered high BP (hypertension) Stage 1
140 or higher systolic or 90 or higher diastolic
what is considered a hypertensive crisis (IT IS NOT 190)
-you need to tell your dr right away
-higher than 180 systolic and or higher than 120 diastolic
what are non modifiable risk factors of HTN
-ethnicity
-age
-family history
-gender (men and women have different symptoms, men have chest pain and a splitting headache)
-culture
what are modifiable risk factors
-abdominal obesity
-smoking
-high BP
-diabetes
-high cholesterol
-psychosocial factors
-alcohol consumption
-stress
-high cholesterol
what are the symptoms of severe HTN
-fatigue
-dizziness (severe)
-palpitation
-angina (chest pain)
-dyspnea
what conditions are consistent with the symptoms of HTN.
-Headache, neuro changes (ask about onset) (severe)
-Vision changes (severe)
-Anxiety
-Flushed face(severe)
-Nose bleeds(severe)
-Bounding pulses –> bc you are pushing on those vessels (severe)
-Edema
what is the main goal with diagnostics for HTN
-to figure out if there is a secondary cause
what do you need to be able to diagnose HTN
you need more than one reading for the diagnosis
why are labs done
-to identify or rule out secondary HTN
-evaluate target organ disease (kidneys, eyes, heart and brain all hate HTN )
-determine Cardiovascular risk (bc the vessels are narrowed so check the cholesterol, and troponin)
-check the troponin for any pt with chest pain
-troponin leaks can also happen because of the amount of pressure of the vessels (this all puts us at risk for heart attack)
-make sure to establish baselines before starting therapy
what are other tests that you can run for hypertension
-echo
-liver function test
-thyroid stimulating hormone
-high density lipids
-low density lipids
-triglycerides (all fats)
what are nursing diagnoses for HTN
-Altered blood pressure
-Ineffective tissue perfusion
-Impaired sexual function (erectile dysfunction)
-Potential complications: stroke, MI, heart attack)
-ask about other medications
what are the goals that we want to reach for HTN
-Achieve and maintain goal BP
-Minimal side effects
-Manage and cope with condition
what solutions do you want to generate for HTN
-lifestyle changes
-meds,
-excessive
-no smoking
-low sodium (to increase the pliability of the vessels)
-veggies
-low fat
-whole grain
- no red meat
-lower alcohol consumption
what should you focus on when talking about lifestyle modifications
-focus on the modifiable risk factors
describe reduced sodium intake
-less than 2,000 mg/day any processed, canned, prepackaged food and will contain excessive salt
-this is apart of lifestyle modifications (this is modifiable)
Describe the physical activity for HTN
Moderate-intensity aerobic activity, at least 30 minutes, most (at least 5) days of the week for goal of 150 minutes/week
-this is one of the modifiable ones
what are the complications of HTN (these are the organs that hate HTN)
-hypertensive crisis
Heart: coronary artery disease, heart failure, atherosclerosis myocardial infarction (this is the most important one)
Brain: transient ischemic attack/ stroke (this is the biggest one)
Peripheral vascular disease: atherosclerosis,(plaque buildup) intermittent claudication(blood stasis, there is no good blood return from diabetes and HTN)
Kidneys: chronic kidney disease (have to keep BP less than 120/80 for kidneys to function the right way) diabetes, HTN and kidney disease go together often)
Eyes: blurry or loss of vision
Damaged retinal vessels indicate concurrent damage to vessels in heart, brain, and kidneys.
Sedentary life style increases the risk of HTN
what is the DASH diet and what is it for
Dietary Approaches to Stop HTN
-this is a guideline for a healthier more balanced diet
weight reduction:
-weightless of 1 kg will decrease SBP by 1mm Hg
-calorie restriction and physical activity
DASH eating plan:
-fruits
-vegetables
-fat free or low fat milk/milk products, whole grains, fish , poultry, beans, seeds and nuts
-eggs have good cholesterol and it needs b12 to be absorbed
how much of each food group for the DASH deit can the pt have
grains: 6 to 8 servings per day
lean protein: 6 or less servings per day
legumes or nuts/sees: 4to5 servings per week
fats and sweets: LIMITED
Low fat dairy: 2-3 servings per day
fresh fruits and veggies: 4 to 5 servings of each per day
what are the psychosocial risk factors for HTN
-socioeconomic status,–> food dessert, food insecurity, healthy food is expensive
-resources to meet daily needs
stress at work and in family life,
-access to health care,
-safe housing, exposure to crime and violence,
-negative emotions (e.g., depression, hostility)
nursing interventions for acute (short term) care (hint:vitals)
-BP—assess VS, volume status, effects of drugs; look at trends. What other co morbidities does this pt have going on ( 2 or more diseases that the pt has at the same time )
-Patients with persistent increased BP should be evaluated for HTN; follow up with HCP
what are the the nursing interventions for ambulatory care (long term management)
-Help patient reduce BP
-Evaluate therapeutic effectiveness
-Assess and enhance adherence
Patient and caregiver teaching:
-Lifestyle modifications, -Nutritional therapy
-Drug therapy, Home BP monitoring
what 2 PRIMARY actions of the drug therapy that is used for HTN
-Decrease circulating blood volume (though diuretics ala furosemide, aka Lasix)
Reduce SVR (system vascular resistance): you would give ACE inhibitors to help with this. they end in -pril and they help dilate the veins and arteries
ACE inhibitors block/ inhibit the RAAS system so that you dont retain that extra fluid
what would be important when providing patient education
-Take meds at the same time everyday. If the med is not a diuretic then they can take it in the evening
-if its a diuretic than help the pt plan around their scheduled
what kind of meds would be given to a pt with HTN
nonpharmacologic treatment + 1 first line pharmacologic drug
what kind of meds would be given to a pt with secondary HTN
-Patient with stage 2 HTN—nonpharmacologic therapy (lifestyle changes) + 2 antihypertensives from two different classifications
-Monthly follow-up visits until at goal BP; then 3 to 6 months
Stage 2 HTN or comorbidities—more frequent
what are the reasons for poor adherence/ compliance
-Inadequate teaching
-Low health literacy (they don’t know how the body works and what is going on with it)
-Unpleasant side effects of drugs (diuretics and adjusting their schedule, coffee is also a diuretic)
-Return to normal BP
-High cost of drugs
-Lack of insurance
how would we enhance adherence/ compliance
-Individualize plan
-Active patient participation
-Select affordable drugs
-Involve caregivers
-Combination drugs
-Patient teaching
what are some Gerontologic Considerations for Hypertension
-Increased incidence with age; 90% risk age greater than 55
Age-related physical changes contribute to HTN:
-Our metabolism, distribution and excretion are low
-Loss of elasticity in arteries
-Increased PVR (peripheral vascular resistance)
-Decreased adrenergic receptor sensitivity
-Blunted baroreceptor reflexes (barreceptors in the aortic arch)
-Decreased renal function
-Decreased renin response to sodium and water depletion (can increase chance of dehuydrateion)
what do you have to watch when giving diuretics
monitor K+ bc hypokalemia causes dysthymias (decreased T wave)
what is the primary therapy thats given for hypertension
thiazide diuretics
what other medication would you give after diuretics
-calcium channel blockers
-ACE inhibitors
-ARBs ( angiotensin receptor blockers)
start the dose low and gradually increase and monitor postural BP
how would you evaluate if your interventions are working
-By the numbers
Lower the pressure, but not too fast!
-Bc hypotension affects end organ perfusion too! This is also a big deal
-Urine will be decreased (normal is 30ml/ hr
-Resolve signs/symptoms
-Education
-Teach back
-Demonstration
-Medication Plan
-No secondary organ involvement
-Stroke
-Heart Attack
-Renal Failure
-Compliance and lifestyle modification
what are the 3 types of cardiomyopathy
-dilated
-hypertonic
-restrictive
describe dilated cardiomyopathy
-progressive cardiac dilation and contractile dysfunction
-heart is enlarged 2-3 timed time normal weight
-heart is flabby with dilation of all 4 chambers (at least usually)
-HTN contributes to it
-seen in chronic cocaine use
-the heart muscle will thicken and we loos space of oxygenated blood to leave (systolic dysfunction)
-this is the most common type
describe hypertrophic cardiomyopathy
-hypertrophied (thickened) left ventricle reduced chamber size and ventricular septum -diastolic dysfunction
-risk of sudden death in young athletes
describe restrictive cardiomyopathy
myocardium is rigid and non compliant
-diastolic dysfunction
-least common type
-rigid ventricular walls
-this happens when the pt has a heart attach and part of the heart is dead
what is heart failure
-an abnormal condition involving impaired cardiac pumping/ filling
-the heart is unable to produce an adequate cardiac output (CO) to meet metabolic needs
-Unable to pump blood to the rest of the body, including the brain and vital organs
-Decreased cardiac output leads to decreased tissue perfusion
what does decrease CO mean
-decreased end organ perfusion
what is the normal CO
-8-10 L/ min
what increases preload
-hypervolemia
-regurgitation of cardiac valves
-heart failure
what increases afterload
hypertension and vasoconstriction
what does increased after load result in
-increased cardiac workload
what are the primary risk factors for heart failure
Hypertension:
-Modifiable risk factor
-If aggressively treated and managed, incidence of HF can be reduced by 50%
-Coronary artery disease (CAD) (r/t high cholesterol and obestity and diabetes)
describe right sided heart failure
-RV does not pump effectively
-Fluid backs up in venous system
-Fluid moves into tissues and organs–> this manifests as dependent edema and the right left will be a little more swollen than the left
-te pt will gain weight bc the fluid is backing up
-if the pt gains more than 5lb then take them to the ER
-ascites
what is the most common cause of right sided HF
-Left-sided HF and no you are at risk of lung problems
what are other causes of right sided heart failure
Other causes include RV infarction, PE, COPD, obstructive sleep apnea (OSA, give BPAP) heart attack and cor pulmonale
what are the manifestations of right sided heart failure
-fatigue
-increased peripheral venous pressure
-enlarged liver and spleen
-can be secondary to chronic pulmonary problem
-JVD bc of fluid overload
-anorexia and complaints of gi distress
-weight gain
-dependent edema
N/A? bloating (ascities)
describe left sided HF
-Most common form of HF
Results from inability of left ventricle to:
-Empty adequately during systole, or
-Fill adequately during diastole
Further classified as:
-HFrEF (systolic HF)
-HFpEF (diastolic HF)
-Or combination of the two
-Blood backs up into left atrium (LA)
-Increased pulmonary hydrostatic pressure causes pulmonary congestion and edema
what are the manifestations of left sided heart failure
-paroxysmal nocturnal dyspnea
-elevated pulmonary capillary wedge pressure
Pulmonary congestion:
-cough
-crackles
-wheezes
-blood tinged sputum (pulmonary edema, bc the alveoli are popping and leaking a small amount of blood into the sputum)
-tachypnea
-restlessness
-confusion
-orthopnea
-tachycardia
-exertional dyspnea
-fatigue
-cyanosis
what is the primary cause of HTN
-Heart failure preserving ejection fraction (diastolic HF)
-inability of the ventricles ot relax and fill during diastole, resulting in decreased SV and CO
describe chronic HF
-Slow progressive decline
-Fatigue, depression, anxiety
-Weight gain gain more than 5 pounds in a week, check daily weights (this is a nursing intervention)
-Give them diuretics to get rid of the extra fluid (IV Lasix unless they have kidney disease)
-Ankle swelling
-Dyspnea, orthopnea, cough
Insomnia
Acute HF
(this is what we are trying to avoid) -Sudden increase in symptoms of HF with decrease in functional status
-Life-threatening situation
-Anxious, pale, cyanotic
-Dyspnea, Orthopnea, Tachypnea (remember ABCs)
-Pulmonary edema
Troponin
-this is the primary diagnostic that you do when someone says that they have chest pain
-this is for acute HF
-specific to cardiac myocytes and it is secreted when they die off, if you have high levels then you are in cardiac distress,
what would the CBC and BMP look for when trying to diagnose Acute HF
-look for anemia and electrolytes
-we are concerned about K+, Na+, Magnesium bc of contractility, we can also look at Ca+ but its not in the top three)
what tests do you run for acute HF
-CBC and BMP
-BNP
-Troponin
-Cholesterol- Total Cholesterol, HDL, LDL, Triglycerides
-Triage Cardiac panel- Chest pain emergencies-
-CK- MB- Looking for damaged tissue
what are the primary chronic HF diagnostics
Chest x-ray:
-looking for pulmonary edema and heart enlargement–> not normal
-fluid overload on the lungs, and it will look fluffy
Echocardiogram (assessing cardiac function):
- tells us if there is any clots and contractility
-Transthoracic echo
-Transesophageal echo
-O2 saturation-can be cyanotic and have a high Sat
what are the tests that you run for chronic HF
-Serum electrolytes
-BUN, creatinine (measure of kidney function)
-Liver function tests
-BNP (measures the increase in stretch of the heart with volume overload)
Chest x-ray:
-looking for pulmonary edema and heart enlargement=not normal
- fluid overload on the lungs, and it will look fluffy
Echocardiogram (assessing cardiac function) tells us if there is any clots and contractility
-Transthoracic echo
-Transesophageal echo
-ECG
-O2 saturation-can be cyanotic and have a high Sat
what are the overall goals of HF
-Decrease in symptoms
-Decrease in peripheral edema
-Increase in exercise tolerance
-Adherence to the treatment plan
-No complications related to HF
what are the solutions for chronic HF (hint this is all education)
-HF is a progressive disease (there is no cure) (watch Na intake)
-Treatment plans established with quality-of-life goals
Symptom management depends on adherence to self-management protocols (this is up to the pt)
-Precipitating factors, etiologies, and comorbid conditions must be addressed
-Complex care needs often require multiple settings, increasing fragmented care
-Support systems are essential to success
describe nutritional therapy, fluid respirations, and why daily weights are important for Chronic HF
Nutritional therapy:
Diet and weight reduction: Individualize recommendations and consider cultural background
Recommend Dietary Approaches to Stop Hypertension (DASH) diet.
Sodium is usually restricted to 2 g per day.
-Fluid restriction & monitor I & O
Daily weights are important:
Same time, same clothing each day
-Weight gain of 2 lb in 1day or 5-lb gain over a week should be reported to health care provider!!
What are the priority actions to take for acute Decompensated HF
-monitor respiratory status
-daily weights
I&O
what are the other actions that you can take for Acute Decompensated HF(O2, posture,drugs,blood,edema)
-administer O2 therapy
-semi fowlers position
-administer prescribed drugs
-monitor hemodynamic status
-monitor edema
what are the drugs for Acute Decompensated HF (morphine, positive inotropes, beta blockers)
Morphine:
-Reduces preload and afterload
Relieves dyspnea and anxiety
Make sure you start low and go slow
Positive inotropes (these are given IV):
-Increases cardiac contractility
-Examples: β-agonists dopamine, dobutamine, norepinephrine, milrinone, Digitalis (Digoxin)-> be careful with this one bc it has a narrow therapeutic window, and you can give toxicity to pt. this is why you try to stick to milrione
Beta-Blockers:
-Decreases workload on the heart, decreases heart rate
-Examples: “-a/olol”, metoprolol, labetalol, etc.
-Decreases contractility by decreasing HR
what are the other drugs for Acute Decompensated HF (diuretics and vasodialtors)
Vasodilators:
Reduction in blood pressure by reducing the SVR and slows the volume return to the heart (decrease stretch of the heart)
Diuretics:
Decrease volume overload (preload) and afterload
Helps pull fluid out of the lungs
Loop diuretics—Furosemide
what is the evaluation of chronic HF (priority)
-Weight loss
-Stabalized BP
-No SOB or fatigue
what are the expected outcomes for pt with HF
-Treating underlying disorders
-Alleviate symptoms through lifestyle changes and medication management
-Prevent progression of disease
-Maintain adequate O2 needs of the body
-Reduction or absence of edema and stable baseline weight
-Achieve a realistic program of activity that balances with energy conserving activities
