MED SURG TEST 2 Flashcards
BP
the force exerted by the blood against the walls of the blood vessel
CO
the total blood flow through the systemic or pulmonary circulation per minute
Stroke Volume
the amount of blood pumped out of the left ventricle (70ml) multiplied by the HR for 1 minute
Hypertension
Persistent elevation of : Systolic blood pressure ≥140 mm Hg »OR Diastolic blood pressure ≥90 mm Hg »OR Current use of antihypertensive medications
Prehypertension
Systolic BP: 120 to 139 mm Hg
»OR
Diastolic BP: 80 to 89 mm Hg
Isolated Systolic Hypertension (ISH)
oAverage SBP > 140 mm Hg & DBP < 90 mm Hg
or loss of elasticity from atherosclerosis
ISH is more common in older adults because of changes in BP patterns. SBP rises with aging, and DBP rises until approximately age 55 and then declines.
Pseudo Hypertension
Advanced atherosclerosis –don’t collapse
Sclerotic arteries do not collapse when the cuff is fully inflated. This results in much higher cuff pressures than are actually present within the vessels. Suspect pseudohypertension if arteries feel rigid, or when few retinal or cardiac signs are found relative to the pressures obtained by cuff.
Primary (essential or idiopathic) hypertension
Elevated BP without an identified cause
- 90% to 95% of all cases
Secondary Hypertension
Elevated BP with a specific cause
Contributing Factors
Coarctation of aorta (narrowing)
Renal disease (artery stenosis)
Endocrine disorders (Cushing syndrome, thyroid disease)
Neurologic disorders (brain tumors)
Cirrhosis
Sleep apnea
Cocaine
•Treatment of is aimed at eliminating the underlying cause
•Secondary hypertension is a contributing factor to hypertensive crisis
Risk Factors for Primary Hypertension
•Age •Alcohol •Cigarette smoking •Diabetes mellitus •Elevated serum lipids •Excess dietary sodium •Gender •Family history •Obesity •Ethnicity •Sedentary lifestyle •Socioeconomic status Stress
Contributing Factors for Primary Hypertension
•Heredity
•Water and Na retention
oHigh sodium intake may activate a number of pressor mechanisms, resulting in water retention.
•Altered renin-angiotensin aldosterone mechanism
oContributes to the development of HTN
•Stress and increased SNS
oIncrease vasoconstriction, increased HR, renin release
•Insulin resistance
oHigh insulin concentration stimulates SNS activity, impairs nitric oxide
Hypertension Symptoms
•Symptoms are often secondary to organ damage and can include oFatigue, reduced activity tolerance oDizziness oPalpitations, angina oDyspnea
Diagnostic Studies of Hypertension
•History and physical examination
•Bilateral BP measurement
oUse arm with higher reading for subsequent measurements.
oBP is highest in early morning, lowest at night.
•Use a properly calibrated instrument.
•Patient should be seated quietly for 5 minutes in a chair, with feet on the floor and arms supported at heart level.
•Use appropriately sized cuff to ensure accurate readings.
•Obtain at least two measurements on two visits.
•“White coat” phenomenon may precipitate the need for ambulatory blood pressure monitoring (ABPM).
oNoninvasive, fully automated system that measures BP at preset intervals over 24-hour period
•Urinalysis, creatinine clearance
•BMP-Serum electrolytes, glucose, BUN and serum creatinine
•CBC
•Serum lipid profile
•ECG
•Echocardiogram
**These test are usually performed to rule out secondary HTN, or to determine damage caused by uncontrolled HTN
Complications of Hypertension
Damage occurs most frequently in the
oHeart
oBrain
oPeripheral vasculature
oKidney
oEyes
•Hypertensive heart disease
oCoronary artery disease
oLeft ventricular hypertrophy
oHeart failure
•Cerebrovascular disease
oStroke (risk 4x higher)
•Peripheral vascular disease
oIncreased development of atherosclerosis, aortic aneurysm, aortic dissection
•Nephrosclerosis
oHTN leading cause of ESRD (especially among African Americans)
•Retinal damage
oBlurred vision, retinal hemorrhage, loss of vision
•Hypertension is a major risk factor for cerebral atherosclerosis and stroke. Even in mildly hypertensive people, the risk of stroke is 4 times higher than in normotensive people.
•Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels, leading to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection.
•Some degree of renal dysfunction is usually present in the hypertensive patient, even one with a minimally elevated BP. Renal dysfunction is the direct result of ischemia caused by the narrowed lumina of intrarenal blood vessels.
The appearance of the retina provides important information about the severity and duration of hypertension.
Nursing Intervention for HTN
•Teach patients lifestyle modifications
oWeight reduction: Weight loss of 10 kg
(22 lb) may decrease SBP by approx. 5 to
20 mm Hg
oDASH eating plan
- Emphasizes vegetables, fruits, and fat-free or low-fat dairy products
- Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils
- Limits sodium, sweets, sugary beverages, and red meats
In terms of nutrition content, DASH is:
-Low in saturated and trans fats
- Rich in potassium, calcium, magnesium, fiber, and protein
- Dietary sodium reduction: <1500mg of sodium/day
oModeration of alcohol consumption:
§Men: No more than 2 drinks/day
§Women: No more than 1 drink/day
•When a person decreases caloric intake, sodium and fat intakes usually are also reduced. Although reducing the fat content of the diet has not been shown to produce sustained benefit for BP control, it may slow the progress of atherosclerosis and reduce overall CVD risk.
oPhysical activity: Regular physical (aerobic) activity, at least 30 minutes, most days of the week
oAvoidance of tobacco products
oPsychosocial risk factors
§Socioeconomic status, social isolation, lack of support, stress at work and family life, and depression
Medication Interventions for HTN
•Drug therapy: Classifications of common drugs used to treat hypertension
oDiuretics-Furosemide
oB-Adrenergic inhibitors -Metoprolol
oDirect vasodilators-Clonidine
oAngiotensin-converting enzyme inhibitors
§Lisinopril
oAngiotensin II receptor blockers-Valsartan
oCalcium channel blockers-Amlodipine
Side Effects of Cardiac Medications
•Drug therapy and patient teaching oIdentify, report, and minimize side effects. §Orthostatic hypotension §Sexual dysfunction §Dry mouth §Frequent urination §Electrolyte imbalance (K, Mg) §Some side effects may decrease over time
Nursing Diagnoses for HTN
oIneffective health maintenance oAnxiety oSexual dysfunction oIneffective self-health management oDisturbed body image oIneffective tissue perfusion oRisk for falls
What Happens when HTN Occurs in Older Adults?
- Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50.
- Older adults are more likely to have “white coat” hypertension.
- Often a wide gap between the first Korotkoff sound and subsequent beats is called the ausculatory gap.
- Failure to inflate the cuff high enough may result in serious underestimation of the SBP.
- Older adults have varying degrees of impaired baroreceptor reflex mechanisms.
- Consequently, orthostatic hypotension occurs often, especially in patients with ISH.
- Altered metabolism of medications.
Hypertensive Emergency
oSevere increase in BP (>220/140mm Hg) oEvidence of acute organ damage, especially in the CNS •Develops over hours to days •Often occurs in patients with a history of HTN who have failed to comply with medications or who have been under medicated •Secondary HTN is contributing cause •Evidence of acute organ damage: oHypertensive encephalopathy, cerebral hemorrhage oAcute renal failure oMyocardial infarction oHeart failure with pulmonary edema •Signs and symptoms of hypertensive encephalopathy: oSevere headache oN/V oSeizures, confusion oComa §Renal failure §MI §Pulmonary edema
Hypertensive Urgency
develops over days to weeks. This is a situation in which a patient’s BP is severely elevated (180/110mmHg), but no clinical evidence of target-organ damage is found.
May or may not require hospitalization
•Managed with oral medications
•Requires frequent follow up
Nursing Interventions HTN Emergency
•Requires Hospitalization
oIV drug therapy: Titrated to decrease no more than MAP 25% in first hour (110-115mm Hg
oMonitor cardiac and renal function
oNeurologic checks
oDetermine cause
oEducation to avoid future crises
•When hypertensive emergencies are managed, mean arterial pressure (MAP) is often used instead of systolic and diastolic BP readings to guide and evaluate drug therapy.
•The initial treatment goal is to decrease MAP by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours.
MAP
(SBP+2DBP)/3
§MAP at least 60, normally between 70-110
WBC
5,000 - 10,000/mm3
Hbg
Male: 14-17.4 g/dL
Female: 12-16 g/dL
Hct
Male: 42-52%
Female: 36-48%
Plt
140-400
BUN
6-20mg/dL
Elderly: 8-23mg/dL
Creatinine
Female: 0.4-1mg/dL
Male: 0.6 -1.2 mg/dL
BNP
<100pg/mL
PTT
60-70 sec
PT
11-13 sec (therapy > 1.5-2 times control)
INR
0.8-1.2
What is the most common type of cardiovascular disease and accounts for the majority of these deaths?
Coronary artery disease
Patients with CAD can have two outcomes, what are they?
Asymptomatic or chronic stable angina
Atherosclerosis
Type of blood vessel disorder-major cause of CAD
oBegins as soft deposits of fat that harden with age
oReferred to as “hardening of arteries”
oCan occur in any artery in the body
oAtheromas (fatty deposits)
§Preference for the coronary arteries
Nonmodifiable Risk Factors for CAD and ACS
•Age •Gender •Ethnicity •Family history •Genetic predisposition Vietnam Vets – Exposed to Agent Orange ext
Modifiable Risk Factors for CAD and ACS
- Elevated serum lipids (*LDL)
- Hypertension
- Tobacco use
- Physical inactivity
- Obesity
- Diabetes
- The incidence of CAD and MI is highest among white, middle-aged men.
- After age 65, the incidence in men and women equalizes, although cardiovascular disease causes more deaths in women than in men.
- Additionally, CAD is present in African American women at rates higher than in their white counterparts.
Diagnostics Tests for CAD and ACS
•H&P •Chest Xray •ECG •Lipid Profile •Cardiac catheterization •Percutaneous Cardiac Intervention oAngioplasty oStenting-must be on o antiplatelet therapy •CT (Electronic Beam) oCalcium and plaque deposits •Stress Test oImpact of blood flow •ECG •Echocardiogram
Nursing Interventions for CAD
•Teach patients health-promoting behaviors
oLow fat, low cholesterol, low sodium diet
o30 minutes of physical on most days/week
oRegular physical activity contributes to
§Weight reduction
§Reduction of >10% in systolic BP
§Increase in HDL cholesterol
Medications for CAD
•β-Adrenergic Blockers-Preferred drug oDecrease myocardial contractility, HR, SVR, BP •Calcium Channel Blockers oVasodilation, decreased SVR, myocardial contractility •Ace Inhibitors oDecrease risk for cardiac events (MI) •Antiplatelet therapy oASA-recommended for most people at risk oClopidogrel (Plavix)
Gerontologic Considerations for CAD
•Strategies to reduce risk factors are effective but often under prescribed and under utilized
•Necessary to modify guidelines for physical activity (walking)-start slowly
oTwo points when elderly may consider lifestyle change(s):
§When hospitalized
§When symptoms result from CAD and not from normal aging
Chronic Stable Angina
•Myocardial Ischemia
oDemand for myocardial O2 exceeds the ability of the coronary arteries to supply
•Angina
oChest pain caused by reversible myocardial ischemia
•Chronic Stable Angina
oCP that occurs intermittently over a long period of time with the same pattern of onset, duration, and intensity of symptoms
Diagnostic Tests for Chronic Stable Angina
- H&P
- CXR
- ECG
- Cardiac markers
- Lipid Panel
- Cardiac catheterization-Most Specific
- Stress Test
- Echocardiogram
Chronic Angina Drug Therapy
•Drug therapy: Nitrates (short and long acting)
§preload and afterload
§myocardial O2 demand
•Administration:
oSublingual or spray: Quick, short acting
oNitroglycerin ointment
oTransdermal controlled-release nitroglycerin
•Side effects
oOrthostatic hypotension, dizziness, HA
Teaching for Chronic Stable Angina
•Medications •Identify factors the precipitate angina oWeather, large meals •Low NA, low fat, low cholesterol diet •Ideal body weight •Physical activity o30 min a day (most days) •NTG use •Smoking cessation
•A Antiplatelet/anticoagulant/antianginal
•B B blocker/blood pressure control
•C Cigarette smoking cessation, cholesterol
management, calcium channel blockers,
cardiac rehab
•D Diet, diabetes management, depression
•E Education, exercise
F Flu vaccine
What is PQRST used for and what does it stand for?
It is used to asses chest pain P - Precipitating Events Q - Quality of the pain R - Radiation of pain S - Severity of Pain T - Timing
What do ABCDEF stand for in Chronic Stable Angina teaching?
A - Antiplatelet/anticoagulant/antianginal
B - B blocker/ blood pressure control
C - Cigarette smoking cessation, cholesterol management, calcium channel blockers, cardiac rehab
D - Diet, diabetes management, depression
E - Education, exercise
F- Flu vaccine
What is Acoronary Syndrome (ACS)
Ischemic discomfort resulting from plaque accumulation and/or rupture leading to thrombus formation
What kind of chest pain occurs in an unstable angina?
New, occurs at rest, or has worsening pattern. It’s unpredictable and emergent
What are early warning signs of a heart attack?
Pressure in center of chest
Pain in shoulders, neck or arms
Chest discomfort with fainting, sweating or nausea
What are clinical manifestations of a MI?
Left chest pain, pressure, burning with or without radiation to left arm or jaw ( NOT releived by positioning, rest, or nitrates)
Diaphoresis, ashen, clammy, cool to touch
BP and HR elevated initially
BP and HR drops as CO is decreased
N/V
Fever- may increase in 1t 24 hrs
Crackles, JVD, hepatic engorgement, edema-may occur hours to days later
