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Spring 2015 > MNT 2 - Exam #1 > Flashcards

MNT 2 - Exam #1 Flashcards

1
Q

What is the Nutrition Prescription?

A

Concise statement of plan to best meet patient/client’s nutrition needs (developed by the RD)

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2
Q

What is the Nutrition Prescription NOT?

A

the admit/current diet order (MD orders)

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3
Q

What is the PURPOSE of the Nutrition RX?

A

To communicate RD’s nutrition/ diet recommendations (based on complete assessment)

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4
Q

What is found within the Nutrition RX?

A
  • Content should be related to the PES statement;
  • EX: if problem= inadequate energy intake, then nutrition RX should address meeting energy needs;
  • Enmount of desired weight gain/specific time period (ie:wk)
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5
Q

What should the RX include?

A
  1. Energy level;
  2. Amount of desired weight gain/specific time period (i.e.:wk);
  3. May include specifications of:
    - meals & snacks
    - supplemental feedings;
    - enteral feedings;
    - Environmental changes to promote intake;
    - % energy from specific macronutrients
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6
Q

Items from the IDNT that might be in the RX:

A
  • Number, size, frequency of meals;
  • Macronutrient rec’s (specify gm/day or %kcal);
  • Micronutrient rec’s ;
  • Bioactive substances;
  • Texture/ consistency of solid or liquids;
  • Liquid diet (ie: clear/ full);
  • Food groups/ exchanges/ servings;
  • Enteral/ parenteral feedings (specify formula/solution, rate, access, schedule)
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7
Q

What are the 4 categories of Intervention Strategies?

A
  1. Food and/or Nutrient Delivery
  2. Nutrition Education
  3. Nutrition Counseling
  4. Coordination of Nutrition Care
    * *Use IDNT terminology
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8
Q

What are some CLINICAL goals for Monitoring/Eval?

A
  1. Weight gain/loss (specify amt/time frame);
  2. Protein status: biochemical indicators, physical findings, body composition;
  3. Biochemical Assessment(LDL C, serum glu,Hgb A1C);
  4. Hydration status indicators: biochemical, physical findings, anthropometrics, cognitive function
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9
Q

What are some BEHAVIORAL goals for Monitoring/Eval?

A
  1. Change in eating behavior (e.g. increasing fruit and vegetable intake);
  2. Change in nutrition knowledge/ awareness ;
  3. Change in environment/continuum of care?;
  4. Provision of nutrient intake (ie: energy intake, enteral/parenteral feedings)
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10
Q

What is Enteral Nutrition?

A
  • Feeding through the GI tract via a tube, catheter, or stoma that delivers nutrients distal (after) the oral cavity → Nutrient intake that is NOT consumed orally;
  • “Enteral or Tube Feeding”;
  • NO “volitional” intake
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11
Q

What are the indications for the need of Enteral Nutrition?

A

**FUNCTIONAL GI tract, but cannot adequately feed (orally) themselves;
Recommended for patients:
-Altered mental status;
-Swallowing dysfunction;
-Upper GI disorders → Bypass by insertion of tube past dysfunction

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12
Q

What Nutrition Diagnoses could indicate Enteral Nutrition?

A
  • Malnutrition;
  • Increased energy expenditure;
  • Involuntary weight loss;
  • Inadequate oral food/beverage intake ;
  • Inadequate fluid intake ;
  • Increased nutrient needs;
  • Biting/chewing difficulties;
  • Impaired swallowing;
  • Impaired nutrient utilization
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13
Q

What are the CONTRAINDICATIONS to Enteral Nutrition?

A

**DO NOT utilize enteral tube feeds;
Serious medical conditions of GI tract =
-Diffuse peritonitis (inflammation/infection of the peritoneal lining of abdominal cavity);
-GI bleeding;
-Obstruction or ileus that prevent passing of intestinal contents;
-Intractable vomiting or diarrhea not responsive to medical treatment

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14
Q

ADAVANTAGE of Enteral Nutrition

A
  • Cost-effective;
  • Reduced hospital stay;
  • Reduced surgical interventions;
  • Reduce rate of infectious complications in critical care patients;
  • Improved wound healing;
  • Maintenance of GI function
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15
Q

When might Enteral be used along with Parenteral Nutrition?

A
  • Even when pt. cannot meet all nutritional needs through EN, trophic or “trickle” may be prescribed with parenteral to minimize villous atrophy and prevent bacterial translocation → Keeps protective villi alive and maintains immunity ;
  • “Use It or lose it”
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16
Q

DISADVANTAGES of Enteral Nutrition

A

-Potential difficulty of administration;
-Poor tolerance;
-Difficulty meeting nutritional requirements
→ Minimize disadvantages by careful patient selections through nutrition physical and standard protocols

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17
Q

What decisions need to be made about implementing Enteral Nutrition?

A
  1. GI Access;
  2. Formula;
  3. Delivery schedule;
  4. Duration
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18
Q

What is a Nasogastric tube feed?

A

Nose → stomach;

  • Normal GI function;
  • Stimulates normal digestion;
  • Meds can be placed in tube;
  • Bedside insertion;
  • Can potentially cause aspiration, discomfort, nasal irritation and tube displacement
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19
Q

What is a Nasoduodenal tube feed?

A

Nose → duodenum (intestine);

  • Normal SI function, but need to bypass stomach;
  • Tube insertion bedside;
  • Can lead to discomfort and tube displacement
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20
Q

What is a Nasojejunal tube feed?

A

Nose → ileum (intestine);

  • Normal SI function, but need to bypass stomach;
  • Tube insertion bedside;
  • Can lead to discomfort and tube displacement
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21
Q

What is a Gastrostomy tube feed?

A

Directly into stomach (surgically through skin);

  • Normal GI function but need to bypass upper GI;
  • Long-term feeding access;
  • Reduced risk of tube displacement;
  • Allows bolus feedings;
  • Surgical procedure accompanied with possible irritation or infection
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22
Q

What is a PEG (percutaneous endoscopic gastrostomy)?

A

Directly into stomach (laparoscopic through skin);

  • Normal GI function but need to bypass upper GI;
  • Long-term feeding access;
  • Outpatient procedure w/o anesthesia;
  • Less expensive and lower risk of displacement;
  • Allows bolus feedings;
  • Risk of irritation and infection
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23
Q

What is Jejunostomy tube feed?

A

Directly into jejunum (through skin);

  • Normal GI function but need to bypass part of GI;
  • Long-term feeding access;
  • Surgical procedure with risk of irritation and infection;
  • Small lumen of tube, so risk of clogging increased
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24
Q

What needs to be assessed to determine the appropriate formula for Enteral feeding?

A
  • Medical diagnosis;
  • Nutrition diagnosis;
  • Labs;
  • Skin breakdown;
  • Weight (weight loss/gain);
  • Tolerance of previous tube feedings;
  • Risk of aspiration;
  • Vomiting/diarrhea;
  • PO or NPO;
  • Activity
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25
Q

What are the most common formulas used for Enteral Feedings?

A
  1. Jevity
  2. Jevity 1.2
  3. Jevity 1.5
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26
Q

Other formulas

A
  • Glucerna 1.0, 1.2, 1.5;
  • Suplena;
  • Nepro;
  • Hi-Cal;
  • Optimental
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27
Q

What the 3 different type of delivery schedules for Enteral Feeding?

A
    • Enteral nutrition delivery is usually regulated by a small, programmable feeding pump;
      1. Bolus;
      2. Intermittent;
      3. Continuous
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28
Q

What are Bolus Feedings?

A
  • Rapid administration of formulas of 240-480 ml of formula several times a day;
  • Calculate amount needed in number of cans per feeding and how many times per day
  • Example: 2 cans three times/day and 1 can HS = Mimics 3 meals and a bedtime snack
  • Note: 1 can = 240 ml
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29
Q

When might bolus feeding be appropriate?

A

–

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30
Q

What are Intermittent Feedings?

A
  • Administered several times a day;
  • Administered a little slower than bolus;
  • Usually over 20-30 minutes;
  • Uses a pump to administer formula;
  • If a pump is not available then can use gravity drip
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31
Q

What are Continuous Feedings?

A
  • Administered over 8-24 hours daily;
  • Uses a pump to control the feeding rate;
  • Preferred in acute care settings;
  • GI tolerance is best with continuous feedings;
  • Disadvantage: limited mobility
  • -How to overcome- adjust feeding schedule to feed over 8-12 hours rather than 24 hours
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32
Q

When should Continuous Feedings be chosen?

A
  • Pt often has residuals;
  • Cannot tolerate large amounts of volume at a time;
  • Bedbound;
  • Not active;
  • NPO;
  • Not attending rehab therapy
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33
Q

How should a Continuous Tube Feed be INITIATED?

A

If a NEW TF patient =

Start at 45-50 ml/hr and progress by 10-20 ml/hr every 8 hours until goal rate is obtained

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34
Q

How should a Bolus Tube Feed be INITIATED?

A

If a NEW TF patient =

  • Initiate 120 ml (1/2 can) every 3 hours for 2 feedings;
  • Then increase by 120 ml every 2 feedings to final goal volume per feeding
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35
Q

How are water needs determined with CONTINUOS Tube Feeds?

A

*Need to determine if the pump AUTO FLUSHES

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36
Q

If the pump auto flushes…

A
  • If so, the pump will automatically provide 25 ml of water/hour;
  • This will provide an additional 600 ml of water/24 hours;
  • Make sure this provides enough fluid for patient
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37
Q

How would you check to see if provision of fluid is adequate?

A

–

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38
Q

What is the pump does NOT auto flush for a Continuous Tube Feed?

A
  • Determine the amount of water provided by the formula;

- Subtract amount of water provided by formula from fluid needs you have calculated for the patient

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39
Q

Example of Water Calc (NO auto flush)

A
  • Fluid needs calculated = 1800 ml/day;
  • Water in formula provides 1150ml/day;
  • Difference is 650ml;
  • Divide 650 by 3 = 217ml/flush;
  • Round to nearest 25ml = 225 ml/flush;
  • 225ml/flush X 3 = 675 ml water provided by flushes + 1150 water provided by formula = 1825 ml total water
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40
Q

What is the most a Water Flush should ever be?

A

Water flushes should not exceed 275-300 ml/flush → Typically 150-175 ml/flush 3-4 times a day (TID or QID)

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41
Q

How should water flush recommendations be written?

A
  1. Flush 225 ml water 3 times/day to provide a total of 1825 ml/day
    - OR
  2. Could be 175 ml 4 times/day to provide a total of 1850 ml/day
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42
Q

How are water flushes determined for BOLUS Feedings?

A
  1. Calculate the amount of water provided from total number of cans given per day;
  2. Subtract the amount of water in formula from estimated fluid needs;
  3. Write the recommendation the same as continuous feeding
    * *All water flushes should be rounded up to the nearest 25, 50, 75, or 100 ml
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43
Q

What is monitored for tolerance of Tube Feeds?

A 
1. Residuals;
2 Intake/Output;
3. Nausea/Vomiting;
4. Diarrhea/Constipation;
5. Weight;
6. Labs;
7. Aspiration
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44
Q

What are Residuals?

A

-Undigested feeding solution remaining from previous feeding;
-May result from =
•High volume
•High rate
•Not tolerating a specific formula

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45
Q

How often are Residuals checked?

A
  • ~every 4-6 hours;
  • MDs write order to stop feeding if =
    1. residuals are > 1.0-1.5 times the hourly rate or
    2. > 150 ml before the next bolus or intermittent TF
  • *Controversial topic
  • You need to monitor nurses notes;
  • If residuals are too high, TF may be held
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46
Q

How is Intake/Output used to monitor tolerance?

A
  • If intake > output, could be dehydrated;

- → increase flushes or change formula (that is less concentrated so lower kcal/ml)

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47
Q

How is Nausea/Vomiting used to monitor tolerance?

A
  • Decrease volume by increasing kcal/ml ;
  • Change formula to a higher kcal concentration;
  • Example: Change Jevity 1.2 to Jevity 1.5;
  • Spread out the flushes;
  • Spread out the bolus feedings
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48
Q

How is Diarrhea/Constipation used to monitor tolerance?

A
  • Change formula with more fiber;
  • Check medications;
  • Consider possible bacterial etiology (diarrhea)
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49
Q

What labs are check for tolerance of Tube Feed?

A
  • Glucose, BUN, Cr, K, Na…;
  • May need to change formula;
  • Increase flushes or even decrease flushes if over hydrated;
  • Medications may need to be adjusted;
  • Monitor for dehydration or even over-hydration
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50
Q

How is aspiration monitored for tolerance of tube feed?

A
  • Look in nurses notes;
  • Xray results, formula coming out of mouth or out of tube;
  • HOB at or > 30 degrees;
  • Continuous feeding may help improve aspiration or decrease risk of aspiration
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51
Q

What are the characteristics of a successful nutrition counselor?

A
  • Respect all clients;
  • Be genuine = real person;
  • Consider client’s feelings, experiences, beliefs;
  • Be flexible, non judgmental, optimistic;
  • Consider client’s role in family, culture;
  • Provide structure – explain what you will do/ why/ how
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52
Q

How do you establish rapport?

A
  • Use open ended questions (Begin with “what”, “why”, “how”; “Can you tell me more about….?”);
  • Share control;
  • Demonstrate sincere concern;
  • Utilize active listening → Clients often need to talk/ express feelings;
  • Watch for non verbal responses
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53
Q

What are the component of effective communication?

A
  • Listening sensitivity vs. information expert;
  • Body language shows client is important ( Eye contact, Posture, gestures);
  • Terminology client can understand → Use handouts! ;
  • Don’t argue or insist / roll with resistance;
  • Be open;
  • Encourage discussion/ explore why patient is resistant
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54
Q

What is the traditional model of RD counseling?

A
  • Used same intervention technique for everyone;
  • Used change process matched to action and maintenance stages;
  • PROBLEM: many clients in pre-action stage/ not ready to change;
  • RESULT: POOR success!
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55
Q

What are the current counseling guidelines?

A
  • Assess readiness to change;
  • Raise awareness of disease, diet concerns (discuss how nutrition “can help with” …);
  • Address client concerns;
  • Correct misinformation (be non judgmental);
  • Provide education
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56
Q

What are the stages of change/

A
  1. Pre contemplation (client not aware of problem/ needs info)
  2. Contemplation (ambivalence/ discrepancy/ to change or not to change)
  3. Preparation (identify options/set short term goals/ action plan)
  4. Action (client engages in actions of change)
  5. Maintenance (provide support, additional education/ revise goals, action plan)
  6. Relapse (normal / anticipate/ restart change process)
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57
Q

What else can help the patient?

A
  • Help client visualize self in healthy lifestyle → Privilege vs punishment;
  • Identify unhealthy behaviors and healthier alternatives;
  • Identify unhealthy thoughts/ attitudes and strategies for change (CBT);
  • Realistic goal setting (1-2 behavioral goals)
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58
Q

How do you identify unhealthy behaviors and strategies?

A
  • How to change environment (Stimulus control);

- Strategies for healthier food and exercise choices

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59
Q

What is realistic goal setting?

A
  • Acceptable, Achievable , Appropriate;
  • Using guidelines presented, emphasize client choices re: action plan;
  • Ask what client is willing to change (remember, most people don’t want to change; can negotiate such as reducing # soft drinks). ;
  • Discuss options for goals (present to client in writing if possible);
  • Example: If you have identified need to increase F/V, decrease sodium, increase dairy, patient can identify a category they would prefer to start with.
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60
Q

What are tools that can be used in counseling?

A
  • Self monitoring tools = Offer possibilities: what they are, how they work;Client participates in choice of tools, frequency used;
  • Support sense of self efficacy → Help client identify small successes in past and present;
  • Follow up plan- develop with client;
  • Relapse Management;
  • On going support
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61
Q

What should a counselor DO?

A
  • Choose/develop handouts carefully (quality vs quantity);
  • Be creative with handouts: think color, interest, easy to read;
  • Utilize form/contract to document goals with client;
  • Place educational information in front of client
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62
Q

What should a counselor AVOID?

A
  • saying “on a diet”;
  • reading your PES statement to the client;
  • using “ words” like “intaking”;
  • referring client to internet source for basic information you should be providing;
  • using .coms as additional resources
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63
Q

What should/not be in a sample menu?

A
  1. Do not include deli turkey or fruited yogurt;
    - Foods should be healthy, yet accessible;
    - Consider client schedule, time, use of restaurant food, budget, familiar foods, family meals;
  2. Look over menu with client and allow for questions and requests for changes;
    - Though you will not have time to go through each menu item, you should focus on a few specific areas of the menu and be willing to adjust according to patient preferences or schedule.;
  3. Leave room on menu to make adjustments with client during session
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64
Q

How common is CVD in the US?

A
  • *CVD remains the leading cause of death in U.S=
  • estimated 1 in 3 adults in U.S. have one or more types of CVD;
  • even though relative rate of death from CVD declined by 32% from 1999-2009, 1 in every 3 deaths still attributed to CVDl;
  • “The total direct and indirect cost of CVD and stroke in the United States for 2009 is estimated to be $312.6 billion”
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65
Q

What causes a large portion of death from CHD?

A
  • More than ½ of the deaths from CHD are related to ISCHEMIA (impaired blood flow) → From constriction or obstruction;
  • Most CVD deaths seen with older persons (>65yrs), 1/3 of deaths occur prematurely (in persons <75yrs per above reference);
  • Almost 50% of decrease due to identification of risk factors;
  • Remainder due to treatment (includes Increased detection/mgt of HTN)
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66
Q

What is the Specialized Conduction System of the Heart?

A
  • Electrical activity initiated in the heart at the SA node.;
  • The change in electrical energy potential (depolarization) in SA node causes atria to contract.;
  • Depolarization carried from atria to ventricles by AV node.;
  • Depolarization of AV node is carried into the ventricles by bundle of His which splits into rt.;
  • And L branches.;
  • Depolarization is spread through ventricles by Purkinje fibers
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67
Q

What is the Cardiac Cycle?

A

-Repeating contraction/relaxation of the heart:
1. Systole (contraction )
2. Diastole (relaxation)
= Force exerted on the walls of blood vessels during contraction and relaxation of the VENTRICLES: “systolic blood pressure” and “diastolic blood pressure” respectively

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68
Q

What is Stroke Volume?

A

volume of blood ejected with each contraction of LV

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69
Q

What regulates Stroke Volume?

A

-End-diastolic volume (EDV) ;
-Mean arterial blood pressure (MAP);
- Strength of ventricular contraction
→ All additively contribute to the volume of blood ejected!!

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70
Q

What is End Diastolic Volume (EDV)?

A

How much blood is in the left ventricle at the END of relaxation period (prior to next contraction)

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71
Q

What is Mean Arterial Pressure?

A
  • average force of the blood against the wall during the cardiac cycle;
  • regulated by cardiac output and total peripheral resistance
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72
Q

What is the Ejection Fraction?

A
  • Percentage of the blood within the left ventricle that is ACTUALLY ejected during contraction → used to determine the functioning of the heart;
  • A small ejection fraction can lead to enlargement of the heart, due to the attempt to pump more blood; Largely due to increased resistance of circulation
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5
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73
Q

What is involved in the regulation of Mean Arterial Pressure?

A
  1. Sympathetic/ parasympathetic nervous system
    — Parasympathetic – decreases heart rate
    — Sympathetic – increases heart rate
  2. Renin-angiotensin system
  3. Renal function — Renin is secreted by the kidneys!
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74
Q

What hormones are involved in the regulation of MAP?

A
  • Epinephrine
  • Vasopressin
  • Angiotensin II
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75
Q

How does Epinephrine affect MAP?

A

–

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76
Q

How does Angiotensin II affect MAP?

A

–

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77
Q

How does Vasopressin affect MAP?

A

–

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78
Q

What are the purposes or differences in the JNC 7 and JNC 8?

A
  • Publication of many new studies.;
  • JNC 7 were NOT all randomized control trials, but JNC 8 are ALL randomized control trials;
  • Need for a new, clear, and concise guideline useful for clinicians.
  • Need to simplify the classification of BP.
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79
Q

What were the changes between the JNC6 and the JNC7?

A

-JNC 7 Normal BP 120/160/>100 (no more stage 3)

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80
Q

What is Hypertension?

A

Chronic elevation in blood pressure

81
Q

What are the classification of BP?

A

JNC8=

  1. Normal
  2. Pre-HTN
  3. HTN Stage 1
  4. HTN Stage 2
82
Q

JNC 8 Normal BP

A

<80 mm Hg diastolic

83
Q

JNC 8 Pre-HTN

A

120-139 systolic or 80-89 diastolic

84
Q

JNC 8 HTN Stage 1

A

140-159 systolic or 90-99 diastolic

85
Q

JNC 8 HTN Stage 2

A

> /equal to 160 or >/equal to 100

86
Q

What are the JNC 8 subgroup recommendations: 60 and over?

A

Target:
< 150 systolic/< 90diastolic
**Target BP used to be for 80y/o, now reduced to 60y/o

87
Q

What are the JNC 8 subgroup recommendations: Under 60?

A

Target:

< 140 systolic /< 90 diastolic

88
Q

What are the JNC 8 subgroup recommendations: Over 18 with CKD (kidney disease)?

A

Target:

< 140 systolic /< 90 diastolic

89
Q

What are the JNC 8 subgroup recommendations: Over 18 with DM?

A

Target:

< 140 systolic /< 90 diastolic

90
Q

ASH/ISH 2014 Recommendations for HTN management for patients with DM

A
  • WITHOUT chronic renal disease = angiotensin converting enzyme inhibitor or angiotensin receptor blocker;
  • WITH chronic renal disease or proteinuria = angiotensin converting enzyme inhibitor or angiotensin receptor blocker
91
Q

What does JNC 8 state about Beta-Blockers?

A

Beta-blockers are NOT a preferred anti-HTN agent in absence of comorbid conditions (CHF, CAD)

92
Q

What is the definition of HTN in children?

A

-BP—95th percentile or greater, adjusted for age, height, and gender

93
Q

How to treat children with HTN?

A
  • Use lifestyle interventions first, then drug therapy for higher levels of BP or if insufficient response to lifestyle modifications;
  • Drug choices similar in children and adults, but effective doses are often smaller;
  • Uncomplicated HTN not a reason to restrict physical activity.
94
Q

What are the CVD Risk Factors?

A
  • Hypertension* → Metabolic syndrome;
  • Cigarette smoking
  • Obesity* (BMI >30 kg/m2) → Metabolic syndrome
  • Physical inactivity
  • Dyslipidemia* → Metabolic syndrome (any abnormalities in the lipid panel)
  • Diabetes mellitus* → Metabolic Syndrome ;
  • Microalbuminuria or estimated GFR <60 ml/min → Impaired renal function; Defect in the nephrons of the kidneys so large proteins that should NOT be excreted and passing through basically h
  • Age (older than 55 for men, 65 for women);
  • Family history of premature CVD → (men under age 55 or women under age 65)
95
Q

Why is Microalbuminuria a risk factor for HTN?

A

→ Impaired renal function; Defect in the nephrons of the kidneys so large proteins that should NOT be excreted and passing through basically holes in the nephrons of the kidneys, so protein is lost;

96
Q

Why is the age-of-risk GREATER for women?

A
  • After women go through menopause and lose production of estrogen which is PROTECTIVE, so they get more time of decreased risk;
  • Until about age 65, their female hormones ward off HTN and CVD
97
Q

What are the identifiable causes of HTN?

A
  • *Secondary HTN =
  • Sleep apnea
  • Drug-induced or related causes
  • Chronic kidney disease
  • Primary aldosteronism
  • Renovascular disease
  • Chronic steroid therapy and Cushing’s syndrome
  • Thyroid or parathyroid disease
98
Q

What is Primary HTN?

A

Greater proportion of CVD is IDIOPATHIC (unknown)

99
Q

How are considerations for HTN different in women?

A
  • Oral contraceptives may increase BP, and BP should be checked regularly. In contrast, HRT does not raise BP.*;
  • Development of HTN—consider other forms of contraception.*;
  • Pregnant women with HTN should be followed carefully. Methyldopa, BBs, and vasodilators, preferred for the safety of the fetus. ACEI and ARBs contraindicated in pregnancy.
100
Q

What is the prevalence of HTN in the US?

A

HTN prevalence ~ 78 million people in the United States (AHA report 2013).

101
Q

What is the relationship of BP to CVD?

A
  • Continuous, consistent, and independent of other risk factors.;
  • Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg;
  • No evidence to support treating to this low of a level, so target 140/90
102
Q

What does Pre-HTN indicate?

A

-Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension;
→ PreHTN was implemented in the JNC7 (2003)

103
Q

How does HTN relate to risk of a myocardial infarction (MI)?

A

-175/105 = 8X risk of MI;
-155/95 = 4X risk of MI;
-135/85 = 2X risk of MI
→ Systolic must be < 120 for maximum benefit

104
Q

What is the prevalence of HTN across ethnic groups and gender?

A

Rates vary by ethnic group and gender =

  • LOWEST prevalence: Hispanic/ Latino
  • Mexican American: HIGHER rates
  • HIGHEST rates: Black males and females → African American population is overall at the greatest risk!!
  • Prevalence RISE dramatically with AGE
105
Q

What is the prevalence of HTN in the US by age group?

A
  • NHANES data =
  • 45-54 = 31%;
  • 55-64 = 48%;
  • 65-74 = 65%;
  • 75+ = 78%
106
Q

What is the trend of HTN in older persons?

A
  • More than two-thirds of people over 65 have HTN.*;

- This population has the LOWEST rates of BP CONTROL. * → Need to focus on simply CONTROLLING the BP of older people

107
Q

Are there differences in treating HTN in older people?

A

-Treatment, including those with isolated systolic HTN, should follow SAME principles outlined for general care of HTN. → Diagnosis can be with an elevated systolic or diastolic!
(Still have HTN even if controlled);
-Lower initial drug doses may be indicated to avoid symptoms; standard doses and multiple drugs will be needed to reach BP targets

108
Q

What are the consequences of HTN?

A
  • HTN = strong risk factor for CVD morbidity/mortality;
  • Consequences:
    1. HF
    2. Kidney Failure
    3. MI, Stroke, Aneurysms
    4. Vision problems
109
Q

What organs are affected by HTN?

A
  • END-ORGAN Damage =
    1. Brain - hemorrhage, stroke;
    2. Eyes - retinopathy;
    3. Circulatory - peripheral vascular disease;
    4. Kidneys - renal failure, proteinuria;
    5. Heart — LVH, CHD, CHF
110
Q

What is Heart Failure?

A

CHF – heart can’t pump adequately to meet the need of all the tissues

111
Q

What is Renal Failure?

A

CRF – secondary to the impairment of the nephrons and tubule malfunctions; and decreased blood flow

112
Q

What are the comorbidities of HTN?

A
  1. Coronary Artery Disease (50%);
  2. Left Ventricular Hypertrophy (15-20%);
  3. Ischemic Stroke (77%);
  4. Chronic Kidney Disease (8-15%);
  5. DM (75%);
  6. Peripheral Artery Disease(74%)
113
Q

How might HTN lead to CAD?

A

Starts with an injury to the arterial wall and develops CAD (“injury” could be the HTN and the stretching of the arterial wall)

114
Q

What 3 conditions are very strongly correlated to one another?

A
  • Very strong correlation be HTN, DM and Renal Disease;

- Getting blood pressure under control is key relating to the other diseases

115
Q

What is the incidence of End Stage Renal Disease (ESRD) in relation Systolic BP?

A

A systolic BP > 140 exponentially increases (more than doubles) the risk of ESRD;

  • 83% of black men with >140;
  • 32% of white men with >140
116
Q

What is Dementia?

A
  • Dementia and cognitive impairment occur more commonly in people with HTN. ;
  • Reduced progression of cognitive impairment occurs with effective antihypertensive therapy.
117
Q

What is the are the etiologies of HTN?

A
  • Primary/essential – idiopathic (90%);

- Secondary – result of another chronic condition

118
Q

What are the LIFESTYLE factors that contribute to PRIMARY HTN?

A
  • Lack of activity;
  • Smoking and tobacco use ;
  • Diet;
  • Genes affecting mechanisms that regulate sodium balance;
  • Inflammatory response (General overall inflammation with obesity)
119
Q

What Dietary factors contribute to HTN?

A
  • High sodium
  • Low potassium
  • Low fruit/veggie intake
  • Low fiber
  • Low calcium
  • Low water intakes; High intakes of sugary beverages
  • High alcohol consumption
120
Q

What are some pathophysiological factors that contribute to HTN?

A

-Excessive secretion of vasopressin & angiotensinogen;
-Smoking;
-Renal disease;
-Adrenal disorders;
Neurological disease:

121
Q

Excessive vasopressin and angiotensinogen and HTN

A

-Causes vasoconstriction and damages arterial walls

122
Q

Smoking and HTN

A
  • Mechanism unclear;
  • Interference with Nitric Oxide;
  • Impairs relaxation ;
  • Prevents antioxidant protective effects on free radical formation and oxidative stress
123
Q

Renal Disease and HTN

A
  • Decreased blood flow leads to release of ATII;
  • Leads to vasoconstriction & increased blood volume;
  • Ultimately increased arterial pressure
124
Q

Adrenal Disorders and HTN

A

-Excessive secretion of hormones = Epinephrine + norepinephrine = vasoconstriction

125
Q

Neurological Disease and HTN

A
  • May impact medulla oblongata & upset balance between sympathetic and parasympathetic nervous system so normal BP not maintained;
  • Sympathetic =INCREASES;
  • Parasympathetic = DECREASES
126
Q

What is the JNC 8 target BP for all conditions?

A

140/90;

-NO evidence to support an increased benefit of a lower target (used to be 130/80 for kidney disease, CAD, and DM)

127
Q

What were the 3 objectives of the JNC 7?

A
  1. Assess lifestyle and other CVD factors → Obesity, dyslipidemia, DM, smoking, inactivity…;
  2. Reveal any identifiable causes of HTN;
  3. Assess the presence or absence of organ damage
128
Q

What are the main treatment goals for HTN?

A

Reduce risk of CVD and Renal disease

129
Q

How are the treatment goals achieved?

A
  • Weight reduction, physical activity, nutrition therapy;

- Pharmacological Intervention

130
Q

What is included in the Nutr. Assessment for HTN?

A
  1. Diet Hx: Identify dietary factors and patterns
  2. Medical Hx/ Current Medical Diagnosis
  3. Biochemical Assessment
  4. Lifestyle assessment: Identify additional risk factors
  5. Evaluate need for weight control
131
Q

What are the possible IDNT Nutr. Diagnoses for HTN?

A
  1. Excessive energy intake
  2. Excessive or inappropriate intake of fats
  3. Excessive sodium intake
  4. Inadequate calcium, fiber, potassium, or magnesium intake
  5. Overweight/obesity
  6. Food and nutrition knowledge deficit
  7. Physical inactivity
132
Q

What are the Nutr. interventions for HTN?

A
  • Nutrition RX
  • Prioritize methods to meet DASH dietary goals;
  • Possible interventions:
    1. DASH
    2. Weight loss
    3. Decrease Sodium
    4. Moderate Alcohol
    5. Physical Activity
    6. (Smoking Cessation)
133
Q

What are the recommended lifestyle modifications to lower BP?

A
  1. Reduce weight;
  2. Adopt DASH diet;
  3. Reduce sodium intakes;
  4. Increase physical activity;
  5. Moderate alcohol consumption
    * *Combining 2 or more of these modifications may or may not have an additive effect on blood pressure reduction.
134
Q

What is the effect of a weight reduction?

A

-Maintain normal body weight (BMI 18.5-24.9) = 3-20mmHG systolic reduction

135
Q

What is the effect of adopting DASH?

A

-Rich F/V, low fat dairy, reduce fat = 8-14mmHG systolic reduction

136
Q

What is the effect of reducing sodium intakes?

A

-Less than 2300mg/1500mg a day = 2-8mmHG systolic reducition

137
Q

What is the effect of increasing physical activity?

A

-Aerobic activity >30 min/day most days = 4-9mmHG systolic reduction

138
Q

What is the effect of moderating alcohol consumption?

A

-Men 2, Women 1 = 2-4mmHG systolic reduction

139
Q

What was the DASH Study?

A
  • 1997 (NEJM, 1997);
  • 11 week study, 459 adults;
  • Mean baseline BP: ~131.3/84.7 mmHg;
  • 3 groups: (Na intakes constant for all 3 groups- 3gm)
    1. Control diet (normal american);
    2. Diet rich in fruits and vegetables;
    3. Combination diet → rich in f/v and low-fat dairy, with reduced saturated fat and total fat. → Gained big support!
140
Q

What were the results of DASH?

A

*COMBO diet =
1. Reduced BP in subjects with HTN AND without HTN more than the f/v diet or control;
2. Those with HTN had greater results
— SBP decreased 11.4 mmHg more than control group;
— DBP decreased 5.5 mm Hg more than control group

141
Q

What were the other findings of DASH?

A
  1. Changes in BP:
    — w/in 2 weeks of starting diet
    — maintained for the next 6 weeks.
  2. Reductions in BP:
    — all participants (men, women, minorities…)
    — in participants WITHOUT HTN → Overall beneficial, protective and preventative
142
Q

What was the DASH Sodium Study?

A
  • 2001 Study;
  • 412 participants;
  • Randomized to either Control diet or DASH diet;
  • Results =Reduction of blood pressure: all Na+ levels in both groups
143
Q

What were the results of the Control group for DASH-Sodium?

A

Control group:

  • High → intermediate= 2.1 mmHg reduction of SBP
  • Intermediate → low= additional 4.6 mmHg reduction of SBP
144
Q

What were the results of the DASH group for DASH-Sodium?

A

DASH group:

  • High→ intermediate= 1.3 mmHg reduction of SBP
  • Intermediate → low= additional 1.7 mmHg reduction of SBP
145
Q

Where were the comparative results of DASH-Sodium?

A

Control vs DASH (low sodium ~ 1500 mg Na/d)=

  • Those without HTN: SBP was 7.1 mmHg lower ;
  • Those with HTN: SBP was 11.5 mm Hg lower
146
Q

Wha was the Premier Study?

A

Research Questions:

  1. What happens when people have to obtain/prepare own food?
  2. What would effect be if combined DASH diet with lifestyle changes known to decrease BP
  3. Primary outcome: blood pressure and HTN status
147
Q

What were the participants groups for Premier?

A
  • 810 subjects (w/ pre-hypertension or stage I HTN);
  • Randomly assigned to 1 of 3 groups
    1. Advice only
    2. Established Recommendations
    3. Established plus DASH
148
Q

What was the treatment for the “Advice Only” group?

A
  • 1 time education session (usually RD);
  • Gave instruction on factors that affect BP;
  • Weight, Na intake, physical activity and DASH;
  • Provided handouts;
  • 1 visit for 30 minutes;
  • No counseling on behavior change and no other contact
149
Q

What was the treatment for the “Established Recommendations” group?

A
  • Behavioral counseling on established recommendations for BP mgt ;
  • 18 sessions w/ trained prof. over 6 mos.;
  • Goals set for subjects =
    1. weight loss of at least 15 lb at 6 months for those with BMI of 25 or greater
    2. At least 180 min/wk of moderate activity
    3. no more than 2300 mg Na/day
    4. daily intake of 1 oz or less of alcohol for men, and ½ oz for women
    5. *** saturated fat (≤ 10%), total fat (≤ 30%)
    6. NO goals for f/v or dairy → DIFFERENCE form DASH
150
Q

What was the treatment for the “Established plush DASH” group?

A
  1. SAME 4 goals as Established, PLUS goals set for DASH
  2. 9-12 servings of f/v each day;
  3. 2-3 servings of low-fat dairy products;
  4. Reduced saturated fat intake (≤ 7% kcal);
  5. Reduced total fat intake (≤ 25% kcal)
151
Q

What was the contact pattern with the Premier groups that received recommendations?

A
  • Contact pattern was the same in both groups;
  • Subjects kept food diaries, recorded exercise, monitored calorie and Na intake;
  • Established plus DASH- also recorded f/v, dairy, and monitored fat intake
152
Q

What were the results of Premier?

A 
1. Overall mean changes: 
— Advice only:  SBP ↓ 6.6 mmHg
— Established: SBP ↓ 10.5mmHg
— Established plus DASH: SBP ↓ 11.1 mmHg
2. Mean changes in those with HTN
— Advice only: SBP ↓ 7.8 mmHg
— Established: SBP↓ 12.5 mmHg
— Established plus DASH: SBP ↓ 14.2 mmHg
153
Q

Summary of DASH

A
  1. Low in saturated fat, cholesterol and total fat;
  2. Focus is on fruits, vegetables, fat-free or low-fat dairy products → 9 fruits/veggies a day!! KNOW;
  3. Whole grains → Fiber!;
  4. Fish, poultry, beans, seeds, and nuts;
  5. Limited red meats and processed meats;
  6. Fewer sweets, added sugars, sugary beverages than typical diet
154
Q

What are the DASH nutrient goals for a 2000kcal diet?

A 
Fat = 27%;
Sat. Fat = 6%;
Protein = 18%;
CHO = 55%;
Chol = 150mg;
Sodium = 2300mg (1500mg gets even lower);
Potassium = 4700mg;
Magnesium = 1250 mg;
Fiber = 30g
155
Q

What are the DASH food group recommendations for a 2000kcal diet?

A
  • Grains = 6-8;
  • Veggie = 4-5;
  • Fruits = 4-5;
  • Lowfat/FF dairy = 2-3;
  • Lean meats, poultry, fish = 6 or less;
  • Nuts, seeds = 4-5/wk;
  • Fat and oils = 2-3;
  • Sweets = 5 or less/wk;
  • MAX sodium = 2300mg/day
156
Q

What are the DASH meal patterns?

A

-Other kcal levels from 1200-3100 kcal/d can be found in 2010 DGAs (1600, 2600, 3100 kcal in Pennington Guide posted-Moodle)

157
Q

What are the differentiations in sodium recommendations?

A

-MAX = 2300mg/day
(2300 is the UL for sodium for those 14 years and older);
-1500 mg/day = Additional lowering benefits

158
Q

Who should only consume 1500mg/day sodium?

A

Recommended for: (DGA 2010)

  1. 51 years and older
  2. African Americans
  3. Those with HTN or on HTN meds
  4. Those with Diabetes
  5. Those with chronic kidney disease
159
Q

What are the different sodium nutrient labels?

A
  • Sodium free: less than 5 mg/serving;
  • Very low sodium: 35 mg or less/serving;
  • Low sodium: 140 mg or less/serving;
  • Reduced sodium: at least 25% reduction than regular version;
  • Light sodium: 50% reduction;
  • Unsalted or No Salt Added: no salt added during processing (not a sodium-free food)
    • Remember > 20% DV = High; < 5% DV= Low
160
Q

What is the AI for Potassium?

A
  • *Counters the effects of Sodium!

- AI=4700 mg/d

161
Q

What is the In-Office BP Measurement Technique?

A

Two readings, 5 minutes apart, sitting in chair. Confirm elevated reading in contralateral arm.

162
Q

What is Ambulatory BP Monitoring?

A
  • Indicated for evaluation of “white-coat” HTN;

- Absence of 10–20% BP decrease during sleep may indicate increased CVD risk.

163
Q

What is the method of Ambulatory BP Monitoring?

A
  • ABPM is warranted for evaluation of “white-coat” HTN in the absence of target organ injury. ;
  • Ambulatory BP values are usually lower than clinic readings.;
  • Awake, individuals with hypertension have an average BP of >135/85 mmHg and during sleep >120/75 mmHg.;
  • BP drops by 10 to 20% during the night; if not, signals possible increased risk for cardiovascular events.
164
Q

What is Self-Meausurement BP Monitoring?

A
  • Provides information on response to therapy;
  • May help improve adherence to therapy and evaluate “white-coat” HTN;
  • Home measurement of >135/85 mmHg is generally considered to be hypertensive.;
  • Home measurement devices should be checked regularly.
165
Q

What are the routine tests for monitoring HTN?

A
  1. Electrocardiogram
  2. Urinalysis → Looking for Renal disease and kidney problems (especially relating to sodium levels);
  3. Blood glucose, and hematocrit ;
  4. Serum potassium, creatinine, or the corresponding estimated GFR (glomerular filtration rate), and calcium → Indicate kidney function;
  5. Lipid profile, after 9- to 12-hour fast, that includes high-density and low-density lipoprotein cholesterol, and triglycerides
166
Q

What are the optional tests for monitoring HTN?

A
  • Measurement of urinary albumin excretion or albumin/creatinine ratio = Albumin should be too large to pass through the nephrons, but with kidney problems albumin will be excreted;
  • More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved
167
Q

What needs to be included int he Nutr. Rx?

A
  • Type of diet = DASH → Simplifies diet order!;
  • Level of sodium (2300 mg or 1500 mg);
  • Energy level (for weight maintenance or weight loss);
  • Any other specific recommendations to decrease or increase
168
Q

What are the overall MNT goals for patients with HTN?

A
  • Achieve and maintain a healthful weight ;
  • Reduce blood pressure ;
  • Reduce risk for diabetes, kidney disease, and cardiovascular disease
169
Q

What are possible education/counseling intervention for HTN?

A
  • Dietary Approaches to Stop Hypertension Eating Plan
  • Limit alcohol intake
  • Reduce intake of excessive sodium
  • Identify and limit food sources of saturated fat, cholesterol, total fat, and sodium
  • Discuss ways to increase f/v, nuts, beans, low fat dairy foods
  • Describe seasoning alternatives to salt and high-sodium sauces
  • Educate on use of food labels/ to monitor sodium and fat
  • Discuss strategies for making wise food choices when eating outside the home
  • Discuss the importance of increasing fluids as fiber intake increases/ strategies to increase fluids
  • Discuss kcal level needed for weight management
  • Include physical activity: role in BP mgt/ goal setting
  • Support smoking cessation
170
Q

What is the needed Monitoring/Eval for patients with HTN?

A
  • Treatment plans
  • Blood pressure
  • Laboratory values
  • Current dietary intake
  • Ability to chew, swallow, and consume adequate nutrients
  • Physical activity habits
  • Weight and weight changes
  • Readiness for education
171
Q

What are the current Physical Activity recommendations for adults in the US?

A
  1. Moderate-intensity* aerobic physical activity for a minimum of 30 minutes on 5 days each week, or
  2. Vigorous-intensity† aerobic physical activity for a minimum of 20 minutes on 3 days each week, or
  3. Combinations thereof for adults between the ages of 18 and 65 years,
    …and…
  4. Muscle-strengthening activities for a minimum of 2 nonconsecutive days each week.
172
Q

What counts as moderate-intensity?

A

Exemplified by a brisk walk; noticeably accelerates heart rate.

173
Q

What counts as vigorous-intensity?

A

Exemplified by jogging; causes rapid breathing and a substantial increase in heart rate.

174
Q

What factors affect physical activity?

A
  • Age
  • Economic status
  • Education level
  • Beliefs and attitudes about being overweight or obese
  • Beliefs and attitudes about exercise
  • Medical conditions and health problems
  • Energy level
  • Self-motivation
  • Time constraints
  • Social responsibilities
  • Social support
  • Weather
  • Concerns about safety
175
Q

What are they types of BP meds?

A
  • Diuretics
  • ACE Inhibitors
  • Beta Blockers
  • Angiotensin-2 Receptor Blockers
  • Calcium Channel Blockers
  • Aldosterone Blockers
176
Q

What are the types of Diuretics?

A
  1. Loop = Furosemid (lasix), Bumetanide (bumex)

2. Thiazide = HCTZ (hydrodiuril)

177
Q

What is the mechanism of Loop Diuretics?

A
  1. Decrease blood volume by inhibiting renal sodium, chloride and potassium reabsorption in Loop of Henle àincreased urinary output;
  2. Increasing prostoglandinsà vasodilation
178
Q

What is the mechanism of Thiazide Diuretics?

A

-Also inhibit renal sodium, chloride and potassium reabsorption = but in distal tubules and ascending loop of Henle

179
Q

What are Aldosterone Antagonists?

A
  • *Potassium sparing diuretics;
  • Generic name: spironolactone
  • Brand name: aldactone
  • Food/drug interactions: hyperkalemia;
  • Potential side effects: vomiting, diarrhea, GI distress (and more)
180
Q

How do Aldosterone Antagonists work?

A
  1. How it works: interupt aldosterone stimulation;
  2. INCREASES sodium and water excretion (also effects Na+/K exchange in renal tubules;
    — Aldosterone would lead to Na+ retention in the renal tubules, so the ANTAGONIST prevents this function and renal stimulation, so in response cause retention of Potassium
181
Q

What are the possible FOOD-DRUG interactions for DIURETICS?

A
  • WATEffects:
  • Hypokalemia**
  • Hyperlipidemia
  • Hypertriglyceridemia
  • Hypercholesterolemia
  • Glucose Intolerance
  • Avoid Natural Licorice
182
Q

What are the possibles SIDE EFFECTS interactions for DIURETICS?

A 
*WATER Excretion!;
Side Effects:
-N/V
-Diarrhea/ Constipation
-Anorexia
-Dry Mouth
-Fatigue
-Leg cramps
183
Q

What are the ACE Inhibitors?

A

-Benazepril (Lotensin)
-Enalapril (Vasotec)
-Captopril (Capoten)
-Lisinopril (Prinivil, Zestril)
-Quinapril (Accupril)
0Ramipril (Altace)

184
Q

How do ACE Inhibitors work?

A

-VASODILATORS = Decrease peripheral vascular resistance.;
-Interfere with formation of angiotensin II from angiotensin I (competitively block ACE);
-This causes the blood vessels to relax and allow blood to flow more easily so blood pressure goes down;
→ NO angiotensin II formed, NO thirst triggered, NO aldosterone triggered from the adrenal cortex → No Sodium retention, No water retention = LOWER BP

185
Q

What are the possible FOOD-DRUG Interactions of ACE Inhibitors?

A
  • Hyperkalemia ;

- Avoid Natural Licorice → Have “aldosterone-like” activities

186
Q

What are the possible SIDE EFFECTS of ACE Inhibitors?

A
  • Cough**;
  • Hypotension/ postural hypotension;
  • Rash or itching;
  • Allergic reaction
187
Q

What are the possible BENEFITS of ACE Inhibitors?

A
  • Protective effect on kidneys**;

- Less likely to effect BG

188
Q

What are Beta-Blockers?

A

→ Decrease heart rate and cardiac output.*;
1. Drug Food Interactions → Calcium may interfere with absorption;
2. Side effects =
— Nausea, diarrhea, GI distress
— With Diabetes, beta blockers may hide some warning signs of hypoglycemia

189
Q

What are the Angiotensin-2 (AT-2) Receptor Antagonists/ Blockers (ARB’s)?

A
  • Irbesartan (avapro);
  • Losartan (cozaar)*;
  • Telmisartan (micardis);
  • Valsartan (diovan)*
190
Q

How do AT-2 Receptor Antagonists work?

A
  1. Work in different way, but produce similar effects to ACE Inhibitors;
  2. May be better tolerated than ACE Inhibitors because they produce less cough;
  3. They shield blood vessels from AT-2, so vessels become wider and BP goes down
191
Q

What are the Possible Food-Drug Interactions/Side Effects/ Benefits (ARB’s)?

A
  • Side effects: → Nausea, Dizziness;

- Food-Drug Interactions: → Hyperkalemia

192
Q

What are the Calcium Channel Blockers?

A
  • Amlodipine (norvasc)
  • Felodipine (plendil)
  • Nifedipine (adalat, procardia)
  • Verapamil (calan, isoptin)
193
Q

How do Calcium Channel Blockers work?

A
  1. Decreased calcium entering muscle cells of heart and blood vessels = decreased contraction of vascular smooth muscle which leads to VASODILATION;
  2. This causes blood vessels to relax and blood pressure goes down.
194
Q

What are the possible Food-Drug Interactions/Side Effects/ Benefits of Calcium Channel Blockers?

A 
*Food-Drug Interactions:
— Grapefruit juice (especially with felodipine)
— Limit caffeine
— Avoid or limit alcohol
— Avoid natural licorice
*Side Effects
— Edema legs and feet
— Nausea, heartburn
195
Q

What major hormones affect fluid and electrolyte balance?

A
  1. RAAS (Renin-Angiotensin-Aldosterone System) – driven by DECREASING hydrostatic pressure;
  2. Vasopressin (hormone) – released by the pituitary; AKA antidiuretic hormone (ADH)
196
Q

How does RAAS influence fluid balance?

A
  1. Baroreceptors in blood vessels – stimulated by low hydrostatic pressure due to low blood volume ;
  2. Renin (hormone) is released, converting angiotensinogen to angiotensin I;
  3. Angiotensin I becomes angiotensin II → as volume increases aldosterone (hormone) from the adrenal cortex;
  4. Aldosterone makes kidneys RETAIN Na+ ;
  5. Na+ concentration then rises, osmotic pressure increases retaining fluid in blood;
  6. Blood volume is then returned to normal levels
197
Q

How does Vasopressin influence fluid balance?

A
  • Stimulated by 1) high osmolality of ECF and 2) decreasing hydrostatic pressure by baroreceptors in the blood vessels ;
  • Vasopressin leads retention of fluid by kidney tubules → Increases blood volume and lowers osmolality
198
Q

What is stimulated once RAAS creates Angiotensin II?

A
  1. Vasopressin increased = water retention;
  2. Thirst mechanism activated = increase fluid intake;
  3. Arteriolar vasoconstriction = increase fluid intake
199
Q

What regulates SODIUM levels?

A
  • *Great influence on HTN;
    1. RAAS – as water balance is controlled by vasopressin and aldosterone sodium is also regulated as well → stimulated by LOW blood volume/pressure ;
    2. ANP (atrial natriuretic peptide = antagonist to RAAS); OPPOSITE to RAAS – released when arterial blood pressure increases; Causes increased urinary excretion of sodium and fluid to lower blood volume and thus osmolality concentration increases

Spring 2015 (14 decks)

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