Hypertension



Hypertension

Blood pressure: force exerted by the blood against the inner walls of vessels.

Factors Affecting BP

• Blood pressure is affected by:

• Baroreceptors: sensitive to changes in pressure***

• Activate the nervous system

• Blood volume: BP proportional to volume of blood in the body

• Heart action: cardiac output & stroke volume

• Peripheral resistance: changes in arterioles

The efficiency and effectiveness of your heart is going to effect BP

Where salt goes, water follows

• Stress: SNS

• Obesity:

• Diet: Na+ intake

• Kidney: Regulatory

• Age:

Hypertension: Silent Killer

• Between 28% and 31% of US adults have hypertension; often symptom free

• 90% to 95% of this group have primary hypertension

• 5% to 10% have secondary hypertension

Seventh Report of the Joint

National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

(AKA JNC 7)

Defines Htn as: systolic bp > 140mm/Hg

and diastolic bp > 90 mm/Hg on 2

or more contacts with HCP

Primary: etiology unknown, unidentified cause; previously as essential hypertension; 90%to 95% of clients with HTN have primary hypertension

Secondary hypertension: cause is known, related to underlying pathology or condition:

• chronic renal disease

• renovascular disease

• oral contraceptives induced

• coarctation of the aorta

• primary aldosteronism

• Cushings syndrome

• Pheochromocytoma

• sleep apnea

• thyroid or parathyroid disease

JNC7 HTN Classifications

| |Systolic |Diastolic |

|Normal |< 120 |< 80 |

|Pre-HTN |120-139 |80-89 |

|Stage 1 HTN |140-159 |90-99 |

|Stage 2 HTN |> or = 160 |> or = 100 |

HTN

• Considered as:

• Sign: indicator of underlying problem

• Risk factor: atherosclerotic plaque

• Disease: contributing factor in many diseases and comorbidities

Patho of HTN

Multifactorial:

• Genetic component: gene mutations

• Peripheral resistance change

• Cardiac output change

• Dysfunction in autonomic nervous system

Renin angiotensin aldosterone mechanism

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Assessment and Diagnosis

• Thorough health history: family history, patient history, lifestyle history

• Complete physical examination: head to toe assessment with vital signs

Diagnostic Labs

• Done to assess organ damage.

• Urinalysis/24 hour creatinine clearance

• Chemistry: electrolytes, BUN, creatinine

• Lipid panel: cholesterol, HDL, LDL, triglycerides

• ECG: 12 lead

Risk Factors

• If the client is hypertensive they are at significantly > risk for heart disease.

• HTN with:

• Smoking

• Diabetes

• Dyslipidemia

• kidney disease

• Obesity

• physical inactivity

• Age

• family history of heart disease

• > risk if a female family member was diagnoses under 65 y/o and males under 55 y/o

Organ Damage

• Prolonged or uncontrolled HTN leads to:

• Heart disease

• Stroke

• Chronic kidney disease

• Peripheral artery disease

• Retinopathy

Treatment Modalities

• Lifestyle changes: exercise, diet, control of weight, reduction of stress, low Na+ diet

• Medications: diuretics, sympathetic inhibitors, MANY drugs for HTN

Goals of Treatment

[pic]

Lifestyle Changes

|Modification |Goal of SBP Reduction |

|Weight reduction |5-20 mm/Hg per 10 kg |

|DASH diet |8-14 mm/Hg |

|Reduced Na+ |2-8 mm/Hg |

|Exercise |4-9 mm/Hg |

|Alcohol |2-4 mm/Hg |

Medical Management

• Diuretics and related drugs:

• Thiazide diuretics

• Loop diuretics

• Potassium sparing diuretics

• Beta blockers

• Alpha blockers

• Combination alpha and beta blockers

• Vasodilators/Arterial dilators

• ACE inhibitors:

• angiotensin converting enzyme inhibitors

• Angiotensin II receptor blockers

• Calcium channel blockers:

• Nondihydropyridines

• dihydroyridines

Nursing Process for the Client with HTN

• Assess:

• knowledge base

• subjective data

• objective data

• health history

• Planning:

• r/t lifestyle changes

• r/t medication mgmt

• Implementation: action taken by nurse

• Evaluation: outcome of interventions

Hypertensive Crisis

• Hypertensive emergency: extremely elevated BP (>180/120 mm Hg) and must be lowered to prevent or halt organ damage

• Hypertensive urgency: very elevated BP without any indication of organ damage

Orthostatic Hypotension

• Position change; drop BP

• S/S

• Normal postural changes

• Postural changes

• Nursing Action- pt education, get up slowly (1-3 min)

Vascular Disorders

Vascular System

• Arteries and arterioles- difference is wall thickness

• Capillaries

• Veins and venules

• Lymphatic system- compliments the vascular sys, transports lymph to intersititial tissues

Function of the Vascular System

• Supplies oxygen to tissues

• Supplies nourishment to tissues

• Removes waste from tissues

A&P Review

Arteries: carry oxygenated blood

• thick walled: makes up 25% of diameter in most

• three layers:

• intima or inner layer made up of endothelial cells

• media or middle layer made up of smooth muscle and elastic tissue

• adventitia or outer layer made up of connective tissue

Veins: carry deoxygenated blood

• Thin walled: makes up 10% of diameter

• Have one way bicuspid valves, to prevent backflow

• Also three layers, but less defined

Lymphatic vessels: collects lymphatic fluid from vessels and transports to venous circulation, permeable to proteins

• Right lymphatic duct: right side of head, neck, thorax, and upper arms

• Thoracic duct: rest of body

• Regional lymph nodes: lymph passes thru regional nodes before entering venous system

Circulation

• Unidirectional: one way!!

• Systemic circulation: throughout the body

• Pulmonary circulation: throughout the lungs

Peripheral Vascular Assessment

• Physical exam: pulses, thorough skin assessment

• Health history: any risk factors, previous problems, medication history

• Diagnostic testing: Doppler studies, exercise study, CT scan, MRI, angiography, lymphoscintigraphy, lymphangiography, contrast phlebography, air plethysmography

Cellulitis

• Infectious process

• Etiology: bacteria enter skin via open entry area and bacteria releases toxins

Signs and Symptoms

• Swelling

• Localized redness

• Pain

• Fever

• Chills

• Sweating

Treatment

• Mild cases: oral antibiotics

• Severe cases: IV antibiotics for 7-10 days

• Elevate affected area above level of heart

• Warm, moist packs to site

• Pain management

Lymphedema

• Condition of the lymphatic system where lymph does not drain into the venous circulation, but collects in the tissues

Patho

• Primary: congenital malformation

• Secondary: acquired

• surgery

• obesity

• parasites

• varicose veins

Elephantiasis, Lymphangitis and Lymphadenitis

• Elephantiasis: occurs after chronic lymphedema, thickening of the subQ tissue, chronic fibrosis

• Lymphangitis: acute inflammation of the lymphatic channels, focal, from hemolytic strep

• Lymphadenitis: acute or suppurative, acute stage- large and tender

Treatment

• Goal: to reduce and ctrl edema and prevent infection

• active and passive exercises

• compression

• manual drainage

• pneumatic pumps

• pharmacologic therapy- diuretics, pain meds, antibiotics if indicated

• surgical management

Venous Disorders

• Venous thrombosis: aggregates of platelets

• Deep vein thrombosis: found in deep veins

• Thrombophlebitis: inflammation of vein wall

• Phlebothrombosis: thrombus w/o inflammation

Virchow’s Triad

• Stasis of blood: not moving normally

• Obesity, heart failure, shock, hx of veroscities, over age 65, have had anesthesia

• Vessel wall injury: endothelial damage

• Trauma, surgery, pacing wires, central venous catheters, dialysis caths, local vein damage (IV sites), repetitive competative injury

• Altered blood coagulation: abnormal clotting

• PG, BCP, clotting factors, septicemia

Deep vs Superficial Thrombus

• Superficial vein:

• s/s: pain, tenderness, redness, warmth

• typically resolves spontaneously

• treated with BR, elevation, analgesics, and anti-inflammatory meds

• Deep veins:

• s/s: edema, swelling of extremity, heat, tenderness at later stage

• treatment: usually requires medical mgmt and may include medication and surgery

Phlegmasia Cerulea Dolens

• involves entire extremity

• s/s: massive swelling, tense, painful, cool

• aka: massive iliofemoral venous thrombus

Diagnostics

• Physical exam with history

• Pulse checks

• Doppler studies

• Arteriography

• Venography

DVT Treatment

• Best option: prevention!!!

• elastic compression

• intermittent pneumatic compression devices (SCD’s)

• Positioning

• Exercise

• Mobilization

• Usually to prevent growth of thrombus and from fragmenting and forming pulmonary embolism

• Medications:

• Heparins

• Fibrinolytics

• factor XA inhibitor

• oral anticoagulants

Heparins

• Unfractionated heparin: SQ or IV

• tx x 5 to 7 days

• IV may be intermittent or continuous

• may be given w/ oral anticoagulants

• labs: aPTT, INR, and platelet cts

• Low molecular weight heparin: SQ

• longer half life than unfractionated

• med adjusted for weight

• fewer complications than unfractionated heparins

Thrombolytic Therapy

• Fibrinolytics: or thrombolytics

• lyses thrombi in 50% of clients

• given within three days of formation

• 3x greater risk of bleeding than heparin

• examples: staphlokinase, urokinase, streptokinase, Altepase, Activase, reteplase, tenecteplase

Additional meds

• Fondaparinus (Arixtra):

• inhibits factor Xa, ½ life of 17 hrs, used as prophylaxis for ortho surgeries, given SQ

• Oral agents:

• Warfarin (Coumadin)

• vit K antagonist,

• used for extended therapy,

• labs to monitor are PT,

• limit diet of Vit K rich foods

• Sometimes FFP

Nursing Care for DVT

• Monitor for bleeding

• Monitor labs for thrombocytopenia

• Bedrest with affected limb elevated

• Compression of affected extremity

• Pain control

• Monitor for PE

• S/Sx of PE: chest pain, SOB, increased respiratory rate, sputum, decrease in BP

Chronic Venous Insufficiency

• Etiology: obstruction of venous valves reflux r/t incompetent valves

• s/s: pain “aching” / “heaviness”

• Postthrobotic syndrome: chronic venous stasis = edema, pain, altered pigmentation, stasis dermatitis

Venous Stasis Ulcers***

• Stasis ulcers: approx 75% of all stasis ulcers are from venous insufficiency

• Patho: open inflamed sore develop 20 to poor venous return, results in necrosis

• Appearance: large, superficial, and exudative, usually at medial or lateral malleolus

• Treatment: wound care, elevation, pain control, compression hose

• Avoid prolonged sitting and don’t wear constrictive clothing such as tight socks around the ankles

Varicose Veins

• Varicosities: dilated, tortuous, superficial veins

• Path: incompetent valves

• Treatment: ligation, thermal ablation, & sclerotherapy

• Other options: wear compression hose, legs elevated, weight control

Arterial Disorders

• Arteriosclerosis: “hardening of arteries”

• Atherosclerosis: plaque or atheromas

• Peripheral arterial occlusive disease: arterial insufficiency

• Raynaud’s disease: arterial vasoconstriction in digits

Arteriosclerosis

• Most common disease of arteries

• Patho: muscle fibers/endothelial lining of arteries become thick

• not isolated to single vessel, diffuse throughout body

• occurs with atherosclerosis

Atherosclerosis

• Patho: plaque builds up in lumen, causing decreased diameter thru which blood can flow

• Fatty streaks: typically no clinical symptoms, not age related

• Fibrous plaques: progressive & irreversible

• s/s: intermittent claudication, labs, TIAs, stroke

• Risk factors:

• modifiable: nicotine, diet, HTN, ctrl of diabetes, obesity, stress, sedentary lifestyle, elevated c-reactive protein, hyperhomocysteinemia

• nonmodifiable: age, gender, genetics

• Complications from atheroslcerosis: atheroma (plaque mass on arterial wall)….hemorrhage, ulceration calcification, and thrombosis

• May result in: myocardial infarction, stroke, and gangrene

• Treatment options: best tx is preventative measures

• Surgery:

• inflow & outflow

• grafting

• Radiologic: angioplasty (PTCA), stent placement

Peripheral Artery Disease

• Aka: peripheral arterial insufficiency of the extremities

• s/s: claudication pain, resting pain in forefoot, pallor, rubor, or cyanosis, weak or absent peripheral pulses, altered skin integrity

• Treatment: exercise, positioning medication, indirect heat, pain mgmt, appropriate protective clothing (shoes, warm clothing), good nutrition, maintain skin integrity

Arterial Ulcers

• Patho: caused by ischemia & pressure

• Appearance: small, deep, circular; usually on toe tips or web spaces of toes

• Treatment: keep clean and dry

Reynaud’s Disease

• Definition: form of intermittent arteriolar vasoconstriction

• Etiology: unknown, often related with immunological disorders

• Symptoms: coldness, pain, and pallor of toes and fingertips

• Vasoconstriction leads to cyanosis as deoxygenated blood pools in affected digit. When vasospasm stops, blood returns rapidly.

• White to blue to red; bilateral and symmetric.

• Treatment:

o Minimize exposure to cold

o Stop smoking

o Pharmacological intervention

o Sympathectomy

• Reminders:

o V = venous, position higher than heart

▪ “legs” of V are UP

o A= arterial, position lower than heart

▪ “legs” of A are DOWN

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