Cardiovascular Dysfunction

Part one: HYPERTENSION

What is hypertension?
Sustained systolic pressure greater than 140mm Hg and diastolic pressure greater than 90mm Hg Based on more than one blood pressure measurement taken at different times.

Classification of HTN
JNC VII report now redefines blood pressure stages Refer to handout regarding classifications

Types of Hypertension
Primary or essential hypertension-the reason for the increased blood pressure cannot be identified Secondary-elevated blood pressure from an identified cause

Is HTN always a disease?

Elevated BP may be
-a vital sign that is routinely monitored as part of clinical status

Risk factor for atherosclerosis (plaques accumulate on arterial walls also called hardening of the arteries) Disease that contributes to death from cardiac, renal and peripheral vascular disease

Pathophysiology
Blood pressure (BP) equals cardiac output (CO) times peripheral resistance (PR) BP= CO X PR Hypertension equals increased CO and/or increased PR (figure 32-1, page 857)

What is cardiac output?

CO is the volume of blood flowing through either the systemic or the pulmonary circuit per minute. This blood flow exerts pressure on the walls of arteries. It is effected by sodium intake, fluid volume, venous constriction and stress

Peripheral resistance
Resistance to blood flow within the arteries and arterioles. The smaller the diameter of the vessel, the greater the resistance. The larger the diameter the less the resistance. It is influenced by obesity,sympathetic nervous system activity, hormonal substances and other factors (p.819)

Preload and Afterload

Preload determined by the volume of the blood within the ventricle at the end of diastole. It is the degree of stretch by the cardiac fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from the ventricle (SVR)

Aging and blood pressure

Isolated systolic hypertension is common in the elderly. Problems associated with aging cause a decrease in the elasticity of major blood vessels. Force of the blood that would have caused the vessels to stretch, now raises the blood pressure.

Symptoms anyone?
May be asymtomatic-silent killer Retinal changes-cotton wool spots, papilledema Target organ damage-heart, kidneys and cerebrovascular system

What is target organ damage?

Major vessels affected by hypertension: Heart-CAD (angina, MI, heart failure) Kidneys- renal failure (nocturia) Cerebrovascular- TIAs, stroke Peripheral vascular disease Eyes-retinopathy

Diagnosing hypertension
Health history and physical exam Eye exam-particularly the retinas Risk factor assessment Laboratory studies -urinalysis and blood chemistry (Na, K, creatinine, fasting glucose, cholesterol, LDL, HDL) -12 lead EKG -Echocardiogram

Lab data
Routine lab work is a base line and may indicate a problem for further study -elevated LDL in atherosclerosis Renal damage is assessed by protein in urine and elevated BUN and creatinine levels Echocardiogram can diagnose ventricular hypertrophy

Goal of treatment
To achieve and maintain the patients BP below 140/90 in order to prevent complications and death. To provide care that is inexpensive, simple and causes the least possible disruption in the patients life.

Treatment recommendations
Lifestyle modifications
-weight loss -reduce alcohol and sodium intake -regular physical activity -diet high in fruits and vegetables -stop smoking -reduce saturated fat and cholesterol -maintain adequate intake of K, Ca, and Mag

If lifestyle change isnt enough, then what?

Medications to reduce the blood pressure are then ordered. There are several types which function differently. -diuretics
-Andrenergic Inhibitors -Beta-blockers -Alpha- blockers -vasodilators -Angiotensionconverting enzyme inhibitors -Angiotensin II receptor blockers-

Medications cont
Calcium channel blockers Peripheral vasodilators

How do diuretics work to lower the blood pressure?

Primary action is in the kidney -decrease blood volume
-decrease the reabsorption of Na and water -decrease cardiac output -increase renal blood flow

May be one of three types

-thiazide -loop -potassium sparing

Adrenergic inhibitors vs. diuretics

Adrenergic inhibitors work on norephinephrine (increases the BP)
-impairs synthesis and reuptake of norephinephrine -prevents release of norephinephrine -decreases stores of norephinephrine Includes Catapres, Aldomet, Serpasil

A&Bs of blockers
Beta-blockers-block sympathetic nervous system (beta-adrenergic receptors) Inderal and Lopressor
- slower heart rate-lower blood pressure

Alpha-blockers-peripheral vasodilation directly to blood vessel (Minipress) - lowers blood pressure

Vasodilators for control?

Vasodilators-work on smooth muscle of arterial vessels
- decrease peripheral resistance - reduces systolic and diastolic blood pressure - peripheral vasodilation Includes Apresoline, nitroglycerin, Nitropres

Angiotensin
Angiotensin is a polypeptide in the blood that causes BP to elevate.
- angiotensin-converting enzyme inhibitors prevent converion of angiotensin I to angiotensin II (Capoten and Vasotec) - angiotensin II receptor blockersblock effects of angiotensin II at the receptor (Cozaar and Diovan)

Side effects of meds

Anticholinergic effects Effects on electrolytes GI symptoms Postural hypotension Sexual dysfunction Mental depression-see medication handout
for hypertension

BP checks
Screening
- routine monitoring of all patients (may be asymtomatic)

Initial Detection
- regular intervals

Monitor effects of treatment regimen

- routinely scheduled intervals to determine if treatment is working and to determine if changes need to be made in treatment

Assessment
Nurse also needs to assess
- complete history (especially symptoms that may indicate target organ damage) - physical exam (rate, rhythm and character of apical and peripheral pulses)

Nursing diagnoses
Knowledge deficit regarding the relation between treatment regimen and control of the disease process. Noncompliance with the therapeutic regimen related to side effects of prescribed therapy

Other problems?
Collaborative Problems/potential complications
- left ventricular hypertrophy - myocardial infarction - heart failure - TIAs - Stroke - Renal insufficiency and retinal hemorrhage

Major nursing goals

Major goals/outcomes
- patient will develop an understanding of the disease process and its treatment - patient will participate in a self-care program - patient will be free from complications of hypertension

Interventions
1. Increase patients knowledge
- explain what hypertension is - explain how hypertension is treated (lifestyle modifications and medication regimen) - explain physician and nurses role - explain patients role

Interventions continued
2. Teach and support Self-Care
- lifestyle modifications are - weight loss - reduce alcohol consumption - quit smoking - support groups for weight, smoking and stress - exercise regimen - stress management

Nursing Interventions
2. Teach and support self-care cont
- medications - what, when, how - expected results, side effects - Self monitoring of BP - Follow-up with health care professional

Nursing Interventions
3. Monitor clinical status
- routinely check BP and vital signs - routinely check lab data - administer prescribed medications (client response and adverse reactions) - monitor for target organ problems

Evaluation of Outcome #1
Knows normal & abnormal values of BP Knows the need to modify diet, take medications, routinely exercise, quit smoking, decrease alcohol intake Knows that doctor/nurse will-inquire
about lifestyle modifications, monitor response to meds, assess for complications of hypertension, adjust/add medications as needed

Evaluation of Outcome #1
Knows importance of compliance
- lifestyle changes - medication regimen - follow-up visits - reporting effects/side effects

Evaluation of Outcome #2
Knows which lifestyle changes are needed
- adheres to dietary regimen - exercise regularly - quit smoking - reduce use of alcohol - attend support groups for weight, smoking, and stress

Evaluation of Outcome #2
Know what medication she/he is taking - can name them
- knows the expected side effects - knows when to take, how to take - knows what side effects to report to physician - knows not to stop them without consulting with physician first

Evaluation of Outcome #2
Knows how to take own blood pressure of knows resources for BP checks Has follow-up appointment with physician Knows importance of keeping appointments

Evaluation of Outcome #3
Patient has no complications of hypertension
- maintains BP and vital signs in normal range - reports no changes in vision - exhibits no retinal damage on vision testing - reports no dyspnea or edema - results of renal function tests are normal

Evaluation of Outcome #3
Demonstrates no motor, speech, or sensory deficits Reports no headache, dizziness, weakness, changes in gait or falls

Geriatric treatment
Single medication once a day if possible Schedules to help them remember when and how to take medications Expense is considered Involve family

Noncompliance problems
Acute, life-threatening blood pressure elevations that require prompt treatment in an intensive care setting Hypertensive emergency-meds would be by IV-vasodilators that have an immediate action Hypertensive urgency

Hypertensive crisis continued

Hypertensive emergency-BP must be lowered immediately to halt or prevent damage to target organs such as acute MI, dissecting aortic aneurysm and intracranial hemmorhage Hypertensive urgency-BP must be lowered within several hours

Geriatric considerations
Incidence: Affects 35-45% of elderly over 65, women>men Control harder to achieve due to comorbidities Drug therapy-dosages started low and increased slowly

Conclusion
Hypertension-the silent killer-is treatable,
but not curable-can sometimes be controlled with change in lifestyle alone-meds are prescribed from ones with fewest side effects, least expensive and reduces BP