Hypertension Final 2


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  • The 7th Joint National Committee on the prevention, detection, evaluation, and treatment of high blood pressure report was put out in 2003 The commission added a pre hypertensive category because studies noted people with b/p >122/80 were shown to have twice the risk for developing HTN !!!! These guidelines are the recommendations that a responsible physician would follow. Modify lifestyle changes are recommended in all categories of risk. Empathy is our key motivator in monitoring blood pressures and life style changes.
  • Determine factors regulating blood pressure— Regulating Factors Classify the characteristics of hypertension-- Classifications Review classifications of hypertensive medications-- Medications Review current national recommendations for treatment of hypertension-- Recommendations Identify treatment of hypertension in specific populations— Populations Practice – Goals: The job of the blood pressure to maintain tissue perfusion during activity and rest .
  • Blood pressure is the product of cardiac output and systemic vascular resistance. Cardiac Output with each beat is the stroke volume ??/ CC per beat 70--
  • Deficits of control mechanisms may be genetic, hereditary, or familiar, or environmental. The body is unable to eject blood and pooling takes place— Ask where in the system we can have backup—heart, lungs, periphery. Hypertension over time will decrease vascular tone and compliance so over time the volume of blood that fills the ventricles is not the volume that can’t be pumped out. -- CHF
  • Hypertension will cause Cardiovascular disease(CVD) without other risk factors. If you live to be 55 you have a lifetime risk to develop HTN. If you are between ages 40 – 70 the risk for CVD double for each increment of 20 mm Hg for the systolic and 10 mm Hg for the diastolic Now let complicate the waters .
  • Primary HTN cause is unknown but was is certain is this grouping of risk factors leads to CV disorders What other risk factors could we assess for behavior modification? ETOH and Smoking: Risk worse when Combined! Stress Physical Diet ?? Sodium intake Can’ Contol Age Family history of Heart disease <55 Race- Blacks--vasodilatation of the renal control of the kidney
  • What medications can cause secondary HTN estogen --BCP steroids--sports sympathomimetics –decongestants Risk factor are related to disruptions in the body's regulating Mechanisms. Diseased states—called-Target organ Injury
  • Factors such as Insulin and endothelial function affect cardiac output and systemic vascular resistance Heart Failure— Inadequate glucose control-accelerate atherosclerosis, increases left ventricular work lead to renal insufficiency
  • These classifications and values current not the Table 32:2 on page 779 Chart is for ages 18-74 30 percent of the 50, million do not know they have HTN. So by the time they are diagnosed they have other indicators require drug combinations to get the pressure 130/80 Normal- The commission recommended lifestyle changes when your blood pressure is normal <120/80 PRE -Compelling indicators to treat would be such as obesity, lipidemia, glucose intolerance, or they maintaining b/p greater than 130/80. Stage 1- Adjust doses or med classifications to reduce the systolic pressure especially in light of diabetes or chronic kidney disease Stage 2 - Patients treated in should be monitored for hypotension, kidney function, and potassium changes. Review Drug Classifications
  • This class is the basic in preventive therapy. These meds end in azide and azone. Review labs. Educate patient on monitoring Digoxin levels, potassium rich foods SE: vertigo, anorexia---Inhibit NaCl reabsorption in kidney
  • K Normal: 3.5-5.5 Inhibit NaCl reabsorption in kidney Electrolyte imbalance except calcium not HDL cholesterol
  • These act on the heart and B Blockers are added to initially treat acute coronary syndrome. Used with ischemic heart disease the most common form of target organ injury caused by hypertension. Rennin reduction decreases circulating volume by excreting sodium. Reduces rennin, Decreases cardiac output--.
  • Uncontrolled AF>170 ICU Peripheral edema
  • A adrenergic receptors are blocked from constricting as part of the sympathetic response Sudden withdrawal: Rebound HTN, Tachycardia, HA, tremors and sweating Educate the patients on the rebound effects
  • Assessment: Cough r/t angio edema—switch ACE-ARB—Africi an American population Work to decrease constriction in the kidney. Kidney specific labs Creatinine / Bun/ UA—blood, ketones, protein Reduce Angiotensin I to angiotensin II Prevent Angiotensin II from working Meds Captopril- Capoten, /// ramipril,- vasotec ARB’s Valstatan--Diovan , Losartan--Cozaar
  • Na and water leave the body and K is retained Watch for hyperkalemia: don’t use if k+ already>5 and they have not started the medicine
  • What is a means of verifying your readings: Compare arms The silent or auscultatory gap underestimated the b/p reading if the systolic pressure Occurs when the sounds disappear between the systolic and diastolic pressures. Patients may have to do daily activities and sleep if we suspect the increased in pressure is related to “white coat” Knowledge: Disease process, history and the implications of these— Interest develops rapport Noncompliant Behaviors Stress Reduction Forms of Relaxation Physical Target Organ Injury Headache Nose Bleeds Dizziness Visual changes Skin: Color and Edema
  • B/P and Weight, Exercise, Diet logs Discharge Instruction: Only a MD should start and stop hypertensive medications! Non food rewards for changing behaviors.
  • Why??? No 10-20 % decrease in B/P during the night or nocturia –White Coat vs Target Organ Injury—HTN in light of no risk factors Purpose of testing?? Obtain base line and evaluate for secondary causes EKG- T waves elevated LVH Chest – Heart Size Dx. Cardiomegaly What value on the u/a should we watch??--SG
  • Hospitalization is necessary for emergency crisis that show evidence of acute organ damage treatment heart, kidney, especially the brain. Pressures in the range of 240/120 need emergency management. ICU monitoring Arterial blood pressure readings Vitals Signs Urinary Output Malignant hypertension related to surgery Post-Operative care givers life threatening. Studies are unclear about the risk and benefits of acutely lowing the b/p during stroke. Lowering the pressure to far or too fast may cause an stroke, MI or visual changes Once crisis is resolved determine cause to match treatment. Long term Meds: Ace and Thiazide reduce stroke reoccurrence.
  • Empathy builds trust and trust is the key motivator for lifestyle changes
  • 2004 First evidence based guidelines published. Women and health professionals are unaware of CVD being the leading cause of female deaths. Only 60% are being treated and 1/3 of them are not controlled < 140/90 Ischemic heart disease and stroke rates are unchanged for women. After the age of 60 women’s systolic pressures are no longer lower than men.
  • Long term exercise may lower blood pressure. Make adjustments for age, height, and sex
  • For the elderly and those less than age 50 diastolic control may be the goal; Diastolic control is a less important risk factor in regards to CVD. So for the elderly lack of systolic control increase CVD risk Initial doses for elderly may be lowered but otherwise general care is unchanged for this population. Be careful with combinations of diuretics, nitrates, and psychotropic drugs
  • Aspirin Therapy
  • Hypertension Final 2

    1. 1. Lilith Hutchinson BSN, RN
    2. 2. <ul><li>Determine factors regulating blood pressure </li></ul><ul><li>Classify the characteristics of hypertension </li></ul><ul><li>Review current national recommendations for treatment of hypertension </li></ul><ul><li>Review classifications of hypertensive medications </li></ul><ul><li>Nursing Care Practices </li></ul><ul><li>Identify treatment of hypertension in specific populations </li></ul>
    3. 3. <ul><li>There are intrinsic, neurological, hormonal, renal mechanisms to control the blood pressure. </li></ul><ul><li>Blood pressure (BP) is the forced exerted by the blood(cardiac output) against the walls of the blood vessel (vascular resistance) </li></ul>
    4. 4. <ul><li>Hypertension (HTN) develops when any one or a combination of the systemic and local peripheral mechanisms are defective. </li></ul><ul><li>The blood flow can’t overcome the opposing forces of resistance to maintain cardiac output and over time the arterial pressure will fall. </li></ul>
    5. 5. <ul><li>Initial therapy is directed by: </li></ul><ul><li>Blood Pressure Readings </li></ul><ul><li>Primary and secondary causes </li></ul><ul><li>The guidelines are based on the mean of two </li></ul><ul><li>or more properly measured </li></ul><ul><li>seated B/P . </li></ul>
    6. 6. <ul><li>Obesity( central) </li></ul><ul><li>Insulin resistance or overproduction is its own hypertensive risk factor </li></ul><ul><li>Dyslipidema is the metabolic dysfunction of the lipids </li></ul><ul><li>Maintaining B/P >130/80 </li></ul>
    7. 7. <ul><li>Intrinsic: tissue perfusion </li></ul><ul><ul><li>Coractation, SNS overacting </li></ul></ul><ul><li>Neurological: vasomotor center </li></ul><ul><ul><li>Brain injuries, tumors </li></ul></ul><ul><li>Hormonal: vasomotor tone and volume </li></ul><ul><ul><li>Aldosteronism </li></ul></ul><ul><li>Renal mechanisms </li></ul><ul><ul><li>Cushing’ Disease, Polycystic Kidneys </li></ul></ul>
    8. 8.
    9. 9. Blood Pressure (B/P) Classification Systolic Diastolic Initial Drug Therapy Normal <120 and< 80 None Pre Hypertension 120-1 39 OR 80-89 Treat indicators Stage 1 Hypertension 140-159 OR 90-99 Treat the pressure Stage 2 Hypertension >160 OR > 100 Diuretic Ace Inhibitor B-Blocker
    10. 10. <ul><ul><li>Enhances Drug Regimens </li></ul></ul><ul><ul><li>Affordable B/P Control~ Underused </li></ul></ul><ul><ul><li>Slow demineralization in Osteoporosis </li></ul></ul><ul><ul><li>Side Effects: , decreased libido, glucose intolerance, potentiates digoxin toxicity </li></ul></ul><ul><ul><li>Contraindications: Gout and Low NA+ </li></ul></ul>
    11. 11. <ul><li>Heart Failure </li></ul><ul><li>Potent with short duration of action </li></ul><ul><ul><li>Side Effects: Ototoxicity, lipid increase, Non-potassium sparing the K+ </li></ul></ul><ul><li>Nursing Implications </li></ul><ul><ul><li>Orthostatic changes </li></ul></ul><ul><ul><li>Electrolyte abnormities </li></ul></ul><ul><ul><li>Medicine Compliance </li></ul></ul>
    12. 12. <ul><li>Stable angina </li></ul><ul><li>Asymptomatic ventricular dysfunction </li></ul><ul><li>Arial tachyarrhythmia/ fibrillation </li></ul><ul><li>Preoperative hypertension: direct arterial vasodilatation </li></ul><ul><li>Contraindications: asthmatic, heart block, restrictive airway disease </li></ul><ul><li>Implications: monitor pulses, Check blood sugars due to its masking effect of hypoglycemia, </li></ul>
    13. 13. <ul><li>Asymptomatic ventricular dysfunction </li></ul><ul><li>Arrhythmias </li></ul><ul><li>Action: Block extracellular calcium in to cells </li></ul><ul><ul><li>Vasodilatation and decreases vascular resistance </li></ul></ul><ul><li>Side effects : reflex tachycardia, hypotension </li></ul><ul><li>Contraindication: 2 nd and 3 rd heart block </li></ul>
    14. 14. <ul><ul><li>Peripheral : Prevent the release of norepinephrine or deplete the stores to cause vasodilatation </li></ul></ul><ul><ul><ul><ul><li>Avoid with elderly and coronary or cerebral compromise </li></ul></ul></ul></ul><ul><ul><li>a Adrenergic Blockers : Block adrenergic receptors causes vasodilatation and orthostatic hypotension </li></ul></ul><ul><ul><li>Central : reduce sympathetic out from CNS to cause vasodilatation </li></ul></ul><ul><ul><ul><li>Clonidine, Methyldopa </li></ul></ul></ul><ul><ul><ul><ul><li>Daytime sedation. Dry mouth, Caution use with Bradycardia with conduction disorders </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sudden withdrawal: Rebound HTN, Tachycardia, HA, tremors and sweating </li></ul></ul></ul></ul>
    15. 15. <ul><li>ACE: ANGIOTENSION-CONVERTING ENZYME </li></ul><ul><li>ARB’S:ANGIOTENSION II RECEPTOR BLOCKERS </li></ul><ul><li>Prevents vasoconstriction </li></ul><ul><li>SE: loss of taste, cough, renal failure </li></ul><ul><li>Meds: (Ramipril, Vasotec) </li></ul><ul><ul><li>Not with CVVH </li></ul></ul><ul><li>Produces vasodilatation </li></ul><ul><ul><li>Na and water retention </li></ul></ul><ul><li>SE: Hyperkalemia, Decrease renal function </li></ul><ul><li>Meds: (Lorstan, Cozaar) </li></ul>Ace and ARB’s Cause fetal morbidity and mortality
    16. 16. <ul><li>Potassium-Sparing Diuretics </li></ul><ul><li>End- Sage Heart Disease </li></ul><ul><li>Combines with Ace inhibitors and BB </li></ul><ul><li>Decreased Renal excretion or filtration </li></ul><ul><ul><ul><li>Inhibit bodies ability to retain NA and excrete K+ </li></ul></ul></ul><ul><li>Hormonal SE: gynecomastia, impotence, decreased libido and menstrual irregularities </li></ul>
    17. 17. <ul><li>The presence of a silent gap should be recorded </li></ul><ul><li>White Coat HTN is the elevation of the B/P without organ injury </li></ul><ul><li>Knowledge: Illness and Management </li></ul><ul><li>Physical Findings </li></ul>
    18. 18. <ul><li>Documentation </li></ul><ul><li>Goal directed </li></ul><ul><li>Follow-up / Reinforcement Mechanisms </li></ul><ul><li>Written: Medications /Reactions </li></ul><ul><li>Support Systems </li></ul><ul><li>Include pharmacists, social services, and dietitians </li></ul><ul><ul><li>Evaluate diuretic uses </li></ul></ul><ul><ul><li>Cost and barriers to access medical care </li></ul></ul><ul><ul><li>Eating to change health </li></ul></ul>
    19. 19. <ul><li>Ambulatory B/P monitoring </li></ul><ul><li>EKG </li></ul><ul><li>Chest </li></ul><ul><li>Labs </li></ul><ul><ul><li>CBC </li></ul></ul><ul><ul><li>BMP </li></ul></ul><ul><ul><li>Creatinine/BUN </li></ul></ul><ul><ul><li>U/A </li></ul></ul><ul><ul><li>Lipids </li></ul></ul>
    20. 20. <ul><li>Malignant hypertension related to noncompliance </li></ul><ul><li>Degree of crisis is related to target organ damage </li></ul><ul><ul><li>Vision Disturbances /level of consciousness (LOC) </li></ul></ul><ul><li>Level 160/100: Manage the rate the B/P is rising </li></ul><ul><li>Clinical : Headache, N/V, Seizures, Changes in LOC </li></ul><ul><li>Meds: IV Nipride (Nitroprusside) protect from light </li></ul><ul><ul><li>Caution direct dilators with left ventricular hypertrophy </li></ul></ul>
    21. 21. <ul><ul><li>Absence of target organ damage </li></ul></ul><ul><ul><li>No IV Medications to control B/P </li></ul></ul><ul><li>Managed outpatient basis </li></ul><ul><ul><li>Rest </li></ul></ul><ul><ul><li>Oral medications </li></ul></ul><ul><ul><li>Next day follow-up </li></ul></ul><ul><ul><li>Education </li></ul></ul>
    22. 22. <ul><ul><li>Support the need to expression of fears and </li></ul></ul><ul><ul><li> any reactions to treatments </li></ul></ul><ul><li>Hispanic and American Indians least controlled population </li></ul><ul><ul><li>Understand cultural differences builds trust </li></ul></ul><ul><li>Dispel cultural misunderstandings </li></ul><ul><ul><li>Lack of symptoms = no disease </li></ul></ul><ul><ul><li>Medications = ill health </li></ul></ul>
    23. 23. <ul><li>Oral contraceptive increases risk of HTN </li></ul><ul><li>Watch for Creatinine levels of >1.3 for women 1.5 men </li></ul><ul><li>Women and lighter weight persons are caution to limit one drink per day </li></ul><ul><li>Pregnant and sexually active girls should not be on ARB’s or ACE inhibitors </li></ul>
    24. 24. <ul><li>The use of anabolic steroids causes fluid retention and increase LDH </li></ul><ul><li>80 % of the children have an identifiable cause </li></ul><ul><ul><li>Kidney disease , coarctation of the aorta </li></ul></ul><ul><li>Repeated B/P measurements at 95 percentile </li></ul><ul><li>Diastolic determined by the fifth Korotkoff sound </li></ul><ul><li>No restriction of physical activities </li></ul><ul><li>Medications instituted when lifestyle changes fail Adjusts doses for child's body makeup </li></ul>
    25. 25. <ul><li>Isolated Systolic Hypertension: Sustain >160/90 </li></ul><ul><li>Difficult to get systolic control </li></ul><ul><ul><li>Loss of tissue elasticity: stiff myocardium </li></ul></ul><ul><ul><li>Decreased physiological response to sodium and water depletion </li></ul></ul><ul><ul><li>Increased of orthostatic hypotension >10mmHg </li></ul></ul><ul><ul><ul><li>Dementia /Cognitive impairments related to HTN </li></ul></ul></ul><ul><ul><li>Decreased renal and liver function affects medication absorption ,metabolism, and, excretion </li></ul></ul>
    26. 26. <ul><li>Degree of Participation </li></ul><ul><ul><li>Dietary </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>B/P levels </li></ul></ul><ul><li>Lipid management ~ Preventive </li></ul><ul><li>Smoking Drinking Cessation Efforts </li></ul><ul><li>Documented Reactions </li></ul>
    27. 27. <ul><li>Chobanian, A., Bakris, G., Black, H., Cushman, W., Green, L., Izzo, J., Jones, D., Materson, B., Oparil, S., Wright, T., Roccella, E., and the National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevent, Detection, Evaluation and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. </li></ul><ul><li>Hall, J., Granger, J., Reckelhoff, J. Sandberg, K. Hypertension and Cardiovascular Disease in Women. down loaded on February 11, 2008 www.ahajournals.org/cgi/reprint/HYPERTENSIONAHA.107.009813v1 </li></ul><ul><li>Lewis, S., Heitkemper, M., and Dirksen, S., </li></ul><ul><li> (6 th ed). (2004). Medical-surgical nursing – Assessment and management of clinical problems. St. Louis: Mosby. </li></ul>