Fall$2019$)$Spring$2020$

1$

OXYGENATION$NEEDS$

Fall$2019$–$Spring$2020$

1$Fall$2019$)$Spring$2020$

OXYGENATION*NEEDS*

•  Hypertension$•  Coronary$Artery$Disease$•  Myocardial$InfarcFon$

•  Heart$Failure$•  Peripheral$Vascular$Disease$$

• VenFlaFon$$• Perfusion$• Diffusion$$*Describe$each$$$$concept$

*What$nursing$physical$assessments$are$involved?$

2$Fall$2019$)$Spring$2020$

OXYGENATION*NEEDS*–RISK*FACTORS*

•  Major*modifiable*risk*factors:*–  Elevated$serum$lipids$$

–  Hypertension$–  Excess$dietary$sodium$

–  Alcohol$–  Tobacco&use&–  Second-hand&smoke&–  Physical$inacFvity/Sedentary$lifestyle$–  Socioeconomic$status$–  Stress$–  Obesity$

•  ContribuFng*modifiable*risk*factors:*–  Diabetes$mellitus$

–  Metabolic$syndrome$

–  Psychologic$states$–  Homocysteine$level$

–  Substance$abuse$•  CAD,$MI,$CKD,$$

Nonmodifiable*risk*factors:*•  Age$$•  Gender$•  Ethnicity$•  Family$history$

•  GeneFc$predisposiFon$

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3$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

2$

Nursing$Process$1st*Level*Assessment*

2nd*Level*SFmuli*

Nursing*Diagnosis*

Goal/Expected*Outcomes*

Nursing*IntervenFons*

EvaluaFon*

SubjecFve:$$$$$$ObjecFve:$$$$$$$$

Patho$Culture$MedicaFons$Mobility$$Psychosocial$$

Problem$$Statement$r/t$EFology$$$as$manifested$by:$1.$2.$3.$

Goal:$$$$$Expected$$outcomes:$1.$$2.$3.$$*ObjecFve,$specific,$measureable,$with$Fme$frame$for$achievement.$

1.$2.$3.$4.$5.$6.$$*Manipulates$idenFfied$sFmuli$in$the$problem$statement$and$demonstrates$how$will$achieve$idenFfied$$expected$outcome.$$Includes$raFonale$for$each$intervenFon$specific$to$paFent$needs.$

1.$2.$3.$$$*Evaluates$if$met$the$idenFfied$expected$outcomes$and$includes$the$specific,$measurable$behavior$re)assessed.$$If$not$met,$includes$what$will$do$in$order$to$meet$expected$outcome.$

4$Fall$2019$)$Spring$2020$

Nursing$Assessment$

•  A$RN$is$able$to$independently$idenFfy$problems$and$start$intervening$in$order$to$prevent$the$problem$from$ge`ng$worse$

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•  Need$to$know$fundamental$nursing$concepts$–the$foundaFon$for$all$of$nursing$

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5$Fall$2019$)$Spring$2020$

1st$Level$Assessment$

•  Cardiopulmonary$and$vascular$physical$assessment$skills$to$obtain$objecFve$data$

•  Ask$the$relevant(quesFons$in$order$to$obtain$subjecFve$data$

•  Must$hone$in$on$assessment$skills$to$idenFfy$abnormaliFes$

•  Learn$and$know$your$paFent$behaviors,$paderns,$cues$so$will$know$when$a$problem$is$happening$or$going$to$happen$

6$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

3$

OXYGENATION$NEEDS:$DIAGNOSTIC$STUDIES$

•  SERUM$LABS:$Electrolytes$(BMP,$CMP)$includes$$BUN,$creaFnine,$glucose,$CBC,$BNP,$cardiac$biomarkers$(troponin,$CK)MB),$coagulaFon$studies$(PT/INR/PTT),$LFT,$lipid$profile,$CRP,$uric$acid$levels,$ABG$

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•  Urine$analysis,$CreaFnine$clearance$$

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•  Measurement$of$BP$

•  12)lead$ECG$

•  Chest$x)ray$

•  Echocardiogram$

•  Exercise$stress$test$(physical/pharmacologic)$

•  Coronary/Vascular$CT$Angiography$–diagnosFc$and$intervenFonal$

•  Doppler$ultrasound$$

7$Fall$2019$)$Spring$2020$

HYPERTENSION$

8$Fall$2019$)$Spring$2020$

Hypertension$

•  Affects$1$in$3$adults$in$United$States$

•  83%$of$people$>$age$20$with$hypertension$are$aware$they$have$high$BP$–  76%$are$being$treated$–  48%$of$those$aware$do$not$currently$have$their$BP$well$controlled$

•  As$BP$increases,$so$does$the$risk$of$– MI$–  Heart$failure$–  Stroke$–  Renal$disease$$

*Explain$why$&$how$

9$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

4$

While$performing$blood$pressure$screening$at$a$health$fair,$the$nurse$counsels$which$person$as$having$the$greatest$risk$for$developing$hypertension?$a.  A$56)year)old$man$whose$father$died$at$age$62$from$a$

stroke$

b.  A$30)year)old$female$adverFsing$agent$who$is$unmarried$and$lives$alone$

c.  A$68)year)old$man$who$uses$herbal$remedies$to$treat$his$enlarged$prostate$gland$

d.  A$43)year)old$man$who$travels$extensively$with$his$job$and$exercises$only$on$weekends$

Audience*Response*QuesFon*

10$Fall$2019$)$Spring$2020$

CriFcal$Thinking$

•  You$are$the$nurse$on$the$0700)1900$shin.$The$CNA$reports$to$you$at$0730$that$your$paFent$in$room$419$has$a$BP$=$175/65,$HR$56.$The$paFent$is$a$72$year)old$male$admided$for$Pneumonia,$and$has$a$past$medical$history$of$hypertension,$diabetes$mellitus$type$2,$chronic$kidney$disease,$and$hypothyroidism.$$$

•  What$is$your$analysis?$$

•  What$will$you$do$first?$$

•  What$will$you$do$next?$

•  What$are$your$nursing$intervenFons?$

•  What$is$the$expected$outcome?$

$

•  MedicaFons$on$MAR:$•  Amlodipine$10$mg$PO$daily$

•  Aspirin$81$mg$PO$daily$

•  Azithromycin$400$mg$IV$every$12$hours$

•  Carvedilol$25$mg$PO$BID$

•  Colace$100$mg$PO$BID$

•  FamoFdine$20$mg$PO$BID$

•  Hydralazine$25$mg$PO$TID$

•  Lisinopril$20$mg$PO$daily$

•  Prednisone$40$mg$PO$BID$

•  Acetaminophen$650$mg$PO$every$6$hours$prn$Temp$>$101.5$or$pain$1)3/10$

•  Acetaminophen$325$mg$–$hydrocodone$5$mg$PO$every$6$hours$prn$pain$4)7/10$$

•  Hydralazine$20$mg$IV$every$4$hours$prn$SBP$>$170$

•  Morphine$2$mg$IV$every$4$hours$prn$pain$8)10$

•  *Hospital$daily$medicaFon$schedule$is$0900$

•  *The$paFent$has$not$received$any$prn$medicaFons$for$the$last$24$hours.$

11$Fall$2019$)$Spring$2020$

Factors$Influencing$BP$

Blood Pressure =

Cardiac Output ×

Systemic Vascular

Resistance

12$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

5$

Factors$Influencing$BP$

•  SympatheFc$nervous$system$(SNS)$

•  Baroreceptors$

–  SensiFve$to$stretching$–  Send$impulses$to$sympatheFc$

vasomotor$center$

•  Vascular$endothelium$

–  EssenFal$to$regulaFon$of$vasodilaFng$and$vasoconstricFng$substances$$

•  Renal$system$

–  Control$sodium$excreFon$and$ECF$volume$

–  RAAS$system$

–  Prostaglandins$–vasodilaFng$$•  Endocrine$system$

–  Epinephrine$and$norepinephrine$from$adrenal$medulla$

–  Aldosterone$from$adrenal$cortex$

–  ADH$from$posterior$pituitary$

13$Fall$2019$)$Spring$2020$

The$nurse$determines$that$the$paFent$has$stage$2$hypertension$when$the$paFent’s$average$blood$pressure$is$(select(all(that(apply)$a.  150/96$mm$Hg.$b.  155/88$mm$Hg.$c.  172/92$mm$Hg.$d.  160/110$mm$Hg.$e.  182/106$mm$Hg.$$*Must(establish(how(high(is(too(high.(What(is((your(personal(parameter?(For(all(Vital(Signs?*(

Audience*Response*QuesFon*

14$Fall$2019$)$Spring$2020$

EFology$of$Hypertension$

•  Primary$hypertension$$–  Also$called$essenFal$or$idiopathic$hypertension$

–  Elevated$BP$without$an$idenFfied$cause$$

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•  Secondary$hypertension$–  Elevated$BP$with$a$specific$cause$

–  Clinical$findings$relate$to$underlying$cause$$

–  Treatment$aimed$at$removing$or$treaFng$cause$

*What$is$an$example?$

15$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

6$

Pathophysiology$$Primary$Hypertension$

•  Persistently$increased$SVR$•  AbnormaliFes$in$any$mechanisms$involved$in$maintenance$of$normal$BP$

•  Water$and$sodium$retenFon$– The$effect$of$sodium$on$BP$has$a$strong$geneFc$component$

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16$Fall$2019$)$Spring$2020$

Primary$Hypertension$Pathophysiology$

•  Stress$and$increased$SNS$acFvity$– Causes$increased$vasoconstricFon$– ↑$HR$

– ↑$Renin$release$

•  Altered$renin)angiotensin)aldosterone$system$(RAAS)$–  Increased$renin$acFvates$RAAS$– Renin$levels$do$not$decrease$in$response$to$elevated$BP$

17$Fall$2019$)$Spring$2020$

Primary$Hypertension$Pathophysiology$

•  Insulin$resistance$and$hyperinsulinemia$– High$insulin$levels$sFmulate$SNS$acFvity$and$impair$nitric$oxide–mediated$vasodilaFon$

•  Endothelial$dysfuncFon$–  Impaired$response$to$nitric$oxide$vasodilaFon$

– Elevated$endothelin$→$vasoconstricFon$

18$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

7$

Hypertension$Clinical$ManifestaFons$

•  “Silent$killer”$)how$will$you$know?$•  Symptoms$of$severe$hypertension$– FaFgue$– Dizziness$– PalpitaFons$– Angina$– Dyspnea$

19$Fall$2019$)$Spring$2020$

Hypertension*ComplicaFons*

Target$organ$diseases$occur$most$frequently$in$$

•  Heart$

•  Brain$

•  Peripheral$vascular$disease$$

•  Kidney$

•  Eyes$$

20$Fall$2019$)$Spring$2020$

Hypertension$$Interprofessional$Care$

•  Overall$Goals$$– Control$blood$pressure$•  Lifestyle$modificaFons$

•  Drug$thearpy$– Reduce$CVD$risk$factors$and$target$organ$disease$

21$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

8$

Hypertension$Lifestyle$ModificaFons$

•  Weight$reducFon$– Weight$loss$of$22$lb$(10$kg$)$may$decrease$SBP$by$approx.$5$to$20$mm$Hg$

– Calorie$restricFon$and$physical$acFvity$•  DASH$eaFng$plan$– Fruits,$vegetables,$fat)free$or$low)fat$milk,$whole$grains,$fish,$poultry,$beans,$seeds,$and$nuts$

22$Fall$2019$)$Spring$2020$

Hypertension$Lifestyle$ModificaFons$

•  Dietary$sodium$reducFon$– <$2300$mg/day$for$healthy$adults$

– <$1500$mg/day$for$$•  African$Americans$

•  Middle)aged$and$older$$

•  Those$with$hypertension,$diabetes,$or$chronic$kidney$disease$

•  ModeraFon$of$alcohol$intake$

23$Fall$2019$)$Spring$2020$

Hypertension$Lifestyle$ModificaFons$

•  Physical$acFvity$– Moderate)intensity$aerobic$acFvity,$at$least$30$minutes,$most$days$of$the$week$

– Vigorous)intensity$aerobic$acFvity$at$least$20$minutes,$3$days$a$week$

– Muscle)strengthening$acFviFes$at$least$2$Fmes$a$week$

– Flexibility$and$balance$exercises$2$Fmes$a$week$

24$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

9$

Hypertension$Lifestyle$ModificaFons$

•  Avoidance$of$tobacco$products$– NicoFne$causes$vasoconstricFon$and$elevated$BP$– Smoking$cessaFon$reduces$risk$factors$within$1$year$

•  Psychosocial$risk$factors$– Low$socioeconomic$status,$social$isolaFon$and$lack$of$support,$stress,$negaFve$emoFons$

– AcFvate$SNS$and$stress$hormones$

25$Fall$2019$)$Spring$2020$

Drug$Therapy$–Pharmacologic$Mechanism$of$AcFon$

•  Beta)adrenergic$blockers$

•  Calcium)channel$blockers$

•  Angiotensin)converFng$enzymes$inhibitors/receptor$blockers$

•  DiureFcs$

•  Direct$arterial$vasodilators$

26$Fall$2019$)$Spring$2020$

Drug$Therapy$

•  Check$Your$PracFce,$p.$687$•  Can$a$paFent$be$on$more$than$one$medicaFon$for$hypertension?$

•  What$will$you$teach$your$paFent$about$taking$medicaFons$for$hypertension?$

27$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

10$

Resistant$Hypertension$

•  Failure$to$reach$goal$BP$in$paFents$taking$full$doses$of$an$appropriate$3)drug$therapy$regimen$that$includes$a$diureFc.$Reasons$include$–  Improper$BP$measurement$

– Drug)induced$– Associated$condiFons$–  IdenFfiable$causes$of$secondary$hypertension$

28$Fall$2019$)$Spring$2020$

A$paFent’s$BP$has$not$responded$consistently$to$prescribed$drugs$for$hypertension.$The$first$cause$of$this$lack$of$responsiveness$the$nurse$should$explore$is$

a.  progressive$target$organ$damage.$

b.  the$possibility$of$drug$interacFons.$c.  the$paFent$not$adhering$to$therapy.$d.  the$paFent’s$possible$use$of$recreaFonal$

drugs.$$

Audience*Response*QuesFon*

29$Fall$2019$)$Spring$2020$

Hypertension$

•  Reasons$for$poor$adherence$to$treatment$plan$are$complex$–  Inadequate$teaching$–  Low$health$literacy$–  Unpleasant$side$effects$of$drugs$

–  Return$to$normal$BP$while$on$drugs$

–  High$cost$of$drugs$–  Lack$of$insurance$

•  Measures$to$enhance$compliance$

–  Individualize$plan$–  AcFve$paFent$parFcipaFon$

–  Select$affordable$drugs$–  Involve$caregivers$–  CombinaFon$drugs$(ACE$inhibitors)DiureFcs)$

–  PaFent$teaching$

30$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

11$

Hypertension$Nursing$Assessment$

•  SubjecFve$Data$$–  Past$health$history$

•  Hypertension$•  Cardiovascular,$cerebrovascular,$renal,$thyroid$disease$

•  Diabetes$mellitus,$pituitary$disorders,$obesity,$dyslipidemia$

•  Menopause$or$hormone$replacement$$

–  Drugs*(medicaFon*reconciliaFon)*****

$

•  SubjecFve$Data$$–  Family$history$–  Salt$and$fat$intake$– Weight$gain$or$loss$–  Nocturia$–  FaFgue,$dyspnea$on$exerFon,$palpitaFons,$pain$

–  Dizziness,$blurred$vision$–  ErecFle$dysfuncFon$–  Stressful$events$

31$Fall$2019$)$Spring$2020$

Hypertension$Nursing$Assessment$

•  ObjecFve$Data$$– Blood$pressure$readings$

– Heart$sounds$– Pulses$– Edema$– Body$measurements$– Mental$status$changes$$

32$Fall$2019$)$Spring$2020$

Hypertension$Nursing$Planning$

PaFent$will$$– Achieve$and$maintain$goal$BP$

– Follow$the$therapeuFc$plan$•  Including$HCP$appointments$

– Experience$minimal$side$effects$of$therapy$

– Manage$and$cope$with$this$condiFon$

33$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

12$

Hypertension$Nursing$ImplementaFon$

•  Acute$Care$– MAR$meds$

–  PT/OT$–  Dialysis$–  NPO$for$invasive/surgical$$procedures$$

•  Health$PromoFon$&$Ambulatory$Care:$

•  Individualized$Teaching*•  Primary$prevenFon$via$

lifestyle$modificaFon$

•  Evaluate$therapeuFc$effecFveness$

•  Detect$and$report$adverse$effects$

•  Assess$and$enhance$compliance$

34$Fall$2019$)$Spring$2020$

Hypertension$Nursing$Management$

•  Nursing$EvaluaFon$$– PaFent$will:$$•  Achieve$and$maintain$goal$BP$$

–  BP$160/80,$post$medicaFon$BP$130/60?$

•  Understand,$accept,$and$implement$treatment$plan$$

•  Report$minimal$side$effects$of$therapy$$

35$Fall$2019$)$Spring$2020$

A$paFent’s$BP$has$not$responded$consistently$to$prescribed$drugs$for$hypertension.$The$first$cause$of$this$lack$of$responsiveness$the$nurse$should$explore$is$

a.  progressive$target$organ$damage.$

b.  the$possibility$of$drug$interacFons.$c.  the$paFent$not$adhering$to$therapy.$d.  the$paFent’s$possible$use$of$recreaFonal$

drugs.$$

Audience*Response*QuesFon*

36$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

13$

Hypertension$in$Older$Persons$

•  Increased$incidence$with$age$

•  Isolated$systolic$hypertension$(ISH):$Most$common$form$of$hypertension$in$individuals$age$>50$

•  Age)related$physical$changes$contribute$to$hypertension$–decreased$response$in$factors$associated$with$BP$

•  PharmacokineFcs$

•  ↑ Risk&for&orthostaFc$hypotension$

•  Also$postprandial$hypotension$

•  “White$coat”$hypertension$

$

37$Fall$2019$)$Spring$2020$

Hypertensive$Crisis$

–  What$medicaFons$are$needed?$

–  Vasodilators$–  Adrenergic$inhibitors$–  Calcium$channel$blockers$

IV,$PO$

–  Hypertensive$urgency$$•  Develops$over$hours$to$days$

•  May$not$require$hospitalizaFon$

–  Hypertensive$emergency$$

•  Very$severe$problems$can$result$if$prompt$treatment$is$not$obtained$

•  Rate$of$rise$more$important$than$absolute$value$

38$Fall$2019$)$Spring$2020$

Hypertensive$Crisis$Clinical$ManifestaFons$

•  Hypertensive$encephalopathy$– Headache,$nausea/vomiFng,$seizures,$confusion,$coma$

•  Renal$insufficiency$–what$assessments?$

•  Cardiac$decompensaFon$– MI,$HF,$pulmonary$edema$

•  AorFc$dissecFon$

39$Fall$2019$)$Spring$2020$

Fall$2019$)$Spring$2020$

14$

Hypertensive$Crisis$Nursing$and$Interprofessional$Mgmt$•  HospitalizaFon$–  IV$drug$therapy:$Ftrated$to$MAP$

– Monitor$cardiac$and$renal$funcFon$

– Neurologic$checks$– Determine$cause$

– EducaFon$to$avoid$future$crisis$

40$Fall$2019$)$Spring$2020$