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 BPWhere 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 JointNational 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 ClassificationsSystolic Diastolic

Normal < 120 < 80Pre-HTN 120-139 80-89Stage 1 HTN 140-159 90-99Stage 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 HTNMultifactorial:

• Genetic component: gene mutations• Peripheral resistance change• Cardiac output change• Dysfunction in autonomic nervous system

Renin angiotensin aldosterone mechanism

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

Lifestyle ChangesModification Goal of SBP ReductionWeight reduction 5-20 mm/Hg per 10 kgDASH diet 8-14 mm/HgReduced Na+ 2-8 mm/HgExercise 4-9 mm/HgAlcohol 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

tissuesPatho

• 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:

oMinimize exposure to coldo Stop smokingo Pharmacological interventiono Sympathectomy

Reminders: oV = venous, position higher than heart

“legs” of V are UPoA= arterial, position lower than heart

“legs” of A are DOWN