HypertensionHypertension

ObjectivesObjectives

Describe the mechanisms of blood Describe the mechanisms of blood pressure elevationpressure elevation

List risk factors for hypertension & CHFList risk factors for hypertension & CHF Describe the clinical manifestations of Describe the clinical manifestations of

hypertension & CHF and their significance hypertension & CHF and their significance for therapeutic management and nursing for therapeutic management and nursing carecare

HypertensionHypertension

A systolic blood pressure greater than A systolic blood pressure greater than 140mm Hg and a diastolic pressure 140mm Hg and a diastolic pressure greater than 90mm Hg over a sustained greater than 90mm Hg over a sustained periodperiod

Heart is working harder putting heart & Heart is working harder putting heart & blood vessels under strainblood vessels under strain

High BP can contribute to myocardial High BP can contribute to myocardial infarction, stroke, renal failure & infarction, stroke, renal failure & atherosclerosisatherosclerosis

Primary (Essential) HypertensionPrimary (Essential) Hypertension

Elevated BP without an identified causeElevated BP without an identified cause Accounts for 90 – 95% of all casesAccounts for 90 – 95% of all cases Exact cause unknownExact cause unknown Contributing factors include increased Contributing factors include increased

SNS activity, overproduction of Na-SNS activity, overproduction of Na-retaining hormones & vasoconstrictors, retaining hormones & vasoconstrictors, ↑ ↑ Na intake, obesity, diabetes mellitus & Na intake, obesity, diabetes mellitus & excessive alcohol intakeexcessive alcohol intake

Pathophysiology of Primary Pathophysiology of Primary HypertensionHypertension

For arterial pressure to rise there must be For arterial pressure to rise there must be an increase in either CO or SVRan increase in either CO or SVR

Hallmark of hypertension is a persistent Hallmark of hypertension is a persistent elevation in systemic vascular resistance elevation in systemic vascular resistance (SVR)(SVR)

Secondary HypertensionSecondary Hypertension

Elevated BP with a specific cause that Elevated BP with a specific cause that often can be identified & correctedoften can be identified & corrected

Causes include narrowing of aorta, renal Causes include narrowing of aorta, renal diseases, endocrine disorders, diseases, endocrine disorders, neurological disorders, medications & neurological disorders, medications & pregnancy-induced hypertensionpregnancy-induced hypertension

Risk FactorsRisk Factors

Increasing ageIncreasing age Excessive alcohol Excessive alcohol

intakeintake SmokingSmoking Diabetes mellitusDiabetes mellitus Elevated serum lipidsElevated serum lipids Excessive dietary Excessive dietary

sodiumsodium

Gender (men & post-Gender (men & post-menopausal womenmenopausal women

Family historyFamily history ObesityObesity Sedentary lifestyleSedentary lifestyle Lower socio-Lower socio-

economic groupseconomic groups StressStress

Clinical ManifestationsClinical Manifestations

““Silent killer” – frequently asymptomatic until Silent killer” – frequently asymptomatic until severe & target organ diseases has occurredsevere & target organ diseases has occurred

Severe hypertension may produce symptoms as Severe hypertension may produce symptoms as result of effects on blood vessels & increased result of effects on blood vessels & increased workload of heartworkload of heart

Can include fatigue, reduced activity tolerance, Can include fatigue, reduced activity tolerance, dizziness, palpitations, angina & dyspnoeadizziness, palpitations, angina & dyspnoea

Headaches, nosebleeds & dizziness usually only Headaches, nosebleeds & dizziness usually only occur with very high or very low BPoccur with very high or very low BP

Risk factors for CV Problems in Risk factors for CV Problems in Hypertensive PtsHypertensive Pts

Major Risk FactorsMajor Risk Factors SmokingSmoking LipidemiaLipidemia Diabetes mellitusDiabetes mellitus Over 60yrsOver 60yrs Gender (men & Gender (men &

postmenopausal postmenopausal women)women)

Family historyFamily history

Complications -Target Complications -Target Organ DamageOrgan Damage

Heart diseasesHeart diseases Stroke or TIAStroke or TIA NephropathyNephropathy Peripheral arterial Peripheral arterial

diseasedisease RetinopathyRetinopathy

Heart FailureHeart Failure

Heart FailureHeart Failure

GlossaryGlossary Cardiac Output Cardiac Output Stroke volume Stroke volume Syndrome Syndrome Hypertrophy Hypertrophy Cardiomyopathy Cardiomyopathy Hepatomegaly Hepatomegaly Splenomegaly Splenomegaly Tachypnoea Tachypnoea Orthopnoea Orthopnoea Rhonchi Rhonchi Crackle Crackle

Heart FailureHeart Failure

Inability of the heart to pump sufficient blood to Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and meet the needs of the tissues for oxygen and nutrientsnutrients

A clinical syndrome characterized by signs and A clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate symptoms of fluid overload or of inadequate tissue perfusiontissue perfusion

Signs & symptoms results when the heart is Signs & symptoms results when the heart is unable to generate a CO sufficient to meet the unable to generate a CO sufficient to meet the body’s demandsbody’s demands

Heart FailureHeart Failure

Most often this is a lif-long diagnosis that Most often this is a lif-long diagnosis that is managed with lifestyle changes and is managed with lifestyle changes and medications to prevent acute congestive medications to prevent acute congestive episodesepisodes

Congestive heart failure (CHF) is usually Congestive heart failure (CHF) is usually an acute presentation of heart failure (HF)an acute presentation of heart failure (HF)

HFHF

Incidence increases with ageIncidence increases with age Incidence similar in men & womenIncidence similar in men & women The most common reason for The most common reason for

hospitalization in adults over 65 yrshospitalization in adults over 65 yrs Medical management is based on the Medical management is based on the

type, severity and cause of HFtype, severity and cause of HF

Types of HFTypes of HF

Two types identified by assessment of left Two types identified by assessment of left ventricular functioningventricular functioning

1.1. Diastolic heart failure – alteration in Diastolic heart failure – alteration in ventricular fillingventricular filling

2.2. Systolic heart failure – alteration in Systolic heart failure – alteration in ventricular contractionventricular contraction

Pathophysiology of HFPathophysiology of HF

Results from a variety of CV diseases but Results from a variety of CV diseases but leads to some common abnormalities that leads to some common abnormalities that result in decreased contraction (systole), result in decreased contraction (systole), decreased filling (diastole) or bothdecreased filling (diastole) or both

Significant myocardial dysfunction usually Significant myocardial dysfunction usually present before patient experiences signs & present before patient experiences signs & symptoms of HFsymptoms of HF

Systolic FailureSystolic Failure

Most common cause of HFMost common cause of HF Left ventricle loses ability to generate Left ventricle loses ability to generate

enough pressure to eject blood forward enough pressure to eject blood forward through the high pressure aortathrough the high pressure aorta

Caused by impaired contractile function Caused by impaired contractile function e.g.. MI, hypertension, cardiomyopathy & e.g.. MI, hypertension, cardiomyopathy & cardiac valvular diseasecardiac valvular disease

Diastolic HFDiastolic HF

Impaired ability of ventricles to fill during diastole Impaired ability of ventricles to fill during diastole resulting in decreased stroke volumeresulting in decreased stroke volume

Characterised by high filling pressures & Characterised by high filling pressures & resultant venous engorgement in both resultant venous engorgement in both pulmonary and systemic vascular systemspulmonary and systemic vascular systems

Usually the result of LV hypertrophy from Usually the result of LV hypertrophy from hypertensionhypertension

Diastolic & Systolic Heart FailureDiastolic & Systolic Heart Failure

Mixed Systolic and Diastolic FailureMixed Systolic and Diastolic Failure

Seen in dilated cardiomyopathySeen in dilated cardiomyopathy Biventricular failureBiventricular failure

Left-sided FailureLeft-sided Failure

Most common formMost common form Blood backs up through the left atrium into Blood backs up through the left atrium into

pulmonary veinspulmonary veins ↑ ↑ pulmonary pressure causes fluid to pulmonary pressure causes fluid to

escape from the pulmonary capillary bed escape from the pulmonary capillary bed into the alveoliinto the alveoli

Pulmonary congestion and oedema resultPulmonary congestion and oedema result

Right-sided FailureRight-sided Failure

Primary cause is L) sided failurePrimary cause is L) sided failure Causes backward flow to the right atrium Causes backward flow to the right atrium

and venous circulationand venous circulation Venous congestion in the systemic Venous congestion in the systemic

circulation results in peripheral oedema, circulation results in peripheral oedema, hepatomegaly, splenomegaly, vascular hepatomegaly, splenomegaly, vascular congestion of GI tract & jugular vein congestion of GI tract & jugular vein distensiondistension

Risk FactorsRisk Factors

CADCAD ↑ ↑ ageage HypertensionHypertension ObesityObesity Cigarette smokingCigarette smoking Diabetes mellitusDiabetes mellitus High cholesterolHigh cholesterol Maori descentMaori descent

AcuteAcute Congestive Heart Failure Congestive Heart FailureClinical ManifestationsClinical Manifestations

Typically presents as Typically presents as pulmonary oedemapulmonary oedema Most common cause is LVF secondary to CADMost common cause is LVF secondary to CAD AgitationAgitation Pale or cyanotic, cold, clammy skinPale or cyanotic, cold, clammy skin Severe dyspnoea, tachypnoea, orthopnoeaSevere dyspnoea, tachypnoea, orthopnoea Wheezing, coughing, production of frothy, blood-Wheezing, coughing, production of frothy, blood-

tinged sputumtinged sputum Crackles, wheezes & rhonchi throughout lungsCrackles, wheezes & rhonchi throughout lungs

Heart FailureHeart Failure

ChronicChronic Congestive Heart Failure Congestive Heart FailureClinical ManifestationsClinical Manifestations

Depend on pt’s age, type & extent of heart disease & which Depend on pt’s age, type & extent of heart disease & which ventricle is failing to pump effectivelyventricle is failing to pump effectively

FatigueFatigue Dyspnoea – Paroxysmal nocturnal dyspnoeaDyspnoea – Paroxysmal nocturnal dyspnoea TachycardiaTachycardia OedemaOedema NocturiaNocturia Skin changesSkin changes Chest painChest pain Weight changesWeight changes Behavioural changes – restlessness, confusion, Behavioural changes – restlessness, confusion, ↓ attention span↓ attention span

Pitting OedemaPitting Oedema

Heart FailureHeart Failure

Signs & SymptomsSigns & Symptoms

GlossaryGlossary Cardiac Ouput = heart rate X stroke volumeCardiac Ouput = heart rate X stroke volume Stroke volume = amount of blood pumped by ventricle with each Stroke volume = amount of blood pumped by ventricle with each

contractioncontraction Syndrome = collection of signs and symptomsSyndrome = collection of signs and symptoms Hypertrophy = increase in the size of an organHypertrophy = increase in the size of an organ Cardiomyopathy = any disease that affects the structure and Cardiomyopathy = any disease that affects the structure and

function of the heartfunction of the heart Hepatomegaly = abnormal enlargement of the liverHepatomegaly = abnormal enlargement of the liver Splenomegaly = abnormal enlargement of the spleenSplenomegaly = abnormal enlargement of the spleen Tachypnoea = abnormal rapid rate of breathingTachypnoea = abnormal rapid rate of breathing Orthopnoea = abnormal condition when a person must sit or stand Orthopnoea = abnormal condition when a person must sit or stand

to breathe deeply or comfortablyto breathe deeply or comfortably Rhonchi = abnormal sounds heard on auscultation of an obstructed Rhonchi = abnormal sounds heard on auscultation of an obstructed

airwayairway Crackle = abnormal respiratory sound heard on auscultation of the Crackle = abnormal respiratory sound heard on auscultation of the

chest, characterized by discontinuous bubbling noiseschest, characterized by discontinuous bubbling noises