care of adult with altered cardiac function
TRANSCRIPT
Care of Adult With Altered Care of Adult With Altered Cardiac FunctionCardiac Function
Presented by: Jayson T. Valerio RN. MSNPresented by: Jayson T. Valerio RN. MSN Esmeralda Garza RN, MSNEsmeralda Garza RN, MSN
The HeartThe Heart
Concepts of Optimal Cardiac Concepts of Optimal Cardiac FunctionFunction
Assessment of the Cardiovascular Assessment of the Cardiovascular System (CVS)System (CVS)
SubjectiveSubjective Demographic dataDemographic data Personal and Family HistoryPersonal and Family History Diet history Diet history Socioeconomic statusSocioeconomic status Modifiable risk factorsModifiable risk factors Current health problemsCurrent health problems ObjectiveObjective General AppearanceGeneral Appearance Integumentary SystemIntegumentary System Blood PressureBlood Pressure Venous & Arterial PulsationsVenous & Arterial Pulsations PrecordiumPrecordium
How to assess jugular vein How to assess jugular vein pressure?pressure?
External Jugular Vein External Jugular Vein DistentionDistention
QuestionQuestion
The nurse is performing a cardiac The nurse is performing a cardiac assessment, identify where the nurse assessment, identify where the nurse places the stethoscope to best places the stethoscope to best auscultate the point of maximal auscultate the point of maximal impulse..impulse..
Diagnostic AssessmentDiagnostic AssessmentNurses’ responsibilitiesNurses’ responsibilities
-identification of allergies and client safety-identification of allergies and client safety-explanation of procedure including purpose-explanation of procedure including purpose-consent obtained, if needed.-consent obtained, if needed.-administration of pre-procedure medication-administration of pre-procedure medication-administer comfort measures.-administer comfort measures.-explain results after physician has -explain results after physician has
discussed with client.discussed with client.-positioning of patient-keeping NPO-positioning of patient-keeping NPO-ensure test is scheduled-ensure test is scheduled
Diagnostic TestsDiagnostic Tests
Laboratory TestsLaboratory Tests
* Serum markers of * Serum markers of myocardial damage:myocardial damage:- Creatinine kinaseCreatinine kinase- TroponinTroponin- Lactate dehydrogenaseLactate dehydrogenase
* Serum lipids* Serum lipids
** HomocysteineHomocysteine• C-reactive proteinC-reactive protein• BNPBNP
*Blood Coagulation *Blood Coagulation TestsTests- - Prothrombin and Prothrombin and international normalized international normalized ratio (PT and INR)ratio (PT and INR)- Partial Thromboplastin - Partial Thromboplastin Time (PTT)Time (PTT)
*Arterial Blood Gases*Arterial Blood Gases*Serum electrolytes*Serum electrolytes*Complete Blood Count*Complete Blood Count
Critical Thinking ChallengeCritical Thinking ChallengeA middle aged man with multiple cv risk A middle aged man with multiple cv risk factors comes to the ER with c/o dull factors comes to the ER with c/o dull aching feeling in his shoulder and arm. His aching feeling in his shoulder and arm. His admission lab results include creatinine admission lab results include creatinine kinase 190 units/l troponin greater than kinase 190 units/l troponin greater than 2.0ng/ml,, and c reactive protein of 2.0ng/ml,, and c reactive protein of 1.0mg/dl.1.0mg/dl.1. What additional assessment should you 1. What additional assessment should you perform for this client?perform for this client?2. What is the significance of each of this 2. What is the significance of each of this test results.test results.
Diagnostic TestsDiagnostic TestsRadiographic ExamsRadiographic Exams
*Chest X-ray*Chest X-ray
*Cardiac Fluoroscopy*Cardiac Fluoroscopy
*Angiography*Angiography
*Cardiac *Cardiac CatheterizationCatheterization
Critical thinking challengeCritical thinking challengeA nurse is taking a health history for a A nurse is taking a health history for a client about to have a cardiac client about to have a cardiac catheterization. Which of the following catheterization. Which of the following findings must the physician know about findings must the physician know about immediately?immediately?
A. smoking 1 pack of cigarettes per dayA. smoking 1 pack of cigarettes per day
B. digoxin .25mg held todayB. digoxin .25mg held today
C. client ate a liquid breakfastC. client ate a liquid breakfast
D. presence of seafood allergyD. presence of seafood allergy
Critical thinking challengeCritical thinking challengeImmediately following a femoral artery Immediately following a femoral artery approach for cardiac catheterization, it approach for cardiac catheterization, it would be most important to include which would be most important to include which of these measures in the client’s care?of these measures in the client’s care?A. Auscultating lungs and cardiac soundsA. Auscultating lungs and cardiac soundsB. Observing insertion site for infectionB. Observing insertion site for infectionC. Elevating the head of bed to 60-90 C. Elevating the head of bed to 60-90 degrees.degrees.D. Maintaing strict bedrest for 4-6 hour D. Maintaing strict bedrest for 4-6 hour and palpating distal pulses.and palpating distal pulses.
Other Diagnostic TestsOther Diagnostic Tests
*Electrophysiologic Studies*Electrophysiologic Studies
*Exercise Electrocardiography (Stress *Exercise Electrocardiography (Stress test)test)
*Echocardiography*Echocardiography
Other Diagnostic TestsOther Diagnostic Tests
Coronary Artery DiseaseCoronary Artery DiseaseCoronary arteries become narrow or even Coronary arteries become narrow or even blocked secondary to plaque deposits.blocked secondary to plaque deposits.
These are the arteries that deliver oxygen These are the arteries that deliver oxygen enriched blood to the heart muscle enriched blood to the heart muscle (myocardium)(myocardium)
If there is a complete block (occlusion) If there is a complete block (occlusion) then a heart attack (myocardial infarction) then a heart attack (myocardial infarction) occurs. occurs.
How prevalent is Coronary Artery How prevalent is Coronary Artery Disease?Disease?
Most common form of Heart DiseaseMost common form of Heart Disease
Number 1 cause of death in both men and women Number 1 cause of death in both men and women in the United Statesin the United States
CAD caused more than 1 out of every five deaths CAD caused more than 1 out of every five deaths in the US in 2001in the US in 2001
About every 26 seconds an American suffers a About every 26 seconds an American suffers a coronary event and every minute there is a death coronary event and every minute there is a death
Prevalence ….continuationPrevalence ….continuationAbout 340,000 deaths occur within the ER or About 340,000 deaths occur within the ER or before the person reaches the hospital.before the person reaches the hospital.
64% of females and 50% of males who died 64% of females and 50% of males who died suddenly…had NO previous symptoms of disease.suddenly…had NO previous symptoms of disease.
38% of females and 25% of males will die within 38% of females and 25% of males will die within one year after an initial recognized MI. one year after an initial recognized MI.
Hospital Hospital Readmissions Readmissions and Costsand Costs
The estimated cost in 2004 of CVD is $368.4 billion dollars.
In 1999 an avg. of $7,883 per discharge was paid out by Medicare alone ( about $26 billion)
When the client is readmitted it is expensive, very stressful, and significantly diminishes their quality of life
In order to reduce readmission rates, a comprehensive d/c plan must be implemented and must include patient teaching.
They may have had their treatment, but there is still a risk of CAD progression
Lifestyle changes are needed to protect the patient and avoid unnecessary readmissions
The Nurse as The Nurse as Key EducatorKey Educator
Research has shown repeatedly that education contributes to prevention, early detection, and eventual recovery
Patient teaching cornerstone of standards of care
NLN officially established teaching as an independent function for each nurse
Education regarding lifestyle changes are associated with decreased mortality and retardation of atherosclerosis
PathophysiologyPathophysiologyFatty streaks-earliest lesion lipid filled Fatty streaks-earliest lesion lipid filled smooth muscle cells. Yellow tinge smooth muscle cells. Yellow tinge appears.appears.
Raised fibrous plaque resulting from Raised fibrous plaque resulting from smooth muscle cell proliferationsmooth muscle cell proliferation
Complicated lesion-is most dangerous Complicated lesion-is most dangerous plaque consists of core of lipid materials plaque consists of core of lipid materials (mainly cholesterol) with an area of (mainly cholesterol) with an area of dead tissue. dead tissue. Partially or totally Partially or totally occlude an artery.occlude an artery.
Plaque may rupture Plaque may rupture Collateral circulation Collateral circulation
develops.develops.
Risk FactorsRisk Factors Family history of cardiovascular disease
•High levels of LDL (bad) cholesterol and triglycerides •Low levels of HDL (good) cholesterol •Uncontrolled high blood pressure (even in the teenage years) •Smoking •Lack of regular exercise •High-fat diet •Overweight or obesity •Uncontrolled diabetes •Chronic stress or depression • Age->65 Gender –middle aged Caucasian maleRace-CaucasianGenetic inheritance-mechanism of inheritance not fully understood defects in coronary walls predispose to plaque formation.
Benefits of Smoke CessationBenefits of Smoke Cessation
20 minutes20 minutes- after quitting the BP and pulse decrease and - after quitting the BP and pulse decrease and body temp of feet and hands increase.body temp of feet and hands increase.
At 6 hoursAt 6 hours- the Carbon Monoxide and Oxygen levels return - the Carbon Monoxide and Oxygen levels return to normal.to normal.
At 24 hoursAt 24 hours- the chances of heart attack decreases.- the chances of heart attack decreases.
Within 3 monthsWithin 3 months- circulation improves, walking is easier - circulation improves, walking is easier and lung function improves.and lung function improves.
At 1 yearAt 1 year- the ex-smokers risk of CHD is decreased to ½ - the ex-smokers risk of CHD is decreased to ½ that of a smoker.that of a smoker.
By 15 yearsBy 15 years- the risk of CAD is then similar to that of a - the risk of CAD is then similar to that of a person who has never smoked.person who has never smoked.
Clinical ManifestationsClinical ManifestationsSymptoms typically Symptoms typically associated with CAD associated with CAD include include chest painchest pain ( (anginaangina) and ) and shortness of breathshortness of breath, , especially after especially after stressstress or or exerciseexercise. Women . Women with CAD may with CAD may experience breast pain experience breast pain or a feeling of or a feeling of indigestion in the upper indigestion in the upper abdomen. abdomen.
However, about 25 to 30 However, about 25 to 30 percent of patients have percent of patients have no symptoms, despite the no symptoms, despite the presence of CAD. They presence of CAD. They may have may have silentsilent ischemiaischemia, , or be unaware of or be unaware of potentially dangerous potentially dangerous abnormal heart rhythms (abnormal heart rhythms (arrhythmiasarrhythmias). The absence ). The absence of chest pain or other of chest pain or other common symptoms can common symptoms can also set the stage for a also set the stage for a heart attackheart attack that occurs that occurs without warning.without warning.
Stable AnginaStable Angina
Exercise induced.Exercise induced.
Take med and wait Take med and wait 30min to 1 hr 30min to 1 hr before engaging in before engaging in activity.activity.
Unstable AnginaUnstable Angina
Unpredictable, can Unpredictable, can occur at restoccur at rest
ASA, anticoagulants, ASA, anticoagulants, nitrates and beta nitrates and beta blockers first line of blockers first line of treatment.treatment.
If spasm is cause, If spasm is cause, calcium channel calcium channel blockers are ordered.blockers are ordered.
Therapeutic ManagementTherapeutic ManagementAngioplasty
Therapeutic ManagementTherapeutic Management
Antiplatelet aggregationAntiplatelet aggregation
-ASA, -ASA, Persantine(dipyridamole)Persantine(dipyridamole)
Nitrates(vasodilate) first Nitrates(vasodilate) first line therapyline therapy
-nitroglycerin-nitroglycerin
Beta-Adrenergic blocking Beta-Adrenergic blocking agentsagents
-lopressor, inderal -lopressor, inderal (Generics ending in olol)(Generics ending in olol)
Calcium Channel blocking Calcium Channel blocking agentsagents
-nifedipine, Cardizem-nifedipine, Cardizem, , verapamilverapamil
ASA-inhibits platelet ASA-inhibits platelet aggregationaggregation
Nitrates-decrease Nitrates-decrease SVR,venous pooling and SVR,venous pooling and decrease venous return decrease venous return to the heart and dilate to the heart and dilate coronary arteries.coronary arteries.
Beta adrenergic blockers-Beta adrenergic blockers-decrease myocardial decrease myocardial contractility,HR, SVR and contractility,HR, SVR and BP which decrease BP which decrease myocardial O2 demand.myocardial O2 demand.
Calcium channel blockersCalcium channel blockers1. Systemic vasodilation-1. Systemic vasodilation-decrease SVRdecrease SVR2. Decrease myocardial 2. Decrease myocardial contractilitycontractility3. Coronary vasodilation.3. Coronary vasodilation.
InteractionsInteractionsA 50 year old diabetic client is hospitalized A 50 year old diabetic client is hospitalized with a diagnosis of CAD. In monitoring the with a diagnosis of CAD. In monitoring the blood sugar the nurse attains a reading of blood sugar the nurse attains a reading of 30mg per 100cc, yet the client is 30mg per 100cc, yet the client is asymptomatic. Which of the following asymptomatic. Which of the following drugs used to treat the client’s CAD would drugs used to treat the client’s CAD would affect the blood glucose level results?affect the blood glucose level results?1. digoxin1. digoxin2. nadolol2. nadolol3. furosemide3. furosemide4. isosobide4. isosobide
Nursing ManagementNursing ManagementNursing Dxes:Nursing Dxes:
PainPain
AnxietyAnxiety
Decreased CODecreased CO
Activity intoleranceActivity intolerance
Acute Intervention Acute Intervention (ER Setting)(ER Setting)
- Assess pain, ECG, - Assess pain, ECG, Cardiac enzymesCardiac enzymes
TTMMOONNAA
Heart FailureHeart FailureHeart failure (sometimes known as Heart failure (sometimes known as congestive heart failure [CHF]) is a congestive heart failure [CHF]) is a serious condition in which the heart is not serious condition in which the heart is not pumping well enough. In late stages, the pumping well enough. In late stages, the heart is unable to meet the body’s heart is unable to meet the body’s demand for oxygen. Heart failure is so demand for oxygen. Heart failure is so named because the heart is named because the heart is failingfailing to to pump efficiently, which often results in pump efficiently, which often results in congestion in the lungs. As a result, the congestion in the lungs. As a result, the heart tries to work harder, which only heart tries to work harder, which only makes the problem worse. makes the problem worse.
Case StudyCase Study
Bea Singer age 67 awakens with a Bea Singer age 67 awakens with a start from a sound sleep gasping. start from a sound sleep gasping. She sits up, trying to catch her She sits up, trying to catch her breath, and shakes her husband, “Fix breath, and shakes her husband, “Fix my pillows.”. Just as he has every my pillows.”. Just as he has every night he fetches three pillows and night he fetches three pillows and arranges them behind her back to arranges them behind her back to prop her up. This time it does not prop her up. This time it does not help.help.
Epidemiology………….. Epidemiology………….. as of February as of February
20042004
According to current statistics from the American Heart According to current statistics from the American Heart Association, there are about five million heart failure Association, there are about five million heart failure patients in the United States, and 550,000 new cases patients in the United States, and 550,000 new cases
of heart failure diagnosed in the United States of heart failure diagnosed in the United States every year. This includes 10 out every 1,000 people every year. This includes 10 out every 1,000 people
over the age of 65. Of newly diagnosed patients over the age of 65. Of newly diagnosed patients under the age of 65, 80 percent of the men and 70 under the age of 65, 80 percent of the men and 70
percent of the women will die within 8 years. In percent of the women will die within 8 years. In people diagnosed with heart failure, people diagnosed with heart failure,
sudden cardiac deathsudden cardiac death occurs at six to nine times the occurs at six to nine times the rate of the general population.rate of the general population.
Risk FactorsRisk FactorsConditions that could lead to heart failure include the Conditions that could lead to heart failure include the following: following: Coronary artery diseaseCoronary artery disease High High blood pressureblood pressure ( (hypertensionhypertension) ) Heart attackHeart attack DiabetesDiabetes mellitus mellitus CardiomyopathyCardiomyopathy Heart valve diseaseHeart valve disease (e.g., (e.g., valvular stenosisvalvular stenosis or or valvular regurgitationvalvular regurgitation) ) Infection in the heart valves (Infection in the heart valves (valvular endocarditisvalvular endocarditis) or of ) or of the heart muscle (the heart muscle (myocarditismyocarditis) ) Congenital heart diseaseCongenital heart disease (cardiac conditions present since (cardiac conditions present since birth) birth) Severe lung disease (e.g., Severe lung disease (e.g., pulmonary hypertensionpulmonary hypertension) or ) or obstructive obstructive sleep apneasleep apnea Pericardial disease (Pericardial disease (pericarditispericarditis))
Types of Heart FailureTypes of Heart FailureLeft-sided heart failure Left-sided heart failure occurs when the left occurs when the left ventricleventricle cannot cannot adequately pump oxygen-adequately pump oxygen-rich blood from the heart rich blood from the heart to the rest of the body. to the rest of the body. The main symptoms for The main symptoms for this condition include this condition include shortness of breathshortness of breath, , fatigue and coughing, fatigue and coughing, especially at night or especially at night or while lying down. There while lying down. There may also be may also be lunglung congestion (with both congestion (with both blood and fluid). blood and fluid).
Right-sided heart failure (Right-sided heart failure (cor pulmonalecor pulmonale) takes place ) takes place when the right ventricle is not when the right ventricle is not pumping adequately, which pumping adequately, which tends to cause fluid build-up tends to cause fluid build-up in the in the veinsveins and swelling ( and swelling (edemaedema) in the legs and ) in the legs and ankles. Right-sided heart ankles. Right-sided heart failure usually occurs as a failure usually occurs as a direct result of left-sided direct result of left-sided heart failure. It can also be heart failure. It can also be caused by severe lung disease caused by severe lung disease (e.g., (e.g., chronic obstructive pulmonarychronic obstructive pulmonary disease disease, , pulmonary hypertensionpulmonary hypertension) in ) in which the right side of the which the right side of the heart cannot generate enough heart cannot generate enough force to pump blood through a force to pump blood through a diseased pair of lungs.diseased pair of lungs.
Clinical ManifestationsClinical ManifestationsLeft sided failure-Left sided failure-
excessive preload lungsexcessive preload lungsCheyne-stokes respirations, Cheyne-stokes respirations, increases HR, poor oxygen increases HR, poor oxygen exchangeexchangePulmonary edema, S3 & S4Pulmonary edema, S3 & S4Dyspnea,dry hacking cough, Dyspnea,dry hacking cough, nocturianocturiaLow PAO2 , increased PCO2Low PAO2 , increased PCO2Orthopnea, Paroxysmal Orthopnea, Paroxysmal nocturnal dyspneanocturnal dyspneaCrackles , wheezing, frothy Crackles , wheezing, frothy pink-tinged sputumpink-tinged sputumElevated B/PElevated B/PFatigueFatigue
Right-sided failure-excessive Right-sided failure-excessive preload on right side of preload on right side of heartheartRV heavesRV heavesMurmursMurmursPeripheral edemaPeripheral edemaWeight gainWeight gainEdema dependent body partsEdema dependent body partsAscitesAscitesAnasarcaAnasarcaJVDJVDLiver engorgementLiver engorgementRight pleural effusionRight pleural effusionFatigue, nausea, anorexia, Fatigue, nausea, anorexia, bloatingbloating
Left-sided Heart FailureLeft-sided Heart FailureSystolic ventricular dysfunction- Systolic ventricular dysfunction- occurs when the heart muscle is too occurs when the heart muscle is too weak to contract fully. A reduced weak to contract fully. A reduced volume leaves the ventricle.volume leaves the ventricle.Diastolic dysfunction- occurs when Diastolic dysfunction- occurs when the left ventricle has increased the left ventricle has increased diastolic stiffness and can’t diastolic stiffness and can’t adequately fill at normal diastolic adequately fill at normal diastolic pressures.pressures.
Diagnostic TestingDiagnostic Testing
Transthoracic EchocardiogramTransthoracic Echocardiogram
Doppler flow studiesDoppler flow studies
12-lead EKG12-lead EKG
MRIMRI
CXRCXR
Therapeutic ManagementTherapeutic ManagementACUTE WITH PULMONARY EDEMAACUTE WITH PULMONARY EDEMA
High Fowler’s positionHigh Fowler’s position
O2 with mask or nasal cannulaO2 with mask or nasal cannula
Morphine IVMorphine IV
Diuretics IV(Lasix, Bumex)Diuretics IV(Lasix, Bumex)
Nitroglycerin,nitroprussideNitroglycerin,nitroprusside
Dopamine, dobutrexDopamine, dobutrex
V/S q1 hrV/S q1 hr
Daily weightsDaily weights
Endotracheal intubation/mechanical Endotracheal intubation/mechanical ventilationventilation
Therapeutic Management: Therapeutic Management: Chronic CHFChronic CHF
O2 2-6l/minO2 2-6l/minRestRestDigitalis preparationsDigitalis preparationsDiureticsDiureticsVasodilators-Ace inhibitors, Vasodilators-Ace inhibitors, Nitrates,nesiritide(natrecor)Nitrates,nesiritide(natrecor)Inotropic drugs- dopamine, dobutrex, Inotropic drugs- dopamine, dobutrex, inocorinocorDaily weightsDaily weightsSodium restricted dietsSodium restricted dietsIntraaortic balloon pumpIntraaortic balloon pumpVentricular assist deviceVentricular assist deviceCardiac transplantCardiac transplant
•
Nursing ManagementNursing Management
Impaired gas exchange r/t Impaired gas exchange r/t inadequate cardiac pump functioninadequate cardiac pump function
Decreased cardiac output r/t a Decreased cardiac output r/t a reduction in stroke volumereduction in stroke volume
Activity tolerance r/t an imbalance Activity tolerance r/t an imbalance between oxygen demand and supplybetween oxygen demand and supply
Nursing InterventionsNursing Interventions
Health maintenance & PromotionHealth maintenance & Promotion
-prevention of heart failure-prevention of heart failure
-teaching about importance of -teaching about importance of medicationsmedications
-early detection of s/s of failure-early detection of s/s of failure
-importance of diet and exercise-importance of diet and exercise
HypertensionHypertension
High High blood pressureblood pressure (hypertension), is a condition (hypertension), is a condition commonly associated with commonly associated with narrowing of the narrowing of the arteriesarteries. .
EpidemiologyEpidemiology
In 1999 to 2000, an estimated 28.7% In 1999 to 2000, an estimated 28.7% population or more than 58 million population or more than 58 million Americans had hypertension. This Americans had hypertension. This represents an increase of 3.7% since represents an increase of 3.7% since 1988 to 1991. 1988 to 1991.
In 2000, HTN was listed as a primary In 2000, HTN was listed as a primary or contibuting cause of death in or contibuting cause of death in about 251,000 Americans.about 251,000 Americans.
Types of HypertensionTypes of HypertensionPrimary Hypertension Primary Hypertension
(Essential)- etiology is (Essential)- etiology is unknown ,accounts for unknown ,accounts for 95% of all cases95% of all casesContributing factors:Contributing factors:
- increased SNS - increased SNS activityactivity- overproduction of - overproduction of sodium retaining sodium retaining hormones hormones- obesity- obesity- diabetes mellitus- diabetes mellitus- excessive alcohol - excessive alcohol
intake intake
Secondary HypertensionSecondary Hypertensioncauses- renal disease, causes- renal disease, adrenal tumors, adrenal tumors, Cushings syndrome, Cushings syndrome, Coarctation or Coarctation or narrowing of the aorta, narrowing of the aorta, head injury, neurologic head injury, neurologic disorders such as brain disorders such as brain tumors,medications tumors,medications such as sympathetic such as sympathetic stimulants and stimulants and pregnancy induced pregnancy induced hypertension.hypertension.
Blood Pressure Classification Blood Pressure Classification
BP ClassificationBP Classification Systolic BPSystolic BP
(mmHg)(mmHg)Diastolic Diastolic BP(mmHg)BP(mmHg)
NormalNormal <120<120 And <80And <80
PrehypertensionPrehypertension 120 to 139120 to 139 Or 80 to 89Or 80 to 89
Stage 1 HTNStage 1 HTN 140 to 159140 to 159 Or 90 to 99Or 90 to 99
Stage 2 HTNStage 2 HTN > 160> 160 Or > 100Or > 100
Seventh Report of the Joint National Committee on Prevention,Detection, Evaluation and Treatment of High Blood Pressure
Risk FactorsRisk FactorsAge-65 and olderAge-65 and olderSex- men young adulthood and middle ageSex- men young adulthood and middle ageRace - African AmericansRace - African AmericansObesityObesityCigarette SmokingCigarette SmokingExcess Sodium IntakeExcess Sodium IntakeElevated Serum LipidsElevated Serum LipidsSedentary LifestyleSedentary LifestyleDiabetes MellitusDiabetes MellitusSocioeconomic StatusSocioeconomic StatusStressStress
Blood Pressure
Blood Volume Peripheral ResistanceDiameter of Arterioles Cardiac Output
- Fluid loss•Dehydration-Fluid Retention•Aldosterone•ADH
• Sympathetic nervoussystem activity• Renin/Angiotensin II• Increase Blood Viscosity
-Stroke Volume•Preload•Contractility•Afterload-Heart Rate•SNS•Epinephrine
BP
Compensatory action by CVS
Compensatory action by kidneys
Vasodilation Stroke Volume Heart Rate Urine Output
Cardiac output Blood Volume
Blood pressurereturns to normal
Blood Pressure Homeostasis
Gerontology ConsiderationsGerontology ConsiderationsLoss of tissue elasticityLoss of tissue elasticityIncreased collagen content and Increased collagen content and stiffness of myocardiumstiffness of myocardiumIncreased peripheral vascular Increased peripheral vascular resistanceresistanceDecreased renal functionDecreased renal functionDecreased renin response to sodium Decreased renin response to sodium and water depletionand water depletion
Clinical ManifestationsClinical Manifestations
““Silent Killer” –asymptomaticSilent Killer” –asymptomatic
Secondary symptoms-fatigue, Secondary symptoms-fatigue, reduced activity tolerance, dizziness, reduced activity tolerance, dizziness, palpitations, angina, and dyspnea.palpitations, angina, and dyspnea.
Nosebleeds,Headache and Nosebleeds,Headache and dizziness= in hypertension and dizziness= in hypertension and general population.general population.
Nursing ManagementNursing Management
Nursing Diagnosis:Nursing Diagnosis:
a.a. Risk for ineffective therapeutic Risk for ineffective therapeutic management r/t non compliance management r/t non compliance with treatmentwith treatment
b.b. Deficient knowledge r/t information Deficient knowledge r/t information misinterpretationmisinterpretation
Untreated HypertensionUntreated Hypertension
Therapeutic ManagementTherapeutic Management
The ultimate goal of The ultimate goal of antihypertensive therapy is to antihypertensive therapy is to reduce cardiovascular and renal reduce cardiovascular and renal morbidity and mortality.morbidity and mortality.
A.A. Lifestyle modificationsLifestyle modifications- Weight reductionWeight reduction
Lifestyle modifications …..continuationLifestyle modifications …..continuation
Therapeutic ManagementTherapeutic ManagementB. Drug TherapyB. Drug TherapyFacts….Facts….Based on clinical outcomes data, the JNC 7 Based on clinical outcomes data, the JNC 7
recommends thiazide diuretics as initial therapy in recommends thiazide diuretics as initial therapy in most patients with HTN, either alone or combined most patients with HTN, either alone or combined with an ACEI, ARB, BB, CCBwith an ACEI, ARB, BB, CCB
Most people with HTN will require two or more drugs to Most people with HTN will require two or more drugs to meet BP goals with adequate doses of one drug, a meet BP goals with adequate doses of one drug, a second agent from another class should be added.second agent from another class should be added.
When BP is > 20 mmHg above the SBP goal or 10 When BP is > 20 mmHg above the SBP goal or 10 mmHg above the DBP, consideration should be given mmHg above the DBP, consideration should be given to initiating therapy with 2 drugs , one of which to initiating therapy with 2 drugs , one of which usually should be thiazide-type diuretic. usually should be thiazide-type diuretic.
Drug TherapyDrug TherapyCommonly Commonly
prescribed drugsprescribed drugs
A. Diuretics A. Diuretics
B. ACEIsB. ACEIs
C. ARBsC. ARBs
D. BBsD. BBs
E. CCBsE. CCBs
Alternative AgentsAlternative Agents
A.A. Spironolactone Spironolactone (Aldactone)(Aldactone)
B.B. Eplerenone (Inspra) Eplerenone (Inspra) – new agent– new agent
C.C. Doxazosin (Cardura)Doxazosin (Cardura)
D.D. Clonidine (Catapres)Clonidine (Catapres)
E.E. Hydralazine Hydralazine (Apresoline)(Apresoline)
Special PopulationsSpecial PopulationsIn older people, drug therapy is started at In older people, drug therapy is started at lower doses and titrated slowly to avoid lower doses and titrated slowly to avoid orthostatic hypotension.orthostatic hypotension.In African Americans, BP response during In African Americans, BP response during monotherapy is usually better with monotherapy is usually better with diuretics or CCBs than with ACEIs, ARBs, or diuretics or CCBs than with ACEIs, ARBs, or beta-blockers.beta-blockers.In pregnancy, methyldopa (Aldomet) is the In pregnancy, methyldopa (Aldomet) is the drug of choice.drug of choice.ACEIs and ARBs are contraindicated in ACEIs and ARBs are contraindicated in pregnancy. pregnancy.
Critical thinkingCritical thinkingThe nurse is caring for a cardiac The nurse is caring for a cardiac patient who is taking Digoxin, Lasix, patient who is taking Digoxin, Lasix, Colace and Isordil. Which of the Colace and Isordil. Which of the following side effects can be caused following side effects can be caused by a potential drug interaction?by a potential drug interaction?A. HypokalemiaA. HypokalemiaB. ConstipationB. ConstipationC. HeadacheC. HeadacheD. HypotensionD. Hypotension
Critical ThoughtCritical Thought
When administering any drug that When administering any drug that effects cardiac rhythm, which is the effects cardiac rhythm, which is the most important for the nurse to most important for the nurse to assess?assess?
A. EKGA. EKG
B. Pulse rateB. Pulse rate
C. Respiratory rateC. Respiratory rate
D. Blood Pressure.D. Blood Pressure.
Critical ThoughtCritical Thought
When evaluating effectiveness of When evaluating effectiveness of digoxin, which blood test results digoxin, which blood test results indicates a positive outcome?indicates a positive outcome?
A. Potassium 3 mEq/L.A. Potassium 3 mEq/L.
B. Calcium 8.8mEq/l.B. Calcium 8.8mEq/l.
C. Digoxin 0.5-2.0mg/mlC. Digoxin 0.5-2.0mg/ml
D. Digoxin 2.5-3.0mg/ml.D. Digoxin 2.5-3.0mg/ml.
Critical thoughtCritical thoughtA client with diagnosis of MI is receiving A client with diagnosis of MI is receiving nitroglycerine. The client c/o headache. nitroglycerine. The client c/o headache. What would be the most appropriate What would be the most appropriate statement by the nurse?statement by the nurse?A. I will increase the medicationA. I will increase the medicationB. Headache is a common side effect. Take B. Headache is a common side effect. Take a tylenola tylenolC. Your headache is probably due to C. Your headache is probably due to stress.stress.D. I will call your health care provider to D. I will call your health care provider to change your medication.change your medication.
Critical ChallengeCritical Challenge
Which lifestyle changes decrease risk Which lifestyle changes decrease risk status after an MI? Which habits status after an MI? Which habits increase risk?increase risk?
Critical ChallengeCritical Challenge
Compare and contrast the risk Compare and contrast the risk factors of CV disease for a 36 year factors of CV disease for a 36 year old and a 72 year old man.old and a 72 year old man.
Critical challengeCritical challenge
The EKG and blood work for a client The EKG and blood work for a client with chest pain were inconclusive but with chest pain were inconclusive but the physician is concerned about his the physician is concerned about his symptoms. Discuss why there is symptoms. Discuss why there is reason for concern.reason for concern.
Too pooped to pumpToo pooped to pump
Normal ejection fraction isNormal ejection fraction is
A. 40-55 %A. 40-55 %
B. 60-80%B. 60-80%
C. 85-95%C. 85-95%
Too pooped to pumpToo pooped to pump
Which of the following are considered Which of the following are considered the cardinal signs of heart failure?the cardinal signs of heart failure?
A. shortness of breath, hypotension A. shortness of breath, hypotension and edemaand edema
B. anxiety chest pain and diaphoresisB. anxiety chest pain and diaphoresis
C. dyspnea, fatigue and fluid C. dyspnea, fatigue and fluid retentionretention
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Raising the heart rate causes the Raising the heart rate causes the cardiac output tocardiac output to
A. also increaseA. also increase
B. decreaseB. decrease
C. stay the sameC. stay the same
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Which of the following is the most Which of the following is the most commonly used and most useful commonly used and most useful diagnostic test for heart failure?diagnostic test for heart failure?
A. 12 lead ekgA. 12 lead ekg
B. cardiac cathB. cardiac cath
C. transthoracic echocardiogramC. transthoracic echocardiogram
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Which of the following drugs is Which of the following drugs is usually the initial treatment of heart usually the initial treatment of heart failure?failure?
A. digoxinA. digoxin
B. lasixB. lasix
C. lopressorC. lopressor
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Obtaining a baseline weight for a Obtaining a baseline weight for a patient with heart failure is most patient with heart failure is most important forimportant for
A. assess intake and outputA. assess intake and output
B. indicating when the patient needs B. indicating when the patient needs to have afterload increasedto have afterload increased
C. evaluating the effectiveness of C. evaluating the effectiveness of therapies.therapies.
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Administration of nesiritide results inAdministration of nesiritide results in
A. fluid retentionA. fluid retention
B. an increase in preloadB. an increase in preload
C. a decrease in preload.C. a decrease in preload.
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Advise your patient to notify her Advise your patient to notify her primary care provider or cardiologist primary care provider or cardiologist if if
A. awakens at night to urinateA. awakens at night to urinate
B. loses 5 pounds in a weekB. loses 5 pounds in a week
C. gains 2 pounds over night.C. gains 2 pounds over night.