nurs 2204 hypertension & peripheral vascular disease connie barbour, rn, msn

NURS 2204 HYPERTENSION & PERIPHERAL VASCULAR DISEASE Connie Barbour, RN, MSN

Introducing Mr. Kelly Mr. Kelly is a 51 year old unmarried, caucasian male with a teenage son. He has a current girlfriend. He works in a small engine repair shop. He is 6 feet tall and weighs 245 pounds with an abnormal distribution of this weight around his abdomen. He does not regularly exercise, and eats fast food at least twice a week. He does not prepare many of his own meals. He drinks a few beers after work each night and denies any problem with ETOH. He smokes 1 ppd since the age of 20. His father had HTN and died of an MI at the age of 60. He has no current diagnosed medical problems. He decided to have a physical when he recently became more easily fatigued, dizzy and weak with mild activity. He currently has no health insurance.

Lab Results from Physical Chemistry: BUN: 29 Creatinine 1.48 Sodium: 134 Potassium: 4.0 Glucose: 166 Lipid Profile: Total cholesterol 245 LDL: 188 HDL: 29 Triglycerides: 344 UA: Color: yellow Clarity: clear Sp. Gravity: 1.015 pH: 5.5 urobilinogen: normal protein-moderate glucose-moderate ketone-neg blood-neg nitrite-neg leukocyte esterase-neg RBC-20 WBC-none Bacteria-occasional Epithelial-few

Antihypertensive Drugs Diuretics Adrenergic agents Alpha Beta ACE inhibitors Angiotensin receptor blockers (ARBs) Calcium channel blockers

5 Diuretics Loop Bumetanide (Bumex) Furosemide (Lasix) Thiazide-Type Chlorothiazide Hydrochlorothiazide (HCTZ) Potassium-Sparing Spironolactone (aldactone)

6 Pharmacologic: Diuretics Mechanism of Action: Thiazides, Loop, Potassium Sparing S/E: fluid and electrolyte imbalances K+, Mg++ CNS effects GI effects Nursing Considerations: Monitor for orthostatic hypotension dehydration Hypokalemia

Beta- Blockers/olols Blocks beta ( ) adrenergic receptors specific to the heart Results in decreasing cardiac output by decreasing heart rate and contractility Most common side effect Bradycardia and brady arrhythmias Masks hypoglycemia symptoms Nursing implications Hold if HR less than 60 Teach not to stop abruptly (tapered over 2 wks) May cause increased fatigue Use with caution for patients with heart failure

Core Measure for MI Beta Blockers are consider a Core Measure for treatment after myocardial infarction Long-term use of beta-blockers for patients who have suffered an acute myocardial infarction (AMI) can reduce mortality and morbidity. Studies have demonstrated that the use of beta- blockers is associated with about a 20% reduction in this risk (Yusuf, 1988), and there is evidence of effectiveness in broad populations of patients with AMI (Krumholz, 1998). National guidelines strongly recommend long-term beta-blocker therapy for the secondary prevention of subsequent cardiovascular events in patients discharged after AMI (Antman, 2004; Antman, 2008; Anderson, 2007; and Smith 2006). http://www.qualitymeasures.ahrq.gov/content.aspx?id=355 15 http://www.qualitymeasures.ahrq.gov/content.aspx?id=355 15

ACE Inhibitors/prils Angiotensin Converting Enzyme Prevents conversion of angiotension I to angiotension II This prevents vasoconstriction of arteries Most common side effect = cough Is considered renal protective so good drug of choice for DM First drug of choice for a client with Diabetes Heart Failure History of Myocardial Infarction

ARBs/sartans Angiotensin II receptor blockers More specific to the R-A-A system ACE and ARBS very dangerous with preganancy Can cause 1 st does hypotension Can cause hyperkalemia Hypotension Dizziness Cough usually not as common as ACE Heart failure Angioedema

Ca+ Channel Blockers/pines Blocks the flow of calcium ions across the cell membrane resulting in relaxed vascular and heart tissue, lowers peripheral resistance through vasodilation Used to treat angina Increases oxygen to heart by dilating coronary arteries Used to treat arrhythmias (can decrease HR) Decreases excitability of cardiac muscle

Ca+ Channel Blockers/pines Side Effects flushing, constipation (most common) Hypotension Bradycardia AV block Nausea H/A Peripheral edema (most significant) Monitor I&O closely Nursing Considerations: Always obtain BP-HR before giving use with caution in patients with heart failure Orthostatic BP = Change position slowly contraindicated in patients with 2 nd or 3 rd degree heart block Concurrent use w/b- blockers increases risk of CHF

Figure 323 Sites of antihypertensive drug action, pg 1027, Medical-Surgical 5 th ed., LeMone & Burke

Nursing Diagnoses Ineffective health maintenance Imbalanced nutrition: more than body requires Impaired cardiac output Fluid volume excess

Hypertensive Crises Sudden, rapid, significant elevation of blood pressure SBP greater than 180 DBP greater than 120 Symptoms Blurred vision, swelling of optic nerve (papilledema) Headache Confusion, restlessness Numbness and tingling in extremities Medical emergency Can lead to stroke, MI, and/or acute renal failure

Treatment Immediate hospitalization Vasodilators = usually given IV Nipride (sodium nitroprussdie) Nitroglycerin Apresoline (hydralazine) Need to avoid rapid decrease in BP No more than 25% within first hour Goal to get 160/100 within 2 to 6 hours Rapid decrease can cause renal, cerebral, or cardiac ischemia Therefore = Checking vital signs every 15 minutes

Aneurysms Abdominal aortic aneurysm = AAA Associated with HTN and arteriosclerosis Abnormal Dilation of Aorta & other aterial vessels True Fusiform Circumferential False Pseudo or saccular Berry Dissecting

The AAA.. Beware of the pulsating mass!!!

Post-op Care of Aneurysm Repair New or expanding ecchymosis Peripheral circulation, pulses Abdominal girth (AAA) Pain (new onset or worsening) Decreased urinary output (sign of decreased perfusion to kidneys) Decreased cardiac output (vital sign changes) Prevent straining with bowel movement Maintain calm environment to reduce stress (want to keep BP low normal decreased pressure on graft sight)

Peripheral Vascular Disease PVD form of atherosclerosis (hardening of the arteries) Impaired blood flow through arteries and veins, especially in the lower extremities Can cause partial or total occlusion

PVD/PAD (Peripheral Arterial Disease) Chronic, slow, progressive narrowing disease Lower extremity disease most common Femoral-popliteal seen often Develops earlier in diabetes and HTN Below the knee most common in diabetes causing amputation Risk factors Smoking Hypertension Hyperlipidemia Same process that happens in the brain, happens in the coronary arteries, is happen in the peripheral arteries Ischemia leads to tissue death, gangrene, and amputation in extremeties

Symptoms of PVD/PAD Intermittent claudication Pain at rest is a worsening sypmtom Paresthesia (decreased sensation) Pallor with elevation & redness with dependent position Absent/diminished pulses Skin changes pale, shiny, taut, hair loss

Nursing Assessment for Vascular Problems Blood pressure Pulses Temperature differences Skin changes Capillary refill Check for bruits Evaluate labs cholesterol, lipids, triglycerides diagnostic tests such as ultrasound studies and Doppler studies

Five Ps of Acute Arterial Occlusion PAIN PALLOR PULSELESSNESS PARESTHESIA PARALYSIS

Diagnostics of PVD Ankle brachial index (ABI) Use of blood pressure cuff and Doppler Single most important diagnostic test Ultrasound LEAFS = Lower Extremity Arterial Flow Study Angiography

Treatment of PVD Medical management = address each risk factor that lead to the development of PVD Diabetes, HTN, Hyperlipidemia, smoking, etc Exercise shown to improve circulation Promote vasodilation Medications Anti-platalet aggregation Antihyperlipedemics antihypertensives

Invasive Treatments Angioplasty percutaneous laser assisted Arterial bypass (revascularization)

Revascularization Inflow Aorto-iliac Aorto-femoral Axillo-femoral Outflow femoro-popliteal femoro-tibial Bypass Grafts

Post-op Care Assess for: Graft patency extremity hourly color pulses pain Vital signs Mobility of extremity Edema Drainage Infection

Drug Therapy Anti-platelet drugs aspirin Plavix Trental Increases flexibility of RBCs Used more for the pain of intermittent claudication Pletal Has vasodilation properties as well as anticoagulation properties Also for intermittent claudication Dont use with CHF

Nursing Diagnosis Ineffective Tissue Perfusion Need to state what type when using this NANDA Cerebral, cardiopulmonary, peripheral arterial, peripheral venous, etc. With PVD the R/T is interruption of blood flow Expected outcome = demonstrate adequate tissue perfusion by have warm skin, palpable pulses, no edema, no pain, etc

Nursing Interventions Peripheral pulse assessment Skin assessment Vital signs Wound/Ulceration care Risk factor modification Protective interventions

Client Teaching for PVD Disease process Optimize circulation Elevate when at rest Walking can help Good foot/skin care Protect extremities Well- fitting shoes See podiatrist regularly

Raynauds Phenomenon Spasm of smaller arteries Affects fingers & toes 3 color changes White, blue, red Symptoms of cold, numbness, tingling Protect from cold!

Thrombophlebitis Clot formation with inflammation of vein DVT - deep vein thrombosis SVT superficial vein thrombosis Virchows triad: Venous stasis Endothelial damage Hypercoagulability

Symptoms of Thrombosis Varies as to size of thrombus & area affected May have no symptoms Superficial Firm, palpable vein area Tender to touch, red, warm, mild temperature elevation Caused by IV therapy, varicose veins Deep Vein Thrombosis Pain, very warm, red, swollen/edema Positive Homans sign

Complication of DVT Pulmonary embolus Life threatening complication Embolus travels from lower extremity venous system into pulmonary system (covered in lower respiratory lecture)

Diagnostics for DVT Lower Extremity Doppler study to assess adequacy of blood flow and look for clot CT scan of lungs if having respiratory symptoms Coagulation studies - monitors anticoagulant therapy PTT PT/INR

Treatment of DVT Prevention is #1 treatment Early ambulation after surgery Compression hose Hydration Avoid prolonged standing or sitting Avoid crossing legs Teach ankle flexion and extension exercises (calf pumps) Even when bed bound

Treatment of DVT Hospitalization is required Bedrest with very limited ambulation privileges Usually for 3-6 days Dont want the thrombus to dislodge and travel Compression hose with elevation of extremity Pain medication if needed Anticoagulation therapy Possible thrombectomy Possible placement of vena cava filter Green filter is a type (see figure 32-11, page 1054)

Figure 3211 Venal caval filters. A, Greenfield filter. B, Nitinol filter.

Anti-Coagulant Medications Parenteral is short-term use Continuous heparin gtt for DVT or PE Heparin, Lovenox, Fragmin, Arixtra SQ for prophylaxis Monitor PTT Oral is for long-term use Coumadin (warfarin) Monitor PT/INR Antidotes Heparin = protamine sulfate Coumadin = vitamin K

Nursing Implications for Anticoagulation Therapy Monitor for any signs of bleeding = bruising, tarry stools, hematuria, coffee-ground emesis, vaginal bleeding, etc Monitor c/o flank/abdominal pain (abdominal bleed) Monitor for mental status changes (cerebral bleed) Apply pressure to all sticks for 5+ minutes Administer SQ injection in abdomen only, do not aspirate or massage

Client Teaching with Anticoagulation therapy Prevent injury, wear medic alert bracelet Use soft toothbrush, observe gums for bleeding Use electric razor Avoid aspirin products and use NSAIDS sparingly unless okay with physician Report unusual bleeding or bruising With Coumadin avoid foods high in vitamin K (yellow and dark green vegetables) With Coumadin try to take at the same time everyday

Chronic Venous Insufficiency Caused by recurrent thrombophlebtitis Valve destruction Retrograde blood flow Complications Venous stasis dermatitis Venous stasis ulceration

Venous Stasis Dermatitis

Venous Stasis Ulcers

Arterial vs. Venous Leg Ulcers ARTERIAL Toes and feet, shin Ulcer deep, pale Skin is shiny, hairless, pallor on elevation, cool temperature Mild or absent edema Intermittent, severe, resting pain Decreased or absent pulses VENOUS Usual around ankle Ulcer superficial, pink, beefy red, irregular edges Skin leathery, brown, purple discoloration, stasis dermatitis present Significant edema Aching, mild pain Pulses usually normal

Nursing Care for Chronic Venous Insufficiency Care is very similar to that mentioned earlier for arterial disease Teach patient/family Protect extremities Good skin and foot care (well fitting shoes, see podiatrist) Inspect skin on a regular basis Promote circulation with elevation whenever possible

Treatment Meticulous skin care to prevent infection Good fitting shoes Prevent dry skin by using lotions/creams Promote lymph flow with exercise and elevating limb, compression stockings Treat infections early (cellulitis) and may take prophylactic antibiotics Diuretics used more with primary lymphedema Surgical intervention if experiencing recurrent infections/cellulitis = redirects lymph flow

Case Study - PAD Initial ED Presentation: Mr. Pederson is a 62 year old man who has a non-healing wound on the 4th digit on his right foot. This wound has been present for the last 2 months. Yellow drainage present the last 2 weeks. He presents to the ED today due to increasing foot pain and red streaks that developed over the last 2 days in the lower right leg. Rates the pain 6/10 as a dull ache and is persistent whether he is at rest or ambulates. Day of Surgery PACU report: Successful right fem/pop bypass. 3 liters LR given. Both feet warm with cap refill

Case Study - PAD Your Initial VS: T: 100.4 (o) P: 88 reg R: 20 BP: 132/86 O2 sats: 92% 2l per n/c WILDA Pain Scale (5th VS) Words: Dull ache Intensity: 5/10 Location: Right foot and lower leg Duration: started 10 minutes ago Aggravate: Nothing Alleviate: Nothing Your Initial Nursing Assessment: RESP: breath sounds diminished bilat with scattered light exp. wheezing. No c/o SOB CARDIAC: pink, warm & dry, S1S2, no edema, pulses 2+ in upper extremities. Left foot able to palpate faint pulse, but unable to palpate pulses in right foot. Right foot is pale and cool to touch with cap refill of 3-4 seconds. Left foot is pink, warm to touch with brisk cap refill NEURO: alert & oriented x4 GI/GU: active BS in all quads, abd. soft/non-tender, voiding without difficulty SKIN: erythema of foot to midcalf. Stage III ulcer 4th digit rt. foot 2x3 cm. Rt. Groin & thigh incisions D/I

Case Study - PAD BMP Current Recent High/Low/WNL? Sodium 142 140 WNL Chloride 105 102 WNL Potassium 3.8 3.9 WNL Glucose 185 125 High Creatinine 1.1 1.0 WNL CBC Current Recent High/Low/WNL? WBC 14.8 10.5 High Neut. % 92 78 High Hgb. 11.2 13.3 Low Platelets 168 175 WNL

Case Study - PAD Physician Orders (routine post-op): Assess circulation in lower extremities every 15 x4, then every 30 x2 and then hourly x4 Restart Heparin IV gtt at 900 units/hour Ceftriaxone (Ancef) 1 g. IVPB bid Hydromorphone (Dilaudid) PCA 0.2 mg bolus/0.2 mg continuous Glucometers qid ac with Humalog slid VS/assessment:ing scale

nurs 2204 hypertension & peripheral vascular disease connie barbour, rn, msn

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