HTN, COPD, CHF, PVD - OoCities - Geocities Archive ... · Web viewIneffective Airway Clearance r/t excessive mucous Ineffective Breathing Pattern r/t SOB, mucous Self-Care Deficit

Chronic Midterm 18 Questions Page 1 of 169-9 Notes – Chronic HTN, COPD, CHF, PVD T. Lyons & L. Jones

I. Hypertension: The Silent KillerA. Can hide for years

B. Quietly ravaging vital body organs

C. Assaults fragile tissues in eyes, brain, kidneys, and heart

D. Hardens arteries and arterioles

E. Enlarges and weakens the heart

F. Leads to CHF, PVD (peripheral vascular disease)

G. Primary cause of MIs and CVAs

H. Readily treatable once detected

I. Screening= important to test everyone for high blood pressure regardless of

symptoms!!!

II. What Causes Heart Disease?

A. Heart disease leading cause of death in US

B. 3 Major Contributors to Heart Disease:

1. hypertension (HTN)

2. hyperlipidemia

3. smoking

III.Definition

A. Amount of force of blood against the walls of the arteries as it is pumped through

them-very important to be comfortable with this definition for teaching patient

purposes.

B. Systolic=force of heart’s contraction as it pumps blood out of L ventricle.

1. HTN is persistent elevation of systolic pressure > 140 mmHg.

2. Among older adults, systolic bp readings are a better predictor of possible

future events.

C. Diastolic=resting tone of the arteries.

1. HTN is persistent elevation of diastolic pressure > 90 mmHg.

2. Increased diastolic = overworking of the heart.

3. Worry about increased diastolic pressure b/c the heart should be resting!D. Normal= less than 140/90


IV. Incidence of Hypertension (which is polygenic and multifactorial)

A. 50 million Americans age 6 and over r/t obesity and lack of exercise.

B. 1/3 of the people with HTN do not know they have the disease

C. Of those people that are aware they have HTN, 70-75% not controlled with very

high bp.

D. Primary/essential HTN= there is no single cause (95%); multitude of causes.

Idiopathic-lifestyle, genetics, etc.

E. Secondary HTN: physical cause that can be treated or cured, adrenal gland

tumors, kidney disorders, drugs (5%). Tumors can cause high bp, but once they

are removed, that should cure the high bp. Meds such as birth control pills,

alcohol, coaine can also cause high bp.

F. White coat HTN: elevated only at doctor’s office.

G. Malignant = diastolic >110, very serious, medical emergency-can lead to stroke

or death.

V. Major Risk Factors

A. Non-Modifiable

1. Family history

2. Age-older = increased incidence

3. Gender-Initially, M>W, then after menopause, W=M

4. Ethnicity – African American Women die the most from HTN.

B. Modifiable

1. Stress – emotional or physical

2. Obesity – upper body obesity/apple shaped is greater threat.

3. Nutrients – increased sodium and fat.

4. Substance abuse – alcohol intake, amphetamines, illicit drug use, and

caffeine.

VI. Symptoms – important to take thorough history: E.g. stress, family history, diet,

exercise, habits, height, weight, proportions, blood pressure, etc. To take bp, patient

should ideally wait 30 minutes before checking bp in Dr.’s office. Use correct cuff

size and take b.p. on a bare arm. If elevated or abnormal, take it on both arms.

Check pedal pulses, breath sounds, eyes with fundiscope for microhemorrhages, neck


for bruits and distended veins. Check lab values on CBC, BUN, Creat, electrolytes,

HDL, cholesterol and a 12 lead EKG!

A. Headache, sometimes with N&V

B. Drowsiness, confusion, fatigue

C. Blurred vision-target organs=

brain, eyes, kidneys b/c of very

tiny blood vessels & increased

pressure can cause

microvasculature problems.

D. Nocturia-due to kidney changes

E. Dependent edema-e.g. PVD in

lower legs and dependent edema

F. Epistaxis-nose bleeds

G. ***Mainly, no symptoms!

VII. Assessment: Ideally bp should be taken 30 minutes after sitting with the right cuff

on a bare arm. If elevated, take on both arms. Check for bruits in neck. Look at

back of eye for micro-hemorrhages.

VIII. Blood Pressure Stage: either systolic or diastolic elevations will bring

diagnosis.

A. High-norma l: 130-139/85-89

B. Stage 1 : 140-159/90-99

C. Stages 2 and 3 : >160/>100

IX. Lifestyle Modification – can teach at anytime. Teach this if patient is at risk, or at

high normal. These are the 1st recommendations!

A. Stop smoking

B. Reduce stress

C. Reduce alcohol intake: normal for men – two servings, women – one serving. Red

wine dilates vessels and small anticoagulant.

D. Weight reduction-w/in BMI

E. Exercise – 3-4 times/wk for 30-45 mins.

F. Sodium restriction – American normal (5-15 g); should be 2-4 g.

G. Dietary fat modification – 20-30% or 25-35% of total Kcal.

H. Caffeine restriction

I. Potassium supplementation - diet change with reduced sodium and increased K,

Mg, and Ca.

X. DASH Food Plan (p. 1388): Dietary Approaches to Stop Hypertension


A. low fat, high in fruits and vegetables

B. lowfat or nonfat dairy products-e.g yogurt

C. rich in magnesium (potatoes), potassium (cantaloupe), calcium (dark green leafy),

protein, and fiber

D. low in sodium

E. 2000 calories/day

XI. Drug Therapy – all do something a little different

A. Diuretics: may decrease electrolytes and increase glucose levels.; decrease blood

volume, thereby decrease blood pressure. Fluid/urine output increases, so take in

a.m., so they can reduce the risk of nocturia.

1. Thiazide:

2. Loop: Monitor K levels with Potassium depleting diuretics.

3. Potassium-sparing

B. Selective Beta Blocker-dilate blood vessels and decrease heart rate. Improve

contractility. Before giving, check apical pulse. Do not give if hr is <50bpm,

b/c beta blockers reduce heart rate. Side effects: Can induce bronchospasms—

careful with asthmatics. Cause impotence in men—risk for noncompliance.

C. Nonselective Beta Blocker

D. Peripheral-acting adrenergic antagonist

E. Central-acting alpha agonists

F. Ca Channel blockers: decrease heart rate, increase contractility, dilates coronary

arteries.

G. ACE inhibitors-dilates blood vessels and decreases peripheral vascular

resistance. Can increase K+ levels. Side Effects: dry cough, mouth swelling.

May need to switch meds with cough.

H. Alpha-receptor blockers

I. Alpha-Beta blocker

J. Vasodilator


K. Notes about Beta Blockers: Decrease heart rate, dilates blood vessels, and

improves contractility. Take apical pulse before administering. Possible side

effects include bronchospasm, CHF, impotence, increased triglycerides and

cholesterol. African American people do not respond as well. Try diuretics and

Ca channel blockers instead.

XII. Stepped-Care Therapy

A. Step 1: DASH diet and wt redux. Implement lifestyle modifications. If BP

uncontrolled, move to Step 2.

B. Step 2: Initial drug therapy + lifestyle modification.If BP uncontrolled, move to

Step 3. Start low and go slow.

C. Step 3:Increase med dose or change med or add med. If uncontrolled, move to

Step 4. Reducing drugs should be considered after 1 yr of effective control.

D. Step 4: Add 2nd or 3rd med, refer to specialist.

XIII. Nursing Actions

A. Prevention and Education of Public-biggest

B. Screening-go out and do it

C. Cultural sensitivity-ethnicity, lifestyles, nutrition, etc.

D. Family and friends’ lifestyle

E. Medication: Dosage, side effects, interaction with other meds, alcohol-teach about

meds.

Managing the Client with Chronic Airway Problems: COPDI. Chronic Obstructive Pulmonary Disease (obstructive bronchitis, emphysema,

asthma)

A. broad classification of disorders

B. irreversible condition-cannot cure

C. dyspnea on exertion-biggest symptoms of COPD—find out hoow m8uch exertion

brings on the client’s dyspnea.

D. reduced airflow in or out of lungs

E. over 25% of adult population affected

F. 4th most common cause of death in U.S.; by 2020, maybe 3rd.

G. 14 million Americans


II. Etiology

A. Interaction between genetics and the environment

B. cigarette smoking, air pollution, occupational exposures, chronic lung infections,

allergies, aging process-(e.g. occ. Exposures such as oil painter with paint fumes)

C. may develop over 20-30 years

III. Pathophysiology – COPD includes any or a combination of the following three:

Chronic Bronchitis, Emphysema, or Asthma.

A. Chronic Bronchitis – hypoxemia and hypercapnia

1. Inflammation of the bronchi; first only the larger and then moves down.

2. Increased mucous production; mucus-secreting glands are hypertrophied.

3. Chronic cough (3 months/year for 2 consecutive years to diagnose)

4. Impaired ciliary function-cant clear mucus

5. Bronchioles become narrow and clogged, especially during expiration.

6. Alveoli damaged and fibrosed

7. Decreased O2 + increased CO2 in blood= do NOT GIVE O2 b/c it can

impair body’s need/desire to breathe. These patients have hypoxic drive

whereby the low O2 level in the blood actually stimulates their breathing. If

you give 100% O2, patient may lose their drive to breathe!!!

8. Mucous secreting glands are hypertrophied and increase production creates a

barrier to breathing.

9. Can’t get air in and out = hypoxemia (low O2 in the blood)

10. May retain CO2 = hypercapnia (Increased CO2 in blood)

B. Pulmonary Emphysema

1. Hyperinflation of alveoli

2. Alveolar walls destroyed

3. Destruction of alveolar capillary walls causes decreased oxygen perfusion.

4. Loss of lung elasticity with permanent over distension of air and spaces

(alveoli)

5. Patients take in air, but b/c of decreased elasticity, cannot expel it. Barrel

chested and pressure on diaphragm. “pink puffer”—air in, but not out.


IV. Physical Assessment

Chronic Bronchitis: (40-50 yrs) Emphysema (50-75 yrs)

cough minimal cough

SOB, DOE SOB, DOE

h/o cigarette smoking increased anteroposterior chest (barrel chest)

hypoxemia, hypercapnia hypoxemia

cyanotic tachypnea

RBCs polycythemia thin, underweight

normal weight, robust Hyperresonance upon percussion

“Blue Bloater” “Pink Puffer”

V. Assessment:

A. Speech pattern

B. Distended neck veins

C. Clubbing of digits-esp with

chronic hypoxemia

D. Nicotine stains

E. Peripheral edema-check

peripheral pulses and peripheral

edema

F. Fatigue, weakness-due to lack of

O2 or retention of CO2

G. Sleep patterns-e.g. orthopnea—

sleep sitting up in a chair

H. Poor exercise tolerance

I. Posture and positioning—

commonly seen sitting and

leaning forward in “3 point

position”

J. ADLs

K. Anxiety

L. Depression

M. Isolation

I. Nursing Diagnoses

A. Impaired Gas Exchange r/t alveolar destruction

B. Ineffective Airway Clearance r/t excessive mucous

C. Ineffective Breathing Pattern r/t SOB, mucous

D. Self-Care Deficit r/t fatigue, SOB

E. Activity Intolerance r/t fatigue, weakness

F. Ineffective Individual Coping (Family Coping)

G. Knowledge Deficit


H. Anxiety

I. HR for Infection

J. Altered Nutrition r/t dyspnea, fatigue, anorexia, N&V

K. Body Image Disturbance

L. Altered Role Performance

M. Altered Sexuality Patterns r/t SOB, DOE

N. Impaired Social Interaction

O. Sleep Pattern Disturbance

II. Planning

A. Keep airways open, patent-#1 for all three causes

1. Stop smoking, passive smoke-e.g. especially important if pt. lives with a

smoker

2. Avoid irritants-pollution, chemicals, ozone alerts, extreme cold

3. Liquefy secretion, humidity : do not want secretions to get clogged up-if they

dry up, they clog. Keep the secretions liquefied by drinking lots of luid.

4. Postural drainage, coughing-find out where the secretions are---then loosen

them for removal by adjusting pt’s positions and chest PT. Use gravity to

move secretions to trachea where they might be coughed up or suctioned.

5. Aerosol therapy, bronchodilators; medications to break up secretions.

E.g. bronchodilators: pill forms or inhalers reduce bronchospasm and

relaxes bronchial muscle; anticholinergics also inhibit bronchospasm.

6. Oxygen therapy

7. Controlled breathing, suctioning-2 kinds to teach on pts who are short of

breath:

Pursed lip – prolonging expiration. Flicker candle flame, not blow out.

a. Inhale through nose; slowly exhale through pursed lips. Exhale

should be 2X as long as inhale. Candle: Light it==inhale through

nose and exhale over flame without blowing it out.

Abdominal or diaphragmatic-esp. to cough up secretions. Cough with

diaphragm.

8. Increase Fluid Intake


B. Prevent infection.

1. Influenza, pneumococcal vaccines

2. Recognize signs/symptoms; Start antibiotics with change in sputum color.

3. Keep resp. devices clean- e.g. nebulizers

4. Avoid public exposure

5. Antibiotics

6. Steroids cause moon face—given sometimes for acute exacerbations or even

long-term to tx. COPD.

7. Teach about sputum color change—possible infection and necessitates

antibiotics.

C. Balance rest and activity.

1. Recognize demands for oxygen

2. Oxygen therapy

3. Breathing techniques-e.g. pursed lip and abdominal breathing

4. Modify home environment-e.g. up and down stairs to go to bedroom= may

need to sleep downstairs; possible bedside commode

5. Assistive devices—walker, wheelchairs

6. Periods of rest

7. Assistance at home-may benefit from meals on wheels, housekeeping, etc.

D. Adequate nutrition. They exert a lot of energy breathing.

1. Easy to prepare foods

2. Easy to eat foods

3. High-protein, high-calorie

Small meals-6 small meals a day is a plus!

5. Avoid gas-producing foods-to keep down pressure on diaphragm

6. Meal assistance

7. Drink fluids between meals (3-4 L if no CHF).

E. Inter and intra-personal needs met.

1. Recognize COPD can cause irritability, anxiety, depression

2. Educate family, friends—include them in the planning

3. Sexual dysfunction common


4. Socialization and recreation

5. Occupational role

6. Financial issues – very expensive.

III.Interventions

I.

A. Breathing Retraining

B. Bronchial Hygiene

C. Oxygen therapy

D. Medications

E. Acute episodes

F. Self-monitoring

G. Exercise

H. Nutrition

I. Sleep

J. Sexuality

K. Spiritual needs

L. Financial assistance

M. Relaxation

N. Family and friends

II.

I. Chronic Congestive Heart FailureA. Inability of the heart to pump oxygenated blood necessary for effective venous

return and to meet metabolic demands

B. circulatory congestion due to decreased myocardial contraction

C. CO inadequate to maintain blood flow to organs and tissues

D. Acute CHF is curable. Chronic CHF is IRREVERSIBLE.

II. Causes of Chronic CHF

A. Coronary heart disease: MI, hypertension, congenital heart disease,

cardiomyopathies, arrhythmias

B. COPD

C. Heart Failure caused by:

1. Abnormal loading conditions

2. Abnormal muscle function

3. Conditions or diseases that limit ventricular filling.

III.Physical Assessment

A. Right-Sided (backward): inability to eject completely.

1. systemic congestion

2. peripheral edema

3. weight gain w/ fluid

4. liver, spleen congestion-b/c

fluid is backing up into them

5. jugular vein distention

6. fluid in body cavities

7. anorexia, nausea

8. nocturia—b/c of affected

kidneys

9. weakness, fatigue

10. orthopnea

B. Left-Sided (forward): inadequate perfusion

1. pulmonary congestion

2. SOB, dyspnea

3. orthopnea, insomnia

4. pulmonary edema

5. cough-blood tinged sputum

6. S3 heart sounds

7. tachycardia

8. restlessness

9. weakness, fatigue

IV. Nursing Diagnoses

A. Decreased cardiac output r/t heart failure

II.

B. Fluid volume excess r/t Na+/H2O retention

C. Impaired gas exchange r/t fluid in alveoli

D. Impaired skin integrity

E. Altered nutrition

F. Sleep pattern disturbance

G. Anxiety r/t SOB

V. Planning for CHF

A. Improve cardiac output--# 1 goal

1. Digitalis preparation, toxicity

Digoxin/digitalis: Still the #1 drug to improve cardiac function. It

improves pumping action, slows heart rate—causes heart to pump more

effectively.

Side Effects: Toxicity: can build up in the blood and become toxic.

Teaching is very important as Dig can slow the hr too much.

Must take apical pulse/h.r. for 60 full seconds before administration!!

(b/c ppl can have irregular heartrates, and a 15 second count might not

get an accurate measure of pt’s heartrate.)

Hold dose if HR<60 bpm

S&S of Dig toxicity: Nausea and Vomiting; GI problems usually

present before the heart rate goes down.

Therapeutic range for dig: 1.0-2.0 ng/ml K<3 mEq/L

2. Antihypertensives

3. Antiarrhythmics

4. Diuretics

5. Vasodilators

B. Adequate nutrition.

1. Sodium restrictions (2 gm/day)—helps restrict fluid buildup

2. Fluid restrictions; daily wts to monitor fluid retention, q day, same time.

3. Easy to prepare, easy to eat

4. Weight reduction, daily weights

II.

5. High potassium to prevent dig toxicity—especially important with digoxin and

lasix combination.

C. Balance rest and activity.

1. Elevate HOB

2. Elevate lower extremities, edema (Do not elevate in an acute CHF situation)

3. Fall precautions

4. Oxygen

D. Self-care and health maintenance.

1. Meticulous skin care

2. Frequent urination

3. Manage anxiety, stress

VI. Interventions

A. Medication regimen: meds can be very complicated—need to do a lot of teaching

B. Promote tissue perfusion, oxygenation

C. Promote rest

D. Positioning

E. Relieve anxiety

F. Avoid stress

G. Dietary guidelines

H. Daily weight

I. LE circumference: measure for edema—teach pts to measure to check for

swelling/fluid retention

J. Signs and symptoms toxicity, K+ depletion, infection, CHF worsening

I. Chronic Peripheral Vascular Disease/Arterial OcclusionA. Peripheral occlusion disorders involving narrowing of venous and arterial lumen

or damage to the endothelial lining

B. Usually caused by atherosclerosis, embolism, thrombosis, trauma, diabetes, etc.

C. Obesity is major risk factor.

II. Clinical Manifestations

II.

A. Intermittent claudication: severe pain in calf muscles occurring during walking

but subsides with rest. Reproducible when muscle is forced to contract without

adequate blood supply.

B. Rest pain:as above but at rest, esp. at night

C. Weak or absent pedal pulses

D. Color and temperature changes of LE:

1. Dependent rubor with arterial occlusion; white pallor when leg is elevated.

E. Hypertrophied toenails

F. Ulceration and gangrene-b/c of poor circulation leading to skin breakdown—

leading to loss/ulcerations

III.Nursing Diagnoses

A. Alt. Peripheral Tissue Perfusion

B. HR Impaired Skin Integrity

C. HR Activity Intolerance

IV. Medical Interventions

A. 1st Intervention Prevent!!!

1. Ted hose

2. Do not cut own toenails—see podiatrist

3. Adequate/meticulous skin care!

B. Angioplasty-dilate vessels with a catheter

C. Atherectomy-remove plaque from arteries with a catheter procedure

D. Stents-scaffold placed to hold open artery

E. Thrombolytic therapy-to keep clots from forming (meds)

F. Arterial bypass-used grafted artery to bypass failed artery

G. Amputation-if attempts to improve circulation fail—last resort

V. Quality of Life

A. Illness phenomenon

1. How does the person respond to their chronic condition?

2. How does the condition affect them physically and mentally?

Dyspnea, fatigue, pain, discomfort

Anorexia, N&V, body changes

II.

Low energy, depressed, anxious

B. Perceptions

1. How does a person view and interpret their health status? Functioning? Well-

being? Life quality?

2. Do they have a sense of mastery with their chronic condition?

controlled breathing techniques

understanding medical regimen

C. Functional Capacity

1. Can the person perform activities of daily life: physical, emotional, spiritual,

social?

2. Altered role functioning impacts person and family and friends: occupational,

recreational, sexual

D. Personal Resources

1. What assets does the person have available to them: physical, cognitive,

emotional, social, economic, spiritual?

2. Nutrition, sleep and rest, support persons, values, belief system, motivation,

knowledge

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HTN, COPD, CHF, PVD - OoCities - Geocities Archive ... · Web viewIneffective Airway Clearance r/t excessive mucous Ineffective Breathing Pattern r/t SOB, mucous Self-Care Deficit