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OXYGENATION NEEDS
Fall 2019 – Spring 2020 Fall 2019 -‐ Spring 2020 1
OXYGENATION NEEDS
• Hypertension • Coronary Artery Disease • Myocardial InfarcFon • Heart Failure • Peripheral Vascular Disease
• VenFlaFon • Perfusion • Diffusion *Describe each concept *What nursing physical assessments are involved?
Fall 2019 -‐ Spring 2020 2
OXYGENATION NEEDS –RISK FACTORS
• Major modifiable risk factors: – Elevated serum lipids – Hypertension – Excess dietary sodium – Alcohol – Tobacco use – Second-‐hand smoke – Physical inacFvity/Sedentary lifestyle – Socioeconomic status – Stress – Obesity
• ContribuFng modifiable risk factors: – Diabetes mellitus – Metabolic syndrome – Psychologic states – Homocysteine level – Substance abuse
• CAD, MI, CKD,
Nonmodifiable risk factors: • Age • Gender • Ethnicity • Family history • GeneFc
predisposiFon
Fall 2019 -‐ Spring 2020 3
Nursing Process 1st Level Assessment
2nd Level SFmuli
Nursing Diagnosis
Goal/Expected Outcomes
Nursing IntervenFons
EvaluaFon
SubjecFve: ObjecFve:
Patho Culture MedicaFons Mobility Psychosocial
Problem Statement r/t EFology as manifested by: 1. 2. 3.
Goal: Expected outcomes: 1. 2. 3. *ObjecFve, specific, measureable, with Fme frame for achievement.
1. 2. 3. 4. 5. 6. *Manipulates idenFfied sFmuli in the problem statement and demonstrates how will achieve idenFfied expected outcome. Includes raFonale for each intervenFon specific to paFent needs.
1. 2. 3. *Evaluates if met the idenFfied expected outcomes and includes the specific, measurable behavior re-‐assessed. If not met, includes what will do in order to meet expected outcome.
Fall 2019 -‐ Spring 2020 4
Nursing Assessment
• A RN is able to independently idenFfy problems and start intervening in order to prevent the problem from ge`ng worse
• Need to know fundamental nursing concepts –the foundaFon for all of nursing
Fall 2019 -‐ Spring 2020 5
1st Level Assessment
• Cardiopulmonary and vascular physical assessment skills to obtain objecFve data
• Ask the relevant quesFons in order to obtain subjecFve data
• Must hone in on assessment skills to idenFfy abnormaliFes
• Learn and know your paFent behaviors, paderns, cues so will know when a problem is happening or going to happen
Fall 2019 -‐ Spring 2020 6
OXYGENATION NEEDS: DIAGNOSTIC STUDIES
• SERUM LABS: Electrolytes (BMP, CMP) includes BUN, creaFnine, glucose, CBC, BNP, cardiac biomarkers (troponin, CK-‐MB), coagulaFon studies (PT/INR/PTT), LFT, lipid profile, CRP, uric acid levels, ABG
• Urine analysis, CreaFnine clearance
• Measurement of BP • 12-‐lead ECG • Chest x-‐ray • Echocardiogram • Exercise stress test (physical/
pharmacologic) • Coronary/Vascular CT
Angiography –diagnosFc and intervenFonal
• Doppler ultrasound
Fall 2019 -‐ Spring 2020 7
HYPERTENSION
Fall 2019 -‐ Spring 2020 8
Hypertension
• Affects 1 in 3 adults in United States
• 83% of people > age 20 with hypertension are aware they have high BP – 76% are being treated – 48% of those aware do not currently have their BP well controlled
• As BP increases, so does the risk of – MI – Heart failure – Stroke – Renal disease
*Explain why & how
Fall 2019 -‐ Spring 2020 9
While performing blood pressure screening at a health fair, the nurse counsels which person as having the greatest risk for developing hypertension? a. A 56-‐year-‐old man whose father died at age 62 from a
stroke b. A 30-‐year-‐old female adverFsing agent who is
unmarried and lives alone c. A 68-‐year-‐old man who uses herbal remedies to treat
his enlarged prostate gland d. A 43-‐year-‐old man who travels extensively with his
job and exercises only on weekends
Audience Response QuesFon
Fall 2019 -‐ Spring 2020 10
CriFcal Thinking • You are the nurse on the 0700-‐1900
shin. The CNA reports to you at 0730 that your paFent in room 419 has a BP = 175/65, HR 56. The paFent is a 72 year-‐old male admided for Pneumonia, and has a past medical history of hypertension, diabetes mellitus type 2, chronic kidney disease, and hypothyroidism.
• What is your analysis? • What will you do first? • What will you do next? • What are your nursing intervenFons? • What is the expected outcome?
• MedicaFons on MAR: • Amlodipine 10 mg PO daily • Aspirin 81 mg PO daily • Azithromycin 400 mg IV every 12 hours • Carvedilol 25 mg PO BID • Colace 100 mg PO BID • FamoFdine 20 mg PO BID • Hydralazine 25 mg PO TID • Lisinopril 20 mg PO daily • Prednisone 40 mg PO BID • Acetaminophen 650 mg PO every 6 hours prn
Temp > 101.5 or pain 1-‐3/10 • Acetaminophen 325 mg – hydrocodone 5 mg PO
every 6 hours prn pain 4-‐7/10 • Hydralazine 20 mg IV every 4 hours prn SBP >
170 • Morphine 2 mg IV every 4 hours prn pain 8-‐10 • *Hospital daily medicaFon schedule is 0900 • *The paFent has not received any prn
medicaFons for the last 24 hours. Fall 2019 -‐ Spring 2020 11
Factors Influencing BP
Blood Pressure =
Cardiac Output ×
Systemic Vascular
Resistance
Fall 2019 -‐ Spring 2020 12
Factors Influencing BP • SympatheFc nervous system
(SNS) • Baroreceptors
– SensiFve to stretching – Send impulses to sympatheFc
vasomotor center • Vascular endothelium
– EssenFal to regulaFon of vasodilaFng and vasoconstricFng substances
• Renal system – Control sodium excreFon and
ECF volume – RAAS system – Prostaglandins –vasodilaFng
• Endocrine system – Epinephrine and
norepinephrine from adrenal medulla
– Aldosterone from adrenal cortex
– ADH from posterior pituitary
Fall 2019 -‐ Spring 2020 13
The nurse determines that the paFent has stage 2 hypertension when the paFent’s average blood pressure is (select all that apply) a. 150/96 mm Hg. b. 155/88 mm Hg. c. 172/92 mm Hg. d. 160/110 mm Hg. e. 182/106 mm Hg. *Must establish how high is too high. What is your personal parameter? For all Vital Signs?*
Audience Response QuesFon
Fall 2019 -‐ Spring 2020 14
EFology of Hypertension
• Primary hypertension – Also called essenFal or idiopathic hypertension
– Elevated BP without an idenFfied cause
• Secondary hypertension – Elevated BP with a specific cause
– Clinical findings relate to underlying cause
– Treatment aimed at removing or treaFng cause
*What is an example?
Fall 2019 -‐ Spring 2020 15
Pathophysiology Primary Hypertension
• Persistently increased SVR • AbnormaliFes in any mechanisms involved in maintenance of normal BP
• Water and sodium retenFon – The effect of sodium on BP has a strong geneFc component
Fall 2019 -‐ Spring 2020 16
Primary Hypertension Pathophysiology
• Stress and increased SNS acFvity – Causes increased vasoconstricFon – ↑ HR – ↑ Renin release
• Altered renin-‐angiotensin-‐aldosterone system (RAAS) – Increased renin acFvates RAAS – Renin levels do not decrease in response to elevated BP
Fall 2019 -‐ Spring 2020 17
Primary Hypertension Pathophysiology
• Insulin resistance and hyperinsulinemia – High insulin levels sFmulate SNS acFvity and impair nitric oxide–mediated vasodilaFon
• Endothelial dysfuncFon – Impaired response to nitric oxide vasodilaFon – Elevated endothelin → vasoconstricFon
Fall 2019 -‐ Spring 2020 18
Hypertension Clinical ManifestaFons
• “Silent killer” -‐how will you know? • Symptoms of severe hypertension – FaFgue – Dizziness – PalpitaFons – Angina – Dyspnea
Fall 2019 -‐ Spring 2020 19
Hypertension ComplicaFons
Target organ diseases occur most frequently in • Heart • Brain • Peripheral
vascular disease • Kidney • Eyes
Fall 2019 -‐ Spring 2020 20
Hypertension Interprofessional Care
• Overall Goals – Control blood pressure
• Lifestyle modificaFons • Drug thearpy
– Reduce CVD risk factors and target organ disease
Fall 2019 -‐ Spring 2020 21
Hypertension Lifestyle ModificaFons
• Weight reducFon – Weight loss of 22 lb (10 kg ) may decrease SBP by approx. 5 to 20 mm Hg
– Calorie restricFon and physical acFvity • DASH eaFng plan – Fruits, vegetables, fat-‐free or low-‐fat milk, whole grains, fish, poultry, beans, seeds, and nuts
Fall 2019 -‐ Spring 2020 22
Hypertension Lifestyle ModificaFons
• Dietary sodium reducFon – < 2300 mg/day for healthy adults – < 1500 mg/day for
• African Americans • Middle-‐aged and older • Those with hypertension, diabetes, or chronic kidney disease
• ModeraFon of alcohol intake
Fall 2019 -‐ Spring 2020 23
Hypertension Lifestyle ModificaFons
• Physical acFvity – Moderate-‐intensity aerobic acFvity, at least 30 minutes, most days of the week
– Vigorous-‐intensity aerobic acFvity at least 20 minutes, 3 days a week
– Muscle-‐strengthening acFviFes at least 2 Fmes a week
– Flexibility and balance exercises 2 Fmes a week
Fall 2019 -‐ Spring 2020 24
Hypertension Lifestyle ModificaFons
• Avoidance of tobacco products – NicoFne causes vasoconstricFon and elevated BP – Smoking cessaFon reduces risk factors within 1 year
• Psychosocial risk factors – Low socioeconomic status, social isolaFon and lack of support, stress, negaFve emoFons
– AcFvate SNS and stress hormones
Fall 2019 -‐ Spring 2020 25
Fall 2019 -‐ Spring 2020
Drug Therapy –Pharmacologic Mechanism of AcFon • Beta-‐adrenergic
blockers • Calcium-‐channel
blockers • Angiotensin-‐
converFng enzymes inhibitors/receptor blockers
• DiureFcs • Direct arterial
vasodilators
26
Drug Therapy
• Check Your PracFce, p. 687 • Can a paFent be on more than one medicaFon for hypertension?
• What will you teach your paFent about taking medicaFons for hypertension?
Fall 2019 -‐ Spring 2020 27
Resistant Hypertension
• Failure to reach goal BP in paFents taking full doses of an appropriate 3-‐drug therapy regimen that includes a diureFc. Reasons include – Improper BP measurement – Drug-‐induced – Associated condiFons – IdenFfiable causes of secondary hypertension
Fall 2019 -‐ Spring 2020 28
A paFent’s BP has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is a. progressive target organ damage. b. the possibility of drug interacFons. c. the paFent not adhering to therapy. d. the paFent’s possible use of recreaFonal
drugs.
Audience Response QuesFon
Fall 2019 -‐ Spring 2020 29
Hypertension
• Reasons for poor adherence to treatment plan are complex – Inadequate teaching – Low health literacy – Unpleasant side effects of drugs
– Return to normal BP while on drugs
– High cost of drugs – Lack of insurance
• Measures to enhance compliance – Individualize plan – AcFve paFent parFcipaFon
– Select affordable drugs – Involve caregivers – CombinaFon drugs (ACE inhibitors-‐DiureFcs)
– PaFent teaching
Fall 2019 -‐ Spring 2020 30
Hypertension Nursing Assessment
Fall 2019 -‐ Spring 2020
• SubjecFve Data – Past health history
• Hypertension • Cardiovascular, cerebrovascular, renal, thyroid disease
• Diabetes mellitus, pituitary disorders, obesity, dyslipidemia
• Menopause or hormone replacement
– Drugs (medicaFon reconciliaFon) ***
• SubjecFve Data – Family history – Salt and fat intake – Weight gain or loss – Nocturia – FaFgue, dyspnea on exerFon, palpitaFons, pain
– Dizziness, blurred vision – ErecFle dysfuncFon – Stressful events
31
Hypertension Nursing Assessment
• ObjecFve Data – Blood pressure readings
– Heart sounds – Pulses – Edema – Body measurements – Mental status changes
Fall 2019 -‐ Spring 2020 32
Hypertension Nursing Planning
PaFent will – Achieve and maintain goal BP – Follow the therapeuFc plan
• Including HCP appointments
– Experience minimal side effects of therapy – Manage and cope with this condiFon
Fall 2019 -‐ Spring 2020 33
Hypertension Nursing ImplementaFon
Fall 2019 -‐ Spring 2020
• Acute Care – MAR meds – PT/OT – Dialysis – NPO for invasive/surgical procedures
• Health PromoFon & Ambulatory Care:
• Individualized Teaching • Primary prevenFon via
lifestyle modificaFon • Evaluate therapeuFc
effecFveness • Detect and report adverse
effects • Assess and enhance
compliance
34
Hypertension Nursing Management
• Nursing EvaluaFon – PaFent will:
• Achieve and maintain goal BP – BP 160/80, post medicaFon BP 130/60?
• Understand, accept, and implement treatment plan • Report minimal side effects of therapy
Fall 2019 -‐ Spring 2020 35
A paFent’s BP has not responded consistently to prescribed drugs for hypertension. The first cause of this lack of responsiveness the nurse should explore is a. progressive target organ damage. b. the possibility of drug interacFons. c. the paFent not adhering to therapy. d. the paFent’s possible use of recreaFonal
drugs.
Audience Response QuesFon
Fall 2019 -‐ Spring 2020 36
Hypertension in Older Persons • Increased incidence with
age • Isolated systolic
hypertension (ISH): Most common form of hypertension in individuals age >50
• Age-‐related physical changes contribute to hypertension –decreased response in factors associated with BP
• PharmacokineFcs • ↑ Risk for orthostaFc hypotension
• Also postprandial hypotension
• “White coat” hypertension
Fall 2019 -‐ Spring 2020 37
Hypertensive Crisis
– What medicaFons are needed? – Vasodilators – Adrenergic inhibitors – Calcium channel blockers IV, PO
– Hypertensive urgency • Develops over hours to days
• May not require hospitalizaFon
– Hypertensive emergency • Very severe problems can result if prompt treatment is not obtained
• Rate of rise more important than absolute value
Fall 2019 -‐ Spring 2020 38
Hypertensive Crisis Clinical ManifestaFons
• Hypertensive encephalopathy – Headache, nausea/vomiFng, seizures, confusion, coma
• Renal insufficiency –what assessments? • Cardiac decompensaFon – MI, HF, pulmonary edema
• AorFc dissecFon
Fall 2019 -‐ Spring 2020 39
Hypertensive Crisis Nursing and Interprofessional Mgmt • HospitalizaFon – IV drug therapy: Ftrated to MAP – Monitor cardiac and renal funcFon – Neurologic checks – Determine cause – EducaFon to avoid future crisis
Fall 2019 -‐ Spring 2020 40
