NURS 334, exam 3, perfusion and exemplars

perfusion

The flow of blood through arteries and capillaries, delivering nutrients and oxygen to cells and removing cellular waste products

central perfusion

force of blood movement generated by cardiac output

-->affected by BV, myocardial function.

-requires adequate cardiac function, blood pressure, and blood volume

-CO=(SV)(HR)

tissue or local perfusion

volume of blood that flows to target tissue.

-->affected by central perfusion or patency of blood vessels

-->requires patent vessels, adequate hydrostatic pressure, and capillary permeability

ischemia

an inadequate blood supply to an organ or part of the body, especially the heart muscles.

infarction

tissue death caused by lack of oxygen due to an obstruction of tissues or blood supply.

anoxia

absence of oxygen

impaired central perfusion

-when CO is inadequate

--reduced CO results in a reduction of oxygenated blood reaching the body tissues, creating a systemic effect

**if severe, associated with shock

**if untreated, leads to ischemia, cell injury, and cell death.

impaired tissue perfusion

associated with loss of vessel patency or permeability, or inadequate central perfusion

**results in impaired blood flow to the affected body tissue causing a localized effect.

-->leads to ischemia and ultimately cell death if uncorrected.

population risk factors for impaired perfusion

-middle age and older adults

-Males

-African American, -infants with congenital heart defects

-people with trauma

individual risk factors for impaired perfusion

smoking

obesity

sedentary lifestyle

chronic disease

traumatic brain injury

heart disease

MI

thrombus

PE

impaired perfusion in infants

poor feeding

poor weight gain

failure to thrive

dusky color

fatigue

SOB

pain

impaired perfusion in toddlers and children

squatting and fatigue to improve perfusion

developmental delay

creatinine kinase and IP

enzyme found in the brain, skeletal muscle, and heart muscle.

elevated with damaged myocardium

Lactic dehydrogenase (LDH) and IP

blood test to determine the level of LDH enzyme, which is increased in muscular dystrophy, damage to skeletal muscles, after a pulmonary embolism, and during skeletal muscle malignancy

Naturetic Peptides ( ANP and BNP) and IP

biomarkers used to diagnose CHF or an MI

includes BNP and ANP

Troponin and IP

regulatory protein that binds to actin, tropomyosin, and calcium

used to diagnose a MI. will be elevated

Homocysteine and IP

Simple amino acid. that elevates with stroke, thrombus, or damaged myocardium

C-reactive protein (CRP) and IP

an acute phase reactant; protein that is made in the liver.

blood test used to measure the level of inflammation in the body;

may indicate conditions that lead to cardiovascular disease. not specific to the location of inflammation.

serum lipids and IP

increased risk for IP with increased lipids as there is a higher chance of developing atherosclerosis

Platelets

blood clotting cells

prothrombin time

test of the ability of blood to clot (for warfarin)

Partial Thromboplastin Time (PTT)

test to determine coagulation defects, such as platelet disorders (for heparin)

International Normalized Ratio (INR)

Blood coagulation test; commonly performed on patients taking anticoagulants (i.e. coumadin/warfarin)

other diagnostic tests and IP

--EKG

--cardiac stress test (exercise or pharmacologic test)

--radiographic studies (CXR, ultrasound, arteriogram)

primary prevention and IP

smoking and nicotine cessation

diet

exercise

weight control

secondary prevention and IP

BP screening

lipid screening

at what age should BP screenings begin?

and how often?

18 years and older.

recommended every 2 years if normal. in younger children, they should be preformed with well-child visits.

When should lipid screening begin?

In children with significant family history, begin at 2 years - 10 years

if no risk factors..

men- 35

women-45

most common strategies for impaired perfusion

diet modification and smoking cessation

increased activity (conditioning)

pharmacotherapy

antihypertensive and impaired central perfusion

used to lower BP to allow for increased vasodilation

antiarrhythmic drugs and impaired central perfusion

used to lower rhythm of the heart

--tambovcor (flecainide)

--procanbid (procainamide)

--cordarone (amiodarone)

--betapace (sotalol)

ionotropics and impaired central perfusion

used to improve circulation

dopamine and NE

antianginal agents and impaired central perfusion

used to treat CP and improve circulation to bring more oxygen to the areas.

nitroglycerine

nitro-bid

nitro-duro

isosorbide dinitrate

vasopressors and impaired central perfusion

used to improve circulation

isoproternol (isoprel)

dobutamine (dobutex)

vasodilators and impaired central perfusion

used to dilate the blood vessels, improving blood flow and perfusion to the tissues

Nitro

Hydralazine

anticoagulants and impaired tissue (local) perfusion

*coumadin (subq)

*heparin (subq, IV, NEVER push)

*lovenox (subq)

*xarelto (oral)

thrombolytics and impaired tissue (local) perfusion

*all IV drip*

used to treat strokes and heart attacks. break apart blood clots.

lanoteplase

reteplase

staphyokinase

urokinase

lipid-lowering agents and impaired tissue (local) perfusion

used to reduce lipid levels in the blood (reductase, inhibitors, statins)

atorvastatin (lipitor)

fluvastatin (lescol)

lovastatin (mevacor)

pitavastatin (livsalo, pravachool)

rosuvastatin (crestor)

simvastatin (zocor)

antiplatelet agents and platelet inhibitors and impaired tissue (local) perfusion

used to decrease platelet formation

aspirin

clopdegrel (plavix)

persantine

pacemaker insertion

device planed in the chest, uses a low energy impulse to stimulate the rhythm of the heart

electrical cardioversion

medical procedure done to restore a normal HR.

small electric shock sent through a heart to return to normal

intraaortic balloon pump (IABP)

mechanical device increasing coronary artery blood flow and oxygen.

a balloon that deflates in systole and inflates in diastole

cardiac valve surgery

surgically replace the heart valve.

cardiac transplant

a procedure in which a patient's diseased heart is surgically replaced using a heart from a recently deceased organ donor

bypass and/or graft surgery

done to restore blood flow to the heart by creating a diversion around a blockage

stent or angioplasty

placed in an artery to prevent collapse

endarterectomy

removal of the inner lining of the heart containing plaque and fatty deposits that have formed.

age and htn

after age 50, SBP naturally rises slowly, followed by the DBP.

alcohol and htn

excessive intake is strongly associated with htn, tolerance levels may vary

tobacco use and htn

smoking greatly increases risk for cardiovascular disease which then increases the risk for HTN

diabetes mellitus and htn

more common in this population, regardless of age.

prevention: keep HbA1C below 7%. control diet and health choices.

elevated serum lipids and htn

elevated cholesterol (>200) and triglycerides (>150) are risk factors for atherosclerosis which causes HTN

excess dietary sodium and htn

recommended less than 2,000 mg/day. can also help the effectiveness of anti-HTN medications

gender and htn

more common in males than females in younger years.

in mid-50s, more common in females than men

family history and htn

increased risk

obesity and htn

Obesity contributes to the mechanisms that cause HTN. Especially Endothelial Dysfunction & Renal Na+ Retention

**higher weight retention in the abdomen is directly associated with an increased risk for hTN

ethnicity and htn

two-times more prevalent in african american population

sedentary lifestyle and htn

decreased perfusion to the extremities and increased risk for obestiy

socioeconomic status and htn

impacts the diet and exercise regimen.

stress and htn

causes increased HR and increased Renin release

clinical manifestation of htn

"silent killer" (often no S/S to indicate HTN is usually underdiagnosed.

fatigue

dizziness

palpitations

angina

dyspnea

headache

nosebleed

complications of htn

most frequently occur in:

heart

brain

peripheral vascular disease

kidneys (BUN and creatine

eyes

Ambulatory blood pressure monitoring

Noninvasive, fully automated system that measures BP at preset intervals over 24-hour period.

preferred to avoid "white coat syndrome"

BUN

10-20 mg/dL

Creatinine

0.6-1.2 mg/dL

creatinine clearance test

Males: 90-139 mL/min

Females: 80-125 mL/min

cholesterol level

<200 mg/dL

triglyceride level

<150 mg/dL

uric acid level

Male: 4.4-7.6 mg/dL

Female: 2.3-6.6 mg/dL

can be elevated by diuretic therapy

ecg and htn

provides information about cardiac status and ventilation.

hypertrophy, old MI, or period of ischemia?

echocardiogram

to observe sophisticated study of the heart. if suspected damage.

ophthalmic exam

to obtain a good baseline for vision

overall goals of collaborative care

1. control BP using interventions and diagnosing early

2. reduce CVD risk factors and target organ disease

3. lifestyle modifications

drug therapy for HTN

diuretics,

adrenergic inhibitors

direct vasodilators

angiotensin inhibitors

calcium channel blockers

triple pill: combination of telmisartain, amlopdipine, chlorothalidone

follow up care

identify, report, and minimize side effects:

orthostatic hypotension

sexual dysfunction

dry mouth

frequent urination

time of the day to take the drug is very important

stepped care therapy

goal- to control BP with minimal side effects.

1: lifestyle modifications

2: step one and medication

3.: step two and another medication

4: step three and another medication

step-down therapy

-Medications decreased slowly once a client has been controlled for one year and at least four office visits

-Regular follow-up is essential

subjective data and HTN

past health history:

-hypertension

-cardiovascular, cerebrovascular, renal, thyroid disease

-diabetes mellitus, pituitary disorders, obesity, dyslipidemia

-menopause or hormone replacement

drugs

Subjective data: family history, salt and fat intake, weight gain or loss, nocturia, fatigue, dyspnea on exertion, palpitations, pain, dizziness, blurred vision, erectile dysfunction, stressful events

objective data:

BP readings, heart sounds, pulses, edema, body measurements, mental status changes

bp measurement

-take in both arms initially

-proper size and placement of cuff (if too big: low reading, if too small; high reading)

-can use forearm if needed: document site

assess for orthostatic hypotension:

-BP and pulse supine, sitting, and standing

-measure again within 1-2 minutes of position change

-positive if: decrease in SBP of 20 mmHg or more; decrease in DBP of 10 mmHg or more; or increase of 20 BPM or more

nursing diagnosis and htn

*ineffective self-health management

*anxiety

*sexual dysfunction

*risk for decreased cardiac perfusion

*risk for ineffective cerebral and renal perfusion

*potential complications: stroke, MI

nursing planning and HTN

patient will:

-achieve and maintain the goal BP

-understand and follow the therapeutic plan

-experience minimal or no unpleasant side effects of therapy

-be confident of ability to manage and cope with this condition

nursing implementation and htn

health promotion

: -primary prevention via lifestyle modification

-individual evaluation and education

-screening programs

-cardiovascular risk factor modification

ambulatory and home care:

-evaluate therapeutic effectiveness

-detect and report adverse effects

-asses and enhance compliance

-patient and caregiver teaching

Reasons for noncompliance

Inadequate teaching

Side effects

Return to normal BP

Lack of motivation

Financial

Lack of trust

measures to enhance compliance

Individualize plan

Active patient participation

Select affordable drugs

Involve caregivers

Combination drugs

Patient teaching

patient and caregiver teaching includes:

Nutritional therapy

Drug therapy

Physical activity

Home BP monitoring (if appropriate)

Tobacco cessation (if applicable)

nursing evaluation

Patient will:

- Achieve and maintain goal BP

- Understand, accept, and implement treatment plan

- Report minimal side effects of therapy

hypertension in older persons

- Increased incidence with age

- Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50

- Older adults are more likely to have "white coat" hypertension

- Age-related physical changes contribute to hypertension

- Altered drug absorption, metabolism, and excretion

- Often a wide gap between first Korotkoff sound and subsequent beats is called auscultatory gap

- ↑ Risk for orthostatic hypotension

- Also postprandial hypotension

- BP goal for people over 60 is < 150/90

- Preferred antihypertensive drugs: Thiazide diuretic, Calcium channel blockers, and ACE inhibitors or ARBs

- Caution use of NSAIDS

hypertensive emergency

Occurs over hours to days

BP >220/140 with target organ disease

tolerance for this pressure level is not often sustained

hypertensive urgency

Occurs over days to weeks

BP >180/110 with no clinical evidence of target organ disease

****RATE OF RISE IS MORE IMPORTANT THAN THE ABSOLUTE VALUE

clinical manifestations of hypertensive crisis

Hypertensive encephalopathy:

Headache, n/v, seizures, confusion, coma

Renal insufficiency

Cardiac decompensation:

MI, HF, pulmonary edema

Aortic dissection

nursing management for hypertensive crisis

hospitalization:

-IV drug therapy is titrated to MAP: completed before transfer to a different unit; monitor urinary output of the patient

-monitor cardiac and renal function: continuous monitoring of cardiac functioning, BP, HR, O2sat; these patients often require ICU care; BP q2minutes

-neuro checks

-determine underlying cause

-education to avoid in future

-AMLODIPINE should be taken in the early morning and patient should avoid grapefruit while taking this drug.