HYPERTENSION

Ventilation

Transport

Perfusion

3 key steps in the body’s chain of getting O2 to tissues & removing CO2

Ventilation

air moving in & out of the lungs

Transport

– O2 moving through the bloodstream attached to RBC

Perfusion

actual flow of blood through the capillary beds surrounding the alveoli & body organs

Delivers nutrient-rich, oxygenated blood to cells & takes away waste products (like CO2) to be exhaled.

Role of Perfusion:

Vascular Tone & Cardiac Output

matching the ventilated areas of the lung

known as V/Q matching

Main driver of perfusion:

air entering the lungs (V)

blood flow circulating through the lung capillaries (Q)

V/Q Mismatch

mismatch happens when the __________does not match the __________

Normal average ratio of V/Q

0.8 (5L air to 6L blood per minute)

high >1 V>Q

low <0.8 Q>V

shunt V/Q = 0

dead space V/Q = oo

Abnormal conditions in V/Q (ventilation-perfusion)

plenty of air, not enough blood flow

pulmonary embolism (blood clot blocking blood flow)

high (>1) V>Q:

plenty of blood flow, not enough air

happens when airways are blocked or diseased

low (<0.8) Q>V:

blood flows past alveoli that receive no air at all

shunt (V/Q=0):

alveoli receive air but no blood flow

dead space (V/Q=oo):

COPD & Asthma

pulmonary embolism (blood clot)

Pneumonia or fluid in the lungs

Pulmonary fibrosis or scarring

ARDS

Common Causes of V/Q (abnormal)

SOB

fatigue or low energy

dizziness or headaches

bluish or gray skin color (cyanosis) around lips or nails

Clinical Manifestation of V/Q (abnormal)

V/Q scan

Chest x-ray

CT scans

ABG

Diagnostic test of V/Q

Health management for V/Q

supplemental O2 - help correct low O2 levels (hypoxemia) caused by the mismatch

Hypertension

CAD Coronary Artery disease

ACS Acute Coronary Syndrome

Vascular disorder: Buerger’s disease

Oxygenation: Perfusion problems

• chronic , force of blood against arterial walls remains persistently

  elevated above normal levels

• Serious complications develop

• Vital organs: heart, brain, kidneys, eyes, vascular system,

• heart attacks, strokes, heart failure, kidney disease, vision loss

Hypertension (HTN /HPN)

• high blood pressure

• ______medical condition in which the __________

• “silent killer”

• typically produces no noticeable symptoms until ___________

• left untreated, it damages ___________

leading to ___________

Age (risk increase with aging)

Family History & genetic Predisposition
Race & ethnicity

Gender

Non-modifiable (Hypertension)

Hypertension

(higher prevalence in African Americans)

Hypertension

65, menopause

__________

(men at higher risk until age ____; women’s risk increases after _______)

Dietary

Lifestyle behaviors

Weight

Chronic Stress

Comorbid Conditions

Sleep disorder

Medication use

Modifiable Risk Factor (Hypertension)

• high sodium, high saturated & trans fats, low potassium, low fruits & vegetables, excessive alcohol consumption

• physical inactivity, sedentary lifestyle, smoking

• overweight or obesity (BMI ≥25 kg/m2)

• prolonged psychological stress, anxiety

• diabetes mellitus, dyslipidemia, chronic kidney disease

• obstructive sleep apnea, chronic sleep deprivation

• NSAIDs, oral contraceptives, stimulants

MODIFIABLE RISK FACTORS

Dietary:

Lifestyle behaviors

Weight

Chronic Stress

Comorbid Conditions

Sleep disorder

Medication use

cardiac output x systemic vascular resistance

BP= ____________________

• _____ – volume of blood the heart pumps per minute

• _____- degree of constriction & dilation in the arterioles

• volume of blood the heart pumps per minute

• degree of constriction & dilation in the arterioles

Cardiac output: ________

Systemic vascular resistance: ________

• cardiovascular system

• kidneys

• autonomic nervous system, &

• hormonal pathways the renin-angiotensin-aldosterone system (RAAS)

BP = cardiac output x systemic vascular resistance

• cardiac output – volume of blood the heart pumps per minute

• systemic vascular resistance – degree of constriction & dilation in the arterioles

• involves complex interactions between:

• _________,_____,_______,________-_____

Renin Release

Angiotension II formation

Vasoconstriction & aldosterone secretion

Sodium & Water Retention

Hypertension pathophysiology

Renin

Angiotensin (produced by the liver) to angiotensin I, angiotensin II, ACE

Vasoconstriction (narrowing of blood vessels), raising vascular resistance, trigers adrenal glands to release aldosterone

aldosterone sodium and water retention

• when BP drops, kidneys release enzyme ______ into the bloodstream

• Renin converts _________ to _________ which is then converted to ________ by the _______ converting enzymes in the lungs

• Angiotensin II causes powerful __________, ___________, ________-

• _______ promotes ____-&_______, increasing volume & further elevating the BP

Chronic hypertension

Causes structural & functional changes in blood vessels and organs

Arterial stiffening

Left Ventricular Hypertrophy LVH

Kidney Damage

Retinopathy

Cerebrovascular disease

Chronic Hypertension can lead to

Constant high pressure damages the endothelial lining of the arteries,

causing inflammation, plaque buildup (atherosclerosis), Loss of elasticity

Arterial Stiffening

heart muscles thickens to overcome increased resistance

leading to heart failure if untreated

Left Ventricular Hypertrophy

high pressure damages the delicate filtering units (nephrons),

• reducing kidney function & potentially causing CKD

Kidney Damage

Blood vessel in the retina narrow, leak, or hemorrhage

impairing vision

Retinopathy

weakened blood vessel in the brain increase stroke risk

Cerebrovascular disease

Primary (essential) hypertension

Secondary Hypertension

Types of Hypertension

90-95%

no single identifiable cause

genetic, environmental, & lifestyle factors

adulthood & progresses gradually

Primary (Essential) hypertension

• approximately_______ of cases

• __________

• multiple ___________contribute to its development over many years

• typically emerges in _______-& _________

5-10%

underlying medical condition or medication

• renal disease

• endocrine disorders

• Medications

• obstructive sleep apnea

• coarctation of the aorta

Secondary hypertension

• remaining _____of cases

• caused by an _____________

• common causes:

_________: chronic kidney disease, polycystic kidney disease, renal artery stenosis

_________ primary aldosteronism, Cushing’s syndrome, pheochromocytoma,

hyperthyroidism

___________: oral contraceptives, NSAIDs, corticosteroids, decongestants, certain antidepressants

_____________ repeated episodes of O2 desaturation & sympathetic activation

_____________ congenital narrowing of the aorta

• CKD, polycystic kidney disease, renal artery stenosis

• Primary aldosteronism, Cushing’s syndrome, pheochromocytoma, hyperthyroidism.

• Oral contraceptives, NSAIDs, corticosteroids, decongestants, certain antidepressants

• repeated episodes of O2 desaturation & Sympathetic activation

• congenital narrowing of the aorta

Common Causes of Secondary Hypertension

• renal disease :

• endocrine disorders :

• Medications :

• obstructive sleep apnea :

• coarctation of the aorta:

Headache, especially occipital (back of the head ) in the morning

dizziness or lightheadedness

fatigue or generalized weakness

blurred vision or visual disturbances

palpitations of sensation of a full heartbeat

shortness of breath with exertion

Nosebleeds (epistaxis), (not common)

Clinical manifestation (Subjective)

Nosebleeds (epistaxis)

not as common as previously believed

• Elevated BP readings

• Cardiovascular findings

• Retinal Changes

• Peripheral edema

• Weight gain

• Decreased urine output

Objective data

• consistently ≥130/80 mmHg on multiple occasions

• in both arms initially, vascular disease

Objective data (1/6):

• Elevated BP readings:

  • BP should be ________; a difference of >10 mmhg indicate ________

• abnormal heart sounds (S4 gallop indicates ventricular stiffness)

• Displaced point of Maximal Pulse (PMI), suggesting Left ventricular hypertrophy

• Irregular heart rhythms (atrial fibrillation is more common with HPN)

Objective data (2/6):

• Cardiovascular findings

S4 gallop

Indicates ventricular stiffness

Displaed point of Maximal Pulse (PMI)

• suggesting Left ventricular hypertrophy

atrial fibrillation

• irregular heart rhythm_______ is more common with HPN

Fundoscopic exam

• narrowed arterioles

• arteriovenous nicking

• Hemorrhages

• Papilledema in severe cases

Objective data (3/6):

Retinal changes

• Retinopathy visible on __________ (____,______,_____,______)

Swelling in the ankles, feet, or sacral area indicating fluid retention

Objective data (4/6):

Peripheral edema

rapid weight gain from fluid retention

Objective data (5/6):

Weight gain

indicate kidney dysfunction

Objective data (5/6):

Decreased urine output

Decreased urine output

indicate kidney dysfunction

Hypertensive Crisis

• BP >180/120 mmHg with acute target organ damage

A medical emergency

• Severe, sudden headache

• Severe SOB or respiratory distress

• Chest pain or pressure

• Confusion, altered mental status, or decreased LOC

• Seizures

• Severe anxiety or a sense of impending doom

• Weakness, numbness, or paralysis on one side of the body (stroke symptoms)

• Vision loss or sudden visual changes

• Severe nosebleed that won’t stop

Red-flag symptoms (hypertensive Crisis)

• chest pain (angina)

• heart attack

• heart Failure

• Irregular heart beat

Complications of uncontrolled HTN

Heart Attack

- occurs when the blood supply to the heart is blocked & heart muscle cells die from lack of O2;

- the longer the blood flow is blocked, the greater the damage to the heart

Heart failure

occurs when the heart cannot pump enough blood & O2 to other vital body organs

Irregular heart beat

can lead to a sudden death

Hypertension

the only way to know is to get the blood pressure checked

• 2 numbers

• pressure in blood vessels when the heart contracts or beats

• pressure in the vessels when the heart rests between beats

Blood Pressure

-written as_____

first (systolic) number represents the _________

-second (diastolic) number represents the __________

• when it is measured on 2 different days

• systolic BP readings on both days is ≥140 mmHg &/or

  the diastolic BP readings on both days is ≥90 mmHg

Hypertension

Diagnosed if:

Hypertension

• when the pressure in the blood vessels is too high

(140/90 mmHg or higher)

Normal: < 120 / 80 mmHg

Elevated: 120-129 mmHg systolic & <80 mmHg diastolic

Stage 1 HPN: 130-139 mmHg systolic or 80-89 mmHg diastolic

Stage 2 HPN: 140 mmHg or higher systolic or 90 mmHg or higher diastolic

Hypertensive Crisis:

higher than 180 mmHg systolic &/or

higher than 120 mmHg diastolic

BP categories

Hypertensive crisis

(requires immediate emergency care if accompanied by symptoms)

Complete Metabolic Panel CMP
Lipid Panel

urinalysis

Urine albumin-to-creatinine ration

thyroid stimulating hormone

Routine Laboratory Test (5)

• serum creatinine and BUN

  • assess kidney function

• Estimated GFR

• Electrolytes (sodium potassium, calcium , chloride, bicarbonate)

• Fasting glucose or hemoglobin A1C, HbA1C (glycated hb)

  • assess for diabetes

Complete Metabolic Panel CMP

total cholesterol, LDL, HDL, Triglycerides

Lipid panel

check for protein (marker of kidney damage),

blood

glucose

Urinalysis

Urine albumin to creatinine ratio

Detects early kidney damage

TSH

Rule out thyroid disorders

Electrocardiogram ECG/EKG

Echocardiogram

Chest x-ray

24-hour ambulatory BP monitoring

Renal ultrasound or CT

sleep study

Additional diagnostic test (as indicated)

Left ventricular hypertrophy

arrhythmia

previous MI

ECG/ EKG electrocardiogram assess for?

ventricular size

wall thickness

ejection fraction EF

Echocardiogram evaluates?

heart size

pulmonary edema

Chest x-ray assess

confirms diagnosis

assess nocturnal BP pattern

24 hour ambulatory BP monitoring confirms

kidney size

rule out polycystic kidney disease or masses

Renal ultrasound or CT evaluates

obstructive apnea is suspected

Sleep study is done if?

• • Fruits & vegetables: 8–10 servings daily

  • Whole grains: brown rice, whole wheat bread, oatmeal, quinoa

  • Lean proteins: skinless poultry, fish, beans, lentils, tofu

  • Low-fat dairy: skim milk, low-fat yogurt, reduced-fat cheese

  • Nuts, seeds, & healthy fats: almonds, walnuts, olive oil, avocado

  • Potassium-rich foods: bananas, oranges, potatoes, spinach, tomatoes

Health education / Dietary modifications DASH diet

Dietary approach to stop Hypertension

DASH diet stands for

Sodium

Saturated & trans fat

Added sugar

Alcohol

Food to limit or avoid

• <2,300 mg daily (or <1,500 mg if recommended);

Food to limit or avoid:

Sodium

limit to ______________ avoid adding salt at the table,

reduce salt in cooking, avoid processed foods, canned soups, deli meats, frozen dinners, salty snacks, & restaurant meals

• processed foods, canned soups, deli meats, frozen dinners, salty snacks,

  & restaurant meals

• red meat, full-fat dairy, fried foods, baked goods

• Sugary drinks, desserts, candy

• Limit to ≤2 drinks/day for men, ≤1 drink/day for women

Food to limit or avoid:

Sodium:

Saturated & trans fat:

Added Sugar

Alcohol

Alcohol

• Limit to ≤2 drinks/day for men, ≤1 drink/day for women

read nutrition labels

Cook at home more often

use herbs, spices, lemon & garlic inntead of salt

fresh or frozen vegetables over canned ones

Practical tips

<140 mg sodium

Read nutrition labels: choose products with _________per serving

• 150 minutes of moderate-intensity aerobic exercise weekly

• slowly if currently inactive, 10-minute

• Warm up & cool down

• chest pain, severe shortness of breath, dizziness, or palpitations

Physical Activity

Recommendations:

• Goal: at least _____________ (e.g., 30 minutes most days)

• Good choices: brisk walking, swimming, cycling, dancing, water aerobics, yard work

• Start__________; even _______sessions provide benefit

• ________to prevent injury

• Stop & seek help if experiencing_______,_______,_____,________ during excercise

• chest pain, severe shortness of breath, dizziness, or palpitations during

  exercise

Stop & seek help if experiencing_______,_______,_____,________ during excercise

Smoking cessation

Alcohol Moderation

Stress Management

Weight Management

Lifestyle Modification

• Nicotine raises BP & Heart Rate

• Smoking damages blood vessels & increase heart attack/ stroke risk

• Resources:

  • nicotine replacement therapy

  • medications (varenicline, buproprion)

  • Counselling

Smoking Cessation

prescription medications used to help people quit smoking

• varenicline, buproprion

• excessive alcohol raises BP

• limit to to ≤2 drinks/day for men, ≤1 drink/day for women

• One drink = 12 oz beer, 5 oz wine, or 1.5 oz spirits

Alcohol Moderation

• Chronic Stress contributes to high BP

• Effective techniques: deep breathing, meditations, yoga, regular excercise, adequate sleep, hobbies, social connection

• counseling if stress or anxiety is overwhelming

Stress management

10 pounds, systolic BP by 5-20 mmHg5-20 mmHg

• gradual weight loss (0.5–1 kg per week)

• sustainable lifestyle changes, not extreme diets

Weight Management

• every ______ of weight loss can reduce __________

• Aim for ______________through diet & activity changes

• Focus on __________

• validated, upper-arm cuff device

• same times each day (morning before medications, evening before dinner)

• Sit quietly for 5 minutes

• Sit with back supported, feet flat on the floor, arm at heart level

• Don’t talk

• 2–3 readings 1 minute apart

• Bring log

Home BP monitoring

Technique:

• Use a _________,________- (avoid wrist or finger monitors)

• Measure at the ________ (__________,_______)

• ________ before measuring

• ________,_________,_______

• _______ during measurement

• Take ___________; record all results

• _______ to all appointments

Readings consistently above target range

• Readings >180/120 mmHg (hypertensive urgency)

• New or worsening symptoms

Home BP monitoring:

When to call healthcare provider?

ok

Warning signs requiring immediate medical attention

Call hotline / 911 or go to the emergency room immediately for:

• Severe headache (worst headache)

• Chest pain or pressure

• Severe shortness of breath

• Sudden weakness, numbness, or difficulty speaking (stroke symptoms)

• Severe anxiety or sense of doom

• Vision loss or sudden vision changes

• BP >180/120 mmHg with symptoms

• Seizures

Diuretics “water pills”

Ace Inhibitors

Angiotensin II Receptor Blockers ARBS

Calcium channel Blockers

Beta Blockers

Hypertension medications

Thiazide: Hydrochlorothiazide

Loop: Furosemide

Potassium sparing: spironolactone

• Decrease blood volume by sodium and water excretion

• Hypokalemia (thiazide and loop) Hyperkalemia (potassiu sparing)

• orthostatic hypotension, dehydration

• monitor electrolytes, Daily weights, I&O , teach to take in the morning

DIURETICS water pill

Example:

Action:

Side effects:

Nursing Responsibilities:

• lisinopril, enalapril, ramipril

• block conversion of angiotensin I to angiotensin II, reducing vasoconstriction

• dry cough, hyperkalemia, angioedema (rate but serious)

• monitor potassium, teach about cough, assess for angioedema

ACE Inhibitor

Example:

Action:

Side effects:

Nursing Responsibilities: