Understanding Hypertension

Desired Blood Pressure

• For individuals over 60 years old, the goal is below 150/90 mm Hg.
• For those under 60, the target is below 140/90 mm Hg.
• Drug therapy should be considered if blood pressure consistently exceeds these goals.

Normal Blood Pressure

• Systolic (S): 120
• Diastolic (D): 80-89

Hypertension Types

• Essential hypertension has an unknown cause and accounts for 90% of cases.
• Secondary hypertension is related to an underlying condition, such as chronic kidney disease (CKD).

Effects of Hypertension

• Hypertension can damage vital organs.
• Medial hyperplasia, or thickening of the arterioles, can result from hypertension.

Hypertension Risk Factors

• Modifiable risk factors include obesity, smoking, and stress.
• Non-modifiable risk factors include family history.

Secondary Hypertension Causes

• Can result from renal disease, primary aldosteronism, pheochromocytoma, Cushing's syndrome, pregnancy, or medications like estrogens and glucocorticoids.

Malignant Hypertension Symptoms

• Classified as a "hypertensive crisis," it progresses rapidly.
• Symptoms include severe headache, dizziness, blurred vision, shortness of breath (SOB), and severe anxiety.
• It is an emergency that can lead to kidney failure or stroke.

Malignant Hypertension Treatment

• Place the patient in a semi-Fowler's position and administer oxygen.
• Start IV fluids with 0.9% normal saline (NS).
• Administer IV medications as prescribed and monitor blood pressure frequently.
• Watch for neurological or cardiovascular complications, and lower blood pressure slowly to prevent adverse reactions.

Hypertension Assessment

• Obtain patient history including age, diet, ethnicity, family history, and comorbidities.
• Physical assessment may reveal no symptoms, or headache, flushing, and dizziness/fainting.
• Psychological assessment should consider anxiety and stressors.
• Diagnostic assessments include monitoring for tachycardia, sweating, stressors, blood pressure, and lab values, along with an EKG.

Hypertension Lifestyle Changes

• Recommendations include sodium restriction, weight reduction, reduced alcohol intake (1 drink for women, 2 for men), exercise, stress reduction, and smoking cessation.
• Complementary and alternative therapies, such as herbal remedies, may also be considered.

Hypertension Drug Therapy

• Common medications used for hypertension include diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, and Angiotensin II Receptor Blockers (ARBs).

Diuretics

• Types of diuretics include thiazides (hydrochlorothiazide), loop diuretics (furosemide, bumetanide), osmotic diuretics (mannitol), carbonic anhydrase inhibitors, and potassium-sparing diuretics (spironolactone, triamterene).

Beta Blockers

• Monitor heart rate when administering beta-blockers.

ACE Inhibitors

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Types of Sensory Perception

• Include sight (visual), hearing (auditory), touch (tactile), smell (olfactory), taste (gustatory), and movement/position (kinesthetic).

Calcium Channel Blockers

• Mechanism of Action (MOA): Block calcium channels, leading to vasodilation.
• Side effects: Weakness, headache, dizziness, edema, fatigue, blurred vision, nausea, constipation, erectile dysfunction (ED), bradycardia, hypotension, pharyngitis, and rhinitis.
• Examples include verapamil, diltiazem, amlodipine, and felodipine.

Sensory Deficit

• A problem with senses like sight, hearing, or touch due to damage or malfunction, which may be permanent or temporary.
• People adapt with tools or strategies.

Sensory Deficit Examples

• Vision deficits include cataracts, glaucoma, diabetic retinopathy, macular degeneration, and infections/inflammation.
• Hearing deficits include cerumen accumulation and infections.
• Taste deficits include xerostomia and dry mouth.
• Balance deficits include dizziness.
• Neurological deficits include peripheral neuropathy and stroke.

Sensory Overload

• Occurs when multiple senses are overstimulated beyond normal intensity.
• Results in symptoms like racing thoughts, anxiousness, and restlessness.

Sensory Overload Interventions

• Reduce excessive stimuli by dimming lights, reducing noise, limiting equipment use, and minimizing interruptions.
• Organize care by clustering nursing tasks and scheduling rest periods.
• Use clear, simple communication, speaking calmly and giving one instruction at a time.
• Limit visitors and educate family about maintaining a calm environment.
• Provide orientation cues such as clocks, calendars, and introductions.
• Reassure the patient and teach relaxation techniques.

Sensory Deprivation

• Occurs when the brain does not receive enough stimulation.
• It Causes confusion, boredom, anxiety, and hallucinations.
• Happens in isolated or unstimulating environments

Sensory Deprivation Interventions

• Provide meaningful stimulation by offering books, TV, music, conversation, tactile objects, and aromatherapy.
• Encourage social interaction through visits, calls, and group activities.
• Provide access to calendars or clocks for orientation.
• Use visual and auditory aids like glasses and hearing aids, ensure adequate lighting, and speak clearly.
• Use touch therapy like gentle hand holding or massage.
• Structure routine care and encourage movement.
• Stimulate all senses with scents, textured objects, warm baths, music, or visually engaging items.

Delusions

• False, fixed beliefs that are not reality-based, common in psychosis or dementia.
• Nursing interventions: Do not argue, redirect gently, ensure safety, and use a calm tone.

Illusions

• Misinterpretation of real sensory input, often in low light or unfamiliar settings/delirium.
• Nursing interventions: Clarify reality, improve lighting, reorient the patient, and reduce sensory triggers.

Hallucinations

• Sensory experiences without external stimuli (auditory/visual).
• Nursing interventions: Acknowledge the experience without validating the content, ensure safety, reduce stimuli, stay present, and involve mental health team.

Confusion

• General term for disorientation, impaired memory, and poor decision-making.
• Nursing interventions: Reorient frequently, maintain a calm environment, speak clearly, limit choices, and encourage family presence.

Delirium

• Acute, sudden confusion often caused by illness, meds, infection, or sensory overload/deprivation.
• It Fluctuates in severity —worse at night (sundowning).
• Key signs include a sudden onset, inattention, and restlessness, plus hallucinations or paranoia.
• Can be reversible with treatment.
• Nursing interventions: Treat the underlying cause, provide consistent caregivers, reduce noise, use reorientation cues, and ensure sensory aids are used, as well as Prevent injury.

Depression

• Mood disorder, not a normal part of aging, and often reversible with treatment.
• Can mimic dementia (pseudodementia).
• Key signs: Sadness, hopelessness, apathy, changes in sleep/appetite/energy, withdrawal, and trouble concentrating.
• Nursing interventions: Screen regularly, encourage social engagement and routine, allow expression of feelings, collaborate with mental health providers, and never ignore suicidal thoughts.

Dementia

• Chronic, progressive decline in memory, judgment, and language, and is not reversible.
• Characteristics/ Key signs: Short-term memory loss, word-finding difficulty, poor judgement, disoriented to time/place/person.
• Early stage = forgetfulness
• Late stage = profound cognitive loss, requires full care
• Nursing Interventions: Maintain routine and structure, use simple instructions and visual cues, reassure without arguing, ensure safety, and encourage independence within ability.

Nursing Interventions: Hearing Impairment

• Optimize communication by facing the patient, speaking clearly, rephrasing if needed, and using gestures/written notes.
• Support use of hearing devices by ensuring they are clean, working, and worn correctly; educate on care.
• Reduce background noise and promote understanding with short, simple sentences.
• Insure safety with visual alarms, alerts to important sounds, and Encourage socialization.

Nursing Interventions: Smell Impairment

• Insure safety by teaching patients to check gas stoves/smoke alarms/food expiration dates and recommending electric appliances.
• Support nutrition by encouraging flavorful foods and monitoring for weight loss and promote hygiene and comfort with daily routines and pleasant scents.
• Establish routine checks for food spoilage or hygiene issues.

Nursing Interventions: Sight Impairment

• Insure safety by removing hazards, ensuring lighting, and using contrasting colors.
• Promote orientation by announcing your presence, explaining locations, and keeping belongings consistent.
• Support use of visual aids like glasses, magnifiers, large-print labels, audiobooks, and voice-assisted technology.
• Enhance communication by speaking directly and offering verbal cues.
• Encourage independence by labeling items and involving the patient in ADLs.

Nursing Interventions: Taste (Gustatory) Impairment

• Support nutrition by offering variety in flavor/texture/temperature.
• Encouraging foods with natural seasonings, and monitoring eating habits.
• Promote oral hygiene with regular brushing/flossing and mouth rinses.
• Monitor medication effects, encouraging familiar foods.
• Enhance combined senses with smell and visual appeal; encourage family-style eating.

Delegation

• The process of transferring responsibility for a task to another competent individual while retaining accountability for the outcome.

5 Rights of Delegation

• Right Task
• Right Circumstances
• Right Person
• Right Direction/Communication
• Right Supervision

Right Task

• One that is appropriate to delegate based on the situation, within the delegatee's job description, and low risk/routine.
• It Must be repetitive, noninvasive, and predictable and not require complex assessment or decision-making.

Right Circumstances

• Delegate only when the patient is stable, the setting is appropriate, and resources are available. The nurse must assess the environment and patient before deciding.

Right Person

• Has the right skills, training, and job description to do the task and is competent and authorized to perform it safely.

Right Direction/Communication

• The nurse gives clear, specific instructions, including what to do, when to do it, what to report, and expected outcomes.
• Communicate the exact task, timing/frequency, specific instructions, and what to report back.
• Be respectful and encourage questions or clarification.

Right Supervision

• Monitor performance, evaluate the outcome, and provide feedback or intervene as needed.
• The Nurse remains responsible for ensuring the task is done safely and correctly.

Physiological Reactions to Pain

• Sympathetic stimulation: Dilation of bronchial tubes, increased respiratory rate (RR) and heart rate (HR), peripheral vasoconstriction, increased blood glucose, diaphoresis, and dilation of pupils.
• Parasympathetic stimulation: Pallor, muscle tension, rapid irregular breathing, pupil constriction, and decreased heart rate and blood pressure.

Types of Pain

• Acute/Transient Pain
• Chronic/Persistent non-cancer pain
• Chronic episodic pain
• Cancer pain
• Pain by inferred pathological process
• Nociceptive pain:
  • Somatic (musculoskeletal)
  • Visceral (internal organ)
• Neuropathic Pain
• Idiopathic pain

Pain Assessment

• Evaluate a patient's pain location, intensity, quality, duration, and impact, at regular intervals.

• Key components:

  • Use a systematic tool like PQRST:
    • P - Provokes: What causes or relieves it?
    • Q - Quality: What does it feel like? (sharp, dull, burning)
    • R - Region/Radiation: Where is it? Does it spread?
    • S - Severity: How bad is it? (Use a pain scale, e.g., 0-10)
    • T - Timing: When did it start? Constant or intermittent?
  • Assess impact on ADLs, mood, sleep, appetite
  • Patient's verbal/nonverbal cues
  • Cultural and developmental influences on pain reporting

• Types of Pain Scales

  • Numeric Rating Scale (NRS) - 0 (no pain) to 10 (worst pain)
  • Wong-Baker Faces Scale - for children or non-English speakers
  • FLACC - for infants or nonverbal patients (Face, Legs, Activity, Cry, Consolability)
  • PAINAD - for patients with advanced dementia

• Nurse's Responsibilities

  • Believe the patient — pain is subjective
  • Reassess after interventions (typically 30-60 min)
  • Document pain before and after treatment
  • Involve the patient in setting realistic goals for relief

Informed Consent

• Surgery cannot proceed legally or ethically without a signed informed consent form, except in emergencies.
• Consent must be obtained before any sedation to ensure the patient is alert and can make a voluntary decision.
• The surgeon (not the nurse) is responsible for explaining the procedure, risks/benefits/alternatives, and who will perform it.
• Nurse's Role is to witness the signature, not explain the procedure:
  • Ensure the patient:
    • Appears competent and alert
    • Is signing voluntarily
  • Report concerns to the provider or anesthesia team before surgery if the patient seems confused or uncertain.

Types of Surgeries

• Seriousness:
  • Major : High risk, extensive alteration. Examples: Coronary artery bypass, colon resection, lung lobe removal
  • Minor - Minimal risk or alteration. Examples: Cataract extraction, plastic surgery, tooth extraction
• Urgency:
  • Elective: Planned by patient choice; not essential. Examples: Hernia repair, bunionectomy, cosmetic procedures
  • Urgent: Necessary for health, not emergency. Examples: Gallbladder removal, vascular repair
  • Emergency: Must be done immediately. Examples: Perforated appendix, traumatic amputation
• Purpose:
  • Diagnostic: Confirm diagnosis. Example: Breast biopsy, exploratory laparotomy
  • Ablative: Remove diseased tissue. Example: Appendectomy, amputation
  • Palliative: Relieve symptoms without cure. Example: Colostomy, nerve root resection
  • Reconstructive/Restorative: Restore function or appearanceExample: Fracture fixation, scar revision
  • Procurement for Transplant: Removal for donationExample: Kidney, heart donation
  • Constructive: Correct congenital defect. Example: Repair of cleft palate
  • Cosmetic: Improve appearance. Example: Rhinoplasty, blepharoplasty

ASA Physical Status Table

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Types of Consent

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Nursing Roles: Intraop

• Circulating Nurse (RN):
  • Manages overall OR environment and patient care
  • Performs time-outs, ensures sterility, and documents all intraoperative activities -Manages: Patient positioning, skin prep and surgical site verification, instrument and sponge counts, specimen handling, and Safety checks on equipment
• Scrub Nurse (RN or CST):
  • Works directly in the sterile field.
  • Prepares sterile instruments, anticipates surgeon's needs, maintains sterility and passes instruments during procedure

Nursing Process: OR

• Assessment:
  • Reassess clinical status, skin, joint positioning
  • Confirm allergies, risk factors (e.g., latex, pressure injury)
• Planning/Priorities:
  • Maintain airway and perfusion
  • Prevent injury and infection
  • Ensure all documentation and equipment checks are complete
• Implementation:
  • Protect patient dignity
  • Maintain normothermia
  • Apply antiembolism devices
  • Use grounding pad if electrosurgery is used
  • Assist anesthesia and surgical teams as needed
• Evaluation:
  • Ongoing monitoring of patient condition, safety, and positioning
  • Update family if appropriate
• Prepare patient for PACU handoff

Postoperative Complications and How to Prevent Them​

• Pulmonary Complications (e.g., atelectasis, pneumonia)
  • Prevention: Incentive spirometry, deep breathing/coughing every 1-2 hours, early ambulation, upright positioning, and pain control
• Circulatory Complications (e.g., DVT, PE)
  • Prevention: Leg exercises hourly while awake, sequential compression devices (SCDs)/compression stockings, early ambulation, and assess for postural hypotension
• Neurologic Complications (e.g., delayed awakening, confusion)
  • Prevention: Reorient patient, monitor oxygenation, promote deep breathing
• Infection (Surgical Site, UTI, IV site)
  • Prevention: Aseptic technique, remove catheters/IV lines ASAP, and monitor for fever/redness/drainage, wound care teaching
• Fluid & Electrolyte Imbalance
  • Prevention: Monitor I&Os, IV fluids, drains, advance oral intake gradually, and assess for hypovolemia or electrolyte shifts
• GI Complications (e.g., constipation, ileus, nausea)
  • Prevention: Encourage early ambulation, monitor bowel sounds/flatus, advance diet slowly, and manage nausea proactively
• GU Complications (e.g., retention, low output)
  • Prevention: Palpate distension and monitor urine output