ALTERED-VENTILATORY-FUNCTION-Midterm-V-VI PDF

NCM 118 MODULE 5: RESPONSES TO ALTERED VENTILATORY FUNCTION Prepared by: Claire B. Villaveja, RN Mucosa’s gland moistens the air and traps...

NCM 118 MODULE 5: RESPONSES TO ALTERED VENTILATORY FUNCTION Prepared by: Claire B. Villaveja, RN Mucosa’s gland moistens the air and traps incoming bacteria and other foreign debris and lysosome enzyme destroy bacteria chemically. The ciliated cells of the nasal mucosa create a gentle current that moves the sheet of contaminated mucous posteriorly toward the throat Conchae Are found in the lateral walls of nasal cavity which greatly increase the surface area of the mucosa exposed to the air. It also increase air turbulence in the nasal cavity. respiratory system Palate It share responsibility with cardiovascular Separates nasal cavity from oral cavity. system for supplying the body with oxygen The hard palate is the anterior palate which and disposing of carbon dioxide. is supported by bones and soft palate is the It oversee the gas exchange that occur unsupported posterior part of the palate. between the blood and external environment. Paranasal sinuses it lightens the skull and act as resonance chambers of speech. It is upper located in the frontal, sphenoid, ethmoid and respiratory maxillary. the blowing of nose helps drain the (within thorax) sinuses. The nasolacrimal ducts, which drain tears Nose from the eyes also empty into the nasal Nasal Cavity cavity. Sinuses Pharynx PHARYNX Larynx Commonly called throat Lower Is a muscular passageway that vaguely respiratory resembles a short length garden hose. (outside thorax) It is continuous with the nasal cavity anteriorly via the posterior nasal aperture. Trachea The air enters the superior portion, the Bronchial nasopharynx and then descends the Tree oropharynx and laryngopharynx to enter the Lungs larynx below. The pharyngotympanic tubes, which drain the middle ear open into nasopharynx. The pharyngeal tonsils are often called adenoid which is located high in nasopharynx. NOSE The palatine tonsils are in the oropharynx at the end of soft palate. Pug- or ski jump in shape, is the only Lingual tonsils which lie at the base of the externally visible part of the respiratory tongue. system. The air enter the nose through the nostrils or nares. The interior of the nose consist of the nasal cavity, divided by nasal septum. Olfactory receptor for the sense of smell are located in the mucosa in the slitlike superior part of the nasal cavity just beneath the ethmoid. Respiratory mucosa, rests on a rich network of thinned walled veins that warms the air as it flows past.  02 LARYNX Or voice box, routes air and food into the proper channels and plays a role in speech. Epiglottis contains an eight rigid hyaline cartilages and spoon-shaped flap of elastic cartilage. Sometime called the guardian of the airway. Thyroid cartilage is the largest of the hyaline cartilage which protrudes anteriorly and is commonly called Adams apple. Vocal Folds or true vocal cords – part of the mucus membrane in the larynx which vibrate with expelled air- allow us to speak. Glottis is a slit like passageway between the vocal folds. TRACHEA Also known as the windpipe. Is a rigid which reinforced with C-shaped rings of hyaline cartilage. The open parts of the rings about the esophagus and allow it to expand anteriorly when we swallow a large piece of food. The solid portion support the tracheal walls The pleural membranes produce pleural and keep it patent, in spite of the pressure fluid, a slippery serous secretion which allow changes that occur during breathing. lungs to glide easily over the thorax wall during breathing movements and causes the pleural layers to cling together. BRONCHIOLES Small conducting passageway of air entering the lungs RESPIRATORY TREE MAIN BRONCHI The network that is formed from the The right and left main bronchi are formed by branching and rebranching of the respiratory the division of trachea passageways within the lungs. The right bronchus is wider, shorter and straighter than the left. The most common ALVEOLI site for an inhaled foreign object to become dislodged. Air sacs LUNGS RESPIRATORY ZONES Occupy the entire thoracic cavity. Includes the respiratory bronchioles, alveolar The narrow superior of the lungs, the apex, ducts and alveolar sacs and the alveoli. is just deep to the clavicle. The broad lung area resting on the diaphragm is the base. Each lung is divided into lobes by fissures, the left lung has two lobes and the right lung has three lobes. The surface of the lung is covered with a visceral pleura. The thoracic cavity is lined by parietal pleura.  03 RESPIRATORY MEMBRANE Expiration Air-blood barrier. When air is leaving the lungs. Membranes that fused capillary walls and It follows passively as thoracic volume alveoli. decreases and intrapulmonic pressure rises It has gas flowing past on one side and the above atmospheric, with the recoil of the rib blood flowing past on the other side. cage and contraction of the lungs. The gas exchange occur by simple diffusion through the respiratory membrane. Respiratory Physiology RESPIRATIONS Four distinct events must occur Pulmonary Ventilation External Respiration Respiratory Gas Transport Internal Respiration I PULMONARY VENTILATION EXTERNAL RESPIRATION Commonly known as breathing. Air must move into and out of the lungs Gas exchange (oxygen loading and carbon so that gases in the air sacs of the dioxide unloading) between the pulmonary lungs continuously refreshed. blood and alveoli must takes place. Two phases include inspiration and Gas exchange are being made between the expiration. blood and the body exterior Mechanics of Breathing Is a completely mechanical process that depends on volume changes occurring in the thoracic cavity. Volume changes leads to pressure changes, which lead to the flow of gases to equalize the pressure. Inspiration When air is flowing into the lungs. Occurs when contraction of respiratory muscles cause an increase in thoracic volume, with expansion of lungs and a decrease in intrathoracic and intrapulmonic pressure.  04 RESPIRATORY GAS TRANSPORT Assessment Oxygen and carbon dioxide must be normal physical assessment of the transported to and from the lungs and tissue respiratory system cells of the body via bloodstream. Nose Symmetric with no deformities. If the oxygen transported in the blood, only Nasal mucosa pink, moist with small amount is dissolved in the plasma. no edema, exudate, blood, or More than 99% of the oxygen is carried by polyps hemoglobin molecules in the red blood cells Nasal septum straight; nares Carbon dioxide carried in the blood is mostly patent bilaterally. converted to bicarbonate ions in the red blood Oral Mucosa Light pink, moist, with no cells and released into the plasma. exudate or ulcerations. Pharynx Smooth, moist, and pink. Neck Trachea midline Chest Anteroposterior to lateral diameter 1:2 Respirations nonlabored at 14 breaths/min Breath sounds vesicular without crackles, rhonchi, or wheezes Excursion equal bilaterally with no increase in tactile fremitus FOCUSED ASSESSMENT Respiratory System INTERNAL RESPIRATION Use this checklist to make sure the key assessment steps have been Gas exchange between the blood and cells done. inside the body. Subjective Ask the patient about any of the following and note responses. Shortness of breath Y N Wheezing Y N Sputum production (calor, Y N quantity) Pain with breathing Y N Cough Y N objective: diagnostic Check the following laboratory tests for critical values. Arterial blood gases Chest x-ray Het, Hgb objective: physical examination Observe Respirations for rate, quality, and pattern Inspect Skin and nails for integrity and color Neck for position of trachea Shape, symmetry, and movement of chest wall palpate Chest and back for masses Auscultate Lung (breath) sounds 05  06 DIAGNOSTIC ASSESSMENT  07 ALTERATIONS IN VENTILATION ACUTE and CHRONIC Obstructive Pulmonary Disease Obstructive pulmonary disease, the most common chronic lung disease, is characterized by increased resistance to airflow as a result of airway obstruction or airway narrowing. Types of Obstructive Lung diseases 1. Asthma 2. COPD 3. Cystic Fibrosis (CF), 4. Bronchiectasis I Asthma is a chronic inflammatory lung disease that results in variable episodes of airflow obstruction, but it is usually reversible. The chronic inflammation leads to recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night or in the early morning PULMONARY CAPILLARY WEDGE PRESSURE Risk Factors for Asthma and Triggers is an integrated measurement of the of Asthma Attacks compliance of the left side of the heart and “GRAND POGI” the pulmonary circulation. The measurement of PCWP can be useful in several diagnostic Genetics settings. Atopy, the genetic predisposition to It is frequently used to assess left ventricular develop an allergic (immunoglobulin filling, represent left atrial pressure, and E [IgE]–mediated) response to assess mitral valve function. It is measured by common allergens, is a major risk inserting a balloon-tipped, multi-lumen factor for asthma. catheter (Swan-Ganz catheter) into a central Respiratory Tract Infections. vein and advancing the catheter into a branch Allergens. of the pulmonary artery. The balloon is then Nose and Sinus Problems. inflated, which occludes the branch of the Drugs and Food Additives. pulmonary artery and then provides a Psychological Factors. pressure reading that is equivalent to the Occupational Factors. pressure of the left atrium. Gastroesophageal Reflux Disease. Immune Response. 08  09 Clinical Manifestations Diagnostic Studies “CAPT CAMP B” Wheezing Cough Clinical manifestations Dyspnea A detailed history Expiration may be prolonged. Instead of Peak flow variability or spirometry a normal inspiratory-expiratory ratio of The peak expiratory flow rate (PEFR) 1:2, it may be prolonged to 1:3 or 1:4. measured by the peak flow meter is an aid to diagnose and monitor asthma. Complications Chest x-ray Allergy skin testing (if indicated) Severe and Life-Threatening Asthma Measurement of oximetry Exacerbations. Pulmonary function tests (PFTs) can be used to determine the reversibility of Occur when the patient is dyspneic bronchoconstriction (using at rest and the patient speaks in bronchodilators) and thus establish the words, not sentences, because of diagnosis of asthma the difficulty of breathing. Blood level of eosinophils and IgE (if The patient is usually sitting forward indicated) to maximize the diaphragmatic movement with prominent Collaborative wheezing, a respiratory rate higher “IIP DADA” than 30 breaths/minute, and pulse greater than 120 beats/minute. Intermittent and Persistent Asthma Accessory muscles in the neck are Identification and avoidance or straining to lift the chest wall, and elimination of triggers the patient is often agitated. Patient and caregiver teaching Drug therapy Asthma action plan SAFETY ALERT Desensitization (immunotherapy) if indicated If the patient has been wheezing and Assess for control (e.g., Asthma Control then there is an absence of a Test [ACT]) wheeze (i.e., silent chest) and the patient is obviously struggling, this is a life-threatening situation that may require mechanical ventilation.  10 DRUG THERAPY Long-Term Control Versus Quick Relief of Asthma Long-Term Control Quick-Relief Medications Medications Anti inflammatory Anti inflammatory Drugs Drugs Corticosteroids Corticosteroids Inhaled (e.g., (systemic) (e.g., fluticasone prednisone)† [Flovent Diskus or HFA]) Oral (e.g., prednisone) Leukotriene modifiers (e.g., COLLABORATIVE CARE montelukast [Singulair]) Acute Asthma Exacerbations. Anti-IgE (omalizumab [Xolair]) Usually the symptoms are relieved at home promptly with an SABA such as Bronchodilators Bronchodilators albuterol delivered via a nebulizer or metered-dose inhaler (MDI) with a Long-acting Short-acting spacer. For any classification of asthma inhaled ẞ2- inhaled ẞ2- in a “rescue plan,” patients are adrenergic agonists adrenergic agonists instructed to take 2 to 4 puffs of (e.g., salmeterol (e.g., albuterol [Serevent]) [Proventil HFA]) albuterol every 20 minutes three times Long-acting oral Anticholinergics to gain rapid control of symptoms. ẞ2-adrenergic (inhaled) (e.g., Occasionally a short course of oral agonists (e.g., ipratropium corticosteroids is needed to decrease albuterol [VoSpire [Atrovent HFA]) airway inflammation. ER]) Relief is provided with the SABA Methylxanthines delivered as in the mild exacerbation, (e.g., theophylline [Theo-24) and oral corticosteroids are needed. Oral routes are usually as effective as IV routes.  11 Severe and Life-Threatening Asthma DRUG THERAPY Exacerbations. Medications are divided into two SaO2 monitoring general classifications: ABGs Inhaled β2-adrenergic agonists 1 Quick-relief or rescue Inhaled anticholinergic agents (only in medications the initial treatment) O2 by mask or nasal prongs to treat symptoms and IV or oral corticosteroids exacerbations, such as SABAs. IV fluids IV magnesium and/or heliox 2 Long-term control medications Intubation and assisted ventilation to achieve and maintain control of persistent asthma, such as ICSs.  12 DRUG ALERT β2-Adrenergic Agonists Use with caution in patients with cardiac disorders, as they may cause elevated blood pressure, increased heart rate, central nervous system stimulation, and increased risk of dysrhythmias. Overuse of SABAs can lead to rebound bronchospasm. Long-Acting β2-Adrenergic Agonists (LABAs): Should not be the first medicine used for asthma treatment. Should never be used as the only medication for asthma; only add LABAs if other controller medicines do not provide sufficient control. Do not use LABAs for worsening wheezing; use a SABA instead for sudden wheezing. Theophylline Instruct patients to report signs of toxicity such as nausea, vomiting, seizures, and insomnia. Advise patients to avoid caffeine, as it may intensify the adverse effects of theophylline.  13 II Cystic fibrosis Another form of obstructive pulmonary disease Is a genetic disorder that produces airway obstruction because of changes in exocrine glandular secretions, resulting in increased mucus production. Is an autosomal recessive, multisystem disease characterized by altered transport of sodium and chloride ions in and out of epithelial cells. This defect primarily affects the lungs, gastrointestinal tract (pancreas and biliary tract), and reproductive tract. CF was first described in 1938 when autopsies of young children revealed multiple cysts in the pancreas, so the disease was called “cystic fibrosis of the pancreas.” Etiology and Pathophysiology The CF gene is located on chromosome 7 and produces a protein called CF transmembrane regulator (CFTR). The CFTR protein localizes to the epithelial surface of the airways, gastrointestinal tract, and ducts of the liver, pancreas, and sweat glands. CFTR regulates sodium and chloride Cystic Fibrosis channels. Bacterial Infections Mutations in the CF gene alter this protein in such a way that the channels are blocked. As a result, cells that line the Mucociliary mechanism is damaged passageways of the lungs, pancreas, intestines, and other organs produce secretions that are low in sodium chloride content (thus low in water Bacteria and mucus to content), making mucus abnormally accumulate within the pockets thick and sticky. This mucus fills (plugs up) the glands in these organs and causes the glands to atrophy, ultimately resulting in organ Reduced ability to clear mucus failure. from the lungs and decreased The hallmark of respiratory involvement expiratory airflow in CF is its effect on the airways. The disease progresses from being a Clinical manifestation disease of the small airways (chronic bronchiolitis) to involvement of the An initial finding of meconium ileus in larger airways, and finally causes the newborn infant prompts the destruction of lung tissue. diagnosis in 20% of people with CF. The mucus becomes dehydrated and acute or persistent respiratory tenacious due to the defect in the symptoms (wheezing, coughing, chloride secretion and excess sodium frequent pneumonia), failure to thrive absorption. Cilia motility is decreased, or malnutrition, steatorrhea (large, oily, thus allowing mucus to adhere to the frequent bowel movements), and family airways. The bronchioles become history. obstructed with thick mucus, leading to Without treatment, a large, protuberant air trapping and hyperinflation of the abdomen may develop with an lungs. emaciated appearance of the extremities. One of the most common symptoms of CF in the adult is frequent cough. With time, the cough becomes persistent and produces viscous, purulent, often yellow or greenish sputum.  14 II If the patient with CF develops DIOS (Distal Intestinal Obstruction Sweat Chloride Test: Syndrome), he or she may have right lower quadrant pain (the area of the The sweat chloride test is ileocecal valve), loss of appetite, performed with the pilocarpine nausea, emesis, and often a palpable iontophoresis method. mass. Pilocarpine is placed on the skin Insufficient pancreatic enzyme release and carried by a small electric causes the typical pattern of protein current to stimulate sweat and fat malabsorption with a person production. This part of the process being thin with a low body mass index II takes about 5 minutes, and the (BMI) and frequent, bulky, foul-smelling patient feels a slight tingling or stools. warmth. Both males and females have delayed The sweat is collected on filter puberty paper or gauze and then analyzed Some women with CF have difficulty for sweat chloride concentrations. conceiving; the cervical mucus is The test takes approximately 1 thought to be thickened. During hour. exacerbations, menstrual irregularities Sweat chloride values above 60 and secondary amenorrhea are mmol/L are considered positive for common. the diagnosis of CF. Usually, a second sweat chloride test is obtained at the same time (one test in each arm) to confirm the diagnosis. II Complications Complications in CF include CFRD (cystic fibrosis-related diabetes), bone Collaborative Care disease, sinus disease, and liver disease. Aerosol and nebulization treatments of Pneumothorax, a relatively uncommon medications used to dilate the airways, but serious complication, is caused by liquefy mucus, and facilitate clearance. the formation of bullae and blebs. Agents that degrade the DNA in CF A small amount of blood in sputum is sputum (e.g., dornase alfa common in the CF patient because of [Pulmozyme]) increase airflow and chronic lung infection. reduce the number of acute pulmonary exacerbations. DIAGNOSTIC STUDIES Inhaled hypertonic saline (7%) is effective in clearing mucus and also The diagnostic criteria for CF include a decreases the frequency of combination of clinical presentation, exacerbations. family history, laboratory testing, and Bronchodilators (e.g., β2-adrenergic genetic testing. agonists) may be used to control The sweat chloride test is considered bronchospasm, but the long-term the gold standard for the diagnosis of benefit is not proven. CF. CPT (including postural drainage with A blood sample or cells taken inside the percussion and vibration) cheek (buccal smear) are sent to a Standard treatment of infections laboratory that specializes in genetic includes antibiotics for exacerbations testing. Most laboratories test for only and may include chronic suppressive the most common mutations of the CF therapy in conjunction with airway gene. clearance.  15 II The management of pancreatic insufficiency includes pancreatic enzyme replacement of lipase, protease, and amylase (e.g., pancrelipase [Pancreaze, Creon, Ultresa, Viokase, Zenpep]) administered before each meal and snack. Adequate intake of fat, calories, protein, and vitamins is important. Fat- soluble vitamins (A, D, E, and K) must be supplemented, since they are malabsorbed. Use of caloric supplements improves nutritional. If the patient develops DIOS with complete bowel obstruction, gastric decompression may be needed Ivacaftor (Kalydeco) is used to treat patients who have a specific G551D mutation in the CFTR gene. Aerobic exercise is effective in clearing the airways.  16 III Bronchiectasis Clinical Manifestations Is an obstructive disease characterized The hallmark of bronchiectasis is by dilated bronchioles. It most persistent cough with consistent frequently results from untreated or production of thick, tenacious, purulent poorly treated pulmonary infections that sputum. cause an increase in sputum Recurrent infections injure blood production. vessels, and hemoptysis occurs. Characterized by permanent, abnormal Pleuritic chest pain, dyspnea, wheezing, dilation of medium-sized bronchi that is clubbing of digits, weight loss, and a result of inflammatory changes that anemia. destroy elastic and muscular structures supporting the bronchial wall. Infection is the primary reason for the continuing cycle of inflammation, airway damage, and remodeling. Airways can become colonized with microorganisms (e.g., Pseudomonas species), which cause the bronchial walls to weaken, and pockets of infection begin to form. Diagnostic Studies An individual with a chronic productive cough with copious purulent sputum (which may be blood streaked) should be suspected of having bronchiectasis. Chest x-rays may show some nonspecific abnormalities. A high-resolution CT (HRCT) scan of the chest is the preferred method for diagnosing bronchiectasis. Sputum examination  17 Collaborative Care Antibiotics are the mainstay of treatment and are often given empirically, but attempts are made to culture the sputum. Long-term suppressive therapy with antibiotics is reserved for those patients who have symptoms that recur a few days after stopping antibiotics. Concurrent bronchodilator therapy with LABAs, SABAs, or anticholinergics is given to prevent bronchospasm and stimulate mucociliary clearance Maintaining good hydration is important to liquefy secretions. CPT and other airway clearance techniques are important to facilitate expectoration of sputum. Teach the patient to reduce exposure to excessive air pollutants and irritants, avoid cigarette smoking, and obtain pneumococcal and influenza vaccinations. IV Chronic Obstructive Pulmonary Disease (COPD) Is a disease with progressive limitation in airflow that is not fully reversible. is a preventable and treatable disease characterized by persistent airflow limitation that is slowly progressive. COPD have included such terms as chronic bronchitis and emphysema.  18 Emphysema Clinical Manifestations Is an abnormal permanent enlargement A chronic intermittent cough, which is of the air spaces distal to the terminal often the first symptom to develop. bronchioles, accompanied by dyspnea is progressive, usually occurs destruction of their walls and without with exertion, and is present every day. obvious fibrosis. Patients may complain of not being able to take a deep breath, heaviness in the chest, gasping, increased effort to breathe, and air hunger. In late stages of COPD, dyspnea may be present at rest Wheezing and chest tightness may be present, but may vary by time of the day or from day to day, especially in patients with more severe disease. The person with advanced COPD frequently experiences fatigue, weight loss, and anorexia. The anteroposterior diameter of the chest is increased (“barrel chest”) from the chronic air trapping. Chronic Bronchitis The patient may sit upright with arms supported on a fixed surface such as an Is the presence of chronic productive overbed table (tripod position). cough for 3 months in each of 2 The patient may naturally purse lips on consecutive years in a patient in whom expiration (pursed-lip breathing) other causes of chronic cough have Edema in the ankles may be the only been excluded. clue to right-sided heart involvement Inflammation and eventual scarring of (cor pulmonale). the lining of bronchial tubes. This restricts airflow to and from the lungs, classification which produces heavy mucus and phlegm. The mucus-lined tubes are an ideal breeding place for bacterial infections. Blue bloaters often take deeper breaths but can’t take in the right amount of oxygen. complications Cor Pulmonale results from pulmonary hypertension, which is caused by diseases affecting the lungs or pulmonary blood vessels In COPD, pulmonary hypertension is caused primarily by constriction of the pulmonary vessels in response to ETIOLOGY alveolar hypoxia, with acidosis further potentiating the vasoconstriction. Cigarette Smoking. Chronic alveolar hypoxia causes Occupational Chemicals and Dusts vascular remodeling. Chronic hypoxia Air Pollution. also stimulates erythropoiesis, which Infection causes polycythemia. This results in Genetics increased viscosity of the blood. An α1-Antitrypsin (AAT) Deficiency. α1- anatomic reduction of the pulmonary Antitrypsin (AAT) deficiency is an vascular bed, as seen in emphysema autosomal recessive disorder that may with bullae, may occur. affect the lungs or liver Dyspnea is the most common symptom Aging of chronic cor pulmonale. Lung sounds are normal, or crackles may be heard in the bases of the lungs bilaterally.  19 Heart sound changes occur but are The BODE index can be used to assess usually masked by the underlying lung not only the risk of death from COPD, disease. but also the pulmonary and systemic Other manifestations of right-sided manifestations heart failure may develop, including COPD Assessment Test (CAT) and distended neck veins (jugular venous modified Medical Research Council distention), hepatomegaly with right (mMRC) Dyspnea Scale upper quadrant tenderness, peripheral edema, and weight gain. Collaborative Care Smoking Cessation Drug Therapy Bronchodilators (Beta adrenergic agonist) Anticholinergic Methylxanthines Roflumilast (Daliresp) is an oral medication used to decrease the frequency of exacerbations in severe COPD. This drug is a phosphodiesterase inhibitor, which is an anti-inflammatory drug that suppresses the release of cytokines and other inflammatory mediators, and inhibits the production of reactive oxygen radicals Oxygen Therapy COPD Exacerbation is an acute event Breathing Retraining in the natural course of the disease. The primary causes of exacerbations The purpose of pursed-lip breathing are bacterial or viral infections. (PLB) is to prolong exhalation and Exacerbations are signaled by an acute thereby prevent bronchiolar collapse change in the patient’s usual dyspnea, and air trapping. PLB is simple and cough, and/or sputum (i.e., something easy to teach and learn, and it gives different from the usual daily patterns) the patient more control over Be alert for signs of severity such as breathing, especially during exercise use of accessory muscles, central and periods of dyspnea cyanosis, edema in the lower Diaphragmatic (abdominal) extremities, unstable BP, right-sided breathing focuses on using the heart failure, and altered alertness. diaphragm instead of the accessory Patients with severe COPD who have muscles of the chest to (1) achieve exacerbations are at risk for respiratory maximum inhalation and (2) slow failure. the respiratory rate. Discontinuing bronchodilator or corticosteroid medication may also Airway Clearance Techniques. It loosen precipitate respiratory failure mucus and secretions so they can be Chronic treatment with β-blockers may cleared by coughing. improve survival and reduce the risk of Effective Coughing. exacerbations of COPD. Huff coughing is an effective forced Many patients with COPD experience expiratory technique that you can depression and anxiety. easily teach the patient Help the patient with muscle relaxation exercises that can reduce anxiety Chest physiotherapy (CPT) is primarily Cognitive and a behavioral therapy used for patients with excessive along with COPD teaching may improve bronchial secretions who have difficulty the quality of life. clearing them Buspirone (BuSpar), which is used to treat anxiety, has few if any respiratory Postural drainage is the use of depression effects positioning techniques that drain secretions from specific segments of Diagnostic Studies the lungs and bronchi into the trachea. Spirometry confirms the presence of The purpose of various positions in airflow obstruction and determines the postural drainage is to drain each severity of COPD segment toward the larger airways. Chest x-rays- hyperinflation A side-lying position can be used for Ct scan – emphysema the patient who cannot tolerate a 6-minute walk test head down position.  20 Percussion and vibration are manual The second surgical procedure is or mechanical techniques used to bullectomy. This procedure is used augment postural drainage. These for carefully selected patients with techniques are used after the emphysematous COPD who have patient has assumed a postural large bullae (larger than 1 cm). drainage position to assist in The third surgical procedure is lung loosening the mobilized secretions. transplantation, which benefits Vibration is accomplished by tensing carefully selected patients with the hand and arm muscles advanced COPD. Although single- repeatedly and pressing mildly with lung transplant is the most the flat of the hand on the affected commonly used technique because area while the patient slowly of a shortage of donors, bilateral exhales a deep breath transplantation can be performed Airway bypass is a Nutritional Therapy bronchoscopic procedure currently under evaluation to Sometimes it is difficult for patients determine if creating small with COPD to consume adequate extra-anatomic openings amounts of nutrients. Teach the between the diseased lung and patients to make mealtimes easier the distal bronchi can reduce and more nutritious by increasing hyperinflation calories and protein without increasing the amount of food eaten. Eat high-calorie foods first. Limit liquids at mealtimes. Rest before meals. Try more frequent meals and snacks. Increase calories by adding margarine, butter, mayonnaise, sauces, gravies, and peanut butter to foods. Keep favorite foods and snacks on hand. Try cold foods, which can make you feel less full than hot foods. Keep ready-prepared meals available for times when you have increased shortness of breath. Eat larger meals when you are not as tired. Avoid foods that you know cause gas (e.g., cabbage, beans, cauliflower). Add skim milk powder (2 tbs) to regular milk (8 oz) to add protein and calories. Use milk or half-and-half instead of water when making soups, cereals, instant puddings, cocoa, or canned soups. Add grated cheese to sauces, vegetables, soups, and casseroles. Choose dessert recipes that contain egg (e.g., sponge cake, angel food cake, egg custard, bread pudding, rice pudding). Surgical Therapy for COPD Lung volume reduction surgery (LVRS). The goal of this surgery is to reduce the size of the lungs by removing the most diseased lung tissue so the remaining healthy lung tissue can perform better.  NCM 118 MODULE 6: RESPONSES TO ALTERED TISSUE PERFUSION Prepared by: Claire B. Villaveja, RN Alterations in tissue perfusion also are sufficient The major functions of the to contribute to systemic inflammation. Reduced cardiovascular system cardiac output (particularly during exercise) and increased venous pressure are central to all The cardiovascular system consists of two etiologies of heart failure and result in reduced main loops, systemic circulation, and end organ blood flow. pulmonary circulation. The purpose of the cardiovascular system is to provide adequate Organ Systems Involved circulation of blood through the body. Pulmonary circulation allows for the The heart is the organ that pumps blood oxygenation of the blood, and systemic through the vessels. It pumps blood directly circulation provides for oxygenated blood and into arteries, more specifically, the aorta or nutrients to reach the rest of the body. the pulmonary artery. Blood vessels are critical because they Mechanism control the amount of blood flow to specific parts of the body. Blood vessels include Blood comes into the right atrium from the arteries, capillaries, and veins. body, moves into the right ventricle and is Arteries carry blood away from the heart and pushed into the pulmonary arteries in the can divide into large and small arteries. lungs. After picking up oxygen, the blood travels back to the heart through the Large arteries receive the highest pressure pulmonary veins into the left atrium, to the of blood flow and are thicker and more left ventricle and out to the body's tissues elastic to accommodate the high through the aorta. pressures. Smaller arteries, such as arterioles, have more smooth muscle, which contracts or relaxes to regulate blood flow to specific portions of the body. Arterioles face a smaller blood pressure, meaning they don't need to be as elastic. Arterioles account for most of the resistance in pulmonary circulation because they are more rigid than larger arteries. Furthermore, the capillaries branch off of arterioles and are a single-cell layer. This thin layer allows for the exchange of nutrients, gases, and waste with tissues and organs. Also, the veins transport blood back to the heart. They contain valves to prevent the backflow of blood.  22 Your cardiac conduction system contains The bundle of His runs down the length specialized cells and nodes that control your of the interventricular septum, the heartbeat. These are the: structure that separates your right and a. Sinoatrial node. left ventricles. The bundle of His has b. Atrioventricular node. two branches: c. Bundle of His (atrioventricular bundle). d. Purkinje fibers. Left bundle branch sends electrical signals through the A Sinoatrial node Purkinje fibers to your left ventricle. Right bundle branch sends Your sinoatrial node is sometimes called electrical signals through the your heart’s natural pacemaker. It Purkinje fibers to your right sends the electrical impulses that start ventricle. the heartbeat. The SA node is in the upper part of D Purkinje fibers your heart’s right atrium. It is at the edge of your atrium near your superior The Purkinje fibers are branches of vena cava (vein that brings oxygen- specialized nerve cells. They send poor blood from your body to your electrical signals very quickly to your heart). right and left heart ventricles. Your autonomic nervous system Your Purkinje fibers are in the controls how fast or slowly your SA subendocardial surface of your ventricle node sends electrical signals. This part walls. The subendocardial surface is of the nervous system directs hormones part of the endocardium, the inner layer that control your heart rate based on of tissue that lines your heart’s what you are doing. For example, your chambers. heart rate increases during exercise and When the Purkinje fibers deliver slows when you are asleep. electrical signals to your ventricles, the The autonomous nervous system ventricles contract. As they contract, includes your: blood flows from your right ventricle to your pulmonary arteries and from your Sympathetic nervous system left ventricle to your aorta. The aorta is (fight or flight response) makes the body’s largest artery. It sends blood your SA node work faster, which from your heart to the rest of your increases your heart rate. body. Parasympathetic nervous system (rest and digest response) Mechanism Cardiac Conduction makes your SA node work slower, which decreases your heart rate. Your heart pump that sends blood through your body. For each heartbeat, electrical B Atrioventricular node signals travel through the conduction pathway of your heart. It starts when your sinoatrial The atrioventricular node delays the SA (SA) node creates an excitation signal. This node’s electrical signal. It delays the electrical signal is like electricity traveling signal by a consistent amount of time (a through wires to an appliance in your home. fraction of a second) each time. The delay ensures that your atria are empty of blood before the contraction stops. The atria are the heart’s upper chambers. They receive blood from your body and empty it into the ventricles. Your AV node is located in an area known as the triangle of Koch (located between the septal leaflet of the tricuspid valve, the coronary sinus and the membranous portion of the interatrial septum). This is near the central area of the heart. C Bundle of His The bundle of His is also called the atrioventricular bundle. It is a branch of fibers (nerve cells) that extends from your AV node. This fiber bundle receives the electrical signal from the AV node and carries it to the Purkinje fibers.  23 The excitation signal travels to: Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan 1. Your atria (top heart chambers), telling Ineffective tissue perfusion describes the lack them to contract. of oxygenated blood flow to areas of the 2. The atrioventricular (AV) node, delaying body. Proper perfusion is detrimental to the the signal until your atria are empty of function of organs and body systems as blood. organs and tissues that are not perfusing will A The bundle of His (center bundle of nerve 3. die. fibers), carrying the signal to the Purkinje fibers. ASSESSMENT 4. The Purkinje fibers to your ventricles (bottom heart chambers), causing them (As evidenced by) Cardiopulmonary to contract. 5. These steps make up one full contraction Subjective: Objective: of your heart muscle. Your heart (patient reports) (nurse assesses) conduction system sends out thousands of signals per day to keep your heart Chest Pain Arrhythmias beating. Dyspnea Capillary refill >3 Sense of seconds impending Altered respiratory rate doom Use of accessory muscles to breathe Abnormal arterial blood gases (As evidenced by) Gastrointestinal Subjective: Objective: (patient reports) (nurse assesses) Nausea Hypoactive or absent Abdominal bowel sounds Pain Distended abdomen Vomiting Electrolyte imbalance (As evidenced by) Renal Subjective: Objective: (patient reports) (nurse assesses) Nausea High or low blood Abdominal pressure Pain Decreased urine output Elevated BUN/creatinine Cerebral (As evidenced by) Altered Mental Status Subjective: Objective: (patient reports) (nurse assesses) Nausea Restlessness Unconscious/ Changes in speech Lethargic Difficulty swallowing Abdominal Motor weakness Pain Changes in pupillary reaction (As evidenced by) Peripheral Subjective: Objective: (patient reports) (nurse assesses) Altered skin Weak or absent sensations peripheral pulses Claudication Cool skin temperature Thickened nails Skin discoloration; pallor when legs are raised and rubor when dependent Loss of hair to legs Edema Delayed wound healing  24 Diagnostic test A Non-invasive: ECG An electrocardiogram (ECG) is a simple, non-invasive test that records the electrical activity of the heart. Echocardiography An echocardiogram, or "echo", is a scan used to look at the heart and nearby blood vessels. It's a type of ultrasound scan, which means a small probe is used to send out high-frequency sound waves that create echoes when they bounce off different parts of the body. B invasive: Cardiac Catheterization Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. Central Venous Pressure (CVP) Central venous pressure (CVP) is the blood pressure in the vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system.  25 Pulmonary Artery Pressure (PAP) ACUTE ISCHEMIC HEART DISEASE The normal pulmonary artery Acute coronary syndrome (ACS, formerly systolic pressure is 20 mm Hg or called ischemic heart disease) refers to a large less, and the normal mean spectrum of clinical conditions including (average) pulmonary artery unstable angina, myocardial injury, and pressure is 12 mm Hg. A number of myocardial infarction (MI). ACS is caused by a disease processes affect the sudden onset of cardiac tissue ischemia pulmonary circulation and increase secondary to impaired blood flow. the pressure levels in the pulmonary Ischemia is defined as inadequate blood arteries and right ventricle. supply (circulation) to a local area due to blockage of the blood vessels supplying the Intra-arterial blood pressure area. monitoring Ischemic means that an organ (e.g., the heart) is not getting enough blood and Done through the cannulation of oxygen. Ischemic heart disease, also called a peripheral artery. This form of coronary heart disease (CHD) or coronary monitoring is commonly utilized artery disease, is the term given to heart in the management of critically problems caused by narrowed heart ill and perioperative patients. (coronary) arteries that supply blood to the heart muscle. The narrowing can be caused by a blood clot or by constriction of the blood vessel, most often it is caused by buildup of plaque, called atherosclerosis. When the blood flow to the heart muscle is completely blocked, the heart muscle cells die, which is termed a heart attack or myocardial infarction (MI). Angina is a clinical The discomfort experienced when the heart syndrome muscle is deprived of adequate oxygen by characterized is called angina pectoris. discomfort in the Angina is a clinical syndrome characterizedjaw, chest, by discomfort in the chest, jaw, shoulder, back, shoulder, back, or or arms that is typically aggravated by exertion or emotional stress and relieved NURSING DIAGNOSIS promptly with rest or by taking Activity Intolerance related to Insufficient nitroglycerin. Oxygen for Activities of Daily Living Angina usually Anxiety related to Breathlessness Imbalanced occurs in patients Nutrition: Less than Body Requirements with CHD, but also related to Nausea; Anorexia Secondary to can occur in Venous Congestion individuals with Impaired Peripheral Tissue Perfusion related valvular disease, to Venous Congestion hypertrophic Disturbed Sleep Pattern related to Nocturnal cardiomyopathy, Dyspnea and uncontrolled Powerlessness related to Progressive Nature hypertension. of Condition High Risk for Ineffective Therapeutic Regimen Management related to Lack of Knowledge Pain related to Impaired Circulation PLANNING Recognize Myocardial ischemia Relieve chest pain Maintain a calm environment Balance of myocardial oxygen supply and demand Optimize cardiopulmonary function Promote comfort and emotional support Monitor effects of Pharmacologic therapy Patient education  26 Nursing Intervention HEART FAILURE Administer oxygen along with medication Heart failure, also known as congestive therapy to assist with relief of symptoms. heart failure, is a condition that develops Encourage bed rest with the back rest when your heart doesn't pump enough blood elevated to help decrease chest discomfort for your body's needs. This can happen if your and dyspnea. heart can't fill up with enough blood. It can also happen when your heart is too weak to Surgical Interventions pump properly. Implantable cardioverter Heart failure can be caused by a defibrillator (ICD) weakened, damaged or stiff heart. An ICD is a small device implanted If the heart is damaged or weakened, the beneath your skin in your chest or heart chambers may stretch and get bigger. abdomen. When it detects an irregular The heart can't pump out the needed amount heart rhythm, the ICD sends small of blood. electrical charges to your heart to put it If the main pumping chambers of the heart, back in a normal rhythm. You may need called the ventricles, are stiff, they can't fill an ICD if you’re at risk for life- with enough blood between beats. threatening ventricular arrhythmias or The heart muscle can be damaged by certain sudden cardiac death. infections, heavy alcohol use, illegal drug use and some chemotherapy medicines. Your Cardiac resynchronization therapy genes also can play a role. (CRT) Any of the following conditions also can CRT is a specialized treatment for damage or weaken the heart and cause people who have heart failure. It helps heart failure keep your heart in steady rhythm using a device called a biventricular Coronary artery disease and heart attack. pacemaker. It includes leads placed High blood pressure. within your heart and a pulse generator Heart valve disease. placed below the skin in your chest. Inflammation of the heart muscle, also called The biventricular pacemaker helps myocarditis. synchronize your heart rhythm so that A heart problem that you're born with, also your heart contracts and pumps blood called a congenital heart defect. more effectively. Irregular heart rhythms, called arrhythmias. Percutaneous coronary intervention Causes of sudden heart failure also (PCI) include: A PCI is a catheter-based procedure to Allergic reactions. open a blocked artery. Your physician Any illness that affects the whole body. uses a small, hollow tube (catheter) to Blood clots in the lungs. send a balloon to your coronary artery. Severe infections. When the balloon inflates, it Use of certain medicines. compresses plaque and opens your Viruses that attack the heart muscle. artery. Then they place a mesh tube called a stent in the artery. The stent is Type of heart coated with medication and provides Description failure support to keep your artery open long- term. This type affects the lower right heart chamber, called the right Right-sided heart ventricle. Fluid may back up into Atherectomy failure the belly, legs and feet, causing swelling. Sometimes a blockage is hardened and can’t effectively be treated with a PCI. This type affects the lower left In this case, your doctor may use a Left-sided heart heart chamber, called the left catheter to insert a small drill-like failure ventricle. Fluid may back up in the device or laser into your artery to break lungs causing shortness of breath. apart the plaque and remove it. Heart failure with This is a type of left-sided heart reduced ejection failure. The left ventricle can't fraction (HFTEF), also squeeze as strong as it should. The Coronary artery bypass graft (CABG) called systolic heart heart isn't strong enough to pump surgery failure enough blood to the body. CABG is an open-heart surgery. During Heart failure with This is a type of left-sided heart the procedure, your surgeon uses a preserved ejection failure. The left ventricle can't relax fraction (HFPEF), also or fill fully. The heart has a blood vessel from another part of your called diastolic heart body to create a new path around one problem filling with blood. failure or more blocked arteries.  27 Nursing Interventions RISK FACTORS Improve myocardial contractility and A heart attack is the most common cause of perfusion. cardiogenic shock. A severe heart attack can Enhance heart's pumping function to ensure damage your heart’s main pumping chamber adequate blood flow to organs through (left ventricle). When this happens, your body medications can’t get enough oxygen-rich blood. Monitoring vital signs In rare cases of cardiogenic shock, it’s the Optimizing fluid balance bottom right chamber of your heart (right Manage fluid volume ventricle) that’s damaged. The right ventricle pumps blood to your lungs, where it gets CARDIOGENIC SHOCK oxygen and then goes to the rest of your body. Cardiogenic shock, also known as cardiac Other conditions that make your heart weak shock, happens when your heart cannot and can lead to cardiogenic shock include: pump enough blood and oxygen to the brain Damaged heart muscle from having a heart and other vital organs. This is a life- attack. threatening emergency. It is treatable if Inflammation of your heart muscle diagnosed right away, so it's important to (myocarditis). know the warning signs. An infection of your heart’s inner lining and valves (endocarditis). Cardiogenic shock stages range from being An abnormal heart rhythm (arrhythmia). at risk to being very ill. Stages are Too much fluid or blood around your heart (cardiac tamponade). At risk: Heart disease, such as heart attack A blood clot that suddenly blocks a blood A vessel in your lung (pulmonary embolism). or heart failure, but no signs of shock. B Beginning: Low blood pressure or heart A heart valve problem, such as torn muscles rate. supporting your valve or an artificial valve not C Classic: Need for medicine or devices to working right. help get blood to organs. Damage to the septum that divides the left D Deteriorating: Not responding to and right ventricles of your heart. medicine or devices and getting worse. Heart failure. E Extremis: Cardiac arrest that needs CPR, Injury to your chest. ventilator and defibrillator. DIAGNOSTIC TEST SYMPTOMS Blood Pressure: To check for low blood Chest pain that lasts for more than a few pressure. minutes or goes away and comes back. Your Cardiac Catheterization: This procedure chest may feel heavy, tight, full or numb. You helps your healthcare provider find blockages may feel pressure, aching, burning or in the arteries that supply blood to your heart squeezing. The pain may feel like heartburn. (coronary arteries). Your provider can also In some patients, especially women, chest use a catheterization to check the amount of pain isn't always the main symptom. Be alert blood your heart is pumping with each beat for other signs listed below. (cardiac output). A long, thin tube called a Pain or discomfort in your upper body and/or catheter is inserted in an artery through a down your left arm. small puncture, usually in your wrist or groin. Pain in the upper abdomen, throat or jaw. Electrocardiogram (ECG/EKG): A Trouble breathing. recording of your heart’s electrical activity Sweating or “cold sweats.” (heart rhythm). Fast or irregular heartbeat. Echocardiogram: An ultrasound of your Feeling very weak, lightheaded and/or heart that allows your healthcare provider to anxious. determine the strength of your heart and look for any structural abnormalities such as Other symptoms related to cardiogenic problems with the valves. shock can include Chest X-ray: To look for fluid in your lungs and get pictures of your heart and blood Confusion or not being alert. vessels. Fainting. Blood tests: To check the oxygen level in Very low blood pressure. your blood and check for damage to major Weak pulse. organs, such as your kidneys, heart and liver. Trouble breathing. They’ll also look at your electrolyte level. Peeing less than normal. Cool hands and feet. Pale skin. Feeling very tired. Swelling in your belly and legs. Poor appetite.  28 CORONARY ARTERY DISEASE Women and people AFAB are more likely to have additional, atypical symptoms that Coronary artery disease (CAD) is a condition include: that affects your coronary arteries, which supply blood to your heart. With CAD, plaque Shortness of breath, fatigue and insomnia buildup narrows or blocks one or more of your that began before the heart attack. coronary arteries. Chest discomfort (angina) is Pain in their back, shoulders, neck, arms or the most common symptom. CAD can lead to belly. a heart attack or other complications like Heart racing. arrhythmia or heart failure. Feeling hot or flushed. FORMS OF CORONARY ARTERY DISEASE Causes There are two main forms of coronary Atherosclerosis causes coronary artery artery disease: disease. Atherosclerosis is the gradual buildup of plaque in arteries throughout your body. 1 Stable ischemic heart disease When the plaque affects blood flow in your coronary arteries, you have coronary artery This is the chronic form. Your coronary disease. arteries gradually narrow over many Plaque consists of cholesterol, waste years. Over time, your heart receives products, calcium and fibrin (a substance that less oxygen-rich blood. You may feel helps your blood clot). As plaque continues to some symptoms, but you’re able to live collect along your artery walls, your arteries with the condition day to day. become narrow and stiff. Plaque can clog or damage your arteries, 2 Acute coronary syndrome: which limits or stops blood flow to a certain part of your body. When plaque This is the sudden form that’s a medical builds up in your coronary arteries, your emergency. The plaque in your heart muscle can’t receive enough blood. coronary artery suddenly ruptures and So, your heart can’t get the oxygen and forms a blood clot that blocks blood nutrients it needs to work properly. This flow to your heart. This abrupt blockage condition is called myocardial ischemia. causes a heart attack. It leads to chest discomfort (angina) and puts you at risk for a heart attack. Symptoms of chronic CAD include: People who have plaque buildup in their coronary arteries often have buildup Stable Angina: This is the most common elsewhere in their body, too. This can lead symptom. Stable angina is temporary chest to conditions like carotid artery disease pain or discomfort that comes and goes in a and peripheral artery disease. predictable pattern. You’ll usually notice it during physical activity or emotional distress. RISKs It goes away when you rest or take nitroglycerin (medicine that treats angina). Lifestyle factors Shortness of Breath (dyspnea): Some people feel short of breath during light Diet high in saturated fat or refined physical activity. carbohydrates. Sometimes, the first symptom of CAD is a Lack of physical activity. heart attack. Sleep deprivation. Smoking, vaping or other tobacco use. Symptoms of a heart attack include: Cardiovascular conditions Chest pain or discomfort (angina). Angina can range from mild discomfort Atherosclerosis. to severe pain. It may feel like High blood pressure. heaviness, tightness, pressure, aching, High LDL (“bad”) cholesterol. burning, numbness, fullness, squeezing High triglycerides (hypertriglyceridemia). or a dull ache. The discomfort may spread to your shoulder, arm, neck, Other medical conditions back or jaw. Shortness of breath or trouble Anemia. breathing. Autoimmune diseases, including lupus and Feeling dizzy or lightheaded. rheumatoid arthritis. Heart palpitations. Chronic kidney disease. Feeling tired. Diabetes. Nausea, stomach discomfort or HIV/AIDS. vomiting. This may feel like indigestion. Metabolic syndrome. Weakness. Overweight/obesity. Sleep disorders like sleep apnea.  29 Risk factors that affect women and Eat a heart-healthy diet that’s low in sodium, people assigned female at birth saturated fat, trans fat and sugar. The Mediterranean diet has been proven to lower Early menopause (before age 40). your risk of a heart attack or stroke. Endometriosis. Exercise: Aim for 30 minutes of walking five History of gestational diabetes, eclampsia or days a week, or find activities you enjoy. preeclampsia. Limit alcohol. Use of hormonal birth control. HYPERTENSIVE CRISIS DIAGNOSTIC TEST Hypertensive crisis is very high blood pressure Blood tests: Check for substances that harm that happens without warning. Your reading your arteries or increase your risk of CAD. can be 180/120 mmHg or higher. If this Cardiac catheterization: Inserts tubes into happens, take it seriously and call for help your coronary arteries to evaluate or confirm immediately. Without treatment for this CAD. This test is the gold standard for dangerous condition, you can have life- diagnosing CAD. limiting issues with your heart, lung or brain. Computed tomography (CT) coronary angiogram: Uses CT and contrast dye to Types of Hypertensive Crisis view 3D pictures of your heart as it moves. Detects blockages in your coronary arteries. Coronary calcium scan: Measures the amount of calcium in the walls of your coronary arteries (a sign of atherosclerosis). This doesn’t determine if you have significant blockages, but it does help determine your risk for CAD. Echocardiogram (echo): Uses sound waves to evaluate your heart’s structure and function. Electrocardiogram (EKG/ECG): Records your heart’s electrical activity. Can detect old or current heart attacks, ischemia and heart rhythm issues. Exercise stress test: Checks how your heart Clinical Manifestation responds when it’s working very hard. Can detect angina and blockages in your coronary Shortness of breath arteries. Headache Chest pain MEDICAL MANAGEMENT Blurry vision Heart palpitation Treatment for CAD often includes lifestyle Anxiety changes, risk factor management and Dizziness medications. Some people may also benefit Nosebleed from a procedure or surgery. Vomiting Your healthcare provider will talk with you about the best treatment plan for you. It’s Risk Factors important to follow your treatment plan so you can lower your risk of serious Failure to take prescribed blood pressure complications from CAD. medicines. This is the most common cause. Medications can help you manage your risk Suddenly stopping the use of blood pressure factors plus treat symptoms of coronary artery medicines. disease. Your provider may prescribe one or Medications interacting with each other. more of the medications listed below. Not receiving higher doses when current doses aren’t enough. Medications to lower your blood pressure. Kidney disease. Medications to lower your cholesterol. Endocrine issues. Medications to manage stable angina. Preeclampsia or eclampsia during pregnancy. These include nitroglycerin and Use of recreational drugs. ranolazine. Head trauma. Medications to reduce your risk of blood Brain tumor. clots (ASPIRIN) Medication may cause Hypertensive Crisis NURSING MANAGEMENT Steroids. Lifestyle changes play a big role in managing Medicines for depression. CAD. Such changes include: Cyclosporine. Pseudoephedrine. Don’t smoke, vape, or use any tobacco products.  30 Complication Pulmonary edema. Hypertensive encephalopathy (swelling in your brain). Heart failure. Heart attack. Aortic dissection. Stroke. Bleeding around your brain. DIAGNOSTIC TEST Blood pressure check. Blood tests. Chest X-ray. Types of Cardiomyopathy Urine (pee) tests. Electrocardiogram (EKG). 1. Dilated cardiomyopathy. Computed tomography (CT) scan of your 2. Hypertrophic cardiomyopathy. chest or head. 3. Ischemic cardiomyopathy. Transthoracic echocardiogram (TTE). 4. Arrhythmogenic right ventricular dysplasia (ARVD). Treatment 5. Restrictive cardiomyopathy. 6. Transthyretin amyloidosis cardiomyopathy The goal of hypertensive crisis treatment is to (ATTR-CM). bring your blood pressure down to a safe 7. Broken heart syndrome (stress-induced or level. However, a provider will lower your takotsubo cardiomyopathy). blood pressure more quickly or slowly 8. Chemotherapy-induced cardiomyopathy. depending on what other medical condition 9. Alcohol-induced cardiomyopathy. you have. They may lower it immediately or 10. Left ventricular non-compaction (LVNC). by 15% to 25% over an hour or two. 11. Peripartum cardiomyopathy. Hypertensive Hypertensive Clinical Manifestation emergency urgency Fatigue. A provider will admit A provider will give you Heart palpitations. you to a hospital’s medicine that you Chest pain. intensive care unit for swallow to lower your Arrhythmia. treatment. In the blood pressure. You hospital, a provider will can go home from the Shortness of breath (dyspnea). monitor your blood emergency Swelling (edema) in your legs or ankles. pressure and