Hypertention (chapter 33) (1).txt

Priority and Interrelated Concepts The priority concepts for this chapter are: Perfusion Clo ing The Perfusion concept exemplar for this chapter is Hypertension. The Clo ing concept exemplar for this chapter is Venous Thromboembolism. The interrelated concept for this chapter is: Inﬂammation Perfusion Concept Exemplar: Hypertension Hypertension, or high blood pressure (BP), is the most common health problem seen in primary care se ings and can cause stroke, myocardial infarction (MI) (heart a ack), kidney failure, and death if not treated early and eﬀectively. Current guidelines from the American College of Cardiology (ACC) and the American Heart Association (AHA) recommend a BP below 130/80 mm Hg in all people. This BP recommendation is lower than the guidance provided by the Eighth Joint National Commi ee (JNC 8) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. According to JNC 8, in the general population ages 60 years and older, the desired BP is below 150/90. For people younger than 60 years, the desired BP is below 140/90. Patients with a BP above these goals should be treatment with medication (James et al., 2014). The ACC/AHA guidelines suggest that patients with BP above the goal should be treated with drug therapy and lifestyle modiﬁcations (Whelton et al., 2017). Adult patients with speciﬁc risk factors for developing hypertension should be treated at any age, as described later under Drug Therapy. Pathophysiology Review To best understand the pathophysiology of hypertension, a review of normal BP and how it is normally maintained is essential. Mechanisms That Influence Blood Pressure The systemic arterial BP is a product of cardiac output (CO) and total peripheral vascular resistance (PVR). CO is determined by the stroke volume (SV) multiplied by heart rate (HR): Control of PVR (i.e., vessel constriction or dilation) is maintained by the autonomic nervous system and circulating hormones, such as norepinephrine and epinephrine. Consequently, any factor that increases PVR, HR, or SV increases the systemic arterial pressure. Conversely, any factor that decreases PVR, HR, or SV decreases the systemic arterial pressure and can cause decreased perfusion to body tissues. Stabilizing mechanisms exist in the body to exert an overall regulation of systemic arterial pressure and to prevent circulatory collapse. Four control systems play a major role in maintaining blood pressure: The arterial baroreceptor system Regulation of body ﬂuid volume The renin-angiotensin-aldosterone system Vascular autoregulation Arterial baroreceptors are found primarily in the carotid sinus, aorta, and wall of the left ventricle. They monitor the level of arterial pressure and counteract a rise in arterial pressure through vagally mediated cardiac slowing and vasodilation with decreased sympathetic tone. Reﬂex control of circulation therefore elevates the systemic arterial pressure when it falls and lowers it when it rises. Why baroreceptor control fails in hypertension is not clear (McCance & Huether, 2019). Changes in ﬂuid volume also aﬀect the systemic arterial pressure. For example, if there is an excess of sodium and/or water in a person's body, the BP rises through complex physiologic mechanisms that change the venous return to the heart, producing a rise in cardiac output (CO). If the kidneys are functioning adequately, a rise in systemic arterial pressure produces diuresis (excessive voiding) and a fall in pressure. Pathologic conditions change the pressure threshold at which the kidneys excrete sodium and water, thereby altering the systemic arterial pressure. The renin-angiotensin-aldosterone system also regulates BP (see discussion in Chapter 13). The kidney produces renin, an enzyme that acts on angiotensinogen to split oﬀ angiotensin I, which is converted by an enzyme in the lung to form angiotensin II. Angiotensin II has strong vasoconstrictor action on blood vessels and is the controlling mechanism for aldosterone release. Aldosterone then works on the collecting tubules in the kidneys to reabsorb sodium. Sodium retention inhibits ﬂuid loss, thus increasing blood volume and subsequent BP. Inappropriate secretion of renin may cause increased peripheral vascular resistance (PVR) in patients with hypertension. When the BP is high, renin levels should decrease because the increased renal arteriolar pressure usually inhibits renin secretion. However, for most people with essential hypertension, renin levels remain normal. The process of vascular autoregulation, which keeps perfusion of tissues in the body relatively constant, appears to be important in causing hypertension. However, the exact mechanism of how this system works is poorly understood. Classifications of Hypertension Blood pressure is categorized into four levels: normal, elevated (or prehypertension), and stage 1 or 2 hypertension (Table 33.1). Hypertension, categorized as stage 1 or stage 2, can be classiﬁed as either essential (primary) or secondary (Whelton et al., 2017). Essential hypertension is the most common type and is not caused by an existing health problem. However, a number of risk factors can increase a person's likelihood of becoming hypertensive. Continuous BP elevation in patients with essential hypertension results in damage to vital organs by causing medial hyperplasia (thickening) of the arterioles. As the blood vessels thicken and perfusion decreases, body organs are damaged. These changes can result in myocardial infarctions (MIs), strokes, peripheral vascular disease (PVD), or kidney failure. Speciﬁc disease states and drugs can increase a person's susceptibility to hypertension. A person with this type of elevation in BP has secondary hypertension. Hypertensive crisis (or malignant hypertension) is a severe type of elevated BP that rapidly progresses and is considered a medical emergency. A person with this health problem usually has symptoms such as morning headaches, blurred vision, and dyspnea and/or symptoms of uremia (accumulation in the blood of substances ordinarily eliminated in the urine). Patients are often in their 30s, 40s, or 50s with their systolic BP greater than 200 mm Hg. The diastolic BP is greater than 150 mm Hg or greater than 130 mm Hg when there are pre-existing complications. Unless intervention occurs promptly, a patient with hypertensive crisis may experience kidney failure, left ventricular heart failure, or stroke. Etiology and Genetic Risk Essential hypertension can develop when a patient has any one or more of the risk factors listed in Table 33.2. Kidney disease is one of the most common causes of secondary hypertension (see Table 33.2). Hypertension can develop when there is any sudden damage to the kidneys. Renovascular hypertension is associated with narrowing of one or more of the main arteries carrying blood directly to the kidneys, known as renal artery stenosis (RAS). Many patients have been able to reduce the use of their antihypertensive drugs when the narrowed arteries are dilated through angioplasty with stent placement. Dysfunction of the adrenal medulla or the adrenal cortex can also cause secondary hypertension. Adrenal-mediated hypertension is caused by primary excesses of aldosterone, cortisol, and catecholamines. In primary aldosteronism, excessive aldosterone causes hypertension and hypokalemia (low potassium levels). It usually arises from benign adenomas of the adrenal cortex. Pheochromocytomas are tumors that originate most commonly in the adrenal medulla and result in excessive secretion of catecholamines, resulting in life-threatening high blood pressure. In Cushing syndrome, excessive glucocorticoids are excreted from the adrenal cortex. The most common cause of Cushing syndrome is either adrenocortical hyperplasia or adrenocortical adenoma (tumor). TABLE 33.1 Categories of Blood Pressure in Adults\ Guidelines From Eighth Joint National Committee (JNC 8) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Guidelines and From American College of Cardiology (ACC)/American Heart Association (AHA) Data from Whelton, P.K., Carey, R.M., Aronow W.S., et al. (2017). CC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension, Nov 13; and James, P.A., Oparil, S., Carter, B.L., Cushman, W.C., Dennison-Himmelfarb, C., Handler, J., et al. (2014). 2014 evidence-based guidelines for the management of high blood pressure in adults: Report from the panel members appointed to the Eighth National Commi ee (JNC 8). JAMA: The Journal of the American Medical Association, 311(5), 507--520. TABLE 33.2 Etiology of Hypertension Drugs that can cause secondary hypertension include estrogen, glucocorticoids, mineralocorticoids, sympathomimetics, cyclosporine, and erythropoietin. The use of estrogen-containing oral contraceptives is likely the most common cause of secondary hypertension in women. Drugs that cause hypertension are discontinued to reverse this problem. Incidence and Prevalence Hypertension is a worldwide epidemic. In the United States, it is estimated that 85.7 million adults 20 years of age and older have high blood pressure (Benjamin et al., 2018). The disease can shorten life expectancy. Patient-Centered Care: Gender Health Considerations A higher percentage of men than women have hypertension until 45 years of age. From ages 45 to 64, the percentages of men and women with hypertension are similar. After age 64, women have a higher percentage of the disease (Benjamin et al., 2018). The causes for these diﬀerences are not known. Patient-Centered Care: Cultural/Spiritual Considerations The prevalence of hypertension in African Americans in the United States is among the highest in the world and is increasing. When compared with Euro-Americans, they develop high blood pressure earlier in life, making them much more likely to die from strokes, heart disease, and kidney disease (Benjamin et al., 2018). The exact reasons for these diﬀerences are not known. Because of the prevalence in the African-American population, JNC-8 guidelines as well as ACC/AHA guidelines oﬀer population-speciﬁc recommendations for treatment (Whelton et al., 2017; James et al., 2014). Health Promotion and Maintenance Control of hypertension has resulted in major decreases in cardiovascular morbidity and mortality. The U.S. Healthy People 2020 campaign includes a number of objectives related to hypertension to decrease cardiovascular mortality (Table 33.3). Many of these objectives remain goals in the projected development of Healthy People 2030. Evidence-based dietary and exercise practices that can help lower blood pressure include: Achieve weight reduction through lifestyle changes using a combination of reduced caloric intake and increased physical activity. TABLE 33.3 Meeting Healthy People 2020 Objectives: Heart Disease and Stroke Selected objectives retained from Healthy People 2010: Increase the proportion of adults with high blood pressure who are taking action to help control their blood pressure. Increase the proportion of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high. Selected objectives retained but modiﬁed from Healthy People 2010: Reduce the proportion of people in the population with hypertension. Increase the proportion of adults with hypertension who meet the recommended guidelines for: a. Body mass index (BMI) b. Saturated fat consumption c. Sodium intake d. Physical activity e. Moderate alcohol consumption New objectives for Healthy People 2020: Increase the proportion of adults with hypertension who are taking the recommended medications to decrease their blood pressure. Leading Health Indicator and high-priority health issue: Increase the proportion of adults with hypertension whose blood pressure is controlled. Data from Department of Health and Human Services. (2020). Healthy People 2020. Retrieved from: h ps://www.healthypeople.gov/2020/topics-objectives/topic/heartdisease-and-stroke/objectives. Implement Dietary Approaches to Stop Hypertension (DASH), a diet that is high in fruits, vegetables, and low-fat dairy products; enhance intake of potassium, calcium, magnesium, and ﬁber. Reduce the intake of dietary sodium. The optimal goal is less than 1500 mg of sodium per day. Increase physical activity that includes aerobic exercise, resistance training, and static isometric exercise. In addition to following speciﬁc dietary and physical activity guidelines, teach patients ways to decrease other modiﬁable risk factors for hypertension, such as smoking cessation and stress reduction. Risk factor prevention and lifestyle changes are discussed in more detail in Chapter 35. Interprofessional Collaborative Care Assessment: Recognize Cues History Review the patient's risk factors for hypertension. Collect data on the patient's age; ethnic origin or race; family history of hypertension; average dietary intake of calories, sodium- and potassium-containing foods and alcohol; and exercise habits. Also assess any past or present history of kidney or cardiovascular disease (CVD) and current use of drug therapy or illicit drugs. Physical Assessment/Signs and Symptoms When a diagnosis of hypertension is made, most people have no symptoms. However, some patients experience headaches, facial ﬂushing (redness), dizziness, or fainting as a result of the elevated blood pressure. Obtain blood pressure readings in both arms. Two or more readings may be taken at each visit (Fig. 33.1). Some patients have high blood pressure due to anxiety associated with visiting a health care provider. Be sure to take an accurate blood pressure by using an appropriate-size cuﬀ. FIG. 33.1 Blood pressure screening during history and physical examination. From Wilson S.F., Giddens J.F. \[2017\]. Health assessment for nursing practice \[6th ed.\]. St. Louis: Mosby. To detect postural (orthostatic) changes, take readings with the patient in the supine (lying) or si ing position and at least 3 minutes later when standing (McCance & Huether, 2019). Orthostatic hypotension is a decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) when the patient changes position from lying to si ing. Funduscopic examination of the eyes to observe vascular changes in the retina is done by a skilled health care practitioner. The appearance of the retina can be a reliable index of the severity and prognosis of hypertension. Physical assessment is also helpful in diagnosing several conditions that produce secondary hypertension. The presence of abdominal bruits is typical of patients with renal artery stenosis (RAS). Tachycardia, sweating, and pallor may suggest a pheochromocytoma (adrenal medulla tumor). Coarctation of the aorta is evidenced by elevation of blood pressure in the arms, with normal or low blood pressure in the lower extremities. Psychosocial Assessment Assess for psychosocial stressors that can worsen hypertension and aﬀect the patient's ability to adhere to treatment. Evaluate job-related, economic, and other life stressors and the patient's response to these stressors. Some patients may have diﬃculty coping with the lifestyle changes needed to control hypertension. Be sure to assess past coping strategies. Diagnostic Assessment Although no laboratory tests are diagnostic of essential hypertension, several laboratory tests can assess possible causes of secondary hypertension. Kidney disease can be diagnosed by the presence of protein and red blood cells in the urine, elevated levels of blood urea nitrogen (BUN), and elevated serum creatinine levels. The creatinine clearance test directly indicates the glomerular ﬁltration ability of the kidneys. The normal value is 107 to 139 mL/min for men and 87 to 107 mL/min for women (Pagana et al., 2018). Decreased levels indicate acute or chronic kidney disease. Urinary test results are positive for the presence of catecholamines in patients with a pheochromocytoma (tumor of the adrenal medulla). An elevation in levels of serum corticoids and 17-ketosteroids in the urine is diagnostic of Cushing disease. No speciﬁc x-ray studies can diagnose hypertension. Routine chest radiography may help recognize cardiomegaly (heart enlargement). An electrocardiogram (ECG) determines the degree of cardiac involvement. Left atrial and ventricular hypertrophy is the ﬁrst ECG sign of heart disease resulting from hypertension. Left ventricular remodeling can be detected on the 12-lead ECG (see Chapter 35 for discussion of remodeling). Analysis: Analyze Cues and Prioritize Hypotheses The priority collaborative problems for most patients with hypertension are: 1. Need for health teaching due to the plan of care for hypertension management 2. Potential for decreased adherence due to side eﬀects of drug therapy and necessary changes in lifestyle Planning and Implementation: Generate Solutions and Take Action Health Teaching Planning: Expected Outcomes The patient with hypertension is expected to verbalize his or her individualized plan of care for hypertension. Interventions Lifestyle changes are considered the foundation of hypertension control. If these changes are unsuccessful, the primary care provider considers the use of antihypertensive drugs. There is no surgical treatment for essential hypertension. However, surgery may be indicated for certain causes of secondary hypertension, such as kidney disease, coarctation of the aorta, and pheochromocytoma. Lifestyle Changes In collaboration with the health care team, teach the patient to (Whelton et al., 2017): Restrict dietary sodium according to ACC/AHA guidelines Reduce weight, if overweight or obese Implement a heart-healthy diet, such as the DASH diet Increase physical activity with a structured exercise program Abstain or decrease alcohol consumption (no more than one drink a day for women and two drinks a day for men) Stop smoking and tobacco use Use relaxation techniques to reduce stress Strategies to help patients make these changes are discussed in Chapter 35. Complementary and Integrative Health Garlic, coenzyme Q10, and ﬁsh oil have been used for a number of health problems, but evidence to support their use to prevent hypertension is controversial. Evidence by consensus and case reports do support garlic's cholesterol-lowering ability and its ability to decrease blood pressure in patients with hypertension (National Center for Complementary and Integrative Health, 2018). Garlic can increase the risk of bleeding in patients taking anticoagulants and can interfere with the eﬀectiveness of some drugs. Teach patients to check with their primary health care provider before starting any herbal therapy because of possible side eﬀects and interactions with other herbs, foods, or drugs. Some patients have also had success with biofeedback, meditation, and acupuncture as part of their overall management plan. These methods may be most useful as adjuncts for patients who experience continuous and severe stress. Drug Therapy Drug therapy is individualized for each patient, with consideration given to culture, age, other existing illness, severity of blood pressure elevation, and cost of drugs and follow-up. Once-a-day drug therapy is best, especially for the older adult, because the more doses required each day, the higher the risk that a patient will not follow the treatment regimen. However, many patients with hypertension need two or more drugs to adequately control blood pressure. In the largest hypertensive trial done to date, Antihypertensive and Lipid-Lowering Treatment to Prevent Heart A ack Trial (ALLHAT), the use of diuretics has been practically unmatched in preventing the cardiovascular complications of hypertension (ALLHAT, 2002). Current guidelines recommend use of one or more of these four classes of drugs: thiazide-type diuretics, calcium channel blockers (CCBs), angiotensinconverting enzyme inhibitors (ACEIs), and angiotensin II receptor blockers (ARBs). Using an ACEI, ARB, and/or renin inhibitor simultaneously is potentially harmful and is not recommended in the treatment of hypertension. Patients who do not respond to these ﬁrst-line drugs may be placed on other diuretics, an aldosterone receptor antagonist (blocker), a beta-adrenergic blocker, or a renin inhibitor. Examples of commonly used drug classes for hypertension are listed in the Common Examples of Drug Therapy: Hypertension Management box. Diuretics.Diuretics are the ﬁrst type of drugs for managing hypertension. Three basic types of diuretics are used to decrease blood volume and lower blood pressure in the order of how commonly they are typically prescribed: Thiazide (low-ceiling) diuretics, such as hydrochlorothiazide, inhibit sodium, chloride, and water reabsorption in the distal tubules while promoting potassium, bicarbonate, and magnesium excretion. However, they decrease calcium excretion, which helps prevent kidney stones and bone loss. Because of the low cost and high eﬀectiveness of thiazide-type diuretics, they are usually the drugs of choice for patients with uncomplicated hypertension. These drugs can be prescribed as a single agent or in combination with other classes of drugs. Nursing Safety Priority Drug Alert Teach men that they may experience decreased libido (desire for sex) and decreased sexual performance when taking thiazide diuretics. Thiazide diuretics should be used with caution in patients with diabetes mellitus because they can interfere with serum glucose control. Caution is also indicated for patients with gout or a history of signiﬁcant hyponatremia (decreased serum sodium level) because these problems can worsen when thiazides are taken. Loop (high-ceiling) diuretics, such as furosemide and torsemide, inhibit sodium, chloride, and water reabsorption in the ascending loop of Henle and promote potassium excretion. Common Examples of Drug Therapy\ Hypertension Management AV, Atrioventricular; SA, sinoatrial. Nursing Safety Priority Drug Alert The most frequent side eﬀect associated with thiazide and loop diuretics is hypokalemia (low potassium level). Monitor serum potassium levels and assess for irregular pulse, dysrhythmias, and muscle weakness, which may indicate hypokalemia. Teach patients taking potassium-depleting diuretics to eat foods high in potassium, such as bananas, potatoes, and orange juice. Most people also need a potassium supplement to maintain adequate serum potassium levels. Assess for hyperkalemia (high potassium level) in patients taking potassium-sparing diuretics such as spironolactone. Like hypokalemia, an increased potassium level can also cause weakness, irregular pulse, and cardiac dysrhythmias. In some cases, patients may have painful muscle spasms (cramping) in their legs. These electrolyte imbalances are described in detail in Chapter 13. Monitor renal function prior to administration because renal failure is a side eﬀect of thiazide and loop diuretics. Tinnitus and hearing loss may occur when high doses are given over an extended period of time or when given as a rapid infusion. Patient-Centered Care: Older Adult Considerations Loop diuretics are not used commonly for older adults because they can cause dehydration and orthostatic hypotension. These complications increase the patient's risk for falls. Teach families to monitor for and report patient dizziness, falls, or confusion to the primary health care provider as soon as possible and discontinue the drug. Potassium-sparing diuretics, such as spironolactone, triamterene, and amiloride, act on the distal renal tubule to inhibit reabsorption of sodium ions in exchange for potassium, thereby retaining potassium in the body. When used, they are typically in combination with another diuretic or antihypertensive drug to conserve potassium. Frequent voiding caused by any type of diuretic may interfere with daily activities. Teach patients to take their diuretic in the morning rather than at night to prevent nocturia (voiding during the night). Other Antihypertensive Drugs. Calcium channel blockers (CCBs), such as verapamil hydrochloride and amlodipine, lower blood pressure by interfering with the transmembrane ﬂux of calcium ions. This results in vasodilation, which decreases blood pressure. These drugs also block sinoatrial (SA) and atrioventricular (AV) node conduction, resulting in a decreased heart rate (HR). Calcium channel blockers, in combination withthiazide diuretics, are ﬁrst-line drug therapy for African Americans (Whelton et al., 2017). Some CCBs, especially felodipine and nifedipine, react with grapefruit and grapefruit juice. Teach the patient to avoid grapefruit juice to prevent complications such as kidney failure, heart failure, GI bleeding, or even death. A newer CCB, clevidipine butyrate, is available only in IV form and must be administered using an infusion pump. This drug, indicated when oral therapy is not possible, is used for severe hypertension. The most common side eﬀects are headache and nausea. Notify the health care provider immediately if neurologic symptoms, visual changes, or symptoms of heart failure occur (Skidmore-Roth, 2018) Angiotensin-converting enzyme inhibitors (ACE inhibitors or ACEIs), known as the "-pril" drugs, are also used as single or combination agents in the treatment of hypertension. These drugs block the action of angiotensinconverting enzyme (ACE) as it a empts to convert angiotensin I to angiotensin II, one of the most powerful vasoconstrictors in the body. This action also decreases sodium and water retention and lowers peripheral vascular resistance (PVR), both of which lower blood pressure. ACEIs include captopril, lisinopril, and enalapril. The most common side eﬀect of this group of drugs is a nagging, dry cough. Teach patients to report this problem to their primary health care provider as soon as possible. If a cough develops, the drug is discontinued. Nursing Safety Priority Drug Alert Instruct the patient receiving an ACEI for the ﬁrst time to get out of bed slowly to avoid the severe hypotensive eﬀect that can occur with initial use. Orthostatic hypotension may occur with subsequent doses, but it is usually less severe. If dizziness continues or there is a signiﬁcant decrease in the systolic blood pressure (more than a change of 20 mm Hg), notify the health care provider or teach the patient to notify the health care provider. The older patient is at the greatest risk for orthostatic hypotension because of the cardiovascular changes associated with aging. Angiotensin II receptor antagonists, also called angiotensin II receptor blockers (ARBs) or the -sartan drugs, make up a group of drugs that selectively block the binding of angiotensin II to receptor sites in the vascular smooth muscle and adrenal tissues by competing directly with angiotensin II but not inhibiting ACE. Examples of drugs in this group are candesartan, valsartan, losartan, and azilsartan. ARBs can be used alone or in combination with other antihypertensive drugs. These drugs are excellent options for patients who report a nagging cough associated with ACEIs. In addition, they do not require initial adjustment of the dose for older adults or for any patient with renal impairment. Like the ACEs, the ARBs are not as eﬀective in African Americans unless they are taken with diuretics or another category such as a beta blocker or calcium channel blocker (CCB) (Whelton et al., 2017). In 2018 the U.S. Food and Drug Administration (FDA) found that there were impurities that presented a safety concern in some ARBs, most notably valsartan. This recall expanded in 2019 to include certain manufacturers of losartan and irbesartan (FDA, 2019). It is important to note that the FDA recalled certain lots of the drugs, and formulations with the known impurities are no longer on the U.S. market. Unaﬀected ARBs remain on the market and continue to be used safely (FDA, 2018; FDA, 2019). Beta-adrenergic blockers, identiﬁed by the ending -olol, are categorized as cardioselective (working on only the cardiovascular system) and noncardioselective. Cardioselective beta blockers, aﬀecting only beta1 receptors, may be prescribed to lower blood pressure by blocking beta receptors in the heart and peripheral vessels. By blocking these receptors, the drug decreases heart rate (HR) and myocardial contractility. Teach patients about common side eﬀects of beta blockers, including fatigue, weakness, depression, and sexual dysfunction. The potential for side eﬀects depends on the "selective" blocking eﬀects of the drug. Atenolol, bisoprolol, and metoprolol are cardioselective beta blockers given for hypertension. Patients with diabetes who take beta blockers may not have the usual manifestations of hypoglycemia because the sympathetic nervous system is blocked. The body's responses to hypoglycemia such as gluconeogenesis may also be inhibited by certain beta blockers. Beta blockers are often the drug of choice for hypertensive patients with ischemic heart disease because the heart is the most common target of endorgan damage with hypertension. If this drug is not tolerated, a long- acting CCB can be used. In patients with unstable angina or myocardial infarction (MI), beta blockers or CCBs should be used initially in combination with ACEIs or ARBs, with addition of other drugs if needed to control the blood pressure (see Chapter 35). It is important to teach patients that beta blockers should not be stopped abruptly. Tapering oﬀ of these medications over a 2-week period is recommended because abrupt cessation can lead to angina or MI. NCLEX Examination Challenge 33.1 Health Promotion and Maintenance The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can aﬀect your glucose control." E. "Increased urination is expected with this drug. Promoting Adherence to the Plan of Care Planning: Expected Outcomes The patient with hypertension is expected to adhere to the plan of care, including making necessary lifestyle changes. Interventions Patients who require medications to control essential hypertension usually need to take them for the rest of their lives. Some patients stop taking them because they have no symptoms and have troublesome side eﬀects. In the hospital se ing, interprofessional collaboration with the pharmacist to discuss the outcomes of therapy with the patient, including potential side eﬀects, can help the patient tailor the therapeutic regimen to his or her lifestyle and daily schedule. Patients who do not adhere to antihypertensive treatment are at a high risk for target organ damage and hypertensive crisis, a severe elevation in blood pressure (\>180/120) that can cause organ damage in the kidneys or heart (target organs) (see the Best Practice for Patient Safety & Quality Care: Emergency Care of Patients With Hypertensive Crisis box). Patients in hypertensive crisis are admi ed to critical care units, where they receive IV antihypertensive therapy such as nitroprusside, nicardipine, fenoldopam, or labetalol. For adults without a compelling condition, systolic BP should be reduced by no more than 25% within the ﬁrst hour; then, if stable, to 160/100 mm Hg within the next 2 to 6 hours; and then cautiously to normal during the following 24 to 48 hours (Whelton et al., 2017). A gradual reduction in blood pressure is preferred because rapid reduction can cause cerebral ischemia, MI, and renal failure. Provide oxygen to the patient and monitor oxygen saturation levels. When Best Practice for Patient Safety & Quality Care Emergency Care of Patients With Hypertensive Crisis Assess: Severe headache Extremely high blood pressure (BP) Dizziness Blurred vision Shortness of breath Epistaxis (nosebleed) Severe anxiety Intervene: Place patient in semi-Fowler position. Administer oxygen. Administer IV beta blocker or nicardipine or other infusion drug as prescribed; when stable, switch to oral antihypertensive drug. Monitor BP every 5 to 15 minutes until the diastolic pressure is below 90 and not less than 75; then monitor BP every 30 minutes to ensure that BP is not lowered too quickly. Observe for neurologic or cardiovascular complications, such as seizures; numbness, weakness, or tingling of extremities; dysrhythmias; or chest pain (possible indicators of target organ damage). the patient's blood pressure stabilizes, oral antihypertensive drugs are given. Care Coordination and Transition Management Home Care Management Hypertension is a chronic illness. Allow patients to verbalize feelings about the disease and its treatment. Emphasize that their involvement in the collaborative plan of care can lead to control of the disease and can prevent complications. Some patients do not adhere to their drug therapy regimen at home because they have no symptoms or they simply forget to take their drugs. Others may think they are not sick enough to need medication. Some patients may assume that once their blood pressure (BP) returns to normal levels, they no longer need treatment. They may also stop taking their drugs because of side eﬀects or cost. Develop a plan with the patient and family and identify ways to encourage adherence to the plan of care. Self-Management Education Health teaching is essential to help patients become successful in managing their BP. Provide oral and wri en information about the indications, dosage, times of administration, side eﬀects, and drug interactions for antihypertensives. Stress that medication must be taken as prescribed; when all of it has been consumed, the prescription must be renewed on a continual basis. Suddenly stopping drugs such as beta blockers can result in angina (chest pain), myocardial infarction (MI), or rebound hypertension. Urge patients to report unpleasant side eﬀects such as excessive fatigue, cough, or sexual dysfunction. In many instances, an alternative drug can be prescribed to minimize certain side eﬀects. Teach the patient to obtain an ambulatory BP monitoring (ABPM) device for use at home so the pressure can be checked. Evaluate the patient's and family's ability to use this device. If weight reduction is a desired outcome, suggest having a scale in the home for weight monitoring. For patients who do not want to self-monitor, are not able to self-monitor, or have "white-coat" syndrome when they go to their primary health care provider (causing elevated BP), continuous ABPM may be used. The monitor is worn for 24 hours or longer while patients perform their normal daily activities. BP is automatically taken every 15 to 30 minutes and recorded for review later. The advantage of this technique is that the primary health care provider can view the changes in BP readings throughout the 24-hour period to get a picture of a true BP value. Research strongly supports 24-hour ambulatory BP monitoring as a ﬁrst-line procedure to determine the need for antihypertensive therapy (U.S. Preventive Services Task Force, 2017). Instruct the patient about sodium restriction, weight maintenance or reduction, alcohol restriction, stress management, and exercise. If necessary, also explain about the need to stop using tobacco, especially smoking. Health Care Resources A home care nurse may be needed for follow-up to monitor the BP. Evaluate patient or family ability to obtain accurate BP measurements and assess adherence with treatment. The American Heart Association, the Red Cross, or a local pharmacy may be used for free BP checks if patients cannot buy equipment to monitor their BP. Health fairs and BP screening programs located in faith-based centers are also available in most locations. Evaluation: Evaluate Outcomes Evaluate the care of the patient with hypertension on the basis of the identiﬁed patient problems. The expected outcomes are that the patient will: Verbalize understanding of the plan of care, including drug therapy and any necessary lifestyle changes Report adverse drug eﬀects, such as coughing, dizziness, or sexual dysfunction, to the primary health care provider immediately Consistently adhere to the plan of care, including regular followup with the primary health care provider Clinical Judgment Challenge 33.1 Patient-Centered Care; Teamwork and Collaboration; EvidenceBased Practice The nurse is performing an assessment in the outpatient clinic on a 63year-old male client. His initial blood pressure is 189/113 mm Hg, heart rate is 94 beats/min, and respiration rate is 26 breaths/min. The client reports a smoking history of 25 cigare es per day and an average of two alcoholic drinks per day. The client also informs the nurse that he recently lost his job as the director of sales at a local company and is worried about providing for his family. The client exercises once a week by walking with his family in the park. The client does not take any prescription or herbal medications. 1. Recognize Cues: What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information ﬁrst to determine what is most important.) 2. Analyze Cues: What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) 3. Prioritize Hypotheses: Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.) 4. Generate Solutions: What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided or are potentially harmful? (Hint: Determine the desired outcomes ﬁrst to decide which interventions are appropriate and those that should be avoided.) 5. Take Action: Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.) 6. Evaluate Outcomes: What client assessment would indicate that the nurse's actions were eﬀective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) Arteriosclerosis and Atherosclerosis Pathophysiology Review Arteriosclerosis is a thickening, or hardening, of the arterial wall that is often associated with aging. Atherosclerosis, a type of arteriosclerosis, involves the formation of plaque within the arterial wall and is the leading risk factor for cardiovascular disease (CVD). Usually the disease aﬀects the

Hypertention (chapter 33) (1).txt

Document Details

Tags

Related

Full Transcript

Upgrade to continue