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primary hypertension
cause is unknown
major risk factor is family histroy
85-90% of pop with hypertension has primary
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secondary hypertension:
disease states and meds that increase susceptibility
Renal disease most common
disfunction of the adrenal gland
cushing disease - excess glucocorticoids
RAS - renal stent treamtment
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secondary causes of secondary hypertension
coarctation of aorta- twisting
brain tumors
encephalitis - brain inflammation
psychiatric disturbances
pregnancy
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medications: causing secondary HTN
estrogen - most common
glucocorticoids
mineralocorticoids- fluorinef
sympathomimetic- drugs that help with heart failure, dobutrex
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Important points with PT's with HTN
prolonged B/P elevation damages blood vessels throughout the body
consequences of uncontrolled HTN: stroke, renal damage
Left ventricular enlargement: the "pump" ventricle in the heart
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B/P formula
B/P = Cardiac output X peripheral resistance
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B/P effected by:
increased sympathetic nervous system
excess sodium intake
kidney damage
genetic alteration, obestiy, endothelial factors
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Assessment of a PT:
history and risk factors associated with HTN
age
race
family history
average dietary intake of foods leading HTN: sodium, fat etc.
alcohol intake
exercise habits: coronaries
smoking history
- past or present history of renal and
- cardiovascular disease: TIA, MI, etc.
medications prescribed or illicit (cocaine)
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S/S of HTN
Generally asymptomatic
facial flusing can occur: check B/P bilat
B/P elevated
Abdominal Bruie
Tachycardia
Femoral pulses abscent
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Diagnostic testing HTN
no test to tell
secondary: lab tests looking a renal function
increase in catacholamines in urine
Echocardiogram: flow of blood through heart and valves
Chest X-ray: shows enlargement
EKG: shows hypertrophy, first signs of HTN
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Main diagnoses for HTN
deficient knowledge
risk for ineffective for therapuetic regimen
pg 799
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Treatment of HTN
goal is to prevent death by reducing and maintaing level of 140/90
first attempt is lifestyle changes
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Nursing interventions for HTN
main problem relates to knowledge deficit and noncompliance
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Nursing interventions for HTN
educating:(s/s stroke and complications)
increase knowledge
monitoring and managing potential complications
*involvement of the family members in care and treatment*
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Medical mgmt of HTN
1st line: diuretics: thaizide
- Need to have K levels checked
- report pulse irregularities
- encourage K intake (bananas, OJ)
- 2nd line:
- ACE inhibitors- 'pril drugs. often has nagging cough symptoms
Calcium channel blockers
Beta blockers- 'lol drugs
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Hypertensive Crisis
Emergency
BP needs to be brought down immediately or stroke will occur
BP over 200
PT reports extreme headache
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Interventions for Hypertensive Crises
semi fowlers
02
meds-vasodialators given IV
cardine-straight IV
nitroprussid-IV drip (concetration damaged by light)
BP monitered q 15 min until BP lower than 90
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Malignant Hypertension
morning headaches
- systolic greater than 200
- diastolic greater than 150
may cause: renal failure, stroke, left ventricular failure
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Heart Failure
inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
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Major types of heart failure
- left sided
- right sided
- high output
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patho of HF
begins with failur of the left ventricle and progresses to failure of both ventricles
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conditions that lead to HF
Damage or deterioration of myocardial tissue
Dysrhthmia- most common atrial fibrillation
HTN
decreased tissue perfusion
coronary artery and valvular disease
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S/S of left sided cardiac failure
blood backs up into the lung
therefore creates respiratory related distress:
- dyspnea
- pallor
- crackles
- wheezing
- pink tinged sputum
- weak peripheral pulses, cool extremities
- S3/S4 gallop indicating CHF
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S/S of right sided cardiac failure-backward failure
systemic
dependent edema; fluid not getting back to heart
hepatomegaly, splenomegaly
weight gain due to fluid retention
anorexia
jugular vein distention
distended abdomen
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lab studies for CHF
K
Na
Mg
Ca
Cl
*important for m. contractions
- BUN (increased)
- creatnine(increased)
- urinalysis
- protein
- high specific gravity
- HGB
- HCT- excess volume in body HCT very dilute
- anemia
BNP- done to determine heart failure (increased in heart failure, normal 0-100)
microalbumineria- shows up before BNP
Imaging studies
EKG shows dysrythmia
pulmonary artery catheter test pressure
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medical mgmt for HF
02 therapy above 90%
- meds
- 1st- diuretic to remove fluid
Digoxin (cardio glycosides)-improve contractility of heart
vasodialators- nitroglycerine
morphine- help pt relax, reduce preload and afterload
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interventions of CHF
nutritional therapy- reduce sodium and water retention
fluid restrictions
weigh daily- use same scale before breakfast
high fowlers position
deep breathing and coughing (DB& C) q2h
I&O's strict
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priority nursing diagnoses for CHF
Impaired gas exchange related to ventilation/perfusion imbalance
decreased cardiac output related to altered contractility, preload and afterload
activity intolerance related to an imbalance between oxygen supply and demand
pg 770
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potential for pulmonary edema
treated the same as left sided heart failure
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indications of worsening HF
rapid weight gain- 1 to 2 lbs overnight
decrease in exercise tolerance
cold symptoms
execissive wakening at night to urinate
worsening angina
increased swelling in feet, ankles and hands
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theureputic level digoxin
0.5- 2.0 ng/ml
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Capoten pt education
signs of angioedema
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Lasix info included when explaining how it helps heart
reduction of cardiac preload
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places pt digoxin at greatest risk of toxicity and associated dysrhythmias
hypercalcemia
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early indications of digitalis toxicity
anorexia, n/v
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electrolyte closely monitered after treatment with digibind
K
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Oxyhemoglobin Dissociation
Oxygen affinity is related to:
pH
PCO2
Body Temp
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intefering factors with oxygenation
coronary atery disease
blood volume depletion
inadequate blood flow
diseases of the lungs
anemia
toxic inhalants
airway obstruction
fever
decrease chest wall motion
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Hyperventilation
excessive ventilation (fever)
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Hypoventilation
inadequate alveolar ventilation (atelectasis)
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Hypoxia
inadequate tissue oxygenation (anemia)
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Hypoxia
life threatening
decreased HGB levels
diminished inspired oxygen
poor tissue perfusion
impaired ventilation
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s/s of Hypoxia
restlessness
apprehension, anxiety
disorientation
decreased concentration
decreased LOC
fatigue
dyspnea
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Altered Respiration in Hypoxia
increased pulse rate
respiration rate and depth increased
b/p elevated
cardiac dysrrhythmias
pallor/cyanosis
dyspnea
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Maintaining Respiration
Cough, turn, and deep breath with early ambulation (CTDB)
incentive spirometer
cutaneous oximetry
positioning q 2 h
adequate hydration
humidification
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Wheezing characteristics
breathing sounds more musical in nature than normal sounds
high or low pitched
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Wheezing indications and causes
indicates the airway is narrowed
most common causes are asthma and COPD (emphysema or chronic bronchitis)
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benefits of 02
expands lungs
mobilizes secretions
maintains patent airway
keeps tissue oxygenated
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Thoracentesis
withdrawal of fluid from pleural cavity
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bronchoscopy
provides direct visualization
NPO 6hrs before
peop med & airway anesthetized topically
post op check for gag reflex
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Respiratory acidosis
pH & PaC02
pH less than 7.35
PaC02 greater than 45 mm Hg
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Respiratory Acidosis causes and results from
caused by an accumulation of C02 which combines with water in the body to produce carbonic acid, to lower the pH
any condition that results in hypoventilation can cause respiratory acidosis:
CNS depression from head injury, meds, anesthesia, neuro disease etc.
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Respiratory Alkalosis
pH & PaC02
pH greater than 7.45
PaC02 less than 35 mmHG
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Respiratory Alkalosis results from
any condition that causes hyperventilation such as:
anxiety, fear, pain, fever, pregnancy, meds etc.
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Metabolic acidosis levels
bicarbonate less than 22 mEq/L
pH less than 7.35
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metabolic alkalosis levels
bicarbonate level greater than 25 mEq/L
pH greater than 7.45
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Inhaler peak flowmeter (what is "normal" peak flow?)
measures peak expiratory volume
normal peak flow: 300-700 L/min
baseline values are needed for comparison
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COPD and diseases often associated
long term, irreversible diseases making breathing difficult because air does not easily flow out of lungs.
chronic bronchitis and emphysema (both caused by smoking tobacco)
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avg fluid amt intake and output
2600 ml per day
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both fluid and ion move across membrane
diffusion
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"normal" C02, pH, HC03
35-45 pg 655
7.35-7.45
21-28
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bronchoscopy post op
check for gag reflex
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thorocentisis
pneumothorax, need informed consent because it's invasive
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most important nursing intervention post op
airway!! respirations
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pt with thorocentisis with suspected pneumothorax
pt may be tachy with signs of hypoxia
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pt having respiratory problems most important thing to ask
occupation
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s/s respiratory alkalosis
hyperventilation
seizure
tachycardia
severe pain
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s/s metebolic acidosis
hyperkalemia
m. twitching
vasodilation
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hypervalemia
increased and bounding pulse
pale cool skin
increased b/p
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causes of low Na
excessive diaphoresis (sweating)
diuretics
wound drainage
decreased secretion of aldosterone
renal disease
NPO, low Na diet
hyperglycemia
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s/s of hyponatremia
rapid pulse
nausea and diarrhea, hyperactive bowels
seizures when below 120
death below 115
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kayexalate
drug of choice for treating hyperkalemia
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Acid-base balance
- homeostasis of hydrogen ion concentration in body fluid.
- Maintained by controlling the H ion concentration of body fluids, especially ECF
- Concentration of H ions in body fluid is expressed as the pH
- Lungs and kindeys are major regulators
- Lungs compensate for respiratory distrubances
- Kidneys compensate for metabolic disturbances
- Buffer systems regulate acid base balance
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How do ABG levels help determine a patients acid-base balance
evaluating pulmonary gas exchange efficiency
Assessing the respiratory system
Evaluating blood oxygenation
Monitoring respiratory therapy effectiveness
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