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Hypertension
occurs when the systolic blood pressure is above 140 mm Hg or the diastolic blood pressure is above 90 mm Hg
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Essential Hypertension (primary hypertension)
No known cause. Accounts for 90-95% of all cases. No identified cause.
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Secondary Hypertension
related to other identified causes. Some of these include:
- -renal disease
- -hyperaldosterone, cushings disease,thyroid/parathyroid disorder
- -sleep apnea
- -pregnancy
- -medications
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Hypertension Contributes to Cardiovascular disease
- Obesity
- Diabetes
- Elevated cholesterol and triglycerides
- smoking
- sedentary lifestyle
- family history
- age
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Pathophysiology of Hypertension
Each time the heart contracts pressure is exerted by the blood vessels
Hypertension can result from an increase in cardiac output, an increase in peripheral or both
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Vasoconstriction and Vasodilation
Arterial opening is an important determinant of peripheral vascular resistance
Vessels have the ability to widen or narrow quickly in response to body needs (such as oxygen demands of nearby tissues, temperature regulation,fluid loss NS response)
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Progression of cardiovascular disease
Elevated blood pressure roughs up the normally smooth lining
Sets the stage for fat streaks, blood cells, or calcium to adhere
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ASHD (Ateriosclerotic Heart Disease)
Thickening and buildup reduces blood flow and increases resistance.
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Consistantly elevated BP can have the following negative outcomes
1. Damage to the endothelial lining of the arteries
2. Increased workload of the heart causes heart failure
3. Rupture of hemorrhage of arterioles
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Target organs of hypertension
Brain, Heart, Kidneys, Blood Vessels, Eyes
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Regulatory Mechanisms of hypertension
Sympathetic Nervous System and RAAS (Renin-agiotensin-aldosterone-system)
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Sympathetic Nervous System
activity in response to feedback mechanisms signals
- -vessels to constrict or to relax and open
- -fluid retention
- -heart rate and contractility
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RAAS (renin-angiotension-aldosterone-system)
Important pathway causing vasoconstriction and sodium/fluid retension
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Safe, Effective Care of hypertension
- -Hypertension is under diagnosed
- -No visible symptoms
- -Often called the "silent killer"
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Risk Factors for Development of Primary HTN
age-related to ↓ elasticity of blood vessels
- family history
- ethnicity
- obesity
- diabetes, sleep apnea
- Diet
- alcohol consumption
- oral contraceptives in women
- smoking
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Clinical Manifestations (signs and symptoms)
Elevated blood pressure readings
Most people have no outward symptoms
- Sometimes (infrequently) reported by patients:
- -Dull headache, Nosebleeds,Dizziness, Blurred Vision
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Pharmacologic Therapy
(Drugs used to treat hypertension have two main factors)
1.They decrease the volume of circulating blood
2. They reduce peripheral vascular resistance
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When administering antihypertensive medication drugs to patients always determine
Blood pressure and heart rate
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(Drug Class)
Diuretics
- Mechanism of Action
- ↑ urine output ↓ Blood volume
Inhibits sodium reabsorption in kidneys
- Side Effect & Adverse Effects
- Volume depletion/dehydration
- ↓ K (hypokalemia)
- ↓ sodium (hyponantremia)
- Headache
- Weakness
- Vertigo
- Orthostatic hypotension
- Dry mouth
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(Drug Class)
Angiotensin-Converting Enzyme (ACE) Inhibitors
-castopril(Capoten)
-lisinopril(Zestril)
-enalapril(Vasotec)
- Inhibits conversion of angiotensin 1 to angiotensin 2 resulting in vasodilation lower peripheral resistance
- ↓ blood volume
- Side Effects & Adverse Effects
- Persistent, dry cough
- Hyperkalemia (high K)-especially in patients with kidney disease
- First dose hypotension
- Angioedema(usually stridor) (potentially fatal)
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Treatment Goals for Patients with Hypertension
Lowering and controlling blood pressure
- -Maintain 140/90 or lower
- -Maintian 130/80 or lower in patients with diabetes or chronic kidney disease
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Nursing Care of Patients with Hypertension
(Assessment)
- Pain-where, how often,how severe
- Dizziness
- Vision
- Breathing, SOB
- Fatigue
- Urinating
- Sexual dysfunction
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(Physical) Assessment Of Hypertension
- -Blood pressure
- -Heart rate, rhythm
- -Peripheral pulses
- -Peripheral edema
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Patient Teaching
- -Emphasize concept of controlling rather than curing hypertension
- -For most will be a lifelong, chronic illness.
- -Treatment will Greatly decrease associated cardiovascular risks.
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Hypertensive crisis
- -A Hypertensive crisis exists when blood pressure is severely elevated.
- -Acute situation that requires prompt treatment to halt or prevent serious damage to target organs
- -Severity of situation is determined by evidence of organ damage. (cerebral hemorrhage,MI,heart failure, Kidney failure)
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How High is TOO High
- -No clear guidelines
- -200/120 requires immediate treatment
- -180-199 systolic or 110-119 may require immediate treatment or evaluation within 24-48 hrs
- Hypertensive EMERGENCY there is evidence of target organ damage.
- -Hypertensive URGENCY no organ damage is evident (Sometimes called asymptomatic severely elevated blood pressure)
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Oxygenation
Occurs when O2 molecules enter the tissues of the body
-Blood is oxygenated in the lungs where oxygen molecules travel from the air and into the blood
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Vital Signs
A persons temp,pulse,respiration, blood pressure and pain assessment
-ex: 98.5-72-18-120/80. pt denies pain 0/10
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Prevalence of Conditions related to Oxygenation
- Respiratory infectious diseases
- -Flu
- -Pneumonia
- Hypertension
- Coronary Artery Disease (CAD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Anemia
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Multiple systems involved in regulating oxygenation
- -Nervous system
- -Cardiovascular system
- -Respiratory system
- -Metabolic processes
- -Hormones
- -Electrolytes
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(Reciprocal Relationship of Vital Signs)
They have a relationship to each other and together they are indicators of a persons health status.
-They refect how the circulatory,respiratory,nervous,and endocrine systems are functioning.
-Many things can affect VS
-An alternation in one VS often affects others and needs to be seen in context with other health care assessments
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Physical Assessment
- Technique
- -Inspection
- -Palpation
- -Percussion
- -Auscultation
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- Stethoscope
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Temperature
- Balance of heat produced and lost from the body
- normal temperature range:
- 36-38 C 96.8-100 F
- Heat produced-heat lost=body temp
Core temp-temp of the deep tissues, relatively constant
Surface temp-fluctuates
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Heat production
- -Is a by product of metabolism
- -Food is the main fuel for metabolism
- -Increase metabolism increase heat
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Heat loss
is lost mainly through the skin by
- radiation convection
- conduction evaporation
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(Thermoregulation)
Nervous System
Hypothalamus (set point)-is the thermo-regulatory center controlling body temperature.
- Anterior-controls heat production
- Posterior-controls heat loss
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(Thermoregulation)
Cardiovascular Vascular System
Vasodilation
Body becomes too warm superficial vessels dilate and leads to heat loss
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(Thermoregulation)
Cardiovascular System
Vasoconstriction
Body becomes too cold and superficial vessels constrict leads to heat conservation
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(Thermoregulation)
Hormones/Respiratory System
- -Thyroxin
- -Progesterone
- -Testosterone
-Increased temperature-see increased metabolism,fluid loss,R, & tissue O2 demands.
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Factors Influencing Temperature
-Stress-physical/emotional
-Gender-female greater fluctuation
-Circadian rhythm- (24 hour cycle) 1-2 F change, lowest 1-4 am and highest 4-7pm
-Age
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Factors Influencing Temp
Environment
very young and very old are more sensitive to environment changes
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Heat Stroke
Overexposure to heat T-↑ 105 F
- Signs and Symptoms
- Giddiness,confusion,delirium,hot dry skin
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Heat exhaustion
Heat exposure that leads to diaphoresis(profuse sweating) and fluid and electrolyte imbalance
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Hypothermia
- from heat loss as a result of exposure to cold
- -Temp below 95 F, shivering,poor judgment and memory, depression
- -usually develops slowly-person thinks "Im Ok"
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Fever(Pyrexia)
- Results of:
- -Pyrogens(bacteria & viruses)
- which trigger the immune response
- -Hypothalamus
- raises the set point so the bosy produces & conserves more heat
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Three phases of a fever
1) chills,shivers,feel cold- new set point
2) feel warm & dry-at set point
3) feel warm, flushed, diaphoretic-set point drops
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Febrile
Temperature above normal 100.4
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types of fevers
- Constant Intermittent
- Crisis Remittent
- Relapsing Lysis
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Health Promotion and Maintenance
Aging Process
- -Narrower range of body temp
- -Reduced metabolism
- -Reduced sweat gland activity
- -Less subcutaneous tissue
- -Poor vasomotor control
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Health Promotion and Maintenance
Self Care
- -Immunizations
- -Annual Physical
- -Documentation regarding illness,treatment,response
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Physiology Integrity
Basic Care and Comfort
- -Non-pharmacological comfort interventions
- -Provide rest,dry linens/clothes
- -Offer well balanced meals
- -Frequent oral hygiene
- -Cooling techniques
- -Tepid sponge baths, room temp 70-80
- -decrease clothing, cooling blanket
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Physiological Integrity
Pharmacological therapiesds
- Antipyretics
- -Expected effects-reduce fever and pain with action therapists in 30-60 min
- -Acetaminophen
- -ASA
- -NSAIDS
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Pulse
Contraction of the left ventricle sends a wave of blood into the arteries causing their walls to distend-felt as a beat then walls relax until next beat.
Apical pulse is more accurate than a peripheral
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Cardiac Output
- Pulse rate- heart rate- BPM (beats per minute)
- Stroke Volume
-amount of blood amount of blood ejected from the heart with each beat - Stroke Volume
×Heart Rate=Cardiac Output
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(Physiology of Pulse Regulation)
Cardiovascular System
- -Automaticity
- -SA node
- -Blood volume
- -Stroke volume
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Autonomic Nervous System
Sympathetic Nervous System-stimulation of the SA node increases heart rate and force of contraction
Parasympathetic- stimulation of SA node via vagus nerve decreases heart rate.
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(physiology Of Pulse Regulation)
Respiratory System
- -Cardiovascular and respiratory systems are closely related
- -Chief function-supplies O2 to the blood and removes CO2 from the blood
- -Circulatory System-brings O2 to the cells and removes CO2
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(Physiology Of Pulse Regulation)
Hormones
- -ADH-regulates vascular volume
- -Aldosterone-affects vascular volume
- -Epinephrine & norepinephrine-affect rate
- -Renin-causes vasoconstriction
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Electrolytes
Maintain rhythmicity of the heart
- -K-potassium:3.5 mEq/L
- -Na-Sodium:135-145 mEq/L
- -Ca-Calcium: 9-10.5 mg/dL
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Arterial Blood Gases (ABG's)
Blood drawn from radial or femoral artery to assess patients oxygen status and acid base balance
- -pH 7.35-7.45
- -PaCO2 35-45 mmHg
- -PaO2 70-100mm Hg
- -HCO3 19-25 mEq/L
- -O2 saturation 95-100%
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Normal Adult Values
- Rate
- 60-100 bpm
- Bradycardia<60 bpm
- Tachycardia >100 bpm
- Rhythm
- Regular
- Equality
- Equal in both extremities
- Amplitude
- +3
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Normal Values Cont'd
- Amplitude Strength
- 0 Absent
- +1 Thready
- +2 Weak
- +3 Normal
- +4 Bounding
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Peripheral Vascular (CSM Signs)
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-Circulation
- Color
- Temperature
- Pulse
- Capillary Refill-less than 3 seconds
- -Sensation
- Paresthesia
- Absence of feeling
- -Motion
- -Weakness,Paralysis
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Factors Affecting the Pulse
- -Medications -Exercise
- -Hemorrhage -Gender
- -Postural changes -Temp
- -Pulmonary -Environment
- disease -Psychosocial state-pain,
- -age anxiety,relaxation
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Respiration
The process of transporting O2 from the atmosphere to body cells and transporting CO2 from body cells to the atmosphere
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External respiration
Involves ventilating lungs & exchange of gases at alveoli
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Internal Respiration
Involves exchange of gases from blood to cells and cells to blood
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Ventilation
Movement of gases in & out of the lungs
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Diffusion
Exchange of O2 & CO2 between alveoli & circulating blood-assess O2 saturation
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Perfusion
Exchange of O2 & between circulating blood & tissue cells-assess O2 saturation
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Nervous System
Maintains rhythm & depth of respiration & balance between inspiration & expiration
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Respiratory Center
medulla oblongata
Automatic control of breathing
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Cerebral Cortex
Voluntary control of breathing
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Cardiovascular System
Controls the oxygenation and delivery of blood to cells
- Factors to consider
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Quality of blood - -Hgb 12-18 g/dL
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- Quality of blood-Hct
- -F 37-48%
- -M 42-52%
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Physiology Of Respiratory Function
Metabolic process
Anything that increases metabolism increases respirations
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Physiology of Respiratory Function
Blood Gases
CO2, O2 & H+ affect blood pH- most important factor is CO2 level
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Physiology Of Respiratory Function
Chemoreceptors
Stimulate respirations to maintain normal blood gases
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Assessment Of Diffusion and Perfusion
Oxygen Saturation(SaO2)
the percentage of Hgb bound with O2 in the arterial circulation
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Assessment of Diffusion/Perfusion
Normal value
SaO2-95-100%
Anything that alters perfusion/diffusion will affect this anemia-insufficient respiratory status
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Assessment of Lung Sounds
-Assess over trachea,bronchi,and peripheral lung fields
-Normal lung sounds are quiet and heard only through the stethoscope
-Abnormal sounds(adventitious) caused by narrowing, moisture, inflammation or consolidation
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O2 Assessment
Skin Color
- Normal
- -Abnormal
- Ruddiness
- Cyanosis-blue
- Pallor-pale
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O2 Assessment
Clubbing of the nails
- result of chronic O2 deficiency
- Normal-angle between nail & skin=160 degrees
- Abnormal(clubbing)
- 180 degree-flat to > 180 degree
- Nail base is spongy & swollen
 
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O2 Assessment
- -Cough
- -Body position
- -Shape of chest cavity
- -History of smoking
- -Activity tolerance
- -Shortness of breath
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Patient Centered Care Health Promotion and Maintenance
- -Variations through life span
- -Changes associated with aging
- ↓ elasticity
↓ maximum capacity
↓ thoracic and abdominal muscle strength
-These changes increases the risk for disease like pneumonia
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Patient-Centered Care
Basic care and comfort
- Positioning
- -fowlers
- O2 administration
- -O2 via nasal cannula
- Fluid intake
- -2-3L daily if medically able
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Patient Centered Care
Pharmacological therapies
- Expected effects/outcomes/contradictions
- Nicotine supplements
- Gum
- Patch
- Bronchodilators
- Reduction of risk potential
- Assessment of VS before administering meds affecting respirations
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Pulse Pressure
systolic-diastolic=PP
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Cardiovascular system
SVxHR=CO
- Increased CO=Increased BP
- Increased HR=Increased BP up to a point
- Blood Volume-(5-6L)
- increased-elevated BP,decreased=lower BP
Viscosity(amount RBC in plasma), increased=increased BP
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Cardiovascular system (cont)
- Elasticity of vessels-decreased leads to increased BP
- Peripheral resistance-increase see increased BP,decrease see decreased BP
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Physiology Of BP Regulation
Nervous System
- Cardiac reflex center-In Medulla-ANS
- -Stimulate parasympathetic branch impulses to heart via vagus nerve, decrease rate
- Vasomotor reflex center-In Medulla
- -Regulates vasoconstriction/vasodilation of vessels
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Baroreceptors
- -Pressure sensitive receptors (pressure receptors)
- -Located in aortic arch and walls of arteries
- -Respond to changes in diameter of vessels
- -Send impulses to cardiovascular center
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Physiology of BP Regulation
- Hormones
- -ADH-recall
- -Aldosterone-recall
- -Renin-recall
- Electrolytes
- -Role in normal heart rhythm so influence BP
- Blood gases
- -↓O2-Vasoconstriction
-↑ CO2- Vasodilation
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Assessment Of BP
- Normal Values
- -Systolic <120mmHg
- -Diastolic <80 mmHg
- Consider
- -Baseline
- -Position changes
- -Cuff size
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Assessment Of BP
Korotkoff sounds
- Phase 1-faint tapping sounds
- Phase 2
-muffled or swishing sounds-may disappear up to 40 mmHg- Phase 3-
loud sounds- Phase 4
-softer fading muffled sounds- Phase 5
-last sound heard(diastolic pressure)
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Hypotension
- -Below normal BP-systolic <90 -normal for some
- Other S&S-tachycardia,pallor,confusion,clammy skin,mottled skin (Report Immediately)
- Causes
- -Dilation of arteries
- -Decreased blood volume
- -Failure of heart's pumping ability
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Assessment Of BP
Orthostatic(postural) hypotension
-Systolic drop of at least 20 mmHg or diastolic by at least 10 mmHg after position change supine to sitting, sitting to standing or supine to standing assess BP and pulse 1-3 minutes after each position change
-Causes; dehydration, blood loss, prolonged bed rest, older, surgery
-Other S&S-weak, dizzy,faint
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Patient-Centered Care
Aging Process
- Resistance to blood flow increases yearly
- -↓ elasticity of arteries and the size of the lumen
-Resulting in ↑ systolic and diastolic pressure
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Physiological Integrity
Pharmacological Therapies
- Expected effects/outcomes
- Adverse effects
-contradictions - -Orthostatic hypotension
- -Electrolyte imbalance
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