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Pediatrics
Pediatrics 150 150 Tony Guo

Pediatrics

 

21st Century Pediatric Nursing

Pediatric Health Promotion

  • 24% of the US population is made up of children
  • Healthy People 2020
    • Goals:
      • Increase quality and length of healthy life
      • Eliminate health disparities
    • Leading Health Indicators
      • Physical activity
      • Overweight and obesity
      • Tobacco use
      • Substance abuse
      • Responsible sexual behavior
      • Mental health
      • Injury and violence
      • Environmental quality
      • Injury and violence
      • Access to health care
  • Bright Futures
    • National Health Promotion Initiative with the goal to improve the health of our nation’s children
    • Major themes are:
      • Promoting family support, child development, mental health, healthy nutrition that leads to healthy weight, physical activity, oral health, healthy sexual development and sexuality, safety and injury prevention, and the importance of community relationships and resources.
  • Development
    • Unique to each stage of development- continuous screening and assessment are needed for early intervention.
    • AAP policy statement on screen viewing time – shift of importance from what is on the screen to who is viewing the information with the child.
  • Childhood Health Problems
    • Oral health- dental caries is the most common chronic disease in childhood
      • Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene, beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care.
    • Obesity & Type 2 DM
      • The most common nutritional problem among children in the United States
      • Overweight is defined as a BMI at or above the 85th percentile and below the 95th percentile for children and teens of the same age and sex.
      • Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low-income minority children.
    • Childhood injuries
      • Most common cause of death & disability in children
      • Risk factors
        • Sex
          • Preponderance of males; difference mainly the result of behavioral characteristics, especially aggression
        • Temperament
          • Children with difficult temperament profile, especially persistence, high activity level, and negative reactions to new situations
        • Stress
          • Predisposes children to increased risk-taking and self-destructive behavior; general lack of self-protection
        • Alcohol and drug use
          • Associated with higher incidence of motor vehicle injuries, drownings, homicides, and suicides
        • History of previous injury
          • Associated with increased likelihood of another injury, especially if initial injury required hospitalization
        • Developmental characteristics
        • Mismatch between child’s developmental level and skill required for activity (e.g., all-terrain vehicles)
        • Natural curiosity to explore environment
        • Desire to assert self and challenge rules
        • In older child, desire for peer approval and acceptance
        • Cognitive characteristics (age-specific)
        • Infant
          • Sensorimotor: explores environment through taste and touch
        • Young child
          • Object permanence: actively searches for attractive object; cause and effect: lacks awareness of consequential dangers; transductive reasoning: may fail to learn from experiences (e.g., perceives falling from a step as a different type of danger from climbing a tree); magical and egocentric thinking: is unable to comprehend danger to self or others
        • School-age child
          • Transitional cognitive processes: is unable to fully comprehend causal relationships; attempts dangerous acts without detailed planning regarding consequences
        • Adolescent
          • Formal operations: is preoccupied with abstract thinking and loses sight of reality; may lead to feeling of invulnerability
        • Anatomic characteristics (especially in young children)
        • Large head
          • Predisposes to cranial injury
        • Large spleen and liver with wide costal arch—
        • Predisposes to direct trauma to these organs
        • Small and light body
          • May be thrown easily, especially inside a moving vehicle
        • Other factors
          • Poverty, family stress (e.g., maternal illness, recent environmental change), substandard alternative child care, young maternal age, low maternal education, multiple siblings
      • Drowning is one of the leading causes of death; Children left unattended are unsafe even in shallow water
      • Burns are among the top three leading causes of death from injury in children 1 to 14 years of age
      • Improper use of firearms is the fourth leading cause of death from injury in children 5 to 14 years of age
    • Violence
      • Strikingly higher homicide rates are found among minority populations, especially African-American children.
      • Violence seems to permeate US households through television programs, commercials, video games, and movies, all of which tend to desensitize the child toward violence.
      • Families that own firearms must be educated about their safe use and storage.
    • Bullying
      • This is a serious problem and can involve emotional, physical, verbal, and cyber-related abuse
      • When youth are not well accepted by their peers, they are vulnerable to bullying; physical disabilities, obesity, and sexual orientation can be risk factors creating vulnerability.
    • Mental health problems
      • Nurses should be alert to the symptoms of mental illness and potential suicidal ideation and be aware of potential resources for high-quality integrated mental health services.

Infant Mortality

  • Number of deaths per 1000 live births during first of life
    • 5.9 per 1000 in the U.S.
  • Leading causes of death in the U.S.:
  • Birth defects
  • Preterm birth & low birth weight
  • Sudden Infant Death Syndrome (SIDS)
  • Maternal pregnancy complications
  • Texas has a rate of 5.9 per 1000

 

Child Mortality

  • Death rates for children older than 1 year of age have always been lower than those for infants.
  • A sharp rise occurs during later adolescence, primarily from injuries, homicide, and suicide
  • Five leading causes of Death in Children in the United States: Selected Age intervals by Rate per 100,000 population
Rank 1-4 years of age 5-9 years of age 10-14 years of age 15-19 years of age
Causes Rate Causes Rate Causes Rate Causes Rate
1 Injuries  7.6 Injuries  3.6 Injuries  3.6 Injuries  17.7
2 Congenital anomalies  2.5 Cancer  2.1 Suicide  2.1 Suicide  8.7
3 Homicide  2.3 Congenital anomalies  0.9 Cancer  2.0 Homicide  6.7
4 Cancer  2.0 Homicide  0.6 Congenital anomalies  0.8 Cancer  2.9
5 Heart disease  0.9 Heart disease  0.3 Homicide  0.8 Heart disease  1.4

 

Childhood Morbidity

  • Illnesses severe enough to limit activity or require medical attention
    • Most common childhood illness is the cold
    • Respiratory illness accounts for 50% of all acute conditions
    • 11% are caused by infections and parasitic disease
    • 15% are caused by injuries

 

Pediatric Nursing Care

  • Family-centered care:
    • Recognize the family as a constant in the child’s life
    • Support the competence of the family
    • Address the needs of all family members
    • Enable and empower families
  • Key elements of Family-Centered Care
    • Incorporating into policy and practice the recognition that the family is the constant in a child’s life, whereas the service systems and support personnel within those systems fluctuate
    • Facilitating family-professional collaboration at all levels of hospital, home, and community care:
      • Care of an individual child
      • Program development, implementation, and evaluation
      • Policy formation
    • Exchanging complete and unbiased information between family members and professionals in a supportive manner at all times
    • Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality within and across all families, including ethnic, racial, spiritual, social, economic, educational, and geographic diversity
    • Recognizing and respecting different methods of coping and implementing comprehensive policies and programs that provide developmental, educational, emotional, environmental, and financial support to meet the diverse needs of families
    • Encouraging and facilitating family-to-family support and networking
    • Ensuring that home, hospital, and community service and support systems for children needing specialized health and developmental care and their families are flexible, accessible, and comprehensive in responding to diverse family-identified needs
    • Appreciating families as families and children as children, recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support

 

  • Empowerment describes the interaction of professionals with families in such a way that families maintain or acquire a sense of control over their family lives and acknowledge positive changes that result from helping behaviors that foster their own strengths, abilities, and actions.

 

Family, Social, Cultural, and Religious Influences on Child Health Promotion

  • Family Systems Theory
    • A change in any part of a family system affects all other parts of the family
  • Family Stress Theory
    • Stress is an inevitable part of family life and any event can be stressful on the family
  • Developmental Theory 
    • Families develop and change over time in similar and consistent ways

 

Assumptions Strengths Limitations Applications
Family Systems Theory
A change in any one part of a family system affects all other parts of the family system (circular causality).

Family systems are characterized by periods of rapid growth and change and periods of relative stability.

Both too little change and too much change are dysfunctional for the family system; therefore, a balance between morphogenesis (change) and morphostasis (no change) is necessary.

Family systems can initiate change, as well as react to it.

Applicable for family in normal everyday life, as well as for family dysfunction and pathology.

Useful for families of varying structure and various stages of life cycle.

More difficult to determine cause-and-effect relationships because of circular causality. Mate selection, courtship processes, family communication, boundary maintenance, power and control within family, parent-child relationships, adolescent pregnancy and parenthood.

 

Acute Pyelonephritis
Acute Pyelonephritis 150 150 Tony Guo

Acute Pyelonephritis

  • Etiology and Pathophysiology
    • Inflammation of renal parenchyma and collecting system (including the renal pelvis)
    • Most common cause is bacterial infection
    • Fungi, protozoa, or viruses can also infect kidneys
    • Cortical surface shows grayish white areas of inflammation and abscess formation

 

  • Urosepsis

 

  • Systemic infection from urologic source
  • Prompt diagnosis/treatment critical 
    • Can lead to septic shock and death unless promptly treated
  • Usually begins with colonization and infection of lower tract via ascending urethral route
  • Frequent causes 
    • Escherichia coli
    • Proteus
    • Klebsiella
    • Enterobacter
  • Preexisting factor usually present
    • Vesicoureteral reflux
      • Retrograde (backward) movement of urine from lower to upper urinary tract
    • Dysfunction of lower urinary tract
      • Obstruction from BPH
      • Stricture
      • Urinary stone
    • CAUTI
  • Clinical manifestations
    • Mild fatigue
    • Chills
    • Fever
    • Vomiting
    • Malaise
    • Flank pain
    • LUTS characteristic of cystitis
      • Dysuria, urgency, frequency
    • Costovertebral tenderness to percussion typically present on affected side
    • Manifestations may subside in a few days, even without therapy
      • Bacteriuria and pyuria still persist
  • Diagnostic Studies
    • History and physical examination
      • Palpation for CVA pain
    • Laboratory tests
      • Urinalysis
      • Urine for culture and sensitivity
      • CBC with WBC differential
      • Blood culture (if bacteremia is suspected)
    • Ultrasound
    • CT Scan
  • Interprofessional Care
    • Hospitalization for patients with severe infections and complications 
      • Such as nausea and vomiting with dehydration
    • Signs/symptoms typically improve within 48 to 72 hours after therapy starts
    • Drug therapy
      • Antibiotics
        • Parenteral administration in hospital to rapidly establish high drug levels
      • NSAIDs or antipyretic drugs
        • Fever
        • Discomfort
      • Urinary analgesics
    • Relapses may be treated with 6-week course of antibiotics
      • Antibiotic prophylaxis may be used for recurrent infection
      • Follow-up urine culture and imaging studies
    • Urosepsis is characterized by bacteriuria and bacteremia
      • Close observation and vital sign monitoring are essential
      • Prompt recognition and treatment of septic shock may prevent irreversible damage or death

Nursing Management

  • Nursing Assessment
    • Mild Symptoms
      • Outpatient management or short hospitalization
        • Adequate fluid intake
        • Nonsteroidal anti-inflammatory drugs (NSAIDs) or antipyretic drugs
        • Follow-up urine culture and imaging studies
    • Severe Symptoms
      • Hospitalization
      • Adequate fluid intake (parenteral initially; switch to oral fluids as nausea, vomiting, and dehydration subside)
      • NSAIDs or antipyretic drugs to reverse fever and relieve discomfort
      • Follow-up urine culture and imaging studies
  • Nursing Planning
    • The overall goals are that the patient with pyelonephritis will have 
      • Normal renal function
      • Normal body temperature
      • No complications
      • Relief of pain
      • No recurrence of symptoms
  • Nursing Implementation
    • Nursing interventions vary depending on the severity of symptoms. 
    • These interventions include teaching the patient about the disease process with emphasis on
      • Continuing medications as prescribed
      • Having a follow-up urine culture
      • Recognizing manifestations of recurrence or relapse
      • In addition to antibiotic therapy, encourage the patient to drink at least eight glasses of fluid every day, even after the infection has been treated. 
      • Rest will increase patient comfort.

 

Acute Kidney Injury and Chronic Kidney Disease

 

Comparison of Acute Kidney Injury and Chronic Kidney Disease

Acute Kidney Injury Chronic Kidney Disease
Onset Sudden  Gradual, often over many years
Most common cause Acute tubular necrosis Diabetic nephropathy
Diagnostic criteria Acute reduction in urine output and/or Elevation in serum creatinine GFR <60 mL/min/1.73 m2 for >3 mo. and/or Kidney damage >3 mo.
Reversibility Potentially Progressive and irreversible
Primary cause of death Infection Cardiovascular disease

  • Acute Kidney Injury
    • Causes of Acute Kidney Disease
      • Prerenal
      • Intrarenal
      • Postrenal 
    • Etiology and Pathophysiology
      • Prerenal
        • Causes are factors that reduce systemic circulation, causing reduction in renal blood flow
          • Severe dehydration, heart failure, lowered CO
        • Decreases glomerular filtration rate
          • Causes oliguria
        • Autoregulatory mechanisms attempt to preserve blood flow
      • Intrarenal
        • Causes include conditions that cause direct damage to kidney tissue
          • Prolonged ischemia, nephrotoxins
          • Hemoglobin released from hemolyzed RBCs
          • Myoglobin released from necrotic muscle cells
        • Acute tubular necrosis (ATN)
          • Results from ischemia, nephrotoxins, or sepsis
          • Severe ischemia causes disruption in basement membrane
          • Nephrotoxic agents cause necrosis of tubular epithelial cells
          • Potentially reversible
      • Postrenal
        • Causes include mechanical obstruction of outflow
          • Benign prostatic hyperplasia
          • Prostate cancer
          • Calculi
          • Trauma
          • Extrarenal tumors
          • Bilateral ureteral obstruction
Common Causes of Acute Kidney Injury
Prerenal Intrarenal Postrenal
Hypovolemia Nephrotoxic Injury
  • Dehydration
  • Hemorrhage
  • GI losses (diarrhea, vomiting)
  • Excessive diuresis
  • Hypoalbuminemia
  • Burns
  • Drugs: aminoglycosides (gentamicin, amikacin), amphotericin B
  • Contrast media
  • Hemolytic blood transfusion reaction
  • Severe crush injury
  • Chemical exposure: ethylene glycol, lead, arsenic, carbon tetrachloride
  • Benign prostatic hyperplasia
  • Bladder cancer
  • Calculi formation
  • Neuromuscular disorders
  • Prostate cancer
  • Spinal cord disease
  • Strictures
  • Trauma (back, pelvis, perineum)
Decreased Cardiac Output Interstitial Nephritis
  • Cardiac dysrhythmias
  • Cardiogenic shock
  • Heart failure
  • Myocardial infarction
  • Allergies: antibiotics (sulfonamides, rifampin), nonsteroidal anti-inflammatory drugs, ACE inhibitors
  • Infections: bacterial (acute pyelonephritis), viral (CMV), fungal (candidiasis)
Decreased Peripheral Vascular Resistance Other Causes
  • Anaphylaxis
  • Neurologic injury
  • Septic shock
  • Prolonged prerenal ischemia
  • Acute glomerulonephritis
  • Thrombotic disorders
  • Toxemia of pregnancy
  • Malignant hypertension
  • Systemic lupus erythematosus
Decreased Renovascular Blood Flow
  • Bilateral renal vein thrombosis
  • Embolism
  • Hepatorenal syndrome
  • Renal artery thrombosis

 

  • Clinical Manifestations
    • RIFLE classification
      • Risk (R)
      • Injury (I)
      • Failure (F)
      • Loss (L)
      • End-stage renal disease (E)
Stage GFR Criteria Urine Output Criteria Clinical Example
Risk Serum creatinine increased × 1.5

OR

GFR decreased by 25%

Urine output <0.5 mL/kg/hr for 6 hr 68-yr-old African American woman with type 2 diabetes, hypertension, CAD, and CKD.

Scheduled to undergo emergency coronary artery bypass graft.

Serum creatinine is 1.8 mg/dL (increased) and she weighs 60 kg.

Calculated GFR is 35 mL/min/1.73 m2.

She has Stage 3b CKD.

Injury Serum creatinine increased × 2

OR

GFR decreased by 50%

Urine output <0.5 mL/kg/hr for 12 hr During surgery, she experiences hypotension for a sustained period.

Acute tubular necrosis is diagnosed.

After surgery: Serum creatinine is 3.6 mg/dL and urine output is reduced to 28 mL/hr

Failure Serum creatinine increased × 3

OR

GFR decreased by 75%

OR

Serum creatinine >4 mg/dL with

acute rise ≥0.5 mg/dL

Urine output <0.3 mL/kg/hr for 24 hr (oliguria)

OR

Anuria for 12 hr

72 hours after surgery and in ICU develops ventilator-associated pneumonia and sepsis.

Serum creatinine rises to 5.2 mg/dL and urine output drops to 10 mL/hr.

BP remains low despite dopamine therapy.

Loss Persistent acute kidney failure.

Complete loss of kidney function >4 wk

Continuous venovenous hemodialysis is started.

After 3 wk of therapy she has a cardiopulmonary arrest and does not survive.

End-Stage

Renal Disease

Complete loss of kidney function >3 mo

 

  • Oliguric phase
    • Urinary changes- oliguria
      • Urinary output less than 400 mL/day
      • Occurs within 1 to 7 days after injury
      • Lasts 10 to 14 days
      • Urinalysis may show casts, RBCs, WBCs
    • Fluid volume
      • Hypovolemia may exacerbate AKI
      • Decreased urine output leads fluid retention
        • Neck veins distended
        • Bounding pulse
        • Edema
        • Hypertension
      • Fluid overload can lead to heart failure, pulmonary edema, and pericardial and pleural effusions
    • Metabolic acidosis
      • Impaired kidney cannot excrete hydrogen ions
      • Serum bicarbonate production is decreased
      • Severe acidosis develops
        • Kussmaul respirations
    • Sodium balance
      • Increased excretion of sodium
      • Hyponatremia can lead to cerebral edema
    • Potassium excess
      • Impaired ability of kidneys to excrete potassium
      • Increased risk with massive tissue trauma
      • Usually asymptomatic
      • ECG changes
    • Hematologic disorders
      • Leukocytosis
    • Waste product accumulation
      • Elevated BUN and serum creatinine levels
    • Neurologic disorders
      • Fatigue and difficulty concentrating
      • Seizures, stupor, coma
  • Diuretic phase
    • Daily urine output is 1 to 3 L
    • May reach 5 L or more
    • Monitor for hyponatremia, hypokalemia, and dehydration
  • Recovery phase
    • May take up to 12 months for kidney function to stabilize
  • Diagnostic studies 
    • Thorough history and physical examination
    • Identification of precipitating cause
    • Serum creatinine and BUN levels
    • Serum electrolytes
    • Urinalysis
    • Kidney ultrasonography
    • Renal scan
    • CT scan
    • Renal biopsy
    • Contraindicated
      • MRI with gadolinium contrast medium
      • Magnetic resonance angiography (MRA) with gadolinium contrast medium
        • Nephrogenic systemic fibrosis 
        • Contrast-induced nephropathy (CIN)
  • Management
    • Treatment of precipitating cause
    • Fluid restriction (600 mL plus previous 24-hr fluid loss)
    • Nutritional therapy
    • Adequate protein intake (0.6-2 g/kg/day) depending on degree of catabolism
    • Enteral nutrition
    • Parenteral nutrition
    • Dietary restrictions (potassium, phosphate, sodium)
    • Measures to lower potassium (if elevated) 
      • Therapies for Elevated Potassium levels
        • Regular Insulin IV
          • Potassium moves into cells when insulin is given.
          • IV glucose is given concurrently to prevent hypoglycemia.
          • When effects of insulin diminish, potassium shifts back out of cells.
        • Sodium Bicarbonate
          • Therapy can correct acidosis and cause a shift of potassium into cells.
        • Calcium Gluconate IV
          • Generally used in advanced cardiac toxicity (with evidence of hyperkalemic ECG changes).
          • Calcium raises the threshold for excitation, resulting in dysrhythmias.
        • Hemodialysis
          • Most effective therapy to remove potassium.
          • Works within a short time.
        • Sodium Polystyrene Sulfonate (Kayexalate)
          • Cation-exchange resin is administered by mouth or retention enema.
          • When resin is in the bowel, potassium is exchanged for sodium.
          • Therapy removes 1 mEq of potassium per gram of drug.
          • It is mixed in water with sorbitol to produce osmotic diarrhea, allowing for evacuation of potassium-rich stool from body.
        • Dietary Restriction
          • Potassium intake is limited to 40 mEq/day.
          • Primarily used to prevent recurrent elevation. Not used for acute elevation.
        • Patiromer (Veltassa)
          • Oral suspension that binds potassium in GI tract.
          • It is used to treat chronic kidney disease.
          • It should not be used as an emergency drug for life-threatening hyperkalemia.
    • It has a delayed onset of action.
    • Calcium supplements or phosphate-binding agents
    • Initiation of dialysis (if necessary)
    • Continuous renal replacement therapy (if necessary)
  • Interprofessional Care 
    • Primary goals
      • Eliminate cause 
      • Manage signs and symptoms
      • Prevent complications
    • Ensure adequate intravascular volume and cardiac output
      • Force fluids
      • Loop diuretics (e.g., furosemide [Lasix])
      • Osmotic diuretics (e.g., mannitol)
    • Closely monitor fluid intake during oliguric phase
    • Hyperkalemia
      • Insulin and sodium bicarbonate
      • Calcium carbonate
      • Sodium polystyrene sulfonate (Kayexalate)
    • Indications for renal replacement therapy (RRT)
      • Volume overload
      • Elevated serum potassium level
      • Metabolic acidosis 
      • BUN level > 120 mg/dL (43 mmol/L)
      • Significant change in mental status
      • Pericarditis, pericardial effusion, or cardiac tamponade
    • Renal replacement therapy (RRT)
      • Peritoneal dialysis (PD)
        • Not frequently used
      • Intermittent hemodialysis (HD)
      • Continuous renal replacement therapy (CRRT)
        • Cannulation of artery and vein
    • Nutritional therapy
      • Maintain adequate caloric intake
        • Primarily carbohydrates and fat
        • Limited protein
      • Restrict sodium
      • Increase dietary fat
      • Enteral nutrition

Nursing Management

  • Nursing Assessment
    • Measure vital signs
    • Measure fluid intake and output
    • Examine urine
    • Assess general appearance
    • Observe dialysis access site
    • Mental status/level of consciousness
    • Oral mucosa
    • Lung sounds
    • Heart rhythm
    • Laboratory values
    • Diagnostic test results
  • Nursing Diagnoses
    • Risk for infection related to invasive lines, uremic toxins, and altered immune responses secondary to kidney injury
    • Excess fluid volume related to kidney injury and fluid retention
    • Fatigue related to anemia, metabolic acidosis, and uremic toxins
    • Anxiety related to disease processes, therapeutic interventions, and uncertainty of prognosis
    • Potential complication: dysrhythmias related to electrolyte imbalances
  • Nursing Planning
    • The patient with AKI will
      • Completely recover without any loss of kidney function
      • Maintain normal fluid and electrolyte balance
      • Have decreased anxiety
      • Adhere to and understand need for careful follow-up care
  • Nursing Implementation
    • Health Promotion
      • Identify and monitor populations at high risk 
      • Control exposure to nephrotoxic drugs and industrial chemicals
      • Prevent prolonged episodes of hypotension and hypovolemia
      • Measure daily weight
      • Monitor intake and output
      • Monitor electrolyte balance
      • Replace significant fluid losses
      • Provide aggressive diuretic therapy for fluid overload
      • Use nephrotoxic drugs sparingly
    • Acute Care
      • Accurate intake and output 
      • Daily weights
      • Assess for signs of hypervolemia or hypovolemia
      • Assess for potassium and sodium disturbances
      • Meticulous aseptic technique
      • Careful use of nephrotoxic drugs
      • Skin care measures/mouth care
    • Ambulatory Care
      • Regulate protein and potassium intake
      • Follow-up care
      • Teaching the patient the signs and symptoms of recurrent kidney disease
      • Appropriate referrals for counseling
        • If the kidneys do not recover, the patient will need to transition to life on chronic dialysis or possible future transplantation
    • Evaluation
      • The expected outcomes are that the patient with AKI will
        • Regain and maintain normal fluid and electrolyte balance
        • Adhere to the treatment regimen
        • Experience no complications
        • Have complete recovery
  • Gerontologic considerations
    • More susceptible to AKI
      • Dehydration
        • Polypharmacy- diuretics, laxatives
        • Illness and immobility
    • Hypotension
    • Diuretic therapy
    • Aminoglycoside therapy
    • Obstructive disorders
    • Surgery
    • Infection

 

  • Chronic Kidney Disease
    • Progressive, irreversible loss of kidney function
    • Mortality rates are as high as 19% to 24% for individuals with ESRD on dialysis
    • Many different causes, the leading causes are 
      • Diabetes (about 50%) 
      • Hypertension (about 25%).
    • Less common etiologies include glomerulonephritis, cystic diseases, and urologic diseases.
  • Stages of Chronic Kidney Disease
Description GFR (mL/min/1.73 m2)  Clinical Action Plan
Stage 1

Kidney damage with normal or increased GFR

≥90  Diagnosis and treatment

CVD risk reduction

Slow progression

Stage 2

Kidney damage with mild decreased GFR

60-89  Estimation of progression
Stage 3a

Moderate decreased GFR

45-59 Evaluation and treatment of complications
Stage 3b

Moderate decreased GFR

30-44  More aggressive treatment of complications
Stage 4

Severe decreased GFR

15-29 Preparation for renal replacement therapy (dialysis, kidney transplant)
Stage 5

Kidney failure

<15 (or dialysis) Renal replacement therapy (if uremia present and patient desires treatment)

 

  • Clinical Manifestations
    • Result of retained 
      • Urea
      • Creatinine
      • Phenols
      • Hormones
      • Electrolytes
      • Water
    • Uremia is a syndrome in which kidney function declines to the point that symptoms may develop in multiple body systems
    • Manifestations of uremia vary among patients according to the cause of the kidney disease, co-morbid conditions, age, and degree of adherence to the prescribed medical regimen
    • Cultural and ethnic health disparities
      • Chronic kidney disease (CKD) has a high incidence in minority populations, especially African Americans and Native Americans.
      • Hypertension and diabetes mellitus are also more common in African Americans and Native Americans.
        • African Americans 
          • The risk of CKD as a complication of hypertension is significantly increased in African Americans.
          • African Americans have the highest rate of CKD, nearly four times that of whites.
        • Native Americans
          • Native Americans have a rate of CKD twice that of whites.
          • The rate of CKD is six times higher among Native Americans with diabetes than among other ethnic groups with diabetes.
        • Hispanics
          • The rate of CKD in Hispanics is 1.5 times higher than in non-Hispanic whites.
    • Urinary system
      • In the early stages of CKD, patients usually do not report any change in urine output
      • Since diabetes is the primary cause of CKD, polyuria may be present, but not necessarily as a consequence of kidney disease
      • As CKD progresses, patients have increasing difficulty with fluid retention and require diuretic therapy
      • Anuria may develop after a period on dialysis
    • Metabolic Disturbances
      • Waste Product Accumulation. 
        • As the GFR decreases, the BUN and serum creatinine levels increase. 
        • The BUN is increased not only by kidney disease but also by protein intake, fever, corticosteroids, and catabolism. 
        • For this reason, serum creatinine clearance determinations (calculated GFR) are considered more accurate indicators of kidney function than BUN or creatinine. 
        • Significant elevations in BUN contribute to development of nausea, vomiting, lethargy, fatigue, impaired thought processes, and headaches.
      • Altered Carbohydrate Metabolism. 
        • Defective carbohydrate metabolism is caused by impaired glucose metabolism, resulting from cellular insensitivity to the normal action of insulin.
      • Mild to moderate hyperglycemia and hyperinsulinemia may occur.
    • Possible clinical manifestations of chronic kidney disease
Body System Manifestations
  1. Psychologic
  • Anxiety
  • Depression
  1. Neurologic
  • Fatigue
  • Headache
  • Sleep disturbances
  • Encephalopathy
  1. Ocular
  • Hypertensive retinopathy
  1. Cardiovascular
  • Hypertension
  • Heart failure
  • Coronary artery disease
  • Pericarditis
  • Peripheral artery disease
  1. Pulmonary
  • Pulmonary edema
  • Uremic pleuritis
  • Pneumonia
  1. Gastrointestinal
  • Anorexia
  • Nausea
  • Vomiting
  • Gastrointestinal bleeding
  • Gastritis
  1. Endocrine/Reproductive
  • Hyperparathyroidism
  • Thyroid abnormalities
  • Amenorrhea
  • Erectile dysfunction
  1. Integumentary
  • Pruritus
  • Ecchymosis
  • Dry, scaly skin
  1. Musculoskeletal
  • Vascular and soft tissue calcifications
  • Osteomalacia
  • Osteitis fibrosa
  1. Metabolic
  • Carbohydrate intolerance
  • Hyperlipidemia
  1. Hematologic
  • Anemia
  • Bleeding
  • Infection
  1. Peripheral neuropathy
  • Paresthesias
  • Restless legs syndrome

 

  • Diagnostic studies
    • History and physical examination
    • Identification of reversible kidney disease
    • Renal ultrasound, renal scan, CT scan
    • Renal biopsy
    • BUN, serum creatinine, and creatinine clearance levels
    • Serum electrolytes
    • Lipid profile
    • Urinalysis
    • Protein-to-creatinine ratio in first morning voided specimen
    • Hematocrit and hemoglobin levels
  • Management
    • Correction of extracellular fluid volume overload or deficit
    • Renal replacement therapy (dialysis, kidney transplant)
    • Nutritional therapy 
    • Measures to lower potassium 
  • Drug Therapy
    • Calcium supplementation, phosphate binders, or both
    • Antihypertensive therapy
    • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
    • Erythropoietin therapy
    • Lipid-lowering drugs
    • Adjustment of drug dosages to degree of renal function
  • Risk factors for Chronic Kidney Disease
Risk Factors Prevention and Management
Diabetes Achieve optimal glycemic control.
Hypertension Maintain BP in normal range with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs).
Age >60 yr. Prevent insult or injury to kidneys.
Cardiovascular disease Institute aggressive risk factor reduction.
Family history of CKD Teach about increased risk and assist with appropriate screening (BP measurement, urinalysis).
Exposure to nephrotoxic drugs Limit exposure and give sodium bicarbonate as treatment.
Ethnic minority (e.g., African American, Native American) Teach about increased risk and assist with appropriate screening (BP measurement, urinalysis).

 

  • Nutritional therapy
    • Protein restrictions
      • Calorie-protein malnutrition is a potential and serious problem that results from altered metabolism, anemia, proteinuria, anorexia, and nausea
      • Additional factors leading to malnutrition include depression and complex diets that restrict protein, phosphorus, potassium, and sodium.
      • Frequent monitoring of laboratory parameters, especially serum albumin, prealbumin (may be a better indicator of recent or current nutritional status than albumin), and ferritin, and anthropometric measurements are necessary to evaluate nutritional status
    • Fluid restrictions
      • Water and any other fluids are not routinely restricted in patients with CKD stages 1 to 5 who are not receiving HD
      • Use of diuretics to reduce fluid retention
      • Patients on HD are on more restriction and depends on daily urine output
    • Sodium and Potassium restrictions
      • Sodium-restricted diets may vary from 2 to 4 g/day.
      • Instruct the patient to avoid high-sodium foods, such as cured meats, pickled foods, canned soups and stews, frankfurters, cold cuts, soy sauce, and salad dressings
      • Potassium restriction depends on the kidneys’ ability to excrete potassium. 
      • Salt substitutes should be avoided in potassium-restricted diets because they contain potassium chloride.
      • High-Potassium foods
Fruits Vegetables Other Foods
  • Apricot, raw (medium)
  • Avocado ( 114 whole)
  • Banana ( 114 whole)
  • Cantaloupe
  • Dried fruits
  • Grapefruit juice
  • Honeydew
  • Orange (medium)
  • Orange juice
  • Prunes
  • Raisins
  • Baked beans
  • Butternut squash
  • Refried beans
  • Black beans
  • Broccoli, cooked
  • Carrots, raw
  • Greens, except kale
  • Mushrooms, canned
  • Potatoes, white and sweet
  • Spinach, cooked
  • Tomatoes or tomato products
  • Vegetable juices
  • Bran or bran products
  • Chocolate (1.5-2 oz)
  • Granola
  • Milk, all types (1 cup)
  • Nutritional supplements (use only under the direction of physician or dietitian)
  • Nuts and seeds (1 oz)
  • Peanut butter (2 Tbsp)
  • Salt substitutes, Lite Salt
  • Salt-free broth
  • Yogurt

 

  • Phosphate restrictions
    • As kidney function deteriorates, phosphate elimination by the kidneys is diminished and the patient begins to develop hyperphosphatemia.
    • Foods that are high in phosphate include meat, dairy products (e.g., milk, ice cream, cheese, yogurt), and foods containing dairy products (e.g., pudding).
    • Many foods that are high in phosphate are also high in protein.
    • Patients on dialysis are encouraged to eat a diet containing protein, phosphate binders are essential to control the phosphate level.

 

Nursing Management

  • Nursing Assessment
    • History and Past family medical history
    • Current and past use of prescriptions and over-the-counter drugs and herbal preparations
      • Many drugs are potentially nephrotoxic
    • Assess the patient’s dietary habits
    • Assess the patient’s support system
  • Nursing Diagnoses
    • Excess fluid volume related to impaired kidney function
    • Risk for electrolyte imbalance related to impaired kidney function resulting in hyperkalemia, hypocalcemia, hyperphosphatemia, and altered vitamin D metabolism
    • Imbalanced nutrition: less than body requirements related to restricted intake of nutrients (especially protein), nausea, vomiting, anorexia, and stomatitis
  • Nursing Planning
    • The overall goals are that a patient with CKD will 
      • Demonstrate knowledge of and ability to comply with the therapeutic regimen
      • Participate in decision making for the plan of care and future treatment modality
      • Demonstrate effective coping strategies
      • Continue with activities of daily living within physiologic limitations.
  • Nursing implementation
    • Health promotion
      • Individuals should have regular checkups that include a routine urinalysis and calculation of the estimated GFR
        • Diabetes or hypertension
        • People with a history (or a family history) of kidney disease 
        • Repeated urinary tract infections
      • People with diabetes need to have their urine checked for albuminuria if routine urinalysis is negative for protein.
        • Report any changes in urine appearance (color, odor), frequency, or volume to HCP
      • Monitor kidney function with serum creatinine and BUN and GFR if are on potentially nephrotoxic medications
      • Prevention and detection of chronic kidney disease
        • Early detection and treatment are the primary methods for reducing chronic kidney disease.
        • Monitor BP to detect elevations so that treatment can be started early.
        • Treat hypertension appropriately and aggressively, since it is the second leading cause of chronic kidney disease.
        • Ensure proper diagnosis and treatment of diabetes mellitus, since it is the leading cause of chronic kidney disease.
      • Glycemic control for patients with diabetes
    • Acute care
      • In-hospital care is required for management of complications and for kidney transplantation (if applicable)
    • Ambulatory care
      • Encourage the patients to participate in their care
        • Include the following information in the teaching plan for the patient and caregiver.
          • Dietary (protein, sodium, potassium, phosphate) and fluid restrictions.
          • Difficulties in modifying diet and fluid intake.
          • Signs and symptoms of electrolyte imbalance, especially high potassium.
          • Alternative ways of reducing thirst, such as sucking on ice cubes, lemon, or hard candy.
          • Rationales for prescribed drugs and common side effects.
            • Examples:
  • Phosphate binders (including calcium supplements used as phosphate barriers) should be taken with meals.
  • Calcium supplements prescribed to treat hypocalcemia should be taken on an empty stomach (but not at the same time as iron supplements).
  • Iron supplements should be taken between meals.
  • The importance of reporting any of the following:
    • Weight gain >4 lb (2 kg)
    • Increasing BP
    • Shortness of breath
    • Edema
    • Increasing fatigue or weakness
    • Confusion or lethargy
  • Need for support and encouragement. Share concerns about lifestyle changes, living with a chronic illness, and decisions about type of dialysis or transplantation.
  • The expected outcomes are that the patient with CKD will maintain
    • Fluid and electrolyte levels within normal ranges
    • An acceptable weight with no more than a 10% weight loss
Urinary Tract Infection Part II
Urinary Tract Infection Part II 150 150 Tony Guo
  • Acute Care
    • Adequate fluid intake
      • Patient may think condition will worsen because of discomfort 
      • Dilutes urine, making bladder less irritable
      • Flushes out bacteria before they can colonize
    • Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods 
      • Potential bladder irritants
    • Application of local heat to suprapubic or lower back may relieve discomfort
    • Instruct patient about drug therapy and side effects
    • Emphasize taking full course of antibiotics despite disappearance of symptoms
    • Second or reduced dosage of a drug may be ordered after initial course in susceptible patients
    • Instruct patient to monitor for signs of improvement and decrease in or cessation of symptoms
    • Teach patient to promptly report to HCP
      • Persistence of LUTS beyond antibiotic treatment course
      • Onset of flank pain 
      • Fever
  • Ambulatory Care
    • Emphasize importance of compliance with drug regimen
      • Take as ordered
    • Maintain adequate fluids
    • Regular voiding (every 3 to 4 hours)
    • Void after intercourse
  • Patient & Caregiver Teaching
    • When teaching a patient and caregiver measures to prevent a recurrence of a urinary tract infection (UTI), include the following.
      • Take all antibiotics as prescribed. Symptoms may improve after 1-2 days of therapy, but organisms may still be present.
      • Practice appropriate hygiene, including the following:
        • Carefully clean the perineal region by separating the labia when cleansing.
        • Wipe from front to back after urinating.
        • Cleanse with warm soapy water after each bowel movement.
      • Empty the bladder before and after sexual intercourse.
      • Urinate regularly, approximately every 3-4 hr. during the day.
      • Maintain adequate fluid intake.
      • Avoid vaginal douches and harsh soaps, bubble baths, powders, and sprays in the perineal area.
      • Report to the HCP symptoms or signs of recurrent UTI (e.g., fever, cloudy urine, pain on urination, urgency, and frequency).
      • Consider drinking unsweetened cranberry juice (8 oz. three times a day) or taking cranberry extract tablets 300-400 mg/day for UTI prevention. (This practice may not be effective with every patient.)
  • Nursing Evaluation
    • The patient with a UTI will
      • Experience normal urinary elimination patterns
      • Report relief of bothersome urinary tract symptoms
      • Verbalize knowledge of treatment regimen
Urinary Tract Infection
Urinary Tract Infection 150 150 Tony Guo

Urinary Tract Infection

  • Most common bacterial infection in women
  • May be caused by a variety of disorders
    • Bacterial infection most common
  • Bladder and its contents are free of bacteria in majority of healthy people
  • Minority of healthy individuals have some bacteria colonizing in bladder
    • Called asymptomatic bacteriuria and does not justify treatment
  • Escherichia coli  (E. coli) most common pathogen
  • Other causes of UTIs
    • Enterococcus
    • Klebsiella
    • Enterobacter
    • Proteus
    • Pseudomonas
    • Staphylococcus
    • Serratia
    • Candida albicans
  • Counts of 105 CFU/mL or more indicate significant UTI
  • Counts as low as 102 CFU/mL in a person with signs/symptoms are indicative of UTI
  • Fungal and parasitic infections may cause UTIs
  • Patients at risk
    • Immunosuppressed
    • Diabetic
    • Have kidney problems
    • Have undergone multiple antibiotic courses
    • Have traveled to developing countries
  • Classification of UTI
    • Upper versus lower
      • Upper urinary tract 
        • Renal parenchyma, pelvis, and ureters
        • Typically causes fever, chills, flank pain
        • Example 
          • Pyelonephritis: inflammation of renal parenchyma and collecting system
      • Lower urinary tract 
        • Usually no systemic manifestations
        • Examples
          • Cystitis: inflammation of bladder
          • Urethritis: inflammation of urethra
      • Urosepsis
        • UTI that has spread systemically
        • Life-threatening condition requiring emergent treatment
    • Complicated versus uncomplicated 
      • Complicated UTI
        • Coexists with presence of
          • Obstruction or stones
          • Catheters
          • Abnormal GU tract
          • Diabetes/neurologic disease
          • Resistance to antibiotics
          • immunocompromised
          • Pregnancy-induced changes
          • Recurrent infection

Etiology and Pathophysiology

  • Urinary tract above urethra normally sterile
  • Defense mechanisms exist to maintain sterility/prevent UTIs
    • Complete emptying of bladder
    • Ureterovesical junction competence
    • Ureteral peristaltic activity
  • Defense mechanisms
    • Acidic pH (less than 6.0)
    • High urea concentration
    • Abundant glycoproteins
  • Predisposing factors to UTI:
    • Factors increasing urinary stasis
      • Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH)
      • Extrinsic obstruction (tumor, ibrosis compressing urinary tract)
      • Urinary retention (e.g., neurogenic bladder)
      • Renal impairment
    • Foreign bodies such as:
      • Urinary tract calculi
      • Catheters (indwelling, external condom catheter, ureteral stent, nephrostomy tube, intermittent catheterization)
      • Urinary tract instrumentation (cystoscopy)
    • Anatomic factors
      • Congenital defects leading to obstruction or urinary stasis
      • Fistula (abnormal opening) exposing urinary stream to skin, vagina, or fecal stream
      • Shorter female urethra and colonization from normal vaginal flora
      • Obesity
    • Compromising immune response factors
      • Aging
      • Human immunodeficiency virus infection
      • Diabetes mellitus
    • Functional disorders
      • Constipation
      • Voiding dysfunction with detrusor sphincter dyssynergia
    • Other factors
      • Pregnancy
      • Menopause
      • Multiple sex partners (women)
      • Use of spermicidal agents, contraceptive diaphragm (women), bubble baths, feminine sprays
      • Poor personal hygiene
      • Habitual delay of urination (“nurse’s bladder,” “teacher’s bladder”)
  • Gram-negative bacilli normally found in GI tract: common cause
  • Urologic instrumentation allows bacteria to enter urethra and bladder
  • Organisms introduced via ascending route from urethra that originated from the perineum
  • Contributing factor: 
    • Sexual intercourse promotes “milking” of bacteria from perineum and vagina
      • May cause minor urethral trauma
  • Less common routes 
    • Bloodstream
    • Lymphatic system
  • Catheter-associated urinary tract infections (CAUTI) are the most common HAI 
    • Causes
      • Often: E. coli
      • Less frequently: Pseudomonas species
    • Most are underrecognized and undertreated

Clinical Manifestations

  • Painful urination
  • Abdominal or back pain
  • Fever
  • Sepsis
  • Decreased kidney function in some cases of pyelonephritis
  • Symptoms related Storage:
    • Urinary frequency 
      • Abnormally frequent (more often than  every 2 hours)
    • Urgency
      • Sudden, strong desire to void immediately
    • Incontinence
      • Loss or leakage or urine
    • Bladder storage
      • Nocturia
        • Waking up two or more times at night to void
        • May be diurnal or nocturnal depending on sleep schedule
      • Nocturnal enuresis
        • Loss of urine during sleep
    • Bladder emptying
      • Weak stream
      • Hesitancy
        • Difficulty starting the urine stream
        • Delay between initiation of urination (because of urethral sphincter relaxation) and beginning of low of urine
        • Diminished urinary stream
      • Intermittency
        • Interruption of urinary stream during voiding
      • Post-void dribbling
        • Urine loss after completion of voiding
      • Urinary retention
        • Inability to empty urine from bladder
        • Caused by atonic bladder or obstruction of urethra
        • Can be acute or chronic
      • Dysuria
        • Painful or difficulty voiding
    • Flank pain, chills, and fever indicate infection of upper tract 
      • Pyelonephritis
    • In older adults
      • Symptoms often absent 
      • Nonlocalized abdominal discomfort rather than dysuria
      • Cognitive impairment possible
      • Fever less likely

 

  • Diagnostic Studies
    • History and physical examination
    • Dipstick urinalysis 
      • Identify presence of nitrites, WBCs, and leukocyte esterase
    • Urine culture
      • Urine for culture and sensitivity (if indicated)
        • Clean-catch sample preferred
        • Specimen by catheterization or suprapubic needle aspiration more accurate
        • Determine bacteria susceptibility to antibiotics
    • Imaging studies 
      • Ultrasound
      • CT scan (CT urogram)

 

  • Drug Therapy
    • Antibiotics
      • Selected on empiric therapy or results of sensitivity testing
      • Uncomplicated cystitis
        • Short-term course (typically 3 days)
      • Complicated UTIs 
        • Long-term treatment (7 to 14 days or more)
      • Trimethoprim/sulfamethoxazole 
      • Used to treat uncomplicated or initial UTI
        • Inexpensive
        • Taken twice a day
      • Nitrofurantoin (Macrodantin)
        • Given three or four times a day
        • Long-acting preparation (Macrobid) is taken twice daily
      • Ampicillin, amoxicillin, cephalosporins
        • Treat uncomplicated UTI
      • Fluoroquinolones
        • Treat complicated UTIs
        • Example: ciprofloxacin (Cipro)
    • Antifungals
      • Amphotericin or fluconazole
        • UTIs secondary to fungi
    • Urinary analgesic
      • Phenazopyridine
        • Used in combination with antibiotics
        • Provides soothing effect on urinary tract mucosa
        • Stains urine reddish orange 
          • Can be mistaken for blood and may stain underclothing

 

Nursing Managment

  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Previous urinary tract infection. 
          • Urinary calculi, reflux, strictures, or retention. 
          • Neurogenic bladder, pregnancy, benign prostatic hyperplasia, bladder cancer, sexually transmitted infection.
        • Medications: Antibiotics, anticholinergics, antispasmodics
        • Surgery or other treatments: 
          • Recent urologic instrumentation (catheterization, cystoscopy)
      • Functional Health Patterns
        • Health perception–health management: 
          • Urinary hygiene practices.
        • Lassitude, malaise
        • Nutritional-metabolic: 
          • Nausea, vomiting, anorexia. Chills
        • Elimination: 
          • Urinary frequency, urgency, hesitancy. Dysuria, nocturia
        • Cognitive-perceptual: 
          • Suprapubic or low back pain, costovertebral tenderness, bladder spasms, dysuria, burning on urination
        • Sexuality-reproductive: Multiple sex partners (women), use of spermicidal agents or contraceptive diaphragm (women)
    • Objective Data
      • General
        • Fever, chills, dysuria
        • Atypical presentation in older adults: afebrile, absence of dysuria, loss of appetite, altered mental status
      • Urinary
        • Hematuria. Cloudy, foul-smelling urine. Tender, enlarged kidney
      • Possible Diagnostic Findings
        • Leukocytosis. UA positive for bacteria, pyuria, RBCs, WBCs, and nitrites. Positive urine culture. Ultrasound, CT scan (CT urogram), VCUG, and cystoscopy indicating urinary tract abnormalities
  • Nursing Diagnoses
    • Impaired urinary elimination related to the effects of UTI
    • Infection
    • Risk for urge urinary incontinence
    • Acute pain: dysuria related to inflammatory process in bladder
    • Readiness for enhanced health management
  • Nursing Planning
    • Patient will have
      • Relief from lower urinary tract symptoms (LUTS)
      • No upper urinary tract involvement
      • No recurrence
  • Nursing implementation
    • Health Promotion 
      • Recognize individuals at risk
        • Debilitated persons
        • Older adults
        • Underlying diseases (HIV, diabetes)
        • Taking immunosuppressive drug or corticosteroids
      • Emptying bladder regularly and completely
        • Evacuating bowel regularly
        • Wiping perineal area front to back
        • Drinking adequate fluids (person’s weight in pounds/2)
          • 20% of fluid comes from food
      • Cranberry juice or cranberry tablets may reduce number of UTIs
      • Avoid unnecessary catheterization and early removal of indwelling catheters
      • Aseptic technique must be followed during instrumentation procedures
      • Routine and thorough perineal care for all hospitalized patients
      • Answer call lights and offer bedpan or urinal at frequent intervals
    • Prevention of CAUTI
      • Avoidance of unnecessary catheterization
      • Early removal of indwelling catheters
      • Follow aseptic technique for procedures
      • Handwashing before and after patient contact
      • Wear gloves for care of urinary catheters
Pancreatitis
Pancreatitis 150 150 Tony Guo

Pancreatitis

Acute Pancreatitis

  • Acute inflammatory process of pancreas
  • Spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion and severe pain 
  • Varies from mild edema to severe necrosis

Etiology and Pathophysiology

  • Gallbladder disease (women)
  • Chronic alcohol intake (men)
  • Smoking
  • Hypertriglyceridemia
  • Less common causes 
    • Trauma
    • Viral infections
    • Penetrating duodenal ulcers
    • Cysts
    • Abscesses
    • Cystic fibrosis
    • Kaposi sarcoma
    • Certain drugs
    • Metabolic disorders
    • Vascular diseases
    • Idiopathic causes
  • Caused by auto-digestion of pancreas
    • Injury to pancreatic cells 
    • Activation of pancreatic enzymes
      • Autodigestive effects of pancreatic enzymes
        • Trypsin
          • Edema
          • Necrosis
          • Hemorrhage
        • Elastase
          • Hemorrhage
        • Phospholipase A and lipase
          • Fat necrosis
        • Kallikrein
          • Edema
          • Vascular permeability
          • Smooth muscle contraction
          • Shock
  • Alcohol consumption is another common cause
    • Exact mechanism unknown
    • Alcohol may increase production of pancreatic enzymes
    • 5% to 10% of alcohol abusers develop pancreatitis
  • Classification
    • Mild pancreatitis
      • Edematous or interstitial
    • Severe pancreatitis
      • Necrotizing 
      • Endocrine and exocrine dysfunction
      • Necrosis, organ failure, sepsis
      • Rate of mortality: 25%

 

  • Clinical Manifestations
  • Abdominal pain predominant 
    • Left upper quadrant or midepigastrium
    • Radiates to back
    • Sudden onset
    • Deep, piercing, continuous or steady
    • Aggravated by eating
    • Starts when recumbent
    • Not relieved with vomiting
  • Flushing
  • Cyanosis
  • Dyspnea
  • Nausea/vomiting
  • Low-grade fever
  • Leukocytosis
  • Hypotension, tachycardia
  • Jaundice
  • Abdominal tenderness with muscle guarding
  • Decreased or absent bowel sounds
  • Crackles in lungs
  • Abdominal skin discoloration
    • Grey Turner’s spots or sign
    • Cullen’s sign
  • Shock

 

  • Complications
    • Pseudocyst
      • Fluid, enzyme, debris, and exudates surrounded by wall 
      • Abdominal pain, palpable mass, nausea/vomiting, anorexia
      • Detected with imaging
      • Resolves spontaneously or may perforate and cause peritonitis
      • Surgical or endoscopic drainage
    • Pancreatic abscess
      • Infected pseudocyst
      • Results from extensive necrosis
      • May rupture or perforate
      • Upper abdominal pain, mass, high fever, leukocytosis
      • Requires prompt surgical drainage
    • Systemic complications
      • The pulmonary complications are likely due to the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels
        • Pleural effusion
        • Atelectasis
        • Pneumonia 
        • ARDS (acute respiratory distress syndrome)
        • Hypotension
        • Thrombi, pulmonary embolism, DIC
        • Hypocalcemia: tetany
          • Due in part to the combining of calcium and fatty acids during fat necrosis. 
          • The exact mechanisms of how or why hypocalcemia occurs are not well understood
  • Diagnostic studies
    • Laboratory tests
      • Serum amylase level
        • Usually elevated early and remains elevated for 24 to 72 hours.
      • Serum lipase level
        • Also elevated in acute pancreatitis
        • Is an important test because other disorders (e.g., mumps, cerebral trauma, renal transplantation) may increase serum amylase levels
      • Liver enzyme levels
      • Triglyceride levels
      • Glucose level
      • Bilirubin level
      • Serum calcium level
    • Abdominal ultrasonography
    • X-ray
    • Contrast-enhanced CT scan
      • Identify pancreatic problems
    • Endoscopic retrograde cholangiopancreatography (ERCP)
    • Endoscopic ultrasonography (EUS)
    • Magnetic resonance cholangiopancreatography (MRCP)
    • Angiography
    • Chest x-ray
      • May show pulmonary changes, including atelectasis and pleural effusions

 

  • Interprofessional Care
    • Objectives include
      • Relief of pain
      • Prevention or alleviation of shock
      • Decreased pancreatic secretions
      • Correction of fluid/electrolyte imbalance
      • Prevention/treatment of infections
      • Removal of precipitating cause
    • Conservative Therapy 
      • Supportive care
        • Aggressive hydration
        • Pain management
          • IV morphine, antispasmodic agent
        • Management of metabolic complications
          • Oxygen, glucose levels
        • Minimizing pancreatic stimulation
          • NPO status, NG suction, decreased acid secretion, enteral nutrition if needed
      • Conservative Therapy
        • Shock 
          • Plasma or plasma volume expanders (dextran or albumin)
        • Fluid/electrolyte imbalance
          • Lactated Ringer’s solution
        • Ongoing hypotension
          • Vasoactive drugs: dopamine 
        • Prevent infection
          • Enteral nutrition
          • Antibiotics
          • Endoscopically or CT-guided percutaneous aspiration
      • Surgical Therapy 
        • For gallstones 
          • ERCP
          • Cholecystectomy
        • Uncertain diagnosis 
        • Not responding to conservative therapy
        • Drainage of necrotic fluid collections
      • Drug Therapy
        • IV morphine
        • Antispasmodics 
        • Carbonic anhydrase inhibitors
        • Antacids
        • Proton pump inhibitors
Drug Mechanism of Action
Acute Pancreatitis
Morphine Relief of pain
Antispasmodics (e.g., dicyclomine [Bentyl])
  • Decreased vagal stimulation, motility, pancreatic outflow (decreased volume and concentration of bicarbonate and enzyme secretion)
  • Contraindicated in paralytic ileus
Carbonic anhydrase inhibitor (acetazolamide)
  • Decreased volume and bicarbonate concentration of pancreatic secretion
Antacids 
  • Neutralization of gastric hydrochloric (HCl) acid secretion
  • Decreased production and secretion of pancreatic enzymes and bicarbonate
Proton pump inhibitors (e.g., omeprazole [Prilosec])
  • Decreased HCl acid secretion (HCl acid stimulates pancreatic activity)
Chronic Pancreatitis
Pancreatic enzyme products (pancrelipase [Pancrease, Zenpep, Creon, Viokace])
  • Replacement therapy for pancreatic enzymes
Insulin 
  • Treatment for diabetes mellitus or hyperglycemia, if needed

 

  • Nutritional Therapy
    • NPO status initially 
    • Enteral versus parenteral nutrition
    • Monitor triglycerides if IV lipids given
    • Small, frequent feedings when able
      • High-carbohydrate
    • No alcohol
    • Supplemental fat-soluble vitamins

 

Nursing Management: Acute Pancreatitis

  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Biliary tract disease, alcohol use, abdominal trauma, duodenal ulcers, infection, metabolic disorders
        • Medications: 
          • Thiazides
          • Nonsteroidal anti-inflammatory drugs
        • Surgery or other treatments: 
          • Surgical procedures on the pancreas, stomach, duodenum, or biliary tract. 
          • Endoscopic retrograde cholangiopancreatography (ERCP)
      • Functional Health Patterns
        • Health perception–health management: 
          • Chronic alcohol use, fatigue
        • Nutritional-metabolic: 
          • Nausea and vomiting, anorexia
        • Activity-exercise: 
          • Dyspnea
        • Cognitive-perceptual: 
          • Severe midepigastric or left upper quadrant pain that may radiate to the back, aggravated by food and alcohol intake and unrelieved by vomiting
    • Objective Data
      • General
        • Restlessness, anxiety, low-grade fever
      • Integumentary
        • Flushing, diaphoresis, discoloration of abdomen and flanks, cyanosis, jaundice. Decreased skin turgor, dry mucous membranes
      • Respiratory
        • Tachypnea, basilar crackles
      • Cardiovascular
        • Tachycardia, hypotension
      • Gastrointestinal
        • Abdominal distention, tenderness, and muscle guarding. Diminished bowel sounds
      • Possible Diagnostic Findings
        • Increased serum amylase and lipase
        • Leukocytosis
        • Hyperglycemia
        • Hypocalcemia
        • Abnormal ultrasound and CT scans of pancreas
        • Abnormal ERCP or MRCP
  • Nursing Diagnoses
    • Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort measures
    • Deficient fluid volume related to nausea, vomiting, restricted oral intake, and fluid shift into the retroperitoneal space
    • Imbalanced nutrition: less than body requirements related to anorexia, dietary restrictions, nausea, loss of nutrients from vomiting, and impaired digestion
    • Ineffective health management related to lack of knowledge of preventive measures, diet restrictions, alcohol intake restriction, and follow-up care
  • Nursing Planning
    • The overall goals are that the patient with acute pancreatitis will have 
      • Relief of pain
      • Normal fluid and electrolyte balance
      • Minimal to no complications
      • No recurrent attacks
  • Nursing Implementation
    • Health Promotion
      • Assessment of patient for predisposing and etiologic factors
      • Encouragement of early treatment of these factors
      • Early diagnosis/treatment of biliary tract disease
      • Elimination of alcohol intake
    • Acute Care
      • Monitoring vital signs
      • Monitor response to IV fluids
      • Closely monitor fluid and electrolyte balance
      • Assess respiratory function
      • Monitor fluid and electrolyte balance
        • Chloride, sodium, and potassium
        • Hypocalcemia 
          • Tetany
          • Calcium gluconate to treat
            • Chvostek’s sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. 
            • Trousseau’s sign is a carpal spasm induced by 
            • Inflating a blood pressure cuff above the systolic pressure for a few minutes.
        • Hypomagnesemia
      • Pain assessment and management
        • Morphine
        • Position of comfort with frequent position changes
          • Flex trunk and draw knees to abdomen
          • Side-lying with head of bed elevated 45 degrees
        • Frequent oral/nasal care
        • Proper administration of antacids
        • Observation for signs of infection
        • TCDB, semi-Fowler’s position
        • Wound care
        • Observation for paralytic ileus, renal failure, mental changes 
        • Monitor serum glucose
        • Post-op wound care
    • Ambulatory Care
      • Physical therapy
      • Assessment of opioid addiction
      • Counseling regarding abstinence from alcohol and smoking
      • Dietary teaching
        • Low-fat, high-carbohydrate
        • No crash diets
      • Patient/family teaching
        • Signs of infection, diabetes mellitus, steatorrhea
        • Medications/diet
      • Expected Outcomes
        • Have adequate pain control
        • Maintain adequate fluid volume
        • Be knowledgeable about treatment regimen
        • Get help for alcohol dependence and smoking cessation (if appropriate)

Chronic Pancreatitis

  • Continuous, prolonged inflammatory, and fibrosing process of the pancreas
  • Etiology
    • Alcohol, gallstones, tumor, pseudocysts, trauma, systemic disease
    • Acute pancreatitis
    • Idiopathic
  • Classifications
    • Two major types
      • Chronic obstructive pancreatitis
        • Inflammation of sphincter of Oddi
        • Cancer of ampulla of Vater, duodenum, or pancreas
      • Chronic non-obstructive pancreatitis
        • Inflammation and sclerosis in head of pancreas and around duct
        • Most common cause is alcohol abuse
  • Clinical Manifestations
    • Abdominal pain
      • Located in same areas as in acute pancreatitis 
      • Heavy, gnawing feeling; burning and cramp-like
    • Malabsorption with weight loss
    • Constipation
    • Mild jaundice with dark urine
    • Steatorrhea
    • Diabetes mellitus
  • Interprofessional Care
    • Pancreatic enzyme replacement
    • Bile salts
    • Insulin or oral hypoglycemic agents
    • Acid-neutralizing and acid-inhibiting drugs 
    • Antidepressants
  • Nursing Management
    • Focus is on chronic care and health promotion
    • Patient and family teaching 
      • Dietary control
      • Pancreatic enzyme with meals/snack
      • Observe for steatorrhea
      • Monitor glucose levels
      • Antacids after meals and at bedtime
      • No alcohol

 

Nursing and Interprofessional management: Obesity
Nursing and Interprofessional management: Obesity 150 150 Tony Guo

Nursing and Interprofessional management: Obesity

  • Nursing Assessment
    • Subjective Data
      • Important Health information
        • First rule out physical conditions that may be causing or contributing to obesity
          • Be sensitive and nonjudgmental
          • Clarify rationale for inquiries about weight, dietary habits, and exercise
          • Address patient concerns
      • Past health history
        • Time of obesity onset
        • Diseases related to metabolism and obesity
          • Hypertension
          • Cardiovascular problems
          • Stroke 
          • Cancer
          • Chronic joint pain
          • Respiratory problems
          • Diabetes mellitus
          • Cholelithiasis
          • Metabolic syndrome
      • Medications
        • Thyroid preparations
        • Diet pills
        • Herbal products
      • Surgery or other treatments
        • Prior weight-reduction procedures (bariatric surgery)
    • Functional Health patterns
      • Health perception–health management: Family history of obesity; perception of problem; methods of weight loss attempted
      • Nutritional-metabolic: Amount and frequency of eating; overeating in response to boredom, stress, specific times, or activities; history of weight gain and loss
      • Elimination: Constipation
      • Activity-exercise: Typical physical activity; drowsiness, somnolence; dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea
      • Sleep-rest: Sleep apnea, use of continuous positive airway pressure
      • (CPAP)
      • Cognitive-perceptual: Feelings of rejection, depression, isolation, guilt, or shame; meaning or value of food; adherence to prescribed reducing diets, degree of long-term commitment to a weight loss program
      • Role-relationship: Change in financial status or family relationships; personal, social, and financial resources to support a reducing diet
      • Sexuality-reproductive: Menstrual irregularity, heavy menstrual low in women, birth control practices, infertility; effect of obesity on sexual activity and attractiveness to significant other
    • Objective Data
      • General
        • Body mass index ≥30 kg/m2; waist circumference: woman >35 in (89 cm), man >40 in (102 cm)
      • Respiratory
        • Increased work of breathing; wheezing; rapid, shallow breathing
      • Cardiovascular
        • Hypertension, tachycardia, dysrhythmias
      • Musculoskeletal
        • Decreased joint mobility and flexibility; knee, hip, and low back pain
      • Reproductive
        • Gynecomastia and hypogonadism in men
      • Possible Diagnostic Findings
        • Elevated serum glucose, cholesterol, triglycerides; chest x-ray demonstrating enlarged heart; electrocardiogram showing dysrhythmia; abnormal liver function tests
  • Nursing planning
    • Overall Goals
      • Modify eating patterns
      • Participate in a regular physical activity program
      • Achieve and maintain weight loss to a specified level
      • Minimize or prevent health problems
  • Nursing implementation
    • Obesity is one of most challenging health problems
      • Successful weight management can be both difficult and lifelong
      • Treatment begins with patients understanding their weight history and deciding on a plan that is best for them
    • An “ideal” BMI is not necessary and may not be realistic
      • Modest weight loss of 3% to 5% can have clinical benefits
      • Greater weight loss produces greater benefits
      • Average weight loss programs result in a 10% reduction of body weight
    • Explore motivation – it is key
    • Supervised plan of care should be directed toward
      • Successful weight loss
        • Requires a short-term energy deficit
      • Successful weight control
        • Requires long-term behavior changes

 

Upper Gastrointestinal Bleeding

  • Each year, 300,000 hospital admissions for UGI bleeding
  • Approximately 60% of patients are older than 65 years
  • Mortality rate has been 6% to 13% for past 45 years

Etiology and Pathophysiology

  • Most serious loss of blood from UGI characterized by sudden onset
  • Insidious occult bleeding can be a major problem
  • Severity depends on bleeding origin
    • Venous
    • Capillary
    • Arterial
  • Types of UGI bleeding
    • Obvious bleeding
      • Hematemesis
        • Bloody vomitus 
        • Appears fresh, bright red blood or “coffee grounds”
      • Melena
        • Black, tarry stools
        • Caused by digestion of blood in GI tract
        • Black appearance—due to iron
    • Occult bleeding
      • Small amounts of blood in gastric secretions, vomitus, or stools
      • Undetectable by appearance
      • Detectable by guaiac test

 

Massive UGI Bleed

  • Massive upper GI hemorrhage is defined as 1500 mL of blood
    • Of patients who have massive hemorrhage, 80% to 85% spontaneously stop bleeding
    • Cause still must be identified and treatment started immediately

Common Causes of UGI Bleeding

  • Esophageal origin
    • Chronic esophagitis
      • GERD
      • Mucosa-irritating drugs
      • Smoking
      • Alcohol use
    • Mallory-Weiss tear
    • Esophageal varices
  • Stomach and duodenal origin
    • Peptic ulcer disease
      • Bleeding ulcers account for 40% of cases of UGI bleeding
    • Drugs 
      • Aspirin, NSAIDs, corticosteroids
    • Stress-related mucosal disease (SRMD)
      • Also called physiologic stress ulcers
      • Most common in critically ill patients
        • Severe burns, trauma, or major surgery
        • Patients with coagulopathy on mechanical ventilation
  • Drug-induced origin
    • Corticosteroids
    • Nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Salicylates
  • Systemic disease origin
    • Blood dyscrasias (e.g., leukemia, aplastic anemia)
    • Renal failure

 

Diagnostic Studies

  • Endoscopy
    • Primary tool for diagnosing source of upper GI bleeding
    • Before performing
      • Lavage may be needed for clearer view
        • NG or orogastric tube placed, and room-temperature water or saline used
        • Do not advance tube against resistance
    • Stomach contents aspirated through a large-bore (Ewald) tube to remove clots
  • Angiography
    • Used to diagnose only when endoscopy cannot be done
    • Invasive procedure
      • May not be appropriate for high-risk or unstable patient
    • Catheter placed into left gastric or superior mesenteric artery until site of bleeding is discovered
  • Laboratory studies
    • Complete blood cell count (CBC)
    • Blood urea nitrogen (BUN)
    • Serum electrolytes
    • Prothrombin time, partial thromboplastin time
    • Liver enzyme measurements
  • Laboratory tests
    • ABG measurements
    • Typing/cross matching for possible blood transfusions
    • Test vomitus/ stools for presence of gross and occult blood

 

Interprofessional Care

  • Endoscopic hemostasis therapy
    • First-line therapy of upper GI bleed
    • Goal: to coagulate or thrombose the bleeding vessel
    • Useful for gastritis, Mallory-Weiss tear, esophageal and gastric varices, bleeding peptic ulcers, and polyps
    • Several techniques are used including 
      • Thermal (heat) probe
      • Multipolar and bipolar electrocoagulation probe
      • Argon plasma coagulation (APC)
      • Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser
      • Mechanical therapy with endoscopic clips or bands.
      • Multipolar electrocoagulation and thermal probe
  • Surgical Therapy
    • Indicated when bleeding continues 
      • Regardless of therapy provided
      • Site of bleeding identified
    • May be necessary when 
      • Patient continues to bleed after rapid transfusion of up to 2000 mL whole blood
      • Remains in shock after 24 hours
    • Site of hemorrhage determines choice of operation 
    • Surgeon must consider age of patient
      • Mortality rates increase considerably in older patients
  • Drug Therapy
    • During acute phase, used to 
      • Decreased Bleeding
      • Decreased HCl acid secretion
      • Neutralize HCl acid that is present
    • Empiric PPI therapy with high-dose IV bolus and subsequent infusion
    • Injection therapy with epinephrine during endoscopy for acute hemostasis
      • For bleeding due to ulceration
      • Produces tissue edema → pressure on bleeding source
    • Somatostatin or somatostatin analog octreotide 
    • Used for upper GI bleeding
      • Reduces blood flow to GI organs and acid secretion
      • Given in IV boluses for 3–7 days after onset of bleeding

 

Nursing Management

  • Nursing Assessment
    • Subjective Data
      • Important Health Information
        • Past health history: 
          • Precipitating events before bleeding episode
          • Previous bleeding episodes and treatment
          • Peptic ulcer disease
          • Esophageal varices
          • Esophagitis
          • Acute and chronic gastritis
          • Stress-related mucosal disease
        • Medications: 
          • Aspirin
          • Nonsteroidal anti-inflammatory drugs
          • Corticosteroids
          • Anticoagulants
      • Functional Health Patterns
        • Health perception–health management: 
          • Family history of bleeding
          • Smoking
          • Alcohol use
        • Nutritional-metabolic: 
          • Nausea
          • Vomiting
          • Weight loss
          • Thirst
        • Elimination: 
          • Diarrhea
          • Black, tarry stools
          • Decreased urine output.
          • Sweating
        • Activity-exercise: 
          • Weakness
          • Dizziness
          • Fainting
        • Cognitive-perceptual: 
          • Epigastric pain
          • Abdominal cramps
        • Coping–stress tolerance: 
          • Acute or chronic stress
    • Objective Data
      • General
        • Fever
      • Integumentary
        • Clammy, cool, pale skin. Pale mucous membranes, nail beds, and conjunctivae. Spider angiomas, jaundice, peripheral edema
      • Respiratory
        • Rapid, shallow respirations
      • Cardiovascular
        • Tachycardia, weak pulse, orthostatic hypotension, slow capillary refill
      • Gastrointestinal
        • Red or “coffee-ground” vomitus. 
        • Tense, rigid abdomen, ascites.
        • Hypoactive or hyperactive bowel sounds. 
        • Black, tarry stools
      • Urinary
        • Decreased urine output, concentrated urine
      • Neurologic
        • Agitation, restlessness. Decreasing level of consciousness
      • Possible Diagnostic Findings
        • Decreased hematocrit and hemoglobin, hematuria. Guaiac-positive stools, emesis, or gastric aspirate. Decreased levels of clotting factors, ↑ liver enzymes, abnormal endoscopy results
  • Nursing Diagnoses
  1. Risk for decreased cardiac output related to loss of blood
  2. Deficient fluid volume related to acute loss of blood and gastric secretions
  3. Ineffective peripheral tissue perfusion related to loss of circulatory volume
  4. Anxiety related to upper GI bleeding, hospitalization, uncertain outcome, source of bleeding
  • Nursing Planning
    • The overall goals are that the patient with upper GI bleeding will 
      • Have no further GI bleeding
      • Have the cause of the bleeding identified and treated
      • Experience a return to a normal hemodynamic state
      • Experience minimal or no symptoms of pain or anxiety
  • Nursing Implementation
    • Health Promotion 
      • Patient with a history of chronic gastritis, cirrhosis, or peptic ulcer disease is at high risk
      • Patient who has had previous upper GI bleeding episode is more likely to have another bleed
      • Patient on daily low-dose aspirin to reduce cardiovascular disease risk are at risk
      • Patient teaching
        • Avoidance of gastric irritants
          • Alcohol
          • Smoking
          • Stress-inducing situations
        • Take only prescribed medications
        • Methods of testing vomitus/stools for occult blood
        • Potential need for prophylactic PPI
        • Prompt treatment of upper respiratory infection in patient with esophageal varices
        • Take drugs that produce gastroduodenal toxicity with meals or snacks
    • Acute Care
      • Place IV lines
        • Preferably 2, with 16- or 18-guage needle for fluid and blood replacement
      • Administer fluid and blood replacement as ordered
      • Accurate I/O record
        • Record urine output hourly
        • At least 0.5 mL/kg/hr indicates adequate renal perfusion
        • Measure urine specific gravity
      • Maintain NG patency and position
      • CVP line or PAC readings every 1–2 hours
      • Observe older adults and patients with history of cardiovascular problems closely
        • ECG monitoring
        • Vital signs
      • Approach in calm, assured manner to decrease anxiety
      • Use caution when administering sedatives for restlessness
        • Warning sign of shock may be masked by drugs
      • Emergency management
Assessment Findings
Abdominal and GI Findings Hypovolemic Shock
  • Hematemesis
  • Melena
  • Nausea
  • Abdominal pain
  • Abdominal rigidity
  • Decreased BP
  • Decreased pulse pressure
  • Tachycardia
  • Cool, clammy skin
  • Decreased level of consciousness
  • Decreased Urine output (<0.5 mL/kg/hr)
  • Slow capillary refill
Interventions
Initial Ongoing Monitoring
  1. If unresponsive, assess circulation, airway, and breathing.
  2. If responsive, monitor airway, breathing, and circulation.
  3. Establish IV access with large-bore catheter and start fluid replacement therapy. Insert additional large-bore catheter if shock present.
  4. Give O2 via nasal cannula or non-rebreather mask.
  5. Initiate ECG monitoring.
  6. Obtain blood for CBC, clotting studies, and type and crossmatch as appropriate.
  7. Insert NG tube as needed.
  8. Insert indwelling urinary catheter.
  9. Give IV proton pump inhibitor (PPI) therapy to decrease acid secretion.
  1. Monitor vital signs, level of consciousness, O2 saturation, ECG, bowel sounds, and intake/output.
  2. Assess amount and character of emesis.
  3. Keep patient NPO.
  4. Provide reassurance and emotional support to patient and caregiver

 

  • Assess stools and NG output for blood
  • Rule out other sources of bleeding
  • When vomitus contains blood but stool does not, hemorrhage is considered to be of short duration
  • Nutrition
    • Observe for symptoms of nausea and vomiting
    • Recurrence of bleeding
    • Feedings: initially clear fluids given hourly
    • Gradually introduce of foods as tolerated
  • Hemorrhage that is result of chronic alcohol abuse
    • Closely observe for delirium tremens 
      • Agitation
      • Uncontrolled shaking
      • Sweating
      • Vivid hallucinations
  • Ambulatory Care
    • Patient teaching
      • Patient/family taught how to avoid future bleeding episodes
      • Made aware of consequences of not adhering to drug therapy
      • Emphasize that no drugs other than those prescribed should be taken
      • No smoking or alcohol
      • Need for long-term follow-up care
      • Instruction if an acute hemorrhage occurs in future
  • Nursing Evaluation
    • The expected outcomes are that the patient with upper GI
    • bleeding will
      • Have no upper GI bleeding
      • Maintain normal fluid volume
      • Experience a return to a normal hemodynamic state
      • Understand potential etiologic factors and make appropriate lifestyle modifications
Obesity
Obesity 150 150 Tony Guo

Obesity

  • Classifications of Body Weight and Obesity
    • Patient assessment
      • BMI is calculated by dividing a person’s weight (kg) by the square of the height (m2).
        • BMI less than 18.5 kg/m2 is considered underweight
        • BMI of 18.5 to 24.9 kg/m2 is considered normal weight
        • BMI of 25 to 29.9 kg/m2 is considered overweight
        • BMI above 30 kg/m2 is considered obese
        • BMI greater than 40 kg/m2 is extreme obesity
      • Waist circumference
        • People with visceral fat and truncal obesity are at an increased risk for cardiovascular disease and metabolic syndrome
          • Men >40” waist
          • Women >35” waist
      • Waist-to-Hip Ratio
        • Method of describing distribution of subcutaneous and visceral adipose tissue
        • Waist measurement/hip measurement
          • WHR <0.8 optimal
          • WHR >0.8 at risk for health complications
      • Body shape
        • Apple-shaped body
          • Fat located primarily in abdominal area
          • Android obesity
        • Pear-shaped body
          • Fat located primarily in upper legs
          • Gynoid obesity

 

Relationship between Body shape and Health risks
Body Shape Characteristics Health Risks
Gynoid (pear) Fat mainly located in the upper legs Osteoporosis
Has a better prognosis but difficult to treat Varicose veins
Cellulite
Subcutaneous fat traps and stores dietary fat
Trapped fatty acids stored as triglycerides
Android (apple)  Fat primarily located in abdominal area Heart disease
Fat also distributed over upper body (neck, arms, shoulders) Diabetes mellitus
Greater risk for obesity-related complications Breast cancer
Endometrial cancer
Visceral fat more active, causing decreased insulin sensitivity
Increased triglycerides
Decreased HDL cholesterol
Increased BP
Increased free fatty acid release into blood

 

  • Primary obesity 
    • Excess caloric intake for body’s metabolic demands
  • Secondary obesity
    • Chromosomal and congenital anomalies
    • Metabolic problems
    • CNS lesions and disorders
    • Drugs (corticosteroids, antipsychotics)
  • Epidemiology of obesity
    • About 34% of adults in U.S. are obese
    • 1 in 10 children become obese as early as ages 2 to 5
    • Obesity rates are highest
      • In the South
      • Among African Americans and Hispanics
      • Among lower income and less educated
    • The processes leading to and sustaining obese state are complex
      • Body weight beyond physical requirements
      • Abnormal increase and accumulation of fat cells
    • Increase in number (hyperplasia) and size (hypertrophy) of adipocytes
      • Large increases in lipid storage
      • Preadipocytes are triggered to become adipocytes once storage of existing fat cells is exceeded
  • Genetic/Biologic basis
    • Strong evidence of significant genetic/biologic susceptibility factors that are highly influenced by environmental and psychosocial factors
      • Factors can be considered individually but in reality they are interrelated
    • Research has identified several genes linked to obesity
      • Energy thrifty genes
      • Strong link between FTO gene and BMI
        • People with 2 copies of a certain allele at the FTO gene weigh 7-8 lbs. more and have greater risk of obesity
    • Research focused on processes that control 
      • Eating behavior
      • Energy metabolism
      • Body fat metabolism
    • Hormones and peptides in obesity
Where Produced Normal Function Alteration in Obesity
Anorexins (Suppress Appetite) 

Leptin

Adipocytes Suppresses appetite and hunger

Regulates eating behavior

Obesity is associated with high levels. Leptin resistance develops; thus obese people may lose the effect of appetite suppression.
Insulin
Pancreas  Decreases appetite  Increased insulin secretion which stimulates increased liver synthesis of triglycerides and decreased HDL production
Peptide YY
Colon  Inhibits appetite by slowing GI motility and gastric emptying Circulating levels are decreased. Decreased release after eating
Cholecystokinin
Small intestine Inhibits gastric emptying 

Sends satiety signals to hypothalamus

Unknown role
Glucagon-Like Peptide-1 (GLP-1)
Small intestine Stimulates insulin secretion from pancreas

Increases satiety (mediated by GLP-1 receptors in brain)

Unknown role
Orexins (Stimulate Appetite)

Neuropeptide Y

Hypothalamus Stimulates appetite  Imbalance causes increased appetite
Ghrelin
Stomach (primarily) Stimulates appetite increase after food deprivation

Decrease In response to food in the stomach

Normal postprandial decline does not occur, which can lead to increased appetite and overeating

 

  • Cultural and ethnic health disparities
    • African Americans and Hispanics have a higher prevalence of obesity than whites.
    • Among women, African Americans have the highest prevalence of being overweight or obese, and 15% have extreme obesity.
    • Among men, Hispanics have the highest prevalence of being overweight or obese.
    • African American and Hispanic women with low incomes have the greatest likelihood of being overweight when compared with other socioeconomic groups.
    • Native Americans have a higher prevalence of being overweight than the general population.
    • Among Native Americans ages 45 to 74, more than 30% of women are overweight and more than 40% are obese.
    • Asian Americans have the lowest prevalence of being overweight and obese compared with the general population
  • Health risks associated with obesity
    • Psychosocial
      • Depression
      • Low self-esteem
      • Risk of suicide
      • Discrimination
      • Social isolation
    • Endocrine/Metabolic
      • Type 2 diabetes mellitus
      • Metabolic syndrome
      • Polycystic ovary syndrome
    • Respiratory
      • Obesity hypoventilation syndrome
      • Sleep apnea
      • Asthma
      • Pulmonary hypertension
      • Exercise intolerance
    • Reproductive (Women)
      • Menstrual irregularities
      • Infertility
      • Gestational diabetes
    • Reproductive (Men)
      • Hypogonadism
      • Gynecomastia
      • Sexual dysfunction
    • Musculoskeletal
      • Osteoarthritis
      • Impaired mobility and flexibility
      • Gout
      • Lumbar disk disease
      • Chronic low back pain
    • Cardiovascular
      • Hyperlipidemia
      • Sudden cardiac death
      • Right-sided heart failure
      • Left ventricular hypertrophy
      • Coronary artery disease
      • Deep venous thrombosis
      • Atrial fibrillation
      • Hypertension
      • Cardiomyopathy
      • Venous stasis
      • Varicose veins
    • Gastrointestinal
      • Nonalcoholic steatohepatitis (NASH)
      • Gallstones
      • Gastroesophageal reflux disease (GERD)
    • Genitourinary
      • Kidney cancer
      • Chronic kidney disease
      • Stress incontinence
    • Cancer
      • Esophagus, pancreas, thyroid, colorectal, and gallbladder cancer (both genders)
      • Endometrial, breast, and ovarian cancer (women)
  • Physiological regulatory mechanism
    • Two major consequences of obesity are due to
      • Increase in fat mass
      • Production of adipokines
        • Contribute to insulin resistance and atherosclerosis
        • Disrupt immune factors and predispose to certain cancers
  • Environmental factors
    • Greater access to food with poor nutritional quality
      • Common to underestimate food and caloric intake
    • Lack of physical exercise
    • Low socioeconomic status
  • Psychosocial factors
    • People use food for many reasons
      • Associations begin in childhood
      • Sense of satiety can be altered
      • Mindless eating
      • Eating is social and often associated with pleasure and fun

 

Heart Failure
Heart Failure 150 150 Tony Guo

Heart Failure

 

  • Complex clinical syndrome resulting in insufficient blood supply/oxygen to tissues and organs
    • Involves diastolic or systolic dysfunction
    • Ejection fraction (EF) is amount of blood pumped by LV with each heart beat
  • Associated with CVDs
  • Increase in incidence and prevalence
  • Most common cause for hospital admission in adults over age 65

 

Risk factors

  • Primary risk factors
    • Hypertension 
      • Modifiable risk factor
      • Properly treated and managed, incidence of HF can be reduced by 50%
    • CAD
  • Co-morbidities contribute to development of HF

 

Etiology of Heart failure

  • Anything that interferes with mechanisms that regulate cardiac output (CO)
  • Primary causes
    • Conditions that directly damage the heart
      • Hypertension, including hypertensive crisis
      • Coronary artery disease, including myocardial infarction
      • Rheumatic heart disease
      • Congenital heart defects (e.g., ventricular septal defect)
      • Pulmonary hypertension
      • Cardiomyopathy (e.g., viral, postpartum, substance abuse)
      • Hyperthyroidism
      • Valvular disorders (e.g., mitral stenosis)
      • Myocarditis
  • Precipitating causes
    • Conditions that increase workload of ventricles
Cause Mechanism
Anemia  Decrease O2-carrying capacity of the blood stimulating

Increase in CO to meet tissue demands, leading to increase in cardiac workload and increase in size of LV

Infection  Increased O2 demand of tissues, stimulating increase CO
Thyrotoxicosis Changes the tissue metabolic rate, increased HR and workload of the heart
Hypothyroidism Indirectly predisposes to increased atherosclerosis.

Severe hypothyroidism decreases myocardial contractility.

Dysrhythmias May decreased CO and increased workload and O2 requirements of myocardial tissue
Bacterial endocarditis Infection: increased metabolic demands and O2 requirements

Valvular dysfunction: causes stenosis or regurgitation

Obstructive sleep apnea Frequent nighttime apnea results in increased afterload, intermittent hypoxia, and increased sympathetic nervous system activity.
Pulmonary embolism Increased pulmonary pressure resulting from obstruction leads to pulmonary hypertension, decreased CO.
Paget’s disease Increased workload of the heart by increased vascular bed in the skeletal muscle
Nutritional deficiencies May decrease cardiac function by increased myocardial muscle mass and myocardial contractility
Hypervolemia Increased preload causing volume overload on the RV

 

Gender differences

  • Men
    • Men experience systolic failure more frequently than women.
    • Men with asymptomatic systolic failure experience greater mortality benefit from ACE inhibitor therapy than women.
  • Women
    • Women experience diastolic failure more frequently than men.
    • Women have a higher risk of ACE inhibitor–related cough than men.
    • Women experience more digitalis-related death than men.
    • Women with diabetes are more predisposed to HF than men.

 

Classification of heart failure

  • Left-sided HF
    • Most common form of HF
    • Results from inability of LV to
      • Empty adequately during systole
      • Fill adequately during diastole
    • Further classified as
      • Systolic
      • Diastolic
      • Mixed systolic and diastolic
    • Blood backs up into left atrium and pulmonary veins
    • Increased pulmonary pressure causes fluid leakage →→ pulmonary congestion and edema

 

Pathophysiology

  • Systolic heart failure
    • HFrEF – HF with reduced EF
    • Inability to pump blood forward
    • Caused by
      • Impaired contractile function 
      • Increased afterload 
      • Cardiomyopathy
      • Mechanical abnormalities 
    • Decreased LV ejection fraction (EF)
  • Diastolic heart failure
    • HFpEF – HF with preserved EF
    • Impaired ability of the ventricles to relax and fill during diastole, resulting in decreased stroke volume and CO
    • Result of left ventricular hypertrophy from hypertension, older age, female, diabetes, obesity
    • Same end result as systolic failure
  • Mixed heart failure
    • Mixed systolic and diastolic failure
      • Seen in disease states such as dilated cardiomyopathy (DCM)
      • Poor EFs (<35%)
      • High pulmonary pressures
      • Biventricular failure 
        • Both ventricles may be dilated and have poor filling and emptying capacity
  • Right-sided heart failure
    • RV fails to pump effectively
    • Fluid backs up in venous system
    • Fluid moves into tissues and organs
    • Left-sided HF is most common cause
      • Other causes include RV infarction, PE, and cor pulmonale (RV dilation and hypertrophy)
  • Heart failure
    • Ventricular failure leads to:
      • Low blood pressure (BP)
      • Low CO
      • Poor renal perfusion
    • Abrupt or subtle onset
    • Compensatory mechanisms mobilized to maintain adequate CO.

 

Compensatory mechanism

  • Renin-Angiotensin-Aldosterone-System (RAAS)
  • Neurohormonal response – RAAS
  • Endothelin release (contractility)
  • Cytokine release (Hypertrophy)
  • Inadequate stroke volume and CO –  (Epi and NoreEpi)
  • Ventricular remodeling
    • Continuous activation of neuro-hormonal responses (RAAS and SNS)
    • Hypertrophy of ventricular myocytes
    • Ventricles larger but less effective in pumping
    • Can cause life-threatening dysrhythmias and sudden cardiac death
  • Dilation
    • Enlargement of chambers of heart that occurs when pressure in left ventricle is elevated
    • Initially effective
    • Eventually this mechanism becomes inadequate and CO decreases
  • Hypertrophy 
    • Increase in muscle mass and cardiac wall thickness
    • Initially effective
    • Over time leads to poor contractility, increased O2 needs, poor coronary artery circulation, and risk for ventricular dysrhythmias

Counterregulatory mechanism

  • Natriuretic peptides
    • Atrial natriuretic peptide (ANP),
      b-type natriuretic peptide (BNP)
    • Released in response to increased blood volume in heart
    • Causes diuresis, vasodilation, and lowered BP
    • Counteracts effects of SNS and RAAS
  • Nitric oxide (NO) and prostaglandin
    • Released from vascular endothelium in response to compensatory mechanisms 
    • NO and prostaglandin relaxes arterial smooth muscle, resulting in vasodilation and decreased afterload

 

Acute Decompensated Heart Failure

  • Clinical manifestation
    • ADHF
      • Sudden onset of signs and symptoms of HF
      • Requires urgent medical care
      • Pulmonary and systemic congestion due to increased left-sided and right-sided filling pressures
    • Early → increased pulmonary venous pressure
      • Increase in the respiratory rate 
      • Decrease in PaO2 
    • Later → interstitial edema
      • Tachypnea 
    • Further progression → alveolar edema
      • Respiratory academia
    • Can manifest as pulmonary edema
    • Life-threatening situation – alveoli fill with fluid
    • Most commonly associated with left-sided HF

 

Right-sided heart failure Left-sided heart failure
Signs
RV heaves LV heaves
Murmurs Pulsus alternans (alternating pulses: strong, weak)
Jugular venous distention Increased HR
Edema (e.g., pedal, scrotum, sacrum) PMI displaced inferiorly and left of the midclavicular line (LV hypertrophy)
Weight gain Decreased PaO2, slight increased PaCO2 (poor O2 exchange)
Increased HR Crackles (pulmonary edema)
Ascites S3 and S4 heart sounds
Anasarca (massive generalized body edema) Pleural effusion
Hepatomegaly (liver enlargement) Changes in mental status
Restlessness, confusion
Symptoms
Fatigue Weakness, fatigue
Anxiety, depression Anxiety, depression
Dependent, bilateral edema Dyspnea
Right upper quadrant pain Shallow respirations up to 32-40/min
Anorexia and GI bloating Paroxysmal nocturnal dyspnea
Nausea Orthopnea
Dry, hacking cough
Nocturia
Frothy, pink-tinged sputum (advanced pulmonary edema)

 

Chronic heart failure

  • Clinical manifestation
    • Dependent on age, underlying type and extent of heart disease, and which ventricle is affected
    • FACES
      • Fatigue
      • Limitation of Activities
      • Chest congestion/cough
      • Edema
      • Shortness of breath
    • Fatigue 
    • Dyspnea 
    • Orthopnea
    • Paroxysmal nocturnal dyspnea
    • Tachycardia
    • Edema 
    • Dependent, liver, abdominal cavity, lungs
    • Edema may be pitting in nature 
    • Sudden weight gain of >3 lb (1.4 kg) in 2 days may indicate ADHF, an exacerbation of chronic HF
    • Nocturia
  • Edema 
    • Dependent, liver, abdominal cavity, lungs
    • Edema may be pitting in nature 
    • Sudden weight gain of >3 lb (1.4 kg) in 2 days may indicate ADHF, an exacerbation of chronic HF
  • Nocturia

 

Heart failure 

  • Complications
    • Pleural effusion
    • Dysrhythmias – atrial and ventricular
    • Left ventricular thrombus
    • Hepatomegaly
    • Renal failure

 

  • Diagnostic studies
    • Determine and treat underlying cause
    • Echocardiogram
      • Provides information on EF, heart valves and heart chambers
    • ECG, chest x-ray, 6-minute walk test, MUGA scan, cardiopulmonary exercise stress test, heart catheterization, EMB
    • BNP levels

 

ADHF

  • Interprofessional care
    • Continuous monitoring and assessment
      • VS, O2 saturation, urinary output
    • Hemodynamic monitoring if unstable 
    • Supplemental oxygen
    • Mechanical ventilation if unstable
    • High Fowler’s position
    • Ultrafiltration (aquapheresis) for patients with volume overload and resistance to diuretics
    • Circulatory assist devices for patients with deteriorating HF
      • Intra-aortic balloon pump (IABP)
      • Ventricular assist devices (VADs)
  • Drug therapy
    • Diuretics
      • Decrease volume overload (preload)
        • Loop diuretics – Furosemide (Lasix)
    • Vasodilators
      • Reduce circulating blood volume and improve coronary artery circulation
        • IV nitroglycerin
        • Sodium nitroprusside 
        • Nesiritide (Natrecor)
    • Morphine
      • Reduces preload and afterload
      • Relieves dyspnea and anxiety
    • Positive inotropes
      • β-agonists (dopamine, dobutamine, norepinephrine  [Levophed])
      • Phosphodiesterase inhibitor (milrinone)
      • Digitalis

Chronic HF

  • Interprofessional care
    • Main treatment goals
      • Treat the underlying cause and contributing factors
      • Maximize CO
      • Reduce symptoms
      • Improve ventricular function
      • Improve quality of life
      • Preserve target organ function
      • Improve mortality and morbidity
    • Oxygen therapy
      • Relieves dyspnea and fatigue
    • Physical and emotional rest
      • Conserve energy and decrease oxygen needs
      • Dependent on severity of HF
    • Structured exercise program
      • CR associated with better outcomes
    • CardioMems system
    • Implantable cardioverter-defibrillator (ICD)
    • Biventricular pacing/cardiac resynchronization therapy (CRT)
    • IABP and VADs as bridge to transplant (BTT) or as destination therapy (DT)
  • Drug therapy
    • Diuretics
      • Reduce edema, pulmonary venous pressure, and preload
      • Promote sodium and water excretion
      • Loop diuretics 
      • Thiazide diuretics 
      • Monitor potassium levels (hypokalemia)
    • RAAS inhibitors
      • ACE inhibitors 
      • Angiotensin II receptor blockers 
      • Aldosterone antagonists
      • Monitor potassium levels (hyperkalemia)
    • β-Blockers
    • Vasodilators
      • Nitrates
    • Combination therapy
      • BiDil
    • Positive inotropic agents 
      • Digitalis
    • Inhibitor of cardiac sinus node
      • Ivabradine (Corlanor)
      • Must be in sinus rhythm with resting HR of > 70 bpm and taking highest dose β-blockers
        • Inhibits sinus node
        • Reduces HR
        • Decreases risk of hospitalization for worsening HF
  • Nutritional therapy
    • Low sodium diet
    • Individualize recommendations and consider cultural background www.nhlbi.nih.gov/health/index.htm#recipes
    • Recommend Dietary Approaches to Stop Hypertension (DASH) diet 
    • Sodium is usually restricted to 2 g/day
    • Fluid restriction not generally required
    • If required, < 2L/day
      • Ice chips, gum, hard candy, ice pops to help thirst
    • Daily weights important
      • Same time, same clothing each day
    • Weight gain of 3 lb (1.4 kg) over 2 days or a 3- to 5-lb (2.3 kg) gain over a week should be reported to HCP

 

Nursing management: Heart Failure

  • Nursing Assessment
    • Subjective data
      • Health information
        • Past health history: 
          • CAD (including recent MI)
          • Hypertension
          • Cardiomyopathy
          • Valvular or Congenital heart disease
          • Diabetes mellitus
          • Hyperlipidemia
          • Renal disease
          • Thyroid or lung disease
          • Rapid or irregular heart rate
        • Medications: 
          • Use of and adherence with any heart drugs. 
          • Use of diuretics, estrogens, corticosteroids, nonsteroidal anti-inflammatory drugs, over-the-counter drugs, herbal supplements
      • Functional health pattern
        • Health perception–health management: 
          • Fatigue, depression, anxiety
        • Nutritional-metabolic: 
          • Usual sodium intake. Nausea, vomiting, anorexia, stomach bloating. Weight gain, ankle swelling
        • Elimination: 
          • Nocturia, decreased daytime urine output, constipation
        • Activity-exercise: 
          • Dyspnea, orthopnea, cough (e.g., dry, productive). Palpitations, dizziness, fainting
        • Sleep-rest: 
          • Number of pillows used for sleeping. Paroxysmal nocturnal dyspnea, insomnia, sleep apnea
        • Cognitive-perceptual: 
          • Chest pain or heaviness. RUQ pain, abdominal discomfort. Behavioral changes, visual changes
    • Objective data
      • Integumentary
        • Cool, diaphoretic skin. Cyanosis or pallor. Peripheral edema (right-sided heart failure)
      • Respiratory
        • Tachypnea, crackles, wheezes. Frothy, blood-tinged sputum 
      • Cardiovascular
        • Tachycardia, S3, S4, murmurs. Pulsus alternans. PMI displaced inferiorly and posteriorly, lifts and heaves, jugular venous distention
      • Gastrointestinal
        • Abdominal distention, hepatosplenomegaly, ascites
      • Neurologic
        • Restlessness, confusion, decreased attention or memory
      • Possible Diagnostic Findings
        • Altered serum electrolytes (especially Na+ and K+)
        • Increased BUN, creatinine, or liver function tests
        • Increased NT-proBNP or BNP
        • Chest x-ray demonstrating cardiomegaly, pulmonary congestion, and interstitial pulmonary edema. 
        • Echocardiogram showing increased chamber size, decreased wall motion, decreased EF or normal EF with evidence of diastolic failure. 
        • Atrial and ventricular enlargement on ECG. 
        • Decreased O2 saturation
  • Nursing Diagnoses
    • Impaired gas exchange related to increased preload and alveolar-capillary membrane changes
    • Decreased cardiac output related to altered contractility, altered preload, and/or altered stroke volume
    • Excess fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure
    • Activity intolerance related to imbalance between O2 supply and demand secondary to cardiac insufficiency and pulmonary congestion
  • Nursing planning
    • Overall Goals
      • Decrease in symptoms 
      • Decrease in peripheral edema
      • Increase in exercise tolerance
      • Compliance with the treatment regimen
      • No complications related to HF
  • Nursing intervention
    • Monitor respiratory status
    • Administer oxygen therapy
    • Semi-Fowler’s position
    • Monitor hemodynamic status
    • Daily weights
    • I and O
    • Administer prescribed drugs
    • Monitor edema
    • Alternate rest with activity
    • Provide diversionary activities
    • Monitor response to activity
    • Collaborate with OT/PT
    • Reduce anxiety
    • Evaluate support system
    • Patient teaching
      • Signs and symptoms of HF exacerbations – what to do/report
      • Importance of early detection
      • Can have positive outlook with chronic health problem if treatment plan is followed
      • Drug therapy
        • Expected actions 
        • Signs of drug toxicity
        • How to take HR and what to report
        • Signs and symptoms of hypokalemia and hyperkalemia
        • BP monitoring as needed
      • Dietary therapy
        • Dietary therapy
        • Written plan 
        • Reading labels for sodium 
        • No added salt
        • Daily weights
        • Smaller, more frequent meals
      • Activity/rest
        • Energy-conserving and energy-efficient behaviors
        • Exercise training (cardiac rehab)
        • Increase gradually
        • Avoid heat and cold extremes
        • Rest after exertion
        • Avoid emotional upsets
      • Ongoing monitoring
        • Know FACES
        • Reappearance of symptoms
        • What to report
          • Weight gain of 3 lb (1.4 kg) in 2 days, or 3-5 lb (2.3 kg) in a wk
          • Difficulty breathing, especially with activity or when lying lat
          • Waking up breathless at night
          • Frequent dry, hacking cough, especially when lying down
          • Fatigue, weakness
          • Swelling of ankles, feet, or abdomen. Swelling of face or difficulty breathing (if taking ACE inhibitors)
          • Nausea with abdominal swelling, pain, and tenderness
          • Dizziness or fainting
        • Regular follow-up
        • Support group
      • Health promotion
        • Vaccinations
          • Annual flu vaccination
          • Pneumococcal vaccine
        • Reduce risk factors
    • Ambulatory Care
      • Explain to patient and caregiver physiologic changes that have occurred 
      • Assist patient to adapt to both physiologic and psychologic changes
      • Include patient and caregiver(s) in overall care plan
  • Nursing evaluation
    • Monitoring to assess outcomes and prevent/ limit future hospitalizations
      • Vital signs
      • Weight
      • Pulse oximetry
      • Dyspnea
    • Home health nurses can be essential
    • Can use electronic monitoring

 

Heart Transplantation

  • Treatment of choice for patients with refractory end-stage HF, inoperable CAD, and cardiomyopathy
    • 3,000 on list; average 2,000 available
    • Survival rate of 85%-90% at 1year; 75% at 3
  • Selection process identifies patients who would most benefit from a new heart  
  • Candidates must undergo physical, diagnostic, and psychologic evaluation
  • Transplant candidates are placed on a list 
    • Stable patients wait at home and receive ongoing medical care 
    • Unstable patients may require hospitalization for more intensive therapy
    • Overall waiting period for a heart is long; many patients die during this time
  • Heart retrieval first step
  • Second step is removal of recipient’s heart except for portions of atria (2 different approaches) and venous connections
  • Final step is implantation of donor heart
Coronary Artery Disease
Coronary Artery Disease 150 150 Tony Guo

Coronary Artery Disease

  • Atherosclerosis
  • Begins as soft deposits of fat that harden with age
  • Referred to as “hardening of arteries”
  • Atheromas (fatty deposits) prefer coronary arteries
  • Etiology and pathophysiology
    • Atherosclerosis is major cause of CAD
      • Characterized by lipid deposits within intima of artery
      • Endothelial injury and inflammation play a major role in development
    • C-reactive protein (CRP)
      • Nonspecific marker of inflammation
      • Increased in many patients with CAD
      • Chronic exposure to CRP linked with unstable plaques and oxidation of LDL cholesterol
    • Collateral circulation
      • Arterial anastomoses (or connections) within coronary circulation
      • Increased with chronic ischemia
      • May be inadequate with rapid-onset CAD
  • Developmental stages
    • Chronic Endothelial Injury due to 
      • Hypertension
      • Tobacco use
      • Hyperlipidemia
      • Hyperhomocysteinemia
      • Diabetes
      • Infections
      • Toxins
    • The stages of atherosclerosis development are
      • Fatty streak
        • Lipids accumulate and migrate into smooth muscle cells
      • Fibrous plaque
        • Collagen covers the fatty streak
        • Vessel lumen is narrowed
        • Blood flow is reduced
        • Fissures can develop
      • Complicated lesion
        • Plaque rupture
        • Thrombus formation
        • Further narrowing or total occlusion of vessel
  • Risk factors of coronary artery disease
    • Non-modifiable risk factors
      • Increasing age 
      • Gender (more common in men than in women until 75 yr of age)
      • Ethnicity (more common in white men than in African Americans)
      • Family history of heart disease
      • Genetic predisposition
    • Major modifiable risk factors
      • Elevated serum lipids
        • Cholesterol >200 mg/dL (5.2 mmol/L)
        • Triglycerides >150 mg/dL (3.7 mmol/L)
        • High-density lipoproteins (HDL)
        • Low-density lipoproteins (LDL)
          • Reduce total fat intake.
          • Reduce animal (saturated) fat intake.
          • Take prescribed drugs for lipid reduction.
          • Adjust total caloric intake to achieve and maintain ideal body weight.
          • Engage in daily physical activity.
          • Increase amount of complex carbohydrates, fiber, and vegetable proteins in diet.
      • Hypertension
        • Monitor home-based BP and obtain regular checkups.
        • Take prescribed drugs for BP control.
        • Reduce salt intake.
        • Stop tobacco use. Avoid exposure to environmental tobacco (secondhand) smoke.
        • Control or reduce weight.
        • Perform physical activity daily.
      • Physical Inactivity
        • Develop and maintain at least 30 min of moderate physical activity daily (minimum 5 days a week). 
        • Increase activities to a fitness level.
      • Obesity: Waist circumference ≥102 cm (≥40 in) in men and ≥88 cm (≥35 in) in women
        • Change eating patterns and habits.
        • Reduce caloric intake to achieve body mass index of 18.5–24.9 kg/m2.
        • Increase physical activity to increase caloric expenditure.
        • Avoid fad and crash diets, which are not effective over time.
        • Avoid large, heavy meals. Consider smaller, more frequent meals.
      • Diabetes
        • Follow the recommended diet.
        • Control or reduce weight.
        • Take prescribed drugs for diabetes.
        • Monitor blood glucose levels regularly. 
      • Psychologic state
        • Increase awareness of behaviors that are harmful to health.
        • Alter patterns that add to stress (e.g., get up 30 min earlier so that breakfast is not eaten on way to work).
        • Set realistic goals for self.
        • Reassess priorities in light of identified risk factors.
        • Learn effective stress management strategies
        • Seek professional help if feeling depressed, angry, and anxious, etc.
        • Plan time for adequate rest and sleep

 

  • Contributing
    • Fasting blood glucose ≥100 mg/dL 
    • Psychosocial risk factors (e.g., depression, hostility, anger, stress)
    • Elevated homocysteine levels

 

  • Nursing and Interprofessional care: Chronic Artery Disease
    • Nutritional therapy
      • Decrease saturated fats and cholesterol
      • Increase complex carbohydrates and fiber
      • Increase red meat, egg yolks, whole milk
      • Increase omega-3 fatty acids
        • Strong scientific evidence for reduction of triglyceride levels
    • Lipid-lowering drug therapy
      • If diet and exercise ineffective
      • Statins
        • Inhibit cholesterol synthesis, decrease LDL, increase HDL
        • Monitor for liver damage and myopathy
      • Niacin
        • Lowers LDL and triglyceride by inhibiting synthesis
        • Increases HDL
        • Flushing, pruritus, GI side effects, orthostatic hypotension
      • Fibric acid derivatives (Lopid)
        • Decrease triglycerides and increase HDL
        • GI side effects
    • Increase lipoprotein removal
      • Bile acid sequestrants
        • Increase conversion of cholesterol to bile acids
        • GI side effects; bind with other drugs
      • Decrease cholesterol absorption
        • Ezetimibe (Zetia)
          • Decrease absorption of dietary and biliary cholesterol
    • Antiplatelet therapy 
      • ASA
      • Clopidogrel (Plavix)
  • Cultural and ethnic health disparities
    • Whites
      • White men have the highest incidence of coronary artery disease (CAD).
    • African Americans
      • African Americans have an early age of onset of CAD.
      • Deaths from cardiovascular diseases (e.g., CAD, stroke) are higher for African Americans than for the overall population in the United States.
      • African American women have a higher incidence and death rate related to CAD than white women.
    • Native Americans
      • Native Americans die from heart disease earlier than expected.
      • Mortality rates for those under 65 yr old are twice as high as those of other Americans.
      • Major modifiable cardiovascular risk factors for Native Americans are tobacco use, hypertension, obesity, and diabetes.
    • Hispanics
      • Hispanics have slightly lower rates of CAD than either non-Hispanic whites or African Americans.
      • Hispanics have lower death rates from CAD than non-Hispanic whites
  • Gender differences
    • Coronary Artery disease
      • Men
        • First heart event for men is more often Ml than angina.
        • Men report more typical signs and symptoms of angina and MI.
        • Men receive more evidence-based therapies (e.g., aspirin, statins, diagnostic catheterization, PCI) when acutely ill from CAD (e.g., MI) than women.
        • Mortality rates from CAD have decreased more rapidly for men than women.
      • Women
        • Women experience the onset of heart disease approximately 10 years later than men.
        • CAD is the leading cause of death for women, regardless of race or ethnicity.
        • More women with MI (compared to men with MI) die of sudden cardiac death before reaching the hospital.
        • Before menopause, women have higher HDL cholesterol levels and lower
        • LDL cholesterol levels than men. After menopause LDL levels increase.
    • Acute coronary syndrome
      • Men
        • After age 75, the incidence of MI in men and women equalizes.
        • Men present more frequently than women with an acute MI as the first manifestation of CAD.
        • Men develop greater collateral circulation than women.
        • Men have larger-diameter coronary arteries than women.
        • Vessel diameter is inversely related to risk of restenosis after interventions.
        • Standard screening for risk of sudden cardiac death (e.g., EP studies) is more predictive in men.
      • Women
        • Women are older than men when seen with first MI and often have more co-morbidities.
        • Women seek medical care later in the CAD process and often are more ill on presentation than men.
        • First heart event for women is more often unstable angina than MI.
        • Once a woman reaches menopause, her risk for an MI quadruples.
        • Fewer women than men manifest the “classic” signs and symptoms of UA or MI.
        • Fatigue is often the first symptom of ACS in women.
        • Women experience more “silent” MIs compared with men.
        • Among those who have an MI, women are more likely to suffer a fatal heart event within 1 year than men.
        • Women report more disability after a heart event than men.
        • Women who have coronary artery bypass graft surgery have a higher mortality rate and more complications after surgery than men.

 

  • Clinical manifestation of CAD
    • Angina
      • Chronic and progressive disease
        • O2 demand > O2 supply → myocardial ischemia 
        • Angina = clinical manifestation
          • Occurs when arteries are blocked 70% or more
          • 50% or more for left main coronary artery
      • Locations and patterns of Angina
        • Mid sternum, left shoulder and down both arms, neck and arms
        • Substernal radiating to neck and jaw and substernal radiating down left arm
        • Epigastric and radiating to neck, jaw, and arms
        • Intrascapular
      • PQRST Assessment of Angina
Factor Questions to ask the patient
P Precipitating events What events or activities precipitated the pain or discomfort (e.g., argument, exercise, resting)?
Q Quality of pain  What does the pain or discomfort feel like (e.g., pressure, dull, aching, tight, squeezing, heaviness)?
R Region (location) and radiation of pain Can you point to where the pain or discomfort is located? Does the pain or discomfort radiate to other areas (e.g., back, neck, arms, jaw, shoulder, and elbow)?
S Severity of pain On a scale of 0 to 10, with 0 indicating no pain and 10 being the most severe pain you could imagine, what number would you give the pain or discomfort?
T Timing When did the pain or discomfort begin? Has it changed since this time? Have you had pain/discomfort like this before?
  • Precipitating factors of Angina
    • Physical Exertion
      • Increases HR, reducing the time the heart spends in diastole (the time of greatest coronary blood low), resulting in an increase in myocardial O2 demand.
      • Isometric exercise of the arms (e.g., raking, lifting heavy objects, snow shoveling) can cause exertional angina.
    • Temperature Extremes
      • Increase the workload of the heart.
      • Blood vessels constrict in response to a cold stimulus.
      • Blood vessels dilate and blood pools in the skin in response to a hot stimulus.
    • Strong Emotions
      • Stimulate the sympathetic nervous system, activating the stress response.
      • Increase the workload of the heart.
    • Consumption of Heavy Meal (e.g., holiday meals)
      • Can increase the workload of the heart.
      • During the digestive process, blood is diverted to the GI system, reducing blood low in the coronary arteries.
    • Tobacco Use and Environmental Tobacco Smoke
      • Diminish available O2 by increasing the level of carbon monoxide.
      • Nicotine stimulates catecholamine release, causing vasoconstriction and an increased HR.
    • Sexual Activity
      • Increases the cardiac workload and sympathetic stimulation.
      • In a person with CAD, the extra cardiac workload may precipitate angina.
    • Stimulants (e.g., cocaine, amphetamines)
      • Increase HR and BP and subsequently increases myocardial O2 demand.
      • Stimulate vasoconstriction and subsequently decreases myocardial O2 supply.
      • May precipitate dysrhythmias
    • Circadian Rhythm Patterns
      • Manifestations of CAD tend to occur in the early morning after awakening.

 

  • Chronic stable angina
    • Intermittent chest pain that occurs over a long period with same pattern of onset, duration, and intensity of symptoms
    • Few minutes in duration
    • ST segment depression and/or T-wave inversion
    • Control with drugs
  • Types of Angina
    • Silent ischemia
      • Ischemia that occurs in absence of any subjective symptoms 
      • Associated with diabetic neuropathy
      • Confirmed by ECG changes
    • Prinzmetal’s (variant) angina
      • Rare
      • Occurs at rest
      • Can be seen in patients with a history of migraine headaches, Raynaud’s phenomenon and heavy smoking
      • Spasm of a major coronary artery
      • CAD may or may not be present
    • Microvascular angina
      • Syndrome X (Common in women)
      • Chest pain occurs in the absence of significant CAD or coronary spasm of a major coronary artery
      • Prevention and treatment follows CAD recommendations
  • Interprofessional care
    • Goal: decrease O2 demand and/or increase O2 supply
      • Short-acting nitrates
        • Dilate peripheral and coronary blood vessels 
        • Give sublingually or by spray
        • If no relief in 5 minutes, call EMS; if some relief ,repeat every 5 minutes for maximum 3 doses
        • Patient teaching
        • Can use prophylactically
      • Long-acting nitrates
        • To reduce angina incidence
        • Main side effects: headache, orthostatic hypotension
        • Methods of administration
          • Oral
          • Nitroglycerin (NTG) ointment
          • Transdermal controlled-release NTG
      • Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARBs)
      • β-Blockers
      • Calcium channel blockers
      • Lipid lowering drugs
        • Sodium current inhibitor
          • Ranolazine (Ranexa)
    • Diagnostic studies
      • Chest x-ray
      • 12-lead ECG
      • Laboratory studies
      • Echocardiogram 
      • Exercise stress test
      • EBCT
      • CCTA
    • Cardiac catheterization/coronary angiography
      • Visualize blockages (diagnostic)
      • Open blockages (interventional)
        • Percutaneous coronary intervention (PCI)
        • Balloon angioplasty
        • Stent

 

Acute coronary syndrome

  • Etiology and pathophysiology
    • Process
      • Deterioration of once stable plague
      • Rapture
      • Platelet aggregation
      • Thrombus
    • Result
      • Partial occlusion of coronary artery: UA or NSTEMI
      • Total occlusion of coronary artery: STEMI
  • Clinical manifestation of ACS
    • Unstable Angina
      • New in onset
      • Occurs at rest
      • Increase in frequency, duration, or with less effort
      • Pain lasting > 10 minutes
      • Needs immediate treatment
      • Symptoms in women often under-recognized
    • Myocardial infarction (MI)
      • ST-elevation and non-ST-elevation
      • Result of abrupt stoppage of blood flow through a coronary artery, causing irreversible myocardial cell death (necrosis)
        • Pre-existing CAD
        • STEMI – occlusive thrombus
        • NSTEMI – non-occlusive thrombus
      • Pain
        • Severe chest pain not relieved by rest, position change, or nitrate administration
          • Heaviness, pressure, tightness, burning, constriction, crushing
          • Substernal or epigastric
          • May radiate to neck, lower jaw, arms, back
        • Often occurs in early morning
        • Atypical in women, elderly
        • No pain if cardiac neuropathy (diabetes)
      • Catecholamine release and stimulation of SNS
        • Release of glycogen
        • Diaphoresis
        • Increased HR and BP
        • Vasoconstriction of peripheral blood vessels
        • Skin: ashen, clammy, and/or cool to touch
      • Cardiovascular
        • Initially, increase HR and BP, then decrease BP (secondary to decrease in CO) 
        • Crackles 
        • Jugular venous distention
        • Abnormal heart sounds
          • S3 or S4
          • New murmur
      • Nausea and vomiting
        • Reflex stimulation of the vomiting center by severe pain
        • Vasovagal reflex
      • Fever
        • Up to 100.4° F (38° C) in first 24-48 hours
        • Systemic inflammatory process caused by heart cell death

 

Myocardial infarction

  • Healing process
    • Within 24 hours, leukocytes infiltrate the area of cell death
    • Proteolytic enzymes of neutrophils and macrophages begin to remove necrotic tissue by fourth day → thin wall 
    • Necrotic zone identifiable by ECG changes 
    • Collagen matrix laid down
    • 10 to 14 days after MI, scar tissue is still weak 
    • Heart muscle vulnerable to stress
    • Monitor patient carefully as activity level increases
    • By 6 weeks after MI, scar tissue has replaced necrotic tissue
      • Area is said to be healed, but less compliant
    • Ventricular remodeling
      • Normal myocardium will hypertrophy and dilate in an attempt to compensate for infarcted muscle
  • Complications of myocardial infarction
    • Dysrhythmias
      • Most common complication
      • Present in 80% to 90% of MI patients
      • Can be caused by ischemia, electrolyte imbalances, or SNS stimulation
      • VT and VF are most common cause of death in prehospitalization period
    • Heart failure
      • Occurs when pumping power of heart has diminished
      • Left-sided HF
        • Mild dyspnea, restlessness, agitation, slight tachycardia initially
      • Right-sided HF
        • Jugular venous distention, hepatic congestion, lower extremity edema
    • Cardiogenic shock
      • Occurs because of 
        • Severe LV failure, papillary muscle rupture, ventricular septal rupture, LV free wall rupture, right ventricular infarction
      • Requires aggressive management
        • Associated with a high death rate
    • Papillary muscle dysfunction or rupture
      • Causes mitral valve regurgitation
      • Aggravates an already compromised LV → rapid clinical deterioration
    • Left ventricular aneurysm
      • Myocardial wall becomes thinned and bulges out during contraction
      • Leads to HF, dysrhythmias, and angina
    • Ventricular septal wall rupture and left ventricular free wall rupture
      • New, loud systolic murmur
      • HF and cardiogenic shock
      • Emergency repair 
      • Rare condition associated with high death rate
    • Acute pericarditis
      • Inflammation of visceral and/or parietal pericardium
      • Mild to severe chest pain 
        • Increases with inspiration, coughing, movement of upper body
        • Relieved by sitting in forward position 
      • Pericardial friction rub 
      • ECG changes
    • Dressler syndrome
      • Pericarditis and fever that develops 1 to 8 weeks after MI
      • Chest pain, fever, malaise, pericardial friction rub, arthralgia
      • High dose aspirin is treatment of choice

 

  • Unstable Angina and MI
    • Diagnostic studies
      • Detailed health history 
      • 12-lead ECG
        • Compare to previous ECG
        • Changes in QRS complex, ST segment, and T wave 
        • Distinguish between STEMI and NSTEMI
        • Serial ECGs reflect evolution of MI
      • Coronary angiography
        • For patients with a STEMI
        • Not for patients with UA or NSTEMI
      • Pharmacologic stress testing
        • For patients with abnormal but non-diagnostic ECG and negative biomarkers

 

  • Interprofessional care
    • Acute Coronary Syndrome
      • Initial interventions
        • 12-lead ECG
        • Upright position
        • Oxygen – keep O2 sat > 93%
        • IV access 
        • Nitroglycerin (SL) and ASA (chewable)
        • Statin
        • Morphine
      • Ongoing monitoring
        • Treat dysrhythmias
        • Frequent vital sign monitoring
        • Bed rest/limited activity for 12–24 hours
      • UA or NSTEMI 
        • Dual antiplatelet therapy and heparin
        • Cardiac catheterization with PCI once stable
      • NSTEMI 
        • Reperfusion therapy

      • Emergent PCI 
        • Treatment of choice for confirmed STEMI
        • Goal: 90 minutes from door to catheter laboratory
        • Balloon angioplasty + stent(s) 
        • Many advantages over CABG
      • Thrombolytic therapy
        • Only for patients with a STEMI
          • Agencies that do not have cardiac catheterization resources
        • Given IV within 30 minutes of arrival to the ED
        • Patient selection critical
        • Draw blood and start 2–3 IV sites
        • Complete invasive procedures prior
        • Administer according to protocol
        • Monitor closely for signs of bleeding
        • Assess for signs of reperfusion
        • Return of ST segment to baseline best sign
      • IV heparin to prevent reocclusion
      • Coronary surgical revascularization 
        • Failed medical management
        • Presence of left main coronary artery or three-vessel disease 
        • Not a candidate for PCI (e.g., blockages are long or difficult to access)
        • Failed PCI with ongoing chest pain
        • History of diabetes mellitus, LV dysfunction, chronic kidney disease
      • Traditional coronary artery bypass graft (CABG) surgery
        • Requires sternotomy and cardiopulmonary bypass (CPB)
        • Uses arteries and veins for grafts 
          • The internal mammary artery (IMA) is most common artery used for bypass graft
      • Radial Arterty Graft
        • Radial artery is another potential graft 
          • Thick muscular artery that is prone to spasm
          • Perioperative calcium channel blockers and long-acting nitrates can control the spasms
          • Patency rates are not as good as IMA but better than saphenous veins
      • Acute coronary syndrome
        • Minimally invasive direct coronary artery bypass (MIDCAB)
          • For patients with disease of left anterior descending or right coronary artery
          • Does not involve a sternotomy and CPB
        • Off-pump coronary artery bypass (OPCAB)
          • Sternotomy but no CPB
        • Robotic or totally endoscopic coronary artery bypass (TECAB)
        • Transmyocardial laser revascularization
          • Indirect revascularization
          • High-energy laser creates channels in heart to allow blood flow to ischemic areas
        • Drug therapy
          • IV nitroglycerin (NTG)
          • Morphine
          • β-adrenergic blockers
          • ACE inhibitors
          • Antidysrhythmic drugs
          • Lipid-lowering drugs
          • Stool softeners

      Nursing management

      • Nursing Assessment: 
        • Subjective Data
          • Health history
            • CAD/chest pain/angina/ MI
            • Valve disease
            • Heart failure/cardiomyopathy,
            • Hypertension, diabetes, anemia, lung disease, hyperlipidemia
          • Drugs
            • Use of anti-platelets or anticoagulants 
            • Nitrates
            • Angiotensin-converting enzyme inhibitors
            • β-blockers
            • Calcium channel blockers
            • Antihypertensive drugs
            • Lipid-lowering drugs
            • Over-the-counter drugs (e.g., vitamin and herbal supplements)
          • History of present illness
            • Description of events related to current illness
          • Health perception–health management: 
            • Family history of heart disease.
            • Sedentary lifestyle
            • Tobacco use
            • Exposure to environmental smoke
          • Nutritional-metabolic
            • Indigestion/heartburn; nausea/vomiting
          • Elimination
            • Urinary urgency or frequency
            • Straining at stool
          • Activity-exercise
            • Palpitations, dyspnea, dizziness, weakness
          • Cognitive-perceptual
            • Substernal chest pain or pressure (squeezing, constricting, aching, sharp, tingling)
            • Possible radiation to jaw, neck, shoulders, back, or arms
          • Cognitive-stress tolerance
            • Stress, depression, anger, anxiety
        • Objective Data
          • Anxious, fearful, restless, distressed
          • Integumentary effects
            • Cool, clammy, pale skin
          • Cardiovascular 
            • Tachycardia or bradycardia
            • Pulsus alternans
            • Pulse deficit
            • Dysrhythmias  
            • S3, S4, increased or decreased BP, murmur
          • Possible diagnostic findings
            • Positive serum cardiac biomarkers
            • Increased serum lipids; 
              • Increased WBC count. 
            • Positive exercise or pharmacologic stress test and thallium scans. 
            • Pathologic Q wave, ST segment elevation, and/or T wave abnormalities on ECG.
            • Cardiac enlargement, calcifications, or pulmonary congestion on chest x-ray. 
            • Abnormal wall motion with stress echocardiogram. 
            • Positive coronary angiography
        • Psychosocial responses to Acute coronary syndrome
          • Denial
            • May have history of ignoring signs and symptoms related to heart disease
            • Minimizes severity of health condition
            • Ignores activity restrictions
            • Avoids discussing illness or its significance
          • Depression
            • Mourns loss of health, altered body function, and changes in lifestyle
            • Realizes seriousness of situation
            • Begins to worry about future implications of health problem
            • Shows manifestations of withdrawal, crying, apathy
            • May be more evident after discharge
          • Anger and Hostility
            • Is commonly expressed as, “Why did this happen to me?”
            • May be directed at family, staff, or medical regimen
          • Anxiety and Fear
            • Fears long-term disability and death
            • Overtly displays apprehension, restlessness, insomnia, tachycardia
            • Less overtly displays increased verbalization, projection of feelings to others, hypochondriasis
            • Fears activity
            • Fears recurrent chest pain, heart attacks, and sudden death
          • Dependency
            • Is totally reliant on staff
            • Is unwilling to perform tasks or activities unless approved by HCP
            • Wants to be monitored by ECG at all times
            • Is hesitant to leave the intensive care or telemetry unit or hospital
          • Realistic Acceptance
            • Focuses on optimum rehabilitation
            • Plans changes compatible with altered cardiac function
            • Actively engages in lifestyle changes to address modifiable risk factors
      • Nursing diagnoses
        • Decreased cardiac output related to altered contractility and altered heart rate and rhythm
        • Acute pain related to an imbalance between myocardial O2 supply and demand
        • Anxiety related to perceived or actual threat of death, pain, and/or possible lifestyle changes
        • Activity intolerance related to general weakness secondary to decreased cardiac output and poor lung and tissue perfusion
        • Ineffective health management related to lack of knowledge of disease process, risk factor reduction, rehabilitation, home activities, and medications
      • Planning
        • Overall goals
          • Relief of pain
          • Preservation of heart muscle
          • Immediate and appropriate treatment
          • Effective coping with illness-associated anxiety
          • Participation in a rehabilitation plan
          • Reduction of risk factors
      • Acute interventions: Chronic stable angina
        • Upright position
        • Supplemental oxygen
        • Assess vital signs
        • 12-lead ECG
        • Administer NTG followed by an opioid analgesic, if needed
        • Assess heart and breath sounds
      • Acute care: Acute coronary syndrome
        • Pain: nitroglycerin, morphine, oxygen
        • Continuous monitoring
          • ECG
          • ST segment 
          • Heart and breath sounds
          • VS, pulse oximetry, I and O
        • Rest and comfort
          • Balance rest and activity
          • Begin cardiac rehabilitation
        • Anxiety reduction
          • Identify source and alleviate
          • Patient teaching important
        • Emotional and behavioral reaction 
          • Maximize patient’s social support systems
          • Consider open visitation
      • Coronary revascularization: PCI
        • Monitor for recurrent angina
        • Frequent VS, including cardiac rhythm
        • Monitor catheter insertion site for bleeding
        • Neurovascular assessment
        • Bed rest per institutional policy
      • Coronary revascularization: CABG
        • ICU for first 24–36 hours
        • Pulmonary artery catheter
        • Intra-arterial line 
        • Pleural/mediastinal chest tubes 
        • Continuous ECG
        • ET tube with mechanical ventilation
        • Epicardial pacing wires
        • Urinary catheter
        • NG tube
      • Ambulatory Care
        • Resumption of sexual activity
          • Teach when discuss other physical activity
          • Erectile dysfunction drugs contraindicated with nitrates
          • Prophylactic nitrates before sexual activity
          • When to avoid sex
          • Typically 7–10 days post MI or when patient can climb two flights of stairs
      • Evaluation
        • Stable vital signs
        • Relief of pain
        • Decreased anxiety
        • Realistic program of activity
        • Effective management of therapeutic regimen

      Sudden cardiac death

      • Nursing/Interprofessional care
        • Diagnostic workup to rule out or confirm MI 
          • Cardiac biomarkers
          • ECGs
          • Treat accordingly
        • Cardiac catheterization
        • PCI or CABG
        • 24-hour Holter monitoring
        • Exercise stress testing
        • Signal-averaged ECG
        • Electrophysiologic study (EPS)
        • Implantable cardioverter-defibrillator (ICD)
        • Antidysrhythmic drugs
        • LifeVest

      Role of Nursing Personnel

      • Registered Nurse (RN)
        • Pre-procedure
          • Assess for allergies, especially to contrast dye. Perform baseline assessment, including vital signs, pulse oximetry, heart and breath sounds, neurovascular assessment of extremities (e.g., distal pulses, skin temperature, skin color, sensation).
          • Assess baseline laboratory values (e.g., cardiac biomarkers, creatinine).
          • Teach patient and caregiver about procedure and post-procedure care.
        • Post-procedure
          • Perform assessment and compare to baseline: vital signs, pulse oximetry, heart and breath sounds, neurovascular assessment of extremity used for procedure, assessment of catheter insertion site for hematoma, bleeding, and bruit.
          • Monitor ECG for dysrhythmias or other changes (e.g., ST segment elevation).
          • Monitor patient for chest pain and other sources of pain or discomfort.
          • Monitor IV infusions of anticoagulants, antiplatelets.
          • Teach patient and caregiver about discharge drugs (e.g., aspirin, clopidogrel, antianginal drugs).
          • Teach patient and caregiver about discharge care including signs and symptoms to report to HCP (e.g., site complications, return of chest pain).
      • Licensed Practical/Vocational Nurse (LPN/LVN)
        • Give drugs before and after the procedure (consider state nurse practice act and agency policy).
        • Assess neurovascular status of involved extremity every 15 min for the first hour, then according to agency policy (consider state nurse practice act and agency policy).
        • Check for bleeding at catheter insertion site every 15 min for the first hour, then according to agency policy.
        • Report changes in neurovascular status of involved extremity or any bleeding to the RN.
      • Unlicensed Assistive Personnel (UAP)
        • Take vital signs and report increases or decreases in HR or BP to RN.
        • Report decreases in pulse oximetry to the RN.
        • Report patient complaints of chest pain, shortness of breath, and/or any other discomfort or distress to RN.
        • Assist with oral hygiene and hydration, meals, and toileting.
        • Record oral intake and urine output as ordered.
        • Perform related skills as ordered (e.g., capillary blood glucose).
      • Role of Other Team Members
        • Respiratory Therapist
          • Provide respiratory therapies (e.g., nebulizer treatments) as ordered and per agency policy.
Hypertension
Hypertension 150 150 Tony Guo

Hypertension

 

  • Hypertension, or high blood pressure (BP), is one of the most important modifiable risk factors that can lead to the development of cardiovascular disease (CVD). 
  • As BP increases, so does the risk of
    • MI, Heart failure, Stroke and Renal disease 
  • Affects 1 in 3 adults in United States
  • High priority health concern identified in Healthy People 2020
  • 83% of people > age 20 with hypertension are aware they have high BP
    • 76% are being treated
    • 48% of those aware do not currently have their BP well controlled

 

  • Blood pressure (BP) is the force exerted by the blood against the walls of the blood vessel.
  • BP is primarily a function of cardiac output (CO) and systemic vascular resistance (SVR)
  • Systemic vascular resistance (SVR) is the force opposing the movement of blood within the blood vessels

 

Factors affecting BP

Blood pressure = Cardiac output X Systemic vascular resistance

 

  • Cardiac output
    • Cardiac
      • Heart rate
      • Contractility
      • Conductivity
    • Renal fluid volume control
      • Renin-angiotensin-aldosterone system
      • Natriuretic peptides
  • Systemic vascular resistance
    • Sympathetic nervous system
      • α1– and α2-Adrenergic receptors (vasoconstriction)
      • β2-Adrenergic receptors (vasodilation)
    • Local regulation
      • Vasodilators
  • Prostaglandins
  • Nitric oxide
  • Vasoconstrictors
  • Endothelin
  • Neurohormonal
    • Vasoconstrictors
      • Angiotensin
      • Norepinephrine

 

  • Cultural and ethnic health disparities
  • African Americans
    • Have the highest prevalence of hypertension in the world
    • Develop hypertension at a younger age than whites
    • Have a higher incidence of hypertension among women than among men
    • Demonstrate more nocturnal non-dipping BP than whites
    • Hypertension is more aggressive and results in more severe end-organ damage.
    • Have a higher death rate resulting from hypertension than whites
    • Produce less renin and do not respond well to renin-inhibiting drugs
    • Calcium channel blockers and diuretics provide better BP control, especially with monotherapy.
    • Have a higher risk of angioedema with angiotensin-converting enzyme inhibitors than whites
  • Mexican Americans
    • Are less likely to receive treatment for hypertension than whites and African Americans
    • Have lower rates of BP control than whites and African Americans
    • Have lower levels of awareness of hypertension and its treatment than whites and African Americans
  • Gender differences
    • Men
      • Before early middle age, hypertension is more common in men than in women.
    • Women
      • Hypertension is two to three times more common in women who take oral contraceptives than in women who do not.
      • A history of preeclampsia may be an early sign of risk for cardiovascular disease.
      • After age 64, hypertension is more common in women than in men. Part of the rise in BP in women is attributed to menopause related factors such as estrogen withdrawal, overproduction of pituitary hormones, and weight gain.
      • It is more difficult to control hypertension in older women (ages 70-79) than in women ages 50-69, despite having similar rates of treatment.

 

  • Sympathetic nervous systems (SNS)
    • Activation increases HR and cardiac contractility
    • Vasoconstriction and renin release
    • Increases CO and SVR
  • Baroreceptors
    • Sensitive to stretching
    • Send impulses to sympathetic vasomotor center
  • Vascular endothelium
    • Essential to regulation of vasodilating and vasoconstricting substances 
  • Renal system
    • Control sodium excretion and ECF volume
    • RAAS system
    • Prostaglandins
  • Endocrine system
    • Epinephrine and norepinephrine from adrenal medulla
    • Aldosterone from adrenal cortex
    • ADH from posterior pituitary

 

Classification of hypertension

  • Normal
    • SBP (mmHg) <120 
    • DBP (mmHg) <80
  • Prehypertension
    • SBP (mmHg) 120-139 
    • DBP (mmHg) 80-89
  • Hypertension, stage 1
    • SBP (mmHg) 140-159  
    • DBP (mmHg) 90-99
  • Hypertension, stage 2
    • SBP (mmHg)  ≥160 
    • DBP (mmHg) ≥100

Causes of secondary hypertension

  • Cirrhosis
  • Coarctation or congenital narrowing of the aorta
  • Drug-related: estrogen replacement therapy, oral contraceptives, corticosteroids, nonsteroidal anti-inflammatory drugs (e.g., cyclooxygenase-2 inhibitors), sympathetic stimulants (e.g., cocaine, monoamine oxidase)
  • Endocrine disorders (e.g., pheochromocytoma, Cushing syndrome,thyroid disease)
  • Neurologic disorders (e.g., brain tumors, quadriplegia, traumatic brain injury)
  • Pregnancy-induced hypertension
  • Renal disease (e.g., renal artery stenosis, glomerulonephritis)
  • Sleep apnea 

 

Etiology of hypertension

  • Primary hypertension 
    • Also called essential or idiopathic hypertension
    • Elevated BP without an identified cause 
    • 90% to 95% of all cases
    • Exact cause unknown but several contributing factors
  • Secondary hypertension
    • Elevated BP with a specific cause
    • 5% to 10% of adult cases
    • Clinical findings relate to underlying cause 
    • Treatment aimed at removing or treating cause

 

Risk factors for primary hypertension

  • Age
    • SBP rises progressively with increasing age, although DBP may decrease with age.
    • After age 50, SBP >140 mm Hg is a more important cardiovascular risk factor than DBP
  • Alcohol
    • Excessive alcohol intake is strongly associated with hypertension.
    • Moderate intake of alcohol has cardioprotective properties; males with hypertension should limit their daily intake of alcohol to 2 drinks per day, and 1 drink per day for females with hypertension.
  • Tobacco use
    • Smoking tobacco greatly increased risk of cardiovascular disease.
    • People with hypertension who smoke tobacco are at even greater risk for cardiovascular disease.
  • Diabetes mellitus
    • Hypertension is more common in patients with diabetes.
    • When hypertension and diabetes coexist, complications (e.g., target organ disease) are more severe.
  • Elevated serum lipids
    • Increased levels of cholesterol and triglycerides are primary risk factors in atherosclerosis.
    • Hyperlipidemia is more common in people with hypertension.
  • Excess dietary sodium
    • High sodium intake can
    • Contribute to hypertension in salt-sensitive patients.
    • Decrease the effectiveness of certain antihypertensive medications.
  • Gender
    • Hypertension is more prevalent in men in young adulthood and early middle age.
    • After age 64, hypertension is more prevalent in women.
  • Family history
    • History of a close blood relative (e.g., parents, sibling) with hypertension is associated with an increased risk for developing hypertension.
  • Obesity
    • Weight gain is associated with increased frequency of hypertension.
    • Risk increases with central abdominal obesity.
  • Ethnicity
    • Incidence of hypertension is 2 times higher in African Americans than in whites.
  • Sedentary lifestyle
    • Regular physical activity can help control weight and reduce cardiovascular risk.
    • Physical activity may decrease BP.
  • Socioeconomic status
    • Hypertension is more prevalent in lower socioeconomic groups and among the less educated.
  • Stress
    • People exposed to repeated stress may develop hypertension more frequently than others.
    • People who develop hypertension may respond differently to stress than those who do not develop hypertension.

 

Link among salt intake, blood pressure, and changes in the heart

  • High dietary salt intake
    • Ventricular hypertrophy
      • BP (afterload)
      • Intravascular volume (preload)
      • Direct effects on protein synthesis of myocardial cells
    • Ventricular fibrosis
      • Increased aldosterone synthesis in myocardium
      • Increased angiotensin receptors in myocardial cells
        • Increased concentration of TGF-β1

 

Clinical manifestation

  • “Silent killer”
  • Symptoms of severe hypertension
    • Fatigue
    • Dizziness
    • Palpitations
    • Angina
    • Dyspnea

Complications

  • Target organ diseases occur most frequently in 
    • Heart
      • Hypertensive heart disease
        • Coronary Artery disease
          • Hypertension disrupts the coronary artery endothelium
          • This results in a stiff arterial wall with a narrowed lumen, and accounts for a high rate of CAD, angina, and MI.
        • Left ventricular hypertrophy
          • Increased contractility increases myocardial work and O2 demand
        • Heart failure
          • Occurs when the heart’s compensatory mechanisms are overwhelmed and the heart can no longer pump enough blood to meet the body’s demands
    • Brain
    • Cerebrovascular disease
      • When BP exceeds the body’s ability to autoregulate, the cerebral vessels suddenly dilate, capillary permeability increases, and cerebral edema develops. 
      • This produces a rise in intracranial pressure. If left untreated, patients can die quickly from brain damage
    • Peripheral vascular disease
      • Hypertension speeds up the process of atherosclerosis in the peripheral blood vessels. 
      • This leads to the development of peripheral vascular disease, aortic aneurysm, and aortic dissection
    • Kidney
      • Nephrosclerosis
        • Results from ischemia caused by the narrowing of the renal blood vessels. 
        • This leads to atrophy of the tubules, destruction of the glomeruli, and eventual death of nephrons. 
        • Initially intact nephrons can compensate, but these changes may eventually lead to renal failure
        • Laboratory indications of renal disease are albuminuria, proteinuria, microscopic hematuria, and elevated serum creatinine and blood urea nitrogen (BUN) levels.
    • Eyes
      • Retinal damage
        • Damage to the retinal vessels provides an indication of related vessel damage in the heart, brain, and kidneys. 
        •  Manifestations of severe retinal damage include blurring of vision, retinal hemorrhage, and loss of vision.

    Diagnostic studies

    • Diagnostic assessment
      • History and physical examination, including an ophthalmic examination
      • Routine urinalysis
      • Basic metabolic panel (serum glucose, sodium, potassium, chloride, carbon dioxide, BUN, and creatinine)
      • Complete blood count
      • Serum lipid proile (total lipids, triglycerides, HDL and LDL cholesterol, total-to-HDL cholesterol ratio)
      • Serum uric acid, calcium, and magnesium
      • 12-lead electrocardiogram (ECG)
      • Optional:
        • 24-hr urinary creatinine clearance
        • Echocardiography
        • Liver function studies
        • Serum thyroid-stimulating hormone (TSH)
    • Management
      • Periodic monitoring of BP
      • Home BP monitoring
      • Ambulatory BP monitoring
      • Every 3-6 months by a HCP once goal BP is achieved and stabilized
      • Nutritional therapy
      • Restrict salt and sodium
      • Restrict cholesterol and saturated fats
      • Maintain adequate intake of potassium, calcium, and magnesium
      • Weight management
      • Regular, moderate physical activity
      • Tobacco cessation 
      • Moderation of alcohol intake
      • Stress management techniques 
      • Antihypertensive drugs
      • Patient and caregiver teaching

    Lifestyle modifications

    • Weight reduction
      • Weight loss of 22 lb (10 kg ) may decrease SBP by approx. 5 to 20 mm Hg
      • Calorie restriction and physical activity
    • DASH eating plan
      • Fruits, vegetables, fat-free or low-fat milk, whole grains, fish, poultry, beans, seeds, and nuts
    • Dietary sodium reduction
      • < 2300 mg/day for healthy adults
      • < 1500 mg/day for 
        • African Americans
        • Middle-aged and older 
        • Those with hypertension, diabetes, or chronic kidney disease
    • Moderation of alcohol intake
    • Physical activity
      • Moderate-intensity aerobic activity, at least 30 minutes, most days of the week
      • Vigorous-intensity aerobic activity at least 20 minutes, 3 days a week
      • Muscle-strengthening activities at least 2 times a week
      • Flexibility and balance exercises 2 times a week
    • Avoidance of tobacco products
      • Nicotine causes vasoconstriction and elevated BP
      • Smoking cessation reduces risk factors within 1 year
    • Psychosocial risk factors
      • Low socioeconomic status, social isolation and lack of support, stress, negative emotions
      • Activate SNS and stress hormones
    • Drug therapy and patient teaching
      • Follow-up care
      • Identify, report, and minimize side effects
        • Orthostatic hypotension
        • Sexual dysfunction
        • Dry mouth
        • Frequent urination
      • Time of day to take drug
      • Diuretics promote sodium and water excretion, reduce plasma volume, and reduce the vascular response to catecholamines.
      • Adrenergic-inhibiting agents act by diminishing the SNS effects that increase BP. Adrenergic inhibitors include drugs that act centrally on the vasomotor center and peripherally to inhibit norepinephrine release or to block the adrenergic receptors on blood vessels.
      • Direct vasodilators decrease the BP by relaxing vascular smooth muscle and reducing SVR.
      • Calcium channel blockers increase sodium excretion and cause arteriolar vasodilation by preventing the movement of extracellular calcium into cells.
      • Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I to angiotensin II and reduce angiotensin II (A-II)–mediated vasoconstriction and sodium and water retention.
      • A-II receptor blockers (ARBs) prevent angiotensin II from binding to its receptors in the walls of the blood vessels.

    Hypertension medication

    Drug Examples Mechanism of Actions Nursing considerations
    Diuretics
    Thiazide and Related Diuretics Chlorothiazide (Diuril)

    Chlorthalidone

    Hydrochlorothiazide

    Indapamide

    Metolazone (Zaroxolyn)

    Inhibit NaCl reabsorption in the distal convoluted tubule. Increase excretion of Na+ and Cl. Initial decrease in ECF. Sustained decrease in SVR. Lower BP moderately in 2-4 wk. Monitor for orthostatic hypotension, hypokalemia, and alkalosis. 

    Thiazides may potentiate cardiotoxicity of digoxin by producing hypokalemia. 

    Dietary sodium restriction reduces the risk of hypokalemia. NSAIDs can decrease diuretic and antihypertensive effect of thiazide diuretics and potentially cause renal impairment. 

    Advise patient to supplement with potassium-rich foods.

    Loop Diuretics Bumetanide (Bumex)

    Furosemide (Lasix)

    Torsemide (Demadex)

    Inhibit NaCl reabsorption in the ascending limb of the loop of Henle. Increase excretion of Na+ and Cl. More potent diuretic effect than thiazides, but shorter duration of action. Less effective for hypertension.  Monitor for orthostatic hypotension and electrolyte abnormalities. 

    Loop diuretics remain effective despite renal insufficiency. Diuretic effect of drug increases at higher doses.

    Potassium-Sparing Diuretics Amiloride (Midamor)

    Triamterene (Dyrenium)

    Reduce K+ and Na+ exchange in the distal and collecting tubules. Reduce excretion of K+, H+, Ca++, and Mg++. Monitor for orthostatic hypotension and hyperkalemia. 

    Contraindicated in patients with renal failure. Use with caution in patients on ACE inhibitors or angiotensin II blockers. 

    Avoid potassium supplements.

    Aldosterone Receptor Blockers Spironolactone (Aldactone)

    Eplerenone (Inspra)

    Inhibit the Na+-retaining and K+-excreting effects of aldosterone in the distal and collecting tubules. Monitor for orthostatic hypotension and hyperkalemia. 

    Do not combine with potassium-sparing diuretics or potassium supplements. Use with caution in patients on ACE inhibitors or angiotensin II blockers. These drugs are also classified as potassium-sparing diuretics.

    Adrenergic Inhibitors
    Central-Acting α-Adrenergic Agonist Clonidine (Catapres)

    Clonidine patch (Catapres-TTS)

    Reduce sympathetic outflow from CNS.

    Reduce peripheral sympathetic tone, produces vasodilation, and decreases SVR and BP.

    Sudden discontinuation may cause withdrawal syndrome, including rebound hypertension, tachycardia, headache, tremors, apprehension, sweating.

    Chewing gum or hard candy may relieve dry mouth. 

    Alcohol and sedatives increase sedation. Transdermal patch may be related to fewer side effects and better adherence.

    Guanabenz

    Guanfacine (Tenex)

    Same as clonidine, but not available in transdermal formulation.
    Methyldopa Instruct patient about daytime sedation and avoidance of hazardous activities. 

    Taking a single daily dose at bedtime minimizes sedative effect.

    Peripheral-Acting α-Adrenergic Agonist Reserpine Depletes central and peripheral stores of norepinephrine. Results in peripheral vasodilation (decreases SVR and BP). Must be given twice daily. Contraindicated in patients with history of depression. Monitor mood and mental status regularly. 

    Advise patient to avoid barbiturates, alcohol, opioids.

    α1-Adrenergic Blockers Doxazosin (Cardura)

    Prazosin (Minipress)

    Terazosin

    Block 1-adrenergic effects, producing peripheral vasodilation (decreases SVR and BP). Beneficial effects on lipid profile. Reduced resistance to the outflow of urine in benign prostatic hyperplasia. Taking drug at bedtime reduces risks associated with orthostatic hypotension.
    Phentolamine (Regitine)  Blocks 1-adrenergic receptors, resulting in peripheral vasodilation (decreases SVR and BP). Used in short-term management of pheochromocytoma. Also used locally to prevent necrosis of skin and subcutaneous tissue after extravasation of adrenergic drug. 

    No oral formulation.

    β-Adrenergic Blockers Cardioselective Blockers 

    Acebutolol (Sectral)

    Atenolol (Tenormin)

    Betaxolol

    Bisoprolol (Zebeta)

    Esmolol (Brevibloc)

    Metoprolol (Lopressor)

    Nebivolol (Bystolic)

    Cardioselective agents block -β1– adrenergic receptors. Reduce BP by blocking –adrenergic effects. Decrease CO and reduce sympathetic vasoconstrictor tone. Decrease renin secretion by kidneys. Monitor pulse and BP regularly. Use with caution in patients with diabetes because drug may depress the tachycardia associated with hypoglycemia and may adversely affect glucose metabolism.

    Drug of choice for patients with a history of an MI or heart failure. Less effective BP reduction in African American patients. Esmolol is for IV use only. 

    Cardioselective agents lose cardioselectivity at higher doses.

    Non-cardioselective Blockers

    Nadolol (Corgard)

    Pindolol

    Propranolol (Inderal)

    Nonselective agents block -β1– and -β2-adrenergic receptors. Reduce BP by blocking -β1– and -β2-adrenergic effects. Same as cardioselective, except nonselective agents may cause bronchospasm, especially in patients with a history of asthma.
    Mixed α and β-Blockers Carvedilol (Coreg)

    Labetalol

    α1-, -β1-, and -β2-adrenergic blocking properties producing peripheral vasodilation and decreased heart rate. Reduce CO, SVR, and BP. Same as –blockers. IV form available for hypertensive crisis in hospitalized patients. Patients must be kept supine during IV administration. 

    Assess patient tolerance of upright position (severe orthostatic hypotension) before allowing upright activities (e.g., commode).

    Direct Vasodilators Fenoldopam (Corlopam) Activates dopamine receptors, resulting in systemic and renal vasodilation. IV use only for hypertensive crisis in hospitalized patients. 

    Use cautiously in patients with glaucoma. Patient should remain flat for 1 hr after administration.

    Hydralazine Reduces SVR and BP by direct arterial vasodilation. IV use for hypertensive crisis in hospitalized patients. Twice-daily oral dosage. Not used as monotherapy because of side effects. 

    Contraindicated in patients with coronary artery disease.

    Minoxidil Reduces SVR and BP by direct arterial vasodilation. Reserved for treatment of severe hypertension associated with renal failure and resistant to other therapy. Once- or twice-daily dosage.
    Nitroglycerin Relaxes arterial and venous smooth muscle, reducing preload and SVR. At low dose, venous dilation predominates; at higher dose, arterial dilation is present. IV use for hypertensive crisis in hospitalized patients with myocardial ischemia. 

    Given by continuous IV infusion with pump or control device.

    Sodium nitroprusside Direct arterial vasodilation reduces SVR and BP. IV use for hypertensive crisis in hospitalized patients. Given by continuous IV infusion with pump or control device. 

    Arterial monitoring of BP recommended. Wrap IV solutions with an opaque material to protect from light. Stable for 24 hr. 

    Metabolized to cyanide, then thiocyanate. Monitor thiocyanate levels with prolonged use (>3 days) or doses ≥4 mcg/kg/min.

    Angiotensin Inhibitors
    Angiotensin-Converting Enzyme Inhibitors Benazepril (Lotensin)

    Captopril

    Enalapril (Vasotec)

    Fosinopril

    Lisinopril (Zestril)

    Moexipril (Univasc)

    Perindopril (Aceon)

    Quinapril (Accupril)

    Ramipril (Altace)

    Trandolapril (Mavik)

    Inhibit ACE, reduce conversion of angiotensin I to angiotensin II (A-II). Inhibit A-II–mediated vasoconstriction. Aspirin and NSAIDs may reduce drug effectiveness. Addition of diuretic enhances drug effect. 

    Should not be used with potassium-sparing diuretics. Can cause increase in serum creatinine. Inhibit breakdown of bradykinin, which may cause a dry, hacking cough that can occur at any point during treatment, even years later. Captopril may be given orally for hypertensive crisis.

    Angiotensin II Receptor Blockers Azilsartan (Edarbi)

    Candesartan (Atacand)

    Eprosartan (Teveten)

    Irbesartan (Avapro)

    Losartan (Cozaar)

    Olmesartan (Benicar)

    Telmisartan (Micardis)

    Valsartan (Diovan)

    Prevent action of A-II and produce vasodilation and increased Na+ and water excretion. Full effect on BP may not be seen for 3-6 wk. Do not affect bradykinin levels, therefore acceptable alternative to ACE inhibitors in people who develop dry cough. 

    In patients with kidney disease, ACE inhibitors and ARBs should not be used together due to adverse renal effects.

    Renin Inhibitors Aliskiren (Tekturna) Directly inhibits renin, thus reducing conversion of angiotensinogen to angiotensin I.  May cause angioedema of the face, extremities, lips, tongue, glottis, and/or larynx.

    Not to be used in pregnancy.

    Calcium Channel Blockers
    Non-Dihydropyridines Diltiazem extended release (Cardizem LA)

    Verapamil intermediate release (Calan)

    Verapamil long-acting (Covera-HS)

    Verapamil timed-release (Verelan PM)

    Inhibit movement of Ca++ across cell membrane, resulting in vasodilation

    Cardioselective resulting in decrease in heart rate and slowing of AV conduction.

    Use with caution in patients with heart failure. Serum concentrations and toxicity of certain calcium channel blockers may be increased by grapefruit juice; avoid concurrent use. 

    Used for supraventricular tachydysrhythmias. 

    Avoid in patients with second- or third-degree AV block or left ventricular systolic dysfunction.

    Dihydropyridines Amlodipine (Norvasc)

    Clevidipine (Cleviprex)

    Felodipine

    Isradipine

    Nicardipine sustained release

    Nifedipine long acting (Procardia XL)

    Nisoldipine (Sular)

    Cause vascular smooth muscle relaxation resulting in decreased SVR and arterial BP. More potent peripheral vasodilators. Clevidipine is for IV use only. Use of sublingual short-acting nifedipine in hypertensive emergencies is unsafe and not effective. 

    Serious adverse events (e.g., stroke, acute MI) have been reported. IV nicardipine available for hypertensive crisis in hospitalized patients. Change peripheral IV infusion sites every 12 hr.

    Resistant hypertension

    • Failure to reach goal BP in patients taking full doses of an appropriate 3-drug therapy regimen that includes a diuretic. Reasons include
      • Improper BP measurement
      • Drug-induced
        • Nonadherence (e.g., due to drug side effects, finances)
        • Illegal drugs (e.g., cocaine, amphetamines)
        • Inadequate drug dosages
        • Inappropriate combinations of drug therapy
        • Nonsteroidal anti-inflammatory drugs
        • Sympathomimetics (e.g., decongestants, diet pills)
        • Oral contraceptives
        • Corticosteroids
        • Cyclosporine and tacrolimus (Prograf)
        • Erythropoietin
        • Licorice
        • Some chewing tobacco
        • Selected over-the-counter dietary or herbal supplements and drugs (e.g., ma huang, bitter orange)
      • Associated conditions
        • Increasing obesity
        • Excess alcohol intake
      • Identifiable causes of secondary hypertension

    Nursing management

    • Nursing Assessment
      • Subjective Data
        • Important Health Information
          • Past health history: Known duration and past workup of high BP; cardiovascular, cerebrovascular, renal, or thyroid disease; diabetes mellitus; pituitary disorders; obesity; dyslipidemia; menopause or hormone replacement status
          • Medications: Use of any prescription or over-the-counter, illicit, or herbal drugs or products; previous use of antihypertensive drug therapy
        • Functional Health Patterns
          • Health perception–health management: Family history of hypertension or cardiovascular disease; tobacco use, alcohol use; sedentary lifestyle; health literacy; readiness for change 
          • Nutritional-metabolic: Usual salt and fat intake; weight gain or loss
          • Elimination: Nocturia
          • Activity-exercise: Fatigue; dyspnea on exertion, palpitations, exertional chest pain; intermittent claudication, muscle cramps; usual pattern and type of exercise
          • Cognitive-perceptual: Dizziness; blurred vision; paresthesias
          • Sexual-reproductive: Erectile dysfunction, decreased libido
          • Coping–stress tolerance: Stressful life events
      • Objective Data
        • Cardiovascular
          • SBP consistently >140 mm Hg or DBP >90 mm Hg for patients <60 yr old or >150 mm Hg or DBP >90 mm Hg for patients >60 years old.
          • Orthostatic changes in BP and HR; bilateral BPs significantly different; abnormal heart sounds; laterally displaced apical pulse; diminished or absent peripheral pulses; carotid, renal, or femoral bruits; peripheral edema
        • Gastrointestinal
          • Obesity (BMI ≥30 kg/m2); abnormal waist-hip ratio
        • Neurologic
          • Mental status changes
      • Possible Diagnostic Findings
        • Abnormal serum electrolytes (especially potassium) 
        • Increased BUN, creatinine, glucose, cholesterol, and triglyceride levels 
        • Proteinuria, albuminuria, microscopic hematuria
        • Evidence of ischemic heart disease and left ventricular hypertrophy on ECG
        • Evidence of structural heart disease and left ventricular hypertrophy on echocardiogram; evidence of arteriovenous nicking, retinal hemorrhages, and papilledema on funduscopic examination
      • BP Measurement
        • Take in both arms initially
        • Proper size and placement of cuff
        • Can use forearm if needed
          • Document site 
        • Assess for orthostatic hypotension
          • BP and HR supine, sitting, and standing
          • Measure within 1 to 2 minutes of position change
          • Positive if decrease of 20 mm Hg or more in SBP, decrease 10 mm Hg or more in DBP, or increased 20 beats/minute or more in heart rate
    • Nursing diagnoses
      • Ineffective health management related to lack of knowledge of pathology, complications, and management of hypertension
      • Anxiety related to complexity of management regimen
      • Sexual dysfunction related to side effects of antihypertensive medication
      • Risk for decreased cardiac tissue perfusion
      • Risk for ineffective cerebral tissue perfusion
      • Risk for ineffective renal perfusion
      • Potential complication: stroke, MI
    • Planning
      • Patient will
        • Achieve and maintain the goal BP
        • Follow the therapeutic plan
          • Including appointments with the HCP
        • Experience minimal side effects of therapy
        • Manage and cope with this condition.
    • Nursing implementation
      • Health Promotion
        • Primary prevention via lifestyle modification
        • Individual patient evaluation and education
        • Screening programs
        • Cardiovascular risk factor modification
      • Ambulatory Care
        • Evaluate therapeutic effectiveness
        • Detect and report adverse effects
        • Assess and enhance compliance
        • Patient and caregiver teaching
      • Home BP monitoring
        • Patient teaching is critical for accuracy
          • Proper equipment
          • Proper procedure
          • Frequency
          • Accurate recording and reporting
          • Target BP
      • Reasons for poor adherence to treatment plan are complex
        • Inadequate teaching
        • Low health literacy
        • Unpleasant side effects of drugs
        • Return to normal BP while on drugs
        • High cost of drugs
        • Lack of insurance
      • Measures to enhance compliance
        • Individualize plan
        • Active patient participation
        • Select affordable drugs
        • Involve caregivers
        • Combination drugs
        • Patient teaching
    • Nursing evaluation
      • Patient will: 
        • Achieve and maintain goal BP 
        • Understand, accept, and implement treatment plan 
        • Report minimal side effects of therapy
    • Hypertension in older persons
    • BP goal for people > 60 is < 150/90
    • Preferred antihypertensive drugs
      • Thiazide diuretic
      • Calcium channel blockers
      • ACE inhibitors or ARBs
    • Caution use of NSAIDS
    • Hypertensive crisis
      • SBP >180 mmHg and/or DBP >110 mmHg
        • Hypertensive urgency 
          • Develops over hours to days
          • May not require hospitalization
        • Hypertensive emergency 
          • Very severe problems can result if prompt treatment is not obtained
      • Rate of rise more important than absolute value
      • Causes of hypertensive crisis
        • Exacerbation of chronic hypertension
        • Renovascular hypertension
        • Preeclampsia, eclampsia
        • Pheochromocytoma
        • Drugs (cocaine, amphetamines)
        • Monoamine oxidase inhibitors taken with tyramine-containing foods
        • Rebound hypertension (from abrupt withdrawal of some antihypertensive drugs such as clonidine [Catapres] or –blockers)
        • Head injury
        • Acute aortic dissection
      • Clinical manifestation
        • Hypertensive encephalopathy
          • Headache, nausea/vomiting, seizures, confusion, coma
        • Renal insufficiency
        • Cardiac decompensation
          • MI, HF, pulmonary edema
        • Aortic dissection
      • Nursing and interprofessional management
        • Hospitalization
          • IV drug therapy: titrated to MAP
          • Monitor cardiac and renal function
          • Neurologic checks
          • Determine cause
          • Education to avoid future crisis

    Role of Nursing Personnel

    • Registered Nurse (RN)
      • Develop and conduct hypertension screening programs.
      • Assess patients for hypertension risk factors and develop risk modification plans.