Nursing Case Study Hypertension
Hypertension is highly prevalent among aging adults and can lead to coronary artery disease, diastolic and systolic heart failure and other cardiovascular conditions. Hypertension is also known to worsen clinical heart failure since high afterload increases the work of the heart, prompting a maladaptive state that is reflected by congestion, fatigue and edema. Due to the level of risk, it poses, it is essential that communities get educated on how to handle hypertension.
Excessive alcohol intake is strongly associated with?
Stage 2 hypertension is described as a Systolic blood pressure of greater than or equal to …mm Hg or a Diastolic blood pressure of greater than, or equal to, … mm Hg.
1, Diuretics. 2, Adrenergic inhibitors. 3, Vasodilators. 4, ACE inhibitors. 5, Calcium antagonist. ACE, Angiotensin-converting enzyme.
This is a common side effect of many antihypertensive medications, including atenolol (Tenormin), which is a beta-blocker
An irritating … -This is a common side effect of ACE inhibitors.
a weakness in the wall of the aorta that makes it susceptible to rupture.
calcium blocker (trade name Procardia)
Grapefruit decreases the effectiveness of nifedipine (Procardia), a …. channel blocker.
hypertension can occur with sudden discontinuation of many antihypertensives. Discontinuation of these medications should be done under the direction of his healthcare provider.
Step-down therapy is not started until after one year of good blood pressure control.
Case Study – HTN
Mr. H.T.N. is a 5’6″, 210 lb, 64-yr old male patient with a seven-year history of hypertension. His BP is currently around 180/110 mmHg. He has been referred to the hospital clinic because his BP is proving difficult to control. Clinical examination is unremarkable; BP 185/115. His WBC is normal, as are electrolytes and serum albumin. Mild elevations in BUN and creatinine are noted, is a hemoglobin level of 12 g/dL. CXR shows mild cardiac enlargement with clear lung fields. ECG reveals abnormalities suggestive of left ventricular hypertrophy.
HTN is high blood pressure ~ 140/80 and above
What is the distinction between essential and secondary hypertension?
primary HTN – essential HTN – no known cause
secondary HTN – has a physiological cause
What are three major risk factors for HTN? Be sure to explain how they give rise to or relate to HTN from a physiological standpoint.
these risk factors promote atherosclerosis/vasoconstriction/fat deposition –> increase in total peripheral resistance –> give rise to HTN
Persistent HTN puts our patient at risk for a number of comorbidities. Identify three of the comorbidities and explain the relationship between HTN and these disease outcomes.
cardiovascular comorbidities – causes increased afterload and makes his heart work harder, putting him at risk for heart failure
Explain the significance of left-ventricular hypertrophy with regards to hypertension.
as we have HTN, we have a reduced radius which means we have increased resistance, meaning that the heart has to work harder
mild left side enlargement and hypertrophy as part of the adaptive response or compensation to increase contractility to push the blood out of the heart
increased demand on the heart and decreased supply [bc soon the hypertrophied cells will fill the ventricle] creates lowered end-diastolic volume and lowered ejection fraction causes a patient not to be able to keep up with the demands of the body
Define afterload. What is the relationship between HTN and afterload?
afterload – the force that the heart has to work against to push the blood out of the ventricle
HTN is a major cause of increased afterload
HTN creates a very narrowed set of vessels where you have to push the blood into a small opening so the heart has to work harder
changes in chamber structure [hypertrophy] imbalance between supply and demand
Explain how prolonged HTN can give rise to heart failure?
unresolved HTN means the heart will have to work harder leading to myocardial hypertrophy continuously; this causes less blood to move forward and more myocardial tissue filling the heart chambers equals decreased tissue perfusion, which over time increases the patient’s risk of heart failure bc the heart will not be able to keep up with metabolic demand
also, if atherosclerosis is underpinning the HTN, the patient may have coronary artery disease [CAD], starting causing occlusion of the vessels that feed the heart itself, which can also increase the patient’s risk of heart failure
What do his mild anemia and increased BUN and creatinine suggest about renal function?
indicates some renal compromise
HTN & decrease perfusion –> renal HTN and inadequate blood volume –> decreased glomerular filtration rate –> inability to filter toxins out of the blood [increased BUN & creatinine]; this is also causing the kidney itself to be affected –> decreased erythropoeitin production –> lowered RBC count –> anemia
What is the normal role of the kidneys with regard to RBC production?
kidneys make erythropoietin which stimulates RBC production in the marrow of long bones
What is the rationale behind each of the following possible treatment strategies: oral diuretic, beta-blocker, calcium-channel blocker.
oral diuretic – decrease fluid overload and congestion
beta-blocker – slow the heart to take some of the increased workload/demand off the heart
calcium channel blocker – promote vasodilation to reduce afterload
what drugs impact xerostomia
calcium channel blockers
what drugs impact gingival overgrowth
calcium channel blockers
What drugs impact lichenoid reactions?
what drugs affect scalded mouth syndrome
what gender more affected
what age most affected
what race/ethnicity most affected
Who’s more affected? US-born or non-US born
who is more affected <65: with private insurance; with public insurance, with no insurance
t/f: diabetics have a higher hypertension prevalence
t/f: those who are NOT obese have higher hypertension prevalence
how many Americans affected
at age 55, there is a 90% lifetime risk of developing hypertension
What population is most affected?
higher income indicates what
less prevalence for hypertension
<100 or 100-199 thousand income: 32.6%
higher education indicates what
less prevalence for hypertension
who is more affected disabled or not disabled
normal BP SBP range and DBP range
<120 and <80
pre-hypertension SBP and DBP range
stage 1 hypertension SBP and DBP range
stage 2 hypertension SBP and DBP range
SBP of 120-139 or a DBP of 80-89
people, w/ BP range of 130-139/85-89 are what
twice as likely to develop hypertension than those with lower values
stroke or heart attack doubles for each increase in BP in what increments
in 20/10 mm Hg increments form 115/75 mm Hg
what systemic conditions
arteriosclerosis–thicken/harden arterial walls
heart–myocardial infarction leading to cardiac failure
all forms of stroke
peripheral artery disease
chronic kidney disease
conditions that are risk factors for hypertension
lifestyle diet risk factor for hypertension
diet/increased sodium intake
most sodium comes from processed foods/fast food, and most Americans consume more than the daily recommended amy of sodium before they even add salt
lifestyle physical activity for hypertension
inactivity can lead to weight gain and thus increase hypertension
hypertension and weight relate how
overweight increases the risk for developing hypertension
does alcohol contribute to hypertension development
does tobacco contribute to the development of hypertension
t/f: we are increased in risk for developing hypertension as we age
t/f: Hypertension can run in families
true. thus some genes can lead to the development of hypertension
Interaction of nonselective beta-blockers with epinephrine in local anesthetics can result in what
a reduction in cardiac output through an alpha-receptor-induced increase in blood pressure & concomitant compensatory vagal reflex-mediated decrease in heart rate
When epinephrine is used in patients receiving non-potassium-sparing diuretics, potassium levels can do what
decrease resulting in dysrhythmias
Prolonged used of NSAIDs can lessen what effects
antihypertensive effectiveness of diuretics, beta-blockers, alpha-blockers, vasodilators, ACE inhibitors & central agonists
Widely recommended that vasoconstrictor usage be minimized or increased in patients with increased risk of developing CVD.
with careful administration, frequent aspiration, and monitoring of vital signs, patients treated with nonselective b-blockers can safely receive how much epinephrine
two or three cartridges of anesthetic with 1:100,000 epinephrine
what amt of epinephrine is considered ambulatory safe for all pts except those w/ severe CVD
two to three cartridges of lidocaine with 1:100,000 epinephrine (approximately 0.036-0.054 mg epinephrine) is considered safe
t/f: the use of retraction cords containing epinephrine has no reason to be avoided
Antibiotic prophylaxis before dental procedures is recommended ONLY for patients who are what
the highest risk for adverse outcomes (have a history of previous IE, cardiac valve replacement, or surgically constructed pulmonary shunts or conduits).
when should antibiotics be administered before procedures
if antibiotics are not given before then, they may be given up to what duration afterward
up to 2 hours after
administered in a single dose
what conditions is antibiotic prophylaxis indicated before invasive dental procedures
Patients that have had valve replacement or surgery, Previous IE, congenital heart disease, cardiac transplants, cardiac implants.
identify dental procedures which are considered invasive from an antibiotic prophylaxis viewpoint
manipulation of gingiva and periapical region of teeth
perforation of oral mucosa
Describe the measures besides antibiotic prophylaxis that can reduce the risk of bacteremia resulting from dental procedures
oral hygiene? Antimicrobial mouth rinses brushing teeth flossing?
pts can reduce the risk of IE [SBE] by maintaining good oral hygiene/health
visit dentists regularly and maintain dental care at home can prevent IE/SBE better than prophylaxis treatment
pts can reduce the risk of IE [SBE] by doing what
maintaining good oral hygiene/health
t/f: visit dentists regularly and maintain dental care at home can prevent IE/SBE better than prophylaxis treatment
Explain how the thiazide drugs work to lower blood pressure.
Thiazide diuretics act primarily on the diluting segment of the distal convoluted tubules of kidney nephrons, inhibiting sodium reabsorption from decreasing circulating fluid volume.
What is essential hypertension?
Essential hypertension is elevated blood pressure where no specific underlying cause can be identified. The most common form of hypertension is blood pressure elevated consistently at or above 140mmHg systolic/90mmHgdiastolic pressure.
What is liquorice, and how does it cause hypertension?
Liquorice is produced from the dried root of the plant Glycyrrhiza glabra. The active ingredient in liquorice is glycyrrhizic acid and makes up 10‐25% of the root extract. Glycyrrhizic acid is responsible for the sweet taste of liquorice.
What is pseudohyperaldosteronism?
Pseudohyperaldosteronism is a condition that clinically mimics hyperaldosteronism with suppression of plasma renin activity and aldosterone levels. Causes of pseudo‐hyperaldosteronism can be categorized into dietary, genetic, and endocrinal causes. Dietary causes include prolonged overconsumption of licorice, carbenoxolone, or grapefruit due to an acquired reduction in the activity of 11β‐hydroxysteroid dehydrogenase type 2.
Explain how Beta‐blockers work to reduce blood pressure.
β‐blockers are competitive antagonists that competitively bind to two types ofβ‐adrenergic receptors (β1 and β2) of the sympathetic nervous system. The binding of β‐blockers to these receptors inhibits the binding of adrenaline, noradrenaline, and isoprenaline. β‐blockers can be selective (e.g., atenolol), blocking β1‐receptors in the heart, or nonselective (e.g., propranolol), blocking β1‐receptors in the heart and β2‐receptors in the bronchioles of the lungs.
pregnancy complications with high BP or just poor control of blood pressure can lead to baby loss because you have to have a robust cardiovascular system to keep the blood flowing for the baby because you are sharing blood with the baby.
can you get by with life without a sympathetic nervous system
Not having a sympathetic nervous system would not kill you because the heart has pacemaker cells, will beat anyway. Quality of life and reaction and energy will be shit, though.
Not having a robust cardiovascular system would affect the mother’s ability to
carry the baby and deliver it
this is probably not a parasympathetic disorder because
This is a disorder for lacking sympathetic
What happens to your blood when you sit up and what is the normal response to this?
the blood will want to pool from your head, but we have a reflex in which baroreceptors will cause vasoconstriction and a huge sympathetic increase to counteract the BP dropped
If you take blood just after standing up, what do you expect?
Take blood just after this sit up and analyze it you would expect an increase in NA
If she had no change in NA, what does this mean?
She had no change in NA, so she is not making these transmitters.
How is NA made?
Dopamine is pumped into a vesicle and made into NA by dopamine beta-hydroxylase.
So what must she have a deficiency of?
So she must have a deficiency in that enzyme
How would you treat this?
Can give a substrate that bypasses the need for that enzyme, and so you can make noradrenaline and adrenaline. Just need to take this supplement
What would happen to the heart if someone with hypertension did not receive treatment?
Hypertrophy, enlargement of the heart, remodeling of the heart over time.
What are we worried about when someone has high hypertension?
There is pressure on the blood vessels in the heart/coronary circulation muscles, So we are super worried about a heart attack – there could be a burst or occlusion of a blood vessel in the heart.
How is this affected the valves of the heart as well?
Elevated blood pressure means the heart is pushing against the valves, and the blood in the aorta is at a higher pressure than normal, so it is hard to push the blood out of the heart and into the aorta making it extra work. So the valve is stuck in this higher pressure situation; eventually, you have to change/replace the valves.
What would happen in the brain
Stroke could be hemorrhagic or occlusive
What is a challenge in the kidney that people with diabetes and HT face?
you do not get the right perfusion of blood through the kidney
When BP is elevated, you start damaging blood vessels
And people with diabetes get thickening of the blood vessel or a changing of the morphology
What does this change in morphology/thickening lead to?
This leads to the kidney not getting properly perfused – this can cause wasting away of the kidney – kidney disease
What could happen to the vasculature/blood vessels in hypertension
Blood vessels are getting damaged because you are driving a high BP
Therefore you get peripheral vascular disease, the blood vessels are used up and are not getting repaired and more likely to get bleeding
What could happen to the eyes?
apillary disease, damage to the capillaries serving the retina
The retina is where all the photoreceptors convert the light into a chemical signal
Vision is a highly energy-dependent part of your body because there is so much transmitter release
Therefore need a very rich capillary supply there
It could lead to blindness if you have retinopathy
what do you immediately do?
Get him to come back a third time probably unless it was super elevated; then you would immediately take action
What would you prescribe if he comes back again and it’s the same thing?
but if this patient had kidney disease, would you give them a diuretic?
No, because you would be stressing an organ that is already compromised for someone because diuretics increase urine production to decrease blood volume.
What other alternative treatment could you do?
Also, maybe talk to them about exercise and diet – this rarely ever works
If the patient develops diabetes, would you stop the diuretic?
Stop the diuretic because it is reducing the perfusion through the kidney due to lower blood volume, and you want to promote better perfusion through the kidney to prevent kidney disease
What could we use instead if he develops diabetes?
ACE inhibitors because they have a renal protective value that is not understood