Nursing Case Study Hypertension

Nursing Case Study Hypertension

Introduction

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?

hypertension

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.

160,100

antihypertensive drugs

1, Diuretics. 2, Adrenergic inhibitors. 3, Vasodilators. 4, ACE inhibitors. 5, Calcium antagonist. ACE, Angiotensin-converting enzyme.

impotence

This is a common side effect of many antihypertensive medications, including atenolol (Tenormin), which is a beta-blocker

cough

An irritating … -This is a common side effect of ACE inhibitors.

Aortic aneurysm

a weakness in the wall of the aorta that makes it susceptible to rupture.

Procardia

calcium blocker (trade name Procardia)

calcium

Grapefruit decreases the effectiveness of nifedipine (Procardia), a …. channel blocker.

Rebound

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.

 

Define Hypertension.

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.

obesity

high cholesterol

DM

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

beta-blockers

ace inhibitors

calcium channel blockers

diuretics

what drugs impact gingival overgrowth

calcium channel blockers

 

What drugs impact lichenoid reactions?

thiazides

methyldopa

propanolol

ace inhibitors

furosemide

spironolactone

labetalol

what drugs affect scalded mouth syndrome

ace inhibitors

 

what gender more affected

men

 

30.6%

 

what age most affected

65+

 

70.3%

 

what race/ethnicity most affected

non-Hispanic blacks

 

42%

 

Who’s more affected? US-born or non-US born

us born–30.8%

 

who is more affected <65: with private insurance; with public insurance, with no insurance

public insurance–32.1%

 

t/f: diabetics have a higher hypertension prevalence

true 57.3%

 

t/f: those who are NOT obese have higher hypertension prevalence

false

 

obese: 39.3%

 

how many Americans affected

50 million

 

normotensive factor

at age 55, there is a 90% lifetime risk of developing hypertension

 

What population is most affected?

non-Hispanic blacks

 

higher income indicates what

less prevalence for hypertension

 

<100 or 100-199 thousand income: 32.6%

 

higher education indicates what

less prevalence for hypertension

 

lower education–37.3%

 

who is more affected disabled or not disabled

disabled–39.3%

 

normal BP SBP range and DBP range

<120 and <80

 

pre-hypertension SBP and DBP range

120-139

or

80-89

 

stage 1 hypertension SBP and DBP range

140-159

or

90-99

 

stage 2 hypertension SBP and DBP range

>=160

or

>=100

 

prehypertension people

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

atherosclerosis–plaque build-up

arteriosclerosis–thicken/harden arterial walls

heart–myocardial infarction leading to cardiac failure

all forms of stroke

diabetes

peripheral artery disease

chronic kidney disease

cardiovascular disease

 

conditions that are risk factors for hypertension

prehypertension

diabetes

 

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

yes

 

does tobacco contribute to the development of hypertension

yes

 

t/f: we are increased in risk for developing hypertension as we age

true

 

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.

minimized

 

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

false

 

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

30-60 minutes

 

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

true

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.

Preeclampsia

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?

Retinopathy

 

Retinopathy

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?

a diuretic

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

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