Hypertension • What is Blood Pressure? • Diagnosis o Two or more elevated blood pressure readings, supine and sitting on at least two separate occasions. o Systolic and/or Diastolic is elevated. • Clinical Manifestations o Mostly asymptomatic (Therefore known as the “silent killer”) o Can have headache (especially early morning headache) o Blurred vision o Spontaneous nosebleed • Pathophysiology o Hyperactivity of the Sympathetic Nervous System  Baroreceptors in the aortic arch and carotid sinus signal the SNS via the CV control center in the medulla • Æ ↑ HR, CO, and vasoconstriction  Brain alerts the adrenal glands • Adrenals secrete catecholamines – epinephrine and norepinephrine • Neurotransmitters bind to alpha 1 receptors in blood vessels which causes constriction and beta 1 receptors in heart which causes increased HR. Net result is HTN o Hyperactivity of the Renin -Angiotension - Aldosterone System  Decreased BP cause kidneys to secrete Renin  Renin forms Angiotension I  Angiotension I converts to Angiotension II  Angiotension II signals Adrenals to secrete aldosterone which cause Na+ and H20 retention  Net result is HTN o Endothelial dysfunction  Inner layer of blood vessels (endothelium) is damaged preventing the vessel from dilating  Net result is HTN • Hypertension o Primary o Secondary • Who is at Risk? o Non Modifiable Risk Factors  Age – 60 years or greater  Male  African American  Postmenopausal  Hx DM, Hyperlipidemia  Positive family Hx o Modifiable Risk Factors  Obesity  Smoking  Sedentary lifestyle  Excessive sodium and alcohol intake Chronic Stress  Atherosclerosis • Nursing Diagnosis o Knowledge Deficit o Noncompliance with therapeutic regime o Others? • Risk Reduction o Obesity Æ Weight loss o Smoking Æ Smoking cessation o Sedentary lifestyle Æ Increase Activity o Excessive sodium and alcohol intake Æ 2 – 4 Gm day / I serving day o Chronic Stress Æ Stress management • Cigarette Smoking o Causes direct vasoconstriction of blood vessels and significantly increases the blood pressure, thereby counteracting the benefit of antihypertensive therapy. o Smoking Cessation  “Research shows that nurses are very effective at helping people stop smoking. • Medications o Diuretics o ACE Inhibitors o Angiotension II Receptor Blockers o Calcium Channel Blockers o Adrenergic Blockers: Alpha Adrenergic Blockers o Adrenergic Blockers: Beta Adrenergic Blockers o Centrally Acting Adrenergics • Medications o Diuretics and Beta blockers commonly prescribed for uncomplicated Stage I and II HTN o Other categories commonly prescribed if first line drugs are ineffective or contraindicated. o Often two or more medications are needed. Hyperlipidemia • Increased lipids in the blood. • The combination of Diabetes Mellitus, Hypertension, and Hyperlipidemia is called Metabolic Syndrome. • Cholesterol o Total Cholesterol o LDL Cholesterol o HDL Cholesterol • Heart Attack Risk - LDL • Heart Attack Risk - HDLo HDL – the higher the better!! o The higher the HDL is the lower your risk of heart disease is!! o An HDL below below 40 is a definite risk factor for heart attack • The ratio of total cholesterol to HDL cholesterol should be 3 to 1 or better. • Heart Attack Risk - HDL o Total of 195 – you need an HDL of 65 to have a 3 to 1 ratio. o Total of 150 – an HDL of 50 is fine. • Cholesterol Quiz o Total 251 o HDL 91 o LDL 159 o No risk factors • Cholesterol Quiz o Total 300 o HDL 60 o LDL 230 o Diabetic, Obese, HTN 168/90 o Age 55 • What can you do? o To learn how you can raise your HDL and lower you Total Cholesterol visit www.BoeingWellness.com o Click on Diseases and Conditions tab o Look for “High Cholesterol” under Diseases and Conditions A – Z. • Cholesterol Reducing Medications o HMG CoA reductase inhibitors  “Statins” – Inhibits enzyme necessary in cholesterol synthesis o Bile Acid Sequestrants  Bind cholesterol in GI tract o Nicotinic Acid  Decreases hepatic lipoprotein synthesis o Fibric Acids  Inhibits peripheral lipolysis Chronic Arterial Occlusive Disease • Commonly called Peripheral Vascular Disease (PVD) o Progressive narrowing, degeneration and obstruction from arteriosclerosis and atherosclerosis o Plaque lesions commonly at the point of bifurcation o Vessel is 70% occluded before sx o Clinical Manifestations  Intermittent claudication – classic symptom  Gravity improves perfusion  Rest ischemia - (severe disease)  Ischemic or arterial ulcers • Pale, round, painful • May be crusty• Necrotic tissue may be present • Hair loss • Thick, brittle, slow growing nails • Impaired motor function  Skin shiny and taunt, dry and scaly  Skin cooler than normal  Paleness when elevated above heart level for 5 minutes  Reactive hyperemia (rubor)when lowered o Diagnosis  History and physical exam  Ankle-brachial index • Measures the difference in blood pressure and blood flow in upper and lower extremities – an objective measure of stenosis. o Treatment  Lifestyle modifications  Pharmocologic therapy • Goal is to improve blood flow and prevent thrombus formation • Vasodilators (not very effective) • Blood viscosity reducing agents o Trental o Also increases erythrocyte flexibility • Antiplatelet agents o ASA o Persantine o Ticlid  Inhibits formation of arterial thrombi Acute Arterial Occlusive Disease • Can occur in health or diseased artery • Typically occurs suddenly without warning • Embolus dislodges and travels • Blood supply distal to obstruction is abruptly interrupted. • Symptoms depend on location and size of obstruction and patency of surrounding vessels. • Clinical Manifestations o Six “P”s of neurovascular assessment  Pain  Pallor  Pulselessness  Paresthesia  Paralysis  Poikilothermia • Diagnosis o History and physical assessment o Ankle-brachial index o Doppler ultrasonograophy o Magnetic Resonance Imaging (MRI) o Angiography • Medicationso Goal is to dissolve the clot and prevent further clot formation  Thrombolytic • Urokinase  Anticoagulant therapy (short term) • Heparin • Coumadin (long term) Deep Vein