Air Requisite: Circulatory Disorders chapters 32, 33 & 38Anatomy and Physiology ReviewVascular system- Vast network of vessels- Delivers nutrients to tissues- Removes metabolic wastes- Blood flow is delivered proportionate to metabolic needsSystemic aorta, arteries, arterioles, capillaries, venules, veins, vena cava, rt atriumPulmonary circulation rt ventricle, pulmonary artery, arterioles, pulmonary capillaries, venules, pulmonary vein and lt atriumSystemic and Pulmonary CirculationPrimary Nursing DiagnosisALTERATION IN TISSUE PERFUSIONThink about some potential self care deficits?Arteries and VeinsArteriesDefining featuresThree layersIntima – single layer of endothelial cells and elastic membrane- smooth so cells flow wellMedia – near the vessel lumen receive O2 and nutrients by direct diffusion in small arteries; vasa vasorum in larger arteriesAdventia – connective tissue, nerve fibers & vasa vasorumThree typesLarge elasticMedium muscular (HTN)Small (within tissues and organs)ArteriolesPrinciple point of resistance to blood flowSharp decrease in pressure and velocity Changes from pulsatile to steady flowVeinsDefining featuresLarger diameters Larger luminaThinner less organized wallsHigh volume low pressureReverse flow is prevented by venous valves in the extremitiesWhat if the valves are damaged?Veins with poor support are predisposed to irregular dilation, or compression, and inflammatory processes damage them easily.2/3 of all systemic blood is in veinsVascular SystemArteries arterioles capillaries venules veins heart  arteriesWhen the heart contracts, it forces blood out of the heart along the vascular pathways. The energy generated is called the hydrostatic force.Blood flow and hydrostatic force decrease as it moves farther away from the heartThe volume of blood flowing from arteries to capillaries determines blood pressure blood pressure control systems1. Arterial baroreceptor and chemoreceptor system2. Regulation of body fluid volume3. Renin-angiotensin system4. Vascular auto regulationBaroreceptor chemoreceptor controlHormonal Response– Long term adaptive mechanisms– Renin-angiotension-aldosterone system activated by renal system– Bradykinins and histamine (inflammatory response) can cause vasodilation and increases in capillary wall permeability– Serotonin and prostaglandins can have vasoconstrictive or vasodilator effectsRegulation of body fluid volume– When sodium and water levels increase the total blood volume is increases– Diseases that change kidney function alter BPRenin-angiotensin systemDecreased blood flow to the kidneys causes renin to be released into the bloodstream. This leads to the production of -Angiotensin I in the liverAngiotensin I is converted to Angiotensin II in the lung by the ACE enzyme.Angiotensin II is a potent vasoconstrictor which helps raise B/P. Angiotensin II also stimulates the adrenal cortex to produce Angiotensin III which releases Aldosterone from the adrenals, which preserves sodium and water, further increasing B/P. AssessmentAccurate HistoryChief complaintHistory and physical assessmentPast medical historyCurrent meds, OTC’sPhysical examInspect- skin, hair, capillary refill, edema, ulcersPalpate- temperature Auscultate- bruits (turbulent blood flow), B/P both armsBlood Pressure– Reflects left ventricular function– Systolic reading represents force of ventricular contraction– Diastolic reading indicates vascular resistance (afterload)– Pulse pressure is difference between systolic and diastolic, normal 40 mmHgTaking an accurate blood pressure– Best indicator of arterial perfusion– Arm at heart level– Proper size of the cuff – Both arms; supine, sitting and standing 1st time – Document position– Repeat in arm with highest reading– Assess for anxiety– Timing (rest five minutes, between each measurement)– Can you take blood pressures in the leg or forearms?HYPERTENSIONHypertension50 million Americans have hypertensionPrevalenceOlder adults African-AmericansLess educated, lower socioeconomic groupsASHD, CVA, nephropathy, PVD, AAUntreated mortality50% Heart Disease33% CVA12% renal failureWhen is it “hypertension?”Normal: less than 120/80Pre-hypertension: 120-139/80-89No medicationsNeed lifestyle modificationsStage 1 hypertension: >140-159/90-99Thiazide-type diuretics Consider ACEI, ARB, BB, CCB130/80 for patients with DM or Chronic Kidney DiseaseStage 2 hypertension: 160/100Two drug combinationThiazide-type diuretics + ACEI? ARB? BB? CCB?The Seventh Report of the joint National Committee on Detection , Evaluation and Treatment for High Blood Pressure (JNC VII ); Healthy People 2010What is …………….PreloadVenous return that builds during diastole; ventricular stretch just before contraction How would preload change if someone is hypovolemia?AfterloadResistance that the heart must overcome to achieve ejection of bloodHow would the left side of the heart be affected by hypertension?Preload and AfterloadHypertensionCharacterized by type, cause and severity1. Primary (essential) hypertension2. Secondary hypertension3. Isolated systolic hypertension4. Resistant hypertension (malignant hypertension)1. Refractory- untreated or unresponsive to treatment2. Is an emergency condition is uncheckedPrimary (essential) HypertensionMultifactoral with no identifiable causePersistent, progressive , peripheral artery resistanceSeverity depends on # of risk factorsLength of time with hypertensionComorbid conditionsSecondary HypertensionThere is an identifiable causeChronic renal disease (renal artery stenosis)Adrenal tumors (pheochromocytoma)Increased aldosteroneAcute stressPituitary tumorsNon-modifiable Risk Factors for HTNGenetic factorsAge: women over 65, men over 55Gender: men, and post-menopausal womenEthnicity: Hispanic, African-AmericanFamily historyModifiable Risk Factors for HTNDiabetesStressObesityNutritionHigh Sodium diet (name 5 high sodium foods)Low calcium, K+, MagnesiumSubstance abuseCigarette smokingCocaineETOHCaffeine??SmokingSmoking affects blood vessels in two ways.What are they?Endothelial damage (CARBON AND TAR)Vasoconstriction (NICOTINE)Patient EducationWeight ReductionSodium restrictionFat ModificationExerciseAlcohol RestrictionCaffeine RestrictionRelaxationSmoking CessationPotassium SupplementationMedicationsALWAYS TRY LIFESTYLE MODIFICATIONS FIRSTGOAL = NORMALIZE B/P AND REDUCE RISK OF ORGAN DAMAGEPharmacotherapy: DiureticsThiazide