arterial and venous 2010

ARTERIAL AND VENOUS DISORDERS

MAIN POINTS

Raynaud’s diseaseBuerger’s diseaseAssessment of aortic aneurysmsHypertensionClient instructions related to arterial and

venous disorders

SITES FOR PALPATING PERIPHERAL PULSES

From Monahan, F. & Neighbors, M. (1998). Medical-surgical nursing: Foundations for clinical practice, ed 2, Philadelphia: W.B. Saunders

VEINS IN THE LEG

From Jarvis, C. (2000). Physical examination and health assessment, ed 3, Philadelphia: W.B. Saunders

VENOUS THROMBOSIS

DESCRIPTION Thrombus can be associated with an inflammatory

process When a thrombus develops, inflammation occurs that

thickens the vein wall leading to embolization

TYPES OF VENOUS THROMBOSISTHROMBOPHLEBITIS

A thrombus associated with inflammationPHLEBOTHROMBUS

A thrombus without inflammationPHLEBITIS

Vein inflammation associated with invasive procedures such as IVs

DEEP VEIN THROMBOPHLEBITIS (DVT) More serious than a superficial thrombophlebitis

because of the risk for pulmonary embolism

RISKS FACTORS FOR VENOUS THROMBOSIS

Venous stasis from varicose veins, heart failure, immobility

Hypercoagulability disordersInjury to the venous wall from IV injections,

fractures, traumaFollowing surgery, particularly hip surgery

and open prostate surgeryPregnancy Ulcerative colitisUse of oral contraceptives

PHLEBITISASSESSMENT

Red, warm area radiating up an extremity Pain and soreness Swelling

IMPLEMENTATION Apply warm, moist soaks as prescribed to dilate the

vein and promote circulation Assess temperature of soak prior to applying Assess for signs of complications such as tissue

necrosis, infection, or pulmonary embolus

DEEP VEIN THROMBOPHLEBITIS (DVT)

ASSESSMENT Calf or groin tenderness or pain with or without

swelling Positive Homans’ sign Warm skin that is tender to touch

IMPLEMENTATION Provide bed rest Elevate the affected extremity above the level of the

heart as prescribed Avoid using the knee gatch or a pillow under the

knees Do not massage the extremity Provide thigh-high compression or antiembolism

stockings as prescribed to reduce venous stasis and to assist in the venous return of blood to the heart

IMPLEMENTATION Administer intermittent or continuous warm, moist

compresses as prescribed Palpate the site gently, monitoring for warmth and

edema Measure and record the circumference of the thighs

and calves Monitor for shortness of breath and chest pain, which

can indicate pulmonary emboli

IMPLEMENTATION Administer thrombolytic therapy (t-PA, tissue

plasminogen activator) if prescribed, which must be initiated within 5 days after the onset of symptoms

Administer heparin therapy as prescribed to prevent enlargement of the existing clot and prevent the formation of new clots

Monitor APTT during heparin therapy Administer warfarin (Coumadin) therapy as

prescribed when the symptoms of DVT have resolved

IMPLEMENTATION Monitor PT and INR during warfarin (Coumadin)

therapy Monitor for the hazards and side effects associated

with anticoagulant therapy Administer analgesics as prescribed to reduce pain Administer diuretics as prescribed to reduce lower

extremity edema Provide client teaching

ASSESSING FOR PERIPHERAL EDEMA

From Black, J., Hawks, J, and Keene, A. (2001). Medical-surgical nursing, ed 6, Philadelphia: W.B. Saunders

CLIENT EDUCATION Hazards of anticoagulation therapy Signs and symptoms of bleeding Avoid prolonged sitting or standing, constrictive

clothing, or crossing legs when seated Elevate the legs for 10 to 20 minutes every few hours

each day Plan a progressive walking program

CLIENT EDUCATION Inspect the legs for edema and how to measure the

circumference of the legs Antiembolism stockings (hose) as prescribed Avoid smoking Avoid any medications unless prescribed by the

physician Importance of follow-up physician visits and

laboratory studies Obtain and wear a Medic Alert bracelet

ANTIEMBOLISM HOSE

From Elkin MF, Perry AG, Potter PA: Nursing interventions and clinical skills, ed. 2, St. Louis, 2000, Mosby.

VENOUS INSUFFICIENCY

DESCRIPTION Results from prolonged venous hypertension that

stretches the veins and damages the valves The resultant edema and venous stasis causes venous

stasis ulcers, swelling, and cellulitis Treatment focuses on decreasing edema and

promoting venous return from the affected extremity Treatment for venous stasis ulcers focuses on healing

the ulcer and preventing stasis and ulcer recurrence

VENOUS INSUFFICIENCYASSESSMENT

Stasis dermatitis or discoloration along the ankles extending up to the calf

Edema The presence of ulcer formation

PERIPHERAL VASCULAR DISEASE

From Bryant RA (1992): Acute and chronic wounds: nursing management, St. Louis: Mosby. Courtesy of Abbott Northwestern Hospital, Minneapolis, MN.

VENOUS INSUFFICIENCYWOUND CARE

Provide care to the wound as prescribed by the physician

Assess the client’s ability to care for the wound, and initiate home care resources as necessary

If an Unna boot (a dressing constructed of gauze moistened with zinc oxide) is prescribed, it will be changed by the physician weekly

VENOUS INSUFFICIENCYWOUND CARE

The wound is cleansed with normal saline prior to application of the Unna boot; providone-iodine (Betadine) or hydrogen peroxide is not used because they destroy granulation tissue

The Unna boot is covered with an elastic wrap that hardens, to promote venous return and prevent stasis

Monitor for signs of arterial occlusion from an Unna boot that may be too tight

Keep tape off of the client’s skin

VENOUS INSUFFICIENCYMEDICATIONS

Apply topical agents to wound as prescribed to debride the ulcer, eliminate necrotic tissue, and promote healing

When applying topical agents, apply an oil-based agent as petroleum jelly (Vaseline) on surrounding skin, because debriding agents can injure healthy tissue

Administer antibiotics as prescribed if infection or cellulitis occur

VENOUS INSUFFICIENCYCLIENT EDUCATION

Wear elastic or compression stockings during the day and evening as prescribed

Put on elastic stockings upon awakening before getting out of bed

Put a clean pair of elastic stockings on each day and that it will probably be necessary to wear the stockings for the remainder of life

CLIENT EDUCATION Avoid prolonged sitting or standing, constrictive

clothing, or crossing legs when seated Elevate the legs for 10 to 20 minutes every few hours

each day Elevate legs above the level of the heart when in bed

CLIENT EDUCATION The use of an intermittent sequential pneumatic

compression system, if prescribed; instruct the client to apply the compression system twice daily for 1 hour in the morning and evening

Advise the client with an open ulcer that the compression system is applied over a dressing

VARICOSE VEINSDESCRIPTION

Distended protruding veins that appear darkened and tortuous

Vein walls weaken and dilate, and valves become incompetent

ASSESSMENT Pain in the legs with dull aching after standing A feeling of fullness in the legs Ankle edema

NORMAL VEINS AND VARICOSITIES

VARICOSE VEINS

From Mosby’s Medical, Nursing, and Allied Health Dictionary, ed 6, (2002). St. Louis: Mosby

VARICOSE VEINSTRENDELENBURG TEST

Place the client in a supine position with the legs elevated

When the client sits up, if varicosities are present, veins fill from the proximal end; veins normally fill from the distal end

TRENDELENBURG TEST

VARICOSE VEINSIMPLEMENTATION

Assist with the Trendelenburg test Emphasize the importance of antiembolism stockings

as prescribed Instruct the client to elevate the legs as much as

possible Instruct the client to avoid constrictive clothing and

pressure on the legs Prepare the client for sclerotherapy or vein stripping,

as prescribed

SCLEROTHERAPYDESCRIPTION

A solution is injected into the vein followed by the application of a pressure dressing

An incision and drainage of the trapped blood in the sclerosed vein is performed 14 to 21 days after the injection, followed by the application of a pressure dressing for 12 to 18 hours

VEIN STRIPPING

DESCRIPTION Varicose veins are removed if they are larger than 4

mm in diameter or if they are in clusters

PREOPERATIVE Assist the physician with vein marking Evaluate pulses as a baseline for comparison

postoperatively

VEIN STRIPPING

POSTOPERATIVE Maintain elastic (Ace) bandages on the client’s legs Monitor the groin and leg for bleeding through the

elastic bandages Monitor the extremity for edema, warmth, color,

and pulses Elevate the legs above the level of the heart

VEIN STRIPPINGPOSTOPERATIVE

Encourage range-of-motion exercises of the legs Instruct the client to avoid leg dangling or chair

sitting Instruct the client to elevate the legs when sitting Emphasize the importance of wearing elastic

stockings after bandage removal

PERIPHERAL ARTERIAL DISEASE (PAD)

DESCRIPTION A chronic disorder in which partial or total arterial

occlusion deprives the lower extremities of oxygen and nutrients

Tissue damage occurs below the level of the arterial occlusion

Atherosclerosis is the most common cause of PAD

ARTERIES IN THE LEG

ASSESSMENT Intermittent claudication (pain in the muscles

resulting from an inadequate blood supply) Rest pain, characterized by numbness, burning or

aching in the distal portion of the lower extremities, that awakens the client at night and is relieved by placing the extremity in a dependent position

Lower back or buttock discomfort

ASSESSMENT Loss of hair and dry scaly skin on the lower

extremities Thickened toenails Cold and gray-blue color of skin in the lower

extremities Elevational pallor and dependent rubor in the

lower extremities Decreased or absent peripheral pulses

ASSESSMENT Signs of arterial ulcer formation occurring on or

between the toes, or on the upper aspect of the foot, that are characterized as painful

Blood pressure measurements at the thigh, calf, and ankle are lower than the brachial pressure (normally BP readings in the thigh and calf are higher than those in the upper extremities)

ARTERIAL OBSTRUCTIONS AND CORRESPONDING AREAS OF

CLAUDICATION

ARTERIAL INSUFFICIENCY

From Lemmi FO, Lemmi CAE: Physical assessment findings CD-ROM, Philadelphia, 2000, W.B. Saunders.

GANGRENE

From Auerbach PS: Wilderness Medicine: Management of wilderness and environmental emergencies, ed. 3, St. Louis, 1995, Mosby.

IMPLEMENTATION Assess pain Monitor the extremities for color, motion and

sensation, and pulses Obtain BP measurements Assess for signs of ulcer formation or signs of

gangrene Assist in developing an individualized exercise

program that is initiated gradually and slowly increased

IMPLEMENTATION Encourage prescribed exercise, which will improve

arterial flow through the development of collateral circulation

Instruct the client to walk to the point of claudication, stop and rest, then walk a little further

IMPLEMENTATION As swelling in the extremities prevents arterial blood

flow, instruct the client to elevate his or her feet at rest, but to refrain from elevating them above the level of the heart, because extreme elevation slows arterial blood flow to the feet

In severe cases of PAD, clients with edema may sleep with the affected limb hanging from the bed or they may sit upright in a chair for comfort

CLIENT EDUCATION Avoid crossing the legs, which interferes with blood

flow Avoid exposure to cold (causes vasoconstriction) to

the extremities and to wear socks or insulated shoes for warmth at all times

Never to apply direct heat to the limb such as with a heating pad or hot water, because the decreased sensitivity in the limb may result in burning

CLIENT EDUCATION Inspect the skin on the extremities daily and to report

any signs of skin breakdown Avoid tobacco and caffeine because of their

vasoconstrictive effects Use of hemorrheologic and antiplatelet medications as

prescribed Importance of taking all medications prescribed by

the physician

PROCEDURES TO IMPROVE ARTERIAL BLOOD FLOW Percutaneous transluminal angioplasty Laser-assisted angioplasty Atherectomy Bypass surgery (aortofemoral or femoral-popliteal)

RAYNAUD’S DISEASEDESCRIPTION

Vasospasms of the arterioles and arteries of the upper and lower extremities

Vasospasm causes constriction of the cutaneous vessels

Attacks are intermittent and occur with exposure to cold or stress

Affects primarily fingers, toes, ears, and cheeks

RAYNAUD’S DISEASE

ASSESSMENT Blanching of the extremity, followed by cyanosis

during vasoconstriction Reddened tissue when the vasospasm is relieved Numbness, tingling, swelling, and a cold temperature

at the affected body part

RAYNAUD’S PHENOMENON

From Barkauskas VH et al (1998) Health and physical assessment (2nd ed.). St. Louis: Mosby.

RAYNAUD’S DISEASE

IMPLEMENTATION Monitor pulses Administer vasodilators as prescribed Assist the client to identify and avoid precipitating

factors such as cold and stressCLIENT EDUCATION

Medication therapy Avoid smoking Wear warm clothing, socks, and gloves in cold

weather Avoid injuries to fingers and hands

BUERGER'S DISEASE

DESCRIPTION An occlusive disease of the median and small arteries

and veins The distal upper and lower limbs are most commonly

affected Also known as thromboangiitis obliterans

BUERGER'S DISEASE

ASSESSMENT Intermittent claudication Ischemic pain occurring in the digits while at rest Aching pain that is more severe at night Cool, numb, or tingling sensation Diminished pulses in the distal extremities Extremities are cool and red in the dependent position Development of ulcerations in the extremities

BUERGER'S DISEASE

IMPLEMENTATION Instruct the client to stop smoking Monitor pulses Instruct the client to avoid injury to the upper and

lower extremities Administer vasodilators as prescribed Instruct the client regarding medication therapy

AORTIC ANEURYSMS

DESCRIPTION Abnormal dilation of the arterial wall, caused by

localized weakness and stretching in the medial layer or wall of an artery

The aneurysm can be located anywhere along the abdominal aorta

The goal of treatment is to limit the progression of the disease by modifying risk factors, controlling the BP to prevent strain on the aneurysm, recognizing symptoms early, and preventing rupture

ARTERIAL OCCLUSION AND ANEURYSMS

TYPES OF ANEURYSMS

FUSIFORM Diffuse dilation that involves the entire circumference

of the arterial segment

SACCULAR Distinct localized outpouching of the artery wall

TYPES OF ANEURYSMS

DISSECTING Created when blood separates the layers of the artery

wall forming a cavity between them

FALSE (PSEUDOANEURYSM) Occurs when the clot and connective tissue are

outside the arterial wall Formed after complete rupture and subsequent

formation of a scar sac

TYPES OF ANEURYSMS

THORACIC AORTIC ANEURYSM

ASSESSMENT Pain extending to neck, shoulders, lower back, or

abdomen Syncope Dyspnea Increased pulse Cyanosis Weakness

ABDOMINAL AORTIC ANEURYSM

ASSESSMENT Prominent, pulsating mass in abdomen, at or above

the umbilicus Systolic bruit over the aorta Tenderness on deep palpation Abdominal or lower back pain

RUPTURING ANEURYSMASSESSMENT

Severe abdominal or back pain Lumbar pain radiating to the flank and groin Hypotension Increased pulse rate Signs of shock

RUPTURED ABDOMINAL AORTIC ANEURYSM

From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

AORTIC ANEURYSMS

DIAGNOSTIC TESTS Done to confirm the presence, size, and location of the

aneurysm Includes abdominal ultrasound, CT scan, and

arteriography

AORTIC ANEURYSMS

IMPLEMENTATION Monitor vital signs Obtain information regarding back or abdominal pain Question the client regarding the sensation of

palpation in the abdomen Inspect the skin for the presence of vascular disease

or breakdown

AORTIC ANEURYSMS

IMPLEMENTATION Check peripheral circulation including pulses,

temperature, and color Observe for signs of rupture Note any tenderness over the abdomen Monitor for abdominal distention

AORTIC ANEURYSMS

NONSURGICAL IMPLEMENTATION Modify risk factors Instruct the client regarding the procedure for

monitoring BP Instruct the client on the importance of regular

physician visits to follow the size of the aneurysm

AORTIC ANEURYSMS

NONSURGICAL IMPLEMENTATION Instruct the client that if severe back or abdominal

pain or fullness, soreness over the umbilicus, sudden development of discoloration in the extremities, or a persistent elevation of BP occurs, to notify the physician immediately

Instruct the client with a thoracic aneurysm to immediately report the occurrence of chest or back pain, shortness of breath, difficulty swallowing, or hoarseness

AORTIC ANEURYSMS

PHARMACOLOGICAL IMPLEMENTATION Administer antihypertensives to maintain the BP

within normal limits and to prevent strain on the aneurysm

Instruct the client in the purpose of the medications Instruct the client about the side effects and schedule

of the medication

ABDOMINAL AORTIC ANEURYSM RESECTION

DESCRIPTION Surgical resection or excision of the aneurysm The excised section is replaced with a graft that is

sewn end-to-end

ANEURYSM RESECTION WITH GRAFT

PREOPERATIVE Assess all peripheral pulses as a baseline for

postoperative comparison Instruct the client on coughing and deep-breathing

exercises Administer bowel preparation as prescribed

POSTOPERATIVE Monitor vital signs Monitor peripheral pulses distal to the graft site Monitor for signs of graft occlusion, including changes

in pulses, cool to cold extremities below the graft, white or blue extremities or flanks, severe pain, or abdominal distention

Limit elevation of the head of the bed to 45 degrees to prevent flexion of the graft

POSTOPERATIVE Monitor for hypovolemia and renal failure due to

significant blood loss during surgery Monitor urine output hourly, and notify the physician

if it is less than 50 ml per hour Monitor serum creatinine and BUN daily Monitor respiratory status and auscultate breath

sounds to identify respiratory complications

POSTOPERATIVE Encourage turning, coughing and deep breathing, and

splinting the incision; ambulate as prescribed Maintain nasogastric tube to low suction until bowel

sounds return Assess for bowel sounds and report their return to the

physician Monitor for pain and administer medication as

prescribed Assess incision site for bleeding or signs of infection

POSTOPERATIVE Prepare the client for discharge by providing

instructions regarding pain management, wound care, and activity restrictions

Instruct the client not to lift objects greater than 15 to 20 pounds for 6 to 12 weeks

Advise the client to avoid activities requiring pushing, pulling, or straining

Instruct the client not to drive a vehicle until approved by the physician

THORACIC AORTIC ANEURYSM REPAIR

DESCRIPTION A thoracotomy or median sternotomy approach is

used to enter the thoracic cavity The aneurysm is exposed, excised, and a graft or

prosthesis is sewn onto the aorta Total cardiopulmonary bypass is necessary for

excision of aneurysms in the ascending aorta Partial cardiopulmonary bypass is used for clients

with an aneurysm in the descending aorta

POSTOPERATIVE Monitor vital signs Monitor for signs of hemorrhage such as a drop in BP,

increased pulse rate and respirations, and report to the physician immediately

Monitor chest tubes for an increase in chest drainage, which may indicate bleeding or separation at the graft site

POSTOPERATIVE Assess sensation and motion of all extremities and

notify the physician if deficits occur, which can be due to a lack of blood supply during surgery

Monitor respiratory status and auscultate breath sounds to identify respiratory complications

Encourage turning, coughing, and deep breathing, splinting the incision

Monitor cardiac status for dysrhythmias

POSTOPERATIVE Monitor for pain and administer medication as

prescribed Assess the incision site for bleeding or signs of

infection Prepare the client for discharge by providing

instructions regarding pain management, wound care, and activity restrictions

POSTOPERATIVE Instruct the client not to lift objects greater than 15 to

20 pounds for 6 to 12 weeks Advise the client to avoid activities requiring pushing,

pulling, or straining Instruct the client not to drive a vehicle until

approved by the physician

EMBOLECTOMY

DESCRIPTION Removal of an embolus from an artery using a

catheter A patch graft may be required to close the artery

EMBOLECTOMY

PREOPERATIVE Obtain a baseline vascular assessment Administer anticoagulants as prescribed Administer thrombolytics as prescribed Place a bed cradle on the bed Avoid bumping or jarring the bed Maintain the extremity in slightly dependent position

EMBOLECTOMY

POSTOPERATIVE Assess cardiac, respiratory, and neurological status Monitor affected extremity for color, temperature, and

pulse Assess sensory and motor function of the affected

extremity Monitor for signs and symptoms of new thrombi or

emboli Administer oxygen as prescribed Monitor pulse oximetry

EMBOLECTOMY

POSTOPERATIVE Monitor for complications caused by reperfusion of

the artery, such as spasms and swelling of the skeletal muscles

Monitor for signs of swollen skeletal muscles, such as edema, pain on passive movement, poor capillary refill, numbness, and muscle tenseness

Maintain bed rest initially, with the client in semi-Fowler’s position

Place a bed cradle on the bed

EMBOLECTOMY

POSTOPERATIVE Check the incision site for bleeding or hematoma Administer anticoagulants as prescribed Monitor laboratory values related to anticoagulant

therapy Instruct the client to recognize the signs and

symptoms of infection and edema Instruct the client to avoid prolonged sitting or

crossing the legs when sitting

VENA CAVAL FILTER AND LIGATION OF INFERIOR VENA CAVA

VENA CAVAL FILTER Insertion of an intracaval filter (umbrella) that

partially occludes the inferior vena cava and traps emboli to prevent pulmonary emboli

LIGATION Suturing or placing clips on the inferior vena cava to

prevent pulmonary emboli

VENA CAVAL FILTERS

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders

PREOPERATIVE If the client has been taking an anticoagulant, consult

with the physician regarding discontinuation of the medication to prevent hemorrhage

POSTOPERATIVE Monitor vital signs Assess cardiac and respiratory status Administer oxygen as prescribed Monitor pulse oximetry Maintain semi-Fowler’s position Avoid hip flexion Maintain antiembolism stockings as prescribed

POSTOPERATIVE Provide activity as prescribed Check the insertion site for bleeding and hematoma Assess for peripheral edema Monitor laboratory values related to anticoagulant

therapy

CLIENT EDUCATION Signs and symptoms of infection and edema Avoid prolonged sitting or crossing legs when sitting Elevate the legs when sitting Wear antiembolism stockings as prescribed and how

to remove and reapply the stockings Ambulate daily About anticoagulant therapy and the hazards

associated with anticoagulants

HYPERTENSION

DESCRIPTION Persistent elevation of the systolic blood pressure

above 140 mmHg and the diastolic blood pressure above 90 mmHg

Most significant predictor of developing coronary artery disease and a major risk factor for coronary, cerebral, renal, and peripheral vascular disease

The disease is initially asymptomatic

HYPERTENSION

DESCRIPTION The goals of treatment include to reduce the blood

pressure and to prevent or lessen the extent of organ damage

Nonpharmacological approaches, such as lifestyle changes, may be initially prescribed and if the BP cannot be decreased after a reasonable time period (1 to 3 months), then the client may require pharmacological treatment

HYPERTENSION ORGAN INVOLVEMENT

EYES Visual changes

BRAIN Cerebrovascular accident (CVA)

CARDIOVASCULAR SYSTEM Congestive heart failure (CHF), hypertensive crisis

KIDNEYS Renal failure

HYPERTENSIVE RETINOPATHY

From Michelson JB, Friedlaender MH (1996) The eye in clinical medicine. London: Times Mirror International Publishers.

HYPERTROPHY OF THE LEFT VENTRICLE IN HYPERTENSION

From Cotran RS, Kumar V, Collins T: Robbins’ pathologic basis of disease, ed. 6, Philadelphia, 1999, W.B. Saunders.

HYPERTENSION

TYPES Primary or essential Secondary

PRIMARY OR ESSENTIAL HYPERTENSION

DESCRIPTION No known etiology

RISK FACTORS Aging Family history Black race with higher prevalence in males Obesity Smoking Stress

SECONDARY HYPERTENSION DESCRIPTION

Occurs as a result of other disorders or conditions Treatment depends on the cause and the organs

involvedPRECIPITATING CONDITIONS

Cardiovascular disorders Renal disorders Endocrine system disorders Pregnancy Medications

HYPERTENSION

ASSESSMENT May be asymptomatic Headache Visual disturbances Dizziness Chest pain Tinnitus Flushed face Epistaxis

HYPERTENSION

IMPLEMENTATION: GOALS To reduce the blood pressure To prevent or lessen the extent of organ damage

HYPERTENSION

IMPLEMENTATION Question the client regarding the signs and

symptoms indicative of hypertension Obtain the blood pressure (BP) two or more

times on both arms with the client supine and standing; compare the BP with prior documentation

Determine family history of hypertension Identify current medication therapy Obtain weight Evaluate dietary patterns and sodium intake

HYPERTENSION

IMPLEMENTATION Assess for visual changes or retinal damage Assess for cardiovascular changes, such as distended

neck veins, increased heart rate, dysrhythmias Evaluate chest x-ray for heart enlargement Assess neurological system Evaluate renal function Evaluate results of diagnostic and laboratory studies

HYPERTENSION

NONPHARMACOLOGICAL Weight reduction, if necessary, or maintenance of

ideal weight Dietary sodium restriction to 2 g daily as prescribed Moderate intake of alcohol and caffeine-containing

products Initiation of a regular exercise program

HYPERTENSION

NONPHARMACOLOGICAL Avoidance of smoking Relaxation techniques and biofeedback therapy Elimination of unnecessary medications that may

contribute to the hypertension

HYPERTENSION: STEPPED CARE APPROACH

DESCRIPTION If a pharmacological approach to treating

hypertension is required, a single medication is prescribed and monitored for its effectiveness

Medications are added to the treatment regimen until the BP is controlled

Refer to the module entitled Cardiovascular Medications, for information regarding medications to treat hypertension

STEP 1 A single medication is prescribed, which may be

a diuretic, beta blocker, calcium channel blocker, or angiotensin-converting enzyme (ACE) inhibitor

STEP 2 Step 1 therapy is evaluated after 1 to 3 months If the response is not adequate, compliance is

evaluated The medication may be increased or a new

medication is prescribed, or a second medication is added to the treatment plan

STEP 3 Compliance is evaluated Further evaluation of Step 2 If a therapeutic response is not adequate, a second

medication is substituted or a third medication is added to the treatment plan

STEP 4 Compliance is evaluated Careful assessment of factors limiting the

antihypertensive response is done A third or fourth medication may be added to the

treatment plan

HYPERTENSION: CLIENT EDUCATION

Importance of compliance with the treatment plan

The disease process, explaining that symptoms usually do not develop until organs have suffered damage

Planning a regular exercise program, avoiding heavy weight lifting and isometric exercises

Importance of beginning the exercise program gradually

Express feelings about daily stressIdentify ways to reduce stress

Relaxation techniquesIncorporate relaxation techniques into the

daily living patternTechnique for monitoring blood pressureMaintain a diary of blood pressure readings Importance of lifelong medication and the

need for follow-up treatmentDietary restriction, which may include

sodium, fat, calories, and cholesterol

How to shop and prepare low-sodium mealsList of products that contain sodiumRead labels of products to determine sodium

content focusing on substance listed as sodium, NaCl, and MSG

Bake, roast, or boil foods, avoid salt in preparation of foods, and avoid using salt at the table

Fresh foods are best to consume and to avoid canned foods

The action, side effects, and scheduling of medications

If uncomfortable side effects occur, to contact the physician and not to stop the medication

Avoid over-the-counter medicationImportance of follow-up care

HYPERTENSIVE CRISIS

DESCRIPTION Any clinical condition requiring immediate reduction

in blood pressure An acute and life-threatening condition The accelerated hypertension requires emergency

treatment, since target organ damage (brain, heart, kidneys, retina of the eye) can occur quickly

Death can be caused by stroke, renal failure, or cardiac disease

HYPERTENSIVE CRISIS

ASSESSMENT A diastolic pressure above 120 mmHg Headache Drowsiness Confusion Changes in neurological status Tachycardia and tachypnea Dyspnea Cyanosis Seizures

HYPERTENSIVE CRISIS

IMPLEMENTATION Maintain a patent airway Administer IV antihypertensive medications as

prescribed Monitor vital signs assessing BP every 5 minutes Assess for hypotension during the administration of

antihypertensives Place the client in a supine position if hypotension

occurs

HYPERTENSIVE CRISIS

IMPLEMENTATION Have emergency medications and resuscitation

equipment readily available Maintain bed rest, with the head of the bed elevated

at 45 degrees Monitor IV therapy assessing for fluid overload Monitor I&O Insert Foley catheter as prescribed Monitor urinary output, and if oliguria or anuria

occurs, notify the physician

arterial and venous 2010

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