NURS 660 Final Exam Study Guide
Hypertension
● Risk of CVD, stroke, CAD, PVD, HF
○ Primary prevention: reduce risk of first event
○ Secondary prevention: reduce risk of recurrent events
● Risk for renal Disease
○ Renal Failure and Glomerulosclerosis
● Guidelines
○ Normal: less than 120/80 mm Hg
○ Elevated: Systolic between 120-129 or diastolic less than 80
○ Stage 1: Systolic between 130-139 or diastolic between 80-89
■ Prescribe medication if patient has hx of CV events such as stroke or heart
attack or is at high risk of heart of stroke based on age, hx of DM, CKD, or
rx for atherosclerosis
■ Lifestyle changes for 6 months before adding medication
○ Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
○ Hypertensive Crisis: Systolic over 180 and/or diastolic over 120
■ Prompt change in medication if no other issues occurring
■ Immediate hospitalization if there are signs of organ damage (chest pain,
change in mental status)
○ May require 2 medications to control BP
○ Socioeconomic stress/psychosocial stress are rx factors for high BP
● Risk Factors
○ Family history, age, ethnicity (AA, hispanics), lifestyle (weight, diet, alcohol,
tobacco)
● Evaluation
○ White coat hypertension: high BP in office but normal outside
■ Confirm with ambulatory BP monitor
○ Masked Hypertension: normal BP in office but elevated outside
■ Confirm with ambulatory BP or home BP readings greater than 135/85
■ Confirm if patients have evidence of target organ damage
● Substances causing elevated BP
○ Caffeine, alcohol, Antidepressants (tricyclic), antipsychotics, decongestants
(pseudoephedrine), oral contraceptives, NSAIDs, corticosteroids, recreational
drugs (cocaine, meth)
● Secondary Hypertension → due to another cause
○ Common Causes:
■ Renal parenchymal disease
, ■ Renovascular disease
■ primary aldosteronism
■ Obstructive sleep apnea
■ Drug/alcohol use
● Nonpharmacologic Treatment
○ Weight loss
○ Heart healthy diet (DASH diet - NA reduction and K supplementation unless
contraindicated for CKD)
○ Increased physical activity w/ structured exercise (30 min 5-6 days a week)
○ Reduced alcohol intake (1 drink per day for women, 2 drinks for men)
● Subjective: may complain of headache in occiput when awakening
● Objective: two measurements of BP in both arms, with the patient
seated with both feet on a flat surface and the back supported
with the arm (i.e., brachial artery) at heart level
● Diagnostics
○ Assess for target organ damage
○ Fasting blood glucose → assesses for undiagnosed DM
○ CBC
○ Lipid profile
○ Serum creatinine w/ eGFR, sodium, potassium, calcium → TOD assessment
○ TSH → secondary HTN cause
○ UA → assess for protein to detect kidney damage
○ EKG
● Pharmacologic Treatments
○ First line (primary agents)
■ Thiazide diuretics
● Chlorthalidone (longer half life)
● Hydrochlorothiazide 12.5 mg - 50 mg
● Monitor potassium, sodium, calcium, uric acid
● Hx of gout avoid d/t already elevated UA and thiazide elevated
further
● Can impair glucose metabolism → caution in DM
■ ACE or ARB
● ACE (-prils): Benazepril, Captopril, Enalapril, Lisinopril,
Ramipril)
○ No combo w/ ARBS or renin inhibitors
○ Rx for hyperkalemia with renal failure, K sparing diuretics
(spironolactone/triamterene)
, ○ Angioedema rx and dry cough SE
○ Can cause RF in Renal artery stenosis patients
○ Do not use in pregnancy
● ARBs (-sartan): valsartan, losartan, irbesartan, candesartan
○ Use if intolerant to ACE due to cough/angioedema but wait
6 weeks between starting ARB after d/c ACE
○ Contraindicated if angioedema occurs with ARB
■ CCB
● Dihydropyridines (-dipines): amlodipine, felodipine, nifedipine,
nicardipine
○ Avoid in HF w/ reduced EF bc it can cause pedal edema
● Nondihydropyridines (diltiazem, verapamil)
○ Do not use with HF reduced EF
○ Avoid if patient is on BB due to increased risk for heart
block
■ Second Line
● Loop diuretics (-ide): furosemide, bumetanide, torsemide
○ Use in pt with HF and RF w/ moderate to severe CKD
(GFR <30)
○ In combo with ACE and ARB
● Potassium Sparing diuretics (Amukoride, triamterene)
○ Avoid if GFR is < 45 bc increased rx for hyperkalemia
○ If hypokalemic on hydrochlorothiazide add triamterene to
reduce K loss
● Diuretic aldosterone antagonist (spironolactone)
○ Use in resistant HTN and in primary aldosteronism
(potassium sparing),
○ monitor K levels rx for gynecomastia/impotence
● Cardioselective BB (-olol): atenolol, metoprolol, betaxolol,
bisoprolol
○ First line only with ischemic HD or HF
○ Avoid abrupt stop bc rebound HTN can occur
● Non Cardioselective BB (propranolol, nadolol)
○ Avoid in obstructive airway disease such as asthma bc rx
for bronchospasm
○ Rebound HTN rx
● BB w/ alpha and beta receptors (carvedilol, labetalol)
○ Carvedilol for HF with reduced EF
● Direct renin inhibitor (Aliskren)
, ○ Very long acting, avoid w/ ACEI or ARB d/t increased rx for
hyperkalemia
○ Avoid in pregnancy
● Alpha-1 Blockers (-zosin): doxazosin, Prazosin, terazosin
○ Rx for orthostatic hypotension in older
adults ■ Take at night
○ Beneficial in men w/ benign prostatic hypertrophy
● Centrally acting drugs: clonidine, methyldopa
○ Last line due to CNS effects
○ Do not stop clonidine abrupt bc it can cause hypertensive
crisis
● Direct Vasodilators: hydralazine, minoxidil
○ Minoxidil SE: Secondary hirsutism ○
Hydralazine SE: lupus like syndrome
○ Stage 2 or avg BP 20/10 mmHg above target → 2 first line drugs
○ Assess monthly after adjusted regimen to assess for adherence and response
● HTN with comorbidities
○ CVD, DM, CKD w/ or w/o transplant, HF, secondary stroke prevention, PAD ■
Goal: <130/80
● Hypertensive Crisis
○ >180/120
■ Target organ damage/new/progressive/worsening
● Admit to ICU
■ No Target organ damage → reinstitute, intensify tx
○ Subjective: complaints related to the particular type of end-organ damage (e.g.,
chest pain from cardiac ischemia, blurred vision from papilledema, mental status
changes from TIA)
Falls
● Causes:
○ Balance disorders, environmental hazards, syncope, orthostatic hypotension,
elimination issues (i.e incontinence, nocturia), disease processes (i.e. weakness,
vision changes, fatigue, impaired mobility), improper use of assistive devices
● Rx Factors in LTC: recent admission, dementia, psychotropic drugs, polypharmacy, low
staff to patient ratios, unsupervised activities, slippery floors/environmental hazards ●
Prevention:
○ Modify environment/medication regimen
○ Workup of symptoms associated with falls - dizziness, syncope, overactive
bladder
○ Gait/balance assessment
Hypertension
● Risk of CVD, stroke, CAD, PVD, HF
○ Primary prevention: reduce risk of first event
○ Secondary prevention: reduce risk of recurrent events
● Risk for renal Disease
○ Renal Failure and Glomerulosclerosis
● Guidelines
○ Normal: less than 120/80 mm Hg
○ Elevated: Systolic between 120-129 or diastolic less than 80
○ Stage 1: Systolic between 130-139 or diastolic between 80-89
■ Prescribe medication if patient has hx of CV events such as stroke or heart
attack or is at high risk of heart of stroke based on age, hx of DM, CKD, or
rx for atherosclerosis
■ Lifestyle changes for 6 months before adding medication
○ Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg
○ Hypertensive Crisis: Systolic over 180 and/or diastolic over 120
■ Prompt change in medication if no other issues occurring
■ Immediate hospitalization if there are signs of organ damage (chest pain,
change in mental status)
○ May require 2 medications to control BP
○ Socioeconomic stress/psychosocial stress are rx factors for high BP
● Risk Factors
○ Family history, age, ethnicity (AA, hispanics), lifestyle (weight, diet, alcohol,
tobacco)
● Evaluation
○ White coat hypertension: high BP in office but normal outside
■ Confirm with ambulatory BP monitor
○ Masked Hypertension: normal BP in office but elevated outside
■ Confirm with ambulatory BP or home BP readings greater than 135/85
■ Confirm if patients have evidence of target organ damage
● Substances causing elevated BP
○ Caffeine, alcohol, Antidepressants (tricyclic), antipsychotics, decongestants
(pseudoephedrine), oral contraceptives, NSAIDs, corticosteroids, recreational
drugs (cocaine, meth)
● Secondary Hypertension → due to another cause
○ Common Causes:
■ Renal parenchymal disease
, ■ Renovascular disease
■ primary aldosteronism
■ Obstructive sleep apnea
■ Drug/alcohol use
● Nonpharmacologic Treatment
○ Weight loss
○ Heart healthy diet (DASH diet - NA reduction and K supplementation unless
contraindicated for CKD)
○ Increased physical activity w/ structured exercise (30 min 5-6 days a week)
○ Reduced alcohol intake (1 drink per day for women, 2 drinks for men)
● Subjective: may complain of headache in occiput when awakening
● Objective: two measurements of BP in both arms, with the patient
seated with both feet on a flat surface and the back supported
with the arm (i.e., brachial artery) at heart level
● Diagnostics
○ Assess for target organ damage
○ Fasting blood glucose → assesses for undiagnosed DM
○ CBC
○ Lipid profile
○ Serum creatinine w/ eGFR, sodium, potassium, calcium → TOD assessment
○ TSH → secondary HTN cause
○ UA → assess for protein to detect kidney damage
○ EKG
● Pharmacologic Treatments
○ First line (primary agents)
■ Thiazide diuretics
● Chlorthalidone (longer half life)
● Hydrochlorothiazide 12.5 mg - 50 mg
● Monitor potassium, sodium, calcium, uric acid
● Hx of gout avoid d/t already elevated UA and thiazide elevated
further
● Can impair glucose metabolism → caution in DM
■ ACE or ARB
● ACE (-prils): Benazepril, Captopril, Enalapril, Lisinopril,
Ramipril)
○ No combo w/ ARBS or renin inhibitors
○ Rx for hyperkalemia with renal failure, K sparing diuretics
(spironolactone/triamterene)
, ○ Angioedema rx and dry cough SE
○ Can cause RF in Renal artery stenosis patients
○ Do not use in pregnancy
● ARBs (-sartan): valsartan, losartan, irbesartan, candesartan
○ Use if intolerant to ACE due to cough/angioedema but wait
6 weeks between starting ARB after d/c ACE
○ Contraindicated if angioedema occurs with ARB
■ CCB
● Dihydropyridines (-dipines): amlodipine, felodipine, nifedipine,
nicardipine
○ Avoid in HF w/ reduced EF bc it can cause pedal edema
● Nondihydropyridines (diltiazem, verapamil)
○ Do not use with HF reduced EF
○ Avoid if patient is on BB due to increased risk for heart
block
■ Second Line
● Loop diuretics (-ide): furosemide, bumetanide, torsemide
○ Use in pt with HF and RF w/ moderate to severe CKD
(GFR <30)
○ In combo with ACE and ARB
● Potassium Sparing diuretics (Amukoride, triamterene)
○ Avoid if GFR is < 45 bc increased rx for hyperkalemia
○ If hypokalemic on hydrochlorothiazide add triamterene to
reduce K loss
● Diuretic aldosterone antagonist (spironolactone)
○ Use in resistant HTN and in primary aldosteronism
(potassium sparing),
○ monitor K levels rx for gynecomastia/impotence
● Cardioselective BB (-olol): atenolol, metoprolol, betaxolol,
bisoprolol
○ First line only with ischemic HD or HF
○ Avoid abrupt stop bc rebound HTN can occur
● Non Cardioselective BB (propranolol, nadolol)
○ Avoid in obstructive airway disease such as asthma bc rx
for bronchospasm
○ Rebound HTN rx
● BB w/ alpha and beta receptors (carvedilol, labetalol)
○ Carvedilol for HF with reduced EF
● Direct renin inhibitor (Aliskren)
, ○ Very long acting, avoid w/ ACEI or ARB d/t increased rx for
hyperkalemia
○ Avoid in pregnancy
● Alpha-1 Blockers (-zosin): doxazosin, Prazosin, terazosin
○ Rx for orthostatic hypotension in older
adults ■ Take at night
○ Beneficial in men w/ benign prostatic hypertrophy
● Centrally acting drugs: clonidine, methyldopa
○ Last line due to CNS effects
○ Do not stop clonidine abrupt bc it can cause hypertensive
crisis
● Direct Vasodilators: hydralazine, minoxidil
○ Minoxidil SE: Secondary hirsutism ○
Hydralazine SE: lupus like syndrome
○ Stage 2 or avg BP 20/10 mmHg above target → 2 first line drugs
○ Assess monthly after adjusted regimen to assess for adherence and response
● HTN with comorbidities
○ CVD, DM, CKD w/ or w/o transplant, HF, secondary stroke prevention, PAD ■
Goal: <130/80
● Hypertensive Crisis
○ >180/120
■ Target organ damage/new/progressive/worsening
● Admit to ICU
■ No Target organ damage → reinstitute, intensify tx
○ Subjective: complaints related to the particular type of end-organ damage (e.g.,
chest pain from cardiac ischemia, blurred vision from papilledema, mental status
changes from TIA)
Falls
● Causes:
○ Balance disorders, environmental hazards, syncope, orthostatic hypotension,
elimination issues (i.e incontinence, nocturia), disease processes (i.e. weakness,
vision changes, fatigue, impaired mobility), improper use of assistive devices
● Rx Factors in LTC: recent admission, dementia, psychotropic drugs, polypharmacy, low
staff to patient ratios, unsupervised activities, slippery floors/environmental hazards ●
Prevention:
○ Modify environment/medication regimen
○ Workup of symptoms associated with falls - dizziness, syncope, overactive
bladder
○ Gait/balance assessment
