nur 6111 exam 3 study notes on hypertension and related conditions.exam questions and answers

NUR 611 1 EXAM 3 - NUR 6111 1
EXAM 3 NOTES EXAM
QUESTIONS WITH CORRECT
ANSWERS

ADV PRACTICE NURSING I
(WILLIAM PATERSON UNIVERSITY)




xr

,Epidemiology Risk Factors xr

• 30% of adults xr xr
• family hx xr
• Men > Women xr xr
• obesity, poor diet, stress
• ↑ w age: men- 50s; women- postmenopausal & >65
xr xr xr

xr xr xr xr xr xr xr xr
• ETOH, Smoking xr

• highest incidence: African Americans & Filipinos
xr xr xr xr xr
• physical inactivity xr
• RF for CAD, HF, Stroke, PAD, kidney disease, retinopathy
xr xr xr xr xr xr xr xr
• dyslipidemia
• 20mmHg ↑ SBP & 10mmHg ↑ DBP = associated w 2x risk of death
xr xr xr xr xr xr xr xr xr xr xr xr xr
• age
Etiology Secondary HTN xr

• Primary HTN: 90-95% of adults xr xr xr xr
• younger: <30; severe & acute; resistant (at least 3 meds)
xr xr xr xr xr xr xr xr xr

• Pregnancy induced HTN xr xr
• malignant: organ damage, acute RF, retinal hemorrhages
xr xr xr xr xr xr

• Secondary HTN: xr
• Causes by Age: xr xr

-Renal- acute glomerulonephritis, CRF, PkD, pyelonephritis
xr xr xr xr xr
-Younger adults: renal artery stenosis xr xr xr xr

-Vascular- renal artery stenosis, coarctation of the aorta
xr xr xr xr xr xr xr
-Middle-aged: endocrine xr

-Endocrine- thyroid, pheochromocytoma, primary hyperaldosteronism, Cushing’s
xr xr xr xr xr
-Older adults: CkD
-Other-
xr xr




‣ OSA, excessive caffeine, ETOH xr xr xr


‣ Pharm(stimulants, steroids, cocaine, NSAIDS, oral contraceptives, decongestants) xr xr xr xr xr xr


Clinical Presentation & Physical Exam
xr xr xr xr


• most pts asymptomatic (HTN may be incidental finding)
xr xr xr xr xr xr xr


• occipital HA, blurry vision xr xr xr

• PE: identify cause of HTN & assess for target organ disease
xr xr xr xr xr xr xr xr xr xr


-ENT: optic fundi- AV nicking, arteriolar narrowing, silver/coppery wire, hemorrhage, papilledema
xr xr xr xr xr xr xr xr xr xr


-Cardiac: S4, LVH xr xr


-Vascular: extremity changes dt peripheral circulatory impairment, bruit carotid/aortic/renal
xr xr xr xr xr xr xr xr


-Thyroid: goiter, evidence of hyperthyroidism xr xr xr xr

-Neurologic: TIA, CVA symptoms xr xr xr


HTN Guidelines
xr
Dx
• 2 or more readings are required to dx HTN
xr xr xr xr xr xr xr xr
• Goal: identify if target organ damage or secondary cause
xr xr xr xr xr xr xr xr

• JNC = pharm tx at stage 1
xr xr xr xr xr xr
• CBC. CMP, Cr, fasting Lipids, TSH, UA, ECG, Echo
xr xr xr xr xr xr xr xr

• ACC/AHA only drugs at stage 1 if 10yr CV risk >10%
xr xr xr xr xr xr xr xr xr xr
• CXR- if hx of smoking
xr xr xr xr


• 24-hr urine cortisol- if Cushing’s suspected
xr xr xr xr xr


• 24-hr Cr, Catecholamines, Metanephrines- pheochromocytoma suspected
xr xr xr xr xr


• Uric acid, Urinary albumin to Cr Ratio
xr xr xr xr xr xr




Goals of Tx xr xr



Clinical Conditions xr BP Threshold mmHg
xr xr BP Goal mmHg
xr xr


General
Clinical CVD or 10yr ASCVD risk ≥10%
xr xr xr xr xr xr ≥130/80 <130/80
No clinical CVD & 10yr ASCVD risk <10%
xr xr xr xr xr xr xr ≥140/90 <130/80
Older persons (≥65 yrs; noninstitUtionalized, ambUlatory, commUnity-living)
xr xr xr xr xr xr ≥130 SBP xr <130 SBP xr


Specific Comorbidities xr


Diabetes Mellitus xr ≥130/80 <130/80
CKD ≥130/80 <130/80
CKD after Renal Transplant
xr xr xr ≥130/80 <130/80
HF ≥130/80 <130/80
Stable Ischemic Heart Disease
xr xr xr ≥130/80 <130/80
Secondary Stroke Prevention xr xr ≥140/80 <130/80
Secondary Stroke Prevention (lacunar)xr xr xr ≥130/80 <130/80
PAD ≥130/80 <130/80

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, Hypertension contd… x r




Management
• Elevated BP or Stage 1 HTN w low ASCVD Risk-
xr xr xr xr xr xr xr xr xr

-non-pharm therapy, recheck in 3-6m xr xr xr xr


• Stage 1 HTN & High ASCVD Risk (≥10% 10yr ASCVD risk)-
xr xr xr xr xr xr xr xr xr xr


-non-pharm & antihypertensive drug therapy, repeat BP in 1m xr xr xr xr xr xr xr xr

• Stage 2 HTN- xr xr

-non-pharm & 2 antiHTN drugs of different classes w repeat BP in 1m
xr xr xr xr xr xr xr xr xr xr xr xr


• Adults w a very high average BP (≥160 SBP or ≥100 DBP)-
xr xr xr xr xr xr xr xr xr xr xr

-prompt eval, drug tx ➜ careful monitoring & upward dose adjustment
xr xr xr xr xr xr xr xr xr xr


Pharm Tx xr


• Note:
-↑ or add after 1 month if not at goal
xr xr xr xr xr xr xr xr xr

-No ACE or ARB together xr xr xr xr


-3 meds & not controlled ➜ refer to specialist
xr xr xr xr xr xr xr xr


Non- Thiazides, CCB, ACEI, ARB Thiazides xr xr xr xr


Black Blac xr , CCBxr


ks CKD or
xr xr xr ACE or ARB xr xr x


DM MI xr BB
r


Pregnancy Methyldopa, Labetalol, Hydralazine xr xr




Thiazides xr Hydrochlorothiazide (Microzide), Chlorthalidone (Hygroton) ✓ for Blacks xr xr xr xr



CCB Dihydropyridine (DHP): “-pines”: ✓ for Blacks xr xr xr


Amlodipine (Norvasc), Nifedipine (Procardia), Nicardipine (Cardene) DPH (Amlodipine) ✓ for HF
xr xr xr xr xr xr xr xr xr

Non-Dihydropyridine (NDPH): “non-pines”: NDPH (Diltiazem, Verapamil) X for HF xr xr xr xr xr xr xr

Diltiazem (Cardizem), Verapamil (Calan) X for systolic HF
xr xr xr xr xr xr



ACE “-pril”: ✓ for DM, CkD, HF xr xr xr

Enalapril (Vasotec), Lisinopril (Zestril), Ramipril (Altace) xr reduces mortality in HF & renal decline in CkD SE: c xr xr xr xr xr xr xr xr xr xr xr xr xr xr


ough, angioedema xr



ARB B xr Losartan (Cozaar), Valsartan (Diovan), Olmesartan (Benicar)xr ✓ for DM, CkD, HF xr xr xr xr xr xr xr


for pts intolerant to ACE (cough, angioedema) xr xr xr xr xr xr



B Selective (Beta-1 Specific): xr better for CAD, HFrEF, post- MI instead of HTN
xr xr xr xr xr xr xr xr xr


Atenolol (Tenormin), Nebivolol (Bystolic), Esmolol, Bisoprolol Meto X for asthma (especially non-
xr xr xr xr xr xr xr xr xr xr


prolol Succinate (Toprol XL), Metoprolol Tartrate (Lopressor)
xr selective) avoid in younger pts dt SE- xr xr xr xr xr xr xr xr xr xr xr


Non-Selective (Beta-1 & 2): fatigue
xr xr xr xr


Propranolol, Carvedilol, Labetalol, Nadolol xr xr xr



Loop Diuretics Furosemide (Lasix)
xr xr xr



k- Sparing Spironolactone (Aldactone) xr



Alpha Agonists Methyldopa (Aldomet), Clonidine (Catapres)
xr xr xr xr xr



Renin-Inhibitor Aliskiren (Tekturna) xr xr



Non-Pharm Tx x r


• DASH Diet xr • Exercise:
xr


• Weight loss: 1 kg = 1 mmHg xr xr xr xr xr xr -30min moderate-intensity aerobic at least 5days/wk for a total of 150min
xr xr xr xr xr xr xr xr xr xr

• smoking & drug abuse cessation xr xr xr xr -25min vigorous aerobic activity at least 3days/wk for total 75min (or combo of mod & vigorous)
xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr

• ETOH- avoid or limit xr xr xr -moderate-high intensity muscle-strengthening activity at least 2days/wk xr xr xr xr xr xr


• educate on disease (pts may feel fine) xr xr xr xr xr xr -for lowering BP & cholesterol: 40min moderate-to-vigorous-intensity aerobic activity 3-4x/wk
xr xr xr xr xr xr xr xr xr

• PREVENTION
White Coat Syndromexr xr
Other Considerations xr

• Office BP: ≥130/80 but <160/100 sp 3m lifestyle mod
xr xr xr xr xr xr xr xr
• Follow-up: labs, add-med? xr xr

• HBPM (home bp monitoring) xr xr xr
• Referral: elderly pts, dietitian, cardiologist, nephrology, endocrinology
xr xr xr xr xr xr

• ABPM (ambulatory BP monitoring)
xr xr xr
• lifestyle changes xr

• if >130/80 – start antihypertensive med
xr xr xr xr xr
• Elderly: start low-go slow, comorbidities, polypharm, schedule, orthostatic
xr xr xr xr xr xr xr

ICD-10 Codes xr • Complications
• 110- Essential (primary) HTN
xr xr xr

• 112.9- HTN CKD w stage 1-4 CKD or unspecific CKD
xr xr xr xr xr xr xr xr xr

• 115.2- HTN secondary to endocrine disorders
xr xr xr xr xr


• 111.0- HTN heart disease w HF
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xr xr xr xr xr xr xr xr

, Atrial Fibrillaiton x r



A-fib: ventricular arrhythmia
xr xr


Impact of A-fib xr xr


• ↑ risk for stroke by 4-5x
xr xr xr xr xr

• causes abt 25% of ischemic strokes
xr xr xr xr xr

• doubles the risk of heart-related deaths
xr xr xr xr xr

• absent atria contraction ➜ loss of CO (15-30%) dt no "atrial kick", contributing to HF
xr xr xr xr xr xr xr xr xr xr xr xr xr xr


Risk Factors xr


• advancing age xr • HTNxr • CADxr • Cardiomyopathy
xr


• Obesity • athletes
xr • DM xr • European ancestry
xr xr


• HF • Hyperthyroidism
xr • CKDxr • heavy ETOH use
xr xr xr


• rheumatic heart disease xr xr • valvular heart disease
xr xr xr • sleep apnea
xr xr • pericarditis/myocarditis
xr

• enlarged L heart chambers xr xr xr


Valvular vs. Non-Valvular A-fib xr xr xr


• Valvular: AF w moderate-to-severe mitral stenosis (potentially requiring sx) or in the presence of an artificial (mechanical) heart valve
xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr

• Non-Valvular: AF in the absence of moderate-to-severe mitral stenosis or a mechanical heart valve
xr xr xr xr xr xr xr xr xr xr xr xr xr


Clinical Presentation & Physical Exam
xr xr xr xr


• many are asymptomatic & unaware of their dx- sometimes it is an incidental finding upon exam
xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr


Symptomatic Presentation Physical Exam x r xr


• General Fatigue • Rapid/Irregular heartbeat
xr • Irregular Heart Rhythm: hallmark of AF xr xr xr xr xr xr xr

• Fluttering/"thumping" in chest • Dizziness • Tachycardia (typically 110-140s), Hypotension
xr xr x r xr xr xr xr

• SOB • Anxiety • Possible findings: xr xr


• Weakness • Faintness -JVD, Rales, Effusion from HF, LE edema (HF or DVT) xr xr xr xr xr xr xr xr xr xr


• Confusion • Fatigue w exercise -Murmurs (suggesting stenosis or regurgitation); Exophthalmia xr xr xr xr xr xr xr xr


• CP or Pressure ➜ Call 911
xr xr xr-Stroke S&S (facial droop, arm weakness, slurred speech)
xr xr xr xr xr xr xr xr xr



EKG
• Gold Standard:
xr


-No visible P-waves (no measurable PR interval)
xr xr xr xr xr xr


-Irregularly irregular QRS x r x r


-Ventricular rate is frequently fast xr xr xr xr


• Irregular R-R intervals (irregular ventricular response)
xr xr xr xr xr


• No distinct P-waves
xr xr


• F-waves (fibrillatory) replace P-waves (varying amplitude)
xr xr xr xr xr




Classifying A-fib x r



Paroxysmal AF -AF that terminates spontaneously or w intervention within 7days of onset
xr xr xr xr xr xr xr xr xr xr xr


-episodes may recur w variable frequency xr xr xr xr xr


Persistent AF -continuous AF that is sustained >7days
xr xr xr xr xr xr


Long-standing Persistent AF -continuous AF >12m in duration
xr xr xr xr xr xr


Permanent AF -term used when pt & clinician decide to stop further attempts to restore & or maintain NSR
xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr

-acceptance of AF represents a therapeutic attitude on the part of the pt & clinician rather than pathophysiology of AF xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr


-acceptance of AD may change as symptoms, efficacy of interventions, & pt or clinician preferences evolve xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr


Nonvalvular AF -absence of rheumatic mitral stenosis, mechanical or bioprosthetic heart valve, or mitral valve repair
xr xr xr xr xr xr xr xr xr xr xr xr xr xr



Dx
• Labs: CBC, CMP, TSH, BNP, PT, PTT, INR
xr xr xr xr xr xr xr

• Echocardiogram-
-evaluation of size & function of atria & ventricles, detect valvular heart disease, LV hypertrophy, & pericardial disease
xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr xr

• Transesophageal Echocardiogram (TEE)- xr xr


-most sensitive & specific technique to detect LA thrombi
xr xr xr xr xr xr xr xr

• Event Recorders (Implantable Loop Recorders or Holter monitors)-
xr xr xr xr xr xr xr


-identify arrhythmia if intermittent, to correlate symptoms, or rate control strategies
xr xr xr xr xr xr xr xr xr xr


• Stress Test xr


• EP Study
xr




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