NUR 611 1 EXAM 3 - NUR 6111 1 EXAM 3 NOTES EXAM QUESTIONS WITH CORRECT ANSWERS ADV PRACTICE NURSING I

NUR 611 1 EXAM 3 - NUR 6111 1 EXAM 3
NOTES EXAM QUESTIONS WITH CORRECT
ANSWERS
ADV PRACTICE NURSING I




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,Epidemiology Risk Factors jl

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

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

• Primary HTN: 90-95% of adults jl jl jl jl
• younger: <30; severe & acute; resistant (at least 3 meds)
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• Pregnancy induced HTN jl jl
• malignant: organ damage, acute RF, retinal hemorrhages jl jl jl jl jl jl

• Secondary HTN: jl
• Causes by Age: jl jl

-Renal- acute glomerulonephritis, CRF, PkD, pyelonephritis jl jl jl jl jl
-Youngeradults:renalarterystenosis jl jl jl jl

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

-Endocrine- thyroid, pheochromocytoma, primary hyperaldosteronism, Cushing’s jl jl jl jl jl
-Older adults: CkD
-Other-
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‣ OSA, excessive caffeine, ETOH jl jl jl


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


Clinical Presentation & Physical Exam jl jl jl jl


• most pts asymptomatic (HTN may be incidental finding)
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• occipital HA, blurry vision jl jl jl

• PE: identify cause of HTN & assess for target organ disease
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-ENT: optic fundi- AV nicking, arteriolar narrowing, silver/coppery wire, hemorrhage, papilledema
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-Cardiac: S4, LVH jl jl


-Vascular: extremity changes dt peripheral circulatory impairment, bruit carotid/aortic/renal
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-Thyroid: goiter, evidence of hyperthyroidism jl jl jl jl

-Neurologic: TIA, CVA symptoms jl jl jl


HTN Guidelines
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Dx
• 2 or more readings are required to dx HTN
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• Goal: identify if target organ damage or secondary cause
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• JNC = pharm tx at stage 1 jl jl jl jl jl jl
• CBC. CMP, Cr, fasting Lipids, TSH, UA, ECG, Echo
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• ACC/AHA only drugs at stage 1 if 10yr CV risk >10% jl jl jl jl jl jl jl jl jl jl
• CXR- if hxof smokingjl jl jl jl


• 24-hr urine cortisol- if Cushing’s suspected
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• 24-hr Cr, Catecholamines, Metanephrines- pheochromocytoma suspected
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• Uric acid, Urinary albumin to Cr Ratio
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Goals of Tx jl jl



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


Specific Comorbidities jl


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

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, Hypertension contd… j l




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

-non-pharmtherapy,recheck in3-6m jl jl jl jl


• Stage 1 HTN & High ASCVD Risk (≥10% 10yr ASCVD risk)-
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-non-pharm & antihypertensive drug therapy, repeat BP in 1m jl jl jl jl jl jl jl jl

• Stage 2 HTN- jl jl

-non-pharm & 2antiHTN drugs ofdifferent classes w repeat BPin1m jl jl jl jl jl jl jl jl jl jl jl jl


• Adults w a very high average BP (≥160 SBP or ≥100 DBP)-
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-prompt eval, drug tx ➜ careful monitoring & upward dose adjustment jl jl jl jl jl jl jl jl jl jl


Pharm Tx jl


• Note:
-↑ or add after 1 month if not at goal
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-No ACE or ARB together jl jl jl jl


-3 meds & not controlled➜ refer to specialist
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Non- Thiazides, CCB, ACEI, ARB Thiazides, jl jl jl jl j


Black Blac jl CCB
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ks CKD or
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DM MI jl BB
Pregnancy Methyldopa, Labetalol, Hydralazine jl jl




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



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


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

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

Diltiazem (Cardizem), Verapamil (Calan) X for systolicHF jl jl jl jl jl jl



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

Enalapril (Vasotec), Lisinopril (Zestril), Ramipril (Altace) reducesmortality inHF&renaldeclineinCkD SE: cou
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gh,angioedema jl



ARB B jl Losartan (Cozaar), Valsartan (Diovan), Olmesartan (Benicar) ✓ for DM, CkD, HF
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for pts intolerant to ACE (cough, angioedema) jl jl jl jl jl jl



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


Atenolol (Tenormin), Nebivolol (Bystolic), Esmolol, Bisoprolol Metop X for asthma(especially non-
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rolol Succinate (Toprol XL), Metoprolol Tartrate (Lopressor)
jl selective) avoid in younger pts dt SE- jl jl jl jl jl jl jl jl jl jl jl


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


Propranolol, Carvedilol, Labetalol, Nadolol jl jl jl



Loop Diuretics Furosemide (Lasix)
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k- Sparing Spironolactone (Aldactone) jl



Alpha Agonists Methyldopa (Aldomet), Clonidine (Catapres)
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Renin-Inhibitor Aliskiren (Tekturna) jl jl



Non-Pharm Tx j l


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

• smoking & drug abuse cessation jl jl jl jl -25min vigorous aerobic activity at least 3days/wk for total 75min (or combo of mod & vigorous)
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• ETOH- avoid or limit jl jl jl -moderate-high intensity muscle-strengthening activity at least 2days/wk jl jl jl jl jl jl


• educate on disease (pts may feel fine) jl jl jl jl jl jl -for lowering BP & cholesterol: 40min moderate-to-vigorous-intensity aerobic activity 3-4x/wk
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• PREVENTION
White Coat Syndrome jl jl
Other Considerations jl

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

• HBPM (home bp monitoring) jl jl jl
• Referral: elderly pts, dietitian, cardiologist, nephrology, endocrinology
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• ABPM (ambulatory BP monitoring) jl jl jl
• lifestyle changes jl

• if >130/80 – start antihypertensive med
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• Elderly: start low-go slow, comorbidities, polypharm, schedule, orthostatic
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ICD-10 Codes jl • Complications
• 110- Essential (primary) HTN
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• 112.9- HTN CKD w stage 1-4 CKD or unspecific CKD
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• 115.2- HTN secondary to endocrine disorders
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• 111.0- HTN heart disease w HF jl Downloaded by Wambo Jeni ()
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, Atrial Fibrillaiton j l



A-fib: ventricular arrhythmia
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Impact of A-fib jl jl


• ↑risk for stroke by 4-5x
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• causes abt 25% of ischemic strokes
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• doubles the risk of heart-related deaths
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• absent atria contraction ➜ loss of CO (15-30%) dt no "atrial kick", contributing to HF
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Risk Factors jl


• advancing age jl • HTN
jl • CAD jl • Cardiomyopathy
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• Obesity • athletes
jl • DM jl • European ancestry
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• HF • Hyperthyroidism
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• rheumatic heart disease jl jl • valvular heart disease
jl jl jl • sleep apnea
jl jl • pericarditis/myocarditis
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• enlarged L heart chambers jl jl jl


Valvular vs. Non-Valvular A-fib jl jl jl


• Valvular: AF w moderate-to-severe mitral stenosis (potentially requiring sx) or in the presence of an artificial (mechanical) heart valve
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• Non-Valvular: AF in the absence of moderate-to-severe mitral stenosis or a mechanical heart valve
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Clinical Presentation & Physical Exam jl jl jl jl


• many are asymptomatic & unaware of their dx- sometimes it is an incidental finding upon exam
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Symptomatic Presentation Physical Exam j l jl


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

• Fluttering/"thumping" in chest • Dizziness • Tachycardia (typically 110-140s), Hypotension jl jl j l jl jl jl jl

• SOB • Anxiety • Possible findings: jl jl


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


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


• CP or Pressure ➜ Call 911
jl jl -Stroke S&S (facial droop, arm weakness, slurred speech)
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EKG
• Gold Standard: jl


-No visible P-waves (no measurable PR interval)
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-Irregularly irregular QRS j l j l


-Ventricular rate is frequently fast jl jl jl jl


• Irregular R-R intervals (irregular ventricular response)
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• No distinct P-waves
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• F-waves (fibrillatory) replace P-waves (varying amplitude)
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Classifying A-fib j l



Paroxysmal AF -AF that terminates spontaneously or w intervention within 7days of onset
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-episodes may recur w variable frequency jl jl jl jl jl


Persistent AF -continuous AF that is sustained >7days
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Long-standing Persistent AF -continuous AF >12m in duration jl jl jl jl jl jl


Permanent AF -term used when pt & clinician decide to stop further attempts to restore & or maintain NSR
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-acceptance of AF represents a therapeutic attitude on the part of the pt & clinician rather than pathophysiology of AF jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl jl


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


Nonvalvular AF -absence of rheumatic mitral stenosis, mechanical or bioprosthetic heart valve, or mitral valve repair
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Dx
• Labs: CBC, CMP, TSH, BNP, PT, PTT, INR
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• Echocardiogram-
-evaluation of size & function of atria & ventricles, detect valvular heart disease, LV hypertrophy, & pericardial disease
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• Transesophageal Echocardiogram (TEE)- jl jl


-most sensitive & specific technique to detect LA thrombi
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• Event Recorders (Implantable Loop Recorders or Holter monitors)-
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-identify arrhythmia if intermittent, to correlate symptoms, or rate control strategies
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• Stress Test jl


• EP Study
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