8th Lecture (NCM103 CVS IV) Care of Clients With Problems in Oxygenation

Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Cardiovascular System: Hypertension, Peripheral Disorders Hypertension (HTN) • Persistent elevation of Blood Pressure • To be considered HTN: × Has to be taken twice from initial up to 3 rd week × Has to be taken by a health care provider • Systolic Pressure > 140 mm Hg; Diastolic Pressure > 90 mm Hg Classification of Blood Pressure for Adults Classification Systolic BP (mm Hg) Diastolic BP (mm Hg) Normal < 120 < 80 Prehypertension 120 – 139 80 – 89 Stage 1 Hypertension 140 – 159 90 – 99 Stage 2 Hypertension > 160 > 100 Diagnostic Procedure × For Prehypertension – Get a Check Up once every 6 months © Types of Hypertension 1. Primary Hypertension o 90% - 95% o Unknown cause º NOT CURABLE, But CONTROLLABLE º Not associated with any possible cause! (Idiopathic) 2. Secondary Hypertension o 5% - 10% o Related to known cause 1. Pregnancy Induced Hypertension (PIH) 2. Kidney Disorders 3. Liver Disorders Risk Factors (Vasoconstriction!!) 1. Dyslipidemia (Abnormal blood fat levels) 2. Obesity ÷ Associated with Atherosclerosis 3. Diabetes Mellitus 4. Sedentary Lifestyle ↓ Insulin ↑ Blood Sugar Stored Fat (Abnormal ) Hyperlipidemia Diabetes Mellitus Causes: 1. ↑ Sympathetic Nervous System Activity 2. ↑ Renal Reabsorption of Na, Cl and H2O 3. ↑ Activity of Renin-Angiotensin-Aldosterone Topics Discussed Here Are: 1. Hypertension 2. Buerger’s Disease 3. Raynaud’s Disease 4. Aneurysm × Thoracic × Abdominal 5. Phlebitis 6. Thrombophlebitis/Phlebothrombosis 7. Varicose Veins LOOKY HERE © Most Important is the DIASTOLIC Reading ¬ Because it is the ventricular relaxation Rule of Thumb! × Age + 100 = Systole! × NONE = Diastole XD Caused by STIMULATION of Sympathetic Nervous System usually by STRESS!! 4. ↓ Vasodilation 5. Resistance to insulin action Clinical Manifestation • SILENT KILLER × They don’t present clinical manifestations! × ONLY ↑ BP C • Nuxial pain / rigidity • Morning frontal lobe head ache • Dizziness • Chest pain Management Non-Pharmacologic Management ¬ Lifestyle Changes 1. Weight Reduction – Maintain normal body weight 2. Adopt DASH (Dietary Approaches to Stop Hypertension) Diet rich in fruits, vegetables, low at dairy products and reduced saturated and total fat 3. Dietary Sodium Reduction º 2.4 g – 6 g Na 4. Physical Activity º Regulates aerobic physical activity as brisk walking (30 mins) 5. Moderation of alcohol intake º No more than 2 drinks per day (24 oz beer, 10 oz wine, 3 oz 80% whisky) Pharmacologic Management ¬ Initial medications º Diuretics, Beta Blockers / Both º Initially LOW DOSE ¬ If BP does not fall to less than 140/90 mm Hg ¬ Dose gradually increased and additional medications are given ¬ If diuretics are discontinued º Can cause REBOUND HYPERTENSION (↑ BP MUCH HIGHER THAN BEFORE) º So, drugs SHOULD be GRADUALLY decreased © ¬ Side Effect of Anti Hypertension ORTHOSTATIC HYPOTENSION / POSTURAL HYPOTENSION º To Prevent Orthostatic Hypotension º Take medications at NIGHT (Before Sleep) º Take in the morning (Lie in bed for 20 – 30 mins before continuing ADLs) º Don’t stay too long under the SUN! º Don’t take a bath with WARM water, but with LUKEWARM water © Peripheral Disorders 1. Buerger’s Disease - Thromboangitis Obliterans (Other name XD) º Presence of Blood Clot + Inflammation of Artery º Affected: Blood Vessels of LOWER EXTREMITIES - More common among males - Cause: º SMOKING ÷ Most common  Nicotine causes VASOCONSTRICTION and ↑ VISCOSITY of Blood O Can cause CLOT FORMATION O ↓ Blood FLOW to LOWER EXTREMITIES - Manifestations: 1. ↓ Temperature 2. Paleness / Pallor 3. Cyanosis (Peripheral) 4. Heaviness (Numbness) ÷ Due to poor healing process, lack of blood supply 5. Pain at the calf muscles  Intermittent Claudication (WARNING) O Pain is experienced while walking or standing for a long time O Pain is relieved by rest © 6. Trophic Changes  Skin is STRETCHABLE / SHINY  Decrease growth of hair  Sole of patient is very THICK  Clubbing of toenails - Plan of Care 1. Preventive Measures < STOP SMOKING < DO NOT SMOKE 2. Perform Leg Exercises < Buerger-Allen Exercise f Fix on bed, lower extremities elevate 45° (for 30 – 60 secs) f Sit on edge of the bed, dangle legs (for 30 – 60 secs) f Go back to bed, but legs are now flat (for 30 – 60 secs) < To improve the circulation on the lower extremities < To further enhance blood flow, ask patient to WIGGLE the toes < Put blanket / top sheet on top of legs to promote vasodilation 3. Care of the Foot (Podiatrist) < Don’t walk BAREFOOT to prevent wound formation and gangrene formation < PUT ON SOCKS < Buy a pair of shoes on the afternoon, because feet are LARGER in the afternoon < Buy 1 size bigger < Get a basin with lukewarm water, liquid soap/baby oil then immerse feet for 15 – 30 mins, get pumice stone / face towel / loofa then wipe off outer layers of the skin < If Gangrene has formed… AMPUTATION 2. Raynaud’s Disease o Counterpart of Buerger’s Disease º The UPPER EXTREMITIES are AFFECTED o Not common in the Philippines o Brought about by: º STRESS and COLD 3. Aneurysm - A localized sac / dilatation formed at weak points on the wall of the arteries Types of Aneurysms a. Thoracic Aortic Aneurysm a. Incidence = More in men (40 – 70 y/o) b. Cause – 85% due to atherosclerosis c. Clinical Manifestations: Some may be ASYMPTOMATIC 1. Pain - Constant and Boring - Occurs when patient is SUPINE 2. Dyspnea (SOB) 3. Coughing 4. Stridor 5. Compression on Larynx - Changes in voice, absence of or total absence of voice 6. Compression on Esophagus: Dysphagia~ d. Diagnostic Tests  Chest X-Rays  TEE º Management: f SURGERY b. Abdominal Aortic Aneurysm º Cause:  Atherosclerosis  Congenital Weakness  Trauma º Clinical Manifestations:  40% have symptoms  Feels their heart beat in the abdomen when lying or abdominal mass / throbbing º Assessment Findings  Palpate abdomen, can feel a PULSATING mass  Pulsating mass at the MIDDLE and UPPER ABDOMEN  Systemic bruit over the mass ÷ THRU AUSCULTATION º Diagnostic Findings:  Ultrasonography  CT Scan º Management:  Pharmacologic Therapy a. Anti-Hypertensive Drugs b. Diuretics c. Beta Blockers d. ACE Inhibitors e. Ca + Channel Blockers  Prevent RUPTURE OF ANEURYSM!! - Surgery o Treatment of Choice º For more than 5.5 cm big (2 inches) º Involves: • Resection of vessel • Endovascular grafting – Transluminal placement and attachment of sutureless aortic graft prostheses Phlebitis, Thrombophlebitis, Phlebothrombosis Phlebitis Definition: Inflammation of the vein Causes: 1. Prolonged intravenous therapy (2 – 3 weeks) 2. Prolonged intravenous therapy of HIGHLY IRRITATING drugsC Local Manifestations: × Redness (Rubor) × Heat (Calor) × Pain (Dolor) × Swelling (Tumor) Systemic Manifestations: × Fever × ↑ Level of WBC Lower Extremity Heart Congestion Stretch/Dilate Varicosities Will turn into REDDISH or BLUISH color Heart Legs Artery Vein (Valves) VEIN YAN NA MAY VALVE LOL Brought About By: 1. Needle out of place 2. Inflamed Vein a. Notify Physician b. Remove IV c. Apply PRESSURE with COLD COMPRESS! Thrombophlebitis / Phlebothrombosis º Common cause: Blood Clot (Thrombus) × Definition: o Thrombophlebitis – Blood Clot + Inflammation of Veins o Phlebothrombosis – Blood Clot + with or without inflammation of veins º Important Nursing Responsibilities 1. NEVER Massage affected part a. Embolus – Moving Blood Clot b. Thrombus – Non-moving Blood Clot 2. NEVER Apply HOT Compress - Deep Vein Thrombosis (DVT) º Legs are swollen º Pain º Keep patient on rest º Apply elastic bandage º Anti-coagulants Varicose Veins - Dilation of veins - Saphenous Vein ÷ Most common to dilate × At the Lower Extremities - Causes: Prolonged standing - Presence of: × Bluish/Reddish × Heat × Heaviness / Numbness × Cramping sensation - Diagnostic Test × Trendelenburg Test + Draining of blood on lower extremities + Then stand, observe Saphenous veins how they fill up 1. Gradually = (-) Trendelenburg Test; (-) Varicose Veins 2. Abruptly = (+) Trendelenburg Test’ (+) Varicose Veins - Management: 1. Use Support Stockings 2. When resting, elevate lower extremities 3. DON’T CROSS LEGS - Surgery 1. Vein Stripping – Ligation of Saphenous Veins 2. Sclerotherapy – Injecting of solution at site of varicosities, formation of hematoma 4 g – 6 g Na 4. drugs SHOULD be GRADUALLY decreased   Side Effect of Anti Hypertension ORTHOSTATIC HYPOTENSION / POSTURAL HYPOTENSION  To Prevent Orthostatic Hypotension  Take medications at NIGHT (Before Sleep)  Take in the morning (Lie in bed for 20 – 30 mins before continuing ADLs)  Don’t stay too long under the SUN!  Don’t take a bath with WARM water. Beta Blockers / Both  Initially LOW DOSE  If BP does not fall to less than 140/90 mm Hg  Dose gradually increased and additional medications are given  If diuretics are discontinued  Can cause REBOUND HYPERTENSION (↑ BP MUCH HIGHER THAN BEFORE)  So. Adopt DASH (Dietary Approaches to Stop Hypertension) Diet rich in fruits. 3 oz 80% whisky) Pharmacologic Management  Initial medications  Diuretics. Physical Activity  Regulates aerobic physical activity as brisk walking (30 mins) 5. Weight Reduction – Maintain normal body weight 2. Buerger’s Disease Thromboangitis Obliterans (Other name XD)  Presence of Blood Clot + Inflammation of Artery  Affected: Blood Vessels of LOWER EXTREMITIES More common among males Cause:  SMOKING  Most common - . Moderation of alcohol intake  No more than 2 drinks per day (24 oz beer. vegetables. 5.4. Dietary Sodium Reduction  2. but with LUKEWARM water  Peripheral Disorders 1. low at dairy products and reduced saturated and total fat 3. 10 oz wine. ↓ Vasodilation Resistance to insulin action Clinical Manifestation • SILENT KILLER  They don’t present clinical manifestations!  ONLY ↑ BP  Nuxial pain / rigidity Morning frontal lobe head ache Dizziness Chest pain • • • • Management Non-Pharmacologic Management  Lifestyle Changes 1. ↓ Temperature 2. get pumice stone / face towel / loofa then wipe off outer layers of the skin  If Gangrene has formed… AMPUTATION - 2. because feet are LARGER in the afternoon  Buy 1 size bigger  Get a basin with lukewarm water. Pain at the calf muscles  Intermittent Claudication (WARNING)  Pain is experienced while walking or standing for a long time  Pain is relieved by rest  6. ask patient to WIGGLE the toes  Put blanket / top sheet on top of legs to promote vasodilation 3. lower extremities elevate 45° (for 30 – 60 secs)  Sit on edge of the bed. Trophic Changes  Skin is STRETCHABLE / SHINY  Decrease growth of hair  Sole of patient is very THICK  Clubbing of toenails Plan of Care 1. Perform Leg Exercises  Buerger-Allen Exercise  Fix on bed. Raynaud’s Disease o o o Counterpart of Buerger’s Disease  The UPPER EXTREMITIES are AFFECTED Not common in the Philippines Brought about by:  STRESS and COLD 3. Care of the Foot (Podiatrist)  Don’t walk BAREFOOT to prevent wound formation and gangrene formation  PUT ON SOCKS  Buy a pair of shoes on the afternoon. Nicotine causes VASOCONSTRICTION and ↑ VISCOSITY of Blood  Can cause CLOT FORMATION  ↓ Blood FLOW to LOWER EXTREMITIES Manifestations: 1. Preventive Measures  STOP SMOKING  DO NOT SMOKE 2. lack of blood supply 5. but legs are now flat (for 30 – 60 secs)  To improve the circulation on the lower extremities  To further enhance blood flow. dangle legs (for 30 – 60 secs)  Go back to bed. Heaviness (Numbness)  Due to poor healing process. Aneurysm . liquid soap/baby oil then immerse feet for 15 – 30 mins. Cyanosis (Peripheral) 4.A localized sac / dilatation formed at weak points on the wall of the arteries . Paleness / Pallor 3. Constant and Boring . Compression on Esophagus: Dysphagia~ d. Pain .Changes in voice.Occurs when patient is SUPINE 2. absence of or total absence of voice 6. Clinical Manifestations: Some may be ASYMPTOMATIC 1. Coughing 4. Anti-Hypertensive Drugs b.- Types of Aneurysms a. can feel a PULSATING mass  Pulsating mass at the MIDDLE and UPPER ABDOMEN  Systemic bruit over the mass  THRU AUSCULTATION  Diagnostic Findings:  Ultrasonography  CT Scan  Management:  Pharmacologic Therapy a. Beta Blockers d. Incidence = More in men (40 – 70 y/o) b. Compression on Larynx . Ca+ Channel Blockers  Prevent RUPTURE OF ANEURYSM!! Surgery o Treatment of Choice  For more than 5. Diuretics c. Dyspnea (SOB) 3.5 cm big (2 inches)  Involves: • Resection of vessel . ACE Inhibitors e. Abdominal Aortic Aneurysm  Cause:  Atherosclerosis  Congenital Weakness  Trauma  Clinical Manifestations:  40% have symptoms  Feels their heart beat in the abdomen when lying or abdominal mass / throbbing  Assessment Findings  Palpate abdomen. Cause – 85% due to atherosclerosis c. Diagnostic Tests  Chest X-Rays  TEE  Management:  SURGERY b. Thoracic Aortic Aneurysm a. Stridor 5. • Endovascular grafting – Transluminal placement and attachment of sutureless aortic graft prostheses Phlebitis. Phlebothrombosis Phlebitis Definition: Inflammation of the vein Causes: 1. Prolonged intravenous therapy of HIGHLY IRRITATING drugs Local Manifestations:  Redness (Rubor)  Pain (Dolor)  Heat (Calor)  Swelling (Tumor) Systemic Manifestations:  Fever  ↑ Level of WBC . Thrombophlebitis. Prolonged intravenous therapy (2 – 3 weeks) 2. Vein Stripping – Ligation of Saphenous Veins 2. (-) Varicose Veins 2. Sclerotherapy – Injecting of solution at site of varicosities. NEVER Apply HOT Compress . Remove IV c. Gradually = (-) Trendelenburg Test. Abruptly = (+) Trendelenburg Test’ (+) Varicose Veins  Management: 1. DON’T CROSS LEGS  Surgery 1.Brought About By: 1. Apply PRESSURE with COLD COMPRESS! Thrombophlebitis / Phlebothrombosis  Common cause: Blood Clot (Thrombus)  Definition: o Thrombophlebitis – Blood Clot + Inflammation of Veins o Phlebothrombosis – Blood Clot + with or without inflammation of veins Important Nursing Responsibilities 1.Deep Vein Thrombosis (DVT)  Legs are swollen  Pain  Keep patient on rest  Apply elastic bandage  Anti-coagulants  Varicose Veins  Dilation of veins  Saphenous Vein  Most common to dilate  At the Lower Extremities Varicosities Stretch/Dilate Congestion Heart VEIN YAN NA MAY VALVE LOL Will turn into REDDISH or BLUISH color Vein (Valves) Legs Heart Artery  Causes: Prolonged standing  Presence of:  Bluish/Reddish Lower Extremity  Heat  Heaviness / Numbness  Cramping sensation  Diagnostic Test  Trendelenburg Test  Draining of blood on lower extremities  Then stand. observe Saphenous veins how they fill up 1. Use Support Stockings 2. elevate lower extremities 3. When resting. Thrombus – Non-moving Blood Clot 2. Embolus – Moving Blood Clot b. formation of hematoma . Needle out of place 2. Notify Physician b. NEVER Massage affected part a. Inflamed Vein a.