HTN
a. Beta blocker like Metoprolol to decrease contractility and blood pressure b. Calcium channel blocker like Nicardipine to decrease contractility and BP c. Possibly a vasodilator like Hydralazine to decrease afterload d. Would NOT expect a diuretic because her lungs are clear and she is oxygenating well -there's no sign of volume overload
3. What medications do you anticipate the provider ordering for Mrs. Phillips? Upon further assessment, Mrs. Phillips' lungs are clear, pulses are 2+ bilaterally in radial and pedal pulses, S1/S2 are present with no extra sounds. Her vital signs were as follows: BP 216/108 mmHg Ht 162 cm HR 92 bpm and regular Wt 107 kg RR 20 bpm SpO2 96% on Room Air Temp 36.9°C
a. Administer 10 mg Hydralazine IV push (ordered PRN for SBP>200) b. Recheck blood pressure in 30 minutes c. Notify provider of blood pressure not responsive to medications
4. Which order should you implement first? Why? You initiate two large bore IV's for Mrs. Phillips and send off blood work. You administer 5 mg Metoprolol over slow IV push and attach Mrs. Philips to a bedside cardiac monitor. She is still complaining of 7/10 pain in her head, so you also administer 2 mg Morphine IV push. You return 30 minutes later to take another set of vital signs and find the following: BP 204/102 mmHg Pain 7/10 HR 86 bpm SpO2 94% on Room Air RR 14 bpm Mrs. Phillips's lab results have also resulted, the following abnormal values were reported: Glucose 193 mg/dL Hgb A1c 9.2% BNP 160 pg/mL
a. Based on her weight, this patient is obese b. Based on her A1c, this patient is a diabetic c. She is an African American female which also puts her at higher risk
6. What risk factors have you identified that put Mrs. Phillips at risk for hypertensive crisis? You initiate two large bore IV's for Mrs. Phillips and send off blood work. You administer 5 mg Metoprolol over slow IV push and attach Mrs. Philips to a bedside cardiac monitor. She is still complaining of 7/10 pain in her head, so you also administer 2 mg Morphine IV push. You return 30 minutes later to take another set of vital signs and find the following: BP 204/102 mmHg Pain 7/10 HR 86 bpm SpO2 94% on Room Air RR 14 bpm Mrs. Phillips's lab results have also resulted, the following abnormal values were reported: Glucose 193 mg/dL Hgb A1c 9.2% BNP 160 pg/mL
a. Dropping the blood pressure too low too fast can cause perfusion issues. The organs are used to perfusing at a higher blood pressure. This phenomenon is called relative hypotension. The patient can experience signs of hypotension even with a numerically high blood pressure because their body is used to the high pressures. b. The goal is to decrease the blood pressure by max 20% for the first 6-12 hours, then to aim for a SBP of 160 mmHg with IV or short-acting PO antihypertensives, then to transition to long-acting PO meds to target a SBP < 140.
7. Why don't the providers want her SBP going below 180 mmHg at this time? Mrs. Phillips' blood pressure after the Hydralazine 10mg IV push went up to 218/110 and her heart rate went up to 104 bpm. She is transferred to the ICU to be started on a Nicardipine infusion, which is initiated at 2.5 mg/hr to keep her SBP between 180-200 mmHg.
a. Diet & Lifestyle changes - she needs to be on a low-sodium diet and needs to lose weight. She should also cut caffeine and try to decrease stress. b. Medication management - Mrs. Phillips should be taught how to prevent orthostatic hypotension by rising slowly, and what symptoms to report to her provider. Also, make sure she knows the schedule for taking her meds so that she doesn't take them all at the same time and experience hypotension. c. Follow-Up - she needs to see a healthcare provider regularly and should probably start checking her blood pressure at home or at a local pharmacy. Because hypertension can be asymptomatic, it's important that she continues to take her medication and monitor her blood pressure even after she feels better. She will also likely need to follow up with a neurologist because of her stroke
9. What education topics would you want to provide to the patient before discharge? Mrs. Phillips is taken to the OR to evacuate a large subarachnoid hematoma from around her brain. You inform her family that she has had a hemorrhagic stroke because of her high blood pressure. After 2 days in the ICU, she has recovered all movement in her arms, her speech and facial symmetry are normal, and she has been transitioned from IV Nicardipine to PO metoprolol, amlodipine, and hydrochlorothiazide. She is tolerating these medications well and has been ambulating to the bathroom easily as needed. Her blood pressure is now averaging 140-150 systolic. She tells you she had no idea that she had high blood pressure, she's never been sick or even felt bad until she got the headache. She reports not getting yearly check-ups because she "felt fine". She will be discharged on the same medications tomorrow.
a. Full Pain assessment (PQRST or OLDCARTS) b. Full set of Vital signs i. Ensure proper fitting blood pressure cuff c. Heart sounds, lung sounds d. Peripheral perfusion (pulses, cap refill) e. Pupillary assessment
1. What initial nursing assessments need to be performed for Mrs. Phillips? Mrs. Phillips, a 43-year old African American female, presents to the Emergency Department (ED) complaining of the worst headache of her life. She says it started about 3 hours ago. She reports taking 1,000 mg of Acetaminophen with no relief. Upon further questioning, Mrs. Phillips also reports blurry vision. She denies any past medical history.
a. Her blood pressure is extremely high. This combined with the headache and vision problems indicate she may be experiencing hypertensive crisis
2. What are your top concerns for Mrs. Phillips at this time? Why? Upon further assessment, Mrs. Phillips' lungs are clear, pulses are 2+ bilaterally in radial and pedal pulses, S1/S2 are present with no extra sounds. Her vital signs were as follows: BP 216/108 mmHg Ht 162 cm HR 92 bpm and regular Wt 107 kg RR 20 bpm SpO2 96% on Room Air Temp 36.9°C
a. Mrs. Phillips is in hypertensive crisis. Because her blood pressure is extremely high, it has caused a bleed within the vessels of her brain - leading to a hemorrhagic stroke.
What, physiologically, is going on with Mrs. Phillips at this time? Shortly after arriving in the ICU, Mrs. Phillips is no longer able to speak, the right side of her face is drooping, and she cannot lift her right arm. You check another set of vital signs to find her BP is 208/112 mmHg, HR 110, SpO2 92%.
Family history Diabetes Smoking ETOH use Past Cardiovascular, Stroke, renal/thyroid disease.
what is Assessment?
120/80 normal 120-129/80 elevated 130-139/80-89 stage 1 140/90 stage 2 180/120 hypertensive crisis
what is BP values?
Assess BP in 3 separate readings >140 SBP >90 DBP
what is Diagnostics Data?
DIURETIC D-Daily Weight I-Intake and Output (I & O) U-Urine Output R-Response of BP E-Electrolytes T-Take Pulses I-Ischemic Episodes (TIA) C-Complications: The 4 Cs on Hypertension
what is Hypertension - Nursing care Mnemonic? For patients with elevated blood pressure, monitor daily weights, intake and output, and urine output to watch for fluid retention. Monitor blood pressure and pulse in response to treatments. Diuretics may cause increased loss of electrolytes in the urine.
Control BP down to a safe level Fluid Restriction Cardiopulmonary assessment (heart sounds, lung, pulses, edema-looking for s/s of fluid overload in the lungs{crakles}, edema, murmurs) Promote rest Decrease Stress Medications (antihypertensives) Assess BP & HR before administering meds Assess and Manage Pain (PQRST) Promote Optimal CO Optimize Activity Tolerance Educate the PT (disease process, tx, dietary changes)
what is Nursing Interventions?
Elevation in Blood Pressure Primary Secondary - atherosclerosis, endocrine disorders, excess aldosterone, cortisol, or catecholamines.
what is Pathophysiology of HTN?
DASH (Dietary Approaches to Stop Hypertension) low SA No processed/canned food Limit Caffeine/alcohol Lifestyle Changes Exercise Smoking Cessation Reduce WT Follow-up Annual Check-ups Cardiology visits At-home BP monitoring
what is Patient Education
PRIMARY Ethnicity (African Americans) Age (older) Family Hx WT (Obesity) Sedentary lifestyle lack of Vitamin D lack of K+ high SA intake Stress SECONDARY kidney/adrenal/thyroid problems congenital blood vessel defects drug use smoking alcohol
what is Risks factors?
Record I&O Assess CV changes SA restrictions WT reduction Assess renal and neuro status smoking cessation
what is Therapeutic Management of HTN?
Strokes (cerebrovascular accidents) Hypertensive Encephalopathy (confusion, headahce, convulsion) Hypertensive Retinopathy (retinal vascular damage - s/s reduced vision, eye swelling, bursting of a blood vessel, double vision accompanied by headaches. MI HF >blood sugar Chronic renal failure The 4 C's C-Coronary Artery Disease C-Congestive Heart Failure C-Cerebral Vascular Accident C-Chronic Renal Failure Complications of untreated hypertension
what is complications?
ACE Inhibitors (antihypertensive) ARBs Beta-Blockers (antihypertensive) (olol's) CCB's (antihypertensive) (pines) Diuretics (ides)
what is medications? ACE & ARBs=decrease H2O->vasodilation Beta=slows HR->lowers BP CCBs=relax smooth muscles->vasodilation
Epistaxis (nose bleed) Kidney failure Change in LOC Evidence of Stroke
what is objective data HTN assessment?
Headaches SOB Visual Changes Dizzines Chest Pain/Angina
what is subjective data HTN assessment