Diagnostic Tests for Aortic Aneurysm

Posted on September 17, 2007 by david

Most aortic aneurysms are found during a routine physical examination or chest X-ray. A physician may also use ultrasound, CT, MRI, and aortoiliac angiography to diagnose the condition.If the patient has an aortic aneurysm, a chest X-ray may show a widening of the mecamylamine silhouette and aortic arch. If the aneurysm is in the abdominal aorta, an abdominal X-ray may show calcification in the aorta’s wall. If the patient reports thoracic pain, the physician also may use an ECG to rule out an MI.

Diagnostic Tests for Aortic AneurysmIf the physician suspects an aortic aneurysm, he may order ultrasonography to confirm the aneurysm and detect thrombus formation. He may order a CT scan to determine the anterior-to­posterior and crosssectional diameters of the aneurysm. A CT scan also helps to detect a thrombus in the pouch of the aneurysm. The physician may use an MRI to help diagnose these aortic conditions. And he may use aortoiliac angiography, an invasive procedure for locating the aneurysm’s exact position, to help determine whether other arteries that receive blood from the aorta are affected by the condition.

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Cause of Hypertensive Retinopathy

Posted on September 13, 2007 by david

Hypertensive retinopathy results from chronic primary hypertension, malignant hypertension, or eclampsia. If untreated, it can lead to retinal detachment. Plus, retinal vessel damage suggests that the patient has suffered damage to other organs, as well.

Pathophysiology

With retinopathy, retinal changes are categorized according to the severity of the vessel damage. Retinal arteriolar narrowing and increased dias­tolic blood pressure are directly related.

Grade I retinal changes may occur when a patient has mildly elevated diastolic blood pressure, about 90 mm Hg. These retinal changes include vascular spasm and arteriolar constriction.

Grade II retinal changes occur when a patient has sustained elevated diastolic blood pressure of more than 100 mm Hg. These retinal changes include localized and generalized arteriole nar­rowing at arteriovenous junctions.

Cause of Hypertensive Retinopathy

If the patient’s hypertension is left untreated and his diastolic blood pressure remains above 100 mm Hg, he may experience grade III retinal changes. Occlusion of the retinal arterioles may cause superficial, flame-shaped hemorrhages and small, white areas of retinal ischemia called soft exudate or cotton wool spots. Hard, yellow ­white exudate may produce a star-shaped figure around the macula.

Further untreated hypertension can lead to grade IV retinal changes. The occluded arterioles cause the optic disk to become congested and edematous, leading to papilledema (swelling of the optic nerve head). Papilledema causes the optic disc margins to become blurred and indistinct. Without treatment, this condition can lead to blindness.

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Nursing Considerations about Diet and Weight Reduction

Posted on September 10, 2007 by david

In helping a hypertensive patient control his weight, your primary responsibilities include educating him about his prescribed diet and monitoring his weight reduction. You’ll also need to regularly measure his blood pressure.Review the elements of the weight-reduction diet with your patient. If appropriate, obtain a referral for a dietitian to assist him and his family with planning appropriate meals. Provide him with suggestions to help him comply with the prescribed diet,Nursing Considerations about Diet and Weight Reduction keeping in mind his food preferences and ethnic background. Also, recommend alternative food choices for patients with poor dentition, food intolerances, and limited physical mobility. And stress the importance of reducing weight to reduce blood pressure.

When teaching your patient, tell him to eat regularly planned meals and to not skip meals. Teach him to measure his foods to determine the correct portions. Also, tell him to avoid foods that are high in fat and sugars and to reduce the amount of fat he uses in cooking. Suggest baking, broiling, or steaming food as a way to eliminate all fried foods from his diet. Also, recommend he reduce fat by removing the skin on poultry before cooking and have him increase his daily intake of fruits and vegetables. And warn your patient to avoid fad and crash diets, which reduce weight only temporarily. Monitor the success of your patient’s weight reduction by recording weekly weights. Don’t measure daily weights because they reflect the body’s fluid status and don’t usually indicate total body weight reduction.

Use ongoing blood pressure measurement to evaluate his body’s response to weight reduction. Blood pressure readings don’t immediately show dramatic decrease. However, some reduction in blood pressure may occur with a weight loss of as little as 10 pounds. Reinforce the success of weight and blood pressure reductions with your patient to encourage ongoing compliance with the prescribed regimen.

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Nursing Considerations for Emergency Hypertension

Posted on September 5, 2007 by david

During treatment and then every hour thereafter, assess your patient’s organ functions until his blood pressure stabilizes. Once his blood pressure is stable, continue your assessments every 4 hours. Immediately report any changes to the physician.Assess your patient’s cardiovascular system for signs and symptoms of heart failure, including increased heart rate, arrhythmias, chest pain, shortness of breath, jugular vein distention, edema, crackles, murmurs, and heart sounds. Listen for carotid and abdominal bruits . Also, palpate peripheral pulses to determine whether they are of equal strength.Nursing Considerations for Emergency Hypertension

Monitor your patient’s neurologic status by determining his level of consciousness, pupil size, reaction to light, limb movement, and reactions to physical stimuli. To determine if his retinal function is impaired, ask him if he has experienced blurred vision, loss of vision, and any other vision changes.

Assess your patient’s renal status by measuring fluid intake and output hourly. Oliguria is the first sign of renal impairment, so immediately report urine output of less than 30 ml per hour for 2 consecutive hours. Obtain a urinalysis for proteinuria and hematuria. Also, obtain laboratory studies to detect rising BUN and creatinine levels.

When administering a parenteral drug to initially reduce your patient’s blood pressure, be sure to titrate the dosage based on the prescribed target pressure. Following the physician’s guidelines, decrease the dosage or discontinue the drug if the patient’s blood pressure drops below the target level.

While you titrate the dosage, monitor your patient’s blood pressure and MAP every 1 to 5 minutes, using an intra-arterial line. Intra-arterial pressure monitoring reflects systemic vascular resistance, not just blood flow.

When using intra-arterial blood pressure monitoring, remember to immobilize the insertion site and keep it visible. If the line is ejected or the tubing becomes detached, the patient can quickly lose a great deal of blood.

Familiarize yourself with the tubing and stop­cock positions. Set the alarm parameters 10 to 20 mm Hg above and below the patient’s baseline blood pressure and leave the alarm on at all times.

To ensure accurate readings, level the transducer’s air reference point at the phlebostatic axis-an imaginary line between the fourth intercostal space and the anteroposterior chest wall. And compare the arterial line pressure with the cuff pressure at least once per shift.

If direct blood pressure monitoring isn’t available, use an automated blood pressure monitoring machine. Monitor blood pressure and MAP every 15 to 30 minutes after your patient’s blood pressure stabilizes.

To prevent orthostatic hypotension, a common adverse effect of antihypertensive drugs, keep your patient on bed rest and help him change positions slowly. When his blood pressure stabilizes, administer an oral antihypertensive drug, as ordered, and monitor his blood pressure every 1 to 2 hours.

To relieve your patient’s anxiety, explain all procedures, monitoring equipment, and unfamiliar sounds. Also, explain why he must remain in the ICU. Don’t overwhelm him with too much information, but try to allay his fears by discussing his concerns and by making him as comfortable as possible.

Determine the extent of your patient’s pain and the severity of his headaches. Provide analgesics and anxiolytics, as prescribed, and monitor their effectiveness. Maintain a quiet environment and, if possible, place your patient in a private room. Reassure him that efforts are being made to reduce his blood pressure.

What to Tell The Home Care Nurse?

When your patient is discharged after treatment for emergency hypertension, give this information to his home care nurse:

  • systolic and diastolic blood pressures at the time of discharge
  • blood pressure abnormalities to report to the patient’s physician
  • time of the last dose of each drug given in the hospital
  • physical assessment findings upon discharge, including cardiovascular, neurologic, retinal, and renal findings
  • a list of patient-education topics covered in the hospital and a note indicating which points may need reinforcement
  • observations of interactions between the patient and his family
  • an assessment of the patient’s ability to handle stress and a list of coping mechanisms that worked and didn’t work during his hospitalization.

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How to Measure Blood Pressure?

Posted on September 4, 2007 by david

You can measure a patient’s blood pressure directly or indirectly. To measure it directly, you’ll need an arterial catheter attached to a pressure measuring monitor. To measure it indirectly, you’ll need a blood pressure cuff, a stethoscope, and a sphygmomanometer, such as a mercury gravity or aneroid type.When performed correctly, indirect measurements are within 5 mm Hg of direct measurements. To measure blood pressure indirectly, first place an appropriate-sized blood pressure cuff on the patient’s arm. Then, place the bell of the stethoscope over the artery distal to the cuff. Next, inflate the cuff 30 mm Hg beyond the patient’s systolic pressure, at which point blood flow in the artery stops. Then, lower the cuff pressure and auscultate for Korotkoff sounds.

Korotkoff sounds

During auscultation, you’ll hear five Korotkoff sounds or phases. Phase 1 is characterized by a faint, clear, rhythmic tapping gradually increasing in intensity. The first sharp thump you hear is the systolic blood pressure, and this sound is produced by blood rushing into the collapsed artery as the pressure in the cuff decreases. The force of the blood determines the intensity of the sound.How to Measure Blood Pressure

Phase 2 begins when murmuring or swishing sounds are produced by blood flowing through the narrowed artery under the pressure cuff and into a wider artery distal to it. The difference in artery widths creates currents that cause the blood and vessel walls to vibrate. These sounds may temporarily disappear, particularly in hypertensive patients, and this silence is called the auscultatory gap. If you don’t detect the auscultatory gap, you may underestimate the patient’s systolic blood pressure or overestimate his diastolic pressure.

Phase 3 begins when the murmur of phase 2 disappears and the sounds begin to increase in intensity and clarity. In phase 3, the compressed vessel opens during systole but closes during diastole.

Phase 4 occurs when the sounds become muffled and less intense. This phase is referred to as the first diastolic pressure.

Finally, the sounds disappear completely in phase 5, also called the second diastolic pressure. During this phase, the vessel is completely open, and blood flows freely through the artery. At this point, you can palpate a strong radial pulse

Capillaries

Capillaries are the smallest and most numerous vessels in the arterial circulatory system. The walls of the capillaries consist of a fine, transparent, endothelial layer of tissue similar to the inner layer of the arteries. Capillaries have no elastic or muscular tissues, so nutrients and metabolic end products can pass through their thin walls.

Capillaries are interposed between arterioles and venules, creating networks. These networks permeate all tissues, supplying blood and nutrients. The more active the function of an organ or tissue, the greater the network of capillaries with­in it. These networks are typically large in bones and ligaments, smaller in glands and mucous membranes, and nearly absent in tendons.

Capillary networks contain specialized channels called metarterioles and rings of smooth muscle called precapillary sphincters. These sphincters contract and relax, regulating the flow of blood through the capillaries. Blood enters the capillary network as arterial blood, and after the exchange of nutrients and metabolic end products takes place, it exits as venous blood returning to the heart through the venous system .

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Benefits of Exercise Program for Hypertension Patients

Posted on August 31, 2007 by david

When your hypertensive patient begins an exercise program, teach him about the prescribed exercise. Monitor his exercise tolerance and continue to regularly measure his blood pressure.During your patient teaching, tell him to exercise at the same time every day. Instruct him to wear loose-fitting clothing and to wear shoes that properly support his feet. If his exercise consists of walking, tell him to walk at a comfortable pace on level ground. Also, urge him to carry identification and a list of the drugs he’s taking.

Hypertensive patients with other health problems may need special deviBenefits of Exercise Program for Hypertension Patientsces, such as braces or splints, to assist them in an exercise program. Assess your patient’s overall physical status and consult with a physical therapist or cardiac rehabilitation specialist for exercise suggestions.

To help your patient adapt his exercise program to his needs and tolerance level, advise him to measure his pulse rate before and immediately after he exercises. He can use his pulse as a guide to increasing or decreasing his activity. Also, tell him to assess himself after 5 minutes of exercise. He should feel warm, not hot and sweating.

Until the patient knows his exercise tolerance, he should exercise with someone else. Instruct him to stop exercising if he becomes extremely tired, short of breath, dizzy, or light-headed. If he develops chest pain, palpitations, or tingling, numbness, or pain in his arms or legs, he should stop exercising and contact his physician. Tell him to seek emergency care if any of these symptoms persists for more than 15 minutes after the exercise activity is stopped.

Review the key elements of the exercise program with your patient. Provide suggestions to help him comply with the plan and stress the importance of exercise for managing his hypertension. Encourage him to do exercises that he enjoys so that he’ll be more likely to do them regularly.

Advise your patient to set realistic goals and advance his exercise program at his own pace. To ensure compliance, suggest that he join a walking group such as one that walks in malls.

Monitor the success of your patient’s exercise program by checking his blood pressure and resting heart rate weekly. If his blood pressure decreases, emphasize the success of the exercise program to encourage continued compliance.

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Aortic Aneurysm and its Pathophysiology

Posted on August 30, 2007 by david

Aortic aneurysms-dilated segments of the aorta-are more common in men ages 50 to 70. Hypertension increases the risk of a patient developing an aortic aneurysm by accelerating atherosclerosis in peripheral blood vessels. If an aortic aneurysm is larger than 6 mm in diameter, it has a 50% chance of rupturing within a year.

Pathophysiology

An aortic aneurysm results from atherosclerotic plaque formation on the aorta’s walls. These plaques, consisting of lipids, cholesterol, fibrin, and other debris, causeAortic Aneurysm and its Pathophysiology degenerative changes in the aorta’s medial layer. The aorta loses elasticity and becomes weak. The pulsatile flow of the blood places additional stress on the weakened aorta, causing it to dilate, thus forming an aneurysm.

The growth rate of an aortic aneurysm can’t be determined, but the larger the aneurysm, the greater the risk of rupture. An aneurysm can form anywhere along the aorta. But the most common location is the abdominal aorta below the renal arteries. Typically, an abdominal aortic aneurysm involves the iliac arteries at the point of bifurcation.

Aneurysms are divided into two classifications: true aneurysms and false aneurysms. In a true aneurysm, at least one layer of the aorta remains intact. One-fourth of true aneurysms occur in the thoracic region and three-fourths occur in the abdominal region. A true aneurysm may be a fusiform or saccular dilation .

A false aneurysm is a disruption of all three layers of the aorta. This condition results in blood leakage into a contained area.

The rupture of an aortic aneurysm is a life­threatening complication. If the rupture causes bleeding into the retroperitoneal space, it may be stopped by compression from the nearby organs. Bleeding into the abdominal cavity is fatal.

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Restrictions for Hypertension Patient

Posted on August 29, 2007 by david

Alcohol

When obtaining your patient’s health history, ask him how much alcohol he drinks. If appropriate, advise him to reduce his intake to less than 1 ounce per day.

The exact mechanism by which alcohol raises blood pressure isn’t known, but alcohol may increase renin or aldosterone release. Chronic alcohol abuse

Restrictions for Hypertension Patient

can also increase blood cortisol levels, which can aggravate hypertension.

Alcohol consumption also affects weight reduction. Alcohol provides empty calories. Plus, one or two drinks a day can slow a person’s metabolism by as much as 25%. Drinking three or more alcoholic drinks a day also increases a person’s risk of hypertension.

Caffeine

By constricting the peripheral blood vessels, caffeine increases the heart rate and blood pressure. Therefore, you should encourage your hypertensive patient to reduce his intake of caffeinated beverages. Tell him that most drinks such as coffee, tea, and soda are now available in caffeine-free preparations. Also, teach him that many other products contain caffeine, including foods such as chocolate and over-the-counter (OTC) drugs used for the treatment of headaches.

Sodium

You should advise your patient to limit his sodium intake, especially if he’s sodium sensitive. Restricting sodium intake may reduce extracellular fluid and total circulating blood volume, thus decreasing the heart’s workload.

Sodium may interfere with the effectiveness of certain antihypertensive drugs. Thus, by limiting his sodium intake, the patient may be able to control his blood pressure with lower doses of antihypertensive drugs. And by using lower dosages, he will have less risk of developing adverse effects from the drugs.

Usually, sodium is restricted to 2 grams of sodium or 5 grams of salt per day. A patient can achieve this restriction by not adding table salt to food and by avoiding foods that are high in sodium.

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Coronary Artery Disease

Posted on August 27, 2007 by david

Hypertension is a major modifiable risk factor for CAD. Normally, CAD takes years to develop, but hypertension accelerates the atherosclerotic process that causes CAD. Then, as CAD progresses, the resulting arterial narrowing worsens the hypertension.

Its Pathophysiology

In CAD, atherosclerotic plaques collect in the arteries. These deposits, which line the intimal layer, consist of cholesterol and lipids.

In a person with hypertension, the elevated blood pressure causes high shear stress,Coronary Artery Disease speeding the atherosclerotic process. As a result, the artery’s endothelial lining is injured. Then, platelets begin to accumulate at the site of the damage, resulting in a denuding injury.

Alternatively, hypertension can result when CAD causes a non denuding injury. After the endothelium is damaged, low-density lipoproteins (LDLs) and growth factor from platelets stimulate smooth-muscle proliferation and arterial-wall thickening. Smooth-muscle cells proliferate, trapping lipids. Over time, the lipids calcify and irritate the endothelium, causing platelets to adhere and aggregate. Thrombin is generated, and fibrin and thrombi form.

With denuding and nondenuding injuries, the thickened walls of atherosclerotic arteries lose their elasticity. Thus, the heart must beat harder to pump blood through the restricted vessels, increasing blood pressure even more .

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How to Identify Hypertension

Posted on August 24, 2007 by david

How to Identify HypertensionAt first, many patients with hypertension have no symptoms. As the disease progresses, some patients actually become accustomed to its symptoms-headaches, dizziness, and blurred vision­and view them as insignificant. Thus, diagnosing and treating hypertension may require a thorough patient assessment. This usually includes obtaining and interpreting a patient’s health history, performing a physical examination, taking blood pressure readings, and monitoring the results of diagnostic tests.You also may use your assessment skills to help identify someone who may develop hypertension. And you may use them to evaluate a patient who has just been diagnosed with hypertension, to monitor a hypertensive patient’s treatment, and to detect complications resulting from hypertension.

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