What is Diastole?

Relaxation of myocardium

what is Stroke Volume?

–      The amount of blood ejected from the ventricle with each heartbeat

What is Cardiac output?

–      Amount of blood pumped by each ventricle in 1 minute- CO= SV x HR

How do you determine Cardiac index?

CO divided by body surface area

–      Preload

–      Volume of blood in ventricles at the end of diastole

–      Contractility

–      Afterload

–      Peripheral resistance against which the left ventricle must pump 

§  Blood vessels

§  Arteries, arterioles

§  Veins, venules

§  Capillaries

–      Autonomic nervous system

–      Baroreceptors

–      Chemoreceptors

What is blood pressure?

How is it calculated?

•       Measurement of arterial blood pressure

•       Pulse pressure

•       Mean arterial pressure(MAP)

•       Calculate MAP

•       (SBP + 2DBP) / 3

–      Noninvasive studies

–      Blood studies

–      Chest x-ray

–      Electrocardiogram

–      Resting ECG

–      Ambulatory ECG monitoring

–      Event monitor or loop recorder

–      Exercise or stress testing

–      6-minute walk test

–      Persistent elevation of

–      Systolic blood pressure ≥140 mm Hg

–      OR

–      Diastolic blood pressure ≥90 mm Hg

–      OR

–      Current use of antihypertensive medication(s)

–      Elevated BP without an identified cause

–      90% to 95% of all cases

–      ↑ SNS activity

–      ↑ Sodium-retaining hormones and vasoconstrictors

–      Diabetes mellitus

–      Ideal body weight

–      ↑ Sodium intake

–      Excessive alcohol intake

Secondary hypertension

–      Elevated BP with a specific cause

–      5% to 10% of adult cases

–      Coarctation of aorta

–      Renal disease

–      Endocrine disorders

–      Neurologic disorders

–      Cirrhosis

–      Sleep apnea

–      Family history

–      Obesity

–      Ethnicity

–      Sedentary lifestyle

–      Socioeconomic status

–      Stress

–      Water and sodium retention

–      Certain demographics are associated with “salt sensitivity.”

–      Altered renin-angiotensin mechanism: High plasma renin activity

–      Endothelial cell dysfunction

Referred to as the “silent killer” because patients are frequently asymptomatic until target organ disease occurs

–      Symptoms are often secondary to target organ disease and can include

–      Fatigue, reduced activity tolerance

–      Dizziness

–      Palpitations, angina

–      Dyspnea

Target organ diseases occur most frequently in the

–      Heart

–      Brain

–      Peripheral vasculature

–      Kidney

–      Eyes

Hypertensive heart disease complications

–      Coronary artery disease

–      Left ventricular hypertrophy

–      Heart failure

Hypertension Complications

–      Coronary artery disease

–      Left ventricular hypertrophy

–      Heart failure

Hypertension Diagnostic Studies

–      History and physical examination

–      Bilateral BP measurement

–      Use arm with higher reading for subsequent measurements.

–      BP is highest in early morning, lowest at night.

–      Urinalysis, creatinine clearance

–      Serum electrolytes, glucose

–      BUN and serum creatinine

–      Serum lipid profile

–      ECG

–      Echocardiogram

“White coat” phenomenon may precipitate the need for ambulatory blood pressure monitoring (ABPM).

Noninvasive, fully automated system that measures BP at preset intervalsover 24-hour period

–      Use auscultation with a properly calibrated instrument.

–      Patient should be seated quietly for 5 minutes in a chair, with feet on the floor and arms supported at heart level.

–      Use appropriately sized cuff to ensure accurate readings.

–      Obtain at least two measurements. 

–      Control blood pressure

–      Reduce CVD risk factors

–      Strategies for adherence to regimens

–      Empathy increases patient trust, motivation, and adherence to therapy.

–      Consider patient’s cultural beliefs and individual attitudes when formulating treatment goals

Lifestyle modifications

–      Weight reduction: Weight loss of 10 kg
(22 lb) may decrease SBP by approx 5 to
20 mm Hg

–      DASH eating plan

(Dietary approaches to stop HTN) 

–      Reduce SVR

–      Reduce volume of circulating blood

Thiazide diuretics

Loop diuretics

Potassium sparing

Aldosterone receptor blockers

Angiotensin-Converting Enzyme Inhibitors (ACE- inhibitors)

Angiotensin II receptor blockers (ARB’s)

Direct Vasodilators

Calcium Channel Blockers

Beta Adrenergic Blockers

–      Furosemide (Lasix)

–      Bumetanide (Bumex)

–      Torsemide (Demadex)

"ides"

–      Metolazone (Zaroxolyn)

–      Spironolactone (Aldactone)

–      Lisinopril (Zestril, Prinivil)

–      Quinapril (Accupril)

–      Captopril (Capoten)

–      Enalapril (Vasotec)

–      Ramipril (Altace)

–      Primary effects to lower BP

–      Interfere with enzyme conversion necessary for production of Angiotensin II

"prils"

–      Candesartan (Atacand)

–      Losartan (Cozaar)

–      Olmesartan (Benicar)

–      Valsartan (Diovan)

–      Primary effects to lower BP

–      Produce vasodilation and increased salt and water excretion

"sartans"

Calcium Channel Blockers drugs?

–      Atenolol (Tenormin)

–      Metoprolol (Lopressor)

–      Nadolol (Corgard)

–      Propanolol (Interal)

–      Carvedilol (Coreg)

–      Primary effects to lower BP

–      Blocks beta receptors in the heart and peripheral vessels, reducing cardiac rate and output

"olol's"

–      Identify, report, and minimize side effects.

–      Orthostatic hypotension

–      Sexual dysfunction

–      Dry mouth

–      Frequent urination

–      Potential complication: Adverse effects from antihypertensive therapy

–      Potential complication: Hypertensive crisis

–      Potential complication: Stroke

–      Potential complication: Myocardial infarction

–      Achieve and maintain the individually determined goal BP.

–      Understand, accept, and implement the therapeutic plan.

–      Experience minimal or no unpleasant side effects of therapy.

–      Be confident of ability to manage and cope with this condition.

Isolated systolic hypertension (ISH)

Isolated systolic hypertension (ISH): Most common form of hypertension in individuals age >50

Older adults are more likely to have “white coat” hypertension.

Often a wide gap between the first Korotkoff sound and subsequent beats is called the auscultatory gap.

Failure to inflate the cuff high enough may result in serious underestimation of the SBP.

Older adults have varying degrees of impaired baroreceptor reflex mechanisms.

Consequently, orthostatic hypotension occurs often, especially in patients with ISH.

Peripheral Artery Disease (PAD)

·      Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities

·      Atherosclerosis is the leading cause in majority of cases.

·      Typically appears at ages 60s to 80s

·      Largely undiagnosed

·      Cigarette smoking

·      Hyperlipidemia

·      Hypertension

·      Diabetes mellitus

Classic symptom of PAD

intermittent claudication

·      Ischemic muscle ache or pain that is precipitated by a constant level of exercise

·      Resolves within 10 minutes or less with rest

·      Reproducible

Manifestations of PAD

·      Paresthesia

·      Numbness or tingling in the toes or feet

·      Produces loss of pressure and deep pain sensations

·      Injuries often go unnoticed by patient

·      Pain at rest

·      Occurs in the forefoot or toes

·      Aggravated by limb elevation

·      Occurs from insufficient blood flow

·      Occurs more often at night

Complications of PAD

·      Atrophy of the skin and underlying muscles

·      Delayed healing

·      Wound infection

·      Tissue necrosis

·      Arterial ulcers

·      Nonhealing arterial ulcers and gangrene are most serious complications.

·      May result in amputation if blood flow is not adequately restored, or if severe infection occurs

Assessment Data for PAD

·      Thin, shiny, and taut skin

·      Loss of hair on the lower legs

·      Diminished or absent pedal, popliteal, or femoral pulses

·      Pallor of foot with leg elevation

·      Reactive hyperemia of foot with dependent position

Diagnostic Studies for PAD

·      Doppler ultrasound   

·      Segmental blood pressures

·      Ankle-brachial index (ABI)

·      Duplex imaging

·      Bidirectional, color Doppler

Collaborative Care for PAD

·      Smoking cessation, including use of nicotine products

·      Aggressive treatment of hyperlipidemia

·      BP maintained <140/90

·      Glycosylated hemoglobin <7.0% for diabetics

·      Antiplatelet agents

·      Aspirin

·      Clopidogrel (Plavix)

·      ACE inhibitors

Drugs prescribed for treatment of intermittent claudication

·      Pentoxifylline (Trental)

·      Cilostazol (Pletal)

Exercise improves oxygen extraction in the legs and skeletal metabolism.

Walking is the most effective exercise for individuals with claudication.

30 to 60 minutes daily

Past health history for PAD?

·      Diabetes mellitus

·      Smoking

·      Hypertension

·      Hyperlipidemia

·      Obesity

Nursing Assessment of PAD

·      Exercise intolerance

·      Loss of hair on legs and feet

·      Decreased or absent peripheral pulses

Acute Ischemic Disorders

·      A sudden interruption in the arterial blood supply to a tissue, organ, or extremity that, if left untreated can result in tissue death.

Six “P”’s?

·      Pain

·      Pallor

·      Paralysis

·      Pulselessness

·      Parasthesia

·      Poikilothermia 

Collaborative Care for Acute Ishemic disorder?

·      Early treatment

·      IV Heparin

·      Prevent thrombus enlargement and inhibit further embolization

·      Long term prevention

·      Warfarin (Coumadin)

·      Lab- INR

Buerger’s Disease

·      Thrombosis and fibrosis occur in blood vessel walls causing tissue ischemia.

·      Intermittent claudication of the feet, hands, or arms

·      Rest pain

·      Ischemic ulcerations

·      Color and temperature changes

·      Parasthesia

·      Superficial vein thrombosis

·      Cold sensitivity

Raynaud’s Phenomenon

·      Episodic vasospasms of small arteries

·      Color changes- red, blue, white

Teaching for Raynauds

·      Protect from cold

·      Avoid temperature extremes

·      Warm water often decreases vasospasm

·      Stop tobacco products

·      Avoid caffeine/amphetamines/cocaine/pseudoephedrine

Venous Thrombosis

·      Unilateral edema

·      Extremity pain

·      Sense of fullness

·      Parasthesia

·      Warm skin

·      Erythema

·      Positive Homan’s sign

Chronic Venous Insufficiency 

·      Common in elderly

·      Valves in veins damaged

·      Retrograde blood flow/pooling of blood in legs/swelling

·      Leads to venous leg ulcers

Causes for Chronic venous insuff.

·      Vein valve incompetence

·      Deep vein obstruction

·      Congenital venous malformation

·      AV fistula

Clinical Manifestations of Chronic venous insuff?

·      Skin of lower leg is leatherly

·      Brown color appearance of skin

·      Edema

·      Eczema-stasis dermatitis

·      Itching is a major complaint because of eczema

·      Higher skin temperature in ankle area

Venous Ulcers

·      Classically located above the medial-malleolus

·      Painful especially if edema or infection present

·      Pain is worse in dependent position

·      Heavy drainage present

·      Can develop infection and cellulitis

Collaborative Care for venous ulcers?

·      Compression

·      Essential treatment for CVI and venous ulcer healing and prevention of ulcer recurrence

Teaching for venous ulcers?

·      Daily moisturizing

·      Avoid standing or sitting for long periods

Aortic Aneurysm

Outpouchings or dilations of the arterial wall

·      Common problems involving aorta

·      Occur in men more often than in women

·      Incidence ↑ with age

·      Occur in 18% of men and 5% of women over 60

·      Most occur below renal arteries.

Abdominal Aortic Aneurysm

·      Dilated aortic wall becomes lined with thrombi that can embolize.

·      Leads to acute ischemic symptoms in distal branches

Causes of Abd aortic aneurysm?

Penetrating or blunt trauma

Thoracic aorta aneurysms 

·      Often asymptomatic

·      Most common manifestation

·      Deep diffuse chest pain

·      Pain may extend to the interscapular area.

Ascending aorta/aortic arch

·      Edema of head and arms 

Abdominal aortic aneurysms (AAA)

·      Often asymptomatic

·      Frequently detected On physical exam When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

·      May mimic pain associated with abdominal or back disorders

·      May spontaneously embolize plaque

·      Causing “blue toe syndrome”

·      Patchy mottling of feet/toes with presence of palpable pedal pulses

Rupture into retroperitoneal space

·      Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death.

·      Severe pain

·      May/may not have back/flank ecchymosis

Rupture into thoracic or abdominal cavity

·      Massive hemorrhage

·      Most do not survive long enough to get to the hospital.

X-rays for Aortic aneurysms

·      Chest—demonstrate mediastinal silhouette and any abnormal widening of thoracic aorta

·      Abdomen—may show calcification within wall of AAA

·      ECG—to rule out MI

Diagnostic Studies for Aortic aneurysms

·      Echocardiography

·      Assists in diagnosis of aortic valve insufficiency

·      Ultrasonography

·      Useful in screening for aneurysms

·      Monitors aneurysm size

·      CT scan

·      Most accurate test to determine

·      Anterior-to-posterior length

·      Cross-sectional diameter

·      Presence of thrombus

·      MRI

·      Diagnose and assess the location and severity

·      Goal—prevent aneurysm from rupturing

·      Early detection/treatment imperative

Collaborative Care for Aortic aneurysms

5.5 cm is threshold for repair

Intervention at >5 cm in women with AAA

Risk factor modification for AA

·      ↓ blood pressure

·      Ultrasound, MRI, CT scan monitoring annually

Surgical therapy for AorticAnuerysms

If ruptured, emergent surgical intervention required

90% mortality with ruptured AAAs

Aortic Aneurysms

·      Thorough history and physical exam

·      Watch for signs of cardiac, pulmonary, cerebral, and lower extremity vascular problems.

·      Establish baseline data to compare postoperatively

·      Note quality and character of peripheral pulses and neurologic status.

·      Mark/document pedal pulse sites and any skin lesions on lower extremities before surgery.

·      Monitor for indications of rupture.

·      Diaphoresis

·      Paleness

·      Weakness

·      Tachycardia

·      Hypotension

How to Monitor for indications of rupture.

·      Abdominal, back, groin, or periumbilical pain

·      Changes in level of consciousness

·      Pulsating abdominal mass

Health Promotion to prevent Aortic Aneurysms

·      Alert for opportunities to teach health promotion to patients and their caregivers

·      Encourage patient to reduce cardiovascular risk factors.

·      These measures help ensure graft patency after surgery.

Aortic Dissection

Often misnamed “dissecting aneurysm”

·      Not a type of aneurysm

·      Result of a false lumen through which blood flows

·      Classified by location and duration of onset

Pathophysiology of Aortic dissection

·      Due to degeneration of the elastic fibers in the medial layer

·      Tear in intimal lining allows blood to “track” between intima and media.

·      As heart contracts, each systolic pulsation ↑ pressure on damaged area

·      Further ↑ dissection

·      May occlude major branches of aorta

·      Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities

Pain characterized as ______ in Aortic dissections 

·      Sudden, severe pain in anterior part of chest, or intrascapular pain radiating down spine to abdomen or legs

·      Described as “sharp” and “worst ever”

·      May mimic that of MI 

·      Aorta may rupture.

·      Results in exsanguination and death

·      Hemorrhage may occur in mediastinal, pleural, or abdominal cavities.

·      Occlusion of arterial supply to vital organs

·      ↓ BP and myocardial contractility to diminish pulsatile forces within aorta Conservative therapy

·      If no symptoms

·      Can be treated conservatively for a period of time

·      Pain relief and BP control