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					Chronic Midterm 18 Questions                    Page 1 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD         T. Lyons & L. Jones

Hypertension: The Silent Killer
   A. Can hide for years
   B. Quietly ravaging vital body organs
   C. Assaults fragile tissues in eyes, brain, kidneys, and heart
   D. Hardens arteries and arterioles
   E. Enlarges and weakens the heart
   F. Leads to CHF, PVD (peripheral vascular disease)
   G. Primary cause of MIs and CVAs
   H. Readily treatable once detected
   I. Screening= important to test everyone for high blood pressure regardless of
       symptoms!!!
What Causes Heart Disease?
   J. Heart disease leading cause of death in US
   K. 3 Major Contributors to Heart Disease:
       1. hypertension (HTN)
       2. hyperlipidemia
       3. smoking
Definition
   L. Amount of force of blood against the walls of the arteries as it is pumped through
       them-very important to be comfortable with this definition for teaching patient
       purposes.
   M. Systolic=force of heart’s contraction as it pumps blood out of L ventricle.
       1. HTN is persistent elevation of systolic pressure > 140 mmHg.
       2. Among older adults, systolic bp readings are a better predictor of possible
             future events.
   N. Diastolic=resting tone of the arteries.
       1. HTN is persistent elevation of diastolic pressure > 90 mmHg.
       2. Increased diastolic = overworking of the heart.
      3. Worry about increased diastolic pressure b/c the heart should be resting!
   O. Normal= less than 140/90
Chronic Midterm 18 Questions                  Page 2 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD       T. Lyons & L. Jones

Incidence of Hypertension (which is polygenic and multifactorial)
   P. 50 million Americans age 6 and over r/t obesity and lack of exercise.
   Q. 1/3 of the people with HTN do not know they have the disease
   R. Of those people that are aware they have HTN, 70-75% not controlled with very
       high bp.
   S. Primary/essential HTN= there is no single cause (95%); multitude of causes.
       Idiopathic-lifestyle, genetics, etc.
   T. Secondary HTN: physical cause that can be treated or cured, adrenal gland
       tumors, kidney disorders, drugs (5%). Tumors can cause high bp, but once they
       are removed, that should cure the high bp. Meds such as birth control pills,
       alcohol, coaine can also cause high bp.
   U. White coat HTN: elevated only at doctor’s office.
   V. Malignant = diastolic >110, very serious, medical emergency-can lead to stroke
       or death.
Major Risk Factors
   W. Non-Modifiable
       1. Family history
       2. Age-older = increased incidence
       3. Gender-Initially, M>W, then after menopause, W=M
       4. Ethnicity – African American Women die the most from HTN.
   X. Modifiable
       1. Stress – emotional or physical
       2. Obesity – upper body obesity/apple shaped is greater threat.
       3. Nutrients – increased sodium and fat.
       4. Substance abuse – alcohol intake, amphetamines, illicit drug use, and
           caffeine.
Symptoms – important to take thorough history: E.g. stress, family history, diet,
   exercise, habits, height, weight, proportions, blood pressure, etc. To take bp, patient
   should ideally wait 30 minutes before checking bp in Dr.’s office. Use correct cuff
   size and take b.p. on a bare arm. If elevated or abnormal, take it on both arms.
   Check pedal pulses, breath sounds, eyes with fundiscope for microhemorrhages, neck
Chronic Midterm 18 Questions                   Page 3 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD        T. Lyons & L. Jones

   for bruits and distended veins. Check lab values on CBC, BUN, Creat, electrolytes,
   HDL, cholesterol and a 12 lead EKG!
   Y. Headache, sometimes with N&V                      BB.          Nocturia-due to kidney
   Z. Drowsiness, confusion, fatigue                       changes
   AA.         Blurred vision-target                    CC.          Dependent edema-e.g.
       organs= brain, eyes, kidneys b/c                    PVD in lower legs and dependent
       of very tiny blood vessels &                        edema
       increased pressure can cause                     DD.          Epistaxis-nose bleeds
       microvasculature problems.                       EE. ***Mainly, no symptoms!
Assessment: Ideally bp should be taken 30 minutes after sitting with the right cuff on a
   bare arm. If elevated, take on both arms. Check for bruits in neck. Look at back of
   eye for micro-hemorrhages.
Blood Pressure Stage: either systolic or diastolic elevations will bring diagnosis.
   FF. High-normal: 130-139/85-89
   GG.         Stage 1: 140-159/90-99
   HH.         Stages 2 and 3: >160/>100
Lifestyle Modification – can teach at anytime. Teach this if patient is at risk, or at high
   normal. These are the 1st recommendations!
   II. Stop smoking
   JJ. Reduce stress
   KK.         Reduce alcohol intake: normal for men – two servings, women – one
       serving. Red wine dilates vessels and small anticoagulant.
   LL. Weight reduction-w/in BMI
   MM.         Exercise – 3-4 times/wk for 30-45 mins.
   NN.         Sodium restriction – American normal (5-15 g); should be 2-4 g.
   OO.         Dietary fat modification – 20-30% or 25-35% of total Kcal.
   PP. Caffeine restriction
   QQ.         Potassium supplementation - diet change with reduced sodium and
       increased K, Mg, and Ca.
DASH Food Plan (p. 1388): Dietary Approaches to Stop Hypertension
   RR.         low fat, high in fruits and vegetables
Chronic Midterm 18 Questions                   Page 4 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD        T. Lyons & L. Jones

   SS. lowfat or nonfat dairy products-e.g yogurt
   TT.rich in magnesium (potatoes), potassium (cantaloupe), calcium (dark green leafy),
       protein, and fiber
   UU.         low in sodium
   VV.         2000 calories/day
Drug Therapy – all do something a little different
   WW.         Diuretics: may decrease electrolytes and increase glucose levels.;
       decrease blood volume, thereby decrease blood pressure. Fluid/urine output
       increases, so take in a.m., so they can reduce the risk of nocturia.
       1. Thiazide:
       2. Loop: Monitor K levels with Potassium depleting diuretics.
       3. Potassium-sparing
   XX.Selective Beta Blocker-dilate blood vessels and decrease heart rate. Improve
       contractility. Before giving, check apical pulse. Do not give if hr is <50bpm,
       b/c beta blockers reduce heart rate. Side effects: Can induce bronchospasms—
       careful with asthmatics. Cause impotence in men—risk for noncompliance.
   YY.         Nonselective Beta Blocker
   ZZ. Peripheral-acting adrenergic antagonist
   AAA.        Central-acting alpha agonists
   BBB.        Ca Channel blockers: decrease heart rate, increase contractility, dilates
       coronary arteries.
   CCC.        ACE inhibitors-dilates blood vessels and decreases peripheral vascular
       resistance. Can increase K+ levels. Side Effects: dry cough, mouth swelling.
       May need to switch meds with cough.
   DDD.        Alpha-receptor blockers
   EEE.        Alpha-Beta blocker
   FFF.        Vasodilator
   GGG.        Notes about Beta Blockers: Decrease heart rate, dilates blood vessels, and
       improves contractility. Take apical pulse before administering. Possible side
       effects include bronchospasm, CHF, impotence, increased triglycerides and
Chronic Midterm 18 Questions                     Page 5 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD          T. Lyons & L. Jones

       cholesterol. African American people do not respond as well. Try diuretics and
       Ca channel blockers instead.
Stepped-Care Therapy
   HHH.        Step 1: DASH diet and wt redux. Implement lifestyle modifications. If BP
       uncontrolled, move to Step 2.
   III. Step 2: Initial drug therapy + lifestyle modification.If BP uncontrolled, move to
       Step 3. Start low and go slow.
   JJJ. Step 3:Increase med dose or change med or add med. If uncontrolled, move to
       Step 4. Reducing drugs should be considered after 1 yr of effective control.
   KKK.        Step 4: Add 2nd or 3rd med, refer to specialist.
Nursing Actions
   LLL.        Prevention and Education of Public-biggest
   MMM.        Screening-go out and do it
   NNN.        Cultural sensitivity-ethnicity, lifestyles, nutrition, etc.
   OOO.        Family and friends’ lifestyle
   PPP.        Medication: Dosage, side effects, interaction with other meds, alcohol-
       teach about meds.

Managing the Client with Chronic Airway Problems: COPD
I. Chronic Obstructive Pulmonary Disease (obstructive bronchitis, emphysema,
   asthma)
   A. broad classification of disorders
   B. irreversible condition-cannot cure
   C. dyspnea on exertion-biggest symptoms of COPD—find out hoow m8uch exertion
       brings on the client’s dyspnea.
   D. reduced airflow in or out of lungs
   E. over 25% of adult population affected
   F. 4th most common cause of death in U.S.; by 2020, maybe 3rd.
   G. 14 million Americans
Etiology
   H. Interaction between genetics and the environment
Chronic Midterm 18 Questions                   Page 6 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD        T. Lyons & L. Jones

   I. cigarette smoking, air pollution, occupational exposures, chronic lung infections,
       allergies, aging process-(e.g. occ. Exposures such as oil painter with paint fumes)
   J. may develop over 20-30 years
Pathophysiology – COPD includes any or a combination of the following three: Chronic
   Bronchitis, Emphysema, or Asthma.
   K. Chronic Bronchitis – hypoxemia and hypercapnia
       1. Inflammation of the bronchi; first only the larger and then moves down.
       2. Increased mucous production; mucus-secreting glands are hypertrophied.
       3. Chronic cough (3 months/year for 2 consecutive years to diagnose)
       4. Impaired ciliary function-cant clear mucus
       5. Bronchioles become narrow and clogged, especially during expiration.
       6. Alveoli damaged and fibrosed
       7. Decreased O2 + increased CO2 in blood= do NOT GIVE O2 b/c it can
           impair body’s need/desire to breathe. These patients have hypoxic drive
           whereby the low O2 level in the blood actually stimulates their breathing. If
           you give 100% O2, patient may lose their drive to breathe!!!
       8. Mucous secreting glands are hypertrophied and increase production creates a
           barrier to breathing.
       9. Can’t get air in and out = hypoxemia (low O2 in the blood)
       10. May retain CO2 = hypercapnia (Increased CO2 in blood)
   L. Pulmonary Emphysema
       1. Hyperinflation of alveoli
       2. Alveolar walls destroyed
       3. Destruction of alveolar capillary walls causes decreased oxygen perfusion.
       4. Loss of lung elasticity with permanent over distension of air and spaces
           (alveoli)
       5. Patients take in air, but b/c of decreased elasticity, cannot expel it. Barrel
           chested and pressure on diaphragm. ―pink puffer‖—air in, but not out.
Chronic Midterm 18 Questions                    Page 7 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD         T. Lyons & L. Jones

Physical Assessment
                   Chronic Bronchitis: (40-50 yrs)                     Emphysema (50-75 yrs)
           cough                                          minimal cough
           SOB, DOE                                       SOB, DOE
           h/o cigarette smoking                          increased anteroposterior chest (barrel chest)
           hypoxemia, hypercapnia                         hypoxemia
           cyanotic                                       tachypnea
           RBCs polycythemia                             thin, underweight
           normal weight, robust                          Hyperresonance upon percussion
           ―Blue Bloater‖                                 ―Pink Puffer‖
V. Assessment:                                         S. Sleep patterns-e.g. orthopnea—
      M. Speech pattern                                    sleep sitting up in a chair
      N. Distended neck veins                          T. Poor exercise tolerance
      O. Clubbing of digits-esp with                   U. Posture and positioning—
         chronic hypoxemia                                 commonly seen sitting and
      P. Nicotine stains                                   leaning forward in ―3 point
      Q. Peripheral edema-check                            position‖
         peripheral pulses and peripheral              V. ADLs
         edema                                         W. Anxiety
      R. Fatigue, weakness-due to lack of              X. Depression
         O2 or retention of CO2                        Y. Isolation
VI.       Nursing Diagnoses
      A. Impaired Gas Exchange r/t alveolar destruction
      B. Ineffective Airway Clearance r/t excessive mucous
      C. Ineffective Breathing Pattern r/t SOB, mucous
      D. Self-Care Deficit r/t fatigue, SOB
      E. Activity Intolerance r/t fatigue, weakness
      F. Ineffective Individual Coping (Family Coping)
      G. Knowledge Deficit
      H. Anxiety
      I. HR for Infection
Chronic Midterm 18 Questions                    Page 8 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD         T. Lyons & L. Jones

   J. Altered Nutrition r/t dyspnea, fatigue, anorexia, N&V
   K. Body Image Disturbance
   L. Altered Role Performance
   M. Altered Sexuality Patterns r/t SOB, DOE
   N. Impaired Social Interaction
   O. Sleep Pattern Disturbance
Planning
   P. Keep airways open, patent-#1 for all three causes
       1. Stop smoking, passive smoke-e.g. especially important if pt. lives with a
           smoker
       2. Avoid irritants-pollution, chemicals, ozone alerts, extreme cold
       3. Liquefy secretion, humidity : do not want secretions to get clogged up-if they
           dry up, they clog. Keep the secretions liquefied by drinking lots of luid.
       4. Postural drainage, coughing-find out where the secretions are---then loosen
           them for removal by adjusting pt’s positions and chest PT. Use gravity to
           move secretions to trachea where they might be coughed up or suctioned.
       5. Aerosol therapy, bronchodilators; medications to break up secretions.
              E.g. bronchodilators: pill forms or inhalers reduce bronchospasm and
               relaxes bronchial muscle; anticholinergics also inhibit bronchospasm.
       6. Oxygen therapy
       7. Controlled breathing, suctioning-2 kinds to teach on pts who are short of
           breath:
              Pursed lip – prolonging expiration. Flicker candle flame, not blow out.
               a. Inhale through nose; slowly exhale through pursed lips. Exhale
                     should be 2X as long as inhale. Candle: Light it==inhale through
                     nose and exhale over flame without blowing it out.
              Abdominal or diaphragmatic-esp. to cough up secretions. Cough with
               diaphragm.
       8. Increase Fluid Intake
   Q. Prevent infection.
       1. Influenza, pneumococcal vaccines
Chronic Midterm 18 Questions                 Page 9 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD      T. Lyons & L. Jones

       2. Recognize signs/symptoms; Start antibiotics with change in sputum color.
       3. Keep resp. devices clean- e.g. nebulizers
       4. Avoid public exposure
       5. Antibiotics
       6. Steroids cause moon face—given sometimes for acute exacerbations or even
           long-term to tx. COPD.
       7. Teach about sputum color change—possible infection and necessitates
           antibiotics.
   R. Balance rest and activity.
       1. Recognize demands for oxygen
       2. Oxygen therapy
       3. Breathing techniques-e.g. pursed lip and abdominal breathing
       4. Modify home environment-e.g. up and down stairs to go to bedroom= may
           need to sleep downstairs; possible bedside commode
       5. Assistive devices—walker, wheelchairs
       6. Periods of rest
       7. Assistance at home-may benefit from meals on wheels, housekeeping, etc.
   S. Adequate nutrition. They exert a lot of energy breathing.
       1. Easy to prepare foods
       2. Easy to eat foods
       3. High-protein, high-calorie
       4. Small meals-6 small meals a day is a plus! 
       5. Avoid gas-producing foods-to keep down pressure on diaphragm
       6. Meal assistance
       7. Drink fluids between meals (3-4 L if no CHF).
   T. Inter and intra-personal needs met.
       1. Recognize COPD can cause irritability, anxiety, depression
       2. Educate family, friends—include them in the planning
       3. Sexual dysfunction common
       4. Socialization and recreation
       5. Occupational role
Chronic Midterm 18 Questions                    Page 10 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD         T. Lyons & L. Jones

       6. Financial issues – very expensive.
Interventions
  U. Breathing Retraining        Z.   Self-monitoring               EE. Spiritual needs
  V. Bronchial Hygiene           AA. Exercise                       FF. Financial assistance
  W. Oxygen therapy              BB. Nutrition                      GG. Relaxation
  X. Medications                 CC. Sleep                          HH. Family and friends
  Y. Acute episodes              DD. Sexuality



I. Chronic Congestive Heart Failure
   A. Inability of the heart to pump oxygenated blood necessary for effective venous
       return and to meet metabolic demands
   B. circulatory congestion due to decreased myocardial contraction
   C. CO inadequate to maintain blood flow to organs and tissues
   D. Acute CHF is curable. Chronic CHF is IRREVERSIBLE.
Causes of Chronic CHF
   E. Coronary heart disease: MI, hypertension, congenital heart disease,
       cardiomyopathies, arrhythmias
   F. COPD
   G. Heart Failure caused by:
        1. Abnormal loading conditions
        2. Abnormal muscle function
        3. Conditions or diseases that limit ventricular filling.
Physical Assessment
   H. Right-Sided (backward): inability to eject completely.
       1. systemic congestion                              6. fluid in body cavities
       2. peripheral edema                                 7. anorexia, nausea
       3. weight gain w/ fluid                             8. nocturia—b/c of affected
       4. liver, spleen congestion-b/c                         kidneys
           fluid is backing up into them                   9. weakness, fatigue
       5. jugular vein distention                          10. orthopnea
   I. Left-Sided (forward): inadequate perfusion
Chronic Midterm 18 Questions                  Page 11 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD       T. Lyons & L. Jones

       1. pulmonary congestion                            6. S3 heart sounds
       2. SOB, dyspnea                                    7. tachycardia
       3. orthopnea, insomnia                             8. restlessness
       4. pulmonary edema                                 9. weakness, fatigue
       5. cough-blood tinged sputum
II. Nursing Diagnoses
   A. Decreased cardiac output r/t heart failure
   B. Fluid volume excess r/t Na+/H2O retention
   C. Impaired gas exchange r/t fluid in alveoli
   D. Impaired skin integrity
   E. Altered nutrition
   F. Sleep pattern disturbance
   G. Anxiety r/t SOB
Planning for CHF
   H. Improve cardiac output--# 1 goal
       1. Digitalis preparation, toxicity
              Digoxin/digitalis: Still the #1 drug to improve cardiac function. It
               improves pumping action, slows heart rate—causes heart to pump more
               effectively.
              Side Effects: Toxicity: can build up in the blood and become toxic.
               Teaching is very important as Dig can slow the hr too much.
              Must take apical pulse/h.r. for 60 full seconds before administration!!
               (b/c ppl can have irregular heartrates, and a 15 second count might not
               get an accurate measure of pt’s heartrate.)
              Hold dose if HR<60 bpm
              S&S of Dig toxicity: Nausea and Vomiting; GI problems usually
               present before the heart rate goes down.
              Therapeutic range for dig: 1.0-2.0 ng/ml K<3 mEq/L
       2. Antihypertensives
       3. Antiarrhythmics
       4. Diuretics
Chronic Midterm 18 Questions                  Page 12 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD       T. Lyons & L. Jones

       5. Vasodilators
   I. Adequate nutrition.
       1. Sodium restrictions (2 gm/day)—helps restrict fluid buildup
       2. Fluid restrictions; daily wts to monitor fluid retention, q day, same time.
       3. Easy to prepare, easy to eat
       4. Weight reduction, daily weights
       5. High potassium to prevent dig toxicity—especially important with digoxin and
           lasix combination.
   J. Balance rest and activity.
       1. Elevate HOB
       2. Elevate lower extremities, edema (Do not elevate in an acute CHF situation)
       3. Fall precautions
       4. Oxygen
   K. Self-care and health maintenance.
       1. Meticulous skin care
       2. Frequent urination
       3. Manage anxiety, stress
Interventions
   L. Medication regimen: meds can be very complicated—need to do a lot of teaching
   M. Promote tissue perfusion, oxygenation
   N. Promote rest
   O. Positioning
   P. Relieve anxiety
   Q. Avoid stress
   R. Dietary guidelines
   S. Daily weight
   T. LE circumference: measure for edema—teach pts to measure to check for
       swelling/fluid retention
   U. Signs and symptoms toxicity, K+ depletion, infection, CHF worsening
Chronic Midterm 18 Questions                  Page 13 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD       T. Lyons & L. Jones


I. Chronic Peripheral Vascular Disease/Arterial Occlusion
   A. Peripheral occlusion disorders involving narrowing of venous and arterial lumen
       or damage to the endothelial lining
   B. Usually caused by atherosclerosis, embolism, thrombosis, trauma, diabetes, etc.
   C. Obesity is major risk factor.
II. Clinical Manifestations
   A. Intermittent claudication: severe pain in calf muscles occurring during walking
       but subsides with rest. Reproducible when muscle is forced to contract without
       adequate blood supply.
   B. Rest pain:as above but at rest, esp. at night
   C. Weak or absent pedal pulses
   D. Color and temperature changes of LE:
       1. Dependent rubor with arterial occlusion; white pallor when leg is elevated.
   E. Hypertrophied toenails
   F. Ulceration and gangrene-b/c of poor circulation leading to skin breakdown—
       leading to loss/ulcerations
Nursing Diagnoses
   G. Alt. Peripheral Tissue Perfusion
   H. HR Impaired Skin Integrity
   I. HR Activity Intolerance
Medical Interventions
   J. 1st Intervention  Prevent!!!
       1. Ted hose
       2. Do not cut own toenails—see podiatrist
       3. Adequate/meticulous skin care!
   K. Angioplasty-dilate vessels with a catheter
   L. Atherectomy-remove plaque from arteries with a catheter procedure
   M. Stents-scaffold placed to hold open artery
   N. Thrombolytic therapy-to keep clots from forming (meds)
   O. Arterial bypass-used grafted artery to bypass failed artery
   P. Amputation-if attempts to improve circulation fail—last resort
Chronic Midterm 18 Questions                  Page 14 of 14
9-9 Notes – Chronic HTN, COPD, CHF, PVD       T. Lyons & L. Jones

Quality of Life
   Q. Illness phenomenon
       1. How does the person respond to their chronic condition?
       2. How does the condition affect them physically and mentally?
              Dyspnea, fatigue, pain, discomfort
              Anorexia, N&V, body changes
              Low energy, depressed, anxious
   R. Perceptions
       1. How does a person view and interpret their health status? Functioning? Well-
           being? Life quality?
       2. Do they have a sense of mastery with their chronic condition?
              controlled breathing techniques
              understanding medical regimen
   S. Functional Capacity
       1. Can the person perform activities of daily life: physical, emotional, spiritual,
           social?
       2. Altered role functioning impacts person and family and friends: occupational,
           recreational, sexual
   T. Personal Resources
       1. What assets does the person have available to them: physical, cognitive,
           emotional, social, economic, spiritual?
       2. Nutrition, sleep and rest, support persons, values, belief system, motivation,
           knowledge

				
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