vascular disorders

VASCULAR DISORDERS

IAN VER PENDON, RN

5/1/2011

copyright (your organization) 2003

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PRIMARY HYPERTENSION Description a disorder characterized by bloodpressure that consistently exceeds 140/90, confirmed on at least two visits several weeks apart; onset is primarily in people 25 to 55; greatest occurrence is in African Americans

Etiology and Pathophysiology1.Hypertension can be primary (essential) or secondary; primary hypertension accounts for 90-95 percent of all cases; there is no known cause but risk factors include: a. Positive familial history b. High sodium intake5/1/2011

c. Obesity d. Inactivity2


e. Excessive alcohol intake

Pathophysiologya. There is no single cause for primary hypertension

Assessment1.Subjective data a. Past history of cardiovascular, cerebrovascular, renal, or thyroid diseases, diabetes, smoking, or alcohol use b. Family history of HTN or CV disorders c. Possible absence of symptoms

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Renin aldosterone system Decrease blood volume

Juxtaglumerular cells of the kidney produces renin

Liver produces angiotensinogen

Renin combines with angiotensinogen in the blood Angiotensin 1 is formed

Angiotensin 1 passes through the lungs where angiotensin converting enzyme is present

Angiotensin 2 is formed

Adrenal cortex produces aldosternone

Vasoconstriction of arterioles

Increase sodium reabsorption by the kidney

Increase BP

Increase blood volume Increase BP

Increase blood volume

d. Reports of fatigue, nocturia, dyspnea on exertion, palpitations, angina, headaches, wt gain, edema, muscle cramps, or blurred vision; symptoms may be caused by target organ damage rather than the high blood pressure itself. Objective data a. BP consistently over 140 mmhg systolic and 90 mmhg diastolic b. Peripheral edema, retinal vessel changes, diminished or absent peripheral pulses, bruits, murmurs.

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Diagnostic testsa. Abnormal potassium level b. Elevated BUN, creatinine, glucose, cholesterol and triglycerides c. Abnormal urinalysis d. Cardiomegaly on x-ray e. Abnormal ECG showing left ventricular hypertrophy

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Priority nursing diagnosis:a. Ineffective health maintenance b. Risk for noncompliance c. Decreased cardiac output

Planning and implementationa. Tell client the numeric BP readings so he or she can keep an ongoing record b. Inform client that HTN is usually asymptomatic, and symptoms will not reliably indicate BP levels c. Explain long term follow up and therapy will be necessary d. Accurately record intake and output and daily weights of hospitalized clients5/1/2011 copyright (your organization) 2003 8

Medication therapya. No one primary drug is used; a combination of drugs are used until desired BP is achieved with the least side effects b. Medications used include diuretics, beta-blockers, calcium channel blockers, angiotensin converting enzyme inhibitors and vasodilators c. The stepped care approach is often used to guide treatment; this protocol begins with lifestyle changes and adds medications based on response to previous therapy.

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Client education1. Teach lifestyle modification a. Sodium restriction b. Wt reduction c. Moderate alcohol intake d. Exercise e. Relaxation techniques f. No smoking

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2. Teach general modification therapy and potential side effects a. Supplement potassium if taking loop diuretics b. Prevent orthostatic hypotension by rising out of bed slowly or chair slowly c. Avoid hot baths and strenuous exercise within 3 hours after taking vasodilators

3. Reinforce importance of adering to treatment plan; compliance may be an issue if client does not understand that treatment can reduce risk of target organ damage or if the disorder is not taken seriously because there are no symptoms5/1/2011 copyright (your organization) 2003 11

Expected outcomes/evaluationa. A decrease in BP to less than 140/90 b. No target organ damage (kidneys, heart, nervous system, eyes) c. Client voices understanding of management of HTN

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PERIPHERAL ARTERIAL DISEASE Description disorders that interrupt or impede arterialperipheral blood flow due to vessel compression, vasospasm, and/or structural defects in the vessel wall

Etiology and Pathophysiology1. PAOD is primarily caused by atherosclerosis, but also may be caused by trauma, embolism, thrombosis, vasospasm, inflammation or autoimmunity 2. By the time symptoms appear, the vessel is about 75% narrowed 3. The femoral-popliteal area is the site most commonly affected in non-DM patients; DM clients most often develop disease in the arteries below the knees5/1/2011 copyright (your organization) 2003 13

4. Chronic arterial obstruction leads to inadequate oxygenation of the tissues causing intermittent claudication, which is ischemic muscle pain precipitated by a predictable amount of exercise and relieved by rest.

AssessmentSubjective a. Client reports aching, cramping, fatigue or weakness in the legs that is relieved by rest (claudication); this is an early indication of disease b. Client reports rest pain, which is pain that occurs while resting that may even awaken the client at night; pain is usually is the distal portion of the extremity and is relieved when foot is placed in the dependent position; this indicates more advanced disease c. Client complaints of coldness or numbness in the lower extremities5/1/2011 copyright (your organization) 2003 14

Objective a. Extremities may be cool and pale with a cyanotic color on elevation b. Peripheral pulses may be diminished or absent c. Nails may be thickened d. Ulcers may be present on the lower extremities in the areas affected by reduced circulation

Diagnostic testinga. Angiography b. Doppler ultrasound c. Plethysmography

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Priority nursing diagnosisa. Ineffective tissue perfusion b. Impaired skin integrity c. Pain

Planning and implementation1. goal: adequate tissue perfusion a. Assess and record strength of pulses b. Encourage client to stop smoking as nicotine causes vasoconstriction and hypercoagulabilty of blood c. Teach client to change position at least hourly and avoid crossing the legs d. Encourage client to exercise and walk to the point of pain as this decreases claudication5/1/2011 copyright (your organization) 2003 16

e. Teach client to avoid restrictive clothing, including girdles, garters, and socks 2. goal: relief of pain a. Assess pain and provide analgesics as ordered b. Teach relaxation techniques because stress increases vasoconstriction c. Keep feet warm and in a dependent position; do not elevate feet if pain is present 3. goal: intact, healthy skin on extremities a. Teach client skills in skin care and daily inspection of feet b. Teach client to always wear shoes/slippers to avoid trauma to the feetc. Teach client to have toenail care performed by a professional only5/1/2011 copyright (your organization) 2003 17

4. If surgery is indicated, provide appropriate postoperative care a. Angioplasty b. Bypass grafting c. Endarterectomy - Monitor neurovascular status of the affected extremity - Notify physician if client experiences weak or thready pulse, coolness, numbness, or tingling of the extremity - Monitor for signs of bleeding - Provide standard postoperative care

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Medication therapya. Aspirin b. Pentoxyfylline (trental) c. Cilostazol (pletal)

Client educationa. Promote vasodilation b. Proper positioning c. Stop smoking d. Meticulous foot care e. Exercise

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Expected outcomes/evaluationa. Improved peripheral tissue perfusion manifested by palpable or audible pulses and the absence of claudication b. Absence of arterial ulcers c. Improved activity tolerance

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ARTERIAL EMBOLISM- Arterial emboli usually arise from thrombi that developed in the heart as a result of atrial fibrillation, myocardial infartion, prosthetic valves, or congestive heart failure.

Etiology and Pathophysiologya. Thrombi become detached and are carried from the left side of the heart into the arterial system where they mat lodge and cause obstruction b. The symptoms may be abrupt and will depend on the size and location of the embolus c. Ischemia will progress to necrosis and gangrene within hours5/1/2011 copyright (your organization) 2003 21

Assessment: the six Ps1. Pain 2. Pallor (pale color) 3. Pulselessness (diminished or absent pulses) 4. Paresthesias (altered local sensation) 5. Paralysis (weakness or inability to move extremity) 6. Poikilothermia (body temperature that varies with environment)

Priority nursing diagnosis:a. Ineffective tissue perfusion b. Impaired protection5/1/2011 copyright (your organization) 2003 22

Planning and implementationa. Assess peripheral pulses and neurovascular status q2-4h b. Place affected extremity in neutral position with no restrictive bedding/clothing c. Assess level of pain using a 1-10 scale d. Change position q2h to increase collateral circulation e. Assess for and report unusual bleeding from anticoagulant therapy f. Monitor lab results, including APTT, PT, and INR levels g. If necrosis is present, surgical treatment is required; an emergency embolectomy needs to be performed within 4-5h of embolism to prevent necrosis and permanent damage to the extremity.5/1/2011 copyright (your organization) 2003 23

Medication Therapy:a. Thrombolytic therapy with streptokinase b. Heparin or coumadin therapy at home

Client education:a. pre- and post-operative teaching if embpcetomy is performed b. Measures to promote peripheral circulation 5/1/2011

Stop smoking Lose wt and eat low fat diet Do not cross legs while sitting Elevate feet at rest, but not above heart level Do not stand or sit for long periods of time Do not wear restrictive clothing Keep affected extremity warm Begin/maintain an exercise programcopyright (your organization) 2003 24

Expected outcomes/evaluationa. Peripheral pulses strong bilaterally b. No tissue damage or necrosis c. Therapeutic lab values for anticoagulant therapy

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BUERGERS DISEASE (Thromboangitis obliterans)An inflammatory disease of the small and medium sized veins and arteries accompanied by thrombi and sometimes vasospasm of arterial segments; may occur in upper and lower extremities but is most common in the leg or foot

Etiology and Pathophysiologya. The cause of Buergers disease is unknown, but since it occurs mostly in young men who smoke, it is currently thought to be a reaction to something in cigarettes and/or to have a genetic or autoimmune component b. Inflammation occurs; microthrombiform; these can lead to vasospasm, and this process ultimately obstructs bloodflow5/1/2011 copyright (your organization) 2003 26

Assessmenta. The first signs and symptoms are usually a bluish cast to a toe or finger and a feeling of coldness in the affected limb b. Since the nerves are also inflamed, there may be severe pain and constriction of the small blood vessels controlled by them; rest pain is common c. Overactive symphatetic nerves also may cause feet to sweat excessively, even though they feel cold d. As the blood vessels become blocked, intermittent claudication and other symptoms similar to those of chronic arterial disease often appear e. Ischemic ulcers and gangrene are common complications of progressive buergers disease

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Priority nursing diagnosisa. Ineffective tissue perfusion

Planning and implementationa. Arrest progress of disease by smoking cessation b. Take measures to promote vasodilation c. Provide for pain relief d. Provide emotional support

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Medication Therapy:a. Analgesic pain medication b. CCB c. Pentoxyfylline

Client educationa. Stop smoking b. Take measures to promote peripheral circulation and maintain tissue integrity

Expected outcomes/evaluationa. Absence of ulcers/impaired skin integrity b. Relief of pain c. Cessation of smoking5/1/2011 copyright (your organization) 2003 29

RAYNAUDS DISEASElocalized, intermittent episodes of vasoconstriction of small arteries of the hands and less commonly the feet, causing color and temperature changes

Etiology and Pathophysiologya. A vasospastic disorder of unknown origin that primarily affects young women. b. Vasospastic attacks ten to be bilateral and manifestations usually begin at the tips of the digits causing pallor, numbness, and sensation of cold c. Attacks are triggered by exposure to cold, emotional stress, caffeine ingestion and tobacco use5/1/2011 copyright (your organization) 2003 30

Assessmenta. Symptoms usually appear in the hands after exposure to cold and/or stress; are bilateral and symmetrical. b. Classic triphasic color changes (pallor, cyanosis, and rubor) in the hands accompanying reduction in skin temperature. c. The intensity of pain increases as disease progresses d. The skin of the fingertips may thicken and nails become brittle

Priority nursing diagnoses:a. Ineffective tissue perfusion b. Chronic pain

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Planning and implementationa. Keep hands warm and free from injury b. Avoid stressful situations c. In severe cases, a symphathectomy (surgical dissection of the nerve fibers that allows vasoconstriction to occur) may be performed to relieve symptoms associated with vasospasm

Medication therapya. Analgesics for pain b. Vasodilators may provide some relief of symptoms, as well as vascular smooth muscle relaxants and CCB

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Client educationa. Keep hands warm: wear gloves when out of doors, in airconditioned environments, or when handling cold foods b. Avoid injury to hands c. Lifestyle changes: stop smoking; employ stress relief, such as biofeedback

Expected outcomes/evaluationa. Decrease in or absence of attacks b. No injury to hands and/or wounds heal quickly

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AORTIC ANEURSYMA localized dilation or outpouching of a weakened area in the aorta that is classified by region as thoracic or abdominal and dissecting.

Etiology and Pathophysiologya. The aorta is particularly susceptible to aneurysm formation because of constant stress on the vessel wall b. Aneurysms occur in men more often than women aand their incidence increases with age c. The growth rate of aneurysm is unpredictable d. Half of all aneurysms greater than 6 cm in size will rupture within 1 year e. The major risk factor is atherosclerosis5/1/2011 copyright (your organization) 2003 34

Assessment1. Thoracic aneurysms are often asymptomatic with the first sign being rupture a. symptoms may include pain in the back, neck, and substernal area that may occur when lying supine. b. the client may experience dysphagia and dyspnea, stridor, or cough when pressing on the esophagus or laryngeal nerve

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2. Abdominal aneursym may also be asymptomatic until rupture. a. The client may report a heartbeat in the abdomen when lying down b. A pulsating abdominal mass may be present c. Moderate to severe abdominal pain or lumbar back pain may be present (severe pain may be sign of impending rupture) d. The client may experience claudication e. Cool or cyanotic extremities may be noted.

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3. Dissecting aneurysms present with sudden, severe, and persistent pain described as tearing or ripping in the anterior chest or the back a. Pain may extend to the shoulder, epigastric area, or abdomen b. Pallor, sweating, and tachycardia will be evidenced c. Initially the client may have an elevated BP that may be different in one arm from the other d. Possible syncope and paralysis of lower extremities may be present

Priority nursing diagnosisa. Ineffective tissue perfusion b. Pain5/1/2011 copyright (your organization) 2003 37

c. Anxiety

Planning and implementation1. Diagnostic tests that may be ordered a. Chest x-ray b. Transesophageal echocardiography c. Ultrasound d. CT scan or MRI 2. Overall goals for a client with an aneurysm a. Normal tissue perfusion b. Intact motor and neurologic function c. Reduction in anxiety d. No complication of surgical repair5/1/2011 copyright (your organization) 2003 38

3. Surgical care a. Surgical management may be performed on an emergency basis or elective basis. b. Emergency surgery is the only intervention for clients with a ruptured aneurysm c. Once the aorta ruptures into the peritoneal cavity, death is almost certain d. Surgical technique involves excision of the aneurysm with replacement of the excised segment with a synthetic graft e. Pre-op the nurse marks and assesses all peripheral pulses for comparison post-op f. Post-op assessment of complication like respiratory distress, graft occlusion, renal failure.

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Medication therapya. The goal of nonsurgical management is to maintain blood pressure at a normal level to decrease pressure on the arterial system and reduce risk of rupture b. Antihypertensive therapy and diuretics may be prescribed c. Pulsatile flow may be reduced by medications that reduce cardiac contractility d. Post-op clients will be placed on anticoagulant therapy; heparin while the client is in the hospital and warfarin (coumadin) when discharged.

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Client educationa. Clients who do not undergo operative repair must be urged to receive routine physical examinations to monitor status of aneurysm b. Teach the client signs and symptoms of impending rupture c. Teach the client to monitor BP and report any increase immediately d. Provide teaching about anticoagulant therapy e. For post-op clients, teach routine postoperative care

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Expected outcomes/evaluationa. Client has normal tissue perfusion b. The aneurysm does not rupture c. For surgical clients, absence of post-op complications and maintenance of normal tissue perfusion postsurgical grafting

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THROMBOPHLEBITISThe formation of a thrombus in association with inflammation of the vein; classified as superficial or deep

Etiology and Pathophysiology1. Etiology: Virchows triad (at least 2 of 3 present for thrombosis to occur) a. Stasis of blood flow b. Damage to the inner lining of the vein (endothelial layer) c. Hypercoagulability of the blood

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2. Pathophysiologya. RBCs, WBCs, and platelets adhere to form a thrombus (usually in valve cusps of veins) b. As thrombus enlarges it eventually occludes the lumen of the vein c. If only partial occlusion of the vein occurs, blood flow continues and the thrombotic process stops; if detachment does not occur, it will firmly organized and attached within 24 to 48 hours d. If detachment occurs, emboli form which generally flow through the venous system, back to the heart, and into the pulmonary circulation

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Assessment1. Subjective: Hx of thrombophlebitis, pelvic/abdominal surgery, obesity, neoplasm, CHF, atrial fibrillation, prolonged immobility, MI, pregnancy and/or postpartum period, iv therapy, hypercoagulable states. 2. Objective: signs vary according to thrombus size, location, adequacy of collateral circulation A. Superficial - palpable, firm - Surrounding area warm, red, tender to touch - Edema may be present or may not be present - Most common cause in the arms is IV therapy5/1/2011 copyright (your organization) 2003 45

B. Deep -Unilateral edema -Pain -Warm skin -If inferior vena cava is involved, both legs will be edematous -If superior vena cava is involved, both upper extremities, neck, back, and face may become edematous or cyanotic

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Diagnostic studiesa. Venous duplex scanning b. Doppler ultrasound c. D-dimer, a product of fibrin degradation, indicates fibronylysis (that occurs as a reaction too thrombosis d. Venography e. MRI f. Lung scan

Priority nursing diagnoses:a. Pain b. Ineffective tissue perfusion c. Risk for impaired skin integrity5/1/2011 copyright (your organization) 2003 47

Planning and implementation1. Educate client about diagnostic tests that may be performed 2. Provide for relief of pain - Assess pain - Elevate affected leg higher than the heart to promote venous drainage - Provide analgesics as ordered 3. Decrease edema - Apply warm, moist compress, intermittent or continuous, to affected extremity - Measure and monitor leg/arm circumference when edema is present - Monitor status of peripheral pulses5/1/2011 copyright (your organization) 2003 48

Planning and implementation1. Educate client about diagnostic tests that may be performed 2. Provide for relief of pain - Assess pain - Elevate affected leg higher than the heart to promote venous drainage - Provide analgesics as ordered 3. Decrease edema - Apply warm, moist compress, intermittent or continuous, to affected extremity - Measure and monitor leg/arm circumference when edema is present - Monitor status of peripheral pulses5/1/2011 copyright (your organization) 2003 49

Medication therapya. Anticoagulant therapy b. Thrombolytics c. Analgesics

Client education1. Prevention Early ambulation postoperatively Use of compression stockings Low dose anticoagulant therapy Avoid prolonged standing or sitting/crossing legs Avoid restrictive clothing Stop smoking

2. Provide education about anticoagulant therapy5/1/2011 copyright (your organization) 2003 50

Expected outcome/evaluation1. No pain, edema, or tenderness 2. No impaired skin integrity 3. No embolus

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VENOUS INSUFFICIENCYInadequate venous return over a long period of time that causes pathologic changes as a result of ischemia in the vasculature, skin, and supporting tissues

Etiology and Pathophysiology1. Venous insufficiency occurs after prolonged venous hypertension, which stretches the veins and damages the valves, preventing blood return 2. Venous insufficiency also occurs after thrombus formation or when valves are not functioning correctly, which may result from: a. Prolonged standing/sitting b. Pregnancy and obesity

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3. With time, stasis results in edema of the lower limbs, discoloration to skin of the legs and feet, and venous stasis ulceration

Assessment1. Subjective a. Past hX of thrombophlebitis, HTN, varicosities b. Past Hx of long periods of sitting and standing

2. Objective a. Edema of the lower legs, may extend to the knee b. Thick, coarse, brownish skin around the ankles and feet c. Stasis ulcers5/1/2011 copyright (your organization) 2003 53

Priority nursing diagnosis:a. Impaired skin integrity b. Risk for infection c. Disturbed body image d. Ineffective tissue perfusion

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Planning and implementation1. Increase venous blood return, decrease venous pressure a. Bedrest b. Keep legs elevated above heart level c. Avoid long periods of standing d. Wear elastic support or compression stockings - Apply stockings before getting out of bed and placing the leg in a dependent position - Wear stockings during the day and evening, remove at night - Never push stockings down around the leg they will further impair circulation - Handwash stockings daily and air dry; machine washing or drying will damage elastic fibers5/1/2011 copyright (your organization) 2003 55

2. Treat venous stasis ulcers a. Open lesions are treated with a hydrocolloid dressing and compression wraps; a topical ointment, such as low-dose hydrocortisone, zinc oxide, or antifungal may also be indicated b. Ulcers may be treated with an unna boot or other compression wrap that is changed every 1-2 wks and is usually applied over a based dressing c. Severe ulcers may need surgical debridement

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Medication therapy1.Topical agents to skin ulcers, such as hydrocortisone, antifunglas or zinc oxide, may be prescribed 2. Oral or IV antibiotics may be prescribed when ulcers become infected or cellulitis occurs 3. Sclerosing agents (sclerotherapy) may be used to occlude bloodflow in a vein, causing disappearance of the varicosity; this may be followed up with use of compression bandage for a short period of time

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Client education1. Elevate legs for at least 20 minutes 4x a day 2. Keep legs above the level of the heart when in bed 3. Avoid prolonged standing or sitting 4. Do not cross legs when sitting 5. Do not wear tight, restrictive pants, socks, or boots; avoid girdles and garters that restrict circulation in the upper legs 6. Wear support stockings

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Expected outcomes/evaluation1. Reduction in edema 2. Healing/prevention of stasis ulcers

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VARICOSE VEINS- A vein or veins in which blood has pooled, producing distended, tortuous, and palpable vessels

Etiology and Pathophysiology1. One in five people worldwide develop varicosities 2. They are more common in women over 35yo, obesity, those with positive familial hX of varicosities, and in those who stand for long periods of time 3. Varicose veins may develop after trauma or damage to a vain or valve or from gradual venous distension, which diminishes the action of the muscle pump, and increases the pull of gravity on blood within the legs 4. As the vein swells, increased hydrostatic pressure will push plasma through the stretched vessel walls and edema of surrounding tissue may occur5/1/2011 copyright (your organization) 2003 60

Assessment1. Subjective : the client may complain of aching, heaviness, itching, swelling and unsightly appearance to the legs 2. Objective A. dilated, tortuous superficial veins will be seen along the upper and lower leg B. Superficial inflammation may develop along the path of the varicose vein C. Positive trendelenburg test ( done to evaluate competence ) - Client is placed in a supine position with legs elevated - As the client sits up. The vein would normally fill from the distal end - If there are varicosities, the veins fill from the proximal end5/1/2011 copyright (your organization) 2003 61

Priority nursing diagnoses:1. Pain 2. Ineffective tissue perfusion 3. Risk for impaired skin integrity 4. Risk for peripheral neurovascular dysfunction

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Planning and implementation1. Assess and provide pain relief a. Assess pain b. Provide analgesics as needed 2. Improve venous circulation a. Assess pulses and NVS of LE b. Teach/apply support stockings c. Avoid prolonged sitting and standing d. Never cross legs e. Walking is encouraged f. Elevate feet above heart level when lynig down g. Avoid restrictive clothing5/1/2011 copyright (your organization) 2003 63

3. Prevent skin breakdown; teach proper skin care and importance of avoiding trauma to the skin 4.Teach preoperative and postoperative care if surgery is chosen a. Sclerotherapy involves injecting a sclerosing agent into the varicosed vein usually in the physicians office - Procedure is palliative but not curative - Elastic bandages may need to be worn for up to 6 weeks b. Vein ligation surgery involves ligation (tying off) of the entire vein (usually the saphenous vein) and dissection and removal of the incompetent tributaries - Perform hourly circulation checks postoperatively - Elevate extremity to a 15 degree angle to prevent stasis and edema - Apply compression gradient stockings from foot to groin5/1/2011 copyright (your organization) 2003 64

Medication therapy:- No specific medications are used

Client education1. Prevention - Avoid sitting or standing for long periods - Change position often - Avoid constrictive clothing - Elevate legs when sitting - Maintain ideal body weigth

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Expected outcomes/evaluation1. Relief of discomfort 2. Improved circulation 3. Avoidance of complications such as ulcerations and thrombophlebitis

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Comparison of Arterial and Venous DiseaseAssessment color Edema Nails Pain Pulses Temp of extremity Ulcers Arterial disease Pale None/minimal Thick/brittle Worse with elevation Weak Cool Dry and necrotic Vascular disease Ruddy; cyanotic Usually present Normal Better with elevation Normal Warm Moist

AntihypertensiveCentrally acting adrenergic inhibitors Mechanism of action- stimulate alpha receptors in the CNS to inhibit vasoconstriction and cardioacceleration, thus reducing peripheral resistance (commonly given with a diuretic) Drug examples -Clonidine -Methyldopa (aldomet) Indications -To treat moderate HTN Contraindications and precaution - Contraindicated in clients with asthma, use cautiously in pregnant or breast feeding women5/1/2011 copyright (your organization) 2003 68

Nursing Responsibilities-Instruct the client to take clonidine at bedtime orthostatic hypotension -Warn the client taking methyldopa that the drug may darken urine

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Peripherally acting adrenergic inhibitorsMechanism of action -Reduce the effects of norepiniphrine at peripheral nerve endings to decrease sympathetic vasoconstriction (commonly given with diuretic) Drug examples -reserpine(serpasil) -Prazosin(minipress) Indications -to treat moderate to essential hypertension Contraindications/precautions -contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 70

Peripheral Vasodilating DrugsMechanism of action -Exert direct action on arteries alone or on arteries and veins to decrease peripheral vascular resistance (commonly given with a beta-adrenergic blocker) Drug examples -hydralazine hCL (apresoline) -Nitroprusside sodium (nipride) Indications -These drugs are used to treat moderate ato severe hypertension Contraindications and precautions - Contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 71

Nursing Responibilities- Advise

the patient to take reserpine with food, milk, or water to minimze GI irritation

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Peripheral Vasodilating DrugsMechanism of action -Exert direct action on arteries alone or on arteries and veins to decrease peripheral vascular resistance (commonly given with a betaadrenergic blocker) Drug examples -hydralazine hCL (apresoline) -Nitroprusside sodium (nipride) Indications -These drugs are used to treat moderate ato severe hypertension Contraindications and precautions - Contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 73

Nursing Responsibilities-Closely monitor the patient for fluid volume excess; monitor the clients blood pressure every 5 minutes at the start of the infusion and at least every 15minutes during the infusion. -Weigh the patient daily, and record daily intake and output

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Beta-adrenergic blockersMechanism of action -Compete with epinephrine for beta-adrebergic receptors sites; inhibit the response to beta-adrenergic stimulation, thereby decreasing cardiac output Drug examples -metoprolol -propanolol -atenolol Indication -To treat mild nypertension Contraindications and precaution Contraindicated in patients with asthma5/1/2011 copyright (your organization) 2003 75

Nursing Responsibilities-Warn the patient not to stop taking the drug abruptly; this can exacerbate angina or precipitate an MI -Administer propanolol consistently with meals; food may increase absorption

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Angiotensin-coverting enzyme (ACE) inhibitorsMechanism of action -Block conversion of angiotensin I to angiotensin II, preventing peripheral vasoconstriction Drug examples -captopril(capoten) -Enalapril(vasotec) -Quinapril(accupril) Indications -To treat mild hypertension -Reduce the risk of MI, stroke Contraindications - Contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 77

Nursing Responsibilities-Administer captopril on an empty stomach, preferably 1 hour before meals, for maximum effectiveness -Monito the client taking captopril for proteinuria every 2-4 weeks for the first 3 months of therapy to detect decreased renal function -Tell the client to report light-headedness, especially in the first few days of starting therapy, so dosage may be adjusted -Advise the patient to avoid sudden changes to minimze orthostatic hypotension5/1/2011 copyright (your organization) 2003 78

Calcium Channel BlockerMechanism of action -Dilate vessels by blocking the slow channel, preventing calcium from entering the cell Drug examples -amlodipine(norvasc) -Diltiazem(cardizem) -Felodipine(plendil) -Nifedipine(adalat) Indication -to treat mild hypertension Contraindications - Contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 79

Nursing Responsibilities-Know that nifedipine can be given sublinguallythe client can puncture the end of the capsule and squeeze the liquid under the tongue some institutions vary in this policy and the client may be asked to swallow the capsule after sublingual dosing

- Warn the client not to stop the drug abruptly; gradually reducing the dosage under physician supervision helps prevent rebound hypertension

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DiureticsMechanism of action -Inhibit sodium and chloride reabsorption, thereby increasing urine output and decreasing edema, circulating blood volume, and cardiac output Drug examples -chlorothiazide(diuril) -Furosemide(lasix) Indication -to treat mild hypertension Contraindication -contraindicated in clients with asthma5/1/2011 copyright (your organization) 2003 81

Nursing Responsibilities-Monitor the clients vital signs and assess for risk factors for HTN -Tell the client about the importance of complying with therapy -Instruct the patient not to take a double dose after missing a dose -Warn the client not to stop the drug abruptly because this may cause rebound hypertension -Teach the client to monitor BP weekly (to help determine drug effectiveness) and to watch for wt gain and peripheral edema (to detect fluid retention0 -Advise the patient to change position slowly to minimize orthostatic hypotension -Instruct the patient to avoid hot baths and showers, which can lead to hypotension Caution the client not to consume excessive amounts of coffee5/1/2011 copyright (your organization) 2003 82

Teaching about Anithypertensives1. Medication therapy regimen, including the drugs name, dose, frequency, duration, and possible adverse effects 2. Signs and symptoms of possible adverse effects and when to notify physician 3. Continuation of drug even if the client feels better 4. Need for adequate drug supply and instructions for missed doses 5. Dietary restrictions, including fluid and sodium restrictions as appropriate 6. Wt monitoring 7. Safety measures 8. Avoidance of OTC medications unless permitted by the physician 9. Lifestyle modification 10.Measures to ensure compliance with therapy 11.Medical follow-up5/1/2011 copyright (your organization) 2003 83

AntilipemicsBile acid sequestrants Mechanism of action -Bind bile acids in the Gi tract to form an insoluble complex that is excreted, thereby increasing cholesterol clearance and lowering serum LDL levels Drug examples -cholystyramine(questran) -Colestipol(colestid) Indications -To treat hyperlipidemia -Cholystyramine is also used to relieve priritus asociated with partial biliary obstruction5/1/2011 copyright (your organization) 2003 84

Contraindications -Contraindicated in clients hypersensitive to this drug

Nursing Responsibilities-Instruct the client to take the drug before meals and at least 1 hour before or 4-6 hours after taking another drug -Tell the patient to mix the powder form with beverages -Advise the client to swallow colestipol tablets whole and not to crush, chew or cut them -Monitor the clients blood choloesterol level, liver enzymes periodically during the first 6mos of therapy -Instruct client to follow recommended diet and restrict intake of fat -Suggest a laxative or increased fluid and fiber intake to prevent constipation5/1/2011 copyright (your organization) 2003 85

HMG-CoA reductase inhibitorsMechanism of action -Block 3-hydroxy-3-methylglutaryl(HMG) CoA reductase in the liver, preventing cholesterol synthesis; reduce serum cholesterol and LDL levels Drug examples -atorvastatin(lipitor) -Simvastatin(zocor) -Lovastatin(mevacor) Indication -To treat increase LDL Contraindications -Hypersensitivity5/1/2011 copyright (your organization) 2003 86

Nursing Responsibilities-Initiate therapy with HGM-CoA reductase inhibitors only after diet therapy has proven ineffective -Give lovastatin with the evening meal; absorption is enhanced and cholesterol biosynthesis is greater in the evening -These drugs are usually administered at bedtime, without regard to food -Monitor liver enzymes -Advise client to restrict alcohol intake

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Miscellaneous antilipemicsMechanism of action -these drugs decrease hepatic synthesis or accelerate breakdown of LDLs -Niacin increases serum HDL levels and reduces the serum levels of LDLs Drug examples -Clofibrate -Fenofibrate -Genfibrozil(lopid) -Niacin(vit b3,nicobid,nicolar,nicotinex)5/1/2011 copyright (your organization) 2003 88

Madamo gid na salamat sa inyo Pagpamati!

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