N113 - Content Outline - Exam 3 Breasts, Lungs, and Thorax A. Client’s history, focus on thorax, lungs and breast 1. 2. 3. 4. 5. ● ● ● Obtain hx Inspect Palpate (percuss) Auscultate Family hx ○ Occupational history ○ Country of origin ○ Exposure Medical history ○ Trauma or surgery ○ Chest pain with deep breathing ○ Cough ○ Hx of smoking (how long, and how many packs/day) ○ Allergies ○ Environmental exposures to chemicals, asbestos, or smoke ○ Lung disease (hx in family or self) ○ Hx of frequent of chronic respiratory infections ○ Pillow use Health Hx in relation to Breast Health ○ History of pain in one or both breasts, including relationship to menstrual period ○ History of lumps or swelling, redness, change in size, or dimpling in the breasts ○ History of discharge from the breast ○ Family history of ovarian or breast cancer ○ History of breast disease, biopsy, or surgery ○ Menstrual and pregnancy history, breastfeeding ○ Use of hormones, oral contraceptives ○ Knowledge related to breast self-awareness ○ Most recent mammogram B. Inspect/palpate thorax for the following 1. Breast - conducted to identify any lumps in the breasts and/or enlargement or pain in axillary lymph nodes •Symmetry - Shape and size should be equal and smooth •Presence of discharge - abnormal finding except in pregnancy •Nipple integrity - Inspect for inverted nipples, skin depressions, puckering, dimpling •Tenderness - breasts are normally tender during the week before menstruation, or could indicate fibrocystic disease - Discharge, lumps, lesions, dimpling, asymmetry, and palpable lymph nodes may be indicative of N113 - Content Outline - Exam 3 breast cancer - axillary lymph nodes are normally non-palpable and non-tender •Masses - Palpate the breasts in each of the four quadrants (the upper outer quadrant, the lower outer quadrant, the upper inner quadrant, and the lower inner quadrant) to detect any abnormal lumps - If a mass is detected, carefully assess its location, size, shape, consistency, and tenderness. 2.Thorax •Symmetry - symmetrical shape and downward angled contour of rib cage, inspect even muscle development - color should be consistent with color of face •Vital signs: respiratory rate, rhythm, depth •Sputum (color) •Respiratory movement - inspect for even breathing patterns, palpate for vibrations (fremitus), masses, tenderness - thorax should expand symmetrically •AP diameter approximation - Anteroposterior diameter is 2:1 to transverse diameter (normal) (chest is twice as wide as it is long) - chest shape and size is oval C. Auscultate lungs for the following i. Adventitious breath sounds (TAYLOR pg 718) a. Wheeze (sibilant) i. musical or squeaking ii. high-pitched iii. heard during inspiration and expiration iv. air passing through narrowed airways b. Rhonchi (sonorous wheeze) i. Sonorous or coarse; snoring quality ii. Low-pitched, continuous sounds iii. Auscultate during both inspiration and expiration iv. coughing may clear the sound somewhat v. air passing through or around secretions c. Crackles i. “bubbles” crackling, popping ii. low to high pitch iii. auscultated during both inspiration and expiration iv. opening of deflated small airways and alveoli; air passing through fluid in the airways d. Stridor - emergency!! i. harsh, loud, high-pitched ii. auscultated on inspiration iii. narrowing of upper airway (larynx or trachea); presence of a foreign body in the airway e. Friction Rub - “balloon” rub sounds i. Rubbing or grating ii. loudest over lower lateral anterior surface iii. auscultated during inspiration and expiration iv. inflamed pleura rubbing against chest wall N113 - Content Outline - Exam 3 ii. Normal breath sounds (TAYLOR pg 717) a. Bronchial or Tubular i. Blowing hollow sounds auscultated over the larynx and trachea (throat) ii. Sound on expiration is longer than inspiration b. Bronchovesicular i. Medium-pitched, medium intensity, blowing sounds; auscultated over the first and second intercostal spaces anteriorly and the scapula posteriorly ii. Inspiration and expiration have similarly pitch and duration c. Vesicular i. Soft, low-pitched, whispering sounds; heard over most of the lung fields ii. Sound on inspiration is longer, louder and higher-pitched than expiration D. Deviations from normal •Skin lesions •Chest asymmetry 1. Barrel chest - Ratio of AP to transverse diameter is 1:1 - Increased AP diameter is normal for COPD patients - Caused by chronic lung diseases (emphysema) chronic overinflation of the lungs 2. Pigeon chest - (pectus carinatum) - occurs as a result of anterior displacement of the sternum, which also increases the anteroposterior diameter. May occur with rickets, marfan syndrome, or severe kyphoscoliosis 3. Funnel chest - (pectus excavatum) - occurs when there is a depression in the lower portion of the sternum. may compress the heart and great vessels, resulting in murmurs. - may occur with rickets or Marfan syndrome. •Exaggerated spinal curvature 1. Scoliosis- lateral curvature/deviation of the spine - Scoliosis in adults may be caused by trauma - may have been present since birth - idiopathic scoliosis has no identifiable cause 2. Kyphosis - excessive convex curvature of the thoracic spine (person leans forward) may be caused by osteoporosis •Abnormal breathing patterns with use of accessory muscles - symptoms of respiratory disease (COPD or Asthma) •Unequal chest expansion - may occur in chest trauma or pneumonia E.Cultural variations of the thorax, lung and breast Disparities in Pulmonary Health Related to Socioeconomics, Race, and Ethnicity (HINKLE chart 20-8) ● ● Disparities in Pulmonary Health Related to Socioeconomics, Race, and Ethnicity: A Snapshot Individuals living in rural areas are more likely to use tobacco and be exposed to secondhand smoke, yet have N113 - Content Outline - Exam 3 ● ● ● ● ● less access to smoking cessation programs. Older African Americans and Hispanics are less likely to receive influenza and pneumonia vaccinations than Caucasians. Adults living below the poverty level are more likely to experience severe asthma exacerbations, hospitalizations, and death. More Hispanics live and work in areas with greater levels of pollution, have higher prevalence rates of asthma than Caucasians, and yet are less likely to be diagnosed with asthma than all other racial and ethnic groups. African American men are 37% more likely to get lung cancer than Caucasians even though smoking rates between these two groups are comparable. American Indians/Alaska Natives and African Americans are at a higher risk of complications resulting from influenza and pneumonia. F. Common thorax and lung variations in older adults include: ● ● ● ● ● ● ● Increased anteroposterior chest diameter Increase in the dorsal spinal curve (kyphosis) Decreased thoracic expansion Use of accessory muscles to exhale at approx 50 years of age, the alveoli begin to lose elasticity, reduces surface area available for oxygen/carbon dioxide exchange older adults may have decreased activity tolerance and need longer to recover from prolonged or vigorous activity Granular, pendulous breasts in women G. Promotion of health screening, health maintenance including self-care and associated teaching/education - Teaching Breast Self-Awareness - All women should be familiar with how their breasts normally look and feel so that they are prepared to notice changes Taylor, C., Lynn, P., Bartlett, J. L., Chapter 26, pp. 714-716, 721-724; Assessment of the Thorax and Lungs; Assessing the Breasts and Axillae Chapter 26, pp. 717 Table 26-2; Normal Breath Sounds Chapter 26, pp. 718 Table 26-3; Adventitious Breath Sounds Chapter 39, pp. 1480-1485, 1488-1512. - Oxygenation and Perfusion Hinkle, J. L. & Cheever, K. H., Chapter 20, pp. 480-484, 488-503; Assessment of Respiratory Function Chapter 58, pp. 1720-1724; Assessment and Management of Patients with Breast Disorders N113 - Content Outline - Exam 3 Integumentary System (skin, hair, nails) A. Nursing history focus for the integument ● ● ● ● ● ● use of hair and skin products any family and personal history of: skin allergies allergic reactions to food, medications, and chemicals previous skin condition skin cancer 1. Inspect and palpate for the following: Skin (normal findings, variations in older adults, deviations from normal) B. ● Color ● ● ● ● ● ● cyanosis: bluish discoloration that results from lack of oxygen in the blood ○ exposed areas, particularly the ears, lips, inside of the mouth, hands and feet, nail beds ○ appears with cold environment, shock or with respiratory or circulatory compromise (decreased oxygenation) ○ other indications of decreased tissue perfusion include cold, clammy skin; a rapid, thready pulse; and rapid, shallow respirations ○ in a person with dark skin, skin usually appears grayish; in order to detect cyanosis, the areas around the mouth and lips and over the cheekbones and earlobes should be observed erythema: redness of the skin caused by the dilation of capillaries; “flushing” ○ localized are on body or present in the face ○ Possible causes: blushing, alcohol intake, fever, injury trauma, infection ○ Dark skin tends to assume a purple-gray tinge; difficult to detect erythema. Use palpation to identify warmth or edema at sites of inflammatory process.. jaundice: yellowing of the skin directly related to elevations in serum bilirubin ○ first observed in the sclerae (eyes) and mucous membranes. ○ associated with liver disease In people with dark skin, observe sclerae, check for yellow-orange tinge in palms and soles of feet. pallor: generalized paleness due to decreased perfusion and blood volume (shock), decreased hematocrit (anemia) or local arterial insufficiency ○ brown skin appears yellow-brown, dull; black skin appears ashen gray, dull (observe areas with least pigmentation, conjunctiva, mucus membranes vitiligo: whitish patchy areas on the skin caused by loss of pigmentation ○ could occur in overall skin areas, lips, nail beds, and conjunctivae ○ congenital or autoimmune conditions leading to depigmentation ○ especially noticeable in people with dark skin, can lead to psychological discomfort Lesions ● lesions: areas of diseased or injured tissue such as bruises, scratches, cuts, burns, insect bites, and wounds (breaks in the continuity of the skin) ○ assess for rash in presence of pruritus (itching) ○ assess lesions for their location, distribution, color, and size ○ palpate lesion to determine texture, shape, and border, and to see if they are soft and filled with fluid or hard and fixed N113 - Content Outline - Exam 3 1) primary lesions: initial lesion; characteristic of the disease itself ○ macule: <1cm, circumscribed border / patch: >1cm, irregular border ■ flat and non-palpable skin color change ■ ex: freckles, flat moles, petechiae, rubella, vitiligo, ecchymosis ○ vesicle: <0.5cm, small blister (ex: herpes, 2nd degree burn, poison ivy) / bulla: >0.5cm, larger blister (ex: large burn injuries, contact dermatitis, poison ivy) ■ circumscribed (obvious border), elevated, palpable mass containing serous fluid (clear fluid) ■ steven johnson syndrome: huge blister from allergic reaction, fluid build up ■ pemphigus vulgaris: creates blisters all over body ○ papule: <0.5 cm, smaller than plaque (ex: wart) / plaque: >0.5 cm, may be coalesced papules with flat top (ex: psoriasis) ■ elevated, palpable, solid mass with a circumscribed borders ○ wheal: elevated mass with transient borders; often irregular; size and color vary ■ ex: mosquito bite, hives (urticaria) ○ nodule: 0.5-2 cm; circumscribed; smaller (ex: lipoma, squamous cell carcinoma, poorly absorbed injection) / tumor: >1-2 cm; do not always have sharp borders (ex: larger lipoma, carcinoma) ■ palpable, elevated solid masses that extend into the dermis. ○ cyst: encapsulated fluid-filled or semi-solid mass in the subcutaneous tissue or dermis ○ pustule: pus-filled vesicle or bulla, ■ ex: acne, impetigo, furuncles ■ differentiated by vesicle/bulla by pus (white blood cells) 2) secondary lesions: result from changes in primary lesions from external causes such as; scratching, trauma, infections, or changes caused by wound healing. ○ erosion: loss of superficial epidermis that does not extend to the dermis; depressed moist area. ■ ex: when blisters pop, erupt, scratch marks ○ scar (cicatrix): skin mark left after healing of a wound or lesion ○ ulcer: skin loss extending past epidermis; necrotic tissue loss; bleeding and scarring is possible. ■ ex: stasis ulcer of venous insufficiency, diabetic ulcer, pressure ulcer ○ keloid: hypertrophic scar tissue secondary to excessive of collagen formation during healing; elevated, irregular, red ■ keloid of piercing or surgical incision ○ fissure: linear crack in the skin that may extend to dermis. ■ ex: chapped lips that crack, cracking hands and cuticles, tinea pedis ○ scales: flakes secondary to desquamated, dead epithelium that may appear on the skin surface. ■ ex: severely dry skin, dandruff, pityriasis rosea, and psoriasis. ○ atrophy: thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible ■ ex: normal aging skin, arterial insufficiency ○ crust: dried residue of serum, blood, or pus on skin surface ■ large, adherent crust is a scab ■ residue left after vesicle rupture: impetigo, herpes, eczema ○ lichenification: thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, scratching (ex: contact dermatitis) N113 - Content Outline - Exam 3 skin lesion configurations: ○ linear: in a line ○ annular and arciform: circular or arcing ○ zosteriform: linear along a nerve route ○ grouped: clustered ○ discrete: separate and distinct ○ confluent: merged 3) vascular lesions: petechiae, ecchymosis, telangiectasias (venous stars), and angiomas. ○ ecchymosis: round or irregular macular lesion, larger than petechiae, a collection of blood in the subcutaneous tissues, causing a purplish discoloration ■ associated with trauma, bleeding tendencies ○ petechiae: round red or purple macule, small hemorrhagic spots caused by capillary bleeding ○ cherry angiomas, spider angiomas, telangiectasias are all benign changes in the elderly ● SEE HINKLE PG 1799 FOR PICTURES ● ● Moisture ● Normally dry; increased moisture may indicate elevated body temperature ● diaphoresis: an excessive amount of perspiration, such as when the entire skin is moist ● Texture ● Varies from smooth/soft to rough/dry. ● in the dehydrated patient: skin is dry, loose, and wrinkled, with mucous membranes cracked and dry ● Temperature ● warm and dry; increase in skin temperature can indicate elevated body temperature ● localized warmth could indicate inflammatory process, erythema ● Turgor ● ● ● ● Fullness or elasticity of the skin Normal: fold returns to its usual shape when released abnormal findings: dehydration causes skin elasticity to decrease, skin folds return slowly deviations in older adults: decreased skin turgor, decreased elasticity and thinning or the dermis with increase age Edema ● indicated when the skin appears tense and shiny, when a finger gently pressed into the skin leaves and indentation or “pit” ● assessing the depth of the pit and the length of time to resolution indicates the extent of the edema ○ 1+ (trace) ○ 2+ (4 mm) ○ 3+ (6 mm) ○ 4+ (8 mm) 2. Hair ● Normal findings ● even distribution; curly, straight, coarse, or kinky ● palpate scalp for lumps and masses ● Older adults ● N113 - Content Outline - Exam 3 ● ● thinner hair, distribution ● white hair Deviations from normal ● Hirsutism → abnormal growth of hair on face and body ● Alopecia → partial or complete absence of hair ○ may be normal, or the result of chemotherapy, radiation therapy, infection, hormonal disorders, or inadequate nutrition ○ androgenic alopecia: male-pattern baldness; affects more than half of all men ● Tinea Capitis → rash caused by fungal infection, appearance is usually circular. ● itching, inflammation, scaling, signs of infestation (lice, nits, or mites) ● body hair distribution: decreased oxygenation of the peripheral tissues, ex: lower extremities, may cause loss of hair 3. Nails ● Color/texture ○ normal findings: pink smooth nail bed should be firm not tender ○ convex plate, 160 degrees ● Capillary refill ○ 3 seconds or less (brisk) ● Variations in older adults ○ Slower growth, splitting ● Deviations from normal ○ beau lines: transverse depression in the nails ■ may indicate diabetes and PVD ○ pitted surface of the nails indicates psoriasis ○ spooning (koilonychia): spoon-shaped nails can indicate severe iron-deficiency anemia ○ clubbing: bulging of the last part of the finger with curved, convex nails ■ related to reduced oxygen in the blood ○ infection, painless separation of the nail plate from nail, increased thickness and brittleness C. Cultural variations related to the integument D. Promote health screening, health maintenance including self-care and associated teaching/education Taylor, C., Lynn, P., Bartlett, J. L., Chapter 26, pp. 706-708; Assessing the Integument Chapter 32, pp. 1044-1045; Skin Integrity and Wound Care Hinkle, J. L. & Cheever, K. H., Chapter 60, pp. 1790-1804; Assessment of Integumentary Function N113 - Content Outline - Exam 3 HEENT A. Nursing history focus for the HEENT (TAYLOR pg 708) ● ● ● ● ● ● ● ● ● ● ● B. Changes in vision or hearing with aging History of use of corrective lenses or hearing aids History of allergies History of disturbances in vision or hearing History of chronic illnesses such as hypertension, diabetes mellitus, or thyroid disease Exposure to harmful substances or loud noises History of smoking (how long, how many packs/day), chewing tobacco, or cocaine use Presence of body piercings and/or tattoos History of eye or ear infections History of head trauma Oral and dental care practices Inspect and palpate the following (include variations in older adults): 1. Head - part hair and inspect scalp, palpate entire head for symmetry ● Shape and symmetry of skull - normal finding: symmetrical ● Masses ● Tenderness ● Deviations from normal - presence of lumps, cysts, injury, wounds, tenderness, loss of hair (abnormal loss of hair including patches or new loss of hair), infestation 2. Face ● Symmetry - facial droop is cause for alarm - early identification of stroke ● Deviations from normal - tics, tremors, involuntary facial movements - edema of the face, especially around the eye (periorbital edema) 3. Neck ● ● ● - assessment includes trachea, lymph nodes, and thyroid gland Movement Ask patient to tilt head backward, forward, and side to side to assess range of motion (ROM) - should be smooth and controlled ROM - Inspect trachea and thyroid: should be midline and symmetrical Lymph nodes - Palpate the lymph nodes with the pads of the fingers - nodes are generally not palpable - Palpate the carotid arteries one at a time, note the strength of the pulse, symmetry, document with the peripheral pulses Deviations from normal - Venous distention (indicating heart problems) - asymmetry, enlargement, lumps, and bulging of thyroid gland (observed, nurse does not palpate N113 - Content Outline - Exam 3 - thyroid) Enlarged lymph nodes may indicate infection, autoimmune disorders, or metastasis of cancer 4. Eyes - primary assessment technique is Inspection ● Symmetry - Inspect the eyes, eyebrows, eyelids, eyelashes, lacrimal glands, pupils, and iris for position and alignment - The eyebrows should be equally distributed; the eyelashes should curl outward. ● Shape ● Color - The pupils are normally black, equal in size, round, and smooth ● Pupillary response - Pupillary reaction and size are assessed with light test - Accommodation - Pencil/finger test - hold object about 4-6 inches from the bridge of the patient’s nose - ask the patient - look at object, then distant object, then back to the object being held - normal finding: pulp constricts when looking at near object and dilates when looking at distant object - Convergence - Hold our finger about 6-8 in from the bridge of patient’s nose - move your finger toward the patient’s nose to assess convergence (cross-eyed appearance, normal finding) ● Visual acuity - Assess with Snellen chart - EOM (extraocular movements) (TAYLOR pg 710) - Peripheral Vision - used to assess retinal function and optic nerve function ● Inspect and palpate the lacrimal glands for edema and pain. ● Deviations from normal - Asymmetry of position and alignment of the eyes may be caused by muscle weakness or a congenital abnormality. - The pupils may be pale and cloudy if the patient has cataracts (loss of opacity of the lens) - unequal pupils may result from central nervous system injury or illness - Decreased or absent pupillary response indicates blindness or serious brain damage. - ptosis- drooping of the upper lid - can be attributed to damage to oculomotor nerve function, myasthenia gravis, or a congenital disorder - entropion - inward turning of lower lid and lashes - ectropion- outward turning of lower lid and lashes - redness or drainage possible infection of the lid margins, conjunctivae, or hair follicles 5. Ears ● ● - Assess the external ear by inspection and palpation - assess for shape, size, and lesions - should be smooth, proportional to the head, and symmetric - Assessing hearing and sound conduction (whisper test) Color - ears should be even in color Symmetry N113 - Content Outline - Exam 3 ● ● ● Position Tenderness Deviations from normal - abnormal findings include unequal height and size, uneven color, and lesions - note presence of cerumen (wax), edema, discharge, or foreign bodies - palpate for pain, edema, or presence of lesions - pain when manipulating the pinna is a symptom of an infection of the external ear 6. Nose and sinuses - Inspect nose and palpate the sinuses - Assessment includes examining the external nose, the nares, and the turbinates. • Shape •Size •Color - Normally, the nasal mucosa is moist and darker red than the oral mucosa •Patency - Occlude one nostril at a time and ask patient to inhale and exhale through the nose •Discharge •Tenderness - Palpate the frontal and maxillary sinuses for pain and edema - frontal - gently pressing upward on the bony prominences located above each eye - maxillary - gentle pressure on the bony prominences of the upper cheek •Deviations from normal - Pain in sinuses with palpation can indicate that sinuses are infected or obstructed - presence of lesions, swelling, exudate, or discharge 7. Mouth - The mouth and pharynx include the lips, tongue, teeth, gums, hard and soft palate, salivary gland, tonsillar pillars, and tonsils • Lips and buccal mucosa - pink, moist, and smooth • Oropharynx - examine the mucous membrane of the oropharynx while depressing the base of the tongue with a tongue depressor - uvula - centered and freely movable - tonsils - small, pink and symmetric • Tongue and floor of mouth - pink, moist, and free of swelling or lesions • Palate • Abnormal findings: pallor, cyanosis, or redness and swelling of the mucous membranes; lesions of the mucosa and lips; swollen, red tonsils (indicating infection); swollen, red, and bleeding gums (from nutritional deficits, inflammation or infection, poorly fitted dentures, or poor oral hygiene); poorly aligned, missing, or carious teeth; a white coating on the tongue (from poor oral hygiene, irritation, or smoking); a fissured tongue (from dehydration); a bright-red tongue (seen in deficiencies of iron, vitamin B12, or niacin); or a black, hairy tongue (from antibiotic use). C. Cultural variation related to HEENT N113 - Content Outline - Exam 3 D. Promote health screening, health maintenance including self-care and associated teaching/education E. Common head and neck variations in the older adult include: ● ● ● ● ● ● ● ● ● Impaired near vision (presbyopia) Decreased color vision and peripheral vision Decreased adaptation to light and dark A white ring around the cornea (arcus senilis) Entropion (eyelid turns inward) and ectropion (eyelid turns outward) Hearing loss (presbycusis) Elongated earlobes Decreased neck ROM Smaller, more easily palpated lymph glands Taylor, C., Lynn, P., Bartlett, J. L., Chapter 26, pp. 708-714; Assessing the Head and Neck Hinkle, J. L. & Cheever, K. H., Chapter 63, pp. 1876-1881; Assessment and Management of Patients with Eye and Vision Disorders Chapter 64, pp. 1915-1926; Assessment and Management of Patients with Hearing and Balance Disorders N113 - Content Outline - Exam 3 Hypertension A. Overview • Demographics/incidence ● Primary: 95% unidentifiable cause ● Secondary: 5%; due to underlying disease such as; renal disease, sleep apnea, and pregnancy. ○ pregnancy increases the risk of ischemic HD (reduced blood flow to organs) • Definition ● SBP: of 140 or higher ● DBP: 90 or higher • Classification B. Pathophysiological mechanisms 1) 2) 3) 4) 5) 6) excess sodium intake → renal sodium retention → increased fluid volume excess sodium intake, stress, and fewer nephrons → decreased filtration surface → increased fluid volume excess stress → SNS overactivity → increased contractility excess stress → renin-angiotensin excess → sympathetic activation → increased cardiac output, contractility genetic alterations → cell membrane alteration→ increased peripheral resistance obesity → hyperinsulinemia → increased peripheral resistance Increased activity of RAAS system C. Predisposing/risk factors • Gender →men are at higher risk of getting HTN • Age → chances of HTN increases with age • Race → African Americans are at the highest risk of developing HTN • Lifestyle → • Family history → D. Complications/consequences associated with hypertension • Heart disease → • Cerebrovascular disease → • Peripheral vascular disease → • Chronic kidney disease → HTN causes arteries around kidneys to narrow and weaken or harden. arteries will not be able to deliver enough blood to kidneys, therefore losing the inability to properly filter blood • Retinal damage → retinal blood vessels may thicken causing blood vessels to become narrow, restricting blood flow and swollen retina E. Medical management • Lifestyle modifications ● non modifiable: age, gender, ethnicity/race, family Hx ● modifiable: poor diet habits, excessive alcohol intake, sedentary lifestyle ● contributing factors: smoking, sleep apnea, stress • Drug therapy 1. Diuretics a. thiazide diuretics i. may result in hypokalemia - can lead to cardiac arrest ii. monitor levels of potassium N113 - Content Outline - Exam 3 b. 2. 3. 4. 5. 6. 7. 8. loop diuretics - furosemide (Lasix) i. monitor potassium and I&o especially if pt. is on Digoxin 1. Digoxin - decreased HR c. Aldosterone receptor blockers (Potassium-sparing diuretics) - spironolactone (Aldactone) i. Monitor for hyperkalemia Beta-blockers - The LOLs a. non-selective - hits b1 (heart) and b2 (lungs) i. propranolol (Inderal) ii. monitor for respiratory depression b. Cardio-selective i. metoprolol (Lopressor) ii. no bronchoconstriction iii. monitor for severe bradychardia c. Have sexual side effects - ED Centrally acting alpha2-agonists a. clonidine (Catapres TTS) b. Stimulates the alpha2-receptor in the heart c. dizziness, sleepiness, fatigue, constipation, and ED Combined alpha and beta-blockers a. carvedilol (Coreg) b. Blocks both alpha and the beta-adrenergic receptors c. Watch for tachycardia and respiratory depression Vasodilators a. nitroprusside (Nitropress) hydralazine (Apresoline) b. Decreasing peripheral resistance c. For use in HTN emergency d. IV Push for immediate reduction in BP e. monitor for hypotension, have IV fluids ready to administer to bring BP back up ACE-Inhibitors a. The “prils” b. Recommended as a first line intervention c. prevents angiotensin-ii related vasoconstriction d. watch for hyperkalemia Angiotensin-II receptor blockers (ARB) a. the “tans” b. prevents angiotensin-ii related vasoconstriction c. Monitor for hyperkalemia d. Losartan (Cozaar), Valsartan (Diovan) Calcium-channel Blockers (CCB) a. The “pines” b. amlodipine (Norvasc), diltiazem (Cardizem) c. Reduce cardiac workload, coronary artery vasodilation, decreased HR d. Acts on the heart muscle cells by inhibiting the flow of Ca++ F. Nursing process 1. Assessment N113 - Content Outline - Exam 3 ● Hx, risk factors ○ S/S that indicate target organ damage ○ Monitoring BP ○ physical examination ○ ability to adhere to adhere to an antihypertensive medication regimen ○ perceptions about the diagnosis of HTN 2. Nursing/collaborative interventions • Increasing knowledge • Promoting adherence to the therapeutic regimen • Promoting home, community -based, and transitional care •Monitoring and managing potential complications G. Teaching guidelines • Managing BP •Expected effects and side effects of medications •Consequences of untreated hypertension •Home BP monitoring H. Lifestyle modifications –areas of focus: •Weight reduction •DASH diet, decreased sodium intake •Regular physical activity •Smoking cessation •Reduced alcohol consumption Hinkle, J. L. & Cheever, K. H., Chapter 31, pp. 884-899; Assessment and Management of Patients With Hypertension
