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case study about hypertension with electrolyte imbalance part 1

case study about hypertension with electrolyte imbalance part 1

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Published by THE NURSING CORNERS

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Published by: THE NURSING CORNERS on Sep 15, 2010
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05/30/2013

 
HYPERTENSION
Hypertension is one of the most common worldwide diseasesafflicting humans. Because of the associated morbidity and mortality andthe cost to society, hypertension is an important public health challenge.Over the past several decades, extensive research, widespread patienteducation, and a concerted effort on the part of health care professionalshave led to decreased mortality and morbidity rates from the multipleorgan damage arising from years of untreated hypertension.Defining abnormally high blood pressure is extremely difficult andarbitrary. Furthermore, the relationship between systemic arterialpressure and morbidity appears to be quantitative rather thanqualitative. A level for high blood pressure must be agreed upon inclinical practice for screening patients with hypertension and forinstituting diagnostic evaluation and initiating therapy. Because the riskto an individual patient may correlate with the severity of hypertension,a classification system is essential for making decisions aboutaggressiveness of treatment or therapeutic interventions.Based on recommendations of the Seventh Report of the JointNational Committee of Prevention, Detection, Evaluation, and Treatmentof High Blood Pressure (JNC VII), the classification of blood pressure(expressed in mm Hg) for adults aged 18 years or older is as follows:
Normal - Systolic lower than 120, diastolic lower than 80
Prehypertension - Systolic 120-139, diastolic 80-99
Stage 1 - Systolic 140-159, diastolic 90-99
Stage 2 - Systolic equal to or more than 160, diastolic equal to ormore than 100Non-modifiable risk factors for hypertension includes family history,age in which primary hypertension typically appears between ages of 30-50 years, gender in which overall incidence is higher in men than inwomen until about the age 55 years and ethnicity where blacks are athigh risks.On the other hand, modifiable factors includes diabetes, stress,obesity, excessive sodium consumption and substance abuse such ascigarette smoking, heavy alcohol consumption and some illicit drugs arerisks for having hypertension.
INTRODUCTION
 
 This is based on the average of 2 or more readings taken at each of 2or more visits after initial screening. Normal blood pressure with respectto cardiovascular risk is less than 120/80 mm Hg. However, unusuallylow readings should be evaluated for clinical significance.Prehypertension, a new category designated in the JNC VII report,emphasizes that patients with prehypertension are at risk for progressionto hypertension and that lifestyle modifications are important preventivestrategies. Hypertension may be either essential or secondary. Essentialhypertension is diagnosed in the absence of an identifiable secondarycause. Approximately 95% of American adults have essentialhypertension, while secondary hypertension accounts for fewer than 5%of the cases.Blacks have a higher prevalence and incidence of hypertension thanwhites. The prevalence of hypertension was increased by 50% in AfricanAmericans. In Mexican Americans, the prevalence and incidence of hypertension is similar to or lower than in whites. The National Healthand Nutrition Examination Survey (NHANES) III reported an age-adjustedprevalence of hypertension at 20.6% in Mexican Americans and 23.3% innon-Hispanic whites.A progressive rise in blood pressure with increasing age is observed. The third NHANES survey reported that the prevalence of hypertensiongrows significantly with increasing age in all sex and race groups.National health surveys in various countries have shown a highprevalence of poor control of hypertension. These studies have reportedthat prevalence of hypertension is 22% in Canada, of which 16% iscontrolled; 26.3% in Egypt, of which 8% is controlled; and 13.6% inChina, of which 3% is controlled. Hypertension is a worldwide epidemic;in many countries, 50% of the population older than 60 years hashypertension. Overall, approximately 20% of the world's adults areestimated to have hypertension. The 20% prevalence is for hypertensiondefined as blood pressure in excess of 140/90 mm Hg. The prevalencedramatically increases in patients older than 60 years.
HYPOKALEMIA
Potassium, the most abundant intracellular cation, is essential forthe life of the organism. Potassium is obtained through the diet, andcommon potassium-rich foods include meats, beans, fruits, and potatoes.Gastrointestinal absorption is complete, resulting in daily excess intakeof approximately 1 mEq/kg/d (60-100 mEq). Ninety percent of this excessis excreted through the kidneys, and 10% is excreted through the gut.Potassium homeostasis is maintained predominantly through theregulation of renal excretion.
 
Potassium is predominantly an intracellular cation; therefore,serum potassium levels can be a very poor indicator of total body stores.Because potassium moves easily across cell membranes, serumpotassium levels reflect movement of potassium between intracellularand extracellular fluid compartments, as well as total body potassiumhomeostasis.Muscle contains the bulk of body potassium, and the notion thatmuscle could play a prominent role in the regulation of serum potassiumconcentration through alterations in sodium pump activity has beenpromoted for a number of years. Insulin stimulated by potassiumingestion increases the activity of the sodium pump in muscle cells,resulting in an increased uptake of potassium. Studies in a model of potassium deprivation demonstrate that acutely, skeletal muscledevelops resistance to insulin-stimulated potassium uptake even in theabsence of changes in muscle cell sodium pump expression. However,long term potassium deprivation results in a decrease in muscle cellsodium-pump expression, resulting in decreased muscle uptake of potassium. Thus, there appears to be a well-developed system for sensingpotassium by the pancreas and adrenal glands, resulting in rapidadjustments in immediate potassium disposal and for long-termpotassium homeostasis. High potassium states stimulate cellular uptakevia insulin-mediated stimulation of sodium-pump activity in muscle andstimulate potassium secretion by the kidney via aldosterone-mediatedenhancement of distal renal expression of secretory potassium channels(ROMK). Low potassium states result in insulin resistance, impairingpotassium uptake into muscle cells, and cause decreased aldosteronerelease, lessening renal potassium excretion.In the general population, data are difficult to estimate; however,probably fewer than 1% of people on no medications have a serumpotassium level of lower than 3.5 mEq/L. Potassium intake variesaccording to age, sex, ethnic background, and socioeconomic status.Whether these differences in intake produce different degrees of hypokalemia or different sensitivities to hypokalemic insults is notknown. Up to 21% of hospitalized patients have serum potassium levelslower than 3.5 mEq/L, with 5% of patients achieving potassium levelslower than 3 mEq/L. Of elderly patients, 5% demonstrate potassiumlevels lower than 3 mEq/L.Hypokalemia generally is associated with higher morbidity andmortality, especially due to cardiac arrhythmias or sudden cardiac death.However, an independent contribution of hypokalemia to increasedmorbidity/mortality has not been conclusively established.

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