OBSTRUCTIVE PULMONARY proteinases and anti-proteinases
DISEASES in the lung;- responsible for
Obstructive pulmonary disease airflow limitation. -describes conditions in which airflow • When activated by chronic in the lungs is obstructed. inflammation, proteinases and - Resistance to inspiration is other substances may be released, decreased, whereas resistance to damaging the parenchyma of the expiration is increased, so that the lung. expiratory phase of respiration is • The parenchymal changes may prolonged (Bullock & Henze, 2000). also be consequences of Chronic obstructive pulmonary inflammation, environmental, or disease: genetic factors. -(COPD) is an umbrella term for • Early course of COPD; the chronic lung diseases that inflammatory response causes have limited airflow in and out of the pulmonary vasculature changes lungs. that are characterized by -Symptoms include chronic cough and thickening of the vessel wall. expectoration, dyspnea, • Occur as a result of exposure to shortness of breath, wheezing, and cigarette smoke or use of tobacco impaired expiratory airflow. products or as a result of the -COPD- diseases that cause airflow release of inflammatory mediators. obstruction or a combination. • Categories of COPD: - emphysema, chronic bronchitis and • A. Emphysema- disease of the other diseases such as cystic airways characterized by fibrosis, bronchiectasis and asthma. destruction of the walls of over Pathophysiology: distended alveoli. - airflow limitation is both progressive - a pathological term that describes an and associated with an abnormal abnormal distention of the walls of inflammatory response of the lungs to alveoli. noxious particles or gases. - the End Stage- walls of the alveoli are - the inflammatory process occurs destroyed (process accelerated by throughout the airways, parenchyma recurrent infections), and pulmonary vasculature. a. the alveolar surface area in direct - the chronic inflammation and the contact with the pulmonary capillaries body’s attempts to repair it, narrowing continually decreases, causing an occurs in the small peripheral airways. increase in dead space (no gas - this injury-and-repair process causes exchange); scar tissue formation and narrowing b. impaired oxygen diffusion which of the lumen. leads to hypoxemia. - airflow obstruction may also be due Later Stage- carbon dioxide tension in to parenchymal destruction, arterial blood (hypercarpnia) and (emphysema), a disease of the alveoli causing respiratory acidosis. or gas exchange units. -As the alveolar walls continue to • In addition to inflammation; break down, the pulmonary bed is processes relating to imbalances of reduced. Pulmonary blood flow increased, 1. depresses the activity of scavenger forcing the right ventricle to cells and affects the respiratory tract’s maintain a higher blood pressure ciliary cleansing mechanism, in the pulmonary artery. 2. irritates the goblet cells and mucus Hypoxemia increase pulmonary glands, causing an increased pressure, thus right- sided heart accumulation of mucus. failure (cor pulmonale) as a 3. carbon monoxide (byproduct of complication. smoking)- combines ==congestion, dependent edema, with hemoglobin to form distended neck veins, or pain in the carboxyhemoglobin- cannot carry region of the liver. oxygen efficiently. • Two main types of Emphysema: b. prolonged and intense exposure to 1. Panlobar (panacinar)- there is occupational dusts and destruction of the respiratory chemicals, indoor air pollution and bronchiole, alveolar duct and outdoor air pollution. alveoli. c. deficiency of alpha, antitrypsin, an - all air spaces within the lobule are enzyme inhibitor that essentially enlarged, but there is little process the lung parenchyma from inflammatory disease. injury. - manifestations-hyperinflated • Clinical manifestations: (hyperexpanded), chest (barrel chest), - cough, sputum production marked dyspnea on exertion and and dyspnea in exertion, weight loss, weight loss. - barrel chest (chronic = negative pressure during hyperinflation)- loss of lung elasticity inspiration- to move air and out of the • Assessment and Diagnostic lungs. findings: = adequate level of positive pressure - pulmonary function studies- must be attained and maintained determine disease severity during expiration. - spirometry- evaluate airflow 2. Centrilobular (Centroacinar)- take obstruction place mainly in the center of the - arterial blood gas- obtained to assess secondary lobule, preserving the baseline oxygenation and gas peripheral portions of the acinus. exchange. - derangement of ventilation - chest x-ray- -perfusion ratios, producing chronic - alpha1 antitrypsin deficiency hypoxemia, hypercarpnia (increased screening CO2 in the arterial blood), • Complications: polycythemia and episodes of right - Respiratory insufficiency and sided heart failure; leads to central failure, pneumonia, atelectasis, cyanosis, peripheral edema and pneumothorax and cor respiratory failure. pulmonale (pulmonary heart disease). Risk Factors: • Medical management: a. cigarette smoking/ passive smoking 1. Smoking cessation 2. Pharmacologic therapy: a. bronchodilators- relieve helps the patient to control the bronchospasm and reduce airway rate and depth of respiration. obstruction by allowing increased 3. Inspiratory muscle training- oxygen distribution throughout the diaphragmatic breathing; to lungs and improving alveolar strengthen the muscles ventilation. 4. Self care activities- take short walks, = metered-dose inhaler (MDI)- resting as needed to avoid fatigue pressurized device containing an and excessive dyspnea. Fluid should aerosol powder of medication. always available and patient should b. Corticosteroids- begin to drink fluids without having to • Management of Exacerbation: be reminded. • Causes: tracheobronchial infection 5. Physical conditioning- breathing and air pollution; pneumonia, exercise and general exercises to pulmonary embolism, conserve energy and increase pneumothorax, rib fractures or pulmonary ventilation. chest trauma. 6. oxygen therapy at home- portable • Treatment: indications for oxygen system; proper flow rate and hospitalization: requires number of hours for oxygen 1. optimization of bronchodilator use. medication-first line therapy.; - precaution – smoking is not allowed 2. antibiotic agents. (explode) 3. oxygen therapy 7. nutritional therapy- caloric needs 4. intensive respiratory intervention and counseling about meal planning • Oxygen therapy- long-term • Coping measures- patient and continuous therapy family • Surgical management: B. Chronic Bronchitis- chronic 1. bullectomy- reduce dyspnea and inflammation of the lower respiratory improve lung function. Done tract characterized by excessive mucus thoracoscopically ( video secretion, cough and dyspnea assisted thoracoscope). associated with recurring infections of 2. lung volume reduction surgery- the lower respiratory tract. removal of a portion of the diseased • Pathophysiology: lung parenchyma. Allows the - smoke or other environmental functional tissue to expand, resulting pollutants irritate the airways, in improved elastic recoil of the lung resulting in hyper secretion of mucus and improved chest wall and and inflammation. diaphragmatic mechanism. - Constant irritation causes the mucus- 3. lung transplant- viable alternative secreting glands and goblet cells to for definitive surgical treatment of increase in number, ciliary function is end stage emphysema. reduced. • Nursing management: - the bronchial walls thickened, the 1. Patient education bronchial lumen is narrowed, 2. Breathing exercises- pursed-lip and mucus plug the airway. breathing helps to slow expiration, - alveoli adjacent to the bronchioles prevent collapse of small airways, may be damaged and fibrosed resulting in altered function of the 1. Improving airway clearance alveolar macrophages. 2. Improving breathing pattern • Signs/symptoms: 3. Controlling infection a. presence of cough and sputum 4. Improving gas exchange production for at least three months in 5. Nutrition each of 2 consecutive years. 6. Increased activity tolerance b. production of thick, gelatinous 7. Improving sleep patter sputum, greater amounts producing 8. Enhancing coping superimposed infections Other Classified Diseases as c. wheezing and dyspnea as disease COPD: progresses A. ASTHMA: Diagnostic evaluation: Asthma is usually a reversible 1. pulmonary function test- obstructive disease of the lower demonstrate airflow obstruction- airway. Inflammation of the airway - reduced FEV to FVC ratio and hyper responsiveness of the - increased residual volume to total airway to internal or external stimuli lung capacity (TLC )ratio characterize asthma. 2. ABG’s decreased PaO2,pH and Pathophysiology and Etiology: increased O2 There are two types of asthma: 3. CXR- (late stage)- hyperinflation, 1. allergic asthma (extrinsic),- which flattened diaphragm, increased occurs in response to allergens, such retrosternal space, decreased vascular as pollen, dust, spores, and animal markings, possible bullae. dander; and • Management: 2. non-allergic asthma (intrinsic),- 1. smoking cessation associated with factors such as upper 2. bronchodilators respiratory infections, emotional - symphathomimetics; upsets, and exercise. ***Many clients metaproterenol-to protect against experience mixed asthma, which has bronchospasm ( aerosol characteristics of allergic and non- formulations); MDIs. allergic asthma. - methylxanthines- theophylline • Acute asthma results from 3. Antimicrobial agents- infection increasing airway obstruction 4. corticosteroids- acute exacerbations caused by bronchospasm and for anti-inflammatory effect. bronchoconstriction, inflammation 5. Chest physical therapy and edema of the lining of the 6. Low-flow oxygen bronchi and bronchioles, and 7. Pulmonary rehabilitation- limit production of thick mucus that can activity plug the airway. • Complications: • The airways in people with - respiratory failure asthma are hyper-reactive in - pneumonia- overwhelming response to stimuli. respiratory infection • Allergic asthma causes the - right heart failure; dysrythmias immunoglobulin E (IgE) - depression; inflammatory response. Nursing Management: • These antibodies attach to =During an acute episode, the mast cells (granulocyte contain work of breathing greatly histamine and heparin) within the increases, and the client lungs. may suffer from a sensation of • Reexposure to the antigen suffocation. causes the antigen to attach to the -The client frequently antibody, releasing mast cell assumes a classic sitting position, products such as histamine. with the body leaning • Because alveoli cannot expel slightly forward and the arms at air, they hyperinflate and trap air shoulder height. in the lungs. - This position facilitates • The client breathes faster, chest expansion and more blowing off excess CO2. effective excursions of • Although the client tries to the diaphragm. force the air out, the narrowed • Diagnostic Findings: airway makes it difficult. 1. Chest auscultation reveals • Wheezing usually is audible expiratory and sometimes inspiratory with expiration, resulting from air wheezes and diminished breath being forced out of the narrowed sounds. airway. 2. Pulmonary function studies; • Other pathophysiologic - Forced expiratory volume changes include interference with - abnormal gas exchange, poor perfusion, - Total Lung Capacity (TLC) and possible atelectasis, and Functional Residual Volume (FRV) respiratory failure if inadequately increased secondary to trapped air. treated. Forced Expiratory Volume (FEV) and • Asthma may develop at any Forced Vital Capacity (FVC) are age. decreased. • Significant relationship 3. During acute attacks, blood gases between bronchiolitis (ABG) show hypoxemia. (inflammation - The partial pressure of carbon of the bronchioles) in the first dioxide (PaCO2) level may be elevated year of life and development of if the asthma becomes worse, but asthma in early childhood. usually the PaCO2 level is decreased • Assessment Findings: because of the rapid respiratory rate. • Signs and Symptoms: - A normal PaCO2 level in the latter =paroxysms of shortness of part of an asthma attack may indicate breath, wheezing, and coughing and impending respiratory failure. the production of thick, • Medical Management: tenacious sputum. 1. If the history and diagnostic tests = Duration of acute episodes indicate allergy as a causative factor, varies; it may be brief (less treatment includes avoidance of the than 1 day) or extended allergen, desensitization, or (lasting for several weeks). antihistamine therapy. 2. Oxygen usually is not necessary - bronchial obstruction by tumor or during an acute attack because most foreign body, clients are actively hyperventilating. - congenital abnormalities, Oxygen may be necessary if cyanosis - exposure to toxic gases, occurs. - chronic pulmonary infections. 3. Pharmacologic management: Pathophysiology: - metered-dose inhalers (MDIs). - damage to the bronchial wall, which - Bronchodilators are used to manage leads to buildup of thick sputum, acute breathing disorders causing obstruction. • Nursing Management: - severe coughing result in permanent 1. administers oxygen if indicated and dilatation of bronchial walls. puts the client in a sitting position. • The structure of the wall tissue 2. Rest and adequate fluid intake- subsequently changes, resulting secretions less tenacious and replaces in formation of saccular the fluids lost through perspiration. dilatations, which collect purulent 3. checks the intravenous (IV) site material. frequently for signs of extravasation. • Airway clearance is further 4. when the client is receiving impaired, and the purulent epinephrine or other adrenergic material remains, causing more agents, which may cause palpitations, dilatation, structural damage, nervousness, trembling, pallor, and and more infection. insomnia. • Nursing Management for the 5. instructs the client in using the peak Elderly; flow meter to monitor the degree of • The goals of therapy in the asthma control. elderly with COPD: • Nutrition: • to treat and prevent chronic 1. Encourage clients with asthma to symptoms, consume adequate calories and • decrease emergency room protein to optimize health and resist visits and hospitalizations, infection. optimize and preserve activity 2. Large meals may aggravate asthma level, by distending the stomach; small • optimize pulmonary function frequent meals may be better with minimal adverse effect from tolerated. medications. 3. Certain vitamins and minerals are • Management should also focus important for immune function, on improving health status especially vitamins A, C, B6, and the (quality of life), which is greatly mineral zinc. impaired by respiratory symptoms 4. Food allergens that may trigger such as breathlessness and by asthma include milk, eggs, seafoods symptoms of anxiety and and fish. depression. • B. Bronchiectasis- a chronic, • Clinical manifestations: irreversible dilatation of the 1. persistent cough with production of bronchi and bronchioles. copious amounts of purulent sputum. • Causes: 2. intermittent hemoptysis; - When two carriers give birth to a breathlessness child, the child has a 25% chance of 3. recurrent fever and bouts of having CF, a 50% chance of being a pulmonary infection carrier, and a 25% chance of not 4. crackles and rhonchi being a carrier. ( whistling/snoring) heard over • The genetic defect causes involved lobes inadequate synthesis of a protein 5. finger clubbing (CF gene product) referred to Diagnostic evaluation; as the CF transmembrane -CXR- may reveal areas of atelectasis conductance regulator (CFTR). with widespread dilatation of bronchi. • CFTR molecules are located in - sputum examination- pathogens the cells lining the ducts of the • Medical Management exocrine glands, particularly the 1. drainage of purulent material from lungs, pancreas, intestine, and the bronchi; antibiotics, sweat ducts. bronchodilators, and mucolytics to • Clients with CF cannot improve breathing and help raise synthesize adequate CFTR to secretions; regulate the 2. humidification to loosen secretions; combination of water and 3. surgical removal if bronchiectasis is electrolytes with exocrine secretions confined to a small area. and mucus. Nursing management: Subsequently, thick, viscous secretions 1. instructing the client in postural and protein plugs eventually block the drainage techniques, which help the ducts of the exocrine glands. client mobilize and expectorate Eventually, ducts may become secretions. fibrotic and convert into cysts 2. Chest percussion and vibration may (Bullock & Henze, 2000). be performed during this time. • Airflow obstruction is a key 3. Encourage increased intake of fluid feature in the presentation CF. to reduce viscosity of sputum and • This obstruction is due to make expectoration easier. bronchial plugging by purulent C. Cystic Fibrosis - an inherited secretions, bronchial thickening multisystem disorder that affects due to inflammation resulting infants, children, and young adults. airway obstruction. - It obstructs the lungs, leading to • Chronic retained secretions in major lung infections, as well as the airways set up an excellent obstructing the pancreas. reservoir for continuous bronchial • Pathophysiology and Etiology infection. - CF results from a defective autosomal • Clinical manifestations: recessive gene. • respiratory infections, ranging - A person with CF inherits a defective from URIs with increased cough copy of the CF gene from both parents. and purulent sputum to the - A person who is a carrier has one production of thick, tenacious normal copy of the gene and one mucus. defective copy. • Finger clubbing is common. • Hemoptysis also may occur as successfully and have the benefit of blood vessels are damaged in the decreasing systemic absorption. lungs, secondary to frequent • Nursing management: coughing and constant efforts to 1. chest physical therapy (including clear mucus. postural drainage, percussion, and • Sinusitis and nasal polyps vibration) two to four times daily, • Assessment and diagnostic 2. deep-breathing and coughing findings: exercises, nebulized treatments, and • Pilocarpine iontophoresis medications. sweat test. Up to 20 years of age, 3. prophylactic antibiotic therapy to levels decrease recurrence of infection higher than 60 mEq/L are diagnostic, and those between 50 and 60 mEq/L are highly suggestive for CF. • Chest radiography demonstrates widespread consolidation, fibrotic changes, and overaerated lungs. Pulmonary function tests assist in determining current function as well as progression of the disease. • Radiographic studies of the GI system show fibrous abnormalities. • In 80% of those with CF, tests for pancreatic enzymes in duodenal contents fail to show evidence of trypsin. • Medical management; • promoting the removal of the thick sputum through postural drainage, • chest physical therapy with vigorous percussion and vibration, breathing exercises, • hydration to help thin secretions, • bronchodilator medications, nebulized mist treatments with saline or mucolytic • lung infections with antibiotics. • Inhaled antibiotics, such as tobramycin, are being used Narrowing of arteries supplying blood to the heart Ischemia ( inadequate blood supply) Ischemic heart disease known as; a. Coronary heart disease (CHD) b. Coronary artery disease (CAD) c. Myocardial infarction (heart attack)- persistence of deficient blood supply, tissue dies. - Dead area (Necrosis): an infarct Heart attack may result from; - cardiac arrest- some interruption of normal pattern of cardiac contraction - Coronary thrombosis- sudden blockage of coronary artery with a blood clot, - Strenuous exercises resulting in suddenly increased need for oxygen. Mortality associated with MI Over 70 and 2x under the age 70 Symptoms of MI may differ in older people than in younger ones. - complete absence of chest pain is very rare in acute MI up to middle age, Chronic Illness/ Conditions it is a “mundane occurrence” in old Heart disease, people. Hypertension, - “only about 1/3 of elderly patients Chronic obstructive Pulmonary present with classical prolonged Disease COPD episode of chest pain”. (Kart & Kinny) Diabetes, Gerontology: Cancer and - elderly patients: more likely to Dementia, experience silent MIs have atypical Stroke symptoms- hypotension, low body A. Heart Disease temperature, vague complaints of Principle cause of death discomfort, mild perspiration, stroke- Accounts for significant morbidity, like symptoms ( dizziness, change in disablement and inactivity sensorium). Dominant factors; atherosclerosis Etiology (build-up of fatty deposits within 1. Acute Coronary thrombosis (partial arterial walls or total)– associated with 90% of Mis. Pathophysiology/Mechanism a. severe coronary artery disease Atherosclerosis buildup (greater then 70% narrowing of a. Transmural (Q wave) infarction- the area of necrosis occurs throughout the artery) precipitates thrombus entire thickness of the heart muscle. formation. b. Subendocardial b. Intramural hemorrhage into (nontransmural/non-Q) infarction- atheromatous plaques causes area of necrosis is lesion to confined to the innermost layer of the enlarge and occlude the vessel; heart lining the chambers. dissecting 5. Location of damaged heart muscle hemorrhage can also occur. within the left ventricle; inferior, c. plaque ruptures into the vessel anterior, lateral and posterior; lumen and a thrombus forms on a. left ventricle- most common and top of the ulcerated lesion, with dangerous location- main pumping resultant vessel occlusion. chamber of the heart. 2. Other etiologic factors; b. right ventricular infarctions – occur - coronary artery spasm, coronary in conjunction with damage to the artery embolism, infectious disease inferior and/or posterior wall of the causing arterial inflammation, left ventricle. hypoxia, anemia severe exertion or 6. Region of the heart muscle that stress on the heart in the presence of becomes damaged- determined by the significant coronary artery disease. coronary artery that becomes 3. Degrees of Damage occur to the obstructed. heart muscle: 7. Amount of heart muscle damage a. Zone of necrosis- death to the and the location of the MI- determines heart muscle caused by extensive prognosis. and complete oxygen deprivation; Heart Disease: Modifiable Factors: (Irreversible damage). Cigarette smoker: 2x MI rate of non- b. Zone of Injury – region of the smokers heart High B/p muscle surrounding the area of High serum cholesterol levels necrosis; Diabetes - inflamed and injured, but still Obesity viable if adequate oxygenation can Sedentary lifestyle be Healthy people 2000 restored. 1. Increase proportion of people c. Zone of ischemia- region of the whose high B/P is under control heart muscle surrounding the 2. reduce mean-serum cholesterol area of injury, which is ischemic and levels viable; 3. reduce dietary fat intake and - not endangered unless extension average unsaturated fat intake of the infarction occurs. 4. reduce prevalence rates of 4. Layers of the layers of the heart obese/overweight adults muscle 5. increase proportion of children and involved; Classified as: adults engaging in regular, daily physical activity at least 30min/day. 6. reduce cigarette smoking among and demand by decreasing HR, B/P people age 20 and older and dilating coronary vessels. (.http://www.health.gov/healthypeop D. Percutaneous Transluminal le). Coronary Angioplasty (PTCA)- Management: mechanical opening of the coronary A. oxygen therapy- improves vessel can be performed during an oxygenation evolving infarction. B. Pain Control; E. Surgical Revascularization- i. Opiate analgesic therapy= coronary artery bypass surgery (w/in - morphine- improve cardiac 6hrs of evolving infarction) hemodynamics by reducing - definite treatment of the stenosis preload and afterload; provide and less scar formation of the heart. anxiety relief. Gerontology Consideration: - Meperidine (demerol)- allergic to Elderly patients are extremely morphine or sensitive to susceptible to respiratory depression respiratory depression. in response to narcotics. ii. Vasodilator therapy- Analgesic agents with less profound - nitroglycerine (sublingual, paste) effects on the respiratory center - myocardial oxygen demand should be used. - persistent chest pain – IV Anxiolytic agents nitroglycerin Nursing care: iii. Anxiolytic therapy- Reducing pain- administer O2, - benzodiazepines- with medication; analgesic. Alleviating anxiety- explain C. Pharmacologic therapy- equipment, procedures and need for i. Thrombolytic agents- tissue frequent assessment plasminogen activator; steptokinase, Maintaining hemodynamic stability- urokinase; reestablish blood flow in monitor v/s. coronary vessels by dissolving Increasing activity tolerance- promote obstructing thrombus. rest with early gradual increase in ii. Anticoagulant therapy- adjunct mobilization to thrombolytic therapy. Preventing bleeding- monitor V/s; iii. Beta-adrenergic blocking agents- thrombolytic agent. improve O2 supply and demand, Assignment: decrease sympathetic stimulation to Read about Hypertension, COPD and the heart, promote blood flow in the Diabetes mellitus. small vessels of the heart; have anti Hypertension: High Blood Pressure -dysrhythmic Disease of the vascular regulation in effects which the mechanism that control iv. Anti-dysrhythmic therapy; arterial pressure within normal range lidocaine- decreases ventricular are altered. irritability. Mechanism control: v. Calcium channel blockers - CNS (Dilzem)- improve the balance b/w O2 - renal pressure system (renin- angiotensin-aldosterone system - extracellular fluid volume. cardiac hormone which gene and B/p elevation- increased cardiac receptors are widely present in the output and peripheral vascular body. resistance. Main functions: Hypertension To lower blood pressure and to Pathophysiology/Etiology: control electrolyte homeostasis. A. Primary or Essential Hypertension Causing a reduction in expanded - approx. 90% of patients with hpn extracellular fluid (ECF) volume by - diastolic pressure is 90mmHg or increasing renal sodium excretion. higher and other causes of B. Secondary hypertension hypertension are absent. - approx. 5%-10% of patients with - considered hpn when the average of hypertension 3 or more B/p readings taken at rest Causes: several days apart exceeds the upper 1. follows other pathology limits. 2. Renal Pathology- a. congenital anomalies, Causes: pyelonephritis, renal artery Unknown obstruction, acute and chronic Hyperactivity of sympathetic glomerulonephritis. vasoconstricting nerves b. reduced blood flow to kidney Presence of blood component (atherosclerotic plaque) release containing a vasoconstrictor that acts of renin. on smooth muscle, sensitizing it to - renin reacts with serum protein in constrictor substances liver (a2- globulin) angiotensin I; Increases cardiac output, followed by and angiotensin-converting enzyme arteriole constriction. (ACE) Prostaglandins affect regulatory Angiotensin II leads to increase mechanism, which include the renin- B/P. angiotensin system, renal Na and Renal artery disease can cause of water excretion and vascular smooth narrowing of the vessel lumen muscle tone. (stenosis). Familial (genetic) tendency. Reduced lumen diameter decreases Decsription: the pressure at the afferent arteriole Labile- intermittently elevated B/P in the kidney and reduces renal Accelerated- sudden and severe perfusion. escalation in arterial pressure, Stimulates renin release by the kidney, producing many symptoms and which increases vascular damage circulating angiotensin II (AII) Resistant- hpn that is not responsive and aldosterone. to usual treatment These hormones increase blood Atrial natriuretic peptide (ANP) or volume by enhancing renal atrial natriuretic factor (ANF) is a reabsorption of sodium and water. natriuretic peptide hormone secreted Increased AII also causes systemic from the cardiac atria. vasoconstriction and enhances sympathetic activity. Chronic elevation of all promotes angiotensin-aldosterone system, cardiac and vascular hypertrophy. which leads to an increase in blood The net effect of these renal volume. mechanisms is an increase in blood This further increases arterial volume that augments cardiac output pressures in the upper body and may by the Frank-Starling mechanism. largely offset the reduction in lower Therefore, hypertension caused by body arterial pressures. renal artery stenosis results from both This condition is readily diagnosed by an increase in systemic vascular comparing arterial pressures resistance and an increase in cardiac measured in the arms and legs. output. 4. Endocrine disturbances – Frank–Starling law of the heart a. Pheochromocytoma- tumor of the represents the relationship between adrenal gland – causes release of stroke volume and end diastolic epinephrine and norepinephrine and a volume. rise in b/p - states that the stroke volume of b. Adrenal cortex tumors- leads to the heart increases in response to an increase in aldosterone secretion and increase in the volume of blood in the an elevated blood pressure. ventricles, before contraction, when Increased secretion of aldosterone all other factors remain constant.. generally results from adrenal Hypertension- the leading causes of adenoma or adrenal hyperplasia. CKD due to the deleterious effects that Increased increased BP has circulating aldosterone causes renal on kidney vasculature. retention of sodium and water, which - damage impairs the kidney's ability causes blood volume and arterial to filter fluid and waste from the pressure to increase. blood, leading to an increase of fluid Plasma renin levels are generally volume in the blood causing an decreased as the body attempts to increase in BP suppress the renin-angiotensin 3.Coarctation of aorta (stenosis of system; there is also hypokalemia aorta)- blood flow to upper associated with the high levels of extremities is greater than flow to aldosterone. lower extremities hpn of upper c. Cushing syndrome leads to an body part. increase in adrenocortical steroids Coarctation (narrowing) of the aorta is and hypertension. a congenital defect that most d. Hyperthyroidism. commonly is found just distal to the C. Accelerated Hypertension- left subclavian artery in the arch of the Hypertensive Crisis Blood pressure aorta. elevates very rapidly, threatening one Obstruction of the aorta at this point or more of the target organs; brain, reduces distal arterial pressures and kidney heart elevates arterial pressures in the head Classification and arms. Prevalence and Risk factors The reduced systemic arterial No Symptoms- is termed as “silent pressure activates the renin- killer” Factors; Participation in a self-care program. - age-30-70 Absence of complications. - race- african american BP within acceptable limits for - birth control pills individual. - overweight Cardiovascular and systemic - family history complications prevented/minimized. - smoking Disease process/prognosis and - sedentary lifestyle therapeutic regimen understood. - stress Necessary lifestyle/behavioral - diabetes mellitus changes initiated. Clinical manifestation Plan in place to meet needs after Usually asymptomatic discharge. Headache, Nursing Priorities dizziness, Maintain/enhance cardiovascular blurred vision when greatly elevated functioning. Diagnostic evaluation Prevent complications. ECG– left ventricular hypertrophy, Provide information about disease ischemia process/prognosis and treatment Chest x-ray- cardiomegaly regimen. Proteinuria- elevated BUN, creatinine Support active patient control of Serum K- decreased in primary condition. aldosteronism- elevated in cushing Nursing Interventions syndrome Objective: focuses on lowering and Urine catecholamines- increased controlling the blood pressure without pheochromocytoma adverse effects and without undue Nursing Management cost. Goal: to help achieve a normal blood 1. Encourage the patient to consult a pressure through independent and dietitian to help develop a plan for dependent interventions. improving nutrient intake or for Assessment: weight loss. On antihypertensive medication,- 2. Encourage restriction of sodium and blood pressure is fat assessed to determine the 3. Emphasize increase intake of fruits effectiveness and detect changes in and vegetables. the blood pressure. 4. Implement regular physical activity. Complete history should be obtained 5. Advise patient to limit to assess for signs and symptoms that alcohol consumption and avoidance indicate target organ damage. of tobacco. Pay attention to the rate, rhythm, and 6. Assist the patient to develop and character of the apical and peripheral adhere to pulses. an appropriate exercise regimen. Major goals for a patient with Evaluation: hypertension are as follows: Maintain blood pressure at less than Understanding of the disease process 140/90 mmHg with lifestyle and its treatment. modifications, medications, or both. Demonstrate no symptoms of angina, • 4 to 5 servings of legumes or palpitations, or visual changes. nuts/seeds per week Has stable BUN and serum creatinine • Limited fats and sweets levels. Has palpable peripheral pulses. Physiological Changes and COPD in Evaluation; the Elderly Adheres to the dietary regimen as Aging affects the structure, function, prescribed. and control of the respiratory system. Exercises regularly. The elastic recoil of the lungs is the Takes medications as prescribed and major determinant of maximal reports side effects. expiratory flow and is diminished with Measures blood pressure routinely. aging, causing increased lung Abstains from tobacco and alcohol compliance at high lung volumes. intake. Bronchiolar diameters diminish and Exhibits no complications. alveolar ducts enlarge as a result of Discharge and Home care Guidelines the change in lung matrix and elastic The nurse can help the patient achieve properties of lungs. blood pressure control These changes result in decreased through education about managing expiratory flow and decreased surface blood pressure. area for gas exchange, respectively. Assist the patient in setting goal blood Airways in dependent portions of the pressures. lung close at higher volumes with Provide assistance with social advancing age, so that more airways support. are closed during all or part of the Encourage the involvement of family respiratory cycle. members in the education program to Lower portions of the lung are better support the patient’s efforts to control perfused at all ages, but higher closing hypertension. volume with age increases ventilation Provide written information about perfusion mismatch and accounts for expected effects and side effects. the declining Pao2 (oxygen pressure) Encourage and teach patients to with age. measure their blood pressures at In contrast to the lungs, the chest wall home. stiffens with age and compliance Emphasize strict compliance of follow- decreases. up check up. Costochondral cartilages become DASH Guidelines calcified, and intercostal muscle • 6 to 8 servings of grains per day contraction accounts for less chest • 4 to 5 servings of fresh fruits per day expansion. • 4 to 5 servings of fresh vegetables Respiratory muscle strength and per day endurance diminish with age, • 2 to 3 servings of low-fat dairy per especially above the age of 55 years. day The anterior-posterior diameter of the • 6 or less servings of lean protein per thorax and the kyphosis of the day thoracic spine also increase with age. Changes in skeletal muscle and the thoracic wall may affect clearing of the airway in states where airway mucus hypersecretion occurs.