CARE OF CLIENTS WITH CARDIOVASCULAR DISORDERS

LEARNING OBJECTIVES:
1.

2.
3. 4. 5. 6.

Discuss the different assessment parameters for cardiac functioning. Describe Nursing care of clients undergoing diagnostic tests to assess cardiac functioning. Describe treatment modalities for clients with cardiac disorders. Explain the basic pathophysiology, clinical manifestations and collaborative management of cardiac disorders. Design a nursing care plan for clients with cardiac disorders. Discuss about the prevention, management and rehabilitation factors that optimize health.

OUTLINE
ANATOMY AND PHYSIOLOGY OF THE HEART II. DIAGNOSTIC TEST: ELECTROCARDIOGRAM III. CORONARY HEART DISEASES IV. ANGINA PECTORIS V. MYOCARDIAL INFARCTION VI. CONGESTIVE HEART FAILURE VII. CARDIAC TAMPONADE VIII. HYPERTENSION
I.

ANATOMY AND PHYSIOLOGY OF THE HEART

ELECTROCARDIOGRAM
A non-invasive procedure

that evaluates the electrical activity of the heart

Deflection Waves of ECG

1. P wave - initial wave, demonstrates the depolarization from SA Node through both ATRIA; the ATRIA contract about 0.1 s after start of P Wave. 2. QRS complex - next series of deflections, demonstrates the depolarization of AV node through both ventricles; the ventricles contract throughout the period of the QRS complex, with a short delay after the end of atrial contraction; repolarization of atria also obscured 3. T Wave - repolarization of the ventricles (0.16 s) 4. PR (PQ) Interval - time period from beginning of atrial contraction to beginning of ventricular contraction (0.16 s) 5. QT Interval - the time of ventricular contraction (about 0.36 s); from beginning of ventricular depolarization to end of repolarization.

CORONARY HEART DISEASES

A. PRESDISPOSING FACTORS 1. Sex: male 2. Race: black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. Sedentary lifestyle 7. Diabetes Mellitus 8. Hypothyroidism 9. Diet: increased saturated fats 10. Type A personality

B. SIGNS AND SYMPTOMS 1. Chest pain 2. Dyspnea 3. Tachycardia 4. Palpitations 5. Diaphoresis C. TREATMENT Percutaneous Transluminal Coronary Angioplasty and Intravascular Stenting

Percutaneous Transluminal Coronary Angioplasty Mechanical dilation of the coronary vessel wall by compresing the atheromatous plaque. It is recommended for clients with singlevessel coronary artery disease.

Prosthetic intravascular cylindric stent maintain good luminal geometry after ballon deflation and withdrawal.

Intravascular stenting is done to prevent restenosis after PTCA.

CORONARY ARTERIAL BYPASS GRAFT SURGERY

Greater and lesser saphenous veins are commonly used for

bypass graft procedures

Objectives of CABG Nursing Management: 1. Revascularize Nitroglycerine is the myocardium drug of choice for relief of pain from acute 2. To prevent angina ischemic attacks 3. Increase survival rate 4. Done to single occluded Instruct to avoid over fatigue vessels Plan regular activity 5. If there is 2 or more program occluded blood vessels CABG is done

For Saphenous Vein Site: Wear support stocking 4-6 week postop Apply pressure dressing or sand bag on the site Keep leg elevated when sitting

3 Complications of CABG 1. Pneumonia: encourage to perform deep breathing, coughing exercise and use of incentive spirometer 2. Shock 3. Thrombophlebitis

ANGINA PECTORIS
DEFINITION: Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting to myocardial ischemia. Clinical syndrome characterized by paroxysmal chest pain that is usually relieved by rest or nitroglycerine due to temporary myocardial ischemia Types of Angina Pectoris Stable Angina: pain less than 15 minutes, recurrence is less frequent. Unstable Angina : pain is more than 15 mins.,but not less than 30 minutes, recurrence is more frequent and the intensity of pain increases. Variant Angina ( Prinzmetals Angina ): Chest pain is on longer duration and may occur at rest. Result from coronary vasospasm. Angina Decubitus: paroxysmal chest pain that occur when the client sits or stand.

A. PRESDISPOSING FACTORS 1. Sex: male 2. Race: black 3. Smoking 4. Obesity 5. Hyperlipidemia 6. Sedentary lifestyle 7. Diabetes Mellitus 8. Hypertension 9. CAD: Atherosclerosis 10. Thromboangiitis Obliterans 11. Severe Anemia 12. Aortic Insufficiency: heart valve that fails to open & close efficiently 13. Hypothyroidism 14. Diet: increased saturated fats 15. Type A personality

B. PRESIPITATING FACTORS 4 Es of Angina Pectoris 1. Excessive physical exertion: heavy exercises, sexual activity 2. Exposure to cold environment: vasoconstriction 3. Extreme emotional response: fear, anxiety, excitement, strong emotions 4. Excessive intake of foods or heavy meal. C. SIGNS AND SYMPTOMS 1. Levines Sign: initial sign that shows the hand clutching the chest 2. Chest pain: characterized by sharp stabbing pain located at sub sternal usually radiates from neck, back, arms, shoulder and jaw muscles usually relieved by rest or taking nitroglycerine(NTG) 3. Dyspnea

4.Tachycardia 5. Palpitations 6. Diaphoresis D. DIAGNOSTIC PROCEDURE 1. History taking and physical exam 2. ECG: may reveals ST segment depression & T wave inversion during chest pain 3. Stress test / treadmill test: reveal abnormal ECG during exercise 4. Increase serum lipid levels 5. Serum cholesterol & uric acid is increased

E. MEDICAL MANAGEMENT 1. Drug Therapy: if cholesterol is elevated Nitrates: Nitroglycerine (NTG) Beta-adrenergic blocking agent: Propanolol Calcium-blocking agent: nefedipine Ace Inhibitor: Enapril 2. Modification of diet & other risk factors 3. Surgery: Coronary artery bypass surgery 4. Percutaneuos Transluminal Coronary Angioplasty (PTCA)

F. NURSING INTERVENTIONS 1. Enforce complete bed rest 2. Give prompt pain relievers with nitrates or narcotic analgesic as ordered 3. Administer medications as ordered:

A. Nitroglycerine(NTG): when given in small doses will act as venodilator, but in large doses will act as vasodilator Give 1st dose of NTG: sublingual 3-5 minutes Give 2nd dose of NTG: if pain persist after giving 1st dose with interval of 3-5 minutes Give 3rd& last dose of NTG: if pain still persist at 3-5 minutes interval

NTG Tablets(sublingual)
Keep the drug in a dry place,

NTG Nitrol or Transdermal patch

Nitropatch is applied once a day,

avoid moisture and exposure to sunlight as it may inactivate the drug Change stock every 6 months Offer sips of water before giving sublingual nitrates, dryness of mouth may inhibit drug absoprtion Relax for 15 minutes after taking a tablet: to prevent dizziness Monitor side effects: orthostatic hypotension, flushed face. Transient headache & dizziness: frequent side effect Instruct the client to rise slowly from sitting position Assist or supervise in ambulation

usually in the morning. Avoid placing near hairy areas as it may decrease drug absorption Avoid rotating transdermal patches as it may decrease drug absorption Avoid placing near microwave ovens or during defibrillation as it may lead to burns (most important thing to remember)

B. Beta-blockers: decreases myocardial oxygen demand by decreasing heart rate, cardiac output and BP Propanolol Metropolol Pindolol Atenolol Assess PR, withhold if dec.PR Administer with food ( prevent GI upset )

Propanolol: not given to COPD cases: it causes bronchospasm and DM cases: it cause hypoglycemia Side Effects: Nausea and vomiting, mental depression and fatigue

 C. Calcium Channel Blockers: relaxes smooth cardiac muscle, reduces

coronary vasospasm Amlodipine ( norvasc ) Nifedipine ( calcibloc ) Diltiazem ( cardizem ) Assess HR and BP Administer 1 hour before meal and 2 hours after meal ( foods delay absorption )

4. Administer oxygen inhalation 5. Place client on semi-to high fowlers position 6. Monitor strictly V/S, I&O, status of cardiopulmonary fuction & ECG tracing 7. Provide decrease saturated fats sodium and caffeine

8. Provide client health teachings and discharge planning Avoidance of 4 Es Prevent complication (myocardial infarction) Instruct client to take medication before indulging into physical exertion to achieve the maximum therapeutic effect of drug Reduce stress & anxiety: relaxation techniques & guided imagery Avoid overexertion & smoking

Avoid extremes of

temperature Dress warmly in cold weather Participate in regular exercise program Space exercise periods & allow for rest periods The importance of follow up care 9. Instruct the client to notify the physician immediately if pain occurs & persists despite rest & medication administration

MYOCARDIAL INFARCTION
Death of myocardial cells from

inadequate oxygenation, often caused by sudden complete blockage of a coronary artery Characterized by localized formation of necrosis (tissue destruction) with subsequent healing by scar formation & fibrosis Heart attack Terminal stage of coronary artery disease characterized by malocclusion, necrosis & scarring.

Types of M.I Transmural Myocardial Infarction: most dangerous type characterized by occlusion of both right and left coronary artery Subendocardial Myocardial Infarction: characterized by occlusion of either right or left coronary artery The Most Critical Period Following Diagnosis of Myocardial Infarction 6-8 hours because majority of death occurs due to arrhythmia leading to premature ventricular contractions (PVC)

A. PREDISPOSING FACTORS 1. Sex: male 2. Race: black 3. Smoking 4. Obesity 5. CAD: Atherosclerotic 6. Thrombus Formation 7. Genetic Predisposition 8. Hyperlipidemia 9. Sedentary lifestyle 10. Diabetes Mellitus 11. Hypothyroidism 12. Diet: increased saturated fats 13. Type A personality

SYMPTOMS 1. Chest pain Excruciating visceral, viselike pain with sudden onset located at substernal& rarely in precordial Usually radiates from neck, back, shoulder, arms, jaw & abdominal muscles (abdominal ischemia): severe crushing Not usually relieved by rest or by nitroglycerine

B. SIGNS AND

2. N/V 3. Dyspnea 4. Increase in blood pressure & pulse, with gradual drop in blood pressure (initial sign) 5. Hyperthermia: elevated temp 6. Skin: cool, clammy, ashen 7. Mild restlessness & apprehension

8. Occasional findings: Pericardial friction rub Split S1& S2 Rales or Crackles upon auscultation S4 or atrial gallop

DIAGNOSTIC PROCEDURES
1. Cardiac Enzymes CPK-MB: elevated Creatinine phosphokinase(CPK):elevate d Heart only, 12 24 hours Lactic acid dehydrogenase(LDH): is increased Serum glutamic pyruvate transaminase(SGPT): is increased Serum glutamic oxal-acetic transaminase(SGOT): is increased 2. Troponin Test: is increased 3. ECG tracing reveals ST segment elevation T wave inversion Widening of QRS complexes: indicates that there is arrhythmia in MI 4. Serum Cholesterol & uric acid: are both increased 5. CBC: increased WBC

NURSING INTERVENTIONS
Goal: Decrease myocardial oxygen demand 1. Decrease myocardial workload (rest heart) Establish a patent IV line Administer narcotic analgesic as ordered: Morphine Sulfate IV: provide pain relief(given IV because after an infarction there is poor peripheral perfusion & because serum enzyme would be affected by IM injection as ordered) Side Effects: Respiratory Depression Antidote: Naloxone (Narcan) Side Effects of Naloxone Toxicity: is tremors 2. Administer oxygen low flow 2-3 L / min: to prevent respiratory arrest or dyspnea & prevent arrhythmias 3. Enforce CBR in semi-fowlers position without bathroom privileges(use bedside commode): to decrease cardiac workload 4. Instruct client to avoid forms of valsalva maneuver 5. Place client on semi fowlers position 6. Monitor strictly V/S, I&O, ECG tracing & hemodynamic procedures

7. Perform complete lung / cardiovascular assessment 8. Monitor urinary output & report output of less than 30 ml/ hr: indicates decrease cardiac output 9. Provide a full liquid diet with gradual increase to soft diet: low in saturated fats, Na & caffeine 10. Maintain quiet environment 11. Administer stool softeners as ordered:to facilitate bowel evacuation & prevent straining 12. Relieve anxiety associated with coronary care unit(CCU)environment

13. Administer medication as ordered: a. Vasodilators: Nitroglycirine (NTG), Isosorbide Dinitrate, Isodil (ISD): sublingual b. Anti Arrythmic Agents: Lidocaine (Xylocane), Brithylium Side Effects: confusion and dizziness c. Beta-blockers: Propanolol (Inderal) d. ACE Inhibitors: Captopril (Enalapril) e. Calcium Antagonist: Nefedipine f. Thrombolytics / Fibrinolytic Agents: Streptokinase, Urokinase, Tissue Plasminogen Activating Factor (TIPAF) Side Effects: allergic reaction, urticaria, pruritus Nursing Intervention: Monitor for bleeding time

g. Anti Coagulant Heparin Antidote: Protamine Sulfate Nursing Intervention: Check for Partial Thrombin Time (PTT) Caumadin(Warfarin) Antidote:Vitamin K Nursing Intervention: Check for Prothrombin Time (PT) h. Anti Platelet: PASA (Aspirin): Anti thrombotic effect Side Effects:Tinnitus, Heartburn, Indigestion / Dyspepsia Contraindication: Dengue, Peptic Ulcer Disease, Unknown cause of headache

teaching & discharge planning concerning: a. Effects of MI healing process & treatment regimen b. Medication regimen including time name purpose, schedule, dosage, side effects c. Dietary restrictions: low Na, low cholesterol, avoidance of caffeine d. Encourage client to take 20 30 cc/week of wine, whisky and brandy:to induce vasodilation e. Avoidance of modifiable risk factors

14. Provide client health

f. Prevent Complication Arrhythmia: caused by premature ventricular contraction Cardiogenic shock: late sign is oliguria Left Congestive Heart Failure Thrombophlebitis: homans sign Stroke / CVA Dresslers Syndrome(Post MI Syndrome):client is resistant to pharmacological agents: administer 150,000450,000 units of streptokinase as ordered

g. Importance of participation in a progressive activity program h. Resumption of ADL particularly sexual intercourse: is 4-6 weeks post cardiac rehab, post CABG & instruct to: Make sex as an appetizer rather than dessert Instruct client to assume a non weight bearing position Client can resume sexual intercourse: if can climb or use the staircase

i. Need to report the ff s/sx: Increased persistent chest pain Dyspnea Weakness Fatigue Persistent palpitation Light headedness j. Enrollment of client in a cardiac rehabilitation program k. Strict compliance to mediation & importance of follow up care

CONGESTIVE HEART FAILURE

Inability of the heart to pump

blood towards systemic circulation

I. LEFT-SIDED HEART FAILURE A. PREDISPOSING FACTORS 1. 90% - Mitral valve stenosis RHD Inflammation of mitral valve Anti-streptolysin O titer (ASO) 300 todd units Penicillin, PASA, steroids Aging 2. MI 3. IHD 4. HPN 5. Aortic valve stenosis

B. SIGNS AND SYMPTOMS 1. Pulmonary edema/congestion Dyspnea, PND (awakening at night d/t difficulty in breathing), 2-3 pillow orthopnea Productive cough (blood tinged) Rales/crackles Bronchial wheezing Frothy salivation 2. Pulsus alternans (A unique pattern during which the amplitude of the pulse changes or alternates in size with a stable heart rhythm.)This is common in severe left ventricular dysfunction.) 3. Anorexia and general body malaise 4. PMI displaced laterally, cardiomegaly 5. S3 (ventricular gallop)

C. DIAGNOSTICS
1. CXR cardiomegaly 2. PAP pulmonary arterial pressure Measures pressure in right ventricle Reveals cardiac status 3. PCWP pulmonary capillary wedge pressure Measures end-systolic and enddiastolic pressure (elevated) Done through cardiac catheterization (Swan- Ganz) 4. Echocardiograph reveals enlarged heart chamber 5. ABG analysis reveals elevated PCO2 and decreased PO2 (respiratory acidosis) hypoxemia and cyanosis

 Tracheostomy for severe

respiratory distress and laryngospasm performed at bedside within 10-15 minutes CVP reveals fluid status; Normal = 4-10cm H2o; right atrium PAP cardiac status; left atrium ALLENS test collateral circulation Cardiac Tamponade: pulsus paradoxus, muffled heart sounds, HPN

RIGHT SIDED HEART FAILURE A. PREDISPOSING FACTORS 1. Tricuspid valve stenosis 2. COPD 3. Pulmonary embolism (char by chest pain and dyspnea) 4. Pulmonic stenosis 5. Left sided heart failure

B. SIGNS AND SYMPTOMS (Venous congestion) 1. Jugular vein distention 2. Pitting edema 3. Ascites 4. Weight gain 5. Hepatosplenomegaly 6. Jaundice 7. Pruritus/ urticaria 8. Esophageal varices 9. Anorexia 10. Generalized body malaise

C. DIAGNOSTICS

1. CXR cardiomegaly 2. CVP measures pressure in right atrium; N = 410cc H2O During CVP: trendelenburg to prevent pulmo embolism and to promote ventricular filling Flat on bed post CVP, check CVP readings Hypovolemia fluid challenge Hypervolemia diuretics (loop) 3. Echocardiography reveals enlarged heart chamber Muffled heart sounds cardiomyopathy

Cyanotic heart diseases TOF tet spells cyanosis with hypoxemia Tricuspid valve stenosis Transposition of aorta Acyanotic PDA machine-like murmur DOC: indomethacin SE: corneal cloudiness 4. Liver enzymes SGPT up SGOT up

D. NURSING MANAGEMENT Goal: increase myocardial contraction increase CO; Normal CO is 3-6L/min; N stroke volume is 60-70ml/h2o 1. Administer medications as ordered Cardiac glycosides Digoxin (N=.5-1.5, tox=2) Tox: Anorexia, N&V; A: Digibind Digitoxin given if (+) ARF; metabolized in liver and not in kidneys Loop diuretics Lasix IV push, mornings Bronchodilators Aminophylline (theophylline) Tachycardia, palpitations CNS hyperactivity, agitation

 Narcotic analgesics Morphine sulfate

induces vasodilation Vasodilators NTG and ISDN Anti-arrhythmic agents Lidocaine (SE: dizziness and confusion) Bretyllium YOU DONT GIVE BETABLOCKERS TO THESE PATIENTS

2. Administer O2 inhalation at 3-4 L/minute via NC as ordered high flow 3. High fowlers, 2-3 Pillows 4. Restrict Na and fluids 5. Monitor strictly VS and IO and Breath Sounds 6. Weigh pt daily and assess for pitting edema 7. abdominal girth daily and notify MD 8. provide meticulous skin care

9. provide a dietary intake which is low in saturated fats and caffeine 10. Institute bloodless phlebotomy ROTATING TOURNIQUET Rotated clockwise every 15 minutes to promote a decrease in venous return 11. Health teaching and discharge planning Prevent complications : Arrhythmia, Shock, Thrombophlebitis, MI, Cor pulmonale RV hypertrophy Regular adherence to medications Diet modifications Importance of ffup care

CARDIAC TAMPONADE
Also known as pericardial

tamponade, is an emergency condition in which fluid accumulates in the pericardium. (the sac in which the heart is enclosed). If the fluid significantly elevates the pressure on the heart it will prevent the heart's ventricles from filling properly. This in turn leads to a low stroke volume. The end result is ineffective pumping of blood, shock, and often death.

A. PREDISPOSING FACTORS 1. Chest trauma ( blunt or penetrating ) 2. Myocardial ruptured 3. Cancer 4. Pericarditis 5. Cardiac surgery ( first 24 48 hours ) 6. Thrombolytic therapy

B. SIGNS AND SYMPTOMS 1. Becks Triad Hypotension Jugular venous distension Muffled heart sound 2. Pulsus paradoxus ( drop of at least 10 mmHg in arterial BP on inspiration ) 3. Tachycardia 4. Breathlessness 5. Decrease in LOC

C. NURSING INTERVENTIONS 1. Administer oxygen 2. Elevate head of bed, place pillow on the overbed table so that the patient can lean on it. 3. Bed rest 4. Administer prescribed pharmacotherapy. c. ASA to suppress inflammatory process d. Corticosteriods for more severe symptoms 5. Assist in pericardiocentesis and thoracotomy 6. Pericardiocentesis is aspiration of blood or fluid from pericardial sac.

HYPERTENSION
Is an abnormal elevation of

Bp, systolic pressure above 140 mmHg and or diastolic pressure above 90mmHg at least two readings WHO: BP >160/95 mmHg AHA: BP >140/90 mmHg In hypertension, vasoconstriction vasospasm increases PVR decrease blood flow to the organ.

Target Organs: Heart : MI, CHF, Dysrhythmias Eyes: blurred / impaired vision, retinopathy, cataract. Brain: CVA, encephalopathy Kidneys : renal insufficiency, RF Peripheral Bloods Vessels aneurysm, gangrene

 CLASSIFICATION OF BP

FOR ADULTS 18 YRS AND OLDER (PHIL. SOCIETY OF HPN) Optimal o <120 mmHg / <80 mmHg Recheck in 2 years. Normal o 120-129 mmHg / 80-84 mmHg Recheck in 2 years. High normal o 130-139 mmHg / 85-89 mmHg Recheck in 1 year.

Stage 1 (mild) HPN o 140-159 mmHg / 90-99

mmHg Confirm in 2 months. Stage 2 (moderate) HPN o 160-179 mmHg / 100109 mmHg Evaluate within a month. Stage 3 (severe) HPN o 180-209 mmHg / 110119mmHg Evaluate within a week. Stage 4 (very severe) HPN o 210 mmHg / >/=120 mmHg Evaluate

A. CLASSIFICATION Essential / Idiophatic / Primary HPN, accounts for 90 95% of all cases of HPN, cause is unknown Secondary HPN, due to known causes ( Renal failure, Hypertension ) Malignant Hypertension, is severe, rapidly progressive elevation in BP that causes rapid onset of end organ complication

Labile HPN,

intermittently elevated BP Resistant HPN, does not respond to usual treatment White Coat HPN, elevation of B only during clinic or hospital visits

situation that requires immediate blood pressure lowering 240mmHg / 120 mmHg B. RISK FACTORS 1. Family history 2. Age 3. High salt intake 4. Low potassium intake 5. Obesity 6. Excess alcohol consumption 7. Smoking 8. Stress

Hypertensive Crisis,

C. SIGNS AND SYMPTOMS 1. Headache 2. Epistaxis 3. Dizziness 4. Tinnitus 5. Unsteadiness 6. Blurred vision 7. Depression 8. Nocturia 9. Retinopathy

D. TREATMENT STRATEGIES Non-pharmacologic therapy 1. Low salt diet. 2. Weight reduction. 3. Exercise. 4. Cessation of smoking. 5. Decreased alcohol consumption. 6. Psychological methods: Relaxation / meditation. 7. Dietary decrease in saturated fat.

Drug therapy Stepped Care Progressive addition of drugs to a regimen, starting with one, usually a diuretic, and adding, in a stepwise fashion, a sympatholytic, vasodilator, and sometimes an ACE inhibitor. Monotherapy Advantageous because of its simplicity, better patient compliance, and relatively low incidence of toxicity.

 CATEGORIES OF ANTI-HYPERTENSIVE

Drugs that alter

DRUGS Drugs that alter sodium and water balance Diuretics. Loop diuretics Thiazides Spironolactone and Triamterene

sympathetic nervous system function Sympatholytic drugs. Centrally-acting sympatholytics Clonidine Guanabenz Guanfacine Methyldopa Peripherally-acting sympatholytics Guanadrel Guanethidine Reserpine

a-blockers Doxazosin Prazosin b-blockers Acebutolol - Labetalol Atenolol - Metoprolol Betaxolol - Nadolol Bisoprolol - Penbutolol Carteolol - Pindolol Carvedilol - Propranolol Esmolol - Timolol

Vasodilators Direct vasodilators Diazoxide - Hydralazine Minoxidil - Nitroprusside Fenoldopam Calcium channel blockers Amlodipine - Nifedipine Diltiazem - Nimodipine Felodipine - Nisoldipine Isradipine - Nitrendipine Manidipine - Nicardipine Lacidipine - Verapamil Lercanidipine Gallopamil

PRODUCTION OR ACTION OF ANGIOTENSIN ACE inhibitors Benazepril - Moexipril Captopril - Quinapril Enalapril - Perindopril Fosinopril - Ramipril Lisinopril - Trandolapril AT1-receptor blockers Irbesartan - Losartan Telmisartan - Valsartan Candesartan - Eprosartan

AGENTS THAT BLOCK THE

DRUGS FOR HYPERTENSIVE EMERGENCIES OR CRISES Trimethaphan o 1 mg/ml IV infusion; titrate; instantaneous onset Sodium nitroprusside o 5-10 mg/L IV infusion; titrate; instantaneous onset Diazoxide o 300-600 mg Rapid IV push; instantaneous onset Nifedipine o 10-20 mg Sublingual or chewed; onset within 5-30 min. Labetalol o 20-80 mg IV at 10-minute intervals (max.dose: 300mg); immediate onset

INTERVENTIONS 1. Patient Teaching and Counselling Teaching about HPN and its risk factors Stress therapy Low NA and low saturated fat Avoid stimulants ( caffeine, alcohol, smoking ) Regular pattern of exercise Weight reduction if obese

E. NURSING

2. Teaching about medication The most common side effects of diuretics are potassium depletion and orthostatic hypotension. The most common side effect of the different antihypertensive drugs is orthostatic hypotension. Take anti hypertensive medications at regular basis Assume sitting or lying position for few minutes

 Avoid very warm bath Avoid prolonged sitting

and standing Avoid alcoholic beverages Avoid tyramine rich foods ( proteins ) as follows: ( this may cause hypertensive crisis ) Aged cheese Liver Beer Wine Chocolate Pickles Sausages Soy sauce

3. Preventing Non-compliance Inform the client that absence of symptoms does not indicate control of BP Advise the client against abrupt withdrawal of medication, rebound hypertension may occur. Device ways to facilitate remembering of taking medications