CIRCULATORY SYSTEM Shock and Hypertension

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CIRCULATORY SYSTEMShock and Hypertension

• Madeline Gervase RN,MSN,CCRN,FNP

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SHOCKClassifications

• Hypovolemic
• ? central vascular volume
• TBW may not be ?
• Cardiogenic
• Pump failure
• TBW not ?

Obstructive Cardiac function ? TBW not
affected Central volume ? Distributive Fluid
shifts TBW normal or ?
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STAGES OF SHOCK
Initial stage Nonprogressive
stage Progressive stage Refractory stage
Death
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Key Features of Shock

• Cardiovascular
• ? CO.
• ? HR
• Thready pulse
• ? BP
• Narrow MAP
• Postural hypotension
• Low CVP

flat neck and hand veins lt capillary refill ?
peripheral pulses
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Respiratory features of shock

• ? RR
• Shallow respirations
• ? PaCo2
• ? PaO2
• Circumoral cyanosis
• Peripheral cyanosis

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Neuromuscular Signs of Shock
Early Anxiety Restlessness Late ? CNS
activity Muscle weakness ? or absent deep
tendon reflexes Sluggish pupillary response to
light
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Renal and Integumentary

• Renal
• ? urinary output
• ? specific gravity
• Sugar and acetone in urine

Integumentary Cool to cold Pale to mottled
to cyanotic Moist, clammy Mouth dry,
paste-like coating present
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Gastrointestinal

• ? motility
• ?or absent bowel sounds
• Nausea and vomiting
• Constipation
• Increased thirst

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Diagnosis

• CNS
• Thirst
• LOC
• Orientation Restless/anxiety
• Confusion
• Lethargy

• Renal/Urinary
• Hourly outputs
• Urine color
• Specific gravity

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• Assessment
• History
• Physical
• Pulse
• BP
• O2 saturation
• Skin
• Temperature
• Color
• Moisture

• Capillary refill
• Respiratory
• Rate
• Depth
• Ease
• Breath sounds

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Assessment

• M/S
• Muscle strength
• Pain
• DTRs
• Psychosocial
• Behavior
• Sleep/wake
• Concentration

• Laboratory
• No single lab
• ABGs
• H H
• K
• U/A
• Urine cultures
• Blood cultures
• CBC

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Sepsis InducedDistributive Shock

• Inflammatory response
• C.O. ? in first phase or high output phase (warm
  shock)
• Tachycardia, ? S.V., normal to ? systolic BP,
  normal CVP
• Skin color normal and warm

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• Disseminated intravascular coagulation (DIC)
• Organ and tissue hypoxia and ischemia ? anaerobic
  metabolism ? depletion of clotting factors ?
  hemorrhage

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Second Phase of Sepsis-induced Distributive Shock

• Clotting factors gone
• Vessels dilated
• Hypovolemia
• C.O. ? BP ? Pulse pressure ?
• Low-output or cold-shock phase
• ARDS may occur
• Poor prognosis

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Interventions

• Maintain tissue oxygenation
• Administer O2
• Intravenous therapy

• Colloid fluid replacement
• Whole blood
• RBCs
• Plasma and plasma protein fractions
• Crystalloid fluid replacement
• Ringers lactate
• Normal saline

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Drug Therapy

• Vasoconstricting agents (? C.O. and MAP)
• Dopamine
• ? myocardial O2 consumption
• Higher doses ? renal perfusion and urinary output

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• Epinephrine
• May cause ventricular dysrhythmias
• Vasoconstriction may impair cardiac oxygenation
• Norepinephrine (Levophed)
• Extravasation
• Severe tissue damage and necrosis

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Agents Enhancing Contractility

• ? filling time gt ? blood in the left ventricle
  and ? stretch of the myocardial fibers gt ? C.O.
  Atropine Sulfate
• may cause rebound tachycardia
• may cause urinary retention

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• Amrinone (Inocor)
• Hypertension is symptom of OD
• Dobutamine hydrochloride (Dobutrex)
• ? myocardial O2 consumption
• Hypertension is symptom of OD

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Agents Enhancing Myocardial Perfusion

• Dilate coronary vessels while causing minimal
  systemic vasodilation
• Sodium nitroprusside (Nipride)
• Higher doses can cause some systemic vasodilation
  and ? shock

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Treat the underlying cause of shock
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Effects of Aging on Cardiovascular System

• Valves calcify
• Assess for murmurs
• Conduction system
• pacemaker cells ?

Conduction time ? Atrial dysrhythmias in
50-90 PVCs in 80
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More Cardiovascular Changes of Aging

• Left ventricle ?
• in size
• LV stiffens
• Early diastolic filling ? by 50
• Conduction time ?

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More Cardiovascular Changes of Aging

• Aorta and other large arteries thicken and become
  stiffer
• SVR ? gt greater resistance gt LV hypertrophy
• Baroceptors become less sensitive

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Components of Blood Pressure
Blood Pressure
Cardiac Output x Peripheral resistance
Heart rate x Stroke volume
Sympathetic nervous system control
Local Control
Humoral Control
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Stages of Hypertension

• Stage 2
• Systolic 160-179
• Diastolic100-109 Stage 4
• Systolicgt210
• Diastolic gt 120

• Stage 1
• Systolic 140-159
• Diastolic 90-99
• Stage 3
• Systolic 180-209
• Diastolic 110-119

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Regulation of Blood Pressure

• Control Systems
• Arterial baroreceptor system
• regulation of body fluid volume
• Rein-angiotensin-aldosterone system
• Vascular autoregulation

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Complications of HTN

• Damage to target organs
• Medial hyperplasia (thickening) of arterioles
• Perfusion?

• MIs
• CVAs
• PVD
• Renal failure

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Etiology of Essential Hypertension

• No know cause
• Associated risk factors
• Family hx of HTN
• High Na intake
• Excessive calorie consumption
• Physical inactivity
• Excessive alcohol intake
• Low K intake

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Etiology of Secondary Hypertension

• Renal vascular and renal parenchymal disease
• Primary aldosteronism

• Pheochromo-cytoma
• Cushings disease
• Coarctation of the aorta

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• Brain tumors
• Encephalitis
• Psychiatric disturbances
• Pregnancy

• Medications
• Estrogen
• Glucocorticoids
• Mineralocorticoids
• Sympathomimetics

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Incidence/Prevalence

• 50 million Americans or 1 in every 4 adults
• Elderly
• Most prevalent cardiovascular disease

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• Transcultural
• African Americans 2 x greater
• ? incidence in AA and Caucasians living in SE US
• Womens health
• ? AA women

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Diagnosis

• Funduscopic eye exam
• Life style
• No specific labs
• No xrays
• ECG

• History
• Physical assessment
• Bilateral BP
• Postural
• Multiple readings

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Interventions

• Sodium restriction
• Weight reduction
• Moderation of alcohol intake
• Exercise

Relaxation techniques Tobacco avoidance
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Drug Therapy

• Diuretics
• Thiazide such as hydrochlorothiazide (Diuril)
• Loop (furosemide (Lasix)
• Potassium sparing (Aldactone)

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Beta Blockers

• Block cardiac and peripheral vessel
  beta-receptors ? ?HR and ? contractility.
  Bradycardia and heart failure may occur.

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• May cause bronchospasm, block signs of
  hypoglycemia, sexual dysfunction, depression,
  fatigue, weakness.
• Propranolol (Inderal)
• Atenolol (Tenormin)
• Nadolol Cogard)
• Metoprolol (Lopressor)

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Calcium Channel Blockers

• Effective in elderly and African Americans
• Interferes with transmembrane flux of Ca ?
  reduced vasoconstriction.
• Affects AV conduction and slows HR.

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• Nifedipine (Procardia)
• Pedal edema can occur
• Verapamil (Calan, Isoptin)
• Hypotension and ? HR and constipation
• Diltiazem(Cardizem)
• Hypotension and ? HR

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Angiotensin-Converting Enzyme Inhibitors (ACE)

• Captopril (Capoten)
• Enalapril (Vasotec)
• Lisinopril/Zestil (Prinvil) (Monitor BP and renal
  function)
• Elderly at risk for severe hypotension.
• Effective in young Caucasian adults

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Central Alpha Agonists

• Act on CNS preventing reuptake of norepinephrine
  ? lowering of PVR and BP
• Clonidine (Catapres)

• Methyldopa (Aldomet) (hemolytic anemia and
  inflammatory disorder of the liver)
• Can cause sedation, postural hypotension, and
  impotence

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More on Drug Therapy

• Vasodilators
• Hydralazine (Apresoline)
• Tachycardia
• Alpha-Adrenergic Receptor Agonists
• Prazosin (Minipres)
• many side effects and rarely used

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• Initial therapy recommendations are
• Thiazide diuretic or beta blocker
• 1 to 3 mos? dose, substitue a drug from another
  class or 2nd drug