Identify the Risk Factors for Cardiovascular Problems that need to be Modified for this Patient

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Identifying the patients at risk
A 50-year-old male presents to the community clinic. He has just relocated to the area and has no primary provider. He is a long distance truck driver and requires a physical examination as a requirement for his continued employment.
Physical examination demonstrates a BMI of 33, blood pressure of 180/90 mm Hg, diminished femoral pulses and bilateral varicose veins with 1+ pitting edema in both ankles. He has a 30 year history of smoking two packs of cigarettes per day.
Initial Discussion Post:
• Identify the risk factors for cardiovascular problems that need to be modified for this patient.
• Using evidence based research, determine which risk factor the RN will address first.
• Describe how the RN will implement a patient centered plan to address the priority risk factor for this patient.
This are module material that can help write the Discussion question…..
Outcomes of Therapy:
Managing Ischemic Heart Disease
1. Decrease myocardial oxygen demand by having patient stop activity.
Aspects that increase oxygen demand include: temperature extremes (hot/cold); eating a large meal; stress or emotional event.
2. Improve myocardial oxygen supply. Interventions may involve administration of medication and oxygen.
3. Aggressive risk factor modification which includes life style changes after the acute event is addressed.
4. Promote self-care with the support of family/friends/community through education.
Class Medication examples Action Special considerations
Nitroglycerin (NTG) May be ointment, patch, oral, sublingual tablets or spray Dilates veins and arteries. ↓venous return;↓oxygen demand May cause headache/ hypotension. Do not take within 24 hour of use of sidenafil (Viagra) or tadalafil (Cialis). Alcohol may enhance hypotension. May build a tolerance if continuous use.
Oxygen Mask or nasal cannula ↑oxygen in blood, ↓work of breathing High oxygen levels can be toxic to the lungs or depress ventilation in the patient with COPD.
Oxygen supports combustion.
Beta Blockers
Usually ends in “lol” Atenolol; esmolol; sotalol; metoprolol; labetalol. ↓effects of sympathetic nervous system; ↓heart rate ↓blood pressure ↓myocardial oxygen consumption May cause low heart rate; fatigue; erectile dysfunction; and mask symptoms of hypoglycemia. Abrupt withdrawal can cause life threatening issues. Not to skip or double up on missed doses.
Calcium Channel Blockers Amlodipine; diltiazem; nicardipine; verapamil ↓heart rate; ↓force of heart contraction; ↓preload; ↓vasospasm; dilates coronary arteries May cause peripheral edema; rash; gingival hyperplasia; photosensitivity. Has many drug to drug interactions.
Not to be abruptly stopped.
Antiplatelet Aspirin (ASA)
Clopidogrel (plavix) Prevents platelets from sticking together to form a blood clot Chew an aspirin tablet if having acute angina while calling emergency response.
May cause gastrointestinal bleeding
Anticoagulation Heparin Prevent formation or extension of blood clot May cause bleeding. May be used in acute angina.
Antihyperlipidemics Atorvastatin (Lipitor)
Simvastatin (Zocor) ↓LDL cholesterol; may stabilize plaque in arteries; ↓incident of acute myocardial infarct and stoke May cause myalgias, rhabdomyolysis, cataracts, gastrointestinal discomfort.
Nursing Process
Assessment:
• Obtain baseline blood pressure and heart rate.
• Obtain health and medication history.
Potential Nursing Diagnoses:
• Activity intolerance related to imbalance between oxygen supply and demand
• Anxiety related to cardiac issues
• Acute pain related to inadequate oxygen supply to cardiac muscle
• Decreased cardiac output related to myocardial dysfunction or decreased oxygen supply to cardiac muscle.
• Ineffective health maintenance related to (specific to patient’s situation)
• Deficient knowledge related to diagnosis of cardiac disease
Planning and Outcomes:
• Immediate treatment of angina
• Prevention of angina
• Increase knowledge of disease and treatment
• Adherence to self care program
Nursing Intervention:
• Relieve angina
• Decrease risk factors
• Promote self care and life style changes
Evaluation:
• The patient is free of significant side effects of the medications.
• The patient is able to incorporate new health regime into lifestyle.
• The patient will be able to identify and report potential issues.
Outcomes of Therapy:
Pharmacological Therapy post Myocardial Infarction (MI)
1. Decrease myocardial oxygen demand by having patient stop activity.
Aspects that increase oxygen demand include: temperature extremes (hot/cold); eating a large meal; stress or emotional event.
2. Improve myocardial oxygen supply. Interventions may involve administration of medication and oxygen.
3. Aggressive risk factor modification which includes life style changes after the acute event is addressed.
4. Promote self-care with the support of family/friends/community through education.
Class Medication examples Action Special considerations
Nitroglycerin (NTG) May be ointment, patch, oral, sublingual tablets or spray Dilates veins and arteries. ↓venous return;↓oxygen demand May cause headache/ hypotension. Do not take within 24 hour of use of sidenafil (Viagra) or tadalafil (Cialis). Alcohol may enhance hypotension. May build a tolerance if continuous use.
Oxygen Mask or nasal cannula ↑oxygen in blood, ↓work of breathing High oxygen levels can be toxic to the lungs or depress ventilation in the patient with COPD.
Oxygen supports combustion.
Beta Blockers
Usually ends in “lol” Atenolol; esmolol; sotalol; metoprolol; labetalol. ↓effects of sympathetic nervous system; ↓heart rate ↓blood pressure ↓myocardial oxygen consumption May cause low heart rate; fatigue; erectile dysfunction; and mask symptoms of hypoglycemia. Abrupt withdrawal can cause life threatening issues. Not to skip or double up on missed doses.
Calcium Channel Blockers Amlodipine; diltiazem; nicardipine; verapamil ↓heart rate; ↓force of heart contraction; ↓preload; ↓vasospasm; dilates coronary arteries May cause peripheral edema; rash; gingival hyperplasia; photosensitivity. Has many drug to drug interactions.
Not to be abruptly stopped.
Antiplatelet Aspirin (ASA)
Clopidogrel (plavix) Prevents platelets from sticking together to form a blood clot Chew an aspirin tablet if having acute angina while calling emergency response.
May cause gastrointestinal bleeding
Anticoagulation Heparin Prevent formation or extension of blood clot May cause bleeding. May be used in acute angina.
Antihyperlipidemics Atorvastatin (Lipitor)
Simvastatin (Zocor) ↓LDL cholesterol; may stabilize plaque in arteries; ↓incident of acute myocardial infarct and stoke May cause myalgias, rhabdomyolysis, cataracts, gastrointestinal discomfort.
Nursing Process
Assessment:
• Obtain baseline blood pressure and heart rate.
• Obtain health and medication history.
Potential Nursing Diagnoses:
• Activity intolerance related to imbalance between oxygen supply and demand
• Anxiety related to cardiac issues
• Acute pain related to inadequate oxygen supply to cardiac muscle
• Decreased cardiac output related to myocardial dysfunction or decreased oxygen supply to cardiac muscle.
• Ineffective health maintenance related to (specific to patient’s situation)
• Deficient knowledge related to diagnosis of cardiac disease
Planning and Outcomes:
• Immediate treatment of angina
• Prevention of angina
• Increase knowledge of disease and treatment
• Adherence to self care program
Nursing Intervention:
• Relieve angina
• Decrease risk factors
• Promote self care and life style changes
Evaluation:
• The patient is free of significant side effects of the medications.
• The patient is able to incorporate new health regime into lifestyle.
• The patient will be able to identify and report potential issues.
Managing hypertension
What does the evidence recommend?
Area Recommendation Approximate reduction in SBP
Weight Maintain a normal body weight (body mass index 18.5 to 24.9). 5 to 20 mmHg for 22 pounds (10 kilograms)
Diet – DASH* A diet high in fruits, vegetables, fiber. Dairy products should be low fat and meats lean. Limit saturated and trans fats and added sugars. 8 to 14 mmHg
Sodium Reduce dietary sodium to no more than 2.4 grams sodium or 6 grams of sodium chloride per day; Read labels on foods and supplements. 2 to 8 mmHg
Activity Regular aerobic activity for 30 minutes most days of the week. 4 to 9 mmHg
Alcohol No more than 2 drinks per day for men; 1 drink for women 2 to 4 mmHg
*DASH = Dietary Approaches to Stop Hypertension.
What about smoking? Smoking temporarily increases blood pressure and does increase risk for cardiac and respiratory diseases. Provide resources and support for smoking cessation, including possible pharmacologic treatment.
If life style changes are not effective or cannot be achieved, medications are the next treatment prescribed.
All members of the healthcare team must work together to improve patient/family well being.
Basic teaching guidelines for patients on antihypertensives:
1. Establish a trusting relationship with the patient/family, provide positive feedback.
2. Reinforce the established blood pressure goal with the patient.
3. Encourage the patient to communicate with the healthcare team all medications currently prescribed.
Encourage discussion prior to taking over the counter medications; dietary supplements and herbal products.
4. Encourage discussion prior to taking over the counter medications; dietary supplements and herbal products.
5. Collaborate with patient/family on methods to improve medication adherence.
6. Teach patient/ family how to take blood pressure at home.
7. Instruct patients to change position slowly to minimize postural hypotension.
8. Review with patients/families signs and symptoms that require medical attention.
Class Medication examples Special Considerations
Thiazide diuretics chlorothiazide (Diuril)
hydrochlorothiazide (HydroDIURIL) ↑ sodium and water excretion.
May cause hypokalemia.
Use sunscreen to prevent photosensitivity reactions
Loop diuretics bumetanide (Bumex)
furosemide (Lasix)
torsemide (Demadex) ↑water, sodium, magnesium, potassium and calcium excretion; assess electrolytes.
May cause tinnitus and hearing loss
Potassium-sparing diuretics amiloride (Midamor)
triamterene (Dyrenium)
spironolactone (Aldactone) Inhibits sodium reabsorption in the kidney while retaining potassium and hydrogen ions.
May cause hyperkalemia
Beta-1 adrenergic Blockers (cardioselective) atenolol (Tenormin)
metoprolol (Lopressor)
nadolol (Corgard) May cause fatigue, weakness, ↓libido, depression, bradycardia.
May mask signs of hypoglycemia.
Abrupt discontinuation can cause rebound hypertension, dysrhythmias and myocardial ischemia.
Betablocker with alpha blocking action carvedilol (Coreg)
labetalol (Normodyne) May cause bradycardia, bronchospasm, Stevens-Johnson syndrome, angioedema.
May mask signs of hypoglycemia.
Abrupt withdrawal can be life threatening.
Angiotensin-Converting Enzyme Inhibitor (ACE) Captopril(Capoten)
Enalapril (Vasotec)
Lisinopril (Zestril)
Quinapril (Accupril) ↓progression of diabetic nephropathy (captopril)
↓development of overt heart failure after MI
Possible adverse effects: Irritating cough; angioedema; hyperkalemia.
Angiotensin II Receptor Blockers (ARB) Losartan (Cozaar)
Valsartan (Diovan) Vasodilatation and ↓ peripheral resistance
Does not cause the irritating cough of ACE
Possible adverse effects: hyperkalemia; drug induced hepatitis
Calcium channel blockers Diltiazem (Cardizem)
Verapamil (Calan)
Amlodipine(Norvasc)
Nicardipine (Cardene) Normally not prescribed with beta-blockers.
More effective for African Americans than other antihypertensives.
Possible adverse effects: ankle edema and heart block
Alpha 1 blockers Doxazosin (Cardura)
Prazosin (Minipress) Dilates both arteries and veins
↓ symptoms of prostatic hyperplasia
Alpha 2 agonists Clonidine (Catapres)
Methyldopa (Aldomet)
reserpine ↓sympathetic activity; ↑vagus activity
May cause sodium and water retention; may be given with diuretics.
Vasodilators Hydralazine (Apresoline)
Minoxidil (Loniten) May cause sodium retention; tachycardia; drug induced lupus syndrome
↑ = increase ↓= decrease
Anticoagulation: Antiplatelet and Thrombolytic therapy
What does the evidence recommend?
Area Recommendation Approximate reduction in SBP
Weight Maintain a normal body weight (body mass index 18.5 to 24.9). 5 to 20 mmHg for 22 pounds (10 kilograms)
Diet – DASH* A diet high in fruits, vegetables, fiber. Dairy products should be low fat and meats lean. Limit saturated and trans fats and added sugars. 8 to 14 mmHg
Sodium Reduce dietary sodium to no more than 2.4 grams sodium or 6 grams of sodium chloride per day; Read labels on foods and supplements. 2 to 8 mmHg
Activity Regular aerobic activity for 30 minutes most days of the week. 4 to 9 mmHg
Alcohol No more than 2 drinks per day for men; 1 drink for women 2 to 4 mmHg
*DASH = Dietary Approaches to Stop Hypertension.
What about smoking? Smoking temporarily increases blood pressure and does increase risk for cardiac and respiratory diseases. Provide resources and support for smoking cessation, including possible pharmacologic treatment.
If life style changes are not effective or cannot be achieved, medications are the next treatment prescribed.
All members of the healthcare team must work together to improve patient/family well being.
Basic teaching guidelines for patients on antihypertensives:
1. Establish a trusting relationship with the patient/family, provide positive feedback.
2. Reinforce the established blood pressure goal with the patient.
3. Encourage the patient to communicate with the healthcare team all medications currently prescribed.
Encourage discussion prior to taking over the counter medications; dietary supplements and herbal products.
4. Encourage discussion prior to taking over the counter medications; dietary supplements and herbal products.
5. Collaborate with patient/family on methods to improve medication adherence.
6. Teach patient/ family how to take blood pressure at home.
7. Instruct patients to change position slowly to minimize postural hypotension.
8. Review with patients/families signs and symptoms that require medical attention.
Class Medication examples Special Considerations
Thiazide diuretics chlorothiazide (Diuril)
hydrochlorothiazide (HydroDIURIL) ↑ sodium and water excretion.
May cause hypokalemia.
Use sunscreen to prevent photosensitivity reactions
Loop diuretics bumetanide (Bumex)
furosemide (Lasix)
torsemide (Demadex) ↑water, sodium, magnesium, potassium and calcium excretion; assess electrolytes.
May cause tinnitus and hearing loss
Potassium-sparing diuretics amiloride (Midamor)
triamterene (Dyrenium)
spironolactone (Aldactone) Inhibits sodium reabsorption in the kidney while retaining potassium and hydrogen ions.
May cause hyperkalemia
Beta-1 adrenergic Blockers (cardioselective) atenolol (Tenormin)
metoprolol (Lopressor)
nadolol (Corgard) May cause fatigue, weakness, ↓libido, depression, bradycardia.
May mask signs of hypoglycemia.
Abrupt discontinuation can cause rebound hypertension, dysrhythmias and myocardial ischemia.
Betablocker with alpha blocking action carvedilol (Coreg)
labetalol (Normodyne) May cause bradycardia, bronchospasm, Stevens-Johnson syndrome, angioedema.
May mask signs of hypoglycemia.
Abrupt withdrawal can be life threatening.
Angiotensin-Converting Enzyme Inhibitor (ACE) Captopril(Capoten)
Enalapril (Vasotec)
Lisinopril (Zestril)
Quinapril (Accupril) ↓progression of diabetic nephropathy (captopril)
↓development of overt heart failure after MI
Possible adverse effects: Irritating cough; angioedema; hyperkalemia.
Angiotensin II Receptor Blockers (ARB) Losartan (Cozaar)
Valsartan (Diovan) Vasodilatation and ↓ peripheral resistance
Does not cause the irritating cough of ACE
Possible adverse effects: hyperkalemia; drug induced hepatitis
Calcium channel blockers Diltiazem (Cardizem)
Verapamil (Calan)
Amlodipine(Norvasc)
Nicardipine (Cardene) Normally not prescribed with beta-blockers.
More effective for African Americans than other antihypertensives.
Possible adverse effects: ankle edema and heart block
Alpha 1 blockers Doxazosin (Cardura)
Prazosin (Minipress) Dilates both arteries and veins
↓ symptoms of prostatic hyperplasia
Alpha 2 agonists Clonidine (Catapres)
Methyldopa (Aldomet)
reserpine ↓sympathetic activity; ↑vagus activity
May cause sodium and water retention; may be given with diuretics.
Vasodilators Hydralazine (Apresoline)
Minoxidil (Loniten) May cause sodium retention; tachycardia; drug induced lupus syndrome
↑ = increase ↓= decrease

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