Hypertension (HTN)

Definition:
Consistent elevation of systemic arterial blood pressure. Systolic blood pressure ≥130 mmHg or diastolic blood pressure ≥80 mmHg.

Etiology & Risk Factors:

Primary (Essential) Hypertension: No identifiable cause.
Risk factors include:

• Family history
• Age
• Race (more prevalent in African Americans)
• Obesity
• High sodium intake
• Excessive alcohol consumption
• Physical inactivity
• Stress
• Smoking

Secondary Hypertension:
Caused by underlying conditions, such as:

• Renal disease
• Endocrine disorders (hyperaldosteronism, Cushing’s syndrome, pheochromocytoma)
• Sleep apnea
• Certain medications

Signs & Symptoms:

• Often asymptomatic, especially early on (“silent killer”).
• Severe HTN:
  • Headache
  • Dizziness
  • Blurred vision
  • Epistaxis (nosebleed)
  • Severe anxiety
  • Shortness of breath

Long-term complications: Damage to target organs (heart, brain, kidneys, eyes).

Nursing Assessments:

Blood Pressure Measurement:
Use proper technique (correct cuff size, patient seated quietly, arm supported at heart level). Take multiple readings.

History:
Risk factors, medications, family history, lifestyle.

Physical Exam:

• Assess for signs of target organ damage (e.g., fundoscopic exam for retinal changes, auscultation for heart murmurs).
• Check for edema.
• Neurological assessment (rule out stroke symptoms).
• Check renal function by measuring intake and output, edema

Diagnostic Tests:

• ECG
• Urinalysis (proteinuria)
• Blood tests (serum electrolytes, BUN, creatinine, glucose, lipid panel)

Nursing Interventions:

Lifestyle Modifications (First-Line Treatment):

• Dietary Approaches to Stop Hypertension (DASH) diet: High in fruits, vegetables, low-fat dairy, and low in sodium, saturated fat, and cholesterol.

• Weight management
• Regular physical activity (at least 30 minutes of moderate-intensity exercise most days of the week).
• Reduce sodium intake (<2300 mg/day; ideally <1500 mg/day).
• Limit alcohol consumption.
• Smoking cessation.
• Stress management techniques.

Medication Administration:
Administer antihypertensive medications as prescribed. Common classes include:

• Diuretics (thiazide, loop, potassium-sparing)
• ACE inhibitors
• Angiotensin II receptor blockers (ARBs)
• Beta-blockers
• Calcium channel blockers

Patient Education:
Explain the importance of adherence to medications and lifestyle modifications, how to monitor BP at home, and when to seek medical attention.

Monitor for Complications:
Assess for signs of hypertensive crisis (severe headache, chest pain, shortness of breath, altered mental status) and target organ damage.

Heart Failure (HF)

Definition:
The heart’s inability to pump enough blood to meet the body’s metabolic demands.

Etiology:

Coronary artery disease (CAD)
Hypertension
Myocardial infarction (MI)
Valvular heart disease
Cardiomyopathy
Congenital heart defects
Arrhythmias
Infections (e.g., myocarditis)

Types of Heart Failure:

• Left-sided Heart Failure:
  Most common. Blood backs up into the lungs.
• Systolic Heart Failure:
  Reduced ejection fraction (HFrEF). The heart muscle can’t contract forcefully enough.
• Diastolic Heart Failure:
  Preserved ejection fraction (HFpEF). The heart muscle is stiff and can’t relax properly.
• Right-sided Heart Failure:
  Blood backs up into the systemic circulation. Often caused by left-sided HF or pulmonary hypertension.

Signs & Symptoms:

Left-sided HF:

• Dyspnea (shortness of breath), especially on exertion or when lying down (orthopnea)
• Paroxysmal nocturnal dyspnea (PND)
• Cough (may be frothy or blood-tinged)
• Crackles (rales) in the lungs
• Fatigue
• Weakness
• S3 heart sound (“ventricular gallop”)
• Tachycardia
• Pulmonary edema (severe respiratory distress)

Right-sided HF:

• Peripheral edema (especially in the ankles and legs)
• Jugular venous distension (JVD)
• Ascites (abdominal swelling)
• Hepatomegaly (enlarged liver)
• Weight gain
• Anorexia
• Nausea

Nursing Assessments:

History:
Underlying cardiac conditions, medications, lifestyle factors, family history.

Physical Exam:

• Assess respiratory rate, depth, and effort.
• Auscultate lung sounds (crackles, wheezes).
• Assess heart sounds (S3, murmurs).
• Check for edema (location, severity).
• Measure JVD.
• Assess abdominal girth.
• Monitor weight daily.

Diagnostic Tests:

• ECG
• Echocardiogram (to assess ejection fraction and heart structure)
• Chest X-ray (for pulmonary congestion)
• BNP (B-type natriuretic peptide) – elevated in HF
• Serum electrolytes, BUN, creatinine

Nursing Interventions:

Medication Administration:
Administer medications as prescribed, including:

• Diuretics (loop, thiazide, potassium-sparing)
• ACE inhibitors or ARBs
• Beta-blockers
• Digoxin (in select patients)
• Nitrates
• Vasodilators

Oxygen Therapy:
Administer oxygen to maintain adequate oxygen saturation.

Positioning:
Elevate the head of the bed to reduce orthopnea.

Fluid and Sodium Restriction:
Follow dietary guidelines to limit fluid and sodium intake.

Daily Weights:
Monitor for fluid retention.

I&O Monitoring:
Strict intake and output monitoring.

Patient Education:
Teach patients about their medications, diet, activity restrictions, signs and symptoms to report, and the importance of follow-up care.

Monitor for Complications:
Pulmonary edema, cardiogenic shock, arrhythmias.

Myocardial Infarction (MI)

Definition:
Necrosis (death) of heart muscle due to prolonged ischemia (lack of blood supply). Typically caused by a thrombus (blood clot) obstructing a coronary artery.

Etiology:

Atherosclerosis (plaque buildup in the coronary arteries) is the primary cause.

Risk factors are similar to those for coronary artery disease:

• Hypertension
• Hyperlipidemia
• Smoking
• Diabetes mellitus
• Obesity
• Family history
• Age
• Gender (men are at higher risk)

Types of MI:

• STEMI (ST-Elevation Myocardial Infarction):
  Complete blockage of a coronary artery. ECG shows ST-segment elevation.
• NSTEMI (Non-ST-Elevation Myocardial Infarction):
  Partial blockage of a coronary artery or severe reduction in blood flow. ECG may show ST-segment depression or T-wave inversion.

Signs & Symptoms:

Chest Pain:
Severe, crushing, squeezing, or pressure-like pain. May radiate to the left arm, shoulder, jaw, back, or epigastric region.

• Shortness of Breath
• Diaphoresis (sweating)
• Nausea/Vomiting
• Anxiety
• Dizziness/Lightheadedness
• Palpitations
• Weakness
• Fatigue

Silent MI:
Some individuals, especially women, elderly, and diabetics, may experience atypical symptoms or no symptoms at all.

Nursing Assessments:

Pain Assessment:
Location, intensity, quality, aggravating/alleviating factors.

Vital Signs:
Blood pressure, heart rate, respiratory rate, temperature, oxygen saturation.

Cardiac Assessment:
Auscultate heart sounds, assess for murmurs or gallops.

Respiratory Assessment:
Auscultate lung sounds, assess for signs of pulmonary edema.

ECG:
To identify ST-segment elevation or depression, T-wave inversion, or other abnormalities.

Cardiac Markers:
Blood tests to measure troponin (highly specific for myocardial damage), CK-MB, and myoglobin.

Nursing Interventions:

Immediate Actions (MONA):

• Morphine: For pain relief (if not hypotensive).
• Oxygen: Administer oxygen to maintain oxygen saturation >90%.
• Nitroglycerin: Sublingual or IV to dilate coronary arteries.
• Aspirin: Administer aspirin (chewable) to prevent further clot formation.

ECG Monitoring:
Continuous ECG monitoring to detect arrhythmias.

IV Access:
Establish IV access for medication administration.

Thrombolytic Therapy:
If STEMI and PCI (percutaneous coronary intervention) is not immediately available, administer thrombolytic agents (e.g., alteplase, reteplase) to dissolve the clot. Contraindications need to be assessed.

Percutaneous Coronary Intervention (PCI):
Angioplasty with stent placement to open the blocked artery.

Medication Administration:

• Antiplatelet agents (e.g., clopidogrel, prasugrel, ticagrelor)
• Anticoagulants (e.g., heparin, enoxaparin)
• Beta-blockers
• ACE inhibitors or ARBs
• Statins (to lower cholesterol)

Bed Rest:
Initially, bed rest to reduce cardiac workload. Gradually increase activity as tolerated.

Emotional Support:
Provide emotional support and address anxiety.

Patient Education:
Teach patients about their medications, lifestyle modifications (diet, exercise, smoking cessation), signs and symptoms to report, and the importance of cardiac rehabilitation.

Arrhythmias

Definition:
Irregularities in the heart’s rhythm.

Etiology:

• CAD
• Hypertension
• Heart failure
• Electrolyte imbalances (e.g., potassium, magnesium)
• Hypoxia
• Drug toxicity (e.g., digoxin)
• Myocardial ischemia or infarction
• Thyroid disorders
• Caffeine, alcohol, or stimulant use

Atrial Fibrillation (A-Fib):

Definition:
Rapid, irregular atrial electrical activity, resulting in an irregular ventricular rate.

Signs & Symptoms:

• Palpitations
• Irregular pulse
• Fatigue
• Shortness of breath
• Dizziness
• Chest pain

ECG Characteristics:

• Absence of distinct P waves.
• Irregularly irregular R-R intervals.
• Atrial rate 350 bpm (usually not measurable).

Nursing Interventions:

Medication Administration:

• Anticoagulants (e.g., warfarin, dabigatran, rivaroxaban, apixaban) to prevent stroke.
• Rate control medications (e.g., beta-blockers, calcium channel blockers, digoxin) to slow the heart rate.
• Rhythm control medications (e.g., amiodarone, flecainide, propafenone) to convert the rhythm back to normal sinus rhythm or maintain sinus rhythm.

Cardioversion:
Electrical shock to restore normal sinus rhythm (if medications are ineffective or the patient is unstable).

Catheter Ablation:
Procedure to destroy the abnormal electrical pathways in the atria.

Monitor for Complications:
Stroke, heart failure.

Ventricular Tachycardia (V-Tach):

Definition:
Rapid, regular ventricular rhythm with a rate >100 bpm (usually 150-250 bpm).

Signs & Symptoms:

• Palpitations
• Dizziness
• Lightheadedness
• Syncope (fainting)
• Chest pain
• Shortness of breath
• Cardiac arrest (if prolonged or unstable)

ECG Characteristics:

• Wide QRS complexes (>0.12 seconds).
• Regular rhythm.
• Absence of P waves (or P waves may be buried within the QRS complex).

Nursing Interventions:

Stable V-Tach:

Medication Administration:

• Amiodarone
• Lidocaine

Monitor vital signs and ECG closely.

Unstable V-Tach (hypotension, altered mental status, chest pain):

Cardioversion (synchronized electrical shock).

Pulseless V-Tach:

CPR (cardiopulmonary resuscitation).
Defibrillation (unsynchronized electrical shock).
Medication Administration: Epinephrine, amiodarone.

Angina

Definition:
Chest pain or discomfort caused by reduced blood flow to the heart muscle (myocardial ischemia).

Types:

• Stable Angina:
  Predictable chest pain that occurs with exertion or emotional stress and is relieved by rest or nitroglycerin.
• Unstable Angina:
  Unexpected chest pain that occurs at rest or with minimal exertion. It is more severe, prolonged, or frequent than stable angina and is a warning sign of impending MI.
• Prinzmetal’s (Variant) Angina:
  Chest pain caused by coronary artery spasm. Often occurs at rest and may be associated with ST-segment elevation on ECG.

Signs & Symptoms:

• Chest pain or discomfort: Described as pressure, squeezing, tightness, or burning. May radiate to the left arm, shoulder, jaw, back, or epigastric region.
• Shortness of breath
  Diaphoresis
  Nausea
  Fatigue
  Dizziness

Nursing Assessments:

• Pain Assessment:
  Location, intensity, quality, aggravating/alleviating factors.
• Vital Signs:
  Blood pressure, heart rate, respiratory rate, oxygen saturation.
• ECG:
  To detect ST-segment depression, T-wave inversion, or other abnormalities.
• Cardiac Markers:
  Blood tests to rule out MI (troponin, CK-MB).
• History:
  Risk factors for CAD, medications, previous episodes of angina.

Nursing Interventions:

Immediate Actions:

• Stop activity and rest.
• Administer nitroglycerin (sublingual or spray). Repeat every 5 minutes for up to 3 doses if pain persists.
• Administer oxygen.
• Monitor vital signs and ECG.

Medication Administration:

• Nitrates (long-acting)
• Beta-blockers
• Calcium channel blockers
• Aspirin
• Antiplatelet agents (e.g., clopidogrel)
• Statins

Patient Education:
Teach patients about their medications, lifestyle modifications (diet, exercise, smoking cessation), how to use nitroglycerin, signs and symptoms to report, and the importance of follow-up care.

Monitor for Complications:
MI, arrhythmias.

Basic ECG Interpretation

ECG Component	Description	Normal Values
P wave	Atrial depolarization (contraction)	<0.12 seconds in duration
PR interval	Time it takes for the electrical impulse to travel from the SA node to the ventricles	0.12-0.20 seconds
QRS complex	Ventricular depolarization (contraction)	<0.12 seconds in duration
ST segment	Period between ventricular depolarization and repolarization	Usually flat (isoelectric)
T wave	Ventricular repolarization (relaxation)	Asymmetrical, upright
QT interval	Total time for ventricular depolarization and repolarization	Varies with heart rate (usually <0.44 seconds)

Heart Rate:
Count the number of R waves in a 6-second strip and multiply by 10 (rough estimate). For more accurate calculation, count the number of small squares between two R waves and divide 1500 by that number.

Rhythm:
Assess the regularity of the R-R intervals. Is it regular or irregular?

P Waves:
Are P waves present? Are they upright and uniform? Is there one P wave for every QRS complex?

PR Interval:
Is the PR interval within the normal range? Is it consistent?

QRS Complex:
Is the QRS complex within the normal range? Is it narrow or wide?

ST Segment:
Is the ST segment elevated or depressed?T Wave:
Is the T wave upright or inverted?