I'm going to start doing some of these a little more in depth. So you're going to see two of them on the test. I'm not sure if I told you that last week or not.
You want to see some prior work as well. The hypertension mix, those are ones that you should focus on. I pulled one from pretty much each class so that you can see how they work.
Now, the main campus, one of the students there said, we have to know how they work. It will be very helpful. You have to know how they work.
Just so you can educate the patient and it ties into the side effects that you're going to have. So pay attention when you get to that. Will we need to know the class or just really the mechanism?
Technically, you should know. I mean, you should know that Rosemite is a diuretic. The hydrochlorothiazide is a diuretic.
The centipriles are a diuretic. That helps you too because each class has different side effects like the diarrhea. There are cost problems. There are electrical problems.
So you should know all of this. The article. I'm going to talk about this one first before we get to the slides. Just because patient education is a big thing and labels can be confusing and sometimes that's intentional.
It's a marketing thing. that something might say it's like oh it's like super duper low what does that mean so when you're going through the dash diet and decreasing amount of sodium has examples but it's got some good foods in here it kind of gives a quick and easy breakdown of what is good versus what is bad then the other table It kind of explains because if somebody is on a really restricted sodium diet, then sometimes you wouldn't be able to help them pick out or to know what is what. If I'm supposed to have, okay, this is not a diet, but if the doctor tells me I have zero sodium intake, I can't have any sodium at all, my heart will explode if I eat one more speck of sodium, then which one of these is the right one? reduced sodium doesn't mean a whole lot.
It's like 75% of my heart might not explode at 25% of will. So knowing what the labels mean is going to be important to patient education. Now the prioritization chart, as we move forward, you're going to get more prioritization questions from me. So the general gist of it is, we start with airway, green circle, is there an airway issue? Then we go down the line.
Is it a Maslow's issue? Is it a physiological over psychosocial? It's not that. Is it an acute issue versus a chronic issue? Something brand new versus something that's been going on a long, long time.
So you can look at things in different ways until, if you can't figure it out, you just basically look and say, is one of these going to kill the patient faster than the other? So in this, there are some practice steps for you. So I would really encourage you to start looking at those. You're going to see more of it in PCC2 and Salk.
And the new hypertension thing you posted, is that the same one that's in the unit? Is it in this one? From the unit. So it's going to interact with the whole packet? Yes.
I just added some things in for us to go over in class today. I wanted to make sure I saw that one. Okay.
The only thing in here are the practice questions. You're going to see lots and lots of high blood pressure patients in the future. These are disorders that we have in the world.
So, we're not seeing a lot of these practice stuff. The medications, the education, the health. The first thing people have is lots of things to teach.
Prevention, medications, exercise, diet, multi-living. There are lots of things that you want to talk to patients about with hypertension. So the basics.
Some of this is going to be a refresher from some of this. So different levels of hypertension. So a good blood pressure is less than 120. So 116 over 64 is good.
112 over 76 is good. It's usually good until that systolic starts dropping below. So some people naturally run a little lower than others.
There are people that I've seen that their blood pressure was like 88 over 60 something for that person. And heavy impacts. Now when we start worrying about hypertension, they're going up.
And according to the American Heart Association, it's broken down into categories. So you can have normal, elevated, stage one, stage two, and hypertensive crises, which we're going to talk about urgencies versus emergencies. Now there's another organization that lists instead of elevated, They call it prehypertension. But your book has the American Heart Association.
It's what most everybody follows. So if you see something or somebody says they have prehypertension, it's pre-equivalent to elevated. Hypertension typically has symptoms in people. When my blood pressure goes up, I get a headache. I get fatigued, tired all day long.
And sometimes I'll hear the swooshing in my ears. Other people don't get that. Some people have consistently elevated blood pressures and they don't have any of those symptoms.
They don't know what's going on. So it's called the silent killer because blood pressure does damage to like the really small fine vessels in different organs. In your eyes, in your brain, in your heart, in your kidneys.
So all of those things can be damaged over a period of time when a person's blood pressure just is uncontrolled and they don't know it. So that's why it's important to do regular blood pressure checks when a person comes in, even for well visits at the doctor. Now there's a problem with that. I told the bill people yesterday.
It's like, I don't think my blood pressure has been checked accurately according to the guidelines since I was a child. So Oceana people, Wyoming County people, did anybody here ever know Doc Shannon? Yeah. From Oceana. It's like penicillin for everything.
Penicillin for everything. So the nurse there, I remember my blood pressure being checked there when I was little after sitting for like three or four hours in the waiting room. So that was really the last time that I remember having an accurate check at any doctor's office.
So there are problems that we create for ourselves and patients because of. and we're going to talk more about blood pressure checks in a couple of minutes but one of the big contributing factors to coronary artery disease heart disease it's um it's blood pressure the hypertensive heart disease can cause lots of issues with your heart and the structure now there are different things that increase blood pressure your body has a few systems in place to maintain blood pressure the problem is that Some of those settings are off a bit, I want to say. It's like a thermostat that my body might like the setting at 80 degrees.
What do you all think about 80 degrees? It's too hot. Other people's set spot might be somewhere around 72, 74. Same thing with blood pressure. My body might like my blood pressure to be like 150 something over 110. It's the way that my body is built. Other people might be naturally lower.
Some of that plays into genetics. My mother had hypertension, my father had hypertension, my paternal grandfather had hypertension. So my paternal grandfather's mother had hypertension. It's like she went through goodie powers like there was no tomorrow.
So two of those, my grandfather and great grandmother, they died from complications. They had heart attacks because their blood pressure hadn't been controlled. So when we're talking about family members, it's typically when we look at family history, it's usually first degree relatives, like brothers, sisters, mothers, fathers.
You can look a little farther back, but when we're talking family history, those are the main people. Do we need to know who's pathos work for Monsanto? Like how it goes?
Oh yeah, we're talking about these. Especially the Ren and Angie Tinson-Aldos strong system. That's one of the big players in blood pressure management.
So we talked about sympathetic nervous system last week. So when that is activated, it's getting its rate of runner up. So it increases blood pressure. The ways that it gets glucose and oxygen to the muscles where it's needed to get away from the thyroid. The renin-angiotensin-aldosterone system, this is one that...
It has to do with constricting the arteries, which increases blood pressure, and it also deals with fluid volume. That's with the same amount of fluid? No, these work in different receptors. So the top one, we're dealing with the sympathetic stuff, the alpha 1s, alpha 2s, and beta 1s and betas.
So the others, the renin-angiotensin, it has receptors too, but it's a different kind. It's still like a light switch. It's just activated by different stuff.
Now, primary hypertension is what most of the people in the United States are diagnosed with. So it just means it's there. It's like there's not a problem causing it.
You just got the hypertension. Secondary hypertension is because the blood pressure is caused by something else. that it could be like an adrenal tumor. It could be like excessive weight. It could be like chronic kidney disease where you're retaining fluid.
So if you fix those problems, then the blood pressure goes away. But for the most part, you're going to see people in the hospital and in the clinics and in the community that have primary hyperplasia. It's just there. Now risk factors. There are certain things that are going to predispose people to high blood pressure.
The modifiable, non-modifiable. The non-modifiable, you can't do anything about it. I cannot suddenly go back and erase hypertension from another. I can't change my ethnicity. I can't change my gender.
So those things are there. It's like we deal with those the best we can. When we're educating patients and trying to make better lifestyle choices, we have to focus on the modifiable first.
So, obesity. I am thick, right? I'm stealing your words, you young people. So, to help me lose weight, when I lose weight and go below 200, 210, somewhere around there, my blood pressure's perfect. I don't need medication.
So, if I were to lose weight, I would have to take blood pressure medication based on my past experiences. Smoking, I don't smoke, but smoking does cause some vasoconstriction and damage to the arteries and vessels, so... By getting this stopped, it'll decrease your systolic blood pressure a certain amount and it will stop irritating those vessels so you have a lower chance of developing atherosclerosis or peripheral artery disease and excessive alcohol.
I'm not going to look at anybody in particular, but it's like, it's like, who are we looking at? Who's the drunk in our class? Come on. It's got to be Jesse.
Okay, so excessive alcohol intake does tend to increase blood pressure. So the do you remember the limits on what you're supposed to have? It's really unfair. Is it 12 ounces?
You're supposed to have, it depends on what we're drinking. So basically it's one serving of alcohol per day for women, two servings per day for men. Now, 12 ounces of beer, like one or two, two cans of beer for men. Now, the reason I bring it down is like, if we're talking hard liquor, 12 ounces of alcohol vodka, tequila, whiskey. So 12 ounces of that's going to be a little bit above.
So we have like the little shot glass that much. We have a wine glass with that much. We've got a can of beer that much.
So the harder the liquor, the smaller the... You said how long? Per day? Per day? Yeah.
That's gone. Well, I'm wondering, is it that I've drank in the past, I was convinced I was going to fall off of the earth if I wasn't holding onto the grass. Did he say 12 ounces was a serving? I'm going to ask. I'm going to find out.
It's like, I didn't know I was going to go back to the motel. So, All right, so the, let's go smoking. Now, here's where Sally Sales tricks you all in the second year. And it's kind of mixed up, but we want to improve people with smoking.
In the NCLEX, it's a perfect world. In practice, if somebody's smoking three packs a day, then it might not be reasonable for us to expect to ever get them to stop. In our world, we might say, it's like, okay, we need to cut you down from three packs a day, taper it down to a pack a day. Now, in the in-class world, it's always going to be stop smoking because it's a perfect world where every patient is going to do as you ask or as you teach them. So, do we have any smokers in here?
How much do you smoke a day? Well, it depends on my stress levels. So, usually a pack a day. So, on a test day... What are we talking about?
A pack. A pack a day. So, in real world practice, when I'm talking to you and it's like, okay, so a pack a day, 20 cigarettes, we need to try to cut that down a little to decrease the risk of these health conditions starting.
So instead of a pack a day, how about we taper down to half? So, see, that's the thing. It's like a lot of people are never going to stop.
But in the real world, It's very difficult. But in NCLEX rural, okay, let's talk about cutting you down. What's a good date?
Do you think you can do it in two weeks or three weeks or four weeks? Four weeks, okay. In a month from today, then we're gonna stop smoking. So during that time, do you think you could quit cold turkey or do you need to taper down?
So we too. Sorry. We don't have the money you're saving.
Can we negotiate? Sometimes it is a negotiation in the real world. But when you get to Sally sale, it's like every year I'll look at those test questions.
It's like everybody's getting like 60 70% on questions until that one where it's like, and it's the one where she says decrease smoking. It's stop smoking on the tests. So what's the right answer for Sally? It's not taper or decrease, it's stop.
So there's like an option where it says decrease smoking and there's an option to stop smoking? No, no, it's the decrease smoking is what everybody chooses. But there's another answer that's more right.
Note to self. All right, I'll remember that. Okay, so sanitary lifestyle. So do you remember what the activity levels you are encouraged to do are?
30 minutes a day? We've got 30 minutes a day or 150 minutes of moderate level activity per week. That's for a normal adult.
Now, some people are not going to be able to just go up and start doing 150 minutes of activity a week. If you tell me I have to start doing brisk walking around here every day, starting right now, it's probably not going to happen. So, you can start small.
Start low. It's like... You all have not met Cheryl Belcher yet, who teaches in the bachelor's program.
She was Cheryl Winter when I went here and when I first started working here. She tricked me. She's like, "Let's do a walk around." She's healthy.
She enjoys walking. She's like, "Let's do a walk around the building there." And it's like, I don't know, I think one lap around the building is like an eighth of a mile. And I'm like, "Okay." It's like, "I can do that." So we started off.
around the building, out, well, it's like starting our office, around, back up, then around the big parking lot with the boulder, then back to the road, down to Silver Point Homes, and by this time it's like I knew I had been snowed through. So that did not fit well with me, so I never walked in with her again. So if you have somebody that just doesn't enjoy something like that, then start small. It's like, so our goal is today, walk around the building.
Tomorrow, walk around the building. Day after that, try walking around the building and going out into the room. And some people just might not be physically fit enough at the moment to do 130 minutes solid a day. Some of the older people who have health issues might not be able to do that initially. So the goal is start low and build up.
Walk to the mailbox. Now, the diet, the DASH diet, I've got some of the foods in there listed for you a little later on. The key thing in that is it's decreased, if you look at it from top of the table down, we're going more grains, more healthier foods, more grains, all the way down to the bottom where it's less sugars.
So oils and sugars are used less than the... healthier foods like whole grain breads. Now, sodium plays a big part in the diet too, and potassium does. Sodium first is that in an American diet, some of the articles say that we eat normally around 5 to 6,000 milligrams of sodium a day. It's part of our normal diet because it sneaks in in lots of foods.
Who here is going to go get something fast food for lunch? So, a lot of it is high in sodium. When we went down to a meeting at Bluefield Campus last year at some point, I don't remember what it was, we had some meeting down there.
We went to a Mexican restaurant, really good food. They oversalted everything. It's like my blood pressure shot up at home and it's from like high salt.
So, what else do we eat a lot of? You cook every night. You threw a hot pocket in the microwave? Processed foods.
Processed foods. Do you eat canned soup? Do you eat turkey bacon?
You just like the tequila. It was one time and I was on vacation. So many things are making sense now.
It was one time. I still have it. So we're really bad about processed foods, like mac and cheese. When I was a little boy, I was all like, oh. So there's usually a lot of sodium in processed foods and things like that.
So that's why we try to cut those out and have the person eat a healthier mix of higher-end brands like possums. Now, potassium. There are studies that show that increasing potassium intake actually lowers blood pressure. It's not a super duper drop, but I mean, over the long term, the increase is solid.
Adds up. So, high potassium foods. What have we got potassium wise?
Bananas? B-A-N-A-S. Bananas. Citrus fruits. What about potatoes?
Potatoes. Are they good or bad? They're not potassium. Two things. So the goal is to increase foods that are quote unquote healthier with potassium and decrease things that have sodium.
The American Heart Association is positive for the DASH diet. They recommend no more than 2,300 milligrams of sodium a day really for everybody. So if somebody's putting on like a restricted sodium The doctor tells them that they need to eat a low sodium diet.
Usually 2,300 is what we consider the number. However, the American Heart Association can't make up its mind. So there's a little asterisk right beside it that you should eat 2,300 or less, but you get better benefits if you decrease it down to 1,500 milligrams a day.
They'll say you'll get a better benefit from 2,300. Sodium? Sodium? Sodium?
Sodium? I don't think they have a number on here. So, and you said realistically most people eat around 3,000? 5,000 to 6,000.
Oh, 5,000 to 6,000. Gosh. So added salt, I mean, when we're talking about like 2,300 milligrams, it's basically a teaspoon of added salt.
So in reality, if you could... let's say with meat for instance, you know most people salt their meat, but would you recommend for someone let's say that had hypertension if they were kind of healthy to lower like the amount of salt they would use on their food or just cut it down altogether? If they don't have a blood pressure problem, we, it's like I'm talking about being addicted to caffeine, we love caffeine but we're addicted kind of salt too because Why do we add salt to stuff? It's flavor.
It's flavor. If you stop, if you cut down on salt, your taste buds are going to nose. And it's going to take several weeks for them to adjust and your taste to adapt.
And some people aren't going to, it's like, I get like the slightest headache, not even from missing a Coke, but it's like, as soon as I get that headache, it's like I'm running to the bottle. Like, you like them, dude? Yeah. You like them, dude? I didn't even drink it.
I just have the bottle. Okay. Bring it and show it. Okay.
That's illegal, ain't it? To have alcohol on... Yeah, because you're underage. Yeah, I'm underage.
I can't have alcohol on... But didn't you say the legal drinking age in Mexico was 18? Yeah, but I'm in America now.
I'm not doing that. I swear I'm not an alcoholic. We've never had any other extreme present.
No. Well, I... I don't know what to say. Okay.
So, stress. Stress is another thing. So, we get very stressed in nursing school. Pretty much constantly, right?
I have a stress ulcer right now. Oh, okay. So, what medication are we going to give you for that?
I fell right for it. Okay, technically there are multiple, so I'll give you that on the technicality. Yeah.
Okay. So, but think about if you were in like a test day situation. emotion all the time.
You're going to have like elevated sympathetic activity happening in your body that keeps your blood pressure elevated. So we have it fairly easy. But there are people out there living in poverty that are fighting to get enough money to eat once a day.
So poor people who are struggling can have like a lot more stress. The I don't know which class it's in, but there's one where we'll talk about how it's like about the how money doesn't buy happiness. Kind of a lie. It's like you could be happier as a millionaire than as somebody who's working part-time at a job that only pays $7.25 an hour. Would you be happier if you could just up and fly to some resort?
I would too. Okay, now we'll talk a little bit more of this in a second, but when we're talking about the ethnicity, it's like African American nations and people who are American Indians, they typically have more issues with blood pressure, hypertension, and it usually happens younger than in white people. gender.
Men typically have a higher incidence of hypertension in their younger days, but when we reach the mid-60s, ladies usually catch it. Is there like a specific physiological reason why the African Americans and the Spanish have that problem? One part is, I can't tell you the whole thing because the articles go way too in-depth for me.
It's like at a certain point, I just kind of like If it's not clear in the abstract or the conclusion, then it's just like, it's kind of like y'all when you're three-year-olds. You fade out after a while. So one of the things is that in your generic white person, it's typically a renin issue. You have high renin and hypertension. In African-American patients, it's usually sodium-rich.
So, that will play into what's coming in when we get to the Department of Ecology and some of the medication. Did you say Native American? Or is that just like, I don't know.
Indigenous people, I think the book says. So, is that the same thing as like a Latino American? Or are you calling out?
Different, but they're in that group too. Trying to be culturally appropriate. Okay. I want to get canceled for that.
Okay. When we get to a certain slide, a scenario, it's like, I had thoughts. It was funny initially, then I'm like, oh my gosh, I can't do that. So, asymptomatic.
So a lot of people are not going to have symptoms with this. Again, silent killer is popular out there in the world and education. So people can go through this without having any symptoms. When your blood pressure goes high for a long time, the things you typically see, Some people have a headache, frontal headaches, throbbing headaches that I'm describing as. The swishing in the ear, vision problems, or flurries, they have trouble focusing on something.
The chest palpitations are when it's, excuse me, high high, fatigue too. Hypertension can make some people feel extremely tired. When my blood pressure goes up, I just... I'm like tired. I'll just sit and I'm like, why am I so tired?
Because I'm really negligent about checking my blood pressure on a regular basis. So I'm like, why am I so tired? Why are my uterus swishing? And I'll check my blood pressure and it's like, oh, okay, 200 over 120. That's why. Now, some people can have nosebleeds.
I haven't seen it very often, but it can happen because your sinuses are really masculine. And pressure builds up and it can rupture the little vessels. Now, when we're talking about, your book might call it target organ damage.
I usually call it new organ damage because that's just what I learned years and years ago. But high blood pressure damage is a lot of vessels that has really fine vasculature. Lots of little vessels in there. So when we're talking about the heart, it's usually high blood pressure is one of the leading causes of, that ties into future heart attacks. It can damage the little vessels, scar them up so that the heart isn't getting the oxygen it needs to the tissues.
The strokes, so the neurologic part, high blood pressure increases blood pressure. So those little vessels in the brain that are only supposed to be like, pump like this, like when blood flows up through, it does this. Increased blood pressure is making them do this. So that stretch can cause damage to the lining, but it can also weaken part of it so that side bulges out and ruptures. And you have a hemorrhagic stroke.
The chronic kidney disease, so it damages the little vessels that help move blood through to filter urine out. Now when you have chronic kidney disease, you start to see things like when you go to the doctors. Has anybody ever had a urinalysis or done the dipstick?
Yes. Okay, so, who said yes? So, not a drug one, right?
We're not talking about drugs. Oh, I've been tested for drugs too. We all have. Oh, do they do the dipstick on y'all?
Okay, so when we're looking at the urine dipsticks for the urinalysis, protein is one of the things on there. So your pee shouldn't have protein in it. So if you're leaking protein out, then that's a sign that there is some kind of kidney damage happening.
When you pee and it's really, really frothy, that's a sign that there could be protein in the urine. Question. So for instance, you have someone that their kidney function, let's say 45%, and you know, let's just make it, I know you said after a certain age, such as women's, blood pressure goes up. At that point, what levels are we looking at? Because, you know, their kidneys are already working under half.
Would that cause their pressure to be even higher? It can, because if your kidneys aren't filtering out the fluid, say, if here's the fluid. This is not appropriate.
So fluid in through drinking, you should lose a little less of that pee. We lose some through breathing and sweating and a few other ways. So if I'm taking this fluid in and I'm letting this much out, then it's going to increase the amount of volume and increase the blood pressure. And it gets really tricky when you're dealing with multiple issues.
happens a lot when you're older so there are different medication choices that they they the doctors can order at that point now the retinopathy so your eyes your retina has like really thin baskets So when the eye doctor is doing the exam, they can see things. Some doctors can tell if you're hypertensive just by the size of the vessels. And you get, you probably didn't talk about this in fundamentals for an assessment, but you can get like little cotton accidents.
It's like little fluffy things on the back of the eye. Now, blood pressure. So you all have checked manual blood pressures.
So the latest guidelines for One of the big option choices is the cup size. Have you seen the neonatal ones? It's like the little baby size.
You've got the pediatric ones and you've got the normal adult and you've got the larger adult. Sometimes a regular adult cup isn't appropriate for a very thin... They use the pediatric ones. So not the pediatric but like the top. Yeah.
So there a quick guide is it's like it's called the 84 year old. Who's this? This is one of them.
They brought it in yesterday first of it for that guy. Is this the SJ thing? Yeah.
Oh, we got trouble to make campus. That's what he was saying. That's what he was saying. Why are you in trouble? Because the the neck where the nursing classes are at now It's a locked unit.
You can't come on, nobody's allowed on there. If the nursing faculty are in the building. We just got the housekeeper and got her to open the door. Went into like every room and pasted these everywhere.
I'm like, well first that's kind of tacky. I mean, you've got to break into a place to hang a hundred posters of yourself on each computer. Okay, so.
Okay. Okay, so the 80/40 rule. We're just going to say that this is the blood pressure. It has a bladder in it. It's got an inflatable bladder.
So hold your arm up high. So we're going to say this is her upper arm, okay? So what you did wrong, that bladder should cover about 80% of the circumference. The 40, that, it should cover like 40% of it. The problem comes if Say, for example, we don't have an adult cuff, so we use the pediatric cuff, the toddler cuff here.
Then right here, there's, okay, it'll go around, but there's no way this is 40% right here. So by doing this, we're going to get an artificially high blood pressure. If we decide to use the dick person cuff, do it around, you can see that that is way more than 80-40.
So it's going to give you a false low rate of pain. So picking the right cuff size is important to making sure that you're getting accurate readings. And you said if it's too tight, it'll be what now?
Okay, so if it's too large, you're going to get a low blood pressure. If it's too small, you're going to get a higher reading. So it's basically like this.
Now, there are certain lab tests that are usually done when a person, we're looking at a person with high hypertension. We're checking basically for damage. We're looking at the BMP.
That's gonna show us some electrolyte issues. It's just like that little basic work your body, electrolyte. The kidney function, we're looking at the creatinine to see if it's elevated and indicated any kind of damage.
We were doing urinalysis to look for things like protein in the urine to see. Because if protein's leaking out, there's some kind of damage to the kidneys. The EKG and the Picardia brand, they're looking for, the EKG is looking at the electrical conduction right through the heart. So you all haven't talked about it yet, but in the fourth semester, Ms. Sale will give you the rhythm strip lecture. So basically, they're just looking for changes in that.
Because over time, if you have high blood pressure for a period of time, it can affect the cell wall or the heart begins, for example. So if this is a normal, here is your ventricle, okay? So it's squeezing. High blood pressure makes it work harder, and your heart's a muscle, so what happens to a muscle when you exercise? It grows.
So a normal person's ventricle walls are like this, someone with hypertension might have a ventricle wall like that. That excess of growth can cause changes in the electrical conduction, and it can cause problems with heart pumping ability and the amount of blood that's going on. So basically we're doing these to look for any kind of changes or damage that high blood pressure has done to different organs.
How to check a blood pressure. The person needs to be sitting still and relaxed for about five minutes. Because if, okay, on the death run that Cheryl Wicker had me do around the building, the lot, now if we just checked my blood pressure right at that point, what would it have been?
It would have been very, it would have been higher. So they need to rest so that you can get them back to a baseline. The caffeine smoking exercise, again, caffeine is gonna cause tachycardia and some people exercise the same. So we don't want a blood pressure right after they get excessively active or we'll get false high reading compared to when they are resting. Now the bladder.
How many of you have sat through a class where you're about to bust? How do you feel when that happens? What's going on in your head? You're getting antsy.
He said that could increase blood pressure too. Now, this isn't correctly. So, this chair is too high. Look, okay, still too high.
So, I should be sitting comfortably with my feet on the ground, rested. No legs crossed, none of that, none of this. Now, when I said my blood pressure had not been checked correctly for the guidelines since I was a kid, when I go to the doctor, whether or not I've been on my blood pressure medicine, the reading is usually 120 over 80. How likely is that to happen?
It's not likely that that happens once for me, but like when you're doing three visits in a row, it's like, that's abnormal, especially when I've gone for two or three weeks without blood pressure medicine. your arm needs to be resting on something. They've done studies that holding the arm out like this, which is usually when they check it there.
So I try to support my arm, no, no, don't do that, hold it up. And I'm like, why do I hold it back? You'll see there anyway, I just need somebody to help me. So I'm going to be honest. And even some of the studies show that like even resting on your lap is going to alter the reading some.
So, I will admit it, but I don't need a doctor to diagnose me. It's like I usually know what's going on. You will too when you work as a while or as a nurse.
Now, one of the things that I've talked about yesterday with the main campus people is that Checking blood pressure at home can be difficult for some people. Not everybody is trained as a nurse or has a nurse in the family that can come check it on a regular basis. That means that they're likely going to need an automated cuff of some type.
The wrist cuffs are really popular, but they aren't really that great because there are lots of physician issues. I tested this last night just to make sure because I felt the wrist cup of house. So that if you hold your arm up high, which is really exaggerated, I got like 90 over 50 something.
When I held it down, it was like 160 over, I don't remember. And right back here where it should be, it was like 120 something. So it's really exaggerated, but those little position changes are going to alter the read. So on that cup, it's like, there's this little miracle support to keep it right at the heart. So it's hard to manage those.
The American Medical Association has a lot of recommendations. It's usually a lot of the brand names are like it was Omron, Ompron, the old one. But it needs to be like the cuff that goes here.
Some people have a little blood pressure cup. Some people have a cup that if you had to put your blood pressure cup on yourself, is it easier or difficult to manage? Sometimes it's hard to manage.
There's one of them that you can slip, it has like a little metal bar on it that you can, you slip it up on your arm and you can pull it with one hand and attach the Velcro. So that would be good for somebody who lives alone that doesn't have something that can help attach it. Because if it's too loose, you're not going to get a good reading.
It's just how it happens. I always heard that you shouldn't check it twice in the same arm, one time after another. Well, you should, if you do, you should wait for at least a minute or two to let it reset.
Because if you squeeze it on something, it's like if I squeeze really hard right here and again, this is not a super good example, but when I move my hand you're gonna see that some of the like this peripheral vessels are latched out. So I mean it's pressing on those other vessels too internally. So you're getting something similar.
So if you have to recheck it, it should be after a minute. Now, which arm should we check it? The donor arm.
Okay, so when a patient first comes in, according to the American Heart Association, you should check those arms and then continue to use the arm that had the highest reading from that point on. Because when they looked at it, they found that it wasn't a huge amount of people. It was like 4% of people, when they used the higher arm, were found to have hypertension.
They were diagnosed with hypertension. Now, there are certain situations where you can't check in on. You all talked about those?
Is it when they have IVs in them? Or like ulcers? Skin damage? Okay, those are two things.
There's another really good one that always has the Novi P's in this arm. Breast remission? We had a, I was about to say we had a patient who had a mastectomy and couldn't do a blood pressure and that was okay.
Right. So if they've had a mastectomy or like major surgery, then you don't use it on that side. Same thing with the dialysis surgery.
the fistulas or the shunts that you don't use that arm because you don't want to be the responsible for that. So talk about the cuffs. Now this is American Heart Association that a lot of their materials look at averages.
So the people will check blood pressures at different times, different rates. So for example, somebody who's newly diagnosed might be told to check their blood pressure in the morning and again in the evening. Blood pressure typically runs a little higher in the morning.
Another person, a lot of it depends on what the doctor orders. So if you look at an average blood pressure over time, it's basically we add all of the systolic. If we check blood pressure 10 times, we add all of the systolic readings, all the diastolic readings, and then divide those by 10. So let's do an example of two.
So if my blood pressure in the morning was 200 over 100, so 200 over 100, and then the evening was 100 over 50. So we would just add them together. So we got 300 by two readings, and it was 150. And then 150 divided by two is what? So the average of the day would be like I've never seen anybody do that in real world practice. It's basically here's the list of my morning reading and here's the one with my evening.
But I just remember it's just what the guideline says to do. So if somebody says that this is their average reading, you kind of see that. Does that make sense? Would we do that, let's say, if they come from home and they're checking it on an annual basis? Would we say, okay, what did you check this morning and do that as well after we've checked it, just add that to the list or no, just go all fairs?
Well, you want to find out about their blood pressure at home because there are a couple of conditions that make it and give us false readings. And we'll get to that in just a second. snap your fingers when you think we get there. Okay, so here, actually checking it, some of y'all are awful on this feed here, okay? Not just you, but every nursing student that's gone through the labs forever.
It's like, if we are checking a blood pressure, we don't talk, they don't talk, we don't want the patient talking because that talk is making quick changes in our intra-abdominal, intra-plurassic pressures. So it's going to make, instead of that nice smooth like this, you see the bump, you're going to get, when you're talking, it's going to be doing this sort of thing, the bare skin. It's like when we use the stethoscopes and the pressure comes in the real world, it's supposed to be the right against the skin. We don't always do that because in labs, it's like nobody wants to see anybody else naked in the lab. And in the hospitals, sometimes it's hard to manage with people who've got like five or six gallons on the cost of cold.
But in the complex world, skin to stethoscope. When you all talked about blood pressures and fundamentals, did you all do like the little pre-check to find out where? Raise your arm again. So we're going to put the cuff on first. I'm going to palpate to find the pulse.
Then I'm going to inflate it. And I'm going to say that it disappears at 120. Okay? I release it and I can feel it again. So then, let the arm relax for a minute.
Then I'm going to use my stethoscope and inflate it up to 120 since I first felt it disappear at that. Then we're going to slowly release. It should be like...
Each of those little dots is like two millimeters of money. So if you're doing too fast, you're not going to get the reading. If you do it too slow, here's what you got. The person's arm is going to die off of circulation issues. Then it just stops.
Then you loosen it too fast. It goes like that. So it just takes practice on managing it.
It should be like a smooth movement like that right there. And then when I get to the around the under, you should start hearing and see the bumps. So I was struggling with that.
So what you're saying is use the palpation. Would you go right back there with your stethoscope at that point? Well, you'd let it rest for a minute.
Technically, that's the way you're supposed to. If you're asking me if I do that, the electronic cuffs in the hospital don't do that. But in the perfect world, that's what the answer would be.
Okay, so the dashboard. We talked about this. It's focusing more on whole grains than meats and fats and sugars.
So let's say, let's do a little exercise. I am your patient. And you all, you've known me for how long now?
Too long. You know that I am a horribly non-compliant patient. That's like, I mean, that's just how it is. So you have to talk to me about the dash dog.
It's like in my freezer now, there are these little White Castle cheeseburgers. I've got some Hot Pockets. I got the pre-breaded chicken. So in your head, because what's in your head versus what you say can be different things.
So what do you think in your head? high sodium. So we wanted to get you down to at least 140 milligrams of sodium a day or a hundred and... hold on...
milligrams. So... I'm negotiating. Yeah.
Let's cut out one of these foods. Okay, good slide. And we replace it with a banana. So the whole thing would be, it's like, okay, in my head, this is what goes through my head when I'm dealing with some of the patients. It's like, how has your heart not exploded?
It's not therapeutic to say that. So in my head, it's like, okay, this guy, it's like he's 90% salt in his diet. It's like, so in my head, I'm thinking it's this, but got to translate that into something different. therapeutic for the patient.
And that would be, talking about your diet, it seems like you're eating lots of fast foods and that your sodium levels are probably higher than they should be. Do you think that that's something that you'd agree with? I'd be like, yeah, I know it.
It's like my stope hasn't been on in two years. So, It's like, that is not a healthy diet. It's like, you're a nurse, you know what you should be eating.
So, is there something that's keeping you from that? It tastes good. I call it a salt.
It's good. So it's like, yes, but it's like, we're going to have to, it's like, you really should replace something. It's like, so instead of eating the, it's like, instead of going to Taco Bell and getting like the super salty burrito, it's like, why don't you look at the menu before you go and see if there's something with a lower sodium in it. So for instance, with the diet out of your print off that you had in Moodle, when it says 140 milligrams or less of sodium per serving, of course I know we wanted to keep them at like 2,300.
How many, so would we want to split their meals, like go with a morning and evening? So when you say the 140, what's that labeled as? Low sodium. So low sodium. So if I'm going to pick up something that's low sodium, then that would be the limit on that.
Okay. So per serving, it's like, what was it, 140 milligrams? 140 milligrams.
Okay. So if I want a low sodium food, then that's what I would be looking for. Okay.
Something with that amount in it, or less. Okay. It has no taste at all.
So that's going to be a big complaint, though, when we're talking about diet. So if we tell a person we can't have salt, what can we substitute? The dash power.
Mrs. Dash power. So it has potassium in it instead of sodium. I'm not sure. Have you tried it?
Yeah. Is it okay? It's not bad.
Okay. So you can use salt substitutes unless they're on certain medications. We'll get to that in a bit.
So we want to try to substitute things when we can. Which that's a double bonus. We're not getting the sodium, but we're increasing our potassium intake, which helps lower blood pressure. The smoking we talked about, the weight loss, we looked at the diet.
Here are some options when it comes to the DASH diet. So let's look down you. Look on the right-hand column about the healthy choices. How many of those do you eat on a regular basis?
Now don't lie and say whole wheat bread is not the white bread. So how many of those would you say you eat maybe in a week? The servings or like the food?
Just the food. I eat sweets every day. And fats and oils and red meats.
The fruits. So, see here. A lot of sweets. I'm famous for honey buns.
Sodium. Mine is way too high. Fancy oils.
I eat walnuts pretty often. Not so many walnuts. Not so many walnuts. Chickpeas.
Well, I think that is... So, but right here, these are the healthier options. Each of these on sweets.
If I had to make a choice between honey buns and dark chocolate, then dark chocolate would be the better option. So, does anybody eat whole wheat bread regularly? Quinoa?
Do you eat quinoa? That's my whole house. I'm a freak. Okay.
That's pretty much all. broccoli I eat carrots I eat bell peppers yes so I'm good on this one I'm not great on this one skin milk no what about cheese no skinless turkey chicken no skin on lean beef yes olive oil olive oil that's the problem about dips you have to have chips Now the answer is somewhere like 150 minutes of moderate level activity a week is what we always call a level. Now there's a lot of misunderstanding about what moderate level versus higher level is. So I've included a slide for that. Now 150 minutes is based on adults.
Children should be more active than adults. You all are younger than me. So what did you do when you were in grade school activity wise?
Recess. Recess? Played basketball.
Rode bikes. Mind cold. What did you do on summer days when school was out? Swim, solve problems.
Amen. Can you talk to me too? That's cool.
So, culturally we're changing. It's like when I was young, it's like I'd be out on a bicycle going and I wouldn't be home until the streetlights came on. It's like 6 o'clock was, it was time to eat dinner. Okay, now you can ask. Amen.
It's like boredom is bad nowadays, so we're talking about games. And kids are becoming less active. And that's one of the reasons why child hypertension is on the increase.
So kids in general should be doing about 300 minutes per week of moderate to vigorous activity. 300 minutes per week? 300 minutes per week. And then 150 per week. So if we are telling little Nana, 89 year old Nana who has high blood pressure, she wants to become more active, then one of the things that you're recommending is light gardening, risk walking, power walking around the mall.
That used to be a big thing. Do people still... Do people still do that? I see some older people do it, but they're not like how we're walking. They're just walking.
Okay, so you all have missed a cultural phenomenon because there used to be... Crossroads Mall. I used to go there pretty often.
And it was not strange to see, like, there's one that comes to mind right down where it's near the middle where the Orange Jewelers used to be. It's like there was a K-Jeweler or something. And then JCPenney's was right there.
It's like coming around the corner were like three little power walking women that all had like matching suits on. and it's like they were all synced up too and i don't know if you see that as often nowadays but it's a good thing for the disc walk we are not going to recommend that nana go uh hiking up the side of the mountain with a heavy backpack so swimming wouldn't be the option the tai chi stuff that was an option so um there are lots of things that And I pulled this right off of the American Heart Association. So this isn't me making up what's what.
Alcohol. Okay, so two drinks a day for men, one for women. So on the breakdown, here's what we've got. A 12 ounce can of beer. The wine, the, is almost a little less than half of it.
And the liquor, who here does shots? What is your favorite shot? Crown.
Palm Bay Sapphire. Palm Bay Sapphire. Okay. So how many of those shots do you have when you go out? Have your teenage parties or whatever?
Now, one thing that you always need to check is whether or not the person is taking their medicine. And this doesn't happen often, but it's problematic. Because if you're not at it, if I go in, like I said, my blood pressure is real, it somehow is consistently 120 over 80 whenever I go in.
It's like I know mine has been higher on several times when I go through because I for several weeks when I have medications and if I saw good take in my dietary stuff, it's like there's no way. So if the doctors are getting, the nurses take blood pressures now they're in the doctor's office and if the doctor looks at that sheet, well just say for example that they're getting wrong information because the blood pressure's not being checked correctly. My baseline blood pressure might be 160 over 130, and I might really need a blood pressure medication adjustment, but if you're not giving the right information, then what needs to be done might not be done. It's like the... The person might be over or under medicated because the doctor who was going to spend five minutes in there in some situations, they're looking at what the nurse took.
So you all are kind of responsible in that we're making sure that the information you collect is correct. Now, worsening signs and symptoms. So if somebody's being treated, you always want to look to see if it's getting worse.
And you're not going to have time to do a big chart review. So talk to the person. Say, are you having any more symptoms? It's been three months since you've been in. Have you noticed any changes?
at that point. And that's really easy to do when you're taking the vital signs and stuff in the doctor's office or in history when you're in the hospital. So have you noticed any big changes?
It's like, I see you've got high blood pressure. It's like, is it controlled? And most people say either yes or no without really knowing. So have you noticed any other symptoms like increase, are you having headaches or swishing in your ears or any nosebleeds? No?
Okay, good. Now, here's a new slide for you. This is getting you ready for psych.
because I don't know what it was, but when AI came up and we got all of these new image generators, chat bots, all of the fun stuff, I decided to make this up. So here we've got Miao Tilda. Miao Tilda is a 52-year-old female, blood pressure's 148/92. She's a smoker, overweight, sedentary, No symptoms, but she's got high cholesterol and her kidney function is okay. And I'm going to go ahead and say that her urinalysis is okay too.
Now, when we're talking about the cultural thing, now Tilda's original name was Lopez. So I said, I went in to chat GPT. I said, give me some funny Latino cat names or Latina cat names. First one it gave me was Taco Bella.
And I thought, yeah. I said, that's fun. But I'm like, oh my gosh, here we go.
I can't hear you. Which made me think that I'm going to talk about Orange today. So right here on Meowtilda, looking back, what stage do you say she has? Stage two. lifestyle modifications.
What is she doing back? Smoking. She's smoking. She's not exercising. She smokes.
She's thick. She doesn't move. Okay. So smoking.
For NCLEX purposes, Stop smoking. Stop it. You need to stop.
It's like smoking is hazardous to your health. It's like you see the warnings are on the package, right? Does it say smoking causes cancer or something like that? That's really tame compared to some other countries.
Australia, somewhere else, it actually shows pictures of lung cancer stuff on it, on the package. So it's like... I tell them it's like smoking is really hard on them because of a lot of issues.
So would you be willing to stop smoking? I'd gladly give you information on that. And of course, in perfect, complex world, it's like, yes, I've wanted to stop.
So you set a stop date. Set a stop date. If you don't set a time for yourself, what do you do?
Keep procrastinating. You keep procrastinating. And then at the very end, it's like, OK, well, you know what?
That Friday wasn't really important. I just chose it random, so let's make it another Friday. And then you just keep going and going and going. So setting a firm stop date is helpful, whether it be stopping cold turkey or tapering down until that day when it stops. Now, medications.
What do you think? - Or high cholesterol. - She's going to need cholesterol medication because high cholesterol is another risk factor for coronary artery disease and vascular disease. Did you say to try, like if they're overweight or like she's smoking, did you say to try that stuff before putting them on medications? You can, since she's just diagnosed, we could try dietary intervention, weight loss, to see if that will decrease her blood pressure.
So we kind of talked about the basic components here. Now for you, let's do a practice. Maybe use a phone or the language. I have a question.
We've gotten some food questions on the previous exams. May I tell the one question? Can I be as easy as that one?
Because that one's like pretty self-explanatory. All of the questions are easy. What?
I don't know. I've only been in this room for about five days. I think you've learned about this finger food question. Is this the one about alcohol? Is it a male or female question?
No. - Exercise plan. - I'm sorry. I'm sorry.
We've got 22 responses. Billy, is it true that anemia can cause your heart to enlarge over time? Yes.
Why? Because it has to work harder. When you have anemia, you're not getting really great oxygen transport.
So your body has to work harder to move more red blood cells through to get the muscles, the tissues, the oxygen. And there's different types of anemias. If it was an iron-deficient anemia, can all of the anemias cause your heart to enlarge or just iron-deficient anemia? All of them technically could. but the, all of it in some way decreases the amount of chemical element that's being transported through the body.
So, iron deficiency in India is probably the biggest reason for producing iron in the world. If you have low iron, then there are things you can do. It was such a problem when I did the anemia study for this in here. It's like, there was a country, like Southeast Asia, that anemia was so bad that they had scientists come in and study, and it was due to poor iron intake. So they created a little thing, like a piece of cast iron in the shape of...
Little fishy? I've seen it before. It's a lucky fish.
So if you cook that with, like, foods with a little bit of acid to it, it releases ions into the food so that some of it's absorbed. I've seen that before. I thought that was cool.
I can boil it with your food. Yep. 20 seconds. Close enough. I don't even know how many people are in here.
So how are y'all doing? Oh, wait, let's come back up. Is it a dream or nightmare at this point? It is what it is.
Just wait until you graduate and pass your boards. You will feel so much better. I don't think I'm going to get there. I don't know, dude. We'll just skip Jeff on that.
Okay, so. Dang, we're good. All right, so question number one.
I'm so scared I'm going to be like the 1% that gets it wrong. I was pretty sure that the 1% would get somebody with the pasta alfredo. So pasta Alfredo, why would that not be?
Sodium. We've got sodium. Pastas are kind of good, but Alfredo sauce?
And garlic bread. Garlic bread. What is in that garlic bread besides garlic?
Salt. Butter. Butter, salt.
Okay, so we did pick the bad ones. Okay, so we got some variation. Okay, so with meow tilde, American Heart guidelines, what's the most appropriate for a 52 year old woman with hypertension? - You said adults?
So here, 20 minutes of high intensity. So we need more than 20 minutes of high intensity. Poor cat, do you wanna kill her feet? So 150 minutes of moderate level activity, the 60 minutes of strength training, the light vigorous stretching, and yoga only.
So moderate level. So some of you got tripped up on that. So here, in our perfect world, the reduced smoking, five cigarettes a day, no. In real world practice, that might be an option, but in the in-plex, everything is perfect.
So we want to stop smoking. So for the exercise, just to be clear, because that's what the Tossin Fundamental was like, work, we want to be, we want to do the 150 minutes or no? 150 minutes. Okay.
Our goal, now again, it's like we might have to build up to it. But the goal is for an adult to have 150 minutes of moderate level activity per week. Okay.
Now, the green on that, the light stretching, that might have been correct if it's like start with light stretching and move up to this much activity a week. Now here, quick smoothie. Okay, so alcohol intake.
So she has, or until then, One drink a day for her. Okay, y'all are just cruel. I'm not letting it for the lady of her dream. So yeah, it's like no more than one drink over a day.
She's not religious, she's not Baptist, she can drink. Have you watched Young Shelton? Yeah.
That mother is just kind of crazy. It's like, you know, you can talk about my people. It's like, why don't we kind of school a Baptist? I'm a Baptist.
Like... Your preacher. My uncle does. Yeah.
I don't know. Now for the hypertension that goes bad, the crisis. So hypertensive emergency and hypertensive urgency are similar but different. Hypertensive urgency happens when your blood pressure goes over 180, over 20, but you don't have SYN.
So that's one that can be treated with PO medication. I can start taking my Valsartan again and it'll go down. Now the hypertensive emergency typically needs more intense intervention. It's where you have that same elevated blood pressure 180 over 120, but you're having symptoms with it. Chest pain, neurological symptoms.
Half of my face has started to do this droopy thing. So you're going to have some kind of symptom that goes with it. And those symptoms show that it's causing end-organ damage.
Now for me, I'm kind of like a little mini expert on this because I've sent myself into hypertensive emergencies and emergencies in the past. So do you know what the main cause of hypertensive urgency is? Take a guess.
I'm gonna guess stress. There's another bigger one. Not taking medication.
That non-compliance with medications, your hypertensive medication is one of the things that causes hypertensive urges. Now the hypertensive emergencies, I have added a couple of those myself that I've managed at home, which should not have been done, but I know better. It's like I worked as an internal medicine doctor for a couple, for a few years.
So it's like, I know how this is handled. It's like, So I was in the couch one time. I was just like in the recliner and it was like that similar situations. It's just like I automatically forget every other symptom I've had. It's like why am I so tired?
Why is my head hurting? Why am I swooshing? It's like why is everything fuzzy around the edges of my vision? It's like that's good.
Then I check my blood pressure and it's like 200 over 100 something. So back in the good old days, When my mother passed, and she had lots of hypertension issues, so I had like a doc of medications. It's like, okay, my blood pressure's up, I don't have mine.
Ooh, here's hydrolyze, vasodilator, I'll take that one, that's the one. Then it's the next one. It's like, still not down, here's metoprolol. Still not there.
Oh, she's at amlodipine and azapril. There's one. So it's like I manage my own stuff, even though that was not appropriate.
And it went fine until one day, it's like that happened again for like the third or fourth time. And I kind of overdid it a little bit. It's like I'm in the recliner. I needed to get up. It's like I had managed myself and I feel, it's like, okay, I feel pretty good now.
It's back down. I stood up, or I tried to stand up, and the next thing I know, I'm like back in the recliner, and it's like, my vision, have you all ever had like your vision go completely fuzzy? It's like, oh, I can't see anything at all, but I feel high. And it's like why would you believe in any drugs, like street drugs? So I had over corrected my blood pressure and caused like a really big orthostatic event, which is okay-ish until you realize if you drop the blood pressure too fast, it can cause perfusion issues with your really important organs.
Like when I stood up, what was not getting perfused? My brain was not getting good perfusion, which probably explains why I felt so good for a couple of minutes. But it could have been really damaging by not getting enough circulation into my kidneys or my heart or my brain.
Now will I do that again? Because for a hypertensive emergency, that person needs medical care that usually involves IV medication and lowering the blood pressure over a period of time. So did you get a headache from that too? From blood pressure? No, it's like I felt really good there for a minute.
No, I mean it's like the meds you took for it. Did you get a headache out of that? If I did, I didn't even notice.
I was looking at when you said that one meds on the list that had the headache and dizziness on there. Was it the hydralazine? No, it was the however you said the A1 though. I'm looking. Yeah.
Okay, so amlopene. Yes. And we'll get to that one in a few minutes as to why that can cause headaches.
I don't think we're going on with me at that point. So like, is the emergency also calls for not taking your medicine? Yes. And is the stroke usually caused from the aneurysm? Yeah, so what happens in strokes happen for a couple of reasons.
Either the brain's not getting great circulation or you burst a vessel. So the first one is schemic stroke, that there's not great blood flow. The next one, hemorrhagic stroke, where your blood pressure goes so high it causes a vessel to bulge and burst.
Now, children's. Hypertension is increasing in children, along with diabetes. Why do you think that is?
Because they don't do anything. They don't do anything. Well, they're not as active. Right.
It's like activity levels have gone down. Instead of being out on the bicycle and playing during the summer from dusk to dawn, it's like people are on their Nintendo Switches. They're on games.
They're playing Top Heroes on their phones. Oh, hold on. Sorry, I had to put in my fast food lunch order.
It's Chick-fil-A, it's not chicken. That can't be bad for you. That doesn't matter.
At least it's real chicken and not processed, right? It is real chicken. Yes.
Yeah. At least it's not processed. It's bad, but it's good.
Children. So kids are less active nowadays than they used to. The diet is not that great. A lot of the things that are marketed as children's foods have lots of sugar in them.
It's like the juices. If you look at the label, a lot of juices are mostly sugar. You'll see water, then sugar. sugar of some type, and then a few things down the list, you'll see orange juice from concentrate.
So kids today are getting a lot more sugar than they have in the past. The diet has changed too. Instead of the 1950s home cooking, they're getting the little dino nuggets. McDonald's tastes like balloons. I'll never eat one again.
I had a good batch of McDonald's yesterday. I got six nuggets from McDonald's yesterday. Some things were fresh.
They were so good. It's like when I worked in the nursery, it's like we would always check to get a baby's blood pressure reading for a baseline. And for the most part, unless there's some congenital disorder, they don't start checking blood pressures regularly until age three. Then when they do like the vaccine visits and the well checkup visits, they'll start taking blood pressure at that point naturally, unless there's some medical issue that it needs to be monitored or something just flash. In older people, has everybody heard of atherosclerosis?
Hardening of the artery. That as you age, your blood vessels tend to get stiffer. Meaning that when, like right now, we're all young people here, right?
We're here, we do the dancing on the clubs at the weekends and do the FaceTimes. So our play vessels, when they dilate, they'll go, I mean, they'll open wide. But as you get older, they get stiffer, so they're not going to relax like they did in the younger years. So that leads to an increased blood pressure as they age. It's called isolated systolic hypertension.
It's a normal expected finding that as you age, your systolic number tends to go up some. with treating the elderly for blood pressure. Now, for if anybody here has hypertension, then the goal might be to keep a blood pressure below 130 over.
So that might be a goal for a normal younger adult. Elderly, since they take so many medications, since there's a lot of polypharmacy, drug interactions happening, and they tend to have more pronounced effects to medications than younger people, that sometimes it's more reasonable, doctors will decide not to treat them that way. So getting theirs into the 140s system might be more of an option. Because one of the big things with blood pressure medications are they can cause, a lot of them cause orthostatic hypertonia.
So it's more pronounced in the elderly. So we don't want them to hit their head on the side of the table or cause any kind of brain damage or brain damage or break a hip. So sometimes the doctors will treat them less aggressively. Now When you ask about comparing the readings at home versus the readings at the office, we like patients to bring in their home readings because blood pressures can be tricky in heights or they can be higher or lower in height.
The one you typically hear about is white coat hypertension. That somebody at home has perfect blood pressure readings. That's like they're never high. Then when they go to the doctor's office, it jumps up.
And that's called white coat hypertension. Now the opposite can happen. That a person can have elevated blood pressures at home and then comes to the doctor and it drops to normal.
Mass hypertension. So I can't tell you the exact physiology behind the mass hypertension, but you always have to be careful because, like I said, when I go into the doctor's office, my blood pressure is 120 over 80, more than it ought to be. So it could be a collection issue. That's why we want to compare the home versus the clinic.
Hypertensive crisis. Mrs. Garcia is 68. Blood pressure is 210 over 120. She has hypertension. She's not adhering to her medications.
Diabetes, chronic kidney disease, headache, confusion, blurred vision, nausea, creatinine, protein in the urine, on lisinopril that hasn't taken for weeks. That could have been me. Why do we say this is an emergency rather than urgency?
Because the blood pressure is so high. That could get exposed. You have more symptoms.
We're symptomatic. It tells us chronic kidney disease and type 2 diabetes. Right. So we've got lots of things happening there. We can see with the headache, confusion, blurred vision, and nausea, those are signs that something acute is happening.
The creatinine and proteinuria, that can be tied to... few of the diseases, but the clue right there is it's just symptomatic. What do we want to do? - We need to restart the lisinopril.
But in the emergency room, I pushed IV libate law. So libate law, what class of drug is that? Is it a beta blocker? Beta blocker. Is it an A1 or a B1 blocker?
It's a beta blocker, so beta 1 and beta 2. It's non-specific, so it's going to affect both of them. So with that, it's done as a slow IV push. Now there's another drug called sodium nitropervacide that is used more in the units. You typically don't see that in the emergency room because it's a high-powered medication and you usually have to be on the monitor and have close nursing contact available in case your blood pressure drops too much. So that's one in the unit.
What's going to happen if we don't fix this right now? She can have a stroke or an aneurysm. Okay. How are we going to get her to take the medications? I'll stick her with a needle and It's like unless you're going to move in with her.
Tell her that she's going to die if she don't start taking her medicines. Inform her that all the things that can happen if she doesn't take it serious. Okay. Now say that in a therapeutic way. If you do not take your medications correctly, you can lead to death.
It's like you're going to die. Is that therapeutic? It's like...
Well, I mean, there ain't no other way to explain people to die. Mrs. Garcia, do you have your will in order because the kids are going to be getting their inheritance pretty soon? You can't say that out loud.
That's what I mean. It might go through your mind. But it's like one of the things you should do is go back into assessment. It's like, Ms. Garcia, it's like you said earlier that you weren't taking your lisentral for weeks. Is there a reason?
Y'all get real judgy on Ms. Garcia. Y'all know what her business. So is there a reason that you haven't been taking it? And it might be financial, it might be because of side effects, it might be a dozen other reasons.
We want to see if it's something that we can fix. You're going to feel real bad if you talk trash to her and she said, "I lost my health insurance when my husband died three weeks ago." Yes, usually case managers get involved or We can pass along information, but I don't know how many people I've talked to about good audience. I mean, it seems like it's an internet scam, but it does lower some people's medications.
We might change pharmacies for medications. So at one point when I left, we were with Dr. Hassan, there was like a three month period where I didn't have health insurance until I started here. So when I picked up Lisinopril, they were like, it's 80 bucks. I'm like, 80 bucks, I can handle that. But I'm like, on principle, I'm like, no, this is like a 50 cent pill per.
So I'm like, transfer it to Walmart. It's like it's on the $5 or $4 list. So they're like, oh, no, no, no, we can find a way to lower it. The geology inhaler that they wanted me to take because my oxygen, like my lung capacity was like really bad.
They even gave me a discount with them. It was like $100 including with my insurance. Like a month. It was $300 a month with the discount and I had at that time really been insured.
So it's definitely expensive. So it might be finding a resource that helps them or it might be changing to another pharmacy. Back in the Health Right days, the funniest one.
Okay, so I'm too off topic. So try to find the right spot for if we have to change pharmacies. Viagra was a big thing at the health right. Little men coming and want the Viagra.
So one pharmacy was doing a deal that's like that you could buy it there. You had to buy like this milligram pill and you could get it for like 20 bucks. So it's like, so instead of coming to the health right, having to pay to like a copay, he wanted a prescription sent there so he could get like the prescription for less. What was the name of the IV medication you said? Sodium nontropresonative.
Okay. Okay. Now we're getting right ahead into the medication. So the mechanics of blood pressure really come down to two major categories.
You've got the amount of blood flowing out of the heart and the resistance that it has to overcome. The resistance in the arterial system. Those are two big categories that we deal with when we're dealing with high blood pressure and managing it with medication.
So when we're talking about cardiac output, now we're moving into the stage about how we look. And blood pressure medications that we use can affect several of these like the cardiac output we can slow the heart rate down like effect decreasing the speed of the electrical conduction decreases the heart rate from this to this and decreases the amount of squeeze so it's not as it's not squeezing as hard by doing that we're decreasing the cardiac output so is your cardiac output the same as your ejection fraction They're tied together. The same but different.
The ejection fracture, we're looking at what percentage of the heart is pumping out per squeeze. It's usually mid-60s. So they're connected, but slightly different. You'll worry about the...
You'll talk more about the ejection fracture when you get to miss sale and talk about... So we've got decreasing the speed and contractility of the heart. The fluid plays a part in that too. Medications like diuretics were removing fluid from the circulatory system and basically peeing stuff out. So less fluid going back to the heart, less going in means less coming out.
Then on the vascular resistance it comes back to some of the stuff we talked about last week. We're blocking those alpha-1 receptors. So instead of those tight vessels, they're opening up. So it's easier to pump blood out.
The less force that's needed to pump stuff into the arteries, the lower the blood pressure. We'll talk more about vasodilators in there. And we've already talked about the angiotensin.
It's part of the renin-angiotensin-aldosterone system. So it plays a part in the squeeze two of the arteries. So the medications that we typically use affect one or more of these. It's to decrease blood pressure, We slow the heart down so it's pumping less. We remove fluid from circulation so that less going back to the heart means less coming out.
And we open up the arteries so that it's easier for the heart to pump. Those are the main ways that we... Now, I want y'all to smile because every year when Sally starts talking about her cardiac stuff in second year, she says the words preload and afterload and everybody everybody is just like, clutch a pearl.
We have never heard that before in our lives. This is totally new. It has never been mentioned in my presence before. When they did that last year, Sally showed me the picture.
So preload and afterload are going to be big things, cardiac orders in the future. Is it going to be big for this thing? Not big, big. You're not going to have it in order to? It's easy though.
It is super easy. Afterload is the force that the heart has to overcome to pump blood out. To the arteries.
Yeah. Okay. Now, we're going to do a couple things here.
I want you to take a deep breath in, purse your lips, and blow out as hard as you can. I'm seeing stars. Come on.
Okay. Now, ooh, there's that lightheaded feeling. Okay, now take a deep breath in, open your mouth as wide as you can and blow out. Which one was easier?
Okay, so when you decrease afterload, you get that wide open mouth effect. It's easier to get that air out. It's the same thing with blood.
That if those vessels are tight, you get that And if you're blowing hard enough, your cheeks hurt. So by opening up those vessels, it's the same thing as opening up your mouth. You get that air and blood out easier.
Preload is like taking that breath in. Okay? So preload, deep breath. More in the lungs, more to come out.
But if you only take half a breath in, preload is the amount of blood that's coming back to your heart to fill it up. So if you decrease preload, that means you're taking that shallower breath. Less is coming in, so less goes out. So that's important to keep, that's why it's important to keep the blood pressure where it needs to be, so that way you have a proper preload and afterload?
Sort of, yeah. Okay. So if, because if one of them, if like a preload goes too low and you're not getting enough blood back, well, if you're not getting blood back and you go too much on it, then you're going to get that.
So according to the slide, I'll make sure I understand it right. Where it's saying distal. So my distal is my preload and my afterload is my systolic.
Is that what that means? Where are you saying that? Left side where it says preload or your right side, I guess. It says over there under preload, it says volume of blood and ventricles at the end of distal. Oh, diastole.
Yeah, so the systole and diastole. So systole, heart squeezes. Diastole is when your heart's relaxed. Okay.
So it's the amount of blood that's coming back in to fill up the atrium. Basically, it's what's coming back in to fill up the heart. Okay.
So if you don't have, this is not going to be great because I've seen it in my mind. Sure. You guys can't see that.
So let's say this is the heart. Blood is coming back in and it fills it up. If there's a lot of fluid coming back, it's going to get...
So if we decrease the amount of fluid that's coming back, we're only going to get filled up like that. So that's how less coming back equals less going out. Okay.
But like my question is though, is my distal pressure, is that my preload number or does that have nothing to do with it? Preload is the amount of fluid available when the heart's resting. Okay. So it's the amount that's coming back up to the heart.
Gotcha. Do you want like a hot preload? Not for blood pressure issues.
If we're treating high blood pressure, we look at medications that decrease pre-blood. One of the biggest in that category are diuretics. So it makes you pee out fluid.
So it decreases the amount coming back to the high pressure. Pharmacology. Do you all need like a mini break? Absolutely.
All right. I'm going to set the timer for five minutes. So we have a kind of group of first drug options. Some of it, the Sometimes the doctor will look at, or if you tell them it's like you don't want a certain medication for a reason. For example, if you have to work on, you're working in an Amazon factory, okay, and you're not allowed to take any extra breaks, a drug like a thiazide that's going to make you pee very frequently might not, it's like the, I say Amazon because I think that's what they're building down at the road.
So, So they might not let you go to take a pee break every hour and a half even though they call it, like that's a side effect of medicine. So another drug would be an ACE inhibitor or an ARB or calcium channel blockers. Now we have other drug classes but when somebody started it's usually on the window and there are some conditions that or some issues that one is preferred over My brother, bless his heart, he is on a convoluted drug there, hydrochlorothiazide and acetylurethane.
He's out on the road, so he has to stop. He often takes drugs. It's like evil younger brother laughs.
It's just like the way it is. I take, right now I take Dalsart, which is an herb. Its main effect is like opening up the arteries and decreasing afterload. But it also has a minor effect by increasing your output, which they say it's like, oh, it's not really big enough.
That's not a big enough issue to worry about. And I believed that until I forgot to take it one morning and took it in the morning. And I noticed how pronounced that diuretic effect was.
So these medications are probably going to be the ones we see the most? You're going to see these very often. What if you're on, my best friend is on, No, no they work in two different systems So a lot of people who take blood pressure medicine can't be controlled with one medicine and they need multiple Well, the diuretic makes it loose fluid. You pee fluid out with the calcium channel.
You know what the calcium channel is? - Amlodipine. - Amlodipine.
Okay, so that's gonna work by slowing the heart rate down and by causing the blood vessels in the periphery to die. So you're getting three effects, whereas hydrochlorothiazide would only make you pee out the fluid. Now, other medications. A person with other conditions, comorbid conditions, might be starving on another one because of, I wanna say convenience? that older men typically have prostate issues.
The prostate enlarges as you age and you have trouble peeing. Well, one of the medications like Prezosin that blocks alpha-1 receptors, it's going to lower blood pressure by causing the arteries to dilate, but it also relaxes that smooth muscle lining in the prostate. it's easier for a guy to pee.
So if there's a condition like that, then that might be a reason that another medicine that's not typically one of the first line ones is prescribed. Same thing for cardiac issues. One of my nieces works with cardiologists and basically it's like everybody gets put on a bedlocker because they have some type of comorbid cardiac condition. It's like they have heart attacks in the past. So a beta blocker is going to lower blood pressure and it's going to decrease the workload of the heart so that they don't have chest pain with exertion or that they're less likely to have a heart attack because the pumping is harder.
So even though these are the ones we typically see first, if the person does have another medical condition, another thing can be started. Now the big classes, these are the ones we see the most. There are other ones out there, but these are typically what we see.
Now the drug endings. You will see drugs on the board that we do not talk about. The best way to try to remember is by classes. Like the ARVs, SART, CREALs, ACEs, the OSINs, the LAWs, The calcium channel blockers are a little different.
Some of them will end in -dine, some not. Same thing with the vasodilators. They will, they have different endings because they work in different ways. But try to remember the endings will help you in the lung because even though, it's like, I don't talk about enalapril here. Enalapril.
But by in that preal, what was it? A-syngenta. Now, some of the medications have different effects depending on race and gender.
Now, in the first drug choices, let's talk about the races first. There have been articles written that patients who are African American tend not to respond as well to ACE inhibitors for ARBs compared to white patients. So that would not be a great first choice for an actin area. Generic white people, like me, typically have high blood pressure related to higher renin levels. So ACE inhibitors and ARBs, they work in that system.
So those are big choices for me. But the articles also say that African American patients tend to have hypertension issues related to solid retention issues. So for them, it would be a diuretic, like hydrochloric azide, that tells the body to get rid of sodium in the urine.
Calcium channel blockers also are a good first choice for African Americans because it doesn't... dilate the vessels without call it without interacting with the renin-angiotensin system. Now, men versus women. Asin inhibitors.
We intend to have more side effects like the cough. The cough is a side effect that happens pretty often with asin inhibitors just because of where they work. We'll talk about that when we get to the renin-antibody system.
Men have issues with beta blockers because, women too, because it can interfere with men's ability to maintain an erection and it can affect men and women's ability to achieve orgasm. The story I've been telling for years, and I'm hoping this guy does not have any family that would recognize me as being a former co-worker of his, but several years ago there was a guy that started on a beta blocker for blood pressure issues and after a while he did not like that. he was very active in the bedroom with his wife and this was affecting his ability so he stopped taking it which when a patient tells us that what's our typical response what should our response be need to continue it's like it's like um somebody give me a fake name john john it's like um stopping a medication like that it's like you're on it for high blood pressure issues.
It's like you need treatment. So if you can't tolerate the side effects from this one, you shouldn't just stop. You should contact the doctor's office to see if they will prescribe something else, which I think that's why he did and then had a gal player for the next medication they gave him. So he just didn't have any luck at all. So based off the list, he, I mean, just looking at the side effects here, he went from, uh, metopretholol to the, what is that, propranolol?
Oh no, he went, so he went from, it was, I'm not sure if it was propranolol or metoprolol, it was probably metoprolol because that's usually what started and then he was changed to a thiazide diuret. Okay, well my question would be since, did he need the beta blocker or was that just the best option? That's not a typical first start one.
And I didn't want to be all up in his business because I don't get heart issues or something else. He was a very anxious person. And something like propranolol, if that was the one that he was on, then they would use that for anxiety issues because it blocks that sympathetic response. The anxiety is still there, but you don't have the symptoms of it.
So it may have been that one. But he couldn't tolerate it because special time night with the wife was happening less often so he was switched to hydrochloric thiazide which triggered a gout. Is that just like your non-specific beta blockers or is it like beta 1, beta 2? Procranolol is a non-specific one so it's affecting beta 1 and beta 2. the Metoprolol or Metrolon is a bit more specific to Beta-1. Oh, well like, will Beta-1 and Beta-2 both cause ED?
Yes, yeah, they both get that. Both of them have that effect. Now, for women, back to this, here's a big important one right here. That any of the medications that work in the remnant angiotensin-aldosterone system are pretty much contraindicated for prednisone.
They are known to cause So if a woman is having blood pressure issues, hypertension, and she's planning on becoming pregnant, then this needs to switch to another medication that's not going to cause fetal issues. Or if she's taking this and becomes pregnant, it's one of those surprise babies, then it needs to be stopped ASAP. Now, the renin-angiotensin-aldosterone system, this confuses a lot of people.
The way I explained it to the main campus students yesterday is that if we start at the top of this, rhythm and angiotensinogen come together. It's the mommy and daddy. One is made in the liver, the other is made.
They come together and make baby angiotensin 1. Angiotensin 1 is a weak one. It's a weak vasoconstrictor. So it goes to the genome, once it's in the lungs, where it meets the angiotensin converting enzyme, ACE.
It gets buffed up into angiotensin II. Angiotensin II is a very strong vasoconstrictor. So when angiotensin II is circulating in the system, it causes strong arterial vasoconstriction. It also tells its friend in the adrenal glands to start producing aldosterone. Aldosterone tells the body to keep salt and water and kick potassium.
So when we would lower sodium, would the potassium exiting also decrease as well? One of the drugs that when we get to the very end of the system, there are Well, not even hit the drugs that we give in this to decrease blood pressure are going to flip the switch in some way. So most of the medications are going to tell the body or the kidneys to keep potassium and get rid of sodium.
Angiotensin twos will activate the LL train. Yeah. Let's go to this one right here. So right here, this is from the old books. I love this diagram.
What it does is these two forms. Now, different medications would kind of talk about they work in different spots in this system. So a lot of our what we call downstream that there are some direct reading that stop it right here. So it decreases and you intensive one for me. So the next one, one of the most popular is the basic right here is where angiotensin one gets, it has lungs because that's where most of it happens in one.
So by blocking this, we use the ACE inhibitors here. So angiotensin one is created, but it decreases the production of angiotensin two. So angiotensin two is the really strong one. It causes vasoconstriction to happen.
And it also tells the adrenal glands to produce aldosterone. So right here with angiotensin two, we have the ARs, the angiotensin receptor blockers. So right here, the angiotensin II, it's there, but it's blocked.
It can't attach to those receptors. It's similar process to the autonomic receptors, just in a different system. It's the same process, different neighborhood.
So right here, by blocking that, we're getting decreased basal constriction and decreased aldosterone production. Now, aldosterone is the substance that tells the kidneys, hold on to water, hold on to sodium, and kick out potassium. What the drugs here, like the aldosterone blockers, receptor blockers, by blocking that, the kidneys aren't getting that signal.
So they're keeping potassium, getting rid of sodium, getting rid of water. So the drugs that work through here, like the ACEs and ARBs and the direct-to-mint inhibitors, they mainly cause vasoconstriction. That's their primary effect. But the secondary effect is we're decreasing the aldosterone in the system even more.
This is where the potassium sparing diarrhea, that we kind of mentioned in a little bit, So here, we're decreasing afterload as the big part because we're opening up the arteries. And here, we're decreasing preload because we're peeing stuff out. Peeing water out. Okay. Now, repeat that back.
I want you to say the word so you remember. Why is preload decreased? Because the fluid's getting excreted in.
Yeah. Say the word. You're peeing up the fluid so it's not going back to the artery. So we lower the sodium count potassium is the excretions lesson so when we do that our veins are going to open, our vessels are going to open, thus reducing pressure.
Right. Okay, I got you. So the concept is, and I think of it this way because I'm a contractor, the bigger the pipe is, the more volume push I got to have to push through.
Okay. Okay, so here, this is just basically what I said, how they work in the system. So the direct remaining inhibitors, they work at the very beginning. They stop bonding and data from coming together, so angiotensin ones. The acid inhibitors, they block off the doors of the gym.
So angiotensin I can't milk out the trainer ACE. So he doesn't get buffed up to angiotensin II. Since angiotensin II is not there, you don't get the vasoponstriction and you don't get a lot of the aldosterone production.
The arms, angiotensin II is there, but it can't attach to the receptors to tell the vessels to close. And since it can't do anything, you get decreased aldosterone. with the industrial antagonists all of this stuff is all of the stuff is already worked as it's supposed to do any blood pressure but here it's telling the body to lose fluid so we've got the medication like sperm lactone potassium is very dire so that's why your ace and arms are prescribed the most okay yeah ace side effects one of the most common that you see is the cough That happens because where it works in the system, it increases the production of cotton.
Braydecontin is the one you'll hear about the most often. This is not the exact patho, but braydecontin basically irritates the lungs. So you get that cough.
Now I had that cough when I was taking lisinacril. One of the students counted 87 coughs during a lecture one time. So finally I got tired of that and I actually switched to an ARV. And because it doesn't affect, since it happens after the lung part, I don't get the cough.
I get nasal drip cough, but not that irritating trihacky cough. One of the most worrying side effects is hyperkalemia because these tell the body to retain potassium. Anything in the system that's blocking the natural flow is going to make a potassium increase.
So at that point, would we tell our patient or as education, would we tell them to lessen the amount of potassium intake? Okay. Yes.
You have to be very careful with that. This is where you kill somebody with potassium supplements. So on this one, if the person has hypertension and are taking this, then we don't recommend the salt substance because they're high in potassium.
So we would decrease the amount of potassium rich foods. Will we also tell them to watch, let's say they're taking a multivitamin, to watch their vitamin intake as well? Yeah, because a lot of those have, a lot of them have like potassium and calcium and some of the other stuff in them.
So we'd be very careful. We want to watch them like that. Now, when we start affecting potassium levels in the body, one of the most common complaints people get are like achy muscles. So if we'll, we would just basically say it's like, if you start really achy, especially like the big muscles, your legs are cramping or so, then call the office and we'll let the doctor know because we might need to check the potassium level. Now, angioedema is another thing that happens with They can't have them in the PCV.
One of our graduates, she worked in the emergency room and she saw a person with angioedema and she asked him, she said, do you take lisidoprim? I'm like, what's this? I do. I just started on it a couple of weeks ago.
How did you know? And I imagined her doing like the, I am super smart hair clip, and went to the doctor and said, I think this person has angioedema. He looked and said, you're right.
How did you know? I'm like, I learned that in the nurse's room. So I take credit for that. So angioedema is basically swelling in the face, mouth, upper throat.
So it can cause airway issues that it can block the airway. A person's tongue can swell to the point that it blocks things off. Have you looked at the prioritization in the end in that tool?
Packag, any of you? So this was one of the examples of the angioedema causing respiratory issues. So if this happens, they need change from the other medication.
Sometimes they will change it to an ART because it doesn't have the same risk. It can still happen though, but the risk of this. With the eyes, with angioedema, would that be the vessels in the eyes, you see them expanded really big?
Right here. You see big puppy eyes. I tried to make the cat picture here too, but it just made them look all adorable and they didn't look like they were suffering at all. It's like a cat with swollen eyes, swollen tongue. No, it's just like a little cute kitten picture.
It's like that just did not convey the seriousness. So it's not necessarily the eyeball itself. It's actually the area around the eye will be swollen. Yeah.
So you're right. This kid has angioedema around the eye. Now, the tongue and the back of the throat are the more dangerous spots where it can happen because of the pain.
This is here. We have an African American, 52-year-old male, hypertension, started on an AC inhibitor, 10 milligrams. He's got a cough, dizziness, poorly controlled.
He started almost in a pre-roll. several weeks, dry cough, blood pressure is elevated despite adherence to the medication. Okay, so what do we notice?
He's got the side effects of loraprenzolol. We've got the cough which is normal. It's not working.
It's not working. Why is it likely not working? Maybe because it's not a strong enough dose or it could be where it's an ACE inhibitor. ACE inhibitors are not a good first choice for African-American infections unless it's in combination with something else. So African-American infections, remember, typically more due to salt retention issues.
And this isn't going to do anything with that. So you would do a combination drug? It could be a combination drug.
It could be like acinopril and hydrochlorothiazide. Or it could be a calcium channel blocker. Those would be have been better first options for him. ARBs. So again, ARBs work later in the system.
You're still going to get similar side effects except for the cough. There's a risk for hypertension because anytime we're treating to do something, there's a chance they could have an exaggerated effect, especially in the beginning. ACEs and ARBs, or ACEs, let's just say, aces that they're famous for like first dose hypotension person's blood pressure can drop significantly because of the sudden decrease in angiotensin to the body. So we would want to educate the people that's like you might have a very pronounced effect on this. So take your first pill and you're going to bed so you won't be up and active and at risk for falling and you take it Or if you have to take it during the day, make sure that you're not eating.
Be very active. Rise slowly from a sitting position to make sure that you don't get all fuzzy-handed. Let us know if anything happens.
Question on the patho. So we're trying to lower the blood pressure anyway. Would that mean their heart rate would speed up to compensate?
You hit on something important that we'll talk about when we get to some of the other medications. What you're talking about is reflex tachycardia. So, yeah, we'll get there. You're jumping ahead.
Why are you jumping ahead? - Brain's working today, I guess. - Yes. We'll get there. So, reflex tachycardia does happen with several medications.
Oh, and some calcium channel blockers just happen to be that. So, calcium channel blockers work in a couple of ways. The first one, your nitrification. Brand name is Procardia.
It mostly opens up the career. It causes them to die. So by doing that, we're decreasing after life.
It's easier for the heart to come out. A side effect of this is one of the expected ones is edema in the legs. Fluid starts to leak out.
Did you spit pop up? Did you spit a pop up? Jesse, we're talking all about tequila.
You might want to like... I feel like a Catholic right now. Okay, so, um, so noctadapine has no effect in the heart.
Whereas the other two on here do. They're going to slow down the electrical conduction through the heart, changing the pulse rate from fast to slower. They also cause the peripheral arteries to open.
Now, the nifedipine is the one that causes an effect like you mentioned, the reflex tachycardia. Your body likes stuff where it's at. My body decided a while back through genetics or whatever, poor diet, body weight, that my blood pressure should be 150 over 110, just as an example. That's what my body has decided that my blood pressure should be. Other people's bodies decide that their blood pressure would be like 120 over 8 or 110 over 60. So it likes what it's used to.
So if there is a sudden change, like when we give a blood pressure medicine, the body is not smart. It's stubborn. It wants stuff its way. So all it knows is it's like, oh, something just dropped out of my comfort zone.
And I need to fix that. So the way it does is that it speeds up the heart because that's what it's doing. Your arteries have what are called baroreceptors. So when they sense a big drop in blood pressure, then it goes into panic mode.
It's like something's happening. This should not be like this. So I need to fix it.
And since nifedipine doesn't have any effect on the heart, the body's free to speed it up to try to increase cardiac output to increase blood pressure. Nifedipine isn't the only drug that this happens with. It can happen with any of them that affect the arteries and veins, but not the heart.
So diuretics, case inhibitors, the dilators, those are things that can, if they don't affect the heart, the heart's ability to pump, then the body tries to compensate by increasing the pulse rate. Now, after a while, if you're taking blood pressure for a while, the body gets used to the new more. So I'm taking my blood pressure, and my systolic is up from 150s down to 110. So once it's there, then it's going to keep it like that for a while.
Now if I stop taking my blood pressure, different things can happen. It can go back up immediately or it can start trailing back up slowly until it gets back to what it used to like. So that's why we can't just medicate down at one point and then stop.
When we medicate a person down to like a good blood pressure, we still have to keep giving them that blood pressure medicine continuously or the blood pressure's going to start going back up. Is there a point at which, so I know it's important to keep a baseline, so is that why we need to keep a baseline before we start giving medication and then afterward to see where we want to cut that off before the heart basically explodes on itself from beats per minute? No, I'm not sure what you're saying.
So, for instance, before we start giving medication, because we're trying to lower the blood pressure anyway, obviously we don't want the heart beating out of his chest, so... would it be, is there like a cap or we just want to watch and see how many beats they're having per minute versus how much medication we give to make that kind of even out at first? Well, there's what they typically do.
If your heart's thumping too fast for too long, it's going to, it's not going, it causes certain things. You're, if it's, I can't, sorry, I can't, I can't court it. They want to do this thing instead of this. So if it pumps too hard, too long, then you're going to have problems with cardiac's coronary artery circulation.
Because the heart only gets blood when it's relaxing. So if it's pumping too fast, there's going to be less oxygen moving through the heart. It's also going to increase the risk of that muscle buildup. So if they have to have something like that only affects the vessels, they typically will give something to decrease the heart rate, like a beta blocker.
Now, the last two, the rapionylgalcogine, they have similar side effects. They're going to cause swelling, too, because they open up the vessels and fluid just starts to leak out. That's expected.
They're going to slow down something called constipation. It's really more pronounced in the rapid world. All the calcium channel blockers again, there's a risk of hypotension.
So some headaches happen. You'll talk about this in Unit 6. So if we have a blood vessel here, the things that can happen is when you give a calcium channel blocker It doesn't know where it it affects your upper vestibular. It doesn't specifically target the ones in your legs. It just tells them to open and that suddenly open that sudden opening can cause headaches in some people. So that's an expected side effect.
Hopefully it will get better as time goes along, but not guaranteed. Now the dizziness again that ties into the orthostasis. I potentially talk about the fatigue sometimes.
So when you give a blood pressure medicine, you're going to decrease the cardiac output. It's not strange for beta blockers and calcium shot blockers, things that slow the heart down, make you feel tired. It's normal in the beginning.
Again, it's one of those things that should improve over time. But if somebody calls in a panic that they could take in a beta blocker or a draft meal for three or four days and suddenly they feel tired, it's like, that's expected. It should improve the constipation. So at one time I decided that I wanted to try hemoglobin, another calcium channel blocker. I did that.
It did not cause constipation, but it slowed my GI tract down noticeably. I was gassy. I was bloated. It's like my stomach hurt from all the gas.
What medication would I give myself from previous lecture to help move that gas along? Sementra. Sementra.
Now, bradycardia can be a side effect of this. It's one of the ways that the rapamyelitis and tyosin work. It slows the electrical conduction through the heart down. So that's why these two don't cause reflex tachycardia, is they have a part in slowing the heart.
The body might want to increase the speed. It might want to speed the heart up, but it can't because the medicine can't be the thing. I feel like I've talked about syncope in all the spaces a lot.
Now, the heart block. So here, you'll talk about this more in fourth semester with Sally Zell and during the EKG lecture. But there are certain conditions where the electrical pathway through the heart is not working the way it should or it's damaged and you have certain heart blocks. Medications like these that are going to slow the rate down can worsen those and they can become more symptomatic.
And I will save the rest of that for Sally. Now, vasodilators are another part. There are three medications we typically talk about. The hydralazine, the sodium nitroprusside, and minoxidil.
These cause vasodilation in different ways. So it's not directly related to the receptors we've talked about before. It's just they cause vasodilation.
Now, the hydralazine is a pretty common one. So if we are causing vasodilation, it's going to decrease after a while. Now, the side effects that go along with it, one of them seems the fluid retention. So the reason for this is that these can decrease the amount of blood going to the, I'm going to check my spazzy now. It's like I had like this psychic sense that my food has arrived.
It's getting cold. So, it can decrease perfusion to the kidneys. So, when that happens, the kidneys send a signal to try to retain the fluid they can.
And it's free to do that because there's nothing in hydralazine that makes the kidneys keep or excrete fluid. So, again, it's one of those little systems like the reflex tachycardia. The body senses that the blood pressure is dropping, it doesn't know why, so it's trying to fix it the best way it can. So you can get the fluid retention, the reflex tachycardia probably doesn't do anything to slow the heart rate too. The big one that comes along with this is systemic lupus-like reaction.
That should be in your book. You haven't talked about lupus yet, but it's an autoimmune disease where your body starts attacking its own cells. One of the key things that you see with this is what's called a malar rash, the little butterfly rash on the cheeks. Have you ever seen that before?
Yeah. Probably because my mom has lupus. Okay, so does she get like the red inflamed growth? Yeah, it literally does look like a butterfly like that.
Okay, so fake lupus can happen with this. It's not lupus, but it can cause damage. So if you start to see this, then the medication has to be stopped.
Now, hydralazine is not used as often as some of the other medications. Not just because of this. It's because it's the half-life is shorter. It's multiple times a day dosing. So if you have blood pressure issues, would you rather take one pill a day or one three or four times a day?
The once a day is better for compliance and it's more convenient for people. And when you're out working in the real world, convenience is a big thing for patients. The sodium nitroprusside, this is one that we use in hypertensive emergencies. It's given IV and a dose is usually, it's usually started like a very small dose.
It's like 0.3 micrograms per kilogram. So it's a very potent drug. The problem with this, there are a couple of them.
As soon as you start the IV and it starts entering the blood, its effect starts. When you stop it, the event stops. So when they are starting on this in the unit, and they have to be pretty much in a unit for this to be given because they have to monitor it continuously, that you have to start some other blood pressure medicine to keep the blood pressure down.
Because if you just put them on this, get the blood pressure to 120 over 80, and then stop it, transfer it back out to the unit, the blood pressure's gonna shoot right back up to what it was before, 200 over 180. - So it's an on-command. - Yes. It's like, while it's running, it's working through. When you stop it, then it stops. So you start them on this, and then you start them on like a PO medication, like, Which one struck you?
Which drug did you like so far? I just like the word levadolol. No, we're not talking about that. What was it? I like the word levadolol.
Levadolol. Okay, so we'll start on levadolol during, while it's in ministry, and slowly taper down the sodium nitroprusside. Now, this drug speaks to me on a couple of levels. Well, I think you all know I like murdery stuff.
I was raised watching Murder, She Wrote, reading Agatha Christie. The woman loved her poisons. It's like she loves cyanide.
This is one that is given at low doses for a limited period of time because it has cyanide in it. Your body has the ability to process some of that out. But if you give this medication too fast or too long, it overwhelms the body's ability to clear it out.
So a person can become toxic from cyanide poisoning. Just FYI, if you all want to ever just have your own Netflix special, I guess, as a nurse dad. So with that toxicity, let's say they've been on it, and that toxicity...
According to this, would that cause the hypotension, that toxicity, or no? Well, if they're becoming toxic, we've got bigger issues. Okay. The blood pressure dropping.
So hypotension, it's similar in the risk of that happening, like it happens with all the others. When we start meditating for something, it's possible to have it. So, side effects. Now, let me talk about one thing since this is one of the medications we use for hypertensive emergency.
I think your book spells it out pretty good in this section that when you're treating a hypertensive emergency, you have to be careful about how fast you blur in the blood pressure now. That there are some conditions where it's brought down quickly, but in a big chunk of patients, it's brought down slowly. It's not brought from 220 over 150 down to 120 over 80 in 30 minutes.
If you do that, you're going to cause perfusion. It's like I said, when I self-medicated myself, I stood up and my blood pressure dropped down and I had like a, that was a static event. If you do that too quickly, it's going to cause issues with perfusion.
Your brain's not going to get perfused, your kidneys aren't going to get perfused, your heart might not get perfused. So it can cause damage. So it has to be brought down slowly over a period.
I don't remember the specifics, but it's listed in your blood. You can sense my intellect shock state if you do it too fast, and it's not good. Now, minoxidil, honest to gosh, I see this more often than I should in Raleigh General Hospital.
There was a constant fight when I worked with Dr. Aslan, and there was a nephrologist consult that stopped every blood pressure medicine we had and wanted to put them on minoxidil. I don't know if the man owned stocking company or what, but apparently it is good. It's not hard on the kidneys because he prescribed it for everybody. But it's a very potent vasodilator. It's not really seen as a first choice medication just because some of the side effects can be more severe than the other.
The fun side effect for this is what is minoxidil also used for? Hair growth. So one of the side effects that you get with this is hypercoccus, excessive hair growth. It causes fluid retention for the same reason, hydrolyzing does.
It's like the kidney sense that drop in blood pressure, so they try to hold on, they hold on to fluid. The reflex tachycardia, again, this doesn't do anything to affect heart rate. So anything that drops blood pressure using the blood vessels only, you can get reflex tachycardia. diuretics are one of the big ones you're going to see.
Just take a minute and stretch. It's like I'm getting tired so I know you guys are. So diuretics are a The ones you typically see with hypertension are the ones like hydrochloric dyeside, dyeside-type diuretics.
There are other ones that are used less frequently. You have the loop diuretics like the rosamide, and you have these potassium speridine diuretics like squironolactone. For basic blood pressure issues, dyeside diuretics are the primary one. The loop diuretics aren't used as much in hypertension management because it moves a lot of fluid back. The grand name for this is Lasix.
And way back when I was having pharmacology class in nursing school, an instructor said Lasix lasts six hours. So it's six to eight hours, I think. So hydroclothiazide is like one dose a day.
You take it in the morning and it has an effect throughout. Lasix, the effect only lasts for six hours, so you have to take multiple doses a day. And it's not a great choice for management of hypertension because it moves so much fluid.
It's easier for a person to become dehydrated on that than with diet. The potassium and diuretics, they're usually used when a person has another condition. The one I see it the most in is with cirrhosis. So it's not a first choice one. that you usually see the furosemide sprolytol if they have blood pressure and another condition that's being managed.
Now hydrochlorothiazide, since we're telling the kidney to come down fluid, we use electrolytes, lose electrolytes with it too. The big ones we lose, sodium and potassium. Sodium is okay because that helps lower the blood pressure. The potassium is an issue.
So on medications like the hydrochloric thiazide and Lasix and Pluralin that typically need a potassium supplement or to really increase the potassium rich foods. The funny thing about hydrochloric thiazide and thiazide are that there's a specific electrolyte that keeps calcium. It also affects uric acid levels.
like i said it decreases the excretion of uric acid and that's why uh or john from one of the previous jobs got a gout attack trigger you know that should make more sense when you talk about gout but it's going to increase that so so would we want them drained a lot well i mean considering the right fluids but we one thing on a lot of fluids. Here's the problem is that you're giving the medication to decrease the circulating fluid. So if you start drinking more water, you're kind of countering the effect. It's true. So in a person with gout or uric acid issues, this really shouldn't have been something prescribing.
Now, blood sugar levels. Sometimes this will cause people to have excess blood sugar levels to raise. So hyperglycemia is possible. We're going to want to check the blood pressures on this one. They need to be taught how to check blood pressures at home.
They need to know the signs of dehydration. What are some signs of dehydration? Horse chest, skin tumor.
Okay. Dry mouth. Dry mouth.
Dizziness. Decreased output. What should your urinary output be? What happens to your full and plump or sunk?
Plump. Now, right, these side effects. Frequent urination is the expected side effect from this.
So it's best to take this one in the morning. Take it at night. It's going to be torture for them because they'll be up very frequently.
to go to the bathroom. So, always educate them to take these. The dizziness, again, they can have those orthostatic events typically early on in treatment.
So, we always need to teach them that anytime we're missing some blood pressure, we need to make sure that they know what to do and what the signs are that it starts to drop too low. Now, LASIKs. Lasix is a loop diuretic. It is the more potent one of the two when we're looking at thiazides and brosonide. So this is what it calls like really quick, really massive fluid loss.
It's used in conditions like pulmonary edema, ejection, when we want to clear fluid out of the body relatively quickly. So given this IV push, you're going to see urination start within a few minutes. PO, it's usually within an hour that you start to see the symptoms.
You will give this in the hospital as an IV pusher. You have to be very careful about the speed because it can cause ototoxicity. It can damage the auditory nerve if you give it too fast.
The person will have tinnitus for possibly the rest of their lives. So it's given slowly as a push. So the old standard used to be at least one minute per 10 milligrams. So if you have 20 milligrams, you're sitting there doing a push over two minutes.
And you said that could cause, did you say tinnitus? Tinnitus. It'll damage the auditory nerves.
So a person could hear ringing in their ears for possibly a lifetime after that. If it's given, looking at the considerations, why would we you worried so much about the BP or already given it for BP? Oh, it can cause sudden dropping blood pressure. Okay.
So it this moves a lot of fluid really fast so it's possible that a person's blood pressure they could get like a low blood pressure particularly with this just because you lose so much fluid so fast. Okay now We lose electrolytes with this one too. So again, potassium supplement is usually ordered for people who are on Lasix for a long period of time.
Now, you all know the normal potassium level? 3.5. Okay.
So when you start seeing, when you're using things like the first two diabetics, the Lasix and thiazide supplements, it's a risk it'll go low. The spironolactone is the opposite. If it's potassium sparing, it's a risk it'll go high.
What pressure are we talking about there? Dehydration. So the thiazide, potassium, what was the question? The thiazide, that'll drop potassium?
Yeah. Out of the three we're talking about, the thiazide, hydrochlorothiazide, and the aphorosamide, those will drop potassium levels. The spironolactone is the opposite. It'll cause you to go high when we talk about these, except for the daily weights.
So in blood pressure, daily weights is not a big thing that we, we typically don't check daily weights if we're using like Lasix 4, which is rarely done. It's usually for people with a larger diagnosis, like congestive heart failure. Because there's a certain, if you start to gain too much weight, that means you're getting too And you have to adjust for that. You'll talk about that with Sally Sale in the future.
So, the spironolactone. It can be used for hypertension, but it's not really unless there's another condition that goes along with it. Like I said, the one I typically see are people with liver issues like cirrhosis. Now, this is one that works in the renin, angiotensin, and acrostrolisis at the very end of the process.
it blocks aldosterone's ability to latch on to the receptors in the kidneys. So we lose water, we lose sodium, we keep potassium. So it's increasing the risk of hyperkalemia. So we'll see those potassium levels go up.
5.1, 5.2, 5.3, 7.7. What happens when we start seeing elevations? Is it a, oh, we'll worry about that later? Potassium plays a big part in the electrical conduction system in this part.
So if potassium levels start going too high, a person could have a cardiac event. One of the people at the campus yesterday started talking about the EKG and T waves. So I don't think that we saw, we looked at some of the monitors, but we didn't talk a whole lot about the real thing.
But I'm going backwards here, okay? So we have here QRS and then T. So the T is the little bump, like at the very end of the little part you see. If your potassium levels starts to go high, that becomes peaked.
So when your potassium goes up, that T wave goes a little higher than it should. That's one of the things they look at on an electrocardiogram. Just as an aside. There's a lot more they look at on it, but...
If you start to see peak T waves, that's a sign that the passing levels can be too high. You get a bonus point for that. Do you have any friends on the main campus? Somebody here has friends on the main campus. They dark, but not giving names.
So Brandon's the guilty part. I am the one. Okay.
So with this one, the big thing is it's like not used for hypertension alone. It's one of those that you'll use in combination with something else. and you have to be very careful about potassium levels and other medications that might cause potassium retention.
We've talked about the first couple of aids. The last one, the Cytomax. Now, this has anti-androgen effects that go along with it. So it's blocking like male sex hormones.
So in men, you can get effects like gynecomastia in large breast tissue. in women this is also one of the medications they use to treat uh picos polycystic ovarian syndrome does anybody ever does anybody hear that because and you have a relative what is it exactly because polycystic ovarian syndrome okay ask miss williams about that if that's an idea so um they will use that to treat I'll use for a while because it blocks androgens. One of the things that you get from PCOS is like excessive airbrush.
It's like they get the little hairy chins. So what it helps, it helps decrease those. So it's just one of the medications.
Now, drug interactions. ACEs and ARs because they also increase potassium levels. The NSAIDs. So NSAIDs decrease kidney perfusion. Have we talked about this before?
Yes. Okay, so it decreases kidney. So since we're giving a drug to make the person pee, if we're giving something that counters the kidney's abilities to do that, then it's going to blunt the effect of the medication. Digoxin is one that Mrs. Sale will talk to you about in the future.
So it's used during heart failure and some other cardiac conditions. It has a weird connection to potassium. That when potassium goes high, the dioxin goes low. When potassium goes low, the dioxin goes high.
A lot of things we talk about seem to have like that little flip effect. So you'll worry about that more when we pass this sale in the future. So here with spironolactone, we want to decrease all of those things. It's like you love bananas? Okay, you're decreasing the amount of bananas you can eat.
Potatoes, sweet potatoes, same with that. We can decrease the amount of No supplements. No salt supplements with potassium in it.
The urination supplement. You can look at these on your own. But when you want to educate somebody about foods that are high in potassium, so we've got, I don't eat a lot of dry food, but I do eat potatoes, sweet potatoes, spinach on and off. I love the little salsa avocado packs. Coconut water, that just, it's too good to eat.
bananas. So look at this and these are good options for people that are on Lasix, hydrochloric biazide and these are some foods that might be good options for people that are taking Spirulinax. Okay so medication side effects here. Symptoms.
Okay so what is our weak symptom we see here? Which one of these do you think is connected to the most likely connected to the metoprolol? Heart rate, so we've got brain heart rate. That's an expected side effect because this slows the heart rate.
What about fatigue? Fatigue can be? It's a side effect. Now the occasional wheezing. That could be from the asthma.
It's probably the asthma because there's metoprolol effect. Beta 1 or beta 2? Beta 1. Beta 1. So this is if somebody had, if you had to have a beta blocker with asthma, this would be one of the ones more likely to be prescribed. Because it doesn't cause bronchial constriction. So you can look through this with all the students to see what medications might be best for you.
How does that feel? Do you feel okay? It's moved from cart brown water back to trout water.