Alert Any patient with a wound that has lasted more than 8 weeks and who has tried standard wound care and revascularization without improvement should consider hyperbaric oxygen therapy. This treatment may speed healing by allowing more oxygen to get to the wound and may therefore result in fewer amputations.
Keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy, nephropathy, and neuropathy. In type 2 diabetes, blood pressure control as well as smoking cessation reduces the onset and progression of complications, including cardiovascular disease.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Hypertension:
Treatment
(Professional Guide to Diseases (Eighth Edition))
The National Institutes of Health recommend the following approach for treating primary hypertension:
❑ First, help the patient initiate necessary lifestyle modifications, including weight reduction, moderation of alcohol intake, regular physical exercise, reduction of sodium intake, and smoking cessation.
❑ If the patient fails to achieve the desired blood pressure or make significant progress, continue lifestyle modifications and begin drug therapy.
❑ For stage 1 hypertension (systolic [SBP] blood pressure 140 to 159 mm Hg, or diastolic blood pressure [DBP] 90 to 99 mm Hg) in the absence of compelling indications (heart failure, postmyocardial infarction, high coronary disease risk, diabetes, chronic kidney disease, or recurrent stroke prevention), give most patients thiazide-type diuretics. Consider using an angiotensin-converting enzyme (ACE) inhibitor, beta-adrenergic blocker, calcium channel blocker (CCB), angiotensin-receptor blocker (ARB), or a combination.
❑ For stage 2 hypertension (SBP ≥ 160 mm Hg, or DBP ≥ 100 mm Hg) in the absence of compelling indications, give most patients a two-drug combination (usually a thiazide-type diuretic and an ACE inhibitor, ARB, CCB, or beta-adrenergic blocker).
❑ If the patient has one or more compelling indications, base drug treatment on benefits from outcome studies or existing clinical guidelines. Treatment may include the following, depending on indication:
– Heart failure — diuretic, beta-adrenergic blocker, ACE inhibitor, ARB, or aldosterone antagonist
– High coronary disease risk — diuretic, beta-adrenergic blocker, ACE inhibitor, or CCB
– Diabetes — diuretic, beta-adrenergic blocker, ACE inhibitor, or CCB
– Chronic kidney disease — ACE inhibitor or ARB
– Postmyocardial failure — ACE inhibitor, beta-adrenergic blocker, or aldosterone antagonist
– Recurrent stroke prevention — diuretic or ACE inhibitor.
Give other antihypertensive drugs as needed.
❑ If the patient fails to achieve the desired blood pressure, continue lifestyle modifications and optimize drug dosages or add additional drugs until the goal blood pressure is achieved. Also, consider consultation with a hypertension specialist.
Treatment of secondary hypertension focuses on correcting the underlying cause and controlling hypertensive effects.
Typically, hypertensive emergencies require parenteral administration of a vasodilator or an adrenergic inhibitor or oral administration of a selected drug, such as nifedipine, captopril, clonidine, or labetalol, to rapidly reduce blood pressure. The initial goal is to reduce mean arterial blood pressure by no more than 25% (within minutes to hours) then to 160/110 within 2 hours while avoiding excessive falls in blood pressure that can precipitate renal, cerebral, or myocardial ischemia.
Examples of hypertensive emergencies include hypertensive encephalopathy, intracranial hemorrhage, acute left-sided heart failure with pulmonary edema, and dissecting aortic aneurysm. Hypertensive emergencies are also associated with eclampsia or severe gestational hypertension, unstable angina, and acute myocardial infarction.
Hypertension without accompanying symptoms or target-organ disease seldom requires emergency drug therapy.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Pregnancy-induced hypertension:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Therapy for preeclampsia is designed to halt the disorder’s progress — specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown — and to ensure fetal survival. Some physicians advocate the prompt induction of labor, especially if the patient is near term; others follow a more conservative approach. Therapy may include complete bed rest to increase placental perfusion, reduce hypertension, and evaluate response to therapy. Antihypertensive therapy doesn’t alter the potential for developing eclampsia. Diuretics aren’t appropriate during pregnancy.
If the patient’s blood pressure fails to respond to bed rest and sedation and persistently rises above 160/100 mm Hg, or if central nervous system irritability increases, magnesium sulfate may produce general sedation, promote diuresis, and prevent seizures. Cesarean birth or oxytocin induction may be required to terminate the pregnancy.
Emergency treatment of eclamptic seizures consists of immediate administration of magnesium sulfate (I.V. drip), oxygen administration, and electronic fetal monitoring. After the seizures subside and the patient’s condition stabilizes, delivery should proceed with induction of labor or cesarean birth, depending upon the circumstances.
Adequate nutrition, good prenatal care, and control of pre-existing hypertension during pregnancy decrease the incidence and severity of preeclampsia. Early recognition and prompt treatment of preeclampsia can prevent progression to eclampsia.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Hypertensive crisis:
Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))
Nitroprusside, nitroglycerin, diazoxide, hydralazine, methyldopa
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Pulmonary hypertension:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment usually includes oxygen therapy to decrease hypoxemia and resulting pulmonary vascular resistance. It may also include vasodilator therapy (nifedipine, diltiazem, or prostaglandin E). For patients with right-sided heart failure, treatment also includes fluid restriction, cardiac glycosides to increase cardiac output, and diuretics to decrease intravascular volume and extravascular fluid accumulation. Treatment also aims to correct the underlying cause.
Some patients with pulmonary hypertension may be candidates for heart-lung transplantation to improve their chances of survival.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Renovascular hypertension:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Surgery, the treatment of choice, is performed to restore adequate circulation and to control severe hypertension or severely impaired renal function by renal artery bypass, endarterectomy, arterioplasty or, as a last resort, nephrectomy. Balloon catheter renal artery dilation is used in selected cases to correct renal artery stenosis without the risks and morbidity of surgery. Symptomatic measures include antihypertensives, diuretics, and a sodium-restricted diet.
Medications that may be used in an attempt to control blood pressure include diuretics, beta-adrenergic blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and alpha-adrenergic blockers. Diazoxide or nitroprusside may be given in the hospital if symptoms are acute. Response to medications is highly individual and the dosage or specific drug used may need frequent adjustment.
Lifestyle changes may be recommended, including weight, exercise, dietary adjustments, smoking cessation, and avoidance of alcohol. These habits add to the effects of hypertension in causing complications.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Blood pressure increase [Hypertension]:
Patient counseling
(Professional Guide to Signs & Symptoms (Fifth Edition))
Encourage the patient to lose weight, if necessary, and to restrict sodium intake. Suggest that he participate in an exercise or stress management program as well. Then teach the patient how to monitor his blood pressure so that he can evaluate the effectiveness of drug therapy and lifestyle changes. Have him record blood pressure readings and symptoms, and ask him to share this information on his return visits.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Diabetes mellitus:
Treatment
(Handbook of Diseases)
Effective treatment for both types of diabetes normalizes blood glucose and decreases complications.
Type 1 diabetes
Treatment includes insulin replacement, diet, and exercise. Current forms of insulin replacement include single-dose, mixed-dose, split-mixed dose, and multiple-dose regimens. The multiple-dose regimens may use an insulin pump.
Human insulin may be rapid-acting (Regular), intermediate-acting (NPH or Lente), long-acting (Ultralente, Lantus), or a combination of rapid-acting and intermediate-acting (70/30, 75/25, or 50/50 of NPH and Regular).
Clinical tip Insulin Lispro or Novalogue may be used in place of Regular insulin. It’s rapid in onset (15 minutes) and makes waiting to eat after injection unnecessary. It has a short duration of action (4 hours), which decreases between-meal and nocturnal hypoglycemia.
Islet cell or pancreas transplantation is available and requires chronic immunosuppression.
Type 2 diabetes
Patients may require oral antidiabetic drugs to stimulate endogenous insulin production, increase insulin sensitivity at the cellular level, suppress hepatic gluconeogenesis, and delay GI absorption of carbohydrates.
UNDER STUDY: Studies have shown that treatment with a lipase inhibitor (such as orlistat) combined with a low-calorie diet significantly decreases the weight of overweight patients with type 2 diabetes. Patients following this therapy also displayed improvements in glycemic control and cardiovascular risk profile; levels of glycosylated hemoglobin, fasting glucose, and postprandial glucose improved significantly.
Both types
Treatment of both types of diabetes requires a diet planned to meet nutritional needs, to control blood glucose levels, and to reach and maintain appropriate body weight.
For the obese patient with type 2 diabetes, weight reduction is a goal. In type 1, the calorie allotment may be high, depending on growth stage and activity level. For success, the diet must be followed consistently and meals eaten at regular times.
UNDER STUDY: Vitamin E is under investigation for its cellular effects that can possibly reduce the risk of macrovascular disease in patients with type 2 diabetes mellitus. The antioxidant effects of vitamin E were supported, and it was found that, in high doses, vitamin E acts as an anti-inflammatory. It’s postulated that heart disease and stroke risk can be decreased because vitamin E reduces plaque formation at the endothelial level. Vitamin E may also have an effect on the metabolic syndrome that causes diabetes mellitus and may prevent the disease from occurring.
Complications
Treatment of long-term diabetic complications may include transplantation or dialysis for renal failure, photocoagulation for retinopathy, and vascular surgery for large-vessel disease. Meticulous blood glucose control is essential.
The Diabetes Control and Complications Trial has proved that intensive insulin therapy that focuses on keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy (up to 63%), nephropathy (up to 54%), and neuropathy (up to 60%).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Hypertension:
Treatment
(Handbook of Diseases)
Secondary hypertension treatment focuses on correcting the underlying cause and controlling hypertensive effects.
The National Institutes of Health recommend the following approach for treating primary hypertension:
❑ First, help the patient initiate necessary lifestyle modifications, including weight reduction, moderation of alcohol intake, regular physical exercise, reduction of sodium intake, and smoking cessation.
❑ If the patient fails to achieve the desired blood pressure or make significant progress, continue lifestyle modifications and begin drug therapy.
❑ For stage 1 hypertension (systolic [SBP] blood pressure 140 to 159 mm Hg, or diastolic blood pressure [DBP] 90 to 99 mm Hg) in the absence of compelling indications (heart failure, postmyocardial infarction, high coronary disease risk, diabetes, chronic kidney disease, or recurrent stroke prevention), give most patients thiazide-type diuretics. Consider using an angioten-sin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), beta-adrenergic blocker (BB), calcium channel blocker (CCB), or a combination.
❑ For stage 2 hypertension (SBP ≥ 60 mm Hg, or DBP ≥ 100 mm Hg) in the absence of compelling indications, give most patients a two-drug combination (usually a thiazide-type diuretic and an ACEI, ARB, BB, or CCB).
❑ If the patient has one or more compelling indications, base drug treatment on benefits from outcome studies or existing clinical guidelines. Treatment may include the following, depending on indication:
❑ Heart failure — diuretic, BB, ACEI, ARB, or aldosterone antagonist
❑ Post myocardial infarction — BB, ACEI, or aldosterone antagonist
❑ High coronary disease risk — diuretic, BB, ACEI, or CCB
❑ Diabetes — diuretic, BB, ACEI, ARB, or CCB
❑ Chronic kidney disease — ACEI or ARB
❑ Recurrent stroke prevention — diuretic or ACEI.
Give other antihypertensive drugs as needed.
❑ If the patient fails to achieve the desired blood pressure, continue lifestyle modifications and optimize drug dosages or add additional drugs until the goal blood pressure is achieved. Also, consider consultation with a hypertension specialist.
UNDER STUDY: Studies have shown that omega-3 fatty acids used in the treatment of hypertension significantly reduce total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels and lower systolic and diastolic blood pressure.
Clinical tip The treatment for renal artery stenosis includes the use of ACE inhibitors and renal artery stents.
Hypertensive emergencies
Examples of hypertensive emergencies include hypertensive encephalopathy, intracranial hemorrhage, acute left-sided heart failure with pulmonary edema, and dissecting aortic aneurysm. Hypertensive emergencies are also associated with eclampsia and severe pregnancy-induced hypertension, unstable angina, and acute MI.
Typically, hypertensive emergencies require parenteral administration of a vasodilator or an adrenergic inhibitor or oral administration of a selected drug, such as nifedipine, captopril, clonidine, or labetalol, to rapidly reduce blood pressure.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Hypertension, pregnancy-induced:
Treatment
(Handbook of Diseases)
Adequate nutrition, good prenatal care, and control of preexisting hypertension with hydralazine during pregnancy decrease the incidence and severity of preeclampsia. Early recognition and prompt treatment of preeclampsia can prevent progression to eclampsia.
Therapy for preeclampsia is designed to halt the disorder’s progress — specifically, the early effects of eclampsia, such as seizures, residual hypertension, and renal shutdown — and to ensure fetal survival. Some physicians advocate the prompt induction of labor, especially if the patient is near term; others follow a more conservative approach.
Conservative measures
Therapy may include sedatives, such as phenobarbital, along with complete bed rest to relieve anxiety, reduce hypertension, and evaluate response to therapy. If renal function remains adequate, a high-protein, low-sodium, low-carbohydrate diet with increased fluid intake is recommended.
If blood pressure fails to respond to bed rest and sedation and persistently rises above 160/100 mm Hg or if CNS irritability increases, magnesium sulfate may produce general sedation, promote diuresis, reduce blood pressure, and prevent seizures.
Cesarean delivery
If these measures fail to improve the patient’s condition or if fetal life is endangered (as determined by stress or nonstress tests), cesarean delivery or oxytocin induction may be required to terminate the pregnancy.
Treatment for seizures
Emergency treatment of eclamptic seizures consists of immediate administration of I.V. diazepam, followed by magnesium sulfate (I.V. drip), oxygen administration, and electronic fetal monitoring. After the patient’s condition stabilizes, a cesarean delivery may be performed.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Pulmonary hypertension:
Treatment
(Handbook of Diseases)
Appropriate treatment usually includes oxygen therapy to decrease hypoxemia and resulting pulmonary vascular resistance. For patients with right-sided heart failure, treatment also includes fluid restriction, cardiac glycosides to increase cardiac output, and diuretics to decrease intravascular volume and extravascular fluid accumulation. An important goal of treatment is correction of the underlying cause.
CLINICAL TIP: Patients with primary pulmonary hypertension usually respond to epoprostenol (PGI2) as a continuous home infusion.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Blood pressure, increased [Hypertension]:
Nursing considerations
(Nursing: Interpreting Signs and Symptoms)
▪ If routine screening detects elevated blood pressure, prepare the patient for routine blood tests, urinalysis, and depending on the suspected cause of the increased blood pressure, radiographic studies, especially of the kidneys.
▪ Administer antihypertensives, as ordered, and evaluate their effect.
Patient teaching
▪ Explain the importance of regular blood pressure monitoring and keeping follow-up appointments.
▪ Explain how to take prescribed antihypertensives correctly and adverse effects that should be reported.
▪ Instruct the patient not to discontinue medications without contacting the practitioner.
▪ Emphasize the importance of weight loss and regular exercise.
▪ Explain the need for sodium restriction.
▪ Discuss stress management.
▪ Discuss ways of reducing other risk factors for coronary artery disease, such as smoking cessation and lowering elevated cholesterol levels.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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