Introduction: – This article was written by Linda Bern, Monica Brandt, Nwanneka Mubela, Uzanma Asoyne, Tracey Fisher, Yolanda Shaver and Carla Serrill. It has been peer reviewed being written for scholarship. The copyright is assigned to MEDSURG Nursing: Journal of Adult Health. It is the Property of Janniette Publications Inc.
Article focus: – The focus of this article is to inform an audience about a research conducted to determine the accuracy of a contemporary automated device, noninvasive blood pressure device in hospitalized medial patients (Bern et.al, 2007)
Methodology: – The researchers adopted a scientific research technique by retrieving a sample form the potential population of patients. A comparative analysis approach was applied to explain findings.
Instruments and Materials: – For this study the researchers employed physical material as the instruments. They were the manual Sphynomanometer and Automatic BP.
Procedure and Data collection techniques: – Data were collected by first dividing the sample into two groups. The first group had their BP taken with the manual BP apparatus then the automated. Subsequently, the second group had theirs taken by the automated BP apparatus, first. After that the manual device was used. There were a total of 126 patients selected with seven trained staff assigned to taking the blood pressure over a period of six months.
Interpretation and data analysis: – The researchers choose to interpret, summarize and display their findings using descriptive statistics as a quantitative measurement and comparative analysis in the qualitative capacity. Tables were also used in assisting of the display of data.
Results-Clinical implications: – It was revealed that there were significant differences in systolic values between Blood Pressure taken by the automated device and ones conducted manually.
Critique
Once the aims, methodology, procedures, instrumentation, data collection techniques, interpretation and results have been completed there are now questions to be asked form a scientific methodology perspective.
The sampled population: – When carefully examined, the selection can create some degree of bias to the study and conclusions drawn. The focus was to determine accuracy of measurements between two devices used among inpatients. Accuracy of measurement has then become the independent variable. The two devices and the inpatients have become the dependant variables. Why is the study then limited to inpatients? There could be a great difference in the degree of accuracy among inpatients and out patients as well. What good it does to diagnosis and medicine if there is information available only on inpatients? A bias exists in this sense of arriving at a valid conclusion.
Data collection technique: – Seven trained nurses were used to take the readings on 126 in patients over a six month period. Patients had to qualify having had some specific arm circumference measurements. This then means that significant numbers of the population were excluded using this data collection technique.
What about the patients who were not hospitalized at that time with the arm measurement criteria? They again have been excluded from the assessment. Why the inpatient population then was divided? That was not fully explained because scientific studies which carry controls do not utilize identical populations. Here is where the control of out patients would have bee applicable.
Conclusions: – When utilizing descriptive statistics it has been concluded that there were differences in systolic measurements. This was observed from among the groups that were sampled for the study. These conclusions were arrived at after the devices had been applied. There were no significant changes in the diastolic pressure. It is still left to be explained where the determination in accuracy of measurement utilizing these two devices lay.
Reference
Bern et.al (2007). Differences in Blood Pressure values obtained with Automated and Manual Methods in Medical inpatients. MEDSURG Nursing: Journal of Adult Health, 4(1), 31-45.
Jerry is an office assistant allowed to call in approved refills. While Dr. William was away, a patient called the office asking him to help with a prescription of Valium. As a result, Jerry is faced with an ethical dilemma. He has the medical ethics and the law to guard his conduct as a licensed nurse.
Qualification
He is not authorized to give prescriptions. He can only do that with a direct order from Dr. William. This can only happen if he decides to inform the doctor of the situation at the office. Another reason could be a well defined standing order indicating that the patient needed refill from the records of the patient. The law does not allow medical assistants to prescribe medicines or do refills (Aristotle and Smith, 2006). Only the required medical practitioners in the respective fields are allowed to do so.
The case of high blood pressure
There would be no difference even with a case of high blood pressure. The patient may be in dire need of the drug but the best solution is to involve qualified personnel to do the prescription. It is only in politics where the end justifies the means. In medicine, the uncertainties involved are always dangerous hence practitioners are not allowed to use ‘any’ means. There is always a better solution to every medical problem, even emergencies. However, the need for a standing order to practice such duties can be considered (Fremgen, 2006). If the doctor decides to order Jerry to do the refill upon hearing the case, then he would have no choice but to succumb. Even if the patient daily relies on the medicine, it would be inappropriate for Jerry to do the refill because the law does not allow him.
Respondent superior
The doctrine of respondent superior can be applied in a case such as Jerry’s where a medical assistant is faced with a challenge and has decided to prescribe a drug to a patient. The doctrine makes Dr. William liable for any mistake done by his follower. It is believed that that all medical practitioners can only perform to some limit hence the higher level medical officers have a responsibility to supervise the activities of their seniors and the juniors should respond to that by following orders (Aristotle and Smith, 2006). Due to such standards, Jerry is a responsibility of his doctor. However, William can only take the responsibility when Jerry acts within his jurisdiction. Jerry is not allowed to prescribe any medicine therefore such a behavior will be considered as practicing medicine without a license which is unethical and illegal because it can expose the patient to danger.
Advice
My advice to him is to contact the doctor so as to know what to do. It does not necessarily mean that he must talk to Dr. Williams; he can refer the situation to other qualified medical officer in order to avoid falling into temptations that can cause him both his freedom and his license. Filling the prescription will mean a breach of the law which may also affect Dr. William. The patient mentioned that he got the prescription from the doctor because of the relation they had. Jerry should stay away from such vices to guard his career. He should not follow all that Dr. William does because the law may protect him but his conscience may not let him be at peace.
Issues in decision making
Jerry is in a decision dilemma is affected by laws regarding his scope (Fremgen, 2006). Different states for instance practice different laws. If he was in California where medical assistants are allowed to conduct examinations to patients and administer drugs, he would easily make a swift decision. However, such state laws only allow qualified medical officers to prescribe medicine. Jerry is also affected by the fact that he is an APN hence his work must always be supervised by a registered physician or nurse. Apart from the legal requirements, it is also unethical to perform duties that require higher medical responsibility when qualifications do not allow for it. Jerry might want to avoid mistakes of omission that could harm the patient who can decide to sue the entire institution.
Problem solving methods
Before making any ethical decision, one should identify the problem (Aristotle and Smith, 2006). Once the problem is identified, it will be easy to know the best decision to make in order to find a solution. Making a decision involves weighing alternative actions therefore it is also very important to list all the alternatives and choose the ethical ones in order of their effectiveness. There is a slight difference between ethics and laws; however, laws originate from ethics hence one should consider doing what is within the law when making decisions.
Conclusion
Even with the absence of the doctor, Jerry’s duties are still limited.The fact that he is the only one in the office does not mean he should take the position of Dr. Williams. He still remains the medical assistant.
References
Aristotle,., & Smith, J. A. (2006). Ethics. Teddington, Middlesex: Echo Library.
Fremgen, B. F. (2006). Medical law and ethics. Upper Saddle River, N.J: Pearson/Prentice Hall.
Normal response of the heart rate and blood pressure when one changes from supine position to sitting and standing
The normal heart rate is in is 80-100 beats per minute, and the normal BP is 120/80. From sitting to standing, blood pressure decreases initially, as a result of the pooling of blood in the venous circulation. This results in decreased venous return and, thus, decreased stroke volume. This leads to decreased cardiac output and, hence, lowers blood pressure. The blood pressure should not fall by greater than 20mmHg systolic and greater than 10mmHg diastolic. This is due to the baroreceptor reflex, whereby, stretch receptors in the carotid artery are not stimulated resulting in less stimulation of the cardiovascular center. This results in decreased vagal activity and increased sympathetic stimulation of the heart. Stimulation of beta 2 adrenergic receptors results in an increased rate of contraction of the heart muscles, thereby, increasing heart rate. Stimulation of alpha 1 receptors results in constriction of the arteries, increasing peripheral vascular resistance and, consequently, blood pressure.
List of dysfunctional locations in the cardiovascular system that could affect the baroreceptor reflex
The carotid sinus
The heart such as in cardiomyopathy
The blood vessels
Decreased blood oxygen-carrying capacity such as, in anemia and decreased blood volume.
The cardiovascular center in medulla oblongata.
The aortic arch body
The afferent nerves (glossopharyngeal).
The efferent nerve (vagus).
The receptors such as beta 2, M2 and M3
Neurotransmitter deficiency
A lymphatic system such as, in obstructed vessels
Autonomic nervous system
Preganglionic fibers
Ganglia
Postganglionic fibers
Receptors on effector cells
Role of the muscarinic system in blood pressure regulation
M3 receptors are located in vascular endothelium, smooth muscle and in glands. They are G-coupled receptors. Their stimulation results in activation of the phospholipase C-inositol triphosphate cascade. This results in vasodilatation. This reduces total peripheral resistance (TPR) and lowers the blood pressure because (Blood pressure) BP= Cardiac output (CO) × TPR.
Blockade of the M3 receptors did not result in a change in the heart rate. This is abnormal because stimulation of M3 receptors should cause vasodilatation lowering TPR and, hence, lowering BP. This should be followed by reflex tachycardia if the baroreceptor mechanism is intact. Blockade of the vagus nerve will result in uninhibited sympathetic stimulation of the sinoatrial node. This causes tachycardia due to sympathetic stimulation.
Account for these results
The heart rate did not change, because the sympathetic system is not working properly. The muscarinic blockade should have resulted in tachycardia. This is because the blockade caused vasodilatation and according to the formula mean arterial pressure (MAP) = CO × TPR. The total peripheral resistance is determined by vessel caliber and blood viscosity. In this case, the diameter of the vessel is increased lowering the TPR. This lowers the MAP. Increased heart rate should occur to restore the blood pressure.
Role of the sympathetic nervous system in blood pressure regulation
The sympathetic response is the most important control of blood pressure. It is especially important in rapid minute-to-minute control of BP. It is involved in baroreflex, chemoreflex, and medullary ischemic response. The sympathetic fibers arise from the thoracolumbar (T1-T12 & L1-L3) region of the spinal cord. The nerve endings release and act through catecholamines. They stimulate alpha1 and beta2 receptors found on the target organs.
The sympathetic system stimulates most vessels to constrict but dilates vessels in the cardiac and skeletal muscle. The receptors are found on all vessels except capillaries. In baroreflex, a decrease in BP results in increased sympathetic response leading to increased heart rate and vasoconstriction, therefore, elevating the blood pressure. The chemoreflex refers to the sympathetic response to hypoxemia, hypercapnia and acidosis. The chemoreceptors are located in the carotid and aortic bodies.
Medullary ischaemic response refers to the sympathetic response that results when the medulla is subjected to ischaemia. Stress, anger and arousal can stimulate an increase in blood pressure mediated through the sympathetic nervous system.
This is a normal response. Catecholamines are the neurotransmitters that mediate action in sympathetic activity. They bind to alpha1 receptors on vascular endothelium and on beta2 receptors in the heart. This results in vasoconstriction increased rate and strength of contractility respectively. This results in increased heart rate and blood pressure.
Account for the result
The result is due to sympathetic activity increasing heart rate and total peripheral vascular resistance. According to BP=CO × TPR. Whereby CO= heart rate (HR) × Stroke volume. Increased heart rate increases cardiac output. This, together with the increased TPR results in increased blood pressure.
The system affected
The patient’s problem lies in the sympathetic nervous system. The patient suffers from orthostatic hypotension. The results demonstrate that the cardiovascular effectors (sinoatrial node, ventricular myocardium, vascular smooth muscle) receive their normal tonic inputs over the autonomic pathways. The SA node is responding normally to its parasympathetic and sympathetic inputs (normal resting HR of 70beats/min changes appropriately when the sympathetic input is stimulated). The myocardium and blood vessels respond normally to increased levels of catecholamines.
It is, subsequently, hypothesized that the patient’s problem lies either between the baroreceptors and the central nervous (either the baroreceptors do not respond normally, or the signal does not reach the brainstem) or within the brain itself (if the information from the baroreceptors is not processed correctly). In either case, the patient’s heart rate does not increase upon standing up.
The major clinical problems for patients with orthostatic hypotension are dizziness and fainting in the erect position.
Compensatory mechanisms of the cardiovascular system upon consumption of seawater
Seawater differs from blood in composition and concentration. Blood is constituted mostly by water; the rest is made up of cells. Electrolytes such as sodium and potassium are found in the plasma. Nutrients such as amino acids and glucose are also found in plasma. The cells are made up of white blood cells, red blood cells and platelets. Sea water on the other hand is made up of water salt, iodides and potassium. It can also contain toxins such as lead causing heavy metal poisoning if taken in large quantities.
The major problem caused by consuming large quantities of sea water lies in its increased sodium concentration which is about 3.5%. This is about three times the sodium concentration in blood which is about 0.9%. When the body is subjected to this large concentration, there is osmotic pulling of fluid from the intracellular to the extracellular compartment. This leads to dehydration of cells and eventually cell death if the situation is not corrected.
The increased intravascular volume increases the work load of the heart since, there is increased venous return. The end diastolic volume increases and according to Starling’s law, there is increased stretching of the muscle fibers and increased stroke volume. The net result is increased cardiac output and, therefore, increased mean arterial pressure. This means that there is development of hypertension in a heart that is already deprived of water. There increased rate of contraction means that there is reduced perfusion of the heart as the heart is perfused during diastole. Cardiomegally results in the long run, as the heart muscles hypertrophy in order to meet the demands of pumping more fluid. This compounds the already existing problem of lack of cardiac perfusion, as the number of cells has now increased. In the long run there is decompensation according to the Starling’s law of the heart, and heart failure develops.
Drinking sea water, especially by people out at sea, should be discouraged. This is because it does not serve to hydrate the body; on the contrary, it only increases thirst. The kidneys function to remove the excessive sodium from the body by increasing sodium losses. The loss in sodium leads to increased water loss as the water is osmotically pulled into the lumen of the tubules. This leads to hypovolemia and the RAAS system is activated. Then angiotensin II produced stimulates thirst, causes vasoconstriction and stimulates the synthesis of aldosterone. This hormone stimulates the reabsorption of sodium, and the vicious cycle begins again. The net result is hypertension as the total peripheral vascular resistance increases. The compensatory mechanisms of the cardiovascular system fail in the long run and the end result is, death.
How starvation alters capillary exchange and causes edema
Capillary exchange is determined by the Starling forces. They include capillary hydrostatic pressure, interstitial hydrostatic pressure, plasma colloid osmotic pressure and interstitial colloid osmotic pressure. The plasma colloid osmotic pressure is contributed by the plasma proteins and is usually about 28mmHg. The capillary hydrostatic pressure opposes plasma oncotic pressure and is about 30mmHg at the arterial end and 10mmHg at the venous end. The interstitial colloid osmotic pressure is due to plasma proteins that have leaked into the interstitium. It pulls fluid into the interstitium opposing the capillary hydrostatic pressure and is about 8 mmHg. The interstitial fluid hydrostatic pressure opposes capillary hydrostatic pressure and is about 3mmHg. The net inward force is 7mmhg while net outward force is about 13mmHg. This means that there is a difference of 6mmHg allowing fluid to filter out of the capillaries and supply tissues with nutrients. The fluid is reabsorbed at the venous end back into the blood vessels but some is left behind and drains into the lymphatic system.
Starvation results in a wide variety of biochemical changes in the body which result in breakdown of body stores to provide glucose to meet the metabolic requirements of various tissues. The catabolism of proteins in particular has significant effect on microfiltration at the capillary level. Low protein level lowers the plasma colloid pressure. This increases the net outward force and increases the fluid that leaks out. Increased interstitial fluid leads to pitting edema. The effect of this is to reduce the blood volume. Hypovolemia results in compensatory mechanisms of the cardiovascular system. There is increased heart rate in order to meet the needs of the body. The kidneys increase the reabsortion of sodium under the influence of aldosterone whose release is stimulated by the rennin angiotensin aldosterone system.
Starvation leads to hypoprotenemia that results from breakdown of proteins into amino acids that are utilized for gluconeogenesis. Chief among the vital proteins is albumin, which is an essential contributor to oncotic pressure, not to mention, it is a carrier protein for substances such as heme. Proteins are vital for formation of immunoglobulins, and for contributing to plasma colloid pressure that opposes the hydrostatic pressure. The resulting imbalance of starling forces causes fluid to leak out of capillaries and causes edema. This can be treated using diuretics and a high protein diet.
To ensure that learners are provided with a sufficient range of opportunities for learning, one must control the quality of the academic materials constantly. The current education materials used are outdated and thus need to be updated so that they can reflect the latest perspectives on the issue under analysis. To explore the new hypertension guidelines that have been tightened for patients to familiarize themselves with.
Justification of the Proposed Updated Educational Materials
Previously, patients with low blood pressure rates would not have been registered as under a threat of developing the condition in question. However, with the recent advanced in healthcare technology, opportunities for more accurate diagnosing have emerged. The American Heart Association College of Cardiology 2017 created new rules that reduced the number of high blood pressure diagnoses to 130/80 (mm Hg) (“Reading the new blood,” 2021). Previously, the guidelines had been set as “140/90 mm Hg” for individuals below the age of 65 years and 150/80 mm Hg for those above 65 years (“Reading the new blood,” 2021). This means that 70% to 79% of men above 55 years are currently considered hypertensive (“Reading the new blood,” 2021). Therefore, a lot of men who previously were healthy now have high blood pressure.
There are changes in the new guidelines different from the previous ones. These changes will help people address the problem of hypertension and other accompanying illnesses, such as stroke and heart attack, earlier. Namely, no new recommendations are offered for young and elderly people above 65 years (“Reading the new blood,” 2021). The main reason is that the study examined everyone irrespective of their age. Moreover, there was no group division either above or below a certain age. Therefore, the new study redefined new categories of hypertension.
Currently, some individuals that are considered hypertensive, specifically, people with 120 to 129 systolic and less than diastolic 130 to 139 systolic, now have stage 2 hypertension (“Reading the new blood,” 2021). Additionally, a reading of more than 140/90 mm Hg is a confirmation of Stage 2 hypertension. Moreover, any measurement beyond 180/120 mm Hg is termed critical (“Reading the new blood,” 2021). Finally, hypertension measurement, along with the use of home blood pressure monitors, is highly recommended daily.
Reference
Reading the new blood pressure guidelines. (2021). Harvard Health. Web.
PROBLEM STATEMENT: The patient, a 57-year-old Hispanic male presented to the office with the chief complaint of “high blood pressure.” Reports having headaches in the morning, which make him tired throughout the day, and sleep apnea. These symptoms are complemented by heavy snoring and the lack of pain except for the headaches (behind the eyes), which are becoming more frequent (2-3 times per week) and last for a couple of hours. The fatigue started about six months ago, and the symptoms are treated by Ibuprofen 800 mg TID, 2-3x/week. The patient reports little exercise (walking the dog), smoking, and unhealthy eating patterns, and he is positive for a family history of diabetes mellitus and heart attacks.
Assessment: Headaches alongside high blood pressure can be symptoms of various conditions related to the impaired functioning of organs. First, they increase the risk of heart disease, attacks, and strokes, thereby adding to the patient’s family history of these issues (Watson, 2020). Second, these problems contribute to the probability of emerging issues with his eyes or, more specifically, hypertensive retinopathy, even though they have not been reported yet (Seltman, 2020). Moreover, this condition is frequently neglected by patients due to the lack of evident signs at the initial stages (Seltman, 2020). Therefore, the risks correspond to the situation under consideration and should be timely eliminated by further examination.
Primary Diagnosis and ICD-10 code: Other secondary hypertension, unspecified, I15. 8.
Differential Diagnoses
Pseudo-Resistant Hypertension – is a common cause of hypertension alongside headaches. It is important to distinguish between the factors triggering the emergence of this condition, which is seemingly unaffected by medication, supplements, or diet (“Pseudo-resistant hypertension,” n.d.). It should be controlled by managing the smoking and unhealthy eating habits of the patient.
Hypertensive Retinopathy – This diagnosis was not confirmed during a routine eye exam, but it is vital to consider the risks of the development of this condition in the future (Seltman, 2020). The lasting fatigue might result in this complication and cause vision problems, considering the fact that the experienced pain is similar to the one of this issue.
Obstructive Sleep Apnea – This problem was confirmed during the examination, and it includes most symptoms experienced by the patient. They are daytime sleepiness and fatigue, loud snoring, and morning headaches adversely affecting the overall well-being of the person.
Additional laboratory and diagnostic tests
Fasting blood glucose, total cholesterol, and HDL cholesterol.
Fluorescein angiography.
Polysomnography, AHI.
Consults: Referral to an ophthalmologist for further evaluation and regular examinations to trace the development of the condition (hypertensive retinopathy). Referral to a cardiologist for evaluating the risks of cardiovascular diseases resulting from the current issues and family history (Huang et al., 2017).
Nonpharmacological: Healthy diet (avoid consuming too much salt), recommendations to stop smoking, regular visits to the hospital in order to monitor the condition and its development, and exercise (“Pseudo-resistant hypertension,” n.d.).
Health Promotion: The patient will start to engage in light exercise several times a week. He will also cut back on his salt intake and smoking, and eat healthier food instead of fast food and snacks. These measures will help reduce cardiovascular risks, lose weight, and maintain a good condition through healthy habits and limited consumption of some substances. They should be complemented by regular health screening, especially visits ophthalmologists to exclude the probability of vision impairment.
Patient education: The patient will be taught about the possible consequences of the neglect of hypertension as well as the revealed conditions (obstructive sleep apnea, pseudo-resistant hypertension) and their management. The education will also include the side effects of medication and recommended changes in his lifestyle.
Disposition/follow-up instructions: Meet up with a cardiologist in 48 hours. Meet up with an ophthalmologist in 72 hours.
References
Huang, Y., Huang, W., Mai, W., Cai, X., An, D., Liu, Z., Huang, H., Zeng, J., Hu, Y., & Xu, D. (2017). White-coat hypertension is a risk factor for cardiovascular diseases and total mortality. Journal of Hypertension, 35(4), 677-688. Web.
The article entitled “Body of Evidence in Favor of Adopting 130/80 mm Hg as New Blood Pressure Cut-Off for All the Hypertensive Disorders of Pregnancy” aims to develop new clinical guidelines for assessing the health state of pregnant women who run the risks of developing hypertension. The article suggests that adopting the 130/80 mm Hg as a new blood pressure cut-off would allow reducing the risks of maternal and infant mortality associated with higher blood pressure (Sisti & Williams, 2019). The article is clinically significant and has a practical application, as the use of new standards will allow for intervention at earlier stages to save lives and avert complications.
The evidence presented in the article might change my practice in the sense that I would be more attentive in measuring pregnant women’s blood pressure and making a decision on whether to intervene. I believe that I would be guided by new practices for medical intervention and adopt 130/80 mm Hg as a new blood pressure cut-off remembering the mortality risks. Based on the article, I would recommend changing the existing guidelines to a new standard of 130/80 mm Hg. Thus, the pressure of 130/80 would be a new cut-off for medical intervention. The other changes in my practice would include more frequent measuring of blood pressure in hypesthesia-prone pregnant women since the risk of missing a critical state is very high. I would also recommend my patients measure their blood pressure regularly and address me if it is above the new 130/80 mm Hg cut-off. I believe the given measures will help to reduce the maternal and infant mortality rates caused by hypertension in pregnant women.
Sedative drugs in patients are used in ventilated Patients to reduce anxiety and also to reduce instability of the cardiovascular to maintain ventilator synchrony in the patient. Propofol is a commonly used drug in sedation but this drug has analgesic properties that are used to control pain in ventilated patients. The problem with this kind of drug is that it is very addictive when it is used over some time to the ventilated patient and this can bring other problems in the patient like respiratory depression and the patient always find it difficult to exuberate.
Sleep is very important for terminally ill patients because it facilitates quick healing to patients and this is why medical personnel will use sedatives to ventilated patients so that the patient can achieve the right balance in sleep because patients who are having enough sleep will recover quickly.
The use of sedation in patients who are in the ICU is commonly used to promote sleep and reduce the anxiety which sometimes is found in these patients and this will ultimately optimize the care that is given to these patients, the, most commonly used type of drug in the ICU is midazolam and lorazepam. Continued usage of these two drugs will cause over sedation and will cause the patient to develop pneumonia and this can lead to death it is not diagnosed earlier. “Sometimes oversedation of midazolam and lorazepam will cause the patient not recovering quickly and this will lead the patient to overstay in the hospital or the ICU” (Parrillo 2001).
“Benzodiazepines (BNZs) is a commonly used type of drug in sedation for ventilated patients” (Leikin 2007). This type of drug usually interacts with the body-specific receptors and is part of gamma-aminobutyric acid. This type of drug will depend on the body of the patient because the effect of this particular drug can be reversed by an antagonist This type of drug is safe if it is safely used but when it is associated with alcohol which is usually used in cirrhotic patients it will depress the respiratory center and the effect of this will induce apnea in the terminally ill patient. “The other effect of this type of a drug, as it was observed in other patients is that it caused depression in patients” (Mohr 2004). “The depression has been brought about by direct effects on hemodynamics in addition to indirect effect when it blocks ‘adrenergic drive’ in the patient” (Lachmann 2007).
Propofol is an extreme lipophilic drug and it is used generally for terminal patients to induce and maintain anesthesia inpatient. This type of drug was recently allowed to be used as a sedative in the I.C.U. the main purpose of using this type of drug in terminally ill patients is because it can dissolve fats emulsion in the patient body, an example of that fat which is found in the patient body is glycerol. Propofol has a quick response and this will prompt the patent to arousal after a single dose. This type of drug metabolism can be extracted by the kidneys. Some problems are being associated with this drug cause it causes transient elevation to the patients and to the extent it will cause allergic reactions to the patient. his type of drug in the terminally ill patient will cause cardiovascular and respiratory depression effect in the patient and sometimes it may affect the heart rate of the patient. “In some incidents, this type of drug has brought infectious complications to patients and this has been brought about by contamination by fat emulsion which is found in the patient body” (Hogarth 2008).
Etomidate is this type of drug used to induce anesthesia to a ventilated patient, this kind of drug has shown some advantages when applied as a sedative to patients who are in ICU and is usually applied in emergency cases such as endotracheal and cardioversion procedures. This type of drug will produce hypnosis in patients and the patient will start to have nausea and the ventilated patient will feel like vomiting, it can cause seizures to ventilated patient. When this drug is mostly used in a ventilated patient it increases the mortality of the patient and this is a result of the suppression of adrenal steroidogenesis which is found in the human body.
Ketamine is a derivative of phencyclidine and the patient being administered with this drug will have anesthesia, and this is caused by the interactions between the drug and the neurotransmitter glutamic acid and this will be found in the limbic system. In this state is where the patient will the advantage of this type of drug is that it can be eliminated by the kidneys and has minimal respiratory depression which can be experienced in ventilated patients. The disadvantage of this type of drug is that it will increase the heart rate of the patient and also the blood pressure of the patient will increase. To some extend ketamine increases salivation and produces muscle movement in the patient body. “but the most worry doctors have when they use this type of drug is that the patient will hallucinate and delirium that why this type of drug is rarely used for patients who are in the ICU” (Barash 2009).
Reference List
Barash, P.G. (2009). Clinical Anesthesia. London: Lippincott Williams & Wilkins.
Hogarth, D.K. (2008). Critical care medicine: just the facts. London: McGraw-Hill Professional.
Lachmann, B. (2007). Mechanical Ventilation: Clinical Applications and Pathophysiology.London: Elsevier Health Sciences.
Leikin, J.B. (2007). Poisoning and toxicology handbook. New York: Informa Health Care.
Mohr, J. P. (2004). Stroke: pathophysiology, diagnosis, and management. London: Elsevier Health Sciences.
Parrillo, J.E. (2001). Critical care medicine: principles of diagnosis and management in the adult. London: Elsevier Health Sciences.
Today’s paper was about assessing blood pressure using a blood pressure gauge. The procedure was divided into two steps: preparation and measurement. In the first step, I need to calm the patient to ensure they are okay to get the procedure. I first learned how to give the patient’s body and hands the correct position. The hand should be placed palm up, and a roller should be placed under the hand.
The second stage was the measurement, where I evaluated the data and recorded them on a sheet. First, I placed the cuff of the tonometer on the patient’s shoulder so that my finger could pass comfortably between the cuff and the skin. I was lucky enough to locate the location of the pulsation on the elbow immediately. Having secured the place, I hooked up the tonometer and began gradually pumping air. The goal of this step is for the pulsation to disappear, after which I need to slowly open the valve and decrease the movement in the cuff. This was the most difficult because observing the pressure at the first and second tones was also necessary. After I got all the data, I wrote them down on a dynamic observation sheet.
The Senses
A while ago, I thought it was an easy procedure, as I understood its importance and the process. However, in practice, I experienced the excitement and responsibility of knowing that these measurements would directly influence the future diagnosis and prescription of medications. I was concerned that my actions could lead to mistakes and tried to do everything carefully, but I was still worried. After this assignment, I pondered why I experienced such excitement (my hands were sweating). Probably it was the lack of experience because I would not have been able to do everything quickly and reliably in a responsible situation. I need to practice more to develop confidence in my actions.
Evaluation
I think it was a positive experience: the demonstration of measuring BP was clear and understandable, but I still failed. The first and second attempts to measure blood pressure were unsuccessful, but I came close to a good result the third time.
Event Analysis
During the demonstration of the BP measurement technique, I carefully observed. I had read about the systolic and diastolic pressures the day before, so I had an idea of what each tone needed to be properly listened to. However, it turned out to be more difficult in practice: it took me several attempts before I could distinguish the tones. My excitement did not allow me to capture the moment of that muffled sound well. I understood the importance of measuring, but unfortunately, I was unprepared. If I had watched a few video tutorials beforehand and practiced my pronunciation, I would have had a better attempt. For example, I did not manage to open the flap easily: it was difficult because the wheel was stiff, and I could not do two things at once. Finally, I lacked stamina because I was frustrated after the first attempt and became even more worried.
Conclusion
Now I would like to summarize this class on BP measurement: it was a great experience that showed me my pros and cons. First, I want to mention the complexity of the technical process: the need to observe the pulse, listen to the tones and turn the valve wheel. Secondly, it was the emotional preparation: I was so anxious that my hands were sweating, and the wheel would not budge on me in any way. The test subject was also nervous because my excitement made me not pay attention to him. Although I had theoretical training and observed the demonstration measurement, I did not have enough to complete the session. Nevertheless, I am glad that I was able to try the blood pressure measurement three times. Now I know better how to lead next time because I will consider my mistakes.
Action Plan
I want to make the most of my theoretical potential and improve my pressure measurement skills. I will do this with my little plan of action to improve my professionalism and stress tolerance and emotional preparedness.
I will try to address at what point the excitement about the procedure begins. Stein and Hollen note that the level of stress in such a procedure is normal, but I think I can find a way to reduce it (Stein & Hollen, 2020). To do this, I plan to refer to material on psychological training for nurses to identify the causes of my anxiety and figure out how to cope with stress.
I will be working on raising my stress tolerance. In particular, psychology classes can be a great way to sort out my problem. Also, my older colleagues can help me: I want to ask them for a demonstration to find out what and how they feel during the procedure.
Finally, I plan to devote more time to learning the technicalities of the procedure. Maybe I’ll rent a tonometer and try to practice with my fellow students. I need to take the time to learn how to screw and open the valve properly, how to distinguish tones, and how to monitor the heart rate.
Reference
Stein, L. & Hollen, C. J. (2020). Concept-based clinical nursing skills. Fundamental to advanced. Elsevier Health Sciences.
Cardiac output is calculated as the sum of stroke volume and heart rate and expressed in liters per minute. The most typical definition of HR is how many times it beats in a minute. Systolic volume (SV) is the amount of blood expelled during each heartbeat or ventricular contraction. End-diastolic volume, also known as EDV, is the amount of blood that fills the heart at the end of diastole but cannot all be expelled during systole. Several things simultaneously impact heart rate (HR) and SV. Humans typically have a heart rate range of 5–6 L/min while at rest to over 35 L/min while exercising (Kelly et al., 2012). The other main predictor of cardiac output is SV, which is likewise influenced by some variables.
Preload, distensibility, and afterload affect how much blood is expelled during each beat. Preload is the collective term for the causes of passive muscle contractions in the muscles during rest. The volume of blood in the ventricles just before systole, or end-diastolic ventricular volume, determines preload. More significant end-diastolic blood flow volumes boost the heart’s ability to stretch its muscles passively. The Frank-Starling law of the heart, which is a result of this, causes the ventricles to contract more forcefully (Kelly et al., 2012). The strength of myocyte tension, also known as inotropy, is referred to as contractility.
The effect of cardiac output on blood pressure can be explained further using examples. The first instance is when the cardiac output is high, following increased heart contractility and the blood pressure gets elevated. This elevation is due to the direct proportionality between cardiac out and blood pressure. The second instance is in increased dromotrope, meaning the nervous conduction between the sinus node and atrioventricular node is increased.
Increased dromotrope results in raised cardiac output, which heightens blood pressure (Kelly et al., 2012). On the other hand, blood pressure can be reduced by reducing the cardiac out. For example, when the heart rate or stroke volume is reduced through activation of the parasympathetic nervous system, the cardiac output lowers, causing a decline in blood pressure. Additionally, if the rate of nervous conduction between the sinus node and atrioventricular node, which promotes heart contraction is reduced, is reduced, the cardiac output lowers, reducing the overall blood pressure.
Peripheral Vascular Resistance
Peripheral vascular resistance is a circulatory system resistance that affects the heart’s ability to pump blood and regulate blood pressure. SVR rises as a result of vasoconstriction, the tightening of blood vessels. Vasodilation causes blood vessels to widen, which lowers SVR. Pulmonary vascular resistance is the term used to describe resistance found inside the pulmonary vasculature (PVR). Vascular resistance decreases in situations like shock, which results in reduced organ perfusion and organ dysfunction (Kelly et al., 2012). Because metabolites locally mediate peripheral arterial resistance and regionally on a neuro-hormonal level, alterations in many different factors may affect peripheral vascular resistance.
At the level of the arterioles, the central control of the peripheral vascular resistance takes place. Distinct neural and hormonal cues cause the arterioles to dilate and contract. Norepinephrine hormone attaches to the smooth muscle cells of the vascular via binding to an alpha-1 receptor, Gq protein, during an adrenergic response. This leads to a rise in GTP in the cell, which stimulates phospholipase C and produces IP3 (Kelly et al., 2012). The discharge of the calcium that has been held intracellularly as free calcium is signaled by IP3.
Similar to cardiac output, the effect of peripheral resistance can be explained using examples. In the first instance, metabolites such as carbon dioxide accumulate in tissues, especially after strenuous exercises. These metabolites cause arterials to vasodilate to promote their removal from the tissue, thereby reducing blood pressure. Conversely, a lack of metabolites or other vasodilating factors causes the arterial walls to contract, reducing the diameter of the lumen, which increases peripheral resistance and thus raises blood pressure (Kelly et al., 2012). Vasoconstriction increases peripheral resistance while vasodilation reduces it, which in turn raises and lowers blood pressure respectively.
Reference
Kelly A. Y., James A. W., & Peter D. (2012). Anatomy and physiology (1st ed.). OpenStax.
Normal blood pressure is a vital component for the normal functioning of the organism. High blood pressure (BP) is a major risk factor for coronary heart disease, stroke, and other illnesses, as well as morbidity and early death (Kjeldsen, 2018). The reasons for high blood pressure are complicated and linked to a variety of environmental and hereditary variables (Chang et al., 2018). Obesity is one such recognized and researched risk factor (Chu et al., 2018). Body mass index (BMI), a broad indicator of obesity, has previously been shown to be a predictor of high blood pressure (Nurdiantami et al., 2018). An increasing body of research shows that key indicators of obesity, such as waist and hip circumferences, the waist-to-hip ratio (WHR), and the waist-to-height ratio (WHtR), are also linked to blood pressure (Luzi, 2021). The results of several research that have already looked at the relationship between various measures of central and overall obesity and BP have been mixed (Rodgers & Gibbons, 2020). According to certain research, waist size and blood pressure are connected more closely than BMI (Fu et al, 2018). Others, however, disagreed, demonstrating that BMI was a greater predictor of blood pressure than waist circumference (Tebar et al., 2018).
Additionally, Western individuals have been used in the majority of the current investigations. Asian and Western populations have different genetic profiles and BMI-based obesity assessment standards (Fu et al., 2018). It may be possible to learn more about the relationship between blood pressure and various indicators of overall or central obesity by conducting research with a limited number of adult men and women who reside in Hong Kong. This may not only assist in guiding public health policies for the prevention of high blood pressure and associated cardiovascular disease, but it may also give important information on this subject for global cardiovascular disease research.
The current research examined cross-sectional data on a small group of 38 adults, including 27 females and 11 males were examined. The age of the participants was not recorded for privacy protection. This group of people is part-time students and has already undergone a 2-year sedentary, Zoom class study due to the pandemic. This report aims to study the relationship between general and central adiposity vs. blood pressure.
Materials & Methods
Main adiposity variables, either directly measured or derived, were assessed. They included gender (male and female), normal and infrared stadiometer measures, weight, waist-to-height ratio, waist and hip circumference, waist-to-hip ratio, bioelectrical impedance analysis, and blood pressure. Participants were wearing light clothes and no shoes. Weight was measured to the nearest 0.1 kg using a body composition analyzer (TANITA-TBF-521; Tanita Corporation). Waist circumference and hip circumference were measured to the nearest 0.1 cm using a soft non-stretchable tape. Body fat percentage was estimated to be fat weight by the Tanita body composition analyzer. Multiple linear regression has been applied to estimate the effects on systolic blood pressure (SBP) of general adiposity (body mass index, body fat percentage, weight) and central adiposity (waist circumference, hip circumference, waist-hip ratio).
Results
Among the included participants, the overall mean BMI was 21.18 kg/m2, with no one participant having a BMI higher than 30 kg/m2. The mean BMI for males is 22.17 kg/m2, while for females, it is 20.78 kg/m2. In most cases, a higher body mass index in both men and women was associated with higher blood pressure. Measurement of blood pressure in men generally showed higher results than in women. A similar trend applies to the waist-to-height. People with a higher WHtR often had higher blood pressure than people with a lower WHtR, but the difference is less significant than in the case of body mass index. In men, this relationship is much less than in women. Waist-to-hip ratio was the least associated with changes in blood pressure. Bioelectrical impedance analysis also showed no significant relationship with blood pressure.
Discussion
In this cross-sectional study of 38 adults, body mass index turned out to be the strongest predictor of blood pressure in both men and women. Among the widely used clinical measures of adiposity, waist-to-height was the next strongest predictor of high blood pressure and was largely consistent with BMI. WHR was a relatively weak predictor in the selected group. The results of this study are consistent with previous studies and confirm that BMI is a stronger predictor of high blood pressure, but differ from those stating that WHR waist height ratio was a stronger predictor of blood pressure than BMI. The reasons for these discrepancies are complex, but this study is much larger than any previous studies and uses measured blood pressure rather than a history of hypertension. These differences are not that large, and given the small sample size, this may be due to randomness or differences in levels not large enough to cause confusion.
It is also worth considering that most of the other studies were conducted with Western participants. Therefore the insignificance of the effect of WHR on blood pressure may be due to genetic differences and differences. In addition, the sample consisted of students who have been studying remotely for several years due to the COVID-19 pandemic and related lockdowns. An unaccustomed lifestyle can be reflected in various measurements of volume, as a decrease in physical activity could lead to loss of muscle mass (Saxton et al., 2019). It is unclear whether these data are sufficient to stress the association between blood pressure and their measures because very few research participants were fat. It’s also likely that the degree of this association is not biologically universal but instead varies regionally or over time, for instance as a result of interactions with other environmental variables like nutrition or genetic risk factors for either blood pressure or obesity (Maltoni et al., 2021). The results of the current study demonstrate that central obesity is a less significant predictor of blood pressure than overall obesity, and their relationship with blood pressure may be mostly or entirely because of their close relationship to measures of overall obesity.
Weight-for-height was a reliable predictor, but without using weight-for-height tables again, it is difficult to use this variable in clinical practice. However, each of the indications supplemented the other with some independent prediction data (Fowokan, 2019). These findings demonstrate that adipose tissue, in general, rather than simply that located around the abdomen or specifically in the intra-abdominal area, can contribute to elevated blood pressure (He et al., 2019). This may be a counterargument to the theory that adiposity primarily raises blood pressure through physical kidney compression or systemic inflammation and oxidative stress, which are highly dependent on the quantity of intra-abdominal fat (Hall et al., 2019). High blood pressure may instead be brought on by other theories that are mostly independent of intra-abdominal fat, such as adipose tissue malfunction and sympathetic nervous system activation (Valenzuela et al., 2021).
Conclusion
The best predictor of blood pressure in both men and women was found to be body mass index. The second best predictor of high blood pressure among the commonly used clinical measures of adiposity was waist-to-height, which was essentially consistent with BMI. WHR performed poorly as a predictor in the chosen group. The findings of this study differ from those claiming that waist height ratio (WHR) was a better predictor of blood pressure than BMI, but they are in line with other studies in that they demonstrate that BMI is a greater predictor of high blood pressure. Suppose BMI is a particularly effective predictor of blood pressure. In that case, the capacity of BMI and WC to predict the risk of CVD may also change among communities and over time, as may be seen in Western nations as diabetes becomes more common increases. However, the typical arterial pressure falls as people get older. These theories should be tested by large prospective cohort studies that are now being conducted in a variety of populations (Ramírez Manent et al., 2022). There may also be a need for more research on the association of BIA with elevated blood pressure, as only one Tanita analyzer was used. A study with several analyzers from different manufacturers would have given more accurate results and made it possible to establish such a relationship. In addition, the sample was quite small and uneven in terms of gender. Increasing the number of participants could help to reveal clearer patterns in the ratio of different measurements to blood pressure.
Fowokan, A. (2019). Elevated blood pressure and hypertension in South Asian Children: A mixed-methods analysis exploring associated factors and behavioural influences. Simon Fraser University.