Nursing Care for Hypertension......

Nursing can be a lot to take into sometimes. You have to study hundreds of diseases and pick out the most appropriate nursing actions to address them. But how do you do that when you have so much to learn? For cases such as hypertension, for example. Here’s a mnemonic trick that would help you remember the interventions needed and things to consider for hypertension.

When hypertensive, remember: DIURETIC

D -daily weight

If the patient is hypertensive or even suspected to be, then his/her weight must be monitored. He/she must be weighed daily. Indicators for risk of hypertension include obesity, abdominal obesity and weight gain.Weight gain was associated with increased risk of developing hypertension.On the other hand, weight-loss can lead to a significant drop in blood pressure.

I-Intake and Output

Intake and output of the patient must also be kept closely monitored. Sodium balance is precisely regulated by intake and output.High salt intake increases extracellular volume (ECV), blood volume, and cardiac output resulting in elevation of blood pressure. Normal blood pressure are attained by increased glomerular filtration and decreased sodium reabsorption. In some individuals, the kidneys have difficulty in excreting sodium, so the equilibrium is achieved at the expense of elevated blood pressure. At times, the sodium balance must be achieved via dialysis and ultrafiltration.

U-Urine Output

When BP is low, renal blood flow drops. This stimulates renin and angiotensin production by the kidney. Angiotensin is converted to angiotensin II in the lung. This is controlled by angiotensin-converting enzyme. Angiotensin II is a vasoconstrictor – which will increase SVR. Angiotensin II also stimulates the adrenal cortex to produce aldosterone. Aldosterone causes sodium and water to be retained by the kidney. This will increase the extra cellular fluid (ECF) volume and therefore the circulating blood volume. This is also supported by antidiuretic hormone (vasopressin) which is produced by the hypothalamus and released by the posterior pituitary in response to angiotensin II. Angiotensin II also stimulates thirst, leading to increased fluid intake.

R-Response of B/P

A person’s blood pressure is not fixed as it rises and falls throughout the day in response to what that person is doing and what is happening around him/her. It’s important that the BP be monitored so as to know whether it is responding appropriately to your interventions, or to modify the treatment regimen.

E-Electrolytes

Dietary choices, even the amount of electrolytes you consume, can influence the blood pressure. These electrolytes such as sodium and potassium play a major role in regulating a person’s blood pressure.One of the functions of electrolytes is the balance of fluid in and around your cells. Electrolytes partially break down in water to form an ion. When this occurs, they influence where the fluids inside your body go. Sodium boosts water retention, leading to excess fluid in blood vessels and higher blood pressure.

TI-Transient Ischemic Episodes (TIA)

A transient ischemic attack (TIA) occurs when blood flow to a part of the brain stops for a brief time.High blood pressure is the main risk for TIAs and stroke.

C-Complications: 4 Cs (CAD, CRF, CHF, CVA)

You also have to remember that if left untreated, hypertension can cause certain complications. Over time this extra pressure can increase your risk of a heart attack, stroke and kidney disease.High blood pressure can cause many different diseases of the heart and blood vessels (medically known as cardiovascular diseases) and can also damage the small blood vessels in your kidneys and stop them from working properly.

Sources:

• http://www.obesityaction.org/educational-resources/resource-articles-2/obesity-related-diseases/hypertension-and-obesity-how-weight-loss-affects-hypertension
• http://www.patient.co.uk/education/hypertension
• http://www.ncbi.nlm.nih.gov/pubmed/19090863
• http://www.livestrong.com/article/434371-do-electrolytes-cause-high-blood-pressure/

Related Nursing Articles

1. Pathophysiology of Hypertension Hypertension (high blood pressure) is a disease of vascular regulation resulting from malfunction of arterial pressure control mechanisms (central nervous system, rennin-angiotensinaldosterone system, extracellular fluid volume.) the cause is unknown,......
2. Nursing Care Plan – Hypertension Hypertension refers to a state where a person’s blood pressure remains at an elevated level at all times. This condition is formally known as arterial hypertension and is popularly called......
3. Nursing Care Plan – Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia) Preeclampsia is a common problem during pregnancy. The condition — sometimes referred to as pregnancy-induced hypertension — is defined by high blood pressure and excess protein in the urine after......
4. Pathoyphysiology of Pregnancy Induced Hypertension (PIH)Preeclampsia is a characterized, by vsospasms, changes in the coagulation system, and disturbances in systems related to volume and BP control. Vasospasms results from an increased sensitivity to circulating pressors,......
5. Pulmonary Hypertension Pulmonary Hypertension is a condition wherein the systolic pulmonary artery pressure exceeds 30mm Hg or the mean pulmonary artery pressure exceeds 25 mm Hg. Unlike blood pressure which can be......

Rapid Algorithm Review Acute Coronary Syndrome....

Cardiovascular Medications

Code Blue

Tips to keep your Brain Fit....

 Exercise—Physically active people can reduce their risk of dementia by 30 to 40 percent. Weight Training—Studies have shown that resistance training can increase brain growth factors, which protect nerve cells.

 Learn Something New—Challenging your brain does in fact increase the number of brain cells and the connections between them. 

Relax—Regular, chronic stress can lead to impaired memory because it floods your brain with cortisol.

 Go Greek—Eating a diet rich in fish, vegetables, fruits, nuts and beans (otherwise known as a Mediterranean diet) has been shown to reduce Alzheimer’s risk by 34 to 48 percent in Columbia University studies. 

Spice It Up— Many herbs and spices are high in antioxidants, which may help build brainpower. Set a Goal—Having a clear path or mission in life can reduce your chances of developing Alzheimer's disease. 

Socialize—People who need people, well, they may be protected against dementia because social interaction provides emotional and mental stimulation. 

Reduce Other Risk Factors—Many chronic health conditions, such as diabetes, obesity and hypertension, have been linked with an increased risk of dementia. 

Take a Vitamin—Declines in digestive acids or as a result of medication interference can inhibit your absorption of some of the nutrients you need from foods, particularly B12, which can affect your brain’s vitality. Incorporate some or all of these tips into your daily life and you will be doing your part to keep your mind sharp and your brain active long into your golden years.....

More Info about the Heart.....

How Does It Work?

The heart is located under the rib cage, to the left of the breastbone (sternum) and between the lungs. Your heart is an amazing organ. Shaped like an upside-down pear, this fist-sized powerhouse pumps five or six quarts of blood each minute to all parts of your body.

Outside the Heart

Looking at the outside of the heart, you can see the heart is made of muscle. The strong muscular walls contract (squeeze), pumping blood to the arteries.
The major blood vessels that enter the heart include:

• aorta
• superior vena cava
• inferior vena cava
• pulmonary artery takes oxygen-poor blood from the heart to the lungs
• pulmonary vein -- brings oxygen-rich blood from the lungs to the heart
• the coronary arteries.

Inside the heart

The heart is a four-chambered, hollow organ.

Get a larger view

It is divided into the left and right side by a muscular wall called the septum. The right and left sides of the heart are further divided into:

• two atria - top chambers, which receive blood from the veins and
• two ventricles - bottom chambers, which pump blood into the arteries

The atria and ventricles work together, contracting and relaxing to pump blood out of the heart.

The normal aortic valve

As blood leaves each chamber of the heart, it passes through a valve. There are four heart valves within the heart:

• mitral valve
• tricuspid valve
• aortic valve
• pulmonic valve (also called pulmonary valve)

The tricuspid and mitral valves lie between the atria and ventricles. The aortic and pulmonic valves lie between the ventricles and the major blood vessels leaving the heart.
The heart valves work the same way as one-way valves in the plumbing of your home, preventing blood from flowing in the wrong direction.

The normal mitral valve

Get a larger view

Each valve has a set of flaps, called leaflets or cusps. The mitral valve has two leaflets; the others have three. The leaflets are attached to and supported by a ring of tough, fibrous tissue called the annulus. The annulus helps to maintain the proper shape of the valve.
The leaflets of the mitral and tricuspid valve are also supported by tough, fibrous strings called chordae tendineae. These are similar to the strings supporting a parachute. The chordae tendineae extend from the valve leaflets to small muscles, called papillary muscles, which are part of the inside walls of the ventricles

The atria and ventricles work together, alternately contracting and relaxing to pump blood through your heart. The electrical system of your heart is the power source that makes this possible.

The heart's electrical system

Your heartbeat is triggered by electrical impulses that travel down a special pathway through your heart:

1. SA node (sinoatrial node) – known as the heart’s natural pacemaker
   The impulse starts in a small bundle of specialized cells located in the right atrium, called the SA node. The electrical activity spreads through the walls of the atria and causes them to contract. This forces blood into the ventricles.
   The SA node sets the rate and rhythm of your heartbeat. Normal heart rhythm is often called normal sinus rhythm because the SA (sinus) node fires regularly.
2. AV node (atrioventricular node)
   The AV node is a cluster of cells in the center of the heart between the atria and ventricles, and acts like a gate that slows the electrical signal before it enters the ventricles. This delay gives the atria time to contract before the ventricles do.
3. His-Purkinje Network
   This pathway of fibers sends the impulse to the muscular walls of the ventricles and causes them to contract. This forces blood out of the heart to the lungs and body.
4. The SA node fires another impulse and the cycle begins again.

At rest, a normal heart beats around 50 to 99 times a minute. Exercise, emotions, fever and some medications can cause your heart to beat faster, sometimes to well over 100 beats per minute.

How fast does the normal heart beat?

How fast the heart beats depends on the body's need for oxygen-rich blood. At rest, the SA node causes your heart to beat about 50 to 100 times each minute. During activity or excitement, your body needs more oxygen-rich blood; the heart rate rises to well over 100 beats per minute.
Medications and some medical conditions may affect how fast your heart-rate is at rest and with exercise.

How do you know how fast your heart is beating?

You can tell how fast your heart is beating (your heart rate) by feeling your pulse. Your heart-rate is the amount of times your heart beats in one minute.
You will need a watch with a second hand.

Place your index and middle finger of your hand on the inner wrist of the other arm, just below the base of the thumb.
You should feel a tapping or pulsing against your fingers.
Count the number of taps you feel in 10 seconds.
Multiply that number by 6 to find out your heart-rate for one minute:
Pulse in 10 seconds x 6 = ____ beats per minute (your heart-rate)
When feeling your pulse, you can also tell if your heart rhythm is regular or not.

• Learn about abnormal heart rhythms

Print out a diagram of the Electrical System of the Heart

The right and left sides of the heart work together

Right Side

Blood enters the heart through two large veins, the inferior and superior vena cava, emptying oxygen-poor blood from the body into the right atrium.

Left Side

The pulmonary vein empties oxygen-rich blood, from the lungs into the left atrium.

Atrial contraction

Right Side

Blood flows from your right atrium into your right ventricle through the open tricuspid valve. When the ventricles are full, the tricuspid valve shuts. This prevents blood from flowing backward into the atria while the ventricles contract (squeeze).

Left Side

Blood flows from your left atrium into your left ventricle through the open mitral valve. When the ventricles are full, the mitral valve shuts. This prevents blood from flowing backward into the atria while the ventricles contract (squeeze).

Ventricular contraction

Oxygen and carbon dioxide travels to and from tiny air sacs in the lungs, through the walls of the capillaries, into the blood.

Right Side

Blood leaves the heart through the pulmonic valve, into the pulmonary artery and to the lungs.

Left Side

Blood leaves the heart through the aortic valve, into the aorta and to the body. This pattern is repeated, causing blood to flow continuously to the heart, lungs and body.

How does blood flow through your lungs?

Once blood travels through the pulmonic valve, it enters your lungs. This is called the pulmonary circulation. From your pulmonic valve, blood travels to the pulmonary artery to tiny capillary vessels in the lungs. Here, oxygen travels from the tiny air sacs in the lungs, through the walls of the capillaries, into the blood. At the same time, carbon dioxide, a waste product of metabolism, passes from the blood into the air sacs. Carbon dioxide leaves the body when you exhale. Once the blood is purified and oxygenated, it travels back to the left atrium through the pulmonary veins.

The heart receives its own supply of blood from the coronary arteries. Two major coronary arteries branch off from the aorta near the point where the aorta and the left ventricle meet. These arteries and their branches supply all parts of the heart muscle with blood.

Right Coronary Artery (RCA)

The right coronary artery branches into:

• Right marginal artery
• Posterior descending artery

The right coronary artery supplies:

• right atrium
• right ventricle
• bottom portion of both ventricles and back of the septum

The main portion of the right coronary artery provides blood to the right side of the heart, which pumps blood to the lungs. The rest of the right coronary artery and its main branch, the posterior descending artery, together with the branches of the circumflex artery, run across the surface of the heart's underside, supplying the bottom portion of the left ventricle and back of the septum.

Left Main Coronary Artery (also called the left main trunk)

The left main coronary artery branches into:

• Circumflex artery
• Left Anterior Descending artery (LAD)

The left coronary arteries supply:

• Circumflex artery - supplies blood to the left atrium, side and back of the left ventricle
• Left Anterior Descending artery (LAD) - supplies the front and bottom of the left ventricle and the front of the septum

What is collateral circulation?

Collateral circulation is a network of tiny blood vessels, and, under normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active. This allows blood to flow around the blocked artery to another artery nearby or to the same artery past the blockage, protecting the heart tissue from injury.

• Learn more about coronary artery disease 
•  
• 
  There are four valves within your heart. They are the mitral, tricuspid, aortic and pulmonic valve.
  The mitral valve and tricuspid valve lie between the atria (upper heart chambers) and the ventricles (lower heart chambers). The aortic valve and pulmonic valve lie between the ventricles and the major blood vessels leaving the heart.
  As blood leaves each chamber of the heart, it passes through a valve. Your heart valves make sure that blood flows in only one direction through your heart.
  

  A Closer Look at the Valves

  
  

  Mitral Valve Mouse-over image to see the mitral valve open.
  
  

  Aortic Valve Mouse-over image to see the aortic valve open.
  The valve is made of strong, thin pieces or flaps of tissue called leaflets.
  The leaflets are attached to and supported by a ring of tough fibrous tissue called the annulus. The annulus helps to provide support and maintain the proper shape of the valve.
  The valve leaflets can be compared to doors opening and closing. While the annulus functions as the door frame.
  The leaflets of the mitral and tricuspid valve are also supported by tough, fibrous strings called chordae tendineae. These are similar to the strings supporting a parachute. The chordae tendineae extend from the valve leaflets to small muscles, called papillary muscles, which are part of the inside walls of the ventricles. The chordae tendineae and papillary muscles keep the leaflets stable against any backward flow of blood.
  

  How Valves Work

  The right and left sides of the heart work together to pump blood throughout the whole body. The four heart valves make sure that blood always flows freely in a forward direction and that there is no backward leakage.
  
  
  

  1. Blood flows from your right and left atria into your ventricles through the open mitral and tricuspid valves.
  
  

  2. When the ventricles are full, the mitral and tricuspid valves shut. This prevents blood from flowing backward into the atria while the ventricles contract (squeeze).
  
  

  3. As the ventricles begin to contract, the pulmonic and aortic valves are forced open and blood is pumped out of the ventricles through the open valves into the pulmonary artery toward the lungs, and the aorta, to the body.
  
  

  4. When the ventricles finish contracting and begin to relax, the aortic and pulmonic valves snap shut. These valves prevent blood from flowing back into the ventricles.
  This pattern is repeated, causing blood to flow continuously to the heart, lungs and body.
• Learn more about valve disease

• Your system of blood vessels -- arteries, veins and capillaries -- is over 60,000 miles long. That's long enough to go around the world more than twice!
• The adult heart pumps about 5 quarts of blood each minute - approximately 2,000 gallons of blood each day - throughout the body.
• When attempting to locate their heart, most people place their hand on their left chest. Actually, your heart is located in the center of your chest between your lungs. The bottom of the heart is tipped to the left, so you feel more of your heart on your left side of your chest.
• The heart beats about 100,000 times each day.
• In a 70-year lifetime, the average human heart beats more than 2.5 billion times
• An adult woman's heart weighs about 8 ounces, a man's about 10 ounces
• A child's heart is about the size of a clenched fist; an adult's heart is about the size of two fists.
• Blood is about 78 percent water.
• Blood takes about 20 seconds to circulate throughout the entire vascular system.
• The structure of the heart was first described in 1706, by Raymond de Viessens, a French anatomy professor.
• The electrocardiograph (ECG) was invented in 1902 by Dutch physiologist Willem Einthoven. This test is still used to evaluate the heart's rate and rhythm.
• The first heart specialists emerged after World War I.

Resources

Topol EJ (ed). Cleveland Clinic Heart Book (2000) New York: Hyperion.
Topol EJ (ed). Textbook of Cardiovascular Medicine (1998), Philadelphia: Lippincott-Raven.

The Heart and Blood Vessels

Large red vessel- the aorta;
large artery that carries blood from of the left ventricle to the arteries of the body
Large blue vessel- vena cava;
(includes the superior and inferior vena cava);
large vein that empties blood into the right atrium of the heart.

Inside view of the Heart
Get a larger image

• How does blood travel through your body? Learn more about the heart valves

• How does blood travel through your body? Learn more about the heart valves

• Learn how the heart beats

Outside View of the Front (Anterior) of the Heart
Get a larger image

Right Coronary Artery (RCA) - supplies blood to the right atrium, right ventricle, bottom portion of the left ventricle and the back of the septum
Left Coronary Artery (LCA) - divides into two branches: the circumflex artery & the left anterior descending artery

• What are the coronary arteries?

Left anterior descending artery (LAD) - supplies blood to the front and bottom of the left ventricle and the front of the septum

Outside View of the Back (Posterior) of the Heart)
Get a larger image

Coronary veins (in blue) -take oxygen-poor ("deoxygenated") blood that has already been "used" by muscles of the heart and returns it to the right atrium
Circumflex artery - supplies blood to the left atrium and the side and back of the left ventricle
Pulmonary veins - bring oxygen-rich blood back to the heart from the lungs

As the heart beats, it pumps blood through a system of blood vessels, called the circulatory system. The vessels are elastic tubes that carry blood to every part of the body.

Blood is essential

• It carries oxygen and nutrients to your body's tissues
• It takes carbon dioxide and waste products away from the tissues.
• It is needed to sustain life and promote the health of all the body's tissues.

There are three main types of blood vessels

Arteries

The arteries (red) carry oxygen and nutrients away from your heart, to your body's tissues.
The veins (blue) take oxygen-poor blood back to the heart.

• Arteries begin with the aorta, the large artery leaving the heart.
• They carry oxygen-rich blood away from the heart to all of the body's tissues.
• They branch several times, becoming smaller and smaller as they carry blood further from the heart.

Capillaries

• Capillaries are small, thin blood vessels that connect the arteries and the veins.
• Their thin walls allow oxygen, nutrients, carbon dioxide and waste products to pass to and from the tissue cells.

Veins

• These are blood vessels that take oxygen-poor blood back to the heart.
• Veins become larger and larger as they get closer to the heart.
• The superior vena cava is the large vein that brings blood from the head and arms to the heart, and the inferior vena cava brings blood from the abdomen and legs into the heart.

This vast system of blood vessels - arteries, veins, and capillaries - is over 60,000 miles long. That's long enough to go around the world more than twice!
Blood flows continuously through your body's blood vessels. Your heart is the pump that makes it all possible.

Upper Body Circulation

In the lungs, the pulmonary arteries (in blue) carry unoxygenated blood from the heart into the lungs. Throughout the body, the arteries (in red) deliver oxygenated blood and nutrients to all of the body’s tissues, and the veins (in blue) return oxygen-poor blood back to the heart.
The aorta is the large artery leaving the heart. The superior vena cava is the large vein that brings blood from the head and arms to the heart, and the inferior vena cava brings blood from the abdomen and legs into the heart.

Lower Body Circulation

Arteries (in red) are the blood vessels that deliver blood to the body.
Veins (in blue) are the blood vessels that return blood to the heart.
Deep veins, located in the center of the leg near the leg bones, are enclosed by muscle. The iliac, femoral, popliteal and tibial (calf) veins are the deep veins in the legs.
Superficial veins are located near the surface of the skin and have very little muscle support. The great saphenous vein is a superficial vein.

Educational Opportunities

 

Additional Secure Online Services include:

• MyChart - a secure online tool connecting patients to their own health information from the privacy of their home - clevelandclinic.org/mychart
• MyConsult Online Medical Second Opinion - a secure online service providing remote medical second opinions. Learn more at clevelandclinic.org/myconsult

 

Cleveland Clinic offers a variety of learning opportunities for health care professionals.

Live and Online Presentations

• Grand Rounds and Conferences - Plan to attend a lively CME-approved presentation related to advancements in the diagnosis and treatment of cardiovascular disease. (Access our calendar).
• OnLine CME - FREE CME credit. Heart and vascular topics, and more.
• Physicians can manage their CME credits by using the myCME Web Portal. Available 24/7, the site offers CME opportunities to medical professionals across the globe.
• Presentations - Non-CME presentations from our Heart and Vascular Institute physicians on our website

Journals, Books and Resources

• Cardiac Consult - Free newsletter for physicians, available online and by subscription.
• Cleveland Clinic Journal of Medicine - Published twelve times yearly by Cleveland Clinic, available online and by subscription.
• Disease Management Project - An online medical resource authored by physicians from Cleveland Clinic.
• Books - Textbooks & information for medical professionals from leading authorities.
• Physician eNewsletter - Have the latest cardiovascular health information delivered to your inbox.

Diabetes, Heart Disease, and Stroke....

Diabetes and heart health

Diabetes raises the chances of developing heart problems... eating well and getting or staying active. Even if you have had a heart attack already, you can do a lot more than just take medicines your doctor prescribes.

What causes heart disease?

Atherosclerosis is when, over time, fat deposits from cholesterol build up on the walls of your arteries. As the fat builds up, less blood is flows through. If the blood to your heart is blocked enough, you have a heart attack. If these fat deposits break loose, the result is a stroke. This is why doctors focus on reducing cholesterol.
Diabetes is also more likely to cause heart problems due to damage from high glucose levels and high blood pressure.

Managing A1c levels

A1c is a measure of your blood sugar control over a period of time....daily testing for glucose levels will help manage how well you feel. Regular A1c tests help you know what steps you have to take to keep your blood sugar under control to protect your heart.

Managing blood pressure

 High blood pressure can cause heart and kidney disease. Some people can reduce it with changes in diet or physical activity. Others require medicines. Your doctor or doctors will help you make the best decision for your specific situation.

Managing cholesterol

 This chart shows you what most doctors agree are good measures of the scores you get.

Normal	less than 150 mg/dL
Borderline High	150-199 mg/dL
High	200-499 mg/dL
Very High	500 mg/dL

What are the risk factors for heart disease and stroke in people with diabetes?

Diabetes itself is a risk factor for heart disease and stroke. Also, many people with diabetes have other conditions that increase their chance of developing heart disease and stroke. These conditions are called risk factors. One risk factor for heart disease and stroke is having a family history of heart disease. If one or more members of your family had a heart attack at an early age (before age 55 for men or 65 for women), you may be at increased risk.
You can't change whether heart disease runs in your family, but you can take steps to control the other risk factors for heart disease listed here:

• Having central obesity. Central obesity means carrying extra weight around the waist, as opposed to the hips. A waist measurement of more than 40 inches for men and more than 35 inches for women means you have central obesity. Your risk of heart disease is higher because abdominal fat can increase the production of LDL (bad) cholesterol, the type of blood fat that can be deposited on the inside of blood vessel walls.



• Having abnormal blood fat (cholesterol) levels.
  - LDL cholesterol can build up inside your blood vessels, leading to narrowing and hardening of your arteries-the blood vessels that carry blood from the heart to the rest of the body. Arteries can then become blocked. Therefore, high levels of LDL cholesterol raise your risk of getting heart disease.
  
  - Triglycerides are another type of blood fat that can raise your risk of heart disease when the levels are high.
  
  - HDL (good) cholesterol removes deposits from inside your blood vessels and takes them to the liver for removal. Low levels of HDL cholesterol increase your risk for heart disease.



• Having high blood pressure. If you have high blood pressure, also called hypertension, your heart must work harder to pump blood. High blood pressure can strain the heart, damage blood vessels, and increase your risk of heart attack, stroke, eye problems, and kidney problems.



• Smoking. Smoking doubles your risk of getting heart disease. Stopping smoking is especially important for people with diabetes because both smoking and diabetes narrow blood vessels. Smoking also increases the risk of other long-term complications, such as eye problems. In addition, smoking can damage the blood vessels in your legs and increase the risk of amputation.

What is metabolic syndrome and how is it linked to heart disease?

Metabolic syndrome is a grouping of traits and medical conditions that puts people at risk for both heart disease and type 2 diabetes. It is defined by the National Cholesterol Education Program as having any three of the following five traits and medical conditions:

Traits and Medical Conditions	Definition
Elevated waist circumference	Waist measurement of 40 inches or more in men 35 inches or more in women
Elevated levels of triglycerides	150 mg/dL or higher or Taking medication for elevated triglyceride levels
Low levels of HDL (good) cholesterol	Below 40 mg/dL in men Below 50 mg/dL in women or Taking medication for low HDL cholesterol levels
Elevated blood pressure levels	130 mm Hg or higher for systolic blood pressure or 85 mm Hg or higher for diastolic blood pressure or Taking medication for elevated blood pressure levels
Elevated fasting blood glucose levels	100 mg/dL or higher or Taking medication for elevated blood glucose levels

Source: Grundy SM, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005;112:2735-2752.
Note: Other definitions of similar conditions have been developed by the American Association of Clinical Endocrinologists, the International Diabetes Federation, and the World Health Organization.
[

What can I do to prevent or delay heart disease and stroke?

Even if you are at high risk for heart disease and stroke, you can help keep your heart and blood vessels healthy. You can do so by taking the following steps:

• Make sure that your diet is "heart-healthy." Meet with a registered dietitian to plan a diet that meets these goals:
  • Include at least 14 grams of fiber daily for every 1,000 calories consumed. Foods high in fiber may help lower blood cholesterol. Oat bran, oatmeal, whole-grain breads and cereals, dried beans and peas (such as kidney beans, pinto beans, and black-eyed peas), fruits, and vegetables are all good sources of fiber. Increase the amount of fiber in your diet gradually to avoid digestive problems.
  • Cut down on saturated fat. It raises your blood cholesterol level. Saturated fat is found in meats, poultry skin, butter, dairy products with fat, shortening, lard, and tropical oils such as palm and coconut oil. Your dietitian can figure out how many grams of saturated fat should be your daily maximum amount.
  • Keep the cholesterol in your diet to less than 300 milligrams a day. Cholesterol is found in meat, dairy products, and eggs.
  • Keep the amount of trans fat in your diet to a minimum. It's a type of fat in foods that raises blood cholesterol. Limit your intake of crackers, cookies, snack foods, commercially prepared baked goods, cake mixes, microwave popcorn, fried foods, salad dressings, and other foods made with partially hydrogenated oil. In addition, some kinds of vegetable shortening and margarines have trans fat. Check for trans fat in the Nutrition Facts section on the food package.
  
  
  
• Make physical activity part of your routine. Aim for at least 30 minutes of exercise most days of the week. Think of ways to increase physical activity, such as taking the stairs instead of the elevator. If you haven't been physically active recently, see your doctor for a checkup before you start an exercise program.
• Reach and maintain a healthy body weight. If you are overweight, try to be physically active for at least 30 minutes a day, most days of the week. Consult a registered dietitian for help in planning meals and lowering the fat and calorie content of your diet to reach and maintain a healthy weight. Aim for a loss of no more than 1 to 2 pounds a week.
• If you smoke, quit. Your doctor can help you find ways to quit smoking.

•  
• Ask your doctor whether you should take aspirin. Studies have shown that taking a low dose of aspirin every day can help reduce the risk of heart disease and stroke. However, aspirin is not safe for everyone. Your doctor can tell you whether taking aspirin is right for you and exactly how much to take.
• Get prompt treatment for transient ischemic attacks (TIAs). Early treatment for TIAs, sometimes called mini-strokes, may help prevent or delay a future stroke. Signs of a TIA are sudden weakness, loss of balance, numbness, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache.

How will I know whether my diabetes treatment is working?

You can keep track of the ABCs of diabetes to make sure your treatment is working. Talk with your health care provider about the best targets for you.
A stands for A1C (a test that measures blood glucose control). Have an A1C test at least twice a year. It shows your average blood glucose level over the past 3 months. Talk with your doctor about whether you should check your blood glucose at home and how to do it.

A1C target
Below 7 percent

Blood glucose targets
Before meals	90 to 130 mg/dL
1 to 2 hours after the start of a meal	Less than 180 mg/dL

B is for blood pressure. Have it checked at every office visit.

Blood pressure target
Below 130/80 mm Hg

C is for cholesterol. Have it checked at least once a year.

Blood fat (cholesterol) targets
LDL (bad) cholesterol	Under 100 mg/dL
Triglycerides	Under 150 mg/dL
HDL (good) cholesterol	For men: above 40 mg/dL For women: above 50 mg/dL

Control of the ABCs of diabetes can reduce your risk for heart disease and stroke. changes in diet, activity, and medications can help reach  goals.

What types of heart and blood vessel disease occur in people with diabetes?

Two major types of heart and blood vessel disease, also called cardiovascular disease, are common in people with diabetes: coronary artery disease (CAD) and cerebral vascular disease. People with diabetes are also at risk for heart failure. Narrowing or blockage of the blood vessels in the legs, a condition called peripheral arterial disease, can also occur in people with diabetes.

Coronary Artery Disease

Coronary artery disease, also called ischemic heart disease, is caused by a hardening or thickening of the walls of the blood vessels that go to your heart. Your blood supplies oxygen and other materials your heart needs for normal functioning. If the blood vessels to your heart become narrowed or blocked by fatty deposits, the blood supply is reduced or cut off, resulting in a heart attack.

Cerebral Vascular Disease

Cerebral vascular disease affects blood flow to the brain, leading to strokes and TIAs. It is caused by narrowing, blocking, or hardening of the blood vessels that go to the brain or by high blood pressure.

Stroke

A stroke results when the blood supply to the brain is suddenly cut off, which can occur when a blood vessel in the brain or neck is blocked or bursts. Brain cells are then deprived of oxygen and die. A stroke can result in problems with speech or vision or can cause weakness or paralysis. Most strokes are caused by fatty deposits or blood clots-jelly-like clumps of blood cells-that narrow or block one of the blood vessels in the brain or neck. A blood clot may stay where it formed or can travel within the body. People with diabetes are at increased risk for strokes caused by blood clots.
A stroke may also be caused by a bleeding blood vessel in the brain. Called an aneurysm, a break in a blood vessel can occur as a result of high blood pressure or a weak spot in a blood vessel wall.

TIAs

TIAs are caused by a temporary blockage of a blood vessel to the brain. This blockage leads to a brief, sudden change in brain function, such as temporary numbness or weakness on one side of the body. Sudden changes in brain function also can lead to loss of balance, confusion, blindness in one or both eyes, double vision, difficulty speaking, or a severe headache. However, most symptoms disappear quickly and permanent damage is unlikely. If symptoms do not resolve in a few minutes, rather than a TIA, the event could be a stroke. The occurrence of a TIA means that a person is at risk for a stroke sometime in the future.

Heart Failure

Heart failure is a chronic condition in which the heart cannot pump blood properly-it does not mean that the heart suddenly stops working. Heart failure develops over a period of years, and symptoms can get worse over time. People with diabetes have at least twice the risk of heart failure as other people. One type of heart failure is congestive heart failure, in which fluid builds up inside body tissues. If the buildup is in the lungs, breathing becomes difficult.

Blockage of the blood vessels and high blood glucose levels also can damage heart muscle and cause irregular heart beats. People with damage to heart muscle, a condition called cardiomyopathy, may have no symptoms in the early stages, but later they may experience weakness, shortness of breath, a severe cough, fatigue, and swelling of the legs and feet. Diabetes can also interfere with pain signals normally carried by the nerves, explaining why a person with diabetes may not experience the typical warning signs of a heart attack.

Peripheral Arterial Disease

Another condition related to heart disease and common in people with diabetes is peripheral arterial disease (PAD). With this condition, the blood vessels in the legs are narrowed or blocked by fatty deposits, decreasing blood flow to the legs and feet. PAD increases the chances of a heart attack or stroke occurring. Poor circulation in the legs and feet also raises the risk of amputation. Sometimes people with PAD develop pain in the calf or other parts of the leg when walking, which is relieved by resting for a few minutes.
 

How will I know whether I have heart disease?

One sign of heart disease is angina, the pain that occurs when a blood vessel to the heart is narrowed and the blood supply is reduced. You may feel pain or discomfort in your chest, shoulders, arms, jaw, or back, especially when you exercise. The pain may go away when you rest or take angina medicine. Angina does not cause permanent damage to the heart muscle, but if you have angina, your chance of having a heart attack increases.
A heart attack occurs when a blood vessel to the heart becomes blocked. With blockage, not enough blood can reach that part of the heart muscle and permanent damage results. During a heart attack, you may have

• chest pain or discomfort
• pain or discomfort in your arms, back, jaw, neck, or stomach
• shortness of breath
• sweating
• nausea
• light-headedness

Symptoms may come and go. However, in some people, particularly those with diabetes, symptoms may be mild or absent due to a condition in which the heart rate stays at the same level during exercise, inactivity, stress, or sleep. Also, nerve damage caused by diabetes may result in lack of pain during a heart attack.
Women may not have chest pain but may be more likely to have shortness of breath, nausea, or back and jaw pain. If you have symptoms of a heart attack, call 911 right away. Treatment is most effective if given within an hour of a heart attack. Early treatment can prevent permanent damage to the heart.
Your doctor should check your risk for heart disease and stroke at least once a year by checking your cholesterol and blood pressure levels and asking whether you smoke or have a family history of premature heart disease. The doctor can also check your urine for protein, another risk factor for heart disease. If you are at high risk or have symptoms of heart disease, you may need to undergo further testing.

What are the treatment options for heart disease?

Treatment for heart disease includes meal planning to ensure a heart-healthy diet and physical activity. In addition, you may need medications to treat heart damage or to lower your blood glucose, blood pressure, and cholesterol. If you are not already taking a low dose of aspirin every day, your doctor may suggest it. You also may need surgery or some other medical procedure.

For additional information about heart and blood vessel disease, high blood pressure, and high cholesterol, call the National Heart, Lung, and Blood Institute Health Information Center at 301-592-8573 or see www.nhlbi.nih.gov on the Internet.

How will I know whether I have had a stroke?

The following signs may mean that you have had a stroke:

• sudden weakness or numbness of your face, arm, or leg on one side of your body
• sudden confusion, trouble talking, or trouble understanding
• sudden dizziness, loss of balance, or trouble walking
• sudden trouble seeing out of one or both eyes or sudden double vision
• sudden severe headache

If you have any of these symptoms, call 911 right away. You can help prevent permanent damage by getting to a hospital within an hour of a stroke. If your doctor thinks you have had a stroke, you may have tests such as a neurological examination to check your nervous system, special scans, blood tests, ultrasound examinations, or x rays. You also may be given medication that dissolves blood clots.

What are the treatment options for stroke?

At the first sign of a stroke, you should get medical care right away. If blood vessels to your brain are blocked by blood clots, the doctor can give you a "clot-busting" drug. The drug must be given soon after a stroke to be effective. Subsequent treatment for stroke includes medications and physical therapy, as well as surgery to repair the damage. Meal planning and physical activity may be part of your ongoing care. In addition, you may need medications to lower your blood glucose, blood pressure, and cholesterol and to prevent blood clots.

For additional information about strokes, call the National Institute of Neurological Disorders and Stroke at 1-800-352-9424 or see www.ninds.nih.gov on the Internet.

• If you have diabetes, you are at least twice as likely as other people to have heart disease or a stroke.
• Controlling the ABCs of diabetes-A1C (blood glucose), blood pressure, and cholesterol-can cut your risk of heart disease and stroke.
• Choosing foods wisely, being physically active, losing weight, quitting smoking, and taking medications (if needed) can all help lower your risk of heart disease and stroke.
• If you have any warning signs of a heart attack or a stroke, get medical care immediately-don't delay. Early treatment of heart attack and stroke in a hospital emergency room can reduce damage to the heart and the brain.

Hope through Research

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) is one of the National Institutes of Health (NIH) under the U.S. Department of Health and Human Services. The NIDDK conducts and supports research in diabetes, glucose metabolism, and related conditions. Several studies related to diabetes, heart disease, and stroke are under way.

• The Look AHEAD (Action for Health in Diabetes) trial is studying whether strategies for weight loss in obese people with type 2 diabetes can improve health. This trial is also sponsored by other NIH Institutes and by the Centers for Disease Control and Prevention. For more information on the Look AHEAD trial, visit the website at www.niddk.nih.gov/patient/SHOW/lookahead.htm.
• The EDIC (Epidemiology of Diabetes Interventions and Complications) study is examining the long-term effects of prior intensive versus conventional blood glucose control. It is a follow-up study of patients who took part more than a decade ago in the Diabetes Control and Complications Trial (DCCT), a major clinical study funded by the National Institutes of Health.
• The BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) trial, sponsored by the National Heart, Lung, and Blood Institute, in partnership with NIDDK, is studying approaches to the medical care of people with type 2 diabetes who also have coronary artery disease. For more information on the BARI 2D trial, visit the website at www.bari2d.org or call the nearest research center (listed on the website).
• The ACCORD (Action to Control Cardiovascular Risk in Diabetes) trial is studying three approaches to preventing major cardiovascular events in individuals with type 2 diabetes. For more information on the ACCORD trial, visit the website at www.accordtrial.org or call 1-888-342-2380.
• The NIDDK and other components of the NIH will continue to fund research on the best ways to enhance health promotion, self-management, and risk reduction in people with diabetes.

How to prevent and manage Tumor lysis syndrome.......

POTENTIALLY FATAL, tumor lysis syndrome (TLS) is a metabolic disturbance caused by the death of cancer cells during cancer treatment and the release of their intracellular components into the bloodstream. It's characterized by the rapid development of hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia. Risk factors for TLS include a large tumor size, tumors with rapid cell division and growth, hematologic cancers such as acute leukemia or high-grade (aggressive) lymphoma, and tumors with a high sensitivity to chemotherapy.1,2 Patients with high lactate dehydrogenase levels (greater than 1,000 U/L) and impaired renal function are also at risk, as are some patients with mediastinal tumors.3 Several chemotherapy agents, including cytarabine, cisplatin, etoposide, and paclitaxel, are associated with TLS. Figure. No caption available. Based on the presence of certain risk factors, patients can be placed into low-, intermediate-, or high-risk categories. * High-risk patients are those with Burkitt lymphoma, lymphoblastic lymphoma, or B-cell acute lymphoblastic leukemia. * Patients at intermediate risk have diffuse large-cell lymphoma or another type of rapidly growing cancer. * Low-risk patients have indolent (slow-growing) lymphoma or another slowly proliferating cancer.1 When TLS is present, it's diagnosed by lab tests or clinical signs and symptoms. Used to classify and grade TLS, the Cairo-Bishop Grading System defines lab abnormalities in serum uric acid, potassium, and phosphorus levels as a 25% increase over baseline and a 25% decrease from baseline in serum calcium levels. This system considers lab value changes that occur in patients from 3 days before to 7 days after chemotherapy begins. The clinical abnormalities classified by this system are graded based on severity and include age-adjusted serum creatinine, cardiac dysrhythmias, and seizures.4 How TLS happens In a highly proliferative cancer such as acute leukemia, some leukemia cells die before treatment as part of their life cycle. If many of them lyse and die, TLS may develop before cancer treatment even begins. However, most cancer cells in the bloodstream and bone marrow of patients with acute leukemia are destroyed with chemotherapy. As cells lyse and die, they release intracellular components into the bloodstream. Large amounts of potassium and phosphate are released, along with purine nucleic acids. Signs and symptoms of TLS may occur as early as a few hours after the start of chemotherapy, but it's more common 24 to 48 hours after treatment begins.5 The mortality rate for patients who develop TLS is about 18%.6 (See Recognizing signs and symptoms of TLS.) What's going wrong? Hyperkalemia is often a first sign of TLS because potassium may start to leave dying cancer cells before they lyse. This electrolyte imbalance can impair normal cardiac function and cause lethal dysrhythmias. The kidneys, overwhelmed by excess potassium in the bloodstream, may be unable to excrete enough potassium to compensate for the hyperkalemia.7 Hyperphosphatemia results from the large amount of phosphorus released from malignant cells, especially malignant blood cells.8 The kidneys try to eliminate the excess phosphorus by increasing urine output and reducing the amount of phosphorus reabsorption. But eventually the kidneys reach a point where they can no longer compensate, and phosphorus accumulates in the blood.4 As serum phosphate levels increase, phosphate ions (which are negatively charged) combine with calcium ions (which are positively charged), resulting in decreased serum calcium levels (hypocalcemia). These calcium-phosphate complexes precipitate in soft tissues and the renal tubules, causing tubular obstruction and acute renal failure.5 Hyperphosphatemia usually develops 24 to 48 hours after the start of chemotherapy.8 Purine nucleic acids are also released by lysed cancer cells. Normally, purines are metabolized to hypoxanthine, which is converted to xanthine by the enzyme xanthine oxidase, and then to uric acid, which is excreted by the kidneys.4 Excess amounts of purine nucleic acids are released quickly into the bloodstream during cancer cell lysis, overwhelming the kidneys' ability to excrete the converted excess amounts of uric acid. This results in hyperuricemia and uric acid crystal formation in the kidneys.4 Because of these events, the kidneys are overwhelmed by excess potassium, phosphorus, calcium phosphate precipitates, and uric acid crystals, resulting in acute renal failure. Initially, the kidneys try to compensate for the increased electrolyte and uric acid load by increasing urine output, but they can't maintain normal electrolyte and uric acid levels due to volume depletion and uric acid nephropathy.5 Hyperuricemia is usually seen 48 to 72 hours after chemotherapy begins.8 If a patient is at risk for TLS, lab work is performed every 6 hours for the first 24 hours after chemotherapy is started. Lab work consists of a complete blood cell count, serum electrolytes, calcium, phosphorus, creatinine, uric acid, lactate dehydrogenase, and blood urea nitrogen (BUN). After the first 24 hours, lab values are monitored at least every 12 hours for several days and then daily, or as ordered. The severity of the patient's risk for TLS helps guide the frequency of lab work.9 Preventing and treating TLS To help prevent TLS, assess patients undergoing chemotherapy for risk factors at baseline and monitor them during and after the initiation of treatment as ordered.1 Mainstays of preventive care are hydration and the medications allopurinol and recombinant urate oxidase (rasburicase). Alkalinization of the urine, once a common treatment for TLS, is no longer routinely recommended. (See Urinary alkalinization: Out of favor?) I.V. hydration should begin as soon as possible, ideally 2 days before initiating chemotherapy, and continue during chemotherapy and for 2 to 3 days afterward.5 The optimal fluid volume administered parenterally is 3,000 mL/m2 each day. This will produce the high urine output (over 100 mL/m2 each hour) that's needed to excrete excess potassium, phosphate, and uric acid, with the goal of reducing the risk of calcium phosphate precipitates.7 Electrolytes, such as potassium, aren't added to I.V. fluids to avoid the risk of worsening electrolyte abnormalities. Monitor the patient for signs and symptoms of fluid volume overload, such as peripheral edema, neck vein distension, weight gain, and pulmonary crackles, as well as signs and symptoms of fluid volume deficit (dehydration), such as dry mucous membranes, poor skin turgor, weight loss, and thirst. Use physical assessment, strict intake and output, daily weights, and lab work results to monitor renal function, including serum creatinine and BUN levels, and calcium, phosphate, potassium, and uric acid levels. In some cases, the healthcare provider may order a diuretic such as furosemide to enhance renal excretion, but diuretics should be avoided in patients who are dehydrated or who have renal obstruction.1,4 Allopurinol inhibits the conversion of hypoxanthine to xanthine and of xanthine to uric acid by inhibiting xanthine oxidase. Optimally, it's initiated 1 to 2 days before starting chemotherapy.1 Monitor patients for a skin rash or fever, which may indicate a hypersensitivity reaction. Other signs and symptoms of a hypersensitivity reaction include chills, nausea, vomiting, and a high serum eosinophil count. Common adverse reactions from allopurinol include central nervous system alterations, such as drowsiness or headache. Allopurinol therapy is started before chemotherapy because it helps prevent excess uric acid, but it won't reduce uric acid levels in patients who already have hyperuricemia. Another limitation of allopurinol is that it increases xanthine levels, which could precipitate in the kidneys. In addition, it interferes with the excretion of other drugs used to treat cancer, such as high-dose methotrexate, cyclophosphamide, e-mercaptopurine, and azathioprine.1 Allopurinol is never administered with capecitabine because allopurinol may decrease its effectiveness. Unlike allopurinol, rasburicase is a drug that treats hyperuricemia. Administered I.V., rasburicase converts uric acid to allantoin, which is much more soluble in urine than uric acid. The drug works quickly (in 4 hours) to reduce uric acid levels and also helps control serum potassium, phosphate, calcium, and creatinine levels.10 Most patients receive 2 days of therapy, but just one treatment is effective for some. Patients with a large tumor burden may need longer therapy (up to 7 days) or twice-daily treatment.1,10 If you care for a patient taking rasburicase, take special care when sending lab specimens for uric acid analysis. To ensure accurate uric acid results, the blood specimen must be placed on ice after being drawn, during transport, and while in the lab waiting to be processed. Improperly obtained and maintained specimens will give abnormal false low results due to any uric acid in the tube being degraded by rasburicase at room temperature. Allopurinol must be stopped in patients who are to receive rasburicase. Never use the two drugs together because allopurinol will interfere with rasburicase activity. Make sure the patient is well hydrated before administering rasburicase therapy.10 Because of the risk of a hypersensitivity reaction, make sure emergency medications (such as oxygen, epinephrine, corticosteroids, and diphenhydramine) are available before rasburicase therapy begins. Take baseline vital signs and closely monitor the patient throughout drug administration. Signs of hypersensitivity reactions include urticaria, bronchospasm, chest discomfort, dyspnea, hypoxia, and hypotension. Stop the rasburicase infusion at the first sign of a hypersensitivity reaction, assess and maintain airway, breathing, and circulation, obtain vital signs, notify the healthcare provider, administer treatment as ordered, and support the patient during the reaction. Headache, rash, fever, and vomiting are the most common adverse reactions associated with one dose of rasburicase. With repeated dosing, additional adverse reactions include increased liver enzymes, urticaria, pruritus, flushing, dyspnea, and chest and back pain.11 Hemolysis, hemoglobinuria, and methemoglobinemia have been reported. Rasburicase should never be administered to patients with a glucose-6-phosphate dehydrogenase deficiency because of the risk of severe hemolysis. Treating complications of TLS A patient who develops TLS requires ongoing hydration. Asymptomatic hyperkalemia is managed with sodium polystyrene sulfonate with sorbitol given orally. Monitor the patient for signs and symptoms of hypocalcemia and hypomagnesemia from sodium polystyrene sulfonate with sorbitol.10 Also monitor the patient's 12-lead ECG as indicated and assess cardiac rate and rhythm for dysrhythmias. If the patient has symptomatic hyperkalemia, the healthcare provider may order I.V. regular insulin and dextrose to redistribute potassium, shifting it intracellularly.4,10 I.V. calcium chloride may be ordered to control dysrhythmias by antagonizing the toxic effects of hyperkalemia at the cardiac cellular membrane level and manage hypocalcemia.1,10 However, I.V. calcium shouldn't be administered to patients with hyperphosphatemia because it promotes calcium phosphate precipitates.4 Hyperphosphatemia is managed with phosphate binders such as aluminum hydroxide given in limited dosages to avoid aluminum toxicity.1 Other phosphate binders with calcium, such as calcium acetate or calcium carbonate, may be used instead.12 A patient who doesn't respond to these measures may need renal replacement therapy, such as hemodialysis, to manage electrolyte abnormalities and treat renal failure. Nursing considerations Educate patients and their families about the prevention and management of TLS, including the signs and symptoms of hyperuricemia and information about prescribed medications. For example, make sure they understand each drug's purpose, dosage, expected effects, and possible adverse reactions. Also make sure they know how to recognize serious adverse reactions or signs and symptoms they should notify the healthcare provider about at once. Complete a nursing admission assessment, including a risk factor assessment for TLS. Notify the healthcare provider of any abnormal lab results that may indicate TLS. Administer I.V. hydration as prescribed and monitor fluid balance by weighing the patient daily and documenting intake and output accurately. Urine output should be in balance with the intake. If fluid intake exceeds output, notify the healthcare provider because the patient may be developing renal complications from TLS. To assess a patient's renal function, follow these guidelines. * Assess urine output, including pH, color, odor, volume, and clarity, and test for the presence of red blood cells and hemoglobin. Notify the healthcare provider of oliguria or other abnormalities, which may indicate acute renal failure. Educate the patient about the need to save all urine for measurement and testing. * Insert an indwelling urinary catheter if prescribed, but avoid catheters in patients with low neutrophil or platelet counts due to the risk of infection and bleeding, and remove urinary catheters as soon as they're no longer needed to prevent catheter-associated urinary tract infections. * Assess breath sounds (pulmonary crackles) and heart sounds (S3) for signs of fluid overload. * Weigh the patient daily. * Monitor BUN, serum uric acid and creatinine levels. * Perform medication reconciliation and collaborate with the prescriber and pharmacist to stop or hold any medications that may adversely affect renal function or serum electrolyte and uric acid levels. (See Beware of these medications.) To assess a patient for signs and symptoms of hyperkalemia, hyperphosphatemia, and hypocalcemia, closely monitor electrolyte, phosphorus, and calcium levels, and monitor ECG results. As prescribed, administer phosphate binding agents, medications to reduce serum potassium and uric acid levels, and increase serum calcium levels. Prompt recognition is key By promptly identifying signs and symptoms of TLS and intervening appropriately, you can help your patient recover from this dangerous complication of cancer treatment. Urinary alkalinization: Out of favor? Historically a mainstay of TLS prevention, the use of I.V. sodium bicarbonate to alkalinize the urine has become controversial. Adding sodium bicarbonate to I.V. fluids raises the patient's urine pH above 7, increasing excretion of uric acid.5 When the uric acid level returns to normal, alkalinization is stopped. However, an alkaline environment can promote calcium and phosphorus precipitation and promote renal failure, as well as metabolic alkalosis. When used with allopurinol, alkalinization can also interfere with xanthine and hypoxanthine solubility and promote urinary xanthine crystal deposits in the kidneys. For these reasons, routine alkalinization is no longer recommended, although some practitioners still order it.1 Beware of these medications This is a partial list of medications to avoid in patients with TLS. * angiotensin-converting enzyme inhibitors * antifungals * aspirin * beta-blockers * bisphosphonates * cyclosporine * heparin * mannitol * some antineoplastics * some antibiotics * potassium-sparing diuretics * medications containing potassium or phosphate * nephrotoxic agents such as nonsteroidal anti-inflammatory drugs and aminoglycosides Find Source Article here.... written by.....Jeanne Held-Warmkessel MSN, RN, AOCN, ACNS-BC