AH 1 exam 2 Flashcards
What is the accurate assessment when taking BP?
● 2-3 readings spaced out ● sitting - feet flat - NO talking ● correct size CUFF ➢ too BIG = LOW reading ➢ too SMALL = HIGH reading
What can interaction with BP?
● interactions ➢ STRESS - pn, anxiety ➢ temp changes ➢ barometric pressure ➢ smoking, ETOH
HTN risk factors?
Modifiable ● CKD - chronic kidney disease ● Diabetes ● HIGH cholesterol ● Poor DIET ● obesity ● stress ● SEDENTARY lifestyle, sleep apnea ● tobacco use
Non-Modifiable ● age ➢ vasculature stiffens ● ethnicity/race ➢ African American ● gender ➢ men ➢ women (> 65) ● family hx/genetics ● (social determinants of health)
HTN lifestyle modifications
● weight loss ➢ ↓↓ demand on body ➢ ↓↓ cholesterol = have to work against atherosclerosis ● diet ➢ DASH diet ➢ ↑ K+/ ↓ Na+/↓ fat ● exercise ➢ HR = more efficient ➢ ↓↓ weight & cholesterol ● ETOH ➢ leads to DEHYDRATION ● smoking ➢ clogs arteries → ATHEROSCLEROSIS
HTN medications, AE, pt ed
FIRST line: ➢ ACE, ARBs, Ca channel blockers, thiazide diuretic ● HOLD meds: ➢ HR<60bpm ➢ SYSTOLIC < 90 mmHg ● start LOW & go SLOW
SECONDARY line:
➢ loop diuretics, beta blockers, K+ sparing
AE - orthostatic hypotension, hypotension
Effects of Long-Term HTN
Target organ Damage
Retina/eye changes renal damage myocardial infraction cardiac hypertrophy heart failure stroke
What are the effects of HTN on EYES?
● microaneurysms in the eye, papilledema
● cotton wool spots
● ↑ intraocular pressure = damages vessels
What are the effects of HTN on Kidneys?
● renal damage
● affected by ↑ in pressure
● proteinuria, Dec. urine output
● ↑↑ BUN/creatinine
What are the effects of HTN on the heart?
● angina/palpitations, MI, cardiac hypertrophy
● peripheral pulse = bounding
● dyspnea
What are the effects of HTN on neuro?
● neuro deficits - motor speech, stroke
● headaches/dizziness
● falls, weakness, gait changes
Hypertensive emergency
signs & symptoms ● chest pain ● neuro changes ● ha ● ↑↑ BP = target organ damage
cause
abrupt in ↑↑ BP
SBP >180 or DBP >120
treatment ● in ICU ● IV anti-HTN meds ● SLOWLY lower BP ● tx target organ damage (Encephalopathy, Ischemic stroke, MI, Heart failure, Dissecting aortic aneurysm, Renal failure
HYPERTENSIVE URGENCY
signs & symptoms
more stable
→ NO target organ damage
Cause
SBP >180 or DBP >120
treatment
● usually w. oral meds
● get to the ROOT of WHY they
aren’t adherent
HTN primary vs secondary
Primary unknown
Secondary: related to another disease Cushing's Hyperaldosteronism Aortic coarctation Pheochromocytoma Stenosis of renal arteries.
Cardiovascular modifiable vs. non-modifiable risk factors
modifiable
Smoking, HTN, cholesterol, activity level, diet, stress, obesity, diabetes
non-modifiable
Age, gender, race, Family history
cardiovascular - considerations for older adults?
Hypertrophy Changes in the cardiac structure and function Conduction system Vasculature thickening of rigidity of AV valves
Cardiovascular older adult consideration
hypertrophy
thickening of heart walls
➢ ↓↓ VOLUME of blood into the chamber ➢ ↓↓ STRENGTH of contraction
Cardiovascular older adult consideration
● ↓↓ cardiac output
➢ fatigue, exercise intolerance, HF, VENTRICULAR arrhythmias
Cardiovascular older adult consideration
thickened AV valves
➢ doesnt close properly → leads to BACKFLOW
○ hear murmur
(why they are so common in older adults)
Cardiovascular older adult consideration
conduction system
➢ SA node = pacemaker
➢ CONNECTIVE tissue develops in SA/AV node, and bundle branches = less tissue that can conduct electricity
○ s/s = bradycardia, blocks, ECG changes
Cardiovascular older adult consideration
stiffened vasculature/loses elasticity
➢ must work harder to pump against it
➢ leads to → ventricular hypertrophy
○ ↑↑ systolic BP
(why older adults have high BP)
Cardiovascular older adult consideration
↑↑ size of left atrium
➢ atrial arrhythmias
Cardiovascular older adult consideration
↓↓ sympathetic nervous system
➢ doesn’t react to demand of O2 → intolerance to EXERCISE
Cardiovascular older adult consideration
↓↓ sensitivity in BARORECEPTORS
➢ in CAROTID artery and AORTA
➢ unregulated response to HR/vascular changes → orthostatic hypotension
Cardiovascular older adult consideration
falls
➢ fx, head injuries
BUN Lab
8 - 20 mg/dL
Creatinine lab
- 6 - 1.2 mg/dL (male)
0. 4 - 1 mg/dL (female)
Calcium lab
8.8 - 10.4 mg/dL
Magnesium Lab
1.8 - 2.6 mg/dL
Potassium lab
3.5 - 5 mEq/L
Sodium lab
135 - 145 mEq/L
RBC lab
- 2 mil - 5.4 mil/ mm3 (male)
3. 6 mil - 5.0 mil/ mm3 (female)
Hemoglobin/ Hematocrit labs
14 - 17.4 g/dL 42 - 52% (male)
12 - 16 g/dL 36 - 48% (female)
Platelets lab
140,000 - 400,000/mm3
WBC lab
140,000 - 400,000/mm3
aPTT lab
21 - 35 sec (use w. heparin)
PT lab
11 - 13 sec (use w. warfarin)
INR lab
0.8 - 1.2 (use w. warfarin)
Lipid Tests:
● HIGH LDL/triglycerides = ↑↑ risk of heart disease
● HIGH CRP = indicates INFLAMMATION
● B-type = related to HEART FAILURE
● HOMOCYSTEINE = ↑↑ risk of disease and stroke
electrocardiogram (ECG)
= tests CONDUCTION in the heart
● normal sinus or dysrhythmias
exercise stress test
= how well pt tolerates ↑↑ HR and BP
● on treadmill with tele
● for: chest pn/CAD/big changes in HR and BP
pharmacologic stress test
for people who can’t tolerate being on the treadmill
echocardiogram
= STRUCTURE of the heart
● valves, silhouette of heart, measuring chamber SIZE
cardiac test - chest x-ray
= SIZE of heart
● just a silhouette of heart
fluoroscopy
= see CLOT/NARROWING of arteries ● like a moving x ray ● in cath lab ● w. contrast dye → takes pictures of where is GOES and STOPS
CARDIAC CATHETERIZATION
= for CORONARY & PERIPHERAL arteries
pre - op
● baseline coag studies (INR,PT,PTT)
➢ compare labs - before and after
➢ on HEPARIN
● electrolyte panel and CBC for baseline
● ↑↑ risk
➢ KIDNEY issue: CKD, renal insufficiency, diabetic patients ○ check renal fxn before (BUN/creatinine)
➢ HF
➢ dehydration
➢ other nephrotoxic med (metformin) ➢ older adults
cardiac Catheterization is and can cause
● iodinated contrast dye
➢ iodine allergy or shellfish allergy!
➢ pretreat with benadryl or steroids
CARDIAC CATHETERIZATION Post - op
● bleeding
➢ usually in FEMORAL artery (maybe radial)
➢ must be SUPINE for several hours
➢ constantly monitor for signs of bleeding
➢ usually a clear dressing over insertion site
➢ hematoma development
➢ changes in vitals - ↓↓ bp ↑↑ hr = BLEEDING
○ back pain = retroperitoneal bleeding
● peripheral neurovascular assessment
➢ compare bilaterally
➢ lose pulse/cold = clot/dec blood flow to limb (need to go back to cath lab)
➢ temp/color/cap refill
● on tele
➢ ↑↑ risk of DYSRHYTHMIAS
● edu:
➢ supine 2-6 hrs
➢ report chest pain/bleeding
Normal duration of the QRS complex is
< 0.12 seconds
Duration of normal PR interval is
0.12-0.2 seconds.
Arteriosclerosis
hardening of of arteries
Muscle fibers/endothelial lining become thickened (small arteries/arterioles)
Atherosclerosis
(narrowing)
• Large/medium sized arteries
• Accumulation of fats, calcium, blood components, carbs, fibrous
tissues
● Forms plaques - atheroma ➢ stable & unstable
Path to MI
● arteriosclerosis (hardening) or atherosclerosis (narrowing) ● ↓ blood flow to myocardium = ↓ o2 ● angina (ischemia) ● plaque ruptures ● causes thrombus ● complete obstruction = MI
ANGINA
ISCHEMIA of blood flow to heart muscle → painful
ACUTE CORONARY SYNDROME (ACS)
Unstable - no biomarker changes
NSTEMI - less tissue damage, transient occlusive - increased biomarkers
STEMI - ST elevation + biomarkers - emergency - complete/prolonged occlusion
MI is
= complete occlusion
● ↓ O2 supply and ↑ O2. demand
● causes: blood loss, rapid HR, drug use, thyroid storm
stable angina relieved by
REST & NITRO
unstable angina
= ↑ severity/freq of symptoms; NOT relieved by REST & NITRO
intractable/refractory angina
= severe pain
variant angina
= pain at REST - caused by
VASOSPASM
silent angina
no pain - ECG changes & ischemia are present
CORONARY ARTERY DISEASE (CAD) lab values
total cholesterol < 200 mg/dL LDL cholesterol < 100 mg/dL HDL cholesterol > 40 mg/dL (males) > 50 mg/dL (females) triglycerides < 150 mg/dL
ACS & MI cardiac enzymes lab values Troponin?**** creatine phosphokinase (CPK)? CKMB? myoglobin?
troponin < 0.35 ng/mL creatine phosphokinase (CPK) 50 - 325 mU/mL (males) 50 - 250 mU/mL (females) CKMB 0-5ng/mL myoglobin 0 mcg/mL
STEMI VS NSTEMI ECG changes
STEMI - ST eleveted
NSTEMI - ST depression
CAD Clinical manifest.
depends on LOCATION and amnt of NARROWING ● epigastric distress/indigestion ● angina ● weakness/lightheaded/nausea ● shoulder pain ● SOB
Angina Clinical manifest.
● chest pain ● indigestion ● choking/heavy sensation ● feeling of impending doom ● radiating pain (shoulder) ● pallor ● N/V/lightheaded
ACS & MI Clinical Manifest.
● similar to unstable angina ● DIFFERENCE = biomarkers ➢ MI = biomarkers ● cool, pale, moist skin ● elevated HR & RR ● chest pain ● indigestion
CAD risk factors and managment
Risk factors - smoking, obesity, stress, sedentary lifestyle, high fat diet (saturated fats)
● diet - eat more plants (fiber - omega3 fatty acids) ● physical activity ● medications ● tobacco cessation ● HTN management ● diabetes control
CHOLESTEROL = statins
BLOOD PRESSURE = ACE’s, ARB’s, beta blockers, Ca channel blockers, thiazide diuretics
Angina managment
● medications ➢ stable - nitro, beta blocker, Ca channel blocker, anticoags ➢ unstable - heparin ● oxygen therapy ➢ ↓ demand on heart ● PCIs/CABG
PCIs - balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are put in place
CABG - 1. borrowed piece of blood vessel used to bypass a blocked artery in the heart
2. Traditional, alternative, endoscopic
ACS and MI managment
GET PT TO CATH LAB ASAP
● pain management ➢ oxygen & morphine
● bed rest - elevates HOB
● manage fluid volume ➢ risk of HF
● adequate tissue perfusion
● anxiety ➢ ↓ workload on heart
● prevent complications
➢ ↓ cardiac output (↓BP, cool ext, ↓ pulses)
➢ fluid/electrolyte imbalances (labs, dysrhythmias)
➢ impaired cerebral circ (LOC, neuro symp)
● serial cardiac enzyme levels
ACS/MI MEDS
● nitroglycerin
● analgesics - pain and ↓ O2 demand
● anticoagulants - aspirin, heparin
PERIPHERAL ARTERY DISEASE
eti/patho
atherosclerosis in LE
arteriosclerosis
CHRONIC VENOUS INSUFFICIENCY
eti/patho
● blood NOT returning to heart
● ↑↑ venous pressure → distended veins → causes BACKFLOW = venous stasis
PAD Clincial manifest.
● limb cool or numb ● pale skin ● absent pulses ● intermittent claudication - ↓ blood supply to the tissue causes pain ● ARTERIAL ulcers ➢ small, round, dry, black sores ➢ on TOES and FEET
Chronic venous insufficiency Clincial manifest.
● dull, achy pain ● ruddy skin ● VENOUS ulcers ➢ bigger, red sores ➢ wet & weeping ➢ on MEDIAL & LATERAL malleolus
PAD management
● #1 nicotine cessation ● medication ➢ anti-platelet (aspirin, clopidogrel) ➢ direct vasodilator - for intermittent claudication ● maintain circulation ➢ legs BELOW heart ● promote vasodilation ➢ warm temperatures ➢ avoid cold and trauma ● good nutrition ● meticulous hygiene
Chronic venous insufficiency
pt edu and managment
● monitor skin - keep clean & dry ● DONT: ➢ dangle or cross legs ➢ wear constrictive clothing ● elevate legs at rest
● apply: ➢ compression stockings ➢ SCD’s ● encourage exercise ● good nutrition
DVT PREVENTION:
● early ambulation
● prophylaxis meds ➢heparin, lovenox
● SCDs/ted hose
● ankle exercises
PE PREVENTION:
● bed rest until anticoag therapy
● no exercise → can throw clot to the lungs
● IV heparin
● initiate anti-coag therapy ➢ lovenox, heparin IV (therapeutic levels - draw aPTT)
DVT and PE DIAGNOSIS:
● chest x ray, arterial blood gasses, D-dimer (inflx)
● GOLD STANDARD = CT scan w contrast
DVT and PE NURSE MANAGEMENT
● anticoagulation meds
● endovascular intervention = remove clot
● thrombolytics = clot busters (Alteplase)
● reduce discomfort/manage pain
● relieve anxiety
● mange O2 therapy/ encourage exercise
Lymphangitis
inflammation, acute influx of lymph channels (red streaks that outline lymph vessels as they drain)
Lymphadenitis
involves lymph node; become larger, red, and tender
caused by strep or staph
Lymphedema
tissue swelling due to inc lymph and
obstruction of the lymphatic vessels;
begins soft/pitting, then hard/non pitting
Cellulitis Clinical manifest.
● strep or staph usually
● acute onset of redness, swelling, tenderness
Cellulitis Nurse management
● outline to monitor progression
● cool, moist packs until influx goes does
● don’t use heat
● often recurs - edu about foot care, inspecting between toes ➢ keep clean and dry
Ankle Brachial Index (ABI)
muscleskeletal and aging
- Loss of height due to osteoporosis
- Kyphosis – forward curvature of the thoracic spine
- Thinned intervertebral discs, compressed vertebral bodies
- Flexion of knees and hips
- Menopausal withdrawal of estrogen contributes to osteoporosis
- Loss of muscle strength
- Collagen structures less able to absorb energy
***Many effects of aging can be slowed if the body is kept healthy and active
Neurovascular assessment
6's P's • Pain - ask • Paresthesia - ask for numbness • Pulse - palpate, if none use doppler • Pallor - inspect - temperature • Pressure - can they tell the difference between pressures • Paralysis - too far gone
muscleskeletal - Diagnostic evaluation
- X-ray - “go to” check for texture, breaks, density, bone heal - serial x-ray
- Bone Densitometry - DEXA - bone mineral density - used to diagnose osteoporosis
- Bone Scan - Used to detect tumors, osteomyelitis, and breaks. Requires education, uses radioactive isotope, sits and waits, then gets scanned. Isotope causes a warm flushed sensation, needs an empty bladder.
Arthroscopy - Scope used therapeutically and diagnostically in joints
Arthrocentesis - Aspirate joint synovial fluid - thera. and diagn.
Electromyography (EMG) - test to look at nerve conduction - carpal tunnel - used to determine if its a muscle or nerve issue
osteoarthritis (OA) Risk Factors
older adult, female, post-menopausal, Hispanic and African American, obesity, previous joint injuries
osteoarthritis (OA) diagnosis
X-ray
osteoarthritis (OA) treatment
decrease pain and stiffness - weight loss, incorporate exercise - NSAIDS, Tylenol, steroids, physical therapy, assistive devices,
lastly invasive - surgery
osteoarthritis (OA) CM’s
- Insidious, progressing over multiple years
- Pain – aggravated by movement, relieved at rest
- Stiffness – especially in the morning
- Functional Impairment – decreased ROM
- Joint enlargement
- Crepitus
Total Joint Arthroplasty/Replacement
Surgical removal of unhealthy joint surfaces and replacement with metal artificial surfaces
Total Joint Arthroplasty/Replacement
Nursing Interventions (Post-op)
- Preventing DVT - pain, swelling, change in color, tenderness, warmth - compression devices, ambulation, ankle ROM, anticoagulation meds
- Preventing Infection - fever, high WBC’s, purulent drainage, pain, CHG baths, prophylactic antibiotics
- Managing Pain - ICE, pharm, non-pharm, promote ambulation
- Promoting Ambulation
- Monitoring Wound Drainage
- Preventing Dislocation (THA) HIP - affected extremity will be shorter and external rotation, pain, unable to bear weight, adduction
- Clinical Manifestations of Joint Dislocation
- Hip Precautions - bending over at 90 degree angle, do not cross legs, hips cannot be lower than knee, turn on non-operated side, no internal/external rotation
Osteoporosis
Degenerative disease of the bone characterized by reduced mass, deterioration of matrix, and diminished architectural strength 🡪 Leads to bone fractures
Osteoporosis * Risk factors *
women, post-menopause, small Frame women, Asian and caucasian, calcium and vit D insufficiency, corticosteroid use
Osteoporosis diagnosis
DEXA
Osteoporosis prevention
identify people at risk, exercise, no smoking
Osteoporosis * Foods high in calcium and vitamin D?*
dairy, eggs, almonds, OJ, steamed broccoli
Osteoporosis - education regarding calcium/vitamin D supp and bisphosphonate?
avoid carbonated soft drinks… ?
Osteoporosis nursing interventions
- Promoting Understanding of Regimen
- Relieving Pain - heat
- Preventing Injury ** - fall precautions
- Improving Bowel Elimination (r/t immobility and medication) - w/fiber & fluids
Osteomalacia
Metabolic bone disease characterized by inadequate mineralization of bone - weak, soft bones w/deformities
Osteomalacia treatment & Clinical Manifestations:
Skeletal softness and weakness Skeletal deformities Pain Bowing of bones and spinal kyphosis Pathologic fractures
treatment?
Osteomyelitis - infection of the bone
Causes?
blood-borne infection, contamination during surgery, vascular insufficiency
Osteomyelitis Risk Factors?
malnourished, obesity, long-term steroid use, IV drug use, older adults, chronic illness
Osteomyelitis Treatment? **
long-term antibiotics, PICC
line then oral
Osteomyelitis diagnosis
Arthrocentesis
Osteomyelitis CM’s ***
Pain
Swelling
Extreme tenderness
Osteomyelitis Nursing Interventions:
Relieving Pain
Improving Physical Mobility at comfort level
Controlling the Infectious Process - lots of assessing, antibiotics, lab draws
Low Back Pain Nursing Interventions: **
Relief of Pain
Improved Physical Mobility
Use of Back-Conserving Tech. of Body Mechanics
Weight Reduction
Low back pain causes
improper lifting during activity, weak muscles, comorbidities - depression, stress, obesity, smoking
Low back pain diagnosis
x-ray, CT, MRI
Low back pain CMs **
Pain
Acute (less than 3 months) vs Chronic
Muscle spasms
Radiculopathy(nerve involvement w/pain) shooting, sharp, electric, burning pain/Sciatica(shooting feeling down the leg)
