Cad,DVT,PVD,PAD S.G Test 3- DONE

Question 1

1. Kill, hurt, know antiplatelets. Purpose? (ATI PG.172)

Answer 1

Aspirin, Clopidogrel)

Uses: Clot preventions

bleeding precautions

-GI bleeding ect

-risk for hemorrhage

-black tarry stools

ANTIDOTE : activated charcoal

Caution:

-clients w/GI ulcers

-vitamin k deficiency

-renal/hepatic impairment

-pancytopenic clients

-discontinue use 1 week prior to surgery

Monitor for salicylate poisoning: Main symptom = tinnitus

-take w/meals to reduce GI upset

-Do not take aspirin w/anticoagulants or 2 anticoagulants

LABS (not weekly)

-platelet

-HGB (Less than 7 “go to heaven”), HCT

Question 2

2. Coronary artery disease client education (pp slide 9, flashcard)

Answer 2

check cholesterol levels

-manage HTN

-control diabetes

-stop smoking

-increase physical activity (weight loss if needed)

-Reduce red meat, egg yolks & whole milk

-low fat, high fiber diet (increase foods w/omega 3 fatty acids like tuna/salmon)

Question 3

3. Coronary artery disease nursing actions (pp slide 9)

Answer 3

-Assess characteristics & level of chest pain

-Administer oxygen

-encourage rest

(Oxygen, then nitroglycerin)

Question 4

4. Coronary artery disease risk factors(pp slide 5)

Answer 4

Modifiable:

-High LDL’s

-hypertension

-tobacco & alcohol use

-physical inactivity

-obesity

-diabetes (2-4 times greater risk)

Question 5

6. Manifestations of an MI (PP Slide 16)

Answer 5

-sudden chest pain

-shortness of breath

-indigestion

-Nausea

-Anxiety

-cool, pale, moist skin

• increased HR & RR

Question 6

6. Priorities & key labs for MI (pp slide 21)

Answer 6

Priorities (pp slide 21)

 -oxygen 

-nitroglycerin 

• IV morphine sulfateKey labs: (pp slide 18)

-Troponin is the gold standard to diagnose an MI

Question 7

5. Myocardial infarction client education (pg.334)

Answer 7

-set up cardiac rehab

-gradual exercise that increases w/pts tolerance

-stop smoking

-minimize stressors

-monitor pulse & BP

-report symptoms to PCP ASAP

-diet modifications (avoid foods high in sugar, fat, sodium, red meats)

-establish physical limitations such as maximum amount client can lift

-important to continue medical supervision

-recognize & manage depression

-can resume sexual activity when pt can walk 1 block or climb 2 flights of stairs w/out symptoms

Question 8

7. Manifestations of angina (pp slide 7, flashcard)

Answer 8

*Angina will subside w/nitroglycerin & rest. If it doesn’t subside then it’s a myocardial infarction.

-unusual fatigue

-weakness/numbness

-shortness of breath

-pallor

-diaphoresis

-chest pain radiating from chest to shoulders, arms, especially on left side. Or jaw neck, or teeth.

Question 9

9.DVT manifestations (flashcard)

Answer 9

-pain in the leg

-redness

-warm to touch

-leg swelling (one leg swells, other appears normal)

-low grade fever

Question 10

8. DVT nursing interventions(poster)

Answer 10

-apply warm, moist heat

-increase fluids

-monitor platelets

-reinforce need to perform leg exercises q hr while awake

-encourage ambulation for a few mins each hr while awake

-help client avoid prolonged sitting & poorly fitting, constrictive anti embolic hose

-no crossing legs,no propping extremities w/pillows under the knee

-don’t massage calves/thighs

-apply compression & anti embolic stockings as ordered

-monitor for thrombophlebitis (calf pain, tenderness, warmth, redness swelling, low grade fever) If so notify provider & have client maintain bedrest until further evaluation

Question 11

10.DVT risk factors (poster, flashcard)

Answer 11

-Venous stasis (bed rest, obesity, surgery, immobilization)

-Endothelial damage (trauma, surgery, IV drug usage, indwelling devices)

-Hypercoagulability (pregnancy, cancer, oral contraceptives, dehydration)

Question 12

11.PVD client education (poster, flashcard)

Answer 12

-elevate the legs

-avoid crossing legs & restrictive pants

-change positions often

-DO NOT dangle legs, sit/stand for long periods of time

Question 13

12.Antihyperlipidemic meds (pp slide 12)

Answer 13

(Statins, bile acids, colestipol granules)

-take @ night

-no grapefruit juice

-use sunscreen

-watch for muscle pain (rhabdomyolysis)

-check LFT’s (liver function tests)

-Colestipol mix w/apple sauces or juice to not irritate the esophagus

Question 14

13.Nursing interventions for cerebral aneurysm

Answer 14

-dark quiet room

-no bright lights

-avoid stress & overstimulation

-avoid people (except fam)

Question 15

14.PAD client education (poster, flashcard)

Answer 15

-DON’T elevate legs

-avoid tight clothing

-no heating pads
-check bath water w/thermometer

-low fat diet

-stop smoking

-perform daily skin care w/moisturizer

Question 16

15.Raynaud’s phenomenon client education (poster,flashcard)

Answer 16

-avoid exposure to cold (wear hats, mittens, heavy socks, warm car before going into it)

-avoid tobacco & nicotine products

-avoid trauma

-avoid excessive stress

Question 17

16.Heparin meds (ATI PG.172)

Answer 17

(Heparin, enoxaparin)

To prevent blood clots from becoming larger or forming

Antidote = protamine sulfate

-Major risk for bleeding/hemorrhage

-Monitor for thrombocytopenia, anemia, bruising

Contraindicated: active bleeding, ulcers, history of stroke or recent trauma

• Check LABS (weekly) :

APTT (activated partial thromboplastin time) RANGE: 30-40PTT

Platelet count (can cause low platelet count), PT, INR, CBC

*Heparin and warfarin can be given together at the same time once we reach therapeutic INR lab values, once therapeutic level is reached stop heparin.

Question 18

17.Thrombolytic meds (pp slide 12)

Answer 18

(Alteplase (TPA), streptokinase)

most powerful, breaks up clots

-massive bleed risk/ assess for bleeding

Really low BP, tachycardia, pale, short of breath are signs of bleeding

Adverse reactions: internal bleeding GI, brain

-don’t give to people w/ulcers or bleeding tendencies

-do not give injections

-use EXISTING PERIPHERAL IV to administer

-question provider if client has had a recent trauma, hemorrhage stroke

Question 19

18. Nitroglycerin meds (pp slide 12)

Answer 19

-No sildenafil

-keep in dark original packaging

-causes hypotension

-remove for 10-12 hrs

-expected headaches

Question 20

19.Abdominal Aneurysm nursing interventions (ATI PG.208)

Answer 20

-monitor vital signs & circulation q 15 mins

-monitor & maintain BP w/in normal limits

-maintain warm environment

-monitor I &O’s, weight gain, elevated BUN or creatinine

-monitor bowel sounds & observe for abdominal distention

-monitor PQRST of pain

-Client should avoid straining during BM, coughing & holding breath while changing positions.

Question 21

20.Nursing manifestations for venous stasis

Answer 21

-Pain & heaviness

-varicose veins

-itchy skin

-dark, hard or leathery skin

-swelling

-weak or poor pulse

Question 22

20. Interventions for venous stasis

Answer 22

-assess pt’s lower extremities

-check body temp

-check pulses

-assess for pain

-assess for wounds

Question 23

20. Client education for venous stasis

Answer 23

-walking 3x/week 30-45 mins/day

-avoid smoking

-avoid constricting clothing

-Don’t cross legs at knees

-check bath water w/thermometer

-warm environments

Question 24

21.Early and late indications of increased intracranial pressure

Answer 24

Early: headache

Late: no oxygen, leads to decreased LOC

Question 25

22. Manifestations of varicose veins

Answer 25

(Distended rope like veins)

Manifestations:

-muscle cramps (commonly @ night)

-dull, achy feeling

-increased muscle fatigue

-ankle edema

-heavy feeling in the legs

Question 26

22. Preventions & client education for varicose veins

Answer 26

-compression stocking

-change positions frequently

-daily walking up to 30 mins

-weight reduction plan

-elevate legs above heart level

-avoid sitting/standing for long periods of time, wearing tight socks, crossing legs