Exam 2, Deck 3 Flashcards
Acute pulmonary edema is a medical emergency caused by…. (general)
Anything that decreases the ability of the left ventricle to pump
Acute pulmonary edema is a medical emergency caused by…. (specific, 5)
MI HTN Valvular disease Rapid arrhythmias Exposure to cardiotoxic chemicals
Most symptoms with Pulmonary Edema are ______
PULMONARY
Pulmonary symptoms involved with pulmonary edema (6)
Sudden SOB Paroxysmal Nocturnal Dyspnea (PND) Orthopnea Crackles Gurgling Respirations Pink frothy sputum
Non-Pulmonary Symptoms involved with pulmonary edema (4)
Pale –> Cyanosis
ABGs: Decreased PaO2, Increased PaCO2
Tachycardia
Two nursing goals with pulmonary edema
Improve the pump of the left ventricle
Improve respiratory exchange
Nursing interventions for pulmonary edema (7)
1) Oxygen
2) Positive Inotropics
3) Morphine
4) Diuretics
5) Other meds
6) Pulmonary artery line, arterial line
7) Assess for shock
Oxygen during pulmonary edema (3)
1) PEEP helps alveoli re-open
2) Pulse oximeter
3) Test ABGs
CHF: Def
Chronic Heart Failure: The heart cannot pump adequate amounts of blood to meet metabolic demands
What are the top two most common reasons to visit HCP?
1) HTN
2) CHF
Classifications of CHF (4)
I No limitations
II Slight limitations
III No symptoms at rest; some symptoms with activity
IV Symptoms at rest (Poor prognosis, need assistance with ADLs
Pathophysiology of CHF- Causes (4)
- CAD
- Systemic or pulmonary HTN
- Valvular Heart disease
- Increased workload of the heart
What would cause increased workload of the heart
- Arrhythmias
- Hypoxias
- Really high fevers
- Severe anemia
Pathophysiology of CHF: How does it work? (3 parts)
Decreased amount of blood ejected from left ventricle –> Decreased CO –> Increased SNS –> Increased Renin
Effects of renin (2 chains)
1) Produces angiotensin I –> Angiotensin II–> VASOCONSTRICTION
2) Secretion of aldosterone –> Kidneys retain water and sodium
How are pressures altered with CHF?
Slow rise in pressures in Left ventricles –> Left atria –> Pulmonary vessels
What cycle occurs with CHF? (2 compensations)
The body induces vasoconstiction and fluid retension to compensate for CHF, but vasoconstriction increases AFTERLOAD and fluid retention increases PRELOAD
During CHF, when and why is BNP released?
BNP is released from the ventricles of the heart as pressures increased.
Helps reduce angiotensin systems, not enough to overcome, but enough to slow it down.
Symptoms of Left Ventricular Heart Failure (Left-sided CHF) (7)
- Pulmonary symptoms (observed first)
- Restlessness / anxiousness
- Tachycardia
- Pale, clammy
- Nocturia + Decreased daytime output
- Fatigue
- Weight gain
Changing lab values with left sided heart failure (3)
- Increased BUN and creatinine
- ABGs indicated hypoxia, hypercapnia
- BNPs elevated (from 100 to 800 sometimes)
Pulmonary symptoms observed with Left Sided CHF
- Cough (dry or with sputum)
- Crackles
- Dyspnea on Exertion
- Orthopnea
- Paroxysmal Nocturnal Dyspnea
Why does a CHF patient have changes in urine patterns?
Because of altered kidney perfusion. During the day, there is less kidney perfusion (because blood pools in the legs) and at night, the blood moves towards the kidney again (resulting in nocturia).
Pathophysiology of Right Ventricular Heart Failure (R sided failure)
Right ventricle cannot empty fully –> blood in right atrium becomes backed up, –> Congestion of vessels and body organs.
Causes ofo right ventricular heart failure ((3) - which is the most common?
- Left sided failure - most common
- COPD
- Cor Pulmonale
Cor Pulmonale (def)
Failure of the right side of the heart brought on by long-term high BP in the pulmonary arteries and right ventricles of the heart
Symptoms of Right Ventricular Heart Failure (4)
- Edema and weight gain
- GI issues
- Nocturia
- Fatigue
What readings would indicate right ventricular heart failure (2)
- JVD
- CVP higher than 12 (Central Venous Pressure Lines or Swan Ganz or Right Atria lines)
What GI issues do you see with Right Sided Heart Failure? (3)
- Anorexia
- Hepatspenomegaly
- Ascites
What causes GI issues seen with Right Sided Heart Failure?
Increased portal vein pressure causes engorgement of blood around the organs.
Nursing goals for a patient with CHF
- Decrease workload of the heart
- Increase myocardial activity (more effective pump)
- Eliminiate excess fluid
A CHF patient is on bedrest. What position should their bed be in?
High Fowler’s
What cardiac exacerbation should you watch out for with CHF? What could this lead to?
Watch for arrhythmias (esp Afib) - Could lead to cardiogenic shock
What four nursing interventions have to do with a CHF patient’s edema
- Monitor Is and Os
- Daily weights
- Skin care: Edematous skin is fragile skin
- Decreased sodium diet
Two measures hospitals are taking to decrease CHF readmissions
- CHF clinics
- Daily weights (scale communicates with doctor, alerts if big weight gain over a day or two –> meds can be adjusted, patient education
Pulmonary Embolism (def)
An embolism (blood clot) that becomes lodged in the pulmonary artery, obstructing the blood supply to lungs.
Pulmonary embolism physiology
There is VENTILATION to that area of the lungs, but no PERFUSION.
Five risk factors for Pulmonary Embolism (and DVTs)
1) Diseases / conditions
2) Predisposing Factors
3) Venous Stasis
4) Hypercoagulability
5) Venous endothelial damage
What is Virchow’s triad
1) Venous Stasis
2) Hypercoagulability
3) Venous endothelial damage
What conditions increase risk for PE / DVT? (4)
CHF
Pelvic and leg trauma
Post-op or post-partum
Pregnancy
What predisposing factors put a patient at risk for PE / DVT? (6)
- Age
- Obesity
- Pregnancy
- BCPs
- Sedentary lifestyle
- Smoking
Why are obesity and pregnancy risk factors for PE / DVTs?
Excess pressure on femoral arteries
What causes venous stasis? (5)
- Immobility
- Varicose veins
- Sitting / traveling
- Traction
- Depression (not moving)
What causes hypercoagulability? (3)
- Increased platelet count
- Tumor
- Massive injury
What causes venous endothelial damage?
- IV catheters
- Thrombophlebitis
Pulmonary embolism Nursing Assessment (6)
- Cyanosis
- SOB
- Tachypnea
- Hemoptysis
- Hypoxia, hypercapnia
- Chest pain
How does PE chest pain differ from CHF chest pain
PE chest pain is PLEURITIC – pain increases with each inspiration and pain subsides when the patient holds breath. (Cardiac pain is continuous and doesn’t vary with respiration)
Why would you administer a V/Q scan?
To identify blood clots –> Diagnose PE
How does a V/Q scan work?
Two isotopes: One injected, one inhaled. CAT scan indicates airflow and blood flow to the lungs by observing isotopes.
Prevention of DVTs / PE
- Passive or active ROM
- OOB and ambulating ASAP
- Adequate fluid intake
- Compression stockings
- Do not cross legs at knee
- Meds
Treatment of DVTs / PE (4)
- Oxygen
- Drugs
- Surgical intervention: Embolectomy
- Greenfield filter
Labs / observation of patient with DVT / PE (2). What are you observing for? (2)
- ABGs
- ECG
Observing for Hypoxia, arrhythmias
What is a Greenfield Filter?
Filter threaded to renal vessels, catches clots in legs as they travel up so body can break them down. Decreases risk for PE.
Cardiac Arrest - Def
The heart ceases to produce an effective pulse and blood circulation
Most reliable sign of cardiac arrest
Absence of a pulse
What signs and symptoms occur with cardiac arrest? (4)
- Pulse, consciousness and blood pressure are lost immediately
- Pupils dilate within 45 seconds
Assessment for cardiac arrest - adults v kids
- Adults: Check carotid for pulse
- Kids: Check brachial for pulse
What is the first thing you should do when a patient goes into cardiac arrset
Begin CPR until monitor and defibrillator arrive
What three things do you assess on any cardiac arrest patient
- Heart rate
- Breathing (airway)
- Level of consciousness
How does mortality increase with time after cardiac arrest?
Increases by 10% for every minute of delay in defibrilation
Most cardiac arrest in kids is _______ in orgin
RESPIRATORY
Peripheral vascular Disease (def)
Diseases of the blood vessels that supply the extremities (usually the legs)
Should you elevate the legs with peripheral vascular disease?
Depends on whether the problem is arterial or venous:
eleVate the legs for Venous
dAngle the legs for Arterial
Four causes of Arterial PVD
1) Atherosclerosis or Arteriosclerosis
2) Obstruction by thrombus or emboli
3) Severe vasoconstriction (like Raynaud’s)
4) Arterial Inflammation
What is the difference between Arteriosclerosis and Atherosclerosis
Arterio = hardening Athero = plaques, obstructions forming
Diagnostic studies for arterial PVD (5)
1) Doppler
2) Dulex Ultrasound
3) MRA: Angiography
4) Arteriography
5) Ankle-brachial index
When would you use a doppler for arterial PVD
When you can’t feel pulse with fingers
Benefits of duplex ultrasound (3)
- Non-invasive
- Helps diagnose extent of PVD
- No prep, portable equipment
What do angiography or arteriography look at
The blood flow for arterial PVD
What do you want to see when measuring the ankle-brachial index?
We want the leg and brachial systolic pressure to be pretty much the same
Six assessments for an arterial PVD patient
1) Pain
2) Pulseless (or low pulse)
3) Poikilothermic
4) Pallor
5) Paresthesias
6) Paralysis (in serious cases)
Nature of the pain with arterial PVD
Intermittent claudication with exercise (usually in calf) - pain is one joint level below the arterial narrowing
Define intermittent claudication
Pain is one joint level below the arterial narrowing
Poikilothermic (def)
Patient takes on the temperature of the surrounding room - usually cool
What is an arterial PVD patient’s pallor like? (4)
- Leg may look very pale
- Loss of hair on skin (moves its way up with time)
- Skin takes on characteristic shiny look
- Toenails become thick and rigid
What is the danger with paresthesias for arterial PVD?
Potential for ulcer (often on toe)
4 nursing intervention for arterial PVD
1) Control the underlying diseases and factors
2) Improve blood supply
3) Avoid vasoconstrictors
4) Prevent tissue damage
What can a nurse do to improve the arterial PVD patient’s blood supply?
1) Position - keep legs at level of heart or below
2) Warmth (socks and blankets)
3) Exercise as tolerated
Why do you keep arterial PVD patient’s legs at or below the level of the heart
If you raise their legs, their skin will blanch and get even less blood flow.
What can a nurse do to help prevent tissue damage in an arterial PVD patient (4)
- Keep pressure off the feet (cradle)
- Inspect feet regularly for wounds
- Good nutrition
- Check temperature of water for patient
What medical (non-surgical) procedure can be used to manage arterial PVD?
Percutaneous Transluminal Angioplasty (PTA) - usually with (balloon) stent
Four types of surgical management of arterial PVD
- Endarterectomy
- Vascular grafting (usually manmade)
- Amputation
- Embolectomy
What is Endarterectomy?
For Arterial PVD: Remove the plaque, then sew the artery shut.
Phlebitis (def)
Inflammation of vein
Thromboembolism (def)
Piece of clot breaks off and travels
Thrombophlebitis (def)
Clot and inflammation of vein
Pathophysiology of venous PVD (4 components)
Blood stasis –> Intimal damage –> Hypercoagulability –> Clot
Who’s at risk for venous PVD? (6)
- Family history
- Patient history
- Greater than 40 years of age
- Surgery lasting longer than 30 min
- Varicose veins
- Estrogen treatment
What will a nurse observe for a patient with PVD (3)
- Calf pain and tenderness
- Edema
- Warm leg
Seven nursing interventions t prevent venous stasis
1) TED stockings or sequential compression devices
2) Early ambulation
3) Raise the foot of the bed ocassionaly (note: this is different from arterial PVD)
4) Passive and active ROM
5) Monitor IV sites and discontinue IV ASAP
6) Anticoagulants
* Avoid tight clothes or leg crossing
Nursing interventions if thrombophlebitis is present (3)
- Rest
- Moist heat
- Anticoagulants
What medication should a patient discontinue if they have venous PVD?
Oral birth control
5 nursing interventions for chronic venous stasis
1) Elevate the legs
2) Pressure stockings
3) Encourage walking
4) Protect from trauma
5) Inspect daily; keep clean and dry
What is the difference between venous ulcers and arterial ulcers
Venous ulcers are typically large, superficial and highly exudative, and often occur on the medial or lateral malleolus
Arterial ulcers are small, circular, deep and usually on the tip or side of toe
Carotid Artery Disease - Three symptoms
- Transient blindness
- Weakness / tingling
- Slurred speech
How id carotid artery disease diagnosed
Carotid artery doppler
How is carotid artery disease treated
Carotid stent or carotid endarectomy (removal of the atheroma)
How is carotid artery disease detected
- Listen to the carotids for bruit with stethoscope
5 things to watch for after a carotid endarterectomy
- Beware of labile BP
- Make sure airway is patent (pressure on trachea)
- Check trachea is still midline
- Neuro checks q1hour for first 24 hours
- Watch for bleeding into neck bc placement
How is hypertension diagnosed?
Systolic >140 mmHg
Diastolic >90 mmHg
ON MORE THAN ONE OCCASION
Pre-HTN numbers
Systolic: 120-139
Diastolic: 80-89
Stage 1 HTN numbers
Systolic: 140-159
Diastolic: 90-99
Stage 2 HTN numbers
Systolic: 160-179
Diastolic: 100-109
Stage 3 HTN numbers
Systolic: >180
Diastolic: >110
Life threatening HTN numbers
HYPERTENSIVE CRISIS
Systolic: 210
Diastolic: 120
Two etiologies of HTN
1) Primary (essential) HTN - unclear origin
2) Secondary HTN - treatable if you correct the cause
What are a few causes of secondary HTN?
- Narrowing of renal arteries
- Pregnancy
- Meds
Four body systems affected by HTN
Brain (stroke)
Eyes (blindness)
Heart (MI, CHF, LVH)
Kidney (renal failure)
Prevalence of HTN
25% of adults (estimated) but NOT a normal part of aging.
Nursing interventions for HTN (3)
- Lifestyle modifications
- Pharmacological
- DASH diet
What is the goal for a HTN patient?
Pressure under 140/90
How fast do you want to lower BP in hypertensive shock
To lower BP immediately, but not so rapidly that you cause vascular collapse / shock.
- Lower 25% in first two hours
- Down to 160/100 in the next 2-6 hours
Two causes of hypertensive crisis
- Thyrotoxocis (Thyroid Tissue) - Excess of Epi and NE
- Pheochromocytosis
