PVD/ HEMATOLOGY / hypertension (EXAM 1) Flashcards
Arteries
carry blood away from the heart, and have thick elastic walls
Arterioles
less elastic tissue, the major control of arterial blood pressure, primary distributor of blood flow (responds to O2 levels, CO2, temperature)
Capillaries
very thin, exchange of nutrients and metabolic end products (O2 and CO2) occurs
Veins/ venules
- return blood to the heart
- thin walls
- except for the largest and the smallest, veins have valves to prevent back flow
- skeletal muscles help move blood through veins
- 60% of the blood in the body is in the veins
Lymphatic system
- lymph capillaries, lymph, and nodes carry fluid from interstitial spaces to the blood
- proteins, fats and some hormones return to the blood via the lymph system
- lymph nodes filter pathogens and foreign
particles - Any procedure that removes lymph nodes can cause lymph edema (mastectomy or lumpectomy)
5 Spleen- is a lymph organ
spleen
is a lymph organ
very vascular
houses 1/3 of total platelets has a lot of lymphocytes and monocytes (need for immunitites)
not palpable unless enlarged
tonsils are now believed to play a role in adult immunity
the job is to remove the bad stuff from the body by producing more WBCs
Neurovascular assessment
Pain- does the patient have pain? What time and when does it happen
Pulse- are peripheral pulses present? are they equal on both sides?
Pallor- does the patient have sensation
Paralysis- can the patient move?
pluses
0- absent 1+ - faint, perhaps fleeting 2+ - normal 3+ - increased very strong 4+ - bounding
decreased pulse- arterial problem
always compare pulses side to side but never take both carotids at the same time
Pulse findings that may be present with decreased arterial flow
- absent weak thready (decreased cardiac output)
- forceful or bounding ( hypertension, circulartory overload)
- asymmetric pulse (impaired circulation)
- decreased capillary refill ( decreased arterial flow)
Pathophysiology
arterial insufficiency
the leading cause of PAD
is artherosclerosis
primary psychical change is thickening of the arterial walls which casues a narrowing of the vessel lemen causes
decreased blood flow
the blood flows is decreased the supply of _____ is also decreased
oxygen and nutrients
Pathophysiology
venous insufficiency
- venous blood flows backward, which causes venous congestion. this can be caused by valvular incomplete and high pressures in the deep venous system
Risk Factors of PVD
tobacco use diabetes lack of exercise hypertiglyceridemia hyperlipidemia uncontrolled hypertension genetic predispoition getting older elevated C reactive proteins obesity hyperuricemia (uric acid)
Intermittent claudication
hallmark sign of peripheral arterial disease
pain resolves within 10 minutes of stopping exercise
pain is reproductive
Rest Pain
pain in the foot or toes that is aggravated by elevation this pain occurs more at night
Peripheral edema
0- no edema
1+ (2mm) barely detectable depression with immediate rebound
2+ (4mm) slight indentation that takes 15 seconds to rebound
3+ (6mm) deeper indentation that takes 30 seconds to rebound
4+ (8mm) deep edema that takes greater than 30 seconds to rebound
Diagnostic studies
- angiography
- venography
- doppler ultrasonography
- Duplex
- angle brachial index
Angiograophy
- radiographic exam
- injection of contract medium (check for iodine allergy)
- Consent form required
- Teach patients what to expect (warm flushed feeling as dye passes)
- postest nursing care
Post Angiography nursing care
- assess pulses, vitals and site q15 for 1 hr, then q30 for one hour then q1 until stable
- neurovascular status of affected extremity, temp., pulses, pain,
- encourage fluids to help move the dye, contrast can cause renal failure so monitor I&O
- bedrest up to 6 hours with affected leg straight as not to interrupt blood flow to extremity and not causing trauma to stite
Venography
x-ray determination using contrast media to outline venous filling. defects collateral circulation defined as well
Doppler ultrasonography
used to examine arterial or venous flow, a trasducer directs high frequency sound waves toward the vessel being examined. Measures velocity of blood flow through the vessel
(stroke and heart attacks are caused b plaque and blood clots
Duplex
uses color doppler system to map blood flow through the entire region of an artery or vein. Also provides anatomic and physiologic information about the blood
ankle brachial index
calculated by dividing the ankle systolic blood pressure by the highest brachial systolic blood pressure
A normal ABI is .90-1.30 and ABI between .41 and .89 indicates mild to moderate PAD
Therapeutic Goals
1.Increased arterial blood supply
2. Decrease venous congestion
3. Promote vasodilation
4. Prevent vasculour compression
5. relieve pain
6 maintain tissue intergrity
Important in reaching goals
Teach first - use non pharmocological interventions first (includes patient ed)
Medications- use second
Surgery0 most aggressive treatment- bypass grafts, clot removal, endarterectomy, angioplasty, amputation
Client/ Health education
Smoking cessation
PLacement of extremities
Foot and skin care
Activity
Venous- frequent rest periods and use of elastic stockings
Exercies
Burger- Allen- elevate legs, ;egs dependent, legs level with heart
- walking
- bedrest!! not exercise for leg ulcers and cellulities gangrene or acute thrombotic occlusions
Nutritional Therapy
BMI < 25 kg
Waist circumference < 40 inches for men and <2g
Complications of Peripheral Arterial Disease
- atrophy of the skin and underlying muscles
- delayed healing
- wound infection
- tissue necrosis
- arterial ulcers
- gangrene
Medication Therapy
- antiplatelet agents- aspirin, plavix (dont take both together)
- Ace Inhibitors (angiotension conversion enzyme) Rampiril decrease morbidity and mortality)
- Trental- used for intermittent claudication (pain with activity and ends when activity is stopped, inhibits platelet aggregation increases vasodilation)
- Pletal- used for intermittent claudication
Arteriosclerosis
thickening of the walls of the arteries and arterioles and loss of elasticity often develops in aging and in hypertension and diabetes
Atherosclerosis
focal changes on arterial intima such as lipid and calcium which lead to accumulations (plaque) a type of arteriosclerosis
Peripheral arterial occlusive disease (atherosclerosis obliterns)
common sites for arterial disease: iliac artery, deep femoral artery, superficial femoral artery, anterior tibial artery
- diabetics tend to have trouble below the knees
a. obstructive lesions in aorta below renal arteries to popliteal artery
Symptoms of peripheral arterial occlusive disease
- intermittent claudication- pain that occurs in the leg with exercise resolves with rest, its reproducible, give trental
- bruits
Treatments for peripheral arterial occlusive disease
- Sympathectomy -removing part of a nerve to inhibit constriction)
- Graft- take a different vessel to bypass a blockage (bypass) ca take out a block completely and use synthetic
- Endarterectomy- go it in take out the actual plaque buildup only possible with large arteries
- Angioplasty- non surgical removal of plaque, it is done by catheter
Thromboangiitis obliterans (burgers disease)
- recuring inflammation in the arteries and veins of the lower and upper extremitis resulting in thrombus formation and occlusion of the vessels
- occurs most often in men
- smoking is an etiologic and/or aggravating factor
- treatment
- foot care
- foot care
- bypass or amputation
- will feel cool and cold and have color changes my develop paratesia (decreased sensation) become very sensitive to cold
Aneurysm
points of weakness, dilation, or out pouching of arteries to at least 1.5 times their normal size, most common n the aorta, but can occur in any artery
a. two types: true or false
b. true aneuryssms- wall of the artery forms the aneurysm
c. psuedoaneurysms- are not aneurysms, but a disruption of all the layers of the arterial wall resulting in bleeding that is contained by surrounding structures
d. causes: unknown atherosclerosis trauma congeital
(no surgery until 5mm, unless other problems associated)
abdominal aorta is the most common site of aneurysm
What will the client look like
asymptomatic except for pain from aneurysmm pressing on surrounding structures
how will i know if the client is getting worse
rupture if the location of the rupture is posterior sever back pain , if rupture occurs anteriorly into the abdominal cavity most patients do not survive due to hypovolemic shot tachycardia hypotension pale clammy skin decreased urine output
Nursing care for aneurysm repair
- maintain adequate bp
- continuous ECG monitoring
- Monitor O2
- Neurovascular checks - see if patients can tell difference between hot and cold
- prevent infection
- abdominal assessments (bowel sounds, NG placement)
- Monitor I & O
- Instruct patient to gradually increase activities avoid heavy lifting 4-6 weeks
Embolism
when a clot breaks loose
most common place for an Embolism
arise from thrombi develping in the heart
they become detached and move into arteries and become lodged
Embolism symptoms
acute severe pain
gradual loss of sensory and motor function
embolism treatment
embolectomy
Raynaud’s Disease
an episodic vasospastic disorder of small cutaneous arteries
Characteristics of Raynauds disease
- Intermittent arteriolar vasoconstriction secondary to sympathetic nervous system stimulation
- Symptons- coldness, pain, pallor, and occasionally ulceration of fingertips
- Usually fingers- sometimes toes
- Most common in females
- Triggered by stress or cold
- Reactive hyperemia0 fngers turn white then blue and red
- usually bilateral
- usually bilateral
- ay improve may worsen may show no change
Raynaud’s Nursing Care and Teaching
Loose warm clothing, gloves, temperate extreme should be avoided, stop smoking and avoid caffeine, drug therapy currently used is calcium channel blockers (procardia and cardizem)
Peripheral Venous Health Problems
Venous stasis- blood not moving in the veins
Blood Hypercoagulability- blood is thick and is more likely to clot. More prone are in stage maligancys some kidney diseases some meds including hormone therapy and birth control and tobacco
Venous Thrombosis
Patho- a vein becomes inflamed (this happens 65% of the times with IV therapy) sometimes a thrombus forms in association with the inflammation this is a venous thrombus
Venous Thromboembolism
-is a venous thrombus that has moved from its point of origen
* this is a blood cloth that has broken loose and is floating around in the blood stream
- complications of VTE
- PPulmonary embolism
Chronic venous insufficiency0 can interupt blood flow
- phlegmasia cerulean dolens (rare blue leg, happens quickly, iminese pain , and swelling and really blue leg if there is not an immediate intervention they will lose limb
Non Pharmocolgic VTE prevention
- Reposition
- Exercise limbs (extension and flexion helps move blood)
- OOB
- Teach patients and caregivers (education on what they need to do and why )
- Compression stockings (measure leg and psition properly)
- Sequential compression devices (air pump leg cuffs)
Pharmocolgoic Therapy for VTE prevention
- Oral NSAIDS- ibuprofen, Motrion, Enderal,
- Topical heparin gel
- Coumadin - To prevent not treat (can be used in outpatient setting)
- Heparin- to prevent or treat ( has to be closely monitored in hospital use)
Blood thinner basics
- Blood thiners focus on PT and INR labs, base doasge on INR levels
- INR levels are also based on what you want to prevent (DVT 2.0-3.0)
PTT- is linked to heprin (lovenox)
Blood thinner nursing interventions
check for blood in urine and stool
nose bills happen when people dont clot well
Tachycardia- check pulse, apical heart rate , heart monitor, this is a sign someone might be bleeding, heart will be beating faster and faster to make up for volume loss
Check for brusing (turners sign- flank bleeding)
(collin is bleeding under the skin around belly button)
Venous Ulcers cause
inadequate oxygenation and nutrients causing cell death
Venous Ulcers clinical manifestations
- closely located above the medial malleolus
- Irregular shaped
- Ruddy color
- Swelling of leg
- Painful especially when leg is in a dependent position
Venous Ulcer treatment
- compression0 elastic wraps custom itted compression, paste bandages (Unna boot) the nurse must evaluate which type would be appropriate
- Moist environment dressings- transparent film dressings, hydrogels, gauze moistened with saline, whirlpool therapy, and debridement (removal of dead tissue) or grafting if ulcer fails to respond to conservative therapy
- Proper nutrition- protein vitamins A and C and zinc
Varicose Veins
dilated and tortuous veins that result from increased venous pressure
Varicose Veins Clinical Manifestation
ache or pain after prolonged standing relieved by waking or elevation of the limbs
Prevention of Varicose Veins
- avoid venous stasis
a. standing or sitting for prolonged periods of time
b. COnstricting clothing
c. crossing legs - wear elastic stockings
- Maintain ideal body weight
blood pressure normal range
SBP < 80
Prehypertension
SBP 120-130 or DBP 80-89
Hypertension Stage 1
SBP 140-159 or DBP 90-99
Hypertension Stage 2
SBP >160 or DBP > 100
Cardiac output
is how much blood your heart pumps times the resistance in the arteries
Primary hypertension
is either essental or idopathic
- idopathic we dont know what causes it (most common)
Secondary Hypertension
High BP with a known casue
Primary hypertension contributing factors
- ** contribute but dont cause***
- increased SNS activity0 activated by fight o flight
- increased sodium0 retianing hormones and vasoconstrictors
- Diabetes
- greater than ideal body weight
- increased sodium intake (some are sodium sensitive)
- Excessive alcohol intake
Risk Factors for Primary Hypertension
- age
- alcohol
- smoking
- diabetes
- elevated serum lipids
- excessive dietary sodium
- gender
- family history
- obesity
- ethnicity
- sedentary lifestyle
0 socioeconomic status - stress
Hypertension is known as what
They silent killer
Complications of Hypertension
- target organ disease occur most frequently
- heart wears out and inlarges
- brain stroke
- peripheral vasculature- PVD, varicose veins
- Kidneys damage, will lead to dialysis
- Eyes veins and vessels can burst and go blind
Hypertension Psychopathology
Heredity
Water and sodium retention
Stress and increased SNS activity
Insulin resistance and hyperinsulinemia
Hypertension Assessment
Bilateral BP measurement then use the arm with the highest reading
Use an appropriate sized cuff
Hypertension Diagnostic Studies
- these tests are usually done as a screening
- UA, creatinine clearance- kidney function creatinine (1.0 norm) will be elevated
- Serum electrolytes glucose- glucose free insulin in the blood stream can elevate the blood pressure
- BUN and Creatinine
- Serum Lipid profile- lipid cholestroral, trigelerides
- ECG- damage to heart
- Echocardiogram
Hypertension goals
- control blood pressure
2. reduce CVD risk factors
Lifestyle modifications
- weight reduction
- dash diet
- sodium restriction
- moderation of alcohol consumption
- regular aerobic activity
- avoid all tobacco
- address psychosocial risk factors
Hypertension Medications
- adrenergic inhibitors
- direct vasdilators
- angiotensin coverting enzyme inhibiors
- angiotensin II receptor blockers
- calcium channel blockers
- ace inhibitors
- aldosterone
Hypertension nursing diagnoses
ineffective health maintenance axiety sexual dysfunction ineffective self health management disturbed body image ineffective tissue perfusion knowledge deficit risk for non compliance
Complications associated with hypertension
adverse effects of medications
hypertensive crisis
stroge
myocardial infarction
Hypertension in Older persons
- isolated systolic hypertension (ISH) is the most common in people over 50
- older adults more likely to have “white coat hypertension”
- Often a wide gap between the first Korotkoff sound and subsequent beats is called auscultatory gap
- Failure to inflate the cuff high enough can result in underestimate of SBP
- older adults have varying degrees of impaired baroreceptor reflex mechanisms (orthostatic hypotension occurs often , in patients with ISH)
Hypertensive Crisis
EMERGENCY
- sever increase in BP (.> 220/140)
- often occurs in patients with history of HTN who have failed to comply with meds or undermedicated
clinical manifestations for hypertensive crisis
hypertensive encepholpathy cerebral hemorrhage acute renal failure myocardio inarction heart failure with pulmonary edema * requires hospitalization, aggressive treatment and patient education
