Unit 3 Flashcards
formula for BP
BP = CO x PVR
PVR
peripheral vascular resistence
formula for CO
CO = SV x HR
SV
stroke volume
CO
cardiac output
normal BP
< 120 systolic
< 80 diastolic
What makes HTN the silent killer?
pts are asymptomatic while damage is done
HTN
> 120 systolic
> 80 diastolic
Tx for HTN is initialized at what values for pts ≥ and < 60 yo?
- ≥ 60 yo: > 150/90
- < 60 yo: > 140/90
categories of HTN
- essential
- secondary
etiology of essential HTN
not caused by pre-existing condition
etiology of secondary HTN
caused by pre-existing condition
gender-related HTN risk factors
- < 45 yo: men > women
- 45-65 yo: men = women
- > 65 yo: men < women
nonmodifiable risk factors for essential HTN
- > 60 yo
- postmenopausal
- family Hx
- African-American race
modifiable risk factors for essential HTN
- physical
- overweight/obese
- hyperlipidemia
- diet: ↑ intake
- Na+
- caffeine
- ETOH
- lifestyle
- inactivity
- stress
- nicotine use
risk factors for secondary HTN
- kidney dz
- primary aldosteronism
- pheochromocytoma
- Cushing’s
- coarctation of the aorta
- Brian tumors
- encephalitis
- PG
meds that increase risk of secondary HTN
- estrogen
- glucocorticoids
- mineralocorticoids
- sympathomimetics
continuous BP ↑ →
medial hyperplasia (thickening) of arterioles
↑ thickening of arterioles d/t BP →
↓ perfusion → end organ damage (heart, kidneys, brain)
damage from HTN →
- MI
- CVA
- PVD
- RF
MI
myocardial infarction
CVA
cerebrovascular accident
PVD
peripheral vascular dz
RF
renal failure
foods to improve HTN
- veggies
- fruits
- whole grains
- ↓ fat dairy products
- poultry
- fish
- legumes
- non-tropical oils
- nuts
foods to limit to improve HTN
- sweets
- sugary beverages
- red meat
- dietary Na+
exercise to improve HTN
40 min 3-4x/wk
Na+ restriction to improve HTN
- 2400 mg/day
- preferred: 1500 mg/day
medications for HTN
- diuretics
- BBs
- CCBs
- ACE inhibitors
- ARBs
CCB
Ca channel blocker
BB
beta blocker
ARB
angiotensin receptor blocker
ACE inhibitor
angiotensin-converting enzyme inhibitor
HTN urgencies
- can be managed outpatient
- managed w/ PO meds
- can be acute or chronic
HTN emergencies
- conditions w/ Sx of end organ damage
- acute evolving Sx
- expect ICU admission
- IV meds to manage at first
medical emergencies that can be caused by HTN
- acute CVA
- AKF/AKI
- CP, MI, ACS
ACS
acute cardiac syndrome
ARF
acute renal failure
ARI
acute renal injury
progression of CHD to HF
CAD → angina → MI → HF
stable angina characteristics
- predictable
- < 15 min
- relief: rest, TNG
unstable angina characteristics
- unpredictable
- > 15 min
- ↑ in occurence
- No relief with rest, TNG
Sx of CAD
almost always none
MI characteristics
- > 30 min
- ↑ cardiac enzymes
- requires immediate reperfusion therapy
types of MI
- NSTEMI
- STEMI
routine labs for suspected cardiac dz
- enzymes
- myoglobin
- CK-MB
- Troponin I or T
- lipids
- TC
- HDL
- LDL
- triglycerides
meds for long-term MI Tx
- ASA
- BB
- Ace inhibitors
- ARBs
lifestyle/education for long-term MI Tx
- ↑ activity
- no nicotine
- monitoring + Tx for
- lipids
- BP
- diet: ↓ fat and Na+
HF long-term Tx meds
- diuretics
- antihypertensives
- BBs
- ACE inhibitors
- ARBs
- CCBs
- possibly digoxin
- anticoags
extra lab for HF
BNP
BNP
B-type natriuretic peptide
lifestyle/education for HF long-term Tx
- everything for MI
- Report SOB
- Daily wt: report wt increase > 3 lbs/24 hrs
- – lipid monitoring + Tx, unless indicated
arteriosclerosis
thickening/hardening of arterial walls
atherosclerosis
- type of arteriosclerosis involving plaque formation on vessel walls
- obstructs normal blood flow
- stable or unstable
stable atherosclerosis
collagen ↓ likelihood of rupture
unstable atherosclerosis
rupture can cause more damage than in stable plaque rupture
atherosclerosis modifiable risk factors
- dyslipidemia
- lifestyle
- nicotine
- obesity
- poor diet
- inactivity
- stress
nonmodifiable risk factors for atherosclerosis
- genetic predisposition
- ethnicity
- African-American
- Hispanic
assessment for atherosclerosis
- CV assessment
- echo/doppler flow studies
- labs
CV assessment for atherosclerosis
- NVD
- extra heart sounds
- peripheral pulses
lab values in atherosclerosis
- ↓ HDL-C
- ↑ LDL-C
- ↑ triglycerides
interventions for CAD/atherosclerosis
- change modifiable risk factors
- lipid-lowering agents
groups for whom lipid-lowering meds are unsafe
- liver
- active dz
- Hx of dz
- unexplained ↑ LFTs
- reproductive
- current/possible PG
- lactation
- renal impairment
- ETOH abuse
- meds
- digoxin
- warfarin
PVD
- peripheral vascular dz
- umbrella term for
- peripheral artery dz
- peripheral venous dz (also PVD)
PAD
peripheral artery dz
peripheral artery dz incidence
- most common type of PVD
- legs > arms
etiology of PAD
- systemic atherosclerosis
- same risk factors
PAD characteristics
- chronic
- partial or total occlusion to affected extremities
inflow PAD obstruction location
- ↑ inguinal ligament
- arteries
- distal aorta
- common, internal, and external iliac arteries
inflow obstruction tissue damage
atypical
outflow obstruction location
- arteries
- femoral
- popliteal
- tibial
- ↓ superficial femoral artery
outflow obstruction tissue damage
typical
PAD stages (4)
- Stage I: asymptomatic
- Stage II: claudication
- Stage III: rest pain
- Stage IV: gangrene/necrosis
inflow obstruction pain location
- back
- buttocks
- thighs
severity of inflow obstruction pain
- mild: a couple of blocks
- moderate: 1-2 blocks
- severe: < 1 blocks, or at rest
outflow obstruction pain description
burning, cramping
outflow obstruction pain location
- feet
- toes
- ankles
- calves
outflow obstruction pain relief
dangling feet off furniture
outflow obstruction pain severity
- mild: ~ 5 blocks
- moderate: ~ 2 blocks + maybe intermittent at rest
- severe:
PAD findings are dependent on the _____ of the dz.
severity
PAD assessment: inspection
- hair loss on lower leg, foot
- skin
- dry, scaly, dusky, pale, mottled
- pallor w/ elevation
- severe dz: cold, cyanotic, darkened
- darker-skinned pts: assess palms, soles
- thickened toenails
The _____ _____ pulse is best indicator of PAD.
posterior tibial
PAD ulcer assessment
- typically on or between toes, on foot
- appearance
- round w/ well-defined border
- prolonged occlusion: gangrenous
diagnostics for PAD
- MRA
- CTA
- doppler
- exercise tolerance
- plethysmography
MRA
magnetic resonance angiography
CTA
computed tomography angiography
doppler flow studies for PAD
- assess segmental systolic BP
- location: thigh, calf, ankle
- values
- normal: > brachial
- PAD: < brachial
exercise tolerance test for PAD
- chemical or treadmill
- get resting pulse folume
- induce Sx, repeat pulse volume
- diagnostic
- ↓ ankle pressure (40-60 mm Hg)
- delayed return to normal > 10 min
plethysmography
- waveform tracing of blood flow
- flattened waves = occlusion
inflow obstruction diagnostics
- thigh-level BP < brachial
- indicates severity
- mild: 10-30 mm Hg difference
- severe: 40-50+ mm Hg difference
outflow obstruction diagnostics
- diagnostic: ABI < 0.90 in either leg
- normal: ankle pressure ≥ brachial pressure
ABI
ankle-brachial index
ABI formula
ankle BP ÷ brachial BP = ABI
PAD nonsurgical management
- exercise: promotes development of collateral circulation
- positioning: controversial
- promoting vasodilation
- preventing vasoconstriction
exercise guidelines for PAD management
- gradually ↑ walking
- walk until claudication, rest, walk farther
- ↑ in amount of walking over time
- not for
- venous ulcers
- severe rest pain
- gangrene
guidelines on positioning for PAD
- extremities NOT above heart
- hang feet or sit upright
- don’t cross legs
- no restrictive clothing
promoting vasodilation for PAD management
- encourage warmth w/ socks, shoes, covering
- avoid heating pads d/t ↓ sensation
preventing vasoconstriction for PAD management
- avoid
- cold/exposure
- emotional stress
- caffeine
- nicotine
PAD meds
- hemorheologic agents
- antiplatelets
- antihypertensives (careful w/ BBs)
- lipid-lowering agents
antiplatelets for PAD Tx
- ASA
- clopidogrel
hemorheologic agent action
↓ blood viscosity
less invasive Tx for PAD
- percutaneous vascular intervention
- artherectomy
percutaneous vascular intervention
- arterial entrance through groin
- balloon catheter inserted, stents placed
- common or external iliac arteries typical
artherectomy
- device scrapes walls of vessel to remove plaque
- used in popliteal artery or ↓
PAD surgical management
- arterial revascularization
- bypass occluded area w/ autografted vessel
indications for arterial revascularization
- severe rest pain
- claudication
- interference w/ life
veins used in arterial revascularization
- preferred: saphenous vein (if not needed for CAD bypass)
- alternates: cephalic or basilic vein
- synthetic material
inflow obstruction surgery
- bypasses occlusion above superficial femoral arteries
- indicated for
- aortoiliac
- aortofemoral
- axillofemoral
- less chance of reocclusion or post-op ischemia
outflow obstruction surgery
- bypass at or blow SFAs
- indicated for
- femoropopliteal
- femorotibial
- less successful in relieving pain
- higher chance of reocclusion
pre-op PAD care
- baseline vascular assessment data
- IV access
- prophylaxis abx
post-op PAD care
- incentive spirometry
- vascular assessments
- X marks the spot
- doppler pulses
- BP monitoring
- NPO
- limited ROM
PAD graft occlusion
- post-op emergency
- severe, continuous, aching pain
- thorough pain assessment
- extremity appearance (compare bilat.)
- possible Tx
- thrombectomy
- tPA, other antiplatelets
- watch for infection
home management of PAD
- promote vasodilation
- ID S/Sx of infection
- home health, case manager?
- nicotine cessation
- ↓ dietary fat intake
- Rx tasks
- exercise
- meds
- etc.
- proper foot care
acute PAD
- S/Sx
- sudden onset
- likely embolus, more common in LE
- pain even at rest
- cool, mottled, cold, pulseless
- untreated: necrosis or gangrene
- Hx: often pts w/ recent MI, a-fib
care of acute PAD
- assess 6 Ps
- maybe thrombectomy/embolectomy
- tPA
- risk for reocclusion
types of peripheral venous disease
- venous thromboembolism
- venous insufficiency
- varicose veins
function of veins
carry deoxygenated blood back to heart
structures that assist w/ venous function
- valves
- skeletal muscle
types of venous thromboembolism
- PE
- DVT
PE
pulmonary embolism
DVT
deep vein thrombosis
VTE
venous thromboembolism
defective venous valves →
- venous insufficiency
- varicose veins
Virchow’s triad
- endothelial injury
- venous stasis
- hypercoagulability
types of thrombus
- phlebothrombosis
- thrombophlebitis
- deep vein thrombophlebitis
phlebothrombosis
thrombus w/out inflammation
thrombophlebitis
thrombus w/ inflammation
deep vein thrombophlebitis
- thrombosis: forms in deep vein
- thromboembolism: breaks off and travels to deep vein
- thrombophlebitis: thrombosis w/ inflammation
VTE etiology
- Virchow’s triad
- surgery
- medical conditions
- immobility
- IV placement
DVT signs
- localized tenderness along deep venous system
- unilateral
- swelling of entire leg
- calf swelling > 3 cm
- pitting edema
- dilated superficial veins
- previous DVT
VTE risk factors
- Virchow’s triad
- hip surgery
- TKA
- HF
- immobility
- PG
- oral contraceptives
- active CA
DVT diagnostics
- imaging
- duplex US
- doppler flow study
- MRI
- lab: D-dimer
D-dimer
blood test to detect product of clot breakdown
nursing interventions for existing DVT
- prevent complications
- PE
- venous insufficiency
- post-thrombotic syndrome
- education
- current DVT
- prevention of future DVTs
DVT prevention nursing interventions
- ambulation
- hydration
- compression
- stockings
- SCDs
- anticoagulants
- elevation
compressing stockings guidelines
- must wear for extended period
- measure and use correct size, adjusting for wt changes
- DO NOT massage extremity
- assess
- skin
- 6 Ps
- cap refill
heparin therapy admin for DVT
- IV infusion
- prevents new clots
- body breaks down existing clot
- check labs before admin
labs for heparin therapy
- aPTT: 1.5-2x normal
- PT/INR
- CBC
- UA
- FOBT
- Cr
safety measures for heparin therapy
- reliable IV pump
- assessment
- reach/maintain therapeutic aPTT
- watch for S/Sx of
- bleeding
- HIT
- antidote: protamine
S/Sx of bleeding to watch for during heparin therapy
- bruising
- petechiae
- melena
- hematemesis
- hematoma
therapeutic aPTT for heparin therapy
- 1.5-2x normal
- notify provider if > 70 sec
HIT
heparin-induced thrombocytopenia
heparin-induced thrombocytopenia
- immune rxn to heparin → widespread clotting
- life-threatening
- occurs w/ prolonged therapy
prevention of HIT
- LMWH
- more commonly used
- ↓ complications
warfarin therapy for DVT
- may be added to regimen for home use
- inhibits synthesis of clotting factors in liver
- pt education
- will need regular labs
- watch for S/Sx of bleeding
- prevent injuries
- keep antidote on hand
- antidote: vitamin K
PT/INR values for warfarin therapy after DVT
- INR of 1.5-2 for prevention
- 3.5-4 for pts w/
- CV conditions
- PE
- risk for CVA
inferior vena cava filtration nursing care
monitor for bleeding or infection at insertion site
DVT self-management education
- self-injection of LMWH
- med compliance
- follow-up and monitoring needs
- dietary strategies
- bleeding, bruising, and how to avoid
- drug interactions
- keep antidote on hand
venous insufficiency patho
- prolonged venous HTN
- stretches veins
- damages valves
- → blood backup, stasis
- → ↓ perfusion
- → edema
- → ulcers
- → cellulitis
venous insufficiency risk factors
- sitting or standing for long periods
- obesity
- PG
- thrombophlebitis
venous insufficiency interventions
- promote venous return
- ↓ edema
- heal ulcers
- treat or prevent infection
- prevent ulcer recurrence
venous ulcer care
- topical Tx
- hydrocolloid dressing
- artificial or cultured epithelial autografts
- unna boot
- chemical debridement
- surgical: debridement; other surgeries not effective
varicose vein patho
- distended, tortuous veins
- weakened vessel walls dilate
- valves become incompetent
- advanced dz →
- insufficiency
- edema
- ulcers
varicose vein risk factors
- female
- > 30 yo + prolonged standing
- systemic dz
- HD
- DM
- HTN
- obesity
- PG
- family Hx
types of aneurysms
- fusiform
- saccular
- true
- false
- dissecting
aneurysm
permanent, localized dilation of artery ≥ 2x original size
aneurysm patho
- tunica media weakens, stretching intima and externa
- continued stretching + ↑ tension →
- ↑ size of aneurysm
- risk for rupture
- HTN → ↑
- rate of enlargement
- risk for rupture
- HTN → ↑
fusiform aneurysm
entire artery circumference affected
saccular aneurysm
outpouching affecting only distinct area
true aneurysm
arterial wall weakened by congenital or acquired causes
false aneurysm
vessel injury or trauma to all vessel wall layers
dissecting aneurysm
formed when blood accumulates in artery walls
typical aneurysm locations
- most common: AAA
- less common: TAA
AAA
abd aortic aneurysm
abd aortic aneurysm
- most common aneurysm location
- rarely symptomatic until emergent
- often between bifurcation and renal arteries
TAA
thoracic aortic aneurysm
thoracic aortic aneurysm
- less common than AAA
- often missed or misdiagnosed
- typically in ascending, descending, or transverse aorta
aneurysm risk factors
- nonmodifiable
- age
- gender
- family Hx
- modifiable
- atherosclerosis
- HTN
- hyperlipidemia
- nicotine
AAA assessment
- pain
- sites: abd, back, flank
- steady, gnawing
- duration: hrs or days
- pulsation in upper abd
- DO NOT PALPATE
- auscultate for aortic bruits
TAA assessment
- back pain
- compression of aorta
- SOB
- hoarseness
- difficulty swallowing
- possible visible mass above suprasternal notch
aneurysm rupture
- EMERGENT
- critically ill pts
- TAA: sudden, excruciating chest or back pain
- loss of pulses distally
- retroperitoneal: flank hematoma
- peritoneal: distended abd
- risk for hypovolemic shock
- hypotension
- diaphoresis
- ↓ LOC
- oliguria
nonsurgical aneurysm management
- antihypertensives
- maintain BP
- ↓ rate of enlargement, risk for early rupture
- if small, asymptomatic: frequent CT or US
- pts need to follow up as scheduled
- will be treated nonsurgically as long as possible
surgical management of aneurysm
- rupture = surgical emergency
- Tx of choice
- endovascular stent grafts
- percutaneous insertion
aneurysm post-op care
- close monitoring
- for graft occlusion
- VS
- pulses distal to graft
- surgical site
- pain level
- HTN meds
- HOB < 45˚ to prevent graft flexion
post-op aneurysm home care
- BSC
- limited activity
- no heavy lifting: < 15 lbs. x 6-12 wks
- compliance w/ follow-ups
- HTN meds
- S/Sx of rupture
assessment of popliteal or femoral aneurysm
- may be associated w/ aneurysm elsewhere
- pulsating mass at site
- DO NOT PALPATE
- S/Sx
- ischemia
- ↓ pulses
- cool or cold skin
- pain
Tx of popliteal or femoral aneurysm
- femoral: often uses autogenous saphenous vein graft w/ aneurysm removal
- popliteal: usually bypass
post-op care of popliteal or femoral aneurysm repair
- pulses below site as ordered: X + doppler
- monitor
- 6 Ps
- VS
- hypotension: clot
- HTN: bleeding
- pain level: sudden change = occlusion
- limit bending extremity
aortic dissection
- uncommon
- life-threatening
- patho: sudden tear in intima maybe d/t degeneration of media
- locations
- more common: ascending and descending thoracic
- any major artery from aorta
aortic dissection assessment
- pain
- 10/10
- “ripping”
- “tearing”
- diaphoresis
- N/V
- apprehension
- faintness
- BP
- imminent: HTN
- rupture/tamponade: hypotension
- weak/absent distal pulses
aortic dissection interventions
- large-bore IVs x2
- ↓ BP: BB + nicardipine
- IV fluids
- foley to monitor renal fxn
- long-term: SBP ≤ 130-140
CV conditions ASA is used for
- MI
- long-term Tx
- CP emergency Tx (MONA)
- PAD maintenance
CV conditions requiring heparin therapy
- thrombus formation
- high risk for thrombus formation
when is warfarin used?
home therapy for those at high risk of thromboembolic d/o or with a history of such d/o
