VASCULAR CASE STUDIES Flashcards
Increased pressure in vasculature still damaging blood vessels: higher risk for stroke, MI
Are high risk need be aware of it
Physical assessment/clinical manifestations
Psychosocial
Diagnostic assessment
HTN
Most people have no symptoms - Affects diagnosis of HTN and management; no symp: pat not as aggressive about taking care of it
Some patients experience headaches, facial flushing (redness), dizziness, fainting - extremely high BP
Blood pressure screenings essential
Physical assessment/clinical manifestations
Assess for stressors that can worsen hypertension
Psychosocial
No specific lab or x-rays are diagnostic of primary hypertension - imp to screen
Secondary hypertension can be screened with labs specific to the underlying disease: Ex. kidney disease
Diagnostic assessment
Primary (essential)
Secondary
Classifications and etiology of HTN
Most common type
Not caused by an existing health problem; can develop when a patient has any one or more of the risk factors:
Lot risk factors
US have significantly higher BP - stressors and healthcare disparities
High cholesterol: more plaque in vessels increases pressure
Vasoconstriction - any form of nicotine
Primary (essential)
Family history
African-American ethnicity
Hyperlipidemia
Smoking
Older than 60 or postmenopausal
Excessive sodium and caffeine intake
Overweight/obesity
Physical inactivity
Excessive alcohol intake
Low potassium, calcium, or magnesium intake
Excessive and continuous stress
Not caused by an existing health problem; can develop when a patient has any one or more of the risk factors:
Results from specific diseases and some drugs
Kidney disease is one the most common causes of secondary hypertension
Other disease process
Often kidney disease
Secondary
Find high BP take in
both arms also if low
Answer: Additional assessments should include medical history, family history of CV disease, heart and respiratory rate, and medications being taken.
Pulse
Further assessment into edema
Fam history
Smoking, caffeine: additional modifiable risk factors present/not
Meds
Rationale:
Assessing medical and family history provides needed information associated with etiologies and identification of risk factors.
Heart rate and respiratory rates provide information on the effectiveness of tissue perfusion associated with the high blood pressure.
Assessing medication history might lead to the identification of an adverse response.
What other assessments should the nurse perform?
Answer: Eating a low-sodium diet, limiting his caffeine intake, and quitting smoking. Ask him what a “wholesome meal” is
Eliminating smoking, caffeine, nutrition imp
Limit fast food: cholesterol and sodium
Explore diet habits
Doing right: walking, sleeping well, reading before bed (relaxation), glass (how big) wine not bad, working reasonable amount
Talk about all of this
Rationale:
Sodium increases blood volume, thus increasing blood pressure.
Caffeine and smoking has a vasopressor affect that could increase BP
Recommendations:
Dietary sodium restriction to less than 2 grams; Na restrictions at least less than 2 grams min
Reduce weight
Use alcohol sparingly
Exercise 3-4 days a week for 40 minutes
Use relaxation techniques to decrease stress
Avoid tobacco and caffeine
What lifestyle changes would help Mr. Flynn in managing his blood pressure?
Reason BP low is because taking med - no symp with HTN because not feel bad most time when not take med
Answer: Hypertension is a chronic illness. Without medication, Mr. Flynn’s hypertension will remain uncontrolled.
A plan should be developed with the patient and ways identified to encourage adherence to his medication regimen.
If the patient is taking beta blockers, suddenly stopping these drugs can result in angina, MI, or rebound hypertension
Med compliance really imp
Quit smoking and did other things might be able go off BP med but per pat; make sure stick on meds and adhering to that
Lot AE not tolerated explore with them on why not want take med; can switch it up because lot meds for them
Rationale:
Some patients may assume that once their blood pressure returns to normal levels, they no longer need treatment.
Side effects can also affect compliance with medication so that should be explored
Mr. Flynn returns to his provider’s office for a follow-up. He states that he has been taking his blood pressure every day and that most days it is within the normal range. Mr. Flynn asks the nurse if it is okay to stop his medication? How should the nurse respond to Mr. Flynn?
Reduce preload by decreasing volume and pressure in the left ventricle: This decrease preload (put into heart); less blood volume having less pressure; afterload - what heart pumping against
First-line drug of choice in older adults with HF and fluid overload
First drug for many pats; least side effects
Lot times can be Managed on small dose
Enhance renal excretion of sodium and water
Ex.
Monitor for:
Diuretics
Loop - Furosemide (Lasix)
Loop - Torsemide (Demadex)
Loop - Bumetanide (Bumex)
Loop diuretics: K wasting: lose K when take them; K imp electrolyte for heart muscle - will take K supplements; check K level; may need replace K level with it/before admin
Thiazide – Hydrochlorothiazide (HCTZ); Metolazone (Zaroxolyn)
Potassium-sparing – Spironolactone (Aldactone): K-sparing: K level elevated; hold onto K level
Ex. - Diuretics
Dehydration
Potassium levels (potassium wasting or potassium sparing): Check K level on both because at risk for dysrhythmias
Decreased BP
If creatinine level is greater than 1.8 mg/dL, notify health care provider before administering supplemental potassium - kidneys not functioning not have good effect; monitor renal func as well
I&O and weight imp thing to monitor
Monitor for: - Diuretics
ACE inhibitors; ARBs - arterially vasodilate; decreases afterload: decreases BP
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin-receptor blockers (ARBs)
Arterial vasodilators
Enalapril (Vasotec)
Fisinopril (Monopril)
First drug of choice
Not for African American because not respond as well
Causes dry cough - let know so expect it; orthostatic hypotension: increases K levels; reduces Na - Na substitute which made out of K - watch intake of K;
Monitor for:
Angiotensin-converting enzyme (ACE) inhibitors
Orthostatic hypotension
Acute confusion,
Poor peripheral perfusion
Reduced urine output in patients with low systolic BP
Potassium and creatinine levels
Start slowly
angiodememia: lifethreating risk for ACE: swelling of airway and put on ARBs
Monitor for: - Angiotensin-converting enzyme (ACE) inhibitors
Valsartan (Diovan)
Irbesartan (Avapro)
Losartan (Cozaar)
ACE inhibitors are the first-line drug of choice
May cause dry cough
Monitor for:
Angiotensin-receptor blockers (ARBs)
Orthostatic hypotension
Acute confusion,
Poor peripheral perfusion
Reduced urine output in patients with low systolic BP
Potassium and creatinine levels
Start slowly
Monitor for: - Angiotensin-receptor blockers (ARBs)
Blocks the sympathetic stimulation, increases contractility and decreases demand of heart And workload of heart
Monitor for:
Ex.
Beta blockers
BP and HR
Start slowly and don’t stop abruptly
Use cautiously with diabetic clients
Use cautiously with clients with asthma
**Studies still evaluating risk for diabetic and asthma
Monitor for: - Beta blockers
Carvedilol (Coreg)
Metoprolol succinate (Toprol XL)
Bisoprolol (Zebeta)
Ex. - Beta blockers
Risk for orthostatic hypotension; Rebound HTN
BP and HR
Can decrease glucose production in the liver: glycogen: risk for hypogycemia
Could mask signs of hypoglycemia
Keep eye on BG
Use cautiously with diabetic clients
Possible increased risk for bronchoconstriction
Use cautiously with clients with asthma
Answer: Atherosclerosis
Risk factors include:
Risk factors for HTN and atherosclerosis: buildup of plaque - plaques could move and travel; also fills up vessel; leading cause of CAD which leading cause of MI
What are all of these things risk factors for?
Low HDL
High LDL-C (low density lipoprotein)
Increased triglycerides
Genetic disposition
Diabetes mellitus
Obesity
Sedentary lifestyle
Smoking
Stress
African-American or Hispanic ethnicity - Hispanic males more disposed
Older adult
Risk factors include: atherosclerosis
Lab assessment:
Interventions:
Assessments and interventions
Check make sure always in normal range and imp to watch these
Elevated lipids (cholesterol and triglycerides)
Total serum cholesterol
LDL (bad) cholesterol
HDL (good) cholesterol
Triglycerides
Lab assessment:
Should be below 200 mg/dL
Total serum cholesterol
Increased levels indicate increased risk
Should be < 130
LDL (bad) cholesterol
Increased levels, lower your risk of CAD
Should be >50
HDL (good) cholesterol
Between 40 and 160 mg/dL for men and between 35 and 135 mg/dL for women
Triglycerides
Lifestyle modification such as smoking, weight management, exercise and nutrition
Adjusting diet, weight loss; decreasing cholesterol and increasing HDL
Drug therapy
Interventions:
Statins or other lipid-lowering agents
Statins and other lipid lowering; lot AE with statins probs if at risk for probs with liver avoid because hard on liver; do lifestyle modifications before go to statins
Drug therapy
Mr. Jones is prescribed atorvastatin (Lipitor) by the health care provider. The nurse instructs him to watch for and report which side effect?
A. Nausea and vomiting
B. Cough
C. Headaches
D. Muscle cramps
Answer: D
Indicates Ragodomyelosis: very concerning AE of statin, can cause sig kidney damage if unchecked; breakdown of muscles occludes renal arteries
Can have N&V but not has serious as muscle cramping
Headaches can have, mild AE
Statins (HMG-CoA)
Reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood
Contraindicated in active liver disease or during pregnancy
Discontinued if the patient experiences muscle cramping or elevated liver enzyme levels
Avoid grapefruit and grapefruit juice - Monitor liver enzymes entire time; grapefruit juice interferes with enzymes
Statins (HMG-CoA)
Peripheral arterial disease (PAD)
Has atherosclerosis/build up of plaque: limiting blood supply to extremities
He is now reporting cramping and burning in his lower extremities that occurs during activity, but stops when he rests. Upon assessment of his lower extremities he has decreased pulses and dry, dusky skin with thickened toenails and his feet are slightly cool to the touch. What do you think is going on with Mr. Jones?
Which of the following clients are at risk for PAD? (Select all that apply)
A. Client with hypertension
B. Client with Diabetes
C. Client who smokes cigarettes
D. Client with anemia
E. Client who is very thin
Answer: A, B, C
HTN - Increased pressure in vessels
DM - Affects vasculature
Smoking - Vasoconstriction
Chronic condition occurring with partial or total arterial occlusion: Total: emergent situation
Decreased perfusion to lower extremities: Indicating decreased oxygenation
Atherosclerosis is the most common cause
Clinical manifestations:
Imaging assessment:
Peripheral arterial disease (PAD)
Intermittent claudication
Rest pain
Loss of hair on the lower calf, ankle and foot
Dry, scaly, dusky, pale, or mottled skin
Thickened toenails
With severe disease
Clinical manifestations: - Peripheral arterial disease (PAD)
Magnetic resonance angiography (MRA) can assess blood flow in the peripheral arteries: Inject dye and look at arterial vessels to diagnose
Imaging assessment: - Peripheral arterial disease (PAD)
cramping, burning muscle discomfort or pain occurs during activity, stops after rest
Will have pain
May have some rest pain
Intermittent claudication
numbness or burning sensation located in the toes, foot arches, forefeet, or heels that awakens patients at night and is usually relieved by placing the extremity in a dependent position (below the heart)
Rest pain
cold, cyanotic, and darkened extremity; posterior tibial pulse is most sensitive and specific indicator of arterial function; note signs of ulcer formation
With severe disease
The nurse is instructing a client with PAD about ways to promote vasodilation. What information does the nurse include? (Select all that apply)
A. Maintain a warm environment at home
B. Wear socks or insulated shoes at all times
C. Apply direct heat to the limb by using a heating pad
D. Prevent cold exposure of the affected limb
E. Completely abstain from smoking or chewing tobacco
Answer: A, B, D, E
Focus on dilating vessels and increasing perfusion
Heating pad - decreased circ and sensation: could cause injury with direct sources of heat
Prevent vasoconstriction: smoking, cold
Exercise: circ
Positioning
Promote vasodilation
Drug therapy
Control BP: HTN - damages vessels
Invasive nonsurgical procedures
Surgical management
Interventions for PAD
Avoid crossing legs (pressures on vessels) and wearing restrictive clothing
Elevate legs/feet but avoid raising above the heart level: Above heart - prevents arterial blood flow to feet
extreme elevation slows arterial blood flow to the feet
Positioning
Avoid cold exposure to the affected extremity with warm socks and room temperature modulation
Avoid applying direct heat (heating pad, hot water) to the limb
Avoid emotional stress, caffeine, and nicotine (can cause vasoconstriction)
Promote vasodilation
Hemorheologic agents Pentoxifylline (Trental): Keeps vessels open - Trental
Antiplatelet agents ASA, Clopidogrel (Plavix) - not aggregate platelets
Drug therapy
Percutaneous transluminal angioplasty (PTA): into arterial sys: opening occluded vessels; dye, stents/angioplasty to open vessels
Atherectomy
Invasive nonsurgical procedures
Arterial revascularization
May bypass occluded vessels
Surgical management
Occlusions may be sudden and dramatic
Complete occlusion in artery - lose limb if not revascularize
Usually take in IR or cath lab
Caused by embolus or thrombus
More common in lower extremities
Most patients with an embolic occlusion have had a recent acute MI and/or atrial fibrillation
Manifestations
“Six P’s” of ischemia
Interventions
Acute peripheral arterial Occlusion
Embolus is the most common cause
Clot: thrombectomy; clot that breaks off
Caused by embolus or thrombus
cool or cold, pulseless, and mottled affected extremity
Manifestations - Acute peripheral arterial Occlusion
pain, pallor, pulselessness, paresthesia, paralysis, poikilothermy (coolness)
“Six P’s” of ischemia
Prompt treatment is essential to avoid permanent damage or loss of an extremity: Reperfuse extremity as quickly as possible
Anticoagulant therapy (Heparin)
Surgical
Interventions - Acute peripheral arterial Occlusion
embolectomy or thrombectomy: clot: thrombectomy; atherosclerosis: angioplasty
Surgical Interventions - Acute peripheral arterial Occlusion
Permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter
Weakening and stretching; big concern/comp: rupture; die if ruptured
Types
Etiology
Imaging
Size of the aneurysm and presence of symptoms determine patient management
Nonsurgical management
Surgical management
Aneurysm
Thoracic aortic aneurysms (TAAs)
Abdominal aortic aneurysm (AAA)
Types aneurysms
Account for most aneurysms, commonly asymptomatic, and frequently rupture
most common
See CM/anything enlarging where need intervention
Clinical manifestations:
Abdominal aortic aneurysm (AAA)
Abdominal, flank, or back pain that is usually steady, with a gnawing quality
Pain unaffected by movement
Pain may last for hours or days
Prominent pulsation in the upper abdomen (do not palpate)
Clinical manifestations: - Abdominal aortic aneurysm (AAA)
While assessing a client with AAA, the nurse notes a pulsation in the upper abdomen slightly to the left of midline between the xiphoid process and the umbilicus. What does the nurse do next?
A. Measure the mass with a ruler
B. Palpate the mass for tenderness
C. Percuss the mass to determine borders
D. Auscultate for a bruit over the mass
Answer: D
Never palpate or percuss area - not want risk rupture; bruit because turbulent blood flow
What is the most frequent complication of aneurysms?
Rupture
Yes d/t abrupt and massive hemorrhagic shock results
Pain described as tearing, ripping, and stabbing and located in the chest, back, and abdomen; symptoms of hypovolemic shock; nausea, vomiting, and apprehension
Massive blood loss - then go unconscious
Is this (rupture) life threatening?
Ms. Brown is admitted to the hospital. Which test would the physician order to confirm an accurate diagnosis as well as to determine the size and location of the AAA?
A. CT scan with contrast
B. Electrocardiogram
C. Magnetic resonance imaging
D. Thoracentesis
Answer: A
Measurements of AAA and see where it is
Atherosclerosis
HTN: Increased pressure in vessels
Hyperlipidemia
Smoking: Vasoconstrict vessels
All put stress on vessels
Etiology - Aneurysms
CT scan with contrast is the standard tool for assessing the size and location
Imaging - Aneurysms
Monitor growth and maintain BP at a normal level to decrease the risk for rupture
Sometimes not do anything
Small enough monitor - serial CT scans to see if enlarging
Nonsurgical management - Aneurysms
Resection or repair (aneurysmectomy)
High risk: Other risk factors do surgical management
High risk CV surgery
Endovascular stent graft: Procedure of choice
Surgical management - Aneurysms
VTE (venous thromboembolism)
Both DVT and PE (pulmonary embolism)
DVT (deep vein thrombosis)
Not want DVT to turn into PE because die quickly
One side swollen and painful
What does the nurse suspect is going on with Ms. Adams?
Stasis of blood
Vessel wall injury
Altered blood coagulation
The nurse knows that there are three major factors involved in the development of DVT. These three factors are referred to as Virchow’s triad and include the following - predisposes to DVT:
Which of the medications taken by Mrs. Adams places her at increased risk for the development of DVT?
1. Antibiotics
2. Analgesics
3. Bronchodilator
4. Oral contraceptives
Answer: 4
Increases blood coag - hormones
In addition, Mrs. Adam’s age, weight, and recent surgery all increase her risk for the development of DVT. obese higher risk for DVT
PREVENTION IS KEY TO ADDRESS THIS CHALLENGE IN HEATLH CARE
Patient education
Leg exercises
Early ambulation
Adequate hydration: Increasing blood volume/circ
Graduated compression stockings
Intermittent pneumatic compression, such as sequential compression devices (SCDs)
Venous plexus foot pump
Avoid oral contraceptives if possible
Anticoagulant therapy - prophylactic dose
Nurse sensitive indicator
VTE prevention
Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT?
1. Measure calf circumference bilaterally
2. Observe for excessive bruising
3. Perform test for Homan’s sign
4. Auscultate for bruits
Answer: 1
1 - looking for unilateral swelling; Typ not in both legs; Not diagnose but gives clues
2 - not an indic of thrombosis
3 - not a reliable indicator anymore/accurate
4 - would indicate narrowing of artery (stenosis of artery)
Focused RR assessments: develop PE: clot moved into pulm vascularture
Further assessment of Mrs. Adams by the nurse reveals the following findings:
Swelling, warmth, and mild discomfort of the right calf
Pedal pulses strong (+3/4) bilaterally with capillary refill < 3 seconds
Respirations regular with no dyspnea or cough
What assessment is important concerning the possibility of a pulmonary embolus?
Dyspnea, sudden onset - SOB
Sudden O2 desat
Sharp, stabbing chest pain
Apprehension, restlessness
Feeling of impending doom
Cough
Hemoptysis
Signs of PE
Movement of clot
Emboli enters venous circulation and lodges in the pulmonary vessels and pulmonary blood flow
What is a PE?
Reduces gas exchange, reduces oxygenation, pulmonary tissue hypoxia, decreased perfusion, and potential death
It may be the most common preventable death in hospitalized patients but is often misdiagnosed.
Emboli enters venous circulation and lodges in the pulmonary vessels and pulmonary blood flow
D dimer
Ultrasound
What tests diagnose DVT?
A negative test can rule out a DVT
A positive test requires further testing to specifically diagnose
not diagnostic; elevated for lot diff reasons; screening
D dimer
Assesses the flow of blood and is diagnostic of DVT
Ultrasound
To prevent future thrombi from forming or the extension of the existing thrombus
Heparin IV - know they have a clot
Doing: prevent clot from getting bigger and more clots from forming; clot goes away on own
Weight based; bolus to get therapeutic then start on drip
High risk for bleeding
What is the purpose of the anticoagulant?
breaks up clot - high risk for bleeding
Thrombolytics:
It is shift change. The oncoming nurse enters the room and notices observable hematuria in Mrs. Adam’s urinary catheter. What action should the nurse initiate first?
1. Obtain a stat aPTT
2. Stop the heparin infusion
3. Assess vital signs
4. Observe the surgical site for bleeding
Answer: 2
Will do all; stop heparin because visible signs of bleeding; heparin likely offending thing; will keep bleeding if not stop infusion
After consulting with the HCP, the nurse is to administer a heparin antagonist. Which medication will be administered?
1. Vitamin K
2. Protamine Sulfate
3. Enoxaparin (Lovenox)
4. Ticlopidine (Ticlid)
Answer: 2
All anti-coag is antagonist that reverses the effects
Protamine Sulfate is for heparin And LMWH
K - warfarin antagonist
Enoxaparin: LMWH
Ticlopidine: antiplatelet med
Heparin
Warfarin (Coumadin)
Enoxaparin (Lovenox)
Other medications are available for clot prevention
Thrombolytics
Surgical management:
Meds
Lab to check: PTT (at SLHS we use heparin assay)
Antidote: Protamine sulfate
IV to treat/SQ for prevention
Heparin assay better indic how doing; follow rules on how to admin based on lab values - not want be at risk for bleeding/clots; once within therapeutic range - PTT higher because want higher because blood anticoag; never within norm range keep checking q6h; 2 therapeutic assays not go in q6h
SQ - preventative
Heparin
Lab to check: PT/INR
Antidote: Vitamin K; Given IM
PO
cheap and requires close monitoring of labwork
Prevantative (afib)/know have had a clot
First on it need labs drawn frequently
INR - wherever go numbers same; numbers same regardless of location; 2-3: therapeutic - more anticoag
Warfarin (Coumadin)
Lab to check: PT/INR (per textbook) and anti-factor Xa assay (at SLHS)
Antidote: Protamine sulfate
Treatment dose; lower dose preventative but also high enough dose
SQ to treat or prevention; often used a bridge with warfarin
Enoxaparin (Lovenox)
Ex. rivaroxaban (Xarelto); apixaban (Eliquis)
No labs are required
No antidote is available
Expensive
Tons new drugs on market - no reversal for these
Other medications are available for clot prevention
Tissue plasminogen activators (TPA)
Administered directly into clot through a catheter
Not used often for DVT
High risk for bleeding
Thrombolytics: in IR to bust up clot
Thrombolytics
Thrombectomy - severe enough to remove clot
Inferior vena cava filtration: IVC filter: stops clot; prevents PE because filtering it: Very common for recurrent DVT if on anticoag therapy or continually developing or too much risk to put on anticoag
Surgical management:
To which nursing diagnosis should the nurse give the highest priority when planning care for Mrs. Adams?
1. Pain related to decreased venous flow
2. Risk for injury (bleeding) related to anticoagulant therapy
3. Impaired physical mobility related to prescribed bedrest
4. Knowledge deficit related to lack of discharge teaching
Answer: 2
BLEEDING
Mrs. Adams is transitioned to warfarin by mouth. Mrs. Adams should receive additional teaching about foods Which food should the nurse instruct Mrs. Adams to avoid?
1. Apple products
2. Red meats
3. Green leafy vegetables
4. Nuts
Answer: 3
Green leafy: have K; consistency is imp so helps keeps labs consistent
