week 4 - altered perfusion interventions Flashcards
perfusion blood pressure , what is the formula for it ? and tell me what it means ?
blood pressure = co x svr
heart function is V
and R is blood vessels
this is two main things that play
pump and pipe
vascular disease overview :
recognize cues
s& s related to decrease blood flow
perfusion affected ( inadequate perfusion , check cap refill )
vital organs ?
what is our priorities ( vascular disease overview )
restore blood flow
avoid tissue/organ injury
what would our interventions be ?
meds or surgery to improve blood flow and reduce end organ damage
vascular disease overview ( evaluate/educate )
reduce disease progression
true or false. There’s actually no ‘normal reading’ when it comes to blood pressure, it just depends on the baseline of the patient ( you have to make your judgement
true facts
what is a hypertension? describe it in a way it was always described
silent killer ( more symptoms ) seconday symptoms of hypertension on end organs ( when pipes narrow ) getting lack of perfusion because of decrease of blood flow
when recognizing cues utilizing hypertension: what are the symptoms we could recognize
often this is asymptomatic ( silent killer )
symptoms with ++ high bp
secondary symptoms related to the effect of vital organs
what are the vital organs affected by htn
myocardium
coronary arteries
kidneys
brain
eyes ( retinas )
arterial vessels of lower extremities
true or false. needs good blood flow or else damaged
increase in progression of atherosclerosis
kidneys causes chronic renal failure
brain - doesn’t get enough perfusion - vision especially in the retinas and stroke
true
hypertension ( what is the worst case scenario that could happen )?
hypertensive crisis
describe hypertensive crisis
severe type of hypertension that comes on quickly and considered a med emergency
what is typically the systolic pressure and diastolic of hypertensive crisis
> 200 mmhg, diastolic, <150
what age is hypertensive crisis typically seen
30-50 year olds
what are the symptoms of hypertensive crisis ( neurological symptoms )
severe headache, blurred vision, dizzy, SOB, epitaxis, anxiety
what is epitaxis again?
nose bleed
hypertension : what are our inteventions ?
monitor :
- blood pressure
-for organ damage
-response to medication
what are the meds management of htn
ABCD
ace inhibitors / arbs
beta adnergic blockers
ca channel blockers
diuretics
true or false. the meds can reduce fluid retention as long as we can vasodilate ( diuretics for htn )
yes this this is true
inteventions for hypetensive crisis typically what type of care do we offer?
critical care ( frequent vital signs )
inteventions for hypetensive crisis typically meds do we give?
iv meds: nitroprusside, labetelol ( gradual reduction of bp over 1-2 days )
we have to give antihypetensive into an iv form
what would the position recommended for someone who is having hypertensive crisis
semi fowler’s postiion
true or false. oxygen may be required if the pt needs during htn crisis
true
what type of complications are we going to look for when it comes to htn crisis
monitor for complications ( cns, cvs, renal )
it is important to check neuro status on someone who is having htn crisis.
yes check neurological status ( a and o times 2 or 3 ) see their baseline
why do we put the pt on semi fowler’s position when they are having htn crisis
dont want alot of venous return already has too much int his case
are these true or false when it comes to someone who is having htn crisis:
check extremities
peripheral pulses
if they have foley catheter - need to know if producing urine or decrease urine they are producing ( maybe not getting adequate perfusion
yes this is true
hypertension
disease management relies on lifestyle modification
exercise
healthy diet ( low salt, low lipids )
manage stress
adequate sleep
true or false. it is very important to for lifestyle modification when it comes to htn. So smoking cessation and moderate alcohol intake is something to consider to modify.
yes this is true
coronary artery disease ( recognize ) : what are the symptoms
chest pain ( that may radiate )
n & v
diaphoresis
dyspnea
anxiety/fatigue
what are the symptoms that often indicates disease progression
nausea and vomiting
diaphoresis
dyspnea
anxiety/fatigue
define if these locations is where pain radiates to when it comes to coronary artery disease :
midsternal
left shoulder and down both arms
neck and arms
substernal radiating to neck and jaw
substernal radiating down left arm
yes these are true
is epigastric, epigastric radiating to neck jaw and arms along with intrascapular location that pain can radiato to when it comes to coronary artery disease ?
yes this is true
what happens when it gets too narrow or sudden obstruction ?
clot causes sudden obstruction - pt starts to develop symptoms
we have stable angina and unstable angina
what are the chest pain for coronary artery
different for each pt
is this your normal heart pain ?
coronary artery disease
diagnose testing
ecg
cardiac enzymes ( troponin )
coronary angiogram
what can an ecg detect ?
lack of blood flow - there is change in st, sometimes it’s elevated, sometimes its depression or t wave
what does cardiac enzymes troponin
support the idea heart is getting damaged ( lack of blood flow )
true or false. need to monitor something ? a patient getting a dye every time they take a picture ( presses a pedal and light go out and that means fluoroscopy is on ) radiation is coming and lighting up blood vessels and heart
true
do you drink or eat anything after the angioram ?
no, do no t drink or eat anything in the midnight after the angio
how long is an angiogram ?
20-30 mins ( stent is alot longer )
what is the angioplasty
angioplasty is a way to open up a blocked or blockage of the heart
are these true when it comes to angiogram : risk for bledding ( monitor afterwards ) through the wrist or through the groin
infection
monitor vital signs
blood loss is not always noticable ( could be internal )
yes this is true
coronary artery disease
what can go wrong ?
acute coronary syndrome
recall that acute coronary syndrome is what could go wrong with coronary artery disease: define what this is
acute coronary syndrome is an obstruction of blood flow to myocardium leading to symptoms of ischemia
continuum from stable angina –> can lead to what
ACS
ACS: could lead into what ?
unstable angina, nstemi, stemi
it is producing a lot of symptoms
unstable - 15 to 20 minutes the pain stops
stemi - there is an occlusion ( can progress to occlusion, changes in the blood work, rise in the troponin , we do not have blood flow to some part of the heat )
these are all true
coronary artery disease
interventions for pt with stable CAD
monitor vital signs
administer medication
education on lifestyle changes
they do not have optimal vessels in the heart , one thing you are going to look for :
did they have a stent or stent put in
true or false. once nitro is in ( this is going to drop the blood pressure ) if it’s already low ( worst perfusion outcome )
true
if the pt is on viagra - what do you not take
do not take nitro, vasodilate ( they compound each other ) can cause hypotension
coronary artery disease
interventions for ACS
oxygen administration
ecg/cardiac monitoring ( telemetry )
pain assessment & management
frequent vital signs
IV access and meds ( nitro, asa, clopidogrel ) is utilized using coronary artery disease
yes this is true
oxygen administration ( < 92 % sats )
ensure we have ecg done ( why do you think its important ) it will help triage if its stemi or nstemi
ecg/cardiac monitoring ( telemetry )
goes to straight Cath lab ( should be directly there, blocked artery )
if they are tPA ( we have open up blockage ) more we wait we are losing
the heart is demanding more what is needed for supply
due to narrowing or complete occlusion
if we needed to supplement oxygen ( we need it to do it immediately, probe on and ensuring their oxygen is above 92%) true or false.
true
what helps breakdown platelets, platelets are usually what’s causing the problem
ASA
clopdogrel
anti platelet drug
with a stemi - usually get a big clavix
if you put a stent there is a what ?
big risk of clotting ( so these drugs are good )
insulin, lasix, iv, nitro, have a very big effect quickly ) so this is not the kind of pt u leave for an hour, staying with them is crucial and say in a few mins and how are they feeling
medication, fluid ( be careful with a heart not beating well ) –> MI is a cause of going into the HF
open blocked artery :
TPA ( far from the hospital )
angioplasty
CABG ( open heart sx )
CABG ( open heart sx )
coronary artery by pass grafting
what has to be done before the nitro spray
frequent vital signs
coronary disease interventions post angioplasty: what should we monitor for?
bleeding from insertion site
acute closure of vessel ( CP, increase ST )
contrast dye reaction
vital signs ( decrease BP, dysrhythmias )
true or false. some people react to the dye
anaphylactic or allergic reaction can occur (allergic to shellfish or dye )
true
trans radi band ( cut into the skin and out catheter into the hole )
when we cut arteries under high pressure ( high risk of bleeeding ) and we have to make sure it stops bleeding
** just read *
true or false. theres a risk of bleeding ( stent is ocluded )
looks like a symptom they came in with ( chest pain, ekg will show last two segments will go back up
true
what happens when heart is irritated ?
stretched a bit of the heart, coronary artery is kind of opened up. coronary artery is tissues (starts to die ) oxygen starts circulating
coronary artery disease
What type of care are we typically going to give ?
we are going to give ICU initial care
coronary artery disease: re call that we are going to give ICU initial care : initially what are the steps we going to give ?
intubated, large chest tubes, pacemaker wires
coronary artery disease
what are we watching out for ?
watch for dysrhythmias, fluid and electrolyte imbalance, hypo/hypertension, hypothermia, bleeding, decreased LOC, anginal pain
true or false. brain and kidneys needs to be perfused.
this is true
what will chest pain indicate?
in a cabagge, this will indicate a complication or clot within the graft scheduled etc
what is a complication of any type of heart surgery ?
cardiac tamponade
true or false. coronary artery disease: these pts ned to have bypass surgery
true
true or false. not comfortable yet they have sternum thats unstable so thus is important to check when it comes to complication
true
coronary artery disease: interventions for pts on the cardiac surgery ward
db + c
supervised ambulation
monitor for complications
discharge teaching
cardiac rehab referral
DB + C why do we this for coronary artery disease
want to avoid atelactasis
what type of complications are we going to avoid
DVTs
we want to use anticoagulants complication related to the surgery ( occlusion of the graft )
true or false. infection, decrease cardiac output after surgery, they need blood transfusion
true
true or false. coronary artery disease could go into a HF kinda thing ( listen for crackles, chest, confirm with p )
true, if bp is abnormal hearing crackles might do further investigations
what are the potential complications that could occur : coronary artery disease
decrease in CO
pain
dysrhythmia
decrease 02 sats
infection
surgical/donor site
neuro status
what is the treatment for pain
opoids, morphine, fentanyl route IV not tylenol in the moment
what is the treatment plan for dysrthmias
cardiac monitoring
antiarhythic drugs ( alodarone )
check k levels
decresase 02 sats treatment
give them oxygen
what is the treatment for infection
infection site , take from safinus vein atornal mamory
what could potentially cause infection?
chest tube insertion ( pc wires ) foreign object in the pts body
coronary artery disease : what can go wrong with this
cardiogenic shock
what is cardiogenic shock ?
alot of them dont do well, heart fails the other one fails as well
everything is going down ( not able to supply to the body )
what is the definition of cardiogenic shock ?
sudden severe LV failure causing inadequate oxygen and nutrients supply to tissues ( end organ failure )
what most often occurs with MI
cardiogenic shock
what is our goal for cardiogenic shock ?
goal is to restore perfusion
coronary artery disease : what is needed ?
cardiac catherization ( PCI ) with stent performed ASAP after CP
it is important to stbailize pt until angio coronary:
yes this is true
are there drugs, to make blood vessels tight to get bp up
pump more strongly or put pt on life support ( breathing tube keep them to breathe )
true
exemplar #3 : peripheral vascular disease : recognize cues : what is peripheral arterial disease
a chronic condition in which partial or total arterial occlusion decreases perfusion to extremities
what is the four stages of PAD
1) asymptomatic
2) claudification
3) rest pain
4) necrosis/gangrene
what is caused by a lack of blood flow
peripheral arterial disease ( claudification )
recognize cues : PAD : what are the symptoms
weak peripheral pulses, hairloss ( lower leg– > foot ) , skin thin/shiny/taut, cool, thick toenails, pale with elevation and dependent rubor, muscle atrophy
true or false. skin needs continuous perfusion
yes this si true
hair on toes what does it mean ?
perfusion
peripheral arterial disease in hairless at the bottom
peripheral arterial disease: ankle brachial index ( ABI )
what is it
a PAD screening tool
measured using doppler
ankle pressure divided by branchial pressure (.9 or less indicates PAD ) : ankle brachial index
this is true
peripheral artery disease
what is our priority : arterial ulcers
ulcer location and appearance
end/between of the toes
minimal drainage
ulcer bed pale, round edges
little granulation tissue
peripheral artery disease: sudden peripheral artery occlusion
often from MI or AFib
what is the 6 P’s ischemia
pain
pallor
pulselessness
paresthesia
paralysis
poikolothermy ( coolness )
peripheral artery disease
take action : interventions for stable PAD
risk factor modification
drug therapy : antiplatelets ( * no grapefruit when taking plavix )
peripheral artery disease: what is the drug
pentoxifylliine ( trental ) for claudification ( increase blood flow )
peripheral artery disease: exercise therapy and positioning
walking to increase collateral circulation
walk until discomfort, rest, resume
position with limbs below heart
what happens when u have pain when u have PAD
if pain at night dangle from bed
how do we promote vasodilation for peripheral artery disease
keep feet warm ( socks, insulated shoes )
risk for developing clots on we put them into antiplatelets, aspirin, and plavix, is this true
yea this is true
decreases clauficaition ( proven to be effective )
pts improving blood flow to their legs ( we want them to walk more )
yes this is true
peripheral artery disease
no surgical interventions to increase blood flow
what are the two ways
balloon angioplasty with stent insertion
atherectomy
peripheral artery disease
catheter inserted via femoral artery
balloon inflated to open artery
stent deployed to keep artery open
what is atherectomy
catheter inserted into femoral artery
rotational tip attached to end of catheter
breaks up plaque by rotation
peripheral artery disease: what should we monitor , what is this related to?
bonus : little layer they ffed to the coronary artery, clears out plaque causing out obstruction
( sudden occlusion, sudden chest pain, st elevation, sudden lack of blood flow ) make sure the vessels ( lose pulse )
all related to the ballon angio with stent
refer to rerur ruter
peripheral artery disease
surgical intervention to increase blood flow
fem - pop bypass graft around an occluded femoral artery
what is the post op care
√ VS, Pain, N&V, DB&C, signs of infection
√ operative extremity for CWCM, pain
√ for bleeding, hematoma, compartment syndrome, thrombosis, embolization (***call MD)
are these considered as post op care for pad?
√ Avoid long hours of sitting with legs dependent
√ ambulation as soon as possible
true
what is compartment syndrome ?
swelling- impedes perfusion ( swelling or bleeding
what is hematoma ( bleeding under the skin–> press the area ): is this a true statement
yes this is true
peripheral artery disease
take action : interventions for unstable patient
not want them to walk, can move into the lungs or even the heart
peripheral artery disease
take action : interventions for unstable patient
early treatment essential
- keep client at rest
- call physician immediately
peripheral artery disease
take action : interventions for unstable patient
recall that: early treatment essential
- keep client at rest
- call physician immediately
what else ?
Anticoagulant therapy
- heparin/warfarin- to prevent thrombus enlargement ( they can deliver like thrombus like therapy )
Remove/Dissolve Clot for peripheral artery disease
percutaneous thrombolytic therapy
- catheter threaded through the femoral artery
TPA ( thrombolytic drug ) infused to site of embolus
urgent surgery to remove clot
is this true in terms to remove/dissolve clot for pad
yes this is true
peripheral artery disease
evaluate and educate
what do we do ?
inspect feet/legs daily
stop smoking, eat healthy, exercise
peripheral artery disease
how do we protect from trauma ?
protective roomy footwear
clean cotton socks
avoid heat and cold
avoid pressure
avoid leg crossing is a way to protect from trauma when we are talking abt pad
this is true
peripheral venous disease
recognize cues : to function properly veins must be patent with competent valves
3 health problems alter blood flow in veins :
- thrombus formation ( venous thrombus ) which can lead to PE
- defective valves lead to venous insufficiency and varocise veins ( potential for ulcers )
- skeletal muscles do not contract to help pump blood to veins ( peripheral edema )
true or false. change position frequently, monitor/control infection : keep feet clean, use lotion but not between toes
cover ulcers with sterile drsg
true
alot of people in bed - peripheral edema they do not have muscle contraction that increases venous return
true
peripheral venous disease
analyze cues
what is venous duplex used for ?
assess blood flow
what is the d-dimer blood test used for in peripheral venous disease?
marker of coagulation and fibrin breakdown
what is the d-dimer blood test used for in peripheral venous disease?
recall that it is the : marker of coagulation and fibrin breakdown
what else ?
measures protein fragments that release when a blood clot dissolves
peripheral venous disease: identify priorities : deep vein thrombosis
thrombus formation is associated with :
stasis of blood flow
endothelial injury
hypercoagulability
risk factors of peripheral venous disease
prolonged sitting ( airplanes )
bedrest ( hospitalization, surgery )
what might you see ? in deep vein thrombosis
unilateral leg edema
pain, sense of fullness
hot to touch
systemic temp
postive homen’s
true or false. the risk is bigger hypercoaguability any prolong sitting or laying touch it might be warm
true
peripheral venous disease : venous ulcers
what is the cause?
damaged valves in the veins resulting in retrograde blood flow
pooling of blood in the legs and swelling
hydrostatic pressure causes release of fluid into the skin causing irritation
associted with swelling ( lack of oxygen flow down to the legs ) adequate circulatoion but not returning the blood to the heart
pooling edema and pain ( there is tissue damage as well as swelling )
hyperpigmenetation - accmulation of molacites
jsut read it: peripheral venous disease
yesss
peripheral venous disease : what might you assess?
dull pain, peripheral edema, skin hyperpigmentation
ulcer : irregular boarders with lots of drainage
peripheral venous disease: take action
intervention for stable patient :
anticoagulation therapy
unfractionated heparin ( UF ) or low molecular weight heparin ( LMWH )
warfarin
give both drugs for abt 5 days then d/c heparin once coumadin is at a therapeutic level
peripheral venous disease: blood coagulation tests why are these taken ?
taken frequently to assess therapeutic levels ( aPTT or INR)
DOAC ( rivaroxaban, apixaban )
what is the description for peripheral venous disease
latest development in anticoagulation
efficacy is similar to warfarin therapeutic index so frequent blood tests not required
what is very effective in preventing clots ( becasue it has wide therapeuthic index its better than warfarin )
true
peripheral venous disease : thrombolytic therapy ( for extensive DVT )
using catheter directed approach
TPA directly through a catheter that threads through the femoral vein to the the clot
inferior vene cava filtration
to prevent complication of pe
if the clot got dislodge and travel up this will stop from reaching the lungs
peripheral venous disease : thrombectomy
surgery to remove the clot
peripheral venous disease: inferior vena cava filtration
filtration device inserted into femoral vein or superior vena cava to prevent clots from travelling to lungs
peripheral venous disease
take action
what is our goal ?
decrease edema and promote venous return
peripheral venous disease : decrease edema and promote venous return
compression beandages
balanced diet ( vitamins a, c protein, zinc )
proper skin care/non scented moisturizers
prevent infection and daily walking program these are all true in terms of peripheral venous disease
true
avoid standing or sitting for too long, elevate legs to reduce swelling in terms of peripheral venous disease
true
how is compression bandages helpful ?
this is very helpful ( arterial prophelb -
muslce squeeze helps venous return to the heart - less edema the more they walk
if they stand or sit ( they have worsenging swelling,
true
peripheral venous disease
discharge teaching for anticoagulant therapy
contact ems for bleeding that doesnt stop ( 10-15 mins )
take med at same time everyday
report tarry stools severe headache or stomach pain, confusion or dizziness or bruising more than usual.
avoid contact sports/use soft bristle toothbrush - wear medic alert bracelet ( indicating what you are taking )
is this true amongst discharge teaching for anticoagulant therapy
yes this is true
inform all HCP providers of anticoagulant therapy ( dentist and do not take nsaids or asa is this true amongst peripheral venous disease ( discharge teaching for anticoagulant theraphy)
this is true
exemplar #3 is what ?
aortic aneurysm : what is it
outpounching or dilation of the arterial wall usually caused by atherosclerosis
aortic aneurysm : recognize cues
abdominal aortic aneurysm
what are the charactersitics
pulsatile mass in periumbilical area left of the midline
audible bruits
pain to back, epigastric discomfort
what is it thoracic aneurysm?
diffuse chest pain extending to intrascapular area
often asymptomatic
if the aortic is a little more upper what is the pain?
neck pain, dysphagia could occur
what is aortic ( in aortic aneurysm )
largest artery in your body
splits around the kidney area
what is the aortic aneurysm common ?
most common is the abdominal aortic aneurysm
on exam when palpating there is a forsatile mask area peri umbilical just above the belly button, if there is a stethoscope aneurysm ( bruising - swishing sound )
true
aortic aneurysm : analyze cues
diagnostic imaging
ct scan or ultrasound to assess size and location of aneurysm
aortic aneurysm prioritization : what is aortic aneurysm
potential complication is rupture of aortic aneurysm
aortic aneurysm prioritization : what is aortic aneurysm : anterior ?& posterior
anterior - bleeds fast into abdominal cavity and has poor prognosis
posterior - bleeds into retroperitoneal space and is tamponaded by surronding organs ( better chance to survive )
what is this describing : bleeds into retroperitoneal space and is tamponaded by surronding organs ( better chance to survive )
posterior aortic aneurysm
what is this describing : bleeds fast into abdominal cavity and has poor prognosis
anterior aortic aneurysm
what does anterior and posterior aortic aneurysm
both require immediate action resuscitation and surgery
aortic aneurysm : take actions : interventions
non surgical management ( for small, asymptomatic )
monitor growth ( frequent U/S or CT scans )
maintain BP in normal limits
antihypertensive therpahy if necessary
aortic aneurysm : control the blood pressure
if there is high ( pressure against the wall ) lower the pressure we can decrease the amount of stress we have on arterial wall
angi hypertensive can be order if its elevate ( if not watch and see what type of approach we needa do )
true.
aortic aneurysm : take actions : interventions : open surgical repair name the characteristics
large abd incision
synthetic graft inserted and native wall closed around graft
when must open surgical repair be done during aortic aneurysm ?
must be done in 35-40 minutes so clamps can be removed and organs can be perfused before they are damaged
true or false. aortic aneurysm take actions : will go to icu post ip for 24-48 hours hrs ( intense monitoring required
this is true
aortic aneurysm : take actions : interventions
what is endovascular graft procedure EVAR
minimally invasive
stents are deployed via femoral artery catheter
post procedure care of aortic aneurysm :
care of groin site(s) post angiogram
bed rest and keep affected leg straight for 4-6 hrs
monitor peripheral pulses and groin site
monitor for ischemic complications ( emboli )
aortic aneurysm : is done through what ?
cath ( endovascular procedure )
from the inside we need to protect
aortic aneurysm : evaluate and educate
after endovascular repair educate patients on :
restricted activity level ( may include )
no stairs
no heavy lifting
no driving
may continue to need frequent ultrasounds
true or false. it is important to watch for sign of bleeding
look at pulses and lobe and procedure site
whatever we out in stent for anywhere, clot could develop
true
aortic dissection : recognize cues
tearing of the inner layer of the arota. blood surges through the tear causing the layers of the vessel to seprate this is considered as what ?
life threatening
what might u assess in arotic dissection ?
sudden severe onset of excruciating chest pain back pain jaw teeth - sharp ripping tearing pain that moves from point of origin
* symptoms of decreased cardiac output.
what is the description for : Aortic Arch Dissection
decreased LOC, dizziness, weak carotid and temporal pulses
surgical emergency
Descending Aorta Dissection
- Pain to back abdomen and legs decreased tissue perfusion to abdominal organs to lower extremities
is this true : the tear in inner layer of aorta bleeding actually occurs within the blood vessels
there is different laters - inner wall has rip and it accumulates in the inner wall
yes this is true amongst aortic dissection
usually excruitating pain, hypotensive and tatchy as blood moves from blood vessels into the blood vessels wall ( not intended for perfusion not reaching the area _)
yes this is true
Aortic Dissection
Take Action
what is our goal ?
goal is to prevent rupture and progression of dissection
- Treatment depends on size and severity of symptoms
- Proximal dissections usually require surgery (synthetic graft)
Pre-Op Nursing
- Bedrest, quiet environment*
BP medication IV* (titrate frequently) - Pain medication (opioids)
- Foley catheter inserted
- Observe for changes in p.p., ↑pain, restless, anxiety
is this true amongst aortic dissection
yes this is true
true
bed rest until area has calm down and try to control the blod pressure this is all we can do
to limit pressure inside the dissection
pain 0 anticipate u have to treat it with opoids sudden drop in co we hav tot hink abt urine ( if kidney is geting perfused )
thinkn ab peripherl cirucaltion is beign affected ? all chang in those 3 ps ( there interruption )
yes
