Block II, Test 2: Cardiac - Oxygenation/Perfusion; Iggy Chapters: 35, 36, 37, and 38

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Block II, Test 2: Cardiac - Oxygenation/Perfusion; Iggy Chapters: 35, 36, 37, and 38
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2013-02-21 16:28:07
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Block II Test Cardiac Oxygenation Perfusion
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Block II, Test 2: Cardiac - Oxygenation/Perfusion; Iggy Chapters: 35, 36, 37, and 38
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  1. What are the chambers of the heart?
    • 1. Right Atrium
    • 2. Right Ventricle
    • 3. Left Atrium
    • 4. Left Ventricle
  2. Which chamber of the heart generates the highest pressure?
    Left ventricle, because it is pushing the blood out to the entire body!
  3. Which chamber receives blood from the systemic circulation?
    Right Atrium
  4. Which is the only artery that carries deoxygenated blood?
    Pulmonary artery
  5. Which is the only vein in the body that carries oxygenated blood?
    Pulmonary vein
  6. If our fuel pump (heart) fails, what else fails?
    Profusion of our entire body!
  7. Trace a drop of blood as it enters the heart, starting with the vena cavas.
    • 1. Enters either the Superior or Inferior Vena Cava
    • 2. Dumps into the Right Atrium
    • 3. Goes through the Tricuspid Valve
    • 4. Enters the Right Ventricle
    • 5. Goes through the Pulmonic Valve
    • 6. Flows into the lungs, through the pulmonary arteries
    • 7. Flows back through the Pulmonary veins and drops into the Left Atrium
    • 8. Goes through the Mitral Valve
    • 9. Drops into the Left Ventricle
    • 10. Pushes through the Aortic Valve
    • 11. Enters the body, through the Aorta
  8. What arteries make up the cardiac circulation?
    • 1. Right coronary artery
    • 2. Posterior descending coronary artery
    • 3. Aortic arch
    • 4. Left main coronary artery
    • 5. Circumflex coronary artery
    • 6. Left anterior descending coronary artery


  9. What are the electrical systems of the heart, in the order of importance/electrical power?
    • 1. SA Node
    • 2. AV Node
    • 3. Bundle of HIS
    • 4. Right/Left Bundle Branch
    • 5. Right/Left Purkinje Fibers

  10. What is the main pace maker of the heart?
    The SA node: We expect it to fire between 60 and 100 beats per minute. When this is firing properly, the patient is said to have a Normal Sinus Rhythm. The SA node creates the "P-wave).
  11. What is the second pace maker of the heart?
    The AV node or the "junction": Firing rate is 40 - 60 beats per minute. (P-wave is shorter or missing). If heart beat is 40-60 bpm, the patient may not be getting enough blood flow to their organs and may not be picking up enough oxygen from their lungs.
  12. What is the third pace maker of the heart?
    The purkinje fibers: This creates a heart rate of 40 bpm or less. Many people will be symptomatic with activity, while not showing any signs, while at rest.
  13. When we say "three strikes your out", in relation to the heart, to what are we referring?
    • We are referring to the ability of the three pacemakers to fire an electrical impulse for the heart:
    • First: SA node
    • Second: AV node
    • Third: Purkinje Fibers
    • If these three do not work . . . you're out!
  14. What are the main elements of an EKG Complex?
    • 1. P wave
    • 2. QRS complex
    • 3. T wave

  15. What does the p-wave represent?
    Atrial depolarization
  16. What does the area from the end of the p-wave to the Q represent?
    Electrical depolarization and we expect that at some point here, is the atrial contraction, but it does not represent a contraction.
  17. What does the QRS complex represent?
    Ventricular depolarization
  18. The ST area represents?
    Ventricular contraction which equals a pulse
  19. What does the T wave represent?
    Ventricular repolarization
  20. Why don't we see atrial repolarization?
    Because it is hidden in the event of Ventricular depolarization.
  21. An inverted T wave or an st depression on an ECG (EKG) means what?
    Can we save this tissue?
    • Ischemia - Lack of blood flow
    • Yes, we can save this patient, if we get the blood flowing again.
  22. An ST elevation means what on an ECG (EKG)?
    Can we save this tissue?
    • Injury to the heart
    • Yes, we can save this patient, if we get the blood flowing again.
  23. A deep Q on an ECG (EKG) means what?
    Can we save this tissue?
    • Infarction - tissue death
    • No, this tissue is dead.
  24. Is it possible to have an Infarction, without a deep Q?
    Yes, if it is minor, it may not show up.
  25. Always treat the __a__, not the __b__!
    • a. patient
    • b. strip
  26. How do you calculate Cardiac Output?
    Heart rate x stroke volume = Cardiac output: This is the amount of blood that is pumping out to the body. 

    • The components are:
    • Preload:The amount of incoming blood to the heart, at any given time. (Unhealthy heart, a lot of blood coming in, the patient will not do well).
    • Afterload: Blood pressure, how much pressure does the heart have to overcome to push blood to the body. (B/P of 150/90 is harder to push blood out, than 90/50).
    • Contractility: The force of contractions by the myocardial cells. Strength of contractions can increase, until the heart fails.

    WARNING: A heart rate change is the FIRST indicator that something is changing in your patient!
  27. How does a diuretic (Lasix, for example) effect preload and afterload?
    The diuretic (Lasix) makes the patient pee, thus the B/P goes down and the amount of blood entering the heart also goes down (preload) and the amount of resistance goes down (afterload). This makes it easier for the heart to produce adequate cardiac output.
  28. How does digoxin affect cardiac output?
    It decreased the heart rate and increases the contractility. Which makes the heart function better.
  29. What is the purpose of the lymphatic system, from the standpoint of fluids?
    • 1.) Channels which collect excess intracellular fluid and return it to the vascular space - 3 liters/day
    • 2.) Closed end channels, pumpless (fluid moves via muscle movement), larger channels have valves 
    • 3.) Immune system monitoring
  30. If lymph nodes have been removed from our body, this will affect the flow of fluids.

    So, if the lymph nodes are removed from the right arm, due to breast cancer, what should you do for this patient?
    This arm must be protected. It will be prone to swelling. Thus, we will not put IV's or take B/P from this arm.

    NOTE: Lymphatic issues will be localized to the area effected.
  31. Range of Motion helps to return fluid to what two systems?
    • 1.) Venous return of blood
    • 2.) Lymphatic fluids (approximately 3L/day)
    • This is why it is so important!
  32. What is Hyperlipidemia and how can it be controlled?
    BAD!! When Lipids are high they can contribute to atherosclerosis. 

    • Cholesterol (secreted by the liver to make bile): should be <200 
    • HDL: should be high
    • LDL: should be low

    To control: Diet is first choice, medication is secondary (unfortunately these medications suppress the liver, thus a common side effect is liver failure).
  33. Define Ischemia
    Lack of blood flow.

    This can happen in any tissue of the body, but it is generally associated with the heart.
  34. Define angina and claudication
    • Angina: Chest pain (women may not experience chest pain with a cardiac issue. May be a sore throat, behind shoulder blades, etc. with diaphoresis)
    • Claudication: Pain in the legs, related to Peripheral Vascular Disease. The patient has arterial insufficiency to the lower extremities. When the patient walks around, there is not enough blood flow, so there is pain. When they sit down the pain gets better.
  35. Define thrombosis
    • Condition of clot.
    • Arterial and venous are possible
  36. Define HTN
    • Hypertension: High blood pressure
    • Controlling more tightly than they used to, 120/80 is the ideal B/P
  37. Define Failure/Shock
    When the system decompensates.

    Shock by definition: Systolic B/P <90 AND the patient is symptomatic.  Patient has an altered level of consciousness  they are confused, not making urine, diaphoretic, etc.
  38. Define Dysrhythmias or Arhythmias
    Electrical conduction system of the heart are not working.
  39. Define Edema
    Swelling
  40. What are some forms of Cardio Vascular Disease?
    • CAD PH2AD
    • CAD: Coronary Artery Disease
    • Peripheral Vascular Disease (PVD)
    • Heart Failure
    • Hypertension
    • Angina
    • Deep Vein Thrombosis (DVT)
  41. Define the complications of Coronary Artery Disease (CAD)
    • CAD NI2PS at the heart!
    • Narrowing of coronary arteries
    • Impaired blood flow
    • Ischemia
    • Pain
    • S/S: pain, N/V, diaphoresis, and pallor
  42. Define Artherosclerosis
    Plaque buildup that gets hard, a condition of vessel hardening. It is associated with high cholesterol and a messed up lipid profile (instead of the HDL being high, it is low and instead of the LDL being low, it is high).

    Diseases that can stimulate the build up of Atherosclerosis are: Hypertension and Diabetes. Additionally, really high and low blood flow can stimulate atherosclerosis.
  43. Walk through the process that happens as plaque builds toward atherosclerosis.
    • 1. As the plaque builds up, the inside of the artery gets smaller.
    • 2. If the vessel size gets smaller, the arterial B/P goes up.
    • 3. As the B/P goes up, there is a risk for the plaque to break off, which creates an emboli.
    • 4. An emboli can/will float downstream and lodge in the arteries, creating a blockage. 
    • 5. Anytime something fractures or breaks, the body sees it as and injury and it stimulates an inflammatory response.
    • 6. As the inflammatory response grows, it creates a blood clot
    • 7. A blood clot causes either a heart attack or a stroke, depending on where the injury occurs.
  44. What is the pathophysiology of atherosclerosis?
    • 1.) Injury to artery endothelial cells
    • Caused by: HTN, DM, Increased lipids, Infection
    • 2.) Inflammation
    • Caused by: a) Macrophages race to injured area, release enzymes and O2 radicals, oxidized LDL; b) Macrophages eat oxydized LDL = Foam Cells; c) Fatty streak develops over time
    • 3.) Fibrous plaque with platelet adhesion
    • See causes at: http://www.youtube.com/watch?v=XZB2GciZnr4

    NOTE: This process can also occur in the peripheral arteries and be called Peripheral Artery Disease (PAD)
  45. If a person has atherosclerosis of the heart, will they have it anywhere else?
    YES! It is highly unlikely that an individual will have atherosclerosis in ONE artery! It can happen anywhere in the body and in multiple spots!
  46. What are the different types of angina?
    • Chronic stable angina: Comes and goes, but is relieved by rest = NO change in the vessels. Triggered by exertion or stress.
    • Unstable angina: Other name is Acute Coronary Syndrome (ACS), can be caused by a thrombus, come on at rest, changes in cardiac rhythm. More acute pain, N/V, EKG changes.
    • Vasospastic, Prinzmetal's, Variant Angina: Caused by smoking, electrolyte levels, which give spasms. Can come on during rest OR exercise. EKG changes. Signs/symptoms: squeezing, pressure on the chest.
  47. Your patient presents with chest pain.
    What are the priority nursing assessments?
    Assess pain (scale of 0-10), duration of pain, onset, description of pain, whether or not the pain travels, whether anything makes it better or worse, how long the pain has been present.
  48. Your patient presents with chest pain.
    What are the priority nursing interventions?
    • MONA: 
    • Morphine IV: A vasodilator, decreases preload, decreases O2 demand on the heart, must have a systolic pressure >100
    • Oxygen
    • Nitroglycerin: A vasodilator, decreases preload, decreases O2 demand on the heart, must have a systolic pressure >100
    • Aspirin: Keeps the platelets from sticking together, like slick 50
  49. What are some statistics about Nitroglycerin that we need to know, in regard to storage and administration of the medication.
    • 1. Storage: Should not be exposed to light.
    • 2. Dosage: Patient can be given 1 tablet q5min x 3
    • 3. How it works: Medication causes hypotension
    • 4. Contraindications: <100 systolic B/P; sexually enhancing drugs (even females) in the last 72 hours.
  50. Your patient presents with chest pain.
    What diagnostic tests do you anticipate will be ordered?
    • Xray: Shows size/shape of the heart
    • EKG: Measures the electrical current of the heart.
    • Echocardiogram (noninvasive); Transesophageal echocardiogram (invasive, requires prep, but provides a better measure of the heart valves): Shows the function of the heart muscle, location of the heart, and blood flow studies.
    • Holter Monitor: EKG for an extended period of time; coupled with an activity diary.
    • Stress Test (with or without medications): Don't eat or drink prior to test (especially caffeine products).
    • Cardiac Catheterization/Angiography: may go up through the femoral artery with a camera, pinching or removing pieces, or inflating a balloon, placing a stint, etc.; May do a bypass graph, if blockage found.
  51. How does the ANP, BNP work, in regard to fluids in the body?
    It counteracts the RAAS system of the Kidneys to release fluids.
  52. Regarding Serum Tests, what do you need to know?
    • 1.) Baselines and Trending:
    •  - CBC: WBC (5,000 - 10,000); RBC (4.7 - 6.1 for men; 4.2 - 5.4 for women); Hgb (14 - 18 for men; 12 - 16 for women); Hct (42 - 52% for men; 37 - 47 for women)
    •  - Electrolytes: Na+ (135 - 145); K+ (3.5 - 5.0); Mg+ (1.5 - 2.5)
    •  - BUN (10 - 20); Creatinine (?): Kidney perfusion
    •  - PT (INR) and APTT: Monitor anticoagulant
    •  - ANP, BNP: Severity of CHF (too much fluid or less)
    •  - D-dimer: r/o DVT, PE
    • 2.) Risk for Disease:
    •  - Lipids: LDL; HDL; triglycerides
    •  - C-reactive protein: homocysteine
    • 3.) Diagnosis of cardiac damage
    •  - Cardiac/Isoenzymes Enzymes: CPK (CK) - M
    •  - Troponin T; Myoglobin: MI indicators
  53. What is the silent disease?
    Primary Hypertension, because it is often symptom free
  54. What are some diagnostic methods to determine a Myocardial Infarction (MI)?
    • 1:  Troponin (Specific to an MI - otherwise troponin should not be detectable), q6hrx4
    • 2:  Myoglobin (Specific to the heart)
    • 3:  CPK (CPK-MB is specific to the heart), q6hrx4
    • 4:  LDH (To see if the patient had a heart attach a week or so back)
    • 5:  EKG - q6hrx4
    • 6:  Treadmill
    • 7:  Heart Catheterization
  55. What is the goal of treatment for Coronary Artery Disease?
    The goal is always to restore blood flow ASAP
  56. How prevalent is Hypertension (HTN)?
    50 Million people in the United States have HTN.
  57. What is the relationship between B/P and the risk of Cardo Vascular Disease (CVD)?
    The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.
  58. What does each increment of 20/10 mmHg do to the risk of CVD?
    Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg
  59. Prehypertension signals the need for what?
    Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.
  60. If you suspect Hypertension (HTN), what should you to to confirm the reading?
    Measure both arms (use higher result).
  61. Describe primary (idiopathic) and secondary hypertension.
    • 1.) Primary:  Elevated BP without an identified cause (no one single cause, 90 - 95% of all cases).
    • 2.) Secondary:  Elevated BP with a specific cause, 5 - 10% of all cases.
  62. What is involved in a patient evaluation for hypertension (HTN) and cardio vascular disease (CVD)?
    • 1:  Two consecutive blood pressure measurements.
    • 2:  Assess lifestyle and identify other CV risk factors or concomitant disorders that affects prognosis and guides treatment.
    • 3:  Reveal identifiable causes of high BP.
    • 4:  Assess the presence or absence of target organ damage and CVD.
  63. What are some of the risk factors for Primary Hypertension (Idiopathic)?
    • Age
    • Alcohol
    • Cigarette smoking
    • Diabetes mellitus 
    • Elevated serum lipids
    • Excess dietary sodium
    • Gender
    • Family history
    • Obesity
    • Ethnicity (Black Males highest risk)
    • Sedentary lifestyle
    • Socioeconomic status
    • Stress
  64. Why does sleep apnea cause or contribute to hypertension?
    When a person sleeps, their blood pressure drops. A person with sleep apnea keeps getting woke up by their brain, which in turn causes the blood pressure to rise back up. Eventually it rises higher than the normal.
  65. Why do steroids cause hypertension (HTN)?
    Steroids: Prednisone, corticosteroids, etc. can cause HTN due to causing sodium retention.
  66. What are the levels for mild, moderate, and severe hypertension?
    • 1.) Mild:  140/90 +
    • 2.) Moderate:  160/100 +
    • 3.) Severe:  180/110 +
  67. What are the two different types of Hypertension?
    • 1:  Primary idiopathic (90 - 95%)
    • 2:  Secondary - Related to disease process (5 - 10%)
  68. What are the Blood Pressure classifications?
    • 1. Normal:  <120 systolic; <80 diastolic; encourage a lifestyle modification; No drug therapy is necessary.
    • 2. Prehypertension:  120 - 139 systolic; or 80 - 89 diastolic; A lifestyle change should be made; No drug therapy is necessary.
    • 3. Stage 1 Hypertension:  140 - 159 systolic; or 90 - 99 diastolic; A lifestyle change should be made; A single agent medication is necessary.
    • 4. Stage 2 Hypertension:  Equal to or > 160 systolic; or Equal to or > 100 diastolic; A lifestyle change should be made; A combination medication is necessary.
  69. What is the Hypertension Nursing Care, using the DIURETIC mnemonic?
    • D:  Daily weight
    • I:  Input and Output (I&O)
    • U:  Urine Output
    • R:  Response of B/P
    • E:  Electrolytes
    • T:  Take pulses
    • I:  Ischemic Episodes (TIA)
    • C:  Complications (4 C's)
  70. What are the four (4) C's, in the complications of hypertension?
    • CAD:  Coronary Artery Disease
    • CRF:  Chronic Renal Failure
    • CHF:  Congestive Heart Failure
    • CVA:  Cerebral Vascular Accident
  71. List some of the Antihypertensive Drugs - ABC's and ARB's
    • 1:  ACE Inhibitors (end in PRIL)
    • 2:  Beta Blockers (end in OLOL)
    • 3:  CAlcium Antagonists (Very, Nice, Drugs)
    • 4:  ARB - Angiotensin II Receptor Antagonists (Blockers)
  72. How do ACE Inhibitor's work?
    What are the side effects?
    What are the contraindications?
    • Angiotensin Converting Enzyme (ACE) Inhibitors:
    • Decrease peripheral vascular resistance without increasing cardiac output, without increasing cardiac rate, and without increased cardiac contractility.

    • The side effects are: 
    • 1:  Dizziness
    • 2:  Orthostatic Hypotension
    • 3:  GI Distress
    • 4:  Nonproductive cough
    • 5:  Headache
  73. Explain the Renin-Angiotensin-Aldosterone System (RAAS).
  74. Describe what Angiotensin II Receptor Antagonists (Blockers) = ARB's work.
    • Example:  Losartan (Cozaar)
    • Works:  Similar to ACE Inhibitors
    • ARB's:  Cause vasodilation and decreased peripheral resistance
  75. How do B-Blockers work?
    What are the side effects?
    What are the contraindications?
    • Blocks Beta Receptors in the heart, which causes:
    • 1:  Decreased heart rate
    • 2:  Decreased force of contraction
    • 3:  Decreased rate of A-V Conduction

    • The side effects are:
    • 1:  Bradycardia
    • 2:  Lethargy
    • 3:  GI Disturbance
    • 4:  Congestive Heart Failure (CHF)
    • 5:  Decreased B/P
    • 6:  Depression

    • Contraindications of B-Blockers are:
    • < 60 bpm Heart Rate
    • < 100 Systolic B/P
    • CAUTION when using Non-Selective B2 Blockers: Individuals with diabetes cannot convert glycogen to glucose.

    NOTE:  African American Hypertensive clients do not respond well to beta blockers. They also need diuretics to get the job done!
  76. What are the actions of the two (2) different Beta Blockers?
    • B1:  Selective - works mainly in the heart
    • B2:  Nonselective - works in the heart and lungs
  77. How do CAlcium Antagonists work?
    What are the side effects?
    • Blocks calcium access to cells, which causes:
    • 1:  Decreased contractility of the heart
    • 2:  Decreased conductivity of the heart
    • 3:  Decreased demand for Oxygen (O2)

    • The side effects are: 
    • 1:  Decreased B/P
    • 2: Bradycardia
    • 3: May precipitate A-V block
    • 4: Headache
    • 5:  Abdominal Discomfort (Constipation, nausea)
    • 6: Peripheral edema

    NOTE: If calcium receptors have been blocked by antagonists, then more Ca+ will be in the blood = HyperCalcemia (See Iggy, p. 689)
  78. What are the two types of Cholesterol?
    HDL: Good cholesterol consists of High Density Lipoprotein (HDL) particles which are high in protein and low in fat. They take cholesterol out of the body and help clear existing arterial plaque. Many consider this to be the most important of all the cholesterol scores. A reading over 60 is considered optimal, 50 - 60 good, 40 - 50 borderline, and anything under 40 will require some type of immediate action.

    • LDL: Bad cholesterol is primary a fatty molecule that carries cholesterol into your arteries and roughs up the artery walls. This combination provides the backdrop for dangerous arterial plaque deposits. It only makes good health sense to reduce and maintain this part of your cholesterol scores into a heart healthy range. Less than 100 is considered very good, 100 - 129 is above average, 130 - 159 is borderline high, 160 - 189 is high, and anything over 190 is considered dangerous and will require immediate action.
  79. What should the readings for LDL and HDL be?
    LDL: Want LOW (below 130) or it will lower you into the ground!

    HDL: Want HIGH (above 35) for client to feel healthy!
  80. Define hyperlipidemia
    Anything over 240 is considered high and requires some type of immediate action.

    The overall total cholesterol: less than 200 mg/dL is optimal and 200 - 239 is considered borderline high.
  81. What are some of the antilipidemic medications?
    • 1.) Atorvastatin (Lipitor): Prevent the production of cholesterol in the liver by blocking HMG-CoA reductase, an enzyme that makes cholesterol. Generally well tolerated and is taken once a day. Can cause muscle fatigue, pain and break down and liver damage. 
    • 2.) Nicotinic Acid (Niacin): Niacin can raise HDL (the "good" cholesterol) — by 15 to 35 percent. This makes niacin the most effective drug available for raising HDL cholesterol. While niacin's effect on HDL is of most interest, it's worth noting that niacin also decreases your LDL and triglyceride levels. High levels of LDL and triglycerides are significant risk factors for heart disease.
  82. How does Nicotinic Acid (Niacin) work?
    It prevents ATP synthase (a beta chain), used in making ATP, from picking up the HDL and taking it out of the blood.

    Studies show that Nicotinic Acid can reduce this up take by 27%, which increases the HDL levels by 35%.
  83. What are some of the symptoms of Left-sided heart failure?
    • 1:  Pulmonary Congestion:
    •  - Edema
    •  - Cough
    •  - Crackles
    •  - Wheezes
    •  - Blood-tinged (pink frothy) Sputum
    •  - Tachypnea
    •  - Shortness of Breath (SOB)
    • 2: Paroxysmal Nocturnal Dyspnea
    • 3: Elevated Pulmonary capillary wedge pressure
    • 4: Restlessness
    • 5: Confusion
    • 6: Orthopnea
    • 7: Tachycardia
    • 8: Exertional Dyspnea
    • 9: Fatigue
    • 10: Cyanosis
  84. What are some of the symptoms of Right-sided heart failure?
    • 1: Enlarged Liver and Spleen
    •  - Liver engorgement
    • 2: Increased Peripheral Venous Pressure
    •  - Dependent Edema
    •  - Swelling in the hands and fingers
    •  - Ascites
    •  - Jugular Vein Distension (JVD)
    • 3: Fatigue
    • 4: May be secondary to chronic pulmonary problems
    • 5: Anorexia and complaints of GI Distress

    • NOTE: The most common cause of Right-sided heart failure, is Left-sided heart failure. Thus, you may see left-sided heart failure signs as well.
    • EXAMPLE:  Pulmonary edema, along with systemic edema.
  85. What are the goals, when treating heart failure?
    •  - Decrease workload of the heart
    •  - Increase force and efficiency of the heart
    •  - Eliminate excess fluid
  86. What are some of the drugs used to treat heart failure?
    • 1: Digoxin
    • 2: Diuretics
    • 3: Electrolyte replacement
    • 4: Vasodilators
    • 5: Na+ Restriction
  87. Digoxin (Foxglove) is what type of drug?
    How does it work?
    • Inotrope (Increases contractility)
    • Chronotrope (Decreases rate)
    • Dromotrope (Decreases conduction velocity)
  88. How is Digoxin (Foxglove) delivered?
    • 1: Loading Dose
    • 2: Maintenance Dose

    • Routes and Peaks:
    •  - Oral (4 - 6 hours)
    •  - IV (1 - 4 hours)
    • CAUTION: Toxic levels >2.5 ng/mL (levels must be kept between 0.5 - 2 ng/mL, thus there must be 1-5mL of venous blood in the heart).

    • NOTE: Monitor therapeutic drug levels AND check potassium levels prior to each dose.
    • DO NOT GIVE IF HEART RATE IS <60
  89. How are diuretics used to control edema, related to CHF, cirrhosis, renal disease, and hypertension?
    • Delivery routes:
    • PO, IV, and IM

    • Watch for:
    • 1: Decreased B/P
    • 2: Decreased Na+ (Hyponatremia)
    • 3: Decreased Chloride
    • 4: Decreased K+ (HypoKalemia)
    • 5: Hyperglycemia
    • 6: Decrease in weight
    • 7: Decreased I & O
    • 8: Dehydration
    • ALL DUE TO LOST H2O, HCO3, Na+, K+ AND Cl-
  90. List a couple of the diuretics used for edema, CHF, renal disease, cirrhosis, and hypertension?
    • 1: Hydrochlorothiazide (hydrodiuril) - "Thiazide, sets aside Calcium"
    • 2: Furosemide (Lasix)

    These medications work on the Nephrons and the Loop of Henle.
  91. What is a Deep Vein Thrombosis (DVT)?
    A blood clot formed in situ within the vascular system of the body and impeding blood flow. A piece can break off and create a cardiac emboli or a pulmonary emboli.

    A patient who has hip surgery, immobility, obesity, or varicose veins can be at risk of developing DVT. NOTE: A pic-line can cause a deep vein thrombosis!
  92. What is the D-dimer Test and what is it used to diagnose?
    D-dimer tests are ordered, along with other laboratory tests and imaging scans, to help rule out the presence of a thrombus.

    • Some of the conditions that the d-dimer test is used to help rule out include:
    • 1: Deep vein thrombosis (DVT)
    • 2: Pulmonary embolism (PE)
    • 3: Strokes

    This test may be used to determine if further testing is necessary to help diagnose diseases and conditions that cause hypercoagulability, a tendency to clot inappropriately. A D-dimer level may be used to help diagnose disseminated intravascular coagulation (DIC) and to monitor the effectiveness of DIC treatment.

    • When is it ordered?
    • D-dimer may be ordered when someone has symptoms of DVT, such as:
    • 1: Leg pain or tenderness, usually in one leg
    • 2: Leg swelling, edema
    • 3: Discoloration of the leg

    • It may be ordered when someone has symptoms of pulmonary embolism such as:
    • 1: Sudden shortness of breath, labored breathing
    • 2: Coughing, hemoptysis (blood present in sputum)
    • 3: Lung-related chest pain
    • 4: Rapid heart rate

    D-dimer is especially useful when the doctor thinks that something other than DVT or PE is causing the symptoms. It is a quick, non-invasive way for the doctor to help rule out abnormal or excess clotting.
  93. What are the risks of a Deep Vein Thrombosis (DVT)?
    • Movement of the clot!
    • This can result in a Cardia emboli or a Pulmonary emboli.
  94. What are the medical interventions that can be given to a patient with Deep Vein Thrombosis (DVT)?
    • Anticoagulant medications include:
    • 1: Heparin
    • 2: Coumadin
    • 3: Lovenox

    • Procedures include:
    • 1: Catheter directed thrombolysis
    • 2: Vena Cava Filter (Greenfield)

    NOTE - CAUTION: Do not rub lotion on the legs of a patient with DVT!! You could end up loosening a clot.
  95. What does Warfarin Sodium (Coumadin) do or how does it work on a DVT?
    • 1: Coumadin does not dissolve a clot. It thins the blood (working on clotting factors - I, II, VII, and X), thus vitamin K (clotting agent) does not work in the body. There is an extreme risk for bleeding!
    • 2: Coumadin is used to prevent clot formation with DVT, PE, A-Fib with embolism, TIA, and Coronary Occlusive Problems.
    • 3: An overdose of Coumadin can cause hemorrhage, headache, bruising, and back pain.
    • 4: MUST WATCH THE PT & INR LAB VALUES
  96. How does Heparin work?
    • 1:  Heparin does not lyse or break up clots. It inhibits the clotting time and/or formation. 
    • 2:  Heparin interferes with the conversion of fibrinogen to fibrin and prothrombin with thrombin, which creates the product for clotting.
    • 3: Watch for:
    •  - Spontaneous bleeding, starting in the mucus membranes (rectal, oral, and nasal passages)
    •  - Vasospasms, ecchymosis, and hypersensitivity

    CHECK THE PTT LABS: Bleeding is is a major concern with this medication!
  97. Which lab test is ran on patients taking Coumadin and Warfarin?
    Prothrombin Time (PT) lab test
  98. Which lab test is ran on patients taking Heparin?
    Partial Thromboplastin Time (PTT) & Activated Partial Thromboplastin Time (APTT) lab tests.
  99. List some of the important points about the anticoagulant: Plavix
    • •Platelet aggregation inhibitor
    • •Given PO with or without aspirin
    • •Give with food!
    • •Use cautiously with asthmatic patients!
    • •Labs to watch – AST, ALT, CBC, Hct/Hgb, PT
    • •Monitor patient for signs of bleeding and rash (can cause Stevens Johnson Syndrom)
  100. What can happen with the disorder of venous circulation: Venous Insufficiency?
    • •Inadequate venous return over a long period of time that causes pathologic changes as a result of ischemia in the vasculature, skin and supporting tissues
  101. What are the subjective and objective finding of venous insufficiency?
    • •Subjective findings
    • –History of DVT/thrombophlebitis
    • –HTN
    • –Varicose veins

    • •Objective findings
    • –Edema
    • –Thick, coarse, brownish skin around the ankles and feet
    • –Stasis ulcers
  102. What are peripheral arterial diseases?
    What are the signs and symptoms (s/s)?
    • 1.) Thrombus or embolus which obstructs arterial flow - Types of Emboli
    • S/S: Mottled extremity, cap refill prolonged, and pain (this hurts REALLY bad!!); No pulses, leg may be blue and has the possibility to die, BUT there will NOT BE SWELLING!! Swelling will come after the blood flow is restored, as an inflammatory response.
    • Chronic: Skin is thin and shiny

    • 2.) Atherosclerosis - Deposits of fat and fibrin in vessel walls that hardens over time. (Potential for a piece of the plaque to break off and create an emboli and a blood clot.)
    • S/S: Hypertension, TIA's (causing confusion, drooling, loss of speech, cannot move one side of their body - Transient means it goes away within 24hrs), Chest pain with activity or stress (sign of impaired coronary circulation).
    • Nursing Goal: Restore blood flow, Lower LDL, Cholesterol, Control BP and Blood sugar

    REMEMBER: Time is muscle, the longer it takes to restore blood flow, the more muscle is being destroyed!

    NOTE: Diabetics can have impaired blood flow to the heart and have NO PAIN AT ALL!!

    • 3.) Buerger Disease - Young men and smokers
    • S/S: Pain and tenderness of the hands and feet. Progresses to gangrene.
    • Treatment: Stop smoking, Vasodilators
    • Surgery: Sympathectomy

    • 4.) Raynaud's Disease: White finger tips, due to vasospasms of the small arteries in the fingers.

  103. How do you treat peripheral arterial disease?
    • 1.) Heparin: This is a blood thinner, it does not dissolve clots, it simply keeps the blood from clotting so quickly. In hopes of keeping blood flow open.
    • 2.) Angioplasty: 
    •  - Angioplasty can restore blood flow to the heart. During the procedure, a thin, flexible catheter (tube) with a balloon at its tip is threaded through a blood vessel to the affected artery. Once in place, the balloon is inflated to compress the plaque against the artery wall. This restores blood flow through the artery.Doctors may use the procedure to improve symptoms of CHD, such as angina. The procedure also can reduce heart muscle damage caused by a heart attack.
    •  - Another angioplasty intervention is called a Percutaneous Coronary Intervention. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. A stent is often placed at the site of blockage to permanently open the artery.
    • 3.) Surgery: Thrombectomy (Removing the clot from the vessel itself). If you cannot find a pulse, you must get a doppler, to see if it is there!! You cannot chart all day that you did not find the pulse, they will lose their arm, they will sue, and they WILL WIN!!
  104. Compare the assessments for Arterial vs. Venous Disease
    • 1.)  Arterial Disease:
    • Color: Pale
    • Edema: None or minimal
    • Nails: Thick and brittle
    • Pain: Worse with elevation and exercise; may be sudden or severe; rest pain; claudication
    • Pulses: Decreased, weak or absent
    • Temperature: Cool
    • Extremities: Dry and necrotic

    • 2.) Venous Disease:
    • Color: Ruddy; cyanotic if dependent
    • Edema: Usually present
    • Nails: Normal
    • Pain: Better with elevation; dullness or heaviness
    • Pulses: Normal
    • Temperature: Warm
    • Extremities: Moist; malleolar (ankle)
  105. What are the five (5) cardinal signs of inflammation?
    • 1: Pain
    • 2: Redness
    • 3: Swelling
    • 4: Heat
    • 5: Loss of function (patient does not want to use the affected area)

    This can happen in DEEP VEIN THROMBOSIS!

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