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2014-01-30 09:59:12
cardiovascular disorders

Cardio disorders
Show Answers:

  1. Examples of Disorders of the Aorta and Branches:
    Arterial thrombosis and embolism

    Peripheral Arterial Disease

    Aortic Aneurysms

    Thromboangitis Obliterans

    Raynaud's disease/phenomenon
  2. Examples of Venous Disorders:
    Venous thrombosis: Superficial and Deep

    Chronic Venous Insufficiency

  3. Always start a patient assessment by:
    Gathering Data!

    Take family history and look at the genetic history of developing these disorders
  4. Diagnostic Blood Tests:
    • Cardiac Markers
    • Lipid Panel (Cholesterol Tests)
    • BNP (Brain Natriuretic Peptide)
    • Homocysteine Level
  5. Types of Cardiac Markers
    • CK (creatine kinase)
    • CKMB
    • T/I (troponin)
  6. Creatine Kinase (CK) Ranges for Men/Women
    • Women: 36-160 units/L
    • Men: 50-204 units/L
  7. Normal CKMB Range:
    <4-6% of total CK
  8. Normal Range for Troponin
    • <.35 (I)
    • <.2 (T)
  9. Significance of CK elevation:
    Acute myocardial infarctions release CK into the serum within the first 48 hours and returns to normal in about 3 days
  10. Rise/Peak/Return of CKMB
    CKMB elevation signifies myocardial infarction...

    • Rise: 4-6 hours
    • Peak: 18-24 hours
    • Return: 24-36 hours (1-2 days)
  11. Rise/Peak/Return of Troponin
    • Rise: 2-6 hours
    • Peak: 15-24 hours
    • Return: 7-10 days
  12. Total Cholesterol level
    <200 mg
  13. LDL (bad) normal levels:
  14. Target LDL levels for patients with atherosclerosis, DM, HTN, and Smokers:
  15. HDL (good) normal levels:
    • women: >60
    • men: >40
  16. Normal Triglyceride levels:
    <150 L
  17. Hormone secreted by the left ventricle when the heart muscle is overstretched (from excess volume coming into the heart)
    BNP (brain natriuretic peptide)
  18. Stimulus for BNP to be produced
    Excess volume/pressure coming into the heart
  19. BNP level in a normal heart function
  20. BNP level indicative of mild heart failure
  21. BNP level indicative of moderate heart failure
  22. BNP level indicative of moderate to severe heart failure
  23. Amino Acid that your body uses to make protein and to build and maintain tissue
  24. If homocysteine levels are too high, what happens?
    Encourages clot formation and causes the lining of the vessels to be thicker (inflammation occurs and damages to the inside lining of the artery occur). Therefore, elevated homocysteine levels contribute to strokes and heart problems
  25. Normal Homocysteine Levels
  26. Diagnostic Studies done for Cardiovascular disorders:
    • Chest Xray
    • Echocardiogram
    •    -transthoracic
    •    -transesophageal
    • Electrocardiogram (EKG/ECG)
    • Exercise Stress Testing
    • Myocardial Perfusion Imaging
    • Angiography (cardiac cath)
    • CT (computed tomography/ CAT scan)
    • Electrophysiology Study (EPS)
    • Venous Doppler Study & Duplex Scan
  27. Purpose of Chest X-Ray
    Helps determine the cause for symptoms that the patient is presenting.

    • It will tell if there is excess fluid (indicative of HF), size of the heart, etc. Bright spots that show up are calcium
  28. Chest X-ray is a painless procedure that takes 15 min and evaluates the symptoms of:
    • Shortness of breath
    • Persistent cough
    • Chest pain
  29. What is a major concern/question to ask if a patient is to undergo a chest x-ray?
  30. What is your role as a nurse during a Portable AP view Chest X-Ray on your patient?
    Help pt. sit forward

    Cover the cold, hard plate that is placed behind patient

    Elevate the HOB

    Ask patient to take a deep breath and hold (lowers the diaphragm and expands the lungs to get a better picture)
  31. Non-invasive procedure that utilizes ultrasound to image the heart, muscle, chamber sizes, valves, ejection fraction (normal = >55%) and blood flow
    • Echocardiogram
    •     -transthoracic
    •     -transesophageal (invasive)
  32. Normal Ejection Fraction
    > 55%
  33. 2 Types of Echocardiogram

    Transesophageal (invasive)
  34. What does an echocardiogram tell us?
    heart size, thickness of muscles, pumping ability, ejection fraction, etc.
  35. In a patient with a low Ejection Fraction what is the most important thing to monitor?
    Fluid Intake!

    (a low EF means the heart is barely moving because of excessive fluid)
  36. Most common form of echocardiography (non-invasive)
    Transthoracic Echocardiogram
  37. Transthoracic Echocardiography Procedure
    • No Special Prep
    • Transducer is applied to chest and evaluates:
    •    -size/shape
    •    -valves opening/closing
    •    -abnormal structures
    •    -blood clots/tumors
    •    -walls of the heart
    •    -pumping ability
  38. Transesophageal Echocardiogram Procedure
    • PREP:
    •     NPO for 6 Hours prior to test!
    •      Consent (because it is invasive)
    •     IV access (flush the IV cath to make sure it is open and working properly)
    •     Remove dentures

    •    IV Sedation
    •    Oxygen
    •    Anesthetic gel or spray
    • (patient will have decreased gag reflex so nurse will need to monitor and the pt will be NPO until the gag reflex returns)
    •    Test takes about 15 minute
  39. Nursing Care AFTER the Transesophageal Echocardiogram:
    • -monitor vital signs including pulse ox
    • -no eating or drinking for about 2 hours after or until gag reflex returns!
    • -monitor for shortness of breath, chest pain, bleeding, or fever (in case there was a puncture with the probe during the procedure)
  40. Painless test that records the heart's electrical activity
    Electrocardiogram (EKG/ECG)
  41. EKG procedure
    • No Special Prep 
    • (Patients with hairy chests may need to be shaved) 

    -Electrodes (usually 12) are placed on the specific locations on chest wall and extremities to get a picture of electrical activity in that area of the heart

    -Takes about 5 minutes

    • -To get the most accurate reading, have the patient remain as still as possible...don't talk, don't move, try not to take deep breaths
  42. What can we read from an EKG?
    ischemia of myocardium, infarct, hypertrophy of atria or ventricle, normal/abnormal rhythmias, problems with conduction and what area of the heart, pericarditis
  43. Example of a drug that will cause changes in an EKG reading
  44. Timed interval exercise that shows us how the heart responds to stress when it has to work harder
    Exercise Stress Testing
  45. Goal of Exercise Stress Test
    to reach target heart rate or at least 80%
  46. It is thought that a patient has an underlying heart disease if the patient develops _____ during a stress test:
    • Changes in ECG at low level of exercise
    • Drop in Blood Pressure
    • Extreme/Inappropriate SOB, chest discomfort
  47. Exercise Stress Testing takes about ____
    1/2 hour
  48. Prep for Exercise Stress Testing:
    NPO for 4 hours prior

    No stimulants (coffee, smoking, tobacco)

    • Hold normal medications that depress heart rate (Beta Blockers, Calcium Channel Blockers, Digoxin)
    • Tell pt to wear comfortable clothes

    Get consent form signed
  49. Pharmacologic Stress Agents Used in Stress Test:
    • Adenosine (Adenocard) - most common
    • (side effects disappear in about 15-30 sec)

    Dipyridamole (Persantine) - side effects last about 15-30 minutes (any type of Zanthene can counteract side effects (like caffeine)

    • Dobutamine - used mainly with stress echo
    • (used for pulmonary diseases: COPD/Asthma because it doesn't cause bronchoconstriction) 
  50. When administering Adenosine or Dipyridmole hold _______
    • caffeine for at least 24 hours before test;
    • medications that decrease HR
    • (ex: ccb, beta blockers)
  51. Formula for Cardiac Output
    CO = HR x SV
  52. Abnormal Defects in Myocardial Perfusion Imaging:
    Fixed - indicates infarc....dead and can't be revived

    Reversible - indicates a difference between resting point and stress pictures (an angiogram/cardiac cath needs to be done to further diagnose problem)
  53. Radioisotopes injected into IV for Myocardial Perfusion Imaging:
  54. Typical Standing orders of Stress Test:
    • Consent
    • NPO
    • No caffeine for 24 hours
    • Patent IV
    • Hold Meds that slow HR:
    •    Beta Blockers
    •       (Metoprolol, Carvedilol)
    •    Digoxin
    •    Calcium Channel Blockers
    •       (diltiazem, Verapamil)
  55. Procedure that requires an X-ray dye to be injected in a tube to take pictures of the heart. Large vascular access sheaths are placed in the groin or arm. Contrast dye is injected to detect impaired flow of blood to the coronary arteries
    Angiography (cardiac cath)
  56. Interventions for cardiac cath patient:
    Check to see if pt has allergies to shellfish, iodine or other xray dyes!

    Pressure is held for about 20-30 minutes after procedure - this allows for clot to form (hemostasis)...sometimes closure devices are utilized as the sheath is pulled out to obtain hemostasis fast
  57. Most common site for the insertion of tube during cardiac cath
    • Femoral Artery - 1st choice
    • Brachial Artery - 2nd choice
  58. Cardiac Cath usually lasts for about ____
    1 hour
  59. Typical Standing Orders for Cardiac Cath (Angiogram)
    • Consent!
    • NPO after midnight
    • IV access
    • Shave/prep right/left groin (with clippers!)
    • Hold Anticoagulants
    •     - heparin (must be stopped the day of procedure)
    •      - coumadin (must be stopped 4-5 days in advance)
    •      - lovenox (12 hours before procedure)
    • Check Allergy (iodine, shellfish, contrast dye)
    • (if allergic, give benadryl PO and solucortef)

    Hold basal insulin and oral hypoglycemic agents (monitor blood sugar frequently though because they are NPO and you don't want them hypoglycemic)
  60. Preparation for Cardiac Catheterization:
    • EKG
    • Complete Blood Count
    •     -if WBC elevated cancel test bc of possible infection
    •     -Hg, Hct
    •     -if Platelets are low cancel test to prevent exposing patient to hemmorhage
    • Electrolyte panel
    •     -Sodium, Potassium, BUN, creatinine

    PT/INR (if on coumadin)

    • Risk for contrast-induced nephropathy:
    •     -IV fluids, Na Bicarb drip
    •     -Mucomyst (helps decrease chance of metabolic acidosis)
    • (we want to look at excretion levels because the Xray contrast needs to be excreted from the body! The longer it is in the patient, increases the risk of renal failure!)
  61. Post  Cardiac Cath Care
    Bed Rest for 2-6 hours (the larger the cath, the longer the bed rest)

    HOB elevated <30 degrees

    Keep affected extremity straight

    • Frequent Monitoring:
    •     -V/S every 15 min for 1st hour (x4), every 30 min (x4) and then every hour (bp will be decreased if pt is bleeding)
    •     -Vascular assess site for bleeding/hematoma
    •     -Distal pulses, color, sensation, temp

    Check for orthostatic hypotension when bedrest is complete! (patient will have lost a lot of blood from procedure and could be dehydrated)
  62. Complications of Cardiac Cath
    Contrast Induced Nephropathy


    Allergic Reaction to IV contrast

    • Thrombus/Embolus
    • (usually pt will get small dose of heparin to prevent clots)

    • Dysrhythmias
    •     -Vasovagal (usually given atropine)
    •     -Ventricular

    • Dissection or perforation of heart or vessels
    • Retroperitoneal bleed

    Pseudoaneurysm or A-V fistula
  63. Painless test where X-Ray machine takes clear, detailed "sliced" pictures of the heart
    Cardiac CT (computed tomography)
  64. The _____ the calcium score from the ultrafast CT or EBCT, the _____ the risk for developing cardiovascular disease
    higher; higher
  65. Invasive study used to diagnose dysrhythmias and the conduction system
    EPS (electrophysiology study)
  66. Prep for EPS (electrophysiology study)
    • NPO
    • Consent
    • Shave/prep groin
    • Cath inserted into right femoral vein
  67. Post-Procedure care for EPS (electrophysiology study)
    • Bed rest 3-4 hours
    • Monitor Vital Signs/Puncture site
    • Assess pedal pulses
    • (no x-ray dye)
  68. Noninvasive, painless ultrasound test to detect thrombosis in the superficial and deep veins (may be done on the upper and lower extremities) PRIMARY test for DVT
    Venous Doppler Study and Duplex Scan
  69. Normal BP
    <120 / <80
  70. Prehypertension
    120-139 / 80-89
  71. Stage 1 Hypertension
    140-159 / 90-99
  72. Stage 2 Hypertension
    >160 / >100
  73. In order to diagnose hypertension, you have to:
    take 2 separate readings at 2 separate appointments
  74. A condition most commonly seen in the older adult in which the systolic pressure is greater than 140 mm Hg and the diastolic pressure is within normal limits (less than 90 mm Hg)
    Isolated Systolic Hypertension
  75. False hypertension
  76. High blood pressure from an unidentified cause; also called essential
    Primary Hypertension (essential)
  77. High blood pressure from an identified cause, such as renal disease
    Secondary Hypertension
  78. A situation in which blood pressure is severely elevated and there is evidence of actual or probable target organ damage
    Hypertensive Emergency
  79. A situation in which blood pressure is severely elevated but there is no evidence of target organ damage
    Hypertensive Urgency
  80. Complications of Hypertension:
    • Target Organ Damage 
    •   Heart- Chest Pain?
    •   Brain- Stroke Symptoms?
    •   Peripheral Vasculature- Problems Walking?
    •   Kidneys- Abnormal Labs?
    •   Eyes- Damage to the retina, Vision Changes?

    • Organs will hypertrophy because they are having to work so much harder to pump blood
  81. Diagnostic Evaluation for Hypertension Includes:
    History and Physical

    Urinalysis (look for protein in the urine)

    BMP- Na, K, BUN, Cr, BG

    Lipid Profilefast for 8-12 hours before

    12-lead Electrocardiogram

    Retinal Exam- signs of swelling in the optic nerve

    Risk Factor Assessment

    Optional: 24 hr urine (Cr clearance), Echocardiogram
  82. Evidence Based Practice: Goal for Treatment of HTN
    BP < 140/90

    BP < 130/80 for patients with DM or CKD
  83. CKD (chronic kidney disease) is defined by:
    GFR with Cr > 1.3 females or >1.5 males or albuminuria > 300
  84. First step to treating hypertension:
    • LIFESTYLE modifications
    •     -DASH diet
    • Fish, Fruits/Vegies, Low-fat dairy, Low saturated/total fat

    •     -Dietary Sodium Reduction
    • Everyone should have <2.4 g/day but DM, CKD, and HTN patients should have <1.5
    •     -Weight reduction
    •     -Exercise
    •     -Smoking Cessation

    •     -Limited Alcohol Intake
    •     -Stress Management
  85. Drug Therapy for Hypertension:
    • ALLHAT Study
    •      -Antihypertensive & Lipid Lowering Treatment to prevent Heart Attack Trial

    • Medications:
    •    -Diuretics (1st choice/most common)
    •    -Beta Blockers
    •    -ACE inhibitors
    •    -Angiotensin receptor blockers
    •    -Alpha blockers
    •    -Calcium Channel Blockers
    •    -Alpha-beta Blockers
    •    -Direct Vasodilator
  86. Medication Choices for Hypertension
  87. Check BP prior to Anti-hypertensive medication administration. HOLD medication if the SBP ____
    < 90
  88. Patient Education Regarding Hypertension and home meds
    • Home BP monitoring
    • Adherence to health plan
    • Report Sexual Dysfunction
    • Rebound hypertension
    • OTC meds to avoid
    • Safety to avoid postural hypotension
    • Follow up visits
  89. IV meds given for Hypertensive Emergency
    Nitroprusside (Nipride)


  90. Oral meds given for Hypertensive Urgency
    Labetalol (Trandate)

    ACE inhibitors

    Clonidine (Catapres)
  91. Abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and the lumen
  92. Most prevalent type of cardiovascualr disease
    Coronary Artery Disease (CAD)
  93. What is the major cause of CAD?
  94. Risk Factors for CAD
    • Stress
    • High BP
    • Inactivity
    • Atherosclerosis
  95. Pathophysiology of Atherosclerosis
    *begins with injury to the vascular endothelium and progresses over many years

    *initiated by smoking, hypertension, hyperlipidemia, and other factors. 

    *endothelium undergoes changes and stops producing the normal antithrombotic and vasodilating agents.

    *The presence of inflammation attracts inflammatory cells, such as monocytes (macrophages).

    *The macrophages ingest lipids, becoming “foam cells” that transport the lipids into the arterial wall.

    *Some of the lipid is deposited on the arterial wall, forming fatty streaks.

    *Activated macrophages also release biochemical substances that can further damage the endothelium by contributing to the oxidation of low-density lipoprotein (LDL). The oxidized LDL is toxic to the endothelial cells and fuels progression of the atherosclerotic process 

    *Following the transport of lipid into the arterial wall, smooth muscle cells proliferate and form a fibrous cap over a core filled with lipid and inflammatory infiltrate. These deposits, calledatheromas, or plaques, protrude into the lumen of the vessel, narrowing it and obstructing blood flow 

    *Plaque may be stable or unstable, depending on the degree of inflammation and thickness of the fibrous cap. If the fibrous cap over the plaque is thick and the lipid pool remains relatively stable, it can resist the stress of blood flow and vessel movement. If the cap is thin and inflammation is ongoing, the lesion becomes what is called vulnerable plaque. At this point, the lipid core may grow, causing the fibrous plaque to rupture.

    *A ruptured plaque attracts platelets and causes thrombus formation.

    *A thrombus may then obstruct blood flow, leading to acute coronary syndrome (ACS), which may result in an acute myocardial infarction (MI). When an MI occurs, a portion of the heart muscle no longer receives blood flow and becomes necrotic.The anatomic structure of the coronary arteries makes them particularly susceptible to the mechanisms of atherosclerosis.

    *Atherosclerotic lesions most often form where the vessels branch, suggesting a hemodynamic component that favors their formation

    *Although heart disease is most often caused by atherosclerosis of the coronary arteries, other phenomena may also decrease blood flow to the heart. Examples include vasospasm (sudden constriction or narrowing) of a coronary artery and profound hypotension.
  96. Clinical Manifestations of CAD (coronary artery disease)
    • Angina Pectoris...caused by myocardial ischema and usually atherosclerosis
    • Sudden Cardiac Death (may be first indication of coronary atherosclerosis)
  97. Risk Factors that increase the probability of a person developing heart disease (CAD):
    • Nonmodifiable Risk Factors
    • Family history of CAD (first-degree relative with cardiovascular disease at 55 years of age or younger for men and at 65 years of age or younger for women), Increasing age (more than 45 years for men; more than 55 years for women), Gender (men develop CAD at an earlier age than women), Race (higher incidence of heart disease in African Americans than in Caucasians)

    • Modifiable Risk Factors
    • Hyperlipidemia, Cigarette smoking, tobacco use, Hypertension, Diabetes, Metabolic syndrome, Obesity, Physical inactivity
    • **Metabolic Symdrome
  98. Cluster of metabolic abnormalities including insulin resistance, obesity, dyslipidemia, and hypertension that increase the risk of cardiovascular disease
    Metabolic Syndrome (risk factor for cardiovascular disease)
  99. Diagnosis of Metabolic Syndrome Requires:
    3 of the following:

    • Insulin resistance (fasting plasma glucose more than 100 mg/dL or abnormal glucose tolerancetest)

    • Central obesity (waist circumference more than 35 inches in females, more than 40 inches in males)

    • Dyslipidemia (triglycerides more than 150 mg/dL, HDL less than 50 mg/dL in females, less than 40 mg/dL in males)

    • Blood pressure persistently greater than 130/85 mm Hg

    • Proinflammatory state (high levels of C-reactive protein [CRP])

    • Prothrombotic state (high fibrinogen level)
  100. Main ways to Prevent CAD
    Controlling Cholesterol Abnormalities

    Cessation of Smoking/Tobacco Use

    Managing Hypertension

    Controlling Diabetes
  101. Modifiable/Nonmodifiable Risk Factors for Atherosclerosis and Peripheral Arterial Disease
    • Modifiable Risk Factors
    • Nicotine use (i.e., tobacco smoking or chewing)
    • •Diet (contributing to hyperlipidemia)
    • •Hypertension
    • •Diabetes (speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels)
    • •Hyperlipidemia
    • •Stress
    • •Sedentary lifestyle
    • •Elevated C-reactive protein
    • •Hyperhomocysteinemia

    • Nonmodifiable Risk Factors
    • •Increasing age
    • •Female gender
    • •Familial predisposition/genetics
  102. Antidyslipidemic Therapy
    (restricts lipoprotein production)
    • Statins (HMG-CoA reductase inhibitors)
    • •Lovastatin, pravastatin, atorvastatin, rosuvastatin
    • (Mainly decrease LDL, small increase in
    • HDL)

    • –Niacin
    • •Decrease LDL & triglycerides
    • •Increase HDL (best drug)

    • –Fibric Acid derivatives
    • (fenofibrate, gemfibrozil)
    • •Decrease triglycerides
    • •Increase HDL
  103. Antidyslipidemic Therapy
    (Lipoprotein REMOVAL)
    • Bile acid sequestrants
    • (cholestyramine)

    •Decrease total cholesterol & LDL
  104. Antidyslipidemic Therapy
    (Decreases Cholesterol ABSORPTION)
    –Ezetimibe (Zetia)

    –Vytorin = ezetimibe + simvastatin

    •Research proven enhanced reductions in LDL
  105. 3 Types of Antidyslipidemic Therapy:
    • -Restriction of lipoprotein production
    • -Lipoprotein Removal
    • -Deacrese of Cholesteral Absorption
  106. Disorders of the aorta and branches:
    • Peripheral Arterial Disease
    • Acute Arterial Ischemia
    • Aneurysms
    • Thromboangitis obliterans
    • Raynaud's disease
  107. S/S that will be seen during assessment for Peripheral Arterial Disease (PAD)
    Intermittent Claudication (calf, buttock, and thigh pain)

    Erectile Dysfunction


    Changes to Skin

    Diminished or Absent Pulses
  108. Complications of Peripheral Arterial Disease
    • Atrophy of the skin and muscles
    • Delayed healing
    • Wound infections
    • Tissue necrosis
    • Arterial ulcers
    • Gangrene
    • Amputation
  109. Diagnostic studies for Peripheral Arterial Disease
    • ABI (Ankle-Brachial Index)
    •      -ankle SBP/Brachial SBP
    •      -doppler takes pressures
    •      -normal ABI = .91-1.30
    •      -severe PAD<0.4
    • Angiography
  110. Normal ABI
  111. ABI level indicative of Severe PAD
  112. Treatment Options for PAD
    • Modification of Risk Factors
    • Exercise Therapy
    • Protection from trauma or injury
    •    -lubrication (but avoid soaking feet)
    •   -reverse trendelenburg (improved perfusion)
    •    -wear soft, roomy, protective shoes
    •    -keep arterial ulcers clean and dry!
    •    -IF thrombosis/embolism, EMERGENCY
  113. Drug Therapy for PAD
    • Cilostazol (Pletal)inhibits platelet aggregation & vasodilates, significantly
    • increases walking distance & QOL

    • Pentoxyfylline (Trental)increase RBC
    • flexibility

    • Antiplatelet agents
    • –Aspirin
    • –Plavix

  114. Interventional Radiologic Procedures for PAD
    Percutaneous transluminal balloon angioplasty, Stent placement, Atherectomy
  115. Surgical Therapies for Peripheral Arterial Disease
    • Peripheral arterial bypass operation
    •    -(native vein or synthetic graft used)
    • Endarterectomy
    • Endarterectomy with patch graft angioplasty
    • Amputation
  116. Possible "Outcomes" topics for Care Planning with a patient with Peripheral Arterial Disease
    • Peripheral Tissue Perfusion
    •    -capillary refill
    •    -skin color
    •    -extremity skin color
    •    -femoral pulses
    •    -pedal pulses

    • Activity Intolerance 
    •    -walking pace
    •    -walking distance
    •    -ease of performing ADLs
  117. Nursing Care for a patient with Peripheral Arterial Disease
    Assess peripheral pulses, skin color and temp, capillary refill, sensation, and movement

    Aggressive pain management

    Monitor for complications: bleeding, hematoma, thrombosis, embolization, and compartment syndrome

    Avoid knee-flexed positions except with exercise

    Prioritization: notify Doctor of significant change (increased level of pain, loss of palpable pulse distal to operative site, ext. pallor/cyanosis, cold ext., numbness/tingling)
  118. Patient Teaching for a patient with Peripheral Arterial Disease
    • Risk Factor Management - specifically NO TOBACCO
    • Meticulous foot care

    How to check pulses, temp, capillary refill

    Gradual increase in physical activity post-op

    Regular physical activity
  119. Causes of an Acute Arterial Occlusion
    Thrombosis, Embolism, Trauma
  120. Six P's that are presented with patient that has an acute arterial occlusion
    Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (usually cool)
  121. Treatment of a patient with an acute arterial occlusion:
    Anticoagulation, Thrombolysis, Embolectomy, Surgical Revascularization, Amputation

    *Generally, every effort is made to encourage the patient to move the extremity to stimulate circulation and prevent stasis
  122. Form of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes.
    Raynaud's phenomenon
  123. Signs and Symptoms of Raynaud's Disease
    •Vasospasm induced color changes of fingers, toes, nose, and ears

    –Pallor--decreased perfusion

    •Coldness and numbness

    –Cyanosis--decreased perfusion

    •Throbbing, aching pain


    •Tingling and swelling

    •Precipitated by cold weather, emotional upsets, smoking, or caffeine use

    Usually lasts for minutes
  124. Treatment options for Raynaud's Phenomenon
    •Avoid temperature extremes

    •Smoking cessation

    •Avoid vasoconstrictors (caffeine, meds)

    •Coping strategies

    • •Drug therapies:  Ca-channel blockers
    • (nifedipine [Procardia], amlodipine [Norvasc])

    • •Surgical options:  Sympathectomy
    • (interrupting the sympathetic nerves by removing the sympathetic ganglia or dividing their branches)
  125. Localized sac or dilation formed at a weak point in the wall of the artery
    • Aneurysm
    • (usually thoracic aorta, abdominal aorta, or aortic arch)
  126. The most common type of degenerative aneurysm
    Abdominal Aortic Aneurysm
  127. Thoracic Abdominal Aortic Aneurysms occur most frequently in:
    men between the ages of 50 and 70 years,
  128. Diagnosis of a thoracic aortic aneurysm is principally made by:
    chest x-ray, computed tomography angiography (CTA), and transesophageal echocardiography (TEE).
  129. Etiology of Aneurysms


    •Congenital abnormalities

    •Premature degeneration of vascular elasticity

    •Penetrating or blunt trauma

    •Inflammatory aortitis

    •Infectious aortitis
  130. Aneurysm Classifications:
    • True:
    •    -fusiform
    •    -sacular
    • False:
    •    -pseudoaneurysms
  131. Signs/Symptoms of Thoracic Aneurysm
    –Often asymptomatic

    –Deep, diffuse chest pain




    –Distended neck veins

    –Facial & upper extremity edema
  132. Signs/Symptoms of abdominal aneurysm
    –Often asymptomatic

    –Found on routine exam


    –Pulsatile mass


    –Abdominal or back pain

    –Problems with bowel elimination

    –Distal embolization
  133. Complications of a ruptured aneurysm
    • •RUPTURE!!
    •   –Exsanguination--death
    •   –Retroperitoneal bleed

    • •Grey-Turner  sign
    • –Hypovolemic shock
  134. Diagnostic tests for anuerysms
    •Chest or abd. xray

    • •Electrocardiogram
    • (ECG)


    •Abdominal Ultrasound

    • •Computed tomography (CT scan) ***
    • –Most accurate

    •Magnetic Resonance Imaging (MRI)

  135. Surgical removal of aneurysm occurs if:
    > 5.5 cm (males), > 5 cm (females)
  136. Endovascular Graft Procedure
    •Minimally invasive

    •Used in older, higher risk patients

    •Cannot use in aortoiliac or renal involvement


    •Most common complication: perigraft leak
  137. Open Surgical Repair for aneurysms
    –Cross clamping of aorta

    –Incising diseased segment of aorta

    –Removing intraluminal thrombus & plaque

    –Inserting & suturing synthetic graft

    –Suturing native aortic wall around graft

    –Unclamping aorta
  138. Pre-op Patient Care for a surgical removal of aneurysm
    Pre-op:  Bowel prep, NPO, shower with antimicrobial soap, IV antibiotics
  139. Post-op Patient Care for surgical removal of aneurysm
    Post-op:  ICU

    –Graft patency:  Maintain adequate BP, IV fluids, blood transfusion as needed

    –CV status:  Telemetry monitoring, oxygen, electrolytes, ABGs, pain control

    –Infection: antibiotics, monitor for fever & leukocytosis, Strict aseptic technique – Foley, IVs, incisions

    GI Status: Monitor bowel sounds & passing of flatus; NG tube; early ambulation; NPO-mouth care

    • – What is expected progression post-op?
    • –Monitor for bowel ischemia

    • Neurologic status:
    • –Ascending Ao & arch – cerebral perfusion
    • –Descending Ao – lower ext. movement

    Peripheral perfusion

    Renal perfusion: hourly urine output, I/O & daily wts, BUN & Cr
  140. Discharge Teaching for a patient that has undergone surgical procedure for aneurysm
    •Gradual increase in activity

    •Expect fatigue, poor appetite, & irreg. bowel habits at first

    •Avoid heavy lifting X 4-6 wks

    •Report any fever; redness, swelling, pain, or drainage from incision

    •Prophylactic antibiotics before future procedures

    •Possible sexual dysfunction
  141. Most common location of an aortic dissection
    Thoracic Aorta
  142. Causes of an Aortic Dissection
    HTN, Marfan's (genetic condition that occurs from spontaneous mutation), Blunt Trauma
  143. Symptoms per location of Aortic Dissection (LIFE THREATENING)
    Ripping, Tearing Pain
  144. Complications of aortic dissection
    Cardiac tamponade, exsanguination, death
  145. Diagnostic Tests for an Aortic Dissection
    CXR, Transesophageal echocardiogram, CT scan
  146. Collaborative Care for a patient with an aortic dissection
    Lower BP & myocardial contractility, conservative rx if asx; emergency surgery
  147. Types of Venous Disorders
    •Varicose Veins

    • •VTE (Venous Thromboembolism
    •    –Superficial
    •    –Deep Vein Thrombus

    •Chronic Venous Insufficiency
  148. Major causes of Venous Disorders
    • •Weak or damaged vein walls
    • •Stretched or injured one-way valves
    • •Blood clot
    • (*Virchow's Triad)
  149. Diagnostic Tests for Venous Disorders
    • CT Scan
    • MRI
    • Venogram
    • Venous Duplex
  150. Types of Venous Thromboembolism
    • Superficial
    • - Typically not dangerous

    • Deep vein thrombosis (DVT)
    • -Can be dangerous
    • -Serious complication:  Pulmonary Embolism
  151. Risk Factors for Developing thrombophlebitis of the hand:
    • - Catheter >3 days
    •     - Not flushing line
    •     - Highly irritating medications
  152. Signs/Symptoms of Thrombophlebitis of Hand
    • Redness & Tenderness
    • Cording of vein
    • PAIN
  153. Treatment of Throbophlebitis
    Immediate removal of the catheter

    •Heat or cold application

    •Elevation of affected extremity

    • •Pain management
    •    –Tylenol
    •    –Non-steroidal anti-inflammatory drugs (NSAIDS)

    •Antibiotic Therapy if severe

    •Anticoagulants typically not needed
  154. Prevention for Thrombophlebitis
  155. Types of Patients at Risk for Developing a Deep Vein Thrombosis
    •Major surgery

    •Leg trauma--a broken hip or leg

    •Prolonged travel

    •Family history of a blood-clotting disorder  


  156. Assessment for DVT
    •Majority have no symptoms

    •Dull, aching pain in the affected extremity

    •Leg pain that may worsen when you walk or stand



    •Warm to touch

    (Positive Homan's Sign -- not used anymore)
  157. Venous Thromboembolism Prevention: (Core Measure of Quality)
    •Early & frequent ambulation

    •Graduated compression stockings

    • •Sequential compression devices (SCDs):
    • DO NOT use SCDs if patient has active DVT

    Drug Therapy
  158. Heparin's Antidote
  159. Practical Guidelines for Using Heparin

    •Baseline CBC, PT, PTT, & Platelet Count

    •Bolus given

    •Frequent PTT monitoring

    •Dose adjustments

    •Length of therapy 5-7 days or until INR therapeutic
  160. Practical guidelines for Lovenox (low molecular weight heparin)

    –Baseline CBC, PTT, PT, INR, Platelet  Count

    –No continuous PTT monitoring

    –Dose determined by weight of patient

    –1mg/kg every 12 hours

    –The average administration 7 days or until therapeutic goal of INR is achieved
  161. Blood thinner usually used during Pregnancy
    Fragmin (Low Molecular Weight Heparin)
  162. Antidote for Warfarin
    Vitamin K
  163. Practical guidelines for Warfarin
    •By mouth (PO)

    •Baseline CBC, PT, INR, Platelet Count

    •Dose varies between patients

    •Daily monitoring PT/INR until therapeutic

    •Therapy long term for 6 months or longer

    • •Pt Teaching:
    •    –Food containing Vitamin K
    •    –OTC meds & antibiotics
    •    –ETOH, Safety, Report bleeding
  164. Factor Xa Inhibitors
    • Fondaparinux (Arixtra)
    •    –SC daily 
    •    –No lab monitoring for dosing 
    •    –Prevention & Treatment of VTE with orthopedic surgery

    • Dabigatran (Pradaxa)
    •    –Oral  
    •    –Prevention of VTE with orthopedic surgery
  165. Anticoagulants used for Orthopedic Surgeries
    • Factor Xa Inhibitors:
    • Dabigatran (Pradaxa) and Fondaparinux (Arixtra)
  166. Lab Values to Monitor with Heparin
    • aPTT, every 6 hours until goal reached
    • (measures ability of the blood to clot, measures effect on intrinsic and common pathways)
    • Normal Value: 24-36
    • Goal: 46-70
  167. Lab Values to Monitor with Coumadin
    • PT, Daily until goal reached
    • (measures ability of the blood to clot...inhibition of Vit. K dependent clotting factors)
    • Normal: 10-14
    • Goal: 21-28

    • INR, Daily until goal reached
    • (Used to monitor the effectiveness of anticoagulant)
    • Normal: .9-1.2
    • Goal: 2-3 seconds
  168. Greenfield Filter (IVC Filter)
    Procedure done to treat a DVT...Inserted in the inferior vena cava via femoral may go home in 1-2 days
  169. Pre-procedure care for pt undergoing IVC filter
    Consent, check dye allergy, NPO, Shave
  170. Condition characterized by valve dysfunction in deep veins causing backflow and pooling of blood in the legs leading to edema and changes in the skin.
    Chronic Venous Insufficiency
  171. Causes of Chronic Venous Insuffieciency

    •Sitting/standing for prolonged periods of time

    •Varicose Veins

    •Superficial thrombophlebitis


  172. What is seen during an assessment of pt that has chronic venous insufficiency
    •Leg pain

    •Leg/ankle swelling

    •Discoloration of the skin – hemosiderin

    •Thickened skin

    •Varicose veins

    •Leg ulcers
  173. Most venous skin ulcers develop on ____
    either side of the lower leg, above the ankle and below the calf
  174. Characteristics of venous skin ulcers from Chronic Venous Insuffieciency
    –Dark red or purple over the affected area

    –Thick, dry itchy skin

    –Shallow wound

    –Moderate to heavy drainage

    –Slow to heal
  175. Major Complication of Chronic Venous Insufficiency
  176. Prevention/Treatment for Chronic Venous Insufficiency
    • •Lifelong Compression stockings
    • -Customized Jobs stockings

    •Prevention of venous ulcers

    •Leg Elevation

    •Avoid sitting or standing for long periods of time

    • •Lifestyle changes
    •    -Weight loss
    •    -Exercis
  177. Treatment of Venous Stasis Ulcer
    External Compression – 1st priority

    •Moist dressings

    • •Nutrition
    • – adequate Protein, Vit A & C, Zinc, Iron


    •Stimulated healing

    • •If infection develops:
    •    Wound C&S, Antibiotics

    •Hyperbaric Oxygenation (HBO)

    • •Neg Pressure Wound Therapy
    •    –Vacuum-assisted closure therapy (Wound VAC)

    • •Surgery
    •    –Skin grafts
  178. Cause of Varicose Veins
    Incompetent valves
  179. Risk Factors of Varicose Veins
    FH, Gender, Occupation, Pregnancy, Deep vein obstruction,Trauma
  180. S/S of Varicose Veins
    • Bulging large bluish veins
    • Pain/Discomfort
    • Dull, heavy ache
    • Throbbing
    • Burning
    • Cramping  
    • Swelling
  181. Conservative treatment for varicose veins
    •Weight loss


    •Leg Elevation

    •Graduated Compression stockings

    •Avoid activities that promote venous stasis
  182. Non-Conservative treatment for Varicose Veins
    • Sclerotherapy
    • Laser therapy
    • Endovenous laser
    • Vein Ligation
    • Ambulatory Phlebectomy
  183. Patient education after venous procedures/surgeries
    •Graduated compression stockings/bandages

    •Walking immediately and often

    •Elevate legs (vein stripping)

    •NSAIDs or Tylenol for discomfort

    •Shower after 24 hrs

    •No lotion, tub baths, hot tubs, swimming for 2 wks

    •Report bleeding or “pins & needles” sensation

    •Long-term:  Exercise program & compression stockings
  184. Accumulation of lymphatic fluid in the soft tissue that causes swelling, most often in the arm or leg.
  185. Types of Lymphedema
    Inherited – absent or malformed lymph vessels at birth

    Acquired – lymph node resection, radiation, infection, traumatic injury
  186. Complications of Lymphedema
    –Infection, Skin hypertrophy, Elephantiasis
  187. S/S of Lymphedema
    •Puffiness and a feeling of heaviness in the affected limb

    •Tightness of the skin

    •Limited range of motion

    •Graded 1 – 4+
  188. Prevention/Treatment for Lymphedema
    • Complex  decongestive physiotherapy
    •    -Manual lymph drainage (MLD)
    •    -Compression bandage/stocking
    •    -Elevation of limb
    •    -Skin care
    •    -Exercise
    • •Wear loose fitting clothes
    • •No blood pressure or needle sticks in the affected extremity
  189. Bacterial invasion of SC tissues
  190. Assessment findings of Cellulitis
    edema, localized redness & pain, fever, chills, lymph node enlargement
  191. Treatment of cellulitis

    –ID entry site

    –Elevation of limb

    –Moist heat application

    –Prevention education
  192. Concept Mapping Regarding Disorders
    –Definitions and theoretical basis


    –Case scenario

    –Sorting of data to support nursing diagnoses

    –Prioritization of problems

    –Identification of conceptual relationships b/w problems

    –Appropriate goals, measurable outcomes, and interventions to go with specific nursing diagnoses