Cardiovascular Disease Med Surg
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What is the range for total serum cholesterol?
What is the normal range for LDL-C?
What is the normal range for HDL-C?
What is the normal range for triglycerides?
What are some ways you can decrease cholesterol with nutrition?
- <30% of total carb intake should be fats
- Keep cholesterol <300mg/day
- Canola oil is best for cooking, followed by sunflower oil (coconut and palm are to be avoided)
- Increase fiber to 20-35 g per day
- Patients with LDl 130-159 mg/dL are recommended to follow a fat modified diet
How to Statins (antihyperlipoproteinemics) lower cholesterol?
- Lowers LDL and triglyceride synthesis in liver
- Adverse effects include muscle myopathies and marked decrease in liver function
How does Ezetimibe (Zetia) lower cholesterol?
Inhibits cholesterol absorption in the small intestine
How does the vitamin B complex Niacin (Niaspan) lower cholesterol?
- Lowers LDL and VLDL and increases HDl levels
- May cause flushing and warmth
How does Lavaza (omega-3 ethyl esters) decrease cholesterol?
- FDA approved adjunct to diet
- Reduces Triglycerides >500mg/dL
- Decreases plaque growth, inflammation and blood clotting
What are the stages of HTN?
- Normal: Measures S & D- <120/<80
- PreHTN: S or D- 120-139/80-89
- Stage 1 HTN: S or D- 140-159/90-99
- Stage 2 HTN: S or D- >or=160/100
What is malignant HTN?
- A severe type if elevated BO that rapidly progresses
- > or = 200/150 or 200/130 with preexisting conditions
What is secondary hypertension?
elevated BP related to a specific disease or medication
What is orthostatic HTN?
A decrease in BP (20mmHg Syst and/or 10mmHg Dias) in the first few seconds after changing from sitting to standing
What are some causes of primary HTN?
- Family Hist
- African American Heritage
- 60 year or older or menopause
- Excessive sodium & caffeine intake
- Sedentary lifestyle
- Excessive Alcohol intake
- Excessive and constant stress
- Decreased Potassium, Calcium or magnesium intake
What are some medications used for HTN?
- Calcium Channel Blockers
- ACE Inhib
What are the S/S of a hypertensive crisis?
- Severe Headache
- Extremely High BP (200/150 or higher)
- Blurred Vision
- Severe Anxiety
- Epistaxis (nosebleed)
What are the nursing interventions for a hypertensive crisis?
- Assess for Neuro and Cardio complications
- HOB in Semi Folwers
- Supply O2 as ordered
- IV access with NSS at slow rate
- Monitor BP q5-15min, make sure BP doesnt drop too fast
- Administer meds as ordered
What medications are used in a hypertensive crisis?
- Nitroprusside (Nipride)
- Nicardipine (Cardene IV)
- Fenoldopam (Carlopam)
- Labtalol (Normadyne)
- IV: these meds act as rapid vasodilators
- Oral: Once BP stabilizes, switch to oral meds
What is the difference between Arterioschlerosis and atherosclerosis?
- Arteriosclerosis: thickening or hardening of the arterial wall associated with Aging
- Atherosclerosis: a typer of arteriosclerosis involving the formation of plaque within the arterial wall (*this is the leading risk factor for cardiovascular disease)
What are some risk factors for atherosclerosis?
- High Triglycerides
- Genetics (fam hist)
- Older Adult
- African American or Hispanic Heritage
What are the different kinds of plaque formation?
- Plaque formation: inflammation, fatty appearance on intimal surface (inner lining) of the artery, collagen migrates over fatty deposit forming a fibrous plaque
- Stable Plaque: when rupture, thrombosis and obstruction leading to inadequate perfusion and oxygenation to cell tissue
- Unstable Plaque: prone to rupture, clinically silent until rupture. More severe, platelet adhesion and rapid thrombus formation
- Final Stage: fibrous plaque becomes calcified, hemorrhagic, ulcerated or thrombosed and affect all layers of the vessel
What is considered an elevated LDL-C level?
- Female: >55mg/dL
- Male: >45mg/dL
What is considered a decreased HDL-C level?
Normal is 60-180 mg/dL
What are some nursing assessments for atherosclerosis and cardiovascular disease?
- Complete a thorough assessment
- Bilateral BPs
- All major pulse sites
- Note any temp differences in extremities
- Capillary refill time
- Listen for bruits
- Monitor Labs- HDL, LDL, Total serum cholesterol, and triglycerides
What is PVD?
- Peripheral vascular disease:compromise of vessels outside of the heart/brain that is chronic partial or total occlusion of the vessel
- Arterial: PAD or LEAD (lower extremity arterial disease)
- Venous: PVD
What is the difference between inflow and outflow obstructions?
- Inflow Obstructions: Distal end of the aorta, common, internal and external illiac arteries located above the inguinal ligament
- Gradual occlusions=no significant tissue damage
- Outflow Obstructions: Femoral, popliteal and tibial arteries located below the superficial femoral artery. Gradual occlusions=significant tissue damage
What is the difference in patient pain between inflow and outflow obstructions?
- Inflow: Claudation pain of the butt and thighs, usually distal to occlusion
- Outflow: claudation of the leg and calf, feet and toes, usually distal to the occlusion
- Rest pain is a significant finding and is an emergency!
What is intermittent claudation?
- It is a hallmark sign of PVD
- Pain described as aching, cramping and fatiguing or discomfort consistently produced with the same degree of activity or exercise
- The pain is relieved by rest
Why is "rest pain" an emergency?
- Rest pain means that there is a complete occlusion of blood and this is an EMERGENCY!
- It make wake the patient in the middle of the night
- Only relief is lowering the leg into a dependent position (may show rubor)
- This is an indication of life-threatening disease and often leads to gangrene and amputation of the limb
What are some important physical assessment findings for PAD?
- Progressive pain on the extremity as the disease advances
- Sensation of cold or numbness in the extremities
- Skin is pale when elevated and cyanotic/ruddy when placed in the dependent position
- Hair loss and dry, scaly, pale or mottled skin and thickened toenails
- Muscle atrophy, leg ulceration and gangrene
- Unequal pulses between the extremities
What is the best pulse point to check for PAD in the lower extremities?
- The tibial pulse should ALWAYS be present
- Some people do not have palpable pedal pulses, but everyone should have a tibial pulse
What is the Ankle Brachial Index?
- Equipment: BP cuff, stethoscope, doppler and gel
- Procedure: take bilateral BPs. Using the doppler, get the systolic BPs on each leg at the tibial point and the pedal point
- Be careful not to pump the cuff too high and rupture any occlusions
Why does the ABI work?
- Usually, the BP is higher in the extremities due to resistance
- A decrease in BP indicated decreased blood flow in these extremities
What are some teaching interventions for PAD?
- STOP SMOKING!!-smoking accelerates PAD
- Lose weight-decreases stress on extremities and decrease plaque formation
- Healthy nutriton- DASH diet, low cholesterol, adequate protein and vitamins A,C and Zinc
What are some Hmg-coa-reductase inhibitors?
- THE STATINS
- Atorvastatin (Lipitor)
- Fluvastatin (Lescol)
- Lovastatin (Mevacor)
- Pravastatin (Pravachol)
- Rosuvastatin (Crestor)
- Simvastatin (Zocor)
What are some non-surgical interventions for PAD?
- Exercise (promotes collateral circulation) and positions
- Promote vasodilation with warmth and medications (no massage!)
What are two drugs that pharmacologically manage PAD along with the statins?
- Pentoxyfylline (Trental): reduces blood viscosity and improves supply of 02 blood to muscles
- Cilosstazol (Pletaal): inhibits platelet aggregation and increases vasodilation
What are some surgical interventions for PAD?
- Percutaneous transluminal angioplasty
What is a DVT?
- Deep Vein Thrombosis: Most common type of thrombosis. Also known as Thrombophlebitis
- Blood clot resulting from virchows Triad
- Embolus- the formation of a traveling clot
Who is at risk for a DVT?
- Hip Surgery
- Total Knee Replacement
- Open Prostate surgery
- Ulcerative colitis
- Heart Failure
- Oral Contraceptives
- Venous Phlebitis
What are the s/s of a DVT?
- Warmth, edema, erythema, induration and pain of one limb
- Non symmetrical lower extremity pulses
- Homan's sign is not considered a good way to diagnose DVT
What diagnostic tests are used for DVT?
- Venous Duplex Sonography
- D-Dimer lab is a marker for coagulation activation
- Doppler Study of venous circulation sounds
What is the treatment for DVT?
- Thrombectomy and IVC filter
- IV Heparin & Oral Coumadin
- Warmth and elevation of legs to promote vasodilation (no massage)
- SCDs and Compression stocking
What is some teaching to prevent DVT?
- Do not cross legs
- Stop Smoking
- Exercise regularly
- Limit Salt intake (water retention)
What is the difference between a venous and arterial ulcer?
- Venous are more common on areas of pressure
- Arterial tend to be more painful
- Arterial have a deep, cut out look to them
- Venous are covered in slough, edges are not well defined and may have pigmentation around edges
What is the preoperative and postoperative nursing actions for Surgical management of PAD?
- Preoperative: education and baseline vitals
- Postoperative: Deep breathing every 1-2hr
- Monitor for graft occlusion (emergency!)
- Monitor for compartment syndrome
- access for infection
What are the 6 P's of Arterial Insufficiency?
- Pain: Sudden acute pain
- Pallor: With a clear demarkation
- Pulselessness: decreased below occlusion
- Paresthesia: decreased sensation in limb, tingling and the feeling of it "falling asleep"
- Paralysis: decreased sensory and motor function
- Poikilothermia: coldness in the limbs
How would you identify compartment syndrome and how is it treated?
- Compartment syndrome is a swelling of the fascia in the muscles that swells the muscles more than the skin can hold
- This is seen by tight, shiny skin and unrelieved pain
- The blocks off blood flow and may lead to an amputation
- Treatment is a fasciotomy to return blood flow
- The wound may remain open as swelling subsides and stitched back together over a certain amount of time
What is virchow's triad?
- Endothelial injury (vessel injury)
- Blood Stasis
*perfect condition for a thrombus and thromboembolism
What are the two types of Aneurysms?
- Fusiform: The entire segment of the vessel becomes dilated
- Saccular: One side of the vessel is effected
What is a dissecting aneurysm?
- A tear in the intima of the vessel allows blood in between the layers of the vessel
- This often leads to rupture
What are the Risk Factors for an aneurysm?
- Infection, such as syphilis
- Connective tissue disorder, such as Marfan's syndrome
- Genetic disorder, such as Ehler's-danlos Syndrome
What is an aneurysm of the Peripheral Arteries?
- Femoral and popliteal arteries
- Symptoms include limb ischemia, diminished or absent pulses, cool to cold skin and pain
- Treatment is surgery
What is an aneurysm of the Central Arteries?
AAA and TAA most common
What are the S/S of an aortic dissecting aneurysm?
- May be asymptomatic until rupture, at which point acute pain as tearing, ripping or stabbing may be described
- Generally ruptures when the aneurysm is larger than 5cm
- Palpable pulsatile mass (do not palpate too hard or you may cause a rupture!)
- Bruit may be detected for an AAA left of the abdominal midline
- Results in retroperitoneal bleed and may show Turner's sign
What are the emergency care goals for an aortic dissecting aneurysm?
- Eliminate Pain
- Reduce Blood Pressure
- Decrease Velocity of left ventricular ejection
- Surgical treatment to close rupture or put in a stent to relieve pressure on vessel
What is the assessment for an AAA?
- Patient may feel their pulse in their belly
- Pulsating mass may be visible in the upper middle abdomen
- Gently feel for thrill and listen for bruit
- Patient may have gradually increasing gnawing pain in abdomen, back and flank
- Ultrasound and CT to confirm location and size of aneurysm
What is the nursing management for an AAA?
- Administer meds as ordered
- Emphasize need to decrease abdominal pressure
- No sneezing, coughing, pushing to poo or deep abdominal palpation
- Remind the patient that they will need regular ultrasounds to monitor aneurysm
- Maintain BP at a normal level to decrease risk of rupture and clotting
What is Grey-turner's sign?
- It is visible hemorrhage in the flanks of the patient
- Usually a sign of a retroperitoneal bleed
How would you assess for a TAA?
- Assess for back pain and pain from compression in surrounding structures of chest
- Assess for SOB, hoarseness and dysphagia
- Mass may be visible above the suprasternal notch
- Sudden excruciating chest or back pain may signal a rupture
What are the S/S for a TAA?
- *This is the most common site for dissection
- Lower airways symptoms include: SOB, cough, hoarseness, stridor, dysphagia, pain that is constant (esp when supine)
What diagnostic tests are used for an Aneurysm?
- Xray: will show an "egg shell appearance"
- CT Aortic Arteriograpy
What is the Pre-op prep for an Aneurysm repair?
- Baseline vitals
- Coronary Artery Studies
- Pulmonary function tests
- Corotid duplex (speed and direction of blood flow)
- Blood Studies (T & C)
What is the Post-Op care for Aneurysm repair?
- LOTS OF ASSESSMENTS! THINK ABCs
- May have endotracheal tube and vent
- Coughing and Deep breathing
- Incentive Spirometry
- Should be A+Ox3 and watch for increased ICP
- Watch for occlusion in the spine, sensation and movement of all limbs should be intact
- CMS checks and continuous peripheral pulses
- Continuous EKG monitoring (telemetry)
- They will have a central line to measure CO
- Arterial Line to continuously monitor BP (BP too high, it can rupture. BP too low, it can clot)
- Two large bore IVs
- Daily weights and I/Os (UO at least 60ml/hr)
- Hb/HCT labs
- PCA for pain control
- Assess for signs of infection
- ASSESS FOR OCCLUSION OR HEMORRHAGE
What is Buerger's Disease?
- Thromboangitis Obliterans: relatively uncommon occlusive disease of arteries and veins in distal portion of upper and lower extremities
- Disease is characterized by recurring inflammation of the medium and small arteries and veins
- Often identified with tobacco smoking
- Family or genetic predisposition and autoimmune etiological process possible
What are the assessment findings for Buerger's Disease?
- leg pain
- Instep (of the foot) claudation after exercise, relieved by rest
- Aggravated by smoking, emotional disturbances and cold chilling
- Distal rest pain not changed by activity of rest
- Intense rubor preogresses to cyanosis as disease progresses
- Tissue often dies due to occlusion and amputation is necessary
What are the nursing interventions for Buerger's Disease?
- Even a small wound can pose a huge problem
- Avoid soaking limbs-pat dry
- Lanolin based lotion- not between toes
- Keep skin clean and dry
- Wear loose, dry cotton socks
- Avoid chemicals and heat/cold
- File toenails straight see a podiatrist
- Avoid sitting with legs crossed
- Avoid tight clothing
- NO bare feet
- Control HTN and cholesterol
- Encourage daily exercise and activity
- Decrease sodium and fatty foods
How is Buerger's Disease pharmalogically managed?
- Pentoxyfylline (Trental): reduces blood viscosity and improves supply of 02 blood to muscles
- Cilostazol (Pletaal) inhibits platelet aggregation and increases vasodilation
- Calcium Channel blockers: promote vasodilation
- Beta-Blockers: decrease work of heart
- Ticlopodine (Ticlid) and Clopidogrel: anti-platelet aggregation
What is the nursing care following an amputation?
- Elevate stump for the first 24 hours to minimize edema and promote venous return
- Assess skin for bleeding and hematoma
- Wrap the extremity with elastic bandage
What is Raynaud's Phenomenon?
Caused by vasospasm of the arterioles and arteries of upper and lower extremities
How is Raynaud's treated?
- Nifedipine (Procardia): calcium channel blocker that promotes vasodilation
- Cyclandelate (clyclospasmol):vasodilator
- Phenoxybenzamine: lowers BP
- Lumbar Sympathectomy
- Restrict cold exposure
What is Raynaud's Disease?
- A form of intermittent arteriolar vasoconstriction that results in coldness, pain and pallor of the fingertips and toes
- Cause is unknown, most commonly seen in women
What are the assessment findings for Raynaud's?
- *Think American Flag
- Pallor: white due to vasoconstriction
- Blue: Due to pooling of deoxygenated blood
- Red: due to exaggerated reflow/hyperemia
- Patient may have a tingling sensation or burning in the hands nad feet
How is Raynaud's pharmacologically managed?
Calcium channel blockers are most commonly used to prevent vasospasms and promote vasodilation
What are the nursing interventions for Raynaud's?
- Teach patient safety as they may not feel fingers or toes
- Teach patient to avoid cold, nicotine, and stressful situations which may precipitate an attack
What is a Subclavian Steal?
- Occlusion of the subclavian artery
- Affected arm will have a significant decease in BP
- Bruit may be heard below clavicle
- Surgical intervention is necessary
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