CVPV/EOL EXAM 2 Flashcards
(258 cards)
1
Q
The big picture of CVPV is if blood is flowing to which three locations?
A
- heart
- extremities
- organs
2
Q
If blood is not flowing to the heart, extremities or organs why might this be?
A
- blockage
- Clot
- Vasoconstriction
- Stretched out veins.
3
Q
What are questions we should ask when we want to know if the heart is being an effective pump?
A
- are we generating a good cardiac output
- Are the organs being perfused
4
Q
What is cardiac output?
A
The amount of blood pumped in 1 min
5
Q
What might be some reason that the heart is not being an effective pump? list 3
A
- Ischemic/Infarct issues
- Heart failulre
- Valve problem
6
Q
The lower the cardiac the __1__ the perfusion to organs and extremities
A
- Poorer
7
Q
True or false: The vast majority of cardiac diseases start off as hypertension?
A
True
8
Q
Remember the higher the blood pressure __1__ off the problems will be
A
worse
9
Q
True or false: Poor diets and poor exercise are a huge factor in hypertension?
A
True
10
Q
What are two causes of hypertension?
A
- Increased cardiac output
- Increased peripheral resistance
Can be both or either or…
11
Q
What is stroke volume?
A
The volume of blood pumped out of the left ventricle of the heart during each systolic cardiac contraction
12
Q
When you have increased peripheral resistance as a cause of hypertension what is going on?
A
- increased Blood viscosity
- Decreased vessel diameter
13
Q
True or false: Vasoconstriction due to hyperthermia is a cause of hypertension?
A
True
14
Q
What is primary hypertension?
A
Type of hypertension that can not be placed on a treatable factor
15
Q
What is secondary hypertension?
A
- Hypertension that can be fixed by fixing the factor that is causing it?
16
Q
What salt goes…. water…. does what
A
Goes
17
Q
What are some causes of hypertension?
A
- Renal vascular disease
- Valve disorder
- Sleep apnea
- Pregnancy
- thyroid disorder
- oral contraceptives
- antihistamines
- corticosteroids
18
Q
What does continued HTN do to the blood vessels?
A
- Puts stretch and stress on the vessel leading to damage to the vessel.
- Can cause hypertrophy- enlargement of cells
- Can cause hyperplasia- Over replication of cells (seen often in cancer patients)
- Inflammatory response
** both hypertrophy and hyperplasia happen as a result of an inflammatory response that eventually leads to narrowing of a vessell/
19
Q
What are some risk factors of hypertension?
A
- Family history
- increasing age
- Cigarette smoking
- Obesity
- Heavy alcohol consumption
- black race
- Men (early to middle adulthood)
- Women (over 50 years)
- High dietary sodium intake
- Low dietary intake of K+, Ca++, Mg++
- Glucose intolerance
20
Q
True or false: Hypertension is considered the silent killer?
A
True- builds gradually, people don’t realize the progression until it has progressed to crisis level hypertension
21
Q
True or false: it is not important to attend yearly appointment and have blood pressure checked?
A
False
22
Q
What are s/s of hypertension?
A
- Asymptomatic
- Headache *
- Visual disturbances*
- Chest pain*
- Flushed face*
- Epistaxis *
- Dizziness*
** when patients start experiencing these symptoms it likely means theyve been dealing with high BP for awhile now and prob. never knew.
23
Q
What is complicated HTN??
A
Sustained hypertension that has effects beyond hemodynamics (organ involvement)
24
Q
What are two mechanisms of tissue damage?
A
- Ischemia
- Edema
25
Why is it important to have blood flow everywhere in our body?
1. because it carries oxygen. So if we have decreased blood flow we automatically have decreased oxygen.
26
What is ischemia?
It is when we have decreased oxygen content to a certain area
27
What is edema?
When fluid start to seep into the tissue from the vessels. You can also have edema of organs
28
What common areas "organs" does complicated HTN effect?
1. Heart*
-Myocardium
-Coronary arteries.
2. Kidneys*
-renal disease is most often caused by untreated HTN
3. Brain
-Storke risk increased
4. Eyes
5. Aorta
6. Lower extremity vessels
29
Individuals with elevated BP are assumed to have __1__ HTN.... if they are not dx?
(primary or secondary?)
1. Primary
30
Is a thorough history and physical assessment important for a patient with possible HTN?
Yes
31
What are the steps of having a patient officially dx with HTN?
1. Usually dx by PCP... patient comes into PCP office for a check up and has a increased BP. The nurse will retake a few times while the patient is in the clinic... if still elevated before the patient gets ready to leave the nurse will teach the patient to take bp at home and keep log... Dr. then can use reading from office plus home log to dx patient with HTN
32
What dx test or lab can dx HTN?
1. There is no lab/dx test that can be done to dx HTN. The patient must have several high readings + home log to be dx
33
What is white coat syndrome?
1. Sometimes patients BP will increase simply because they are in the clinic.
34
We know that there are no diagnostic labs for HTN but we will have lab orders for what possible labs just to rule out other issues?
1. Urine, Blood test, ECG reading
35
What are the treatment goals for HTN?
1. Focus on systolic BP because typically diastolic usually follows
2. Goal reading is 130/80 mmhg or lower
3. Treat preexisting conditions (diabetes control, renal disease, heart disease)
36
What are some treatment options for HTN?
1. Lifestyle modifications
2. Diet
-DASH- Dietary approaches to stop hypertension
- rich in fiber and k+, low dietary sodium and saturated fats, includes fruits, vegetables, low in diary, low in carbs, encourage intake of fish, poultry, nuts. Limited red meats and sweats are recommended.
3. Exercise
4. Moderate alcohol consumption.
37
Ace inhibitors all end in what suffix?
PRIL
Captopril
Enalapril
Benazepril
38
Beta-blockers all end in what suffix?
OLOL
Propranolol
Metroprolol
Atenolol
39
How can you remember Calcium antagonist drugs?
1. Very Nice Drugs
V- Verapamil
N- Nifedipine
D- Diltiazem
40
Alpha-Adrenergic Antagonists are not used often as often due to what reason?
1. Side effects..
41
What side effects can alpha-adrenergic antagonists have?
1. Orthostatic hypotension
2. Vertigo
3. Tachycardia
4. Sexual dysfunction
42
What are two examples of alpha-adrenergic antogonists?
1. Daxazosin (cardura)
2. Prazosin (minipress)
43
Furosemide can be used for hypertension... but what might be going on with a patient that the doctor would decide that furosemide was the best tx route?
Edema... fluid build up... causing vessels to stretch which is what causes the HTN
44
What is the main side effect of furosemide that we should be concerned about?
1. Low potassium... dysrhythmias
45
Most the time a patient on furosemide will also be on what?
K+ supplement because they are unable to get enough through diet
46
How long does furosemide work for?
6hours
47
hydrochlorothiazide HCTZ is used to tx HTN... what is something we should monitor when a patient is on this med?
1. Electrolytes balance
48
D-I-U-R-E-T-I-C is a way to remember hypertension nursing care... what does each letter stand for?
D- Daily weight
I- I & O's - kidneys can be effected
U- Urine output
R- Response of B/P
E- Electrolytes
T-Take pulses
I- Ischemic Episodes (TIA)
C- Complications; 4C's
-CAD- Coronary artery disease
- Chronic renal failure
- Congestive heart failure
- Cerebral vascular accident
49
What ensures the best success in tx of HTN?
1. Compliance
50
What is orthostatic hypotension also known as?
Postural hypotension
51
What is orthostatic hypotension?
A decrease in systolic and diastolic pressure upon standing
52
How much does your systolic and diastolic pressure to drop for it to be considered orthostatic hypotension?
1. Drop of 20mmhg or greater systolic
2. Drop of 10mmhg or greater diastolic
53
What are some causes of acute orthostatic hypotension?
1. Altered body chemistry
2. drug action
3. prolonged immobility
4. Starvation
5. Physical exhaustion
6. Volume depletion
7. venous pooling
Long car rides, airplane rides are examples...
54
what age population is at most risk for orthostatic hypotension?
1. Elderly
55
What are some causes of chronic hypotension?
Secondary to a specific disease
1. endocrine (adrenal insuff. , diabetes)
2. Metabolic disorders
3. CNS (intracranial tumors, cerebral infarct)
4. PNS (peripheral neuropathies)
56
What are patients with orthostatic hypotension at most risk for?
Falls
57
What are s/s of orthostatic hypotension?
1. Dizziness
2. Blurring or loss of vision
3. Syncope and fainting
4. Very common postprandial (after meals) in older adults
58
How do you monitor orthostatic hypotension?
1. Take blood pressure lying, sitting, standing... usually TID/QID
59
What is the dx test used to diagnose orthostatic hypotension?
Tilt table test
60
How do you treat orthostatic hypotension?
1. Eliminate any known cause
-Adjust meds
- Give volume
-Replace electrolytes
-Assist with frequent repositioning
2. Assist pt. when sitting/standing
3. Supportive devices (handrails, walkers)
4. Fall percautions
61
What is the primary intervention for orthostatic hypotension?
1. Fall precautions
62
What is preload?
The amount of myocardial stretch just before systole caused by the pressure created by the volume of blood within the ventricle (AKA left ventricular end diastolic pressure LVEDP)
63
What is afterload?
1. The amount of resistance to ejection of blood from ventricle
64
What happens to afterload during HTN or vasoconstriction?
1. Increased
65
True or false: Afterload and cardiac workload are increased during hypertension?
1. True
66
When is preload typically increased?
1. Hypervolemia
2. Regurgitation of cardiac valves
67
What is atherosclerosis?
1. Accumulation of lipid, or fatty substances in the vessel walls
68
Where is atherosclerosis most commonly found?
Coronary Arteries due to all the turns, nooks and crannies so its easier to get stuck
69
What causes atherosclerosis?
1. Inflammatory response, fibrous cap atheroma formed, which leads to ischemia
70
Complicated lesions can have blood clots attached? True or false?
True
71
What are non-modifiable risk factors of CAD (atherosclerosis)?
1. Age
2. Gender
3. Family hx
4. Ethnicity
72
What are some modifiable risk factors of CAD (atherosclerosis)?
1. High cholesterol
2. Smoking
3. Hypertension
4. Hyperglycemia
5. Obesity
6. Physical inactivity
7. Stress
73
True or false: After age 44, CAD incidence in women is equal to men?
False- After age 55
74
True or false CAD is the # 1 killer of men
False- Women
75
What is myocardial ischemia?
1. Pathologic mechanisms interfere with blood flow through the coronary arteries... no enough blood flow
76
What are some possible causes of myocardial ischemia?
1. Atherosclerosis
2. Thrombus formation
3. Vasoconstriction
77
True or false: If we have a vessel that is 50% blocked/occluded/narrowed we are at much greater risk of myocardial ischemia because we are not getting enough blood flow to meet the demands of the heart?
True
78
In myocardial ischemia has inadequate blood flow/oxygen content: Either has.....
1. Decreased supply of blood flow/oxygen
2. Increased demand for blood flow//oxygen
another words deman exceeds supply!!
79
In myocardial ischemia has inadequate blood flow/oxygen content: Either has.....
1. Decreased supply of blood flow/oxygen (blockage)
2. Increased demand for blood flow//oxygen (physical exercise, sick patient, high altitudes, vasoconstriction)
another words demand exceeds supply!!
80
What is angina pectoris?
1. Chest pain caused by myocardial ischemia
-Insufficient coronary blood flow results in decreased oxygen supply to meet the myocardial demand for o2.
81
What are factors precipitating anginal pain?
1. Physical exertion
2. Exposure to cold
3. Eating a heavy meal
4. Stress or emotional situation
82
What is stable angina?
1. Predictable pain on exertion usually only last 3-5 after exertion is stopped as long as blood flow is restored... no permanent damage.
2. Relief when rested
3. Nitrates are a possible tx...
83
What is Prinzmetal angina?
1. Unpredictable, caused by vasospasm
2. Occurs at rest
3. Usually tx with calcium channel blockers because they help with spasms of the chest wall
84
What is silent ischemia?
EKG changes but no reported symptoms or pain
85
What is unstable (preinfarction) angina?
1. Occurs at rest or during minimal activity; increasing severity or frequency... could be with excretion or at rest... doesnt go away.
2. Not relieved with nitrates
20% of these cases will lead to a MI or death
86
True or false: Unstable angina is the type of pain we would expect to see in a person leading up to a MI?
True
87
What are prevention/treatment of angina
1. Diet changes
2. Exercise
3. Medications
4. Tobacco cessation
5. Manage HTN
6. Controlling DM
7. Manage stress
88
What is the average workout time for healthy individuals?
1. 30 mins of exercise 3-4 times a week
89
Evaluation of chest pain includes what?
1. Physically assessment-- a good cardiac assessment
2. EKG
3. Lab
4. Physical exam
-Auscultation-- may here rapid or extra heart beat
- S/S
90
What are some s/s of angina
1. Feeling of indigestion
2. Chocking or heavy pressure in sternum (crushing)
3. May radiate to neck, jaw, shoulder, arms, usually left arm
4. Weakness or numbness in arms, wrists, and hands
5. Shortness of breath, pallor, diaphoresis
6. Dizziness, nausea, vomiting
Women- fatigue
Elderly- dyspnea
91
What are we looking for on an EKG in a patient having chest pain?
1. ST depression
2. ST elevation
92
What is ST depression an indication of?
1. Ischemia - decreased o2 but not complete loss of
93
What is ST elevation an indication of?
1. Injury or infarction-
94
True or false: We want to catch patients when there EKG is showing signs of ST depression so that we can fix the blood flow obstruction and prevent ST elevations?
True
95
True or false: You dont need a 12 lead to "dx" st elevation or depression
False- can use to see but not dx
96
What is acute coronary syndrome an umbrella term for?
1. Unstable angina and myocardial infarction
97
What are some labs for acute coronary syndrome (ACS)
1. CK (Creatinine Kinase) or CK-MB (Creatine Kinase Myocardial bands) CK-MB-- More specific to the heart muscle. Just a CK is any muscle injury/damage.
2. Myoglobin- Protein that is elevated and released with muscle damage/injury not specific to the cardiac muscle
3. BNP- Peptide that is released with overstretched ventricular muscle. Used to dx and evaluate CHF
4. Troponin- Most specific lab for cardiac tissue.. Most specific lab to show myocardial lab.
98
True or false: A patient in the ED that presents with symptoms of an MI has troponin levels checked on arrival and again in 30 mins. If the lab has increased that is a sign the patient is improving?
1. False- It is a sign that they are progressing to MI
99
Which cholesterol level do we want high?
1. HDL
100
True or false: Troponin can tells about our patients heart status up to 14 days prior?
True
101
Do you want you LDL cholesterol level high or low?
1. Low
102
Do you want your HDL cholesterol level low or high?
1. High
103
Do you want your triglyceride cholesterol level low or high?
1. low
104
Do you want your over total cholesterol level high or low?
low
105
What is the one cholesterol level that you want high?
HDL
106
True or false: Cholesterol is a transport system?
True
107
LDL primary transport cholesterol into where ___ but will also make deposits where? Found in what foods?
1. into the cells
2. Vessel walls
3. Fried and fatty foods
108
HDL are your _____ cholesterol.. they carry things away from the ____ and into the ____?
1. Protective
2. Cells
3. Liver
109
HDL is hereditary? True or false
True
110
Triglycerides can be used as an energy source? True or false
True
111
What meds help with cholesterol?
1. Statins
-Atorvastatins
- very common for patients to be allergic too.
-Lower LDL and triglycerides and helps raise HDL
- Must monitor LFT-- because cholesterol is excreted we need to make sure we arnt overworking liver
- muscle tenderness/weakness-- if this happens stop taking
- not recommended for child bearing age
-better absorbed at night
2. Niacin-
- B vitamin
- minimally elevated cholesterol levels... or given along with a statin
- side effects: Flushing 325mg asprin 30mins before might counteract this side effect.
3. Fibrates acids
- decreases synthesis of cholesterol-- decreases LDL levels
- Gemfibrozil
112
After you start a patient on cholesterol medications when do you bring them back in?
1. Every 6 weeks for the first 6months until cholesterol level is met
113
How do we treat angina?
The primary aim of therapy for myocardial ischemia and angina is to reduce myocardial oxygen consumption?
1. Decrease bp
2. Decrease heart rate
3. Assist contractility
4. Decrease left ventricular volume
Meds
114
What diagnostic tests will we run for chest pain?
1. Stress test.
2. Echo
3. Coronary angiography (cardiac cath)
115
How is oxygen a treatment for angina?
1. Increases oxygen delivered to the myocardium
ALWAYS imitate o2 at the onset of chest pain
-monitor o2. sat
- monitor o2 rate and rhythm of respirations
116
What are nursing interventions for chest pain?
1. Oxygen
2. Quick assessment of angine (PQRST)
3. Vital signs
4. Monitor Resp status
5. 12 EKG
6. Nitroglycerin
117
True or false: We tx chest pain as cardiac until proven otherwise?
1. True
118
How does nitroglycerin affect the preload of our heart?
Decreases preload
119
Higher doses of nitro effects the afterload how?
1. Decrease
120
What should we know about nitrates and tx of chest pain?
1. Reduces myocardial consumption there fore decreases ischemia and relieves pain
121
How is nitrate given at home?
1. Sublingal- keep in original contain
122
How many nitros can a patient take at home before needing to call the ambulance?
1. 3 tabs @ 5mins intervals--- call 911
123
What are some side effects of nitrates?
1 Flushing
2. Headaches
3. Decreased BP
4. Tachycardia
124
What medication can you not give nitrates with?
1. EDF meds
125
How do beta blockers work when treating chest pain?
Reduces myocardial o2 consumption by blocking beta adrenergic sympathetic stimulation.
1. Reduces HR
2. Reduces BP
3. Reduce Contractility
126
What patient should you avoid giving a beta blocker?
A patient with asthma... can cause broncospasms
metropolol is used when you have no other choice
127
What type of patient should you monitor closely when taking a beta blocker?
Diabetic patients- may mask symptoms of hypoglycemia
128
What are beta blockers used to treat?
1. bp
2. Chest pain
3. CHF
4. Test anxiety,
5. HEadache
6. Valve issues
7. Recurrent MI
129
What should you monitor when a paitent is on a beta blocker?
1. Monitor heart rate (brady)
2. CHeck BP
3. Monior for bronchospasm
4. Monitor glucose levels (hypoglycemia)
5. Never stop abruptly-- rebound hypertension
130
What happens when you take calcium channel blockers?
1. Decrease SA node impulses & AV node conduction
-slows HR
- decreased myocardial oxygen demand
2. Relaxes blood vessels
- improving coronary perfusion
3. Good for coronary venospasms
-prinzmetal's angina or after invasive coronary procedures
4. DO NOT TAKE WITH GRAPE FRUIT - increases CCB levels
131
What are some antiplatelet & anticoagulant medications?
1. Asprin- prevents platelet activation
- 81mg (baby asprin)
- 325mg
2. Clopidogrel- used alone or with asprin
3. Heparin
4. Enoxaparin
132
What are our number 1 concern with anticoagulants and antiplatelet medications?
Bleeding and GI upset
133
What lab levels are we monitoring with antiplatelets and anticoagulants?
1. Platelets
134
How do we manage angina at home
1. Reduce activates that produce chest pain or dyspnea
2. Avoid temperature extremes
3. Maintain normal BP
4. Avoid OTC meds that can increase BP
5. Stop smoking
6. Take asprin & bblocker as prescribed
7. Carry nitro at all times
135
What is myocardial infarction?
Myocardial tissue abruptly deprived of oxygen... Myocardial cells begin to necrose as blood flow is interrupted
136
True or False: The longer the vessel is occluded the more extensive the damage to heart muscle?
True
137
Time is ____ when is comes to MI?
Muscle
138
What are s/s of myocardial infarction?
1. Sudden onset of chest pain (crushing pain)
2. No response to rest or medication
3. SOB, dyspnea, tachypnea
4. N/V
5. Decreased urinary output- direct indicator of cardiac output if your heart isnt working like it should then neither are your kidneys
6. Cool, clammy, diaphoretics, pale skin
7. Anxiety, restlessness, fear
139
What are some nursing interventions for myocardial infarction?
1. Promote bed rest
2. Stool softener- prevent strain
3. Educate patient on
-Diet
-Caffeine
-Smoking cessation
-Exercise
- S/S of recurrent MI
140
What goals do we have for myocardial medical management?
1. Minimize myocardial damage
2. Preserve myocardial function
3. Prevent complications
-PCTA ( Percutaneous transluminal coronary angioplasty)
- Medications
141
What does M-O-N-A stand for and what does it "treat"
Treats MI
M-Morphine- Decrease preload = Decrease workload on heart
O-Oxygen
N-Nitrates- (vasodialation)
A-Asprin (antiplatelet)
142
Besides morphine, oxygen, nitrates and asprin what other medications might treat Myocardial infraction?
1. Ace inhibitors- decrease bp & cardiac workload
-prevention of further damage (remodeling)
- Increase renal perfusion
2. Beta blockers
- Decrease cardiac output
- reduce incidence of further attack
143
What are the benefits of cardiac rehab?
1. Extend & improve quality of life
2. Limit progression of atherosclerosis
3. Return client to work and pre-illness lifestyle
4. Enhance psychosocial & vocational status
5. Prevent another cardiac event
144
What are some surgical interventions for CAD?
1. Cardiac catheterization & coronary angiography (CCCA)
2. Percutaneous coronary interventions (PCI)
3. Coronary Artery Bypass (CABG/ACBP)
145
What does pre op care of client with cardiac catheterization and coronary angiography (CCCA) consist of?
1. Pre Op- Obtaining concents, starting IV, ensuring NPO status unless its an emergency. Prepare client for expectations of procedures
146
What does post-op cardiac catheterization & coronary angiography care consist of?
1. Assess catheter site for bleeding or hematoma,
2. Check peripheral pulses, color, temperature, pain or numbness
3. Monitor for dysrhythmias
4. Bed rest for 2-6 hours
5. Affected extremity straight
6. HOB no higher than 30 degrees
7. Encourage fluids to flush out dye
8. Ensure safety.
147
What is a CABG?
1. Coronary artery bypass graft- Surgery in which a blood vessel from another part of the body is grafted to the occluded coronary artery so that blood can flow beyond the occlusion
148
What is mitral valve prolapse?
1. Leaflets of the mitral valve billow upward into the atrium.
149
What are s/s of mitral valve prolapse?
1. often asymptomatic
2. Fatigue/lethargy are most common s/s
3. systolic murmur
4. palpitations
5. tachycardia
6. Light headedness, syncope
7. weakness
8. chest tightness
9. anxiety
10. depression
11. panic attacks
12. chest pain
150
What is the tx for mitral valve prolapse?
1. Regular physician reassessment
2. Avoid hypovolemia
3. If it becomes severe may need valve repair/replacement
151
What are two types of valve disorders?
1. Stenosis
2. Regurgitation
152
What do we need to know about the valve disorder stenosis?
1. The valve orifice is constricted or narrowed
2. Blood cannot flow through the valve efficiently
3. Pressure in the chamber rises increases myocardial workload
4. Causes hypertrophy
153
What do we need to know about the valve disorder regurgitation?
1. AKA insufficiency or incompetence
2. Leaflets fail to completely shut
3. Blood is able to leak back into the chamber
4. Increased volume blood must pump
5. Increases work load
6. Dilation and hypertrophy of the chamber
154
What are the s/s of a valve disorder?
1. Dyspnea
2. Weakness/fatigue
3. Murmurs
4. Chest pain
155
How do we manage valve disorders such as regurgitation and stenosis?
1. Medications
-diuretics
-cardiac glycosides (digoxin)
- B blockers
- Prophylactic antibiotics
2. Valve repair or replacement
156
What is a valve replacement? & what types of valves are there?
1. Replacement of valve with prostheses
2. Mechanical valves
3. Tissue valves
-xenografts- pig or cow
-homograft's- human cadaver or tissue donation
-Autografts- patients own valve
157
When a patient has a valve replacement what do we need to watch Closey for?
Heart failure
158
What is heart failure?
Inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients
159
What are typical causes of heart failure?
1. CAD
2. HTN
3. Valve disorders
160
What systemic conditions are associated with heart failure?
1. Fever,
2. Hypoxia & Anemia
3. Dysrhythmias
4. Electrolyte abnormalities
5. Renal failure
6. Thyroid problems
161
How would a patient with left-sided heart failure present?
1. Pulmonary congestion-dyspnea, cough, crackles, decreased o2 saturation, s3 heart sounds
2. Dyspnea on excretion (DOE)
3. Orthopnea
4. Paroxysmal nocturnal dyspnea (PND) (gasping for air in the middle of the night
5. Oliguria
6. Confusion, anxiety, restlessnes
162
What should we know about pulmonary edema?
1. Prevention is KEY!!!
2. Thorough lung assessment
3. Recognize early stages
- Dry, hacking cough
- Fatigue
-Weight gain
- Worsening edema
- Degree of dyspnea
163
How would a patient with right sided heart failure present?
1. JVD
2. Dependent edema- feet, ankles, legs
3. Hepatomegaly- enlarged liver
4. Ascites- fluid in peritoneal cavity
5. Weakness, anorexia, weight gain
164
What are dx tests we might do for heart failure?
1. Most important dx test is an ECHO- confirms HF; gives EF
2. EKG
3. Chest xray (might find enlarged heart)
165
What are some labs we can do on a patient for CHF?
1. Serum Electrolytes, BUN, Creatinine
2. BNP **** The higher the BNP the worse it is.
166
What are the nursing interventions/management for a patient with CHF?
1. I & O
2. Daily weight (assess edema) if a patient gain more than 3 lbs in 24 hours then they need to call doctor
3. Lung assessment
4. Assess for JVD
5. Assess & Evaluate dependent edema
6. Close monitoring of vital signs
7. Skin turgor
8. S/s of fluid overload
9. electrolyte monitoring.
167
How do ACE inhibitors help with heart failure?
1. Promotes vasodilation & diuresis
2. Excrete sodium and retain k+
3. If patient starts to have a persistent cough WARRENTS change****
168
How do ACE helps with heart failure?
1 good to use if intolerant to ace
169
How do beta blockers help with heart failure?
1. Used with ACE
2. Contraindicated for asthma patients
3. Titrate slowly-- rebound hypertension and bradycardia if stopped abruptly
170
How does digoxin help with heart failure?
1. It is a cardiac glycoside used for systolic heart failure, a fib and flutter
2. It increases myocardial contraction; decreases ventricular rate
3. increases cardiac input
4. promote diuresis
171
What are s/s of digoxin toxicity?
1. Fatigue
2. Depression
3. Malaise
4. N/V, anorexia
5. Changes in heart rhythm?- PVC's
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What increases your risk for digoxin toxicity?
1. Risk increases with hypokalemia, oral antibiotics, CCB's quinidine, amiodarone
173
What is the antidote for digoxin?
1. Digibind
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When should we hold digoxin
if apical pulse is less than 60
175
In addition to digoxin what other medications can tx heart failure?
1. Diuretics-thiazide, loop & potassium-sparig
2. Anticoagulant
3. Low sodium diet.
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U-n-l-o-a-d F-a-s-t is a way to help us remember how to tx CHF. What does each letter mean?
U-upright position
N-Nitrates
L-Lasix
O-Oxygen
A-Ace inhibitors
D- Digoxin
F- Fluids (decrease)
A-Afterload (decrease)
S- Sodium retention
T-Test (digoxin level, ABG's, potassium level)
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What are some tips for physical activity when educating our patient who have CHF?
1. Warm-up exercises
2. Avoid extreme heat, cold, or humid weather
3. Should be able to talk during exercise
4. Wait 2 hours after eating to exercise
5. Stop activity if short of breath, pain or dizziness
6. Cool down period
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What is peripheral vascular disease?
Umbrella term for Arterial & venous peripheral vascular disease.... atherosclerosis of peripheral vessels.
179
What is PAD?
Peripheral artery disease... build up of fatty substances in the wall of the artery.
180
What is intermittent claudication in peripheral arterial disease?
1. Pain in extremities with exercise; relieved by rest.
181
What does persistent pain at rest indicate with peripheral arterial disease?
Severe ischemia
182
What can help perfusion with a patient with peripheral arterial disease?
Lowering extremity to a dependent position (dangle)
183
True or false: Pain of int. claud occurs one joint level below disease process. So for example... calf pain may reflect femoral or popliteal artery ischemia?
1. true
184
Since pain of int. calud occurs one joint below the disease process where might abdominal aorta or illiac arteries ischemia pain occur?
1. Pain in hip or buttocks
185
What will the temperature/appearance of the patient with PAD extremity be?
1 Cool, pale, white
2.blanched appearance when elevated.
3. Rubor- reddish discoloration in dependent position
4. Cyanosis-blue
5. Gangrenous changes
6. Loss of hair
7. brittle nails
8. Dry, shiny, scaley skin
9. Ulceration
10. Bruits
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what might a pulse feel like in a patient with PAD?
1. Present or absent
2. doppler can be used to detect flow
187
What are the risk factors for a patient with PAD?
1. Nicotine use
2. Hyperlipidemia
3. Hypertension
4. Diabetes
5. Stress
6. Sedentary lifestyle/obesity
188
What are some nursing interventions/pt edu for PAD?
1.Lower extremity to increase perfusion
2. Exercise program (when appropriate)
3. Avoid extreme cold
4. No nicotine
5. Avoid stress
6. No constrictive clothing; no crossing legs
8. Medication for pain and vasodilation
9. protective shoes, foot care, meticulous hygiene,
10. proper nutrition
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How can we manage PAD?
1. exercise programs,
2. Weight reduction
3. Smoking cessation
Medication
- antiplatelets
- diabetes medication
- lipid lowering agents
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What are some surgical interventions for PAD?
1. Surgical bypass grafts
-aorto-illiac (AIBP)
- Aorto-femoral (AFBP)
- Femoral-popliteal (fem-pop)
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What does post op care consist of for a surgical bypass graft for PAD?
1. Peripheral assessment to include doppler ever hour for the 1st 8hours and then every 4 hours for the remainder of 24 hours.
2. elevate to decrease pressure on graph
192
What is PVD?
Peripheral Venous disease- Venous insufficiency
1. Chronic venous statis
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How does PVD present?
1. Chronic venous deficiency
2. Edema
3. Brownish discoloration
4. Pain
194
What does management of PVD consist of?
1. Elevating extremities
2. Foot pumping
3. Avoid crossing legs
4. avoid constrictive clothing
5. Compression stockings
6. Careful assessment
195
What is Virchow's triad?
1. Venous statis
2. Vessel wall injury
3. Altered blood coagulation
all three is the perfect environment for development of a DVT
196
What is included in the assessment of a DVT?
1. Thorough lower extremity assessment
2. assess
-limb pain
-heaviness
-swelling, redness, warmth
-tenderness
-difference in leg circumference
- venous doppler
197
True or false one you have a DVT you are more at risk for delveloping more?
1. True
198
How can we prevent DVT's?
1. Elastic compression stocking (AE hose-anti embolism)
2. Active and passive leg exercises
3. Early ambulation
4. TCDB
5. Enoxaparin
199
What is the treatment for DVT's?
1. Comfort measures
-Bed rest--- typically 1st line
-Elevation
- Compression stocking
-Analgesics
2. Anticoagulant therapy
-heparin
-Warfarin
-Enoxaparin
200
What do you need to know about IV heparin infusion followed by warfarin?
1. Anti-Xa every 6 hours
2. INR (international normalized ratio)
3. Coumadin
201
What do we need to know about LMWH- low molecular weight heparin?
1. Enoxaparin- begun in hospital and continued outpatient
2. Monitor platelet
202
What do we need to know about Warfarin?
1. Monitor PT/INR
203
What is the antidote for Warfarin?
1. Vitamin K/FFP
204
What is nursing management for anticoagulant therapy?
1. Teach patient about bleeding
2. Thrombocytopenia - monitor for heparin-induced thrombocytopenia
3. Drug interactions- warfarin is tricky; pay attention to drugs that increase or decrease efficacy.
205
What do we need to teach our patient who is taking warfarin
1. Adhere to PT/INR monitoring as directed
2. Avoid OTC meds without medical advice
3. Avoid alcohol
4. Do not stop unless directed
5. Consider wearing ID band
6. Always alert caregiver before any medical tx
-dental or any major or minor surgery
7. Report any bleeding-- blood in urine, stool, excessive bruising, epistaxis
8. Avoid excessive amounts of foods high in vitamin k
206
What is the antidote for heparin?
1. Protamine sulfate
207
What is an inferior vena cava filter?
1. Traps blood clots as they travel up the vena cava preventing them from reach the lungs. the cone-shaped design allows blood to flow around the captured clot.
208
When increased cardiac output is the cause of hypertension what is going on?
1. Increased heart rate and increased stroke volume...
209
Define EOL
1. Generally refers to the final phase of patient's illness when death is imminent
2. Institue of medicine defines this as the period during which an individual cope with declining health from a terminal illness or from the frailties associated with advanced age, even if death is not clearly imminent
3. EOL care is the term used for issues and services related to death dying
210
What is palliative care?
1. Focused on reducing the severity of disease symptoms
2. Improve quality of life
3. Decrease economic costs of health care
4. Alleviate burden of caregivers
211
What is hospice care?
1. Not a place but a concept
2. Help patient die pain free and with dignity
3. When physician feels patient has at least 6 months to death
4. Not allowed any curative treatments for admitting dx
5. Want to provide the best quality of life.
212
True or false: A patient on hospice care cannot receive any curative tx such as chemo or radiation.
True.
213
Where can a patient receive hospice care?
1. Home
2. Inpatient settings
3. Acute and long term care facilities
4. Rehab centers
214
What are the four levels of hospice care?
1. Routine home care
2. Inpatient respite care
3. Continuous care
4. General inpatient care
215
Who is apart of the hospice care team?
1. Team includes physician, aides, SW, chaplains, pharmacists, physical therapists, dieticians and volunteers
216
True or false: palliative care does not include the family?
1. False - it does
217
Palliative care extends how far into the EOL period?
1. All the way to bereavement period after passing
218
Hospice nurses are well educated in what advanced areas?
1. Pain control
2. Symptom management
3. Spiritual assessment
4. assessment and management of family needs
5. In teaching skills, compassion, flexibility, cultural competence and adaptability.
219
What is closed awareness?
The patient is unaware of his or her terminal state, whereas other are aware. May be characterized as a conspiracy between the family and healthcare professionals to guard the "secret". fearing that the patient may not be able to cope with full disclosure about his or her status.
220
What is suspected awareness?
The patient suspects what others know and attempts to find out details about his or her condition. May be triggered by inconsistencies in the family's and clinicians stories.
221
What is mutual pretense awareness?
The patient, the family and the health care professionals are aware that the patient is dying, but all pretend otherwise
222
What is open awareness?
1. The patient, the family and the health care professionals are aware that the patient is dying and openly acknowledge s that reality.
223
What is a DNR?
1. Is an order written medical order given by the physician. It documents the patient's wishes regarding resuscitation and more importantly, the patients desire to avoid CPR
224
What are some DNR options?
1. Full code CPR, No compressions, no intubation and medical ventilation, no chemical tx/drug therapy, medication only, no electrical cardiac conversion, no IV hydration, no enteral nutritional support.
225
True or false: DNR is not suspended for operative or invasive procedures during the intra-operative and immediate post-op periods.
1. False- it is suspended
226
What is an advance directives?
1. Written documents that provide information about the patients wishes and his or her designated spokesperson
227
What is a living will?
1. Depending on which state it may be called natural death acts which may include directive to physician, durable power of attorney for health care, and power of attorney of health care,. Under these acts, an individual can tell the physician exactly what tx is or is not desired.
228
Verbal directives can be given to physicians in the presence of how many witnesses? (living will/advanced directives)
2
229
Who makes decisions when the patient cannot communicate and does this need to be documented?
Surrogate decision makers (most often family or spouce)
230
True or false: It is important to reassess a patients advanced directives because they may change there mind as tx continues?
True
231
What is Euthanasia?
1. The deliberate act of hastening death. The ANA state on this prohibits nurses to participate in active euthanasia because it is in direct violation of the code for nurses, ethical traditions and goals of the profession and its covenant with society.
232
What is physician assisted suicide?
Physician-assisted suicide entails making lethal means available to the patient to be used at a time of the patients own choosing.
233
Which is legal in some states....
A doctor providing the lethal means to the patient to take at a time of there choosing
or
A doctor taking out an active role and pushing lethal IV drugs.
Providing lethal means an allowing patient to take on there own terms.
234
What should we know about organ and tissue donation?
1. Brain death must occur... criteria includes coma, or unresponsiveness, absence of brainstem reflexes, and apnea. All brain function must cease.
A clinical dx and occurs when the cerebral cortex stops functioning or is irreversibly damages
2. family permission must be obtained at time of donation. Life gift is then contacted
235
What are some barriers to improving EOL care?
1. Cure- focus of health care establishment
2. Financial criteria, reimbursement issues
3. Cultural, social issues
4. Discomfort with addressing issues of death (both patient, family), health care providers
5. Psychological, coping responses to death, dying, denial
6. Lack of information
7. May be seen as giving up since they cannot receive curative, life-prolonging tx
8. Physicians may see it as a personal failure
236
What is communication like with EOL care....
1. You are able as the nurse reflect on your own experiences
2. Use lay terms not a bunch of medical jargon
3. Respect cultural background
4. Best time for patient to talk may not be convenient
5. Be fully present during all communication
6. Allow patient, family to set agenda regarding depth of conversation
7. resist impulse to fill empty space
8. All patient and family time to respond
9. Prompt them gently
10. Avoid canned responses
11. Ask question
12. Assess understanding, both your own and the patients
237
Patients goal should direct care management to which symptoms?
1. Pain
2. Dyspnea
3. Nausea
4. Weakness
5. Anxiety
238
What are the signs of approaching death?
1. Refusal of food and fluids
2. Urinary output decreases-may have incontinence
3. Weakness, sleep, confusion, restlessness
4. Impaired vision/hearing-hallucinations
5. Thick secretions-esp in throat
6. Cheyene-stokes reparations
7. CV changes
8. Integumentary changes- develop mottling, kennedy terminal ulcer
9. Third-spacing
239
Signs of approaching death-- what will the patients body temp be like?
1. May be hot and warm due to ciculation slowly
240
Signs of approaching death- how might the pulse be effected?
1. Pulses no longer palpable in feet first within a week or two of death and radial pulses within 24-48 hours of death
241
signs of approaching death- What happens to your heart rate?
1. Irregular rhythm, increased hr then later showing and weakening.
decreased bp
242
What happens to your bowels when death is approching?
1. Bowels will release days or weeks before dath. May not have bowel sounds.
243
What are the last senses to leave a person as they die?
1. Hearing and touch
244
What is a nursing assessment as death approches?
1. Monitor for systm failure
2. If patient is alert,
- Brief review of body systems to detect s/s
-assess for discomfort, pain, nausea, or dyspnea
3. Assess coping abilities of patient and family
4. Attention to subtle physical changes requires vigilance
245
What is the nursing plan at EOL?
1. Nursing care goals involve comfort and safety measures and care of the patient's emotional and physical needs
2. Advocate for the patient so that his/her wishes are met as much as possible
246
What do we need to know about anxiety and depression care during EOL
1.Causes may include uncontrolled pain and dyspnea, impleading death
2. May need meds (opioids, bronchodilators and o2) and nonpharmacological methods (relaxation breathing, muscle relaxation, music, imagery)
247
What do we need to know about anger during EOL care?
1. Normal response to grief
2. The nurse may be the target of anger just try and not take it personal
3.Surviving family memebers may be angry with dying loved one who is leaving me
4. Encourage expression of feelings.
248
What do we need to know about hopelessness and powerlessness in EOL care?
1. Help to see what is in their control and what is out of there control
2. Encourage realist hope within the limits of the situation
249
What should we know about fear in EOL care?
1. May have fear of pain- people typically associate death with pain.
2. Fear of SOB- resp distress and dyspnea are common near EOL ... meds can help
3. Fear of loneliness and abandonment- most dying patients don't want to be alone. Fear family will abandon them.
4. Fear of meaningless- life review-- help patient and family to identify the positive in their lives
250
True or false: Those who are dying deserve and require the same physical care as people who are expected to recover
True
251
What is included in postmortem care?
1. prepare the body for immediate viewing by the family
2. Be considerate of cultures and state laws and agency polices
3. Close patients eyes
4. Replace dentures
5. Wash the body as needed... place pads as needed to absorb
6. Remove appropriate tubes and dressings
7. Leave pillow to support the head and prevent pooling of blood and discoloration of the face
8.prononcement of death
9. Allow privacy as much time as need up to certain time frame
10. Know when to call medical examiner
11. Security takes body to morgue and releases the body to morgue
252
What are the presumptive signs of death?
1. Patient unresponsive
2. No evidence of respirations
3. No palpable pulse
4. Pupils fixed and dilated
5. Skin is cold relative to baseline skin temp with generalized cyanosis
6. Conclusive sign of death is the presence of liver mortis
253
True or false: It is not important to allow family to prepare or assist in preparing the body in some cultures and some types of death?
1. False. it is improtant
254
What is grief?
1. The normal reaction to loss
2. Occurs in response to the real loss of a loved one and loss of what might have been
255
What is anticipatory grief?
1. The grief experience for the caregiver of the patient with a chronic illness often begins long before the actual death event
2. Not uncommon to feel somewhat of a relief when death finally comes
3. Confirm that they should not feel guilty for those feeling. they are normal
256
What is adaptive grief?
1. Grief that assists the person in accepting the reality of death.
2. This is a healthy response
3. Indicators of this is the ability to see some good resulting from the death and positive memories of the deceased
257
What is prolonged grief disorder?
1. Prolonged and intense mourning
2. Can include symptoms such as recurrent and severe distressing emotions and intrusive thoughts related to the loss of a loved one, self-neglect, and denial of the loss for longer than 6 months
3. These people are at risk for illness and may have work and social impairments
258
What are the five stages of grief?
1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance
