VASCULAR CASE STUDIES Flashcards by Kelsey Klipfel

Increased pressure in vasculature still damaging blood vessels: higher risk for stroke, MI
Are high risk need be aware of it
Physical assessment/clinical manifestations
Psychosocial
Diagnostic assessment

HTN

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Most people have no symptoms - Affects diagnosis of HTN and management; no symp: pat not as aggressive about taking care of it
Some patients experience headaches, facial flushing (redness), dizziness, fainting - extremely high BP
Blood pressure screenings essential

Physical assessment/clinical manifestations

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Assess for stressors that can worsen hypertension

Psychosocial

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No specific lab or x-rays are diagnostic of primary hypertension - imp to screen
Secondary hypertension can be screened with labs specific to the underlying disease: Ex. kidney disease

Diagnostic assessment

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Primary (essential)
Secondary

Classifications and etiology of HTN

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Most common type
Not caused by an existing health problem; can develop when a patient has any one or more of the risk factors:
Lot risk factors
US have significantly higher BP - stressors and healthcare disparities
High cholesterol: more plaque in vessels increases pressure
Vasoconstriction - any form of nicotine

Primary (essential)

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Family history
African-American ethnicity
Hyperlipidemia
Smoking
Older than 60 or postmenopausal
Excessive sodium and caffeine intake
Overweight/obesity
Physical inactivity
Excessive alcohol intake
Low potassium, calcium, or magnesium intake
Excessive and continuous stress

Not caused by an existing health problem; can develop when a patient has any one or more of the risk factors:

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Results from specific diseases and some drugs
Kidney disease is one the most common causes of secondary hypertension
Other disease process
Often kidney disease

Secondary

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Find high BP take in

both arms also if low

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Answer: Additional assessments should include medical history, family history of CV disease, heart and respiratory rate, and medications being taken.
Pulse
Further assessment into edema
Fam history
Smoking, caffeine: additional modifiable risk factors present/not
Meds
Rationale:
Assessing medical and family history provides needed information associated with etiologies and identification of risk factors.
Heart rate and respiratory rates provide information on the effectiveness of tissue perfusion associated with the high blood pressure.
Assessing medication history might lead to the identification of an adverse response.

What other assessments should the nurse perform?

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Answer: Eating a low-sodium diet, limiting his caffeine intake, and quitting smoking. Ask him what a “wholesome meal” is
Eliminating smoking, caffeine, nutrition imp
Limit fast food: cholesterol and sodium
Explore diet habits
Doing right: walking, sleeping well, reading before bed (relaxation), glass (how big) wine not bad, working reasonable amount
Talk about all of this
Rationale:
Sodium increases blood volume, thus increasing blood pressure.
Caffeine and smoking has a vasopressor affect that could increase BP
Recommendations:
Dietary sodium restriction to less than 2 grams; Na restrictions at least less than 2 grams min
Reduce weight
Use alcohol sparingly
Exercise 3-4 days a week for 40 minutes
Use relaxation techniques to decrease stress
Avoid tobacco and caffeine

What lifestyle changes would help Mr. Flynn in managing his blood pressure?

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Reason BP low is because taking med - no symp with HTN because not feel bad most time when not take med
Answer: Hypertension is a chronic illness. Without medication, Mr. Flynn’s hypertension will remain uncontrolled.
A plan should be developed with the patient and ways identified to encourage adherence to his medication regimen.
If the patient is taking beta blockers, suddenly stopping these drugs can result in angina, MI, or rebound hypertension
Med compliance really imp
Quit smoking and did other things might be able go off BP med but per pat; make sure stick on meds and adhering to that
Lot AE not tolerated explore with them on why not want take med; can switch it up because lot meds for them
Rationale:
Some patients may assume that once their blood pressure returns to normal levels, they no longer need treatment.
Side effects can also affect compliance with medication so that should be explored

Mr. Flynn returns to his provider’s office for a follow-up. He states that he has been taking his blood pressure every day and that most days it is within the normal range. Mr. Flynn asks the nurse if it is okay to stop his medication? How should the nurse respond to Mr. Flynn?

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Reduce preload by decreasing volume and pressure in the left ventricle: This decrease preload (put into heart); less blood volume having less pressure; afterload - what heart pumping against
First-line drug of choice in older adults with HF and fluid overload
First drug for many pats; least side effects
Lot times can be Managed on small dose
Enhance renal excretion of sodium and water
Ex.
Monitor for:

Diuretics

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Loop - Furosemide (Lasix)
Loop - Torsemide (Demadex)
Loop - Bumetanide (Bumex)
Loop diuretics: K wasting: lose K when take them; K imp electrolyte for heart muscle - will take K supplements; check K level; may need replace K level with it/before admin
Thiazide – Hydrochlorothiazide (HCTZ); Metolazone (Zaroxolyn)
Potassium-sparing – Spironolactone (Aldactone): K-sparing: K level elevated; hold onto K level

Ex. - Diuretics

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Dehydration
Potassium levels (potassium wasting or potassium sparing): Check K level on both because at risk for dysrhythmias
Decreased BP
If creatinine level is greater than 1.8 mg/dL, notify health care provider before administering supplemental potassium - kidneys not functioning not have good effect; monitor renal func as well
I&O and weight imp thing to monitor

Monitor for: - Diuretics

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ACE inhibitors; ARBs - arterially vasodilate; decreases afterload: decreases BP
Angiotensin-converting enzyme (ACE) inhibitors
Angiotensin-receptor blockers (ARBs)

Arterial vasodilators

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Enalapril (Vasotec)
Fisinopril (Monopril)
First drug of choice
Not for African American because not respond as well
Causes dry cough - let know so expect it; orthostatic hypotension: increases K levels; reduces Na - Na substitute which made out of K - watch intake of K;
Monitor for:

Angiotensin-converting enzyme (ACE) inhibitors

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Orthostatic hypotension
Acute confusion,
Poor peripheral perfusion
Reduced urine output in patients with low systolic BP
Potassium and creatinine levels
Start slowly
angiodememia: lifethreating risk for ACE: swelling of airway and put on ARBs

Monitor for: - Angiotensin-converting enzyme (ACE) inhibitors

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Valsartan (Diovan)
Irbesartan (Avapro)
Losartan (Cozaar)
ACE inhibitors are the first-line drug of choice
May cause dry cough
Monitor for:

Angiotensin-receptor blockers (ARBs)

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Orthostatic hypotension
Acute confusion,
Poor peripheral perfusion
Reduced urine output in patients with low systolic BP
Potassium and creatinine levels
Start slowly

Monitor for: - Angiotensin-receptor blockers (ARBs)

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Blocks the sympathetic stimulation, increases contractility and decreases demand of heart And workload of heart
Monitor for:
Ex.

Beta blockers

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BP and HR
Start slowly and don’t stop abruptly
Use cautiously with diabetic clients
Use cautiously with clients with asthma
**Studies still evaluating risk for diabetic and asthma

Monitor for: - Beta blockers

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Carvedilol (Coreg)
Metoprolol succinate (Toprol XL)
Bisoprolol (Zebeta)

Ex. - Beta blockers

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Risk for orthostatic hypotension; Rebound HTN

BP and HR

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Can decrease glucose production in the liver: glycogen: risk for hypogycemia Could mask signs of hypoglycemia Keep eye on BG

Use cautiously with diabetic clients

Possible increased risk for bronchoconstriction

Use cautiously with clients with asthma

Answer: Atherosclerosis Risk factors include: Risk factors for HTN and atherosclerosis: buildup of plaque - plaques could move and travel; also fills up vessel; leading cause of CAD which leading cause of MI

What are all of these things risk factors for?

Low HDL High LDL-C (low density lipoprotein) Increased triglycerides Genetic disposition Diabetes mellitus Obesity Sedentary lifestyle Smoking Stress African-American or Hispanic ethnicity - Hispanic males more disposed Older adult

Risk factors include: atherosclerosis

Lab assessment: Interventions:

Assessments and interventions

Check make sure always in normal range and imp to watch these Elevated lipids (cholesterol and triglycerides) Total serum cholesterol LDL (bad) cholesterol HDL (good) cholesterol Triglycerides

Lab assessment:

Should be below 200 mg/dL

Total serum cholesterol

Increased levels indicate increased risk Should be < 130

LDL (bad) cholesterol

Increased levels, lower your risk of CAD Should be >50

HDL (good) cholesterol

Between 40 and 160 mg/dL for men and between 35 and 135 mg/dL for women

Triglycerides

Lifestyle modification such as smoking, weight management, exercise and nutrition Adjusting diet, weight loss; decreasing cholesterol and increasing HDL Drug therapy

Interventions:

Statins or other lipid-lowering agents Statins and other lipid lowering; lot AE with statins probs if at risk for probs with liver avoid because hard on liver; do lifestyle modifications before go to statins

Drug therapy

Mr. Jones is prescribed atorvastatin (Lipitor) by the health care provider. The nurse instructs him to watch for and report which side effect? A. Nausea and vomiting B. Cough C. Headaches D. Muscle cramps

Answer: D Indicates Ragodomyelosis: very concerning AE of statin, can cause sig kidney damage if unchecked; breakdown of muscles occludes renal arteries Can have N&V but not has serious as muscle cramping Headaches can have, mild AE Statins (HMG-CoA)

Reduce cholesterol synthesis in the liver and increase clearance of LDL from the blood Contraindicated in active liver disease or during pregnancy Discontinued if the patient experiences muscle cramping or elevated liver enzyme levels Avoid grapefruit and grapefruit juice - Monitor liver enzymes entire time; grapefruit juice interferes with enzymes

Statins (HMG-CoA)

Peripheral arterial disease (PAD) Has atherosclerosis/build up of plaque: limiting blood supply to extremities

He is now reporting cramping and burning in his lower extremities that occurs during activity, but stops when he rests. Upon assessment of his lower extremities he has decreased pulses and dry, dusky skin with thickened toenails and his feet are slightly cool to the touch. What do you think is going on with Mr. Jones?

Which of the following clients are at risk for PAD? (Select all that apply) A. Client with hypertension B. Client with Diabetes C. Client who smokes cigarettes D. Client with anemia E. Client who is very thin

Answer: A, B, C HTN - Increased pressure in vessels DM - Affects vasculature Smoking - Vasoconstriction

Chronic condition occurring with partial or total arterial occlusion: Total: emergent situation Decreased perfusion to lower extremities: Indicating decreased oxygenation Atherosclerosis is the most common cause Clinical manifestations: Imaging assessment:

Peripheral arterial disease (PAD)

Intermittent claudication Rest pain Loss of hair on the lower calf, ankle and foot Dry, scaly, dusky, pale, or mottled skin Thickened toenails With severe disease

Clinical manifestations: - Peripheral arterial disease (PAD)

Magnetic resonance angiography (MRA) can assess blood flow in the peripheral arteries: Inject dye and look at arterial vessels to diagnose

Imaging assessment: - Peripheral arterial disease (PAD)

cramping, burning muscle discomfort or pain occurs during activity, stops after rest Will have pain May have some rest pain

Intermittent claudication

numbness or burning sensation located in the toes, foot arches, forefeet, or heels that awakens patients at night and is usually relieved by placing the extremity in a dependent position (below the heart)

Rest pain

cold, cyanotic, and darkened extremity; posterior tibial pulse is most sensitive and specific indicator of arterial function; note signs of ulcer formation

With severe disease

The nurse is instructing a client with PAD about ways to promote vasodilation. What information does the nurse include? (Select all that apply) A. Maintain a warm environment at home B. Wear socks or insulated shoes at all times C. Apply direct heat to the limb by using a heating pad D. Prevent cold exposure of the affected limb E. Completely abstain from smoking or chewing tobacco

Answer: A, B, D, E Focus on dilating vessels and increasing perfusion Heating pad - decreased circ and sensation: could cause injury with direct sources of heat Prevent vasoconstriction: smoking, cold

Exercise: circ Positioning Promote vasodilation Drug therapy Control BP: HTN - damages vessels Invasive nonsurgical procedures Surgical management

Interventions for PAD

Avoid crossing legs (pressures on vessels) and wearing restrictive clothing Elevate legs/feet but avoid raising above the heart level: Above heart - prevents arterial blood flow to feet extreme elevation slows arterial blood flow to the feet

Positioning

Avoid cold exposure to the affected extremity with warm socks and room temperature modulation Avoid applying direct heat (heating pad, hot water) to the limb Avoid emotional stress, caffeine, and nicotine (can cause vasoconstriction)

Promote vasodilation

Hemorheologic agents Pentoxifylline (Trental): Keeps vessels open - Trental Antiplatelet agents ASA, Clopidogrel (Plavix) - not aggregate platelets

Drug therapy

Percutaneous transluminal angioplasty (PTA): into arterial sys: opening occluded vessels; dye, stents/angioplasty to open vessels Atherectomy

Invasive nonsurgical procedures

Arterial revascularization May bypass occluded vessels

Surgical management

Occlusions may be sudden and dramatic Complete occlusion in artery - lose limb if not revascularize Usually take in IR or cath lab Caused by embolus or thrombus More common in lower extremities Most patients with an embolic occlusion have had a recent acute MI and/or atrial fibrillation Manifestations “Six P’s” of ischemia Interventions

Acute peripheral arterial Occlusion

Embolus is the most common cause Clot: thrombectomy; clot that breaks off

Caused by embolus or thrombus

cool or cold, pulseless, and mottled affected extremity

Manifestations - Acute peripheral arterial Occlusion

pain, pallor, pulselessness, paresthesia, paralysis, poikilothermy (coolness)

“Six P’s” of ischemia

Prompt treatment is essential to avoid permanent damage or loss of an extremity: Reperfuse extremity as quickly as possible Anticoagulant therapy (Heparin) Surgical

Interventions - Acute peripheral arterial Occlusion

embolectomy or thrombectomy: clot: thrombectomy; atherosclerosis: angioplasty

Surgical Interventions - Acute peripheral arterial Occlusion

Permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter Weakening and stretching; big concern/comp: rupture; die if ruptured Types Etiology Imaging Size of the aneurysm and presence of symptoms determine patient management Nonsurgical management Surgical management

Aneurysm

Thoracic aortic aneurysms (TAAs) Abdominal aortic aneurysm (AAA)

Types aneurysms

Account for most aneurysms, commonly asymptomatic, and frequently rupture most common See CM/anything enlarging where need intervention Clinical manifestations:

Abdominal aortic aneurysm (AAA)

Abdominal, flank, or back pain that is usually steady, with a gnawing quality Pain unaffected by movement Pain may last for hours or days Prominent pulsation in the upper abdomen (do not palpate)

Clinical manifestations: - Abdominal aortic aneurysm (AAA)

While assessing a client with AAA, the nurse notes a pulsation in the upper abdomen slightly to the left of midline between the xiphoid process and the umbilicus. What does the nurse do next? A. Measure the mass with a ruler B. Palpate the mass for tenderness C. Percuss the mass to determine borders D. Auscultate for a bruit over the mass

Answer: D Never palpate or percuss area - not want risk rupture; bruit because turbulent blood flow

What is the most frequent complication of aneurysms?

Rupture

Yes d/t abrupt and massive hemorrhagic shock results Pain described as tearing, ripping, and stabbing and located in the chest, back, and abdomen; symptoms of hypovolemic shock; nausea, vomiting, and apprehension Massive blood loss - then go unconscious

Is this (rupture) life threatening?

Ms. Brown is admitted to the hospital. Which test would the physician order to confirm an accurate diagnosis as well as to determine the size and location of the AAA? A. CT scan with contrast B. Electrocardiogram C. Magnetic resonance imaging D. Thoracentesis

Answer: A Measurements of AAA and see where it is

Atherosclerosis HTN: Increased pressure in vessels Hyperlipidemia Smoking: Vasoconstrict vessels All put stress on vessels

Etiology - Aneurysms

CT scan with contrast is the standard tool for assessing the size and location

Imaging - Aneurysms

Monitor growth and maintain BP at a normal level to decrease the risk for rupture Sometimes not do anything Small enough monitor - serial CT scans to see if enlarging

Nonsurgical management - Aneurysms

Resection or repair (aneurysmectomy) High risk: Other risk factors do surgical management High risk CV surgery Endovascular stent graft: Procedure of choice

Surgical management - Aneurysms

VTE (venous thromboembolism) Both DVT and PE (pulmonary embolism) DVT (deep vein thrombosis) Not want DVT to turn into PE because die quickly One side swollen and painful

What does the nurse suspect is going on with Ms. Adams?

Stasis of blood Vessel wall injury Altered blood coagulation

The nurse knows that there are three major factors involved in the development of DVT. These three factors are referred to as Virchow’s triad and include the following - predisposes to DVT:

Which of the medications taken by Mrs. Adams places her at increased risk for the development of DVT? 1. Antibiotics 2. Analgesics 3. Bronchodilator 4. Oral contraceptives

Answer: 4 Increases blood coag - hormones In addition, Mrs. Adam’s age, weight, and recent surgery all increase her risk for the development of DVT. obese higher risk for DVT

PREVENTION IS KEY TO ADDRESS THIS CHALLENGE IN HEATLH CARE Patient education Leg exercises Early ambulation Adequate hydration: Increasing blood volume/circ Graduated compression stockings Intermittent pneumatic compression, such as sequential compression devices (SCDs) Venous plexus foot pump Avoid oral contraceptives if possible Anticoagulant therapy - prophylactic dose Nurse sensitive indicator

VTE prevention

Which physical assessment should the nurse perform to assist in the diagnosis of suspected DVT? 1. Measure calf circumference bilaterally 2. Observe for excessive bruising 3. Perform test for Homan’s sign 4. Auscultate for bruits

Answer: 1 1 - looking for unilateral swelling; Typ not in both legs; Not diagnose but gives clues 2 - not an indic of thrombosis 3 - not a reliable indicator anymore/accurate 4 - would indicate narrowing of artery (stenosis of artery)

Focused RR assessments: develop PE: clot moved into pulm vascularture

Further assessment of Mrs. Adams by the nurse reveals the following findings: Swelling, warmth, and mild discomfort of the right calf Pedal pulses strong (+3/4) bilaterally with capillary refill < 3 seconds Respirations regular with no dyspnea or cough What assessment is important concerning the possibility of a pulmonary embolus?

Dyspnea, sudden onset - SOB Sudden O2 desat Sharp, stabbing chest pain Apprehension, restlessness Feeling of impending doom Cough Hemoptysis

Signs of PE

Movement of clot Emboli enters venous circulation and lodges in the pulmonary vessels and pulmonary blood flow

What is a PE?

Reduces gas exchange, reduces oxygenation, pulmonary tissue hypoxia, decreased perfusion, and potential death It may be the most common preventable death in hospitalized patients but is often misdiagnosed.

Emboli enters venous circulation and lodges in the pulmonary vessels and pulmonary blood flow

D dimer Ultrasound

What tests diagnose DVT?

A negative test can rule out a DVT A positive test requires further testing to specifically diagnose not diagnostic; elevated for lot diff reasons; screening

D dimer

Assesses the flow of blood and is diagnostic of DVT

Ultrasound

To prevent future thrombi from forming or the extension of the existing thrombus Heparin IV - know they have a clot Doing: prevent clot from getting bigger and more clots from forming; clot goes away on own Weight based; bolus to get therapeutic then start on drip High risk for bleeding

What is the purpose of the anticoagulant?

breaks up clot - high risk for bleeding

Thrombolytics:

It is shift change. The oncoming nurse enters the room and notices observable hematuria in Mrs. Adam’s urinary catheter. What action should the nurse initiate first? 1. Obtain a stat aPTT 2. Stop the heparin infusion 3. Assess vital signs 4. Observe the surgical site for bleeding

Answer: 2 Will do all; stop heparin because visible signs of bleeding; heparin likely offending thing; will keep bleeding if not stop infusion

After consulting with the HCP, the nurse is to administer a heparin antagonist. Which medication will be administered? 1. Vitamin K 2. Protamine Sulfate 3. Enoxaparin (Lovenox) 4. Ticlopidine (Ticlid)

Answer: 2 All anti-coag is antagonist that reverses the effects Protamine Sulfate is for heparin And LMWH K - warfarin antagonist Enoxaparin: LMWH Ticlopidine: antiplatelet med

Heparin Warfarin (Coumadin) Enoxaparin (Lovenox) Other medications are available for clot prevention Thrombolytics Surgical management:

Meds

Lab to check: PTT (at SLHS we use heparin assay) Antidote: Protamine sulfate IV to treat/SQ for prevention Heparin assay better indic how doing; follow rules on how to admin based on lab values - not want be at risk for bleeding/clots; once within therapeutic range - PTT higher because want higher because blood anticoag; never within norm range keep checking q6h; 2 therapeutic assays not go in q6h SQ - preventative

Heparin

Lab to check: PT/INR Antidote: Vitamin K; Given IM PO cheap and requires close monitoring of labwork Prevantative (afib)/know have had a clot First on it need labs drawn frequently INR - wherever go numbers same; numbers same regardless of location; 2-3: therapeutic - more anticoag

Warfarin (Coumadin)

Lab to check: PT/INR (per textbook) and anti-factor Xa assay (at SLHS) Antidote: Protamine sulfate Treatment dose; lower dose preventative but also high enough dose SQ to treat or prevention; often used a bridge with warfarin

Enoxaparin (Lovenox)

Ex. rivaroxaban (Xarelto); apixaban (Eliquis) No labs are required No antidote is available Expensive Tons new drugs on market - no reversal for these

Other medications are available for clot prevention

Tissue plasminogen activators (TPA) Administered directly into clot through a catheter Not used often for DVT High risk for bleeding Thrombolytics: in IR to bust up clot

Thrombolytics

Thrombectomy - severe enough to remove clot Inferior vena cava filtration: IVC filter: stops clot; prevents PE because filtering it: Very common for recurrent DVT if on anticoag therapy or continually developing or too much risk to put on anticoag

Surgical management:

To which nursing diagnosis should the nurse give the highest priority when planning care for Mrs. Adams? 1. Pain related to decreased venous flow 2. Risk for injury (bleeding) related to anticoagulant therapy 3. Impaired physical mobility related to prescribed bedrest 4. Knowledge deficit related to lack of discharge teaching

Answer: 2 BLEEDING

Mrs. Adams is transitioned to warfarin by mouth. Mrs. Adams should receive additional teaching about foods Which food should the nurse instruct Mrs. Adams to avoid? 1. Apple products 2. Red meats 3. Green leafy vegetables 4. Nuts

Answer: 3 Green leafy: have K; consistency is imp so helps keeps labs consistent

VASCULAR CASE STUDIES Flashcards

(96 cards)