Exam 2 Clinical Exemplar Review

CAD assessment

• ischemia to heart muscle leading to angina pectoris (chest pain) or sudden death

• epigastric distress, pain radiating to jaw/L arm, impending doom, SOB, fatigue, weakness, diaphoresis, dizzy'/lightheaded

• women = nausea, indigestion, palpations, numbness

CAD prevention

• controlling cholesterol abnormalities

• promoting smoking cessation

• managing HTN

• controlling diabetes

HTN limits

SBP > 140 and DBP > 90 based on 2+ separate assessments obtained 1-4 weeks apart

HTN assessment

none other than elevated BP

• organ damage S/S: angina, SOB, altered speech/vision, epistaxis, headaches, vertigo, balance problems, fainting, nocturne, facial flushing

HTN treatments

• lifestyle changes → wt loss, exercise, no caffeine/smoking, reduce fats, salts, and alc

• pharmacological

  • diuretics: decrease blood volume

  • ACE inhibitors: decrease peripheral resistance

  • ARBs: decrease peripheral resistance

  • CCBs: vasodilation and slows rate of conduction

  • beta blockers: lowers HR and force of contractions

antihypertensive warnings

• pt may report feeling worse on meds

• potential for hypotension or F/E loss (diuretics)

• reflex tachycardia compensation

• suddenly stopping causes rebound HTN

• elders susceptible to orthostatic hypotension and hyperkalemia

PAD assessment

intermittent claudication, pain relieved by rest in dependent position, numbness/birning in feet, decreased LE cap refill, diminished LE pulses, cold and cyanotic LE, pallor with elevation, dependent rubor, muscle atrophy, ulcers

PAD interventions

• gradual exercise

• promote vasodilation and avoid constriction

• no restrictive garments

• elevate only to heart level

PAD pharmacological agents

• antiplatelets: prevents platelet aggregation, reduces blood viscosity

• statins: promote dilation → avoid grapefruit!
  analgesics: reduce pain

PVD assessment

pain worse when standing and subsides with elevation, leg cramps, edema of LE, thickening/browning of LE, shallow ulcers, varicose veins

PVD interventions

• elevate legs

• use compression socks

• exercise

PVD pharmacological agents

• diuretics: reduces edema

• anticoagulants: DVT prevention

• hemorrheologics: decreases blood viscosity to improve flow and reduce inflammation

DVT assessment

pain/tenderness in affected area, extreme SOB/chest pain for PE, redness, increased skin temp, elevated d-dimers

DVT interventions

• monitor anticoagulant therapy and bleeding

• elevate extremity to heart level

• administer analgesics and anticoagulants

• compression therapy to unaffected extremity

COPD assessment

dyspnea, chronić cough, recurrent wheeze, thin stature with decreased muscle mass, tripod position, barrel chest, rapid and shallow respirations with crackles

COPD pharmacological agents

• bronchodilators: relaxes smooth muscles lining airway

  • B agonists and antocholijergics

• corticosteroids: anti-inflammatory

• mucolytic agents

• antibiotics

• airway enzyme inhibitor: suppresses enzyme causing airway inflammation

emphysema assessment

dyspnea early in disease, anxious and pursed lip breathing, hyperventilation, pink complexion, hunched, barrel chest, short and jerky sentences, very thin (increase WOB), hypoxemic

chronic bronchitis assessment

SOB, chest discomfort, dyspnea (later in disease), excessive sputum with recurrent cough, wheezing, dusky appearance, delayed cap refill, clubbing, hypoxia, increased use of accessory muscles, peripheral edema, obese

chronic bronchitis interventions

smoking cessation, controlled coughing, increased fluids, breathing treatments, COPD meds

asthma assessment

cough, dyspnea, wheezing

• exacerbations: chest tightness, diaphoresis, tachycardia, hypoxemia, central cyanosis

asthma pharmacological treatment

• quick relief

  • albuterol

  • ipratropium

  • IV systemic corticosteroids (prednisone)→ first choice for exacerbation

• long term

  • inhaled corticosteroids → first choice

  • ICS + LABA

  • bronchodilators

TB assessment

night sweats, wt loss, fatigue, cough lasting 3+ weeks, coughing up blood/sputum

TB interventions

• airborne precautions

• TB skin test to all within contact

• explain med regiment → 6-12 months with anti-TB agents; do NOT discontinue

osteoporosis assessment

low vitamin D and protein, high Ph intake, acute back pain, loss of or decreasing height, unstable gait/restricted movement, prolonged immobility, malabsorption disorder

osteoporosis intervention

• diet rich in calcium and vitamin D (supplements)

• exercise: weight bearing and aerobics

• preventing injury and relieving pain

• bisphosphonates: first line → decreases number of osteoclasts and inhibits bone reabsorption

OA

• degenerative disease with no systemic involvement → localized inflammatory response; small joints

• pain with activity that improves at rest

• high ESR and CRP

OA assessment

joint stiffness, crepitus with movement, joint enlargement/effusion, limping gait

RA

• inflammatory disease

• pain at rest or in morning

• affects large joints with systemic involvement

• positive rheumatoid factor

RA assessment

• early: fatigue/joint discomfort, inflammation, fever, paresthesia, anorexia

• late: swan neck and boutonnières, muscle atrophy, anemia, skin lesions, enlarged lymph nodes, inflammatory complications (excess cortisol)

OA interventions

• adaptive devices

• heat with tenderness

• balance activity with rest

• NSAIDS, COX-2, corticosteroids, acetaminophen

RA interventions

• control pain

• splits (protect joints)

• exercise program

• methylprednisolone, ibuprofen, DMARD therapy

hemorrhage assessment

hypotension, weak/thready/rapid pulse, oliguria, restlessness, anxiety, disorientation, cold and clammy skin, deep and rapid respirations

hemorrhage interventions

• prevention is key!

• stop bleeding and replace blood volume

atelectasis assessment

decreased lung sounds, dyspnea, cyanosis, crackles, restlessness

atelectasis interventions

• deep breathing with splints → promote full aeration of lungs

• incentive spirometer

• turning Q2 hrs and ambulation

• maintain hydration

pneumonia assessment

dyspnea, fever, chills, cough with sputum, crackles, wheezes, chest pain