Nurs 120 Week 6 Perfusion

Parameters for Orthostatic hypotension

SBP should decrease 20 mmHg or more from supine to standing and/or DBP decreases 10 mmHg with 10-20% increase in HR

Troponin

enzyme released from damaged/dead heart muscle that is used in diagnosis of acute coronary syndrome (MI)

Cholesterol level is used for what

Screening of heart disease

Expected reference range for cholesterol

less than 200 mg/dL

LDL is

Bad cholesterol, transports cholesterols to the body's cells from the liver

LDL expected range

Less than 130 mg/dL

Triglyceride levels are used to measure?

Client's risk for heart disease

Triglyceride expected range? (Male and female)

Male: 40 - 160 mg/dL

Female: 35 - 135 mg/dL

HDL is?

Good cholesterol, protects coronary arteries from heart disease by transporting cholesterol from body's cell to liver

HDL expected ranges for male and female?

Female: Greater than 55 mg/dL

Male: Greater than 45 mg/dL

Chest x-ray

Useful for evaluating heart failure and pulmonary edema

What is a transthoracic echocardiogram used for

a non invasive way to measure ejection fraction (Percentage of blood expelled from left ventricle)

-Patient lays on left side for about an hour

Normal Ejection fraction

65%, 35% of blood stays in ventricle

Stress echocardiogram

Examines the coronary arteries efficiency when the heart is placed under stress (exercise or drug induced)

Transesophageal echocardiogram

Ultrasound probe is inserted into the esophagus then pointed towards the heart

(requires moderate sedation)

What does the transesophageal echocardiogram do

removes interference from chest wall and lungs, and can help visualize valve disorders and thrombi

electrocardiogram is used for what

Monitoring electrical activity of the heart

- Used to diagnose dysrhythmias, chamber enlargement, myocardial ischemia, injury or infarction, monitor effects of electrolyte imbalances

- ECG is priority assessment when patient states chest pain

Which is better 12 lead to 3-5 lead

12 lead is for more detailed diagnostic

Exercise/medication stress test

Evaluates heart's response to physical stress in context of cvd

Coronary angiography and angioplasty

Insertion of a catheter through a major vein or artery into the heart or coronary arteries. Angioplasty is the inflation of a balloon and metal stent to hold the vessel open

- Uses contrast medium and fluoroscopy to identify coronary blockages and evaluate blood flow in coronary arteries

Angiography and angioplasty uses which arteries

Femoral, brachial, radial

Nursing considerations before and after coronary angiography and angioplasty

Before: NPO for 8 hours before, evaluate renal function tests, hold metformin 48 hrs before and after contrast

After: Reperfusion can cause dysrhythmias for hours after procedure, watch for hematoma at the insertion site, patient must keep extremity straight and avoid hip flexion for 6 hours after procedure

- patient with stent will require anticoagulation for 12 months

Complications of coronary angiography and angioplasty

Hematoma at insertion site (usually groin)

(Perform neurovascular assessment)

- Embolism

- Kidney injury

- Cardiac dysrhythmias

Risk factors for atherosclerosis (Modifiable and Non modifiable)

Modifiable: Hypertension, poor diabetes management, total cholesterol greater than 200, LDL greater than 130, HDL less than 45-55, triglycerides greater than 160, metabolic syndrome, obesity, smoking, alcohol

Non Modifiable: age, ethnicity, gender (Men at greater risk than women), genetics, family htx, family htx

Statins (Simvastatin, Atorvastatin, Rosuvastatin)

Cholesterol medication

Inhibits synthesis of cholesterol in liver, decreases LDL and increases HDL

What to monitor for when taking Statins?

Liver function tests (ALT and AST) and for rhabdomyolysis (Muscle pain and dark urine)

-PTT may increase with combined use of warfarin

Fibric acid derivatives?

Fenofibrate and Gemfibrozil

- Used to remove very LDL

- Lowers triglycerides increases HDL

What to monitor for when takin fibric acid derivatives

S/S of bleeding with combined use of warfarin

- Increased risk for rhabdomyolysis and elevated liver enzymes when combined with statins

Antiplatelets

Aspirin: Decreases platelet coagulation

What to monitor for when taking aspirin

GI upset, GI ulceration, tinnitus

Peripheral arterial disease

Progressive thickening and narrowing of arterial walls due to atherosclerosis

Chronic venous insufficiency

trapping and stasis of blood in the extremities due to faulty valves and endothelial injury by inflammation

Arteriography

Injection of contrast medium to visualize areas of decreased arterial flow

Exercise stress test

Claudication (calf cramping) during exercise can indicate peripheral arterial disease

Ankle brachial index (ABI)

A doppler is used to determine ankle systolic BP that is divided by brachial systolic BP

What is the expected normal range for PAD when doing the ABI

0.9-1.3, less than 0.9 in either leg is diagnostic for PAD

Risk factors for PAD

HTN, hyperlipidemia, DM, smoking, obesity, sedentary lifestyle, age over 65, genetic predisposition

Signs and symptoms of PAD

Intermittent claudification

- Numbness of burning pain, especially when legs elevated

- Relief of pain when legs are dangled/dependent

- Delayed cap refill

- Weakened non palpable pulses

- Loss of hair on calf, ankle, shin

- Dry, scaly, taut shiny skin

- Pallor when elevated

- Redness of extremity when dangled

- Muscle atrophy

- Ulcerations that look hole punched round and smooth

Medications for PAD?

Aspirin and statins

patient education for PAD

Encourage heat but not directly on extremity

- Avoid cold, stress, caffeine, nicotine, crossing legs, socks that are too tight

- Do not elevate legs above level of the heart, DO dangle to increase blood flow

Manifestations of Chronic venous insufficiency

Brown leathery skin, edema, ulcers over medial malleolus that are irregular in shape, pain

nursing care for chronic venous insufficiency

Wound care (hydrocolloid dressings), elastic stockings, avoid standing or sitting for prolonged periods, elevate legs above level of heart for at least 20 minutes 4-5 times per day,

Set of conditions that lead to VTE formation

Virchow's triad

Venous stasis, endothelial damage, hypercoagulability

Venous stasis

Dysfunctional valves and backward blood flow and/or inactive extremity muscles cause pooling of blood in extremity

Endothelial damage

From chronic inflammatory states, damage activates platelets and clotting factors

Hypercoagulability

Imbalance in clotting mechanisms by almost any inflammatory condition

Nursing care for VTE

No SCD if active DVT, avoid massaging site, elevate legs for edema, patient should ambulate, administer anticoagulation meds, monitor signs for P.E

Heparin

Inhibits thrombin and multiple clotting factors

How is heparin administered

IV (For active DVT) or SQ (Prevention)

What to monitor for when taking heparin

aPTT, platelet counts for heparin induced thrombocytopenia

Antidote to heparin in case of excessive bleeding

Protamine sulfate

Low molecular weight heparin

Enoxaparin, can be used at home

How is low molecular weight heparin administered

SQ

Warfarin

Interferes with vitamin K effects on clotting

How is warfarin administered

Oral

What to monitor for when taking warfarin

Therapeutic effect may take up to 5 days, overlap heparin/Lovenex while starting

- Monitor PT and INR

Antidote for warfarin

Vitamin K

Nursing care of patients on anticoagulants

Bleeding precautions, electric shavers/clippers, soft and gentle toothbrush, signs of GI bleed to report, avoid aspirin, ginko, garlic, NSAIDs, avoid forcefully blowing nose, stool softeners to avoid straining

- Avoid leafy green vegetables if taking warfarin

- Avoid IM and venipunctures

- Assess for unexplained mental status changes as this can indicate cerebral bleeding

Primary HTN

Idiopathic (no known cause)

Secondary HTN

Identifiable cause of hypertension

Elevated BP

120-129/less than 80

Stage 1 HTN

130-139/80-89

Stage 2 HTN

Over 140/ Over 90

Risk factors for HTN

Age, alcohol, diabetes, elevated lipids, ethnicity, excess sodium, family htx, gender, obesity, sedentary lifestyle, stress, tobacco use

Causes of secondary HTN

Diabetes, kidney disease, corticosteroid use, pregnancy, oral contraceptives, endocrine disorders, many prescription and illicit drugs

S/S of HTN

Bounding pulse, headache, facial flushing, dizziness, fainting, retinal/vision change, nocturia, proteinuria

Purpose of diuretics

Promotes sodium and water excretion, reduce plasma volume and reduce vascular response to catecholamines

What does thiazide diuretics cause

Hydrochlorothiazide- Hypokalemia and hypercalcemia

Loop diuretics causes waht

Furosemide- Hypokalemia, greater diuretic effect than thiazide but shorter duration

Potassium sparing diuretics can cause?

Spironolactone- Hyperkalemia

What to monitor when taking diuretics

K, Na, Ca levels, orthostatic hypotension, assess for muscle weakness, irregular pulse, dehydration and Intake and output

Ace inhibtors (Pril)

What to monitor for when taking ACE inhibitors

Angiotensin 2 receptor blockers (ARBs) (sartans)

patient education for ARBs

Beta blockers (lol)

What to monitor for when taking beta blockers

Direct vasodilators

Hydralazine and Nitroglycerine

Hydralazine

Nitroglycerine

Stable angina

Intermittent chest pain that occurs over a long period with the same pattern of onset, duration, and intensity

-Duration less than 15-20 mins

What triggers stable angina

Exercise, emotional stress

What relieves stable angina

Rest or nitroglycerin

patient teaching for nitroglycerin

Give sublingually as tablet or spray when pain occurs

- If no relief of symptoms in 5 minutes after first dose, call 911

-May repeat every 5 minutes for max of 3 doses

- Cannot be given if patient has recently used sildenafil (Viagara) or similar

What must be monitored when taking nitroglycerin

BP, can cause headaches and hold if BP is too low

S/S of unstable angina in women compared to men

women feel more fatigue while men feel like heavy pressure on chest.

Interventions for acute coronary syndromes

1) Assess ABC

2) Upright position

3) O2

4) Assess heart and breath sounds

5) 12 lead ECG

6) NOMA

7) Blood draw for troponin and electrolytes