Vascular Hematology test 2 3rd Semester

What is this modifiable serum lipid?

Normal Value is <200 mg/dL

If over 200 it is associated with arteriosclerosis and high levels are a risk factor for Cardiovascular disease

Cholesterol

Overlapping with parenteral anitcoagulation. It is most common with heparin or SQ enoxaparin. Once the PT/INR is within the therapeutic range, the parenteral therapy will be discontinued.

Bridging

What is this modifiable serum lipid?

Anything over 40 is acceptable and 60 is desireable

High levels prevent lipid accumulation in arteries

Lower levels have a risk of CAD; High levels give a low risk of CAD

HDL (High-density lipoproteins)

What is this modifiable serum lipid?

Normal value is < 100 mg/dL

High levels increase artherosclerosis and CVD/CAD

Low levels are desirable

LDL (Low-density Lipoproteins)

What is this modifiable serum lipid?

Normal value is <150 mg/dL

High levels increase risk for CVD/CAD: >150

Fasting triglycerides

What is the normal lab value for glucose?

65-99 mg/dL

What is the normal lab value for Homocysteine?

4/4-10.9 mm/L

What is the normal lab value for Prothrombin time (PT)?

10-13 seconds

What is the normal lab value for Partial thromboplastin time (PTT)?

25-35 seconds

What is the normal value for international normalized ratio (INR)?

<1.0

What is this vascular disorder?

An inflammatory process comprising a series of highly specific cellular and molecular reactions that lead to the accumulation of atherosclerotic plaque. Plaque will reduce blood flow through an artery and may rupture. This will lead to shrinking the vessel diameter and decreasing blood flow. Slow progression

Risk Factors: High cholesterol, High triglycerides, High LDL’s, Low HDL’s

Manifestations: Myocardial infarction. Sudden Cardiac death, stroke, Gangrene, unstable angina. Chest pain or angina, shortness of breath, fatigue, and arrhythmias.

Can lead to HTN, CAD, PVD

Treatment: Identifying and controlling risk factors (Meds lowering lipid levels are the primary treatment), proper management of diabetes, surgical managment is for the irreversible symptoms

Atherosclerosis/Arteriosclerosis

What is the nursing interventions and teaching for Atherosclerosis?

Interventions: Assess BP in both arms, Palpate pulses, Obtain labs (Lipids)

Teaching: Take BP medication and control it, Healthy diet (low-fat), Exercise, Smoking cessation

What classification of hypertension is this?

SDP <120 and DBP <80

Normal

What classification of hypertension is this?

SDP 120-129 and DBP <80

Elevated (Prehypertension)

What classification of hypertension is this?

SBP 130-139 or DBP 80-89

Hypertension stage I

What classification of hypertension is this?

SBP >140 or DBP >90

Hypertension stage II

What is this vascular disorder?

Risk Factors: Smoking, Obesity, physical inactivity, alcohol use, diet (excessive intake of sodium), stress, dyslipidemia, DM, Age (55 for men, 65 for females), Family history

Manifestations: Headaches, chest pain, vision changes, shortness of breath, renal dysfunction, dizziness, fatigue, nosebleeds

Treatments: Lifestyle changes (Weight, diet, alc use, exercise, stress), Diuretics, Antihypertensives

Complications: Dilated cardiomyopathy, systolic dysfunction, renal failure, stroke, hypertensive crisis

Interventions: Neurological Assessment, BP, palpation for edema and pulses, Labs (Serum creatinine, GFR, 24 hr urine), BMI and waist circumfurance

Hypertension

What is this related to hypertension?

Occurs at systolic BP greater than 180 mm Hg and diastolic greater than 110 mm Hg

Ex. Hypertensive Urgency vs Hypertensive Emergency

Hypertensive Crisis

What type of hypertensive crisis is this?

Develops over hours to days and does not have clinical evidence of target organ disease. It may not require hospitalization to correct.

Hypertensive Urgency

What type of hypertensive crisis is this?

Have target organ disease and most often require hospitalization for prompt, controlled reduction of BP. If prompt treatment is not obtained this can produce severe problems. These include: encephalopathy, intracranial or subarachnoid hemorrhage, heart failure, MI, renal failure, dissecting aortic aneurysm, and retinopathy

Hypertensive emergency

What is this medication for a hypertensive crisi?

Must be administer via a dedicated IV line, nothing else can be given through the line

BP must be lower in a controlled fashion; if lowered to quickly perfusion is compromised

Nitroprusside

What stage of peripheral arterial disease is this?

No claudication pain is experience by patient

Bruit may be heard

Pedal pulses are decreased or absent

Stage I: Asymptomatic PAD

What stage of peripheral arterial disease is this?

Muscle pain, burning, and cramping are experienced with exercise and are relieved by rest

Pain is reproducible with the same amount of exercise

Stage II: Claudication

What stage of peripheral arterial disease is this?

Pain is experienced at rest

Pain often awakens patient at night

Pain is described as numbness and burning and usually occurs in the distal portion of the extremity

Pain is often relieved by putting the extremity in the dependent position

Stage III: Rest pain

What is this type of diuretic?

Ex. Chlorothiazide, Hydrochlorothiazide, Mhlorthalidone, Metolazone, Indapamide

Assessment: BP, K+ level (Causes hypokalemia), urine output, daily weight, Glucose (hyperglycemia)

Thiazide and Thiazide- like diuretics

What is this type of diuretic?

Ex. Spirolactone, Amiloride, Triamterene, Eplerenone

Assessment: BP, K+ level (Causes Hyperkalemia), urine output, daily weight, BUN/Creat (Elevation

Should not be taken with ACE’s or ARBS or if pt has renal dysfunction

Potassium-Sparring diuretics

What is this type of diuretic?

Furosemide, Bumetanide, Etharynic acid

Assessment: BP, K+ level (Causes hypokalemia), Urine output, daily weight, BUN/CREAT (Elevation)

Push slow can causes ototoxicity if pushed fast

Loop Diuretics

What is this hypertensive medication?

Beta blockers

Cardioselective med: Acebutolol, atenolol, betaxolol, metaprolol, bisoprolol. “-lol”

Non-Cardioselective med: Carvedilol, Nadolol, pinodolol, propranolol (ADVERSE REACTION: Bronchospasm)

Assessment: BP, Apical HR, BUN/Creat

Can causes bradycardia, hypotension: assess for dizziness, assist to BR, slow position changes

DO not abruptly stop

Use cautiously with DM

Beta-Adrenergic Blockers

What is this hypertensive medication?

Ex. Hydralazine, Minoxidil, Sodium nitroprusside

Purpose is direct vasodilation of artieries and veins resulting in rapid reduction of blood pressure

Assessment: BP, HR

Major Adverse effect reaction: Cyanide Toxicity (nitroprusside)

Direct-acting Arteriolar Vasodilators

What is this hypertensive medication?

Benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril. “-pril”

Assessment: BP, Serum K+ level (Hyperkalemia)

Serum BUN/Creat

Should not be given with potassium-sparing diuretics, renal dysfunction

#1 side effect: constant, irritated cough

Angiotensin-Converting Enzyme Inhibitors (ACE)

What is this hypertensive medication?

Block the formation of angiotensin II

(-sartan)

Ex. Losartan, Valsartan, Candesartan, Olmesartan, Telmisartan

Assess: BP, Serum K+ level (Hyperkalemia), Serum BUN/Creat

Should not be given with potassium-sparring diuretics, renal dysfunction

Angiotensin II receptor blockers (ARBs)

What is this hypertensive medication?

Sub-classes

• Non-dihydropyridines:

  • Phenylalkamines: Verapamil

  • Benzothiazepines: Diltiazem

• Dihydropyridines: Amlodipine, felodipine, nifedipine, nicardipine. “-dipine”

Assess: BP, HR

Major SE: Bradycardia, Hypotension (assess dizziness, assist pt, do not give if hypotensive or low HR, No grapejuice)

Calcium Channel Blockers (CCBs)

What is this hypertensive medication?

Typically used to treat angina: IV nitroglycerin, Isosorbide, Mononitrate, Isosorrbide, dinitrate

Thereapeutic Effects/Uses: Angina, AMI, hypertensive emergency, pulmonary edema, Heart failure

SE: Headache, blurred vision, dizziness, syncope, weakness, diaphoresis, flushing, nausea, vomiting

Adverse Reaction: Orthostatic Hypotension

Nitrates

What stage of peripheral arterial disease is this?

Ulcers and blackened tissue occur on the toes, the forefoot, or the heel of the foot

Gangrenous odor may be present

Stage IV: Necrosis or gangrene

What is this arterial disorder?

Obstruction of blood flow through large peripheral arteries cause partial or total occlusion

Manifestation: Intermittent Claudication, Reduced BP in the ankle, Atypical lower extremity pain

Symptoms: Numbness or tingling in the toes or feet, neuropathy, loss of pressure and deep pain sensations, injuries often go unnoticed, thin shiny and taut skin, loss of hair on the lower legs, diminished or absent pedal, popliteal, or femoral pulses, elevation pallor, reactive hyperemia (dependent rubor), Pain at rest

Diagnosis: Ankle-brachial index (ABI)- normal is 0.9 and higher

Pulmonary arterial disease

What is this complication caused by PAD?

a condition characterized by chronic, ischemia rest pain lasting more than 2 weeks, nonhealing arterial leg ulcers, or gangrene of the leg from PAD

It is the sustained, severe decrease of arterial blood flow to the affected extremity, leads to limb loss

Obstructive atherosclerotic arterial disease is the most common cause

Treatment: Revascularization via bypass surgery, percutaneous transluminal angioplasty, optimal drug therapy

Critical limb ischemia

What is this complication caused by PAD?

The sudden decrease in blood flow to an extremity that threatens tissue viability

Emboli originating from the heart are the most common causes of this

Acute limb ischemia

What is this arterial disorder?

AKA Buerger’s disease

Acute inflammation and thrombosis in arteries and veins in the hands and feed

Causes unknown but may be autoimmune reaction triggered by smoking

Risk factors: Smoking cigarettes or marijuana

Clinical Manifestation: Intermittent claudication in hands/feet, numbness/tingling, Raynaud’s phenomenon, Ulceration/gangrene of the digits

Treatment: Smoking cessation

Thromboangiitis Obliterans

What is this arterial disorder?

AKA Raynauds Phenomenon

Temporary, severe vasoconstriction in the arteries of the fingers and/or toes in response to cold. Unknown Cause

Risk Factors: Cigarette smoking, alcohol use, connective tissue or autoimmune disorder

Clinical manifestations:

• In response to cold:

  • Distal extremities turn white, then blue, then red as circulation returns, numbness, pain, Severe: Ulceration, development of gangrene

Treatment: smoking cessation, use mittens rather than gloves, avoid stress, avoid sudden changes in temperature

Raynaud’s Disease

What stage in Raynauds does pain start and skin turns blue?

Stage II

What is this Venous Disorder?

Acute inflammation of the walls of small, cannulated veins

S/S: Pain, tenderness, warmth, rendess, swelling, palpable cord

Risk factors: mechanical irritation from an IV catheter, infusion of irritating drugs, and IV catheter location in an area of flexion

Phlebitis

What is this Venous Disorder?

Blood clots in a large vein; usually leg or pelvis

Risk factors: age, active cancer with or without chemotherapy, varicose veins, prior venous thrombosis, pregnancy, postpartum period, and oral contraceptive

Clinical manifestation: Pain and tenderness, edema, erythema, warmth

Diagnosis: D-Dimer, Ultrasonography

Prevention: Ambulation, VTE prophylaxis, Low- molecular weight heparin

Medication: Unfractionated heparin, LMWH, Warfarin, Factor Xa inhibitors

Management: Early ambulation, leg elevation. compression stickings, avoid SCD’s, encourage adequte fluid intake, administer meds as prescribed

DVT

What is this related to DVT?

Decrease flow rate of blood, damage to blood vessel wall, increase tendency to clot

describes the factos implicated in the formation of a venous thrombosis

Virchow’s Triad

What is this Venous Disorder?

A progressive condition that stems from chronic venouse disease and is caused by venous hypertension.

Abnormalities of venous system include edema, skin changes, and venous leg ulcers.

Causes by incompetent valves and valve leakage in the leg or thrombotic or non-thrombotic venous obstruction

Clinical manifestation: Lower extremity pain and edema, Varicose veins, Stasis dermatitis (Brown discoloration), Skin is hard, thick, and contracted

Treatment: Compression, skin care, exercise, leg elevation, adequate nutrition, avoidance of prolonged standing

Medication: Systemic antibiotics, antithrombotics, oral anabolic steroids, prostacyclin analogues, flavonoids

Chronic Venous Insufficiency (CVI)

What type of dressing changes do we do for venous leg ulcers?

Wet to dry dressings

What is the difference between compression on arterial vs venous disorders?

We only use compression on venous disorders, NOT aterial

This helps decrease venous pooling, increasing venous return, and prevent deterioration in the skin and the development of skin ulcers.

Compression therapy

What type of anticoagulant is this?

Ex. Heparin

Admin SQ

Low-molecular weight heparin: Enoxaparin

Assessments: aPTT (every 4-6 hrs), platelet count, BLEEDING (Elevated HR, RR, Hypotension), Monitor every 30-60 min if infusion through IV

MAJOR adverse reaction: Heparin-induced thrombocytopenia (HIT) - PTT is lowered

REVERSAL agent: Protamine sulfate

Educations: Report brusiing, petechiae, hematomas, or black, tarry stools, calf pain, tenderness, or swelling, SOB, mostly report BLEEDING.

Indirect Thrombin Inhibitors

Are we allowed to administer Enoxaprin with air?

Yes

What type of anticoagulant is this?

Ex. Warfarin

Assessments: PT/INR (Therapeutic: 2-3, Serum liver enzymes, Bleeding)

Need to keep a consistent amount of vitamin K in their diet so as not to affect the INR results.

REVERSAL agent: Vitamin K (Take 24-48 hours to take effect). FFP (Fresh frozen plasma) for acute bleeding

Vitamin K Antagonist

What type of anticoagulant is this?

Ex. Rivaroxaban, Apixaban “-ban”

Assessments: Bleeding, does not require any routine monitoring

REVERSAL agent: Andexant Afla

Factor Xa Inhibitors

What type of vascular medication is this?

Ex. Aspirin, Clopidogrel (Others: Abiciximab, tirofiban, and epitifibatide)

Assessments: Bleeding, No routine monitoring

There is no reversal agent, may use platelet infusion if severe

Antiplatelets

What type of vascular medication is this?

Ex. Alteplase, Tenecteoplase (Others: Urokinase, Streptokinase)

Assessment: Fibrin split conducts, aPTT, Bleeding/Hemorrhage (BP, HR, RR)

REVERSAL agent: Aminocarprioc Acid

DO NOT give in severe hypertension (>185/110 mmHg)

Thrombolytics

What type of vascular medication is this?

Ex. Bile-acid Squestrants, Fibrates, Niotinic Acid, Cholesterol absoprtion inhibitors, Hmg-CoA reductase inhibitors (‘-statins”, Atorvastatin, lovastatin, pravastatin, simivastatin)

Assessments: Serum lipid panel, Serum liver enzymes, Any report of muscle cramps (RHABDOMYOLYSIS), No grape fruit, Can cause liver. damage

Antihyperlipidemics

What is this drug to improve blood flow?

Antiplatelet/Vasodilator

An antiplatelet that has dual purpose of inhibiting platelet aggregation as well as causing vasodilation to treat intermittent claudication

Assessments: Serum liver enzymes, Peripheral edema, lightheadedness

Use caution in hepatic and renal disease, tabacco smokers, pregnancy, older adults

SE: Dizziness, headache, nasopharyngitis, nausea, vomitiong, flatulence, diarrhea, melena, back and abdo pain, peripehral edema, increase suspectibility to infection

Adverse reactions: Tachycardia, palpitations, thrombocytopenia, leukopenia, aplastic anemia, agranulocytosis, elevated hepatic enzymes, and dysrhythmias

Cilostazol

What is this drug to improve blood flow?

Hemorrheologic Agent

Improves microcirculation and tissue perfusion by decreasing blood viscosity and improving flexibility of erythrocytes, thus increase tissue oxygenation

Change positions slowly, should be taken with food and patient should avoid smoking (Smoking cessation)

SE: Nausea, vomiting, areflexia, tachycardia, and GI bleeding

Assessments: BP, hx of smoking, bleeding

Pentoxifylline

What is this RBC disorder?

A deficiency in: number of erythrocytes, quanity or quality of hemoglobin, volume packed RBC’s (hct)

Diagnosis based on: CBC, reticulocyte counts, peripheral blood smear

Manifestations: Caused by body’ response to tissue hypoxia. Integrumentary: Pallor (decreased Hbg, decreased blood flow to skin), Jaundice (High billirubin), Pruitus (increased serum and skin bile salt concentration. Cardiopulmonary: Results from heart and lungs trying to provide adequate O2 to tissues, Cardiac output maintained by increasing heart rate and stroke volume

Mild: Hgb 10-12 (may be asymptomatic, may have palpitations, dyspnea with activity)

Moderate: Hbg 6-10 (Palpitation, dyspnea, fatugue, diaphoresis, experienced at rest or during activity)

Severe: Hbg <6 (Involved multiple body systems; pallor, tachycardia, orthopnea, agina, HF, MI, HA, irritability, anorexia, sore mouth, lethargy)

Interventions: Alternate rest and activity, accommodate energy levels, maximize o2 supply for vital functions, aid to minimize risk of injury for falls, monitor cardiorespiratory reponse, evaluate nutritional needs

Anemia

What type of anemia is this?

Most common nutritional disorder; very young, poor diet, women in reproductive years

Manifestations: Asymptomatic early, Later; HA, dyspnea, palpitations, pallor (most common), Glossitis is second, Cheilitis

Diagnostic studies: Decreased Hbg, Hct, MCV, MCH, MCHC, reticulocytes, serum iron, TIBC, bilirubin, Platelets, Stool occult blood, endoscopy, colonoscopy, bone marrow biopsy

GOAL: treat underlying problem causing loss, reduced intake, or poor absorption of iron (Replace iron: Nutritional therapy, oral iron supplements, transfusion of PRBC’s, Relieve symptoms)

MEDS: Ferrous sulfate, Parenteral Iron

Iron deficiency anemia

What drug therapy is this for Iron Deficiency Anemia?

Indicated for malabsorption, oral iron intolerance, need for iron beyond normal limits, poor patient compliance

Can be given IM or IV

IM may stain skin (Z-track method)

Parenteral Iron

What type of deficiency is this?

Caused by impaired DNA synthesis, Presence of large RBC’s (Megaloblasts)

Result from deficiency in: Cobalamin (Vit B12), Folic acid

Most commonly caused by Pernicious anemia (Caused by nutritional deficit, poor GI absorption, Absence of Intrinsic Factor = Pernicious anemia); begins middle age or later

GI symptoms: Sore, red, beefy, shiny tongue, Anorexia, N/V, abdominal pain

Neuromuscular Symptoms: Weakness, Paresthesia of feet and hands, Decreased vibratory and position senses, Ataxia, muscle weakness, impaired thought process

Treatment: Increase dietary of Vitamin B12 (animal protein, eggs, nuts, diary, dried beans, citrus, leafy greens) FOR PA - IM inj of Vit B12 1000 mcg per day for 2 weeks, then weekly until normal, then montly for life. Calomist or Nascobal (INTRANASAL)

Cobalamin Deficiency (Vitamin B12)

What will happen for a patient with Cobalamin deficiency if they do not get Vitamin B12 administration?

They will die within 1-3 years

What type of deficiency is this?

Causes megaloblastic anemia; Needed for DNA synthesis

Common causes: Poor nutrition, malabsorption, Drugs/ chronic alcohol abuse

Similar to Vitamin B12 deficiency, but without neurological symptoms

Symptoms: Fatigue, pallor, weakness, dyspepsia, smooth beefy red tongue

Tests: Low Hgb, Low Hct, Increased RBC indices (MCV), Serum cobalamin level, Replacement therapy (1mg/day PO)

Encourage patient to eat foods with large amounts of folic acid

Folic Acid Deficiency

What type of anemia is this?

Rare disorder

Pancytopenia (Decreased all blood cell types: RBC, WBC, Platelets)

Hypocellular bone marrow

Manifestations: Abrupt or insidious development, symptoms caused by suppression of any or all bone marrow elements, Fatigue, dyspnea, pallor, cardiovascular, and cerebral responses, neutropenia, thrombocytopenia

Management: Stem cell therapy, immunosuppressive therapy

Diagnosis: Decreased Hbg, WBC, platelets, Reticulocyte count, elevated serum iron and TIBC, Hypocellular bone marrow with increased yellow marrow

Aplastic Anemia

What type of anemia is this?

Hemolysis (destruction) of RBC’s at a rate that exceed production

Specific manifestations: Jaundice, enlargement of spleen and liver

Maintenance of renal function is a major focus

Hemolytic Anemia

What type of disorder from hemolytic anemia is this?

An abnormal for of Hbg in RBC, Genetic disorder usually indentified during routine neonatal screening; Incurable

Triggered by low o2 tension in blood, infection is most common factor

Crisis: Severe, painful, acute exacerbation of RBC sickling caused by reduced oxygen levels and results in vaso-occlusive crisis

Triggering situations: Cold water or temps, infection, strenuous exercise, anesthesia, high altitudes, dehydration, hypoxia, vascular stasis, stress

Life-threatening shock is possible result of severe O2 depletion of tissues and reduction of circulating fluid volume

Symptoms: Pain from tissue hypoxia, pallor of muscous membranes, jaundice, fatigue and weakness, exercise intolerance, prone to gallstones (PRIMARY SYMPTOM is severe pain)

Sickle Cell Disease

What type of RBC disorder is this?

Increased production of RBC’s; Hyperviscosity (Thick blood)

Manifestations: SOB, difficulty breathing when lying flat, headache, dizziness, weakness, splenomegaly (feeling of fullness in LUQ), Blurred vision, fatigue, generalized pruritus, facial flushing, weight loss

Treatment: Reducing hyperviscosity, preventing hemorrhage

Complications: Thrombosis, Hemorrhage

Interventions: Increase fluid intake, elevate lower extremitites when sitting, small frequent means, avoid tight, restrictive clothing, and bleeding precautions

Polycythemia Vera

What Platelet disorder is this?

Types: Idiopathic thrombocytopenia purpura (ITP), Hemophilia (deficiency of factor VIII or factor IX), Heparin-induced thrombocytopenia (HIT), Disseminated intravascular coagulations (DIC)

Manifestations: Decreased platelets (east bruising, petechia, bleeding)

Diagnosis: CBC with differential, Coagulation studies, Bone marrow biopsy

Treatment: Immunosuppresents like clucocoritcoids, immunoglobulin, thrombopoietin (ITP), Resolution of underlying conditions (DIC), Replacement of clotting factors (Hemophilia), Discontinue heparin (HIT)

Interventions: Hold pressure longer on puncture sites, Avoid IM injections, Monitor lab values, Administer blood products

Thrombocytopenia

What is the only anti-sickling agent shown to be clinically beneficial?

Hydroxyurea