Announcements

Here is the tentative blueprint for exam #3

• Sensory (eyes and ears): 3-7 • Blood Transfusions: 3-7 • Atherosclerosis and HTN: 15-20 • DM: 15-20 • Dosage calculations: 3 • Skills labs: 5-8 (Blood Glucose; Pain; Meds through NG/G tube; Management/Communication • NEW: 25 questions added for a cumulative final exam, so 75 questions in all.

• 10 - 15 from Unit 1• 10 - 15 from Unit 2• Possibly 5 from Unit 3

• The time for the exam will be adjusted accordingly.• ATI assessment will be given during lab time. Report to your lab and you will proceed to the

assigned rooms. Please remember to bring your ID and password that you used to create your account with ATI. You will not be able to take the assessment without it.

• Sensory may be self study. • Students who need accommodation, please arrange with special services to start your exam

at 12pm. Best of luck with your studying. NUR 133 faculty

Clarification of terms

• DOSE• RATE• CONCENTRATION• PCA – BASAL = CONTINUOUS

– PCA = DEMAND–BOLUS

• Total medication delivered• Total volume delivered

The knowledge of frontline nurses that they gather from their interactionswith patients is critical to reducing medical errors andimproving patient outcomes.

• Involving nurses at a variety of levels across the acute care setting in decision making and leadership benefits the patient, improves the organizations in which nurses practice, and strengthens the health care system in general.• Increasing the time that nurses can spend at the bedside is an essentialcomponent of achieving the goal of patient-centered care.• High-quality acute care settings require integrated systems that use technology effectively while increasing the efficiency of nurses and affording them increased time to spend with patients.• Multidisciplinary care teams characterized by extensive and respectfulcollaboration among team members improve the quality, safety, and effectiveness of care.• Many of the innovations that need to be implemented in the health care system already exist somewhere in the United States, but barriers to their dissemination keep them from being adopted more widely. As Dr. Marilyn Chow observed, “the future is here, it just isn’t everywhere.”

http://www.iom.edu/

The future is now

Not-as-new TECHNOLOGY

Not out of the wrapper yet…

Can you read this?

Atherosclerosis

• http://www.youtube.com/watch?v=OHE1ig4k64M&feature=relmfu

CHAPTER 38 Care of Patients with Vascular ProblemsIgnatavicius Workman. Medical-Surgical Nursing, 800.

Concept Map

• Wait for it…

CHAPTER 38 Care of Patients with Vascular ProblemsIgnatavicius Workman. Medical-Surgical Nursing, 800.

Concept Map - Lifestyle Modifications

• Health Teaching: Instruct the patient about sodium restriction, weight maintenance or reduction, alcohol restriction, stress management, and exercise. If necessary, also explain about the need to stop using tobacco, especially smoking. Provide oral and written information about the indications, dosage, times for administration, side effects, and drug interactions for antihypertensives. Stress that medication must be taken as prescribed and that when all of it has been consumed, the prescription must be renewed on a continual basis. Suddenly stopping drugs such as beta blockers can result in angina (chest pain), myocardial infarction (MI), or rebound hypertension. Also urge patients to report unpleasant side effects, such as excessive fatigue, cough, or sexual dysfunction. In many in-stances, an alternative drug can be prescribed to minimize certain side effects. Ignatavicius Workman. Medical-Surgical Nursing, 803.

• Risk for Ineffective Therapeutic Regimen Management, 802

NURSING PROCESS

• ASSESSMENT DATA FOR NURSING DIAGNOSIS• NURSING DIAGNOSIS COLLABORATIVE PROBLEMS• EXPECTED OUTCOMES WITH INDICATORS• NURSING • INTERVENTIONS• SCIENTIFIC RATIONALE FOR NURSING

INTERVENTIONS• REALISTIC EVALUATION

– Effectiveness of Nursing Interventions– Attainment of Expected Outcomes

How do you know if he has hypertension?

Categories for Blood Pressure Levels in Adults (in mmHg, or millimeters of mercury)

•

Category Systolic (top number)

Diastolic(bottom number)

Normal Less than 120 And Less than 80

Prehypertension 120–139 Or 80–89

High blood pressure

Stage 1 140–159 Or 90–99

Stage 2 160 or higher Or 100 or higher

What are you going to do

about it?

Hypertension case study

Hypertension Algorithm

• Hypertension algorithm

• File

• JNC VII phycard

• http://www.nhlbi.nih.gov/health/dci/index.html

• ATP III Guidelines

TOD

• Target Organ Damage• What is an aneurysm?

http://www.mayoclinic.com/health/aortic-aneurysm/DS00017

• http://www.sts.org/patient-information/aneurysm-surgery/aortic-aneurysms ***

• http://www.mayoclinic.com/health/food-and-nutrition/AN00413 grapefruit interactions

• http://hp2010.nhlbihin.net/atpiii/calculator.asp?usertype=prof

Where does the salt come from?

How Much Salt???• http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intake-i

n-the-United-States/Report-Recommendations-Strategies-to-Reduce-Sodium-Intake.aspx

• http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12818

• http://www.mayoclinic.com/health/sodium/nu00284• http://www.library.umc.edu/pe-db/pe-noaddsalt.pdf• http://www.library.umc.edu/pe-db/pe-sodium.pdf• http://

nutritioncaremanual.org/vault/editor/Docs/2gramsodiumdiet_FINAL.pdf

Tobacco dependence syndrome http://www.ncbi.nlm.nih.gov/pubmed/1859602

• World Health Forum. 1991;12(1):70-2.• Implications of the tobacco dependence syndrome for smoking

control programmes.• Ramström LM, Masironi R.• Institute for Tobacco Studies, Stockholm, Sweden.• Abstract• Motivational and psychosocial treatments for tobacco dependence,

while valuable, are not sufficient to solve nicotine-related problems, which usually require a pharmacological approach. There is also a need for training programmes for health workers and major educational campaigns on the nature of tobacco dependence to be directed at opinion leaders, teachers and the public at large.

• PMID: 1859602 [PubMed - indexed for MEDLINE]

Five Keys for Quitting SmokingStudies have shown that these five steps will help you quit and quit for good. You have the

best chances of quitting if you use them together.

• Get Ready.Get Support.Learn new skills and behaviors.Get medication and use it correctly.Be prepared for relapse or difficult situations.

• http://www.cdc.gov/tobacco/quit_smoking/how_to_quit/you_can_quit/five_keys/

Diagnosis Assess Monitor Do Call

Risk for ineffective therapeutic regimen management:o Smoking cessationo Blood pressure controlo Lipid managemento Physical activityo Weight managemento Diabetic managemento Anti plateletso ACEIo Beta blockerso Influenza vaccination

o Assess the client tobacco use and exposure to tobacco at each visit.

o Assess for presence of prehypertension SBP=120-129 and DBP= 80-89 if not already diagnosed

o Assess for SBP< 130-140 And DBP< 80 if diabetic or CKD if currently receiving HTN treatment (JNC goal for treatment is 130/80 for CKD and DM vs 140/90 otherwise)

o Assess if LDL-C < 100 or < 70 for diabetic clients and clients post MI

o Assess if moderate intensity activities are preformed for 30 minutes per day on most if not all days of the week

o Assess if BMI 18.5-24.9 and waist circumference according to gender

Men < 40 inchesWomen< 35 inches

o Assess fasting blood glucose <100 and if required HgAiC < 7%

o Assess for compliance and tolerance of antiplatelet therapy

o Assess for use of ACEI in presence of LV EF <40%, HTN, DM, CKD

o monitor tolerance to and compliance with antihypertensive therapy

o monitor tolerance to and compliance with antilipemic therapy

o monitor tolerance and compliance with TLC diet

http://www.nhlbi.nih.gov/cgi-bin/chd/step2intro.cgi

o monitor compliance with antidiabetic therapy if indicated

o monitor tolerance to and compliance with anticoagulant therapy

o monitor tolerance to and compliance with ACE inhibitor therapy

o monitor tolerance to and compliance with beta blocker therapy

o If indicated; provide referral to Tobacco cessation program for individual counseling

o Discuss strategies to manage and minimize unique side effects to antihypertensives

o Instruct client in side effects of antilipemic:o Review side

effects for each agent

o Review s/s of liver dysfunction

o Review s/s of myopathy

o Review activity recommendations

o Administer TLC diet o Reinforce instruction

in bleeding precautions

o Review management of orthostatic hypotension in response to ACEI

o Review pulse check and reporting requirements for HR <60

o Teach client s/s to report

o Administer flu vaccine as ordered

o Consult PT/exercise physiologist for exercise prescription

o Refer to nutritionist for dietary consultation

o Call MD if fasting blood glucose > 100 if not previously diagnosed with DM

o Refer to diabetic educator for f/u

o Hold antilipemic and call cardiologist if myopathy or liver dysfunction is present

o Hold antihypertensives and call cardiologist if SBP < 90

o Hold beta blockers and call cardiologist if HR < 50-60

o Call MD if bleeding times are prolonged or s/s of bleeding are present

Diagnosis Assess Monitor Do Call

PC: arterial ischemiaCADAAAPADCVAMesenteric ischemiaRationale: The client with atherosclerosis is at risk for or may be experiencing the complications of arterial ischemia that may manifest throughout the vascular system as indicated by the disorders listed above.

Assess for s/s of arterial ischemiaCAD:

Chest discomfort, shortness of breath, nausea, diaphoresis, activity intolerance

CADMon for the presence of chest discomfort

Be aware that female clients, diabetics and clients of non-white ethnic background may not present with complaints of chest pain.

If present Perform 12 lead EKG stat with complaints of chest discomfort to document degree of ischemia

Initiate ST elevation MI protocol if indicated

Initiate continuous cardiac monitoringInitiate continuous pulse oximetryMon VS q 4 hours and prn

(increase frequency during acute phase and if receiving IV medication that has vasoactive properties)

Mon troponin I and cardiac enzymes q 8 hours as ordered for signs of infarctionAssess baseline bleeding timesMon electrolytes to determine renal function, hydration and levels of potassium and magnesium

Alterations in potassium and magnesium are proarrhythmic

Perform lipid measurement if not already performed

CADInitiate measure to restore perfusionApply oxygen therapy& titrate sao2 > 95%Administer medications to increase myocardial perfusion:

AspirinThrombolytic therapyAntiplatelet therapyNitrates

Sublingual nitroglycerin versus IV nitroglycerin (Tridil)

Heparin therapyAdminister medications to reduce cardiac workload

IV beta blockers followed by beta blockers

Mon s/s of CHF and perform echocardiogram as indicatedAdminister ACEI or ARB for LSVD (left systolic ventricular dysfunction) if orderedPrepare client for reperfusion strategies utilizing percutaneous interventions (PCI) or revascularization (CAGB)Initiate protocol to monitor for complications of myocardial infarctionOtherwise:

Administer as ordered:

AntilipemicAntihypertensivesantiplatelets

CADCollaborate with cardiologist, interventionalist and cardiac surgeon as indicated

Diagnosis Assess Monitor Do Call

PC: arterial ischemiaCADAAAPADMesenteric ischemiaCVA(Continued)

AAA: Assess for abdominal or back pain with a Pulsatile abdominal mass  that is severe, sudden, persistent, or constant; may radiate to groin, buttocks, or legs review appearance of Assess for presence of abdominal bruit on auscultation. Assess for necrotic lesion of toes and feet secondary to distal emboli. Assess for s/s of s/s of shock

PAD:Complaints of intermittent claudication, Decreased peripheral pulses, peripheral arterial bruits, pallor, peripheral cyanosis, gangrene, ulceration

AAAMon vital signs and blood pressure q 4 hours and prn

Increase frequency upon initial complaint and if vasoactive agents are in usePerform abdominal exam q 4 hours and prn Do not palpate a pulsating mass if present

Mon peripheral pulses q 4 hours and prn for signs of emboliPrepare client for CAT scan if required to document size Perform 12 lead EKG and continuous cardiac monitoringMon urine output for signs of renal ischemia secondary to emboliPerform preoperative bloodwork; type cross, CBC, metabolic panel, cardiac workup, PT/PTTPADAssess for presence of acute arterial occlusion manifesting with extremity pain unrelieved by narcotic analgesiaAssess brachial ankle indexPerform peripheral vascular checks q 4 hours and prnMonitor lipid levelsAssess bleeding timesPrepare client for angiographyAssess for s/s of gangrene and necrosis

AAAInitiate hemorrhagic shock protocol if indicated

Apply Oxygen therapyEstablish IV accessAdminister blood productsAdminister IV antihypertensivesInsert Foley catheter and mon hourly I/O Prepare for OR

Otherwise:Administer as ordered:

AntilipemicAntihypertensivesantiplatelets

PADAdminister medications to maintain tissue perfusion:

AspirinAntiplateletspentoxifylline

Position client to maximize tissue perfusion to lower extremities

Do not gatch bedAvoid heavy blankets/pressure on lower extremities

Consider use of bed cradle

Avoid exposure to extremes in temperature changes/air currents/unnecessary coolingManage clients requiring revascularization procedures

Administer as ordered:

AntilipemicAntihypertensivesAntiplatelets

AAACollaborate with vascular surgeon as indicated.PADObtain PT consultCollaborative with vascular surgeon if amputation required.

Diagnosis Assess Monitor Do Call

PC: arterial ischemiaCADAAAPADMesenteric ischemiaCVARationale: The client with atherosclerosis is at risk for or may be experiencing the complications of arterial ischemia that may manifest throughout the vascular system as indicated by the disorders listed above.

Assess for s/s of arterial ischemiaMESENTERIC ISCHEMIA

Sever abdominal pain, nausea, vomiting diarrheaAbdominal distention, Absent bowel sounds, peritoneal signs, frank blood in stool and emesis s/s shock

CVA: Change in mental status headache, blurred vision, paralysis/paresis, change in sensation, nausea, vomitingneurological changes, unequal pupils seizures, slurred speech

MESENTERIC ISCHEMIAMon GI status q4 hours and prnMon for elevated HR and decline in MAP q 4 hours and prnMonitor CBC for leukocytosis, metabolic panel for elevated BUN Assess for metabolic acidosis by ABG as orderedPrepare client for angiography as orderedCVAMonitor neuro checks q 4 hours and prn for neurological changesMonitor for increased blood pressurePrepare client for CAT scan/MRI/MRA as orderedPerform continuous cardiac monitoring to identify arrhythmias. Ands 12 lead EKGPrepare client for carotid Doppler as orderedAssess for presence of hyperglycemia

MESENTERIC ISCHEMIAInitiate shock management if symptomatic according to standard protocolsOxygen, cardiac monitor, IV salineMaintain NPOInsert NG tube for gastric decompression as orderedAdminister IV antibiotics as orderedAdminister IV narcotic analgesic as orderedPrepare client for ORCVAIf s/s present, obtain IV access Administer oxygen as per protocolAdminister medications according to type of stroke.

Prepare to initiate thrombolytic stroke protocol for a thrombotic stroke

Administer antihypertensives according to MAP or SBP in collaboration with neurologistAdminister anticoagulants if thrombotic strokeElevate HOB to 15-30 degrees as toleratedMonitor for s/s of increased ICPOtherwise:

Administer as ordered:

AntilipemicAntihypertensivesAntiplatelets

Prepare client for carotid endarterectomy if required.

MESENTERIC ISCHEMIACollaborate with vascular surgeon and interventional radiologist as indicated CVAConsult neurologist and neurosurgeons as indicated. Prepare for evacuation of bleeding if hemorrhagic stroke

What about my patient?

• my guy

Telehealth

• EBP box p 803

CHAPTER 38 Care of Patients with Vascular Problems

Ignatavicius Workman. Medical-Surgical Nursing, 800.

• Health Teaching: Instruct the patient about sodium restriction, weight maintenance or reduction, alcohol restriction, stress management, and exercise. If necessary, also explain about the need to stop using tobacco, especially smoking. Provide oral and written information about the indications, dosage, times for administration, side effects, and drug interactions for antihyperten-sives. Stress that medication must be taken as prescribed and that when all of it has been consumed, the prescription must be renewed on a continual basis. Suddenly stopping drugs such as beta blockers can result in angina (chest pain), myocardial infarction (MI), or rebound hypertension. Also urge patients to report unpleasant side effects, such as excessive fatigue, cough, or sexual dysfunction. In many in-stances, an alternative drug can be prescribed to minimize certain side effects.

• Ignatavicius Workman. Medical-Surgical Nursing, 803.

Medications

• Page 801• Chart 38-6• Multidrug therapy• The Polypill• Managing “lots of pills” therapy

NURSING PROCESS

• ASSESSMENT DATA FOR NURSING DIAGNOSIS• NURSING DIAGNOSIS COLLABORATIVE PROBLEMS• EXPECTED OUTCOMES WITH INDICATORS• NURSING • INTERVENTIONS• SCIENTIFIC RATIONALE FOR NURSING

INTERVENTIONS• REALISTIC EVALUATION

– Effectiveness of Nursing Interventions– Attainment of Expected Outcomes