Introducing Mr. Kelly Mr. Kelly is a 51 year old unmarried,
caucasian male with a teenage son. He has a current girlfriend. He
works in a small engine repair shop. He is 6 feet tall and weighs
245 pounds with an abnormal distribution of this weight around his
abdomen. He does not regularly exercise, and eats fast food at
least twice a week. He does not prepare many of his own meals. He
drinks a few beers after work each night and denies any problem
with ETOH. He smokes 1 ppd since the age of 20. His father had HTN
and died of an MI at the age of 60. He has no current diagnosed
medical problems. He decided to have a physical when he recently
became more easily fatigued, dizzy and weak with mild activity. He
currently has no health insurance.
6 Pharmacologic: Diuretics Mechanism of Action: Thiazides,
Loop, Potassium Sparing S/E: fluid and electrolyte imbalances K+,
Mg++ CNS effects GI effects Nursing Considerations: Monitor for
orthostatic hypotension dehydration Hypokalemia
Slide 7
Beta- Blockers/olols Blocks beta ( ) adrenergic receptors
specific to the heart Results in decreasing cardiac output by
decreasing heart rate and contractility Most common side effect
Bradycardia and brady arrhythmias Masks hypoglycemia symptoms
Nursing implications Hold if HR less than 60 Teach not to stop
abruptly (tapered over 2 wks) May cause increased fatigue Use with
caution for patients with heart failure
Slide 8
Core Measure for MI Beta Blockers are consider a Core Measure
for treatment after myocardial infarction Long-term use of
beta-blockers for patients who have suffered an acute myocardial
infarction (AMI) can reduce mortality and morbidity. Studies have
demonstrated that the use of beta- blockers is associated with
about a 20% reduction in this risk (Yusuf, 1988), and there is
evidence of effectiveness in broad populations of patients with AMI
(Krumholz, 1998). National guidelines strongly recommend long-term
beta-blocker therapy for the secondary prevention of subsequent
cardiovascular events in patients discharged after AMI (Antman,
2004; Antman, 2008; Anderson, 2007; and Smith 2006).
http://www.qualitymeasures.ahrq.gov/content.aspx?id=355 15
http://www.qualitymeasures.ahrq.gov/content.aspx?id=355 15
Slide 9
ACE Inhibitors/prils Angiotensin Converting Enzyme Prevents
conversion of angiotension I to angiotension II This prevents
vasoconstriction of arteries Most common side effect = cough Is
considered renal protective so good drug of choice for DM First
drug of choice for a client with Diabetes Heart Failure History of
Myocardial Infarction
Slide 10
ARBs/sartans Angiotensin II receptor blockers More specific to
the R-A-A system ACE and ARBS very dangerous with preganancy Can
cause 1 st does hypotension Can cause hyperkalemia Hypotension
Dizziness Cough usually not as common as ACE Heart failure
Angioedema
Slide 11
Ca+ Channel Blockers/pines Blocks the flow of calcium ions
across the cell membrane resulting in relaxed vascular and heart
tissue, lowers peripheral resistance through vasodilation Used to
treat angina Increases oxygen to heart by dilating coronary
arteries Used to treat arrhythmias (can decrease HR) Decreases
excitability of cardiac muscle
Slide 12
Ca+ Channel Blockers/pines Side Effects flushing, constipation
(most common) Hypotension Bradycardia AV block Nausea H/A
Peripheral edema (most significant) Monitor I&O closely Nursing
Considerations: Always obtain BP-HR before giving use with caution
in patients with heart failure Orthostatic BP = Change position
slowly contraindicated in patients with 2 nd or 3 rd degree heart
block Concurrent use w/b- blockers increases risk of CHF
Slide 13
Figure 323 Sites of antihypertensive drug action, pg 1027,
Medical-Surgical 5 th ed., LeMone & Burke
Slide 14
Nursing Diagnoses Ineffective health maintenance Imbalanced
nutrition: more than body requires Impaired cardiac output Fluid
volume excess
Slide 15
Hypertensive Crises Sudden, rapid, significant elevation of
blood pressure SBP greater than 180 DBP greater than 120 Symptoms
Blurred vision, swelling of optic nerve (papilledema) Headache
Confusion, restlessness Numbness and tingling in extremities
Medical emergency Can lead to stroke, MI, and/or acute renal
failure
Slide 16
Treatment Immediate hospitalization Vasodilators = usually
given IV Nipride (sodium nitroprussdie) Nitroglycerin Apresoline
(hydralazine) Need to avoid rapid decrease in BP No more than 25%
within first hour Goal to get 160/100 within 2 to 6 hours Rapid
decrease can cause renal, cerebral, or cardiac ischemia Therefore =
Checking vital signs every 15 minutes
Slide 17
Aneurysms Abdominal aortic aneurysm = AAA Associated with HTN
and arteriosclerosis Abnormal Dilation of Aorta & other aterial
vessels True Fusiform Circumferential False Pseudo or saccular
Berry Dissecting
Slide 18
The AAA.. Beware of the pulsating mass!!!
Slide 19
Post-op Care of Aneurysm Repair New or expanding ecchymosis
Peripheral circulation, pulses Abdominal girth (AAA) Pain (new
onset or worsening) Decreased urinary output (sign of decreased
perfusion to kidneys) Decreased cardiac output (vital sign changes)
Prevent straining with bowel movement Maintain calm environment to
reduce stress (want to keep BP low normal decreased pressure on
graft sight)
Slide 20
Peripheral Vascular Disease PVD form of atherosclerosis
(hardening of the arteries) Impaired blood flow through arteries
and veins, especially in the lower extremities Can cause partial or
total occlusion
Slide 21
PVD/PAD (Peripheral Arterial Disease) Chronic, slow,
progressive narrowing disease Lower extremity disease most common
Femoral-popliteal seen often Develops earlier in diabetes and HTN
Below the knee most common in diabetes causing amputation Risk
factors Smoking Hypertension Hyperlipidemia Same process that
happens in the brain, happens in the coronary arteries, is happen
in the peripheral arteries Ischemia leads to tissue death,
gangrene, and amputation in extremeties
Slide 22
Symptoms of PVD/PAD Intermittent claudication Pain at rest is a
worsening sypmtom Paresthesia (decreased sensation) Pallor with
elevation & redness with dependent position Absent/diminished
pulses Skin changes pale, shiny, taut, hair loss
Slide 23
Nursing Assessment for Vascular Problems Blood pressure Pulses
Temperature differences Skin changes Capillary refill Check for
bruits Evaluate labs cholesterol, lipids, triglycerides diagnostic
tests such as ultrasound studies and Doppler studies
Slide 24
Five Ps of Acute Arterial Occlusion PAIN PALLOR PULSELESSNESS
PARESTHESIA PARALYSIS
Slide 25
Diagnostics of PVD Ankle brachial index (ABI) Use of blood
pressure cuff and Doppler Single most important diagnostic test
Ultrasound LEAFS = Lower Extremity Arterial Flow Study
Angiography
Slide 26
Treatment of PVD Medical management = address each risk factor
that lead to the development of PVD Diabetes, HTN, Hyperlipidemia,
smoking, etc Exercise shown to improve circulation Promote
vasodilation Medications Anti-platalet aggregation
Antihyperlipedemics antihypertensives
Post-op Care Assess for: Graft patency extremity hourly color
pulses pain Vital signs Mobility of extremity Edema Drainage
Infection
Slide 30
Drug Therapy Anti-platelet drugs aspirin Plavix Trental
Increases flexibility of RBCs Used more for the pain of
intermittent claudication Pletal Has vasodilation properties as
well as anticoagulation properties Also for intermittent
claudication Dont use with CHF
Slide 31
Nursing Diagnosis Ineffective Tissue Perfusion Need to state
what type when using this NANDA Cerebral, cardiopulmonary,
peripheral arterial, peripheral venous, etc. With PVD the R/T is
interruption of blood flow Expected outcome = demonstrate adequate
tissue perfusion by have warm skin, palpable pulses, no edema, no
pain, etc
Client Teaching for PVD Disease process Optimize circulation
Elevate when at rest Walking can help Good foot/skin care Protect
extremities Well- fitting shoes See podiatrist regularly
Slide 34
Slide 35
Raynauds Phenomenon Spasm of smaller arteries Affects fingers
& toes 3 color changes White, blue, red Symptoms of cold,
numbness, tingling Protect from cold!
Slide 36
Thrombophlebitis Clot formation with inflammation of vein DVT -
deep vein thrombosis SVT superficial vein thrombosis Virchows
triad: Venous stasis Endothelial damage Hypercoagulability
Slide 37
Symptoms of Thrombosis Varies as to size of thrombus & area
affected May have no symptoms Superficial Firm, palpable vein area
Tender to touch, red, warm, mild temperature elevation Caused by IV
therapy, varicose veins Deep Vein Thrombosis Pain, very warm, red,
swollen/edema Positive Homans sign
Slide 38
Complication of DVT Pulmonary embolus Life threatening
complication Embolus travels from lower extremity venous system
into pulmonary system (covered in lower respiratory lecture)
Slide 39
Diagnostics for DVT Lower Extremity Doppler study to assess
adequacy of blood flow and look for clot CT scan of lungs if having
respiratory symptoms Coagulation studies - monitors anticoagulant
therapy PTT PT/INR
Slide 40
Treatment of DVT Prevention is #1 treatment Early ambulation
after surgery Compression hose Hydration Avoid prolonged standing
or sitting Avoid crossing legs Teach ankle flexion and extension
exercises (calf pumps) Even when bed bound
Slide 41
Treatment of DVT Hospitalization is required Bedrest with very
limited ambulation privileges Usually for 3-6 days Dont want the
thrombus to dislodge and travel Compression hose with elevation of
extremity Pain medication if needed Anticoagulation therapy
Possible thrombectomy Possible placement of vena cava filter Green
filter is a type (see figure 32-11, page 1054)
Anti-Coagulant Medications Parenteral is short-term use
Continuous heparin gtt for DVT or PE Heparin, Lovenox, Fragmin,
Arixtra SQ for prophylaxis Monitor PTT Oral is for long-term use
Coumadin (warfarin) Monitor PT/INR Antidotes Heparin = protamine
sulfate Coumadin = vitamin K
Slide 44
Nursing Implications for Anticoagulation Therapy Monitor for
any signs of bleeding = bruising, tarry stools, hematuria,
coffee-ground emesis, vaginal bleeding, etc Monitor c/o
flank/abdominal pain (abdominal bleed) Monitor for mental status
changes (cerebral bleed) Apply pressure to all sticks for 5+
minutes Administer SQ injection in abdomen only, do not aspirate or
massage
Slide 45
Client Teaching with Anticoagulation therapy Prevent injury,
wear medic alert bracelet Use soft toothbrush, observe gums for
bleeding Use electric razor Avoid aspirin products and use NSAIDS
sparingly unless okay with physician Report unusual bleeding or
bruising With Coumadin avoid foods high in vitamin K (yellow and
dark green vegetables) With Coumadin try to take at the same time
everyday
Arterial vs. Venous Leg Ulcers ARTERIAL Toes and feet, shin
Ulcer deep, pale Skin is shiny, hairless, pallor on elevation, cool
temperature Mild or absent edema Intermittent, severe, resting pain
Decreased or absent pulses VENOUS Usual around ankle Ulcer
superficial, pink, beefy red, irregular edges Skin leathery, brown,
purple discoloration, stasis dermatitis present Significant edema
Aching, mild pain Pulses usually normal
Slide 50
Nursing Care for Chronic Venous Insufficiency Care is very
similar to that mentioned earlier for arterial disease Teach
patient/family Protect extremities Good skin and foot care (well
fitting shoes, see podiatrist) Inspect skin on a regular basis
Promote circulation with elevation whenever possible
Slide 51
Treatment Meticulous skin care to prevent infection Good
fitting shoes Prevent dry skin by using lotions/creams Promote
lymph flow with exercise and elevating limb, compression stockings
Treat infections early (cellulitis) and may take prophylactic
antibiotics Diuretics used more with primary lymphedema Surgical
intervention if experiencing recurrent infections/cellulitis =
redirects lymph flow
Slide 52
Case Study - PAD Initial ED Presentation: Mr. Pederson is a 62
year old man who has a non-healing wound on the 4th digit on his
right foot. This wound has been present for the last 2 months.
Yellow drainage present the last 2 weeks. He presents to the ED
today due to increasing foot pain and red streaks that developed
over the last 2 days in the lower right leg. Rates the pain 6/10 as
a dull ache and is persistent whether he is at rest or ambulates.
Day of Surgery PACU report: Successful right fem/pop bypass. 3
liters LR given. Both feet warm with cap refill
Slide 53
Case Study - PAD Your Initial VS: T: 100.4 (o) P: 88 reg R: 20
BP: 132/86 O2 sats: 92% 2l per n/c WILDA Pain Scale (5th VS) Words:
Dull ache Intensity: 5/10 Location: Right foot and lower leg
Duration: started 10 minutes ago Aggravate: Nothing Alleviate:
Nothing Your Initial Nursing Assessment: RESP: breath sounds
diminished bilat with scattered light exp. wheezing. No c/o SOB
CARDIAC: pink, warm & dry, S1S2, no edema, pulses 2+ in upper
extremities. Left foot able to palpate faint pulse, but unable to
palpate pulses in right foot. Right foot is pale and cool to touch
with cap refill of 3-4 seconds. Left foot is pink, warm to touch
with brisk cap refill NEURO: alert & oriented x4 GI/GU: active
BS in all quads, abd. soft/non-tender, voiding without difficulty
SKIN: erythema of foot to midcalf. Stage III ulcer 4th digit rt.
foot 2x3 cm. Rt. Groin & thigh incisions D/I
Slide 54
Case Study - PAD BMP Current Recent High/Low/WNL? Sodium 142
140 WNL Chloride 105 102 WNL Potassium 3.8 3.9 WNL Glucose 185 125
High Creatinine 1.1 1.0 WNL CBC Current Recent High/Low/WNL? WBC
14.8 10.5 High Neut. % 92 78 High Hgb. 11.2 13.3 Low Platelets 168
175 WNL
Slide 55
Case Study - PAD Physician Orders (routine post-op): Assess
circulation in lower extremities every 15 x4, then every 30 x2 and
then hourly x4 Restart Heparin IV gtt at 900 units/hour Ceftriaxone
(Ancef) 1 g. IVPB bid Hydromorphone (Dilaudid) PCA 0.2 mg bolus/0.2
mg continuous Glucometers qid ac with Humalog slid
VS/assessment:ing scale