Test #3 PVD & Neuro

Metabolic Syndrome Prevention, medical and nursing management

*control cholesterol (goal is low LDL and high HDL - often controlled by diet and exercise) *Manage HTN *Control diabetes mellitus

PAD: Subjective data

*muscle wasting *hairloss in anterior tibial areas *brittle nails (think toe nails too) *thin parchment like skin *skin pale when elevated for 30 seconds, then turns dark red when lowered

Venous Stasis (risk factors)

*obesity *prolonged standing *pregnancy *tall stature *advanced age

The client undergoing femoral popliteal bypass states that he is fearful he will lose the limb in the near future. Which response by the nurse is most therapeutic? "Are you afraid you will not be able to work?" "If you control your diabetes, you can avoid amputation." "Your concerns are valid; we can review some steps to limit disease progression." "What about the situation concerns you most?"

C

INR is used when testing therapeutic effect of what drug?

Coumadin (not Heparin)

FAST for strokes stands for?

Face, Arms, Speech, Time

You can't palpate a pulse. What should you do?

Go get a doppler to try and listen

PTT is used when testing therapeutic effect of what drug?

Heparin (not coumadin)

LDL Goal Values

Less than 160mg/dl for pts with one or no risk factors. Less than 130 for pts with two or more risk factors Less than 100 for pts with CAD or high risk for CAD Less than 70 for pts at high risk for an acute coronary event

Normal PTT vs. therapeutic PTT?

Normal: 30-40 Therapeutic is 1.5-2x normal, so it'd be 45-80 or 60-80

Surgical Management of intermittent claudication

Revascularization or arterial bypass is the first line intervention for ALI. classified as inflow or outflow and depends on degree and location of stenosis or occlusion. When diffuse disease is present, inflow is first. bypass grafts - performed to reroute blood flow around stenosis/occlusion. can use synthetic grafts for anything below the knee. Above require autologous.

Thrombolysis

Thrombotic stenosis or occlusion can be treated by thrombolysis. This is when a catheter is inserted into the affected vessel, thrombolytic agent is injected directly into the thrombus. It lyses the thrombus (clot) and the pt goes to critical care unit for monitoring. Monitor pt for signs of bleeding (most common side effect of thrombolytic therapy) Minimize # punctures (IV, blood work, IM injection) prevent tissue trauma, apply pressure at least twice as long as usual after any procedure is performed.

Difference in arteries vs. veins?

Veins have valves!

A patient is placed on heparin, and the nurse acknowledges that heparin is effecting for preventing clot formation in patients who have which disorders? (select all that apply) a. coronary thrombosis b. Acute MI c. DVT d. hemorrhagic CVA e. disseminated intravascular coagulation

a, b, c, d, e

Which contains the pulse? Arteries or veins?

arteries

A patient is taking Warfarin 5mg/day for A fib. The patient's INR is 3.8. The nurse would consider the INR to be what? a. WNL b. elevated range c. low range d. low average range

b

A patient is admitted to the ED with an acute MI. Which drug does the nurse anticipate the HCP to order for prevention of the tissue necrosis following blood clot blockage in a coronary artery? a. heparin sodium b. clopidrogrel (Plavix) c. alteplase (rPa Activase) d. aminocaproic acid (Amicar)

c

The nurse is teaching a patient about clopidrogrel (Plavix) which information will the nurse include in the patient's teaching plan? a. constipation may occur b. hypotension may occur c. bleeding may increase when taken with aspirin d. normal dose is 25mg tablet per day

c

An outflow PVD versus inflow is based on what?

location (above or below the knees)

Peripheral Arterial Disease: Patho

lumen narrows, ischemia occurs. This progresses to infarction. arteriosclerosis is the most common disease of the arteries and it is a diffuse process where muscle fibers and endothelial linings of the walls of small arteries become thickened. atherosclerosis causes arterial stenosis, obstruction by thrombosis, aneurysm, ulceration, and venous rupture.

What is an important thing to remember about Pradaxa and Xarelto?

they do not have an antidote. If a patient begins bleeding, give PRBC's.

rubor

when an extremity is placed in a dependent position, it becomes reddish blue color called rubor when suffering from PAD. Comparing the contralateral limb is the best way to distinguish color differences

Risk factors for PVD

*HTN *Nicotine use *hyperlipidemia, DM *overweight (BMI >30) *stress *sedentary lifestyle *culture/age/gender *predisposition (genetics/family hx)

Buerger's disease

*caused by cigarette smoking *lose fingers/toes/feet

Anticoagulants

*keep clots from forming in blood vessels *Warfarin, Pradaxa, Xarelto *different from antiplatelets b/c they block other clotting factors *Used for pts with A-fib not caused by a heart valve replacement

Raynaud's

*smoking can cause *red/white/blue coloration of extremities

A client with neurological disorder has difficulty in swallowing. The nurse should take special care of the client's diet because of a potential risk of imbalanced nutrition in the client. Which of the following measures may be taken by the nurse to ensure that the client's diet allows for easy swallowing? Choose all correct options. a) Help the client sit upright when eating and feed slowly b) Adopt techniques to modify the texture and consistency of foods c) Flex the client's chin toward the chest when eating d) Offer liquids frequently in large quantities

A, B, C

A patient who received heparin begins to bleed. The nurse anticipates the HCP will order which antidote? a. protamine sulfate b. Vitamin K c. aminocaproic acid (Amicar) d. potassium chloride (KCl)

a

A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? a) Wear antiembolytic stockings daily to assist with blood return to the heart. b) Do not cross your legs for more than 30 minutes at a time. c) Stop smoking. d) Keep your feet elevated above your heart.

c (Nicotine from tobacco products causes vasospasm and can thereby dramatically reduce circulation to the extremities. When the client elevates the feet above the heart level, the heart must work against gravity to supply blood to the feet. Antiembolytic stocking are helpful for venous return to the heart, but constriction is not helpful for lack of arterial blood flow. Crossing the legs for more than a few minutes at a time compresses arteries and decreases blood supply to the legs and feet.)

A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? a) Numbness, warm skin temperature, and redness b) Swelling, warm skin temperature, and drainage c) Numbness, cool skin temperature, and pallor d) Redness, cool skin temperature, and swelling

c (Signs and symptoms of impaired circulation include numbness and cool, pale skin. Signs of localized infection may include swelling, drainage, redness, and warm skin. Signs of adequate circulation include normal sensation and warm skin with normal return of skin color after blanching.)

A patient had orthopedic surgery and is prescribed dalteparin (Fragmin). What could the nurse teach the patient and or family about this low molecular weight heparin before discharge? a. how to administer this med IM b. PT and INR monitoring will be done weekly c. avoidance of green leafies is recommended d. watch for bleeding/excessive bruising

d

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? a) Increased ability to sleep b) Relief from pain c) Relief from constipation d) Reduced muscle spasticity

d (Dantrolene reduces muscle spacticity. It doesn't increase the ability to sleep or relieve constipation or pain.)

Ways to manage cholesterol

*diet *exercise *smoking cessation *stress management *HTN management *diabetes management

Management of intermittent claudication

*often patients feel better with exercise *are instructed to "walk into" the pain, pause until the pain subsides, and continue walking *often combined with weight reduction and tobacco cessation and sometimes all this will clear up the pain without further intervention

Acute arterial occlusion (The 6 P's)

*pain (severe, shooting, stabbing, burning) *pallor *pulselessness *poikilothermia (cool temp to palpation) *paresthesia *paralysis

Angioplasty (also called percutaneous transluminal balloon angioplasty - PTA)

*performed with or without a stent *balloons are inserted into the vessels via catheter and expanded at the stenotic site within a vessel. Expanding balloon cracks the atherosclerotic plaque and opens the vascular lumen. *stents are inserted to support the vessel wall and maintain patency *complications: Hematoma, embolization, dissection of the vessel, bleeding, intimal damage, and stent migration

Deep Vein Thrombophlebitis: 3 main factors (Virchow's triad)

*stasis of blood (or something that slows blood flow like crossing legs) *Vessel wall injury *altered blood coagulation

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

1 (Because the client is having an evolving stroke, the client is experiencing a worsening of signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse.)

The nurse is caring for a client newly diagnosed with multiple sclerosis. Which referral is appropriate at this time? 1. To a social worker to apply for disability. 2. To a dietician for a nutritional consult. 3. To a psychological counselor for therapy. 4. To a chaplain to discuss spiritual issues.

3 (The client should be referred to a psychological counselor to develop skills for coping with the long-term chronic illness.)

The home health (HH) aide tells the nurse the client diagnosed with multiple sclerosis is having problems getting out of the bed to the chair, and is now having problems getting into the shower. Which intervention should the nurse implement? 1. Ask the HH aide whether the bathroom has grab bars. 2. Assess the client's ability to transfer in the home. 3. Instruct the HH aide to give the client a bed bath. 4. Contact the agency physical therapist about the situation.

4 (The physical therapist is the member of the healthcare team who is responsible for helping the client with mobility issues)

The nurse teaches a client who has had a myocardial infarction (MI) which information regarding diet? Less than 30% of the daily caloric intake should be derived from proteins. Use canola oil rather than palm or coconut oil. Consume 10 mg fiber daily. Work toward lowering your HDL cholesterol levels.

B (Palm and coconut oils are higher in saturated fats and are to be avoided.)

The nurse is teaching the client precautions to take while on warfarin (Coumadin) therapy. Which statement made by the client demonstrates that teaching has been effective? "I can use an electric razor or a regular razor." "Eating foods like green beans won't interfere with my Coumadin therapy." "If I notice I am bleeding a lot, I should stop taking Coumadin right away." "When taking Coumadin, I may notice some blood in my urine."

B (Vitamin K is not found in green beans and will not interfere with the anticoagulant effects of Coumadin.)

The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client should the nurse question? Enalapril (Vasotec) Sodium nitroprusside (Nipride) Dopamine (Intropin) Clevidipine (butyrate)

C

The nurse suspects that the client has developed an acute arterial occlusion of the right lower extremity based on which of the following? Select all that apply. Hypertension Tachycardia Bounding right pedal pulses Cold right foot Numbness and tingling of right foot Mottling of right foot and lower leg

D, E, F (6 P's!)

Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? a) Intermittent claudication b) Dizziness c) Vertigo d) Acute limb ischemia

a (The hallmark symptom of PAD in the lower extremity is intermittent claudication. This pain may be described as aching or cramping in a muscle that occurs with the same degree of exercise or activity and is relieved with rest. Acute limb ischemia is a sudden decrease in limb perfusion, which produces new or worsening symptoms that may threaten limb viability. Dizziness and vertigo are associated with upper extremity arterial occlusive disease)

Which of the following is the most effective intervention for preventing progression of vascular disease? a) Use neutral soaps b) Risk factor modification c) Avoid trauma d) Wear sturdy shoes

b (Risk factor modification is the most effective intervention for preventing progression of vascular disease. Measures to prevent tissue loss and amputation are a high priority. Patients are taught to avoid trauma; wear sturdy, well-fitting shoes or slippers; and use pH neutral soaps and body lotions.)

What drug, prescribed for Parkinson's disease, has neuroprotective properties? a) Levodopa (Larodopa) b) Bromocriptine (Parlodel) c) Selegiline (Eldepryl) d) Amantadine (Symmetrel)

c (Selegiline (Eldepryl), has neuroprotective properties; dopaminergics such as levodopa (Larodopa) or levodopa-carbidopa (Sinemet); amantadine (Symmetrel); dopamine agonists such as bromocriptine (Parlodel); apomorphine (Apokyn), the newest approved drug; and anticholinergics such as benztropine (Cogentin) are prescribed.)

Which of the following are characteristics of arterial insufficiency? a) Superficial ulcer b) Pulses are present, may be difficult to palpate c) Aching, cramping pain d) Diminished or absent pulses

d (A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses.)

A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? a) Decreasing blood pressure and increasing mobility b) Increasing blood pressure and monitoring fluid intake and output c) Increasing blood pressure and reducing mobility d) Stabilizing heart rate and blood pressure and easing anxiety

d (For a client with an aneurysm, nursing interventions focus on preventing aneurysm rupture by stabilizing heart rate and blood pressure. Easing anxiety also is important because anxiety and increased stimulation may raise the heart rate and boost blood pressure, precipitating aneurysm rupture. The client with an abdominal aortic aneurysm is typically hypertensive, so the nurse should take measures to lower blood pressure, such as administering antihypertensive agents, as ordered, to prevent aneurysm rupture. To sustain major organ perfusion, the client should maintain a mean arterial pressure of at least 60 mm Hg. Although the nurse must assess each client's mobility individually, most clients need bed rest when initially attempting to gain stability. )

Parkinson's' disease (PD) results in a decreased level of which of the following neurotransmitters? a) GABA b) Epinephrine c) Acetylcholine d) Dopamine

d (PD is associated with decreased levels of dopamine, resulting in the destruction of pigmented neuronal cells in the substantia nigra, in the basal ganglia region of the brain. The other neurotransmitters are not decreased in PD. )

The nurse is working with a client who has just been diagnosed with an aneurysm. What advice should the nurse provide to this client? a) Avoid situations that contribute to ischemic episodes. b) Minimize bowel movements and coughing. c) Wear wool socks and mittens during cold weather. d) Avoid straining during bowel movements and coughing.

d (The nurse advises the client with an aneurysm to avoid straining during bowel movements and coughing. The client with Raynaud's disease is asked to avoid situations that contribute to ischemic episodes and to wear wool socks and mittens during cold weather.)

When providing discharge teaching for a client with multiple sclerosis (MS), the nurse should include which instruction? a) "Avoid taking daytime naps." b) "Restrict fluid intake to 1,500 ml/day." c) "Limit your fruit and vegetable intake." d) "Avoid hot baths and showers."

d (The nurse should instruct a client with MS to avoid hot baths and showers because they may exacerbate the disease. The nurse should encourage daytime naps because fatigue is a common symptom of MS. A client with MS doesn't require food or fluid restrictions.)

The nurse is advising a client with multiple sclerosis on methods to minimize spasticity and contractures. Which of the following techniques would the nurse instruct the client to perform? a) Avoid swimming and any weight-bearing activity. b) Relax in a hot bath. c) Exercise following a circuit training regimen. d) Apply warm packs to the affected area.

d (Warm packs to the affected area may be beneficial. The client should avoid hot baths because of risk of burn injury secondary to sensory loss and increasing symptoms that may occur with elevation of the body temperature. Swimming and stationary bicycling are useful, and progressive weight-bearing can relieve spasticity in the legs. The client should not be hurried in exercise (as can occur in circuit training), because rushing often increases spasticity.)

Intermittent Claudication Cause + etiology

inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and O2 during exercise. Tissues are forced to complete the energy cycle without adequate nutrients/o2 and lactic acid and muscle metabolites are produced. Pain is experienced as the metabolites aggravate nerve endings of the surrounding tissue. This pain is reproducible from one day to the next on similar terrain. The way you monitor progression of arterial disease is documenting the ambulatory distance before pain is felt.

Arteriosclerosis

most common disease of the arteries and it is a diffuse process where muscle fibers and endothelial linings of the walls of small arteries become thickened.

Lupus

*can cause coagulation problems *butterfly rash or scars on face like SeAL

The nurse is caring for a client with peripheral arterial occlusive disease (PAD). For which symptoms should the nurse assess? Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevated Pulse oximetry reading of 90%

A

Pharmacologic Therapy for PAD

Cilostazol is a vasodilator and interferes with platelet aggregation. Usually used with an exercise program to improve walking distance. Usually used as a first line 3-6 month course for pts with intermittent claudication. Aspirin or clopidrogrel (antiplatelet agents)prevent the formation of thromboemboli which can lead to MI and stroke. This is not for treatment of IC but rather prevention of complications related to IC.

The nurse is teaching the young female client how to prevent venous thromboembolism specific to her hospital stay after intensive orthopedic surgery. Which statement made by the client indicates the need for further teaching? "I must stop taking my birth control pills." "I should drink lots of water so I don't get dehydrated." "I should exercise my legs when I have been sitting or standing for a long time." "If I wear pantyhose, I won't have to wear the stockings the hospital gives me."

D

Normal INR for coumadin therapy?

Normal INR: 1.3-2.0 Therapeutic: 2.0-3.0, although if they are at high risk it might need to be 2.5-3.5.

Collateral Circulation

Rerouting of blood vessels, in which new blood vessels join to take over some of the circulation of blocked vessels. (p 489 pellico)

A home health nurse is seeing an elderly male client for the first time. During the physical assessment of the skin on the lower legs, the nurse notes edema, brown pigmentation in the gater area, pedal pulses, and a few irregularly shaped ulcers around the ankles. From these findings, the nurse knows that the client has a problem with peripheral circulation. Which of the following does the nurse suspect? a) Venous insufficiency b) Neither venous nor arterial insufficiency c) Trauma d) Arterial insufficiency

a (Symptoms of venous insufficiency include present pedal pulses, edema, pigmentation in gater area, and a reddish blue color. Ulcers caused by venous insufficiency will be irregular in shape and usually located around the ankles or the anterior tibial area. Characteristics of arterial insufficiency ulcers include location at the tips of the toes, great pain, and circular shape with a pale to black ulcer base.)

The nurse is caring for a client who is status post operative from a vein stripping. What would the nurse monitor for? a) Swelling in the operative leg b) Warm, pink toes in the inoperative leg c) Swelling in the inoperative leg d) Blood on the dressing on the inoperative leg

a (When the client returns from surgery with a gauze dressing covered by elastic roller bandages on the operative leg, the nurse monitors for swelling in the operative leg(s) and its effect on circulation)

Warfarin, Pradaxa, Xarelto are examples of what category of drug?

anticoagulant

Plavix, aggrenox, trintol, aspirin are examples of what category of drug?

antiplatelets (used to keep you from having a stroke)

A patient is being changed from an injectable anticoagulant to an oral anticoagulant. Which anticoagulant is administered orally? a. enoxaparin sodium (Lovenox) b. warfarin (Coumadin) c. bivalirudin (Angiomax) d. lepirudin (Refludan)

b

Which teaching should the nurse include for a client with peripheral arterial disease (PAD)? Elevate your legs above heart level to prevent swelling. Inspect your legs daily for brownish discoloration around the ankle. Walk to the point of leg pain, then rest, resuming when pain stops. Apply a heating pad to the legs if they feel cold.

c (Exercise may improve arterial blood flow by building collateral circulation; walk until the point of claudication, stop and rest, and then walk a little farther.)

The diagnosis of multiple sclerosis is based upon which of the following tests? a) CSF electrophoresis b) Evoked potential studies c) Neuropsychological testing d) MRI

d (The diagnosis of MS is based on the presence of multiple plaques in the CNS observed with MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.)

Thrombolytics

*"Clot buster" *attack and dissolve blood clots that have already formed *The thrombus disintegrates when a thrombolytic drug is administered within 4hrs after an acute myocardial infarction - necrosis from the blocked artery is prevented/minimized, hospital time may be reduced *Thrombolytic drug should be administered within 3hrs of a thrombotic stroke *Check baseline CBC, PT, or INR before administering. *Contraindications: Recent CVA, active bleeding, severe HTN, anticoagulant therapy, traumatic/head injury *Look for S&S of bleeding up until 24hrs after thrombolytics are dc'd, q15 min for the first hour, q30min till the 8th hour, then hourly *look for S&S of allergic reaction *Avoid administering aspirin of NSAIDS and note if the patient is already taking them

Low-Molecular Weight Heparins

*Fragmin (dalteparin sodium), Lovenox (enoxaparin sodium) *Lower risk of bleeding because they produce more stable responses *Usually to prevent DVT, PE after orthopedic and abdominal surgery *Administered SubQ once or twice daily depending on the drug or drug regimen *Contraindicated in patients with strokes, peptic ulcer, blood anomalies. *NOT for patients having eye, brain, or spine surgery

Peripheral arterial Disease Clinical Manifestations

*often asymptomatic *sometimes critical limb ischemia (with either chronic ischemic pain at rest or ulcers or gangrene) *sometimes acute limb ischemia (sudden decrease in limb perfusion which produces new/worse symptoms that may threaten limb viability) Clinical S&S: manifested in organ supplied by arterial blood flow. Pain in fingers/feet, pain in muscle groups with use (not joints). Walking causes leg muscle pain, physical activity causes pain in upper extremity muscles. Assessment: Description of pain/precipitating factors, skin color and temp (rubor? cyanosis? compare both limbs and cap refill), peripheral pulse presence (unequal or absence is a sign, sometimes absent after exercise, sometimes bruits can be heard with stethoscope).

Tips for palpating peripheral pulses

*use tips of fingers *palpate bilaterally and simultaneously *compare both sides for symmetry in rate, rhythm, and quality *document as present, absent, or bounding

Which of the following are alterations noted in Virchow's triad? Select all that apply. a) Vessel wall injury b) Stasis of blood c) Tenderness d) Altered coagulation e) Edema

A, B, D (Three factors, known as Virchow's triad, are believed to play a significant role in the development of venous thrombosis. They are stasis of blood, vessel wall injury, and altered coagulation. Edema and tenderness are clinical manifestations of venous thrombosis, but are not part of the triad.)

A patient is prescribed enoxaparin (Lovenox). The nurse knows that low-molecular weight heparin has what kind of half life? a. longer half life than heparin b. shorter half life than heparin c. same half life as heparin d. four times shorter half life than heparin

a

A patient is to undergo a coronary angioplasty. The nurse acknowledges that which drug is used primarily for preventing reocclusion of coronary arteries following coronary angioplasty. a. clopidrogrel (Plavix) b. abcixamab (ReoPro) c. warfarin (Coumadin) d. cilostazole (Pletal)

b

A client diagnosed with Parkinson's disease has developed slurred speech and drooling. The nurse knows that these symptoms indicate which of the following? a) The client is having an exacerbation. b) Medication needs to be adjusted to higher doses. c) The client is exhibiting signs of medication overdose. d) The disease has entered the late stages.

d (In late stages, the disease affects the jaw, tongue, and larynx; speech is slurred; and chewing and swallowing become difficult. Rigidity can lead to contractures. Salivation increases, accompanied by drooling. In a small percentage of clients, the eyes roll upward or downward and stay there involuntarily (oculogyric crises) for several hours or even a few days. Options A, B, and C are therefore incorrect.)

As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? a) Assess for skin integrity. b) Assess for the sites of bleeding. c) Demonstrate how to self-administer IV infusions. d) Demonstrate how to apply and remove elastic support stockings.

d (The nurse demonstrates how to apply and remove elastic support stockings. Varicose veins do not require the nurse to demonstrate how to self-administer IV infusions. Varicose veins require the client to elevate legs regularly and perform leg exercises. However, it does not involve bleeding or skin lesions. )

Coronary Artery Disease: About and modifiable and unmodifiable risk factors

*Most prevalent type of cardiovascular disease in adults *Most common cause of CVD in adults is atherosclerosis *risk factors: Age (men >45, women >55) gender (men have greater risk until it becomes equal at age 55), race (african american, mexican american, native american, some asian american are at risk) family Hx of 1st degree relative with premature Dx of heart disease. Modifiable risk factors include obesity, HTN, smoking, physical inactivity, influenza, sleep apnea, metabolic syndrome, increased BMI

Peripheral Artery Disease (PAD)

*Refers to any disease process that effects the arteries BE ALERT FOR: *Structural changes resulting from chronic lack of O2 and nutrient delivery to the tissues (hair loss, thick opaque nails, shiny dry skin, skeletal muscle atrophy) *Skin color changes (pallor, dependent rubor - red color when limb dependent from dilated damaged vessels) *Pulse changes (diminished or absent in area of stenosis/obstruction - pedal, posterior tibial, popliteal, femoral) *Sensation changes (paresthesias, numbness, tingling) *ulceration/gangrene *edema sometimes

Coronary Atherosclerosis (coronary artery disease) Patho + Manifestations

*begins as fatty streaks of lipids that are deposited in the intima of the arterial wall *Continued development involves imflammatory response which begins injury to the vascular endothelium - injury may be initiated by smoking, HTN, and other factors. *smooth muscle cells form a fibrous cap over the lipid and inflammatory infiltrate - these deposits are called atheromas, which narrow and obstruct blood flow *the atheroma may either rupture which causes a thrombus or obstruction which leads to myocardial infarction Manifestations depend on the degree of blockage. Ischemia is the condition where inadequate O2 supply goes to cardiac muscle cells. Angina pectoris (chest pain) results from this. As this goes on, death of cardiac cells or MI can occur.

Peripheral arterial Disease Risk factors

*family hx *Age (20% adults over age 70 have PAD) *obesity *smoking *preexisting health conditions *(coronary artery disease, cerebral artery disease, diabetes, HTN, dyslipidemia, clotting disorders, hyperhomocysteinemia)

Warfarin (coumadin)

*inhibits synthesis of vitamin K *Used to prevent thomboembolic conditions like thrombophlebitis, pulmonary embolism, and embolism formation caused by Afib *Monitored by PT (prothrombin time) and INR *INR is used to report prothrombin time *look for petechiae, ecchymosis, tarry stools, hematemesis *Antidote is Vit K, but can take 24-48hrs to be effective *acute bleeding, give fresh frozen plasma - usually 1-10mg vit K, but if that doesn't work the plasma is given *food delays but doesn't inhibit absorption from the GI tract *half life is 1-7 days *Interacts with aspirin, NSAIDs, antiinflammatories, phenytoin (Dilantin), cimetidine (Tagamet) allopurinol (Zyloprim) and oral hypoglycemics *Use tylenol instead of aspirin Nursing Dx: Risk for injury r/t bleeding, deficient knowledge r/t lack of previous use of anticoagulants Nursing Mgmt: monitor VS, PT, INR, platelet count, examine pt's mouth, urine, stool, skin for bleeding, keep vitamin K handy, electric razor, soft toothbrush, medical ID bracelet, teach to apply firm direct pressure for 5-10 min if bleeding. Teach to avoid large amounts of green leafies, legumes, soybean oil, coffee, tea, cola, alcohol

Metabolic Syndrome Diagnosis

*major risk factor for CAD *Three of the following conditions: -Insulin resistance (Fasting >100mg/dl, abnormal glucose tolerance test) -Abdominal obesity (waist >35" women, >40"men) -Dyslipidemia (trigs >150mg/dl, HDL <50mg/dl women, <40mg/dl men) -HTN -Proinflammatory state (high C-reactive protein) -Prothrombotic state (high fibrinogen) *Many people with type 2 diabetes fit this picture

Risk factors for venous disorders

*major surgery *femoral Fx *prolonged bedrest *acute MI *nursing home (why?) *pregnancy/childbirth (lithotomy position with legs up) *hypercoagulability disorders *Hx superficial phlebitis *chemo *trauma *autoimmune disorders (lupus, crohns, RA, DM, infection/inflammation) *central venous lines (go straight to the heart) *male gender *mediterranean diets (the Vit K increases coagulation) *neurologic dx with paresis

Heparin

*natural substance in the liver that prevents clot formation *Indicated for a rapid anticoagulant effect when a thrombosis occurs because of DVT, PE, or an evolving stroke. Also used in open heart surgery to prevent blood from clotting and in the critically ill patient with disseminated intravascular coagulation *PTT is used to test heparin levels *if overdose, use protamine sulfate *given parenterally because poorly absorbed in GI tract because live enzyme destroys it *Half life is 0.5-2.5 hours Nursing Dx: Risk for injury r/t bleeding, deficient knowledge r/t lack of previous use of anticoagulants Nursing Mgmt: monitor VS, PTT, platelet count, examine pt's mouth, urine, stool, skin for bleeding, keep vitamin K handy, electric razor, soft toothbrush, medical ID bracelet, teach to apply firm direct pressure for 5-10 min if bleeding. Teach to avoid large amounts of green leafies, legumes, soybean oil, coffee, tea, cola, alcohol

Antiplatelets

*used to keep platelets from sticking together (prevent aggregation) *keep you from having a stroke *Plavix, aggrenox, trintol, aspirin *low dose aspirin (81, 162, or 325mg/d) *other drugs include dipyridamole (Persantine) ticlopidine (Ticlid) clopidogrel (Plavix) anagrelide HCl (Agrylin) abciximab (ReoPro) eptifibatide (Integrilin (tirofban (Aggrastat) ticagrelor (Brilinta) *Plavix is frequently used after an MI or stroke to prevent a second event *D/c plavix 7 days before surgery

Intermittent Claudication S&S

--> caused by inability of the arterial system to provide adequate blood flow to the tissues in the face of increased demands for nutrients and O2 during exercise. *cramp like pain in muscle *consistently reproducted with the same degree of exercise/activity *relieved by stopping muscle use *caused by inability of the arterial system to provide blood flow with increased demand *site of arterial disease can be determined by the location of claudication *pain occurs in muscle groups DISTAL to the diseased vessel *70-80% of pts don't have worsening symptoms *1-2% progress to critical limb ischemia *dependent position REDUCES pain

The nurse and unlicensed assistive personnel (UAP) are caring for a minimally responsive client diagnosed with multiple sclerosis who weighs more than 400 pounds. Which action is priority when moving the client in the bed? 1. Obtain a lifting device made for lifting heavy clients. 2. Do not attempt to move the client because of the weight. 3. Get another UAP to help move the client in the bed. 4. Tell the family that the client must assist in moving in the bed.

1 (The nurse and the UAP should protect themselves from injury. A lifting device should be used before attempting to move the client.)

The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson's disease who is experiencing "pill rolling." 4. The client with Huntington's disease who has writhing, twisting movements of the face.

2 (The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation; therefore, the nurse should assess this client first)

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently.

3 (This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet)

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a) rest in an air-conditioned room. b) increase the dose of muscle relaxants. c) take a hot bath. d) avoid naps during the day.

A (Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity)

The client has just undergone arterial revascularization. Which statement by the client indicates a need for further teaching related to postoperative care? "My leg might turn very white after the surgery." "I should be concerned if my foot turns blue." "I should report a fever or any drainage." "Warmness, redness, and swelling are expected."

A (Pallor is one of the signs of compartment syndrome, along with increased pain, poikilothermia, paresthesia, pulselessness, and paralysis.)

The nurse is providing community education about prevention of atherosclerosis-related diseases. Which risk factors should the nurse include in the presentation? Select all that apply. LDL cholesterol of 160 mg Smoking Aspirin (ASA) consumption Type 2 diabetes Vegetarian diet

A, B, D (Correct Feedback: Correct: Having an LDL-C value of less than 100 mg/dL is optimal; 100 to 129 mg/dL is near or less than optimal; with LDL-C 130 to 159 mg/dL (borderline high), client is advised to modify diet and exercise. Correct: Smoking is a modifiable risk factor and should be avoided or terminated. Correct: Diabetes is a risk factor for atherosclerotic disease. Incorrect Feedback: Incorrect: ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease (CAD) to prevent platelet adhesion. Incorrect: A diet high in whole grains, fruits, and vegetables is desirable, to prevent atherosclerosis; vegetarians usually consume fruits, vegetables, and nonanimal sources of protein.)

The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the last appointment. Which actions by the client indicate that teaching has been effective? Select all that apply. Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds since last seen in the clinic Cooks food in palm oil to save money Exercises once weekly Has cut down on caffeine

A, B, E (Correct: Clients with hypertension should consume low-sodium foods and should avoid adding salt. Correct: Weight loss can result in lower blood pressure. Correct: Caffeine promotes vasoconstriction, thereby elevating blood pressure. Incorrect Feedback: Incorrect: Although palm oil may be cost saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. Incorrect: The goal is to exercise three times weekly.)

When administering furosemide (Lasix) to a client who states she does not like bananas or orange juice, the nurse recommends that the client try which intervention to maintain potassium levels? Increase red meat in the diet. Consume melons and baked potato. Add several portions of dairy products each day. Try replacing your usual breakfast with oatmeal or cream of wheat.

B

The client with peripheral arterial occlusive disease has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index (ABI) Dye allergy Pedal pulses Gag reflex

C (Distal pulses must be assessed postprocedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).)

A nurse is reviewing self-care measures for a client with peripheral vascular disease. Which statement indicates proper self-care measures? a) "I have my wife look at the soles of my feet each day." b) "I stopped smoking and use only chewing tobacco." c) "I walk only to the mailbox in my bare feet." d) "I like to soak my feet in the hot tub every day."

a (A client with peripheral vascular disease should examine his feet daily for redness, dryness, or cuts. If a client isn't able to do this examination on his own, then a caregiver or family member should help him. A client with peripheral vascular disease should avoid hot tubs because decreased sensation in the feet may make him unable to tell if the water is too hot. The client should always wear shoes or slippers on his feet when he is out of bed to help minimize trauma to the feet. Any type of nicotine, whether it's from cigarettes or smokeless tobacco, can cause vasoconstriction and further decrease blood supply to the extremities.)

Which of the following are characteristics of arterial insufficiency? a) Diminished or absent pulses b) Superficial ulcer c) Pulses are present, may be difficult to palpate d) Aching, cramping pain

a (A diminished or absent pulse is a characteristic of arterial insufficiency. Venous characteristics include superficial ulcer formation, an aching and cramping pain, and presence of pulses. )

A client who underwent total hip replacement exhibits a red, painful area on the calf of the affected leg. What test validates presence of thromboembolism? a) Homans' b) Rinne c) Phalen's d) Romberg's

a (A positive Homans' sign, or pain in the calf elicited upon flexion of the ankle with the leg straight, indicates the presence of a thrombus. Testing for Romberg's sign assesses cerebellar function. Phalen's test assesses carpal tunnel syndrome. The Rinne test compares air and bone conduction in both ears to screen for or confirm hearing loss. )

A client has been hospitalized for diagnostic testing. The client has just been diagnosed with multiple sclerosis, which the physician explains is an autoimmune disorder. How would the nurse explain an autoimmune disease to the client? a) A disorder in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self" b) A disorder in which histocompatible cells attack the immunoglobulins c) A disorder in which the body has too many immunoglobulins d) A disorder in which the body does not have enough immunoglobulins

a (Autoimmune disorders are those in which killer T cells and autoantibodies attack or destroy natural cells—those cells that are "self." Autoantibodies, antibodies against self-antigens, are immunoglobulins. They target histocompatible cells, cells whose antigens match the person's own genetic code. Autoimmune disorders are not caused by too many or too few immunoglobulins, and histocompatible cells do not attack immunoglobulins in an autoimmune disorder.)

A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? a) Participate in a regular walking program. b) Use a heating pad to promote warmth. c) Keep the extremities elevated slightly. d) Massage the calf muscles if pain occurs.

a (Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and to resume activity when pain subsides. Extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. Heating pads should not be used by anyone with impaired circulation to avoid burns. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest.)

A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? a) Constant, intense back pain and falling blood pressure b) Higher than normal blood pressure and falling hematocrit c) Slow heart rate and high blood pressure d) Constant, intense headache and falling blood pressure

a (Indications of a rupturing abdominal aortic aneurysm include constant, intense back pain; falling blood pressure; and decreasing hematocrit.)

A client newly diagnosed with multiple sclerosis (MS) asks about a cure for her disease process. The nurse gives which of the following information? a) There is no cure for MS. b) Life expectancy for clients with MS is dramatically different from that of those without MS. c) If recommendations for symptom relief are followed, the disease will be cured. d) Medications do not assist with relief of signs and symptoms.

a (No cure exists for MS. Life expectancy for clients with MS is not dramatically different from that of clients without MS. Medications are available for symptom management of clients with MS.)

Which of the following is considered a central nervous system (CNS) disorder? a) Guillain-Barré b) Multiple sclerosis c) Parkinson's disease d) Myasthenia gravis

b (Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Parkinson's disease are peripheral nervous system disorders.)

The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? a) Take over-the-counter decongestants. b) Avoid situations that contribute to ischemic episodes. c) Avoid fatty foods and exercise. d) Report changes in the usual pattern of chest pain.

b (Teaching for clients with Raynaud's disease and their family members is important. The nurse should instruct the clients to avoid situations that contribute to ischemic episodes. Reporting changes in the usual pattern of chest pain or avoiding fatty foods and exercise does not help the client to avoid an attack; it is more contributory for clients with CAD. In addition, the nurse advises clients to avoid over-the-counter decongestants.)

Cilostazol (Pletal) is being prescribed for a patient with coronary artery disease. The nurse understands which is the major purpose for antiplatelet drug therapy? a. dissolve blood clot b. decrease tissue necrosis c. inhibit hepatic synthesis of vitamin K d. Suppress platelet aggregation

d

A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: a) elevating the extremity to prevent pooling of blood. b) encouraging ambulation to prevent pooling of blood. c) providing warmth to the extremity. d) forcing blood into the deep venous system.

d (Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool. Ambulation prevents blood from pooling and prevents DVT, but encouraging ambulation isn't a function of the stockings. Antiembolism stockings could possibly provide warmth, but this factor isn't how they prevent DVT. Elevating the extremity decreases edema but doesn't prevent DVT.)

A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Excess fluid volume related to peripheral vascular disease b) Risk for injury related to edema c) Impaired gas exchange related to increased blood flow d) Ineffective peripheral tissue perfusion related to venous congestion

d (Ineffective peripheral tissue perfusion related to venous congestion takes highest priority because venous inflammation and clot formation impede blood flow in a client with DVT. Impaired gas exchange related to increased blood flow is incorrect because impaired gas exchange is related to decreased, not increased, blood flow. Excess fluid volume related to peripheral vascular disease is inappropriate because there's no evidence that this client has an excess fluid volume. Risk for injury related to edema may be warranted but is secondary to ineffective tissue perfusion.)

A patient is receiving mitoxantrone (Novantrone) for treatment of secondary progressive multiple sclerosis (MS). This patient should be closely monitored for a) hypoxia. b) mood changes and fluid and electrolyte alterations. c) renal insufficiency. d) leukopenia and cardiac toxicity.

d (Mitoxantrone is an antineoplastic agent used primarily to treat leukemia and lymphoma but is also used to treat secondary progressive MS. Patients need to have laboratory tests ordered and the results closely monitored due to the potential for leukopenia and cardiac toxicity. Patients receiving corticosteroids are monitored for side effects related to corticosteroids such as mood changes and fluid and electrolyte alterations. Patients receiving mitoxantrone are closely monitored for leukopenia and cardiac toxicity.)

A nurse is assessing a client diagnosed with multiple sclerosis (MS). Which symptom does the nurse expect to find? a) Tremors at rest b) Flaccid muscles c) Absent deep tendon reflexes d) Vision changes

d (Vision changes, such as diplopia, nystagmus, and blurred vision, are symptoms of MS. Deep tendon reflexes may be increased or hyperactive — not absent. Babinski's reflex may be positive. Tremors at rest aren't characteristic of MS; however, intentional tremors (those occurring with purposeful voluntary movement) are common in clients with MS. Affected muscles are spastic, rather than flaccid.)