DVT
Nitroglycerin via the sublingual route is ordered for a client diagnosed with angina. Which of the following would the nurse include when teaching a client how to administer this drug? a) "Apply the medication to your upper chest area." b) "Place the medication under your tongue." c) "Swallow the medication with a sip of water." d) "Tuck the medication into the inside of your cheek."
"Place the medication under your tongue." Correct Explanation: The nurse should tell the client to keep the medication below the tongue to ensure the sublingual route of administration. The buccal route of administration requires the medication to be kept in the side of the mouth. Oral medications are swallowed; patients should not swallow sublingual tablets. Topical medications are applied to the skin
Heart Failure
A syndrome, not a disease Physiologic state in which the heart can not pump enough blood to meet the metabolic needs of the body 02 supply doesn't meet demands Heart fails to do its job Chronic, progressive
Interventions
ACE-inhibitors beta-blockers aldosterone recerptor blockers Improve symptoms, increase longevity, and slow progression of HF Diuretics (one of the most important) - symptom relief only
Causes of HF #1
Abnormal loading Preload overstretched rubber band Too stretched, too overfilled Hypervolemia Fluid bolus
Causes of HF #2
Abnormal muscle function Impairment of muscle's contractile force MI, CAD
Eye Trauma
Abrasions Penetrating object Chemical burn
Compensation
Activation of the Sympathetic Nervous System (SNS) Increased HR and increased contractility and peripheral vasoconstriction. When kidneys have decreased perfusion, the renin-angiotensin-aldosterone system (RAAS) is activated. More vasoconstriction More Na and water are absorbed
Nursing Care- Acute
Assessment VS Q1 hour (more or less) Pulse pressure: the narrower, the greater the afterload, so you can assess if therapy working Continue to give vasodilators when SBP is in 90's Cardiac rhythm - tachycardia increases the workload of the heart, dysrhythmias reduce myocardial contractility. Report dysrhythmias Heart sounds Q2 hours S3 noncompliant ventricle S4 weak, over distended ventricle
Teaching plan
Bleeding Diet Vitamin K rich foods kale, collards, spinach mustard greens, chard, turnips, brussel sprouts, broccoli, parsley, lettuce, endive, cabbage, spinach noodles Safety
Diagnostic findings
CXR may be normal, may have cardiomegaly Serum electrolytes BUN and creatinine Liver function tests BNP brain natriuretic peptide - ID patients with heart failure
Heart performance
Cardiac Output depends on 4 factors 1 preload 2 afterload 3 contractility 4 heart rate
What order would be questioned for DVT Up with assistance Chair QID Cool compresses to affected leg Pneumatic Compression device Egg Crate Mattress Temp 99.5 call HCP Percocet Guaiac stool
Chair QID Walking ok, avoid long periods of sitting or standing Apply cool compresses to affected leg QID. Warm compresses should be applied
Lovenox
Check platelets . Needs to be >100,000 Antidote: protamine sulfate SQ alternate between left and right anterolateral and left and right posterolateral abdominal wall Do not aspirate or massage
DVT prevention
Different form of BC Steps to help prevent DVT for long distance travelers: Getting up occasionally and walking around. Exercising calf muscles and stretching legs while sitting: Raising and lowering heels while keeping toes on the floor. Raising and lowering toes while keeping heels on the floor. Tightening and releasing leg muscles. Selecting an aisle seat when possible.
Other anticoagulants
Direct factor Xa inhibitors Rivaroxaban (XARELTO) (oral) no antidote Direct thrombin inhibitors (Pradaxa) Praxbind Indirect factor Xa inhibitor Fondaparinux (ARIXTRA) no antidote
Pulmonary embolus manifestations
Dyspnea, SOB, chest pain, anxiety, cough, tachycardia, tachypnea, crackles, low grade fever
Diagnostic findings
Echocardiogram One of the most useful tests Estimates ventricular function Shows abnormal chamber size, valve deformities ♥ normal ejection fraction EF (the percent of blood emptied form the ventricle during diastole) is 50-65 (70)% < 40 in heart failure
Patient assessment
Functional ability Describe activity level (can he perform ADL's) Medications - Ask specific questions: timing, doses, response to diuretics, use of OTC meds Diet - eating habits, including sodium and fluid intake. Low fat or low sodium diet? Smoking and substance abuse - smoke, drink, use recreational drugs? Physical assessment - VS sitting and standing), height, weight, jugular vein distention, hepatomegaly, pulmonary crackles, peripheral edema
Heparin bolus
Give over a minute High alert, double check order, dose, patient, IV pump settings Alternate fondaparinux sodium (Atrixa)
The Core he Measures consist of:
Heart failure core measure 1 - Discharge instructions (inclusion of all of the following) ◦Discharge medications ◦Activity level ◦What to do if symptoms worsen ◦Follow-up appointment ◦Weight monitoring Heart failure core measure 2 - Left ventricular ejection fraction assessment Heart failure core measure 3 - Prescription of ACEI or ARB at discharge to eligible patients (or documentation of contraindication) Heart failure core measure 4 - Smoking cessation
Circumference
Inflammatory response causes vasodilation and increases vessel permeability, causing edema Baseline to assess treatment effectiveness Independent nursing intervention
Cardiac catheterization
Left Requires dye Dangerous with impaired renal function Right measure pressures
Causes of HF #3
Limited ventricular filling External compression of the heart Cardiac tamponade (fluid or blood in pericardial sac)
Drugs to avoid
NSAIDS - increase chance of renal dysfunction (decrease renal blood flow), cause fluid retention Glitazones can cause fluid retention Corticosteroids Calcium channel blockers
Medical management
Prevention is first level. Control potential causes #1 goal is to improve pump function #2 goal is to reduce myocardial workload
Treatment
Restore balance Cardiac output = heart rate x stroke volume Assessments and care are ongoing.
left sided failure
S3 Apex, bell Chest pain and S3 heart sound S3 indicates a noncompliant, stiff ventricle, vibrates Kentucky (y=3rd) Murmur Leaky valve S4 Apex, bell Atrial dysrhythmias and S4 heart sound Due to distended LA. Tennessee (Ten=4th sound)
Nursing care- chronic
Schedule rest periods Diuretic scheduling to avoid nocturia Encourage physical and psychological rest Encourage small meals with rest periods (large meals increase the workload of the heart) Daily weights at the same time, before meals, same amount of clothing Had pneumonia vaccine? Yearly flu vaccine Provide emotional support, support groups
A client with a recent diagnosis of deep vein thrombosis (DVT) has sudden onset of shortness of breath and chest pain that increases with a deep breath. The nurse should first: a) perform range of motion exercises in the involved leg. b) administer morphine sulfate 2 mg IV. c) call the health care provider (HCP). d) assess the oxygen saturation.
assess the oxygen saturation. Correct Explanation: A client with deep vein thrombosis (DVT) is at high risk for a pulmonary embolism from an embolus traveling to the lung. Sudden onset of symptoms and worsening of chest pain with a deep breath suggest a pulmonary embolism. The nurse assesses the client and obtains oxygen saturation levels prior to calling the HCP and administering morphine. Range of motion is a preventive measure for DVT and is not appropriate that this time
Diuretics
Loop diuretics - (Lasix) furosemide Diuresis is the effect, not a side effect (Zaroxolyn) metolazone - thiazide-like diuretic- also used Reduces preload (VOLUME) Reduces BP Check potassium first Check kidney function (sparing) and BP(wasting)
Risk factors for DVT
Oral contraceptive Combination oral contraceptive and 35 with smoking Immobile (trip- car or plane)
Endovascular management
Transvenous embolectomy Thrombolectomy RARE Vena cava catheter (retrievable)
ACE inhibitors- End in "pril"
Vasodilation Excretion of Na and H2O decrease after load and preload, lowers BP Most common side effect is cough. May be substituted with angiotensin receptor blocker Angioedema is side effect Check BP first
Surgical management
Ventricular assist devise Assumes portion of the workload of the heart Used externally by those awaiting transplant May be implanted as alternative to transplant for those who don't qualify when on continuous inotropic therapy Transplant- Gold standard
left sided failure backward symptoms
back up to LA to pulmonary vasculature:
left sided failure -forward symptoms
decreased cardiac output decreased cerebral perfusion: hypoxic tissues: decreased renal blood flow:
Following a total joint replacement, which complication has the greatest likelihood of occurring? a) displacement of the new joint b) deep vein thrombosis (DVT) c) wound evisceration d) polyuria
deep vein thrombosis (DVT) Correct Explanation: DVT is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a deep vein thrombosis or pulmonary embolism are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the health care provider (HCP) for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Displacement of the new joint is unlikely. Wound evisceration is more likely to occur after abdominal surgeries.
right sided failure backward symptoms
neck veins? liver? GI tract ? peripheral vascular beds? ambulatory person recumbent person generalized?
Oral anticoagulants
rivaroxaban (Xarelto) po daily dabigatrin (Padraxa) po BID Reduced dose with renal impairment fondaparinux sodium (Atrixa) for DVT Thrombolytic therapy alteplase
nestritide (Natracor)
synthetic BNP- promotes diuresis, vasodilatation
Orders: Heparin and Coumadin PT, INR now and 4 hours after heparin initiated Heparin 5000 units bolus 1000 UNITS/HOUR cOUMADIN 5 MG po daily
Nurse would call doctor because PTT is not ordered
Assessment
O2 sats Lung sounds Q2 hours Baseline and daily weight Accurate I & O Level of consciousness Peripheral pulses Edema, jugular vein distention O2 as ordered DB and C or suction. Turn Q2 hours Positioning (HOB ↑) Assess skin Warm environment (promotes vasodilation) Space nursing activities to decrease fatigue
Which of the following are risk factors related to venous stasis for DVT and pulmonary embolism? a) Obesity b) Trauma c) Pacing wires d) Surgery
Obesity Correct Explanation: Obesity is a risk factor for DVT and PE related to venous stasis. Trauma, pacing wires, and surgery are related to endothelial damage as a risk factor for DCAT and PE.
Medical management
Oxygen 40 - 70 % May require intubation and ventilator CPAP - slows ventricular remodeling (mechanism unknown), improves CO and ejection fraction. - also relieves sleep apnea (common in patients with HF) Positioning - hi Fowlers Sit on side of bed with arms over bedside table Legs in dependent position
Labs
Partial thromboplastin time (PTT): 60-70 seconds Activated partial thromboplastin time (APTT): 30-40 seconds The heparin dose is manipulated so that the PTT or APTT result is about 1.5 to 2.5 times the normal value.
Aldosterone blockers
Aldosterone increases sodium and water levels in the blood. Blocking its action will reduce the fluid overload spironolactone (Aldactone) Monitor renal function
Coumadin
Another anticoagulant sent home on Takes 3-5 days to become therapeutic INR: 2-3 PT: 1 ½ - 2 times normal
Which of the following terms refers to chest pain brought on by physical or emotional stress and relieved by rest or medication? a) Angina pectoris b) Ischemia c) Atheroma d) Atherosclerosis
Angina pectoris Correct Explanation: Angina pectoris is a symptom of myocardial ischemia. Atherosclerosis is an abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumens. Atheromas are fibrous caps composed of smooth muscle cells that form over lipid deposits within arterial vessels. Ischemia is insufficient tissue oxygenation and may occur in any part of the body
Which of the following nursing actions would help prevent deep vein thrombosis in a patient who has had an orthopedic surgery? a) Apply cold packs b) Instruct about using patient-controlled analgesia, if prescribed c) Apply antiembolism stockings d) Instruct about exercise, as prescribed
Apply antiembolism stockings Correct Explanation: Applying antiembolism stockings helps prevent deep vein thrombosis (DVT) in a patient who is immobilized due to orthopedic surgery. Regular administration of analgesics controls and prevents escalation of pain while ROM exercises help in maintaining muscle strength and tone and prevent contractions. On the other hand, cold packs are applied to help reduce swelling and it does not prevent deep vein thrombosis.
The nurse understands it is important to promote adequate tissue perfusion following cardiac surgery. Which of the following measures should the nurse complete to prevent deep venous thrombosis (DVT) and possible pulmonary embolism (PE) development? Select all that apply. a) Place pillows in the popliteal space. b) Encourage the crossing of the legs. c) Initiate passive exercises. d) Apply antiembolism stockings. e) Avoid elevating the knees on the bed.
Apply antiembolism stockings. • Avoid elevating the knees on the bed. • Initiate passive exercises. Preventative measures utilized to prevent venous stasis include: Application of sequential pneumatic compression wraps or antiembolic stockings; discouraging leg crossing; avoiding elevating the knees on the bed; omitting pillows in the popliteal space; beginning passive exercises followed by active exercises to promote circulation and prevent venous stasis.
HF EBP Core Measures Must be documented
Assessment of LV function ACE or ARB given Discharge teaching (JC CMS dropped January, 2014) Diet Meds Weight monitoring Follow up appt S/S worsening HF Smoking cessation
Delegate
Assist with ambulation (CNA) Apply cool warm compresses to affected leg QID LPN Pneumatic compression device CNA Egg crate mattress CNA Percocet 5/325 (oxycodone 5mg / acetaminophen 325 mg) 2 tablets every 6 hours PRN pain LPN Guaiac stool (credentialed)
Which of the following signs and symptoms would the nurse expect in a client with angina? Select all that apply. a) General muscle aching b) Slowed respiratory rate c) Jaw pain d) Bradycardia e) Chest pressure f) Chest tightness
Chest pressure • Jaw pain • Chest tightness Correct Explanation: Chest tightness, chest pressure, and jaw pain are all symptoms of angina. General muscle aching is not associated with angina. Respirations and heart rate typically increase, not decrease, with anginal attacks
digoxin (Lanoxin)
Given IV over at least 5 minutes used when patient still has symptoms despite treatment with ACE inhibitors, beta blocker, aldosterone blockers and diuretics + inotropic agent Increases contractility Decreases HR Treats atrial fibrillation - most common dysrhythmia with HF Monitor for dig toxicity, especially in the elderly Therapeutic level is 0.5 to 2.0 ng/ml Toxicity occurs in 1 in 5 patients Check Apical HR for 1 minute Low K+ at greater risk for toxicity
intra-aortic balloon pump (IABP)
Helps the heart muscle receive more oxygen and therefore work better at pumping blood and oxygen to the rest of the body Pushes blood forward into the body (vessels) and backward into the coronary arteries
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time? a) Ineffective peripheral tissue perfusion related to venous congestion b) Excess fluid volume related to peripheral vascular disease c) Impaired gas exchange related to increased blood flow d) Risk for injury related to edema
Ineffective peripheral tissue perfusion related to venous congestion Correct Explanation: 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.
The nurse is caring for a 44-year-old female client with a diagnosis of deep vein thrombosis (DVT) in her left lower leg. What assessment method should the nurse perform first? a) Palpate the popliteal and posterior tibial pulses of both legs. b) Inspect the left lower leg for areas of redness. c) Assess for pain by deeply palpating the left leg. d) Lightly palpate the left leg, assessing for edema.
Inspect the left lower leg for areas of redness. Explanation: Inspection is the initial step in peripheral vascular assessment of the extremities. Palpating the popliteal and posterior tibial pulses in both legs would be the second assessment step to take. Palpation of the leg with DVT to assess for edema and pain is contraindicated because of the risk of dislodging the blood clot and the formation of a pulmonary embolism
Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first? a) Massage the area of discomfort before applying the compression devices. b) Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings. c) Leave the compression devices off, and report the assessment findings to the oncoming shift. d) Offer analgesics as ordered, and apply the compression devices.
Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings. Correct Explanation: Localized pain, tenderness, redness, and warmth may be symptoms of deep vein thrombosis (DVT), information the nurse should report to the HCP; the compression devices should not be applied until further evaluation is completed as intermittent compression may dislodge a thrombus. Massaging the area may dislodge a thrombus and is not recommended. The nurse may offer PRN analgesics if the client requires pain management, but the compression devices should not be applied until further evaluation is completed. Diagnosis and treatment of DVT should be discussed with the HCP as soon as possible; the nurse should not wait until the next shift to report findings as a DVT can become life threatening if a thrombus travels to the lung and becomes a pulmonary embolus
Beta-blockers
Nonselective are contraindicated in patients with COPD Started in low doses carvedilol (Coreg) nonselective Decrease HR and contractility Decreases workload Pt- may feel tired and fatigued initially May have difficulty with erection Nurse- Check HR and BP
Diabetic Peripheral Neuropathy
Numbness or reduced ability to feel pain or temperature changes A tingling or burning sensation Sharp pains or cramps Increased sensitivity to touch — for some people, even the weight of a bed sheet can be agonizing Muscle weakness Loss of reflexes, especially in the ankle Loss of balance and coordination Serious foot problems, such as ulcers, infections, deformities, and bone and joint pain
Which of these measures would the nurse implement for prevention of deep vein thrombosis (DVT) in a postoperative client? a) Placing graduated compression stockings on the client. b) Encouraging the client to elevate the head of bed. c) Teaching the client about the use of incentive spirometer. d) Elevating bilateral legs when lying in the bed.
Placing graduated compression stockings on the client. Correct Explanation: Use of graduated compression stockings and/or pneumatic compression devices on the client will help with prevention of DVT, which is a risk for clients after surgery. Elevating the client?s legs will passively improve venous return but not prevent DVT if a client is not up and walking to more actively promote venous return. Elevating the head of bed and using the incentive spirometer help prevent postoperative complications of atelectasis or pneumonia
Patient teaching for HF
Plan your day. pace yourself, take time to rest between tasks Watch your weight. Weigh yourself at the same time every day. If you have an increase of 2 pounds in one day, call doctor. Exercise a little every day. Walk 10 minutes/day. Manage stress Don't eat too much salt. The more salt you eat, the more water you retain. Don't add salt to cook or on table. Avoid salt shaker. Read labels. Sodium = salt. Use herbs and spices instead of salt. Limit fluid intake. Avoid caffeine Watch what you eat. Eat foods low in saturated fats. Avoid oils that are solid at room temperature. Don't fry food. Loose weight if you're too heavy. If hypertensive, get DASH diet at gov/health/public/heart/hbp/dash/new_dash.pdf (check with HCP) If you smoke, stop (support group, patch, gum) Limit your alcohol intake Notify HCP if you feel more tired than usual, SOB, dizzy, or your heart beats faster than normal See HCP regularly -make follow up appointment for client Medications: use of, SE
Symptoms of HF
Related to the forward flow or backward flow of blood in the heart Forward - less blood being pumped out Backward - extra fluid remains in the vasculature
TEDs or a Pneumatic compression device (SCD's)
Remove them for 30 to 60 min daily Assess underlying tissue If ambulatory, remove Teds at night and reapply before arising
Digoxin toxicity
S/S toxicity GI often 1st sign: anorexia/N/V/D EYES : yellow vision, halo, photophobia, scotoma, blurring, flickering flashes of light CNS : H/A, fatigue, restlessness, hallucinations, seizures, lethargy CV : bradycardia, bigemeny, trigemeny If hypokalemic, more at risk for toxicity
Angiotensin receptor blockers
Similar to ACE inhibitors - valsartan (Diovan) decrease after load and preload, decrease BP Angioedema is side effect check BP first
A nurse is providing education about hypertension to a community group. One client reports that his doctor has diagnosed him with hypertension, but that he feels just fine. He asks, "What would happen if I did not treat my hypertension?" Which of the following are possible consequences of untreated hypertension? Choose all that apply. a) Tension pneumothorax b) Pancreatitis c) Coronary artery disease d) Stroke e) Myocardial infarction
Stroke • Myocardial infarction • Coronary artery disease Correct Explanation: People with hypertension may remain asymptomatic for many years. When specific signs and symptoms appear, however, they usually indicate vascular damage. Coronary artery disease with angina and myocardial infarction are common consequences of hypertension. Cerebrovascular involvement may lead to a stroke. Tension pneumothorax and pancreatitis are not directly related to hypertension
BNP
Substance secreted from the ventricles when heart failure present When ventricle stretched, BNP is released A compensatory mechanism Increases H2O & Na loss Causes vasodilation < 100 - no heart failure 100 - 300 suggestive of HF >300 - mild HF >600- moderate HF >900 - severe HF
A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following? a) Tense and relax muscles in lower extremities. b) Consume majority of fluid intake prior to bed. c) Begin estrogen replacement. d) Wear tight-fitting clothing.
Tense and relax muscles in lower extremities. Correct Explanation: Clients are encouraged to perform passive or active exercises, as tolerated, to prevent the development of a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism
Compensation leads to
Ventricular remodeling (change in ventricle's shape and size) Ventricular hypertrophy Ineffective pumping When compensatory mechanisms fail, get signs and symptoms of heart failure Left sided symptoms Right sided symptoms Backward vs. forward
A client is being treated for deep vein thrombosis (DVT) in the left femoral artery. The health care provider (HCP) has prescribed 60 mg of enoxaparin subcutaneously. Before administering the drug, the nurse checks the client's laboratory results. (See image.) Based on these results, what should the nurse do? Platelet 50, 000 PT 12.5 INR 2 a) Withhold the dose of the medication and contact the health care provider (HCP). b) Contact the pharmacist for a lower dose of the medication. c) Administer the medication as prescribed. d) Assess the client for signs of bruising on the extremities.
Withhold the dose of the medication and contact the health care provider (HCP). Correct Explanation: Based on the laboratory findings, prothrombin time and INR are at acceptable anticoagulation levels for the treatment of DVT. However, the platelets are below the acceptable level. Clients taking enoxaparin are at risk for thrombocytopenia. Because of the low platelet level, the nurse should withhold the enoxaparin and contact the HCP. The nurse should not administer the drug until the HCP has been contacted. The HCP, not the pharmacist, will make the decision about the dose of the enoxaparin. The decision about administering the drug will be based on laboratory results, not evidence of bruising or bleeding
Patients who are taking beta-adrenergic blocking agents should be cautioned not to stop taking their medications abruptly because which of the following may occur? a) Worsening angina b) Formation of blood clots c) Internal bleeding d) Thrombocytopenia
Worsening angina Correct Explanation: Patients taking beta blockers are cautioned not to stop taking them abruptly because angina may worsen and myocardial infarction may develop. Beta blockers do not cause the formation of blood clots, internal bleeding, or thrombocytopenia
Which symptom should the nurse teach the client with unstable angina to report immediately to the health care provider (HCP)? a) pain during an argument b) a change in the pattern of the chest pain c) pain during sexual activity d) pain during or after a physical activity
a change in the pattern of the chest pain Correct Explanation: The client should report a change in the pattern of chest pain. It may indicate increasing severity of coronary artery disease. Pain occurring during stress or sexual activity would not be unexpected, and the client may be instructed to take nitroglycerin to prevent this pain. Pain during or after an activity such as lawn mowing also would not be unexpected; the client may be instructed to take nitroglycerin to prevent this pain or may be restricted from doing such activities
A client newly diagnosed with deep vein thrombosis (DVT) of the left lower left extremity is on bed rest. The nurse should instruct the unlicensed assistive personnel (UAP) providing routine morning care for the client to: a) massage the leg and foot with lotion. b) check that the legs are in a low, dependent position. c) ensure that the lower extremity is elevated. d) place one or two pillows under the client's left knee.
ensure that the lower extremity is elevated. Correct Explanation: DVT causes edema; therefore, the UAP should elevate the extremity to promote venous return. Dependent positioning is appropriate for a client with arterial insufficiency. Placing a pillow under the knee would position the foot in a low position, and pressure behind the knee may obstruct venous flow. Massaging the extremity could dislodge the thrombus
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: a) left calf circumference 1" (2.5 cm) larger than the right. b) pallor and coolness of the left foot with decreased sensation. c) a decrease in the left dorsalis pedis and posterior tibial pulses. d) loss of hair on the lower portion of the left leg and foot.
left calf circumference 1" (2.5 cm) larger than the right. Correct Explanation: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased sensation, decreased pulses, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT
How should the nurse instruct the client with unstable angina to use sublingual nitroglycerin tablets when chest pain occurs? "Sit down and then: a) take one tablet. If pain persists after 5 minutes call 911." b) take one tablet every 2 to 5 minutes until the pain stops." c) take one tablet and rest for 15 minutes. Call the physician if pain persists after 15 minutes." d) take one tablet, then if the pain persists take 2 additional tablets in 5 minutes. Call the physician if pain persists after 15 minutes."
take one tablet. If pain persists after 5 minutes call 911." Correct Explanation: The nurse should instruct the client that correct protocol for using sublingual nitroglycerin involves immediate administration when chest pain occurs. Sublingual nitroglycerin appears in the bloodstream within 2 to 3 minutes and is metabolized within about 10 minutes. The client should sit down and place the tablet under the tongue. If the chest pain is not relieved within 5 minutes, then the client should call 911. Although some physicians may recommend taking a second or third tablet spaced 5 minutes apart and then calling for emergency assistance, it is not appropriate to take 2 tablets at once. Nitroglycerin acts within 2 to 3 minutes and the client should not wait 15 minutes to take further action. The client should call 911 to obtain emergency help rather than calling the physician
As an initial step in treating a client with angina, the health care provider (HCP) prescribes nitroglycerin tablets, 0.3 mg given sublingually. This drug's principal effects are produced by: a) improved conductivity in the myocardium. b) antispasmodic effects on the pericardium. c) causing an increased myocardial oxygen demand. d) vasodilation of peripheral vasculature.
vasodilation of peripheral vasculature. Correct Explanation: Nitroglycerin produces peripheral vasodilation, which reduces myocardial oxygen consumption and demand. Vasodilation in coronary arteries and collateral vessels may also increase blood flow to the ischemic areas of the heart. Nitroglycerin decreases myocardial oxygen demand. Nitroglycerin does not have an effect on pericardial spasticity or conductivity in the myocardium
