Theory Exam #2 - Perfusion
A client who denies having any health problems reports taking gemfibrozil. Which question does the nurse ask to determine the reason for the medication? "Have you ever experienced an irregular heartbeat?" "Have you been told that you have high blood pressure?" "Have you been told that your cholesterol is too high?" "Have you been instructed to check your blood sugar?"
"Have you been told that your cholesterol is too high?"
A client diagnosed with primary hypertension asks the nurse about risk factors for this condition. The nurse confirms the client's understanding of teaching with what response? "Taking too much ibuprofen increases my risk." "Lack of exercise makes hypertension more likely." "I may be eating too much dietary sodium." "Obesity often leads to primary hypertension." "My kidney disease worsened my blood pressure."
"Obesity often leads to primary hypertension" Nephrotoxic drugs and chronic kidney disease are common causes of secondary hypertension
unstable angina pectoris
"Pre-infarction" Occurs at rest and more frequently Not relieved by rest and NTG
Clinical manifestations of hypertension
"Silent killer" Fatigue Dizziness Palpitations Angina Dyspnea Headache
stable angina pectoris
"predictable" occurs with exertion
diagnostic and lab tests to determine an individual's perfusion status
- Lipid panel Triglycerides Total cholesterol LDL HDL - Cardiac enzymes myoglobin CK-MB Troponin I Troponin T WBC - Kidney function tests BUN Creatinine GFR
Describe how to manage a patient with CAD
- Lipid-lowering medications (statins) - Heart-healthy diet (DASH diet) - Increased physical activity - Smoking cessation - Hypertension management - Diabetes management
Identify priorities for management of patients with wounds
- Poor perfusion can lead to new wounds and/or poor wound healing - RN role is to educate and intervene to improve perfusion - Perfusion issues such as HTN, CAD, DM and blood stasis can contribute to wound formation and poor wound healing
Describe the mechanism of action for classes of medications that affect perfusion
- Statins: HMG-CoA reductase inhibitors; lipid-lowering meds - Fibrates: decrease triglycerides - Bile acid sequestrates: lower LDL by blocking bile acid in stomach from being absorbed in the blood - Omega 3: reduce plasma triglyceride levels - Cholesterol absorption inhibitor: reduces overall delivery of cholesterol to the liver, promoting synthesis of LDL receptors - Anti-platelets: reduce change of MI
assessment methods used to assess perfusion across the lifespan (gerontological concerns)
- Total body water decreases to 45% —> higher risk for dehydration - Heart contractility lowers —> pulm HTN & pulm edema - sedentary lifestyle - takes longer to heal from illnesses and for wounds to heal General appearance skin and extremities Level of consciousness and orientation chest pain/discomfort Presence of varicose veins unusual fatigue syncope capillary refill peripheral pulses
S/Sx of decreased perfusion
- chest pain - unusual fatigue - weakness - shortness of breath - edema - syncope - muscle cramps - tingling and numbness - pallor - diaphoresis - increased capillary refill time - no peripheral pulses - Decreased LOC -
nursing interventions to promote perfusion
- smoking cessation - DASH diet - increased activity - weight loss - management of HTN - management of DM - Stress management
Serum creatinine levels
0.6-1.2 mg/dL "above 13 is bad for __________"
The nurse explains risk factors for heart failure (HF) to a client. Which factors are considered extrinsic factors? Select all that apply: Diet and weight Pregnancy Coronary artery disease Hypertension Dysrhythmias
Diet and weight Hypertension Coronary artery disease
What is an example of a calcium channel blocker?
Diltiazem
venous thromboembolism symptoms
Edema, warmth over affected area, pain in foot, cyanosis, aching, and engorgement of superficial veins
When someone presents with a hypertensive emergency, by what percentage do you want to lower their BP?
20-25%; don't let MAP drop below 60
Myoglobin levels
25 - 75 ng/ml
BUN levels
7-20 mg/dL
GFR levels
90-120 mL/min
Troponin I levels
< 0.03 ng/mL
Troponin T levels
< 0.1 ng/mL
LDL levels
<100 mg/dL
Triglyceride levels
<150 mg/dL
Total cholesterol levels
<200 mg/dL
CK-MB levels
<5 ng/mL
HDL levels
>40 mg/dL
At discharge, a client with heart failure due to systolic dysfunction is prescribed lisinopril, an angiotensin-converting enzyme (ACE) inhibitor. Which teaching does the nurse include for this medication? Select All that Apply: A "It relaxes blood vessels, which lowers blood pressure." B "It is safe to take during pregnancy." C "This drug may contribute to hyperkalemia." D "Report a cough immediately." E "This drug can make it easier to exercise."
A, C & E
The laboratory results of the client with a history of exertional angina reveal cholesterol of 180 mg/dL, LDL of 175 mg/dL, HDL of 30 mg/dL, and troponin of 0.016 ng/mL. The nurse performs which interventions based on these results? Select all that apply: Give the client sublingual nitroglycerin. Teach the client about a heart-healthy diet. Assess the client's exposure to cigarette smoke. Administer the client's scheduled atorvastatin. Provide the client oxygen via nasal canula.
Administer the client's scheduled atorvastatin
A nurse plans care for a client with acute decompensated heart failure. Which interventions assist the nurse in improving the client's cardiac output? Select all that apply: Treat elevated temperature quickly. Assess fluid intake and output. Provide a restful environment. Assist with breathing exercises when dyspnea occurs. Place patient in upright position. All of the above
All of the above
The healthcare provider (HCP) prescribes amlodipine for a client with hypertension. The nurse teaches the client about which reaction to amlodipine? Select all that apply Flushing Shortness of breath Edema Palpitations Constipation All of the above
All of the above
A client has newly been prescribed enalapril for hypertension. The nurse withholds the enalapril and notifies the health care provider for which findings? Select All that Apply: An orthostatic drop of 20 mm HG in diastolic BP Serum potassium level of 3.2 mmol/L (mEq/L) A persistent, mild, nonproductive cough Swelling of the lips without presence of a rash An increase in urine output in the last 24 hours
An orthostatic drop of 20 mm Hg in diastolic BP Swelling of the lips without presence of a rash
A client is admitted to the hospital with severe headache, tinnitus, and a BP of 202/122 mmHg after running out of medications. After being treated for hypertensive emergency, which approach by the nurse at discharge is best? Instruct the client's spouse to manage medication. Instruct the client to count the number of pills left at home. Assess for barriers to taking the prescribed medication. Tell the client to purchase a medication organizer.
Assess for barriers to taking the prescribed medication.
When caring for a client with mitral valve stenosis (L sided heart failure), the nurse monitors for what symptoms associated with this condition? Select all that apply: Blood-tinged sputum Fatigue Respiratory alkalosis Edema in the legs Hypoventilation
Blood-tinged sputum Fatigue Edema in legs Hypoventilation
What is another vasodilator besides nitroglycerin?
Clonidine
A client with no previous cardiac history reports central chest pain. Which data does the nurse gather prior to administering the immediate prescription for sublingual nitroglycerin? Select all that apply: Time of last oral intake Current blood pressure Oxygen saturation Medications in past 24 hours Current heart rate
Current blood pressure Current heart rate
Ideal positioning for a pt with peripheral arterial disease
Dangle arteries
Peripheral vascular disease
Deoxygenated blood can't get back to the heart leading to pooling of oxygenated blood in the extremities
Peripheral artery disease
oxygenated blood can't get to the distal extremities (hands and feet) leading to ischemia and necrosis
adverse side effects of ACE inhibitors (like Lisinopril)
persistent non-productive cough angioedema hypotension hyperkalemia liver necrosis
Clinical manifestations of peripheral venous disease
pooling of oxygenated blood in the extremities; DVT or pulmonary embolism may result
After load
pressure the heart faces as it pumps forward
Symptoms related to organ damage from hypertension
retinal and other vision changes renal damage myocardial infarction cardiac hypertrophy stroke
Causes of peripheral arterial and peripheral vascular disease
smoking diabetes high cholesterol hypertension
Modifiable risk factors for decreased perfusion
smoking poor diet sedentary lifestyle DM 2 Obesity Stress HTN dyslipidemia
coronary artery bypass graft
surgical technique to bring a new blood supply to heart muscle by detouring around blocked arteries
How would you educate a patient to take nitroglycerin?
take at onset of chest pain up to 3x; one every 5 minutes if symptoms persist after 3rd dose, call 911
Define perfusion
the flow of blood trough arteries and capillaries delivering nutrients and oxygen to the cells
Stages of wound healing
vascular response (clot) inflammatory (neutrophils) proliferation (granulation) remodeling/maturation
nitroglycerin MOA
vasodilation of arteries and veins, vasodilation of veins decreases preload to get blood flowing again
pathology of coronary artery disease
vessel injury inflammation endothelium changes fatty streaks atheroma (plaque formation) vessel obstruction or low blood flow acute coronary syndrome angina and/or MI
Preload
Filling of the left ventricle
A client with coronary artery disease and hyperlipidemia takes simvastatin to manage cholesterol. The nurse asks the client about the presence of which common side effect? Select all that apply: Gastric upset Peripheral edema Headache Rash Muscle pain
Gastric upset Headache Muscle pain
A client with preeclampsia calls the obstetrics triage unit at night and reports a severe headache with blurred vision. What instruction does the nurse give to this client? Take 650 mg acetaminophen and notify the provider in the morning. Have a family member drive her to the hospital immediately for evaluation. Eat a light snack and lie on her left side for two hours and notify if no relief. Report to a local pharmacy and have her blood pressure evaluated.
Have a family member drive her to the hospital immediately for evaluation.
The nurse teaches the client about symptoms for hypertension. Additional education is required when the client states which symptom indicates elevated blood pressure? Leg swelling Headaches Blurred vision Head fullness
Head fullness
Clinical manifestations of peripheral arterial disease
Ischemia and necrosis of the extremities; hypo/hypertension
What does CK-MB indicate?
It is an enzyme released in the bloodstream when the heart, muscles, or brain becomes damaged
A client requests cholesterol testing. Which lab does the nurse identify as placing the client at risk for coronary artery disease (CAD)? LDL 120 mg/dL Triglycerides 120 mg/dL HDL 24 mg/dL Total cholesterol 180 mg/dL
LDL 120 mg/dL (ideal values < 100) HDL 24 mg/dL (ideal values > 40)
What is an example of an ARB?
Losartan
The nurse reviews the health record of a client with coronary artery disease (CAD). When assessing client risk, what elevated lab value is the most likely to cause the progression of CAD? Blood glucose High-density lipoproteins Microalbuminuria Low-density lipoproteins
Low-density lipoproteins
Non-modifiable risk factors for decreased perfusion
Male gender, African American, over 50 years old
What is an example of a beta blocker?
Metoprolol
A client diagnosed with type 2 diabetes, hypertension, and heart failure is prescribed hydrochlorothiazide. The nurse instructs the client to take what actions while on this medication? Select All that Apply: Notify the healthcare provider if heart rate is under 65 beats/min. Increase daily intake of foods high in calcium, like yogurt. Monitor weight each morning in the same clothes after voiding. Increase the frequency of blood glucose monitoring. Increase daily intake of foods high in potassium, like avocados.
Monitor weight each morning in the same clothes after voiding Increase daily intake of foods high in potassium, like avocados
What does high myoglobin indicate?
Muscle damage (possible heart damage)
Low levels of _______________ are good for ruling out MI
Myoglobin
Reperfusion procedures
PCI - percutaneous coronary intervention CABG - coronary artery bypass graft
Describe how to manage a patient with HTN
Patient education! - limit sodium intake - limit alcohol intake - smoking cessation - increase daily exercise - teach pt how to measure BP and keep a record Medications - Diuretics (Hydrochlorothiazide) - ACE inhibitors (Lisinopril) - Beta blockers (Metoprolol) - Ca+ channel blockers (Diltiazem, amlodipine) - Cardiac glycoside (Digoxin) - Statins (atorvastatin) - Anticoagulants (Heparin) - Vasodilators (nitroglycerin) - ARBs (Losartan)
A client is prescribed diltiazem. The nurse assesses which parameter related to the effects of diltiazem? Select all that apply Peripheral edema Heart rhythm Blood pressure Temperature Calcium level
Peripheral edema Heart rhythm (can cause arrhythmias) Blood pressure (can cause hypotension)
A client with hypertension and asthma takes multiple oral medications. The nurse recognizes that which medication places the client at risk for bronchospasm? Amlodipine 5 mg Propranolol 80 mg Lisinopril 5 mg Spironolactone 25 mg
Propranolol 80 mg
A nurse assesses a client with chronic hypertension. What signs does the nurse identify as a chronic complication of hypertension? Select All that Apply: Vomiting Protein in urine Dyspnea at rest Leg pain when climbing stairs Weakness
Protein in urine Dyspnea at rest Weakness Leg pain when climbing stairs
The nurse assesses a client with coronary artery disease who has been hospitalized for three days. The nurse notes moderate peripheral edema bilaterally and crackles in the lungs. What should the nurse do first? Teach the client about a sodium-restricted diet. Request an order for daily weights. Discuss diuretic options with the provider. Review the intake and output since admission.
Review the intake and output since admission
A client has been prescribed losartan. What does the nurse assess related to this medication? Serum creatinine level Last normal menstrual period Post-void residual urine Apical heart rate Serum potassium level
Serum creatinine level (can increase SCr)
assessment methods used to assess perfusion across the lifespan (pediatric concerns)
Things to look for: - poor feeding - poor weight gain - fatigue - increased WOB - presence of abnormally large heart - abnormally high or low HR - cyanosis - clubbing
describe the different surgical interventions used to treat poor perfusion
Transluminal Balloon-Ingiography stent placement atherectomy CABG
What key cardiac lab values are elevated within a few hours after an MI?
Up to 80% of patients with acute MI will have an elevated troponin level within 2-3 hours of emergency department (ED) arrival, versus 6-9 hours or more with CK-MB
Hypertensive urgency vs. emergency
Urgency: over 180 or 120 without end organ damage Emergency: with end organ damage
Define systemic circulation
a high pressure system moving blood from the left side of the heart through aorta to the brain and other organs (from core to the periphery) left side of the heart
Define pulmonary circulation
a low-pressure system; circulation from the right side of the heart to the lungs and back to the left side of the heart
Define coronary circulation
a network of vessels that supply the heart muscle; branches off the aorta; works during diastole of the heart; comprises from left coronary artery and right coronary artery
coronary atherosclerosis
abnormal accumulation of lipid deposits and fibrous tissue within arterial walls and lumen; underlying cause of coronary artery disease
adverse side effects of ARBs (like Losartan)
angioedema dizziness fatigue hyperkalemia muscle weakness
Coronary artery disease
atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle
Percutaneous coronary intervention
balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are put in place
adverse side effects of Beta blockers (like metoprolol)
bradycardia (hold if HR <60) orthostatic hypotension bronchospasm masks hypoglycemia
s/sx of angina
chest pain unusual fatigue weakness shortness of breath dizziness nausea vomiting
angina
chest pain caused by insufficient perfusion to the myocardial tissue; precursor to myocardial infarction
Venous thromboembolism manifestations
deep veins and superficial veins
primary hypertension
denotes high blood pressure from an unidentified cause; also called essential hypertension
surgical management for an aneurysm
dissection
ideal positioning for a pt with Peripheral venous disease
elevate veins; dangling, sitting/standing for long periods of time make symptoms worse
What is an example of a loop diuretic?
furosemide
adverse side effects of Calcium channel blockers (like diltiazem)
headache dizziness arrhythmias bradycardia constipation
Silent ischemia
heart blood flow is interrupted, but there is no pain involved
Cardiac output
heart rate x stroke volume
secondary hypertension
high blood pressure caused by the effects of another disease
During an assessment, the nurse learns that a client who denies any health problems has been taking cholestyramine for three years. For which health problem does the nurse create a care plan? Type 2 diabetes Hyperlipidemia Hypertension Atrial fibrillation
hyperlipidemia
adverse side effects of diuretics (like hydrochlorothiazide)
hypokalemia (decreased potassium) renal failure respiratory distress aplastic anemia hypotension (hold if SBP is <90)
Patient teaching to promote perfusion
importance of diet and exercise, smoking cessation, and management of HTN and DM
common conditions involved with Metabolic syndrome
includes at least three of the following: insulin resistance central obesity dyslipidemia (triglycerides <150, HDL < 40-50) blood pressure consistently > 130/85 high levels of CRP (C-reactive protein) high fibrinogen level
raynaud's disease
intermittent arterial vascular-occlusion, usually in the finger tips and toes
What is an example of an ACE inhibitor?
lisinopril
aneurysm
localized sac or dilation formed at a weak point in the wall of the artery
variant angina
manifestation occur mostly when lying down at night
Describe the scope of perfusion
normal perfusion ischemia - reduced blood flow; less oxygen to tissues infarct - tissue death necrosis - death of most or all cells in an organ or tissue