Care of Patients With Vascular Problems (Iggy ch. 36)
The nurse is teaching a client the 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."
"Eating foods like green beans won't interfere with my Coumadin therapy." - *Vitamin K is NOT found in foods such as green beans, so these foods will not interfere with the anticoagulant effects of Coumadin.* - Warfarin "thins" the blood, so the risk for cutting oneself and bleeding is very high with the use of a regular razor. *The client needs to use an electric razor.* - Clients must apply pressure to bleeding wounds and must seek medical assistance immediately. They do not need to discontinue warfarin therapy on their own. - *Blood in the urine of a client taking warfarin therapy is NOT a side effect. The client must notify the primary health care provider immediately if this occurs.*
When caring for a client with an abdominal aortic aneurysm (AAA), the nurse suspects dissection of the aneurysm when the client makes which statement? "I feel my heart beating in my abdominal area." "I just started to feel a tearing pain in my belly." "I have a headache. May I have some acetaminophen?" "I have had hoarseness for a few weeks."
"I just started to feel a tearing pain in my belly." - *Severe pain of sudden onset in the back or lower abdomen, which may radiate to the groin, buttocks, or legs, is indicative of impending rupture of AAA.* - The sensation of feeling the heartbeat in the abdomen is a *symptom of AAA* but not of dissection or rupture. - Headache may be benign or indicative of cerebral aneurysm or increased intracranial pressure. - *Hoarseness, shortness of breath, and difficulty swallowing may be symptoms of thoracic aortic aneurysm (TAA)*
The nurse is teaching a 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."
"If I wear pantyhose, I won't have to wear the stockings the hospital gives me." - *Wearing the graduated compression stockings is a type of prevention specific to the hospital setting. They are designed to prevent blood clots, unlike regular pantyhose.* - Discontinuation of birth control pills is a routine prevention for thromboembolism, but this prevention is not specific to the client's acute hospitalization. - Drinking a lot of water, where the quantity is not specified, may not be indicated for this client. Exercise is a prevention that can be done outside the hospital.
A 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 must be concerned if my foot turns blue." "I must report a fever or any drainage." "Warmness, redness, and swelling are expected."
"My leg might turn very white after the surgery." - A need for further postoperative teaching about arterial revascularization is needed when the client says that "my leg might turn very white after the surgery." *Pallor is one of the signs of decreased perfusion along with increased pain, poikilothermia (cold), paresthesia, pulselessness, and paralysis.* - The foot turning blue is a sign of poor perfusion. Fever or drainage would indicate an infection. - Warmness, redness, and swelling indicate reperfusion, which is a good sign.
Which teaching point does 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 ankles." "Walk to the point of leg pain, then rest, resuming when pain stops." "Apply a heating pad to the legs if they feel cold."
"Walk to the point of leg pain, then rest, resuming when pain stops." - *Exercise may improve arterial blood flow by building collateral circulation. Instruct the client to walk until the point of claudication, stop and rest, and then walk a little farther.* - *Elevating the legs in PAD DECREASES blood flow and increases ischemia.* - Brown discoloration around the ankles is characteristic of venous occlusive disease. - *Application of heat must be avoided in clients with PAD due to a lack of sensation and possible burns to the legs.*
Chest tube drainage (When to call HCP)
*If drainage is MORE THAN 70-100 mL/hr or if drainage becomes bright red all of a sudden call the physician.*
normal Activated partial thromboplastin time (aPTT) Normal INR range Normal platelet count Normal Hemoglobin normal white blood cell count
*Normal aPTT is 30-40 seconds* *Normal INR range is 0.8-1.1 (2-3 on Warfarin)* *Normal platelet count is 150,000-400,000* *Normal Hemoglobin is 12-18* *normal white blood cell count is 5,000-10,000*
Abdominal aortic aneurysms (AAAs) Thoracic aortic aneurysms (TAAs)
- *Abdominal aortic aneurysms (AAAs) account for most aneurysms, are commonly asymptomatic, and frequently rupture.* Most of these are located between the renal arteries and the aortic bifurcation (dividing area). - *Thoracic aortic aneurysms (TAAs) are not quite as common and are frequently misdiagnosed.* They are typically discovered when advanced imaging is used to assess other conditions. *TAAs commonly develop between the origin of the left subclavian artery and the diaphragm. They are located in the descending, ascending, and transverse sections of the aorta.* They can also occur in the aortic arch and are very difficult to manage surgically. - *Rupture is the most frequent complication and is life threatening because abrupt and massive hemorrhagic shock results.*
Aneurysms of the Central Arteries
- *An aneurysm is a PERMANENT localized dilation of an artery, which enlarges the artery to at least two times its normal diameter.* - Aneurysms tend to occur at specific anatomic sites, *most commonly in the abdominal aorta.* They often occur at a point where the artery is not supported by skeletal muscles or on the lines of curves or flexion in the arterial tree. - An aneurysm forms when the middle layer (media) of the artery is weakened, producing a stretching effect in the inner layer (intima) and outer layers of the artery. *As the artery widens, tension in the wall increases; and further widening occurs, thus enlarging the aneurysm and increasing the risk for arterial rupture.* (A rupture is a medical emergency!)
Heparin Administration
- *Anticoagulants* are the drugs of choice for actual DVT and for patients at risk for DVT. - Some patients with a confirmed diagnosis of an existing blood clot are started on a regimen of *IV unfractionated heparin(UFH) therapy.* - The health care provider prescribes UFH to prevent further CLOTTING, which often develops in the presence of an existing clot, and to prevent enlargement of the existing clot. *Over a long period of time, the body slowly absorbs the existing clot.* - *BEFORE UFH administration, a BASELINE prothrombin time (PT), activated partial thromboplastin time (APTT or aPTT), international normalized ratio (INR), complete blood count (CBC) with platelet count, urinalysis, stool for occult blood, and creatinine level are required.* - *UFH is initially given in a bolus IV dose followed by continuous infusion via an infusion pump.* - *Therapeutic levels of aPTT are usually 1.5 to 2 times normal control levels.* (Normal aPTT is 30-40 seconds so we want aPTT to be *45-80 seconds* when on UFH) - Notify the primary health care provider if the platelet count is below 100,000 to 120,000/mm3, depending on agency protocol.
Surgical Management - PAD (Arterial revascularization, AGO, thrombectomy)
- *Arterial revascularization* is the surgical procedure most commonly used to increase arterial blood flow in an affected limb. - *Acute Graft occlusion (blockage) is a postoperative emergency that can occur within the first 24 hours after arterial revascularization.* Monitor the patient for and report *severe continuous and aching pain*, which may be the first indicator of postoperative graft occlusion and ischemia. - *Monitor the patency of the graft by checking the extremity every 15 minutes for the first hour and then hourly for changes in color, temperature, and pulse intensity.* Compare the operative leg with the unaffected one. *If the operative leg feels cold; becomes pale, ashen, or cyanotic; or has a decreased or absent pulse, contact the surgeon immediately!* - Emergency *thrombectomy (removal of the clot)*, which the surgeon may perform at the bedside, is the most common treatment for acute graft occlusion.
Arteriosclerosis and Atherosclerosis
- *Arteriosclerosis is a thickening, or HARDENING, of the arterial wall that is often associated with AGING.* - *Atherosclerosis, a type of arteriosclerosis, involves the formation of PLAQUE within the arterial wall and is the leading risk factor for cardiovascular disease.* Usually the disease affects the larger arteries, such as coronary artery beds; aorta; carotid and vertebral arteries; renal, iliac, and femoral arteries; or any combination of these. - The fibrous plaque in *atherosclerosis* is often elevated and protrudes into the vessel lumen, *partially or completely obstructing blood flow through the artery.* Plaques are either stable or unstable.
Buerger's Disease
- *Claudication in feet and lower extremities, worse at night* - Causes ischemia and fibrosis of vessels in extremities with increased sensitivity to cold - Ulcerations and gangrene on digits; cause is unknown but is associated with smoking
Venous thromboembolism (VTE)
- *Deep vein thrombophlebitis, commonly referred to as deep vein thrombosis (DVT), is the most common type of thrombophlebitis.* - *It is more serious than superficial thrombophlebitis because it presents a greater risk for PULMONARY EMBOLISM.* - With PE, a dislodged blood clot travels to the pulmonary artery—a medical emergency! - DVT develops most often in the legs but can also occur in the upper arms as a result of increased use of central venous devices. - Millions of people in the United States are affected by DVT each year, and many die from pulmonary embolism.
Essential (Primary) hypertension / Secondary Hypertension
- *Essential hypertension* is the most common type and is NOT caused by an existing health problem. However, a number of risk factors can increase a person's likelihood of becoming hypertensive. - Continuous BP elevation in patients with essential hypertension results in damage to vital organs by causing medial hyperplasia *(thickening) of the arterioles.* - *As the blood vessels thicken and PERFUSION decreases, body organs are damaged.* These changes can result in myocardial infarctions, strokes, peripheral vascular disease (PVD), or kidney failure. - *Secondary Hypertension:* Specific disease states and drugs can increase a person's susceptibility to hypertension. A person with this type of elevation in BP has secondary hypertension. *Kidney disease is one of the most common causes of secondary hypertension.*
Malignant hypertension
- *Malignant hypertension is a severe type of elevated BP that RAPIDLY progresses.* - A person with malignant hypertension has a blood pressure that's typically *above 200/150. Malignant hypertension should be treated as a medical emergency!* - A person with this health problem usually has symptoms such as *morning headaches, blurred vision, and dyspnea and/or symptoms of uremia (accumulation in the blood of substances ordinarily eliminated in the urine).* - *Unless intervention occurs promptly, a patient with malignant hypertension may experience kidney failure, left ventricular heart failure, or stroke.*
Hypertensive Crisis (who is at risk?)
- *Patients who do NOT adhere to antihypertensive treatment are at a high risk for target organ damage and hypertensive crisis, a severe elevation in blood pressure (greater than 180/120), which can cause organ damage in the kidneys or heart (target organs).* - Patients in hypertensive crisis are admitted to critical care units, where they receive IV antihypertensive therapy such as *nitroprusside (Nipride)*, nicardipine (Cardene IV), fenoldopam (Corlopam), or labetalol (Trandate). These drugs act quickly as *vasodilators* to decrease blood pressure by no more than 25% within 2 to 6 hours. - *A GRADUAL reduction in blood pressure is preferred because rapid reduction can cause cerebral ischemia, MI, and renal failure.* - *Provide oxygen to the patient and monitor oxygen saturation levels.* When the patient's blood pressure stabilizes, oral antihypertensive drugs are given.
Peripheral Arterial Disease
- *Peripheral vascular disease (PVD) includes disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation, causing decreased PERFUSION to body tissues.* - It affects the *legs* much more frequently than the arms. Generally, a diagnosis of PVD implies arterial disease (peripheral arterial disease [PAD]) rather than venous involvement. Some patients have both arterial and venous disease. - *PAD is a result of systemic atherosclerosis.* It is a *chronic* condition in which partial or total arterial occlusion (blockage) decreases PERFUSION to the extremities. *The tissues below the narrowed or obstructed arteries cannot live without an adequate oxygen and nutrient supply.* PAD in the legs is sometimes referred to as lower-extremity arterial disease (LEAD). - *Inflow* obstructions involve the distal end of the aorta and the common, internal, and external iliac arteries. *They are located above the inguinal ligament.* - *Outflow* obstructions involve the femoral, popliteal, and tibial arteries and are *below the superficial femoral artery (SFA)*
Normal BUN and Creatinine level
- *The normal serum creatinine range is 0.6-1.3 mg/dL.* - Normal *BUN* is *10 to 20 mg/dL*
Peripheral Venous Disease
- *To function properly, veins must be patent (open) with competent valves.* Vein function also requires the assistance of the *surrounding muscle beds to help pump blood toward the heart.* If one or more veins are not operating properly, they become distended, and signs and symptoms occur. Three health problems alter the blood flow in veins: • *Thrombus formation (venous thrombosis) can lead to pulmonary embolism (PE), a life-threatening complication. Venous thromboembolism (VTE) is the current term that includes both deep vein thrombosis and PE.* • Defective valves lead to venous insufficiency and varicose veins, which are not life threatening but are problematic. • Skeletal muscles do not contract to help pump blood in the veins. This problem can occur when weight bearing is limited or muscle tone decreases.
Assessment of Aneurysms (TAA)
- *When a thoracic aortic aneurysm (TAA) is suspected, assess for back pain and manifestations of compression of the aneurysm on adjacent structures.* - Signs include shortness of breath, hoarseness, and *difficulty swallowing.* TAAs are not often detected by physical assessment, but occasionally a mass may be visible above the suprasternal notch. *Assess the patient with suspected rupture of a thoracic aneurysm for sudden and excruciating back or chest pain. Hypovolemic shock also occurs with TAA.* - Computed tomography (CT) scanning with contrast is the standard tool for assessing the size and location of an abdominal or thoracic aneurysm. Ultrasonography is also used.
Assessment- VTE
- Assess the patient for a history of any type of VTE. In addition, assess him or her for risks that may be associated with the development of VTE such as prolonged periods of sitting or bedrest, recent surgical procedures, or any factors that may affect coagulation. - *The classic signs and symptoms of DVT are calf or groin tenderness and pain and sudden onset of UNILATERAL swelling of the leg.* - *GENTLY palpate the site, observing for induration (hardening) along the blood vessel and for warmth and edema. Redness may also be present.*
Types cntd.
- Atherosclerosis is the most common cause of aneurysms, with hypertension, hyperlipidemia, and cigarette smoking being contributing factors.
Assessment of Atherosclerosis
- Because of the high incidence of *hypertension* in patients with atherosclerosis, assess the blood pressure in BOTH arms. - Palpate pulses at all of the major sites on the body and note any differences. *Palpate each carotid artery separately to prevent blocking blood flow to the brain!* - *Prolonged capillary filling (>3 seconds in young-to-middle-age adults; >5 seconds in older adults) generally indicates poor circulation, although this is not the most reliable indicator of PERFUSION.* With severe atherosclerotic disease, the extremity may be cool or cold with a diminished or absent pulse. - Many patients with vascular disease have a *BRUIT* in the larger arteries, which can be heard with a stethoscope or Doppler probe. *A bruit is a turbulent, swishing sound, which can be soft or loud in pitch.* *It is heard as a result of blood trying to pass through a narrowed artery.* - A bruit is considered abnormal, but it does not indicate the severity of disease. Bruits often occur in the carotid, aortic, femoral, and popliteal arteries.
Management of PAD
- Exercise, positioning, promoting *vasodilation*, drug therapy, and invasive nonsurgical procedures are used to increase arterial flow to the affected leg(s). - Exercise may improve arterial blood flow to the affected leg through buildup of the collateral circulation. *Collateral circulation provides blood to the affected area through smaller vessels that develop and compensate for the occluded vessels.* - *Vasodilation can be achieved by providing warmth to the affected extremity and preventing long periods of exposure to cold.* (Caution the patient to avoid the application of direct heat to the limb with heating pads or extremely hot water. *Sensitivity is decreased in the affected limb. Burns may result!*) - *Emphasize that complete abstinence from smoking or chewing tobacco is essential to prevent vasoconstriction!* The vasoconstrictive effects of each cigarette may last up to 1 hour after the cigarette is smoked.
Interventions: Atherosclerosis (Fat intake, Cholesterol intake)
- For patients with elevated total and LDL-C levels that do not respond adequately to dietary intervention, the primary health care provider prescribes a cholesterol-lowering agent. - *Statins reduce cholesterol synthesis in the liver and increase clearance of LDL-C from the blood.* Therefore they are *contraindicated in patients with active liver disease or during pregnancy* because they can cause muscle myopathies and marked decreases in liver function.
Aneurysms of Central Arteries: Types
- It may be described as *fusiform (a diffuse dilation affecting the entire circumference of the artery)* - *Saccular (an outpouching affecting only a distinct portion of the artery).* - Aneurysms may also be described as *true or false.* - In *true aneurysms*, the arterial wall is weakened by *congenital or acquired problems.* - *False aneurysms occur as a result of vessel injury or trauma to all three layers of the arterial wall.* - *Dissecting aneurysms differ from aneurysms in that they are formed when blood accumulates in the wall of an artery. When dissecting aneurysms occur, the aneurysm enlarges, blood is lost, and blood flow to organs is diminished.*
Assessment: PAD
- Most patients initially seek medical attention for a *classic leg pain known as intermittent claudication* ("to limp"). - Usually they can walk only a certain distance before discomfort, such as cramping or burning muscular pain, forces them to stop. *The pain stops with rest.* *When patients resume walking, they can walk the same distance before it returns. Thus the pain is considered reproducible.* - As the disease progresses, they can walk only shorter and shorter distances before pain recurs. Ultimately it may occur even while at rest *(Stage III)* - Rest pain is a numb or burning sensation, often described as feeling like a toothache that is severe enough to awaken patients at night. *It is usually located in the toes, the foot arches, the forefeet, the heels, and, rarely, in the calves or ankles.* Patients can sometimes alleviate pain by keeping the limb in a dependent position (below the heart). *Those with rest pain often have advanced disease that may result in limb loss.* - Patients with *INFLOW disease* have discomfort in the *lower back, buttocks, or thighs.* Patients with mild inflow disease have discomfort after walking about two blocks. - Patients with *OUTFLOW disease* describe *burning or cramping in the calves, ankles, feet, and toes.* Instep or foot discomfort indicates an obstruction below the popliteal artery. Those with mild outflow disease experience discomfort after walking about five blocks. - Specific findings for PAD depend on the severity of the disease. *Observe for loss of hair on the lower calf, ankle, and foot; dry, scaly, dusky, pale, or mottled skin; and thickened toenails. With severe arterial disease, the extremity is cold and gray-blue (cyanotic) or darkened. Pallor may occur when the extremity is elevated. Dependent rubor (redness) may occur when the extremity is lowered.* Muscle atrophy can result from prolonged chronic arterial disease.
Assessment of Aneurysms (AAA)
- Most patients with abdominal or thoracic aneurysms are *asymptomatic*- it is found upon imaging for another reason. - Assess patients with a *known or suspected abdominal aortic aneurysm (AAA) for abdominal, flank, or back pain.* Pain is usually described as steady with a gnawing quality, unaffected by movement, and lasting for hours or days. - A *pulsation in the upper abdomen* slightly to the left of the midline between the xiphoid process and the umbilicus may be present. - *Auscultate for a bruit over the mass, but avoid palpating the mass because it may be tender and there is risk for rupture!* - *Patients with a RUPTURED AAA are CRITICALLY ILL and are at risk for hypovolemic shock caused by hemorrhage.* Signs and symptoms include *hypotension, diaphoresis, decreased level of consciousness, oliguria (scant urine output), loss of pulses distal to the rupture, and dysrhythmias.*
Raynaud's Phenomenon/Disease
- Painful vasospasms of arteries and arterioles in extremities, ESPECIALLY DIGITS; *causes red-white-blue skin color changes on exposure to cold or stress;* - Cause is unknown, occurs more in women, and *may be autoimmune* because it is associated with many rheumatic diseases such as systemic lupus erythematosus.
Differentiate arterial venous and diabetic ulcers
- Palpate all pulses in both legs. *The strength of each pulse should be compared bilaterally.* - Initially, ARTERIAL ulcers are painful and develop on the TOES (often the great toe), between the toes, or on the upper aspect of the foot. *With prolonged occlusion, the toes can become gangrenous.*
Management of Aneurysms (surgical/nonsurgical)
- Surgical management of an aneurysm may be an *elective* or an emergency procedure. *For patients with a RUPTURING abdominal aortic or a thoracic aneurysm, emergency surgery is performed.* - The most common surgical procedure for *AAA has traditionally been a resection or repair (aneurysmectomy).* However, the mortality rate for elective resection is high and markedly increases for emergency surgery. *Endovascular stent grafts have improved mortality rates and shortened the hospital stay for select patients who need AAA repair.* The repair of AAAs with *endovascular stent grafts* is the procedure of choice for almost all patients on an elective or emergent basis. - *Stents (wirelike devices) are inserted percutaneously (through the skin), avoiding abdominal incisions and therefore decreasing the risk for a prolonged postoperative recovery.* - *Patients may not perform activities that involve lifting heavy objects (usually more than 15 to 20 lbs for 6 to 12 weeks after surgery.* Advise them to use caution for activities that involve pulling, pushing, or straining. Most patients are restricted from driving a car for several weeks after discharge.
Stages of PAD *(How many stages are there?)*
- The clinical course of chronic PAD can be divided into *four stages.* Patients do not experience symptoms in the early stages of disease. *Most patients are not diagnosed until they develop leg pain.*
Assessment - Hypertension
- To detect postural (orthostatic) changes, take readings with the patient in the supine (lying) or sitting position and at least 2 minutes later when standing. *Orthostatic hypotension is a decrease in blood pressure (20 mm Hg systolic and/or 10 mm Hg diastolic) when the patient changes position from lying to sitting.*
Stable vs. Unstable plaque (Atherosclerosis)
- When STABLE plaque ruptures, *thrombosis (blood clot) and constriction obstruct the vessel lumen, causing inadequate PERFUSION and oxygenation to distal tissues.* - *UNSTABLE plaque rupture causes more severe damage.* After the rupture occurs, the exposed underlying tissue causes platelet adhesion and rapid thrombus formation. *The thrombus may suddenly block a blood vessel, resulting in ischemia and infarction (e.g., myocardial infarction).*
Which client who has just arrived in the emergency department does the nurse classify as emergent and needing immediate medical evaluation? A 60-year-old with venous insufficiency who has new-onset right calf pain and tenderness A 64-year-old with chronic venous ulcers who has a temperature of 100.1°F (37.8°C) A 69-year-old with a 40-pack-year cigarette history who is reporting foot numbness A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic
-A 70-year-old with a history of diabetes who has "tearing" back pain and is diaphoretic - *This client's history and clinical manifestations suggest possible AORTIC DISSECTION.* The nurse will immediately assess the client's blood pressure and plan for IV antihypertensive therapy, rapid diagnostic testing, and possible transfer to surgery. - The 64-year-old is most stable and can be seen last. - The 60-year-old and the 69-year-old would both be seen soon, but the 70-year-old client must be seen first.
Which are risk factors that are known to contribute to atherosclerosis-related diseases? *Select all that apply.* Low-density lipoprotein cholesterol (LDL-C) of 160 mg/dL (4.14 mmol/L) Smoking Aspirin (acetylsalicylic acid [ASA]) consumption Type 2 diabetes Vegetarian diet
1,2,4 - Risk factors that contribute to atherosclerosis-related diseases include *LDL-C of 160 mg/dL, smoking, and type 2 diabetes.* - Having an LDL-C value of less than 100 mg/dL is optimal. 100 to 129 mg/dL is near or less than optimal. LDL-C 130 to 159 mg/dL is borderline high. *The client with a LDL-C of 160 mg/dL is advised to modify diet and exercise.* - Smoking is a modifiable risk factor and needs to be avoided or terminated. Diabetes is a risk factor for atherosclerotic disease. - ASA is used as prophylaxis for atherosclerotic disease/coronary artery disease to prevent platelet adhesion. - 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 suspects that a client has developed an acute arterial occlusion of the right lower extremity based on which signs/symptoms? *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
4,5,6 - Signs/symptoms of acute arterial occlusion of the right lower extremity include *cold right foot, numbness and tingling of the right foot, and mottling and tingling of the right foot.* - Pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (cool limb), and mottled color are characteristics of *acute arterial occlusion. (6 Ps)* - Hypertension presents risk for atherosclerosis, but not for acute arterial occlusion. - The pulse rate does not indicate occlusion, but rather quality. Absence of pulse, rather than bounding pulse, is a symptom of acute arterial occlusion.
A client is prescribed lisinopril (Zestril) for control of hypertension. What health teaching will the nurse provide to this patient? Select all that apply. A. "This medication can cause increased potassium levels." B. "It's important to change positions slowly when you start this medication." C. "This medication may cause you to develop a persistent, nonproductive cough." D. "To achieve maximum benefit of Zestril, your diet should include foods high in sodium." E. "Be sure to monitor your BP regularly while taking this medication."
A, B, C, E - Lisinopril (Zestril) is an *ACE inhibitor* which is known to cause *orthostatic hypotension* associated with vasodilation; thus changing positions slowly is important. - *Persistent, nagging cough is also common in this drug category.* - Because this medication is being used to modify BP, regular monitoring is important to assess effectiveness. - *HYPERKALEMIA is also associated with ACE Inhibitors especially for clients with diabetes mellitus and renal dysfunction.* - A high sodium diet is inappropriate for a client with hypertension and would adversely affect BP
A client is being discharged home following 5 days of acute care for treatment of a deep vein thrombosis. Which statement made by the client indicates a need for further teaching? A. "I will be going home on oral Heparin and warfarin." B. "I have an appointment for follow-up care with my primary care provider." C. "I will avoid dark green leafy vegetables while taking warfarin." D. "I will report any signs of bleeding to my primary health care provider."
ANS: A - *Heparin is NOT an oral drug and a patient will not go home on both Heparin and Coumadin.* These medications are overlapped in the hospital for at least 5 days because they work differently to anticoagulate. - A follow-up appointment is appropriate following hospitalization and labs will most likely be assessed for warfarin maintenance. - Dark green leafy vegetables contain Vitamin K which is the antidote for warfarin. Avoidance is appropriate. - Following DVT, all patients will be discharged on anticoagulant therapy. All anticoagulants present a risk for bleeding. Prompt recognition and reporting of bleeding is an appropriate action.
The nurse is caring for a client with intermittent claudication pain related to peripheral arterial disease. Which statement made by the client indicates understanding of proper self-management? A. "I need to reduce the number of cigarettes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."
ANS: D - *Gradual exercise can improve collateral circulation and decrease pain associated with intermittent claudication.* Teach the client to walk until they have pain, then to stop and rest, only to resume walking again. This promotes collateral development. - *Complete abstinence from smoking is essential to prevent vasoconstriction.* - While maintaining warmth is good to promote vasodilation, use of a heating pad is not safe due to the *decreased sensation* that can occur. - Elevation of the extremities may be beneficial to reduce swelling; however, they should NOT be elevated above the heart level.
Normal urine output per hour, daily
At least 30 mL/hr 720 ml daily
For a client with an 8-cm abdominal aortic aneurysm, which problem must be addressed immediately to prevent rupture? Heart rate 52 beats/min Blood pressure (BP) 192/102 mm Hg Report of constipation Anxiety
Blood pressure (BP) 192/102 mm Hg - *Elevated blood pressure can increase the rate of aneurysmal enlargement and risk for early rupture.* - The nurse must consider the client's usual pulse. *However, bradycardia does not pose a risk for aneurysm rupture.* - Straining at stool can elevate blood pressure and pose a risk for dissection. *However, a POTENTIAL problem would not be addressed before an ACTUAL problem.* - Anxiety may be benign or may be a symptom of something serious. However, the elevated blood pressure is an immediate risk.
When administering furosemide (Lasix) to a client who 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 potatoes. Add several portions of dairy products each day. Try replacing your usual breakfast with oatmeal or Cream of Wheat.
Consume melons and baked potatoes. - *Melons and baked potatoes are foods high in potassium.* - Red meat is high in saturated fat and is to be consumed sparingly. Dairy products are high in calcium. Cereals are fortified with iron. Oatmeal contains fiber but not potassium.
The nurse is caring for a client who is being treated for hypertensive emergency. Which medication prescribed for the client would the nurse question? Enalapril (Vasotec) Sodium nitroprusside (Nipride) Dopamine (Intropin) Labetalol (Normodyne)
Dopamine (Intropin) - The nurse would question the prescription for dopamine. *Dopamine is used for its inotropic and vasoconstrictive properties to raise blood pressure, and would not be used in hypertensive emergency.* - *Enalapril, an angiotensin-converting enzyme inhibitor, may be used intravenously in hypertensive emergencies.* - *Sodium nitroprusside, a direct-acting vasodilator, may be used intravenously to lower blood pressure quickly in hypertensive emergencies.* - Labetalol, an intravenous calcium channel blocker, is used in hypertensive emergencies when oral therapy is not feasible.
The nurse in the cardiology clinic is reviewing teaching about hypertension, provided at the client's 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 (1.4 kg) since last seen in the clinic Cooks food in palm oil to save money Exercises once weekly Has cut down on caffeine
Has maintained a low-sodium, no-added-salt diet Has lost 3 pounds (1.4 kg) since last seen in the clinic Has cut down on caffeine - Teaching about hypertension has been effective when the nurse notes that the client has been on a low-sodium, no-added salt diet, has lost 3 pounds (1.4 kg) since the last clinic visit, and has cut down on caffeine. - *Clients with hypertension need to consume low-sodium foods and would avoid adding salt. Weight loss can result in lower blood pressure. Caffeine promotes vasoconstriction, thereby elevating blood pressure.* - Although palm oil may be cost-saving, it is higher in saturated fat than canola, sunflower, olive, or safflower oil. - The goal is to exercise at least three times and not once weekly.
The professional nurse and the nursing student are caring for a group of clients with hypertension. Which problem identified by the nursing student correctly identifies the client at risk for secondary hypertension? Psychiatric disturbance High sodium intake Physical inactivity Kidney disease
Kidney disease - *Kidney disease is one of the most common causes of secondary hypertension.* - Psychiatric disturbance can exacerbate essential hypertension, but *secondary hypertension is caused by a disease process or drugs.* - High sodium intake is a risk factor for essential hypertension, not for secondary hypertension, which is caused by disease states or medications. Physical inactivity is a risk factor for essential hypertension.
Normal LDL levels Normal HDL levels
LDL: <100 mg/dL HDL: 40-60
Which finding in the history of a client with an abdominal aortic aneurysm (AAA) is a risk factor for aneurysm formation? Peptic ulcer disease Deep vein thrombosis (DVT) Osteoarthritis Marfan syndrome
Marfan syndrome - *Marfan syndrome is a risk factor for cardiovascular disorders such as AAA. Marfan syndrome is a genetic connective tissue disorder. It occurs in middle-aged and older people, peaking in adults in their 50s and 60s. Men are more commonly affected than women.* - Peptic ulcer disease is not a risk factor for AAA formation. AAA is an arterial problem, so DVT is not a related risk. Osteoarthritis is related to overuse of joints, and does not present a risk for AAA.
A client with peripheral arterial disease (PAD) has undergone percutaneous transluminal angioplasty (PTA) of the lower extremity. What is essential for the nurse to assess after the procedure? Ankle-brachial index Dye allergy Pedal pulses Gag reflex
Pedal pulses - *After a client with PAD has had a PTA, it is essential for the nurse to assess for pedal pulses.* - Priority nursing care focuses on assessment for bleeding at the arterial puncture site and monitoring distal pulses to ensure adequate perfusion. *Pulse checks must be assessed post procedure to detect improvement (stronger pulses) or complications (diminished or absent pulses).* - *Ankle-brachial index is a diagnostic study used to detect the presence of PAD. This is not necessary after PTA, which is an intervention to treat PAD.* - It is imperative to assess for dye allergy BEFORE performing PTA. - Gag reflex is checked after procedures affecting the throat (e.g., endoscopy, bronchoscopy). - *The femoral artery is generally the access site for PTA.*
A client is receiving unfractionated heparin (UFH) by infusion. Of which finding does the nurse notify the primary health care provider (PCP)? Partial thromboplastin time (PTT) 60 seconds Platelets 32,000/mm3 (32 × 109/L) White blood cells 11,000/mm3 (11 × 109/L) Hemoglobin 12.2 g/dL (122 mmol/L)
Platelets 32,000/mm3 (32 × 109/L) - *UFH can decrease platelet counts. The PCP must be notified if the platelet count is below 100,000 to 120,000/mm3. Heparin-induced thrombocytopenia (HIT), an immune disorder, presents with platelets less than 150,000/mm3 (150 × 109/L).* - A 60-second PTT reflects a therapeutic value within 1.5 to 2 times the normal value. - Mild leukocytosis (increased white blood cells) may be expected with deep vein thrombosis. - A hemoglobin of 12.2 g/dL (122 mmol/L) reflects a normal reading.
The nurse is caring for a client with peripheral arterial disease (PAD). For which symptoms does the nurse assess? Reproducible leg pain with exercise Unilateral swelling of affected leg Decreased pain when legs are elevated Pulse oximetry reading of 90%
Reproducible leg pain with exercise - The symptom the nurse assesses the client with PAD is reproducible leg pain with exercise. *Claudication (leg pain with ambulation due to ischemia) is reproducible in similar circumstances.* - Unilateral swelling is typical of venous problems such as deep vein thrombosis. - With PAD, pain decreases with legs in the dependent position (legs dangling) - Pulse oximetry readings reflect the amount of oxygen bound to hemoglobin. PAD results from atherosclerotic occlusion of peripheral arteries.
Management - Hypertension
See pic.
Which symptom reported by a client who has had a total hip replacement requires emergency action? Localized swelling of one of the lower extremities Positive Homans' sign Shortness of breath and chest pain Tenderness and redness at the IV site
Shortness of breath and chest pain - *Shortness of breath and chest pain indicate a possible pulmonary embolism (PE), which can be life threatening. Orthopedic procedures create high risk for deep vein thrombosis (DVT) and PE.* - Although localized swelling is a symptom of DVT, it is not emergent. - Pain in the calf on dorsiflexion of the foot (positive Homans' sign) appears in only a small percentage of clients with DVT, and false-positive findings are common, so assessing for Homans' sign is not advised. - Tenderness and redness at the IV site indicate phlebitis and are not emergent, but must be attended to after the emergency.
Which vascular assessment by the student nurse requires intervention by the supervising nurse? Measuring capillary refill in the fingertips Assessing pedal pulses by Doppler Measuring blood pressure in both arms Simultaneously palpating the bilateral carotids
Simultaneously palpating the bilateral carotids - *Carotid arteries are palpated separately because of the risk for inadequate cerebral perfusion and the risk for causing the client to faint.* - Prolonged capillary filling generally indicates poor circulation, and is an appropriate assessment. - Many clients with vascular disease have poor blood flow. *Pulses that are not palpable may be heard with a Doppler probe.* - Because of the high incidence of hypertension in clients with atherosclerosis, blood pressure is assessed in BOTH arms.
A client has undergone an embolectomy for acute arterial occlusion after creation of a lower arm arteriovenous fistula for dialysis. Which finding does the nurse report to the primary health care provider (PCP) immediately? Swelling and tenseness in the affected area Incisional pain and tenderness at the surgical site Pink, mobile fingers An order for heparin infusion
Swelling and tenseness in the affected area - *Compartment syndrome may develop after an embolectomy, with swelling of skeletal muscle fibers causes increasing pain, swelling, and tenseness. A fasciotomy may be needed to preserve the limb.* - Incisional pain is expected. Pink fingers and mobility are normal physical assessment findings. Heparin may be prescribed to maintain patency of the vessel after clot removal.
Which sign/symptom is essential for the nurse to report to the primary health care provider (PCP) when caring for a client with Raynaud's phenomenon? Nifedipine (Procardia) administration caused the blood pressure to change from 134/76 to 110/68 mm Hg. The client's extremity became white, then red temporarily. The affected extremity becomes purple and cold. The client states that the digits are painful when they are white.
The affected extremity becomes purple and cold. - When caring for a client with Reynaud's phenomenon, it is essential for the nurse to report to the PCP an affected extremity that becomes purple and cold. *Reynaud's phenomenon is described as painful vasospasms of arteries and arterioles in extremities, especially digits. This causes red-white-blue skin color changes on exposure to cold or stress.* - The cause is unknown, occurs more in women, and may be autoimmune because it is associated with many rheumatic diseases like systemic lupus erythematosus. - Vasodilating drugs are administered as treatment and may lower the blood pressure, but this is not a significant drop. - In severe cases, the attack lasts longer, and gangrene of the digits can occur. *Pain, numbness, and cold are typical findings in Raynaud's phenomenon.*
The nurse is assigned to all of these clients. Which client would be assessed first? The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago The client admitted with hypertensive crisis who has a nitroprusside (Nipride) drip and blood pressure of 149/80 mm Hg The client with peripheral vascular disease who has a left leg ulcer draining purulent yellow fluid The client who had a right femoral-popliteal bypass 3 days ago and has ongoing edema of the foot
The client who had percutaneous transluminal angioplasty (PTA) of the right femoral artery 30 minutes ago - *This client must have checks of vascular status and vital signs every 15 minutes in the first hour after the procedure.* - The client admitted with hypertensive crisis has stabilized and is not in need of immediate assessment. - The client with peripheral vascular disease is the most stable and can be seen last. - The client who had a right femoral-popliteal bypass is not in need of immediate assessment and can be assessed after the PTA client is seen.
The nurse caring for a client who has had abdominal aortic aneurysm (AAA) repair would be most alarmed by which finding? Urine output of 20 mL over 2 hours Blood pressure of 106/58 mm Hg Absent bowel sounds +3 pedal pulses
Urine output of 20 mL over 2 hours - The nurse caring for a client who had an AAA repair would be most alarmed with the client's urine output of 20 mL over 2 hours. *Complications post AAA stent repair include bleeding, which may manifest as signs of hypovolemia and oliguria.* - Reduction of systolic blood pressure to 100 to 120 mm Hg is appropriate. - *Paralytic ileus may be a complication of AAA repair, but is not a priority over decreased urine output (think ABCs).* - +3 pedal pulses is a normal physical assessment finding.
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 oil. Consume 10 mg of fiber daily. Work toward lowering your high-density lipoprotein (HDL) cholesterol levels.
Use canola oil rather than palm oil. - The nurse teaches the client who has had MI to use canola oil rather than palm oil. *Palm oil is higher in saturated fats and needs to be avoided.* Nontropical vegetable oils would be encouraged, e.g., canola. - *Less than 30% of daily calories need to come from fats.* - Clients would be encouraged to consume 30 g of dietary fiber daily. - A higher HDL cholesterol level (good cholesterol) is more desirable. Clients need to strive to reduce low-density lipoprotein cholesterol (bad cholesterol) when elevated.
A client with hypertension is started on verapamil (Calan). What teaching does the nurse provide for this client? "Consume foods high in potassium." "Monitor for irregular pulse." "Monitor for muscle cramping." "Avoid grapefruit juice."
"Avoid grapefruit juice." - *Grapefruit juice must be avoided with calcium channel blockers, such as verapamil, because it can enhance the action of the drug.* - Foods high in potassium would be encouraged for clients taking diuretics, not calcium channel blockers such as verapamil. - *Bradycardia, not irregular pulse, is a typical side effect of verapamil.* - Muscle cramping may occur with *statins*, not with calcium channel blockers.
