Patho pharm and HCCL 2 test 2
R in THROMBINs
R- Renin-Angiotensin-Aldosterone System (RAS) blockade: (ACE Inhibitors or Angiotensin Receptor blockers (ARBs)) .Typically prescribed within 48 hrs after ACS event if: EF is < or = 40% in patients with HTN, diabetes mellitus, or stable chronic kidney disease Helps to prevent ventricular remodeling (cardiomyopathy) and the development of heart failure ( Increases survival after an MI (improves outcomes!) If ACEIs or ARBs are initiated, they should be continued on discharge indefinitely Example: Lisinopril
Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? Relief of anginal pain Improved cardiac output Decreased blood pressure Ease in respiratory effort
Relief of anginal pain
Which outcome would the nurse use to determine the effectiveness of sublingual nitroglycerin? Relief of anginal pain Improved cardiac output Decreased blood pressure Ease in respiratory effort
Relief of anginal pain
Which instruction will the nurse teach the client who had a femoropopliteal bypass graft and is receiving clopidogrel postoperatively ? Eliminate starches and red meats from the diet. Eat more roughage if constipation occurs . Report any occurrence of multiple bruises. Take the medication on an empty stomach .
Report any occurrence of multiple bruises.
cardiogenic shock
Shock caused by inadequate function of the heart, or pump failure. SBP < 90 mmHg (goal is to get systolic BP above 90) narrowed pulse pressure (you'll learn more in HC 4) Heart rate > 100 beats/min (goal is to get heart rate to below 100 beats / minute) Urinary Output <30mL/hr (goal is to get urinary output to at least 30 mL/hr) Weak, thready pulse Diminished heart sounds Cool, clammy skin Mental status deteriorates (subtle changes at first, agitation initially, then lethargy, unconsciousness) Tachypnea Pulmonary Congestion
Which information is important for the nurse to include in the teaching plan of a client who will be taking furosemide and digoxin after discharge from the hospital? Maintenance of a low-potassium diet Avoidance of foods high in cholesterol Signs and symptoms of digoxin toxicity Importance of monitoring output
Signs and symptoms of digoxin toxicity
Which assessment is the nurse's priority before beginning an infusion of tissue plasminogen activator (t - PA) to a client in the emergency department? Vital signs Electrocardiogram (ECG) monitoring Signs of bleeding Level of chest pain
Signs of bleeding
Management of hypertension
Sodium restriction in diet Limit sugar intake Consuming healthy fats. NOT TRANS FATS Monitor BP Weight reduction Modification of diet Restriction of alcohol Stress reduction- meditation and deep breathing Exercise Medications Avoid caffeine and tabaco
Which action will the nurse take when it is time to administer vancomycin to a client with a continuous intravenous (IV) heparin drip? Stop the heparin, flush the line with normal saline, and administer the vancomycin. Administer the vancomycin into the heparin line using an IV piggyback set. Start a second IV line for the vancomycin and continue the heparin as prescribed. Hold the vancomycin and tell the health care provider that the medication is incompatible with heparin.
Start a second IV line for the vancomycin and continue the heparin as prescribed.
Which action will the nurse take when it is time to administer vancomycin to a client with continuous intravenous (IV) heparin drip? Stop the heparin, flush the line with normal saline, and administer the vancomycin. Administer the vancomycin into the heparin line using an IV piggyback set. Start a second IV line for the vancomycin and continue the heparin as prescribed. Hold the vancomycin and tell the health care provider that the medication is incompatible with heparin
Start a second IV line for the vancomycin and continue the heparin as prescribed.
S in THROMBINS2
Statins- lipid lowering agents ⬇️LDL ⬇️Triglycerides ⬆️HDL HMG CoA reductase inhibitors (Statins) example: Atorvastatin - patient teaching? statins can cause muscle pain do not take with grapefruit visit the doctor regularly to keep an eye on cholesterol Take in evening - cholesterol made at night
Hydochorothiazide
Thiazide diuretics (decrease the preload ) Lowering of BP in hypertensive patients and diuresis with mobilization of edema, HF, Renal dysfunction Dizziness, drowsiness, weakness, hypokalemia, dehydration, hypercalcemia, hypovolemia, pancreatitis, cramping, n/v, SJS Assess rashes, monitor BP May give with food or milk to minimize GI irritation Tablets can be crushed and mixed to help with swallowing
pacemaker
This electronic device used to increase the heart rate in severe bradycardia by electronically stimulating the myocardium. The basic pacing circuit consists of a battery-operated pulse generator and one or more conducting leads that pace the atrium and one or both ventricles
Activated partial thromboplastin time (aPTT)
blood test used to monitor anticoagulation therapy for patients taking heparin, an intravenous anticoagulant medication
coronary arteries
blood vessels that branch from the aorta and carry oxygen-rich blood to the heart muscle
main 3 things that are important things to look for regarding perfusion? (organs)
brain kidneys lungs
Stable angina
chest pain caused by myocardial ischemia. Atherosclerotic plaques partially obstruct coronary vessels, and affected vessels cannot dilate in response to increased myocardial demand associated with physical exertion or emotional stress. With rest, blood flow is restored and necrosis of myocardial cells does not occur
unstable angina
chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation is a reversible form of acute coronary syndrome that is a harbinger of impending infarction It is important to recognize this syndrome because it signals that the atherosclerotic plaque has begun to rupture and infarction may soon follow. occurs when a fairly small fissuring or superficial erosion of the plaque leads to transient episodes of thrombotic vessel occlusion and vasoconstriction at the site of plaque damage.
Atherosclerosis
condition in which fatty deposits called plaque build up on the inner walls of the arteries Leading cause of CVD Affects large arteries: coronary artery beds, aorta, carotid and vertebral, renal, illiac, and femoral Vessels damaged and inflamed leading to cell damage and fatty streaks on inside of artery ( collagen for s plaques) Fibrous plaques, become calcified, hemorrhagic, ulcerated, or thrombosed, and effect all Layers of the vessel Risks: smoking, Diabetes ( increase in LDL and triglyceride levels in plasma) , hypertension
foramen ovale
connects the two atria in the fetal heart because the fetus does not depend on the lungs for oxygenation, there is an opening before birth between the right and left atria, that facilitates circulation. This opening closes functionally at the time of birth as the higher pressure in the left atrium pushes a flap, the septum primum, over the hole.
Cardiac Telemetry
continuous monitoring of a patient's heart rate and rhythm via EKG electrodes Can also monitor resp and o2 monitoring
Systole
contraction phase of the heartbeat As the ventricles contract, they create pressure that closes the mitral and tricuspid valves, preventing the backflow of blood into the atria. This ventricular pressure forces the aortic and pulmonic valves to open, resulting in ejection of blood into the aorta (from the left ventricle) and the pulmonary arteries (from the right ventricle). As blood is ejected, the ventricular pressure decreases, causing the aortic and pulmonic valves to close.
angiotensin converting enzyme (ACE)
converts angiotensin I to angiotensin II inhibitors are medicines that help relax the veins and arteries to lower blood pressure. Check out the Renal systems and make sure their urine output is and this can determine cardiac output, BUN and CREATANINE, GFR
infarction
death of tissue Infarction and subsequent necrosis of a central organ are life-threatening
labetalol, atenolol, metoprolol
decrease effects of sympathetic nervous system - ACTS ON AV AND SA NODES Antianginals, Antihypertensives Prevents MI and decreased mortality Do not abruptly withdraw! Can cause rebound hypertension Do not give to pt with asthma Get up slowly - ⬇️Heart rate and myocardial contractility, ⬇️ CO, ⬇️oxygen need and anginal pain • S/e: Bradycardia, Pulm edema, weakness, dizziness/ drowsiness, - Blocks SNS, hypotension -fatigue, Gl disturbances, HF, JHR & BP, arrhythmias, I CO, mask hypoglycemia symptoms (sweating, palpitations, tremulousness, anxiety)**** • Bronchospasms, dyspnea, cough Drug-Drug Interactions: - clonidine (Increases BP); NSAIDS decrease effectiveness Check HR & BBG & BP Contraindications: those who have low HR and BP, or heart block
hypoxemia
deficient amount of oxygen in the blood
PR interval
delay of AV node to allow filling of ventricles
Virchow's triad
describes the 3 broad categories of factors that are thought to contribute to thrombosis -blood flow abnormalities - contact surface abnormalities - clotting component abnormalities
Thromboembolus
detached thrombus Management most often consists of anticoagulation therapy using heparin (low-molecular-weight heparin) and warfarin
Baroreceptors
detect changes in blood pressure
thrombocytopenia diagnosis and management
diagnosis: complete blood count (platelet count) Peripheral blood smear bone marrow aspirate spleen US management- stop drugs causing it steroids platelet or plasma transfusion splenectomy bleeding precautions
Dyspnea
difficulty breathing
Idiopathic Thrombocytopenic Purpura (ITP)
disorder marked by platelet destruction by macrophages resulting in bruising and bleeding from mucous membranes autoimmune disorder in which the span of platelets is decreased by antiplatelets antibodies although platelet production production ins normal This can result in severe hemorrhage following a cesarean birth or lacerations. risks- •Female sex (ages 20 to 50 years) (medications, viruses [HIV, hepatitis C]) •Other autoimmune disorders
A client with left ventricular heart failure is taking digoxin 0.25 mg daily. What changes does the nurse expect to find if this medication is therapeutically effective? diuresis Tachycardia decreased edema Reduce heart murmur decreased pulse rate Jugular vein distention
diuresis decreased edema decreased pulse rate
Catecholamines
dopamine, norepinephrine, epinephrine Cause vasoconstriction to increase bp
Vasopressors
drugs used to increase blood pressure
Plaques: atherosclerosis
hardening or thickening in the artery wall. comes with old age. Play rapture and thrombosis ( blood clot) and the construction abstracts the vessel, lumen causing inadequate perfusion Tissues, cause platelet adhesion, and rapid thrombus formation, which may suddenly block a blood vessel, resulting in ischemia and infarction (MI)
secondary hypertension
high blood pressure caused by the effects of another disease Kidney disease is one of the most common causes of secondary hypertension The use of estrogen-containing oral contraceptives is likely the most common cause of secondary hypertension in women
hypertensive crisis
higher than 180 and/or higher than 120 Acute situation and could cause death Extremely Elevated BP: "The diastolic BP is greater than 150 mm Hg or greater than 130 mm Hg when there are pre-existing complications. Unless intervention occurs promptly, a patient with hypertensive crisis may experience kidney failure, left ventricular heart failure, or stroke" S & S - severe HA, epistaxis (nosebleed), blurred vision, SOB, dyspnea, chest pain, dizziness, disorientation, anxiety, possibly seizures Nurse should start IV immediately if patient doesn't have one - get medications implemented quickly
Deep venous thrombosis (DVT)
occurs primarily in the lower extremity. Three factors promote venous thrombosis: (1) venous stasis (e.g., immobility, age, heart failure), (2) venous endothelial damage (e.g., trauma, surgery, intravenous medications), (3) hypercoagulable states Because DVT is usually asymptomatic and difficult to detect clinically, prevention is important in at-risk individuals and includes early ambulation, pneumatic devices, and prophylactic anticoagulation
Appropriate questions to ask concerning the discomfort during angina or MI include....
onset, location, radiation, intensity, duration, and precipitating and relieving factors COLDSPA If pain is present, ask the patient if the pain is in the chest, epigastric area, jaw, back, shoulder, or arm. Ask the patient to rate the pain on a scale of 0 to 10,
Angiography
or arteriography, is an invasive diagnostic procedure that involves fluoroscopy and the use of contrast media. This procedure is performed when an arterial obstruction, narrowing, or aneurysm is suspected.
Nitroglycerin
vasodilation to decrease venous return to the heart & workload of the heart; oxygenates ischemic heart
are anticoagulants best for the treatment of venous or arterial thrombosis?
venous
QRS complex
ventricular depolarization Ventrical contraction
T wave
ventricular repolarization and relaxation
hBNP (Human B-type Natriuretic Peptides)
elevated in heart failure less than 100 ( no HF) used to differentiate pulm versus cardiac disease as underlying cause of dyspnea
symptoms of impaired perfusion
pain, syncope, dizziness, dyspnea, edema, bleeding and bruising, fatigue
systemic vascular resistance (SVR).
resistance to the ejected blood created by the diameter of blood vessels receiving the blood, The smaller or more constricted the blood vessels, the greater the pressure required to open the semilunar valves to eject the blood Alternatively, the larger or more dilated the blood vessels, the less pressure required to eject blood; thereby reducing the workload on the heart
PTCA (percutaneous transluminal coronary angioplasty)
same as a PCI but using a balloon to help open the artery and inset a stent to keep the vessel open cracks the plaque open
s/s right sides heart failure
-fatigue -increased peripheral venous pressure -ascites -enlarged liver and spleen -may be secondary to chronic pulmonary problems -distended jugular veins -anorexia and complaints of GI distress -weight gain/ polyuria -dependent edema
Within which period of time would a nurse advise the client to anticipate pain relief will begin when nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina? 1 to 3 minutes 4 to 5 seconds 30 to 45 seconds 10 to 15 minutes
1 to 3 minutes
A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? (Select all that apply.) 1.Weight loss 2.Negative nitrogen balance 3.Increased urine specific gravity 4.Excessive loss of potassium ions 5.Pronounced retention of sodium ions
1.Weight loss 4.Excessive loss of potassium ions
metabolic syndrome
A syndrome marked by the presence of usually three or more of a group of factors (hypertension/abdominal obesity, hyperlipidemia, low HDL levels, and high fasting levels of blood sugar) that are linked to increased risk of cardiovascular disease and Type 2 diabetes.
Normal heart rate
60-100 bpm
embolus
A clot that breaks lose and travels through the bloodstream.
cardiac cycle
A complete heartbeat consisting of contraction and relaxation of both atria and both ventricles
pulmonary embolus (PE),
A venous thrombus can break off and travel to the lungs
Which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin ? Administer the injection via the Z-track technique Avoid massaging the injection site after the injection Use 2 of sterile normal saline to dilute the heparin. Inject the medication into the vastus lateralis muscle in the thigh.
Avoid massaging the injection site after the injection
what should the nurse assess before giving a beta blocker
BP and HR
Why can the use of beta blockers in diabetic patients be concerning?
Beta blockers can mask signs of hypoglycemia; therefore they must be used with caution in patients with diabetes
Veins
Blood vessels that carry blood back to the heart
bone marrow biopsy
Bone marrow biopsy. A bone marrow biopsy allows examination of bone marrow, which is used to evaluate patients with hematologic diseases
Perfusion
Circulation of blood within an organ or tissue in adequate amounts to meet current needs of the cells.
Which finding would be of most concern when the nurse is assessing a client with pulmonary embolism diagnosis who is receiving intravenous heparin? Client reports stools are black. Oxygen saturation is 93% Respiratory rate is 25 breaths per minute. Client has an ecchymosis on the ankle .
Client reports stools are black
orthostatic hypotension
Decrease in blood pressure related to positional or postural changes from lying to sitting or standing positions
Which symptom would the nurse include when teaching a client with arthritis who takes large doses of aspirin about the clinical manifestations of aspirin toxicity? Feelings of drowsiness Disturbances in hearing Intermittent constipation Metallic taste in the mouth
Disturbances in hearing
Furosemide
Diuretics (Loop) Diuresis, and mobilization of excess fluid (pleural effusions) Decreases BP Edema in HF, renal disease, hypertension hypovolemia, hypokalemia, dehydration, hypocalcemia, hyponatremia Assess for patient for skin rashes (SJS), monitor for orthostatic HP may have a cross reaction with thiazides and sulfonamides, monitor glucose and potassium levels in labs
Hypertension Medication types
Diuretics Angiotensin converting enzyme inhibitors Angiotensin II receptor blockers Beta-adrenergic blockers Calcium channel blockers
Which adverse effect would a nurse monitor for in a client taking clopidogrel ? Nausea Epistaxis Chest pain Elevated temperature
Epistaxis
Which adverse effect would a nurse monitor for in a client taking clopidogrel? Nausea Epistaxis Chest pain Elevated temperature
Epistaxis
Cardiac stress testing
Evaluates ability of heart to function with increased workload/under stress (increased HR) - ultrasounds Examines electrical rhythm Screens for asymptomatic CAD Types Exercise- walking on treadmill Pharmacologic-administration of medication to increase HR (e.g. dobutamine) NPO for 2-4 hours prior to test No caffeine or tobacco Typically patients do not take cardiac medications on day of test- could alter test results Get adequate rest the night before procedure Clients instructed on symptoms to report during test, sensations they may experience Vitals and 12 lead ECG will be monitored post- test
the lab BNP is most related to the detection of what cardiac incident?
Heart failure
Which action describes a therapeutic effect of atenolol ? Heart rate decreases Blood pressure increases Bronchospasm is relieved Pulse oximetry improves
Heart rate decreases
A client develops a deep vein thrombophlebitis in her leg 3 weeks after giving birth and is admitted for anticoagulant therapy. The nurse would anticipate developing a teaching plan for which anticoagulant ? Heparin Warfarin Clopidogrel Enoxaparin
Heparin
Which adverse effect of valsartan, an angiotensin receptor antagonist , will a nurse monitor for when prescribed for a client? Constipation Hyperkalemia Hypertension Change in visual acuity
Hyperkalemia
Which adverse medication effect will a nurse monitor for in a client with cirrhosis of liver who develops ascites and is prescribed spironolactone ? Bruising Tachycardia Hyperkalemia Hypoglycemia
Hyperkalemia
Long term effects of chronically uncontrolled hypertension
Hypertensive Crisis- Urgent and Emergent Long term effects of chronically uncontrolled BP -Renal failure -Stroke -Heart Failure -Coronary artery disease -Peripheral artery disease -Retinopathy -Myocardial Infarction
Hypertensive crisis
Hypertensive crisis (or malignant hypertension) is a severe type of elevated BP that rapidly progresses and is considered a medical emergency Unless intervention occurs promptly, a patient with hypertensive crisis may experience kidney failure, left ventricular heart failure, or stroke
warfarin inhibits what factors
II, VII, IX, X
Dabigatran inhibits what factors
IIa
Which mechanism of action explains how hydrochlorothiazide increases urine output? Increases the excretion of sodium Increases the glomerular filtration rate Decreases the reabsorption of potassium Increases renal perfusion
Increases the excretion of sodium
inadequate central perfusion in toddlers and children
Infants Poor feeding Poor weight gain Failure to thrive Dusky color Toddlers and children Squatting and fatigue Developmental delay (failure to hit milestones)
cardiac angiography
Invasive procedure to image the heart and blood vessels using radiopaque medium
Which vitamin is essential for the synthesis of prothrombin by the liver? B12 C D K
K
Left sided diastolic heart failure
LV does not accept enough blood from lungs; heart not able to fill during diastolic and stays in the lungs if nothing fills in the heart there is nothing to move to the body all about volume
hBNP- Human B-type natriuretic peptide test
Lab test elevated in heart failure < 100 normal (no heart failure) used to differentiate pulmonary versus cardiac disease as underlying cause of dyspnea
What is intermittent claudication?
Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance. treated with cilostazol
deep vein thrombosis (DVT)
blood clot (thrombus) forms in one or more deep veins, usually in the legs, that occludes the vein thereby impairing the blood return to the heart
peak flow meter
May be useful for clients who have frequent exacerbations who cannot seem to get their asthma under control, even with an appropriate medication regimen
Pericardium
Membrane surrounding the heart The pericardial fluid (about 20 ml) is secreted by cells of the mesothelial layer of the pericardium and lubricates the membranes that line the pericardial cavity, enabling them to slide smoothly over one another with minimal friction as the heart beats
Arteriogenesis
New artery growth branching from pre-existing arteries
Six P's of Arterial Insufficiency
Pain - what is it called? (COLDSPA) Pallor Pulselessness Paresthesia - burning/prickling Paralysis Poikilothermia (coolness)
Left side heart failure s/s
Paroxysmal nocturnal Dyspnea Pulm congestion Cough Crackles/ wheezes Blood tinged sputum Tachypnea Restlessness Confused Orthopnea Tachycardia Exertion dyspnea Fatigue Cyanosis
Troponin I and Troponin T
Preferred and most specific markers for cardiac injury they are part of the cardiac cells contractile apparatus and should only be present in the blood when there is damage to the heart muscle itself
Potassium-sparing Diuretics
Prototype: Spironolactone (Aldactone) - Blocks aldosterone causing loss of Na and water, and retention of K+ • Hyperkalemia (do not need K replacements)- NO SALT/ sodium SUBSTITUTES - Uses: Edema r/t HF - Contraindications: Hyperkalemia, Renal disease, Anuria - Drug-Drug: ACE inhibitors & ARBs= hyperkalemia
left heart
Systemic circulation Pumps blood through the body
stroke volume
The amount of blood ejected from the heart in one contraction.
left heart failure
The heart does not adequately circulate blood to systemic system. Due to pressure overload or volume overload Lung fluid overload
What is a specific adverse effect of Nifedipine? And how can we counteract it?
Reflects tachycardia We can counteractive with using a beta blocker concurrently
dyastole
Relaxation of the heart The phase of the cardiac cycle when ventricles fill with blood is called diastole Coronary arteries fill
Oxygen
Used in ox and respiratory therapy to increase Ox concentrations Ox toxicity, tachypnea Monitor respirations And o2 stats Improvement in respirations and o2 stats
Diets for those with high cholesterol
Veggies Fruits Whole grains Low fat dairy Poultry (no fried) Some nuts Legumes Limit sweets, fats, red meats Reduce trans fats
what medication should be evaluated before giving nitroglycerin?
Viagra (sildenafil)
Which medication increases the risk of hematuria? Warfarin Cimetidine Phenazopyridine Nitrofurantoin
Warfarin
apixaban, edoxaban, rivaroxaban inhibit what factors
Xa
arteriosclerosis
abnormal hardening of the walls of an artery or arteries Associated with age
anoxia
absence of oxygen
ischemia
an inadequate blood supply to an organ or part of the body, especially the heart muscles.
ACE inhibitors
angiotensin converting enzyme inhibitors • Action: inhibits ACE, blocking vasoconstriction; decreasing BP (decreasing afterload) and increasing K+ and decrease Na & water retention (decreases preload) and afterload • Prototype: captopril, benazepril, enalapril the treatment of hypertension, heart failure, and diabetic nephropathy; in addition, these drugs are indicated for myocardial infarction (MI) and prevention of cardiovascular events Side effects: irritating cough, hyperkalemia, renal failure
why would a patient who recently had an MI be presenting with a fever?
because the heart now has ischemia and potential infarction/ dead tissue, the body creates an inflammatory response to counteract and clean up the dead tissues.
vitamin K
blood clotting antidote for warfarin
angina pectoris
chest pain that results when the heart does not get enough oxygen imbalance between the coronary arteries' ability to supply O2 and the hearts demand
Beta Blockers
decrease heart rate and dilate arteries by blocking beta receptors
the older adult has increase or decreased RBCs and WBCs
decreased
syncope
fainting loss of consciousness due to inadequate cerebral perfusion
womens presentation of MI
feels like indigestion heart rate/ flutter tired/ fatigued feeling like heart burn shoulder pain or back pain tend to not seek care right away SOB
Angiogenesis
formation of new blood vessels
central perfusion
generated by cardiac output—the amount of blood pumped by the heart each minute
Risk factors for cardiovascular disease
genetic predisposition smoking, inactivity, an unhealthy diet, and obesity hypertension, type 2 diabetes mellitus,
Serum Lipids
measured to detect hyperlipidemia and include cholesterol lipoproteins (low-density lipoproteins [LDLs], high-density lipoproteins [HDLs], very low-density lipoproteins [VLDs]), and triglycerides. Lipoproteins are an accurate predictor of heart disease. High levels of LDL adhere to the endothelium obstructing blood flow. The function of HDL is to remove lipids from the endothelium to provide a protective effect against heart disease
ejection fraction
measurement of the volume percentage of left ventricular contents ejected with each contraction Measure of stroke volume
Spirolactone
potassium sparing diuretic Blocks aldosterone in distal tubule used for: Hypertension, edema associated with cirrhosis and nephrotic syndrome SJS, arrythmias, hyperkalemia, hyponatremia, GI irritation, muscle cramps, dizziness, gynecomastia, headache Assess for rash, fluid volume, avoid salt substitutes Improve hypertension and BP, decrease edema, prevent hypokalemia (may cause Hyper) administer early in the day Avoid ACE and ARBS- can increase potassium
what position would we lay a pt down in during orthostatic hypotension
supine
Tissue perfusion
to blood that flows through arteries and capillaries to target tissues The valves in each vein keep blood flowing in a forward direction toward the heart.
Non-pharmacologic measures to control angina
• Avoid heavy meals, smoking, extremes in weather changes, strenous exercise, and emotional upset • Proper nutrition, moderate exercise, adequate rest, and relaxation techniques
Ride side heart failure s/s
Fatigue Increase in peripheral venous pressure Ascites Enlarged liver and spleen Distended jugular vein Anorexia Gi distress Weight gain Dependent edema Could be secondary to chronic pulmonary problems
Which topic would the nurse include when doing discharge teaching about ways to avoid another venous thrombosis when caring for a client hospitalized with deep vein thrombosis? Daily use Frequent ambulation Warm to legs Avoidance of cold
Frequent ambulation
Which important nursing action would be taken after a health care provider prescribes losartan for a client? Assess the client for hypokalemia Administer the medication with food. Monitor the client's blood pressure Monitor serum glucose levels
Monitor the client's blood pressure
right sided heart failure
, the blood backs up into the right atrium and venous circulation, producing edema of legs, feet, and ankles, and weight gain from fluid retention
ARBs (Angiotensin 2 receptor blockers)
ARBs Angiotensin 2 receptor blockers Blocking the action of angiotensin II helps to lower blood pressure and prevent damage to the heart and kidneys. decrease preload and afterload
Which medication is often contraindicated when taking warfarin ? Atenolol Ferrous sulfate Chlorpromazine Acetylsalicylic acid
Acetylsalicylic acid
Heparin‑induced thrombocytopenia (HIT)
An immunity‑mediated clotting disorder that causes unexplained low blood platelet count as a result of treatment with heparin •Female sex •Receiving heparin longer than 1 week •Exposure to unfractionated heparin •Postsurgical thromboprophylaxis (prevention of thromboembolic disease)
ARBs
Angiotensin II Receptor Blockers • Action: vasodilation & decreased BP (decreases afterload) and increasing K+ and decrease Na & water retention (decreases preload) • Prototype: Losartan (Cozaar) - Valsartan (Diovan) - Irbesartan (Avapro) • SE: hypotension, ANGIOEDEMA, HA, dizziness, GI complaints • Do not use w/ ACE inhib. Use: MI Hypertension HF - decrease resistance
Which information will the nurse plan to include in the discharge teaching plan for a client who has been admitted for a pulmonary embolism and has a new prescription for an oral anticoagulant? Select all that apply. One, some, or all responses may be correct. Floss twice daily to prevent the need for dental work Avoid eating hot food or liquid that can burn the mouth Use an electric shaver instead of a straight-bladed razor Apply ice to any areas of trauma like bumps and scrapes Use enemas to prevent straining during bowel movements
Avoid eating hot food or liquid that can burn the mouth Use an electric shaver instead of a straight-bladed razor Apply ice to any areas of trauma like bumps and scrapes
what are the drugs of choice for African Americans with hypertension?
Calcium channel blockers work better than ACE and ARBS
Tetrology of Fallot
DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Squatting Cyanosis Clubbing Sycope Heart defect allowing unoxygenated blood to be distributed throughout the body
Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema ? Furosemide Chlorothiazide Spironolactone Acetazolamide
Furosemide
The nurse identifies which anticoagulant medications as safe to administer during pregnancy for treatment of thrombophlebitis? Select all that apply. One, some, or all responses may be correct Heparin Warfarin Enoxaparin Clopidogrel Acetylsalicylic acid
Heparin Enoxaparin
Which priority nursing action would the nurse implement first when caring for a client receiving nitroglycerin for the treatment of angina? Instruct the client to sit or stand slowly Monitor the client's urine output frequently Advise the client to report when experiencing a headache Instruct client to notify the health care provider if pain does not subside after 5 minutes
Instruct the client to sit or stand slowly
priority interventions of PE
O2 and sats high fowlers telemetry IV access morphine and sedatives IV fluids administer anticoagulants assess for bleedings
Thromocytopenia
Platelets Thrombocytopenia less than 150,000 mm3 (150,000 - 400,000 mm3) more severe the more risk of bleedings - Decreased platelet production/Destruction - increased consumption of platelets - splenic sequestering- platelets are trapped in the spleen making the spleen larger acquired- HIIV, Epstein bar, chemo Cues: petechiae (tiny spots on their body) bruising, purpura, bleeding
what is a drug you should not take with ACEs or ARBs? why?
Spironolactone These drugs inhibit potassium excretion, we want to prevent hyperkalemia
s/s of myocardial infarction
Sudden onset and severe Substernal Crushing Tightness May radiate to the back, neck, jaw, shoulder, and arm Dyspnea Syncope N/V Weakness Diaphoresis Increase in HR
Dyslipidemia
abnormal blood lipid levels, including high total, low-density lipoprotein, and triglyceride levels as well as low high-density lipoprotein levels LDL- delivery of cholesterol to the tissues, and an increased serum concentration is a strong indicator of coronary risk. plays a role in endothelial injury, inflammation, and immune responses that have been identified as being important in atherogenesis HDL- "reverse cholesterol transport," which returns excess cholesterol from the tissues to the liver for processing or elimination in the bile. participates in endothelial repair and decreases thrombosis. Low levels of HDL cholesterol also are a strong indicator of coronary risk. Exercise, weight loss, fish oil consumption, and moderate alcohol use result in modest increases in HDL level
Mucolytics
agents that destroy or dissolve mucus Note: a productive cough should not be suppressed unless it interferes with sleep - helps to get bacteria out and to prevent the growth of pneumonia -Acetylcysteine -Dornase alfa -Guaifenesin -Guaifenesin and dextromethorphan (Mucinex DM) - thins secretions and raises cough threshold
thrombus
blood clot that remains attached to a vessel wall A detached thrombus is a thromboembolus. Venous thrombi are more common than arterial thrombi because flow and pressure are lower in the veins than in the arteries. Three factors promote venous thrombosis: (1) venous stasis (e.g., immobility, age, heart failure), (2) venous endothelial damage (e.g., trauma, surgery, intravenous medications), (3) hypercoagulable states (e.g., inherited disorders, malignancy, pregnancy, use of oral contraceptives or hormone replacement therapy). Orthopedic trauma or surgery Accumulation of clotting factors and platelets leads to thrombus formation in the vein, often near a venous valve. If the thrombus creates significant obstruction to venous blood flow, increased pressure in the vein behind the clot may lead to edema of the extremity.
Arteries
carry blood away from the heart
atrial fibrillation
characterized by disorganized electrical activity due to impulses triggering atrial contraction that are not initiated from the SA node. The result is ineffective atrial contraction, with atrial rates as high as 350 to 600 beats/min. Because the ventricles do not have time to fill, cardiac output is reduced. The pulse rhythm is irregularly irregular Clots may form in the atria due to blood stasis, which can become emboli that flow to the brain causing strokes
chronic stable angina
chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms Occurs with moderate to prolonged exertion and in a pattern that's familiar to the patient
apixaban (Eliquis) dabigatran (Pradexa) rivaroxaban (Xarelto) edoxaban (Savaysa)
decrease risk of bleedings (ORAL) used for strokes, DVTs and PEs inhibition of thrombin -Binds to the active site, thereby inactivating both fibrin-bound and unbound fibrin - Prevention thromboembolism in patient Adverse effects -Low risk of bleeding -Gastrointestinal (GI) disturbances à N/V, GI upset Idarucizumab as antidote Drug to drug interaction
hypocoagulability
decreased ability to clot too few platelets causes: meds, disorders
Hypoxia
deficiency in the amount of oxygen reaching the tissues
Hemophilia
group of inherited bleeding disorders caused by a gene mutation leading to the absence of or ineffective production of clotting protein factors. This genetic recessive disorder of the X chromosome affects only males, although females can be carriers of the hemophilia gene. factors 8 and 9
cardiac output
heart rate x stroke volume
risks for DVTs
hip surgery total knee replacement open prostate surgery colitis HF cancer trauma local vein damage repetitive motion injury
education regarding asthma-
immune boosting supplements cleaning allergy meds hand hygiene vaccines how to use inhalers carrying inhalers
DASH diet
increase fruit, vegetables, and low fat dairy; k, mg, ca Prevention of elevated hypertension
Ischemia
lack of blood flow to the tissues is a reversible cellular injury that occurs when the demand for oxygen exceeds the supply because of a reduction or cessation of blood flow. if prolonged, it may result in a lack of oxygen to tissues followed by necrosis and irreversible cellular injury.
Teaching for HF patients
let provider know if you have a cold be active as possible low sodium monitor weight Is/Os
Deep venous thrombosis (DVT)
occurs primarily in the lower extremity. Because DVT is usually asymptomatic and difficult to detect clinically, prevention is important in at-risk individuals and includes early ambulation, pneumatic devices, and prophylactic anticoagulation Management most often consists of anticoagulation therapy using heparin (low-molecular-weight heparin) and warfarin
Thrombocytopenia cues and diagnostic methods
petechiae purpura bleeding- gums, GI- blood in the stool, ears, blood in urine (hematuria), coffee ground emesis *if starting during an anticoagulant or antiplatelet therapy, stop the infusion!! CBC, PT/PTT blood smear bone marrow spleen US
Which drug action will the nurse include when describing the purpose of heparin in a client who develops thrombophlebitis in the right calf and is prescribed bed rest and initiated on an intravenous (IV) infusion of heparin? prevents extension of the It reduces the size of the thrombus It dissolves the blood clot in the vein. It facilitates absorption of red blood cells.
prevents extension of the
Right heart
pulmonary circulation
hypertensive crisis
rapidly progressive hypertension in which systolic pressure is ≥180 mmHg and or diastolic pressure is ≥120 mmHg.
Anticoagulant drugs
reduce the likelihood of blood clotting and formation of fibrin reduce the formation of fibrin inhibits the synthesis of clotting factors and the activity of clotting factors Inhibit clotting factors 2a and 10a
Contractility
refers to the strength of myocardial contraction. The greater the volume of blood in the ventricles (preload), the greater the stretch of the myocardium, and the stronger the myocardial contraction.
Prothrombin Time (PT)
test of the ability of blood to clot
Stroke volume.
the amount of blood ejected from each ventricle during contraction. It is affected by three factors: preload, contractility, and afterload.
Why should you gradually stop hypertensive drugs?
the body is used to being at a lower BP state by stopping them immediately, this could cause a rebound Hypertensive crisis
Left sided heart failure
the most common type, the impairment, causes blood to back up into the left atrium and pulmonary veins Causes dyspnea; coughing up pink, foamy mucus; and irregular heartbeat (S3 heart sound).
hemostasis
to stop or control bleeding 3 major processes- constriction of blood vessels (slows bleeding and presses against vessels) activity of the platelets (primary hemostasis, platelets plug site of injury) activity of clotting factors (when they combine with a glycoprotein they become active)
Renin-Angiotensin-Aldosterone System blockade
use an angiotensin converting enzyme inhibitor or angiotensin receptor blocker to inhibit RAS and enhance ventricular remodeling after MI
Cilostazol
used for intermittent claudication vasodilated and is an antiplatelets
thrombohlebitis
vein inflammation that happens in connection with one or more blood clots
verapamil, diltiazem amlodipine, nifedipine
• Calcium blockers decreases cardiac demand, relax arteriole spasm and relax smooth muscle in the arteries, Antihypertensives - Decreases contractility, afterload, BP, 02 demand Decreased risk of HF/death in Pt with left sided HF Peripheral Edema, hypotension, dizziness/fatigue, bradycardia, headache watch for reflex tachycardia (BP is too low and HR automatically increases to increase blood flow to body) Dont give with digoxin- increase risk of AV block Verapamil- HR and BP Nifedipine-BP ( can cars reflects tachycardia. Can be used with a beta blocker to prevent this.)
six Ps" of ischemia
• Pain • Pallor • Pulselessness • Paresthesia • Paralysis • Poikilothermy (coolness) Anticoagulant therapy with unfractionated heparin (UFH) is usually the first intervention to prevent further clot formation
treatment of Heparin‑induced thrombocytopenia (HIT)
•Anticoagulants with direct thrombin inhibitor (argatroban, lepirudin, bivalirudin)
treatment of thrombotic thrombocytopenic purpura (TTP)
•Antiplatelet medications (aspirin, alprostadil, plicamycin) •Immunosuppressive therapy decreases the intensity of complications.
treatment of idiopathic thrombocytopenic purpura
•Hemoglobin (↓) •Platelet levels (↓) •Blood type and cross match •Corticosteroids and immunosuppressants •Splenectomy can be performed if the client does not respond to medical management.
Which information would the nurse include when preparing a teaching plan for a client prescribed sublingual nitroglycerin ? "Place the tablet under the tongue or between the cheek and gums." takes 30 to 45 minutes for the nitroglycerin to achieve its effect" If dizziness occurs, take a few deep breaths and lean the head back" "To facilitate absorption, drink a large glass of water after taking the medication."
"Place the tablet under the tongue or between the cheek and gums."
Diclofenac
CONTRAINDICATED IN HF NSAID Inhibits prostaglandins synthesis Suppress pain and inflammation, relief of acute migraine attacks HF, MI, STROKE, edema, hypertension, GI bleeding, hyperkalemia, contact dermatitis, dry skin and dizziness, headache is contraindicated in pts. with heart failure, ischemic heart dx, peripheral vascular disease, and cerebrovascular dx due to increased risk of thrombosis
I in THROMBINS2
Invasive Cardiac Interventions i.e. PCI (Percutaneous Coronary Intervention) -Invasive but nonsurgical technique that is PERFORMED WITHIN 90 MINUTES of an acute MI (AMI) Applies to STEMI PTS diagnosis - hint: commit 90 minutes to memory! -Ideally facility has a 24 hour cath lab! -Hospitals required to report how many patients with AMI receive PCI within that 90 minute time frame per the AMI Core Measure Set. -Using coronary angiography -Clot may be removed -Angioplasty (balloon inflation) and stent placement used to open up narrowed or occluded artery
Which response indicates that sublingual nitroglycerin prescribed for a client with unstable angina is effective ? Pain subsides as a result of arteriole and venous dilation. Pulse rate increases because the cardiac output has been stimulated Sublingual area tingles because sensory nerves are being triggered. Capacity for activity improves as a response to increased collateral circulation
Pain subsides as a result of arteriole and venous dilation.
PCI
Percutaneous coronary intervention (placement of a catheter and stent in a coronary artery to open the artery; balloon angioplasty) Goal is to improve blood flow to myocardium Purpose is to "crack" atheroma * stretches the coronary artery * goal: improve blood flow Placed to prevent restenosis & recoil Mesh is used to keep artery open
Thrombotic thrombocytopenic purpura (TTP)
Platelets abnormally clump together in capillaries due to an autoimmune reaction from platelet aggregation, resulting in an insufficient quantity in circulation . This can lead to kidney failure, myocardial infarction, and stroke, and can be fatal within 3 months if untreated
echocardiology
Process of evaluating heart and vessels structures using an ultrasound Transthoracic Ultrasound of the heart - noninvasive -Used to diagnose valve disorders, pericardial effusion, left ventricular malfunction, ventricular aneurysms, cardiac tumors, and cardiomyopathy. -Preprocedure - explain reason for test and that it takes 30 minutes to 1 hour. -Intra procedure - client lies on left side and remains still.
High-density lipoprotein (HDL)
blood fat that helps transport cholesterol out of the arteries, thereby protecting against heart disease Good
low-density lipoprotein (LDL)
blood fat that transports cholesterol to organs and tissues; excess amounts result in the accumulation of fatty deposits on artery walls Bad
MONA:
morphine, oxygen, nitrates, aspirin Management of acute coronary syndrome
-stenosis
narrowing
patients who have a history of Heparin induced Thrombocytopenia... should they receive heparin again?
no best to give them a new anticoagulant
The nurse provides education to a client about the side effects of furosemide (Lasix). Which client statements indicate that the teaching is understood? (Select all that apply.) "I must not eat citrus fruits." "I should wear dark glasses." "I should avoid lying flat in bed." "I should change my position slowly." "I must eat a food that contains potassium every day."
"I should change my position slowly." "I must eat a food that contains potassium every day."
Which instruction would the nurse include when teaching about hydrochlorothiazide given to a client diagnosed with a transient ischemic attack (TIA) related to hypertension? "Resume regular eating habits. "Drink a protein supplement daily" " Avoid eating foods high in insoluble fiber." "Increase the intake of potassium-rich foods.
"Increase the intake of potassium-rich foods.
How would a nurse respond to the spouse of a client with an intracranial hemorrhag asks the nurse , "Why aren't they administering an anticoagulant ?" "It is not advisable because bleeding will increase ." "If necessary, it will be started to enhance circulation." "If necessary, it will be started to prevent pulmonary thrombosis." "It is inadvisable because it masks the effects of the hemorrhage ."
"It is not advisable because bleeding will increase ."
Which statement by a client who had an endarterectomy that is prescribed clopidogrel would cause the nurse to conclude that teaching was effective? Clopidogrel will limit inflammation around my incision. "Taking this medication will help prevent further clogging of my arteries" The medication will lower the slight fever I have had since surgery I will take this medication to reduce the discomfort feel at the surgical incision."
"Taking this medication will help prevent further clogging of my arteries"
A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." Which response would the nurse provide? "This is related to your illness rather than to your medication." "This is an expected side effect; you will become accustomed to it over time." "This side effect is only temporary. You should continue the medication." "The medication may need to be discontinued. Come to the clinic this afternoon."
"The medication may need to be discontinued. Come to the clinic this afternoon."
Dobutamine
(IV for acute HF) Adrenergic- HAR Increased cardiac output without significantly increased HR Short term (48 hours) management of heart failure caused by depressed contractility from organic heart disease Phlebitis, Hypertension, increased heart rate, premature ventricular contractions, angina pectoris, arrythmias, hypotension, palpitations, nausea, vomiting, headache, SOB Give in a large veins
meds for atherosclerosis
- statins Ex. Atorvastatin, lovastatin, simvastatin, pitavastatin Used in conjunction with : low, fat diet, exercise, tobacco cessation
Interventions for acute coronary syndrome
-12 lead ECG within 10 min -Cardiac Profile (Troponin level) -Medications -Percutaneous Coronary Intervention -Relieve Anxiety (examples therapeutic communication?)
Patient Teaching Peripheral Arterial Disease (PAD)
-Avoid crossing the legs -Refrain from wearing restrictive garments (e.g. compression socks, compression leggings, or anti embolic stockings) - pulls blood away from extremities and towards the heart -Do not apply direct heat (e.g. electric blanket, heating pad, hot water bottle) to affected extremity because sensitivity is decreased - may lead to burn -Keep environment comfortably warm (may need to turn up thermostat!) and wear insulated socks -Avoid nicotine, stress, and caffeine (causes vasoconstriction) -Avoid going barefoot (why?). Wear well-fitting, supportive shoes! -Care: Legs and feet should be washed daily. Clean skin is less at risk for breaks in skin integrity or ulcer formation. Legs and feet should be patted dry. Thorough drying (especially between the toes) is important. Apply moisturizing cream after drying skin (reduces risk of drying and cracks, which could put client at risk for infection). -It's OK to elevate legs to alleviate swelling, but not above level of the heart because extreme elevation slows arterial blood flow to feet -Use a bed cradle (A bed cradle is a frame that is placed under sheets and blankets to keep the sheets and blankets from touching the legs and feet. In persons with poor arterial circulation, even the slight pressure of sheets and blankets can increase risk for skin trauma and skin ulcers).
hypertensive crisis nursing care
-Place patient in Semi-Fowler's position - Administer oxygen as needed (watch pulse ox!) -Obtain IV access (2 large bore IVs) -Administer IV antihypertensive(s) per orders. Gradual reduction preferred to reduce risk of cerebral ischemia, MI, and renal failure -Monitor BP every 5 to 15 minutes before, during, and after administration of an IV hypertensive - not low -Observe for s/s of target organ damage (kidneys-watch hourly urinary output) -Monitor EKG to assess cardiac status (why?)
Asthmatic Children with Severe Hypoxia
-Profuse diaphoresis- working too hard to breathe and using accessory muscles -Agitated and suddenly becomes quiet - ominous sign / "silent chest" - BAD! -Inspiratory and expiratory wheezing -Cyanotic nail beds -Nasal flaring -Intercostal retractions (accessory muscle use) (These are serious signs and indicate that the child needs immediate intervention).
How would the nurse determine if a client is experiencing the therapeutic effect of valsartan? Check a lipid profile. Assess an apical pulse. Measure urinary output . Check the blood pressure .
. Check the blood pressure .
Which instruction will the nurse teach the client who had a femoropopliteal bypass graft and is receiving clopidogrel postoperatively ? Eliminate starches and red meats from the diet. Eat more roughage if constipation occurs . Report any occurrence of multiple bruises. Take the medication on an empty stomach.
. Report any occurrence of multiple bruises.
Within which period of time would a nurse advise the client to anticipate pain relief will begin when nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina ? 1to 3 minutes 4 to 5 seconds 30 to 45 seconds 10 to 15 minutes
1to 3 minutes
clopidogrel
Antiplatelet agents Acute coronary syndrome, patients with established peripheral arterial disease, recent MI and or stroke Gi bleeding, neutropenia, dizziness, eosinophilia, cough, dyspnea, fatigue, edema, hypertension, chest pain Monitor bleeding time, CBCs, and signs of thrombotic thrombocytopenic purpura, take meds as directed
Aspirin
Antiplatelet agents Prophylaxis of ischemic attacks and MI Decrease platelet aggregation s/s: DRESS, rash Tinnitus , GI bleeding, dyspepsia, nausea, abdominal pain , vomiting, Anemia DO not give give to children Careful with pts with asthma, allergies, renal failure Monitor for symptoms of dress
Recognizing Cues: Priority Problems with ACS
1. Acute pain due to an imbalance between myocardial oxygen supply and demand 2. Decreased myocardial tissue perfusion due to interruption of arterial blood flow 3. Potential for dysrhythmias due to ischemia and ventricular irritability 4. Potential for heart failure due to left ventricular dysfunction
Omeprazole
Antiulcer agents Diminished accumulation of acid in the gastric lumen with lessened gastroesophageal reflux, healing of duodenal ulcers Heart burn, GERD Chest pain, C-diff, dizziness, drowsiness fatigue, headache, weakness, itching, rash, diarrhea, nausea and vomiting Monitor bowel functions and for black tarry stools, may cause drowsiness or dizziness
Direct Factor Xa Inhibitors
Apixaban, edoxaban, fondaparinux, and rivaroxaban Selectively and reversibly blocking the activity of clotting factor Xa, preventing clot formation. -do not affect platelet aggregation -Treatment and prevention of DVT and acute pulmonary embolism*, and to reduce the risk of stroke and embolism in people with nonvalvular ATRIL FIB. Do not require routine monitoring Contraindicated in pregnancy Adverse reaction: bleeding
The nurse prepares to administer vitamin K to a newborn. Which rationale explains why newborns deficient in this vitamin ? Alterations in blood coagulation interfere with vitamin K production A newborn's liver does not produce it immediately after birth Increased bilirubin levels interfere with vitamin K synthesis during the neonatal period. A newborn's intestinal tract does not synthesize it for several days after birth
A newborn's intestinal tract does not synthesize it for several days after birth
Troponin
A protein of muscle that together with tropomyosin forms a regulatory protein complex controlling the interaction of actin and myosin and that when combined with calcium ions permits muscular contraction this will be checked in a acute situation of chest pain indicates damage to the heart
cardiogenic shock
A state in which not enough oxygen is delivered to the tissues of the body, caused by low output of blood from the heart. It can be a severe complication of a large acute myocardial infarction, as well as other conditions. Necrosis of more than 40% of left ventricle has occurred. Class 4 hear failure
The nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? 59-yearold who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery 76-year-old who has a history of thrombocytopenia
59-yearold who had a knee replacement
Asthma
A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing. Most common chronic disease of childhood! Prevalence, morbidity, and mortality increasing in U.S. Allergic - Atopy - genetic predisposition for development of IgE mediated response - strongest predisposing factor (20-40% of children have no evidence of allergic disease)! Adult onset (about half of adults with asthma had the disease in childhood)
******valsartan losartan
ARBs Angiotensin 2 receptor blockers Lowering BP in patients with hypertension Decreased risk of HF Decreased risk of death due to cardiovascular causes in Pt with left sided HF Treatment of HF and hypertension Reduce risk of death due to left sided HF Edema, hypotension, hypovolemia, hyperkalemia, dizziness, fatigue, headache, angioedema, backpain, renal dysfunction Instruct patient to notify if signs of Angioedema, hypotension, may cause dizziness Volume depletion should be correct May be taken with food Decreased in BP without appearance of excessive side effects, Decreased heart failure related hospital visits in pts with HF Decreased risk of death
Glycoprotein (GP) IIb/IIIa receptor antagonists Abciximab (ReoPro)
Abciximab (ReoPro) Dipyridamole Most effective antiplatelet drugs "Super aspirins" Reversible blockade of platelet GP IIb/IIIa receptors Used in conjunction with aspirin and heparin Therapeutic use: Acute coronary syndromes Percutaneous coronary interventions Binds to platelets in the vicinity of GP IIb/IIIa receptors, thereby preventing the receptors from binding fibrinogen Approved for IV therapy of ACS and for patients undergoing PCI Adverse effect : bleeding Antiplatelet effects persist for 24 to 48 hours after the infusion is stopped
Signs and Symptoms Asthma Attack
Accessory Muscle Use (During attack) Shortness of Breath/ Dyspnea (chest tight, breathlessness - difficult to breathe) Tight Chest/ Tachypnea High Pitched Wheezing (sounds like whistle) Minimal/ diminished breath sounds/silent chest Air Trapping. . . Leading to respiratory Acidosis (leads to prolonged exhalation) Clients with asthma will often have a cough: Initially nonproductive, but may become rattling and productive of clear, frothy, gelatinous sputum. Cough occurs especially at night or early morning. Healthy People 2030 and Asthma: Healthy People 2030
lisinopril enalapril captopril Anything that ends in - Pril
Ace inhibitor Treatment of proteinuria, Lowering of BP in patients with hypertension, and reduction of syndrome in patients with symptomatic heart failure. Decreased development of HF (decrease in preload and afterload ) S/s- Hypotension, chest pain, rash, hyperkalemia, abdominal pain, d/n/v, COUGH, proteinuria, impaired renal function, cough, dyspnea, ANGIOEDEMA Assess patient for angioedema, monitor weight and labs May cause decrease in cardiac output Change positions slowly to minimize orthostatic hypotension
Lab used to determine therapeutic dose of IV heparin
Activated partial thromboplastin time (APTT) 70s
Which measure would the nurse take when administering enoxaparin subcutaneously? Push over 2 minutes Administer in the abdomen. Massage site after administration Remove air pocket from prepackaged syringe before administration.
Administer in the abdomen.
atypical angina
Angina with vague presentation such as indigestion, pain between the shoulders, an aching jaw, or choking sensation that occurs with exertion.
Nitroglycerine
Antianginals used especially if aspirin is not working increased cardiac output and reduction in BP Increase in Coronary blood, dilates the coronary arteries and produce vasodilation, decrease in myocardial Hypotension, reflex tachycardia (BP too low) , syncope, blurred, dizziness, headache, restlessness, weakness, nausea, vomiting IF the nitroglycerine is not working within 15 min, call 911 DO NOT GIVE WITH VIAGRA, check expiration date and keep in original bottle
Digoxin
Antiarrhythmics- cardiac glycoside HAR- narrow therapeutic window Increased cardiac output and slowing of the HR Increased the force myocardial contraction Prolongs refractory period of AV node decreases conduction through the SA and AV nodes hypokalemia can lead to digoxin toxicity HF, atrial fibrillation and atrial flutter, paroxysmal atrial tachycardia dig toxic: Arrythmias, bradycardia, ECG changes, blurred vision, yellow or green vision, anorexia, nausea, vomiting, diarrhea, fatigue Monitor ECG, observe for signs of toxicity med to reverse Dig toxicity- digibine (antidote) ***BEFORE GIVING THIS MED, YOU NEED TO TAKE A PULSE FOR 1 MIN
heparin
Anticoagulant: RAPID Prevention of thrombus formation, and extension of existing thrombi Rapid acting acticoagulant administered IV and SQ S/S: bleeding and hemorrhage, bruising, black tarry stools, hematuria, thrombocytopenia, pain at injection site, fever *preferred anticoagulant during pregnancy and when rapid relief is needed (PE, DVT, and evolving stroke) Antidote: Protamine Sulfate- too much heparin LAB: Activated PTT
treatment of Disseminated intravascular coagulation (DIC)
Anticoagulants (heparin) can be used to decrease micro clots from forming and using up clotting factors.
Contraindicated drugs in heart failure
Antidysrhythmics Calcium channel blockers NSAIDs
valsartan or losartan
Antihypertensives ARBs Decreased risk of HF/ death due to cardiovascular causes in Pt with left sided HF Edema, hypotension, hypovolemia, hyperkalemia, dizziness, fatigue, headache, angioedema, renal dysfunction Instruct patient to notify if signs of Angioedema, hypotension
******Valsartan
Antihypertensives Angiotensin 2 receptor antagonists Lowering BP in patients with hypertension Decreased risk of HF Decreased risk of death due to cardiovascular causes in Pt with left sided HF Treatment of HF and hypertension Reduce risk of death due to left sided HF Edema, hypotension, hypovolemia, hyperkalemia, dizziness, fatigue, headache, angioedema, backpain, renal dysfunction Instruct patient to notify if signs of Angioedema, hypotension, may cause dizziness Volume depletion should be correct May be taken with food Decreased in BP without appearance of excessive side effects, Decreased heart failure related hospital visits in pts with HF Decreased risk of death
aspirin
Antiplatelet First line often paired with Clopidogrel Antiplatelet agents Antipyretics NSAID Prophylaxis of ischemic attacks and MI Produce analgesia, and reduce inflammation and fever, Decrease platelet aggregation reduce inflammation, GI bleeding DO not give give to children Careful with pts with asthma, allergies, renal failure
Clopidogrel (Plavix)
Antiplatelet works similarly to Ticlopidine Block P2Y12 ADP receptors on the platelet surface, preventing ADP-stimulated aggregation Uses: acute coronary syndromes (ACSs), defined as unstable angina or MI. ACS----use with Aspirin Adverse effects similar to those of aspirin Rare: Thrombotic Thrombocytopenic Purpura (TTP) DC before surgery Use with caution in patients taking other drugs that promote bleeding Give with a PPI
When a client who has thrombophlebitis tells the nurse, "am worried about getting a clot in my lungs that will kill me," which action will the nurse take next? Ask what the client already knows about complications of thrombophlebitis . Tell the client that most people with thrombophlebitis do not develop pulmonary emboli. Teach the client that anticoagulant use helps decrease the risk for a pulmonary embolism . Instruct the client to tell the nursing staff about any chest pain of shortness of breath .
Ask what the client already knows about complications of thrombophlebitis .
Which medication is indicated to prevent progression of a myocardial infarction for a client admitted to the emergency department with crushing chest pain? Aspirin Atropine Gabapentin Epinephrine
Aspirin
Which nursing action would be included in the plan of care when a client is admitted with thrombocytopenia? Select all that apply. One, some, or all responses may be correct. Avoid intramuscular injections . Institute neutropenic precautions. Monitor the white blood cell (WBC) count Administer prescribed anticoagulants Examine the skin for ecchymotic areas .
Avoid intramuscular injections . Examine the skin for ecchymotic areas .
Which technique will the nurse employ to prevent excessive bruising when administering subcutaneous heparin ? Administer the injection via the track technique Avoid massaging the injection site after the injection Use 2 ml of sterile normal saline to dilute the heparin Inject the medication into the vastus lateralis muscle in the thigh
Avoid massaging the injection site after the injection
Which discharge instruction would the nurse give the client to decrease the risk of thromboembolic events after an abdominal hysterectomy ? Avoid sitting for long periods of time. Limit fluids to less than 2000 per day Have a blood coagulation test every 2 weeks Continue with hormone replacement therapy
Avoid sitting for long periods of time.
B in THROMBIN
B- Beta Blockers Physician usually prescribes a cardio selective beta blocker within the first 1-2 hours after an M.I. if the patient is hemodynamically stable (e.g. no bradycardia and B/P within normal range) Help to decrease the size of the infarct, the occurrence of ventricular dysrhythmias, and mortality rates in patients with M.I. (improves outcomes!) Allows heart to perform more work without ischemia (helps to cause a decrease in heart rate - WHY WOULDN'T YOU WANT YOUR PATIENT WHO IS EXPERIENCING OR HAS RECENTLY EXPERIENCED AN M.I. TO BE TACHYCARDIC?) increase need for o2 Unless contraindicated, all patients experiencing NSTEMI and STEMI should be discharged on beta blocker therapy DO NOT give with a calcium channel blocker or if HR or BP is too low
Which effect of atenolol is responsible for frequent dizziness in a client with hypertension? Depleting acetylcholine Stimulating histamine release Blocking the adrenergic response Decreasing adrenal release of epinephrine
Blocking the adrenergic response
Calcium Channel Blockers
CONTRAINDICATED IN HF lower blood pressure by interfering with the transmembrane flux of calcium ions. This results in vasodilation, which decreases blood pressure. These drugs also block sinoatrial (SA) and atrioventricular (AV) node conduction, resulting in a decreased heart rate (HR). Calcium channel blockers, in combination withthiazide diuretics, are first-line drug therapy for African Americans Some CCBs, especially felodipine and nifedipine, react with grapefruit and grapefruit juice. Teach the patient to avoid grapefruit juice to prevent complications such as kidney failure, heart failure, GI bleeding, or even death
Reaction from the body based on low o2
Catecholamines (epinephrine and norepinephrine) released in response to hypoxia and pain may increase the heart's rate, contractility, and afterload. These factors increase oxygen requirements in tissue that is already oxygen deprived
In which order will the nurse perform these prescribed actions for a client who is in the emergency department with sudden onset of dyspnea and possible pulmonary embolism ? Place client on cardiac monitor Check oxygen saturation using pulse oximetry Administer oxygen to keep saturation higher than 93 Obtain blood for coagulation studies Administer unfractionated heparin
Check oxygen saturation using pulse oximetry Administer oxygen to keep saturation higher than 93% Place client on cardiac monitor Obtain blood for coagulation studies Administer unfractionated heparin
Which action would the nurse take after noting that a client who has been on anticoagulant therapy after hip surgery is being discharged with no anticoagulant prescription? Explain to the client that anticoagulant therapy will no longer be needed. Suggest that the client take aspirin daily to prevent venous thrombosis. Contact the health care provider to clarify whether anticoagulant therapy is needed. Instruct the client to call the health care provider to ask about anticoagulant medications.
Contact the health care provider to clarify whether anticoagulant therapy is needed.
Which finding about a client's angina is most important for the nurse to communicate to the health care provider ? Causes mild perspiration Occurs after moderate exercise Continues after rest and nitroglycerin Precipitates discomfort in the arms and jaw
Continues after rest and nitroglycerin
Cardiac Catheterization
Diagnose CAD, assess coronary patency, determine the extent of atherosclerosis, measure pressures within heart, evaluate LV motion, ejection fraction, Percutaneous Coronary Intervention ( suck out a clot) Catheter advanced through femoral vein or basilic vein (right sided cath) or femoral, brachial, or radial artery (left sided cath) using fluoroscopy as a guide IV line- sedation, fluids, meds. Continuous BP, ECG monitoring Resuscitation equipment must be present Cardiac angiography can take place during this procedure Must be assessed for allergies (iodine, seafood, contrast media) before using contrast dyes Blood tests (BUN & Creatinine, coagulation profile, electrolytes) Nursing Implications 2-6 hours bed rest after test, freq VS, leg remains straight Monitor for bleeding from site (femoral or brachial artery puncture); frequent neurovascular checks (pain, pallor, pulse, paresthesia, paralysis) Hemostasis- achieved by applying manual pressure, mechanical compression, or collagen/sutures *Do not remove dressing at site without provider order! Assure adequate fluid intake and monitor urine output (need to excrete contrast medium)
Which of the prescribed medications would be withheld and the health care provider notified for a client who reports nausea and loss of appetite one week after being hospitalized for an acute myocardial infarction? Digoxin Propranolol Furosemide Spironolactone
Digoxin
Loop Diuretics
Furosemide (Lasix)- very strong and quick Given if thiazides are not working Thiazides can be used in combination with a loop, but NEVER give to loop diuretics together Used to treat edema heart failure, acute pulmonary edema - Loop diuretics may increase anticoagulation effects Blocks chloride pump in loop of Henle decreasing reabsorption of sodium and chloride and water Decreases. preload S/s: hypokalemia, hyponatremia, hypocalcemia, hypomagnesemia, hypochloremia, hyperglycemia, elevated BUN, and creatinine and elevated lipids Because furosemide and Bumetanide are sulfonamides, patience with allergies to sulfa drugs cannot take these medication's
Which symptom in a client recieving hydrochlorothiazide would cause a nurse to notify the health care provider ? Insomnia Nasal congestion Increased thirst Generalized weakness
Generalized weakness
Which food would the nurse instruct a client taking diltiazem to avoid? Alcohol Grapefruit juice Cheddar cheese Summer sausage
Grapefruit juice
H in THROMBINs
H- Anticoagulant therapy- may be used during Acute Coronary Syndrome. Heparin is commonly used because it's cheap and easily reversible (not long acting)
heart failure
Heart failure develops when either ventricle fails to pump efficiently. This condition can develop in response to a weak myocardium unable to adequately pump blood or excessive afterload that increases the work of the heart associated with hypertension, coronary artery disease, diabetes, and obesity. Causes: hypertension, coronary artery disease, and valvular disease
Low-Molecular-Weight (LMW) Heparins 1.enoxaparin (Lovenox) 2.dalteparin (Fragmin) 3.tinzaparin (Innohep) 4.danaparoid (Organan)
Heparin preparations composed of molecules that are shorter than those found in unfractionated heparin. (Administered subQ) Inhibition of F 10a Therapeutic uses: Prevention/therapy of DVT after surgery Including replacement of hip, knee Prevention of ischemic complications Patients with unstable angina, non-Q-wave myocardial infarction (MI), and ST-elevation MI (STEMI) antidote: Protamine sulfate ***Costs more**** S/S: Bleeding, Thrombocytopenia, Severe neurologic injury for patients undergoing spinal puncture or spinal epidural anesthesia
Which rationale would the nurse include to address the client's concern about why both warfarin and intravenous (IV) heparin are needed at the same time for a partial occlusion of the left common carotid artery ? This permits the administration of smaller doses of each medication. Giving both medications allows clot dissolution while preventing new clot formation. Heparin provides anticoagulant effects until warfarin reaches therapeutic levels. Administration of heparin with warfarin provides immediate and maximum protection against clot formation
Heparin provides anticoagulant effects until warfarin reaches therapeutic levels.
essential hypertension
High blood pressure with no verifiable physical cause, which makes up the overwhelming majority of high blood pressure cases.
Causes of endothelial damage
Hip surgery Total knee replacement Open prostate surgery Ulcerative colitis Heart failure Cancer Trauma Pacing wires Central venous catheters & dialysis access catheters Local vein damage Repetitive motion injury
Hypertension
Hypertension is associated with excessive pressure or force of blood flowing through arteries normal blood pressure is a systolic pressure less than 120 mm Hg and a diastolic pressure less than 80 mm Hg It has recently been redefined as a sustained systolic blood pressure (SBP) of 130 mm Hg or a diastolic blood pressure (DBP) of 80 mm 593Hg or greater Elevated blood pressure increases the workload of the heart and damages endothelium contributing to atherosclerosis. Can cause stroke, myocardial infarction and kidney disease Bp is maintained by: autonomic nervous system and circulating hormones ( epinephrine and norepinephrine) The chance of developing primary hypertension increases with age Salt restriction combined with adequate intake of dietary potassium, magnesium, and calcium improves natriuretic peptide function.
Which medication side effect will a nurse assess for when caring for a client with a myocardial infarction receiving intravenous nitroglycerin to relieve pain? Nausea Delirium Bradycardia Hypotension
Hypotension
Which potential side effect will the nurse mention when instructing the client with angina who is prescribed atenolol? Headache Tachycardia Constipation Hypotension
Hypotension
Which client statement indicates that the teaching about furosemide is understood ? Select all that apply . One, some , or all responses may be correct. It may take 2 or 3 days for this medication to take effect. I should wear dark glasses when outdoors during the day. I should avoid lying flat in bed I need to change my position slowly I should eat more food that is high in potassium.
I need to change my position slowly I should eat more food that is high in potassium
Peripheral Vascular Disease: Venous Insufficiency
Incompetent veins and muscles decrease return of blood to the heart • Valvular damage can lead to a backup of blood and further venous hypertension, resulting in edema and decreased tissue perfusion • With time, this stasis (stoppage) results in venous stasis ulcers, swelling, and cellulitis • Causes: stand or sit in one position for long periods; obesity; thrombus formation; chronic venous insufficiency • S&S: - Reddish-brown discoloration along the ankles, extending up to the calf Stasis ulcers- usually on inner ankle • irregular borders and weeping wounds • Treat edema and wounds
During strenuous physical activity, the heart rate will?
Increase to meet the body's increased gas exchange needs
myocardial nuclear perfusion imaging (MNPI)
Injection of radioactive isotopes into antecubital vein -(technetium imaging - hot spots - damaged myocardial tissue) -(thallium imaging- cold spots - necrotic/ischemic tissue) Detects left ventricular function, myocardial ischemia & infarction Client must be able to lie supine with arms overhead for 20-30 minutes Thallium imaging can be combined with exercise or heart is stressed with med (Persantine - type of platelet inhibitor)
Disseminated intravascular coagulation (DIC)
Life‑threatening coagulopathy in which clotting and anticlotting mechanisms occur at the same time. Risk for both internal and external bleeding, as well as damage to organs resulting from ischemia caused by micro-clots. DIC secondary to other complications Septicemia Cardiopulmonary arrest Trauma (hemorrhage, burns, crush injuries) Obstetric complications Cancer Allergic reaction
Atorvastatin
Lipitor Cholesterol Lipid lowering agents Lowering of total and LDL cholesterol and slightly increases HDL Reduce MI risk Slows progression of coronary atherosclerosis Prevention of coronary heart disease, decrease in LDLs and HDLs Chest pain, peripheral edema, rash, hyperglycemia, abdominal cramps, heart burn, nausea, constipation, confusion, diarrhea RHABDOMYOLYSIS (tea colored urine) Obtain diet history and especially with regard to fat consumption
Angioedema
Localized areas of swelling beneath the skin, FACE SWELLING- often around the eyes, tongue, and lips, but it can also involve other body areas as well. RARE and lifethreatening
Why does furosemide have a major drug interaction with digoxin?
Loop diuretics have a Risk of causing hyperkalemia. By doing this, It enhance the action of the digoxin leading to potential toxic states
M in THROMBINS2
M- Morphine -May be used to relieve discomfort that is unresponsive to Nitroglycerin -Promotes comfort, decreases myocardial oxygen demand (pain relief increases oxygen supply to the myocardium!), relaxes smooth muscle, reduces circulating catecholamines. -Adverse effects: respiratory depression, hypotension, bradycardia, severe vomiting too much morphine- nalaxone (Narcan) **Note that some facilities use Fentanyl instead of morphine (note that Fentanyl is an opiate)
Heart Failure
MAIN CAUSES OF HF - after Mi loss of contractility of the heart Decreased contractility as result of MI loss of 20-25 % of LVF → HF loss of 40 % of LVF → cardiogenic shock (worst kind) Hypertension (why?)- lots of force and pressure causes damage.. heart can go into hypertrophy and gets tired and wears out Pulmonary Disease & pulmonary hypertension (what is this called?)- core pulmonale
exercise tolerance test (stress test)
Measures cardiac function or PVD during defined exercise protocol on a treadmill to assess for ECG changes consistent with ischemia, evaluate medical therapy, and identify those who might benefit from invasive therapy
N in THROMBINS
Medications- Chest Pain- Nitrates (nitroglycerin) 1. Stop activity and rest at first sign of chest pain. 2. Once resting, dissolve one tablet under tongue -if not complete relief, may take up to 3 TABS in 5 MINUTE INTERVALS - if there is continued chest discomfort after 3, call 911! (Client may be experiencing an MI!) 3. stable angina usually responds to nitro! 4. Headache is a common side effect of this medication (may be severe). 5. Encourage patient to sit down, and only stand up slowly after taking nitroglycerin - why? - can cause hypotension and falls can occur *** this med needs to be replaced frequently, expires quickly **** DO NOT TAKE WITH VIAGRA (SILDENAFIL)
Capillaries
Microscopic vessel through which exchanges take place between the blood and cells of the body
Nursing Care of Patients on Oxygen
Monitor flow rate and assure it's appropriate for type of delivery device Patient teaching - home oxygen- safety Precautions - prevention of combustion Assess oral & nasal mucosa Assess for oxygen toxicity - O2 concentrations > 50 % for > 48 hrs increases risk: damage to retina, lungs and CNS, symptoms -nonproductive cough, substernal pain, nasil stuffiness, nausea, vomiting, headache, fatigue, sore throat, hypoventilation Use the lowest dose needed!
arterial thrombus cues
blocked artery- ischemia area is pale and cool to touch weakness/ numbness/ tingling blisters, sores, wounds, sloughing of skin, necrosis
Pharmacological measures to control angina
Nitrates Beta Blockers Calcium Channel. blockers • Action of antianginals- - decreases workload of the heart and promotes vasodilation
MEDS FOR MYOCARDIAL INFARCTION
Nitroglycerin- medication that relaxes the walls of the coronary arteries - Morphine sulfate if unresponsive to NTG • Oxygen 2L/NC to keep 02 saturation > 90% • Antiplatelets: Aspirin (ASA) 325 mg at home or on arrival to ED - Clopidogrel- a platelet inhibitor • Proton pump inhibitor: Omeprazole if risk for GI bleeding • Anticoagulants: Heparin • Beta Blockers: metoprolol XL, carvedilol CR • Statin: atorvastatin Angiotensin-converting enzyme inhibitors (ACEs) or angiotensin receptor blockers (ARBs)
O in THROMBINS2
O-use if patient has hypoxemia (typically 2-4 L/minute will be administered to maintain arterial oxygen saturation of 90% or higher). -Use in the absence of hypoxemia has been shown to increase coronary vascular resistance, decrease coronary blood flow, and increase mortality!
How will the nurse evaluate the effectiveness of the training after teaching a family member how to administer subcutaneous enoxaparin sodium? Return demonstration on a manikin Verbalization of the side effects of the medication Observing the family member administering enoxaparin sodium to the client Correctly verbalizing all necessary steps in enoxaparin sodium administration
Observing the family member administering enoxaparin sodium to the client
Morphine Sulfate
Opioid analgesics Relief of pain in patients with chronic or acute pain Patients experiencing angina pectoris or chest pain, patients coming from surgery, reducing anxiety Sedation, resp depression, constipation, itching, hallucinations, tolerance, dependence Monitor breath sounds and rate, heart rate, orientation
Which clinical indicator would be related to a client receiving aspirin therapy? Urinary calculi Atrophy of the liver Prolonged bleeding time Premature erythrocyte destruction
Prolonged bleeding time
Which medication will the nurse be prepared to administer to a client admitted to the hospital with a diagnosis of deep vein thrombosis who is prescribed intravenous (IV) heparin sodium if the client experiences excessive bleeding? Vitamin K Oprelvekin Warfarin sodium Protamine sulfate
Protamine sulfate
Brain Natriuretic Peptide (BNP)
Responds to stretching and blood volumes Increase renal sodium excretion
Nonsurgical Management of DVT
Rest, preventive measures Elevate legs when in bed/chair Unfractionated heparin (careful dosage calculations, lower doses for renal insufficiency) Low-molecular weight heparin Warfarin Thrombolytics (fibrinolytics) •Given within the first 3 days after acute thrombosis
Argatroban Bivalirudin
Reverseble inhibits thrombin Once bound to the active site, thrombin cannot activate fibrinogen into fibrin, the crucial step in the formation of thrombus. Use in Pts with a history of HIT Adverse effects: Bleeding/Hemorrhage, Back pain, Nausea, headache Monitor Hct, aPTT, aPT, Blood pressure.
Right heart failure
Right heart failure is defined as the inability of the right ventricle to provide adequate blood flow into the pulmonary circulation at a normal central venous pressure. It can result from left heart failure when an increase in left ventricular filling pressure is reflected back into the pulmonary circulation
STEMI
ST elevation on EKG MI, real-time ongoing death of heart tissue due to ischemia -Extends through myocardium - Thrombosis causes occlusion and necrosis -STEMI (ST-elevation myocardial infarction) - indicates full thickness myocardial infarction/ necrosis. Preferred type of treatment: PCI (percutaneous coronary intervention) (90 minutes). if no PCI is available, thrombolytic therapy should be initiated within 30 minutes. *Why thrombolytics? - cause of the M.I. is rupture of an atherosclerotic plaque, followed by rapid thrombus (clot) formation, which is occluding the artery!
STEMI vs NSTEMI
STEMI - due to complete arterial occlusion NSTEMI - ARTERY NOT completely blocked or have collateral vessels
antiplatelet drugs
Suppress platelet aggregation Prevention of thrombosis in arteries Aspirin
THROMBINS for MI
T- thienopyradines (plavics) - antiplatelet drugs. Prevent platelet aggregation. aspirin and clopidogrel H- Anticoagulant therapy- Heparin R- Renin-Angiotensin-Aldosterone System (RAS) blockade: (ACE Inhibitors or Angiotensin Receptor blockers (ARBs)) O-use if patient has hypoxemia- o2 M- Morphine -May be used to relieve discomfort that is unresponsive to Nitroglycerin B- Beta Blockers Physician usually prescribes a cardio selective beta blocker within the first 1-2 hours after an M.I. I- Invasive Cardiac Interventions i.e. PCI (Percutaneous Coronary Intervention) N- Medications- Chest Pain- Nitrates S- Statins- lipid lowering agents
T in THROMBINs
T- thienopyradines (plavics) - antiplatelet drugs. Prevent platelet aggregation. aspirin and clopidogrel NOT A CLOT BUSTER. Should be one of the first agents administered at hospitals. Can not stop meds abruptly (chew 325 mg Asprin or 4 81mg baby asprin and call 911)
when a patient presents to the ER with a MI is the heart tachy or bradycardic?
Tachycardic
what should the nurse tell a patient who is on nitroglycerin who is experiencing headaches?
Take acetaminophen for the headaches headaches are a normal finding
Which information would the nurse include when teaching a client with coronary artery disease about aspirin therapy ? Select all that apply . One, some , or all responses may be correct . Some correct answers were not selected Take aspirin with food. Report ringing in the ears Monitor and report excessive bleeding and bruising . Do not mix aspirin with medications for erectile dysfunction . Avoid over -the -counter pain medications that contain aspirin .
Take aspirin with food. Report ringing in the ears Monitor and report excessive bleeding and bruising . Avoid over -the -counter pain medications that contain aspirin.
Health Promotion Asthma
Teach client/family: -How to use pursed lip breathing -When to seek emergency care -How to recognize and attempt to avoid triggers -Importance of staying up to date on childhood immunizations (also flu, pneumonia, COVID, etc.) -Review importance of taking daily meds as ordered and how/when to use rescue inhaler -Importance of healthy diet and exercise (client with asthma can exercise but must know how to use meds as ordered)
peripheral artery disease
The gradual thickening of arterial walls reduces perfusion in upper and lower extremities, resulting in PAD. Risk factors: tobacco use, hyperlipidemia, uncontrolled hypertension, and diabetes mellitus, age( typically appears in the sixth to eighth decades) Manifestations include decreased to absent peripheral pulses; cool skin temperature; loss of hair and thin, taut, shiny skin on affected extremities; and ischemic pain during exercise (intermittent claudication).
Cardiac changes in older adults
The most relevant age-related changes are stiffening and thickening of the myocardial tissue and decreased elasticity of arterial walls. Heart valves tend to calcify and become fibrose. lead to reduced cardiac efficiency (decreased stroke volume and cardiac output) during exercise and with other factors contributing to increased oxygen demand. Arterial stiffening contribute to increase in blood pressure. A decrease in blood pressure upon standing (orthostatic hypotension) may contribute to falls. The valves in the veins become less efficient contributing to lower extremity edema.
sickle cell disease
The term sickle cell disease (SCD) describes a group of inherited blood cell disorders Normal blood cells live 90 to 120 days, while sickle cells last 10 to 20 days When an affected person experiences dehydration, fever, acidosis, or hypoxia, the hemoglobin S changes its shape to resemble a sickle, causing a sickle cell crisis. The result of the sickle shape is less oxygen-carrying capacity, destruction of the blood cells by the spleen, and clumping of blood cells, impairing perfusion to organs and tissues and causing pain
Fibrinolytic therapy
The therapy that uses medications that act to dissolve blood clots.
A client who smokes has been prescribed combined estrogen-progestin oral contraceptives Which condition is the client at most risk of developing ? Thrombophlebitis Gastrointestinal upset Uterine cancer Decreased effectiveness of estrogen
Thrombophlebitis
A client has been admitted with severe edema and hypertension. Intravenous furosemide (Lasix) has been prescribed. Which subjective clinical manifestations lead the nurse to suspect that the furosemide is infusing too rapidly? Select all that apply. Hunger Tinnitus Weakness Leg cramps Excess salivation
Tinnitus Weakness Leg cramps
Which subjective clinical manifestation in a client wooul lead the nurse to suspect that furosemide is infusing too rapidly? Select all that apply. One, some, or all responses may be correct. Hunger Tinnitus Weakness Leg cramps Excess salivation
Tinnitus Weakness Leg cramps
Which mechanism would the nurse attempt to increase to prevent postoperative deep vein thrombosis? Coagulability of the blood Velocity of the venous return Effectiveness of internal respiration Oxygen-carrying capacity of the blood.
Velocity of the venous return
Warfarin
Vitamin K antagonist Deactivates factors IIa, VIIa, IXa, & X as well as Protein C & S Clinical use: Oral anticoagulant with delayed onset, Not useful in emergencies, Long-term prophylaxis of thrombosis Monitoring treatment: Prothrombin time (PT), International normalized ratio (INR) Adverse effects: Hemorrhage (vitamin K for toxicity) *****CONTRAINDICATED IN PREGNANCY DUE TO FETAL HEMORRHAGE****** Use during lactation food interactions: mayo, canola oil, soybean oil and green leafy veggies
Which action would the nurse include in the plan of care for a client who had an ischemic stroke caused by atrial fibrillation and has been placed on anticoagulation therapy to prevent further strokes from occurring ? Select all that apply. One, some, or all responses may be correct Wearing a medical alert bracelet Initiating bleeding precautions Refraining from estrogen therapy Obtaining routine prothrombin times Notifying providers of anticoagulation
Wearing a medical alert bracelet Initiating bleeding precautions Refraining from estrogen therapy Obtaining routine prothrombin times Notifying providers of anticoagulation
Thromoembolism
blood clot attached to the interior wall of an artery or vein. causes a partial or complete blockage of blood flow to tissue in arteries and away from tissue in veins and reduction of oxygenated blood reaching tissues most common sites : the vessels of the heart (leading to cardiac ischemia or infarction), the brain (leading to ischemic stroke), and the vessels in the legs. Blood clots that form within deep veins are called deep vein thrombosis (DVT) and produce pain, edema, and warm skin temperature.
thrombolytic therapy
When primary PCI is not available, patients should receive immediate thrombolytic agents (if appropriate candidates) and then be transferred to a facility that can perform PCI. * pts who just has an abdominal surgery or brain bleed are NOT good candidates. Could create bleeding -plase (knock the clot out of plase) e.g. alteplase and reteplase Dissolves blood clots (thrombi) in coronary arteries, restoring myocardial blood flow Does not alter the atherosclerotic plaque (only for blood clots) Prevents recurrent thrombus formation and restores blood flow Indicated for clients with chest pain longer than 30 minutes unrelieved by nitroglycerin with indications of STEMI on ECG. Ideally want to start infusion of thrombolytics within 30 minutes of ED admission. (Not indicated for patients with NSTEMI). Started < 6 hours after onset of pain, most effective within 3 hours
Which instruction will the nurse plan to include when educating the client about enalapril maleate? Take the med with orange juice When standing, change positions slowly Check your pulse before taking the med Weekly basic metabolic panels need to be drawn
When standing, change positions slow
What happens in vascular injury
When vascular injury occurs, a complex coagulation process involving platelets, and clotting factors work together to stop bleeding. Vasoconstriction reduces blood flow Platelets are activated and stick to the injured blood vessel to form a platelet plug. clotting factors are activated and proceed in a coagulation cascade to the common final pathway where thrombin stimulates fibrinogen to form insoluble fibrin that stabilizes the clot.
heparin and enoxaparin inhibits what factors
Xa and IIa
Apixaban (Eliquis)
Xa inhibitor Inhibits free and clot-bound factor Xa, as well as prothrombinase activity Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation Oral Should be stopped 24-48 hours prior to any surgery, invasive procedure, or dental work. Cause a very serious blood clot around your spinal cord if you undergo a spinal tap or receive spinal anesthesia (epidural) Do not stop taking medication unless physician indicated to do so.
Rivaroxaban (Xarelto)
Xa inhibitor Oral, take with food Given together with low dose aspirin Importance of proper adherence to med Cause a very serious blood clot around your spinal cord if you undergo a spinal tap or receive spinal anesthesia (epidural) Do not stop taking medication unless physician indicated to do so.
renin-angiotensin-aldosterone system (RAAS)
a hormone cascade pathway that helps regulate blood pressure and blood volume Normally, is compensatory to help maintain BP and ensure kidney perfusion Aldosterone increases sodium and water retention to maintain blood pressure to increase the preload
N-STEMI
a non-segment elevation MI is a heart attack that is not diagnosed on the EKG but is diagnosed by an elevated troponin on blood test Causes of NSTEMI include coronary vasospasm, spontaneous dissection, and sluggish blood flow due to narrowing of the coronary artery -non-STEMI (non ST-segment elevation myocardial infarction) - indicates myocardial ischemia. Thrombolytics not indicated for these patients. (Initial treatment includes nitrates, analgesics, anticoagulants, and antiplatelet therapy. . . Sometimes followed by PCI if indiated).
status asthmaticus
a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure. Could lead to death Treatment: Client will need IV access! Help client to assume most comfortable position to facilitate breathing (often, sitting upright or in tripod).- steroids and fast acting meds -Humidified oxygen, keep sat >90% -Inhaled aerosolized short acting B2 agonists (nebulizer usually) -Anticholinergic such as ipratropium bromide (Atrovent) may be given w/ B2 agonist -Systemic corticosteroid (oral, IV, or IM) will usually be given -IV magnesium sulfate (muscle relaxant effect - decreases inflammation and improves pulmonary function) may be used; epinephrine may be used (very cautiously) *Be prepared for emergency intubation in case it's necessary!
Acites
accumulation of fluid in the peritoneal cavity
Heparin
anticoagulant found in blood and tissue cells
Theinopyridines
antiplatelet blockade
infarction
area of dead tissue
are antiplatelets best for the treatment of venous or arterial thrombosis?
arterial
the primary factor in the development of CAD
atherosclerosis Numerous risk factors, both nonmodifiable and modifiable, contribute to atherosclerosis and subsequently to CAD When the patient is pain free, obtain information about family history and modifiable risk factors, including eating habits, lifestyle, and physical activity levels. smoking and how much alcohol is consumed each day.
coronary artery disease
atherosclerosis of the coronary arteries that reduces the blood supply to the heart muscle Disease affecting the arteries that provide blood, o2, and nutrients to the myocardium
Peripheral Artery Disease
atherosclerotic disease of arteries that perfuse the limbs, especially the lower extremities especially prevalent in smokers and elderly individuals with diabetes. Evaluation for PAD requires a careful history and physical examination that focuses on finding evidence of atherosclerotic disease Treatment includes risk factor reduction (smoking cessation, exercise, and treatment of diabetes, hypertension, and dyslipidemia) and antiplatelet therapy. should be managed with vasodilators in combination with antiplatelet or antithrombotic medications and cholesterol-lowering medications. • Signs & Symptoms of PAD: - Intermittent claudication- exertion pain - Loss of hair on the lower calf, ankle, and foot; dry, scaly, dusky, pale, or mottled skin; and thickened toenails. Severe arterial disease, the extremity is cold and gray-blue (cyanotic) or darkened. MEDS- asprin, clopidogrel, cilostazol, surgery
P wave
atrial depolarization Atria contracts
Statin drugs
hyperlipidemia drugs that reduce cholesterol by blocking the enzyme necessary for cholesterol production in the liver; HMG-CoA reductase inhibitor drugs examples lovastatin, simvastatin, pitavastatin patients need regular laboratory monitoring need to avoid grapefruit and grapefruit juice, and need to alert provider if experience muscle pain and/or cramping
Vasodilatadors
increase the diameter of blood vessels in a variety of ways that block normal mechanisms. They are used to treat hypertension as well as angina.
pitting edema
indentation left after examiner depresses the skin over swollen edematous tissue
D-dimer test
is a global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown) The test is used for the diagnosis of DVT when the patient has few clinical signs stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing a negative D-dimer test can exclude a DVT without an ultrasound.
Troponin I (TnI)
is a serum protein whose measurement is used as a sensitive and specific diagnostic test to help identify myocardial injury during acute coronary syndromes
Hypertrophy of the heart
is characterized by a myocardium that is thickened, scarred, and less able to relax during diastole, leading to heart failure with preserved ejection fraction. Over time, the increased size of the heart muscle increases demand for oxygen delivery, the contractility of the heart is impaired the individual is at risk for myocardial infarction and heart failure with reduced ejection fraction.
Preload
is the amount of blood in the ventricles at the end of diastole, called the end diastolic pressure. Ventricular filling
Afterload
is the force the ventricles must exert to open the semilunar valves (aortic and pulmonic). Push against vascular resistance
What happens when perfusion is impaired to tissues?
ischemia develops and can progress to necrosis, if prolonged
venous thrombus cues
redness and darkening of the affected area pooling of blood pain around the effected area swelling from fluid buildup skin feels warmer
Atrial natriuretic peptide (ANP)
secreted from atrial cells of the heart response to atrial stretching and an increase in circulating blood volume. a diuretic that causes sodium loss and inhibits the thirst mechanism
hypovolemic shock
shock resulting from blood or fluid loss
Clinical Manifestations of pulmonary embolisms
shortness of breath chest pain hematemesis decreased blood pressure rapid pulse Cardiac Low grade fever, petechiae, flu-like symptoms Feeling of impeding doom, anxious, fear
Nitrates
side effects- headaches, hypotension Can be given under the tongue and taken up to three tablets 3, 1 every 5 min and see relief in 15 min. If this does not work, go to the hospital immediately. patient may be having an MI • Nitrates- SL, topical, oral, inhalation, and IV ( stored in a dark container to protect it) - Action: vasodilates veins, arteries, and capillaries, increases bld. flow, lowers BP and resistance • Decreases preload • Decreases afterload • Which decreases cardiac workload & 02 demand - Side effects: • headache, hypotension, dizziness, reflex tachycardia (if nitrate is given too rapidly)- small doses • Rapid onset, metabolized in liver, excreted in urine - Drug-Drug interactions: erectile dysfunction meds • Sildenafil (Viagra)- causes hypotension
risks for altered coagulation
smoking cancer pregnancy oral contraceptives factor V leiden polycethemia prothrombin deficit
antidiuretic hormone (ADH)
stimulates water reabsorption from kidney tubule cells into the blood and vasoconstriction of arterioles.
acute coronary syndrome (ACS)
sudden symptoms of insufficient blood supply to the heart indicating unstable angina or acute myocardial infarction
coronary circulation
supplies blood to the muscle tissue of the heart
embolectomy
surgical removal of an embolus or clot
acute miocardial infarction
sustained ischemia causes irreversible myocardial cell death (necrosis) resulting in acute myocardial infarction (AMI). Most AMIs are caused by a thrombus( atherosclerosis) that impairs blood flow. Risk factors: hypertension, hyperlipidemia, and diabetes, smoking, excessive alcohol use, physical inactivity, unhealthy diet, and excessive alcohol Chest pain; pain or discomfort in one or both arms, jaw, back or stomach; shortness of breath; lightheadedness; and nausea are common symptoms Risks: smoking, hypertension, diabetes, high lipids and metabolic syndrome, age, sex, genetics Decreased contractility, stroke volume, SA node malfunction, dysrhythmias and heart failure
Shock
the cardiovascular system fails to perfuse the tissues adequately, resulting in widespread impairment of cellular metabolism. Because tissue perfusion can be disrupted by any factor that alters heart function, blood volume, or blood pressure, shock has many causes and various clinical manifestations. Ultimately, however, shock progresses to organ failure and death
cardiac catheterization
thin, flexible tube is guided into the heart via a vein or an artery may be performed to determine the extent and exact location of coronary artery obstructions.
left sided systolic heart failure
thin, weak, heart muscle. More blood pooling into chambers, heart cannot pump against afterload. Too weak to pump out the load that has filled into the heart and backs into the lungs Lower EF crackles, pink frothy sputum, orthopnea, tachypnea, low O2
Alteplase Tenecteplase
thrombolytic Lysis of thrombi in coronary arteries, pulm emboli, Deep Venus thrombosis and peripheral arterial thrombosis Intracranial hemorrhage, bronchospasm, bleeding, gi bleeding, hypotension, bronchospasm, fever, musculoskeletal pain Therapeutic uses: Acute MI, Acute ischemic stroke, Acute pulmonary embolism, Clearing a blocked central venous catheter *** increases risk of IC bleeding**** Intravenous: 15-mg bolus, then 50 mg infused over 30 min, then 35 mg infused over 60 mins Half life: 5 mins Assess for bleeding and for bleeding and hypersensitivity, assess neurological status HAR
thrombus
thrombus is a blood clot that remains attached to a vessel wall, in arterial and venous Reduces flow of blood Accumulation of clotting factors and platelets leads to thrombus formation in the vein, often near a venous valve. Inflammation around the thrombus promotes further platelet aggregation, and the thrombus propagates (grows) proximally. This inflammation may cause pain and redness, may lead to edema of the extremity.
warfarin
vitamin K antagonist oral anticoagulant with delayed onset not useful in emergencies long term prophylaxis of thrombosis labs to monitor use: prothrombin time (PT) international normalized ration Adverse effects: hemorrhage not safe during pregnancy or lactations warfarin overdose: vitamin K
heart failure
when the heart is unable to generate an adequate cardiac output, causing inadequate perfusion of tissues, or increased diastolic filling pressure of the left ventricle, or both, so that pulmonary capillary pressures are increased Most heart failure results from dysfunction of the left ventricle
what to ask when a pt presents to the ER with chest pain
where is the pain? whats the nature of the pain? what were you doing before the pain started? always look at the feet for edema, look at HR O2 RR location of radiating pain
stent
wire-mesh tube used to keep arteries open
