Unit 2: mini exam/exam #2

Sulfonylureas

↑ insulin production/secretion from pancreas Major side effect: hypoglycemia (not used in elderly pts very often bc of this) - Also GI symptoms- take with food if occurs Contraindicated with Sulfa drugs Examples -- END IN -IDE - Glipizide (Glucotrol) - Glyburide (Glynase) - Glimepiride (Amaryl) - Usually added to Metformin but may be first line if Metformin is not tolerated - Need beta cell function in order to take this medication - Renal insufficiency (hypoglycemic affect) - Can have weight gain - When given with a beta blocker, hypoglycemia signs may be masked

Prediabetes

↑ Risk for developing type 2 diabetes - Impaired glucose tolerance (IGT) (OGTT: 140-199 mg/dL) - Impaired fasting glucose (IFG) (fasting glucose of 100-125 mg/dL) Intermediate stage between normal glucose homeostasis and diabetes Asymptomatic but long-term damage already occurring (heart, blood vessels) Patient teaching important - Undergo screening - Manage risk factors - Monitor for symptoms of diabetes - Maintain healthy weight, exercise (heart healthy is 150 minutes a week but need more for weight loss- aerobic exercise like walking, weight training, cycling, etc.), make healthy food choices

α-Glucosidase Inhibitors

"Starch blockers" - Slow down absorption of carbohydrate in small intestine Take with first bite of each meal Example - Acarbose (Precose) - Miglitol (Glyset)

False - This is the definition of a concussion - Contusion is bruising of the brain surface

(T/F) Contusion is a temporary loss of neurologic function with no apparent structural damage to the brain.

True

(T/F) Never massage the calves or thighs because of the danger of dislodging an undetected DVT.

Acute Complications of Diabetes

- Hypoglycemia - Hyperosmolar hyperglycemic syndrome (HHS) - Diabetic Ketoacidosis (DKA) - Long term: macrovascular, microvascular, neuropathic

What are ways to promote skin integrity? (SCI)

- Prevention and monitoring of skin frequently, especially under collar, ties from trach, etc. (heels, elbows, back of head, hips, along the spine) - Check often for soilage and keep clean and dry - Turn every 1-2 hours - Use of barriers, mild soaps and water, keep dry, emollient lotions/oil

TIA- Transient Ischemic Attack

- Sign that something is wrong in the brain (like angina in chest) - Lasts 1-2 hours - Sudden loss of motor, sensory, or visual function - Temporary ischemia to specific area of brain - When imaging done (CT), no injury pattern but there is a clot there somewhere (need cerebral angiogram) - Warning of impending stroke

Meglitinides

- ↑ Insulin production from pancreas - Rapid onset: ↓ hypoglycemia - Taken 30 minutes to just before each meal - Should not be taken if meal skipped - Examples * Repaglinide (Prandin) * Nateglinide (Starlix)

Sick Days for Diabetes

1484 LOOK AT CHARTS

Basic Information on Hemorrhagic Strokes

13 % of stroke Causes: - Intracranial (7%) (mainly caused by uncontrolled HTN) - Subarachnoid (8%) (rupture of intracranial aneurism) - Cerebral amyloid angiopathy (older adults -- damage caused by deposit of beta amyloid protein in small and medium size vessels of brain: fragile and prone to bleed) - AV malformation * Aneurysms * Neoplasms * Medication More severe deficits and much longer recovery, mortality rate up to 50%

The client is receiving 5 units of Humalog, a rapid acting insulin, ACHS in addition to Humalog corrective sliding scale dose. The order reads blood glucose level: 150=+0 units, 151-200=+2 units, 201-250=+4 units, 251-299=+6 units, >300= contact the provider. The PCA reports to the nurse that BG is 266. What is total amount of Humalog units to administer?

11 units

Nursing Process

ASSESSMENT Subjective Data 1. Past health history - Viral infections, trauma, infection, stress, pregnancy, chronic pancreatitis, Cushing syndrome, acromegaly, family history of diabetes 2. Medications - Insulin, OAs, corticosteroids, diuretics, phenytoin 3. Recent surgery 4. Malaise 5. Obesity, weight loss or gain 6. Thirst, hunger, nausea/vomiting 7. Poor healing 8. Dietary compliance 9. Constipation/diarrhea 10. Frequent urination, bladder infections 11. Nocturia, urinary incontinence 12. Muscle weakness, fatigue 13. Abdominal pain, headache, blurred vision 14. Numbness/tingling, pruritus (itching) 15. Impotence, frequent vaginal infections 16. Decreased libido 17. Depression, irritability, apathy 18. Commitment to lifestyle changes Objective Data 1. Sunken eyeballs, history of vitreal hemorrhages, cataracts 2. Dry, warm, inelastic skin 3. Pigmented skin lesions (legs usually), ulcers (feet), loss of hair on toes, acanthosis nigricans (dark line on nape of neck) 4. Kussmaul respirations (rapid, deep respirations -- diabetic ketoacidosis) 5. Hypotension 6. Weak, rapid pulse 7. Dry mouth 8. Vomiting 9. Fruity breath 10. Altered reflexes, restlessness 11. Confusion, stupor, coma 12. Muscle wasting 13. Serum electrolyte abnormalities 14. Fasting blood glucose level of 126 mg/dL or higher *(KNOW NORMALS)* 15. Oral glucose tolerance test and/or random glucose level exceeding 200 mg/dL 16. Leukocytosis 17. ↑ Blood urea nitrogen, creatinine 18. ↑ Triglycerides, cholesterol, LDL, VLDL 19. ↓ HDL 20. Hemoglobin A1C value > 6.0% (for pre diabetic, 6.5% for diabetic) 21. Glycosuria 22. Ketonuria 23. Albuminuria 24. Acidosis PLANNING Overall Goals - Active patient participation - Few or no hyperglycemic or hypoglycemic emergencies - Maintain normal blood glucose levels - Prevent or minimize chronic complications - Adjust lifestyle to accommodate diabetes plan with a minimum of stress IMPLEMENTATION Health Promotion - Identify, monitor, and teach patients at risk - Obesity: primary risk factor - Routine screening for all overweight adults and those older than 45 - Diabetes risk test online - Type 2 diabetes may necessitate insulin therapy Intraoperative period - IV fluids and insulin - Frequent monitoring of blood glucose - Concerns are hyperglycemia, F & E imbalances, hypoglycemia as well (NPO) - Need to explain to type II's if they are to take their meds before (usually not) Postoperative EVALUATION Expected Outcomes - Knowledge - Self-care measures - Balanced diet and activity - Stable, safe, and healthy blood glucose levels - No injuries

Intracranial Surgery/Procedures

Craniotomy: opening of the skull surgically 3 types on page 1990 - Remove tumor, relieve increased ICP, evacuate clot, control hemorrhage Craniectomy: excision of portion of the skull Cranioplasty: repair of cranial defect with plastic or metal

Classifications of Stroke

Ischemic - Loss of function as result of disrupted blood supply (such as a clot), hypoperfusion - 87% of stokes Hemorrhagic - 13% of strokes - Extravasation of blood into brain or subarachnoid space - Bleeding into brain or part of the brain

Aortic Aneurysm

Largest artery and responsible for supplying oxygenated blood to essentially all vital organs Thoracic - 70% atherosclerosis - Men 50-70 - Most common site for dissecting Abdominal - Atherosclerosis - Men 2-6x more than women - Caucasian 2-3x more than black males - More prevalent in males > 65 - Below renal arteries - Can extend into the iliac arteries - Growth rate of aneurysms are higher in people that smoke -- the larger the aneurysm the greater the chance of rupture - Aortic emergencies have a high morbidity and mortality - All involve damage to the media layer of the artery -- After it develops they tend to enlarge - Risk factors also include genetics and tobacco use as well as hypertension

Prevention Stroke

Modifiable - BP - Diet - Sedentary lifestyle - Sleep apnea - Migraines w/ aura at higher risk - Stress - Weight - Smoking - Diabetes - High lipids - Surgical - Alcohol (moderation in consumption) - Low dose aspirin for people at risk - Screenings for strokes Non-modifiable - Gender (males have higher age related, but women die from them more often) - Family history - Age (incidence of stroke double for each decade after 55) - Race (African Americans, Hispanics, Latinos have higher stroke rates and mortality) - Surgical: carotidectomy (remove plaque in carotid artery), done on pts with TIA or mild stroke, main complication is stroke, CN injuries, infection, or hematoma; maintain adequate BP bc don't want hypotension (cerebral ischemia) but avoid hypertension (can cause bleed); look for hoarseness and trouble swallowing (CN dysfunction); CN 7 (facial), 12 (hypogloassal), 10 (vagus), and 11 (spinal accessory) -- can place a stent - Conditions that increase risk of stroke: sickle cell, cardiomyopathy, valve heart diseases, chronic disease (lupus, systemic arthritis)

Nursing Management for Hemorrhagic Stroke

Monitor Neuro status Cerebral perfusion - Neurologic deterioration - Aneurysm precaution Relieve anxiety - Keep patient and family well informed Monitor and manage complications - Vasospasm - Seizure - Hydrocephalus - Rebleed - Hyponatremia (watching lab work) Transition to rehab or home

Thiazolidinediones

Most effective in those with insulin resistance Improve insulin sensitivity, transport, and utilization at target tissues Examples - Pioglitazone (Actos) - Rosiglitazone (Avandia) Rarely used because of adverse effects- rare liver failure, infection, headache, pain, resumption of ovulation in perimenopausal women Regularly scheduled liver function studies - Cardiovascular events are a main issue (MI and worsening of HF) -- why they don't start ppl on it anymore - Risk of bladder cancer

Systemic and Pulmonary Circulation

Overview - Needs adequate perfusion for oxygenation and nourishment - This depends on the blood flow so it is also dependent on an adequate pump, patency and responsiveness of blood vessels, adequacy of circulating blood volume Arteries/Arterioles - Thick wall structures, carry blood from heart to tissues, aorta diameter of about 2.5 cm -- has numerous branches which continue to divide to form smaller arteries -- the smallest are called arterioles and are embedded in the tissues - 3 layers 1. Intima: inner endothelial cell layer, close contact with blood that the vessels receive their nourishment by direct diffusion 2. Media: middle layer, smooth muscle and elastic tissue, makes up most of the vessel wall of aorta and other large vessels, gives vessel strength and allows them to constrict and dilate to accommodate blood flow and to maintain even, steady flow of blood 3. Adventitia: outer layer of connective tissue, anchors vessel to its surroundings Capillaries - Walls lack smooth muscle and adventitia, composed of a single layer of endothelial cells - Permits rapid and efficient transport of nutrients to cells and removal of metabolic wastes - Diameter range from 5-10mcm, so RBCs alter their shape to pass through these vessels -- changes to diameter are passive and are subject to contractile changes in blood vessels that carry blood to and from capillaries - Some capillary beds contain arteriovenous anastomoses where blood passes directly from arterial to venous system -- believed to help with heat regulation (found in fingertips) Veins/venules - Formed by capillaries that join together -- continue to get bigger to form veins - Venous system analogous to arterial system (veins/arteries, venules/arterioles, vena cava/aorta) - Thinner, less muscular structure, allows these vessels to distend more than arteries, this ability to distend allows for large volumes of blood to remain in veins under low pressure - About 75% of total blood volume contained in veins - Some veins, like those found in lower extremities, have valves to prevent blood from seeping backward as it is propelled toward heart -- valves are endothelial leaflets and are bicuspid Lymphatic - Complex network of thin-walled vessels, similar to capillaries - Collects lymphatic fluid from tissues and organs and transports the fluid to the venous circulation - These vessels converge into 2 main ducts, thoracic duct and right lymphatic duct, that empty into the junction of the subclavian and the internal jugular veins * Right lymphatic duct, conveys lymph mostly from the right side of head, neck thorax, and upper arms, while the thoracic duct conveys lymph from remainder of body - Plays important role in filtering foreign particles - Works with the function of the circulatory system - Lymph vessels transport lymph (fluid similar to plasma) and tissue fluids (containing protein, cells, and cellular debris) from the interstitial space to systemic veins Function - Needs: amount of blood flow needed by body tissues constantly changes -- % of blood flow received by individual organs or tissues is determined by the rate of tissue metabolism, availability of oxygen, and function of the tissues -- metabolic needs increase with physical activity or exercise, local heat application, fever, and infection -- it decreases with rest, or decrease in physical activity, application of cold, and cooling of body -- if blood vessels fail to dilate in response to need, then ischemia results - Flow: always precedes in the same direction: left side of heart to aorta, arteries, arterioles, capillaries, venules, veins, vena cava, and right side of heart -- unidirectional flow caused by pressure difference between arterial and venous systems -- always flows from higher to lower pressures -- impediments to blood flow offer the opposing force is known as resistance, with increased resistance, a greater driving pressure is required to maintain the same degree of flow -- most long, smooth blood vessels flow is laminar or streamlined, with blood in the center of the vessel moving slightly faster than blood near the vessel walls -- laminar flow becomes turbulent when the blood flow rate increases, when the blood viscosity increases, when the diameter of the vessel becomes greater than normal, or when segments are constricted or narrowed (this creates a bruit, which can be heard with a stethoscope) - Filtration/reabsorption: fluid exchange is continuous -- this fluid, that has same composition as plasma without proteins, forms interstitial fluid -- equilibrium between hydrostatic and osmotic forces of blood and interstitium as well as capillary permeability determines the amount and direction of fluid movement across the capillary -- hydrostatic force is driving pressure generated by BP -- osmotic pressure is the pulling force created by plasma proteins -- high pressure at arterial end of capillaries tends to drive fluid out of capillary and into tissue space -- osmotic pressure tends to pull fluid back into capillary from tissue space but this force can not overcome low hydrostatic pressure and there is a net reabsorption of fluid from the tissue space back into the capillary -- process of filtration, reabsorption and lymph formation aid in maintaining tissue fluid volume and removing tissue waste and debris -- normally this permeability remains constant, if abnormal, fluid filtered out of capillaries greatly exceeds amounts reabsorbed and carried away by the lymphatic vessels, this imbalance can result from damage to capillary walls and subsequent increased permeability, obstruction of lymphatic drainage, elevation of venous pressure, or a decrease in plasma protein osmotic force -- accumulation of excess interstitial fluid that results from these processes is called edema Hemodynamic resistance - Most important factor that determines resistance in vascular system is the vessel radius - Small changes can lead to large changes in resistance - Predominant sites of change is the change in caliber of blood vessels., therefore in the resistance - Peripheral vascular resistance is the opposition to blood flow provided by the blood vessels - Resistance is proportional to the viscosity or thickness of blood and the length of the vessel and is influenced by the diameter of the vessel - Normal conditions viscosity and vessel length do not change Regulation mechanism - Integrated and coordinated regulatory system is necessary so blood flow to individual tissue is maintained in proportion to the needs of those tissues - This mechanism is complex and consists of central nervous system influences, circulating hormones, and chemicals, and independent activity of the arterial wall itself

Nursing Interventions (autonomic dysreflexia)

Place patient in seated position to lower BP *(first and foremost thing THEN assess)* Rapid assessment to identify and eliminate cause - Empty the bladder using a urinary catheter or irrigate or change indwelling catheter - Examine rectum for fecal mass - Examine skin - Examine for any other stimulus Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV Label chart or medical record that patient is at risk for autonomic dysreflexia Instruct patient in prevention and management

Peripheral Arterial Occlusive Disease (PAD)

Where is it? Extremities most often affected, men more frequent, legs more frequently, onset and severity depends on number of risk factors -- usually found in segments of arterial system from aorta to renal arteries to popliteal artery -- if diabetic or older pt, will often see distal occlusion Symptoms - Pain, leading to fatigue, weakness, numbness - Cool, pale-elevated, ruddy cyanotic-dependent - Bruits, decreased or absent pulse - Hallmark is aching, cramping, or inducing fatigue or weakness that will occur with activity, relieved with rest - Common in muscle groups distal to area of occlusion, as progress: decreased ability to walk or increased pain with ambulation -- if severe will have pain with rest - Pain described as persistent, aching, or boring -- may be unrelieved with opioids -- rest pain may be worse at night so difficult to sleep and may be worse when extremity in horizontal or elevated position (dependent position will relieve pain) - Coolness and numbness result of decreased arterial flow -- may find limb cool and pale when elevated and ruddy, cyanotic when elevated - Skin, nail changes may be seen, as well as ulcerations, gangrene, and muscle atrophy - Bruits may be heard with stethoscope - Peripheral pulses may be diminished or absent or unequal Diagnosis - Exam important - Unequal or absent pulses is sign of PAD - History of symptoms: presence, location, and extent of occlusive disease is determined by history of sx and by physical exam -- specifically note color, temperature of extremity, as well as the pulses -- may find nails thicken and opaque, skin may be shiny atrophic, and dry with sparse hair growth -- compare right and left extremity - Diagnosis made with above and Doppler, duplex ultrasound Medical Management 1. Drugs - Trental - Pletal - Antiplatelets - Statins 2. Endovascular - Balloon angioplasty - Stents - Arthrectomy 3. Surgical - Amputation - Endartectomy - Bypass grafts Nursing - Care after any of the surgical procedures would be post-op pt care: maintaining circulation (checking and comparing pulses, color and temperature of limb, capillary refill, sensory and motor function of limb) - Monitor for any complications: I&O, mental status, VS, fluid imbalance, bleeding - Avoid leg crossing and prolonged dependency to prevent thrombus - It is normal to have edema but you need to monitor it, encourage the pt to exercise and elevate legs - d/c planning includes the ability to do ADLs, encourage any lifestyle changes needed by this condition, education on post- op complications (infections, re-occlusion , or decreased blood flow) - Remember most of the time these pts are only in the hospital 2-4 days

Pathophysiology of Hemorrhagic Stroke

- Abnormal bleeding disrupts normal blood flow - Blood vessel bursts, spilling onto brain, robbing brain of blood - Ischemia destroys brain tissue - Subarachnoid: weak spot in blood vessel wall called aneurysm bursts and leaks into space between brain and skull

Autonomic Dysreflexia

- Acute emergency! - *Occurs after spinal shock has resolved and may occur years after the injury* - *Occurs in persons with SC lesions above T6* - Autonomic nervous system responses are exaggerated - Symptoms include severe pounding headache, sudden increase in blood pressure, profuse diaphoresis, nausea, nasal congestion, and bradycardia - Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (e.g. constipation), or stimulation of the skin (pain, tactile stimulation, thermal or pressure) - Anxiety and apprehension (BP as high as 200-300) -- diaphoresis

Manifestations of Brain Injury

- Altered LOC: first thing we might see is change in personality - Pupillary abnormalities: unilaterally dilates or poorly responded can mean hematoma -- fixed and dilated can be upper brain stem issue - Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes -- look for changes in trends (fam and friends can be good source) --Glasgow coma scale (detects early signs of ICP) - Changes in vital signs - Headache - Seizures: often don't occur until a few months after brain injury -- on anticonvulsants until they rule out seizures down the line - Sense of smell anosmia - Loss of speech: aphasia - Squeezing of fingers and movement of toes and fingers - Muscle tone with arms and legs (pushing against resistance) - Deep tendon reflexes and pain response

*True* TEST

*(T/F) Clear rhinorrhea from the nose is a sign of a basilar fracture.*

Type 2 Diabetes: Etiology and Pathophysiology

Genetic link - Insulin resistance - Decreased insulin production by pancreas - Inappropriate hepatic glucose production - Altered production of hormones and cytokines by adipose tissue (adipokines) - Research continues on role of brain, kidneys, and gut in type 2 diabetes Metabolic syndrome increases risk for type 2 diabetes (need to have 3 of these) -- can reduce risk through weight loss - Elevated glucose levels - Abdominal obesity - Elevated BP - High levels of triglycerides - Decreased levels of HDLs

Hypoglycemia

- Abnormally low blood glucose level (below 50 to 60 mg/dL); too much insulin or oral hypoglycemic agents, excessive physical activity, and not enough food - Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger, numbness of lips and tongue, combative behavior, double vision, drowsiness - Central nervous system symptoms: inability to concentrate, headache, confusion, memory lapses, slurred speech, drowsiness - Severe hypoglycemia: disorientation, seizures, loss of consciousness, death Emergency Measures - If the patient cannot swallow or is unconscious: 1. Subcutaneous or intramuscular glucagon (1 mg) (stimulates liver to break down glycogen- stored glucose) (onset 8-10 minutes, lasts 12-27 minutes) 2. 25 to 50 mL of 50% dextrose solution IV - Give snack on awakening to reduce risk of hypoglycemia recurring - Aspiration precautions - Do assessment and call physician Management - Give 15 g of fast-acting, concentrated carbohydrate * Three or four glucose tablets * 4 to 6 oz of juice or regular soda (not diet soda) - Retest blood glucose in 15 minutes; retreat if >70 mg/dL or if symptoms persist more than 10 to 15 minutes and testing is not possible - Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30 to 60 minutes

Bariatric Surgery

- An option for patients with type 2 diabetes - When lifestyle and drug therapy management is difficult - BMI >35 kg/m2

Role of the Nurse

- Be knowledgeable about dietary management - Communicate important info to the dietician or other management specialists - Reinforce patient understanding - Support dietary and lifestyle changes

Glycemic Index

- Combining starchy foods with protein and fat slows absorption and glycemic response - Raw or whole foods tend to have lower responses than cooked, chopped, or pureed foods - Eat whole fruits rather than juices; this decreases glycemic response because of fiber (slowing absorption) - Adding food with sugars may produce lower response if eaten with foods that are more slowly absorbed

Meal Planning

- Consider food preferences, lifestyle, usual eating times, and cultural and ethnic background - Review diet history and need for weight loss, gain, or maintenance - Caloric requirements and calorie distribution throughout the day; exchange lists 1. Carbohydrates: 50% to 60% carbohydrates; emphasize whole grains 2. Fat: 30%, limiting saturated fats to 10% and <300 mg cholesterol 3. Non-animal sources of protein (e.g., legumes, whole grains) and increase fiber

Self-Monitoring of Blood Glucose (SMBG)

- Enables decisions regarding diet, exercise, and medication - Accurate record of glucose fluctuations - Helps identify hyperglycemia and hypoglycemia - Helps maintain glycemic goals - A must for insulin users - Frequency of testing varies - Monitoring depends on several factors: goal, type of diabetes, med regiment, diet, exercise, etc. - Alternative blood sampling sites (toes, earlobe) - Data uploaded to computer - Continuous glucose monitoring * Displays glucose values with updating every 1 to 5 minutes * Helps identify trends and track patterns * Alerts to hypoglycemia or hyperglycemia

Diagnostic Studies

- Hgb A1C > or = 6.5% (how much glucose is attached to RBC over 3 months) - Fasting Blood Sugar > or = 126 mg/dL (on BNP of CMP but have to know when it was taken) --> usually done first - 2 hour Glucose Tolerance Test (OGTT) > or = 200 mg/dL using glucose load of 75 g (8 hours NPO before, take BG, glucola, BG again after) - Symptoms plus random plasma glucose > or = to 200 mg/dL - Other testing * Urinalysis (dipstick for glucose and ketones -- by products of fat breakdown) * Lipid panel Must have 2 of the same test to diagnose (same test on two different days) Dilated eye exam A1C every 6 months but if uncontrolled every 3 months Foot tests every year to check for development of neuropathy (touch 10 spots and they tell you when and where you're touching)

Complications of Insulin Therapy

- Local allergic reactions: around the site, redness, swelling, resolves in a few hours to days, looks like wheal or hive - Systemic allergic reactions: very rare; local reaction that spreads to generalized wheals or hives; watch for wheezing, chest tightness, etc. (anaphylaxis); treat with desensitization (increasing small amounts) - Insulin lipodystrophy: lipoatrophy (loss of subq skin = dimpling) or lipohypertrophy (fat deposits) - Resistance to injected insulin - Morning hyperglycemia * Dawn phenomenon: relatively normal blood glucose until about 3 am, when the level begins to rise (adjust administration time from dinner time to bed time) * Symogi affect: normal or elevated blood glucose at bedtime, a decrease at 2-3 am to hypoglycemic levels, and a subsequent increase caused by the production of counter-regulatory hormones (decrease evening dose of insulin or give bedtime snack) * Insulin waning: progressive rise in blood glucose from bedtime to morning (increase evening (predinner or bedtime) dose of intermediate- or long-acting insulin, or institute a dose of insulin before the evening meal if one is not already part of the treatment regimen)

Exercise

- Lowers blood sugar - Aids in weight loss, easing stress, and maintaining a feeling of well-being - Lowers cardiovascular risk - Refer to Chart 51-4 (pg. 1465) - Needed for diabetes and pre diabetes - Decreases insulin resistance and can have direct affect on lowering blood glucose levels - 3 days a week, 150 minutes a week of moderate intensity - Resistance training 2 times a week - Avoid exercise in extreme hot or cold, uncontrolled hypoglycemia - Stretching is important before and after exercise (10-15 min before) Precautions - Insulin normally decreases with exercise; patients on exogenous insulin should eat a 15-g carbohydrate with protein snack before moderate exercise to prevent hypoglycemia (cheese, peanut butter, crackers) - Potential post-exercise hypoglycemia - Need to monitor blood glucose levels (before -- if elevated, monitor ketones) * If greater than 250 and ketone positive, wait to exercise until it gets into normal range (hydrate before checking ketones again) - Gerontologic considerations WE CANNOT MAKE REFERRALS TO ENDOCRINOLOGISTS, ETC. -- MUST BE MADE BY PCP

Gestational Diabetes

- Onset: during pregnancy hormones secreted by the placenta inhibit the action of insulin - Mothers at risk: obese, personal history of gestational diabetes, glycosuria, strong family history of diabetes, advanced maternal age, ethnicity - Risks to baby: cesarean delivery, increased perinatal death, birth injury, neonatal complications - Future risk: recur in future pregnancies and development of diabetes - Testing: oral glucose tolerance test (OGTT) or glucose challenge test (GCT) at first prenatal visit for high risk and then at 24-28 weeks and at 24-28 weeks for average risk - Treatment: diet, blood glucose monitoring, insulin (if necessary) - Advanced maternal age (>30) and ethnicities mentioned as risk factors

Diagnostic Evaluation (head trauma)

- Physical and neurologic exam: main thing to focus on (CN, sensory, motor, reflexes) - Skull and spinal radiography - CT scan - MRI - PET

Classes of Diabetes

- Type 1 Diabetes - Type 2 Diabetes - Gestational - Other specific types - Prediabetes

Educating Patients in Insulin Self-Management

- Use and action of insulin - Symptoms of hypoglycemia and hyperglycemia (required actions) - Blood glucose monitoring (how often) - Self-injection of insulin - Insulin pump use

Insulin Regimen

- Varies from 1 to 4 injections per day - Combination of a short-acting insulin and a longer-acting insulin - Table 51-4 describes several insulin regimens and the advantages and disadvantages of each - Two general approaches to insulin therapy: 1. Conventional: simpler; 1 or more injections of short and intermediate; no variation in meal pattern or activity; terminally ill or frail 2. Intensive: more active pts; differences in diets, exercising more; give insulin based on what they eat; more flexible - 1 injection daily: NPH or NPH with rapid acting (before breakfast) or Long acting insulin in the evening - 2 injections: NPH or NPH with rapid acting, or premixed (before breakfast and dinner) - 3 or 4 injections: Rapid acting before each meal with: either NPH at dinner or NPH at bedtime, or Long acting one or two times daily

Manifestations of Ischemic Stroke/Brain Attack

- Wide variety: depends on where lesion is & how large - Also is there any collateral circulation - Numbness or weakness - Change in mental status - Trouble speaking or understanding speech - Vision problems - Difficulty walking - Dizziness - Loss of balance or coordination - Sudden severe headache

B. Lower the patient to a flat, side-lying position *Remember how to treat ICP, what normals are, mannitol diuretic for drawing fluid out from tissue into vascular system, prevent valsava (coughing, sneezing, BM, blowing nose), maintain body temp., oxygen, avoid noxious stimuli (suction only if needed, pain), normal cerebral perfusion, how to find MAP and CPP, nutrition, no restraints* ABduction: away ADduction: toward

A patient with a SCI at T5 begins to complain of a severe headache and is diaphoretic and nauseated. Which nursing intervention would not be appropriate? A. Place the patient immediately in a sitting position B. Lower the patient to a flat, side-lying position C. Assess for bladder distention D. Assess the rectum for a fecal mass

Macrovascular, Microvascular, Neuropathy Complications

1. Macrovascular- changes to medium/large BV - CAD - Cerebrovascular disease (increased risk for stroke and death from stroke) - Peripheral vascular disease (hands and feet) (increased risk of arterial disease, gangrene, amputation) - More prevalent in type II 2. Microvascular- capillary basement membrane thickening - Diabetic retinopathy (eye) (leading cause of blindness) (eye doctor once a year- dilated eye exam) - Nephropathy (kidney) (10-15 years) (urine checks for protein, glucose, ketones) (ACE inhibitor or ARBs (-pril) have kidney protective function) (low Na, low protein) - More prevalent in type I 3. Neuropathy - Peripherally: hands and feet (feet most common) - Numbness, tingling, prickling sensations - May be asymptomatic at first - Burning sensation more at night - Decrease in proprioception - Glucose control, anticonvulsant (gabapentin, neurontin, lyrica), tricyclic antidepressants, SSRI (cymbalta) - These things increase over time - 5-10 years after diagnosis but maybe sooner for type II (bc we don't know how long they've had DM without being diagnosed) - Smoking cessation!!! - Checking feet with mirror every day - Control HTN, BG, and cessation of smoking

Diagnosing and Treatment of PAD

1. Modification of risk factors 2. Controlled exercise program (used to improve circulation and functioning capacity) 3. Medication therapy 4. Interventional procedure - Arteriogram (shows where blockage is) - Angioplasty (same as when done in heart) - Atherectomy (reduces plaque build up within artery using a cutting device or laser) 5. Surgical procedure - Inflow: improve blood flow from aorta to femoral artery - Outflow: provide blood supply to vessels below femoral artery

B. "I need to check with my provider before taking over-the-counter medications" Coumadin is INR checked regularly

A patient with a history of ischemic stroke is receiving warfarin therapy. Which of the following statements indicates the patient has a correct understanding of warfarin therapy? A. "I should increase my daily intake of leafy green veggies." B. "I need to check with my provider before taking over-the-counter medications" C. "My activated partial thromoplastin time (aPTT) will need to be checked regularly from now on." D. "The warfarin will help reverse the effects of my stroke so I can have a chance at full recovery."

A. Risk for injury related to decreased sensation. Rationale: Peripheral neuropathy is caused by diminished perfusion to neurons and results in loss of both pressure and deep pain sensations. The patient may not notice lower extremity injuries. Neuropathy increases susceptibility to traumatic injury and results in delay in seeking treatment.

A patient with peripheral artery disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the patient is A. Risk for injury related to decreased sensation. B. Impaired skin integrity related to decreased peripheral circulation. C. Ineffective peripheral tissue perfusion related to decreased arterial blood flow. D. Activity intolerance related to imbalance between oxygen supply and demand.

Oral Agents *KNOW ANY THING FOR ADMINISTRATION OF MEDS FOR TEST*

Work on 3 defects of type 2 diabetes - Insulin resistance - Decreased insulin production - Increased hepatic glucose production Can be used in combination

Head Injury

A broad classification that includes injury to where? - Scalp, skull, or brain Traumatic brain injury (TBI): also called craniocerebral trauma -- an external force of sufficient magnitude to interfere with daily life -- diminished or altered state of consciousness 2.5 million people receive head injuries every year in the United States What is the most common cause of head injuries? - Falls (biggest), MVC, concussions from sports The most common cause of death from trauma Groups at highest risk for brain trauma include: children 0 to 4 years old (falls), adolescents ages 15 to 19 years (sports, MVC), and adults 65 years and older (falls- on anticoagulants so increased risk of intracranial bleeds) Prevention is the best approach - 0-4: educate parent on baby proofing the home to prevent falls - 15-19: seat belts, protective gear for sports - 65+: moving rugs, decrease clutter, appropriate light, non-slip things

D. Facial droop and slurred speech

A health care provider is providing community education on signs and symptoms of stroke. Which of the following best describe the signs and symptoms of a stroke? A. diaphoresis and jaw pain B. indigestion and shortness of breath C. weakness and edema D. Facial droop and slurred speech

B. "You are at increased risk for developing diabetes." - <100: good fasting blood sugar - 100-125: pre-diabetes - >126: diabetes (2 of the same tests on 2 different days)

A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L). Which statement by the nurse is best? A. "You will develop type 2 diabetes within 5 years." B. "You are at increased risk for developing diabetes." C. "The test is normal, and diabetes is not a problem." D. "The laboratory test result is positive for type 2 diabetes."

Types of Brain Injury- CONCUSSION

A temporary loss of neurologic function with no apparent structural damage to the brain Patient may be admitted for observation or sent home Observation of patients after head trauma; report immediately - Observe for any changes in LOC - Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety, seizure, abnormal pupillary response - Difficulty in speaking or movement - Severe or worsening headache - Vomiting Patient should be aroused and assessed frequently May or may not lose consciousness - Grade them mild to severe (based on did they lose consciousness, have amnesia, did they lose equilibrium)

Diabetic Ketoacidosis (DKA)

Absence or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat -- occurs mainly in type I -- no glucose breakdown so body starts breaking down fats which leads to ketones then acidosis then dehydration Clinical features - Hyperglycemia (bc low insulin) - Dehydration - Acidosis Causes - Haven't taken insulin - Illness, injury - Undiagnosed DM Manifestation - Rapid onset - Glucose >250 - Serum and urine ketones present - Polyuria, polydipsia - Hypovolemia - Ketosis: N/V, don't want to eat, fruity breath, Kussmal or hyperventilation, small frequent meals with carbs - Blood sugar checks every 3-4 hours at least Assessment - Blood glucose levels >300 to 1000 - Severity of DKA not only due to blood glucose level - Ketoacidosis is reflected in low serum bicarbonate, low pH; low PCO2 reflects respiratory compensation (Kussmaul respirations) - Ketone bodies in blood and urine - Electrolytes vary according to degree of dehydration; increase in creatinine, Hct, BUN Treatment - Rehydration with IV fluid - IV continuous infusion of regular insulin - Reverse acidosis and restore electrolyte balance - Note: rehydration leads to increased plasma volume and decreased K; insulin enhances the movement of K+ from extracellular fluid into the cells - Monitor blood glucose, renal function and urinary output, ECG, electrolyte levels, VS, lung assessments for signs of fluid overload - K+ through PICC or central line usually - Reversing acidosis: insulin -- only regular insulin IV

Phlebitis

Acute inflammation of walls of small cannulated veins of hand or arm

Nursing Care

Acute phase (1-3 days) - Initiate rehab for any deficits you find - Maintain flow sheet that looks at changes in consciousness, orientation, presence or absence of voluntary and involuntary movements, posture - Temp., I & O Post acute phase (starts after acute phase ends) - Diagnosis (physical mobility, pain, self-care deficits, impaired comfort, impaired verbal communication, skin integrity issues, family issues) - Interventions - Teaching points (want to get as much self care back as possible) - Evaluating mental status: memory, affect, orientation, speech, sensation and perception, motor control, swallowing ability - Need to focus on improvement of functions of ADL's - Stroke support groups - Antidepressant - Include pts family Home care

Other Dietary Concerns

Alcohol - Moderation - Need to be eating along with it or might get hypoglycemia Nutritive and nonnutritive sweeteners - Things labeled sugarless or dietic need to be watched -- read labels!! - Should not be counted as free food - Use sweeteners in moderation - Nutritive: contain some calories with not as much affect on glucose - Nonnutritive: minimal or no calories -- won't even change glucose levels Misleading food labels

Etiology and Pathophysiology (PAD)

Atherosclerosis - Most common result of atherosclerosis is narrowing of lumen, obstruction by thrombus, aneurysm, ulceration, and rupture - Indirectly atherosclerosis will cause malnutrition and subsequent fibrosis of organs that the sclerotic arteries supply with blood Any point in body Males more below knee 2 types of lesions - Fatty streaks: fatty yellow, smooth protrude slightly into lumen of artery -- composed of lipids and elongated smooth muscle cells -- found in arteries of people of all ages including infants, usually do not cause clinical symptoms - Fibrous plaques: smooth muscle cells, collagen fibers, plasma components, and lipids -- are white-yellow and protrude in various degrees into arterial lumen, possibly completely blocking it -- found predominantly in abdominal aorta and coronary, popliteal and internal carotid arteries -- believed to be progressive Possible collateral circulation Leading cause is atherosclerosis with gradual thickening of intima and media = form deposit of cholesterol and lipids within vessel walls and lead to progressive narrowing of artery -- exact cause is unknown, inflammation and endothelial injury play a major role -- leading areas for development are where arteries bifurcate or branch into smaller vessels, with males having more below the knee pathology than females -- lower extremities include distal abdominal aorta, common iliac arteries, orifice of superficial femoral and profunda femoris arteries, and superficial femoral artery in adductor canal, which is narrowed

Types of "Brain Attack"

Based on cause Large artery thrombotic stroke (20%) - Atherosclerotic plaques in large vessel - Plaque causes a thrombus and occludes which causes an infarct Small penetrating artery thrombotic stroke (25%) - Affect one or more vessels - Lacunar stroke (another name) bc it forms a cavity in the brain after the death of the infarcted tissue Cardiogenic embolic strokes (20%) - Cardiac dysrhythmias (AFib) - Can be prevented with anticoagulants Cryptogenic strokes (30%) - No known cause Other (5%) - Illicit drug use (such as cocaine) - Coagulopathies - Migraines/vasospasm - Spontaneous dissection

Dipeptidyl Peptidase-4 (DDP-4) Inhibitor

Blocks inactivation of incretin hormones - ↑ Insulin release - ↓ glucagon secretion - ↓ hepatic glucose production Examples -- END IN -GLIPTIN - Sitagliptin (Januvia) - Saxagliptin (Onglyza) - Linagliptin (Tradjenta) Often added in combination with Metformin or another agent Main benefit of these over other similar drugs: absence of weight gain as side effect Never give to pts with hx of or current pancreatitis Given once a day, need to monitor kidney function

Insulin Therapy

Blood glucose monitoring: - Cornerstone of diabetes management - Self-monitoring of blood glucose (SMBG) levels has dramatically altered diabetes care Categories of insulin - Rapid acting - Short acting: regular insulin - Intermediate acting: NPH insulin - Very long acting: "peakless"

Hemorrhagic Stroke

Causes - Intracerebral hemorrhage - Subarachnoid bleed - Cerebral aneurysm - Arteriovenous malformation Main Presenting Symptoms *- "Exploding headache"* - Decreased level of consciousness Functional Recovery - Slower, usually plateaus at about 18 months

Ischemic Stroke or "Brain Attack"

Causes - Large artery thrombus - Small penetrating artery thrombus - Cardiogenic embolic - Cryptogenic - Other Main Presenting Symptoms - Numbness or weakness of face, arm, or leg, especially on one side of body Functional Recovery - Usually plateaus at 6 months Early treatment with thrombolytic therapy can result in return of a lot of function and fewer symptoms (should be started/given within 3 hours of onset of symptoms)

Complications (brain trauma)

Central Perfusion Pressure (CPP)- is blood flow to the brain - *Formula: CCP = MAP - ICP* - *MAP = (2X diastolic) + systolic divided by 3* Monitor for decreased CPP (mean arterial pressure-ICP) -- normal is >50 mm Hg (50-100) Low CPP causes vasodilation, increased blood to the brain, increased ICP, hypoxia and ischemia Treat: - Elevate HOB - Increase IV fluids Increased ICP: - How to treat? Bed at 30 degrees at least -- maintain alignment of head and neck -- prevent valsalva (don't want extra pressure) -- administer O2 -- maintain fluid balance and blood volume -- avoid painful procedures -- administer sedation for agitation -- maintain cerebral perfusion pressure (50-100) -- control fever (reduce metabolic demands so collateral circulation can help with vein)

Complications of Hemorrhagic Stroke

Cerebral hypoxia and decreased blood flow, extension of injury itself (immediate complications) - Airway first always - Will need adequate hydration to improve blood viscosity - Avoid hypo and hypertension bc it will extend the injury - Treat for seizures bc it will compromise blood flow Vasospasm: narrowing of the lumen of the involved cerebral blood vessel - Very serious complication of subarachnoid bleed - Unknown why it happens - Watch for this with bedside transcranial doppler ultrasound or do a follow up cerebral angiogram - Usually 7-10 days after stroke bc clot is undergoing lysis and increases chance of rebleeding to occur - Managed with the drug nimodipine for all pts with subarachnoid bleeds (it helps prevent and treat vasospasm) Increased intracranial pressure - Can occur after ischemic or hemorrhagic stroke but almost always happens after subarachnoid bleed bc its due to disturbances in circulation of CSF and caused by blood in basal cisterns of brain - Can drain some CSF off with ventricular catheter or use of mannitol (mannitol is noninvasive so try this first probably -- used to control ICP, dehydration, and other disturbances in electrolyte balances -- pulls water out of brain tissue by osmosis and decreases total body weight -- if giving mannitol need fluid balance measurements all the time (every hour) -- look for signs of dehydration and for rebound of ICP) -- HOB 30 degrees -- avoidance of hypo and hyperglycemia Hypertension - Most common cause of intercerebal bleed - Must be treated and goals individualized Re-bleeding

Types of Brain Injury

Closed brain injury (blunt trauma): acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue Open brain injury: object penetrates the brain or trauma is so severe that the scalp and skull are opened Contusion: bruising of the brain -- more severe type of contusion is usually from blunt force trauma (deceleration and acceleration) -- can cause loss of consciousness and stupor -- watch closely for first 18-36 hours (LOC, hemorrhage)

Types of Brain Injury: Subdural Hematoma

Collection of blood between dura and the brain -- more common than epidural -- trauma, anticoagulation, aneurisms rupturing -- change in LOC first, pupillary changes, hemiparesis (one-sided weakness) -- high risk for brain damage, want surgery ASAP Acute or subacute - Acute: symptoms develop over 24 to 48 hours - Subacute: symptoms develop over 48 hours to 2 weeks - Requires immediate craniotomy and control of ICP Chronic - Develops over weeks to months - Causative injury may be minor and forgotten - Clinical signs and symptoms may fluctuate - Treatment is evacuation of the clot

Cellulitis

Common - Most common infectious cause of limb swelling - Occurs at point of entry through normal skin barriers that allow bacteria to enter and release their toxins in the sq tissue - Pathogen usually streptococcus or staph aureus Isolated or series of events Can be misdiagnosed Redness, swelling, warmth, and pain Fever, chills, sweating Outpatient treat for mild cases - Oral antibiotics Severe: hospital - IV antibiotics - Key to prevent recurrent episodes is adequate antibiotics for initial event and to id the source of entry - Can be cracks in skin, look at areas between toes and fingers, drug injection sites, ingrown toenails, and hangnails Nursing - Elevate affected area 3-6 in above heart, cool packs can be used to help with inflammation - If pt has circulatory deficits or sensory problems be careful with the ice packs - Education on skin and foot care

Other Specific Types (Diabetes)

Conditions that cause injury to, interference with, or destruction of Beta cell function in the pancreas Examples: - Cushing syndrome - Hyperthyroidism - Recurrent pancreatitis - Cystic fibrosis - Hemochromatosis - Parenteral nutrition - *Medications: corticosteroids (prednisone), thiazide diuretics, phenytoin (Dilantin), atypical antipsychotics (clozapine)*

Types of Brain Injury Cont.

Contusion: more severe injury with possible surface hemorrhage - Symptoms and recovery depend on the amount of damage and associated cerebral edema - Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs Diffuse axonal injury: widespread axon damage in the brain seen with head trauma -- pt develops immediate coma -- most commonly from blunt force trauma -- causes brain to shift and rotate in skull

Culturally Competent Care

Culture can have a strong influence on dietary preferences and meal preparation High incidence of diabetes - Hispanics - Native Americans - African Americans - Asians and Pacific Islanders

Acute Arterial Ischemia Disorders

Defined as sudden interruption in the arterial blood supply to a tissue, an organ, or an extremity that, if left untreated, can result in tissue death - Caused by embolism or trauma - Embolization of a thrombus from heart is most common cause -- other causes include IV drug abuse, injury from catheters used for arteriography, stent placement or IABP - Piece of clot becomes dislodged, travels through the system, and becomes lodged- usually in a lower extremity in areas where the vessels branch - Hypovolemia (shock), hyperviscosity (polycythemia), and hypercoagulability (chemotherapy) will all predispose a person to thrombotic arterial occlusion Manifestations - Include the six Ps- polar, pallor, pain, paralysis, pulseless, and paresthesia - Without immediate treatment may have ischemia that progresses to tissue necrosis, and gangrene within a few hours -- they can lose a limb! -- if these signs occur you must notify provider ASAP - Paralysis is a late sign and signal death of the nerves supplying the extremity Diagnosis - Echo, ECG, duplex and Doppler scans Treatment - Depends on cause: anticoagulants- heparin, surgical intervention since collaterals would not have formed, emergency embolectomy can also be done - Percutaneous mechanical thrombectomy Care - Early diagnosis and treatment is a must - Anticoagulant therapy is started with IV heparin to prevent thrombus growth and inhibit further embolization - Many times, especially if pt has an endometrectomy, coumadin will be started long term - Clot must be removed ASAP- can be done surgically, or in interventional radiology -- if done in radiology, a catheter is inserted into the femoral artery, thread to the clot, where TPA will be infused for a period of 24-48 hours - Monitor for bleeding, response to treatment, check pulses and skin color and temp, avoid IM injections if received TPA

Manifestations and Complications (aortic dissection)

Depends on location of tear and extent of dissection - Acute Type A aortic dissection: abrupt onset of excruciating anterior chest pain, describe as tearing, ripping, anterior chest or back, and extends to shoulders, epigastric area, or abdomen -- can be confused with MI signs so will delay treatment -- may see tachycardia, pale, sweating, BP may be elevated or different from one arm to the other Acute Type B aortic dissection - Sudden, severe, in anterior chest or intrascapular pain radiating down spine to abdomen or legs - Sharp- "worst ever" - Cardiac, neuro, or respiratory - Aorta may rupture (results in exsanguination and death) - Hemorrhage may occur in mediastinal, pleural, or abdominal cavities - Occlusion of arterial supply to vital organs - Pain location may overlap between Type A and B dissections - Dissection pain can be differentiated from MI pain that is more gradual in onset and has increasing intensity -- as the dissection progresses, pain may migrate and follow the path of the dissection - Older patients are less likely to present with abrupt onset of chest or back pain and are more likely to present with hypotension and vague symptoms -- if aortic arch involved neurologic deficiencies may be present: altered LOC, weakened or absent carotid and temporal pulses, dizziness, syncope Type A - Disruption of blood flow in coronary arteries and aortic valve insufficiency - may develop angina, new MI, and new high pitched heart murmur - Severe cases: heart failure

Diabetes Nutritional & Exercise Therapy

Emphasis on achieving glucose, lipid, and BP goals Weight loss - Nutritionally adequate meal plan with ↓ fat and CHO - Spacing meals - Regular exercise In order to exercise safely: - Monitor blood glucose prior - If BG >250 and ketones in urine- do not exercise - To prevent hypoglycemia during/after exercise * 15 gram carb snack or snack of complex carbs with protein before exercise * Eat snack after exercise and at bedtime - Proper fitting footwear

Nursing Management (PAD)

Exercise - Supervised, assist with walking or other modes of exercise to help promote blood flow and encourage development of collateral circulation - Instruct pt (with MD approval) to walk to the point of pain, then rest til pain is gone, and resume walking- increases endurance -- endurance will increase as collateral forms - Although walking is the most commonly prescribed exercise for PAD pts, alternative modes of exercise (e.g., cycling) also improve walking ability and quality of life in patients with PAD Emotional support - Emotional upset stimulate sympathetic nervous system = constriction - Avoid as much as possible- counseling, alternative or complementary therapies can help Reduce stress Nutritional - Helps to promote healing and helps to prevent tissue breakdown - Remember obesity will strain the heart, increases venous congestion, and reduces circulation, so weight loss encouragement may be need to part of education - Even modest, sustained weight loss of 3% to 5% yields important reductions in triglycerides, glucose, A1C, and the risk of developing type 2 diabetes - Greater weight loss produces greater benefits - Men should aim for waist < 40 inches while women < 35 - Also promotes healing and prevents tissue breakdown Complementary and Alternative Education - Avoid constrictive clothing and accessories, don't cross legs for more than 15 minutes. PAD vs venous insufficiency - Critical limb ischemia is a condition characterized by chronic ischemic rest pain lasting longer than 2 weeks, arterial leg ulcers, and/or gangrene of the leg due to PAD - Pts with PAD encouraged to keep lower extremities in neutral or dependent position, while pts with venous insufficiency blood return to heart needs to be maximized so lower extremities should be elevated Hot or warm temperature - Avoid exposure to cold temps due to vasoconstriction -- adequate clothing and warm clothing will help -- if chilling does occur a warm bath may help or a warm non-alcoholic drink - Teach pt to test temp of bath water and to avoid using hot water bottles or heating pads on extremities - Excess heat may increase metabolic rate and need for O2 beyond what can be provided - If do use heat best to use warmed or electric blanket - Heat source should not be warmer than body temperature Nicotine - Stop Pain - Often chronic, continuous, and disabling - Pts can be depressed, irritable - Teach about their pain meds and side effects Tissue integrity - Carefully inspect, cleanse, and lubricate feet to prevent cracking of the skin and infection - Avoid trauma to feet and legs - Teach to do daily checks - Lesions may heal slowly if at all - Wear sturdy, well fitting shoes or slippers to prevent foot injury and blisters - Neutral soaps and lotions do prevent dry and cracking skin -- do not use lotions between toes (moisture will increase risk of maceration) - Clean, dry stockings, finger and toe nails should be trimmed and corners filed (may need to be done by professional) Aging considerations - Older person: may be more pronounced - If inactive, limb ischemia and gangrene may be first signs - Impairment in circulation is not always apparent until trauma occurs then they don't heal - Outcomes can include reduced mobility and activity as well as loss of independence - Higher rate of hospitalizations and poorer quality of life

False Readings

False elevations or positives - Restriction of dietary CHO - Acute illness - Medications (contraceptives, corticosteroids) - Restricted bedrest False negatives - Impaired GI absorption - Recently taken acetaminophen

Venous Thromboembolism

Formation of blood clot Most common disorder of veins and classified as either superficial or deep - Superficial formation of a clot in a superficial vein, usually the greater or lesser saphenous vein -- usually benign -- about 25% may also have DVT or PE - Deep vein or dvt involves a clot in a deep vein most commonly iliac and/or femoral vein Virchow's Triad (the 3 important factors in the etiology of VTE) 1. Venous stasis: normal depends on action of muscles in extremities and functional valves so blood flow in one direction -- stasis occurs when valves are dysfunctional or muscles are inactive -- more frequent in obese or pregnant,, chronic HF or afib, travel on long trips, or prolonged surgery 2. Endothelium damage: by direct (surgery, trauma) or indirect (chemo, sepsis, diabetes) injury -- stimulates platelet activation and starts coag cascade 3. Hypercoagulability: many disorders (anemia, polycythemia, malignancies), some drugs, women of childbearing years taking estrogen based oral contraceptives or post menopausal women on oral hormone therapy -- increased risk add smoking and risk is extremely high - Involves formation of thrombus in association with inflammation of the vein - DVT and PE together make up this condition - Many of the symptomatic complications in surgical pts occur after the pt goes home -- this is due to the shorten hospital stays Formation of a thrombus often accompanies phlebitis. Can occur in any vein

Interprofessional Care

Goals of diabetes management - Decrease symptoms - Promote well-being - Prevent acute complications - Delay onset and progression of long-term complications Need to maintain blood glucose levels as near to normal as possible Patient teaching - Nutritional therapy - Drug therapy - Exercise - Self-monitoring of blood glucose - Education Diet, exercise, and weight loss may be sufficient for patients with type 2 diabetes

Buerger's Disease (Thromboangiitis Obliterans)

Inflammatory disorder of small and medium arteries and veins of upper and lower extremities - Rarely systemic - Found mostly in younger men (<43) with long history of tobacco and /or marijuana use and chronic periodontal infection but without other CVD risk factors - Acute phase: inflammatory thrombus forms and blocks vessels - Chronic phase: thrombosis and fibrosis occur in vessel, causing tissue ischemia Sx often confused with PAD and other autoimmune disorders -- can have intermittent claudication of feet, hands, or arms -- as condition progresses, rest pain, ulcers, develop -- can also see color and temperature changes No specific lab test to diagnosis -- made by sx, age of onset, history of clinical symptoms, involvement of distal vessels, presence of ulcers, exclusion of other autoimmune disease, diabetes, thrombophilia Primary treatment is cessation of tobacco and marijuana

Gerontologic Considerations

Increased prevalence and mortality Glycemic control challenging - Increased hypoglycemic unawareness - Functional limitations - Renal insufficiency Meal planning and exercise Patient teaching must be adapted to needs - Reduction in beta cells - Decreased sensitivity to insulin - Carb metabolism altered

Hyperosmolar Hyperglycemic Syndrome (HHS)

Life-threatening syndrome (less common than DKA) More commonly occurs with type 2 diabetes, over 60 years old Pt cannot produce enough insulin to prevent hyperglycemia; blood sugar can be over 600 bc they don't have many signs or symptoms -- do NOT start breaking down fat deposits Precipitating factors - UTIs, *pneumonia*, sepsis - Acute illness - Newly diagnosed type 2 diabetes - Impaired thirst sensation and/or inability to replace fluids - Decrease in Na, K, phosphorus -- diaphoresis -- hypovolemia - Body tries to compensate by switching from intracellular to extracellular - Enough circulating insulin to prevent ketoacidosis (no breakdown of fat) - Fewer symptoms lead to higher glucose levels (>600 mg/dL) - More severe neurologic manifestations because of ↑ serum osmolality - Ketones absent or minimal in blood and urine - Slower onset than DKA - Can mimic stroke (so get a blood sugar before calling doctor bc thats first thing they'll ask) - Dry mucus membranes, decreased skin turgor, postural hypotension (S/S of dehydration) - Medical emergency - High mortality rate - Therapy similar to that for DKA * IV insulin and NaCl infusions * More fluid replacement needed * Monitor serum potassium and replace as needed (cardiac rhythms, kidney function) - Correct underlying precipitating cause - Need to know about kidney issues - Need hypotonic solutions bc blood is hypertonic (normal saline or 0.45%) -- when BG gets to 250 they start dextrose so that it doesn't keep plummeting NURSING MANAGEMENT Monitor - IV fluids - Insulin therapy - Electrolytes Assess - Renal status - Cardiopulmonary status - Level of consciousness

Biguanides

Metformin (Glucophage) - Reduces glucose production by liver - Enhances insulin sensitivity - Improves glucose transport - May cause weight loss - Used in prevention of type 2 diabetes - Commonly used with insulin (only one continued when insulin starts) Withhold if patient is undergoing surgery or radiologic procedure with contrast medium - Day or two before and at least 48 hours after - Monitor serum creatinine (at risk for lactic acidosis) Contraindications - Renal, liver (AST & ALT), cardiac disease - Excessive alcohol intake SE: nausea/diarrhea (extended release will help decrease diarrhea), abdominal discomfort; may have weight loss (beneficial) Used as prevention for prediabetics

*Categories of Insulins- TEST*

Rapid- lispro (Humalog), aspart (Novolog), glulisine (Apidra) - Onset: 5-15 minutes - Peak: 30-60 minutes - Duration: 2-4 hours - Used for rapid reduction of glucose level, to treat postprandial hyperglycemia, and/or to prevent nocturnal hypoglycemia Short acting- regular (Humulin R, Novolin R) - Onset: 30-60 minutes - Peak: 2-3 hours - Duration: 4-6 hours - Usually given 20-30 minutes before a meal; may be taken alone or in combination with longer-acting insulin Intermediate acting- NPH (Humulin N, Novolin N) - Onset: 2-4 hours - Peak: 4-12 hours - Duration: 16-20 hours - Usually taken after food Very long acting- glargine (Lantus), detemir (Levemir), glargine (Toujeo) - Continuous or no peak with duration of 24-36 hours - Used for basal dose

Clinical Manifestations and Complications (aneurism)

Rupture—serious complication - Rupture into retroperitoneal space * Severe back or abdominal pain * Low back pain * Falling BP * Decreasing hct * Bleeding may be tamponade by surrounding structures, thus preventing exsanguination and death - Rupture is more likely to occur in people who smoke tobacco - Very serious complication- rupture into thoracic or abdominal cavity-massive hemorrhage

Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

SGLT2 inhibitors work by - Blocking reabsorption of glucose by kidney - Increasing glucose excretion - Lowering blood glucose levels Examples -- END IN -FLOZIN - Canagliflozin (Invokana) - Dapagliflozin (Farxiga) - Empagliflozin (Jardiance) SE: UTIs, increase LDL and HDL, yeast infections, hypoglycemia -- do not give to someone with existing kidney problems

Spinal and Neurogenic Shock

Spinal shock - A sudden depression of reflex activity below the level of spinal injury - Muscular flaccidity, lack of sensation and reflexes - Lower BP and bradycardia possible too - MOTOR AND SENSORY ISSUES Neurogenic shock - Caused by the loss of function of the autonomic nervous system - Blood pressure, heart rate, and cardiac output decrease - Venous pooling occurs because of peripheral vasodilation - Paralyzed portions of the body do not perspire (over-heating) - Difficulty breathing, dyspnea, chest pain - CARDIOVASCULAR

Glucagonlike Peptide-1 Receptor Agonists

Simulate glucagon-like peptide-1 (GLP-1) -- END IN -IDE - Exetanide (Byetta), exetenide extended release (Bydureon), liriglutide (Victoza), albiglutide (Tanzeum), dulaglutide (Trulicity) Increase insulin synthesis and release - Inhibit glucagon secretion - Slow gastric emptying (helps w weight loss) - Increases satiety (helps w weight loss) - Not for type I - Given 1 time daily but extended is given once weekly - Can use as mono therapy or as adjunct with other therapies - Fast-acting oral medications at least 1 hour before - No pancreatitis

C. Enable the patients to become active participants in the management of their disease.

The nurse plans a class for patients who has newly diagnosed type 2 diabetes mellitus. Which goal is most appropriate? A. Make all patients responsible for the management of their disease. B. Involve the family and significant others in the care of these patients. C. Enable the patients to become active participants in the management of their disease. D. Provide the patients with as much information as soon as possible to prevent complications.

Clinical Manifestations and Complications (aneurism)

Thoracic aorta aneurysm (TAA) - Some asymptomatic - Most common manifestation * Deep diffuse chest pain-constant * Pain may extend to interscapular area Ascending aorta/aortic arch - Angina - Transient ischemic attacks - Coughing and shortness of breath, hoarseness and/or dysphagia (from pressure on the laryngeal nerve) - If presses on superior vena cava: * Decreased venous return * Distended neck veins * Edema of face and arms Abdominal Aortic Aneurysm - Asymptomatic- 60% - Heart beating in abdomen - Mass or abdominal throbbing - Frequently detected: * On routine physical exam * When pt examined for unrelated problem (i.e., CT scan, abdominal x-ray) - Compression of nearby anatomic structures and nerves may cause symptoms such as back pain, epigastric discomfort, altered bowel elimination, and intermittent claudication Occasionally, aneurysms spontaneously embolize plaque, causing "blue toe syndrome" (patchy mottling of the feet and toes in the presence of palpable pedal pulses) Complications - Rupture is more likely to occur in people who smoke tobacco - Very serious complication: rupture into thoracic or abdominal cavity-massive hemorrhage, most do not survive long enough to get to the hospital -- the pt who reaches the hospital will be in hypovolemic shock with tachycardia, hypotension, pale clammy skin, decreased urine output, altered level of consciousness, and abdominal tenderness -- in this situation, simultaneous resuscitation and immediate surgical repair are necessary

Etiology and Pathophysiology (Type I and II)

Type 1 Diabetes: - Little or no endogenous insulin Type 2 Diabetes: - Pancreas continues to produce some endogenous insulin but not enough insulin is produced/secreted OR - Body does not use insulin effectively (insulin resistance)

Comparison of Type 1 and Type 2 Diabetes

Type I Diabetes - Formerly known as juvenile diabetes or (IDDM) insulin dependent diabetes - Makes up 5% of all diabetes - Onset age: usually young (<30 years old) - Etiology: genetic, immunologic, environmental - Body type at diagnosis: thin, normal, or obese - Type of onset: signs & symptoms usually abrupt - Symptoms: three P's (polyuria, polydipsia, polyphagia), fatigue, weight loss without trying - Insulin: required - Vascular and neurologic complications: frequent - Acute complication: diabetic ketoacidosis (DKA) Type II Diabetes - Formerly known as adult-onset diabetes (AODM) or non-insulin-dependent diabetes (NIDDM) - Most prevalent type (90% to 95%) - Onset age: any age, usually >30 years -- increasing prevalence in children - Etiology: Obesity, heredity, environmental factors - Body type at diagnosis: obese or normal - Type of onset: gradual - Symptoms: frequently none, but can have fatigue, frequent infections (yeast, thrush, in skin folds), three P's - Insulin: required for some - Vascular and neurologic complications: frequent - Acute complication: hyperglycemic hyperosmolar syndrome (HHS)

Stroke

Umbrella term for functional abnormality of CNS when blood supply to brain is interrupted - Leading cause of long term disability - 87% ischemic strokes - Risk of first stroke is twice as high African Americans than whites -- AA's also have highest death rates for stroke - Death from stroke is decreasing in everyone except hispanics - Risk increases with age

A. Humalog

What category of insulin is rapid acting? A. Humalog B. Humalog R C. Humulin N D. Glargine (Lantus)

Action of Insulin in the Cell

- Transports and metabolizes glucose for energy - Stimulates storage of glucose in the liver and muscle in form of glycogen - Signals the liver to stop the release of glucose - Enhances storage of dietary fat in adipose tissue - Accelerates transport of amino acids into cells - Inhibits breakdown of stored glucose, protein, and fat

Types of Brain Injury: Epidural Hematoma

- Blood collection in the space between the skull and the dura - Patient may have a brief loss of consciousness with return of lucid state; then as hematoma expands, increased ICP will often suddenly reduce LOC (LOC changes, agitated, confused) - An emergency situation! - Treatment includes measures to reduce ICP, remove the clot, and stop bleeding (burr holes or craniotomy) -- will probably add drain too - Patient will need monitoring and support of vital body functions; respiratory support Can have herniation as well: pupils dilate, change in LOC

Spinal Cord Injury

- Causes include MVAs, falls, violence (gunshot wounds), and sports-related injuries - Males account for 80% of SCIs - Average age of injury is 42 - Risk factors include: young age, male gender, alcohol and drug use - Primary prevention is key - The result of concussion, contusion, laceration or compression of spinal cord - Primary injury is the result of the initial trauma and usually permanent - Secondary injury resulting from SCI include edema and hemorrhage - Major concern for critical care nurses - Treatment is needed to prevent partial injury from developing into more extensive, permanent damage *Clinical Manifestations* - Complete spinal cord lesion- loss of both sensory and motor function resulting in paraplegia (2) and tetraplegia (all 4) - *C4 or above: respiratory dysfunction -- paralysis of diaphragm, need ventilator* - Incomplete spinal cord lesion- can still relay messages to and from brain -- sensory and motor function is still present below the lesion - Possible: * Pain * Respiratory dysfunction * Loss of bowel and bladder control Complications - Respiratory complications: respiratory failure, pneumonia - Pressure ulcers - Infection - Venous Thromboembolism - Spinal Shock - Neurogenic Shock - Autonomic Dysreflexia

Pathophysiology of Brain Attack

- Complex series of metabolic events- ischemic cascade: begins when cerebral blood flow decreases 25mL per 100 per min -- neurons switch to anaerobic respiration -- generates a lot of lactic acid which changes pH and makes neurons incapable of producing sufficient quantities of ATP - Penumbra region: early on in cascade -- an area around the infarct -- ischemic tissue that can be salvaged with immediate treatment -- cascade threatens cells in this area -- increased intracellular Ca+ and releases glutamine -- damages pathways -- formation of free radicals and enlarged area of infarct - 1.9 million neuron lost for each minute stroke not treated - Ischemic brain ages 3.6 years each hour without treatment - Can intervene at each step of cascade-limiting damage

Diagnosing and Care (aortic dissection)

- ECG to rule out MI - Chest x-ray (may show a widening of the mediastinum and pleural effusion) - 3-D CT scan (CT scan or MRI can provide more detailed information on the severity of the dissection and related complications (e.g., pericardial effusions, carotid dissection)) - MRI - Transesophageal echocardiography (preferred in very unstable patients or those with contraindications to CT or MRI (e.g., those with metal implants, allergies to contrast material)) Initial goal - HR and BP control (↓ BP and myocardial contractility to diminish pulsatile forces within aorta) - Pain management - Drug Therapy - Conservative (pt with an acute or chronic type B aortic dissection without complications can be treated conservatively for a period of time) - Surgical - Nursing- watch BP & HR - An IV β-adrenergic blocker (e.g., esmolol [Brevibloc]) is titrated to a target heart rate of 60 beats per minute or less or to a systolic BP between 100-110 mmHg - Morphine is the preferred analgesic as it decreases sympathetic nervous system stimulation as well as relieving pain - A calcium channel blocker (e.g., diltiazem [Cardizem], verapamil [Calan]) can be used to lower HR if a β-adrenergic blocker is contraindicated - IV angiotensin-converting enzyme (ACE) inhibitor (e.g., enalaprilat [Vasotec]) may also be used. - Pain relief, HR, and BP control - CVD risk factor modification - Close surveillance with CT or MRI Nursing - Preop: keeping in bed, semi fowlers, maintain quiet environment -- these measures help to keep the HR and systolic BP at the lowest possible level that maintains vital organ perfusion (typically HR less than 60; systolic BP between 110-120 mm Hg) - To prevent the extension of the dissection, manage pain and anxiety because they can cause elevations in the HR and systolic BP - Monitor vital signs frequently, sometimes as often as every 2 to 3 minutes until target BP is reached - If the arteries branching off the aortic arch are involved, monitor the patient's level of consciousness, cranial nerve functions, and limb movement, sensation, and strength - Patients need to understand that antihypertensive drugs must be taken daily for the rest of their lives -- β-adrenergic blockers (e.g., metoprolol [Toprol XL]) are used to control BP and decrease myocardial contractility - The most common cause of death in long-term survivors is aortic rupture from redissection or aneurysm formation

Diagnostic (aneurysm)

- ECHO: assists in diagnosis of aortic valve insufficiency - Ultrasound: useful in screening for aneurysm, monitor size of - CT Scan: most accurate test to determine anterior to posterior length, cross sectional diameter, presence of thrombus, best type of surgical repair - MRI: diagnose and assess location and severity - Duplex ultrasound - Angiography: mapping of aortic system using contrast, not reliable method for determining length or diameter, can provide accurate information about involvement of intestinal, renal, or distal vessels - Aortic aneurysm (pulsatile mass) - Goal: prevent aneurysm from rupturing - Early detection/treatment imperative - Once detected studies done to determine size and location - Conservative therapy consists of risk factor modification; tobacco cessation, decreasing BP, optimizing lipid profile, and annual monitoring of aneurysm size using ultrasound, CT, or MRI - Controlling BP is important in pts with dissecting aneurysms -- beta blockers have been used for many years to as a mainstay for aortic aneurysm, however now ARBS are being shown to also help to retard growth of aortic dilatation - Monitoring by ultrasound every 6 months is recommended for patients with aneurysms smaller than 4.0 cm in diameter - Grows more than 0.5 in 6 months = surgical repair - If found to be greater than 5.5 when found will often do surgical repair

Glasgow Scale

- Eye opening response - Best verbal response - Best motor response - *Total 3-15 -- 3 (least responsive), 15 (most responsive)* - The greater the number the better the functioning and outcome - *Score of 3-8= severe head injury*

Risk Factors for Diabetes

- Family history - Obesity (BMI >/= 30) - Race/Ethnicity (African Americans, Hispanic Americans, Native Americans, Pacific Americans) - Age (45) - Previously identified abnormality (prediabetes) - HTN - HDL </= 35 mg/dL (good cholesterol- cardiac protective) and/or triglycerides >/= 250 mg/dL - History of gestational diabetes or delivery of baby over 9lb

Assessing and Diagnosing Ischemic Stroke/Brain Attack

- First thing: AIRWAY (look for loss of gag and cough reflex, altered respiratory pattern) - Good H & P - *Last time patient seen well* - Non-contrast CT (within 20 minutes -- tells whether ischemic or hemorrhagic) - MRI - PET scan - Cerebral angiography - Transcranial doppler ultrasound - EEG - Lab studies * CBC * CMP * *Blood glucose* - Should be seeing doc within 10 minutes of hitting ER (nurse taking labs and BG)

What are ways to promote mobility? (SCI)

- Maintain proper body alignment till SCI or bony abnormality is ruled out - Turn only if spine is stable and per orders or protocol - Monitor BP with position changes- for hypotension - PROM (or active if possible) at least QID- decrease risk of contractures - Use neck brace or collar as prescribed - Move gradually to erect position - Other techniques for prevention (trochanter rolls (hip flexion), things to prevent foot drop (boots)) - Anticoagulation bc of risk for DVT

Medical Management Stroke

- Management for secondary prevention - Afib = dose adjusted warfarin (target INR 2-3) (aspirin along with placid if can't take anticoagulant) - Platelet inhibiting medications for TIA - Statins, TPA (statin will help with secondary stroke prevention) - Antihypertensive meds (after acute stage) - Increased ICP (managed with osmotic diuretics, PaCO2 at 30-35, positioning, elevating head of bed) - ET tube (intubation tube) - Neuro assessment (per facility policy -- very frequent -- makes sure they're not having an evolving stroke -- watch for complications) - Hemodynamic assessment

What are ways to promote adequate breathing and airway clearance? (SCI)

- Monitor to detect potential airway failure: check pulse ox, ABGs, lung sounds - Early and vigorous pulmonary care to prevent and remove secretions - Suction with caution: how many passes (2), how long between passes (1 min), how long for passes (10 sec) - Breathing exercises: diaphragmatic breathing, chest physiotherapy, incentive spirometry, turning, splinting - Assisted coughing - Humidification and hydration

Aortic Dissection

- Often misnamed - Not an aneurysm - False lumen: aortic dissection results from the creation of a false lumen between the intima (inner lining) and the media (middle layer) --> degenerates - More men than women (most often in 50-70 year olds) - Sixth or seventh decade of life - Due to degeneration of elastic fibers - Chronic HTN hastens Classified based on the location of the dissection and duration of onset - Type A dissection affects the ascending aorta and arch - Type B dissection begins in the descending aorta - Dissections are also classified as acute (first 14 days), sub-acute (14 to 90 days), or chronic (greater than 90 days) based on symptom onset Predisposing factors include age, aortic diseases (e.g., aortitis, coarctation, arch hypoplasia), atherosclerosis, blunt or iatrogenic trauma, tobacco use, cocaine or methamphetamine use, congenital heart disease (e.g., bicuspid aortic valve), connective tissue disorders (e.g., Marfan's or Ehlers-Danlos syndrome), family history, history of heart surgery, male gender, pregnancy, and poorly controlled hypertension Nearly half of all acute aortic dissections in pts younger than 40 years of age occur in pts with Marfan's syndrome - Blood surges through this tear into the middle layer of the aorta, causing the inner and middle layers to separate (dissect) -- if the blood-filled channel ruptures through the outside aortic wall, aortic dissection is often fatal - As heart contracts, each systolic pulsation ↑ pressure on damaged area - Further ↑ dissection - May occlude major branches of aorta (cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities)

Nursing Care (venous thromboembolism)

- Pain relief, decrease edema, increase knowledge, no skin ulcer - No bleeding, no evidence PE - Review meds - Monitor lab - Discharge teaching * Risk factors * Monitor lab results * Dietary and drug instructions * Follow up - Review with pt all drugs, vitamins, minerals, and dietary or herbal supplements being taken- may interfere with anticoag therapy - Depending on anticoag monitor lab, adjust meds from lab, and watch for bleeding -- if on Coumadin INR >5 increased risk of bleeding - Stop smoking, avoid all nicotine products - Limit standing or sitting in a motionless leg dependent position, signs and sx of PE, drug dosage, actions and side effects, need for routine blood tests and what sx need immediate attention - Well balanced diet, Coumadin pts follow consistent diet of food containing vit K and avoid any supplements with vit k - Proper hydration - Overweight- limit carbs and total caloric intake and increase physical activity Nursing assessment includes limb pain, feeling of heaviness, functional impairment, ankle engorgement, edema, warm surface of extremity- especially calf or ankle, area of tenderness (superficial thrombus) - Amount of swelling can be determined by nursing by measuring the circumference of the extremity at various levels; be sure to mark areas with non-washable ink, record the measurements

Raynaud's Phenomenon

- Preventing recurrent episodes - Loose, warm clothing - Avoid temperature extreme - Immerse hands in warm water - Stop using tobacco products - Avoid caffeine and other drugs Episodic vasospastic disorder of small cutaneous arteries, usually in fingers and toes - Primarily in young women and women in general - Due to abnormalities in vascular intravascular and neuronal mechanisms that cause an imbalance between vasodilation and vasoconstriction - Primary Raynaud's is when it is not with other diseases, where as secondary Raynaud's is when it occurs in association with other conditions, such as SLE, rheumatoid arthritis - Diagnosis based on symptoms that persist for at least 2 years - Characterized by vasospasm induced color changes of fingers, toes, ears, nose- white, blue, and red - The decrease in perfusion causes pallor, then cyanosis -- finally they will turn red as flow returns, along with throbbing aching pain - Symptoms from a defect in basal heat production that may decrease ability of cutaneous vessels to dilate - Main teaching: avoid what ever is the particular stimuli that produces the vasoconstriction - Calcium channel blockers may help to relieve symptoms - Main focus: avoid exposure to cold and trauma, and implement measures to improve local circulation -- avoid stress, always wear hat and gloves, warm up cars before getting in, wear sweater in summer when indoors with air-conditioning

Supportive Measures (head trauma)

- Seizure precautions and prevention: anticonvulsants can be used -- cushion rails -- don't put anything in their mouth -- don't hold them down -- respiratory support - NG tube to manage reduced gastric motility and prevent aspiration - Pain and anxiety management: benzodiazepines -- don't want to give anything that diminished cerebral blood flow (ativan) -- propofol (sedative of choice -- short acting) - Nutrition: enteral or J-tubes -- a lot of time start out on TPN (central line) or PPN (picc line)

Not receiving thrombolytic therapy- what to do???

- Supplemental O2 (at least 95%) - HOB up 30 degrees (helps with secretion management and decreases ICP) - Possible hemicraniectomy (when stroke is big and lots of swelling) - Intubation - Continuous hemodynamic monitoring - Frequent neuro assessments - Look for UTI, cardiac, complication of immobility, blood sugars: 40-180

Peripheral Artery Disease (PAD) or Arteriosclerosis and Atherosclerosis

- Upper and lower extremities - Ischemia/tissue necrosis - Arteriosclerosis - Atherosclerosis - Path different of 2 but rarely find one without the other, used interchangeably - Atherosclerosis - generalized disease Involves thickening of artery walls = progressive narrowing of arteries of the upper and lower extremities -- prevalence will increase with age, symptoms usually appearing in the 6th-8th decade of life -- if person has diabetes, PAD will occur earlier -- higher prevalence in lower socioeconomic status, women, and African Americans -- people with PAD have higher risk factor for CAD and stroke -- PAD itself is a marker of advanced systemic atherosclerosis -- there is a low level of awareness about PAD and what its risk factors are in the US -- in general it remains undiagnosed and under treated

Diabetes

- What is diabetes? Inability to control glucose and insulin production and secretion to control their blood sugar - Is it an acute or chronic disease? Chronic - Does diabetes affect a single system or multiple systems? Multiple systems - The problem is with what type of metabolism? Sugar, carbs - What is insulin and where is it produced? A hormone produced in the pancreas by beta cells; main anabolic hormone of the body - What does insulin normally do? Continuously released in blood stream in small increments -- increased release when food ingested -- releases after meals to maintain stable glucose range -- transports glucose from blood across cell membrane to cytoplasm of liver, fat, and muscle cells - What is the problem with insulin in diabetes? Abnormal production or section, abnormal utilization or both (type II) -- too small of amounts or don't produce it at all (type I) - Diagnosed mainly by screening not symptoms -- a lot of people find out from a random basal metabolic panel done without looking for it -- by chance

Clinical Manifestation of Hemorrhagic Stroke

- Wide variety - Similar to ischemic stroke - *Conscious patient- severe headache (the worst headache ever)* - Tinnitus, dizziness, hemiparesis Intracranial aneurysm or AVM (arteriovenous malformation) - Sudden unusual headache - Loss of conscious possibly - Nuchal rigidity - Meningeal irritation - Visual disturbance (if hemorrhage is by ocular motor nerve) * Visual loss * Diplopia (double vision) * Pstosis (drooping or falling of upper eyelid) Prognosis depends on age, condition before hand, comorbidities, and extent and location of bleed - Subarachnoid has greatest mortality

Aneurysms

Aneurysm - Localized sac or dilation formed at a weak point in the wall of an artery - Normal artery - False aneurysm, a pulsating hematoma -- clot and any connective tissue are outside the arterial wall - True aneurysm, where 1, 2, or all 3 layers of arterial wall involved - Fusiform- one of the most common types of aneurysm, symmetrical, spindle shape, involves whole circumference of artery - Saccular - also one of the most common forms of aneurysm, bulb protrusion of one side of arterial wall - Dissecting aneurysm- hematoma splits layers of arterial wall Most common degenerative aneurysm is an abdominal aortic aneurysm - Usual cause is atherosclerotic changes - Aneurysms can also have other causes- congenital, mechanical (AV fistula), traumatic from penetrating trauma or blunt arterial trauma to artery, inflammatory or non-infectious, infectious from bacterial, fungal infections False aneurysms may result from trauma or infection, or may occur after peripheral artery bypass graft surgery at the site of the graft-to-artery anastomosis -- they also may result from arterial leakage after removal of cannulae (e.g., lower extremity arterial catheters, intra-aortic balloon pump devices)

Assessment/ Prevention (Hemorrhagic Stroke)

Assessment - CT scan or MRI scan (type of stroke, size, location, where hematoma is, presence or absence of ventricular bleed, hydrocephalus) - CTA (computed tomography angiography): confirms cerebral aneurism or AVM -- shows location and size of lesion -- provide info about arteries and veins and branches - LP (lumbar puncture): only do this if there is no evidence of ICP - Toxicology screen Prevention - Best approach - Manage (HTN and other comorbidities) - Age - Male gender - Certain ethnicities * Latino * African American * Japanese - Moderate or excessive alcohol

Nursing Process: The Care of the Patient With Brain Injury

Assessment - Health history with focus on the immediate injury, time, cause, and the direction and force of the blow - Baseline assessment - LOC — Glasgow Coma Scale - Frequent and ongoing neurologic assessment - Multisystem assessment Collaborative Problems and Potential Complications - Decreased cerebral perfusion - Cerebral edema and herniation - Impaired oxygenation and ventilation - Impaired fluid, electrolyte, and nutritional balance - Risk of post-traumatic seizures Planning major goals may include: - Maintenance of patent airway and adequate CPP - Fluid and electrolyte balance - Adequate nutritional status - Prevention of secondary injury - Maintenance of normal temperature - Maintenance of skin integrity - Improvement of cognitive function - Prevention of sleep deprivation - Effective family coping - Increased knowledge about rehabilitation process - Absence of complications Interventions - Ongoing assessment and monitoring are vital - LOC - Vital signs - Maintenance of airway - Motor function - Suctioning as needed but don't want to increase ICP - I&O and daily weights - Monitor blood and urine electrolytes and osmolality and blood glucose (blood sugars will be increased from surgery, stress, etc.) -- monitor K+ - Measures to promote adequate nutrition (don't want to put NG tube in if they have CSF leaking out of nose) - Strategies to prevent injury * Assessment of oxygenation * Assessment of bladder and urinary output * Assessment for constriction caused by dressings and casts * Pad side rails * Mittens to prevent self-injury; avoid restraints - Strategies to prevent injury * Reduce environmental stimuli * Adequate lighting to reduce visual hallucinations * Measures to minimize disruption of sleep-wake cycles * Skin care * Measures to prevent infection - Maintaining body temperature * Maintain appropriate environmental temperature * Use of coverings: sheets, blankets to patient needs * Administration of acetaminophen for fever * Cooling blankets or cool baths; avoid shivering - Support of cognitive function - Support of family * Provide and reinforce information * Measures to promote effective coping * Setting of realistic, well-defined short-term goals * Referral for counseling * Support groups - Patient and family teaching

Nursing Process: The Care of the Patient With SCI

Assessment - Airway is priority always before alignment, etc. - Stabilize head and neck/keep aligned and immobilized till rule out SCI or bone instability - Monitor respirations, breathing pattern, lung sounds and cough effort/ability to move secretions, oxygen sat - Cardiovascular, VS (heart monitor) - Monitor for changes in motor or sensory function; report immediately (pg. 2086 for cranial nerves or assessment sheet!!!) - Assess for complications - Monitor for bladder retention or distention, gastric dilation, and ileus - Temperature; potential hyperthermia - Review comprehensive neuro exam from assessment Planning Major goals may include: - Improved breathing pattern and airway clearance - Improved mobility - Improved sensory and perceptual awareness - Maintenance of skin integrity - Promotion of comfort - Absence of complications Interventions - Also on the next 3 notecards - Strategies to compensate for sensory and perceptual alterations - Temporary indwelling catheterization or intermittent catheterization (esp. with autonomic dysreflexia) (teaching family how to in and out catheterize) - NG tube to alleviate gastric distention - High-calorie, high-protein, high-fiber diet - Bowel program and use of stool softeners - Traction pin care (torque screw driver at bedside in case pin comes loose) (someone keeping them aligned while calling the physician) - Hygiene and skin care related to traction devices - Managing complications

Management of the Patient With a Head Injury

Assume cervical spine injury until it is ruled out - Stabilize cervical spine until its ruled out by imaging and exam - Neck brace, back board Therapy to preserve brain homeostasis and prevent secondary damage What are we going to focus on: 1. Cardiovascular/ Respiratory: airway (maintain oxygenation, cardiovascular respiratory function) -- treat to prevent secondary injury --monitor ABG's -- keep O2 up bc we want to perfuse the brain -- fluids (I & O) -- monitor heart rhythm (want them on a heart monitor) -- central venous pressures 2. Maintaining cerebral perfusion: HTN, fluids or blood if bleeding out 3. Cerebral Edema: want to get edema down -- could be intracellular, extracellular, or both -- osmotic diuretics like mannitol (will want a cath, strict I & O) 4. ICP (intracranial pressure): due to blood, brain swelling, or increase is CSF 5. Electrolytes What is a normal ICP? - 5-15 Is surgery possible? - Yes, especially those with depressed injuries and elevation of the skull and debridement in first 24 hours - Sometimes have to evacuate hematoma (burr holes) - Can suture deep lacerations How is CSF leak treated? - Bed rest, fluid restriction, wait and monitor (if that doesn't work may need surgery), restrict heavy lifting, nose blowing (anything that increases pressure) - Look for fever, chills - Drain the leak and can patch it with tissue

Right vs Left Stroke

Right - Paralysis or weakness on left side of body - Left visual field deficit - Spatial-perceptual deficits - Increased distractibility - Impulsive behavior and poor judgement - Lack of awareness of deficits Left - Paralysis or weakness on right side of body - Right visual field deficit - Aphasia (expressive, receptive, or global) - Altered intellectual ability - Slow, cautious behavior

Diabetes

What does the cell do with the glucose? - Uses it for its energy What is done with the excess glucose? - Stored in liver and muscle cells as glycogen What happens at night while we are sleeping to keep blood sugar levels normal? - Released stored glucose from liver, muscle, and fat

Chronic Venous Insufficiency (post-thrombotic syndrome)

Duplex ultrasound - The obstruction and amount of valve incompetence is confirmed by a duplex ultrasound Vein walls thinner, more elastic - dilate - Veins will dilate more easily when the pressure is high, stretching the leaflets of the one-way valves causing the backflow of blood Edema, altered pigmentation, pain, statis dermatitis, statis ulcers - Sx are usually more prominent in the evening - In addition, superficial veins will also dilate - If pt has had for a long time may be disabling and difficult to treat - The statis ulcers will develop as result of rupture of very small skin veins- the rbcs degenerate and that is what makes the brownish discoloration -- this change is pigmentation is usually in the lower part of the legs, around the ankles - Skin may also become dry and cracked, itchy which will increase the risk for infection and further injury Management and care is directed at preventing infection, reducing the ulcerations, and preventing them - Elevate legs not only decreases edema but will also increase venous return -- pt may also feel better - Encourage the use of compression stockings - Instruct that at night sleep with foot of bed elevated, to avoid prolonged standing or sitting in one position - Don't cross legs, but if do, don't compress the popliteal spaces - Socks should not be too tight - Protect from trauma

Medical and Surgical Management (Hemorrhagic Stroke)

Goal - Allow brain to recover, prevent or minimize risk of re-bleed, prevent or treat complications INR - Correct if cause of bleed (vit K or plasma and platelets) Craniotomy - Surgical evacuation of clot Seizure - Treat Clip aneurysm if needed Analgesics - For pain in neck and head - Only Tylenol bc we don't want to use drugs that can alter their LOC Fever - Treat (Tylenol) HTN - After D/C most will require treatment

Intracerebral Hemorrhage

Hemorrhage occurs into the substance of the brain May be caused by trauma or a nontraumatic cause (systemic HTN, aneurism rupture, vascular anomaly, anticoagulation or bleeding disorder) Neuro changes followed by headache Treatment - Supportive care - Control of ICP - Administration of fluids, electrolytes, and antihypertensive medications - Craniotomy or craniectomy to remove clot and control hemorrhage; this may not be possible because of the location or lack of circumscribed area of hemorrhage

B. Assess patient for recent history of bleeding or trauma

When caring for a patient diagnosed with ischemic stroke, which of these is the priority interventions when administering tissue plasminogen activator therapy (tPA)? A. Explain the purpose of tPA therapy to the patient and family B. Assess patient for recent history of bleeding or trauma C. Educate the patient and family on stroke recovery D. Assess patient's motor function to compare to baseline

PAD of Lower Extremities

Iliac, femoral, popliteal, tibial and peroneal arteries Femoral artery most common site for non diabetics Arteries below knee most common for diabetics Intermittent claudication - Classic symptom - Muscle pain caused by exercise, resolves with 10 minutes or less with rest and is reproducible - Results from buildup of lactic acid, occurs in about 1/3 of patients with PAD - Older women experience classic claudication less often than men Paresthesia - AKA numbness or tingling in the toes or feet and may result from nerve tissue ischemia - This neuropathy produces severe shooting or burning pain in extremity - Does not follow any particular nerve roots and can be located by ulcers - This reduced blood flow occurs over time and produces pressure and deep pain sensations causing pts not to notice any injury to their lower legs - These pts need to be taught the importance of checking feet and lower extremities daily for any injury- cut or open sore Pallor vs rubor - The appearance of the lower extremities may provide you with important information- skin will be shiny thin, and taut, with hair loss - Pulses are diminished or absent, blanching or pallor will develop when leg is elevated, while reactive hyperemia or dependent rubor (redness), will develop when extremity is in the dependent position Rest pain - May hear complaints of rest pain, which is pain that occurs in foot or toes and aggravated by limb elevation- may occur frequently at night Critical limb ischemia - Fest pain that occurs for more than 2 weeks resulting in arterial, venous ulcers or gangrene Complications - PAD progresses slowly - If the ischemia is prolonged- atrophy of skin and underlying muscles - Minor trauma to feet can lead to slow wound healing, infection and eventually gangrene - Arterial ulcers may form over bony prominences - Amputation may be needed if blood flow is not restored or if severe infection develops

Vascular Disorders & Problems of Peripheral Circulation

Includes - Arterial disorders - Venous disorders - Lymphatic disorders - Cellulitis Seen both inpatient and outpatient

Signs of Increased Intracranial Pressure (ICP)

Initially: - Change in LOC - Slow HR (bradycardia) - Increased systolic BP As progresses: - Further changes in LOC - Rapid respirations - BP may decrease - HR lowers - If temperature rises rapidly- poor prognosis bc likely brainstem damage *Decorticate: c's, flexion* *Decerebrate: e's, extension*

Types of Hemorrhagic Stroke

Intracerebral - Bleeding into the brain tissue - Most common in pts with HTN and cerebral atherosclerosis - Due to degenerative changes from those diseases that cause vessel to rupture - Can also result from different types of arterial pathologies: brain tumors and different types of medications or amphetamines and illicit drug use - Usually occurs in deeper structures Intracranial/Cerebral Aneurysm - Dilation of cerebral artery that develops as a weakness in the wall - Unknown why it happens - Can occur in an artery in the brain but most common at bifurcations Arteriovenous Malfunction - Abnormality that is from embryonic development - Tangle of vessels and arteries - Area will lack capillary bed (leads to dilation of arteries and veins and eventually they rupture) - Most common cause of hemorrhagic stroke in young people Subarachnoid - Hemorrhage occurring in subarachnoid space -- weak spot in blood vessel wall called aneurysm bursts and leaks into space between brain and skull - Can be result of AV malformation, trauma, or HTN - Common cause is leaking into circle of Willis and congenital AV malformation of the brain

Lymphatic Disorders

Lymphangitis- acute inflammation of lymphatic channels - From a focus of infection - Usually hemolytic streptococcus - Red streaks from infected wound outline vessels Lymphadentis - Nodes enlarged/red/tender - Can become necrotic - Usually groin, axilla, or cervical area Control edema and prevent infection -- active and passive exercises will help move fluid into bloodstream -- initial therapy is Lasix to prevent fluid overload due to mobilization of extracellular fluid -- if lymphedema present good chance of developing cellulitis -- if medical therapy does not work: surgery

Scalp Wounds and Skull Fractures

Manifestations depend on the severity and location of the injury Scalp wounds - Tend to bleed heavily and are portals for infection -- epinephrine helps decrease blood flow - Pain at site - If have an open injury, you want them to have had tetanus within 5 years - Keep it clean and dry at home (do NOT want any moisture) - Sutures usually removed after 10 days Skull fractures - Usually have localized, persistent pain - Fractures of the base of the skull (front of the brain) 1. Bleeding from nose pharynx or ears 2. Battle sign/mastoid—ecchymosis behind the ear 3. CSF leak: halo sign—ring of fluid around the blood stain from drainage - If it is a CSF leak it will be positive for glucose -- can also come out of ear (otorrhea) - Classified by location, type (linear (simple crack), splintered/multiple (multiple fragments- pressure on the brain)) - Risk for meningitis

Losses Associated with Ischemic Stroke/Brain Attack

Motor (upper motor neurons affected) - Hemiplegia (paralysis on one side of body or part of it) - Hemiparesis (weakness on one side of body or part of it) -- can show up initially as flaccid paralysis and loss of or reduction in deep tendon reflexes -- then 24-48 hour later increased muscle tone and spasticity and return of DTR's Communication - Aphasia (inability to express oneself or understand language) 1. Expressive: can't express what you want to say 2. Receptive: can't understand whats being said to you 3. Global: mix of both - Dysarthria (difficulty in speaking) (paralysis of muscles responsible for speech) - Dysphagia (impaired swallowing) - Apraxia (inability to perform particular purposive actions) Perceptual (can't interpret sensations -- TEMP) (can be visual so they can't see anything on one side of the body) Sensory Cognitive impairment & psychological effects - Damage in frontal lobe: personality changes - Learning capacity, memory, higher intellectual functions may be impaired, limited attention spans, lack of motivation

Venous Leg Ulcers

Necrotic skin sloughs off - Cellular metabolism cannot maintain energy balance, cell death or necrosis occurs Most venous etiology Inadequate O2 and other nutrients Characteristics & symptoms determined by cause Older pts more than one cause Manifestations - Determined by cause: venous or arterial - How long the insufficiency has lasted will determine how severe the ulcer is - Arterial: intermittent claudication, pain with activity and relieved with rest -- usually small, circular deep on tips of toes or in the webspaces between toes - Venous: pain that is heavy or aching, foot and ankle may have edema, ulcers can be large, will require a long treatment time, sometimes as long as a year to heal - If pt does not adhere to treatment ulcer will come back Treatment - Meds: antiseptic for short periods of time, if already colonized or shows signs of infection- antibiotic (systemic) - Compression therapy: using stockings that are worn all the time, can be custom made if needed - Debridement: to help with healing it must be kept clean of drainage and necrotic tissue -- can be done in surgery, with the use of dressings, enzymatic applications, calcium alginate dressings and foam dressings - Hyperbaric oxygenation can be beneficial as an adjunct therapy in patients with diabetes with no sign of wound healing after 30 days of standard wound therapy - Vac therapy or negative pressure wound therapy- uses vacuum assisted closure devices (wound vacs) -- helps with healing of complex wounds that have not healed in 3 weeks

Nursing of Aneurysm

Prevent rupture, early detection and treatment Nursing: H& P - Signs of cardiac, pulmonary, cerebral, and lower extremity vascular problems - Baseline to compare to post op - Signs of rupture - Health promotions - Teaching Overall nursing goals: - Normal tissue perfusion, intact motor and sensory function, and no complications related to surgical repair - Bedrest as ordered, explain why and how you will help to keep them comfortable, assess pulses and capillary refill per facility policy - Watch for bleeding at incision site, groin, or signs of retroperitoneal bleed, skin changes of lower extremity, lumbar area, or buttocks- embolization - Watch for infection- temp with all VS - If persistent cough, sneezing or vomiting - notify provider so to prevent hemorrhage - Also monitor BP closely- keep systolic below 180 or what ever is ordered - I&O: fluids important to flush dye from kidneys and maintain blood flow through site - Health promotions: stop smoking, control BP, normal body weight and serum lipids - Acute: emotional support, pre and post op teaching, post op- adequate BP for graft patency, prolonged low bp = thrombosis formation in graft, high bp = stress on anastomoses - Monitor for infection, neuro complications, pulses, Renal perfusion - Ambulatory: gradual increase in activity, no heavy lifting, signs of complications, follow up with provider

Prevention and Management (venous thromboembolism)

Prevention - Graduated compression stockings - Intermittent pneumatic compression devices - Early ambulation - Leg exercises - Sq or low molecular weight heparin Management - Anticoagulant therapy - Prevention Once you have a VTE at risk for another Object of treatment is to prevent thrombus from growing and fragmenting, recurrent thromboembolic, and post thrombotic syndrome. Anticoagulant cannot dissolve the clot that has already formed

Pathophysiology of Brain Damage

Primary injury: consequence of direct contact to head/brain during the instant of initial injury - Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal Secondary injury: damage evolves over ensuing days and hours after the initial injury - Caused by cerebral edema, ischemia, or chemical changes associated with the trauma

Endovascular Therapy & Thrombolytic Therapy

Recommended if meet specific criteria - No deficits prior to stroke - Receiving tPa (tissue plasminogen activator) within 4.5 hours - Internal carotid artery or proximal middle cerebral artery - At least 18 - NIHSS score of at least 6 (pg. 2016) (monitors mental status) - Treatment within 6 hours of symptom onset Treats ischemic stroke by dissolving the blood clot that is obstructing flow - Criteria: must be within 3 hours of onset of symptoms - Time sensitive: within 3 hours, the earlier the better -- goal is 60 minutes from door to needle time - Administered * IV * Intra-arterial: higher concentration right at the site of the blockage (must be at stroke center); time window can be up to 6 hours but prefer it to be soon; can be combined with regular IV anticoagulation - tPa: no sticks or anything for 24 hours (time from when tPa ended) -- contraindications on pg. 2015 -- must have weight in kg -- maximum dose is 90mg -- 10% of dose given bolus over 1 min and remainder is giver pump over 1 hour -- admitted to ICU where they monitor BP (systolic below 180 and diastolic below 105) -- airway management -- support family and patient (huge life event) -- side effects: bleeding

Pathophysiology of Vascular Disorders & Problems of Peripheral Circulation

Reduced blood flow through peripheral blood vessels characterizes all peripheral vascular diseases -- the physiologic effects of altered blood flow depend on the extent to which tissue demands exceed the supply of oxygen and nutrients available Pump Failure - Inadequate peripheral blood flow occurs when the heart's pumping action becomes inefficient -- heart failure Alterations - Must have intact, patent vessels to deliver the needed O2 and nutrients and remove the wastes - Arteries can become damaged, obstructed, as result of atherosclerotic plaque, thromboemboli, chemical or mechanical trauma, infections, or an inflammatory process -- other causes of alterations include vasospastic disorders, and congenital malformations - A sudden occlusion can cause irreversible tissue ischemia and tissue death -- if this same arterial occlusion develops slowly the risk of tissue death reduces since there is a chance for collateral circulation to form - Emboli can also block venous blood flow, can have incompetent venous valves, or there can be reduction in the effectiveness of the pumping action of surrounding muscles - Tissues that are edematous cannot receive adequate nutrition from the blood and therefore are more susceptible to breakdown, injury, and infection Circulatory Insufficiency - Many types of pvd, most will cause ischemia and produce the same sx (pain, skin changes, diminished pulse, and possibly edema) - The type and severity of the sx depend on type, stage, and extent of the disease process and the speed it develops - See chart on slide 4 Aging - Changes to walls of vessels can affect transport of O2 and nutrients to tissue - Intima thickens, elastin fibers of media calcify, thin, and fragment, collagen accumulates in intima and intima -- these cause the vessels to stiffen, resulting in increased peripheral resistance, impaired blood flow, increased lt ventricular workload leading to hypertrophy, ischemia, and failure, thrombosis, and hemorrhage in micro vessels of brain and kidney

Risk Factors/Prevention (PAD)

Risk Factors 1. Modifiable - Nicotine use - Diet - Hypertension - Hypercholesterolemia - Diabetes (increases overall risk 2-4x w amputation rates 5-10x higher than pts without diabetes) earlier onset, more rapid progression, show different anatomical distribution of pathology with greater severity of disease (especially below knee)) - Stress - Hyperlipidemia - Sedentary lifestyle - Elevated C-reactive protein (sensitive marker of cardiovascular inflammation, both systemically and locally, slight increase associated with increased risk of damage in vasculature, especially if accompanied by other risk factors) - Hyperhomocysteinemia (positively correlated with risk of peripheral, cerebrovascular, and coronary artery disease as well as venous thromboembolism -- a protein that promotes coagulation by increasing factor V and factor XI activity while depressing protein c activation and increasing binding of lipoprotein in fibrin -- symptoms occur when vessels are 60-75% blocked) 2. Non-modifiable - Increasing age - Female gender - Familial predisposition/genetics Prevention - Diet modification - Medication - Control hypertension - No one cause identified - Greater risk the more risk factors have so control those you can control - Stop smoking Risk factors are similar but not completely the same as CAD with the most important being tobacco (#1)- one of the most important risk factors in development of lesions -- amount of tobacco used, whether inhaled, (traditional or e) or chewed is directly related to extent of the disease -- these risk factors being present greatly increases the risk for PAD especially in women and African Americans Symptoms depend on the organ and area affected

Manifestations and Complications (venous thromboembolism)

Superficial - Palpable firm sq cordlike vein - Itchy - Tender or painful to touch - Reddened and warm - Mild temperature elevation - Do not dislodge or fragment often Deep - Edema - Swelling - May feel warmer than other extremity - Superficial veins may show more - Tenderness - PE

Treatment (aneurysm)

Surgical - Older treatment - > 5.5 cm (2in) - Resect vessels/graft - General anesthesia Endovascular - Newer and safer - Mainstay - Suture less graft - Local or regional anesthesia - Few years ago treatment for aneurysm was always surgery, where abdomen was incised, vessel resected and bypass graft was placed - Now mainstay treatment is endovascular- make a small surgical cut near the groin, to find the femoral artery -- insert a stent (a metal coil) and a man-made (synthetic) graft through the cut into the artery -- then use a dye to define the extent of the aneurysm -- use x-rays to guide the stent graft up into your aorta, to where the aneurysm is located -- next open the stent using a spring-like mechanism and attach it to the walls of the aorta -- your aneurysm will eventually shrink around it -- lastly use x-rays and dye again to make sure the stent is in the right place and your aneurysm is not bleeding inside your body Endovascular can't be done under certain circumstances: tortuous, small or calcified vessels or if there are many thrombi Potential complications: bleeding, hematoma at femoral site, wound infection, distal ischemia or embolization, dissection or perforation of aorta, break in attachment system, graft migration

D. Risk for aspiration

The health care provider is assessing a patient who is recovering from a stroke. Which of these problems should receive priority for this patient? A. Risk for altered coping B. Impaired communication C. Impaired mobility D. Risk for aspiration

B. 2.5

The healthcare provider is reviewing the International Normalized Ratio (INR) results of a patient with a history of embolic stroke. Which of the following indicates a therapeutic value for this patient? A. 4.1 B. 2.5 C. 1.5 D. 0.5

B. "I should cut back on my walks if it causes pain in my legs." Rationale: Patients should be taught to exercise to the point of discomfort, stop and rest, and then resume walking until the discomfort recurs. Smoking cessation and proper foot care are also important interventions for patients with peripheral arterial disease.

The nurse teaches a patient with peripheral arterial disease. The nurse determines that further teaching is needed if the patient makes which statement? A. "I should not use heating pads to warm my feet." B. "I should cut back on my walks if it causes pain in my legs." C. "I will examine my feet every day for any sores or red areas." D. "I can quit smoking if I use nicotine gum and a support group."