PVD – Flashcard
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Edema and blood clots can be the result of a) venous disease b) arterial disease
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a) venous disease
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Thickening or hardening of the arterial wall that is often associated with aging is known as
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arteriosclerosis
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Formation of plaque within the arterial wall is known as
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atherosclerosis
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Atherosclerosis usually affects which arteries?
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larger arteries: 1. coronary artery beds 2. aorta 3. carotid and vertebral arteries 4. renal iliac 5. femoral arteries
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Risk factors for atherosclerosis
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1. low HDL-C 2. high LDL-C 3. increased triglycerides 4. genetic predisposition 5. diabetes mellitus 5. obesity 6. sedentary lifestyle 7. smoking 8. stress 9. African-American or Hispanic ethnicity 10. age - older adult
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What assessments should be made for a patient with atherosclerosis?
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Complete cardiovascular assessment: 1. BP in both arms 2. palpate pulses at all major sites, note differences 3. assess temperature 4. capillary refill 5. bruit (carotid, aortic, femoral, popliteal)
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Decrease in intensity or complete loss of pulse in a patient with atherosclerosis may indicate what?
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arterial occlusion
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What lab values should be assessed for atherosclerosis?
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LDL, HDL, and triclycerides
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ideal total cholesterol
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200 mg/dL
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Desirable LDL-C level
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<100 - optimal 100-129 - near, above optimal 130-159 - borderline high
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Desirable HDL-C level
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>40
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Desirable triglycerides level
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<150
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Interventions for those with atherosclerosis and those at high risk for the disease
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1. quit smoking 2. weight management 3. exercise 4. dietary changes to lower LDL-C levels 5. aerobic activity 3-4 times a week 6. drug therapy
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Drug intervention for atherosclerosis/high LDL-C
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statins: 1. lovastatin 2. simvastatin 3. pitavastatin
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How do statins work?
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They reduce cholesterol synthesis in the liver and increase clearance of LDL-C from the blood
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contraindications for statin drugs
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1. patients with active liver disease 2. during pregnancy
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Statins have potential to interact with which other drugs
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1. warfarin 2. cyclospirine 3. some antibiotics
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When are statins prescribed and why?
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only when nonpharmacologic management has been unsuccessful - due to possibility of major side effects of statin medications
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Ezetimibe
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1. can be used in place of or in combination with statins 2. inhibits absorption of cholesterol through small intestine
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vyorin
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1. combination drug containing ezetimibe and simvastatin 2. reduces absorption of cholesterol and by decreasing amount of cholesterol synthesis in liver
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When on statin drugs, what should you monitor?
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1. liver enzymes 2. muscle cramping 3. avoid grapefruit juice
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Cardiac output =
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stroke volume x HR
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Pre-hypertensive BP
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120-139/80-89
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Stage 1 Hypertension
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140-159/90-99
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Stage 2 Hypertension
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greater or equal to 160/100
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Malignant hypertension
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BP progresses rapidly to 200/130
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One of the most common causes of secondary hypertension
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kidney disease
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Diseases that commonly cause hypertension
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1. kidney disease 2. renal artery stenosis 3. excess aldosterone and cortisol 4. tumors of the adrenal medula 5. Cushing's syndrome
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Drugs that can cause hypertension
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1. estrogen 2. glucocorticoids 3. mineralcorticoids 4. sympathetic stimulants
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Presence of abdominal bruit is typical of patients with
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renal artery stenosis
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Tachycardia, sweating, and pallor may suggest
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pheochromocytoma (adrenal medulla tumor)
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Elevation of blood pressure in the arms with normal or low blood pressure in the lower extremities with delayed or absent femoral pulses is evidence of
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coarctation of the aorta (narrowing of aorta)
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Hypertension Assessment
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1. history 2. headache, facial flushing, dizziness, fainting 3. BP on both arms 4. assess for orthostatic hypotension 5. assess retina for vascular changes 6. psychological assessment 7. diagnostic assessment
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This electrolyte imbalance is commonly associated with hypertension
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hypokalemia
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drugs for managing hypertension
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1. diuretics* - first choice for hypertension 2. calcium channel blockers (older adults) 3. angiotensin-converting enzyme (ACE) inhibitors 4. angiotensin II Receptor Blockers (ARBs) 5. aldosterone receptor antagonists 6. beta-adrenergic blockers 7. renin inhibitors
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Three types of diuretics
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1. thiazides (low-ceiling diuretics) 2. loop (low-ceiling diuretics) 3. potassium-sparing diuretics
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How do thiazide diuretics work?
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decrease blood volume by inhibiting sodium, chloride, and water reabsorption and promote potassium excretion
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How do loop diuretics work?
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inhibit sodium chloride and water reabsorption, promote potassium excretion
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How do potassium-sparing diuretics work?
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inhibit reabsorption of sodium ions in exchange for potassium, retaining potassium in the body
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How do calcium channel blockers work?
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interfere with transmembrane flux of calcium ions, causing vasodilation and subsequent lower blood pressure. Also block SA and AV node conduction, which decreases heart rate
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It is important for patients on calcium channel blockers such as felodipine and nifedipine to avoid
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grapefruit and grapefruit juice
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What should be monitored closely for patients on loop diuretics?
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potassium levels
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What should be monitored closely for patients on calcium channel blockers?
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BP and heart rate - causes decrease in BP and HR
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Interventions for patients on ACE inhibitors
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1. report nagging cough to health care provider 2. monitor BP carefully, orthostatic checks 3. Do not give if systolic BP below 100
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Nursing interventions for patients on angiotensin II receptor blockers (ARBs)
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1. avoid foods high in potassium 2. monitor BP 3. do not take medication if systolic BP is below 100 4. avoid grapfruit
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Name two angiotensin II receptor blockers (ARBs)
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(sartan drugs) 1. valsartan 2. losartan
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Why might a patient be prescribed ARBs for hypertension?
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great alternative for patients who report a nagging cough, a common symptom of patients taking ACE inhibitors
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How do Beta Blockers (beta-adrenergic blockers) work?
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They block beta receptors in the heart and peripheral blood vessels only (cardioselective), lowering blood pressure and decreasing heart rate and myocardial contractility.
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Common side effects of beta blockers
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1. fatigue 2. weakness 3. depression 4. sexual dysfunction
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Example of beta blockers
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(-lol) 1. metoprolol 2. atenolol
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Nursing interventions for patients on beta blockers
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1. monitor orthostatic hypotension 2. do not give if systolic BP below 100 3. monitor pulse rate daily, do not give if HR below 60 4. use cautiously with patients with diabetes
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What antihypertensive drug would likely be prescribed for patients with ischemic heart disease?
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beta blockers - they are cardioselective to target the heart
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How do renin inhibitors work?
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They inhibit renin, produced in the kidneys, from its action of vasoconstriction and increased peripheral resistance - counteracting this effect causes decrease in blood pressure
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Side effects of renin inhibitors
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minimal and not common: 1. cough 2. diarrhea 3. respiratory distress
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Example of a renin inhibitor
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aliskiren
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A client diagnosed with atherosclerosis has been prescribed lovastatin. Which statement by the client indicates a need for further teaching? a) "I won't need to change my diet because now I'm taking a pill." b) "I'll follow up with my nurse practitioner on a regular basis." c) "I need to quit smoking as soon as I possibly can." d) "I shouldn't drink grapefruit juice while on this drug."
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a) "I won't need to change my diet because now I'm taking a pill."
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A client as prescribed enalapril for control of hypertension. What health teaching well the nurse provide before the client begins therapy? a) "You may develop a higher pulse rate." b) "You may notice some swelling in your feet." c) "You may develop a nagging cough." d) "Your diet should include foods high in sodium."
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c) "You may develop a nagging cough."
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Hypertensive crisis marked by a severe elevation in blood pressure of
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greater than 180/120
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Hypertensive crisis can cause
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damage to the kidneys and heart
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What IV antihypertensive therapy might be used for a patient in hypertensive crisis?
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fast-acting vasodilators: 1. nitroprusside 2. nicardipine 3. fenoldopam 4. labetalol
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Who is at high risk for hypertensive crisis?
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Patients who do not adhere to antihypertensive treatment. They are also at high risk for target organ damage.
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What should the nurse assess for patients with hypertensive urgency or crisis?
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1. severe headache 2. extremely high BP 3. dizziness 4. blurred vision 5. shortness of breath 6. epistaxis (nosebleed) 7. severe anxiety
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How should a nurse intervene for a patient with hypertensive crisis?
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1. semi-fowler's position 2. administer oxygen 3. IV 0.9% NS slowly 4. administer beta blocker or nicardipine 5. monitor BP every 5-15 minutes until diastolic <90 6. observe for neurologic or cardiovascular complications - seizures, numbness, weakness, tingling of extremities, dysrhythmias, chest pain
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Peripheral vascular disease includes what two categories?
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1. arterial - more common 2. venous *can have both
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Describe peripheral arterial disease?
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1. progressive narrowing and degeneration of the arteries of the neck, abdomen, and extremities 2. flow of blood through peripheral circulation is altered 3. partial or total arterial occlusion - decreased perfusion to extremities
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What is the leading cause of PAD?
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systemic atherosclerosis
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What are the two classifications of obstructions in PAD?
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1. inflow 2. outflow
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Inflow obstructions involve
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the distal end of the aorta and common, internal, and external iliac arteries (basically lower trunk)
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Outflow obstructions involve
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the femoral, popliteal, and tibial arteries (basically below lower extremities)
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Which kind of obstructions typically cause significant tissue damage?
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outflow obstructions - lower extremities
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Patients with PAD have an increased risk for developing what conditions?
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1. chronic angina 2. MI 3. stroke
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Name the four stages of chronic peripheral arterial disease
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stage 1: Asymptomatic stage 2: Claudication stage 3: Rest pain stage 4: Necrosis/gangrene
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stage 1 PAD:
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1. no claudication present 2. bruit or aneurysm may be present 3. pedal pulses are decreased or absent
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stage 2 PAD:
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1. muscle pain, cramping, or burning with exercise, relieved by rest 2. symptoms reproducible with exercise
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stage 3 PAD
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1. pain while resting, commonly awakening at night 2. numbness, burning, toothache-type pain 3. pain usually at distal portion of extremities (toes, arch, forefoot, heel), rarely in calf or ankle 4. pain relieved by dangling extremity (dependent position, below heart)
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stage 4 PAD:
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1. ulcers and blackened tissue occur on toes, forefoot, heel 2. gangrenous odor
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claudication
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leg pain
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Discomfort in the lower back, buttocks, or thighs would indicate a) inflow disease b) outflow disease
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inflow disease
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Burning or cramping in the calves, ankles, feet, and toes would indicate a) inflow disease b) outflow disease
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outflow disease
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Assessment for PAD
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1. loss of hair on lower calf, ankle, and foot 2. dry, scaly, dusky, pale, or mottled skin 3. thickened toenails
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Severe arterial disease would be marked by
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1. cold, cyanotic, or darkened extremity 2. pallor when extremity elevated 3. rubor (redness) when extremity lowered
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Arterial PVD
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Location: toes and feet 1. intermittant claudication pain 2. no edema 3. no pulse or weak pulse 4. no drainage 5. round, smooth sores 6. black eschar
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Venous PVD
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location: ankles 1. dull, achy pain 2. lower leg edema 3. pulse present 4. drainage present 5. sores with irregular borders 6. yellow slough or ruddy skin
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5 Ps of Neurovascular Assessment for PVD
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1. pain 2. pulse 3. pallor 4. paresthesia 5. paralysis
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Diagnostic assessments for PVD
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1. MRA 2. doppler ultrasound 3. ankle-brachial index 4. exercise tolerance texting 5. plethysmography
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The nurse is caring for a client with lower extremity peripheral arterial disease. Which statement made by the client regarding self-management requires further health teaching? a) "I need to quit smoking as soon as I can." b) "I will elevate my legs above the level of my heart." c) "I will use a heating pad to promote circulation." d) "I will avoid crossing my legs at all times."
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b) "I will elevate my legs above the level of my heart."
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Drug therapy for patients with chronic PAD
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1. pentoxiflylline - for claudication pain 2. aspirin and clopidogrel - antiplatelet 3. cilostazol - increases vasodilation to promote increased walking distance
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Best medication prescribed to patients with PAD for reducing risk for MI, ischemic stroke, and vascular death
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clopidogrel
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Patients on clopidogrel should be cautioned to
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avoid grapefruit (inhibits metabolism of this drug and can cause too much of drug to remain in bloodstream - causing kidney failure, heart failure, GI bleeding, possibly death)
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Drug prescribed for patients with disabling intermittent claudication, which also increases HDL-C levels
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cilostazol (phosphodiesterase inhibitor)
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Patients taking cilostazol may experience
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1. headaches 2. GI disturbances - flatulence and diarrhea
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Action of cilostazol
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1. increases vasodilation 2. increases walking distance 3. increase HDL-C levels
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Action of pentoxifylline
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1. hemorheologic agent 2. increases flexibility of red blood cells 3. inhibits platelet aggregation to decrease blood viscosity 4. increases blood flow to extremities
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Patients with PAD and no contraindications to antiplatelet therapy should receive either
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1. aspirin 2. clopidogrel
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Acute arterial occlusion signs and symptoms
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1. severe pain below level of the occlusion, even at rest 2. affected extremity is cool, pulseless, mottled 3. small areas on toes blackened/gangrenous 4. "6 P's of ischemia"
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What are the "6 P's" of ischemia?
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1. pain 2. pallor 3. pulselessness 4. paresthesia 5. paralysis 6. poikilothermy (coolness)
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Venous Thromboembolism VTE is the result of one or all of what three components?
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1. endothelial injury 2. venous stasis 3. hypercoagulability
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Deep vein thrombosis carries a high risk factor for what?
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pulmonary embolism
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Predispositions for thrombus formation
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1. hip surgery 2. knee replacement 3. open prostate surgery 4. ulcerative colitis 5. heart failure 6. cancer 7. oral contraceptives 8. immobility 9. phlebitis associated with IV therapy
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Classic signs and symptoms of DVT
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1. groin tenderness and pain 2. sudden onset of unilateral swelling of the leg
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DVT Assessment
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1. Examine area of pain and compare with opposite limb 2. gently palpate site for induration along blood vessel 3. palpate for warmth and edema 4. check for redness
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Diagnostic studies used for diagnosis of DVT
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1. venous duplex ultrasonography 2. doppler flow studies 3. D-dimer - blood test to measure coagulation
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DVT prevention interventions
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1. leg exercises 2. early ambulation 3. adequate hydration 4. compression stockings 5. sequential compression devices 6. patient education 7. anticoagulant therapy
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Signs and symptoms of pulmonary embolism
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1. shortness of breath 2. chest pain 3. acute confusion (in older adults)
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DVT drug therapy
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1. unfractionated heparin therapy (UFH) 2. low-molecular weight heparin 3. warfarin therapy 4. thrombolytic therapy
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heparin antidote
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protamine sulfate
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warfarin antidote
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vitamin K
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Benefit of low-molecular weight heparin (LMWH)
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1. consistent action times 2. longer half-life 3. more predictable response
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Examples of LMWH
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1. enoxaparin 2. dalteparin 3. ardeparin
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The nurse is providing care to a client who has started warfarin after being diagnosed with a deep vein thrombosis. What health teaching will the nurse provide to the client related to self-management of warfarin therapy? a) "You must have your partial thromboplastin time checked every 2 weeks." b) "Massage the injection site after the warfarin is injected." c) "Eat plenty of dark green leafy vegetables while taking warfarin." d) "Report any signs of bleeding to your primary care provider."
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d) "Report any signs of bleeding to your primary care provider."
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What is INR?
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International Normalized Ratio for monitoring therapeutic effect of warfarin
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Partial thromboplastin needs to be checked how often and for what medications?
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daily checked for UFH therapy
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What is unfractionaed heparin (UFH)?
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anticoagulent agent that inhibits clotting factors
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What is the risk associated with UFH?
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heparin-induced thrombocytopenia (HIT) or "white clot syndrome" - formation of antiplatelet bodies that can end up causing occlusion. For this reason, LMWHs are preferred.
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Woods and drugs that interfere with warfarin (coumadin)
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1. broccoli 2. cauliflower 3. spinach 4. kale 5. other green leafy vegetables 6. brussels sprouts 7. cabbage 8. liver
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Cause of venous insufficiency
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1. poor venous return 2. prolonged venous hypertension that stretches veins and damages valves
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A patient with peripheral vascular 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
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a) risk for injury related to decreased sensation
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When teaching a patient with peripheral arterial disease, the nurse determines that further teaching is needed when the patient says a) I should not use heating pads to warm my feet b) i will examine my feet every day for any sores or red areas c) I should cut back on my walks if they cause pain in my legs d) I think I can quit smoking with the use of short-term nicotine replacement and support groups
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c) I should cut back on my walks if they cause pain in my legs
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The hallmark clinical manifestation of peripheral arterial occlusive disease is which of the following? a) angina b) dyspnea c) intermittent claudication d) absent radial pulse
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c) intermittent claudication
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amlodopine
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1. calcium channel blocker 2. slows heart rate 3. hold if HR less than 60 bpm
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lisinopril
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1. ACE inhibitor 2. vasodilator
