Sem 2 Ch 8 Cardiovascular Peripheral Vascular Disorder - Details

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What does the Peripheral vascular system consists of?

Arteries, Capillaries and veins

What is PATCH?

Pulse Appearance Temperature Capillary refill Hardness Edema

What is PATCH helpful for? [ Mnemonic device ]

A uniform assessment and documentation technique for veins and arteries

Capillary refill time/timing

Apply pressure to a toenail or fingernail for several sec until it blanches "loses color" Relieve pressure Note amount of time it takes for color to return should return instantly in less than 2 seconds with an arterial disorder, it will take more than 2 sec for color to return

Signs and Symptoms associated with Arterial disorders

Pain that is aching to sharp cramping brought on by exercise relieved by rest Pulses diminished or absent Edema usually absent Skin changes cool or cold dry shiny hairless pallor develops with elevation

Signs and Symptoms associated with Venous disorders

Aching to cramping relieved by activity or elevating extremity Pulses Usually present Edema usually present increases at end of day when extremity is in a dependent position Skin changes warm thick and toughened darkened pigmentation stasis ulcers

What does the Peripheral vascular system consists of?

Arteries, Capillaries and veins

Means pertaining to those areas away from the center [ heart ]

Peripheral

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure?

Allergy to iodine or shellfish

A client with no history of cardiovascular disease comes into the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which of the following questions would best help a nurse to discriminate pain caused by a non-cardiac problem?

“Does the pain get worse when you breathe in?”

A client with myocardial infarction has been transferred from a coronary care unit to a general medical unit with cardiac monitoring via telemetry. A nurse plans to allow for which of the following client activities?

. Bathroom privileges and self-care activities

A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next?

Review the intake and output records for the last two (2) days

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to:

Check the client status and lead placement

A nurse is assessing the blood pressure of a client diagnosed with primary hypertension. The nurse ensures accurate measurement by avoiding which of the following?

Taking a blood pressure within 15 minutes after nicotine or caffeine ingestion

IV heparin therapy is ordered for a client. While implementing this order, a nurse ensures that which of the following medications is available in the nursing unit?

Protamine sulfate

A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin (Coumadin). The client’s prothrombin time is 20 seconds, with a control of 11 seconds. The nurse assesses that this result is:

Within the therapeutic range

A client who has been receiving heparin therapy also is started on warfarin. The client asks a nurse why both medications are being administered. In formulating a response, the nurse incorporates the understanding that warfarin:

Inhibits synthesis of specific clotting factors in the liver, and it takes 3-4 days for this medication to exert an anticoagulant effect

A 60-year-old male client comes into the emergency department with complaints of crushing chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myocardial infarction. Immediate admission orders include oxygen by NC at 4L/minute, blood work, chest X-ray, an ECG, and two (2) mg of morphine given intravenously. The nurse should first:

Administer the morphine

When administered a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the purpose of this drug is to:

Dissolve clots he may have

When interpreting an ECG, the nurse would keep in mind which of the following about the P wave? Select all that apply

Reflects electrical impulse beginning at the SA node Reflects atrial muscle depolarization Has a duration of normally 0.11 seconds or less In a client who has had an ECG, the P wave represents the activation of the electrical impulse in the SA node, which is then transmitted to the AV node. In addition, the P wave represents atrial muscle depolarization, not ventricular depolarization. The normal duration of the P wave is 0.11 seconds or less in duration and 2.5 mm or more in height.

A client has driven himself to the ER. He is 50 years old, has a history of hypertension, and informs the nurse that his father died of a heart attack at 60 years of age. The client is presently complaining of indigestion. The nurse connects him to an ECG monitor and begins administering oxygen at 2 L/minute per NC. The nurse’s next action would be to:

Start an intravenous line

The nurse receives emergency laboratory results for a client with chest pain and immediately informs the physician. An increased myoglobin level suggests which of the following?

Myocardial infarction

When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol hydrochloride:

Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and Conduction Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction

The most important long-term goal for a client with hypertension would be to:

Make a commitment to long-term therapy

Hypertension is known as the silent killer. This phrase is associated with the fact that hypertension often goes undetected until symptoms of other system failures occur. This may occur in the form of:

Cerebrovascular accident

During the previous few months, a 56-year-old woman felt brief twinges of chest pain while working in her garden and has had frequent episodes of indigestion. She comes to the hospital after experiencing severe anterior chest pain while raking leaves. Her evaluation confirms a diagnosis of stable angina pectoris. After stabilization and treatment, the client is discharged from the hospital. At her follow-up appointment, she is discouraged because she is experiencing pain with increasing frequency. She states that she is visiting an invalid friend twice a week and now cannot walk up the second flight of steps to the friend’s apartment without pain. Which of the following measures that the nurse could suggest would most likely help the client deal with this problem?

Take a nitroglycerin tablet before climbing the stairs

Which of the following symptoms should the nurse teach the client with unstable angina to report immediately to her physician?

A change in the pattern of her pain

The physician refers the client with unstable angina for a cardiac catheterization. The nurse explains to the client that this procedure is being used in this specific case to:

Assess the extent of arterial blockage

As an initial step in treating a client with angina, the physician prescribes nitroglycerin tablets, 0.3mg given sublingually. This drug’s principal effects are produced by:

Vasodilation of peripheral vasculature

The nurse teaches the client with angina about the common expected side effects of nitroglycerin, including:

Headache Because of the widespread vasodilating effects, nitroglycerin often produces such side effects as headache, hypotension, and dizziness. The client should lie or sit down to avoid fainting.

Sublingual nitroglycerin tablets begin to work within 1 to 2 minutes. How should the nurse instruct the client to use the drug when chest pain occurs?

Take one (1) tablet, then an additional tablet every 5 minutes for a total of three (3) tablets. Call the physician if pain persists after three (3) tablets.

A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (Lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on digoxin (Lanoxin), a nurse checks the client’s most recent:

Potassium level

A client who had cardiac surgery 24 hours ago has a urine output averaging 19 ml/hr for 2 hours. The client received a single bolus of 500 ml of IV fluid. Urine output for the subsequent hour was 25 ml. Daily laboratory results indicate the blood urea nitrogen is 45 mg/dL and the serum creatinine is 2.2 mg/dL. A nurse interprets the client is at risk for:

Acute renal failure

A nurse is preparing to ambulate a client on the 3rd day after cardiac surgery. The nurse would plan to do which of the following to enable the client to best tolerate the ambulation?

Premedicate the client with an analgesic

A client’s electrocardiogram strip shows atrial and ventricular rates of 80 complexes per minute. The PR interval is 0.14 second, and the QRS complex measures 0.08 second. The nurse interprets this rhythm is:

Normal sinus rhythm

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. A nurse is most concerned with this dysrhythmia because:

It can develop into ventricular fibrillation at any time Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart.

A home care nurse is making a routine visit to a client receiving digoxin (Lanoxin) in the treatment of heart failure. The nurse would particularly assess the client for:

Anorexia, nausea, and visual disturbances

A client with angina complains that the angina pain is prolonged and severe and occurs at the same time each day, most often in the morning, On further assessment a nurse notes that the pain occurs in the absence of precipitating factors. This type of anginal pain is best described as:

Variant angina Variant angina, or Prinzmetal’s angina, is prolonged and severe and occurs at the same time each day, most often in the morning.

Your patient is beginning a warfarin [coumadin] regimen for the diagnosis of atrial fibrillation. your patient will be expected to

Vitamin k rich foods broccoli leafy greens bleeding and hemorhage monitoring frequent lab studies black tarry stools

What key teaching points will you make as a nurse to a pt who has just been diagnosed with heart failure?

Obtaining an infusion pump for the medication

A radioactive isotope [radioisotope] that is transported actively into normal cells

Thallium-201 If cells are ischemic or infarcted, the thallium will not be picked up

Where does Thallium concentrate?

In tissue with normal blood flow; tissue with inadequate perfusion appears as dark areas on scanning a "cold spot"

On occasion, a murmur swishing sound can be heard in the heart sounds, this can be a normal functional phenomenon produced by

Rapid filling of the ventricles orit can be an abnormal condition produced by ineffective closure of the valves

What is the order of blood flow?

Artery Arteriole Capillary Venule Vein

To sustain life the heart must

Pump blood throughout the body on a continuous basis

The delivery of oxygen and nutrient rich arterial blood to cardiac muscle tissue and the return of oxygen poor blood from this active tissue to the venous system are called the

Coronary Circulation

Blood flows into the heart muscle by way of two small vessels which are the right and left coronary arteries and wrap around the

Myocardium, the openings into these vessels lie behind the flaps of the Aortic Semilunar valves

What brings oxygen and nutrition to the myocardium?

Coronary arteries

Once circulation is completed and carbon dioxide and waste products have been collected blood flows into a large coronary vein and finally into the

Coronary sinus, which empties into the right atrium

What do the tiny branches that serve the heart muscle provide? if an artery becomes occluded blocked or obstructed?

Collateral circulation [alternate routes] to nourish the heart muscle

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