chronic cardio disorders notes

7/29/2019 Chronic Cardio Disorders Notes

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Chronic Cardiovascular Disorders

General Overview

Hypertension

Disorders of aorta and branches

Arterial thrombosis & embolism

Peripheral arterial disease (PAD)

Aortic aneurysms

Thromboangiitis obliterans

Raynauds disease/phenomenon

Venous disorders Venous thrombosis: Superficial & Deep

Chronic venous insufficiency

Lymphedema

General Overview Gender, Cultural, & Ethnic Differences Use of the Genogram Medication Reconciliation Risk factors Diagnostic Tests Collaborative Care Nursing Interventions Prioritization

Cardiac Markers

Creatine Kinase (CK)

Measures an enzyme that is released when there is muscle damage or breakdown

Does not tell specific muscle

CK-MM (skeletal); CK-BB (brain); CK-MB (cardiac)

Report Rise, Peak and Fall levels

Troponin

Elevated levels mean Myocardial Damage

Elevates earlier than CK-MB

Reaches peak @ 24 hours and may not fall for 7-10 days

Good indicator for patient who presents non-classic MI symptoms

Cardiac MarkersBLOOD STUDY RANGE RISE, PEAK, FALL

Creatine Kinase (CK) 36-160 Units/L (F)

50204 units/L (M)

CK-MB < 4-6% of total CK Rise 4-6 hrs

Peak 18-24 hrs

Return to baseline 24-36 hrs

Troponin

< 0.35 ng/ml (I)

< 0.2 mcg/L (T)

Rise 2 6 hrs

Peak 15-24 hrs

Return to baseline 7-10 days


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Lipid Panel (Cholesterol Test)

Blood study Range

Total Cholesterol < 200 mg/dL

Low-density lipoprotein (LDL) or bad cholesterol Without CAD 40 mg/dL (men)

> 60 mg/dl (women)

Triglycerides < 150 L

Brain (or B-type) Natriuretic Peptide (BNP) Test Hormone secreted by the left ventricular when the left ventricular is overstretched

from excess volume

BNP level Condition

< 100 Normal heart function

100-199 Mild heart failure

200-400 Moderate heart failure

>400 Moderate to severe heart failure

Diagnostic Studies

Homocysteine Level

Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue.

Normal: 4.6-11.2 mcg/L

Damage inside lining of artery

Encourage clot formation

Stroke Heart disease

Chest X-ray

A chest x-ray is typically the first imaging test used to help evaluate symptoms such as:

Shortness of breath

Persistent cough

Chest pain

Takes 15 minutes

Painless procedure

PA & Lateral views

Portable AP view

Always check if there is a chance pt is pregnant

Echocardiogram (echo)

Non-invasive ultrasound procedure that utilizes ultrasound to image the heart, muscle, chamber sizes, valves, ejection

fraction, and blood flow

Hypokineases less movement of muscle

A-kineases non movement (MI)

Ejection Fraction tells how well heart is pumping


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Transthoracic Echocardiography (TTE) No special preparation

Transducer is applied to chest wall to evaluate:

Size and shape

Valves

Abnormal structures

Blood clots or tumors

Walls of heart

Pumping ability

Ejection Fraction (EF) Transesophageal Echocardiogram (TEE)

Prep

NPO for 6 hours prior to test

Consent

IV access

Remove dentures

During the procedure

Sedation (Versed)

Oxygen

Anesthetic gel or spray

Test takes about 15-20 minutes

Nursing Care after TEE Vital signs including pulse oximetry

No eating or drinking 2 hours after procedure, or until gag reflex returns

Monitor for shortness of breath, chest pain, bleeding, or fever

Electrocardiogram (EKG or ECG)

Painless test that records the hearts electrical activity

12 specific areas

No special preparation

Place nodes non-hairy area, instruct pt not to talk

Electrodes are placed on specific locations on chest wall and extremities

A machine records the signals on graphic paper

Test takes 5 minutes

Electrocardiogram (ECG)

Electrical activity of different walls of the heart

Stress Test

Exercise stress testing

Nuclear stress testing

Using radioactive isotopes

Shows how the heart responds to increased oxygen demands

Determine what the patients max HR is

Is they reach 80% of that then is considered a successful test

Looking for signs of ischemia as you increase workload (increase incline or speed of treadmill)


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What happens when stress test is performed?

Timed interval exercise

Underlying heart disease is suggested if patient develops:

Changes with ECG at low level exercise

Drop in blood pressure

Extreme or inappropriate shortness of breath, chest discomfort, and weakness

Test takes 1/2 to 3 hours

Return to normal activities

Other Names for Stress Test Exercise Treadmill test

Stress echocardiogram

Dobutamine stress echocardiogram (DSE)

Myocardial Perfusion Imaging (MPI)

Stress Thallium scan, Nuclear stress test

Typical Standing Orders for Stress Test

Consent

NPO

No caffeine for 12-24 hours

Hold medication that slows heart rate

Beta blockers (Metoprolol, Carvedilol)

Digoxin (Lanoxin)

Calcium channel blockers (Diltiazem, Verapamil only)

Angiography or Angiogram

X-ray pictures of arteries (arteriogram) or veins (venogram) using injection of x-ray dye (contrast)

Arteries: usually goes in at femoral artery

Invasive procedure using local anesthesia and conscious sedation

Consent required!!!

NPO

Check for allergy to iodine, shellfish, xray dye

What is Cardiac Catheterization?

Cardiac Catheterization (Cath) is a specialized study of the heart during which a catheter, or thin hollow flexible tube, isinserted into an artery in the groin or arm

Cardiac catheterization is performed to diagnose:

Coronary artery disease

Disease of heart valves Etiology of Congestive heart failure (ex: ischemia or malfunction heart valve)

Structural defects

Cardiac Catheterization (cardiac cath) Large vascular access sheaths are placed in the groin or arm Insertion of a catheter into the heart Contrast dye injected to detect impaired flow of blood to the coronary arteries

Typical Standing Orders for Cardiac Catheterization Explain procedure (Dr. Np or PA only, nurse cannot do this)

Consent

NPO

Intravenous access

Shave and prep right/left groin

Hold anticoagulants

Coumadin has longer half life than Heprin so need to check PT/INR to make sure back to normal before procedure

Do not give 0800 dose of Lovenox

Check allergy

Iodine, shellfish, contrast dye

If allergic, give Benadryl and Solucortef (several doses 24hr period ahead of time)


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Hold basal (ex: lispro) insulin and oral hypoglycemic agents bc NPO

Can give correction dose (sliding scale if BG is high in morning), but not scheduled basal dose

Preparation for Cardiac Catheterization

Several routine tests will be done:

ECG

Complete Blood Count (CBC)

WBC, Hgb, Hct, Platelets

Infection present, any bleeding

If severly anemic do not want to put them at risk for more blood loss Adequate patelets so they can clot

BMP: Electrolyte panel

Sodium, Potassium, BUN, creatinine

xRAY Dye could worsen kidney function

PT/INR (if on Coumadin/Heprin)

What to expect during a cardiac cath? Contrast dye used to visualize the coronary arteries

Procedure lasts one hour

Catheter is usually removed in cath lab

Pressure is held for 20 to 30 minutes

Pressure dressing applied If closure device used, only bandaid applied

Post Cardiac Cath Care

Bed rest for 3 to 4 hours

Head of bed elevated 20 to 30 degrees

Keep the affected extremity straight

Frequent vital signs

Bleeding: BP decrease, HR insrease

Monitor groin site for bleeding

Check pedal pulses

After 3 to 4 hours & stable, check blood pressure and heart rate lying, sitting, and standing

Most common cause of hypotension is dehydration

Complication of Cardiac Catheterization

Dissection of aorta or coronary artery

MI (Heart Attack)

Dislodged athlescrotic plaque

Thrombus/embolus

Stroke

Plaque breaks off, goes into Carotid artery and travels to brain

Hematoma

Retroperitoneal bleed

Pseudoaneursym or A-V fistula

Pseudoaneursym: Bleeding in layers of artery

AV Fistula: is a tear that forms between artery and vein

When palpating pulse @ site you will hear a Bruit and feel/palpate a Thrill

Allergic reaction to xray dye

Warmth, erythema, swelling of tissues lungs: stridor, hives, sneezing, itching

Cardiac CT (computed tomography)

A painless test

X-ray machine takes clear, detailed pictures of the heart.

Each picture shows a small slice of the heart.

A computer will put the pictures together to make a large picture of the whole heart.

Calcium score predicts cardiac events


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Electrophysiology Study (EPS)

An invasive study used to diagnose dysrhythmias - slow or fast rhythms

NPO

Consent

Shave & prep groin

Catheter inserted right femoral vein

Bed rest 3-4 hours

Monitor vital signs and puncture site

Assess pedal pulses

Arterial doppler study (Ultrasound) & Duplex Scan

Venous Doppler Study & Duplex Scan Noninvasive, painless ultrasound test to detect thrombosis in the superficial and deep veins.

May be done on the upper and lower extremities

Hypertension

Blood Pressure Classification SBP (mmHg) DBP (mmHg)

Normal < 120 and < 80

Prehypertension 120-139 or 80-89

Stage I

Hypertension140-159 or 90-99

Stage II

Hypertension>/= 160 or >/= 100

Types of Hypertension

Isolated systolic hypertension

Defined as an average SBP >140 and DBP < 90

More common in older sdults due to a loss of elasticity in large arteries and atherosclerosis

Pseudohypertension False hypertension

Happens a lot in elderly due to thickening in the walls of the arteries (atherosclerosis)

Sclerotic arteries dont collapse when cuff is fully inflatedCuff doesnt fit correctly

Much higher pressures than what are actually present

Susopect if arteries feel rigid and few retinal/cardiac signs are found relative to cuff reading

Primary hypertension

Essential hypertension (idiopathic htn)

Most common (90% of hyoertension)

Elevated BP without a primary cause


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Secondary hypertension

HTN related to a specific cause that can be identified and sometimes treated

Kidney Failure, medications, pregnancy

Anything or disease that causes excessive blood volume

Hypertensive crisis

Excessively high diastolic, sometimes high systolic

Risk factors Heredity

Male > 45 Female > 55 Excess dietary sodium Diabetes mellitus

Hyperlipidemia

Ethnicity Stress

Obesity

Alcohol

Lack of exercise

Smoking Medications

Socioeconomic

Gender, Cultural, & Ethnic Factors Men vs. women

Age onset Males -MI; Females CVA

Cultural & Ethnic African Americans

Highest prevalence Younger onset Women > men

Mexican Americans Lower awareness Less receipt of treatment & adequate control May need more patient teaching

Complications silent killer!!!

Target organ damage:

Heartcardiac hypertrophy, atherosclerosis, tearing of arteries

Brain stroke, encephalopathy

Peripheral vasculature atherosclerosis

Kidneys nephrosclerosis

Eyes Increased IOC, hemorrhage of retinal vessels

Diagnostic Evaluation

H&P Urinalysis detect kidney damage BMP Na, K, BUN, Cr, BG Lipid Profile detect additional risk factors that predispose a patient to CVD Serum uric acid establish a baseline bc often rise w diuretic therapy 12-lead Electrocardiogram Optional: 24 hr. urine (Cr clearance), Echocardiogram

Nursing Assessment of BP

Take BP in both arms

Check for Orthostatic Hypotension

Determine Mean Arterial Pressure (MAP)

MAP = SBP + (DBP X 2) / 3

Indicates tissue perfusion Normal is 70 100. Must be > 60 for organ perfusion

Nursing Judgment

Evidence Based Practice

Lifestyle modifications

DASH diet

Dietary Approaches to Stop HTN

Fish, Fruits and vegetables, Fiber, Water

Dietary Sodium Reduction

< 2.3 g/day (< 1.5 g/day DM, CKD, HTN)


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Research-based Collaborative Care

Additional lifestyle modifications

Losing excess weight

Exercise

Smoking cessation

Limiting alcohol intake

Stress management

Home BP monitoring

Adherence to health plan

Report sexual dysfunction OTC meds to avoid: sudafed (vasoconstriction), afrin

Collaborative Care: Drug Therapy

Medications Diuretics (1

st

choice)

hydrochlorothiazide

Beta blockers

ACE inhibitors

Angiotensin receptor blockers

Alpha blockers

Calcium channel blockers

Alpha-beta blockers Direct vasodilator

Antihypertensive Drug Therapy


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Nursing Implications for Med Administration Check BP prior to administration; Hold antihypertensives if SBP < 100

Atherosclerosis Coronary Artery Disease

CAD, Coronary Heart Disease, ASCHD, ischemic heart disease

Peripheral Arterial Disease

Carotid arteries

Abdomen

Extremities

Risk Factors - Atherosclerosis

Age

> 65 yrs, Men = women

Gender

Ethnicity

Genogram

Family History who, age of dx?

Genetics

Familial hypercholesterolemia

Risk factors Tobacco Use Dyslipidemia Hypertension Diabetes mellitus Physical Inactivity Obesity

Additional risks

Stress

Depression

Metabolic syndrome

Homocysteine

Alcohol

Age

Genetics

Health Promotion & Disease Management

Lifestyle modifications

Dietary measures, weight loss, Exercise, Smoking cessation


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Medications

Antidyslipidemic Therapy Restrict Lipoprotein Production

Statins (HMG-CoA reductase inhibitors) Lovastatin, pravastatin, atorvastatin, rosuvastatin Mainly decrease LDL, small increase in HDL

Niacin Decrease LDL & triglycerides Increase HDL (best drug)

Fibric Acid derivatives (fenofibrate, gemfibrozil)

Decrease triglycerides Increase HDL

Increase Lipoprotein Removal

Bile acid sequestrants (cholestyramine)

Decrease total cholesterol & LDL

Decrease Cholesterol Absorption

Ezetimibe (Zetia)

Vytorin = ezetimibe + simvastatin

Research proven enhanced reductions in LDL

Disorders of the aorta and branches (match columns)

Types of Disorders

Peripheral Arterial Disease

Acute arterial ischemia

Aneurysms


Raynauds disease

Pathophysiology

Occlusive disease Inflammatory

Aneurysmal disease

Vasospastic phenomenon

Peripheral Arterial Disease (PAD)

Signs and Symptoms

Intermittent claudication

Calf pain

Blockage in femoral arteries

Buttock and thigh pain

Blockage in iliac arteries Erectile dysfunction

Paresthesia

Changes to skin

Diminished or absent pulses

Bruit

Complications

Atrophy of the skin and muscles

Delayed healing

Wound infections

Tissue necrosis

Arterial ulcers

Gangrene

Amputation

Diagnostic Studies

Arterial Doppler Ultrasound

Ankle Brachial Index (ABI)

Ankle systolic pressure/brachial SBP

Doppler used to take pressures

Normal ABI 0.91-1.30


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Treatment options Modification of risk factors Exercise therapy Nutritional therapy Protection from trauma or injury

Lubrication (avoid soaking ft) Dangle or reverse trendelenburg for improved perfusion Wear soft, roomy, protective shoes Arterial ulcers keep clean & dry, cover w/ drsg Thrombosis or embolism EMERGENCY!

Drug therapy Antiplatelet agents

Aspirin Plavix

Ace Inhibitors Pentoxyfylline (Trental) increase RBC flexibility Cilostazol (Pletal) inhibits platelet aggregation & vasodilates, significantly increases walking distance & QOL

Interventional & Surgical therapy Interventional Radiologic procedures

Percutaneous transluminal balloon angioplasty, Stent placement, Atherectomy Surgical therapy

Peripheral arterial bypass operation Native vein or synthetic graft used

Endarterectomy

Endarterectomy w/ patch graft angioplasty Amputation

Planning Care of the Patient

Nursing Diagnoses?

Inadequate tissue perfusion

Activity intolerance

Risk for infection

Pain

Skin integrity

Goals?

Pt will have increased tissue perfusion, decreased pain, Increased exercise tolerance..

Outcomes Peripheral Tissue Perfusion

Capillary refill Skin color Extremity skin color Femoral pulses Pedal pulses

Activity Intolerance Walking pace Walking distance Ease of performing ADLs

Nursing Care Assess peripheral pulses, skin color & temp, capillary refill, sensation, & movement Aggressive pain management

Monitor for complications: bleeding, hematoma, thrombosis, embolization, & compartment syndrome Avoid knee- flexed positions except w/ exercise Prioritization: Notify dr. of significant change increased level of pain, loss of palpable pulse distal to operative site, ext.

pallor/cyanosis, cold ext, numbness or tingling.

Patient Teaching

Risk factor management NO TOBACCO!

Meticulous foot care

How to check pulses, temp & capillary refill

Gradual increase in physical activity post-op

Regular physical activity


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Acute Arterial Ischemia

Causes: Thombosis, Embolism, Trauma

EMERGENCY!!!

Six Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (usually cool)

Treatment: Anticoagulation, Thrombolysis, Embolectomy, Surgical Revascularization, Amputation


Buergers disease

Rare, nonathersclerotic, inflammatory disorder

Common in young men Affects:

small and medium size arteries, veins, and nerves

upper and lower extremities

Strong correlation with smoking

Pathophysiology

Inflammatory process damages arterial wall

Lymphocytes and giant cells infiltrate the vessel

Fibroblast proliferation

Thrombosis and fibrosis occur

Tissue ischemia develops

Signs and Symptoms Often confused with PAD or autoimmune disorders

Intermittent claudication of feet, hands, or arms Color and temperature changes in affected limbs

Paresthesia

Superficial thrombophlebitis

Cold sensitivity

Rest pain

Ischemic ulcerations

Treatment options

Smoking cessation

Avoid trauma to the extremity

Medication therapy

Surgical therapy Sympathectomy, bypass

Amputation

Raynauds disease/phenomenon

Episodic, vasospastic disorder

Affects small cutaneous arteries

Occurs primarily in young women

May be an early manifestation of scleroderma

Signs and Symptoms Vasospasm induced color changes of fingers, toes, nose, and ears

Pallor--decreased perfusion Coldness and numbness

Cyanosis--decreased perfusion Throbbing, aching pain

Rubor--hyperemia Tingling and swelling

Precipitated by cold weather, emotional upsets, smoking, or caffeine use Usually lasts for minutes

Treatment options

Prevention of recurring episodes

Avoid temperature extremes

Smoking cessation

Avoid vasoconstrictors (caffeine, meds)

Coping strategies

Drug therapies: Ca-channel blockers

Surgical options: Sympathectomy


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Aortic Aneurysms Aorta

Role: largest artery in the body with major role is tissue perfusion Aneurysm

Definition: bulging in artery wall Common in aorta

Aortic arch Thoracic aorta Abdominal aorta usually below renal arteries

Men > women Incidence increases with age

Etiology Atherosclerosis*** Hypertension** Congenital abnormalities Premature degeneration of vascular elasticity Penetrating or blunt trauma Inflammatory aortitis Infectious aortitis

Aneurysm classification True wall of the artery forms the aneurysm with atleast 1 vessel layer still intact

Fusiform: circumferential; uniform in shape

Saccular: bulging on one side of the vessel

False not an aneurysm but a disruption of wall layers with bleeding pseudoaneurysm

surgery, trauma or infection can cause

Signs and Symptoms

Thoracic aneurysm

Often asymptomatic

Deep, diffuse chest pain

Angina

Hoarseness

Dysphagia

Distended neck veins

Facial & upper extremity edema

Abdominal aneurysm

Often asymptomatic

Found on routine exam

Coincidence

Pulsatile mass

Bruit

Abdominal or back pain

Problems with bowel elimination

Distal emboli

Complications

RUPTURE!!

ExsanguinationBleed to death

People usually dont survive this unless it ruptures in the hospital or on the way to hospital

Retroperitoneal bleed flank area

Grey-Turner sign

Hypovolemic shock cold, clammy, pale, High HR, LOW MAP

Diagnostic Tests

Chest or abd. xray Electrocardiogram (ECG)

Echocardiogram

Abdominal Ultrasound

Computed tomography (CT scan) ***

Most accurate

Magnetic Resonance Imaging (MRI)

Angiography

Treatment options

Prevent rupture Evaluate coexisting disorders

Conservative therapy

Risk factor modification

Blood pressure control

Frequent monitoring of size

Surgical intervention: > 5.5 cm (males), > 5 cm

(females)


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Endovascular Graft Procedure Minimally invasive Used in older, higher risk patients Cannot use in aortoiliac or renal involvement Benefits Most common complication: perigraft leak

Open Surgical Repair

Cross clamping of aorta

Incising diseased segment of aorta Removing intraluminal thrombus & plaque

Inserting & suturing synthetic graft

Suturing native aortic wall around graft

Unclamping aorta

Actual Care of the Patient Pre-op: Bowel prep, NPO, shower with antimicrobial soap, IV antibiotics Post-op: ICU

Graft patency: Maintain adequate BP, IV fluids, blood transfusion as needed CV status: Telemetry monitoring, oxygen, electrolytes, ABGs, pain control Infection: antibiotics, monitor for fever & leukocytosis, Strict aseptic technique Foley, IVs, incisions

Actual Care of the Patient GI status: Monitor bowel sounds & passing of flatus; NG tube (100ml, normal color); early ambulation; NPO-mouth care

Monitor for bowel ischemia: abdominal pain/distension Neurologic status:

Ascending Ao & arch cerebral perfusion Descending Ao lower ext. movement

Peripheral perfusion Renal perfusion: hourly urine output (30 ml/hr), I/O & daily wts, BUN & Cr

Discharge Teaching Gradual increase in activity Expect fatigue, poor appetite, & irreg. bowel habits at first Avoid heavy lifting X 4-6 wks Report any fever; redness, swelling, pain, or drainage from incision Prophylactic antibiotics before future procedures Possible sexual dysfunction

Aortic Dissection Most common location: thoracic Aorta LIFE THREATENING! Causes: HTN, Marfans, Blunt Trauma Sx per location Tearing, ripping pain Complications Cardiac tamponade, exsanguination, death Diagnostic tests: CXR, Transesophageal echocardiogram, CT scan Collaborative care: Lower BP & myo. contractility, conservative rx if asx; emergency surgery


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Venous Disorders

Veins: deoxygenated blood back to heart

Valve malfunction results in stasis of blood clotting clots breaks off and travel to lungspulmonary embolism

Major Causes:

Weak and damaged vein walls

Stretched or injured one-way valves

Blood clot

Types:

Varicose Veins

Thrombophlebitis Deep Vein Thrombus

Chronic Venous Insufficiency

Diagnostic Tests for Venous Disorders

Venous Duplex, CT scan, MRI, Venogram

Varicose Veins

Incompetent valves

Risk Factors: FH, Gender, Occupation, Pregnancy, Deep vein obstruction, Trauma

Signs & Symptoms: Bulging large bluish veins, Pain/Discomfort, Dull, heavy ache, Throbbing, Burning, Cramping,

Swelling

Complications: Ulcers & Non-healing sores

Varicose Vein Treatment

Conservative Treatment

Weight loss

Exercise

Elevate leg

Compression stocking

Avoid activities that promote venous stasis

Treatment of Varicose Veins: Laser therapy, Sclerotherapy

Inflammation, scaring and closing of vein

Surgical Treatment of Varicose Veins

Endovenous Laser, Vein Ligation, Ambulatory Phlebectomy

Patient Education after Endovenous Laser and Ambulatory Phlebectomy

Compression bandage to minimize bruising

Walking is encouraged immediately following the procedure

Compression stocking

Anti-inflammatory medication

Heavy exercise avoided for 2 weeks

Avoid hot tubs and swimming for 2 weeks

Patient Education After Vein Ligation/Stripping Monitor for bleeding Assess extremities for color, movement, sensation, temperature, presence of edema

Check dorsalis pedis & posterior tibial Compression stocking Elevate leg Anti-inflammatory pain medication Resume normal activities in two weeks or less. Exercise


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Venous Thrombosis

Superficial

Typically not dangerous

Deep vein thrombosis (DVT) dangerous bc if breaks off can travel to lungs

Thrombophlebitis of Hand

Risk factors :

Catheter >3 days

Not flushing line

Highly irritating medications

Sign &Symptoms:

Redness

Tenderness

Pain

Treatment:

Immediate removal of catheter

Prevention

Observation

Treatment for Thrombophlebitis

Heat or cold application

Elevation of affected extremity Pain management

Tylenol

Non-steroidal anti-inflammatory drugs (NSAIDS)

Antibiotic Therapy if severe

Anticoagulants typically not needed

Deep Vein Thrombosis

Causes Major surgery Leg trauma--a broken hip or leg Prolonged travel Family history of a blood-clotting disorder

Cancer Oral contraceptives/HRT Smoking Varicose Veins Central venous lines (pacemaker & ICD leads) Repetitive motion

Symptoms of DVT

Unilateral Edema Majority have no symptoms Dull, aching pain in the affected extremity Leg pain that may worsen when you walk or stand Swelling, Redness, Warm to touch Homans sign

Diagnostic Lab Test for Deep Vein Thrombosis

D-dimer A blood test measuring fragments of fibrin as result of fibrin degradation & clot lysis.

Elevated result suggests deep vein thrombosis

Normal:


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Surgical Treatment of DVT

IVC Filter Greenfield Filter

Inserted in the inferior vena cava via femoral vein

Pre: Consent, check dye allergy, NPO, Shave

Post: same as angiography

May go home after 1-2 days

Anticoagulant Therapy: Prevention & Treatment

Heparin

Unfractionated Heparin High Alert Medication

Read dosage carefully

Practical Guideline:

Intravenous: treatment (must monitor aPPT levels closely if given IV)

Baseline CBC, PT, PTT, & Platelet Count

Bolus given

Frequent PTT monitoring (q6-8 hrs)

Dose adjustments by weight

Length of therapy 5-7 days or until INR therapeutic

Once INR gets to 3, pt can come off Heprin and switch to Coumadin

Lovenox (Enoxaparin)

Low molecular weight heparin (LMWH)

Practical Guidelines:

Subcutaneous

Baseline CBC, PTT, PT, INR, Platelet Count

No continuous PTT monitoring

Dose determined by weight of patient

1mg/kg every 12 hours

The average administration 7 days or until therapeutic goal of INR is achieved

Coumadin (Warfarin) (antidote: Vitamin K)

Practical Guideline

By mouth (PO)

Baseline CBC, PT, INR, Platelet Count

Dose varies between patients

Daily monitoring PT/INR

Therapy long term for 6 months or longer

Pt Teaching:

Food containing Vitamin K

Over the counter medication

ETOH, Safety, Report bleeding


18/19

Laboratory Values to Monitor

Look at ppt chart!!

INR: 2-3 seconds is the goal

Higher INR, thinner the blood

More warfarin (Coumadin) = thinner blood i.e. a higher INR

Medication Value Frequency of Test Measures Normal Values Goal of Therapy

Heparin

(Antidote:

protamine

sulfate)

aPTT

Activated Partial

ThromboplastinTime

Q6 hrs until reach

goal of therapy,

then daily

Ability of the blood

to clot; effect on

intrinsic & common

pathway

24-36 sec. 46-70 sec.

Coumadin

(antidote: Vit K)

PT

Prothrombin Time

or Protime

Daily until reach

goal of therapy

Ability of the blood

to clot (inhibition of

Vit. K dependent

clotting factors

10-14 sec. 21-28 sec

Coumadin

(INR)

International

Normalized Ratio

Daily until reach

goal of therapy

Used to monitor

the effectiveness of

anticoagulant

0.9-1.2 sec. 2.0-3.0

seconds

Chronic Venous Insufficiency (CVI)

CVI is a condition characterized by valve dysfunction in deep veins causing backflow and pooling of blood in the legs leading

to edema and changes in the skin.

Causes of Chronic Venous Insufficiency

Smoking

Sitting/standing for prolonged periods of time

Varicose Veins

Superficial thrombophlebitis

DVT

Trauma Symptoms of CVI

Leg pain

Leg/ankle swelling

Discoloration of the skin hemosiderin

Thickened skin

Varicose veins

Leg ulcers

Complication of CVI: Venous Ulcer

Most venous skin ulcers develop on either side of the lower leg, above the ankle and below the calf.

Dark red or purple over the affected area

Thick, dry itchy skin

Shallow wound

Moderate to heavy drainage

Slow to heal

Prevention & Treatment for CVI

Lifelong Compression stockings

Customized Jobst stockings

Prevention of venous ulcers

Elevation

Avoid sitting or standing for long periods of time

Lifestyle changes

Weight loss

Exercise


19/19

Medical/Surgical Intervention for CVI & Venous Ulcer

Wound therapy

Vacuum-assisted closure therapy (Wound VAC)

Surgery

Valve repair

Vein stripping

Skin grafts

Lymphedema

Definition: the accumulation of lymphatic fluid in the soft tissue that causes swelling, most often in the arm or leg. Types:

Inherited absent or malformed lymph vessels at birth

Acquired lymph node resection, radiation, infection, traumatic injury

Lymphedema

Signs and Symptoms:

Puffiness and a feeling of heaviness in the affected limb

Tightness of the skin

Limited range of motion

Graded 1 4+

Prevention and Treatment options for lymphedema Complex decongestive physiotherapy

Manual lymph drainage (MLD)

Compression bandage Compression stocking Skin care Exercise

Wear loose fitting clothes No blood pressure or needle sticks in the affected extremity

Have to get physician order to do so Drug Therapy for Lymphedema

Antibiotics

Coumadin

Lasix

Pain management

NSAIDs

Hydromorphone (Dilaudid)

KNOW:What statements made by client indicates a need for furthering teaching or what is a statement that pt understands teaching of

drug.

chronic cardio disorders notes

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