Rasmussen College: NURSING 2502/MDC3 Final Exam Study Guide_ Latest 2021/2022
• Left Sided Heart Failure (left side: backs up into the lungs)
Left
... [Show More] atrium, Left ventricle, mitral valve, or aortic valve
o Ejection fraction needed to dx LHF <40
o Causes: HTN, Coronary artery disease (CAD), valvular disease
o
(report 2lb in 1 night or 3-5lb in 1-week weight gain), report sleep sitting up, use pillows to prop themselves up, notify provider is increase swelling, and decreased activity tolerance, med compliance (no skipping Lasik’s)
o Signs and symptoms: increased BP and pooling of blood, pink frothy sputum, dyspnea and night, crackles, fatigue, pulmonary congestion, crackles, wheezing
o The main goal is to prevent exacerbation in chronic conditions
o Diagnosis: Ejection fraction (echocardiogram), Lab: BNP (fluid overload), Chest Xray, ECG
o Interventions: Oxygen, position, assess lung sounds, assess VS, cough, and deep breath
o Tx: DASH Diet,
▪ Medications: Overall goal is to manage fluid volume and help the heart to control the fluid volume that is there.
• Diuretics Enhance selective excretion of various
electrolytes & water
o Loop: furosemide: monitor potassium and electrolytes, dehydration (monitor daily weight and I&O, skin turgor, MOITOR BP before giving). If IV push give slowly. Adverse effects: Tinnitus (chronic)
o Thiazide: monitor potassium, possible supplements
o Potassium Sparing- Spironolactone: Monitor POSTASSIUM – This is potassium sparing.
• Ace inhibitors (-pril)
• Arbs
• Beta Blockers (-olol): lowers HR
• Digoxin Enhance Contractility, reduce HR, inhibit
sodium potassium
o Complications: Fluid overload (Pulmonary Edema)
• Heart Failure in General
o Education: monitor daily weight, stay active, low sodium diet,
possible fluid restrictions, Med adherence, avoid NSAID (can lead to sodium and fluid retention)
o What labs do you monitor for HF: BNP (if elevated anticipation that diuretic because it is showing that the heart is stressed, and it shows that more fluid is on the heart)
o Best tool for dx of HF in general- Echocardiogram. This looks at the blood flow
Difference between Left and Right HF: Left backs up into lungs, right backs up into the rest of you. Right side of heart is systemic edema.
Left side is pulmonary edema and the left will lead to the right. Know
the signs and symptoms of each and the differences between them
o What else leads to heart failure in general: HTN, valve disorders, cor pulmonal, smoking, DM, A Fib, MI.
o PRIORITY IS ALWAYS YOUR ABC’s.
o End stage heart failure, the last treatment would be a transplant. They will also be on the LVAD. Education post-transplant: immunosuppressant (avoid large crows, infection, do not eat raw fish or meat, no fresh flowers hand washing, lab and med adherence, watch for low grade fever), confusion
o Hypertension with right sided HF, Hypotension with left sided HF
• Right sided heart Failure
o RF: Left sided HF (left ventricular failure), Right ventricular MI,
Lung disease, Pulmonary Hypertension, pulmonary fibrosis Right atrium
Tricuspid Valve Right ventricle
Pulmonary valve
Signs and symptoms: abdominal ascites, peripheral edema, JVD, weight gain, fatigue, nocturia
o Diagnosis: Echocardiogram, Lab: BNP (best lab), electrolytes, H&H
o Manifestations: Positive JVD, increased ascites (and girth), hepatomegaly (congestive liver), Nausea, Vomiting, peripheral edema, malaise, enlarged liver and spleen, anorexia, dependent edema, distended jugular veins,
o Tx: Same as Left sided HF, unless the cause is dt lung disease, then we will be tx lung disease.
o CHF has an S3 gallop (this can be normal in athletes)
• Mitral Valve Prolapse
o This is on the left side of our heart, between the left atrium and
ventricle.
o If this prolapses it means the valve leaflets are going to fall back into left atrium
o Usually benign, it can progress to mitral valve regurgitation
o You will hear this as a murmur in the heart
Causes
• Valve Stenosis
o Narrowing of the valve causing a decrease in amount of blood that can
flow through. Blood then backs up into lungs.
o This can lead to left sided heart failure
o The valves become stiff, which can narrow the valvular opening
o Blood will back up and cause hypertrophy of the left ventricle. They will have HF manifestations dt back up of blood. They may also have
A. Fib or clots
Causes
treatment
diuretics, blockers, Ca+ blockers
o Presents with an S4 gallop
• Mitral Valve Regurgitation
o The backflow of blood into the left atrium, causing hypertrophy of left
atrium and ventricle because not all the blood is leaving the heart.
Causes
o This can lead to heart failure. Signs and symptoms
tachycardia, fatigue, weakness, high pitched murmur, neck pain, pooling of blood that leads to edema and JVD (this is dt it is backing up into the lungs and then further into the right side of the heart causing symptoms of right sided HF)
Treatment
similar tx for HF; diuretics, low sodium diet, decreased overall volume, surgery to repair or replace valve.
o You will hear this as a murmur in the heart.
o If manifestations of hf occur, they may discuss procedures to repair valve.
o Medications: This can cause R sided HF (VS: HTN, bounding pulses- rt excess fluid, Beta blockers (-olol) will be med to lower HR
• Mechanical Valve replacement
o INR of 3-4
o Will be on anticoagulants (Warfarin) life long. They can ONLY take warfarin. This is due to the fact that blood has an easier time clotting on the metal/ mechanical equipment.
o Will be on abx after dental procedure to prevent Endocarditis.
o Adhere to tx plan or HF sx will likely develop.
• aortic regurgitation
o Back flow of blood from the aortic valve causing left ventricular
hypertrophy, manifestations and decreased cardiac output (fainting, SOB, Bounding Pulse, Murmur, May have no Sx.
Causes
o Overall tx is to improve sx when able. When not able we do a valve replacement.
• Endocarditis
o Inflammation/ infection of the endocardium. (heart muscle tissue)
o If they are confused and have a fever, expect endocarditis
o Causes
: IV drug users, valve recipients, systemic infections, structural cardiac defects
o Manifestations/Assessment: New or changed murmur, embolization (can cause mini strokes), petechiae, fever, chills, night sweats, positive blood cultures.
o HF is most common complication of this.
o TX: antimicrobials (6 weeks), rest, aseptic technique, assess for SX of HF
o Sx: fever, chills, night sweats, malise, fatigue, anorexia, weight loss
o Entry ports: oral, rash, lesion, infection. surgery
o They will want blood cultures to be negative with no SX present.
o They do not use anticoagulants because the emboli are of a vegetative origin, anticoagulants will not have an effect on them because they are not actually a clot.
o Dx: Echocardiogram and blood cultures.
o Pts with hx of this or with a mechanical valve replacement or other heart issue should have abx after dental procedures to reduce risk of this.
o In severe cases they may have to remove an infective valve.
• Pericardial effusion
o When fluid builds up between the heart muscle and the pericardial
sac.
o Can be dt infection, cancer, inflammation
o Manifestations: Mild to Mod doesn’t cause much of an issue, once significantly enlarged it can cause
o This can lead to Cardiac Tamponade (Heart loses ability to pump, the cardiac output suddenly drops and opt will do into cardiac arrest is tx is not done.
▪ TX of this is Pericardiocentesis
▪ This is an emergency
o Tx: can drain it, do diuretics or abx depending on cause
o SX: SOB, Cough, sharp chest pain, increase resp effort
o Typically once you drain fluid they have resolution of symptoms.
• Pericarditis
o Inflammation of pericardial sac surrounding the heart.
o If chronic can cause thickening of the pericardium
o Assess: signs of right sided HF (JVD, Dependent edema, fatigue, dyspnea)
Causes
o Can be dt infection, MI or post-surgery, and connective tissue disorders
o Manifestations: Chest pain what is worse with breathing or coughing or laying flat and is better when sitting up or leaning forward. “Grating, oppressive pain”, pericardial friction rub (low pitched grading sound- rubbing balloons together, ST elevation on ECG, elevated WBC and positive blood cultures
o TX: NSAIDS and ABX, Steroids (inflammation), close monitoring to ensure they do not develop tamponade, sitting upright.
o If not treated that can become cardiac tamponade (this is an emergency where there is excessive fluid in the pericardial cavity causing a pericardiocentesis to be needed.)
o Dx: echocardiogram and CT scan
• Rheumatic carditis
o Inflammation of all layers of the heart and is associated with group a
beta-hemolytic streptococcus (upper resp infection), the pt then
develops Aschoff bodies (nodules in the heart tissues which are eventually replaced by scar tissue which can cause the heart difficulty to pump, this can also effect the valves.
Causes
o Signs and symptoms: pericardial friction rub, pericardial pain, new or changed murmur, cardiomegaly
o Treatment: abx ASAP, managing upper resp infections associated with this.
• Dilated pathy
o Most common kind of cardiomyopathy
o Can happen in both ventricles. Both ventricles are dilatated (left typically worse than the right)
o Risk factors: genetic, idiopathic, alcohol use, chemo drugs, infections and inflammatory processes.
o Manifestations/ signs and sypmtoms: similar to HF, syncope, A. fib,
o Treatment: same as for HF
o Overall goal is to treat the preload and afterload.
o Strenuous exercise is inhibited
• Hypertension
o Risk factors: Smoking, obesity, stress, family hx, dietary factors
o Considered to have HTN is BP is 140/90 and less than 60 yrs old, or if it is 150/90 if over 60 years old. HTN can lead to Atherosclerosis.
o Primary
▪ Most common type
▪ Not cause by a disease process
o Secondary
▪ Due to an underlying disorder that causes HTN
o Signs and symptoms: headache, facial flushing, dizziness, and fainting
o Treatment: anybody who is considered hypertensive should be started on therapy
▪ Modify the modifiable risk factors
▪ When modifiable rf don’t seem to do the job we rely on medications
▪ ABCD Drugs
• All of these drugs effect the RAAS (renin-angiotensin aldosterone) system or they slow the HR to allow the
heart more filling time to make it easier to maintain the cardiac output.
• A: Ace inhibitors (-pril) and ARBs (-sartan)
• B: Beta Blockers (-olol)
• C: Calcium Channel Blockers (-pine)
• D: Diuretics
o Pt education: Involve changing mod RF, DASH diet (<2400 mg
sodium daily), Low fat diet, meds, stress reduction
o Diagnostics: BUN, Cr, Serum corticoids, Chest X ray, ECG, BP monitoring.
o Can cause stroke, MI, kidney failure and death
• Atherosclerosis
o Type of arteriosclerosis (thickening of arterial wall) that involves
formation of plaque in arterial wall
o This can be from HTN or can be common when we get older
o Risk factors: HTN, Smoking, family hx, elevated cholesterol and lipids, cardiovascular disease, smoking, sedentary, obesity, hypercholesterolemia
o Assess: BP, pulse, temp, cap refill, bruit and cholesterol levels
o Nutrition: Minimize fat and cholesterol intake
▪ Legumes, avocado, fish, dark chocolate, whole grains, fruits, veggies
o This is the primary factors for development of Coronary artery disease
o Caused by high LDL, diabetes, smoking, obesity, HTN
o Treatment: medications -statins to decrease cholesterol, Ezetimibe (zetia) inhibits absorption of cholesterol through small intestine.
o Pt education: changing modifiable risk factors
o If modifying doesn’t work should take drugs like statins (help improve cholesterol)- Zetia, Niacin
• Peripheral Artery Disease (arteries take blood away from the heart- O2 rich)
o Blood has a hard time going to the lower extremities, resulting in
decreased perfusion.
o Risk factors: same as atherosclerosis and CAD
o There is a issue with blood getting to the lower extremities, which deprives lower extremities of O2 and nutrients.
o Diagnostics
▪ Most dx occurs dt onset of leg pain
▪ Doppler, MRI, arteriography
o Assess
▪ Intermittent claudication (can walk short distances, then pain starts), hair loss, dry/scaly skin, thickened toenails, cold extremities, pallor, muscle atrophy, arterial ulcers on toes
o Manifestations/ signs and symptoms: peripheral in nature- pain in extremities in activity (gets better with rest in early stages), numbness, tingling, Pain in low back, buttock, thighs and calves/ ankles, hair loss, dry scaly pale skin, thick toenails, ulcers of toes, blood pooling when leg is hanging, muscle atrophy and doppler pulses
▪ Severe blockage- cold, grey, blue skin, pallor
o Treatment: antiplatelet, atherectomy or PCI
▪ Nonsurgical management: exercise, positioning, promote warmth, avoid cold, aspirin, Plavix, PCI, angioplasty, atherectomy
o Pt education: no tobacco, walking program to develop collateral circulation, no constrictive clothing, no crossing legs, no heating pads, promote vasodilation (keep extremity warm, only walk with shoes on, don’t raise legs above heart, proper foot care, If pain upon exercise stop until pain stops.
6 P’s of Arterial Insufficiency: Pain, Pallor,
Pulselessness, Paresthesia, Paralysis, Poikilothermic (coolness)
• Aortic dissection
o The aorta is splitting apart. This will be very painful (chest and back
pain), typically fatal.
o DO NOT give them any anticoagulant medications! They need OR intervention Immediately.
o Nursing intervention: eliminate pain, decrease BP, Decrease velocity of left ventricular ejection, injury prevention.
• Abdominal Aortic Aneurism (AAA)
o Most common type of aneurysm (slow growing)
o Common cause: atherosclerosis, HTN, hyperlipidemia, smoking, family hx,
o Monitor size and growth and try to control the HTN
o Signs and symptoms: steady abdominal discomfort, abdominal mass (NO Palpate), Bruit (DON’T PALPATE), pulsating near naval, deep constant abdominal pain, backpain, (Sharp abdominal pain = get immediate help.
o Treatment: control HTN or surgery – last option. Ideally, they will monitor it because this is a huge surgery.
▪ Non-surgical management: monitor growth, main adequate BP
▪ Surgery: abd aortic aneurism resection, thoracic aortic aneurism repair, endovascular repair (these can be immediate or elective)
o Assess: back pain, sob, hoarsness, dysphagia, mass above supersternal notch, sudden back or chest pain. Do NOT palpate abd.
o Diagnostic: Xray (eggshell) appearance, CT (size and location), aortic arteriography, US
o If aneurism rupture: sudden excruciating pain (back or lower abdomen that radiates), loss of cardiac output (decrease BP, sweaty, pale,
decrease LOC) – emergency that requires surgery with a poor prognosis
• Super Ventricular Tachycardia (HR>150) (SVT)
o Risk factors: caffeine, tobacco, stress, alcohol, increased risk if female
o Can decrease BP dt loss of cardiac output rt decreased filling time (can’t pump properly at that rate)
o Assess/ signs and symptoms: palpitations, chest pain, weakness, fatigue, anxiety, dizziness, syncope (pass out), determine if stable or unstable
o Pt education: vagal maneuvers (bear down) – this helps decrease HR and promote normal sinus rhythm
o The first thing to tell them to do is bear down is HR is high! Vagal maneuvers. If cannot get HR to come back down Give amiodarone.
o Treatment: Tell them to perform a vagal maneuver (bear down)
▪ Adenosine (given to try and slow the rate)
▪ Diltiazem, calcium channel blockers and beta blockers (1st and 2nd line drugs
▪ Controlling heart rate is priority
▪ Tx underlying arrhythmia
▪ Cardioversion when all else fails
• A Fib (decreased cardiac output)
o Quivering pf atria; chaotic rhythm with no clear P wave
o Can lead to DVT, stroke or PE
o Causes: underlying CAD, MI, HF, hyperthyroidism, genetic
o Monitor closely to prevent throwing a clot (decrease HR is necessary)
o Risk factors: caffeine, alcohol, smoking, obstructive sleep apnea, being fluid overloaded
o Common as you age
o Many people are asymptomatic with afib
o Signs and symptoms: palpitations, dizzy, chest pain, SOB, low BP, fatigue, low cap refill, orthopnea (SOB while laying down) – tripod position, poor turgor, tachycardia
o Tx with meds for HR control: Calcium channel blockers (-pine), beta blockers (-olol), Digoxin, Coumadin and then cardioversion after they determined that there are not any clots in the heart
▪ May have to be on anticoagulants
▪ If in permanent Afib will have to be on anticoagulants. If cannot be on anticoagulants they can do a watchman device
(netting that goes in left atrial appendage to help close off appendage to avoid clot formation)
▪ electrocardioversion
o Pt education: adhering to anticoagulants, valve replacement/ repair,
valvuloplasty, percutaneous (less invasive) balloon valvuloplasty. Education for prosthetic mitral valve: coagulation risk (they will forever be on an anticoagulant)
o Rapid A-Fib is when HR is really high as well. Give Cardizem (Diltiazem)- this slows heart rate (this is the drug of choice). Synchronized cardioversion to try and get them back into rhythm. Catheter ablation can be done as well. Risk of Stroke/ clot throwing. Drugs do not cause a normal rhythm, they just slow HR down to help possibly kick it back into NSR.
• Myocardial infarction: MI
o Tissue is abruptly and severely deprived of oxygen.
o Signs and symptoms: elevated troponin, chest pain, pressure, tightness, diaphoresis, N/V, SOB, abdominal discomfort, syncope, bradycardia, cardiogenic shock
▪ STEMI: ST elevation, the thrombus causes an abrupt 100%
blockage of coronary artery. This is an emergency.
▪ Non-STEMI: no ST elevation, but they are still having a MI
o Causes
▪ NSTEMI- coronary vasospasm, spontaneous dissection, sluggish blood flow.
o Diagnostic: electrocardiogram and EKG
▪ Labs: Troponin (increased), CK-MB (increased initially, then back to normal), CBC (increased WBC), C-Reactive Protein (increased)
o Treatment: Primary prevention is key
▪ Plavix, Aspirin, Beta Blocker,
▪ STEMI: PCI (percutaneous coronary intervention)- this can be the TX and the DX
• Use of thrombolytics (fibrinolytics) IF patient present within first 6 hrs of symptoms presenting; pain for over 30 minutes which is not relieved by NITRO and when
PCI is not an option.
• Thrombolytics have worked when they are pain free, have reperfusion arrhythmias and if ECG improves. (monitor for bleeding- frequent neuro checks
• First Follow MONA. Morphine, Oxygen, Nitrates, Aspirin (antiplatelet).
• Coronary Artery Disease (CAD)
o Ischemia: insufficient oxygenation
o With this you will see angina and MI dt clogged vessels. Treatment for angina is Nitro.
o Infarction: necrosis, cell death, occurs when ischemia is prolonged
o RF: htn, hyperlipidemia, smoking, DM, sedentary lifestyle, diet, obesity, psychological variabilities, age, gender, ethnicity, genetic, family hx
▪ Know modifiable vs non-modifiable
o This is the number 1 cause of death in the US
o Diagnostic: ECG, Holter monitor, chest XR, stress test, nuclear scan, angiography
▪ Labs: troponin, CK MB
o Treatment
▪ Medication
• Bile acid sequestrants – Cholestyramine (Questran) – SE Constipation
• Niacin – nicotinic acid (Nicobid) – lowers LDL, triglycerides and increased HDL – SE flushing, red skin (prevent with aspirin)
• Fibrinic Acid derivatives – clofibrate (Atromid) and gemfibrozil (Lopid): decreases LDL
• Statins: atorvastatin (Lipitor) – decreases cholesterol in the liver – SE rhabdomyolysis
• Cholesterol absorption inhibitor – ezetimibe (Zetia) – inhibits absorption of cholesterol in the get
▪ Promotion prevention: increase intake of saturated fat and cholesterol-
• Peripheral Vascular Disease
o Blood has an easy time going to the lower extremities but a difficult
time leaving, resulting in edema.
o This is affecting veins (unoxygenated blood),
Signs and symptoms
dull achy leg pain, thick tough skin, irregular dusky lesions on leg. TX is Statins, anticoagulants, antiplatelet, vasodilators, Statins, stent
• Cell Anemia
o Genetic disorder with ‘C’ shaped RBC; most common in African
Americans in the US
o This is an autosomal recessive disorder that results in chronic anemia, pain, disability, organ damage, increased risk of infection and early death dt poor perfusion
o Assessment: pain, poor perfusion, low o2, cold, anxious
o Priority: admin O2 (ABC), tx pain, hydration
o Skin assessment: lips, tongue, nail beds, conjunctive, palms, soles of feet, jaundice, lower leg ulcers, assess abdominal enlargement, kidney failure, musculoskeletal changes, joint damage, and CNS changes
o Educate: how to prevent crisis – hydration, no heavy exercise (rt joints), iron
o Majority of pain is rt poor tissue oxygenation and joint destruction, making them at risk for infection, sepsis, multiorgan dysfunction and death
o Assess cardio status by comparing peripheral pulses, temp and cap refill
o Risk for pneumonia rt HTN
o Most common cause of death: acute chest syndrome
o Tx in order of priority: hydration, O2, pain (HOP), keep pt warm with blankets and warm environment
o Assessment: fever, pain, swelling of hands and feet, abd pain, pallor, jaundice, fatigue, increased bilirubin, increased electrolytes
o Diagnostic: CBC (hgb), Xray, ECG, CT, MRI
o Education: O2, hydrate, avoid constrictive clothing and crossing legs, keep room above 70 F, warm blankets, extremity circulation, no smoking
o Interventions: o2, pain, hydrate, keep the room warm, neuro checks (6 P’s: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermic)
• Anemia
o Most common inherited anemia: G6PD
o Causes: inherited (hemolytic), acquired from syndromes, autoimmune anemia
o Common Causes: Iron, Folic Acid, and vitamin nB-12 deficiency
▪ Take iron with Vit C
▪ Iron can cause constipation and black tarry stools
▪ Pernicious anemia: lack of B-12
o Signs and symptoms: weakness, fatigue, SOB, dizziness, irregular
heartbeat, chest pain, headache, yellowing of skin/ eyes
• Leukemia
o Uncontrolled production of immature WBC which decreases
production of blood cells in bone marrow
o RF: ionizing radiation, viral infection, exposure to chemicals and drugs, myelodysplastic syndrome, Fanconis anemia, genetic, immunologic and environmental factors
o Diagnosis test is aspiration of bone marrow cells and biopsy
o Objective: Protection from infection or hemorrhage
o Pt education: Now raw meat, veggies, fruit, avoid fresh flowers, large groups and remember infection control, hand washing
o Signs and symptoms: cardio changes, resp changes, intestinal changes, CNS changes, fatigue, bleeding gums, epistaxis, bruising, wt loss, bone pain, hematuria, orthostatic hypotension, somnolence, bone joint pain, neutropenic (low wbc)
▪ Resp changes rt decreased gas exchange from anemia and
infection
▪ Ask about bleeding episodes (decreased platelet function)
▪ Clotting factors and times are typically abnormal
o Treatment: bone marrow transplant (hematopoietic stem cell
transplant)
• Lymphoma
o Hodgkin’s lymphoma
▪ Starts in chain of lymph nodes
▪ RF: vital infection, HIV and leukemia
o Non-Hodgkin’s lymphoma
▪ More common
▪ RF: immunosuppressant drugs
o Multiple myeloma
▪ Cancer that grows in bone marrow and causes anemia (WBC cancer)
▪ Educate to avoid infection
• Thrombocytopenia
o Decreased platelet count
o This occurs with leukemia. Educate patient that we do not want them to get hurt and bleeding precautions. Monitor for bleeding. Watch for bruising, dark stool, oral cavities, blood in urine or vomit.
• Hemophilia
o Hemophilia is a rare disorder in which your blood does not clot normally because it lacks sufficient blood-clotting proteins (clotting factors). If you have hemophilia, you may bleed for a longer time after an injury than you would if your blood clotted normally.
o This is factor 8. With this you will see prolonged PTT, increased bleeding. This (as well as sickle cells) also effects the joints.
• Transfusion Reactions
o Stop transfusion, admin epi, O2, ABC’s
• Thrombotic Thrombocytopenic Purpura
o 5 clinical features: thrombocytopenia (decreased platelet), fever,
kidney failure, red cell fragmentation, transient neurologic deficits
o If left untreated can be deadly
o Treatment: replace plasma repeatedly until patient recothemia Vera
o Increased RCB from chronic hypoxemia. Give: Fluids, anticoagulants (this can help decrease the amount of RBC.)
o Educate that anticoagulants, like Coumadin. Antidote for Coumadin is Vitamin K. Eat less of green leafy veggies. Do not have totally avoid but should eat less.
o Who needs a phlebotomy? Pt with Polycythemia Vera
• Aortic stenosis:
o You will hear systolic crescendo/decrescendo murmur – this sounds
like a bruit/ helicopter blades when going fast. (this info should be sufficient)
• In a valvular disease: echocardiogram is the best dx tool. This shows blood flow in heart.
• Thrombolytic therapy: this is a platelet therapy that dissolves clots. This is used in ischemic stroke. NEVER give if patient is bleeding.
• Inadequate Clotting:
o Occurs when there is an inadequate number of circulating platelets
(thrombocytopenia)
o What are some causes?:
▪ Chemotherapeutic drugs and corticosteroids – why?: Because they cause bone marrow suppression where platelets and other blood cells are produced
o Cirrhosis of the liver – why?
▪ Due to a decreased production of clotting factors, including prothrombin = increased risk for bleeding
• Genetic diseases – such as?
o Recessive sex-linked hemophilia A and B
•
Pneumonic to assess PVD/PAD
“VESSLE”
Assessment Peripheral Artery Disease Peripheral Vascular Disease
Various positions to help alleviate pain - Dangling legs help (dependent position)
- Do not elevate above heart - Elevating legs helps reduce swelling and increase blood flow
- Dangling legs or standing for long periods of time hurts.
Explanation of pain - Sharp, worse at night
- “rest” pain – waking up at night with pain and will dangle legs to help.
- Intermittent claudication- - Heavy, dull, throbbing, aching
- Pain worst when standing/ sitting with legs dependent for long periods
- Elevating legs eases pain and swelling.
activity causes increased pain in calf, thighs and buttock
Skin of lower extremities - Cool to touch, thin, dry, scaly skin
- Hairless, thick toenails
- “Dr. EP”:
Dangle=Rubor; Elevate=pain - Warm to touch
- Thick, tough skin
- Brownish skin
- Edema present
Strength of pulse in
lower extremity - Use doppler; very
poor/ absent - Present and
typically normal
Edema present - Not common - Yes! It is worst at end of day
Lesions (location and appearance) - Location: end of toes, top of feet (dorsum), lateral ankle region (malleolus)
- Ulcers appearance: very little drainage, little tissue granulation, pale/ light pink or black and necrotic, Deep round appearance with noticeable edges. - Location: medial parts of leg and ankle region
- Ulcers appearance: swollen with drainage, granulation present, irregular edges, shallow.
Antidysrhythmic Medication
Drug Category Examples Action/ Uses
Sodium Channel Blockers Disopyramide phosphate (Norpace), Lidocaine Monitor BP and HR, these agents affect conduction patterns
Beta Blockers Propranolol, Sotalol Reduces HR to try and
help manage rhythms
Calcium Channel Blockers Amiodarone (Coradone). Ibutilide Works to delay repolarization and
(Corvert)
Verapamin, Diltiazem prolong the QT interval, repo slowly
Other Digoxin (Lanoxin) Used for AF and atrial flutter
Assess apical HR before admin
Atropine Sulfate Used for bradycardia Monitor HR and
rhythm
Adenosine (Adenocard) Used for paroxysmal SVT
Have emergency equipment avail as short term asystole after administration
Se: facial flushing, sob, chest pain
Normal ejection fraction is 55% - 70%
Review Questions – NCLEX Examination - Chapter 35 Assessment Performance
1. A client admitted for heart failure has a priority problem of hypervolemia related to compromised regulatory mechanisms. Which assessment result obtained the day after admission is the best indicator that the treatment has been effective?
A. The client has diuresis of 400 mL in 24 hours.
B. The client’s blood pressure is 122/84 mm Hg.
C. The client has an apical pulse of 82 beats/min.
D. The client’s weight decreases by 2.5 kg.
2. The client, a college athlete who collapsed during soccer practice, has been diagnosed with hypertrophic cardiomyopathy. The client says, “This can’t be. I am in great shape. I eat right and exercise.” What is the nurse’s best response?
A. “How does this make you feel?”
B. “This can be caused by taking performance-enhancing drugs.”
C. “This may be caused by a genetic trait.”
D. “Just imagine how bad it would be if you weren’t in good shape.”
3. The nurse in the emergency department is caring for a client with acute heart failure who is experiencing severe dyspnea; pink, frothy sputum; and crackles throughout the lung fields. The nurse reviews the medical record, which contains the following information: Physical Assessment Findings Diagnostic Findings Provider Prescriptions Crackles in all fieldsS3 present Oliguria Ejection fraction 30%BNP 560Sodium 130 mEq/L Diagnosis: heart failure Enalapril 10 mg orally daily Heparin 5000 units subcutaneously every 12 hours Furosemide 40 mg IV daily Strict I & O Which prescription does the nurse implement first?
A. Enalapril
B. Heparin
C. Furosemide
D. Intake and output (I & O)
4. Which nursing intervention for a client admitted today with heart failure will assist the client to conserve energy?
A. The client ambulates around the nursing unit with a walker.
B. The nurse monitors the client’s pulse and blood pressure frequently.
C. The nurse obtains a bedside commode before administering furosemide.
D. The nurse returns the client to bed when he becomes tachycardic.
5. The nurse discusses the importance of restricting sodium in the diet for a client with heart failure. Which statement made by the client indicates that the client needs further teaching?
A. “I should avoid eating hamburgers.”
B. “I must cut out bacon and canned foods.”
C. “I shouldn’t put the salt shaker on the table anymore.”
D. “I should avoid lunchmeats but may cook my own turkey.”
6. Which diagnostic test result is consistent with a diagnosis of heart failure (HF)?
A. Serum potassium level of 3.2 mEq/L
B. Ejection fraction of 60%
C. B-type natriuretic peptide (BNP) of 760 ng/dL
D. Chest x-ray report showing right middle lobe consolidation
7. A client with heart failure is taking furosemide (Lasix). Which finding concerns the nurse with this new prescription?
A. Serum sodium level of 135 mEq/L
B. Serum potassium level of 2.8 mEq/L
C. Serum creatinine of 1.0 mg/dL
D. Serum magnesium level of 1.9 mEq/L
8. The nurse is providing discharge teaching to a client with heart failure, focusing on when to seek medical attention. Which statement by the client indicates a correct understanding of the teaching?
A. “I will call the provider if I have a cough lasting 3 or more days.”
B. “I will report to the provider weight loss of 2 to 3 pounds in a day.”
C. “I will try walking for 1 hour each day.”
D. “I should expect occasional chest pain.”
9. Which nursing action may be delegated to a nursing assistant working on the medical unit?
A. Determine the usual alcohol intake for a client with cardiomyopathy.
B. Monitor the pain level for a client with acute pericarditis.
C. Obtain daily weights for several clients with class IV heart failure.
D. Check for peripheral edema in a client with endocarditis.
10. Which client is best to assign to an LPN/LVN working on the telemetry unit?
A. Client with heart failure who is receiving dobutamine (Dobutrex)
B. Client with dilated cardiomyopathy who uses oxygen for exertional dyspnea
C. Client with pericarditis who has a paradoxical pulse and distended jugular veins
D. Client with rheumatic fever who has a new systolic murmur
11. Which medication, when given in heart failure, may improve morbidity and mortality?
A. Dobutamine (Dobutrex)
B. Carvedilol (Coreg)
C. Digoxin (Lanoxin)
D. Bumetanide (Bumex)
12. How does the nurse in the cardiac clinic recognize that the client with heart failure has demonstrated a positive outcome related to the addition of metoprolol (Lopressor) to the medication regimen?
A. Ejection fraction is 25%.
B. Client states that she is able to sleep on one pillow.
C. Client was hospitalized five times last year with pulmonary edema.
D. Client reports that she experiences palpitations.
13. When following up in the clinic with a client with heart failure, how does the nurse recognize that the client has been compliant with fluid restrictions?
A. Auscultation of crackles
B. Pedal edema
C. Weight loss of 6 pounds since the last visit
D. Reports sucking on ice chips all day for dry mouth
14. The nurse is caring for a client with heart failure in the coronary care unit. The client is now exhibiting signs of air hunger and anxiety. Which nursing intervention does the nurse perform first for this client?
A. Determines the client’s physical limitations
B. Encourages alternate rest and activity periods
C. Monitors and documents heart rate, rhythm, and pulses
D. Positions the client to alleviate dyspnea
15. The home health nurse visits a client with heart failure who has gained 5 pounds in the past 3 days. The client states, “I feel so tired and short of breath.” Which action does the nurse take first?
A. Assess the client for peripheral edema.
B. Auscultate the client’s posterior breath sounds.
C. Notify the health care provider about the client’s weight gain.
D. Remind the client about dietary sodium restrictions.
16. A client begins therapy with lisinopril (Prinivil, Zestril). What does the nurse consider at the start of therapy with this medication?
A. The client’s ability to understand medication teaching
B. The risk for hypotension
C. The potential for bradycardia
D. Liver function tests
17. A client who has been admitted for the third time this year for heart failure says, “This isn’t worth it anymore. I just want it all to end.” What is the nurse’s best response?
A. Calls the family to lift the client’s spirits
B. Considers further assessment for depression
C. Sedates the client to decrease myocardial oxygen demand
D. Tells the client that things will get better
18. The nurse is caring for an 82-year-old client admitted for exacerbation of heart failure (HF). The nurse questions the client about the use of which medication because it raises an index of suspicion as to the worsening of the client’s HF?
A. Ibuprofen (Motrin)
B. Hydrochlorothiazide (HydroDIURIL)
C. NPH insulin
D. Levothyroxine (Synthroid)
19. Which intervention best assists the client with acute pulmonary edema in reducing anxiety and dyspnea?
A. Monitor pulse oximetry and cardiac rate and rhythm.
B. Reassure the client that his distress can be relieved with proper intervention.
C. Place the client in high-Fowler’s position with the legs down.
D. Ask a family member to remain with the client.
20. After receiving change-of-shift report about these four clients, which client should the nurse assess first?
A. A 46-year-old with aortic stenosis who takes digoxin (Lanoxin) and has new-onset frequent premature ventricular contractions
B. A 55-year-old admitted with pulmonary edema who received furosemide (Lasix) and whose current O2 saturation is 94%
C. A 68-year-old with pericarditis who is reporting sharp, stabbing chest pain when taking deep breaths
D. A 79-year-old admitted for possible rejection of a heart transplant who has sinus tachycardia, heart rate 104 beats/min
21. The nurse is caring for a client with heart failure. For which symptoms does the nurse assess?
A. Chest discomfort or pain
B. Tachycardia
C. Expectorating thick, yellow sputum
D. Sleeping on back without a pillow
E. Fatigue
22. The nurse prepares to administer digoxin to a client with heart failure and notes the following information:Temperature: 99.8° FPulse: 48 beats/min and irregularRespirations: 20 breaths/minPotassium level: 3.2 mEq/LWhat action does the nurse take?
A. Give the digoxin; reassess the heart rate in 30 minutes.
B. Give the digoxin; document assessment findings in the medical record.
C. Hold the digoxin, and obtain a prescription for an additional dose of furosemide.
D. Hold the digoxin, and obtain a prescription for a potassium supplement.
23. The nurse caring for a client with heart failure is concerned that digoxin toxicity has developed. For which signs and symptoms of digoxin toxicity does the nurse notify the provider?
A. Hypokalemia
B. Sinus bradycardia
C. Fatigue
D. Serum digoxin level of 1.5
E. Anorexia
24. The nurse is assessing a client with a cardiac infection. Which symptoms support the diagnosis of infective ditis instead of pericarditis or rheumatic carditis?
A. Friction rub auscultated at the left lower sternal border
B. Pain aggravated by breathing, coughing, and swallowing
C. Splinter hemorrhages
D. Thickening of the endocardium [Show Less]