1
Q
Define PNA
A
- It is an infection of lower respiratory tract.
- Inflammation and fluid in your lungs caused by bacterial, viral infection or fungal infection, in which the airsacsfill withpus and may become solid. Inflammation may affect bothlungs(double pneumonia), one lung (single pneumonia), or only certain lobes (lobarpneumonia).
2
Q
What is community-acquired pneumonia?
A
It occurs in the community dwelling person or within the first 48 hours after hospitalization or institutionalization.
3
Q
What is hospital-acquired pneumonia (HAP)?
A
The onset of pneumonia symptoms more than 48 hours after admission in patients who had no evidence of infection at the time of hospitalization.
4
Q
How does pneumonia in the immunocompromised host occur?
A
It occurs with use of corticosteroids or other immunosuppressive agents, chemotherapy, nutritional depletion, use of broad-spectrum antimicrobial agents, acquired immunodeficiency syndrome (AIDS), genetic immune disorders, and long-term life-support technology (mechanical ventilation).
5
Q
What are risk factors for community-acquired pneumonia?
A
- Smoking/ETOH
- Alcohol use disorder
- Pre-existing hypoxemia
- Toxic inhalations
- Pulmonary edema
- Altered mental status (e.g., seizure, CVA)
- Presence of comorbid conditions, including chronic respiratory (COPD, asthma) and cardiovascular diseases (HF), cerebrovascular disease, Parkinson disease, epilepsy, dementia, dysphagia, HIV, or chronic kidney or liver disease.
- Malnutrition; underweight
- Immunosuppressive therapies
- Anyone who has a risk for aspiration
- Poor dental hygiene
- Age older than 65 years
- Intravenous drug use
- Regular contact with children
- 10 or more people living in a household
- Previous episodes of pneumonia
- Working and environmental conditions (contact with dust and sudden changes of temperature)
6
Q
With Hospital-acquired pneumonia, the onset of pneumonia symptoms occur more than ____ hours after admission
A
48
7
Q
Ventilation-acquired pneumonia (VAP) is a type of ____.
A
Hospital-acquired pneumonia that is associated with endotracheal intubation and mechanical ventilation.
8
Q
Ventilation-acquired pneumonia (VAP) IS defined as pneumonia that develops in patients who have been receiving mechanical ventilation for at least ____ hours
A
48
9
Q
Hospital-acquired pneumonia occurs when at least one of what three conditions exists?
A
- Host defenses are impaired.
- Microorganisms reach the lower respiratory tract (usually by microaspiration of oropharyngeal microorganisms).
- A highly virulent organism is present.
10
Q
What form of pneumonia has the highest mortality rate?
A
Hospital-acquired pneumonia
11
Q
What can cause a patient on a ventilator to contract ventilator-acquired pneumonia?
A
It can be due to poor mouth care, uncleaned equipment, being immunocompromised. They get it from the ventilator.
12
Q
What are risk factors for hospital-acquired pneumonia and ventilator-acquired pneumonia?
A
- Debilitation: immobility, pre-existing conditions, comorbidity.
- Malnutrition: weakens the immune system.
- Altered mental status
- Previous exposure to antibiotics (within the last 90 days)
- Hospital stays of 5 days or longer
- High rates of antibiotic resistance (hospital or unit-specific)
- Immunosuppressive therapies or diseases
- Prolonged (greater than 48 hours) intubation or a tracheostomy
- Male biologic sex
- Treatment related, e.g., mechanical ventilation, unintentional extubation, upper abdominal surgery, thoracic surgery
- Supine position: lack of movement can lead to atelectasis and then lead to pneumonia.
13
Q
What are the causes of immunocompromised pneumonia?
A
- Chemotherapy: wipes out your WBC so lowered immune system.
- Alcoholics: lacking vitamin B
- Corticoid steroids: they suppress your immune system.
- Use of antimicrobial agents
14
Q
What puts older people at risk for pneumonia?
A
- Decreased lung elasticity.
- Decrease in mobility.
15
Q
What is the treatment for pneumonia in older patients?
A
- Hydration (as long as no risk for fluid overload)
- Supplemental oxygen therapy
- Encourage vaccination (pneumococcal and influzena [if you get one, your more prone to get the other]) as soon as possible
- Isolation if needed.
- Assistance with deep breathing
- Coughing
- Frequent position changes
- Early ambulation.
16
Q
What is the goal for pneumonia treatment in older patients?
A
Goal is to prevent death because they can get serious complications from pneumonia.
17
Q
What may signal the onset of pneumonia in older adults?
A
General deterioration, weakness, abdominal symptoms, incontinence, anorexia, confusion, tachycardia, and tachypnea.
18
Q
Pulmonary infections in older people frequently are ____.
A
Difficult to treat and result in a higher mortality rate than in younger people.
19
Q
What are the clinical manifestations of pneumonia?
A
- Fever (above 100.4)
- Chills; rigors (chills at the extreme)
- Cough (productive [can be purulent] or nonproductive)
- Dyspnea
- Use of accessory muscles (abdomen, neck)
- Hear crackles (indicates fluid in the lungs)
- Chest pain or pleuritic pain (pain in lungs [sudden, intense, and described as sharp, stabbing, or burning])
- Tachycardia
- Fatigue
- Some patients initially exhibit an upper respiratory tract infection (nasal congestion, sore throat), and the onset of symptoms of pneumonia is gradual and nonspecific. Then the predominant symptoms may be headache, low-grade fever, pleuritic pain, myalgia (muscle pain), rash, and pharyngitis.
20
Q
What would a focused assessment for pneumonia include?
A
- Auscultate breath sounds
* May hear bronchial breath sounds over consolidated lung areas, crackles, increased tactile fremitus (vocal vibration detected on palpation) - Assessing for hypoxia
- Color of the skin
- Secretions (amount and color)
- Pulse ox
- Skin turgor
21
Q
What labs/diagnostics would you do for pneumonia?
A
- Chest x-ray to determine if they have pneumonia
- Blood culture
- Sputum culture
- Pulse ox
- ABGs (test for hypoxemia)
- CBC (looking at WBC; 5,000-10,000 is normal)
- Check electrolyte levels
- Bronchoscopy (see what the infection looks like, what the lungs look like)
22
Q
What are some nursing diagnoses for pneumonia?
A
- Impaired gas exchange
- Risk for aspiration
- Ineffective airway clearance
- Activity intolerance
- Ineffective breathing pattern
23
Q
What goals would you plan for a patient who has pneumonia?
A
- Improve airway patency
- Patient will eat 50% of their tray
- Patient understands the need to rest and limit activity
- Patient will use incentive spirometer every hour
- Patient will demonstrate effective cough techniques
24
Q
What are the potential complications for pneumonia?
A
- Shock & Respiratory Failure
- Atelectasis & Pleural Effusion
- Empyema
- Superinfection
- Confusion
- Continuing symptoms after initiation of therapy
25
What are the signs of shock and respiratory failure? What should you monitor?
Severe hypotension, tachycardia.
Monitor pulse ox
26
What is pleural effusion?
Accumulation of fluid in the pleural space.
27
How many lobes can atelectasis effect? How can you clear it?
It can affect 1 lobe or both, usually you can clear it with effective cough and deep breathing.
28
When a patient has pleural effusion, they will complain of what?
Complain of pain on inspiration.
29
What is empyema?
Accumulation of purulent pus in the pleural space.
30
What is a superinfection?
A new, often resistant infection that develops during or immediately after the treatment of a primary infection.
31
Why can confusion occur as a potential complication of pneumonia?
Because of hypoxia, fever, dehydration, lack of sleep
32
If patient is taking antibiotics for pneumonia but the WBC is not decreasing, what would that indicate?
It would indicate that the infection is resistant and could lead to a superinfection.
33
What are collaborative goals for pneumonia?
* Improve airway patency
* Promoting rest and conserving energy
* Promoting fluid intake
* Working with dietician to maintain nutrition
* Promoting patient knowledge
* Monitoring and managing potential complications
* Work with respiratory therapists.
* Work with PT on what activities pt. can do.
* Work with speech therapy if suspecting dysphasia
* Work with health care provider for antibiotics, IV fluid,
34
What are nursing interventions for pneumonia?
* Identify patients at risk
* Administer oxygen
* Sputum assessment
* Monitor vitals
* Encourage fluids
* Encourage ambulation
* Educate on importance of vaccinations
* Elevate head of the bed * High Fowler’s
* Suctioning
* Skin care
* Deep breathing/coughing
* Pain medication, medication for coughing
35
What should you teach a patient who has pneumonia and is being discharged?
* Teach patient to take all medications as prescribed
* Teach patient the signs and symptoms that should be reported to the health care provider or nurse and the need for follow-up.
* Stop or avoid smoking/drinking
* Good hand hygiene
* Make sure they have received their vaccinations before discharge or that they have an appointment scheduled to receive them.
* Avoid large crowds
* Avoid OTC meds unless doctor approved.
36
Define influenza
It is a highly contagious acute viral infection, occurs in children & adults of all ages.
Influenza virus affects the respiratory tract by direct viral infection or by damage from the immune system response.
37
What is the concern with influenza?
Gas exchange
38
How is influenza spread?
Virus transmission occurs through a susceptible individual’s contact with aerosols or inanimate objects that can carry and spread disease and infectious agents from an infected individual.
39
What are the risk factors for influenza?
* Unvaccinated individuals
* Chronic lung disease (asthma, COPD)
* Immunocompromised people
* Pregnant women
* Obese people
* Residents in long-term care facilities (assisted living, nursing homes)
40
What are the gerontological considerations for influenza?
* Immune systems decline as adults age
* Greater risk for having an MI because it will increase the workload on the heart.
* Greater risk for stroke because of decreased
* Greater risk for pneumonia.
41
What are the clinical manifestations for influenza?
* Fever (temp of 100.4 or higher)
* Chills
* Headaches
* Myalgia (body aches)
* Flushed face
* Fatigue
* Diarrhea
42
What should the nurse assess for influenza?
* Vital Signs
*Initial vital signs to establish a baseline
* Listen to the lungs
* You may not hear anything with influenza.
* It becomes a concern if the pt. becomes dyspneic and then you hear crackles in the lungs. Diffuse in the lungs means throughout the lungs; it has spread through all the lungs).
* Need to know PMH
43
What are nursing interventions for influenza?
* Assess if they have the flu vaccine. Teach about flu vaccine. Vaccine encouraged for everyone 6 months and older.
* Droplet isolation for influenza. It’s a private room.
* PPE for droplet: surgical mask and goggles/face shield.
* How to cough, throwing out dirty tissues, hand hygiene.
* Oxygenation
* IV fluids to help thin out the secretions.
* Coughing and deep breathing.
* Analgesics and antipyretics
* Position patient for comfort.
* Monitor I&O
44
Medications must be started ____ hours within the onset of symptoms.
24-48
45
The flu vaccine is done ____ and it is based on the flu from the ____.
Annual, previous year
46
What are the labs/diagnostics for influenza?
* Chest x-ray
* CBC
* Viral culture to know what type of influenza it is. It takes 3-10 days. It helps guide treatment.
* Sputum culture
47
What are some safety considerations for patients with Influenza?
* Get vaccinated.
* Wash hands frequently.
*During the season, avoid crowds or in close contact with others (kissing, hugging, hand shaking, etc.). Especially if you are immunocompromised.
* If you start feeling symptoms of the flu, hydrate, rest, stay home.
48
What are 2 contraindications for the influenza vaccine?
1. History of Gillain-Barré syndrome.
2. Allergies to eggs (most flu vaccines are egg based).
49
What is croup?
An upper respiratory infection.
50
What does croup cause?
Croup causes swelling of the larynx, trachea, and large bronchi due to infiltration of WBC.
51
What adventitious lung sound will you hear with croup?
Stridor
52
Acute laryngotracheobronchitis (LTB) is cause by ____.
A virus
53
What are the causative agents of acute laryngotracheobronchitis (LTB)?
RSV, influenza A and B, and mycoplasma pneumonia, parainfluenza types 1, 2 and 3.
54
Acute spasmodic laryngitis is caused by ____.
Allergens
55
When does acute spasmodic laryngitis occur?
Suddenly at night.
56
What are the clinical manifestations of acute laryngotracheobronchitis?
* Low-grade fever
* Restlessness
* Hoarseness
* Barky cough (sounds like a seal)
* Dyspnea
* Inspiratory stridor
* Retractions
* Infants and toddlers:
* Nasal flaring, intercostal retractions, tachypnea, and continuous stridor.
57
What are the clinical manifestations of acute spasmodic laryngitis?
* Croupy barky cough
* Restlessness
* Difficulty breathing
* Hoarseness
* Nighttime episodes of laryngeal obstruction
58
What are RN assessments for croup?
* History of UTRI
* What is their breathing pattern? Are they using other accessory muscles to breath?
* Monitor oxygen saturation
* Monitor temperature
* Monitor I&O
* Do they have tears when they cry? Dry mouth?
59
Why is having stridor with croup a priority? What should you do immediately if a patient with croup has stridor?
Because it causes an obstruction. Report the stridor to the physician.
60
What are the priority meds for treatment of croup?
* Dexamethasone- oral or IM- steroid
* Antipyretics
* Racemic epinephrine
* Mini nebulizer treatments
61
Why is dexamethasone given for croup?
Because it decreases the inflammatory process in order to open up the airways.
62
Why is racemic epinephrine given for croup? What kind of treatment is it?
Because it enhances breathing. It’s a nebulizer treatment.
63
What are some Collaborative Goals for patients with Croup?
* Maintain patent airway
* Vaccine education (flu vaccine)
* Determine what the allergens that potential caused the reaction (if it is spasmodic laryngitis)
64
What are nursing interventions for croup?
* Facilitate airway clearance-Protect airway
* Cool mist
* Oxygen
* Fluids (popsicles, Pedialyte, diluted juice) small amounts.
* Monitor pulse ox
* Administer medications (steroids, antibitotics, antipyretics)
65
What are some Safety Considerations for patients with Croup?
* Never leave child alone
* Monitor vital signs
* Emergency intubation equipment should be readily available.
66
TB primarily affects the ____.
Lungs
67
TB can spread to ____. When does it do this?
Any organ. When it is not treated.
68
Is TB contagious?
Yes, it's highly contagious.
69
When does the initial infection of TB occur?
2-10 weeks after exposure.
70
How is TB spread?
Spread person to person; airborne transmission. So, people who are coughing, talking, laughing, sneezing etc. will spread it.
71
What type of precaution is TB?
Airborne precautions
72
When someone has TB, it is usually located in what part of the lungs?
Its usually in upper lobe and upper cortex. Not in the lower lungs.
73
What does latent TB mean? Is it contagious?
The person has the infection, but it is dormant; they don’t have the active disease. Isn’t contagious if it is latent; won’t spread.
74
What is active TB?
It is contagious.
75
What PPE is needed for TB?
N95 respirator mask
76
What are risk factors for TB?
* Born in foreign countries with prevalence of TB
* Frequent and close contact with an untreated individual.
* Lower socioeconomic status and without housing.
* Immunocompromised status (HIV, chemotherapy, kidney disease, diabetes mellitus, Chron’s disease, organ transplants).
* Poorly ventilated, crowded environments (correctional or long-term care facilities)
* Advanced age (because of respiratory issues)
* Recent travel outside of the U.S. to areas where TB is endemic.
* Substance use (IV drug users especially because they are at more risk for HIV).
* Health care occupation that involves performance of high-risk activities (respiratory treatments, suctioning, coughing procedures).
* Homeless population
77
What are the gerontological considerations for TB?
Atypical manifestations
78
What are the atypical manifestations for TB in the elderly?
* Altered mental status
* Unusual or erratic behavior (change in behavior)
* Fever
* Anorexia
* Weight loss
79
What are the clinical findings for TB?
* Low grade fever in the afternoon.
* Persistent cough lasting longer than 3 weeks. Couch can be productive or non-productive.
* Purulent sputum (thick, yellow-green), possibly blood-streaked (blood occurs from all the coughing and irritation it caused. The coughing breaks the blood vessels).
* Fatigue and lethargy
* Weight loss and anorexia because they don’t have an appetite.
* Muscle wasting because they are very tired and cannot move around.
* Night sweats
* Neurological deficits if it becomes extra pulmonary (headaches, confusion, pain, dysuria, etc.)
80
What type of room does a TB patient need to be in?
Negative pressure room
81
What kind of mask should a patient with TB wear when being transported out of the room? Why?
Surgical mask. A surgical mask prevents expelled air from coming out. This is why it’s better that the pt. wears this type of mask rather than an N95. With an N95, they would be able to breath out their contagious breath out around them.
82
Foods that are high in what are important for TB patients?
Foods that are high protein, iron, vitamin C and B.
83
What are the nursing interventions for TB?
* Negative pressure room (air comes in but no air goes out).
* Administer heated and humidified oxygen therapy as prescribed.
* Prevent infection transmission
* Administer prescribed medications
* Promote adequate nutrition
* Instruct patient on how to cough, dispose of sputum, washing hands.
* Sputum cultures
* Plan rest periods.
* Observe side effects of medications and educate pt. on them.
84
How is TB determined to be dormant?
3 consecutive negative sputum cultures.
85
When do you collect sputum cultures for a TB patient?
In the morning.
86
What are the 4 medications for treatment of TB?
1. INH (isoniazid)
2. Rifampin (RIF)
3. Pyrazinamide (PZA)
4. Ethambutol
** Remember RIPE **
87
Does isoniazid (INH) need to be taken with food?
No, it should be taken on an empty stomach.
88
What is given with isoniazid (INH)?
Pyridoxine (vitamin B6)
89
Why is pyridoxine (vitamin B6) given with isoniazid (INH)?
Because it protects the neurons and decreases the risk of neurotoxicity.
90
What 2 adverse effects does isoniazid (INH) cause?
1. Hepatotoxicity
2. Neurotoxicity
91
What should you monitor for a patient who is experiencing hepatotoxicity from isoniazid (INH)?
Monitor for liver involvement like jaundice, anorexia, fatigue, LSTs to make sure the liver is functioning properly.
92
What does neurotoxicity from isoniazid (INH) cause?
Tingling of hands and feet.
93
Rifampin is considered what?
Hepatotoxic
94
What should you teach a patient who is on rifampin?
Secretions will turn bright orange, pee will be orange, contacts will turn orange, sweat will be orange
95
What is a drug to drug interaction foer rifampin?
Oral contraceptives
96
Pyrazinamide (PZA) is considered what?
Hepatotoxic.
97
Before administering pyrazinamide (PZA) to a patient, it is important to assess for a history of what? Why?
Assess for a history of gout because it will cause an exacerbation of gout.
98
What should the patient do to prevent gout syndromes when taking pyrazinamide (PZA)?
Drink a full 8 oz glass of water with each dose of meds.
99
Pyrazinamide does affects your what?
Eyes
100
What test should you perform for a patient who is prescribed ethambutol? Why?
Baseline acuity tests. To monitor for optic neuropathy.
101
What is an adverse effect of ethambutol?
Vision changes
102
What is the minimum amount of medications for TB? What is the max?
2; 4
103
How long if TB medication taken for?
6-12 months
104
What are the 2 phases of the medication regimen for TB?
1. Initial phase
2. Continuation phase
105
What medications are given during the initial phase of the medication regimen for TB?
All 4 medications
106
How long is the initial phase of the medication regimen for TB?
8 weeks
107
Why would someone progress to the continuation phase of the medication regimen for TB?
If the patient has a positive sputum culture after 8 weeks.
108
What does the medication regimen for TB change to in the continuation phase?
It will decrease to only the INH and rifampin (as well as vitamin B6).
109
How long is the continuation phase of the medication regimen for TB?
18 to 31 weeks
110
When can a patient leave the continuation phase of the medication regimen for TB?
When they have 3 consecutive negative sputum cultures.
111
What is the INH prophylactic (preventive) measure?
It’s a preventative measure for people who are at risk for TB, such as living with someone who has active TB.
112
Should you take the medications for TB on an empty stomach or with food?
You should take them on an empty stomach.
113
What foods should patients avoid when taking INH for TB? Why?
Foods with tyramine and histamine (tuna, aged cheese, red wine, soy sauce, and anything that uses yeast extract).
Consuming these foods can cause you to palpitation, hypertension, headaches, etc.
114
What labs/diagnostics are performed for TB?
* Mantoux test (PPD): intradermal 2-step test. Read in 48-72 hours.
* Sputum cultures
* Chest x-ray
* Sputum culture
115
What does the Mantoux test look for?
The test looks for an absence of induration (raising of the skin [hardening of the skin; bump]). Does not mean you have active TB but means you have been exposed to the antibody.
116
What does an chest X-ray for TB assess?
It assess for infiltrates.
117
What are the patient teachings for TB?
* Prevention of the spread of infection
* Cover nose and mouth.
* Wear a mask in public.
* Airborne precautions in hospital.
* Teach about good nutrition. Avoiding tyramine and histamine.
* Encourage fluid intake
* Hand hygiene.
118
Why is hypertension known as the silent killer?
Because it's normally asymptomatic.
119
When symptoms arise with hypertension, what does that indicate?
It normally indicates that damage has been done to the other organs.
120
If your patient is put on an antihypertensive medication, why should not stop them abruptly, skip doses, or change doses?
It can cause rebounding hypertension meaning it goes up higher than it was previously. This can cause an MI or stroke.
121
What is primary hypertension?
When someone is hypertensive and you do not know why. There is not an identified cause.
122
What is primary hypertension also called?
Also called essential hypertension or idiopathic hypertension.
123
What is secondary hypertension?
It has an identifiable cause. Ex pregnancy, kidney disease, medication, etc.
124
What is the range of a normal BP?
Systolic: less than 120 and diastolic: less than 80
125
What is the range of an elevated BP?
Systolic: 120-129 or diastolic: less than 80.
126
What is the range of hypertension stage 1?
Systolic: 130-139 or diastolic 80-89
127
What is the range of hypertension stage 2?
Systolic: 140 or higher, or diastolic: 90 or higher
128
What is the range of hypertensive urgency?
Systolic: > 180 or diastolic: 120 without signs and symptoms of end-organ damage.
129
What is the range of hypertensive emergency?
Systolic: >180 or diastolic: 120 mm Hg and objective findings of acute end-organ dysfunction (usually of the heart, kidneys, or brain).
130
What is hemostasis?
It's the balance between clot formation (thrombus) and clot dissolution (fibrinolysis).
It’s clotting and how were getting rid of the clots.
131
What is thrombus?
Clot formation
132
What is fibrinolysis?
Clot dissolution
133
Hemostasis is critical for sustaining life. If your body is not clotting, what can happen?
Hemorrhage
134
What is arterial BP?
It's the force that moves blood through the arterial system due to the contraction and relaxation of the left ventricle.
135
What arterial BP determine by?
It is determined by factors including blood volume, elastic properties of the blood vessels, cardiac output (CO), and peripheral vascular resistance.
136
What is going to impact resistance in arterial BP?
Elasticity, blockages, thickness of blood, size of the vessels, buildup in the vessels.
137
An increase in arterial BP resistance means an increase ____.
Arterial BP
138
What is the goal for hypertensive patients?
To lessen the resistance, manage the resistance.
139
What are risk factors for hypertension?
* Stress
* Dyslipidemia (high cholesterol levels)
* Obesity (BMI greater than or equal to 30)
* Diabetes mellitus (type 2)
* Active or passive cigarette smoking
* Physical inactivity (BIG RISK)
* Excess intake of sodium
* Excess intake of alcohol
* Advancing age
* Family history
* Low social economic status
* Psychosocial stress
* Chronic kidney disease
* Obstructive sleep apnea
* Impaired renal function
140
Why are the elderly more at risk for hypertension?
* The average older American is at risk for polypharmacy.
* Previous stroke or MI
* Atrophy of the muscle, rigidity of the heart muscles, more calcifications.
* Prevalence of HTN increases with age.
* Many older individuals have high BP arising from the vasoconstriction associated with aging, which produces peripheral resistance.
* Hyperthyroidism, Parkinsonism, Paget disease, anemia, and thiamine deficiency can also be responsible for hypertension.
* While hypertension overall presents with few symptoms, waking with a dull headache, impaired memory, disorientation, confusion, epistaxis, and a slow tremor may be symptoms of hypertension, especially in older people.
141
What are the clinical manifestations and nursing assessments of hypertension?
* Anginal pain (chest pain, discomfort, or pressure)
* SOB
* Alterations in speech, vision (retinal damage: blurred vision), or balance
* Epistaxis (means the pt is going into hypertensive crisis)
* Headaches
* Dizziness
* Nocturia
* Vital signs
* Important to document the position of the patient.
* Knowing what their normal is.
* Caffeine and exercise can impact their BP.
* Medications
* Kidneys (BUN, creatine, glomerin filtration rate, hematuria, proteinuria, nocturia: these are the labs your will look at to see how the kidneys are working)
* Cardiovascular assessment
* Cerebral vascular disease
* Intermittent claudication (when pt is walking and having a lot of cramping/leg pain, but when they sit it goes away).
142
What is the goal BP for a hypertensive patient? Why?
If pt is hypertensive, the goal BP is less than 140/90. You don’t want to drop their BP too fast because they could have a stroke or MI.
143
What are the priority labs/diagnostics for hypertension?
* CNP (diagnoses nervous system disorders)
* Lipid profile
* HDLs (good cholesterol) and LDLs (bad cholesterol)
* EKG
* CBC
* Fasting blood glucose
* Serum creatinine
* Serum sodium, potassium, calcium, thyroid-stimulating hormone (to see if this is a reason for the hypertension).
* Urinalysis
* Electrocardiogram
144
What are the priority nursing interventions for hypertension?
* Teach risk factors
* Encourage exercise; slowly increase exercise. Modify their lifestyle and set goals.
* Encourage self-management (self BP monitoring, logging BP and what they were doing)
* Dietician to work with them on nutrition.
* Review their medications.
* Educate on medication adherence. What can you put in place to make sure the pt in adhering.
* Smoking cessation
* Decrease alcohol/drug use
* Decrease sodium intake
145
What are the priority safety concerns for hypertension?
1. Safety on the medications patient is taking
2. Falls
3. Hypotension
4. How much alcohol are they drinking? Males should have 2 drinks or less daily, females should have 1 drink daily or less.
146
What are the patient teachings for hypertensive patients?
* Lifestyle changes
* Weight reduction
* Adopt DASH eating plan
* Dietary sodium reduction
* Physical activity
* Moderation of alcohol consumption
* Alternative therapies
* Biofeedback-assisted home-based breathing relaxation intervention (BAHRI)
* Blood pressure monitoring
* Pharmacological therapy
147
What is the pathophysiology of PVD?
The lumens narrow and ischemia occurs. It is the hardening of the arteries.
148
What is the most common disease of the arteries?
Arteriosclerosis
149
What are risk factors for PAD?
* Diet
* Smoking (Nicotine decreases blood flow, increases heart rate (HR) and blood pressure (BP), and increases the risk for clot formation by increasing platelet aggregation)
* Hypertension
* Diabetes mellitus
* Higher total cholesterol
* Elevated C-reactive protein levels
* Race
* Age
* Family history
150
What pre-existing conditions are risk factors for PAD?
* Coronary artery disease
* Cerebral artery disease
* Diabetes mellitus (every 1% elevation in hemoglobin A1c is associated with a 30% increase PAD risk)
* Hypertension (increases risk by about threefold)
* Dyslipidemia (fasting total cholesterol above 270 mg/dL is associated with a twofold increase in PAD)
* Clotting disorders
* Hyperhomocysteinemia (high levels of homocysteine. It’s a protein that promotes coagulation) is associated with a twofold risk of PAD
151
What is homocysteine?
A protein that promotes coagulation.
152
What are the clinical manifestations of PAD?
* Cramping in the calves
* Pallor when the extremity is elevated. Rubor (red) when it is dependent.
* Loss of hair and shiny skin.
* Thick, opaque nails.
* Dry skin.
* Atrophy (loss of muscle tissue)
* Cool distal to the occlusion
* Weak or diminished pulses.
* Delayed capillary refill.
* Ulcers
* Edema
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What is the cause of cramping in the calves of a patient with PAD?
Intermittent claudication
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What is intermittent claudication?
A cramp-like, aching, or tired pain in the legs (especially calves, thighs, or buttocks) triggered by exercise and relieved by rest.
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What causes intermittent claudication and the pain associated with it?
Buildup of lactic acid.
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Is PAD cramping worse during the day or at night?
At night
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How do patients with PAD sleep?
Patients will sleep sitting up so that their legs can dangle and be dependent to relieve the pain.
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When assess pulses of a patient with PAD, where will you start?
You will start distally (pedal pulse) and work your way up.
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Where are PAD ulcers usually located on the body?
Usually located on the tips of the toes or on the toes. Also, on the lower extremities.
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PAD ulcers are ____ and poor to ____.
Painful, heal.
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Which disease has more severe edema: PVD or PAD?
PVD
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What are the locations of arterial ulcers?
Distal to arterial stenosis, heels, toes, over bony prominences, metatarsals, malleoli, between toes, trauma points.
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What are arterial ulcer bases like?
Dry, pale gray or yellow; may be necrotic.
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What is the shape of arterial ulcers?
Border regular and well demarcated.
** Think of a coin **
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What is the surrounding tissue of an arterial ulcer like?
Pale; cooler than other skin areas. In longstanding insufficiency, skin is thin. Skin can be shiny.
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What is the edema like with arterial ulcers?
Minimal unless leg is dependent often.
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What is the wound treatment for arterial ulcers?
Revascularize the wound for healing (will not heal without revascularization). Monitor for infection. Keep dry gangrene dry.
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What are the locations of venous ulcers?
Around ankle, lower third of leg, more often on medial side.
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What are venous ulcer bases like?
Generally shallow but may be deep. Pink, but may be beefy red with granulation tissue. Ulcer bed usually moist. May have copious drainage.
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What is the shape of venous ulcers?
Irregular border
** Think of cumulus clouds **
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What is the surrounding tissue of a venous ulcer like?
Darkened color in gaiter area. Temperature higher than other skin areas. Brawny edema. Skin may be thick and fibrotic (woody). May be oozing and crusted.Copious, meaning an abundant, plentiful, or large quantity of a substance, typically referring to bodily fluids, secretions, or drainage.
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What is the edema like with venous ulcers?
May be sever; pitting edema +3 or +4
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What is the wound treatment for venous ulcers?
Compression (because the patient has significant edema). Elevation above heart. Absorptive dressings.
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What are the 6 P's for an arterial assessment in PAD?
1. Pain
2. Pallor
3. Pulselessness
4. Poikilothermia
5. Paresthesia
6. Paralysis
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Describe the pain of the arterial assessment in PAD?
Severe, shooting, stabbing, or burning sensation. Pain while walking.
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Describe the pallor of the arterial assessment in PAD?
Lighter color than the rest of the skin. Change in the color of the legs. Pallor when the extremity is elevated. Rubor (red) when it is dependent.
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Describe the pulselessness of the arterial assessment in PAD?
No palpable pulse or diminished pulses.
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Describe the poikilothermia of the arterial assessment in PAD?
Cool temperature to palpation. Coldness; when this occurs there is usually a significant occlusion.
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Describe the paresthesia of the arterial assessment in PAD?
Numbness/tingling, pins and needles., and hot/cold sensations.
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Describe the paralysis of the arterial assessment in PAD?
Immobility, indicates severe tissue damage. Pt unable to wiggle toes.
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What is a late sign of PAD?
Immobility
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What are the priority labs for PAD?
* Lipid panel (indicates plaque buildup)
* ABG
* A1C (if they are diabetic or
* Homocysteine level (protein that promotes coagulation)
* C-reactive protein (it’s the inflammatory marker; tells you if there is inflammation).
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What are the priority diagnostics for PAD?
* Ankle-brachial index
* Doppler ultrasound flow studies
* Angiography (gold standard for PAD [used to diagnose PAD]; it tells you the extent of the PAD).
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What does a ankle-brachial index look for?
It looks at the systolic of the ankle and the brachial with a doppler.
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What is the gold standard diagnostic for PAD called? It is used to diagnose PAD.
Angiography
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What does an angiography tell you?
It tells you the extent of the PAD (location, severity, etc)
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What are 2 surgical interventions for PAD?
1. Revascularization or arterial bypass
2. Angioplasty may be performed with or without a stent.
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What is done in a revascularization or arterial bypass? When is this performed?
They reroute around the occlusion.
This is done a lot when there is an ischemia.
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What are the priority nursing interventions for PAD?
* Perform 6 P’s assessments
* Provide pain relief
* Maintaining tissue integrity
* Repositioning, good shoes, checking their feet.
* Increasing their fluids
* Avoid things that cause constriction such as smoking, tight clothing, caffeine, tight shoelaces.
* Nutrition: reduction of saturated fat, refined sugar, avoid dark leafy greens (because they are on anticoagulants)
* Control hypertension
* Smoking cessation
* Structured exercise program: needs to be coordinated with the physician and make sure the pt. is not in pain. You can medicate them before you get them up.
* Assess for bleeding if they are on anticoagulants. Assess for gum bleeding, nose bleeding, brusing.
* Avoid injury to the extremity.
* No heating pads/heating blankets because they cannot feel it and will get burned.
* No ice packs because it causes vasoconstriction and decreases perfusion.
* Assess any wounds.
* Avoid any stressful situations.
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What are the priority meds for PAD?
* Analgesics
* Anticoagulants
* Antihypertensive meds
* Statin because of the hyperlipidemia.
* ACE inhibitor (ACEI) to control BP
* Antiplatelet agents
* Vasodilator (Cilostazol)
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Why are analgesics given for PAD?
For pain management
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Why are anticoagulants given for PAD?
To prevent blood clots from forming in narrowed arteries.
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Why are antihypertensives given for PAD?
To reduce the high risk of cardiovascular events (heart attack, stroke) and to manage hypertension.
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Why is statin given for PAD?
To lower LDL cholesterol to reduce the risk of major adverse cardiovascular events (heart attack, stroke) and mortality.
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Why are ACE inhibitors given for PAD?
To reduce the high risk of cardiovascular mortality and morbidity (heart attacks, strokes) by lowering BP.
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Why are antiplatelets given for PAD?
To prevent blood clots, reduce the high risk of heart attack, stroke, and vascular death, and improve limb survival.
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Why are vasodilators like Cilostazol given for PAD?
To improve walking distance and reduce leg pain (intermittent claudication).
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What is a pulmonary embolism (PE)?
PE is the obstruction of the pulmonary artery or one of its branches by a thrombus.
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How does a PE occur?
What happens is a VTE occurs, it dislodges and usually goes to the lungs which causes a PE.
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Venous thrombosis can result from ____.
Virchow's triad
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What is Virchow's triad?
It includes 3 factors:
(1) The slowing of blood flow (or venous stasis)
(2) Blood vessel wall injury
* Can be caused by catheter, PIC lines, etc.
(3) Hypercoagulability (altered coagulation)
* Can be caused by postpartum period, smoking, obesity, etc.
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What are the risk factors for VTE/PE?
* Major surgery
* Trauma
* Obesity
* Age older than 40 years
* Central venous catheters
* Medications such as birth control
* Postpartum
* IV drug abuse (because of damage to the vessels)
* Hyperlipidemia (because of atherosclerosis which decreases the blood flow)
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What are the clinical manifestations for VTE?
* Usually unilateral
* Pain in calf
* Dull, achy pain
* Tenderness
* Paresthesia
* Warm and red
* Stasis dermatitis (blood pools under the skin and the skin becomes patchy brown).
* Low grade fever
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What are the clinical manifestations for PE?
* Pleuritic chest pain
* Cough (usually dry)
* Hemoptysis (coughing up blood)
* Palpitations
* Tachypnea
* Crackles
* Tachycardia
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What are the primary labs for VTE/PE?
* ABG analysis
* CBC
* D-dimer (it measures the coagulability in the body. Elevated results can indicate a PE).
* PTT: used to monitor intravenous heparin.
* PT–INR: used to monitor warfarin.
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What are the primary diagnostics for VTE/PE?
* Chest x-ray
* ECG
* Peripheral vascular studies (duplex ultrasound, venogram)
* VQ scan (used to diagnose PE).
* Contrast angiogram CT scan
* Pulmonary angiogram
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What are the priority nursing interventions for VTE?
* Elevate the patient’s leg
* If leg is swollen, measure the circumference of the calf to monitor the swelling.
* You need to make a mark where on the calf where you measured so that the next person measures in the same spot.
* SCDs and TED stockings are used as a preventative for a VTE. TEDs are usually used when out of bed and SDCs are used when patient is in bed. DO NOT use SCDs or TEDs if patient already has a VTE.
* Monitor pt.’s labs
* Encourage early and frequent ambulation (usually within 24 hours of starting heparin).
* Administer analgesics
* Administer medications
* IV heparin to start (if they already have a clot)
* Subcutaneous heparin (if they are at risk for a clot.) It’s used to prevent VTEs from occurring. Injected into the abdomen.
* Monitor for thrombocytopenia (signs/symptoms would be abnormal bleeding, nose bleeds that are difficult to stop, and blood in the urine).
* Protamine sulfate is the antidote for heparin. It is administered very slowly because it can cause bradycardia and hypotension.
* Vitamin K is the antidote for warfarin. Can be given PO or IV.
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What are the priority nursing interventions for PE?
* If you see signs of a PE, you’re calling a RAPID.
* Administer oxygen
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If a patient is on an anticoagulant, what are they at risk for?
Bleeding
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What are the 4 priority medications for VTE/PE?
* Warfarin
* Heparin sodium IV
* Enoxaparin
* Direct thrombin inhibitors
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What is the antidote for warfarin?
Vitamin K
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How long does it take for warfarin to take full effect?
3-5 days, it has a slow onset.
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Why is frequent bloodwork needed for a patient taking warfarin?
You have to make sure that they say within the 2 to 3 range for INR (it measures how long it takes your body to clot).
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Heparin sodium IV is a ____ drug so it requires ____ and it requires ____.
High risk drug. It requires 2 nurses to verify the dose being set on the pump. Close monitoring.
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Anytime the dosage for Heparin sodium Iv needs to be adjusted, it requires ____.
2 RN signatures.
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What is the antidote for heparin sodium IV?
Protamine sulfate
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Where is Enoxaparin (lomanox) injected into the body?
The love handles.
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What type of injection is Enoxaparin (lomanox)?
Subcutaneous injection.
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What lab do you need to monitor for a patient taking Enoxaparin (lomanox)?
Monitor CBC for thrombocytopenia.
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A patient who is taking Enoxaparin (lomanox) should be given a smaller dose if they have ____.
Renal impairment.
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What does a direct thrombin inhibitor do?
It stops the thrombin from making a clot.
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What is the antidote for direct thrombin inhibitors?
There is no antidote.
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What are the priority safety considerations for VTE/PE?
* Signs for bleeding
* Avoid fall
* Watch for change in mental status
* This could indicate bleeding in the brain.
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What are the priority collaborative goals for PTE/VE?
* Collab with pharmacy for drug-to-drug interactions
* Comfort and pain management
* Medication compliance
* Assessing bleeding complications
* Passive or active ROM (with PT)
* Dietician collab to minimize green leafy vegetables high in vitamin K for a patient who is on warfarin (because vitamin K is the antidote for Warfarin).
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What do you need to know about a patient before you give them a Thiazide and related diuretic? Why?
You need to know the patient's potassium level because this medication will deplete it.
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Furosemide is what classification of medication?
Thiazide and related diuretic
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Spironolactone (Aldactone) is what classification of medication?
Potassium-sparing diuretic
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What do you need check for a patient who is taking a Potassium-sparing diuretic? Why?
You need to look at the potassium levels when patient is on this medication because you’re worried about hyperkalemia, which is concerning for arrythmias.
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Cardioselective Beta-Blockers are drugs that have effects on ____.
The cardiovascular system only.
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All cardioselective Beta-Blockers and non-cardioselectove beta-blocker medications end in ____.
"lol"
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What 3 things should you check before administering a cardioselective beta-blocker to a patient?
Check their HR, BP, and the parameters set for the medication.
** If there are no parameters, HR needs to be above 60 **
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What should you monitor for a patient who is taking a cardioselective beta-blocker? Why?
Monitor for hypoglycemia (especially in diabetics) because this medication will mask the symptoms of it.
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Non-Cardioselective Beta-Blockers are drugs that have effects on ____.
All organs and body systems.
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Propanolol (Inderal) is what classification of medication?
Non-cardioselective beta-blocker
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What is important to know about Propranolol (Inderal)? Why?
Need to know that you cannot give this to a patient who is asthmatic because it causes bronchospasms.
236
All angiotensin-converting enzyme inhibitors end in ____.
"pril"
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Lisinopril (Zestril) is what classification of medication?
Angiotensin-Converting Enzyme Inhibitors
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What are the concerns with Angiotensin-Converting Enzyme Inhibitors?
A dry hacky cough and angioedema (swelling of the face, lips, throat, and/or tongue.....emergency airway issue!!!!).
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What is an important nursing consideration for patients taking Angiotensin-Converting Enzyme Inhibitors?
When taking this medication, tell patients to limit direct sunlight, wear protective clothing, and use sunscreen (photosensitivity is a side effect of these drugs).
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What is important to know about calcium channel blockers?
A side effect is constipation.
