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Diabetes Diagnosis Fasting Blood Glucose test (children and non-pregnant adults) - >/=126mg/dL after 8-hour test Glucose

ose Tolerance test - fasting at least 8 hours (water is permitted), fasting blood sample is obtained, drink 300 mL of flavored beverage within 5 min of fasting blood sample, blood samples drawn at 30-min intervals for 2 hours blood glucose level of 200 mg/dl or higher 2 hours after challenge = diabetes Hgb A1C = >6.5% S/S Type 1 3 Ps:Polydipsia, Polyuria, Polyphagia weight loss blurred vision extreme fatigue Type 2 Combination of insulin resistance and impaired insulin secretion Fatigue Frequent urination increased thirst and hunger weight loss/weight gain blurred vision slow healing of wounds or sores Sometimes no symptoms at all Treatment Meds Treat Type 1 with insulin, no oral hypoglycemics used. Type 2 - oral hypoglycemic agents, eventually insulin? Diet Count carbs, balanced diet. Diet - control glucose levels and lipid levels with calories. Eat at regular times. Dont skip meals. 15-20% of calories from protein 60-70% calories from carbs <10% calories from saturated fats Cholesterol - limit to 200 a day 25g of fiber alcohol - 1 drink a day all sweeteners Types (and differences between) Type 1 (juvenile) Results from beta-cell destruction in a genetically susceptible person as a result of an autoimmune process. Antibodies develop against the beta cells which results in reduced insulin levels initially, and no insulin production eventually. Type 2 Body cannot use insulin effectively, insulin resistance.

Gestational Complications and preventions (of complications) Lipohypertrophy The formation of scar tissue in an area that has been used repeatedly for injections. A firm, lumpy area develops. Insulin absorption is changed in this area. Lipodystrophy/Lipoatrophy Used to describe the pitted areas that may form at injection sites. Results from loss or redistribution of fat in the area due to repeated injections with impure insulins. Dawn phenomenon Morning hyperglycemia that results from the release of hormones such as growth hormone, cortisol, and catecholamines in the early morning hours. The live releases glycogen in response to the hormones, which may also partially block the effect of insulin (produced by the body or from an injection). Somogyi effect Morning hyperglycemia that is a result of hypoglycemia from long action insulin. The body release hormones which causes the liver to release large amounts of glycogen. The body responds to the low blood sugar in the same way as in the Dawn phenomenon. hypoglycemia Retionopathy - Damage to small blood vessels. Impaired retinal blood flow leads to tissue hypoxia, cell destruction, and nerve damage. Poor retinal circulation leads to edema and hemorrhage. Microaneurysms form which leak blood and fluid into the eye. Neuropathy - progressive deterioration of nerves that eventually results in loss of unction. It involves all parts of the body including the autonomic nervous system. microvascular complications Charcot foot - rocking chair shape. Nephropathy - pathologic change in the kidney that reduces function and leads to kidney failure.

Anemia S/S Dyspnea, tachycardia, peripheral numbness, confusion, HA, decreased sensory awareness, fever, chills, and night sweats, N/V, glossitis, cheilosis (cracked, fissured lips), bone pain, petechiae, ecchymosis, jaundice, pallor, texture. Iron deficient - most common, chronic anemia, especially in women Pernicious - Deficient intrinsic factor, which is needed for absorption of B12. Aplastic, pancytopenia - decrease in RBC, WBC, platelets is common Acquired hemolytic anemia - Both acute and chronic excessive destruction of


RBCs r/t extrinsic factors such as chemical agents/toxins, ie spider bites, snake bites Autoimmune hemolytic - Antibodies develop and are directed against the antigen on the patients own RBCs Warm antibody anemia - occurs with IgG antibody excess. Cold antibody anemia - occurs with complement protein fixation on IgM and occurs most at 86*F. Assessment Respiratory Assess RR and depth while pt at rest as well as during and after mild physical activity (walking 20 steps in 10 seconds). Assess whether pt is fatigued easily, has SOB at rest or on exertion, or needs extra pillows to sleep comfortably at night. CV Ausculatate for murmurs, gallops, irregular rhythms, and hypotension systolic BP tends to be LOWER than normal in clients with anemia. Cognitive/perceptual Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. GI Tongue may be completely smooth in pernicious anemia or smooth and red in nutritional deficiencies. May occur with fissures at corners of the mouth. Abdominal assessment: Enlarged spleen, liver in R upper quadrant. Palpate gently and cautiously because enlarged spleen may be tender and easily ruptured. Musculoskeletal Rib or sternal tenderness is important sign of hematologic malignancy. Skin Pallor gums, conjunctivae, and palmar creases indicates decreased hemoglobin levels - pale conjuctavae gross measurement of anemia. Assess for petechiae and large bruises (ecchuymosis). Petechie are pinpoint hemorrhagic lesions in the skin. Pallor and cyanosis are more easily detected in darker skin by examining oral mucous membranes and conjuctiva of the eye. Jaundice can be easily seen on the roof of the mouth. Petechiae may be visible only on palms of hands or soles of feet. Treatment (dietary) Iron - liver, red meat, organ meats, legumes, kidney beans, whole-wheat breads/ cereals, leafy green veggies, carrots, egg yolks, raisins, cook food with iron in a SKILLET. Pernicious = green leafy veggies, citrus fruits, soy, animal proteins, eggs, dairy products

Cardiac CAD

Coronary Artery Disease (CAD) is a narrowing of the coronary arteries from either plaque, stricture, or clot that prevents adequate blood flow to myocardium causing ischemia and/or an infarction Ischemia = lack of oxygen Infarction = dying heart muscle Necrosis = dead heart muscle Disorders or complications resulting from CAD are: angina (angina pectoris),Heart Failure, Myocardial Infarction, & Hypertension CVD is the leading cause of death in the U.S. with one death every occurring every 60 sec. Mortality has decreased over the last 40 yrs. due to improved technology and therapy that targets modifiable risk factors. Non-modifiable risk factors: age, gender, heredity, ethnic background Modifiable risk factors: smoking (cessation), obesity (diet and weight control) physical inactivity (increase), stress/Type A personality (road rage), hypertension (treat), and diabetes (diagnose and treat). Obesity is more common in African American Women than Caucasian Women (increase CAD risk) 67% of Hispanic women are overweight Definition of Angina - chest pain resulting from a temporary imbalance in the ability of the coronary artery or arteries to supply oxygen to the myocardium. *Types Chronic Stable has a predictable pattern; chest discomfort is caused by moderate to prolonged exertion or an emotional trigger; this kind of chest pain has a stable pattern of onset, of duration (from a few seconds to about 15 minutes), & in intensity (feels the same each time it occurs). The pain of stable angina is always relieved by rest &/or sublingual NTG It is associated with fixed atherosclerotic plaque and rarely requires aggressive treatment. Acute Coronary Syndrome is the term used to describe either unstable angina (UA) or a myocardial infarction (MI). The pain with UA has an unpredictable or changing pattern, it may occur more easily, and more frequently, while the patient is at rest, and at night; the episodes of chest pain with UA increase in number, duration (lasts longer than 15 minutes), & increase in intensity over time. Variations of angina Variant (also called Prinzmetals) - is chest pain that occurs at rest with ST elevation on the EKG that is due to coronary artery spasm; it does not increase in myocardial workload load and there is no coronary artery disease at heart cath. New-onset angina 1st symptoms. 10-30% of patients progress to MI within 1 year of onset; 29% die within 5 years Pre-Infarction angina - occurs days to weeks before a MI

Atypical angina is pain due to CAD that manifests differently that chest pain. Often mistaken for indigestion, patients may have pain b/t their shoulders, an aching jaw, a choking sensation (panic, anxiety attack), or be misdiagnosed as hypochondriasis. Women are more likely to have atypical pain. The typical "exertion-pain-rest-relief" pattern is a major clue to the diagnosis of stable angina The focus is on relief of the acute attack & prevention of future attacks. Teaching patients how to manage their angina begins with first having them stop whatever activity they are doing. If the pain does not subside with rest, they should be instructed to take a SL nitroglycerin tablet. May repeat 2 more times, 5 minutes apart. If no relief, have them take an aspirin (unless allergic) and CALL 911. Nitroglycerin is a vasodilator (venous and arterial) which decreased venous return to the heart, thereby decreasing the amount of blood the heart has to pump (preload). When the heart does not have to pump as hard, the oxygen requirements of the myocardium decrease, which reduces the pain. This is why Nitroglycerin also decreased blood pressure. At higher doses, nitroglycerin produces arteriolar vasodilation. Aspirin inhibits an enzyme (COX 1) that prevents thromboxane from being produced by platelets. This works to keep the platelets from aggregating or clumping together. Nursing Diagnoses Knowledge Deficit: Dietary modifications - Low fat, low cholesterol, sodium restricted (B/P). Pharmacology in addition to nitro and ASA, medications may include beta blockers, use of OTC and complementary supplements, vitamins, omega 3 fatty acids, as well as any medications needed to treat co-morbid conditions (i.e. hypertension, diabetes, hyperlipidemia) Lifestyle modifications: weight reduction, sodium restriction, stress reduction, smoking cessation Explain significance of reporting discomfort; Identify triggers of fear & anxiety Measurable goals: client will be free of chest pain.(give a time frame) B/P and apical pulse will be within normal range for the patient Perform ADLs without chest pain. Key Features of ACS See Iggy pg. 854 Chart 40-2 Associated symptoms N/V, diaphoresis, pallor, hypotension, SOB, increased pulse rate, anxiety, JVD If blood flow is restored, no permanent myocardial damage occurs.

MI: Etiologyrupture of atheromatous plaque, coronary artery spasm, platelet aggregation/thrombus, emboli, hemorrhage or shock (low BP) from blood loss. JUST A QUICK REVIEW OF THISNOT THE ACUTE CARE *Clinical Manifestations Substernal chest discomfort radiating to LA, back or jaw occurring without cause, lasting more than 30 min often accompanied by nausea, diaphoresis, dyspnea, feelings of fear and anxiety, dysrhythmias, pain relieved by opioids; not usually by NTG) V-Fib is the most lethal dysrhythmia within the first hour of MIDo NOT delay in getting medical assistance Medical Management Establish IV access (x2); stat 12 lead EKG continuous monitoring Opioids: Morphine is the drug of choice; relieves pain, decreases O2 demand, decreases catecholamines. Relieves anxiety.( Dose of 2-5mg IV every 5-15 minutes until pain relief or adverse effects (hypotension). Oxygen Administration: 2-4L/per nasal cannula to keep SaO2 92% or >; Semi-fowlers position NTG: S/L or IV infusion works primarily to decrease venous return; also dilates arteries at larger doses. Can cause hypotension. ASA : Prevents thrombus formation Thrombolytics: Clot busters (t-PA, streptokinase) Beta-Adrenergic blocking agents Metoprolol (Lopressor): Slows heart rate & decreases force of cardiac contraction (contractility/ workload) A CE Inhibitors prevents ventricular remodeling Calcium Channel blockers Inotropic agents increases the force of ventricular contraction. Used to improve contractility. Activity Intolerance: Cardiac rehab begins at the time of diagnosis with an MI (Iggy Chart 4010, p. 871) Cardiac rehab promotes maximum function in patients with known impaired cardiac function Phase 1 - initial acute illness to discharge. Walking, climbing stairs Phase 2 - from discharge through convalescence at home. Formal program ~ 6 weeks Phase 3 - long term conditioning Teach patient how to monitor BP and pulse. When on treadmill or bike, >20mmHg increase in BP, or pulse increase of > 20 beats/minute indicates an intolerance to activity Assess for dyspnea, fatigue, chest pain Altered Sexuality Pattern: ED drugs are vasodilators and lower the blood pressure. In the

majority of patients with heart disease, including those being treated with antihypertensive drugs, this is not a problem. However, the vasodilating effects of ED medications do become potentially hazardous when combined with the vasodilating effects of nitrates. Patients taking both nitrates and sildenafil (Viagra) or Cialis are prone to develop severe hypotension (low blood pressure) and syncope (fainting.) Patients taking nitrates for their coronary artery disease, therefore, should not take sildenafil. Further, anyone who has taken sildenafil during the past 24 hours should not take nitrates. Deficient Knowledge: Life-Style Changes: Smoking Cessation, Physical Activity, Sexual Activity, Relaxation Techniques, Diet, Weight Loss Compliance with medication regimen Blood pressure control Blood glucose control Cholesterol control Cardiac medications Heart Failure of a general term used to describe cardiac dysfunction that leads to inadequate tissue perfusion. It is defined as a physiologic state in which the heart is unable to pump enough blood to meet the metabolic needs of the body at rest or during exercise. Cardiac Output is defined as the amount of blood ejected in one minute. It is product of the HR times the Stroke Volume (SV). The SV = is the amount of blood ejected with each heartbeat. Increasing the HR to improve the CO has limits. An increased HR also increases O2 demand & decreases diastolic filling time. Increasing the stroke volume also increases the CO: stroke volume is dependent on 3 components: 1. Preload how much blood is available to be pumped by the ventricles? 2. Afterload how much resistance must be overcome for the ventricles to be able to pump? 3. Contractility how effectively are the ventricles at squeezing so that blood is ejected? Arterial Vasoconstriction as in HTN increases afterload Afterload in the right ventricle is measured by the amount of resistance in the pulmonary artery. Afterload in the left ventricle is measured by the amount of resistance in the aorta Major determinant of myocardial O2 requirements Classification and staging of heart failure. With the New York Heart Classification, patients can move back and forth between classes depending on their symptoms. Class 1 = activity unlikely to be restricted to Class IV activity severely limited; symptoms at rest. The AHA/American College of Cardiology staging system is progressive in nature. Treatment recommendations are based on symptoms and are additive.

The Killip classification is based on assessment of the lungs and heart following an acute MI. The class (I IV) is related to prognosis. The systems complement each other and are often reported together when describing a patients degree of HF Special cells that line the ventricles in the heart secrete Brain-type Natriuretic Peptide (BNP) in response to fluid overload that stretches the ventricular wall. Less than < 100 is normal. Assess for changes in activity tolerance, if they are following their treatment regimen, for changes in breathing, increased urination at night? WEIGHT GAINis the best indicator of fluid overload.not edema. WHY??? Assess lung sounds. What would you expect to hear and where in a patient with increasing HF? What is the effect of position on your lung assessment? Impaired Gas Exchange: Morphine sulfate to reduce anxiety, vasodilation. These patients cannot breathe, and are scared. Oxygen BiPAP Coughing wont clear congestion from HF.WHY? Decreased cardiac output r/t problems with preload, afterload, or contractility. Manifested as hypotension, decreased urine output, altered LOC Angiotensin Converting Enzyme Inhibitors primarily reduce afterload. Examples of ACEIs are: enalapril (Vasotec), captopril (Capoten), quinapril (Accupril) Suppress the RAA system. Can drop BP rapidly be cautious with 1st dose. Increased risk of orthostatic hypotension Most common SE is development of cough??? (associated with increased production of bradykinin in lung). Monitor for hyperkalemia with ACEIs. Dietary intake of sodium of 3-4 Gm/day (NAS) 2 Gm/day = No salt in cooking Teach patients (family members) to read food labels for sodium content SE of diuretics - monitor for hypokalemia <3.5mEq/L Acronym SUCTION S = skeletal muscle weakness U =wave on EKG C = constipation T = toxic effects of drugs especially Digoxin I = irregular weak pulse O = orthostatic hypotension N = numbness (paresthesia) Treatment IV K+ - 10 mEq diluted in 100 mL at a rate of 100 mL hr. Use an infusion pump, NEVER GIVE IV PUSH Monitor cardiac rhythm (place on telemetry per agency policy) Fluid Volume Restriction - Limit fluids to 1.5 - 2L/day

Daily weight; accurate I & O Diuretics - Loop & Thiazide (HCTZ-Hydrodiuril, metalazoneZaroxolyn) Knowledge Deficit: Medications Verbal & written instructions How to take & record blood pressure and pulse Take your diuretics in AM; weigh yourself each morning ACEs - move slowly, report cough, or dizziness Exercise Cardiac rehab; home walking Walk 200-400 ft/day 3xs/wk Exercise diary Avoid fatigue Dietary Modifications Foods rich in K+ (bananas) No salty processed foods Moderate restriction - 1 Gm/day; NAS, no salty processed foods; and sodium free baked foods Strict- 500 mg/day; avoid all salt & limit natural sodium containing foods (milk, canned meats, eggs) Caution against the use of commercial salt substitutes they are high in K+!! Sea salt coarse grains use less. S &S to Report: Weight gain of more than 2 pounds/24hrs; any dyspnea or increase in dyspnea with exertion, cough, paroxysmal nocturnal dyspnea, decreased exercise tolerance. Ask about their home environment are there resources for their self management? Home environment

Hypertension Essential hypertension has no identifiable cause; however, will have presence of risk factors Risk factors: Age greater than 60 years A family history of hypertension is a major risk factor because a defect in renal secretion of Na+ or heightened sympathetic nervous system response to stress can be familial. Other risk factors we have ID already Secondary HTN: Renal vascular & renal parenchymal diseases are the most common causes. For example, renal artery stenosis is associated with narrowing of main arteries carrying blood directly to kidneys. Renal parenchymal diseases related to infection, inflammation, & changes in kidney structure & function. Dysfunction of adrenal medulla or cortex due to primary excesses of aldosterone, cortisol, & catecholamines. Adrenal Tumors. Isolated Systolic HTN: Major health threat for elders. Is the most COMMON

form of HTN with NO symptoms. In this form of hypertension, after age 55, the DBP stops rising, but the SBP continues to rise. ISH is a significant predictor of not only heart disease but stroke as well. Management of Hypertension: Diet: Sodium Restriction- Reduce sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g NaCl) Mild (2-3 gm) Salt shaker used sparingly, no salt-preserved foods, spices (MSG, garlic salt, mustard), NAS, no processed foods Moderate (1000 mg) No salt in cooking, NAS foods, moderate amt milk (no buttermilk), meat, salt-free baked goods (baking powder, soda), salted butter Strict (500 mg) Meat (5 oz), milk (only 2 Cups), eggs used sparingly; No Added Salt Diet (30004000 mg. Sodium Diet) Avoid: Smoked or cured meats like bacon, bologna, hot dogs, ham, corned beef, luncheon meats, and sausage Canned fish like tuna, salmon, sardines, and mackerel** Buttermilk +, Most cheese spreads and cheeses Salty chips, nuts, pretzels, or pork rinds Some cold (ready to eat) cereals highest in sodium, instant hot cereals Quick cooking rice and instant noodles, boxed mixes like rice, scalloped potatoes, macaroni and cheese, ++ and some frozen dinners, pot pies and pizza* Regular canned vegetables** Pickled foods like herring, pickles, relish, olives, or sauerkraut Regular canned soups, instant soups Butter, fatback, and salt pork Soy sauce, steak sauce, salad dressing, ketchup, barbecue sauce, garlic salt, onion salt, seasoned salts like lemon pepper, bouillon cubes, meat tenderizer, and monosodium glutamate (MSG)* DASH (Dietary Approaches to Stop Hypertension) Consume dietary pattern of 4-6 servings fruits, 4-6 servings vegetables, and 2-3 servings low-fat dairy products and reduce intake of saturated fat and total fat. Lean meats, high fiber Limit alcohol intake to no more than 1 ounce (30 mL) ethanol (e.g., 24 oz [720 mL] beer, 10 oz [300 mL] wine, or 2 oz [60 mL] 100-proof whiskey) per day or 0.5 oz (15 mL) ethanol per day for women and lighter-weight people. Lose weight if overweight. Maintain normal body weight (body mass index 18.5-24.9). Engage in aerobic physical activity (at least 30-45 min most days of the week). Exercise: 30 to 45 min/3-5 x per week Smoking cessation There are 4 systems that are targeted in managing hypertension : Fluid Volume; the heart, the vascular system (through constriction/vasodilation), and the RAAS Thiazides Chlorothiazide (Diuril) Hydrochlorothiazide (Esidrix, hydrodiuril) Loop Furosemide (Lasix, furoside) Ethacrynic acid (edecrin)

K+ sparing Spironolactone (aldactone) Triamterone (Dyrenium) Angiotensin-converting enzyme Captopril (Capoten) Enalapril (Vasotec) Lisinopril (Zestil, Prinvil) Central alpha agonists Clonidine hydrochloride (Catapres) Methyldopa (aldomet) Beta Blockers Propranolol (Inderal, Apo-Propranolol) Atenolol (Tenormin) Nadolol (Corgard) Metoprolol (Lopressor) Carvedilol (both an alpha and beta blocker**) Ca++ Channel Blocker Nifedipine (Procardia, Adalat) Verapamil (Calan, Isoptin) Diltiazem hydrochloride (Cardizem) ARBs block the effects of Angiotension II on the receptors sites allowing vasodilation. Renin Inhibitors- Direct renin inhibitors decrease plasma renin activity and inhibit the conversion of angiotensinogen to Angiotensin I. Whether aliskiren affects other RAAS components, e.g., ACE or non-ACE pathways, is not known. Aliskiren (Tekturna) - Oral administration with or without food. SE- Hypotension; Angioedema of the face, extremities, lips, tongue, glottis and/or larynx has been reported, as has hyperkalemia and diarrhea. Other less common reactions include cough, & rash, increased uric acid/gout.

Peripheral Vascular Disease DVT Acute Arterial Occlusive Disease = sudden occlusion by embolus Symptoms are dependent on the size of embolus, which organ is involved, and if there is collateral circulation. Pathophysiology - Immediate cessation of blood flow distal to site. General progression of ischemia--> infarction--> necrosis--> gangrene. Abrupt onset, without warning Assessment 6 Ps for ARTERIAL OCCLUSION Acute pain below level of occlusion Pulselessness distal to site Pallor Poikilothermia - cool

Paresthesia - loss of sensory function Paralysis- loss of motor function ( is a relatively late sign that signals actual death of nerves in extremity) Interventions: EARLY TX ESSENTIAL TO SAVING AFFECTED LIMB Pulmonary Embolus will produce respiratory symptoms resulting from lack of blood flow to lung for oxygenation. Anticoagulants are the treatment of choice for acute arterial occlusions. Heparin (an anticoagulant) is given to prevent further clotting . Will discuss heparin more I detail with treatment of DVT. Thrombolytics such as t-PA (tissue plasminogen activator) Alteplase may be given to break up the existing clot. Act on plasminogen to produce plasmin (a fibrinolytic enzyme). Are given IV. Must be initiated within 6-8 hrs of onset of symptoms. SEs include excessive bleeding! Can destroy pre-existing clots & cause bleeding @ sites recently healed (recent wounds, needle punctures, site of invasive procedure). Contraindication - intracranial problems, recent hemorrhagic stroke or surgery. Platelet inhibitor medications are also indicated as arterial clots tend to be rich in platelets. Antiplatelet agents works by inhibiting platelet aggregation by blocking certain receptor sites on the surface of the platelet that prevent them from forming a platelet plug one of the first steps in hemostasis. This increases bleeding time. Surgical - Embolectomy/Thrombectomy Incise vessel & remove clot Pre-op care - keep limb @ room temp, level or slightly dependent. Maintain Bed Rest Post-op care - Monitor neurovascular checks Assess pain differentiate between postoperative pain and pain of re-occlusion Encourage movement as allowed by MD; Skeletal muscle swelling can occur which compresses the small blood vessels in the muscles. This leads to swelling and pain and a condition called compartment syndrome. A fasciotomy is a surgical procedure that is done to relieve the pressure and allow the welling to subside. Often done as an emergent procedure. YOU TUBE VIDEO Partial/total arterial occlusion causing nutrition & O 2 at cellular level Insidious, slow, progressive narrowing of lumen with eventual occlusion; Found primarily in lower extremities. Most common occlusion in patients without DM is in the femoral-popliteal area; for patients with DM - it occurs more below the knee. Etiology: Atherosclerosis = formation of plaque within the intima and media of the arterial wall that leads to narrowing of the lumen; Often irregular along the length of the artery. Risk factors discussed previously; age range 60-80s; more males; familial tendency; DM; SMOKING; HTN; HYPERLIPIDEMIA Assessment: Lumen is usually 75% narrowed when sx appear

Severity of symptoms depends on site & extent of occlusion, and adequacy of any collateral circulation Nursing Diagnosis - Alteration in tissue perfusion- peripheral; Impaired skin integrity; Pain; Impaired physical mobility; Activity Intolerance; Deficient Knowledge Antiplatelet Drugs ASA- 81-325 mg/day Suppresses platelet aggregation by inhibiting enzyme required by platelets Clopidogrel (Plavix) Cilostazol (Pletal) inhibits platelet aggregation and also vasodilates. SEs include flushing, headache Dipyridamole (Persantine)- 50-100 mg tid/qid Increases plasma level of adenosine & acts as vasodilator. Suppresses platelet aggregation. pentoxifylline (Trental)- 400 mg bid/tid with meals Takes at least 2 weeks to see effects Increases flexibility of RBC & decreases blood viscosity by decreasing fibrinogen Thereby improving peripheral circulation Side effects- GI upset, flatus, N & V Surgical Interventions: Indicated when symptoms of intermittent claudication become incapacitating When pain is now occurring at rest, or if ulceration/gangrene threatens viability of limb Percutaneous Transluminal Angioplasty (PTA) - Invasive technique that introduces special catheter with a balloon into the artery to be dilated. Opens the blood vessel & improves blood flow by cracking the atherosclerotic shell. Used in patients with relatively short lesions (< 3 cm in length) Laser Assisted Angioplasty- Vaporizes plaque by using heat to bore a hole through occlusion Atherectomy- Rotational atherectomy uses a sharp blade that shaves the plaque away from the wall of the artery. Stent Arterial Revascularization ( arterial bypass, or endarterectomy) Outflow below the SFA involves the femoral, popliteal and tibial arteries Inflow above the inguinal ligament involves the distal aorta, and iliac arteries Aortic-femoral bypass, fem-pop bypass Use native saphenous vein, or synthetic graft

Endarterectomy opens the artery and removes the plaque Chronic Arterial Occlusion: Pre-op- baseline; IV, arterial line, central line Post-op- check extremities q 15 min x 4; q1 hr x 4 Monitor pain, color, temp, pulse, BP, edema MAJOR complication-graft occlusion - PAIN is 1st indicator of occlusion (occurs w/in the first 24hrs; Differentiate between reperfusion pain and ischemic pain. Hemorrhage Compartment Syndrome- Caused by swelling of skeletal muscle; Monitor for worsening pain, fullness, swelling, and tenseness. These symptoms should be reported to the health care provider immediately. Fasciotomy (surgical opening into the tissues) may be necessary to prevent further injury and save the limb. Alteration in Tissue Perfusion, Peripheral r/t decreased or cessation of arterial blood flow/ vasospasms Plan: Show increased arterial blood flow AEB decrease in pain, palpable pulses, pink extremity, warm to touch, no further progression of paresthesia or paralysis. Prevent ulcerations. Interventions: Promote vasodilation- wam environ; Sox, insulated shoes; Protect from extreme temps- warm bath-NEVER HOT (- metabolic needs) Prevent vasoconstriction- No exposure to cold, emotional stress, caffeine, nicotine; NO SMOKING!!!- vasoconstricts 1 hr after each cigarette; No tight clothing Activity Intolerance: Build or improve collateral circulation (provides blood supply through smaller vessels) Exercises, progressive activity program; Walk to claudication, stop, rest, resume when pain subsides; ROM Impaired physical mobility: Position with feet slightly elevated (NOT above heart) if edema; Avoid crossing legs Altered nutrition, More than BR Deficient Knowledge: Prevent progression by working c 3 major risk factors (Stop smoking; low fat diet; wt loss program; control HTN) CHART 39-9 CLIENT EDUCATION GUIDE: Foot Care for the Client with PVD Keep your feet clean by washing them with a mild soap in room-temperature water Keep your feet dry, especially the ankles and between the toes. Avoid injury to your feet and ankles. Wear comfortable, well-fitting shoes. Never go without shoes. Keep your toenails clean and filed. Have someone cut them if you cannot see them clearly. Cut your toenails straight across. To prevent dry, cracked skin, apply a lubricating lotion to your feet. Prevent exposure to extreme heat or cold. Never use a heating pad on your feet. Avoid constricting garments. If a problem develops, see a podiatrist or physician. Avoid extended pressure on your feet or ankles, such as occurs when you lean against something.

Interventions for Raynauds disease (1 question) Interventions: Medical - Pharmacologic- vasodilators, Calcium channel blockers Surgical - Sympathectomy- cut sympathetic nerve fibers to lower ext that causes vasoconstriction; Gangliectomy- cut for upper extremeties Amputation Post-op assessment Assess the residual limb for the following: Adequate circulation, Infection, Healing, Flexion contracture Management Home Maintenance - Prosthesis- may receive temporary prosthesis immediately or c/in 5 wks post-op; Permanent prosthesis after edema decreases; Practice walking, balance; Exam stump - Use mirror to see all sides; Keep clean, dry; F/U c prosthesis maker CHART 55-7 HOME CARE ASSESSMENT of Lower Extremity Amputation in Home

Blood Tranfusions Blood products ???

Electrolytes S/s of low and highs for common electrolytes Potassium - 3.5-5 Hypokalemia is a serum potassium level below 3.5 mEq/L (mmol/L). It can be life threatening because every body system is affected. Prolongs cardiac repolarization. Flattened T waves, confusion, disorientation. Skeletal muscle weakness, anorexia, nausea, vomiting, constipation. Increased irregular pulse, ventricular PVCs, and increased risk of digitalis toxicity. Hyperkalemia Muscle weakness and abnormal cardiac conduction. Slowed ventricular conduction and contraction followed by aystole. Look for tall tented or peaked waves and a shortened QT interval (rapid repolarization) on EKG. Sodium - 135-145 HYPO - decreases with use of diuretics & with fluid volume excess (CHF). Acute confusion, behavioral/LOC changes HYPER muscle weakness, anorexia, constipation Magnesium - 1.3-2.1 HYPO- cause ventricular tachy & fibrillation. Usually occurs along with serum calcium and potassium imbalances. Clinical manifestations are most commonly seen in the neuromuscular, central nervous and intestinal systems. May replace Mg for cardiac patients even if within low normal range.

Medications Actions Indications for adverse reactions (common) Desired (positive) effects Emphasis on cardiac medications