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Scott Gardner N211 Q4F05 Unit 2

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What is an Angiogram?
A radiographic record of the size, shape, and location of the heart and blood vessels after introduction of a radiopaque contrast medium.
Name some locations that can harbor a DVT.
Calf, Femoral, Popliteal or Iliac venis.
What are some other sources of PE besides DVT?
Tumor fragments, air, fat, bone marrow, amniotic fluid, sepsis, heart valve vegetation.
What is the main problems with a PE?
Decreased profusion causes a VQ Mismatch resulting in Hypoxemia.
Large pulmonary vessel blocked can cause Right Sided CHF, atelectasis large tube airway restriction and shock.
List some clinical manifistations of PE.
Pleuritic chest pain
Tachypenia
Dyspnea
Anxiety/Apprehension
Cough diaphoresis, syncope and hemoptysis. Sometimes accentuated S2 or less commonly S3 or S4 (Gallop)
What do ABG and Pulse Oximetry show in PE?
Low Sats. Unresponsive to increased Flow of O2.
Massive PE will give Low O2, Low Co2 and severe respiratory alkalosis.
V/Q Scan does what?
Checks for Ventilation and Pefusion.
What are some other tests used in Dx of PE?
Sprial CT
Quick and less invasive.

Pulmonary angiography
Invasive and used when other tests are inconclusive.
Where is the cathater inserted for a Pulmonary Angiogram?
The Femoral VEIN. NOT ARTERY which is done for most other arteriography.
Name three things that are done in Medical Management of PE.
-Stabalize the underlying Cardiopulmonary System.
-Use Antiocoagulant therapy to prevent more PE.
Use Fibrinolytic therapy to break up embolus, but not so common as was in the past.
What is the PaO2 that needs to be maintained with a PE, and how can that be accomplished?
THe PaO2 should be 60 and can be achieved with O2 via nasal cannula or may require ET.
What needs to happen to BP with supporting a client with PE?
Raise the BP by raising the preload (RV end Diastolic pressure).
How is BP raised with a PE?
IV Fluids
Inotropic drugs
NaBicarbonate if needed to reverse acidosis.
Name two of the actions of Heparin.
Reduce new further clots or stop an existing clot from getting bigger.
What is the antagonist for Heparin?
Protamine Sulfate
How does Low Molecular Weight Heparin differ from normal heparin?
aPTT does not need to be monitored.
What is the name of the protocal for maintaining heparin infusion?
A Nomogram.
What is the INR that is therapeutic for PE when patient is on warfarin?
2.5 - 3
How long does it take coumadin to replace the therapeutic effects of heparin?
2-3 days.
What does Vitamin K do in conjunction with coumadin?
It is an antagonist.
What are two fibrinolytic drugs?
TPA or Steptokyase
What is fibrinolytic Thereapy, and describe why it is not used more agressively?
It lyses clots and restores R Sided Heart Function.
Not used because of high mortality rates.
Name three coplications of PE.
Shock
Respiratory failure
Dysrhythmias
Should clients on high anticoagulants be allowed up ad lib?
No, supervise ambulation to prevent falls.
What is a dietary intervention to do with a client on anticoagulant therapy, and why implement it?
Increase Fiber.
Prevents straining during BM which could cause bleeding.
How and where are filters used.
In the Inferior Vena Cava. Usually introduced in the leg, or possibly neck veins.
Which is better...Anticoagulant or Vena Cava filters?
Filters less effective than Anticoagulant therapy, but used when blood thinners are contraindicated.
What is another name for a VQ Scan?
Ventilation Perfusion Scan
Initially, the acid base problem with a PE is what?
Respiratory Alkolosis.
What therapy is monitored by looking at aPTT levels?
Heparin
What type of therapy is used for a PE when anticoagulation therapy is not an option?
Vena Cava Filter, also called a Greenfield Filter.
If you were looking at an IRN of 2.5-3.0 what medication would this assess?
Warfarin or Coumadin.
Where do you see Intermittent Claudication?
Arterial Disorder
Where will you experience Rest Pain?
Arterial
If your patient has pain in the legs that worsens with Elevation, what do they have?
Arterial Disorder
If the client experiences Aching and Heaviness....A/V?
Venous Disorder
If the client experiences Nocternal Cramping....A/V?
Venous
If Exercise and Elevation decrease pain, venous or arterial?
Venous.
If the client has shiny skin with the lack of hair..A/V?
Arterial.
If the client has Brown Discoloration..A/V?
Venous
If the client has thick toe nails...A/V?
Arterial
If the skin is pale with dependant rubor...A/V?
Arterial
If the skin is cool...A/V?
Arterial
If the clients toenails are normal would your suspect A/V?
Venous.
If the client showed dependent cyanosis...A/V?
Venous.
If there were no change in color, or the skin was slighly warmer...A/V?
Venous.
If the client has decreased sensation...A/V?
Arterial
If the client has decreased or absent pulses...A/V?
Arterial
If the client usually does not exhibit edema...A/V?
Artrial
If the skin of the legs itch whould you suspect...A/V?
Venous
If the pulses are usually present, but difficult to palpate with edema...A/V?
Venous
If the client reports edema that is worse at the end of the day and is improved with elevation...A/V?
Venous.
A broad shallow ulcer...A/V?
Venous
If the ulser is slightly painful...A/V?
Venous
If the ucler is very painful...A/V?
Arterial
Ulcer with surrounding skin that is brown and fibrotic...A/V?
Venous.
Ulcer is smooth and round...A/V?
Arterial.
Specifics of Intermitten claudication.
Cramping in calf
Happens with ambulation
Resolves in 1-2 MInutes
Predictable pain for given distance
Pain is burning, tingling
What are some major sites of peripheral atherosclerosis.
At biforcations junctions, and arches.
If your client has aortic/iliac occlusion, where would the claudication pain present?
Gluteal and thigh.
If your client has femoral occlusion, where would the claudication pain present?
Calf
If your client has Pop/Tib occlusion, where would the claudication pain present?
Calf and foot pain.
How can you test elevation pallor?
-Elevate food 12 Inches.
-Pallor will be evident within 1 minute
-When placed back in dependent position, color takes more than 10 seconds to return.
Define Pallor
Lack of color, paleness.
What is an ABI?
Ankle-Brachial Index
How is ABI Figured?
Client Supine, take both arm BP's
Apply BP cuff to leg just above malleolus.
Systolic Ankle/Higher Syst Arm.
What is an ABI of 1 or more indicate.
Normal
What does an ABI of 0.5 to 0.8 indicate?
Client might experience claudication pain.
What does ABO of 0.4 or less mean?
Client will experinece rest pain.
When is ABI flasley elevated, and what can be done to compensate?
With Diabetes so use Toe Brachial.
What is Ultrasonic Duplex Scanning?
A visual and audible ultrasound which shows localized valsular obstructions and evaluates the degree of stenosis. Used to determine presence of vascular reflux or backward flow.
How is exercise testing used to measure claudication?
1.5 to 2.0 mph at 10-20 degree elevation.
Mild if 5 minutes before pain
Severe if only walk 1 miute
When are CT Scans used with PVD?
AAA
Graft Occlusion
Infectoin
Hemorrhage
When are MRI used with PVD?
Evaluate blood flow
What is MRA and when is it used in PVD?
Magnetic Resonance Angiography.
Evaluates blood flow and viscosity.
Define magnetic resonance angiography (MRA)
Noninvasive radiography of blood vessels using magnetic resonance imaging.
What are some preprocedure care steps for Angiography.
Informed Consent
NPO 2-6
Mild Sedative
Prep Femoral site
Assess Renal Functoin, BUN Creatinine.
Why Assess Renal Function, BUN Creatinine.
To determine if client will be able to clear the contrast, and can cause renal failure.
What are post care procedures after Angiography?
VS
Neurologic Function
Distal Pulses, and Color
Heamtoma at Puncture Site
Bedrest 6-8 flat without flexion
Crystalloid IV 6-8 hours to flush contrast.
What is the max HOB elevation after Angiography?
30 Degrees
If a client has severe pain after an angiography what might that mean?
Hematoma or bleeding.
What are some complications of an Angiography?
Allergy to contast, thrombi, emboli, artery perforation, renal failure, pseudoaneurysm.
What is pseudoaneurysm?
A dilation or tortuosity in a vessel that gives the impression of an aneurysm.
What is Vascular Endoscopy?
Allows visualzation of Artery with fiberoptics. Camera records images.
What will Vascular Endoscopy idendify?
Thrombus, plaque, hemorrhage, ulceration, embolus or Anastomosis.

It can remove debris
What is Anastomosis?
A natural communication between two vessels; may be direct or by means of connecting channels.
A cramping pain of the calf or other muscles caused by partially blocked artery is called
Intermittent Claudication
This test involves inserting a catheter into an artery.
Angiography
Brown discoloration and dependant cyanosis are signs of what type of occlusion?
Venous
A value of 1 or greater is considered normal for this test.
Ankle Brachial.
Are LE or UE more prone to arterial occlusion?
Lower, usually at biforcation.
Are Men or Women more at risk for PVD PAD?
Men, usually at 60-70 years of age. Women are at an increased risk afer menopause.
What percentage of people with cluadication pain have coronary artery disease?
Nearly 50%
What are some risk factors for acute occlusions caused by thrombosis?
Obseity/Sepsis/HypOtension/Low Cardiac Output/Aneurysms.
What is a collateral Arteriole?
A replacement that develops slowly in respones to low oxygen.
What is the pathophysiology of the claudication pain?
It is the build up of lactic and pyruvic acid, with the muscle is forced to work without adequate blood supply.
Define Intermittent claudication and rest pain
-Calves or buttocks
-Sharp cramp or burning sensation
–Does not occur with sitting or standing
Define Paresthesias
Arterioles in muscle steal from cutaneous and peripheral nerves, resulting in coldness and pins and needles sensation
What is Leriche syndrome?
Occlusion of the abdominal aorta by a thrombus at its bifurcation. This causes intermittent ischemic pain (i.e., claudication) in the lower extremities and buttocks, impotence, and absent or diminished femoral pulses.
If you were to see Elevated Hgb, BUN, Cr, Na, lipids and total homocysteine, what might your suspect?
Arteriol/Vascular problems.
How long should one walk to promote PVD PAD Health?
30-45 minutes, or until pain starts. It will promote growth of collaterals.
What are some dietary changes that will support PAD, PVD health?
Low Fat, Cholesterol, Calorie and High Fiber.
What is Pentoxifylline (Trental)
Reduces blood viscosity and increases RBC flexability. This allows for increased duration of exercise.
What is Cilostazol?
A Vasodilator and antiplatelet which increases walking distance.
What is Angioplasty?
Baloon to squish plaque to sides of vessells.
What is Atheroctomy?
Rotor Rooter, ground up the plaque.
What vein is usually used on a Fem-Pop Bypass?
Saphenous Vein.
What is used as a donor vein in a Aortoiliac blockage?
Synthetic Material.
Describe compartment syndrome
Elevation of tissue pressure within a closed fascial compartment, causing a decreased arteriovenous pressure and decreased muscular perfusion.
What happens when synthetic graft becomes infected?
It must be removed.
How might you recognize myoglobinuria?
Rusty brown urine.
What are the Six P's of Acute Arterial Occlusion?
Pain
Pulselessness
Poikilothermic (coldness)
Pallor
Paresthesias
Paralysis
What is a AAA?
Abdominal Aortic Aneurysm.
When does a AAA usually become palpable?
5 CM
Are most AAA's symptomatic? What is the most common symptom?
Most are aysmptomatic.
Most common symptom is awareness of pulsating mass.
Are AAA's painful?
ABD Pain is common. Some have back, groin, or flank pain as well.
Name four classifications of aneurysms.
Saccular
Fusiform
Dissecting
False
What are the charastics of a Saccular aneurysm?
Saccular: unilateral outpouching
What are the charastics of a Fusiform aneurysm?
Fusiform: bilateral outpouching
What are the charastics of a Dissecting aneurysm?
Dissecting: bilateral outpouching in which layers of vessel separate, creating a cavity.
What is an Aortic dissection?
A longitudinal splitting (creation of false lumen) of medial layer of aorta by blood flow. It blocks arterial branches.
What is Marfan's Syndrome?
A hereditary disorder of connective tissue, bones, muscles, ligaments, and skeletal structures. Can result in Aortic Dissection.
What are clinical manifestations of Aortic Dissection?
Abrupt excruciating pain, RIpping, Knife Like that radiates.
Hypertension. Diminished pulses.
What is a TEE?
Transesohageal echocardiogram.
What is Cardiac Tamponade?
Pulses Paradoxus
Muffles Heart Sounds
Narrowed Pulse Pressure.
What common problem is seen with atrial fibrillation and atherosclerosis?
Emoblism.
What bed position might you put a person into to help increase blood flow with arterial problems?
Reverse Trendelenburg.
Splitting of the layers of the aorta is called?
Dissection.
What is DIC?
DIsseminated Intravascular Coagulation.
What is the leading cause of DIC?
Infection.
Name Five Reasons other than infection that can lead to DIC.
Trauma and Burns
Liver Failure
Open Heart Surgery
Obstetirc Complications
Turmos
What is the first phase of DIC?
Microemboli from increaed thrombin, fibrinogen, fibrin clots, and platelet adhesivness.
What is the second phase of DIC?
When clotting factors are all used up, then bleeding begins.
What is D-Dimer?
A by-product of the degradation of blood clots, specifically, of the fibrin within a clot.
What are the two major problems seen in DIC?
Clotting and Bleeding
D-Dimer is a positive findong and shows what?
Fibrin Fragments.
If DIC is detected during the clotting phase, this treatment might be used.
Heparin
What number indicates that platlets are low when assessing lab values for DIC?
<150,000
This is a reproducible pain in calves or buttocks that occurs with activity.
Intermittent claudication
If you see hypertrophied toenails, what might be one explaination?
Arterial Insufficiency.
These ulcers have sharp edges and a pale base.
Arterial ulcer.
Bilateral outpouching of an aneurysm is called.
Fusiform.
What is the Sac around a hemotoma of an aneurysm called?
A Pseudoaneurysm.
What is the name of a drug used to increase walking distance?
Cilostazol.
What is the bed position used to promote arterial circulation?
Reverse Trendelenburg.
Another name for the group of drugs called coenzyme A reductase inhibitors.
Statins
Antiplatelet drug used in arterial problems.
Aspirin
Recommended LDL level to achieve with arterial disease problems.
Less than 100.
Area of rupture with the best prognosis in AAA
Retroperitoneal
When is surgery performed on a AAA
Asymptomatic aneurysm 4-5 cm or greater
What might decreased aortic flow, emboli, decreased cardiac output, inadequate hydration, and clamp time cause?
Renal failure in a AAA surgery patient.
What complication might AAA cause to the spinal cord?
Paraplegia or Hemiplegia.
If the client experiences Cardiac complication, they may require this surgical procedure before repair of the AAA.
Coronary artery bypass?
Monitor this test to assess the nutritional status of a patient with an arterial problem
Albumin
Monitor this test after angiography.
Creatinine
Frequency for checking the distal pulses after arterial surgery for the first 24 hours
Every hour.
How long should client be in Acute Pain /p AAA surgery?
48-72 Hours
Name the Six P's of Arterial Occlusion
Pulselesness
Pain
Palor
Poikilothermia
Parasthesia
Paralysis.
What is DKA?
Diabetic Keto Acidosis.
What is HHNKS?
Hyperglycemic Hyperosmolor Non Ketotic Syndrome.
What are Risk Factors for DKA?
Infection or Stress
Missed Insulin Dose
New Onset Diabetes
Insulin Resistance
In HHNKS what is the Serum Ketone level?
Normal or slightly elevated.
Which has greater hyperglycemia DKA or HHNKS?
HHNKL which can reach 2000.
A common fluid problem in both DKA and HHNKS is
Hypovolemic Shock.
In DKA and HHNKS, this will help decrease Potassium Levels.
Insulin.
What causes Fruity Breath in DKA?
Ketosis.
Which of the following is characteristic of an arterial ulcer?
A. Have irregular edges.
B. Located at medial or lateral metatarsal heads.<<<
C. Are not painful.
D. Have a red base.
Initial IV fluids for a patient with diabetic ketoacidosis include:
A. D5 0.45 NaCl
B. D5 0.9 NaCl
C. 0.45 NaCl
D. 0.9 NaCl <<<
Mortality is higher with HHNS than DKA because of:
A. Hyperglycemia
B. Metabolic acidosis
C. Older patient age<<<
D. Kussmaul respirations
Although treatment is similar in HHNS to that of DKA, one important fact is:
A. Fluid is given cautiously to avoid fluid overload in HHNS.<<<
B. More insulin is given in HHNS.
C. Less total fluids are given in HHNS.
D. Sodium bicarbonate is usually given in HHNS.
A patient with a history of hypertension and coronary artery disease is complaining of a sudden onset of severe, excruciating, abdominal and back pain. Vital signs include BP 100/70, HR 100. Assessment might also include:
A. Pulsating abdominal mass<<<
B. Chest pain
C. Guiac positive stool
D. Severe hyperglycemia
Arterial circulation is enhanced in a patient with arterial disease by:
A. Washing her feet with hot water.
B. Allowing for long periods of knee flexion.
C. Allowing for legs to be slightly dependent when sitting.<<<
D. Putting sheepskin over the legs.
A complication after an abdominal aortic aneurysm resection that is fairly rare is:
A. Myocardial infarction
B. Ulcerative colitis
C. Paraplegia<<<
D. Renal failure
A client with disseminated intravascular coagulation would exhibit which assessment?
Increased fibrinogen
A. Decreased fibrin spit B. products
C. Increased d-dimer screen<<<
D. Decreased prothrombin timE
A treatment used in disseminated intravascular coagulation that may be used in the coagulation phase is:
A. Cryoprecipitate
B. Fresh frozen plasma
C. Platelets
D. Heparin<<<
Typical assessment seen in a pulmonary embolism is:
A. Bradycardia
B. Chest pain unaffected by respiration
C. Negative ventilation perfusion scan
D. Virchow’s triad <<<
Treatment of pulmonary embolism includes:
A. Administration of warfarin to keep the INR at 3<<<
B. Administration of heparin to keep the aPTT above 110.
C. An embolectomy catheter inserted through the femoral artery.
D. Insertion of a Greenfield filter into the pulmonary artery.
Bleeding occurs spontaneously when the platelets are below:
A. 150,000
B. 100,000
C. 50,000
D. 20,000<<<
A patient weighing 187 pounds has an order for a heparin bolus of 80 units/kg and a drip at 14 u/kg/hour. The heparin infusion strength is 25,000 units heparin in 250 ml D5W. The heparin infusion rate in ml per hour is:
A. 12<<<
B. 26
C. 68
D. 119
Femoral artery occlusion leads to claudication oF:
A. gluteal areas
B. thigh areas
C. calf areas<<<
D. popliteal areas
Assessment of compartment syndrome in the leg includes:
A. yellow urine
B. normal sensation
C. typical surgical site pain
D. pain with muscle stretching<<<
With a high potassium level, the EKG will show which of the following?
A. No change will be noted.
B. The QRS wave will be inverted.
C. The PR interval will increase.
D. The T wave will be tall.<<<
Mrs. H., who is admitted to the hospital for treatment of atrial fibrillation but has just converted to NSR, complains of dyspnea and chest pain. Which of the following would the nurse suspect is occurring?
A. heart block
B. myocardial infarction
C. pulmonary edema
D. pulmonary emboli<<<
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