What is the most common cause of an AAA (abdominal aortic aneurysm)
AAA is more common among?
*Caucasians *men (4x more so than women) *elderly
After an aneurysm develops, it tends to ______?
Risk factors of AAA?
*genetic predisposition *tobacco use *hypertension
More than half of patients with aneurysms have ______?
A ______ may be heard of the mass.
Most AAA's occur in patients between ___ and ____ years of age.
60 and 90
The aneurysm is not repaired until is is at least _____ (2 inches) wide.
_____ is the treatment of choice for AAA's more than 5.5 cm wide or those that are enlarging.
Potential complications with surgery of AAA's?
bleeding, hematoma, wound infection (at arterial insertion site), distal ischemia/embolization, dissection or perforation of the aorta, graft thrombosis/infection, graft migration, proximal or distal graft leaks, delayed rupture, or bowel ischemia
Nursing assessment of a pt with an AAA (before surgery) is guided by
anticipating a rupture recognizing that the pt may have cardiovascular, cerebral, pulmonary, and renal impairment from atherosclerosis
Arterial dissections (separations) are commonly associated with???
poorly controlled HTN blunt chest trauma cocaine use
Why is cocaine use associated with arterial dissections?
profound increase in sympathetic response caused by cocaine use creates an increase in the force of left ventricular contraction that causes heightened shear forces upon the aortic wall
microbial infection of the endothelial surface of the heart
Why is infective endocarditis more common in older people?
they are more likely to have: * degenerative or calcific valve lesions *reduced immunologic response to infection *metabolic alterations associated with aging
Also common among?
IV injection drug users
When is hospital-acquired infective endocarditis most likely to occur?
*pt with debilitating disease *indwelling catheters *pt who receive hemodialysis/prolonged IV fluid or antibiotic therapy *pt taking immunosuppressive medications
Incidences of infective endocarditis increase can be attributed to what?
*increase of IV injection drub abuse *body piercing (oral, nasal, and nipple)
Risk factors for infective endocarditis?
*prosthetic material used for valve repair *hx of bacterial endocarditis *congenital heart disease *cardiac transplant recipients with valvulopathy
Primary presenting symptoms of I.E. (infective endocarditis)?
*Fever and heart murmur *clusters of petechiae *small painful nodules (pads of fingers or toes) *splinter hemorrhages (fingernails/toenails)
(vague complaints of malaise, weight loss, and back/joint pain may be confuse with the flu)
Assessment of patients with I.E.
*three sets of blood cultures drawn of a 24 hours period should be obtained before administration of any antimicrobial agents *pt may have elevated WBC count *pt may be anemic and have positive RH factor
Prevention of I.E.
*antibiotic prophylaxis is recommended in high-risk pt immediately before and and after these procedures (dental work, tonsillectomy, surgery involving respiratory mucosa, cytoscopy, bronchoscopy, surgery with infected skin)
What antibiotic should be used in prevention of IE?
2g of amoxicillin orally 1 hr before procedure
Prevention of I.E. (continued)
nurses must ensure meticulous HAND HYGIENE, site prep, and aseptic technique during insertion and maintenance procedures.
(catheters, tubes, drains, and other devices are removed ASAP when they are no longer needed)
Medical management of IE?
antibiotic therapy is administered parenterally in a continuous IV infusion for 2-6 weeks surgical therapy includes valve debridement/excision, debridement of vegetations, and debridement and closure of an abscess, and closure of a fistula
an inflammatory process involving the myocardium
*results from viral or spirochetal infection (such as rheumatic fever) *may develop in pt receiving immunosuppressive therapy, those with IE, Crohn's disease, or systemic lupus erythematosus
The greater the destruction the greater the _____ and ____ with myocarditis.
signs and symptoms
Clinical manifestations of myocarditis
*some pt may be asymptomatic (infection will resolve on its own) *fatigue, dyspnea, palpitations, and occasional discomfort in the chest and upper abdomen *the most common symptoms are flu-like
Getting the flu and hepatitis vaccines can help
Medical treatment of myocarditis
*treat underlying cause if known *bed rest to decrease cardiac workload *with young pt, no athletics for at least 6 months
an inflammation of the pericardium (membranous sac enveloping the heart)
*may be a primary illness or may develop during various medical or surgical disorders
Clinical manifestations of pericarditis
*may be asymptomatic *most common symptoms is chest pain *pain may worsen with deep inspiration and when lying down/turning (may be relieved with leaning forward or sitting) *upon auscultation, hear creaky or scratchy friction rub on LL sternal border
Clinical manifestations (continued)
*mild fever *increased WBC count *anemia *elevated ESR and C-reactive protein level *non-productive cough or dyspnea
Assessment of pt with pericarditis
*dx is made on basis of hx, signs, & symptoms *an echo detects inflammation, pericardial effusion/tamponade, & HF *CT best diagnostic tool for determining size, shape, & location of pericardial effusion *MRI detect inflammation/adhesion
Medical management of pericarditis
analgesics and non-steroidal anti-inflammatory drugs ( aspirin/ibuprofen) for pain relief *Pericardiocentesis- a procedure where some of the pericardial fluid is removed (performed to assist in the identification of cause or relieve symptoms)
Nurse's role in pericarditis management
pain management, position, and psychological support *pt with chest pain often benefit from education and reassurance that the pain is not due to a heart attack *nurse encourages gradual increases of activity
Nursing diagnosis with pericarditis?
pain related to inflammation of the pericardium
What causes leg ulcers?
inadequate exchange of O2 and other nutrients in the tissue
Clinical manifestations with leg ulcers?
determined by the cause of the ulcer *most ulcers (especially in elderly) have more than one cause *two types of ulcers: arterial or venous
*characterized by intermittent claudication (pain cause by activity and relieved after a few minutes of rest) *small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes *may result in gangrene (usually caused by trauma)
Arterial ulcers (continued)
*managing dry gangrene is preferable to debriding the toe (which would cause an open wound that wont heal)
*characterized by pain described as aching/heavy *foot and ankle may be edematous *ulcerations are in the area of the medial/lateral malleolus *large, superficial, highly exudative
Medical management of ulcers
*antibiotic therapy (when ulcer is infected) *adequate compression therapy involves the application of external/counter pressure to the lower extremity to facilitate venous return to the heart
Medical management of ulcers (cont.)
*debridement (promotes healing; wound is kept clean of drainage and necrotic tissue) *wet to dry dressings (removes necrotic tissue) *hyperbaric oxygenation *promote adequate nutrition (diet high in protein, vitamins C/A, iron, and zinc promotes healing)
anything lasting longer than 3 months
*doesn't result in sudden death
Preventable chronic illness
*obesity *COPD *Emphysema *Diabetes
Who knows their body best?
Most of the pt we deal with are on _____ grade leve
don't assume they are literate
When is the right time to start discharge planning?
when the pt is admitted
what are the categories of disabilities?
developmental, acquired, and age-related
What is the leading cause of death?
What is the best lab value to determine nutritional level?
pre-albumin and normal level is 3.5-5.0
Coronary Artery Disease (CAD)
most prevalent type of cardiovascular disease in adults
*most common cause of CAD is atherosclerosis
abnormal accumulation of lipid, or fatty substance, and fibrous tissue in the lining of the arterial blood vessel walls
Complications with atherosclerosis
*injures the vascular endothelium *causes narrowing of the lumen *plaque may rupture and lead to thrombus formation (obstructs blood flow)
With CAD, if atherosclerosis worsens it can lead to?
*acute coronary syndrome which can lead to the point of an MI
(acute coronary syndrome is characterized by acute onset of MI and can lead to death: ACS includes unstable angina and MI)
Myocardial infarction (MI)
an area of the myocardium that is permanently destroyed, plaque ruptures and thrombus formation results in complete occlusion of the coronary artery
episodes of chest pain or pressure in the anterior chest ( need for O2 exceeds the supply) caused by periods of ischemia
*usually caused by atherosclerotic disease *some pt may be asymptomatic *some pt may present dyspneic, weak, or nauseated
measure of inflammation-marker for cardiovascular risk (used with other tests such as cholesterol levels)
total cholesterol should be < 200 mg/dL triglycerides should be < 150 mg/dL LDL should be < 100 mg/dL (< 70 for high risk pt) HDL should be > 60 mg/dL
Dietary recommendations for CAD pt
diet: 25% fat, 50% carb, 15% protein
*fats that are solid at room temp should be avoided
regular exercise 30 mins of moderate most days *set realistic goals *warm up/cool down 5 min *should be able to have convo while exercising *stop activity if chest pain, SOB, or dizziness occurs
is prescribed to take at night because our cholesterol is made in the liver at night
*can't drink grapefruit juice while on these medicines
Pt with CAD should consider
smoking cessation HTN management controlling DM (HgA1c should be < 7%)
clinical syndrome usually characterized by episodes of pain/pressure in the anterior chest *caused by inadequate O2
predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitro
symptoms increase in frequency and severity; may not be relieved with rest and nitro
factors of angina pectoris
*can be precipitated by physical exertion *ingestion of a heavy meal *exposure to cold *stress
clinical manifestations of angina pectoris
*feels like indigestion *chest pressure/pain (may radiate) *dyspneic *nauseated
(pt with DM may not have typical pain)
Treatment of angina
stable angina subsides with rest and administration of nitroglycerin
*unstable angina needs medical intervention
Assessment/diagnostics of angina
*begin with hx r/t ischemia *12 lead EKG *lab tests (CRP(marker of inflammation), myoglobin, troponin, cardiac enzymes) *Stress testing *Cardiac cath
(troponin's I and T are specific cardiac markers)
pt walks on treadmill, pedals a stationary bicycle or uses an arm crank nursing instructions: NPO for 4 hrs prior to testing (avoid nicotine or caffeine), comfortable rubber soled shoes/loose clothing, monitor after test
myocardium is permanently destroyed *may be due to plaque rupture myocardium is deprived of O2 develops of minutes to hours
Assessment for pt with MI
key questions: where is the pain (radiate?), describe, similar pain in past, when did it begin, how long does it last, what brought it on, what helps, any other symptoms
Medical management of MI
*sit and rest *any change in symptoms may indicate worsening *adm nitro x 3 doses for unrelieved pain *O2 @ 2 L/min *address anxiety *prevent complications
Clinical presentation of pt with MI
*may report no previous symptoms *s/s may be like those of unstable angina (chest pain unrelieved with rest and nitro) *may be diaphoretic, nauseated, dyspneic, and anxious
Diagnostics for MI
ECG: T wave inversion; ST segment elevation Echo: looks at funtioning of heart, ventricular functioning, ejection fraction Lab test (CK isoenzymes, myoglobin, troponin)
Management of pt with MI
*goal is to minimize damage and preserve myocardial function and prevent complications *morphine: reduces preload/afterload *analgesic: reduces anxiety, relaxes bronchioles *monitor BP and resp. rate because they can lower
Management of pt with MI (cont)
*thrombolytics (window for therapy 6 hr): dissolve blood clots *stent placement may be necessary to hold the artery open
Phase 1: while hospitalized Phase 2: supervised outpatient program (monitored exercise; individualized) Phase 3: pt is self-directed - long term outpatient program (focuses on maintaining CV stability)
Nursing considerations for pt with MI
diagnoses: ineffective cardiac tissue perfusion r/t decreased coronary blood flow, knowledge deficit, death anxiety, risk for impaired gas exchange
systolic BP of > 140 and diastolic BP of > 90 *based on the avg of 2 or more accurate BP measurements taken during 2 or more contacts with physician
hx and physical exam (retinas, UA, blood chemistry, lipid panel, 12 lead ECG) *echo
Management of HTN
*goal is to lower pressure to 130/80 for pt with DM *diet: more grains, veggies, fruits, and low-fat dairy with less meat, nuts, and beans
Heart failure (HF)
the inability of the heart to pump sufficient blood to meet the needs of the tissues for O2 and nutrients
Chronic Heart Failure (CHF)
characterized by fluid overload and inadequate tissue perfusion *inability of the heart to contract or fill effectively *may be reversible but is usually progressive
Assessment of cardiac hemodynamics
noninvasive method *look, feel, listen invasive method *stress test and echo
Assessment of pt with HF
*peripheral pulse *BP *auscultate (heart and lung sounds) *look for JVD (BIG JUGS :) *may hear S3 *crackles are indicative of HF
Pt presentation with HF
*edema (pt. looks swollen in dependent areas of body) *SOB @ rest *urine output (decreased?) *sleep sitting up or with a bunch of pillows *AMS (altered mental status) *dizzy *fatigue
weakened heart muscle is the cause
caused by stiff and non compliant heart muscle
Patho of HF
*decreased blood volume *sympathetic nervous system release of epi or nor-epi *kidneys release renin (formation of angiotensin 1 to 2) *aldosterone is released from the adrenal cortex *stimulation of ADH
the metabolism of the body
Diagnostics on pt with HF
*echo *chest x-ray (see enlargement) *ECG (see blockages) *Basic metabolic panel (electrolytes, K & NA) *TSH *CBC (hmg & hmt) *BNP (DIAGNOSTIC FOR DIAGNOSIS OF HF) *UA (protein in the urine, specific gravity) *stress test