Chapter 38 Exam 2
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| Arteriosclerosis | a thickening, or hardening, of the arterial wall that is often associated with aging.
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| Atherosclerosis | a type of arteriosclerosis, involves the formation of plaque within the arterial wall and is the leading risk factor for cardiovascular disease
--Affects larger arteries
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| Atherosclerosis risk factors | Low HDL-C
• High LDL-C
• Increased triglycerides
• Genetic predisposition
• Diabetes mellitus
• Obesity
• Sedentary lifestyle
• Smoking
• Stress
• African-American or Hispanic ethnicity
• Older adult
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| Patho of Atherosclerosis | unknown
thought to occur from blood vessel damage that causes an inflammatory response
fatty streak formed, then becomes fibrous plaque
unstable plaque can rupture
rate of formation increased with lifestyle habits, diabetes, and or genes.
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| Stable vs unstable plaque rupture | stable causes inadequate perfusion
unstable causes a rapid thrombus formation due to platelet adhesion at exposed underlying tissue
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| Endothelial damage | high hdl is good -- damage caused by high ldl
low ldl is good -- damage caused by low hdl
toxins from renal system failure
CO from smoking
weakened vessels from aging
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| Young adults | have some small plaque
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| CVD affected population | affects 16 millions, half of which are older 60
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| ASSESSMENT IN PATIENTS WITH ARTHEROSCLEROSIS | palpate pulses
ASSESS BOTH ARMS
feel for temperature in periphery
check for capillary refill (unreliable)
>5 for old
>3 for young
extremity may be cool or cold with absent or diminished pulse.
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| Bruit | -- found in larger arteries and heard with stethoscope
-- a turbulent, swishing sound, which can be soft or loud in pitch.
-- caused by blood moving through small artery
--often occur in the carotid, aortic, femoral, and popliteal arteries.
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| Total serum cholesterol levels | bellow 200 MG/DL is good
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| Total serum LDL LEVELS | bellow 100 MG/DL is good
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| total HDL levels | greater than 40 MG/DL is good
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| Triglycerides | A level higher than 150 mg/dL is bad
135 or higher is bad for women
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| SCREENING FOR ATHEROSCLEROSIS | those older than 20 should get a cholesterol check
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| High risk category | termed “coronary heart disease equivalents.”
• Patients with diabetes but no sign
• Patients with a Framingham Heart Study 10-year absolute risk score of over 20% for coronary heart disease events
• Patients with risk factors
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| fat intake | less than 30% of total calories
up to 10% of total calories should be from polyunsaturated fat, and 10% to 15% should come from monounsaturated fat.
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| Cholesterol intake | intake should also be less than 300 mg daily.
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| Recommended oils | Recommend canola (rapeseed) oil (rich in monounsaturated fat) and safflower and sunflower oil (rich in polyunsaturated oils) over highly saturated oils such as palm or coconut oil.
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| Cholesterol management | increase fiber of 25 to 35g
ldl needs to be lower than 100.
above 130-159, follow a fat-modified diet and regular exercise regimen and increase omega-3 fatty acids in their diet or as a supplement.
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| NCEP–TLC | limits saturated fat to less than 7% of total calories and cholesterol to less than 200 mg/day.
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| Drugs for cholesterol level not responding to lifestyle changes | All the drugs ending in "statin" as well as:
• Gemfibrozil (Lopid)
• Fenofibrate (Tricor)
• Ezetimibe (Zetia)
• Omega-3 ethyl esters (Lovaza)
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| Statins | reduce cholesterol synthesis in the liver and increase clearance of LDL-C from the blood.
discontinued there is muscle cramping or elevated liver enzyme levels.
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| Vytorin ( combination ) | his drug works two ways—by reducing the absorption of cholesterol and by decreasing the amount of cholesterol synthesis in the liver
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| ezetimibe | inhibits the absorption of cholesterol through the small intestine.
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| Nicotinic acid or niacin | decrease LDL-C and VLDL
increase HDL-C
patients experience flushing and a very warm feeling all over.
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| Hypertension definition | systolic blood pressure at or above 140 mm Hg and/or a diastolic blood pressure at or above 90 mm Hg in people who do not have diabetes mellitus.
with diabetes: 130/90.
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| systemic arterial pressure | product of cardiac output (CO) and total peripheral vascular resistance (PVR)
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| maintenance of systemic arterial pressure | maintained by the autonomic nervous system and circulating hormones, such as norepinephrine and epinephrine.
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| Four control systems play a major role in maintaining blood pressure: | • The arterial baroreceptor system
• Regulation of body fluid volume
• The renin-angiotensin/aldosterone system
• Vascular autoregulation.
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| BP elevation signs | headaches, facial flushing (redness), dizziness, or fainting as a result of the elevated blood pressure
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| forearm BP is valid. True or false: | True. especially for obese patients.
Wrist BP can also be used.
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| Orthostatic Hypotension | BP reading while sitting or lying
BP reading standing 2 min later
drop of 20mmhg systolic and or 10mmhg diastolic
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| Funduscopic examination of the eyes | indicates severity and prognosis of hypertension.
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| Tachycardia, sweating, and pallor | pallor may suggest a pheochromocytoma
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| Coarctation of the aorta | evidenced by elevation of blood pressure in the arms, with normal or low blood pressure in the lower extremities. Femoral pulses are also delayed or absent.
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| creatinine clearance test normal | 107 to 139 mL/min for men and 87 to 107 mL/min for women
decreased level indicate kidney disease
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| presence of catecholamines | patients with a pheochromocytoma are positive for it. --indicative of hypertension
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| elevation in levels of serum corticoids and 17-ketosteroids in the urine | diagnostic of Cushing's disease.
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| X-ray | Routine chest radiography may help recognize cardiomegaly (heart enlargement).
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| ECG | Left atrial and ventricular hypertrophy is the first ECG sign of heart disease resulting from hypertension.
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| Garlic | can low BP
can also affect liver and cause bleeding
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| hypokalemia signs | assess for irregular pulse and muscle weakness
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| CCBs | most effect AA
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| ACE and ARBs | Not effective in treating HTN in AA
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| Diebetes patients taking betablocker | hypoglycemia signs not seen
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| Beta blockers side effects | excessive fatigue, cough, or sexual dysfunction.
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| ambulatory blood pressure monitoring (ABPM) device | device that measures and record BP every 15 to 30 minutes
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| Peripheral vascular disease (PVD) | disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation.
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| LEAD | lower extremity arterial disease
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| Inflow vs. Outflow obstructions damage level: | Inflow obstructions cause less damage than outflow obstructions
Inflow obstructions involve the distal end of the aorta and the ---*common, internal, and external iliac arteries.
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| PAD (peripheral arterial disease) | result of systemic artherosclerosis
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| Stage 1 of PAD | Asymptomatic, bruit may be present, decrease or absent pulse
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| Stage 2 of PAD :Claudication | •Muscle pain, cramping, or burning occurs with exercise and is relieved with rest.
•Symptoms are reproducible with exercise.
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| Stage III: Rest Pain | •Pain while resting
•Pain is numbness, burning, toothache-type pain.
•Pain usually occurs in the distal portion(toes, arch, forefoot, or heel), rarely in the calf or the ankle.
•Pain is relieved by placing the extremity in a dependent position.
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| Stage IV: Necrosis/Gangrene | •Ulcers and blackened tissue occur on the toes, the forefoot, and the heel.
•Distinctive gangrenous odor is present.
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| PAD stages summary | stage 1: no symptoms, some bruit
stage 2: pain in legs with exercise (walking a certain distance)
stage 3: pain at rest
stage 4: ulcer on toes
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| Patient with inflow disease | -- have discomfort in the lower back, buttocks, or thighs.
mild inflow: pain after walking two blocks
moderate inflow: pain after walking one or two blocks
severe inflow: less than a block walking causes pain.
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| Patients with outflow disease | mild: can walk 5 blocks
moderate: can walk 2 blocks
severe: 1/2 block
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| PAD diagnoses | use of doppler probe to get BP (thigh and calves pulse higher than brachial pulse is good)
30mmhg less is mild inflow
40-50 mmhg less in severe inflow
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| ankle-brachial index (ABI) (used for outflow diagnoses) | An ABI of less than 0.9 in either leg is diagnostic of PAD.
Patients with diabetes are known to have a falsely elevated ABI.
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| Exercise tolerance testing | there is a decrease in the ankle pressure of 40 to 60 mm Hg for 20 to 30 seconds in the affected limb. If the return to normal pressure is delayed (longer than 10 minutes), the results suggest abnormal arterial flow in the affected limb.
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| acute arterial insufficiency signs (6 Ps) | • Pain
• Pallor
• Pulselessness
• Paresthesia
• Paralysis
• Poikilothermy (coolness)
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| acute arterial occlusion | clot in the arteries
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| treatment of acute arterial occlusion | anticoagulant therapy
thrombectomy or embolectomy
watch for spasms or swelling of muscles after surgery
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| local treatment of occlusions | Local intra-arterial thrombolytic therapy with alteplase (Activase) or t-PA and the use of platelet inhibitors, such as abciximab (ReoPro), have emerged as alternatives to surgical treatment in selected settings.
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| nursing responsibilities if thrombolytics or platelets are given | assess for signs of bleeding, bruising, or hematoma
monitor platelet counts for the first 3, 6, and 12 hours after the start of the infusion
if below 100,000/mm3, the abciximab infusion reajusted or stopped
can rapid response for any of the above
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| aneurysm | permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter
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| fusiform vs saccular | (a diffuse dilation affecting the entire circumference of the artery)
(an outpouching affecting only a distinct portion of the artery)
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| true vs. false aneurysm | true aneurysm is the result of vessel weakening, while false aneurysm is caused by trauma or injury to the tissue
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| where do you get aneurysm | mostly in the abdominal aorta, and vessels not supported by skeletal muscle or on the lines of curves or flexion in the arterial tree.
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| some causes of abdominal aorta aneurysm: | Syphilis (a sexually transmitted disease), Marfan syndrome (a connective tissue disease), and Ehlers-Danlos syndrome (a rare genetic disorder) are other causes of AAAs.
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| assessment postop aneurym of urinary output below 50 ml/hr requires what intervention: | immediately notify the surgeon
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| Buerger's Disease | uncommon occlusive disease of the arteries and veins in the distal portion of the upper and lower extremities.
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| Raynaud's phenomenon | caused by vasospasm of the arterioles and arteries of the upper and lower extremities, usually unilaterally. Raynaud's disease occurs bilaterally.
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| Drugs to avoid when on warfarin | • Allopurinol
• NSAIDs
• Acetaminophen
• Vitamin E
• Histamine blockers
• Cholesterol-reducing drugs
• Antibiotics
• Oral contraceptives
• Antidepressants
• Thyroid drugs
• Herbs, such as St. John's wort, garlic, ginseng, Gin
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