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U world cardiac and leadership 1

Assessment for PAD includes :-

HEART: decreased peripheral

pulses

DERM: cool shiny skin, hair loss,

ulcers, gangrene, impaired

sensation

MISC.: intermittent claudication

S: shiney skin

H: hair loss to the extremity

I: intermittent claudication

N: nasty ulcers

E: extremities will be cool

Causes of PAD includes Causes:

❖ Arteriosclerosis

❖ Raynauds

❖ Buerger’s

❖ Smoking

❖ Diabetes

❖ Hyperlipidemia

❖ Hypertension

❖ Obesity

❖ Sedentary lifestyle

❖ Age

Nursing interventions for PAD includes :-

❖ Check extremities for

paleness, coolness or

necrosis

❖ Meticulous foot care: warm

water, gently dry

thoroughly, use lubricants,

wear clean cotton socks

❖ Do not cross legs

❖ Regular exercise

❖ No smoking

❖ Weight loss

Nursing Teaching for PAD includes:-

❖ Educate the client to

maintain aseptic technique.

❖ Instruct the client on how

to administer IV antibiotics.

❖ Have the client record

temp daily for six weeks.

❖ Encourage oral hygeine for

six weeks with a soft bristle

toothbrush 2x daily.

❖ Have the client clean any

skin lacerations and apply

antibiotic ointment.

❖ Client should inform all

HCP’s of hx of

endocarditis.

❖ Client should use

prophylactic antibiotics for

oral procedures.

❖ Tech the client the signs

and symptoms of emboli

and HF.

Medical treatment for PAD includes:-

❖ Arterial bypass with

autogenous vein or

synthetic graft.

❖ Endarterectomy.

❖ Patch graft angioplasty.

❖ Amputation.

A patient is being discharged following insertion of a permanent pacemaker. The nurse determines that the patient requires further instruction on safety precaution after the following statement:

Overview

A new pacemaker requires limitation of physical activity, including no lifting, pulling, or pushing more than 5 pounds, so the patient will need to be educated further if they speak of lifting something greater than 5 pounds.

Learning Outcomes

A new pacemaker requires limitation of physical activity, including no lifting, pulling, or pushing more than 5 pounds. Other limitations include limiting tasks like sweeping in repetitive motions, keeping the area free from pressure (such as tight clothing or suspenders), and not raising the arm on the affected side above the level of the heart for the first few weeks. The pacemaker insertion site may be bruised, swollen, tender, and instructions may include gentle washing of incision site, and not applying lotion or powder.

Heparin

64. A client with atrial fibrillation who is receiving maintenance therapy of

warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of

these laboratory values, the nurse anticipates which prescription?

1. Adding a dose of heparin sodium

2. Holding the next dose of warfarin

3. Increasing the next dose of warfarin

4. Administering the next dose of warfarin

64. Answer: 2

Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI

units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because

the value of 35 seconds is high, the nurse should anticipate that the client would not

receive further doses at this time. Therefore, the prescriptions noted in the remaining

options are incorrect

68. A client is receiving a continuous intravenous infusion of heparin sodium to

treat deep vein thrombosis. The client’s activated partial thromboplastin time

(aPTT) is 65 seconds. The nurse anticipates that which action is needed?

1. Discontinuing the heparin infusion

2. Increasing the rate of the heparin infusion

3. Decreasing the rate of the heparin infusion

4. Leaving the rate of the heparin infusion as is

68. Answer: 4

Rationale: The normal aPTT varies between 30 and 40 seconds (30 and 40

seconds), depending on the type of activator used in testing. The therapeutic dose of

heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 (45 to

60) and 2.5 (75 to 100) times normal. This means that the client’s value should not be

less than 45 seconds or greater than 100 seconds. Thus, the client’s aPTT is within the

therapeutic range and the dose should remain unchanged.

Test-Taking Strategy: Focus on the subject, the expected aPTT for a client

receiving a heparin sodium infusion. Remember that the normal range is 30 to 40

seconds and that the aPTT should be between 1.5 and 2.5 times normal when the

client is receiving heparin therapy. Simple multiplication of 1.5 and 2.5 by 30 and 40

will yield a range of 45 to 100 seconds. This client’s value is 65 seconds.

Activated partial thromboplastin time (aPTT)

1. The aPTT evaluates how well the coagulation

sequence (intrinsic clotting system) is functioning by

measuring the amount of time it takes in seconds for

recalcified citrated plasma to clot after partial

thromboplastin is added to it.

2. The test screens for deficiencies and inhibitors of all

factors, except factors VII and XIII.

3. Usually, the aPTT is used to monitor the

effectiveness of heparin therapy and screen for

4. Normal reference interval: 30 to 40 seconds

(conventional and SI units [International System of

Units]), depending on the type of activator used.

5. If the client is receiving intermittent heparin therapy,

draw the blood sample 1 hour before the next

scheduled dose.

6. Do not draw samples from an arm into which heparin

is infusing.

7. Transport specimen to the laboratory immediately.

8. Provide direct pressure to the venipuncture site for 3

to 5 minutes.

9. The aPTT should be between 1.5 and 2.5 times normal

when the client is receiving heparin therapy.

10. Elevated values occur in the following: Deficiency of

one or more of the following: factor I, II, V, or VIII;

factors IX and X; factor XI; and factor XII; hemophilia;

heparin therapy; liver disease

If the aPTT value is prolonged (longer than 100 seconds or per

agency policy) in a client receiving IV heparin therapy or in any client at

risk for thrombocytopenia, initiate bleeding precautions.

E. Prothrombin time (PT) and international normalized ratio (INR)

1. Prothrombin is a vitamin K–dependent glycoprotein

produced by the liver that is necessary for fibrin clot

formation.

2. Each laboratory establishes a normal or control value

based on the method used to perform the PT test.

3. The PT measures the amount of time it takes in

seconds for clot formation and is used to monitor

response to warfarin sodium therapy or to screen for

dysfunction of the extrinsic clotting system resulting

from liver disease, vitamin K deficiency, or

disseminated intravascular coagulation.

4. A PT value within 2 seconds (plus or minus) of the

control is considered normal.

5. The INR is a frequently used test to measure the

effects of some anticoagulants.

6. The INR standardizes the PT ratio and is calculated in

the laboratory setting by raising the observed PT ratio

to the power of the international sensitivity index

specific to the thromboplastin reagent used.

7. If a PT is prescribed, baseline specimen should be

drawn before anticoagulation therapy is started; note

the time of collection on the laboratory form.

8. Provide direct pressure to the venipuncture site for 3

to 5 minutes.

9. Concurrent warfarin therapy with heparin therapy can

lengthen the PT for up to 5 hours after dosing.

10. Diets high in green leafy vegetables can

increase the absorption of vitamin K, which shortens

the PT.

11. Orally administered anticoagulation therapy

usually maintains the PT at 1.5 to 2 times the

laboratory control value.

12. Normal reference intervals

a. PT: 11 to 12.5 seconds (conventional

and SI units)

b. INR: 0.81 to 1.20 (conventional and SI

units)

13. For both the PT and INR, elevated values occur in the

following: deficiency of one or more of the following:

factor I, II, V, VII, or X; liver disease; vitamin K

deficiency; warfarin therapy

If the PT value is longer than 25 seconds and the INR is

greater than 3.0 in a client receiving standard warfarin therapy (or per

agency policy), initiate bleeding precautions.

Thiazide diuretics (Box 53-7)

1. Description

a. Thiazide diuretics increase sodium and

water excretion by inhibiting sodium

reabsorption in the distal tubule of the

kidney.

b. Used for hypertension and peripheral

edema

c. Not effective for immediate diuresis

d. Used in clients with normal renal

function (contraindicated in clients

with renal failure)

e. Thiazide diuretics should be used with

caution in the client taking lithium,

because lithium toxicity can occur, and

in the client taking digoxin,

corticosteroids, or hypoglycemic

medications.

2. Side and adverse effects

a. Hypercalcemia, hyperglycemia,

hyperuricemia

b. Hypokalemia, hyponatremia

c. Hypovolemia

d. Hypotension

e. Rashes

f. Photosensitivity

g. Dehydration

3. Interventions

a. Monitor vital signs.

b. Monitor weight.

c. Monitor urine output.

d. Monitor electrolytes, glucose, calcium,

blood urea nitrogen (BUN), creatinine,

and uric acid levels.

e. Check peripheral extremities for edema.

f. Monitor for signs of digoxin or lithium

toxicity if the client is taking these

medications.

g. Instruct the client to take the

medication in the morning to avoid

nocturia and sleep interruption.

h. Instruct the client in how to record the

BP.

i. Instruct the client to eat foods high in

potassium.

j. Instruct the client in how to take

potassium supplements if prescribed.

k. Instruct the client to take medication

with food to avoid gastrointestinal

upset.

l. Instruct the client to change positions

slowly to prevent orthostatic

hypotension.

m. Instruct the client to use sunscreen

when in direct sunlight because of

increased photosensitivity.

n. Instruct the client with diabetes

mellitus to have the blood glucose

level checked periodically.

c. Hypovolemia

d. Hypotension

e. Rashes

f. Photosensitivity

g. Dehydration

3. Interventions

a. Monitor vital signs.

b. Monitor weight.

c. Monitor urine output.

d. Monitor electrolytes, glucose, calcium,

blood urea nitrogen (BUN), creatinine,

and uric acid levels.

e. Check peripheral extremities for edema.

f. Monitor for signs of digoxin or lithium

toxicity if the client is taking these

medications.

g. Instruct the client to take the

medication in the morning to avoid

nocturia and sleep interruption.

h. Instruct the client in how to record the

BP.

i. Instruct the client to eat foods high in

potassium.

j. Instruct the client in how to take

potassium supplements if prescribed.

k. Instruct the client to take medication

with food to avoid gastrointestinal

upset.

l. Instruct the client to change positions

slowly to prevent orthostatic

hypotension.

m. Instruct the client to use sunscreen

when in direct sunlight because of

increased photosensitivity.

n. Instruct the client with diabetes

mellitus to have the blood glucose

level checked periodically.

Cardiac Arrhythmias:

 Normal sinus rhythm- Peaks of p waves are evenly spaced

 V-fib- Chaotic squiggly line. No pattern

 V-tach- Sharp peak & jags. There's a pattern

 Asystole- Flat line

 QRS depolarization- Answer will always be ventricular

 P wave- Answer will always be atrial

 Lack of a P wave- Answer will always be ventricular

 A lack of QRS- Asystole

 A-flutter- Saw tooth

 Chaotic is always the word used to describe fibrillation

 Bizarre is always the word used for tachycardia

Low Priority:

 Premature ventricular contraction (PVC)

 A bunch of PVC’s is like a short run of V-Tach

Moderate Priority:

 If more than 6 PVC’s in a minute or row and/or if PVC falls on the T wave of the previous beat. They never are high priority!

Potentially Life Threatening:

 V-Tach- Pt has a pulse

Lethal Priority: Kills you in 8 mins or less

 Asystole- No pulse

 V-fib- No pulse

Treatment:

Supra Ventricular (Atrial) → ABCD’s

Adenocard (Adenosine):

 Push in less then 8 secs

 Don't worry about Asystole

 When it comes to IV push, when you don’t know go slow

Beta blockers (ending in “lol”)

 Just like CCB’s, same treatment, same side effects

Calcium channel blockers

 Better for asthmatics

Digoxin/Digitalis (Lanoxin)

V-fib → D-fib

Asystole → Epinephrine & Atropine (In that order if Epi doesn’t work)

PVC’s & V-Tach → Use Amiodarone for Ventricular

Various interventions have been utilized for prophylaxis of venous thromboembolism. These include mechanical devices such as graduated compression stockings (GCS), intermittent pneumatic compression (IPC) devices, and pharmacologic agents such as unfractionated heparin, low-molecular-weight heparin. Anticoagulants, including injectables such as heparin or low molecular weight heparin, or tablets such as apixaban, dabigatran, rivaroxaban, edoxaban and warfarin (also called direct-acting oral anticoagulants or DOACs). These medications are used for a number of months.