Med Surg 2 Exam 1 Blueprint Answers PDF

# Med Surg 2 Exam 1 Blueprint Answers ## Medical-Surgical Nursing II (Herzing University) Studocu is not sponsored or endorsed by any college or university ## Cardiomyopathy ### Assessment * Begins with a detailed history of the presenting signs and symptoms * Nurse identifies possible cause factors (heavy alcohol intake, recent illness or pregnancy, or history of the disease in immediate family members). * If the patient reports chest pain, a thorough review of the pain, including its precipitating factors, is warranted. * Review of systems includes the presence of orthopnea, PND, and syncope or dyspnea with exertion. * Number of pillows needed to sleep, usual weight, any weight change, and limitations on activities of daily living are assessed * Patient's usual diet is evaluated to determine the need to reduce sodium intake, optimize nutrition, or supplement with vitamins * Baseline assessment includes components: * Vital signs * Calculation of pulse pressure and identification of pulsus paradoxus * Current weight and any weight gain or loss * Detection by palpation of the point of maximal impulse, often shifted to the left * Cardiac auscultation for a systolic murmur and S3 and S4 heart sounds * Pulmonary auscultation for crackles * Measurement of jugular vein distention * Assessment of edema and its severity ### Diagnostics * Diagnosis is usually made from findings disclosed by the patient's history and by ruling out other causes of heart failure such as myocardial infarction * Echocardiogram is one of the most helpful diagnostic tools: * Structure and function of the ventricles can be observed easily * Cardiac MRI may be used, particularly to assist with the diagnosis of HCM * ECG demonstrates dysrhythmias (atrial fibrillation, ventricular dysrhythmias) and changes consistent with left ventricular hypertrophy (left axis deviation, wide QRS, ST changes, inverted T waves) * ARVC/D there often is a small deflection, an epsilon wave at the end of the QRS * Chest x-ray reveals heart enlargement and possibly pulmonary congestion * Cardiac catheterization is sometimes used to rule out coronary artery disease as a causative factor * Endomyocardial biopsy may be performed to analyze myocardial cells ### Pharmacological mgt * Directed at controlling symptoms ## Valvular Disorders ### Manifestations * **Mitral Valve Prolapse** * Most never have symptoms * Fatigue * May occur regardless of activity level and amount of rest or sleep * Shortness of breath * Not correlated with activity levels or pulmonary function * Lightheadedness * Dizziness * Syncope * Atrial or ventricular dysrhythmias may produce the sensation of palpitations * Have been reported while the heart has been beating normally * Chest pain * Not correlated with activity and may last for days * May be a response to symptoms * Some report anxiety as the only symptom * **Mitral Regurgitation** * Chronic is often asymptomatic * Acute (resulting from a myocardial infarction) usually manifests as severe congestive heart failure * Dyspnea * Fatigue * Weakness * Palpitations * Shortness of breath on exertion * Cough from pulmonary congestion * **Mitral Stenosis** * First symptom is often dyspnea on exertion (DOE) as a result of pulmonary venous hypertension * Symptoms usually develop after the valve opening is reduced by one third to one half its usual size. * May experience progressive fatigue and decreased exercise tolerance as a result of low cardiac output * Enlarged left atrium may create pressure on the left bronchial tree, resulting in a dry cough or wheezing * May expectorate blood (hemoptysis) or experience palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and repeated respiratory infections * Result of increased blood volume and pressure, the atrium dilates, hypertrophies, and becomes electrically unstable (patients experience atrial dysrhythmias) * **Aortic Regurgitation** * Develops without symptoms in most * Some patients are aware of a forceful heartbeat, especially in the head or neck * Marked arterial pulsations visible or palpable at carotid or temporal arteries may be present due to increased force and volume of blood ejected from a hypertrophied left ventricle. * Exertional dyspnea and fatigue follow. * Signs and symptoms of progressive left ventricular failure include breathing difficulties (orthopnea and paroxysmal nocturnal dyspnea (PND)). * **Aortic Stenosis** * Many are asymptomatic. * When symptoms develop, patients usually first have exertional dyspnea * Caused by increased pulmonary venous pressure due to left ventricular failure * Orthopnea * Paroxysmal nocturnal dyspnea (PND) * Pulmonary edema * Reduced blood flow to the brain may cause dizziness and syncope * Angina pectoris is a frequent symptom * Results from increased oxygen demand of the hypertrophied left ventricle with decreased blood supply due to decreased blood flow into the coronary arteries and decreased time in diastole for myocardial perfusion * Blood pressure is usually normal but may be low * Pulse pressure may be low (30 mm Hg or less) due to diminished blood flow ### Medical mgt * **Mitral Valve Prolapse** * Directed at controlling symptoms. * If dysrhythmias are documented and cause symptoms, patient is advised to eliminate caffeine and alcohol from the diet and to stop the use of tobacco products * Most patients don't require medication, but some are prescribed antiarrhythmic medications * Prophylactic antibiotics are not recommended prior to dental or invasive procedures * Chest pain that doesn't respond to nitrates may respond to calcium channel blockers or beta- blockers. * Heart failure is treated the same as it would be for any other case of heart failure * Severe mitral regurgitation and symptomatic heart failure may require mitral valve repair or replacement * **Mitral Regurgitation** * Management is the same as for heart failure * Patients with mitral regurgitation and heart failure benefit from afterload reduction (arterial dilation) by treatment with: * Angiotensin-converting enzyme (ACE) inhibitors ex. captopril (Capoten), enalapril (Vasotec), lisinopril (Prinivil, Zestril) or ramipril (Altace), or hydralazine (Apresoline) * Angiotensin receptor blockers (ARBs) ex. losartan (Cozaar) or valsartan (Diovan) * Beta-blockers ex. carvedilol (Coreg) * Once symptoms of heart failure develop, patient needs to restrict their activity level to minimize symptoms * Symptoms are an indicator for surgical intervention by mitral valvuloplasty (surgical repair of the valve) or valve replacement. * **Mitral Stenosis** * Patients may benefit from anticoagulants to decrease the risk of developing atrial thrombus * May require treatment for angina * If atrial fibrillation develops, cardioversion is attempted to restore normal sinus rhythm * Unsuccessful, ventricular rate is controlled with beta-blockers, digoxin, or calcium channel blockers * Patients are advised to avoid strenuous activities, competitive sports, and pregnancy as they increase heart rate * Surgical interventions * Valvuloplasty, usually a commissurotomy to open or rupture the fused commissures of the valve * Percutaneous transluminal valvuloplasty or valve replacement may be performed * **Aortic Regurgitation** * Symptomatic patient, or patients with decreased left ventricular function, is advised to avoid physical exertion, competitive sports, and isometric exercise * Should be instructed to restrict sodium intake to avoid volume overload * Patients with aortic regurgitation and hypertension should be treated with dihydropyridine calcium channel blockers (felodipine [Plendil], nifedipine [Adalat, Procardia]) or ACE inhibitors (captopril, enalapril, lisinopril, ramipril) to provide afterload reduction * Calcium channel blockers diltiazem (Cardizem) and verapamil (Calan, Isoptin) are contraindicated as they decrease ventricular contractility and may cause bradycardia * Treatment of choice is aortic valve replacement or valvuloplasty, preferably performed before left ventricular failure occurs * Surgery is recommended for any patient with left ventricular dilation, regardless of the presence or absence of symptoms and any patient who is symptomatic * **Aortic Stenosis** * Medications are prescribed to treat dysrhythmia or left ventricular failure * Definitive treatment is surgical replacement of the aortic valve ### Surgical mgt * **Valvuloplasty** * Repair, rather than replacement, of a cardiac valve is referred to as valvuloplasty * Do not require continuous anticoagulation * Type depends on the cause and type of valve dysfunction * Repair may be made to: * Commissures between the leaflets in a procedure known as commissurotomy * The annulus of the valve by annuloplasty, to leaflets * Chordae by chordoplasty * Transesophageal echocardiogram (TEE) usually is performed at the conclusion of a valvuloplasty to evaluate the effectiveness of the procedure. * Most procedures require general anesthesia and often require cardiopulmonary bypass * **Commissurotomy** * Most common valvuloplasty procedure * Repair to the commissures between the leaflets * Site where the leaflets meet is called the commissure * Leaflets may adhere to one another and close the commissure (stenosis) * Less commonly, leaflets fuse in a way that in addition to stenosis, the leaflets are prevented from closing completely, resulting in backward flow of blood (regurgitation). * Is a procedure performed to separate the fused leaflets * Closed Commissurotomy/Balloon Valvuloplasty * Don't require cardiopulmonary bypass * Valve is not directly visualized * More commonly performed in developing nations * A surgical technique performed in the operating room with the patient under general anesthesia * Percutaneous balloon valvuloplasty is the technique most commonly performed in the United States * Beneficial for mitral valve stenosis in younger patients and for patients with complex medical conditions that place them at high risk for complications of more extensive surgical procedures. * Balloon valvuloplasty is performed in the cardiac catheterization lab * Patient may receive light or moderate sedation or a local anesthetic * Mitral balloon valvuloplasty involves advancing one or two catheters into the right atrium, through the atrial septum into the left atrium, across the mitral valve, and into the left ventricle * A guidewire is placed through each catheter, and the original catheter is removed * Most often, a specially designed balloon catheter is placed over the guidewire and positioned with the balloon across the mitral valve * **Aortic balloon valvuloplasty is performed most commonly by introducing a catheter through the aorta, across the aortic valve, and into the left ventricle** * May be performed by passing the balloon or balloons through the atrial septum. * **Open Commissurotomy** * Performed with direct visualization of the valve * Patient is under general anesthesia * **Annuloplasty** * Is the repair of the valve annulus (junction of valve leaflets and muscular heart wall) * General anesthesia and cardiopulmonary bypass are required for most * Narrows the diameter of the valve's orifice * Useful treatment for valvular regurgitation * 2 techniques * Annuloplasty ring * Tightening the annulus by folding elongated tissue over onto itself (taking tucks) in leaflets or tacking leaflets to the atrium or each other with sutures * **Leaflet Repair** * Damage to cardiac valve leaflets may result from stretching, shortening, or tearing * Leaflet repair for elongated, ballooning, or other excess tissue leaflets is removal of the extra tissue * Elongated tissue may be tucked and sutured (leaflet plication) * Wedge of tissue may be cut from the middle of the leaflet and the gap sutured closed (leaflet resection) * Short leaflets are most often repaired by chordoplasty * After short chordae are released, leaflets often unfurl and resume their normal function (closing the valve during systole) * Leaflet may be extended by suturing a piece of pericardium to it * Pericardial or synthetic patch may be used to repair holes in the leaflets * **Chordoplasty** * Is the repair of chordae tendineae * Mitral valve is most often involved * Stretched, torn, or shortened chordae tendineae may cause regurgitation * Stretched chordae tendineae can be shortened, transposed to the other leaflet, or replaced with synthetic chordae * Torn chordae can be reattached to the leaflet * Shortened chordae can be elongated * Stretched papillary muscles, may cause regurgitation, can be shortened or relocated * **Valve Replacement** * Used when valvuloplasty is not a viable alternative (when the annulus or leaflets of the valve are immobilized by calcifications, severe fibrosis or fusion of leaflets, chordae tendineae, or papillary muscles), valve replacement is performed * Multidisciplinary team (cardiologists, cardiac thoracic surgeons, structural valve interventionalists, anesthesiologists, and nurses) work together with the patient to determine candidacy for surgical versus more minimally invasive replacement * General anesthesia and cardiopulmonary bypass are used for most * All prosthetic valve replacements create a degree of stenosis when they are implanted in the heart ## Procedure vs. Diagnoses Used For vs. Description of the Procedure vs. Notes | Procedure | Diagnoses Used For | Described the Procedure | Notes | | -------------------------------- | -------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------| | Valvuloplasty | | *Valvuloplasty: Repair of the cardiac valve* *Balloon: Catheter inserted into the vein or artery and fed through to the heart valve. Balloon is expanded at the valve to open the leaflets Commissurotomy: Cut to separate the fused leaflets Conscious sedation or general anesthesia *Remove part of leaflet- sew it back together on itself Extend the leaflet by adding pericardium to the leaflet General anesthesia- open heart, cardiopulmonary bypass* | *Commissure: Where the leaflets of the valve meets* | | Open Heart Valve Repair (Valvuloplasty) | *Mitral Valve Stenosis Mitral Valve Regurgitation Aortic Valve Stenosis Aortic Valve Regurgitation* | *Remove part of leaflet- sew it back together on itself Extend the leaflet by adding pericardium to the leaflet General anesthesia- open heart, cardiopulmonary bypass* | | | Annuloplasty | *Mitral Regurgitation Aortic Regurgitation* | *General anesthesia- open heart, cardiopulmonary bypass Repair of the annulus: Add a new “ring” Tighten annulus: folding the tissue onto itself* | | | Chordoplasty | *Mitral Valve Regurgitation* | *Repair of chordae tendineae Stretched can be shortened or replaced with synthetic chordae Shortened-can be elongated Torn can be reattached* | | | Valve Replacement | *Mitral Valve Stenosis Mitral Valve Regurgitation Aortic Valve Stenosis* | *General anesthesia- open heart, cardiopulmonary bypass Open heart procedure; cardiopulmonary bypass Old valve is surgically removed and replaced with the new valve TAVI: Transcatheter Aortic Valve Replacement Minimally invasive The new valve is placed inside the old valve Pushes old leaflets out of the way and the new valve takes over Through femoral artery or through small incision in the chest to get to an artery* | *Mechanical Valve Bioprosthetic Animal Valves* | | | | | | ## Infective Endocarditis ### Assessment * Definitive diagnosis is made when a microorganism is found in 2 separate blood cultures, or in vegetation or abscess * At least 2 sets of blood cultures (each set including 1 aerobic and 1 anaerobic culture) drawn from different venipuncture sites over a 24-hour period (each set at least 12 hours apart), or every 30 minutes if the patient's condition is unstable, should be obtained before administration of any antimicrobial agents * Negative blood cultures do not definitely rule out infective endocarditis * Patients may have elevated white blood cell (WBC) counts * Patients may be anemic, have a positive rheumatoid factor, and an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein * Echocardiography may assist in diagnosis by demonstrating a mass on a valve, prosthetic valve, or supporting structures and by identifying vegetations, abscesses, new prosthetic valve dehiscence, or new regurgitation * Echocardiogram may reveal development of heart failure ### Manifestations * Primary presenting symptoms are fever and a heart murmur * Fever may be intermittent or absent, especially in patients who are receiving antibiotics or corticosteroids, in older adults, and in those who have heart failure or kidney injury * Heart murmur may be absent initially but develops in almost all patients * Murmurs that worsen over time indicate progressive damage from vegetations or perforation of a valve or rupture of chordae tendineae. * Clusters of petechiae may be found on the body * Small, painful nodules (Osler nodes) may be present in pads of fingers or toes * Irregular, red or purple, painless flat macules (Janeway lesions) may be present on palms, fingers, hands, soles, and toes * Hemorrhages with pale centers (Roth spots) caused by emboli may be observed in fundi of the eyes * Splinter hemorrhages (reddish-brown lines and streaks) may be seen under the proximal half of fingernails and toenails * Petechiae may appear in conjunctiva and mucous membranes. * Cardiomegaly, heart failure, tachycardia, or splenomegaly may occur. * Headache * Temporary or transient cerebral ischemia; and strokes, which may be caused by emboli to cerebral arteries * Embolization may be a presenting symptom; it may occur at any time and may involve other organ systems * Embolic phenomena may occur. * Heart failure, may result from perforation of a valve leaflet, rupture of chordae, blood flow obstruction due to vegetations, or intracardiac shunts from dehiscence of prosthetic valves, indicates a poor prognosis with medical therapy alone and a higher surgical risk. ### Medical mgt * Objective of treatment is to eradicate invading organisms through adequate doses of an appropriate antimicrobial agent. * Antibiotic therapy usually is given for 2 to 6 weeks every 4 hours or continuously by IV infusion * Serum levels of the antibiotic and blood cultures are monitored to gauge effectiveness of therapy. * Patient's temperature is monitored at regular intervals because the course of fever is one indication of treatment effectiveness: * Febrile reactions may occur as a result of medication * Patients require psychosocial support because although they feel well, they may find themselves confined to the hospital or home with restrictive IV therapy. ### Pathophysiology * Deformity or injury of the endocardium leads to accumulation of fibrin and platelets (clot formation) on the endocardium * Infectious organisms, usually staphylococci or streptococci, invade the clot and endocardial lesion. * Causative microorganisms include fungi (e.g., Candida, Aspergillus) and Rickettsiae * Infection most frequently results in platelets, fibrin, blood cells, and microorganisms that cluster as vegetations on the endocardium * Infection may erode through the endocardium into underlying structures (e.g., valve leaflets), causing tears or other deformities of valve leaflets, dehiscence of prosthetic valves, deformity of chordae tendineae, or mural abscesses ## Myocarditis ### Pharmacological mgt * Directed at controlling symptoms ### Pathophysiology * An inflammatory process involving the myocardium/inflammation of the heart muscle * Usually results from viral (e.g., coxsackievirus A and B, human immune deficiency virus, influenza A), bacterial, rickettsial, fungal, parasitic, metazoal, protozoal (e.g., Chagas disease), or spirochetal infection * May be immune related, occurring after acute systemic infections such as rheumatic fever * May develop in patients receiving immunosuppressive therapy or in those with infective endocarditis, Crohn's disease, or systemic lupus erythematosus * May result from an inflammatory reaction to toxins such as pharmacologic agents used in the treatment of other diseases (e.g., anthracyclines for cancer therapy), ethanol, or radiation (especially to the left chest or upper back) ## Pericarditis ### Nursing mgt * Acute pericarditis require pain management with analgesics, assistance with positioning, and psychological support. * Patients with chest pain often benefit from education and reassurance that the pain is not due to a heart attack. * Pain may be relieved with a forward-leaning or sitting position * To minimize complications, help the patient with activity restrictions until pain and fever subside. * As patient's condition improves, encourage gradual increases in activity * If pain, fever, or friction rub recurs, activity restrictions must be resumed * Educate the patient and family about a healthy lifestyle to enhance the patient's immune system. ### Assessment * Primary symptom is pain: * Assessed by evaluating the patient in various positions * Nurse tries to identify whether pain is influenced by * Respiratory movements, while holding an inhaled breath or holding an exhaled breath * Flexion, extension, or rotation of the spine, including the neck * Movements of shoulders and arms * Coughing * Swallowing * Recognizing events that precipitate or intensify pain may help establish a diagnosis and differentiate pain of pericarditis from the pain of myocardial infarction * When pericardial surfaces lose their lubricating fluid due to inflammation, a pericardial friction rub occurs * The rub is audible on auscultation and is synchronous with the heartbeat * May be elusive and difficult to detect * Pericardial friction rub is a diagnostic of pericarditis * It is a creaky or scratchy sound and is louder at the end of exhalation * Nurses should monitor for pericardial friction rub by placing the diaphragm of the stethoscope tightly against the patient's thorax and auscultating the left sternal edge in the fourth intercostal space * Site where the pericardium comes into contact with the left chest wall. * Rub may be heard best when a patient is sitting and leaning forward * If there is difficulty in distinguishing a pericardial friction rub from a pleural friction rub, the patient is asked to hold their breath: * Pericardial friction rub will continue to be heard * Patient's temperature is monitored frequently * Pericarditis may cause an abrupt onset of fever in a patient who has been afebrile ## Angina Pectoris ### Pathophysiology * Angina is usually caused by atherosclerotic disease * Is a clinical syndrome usually characterized by episodes or paroxysms of pain or pressure in the anterior chest * Caused by insufficient coronary blood flow, resulting in a decreased oxygen supply when there is increased myocardial demand for oxygen in response to physical exertion or emotional stress * Need for oxygen exceeds the supply * Is a cardiac emergency * At an increased risk of heart attack, cardiac arrest, or sudden cardiac death * Types * **Stable** * Predictable and consistent pain that occurs on exertion and is relieved by rest and/or nitro * **Unstable** * Symptoms increase in frequency and severity * May not be relieved with rest or nitro * No pattern * **Intractable or Refractory Angina** * Severe incapacitating chest pain * **Variant Angina/Prinzmetal** * Pain at rest, usually during the night with reversible ST segment elevation * Caused by coronary artery vasospasm * No blockage * **Silent Ischemia** * Objective evidence of ischemia (on ECG with stress test) but patient reports no pain ### Nursing mgt * Gathers information about the patient's symptoms and activities, especially those that precede and precipitate attacks * Appropriate questions * Answers to these questions form the basis for designing an effective program of treatment and prevention. * “Where is the pain (or prodromal symptoms)? Can you point to it?” * “Can you feel the pain anywhere else?” * "How would you describe the pain?" * “Is it like the pain you had before?” * "Can you rate the pain on a 0-10 scale, with 10 being the most pain?" * “When did the pain begin?" * “How long does it last?” * "What brings on the pain?" * “What helps the pain go away?” * “Do you have any other symptoms with the pain?" * Assess the patient's risk factors for CAD, patient's response to angina, patient's and family's understanding of the diagnosis, and adherence to the current treatment plan * **Treating Angina** * If patient reports pain take immediate action * Patient is directed to stop all activities and sit or rest in bed in a semi-Fowler's position to reduce the oxygen requirements of the ischemic myocardium. * Assesses the patient's angina, asking questions to determine whether the angina is the same as the patient typically experiences * Change may indicate a worsening of the disease or a different cause * Continues to assess patient, measuring vital signs and observing for signs of respiratory distress * In the hospital, a 12-lead ECG is usually obtained and assessed for ST-segment and T-wave changes * If the patient has been placed on cardiac monitoring with continuous ST-segment monitoring, the ST segment is assessed for changes * Nitroglycerin is given sublingually: * Assess patient's response for relief of chest pain and effect on blood pressure and heart rate * If the chest pain is unchanged or is lessened but still present, administration is repeated up to 3 doses * Each time blood pressure, heart rate, and the ST segment (if the patient is on a monitor with ST-segment monitoring capability) are assessed * Administers oxygen therapy if the patient's respiratory rate is increased or if the oxygen saturation level is decreased * Usually given at 2 L/min by nasal cannula * If the pain is significant and continues after these interventions, the patient is further evaluated for acute MI and may be transferred to a higher-acuity nursing unit * **Reducing Anxiety** * Exploring the implications the diagnosis has for the patient and providing information about the illness, its treatment, and methods of preventing its progression are important nursing interventions * Stress reduction methods, should be explored with patient * Addressing the spiritual needs of the patient and family may assist in allaying anxieties and fears * **Preventing Pain** * Nurse reviews the assessment findings, identifies the level of activity that causes the patient's pain or prodromal symptoms, and plans the patient's activities accordingly. * If patient has pain frequently or with minimal activity, alternate the patient's activities with rest periods * Balancing activity and rest is an important aspect of an educational plan for patients and family ### Pharmacological mgt * **Nitrates** * Nitroglycerin * Short and long-term reduction of myocardial oxygen consumption through selective vasodilation * **Beta-Adrenergic Blocking Agents (Beta-Blockers)** * Metoprolol * Atenolol * Reduction of myocardial oxygen consumption by blocking beta-adrenergic stimulation of the heart * **Calcium Ion Antagonists (Calcium Channel Blockers)** * Amlodipine * Diltiazem * Negative inotropic effects * Indicated in patients not responsive to beta-blockers * Used as primary treatment for vasospasm * **Antiplatelet Medications** * Aspirin * Clopidogrel (Plavix) * Prasugrel * Prevention of platelet aggregation * **Anticoagulants** * Heparin * Low Molecular Weight Heparin * Enoxaparin (Lovenox) * Dalteparin (Fragmin) * Prevention of thrombus formation ## Atherosclerosis ### Pathophysiology * Thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery. * Abnormal accumulation of lipid, or fatty substances, and fibrous tissue in the lining of arterial blood vessel walls. These substances block and narrow the coronary vessels in a way that reduces blood flow to the myocardium. * Accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery * Plaque * Most common direct results in arteries include narrowing (stenosis) of the lumen, obstruction by thrombosis, aneurysm, ulceration, and rupture * Indirect results are malnutrition and subsequent fibrosis of the organs that the sclerotic arteries supply with blood * Can develop at any point in the body * Certain sites are more vulnerable (regions where arteries bifurcate or branch into smaller vessels, with males having more below-the-knee pathology than females) * Proximal lower extremity include the distal abdominal aorta, common iliac arteries, orifice of the superficial femoral and profunda femoris arteries, and superficial femoral artery in the adductor canal, which is particularly narrow. * Distal to the knee, atherosclerosis can occur anywhere along the artery ### Prevention * Reasonable to measure serum cholesterol and to begin disease prevention efforts that include diet modification * American Heart Association recommends reducing the amount of fat ingested in a healthy diet, substituting unsaturated fats for saturated fats, and decreasing cholesterol intake to reduce the risk of cardiovascular disease. * Certain medications that supplement dietary modification and exercise are used to reduce blood lipid levels: * HMG-CoA reductase inhibitors (statins) for first-line use in patients with PAD for secondary prevention and cardiovascular risk * Bile acid sequestrants (cholestyramine [Questran], colesevelam [WelChol], colestipol [Colestid]), nicotinic acid (niacin [Niacor, Niaspan]) * Fibric acid inhibitors (gemfibrozil [Lopid], fenofibrate [Tricor]) * Cholesterol absorption inhibitors (ezetimibe [Zetia]) * Patients receiving long-term therapy with these medications require close monitoring. * No single risk factor has been identified as the primary contributor to the development of atherosclerotic cardiovascular disease, it is clear that the greater the number of risk factors, the greater the risk of atherosclerosis * Elimination of all controllable risk factors, particularly the use of nicotine products, is strongly recommended * Risk Factors * Nicotine use (tobacco product such as cigarettes, e-cigarettes, or chewing tobacco) * Diet (contributing to hyperlipidemia) * Hypertension * Diabetes (speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels) * Hyperlipidemia * Stress * Sedentary lifestyle * Elevated C-reactive protein * Hyperhomocysteinemia * Increased age ### Nursing mgt * Arterial blood supply to a body part can be enhanced by positioning the part below the level of the heart * Lower extremities, this is accomplished by elevating the head of the patient's bed or by having the patient use a reclining chair or sit with the feet resting on the floor * PAD, blood flow to the lower extremities needs to be enhanced, nurse encourages keeping the lower extremities in a neutral or dependent position * Venous insufficiency, blood return to the heart needs to be enhanced, so the lower extremities are elevated * Can assist the patient with walking or other moderate or graded isometric exercises that may be prescribed to promote blood flow and encourage the development of collateral circulation * Walk to the point of pain, rest until the pain subsides, and then resume walking so that endurance can be increased as collateral circulation develops * Not all patients with peripheral vascular disease should exercise * Before recommending any exercise program, the patient's primary provider should be consulted * Conditions that worsen with exercise: leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions * Promoting Vasodilation and Preventing Vascular Compression * Arterial dilation promotes increased blood flow to the extremities and is a goal for patients with PAD * Applications of warmth to promote arterial flow and instructions to the patient to avoid exposure to cold temperatures, which causes vasoconstriction * Adequate clothing and warm temperatures protect the patient from chilling * If chilling occurs, a warm bath or drink is helpful * A hot water bottle or heating pad may be applied to the patient's abdomen, causing vasodilation throughout the lower extremities. * Vasospastic disorders (Raynaud disease), heat may be applied directly to ischemic extremities using a warmed or electric blanket * Temperature of the heat source must not exceed body temperature * Nicotine from any tobacco product causes vasospasm and can dramatically reduce circulation to the extremities * Tobacco smoke impairs transport and cellular use of oxygen and increases blood viscosity. * Constrictive clothing and accessories, may impede circulation to the extremities and promote venous stasis and should be avoided * Crossing the legs for more than 15 minutes at a time should be discouraged as it compresses vessels in the legs * Relieving Pain * Analgesic agents ex. hydrocodone plus acetaminophen (Vicodin, Norco, Lortab), oxycodone (Roxicodone), oxycodone plus acetylsalicylic acid (Percodan), or oxycodone plus acetaminophen (Percocet, Roxicet) may help reduce pain * Maintaining Tissue Integrity * Poorly perfused tissues are susceptible to damage and infection * When lesions develop, healing may be delayed or inhibited because of the poor blood supply to the area * Infected, non-healing ulcerations of the extremities can be debilitating and may require prolonged and often expensive treatments * Amputation of an ischemic limb may eventually be necessary. Measures to prevent these complications must be a high priority and vigorously implemented. * Trauma to the extremities must be avoided. * Advising the patient to wear sturdy, well-fitting shoes or slippers to prevent foot injury and blisters may be helpful, and recommending neutral soaps and body lotions may prevent drying and cracking of the skin * Nurse should instruct the patient not to apply lotion between the toes as the increased moisture can lead to maceration of tissue * Scratching and vigorous rubbing can abrade the skin and create sites for bacterial invasion * Feet should be patted dry * Stockings should be clean and dry * Fingernails and toenails should be carefully trimmed straight across and sharp corners filed to follow the contour of the nail * If the nails cannot be trimmed safely, it is necessary to consult a podiatrist, who can also remove corns and calluses * Special shoe inserts may be needed to prevent calluses from recurring * All signs of blisters, ingrown toenais, infection, or other problems should be reported to health care professionals for treatment and follow-up * Patients with diminished vision and those with disabilities that limit mobility of the arms or legs may require assistance * Good nutrition promotes healing and prevents tissue breakdown and is included in the overall therapeutic program for patients with peripheral vascular disease. * Eating a diet that contains adequate protein and vitamins is necessary for patients with arterial insufficiency * Key nutrients play specific roles in wound healing * Diet low in lipids may be indicated for patients with atherosclerosis ### Monitoring and Managing Potential Complications * Close monitoring for and early identification of their signs and symptoms are critical

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