Chronic Cardiovascular Disorders General Overview Hypertension Disorders of aorta and branches Arterial thrombosis & embolism Peripheral

heral arterial disease (PAD) Aortic aneurysms Thromboangiitis obliterans Raynauds disease/phenomenon Venous disorders Venous thrombosis: Superficial & Deep Chronic venous insufficiency Lymphedema General Overview Gender, Cultural, & Ethnic Differences Use of the Genogram Medication Reconciliation Risk factors Diagnostic Tests Collaborative Care Nursing Interventions Prioritization Cardiac Markers Creatine Kinase (CK) Measures an enzyme that is released when there is muscle damage or breakdown Does not tell specific muscle CK-MM (skeletal); CK-BB (brain); CK-MB (cardiac) Report Rise, Peak and Fall levels Troponin Elevated levels mean Myocardial Damage Elevates earlier than CK-MB Reaches peak @ 24 hours and may not fall for 7-10 days Good indicator for patient who presents non-classic MI symptoms Cardiac Markers BLOOD STUDY Creatine Kinase (CK)

RANGE 36-160 Units/L (F) 50204 units/L (M) < 4-6% of total CK

RISE, PEAK, FALL

CK-MB

Rise 4-6 hrs Peak 18-24 hrs Return to baseline 24-36 hrs Rise 2 6 hrs Peak 15-24 hrs Return to baseline 7-10 days

Troponin < 0.35 ng/ml (I) < 0.2 mcg/L (T)

 Lipid Panel (Cholesterol Test)

Blood study Total Cholesterol Low-density lipoprotein (LDL) or bad cholesterol < 200 mg/dL Without CAD <130mg/dL With CAD 100mg/dL(< 70) High-density lipoprotein (HDL) or good cholesterol > 40 mg/dL (men) > 60 mg/dl (women) Triglycerides < 150 L Range

Brain (or B-type) Natriuretic Peptide (BNP) Test

Hormone secreted by the left ventricular when the left ventricular is overstretched from excess volume BNP level < 100 100-199 200-400 >400 Condition Normal heart function Mild heart failure Moderate heart failure Moderate to severe heart failure

Diagnostic Studies Homocysteine Level Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue. Normal: 4.6-11.2 mcg/L Damage inside lining of artery Encourage clot formation Stroke Heart disease Chest X-ray A chest x-ray is typically the first imaging test used to help evaluate symptoms such as: Shortness of breath Persistent cough Chest pain Takes 15 minutes Painless procedure PA & Lateral views Portable AP view Always check if there is a chance pt is pregnant Echocardiogram (echo) Non-invasive ultrasound procedure that utilizes ultrasound to image the heart, muscle, chamber sizes, valves, ejection fraction, and blood flow Hypokineases less movement of muscle A-kineases non movement (MI) Ejection Fraction tells how well heart is pumping

Transthoracic Echocardiography (TTE) No special preparation Transducer is applied to chest wall to evaluate: Size and shape Valves Abnormal structures Blood clots or tumors Walls of heart Pumping ability Ejection Fraction (EF) Transesophageal Echocardiogram (TEE) Prep NPO for 6 hours prior to test Consent IV access Remove dentures During the procedure Sedation (Versed) Oxygen Anesthetic gel or spray Test takes about 15-20 minutes Nursing Care after TEE Vital signs including pulse oximetry No eating or drinking 2 hours after procedure, or until gag reflex returns Monitor for shortness of breath, chest pain, bleeding, or fever

Electrocardiogram (EKG or ECG) Painless test that records the hearts electrical activity 12 specific areas No special preparation Place nodes non-hairy area, instruct pt not to talk Electrodes are placed on specific locations on chest wall and extremities A machine records the signals on graphic paper Test takes 5 minutes Electrocardiogram (ECG) Electrical activity of different walls of the heart

Stress Test Exercise stress testing Nuclear stress testing Using radioactive isotopes Shows how the heart responds to increased oxygen demands Determine what the patients max HR is Is they reach 80% of that then is considered a successful test Looking for signs of ischemia as you increase workload (increase incline or speed of treadmill)

 What happens when stress test is performed? Timed interval exercise Underlying heart disease is suggested if patient develops: Changes with ECG at low level exercise Drop in blood pressure Extreme or inappropriate shortness of breath, chest discomfort, and weakness Test takes 1/2 to 3 hours Return to normal activities Other Names for Stress Test Exercise Treadmill test Stress echocardiogram Dobutamine stress echocardiogram (DSE) Myocardial Perfusion Imaging (MPI) Stress Thallium scan, Nuclear stress test Typical Standing Orders for Stress Test Consent NPO No caffeine for 12-24 hours Hold medication that slows heart rate Beta blockers (Metoprolol, Carvedilol) Digoxin (Lanoxin) Calcium channel blockers (Diltiazem, Verapamil only) Angiography or Angiogram X-ray pictures of arteries (arteriogram) or veins (venogram) using injection of x-ray dye (contrast) Arteries: usually goes in at femoral artery Invasive procedure using local anesthesia and conscious sedation Consent required!!! NPO Check for allergy to iodine, shellfish, xray dye What is Cardiac Catheterization? Cardiac Catheterization (Cath) is a specialized study of the heart during which a catheter, or thin hollow flexible tube, is inserted into an artery in the groin or arm Cardiac catheterization is performed to diagnose: Coronary artery disease Disease of heart valves Etiology of Congestive heart failure (ex: ischemia or malfunction heart valve) Structural defects Cardiac Catheterization (cardiac cath) Large vascular access sheaths are placed in the groin or arm Insertion of a catheter into the heart Contrast dye injected to detect impaired flow of blood to the coronary arteries Typical Standing Orders for Cardiac Catheterization Explain procedure (Dr. Np or PA only, nurse cannot do this) Consent NPO Intravenous access Shave and prep right/left groin Hold anticoagulants Coumadin has longer half life than Heprin so need to check PT/INR to make sure back to normal before procedure Do not give 0800 dose of Lovenox Check allergy Iodine, shellfish, contrast dye If allergic, give Benadryl and Solucortef (several doses 24hr period ahead of time)

Hold basal (ex: lispro) insulin and oral hypoglycemic agents bc NPO Can give correction dose (sliding scale if BG is high in morning), but not scheduled basal dose

Preparation for Cardiac Catheterization Several routine tests will be done: ECG Complete Blood Count (CBC) WBC, Hgb, Hct, Platelets Infection present, any bleeding If severly anemic do not want to put them at risk for more blood loss Adequate patelets so they can clot BMP: Electrolyte panel Sodium, Potassium, BUN, creatinine xRAY Dye could worsen kidney function PT/INR (if on Coumadin/Heprin) What to expect during a cardiac cath? Contrast dye used to visualize the coronary arteries Procedure lasts one hour Catheter is usually removed in cath lab Pressure is held for 20 to 30 minutes Pressure dressing applied If closure device used, only bandaid applied Post Cardiac Cath Care Bed rest for 3 to 4 hours Head of bed elevated 20 to 30 degrees Keep the affected extremity straight Frequent vital signs Bleeding: BP decrease, HR insrease Monitor groin site for bleeding Check pedal pulses After 3 to 4 hours & stable, check blood pressure and heart rate lying, sitting, and standing Most common cause of hypotension is dehydration Complication of Cardiac Catheterization Dissection of aorta or coronary artery MI (Heart Attack) Dislodged athlescrotic plaque Thrombus/embolus Stroke Plaque breaks off, goes into Carotid artery and travels to brain Hematoma Retroperitoneal bleed Pseudoaneursym or A-V fistula Pseudoaneursym: Bleeding in layers of artery AV Fistula: is a tear that forms between artery and vein When palpating pulse @ site you will hear a Bruit and feel/palpate a Thrill Allergic reaction to xray dye Warmth, erythema, swelling of tissues lungs: stridor, hives, sneezing, itching Cardiac CT (computed tomography) A painless test X-ray machine takes clear, detailed pictures of the heart. Each picture shows a small slice of the heart. A computer will put the pictures together to make a large picture of the whole heart. Calcium score predicts cardiac events

 Electrophysiology Study (EPS) An invasive study used to diagnose dysrhythmias - slow or fast rhythms NPO Consent Shave & prep groin Catheter inserted right femoral vein Bed rest 3-4 hours Monitor vital signs and puncture site Assess pedal pulses Arterial doppler study (Ultrasound) & Duplex Scan

Venous Doppler Study & Duplex Scan Noninvasive, painless ultrasound test to detect thrombosis in the superficial and deep veins. May be done on the upper and lower extremities

Hypertension
Blood Pressure Classification Normal Prehypertension Stage I Hypertension Stage II Hypertension SBP (mmHg) < 120 120-139 140-159 DBP (mmHg) and < 80 or 80-89 or 90-99

>/= 160

or >/= 100

Types of Hypertension Isolated systolic hypertension Defined as an average SBP >140 and DBP < 90 More common in older sdults due to a loss of elasticity in large arteries and atherosclerosis Pseudohypertension False hypertension Happens a lot in elderly due to thickening in the walls of the arteries (atherosclerosis) Sclerotic arteries dont collapse when cuff is fully inflatedCuff doesnt fit correctly Much higher pressures than what are actually present Susopect if arteries feel rigid and few retinal/cardiac signs are found relative to cuff reading Primary hypertension Essential hypertension (idiopathic htn) Most common (90% of hyoertension) Elevated BP without a primary cause

Secondary hypertension HTN related to a specific cause that can be identified and sometimes treated Kidney Failure, medications, pregnancy Anything or disease that causes excessive blood volume Hypertensive crisis Excessively high diastolic, sometimes high systolic

Risk factors Heredity Male > 45 Female > 55 Excess dietary sodium Diabetes mellitus

Hyperlipidemia Ethnicity Stress Obesity Alcohol

Lack of exercise Smoking Medications Socioeconomic

Gender, Cultural, & Ethnic Factors Men vs. women Age onset Males -MI; Females CVA Cultural & Ethnic African Americans Highest prevalence Younger onset Women > men Mexican Americans Lower awareness Less receipt of treatment & adequate control May need more patient teaching Complications silent killer!!! Target organ damage: Heart cardiac hypertrophy, atherosclerosis, tearing of arteries Brain stroke, encephalopathy Peripheral vasculature atherosclerosis Kidneys nephrosclerosis Eyes Increased IOC, hemorrhage of retinal vessels Diagnostic Evaluation H&P Urinalysis detect kidney damage BMP Na, K, BUN, Cr, BG Lipid Profile detect additional risk factors that predispose a patient to CVD Serum uric acid establish a baseline bc often rise w diuretic therapy 12-lead Electrocardiogram Optional: 24 hr. urine (Cr clearance), Echocardiogram Nursing Assessment of BP Take BP in both arms Check for Orthostatic Hypotension Determine Mean Arterial Pressure (MAP) MAP = SBP + (DBP X 2) / 3 Indicates tissue perfusion Normal is 70 100. Must be > 60 for organ perfusion Nursing Judgment Evidence Based Practice Lifestyle modifications DASH diet Dietary Approaches to Stop HTN Fish, Fruits and vegetables, Fiber, Water Dietary Sodium Reduction < 2.3 g/day (< 1.5 g/day DM, CKD, HTN)

 Research-based Collaborative Care Additional lifestyle modifications Losing excess weight Exercise Smoking cessation Limiting alcohol intake Stress management Home BP monitoring Adherence to health plan Report sexual dysfunction OTC meds to avoid: sudafed (vasoconstriction), afrin Collaborative Care: Drug Therapy Medications
st

Diuretics (1 choice) hydrochlorothiazide Beta blockers ACE inhibitors Angiotensin receptor blockers Alpha blockers Calcium channel blockers Alpha-beta blockers Direct vasodilator

Antihypertensive Drug Therapy

 Nursing Implications for Med Administration

Check BP prior to administration; Hold antihypertensives if SBP < 100

Atherosclerosis
Coronary Artery Disease CAD, Coronary Heart Disease, ASCHD, ischemic heart disease Peripheral Arterial Disease Carotid arteries Abdomen Extremities Risk Factors - Atherosclerosis Age > 65 yrs, Men = women Gender Ethnicity Genogram Family History who, age of dx? Genetics Familial hypercholesterolemia Risk factors Tobacco Use Dyslipidemia Hypertension Diabetes mellitus Physical Inactivity Obesity Additional risks Stress Depression Metabolic syndrome Homocysteine Alcohol Age Genetics Health Promotion & Disease Management Lifestyle modifications Dietary measures, weight loss, Exercise, Smoking cessation

Medications Antidyslipidemic Therapy Restrict Lipoprotein Production Statins (HMG-CoA reductase inhibitors) Lovastatin, pravastatin, atorvastatin, rosuvastatin Mainly decrease LDL, small increase in HDL Niacin Decrease LDL & triglycerides Increase HDL (best drug) Fibric Acid derivatives (fenofibrate, gemfibrozil) Decrease triglycerides Increase HDL Increase Lipoprotein Removal Bile acid sequestrants (cholestyramine) Decrease total cholesterol & LDL Decrease Cholesterol Absorption Ezetimibe (Zetia) Vytorin = ezetimibe + simvastatin Research proven enhanced reductions in LDL Disorders of the aorta and branches (match columns) Types of Disorders Peripheral Arterial Disease Acute arterial ischemia Aneurysms Thromboangiitis obliterans Raynauds disease

Pathophysiology Occlusive disease Inflammatory Aneurysmal disease Vasospastic phenomenon

Peripheral Arterial Disease (PAD) Signs and Symptoms Intermittent claudication Calf pain Blockage in femoral arteries Buttock and thigh pain Blockage in iliac arteries Erectile dysfunction Paresthesia Changes to skin Diminished or absent pulses Bruit Complications Atrophy of the skin and muscles Delayed healing Wound infections Tissue necrosis Arterial ulcers Gangrene Amputation Diagnostic Studies Arterial Doppler Ultrasound Ankle Brachial Index (ABI) Ankle systolic pressure/brachial SBP Doppler used to take pressures Normal ABI 0.91-1.30 <0.4 = severe PAD Angiography

Treatment options Modification of risk factors Exercise therapy Nutritional therapy Protection from trauma or injury Lubrication (avoid soaking ft) Dangle or reverse trendelenburg for improved perfusion Wear soft, roomy, protective shoes Arterial ulcers keep clean & dry, cover w/ drsg Thrombosis or embolism EMERGENCY! Drug therapy Antiplatelet agents Aspirin Plavix Ace Inhibitors Pentoxyfylline (Trental) increase RBC flexibility Cilostazol (Pletal) inhibits platelet aggregation & vasodilates, significantly increases walking distance & QOL Interventional & Surgical therapy Interventional Radiologic procedures Percutaneous transluminal balloon angioplasty, Stent placement, Atherectomy Surgical therapy Peripheral arterial bypass operation Native vein or synthetic graft used Endarterectomy Endarterectomy w/ patch graft angioplasty Amputation

Planning Care of the Patient Nursing Diagnoses? Inadequate tissue perfusion Activity intolerance Risk for infection Pain Skin integrity Goals? Pt will have increased tissue perfusion, decreased pain, Increased exercise tolerance.. Outcomes Peripheral Tissue Perfusion Capillary refill Skin color Extremity skin color Femoral pulses Pedal pulses Activity Intolerance Walking pace Walking distance Ease of performing ADLs Nursing Care Assess peripheral pulses, skin color & temp, capillary refill, sensation, & movement Aggressive pain management Monitor for complications: bleeding, hematoma, thrombosis, embolization, & compartment syndrome Avoid knee- flexed positions except w/ exercise Prioritization: Notify dr. of significant change increased level of pain, loss of palpable pulse distal to operative site, ext. pallor/cyanosis, cold ext, numbness or tingling. Patient Teaching Risk factor management NO TOBACCO! Meticulous foot care How to check pulses, temp & capillary refill Gradual increase in physical activity post-op Regular physical activity

 Acute Arterial Ischemia Causes: Thombosis, Embolism, Trauma EMERGENCY!!! Six Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (usually cool) Treatment: Anticoagulation, Thrombolysis, Embolectomy, Surgical Revascularization, Amputation Thromboangiitis obliterans Buergers disease Rare, nonathersclerotic, inflammatory disorder Common in young men Affects: small and medium size arteries, veins, and nerves upper and lower extremities Strong correlation with smoking Pathophysiology Inflammatory process damages arterial wall Lymphocytes and giant cells infiltrate the vessel Fibroblast proliferation Thrombosis and fibrosis occur Tissue ischemia develops Signs and Symptoms Often confused with PAD or autoimmune disorders Intermittent claudication of feet, hands, or arms Color and temperature changes in affected limbs Paresthesia Superficial thrombophlebitis Cold sensitivity Rest pain Ischemic ulcerations Treatment options Smoking cessation Avoid trauma to the extremity Medication therapy Surgical therapy Sympathectomy, bypass Amputation Raynauds disease/phenomenon Episodic, vasospastic disorder Affects small cutaneous arteries Occurs primarily in young women May be an early manifestation of scleroderma Signs and Symptoms Vasospasm induced color changes of fingers, toes, nose, and ears Pallor--decreased perfusion Coldness and numbness Cyanosis--decreased perfusion Throbbing, aching pain Rubor--hyperemia Tingling and swelling Precipitated by cold weather, emotional upsets, smoking, or caffeine use Usually lasts for minutes Treatment options Prevention of recurring episodes Avoid temperature extremes Smoking cessation Avoid vasoconstrictors (caffeine, meds) Coping strategies Drug therapies: Ca-channel blockers Surgical options: Sympathectomy

 Aortic Aneurysms Aorta Role: largest artery in the body with major role is tissue perfusion Aneurysm Definition: bulging in artery wall Common in aorta Aortic arch Thoracic aorta Abdominal aorta usually below renal arteries Men > women Incidence increases with age Etiology Atherosclerosis*** Hypertension** Congenital abnormalities Premature degeneration of vascular elasticity Penetrating or blunt trauma Inflammatory aortitis Infectious aortitis Aneurysm classification True wall of the artery forms the aneurysm with atleast 1 vessel layer still intact Fusiform: circumferential; uniform in shape Saccular: bulging on one side of the vessel False not an aneurysm but a disruption of wall layers with bleeding pseudoaneurysm surgery, trauma or infection can cause Signs and Symptoms Thoracic aneurysm Often asymptomatic Deep, diffuse chest pain Angina Hoarseness Dysphagia Distended neck veins Facial & upper extremity edema

Abdominal aneurysm Often asymptomatic Found on routine exam Coincidence Pulsatile mass Bruit Abdominal or back pain Problems with bowel elimination Distal emboli

Complications RUPTURE!! ExsanguinationBleed to death People usually dont survive this unless it ruptures in the hospital or on the way to hospital Retroperitoneal bleed flank area Grey-Turner sign Hypovolemic shock cold, clammy, pale, High HR, LOW MAP

Diagnostic Tests Chest or abd. xray Electrocardiogram (ECG) Echocardiogram Abdominal Ultrasound Computed tomography (CT scan) *** Most accurate Magnetic Resonance Imaging (MRI) Angiography

Treatment options Prevent rupture Evaluate coexisting disorders Conservative therapy Risk factor modification Blood pressure control Frequent monitoring of size Surgical intervention: > 5.5 cm (males), > 5 cm (females)

 Endovascular Graft Procedure Minimally invasive Used in older, higher risk patients Cannot use in aortoiliac or renal involvement Benefits Most common complication: perigraft leak Open Surgical Repair Cross clamping of aorta Incising diseased segment of aorta Removing intraluminal thrombus & plaque Inserting & suturing synthetic graft Suturing native aortic wall around graft Unclamping aorta Actual Care of the Patient Pre-op: Bowel prep, NPO, shower with antimicrobial soap, IV antibiotics Post-op: ICU Graft patency: Maintain adequate BP, IV fluids, blood transfusion as needed CV status: Telemetry monitoring, oxygen, electrolytes, ABGs, pain control Infection: antibiotics, monitor for fever & leukocytosis, Strict aseptic technique Foley, IVs, incisions Actual Care of the Patient GI status: Monitor bowel sounds & passing of flatus; NG tube (100ml, normal color); early ambulation; NPO-mouth care Monitor for bowel ischemia: abdominal pain/distension Neurologic status: Ascending Ao & arch cerebral perfusion Descending Ao lower ext. movement Peripheral perfusion Renal perfusion: hourly urine output (30 ml/hr), I/O & daily wts, BUN & Cr Discharge Teaching Gradual increase in activity Expect fatigue, poor appetite, & irreg. bowel habits at first Avoid heavy lifting X 4-6 wks Report any fever; redness, swelling, pain, or drainage from incision Prophylactic antibiotics before future procedures Possible sexual dysfunction Aortic Dissection Most common location: thoracic Aorta LIFE THREATENING! Causes: HTN, Marfans, Blunt Trauma Sx per location Tearing, ripping pain Complications Cardiac tamponade, exsanguination, death Diagnostic tests: CXR, Transesophageal echocardiogram, CT scan Collaborative care: Lower BP & myo. contractility, conservative rx if asx; emergency surgery

Venous Disorders Veins: deoxygenated blood back to heart Valve malfunction results in stasis of blood clotting clots breaks off and travel to lungs pulmonary embolism Major Causes: Weak and damaged vein walls Stretched or injured one-way valves Blood clot Types: Varicose Veins Thrombophlebitis Deep Vein Thrombus Chronic Venous Insufficiency Diagnostic Tests for Venous Disorders Venous Duplex, CT scan, MRI, Venogram Varicose Veins Incompetent valves Risk Factors: FH, Gender, Occupation, Pregnancy, Deep vein obstruction, Trauma Signs & Symptoms: Bulging large bluish veins, Pain/Discomfort, Dull, heavy ache, Throbbing, Burning, Cramping, Swelling Complications: Ulcers & Non-healing sores Varicose Vein Treatment Conservative Treatment Weight loss Exercise Elevate leg Compression stocking Avoid activities that promote venous stasis Treatment of Varicose Veins: Laser therapy, Sclerotherapy Inflammation, scaring and closing of vein Surgical Treatment of Varicose Veins Endovenous Laser, Vein Ligation, Ambulatory Phlebectomy Patient Education after Endovenous Laser and Ambulatory Phlebectomy Compression bandage to minimize bruising Walking is encouraged immediately following the procedure Compression stocking Anti-inflammatory medication Heavy exercise avoided for 2 weeks Avoid hot tubs and swimming for 2 weeks Patient Education After Vein Ligation/Stripping Monitor for bleeding Assess extremities for color, movement, sensation, temperature, presence of edema Check dorsalis pedis & posterior tibial Compression stocking Elevate leg Anti-inflammatory pain medication Resume normal activities in two weeks or less. Exercise

 Venous Thrombosis Superficial Typically not dangerous Deep vein thrombosis (DVT) dangerous bc if breaks off can travel to lungs Thrombophlebitis of Hand Risk factors : Catheter >3 days Not flushing line Highly irritating medications Sign &Symptoms: Redness Tenderness Pain Treatment: Immediate removal of catheter Prevention Observation

Treatment for Thrombophlebitis Heat or cold application Elevation of affected extremity Pain management Tylenol Non-steroidal anti-inflammatory drugs (NSAIDS) Antibiotic Therapy if severe Anticoagulants typically not needed Deep Vein Thrombosis Causes Major surgery Leg trauma--a broken hip or leg Prolonged travel Family history of a blood-clotting disorder Cancer Oral contraceptives/HRT Smoking Varicose Veins Central venous lines (pacemaker & ICD leads) Repetitive motion Symptoms of DVT Unilateral Edema Majority have no symptoms Dull, aching pain in the affected extremity Leg pain that may worsen when you walk or stand Swelling, Redness, Warm to touch Homans sign Diagnostic Lab Test for Deep Vein Thrombosis D-dimer A blood test measuring fragments of fibrin as result of fibrin degradation & clot lysis. Elevated result suggests deep vein thrombosis Normal: <230ng/ml Abnormal: 230ng/mL Venous Thromboembolism Prevention: Core Measure of Quality Early & frequent ambulation Graduated compression stockings Sequential compression devices (SCDs): DO NOT use ICDs if patient has active DVT Drug Therapy

Surgical Treatment of DVT IVC Filter Greenfield Filter Inserted in the inferior vena cava via femoral vein Pre: Consent, check dye allergy, NPO, Shave Post: same as angiography May go home after 1-2 days Anticoagulant Therapy: Prevention & Treatment Heparin Unfractionated Heparin High Alert Medication Read dosage carefully Practical Guideline: Intravenous: treatment (must monitor aPPT levels closely if given IV) Baseline CBC, PT, PTT, & Platelet Count Bolus given Frequent PTT monitoring (q6-8 hrs) Dose adjustments by weight Length of therapy 5-7 days or until INR therapeutic Once INR gets to 3, pt can come off Heprin and switch to Coumadin Lovenox (Enoxaparin) Low molecular weight heparin (LMWH) Practical Guidelines: Subcutaneous Baseline CBC, PTT, PT, INR, Platelet Count No continuous PTT monitoring Dose determined by weight of patient 1mg/kg every 12 hours The average administration 7 days or until therapeutic goal of INR is achieved Coumadin (Warfarin) (antidote: Vitamin K) Practical Guideline By mouth (PO) Baseline CBC, PT, INR, Platelet Count Dose varies between patients Daily monitoring PT/INR Therapy long term for 6 months or longer

Pt Teaching: Food containing Vitamin K Over the counter medication ETOH, Safety, Report bleeding

Laboratory Values to Monitor Look at ppt chart!! INR: 2-3 seconds is the goal Higher INR, thinner the blood More warfarin (Coumadin) = thinner blood i.e. a higher INR Medication Value Frequency of Test Measures Q6 hrs until reach Ability of the blood aPTT goal of therapy, to clot; effect on Heparin Activated Partial then daily intrinsic & common (Antidote: Thromboplastin pathway protamine Time

Normal Values

Goal of Therapy

24-36 sec.

46-70 sec.

sulfate)

Coumadin (antidote: Vit K)

PT Prothrombin Time or Protime

Daily until reach goal of therapy

Ability of the blood to clot (inhibition of Vit. K dependent clotting factors

10-14 sec.

21-28 sec

Coumadin

(INR) International Normalized Ratio

Daily until reach goal of therapy

Used to monitor the effectiveness of anticoagulant

0.9-1.2 sec.

2.0-3.0 seconds

Chronic Venous Insufficiency (CVI) CVI is a condition characterized by valve dysfunction in deep veins causing backflow and pooling of blood in the legs leading to edema and changes in the skin. Causes of Chronic Venous Insufficiency Smoking Sitting/standing for prolonged periods of time Varicose Veins Superficial thrombophlebitis DVT Trauma Symptoms of CVI Leg pain Leg/ankle swelling Discoloration of the skin hemosiderin Thickened skin Varicose veins Leg ulcers Complication of CVI: Venous Ulcer Most venous skin ulcers develop on either side of the lower leg, above the ankle and below the calf. Dark red or purple over the affected area Thick, dry itchy skin Shallow wound Moderate to heavy drainage Slow to heal Prevention & Treatment for CVI Lifelong Compression stockings Customized Jobst stockings Prevention of venous ulcers Elevation Avoid sitting or standing for long periods of time Lifestyle changes Weight loss Exercise

Medical/Surgical Intervention for CVI & Venous Ulcer Wound therapy Vacuum-assisted closure therapy (Wound VAC) Surgery Valve repair Vein stripping Skin grafts

Lymphedema Definition: the accumulation of lymphatic fluid in the soft tissue that causes swelling, most often in the arm or leg. Types: Inherited absent or malformed lymph vessels at birth Acquired lymph node resection, radiation, infection, traumatic injury Lymphedema Signs and Symptoms: Puffiness and a feeling of heaviness in the affected limb Tightness of the skin Limited range of motion Graded 1 4+ Prevention and Treatment options for lymphedema Complex decongestive physiotherapy Manual lymph drainage (MLD) Compression bandage Compression stocking Skin care Exercise Wear loose fitting clothes No blood pressure or needle sticks in the affected extremity Have to get physician order to do so Drug Therapy for Lymphedema Antibiotics Coumadin Lasix Pain management NSAIDs Hydromorphone (Dilaudid) KNOW: What statements made by client indicates a need for furthering teaching or what is a statement that pt understands teaching of drug.