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N172: CARDIOVASCULAR SYSTEM: TEST QUESTIONS WITH
CORRECT ANSWERS
Describe some clinical manifestations of PAD including elevation pallor, reactive hyperemia, rest pain? -- Answer ✔✔ elevation pallor: limb is elevated and becomes pale reactive hyperemia (dependent rubor): limb is dependent > blood pools there rest pain: insufficient blood flow (pain at rest) What are the complications of PAD? -- Answer ✔✔ 1. Prolonged ischemia = muscle atrophy
- Delayed wound healing > wound infection and necrosis
- Amputation What are some diagnostic studies for PAD? What is the diagnostic of choice for PAD? -- Answer ✔✔ Doppler ultrasound, duplex imaging (color mapping flow through artery) Segmental BP: patient lays supine and SBP thigh, knee, ankle, if >30mmhg drop = PAD Ankle-brachial index: ankle SBP + brachial SBP MRI *Angiography (direct visualization) What is the interprofessional care (risk factor modification, drug therapy, exercise therapy, nutritional therapy)? -- Answer ✔✔ Risk factor modification: similar to CAD Drug therapy: ASA or clopidogrel, cilostazol (Pletal) and pentoxifylline (Trental) for intermittent claudication Exercise therapy: training for increased 02 extraction for metabolism, goal: 30-45 min X3 days per week Nutritional therapy: ideal body weight (decreased caloric intake, cholesterol, salt and saturated fat) What is the leg care for PAD? -- Answer ✔✔ similar to DM foot care
Protect from trauma (shoes are soft and roomy) Daily inspection and care, no soaking Heels free from pressure No chemicals, no extremes from heat or cold If ulcerated, clean/dry dressing as indicated Describe the IR interventions for PAD? -- Answer ✔✔ Percutaneous transluminal balloon angioplasty Intravascular stents to prevent problem of restenosis/narrowing of artery Atherectomy: high speed drill on tip of a catheter used to shave plaque from the artery walls (rotoblator), may f/u w/angioplasty and cryoplasty to minimize re-stenosis What are the nursing interventions for acute care for PAD? -- Answer ✔✔ Assess CMS frequently Compare to unaffected limb Report loss/diminished palpable pulses or diminished doppler sound to HCP STAT Check for bleeding, hematoma, thrombosis, compartment syndrome Avoid knee-flexed position in bed Avoid prolonged sitting w/legs dependent OOB X3 on POD # Compression stockings to control leg edema (not before surgery, but done after revascularization surgery to decrease blood flow) What are the 3 types of PAD and explain them -- Answer ✔✔ 1. Acute Arterial Ischemic Disorders (AAID): sudden impaired blood supply to tissues by embolism, thrombosis of an already narrowed lumen, or from trauma
- Thromboangiitis Obliterans (Buerger's): nonatherosclerotic, inflammatory disorder of medium-sized arteries, veins and nerves, strong relationship to tobacco use and periodontal infections
- Raynaud's Phenomenon: vasospastic disorder of small cutaneous arteries (mostly fingers and toes) Define HTN -- Answer ✔✔ sustained, elevated BP SBP > 140, DBP > 90 elevated readings over several weeks on several occasions = DX of HTN 46% of US population is DX, 48% do NOT have controlled BP (asymptomatic)
Why is HTN called the silent killer? What are s/sx of HTN? -- Answer ✔✔ No symptoms until target organs become diseased S/sx: dizziness, fatigue, reduced activity tolerance, palpitations, angina, dyspnea Describe how HTN effects the following organs/systems: Heart, CVS, PVS, kidneys, eyes -- Answer ✔✔ Heart: CAD, LVH, CHF CVS: atherosclerosis, stroke, encephalopathy PVS: aortic aneurysm/dissection, intermittent claudication (pain in legs during physical activity) Nephrosclerosis: ESRD (kidney failure) Retinal damage: retinal hemorrhage and loss of vision When is BP usually the highest? Lowest? -- Answer ✔✔ Highest: AM Lowest: PM What is diurnal variability? What is a reverse dipper? What is the BP target level? -- Answer ✔✔ D.V: BP higher in the AM, decreases at night Reverse dipper: BP low in the morning, high at night (needs medication mgmt) BP target level: 130/80 or lower What are the recommended lifestyle changes for HTN? -- Answer ✔✔ weight reduction dietary changes (DASH diet and Na <2g/day) no smoking/chewing (increased vasoconstriction) decrease alcohol: men <2/day, women <1/day increase physical activity (30 min most days, can divide into smaller increments for same benefit) manage psychosocial risk factors (stress mgmt and coping skills) Describe the DASH diet What is recommended in this diet? -- Answer ✔✔ Dietary Approaches to Stop Hypertension used to access high BP 4 - 6 servings of fruits and veggies and grains 2 - 3 servings of fish and poultry and dairy small servings of fat and sweets
What is the goal of drug therapy for HTN? What is the main action of BP drugs? -- Answer ✔✔ BP < 140/90 for all patients of all ages and if at risk for CAD, DM, CKD SBP < 130 for 65+ BP < 130/80 for all other patients with CVD and other risk factors Main action of drugs: decrease SV, decrease circulating blood volume What is anemia? Is it a disease? What is it? -- Answer ✔✔ Deficiency in the number of erythrocytes (RBCs), the quality of hemoglobin, and/or volume of packed RBCs Not a disease Manifestation of a pathologic process, a condition with many causes Define the 2 classifications of anemia? -- Answer ✔✔ Morphologic: based on cell characteristics Etiologic: underlying cause related to dietary deficiency, malignancy, chronic diseases Describe the 3 causes of anemia -- Answer ✔✔ 1. Decreased RBC Production
- Loss of RBCs/Blood loss
- Increased RBC destruction by hemolysis What are the 5 types of anemia caused by Decreased RBC production and describe them. Which is most common? -- Answer ✔✔ 1. Iron Deficiency Anemia: most common
- Megaloblastic Anemia: Pernicious Anemia or Cobalamin or Vit B12 Deficiency Anemia, Folic acid deficiency anemia
- Thalassemia (genetic)
- Anemia of chronic disease: Chronic inflammatory states, autoimmune disorders, renal disease
- Aplastic anemia: bone marrow suppresses production of RBCs What are the 2 types of blood loss that can cause anemia? -- Answer ✔✔ 1. Acute blood loss: surgery, trauma
- Chronic blood loss: bleeding ulcers, menstrual flow Describe the 2 types of anemia caused by Increased RBC production? Which can happen from ABO incompatibility? -- Answer ✔✔ 1. Sickle cell anemia
- Acquired hemolytic anemia (from ABO incompatibility)
What do the RBC indices look like in iron deficiency anemia? -- Answer ✔✔ ALL are decreased (H/H, MCV, MCH, MCHC, serum iron, ferritin) How do you increase iron in your diet? -- Answer ✔✔ liver and muscle meats Iron preps: s.e: black stools, if liquid: dilute and drink through a straw or will stain teeth over time take on empty stomach for best absorption or after meals to decrease GI distress take with orange juice to increase absorption increase fluids and fiber to prevent constipation Describe thalassemia? What is the treatment? -- Answer ✔✔ Genetic blood disorder characterized by absent or reduced globulin protein = inadequate production of normal hgb = decreased RBCs Tx: blood transfusion Describe Cobalamin (B12) deficiency? What is the treatment? Which patients are at risk for this? -- Answer ✔✔ aka pernicious anemia Intrinsic factor (IF) missing so unable to absorb B Tx: B12 injections for life Post gastrectomy patients due to loss of IF Describe the 3 ways folic acid deficiency can occur? What deficiency of RBCs is this? Tx? -- Answer ✔✔ 1. Malabsorption syndromes
- Drug therapy that interferes with folic acid (chemotherapy drugs)
- Chronic hemodialysis (folic acid gets filtered out) Decreased RBC production Tx: Epogen Describe 4 diseases under "Anemia of Chronic Disease"? Tx? -- Answer ✔✔ 1. ESRD: decreased erythropoietin, folic acid loss in during dialysis
- End-stage liver disease: ETOH abusers have poor nutritional intake and decreased IF secretion, coagulopathies
- Chronic inflammation and malignancies (from chemo and radiation, HIV tx)
- Chronic endocrine diseases (DM, thyroid disorders) Tx: Epogen, increased nutritional intake of iron, folic acid, Vit B12 replacement
Describe aplastic anemia? What do the labs look like in this condition? s/sx? What is found in a bone marrow biopsy for this condition? What could be the cause of this condition? -- Answer ✔✔ usually acquired with unknown origin could be autoimmune (something attacks the bone marrow) h/h decreased, reticulocytes decreased, all other labs are NORMAL S/sx: gradual or sudden onset of pancytopenia Bone marrow biopsy results: hypocellular state w/increased yellow marrow (fat) instead of red marrow Causes: chemo, ABX, meds, radiation, trauma to bone marrow What would the labs look like in acute blood loss? What would cause acute blood loss? -- Answer ✔✔ Decreased RBCs, Decreased h/h, all other labs are normal Hemorrhage, trauma, surgery What would the labs look like in chronic blood loss? What would cause chronic blood loss? -- Answer ✔✔ decreased h/h, RBC indices are decreased, serum iron decreased, TIBC decreased, reticulocytes are normal or elevated (compensation by the body) Causes: bleeding ulcer, hemorrhoids, menses, post-menopausal bleeding (iron is lost instead of returning to bone marrow for use) What cause of anemia is sickle cell anemia? Describe it. What is it triggered by? How do you prevent it? -- Answer ✔✔ Increased Erythrocyte destruction HbS (s-shaped hemoglobin) gene on chromosome 11 (autosomal recessive disorder) Triggered by: hypoxia from infections, high altitude, stress, surgery, blood loss Prevention: Early tx What complications can occur from sickle cell crisis? -- Answer ✔✔ vasoocclusive crisis vasospasm thrombi tissue ischemia infarction necrosis What is the management for sickle cell crisis? -- Answer ✔✔ Prevention! Early intervention for infections (avoid crisis) Get vaccinated
70 - 88 year old females: minimal decrease in hgb Anemia in older adults: R/T underlying causes (dietary deficiency of folate, cobalamin and iron, bleeding, renal insufficiency, chronic inflammatory conditions, cancer, and no identifiable cause Clinical manifestations: same but may not be noticed due to other health issues Multiple co-morbid conditions in older adults increase the risk for anemia Define the following: SBP DPB Pulse Pressure MAP What is the calculation for MAP? What MAP is required for adequate tissue perfusion? If MAP is decreased, what happens to the organs? -- Answer ✔✔ SBP: force on walls during contraction DBP: force on walls during relaxation Pulse Pressure: difference between SBP and DBP MAP: Mean Arterial Pressure = average pressure felt by organs MAP = DBP + 1/3 pulse pressure OR (SBP + 2DBP) / 3 MAP of 60 required for adequate tissue perfusion Decreased MAP = organ damage Define the following: Preload Afterload Contractility Stroke Volume Cardiac Output -- Answer ✔✔ Preload: amount of blood in LV before contraction Afterload: LV wall stress during ejection Contractility: ability to contract Stroke Volume (SV): amount of blood ejected @ each contraction, affected by PAC (Preload, Afterload, Contractility) Cardiac Output (CO) = SV X HR Which demographics of people have the highest rates of HTN? What type of BP meds do African Americans NOT respond well to?
Why are Mexican Americans more likely to have HTN? Describe the age difference for Men and Women with HTN? -- Answer ✔✔ African Americans and Latinos > Whites African Americans: earlier onset, more aggressive, more complications, higher mortality, produce less renin Don’t respond to ACE inhibitors (ex: Lisinopril) Mexican Americans are less likely to seek tx, less control, less aware of HTN and tx HTN increased within males until age 64, then it increases with females Describe how BP is regulated by baroreceptors? What happens to the baroreceptors with consistent HTN? -- Answer ✔✔ BP increase > baroreceptors in aortic arch and carotid artery will trigger and inhibit SNS > decrease HR and decrease force of contraction, vasodilation of peripheral arterioles BP decrease > baroreceptors in aortic arch and carotid artery activates SNS > increase HR and increase force of contraction, vasoconstriction of peripheral arterioles Consistent HTN = baroreceptors accept high BP as "normal" = no response and no s/sx How does the vascular endothelium regulate BP? -- Answer ✔✔ single layer of blood vessels that produce vasoactive substances: Nitric oxide: relaxing factor derived from endothelium = vasodilation (decreased SV and decreased BP) Prostacyclin: maintains low arterial tone at rest = vasodilation (decreased SV and decreased BP) Endothelin: produced by endothelium and is an extremely potent vasoconstrictor (increased afterload, increased SV and increased BP) How does the renal system regulate decreased BP (4)? -- Answer ✔✔ decreased BP: renal retention of water and Na (increases vascular volume to increase BP) Renin-angiotensin-aldosterone response: vasoconstriction and retain fluid to increase BP ADH release: retain fluid to increase BP Activate SNS: increase HR and vasoconstriction to increase BP How does the renal system regulate increased BP (3)? -- Answer ✔✔ Increased BP: inhibit SNS = decreased HR and vasodilation to decrease BP Prostaglandin secretion: vasodilation to decrease BP Natriuretic peptides secretion: diuretics to decrease water and sodium (decreased vascular volume to decrease BP)
Why are HTN meds given in combination? -- Answer ✔✔ achieve desired BP goal with less dose-related S.E. What is the subjective and objective data for HTN assessment? -- Answer ✔✔ Subjective: past health hx, meds, functional health patterns Objective: CV, GI, Neurological, Diagnostic findings List some nursing dx for HTN -- Answer ✔✔ 1. Ineffective self mgmt
- anxiety
- Risk for sexual dysfunction
- risk for decreased tissue perfusion What are the planning/goals for HTN tx? -- Answer ✔✔ 1. Achieve and maintain BP target
- Adhere to dz mgmt regime
- Experience minimal S.E.
- Manage/cope w/HTN What are the nursing interventions for HTN? -- Answer ✔✔ 1. Ongoing BP monitoring
- Record S.E. (ortho hypo)
- Identify/change modifiable risk factors
- Adherence to mgmt regime
- Consistent visits to HCP for review of status (f/u is essential) How do you evaluate HTN mgmt? -- Answer ✔✔ 1. Achieve target BP for age w/minimal S.E.
- Consistent implementation of tx plan
- Modification: if BP remains elevated, might be overactive renal nerves and radio- frequency ablation/renal denervation is needed to lower BP and inhibit SNS activity What are the gerontologic considerations for HTN? -- Answer ✔✔ common in adults
Physiological changes: loss of tissue elasticity, increased collagen content and stiffness of myocardium, increased PVR, decreased baroreceptor reflexes, decreased renal function, decreased renin response to Na and H20 depletion
What does auscultatory gap mean? -- Answer ✔✔ gap between first Korotkoff sound (sound of turbulent blood flow through a compressed artery) and subsequent beats, SBP may be seriously underestimated unless cuff is inflated high enough (pump cuff to 180 or 200 to not miss 1st sound) Why do we start BP meds at a low dose? -- Answer ✔✔ Decreased BP for chronic HTN may cause perfusion problems What is the standard triple therapy for HTN? -- Answer ✔✔ thiazide diuretic, Ca Channel blocker, and an ACEI or ARB Decreased baroreceptor response puts patient at risk for what? How do you measure this? -- Answer ✔✔ postural or orthostatic hypotension > risk for falls Measure BP supine, sitting, standing Why do we caution NSAID use for older patients with HTN? -- Answer ✔✔ may cause loss of BP control and HF, adverse renal effects and/or hyperkalemia when taken w/ACEI or ARBS if the patient has vasodilation, what happens to SV? if the patient has vasoconstriction, what happens to SV? if the patient has increased blood volume, what happens to SV? if the patient has decreased blood volume, what happens to SV? -- Answer ✔✔ decreased SV increased SV increased SV decreased SV Describe CAD? Why is this disease significant? -- Answer ✔✔ Heart disease that stems from atherosclerosis (soft deposits of fat that harden with age) in any artery of the body but happens mostly in coronary arteries. Leading cause of death globally and in the U.S. Describe the etiology of CAD? -- Answer ✔✔ Atherosclerosis is a major cause of CAD Focal deposits of lipids primarily in the intimal wall of the artery Endothelial injury and inflammation are precursors to atherosclerosis
For elevated triglyceride and cholesterol: decrease saturated fats (red meat, eggs), decrease/eliminate alcohol and simple sugars, increase fatty fish 2X/week (salmon and tuna) Drug Therapy for Lipid control contains 4 drugs classes that do different actions. Describe the 4 types and their actions and give examples. Why is low-dose ASA given to these patients? -- Answer ✔✔ 1. Drugs that restrict lipoprotein production in liver Ex: statins (Simvastatin), Nicotinic acid, fibric acid
- Drugs that increase removal of lipoproteins by increasing the conversion of cholesterol to bile for elimination Ex: cholestyramine
- Drugs that decrease LDL from the blood Ex: PCSK9 inhibitors (evoloucumab)
- Drugs that decrease cholesterol absorption Ex: inhibits intestinal absorption (ezetimibe) low dose ASA is given to decrease platelet aggregation for less chance of thrombus formation what are the gerontological considerations for CAD? -- Answer ✔✔ 1. CAD greatly increased in older adults
- Leading cause of death in older adults
- Aggressive tx of HTN and hyperlipidemia w/smoking cessation = decreased risk of CAD
- Older adults need > warm up periods + > low-level exercise sessions + > rest periods between sessions
- Greater incidence of unstable angina and MI complications What are the 2 primary causes of angina and give examples of how these occur? -- Answer ✔✔ 1. decreased supply of 02 (narrowed arteries from atherosclerosis resulting in decreased blood flow), anemia, hypoxemia of respiratory disorders (PNA, COPD), hypovolemia = decreased perfusion
- increased demand for 02 (Physical exertion, hyperthyroidism, tachycardia, anxiety, dysrhythmias, substance abuse w/cocaine or meth) Describe chronic stable angina? -- Answer ✔✔ Chest pain/discomfort in chest or burning in epigastric (substernal) area X few minutes
Constricting/squeezing May radiate to neck, back, and arms Provoked by exertion or stress Usually relieved by rest and nitroglycerine What are the clinical manifestations of chronic stable angina? -- Answer ✔✔ 1. Intermittent chest pain, same pattern (onset, duration, intensity) over time
- Pain lasts 5-15 minutes, ends when precipitating factor is relieved (ST depression from ischemia)
- No pain at rest
- Often predictable and controlled by routine meds Describe silent ischemia -- Answer ✔✔ up to 80% myocardial ischemia not detected by any symptoms Prognosis is the same as painful angina DM patients have increased prevalence R/T diabetic neuropathy to cardiac nerves (masking pain of angina and can’t feel it) Describe Prinzmetal's Angina (rare)? What triggers it? How is it relieved? What is seen on the EKG? Tx? -- Answer ✔✔ - usually occurs at rest, R/T major coronary artery spasm caused by increased intracellular Calcium
- seen in patients w/hx of migraine h/a and Raynaud's phenomenon, may or may not have CAD Triggered by: increased 02 demand, tobacco smoke, increased histamine Relieved by: activity or stops spontaneously EKG reading shows transient ST segment elevation Tx: Ca Channel blockers or nitrates (vasodilators) and lifestyle changes (no smoking, alcohol, cocaine) Describe microvascular angina? Triggered by? Tx? -- Answer ✔✔ - affects small branches of distal coronary arteries
- plaque is evident (diffuse of throughout)
- prevalent in post-menopausal women, men can experience it also
- triggered by physical exertion
- tx interventions are the same for men and women
Describe the difference between NSTEMI and STEMI? Describe the patho of an MI? -- Answer ✔✔ NSTEMI: non-ST elevation MI STEMI: ST-elevation MI Myocardium becomes cyanotic within 10 seconds of coronary occlusion > EKG changes
contractility ceases after several minutes > no glucose delivered > lactic acid accumulation > irritation of myocardial nerves > pain message to cardiac nerves (pain in L shoulder and L arm) > if ischemia is <20 minutes cell injury is reversible > blood flow restored, contractility restored and repair begins What are the diagnostic tests to determine an MI? -- Answer ✔✔ H/P, CAD risk factors Pain: PQRST (precipitating factors, quality, severity, time) Abnormal heart sounds: S4 indicated LV enlargement Chest xray: size of heart EKG: electrical and mechanical function Stress test (Treadmill) ECHO Cardiac Markers: Troponin, Serum CK-MB, Myoglobin Describe Cardiac Markers. Which can reveal if a 2nd MI has occurred? What other labs are done if MI is suspected? -- Answer ✔✔ Troponin: cardiac specific, onset: 4-6 hrs, peak: 10-24 hours, return to normal: 10-14 days (check q 6 hrs X 3) Serum CK-MB: cardiac specific, onset: 6 hrs, peak: 18 hrs, return to normal: 24-36 hrs Myoglobin: NOT cardiac specific, onset: 2 hrs, peak: 3-15 hrs, return to normal: 24 hrs Myoglobin can show if 2nd MI has occurred. Other labs: Lipid panel, CBC, CRP, BMP, homocysteine What are the invasive diagnostic tests done for an MI? Which test is the #1 diagnostic test for MI? -- Answer ✔✔ 1. Transesophageal ECHO
- Nuclear Cardiology
- MRI
- Cardiac Computed Tomography
- Cardiac Catheterization (#1 diagnostic test) Describe Cardiac catheterization/coronary angiogram, PCI, CABG -- Answer ✔✔ Use radial or femoral artery to insert dye into arteries to check patency (best way to see what is happening in the arteries and det. interventions)
PCI: angioplasty (balloon) and stent placement to keep coronary arteries open CABG: Coronary Artery Bypass Graft if angioplasty is not feasible What are the interventions for MI? What is the acronym for ACS interventions? When should fibrinolytic meds be given? -- Answer ✔✔ 12 lead EKG IV access Admin 02 VS (increased HR and BP) Drug therapy: relief of pain w/nitrates (nitroglycerine) and analgesic (morphine for vasodilation), ASA, Beta-blockers, ACEI, ARBS, high dose statin MONA: Morphine (pain and vasodilation), 02, Nitroglycerine, ASA (prevent thrombus) Fibrinolytic meds should be given within 30 min of arrival to reverse injury from hypoxia and ischemia What other interventions are necessary during MI? -- Answer ✔✔ Auscultate heart sounds Position of comfort (semi or high fowlers) Follow-up teaching (once stable): CAD and angina, risk factors, tx goals What is the nursing assessment (subj/obj data) for Chronic Unstable Angina and Acute Coronary Syndrome (UA) -- Answer ✔✔ Subj data: Past Med Hx, risk factors Obj data: CV system and skin assessment, diagnostic tests What are some nursing dx for Chronic Unstable Angina and Acute Coronary Syndrome (UA) -- Answer ✔✔ Acute pain Risk for/Actual decreased Cardiac Output Anxiety Risk for/Actual Activity Intolerance Ineffective Self-Health Mgmt What are some goals for Chronic Unstable Angina and Acute Coronary Syndrome (UA) -- Answer ✔✔ Pain relief Demonstrate effective CO Decreased anxiety Restore/improve activity intolerance Identify measures to reduce risk factors, rehab as necessary
