The newest Diabetes links Hypertension, Atherosclerosis 3/27/2014

3/27/2014
The newest Diabetes links
Hypertension, Atherosclerosis
• DIABETIC SIMULATION Site
• http://www.diabeticretinopathy.org.uk/preve
ntion/insulindosesimulation.htm
• Last link for lots of ppt slides:
• http://www.ndei.org/login.aspx
Readings
• Ch 35 Review assessment
• Ch 38 Focus on Atherosclerosis and
Hypertension
• Read through PVD and aneurysms to gain
overview of complications
• Meds… lots of meds…
• Study by category and prototype med.
More on meds
• Try the medication jeopardy in evolve.
• Use the ATI pharmacology book and templates.
• Think: If a nurse was handing me a medication,
what would I want to know?
• What is it for?
• How does it work?
• What are the major side effects?
• What side effect could kill me? Harm me?
• When should I call the prescriber?
• Is there anything else I should worry about?
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The knowledge of frontline nurses that they gather from their interactions
with patients is critical to reducing medical errors and
improving patient outcomes.
• Involving nurses at a variety of levels across the acute care setting in decision
making and leadership benefits the patient, improves the organizations in which
nurses practice, and strengthens the health care system in general.
• Increasing the time that nurses can spend at the bedside is an essential
component of achieving the goal of patient-centered care.
• High-quality acute care settings require integrated systems that use technology
effectively while increasing the efficiency of nurses and affording them increased
time to spend with patients.
• Multidisciplinary care teams characterized by extensive and respectful
collaboration among team members improve the quality, safety, and effectiveness
of care.
• Many of the innovations that need to be implemented in the health care system
already exist somewhere in the United States, but barriers to their dissemination
keep them from being adopted more widely. As Dr. Marilyn Chow observed, “the
future is here, it just isn’t everywhere.”
The future is now -- LVAD
First LI patient gets
new 'heart' at
Stony Brook
Newsday article
Originally published: April 13,
2010 6:47 PM
http://www.iom.edu/
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Not-as-new TECHNOLOGY
Not out of the wrapper yet…
Can you read this?
Atherosclerosis
• http://www.youtube.com/watch?v=OHE1ig4k
64M&feature=relmfu
The ejection fraction (EF) refers to the amount, or percentage, of blood that is
pumped (or ejected) out of the ventricles with each contraction.
Ejection Fraction Numbers:
50-75% Heart's pumping ability is Normal
36-49% Heart's pumping ability is Below Normal
35% and Below Heart's pumping ability is Low
http://www.hrsonline.org/Patient-Resources/The-Normal-Heart/Ejection-Fraction#axzz2x4GAJPd5
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CHAPTER 38 Care of Patients with Vascular Problems
Ignatavicius Workman. Medical-Surgical Nursing, p. 779 in 7th ed,
p. 800 in 6th ed.
Concept Map
• Wait for it…
CHAPTER 38 Care of Patients with Vascular Problems
Ignatavicius Workman. Medical-Surgical Nursing.
Concept Map - Lifestyle Modifications
•
Health Teaching: Instruct the patient about sodium restriction, weight
maintenance or reduction, alcohol restriction, stress management, and
exercise. If necessary, also explain about the need to stop using tobacco,
especially smoking. Provide oral and written information about the
indications, dosage, times for administration, side effects, and drug
interactions for antihypertensives. Stress that medication must be taken
as prescribed and that when all of it has been consumed, the prescription
must be renewed on a continual basis. Suddenly stopping drugs such as
beta blockers can result in angina (chest pain), myocardial infarction (MI),
or rebound hypertension. Also urge patients to report unpleasant side
effects, such as excessive fatigue, cough, or sexual dysfunction. In many instances, an alternative drug can be prescribed to minimize certain side
effects. Ignatavicius Workman. Medical-Surgical Nursing.
• Risk for Ineffective Therapeutic Regimen Management
NURSING PROCESS
•
•
•
•
•
•
•
How do you know if he has
hypertension?
ASSESSMENT DATA FOR NURSING DIAGNOSIS
NURSING DIAGNOSIS COLLABORATIVE PROBLEMS
EXPECTED OUTCOMES WITH INDICATORS
NURSING
INTERVENTIONS
SCIENTIFIC RATIONALE FOR NURSING INTERVENTIONS
REALISTIC EVALUATION
– Effectiveness of Nursing Interventions
– Attainment of Expected Outcomes
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Categories for Blood Pressure Levels in Adults
(in mmHg, or millimeters of mercury)
From: 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults: Report From the
Panel Members Appointed to the Eighth Joint National Committee (JNC 8)
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427
Category
Systolic
(top number)
Diastolic
(bottom
number)
Normal
Less than 120
And
Less than 80
Prehypertension
120–139
Or
80–89
Stage 1
140–159
Or
90–99
Stage 2
160 or higher
Or
100 or higher
High blood
pressure
•
Figure Legend:
2014 Hypertension Guideline Management AlgorithmSBP indicates systolic blood pressure; DBP, diastolic blood pressure; ACEI,
angiotensin-converting enzyme; ARB, angiotensin receptor blocker; and CCB, calcium channel blocker.
aACEIs and ARBs should not be used in combination.
bIf blood pressure fails to be maintained at goal, reenter the algorithm where appropriate based on the current individual therapeutic
Copyright © 2014 American Medical
plan.
Date of download: 3/25/2014
Association. All rights reserved.
New Guidelines
What are you
going to do
about it?
Hypertension case study
Hypertension Algorithm
• Hypertension algorithm
• File
• JNC VII phycard
• http://www.nhlbi.nih.gov/health/dci/index.html
• ATP III Guidelines
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TOD
Where does the salt come from?
• Target Organ Damage
• What is an aneurysm?
http://www.mayoclinic.com/health/aorticaneurysm/DS00017
• http://www.sts.org/patientinformation/aneurysm-surgery/aortic-aneurysms
***
• http://www.mayoclinic.com/health/food-andnutrition/AN00413 grapefruit interactions
• http://hp2010.nhlbihin.net/atpiii/calculator.asp?
usertype=prof
How Much Salt???
• http://www.iom.edu/Reports/2010/Strategies-to-Reduce-Sodium-Intakein-the-United-States/Report-Recommendations-Strategies-to-ReduceSodium-Intake.aspx
• http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=
12818
• http://www.mayoclinic.com/health/sodium/nu00284
• http://www.library.umc.edu/pe-db/pe-noaddsalt.pdf
• http://www.library.umc.edu/pe-db/pe-sodium.pdf
• http://nutritioncaremanual.org/vault/editor/Docs/2gramsodiumdiet_FINA
L.pdf
Five Keys for Quitting Smoking
Studies have shown that these five
steps will help you quit and quit for
good. You have the best chances of
quitting if you use them together.
• Get Ready.
Get Support.
Learn new skills and behaviors.
Get medication and use it correctly.
Be prepared for relapse or difficult situations.
• http://www.cdc.gov/tobacco/quit_smoking/how_to
_quit/you_can_quit/five_keys/
Tobacco dependence syndrome
http://www.ncbi.nlm.nih.gov/pubmed/1859602
• World Health Forum. 1991;12(1):70-2.
• Implications of the tobacco dependence syndrome for smoking
control programmes.
• Ramström LM, Masironi R.
• Institute for Tobacco Studies, Stockholm, Sweden.
• Abstract
• Motivational and psychosocial treatments for tobacco dependence,
while valuable, are not sufficient to solve nicotine-related problems,
which usually require a pharmacological approach. There is also a
need for training programmes for health workers and major
educational campaigns on the nature of tobacco dependence to be
directed at opinion leaders, teachers and the public at large.
• PMID: 1859602 [PubMed - indexed for MEDLINE]
Diagnosis
Assess
Monitor
Do
Risk for ineffective
therapeutic regimen
management:
o
Smoking cessation
o
Blood pressure control
o
Lipid management
o
Physical activity
o
Weight management
o
Diabetic management
o
Anti platelets
o
ACEI
o
Beta blockers
o
Influenza vaccination
o
o
o
o
o
o
o
o
o
o
o
Assess the client
tobacco use and
exposure to tobacco at
each visit.
Assess for presence of
prehypertension
SBP=120-129 and
DBP= 80-89 if not
already diagnosed
Assess for SBP< 130140 And DBP< 80 if
diabetic or CKD if
currently receiving
HTN treatment (JNC
goal for treatment is
130/80 for CKD and
DM vs 140/90
otherwise)
Assess if LDL-C < 100
or < 70 for diabetic
clients and clients post
MI
Assess if moderate
intensity activities are
preformed for 30
minutes per day on
most if not all days of
the week
Assess if BMI 18.524.9 and waist
circumference
according to gender
Men < 40 inches
Women< 35 inches
Assess fasting blood
glucose <100 and if
required HgAiC < 7%
Assess for compliance
and tolerance of
antiplatelet therapy
Assess for use of
ACEI in presence of
LV EF <40%, HTN,
DM, CKD
o
o
o
o
o
o
monitor tolerance to
and compliance with
antihypertensive
therapy
monitor tolerance to
and compliance with
antilipemic therapy
monitor tolerance and
compliance with TLC
diet
http://www.
nhlbi.nih.go
v/cgibin/chd/ste
p2intro.cgi
monitor compliance
with antidiabetic
therapy if indicated
monitor tolerance to
and compliance with
anticoagulant therapy
monitor tolerance to
and compliance with
ACE inhibitor therapy
monitor tolerance to
and compliance with
beta blocker therapy
o
o
o
o
o
o
o
o
o
Call
If indicated; provide
referral to Tobacco
cessation program for
individual counseling
Discuss strategies to
manage and minimize
unique side effects to
antihypertensives
Instruct client in side
effects of antilipemic:
o
Review side
effects for
each agent
o
Review s/s of
liver
dysfunction
o
Review s/s of
myopathy
Review activity
recommendations
Administer TLC diet
Reinforce instruction in
bleeding precautions
Review management
of orthostatic
hypotension in
response to ACEI
Review pulse check
and reporting
requirements for HR
<60
Teach client s/s to
report
Administer flu vaccine
as ordered
o
o
o
o
o
o
o
o
Consult PT/exercise
physiologist for
exercise prescription
Refer to nutritionist for
dietary consultation
Call MD if fasting
blood glucose > 100 if
not previously
diagnosed with DM
Refer to diabetic
educator for f/u
Hold antilipemic and
call cardiologist if
myopathy or liver
dysfunction is present
Hold antihypertensives
and call cardiologist if
SBP < 90
Hold beta blockers
and call cardiologist if
HR < 50-60
Call MD if bleeding
times are prolonged or
s/s of bleeding are
present
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3/27/2014
Diagnosis
Assess
PC: arterial ischemia
CAD
AAA
PAD
CVA
Mesenteric ischemia
Rationale: The client
with atherosclerosis is
at risk for or may be
experiencing the
complications of arterial
ischemia that may
manifest throughout the
vascular system as
indicated by the
disorders listed above.
Assess for s/s of arterial
ischemia
CAD:
Chest discomfort,
shortness of breath,
nausea,
diaphoresis, activity
intolerance
Diagnosis
Assess
PC: arterial ischemia
CAD
AAA
PAD
Mesenteric ischemia
CVA
Rationale: The client
with atherosclerosis is
at risk for or may be
experiencing the
complications of arterial
ischemia that may
manifest throughout the
vascular system as
indicated by the
disorders listed above.
Assess for s/s of arterial
ischemia
MESENTERIC ISCHEMIA
Sever abdominal
pain, nausea,
vomiting diarrhea
Abdominal
distention, Absent
bowel sounds,
peritoneal signs,
frank blood in stool
and emesis s/s
shock
CVA:
Change in mental
status headache,
blurred vision,
paralysis/paresis,
change in sensation,
nausea, vomiting
neurological
changes, unequal
pupils seizures,
slurred speech
Monitor
Do
Call
CAD
Mon for the presence of
chest discomfort
Be aware that
female clients,
diabetics and clients
of non-white ethnic
background may not
present with
complaints of chest
pain.
If present
Perform 12 lead EKG stat
with complaints of chest
discomfort to document
degree of ischemia
Initiate ST elevation
MI protocol if
indicated
Initiate continuous cardiac
monitoring
Initiate continuous pulse
oximetry
Mon VS q 4 hours and prn
(increase frequency
during acute phase
and if receiving IV
medication that has
vasoactive
properties)
Mon troponin I and cardiac
enzymes q 8 hours as
ordered for signs of infarction
Assess baseline bleeding
times
Mon electrolytes to determine
renal function, hydration and
levels of potassium and
magnesium
Alterations in
potassium and
magnesium are
proarrhythmic
Perform lipid measurement if
not already performed
CAD
Initiate measure to restore
perfusion
Apply oxygen therapy& titrate
sao2 > 95%
Administer medications to
increase myocardial
perfusion:
Aspirin
Thrombolytic
therapy
Antiplatelet therapy
Nitrates
Sublingual
nitroglyceri
n versus IV
nitroglyceri
n (Tridil)
Heparin therapy
Administer medications to
reduce cardiac workload
IV beta blockers
followed by beta
blockers
Mon s/s of CHF and perform
echocardiogram as indicated
Administer ACEI or ARB for
LSVD (left systolic ventricular
dysfunction) if ordered
Prepare client for reperfusion
strategies utilizing
percutaneous interventions
(PCI) or revascularization
(CAGB)
Initiate protocol to monitor for
complications of myocardial
infarction
Otherwise:
Administer as
ordered:
Antilipemic
Antihyperte
nsives
antiplatelet
s
CAD
Collaborate with cardiologist,
interventionalist and cardiac
surgeon as indicated
Monitor
Do
Call
MESENTERIC ISCHEMIA
Mon GI status q4 hours and
prn
Mon for elevated HR and
decline in MAP q 4 hours and
prn
Monitor CBC for leukocytosis,
metabolic panel for elevated
BUN Assess for metabolic
acidosis by ABG as ordered
Prepare client for
angiography as ordered
CVA
Monitor neuro checks q 4
hours and prn for
neurological changes
Monitor for increased blood
pressure
Prepare client for CAT
scan/MRI/MRA as ordered
Perform continuous cardiac
monitoring to identify
arrhythmias. Ands 12 lead
EKG
Prepare client for carotid
Doppler as ordered
Assess for presence of
hyperglycemia
MESENTERIC ISCHEMIA
Initiate shock management if
symptomatic according to
standard protocols
Oxygen, cardiac monitor, IV
saline
Maintain NPO
Insert NG tube for gastric
decompression as ordered
Administer IV antibiotics as
ordered
Administer IV narcotic
analgesic as ordered
Prepare client for OR
CVA
If s/s present, obtain IV
access
Administer oxygen as per
protocol
Administer medications
according to type of stroke.
Prepare to initiate
thrombolytic stroke
protocol for a
thrombotic stroke
Administer antihypertensives
according to MAP or SBP in
collaboration with neurologist
Administer anticoagulants if
thrombotic stroke
Elevate HOB to 15-30
degrees as tolerated
Monitor for s/s of increased
ICP
Otherwise:
Administer as
ordered:
Antilipemic
Antihyperte
nsives
Antiplatelet
s
Prepare client for carotid
endarterectomy if required.
MESENTERIC ISCHEMIA
Collaborate with vascular
surgeon and interventional
radiologist as indicated
CVA
Consult neurologist and
neurosurgeons as indicated.
Prepare for evacuation of
bleeding if hemorrhagic
stroke
Diagnosis
• http://t2health.org/
AAA:
Assess for
abdominal or back
pain with a Pulsatile
abdominal
mass that is severe,
sudden, persistent,
or constant; may
radiate to groin,
buttocks, or legs
review appearance
of
Assess for presence
of abdominal bruit
on auscultation.
Assess for necrotic
lesion of toes and
feet secondary to
distal emboli.
Assess for s/s of s/s
of shock
PAD:
Complaints of
intermittent
claudication,
Decreased
peripheral pulses,
peripheral arterial
bruits, pallor,
peripheral cyanosis,
gangrene, ulceration
Monitor
Do
Call
AAA
Mon vital signs and blood
pressure q 4 hours and prn
Increase frequency
upon initial
complaint and if
vasoactive agents
are in use
Perform abdominal
exam q 4 hours and
prn Do not palpate
a pulsating mass if
present
Mon peripheral pulses q 4
hours and prn for signs of
emboli
Prepare client for CAT scan if
required to document size
Perform 12 lead EKG and
continuous cardiac
monitoring
Mon urine output for signs of
renal ischemia secondary to
emboli
Perform preoperative
bloodwork; type cross, CBC,
metabolic panel, cardiac
workup, PT/PTT
PAD
Assess for presence of acute
arterial occlusion manifesting
with extremity pain unrelieved
by narcotic analgesia
Assess brachial ankle index
Perform peripheral vascular
checks q 4 hours and prn
Monitor lipid levels
Assess bleeding times
Prepare client for
angiography
Assess for s/s of gangrene
and necrosis
AAA
Initiate hemorrhagic shock
protocol if indicated
Apply Oxygen
therapy
Establish IV access
Administer blood
products
Administer IV
antihypertensives
Insert Foley catheter
and mon hourly I/O
Prepare for OR
Otherwise:
Administer as
ordered:
Antilipemic
Antihyperte
nsives
antiplatelet
s
PAD
Administer medications to
maintain tissue perfusion:
Aspirin
Antiplatelets
pentoxifylline
Position client to maximize
tissue perfusion to lower
extremities
Do not gatch bed
Avoid heavy
blankets/pressure
on lower extremities
Consider
use of bed
cradle
Avoid exposure to extremes
in temperature changes/air
currents/unnecessary cooling
Manage clients requiring
revascularization procedures
Administer as
ordered:
Antilipemic
Antihyperte
nsives
Antiplatelet
s
AAA
Collaborate with vascular
surgeon as indicated.
PAD
Obtain PT consult
Collaborative with vascular
surgeon if amputation
required
.
What about my patient?
• my guy
• Metabolic syndrome
CHAPTER 38 Care of Patients with Vascular Problems
Telehealth
• EBP box p 803
Assess
PC: arterial ischemia
CAD
AAA
PAD
Mesenteric ischemia
CVA
(Continued)
Ignatavicius Workman. Medical-Surgical Nursing.
• Health Teaching: Instruct the patient about sodium restriction, weight
maintenance or reduction, alcohol restriction, stress management, and
exercise. If necessary, also explain about the need to stop using
tobacco, especially smoking. Provide oral and written information
about the indications, dosage, times for administration, side effects,
and drug interactions for antihyperten-sives. Stress that medication
must be taken as prescribed and that when all of it has been
consumed, the prescription must be renewed on a continual basis.
Suddenly stopping drugs such as beta blockers can result in angina
(chest pain), myocardial infarction (MI), or rebound hypertension. Also
urge patients to report unpleasant side effects, such as excessive
fatigue, cough, or sexual dysfunction. In many in-stances, an
alternative drug can be prescribed to minimize certain side effects.
•
Ignatavicius Workman. Medical-Surgical Nursing.
7
3/27/2014
Medications
•
•
•
•
Implications of:
Multidrug therapy
The Polypill
Managing “lots of pills” therapy
NURSING PROCESS
•
•
•
•
•
•
•
ASSESSMENT DATA FOR NURSING DIAGNOSIS
NURSING DIAGNOSIS COLLABORATIVE PROBLEMS
EXPECTED OUTCOMES WITH INDICATORS
NURSING
INTERVENTIONS
SCIENTIFIC RATIONALE FOR NURSING INTERVENTIONS
REALISTIC EVALUATION
– Effectiveness of Nursing Interventions
– Attainment of Expected Outcomes
8