Release and observe filling Normal valves slow filling process incompetent

Release and observe filling normal valves slow

This preview shows page 27 - 37 out of 46 pages.

If vein does not fill within 35 sec valves not functioning properly. Release and observe filling Normal valves slow filling process; incompetent valves fill immediately Ankle-Brachial index b/p cuff placed above malleolus and another above brachial artery Doppler probe used to check systolic end point at dorsalis pedis and posterior tibial sites. ABI calculated by dividing ankle pressure by brachial pressure ABI > 1 considered normal Exercise-Stress Test No caffeine or smoking 6-8 hours before No B/P meds and light breakfast
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History Taking Risk factors Diet, exercise, etc. Medications especially OTCs (over-the-counter) Excessive alcohol intake Intermittent claudication Cramping pain in the muscles usually caused by exercise and relieved by rest Common symptom of arterial insufficiency to LE Affects calves mostly, but can affect thighs and gluteus. (Focused Assessment pg 383)
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Physical Assessment Abnormal or extra heart sounds: Murmurs Leaning forward or rolling to left side may make worse Pulses and Doppler stethoscope Bruit- whooping sound in their neck is severely clogged carotid arteries Blood pressure: Correct‑size cuff Orthostatic or postural hypotension (change 20 systolic and/or 10 diastolic) (Also refer to Focused Assessment p. 384.)
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Physical assessment pulse Quality Textbook 0 – absent 1+ weak, thready 2+ light volume 3+ normal 4+ full, bounding Practice (Stanford, VA)(on TEST) 0 – Absent 1+ weak, thread 2+ normal 3+ strong 4+ full, bounding
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Physical Assessment of the Skin Venous insufficiency and skin color Arterial blood flow and “return of color” Cold environment and immobility Malnourished skin – not enough blood flow (smooth, shiny, thin with little to no hair) Capillary refill test Homans’ sign
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Cultural Cues p. 383: Dyspnea as the Major Symptom African Americans often experience dyspnea as the most acute symptom during an MI. Dyspnea is more common than the more classic chest discomfort in this group. For this reason, they may delay seeking assistance.
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PQRST for Pain Assessment P: Precipitating events Q: Quality of pain or discomfort R: Radiation of pain S: Severity of pain T: Timing (Also refer to Table 17-3.) p. 383
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Nursing Diagnosis Risk for infection related to inflammation of lining of heart structures Anxiety related to life‑threatening disease Sleep pattern disturbance related to pain in the legs while at rest Chronic low self‑esteem related to activity intolerance or inability to perform usual roles because of chronic leg ulcers (Refer to Table 17-4 for details.)
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Nursing Goals for Cardiac Disorders Prevent death and complications. Monitor for complications. Promote adequate oxygenation. Alleviate or control pain. Decrease fear and anxiety. Balance activity and rest to prevent fatigue and provide adequate tissue perfusion.
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Nursing Goals for Cardiac Disorders Assist with activities of daily living (ADLs) until patient can resume self‑care.
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