Summary NR_509 Revision Guide For Exams.

NR_509 Revision Guide For Exams. - Transient Arterial Occlusion: Transient compression of both arms by bilateral blood pressure cuff inflation to 20 mm Hg greater than peak SBP augments the murmurs of mitral regurgitation, aortic regurgitation, and ventricular septal defect. Signs of heart failure on assessment: (jen) - An elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis - In patients with obstructive lung disease, the JVP can appear elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure. - An elevated JVP is >95% specific for an increased left ventricular end diastolic pressure and low left ventricular EF, although its role as a predictor of hospitalization and death from heart failure is less clear. - Displacement of the PMI lateral to the midclavicular line or >10 cm lateral to the midsternal line occurs in LVH and also in ventricular dilatation from myocardial infarction (MI) or heart failure. - Pulsus alternans: Patient will have a strong pulse, then weak pulse, indicative of severe left sided HF - A diffuse apical impulse suggests left ventricular dilatation often found in congestive heart failure. - An S3 in adults over age 40 years (an S3 gallop) is usually pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. - In most adults over age 40 years, the diastolic sounds of S3 and S4 are pathologic, and are correlated with heart failure and acute myocardial ischemia. - Orthopnea and PND occur in left ventricular heart failure and mitral stenosis and also in obstructive lung disease Peripheral Artery Disease PAD-refers to stenotic, occlusive, and aneurysmal disease of the abdomen aorta, its mesenteric and renal branches, and the arteries of the lower extremities, exclusive of the coronary arteries. Atherosclerotic disease leading to obstruction of peripheral arteries causing exertional claudication (muscle pain relieved by rest) and atypical leg pain; may progress to ischemic pain at rest. Usually in calf but also in the buttock, hip, thigh, or foot depending on the level of obstruction; rest pain may be distal in the toes or forefoot. PAD timing: may be brief if relieved by rest; if there is rest pain, may be persistent and worse at night. PAD aggravating factors: Exercise such as walking; if rest pain, leg elevation and bedrest. Coronary heart disease risk equivalent: peripheral arterial disease, abdominal aortic aneurysm, carotid atherosclerotic disease, and diabetes mellitus. Relief factors: Rest usually stops the pain in 1-3 min; rest pain may be relieved by walking (increases perfusion), sitting with legs dependent. Associated manifestations: local fatigue, numbness, progressing to cool dry hairless skin, trophic nails, diminished to absent pulses, pallor with elevation, ulceration, gangrene. Asymmetric BPs can be sign of: aortic dissection or coarctation/congenital narrowing of the aorta PAD risk factors: 1. > 50 2. Smoking, dm, htn, elevated cholesterol, african american, or CAD Symptom location suggests the site of arterial ischemia: 1. Buttock, hip-aortoiliac 2. Erectile dysfunction- iliac-pudendal 3. Thigh- common femoral or aortoiliac 4. Upper calf- superficial femoral 5. Lower calf- popliteal 6. Foot- tibial or peroneal Peripheral arterial disease warning signs: these symptoms suggest= intestinal ischemia of the celiac or superior or inferior mesenteric arteries 1. Fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, identify the location. Ask also about erectile dysfunction. 2. Any poorly healing or non-healing wounds on the legs or feet 3. Any pain present when at rest in the lower leg or foot and changes when standing or supine. 4. Abdominal pain after meals and associated “food fear” and weight loss 5. Any 1st degree relatives with AAA (15 %-28%) PAIN IN CALVES great indicator of PVD!!!! Upper extremity DVT- central venous catheters. Ask about arm discomfort, pain, paresthesias, and weaknesses. Most patients are asymptomatic with thrombosis detected on routine screening. Screening tool/diagnostic for all patients with suspected DVT: WELLS CLINICAL SCORE AND THE PRIMARY CARE RULE Risk factors for lower-extremity peripheral arterial disease 1. > 65 year or > 50 years with a hx of dm or smoking 2. Leg symptoms with exertion 3. Non-healing wounds The ankle-brachial index: noninvasively diagnose PAD. The ABI is the ratio of blood pressure measurements in the foot an arm; values <0.9 are abnormal. Mild disease: ABI of 0.71 to 0.9. Moderate disease: ABI 0.7 and 0.41. Severe disease is ABI 0.4 or less. As the internal diameter of a blood vessel changes, the resistance changes as well...Resistance varies proportionally to the fourth power of the diameter Treatment for PAD: supervised exercise program, tobacco cessation, treatment of hyperlipidemia, optimal control of diabetes and htn, use of antiplatelet agents, meticulous foot care and well fitting shoes, revascularization. -expanding hematoma from triple A= may cause symptoms by compressing the bowel, aortic branch arteries, or ureters. -Mesenteric ischemia: food fear, weight loss, or dark stool. These symptoms suggest mesenteric ischemia from arterial embolism, arterial venous thrombosis, bowel volvulus or strangulation, or hypoperfusion. Failure to detect acute symptoms can cause bowel necrosis or death. -Atherosclerotic PAD: symptomatic limb ischemia with exertion. Ask about any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes, called intermittent claudication, pain in calves. -Neurogenic claudication: Pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs, lower legs, or feet. -Spinal stenosis: the positive likelihood ratio LR of spinal stenosis is>6 if the pain is relieved by sitting and bending forward, or if there is bilateral buttock or leg pain. Decreased arterial perfusion: hair loss over the anterior tibiae. Ask about coldness, numbness, or pallor in the legs or feet or loss of hair over the anterior tibial surfaces, and thin, shiny, atrophic skin Venous insufficiency: scaling, redness, varicosities, hyperpigmentation, and painful ulcerative lesion near the medial malleolus. Lymphatics from the ulnar surface of the forearm and hand, the little and ring fingers, and the adjacent surface of the middle finger, drain first into the epitrochlear nodes. Patients with spinal stenosis, have a relief of leg pain when they bend over. Sometimes leg pain can look like claudication, but if the pain is relieved by the patient bending over, it is likely that spinal stenosis, not PVD. Valve Stenosis Arterial/Venous Insufficiency Arterial/Venous Insufficiency Venous Insufficiency (brown) -Venous insufficiency: Often painful. Mechanism is venous stasis and HTN. Pulses are normal, although may be difficult to palpate through the edema. Normal, or cyanotic on dependency petechiae and then brown pigmentation appear with chronicity. Normal temperature. Edema often present. Often brown pigmentation around the ankles, stasis dermatitis, and possible thickening of the skin and narrowing of the leg as scarring develops. If ulceration occurs; develops at sides of ankle, especially medially. NO GANGRENE. Arterial insufficiency (Rubor and ischemic ulcer)