# data[].attributes.body
S/S: visual changes, headaches, elevated BP

Complications: CHF, stroke, renal failure (elevated Cr & BUN), vision loss, R/f PAD/CAD

Education: Stop smoking pls, exercise, DASH, side effects of meds, don't stop taking meds abruptly, check your BP, change positions slowly, avoid alcohol, manage stress, cholesterol, blood sugar, SLEEP, limit caffeine

# data[].attributes.body
Signs, Symptoms, Interventions:

Venous: Brownish/edema, bounding pulses, varicose veins, wounds are wet (dressing changes), irregular borders, r/f DVT (may give heparin), swelling and warmth, heaviness in the legs, pain and tenderness, elevate the legs, compression, ambulate, diuretics for swelling, may tolerate activity better than PAD.

Arterial: Intermittent claudication (pain on exercising that is relieved with rest), cool/pale/blue/dusky skin, no hair, dry, diminished/absent pulse, nonhealing wounds, gangrene, low ABI, atherosclerotic plaque, don't elevate legs, dangle. 6 P's. Perfusion is priority.

Priorities: Maintaining circulation/perfusion, monitoring for pulses, preventing infection, manage pain

Anticoagulation to prevent clots in the extremity. Statins to reduce plaque formation.

# data[].attributes.body
Angina:

Stable: Relieved by rest, can be relieved by nitro

Unstable: Unrelieved by rest and nitro, CALL 911!

STEMI: EKG ST elevation, positive biomarkers

NSTEMI: No ST elevations, positive biomarkers

Labs/Tests/Procedures: Myoglobin, troponin, CKMB, PCI (VS, allergies to contrast, renal impairment, access sites, monitor for arrhythmias)/CABG (VS, heart and lungs sounds, access sites, sternal precautions-don't push, pull or lift, cardiac monitoring for arrhythmias), stress testing (exercise or chemical), EKG/ECG, Echocardiograms (TEE-NPO after midnight, TTE)

Teaching: S/S abnormal heart rhythm, S/S for women-shoulder, back, epigastric pain/heartburn, nausea, more likely to die. Men are more likely to have crushing chest pain. Risk factors: Overexerting yourself/shoveling, taking oral contraceptives, post-menopause, cholesterol (high LDL, high triglycerides, low HDL, high HgbA1C)

Medications: MONA. Nitro-3 max doses 3-5 minutes, check BP and HR between each dose. Aspirin-risk for bleeding/GI bleed/blood in stool. Store nitro in a cool dark place.

Priorities: Prepare for coronary angiography w/contrast (NPO, check for allergies to iodine/shellfish, witness consent) CABG: No lifting, pushing, pulling, sternal precautions, no baths/PCI: Have to lay flat 3 ish hours (if femoral access, no crossing legs), bleeding, EKG/tele/arrhythmias, VS, S/S infection, sternal precautions (CABG), changes in lung/heart sounds, AMS, monitor for cardiogenic shock

# data[].attributes.body
Signs and Symptoms:

DVT: Unilateral pain (usually calf), red/warm to touch, swelling

PE: Chest pain, SOB, bloody sputum, anxiety, hypoxia, cyanosis, rapid HR/hypotension, tachypneic

Labs/Tests:

DVT: D-Dimer, APTT (heparin), INR (warfarin), angiogram/ doppler, CBC

PE: Lung sounds, ABGs, D-Dimer, Coags, CT chest w/ contrast

Medications:

Anticoagulant: Heparin/Warfarin/Apixaban/Enoxaparin

Priorities:

Preventing respiratory failure and DEATH! Preventing PE, maintaining perfusion, exercising frequently, avoiding sedentary activities/long time sitting, hydration, avoiding compression if active DVT, elevate extremity, avoid crossing legs, no massaging

IF in respiratory distress: ELEVATE HOB FIRST, COUGH and DEEP BREATHE, OXYGEN

# data[].attributes.body
Signs and Symptoms:

Pruritis, fluid retention (edema, oliguria/anuria), fluid volume excess (ascites, JVD), low GFR, increased creatinine/BUN, potassium, sodium (depends), phosphorus, low calcium, hemoglobin/hematocrit/anemia (expect this to be low)

Labs/Tests/Procedures:

Hemodialysis: 3x per week for 3-4 hours, performed in hospital or outpatient clinic, central line double lumen/large bore/AV fistula (do NOT compress/tight clothing, do NOT draw blood/IVs or take BP, monitor for bruits and thrills, no arm procedures--have a sign), high risk for infection, rapid fluid and electrolyte shifts, hold medications if needed. Post-dialysis: hypovolemia, central pontine myelinolysis (CPM), disequilibrium syndrome (notify provider!!!!)

Peritoneal Dialysis: Can be performed at home or inpatient, sterile peritoneal catheter. Infection risk is high (cloudy dialysate, peritonitis).

Medications: Calcium supplements, phosphorus binders, no rapid fluid administration, sodium tabs if hyponatremic, give kayexalate or (insulin + dextrose) to bring potassium down.

Priorities: FLUID VOLUME EXCESS, Monitor electrolyte levels, BP, renal function, mental status (especially post dialysis), other organ systems, fistula assessment/avoid compression of fistula, monitor for bleeding (apply pressure), monitor for infection, dialysate cloudy-send cultures! Space out nephrotoxic medications, hold water-soluble meds until after dialysis.

# data[].attributes.body
Signs and Symptoms: Increased BUN & Cr, reduced GFR, fluid retention, ascites/peripheral edema, decreased Urine output/oliguria, uremia, pruritis (chronic over time),

Labs/Tests:

Renal function tests (creatinine, BUN, GFR, CrCl, UA/Urine culture), always get cultures first! KUB, CT scan, bladder scan, MRI, cystography, kidney biopsy

Priorities: Hypotension/Signs of hypovolemic shock, intravascular volume management, electrolytes, preventing CKD by addressing root cause (pre, intra, post), may give fluids or diuretics depending on the cause. Prevent renal injury from medications (contrast, abx, NSAIDs, metformin)

# data[].attributes.body
Signs and Interventions for BPH:

S/S: Difficulty urinating/weak stream, urinary retention, abdominal pain w/ urge to urinate

Interventions: Assist with voiding, bladder scan, straight catheterization, foley/indwelling, coude catheter curved tip, flomax/tamsulosin, proscar/finasteride. Digital rectal exam. Post-void residual bladder scan.

Signs and Interventions for UTI:

S/S: Dysuria, urgency, frequency, new onset incontinence, suprapubic pain, cloudy urine, pyelonephritis/cystitis, watch for confusion/lethargy (sepsis), can lead to prostate CA

Priorities: Urine output! >30mL/hr, preventing sepsis/renal failure, septic shock

# data[].attributes.body
Potassium: Musculoskeletal contraction and electrical impulses.

Hypokalemia: Muscle weakness, constipation, arrhythmias, paralysis, OH, can be caused by diarrhea, vomiting, suctioning/NGT to suction. Treat with supplements, IV fluids with K+ added.

Hyperkalemia: ECG Changes (Tall tented T-Wave, widened QRS), ectopic beats, and FATAL arrhythmias, diarrhea. NEVER PUSH IT! Do not give >20mEq per hour via IV. Precipitated by renal failure/low steroid hormones. TOO much K either PO or IV, salt substitutes. Treat with diuretics, insulin w/ dextrose.

Sodium: Regulates fluid balance between cells

Hyponatremia: Altered mentation/LOC, below 120mEq = seizure. Caused by hemodilution from too much water, vomiting/diarrhea. Treat with fluids GENTLY, don't correct too quickly (risk for CPM)

Hypernatremia: Tenting, agitation, muscle cramps, thirst, low grade fever, lethargy, restlessness. Caused by excessive intake, dehydration/lack of water, renal failure, worsens HTN/CHF. Restrict sodium, hydration with iso/hypotonic, avoiding excess sodium from NS.

Calcium: Causes cardiac contraction, calms the heart

Hypocalcemia: Heart is spazzing, bradycardic, hypotension, fractures, trousseaus sign, Chvostek's sign, TWITCHY tremulous. Caused by renal disease, poor intake, diuretics, diarrhea. Calcium gluconate, vitamin D, phosphorus binders (phos-lo, sevelamer, renvela)

Hypercalcemia: Tachycardia/increased contractility, bone pain, HTN, bounding pulses, constipation, malignancy, Caused by excess Ca+ absorption, AKI, low phosphorus, hyperparathyroidism. Treat with calcitonin, phosphorus supplementation.

Magnesium: Relaxes muscles

Hypomagnesemia: seizures, rapid HR, vomiting, TWITCHY, Increased DTRs, arrhythmias. Caused by diuretics, insulin, diarrhea and vomiting. Treat with Mag sulfate, dietary supplementation.

Hypermagnesemia: Respiratory depression, paralysis, hypotension, decreased DTRs, heart block, FLOPPY/flaccidity, NVD. Caused by laxatives, antacids, excess mag admin, DKA. Treat with diuretics, calcium gluconate.

Blood Glucose: Energy! Regulates insulin and glucagon

Hypoglycemia: Cool, clammy, diaphoretic, tachycardic, confusion. Treat: Give OJ if alert and can take PO, give glucagon if unconscious with NO IV, give dextrose if unconscious but have an IV.

Hyperglycemia: Irritable, hyper, hot/dehydrated, polyuria, polydipsia, polyphagia. Treat: Insulin! (watch potassium levels) Regular is the only one that is given IV. Metformin, glipizide/sulfonylureas (type 2 only).

Phosphorus: Foods high in phosphorus include meats, mixed greens/spinach, cereals, NUTS, canned vegetables

Chloride: SAME AS SODIUM

# data[].attributes.body
Left Sided: Crackles in lungs, SOB, orthopnea, elevated BNP, develop a murmur, pulmonary edema, hypoxia, pale nail beds/extremities, diminished pulses, delayed cap refill, decreased sensation, fatigue/exertional dyspnea, pleural effusion

Right Sided: JVD, hepatomegaly/splenomegaly, pitting edema, ascites, weakness/fatigue, weight gain, diminished pulses if excess fluid or bounding pulses from too much intravascular fluid

Labs/tests: BNP (lung sounds), troponin, myoglobin, CKMB, BMP/CMP, CBC

Medications: Diuretic--Furosemide (potassium, monitor for FVD), HCTZ, Positive inotropes--digoxin (HR and BP)

Priorities: Airway/Breathing!!!!!!! Prevent pulmonary edema!

I&Os, weight (daily), >5lbs/week, 2-3/day, notify your provider

Teaching: Weight daily, avoiding high sodium processed food, watch OTC meds, take your OWN meds as prescribed, ACE wraps, elevate legs

# data[].attributes.body
Types?

Crystalloids: Isotonic (maintain equilibrium, 0.9% normal saline), hypotonic (lower solute concentration; causes cells to swell, 0.45% normal saline), hypertonic (higher solute concentration; causes cells to shrink, increases vascular volume; D5 & NS, D10)

Colloids: Albumin (holds fluid in the vascular space, cardiovascular, respiratory if third spacing is severe, gastrointestinal), proteins, blood!!!, platelets, fibrinogen (clotting factors, given when patient is bleeding!!!! (FYI, may need surgery)

Fluid Volume Deficit? HYPOTENSION/low blood pressure/tachycardic, orthostatic hypotension (fall risk), Dehydration, dry membranes, change is mental status, weak and thready pulse, concentrated urine, urine specific gravity, CBC/BMP, CrCl, Creatinine, BUN, Hemoglobin and hematocrit, intake and output, watch for anything less than 30mL/hr

Fluid Volume Excess? Edema, weight gain, HYPERTENSION, JVD, crackles/respiratory failure, bounding pulses/tachycardic, bladder scan if concerned about retention, hemodilution (decreased H&H, potassium, calcium, sodium), CrCl, Creatinine & BUN

Things to watch out for? URINE OUTPUT AND BLOOD PRESSURE