Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg

by Prof. Lawes

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    00:01 Okay. Now, let's delve into the cardiovascular. I know that was a lot in neurological, but that's predominantly Mr. Johnson's biggest problem since he had a stroke. So these are not going to be as long as we just did with neuro. But you learned some really key information on how nursing addresses the neurological system from start to finish.

    00:20 Now, we'll look at the heart. So, our goal here is just to maintain homeostasis and adequate tissue perfusion. Now, so we're going to monitor his vital signs and his cardiac rhythm. Good news, he's on the telemetry unit, so we can easily do that. We're going to watch his intravascular fluid volume.

    00:37 We don't want him to have too much or too little. So we don't want hypervolemia, extra volume, or hypovolemia, too low a volume. Now, you're going to listen to his lung sounds for signs of pulmonary edema. That's a sign of hypovolemia.

    00:53 So you're going to auscultate lung sounds with your stethoscope.

    00:56 And you want to make sure that you do it in the front and the back, and you want to do it from the bottom and the top, because we're most likely to develop the lung sounds of pulmonary edema, which we call crackles. They won't clear with coughing. But if he has crackles, it's normally going to start first in the back and in the bases.

    01:15 So don't just settle for doing a halfway assessment by listening to his lungs when he's laying down. Have him sit up, because remember, we're in telemetry. He should be able to do that. Have him sit up and listen to his lungs on both sides with deep breaths.

    01:30 If you're starting to hear sounds of crackles in the base of his lungs, they don't clear with coughing, we're starting to get into trouble with hypervolemia. So make sure you listen closely for that.

    01:41 Now, here's a cool one. Lung sounds are little bit easier to process Heart sounds take more practice, but you're listening for a murmur or an S3 or S4 sound. That's another sign of heart failure. So we're watching him for any signs of heart problems. We want to listen for pulmonary edema and listen for a S3 or an S4, a murmur, that's an additional sign of heart failure. Now, watching his blood pressure, keeping it within the orders that the healthcare provider has written.

    02:11 They'll give you a range on where you should maintain his blood pressure, particular to Mr. Johnson. And you're going to want to give anti-hypertensive medications as ordered. Now, remember, patients who've experienced strokes may also have cardiovascular disease.

    02:26 They're kind of common things that go together. So, we really want to watch them for risk of fluid volume overload because they have a higher risk for fluid volume overload than the average patient and also with their blood pressure. So, let's practice with Mr. Johnson.

    02:43 What do you know about him that you're going to be keeping an eye on? We've just discussed some challenges. I want you to pause the video without looking at your notes. Think about the things that you're going to watch for Mr. Johnson's cardiovascular system and special assessments that you'll do.

    03:02 Okay. So, you know that one of our goals is to maintain homeostasis and adequate tissue perfusion. Now, our goal is to prevent another clot from forming. Thrombus is another word for clot, or a venous thrombus. That's what a venothromboembolism -- that's why we shorten it sometimes to VTE. So, if the limbs are paralyzed or not moving as well, they present the highest risk for a VTE. So I'm going to be watching his right side very closely because we know he had a left-sided stroke, we're going to have right-sided problems.

    03:36 I'm going to encourage him to be as mobile and active as possible.

    03:40 That's the best for any patient. Keeps their lungs breathing, keeps their body parts moving. We regain strength. So every patient needs to be as mobile and independent as possible. Now, we'll likely use some compression type of sock and these will be ordered by the healthcare provider, but that's going to help make sure that we don't have that venous pooling. We don't want blood just hanging out down there because it's more likely to make a clot. So I'm going to make sure that if he's starting to look a little swollen in his extremities, that I elevate some of those to decrease that edema. So you want to position each joint higher than the joint proximal to it.

    04:16 So if I don't want dependent edema, if a patient was laying down, I could simply put their arms on some pillows. My wrist is higher than my elbow, and my elbow is higher than my joint. So when I say you want each joint, you want the position higher than the joint proximal to it, that's what you're going to do. So, wrist, higher than elbow, elbow higher than shoulder. I forgot there for my joint for a minute. Same thing with legs.

    04:44 You can tuck a pillow underneath the leg and the feet, and have them elevated if you start to notice some swelling in your patient's legs.

    04:51 So, now's your chance to practice with Mr. Johnson.

    04:54 Think through what we just talked about on the previous slide. What are some specific things you would do to assess him, to plan, implement, and evaluate his care dealing with cardiovascular? Okay. Welcome back. Now, let's see if you can answer this question.

    05:14 Why is a stroke patient at increased risk for a venothromboembolism? Okay. Hopefully, you remembered that a VTE is when a blood clot forms. Most often, it's in the deep veins of the leg. So, sometimes, you'll hear it called a DVT. So it's usually in the deep veins of the leg, but it can also be in the groin or the arm.

    05:35 So it can travel through the circulation and it lodges somewhere real important.

    05:39 Sometimes, it lodges in the lungs. So, if a deep vein thrombosis from my leg, or from my groin, or another part of my body travels around to the blood supply in my lungs, I can end up with a pulmonary embolism. Now these can be life-threatening.

    05:57 I've actually experienced a pulmonary embolus and I would not recommend it to anyone. So that's the biggest risk with a DVT or a VTE, those letters that we use.

    06:09 Things and parts of that or the whole clot can break off, travel around the rest of the body and block off a very important part of your circulation. So now that we've refreshed your memory on what a VTE is, let's answer the question.

    06:23 Why are stroke patients at a higher risk? Well, that's for lots of reasons.

    06:28 They're not as mobile as they used to be in normal life.

    06:31 They may have some paralysis or weakness on one side, so those are particularly going to be the areas where they're at risk to develop a DVT.

    06:39 So, why patients are at an increased risk for developing a clot is because they have increased immobility and weakness or paralysis in these legs. So, they're not moving as much and that gives the blood more time to hook together and make a clot.

    About the Lecture

    The lecture Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg by Prof. Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.

    Included Quiz Questions

    1. Maintain blood pressure within the range determined by the health care provider.
    2. Monitor for intravascular hypovolemia or hypervolemia.
    3. Monitor cardiac rhythm and vital signs regularly.
    4. Perform National Institutes of Health Stroke Scale exams regularly.
    5. Encourage the client to stay active and independent.
    1. In limbs that are paralyzed or immobile
    2. In limbs that have full range of motion
    3. In limbs with compression stockings applied
    4. In limbs with an absence of edema
    1. Decreased mobility
    2. Cardiac complications
    3. Cognitive dysfunction
    4. Lack of interventions after the stroke

    Author of lecture Cardiovascular Interventions: VTE – Stroke Nursing Care in Med-Surg

     Prof. Lawes

    Prof. Lawes

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