NURS 352 Adult Health II
Module 3 Worksheet
Name: Rachel Shin
1. Fill in the table (20 points).
Characteristics
Risk Factors (5 pts.)
Primary Hypertension
Modifiable Factors
• High sodium intake
• Low potassium, calcium,
and magnesium intake
• Obesity
• Excess alcohol
consumption
• Insulin resistance
Secondary Hypertension
•Kidney disease
•Coarctation of the aorta
•Endocrine disorders
•Neurologic disorders
•Drug use
• Pregnancy
(LeMone et al., 2015, p.980).
Nonmodifiable Factors
• Genetic factors
• Family history
• Age
• Race
(LeMone et al., 2015, p.970).
Symptoms (5 pts.)
The early stages of primary
hypertension typically are
asymptomatic, marked only by
elevated blood pressure. Blood
pressure elevations are initially
transient but eventually become
permanent. When symptoms do
appear, they are usually vague.
Headache, usually in the back of
the head and neck, may be
present on awakening, subsiding
during the day. Other symptoms
result from target organ damage,
and may include nocturia,
confusion, nausea and vomiting,
and visual disturbances.
Examination of the retina of the
eye may reveal narrowed
arterioles, hemorrhages,
exudates, and papilledema
(LeMone et al., 2015, p.969).
The pattern of secondary
hypertension varies, depending
on its cause. Pheochromocytoma
may cause attacks of
hypertension that last for
minutes to hours, accompanied
by anxiety, palpitations,
diaphoresis, pallor, and nausea
and vomiting. Primary
aldosteronism may cause
hypertension, weakness,
paresthesia, polyuria, and
nocturia. Symptoms of kidney
disease accompany hypertension
when a renal disorder is the
cause
(LeMone et al., 2015, p.980).
Complications (5 pts.)
The rate of atherosclerosis
accelerates, increasing the risk
for coronary heart disease and
The aorta and its branches may
be affected by occlusions,
aneurysms, and inflammation.
1
NURS 352 Adult Health II
Characteristics
Care Management (5 pts.)
Primary Hypertension
stroke. The workload of the le^
ventricle increases, leading to
ventricular hypertrophy, which
then increases the risk for
coronary heart disease,
dysrhythmias, and heart failure.
Most deaths due to hypertension
result from coronary heart
disease and acute myocardial
infarction or heart failure.
Accelerated atherosclerosis
associated with hypertension
increases the risk for cerebral
infarction (stroke). Increased
pressure in the cerebral vessels
can lead to development of
microaneurysms and an
increased risk for cerebral
hemorrhage. Hypertensive
encephalopathy may develop
(LeMone et al., 2015, p.969).
• Maintain normal body weight;
lose weight if overweight. • Eat a
diet rich in fruits, vegetables, and
low-fat dairy products. • Reduce
sodium intake • Reduce intake of
cholesterol, total and saturated
fat. • Limit alcohol intake to no
more than 1 oz of ethanol (1/2 oz
for women and lighter weight
people) per day. • Engage in
aerobic exercise for 30 minutes
most days of the week (5 to 6). •
Stop smoking. • Use stress
management techniques such as
relaxation therapy. Current
pharmacologic treatment of
hypertension involves using one
or more of the following drug
classes: diuretics, beta-adrenergic
blockers, centrally acting
sympatholytic, vasodilators,
angiotensin converting enzyme
(ACE) inhibitors, angiotensin II
receptor blockers (ARBs), and
calcium channel blockers
(LeMone et al., 2015, p.972).
Secondary Hypertension
These disorders may be chronic
or acute and life threatening
(LeMone et al., 2015, p.980)
• Maintain normal body weight;
lose weight if overweight. • Eat a
diet rich in fruits, vegetables, and
low-fat dairy products. • Reduce
sodium intake • Reduce intake of
cholesterol, total and saturated
fat. • Limit alcohol intake to no
more than 1 oz of ethanol (1/2 oz
for women and lighter weight
people) per day. • Engage in
aerobic exercise for 30 minutes
most days of the week (5 to 6). •
Stop smoking. • Use stress
management techniques such as
relaxation therapy. Current
pharmacologic treatment of
hypertension involves using one
or more of the following drug
classes: diuretics, beta-adrenergic
blockers, centrally acting
sympatholytic, vasodilators,
angiotensin converting enzyme
(ACE) inhibitors, angiotensin II
receptor blockers (ARBs), and
calcium channel blockers
(LeMone et al., 2015, p.972).
2
NURS 352 Adult Health II
2. List 6 Risk factors for developing a Deep Vein Thrombosis (DVT). (6 points)
a. Immobilization: myocardial infarction, heart failure, stroke, post operative
b. Surgery: orthopedic, thoracic, abdominal, genitourinary
c. Cancer: pancreas, lung, ovary, testes, urinary tract, breast, stomach
d. Trauma: fractures of the spine, pelvis, femur, tibia; spinal cord injury
e. Pregnancy and delivery
f. Hormone therapy: oral contraceptives, hormone replacement therapy
(LeMone et al., 2015, p.9987
3. List 4 signs and symptoms of DVT. (4 points)
a. Dull, aching pain in affected extremity, especially when walking
b. Possible tenderness, warmth, erythema along affected vein
c. Cyanosis of affected extremity
d. Edema of affected extremity
(LeMone et al., 2015, p.997)
4. Describe important nursing consideration for preventing DVT. (2 points)
Position patients to promote venous blood flow from the lower extremities, with the feet elevated and the
knees slightly bent. Avoid placing pillows under the knees and positions in which the hips and knees are sharply
flexed. Use a recliner chair or footstool when sitting. Ambulate patients as soon as possible and maintain a
regular schedule of ambulation throughout the day. Teach ankle flexion and extension exercises, and frequently
remind patients to perform them. Apply elastic hose and pneumatic compression devices when appropriate.
Instruct patients to avoid crossing legs when in bed or sitting. Inquire about possible prophylactic heparin or
warfarin therapy for patients undergoing orthopedic surgery or other high-risk procedures. Frequently assess
intravenous sites. Change the site and catheter as dictated by agency protocol and if evidence of local
inflammation is noted
(LeMone et al., 2015, pp. 999-1001).
5. What is the main complication of DVT (1 point)
The major complications of deep venous thrombosis are chronic venous insufficiency and pulmonary embolism.
Pulmonary embolism occurs when the clot fragments or breaks loose from the vein wall. As the clot travels, it
moves through progressively larger veins and into the right side of the heart. From there it enters the pulmonary
circulation, where it eventually occludes arterial flow to a portion of the lungs. The result is a mismatch between
ventilation (air flow) and perfusion (blood flow) in a portion of the lungs. The effect on gas exchange depends on
the size of the embolism and the vessel it occludes (LeMone et al., 2015, p.997).
6. Obstruction of pulmonary blood flow due to a pulmonary embolism affects both Click or tap here to enter
text.and Click or tap here to enter text.. (2 points)
Perfusion and ventilation
(LeMone et al., 2015, p.997).
3
NURS 352 Adult Health II
7. List 5 common manifestations of pulmonary embolism (PE). (5 points)
a. Dyspnea and shortness of breath
b. Chest pain
c. Anxiety and apprehension
d. Cough
e. Crackles (rales)
(LeMone et al., 2015, p.1192)
8. Prepare drug cards for Heparin and Warfarin (Coumadin). (10 points)
DRUG CARD: Heparin
Generic Name
Trade Name (s)
Classification
Heparin
Not listed in the text.
Heparins
Mechanism of Action: (how does this drug work on the body)
Heparin combines with antithrombin III (a natural anticoagulant in the blood) to inactivate clotting factors IX, X, XI, and
XII; inhibit the conversion of prothrombin to thrombin; and prevent thrombus formation. After thrombosis has
developed, heparin can inhibit additional coagulation by inactivating thrombin, preventing the conversion of fibrinogen
to fibrin, and inhibiting factor XIII (fibrinstabilizing factor). Other effects include inhibition of factors V and VIII and
platelet aggregation.
General Indications/Uses: (who takes this and for what reason)
Prophylactically, patients at risk for certain disorders take low doses of heparin prophylactically to prevent DVT and
pulmonary embolism. These disorders include the following: Major illnesses (e.g., acute myocardial infarction, heart
failure, serious pulmonary infections, stroke); major abdominal or thoracic surgery; a history of thrombophlebitis or
pulmonary embolism, including pregnant women; gynecologic surgery, especially in patients who have been taking
estrogens or oral contraceptives or have other risk factors for DVT; restrictions such as bed rest or limited activity
expected to last longer than 5 days.
Side Effects:
Serious Adverse Effects:
Contraindications: (who cannot take this medication)
Hemorrhage is the major side
effect of heparin therapy,
hypersensitivity to the drug has
occurred, and local irritation
with subcutaneous injections of
heparin can cause erythema and
mild pain. Heparin-induced
thrombocytopenia (HIT) (type II)
is a potentially life-threatening
complication of heparin
administration, leading to a
decrease in platelet count and
detectable HIT antibodies. This
condition occurs in 1% to 3% of
people receiving heparin at
therapeutic levels for 4 to 14
days, sometimes sooner in those
who have previously received
heparin
Heparin-induced
thrombocytopenia (HIT) (type II)
is a potentially life-threatening
complication of heparin
administration, leading to a
decrease in platelet count and
detectable HIT antibodies. This
condition occurs in 1% to 3% of
people receiving heparin at
therapeutic levels for 4 to 14
days, sometimes sooner in those
who have previously received
heparin
GI ulcerations (e.g., peptic ulcer disease,
ulcerative colitis), intracranial bleeding,
dissecting aortic aneurysm, blood dyscrasias,
severe kidney or liver disease, severe
hypertension, polycythemia vera, and recent
surgery of the eye, spinal cord, or brain. Caution
is necessary in patients with hypertension, renal
or hepatic disease, alcoholism, history of GI
ulcerations, drainage tubes (e.g., nasogastric
tubes, indwelling urinary catheters), threatened
abortion, endocarditis, and any occupation with
high risks of traumatic injury.
4
NURS 352 Adult Health II
NURSING IMPLICATIONS
Preventing Interactions: (medication interactions, procedural interactions etc.)
Alteplase, direct thrombin inhibitors, platelet inhibitors increase the risk of bleeding. Antithrombin increases
pharmacologic effects. Cephalosporins lead to potential coagulopathies and risk of bleeding. Penicillins (parenteral) lead
to altered platelet aggregation and increased risk of bleeding. Warfarin may prolong and possibly invalidate the PT; if
receiving both heparin and warfarin, draw blood for the PT at least 5 hours after the last IV heparin dose. Antihistamines,
digoxin, nicotine, nitroglycerin (IV), tetracycline decrease the anticoagulant effect.
Administering the Medication: (when, how, frequency etc.)
Prescribers use the activated partial thromboplastin time (aPTT), which is sensitive to changes in blood clotting factors,
except factor VII, to regulate heparin dosage. Thus, normal or control values of aPTT indicate normal blood coagulation,
and therapeutic values of adequate anticoagulation indicate low levels of clotting factors and delayed blood coagulation.
During heparin therapy, the aPTT should be maintained at approximately 1.5 to 2.5 times the control or baseline value.
The normal control value is 25 to 35 seconds; therefore, therapeutic values of adequate anticoagulation are 45 to 70
seconds, approximately. With continuous IV infusion, blood for the aPTT may be drawn at any time; with intermittent
administration, blood for the aPTT should be drawn approximately 1 hour before a dose of heparin is scheduled. It is not
necessary to monitor aPTT with low-dose standard heparin given subcutaneously for prophylaxis of thromboembolism
or with the LMWHs.
Assessing for Therapeutic Effects: (how do you know it is effective and addressing the client’s problem )
The nurse assesses for the absence or reduction of signs and symptoms of thrombotic disorders (e.g., less edema and
pain with DVT, less chest pain and respiratory difficulty with pulmonary embolism, absence of uncontrolled bleeding). It
is also necessary to ensure that aPTT values are within the therapeutic range.
Assessing for Adverse Effects: (distinguish between which are normal side effects and which are adverse effects and need intervention )
The nurse assesses the patient for signs of overt bleeding or HIT. Protamine sulfate, which is discussed in more detail
later in the chapter, is an antidote for standard heparin and LMWHs. Protamine is typically given for bleeding that may
not respond to merely withdrawing the heparin or when hemorrhaging is present.
Patient Teaching: (include those specific to this drug that you would need to teach the patient)
To help prevent blood clots from forming and decreasing blood flow through your arteries, you need to reduce risk
factors that contribute to cardiovascular disease. This can be done by a low-fat, low-cholesterol diet (and medication if
needed) to lower total cholesterol to below 200 mg/dL and low-density lipoprotein cholesterol to below 130 mg/dL;
weight reduction if overweight; control of blood pressure if hypertensive; avoidance of smoking; stress-reduction
techniques; and regular exercise.
Any QSEN Alerts or Black Box Warnings (if listed for this drug):
Several major adverse events have resulted from the use of heparin, and it is classified as a high-alert drug. Nurses
demonstrate consistent practice in administrating heparin by their heightened individual awareness of the risks and by
advocating for systems to account for human error such as bar coding and “smart” pumps. Effective standardized
practices to support safety and quality include special safeguards to reduce the risk of errors that may harm the patient.
(Wilkins et al., p.147)
5
NURS 352 Adult Health II
DRUG CARD: Warfarin
Generic Name
Trade Name (s)
Classification
Warfarin
Coumadin
Vitamin K antagonist
Mechanism of Action: (how does this drug work on the body)
Warfarin acts in the liver to prevent synthesis of vitamin K–dependent clotting factors. Acts as a competitive antagonist
to hepatic use of vitamin K.
General Indications/Uses: (who takes this and for what reason)
Warfarin is most useful in long-term prevention or management of venous thromboembolic disorders, including DVT,
pulmonary embolism, and embolization associated with atrial fibrillation and prosthetic heart valves. In addition,
warfarin therapy after myocardial infarction may decrease reinfarction, stroke, venous thromboembolism, and death.
Side Effects:
Primary adverse effect
associated with warfarin therapy
is hemorrhage. Additionally,
nausea, vomiting, abdominal
pain, alopecia, urticaria,
dizziness, and joint or muscle
pain may occur.
Serious Adverse Effects:
Hemorrhage
Contraindications: (who cannot take this medication)
GI ulcerations, blood disorders associated with
bleeding, severe kidney or liver disease, severe
hypertension, and recent surgery of the eye,
spinal cord, or brain. Caution is warranted in
patients with mild hypertension, renal or hepatic
disease, alcoholism, history of GI ulcerations,
drainage tubes, or occupations with high risks of
traumatic injury. Warfarin, a pregnancy category
X medication, is contraindicated during
pregnancy because it crosses the placenta and
may produce fatal fetal hemorrhage.
NURSING IMPLICATIONS
Preventing Interactions: (medication interactions, procedural interactions etc.)
Acetaminophen (high dose), allopurinol, amiodarone increases the anticoagulant effect. Antithrombin increases the
pharmacologic effect. Cephalosporins result in potential coagulopathies and risk of bleeding. Chlorthalidone may
diminish warfarin’s ability to cause blood clots to form. Ethchlorvynol, trazodone cause effects by unknown mechanism.
Etretinate may induce anticoagulant’s hepatic microsomal enzyme. Chlordiazepoxide, haloperidol, intravenous lipid
emulsions (contains soybean oil), isotretinoin, meprobamate, spironolactone cause effects by various mechanisms.
Administering the Medication: (when, how, frequency etc.)
Vitamin K antagonists such as warfarin have a narrow therapeutic window of adequate anticoagulation without bleeding
and a highly variable individual dose–response that requires monitoring by laboratory testing.
Assessing for Therapeutic Effects: (how do you know it is effective and addressing the client’s problem )
The nurse assesses for the absence or reduction of signs and symptoms of thrombotic disorders (e.g., less edema and
pain with DVT, less chest pain and respiratory difficulty with pulmonary embolism, absence of uncontrolled bleeding,
hematuria or blood in the stools). It is also necessary to ensure that PT and INR values are within the therapeutic range.
Assessing for Adverse Effects: (distinguish between which are normal side effects and which are adverse effects and need intervention )
The nurse assesses for signs of bleeding, including excessive bruising of the skin, bleeding from IV sites or the gum line,
and blood in urine or stool. As previously stated, vitamin K is the antidote for warfarin and may be administered if the
INR level is 5 or more and signs of bleeding are present. Additionally, prothrombin complex concentrate (PCC), human
(Kcentra) is used for urgent warfarin reversal with major or lifethreatening hemorrhage.
Patient Teaching: (include those specific to this drug that you would need to teach the patient)
To help maintain a steady level of anticoagulation with warfarin, do not change your intake of foods that are high in
vitamin K, which decreases the effects of warfarin. These foods include broccoli, brussels sprouts, cabbage, cauliflower,
chives, collard greens, kale, lettuce, mustard greens, peppers, spinach, tomatoes, turnips, and watercress.
Any QSEN Alerts or Black Box Warnings (if listed for this drug):
Warfarin increases the risk of causing major or fatal bleeding
(Wilkins et al., p.153)
6
NURS 352 Adult Health II
References
LeMone, P., Burke, K. M., Bauldoff, G., & Gubrud, P. M. (2015). Medical-Surgical nursing: Clinical
reasoning in patient care (6th ed.).
Wilkins, W. L., Frandsen, G., Pennington, S. S., PhD, & Lynn, P. (2017). Abrams Clinical Drug Therapy
11th Ed. /Lippincott Photo Atlas of Medication Administration 5th Ed.: Rationales for Nursing
Practice (11th ed.). Lippincott Williams & Wilkins.
7