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Prepared by: Ancy Varghese Staff Nurse ICU Department

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Patient Name : xyz Age & sex : 80yrs/female MRN : 196388 Admission Date : 11-2-13@1200h Nationality :Saudi Diagnosis :AF with Poplitial Artery embolization(embolectomy done)

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The patient is 80yrs old female, approximately Weight 75kg..on 12 th February she was intubated on A/C mode.she was under sedative & ionotropics support. .BP :130/80mmhg .PR : 70/mt .RR :12 .Temp:36.5C .SpO2 :98%

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SKIN.Fair Complexion.Warm(but in second day lower extremities were cold).No Palpable mass or lesions, with good tigor

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HEAD.No palpable masses & lesion.No areas of deformity LEVEL OF CONSCIOUS & ORIENTATION.patient was conscious & oriented on admission. She was intubated on second day (12/2/13 ) and then on fully sedation. EYES.Pupils equally round and reactive to light

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EARS.No unusual discharges noted.Pink nasal mucosa NOSE.No unusual discharges.No tenderness in sinus MOUTH.Pink and moist oral mucosa and free of swelling and lesions

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NECK AND THROAT.No palpable limb nodes.No masses and lesions seen CHEST AND LUNGS.Equal chest expansion.Bilateral basal crept present ABDOMEN. Soft abdomen.Bowel sounds present

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GENITALS.Minimal pubic hair

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PAST MEDICAL HISTORY No past medical history PRESENT MEDICAL HISTORY 80yrs old female patient came in ER with the complaint of shortening of breath and burning micturation. Primary care given from ER and then shifted to new ICU.Chest x-ray done,it shows patchy opacity was seen in both lower areas and cardiomegaly.Her ECG shows AF with controlled rhythm.

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The next day patient developed cold lower extremities with absent pulses..So urgent vascular surgery consultation & arterial doppler done. Bilateral poplitial artery embolus seen in doppler. Patient was urgent taken to the OT by vascular surgeon and bilateral poplitial artery embolectomy was done under L/A.Patient developed bradycardia, hypotension, hypoxia and mild bleeding from the wound site, patient was resuscitated with IV fluids and ionotropic

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Support and was mechanically ventilated. After all management patient was extubated and fully conscious and oriented. Patient shifted to peadia ward. MEDICATIONS DRUGDOSEROUTEACTION Inj.augmentin1.2gmivAntibiotic(broad spectrum) Inj.nexium40mgivH2 receptor Inj.clexane60mgs/cLow molecular heparin

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Tab. Aspirin81mgp/oAnt platelet Tab.astatin40mgp/oLipid lowering agent

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TESTPATIENT VALUENORMAL V ALUES WBC8.54.23-9.07 Hb10.513.7-17.5 PLT221163-337 UREA6.281.8-8.3 CREATININE107.8446-92 TROPONIN0.1010.120 CPK3726-308 CPKMB77.0-25.0 SODIUM138135-150 POTTASIUM4.43.5-5.0 CHLORIDE10198-111

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Patchy opacity is seen in both lungs. Apparent cardiomegaly Vascular markings are normal DOPPLER BOTH LIMBS It reveals thrombus filling the lumen of both lower limbs poplitial arteries with flow obstruction distal to it. CAROTID DOPPLER There is normal colour filling and flow pattern. No evidence of any stenosis or plaque seen

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DOPPLER OF BOTH UPPER LIMB Normal colour flow in the both subclavian,axillary,brachial,radial and ulanar arteries. ULTRASOUND KUB Bilateral kidneys are normal in shape with increase cortical echogenicity with partial loss of cortico-medullary demarcation. Bilateral renal disease.

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AFIB: very common arrhythmia and leading cause of embolic CVA Initial Workup: trop, ECG, TSH, Echo, CXR Management: First must determine if stable or unstable (medically manage or cardiovert immediately) For stable Afib: rate and rhythm control (equal in efficacy).

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CHARACTERISTICS P Waves absent Rhythm irregular HR is above 150/mt QRS complex is narrow

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Rhythm - Regular Rate - (68 bpm) QRS Duration - Normal P Wave - Visible before each QRS complex P-R Interval - Normal 0.20sec(

AFIB SBP 90-110 SBP 100 to 120 SBP >120 DIGOXIN Load : 0.5mg IV 6 hrs later; 0.25mg IV 6 hrs later; 0.25 mg IV Maintenance: 0.125 mg daily B-Blocker Initial: Metoprolol 5mg IV 5min x3doses Prn: metoprolol 5mg IV q6h Maintenance: Metoprolol 25 mg po BID (max 100mg BID) Ca2+ Blockers Initial and prn: Diltiazem 10mg IV q6hrs Maintenance: Diltiazem 30mg PO q6hs

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The popliteal artery, like any other peripheral artery, can be affected by embolism. Macroemboli have a tendency to lodge in the popliteal artery at the bifurcation into the tibioperoneal trunk and anterior tibial artery. An embolus in the lower extremities most often has a cardiac source. Other sources include aortic aneurysms and proximal arterial plaque or ulceration. Regardless of the source, acute arterial embolism almost always requires urgent treatment.

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Figure 1b. Normal anatomy. 2004 by Radiological Society of North America

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ANATOMY OF ARTERY

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acute bilateral ischemia of the lower extremities shows abrupt occlusion of both popliteal arteries 2004 by Radiological Society of North America

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Embolism in the most common cause of arterial occlusion Emboli may consist of thrombus, athromatous debris or tumor Emboli most commonly originate in the heart as a result of AF, MI or Heart failure Arteriosclerosis may cause roughening or ulceration of atheromatous plaque which can lead to emboli. May also be associated with immobility, anemia and dehydration. Emboli lead to lodge at bifurcations & atherosclerotic narrowing Other cause of acute occlusion include A. Trauma B. Thrombus C. venous outflow obstruction PATHOPHYSIOLOGY

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Immobility,anemia,dehydration heart arteriosclerosis AF,MI Roughening or ulceration of artery emboli lodge in the roughened artery arterial occlusion

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Acute pain Paralysis of part Pallor & coldness Edema Rigidity of extremity Pulselessness Numbness of the part

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EMBOLUSTHROMBOSISTRAUMA AFVascular graftsBlunt MIAtherosclerosisPenetrating Endo carditisThrombosis of aneurysmlatrogenic Valvular diseaseEntrapement syndrome AneurysmLow flow rate Atherosclerotic plaque

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1.MEDICAL MANAGEMENT Thrombolytic therapy Heparin and anticoagulants 2.SURGICAL MANAGEMENT Embolectomy Balloon embolectomy Aspiration embolectomy Surgical embolectomy

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Balloon embolectomy Typically this is done by inserting a catheter with an inflatable balloon attached to its tip into an artery, passing the catheter tip beyond the clot, inflating the balloon, and removing the clot by withdrawing the catheter. The catheter is called Fogarty, named after its inventor catheter

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Aspiration embolectomy Catheter embolectomy is also used for aspiration embolectomy, where the thrombus is removed by suction rather than pushing with a balloon. It is a rapid and effective way of removing thrombi in thromboembolic occlusions of the limb arteries below the inguinal ligament

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Surgical embolectomy Surgical embolectomy is the simple surgical removal of a clot following incision into a vessel by open surgery on the artery. COMPLICATIONS MI TIA Gangrene Stroke Septic embolism

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Monitor vital signs(peripheral pulse) Assess the wound area,if any bleeding present or not. Provide comfortable position Prevent infection and potential complication Ventilator care 30 head end elevation Mouth care Sedation score

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Suction appropriately Prevent infection Prevent hemodynamic instability Manage the airway Meet the patient nutrional needs Wean the patient appropriately Educate the patient and family

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Impaired physical mobility related to monitoring devices, mechanical ventilation and medication as charecrized by imposed restrictions of movement,decreased muscle strength &limited range of motion. Ineffective breathing pattern related to decreased energy as characterized by dyspnea. Knowledge deficit related to health condition, new equipment& hospitalization as characterized by increased frequency of

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Questions posed by the relatives Risk for impaired skin integrity related to prolonged bedrest,proloanged intubation Risk for infection related to surgery Pain related to surgery NURSING DIAGNOSIS

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ASSESSMENTPLANNINGEVALUATION NURSI NG DIAG NOSIS GOALS OR DESIRED OUTCOME NURSI NG INTER VENTI ON ACTION OR RATION ALE Subjective data: patient in mechanical ventilator Objective data:1.rapid shallow breathing 2.Nail bed cyanosis Ineffective breathing pattern related to decreased energy as characterize d by dyspnoea After 12 hrs of nursing intervention patient will maintain good breathing pattern Endotrach eal suctioning done every 30mts. Patient head is elevated at 30 Placed patient on ventilator with 75% o2 To maintain patent airway To reduce the breathing difficulties To increase the oxygen saturation Breathing pattern maintained with the help of ventilator

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ASSESSMENTPLANNINGEVALUATION NURSI NG DIAGN OSIS GOALS OR DESIRED OUTCOME NURSI NG INTERV ENTIO N ACTION OR RATIONA LE Objective data: General body weakness present,ina bility to perform motor skills due to sedation,pa ralysed for restricted movement Impaired physical mobility related to monitoring device,mechanical ventilation & decreased muscle strength and limited range of motion After 24hrs of nursing intervention patient will maintain good physical activity Position changed 2hrly.Suppo rt the bony prominence with pillows. Isometric exercise given 6 th hrly Deep breathing exercise given 2 nd hrly Head end elevated 30 Sedation tapered slowly To prevent bedsore To improve the blood circulation To helps to expand the lungs To avoid aspiration To help for weaning Goal fully met,patient started obeying orders of nurse, physiotherapist for exercise, mobilizing the legs &hands.

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Teach prevention techniques, such as daily activity, observation for skin breakdown, prevention of injury Teach the importance of taking prescribed medications such as oral anticoagulants. Teach for blood checking regularly(PT,INR,D_DIEMER). Teaching about the nutritional status Maintain regular health check-up Teach the patient to wear elastic stockings as ordered Teach the patient to avoid restrictive clothing(socks,shoes) Teach the patient never to walk barefoot

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80yrs old female patient came in ER with the complaint of shortening of breath and burning micturation. Primary care given from ER and then shifted to ICU.Her ECG shows AF with controlled rhythm. The next day patient developed cold lower extremities with absent pulses..So urgent vascular surgery consultation & arterial Doppler done. Bilateral poplitial artery embolus seen in Doppler. Patient was urgent taken to the OT by vascular surgeon and bilateral poplitial artery embolectomy was done. Patient was resuscitated with IV fluids and ionotropic because of desaturation. After all management patient was extubated and fully conscious and oriented. Patient shifted to peadia ward.

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1.What are the characteristics of AF? 2.What are the layers of artery? 3.What are the etiology of arterial embolism? 4.What are the signs & symptoms of arterial embolism? 5.What are the types of embolectomy? 6.What is the other name of balloon catheter? 7.What is atherosclerosis? 8.What are the complications of embolectomy?

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WIKIPEDIA MEDICAL AND SURGICAL NURSING BOOK(BRUNNER) LUCK MAN AND SORENSENS MEDICAL SURGICAL NURSING

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THANK YOU