revised 2/09 jborrero vascular stressors nr 240. anatomy & physiology arteries – walls are...

Revised 2/09 JBorrero

VASCULAR STRESSORSVASCULAR STRESSORS

NR 240

ANATOMY & ANATOMY & PHYSIOLOGYPHYSIOLOGY

ARTERIESARTERIES – – WALLS ARE THICKER WALLS ARE THICKER DUE TO GREATER SMOOTH DUE TO GREATER SMOOTH MUSCLE, HENCE STRONGER & MUSCLE, HENCE STRONGER & CAN WITHSTAND HIGH CAN WITHSTAND HIGH PRESSUREPRESSURE


PHYSICAL PRINCIPLES THAT PHYSICAL PRINCIPLES THAT DETERMINE BLOOD FLOWDETERMINE BLOOD FLOW

1.1. PRESSURE CREATED BY PRESSURE CREATED BY PUMPING OF HEARTPUMPING OF HEART

2.2. RESISTANCE OF BLOOD RESISTANCE OF BLOOD PUMPED (PVR) PERIPHERAL PUMPED (PVR) PERIPHERAL VASCULAR RESISTANCE VASCULAR RESISTANCE (CHANGE IN VESSEL RADIUS)(CHANGE IN VESSEL RADIUS)

ARTERIAL DISORDERSARTERIAL DISORDERS

SUSTAINED HIGH ARTERIAL PRESSURE SUSTAINED HIGH ARTERIAL PRESSURE INCREASES THE EFFECTS OF INJURY AND INCREASES THE EFFECTS OF INJURY AND DISEASEDISEASE

EFFECTS OF ARTERIAL DISEASE CAUSESEFFECTS OF ARTERIAL DISEASE CAUSES

TISSUE ISCHEMIA TISSUE ISCHEMIA DEATH OF TISSUE DEATH OF TISSUE

SEVERITY OF SYMPTOMS IS DEPENDENT SEVERITY OF SYMPTOMS IS DEPENDENT UPON METABOLIC RATE & TISSUE NEEDSUPON METABOLIC RATE & TISSUE NEEDS

SURGERY MAY RE-ESTABLISH SURGERY MAY RE-ESTABLISH CIRCULATIONCIRCULATION

ARTERIAL ARTERIAL ASSESSMENTASSESSMENT

PURPOSE: TO DETERMINE PURPOSE: TO DETERMINE ADEQUATE TISSUE PERFUSIONADEQUATE TISSUE PERFUSION

GUIDE LINESGUIDE LINES

1.1. COMPARE UPPER & LOWERCOMPARE UPPER & LOWER

2.2. COMPARE BILATERALLYCOMPARE BILATERALLY

3.3. COMPARE DISTAL & PROXIMALCOMPARE DISTAL & PROXIMAL

4.4. SUPINE (VS) DEPENDENT SUPINE (VS) DEPENDENT CHANGESCHANGES


MAJOR AREAS OF MAJOR AREAS OF ASSESSMENTASSESSMENT

1.1. CIRCULATION – PULSE MEANS CIRCULATION – PULSE MEANS PERFUSIONPERFUSION

2.2. MOTION – MUSCLES NEED MOTION – MUSCLES NEED OXYGENOXYGEN

3.3. SENSATION – PAIN, BURNING, SENSATION – PAIN, BURNING, PROPRIOCEPTION, NUMBNESSPROPRIOCEPTION, NUMBNESS


CIRCULATIONCIRCULATIONCHECK PULSE CHECK PULSE

POINTSPOINTS

CAROTIDCAROTID

RADIALRADIAL

FEMORALFEMORAL

DORSALIS PEDISDORSALIS PEDIS

POSTERIOR TIBIALPOSTERIOR TIBIAL

CAPILLARY REFILLCAPILLARY REFILL


PULSES ARE BASED ON A SCALEPULSES ARE BASED ON A SCALE

0 to 4+0 to 4+ 00 = = NO PULSENO PULSE 1+1+ = = THREADY PULSETHREADY PULSE 2+2+ = = NORMAL PULSENORMAL PULSE 3+3+ = = BOUNDING PULSEBOUNDING PULSE 4+4+ = = ANEURYSMANEURYSM


ARTERIAL INSUFFICIENCYARTERIAL INSUFFICIENCY

1.1. SKIN COOL, SHINY THIN, ONION SKIN COOL, SHINY THIN, ONION LIKELIKE

2.2. PAIN /W COLDPAIN /W COLD3.3. PALE /W ELEVATIONPALE /W ELEVATION4.4. DISTAL PULSES DISTAL PULSES OR ABSENT OR ABSENT5.5. DECREASED OR ABSENT HAIRDECREASED OR ABSENT HAIR6.6. ISCHEMIC ULCERSISCHEMIC ULCERS7.7. THICK NAILSTHICK NAILS

COMMON DIAGNOSTIC COMMON DIAGNOSTIC VASCULAR TESTSVASCULAR TESTS

NON-INVASIVE TECHNIQUESNON-INVASIVE TECHNIQUES DUPLEX ULTRASOUNDDUPLEX ULTRASOUND

HELPS Dx NARROWING OR HELPS Dx NARROWING OR OCCULUSION OF INTERNAL OCCULUSION OF INTERNAL CAROTIDS or DVTCAROTIDS or DVT

NO PATIENT PREPNO PATIENT PREP

PAINLESS & SAFEPAINLESS & SAFE

SUPINE POSITIONSUPINE POSITION

FALSE (+) DUE FALSE (+) DUE TO TO CALCIFICATION CALCIFICATION OF VESSELSOF VESSELS


NON-INVASIVE TECHNIQUESNON-INVASIVE TECHNIQUES SEGMENTED ARTERIAL PRESSURE SEGMENTED ARTERIAL PRESSURE

MONITORINGMONITORING

MEASURES PRESSURE DIFFERENCE MEASURES PRESSURE DIFFERENCE BETWEEN EXTREMITIES AT DIFFERENT BETWEEN EXTREMITIES AT DIFFERENT LEVELSLEVELS

USES B/P MONITOR & DOPPLERUSES B/P MONITOR & DOPPLER

ANKLE/BRACHIAL ANKLE/BRACHIAL INDEXINDEX

EXAMPLEEXAMPLE: :

BRACHIAL PRESSURE BRACHIAL PRESSURE =120mmHg=120mmHg

ANKLE PRESSURE = 96mmHgANKLE PRESSURE = 96mmHg

ABI = 96 / 120 = 0.8ABI = 96 / 120 = 0.8NORMALNORMAL 0.9 - 1.20.9 - 1.2 RISK IS RISK IS LOWLOW

VASCULAR VASCULAR DISEASEDISEASE

0.6 – 0.90.6 – 0.9 MODERATEMODERATE

RISK EXISTSRISK EXISTS

SEVERE SEVERE DISEASEDISEASE

< 0.5< 0.5 VERY VERY HIGHHIGH RISK EXISTSRISK EXISTS


CLAUDICATIONCLAUDICATIONINTERMITTANT CRAMPING OF INTERMITTANT CRAMPING OF SKELETAL MUSCLES WITH SKELETAL MUSCLES WITH EXERCISEEXERCISE

• STANDARD – ABLE TO WALK ONE STANDARD – ABLE TO WALK ONE CITY BLOCK W/O PAINCITY BLOCK W/O PAIN

• (+) = PAIN WITH AMBULATION, (+) = PAIN WITH AMBULATION, PAIN WITH ELEVATION, RELIEF PAIN WITH ELEVATION, RELIEF WITH DEPENDENT POSITIONWITH DEPENDENT POSITION

• Tx: pentoxyphylline (Trental)Tx: pentoxyphylline (Trental)• cilostazol (Pletal)cilostazol (Pletal)

ACUTE ARTERIAL ACUTE ARTERIAL INSUFFICIENCYINSUFFICIENCY

THE 5 THE 5 P’sP’sWHEN PRESENT =WHEN PRESENT = SURGICAL SURGICAL

EMERGENCY!EMERGENCY!

1.1. PAINPAIN

2.2. PALLORPALLOR

3.3. PULSELESSNESSPULSELESSNESS

4.4. PARALYSISPARALYSIS

5.5. PARESTHESIAPARESTHESIA


ANGIOGRAPHYANGIOGRAPHY (ANGIOGRAM)(ANGIOGRAM)

INVASIVE TECHNIQUE – USED INVASIVE TECHNIQUE – USED WHEN SURGICAL INTERVENTION IS WHEN SURGICAL INTERVENTION IS BEING CONSIDEREDBEING CONSIDERED

USED TO DIAGNOSEUSED TO DIAGNOSE

EMBOLI, THROMBOSIS, EMBOLI, THROMBOSIS, TRAUMA, TRAUMA, ANEURYSM, ANEURYSM, BUERGER’S DISEASE, BUERGER’S DISEASE,

ARTERIOSCLEROSISARTERIOSCLEROSIS


ARTERIAL SYSTEM PROBLEMS ARTERIAL SYSTEM PROBLEMS CAN BE CONTROLLED BY CAN BE CONTROLLED BY MODIFYING RISK FACTORS:MODIFYING RISK FACTORS:

SMOKINGSMOKINGDIETDIETGLUCOSE CONTROLGLUCOSE CONTROLACTIVITY LEVELACTIVITY LEVELHYPERLIPIDEMIAHYPERLIPIDEMIABP (BP (DOUBLES RISKDOUBLES RISK))

WHEN ARTERIES WHEN ARTERIES BECOME OCCLUDEDBECOME OCCLUDED

HEALTHY ARTERIES ARE BLOOD HEALTHY ARTERIES ARE BLOOD VESSELS WHICH ARE VESSELS WHICH ARE FLEXIBLE,FLEXIBLE,STRONG & ELASTICSTRONG & ELASTIC

THEIR THEIR INSIDE LINING IS INSIDE LINING IS SMOOTHSMOOTH SO BLOOD CAN FLOW SO BLOOD CAN FLOW WITHOUT RESTRICTIONWITHOUT RESTRICTION

Risk Factors cause arteries to Risk Factors cause arteries to become occluded.become occluded.

Progression of OcclusionProgression of Occlusion

PLAQUE DEPOSITPLAQUE DEPOSIT

ORIGINAL DIAMETER


PERIPHERAL ARTERIAL PERIPHERAL ARTERIAL INSUFFICIENCY / OCCLUSIONINSUFFICIENCY / OCCLUSION

ASSESSMENT:ASSESSMENT:

WEAK/ ABSENT PULSESWEAK/ ABSENT PULSES

PAIN /W LEG ELEVATION PAIN /W LEG ELEVATION

SKIN COOL TO TOUCHSKIN COOL TO TOUCH

PALE SKIN COLOR PALE SKIN COLOR

THICKENED TOENAILSTHICKENED TOENAILS


GOALS:GOALS:

1.1. IMPROVE PERIPHERAL IMPROVE PERIPHERAL ARTERIAL CIRCULATION WITH ARTERIAL CIRCULATION WITH EXERCISEEXERCISE

REGULAR EXERCISE SUCH AS REGULAR EXERCISE SUCH AS WALKING INCREASESWALKING INCREASES

CIRCULATIONCIRCULATION


GOALS:GOALS:

2.2. PREVENT VASCULAR PREVENT VASCULAR COMPRESSIONCOMPRESSION

AVOID RESTRICTIVE CLOTHING, AVOID RESTRICTIVE CLOTHING, CROSSING LEGS, SITTING FOR CROSSING LEGS, SITTING FOR PROLONGED PERIODSPROLONGED PERIODS


GOALS:GOALS:

3.3. RELIEVE PAINRELIEVE PAIN

CONSIDER ANALGESICS SO CONSIDER ANALGESICS SO PATIENT CAN PARTICIPATE IN PATIENT CAN PARTICIPATE IN ACTIVITIESACTIVITIES


GOALS:GOALS:4.4. MAINTAIN TISSUE INTEGRITYMAINTAIN TISSUE INTEGRITY

• AVOID TRAUMA, WEAR AVOID TRAUMA, WEAR CORRECT CORRECT SHOE GEAR (NO SHOE GEAR (NO BARE FEET!)BARE FEET!)

• TEST WATER TEMP WITH TEST WATER TEMP WITH HAND HAND NOT FOOT!NOT FOOT!

• REGULAR PODIATRY CAREREGULAR PODIATRY CARE• GOOD NUTRITIONGOOD NUTRITION

ANGIOPLASTYANGIOPLASTY

BALLOON BALLOON ANGIOPLASTY ANGIOPLASTY CATHETERCATHETER

INSERTED INSERTED THROUGH AN THROUGH AN ARTERYARTERY

BALLOON IS BALLOON IS INFLATED AND INFLATED AND COMPRESSES COMPRESSES LESIONLESION

USED FOR INSERTION OF STENTS

ANGIOPLASTYANGIOPLASTY

MEDICAL MEDICAL MANAGEMENTMANAGEMENT

THROMBOLYTIC THERAPYTHROMBOLYTIC THERAPYUSED TO DISSOLVE CLOTS:USED TO DISSOLVE CLOTS:

Retavase, streptokinase, tPaRetavase, streptokinase, tPa

SURGICAL MANAGEMENTSURGICAL MANAGEMENT1.1. GRAFTINGGRAFTING – BYPASS SURGERY– BYPASS SURGERY2.2. ENDARTERECTOMYENDARTERECTOMY – REMOVAL – REMOVAL

OF ATHEROSCLEROTIC PLAQUEOF ATHEROSCLEROTIC PLAQUE3.3. AORTO/FEMORAL/TIBIAL BYPASSAORTO/FEMORAL/TIBIAL BYPASS

NURSING DX/ ARTERIAL NURSING DX/ ARTERIAL DISORDERS & GOALSDISORDERS & GOALS

1.1. ALTERED PERIPHERAL TISSUE ALTERED PERIPHERAL TISSUE PERFUSIONPERFUSION

(( ARTERIAL BLOOD FLOW) ARTERIAL BLOOD FLOW)

GOAL: MAXIMIZE TISSUE GOAL: MAXIMIZE TISSUE PERFUSIONPERFUSION

2.2. ACTIVITY INTOLERANCE – ACTIVITY INTOLERANCE – VASCULAR SUPPLY CAN NOT KEEP VASCULAR SUPPLY CAN NOT KEEP UP WITH TISSUE DEMANDSUP WITH TISSUE DEMANDS

GOAL: MANAGE ACTIVITY WITHIN GOAL: MANAGE ACTIVITY WITHIN LIMITATIONSLIMITATIONS


3.3. ANTICIPATORY GRIEVING RELATED ANTICIPATORY GRIEVING RELATED TO POTENTIAL LOSS OF LIMBTO POTENTIAL LOSS OF LIMB

GOAL: EXPRESS CONCERNSGOAL: EXPRESS CONCERNS

4.4. BODY IMAGE DISTURBANCE AS BODY IMAGE DISTURBANCE AS RELATED TO LOSS OF BODY PARTRELATED TO LOSS OF BODY PART

GOAL: DISCUSS IMAGE & OPTIONSGOAL: DISCUSS IMAGE & OPTIONS


5.5. IMPAIRED TISSUE INTEGRITY IMPAIRED TISSUE INTEGRITY AS RELATED TO AS RELATED TO CIRCULATION CIRCULATION

GOAL: MAINTAIN TISSUE GOAL: MAINTAIN TISSUE INTEGRITYINTEGRITY

6.6. KNOWLEDGE DEFICIT OF SELF KNOWLEDGE DEFICIT OF SELF CARE ACTIVITIES CARE ACTIVITIES

GOAL: EDUCATE PATIENTGOAL: EDUCATE PATIENT


7.7. PAIN DUE TO ISCHEMIAPAIN DUE TO ISCHEMIA

GOAL: RELIEVE PAINGOAL: RELIEVE PAIN8.8. POTENTIAL FOR INJURY DUE TO POTENTIAL FOR INJURY DUE TO

SENSATIONSENSATION

GOAL: EDUCATE PATIENT TO INSPECT GOAL: EDUCATE PATIENT TO INSPECT FOR INJURY, WATCH FOR TRAUMAFOR INJURY, WATCH FOR TRAUMA

9.9. SLEEP PATTERN DISTURBANCE DUE TO SLEEP PATTERN DISTURBANCE DUE TO REST PAINREST PAIN

GOAL: MAXIMIZE SLEEPGOAL: MAXIMIZE SLEEP

NURSING NURSING INTERVENTIONSINTERVENTIONS

1.1. RISK FACTOR MODIFICATIONRISK FACTOR MODIFICATION

SMOKING (Most significant RISK FACTOR)SMOKING (Most significant RISK FACTOR)

NICOTINE CAUSES VASOSPASMSNICOTINE CAUSES VASOSPASMS

WEIGHT LOSSWEIGHT LOSS

REDUCES WORKLOAD IN REDUCES WORKLOAD IN EXTREMITIES EXTREMITIES

LOW FAT DIET WILL RETARD LOW FAT DIET WILL RETARD PROGRESSION OF ATHEROSCLEROSISPROGRESSION OF ATHEROSCLEROSIS

CONTROL HTNCONTROL HTN


2.2. PAIN MANAGEMENTPAIN MANAGEMENT

INTENSITY IS VARIABLEINTENSITY IS VARIABLE

MANAGEMENT- RTCMANAGEMENT- RTC

PAIN MEDICATIONPAIN MEDICATION

(MAY NOT BE (MAY NOT BE EFFECTIVE)EFFECTIVE)

DEPENDENT POSITION DEPENDENT POSITION MAY MAY COMFORTCOMFORT


3.3. MAINTAIN FLUID VOLUMEMAINTAIN FLUID VOLUME

IN SEVERE STENOSIS PATIENT MUST IN SEVERE STENOSIS PATIENT MUST MAINTAIN SUFFICIENT BLOOD MAINTAIN SUFFICIENT BLOOD PRESSURE TO AVOID COMPLETE PRESSURE TO AVOID COMPLETE OCCLUSIONOCCLUSION


4.4. ACTIVITYACTIVITY MONITOR CLAUDICATIONMONITOR CLAUDICATION TEACH PATIENT – PAIN IS NOT TEACH PATIENT – PAIN IS NOT

HARMFUL, BUT A BODY HARMFUL, BUT A BODY SIGNAL FOR NEED TO RESTSIGNAL FOR NEED TO REST EMPHASIZE: EXERCISE INCREASES EMPHASIZE: EXERCISE INCREASES

COLLATERAL COLLATERAL CIRCULATIONCIRCULATION CHECK WITH DOCTOR ABOUT ANY CHECK WITH DOCTOR ABOUT ANY

EXERCISEEXERCISEPROGRESSION SHOULD BE PROGRESSION SHOULD BE

GRADUALGRADUAL


5.5. MAINTAINING TISSUE INTEGRITYMAINTAINING TISSUE INTEGRITY

CHANGE POSITION FREQUENTLYCHANGE POSITION FREQUENTLY

AVOID CROSSING LEGSAVOID CROSSING LEGS

& CONSTRICTIVE CLOTHING& CONSTRICTIVE CLOTHING

METICULOUS FOOT CARE METICULOUS FOOT CARE (PODIATRIST)(PODIATRIST)

PROTECT FROM INJURYPROTECT FROM INJURY

KEEP EXTREMITIES KEEP EXTREMITIES WARMWARM

((NO HEATING BLANKET OR HOT NO HEATING BLANKET OR HOT WATER BOTTLES!WATER BOTTLES!))

SURGICAL NURSING SURGICAL NURSING MANAGEMENTMANAGEMENT

S/P BYPASS SURGERY- PostopS/P BYPASS SURGERY- Postop NEUROVASCULAR ASSESSMENTNEUROVASCULAR ASSESSMENT COMPLICATIONSCOMPLICATIONS

• GRAFT OCCLUSION:THROMBOSISGRAFT OCCLUSION:THROMBOSIS• COMPARTMENT SYNDROMECOMPARTMENT SYNDROME• GRAFT INFECTIONSGRAFT INFECTIONS• FISTULA/ULCER FORMATIONFISTULA/ULCER FORMATION

EDUCATE PATIENT TOEDUCATE PATIENT TO• REPORT PAIN UNRELIEVED BY MEDSREPORT PAIN UNRELIEVED BY MEDS• STOP SMOKINGSTOP SMOKING• ID NORMAL HEALING PROCESSID NORMAL HEALING PROCESS

SURGICAL NURSING SURGICAL NURSING MANAGEMENTMANAGEMENT

S/P BYPASS SURGERYS/P BYPASS SURGERY POSITIONINGPOSITIONING

• KEEP LOWER EXTREMITY KEEP LOWER EXTREMITY LEVELLEVEL

AND AVOID CONSTRICTIONAND AVOID CONSTRICTION• AVOID DEPENDENT POSITION AVOID DEPENDENT POSITION

WHICH WHICH ’s EDEMA , PAIN & ’s EDEMA , PAIN & HEALINGHEALING

• MOBILITY IS PROGRESSIVEMOBILITY IS PROGRESSIVE

ARTERIAL DISEASESARTERIAL DISEASES

BUERGER’S DISEASEBUERGER’S DISEASE [[TAOTAO]]

(aka: Thromboangiitis Obliterans)(aka: Thromboangiitis Obliterans)

1.1. DISEASE IS DISEASE IS LINKED DIRECTLYLINKED DIRECTLY TO TO SMOKINGSMOKING ( (REQUIRED HX FOR DXREQUIRED HX FOR DX))

2.2. POSSIBLE IMMUNOPATHOGENESISPOSSIBLE IMMUNOPATHOGENESIS

3.3. INFLAMMATION PRODUCES CRITICAL INFLAMMATION PRODUCES CRITICAL LIMB ISCHEMIALIMB ISCHEMIA

4.4. DISEASE CAN PROGRESS PROXIMALLYDISEASE CAN PROGRESS PROXIMALLY

Raynaud’s DiseaseRaynaud’s Disease

VASOSPASTICVASOSPASTIC DISORDERS: DISORDERS:

1.1. BLOOD VESSELS (FINGERS & TOES) BLOOD VESSELS (FINGERS & TOES) GO INTO SPASMGO INTO SPASM

2.2. EXTREME SENSITIVITY TO TEMP EXTREME SENSITIVITY TO TEMP CHANGES (ESPECIALLY COLD)CHANGES (ESPECIALLY COLD)

3.3. MORE COMMON FEMALE > MALEMORE COMMON FEMALE > MALE

4.4. Color changes are Red/White/BlueColor changes are Red/White/Blue

RAYNAUD’SRAYNAUD’S

CLASSIFIED:CLASSIFIED:1.1. RAYNAUD’SRAYNAUD’S DISEASEDISEASE = WHEN = WHEN

SYMPTOMS ARE THE ONLY SYMPTOMS ARE THE ONLY PRESENTING FACTORPRESENTING FACTOR

2.2. RAYNAUD’SRAYNAUD’S PHENOMENONPHENOMENON = WHEN = WHEN SYMPTOMS ARE SECONDARY TO SYMPTOMS ARE SECONDARY TO ANOTHER CONDITIONANOTHER CONDITION

EX: RA, SCLERODERMA, LUPUS, CARPAL EX: RA, SCLERODERMA, LUPUS, CARPAL TUNNEL SYDROME, THORACIC OUTLET TUNNEL SYDROME, THORACIC OUTLET SYNDROMESYNDROME

RAYNAUD’SRAYNAUD’S

DX:DX:

1.1. BILATERALBILATERAL

2.2. OCCURS X 2 OCCURS X 2 YEARSYEARS

3.3. NO OTHER CAUSENO OTHER CAUSE

Prevention:Prevention:

1.1. PROTECT FROM COLD EXPOSUREPROTECT FROM COLD EXPOSURE

2.2. AVOID EXCESSIVE EMOTIONAL AVOID EXCESSIVE EMOTIONAL STRESSSTRESS

3.3. DO NOT USE VIBRATING TOOLSDO NOT USE VIBRATING TOOLS

ANEURYSMANEURYSM

ANEURYSMANEURYSM = AN = AN LOCALIZED LOCALIZED ABNORMAL ABNORMAL DILATION OF A DILATION OF A BLOOD VESSELBLOOD VESSEL

HIGH RISK HIGH RISK ININ MARFAN’S MARFAN’S SYNDROMESYNDROME

Abdominal Aortic Abdominal Aortic Aneurysm:PathophysiologyAneurysm:Pathophysiology

Aneurysm-permanent localized Aneurysm-permanent localized dilation of an arterydilation of an artery

-enlarges to 2x normal -enlarges to 2x normal diameterdiameter

-middle layer of artery is -middle layer of artery is weakenedweakened

-HTN produces more -HTN produces more tension and enlargement within tension and enlargement within the arterythe artery

AORTIC ANEURYSMSAORTIC ANEURYSMS

Location: ThoracicLocation: Thoracic Abdominal aortic aneurysmsAbdominal aortic aneurysmsEtiology:Etiology:Atherosclerosis (+HTN & smoking)Atherosclerosis (+HTN & smoking)SyphillisSyphillisMarfan SyndromeMarfan SyndromeEhlers-Danlos syndromeEhlers-Danlos syndrome

AAA AssessmentAAA Assessment

Upper abdomen pulsation, left of Upper abdomen pulsation, left of midlinemidline

+ bruit over mass+ bruit over mass Abdominal, flank or back Abdominal, flank or back

pain- if leaking or rupturedpain- if leaking or ruptured Abd Xray- “Eggshell Calcification”Abd Xray- “Eggshell Calcification” Cat scanCat scan Aortic angiographyAortic angiography UltrasonographyUltrasonography

Interventions Interventions

NonsurgicalNonsurgical Surgical- AAA ResectionSurgical- AAA Resection

- Endovascular stent graft - Endovascular stent graft

Post-op care of the AAA patient:Post-op care of the AAA patient:

VENOUSVENOUSANATOMY & ANATOMY & PHYSIOLOGYPHYSIOLOGY

VEINSVEINS – – HAVE THIN WALLSHAVE THIN WALLS

(LESS SMOOTH MUSCLE)(LESS SMOOTH MUSCLE)

ALLOW VESSELS TO ALLOW VESSELS TO DISTEND MORE THAN DISTEND MORE THAN ARTERIESARTERIES

Venous System Venous System ANATOMY & ANATOMY & PHYSIOLOGYPHYSIOLOGY

BLOOD FLOWS AGAINST BLOOD FLOWS AGAINST GRAVITY BECAUSE:GRAVITY BECAUSE:

VALVES – ONE WAY VALVES VALVES – ONE WAY VALVES PREVENT BACKFLOW. (VALVE PREVENT BACKFLOW. (VALVE COMPETENCY DEPENDS UPON COMPETENCY DEPENDS UPON INTEGRITY OF VEIN WALL)INTEGRITY OF VEIN WALL)

MUSCLE CONTRACTION MILKS MUSCLE CONTRACTION MILKS BLOOD THROUGH VESSELSBLOOD THROUGH VESSELS

VENOUS ASSESSMENTVENOUS ASSESSMENT

VENOUS INSUFFICIENCYVENOUS INSUFFICIENCY

1.1. DRY, FLAKYDRY, FLAKY (BROWN & BLOTCHY)(BROWN & BLOTCHY)2.2. PURPLE – PURPLE – DEPENDENTDEPENDENT

3.3. ELEVATION ELEVATION ’s DEPENDENT ’s DEPENDENT EDEMAEDEMA

4.4. EDEMA MAY OBLITERATE PULSESEDEMA MAY OBLITERATE PULSES5.5. VENOUS STASIS ULCERSVENOUS STASIS ULCERS6.6. PARESTHESIASPARESTHESIAS

Disorders of Venous Disorders of Venous CirculationCirculation

PHLEBITIS-Vein PHLEBITIS-Vein inflammationinflammation

DVT- Deep Vein DVT- Deep Vein ThrombosisThrombosis

TTHROMBOPHLEBITISHROMBOPHLEBITIS

INFLAMMATION OF INFLAMMATION OF WALLS OF VEINS WALLS OF VEINS WITH CLOT WITH CLOT FORMATIONFORMATION

PHLEBOTHROMBOSISPHLEBOTHROMBOSIS

CLOT DEVELOPS DUE CLOT DEVELOPS DUE TO VENOUS STASIS TO VENOUS STASIS OR “THICK BLOOD”OR “THICK BLOOD”

HYPERCOAGUABILITY HYPERCOAGUABILITY & INFLAMMATION& INFLAMMATION

VENOUS DISORDERSVENOUS DISORDERSVIRCHOW’S TRIADVIRCHOW’S TRIAD

PREDISPOSING FACTORSPREDISPOSING FACTORSa)a) VENOUS STASIS – Bedrest, VENOUS STASIS – Bedrest, BP, BP,

HYPOVOLEMIA, HYPOVOLEMIA,

b)b) HYPERCOAGULABILITY – HYPERCOAGULABILITY – CANCER,SMOKING, POLYCYTHEMIA, CANCER,SMOKING, POLYCYTHEMIA, SURGERY, SEPSIS, OC SURGERY, SEPSIS, OC

c)c) ENDOTHELIAL DAMAGE – STIMULATES ENDOTHELIAL DAMAGE – STIMULATES PLATELET AGGREGATION, VENOUS PLATELET AGGREGATION, VENOUS INFLAMMATIONINFLAMMATION

VENOUS DISORDERSVENOUS DISORDERSOther Risk FactorsOther Risk Factors

d)d) IMMOBILIZATION – PARALYSIS, PROLONGED IMMOBILIZATION – PARALYSIS, PROLONGED BEDREST, LONG PLANE OR CAR RIDESBEDREST, LONG PLANE OR CAR RIDES

e)e) DISEASE PROCESSES – SEPSIS, DISEASE PROCESSES – SEPSIS, SLE,HEMATOLOGICAL DISORDERS, SLE,HEMATOLOGICAL DISORDERS, MS,MALIGNANCY, CHF, MI, ULCERATIVE COLITISMS,MALIGNANCY, CHF, MI, ULCERATIVE COLITIS

f)f) PRESSURE – OBESITY, PREGNANCY, TUMORPRESSURE – OBESITY, PREGNANCY, TUMORg)g) TRAUMA – FRACTURES, VENIPUNCTURETRAUMA – FRACTURES, VENIPUNCTUREh)h) CLOTTING DYSFUNCTIONCLOTTING DYSFUNCTIONi)i) SURGICAL PROCEDURES – HIP, GYN & SURGICAL PROCEDURES – HIP, GYN &

UROLOGICAL & in age >40UROLOGICAL & in age >40j)j) OC use- especially in women who smokeOC use- especially in women who smokek)k) OTHER – DEHYDRATION, ADVANCED AGEOTHER – DEHYDRATION, ADVANCED AGE

VENOUS DISORDERSVENOUS DISORDERS

DEEP VENOUS THROMBOSISDEEP VENOUS THROMBOSIS (DVT)(DVT)

1.1. PATHOPHYSIOLOGYPATHOPHYSIOLOGY – DEEP VEIN – DEEP VEIN CLOT MOST COMMON IN LOWER LEG CLOT MOST COMMON IN LOWER LEG (CALF)(CALF)

UNDIAGNOSED DVT OCCURS IN 50% UNDIAGNOSED DVT OCCURS IN 50% OF PATIENTS WITH PULMONARY OF PATIENTS WITH PULMONARY EMBOLIEMBOLI

Assessment of DVTAssessment of DVT

S & SS & S

-Calf or groin tenderness-Calf or groin tenderness

-Pain that can be dull or aching, especially when -Pain that can be dull or aching, especially when walkingwalking

-Sudden onset of unilateral swelling of the leg-Sudden onset of unilateral swelling of the leg

-Cyanosis of the affected extremity-Cyanosis of the affected extremity

-Slightly elevated temp-Slightly elevated temp

-General malaise-General malaise

Assessment of DVTAssessment of DVT

Homan’s Sign-pain on dorsiflexion of footHoman’s Sign-pain on dorsiflexion of foot

NO LONGER ADVISED-can increase the risk NO LONGER ADVISED-can increase the risk of detaching the thrombus as the calf of detaching the thrombus as the calf muscle contractmuscle contract

Coag studiesCoag studies

D Dimer-increased values with venous D Dimer-increased values with venous thrombosis, PE, DIC and Malignancythrombosis, PE, DIC and Malignancy

Duplex ScanDuplex Scan

INTERVENTIONSINTERVENTIONS

*Bedrest and leg elevation*Bedrest and leg elevation

*Warm moist soaks may be ordered*Warm moist soaks may be ordered

*Evaluate for PE*Evaluate for PE

*Anti-inflammatory drugs for superficial *Anti-inflammatory drugs for superficial thrombophlebitis – ASA or NSAIDSthrombophlebitis – ASA or NSAIDS

*Heparin therapy*Heparin therapy

*Warfarin (Coumadin)*Warfarin (Coumadin)

Heparin TherapyHeparin Therapy

1.Prior to initiation of therapy:1.Prior to initiation of therapy:Hx of bleeding disordersHx of bleeding disordersCBC w/ platelet countCBC w/ platelet countUAUAStool for occult bloodStool for occult bloodCreatinine levelCreatinine levelPTT,PT, INR baselinePTT,PT, INR baseline

2. Heparin bolus is given IVP (100u/kg) 2. Heparin bolus is given IVP (100u/kg) followed by continuous infusion and protocolfollowed by continuous infusion and protocol

3. Goal is to attain aPTT level 1.5-2.5x normal3. Goal is to attain aPTT level 1.5-2.5x normal

Heparin therapyHeparin therapy

4. Assess for signs and symptoms of bleeding4. Assess for signs and symptoms of bleeding

5. Monitor platelet counts- can lead to heparin induced 5. Monitor platelet counts- can lead to heparin induced thrombocytopenia.thrombocytopenia.

6. Antidote available- protamine sulfate6. Antidote available- protamine sulfate

Other Options:Other Options:

LMWH-Longer half-life and more predictableLMWH-Longer half-life and more predictable

Lovenox- 1mg/kg Adjust for renal ptsLovenox- 1mg/kg Adjust for renal pts

FragminFragmin

Coumadin- Coumadin- started while pt is on heparinstarted while pt is on heparin

-takes 3-4 days to be therapeutic-takes 3-4 days to be therapeutic

-monitor INR/PT-monitor INR/PT

-antidote-Vitamin K -antidote-Vitamin K


TREATMENTTREATMENTa)a) PREVENTIVEPREVENTIVE

i.i. EARLY AMBULATIONEARLY AMBULATIONii.ii. EXTERNAL COMPRESSION (VCB)EXTERNAL COMPRESSION (VCB)iii.iii. PROPHYLACTIC ANTICOAGULANTSPROPHYLACTIC ANTICOAGULANTS

LOW DOSE HEPARINLOW DOSE HEPARINLOW MOLECULAR WT. HEPARIN (FRAGMIN©)LOW MOLECULAR WT. HEPARIN (FRAGMIN©)

b)b) WHEN DVT EXISTSWHEN DVT EXISTSi.i. BR TO BR TO CHANCE OF EMBOLICHANCE OF EMBOLIii.ii. ELEVATION TO ELEVATION TO VENOUS RETURN & VENOUS RETURN & EDEMA EDEMAiii.iii. ANTICOAGULANTS PREVENT CLOTS FROM ANTICOAGULANTS PREVENT CLOTS FROM

INCREASING (THEY DO NOT DISSOLVE INCREASING (THEY DO NOT DISSOLVE THEM!)THEM!)


AMBULATIONAMBULATION – PERMITTED WHEN EDEMA – PERMITTED WHEN EDEMA . . BELOW KNEE TEDS USED BELOW KNEE TEDS USED IFIF NO ARTERIAL NO ARTERIAL DISEASEDISEASE

(TEDS MAY INTERFERE WITH ARTERIAL (TEDS MAY INTERFERE WITH ARTERIAL FLOW)FLOW)

THROMBECTOMYTHROMBECTOMY – SURGICAL TREATMENT OF – SURGICAL TREATMENT OF CHOICE WHEN ARTERIAL FLOW IS AFFECTED CHOICE WHEN ARTERIAL FLOW IS AFFECTED BY DVTBY DVT

(GREENFIELD FILTER PREVENTS “SHOWER” (GREENFIELD FILTER PREVENTS “SHOWER” OF PULMONARY EMBOLI) INSERTED IN OF PULMONARY EMBOLI) INSERTED IN INFERIOR VENA CAVAINFERIOR VENA CAVA

GREENFIELD FILTERGREENFIELD FILTER

Inserted into Inserted into Inferior Vena Inferior Vena CavaCava

Filters out Filters out clots as blood clots as blood returns to the returns to the right side of right side of the heartthe heart

GREENFIELD FILTERGREENFIELD FILTER

READILY READILY IDENTIFIED ON IDENTIFIED ON X-RAYX-RAY

VENOUS DISORDERSVENOUS DISORDERSHealth TeachingHealth Teaching

Safety and comfort measuresSafety and comfort measures

Balance rest and activityBalance rest and activity

Need for follow upNeed for follow up

Importance of taking drugs and not missing dosesImportance of taking drugs and not missing doses

Medi-alert braceletMedi-alert bracelet

Avoid OTC medsAvoid OTC meds

Avoid hi fat and hi Vitamin K foods- cabbage, Avoid hi fat and hi Vitamin K foods- cabbage, cauliflower,broccoli, asparagus, spinach, kale, fish cauliflower,broccoli, asparagus, spinach, kale, fish and liverand liver

Patient teaching re: LMWH injectionsPatient teaching re: LMWH injections

CHRONIC VENOUS CHRONIC VENOUS INSUFFICIENCYINSUFFICIENCY

1.1. PATHOPHYSIOLOGY & EPIDEMIOLOGYPATHOPHYSIOLOGY & EPIDEMIOLOGY• OCCURS IN 10% OF POPULATION /W DVTOCCURS IN 10% OF POPULATION /W DVT• Stasis of blood in lower extremity-due to Stasis of blood in lower extremity-due to

prolonged standing, sitting in one position, prolonged standing, sitting in one position, pregnancy, and obesitypregnancy, and obesity

• INCOMPETENT VALVES IN DEEP VEINSINCOMPETENT VALVES IN DEEP VEINS VENOUS PRESSURE IMPEDES CAPILLARY VENOUS PRESSURE IMPEDES CAPILLARY

PERFUSIONPERFUSION• PROTEINS LEAK INTO INTERSTITIAL TISSUESPROTEINS LEAK INTO INTERSTITIAL TISSUES• EDEMA IS CHRONIC EDEMA IS CHRONIC ULCERS & SCARRING ULCERS & SCARRING

CHRONIC VENOUSCHRONIC VENOUS INSUFFICIENCYINSUFFICIENCY

Venous Stasis UlcersVenous Stasis Ulcers

2.2. SIGNS & SYMPTOMSSIGNS & SYMPTOMS – INDURATION – INDURATION HYPERPIGMENTATION, STASIS DERMATITIS & HYPERPIGMENTATION, STASIS DERMATITIS & ULCERATIONS, EDEMAULCERATIONS, EDEMA

3.3. GOALS:GOALS: Decrease edema and Promote venous Decrease edema and Promote venous returnreturn

4.4. INTERVENTIONS: INTERVENTIONS: a)a) COMPRESSION – STOCKINGS OR DRESSINGSCOMPRESSION – STOCKINGS OR DRESSINGSb)b) ULCERS TREATED WITH TOPICAL AGENTS-ULCERS TREATED WITH TOPICAL AGENTS-

Unna,AccuzymeUnna,Accuzymec)c) AVOID TRAUMAAVOID TRAUMAd)d) AVOID SITTING FOR LONG PERIODSAVOID SITTING FOR LONG PERIODSe)e) EXERCISE TO EXERCISE TO MUSCLE ACTIVITY MUSCLE ACTIVITYf)f) Platelet derivative growth factor ointments-RegranexPlatelet derivative growth factor ointments-Regranexg)g) Apligraf-type of skin graftApligraf-type of skin graft

Varicose VeinsVaricose Veins

Protruding veins that are Protruding veins that are darkened/tortuous are caused by darkened/tortuous are caused by weak vein walls, increased venous weak vein walls, increased venous pressure & incompetent valvespressure & incompetent valves

Common in patients that stand for Common in patients that stand for long periodslong periods

PregnancyPregnancy ObesityObesity Family hx of varicose veinsFamily hx of varicose veins Systemic problems-heart diseaseSystemic problems-heart disease

Assessment- S & O DataAssessment- S & O Data

Severe, aching pain in legSevere, aching pain in leg Leg fatigue and heavinessLeg fatigue and heaviness Itching over the affected leg (statis Itching over the affected leg (statis

dermatitis)dermatitis) Feelings of heat in the legFeelings of heat in the leg Visibly dilated veinsVisibly dilated veins Thin, discolored skin above the anklesThin, discolored skin above the ankles Increased incidence of PE and Increased incidence of PE and

thrombophlebitisthrombophlebitis

Diagnostic TestsDiagnostic Tests

Tourniquet testTourniquet test Trendelenberg testTrendelenberg test Doppler ultrasound/ angiographyDoppler ultrasound/ angiography

Medical and Surgical Medical and Surgical Interventions for Varicose Interventions for Varicose

VeinsVeins Elevate Elevate

extremityextremity Elastic StockingsElastic Stockings Sclerotherapy-Sclerotherapy-

for small/limited for small/limited # of veins# of veins

Vein stripping or Vein stripping or ligationligation

EndoVenous EndoVenous Laser txLaser tx

RF (radio RF (radio frequency)frequency)

-vein is heated -vein is heated from insidefrom inside

Nursing InterventionsNursing Interventions

Monitor patient postopMonitor patient postop Assess circulationAssess circulation Elevate legs and perform active Elevate legs and perform active

ROMROM Teach re: avoidance of venous Teach re: avoidance of venous

stasis, compression stockings, stasis, compression stockings, exercise, leg elevationexercise, leg elevation

Lymphatic SystemLymphatic SystemANATOMY & PHYSIOLOGYANATOMY & PHYSIOLOGY

LYMPHATIC SYSTEM – WORKS LYMPHATIC SYSTEM – WORKS WITH CIRCULATORY SYSTEMWITH CIRCULATORY SYSTEM

a)a) THORACIC DUCTTHORACIC DUCT

b)b) RIGHT LYMPHATIC DUCTRIGHT LYMPHATIC DUCTab

DRAINAGE:

THORACIC DRAINS ABDOMEN

(R) DRAINS HEAD, NECK & THORAX


LYMPHATIC FLUID COLLECTS & LYMPHATIC FLUID COLLECTS & RETURNS TO VENOUS CIRCULATION RETURNS TO VENOUS CIRCULATION BY EMPTYING INTOBY EMPTYING INTO SUBCLAVIAN SUBCLAVIAN VEINSVEINSWHEN INTERSTITIAL FLUID WHEN INTERSTITIAL FLUID PRESSURE INCREASES LYMPHATIC PRESSURE INCREASES LYMPHATIC FLOW INCREASESFLOW INCREASES

WHEN DRAINAGE IS IMPAIRED WHEN DRAINAGE IS IMPAIRED EDEMA ENSUES (FLUID COLLECTS)EDEMA ENSUES (FLUID COLLECTS)


CAUSES OF LYMPHEDEMA CAUSES OF LYMPHEDEMA INCLUDE:INCLUDE:

LYMPHANGITISLYMPHANGITIS CELLULITIS CELLULITIS

INSUFFICIENT NUMBER OF INSUFFICIENT NUMBER OF VESSELSVESSELS

SECONDARY FACTORSSECONDARY FACTORS

MALIGNANCYMALIGNANCY

TRAUMATRAUMA

SURGICAL REMOVALSURGICAL REMOVAL

AssessmentAssessment

Pain at site of injuryPain at site of injury Redness of skinRedness of skin Fever and chillsFever and chills Red streak on skin extending toward Red streak on skin extending toward

the lymph nodesthe lymph nodes Lymph nodes enlargedLymph nodes enlarged WBC, Blood & Wound culturesWBC, Blood & Wound cultures Lymphangiography-IV dye, XraysLymphangiography-IV dye, Xrays Lymphoscintigraphy-simple,no SELymphoscintigraphy-simple,no SE

INTERVENTIONSINTERVENTIONS

Moist heatMoist heat Elevation and immobilization of the Elevation and immobilization of the

extremityextremity Elastic stockingsElastic stockings Na restrictionNa restriction Antibiotics/antifungals for infectionAntibiotics/antifungals for infection DiureticsDiuretics AnalgesicsAnalgesics

CASE STUDY

MR. CHARLES HORSE WAS ADMITTED TO THE HOSPITAL TODAY WHERE HE PRESENTED HIS CHIEF COMPLAINTS AND RECENT MEDICAL HISTORY. THIS PATIENT IS A FIFTY-THREE YEAR OLD WHITE MALE. MR. HORSE IS A RUGGED INDIVIDUAL WITH AN EXTENSIVE HISTORY.

HE SMOKES 1 PACK OF CIGARETTES PER DAY FOR MORE THAN TWENTY

FIVE YEARS. AS A SINGLE LUMBERJACK HIS DIET HAS RELIED HEAVILY ON FAST FOODS. OVER THE PAST SEVERAL MONTHS MR. HORSE REPORTED HE HAD GRADUALLY BEEN EXPERIENCING PAIN IN THE LEFT LEG. THESE PAINFUL SYMPTOMS INCREASED TO A POINT WHERE HE CANNOT WALK MORE THAN TWO CITY BLOCKS WITHOUT SEVERE CRAMPING IN HIS LEFT LEG.

HE STATES HE MUST STOP, SIT AND RUB HIS LEG UNTIL THE CRAMPING STOPS. MR. HORSE HAS GRADUALLY ADJUSTED HIS ACTIVITIES AROUND THESE SYMPTOMS.

THIS MORNING, MR. HORSE AWOKE FROM A DEEP SLEEP TO SUDDEN, SEVERE PAIN IN THE LEFT LEG. THE PAIN DIMINISHED SLIGHTLY WHEN HE SAT UP AND HUNG HIS LEGS OVER THE SIDE OF THE BED.

HE NOTICED CHANGES IN SKIN COLOR AND TEMPERATURE. CONCERNED ABOUT THE SUDDEN CHANGES, MR. HORSE HEADED DIRECTLY TO THE EMERGENCY ROOM.

WHEN YOU ASSESS THIS PATIENT ATTENTION IS DIRECTED TOWARD HIS LEFT LEG. THE SKIN IS COOL TO TOUCH. ASSESSING PERIPHERAL PULSES YOU NOTE THAT HIS FEMORAL AND POPLITEAL PULSES ARE STRONG AND PALPABLE BILATERALLY.

HOWEVER, HIS POSTERIOR TIBIAL AND DORSALIS PEDIS PULSES ON THE LEFT LEG ARE NOT PALPABLE. A DOPPLER READING INDICATES THERE IS SOME DEGREE OF CIRCULATION PRESENT. NAIL BEDS ARE CYANOTIC; CAPILLARY FILLING IS SLOW (> 3 SECONDS) IN ALL DIGITS ON THE LEFT FOOT.

ATTEMPTING TO IMPROVE MR. HORSE’S COMFORT, THE NURSE ELEVATES HIS FEET. MR. HORSE REPORTS THE PAIN IS SIGNIFICANTLY WORSE!

LEFT LEG DISCUSSION

1. WHAT INFORMATION DOES INSPECTION OF THE PATIENT’S LEG PROVIDE?

a) COLOR OF SKIN

b) COLOR OF NAIL BEDS

PALE

CYANOTIC

2. WHAT CAN PALPATION TELL YOU ABOUT THIS PATIENT’S CONDITION?

a) TEMPERATURE

b) PULSES

COOL TO TOUCH INDICATES BLOOD FLOW, SENSITIVITY

BLOOD FLOW, WEAK PULSES

(+) FEMORAL, (+) POPLITEAL PULSES

CHECK FLOW WITH DOPPLER

3. WHAT POSITION WOULD BE THE MOST COMFORTABLE FOR MR. HORSE?

4. WHAT PROBLEM DO YOU THINK MR. HORSE HAS WITH HIS LEFT LEG?

SUPINE OR DANGLE

ARTERIAL INSUFFICIENCY

5. WHAT WOULD PREDISPOSE MR. HORSE TO DEVELOPING THIS TYPE OF PROBLEM?

6. WHAT IS THE CLINICAL TERM FOR A CONDITION CAUSING PERIODIC CRAMPING BROUGH ON BY WALKING?

SMOKING, LIPIDS, PROBABLY CAD, POSSIBLE DAMAGE TO INTIMAL LAYER OF BLOOD VESSELS

INTERMITTANT CLAUDICATION

7. WHAT ARE THE 5 P’s YOU SHOULD LOOK FOR?

PAIN

PALLOR

PULSELESSNESS

PARALYSIS

PARESTHESIA

THIS IS A SURGICAL EMERGENCY!

FOLLOWING A SUCCESSFUL REVASCULARIZATION PROCEDURE, MR. HORSE WAS D/C’d TO HOME IN GOOD CONDITION. HIS LEFT LEG WAS WARM, PINK IN COLOR AND ALL TOES WERE MOBILE. MR. HORSE WAS PLACED ON MEDICATIONS TO MANAGE HIS CHF, WHICH WAS DISCOVERED DURING IHIS MEDICAL HISTORY AND PHYSICAL EXAM. TWO WEEKS LATER THIS PATIENT RETURNED TO THE HOSPITAL…

PRESENTING WITH DYSPNEA, ORTHOPNEA AND BILATERAL +3 PITTING EDEMA. MR. HORSE WAS READMITTED TO THE HOSPITAL WITH A DX OF CHF. DIGOXIN (A CARDIOTONIC) WAS STARTED AND LASIX (A DIURETIC) ALSO WAS ADDED TO HIS MEDICATION PROFILE. ONCE AGAIN MR. HORSE WAS D/C’d TO HOME AND PROVIDED WITH A HOME HEALTH AIDE TO ASSIST HIM WITH HIS ADL’s. HE WAS INSTRUCTED TO REMAIN ON BED REST

FOR ONE WEEK. HE IS SEEN BY THE VISITNING NURSE IN HIS HOME ON F/U TO ASSESS HIS STATUS. THE NURSE TAKES NOTICE OF MR. HORSE’S +2 PITTING EDEMA IN HIS RIGHT LEG, EXTENDING FROM THE FOOT TO THE LOWER THIGH. SKIN COLOR IS NOTED TO HAVE A REDDISH/ PURPLE HUE AND THE SURFACE TEMP IS INCREASED LOCALLY. THE LIMB IS TENDER TO TOUCH AND PAIN INCREASES WITH DORSIFLEXION.

THE NURSE ALSO NOTES THAT PERIPHERAL PULSES ARE MODERATELY DIMINISHED ON THE RIGHT SIDE ONLY. MR. HORSE COMPLAINS THAT HIS RIGHT LEG FEELS HEAVY AND THROBS.

1. WHAT DOES INSPECTION OF HIS RIGHT LEG REVEAL?

a) SKIN COLOR

b) GIRTH / TENSION

RIGHT LEG DISCUSSION

DUSKY RED

(+) SWELLING

2. WHAT DOES PALPATION TELL YOU ABOUT THE STATUS OF HIS RIGHT LEG?

a) TEMPERATURE

b) EDEMA

TEMP INDICATES INFLAMMATION

(2+) PITTING EDEMA, VENOUS CONGESTION

3. WHAT DO YOU THINK THE PROBLEM IS WITH MR. HORSE’S RIGHT LEG?

4. WHAT DO YOU THINK CAUSED MR. HORSE’S RECENT COMPLICATIONS?

(+) DVT

PROLONGED BED REST DUE TO CHF, INACTIVITY, DEHYDRATION FROM LASIX, BLOOD VISCOSITY

5. HOW COULD THESE PROBLEMS HAVE BEEN AVOIDED?

LMWH, VCB, EXERCISE

BONUS QUESTION

LIST EXAMPLES THAT PREDISPOSE A

PATIENT TO DVT

FACTORS EXAMPLE

IMMOBILIZATION OPERATING ROOM > 2 HOURS

PARALYSIS

DISEASE PROCESS CARDIAC

DIABETES MELLITUS

LOWER EXTREMITY EDEMA

SEPTICEMIA

CANCER

PRESSURE CAST / BRACES

TRACTION

CLOTTING DYSFUNCTION POLYCYTHEMIA

SHORT CLOTTING TIME

FACTORS EXAMPLE

SURGICAL PROCEDURES GYNECOLOGICAL

GENITOURINARY

ANY ABDOMINAL SURGERY

LOWER EXTREMITY FRACTURE

OTHER

TRAUMA

OBESITY

PREGNANCY

TRAUMA TO A VESSEL

NCLEX TIME

Which of the following clients should the nurse assess first?• A.The 76-year-old woman who has had laser-assisted

angioplasty of the right distal femoral artery 30 minutes ago

• B.The 65-year-old man with a history of hypertensive crisis who is on a labetalol drip and current blood pressure is 149/80

• C.The 60-year-old woman with a history of peripheral vascular disease who has a venous leg ulcer draining purulent yellow fluid

• D.The 55-year-old man with a history of axillofemoral bypass 5 years earlier who is currently admitted for a diagnostic cardiac catheterization

NCLEX TIME

Which of the following statements indicates the caregiver does not understand proper care of the client with peripheral arterial disease of the lower legs?

• A.“The client should drink fluids to decrease risk for viscous blood.”

• B.“We must remind the client to refrain from wearing restrictive clothing.”

• C.“The client should apply heat directly to the legs in order to promote blood circulation.”

• D.“The client should be encouraged to stop smoking because it increases the vasoconstriction of the arteries.”

NCLEX TIME

You are caring for a 75-year-old man admitted to the hospital for lower leg cellulitis. On admission, the nurse notes that his blood pressure is 190/100 and notifies the physician. Of the following orders, which would you have the LPN implement?

A.Assess cardiac and respiratory status.B.Administer Clonidine patch for hypertension.C.Obtain an order from the doctor for dietary consult.D.Develop plan for discharge and assess homecare needs.

NCLEX TIME

A group of new graduate nurses is in orientation to work on a cardiothoracic stepdown unit. Which statement, if made by one of the nurses, demonstrates the need for further teaching regarding the difference between arteriosclerosis and atherosclerosis?

• A.“Arteriosclerosis is a thickening, or hardening, of the arterial wall.”

• B.“Atherosclerosis is a type of arteriosclerosis that involves the formation of plaque within the arterial wall and is the leading contributor to coronary artery and cerebrovascular disease.”

• C.“Atherosclerosis is caused by vascular damage.”• D.“Arteriosclerosis happens when platelets aggregate

and then a group of blood lipids accumulate.”

NCLEX TIME

Because Mr. Palan's condition has progressed to severe rest pain that is now threatening loss of his limb, an arterial revascularization has to be performed. Which statement, if made by Mr. Palan, demonstrates that further teaching is needed related to his postoperative care?

A.“I should be concerned if my foot turns blue.”B.“I should not get a fever or any drainage after the

surgery.”C.“I may get a feeling of tenseness after the surgery.”D.“Warmth, redness, and swelling are expected after

surgery.”

NCLEX TIME

5.Clara is teaching a young woman ways to prevent venous thromboembolism during hospitalization. Which statement, if made by the client, indicates the need for further teaching?

• A.“I need to stop taking my birth control pill.”• B.“I should drink a lot of water so I don't get

dehydrated.”• C.“I should exercise my legs when I have been

sitting or standing for a long time.”• D.“If I wear pantyhose, I don't have to wear the

stockings that the hospital gives me.”

revised 2/09 jborrero vascular stressors nr 240. anatomy & physiology arteries – walls are...

Documents

circulation slide

aneurysm slide

arterial assessment

high pressure slide

arteriosclerosis slide

numbness slide

paresthesia slide

high arterial pressure