ch 26 vasulcar disorders and peripheral circulation Flashcards
patient pain left lower leg, edematous and hairless, what health problem
intermittent claudication
ankle brachial index abi of right leg is 0.40 how would you follow up
implement interventions relevant to arterial narrowing
post op plan of care for oral contraceptives
early ambulation and leg exercises, bc use increases blood coagulbility
nurse education venous insufficiency
avoid normal stockings that are tight
large venous leg ulcer - how prevent infection and promote healing
provide high calorie, high protein diet
nursing diagnosis - lymphedema
risk for infection related to lower extremity swelling secondary to lymphedema
preventative measure for varicose veins
walk every hour to promote circulation
visible red streak running up foot and ankle after stepping on nail
lymphangitis
hit and swollen leg, history of chronic venous insufficiency- what intervention
antibiotics to treat cellulitis
history of heart failure and peripheral arterial disease cannot ambulate - prevent which complication?
deep vein thrombosis
most appropriate interventions for altered peripheral tissue perfusion related to compromised circulation
encourage client to engage in moderate amount of exercise
intervention venous insufficiency
elevate lower extremities
client prescribed walk for 10 min 3 times a day following MI what is relationship between walking and heart function
when you walk the muscles in your legs contract and pump the blood in your veins back to your heart, which allows more blood to return to your heart
deep vein thrombophlebitis - lab values that indicate warfarin is at therapeutic levels
international normalized ratio (INR) between 2 and 3
leg pain, type 1 diabetes, smokes a pack a day - nursing education for diagnosis of intermittent claudication
be sure to practice meticulous foot care
femoral to popliteal bypass graft surgery- first post op assessment
assess pulse of affected extremity every 15 minutes
raynaud phenomenon - nursing diagnosis
ineffective tissue perfusion
inability to grasp object w right hand, cool to the touch and bp 20 more than left side - which health problem
upper extremity arterial occlusive disease
gangrene on toe - which health problem
peripheral artery disease
patient on Xa inhibitor, comorbidity with real insufficiency
lower doses of Xa inhibitors are required
nursing action for varicose veins during pregnancy
teach client that circulatory changes during pregnancy frequently cause vv
nursing education for compression stockings for venous insufficiency
the importance of ensuring the stockings are applied evenly with no pressure points
priority risk for leg ulcer
insufficient nutrition
best position for leg ulcers venous in origin
elevate lower extremities
best prevention for skin breakdown of lower extremities post op
ensure clients heels are protected and supported
assessments for chronic leg ulcers
-location and type of pain
-bilateral comparison of peripheral pulses
-comparison of temp in patients legs
-identification of mobility limitations
lymphangitis medication
an antibiotic
best action by nurse for leg swelling and redness post op
inform health care provider of s/s of venous thromboembolism
abdominal aortic aneurysm - assessment for impending rupture
sudden onset of severe back or abdominal pain
what is systemic arteriovenous oxygen different that affect cardiovascular health and tissue oxygenation
the amount of oxygen in aortic blood minus the amount of oxygen in the vena caval blood
on what physiologic variables does adequate blood flow depend
-efficiency of heart as a pump
-adequacy of circulating blood volume
-patency and responsiveness of the blood vessels
peripheral artery disease - no pulse in left foot
use doppler ultrasound to identify the pulses
for which client would assessment of ankle brachial index be most clearly warranted
a client with poorly controlled type 1 diabetes who is a smoker
nursing plan to prevent occurrence of future venous ulcers
high protein diet that is rich in vitamins
digital gangrene - history of what health problem
arterial insufficiency
venous disease - what test
duplex ultrasonography
peripheral arterial occlusive disease - assessment finding
unequal peripheral pulses between both extremities
peripheral artery disease - history of smoking, alcohol, no exercise - priority education
the nicotine in cigarettes is a powerful vasoconstrictor and may cause or aggravate pad
assessment of venous ulcer in area of lateral malleolus and unresponsive to treatment
heavy exudate
