Chapter 26 Assessment & Management of Patients w/ Vascular Disorders & Problems of Peripheral Circulation Flashcards

Question

Precapillary Sphincter

Answer 1

A cuff of smooth muscle (located near arterioles end of capillary) that is responsible for controlling capillary blood flow (along w/arteriole)

Answer 2

Carries deoxygenated blood from the tissues to the RT side of the heart

Answer 3

Venules: Arterioles Veins: Arteries Vena cava: Aorta

Answer 4

Walls are thinner & less muscular Layers are not as well-defined

Answer 5

Allows for the vessel to distend more than arteries Greater distensibility & compliance allows for larger volumes of blood to remain in the veins under low pressure

Answer 6

Venoconstriction can reduce venous volume & increase volume of blood in the general circulation

Answer 7

Constriction of the veins

Answer 8

Creates the primary pumping action to facilitate venous blood flow back to the heart

Answer 9

Collects lymphatic fluid from tissues and organs & transports the fluid to the venous circulation

Answer 10

The thoracic duct & the right lymphatic duct

Answer 11

Conveys lymph primarily from the RT side of the head, neck, thorax, & upper arms

Answer 12

Conveys lymph from the remainder of the body

Answer 13

Efficiency of the heart to work as a pump, the patency & responsiveness of the blood vessels, & adequacy of circulating blood vol

Answer 14

Supplying the circulatory needs of tissue Maintain blood flow & BP Providing capillary filtration & reabsorption Hemodynamic resistance

Answer 15

Rate of Tissue Metabolism Availability of Oxygen Function of the Tissue

Answer 16

...blood vessels dilate to increase the flow of O2 & nutrients to the tissues

Answer 17

... vessels constrict & blood flow to the tissues decrease

Answer 18

Physical activity Local heat application Fever Infection

Answer 19

Rest/decreased activity Local cold application Cooling of the body

Answer 20

Lack of blood supply

Answer 21

Ischemia can be caused if the blood vessels fail to dilate in response to accommodate for increased metabolic needs

Answer 22

LT side of the heart-> aorta-> arteries-> arterioles-> capillaries-> venues-> veins-> vena cava-> RT side of the heart

Answer 23

The differences in blood pressure between the arterial & venous system changes

Answer 24

Arterial BP: 100mmHg Venous BP: 40 mmHg (Fluid flows from an area of higher pressure->lower press)

Answer 25

...a greater press is req to maintain the same degree of flow

Answer 26

Myocardium atrophies to compensate for the greater contractile force

Answer 27

Blood viscosity increases Diameter of the vessels become greater than normal Segments of the blood vessel are constricted

Answer 28

Adventitious sound of blood flowing via narrowed portion of an artery

Answer 29

A driving pressure that is generated by the blood pressure

Answer 30

The pulling force created by plasma proteins

Answer 31

Hydrostatic pressure Drives fluid out of the capillary-> tissue space

Answer 32

Osmotic pressure Osmotic pressure is greater than hydrostatic pressure->net reabsorption of fluid from the tissue space back into the capillary

Answer 33

Filtration

Answer 34

Enters lymphatic circulation

Answer 35

Accumulation of excess interstitial fluid

Answer 36

Damage to capillary walls and subsequent increased permeability Obstruction of lymphatic drainage Elevation of venous pressure, or a decrease in plasma protein osmotic force

Answer 37

Reabsorption

Answer 38

Vessel radius

Answer 39

Norepinephrine

Answer 40

Vasoconstriction

Answer 41

Vasodilation

Answer 42

Angiotensin I

Answer 43

The kidneys

Answer 44

Converting angiotensin I-> angiotensin II

Answer 45

It is a potent vasoconstrictor (especially arterioles)

Answer 46

Substances liberated from platelets that aggregate at the damaged vessel site, causing arteriolar vasoconstriction & continued platelet aggregation at injury site

Answer 47

This occurs when the heart's pumping action becomes inefficient

Answer 48

Causes an accumulation of blood in the lungs & reduction of forward flow (CO) -> inadequate arterial blood flow to the tissues

Answer 49

Systolic HF (HFrEF)

Answer 50

Causes systemic venous congestion & reduced CO (forward flow)

Answer 51

Diastolic HF (HFpEF)

Answer 52

A blood clot that may have been dislodged from the vessel where it originally formed

Answer 53

Sudden: Can cause profound and irreversible tissue ischemia & tissue death Gradual: Less risk of sudden tissue death due to collateral circulation that may develop-> giving the tissue time to adapt to gradually decreasing blood flow

Answer 54

Thromboembolus obstructing a vein Incompetent venous valves Reduction in the effectiveness of surrounding muscle pumping action

Answer 55

Increased venous pressure Subsequent increase in capillary hydrostatic pressure Increase of net filtration of fluid out of the capillaries-> interstitial space Increase in subsequent edema

Answer 56

Cellular proliferation & fibrosis-> intima thickens Elastin fibers of media become calcified, thin, & fragmented Overall changes cause vessels to stiffen-: - Increased peripheral resistance - Impaired blood flow - Increased ventricular workload-> hypertrophy, ischemia, systolic HF

Answer 57

Pain: Intermittent claudication to sharp, unrelenting, constant pain Pulses: Diminished/absent Skin: -Color: Dependent rubor w/ elevation pallor of foot -Texture: Shiny, dry skin w/ cool to cold temp -Hair: Loss os har over toes & dorsum of foot -Nails thickened & ridged

Answer 58

Pain: Aching, throbbing, cramping Pulses: Present but may be diff to palpate due to edema Skin: -Color: Pigmentation in area of medial & lateral malleolus, may be red & blue (freq associated w/dermatitis) -Texture: Skin thickened & tough

Answer 59

Location: Tip of toes, web spaces, heel or other pressure points if pt is immobile Pain: Very painful Depth of ulcer: Deep, often involving joint space Shape: Circular Ulcer base: Pale to black & wet to dry gangrene Leg edema: Minimal unless kept in dependent position constantly to relieve pain

Answer 60

Location: Medial malleolus, lateral malleolus, or anterior tibial area Pain: Minimal to very painful Depth: Superficial Shape: Irregular border Ulcer base: Granulation tissue -Beefy red to yellow fibrinous in chronic long-term ulcer Leg edema: Moderate to severe

Answer 61

Pain, discomfort, or fatigue is caused by the inability of the arterial system to provide adequate blood flow to the tissues in face of increased demands for nutrients & O2 during exercise -Described as aching, cramping, or inducing fatigue or weakness that occurs w/some degree of activity

Answer 62

Placing the extremity in a dependent position reduces the pain -Some patients may sleep w/affected leg hanging over the side of the bed or sleep in a reclining chair

Answer 63

Intermittent claudication

Answer 64

...muscle metabolites & lactic acid are produced -Muscle metabolites aggravate nerve endings-> causes pain

Answer 65

~50% of the arterial lumen or 75% of the cross-sectional area must be obstructed

Answer 66

Rest (decreases metabolic needs of muscles)

Answer 67

Persistent pain in the foot or digits when the patient is resting

Answer 68

Rest pain indicates a severe degree of arterial insufficiency & critical state of ischemia

Answer 69

Lowering the extremity to a dependent position

Answer 70

It can be deduced because pain occurs in muscle groups distal to the diseased vessel

Answer 71

Insufficient blood flow through either the superficial or popliteal artery

Answer 72

Reddish-blue discoloration of the extremities -May be observed w/in 20secs-2mins after extremity is placed in dependent position

Answer 73

Bluish tint of the skin that is manifested when amount of oxygenated hemoglobin contained in the blood is reduced

Answer 74

Palpation is subjective Use light touch & more than just the index finger for palpation (strongest pulse) to avoid mistaking their own pulse for the pt's pulse -Same for thumb Occlusive arterial diseases impairs blood flow & can reduce/obliterate palpable pulses in the extremities Palpate bilaterally & simultaneously Symmetry in: -Rate -Rhythm -Quality

Answer 75

Used to detect blood flow when pulses cannot be reliably palpated

Answer 76

The frequency it produces -The lower the frequency, the deeper the tissue penetration

Answer 77

Place the pt in supine position, elevate HOB 20 to 30 degrees to evaluate the lower extremities -Externally rotate the legs, if possible, to permit access to medial malleolus Apply acoustic water soluble gel to pt's skin Avoid excessive pressure (severely diseased arteries can collapse w/min pressure)

Answer 78

Ratio of the systolic BP in the ankle to the systolic BP in the arm

Answer 79

The ABI is used to quantify the degree of stenosis

Answer 80

1) Have patient lay in supine position for 5 mins 2) Apply appropriate-sized BP cuff to the patient's ankle above the malleolus 3) After ID'ing an arterial signal of the posterior tibial & dorsalis pedis arteries, systolic pressures are obtained while listening to the Doppler signal for both arteries -Diastolic pressures cannot be obtained via Doppler

Answer 81

Use correctly sized BP cuffs Document cuff sizes used Use sufficient inflation -Do not inflate too rapidly Suspect medial calcific sclerosis: - Anytime the ABI is 1.20 or greater - Ankle pressure is more than 250 mmHg Be weary of arterial pressures recorded at less than 40 mmHg (venous signal was confused for arterial signal)

Answer 82

Abnormal, indicates non-compressible arteries -Follow w/ toe-brachial index (TBI)

Answer 83

Borderline

Answer 84

Moderate to mild insufficiency -Seen in pts w/claudication

Answer 85

Found in patients w/ischemic rest pain

Answer 86

Found in pts w/ischemia or severe tissue loss

Answer 87

Perform baseline ABI on any pt w/decreased pulses or any pt 65 yrs or older (especially hx of diabetes & nicotine use) Pts who undergo arterial interventions should have ABIs performed per hospital protocol Prior to Procedure: Educate pts about the indications of ABI and what to expect Avoid nicotine use & caffeine prods for at least 2 hrs prior to testing

Answer 88

Used to determine how long a patient can walk & to measure the the ankle systolic BP in response to walking

Answer 89

Patients w/: - Significant arterial insufficiency - Severe cardiac, pulmonary, or orthopedic problems - Physical disability

Answer 90

Patients walk on a treadmill at 1.5 mph w/ 12% incline for at least 5 mins or Walks w/gradual increase in speed & incline to the point of claudication

Answer 91

Little or no drop in ankle systolic BP after exercise

Answer 92

Ankle pressure drops

Answer 93

Combine B-grade grayscale imaging of tissues, organs, & blood vessels w/capabilities of estimating velocity changes via pulsed Doppler use

Answer 94

Used to determine the level & extent of venous disease and how chronic it is

Answer 95

Non-invasive Patients who undergo abdominal vascular ultrasound need to be NPO status for at least 6hrs prior to exam -Gas released from food can interfere w/ exam Portable

Answer 96

Provides cross-sectional images of soft tissues & visualize area of volume changes to an extremity & the compartment where changes take place

Answer 97

Patients w/impaired renal function may req preprocedural treatment to avoid contrast-induced nephrotoxicity -May include oral/IV hydration 6-12 hrs preprocedure or sodium bicarbonate admin Nurse should encourage fluids & monitor patient's urinary output post-procedure -Should be at least 0.5 kg/mL/h Contrast-induced acute kidney injury may occur 48-96 hrs post-op -Notify & follow-up w/provider if this occurs Screen for iodine & shellfish allergies -Might be given steroids & histamine blockers ahead of time

Answer 98

Alkalinizes urine & protects against free radical damage

Answer 99

May be used to confirm diagnosis of occlusive arterial disease when surgery/other interventions are considered

Answer 100

Abnormal dilation of blood vessel

Answer 101

Patient experiences temporary wam sensation as contrast agent is injected & local irritation may occur at injection site May have an immediate or delayed allergic response to the iodine present in the contrast agents Any reaction must be reported IMMEDIATELY!! Risks include: vessel injury, acute arterial occlusion, bleeding, or contrast nephropathy

Answer 102

Dyspnea N/V Sweating Tachycardia Numbness of the extremities Any of these signs MUST be reported IMMEDIATELY!!

Answer 103

Admin of epinephrine, antihistamines, or corticosteroids

Answer 104

Contraindicated in patients w/metal implants Assess for presence of any incompatible devices: -Aneurysm clips -Old tattoos: May contain trace elements (newer ones may contain nitinol & titanium which are compatible) -Med patches -Cardiac implantable electronic devices -> MUST be screened to determine if they can safely undergo a MRI Inform pt that: -They will be in a small, enclosed space - May hear periodic banging sounds -They will lay on a cold, hard table Ask for pts to close their eyes and keep them closed during procedure to decrease symptoms of claustrophobia Reassure patients that they will be provided a panic button to press if they feel they need to stop the procedure Assess for claustrophobia: May be prescribed a sedative prior to procedure MRA procedures use contrast: Use the same precautions as you would w/contrast angiogram

Answer 105

Involves injecting a radiopaque agent into venous system -If thrombus is present, x-ray will reveal an unfilled segment of vein in otherwise completely filled vein

Answer 106

Hardening of the arteries due to muscle fibers & endothelial lining of walls of small arteries & arterioles becoming thickened

Answer 107

Inflammatory process involving accumulation of lipids, calcium, blood components, carbs, & fibrous tissue on the intimal layer of a large-or medium-sized artery

Answer 108

Arteriosclerosis

Answer 109

Modifiable Risk Factors: -Nicotine use -Hyperlipidemia -Diet (contributing to hyperlipidemia) -Hypertension -Diabetes -Obesity -Stress -Sedentary lifestyle -C-reactive protein: Protein found in liver, indicative of inflammation (typically specific to cardiovascular conditions-increase) -Hyperhomocysteinemia: Increase in protein that promotes coagulation Nonmodifiable Risk Factors: -Age -Gender -Familial predisposition & genetics

Answer 110

Asymptomatic-> Claudication-> Ischemic Rest Pain-> Gangrene (limb loss)

Answer 111

Provide patient education on disease prevention/management * Dietary modifications * Self-care programs * Foot and leg care Medication education * HMG-CoA (statins): 1st line of therapy * Long-term therapy requires close monitoring Encourage elimination of all modifiable risk factors, particularly nicotine use

Answer 112

Symptoms of PAD may be more pronounced -May have adjusted their lifestyle to accommodate the limitations imposed by the disease -Limb ischemia or gangrene may be first sign of disease in inactive patients -May not walk enough to develop symptoms of claudication due to other comorbid conditions (e.g., COPD, HF) Decreased circulation, although may not be apparent until trauma occurs Intermittent claudication may occur more quickly, with shorter distance or slight incline Cognitive impairment may prevent some from verbalizing symptoms such as pain

Answer 113

Modifications of risk factors Controlled exercise program Medication therapy * Cilostrazol (Pletal) * Aspirin or Clopidogrel (Plavix) * Statins Surgical management * Reserved for treatment of rest pain, severe and disabling claudication, or when limb is at risk for amputation due to tissue necrosis. Include: * Inflow and outflow procedures * Bypass grafting * Amputation Endovascular management * Angioplasty * Atherectomy * Stent or Stent Graft placement

Answer 114

AKA: Percutaneous Transluminal Angioplasty (PTA) and atherectomy -Atherectomy reduces the plaque buildup using a cutting device or laser -Complications of both include hematoma formation, embolus, dissection, acute arterial occlusion & bleeding

Answer 115

Reduces risk for restenosis Complications include: distal embolization, dissection, and dislodgement Can be drug-eluting: Candidates must take antiplatelet meds for 6 months post procedure

Answer 116

Improving peripheral arterial circulation Promoting vasodilation and preventing vascular compression Relieving Pain Maintaining tissue integrity Post-op Care: Primary objective is to maintain circulation within arterial repair -Pulses, Doppler assessment, color and temperature, cap refills, and sensory and motor function of affected extremity are checked can compared to other extremity - Observation are every 15mins initially, then a progressively longer when stable -Complete Doppler evaluation of vessel distal to bypass graft ABI monitored every 8hrs for first 24hrs then once daily until discharge * Not usually assessed with pedal artery bypasses due to risk of compression of anastomosis -Absent pulses may indicate thrombotic occlusion of graft ->Notify surgeon immediately Monitor and manage potential complications * Fluid imbalances, bleeding, thrombosis, edema, and compartment syndrome

Answer 117

Dangerous complication where elevated tissue pressures in non-expansible space -Impedes capillary perfusion MEDICAL EMERGENCY: CALL PROVIDER!!!

Answer 118

Limb flat, in neutral position at the level of the heart Do not elevate or cross legs Remove anything restricting limb

Answer 119

Fasciotomy

Answer 120

Assess the patient's ability to manage ADLs independently & patient's support system Modifications in diet, activity, & hygiene (skin care) -Lose weight & adopt low-fat diet -Slightly elevate feet at rest but not above heart level -Keep feet dependent to increase blood flow to legs (as tolerated, avoid prolonged dependency) -Inspect feet daily, keep clean & dry, go to professional for foot care -Wear proper fitting shoes, avoid walking barefoot -Begin and maintain walking program Monitor for s/s of infection, occlusion of artery or graft, or decreased blood flow: -Encourage plan to stop use of tobacco products -Adherence with medications

Answer 121

Localized sac or dilation formed at a weak point in the wall of the artery

Answer 122

Projects from only 1 side of the vessel

Answer 123

An entire arterial segment becomes dilated

Answer 124

Very small aneurysms due to localized infections

Answer 125

Approximately 70% of all cases caused by atherosclerosis Occur most frequently in hypertensive men between 50-70 years old. Most common site for a dissecting aneurysm -Can develop in ascending, transverse or descending aorta Diagnostic testing include chest Xray, CTA, MRA, or transesophageal echocardiography (TEE)

Answer 126

Chest pain/ Upper back pain: May be more severe in supine position Cough, dyspnea (result of pressure of the aneurysm sac against the trachea), hoarseness, and dysphagia Patient may be asymptomatic

Answer 127

Superficial veins of chest, neck, or arms become dilated Edematous areas on chest wall Cyanosis Unequal pupils: Due to pressure against the cervical sympathetic chain

Answer 128

Most common site for formation is below the renal arteries Most common cause is atherosclerosis Prevalence: * 2-6x more common in men than women * 2-3x more common in white men than black men * Most prevalent in patients >65yrs of age Outcome may be rupture and death if left untreated More than half of patients with aneurysms have HTN -Rupture coexists with HTN and aneurysm >6cm Diagnostic Testing includes duplex ultrasonography or CTA

Answer 129

40% of patients are symptomatic Signs of HF or loud bruit may suggest rupture into vena cava Abdominal pain often localized in the middle or lower abdomen to the left of the midline Persistent or intermittent severe back or abdominal pain: sign of impeding rupture May extend to impinge on the renal, iliac, or mesenteric arteries Cyanosis and mottling of toes (“trashing” or “trash toes”)

Answer 130

Pulsatile mass in the middle and upper abdomen palpable during exam Sensitivity depends on size, abdominal girth, and skill of examiner; more difficult to palpate in obese patient Systolic bruit heard over mass Constant, intense back pain, decrease BP and hematocrit = ____________

Answer 131

Based on whether patient is symptomatic, aneurysm is expanding, contains a dissection, or involves branch vessels Control BP: Maintain SBP at 90-120 mm Hg for MAP of 65-75 mm Hg, pre-op * Thoracic: Beta-blockers, angiotensin receptor blockers (ARBs), hydralazine, and Nitroprusside * Aortic - Diuretics, beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers IV fluid and/or blood administration to maintain graft patency Open surgical repair or endovascular grafts * > or equal to 5.5cm (2 inches) * Grafts preferred * Lumbar spinal drains used to decrease spinal cord ischemia and paraplegia w/ endovascular repairs Cerebrospinal fluid drained to decrease the arterial to cerebral spinal fluid gradient, thereby improving spinal perfusion * Keep cerebrospinal fluid pressure < 10 mm Hg (14 cm H2O) and keep MAP > 90 mm Hg for the first 36 to 48 hours, post-op to prevent neuro deficits Assessments should be focused on anticipation of rupture * System-based assessments * Promptly implement medical therapies to stabilize physiologic function Health Promotion and Risk Factor Management * Controlling BP, smoking cessation, increasing physical activity, maintaining healthy body weight & serum lipids, and regular monitoring of smaller aneurysms

Answer 132

Baseline labs and peripheral vascular assessments Preoperative teaching, emotional support, prophylactic antibiotics, reinforcing NPO status, and bowel preparation

Answer 133

Supine position for 6hrs; HOB elevated up to 45 degrees after 2hrs Assess access site, VS & pulses; doppler assessment q15mins initially, and temperature q4hrs Monitor for complications: -Bleeding or hematoma formation, infection, distal ischemia or embolization, dissection or perforation of aorta, post implantation syndrome, arterial occlusion, kidney injury or erectile dysfunction Fluid maintenance

Answer 134

MEDICAL EMERGENCY! CALL PROVIDER!! Clinical Manifestations: -Symptoms usually sudden -Severe and persistent pain: Described as tearing or ripping; in anterior chest or back and extends to shoulder, epigastric area, or abdomen -May be mistaken for an acute myocardial infarction (MI) -Pale, diaphoresis, or tachycardia -BP elevated or markedly different from one arm to the other if dissection involves the orifice of the subclavian artery on one side

Answer 135

Assessment: Arteriography, multidetector-computed tomography angiography (MDCTA), TEE, duplex ultrasonography, and MRA -Medical/surgical treatment and nursing management same as mentioned with aneurysms

Answer 136

May result from invasive catheters, illicit IV drug use or traumas (fracture, compartment syndrome...) * Embolic or Thrombotic Symptoms depend on size and organ involvement * 6 Ps of pain: Pain, Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia Treatment of thrombosis depends on cause; embolic occlusion usually requires surgery; 4–6-hr window to restore blood flow & prevent irreversible tissue death: * t-PA and heparin * Embolectomy and Thrombectomy - Percutaneous or open surgery

Answer 137

1) Pain 2) Pallor 3) Paresthesia 4) Pulselessness 5) Paralysis 6) Poikilothermia: Inability to regulate core body temperature

Answer 138

Assess for therapy contraindications: -Active internal bleeding -Cerebrovascular hemorrhage -Recent major surgery -Uncontrolled HTN -Pregnancy Protect affected extremity from trauma & minimize punctures Obtain accurate weight (heparin drug admin) Monitor VS – q15mins, then progressively longer when stabilize, pulses, doppler signals, ABI, and motor/sensory functions q4hrs for first 24hrs Monitor for complications of arterial occlusion (acute kidney injury, compartment syndrome, etc.) and therapy (bleeding/systemic hemorrhage)

Answer 139

Form of intermittent arteriolar vasoconstriction

Answer 140

Primary or Idiopathic Raynaud's (w/out underlying disease)

Answer 141

Secondary Raynaud’s (underlying disease, such as systemic lupus erythematosus, RA, or scleroderma trauma, etc.)

Answer 142

Triggered by emotional factors, stress, or by unusual sensitivity to cold

Answer 143

Coldness, pain, and pallor of fingers and toes Rubor, cyanosis, numbness, tingling, and burning pain; symptoms bilateral and symmetrical

Answer 144

Provide patient education * Avoid stimulus that provokes vasoconstriction – cold, stress, nicotine No drugs with vasoconstrictive effects - decongestants and other OTC sympathomimetics * Calcium channel blockers (nifedipine, amlodipine) effective in relieving symptoms * Vasodilator; first line therapy * Education about orthostatic hypotension Analgesics for pain

Answer 145

Vasodilators

Answer 146

...results in stasis of blood

Answer 147

1) Endothelial damage 2) Hypercoagulation 3) Venous stasis

Answer 148

Endothelial Damage: -Central venous catheters -Dialysis Access catheters -Local vein damage -Pacing wires -Repetitive motion injury, surgery, & trauma Venous Stasis: -Age: Older than 65 yrs old -Bed rest /immobilization -HF -History of varicosities -Obesity -Spinal cord injury Altered Coagulation: -Pregnancy -Cancer -Polycythemia -Septicemia -Oral contraceptive use

Answer 149

Thrombus formation in the deep veins in thigh, calf, and sometimes arms (patients with PICC lines) Important predictor of Postthrombotic syndrome is lack of recanalization w/in first 6 months after DVT

Answer 150

Clinical Manifestations: -Pain, warmth, tenderness, edema of extremity ->obstruction of venous flow -Large circumference of the thigh or calf; compare to unaffected extremity -Many cases are asymptomatic - Assess for high risk factors! Venous duplex studies: Veins larger than normal, incompressible, and dilated Lab studies: -Baseline complete blood count (CBC), -Coagulation studies: prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR)

Answer 151

Lifestyle modifications - smoking cessation, weight loss, and regular exercise Graduated compression stockings Intermittent pneumatic compression devices * Early ambulation of hospitalized patients * SQ unfractionated heparin or low-molecular-weight heparin (LMWH)

Answer 152

Objectives are to prevent the thrombus from extending and fragmenting (thus risk of PE), recurrent thromboemboli, and postthrombotic syndrome

Answer 153

Anticoagulant Therapy Unfractionated Heparin (SQ or IV): Prevents extension of thrombus & development of new thrombus Low-Molecular Weight Heparins (e.g., Lovenox) Oral Anticoagulants (e.g., Coumadin) Oral Direct Factor Xa Inhibitors (e.g., Apixaban)

Answer 154

Can be admin either SQ or intermittent/continuous IV -IV dose is based on weight Req aPTT & platelet count monitoring Assess for bleeding Admin protamine sulfate for overdose -Monitor for hypotension & bradycardia if admin

Answer 155

Can be admin either 1X daily or twice a day SQ Associated w/fewer bleeding complications than unfractionated heparin Admin protamine sulfate for OD: Less effective in reversing low-molecular weight heparin OD than unfractionated heparin Can be used in pregnancy, IF clearly indicated -Monitor for bleeding

Answer 156

Vitamin K antagonist Effects occur 12-24 hrs after dose admin -Admin 1X day, at the same time each day Req PT & INR monitoring -PT goal: 1.5-2 times normal -INR goal: 2.0-3.0 Req admin w/heparin during drug initiation until the desired effect is achieved Assess pt for bleeding Admin Vitamin K, fresh-frozen plasma, or prothrombin complex concentrate to reverse OD effects CONTRAINDICATED FOR PREGNANCY!!!

Answer 157

Admin 2X a day Assess renal function Alter dose for obese pts Admin activated charcoal to reverse OD effects

Answer 158

For recurrent or extensive thrombi, high risk for pulmonary embolism, or when anticoagulants or thrombolytic therapy is contraindicated Thrombectomy or Vena Cava Filter: Assess and monitor anticoagulant therapy Monitor and manage potential complications * Bleeding, thrombocytopenia, signs of PE, and drug-drug interactions * Be familiar with meds approved to reverse effects of various anticoagulants Reduce discomfort/Pain Management * Elevate affected extremity, graduated compression stockings, analgesic, or warm packs Position the body and encourage exercise * Periodic elevation of extremity and early ambulation

Answer 159

Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originate(s) somewhere in the venous system or in the right side of the heart

Answer 160

Depends on size of thrombus and the area occluded Dyspnea and tachypnea * Most frequent symptoms * Duration and intensity of dyspnea depends on extent of embolization Chest pain: Common; usually sudden and pleuritic; may be substernal and mimic angina Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope Few s/s in many cases; others may mimic other cardiopulmonary disorders (e.g., pneumonia, heart failure)

Answer 161

Chest Xray: Usually normal; useful in excluding other possible causes ECG: Sinus tachycardia and nonspecific ST-T wave abnormalities Pulse oximetry Arterial blood gas analysis: Hypoxemia and hypercapnia from tachypnea or may be normal D-dimer assay Multidetector Computer Tomography (MDCT) and Pulmonary arteriogram (angiogram) * MDCT standard for diagnosing; angiogram reasonable alternative to MDCT * V/Q scan: Not as accurate as the MDCT or pulmonary angiogram

Answer 162

Medical emergency Thrombolytic therapy with t-PA or other agents * Contraindications: a stroke in the past 2 months, other active intracranial processes, active bleeding, surgery within 10 days of thrombotic event, recent labor and delivery, trauma, or severe HTN * Baseline INR, aPTT, HCT, Plt count needed * Other anticoagulants are discontinued * Only essential invasive procedures during therapy Embolectomy Inferior Vena Cava (IVC) filter

Answer 163

Immediate anticoagulation to prevent recurrence or extension of thrombus * May continue for 10 days * Long-term therapy indicated for 6 months; critical in preventing recurrence; extended indefinitely for high-risk patients * Initial anticoagulant same as for DVT * DOACs often prescribed for outpatient therapy * Long-term treatment options are warfarin and the DOACs. -Regular blood draws and higher bleeding risk with warfarin -DOACs don’t require regular blood testing, more costly Choice of warfarin vs DOACs: Depends on risk of bleeding, cost, presence of comorbidities, and provider preference

Answer 164

Monitor Thrombolytic Therapy: Monitor pt's response to therapy, INR, or aPTT q3-4 hrs after start of thrombolytic infusion -Maintain BR, frequent VS, & invasive procedure Manage Pain: Place in Semi-Fowler's Position (makes it more comfortable to breathe) -Usually pleuritic chest pain than cardiac in origin Manage O2 Therapy: Assess frequently for signs of hypoxemia -Nebulizer therapy/percussion & postural drainage may be used for the management of secretions Relieve Anxiety -Encourage pt to talk about fears and concerns -Answer patient and family questions concisely and accurately, explain therapy, and describe how to recognize untoward effects early Monitor for cardiogenic shock or right ventricular failure Monitor UOP, s/s of infection, maintain BP at level that supports perfusion -Elevates foot of bed, encourages isometric exercises, SCD, and walking when permitted prevents peripheral venous stasis and edema of lower extremities -Educate patient about preventing recurrence and reporting s/s Monitor adherence to treatment plan and reinforce instructions and importance of keeping follow-up appointments for coagulation tests and with primary provider

Answer 165

20-50% of patient with DVT develop Postthrombotic syndrome Results from obstruction of the venous valves in the legs or a reflux of blood through the valves Characterized by chronic venous stasis: * Edema * Altered pigmentation * Pain * Stasis dermatitis Symptoms less in morning and more in the evening Superficial veins may be dilated Disorder is longstanding, difficult to treat, and often disabling Increased risk for injury and infection Venous ulceration is the most serious complication Cellulitis and dermatitis can complicate care

Answer 166

Stasis ulcers develop as a result of rupture of small skin veins and subsequent ulcerations Brownish discoloration of tissues, also known as hemosiderin staining, usually in lower part of extremity, medial malleolus of the ankle Skin dry, cracked, and itchy Subcutaneous tissues fibrose and atrophy

Answer 167

Goal is to reduce venous stasis and prevent ulceration

Answer 168

Protect extremities from trauma Report signs of ulceration immediately to provider for treatment and follow-up Increase venous blood flow * Compression of superficial veins: compression therapy -Graduated compression stockings (not anti-embolism stockings/TED stockings), bandages, external or intermittent pneumatic compression devices -Reduces the pooling of venous blood, enhances venous return to the heart and recommended for people with venous insufficiency

Answer 169

Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves -May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)

Answer 170

Fibrinolytic

Answer 171

Pentoxifylline (Trental) & Cilostazal (Pletal)

Answer 172

Between 21-35 secs

Answer 173

1.5 to 2.5 times the baseline control

Answer 174

Protamine sulfate

Answer 175

Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves -May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)

Answer 176

Symptoms may include: dull aches, muscle cramps, increased muscle fatigue in lower legs, ankle edema, and heaviness in legs; nocturnal cramps Edema, pain, pigmentation, and ulcerations are s/s of chronic venous insufficiency when deep venous obstruction occurs

Answer 177

Provide appropriate post-procedural care and patient education regarding post-op care and/or prevention and proper skin care * Gently pat dry, do not rub the incision * Use sunscreen; avoid skin lotion until completely healed Provide comfort/pain management Monitor for bleeding and s/s of infection Assess for temporary/permanent nerve injury * Reported sensation of “pins and needles”

Answer 178

Avoid activities that cause venous stasis Change position frequently, elevate the legs 3 to 6 inches higher than heart level when tired, and getting up to walk for several minutes of every hour promote circulation Graduated compression stockings, especially knee-high stockings Overweight patients should be encouraged to begin a weight reduction plan

Answer 179

Thermal ablation – targeted heat to seal veins Microphlebectomy – removal of superficial vein w/ small incisions Sclerotherapy – chemical injection Ligation/stripping – surgical removal of deep veins

Answer 180

Inflammation or infection of the lymphatic channels

Answer 181

Inflammation or infection of the lymph nodes

Answer 182

Lymph nodes that are enlarged, red, and tender

Answer 183

Lymph nodes that have become necrotic and form an abscess

Answer 184

Tissue swelling related to obstruction of lymphatic flow -Especially marked when extremity in dependent position -Edema initial soft and pitting; as it progresses, it becomes firm, non-pitting and unresponsive to treatment Frequent bouts of acute infections (high fever & chills) and increased residual edema are seen with chronic swelling * Leads to chronic fibrosis, thickening of the subcutaneous tissues, and hypertrophy of the skin * This specific type of lymphedema is known as elephantiasis in which chronic swelling of the extremity recedes only slightly with elevation

Answer 185

Congenital Malformations - Most common -Usually seen in women

Answer 186

Acquired obstruction -Axillary node dissection (breast cancer) -Leg in association w/ varicose veins or chronic thrombophlebitis -> Usually caused by chronic lymphangitis

Answer 187

Goal of therapy is to reduce and control edema and prevent infection

Answer 188

Manual lymphatic drainage by specially trained therapists Diuretic furosemide Antibiotic therapy when lymphangitis or cellulitis is present for 3-7 days Surgical management

Answer 189

Constant elevation of affected extremity Active and passive exercises External compression devices; Custom-fitted graduated compression stockings or sleeves Monitor for complications: * Flap necrosis * Hematoma * Abscess under the flap * Cellulitis Patient/Family Education * Inspect dressing daily * Report any inflammation or unusual dressing * Expected loss of sensation in surgical area * Avoid use of heating pads or exposure to sun * Skin care

Answer 190

Occurs when a microbe enters through broken skin and release their toxins in the subcutaneous tissues, typically, staph or strep

Answer 191

Localized swelling or redness, warmth and pain frequently associated with systemic symptoms fever, chills, and sweating * Redness may not be uniform; develops a pitting “orange-peel” appearance

Answer 192

Treat with oral or IV antibiotics based on severity Elevate affected area 3-6 inches above heart level * Warm, moist packs to site every 2 to 4 hours * Patients with sensory/circulatory deficits should use caution to avoid burns * Educate regarding prevention of recurrence * Reinforce education about skin and foot care

Answer 193

1) f 2) a & c 3) d 4) d 5) a 6) e 7) b 8) c