Chapter 35 Flashcards
Usually forms in the heart, but a roughened atheromatous plaque in any artery also can lead to thrombus formation
If a thrombus breaks loose, it becomes an embolus and travels through the circulatory system until it lodges in a vessel, blocking blood flow distal to the occlusion
Thrombi from the right side of the heart lodges in the lungs causing a PE
Thrombi from the left side of the heart usually affects the legs
Arterial emboli
Signs and symptoms of arterial emboli
Severe, acute pain
Gradual loss of sensory and motor function in the affected areas
Pain aggravated by movement or pressure
Absent distal pulses
Pallor and mottling (irregular discoloration)
Sharp line of color and temperature demarcation: tissue beyond the obstruction is pale and cool
Medical and surgical treatment for arterial emboli
Intravenous anticoagulants and thrombolytic agents
Embolectomy
When should anticoagulant not be used
Active internal bleeding Cardiovascular accident Recent major surgery Uncontrolled hypertension pregnancy
Arterial embolism dx/intervention
Inadequate tissue perfusion Stress Immobility Skin breakdown Inadequate self care
common sites of occlusion for peripheral arterial disease
Common sites for arterial occlusion are the distal superficial femoral and the popliteal arteries
Hypoxia affects all tissues distal to the occlusion in what condition
Peripheral arterial disease
Signs and symptoms of peripheral artery disease
Intermittent claudication (classic sign)
Absence of peripheral pulses below occlusive area
Rest pain (persistent and aching)
Shiny, scaly skin
Pale color
Hairlessness
Ulcers with a gray or yellowish hue (tips of toes, foot, lateral malleolus)
Medical diagnosis of peripheral artery disease
Plethysmography
Duplex imaging
Angiography (if surgery is indicated)
Medical treatment for peripheral artery disease
Lifestyle changes
Smoking cessation
exercise
weight management
Drugs for claudification
cilostazol and Plavix are anticoagulant
pentoxifylline which is a blood viscosity reducing agent
Nursing diagnosis of peripheral artery disease
Impaired activity tolerance Pain Skin breakdown Altered body image Inadequate peripheral circulation Inadequate self-care management Potential infection Inadequate cardiac output Inadequate peripheral circulation Impaired physical mobility
Inflammatory thrombotic disorder of arteries and veins in lower and upper extremities
Thromboangiitis Obliterans aka(Buerger Disease)
intermittent claudication, rest pain, skin color/temperature changes in affected areas, cold sensitivity, abnormal sensation, ulceration, gangrene
Signs and symptoms of Thromboangiitis Obliterans
What is the most important treatment for Thromboangiitis Obliterans
Most important treatment is smoking cessation
affects hands primarily.
Can also affect tips of nose toes
Raynaurds disease
Signs and symptoms of Raynaud disease
Chronically cold hands, numbness, tingling, and pallor
Finger involvement is not symmetric and the thumb is typicall not involved
During an arterial spasm, the skin color changes from pallor to cyanosis to redness
Based on the signs and symptoms and on the absence of evidence of occlusive vascular disease
Raynaurd disease
Nursing diagnosis of Raynaud disease
Pain
Inadequate peripheral tissue oxygenation
stress
A dilated segment of an artery caused by weakness and stretching of the arterial wall
Aneurysm
Most common type of aneurysm
Atherosclerosis
Most common site of aneurysm
Abdominal aorta
Sign and symptoms of aneurysm
Thoracic aneurysms usually have no symptoms, though some report deep, diffuse chest pain
If aneurysm puts pressure on the recurrent laryngeal nerve, patient may complain of hoarseness
Pressure on the coronary arteries can cause angina
Pressure on the esophagus may cause dysphagia
Pressure on the superior vena cava may have edema of the head and arms
Pressure on the pulmonary structures may cause airway obstruction
Aneurysm post operative care
Mark the pedal pulses
Critical care unit for 24-48 hours
Monitor vital signs, hemodynamic status, renal function, and fluid balance
Inspect and palpate the extremities for color, warmth, and peripheral pulses
A small tear in the intima permits blood to escape into the space between the intima and the media
Blood accumulates between the layers, causing the media to split lengthwise
Aortic dissection
Varicosities are dilated, tortuous, superficial veins, often the saphenous veins in the lower extremities
Varicose vein
Dilation of the vessels results from incompetent valves in the veins
Varicose vein
Avoid restrictive garments, prolonged standing or sitting, crossing the legs or knees, and injury to compromised areas
Weight reduction
Support stockings
Sclerotherapy, light therapy, or laser therapy
Ligation and stripping
Varicose vein
Virchow’s triad
Stasis of the blood
Damage to the vessel walls
Hypercoagulability
Pain, redness, warmth, or tenderness in the affected area vein that fells firm and cordlike when palpated
Area around the vein may be warm, red, and tender.
SVT
Edema, pain, warmth, and tenderness at the area of compromise
May have slight elevation in the systemic temperature
DVT
Medical treatment for venous thrombosis
Anticoagulant or thrombolytic therapy, or both
Skin breakdown Pain Anxiety Inability to tolerate activity Inadequate peripheral tissue oxygenation Impaired pulmonary oxygenation Inadequate self care
Nursing diagnosis of venous thrombosis
Culmination of long-standing pressure that stretches the veins and damages the valves
Patho of chronic venous insufficiency
Edema around the lower legs, pain, brownish skin discoloration (stasis dermatitis), and stasis ulcerations
Heaviness or dull ache in the calf or thigh
Skin temperature is warm, and nails are normal
Feet and ankles often cyanotic when in a dependent position
Peripheral pulses are present, but due to edema, they may be difficult to palpate
Signs and symptoms of chronic venous insufficiency
Nursing diagnosis of chronic venous insufficiency
Inadequate peripheral tissue oxygenation
Impaired self concept
Potential infection
Skin breakdown
Acute inflammation of the lymphatic channels
The inflammation is the result of an infectious process, usually caused by streptococcus
Lymphangitis
Enlargement of the lymph nodes along the lymphatic channel
Tenderness as these nodes are assessed
Red streak from the infected wound extends up the extremity along the path of the lymphatics
Elevated temperature and chills
Signs and symptoms of lymphangitis
Diagnosis of lymphangitis
Wound culture and Lymphangiography
Antimicrobials
Abscess is incised to drain the suppurative material
Rest and elevation of the limb; warm, wet dressings; and elastic support hose
Surgical treatment of lymphangitis
Analgesics, antimicrobials, and elevation of the extremity to reduce lymphedema
Application of warm, moist soaks to the infected areas
Elastic support hose
Interventions of lymphangitis
Systolic: <120 mm Hg; diastolic <80 mm Hg
Normal Blood Pressure
Systolic between 120 and 139; diastolic between 80 and 89
Prehypertension
140-159 SBP and 90-99 DBP
Stage 1
≥160 over ≥ 100
Stage 2
