Chapter 38 Flashcards
Taking VS
Auscultating all lung fields
Monitoring O2
Assessing cognition
Checking incisions, body orifices and under the patient for signs of active bleeding
Assessing he skin for bruises and petechiae
Examining all body areas of swelling or discoloration that could indicate internal bleeding
Perform and interpret physical assessment in patients experiencing inadequate oxygenation and tissue perfusion as a result of hypovolemic shock
Muscle pain caused by an inadequate blood supply
Claudication
uncommon occlusive disease of the arteries and veins in the distal portion of the upper and lower extremities
-often extends into the tissues around the vessels, resulting in fibrosis and scarring that bind the artery, vein, and nerve firmly together
Buerger’s Disease (thromboangiitis Obliterans)
permanent localized dilation of an artery which enlarges the artery to at least two times its normal diameter
Aneurysm
to evaluate outflow disease compare ankle pressure with brachial pressure
- dividing the ankle blood pressure by the brachial blood pressure
- ABI less than 0.9 in either leg diagnostic of PAD
Ankle-Brachial index (ABI)
Classic leg pain usually can only walk only a certain distance before a cramping burning muscle discomfort or pain forces them to stop
Intermittent Claudication
involve the femoral, popliteal, and tibial arteries and are below the superficial femoral artery
Outflow Obstructions
Involve the distal end of the aorta and the common, internal, and external iliac arteries
-located above the inguinal ligament
Inflow Obstructions
Systemic atherosclerosis
-chronic condition in which partial or total arterial occlusion (blockage) deprives the lower extremities of oxygen and nutrients
Peripheral Arterial Disease (PAD)
disorders that change the natural flow of blood through the arteries and veins of the peripheral circulation
Peripheral Vascular Disease (PVD)
reddish brown discoloration along the ankles, extending up to the calf
Stasis Dermatitis
results of prolonged venous hypertension that stretches the veins and damages the valves
Venous insufficiency
taking VS assessing peripheral pulses assessing capillary refill checking for sensation and temp completing a pain assessment assessing ulcer
Perform and interpret physical assessment
When patient experiencing inadequate oxygenation and tissue perfusion as a result of peripheral vascular disease
notifying physician immediately or call RRT if aortic rupture suspected
monitoring VS
giving O2 if aneurysm rupture suspected
starting IV line if aneurysm rupture suspected
documenting abnormal peripheral vascular assessment findings
elevating legs if swollen unless arterial blood flow is poor
Respond to patients experiencing inadequate oxygenation and tissue perfusion as a result of peripheral vascular disease
think about how you responded
continue to monitor patient for changes in peripheral blood flow, including pulse assessments
observe patient for decreased report of pain
What should you Reflect on
Redness and swelling in lower leg (venous)
pallor cyanosis (darkened), mottling or rubor in lower leg (atrial )
report of pain/ cramping in lower legs or hands (at rest or during activity)
Ulcers on ankles feet or digitis
Pulsating mass in abdomen (abnormal aortic aneurysm)
decreased level of consciousnes (LOC), diaphoresis, decreased urine output (rupturing aortic aneurysm)
Might notice if the patient is experiencing inadequate oxygenation and tissue perfusion as a result of Vascular Problems
turbulent swishing sound which can be soft or loud in pitch
-result of blood trying to pass through a narrowed artery
Bruit
insufficient supply of blood to an organ, usually due to a blocked artery
Ischemia
provider discontinues heparin admin
- platelet count <150,000
- white clot syndrome
Heparin-induced thrombocytopenia (HIT)
a type of arteriosclerosis, involves formation of plaque within the arterial wall and is leading factor for CVD
Atherosclerosis
thickening or hardening of the arterial wall that is often associated with aging
Arteriosclerosis
disturbances in blood flow which result in damage to tissues of the extremities and organs due to ischemia and the excessive accumulation of waste/fluid due to venous/lymphatic stasis
-condition of blood vessels lending to narrowing and hardening of arteries that supply legs/feet
Peripheral Vascular Disease
lower blood pressure by interfering with the transmembrane flux of calcium ions
- vasodilation decreasing BP
- Blocks SA and AV node conduction, decreasing HR
Calcium Channel Blockers
severe type of elevated blood pressure that rapidly progress
Malignant Hypertension
