Exam 2: Cardiac Flashcards
When a thrombus becomes dislodged and travels what is our biggest life threatening concern
that it will travel to the right side of the heart and become a pulmonary embolus – life threatening
What is a DVT
thrombi developed from platelets, fibrin, RBC, WBC in areas where blood flow is slow or turbulent
What 3 things are involved with the etiology virchow’s triad
Blood: hyper-coagulability
Vessel: vascular damage
Flow: coagulatory stasis
What are risk factors for deep venous thrombosis
heart disease
dehydration
immobility (BR for more than 72 hours, air travel for longer than 4 hours)
paralysis
incompetent vein valves
obesity
pregnancy
surgery
age over 40
female
Risk factors for vessel wall injury
trauma (fracture–long bones and pelvis, burns)
infection
venipuncture
intravenous infusion of irritant solutions
central and peripheral intravenous cath
history of DVT or varicose veins
previous major surgery
Risk factors of hypercoagulability
alterations in hemostatic mechanisms (hemolytic anemias, increased viscosity, inherited coagulation disorders)
trauma or surgery
malignancy
oral contraceptives use
dehydration
Clinical manifestations of the DVT
local pain or tenderness
unilateral edema or swelling
may be bilateral if DVT is located in vena cava
local warmth, redness
mild fever
tender, palpable venous cord in popliteal fossa
positive homan’s signs
no symptoms in 50% of patients
How do we diagnose a DVT…
Noninvasive:
Invasive:
Other exams:
Noninvasive: doppler studies, impedance plethysmography
invasive: venogram
Other: D-dimer, radio labeled fibrinogen scan
Prevention of a DVT
pharm prophylaxis of anticoagulant
mechanical prophylaxis: reduce risk factors as appropriate–immobility, hydration, use of pneumatic devices
Lifestyle modifications: avoid oral contraceptives and smoking
Indications for enoxaparin (lovenox)
total hip arthroplasty
hip fracture
total knee arthroplasty
Indications for danaparoid (Orgaran)
total hip arthroplasty
Indications for Dalteparin (Fragmin)
total hip arthroplasty
Indication for ardeparin (Normiflo)
total knee arthroplasty
Anticoagulant therapy will _________
prevent further clot development
What to know about heparin
SQ or IV
Monitor PTT, H/H, platelets
Assess for bleeding
Initiate bleeding precautions–avoid IM injections, use of razors, soft toothbrushes
Antidote for heparin
protamine sulfate
Indications coumadin (Warfarin)
PO–Initiate concurrently with Heparin therapy
Monitor PT/INR, H/H
teach patient long term implications, dietary considerations, medic alert ID, bleeding precautions
Monitor for signs of bleeding
Antidote for Warfarin
Vitamin K
_______ is a highly selective direct thrombin inhibitor
Bivalirudin (Angiomax)
Thrombolytic therapy
Activate the conversion of plasminogen to plasmin which actively dissolves the clot
We get worried for bleeding
Additional treatments of DVT’s
possible bedrest
pain management
monitor for complications of DVT: PE, Vena cava interruptions/filter
Pulmonary embolisms present with
change in LOC, dyspnea, SOB, productive cough, tachycardia, decreased oxygen saturation
What are indications for vena cava filter placement
recurrent thromboembolisms despite anticoagulation
confirmed deep venous thrombosis or thromboembolism with a contraindication to anticoagulation therapy
complication of anticoagulation requiring discontinuation of therapy
recurrent pulmonary embolism with associated pulmonary hypertension and cor pulmonale
free-floating thrombus
postpulmonary embolectomy
prophylaxis in high risk patients
Varicose veins are
prominent, torturous dilated veins effecting the lower extremities, gravity on venous pressure, valvular incompetence
epidemiology of varicose veins
women in multi pregnancies, increase incidence in women-elderly
Etiology of varicose veins
hereditary factors, obesity, prolonged standing, chronic disease
Symptoms of varicose veins
possibly asymptomatic or swelling, heaviness, pressure, discomfort, nocturnal cramps
Diagnosis of varicose veins
Noninvasive trendelenburg’s test
Treatment of varicose veins
dependent on the severity of varicosities
–> elastic stockings, decrease prolonged standing, lifestyle modifications, avoid tight fitting clothes
Treatment options of varicose veins
sclerotherapy
laser ablation therapy
ligation and stripping surgical procedure
What is sclerotherapy
injection of an irritating solution which leads to fibrosis and obliteration of the vein lumen
outpatient, elastic compression stocking are worn
What is laser ablation therapy
nonsurgical approach using laser fiber contact inside the vein that seals the vein, outpatient compression stockings
Venous ulcers
chronic venous insufficiency (common in legs)
Etiology of venous ulcers
DM, RA, venous stasis, trauma, pressure
Pathophysiology of venous ulcers
leg veins and valves fail to keep blood moving forward, resulting in ambulatory venous htn
serious fluid and RBCs leak from the capillaries and venules into the tissue. This produces edema and chronic inflammatory changes
Enzyme’s in the tissue break down RBCs causing the release of hemosiderin. This causes the brownish skin discoloration.
Skin and subcutaneous tissue around the ankle are replaced by fibrous tissue, resulting in thick, hardened, and contracted skin
Wound management includes
Compression: Unna’s boot
Debridement
Topical therapy: hydrogels, calcium alginate
wound dressing: wet to dry, duoderm
vacuum assisted closure
hyperbaric oxygenation
grafting
PVD: ______ extremities are most often involved
lower
PVD pathophysiology
The most common cause of PVD is atherosclerosis. This is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs. It decreases the oxygen and nutrients sent to the tissue. Blood clots may form on the artery walls. This makes the inner size of the blood vessels even smaller and blocks off major arteries
Complications of PVD
Infection, ulceration, occlusion ischemia, ulcerations, gangrene, amputation
Risk factors of PVD
male
increasing age
smoking
HTN
atherosclerosis
obesity
DM
stress
family history
sedentary lifestyle
hyperlipidemia
Clinical manifestations of occlusive arterial disease
Intermittent claudication
rest pain in advanced disease
diminished hair growth on affected extremities
thick, brittle, slow-growing nails
Shiny, thin, fragile, taut skin
dry, scaly skin
cool skin temperature
diminished or absent pulses
pale, blanched appearance w/ extremities elevation
red coloration w/ extremities in dependent position
decreased motor function
ulcer formation with advanced disease
ankle brachial index of 0.5-0.95
What does ankle brachial index measure
what is the normal and abnormal value
difference in upper extremities and lower extremities blood pressures
normal: 1
arterial insufficiency: 0.5-0.95
ischemic rest pain: 0.5 or less (ultrasound, exercise testing, and arteriography)
Management of the patient with PVD
lifestyle modifications/positioning
interventional radiologic procedures
surgical management: bypass grafting
complications of PVD
re thrombosis, embolism, vasospasm, bleeding
Complications with management of arterial ulceration
treatment
intermittent claudication
small, circular, deep ulcerations–gangrene
toes, web spaces between toes, medial side of foot
treatment: see venous ulcer care, possible amputation
What is the goal with a patient that is going to undergo amputation
preserve as much functioning as possible, while removing infected or necrotic tissue
Amputation: elevate the stump for
first 24 hours
Crutch walking: an accurate measurement of the client for crutches is important because
what is it
an incorrect measurement could damage the brachial plexus
the distance between the axilla and the arm pieces on the crutches should be two finger widths in the axilla space
the elbow should be slightly flexed 20 to 30 degrees when walking
Crutch walking: when ambulating with the client, stand on the
affected side
Crutch walking: instruct the client to never rest
on the axilla of the axillary bars
Crutch walking: instruct the client to look
up and outward when ambulating
Crutch walking: upstairs
walk close to the first stair and hold onto the stair rail
hold onto the rail with one hand and the crutch with the other
push down on the stair rail and the crutch and step up with the good leg
If not allowed to place weight on the “bad” leg, hop up with the “good” leg
If able to place weight, bring the “bad” leg and the crutch up beside the good leg
Lead with good leg
Crutch walking: down stairs
walk to the edge of the stairs in the same way
place the “bad” leg and the crutch down on the step below; support weight by leaning on the crutches and the stair rail
bring the “good” leg down
remember the “bad” leg goes down first and the crutch moves with the “bad leg”
What is buerger’s disease (thromboangiitis obliterans)
obstructive vascular disorder caused by inflammation in the arteries and veins
What is the etiology of buerger’s disease (thromboangiitis obliterans)
Men 20 to 40 years of age, increase in middle east, asia and jewish heritage
buerger’s disease (thromboangiitis obliterans) disease only occurs in ______________
SMOKERS
buerger’s disease (thromboangiitis obliterans) predominantly effects
the lower extremities
buerger’s disease (thromboangiitis obliterans): pathophysiology
effects small and medium arteries and veins –> progressive claudication, cyanosis, coldness, rest pain
buerger’s disease (thromboangiitis obliterans): management goal
arrest disease process and prevent amputation
buerger’s disease (thromboangiitis obliterans): treatment
smoking cessation
calcium channel blockers
Iloprost
thrombolytics
possible amputation
patient/family teaching
Raynaud’s disease
episodic vasospasm involving the arteries of the fingers and toes
Raynaud’s disease: etiology
women
exposure to stress, tobacco, caffiene, cold, vibration
Raynaud’s disease: characteristics
symmetrical/bilateral
ischemic phase-cold, pale, numb
hyperemic phase redness, swelling, throbbing pain
lasts minutes–may persist for hours
Raynaud’s disease: Complications
ulceration, gangrene
Raynaud’s disease: management
mild–no treatment necessary to avoid precipitating factors
drugs: CCB, vascular smooth muscle relaxant, vasodilators, iloprost
sympathectomy
patient/family teaching
Acute arterial occlusive disease: pathophysiology
Acute arterial occlusion, also known as acute limb ischemia, is a medical emergency that occurs when a peripheral artery is suddenly blocked, preventing blood flow to a limb
Acute arterial occlusive disease: complications
necrosis, gangrene, amputation
Acute arterial occlusive disease: 6 P’s
pain
pallor
pulselessness
paresthesia
poikilothermia
paralysis
Acute arterial occlusive disease: diagnosis
physical exam, ultrasound, angiography
Acute arterial occlusive disease: management
anticoagulants, thrombolytics, CCB, pain medication
endovascular procedures-balloon angioplasty
surgical treatment-embolectomy
Acute arterial occlusion: guidelines for safe practice
monitor the affected limb for any change in circulatory status
monitor temp, color, sensation, and pain
monitor peripheral pulses
keep the extremities warm, but don’t apply direct heat
avoid chilling
maintain BR unless activity is specifically ordered
keep the extremities flat or in slightly dependent position to promote perfusion
use an overbed cradle to protect a painful extremity from the pressure of linens
use a sheepskin and 4-in foam mattress beneath the extremity
do not elevate the bed at the knee; no crossing legs
keep the head of the bed low to support circulation to the lower extremities
Aneurysms
weakness, out pouching or dilation of an artery
Aneurysms commonly occur in
aortic-thoracic or abdominal
Aneurysms etiology
men 50 to 70
atherosclerotic disease, trauma, syphilis, congenital, infection
smoking, HTN, PVD, hyperlipidemia, genetic disposition
Types of aneurysms: fusiform
entire circumferential segment of the vessel–> diffuse dilated lesion
Types of aneurysms: saccular
Involve only a portion of the circumference of the vessel, appears to have an out pouching
Types of aneurysms: myctotic
rare; infectious aneurysms of the aorta caused by…
staph
strep
salmonellae
Types of aneurysms: pseudoaneurysms
adventitia is dilated, although the media and intimal layers are unaffected –> clots can mimick this
Aneurysms: characteristics
