Perfusion: Peripheral Vascular Disorders Flashcards
Different parts of the vascular system
- arteries, arterioles, and capillaries
- veins, venules
- lymphatic vessels
What do lymphatic vessels do?
collects lymph back to venous circulation
Functions of vascular system (5)
- provides oxygen and nutrients
- removes metabolites, toxins and CO2
- fluid exchange across capillaries: interstitial fluid
- sympathetic stimulation: vasoconstriction
- constriction of arterioles
What does the constriction of arterioles do?
increased vascular resistance to blood flow
Pathophysiology of Vascular System (6) (issues in the body)
- pump failure
- vessel alterations
- arterial occlusion
- lymphatic obstruction
- edema
- Increased risk for tissue breakdown and infection
Pump failure patho
-right or left HF, a fib (blood stasis)
vessel alterations patho (happens from what diseases?)
-damage (HTN, DM), thromboembolism (DVT, arterial thrombus)
arterial occlusion patho
tissue ischemia, venous occlusion, edema
lympathic obstruction cause…
edema
Why is edema an issue with perfusion?
tissues receive less perfusion due to pressure from excess fluid causing less O2 and less nutrition
Arterial insufficiency/ PAD
narrowing of the arteries, commonly the pelvis and legs
Clinical symptoms of PAD (3)
cramping, pain, tired legs or hip muscles that worsens during walking/activity and subsides with rest
Venous insufficiency/PVD
inadequate return of venous blood from the legs to the heart
clinical symptoms of PVD
tired/heavy, achy cramping in the legs, pain worsens when standing and improves with leg elevation and activity
Vascular system- gerontological considerations (5)
- less vessel elasticity
- calcification
- stiffen vessel’s, increased peripheral resistance, impaired blood flow
- Ischemia, thrombosis, increased BP, LV hypertrophy
- Increased risk for peripheral vascular disorders
Vascular system physical assessment (5)
- skin: Color (pallor, rubor, brown), temp, hair, nails, gangrene
- pulses: dorsalis pedis, post-tibial, popliteal, cap refill
- edema
- sensation: numbness, tingling
- motor: 1-5 motor strength
Neuromuscular assessment (7)
- color
- temp
- cap refill
- peripheral pulses
- swelling
- movement
- sensation
PAD general characteristics (pain, pulses, skin characteristics)
- pain: intermittent claudication to sharp, unrelenting, constant
- pulses: diminished or absent
- skin characteristics: elevation of pallor foot, loss of hair over toes
PAD ulcer characteristics
-very painful, pale to black, minimal leg edema, deep depth of ulcer, circular
PVD general characteristics (pain, pulses, skin characteristics)
- pain: aching, cramping
- pulses: present, but may be difficult to palpate through edema
- skin characteristics: pigmentation, skin thickened and tough.
PVD ulcer characteristics
-minimal pain, superficial depth of ulcer. irregular border, granulation tissue (beefy to yellow), moderate to severe leg edema
When is a doppler ultrasound used?
when pulses cannot be found
What is ABI?
ankle-brachial index
How is ABI calculated?
highest ankle SBP in each foot divided by higher brachial SBP
Result of 1 or higher ABI
no arterial insufficiency or incompressible vessel (ex: pediatric patients with calcified vessels)
Result of 0.50-0.90 ABI
mild to moderate arterial insufficiency
Result of < 0.50 ABI
ischemic rest pain
Result of < 0.40 ABI
severe ischemia or tissue loss
When to assess ABI (5)
- any patient with decreased pulses
- any. patient with hx of poorly controlled diabetes or HTN
- patient 50 or older with a hx of DM or smoking
- pt who undergo an arterial interventional surgery or procedure
- sudden cold or painful limb
Vascular system diagnostic tests (5)
- exercise testing
- dupplex ultrasonography
- CT scan
- angiography
- MRI angiography
Exercise testing (what it is and normal response)
ABI in response to walking- normal response little or no drop in ABI
Dupplex ultrasonography assesses what?
assess blood flow, occlusion, stenosis, plaque
CT scan
images of soft tissues
Renal patients require ….
pre-procedure tx for prevention of contrast induced nephropathy: monitor output
What needs to be administered for iodine/shellfish allergies before a contrast scan?
steroids/histamine blockers
angiography. (What it is, monitor for what?)
contrast into arterial system for vessel visualization; monitor access site for bleeding
MRI angiography contraindications
metal implants or devices, old tattoo
Care for MRI angiography
similar to angiography; pt education; sedative if claustraphobic
D-dimer test
positive may indicate presence of blood clot- diagnosis by CT scan
venography (what it is, may cause, monitor for)
contrast into veins; may cause inflammation, monitor for hematoma
lymphoscintigraphy
contrast injection into lymphatic system; injection site stain blue, blue drainage on incisions for several days
arterial disorders (arteriosclerosis and atherosclerosis) What happens in the body for both
- arteriosclerosis: hardening/thickening of arteries
- atherosclerosis: accumulation of plaque; stenosis, thrombosis, aneurysm, ulceration, rupture, organ ischemia (fatty streaks, fibrous plaque)
Modifiable risk factors of PAD (9)
- nicotine use
- diet
- HTN
- diabetes
- hyperlipidemia
- stress
- sedentary lifestyle
- elevated C-reactive protein
- hyperhomocyteinemia
Nonmodifiable risk factors of PAD (3)
- increasing age
- female gender
- familial predisposition/genetics
PAD prevention (4)
- monitor lipid panel; diet and life style modification for hyperlipidemia and HTN
- LDL < 100mg/dL (<70 for DM, tobacco, atherosclerosis, HTN)
- total cholesterol < 200 mg/dL
- regular exercise, weight management, statins, ASA, clopidogrel
Clinical manifestations of PAD (6)
- decreased or unequal _____, extremities ____, cool, decreased ____ refill, hair or no hair?
- may have decreased ____ and ___
- _____ _____: pain during activity due to quick drain of O2 from tissues
- _____ disease
- _____ disease
- ____, ____, ___: decreased perfusion, sensation and movement
- decreased or unequal pulses, extremity pale, cool, decreased cap refill, hairless
- may have decreased sensation and movement
- Intermittent claudication: pain during activity due to quick drain of O2 from tissues
- raynauds disease
- beurgers disease
- hands, feet, toes: decreased perfusion, sensation and movement
Raynauds disease
cold temperatures trigger acute vasospasm (blue fingers)
Buergers disease
tobacco use triggers chronic vasospasm
PAD medical management
- improvement of blood supply: angioplasty, stent placement, bypass
- carotid atherosclerosis: endarterectomy
PAD nursing collaboration: RN role
-promote perfusion, maintain function
PAD nursing collaboration: post op patient priority
distal neuromuscular assessment
PAD nursing collaboration: promote perfusion (2)
- doppler US and ABI as ordered
- mental status, VS, UO, Hg
PAD nursing collaboration (8)
- how to keep lower extremities
- application of ____. avoid ___ temp
- careful with temp and very ____ heating pads or bottles
- smoking ___, ____ management
- promote ___ ___: Infection tx, avoid. ___
- no ____between toes, no vigorous scratching, rubbing; no crossing ___
- may need ____ for foot care, special footwear
- good ____
- keep lower extremities in neutral or dependent position
- application of warmth, avoid exposure to cold temps
- careful with temperature and very hot heating pads or bottles
- smoking cessation, stress management
- promote tissue integrity: infection tx, avoid trauma
- no lotion between toes, no vigorous scratching, rubbing; no crossing legs
- may need podiatrist for foot care, special footwear
- good nutrition
How to manage intermittent claudication
-walk to the point of pain, rest and resume walkin- increase of collateral circulation and endurance
What is clopidogrel (plavix)?
FDA approved for intermittent claudication; may improve perfusion
How to manage Raynauds disease?
avoid outside activity during cold weather; exercise indoors, heating only with body temp devices (gloves)
How to manage beurgers disease?
immediate smoking cessation
What happens in venous disorders?
reduced blood flow –> blood stasis
Clinical manifestations of venous disorders
-based on pathophysiology (PE, DVT, venous insufficiency, varicose veins): may include dependent edema, skin brown and leathery, irregular border wounds around ankles
What is Virchow’s triad?
- shows an increased risk of VTE
- endothelial damage, venous stasis, altered coagulation
Risk factors of endothelial damage (7)
- trauma
- surgery
- pacing wires
- central venous catheters
- dialysis access catheters
- local vein damage
- repetitive motion injury
risk factors for venous stasis (5)
- bed rest or immobilization
- obesity
- hx of variscosities
- spinal cord injury
- age > 65
Risk factors for altered coagulation (13)
- cancer
- pregnancy
- oral contraceptive use
- protein C. deficiency
- protein S deficiency
- antiphospholipid antibody syndrome
- Factor V leiden defect
- prothrombin G20210A defect
- hyperhomocysteinemia
- elevated factors II, VIII, IX, XI
- antithrombin III deficiency
- polycythemia
- septicemia
DVT clinical manifestations (4)
- nonspecific (may go undetected)
- may lead to edema, pain, feeling of limb heaviness; increased temp of affected leg
- measure limb circumference, no Homan’s sign -> calf pain at dorsiflexion (no clinical value)
- unusual edema, redness after orthopedic surgery (call provider)
DVT or PE diagnosis
-D-Dimer test
D-Dimer results (negative, positive, false positive, what is used for final VTE diagnosis)
- negative result rules out DVT; positive result not diagnostic: must have imaging result (CT scan)
- false positive: inflammatory disease, malignancy, pregnancy, recent surgery or trauma
- final VTE diagnosis: US, CT, MRI
DVT Prevention (8)
- increased ___ intake for at-risk patients
- graduated compression stockings, intermittent pneumatic devices
- early ____ after surgery, leg exercises
- LWMH: ____, ____
- lifestyle changes: ____ loss, ____ cessation, regular ____
- Prevention of ___ growth and fragmentation with _____.
- ____ therapy: clot dissolution, ICU patient monitoring
- increased fluid intake for at-risk patients
- graduated compression stockings, intermittent pneumatic devices
- early mobilization after surgery, leg exercises
- LWMH: enoxaparin, dalteparin
- lifestyle changes: weight loss, smoking cessation, regular exercise
- Prevention of clot. growth and fragmentation: anticoagulation.
- thrombolytic therapy: clot dissolution, ICU patient monitoring
- anticoag meds
examples of anticoagulants (6)
- heparin,
- LMWH
- warfarin
- fondaparinux
- dabigatran
- rivaroxaban
Heparin (____ tx, if drip, ____ monitoring: reduced dosage for ______ patients)
acute treatment, if drip, intensive monitoring; reduced dosage for renal patients
what to monitor when on heparin
APTT, INR, platelets
therapeutic level for heparin
1.5-2 times control level (follow facility policy)
What is normal APTT?
30-40 seconds
What is the antidote for heparin?
protamine sulfate
Ex of LMWH
enoxaparin (lovenox), dalteparin
What is LMWH? What is it based on?
Low molecular weight heparin; subq tx based on patients weight
Difference between Heparin and LMWH
fewer bleeding complications than heparin.
What to monitor for LMWH
platelets
antidote for LMWH
protamine (partial action)
What to use for extended treatment of warfarin
Vitamin K antagonist for extended treatment
Interactions for warfarin
other meds, OTC, herbs and food contains vitamin k (dark greens, beans, prunes, tuna, peas, soy)
warfarin causes an increase risk of ___
bone fractures
Pt ed about warfarin
-must tell providers about warfarin use, use bracelet, assess for symptoms of bleeding, regular follow up
Bridge therapy with ___ for ___to ___ days until full warfarin effect
heparin, 3-5 days
Normal INR
2-3
Antidote for warfarin
vitamin K
ex of Factor Xa inhibitors
fondaparinux subq injection, apixaban (eliquis), rivaroxaban (Xarelto), Dabigatran (pradaxa)
Caution with what patients for Factor Xa inhibitors
renal disease
Lab monitoring for factor Xa inhibitors
no lab monitoring necessary
What are factor Xa inhibitors used for
prophylaxis ortho surgeries, VTE tx
Apixaban issue
33% of pts on axiban used at least one non prescription drug that may cause dangerous side effects in combination with this blood thinner
Nursing ed for apixaban
no OTC or prescription med without review from provider
Antidotes for Xarelto and Eliquis
Andexxa
Antidotes for Pradaxa
idarucizumab
What do thrombolytic drugs do?
lyses and dissolves clots
Ex of thrombolytic meds
alteplase, reteplase, tenecteplase, urokinase
When should thrombolytic meds be given
within 3 days of acute thrombosis
How are thrombolytic meds administers
through a catheter
Thrombolytic meds require ____
extensive monitoring
Ex of antiplatelet action med
clopidogrel
What does clopidegrol do?
prevents clots
The FDA approved Clopidegrol for what? Risk for?
intermittent claudication, risk for heart disease and stroke
What must be screened for a patient on clopidegrol? What must be monitored?
bloody urine or stools
monitor platelets
What needs to be monitored for a pt on anticoagulation therapy?
monitor for bleeding: labs, VS, physical assessment
PT ed for pt on anticoagulant therapy
-monitor stool (red and dark) and urine, teeth brushing, shaving, symptoms of bleeding (unusual fatigue, tachycardia)
Compression therapy
- stockings: place before leaving bed with no uneven pressure points
- physical assessments: must take off stockings
- extremity elevation at rest: promote venous return
- promote early and regular exercise
Chronic venous insufficiency
- obstruction of partial closure of venous valves: venous HTN
- vein distention: back flow of venous blood
- dependent edema, hemosiderin staining (degeneration of RBC in peripheral tissue)
- dry, lethal skin, subq fibrosis, ulcers
Management of venous insufficiency
- elevate extremity (15-20 mini four times daily)
- no prolonged sitting or standing, no leg crossing
- no constricting clothes, socks
- compression stocking essential
- protect extremity from trauma
Arterial leg ulcer characteristics
small, circular, deep, unrelenting pain
venous leg ulcer characteristics
medial or lateral malleolus, aching pains or painless, larger, superficial, moist, irregular borders
Leg ulcer treatment
- compression therapy for venous ulcers
- debridement
- Infection tx
- wound dressing
- skin graft, hyperbaric oxygenation
varicose veins
- due to incompetent venous valves
- lower extremities (Saphenous veins), esophagus, lower trunk
- dull ache, muscle fatigue, ankle edema, feeling of extremity heaviness
- Duplex US: ID reflux site and severity
Varicose veins prevention
- avoid activities that promote venous stasis: tight socks/clothes, crossing legs, long periods of sitting or standing
- change position frequently, elevate extremity higher than heart several times a day
- get up and walk for several minutes every hours; walk 1-2 miles/day
- graduated compression stockings: place while still in bed with no uneven pressure points
- weight reduction
- good nutrition
Varicose veins medical management
- ligation (occlusion) and stripping (removal)
- sclerotherapy: injection of irritating chemical causing vein lumen obliteration; palliative not curing
Perioperative varicose vein management
- bed rest discouraged: ambulate as soon as sedation wears off
- walk hourly for 5-10 min while awake during first 24 hours
- graduated compression stockings for 1 week
- Implement prevention measures
What is lymphedema?
tissue swelling due to inefficient lymphatic drainage
What are lymphedema characteristics?
firm, non-pitting, unresponsive to tx
When can lymphedema happen?
congenital or secondary to node dissection
lymphedema management
reduce, control edema, prevent infection: exercises, GCS, annual drainage, skin care, no BP cuffs, diuretics, elevation
RN Role for Venous diseases
promote perfusion, maintain or improve function
