PVD/DVT/Arteriosclerosis Flashcards
are conditions affecting the peripheral arteries and veins. (can’t get blood back up)
PVD’s; Peripheral Vascular Disease
thickening, loss of elasticity and buildup of calcification on arterial walls.
Arteriosclerosis
a form of arteriosclerosis in which deposits of fat and fibrin obstruct and harden the arteries.
-These pathologic changes impair perfusion to the peripheral tissues and this is PVD.
Atherosclerosis
Inadequate venous return
DVT is most common cause
Chronic venous insufficiency
Peripheral Arterial Disease/Peripheral Atherosclerotic Disease
PAD
lesions obstruct vessel lumen
- Collateral circulation develops; inadequate to meet tissue needs.
- Manifestations occur when vessels are more than 60% occluded.
- Arterial Ulcers may develop.
Peripheral Arterial Disease/Peripheral Atherosclerotic Disease (PAD)
Venous blood stagnates. (can’t get blood back to heart).
- Pressures increase and may impede arterial flow.
- Cells die. Red cell breakdown causes brown pigmentation. (hemosiderin; iron deposited)
- Venous stasis ulcers develop
Chronic venous insufficiency (CVI)
Affects people in their 60’s and 70’s; Men more than women.
Etiology of Arterial insufficiency
Diabetes mellitus
- hypercholesterolemia
- hypertension
- cigarette smoking
- high homocystine levels; increasing PVT
- obesity
- sedentary lifestyle
Risk factors for Arterial insufficiency
- thrombophlebitits
- obesity
- prolonged standing or sitting.
- Right sided heart failure
Risk Factors for Venous insufficiency
- Intermittent claudication
- Rest pain
- Paresthesias (numbness)
- weak, absent pulses
- Pallor with extremity elevation, dependent rubor (redness)
- Thin, shiny, hairless skin, thickened toenails
- Areas of discoloration/skin breakdown
Clinical Manifestations of Peripheral Atherosclerosis
-Edema
-Itching, dull leg pain increases with standing
-Thin shiny atrophic skin
-Cyanosis and brown skin pigmentation of lower leg and foot (hemosiderin)
-Possible weeping dermatitis
-Thick, fibrous (hard) SC tissue
-Recurrent ulcerations of medial or anterior ankle.
-
Clinical Manifestations of Chronic Venous Insufficiency
- Toes, feet, shin
- Ulcer appears-deep, pale
- skin, normal to atrophic
- pallor on elevation and Rubor when dependent
- skin temp Cool
- Edema; absent or mild
- Pain; severe/intermittent claudication/rest pain
- Gangrene may occur
- Pulses decreased or absent
Arterial Ulcers
- Ankle (medial and anterior)
- Ulcer; pink superficial
- Skin; brown, stasis dermatitis, Cyanosis on dependency (down)
- Skin temp; normal warmer
- Edema may be significant
- Pain-usually mild/aching
- No gangrene
- pulses normal.
Venous Ulcers
- Slow atherosclerosis
- maintain tissue perfusion
- keep legs dependent/down
Management of PAD; Peripherial Arterial Disease/ Atherosclerotic
- Relieving symptoms, promoting adequate circulation and prevent tissue damage.
- Reduce edema; diuretics.
- Treat ulcers
- Hosiery/teds
- Elevation of the legs frequently during day and above heart level at night.
Management of CVI; chronic venous insuff
Diagnostic tests
Segmental pressure measurements
Stress testing
Doppler ultrasound; DVT?
Transcutaneous oximetry evaluates oxygenation of tissues
Angiography or Magnetic resonance angiography. SP of ankle over SP of brachial
ankle pressure should be higher than brachial
Management of PAD and CVI
(Perpheral Arterial Disease/Peripheral Atherosclerotic Disease)
(Chronic Venous Insufficiency)
- Aspirin; decreases PLT aggregation
- Clopidogrel (Plavix)
- Cilostazol (Pletal); vasodilator properties
- Pentoxifylline (Trental); decreases viscosity; thickness of blood, better flow; Increase perfusion
Pharmacologic therapies
-Inhibit platelet aggregation
- Smoking cessation (promotes atherosclerosis and Vasospasm)
- Foot care
- Pain relief
- Progressive strenuous exercise (30-40 min walk daily)
- Control
- Diabetes
- Hypertension
- Cholesterol levels
- Weight
Clinical Therapies Arterial/Venous Insufficency
- Revascularization; jump the clot
- Percutaneous transluminal angioplasty
- Stent placement
- Atherectomy (cut out plaque)
- Endarterectomy (roto rooter; carotid artery)
- Bypass grafts (jump over, block CABG)
Surgery for Arterial insufficiency
- Aromatherapy
- Biofeedback
- Healing/therapeutic touch
- Massage
- Herbal therapy
- Exercise/Yoga
- Very low fat/vegatarian diet
- Antioxidants
Complementary Therapies (Arterial/venous insufficiency)
- Elevate legs at rest and sleep
- Walk
- Avoid sitting or standing for prolonged periods
- Avoid Crossing legs
- Avoid tight-fitting garments
- Wear elastic hose as prescribed-tighter at foot instead of calf.
- Foot care
Patient Education for Venous Insufficiency
- Health Hx; evaluate Pain
- CAD, PVD, Hyperlipidemia, HTN, DM, Smoking, Diet, Activity
- Physical examination
- Pulses
- Sensation
- Capillary refill
- Temperature, warm venous, cool arterial
- Color
- Movement
- hair distribution
Assessment PVD
- Disturbed body image
- Ineffective Health Maintenance
- Risk for Infection
- Impaired Physical Mobility
- Impaired Skin Integrity
- Ineffective Tissue Perfusion: Peripheral
- Pain
- Activity Intolerance
Nursing Diagnoses for PVD
- Promote wound healing
- Manage Pain
- Promote tissue perfusion
- Optimize activity tolerance
- Educate on medications
Plan for PVD
Assess peripheral pulses Position extremities Regular exercise benefits Support extremities with foot cradle, warmth (arterial insufficiency) Frequent position changes
Implementation;
Ineffective Tissue Perfusion: Peripheral
(PVD)
Assess q 4hr
Keep extremities warm
Pain relief strategies
Implementation;
Pain
(PVD)
Meticulous skin care
Bed cradle
Specialty mattress
Implementation
Implementation;
Impaired Skin Integrity
(PVD)
Assist with care as needed
Gradual increase in activity/exercise
Diversional activities/stress reduction
Frequent position changes
Implementation;
Activity Intolerance
(PVD)
Positioning to promote perfusion to extremities Abstinence from tobacco products Appropriate wound care/healing States symptoms to report to provider Pain Control
Evaluation for PVD
Virchow’s triad
- stasis of blood
- vessel damage
- increased blood coagulability
3 pathological factors assoc with thrombophlebitis
Virchow’s triad
Deep or superficial veins
Common complication hospitalization, surgery
OB, orthopedic procedures; genetics
Etiology of Deep Vein Thrombosis
Prevention Minimizes Risk
Special Considerations;
-Orthopedic procedures (bones)
-Atrial fibrillation (upper chambers arent’ pumping blood; stagnant)
-Acute myocardial infarcion; doesn’t pump well
-Ischemic stroke
-Genetic predisposition
Risk Factors DVT
Protein C deficiency
Protein S deficiency
Antithrombin III deficiency
Factor V Leiden
Genetic Predisposition to DVT
Remember*
Calf pain; dull, aching, increases with walking
Tenderness
Swelling
Warmth
Erythema
Cyanosis and edema;
**Could be bilateral with OB patients (DVT legs)
-get on anticoagulant then increase walking
**Rare; Palpaple cord along affected vein
Homan’s sign unreliable indicator
Clinical Manifestations of DVT
Chronic venous and pulmonary embolism;
usually unilateral but can be bilateral (heart pts)
Flex pt. foot look for pain. Cont pain after flex DVT
Gold standard; Spiral CT Scan ; emboli
Complications DVT
Duplex venous ultrasonography Plethysmography MRI; decreased perfusion Ascending contrast venography; injectable dye and see where it didn't go Spiral CT
Diagnostic tests DVT
-Low-molecular-weight heparins; lovenox
-Oral anticoagulation; warfarin, PTT, INR
-Elevating foot of bed, knees slightly flexed
-Early mobilization
-Leg exercises
-Intermittent pneumatic compression devices
-Elastic stockings; TEDS
Reverse heparin with Vitamin K
Prophylaxis DVT
Anticoagulants;
Use of heparin.
-dosage calculated to maintain a PTT 2x control ; (usual double PTT range, if normal 23 would be 46)
-continuous infusion
-subcutaneous heparin; not looking @ PTT
IF PLT decrease count or less than 100 call Dr.; consider something else besides heparin.
Warfarin;
Given with IV heparin for 4-5 days.
Takes up to 5 days for full effects
Doses adjusted to maintain INR at 2-3 (level)
Cont. for at least 3 months; DVT coumadin for 3 months
Coumadin with heparin at 1st. takes 4 to 5 days to work
Can increase risk of clotting.
Pharmacologic therapies for DVT
Venous thrombectomy; removed
Filters; Venal Caval filters; Green
(for recurrent thrombosis)
Vein Ligation; open vein and take out clot
Surgery for DVT
Measures to reduce symptoms, inflammation.
-warm, moist compresses
-extremity rest
Anti-inflammatory agents
Bed rest
-elevate legs
-antiemolism stockings, PCD (put on other leg that doesn’t have DVT
Clinical Therapies for DVT
Return to activity
- encourage walking-when ordered. (been on heparin/coumadin long enough)
- avoid prolonged sitting, standing
- avoid tight-fitting garments
Clinical therapies for DVT
Position to promote venous blood flow
- Elevate feet with knees slightly bent
- Avoid pillows under knees
- Avoid sharply flexed hips, knees
- Use recliner, foot stool
- Early ambulation
- Teach ankle flexion, extension exercises; foot pumps
Nursing Process: Assessment DVT
Apply elastic stockings, PCD Avoid crossing legs Possible prophylaxis with heparin, warfarin (high risk client) Assess IV sites (change location with evidence of inflammation) Assessment -health hx -physical exam -family hx -vessel damage risk
Assessment DVT; nursing process
Pain Ineffective Tissue Perfusion:Peripheral Ineffective Protection; predisposing hereditary Impaired Physical Mobility Ineffective Tissue Perfusion: Cardiac
Nursing Diagnosis for DVT
Client will:
- control pain to allow for rest, comfort
- have no complications, thrombosis will not embolize
- Have increased tissue perfusion
Plan for DVT
Assess regularly using pain scale
Sudden chest pain is emergency
Measure calf and thigh diameter
Apply warm moist heat; usually 20min/4xday
Maintain bed rest as ordered. then ambulate when oked.
Implementation: Pain, DVT
Assess skin of affected extremity Elevate extremity Limb care Use specialty mattress Encourage frequent position changes If swollen; lotion relieves stretching
Implementation: Ineffective Tissue Perfusion: Peripheral
DVT
Encourage ROM exercises q 8hr.
Encourage frequent position changes; deep breathing and coughing
Encourage increase in fluids and dietary fiber
Assist with ambulation as needed
Encourage diversional activities (if bored on bedrest)
Implementation: Impaired physical mobility
DVT
Ineffective Protection -monitor lab results Ineffective Tissue Perfusion: Cardiac -frequent assessment of respiratory status -signs of pulmonary embolism
Implementation DVT
Pain controlled
No complications
Strategies to prevent reoccurrence of DVT
Evaluation; DVT
aka thrombophlebitits. is a condition in which a blood clot (thrombus) forms on the wall of a vein and is accompanied by inflammation of the vein wall and some degree of obstructed venous blood flow.
venous thrombosis
deep vein of the body?
those leading to the vena cava
Stimulates the clotting cascade.
- inflammation response triggered
- causes tenderness, swelling and erythema in area of thrombus.
- thrombus floats in vein @ 1st,
- then travels as emboli
- fibroblasts invade thrombus, scarring vein wall and destroying venous valves.
Vessel trauma
pelvis, thigh or calf
Deep Vein locations
thrombus
blood clot
emboli?
piece of thrombus that has broken off and is traveling through vein.
tend to occur @ sites where the vein may be normal, but blood flow is Low.
Venous thrombi
tend to occur @ sites of arterial plaque rupture.
arterial thrombi
immobilization surgery cancer trauma pregnancy hormone therapy coagulation disorders
Factors assoc with venous thrombosis
indomethacin (Indocin)
naproxen (Naprosyn)
reduce inflammation in veins and provide symptomatic relief (part with superficial veneous thrombosis)
NSAIDS DVT
prevent clot extension and reduce risk of pulmonary embolism
Anticoagulants
prothrombin times; clotting
INR
interfers with the clotting cascade by inhibiting the effects of thrombin and preventing the conversion of fibrinogen to fibrin;
prevents the formation of a stable fibrin clot
Heparin
aPTT
partial thromboplastin time
IV; immediate
SubQ; within the hour
most bioavailable fraction of heparin. more precise and predictable anticoagulant effect than unfractionated heparins
LMW; low-molecular weight heparins
ardeparin (Normiflo)
dalteparin (Fragmin)
enoxaparin (Lovenox)!!
tinzaparin (Innohep)
Drug ex of LMW heparins
done when thrombi lodge in the femoral vein and its removal is necessary to prevent pulmonary embolism or gangrene.
Venous thrombectomy
Lab values INR aPTT H & H Encourage Mobility ROM active q 8hr; prevent contractures and muscle atrophy Encourage freq. position change Deep breathing airway clearance coughing Increase fluids and dietary fiber intake Encourage diversional activities
Promote Effective Protection
