PVD week 3 Flashcards
What does PVD involve?
Anything but the heart
What might objective cues will you see with arterial insufficiency?
discoloration (pale), muscular atrophy, hair loss
What might you see with foot elevation and foot dependence in arterial insufficiency?
Elevation - pallor, venous guttering
Dependence - rubor (red, rush of blood)
What are the 6 p’s to assess in PVD
Pulse, paralysis, pain, perishingly cold, pallor, paraesthesia
PVD: risk factors:
smoking, diabetes, high lipids, family hx, lifestyle, stress
PVD: assess
Claudication, 6P’s, perfusion, shiny skin, tight skin, hair loss, thick toenails, cap refill, segmental blood pressure
Claudication
pain the patient can get because lack of blood flow to tissues
If you do not have o2 for tissues, they are still going to perform metabolism, but they do into anaerobic metabolism because they do not have 02 the byproduct of anaerobic metabolism is lactic acid build up = aching, cramping sharp pain
What relieves claudication?
typically relieved with rest
PVD: labs/diagnostics
Lipids C-reactive protein (inflammation) Duplex Doppler (can go all the way down artery) Glucose and Hgba1c Arteriogram (gold standard) Ankle-brachial index
Arteriogram
Go into blood vessel with contrast and take picture of arterial blood flow
PVD: intervetions
Risk modification Control lipids Diet Medications Exercise / weight loss Skin care (do not soak) - regular inspections Keep feet dependent NO constriction May need revascularization
PVS: complications
May progress to rest pain - ulceration - sepsis / gangrene = critical limb ischemia
Amputation
Acute arterial ischemia (sudden obstruction of blood flow caused by embolism, thrombosis, trauma, or atherosclerosis or artery)
PVD: priority nursing implications
assess extremities thoroughly and frequently to detect changes early
provide skincare and refrain from soaking feet or hands to avoid maceration
position clients to avoid constriction; do not bend knees, use knee gatch or cross legs
assess for an manage pain associated with obstruction and claudication
PVD: Asprin (ASA)
Antiplatelet
Doses of 75-325 mg/day
–> watch for bleeding
PVD: Clopidogrel
Antiplatelet - watch for bleeding
Client’s may receive Clopidogrel with ASA following revascularization
PVD: Cilostazol
Inhibits platelet aggregation and is a vasodilator
Used for intermittent claudication
May require additional antiplatelet therapy (Cloprodigrel, dipyridamole)
PVD: heparin
in acute setting to prevent thrombosis
– may be SQ, IV gtt
PVD: priority education/discharge
Teach about vigilant foot care, to wear white, all-cotton socks and to avoid extremities in temperature
Provide client with a complete list of changes to watch for in circulation - appearance of feel and for changes in sensation or function
Teach clients about optimal diet (high fiber, protein, low fat, refined sugars, sodium), and hydration; avoid caffeine
Teach client to relieve extremity pain by placing limb dependent; if edema exists, legs may be elevated by not above level of heart
Upper extremity arterial occlusive disease - cause
Likely caused by vasospasm, trauma, or arterial constrictive disorders
Upper extremity arterial occlusive disease - s/s
difference in BP is significant
Upper extremity arterial occlusive disease - treatment
surgical bypass or PTA
Upper extremity arterial occlusive disease - assessment
same as PVD
Compartment syndrome - patho
Swelling of muscles causing compression of nerves and blood vessels
Compartment syndrome: treatment
Pharmacologic therapy Thrombolysis Surgical management Endovascular intervention Fasciotomy
Compartment syndrome: goal
pain relief
maintain tissue integrity
Raynaud disease: causes
Emotional factors
Raynaud disease: patho
Cyanosis r/t vasospasm then vasodilation causes redness (rubor)
raynaud disease: manifestations
numbness, tingling and burning may occur
Raynaud disease: treatment
Avoid vasoconstrictive activity (cold, smoking, caffeine)
Ca2+ channel blocker to decrease s/s
Sympathectomy (interruption of the sympathetic nerves) may be also needed
Thromboangitis Obliterans (Buerger Disease): patho
Autoimmune disease
Recurring inflammation of the intermediate and small arteries and vein resulting in thrombus formation and vessel occlusion
Thromboangiitis Obliterans (Buerger Disease) - cause
Tobacco use is a causative factor
What are types of venous thrombosis
Deep vein thrombosis (DVT)
Thrombophlebitis
Venous thromboembolism
Venous thrombosis: Virchow Triad
Stasis of blood
vessel wall injury
altered coagulation
Venous thrombosis: clinical manifestations
edema, discoloration
Peripheral venous disease: priority assessments
- Note calf, thigh or groin pain with or without swelling warmth and tenderness superficial to area of pain
- Measure calves and thighs for comparison and baseline
- Superficial venous thrombosis (SVT) – vein can be itchy swollen red or warm
- With venous thromboembolism – SVT + paresthesias – may have fever – marked edema, painful
peripheral venous disease: priority labs and diagnostics
- Venous duplex ultrasound
- d-dimer- if elevated suggests VTE
- CT/MRI
- PTT, PT INR, Hgb, Hct bc on anticoag
Peripheral venous disease: priority nursing interventions
- larger- anticoagulants
- Pain medications, compression stockings, light ambulation
- Acute VTE- bedrest, elevate extremity, antiembolic stockings (pneumatic compression boots), progressive activity
- Anticoagulation =prevent clot increase in size or new clot development
- Warm moist compress
Peripheral venous disease: priority potential and actual complications
- Superficial may progress to VTE
- Pulmonary Embolism
Avoid – massaging clot site and pneumatic compression devices with VTE – may mobilize the clot
- Post-thrombotic syndrome-20-50% of clients with VTEvenous stiffening, hypertension, and scarring-symptoms include pain, swelling, tingling, venous ulceration
Peripheral venous disease: priority nursing implications
- Assess clients at risk and provide preventive teaching and care-exercise, refraining from constrictive clothing
- Assess for risk for bleeding on hemorrhage in clients on anticoagulant therapy (bleeding precautions)
- Avoid massaging of clot site and avoid pneumatic compression devices with actual VTE -may mobilize clot
- Avoid antiplatelets or NSAIDs with anticoagulants
- Encourage clients on bed rest to turn
- Change position every two hours and perform leg exercises every two hours while awake
Heparin
Anticoagulant ◦ Subcutaneously or continuous IV infusion
◦ Monitor aPTT (normal 25-35 seconds, on heparin-1.5-2.5 times the normal)
◦ Antidote is protamine sulfate
◦ With subcutaneous injection, deep into the tissue, do not aspirate or rub site
◦ Watch for heparin-induced thrombocytopenia
◦ Monitor for osteoporosis
Warfarin
◦ Anticoagulant
◦ Monitor INR (International normalized ratio) (0.9-1.1 not on anticoagulants, 2-3 on warfarin, 2.5-3.5 for high-risk clients)
◦ Vitamin K is antidote
Enoxaparin
◦ Low molecular weight heparin
◦ Monitor CBC at regular intervals
◦ Clients may be taught self-administration
◦ Rotate injection sites
PVD: priority teaching
risk of VTE with oral contraceptives or hormone replacement, especially when combined with smoking
prevention for those at risk including leg exercises, increased activity, early ambulation, elastic stockings (must be fitted and worn correctly), sequential compression boots (while in hospital), avoid restrictive clothing or crossing legs when sitting
some herbs (ginger, garlic, ginseng, gingko) increase bleeding
avoid smoking or vasoconstrictive activities
What is an abdominal aneurysm
Damage to the media layer of the vessel
>3 cm aorta
Abdominal aneurysm: manifestations
Severe back pain
Pulsating mass in abdomen
Abdominal aneurysm: treatment
Medicine
Surgical treatment – same as thoracic management
Thoracic aortic aneurysm: cause
atherosclerosis
genetic mutation
Thoracic aortic aneuysm: manifestations
pain or dyspnea, difficulty swallowing
Thoracid aortic aneurysm: treatment
BP control
Post op assessments
Dissecting aneurysm: cause
poorly controlled hypertension
blunt force trauma
Dissecting aneurysm: manifestations
severe tearing pain
Cellulitis
Bacteria enters the subcutaneous tissue
Cellulitis: manifestations
swelling, redness, pain
systemic signs of fever, chills and sweating
mark it to see if infections of getting bigger or smaller
Cellulitis: priorty lab / diagnostics
Complete blood count will show elevated white blood cell count
Wound culture will show the causative bacteria (if it is a seeping wound)
X-ray or computed tomography (CT) scan to look for foreign objects in wound (as in an object left in a surgical wound) or examine deep tissues for signs of infection
Cellulitis: assessments
Assess client for fever and chills, indicative of an infection
- Assess wound for tenderness, swelling, warmth, malodorous and purulent drainage
- Assess pain level. There is usually pain with an infected wound and with cellulitis
- Assess size of wound. Examine wound for dead tissue as necrotic tissue is often present in infected wounds
- Assess complete blood count, expect increase in white blood cells due to infection and fever
- Assess vital signs, expect temperature elevation.
- Assess for cellulitis, manifested as inflammation to surrounding skin and soft tissues under the skin, and red streaking to the skin
- If there is cellulitis, perform ongoing assessments to determine if fever, tachycardia and tachypnea are resolving with treatment
- Assess for septicemia, manifested as chills, fever, tachycardia and tachypnea. Confusion, reduced urine output and shock are likely if septicemia progresses without treatment
- Perform a complete physical assessment
- Complete a detailed health history
Cellulitis: interventions
Collect wound samples for culture and sensitivity and send to the lab promptly
- Administer prompt treatment of septicemia. If present, to prevent progression to sepsis and septic shock.
- Administer antibiotics promptly as prescribed and monitor for effectiveness
- Administer wound treatment as prescribed
- Monitor wound to determine effectiveness of treatment
- Monitor blood test to determine decrease in white blood cell count
- Monitor skin with cellulitis to determine if inflammation is resolving
- Administer analgesics for pain, especially before performing wound care
- Assist with wound debridement procedure to remove dead tissue from wound
- If foreign body in wound, prepare client for procedure to remove the object
- Apply wound vacuum to assist with wound healing, if prescribed and monitor wound drainage
Cellulitis: complications
Chronic infection
Loss of limb as a result of untreated infected wound
Septicemia, which is bacteria in the blood that can result in sepsis. Some still refer to septicemia as blood poisoning or bacteremia.
-Septicemia occurs when bacteria gets into the bloodstream from another part of the body, as in an infected wound. Client can have chills, fever, fast heart rate and respirations, confusion, reduced urine output and shock
Sepsis is a widespread and potentially fatal inflammation of the body in response to bacteria in the bloodstream. Both septicemia and sepsis must be treated promptly
cellulitis: nursing implications
Cellulitis can occur as a result of a wound infection, but it can also be seen in other conditions such as a foreign body in the skin, a tear to the skin, or chronic conditions such as eczema. Cellulitis must be treated promptly
Cellulitis: Cephalexin 250-500mg
Q6
First generation cephalosporin –tx bacterial and skin infections
Cellulitis: Amoxicillin 250-500mg
Q6
In PCN family –skin infections
Cellulitis: augmentin
f
Cellulitis: education
finish all the antibiotics prescribed
how to care for wound at home to prevent re-infection
signs and symptoms of septicemia
signs and symptoms of wound infection and when to contact the healthcare provider
importance of follow-up medical care
healthy nutrition to promote wound healing
management of other health conditions the client has, especially those associated with poor wound healing, like diabetes
management of other health conditions the client has, especially those associated with poor wound healing, like diabetes
schedule visits to a wound care clinic if client is unable to care for wound
Describe an arterial ulcer
end of toes, top of feet, lateral ankle region
very little drainage; little tissue granulation (pale, very light pink, or necrotic/black)
deep “punched out” with noticeable margins/edges that gives it a round appearance
describe venous ulcer:
Medial parts of lower legs; medial ankle region
Swollen with drainage
Granulation present (deep pink to red)
Irregular edges
Shallow
Chronic venous insufficiency: manifestations
Increases pigmentation of the skin (hemosiderosis)
Varicosities and telangiectasis
Chronic venous insuffiency: cause
Edema?
Vascular ulcers: patho
result of increased venous pressure or external trauma
- venous or arterial
Vascular ulcers: treatment
Medication
Wound cleaning and debridement
wound dressing
Lymphedema and elephantiasis - what
obstruction of lymph vessels
Lymphedema and elephantiasis treatment
pharm therapy
exercise and compression
surgery
