Vascular Flashcards
what is Peripheral Artery Disease (PAD)
-Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities
-Atherosclerosis (plaque)is the leading cause in majority of cases.
-causes ischemia
what is ischemia
-Lack of blood flow to an extremity
-Decreased oxygen delivery to the tissues
what are the causes of PAD
-Atherosclerosis
-Emboli formation (blood clot)
-Septic embolism
-Infection (swelling, necrotisis facitis caused by staff)
-Any thing that descreases blood flow and O2 delivery
-Thrombosis
Trauma fracture (compartment syndrome r/t broken bones)
Vasculitis- autoimmune, inflammation of the vasculature
what are the risk factors of PAD
-Cigarette smoking
-Hypercholesterolemia
-Hypertension
-Chronic kidney disease
-Diabetes mellitus
-Family History
-Coronary artery disease
what is Critical Limb Ischemia (CLI) characterized by (don’t forget the ulcers)
-Chronic ischemic pain at rest lasting more than 2 weeks
-Arterial leg ulcers or gangrene
-Can have it an any other extremities
what is pain at rest from Critical Limb Ischemia (CLI)
-(pt could be diabetic) wounds on the lower exreeties= check their blood sugar
-Occurs in the forefoot or toes (elevating makes the pain worst)
-Aggravated by limb elevation
-Occurs from insufficient blood flow
-Occurs more often at night
what are the characteristics of arterial diseases
-intermittent claudication pain
-no edema
-pulse or weak pulse
-no drainage
-round smooth sores
-black eschar
what are the 5 P’s that you need to recognize for PAD, what do you need to do for the pulses
-Pain
- pallor
-paresthesia,
-pulselessness,
-paralysis
-Doppler the pusles- you wont be able to feel them other wise
how will the the extremities feel and what will the wounds look like with PAD
-Wounds that are not healing/slow to heal, appear dy round and possibly necrotic
-Affected extremity cool
-Changes in skin color, texture, and hair growth
-Dependent rubor/pallor with elevation (redness/ flushed when it is dangled)
what is Intermittent claudication-
spasmotic pain, decreased blood flow or oxygenation of the tissue
what is the main diagnostic test of PAD
Angiography:
-imaging of the vessels
and magnetic resonance angiography
-can see all of the vessels, tells us the severity
what are the more general diagnostics for PAD
-Doppler ultrasound
-Ankle-brachial index (ABI)
-Severity of disease? (Acute vs Chronic)?
what will Interventional Radiology Procedures tell us
-Intermittent claudication: -symptoms become incapacitating (they can’t get up and move, stents placed or meds to dissolve the clot)
-Pain at rest
-Ulceration or gangrene (rotten tissue, no O2 or blood floow) severe enough to threaten viability of the limb
what is Percutaneous transluminal angioplasty (PTA)
-his is an interventional procedures
-Involves insertion of a catheter into an artery
-Catheter contains a cylindrical balloon that is inflated
-This compresses the atherosclerosis into the vessel wall
-if more than 90% occlusion then you run the risk of perforating the vessel wall if you place a balloon
Post op- check pulses more frequently (q15x2, q30x2, q1x2)
Atherectomy:
Removal of obstructing plaque using a cutting balloon, laser, or drill
what is surgical therapy for PAD
-Most common surgical approach
-Peripheral artery bypass surgery with autogenous(taking part of the pt original vasculature and graft it to where you need to do a bypass) vein or synthetic graft to bypass blood around the lesion
-PTA with stenting may also be used in combination with bypass surgery
-Amputation
-2 different types of graft are autogenous and synthetic
what are the goals for PAD
-Adequate tissue perfusion
-Relief of pain
-Increased exercise tolerance
-Intact, healthy skin on extremities
-Increased knowledge of disease and treatment plan
what interventions for PAD in an acute care setting
-Frequently monitor after surgery
-Skin color and temperature
-Capillary refill
-Presence of peripheral pulses distal to the operative site
-Sensation and movement of extremity
-This is all under peripheral vascular assessment
-Continued circulatory assessment
-Monitor for potential complications
-Edema, bleeding, thrombosis
-Knee-flexed positions should be avoided except for exercise
-Turn and position frequently
what is health promotion for PAD (this is an intervention)
-ambulatory care
-Importance of meticulous foot care
-Daily inspection of the feet
-Comfortable shoes with rounded toes and soft insoles
-Shoes lightly laced
what are the Risk Factor Modifications for PAD
-Tobacco cessation (constrictic vessels if you keep smoking)
-Diabetic
-Glycosylated hemoglobin <7.0% for diabetics
-Aggressive treatment of hyperlipidemia
-BP maintained <140/90 (you will releave the pressure on the arteries and makes blood flow easier)
what type of drug therapy would be the priority
Antiplatelet agents (aggregate):
-Agent that inhibits platelet aggregation and thus reduces the risk of thrombus formation
e.g. Aspirin, Clopidogrel (Plavix)
Describe what ACE inhibitors would do for PAD
-↑ Peripheral blood flow
-↑ ABI (ankle-brachial index)
-↑ Walking distance
Describe cholesterol medications and what they do for PAD
-statin used to drop the amount of cholesterol in the blood
-To treat hyperlipidemia
describe what excersise can do for PAD
-Helps blood flow
-Exercise improves oxygen extraction in legs and skeletal metabolism
-Walking is most effective exercise for individuals with claudication
-30 to 45 minutes daily, 3 times/week
descibe what nutrition and monitoring for bleeding risk can do for PAD
-Recommend reduced calories and salt for obese or overweight persons
-Long-term antiplatelet therapy
what are the expected outcomes for PAD
-Increased perfusion (pulses present)
-CMS returns to baseline
-Wound healing
-Pain controlled or alleviated
-Increased activity tolerance
-Participation in walking program
-Verbalizing step to improve health (diet, exercise, smoking cessation)
-Able to afford and obtain medications
what are the manifestations of Chronic venous insufficiency (brings deoxygenated blood)
-Swelling in feet/lower legs that improves with elevation (priority)
Itching
-Pain or numbness
-Discoloration of lower extremities (rubor)
-Wounds on legs
-History of obesity, diabetes, DVT, pregnancy, varicose veins
-Changes in skin color, texture, and hair growth
-Warm skin
-Leathery brownish skin- -Hemosiderin staining
-Edema
-Pruritus (stasis dermatitis)
Ulceration- wounds are wet/sloughy with irregular borders
-Pain
-Palpable pulses
what are the diagnostics for CVI
-Doppler ultrasound
-Venogram(to see the veins all coiled up) (priority)
-CT scan (priority)
-Severity of disease?
what are the goals that we have for CVI
-Improve venous return (priority)
-Decrease swelling/pressure in legs
-Restore skin integrity
-Improve nutritional status
-Increase/promote activity
-Decrease pain
what are the interventions for CVI (Increase venous blood return, decrease pressure)
Increase venous blood return, decrease pressure:
-Compression therapy and elevation of legs: TED hose, ACE wraps
what are the interventions for CVI (Treat venous stasis ulcers & restore skin integrity)
-wound care, bed cradle
what are the interventions for CVI (adequate nutrition)
Diabetic diet, monitoring blood glucose (high during infection)- weight management and wound healing
what are the interventions for CVI (medication therapy)
Topical agents- hydrocortisone (steroid anti inflammatory cream), antifungal (bc it is a wet open wound, at risk for yeast infection), zinc oxide
Antibiotics (blood cultures to check for bacterial infections)
what are the expected outcomes for CVI
Edema-Reduction in severity
Wound Care:
Healing/prevention of stasis ulcers
Most management will be outpatient:
Lifestyle modification
Adherence to compression therapy
what is the signs of arterial disease (away)
color-Pale when elevated
Rubor in dependent position
edema-None or minimal
nails-tick and brittle
pulse- Decreased, weak or absent
temp of the extremity-cool
pain-Worse with elevation, claudication,
worsening disease-pain at rest
ulcers- dry and necrotic
what is the signs of venous disease (towards)
color-Ruddy (brownish/red)-hemosiderin
Cyanotic (if dependent)
edema-present
nails-normal
pulse-normal
temp of extremity-warm
pain-Better with elevation; dullness or heaviness
ulcers-Moist andMalleolar (ankle)
what diagnostics test do you run for varicose veins
-Manual compression test
-Doppler ultrasound- a non-invasive diagnostic
what are the treatment options for varicose veins
Sclerotherapy: Injecting a saline solution closes those veins
Laser: fades the appearance of veins
Vein stripping: Outpatient procedure surgical removal vein removal
Ambulatory phlebectomy: Removal smaller varicose veins through a series of tiny skin punctures.
Endoscopic vein surgery: A small video camera inserted in your leg to visualize and close varicose veins, and then removes the veins through small incisions
Angiogenesis: can happen with arteries and veins
what is the main nursing intervention for varicose veins
-Compression stockingsandSCDs
what are the non priority nursing interventions for varicose veins
Prevent skin breakdown
Pain relief
Prevention/Reduce risk factors
what are the expected outcomes for varicose veins after all of the interventions
-Relief from discomfort
-Improved circulation
-Avoidance of complications (blood clot and ischemia)
what is Venous thrombosis/thromboembolism
Formation of a thrombus in association with inflammation of the vein.
what is the biggest clue of Venous thrombosis/thromboembolism
Sudden onset:
-Shortness of breath (SOB)
-Chest pain that worsens with inspiration
-Check for pulmonary embolism
(neuro can respiratory checks are also done)
-Hemoptysis
what are the risk factors Venous thrombosis/thromboembolism
-Prolonged immobility
-Smoking
-Using oral contraceptives
-Recent injury to extremity
-Pregnancy/Post-partum
what do you check for when you suspect Venous thrombosis/thromboembolism
-Unilateral edema
-Red and warm
-Pain/tenderness with palpation
-Dilated superficial veins
-Full sensation in calf or thigh
-Paresthesia in affected extremity
-Positive Homan’s sign (dorsiflextion of the foot hurts in the calf)
what are the acute symptoms of Pulmonary Embolism
-Rapid onset
-Chest pain - Stabbing
-Shortness of breath
-Hypoxia, hemoptysis
what are the interventions for a pulmonary embolism and what is the primary diagnostic tool
-Rescue positioning: Fowlers/O2
-Call for HELP!!!
-CT and VQ scan is the primary diagnostic tool for PE
what are the other diagnostics for pulmonary embolism
-Doppler ultrasound
-Manual compression test
-Venogram
Echocardiogram:
-we want to see if there is any pressure on the lung caused by a clot
-MRI lung
Lab results:
-D-dimer (specific to clot formation, if + it means we havea clot but we don’t know where), coagulation studies (PT, INR, CBC
what are the goals for VTE and PE
-give O2 and anticoagulants- give through IV so that it is absorbed faster. this is so you can get rid of it to prevent the formation of more
-improve venous return
-decrease swelling/ pressure
-restore skin integrity
-improve nutritional status
-increase nutritional status
-increase activity
-reduction of risk factors (surgery or cancer)
how would you prevent VTE and PE
-THIS IS KEY!
-TED hose, Early ambulation
-Sequential compression device
-No massage
-Assess for more blood clots
what are the medications that we could give for VTE and PE
-Low molecular weight heparin
-Unfractionated heparin
-Coumadin
Thrombolytics (tPa)–> don’t do it unless you know a lot of history and the clot cannot be resolved
Complications of therapy- bleeding precautions
what are the priority actions for emergency VTE and PE treatment
-Initial priority actions
-Call Rapid Response Team (RRT) and provider
-Administer oxygen
-Need to reduce hypoxemia
-Non rebreather mask
-Place patient in high fowlers
-Continuous monitoring of VS
-Medications(whatkind?)
-Emotional support for patient and family
-Watch for increasing pain or changes in LOC
-DOCUMENTATION OF EVENTS
what is the surgical interventions for VTE and PE
Pulmonary embolectomy for massive PE:
-For hemodynamically unstable patients in whom thrombolytic therapy is contraindicated
Inferior vena cava (IVC) filter:
-Prevents migration of clots in pulmonary system
what are the risks for anticoagulation
-bleeding!
-bleeding from the gums
-bleeding from the liver
-rectal bleedings
-dark or bloody stools
what do you have to monitor for anticuagulation
-Monitor VS and bleeding
Obtain Baseline labs (over/under coagulated):
-Troponin, ABG, BNP
-PTT and anti-Xa: Heparin
-PT, INR: Coumadin, INR goal >2
D-Dimer: Blood clots slowly break down after they are formed, and this process releases D-dimer into the blood.
Platelets: concern for HIT (platelet count) (Heparin‐induced thrombocytopenia)
what are the antidotes for anticoagulation
Coumadin: Vitamin K
Heparin: Protamine Sulfate
what do you (and the pt) need to know about anticoagulation upon discharge (blood work and safety measures)
Blood work:
-Anticoagulant therapy for at least 6 months
Safety measures:
-Taking other medications- MANY drugs interact with anticoagulants
-Soft toothbrushes
-Report signs of bleeding to physician
-Shoes when ambulating- NO bare feet
Coumadin- check blood levels every week bc low therapeutic indes
what do you (and the pt) need to know about anticoagulation upon discharge (symptoms of bleeding and nutrition)
Symptoms of bleeding:
-Hematuria
-Dark or blood stools
-Bleeding gums
Nutrition:
Food restrictions due to anticoagulation
Many foods contain Vitamin K (kale, green leafy veggies) do not give these foods
what are the outcomes expected outcomes for VTE and PE
-Stable vital signs
-Mentation at baseline
-Anxiety alleviated; Pain decreased/resolved
-Absence/resolution of chest pain
-Prevention of further thromboembolic phenomena
-Education
-Understanding of medications and therapeutic dosing- INR goals?
-Dietary education if on warfarin
