Vascular - Nursing

Question 1

Deep Vein Thrombosis

Answer 1

• causes - trauma, surgery, CVC’s, local vein damage, IV catheters, bed rest, immobility, immobilization, obesity, AMI, CCF, childbirth, pregnancy, advanced age
• clinical manifestations - non-specific symptoms, dull aching pain in affected limb, severe pain especially when walking, cyanosis of affected extremity, slightly elevated temperature, general malaise, limb warm to touch, redness, oedema, swelling of extremities
• management - aims - prevent growing & fragmenting, prevent reoccurance, medical - anticoagulation therapy (heparin IV, warfarin oral, APTT / INR monitored)

Question 2

Anemia

Answer 2

• iron deficiency anemia
  
  • causes - dietary deficiencies, decreased absorption, increased metabolic requirements, blood loss
  • clinical manifestations - pale skin, mucous membranes, conjunctiva & nail beds, fatigue, tires easily, palpations, tachycardia, tachypnoea, dyspnoea on exertion, headaches - if severe - cheilosis, sore smooth tongue, bone pain
  • treatment - locate cause, stop blood loss (if present), iron replacements
• folic acid deficiency anemia
  
  • causes - inadequate dietary intake, increased metabolic requirements, folic acid malabsorption & impaired metabolism
  • clinical manifestations - diarrhoea, nausea, anorexia, glossitis, cheilosis
  • treatment - diet, supplements
• pernicious anemia
  
  • malabsorption of B12 due to lack of intrinsic factor
  • clinical manifestations - parathesias of feet & fingers, difficulty walking, anorexia, abdo pain, weight loss, sore smooth red tongue, enlarged liver, enlarged spleen
  • treatment - B12 injections
• haemolytic anemia
  
  • causes - premature, accelerated destruction of erythrocytes - when RBCs are rendered foreign - RBC cell membrane defects, haemoglobin structure defects, inherited enzyme defects, drugs, chemicals, transfusion reactions
  • clinical manifestations - enlarged spleen, haemoglobinuria, jaundice
  • treatment - removing the cause, treating the underlying disorder, fluid & electrolyte replacement, splenectomy, steroids
• thalassaemia
  
  • inherited disorder - affects haemoglobin
  • clinical manifestations - severe anemia, ineffective production of RBCs & haemolysis
  • treatment - regular blood transfusions (to replace RBCs) & chelation therapy - to remove excess iron in the body
• aplastic anemia
  
  • caused by bone marrow depression - idopathic, injury to stem cells in marrow, radiation, chemicals, toxins, medications
  • clinical manifestations - anemia, bleeding problems (petechiae, bruising, bleeding from nose, gums, GIT), increased risk of infection
  • treatment - stem cell replacement by bone marrow or peripheral blood transplantation, immunosuppressive therapy, blood transfusions to correct anemia, corticosteroids to minimize bleeding

Question 3

Aneurysms

Answer 3

• causes - atherosclerosis, trauma, hypertension, congenital, infections, some diseases
• clinical manifestations - varies depending on location, pain (localised / radiating), symptoms of ischemia, symptoms resulting from pressure on body structures (dysphagia due to pressure on oesophagus), symptoms relate to location & stability - berry - headache, nausea, vomiting, - dissecting - ripping / tearing pain
• management - conservative - antihypertensives & beta blockers to decrease BP, anticoagulants to decrease risk of clot, - surgery - excise the aneurysm, replace with synthetic fabric graft
• nursing management - assessment of tissue perfusion, monitoring of pulmonary (breathing rate, pattern, auscultate), cardiovascular (BP / pulse), cerebral (neurological, GCS) & renal status (urine output, check U&E), pain management, decrease anxiety

Question 4

Peripheral Vascular Disease

Answer 4

• causes - reduced circulation of blood to a body part due to atherosclerosis (fatty deposits narrowing a blood vessel)
• clinical manifestations - intermittent claudication (may feel like cramps, muscle fatigue, heaviness), worsening pain during exercise, easing of pain during rest, coldness of affected body part, numbness, altered sensation, weakness, colour changes, wounds that won’t heal, blackened (gangrenous) areas of skin
• management - medications - lipid lowering, antihypertensives, anticoagulants, angioplasty / stenting to improve blood flow

Question 5

Amputations

Answer 5

• causes - peripheral vascular disease, ateriosclerosis & PVD (lower limbs), infection, trauma, congenital deformities, malignant tumors (osteosarcoma)
• clinical manifestations - to relieve symptoms, improve function & save / improve quality of life
• management - surgery - open amputation (wound remains open until exudate has drained, secondary closure), closed amputation (skin flaps pulled over bone & sutured)

Question 6

Care Plan - DVT

Answer 6

• nursing management
• providing comfort & pain interventions
  
  • assess level of pain (for DVT, pain management is main focus), calf measurements, apply warmth to affected extremity, bed rest, anti-embolic stockings, analgesia
• assessing & monitoring anticoagulant therapy
  
  • IV patency, calculating correct heparin doses, checking blood test results, checking warfarin dosage, educate patient - discharge meds, follow up appointments, report any bleeding
• monitor anticoagulant complications
  
  • check urine for blood, check for bruising, bleeding, educate patient, handle effected limb with care, have reversing drugs on hand - vitamin K for warfarin, protamine sulphate for heparin
• altered tissue perfusion
  
  • assess peripheral pulses, skin integrity, capillary refill, colour, elevate extremities, encourage position changes, promote passive exercise, anti embolic stockings, increase fluid intake

Question 7

Care Plan - Surgery - Amputation

Answer 7

• level of amputation
  
  • at most distal level that will heal, have sufficient blood supply, fit prosthesis & removes all necrotic / infected tissue
• nursing aims
  
  • achieve healing of site, yield non-tender stump, well shaped stump, healthy skin for prosthesis
• nursing problems
  
  • disturbance of self concept, dysfunctional grieving, phantom pain, pain, impaired skin integrity, impaired physical mobility, self care deficit
• preventing hip-knee flexion contractures
  
  • not placing residual limb on pillows, raise base of bed, prone position several times a day to stretch flexor muscles, discourage sitting for long periods, legs should remain close together, ROM exercises
• stump bandaging
  
  • increase venous return, decrease oedema, shape stump for prosthesis, use elastic bandage for shaping, aim to have firm conical shape

Question 8

Management - Aneurysms & Complications

Answer 8

• assessment of tissue perfusion, neurovascular observations, monitoring pulmonary (breathing), cardiovascular (BP / pulse), cerebral (neurological / GCS), renal (output / U&E)
• pain management
• decrease anxiety
• prepare for surgery, administer medications
• complications - rupture - requires immediate surgery, further tears (dissections) within the vessels creating false channels & increasing risk of clots