NR202 Test 4 Nursing management of patients with peripheral arterial perfusion d

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Circulatory system- What is it's function, what is the vessel structure, and explain the lymph system: Function is transportation. It delivers nutrients and oxygen and perfuses the organs
The vessel structure:
tunica adventia supports the vessel
Tunica media constricts and relaxes
Tunica intima is smooth and slippery
The lymph system picks up 1/10th of fluid and plasma proteins and empties into vascular system in chest cavity
Explain Arteries, veins and capillaries: Arteries-Thick walled, high pressure system. They deliver oxygen and nutrients. They also sense info.
Veins are thin walled and have a low pressure system. Veins pick up waste products and valves prevent back-flow (Clots can be around valves)
Capillaries are single thickness vessels. They connect arteriole and venules, they provide the actual exchange of nutrients, oxygen and waste products.
Give an example of a Chronic arterial disease/disorder: Peripheral Atherosclerosis
The primary sites of involvement are the femoral (groin) and peripheral sites (behind the knee)
What is atherosclerosis: It is a form of arteriosclerosis in which deposits of fat and fibrin obstruct and harden the arteries-it impairs blood supply to the peripheral tissues and leads to peripheral vascular disease PVD.
Factors that lead to chronic arterial disease: Factors that cannot be modified- heredity, sex/gender, race increases in African Americans, increase in age
Factors that can be modified:
cigarette smoking
-nicotine causes vasoconstriction and platelet aggregation.
-Carbon monoxide causes: decreased oxygen transport and damage to the inner lining
Hypertension
Diabetes-control of BS effect rate of progression
Cholesterol

Contributing factors
obesity
lack of exercise
stress
Manifestations of chronic arterial disease: S/S are direct result of inability to deliver blood, nutrients, and oxygen to the tissues.
Subjective assessment for chronic arterial dsease: Subjective Data:
Intermittent claudication
-muscle pain below point of occlusion
-caused by tissue hypoxia and lactic acid accumulation
-described as gnawing, burning, cramp-like
-may be relieved by rest or dependency
Objective data for chronic arterial disease: Weak/absent pulses. -Mark where you found the pulse with an X.
Bruit-hum or swish
Thickened, yellowish, discolored nails, temp variation- cooler below occluson and warmer above occlusion due to increased collateral flow
elevational pallor
Dependent rubor
-occurs after prolonged hypoxia
may see muscle atrophy-late sign of long term disease
delayed capillary refill time
numbness and tingling
absence of sweating
may cause impotence in males if occlusion is high
necrosis and ulcer formation
-usually on feet or toes
-well defined edges
-non bleeding
-deep pale base with necrotic tissue
-painful
Ankle arm pressure index
-leg pressure/brachial pressure
-below 1 indicates arterial disease
-pressure normally higher in feet and legs
assess claudication distance
Take leg/ankle pressure BP and divide it by arm pressure. Leg: 140/80...Arm 120/80...140/120>1
Nursing diagnoses for those who have chronic arterial disease: Impaired tissue perfusion
High risk for injury
Activity intolerance
Knowledge deficit
Treatment of chronic arterial disorders risk factor modification: -Risk factor modification
*Emphasis on exercise and smoking cessation
Clean feet, emphasize exercise until pain then stop and rest until pain stops, then start exercising again
Treatment of chronic arterial disorders meds: Meds
-Vasodilators-use is controversial
Rheologic agents
-Pentoxifylline (trental) increases RBC flexibility, decrease platelet aggregation, decreases blood viscosity thus increasing peripheral circulation
--may cause GI upset
--may take several weeks to note improvement

ASA and antiplatelet aggregation agents
-Decrease antiplatelet aggregation
-NDx: potential risk for injury: hemorrhage
Treatment of chronic arterial disorders Percutaneus Transluminal angioplasty-explain: Balloon tip through occlusion
Inflated balloon presses plaque against vessel wall thus improving blood flow
Complications:
-occlusion of artery through spasm, clot or collapse
rupture of artery
Treatment of chronic arterial disorders Name and explain the -ectomys that are done: Emboletomy-removal of blood clot
Endarterectomy-strip plaque on artery lining

Sympathectomy-disruption of sympathetic innervation of vessel (that would cause vasoconstriction) rarely performed today
Treatment of chronic arterial disorders Arterial bypass-explain: Arterial bypass
*Nursing care:
-pain control
-assess color and temp distal to graft
-assess sensation and movement in limb
-assess peripheral pulses
-monitor for edema
-monitor for infection, hemorrhage
-monitor vital signs
-avoid pt crossing legs
-keep pressure off of extremity
- avoid sharp flexion of graft site
- encourage activiy as tolerated
Treatment of chronic arterial disorders Amputation-explain: Amputation
-last resort
save as much of limb as possible
usually for severe necrosis or infection
Ndx: Impaired mobility, Alteration in body image
acute arterial occlusion name some diseaes and describe: Acute arterial occlusion is a group of diseases that result in occlusion of the branches of aorta and arteries. Atherosclerosis (AS) is the most common cause
Etiology of acute arterial occlusion: Underlying chronic arterial disease
Arterial invasive procedure
Post operative vascular patient
Atrial fibrillation
Diabetes
Aneurysm
Trauma with lacerated, compressed or severed vessels
Manifestations and nursing diagnosis for acute arterial occlusion: 1. Sudden onset of pain coldness, numbness.
2. Muscle weakness
3. Decreased or absent pulses
4. Skin is cool to touch

Ndx
Impaired tissue perfusion
High risk for injury
Activity intolerance
Treatment of Acute arterial occlusion: Emergency
Skeletal muscle may survive 6-8 hours
PTA
Arterial Bypass
Treatment-Meds: Fibrinolytics
-Dissolve clot
-IV or arterial
-monitor for infiltration and bleeding
-followed up with heparin or coumadin

Heparin
-During acute period IV or SQ
- Monitor PTT ( 1 1/2 to 2 1/2 X control)
- Over 100 hold dose notify MD
- Antagonist: Protamine sulfate
- Does not dissolve clots, does not interfere with clot formation

Coumadin
-Started 3-5 day overlap with heparin
-usually taken once daily (oral)
- MOnitor PT (1 1/2 to 2 1/2 X control)
-antagonist Vitamin K
What is thrombophlebitis and deep vein thrombosis: Thrombus formation with inflammation of veins.
Risk factors for Deep vein thrombosis: Previous History
Pregnancy
Polycythemia (over abundance of RBCs)
Obesity
Immobility
Varicosities
Manifestations for Deep vein thrombosis: Pain-localized, deep, aching, throbbing, increases with walking
Positive Homan's sign, pain in popliteal area with forceful dorsiflexion
Swelling
vein reddened and warm
other Sx of inflammation
Pathophysiology of Deep Vein thrombosis: thrombus form at bifurcations and veins
Newly formed venous thrombus have tails that may detach (emboli)
24-48 hours later will lyse or adhere to vessel wall
**Virchow's triad: Hypercoagulabilty, stasis, and endothelial damage.
Diagnostic tests for Deep vein thrombosis: Ultrasonography: duplex ultrasound
Ascending contrast venography (Gold standard for diagnosis DVT)
Treatment for Deep Vein thrombosis (prevention): Prevention
-Early ambulation and leg exercises
Support hose
avoid position that promotes stasis
Treatment for acute deep vein thrombosis: Bedrest (4-10 days)
ROM to unaffected extremity
elevate extremity (avoid acute hip flexion)
Moist heat
foot cradle (not used for a long time)
anticoagulation
measure calf
Do not rub or massage
heparin therapy
Pulmonary Embolism: Definition and Etiology: Definition: Blood clot or other embolic material that has lodged in the lung circulation
Etiology
-Venous stasis
-prolonged immobilization
-prolonged sitting/traveling
-varicose veins
-thrombophlebitis

Hypercoagulability
-injury
-surgery (esp vascular 7 orthopedic)
-tumor
-Increased platelet count

Miscellaneous
-Advanced age
-obesity
-pregnancy
-oral contraceptives
-previous hx
-Virchow's Triad
-Smoking
-A-fib
Manifestations of Pulmonary embolism: Chest pain, usually sudden onset, pleuritic (well located, does not radiate)
-dyspnea
-tachypnea
-sx of shock
-cough
-hemoptysis (blood in sputum)
-lungs: wheezing, frx rub, crackles
diagnostic tests for pulmonary embolism: Chest Xray
EKG
ABGs
perfusion lung scan
pulmonary angiography-gold standard for detecting pulmonary embolism
Pathophysiology for Pulmonary Embolism: Partial or complete obstruction of PA
Alveolar dead space
Loss of surfactant-atelectasis
Chemicals released causing vaso and bronchoconstriction which cause shunting
increased PA pressures
Increased rt ventricle work and failure
Treatment of Pulmonary Emolism: Prevention
Oxygen
IV heparin
EKG
Thrombolytic therapy
Possible surgery
vena cava umbrella filter
Hypertensive crisis definition: rapid onset
Systolic pressure > 220-240 mm Hg
diastolic pressure >120-130 mm Hg
Clinical manifestations of Hypertensive crisis: dyspnea, angina, tachycardia, ocular fatigue (eyes tired), occipital headaches, drowsiness
Etiology of hypertensive crisis: Younger people
African Americans
Pregnant women
Underlying collagen and or renal disease
Management of Hypertensive crisis: ICU
IV antihypertensive
reduce MAP 25%--excessive reduction can compromise cerebral perfusion
Danger: intracranial bleeding, MI, CHF
Aneurysms-describe: Abnormal localized vessel dilation caused by a weakness of arterial wall. May allow stasis of blood and thrombus formation
Most commonly located in aorta (greatest pressure)
Manifestations of aneurysms: Most are asymptomatic
Some patients have vague abdominal discomfort described as throbbing. Pulsating sensation in abdomen when lying could occur,and if complaining of back pain, suspect rupture
Types of Aneurysms: False-Actually a pulsating hematoma
true-cause is unknown
Degenerative process
Atherosclerosis
thinning of elastin layers
fusiform: entire circumference of vessel
Sacular-part of vessel
Dissecting: bleeding/hematoma
Diagnostic tests for aneurysms: Chest X-ray may show calcification.
Angiography: insert dye provides clearer picture
Sonography: sound waves-show blood flow and outlines aneurysm-before angiography or CT
CT scan
Etiology for aneurysm: Uncontrolled hypertension most common cause
Involves hemorrhage into vessel wall
Acute life-threatening condition
Dissecting aneurysm -manifestations: Location dependent
Excruciating pain in chest or back
Ripping or tearing
Thigh systolic BP less than brachial BP
Early BP may be increased then drops rapidly
may palpate pulsatile mass
Auscultate systolic bruit
Sx of hemorrhage (tachycardia, pallor, diaphoresis)
Treatment for aneurysm: Control BP
Surgical intervention
Elective surgery 5% mortality
Ruptured and then OR 50-75% mortality
Nursing care for an aneurysm: Monitor for sx of bleeding
Monitor for sx of infection
Monitor for sx of arterial occlusion
assess pedal pulses with VS
Antiembolism stockings
Extend and dorsiflex feet
monitor cardiac status
Monitor urine output
Nursing diagnoses for an aneurysm: High risk for injury
Pain
Ineffective breathing pattern
Bowel elimination

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