Medical Surgical Nursing - Ch 37
Terms
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When obtaining a health hx from a 72yo man w/peripheral areterial disease of the lower extremities, the nurse asks the pt about a hx of other atherosclerotic manifestations such as:
a. venous thrombosis
b. venous stasis ulcers
c. pulmonary - d. Regardless of the location, atherosclerosis is responsible for PAD and is r/t other cardiovascular disease and its risk factors, such as CAD and carotid artery disease. Venous thrombosis, venous stasis ulcers, and pulmonary embolism are diseases fo the veins and are not r/t atherosclerosis.
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A surgical repair is planned for a pt who has a 5-cm abd aortic aneurysm. On physical assessment of the pt, the nurse would expect to find:
a. hoarseness and dysphagia
b. severe back pain w/flank ecchymosis
c. the presence of a bruit in th - c. Although most abd aortic aneurysms are asymptomatic, on physical examination a pulsatile mass in the periumbilical area slightly to the left ot the midline may be detected, and bruits may be audible with a stethoscope placed over the aneurysm.
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A thoracic aoritc aneurysm is found when a pt has a routine chest x-ray. The nurse anticipates that additional diagnostic testing to determine the size and structure of the aneurysm will include:
a. a CT scan
b. angiography
c. echocardiogr - a. A CT scan is the most accurate test to determine the diameter of the aneurysm and whether a thrombus is present. The other tests may also be used, but the CT yields the most descriptive results.
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A pt with a small abd aortic aneurysm is not a good surgical candidate. The nurse teaches the pt that one of the best ways to prevent expansion of the lesion is to:
a. avoid strenuous physical exertion
b. controly htn w/prescribed therapy
- b. Increased systolic BP continually puts pressure on the diseased are of the artery, promoting its expansion. Small aneurysms can be treated by decreasing BP, modifying atherosclerosis risk factors, and monitoring the size of the aneurysm. Anticoagulants are used during surgical treatment of aneurysms, but physical activity is not known to increase their size. Calcium intake is not r/t calcification in arteries.
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During preoperative preparation of the pt scheduled for an abd aortic aneurysm the nurse establishes baseline data for the pt knowing that:
a. postop all physiologic processes will be altered
b. the cause of the aneurysm is a systemic vascular - b. Because atherosclerosis is a systemic disease, the pt with an AAA is likely to have cardiac, pulmonary, cerebral, and/or lower extremity vascular problems tha tshould be noted an dmonitored throughout the perioperative period. Postoperatively, the BP is balanced: high enough to keep adequate flow through the artery to prevent thrombosis but low enough to prevent bleeding at the surgical site.
- A __________ aneurysm may be surgically treated by excising only the weakened area and suturing the artery closed.
- secular
- During conventional aortic aneurysm repair, a __________ __________ is sutured to the aorta above and below the aneurysm, and the native aorta is replaced around the site.
- synthetic graft
- Repair of __________ aneurysms requires cross-clamping of the aorta proximal and distal to the aneurysm.
- all
- A synthetic bifurcation graft is used in aneurysm repair when an abd aortic aneurysm extends into the __________ arteries.
- iliac
- Repair of an aortic aneurysm by placing an aortic graft inside the aneurysm through the femoral artery is called the __________ __________ procedure.
- endovascular graft
- Major complications of aortic aneurysm repair are associated with involvement or obstruction of the __________ arteries.
- renal
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During the pt's acute postop period following repair of an aneurysm, the nurse should ensure that:
a. hypothermia is maintained to decrease oxygen need
b. the BP and all peripheral pulses are evaluated at least every hour
c. IV fluids are - b. The BP an dperipheral pulses are evaluated every hour in the acute postop period to ensure that BP is adequate and that extremities are being perfused. BP is kept within normal range -- if it is too low, thrombosis of the graft may occur, and if it is too high, it may cause leaking or rupture at the suture line. Hypothermia ia induced during surgery, but the pt is rewarmed as soon as the surgery is completed. Fluid replacement to maintain urine output at 100ml/hr would increase the BP too much.
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Following and ascending aortic aneurysm repair, the nurse monitors for and immediately reports:
a. shallow respirations and poor coughing
b. decreased drainage from the chest tubes
c. a change in level of consciousness and ability to speak - c. During repair of an ascending aortic aneurysm, blood supply to the carotid arteries may be interrupted, leading to neurologic complications manifested by a decreased level of consciousness and altered pupil responses to light, as well as changes in facial symmetry, speech, and movement of upper extremities. The thorax is opened for ascending aortic surgery, and shallow breathing, poor cough, and decreasing chest drainage are expected. Often, lower limb pulses are normally decreased or absent for a short period of time following surgery.
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During the nursing assessment of the pt w/a distal descending aortic dissection, the nurse would expect the pt to manifest:
a. a cardiac murmur characteristic of aortic valve insufficiency
b. altered LOC w/dizziness and weak carotid pulses
- d. The onset of an aortic dissection involving the distal, descending aorta is usually charactereized by a sudden, severe, tearing pain in the back, and as it progresses down the aorta, the abd organs and lower extremities may begin to show evidence of ischemia. Aortic dissections of the ascending aorta and aortic arch may affect the heart and circulation to the head, with the development of murmurs, ventricular failure, and cerebral ischemia.
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A pt with a dissection fo the arch of the aorta has a decreased LOC and weak carotid pulses. The nurse anticipates that initial treatment of the pt will include:
a. administration of packed RBCs to replace blood loss
b. immediate surgery to rep - d. Initial treatment for aortic dissection is to lower the BP and myocardial contractility to diminish the pulsatile forces in the aorta. The aorta is fragile after dissection, and surgery is delayed for as long as possible to allow time for blood to clot in the false lumen and for edema to decrease. Anticoagulants would prolong and intensify the bleeding, and blood is administered only if the dissection ruptures.
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The nurse evaluates that treatment for the pt w/ an uncomplicated aortic dissection is successful when:
a. pain is relieved
b. surgical repair is complete
c. renal output is maintained at 30 ml/hr
d. BP is w/i normal range - a. Relief of pain is an indication that the dissection has stabilized, and it may be treated conservatively for an extended time with drugs that lower BP and decrease myocardial contractility.
- The classic ischemic pain of peripheral arterial disease is known as __________ __________.
- intermittent claudication
- Two serious complications of peripheral arterial disease that frequently lead to lower limb amputation are __________ __________ __________ and __________.
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nonhealing ischemic ulcers
gangrene - A pt with chronic arterial disease has a brachial systolic BP of 132 mm Hg and an ankle systolic BP of 102 mm Hg. The ankle-brachial index is __________ and indicates __________ (mild/moderate/severe) arterial disease.
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mild to moderate - Surgery for peripheral artery disease is indicated when the pt has limb pain during __________.
- rest
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Drug therapy for PAD to increase blood flow and prevent intermittent claudication includes the administration of:
a. aspirin
b. cilostazol (Pletal)
c. ticlopidine (Ticlid)
d. clopidogrel (Plavix) - b. Cilostazol (Pletal) is a type II phosphodiesterase inhibitor that inhibits platelet aggregation and increases vasodilation, significantly increasing pain-free walking distnace. The other drugs are all antiplatelet agents used not only to prevent thrombus in diseased peripheral arteries but also to decrease the risk of MI, stroke, and other cardiovascular causes of death.
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A pt with PAD has a nursing diagnosis of ineffective peripheral tissue perfusion. Appropriate teaching for the pt includes instructions to:
a. rest and sleep with the legs elevated
b. soak the feet in warm water 30 minutes a day
c. walk at - c. Walking exercise increases oxygen extraction in the legs and improves skeletal muscle metabolism. The pt with PAD should walk at least 30 min a day, preferably twice a day. Exercise should be stopped when pain occurs and resumed when the pain subsides. Elevation of the limbs impairs arterial circulation, so the legs should be kept dependent. Feet should not be soaked because skin breakdown and maceration may occur. Nicotine in all forms causes vasoconstriction and must be eliminated.
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When teaching the pt with peripheral disease about modifying risk factors associated with the condition, the nurse emphasizes that:
a. amputation is the ultimate outcome if the pt does not alter lifestyle behaviors.
b. risk-reducing behaviors i - d. Peripheral arterial occlusive disease occurs as a result of atherosclerosis, and the risk factors are the same as for other diseases associated with atherosclerosis, such as coronary artery disease, cerebral vascular disease, and aneurysms. Major risk factors are hypertension, cigarette smoking, and hyperlipidemia. The risk for amputation is high in pts with severe occlusive disease, but it is not the best approach to encourage pts to make lifestyle modifications.
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Arterial or venous disease?
Paresthesia - arterial
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Arterial or venous disease?
Heavy ulcer drainage - venous
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Arterial or venous disease?
Edema around the ankles - venous
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Arterial or venous disease?
Gangrene over bony prominences on toes and feet - arterial
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Arterial or venous disease?
Decreased peripheral pulses - arterial
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Arterial or venous disease?
Brown pigmentation of the legs - venous
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Arterial or venous disease?
Thickened, brittle nails - arterial
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Arterial or venous disease?
Ulceration around the medial malleolus - venous
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Arterial or venous disease?
Pallor on elevation of the legs - arterial
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Arterial or venous disease?
Dull ache in calf or thigh - venous
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Arterial or venous disease?
Pruritis - venous
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A pt with peripheral vascular disease has marked peripheral neuropathy. An appropriate nursing diagnosis for the pt is:
a. risk for injury r/t decreased sensation
b. impaired skin integrity r/t decreased peripheral circulation
c. ineffecti - a. Diminshed blood perfusion to nerve tissue cells produces a neuropathy manifested by loss of both sensation and deep pain, and injuries to the extremity often go unnoticed. It is important to teach the pt to protect the feet and detect and prevent injuries to prevent breaks in the skin that can lead to infection and gangrene.
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During care of the pt following femoral bypass graft surgery, the nurse immediately notifies the physician if the pt experiences:
a. fever and redness at the incision site
b. 2+ edema of the extremity and pain at the incision site
c. a los - c. Loss of palpable pulses and numbness and tingling of the extremity are indications of occlusion of the bypass graft and need immediate medical attention. Pain, redness, and serous drainage at the incision site are expected post-op, but decreasing ankle-brachial indices may indicate graft obstruction.
- A pt has chronic a-fib and develops an acute arterial occlusion at the iliac artery bifurcation. What are the six P's of acute arterial occlusion the nurse may find in the pt?
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1. pain
2. pallor
3. pulselessness
4. paresthesia
5. paralysis
6. poikilothermia -
To help prevent embolization of the thrombus in a pt with a DVT, the nurse teaches the pt to:
a. dangle the feet over the edge of the bed q2-3h
b. ambulate for short periods three to four times a day
c. keep the affected leg elevated above - d. Prevention of emboli formation can be achieved by bed rest and limiting movement of the involved extremity until the clot is stable, inflammation has receded, and anticoagulation is achieved. Elevating the affected limb will promote venous return, but it does not prevent embolization, and dangling the legs promotes venous stasis and further clot formation.
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A pt with DVT is to be discharged on long-term warfarin (Coumadin) therapy and is taught about prevention and continuing treatment of DVT. The nurse determines that discharge teaching for the pt has been effective when the pt states:
a. "I shou - d. Exercise programs for pts recovering from DVT should emphasize swimming and wading, which are particularly beneficial because of the gentle, even pressure of the water. Coumadin will not blacken stools, and if these occur, could be signs of GI bleeding. Dark green and leafy vegetables have high amounts of vit K and hsould not be increased during Coumadin therapy, but they do not need to be restricted. The legs must not be massaged because of the risk for dislodging any clots that may be present.
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The nurse teaches the pt with any venous disorder that the best way to prevent venous stasis and increase venous return is to:
a. walk
b. sit with the legs elevated
c. frequently rotate the ankles
d. continuously wear compression grad - a. During walking, the muscles of the legs continuously knead the veins, promoting movement of venous blood toward the heart, and walking is the best measure to prevent venous stasis. The other methods will help venous return, but they do not provide the benefit that ambulation does.
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The most important measure in the treatment of venous stasis ulcers is:
a. elevation of the limb
b. extrinsic compression
c. application of moist dressings
d. application of topical antibiotics - b. Although leg elevation, moist dressings, and topical antibiotics are useful in treatment of venous stasis ulcers, the most important factor appears to be extrinsic cocmpression to minimize venous stasis, venous hypertension, and edema. Extrinsic compression methods include compression gradient stockings, elastic bandages, and Unna's boot.
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A postsurgical pt has an acute onset of dyspnea, tachycardia, and chest pain. While the physician is being notified, the nurse should:
a. elevate the head of the bed
b. administer oxygen at 6L/min
c. elevate the lower extremities
d. s - a. Until the physician is notified and specific orders for IV therapy, oxygen, and medications are received, the pt should be placed in a semi-Fowler's position to facilitate breathing, and the nurse should stay with the pt to explain the situation and provide emotional support. The legs should not be elevated, because increased venous return will increase right ventricular preload, and pulmonary circulation may be significantly obstructed by the emboli.
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To determine the location of a pulmonary embolism, the nurse would expect the physician to order a(n):
a. ECG
b. chest x-ray
c. perfusion lung scan
d. pulmonary angiogram - d. A pulmonary angiogram, in which a contrast medium is used to visualize the pulmonary vasculature, is the most definitive diagnostic test to locate a pulmonary embolism. The pulmonary angiogram is an invasive test, requiring that a catheter inserted into the femoral or antecubital vein be threaded to the pulmonary artery. ECGs and chest x-rays are not specific tools for diagnosing pulmonary embolism, and a perfusion lung scan is more useful in screening for pulmonary embolism and evaluating the effectiveness of medical management.
- A progressive narrowing and degeneration of the arteries of the neck, abdomen, and extremities
- peripheral arterial disease (PAD)
- A gradual thickening of the intima and media of arteries which leads to progressive narrowing of the vessel lumen
- atherosclerosis
- Outpouchings or dilations of the arterial wall - common problems involving the aorta
- aneurysms
- A disruption of all layers of the arterial wall resulting in bleeding that is contained by surrounding structures
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false aneurysm
or
pseuodaneurysm - Type of aneurysm in which the wall of the artery forms the aneurysm - at least one vessel layer is still intact
- true aneurysm
- Type of aneurysm that is circumferential and relatively uniform in shape
- fusiform aneurysm
- Type of aneurysm that is pouchlike with a narrow neck connecting the bulge to one side of the arterial wall
- saccular aneurysm
- The most common clinical manifestion of a thoracic aortic aneurysm is __________ __________.
- chest pain
- Severe back pain and possible flank ecchymosis associated with aneurysm rupture
- Grey Turner's sign
- Anatomic mapping of the aortic system by contrast imagining
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angiography
(doesn't help determine diameter or length of aneurysm) - Signs indicating an aneurysm has ruptured include __________(7 listed).
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1. diaphoresis
2. paleness
3. weakness
4. tachycardia
5. hypotension
6. pain
7. pulsating abd mass - Ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves w/i 10 minutes or less w/rest, and is reproducible
- intermittent claudication
- An episodic vasospastic disorder of small cutaneous arteries - most frequently involves the fingers and toes
- Raynaud's phenomenon
- The first-line drug therapy for treatment of severe Raynaud's disease that hasn't responded to other treatments are __________ ____________ ___________.
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calcium channel blockers
(Procardia, Cardizem, etc) - Formation of a thrombus in association with inflammation of the vein it is in
- venous thrombosis
- Inflammation of a vein
- thrombophlebitis
- A thrombus in a deep vein - most common in the iliac and femoral veins
- deep vein thrombosis (DVT)
- The three important factors in the etiology of venous thrombosis are . . .
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1. venous stasis
2. damage of the endothelium (inner lining of the vein)
3. hypercoagulability of the blood - Valvular destruction allowing retrograde flow of venous blood flow
- chronic venous insufficiency (CVI)
- Pain on forced dorsiflexion of the foot when the leg is raised
- Homan's sign (positive)
- Heparin inhibits thrombin-mediated conversion of __________ to __________.
- fibrinogen to fibrin
- The antidote for heparin is __________ __________.
- protamine sulfate
- The antidote for warfarin (Coumadin) is __________.
- Vit K
- INR is used to monitor __________. The therapeutic value is __________.
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warfarin
2-3 - PTT is used to monitor __________. Ther therapeutic value is __________.
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heparin
46-70 sec - Blockage of pulmonary arteries by thrombus, fat or air emboli, and tumor tissue.
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pulmonary embolism (PE)
(the most common pulmonary complication in hospitalized pts) - Most PEs arise from thrombi in the __________ _________ of the __________.
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deep veins
legs -
Significant risk factors for peripheral arterial disease include:
a. sedentary lifestyle, stress, obesity
b. advanced age, female gender, familial tendency
c. cigarette smoking, hyperlipidemia, hypertension
d. protein S deficiency, pr - c
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A pt is being prepared for an abd aortic aneurysm repair. The nurse suspects rupture of the aneurysm when:
a. the pt becomes dizzy and SOB
b. the pt c/o sudden, severe back pain
c. a bruit and thrill are present at the site of the aneurysm - b
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Important nursing measures after an abd aortic aneurysm repair are to:
a. elevate the legs and apply TED hose
b. assess cranial nerves and mental status
c. administer IV heparin and monitor PTT
d. monitor urine output, BUN, and creati - d
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Rest pain is a manifestation of peripheral arterial disease that occurs as a result of:
a. the beginning of a venous leg ulcer
b. inadequate blood flow to the nerves of the feet
c. inadequate blood flow to the muscles during exercise
- b
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A pt with infective endocarditis develops sudden left leg pain with pallor, paresthesia, and a loss of peripheral pulses. The nurse's initial action should be to:
a. notify the physician
b. elevate the leg to promote venous return
c. wrap - a
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The usual medical treatment of Raynaud's phenomenon involves:
a. transluminal balloon angioplasty
b. amptuation of the affected digits
c. peripheral arterial bypass surgery
d. prescribing calcium channel blockers - d
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The pt who is most likely to have the highest risk for DVT is a:
a. 25 yr old obese woman who is 3 days postpartum
b. 40 yr old woman who smokes and uses oral contraceptives
c. 62 yr old man who has had a stroke with left-sided hemiparesis - b
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The nurse suspects the presence of a DVT based on the findings of:
a. paresthesia and coolness of the leg
b. pain in the calf that occurs with exercise
c. generalized edema of the involved extremity
d. pallor and cyanosis of the invol - c