Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
TT2 Tissue Perfusion
TT2 NHCC Tissue Perfusion
| Question | Answer |
|---|---|
| What are the Characteristics of Veins? | Thin walls, Valves – often become insufficient & aren’t sufficient in returning blood to heart, Low pressure and Low velocity |
| What are Characteristics of Arteries? | Thick walls – layers and layers of muscles, High pressure, High velocity |
| What is the Definition of Thrombophlebitis? | Inflammation of a vein, often accompanied by formation of a clot. |
| What is Virchow’s Triad? | Three important factors in the etiology of venous thrombus are →Venous stasis, Hypercoagulation, & Vascular injury. The patient at risk for the development of venous thrombosis usually has predisposing conditions to these three disorders. |
| What population is at risk for Thrombophlebitis? | immobile, diabetic, elderly, cardiac, obesity |
| How is a thrombus formed? | RBCs, WBCs, platelets, and fibrin adhere |
| Where is A frequent site of thrombus formation? | the valve cusps of veins, where venous stasis allows accumulation of blood products |
| How does a larger clot with a “tail” form? | As the thrombus enlarges, increased amounts of blood cells and fibrin collect behind it, producing a larger clot with a “tail” |
| What effect does the clot with a tail have on the vein? | eventually occludes the lumen of the vein |
| What happins If a thrombus only partially occludes the vein and blood flow continues? | the thrombus becomes covered by endothelial cells and the thrombotic process stops |
| What happens if a thrombus does not become detached? | it undergoes lysis or becomes firmly organized and adherent within 24-48 hours. |
| What is the major factor contributing to its detachment of the thrombus from the vein wall? | The turbulence of blood flow past the thrombus |
| What does valvular destruction cause? | Chronic venous insufficiency and retrograde flow of blood |
| what are the Risk factors for DVT? | Immobilization, Oral contraceptives, Dehydration, Compression, Trauma, Varicose veins |
| Where is a common site for Artery insufficiency? | bifurcation of arteries |
| What are the Risk factors for PAD? | Hypertension, Hyperlipidemia, Cigarettes, Obesity, Diabetes |
| What is Definitions of Atherosclerosis? | – Most common form of arterial occlusive disorder. Arterial wall becomes “calcified” from fatty plaques. Plaques are cholesterol, lipids, tissues, cells, CHO and calcium in the intimate of vessel |
| What is Arteriosclerosis Obliterans? | A gradual narrowing of the arteries with degeneration of the intima and thrombosis. Condition may lead to complete occlusion of artery |
| What are the cause of PAD? | Genetics (inheritable – fatty streak present at birth), High serum cholesterol and high level of circulatory triglycerides, Hypertension (sheer force that scrape endothelial layer), Cytomegalovirus (infect endothelial cells) |
| How does PAD Change the Structure of the vessels? | : 1. Lipids accumulate at certain focal points, along with CHO, blood products, fibrous tissue and calcium deposits, 2. Deposits usually seen at artery bifurcation points, 3. Degeneration of intima occurs, 4. Lesions cause narrowing of artery, 5. Thrombos |
| What is the resulting Change in Function from PAD? | Reduced blood flow or total obstruction |
| What is Peripheral venous disease? | Chronic Venous Insufficiency |
| What are the causes of Peripheral venous disease? | vein incompetence, deep vein obstruction, congenital venous malformation, arterovenous fistula, and calf muscle failure. |
| What does incompetent valves of the deep veins result in? | hydrostatic pressure in the veins increase and serous fluid and RBCs leak from the capillaries and venules into the tissue, resulting in edema |
| What causes the release of hemosiderin? | Enzymes in the tissue eventually break down RBCs in the tissues causing the release |
| What does the release of hemosiderin do? | causes a brownish skin discoloration |
| What is the definition of a Pressure ulcer? | An inflammation, sore, or ulcer in the skin caused by unrelieved pressure resulting in damage to underlying tissue |
| What are the Risk factors for pressure ulcers? | Immobility, Malnutrition, Hyproteinemia, Incontinence, Decreased mental status, Age |
| How does Continuous pressure on soft tissues between bony prominences and hard surfaces cause pressure ulcers? | compresses capillaries and occludes blood flow. This lack of blood flow deprives the tissue of needed O2 and nutrients,. If pressure is not relieved, micro thrombin form in capillaries and blood flow completely occluded. This results in tissue ischemia |
| How does intissue ischemia form a pressure ulcer? | A blister forms with damage to superficial tissues, . Damage to underlying tissue creates necrosis. |
| How do pressure ulcers interfere with the major function of intact skin? | causes a disruption to skin integrity, thus breaking the protective barrier that protecs the body from invading organisms |
| What do you asses for Peripheral tissue perfusion? | Appearance, Pulses, Sensation, Temperature,Edema |
| What is checked in a Pressure ulcer assessment? | Location, Stage, Skin integrity around ulcer, Signs & symptoms of infection, Size, Tunneling – check w/ Q-tip underneath to see where wound edges are, Lab values – pressure ulcer + or - infection |
| What are assessment findings typically present in clients with peripheral arterial disease? | Intermittent claudication –Typically ripping, sharp pain in calf, Color changes – cyanotic, pale, loss of hair, shiny, Pulse change – usually a late symptom, Ulcers, Trophic changes, Paresthesia and/or nerve pain, Complete numbness |
| What are assessment findings typically present in clients with Peripheral venous disease? | Pain, Warmth, Color changes – brownish, ruddy, Stasis ulcers – aka venous ulcers, Edema – most common |
| What are Stasis ulcers – aka venous ulcers? | – stasis blood seeps out into tissue & eventually causes ulcer. Usually occurs in the lower 1/3 of leg. |
| What is Intermittent claudication? | pain due to tissue hypoxia, initially with activity, at rest as it progresses. Typically ripping, sharp pain in calf leg |
| What does ischemia of peripheral nerves cause? | Paresthesia and/or nerve pain |
| How many stages doe pressure ulcers have? | 4 |
| What is the first stage of pressure ulcers? | Non blanching erythema of intact skin |
| What is the second stage of pressure ulcers? | Partial thickness skin loss involving epidermis and/or dermis. Ulcer present as abrasion, blister, or shallow crater |
| What is the third stage of pressure ulcers? | Full thickness. Skin loss involving damage or necrosis of subcutaneous tissue. The damage does not extend through the underlying fascia. Ulcer presents as deep crater. |
| What is the fourth stage of pressure ulcers? | Full thickness. Skin loss with extensive destruction, tissue necrosis, or damage to muscles, bone, or supporting nerves. |
| What are Coagulation tests used for? | used in monitoring effectiveness of treatment. They are not used diagnostically. |
| What are the three coagulation tests? | PT, PTT, INR |
| What is a PTT test? | Test for detect. coagulation defects of the intrinsic system by adding activated partial thromboplastin to a sample of test plasma and to a control sample of norm. plasma. Time req. for the formation of clot in test plasma is comp. with that in norm plas |
| What is the rationale for a PTT test? | Test reflects the activity of Heparin. The PTT is Prolonged (increased) in anticoagulant therapy. The control (normal range) is 32-45 seconds (NMMC) |
| What is the normal range for a PTT? | 32-45 sec. |
| What is the Therapeutic range for a PTT? | 70-100 sec |
| What is the critical value for a PTT? | 110 sec |
| What is considered prolonged for a PTT? | 53 - 61sec |
| What is a PT test? | A one stage test for detecting certain plasma coagulation defects caused by a deficiency of factors V, VII, or X. Thromboplastin and calcium are added to a sample of patient’s plasma and simultaneously to a sample from normal control. |
| What is Prothrombin, Factor II? | a plasma protein that is produced by the Liver |
| PT is the specific lab test used to measure the effectiveness of which drugs? | the coumarin type of anticoagulant drugs, such as warfarin sodium (Coumadin) |
| What is the rationale of using a PT? | A prolonged (increased) PT means there is deficiency in one of the factors as in Liver disease, Vitamin K deficiency or due to anticoagulant therapy (Drug “Coumadin”) |
| What is the normal value of a PT? | 10.6-13.6 sec |
| What is the Prolonged value of a PT? | 17.5 and 38.2 |
| What is the Therapeutic range of a PT? | 22.7 - 33.0 |
| What is the definition of an INR (International Normalized Ratio)? | INR is defined as a mathematical “correction” for the differences in the sensitivity of the thromboplastin reagent. It is calculated by a formula at the lab. |
| What is the Recommended range of INR considered ideal for prevention and treatment of DVT, chronic A-fib, prevention of embolism after an acute MI.? | 2.0-3.0 (therapeutic range of the PT) |
| What is the Recommended range of INR considered ideal for those with prosthetic heart valves? | 2.5-3.5 (therapeutic to prolonged PT) |
| What range is considered critical at the pathway lab of NMMC? | 4.0 or greater |
| What are three important factors in the etiology of venous thrombus according to Virchow’s Triad? | Venous stasis, Hypercoagulation, & Vascular injury. |
| If the INR results have been stable and are now unstable what factors should you consider? | Dose - is the correct dose being given? Drug – Are there any recent addition or deletions from the drug list? Diet- Any new Vit K rich foods on or off menu? Is pt eating? Disease – Any new illness? |
| What drugs may ↑ INR? | antibiotics, cimetidine, diuretics, NSAIDs |
| What drugs may ↓ INR? | antacids, antihistamines, diuretics, Haldol |
| What client factors may ↑ INR? | elderly diarrhea, CHF, fever, Vit K deficiency |
| What client factors may ↓ INR? | edema, hypothyroidism |
| What is a Doppler Ultrasound used for? | Used to evaluate arterial and venous blood flow and to characterize soft tissue masses. |
| What is a Duplex Imaging Scan used for? | Peripheral arterial studies visualize and document the arterial blood flow in the extremities. Duplex ultrasound scans can determine the presence, amount, and location of plaques and are helpful in assessing the cause of claudication |
| What might Abnormal tracings and Doppler signals may provide evidence of in relation to tissue perfusion? | plaque or calcification, stenosis, occlusion, arteritis, aneurysm, pseudoaneurysm, graft diameter reduction, and abnormal communication between artery and vein. |
| What are the Nursing responsibilities related to duplex imaging scan? | Instruct patient to refrain from smoking or consuming caffeine for at least 2 hours before the test. Assure patient that no radiation is employed, typically no contrast medium is injected, and no pain is involved. |
| What is Venography? | the contrast agent study of peripheral or central veins. It is used to assess patency of vessel, stenosis. |
| What is venograhy used to assess? | patency of vessel, stenosis. |
| What is the Allen test used for? | test arterial patency |
| How is the Allen test performed? | Occlude both ulnar artery and radial artery. Let go of ulnar artery and observe hyperemia in hand. |
| What are the signs and symptoms of Superficial Thrombophlebitis? | May have palpable, firm SQ cordlike vein, area surrounding the vein may be tender to touch, reddened & warm, A mild systemic elev temp may be present, possible Leukocytosis, Edema of extremity may/may not occur |
| What are the symptoms of Deep Thrombophlebitis? | May be no symptoms, Unilateral leg edema, Pain, Warm skin, Temp > 100.4, If calf is involved may be tenderness on palpation, pos Homan’s sign |
| If the inferior vena cava is involved in Deep Thrombophlebitis What are the symptoms? | both lower extremities may be edematous and cyanotic |
| If the superior vena cava is involved Deep Thrombophlebitis What are the symptoms? | both upper extremities as well as the neck and back become edematous and cyanotic |
| What are the signs/symptoms of Chronic venous insufficiency? | Skin of the lower leg is leathery/characteristic brownish or “brawny” appearance, Edema usually persistent for a prolonged period, Eczema or “stasis dermatitis, Pruritus |
| What are some nursing dx for Peripheral vascular disorders? | Ineffective peripheral tissue perfusion and Impaired skin integrity - Related factors -Interruption of arterial flow or Interruption of venous flow |
| What are some outcomes for Peripheral vascular disease? | Peripheral pulses palpable, Capillary refill < 3 seconds, Negative Homan’s sign, No edema, Skin intact, Pain control, Skin care |
| What are some outcomes for Pressure ulcers (Impaired skin integrity)? | Daily skin inspection, Skin care, Proper positioning, Activity, Pressure relieving devices, Prevent shear, Consistency – use protocols, Nutrition, Positioning |
| What are interventions for DVT? | Elevate legs – to promote venous return, Warm packs – to encourage phagocytosis to carry debris away, TEDS – prevention (If someone already has a DVT, TEDS only on unaffected leg) |
| What are some nursing interventions for Venous disease? | Elevate extremities, Good skin care, Reduce edema, Prevent compression, Positioning – need to be careful of knee & hip flexion because it causes turbulent flow in veins around those areas. |
| What are some nursing interventions for Peripheral artery disease? | Ambulation, Foot care – dry very well, Positioning – straight out or dependent position, Diet - ↓ Fat ↓ Cholesterol, Pain manage., Meds Teaching – No smoking, BP control, Skin care, Do not elevate legs (keep flat or slightly lower), No tight s |
| PAD is highly associated with diabetes what is a precaution when diabetes is involved? | People often have numbness and they don’t feel when they hurt themselves. |
| What are some nuring interventions for pressure ulcers? | Relieve pressure – padding, airbeds, Ulcer care, Monitor healing, Nutrition, Complications |
| What two classes of drugs are commonly used for tissue perfusion problems? | Anticoagulants: parenteral & oral and Anti-platelet drugs |
Created by:
2007Nurse
Popular Nursing sets