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Vascular disease
| Question | Answer |
|---|---|
| Arterial aneurysm Diagnosis: | : Tissue perfusion, ineffective peripheral, related to decreased blood flow |
| Arterial aneurysm Goal | Patient will maintain adequate tissue perfusion distal to the aneurysm |
| Arterial Interventions | 1) Frequently assess distal pulses and capillary refill 2) Ensure urine output >30cc/hr 3) be alert for complications 4) Report all changes to physician |
| Buerger's Disease Etiology/Pathophysiology: | Inflammation of blood vessels, Leads to obstruction of the blood vessels,Affects primarily the arteries and veins of the lower extremity. Develops in the small arteries and veins in the hands and feet |
| Buerger’s Disease Etiology con't | Wrists and lower legs may also be involved Leads to ischemia, pain and infection and ulceration in later stages Affects men between 20 and 40 who smoke 75 times more common in men than women |
| Buerger’s Disease Subjective Data | Assess pain, claudication and sensitivity to cold in affected extremity. Assess risk factors |
| Buerger’s Disease Objective Data | Assess pulses, skin color and temperature in the affected extremity. |
| Buerger’s Disease Diagnostic Tests | Buerger’s Disease Diagnostic Tests Arteriography, digital subtraction angiography Doppler ultrasound Exercise testing |
| Buerger’s Disease Medical Management | The goal is directed at preventing progression Smoking cessation is a major focus Buerger-Allen exercises to develop collateral circulation Sympathectomy Care of ulcerations Amputation with gangrene |
| Buerger’s Disease Nursing Interventions | Buerger’s Disease Nursing Interventions Manage risk factors Promote tissue perfusion Hydration Cleanliness Provide comfort measures |
| Buerger’s Disease Con’t Buerger’s Disease Con’t Patient Teaching | Buerger’s Disease Con’t Patient Teaching Focuses on smoking cessation None of the palliative interventions are effective if the patient does not stop smoking Prognosis a chronic condition that may lead to gangrene and amputation |
| Question: What is the first clinical manifestation (sign or symptom) seen with Buerger’s Disease? | Answer: Claudication of the arch of the foot. |
| Raynaud's Disease Etiology/Pathophysiology | Raynaud's Disease Etiology/Pathophysiology Characterized by intermittent arterial spasm Results in periodic ischemia to the extremities; especially the fingers, toes, ears, and nose Precipitated by the cold or emotional stimuli Affects women between |
| Raynaud's Disease Etiology Raynaud's Disease Etiology Underlying cause unknown, or may be secondary to other conditions such as | Raynaud's Disease Etiology Underlying cause unknown, or may be secondary to other conditions such as Scleroderma Rheumatoid arthritis Systematic lupus erythematosus Drug intoxication Occupational trauma thickens and the medial wall hypertrophies |
| Raynaud's Disease Clinical Manifestations | Chronically cold hands and feet Pallor, coldness, numbness, cutaneous cyanosis and pain with spasms Chronic Raynaud's may result in ulcerations of the fingers and toes |
| Raynaud's Disease Assessment Subjective Data | Determine underlying diseases process and risk factors Assess patient's perception of pain, numbness, tingling and burning |
| Raynaud's Disease Assessment Objective Data | Raynaud's Disease Assessment Objective Data Pallor Coldness Blanching Cyanosis Reactive hyperemia (increased blood in a part of the body caused by increased blood flow and resulting in redness) Inspection of finger and toes for ulceration |
| Raynaud's Disease Diagnosis Cold Stimulation Test | Patient's hand is submerged in an ice water bath for 20 seconds Skin temperature changes are recorded by a thermistor attached to each finger Ongoing temperatures are compared |
| Raynaud's Disease Medical Management | Raynaud's Disease Medical Management Biofeedback Techniques Medications: promote circulation and reduce pain Vasodilators Calcium channel blockers Vascular smooth muscle relaxants Sympathectomy |
| Raynaud's Disease Nursing Interventions | Promote tissue perfusion Maintain comfort Prevent injury an infection Risk factor management includes stress-reduction techniques |
| Raynaud's Disease Nursing Diagnosis | Knowledge deficit, related to effects of cigarette smoking, stress reduction and avoiding exposure to cold |
| Raynaud's Disease Nursing Goal | Patient will minimize vascular attacks |
| Raynaud's Disease Nursing Interventions | 1. Teach/assess understanding of the effects of smoking on vasoconstriction and arterial blood flow 2. Teach/assess understanding of techniques for smoking cessation 3. Teach/assess understanding of techniques for stress management 4. Teach/assess |
| Raynaud's Disease Con’t Prognosis | Disease may be controlled by protection from the cold Attacks continue, but can be controlled Sometimes associated with the development of rheumatoid arthritis or scleroderma |
| Raynaud’s disease is characterized as | Intermittent arterial spasm |
| Thrombophlebitis Definition: | inflammation of a vein accompanied by the formation of a thrombus |
| Thrombophlebitis Etiology/Pathophysiology | Thrombophlebitis Etiology/Pathophysiology It occurs more frequently in women. Affects people of all races |
| Thrombophlebitis (Factors that Contribute | Thrombophlebitis (Factors that Contribute Inactivity: prolonged sitting Trauma to the vessel wall Venous stasis Hypercoagability |
| Factors that Contribute Con’t | Myocardial infarction or heart failure Elderly patients with heart disease, infections or dehydration Surgery that manipulates blood vessels such as total hip replacement or pelvic surgery Immobilization after surgery |
| Thrombophlebitis Clinical Manifestations | Pain and edema The size of the calf or thigh may increase the circumference Pain on dorsiflexion (Homan's Sign) If the thrombophlebitis is superficial there may be signs of inflammation such as erythema, warmth, and tenderness along the vein |
| Thrombophlebitis Assessment Subjective Data | collection of data includes characteristics of pain, onset, and duration |
| Thrombophlebitis Assessment Objective Data: inspection of extremity includes: | Heat Erythematous Edema Measure both legs circumference Color |
| Thrombophlebitis Diagnostic Tests | Thrombophlebitis Diagnostic Tests Venography Doppler ultrasound Impedance Plethysmography (IPG): preferred test |
| Thrombophlebitis Medical Management | Anti-embolism stockings periodically elevated above the heart to reduce edema DVT requires hospitalization and bed rest during the acute phase Superficial thrombophlebitis is usually treated with bed rest, moist heat and elevation of the affected extre |
| Thrombophlebitis Medical Management Medications | NSAIDS Anticoagulants IV heparin Warfarin Low-molecular weight heparin (LWMH) administered SQ does not require anticoagulant monitoring or dose adjustment Enoxaparin (Lovenox) Dalteparin (Fragmin |
| Thrombophlebitis Surgical Interventions | Thrombophlebitis Surgical Interventions Only indicated when conservative measures have failed Thrombectomy Transvenous placement of grid Umbrella (Greenfield filter) placed in vena cava may prevent flow of emboli to lungs |
| Thrombophlebitis Nursing Interventions | |
| QUESTION: A patient will be receiving a thrombolytic drug as part of the treatment for acute myocardial infarction. The nurse explains to him that this drug is used to: | c; Thrombolytic drugs lyse, or dissolve, thrombi. |
| During thrombolytic therapy, the nurse monitors the patient for adverse effects. What is the most frequent undesirable effect of thrombolytic therapy? | d; Bleeding, both internal and superficial, as well as intracranial, is the most frequent undesirable effect of thrombolytic therapy |
| Thrombolytic Agents Con’t Evaluation: | Lysis of thrombi and restoration of blood flow. Prevention of neurologic sequelae in acute ischemic stroke. Cannula or catheter patency |
| Thrombolytic Agents Patient Teaching: | purpose of medication to report hypersensitivity reactions bedrest and minimal handling during therapy to avoid injury. Avoid all unnecessary procedures such as shaving and vigorous tooth brushing. |
| Thrombolytic Agents Implementation | Avoid invasive procedures, such as IM injections or arterial punctures, with this therapy Acetaminophen may be ordered to control fever. IV Administration: review process. |
| Thrombolytic Agents Implementation High (2)Alert: | Overdosage and underdosage of thrombolytic medications have resulted in patient harm or death.*Do not confuse the abbreviation t-PA for alteplase (Activase) with the abbreviation TNK t-PA for tenecteplase (TNKase) and r-PA for reteplase (Retavase). |
| Thrombolytic Agents Assessment Toxicity and Overdose (High Alert): | If local bleeding occurs, apply pressure to site. Do not administer dextran; it has antiplatelet activity. Aminocaproic acid (Amicar) may be used as an antidote. |
| Thrombolytic Agents Assessment Acute Ischemic Stroke: | Assess neurologic status. Determine time of onset of stroke symptoms. Alteplase must be administered within 3 hr of onset. |
| Thrombolytic Agents Assessment Pulmonary Embolism: | monitor pulse, blood pressure, hemodynamics, and respiratory status (rate, degree of dyspnea, ABGs). |
| Thrombolytic Agents Assessment Deep Vein Thrombosis/Acute Arterial Thrombosis: |
Created by:
ninja3lake
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