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medsurg exam 3
peripheral vascular disease
| Question | Answer |
|---|---|
| peripheral vascular disease | Diseases of the blood vessels (arteries and veins) located outside the heart and brain |
| What is the cause? | mainly a flow problem |
| types of causes of peripheral vascular disease | Damage or obstruction Pump problem Lymph problem |
| Damage or obstruction | arteries: thrombus, plaque, trauma ** Atherosclerosis most common cause veins: thrombus, incompetent valves |
| pump problem | RHF or LHF |
| lymph problem | cancer surgery, radiation |
| peripheral artery disease most common chronic cause | atherosclerosis |
| peripheral artery disease: atherosclerosis occurs when | there are deposits of fat and fibrin that obstructs and hardens arteries |
| 5 Ps of PAD | signs and symptoms of acute limb ischemia |
| PAD is the most common cause of | amputations |
| Peripheral vascular disease (PVD) risk factors | smoking, diabetes, HTN, high cholesterol, obesity, physical inactivity, and age over 50 |
| PVD prevalence | increases with age for both men and women, higher prevalence in after 70yo |
| skin appearance: assessment | mottled appearance, dependent rudor smooth, shiney skin with no hair, can be necrotic |
| mottled appearance | a patchy, net-like, or marbled pattern of red, purple, or blue discoloration, often on the legs, arms, or trunk **occurs when elevated |
| dependent rudor | a dark, dusky red discoloration of the legs or feet that occurs when they are in a hanging (dependent) position |
| pain: assessment | intermittent claudication |
| intermittent claudication | pain, cramping, or fatigue in the leg muscles at rest: there is good blood flow when exercising: ischemia in legs when sit down again: good blood flow again |
| blood flow: assessment | longer capillary refill hard to palpate pulses, need doppler |
| ankle brachial index correlates | with severity of claudification |
| how does ankle brachial index work | compares blood pressure in the ankle to the arm to detect peripheral artery disease |
| as ABI number decreases, | PAD gets more severe |
| PAD management | reduce risk factors!! promote circulation/vasodilation |
| how to reduce risk factors for PAD | Smoking cessation = Reduced progression and risk of amputation Lipid lowering diet = Regression, less claudication Disease Management Program - Diabetes control, Hypertension control |
| how to promote circulation/vasodilation for PAD | Walking regimen decreased symptoms greater than angioplasty - 50 min/3x week Antiplatelet agent Promoting circulation to lower extremities - |
| antiplatelet agents for PAD | Aspirin – 1st choice (CAD, cost) Plavix Pletal Trental |
| promoting circulation to lower extremities | do not cross legs, position limbs dependently, keep extremities warm |
| treatment for PAD | walking, arterial stenosis, bypass vessel (bypass blockage), amputation (last resort) |
| varicose veins are | irregular torturous veins |
| varicose veins usually effect | veins of lower extremities (saphenous vein) |
| varicose veins are caused by | long standing increased venous pressure, vein valves become incompetent |
| varicose veins more likely in | pregnancy and obesity older adults |
| varicose veins manifestations | visible, dilated aching, heavy, fatigued legs itching, heat thin, discolored skin around ankles |
| treatments of varicose veins | conservative, ablation therapy, sclerotherapy, vein stripping |
| conservative treatments of varicose veins | Compression stocking (augment muscle pumping action of legs) Leg elevation Exercise |
| ablation therapy treatments for varicose veins | go in with laser and burn vein |
| vein stripping treatments for varicose veins | rip out vein under anastesia |
| vein ablation | Laser or radiofrequency Heated catheter creates scare tissue and causes vein to close |
| chronic venous insufficiency | Inadequate venous return over a period of time |
| chronic venous insufficiency due to | valve injury, can't prevent backflow |
| chronic venous insufficiency symptoms | cellulitis, dull ache, worse when standing |
| venous statsis ulcer | common complication of CVI |
| how frequent are venous stasis ulcer | compromise 50-70% of leg ulcers |
| avg healing time for venous statsis ulcers | 6-8 month, need to wrap legs |
| lymphedema occurs when | there is damage or destruction of the lymphatic pathway |
| lymphatic system function | lymphatic system removes macromolecules to large for reabsorption into the circulatory system |
| etiology of primary lymphedema | congenital, rare |
| etiology of secondary lymphedema | due to carcinoma, causes damage to section of lymph nodes, trauma, radiation, chronic infection and chronic venous insufficiency |
| lymphedema is | chronic debilitating disease that requires lifelong management |
| if lymphedema is untreated, it can progress which causes | continued proliferation of fibrotic tissue an increase in size of infected limb chronic infections |
| lymphedema results in | an increase in functional impairment and a decrease in quality of life |
| treatment of lymphedema | complete decongestive therapy |
| complete decongestive therapy has to be done by | PT |
| complete decongestive therapy is | Manual Lymph Drainage Bandaging Exercise Skin and Nail Care Instruction in Self Care |
| Home Care to Prevent Injury | Inspect daily for problems Wash & moisturize feet daily |
| Inspect daily for problems | Change in temp, appearance, edema |
| Wash & moisturize feet daily | Between toes, mild soap, lukewarm water Rinse, pat versus rub dry Apply moisturizer (avoid excess) Do not apply moisturizer between toes |
| how to prevent injury | Trim nails Always wear socks and shoes Protect feet from hot & cold (water, sand, etc) Choose well fitting shoes - check in the evening because feet swell during the day |
| educate pt when to contact HCP | any skin breakdown, redness or pain |
| surgery for lymphedema | Lymphaticovenular Bypass |
| Lymphaticovenular Bypass | Microscopic surgery lymphatic fluid is redirected to drain through small veins |
| DVT | The formation of blood clot in the deep veins of an extremity |
| DVT can originate in | any extremity but 80% originate in deep veins of calf |
| DVT is the most common complication of | surgery and immobility |
| DVT/PE Venous Thromboembolism | Increased risk for surgical patient without DVT prophylaxis Pulmonary embolism major complication Roughly 1 out of 10 hospital deaths related to blood clots in the lungs |
| who is at risk for DVT | Hospitalized, immobile Surgery – 20% increase, 50 % increase for orthopedic surgery Obesity Smokers Oral contraceptives Central Venous Catheters |
| DVT assessment: symptoms | Dull, aching pain, tenderness, warmth, erythema Edema (Increase in extremity circumference) Can be asymptomatic |
| Venous Thromboembolism | Blood Clots may: remain in vein which is Deep Vein Thrombosis (DVT) Can dislodge and travel to lungs: Pulmonary Embolism |
| management of Venous Thromboembolism (prophylaxis) | Early ambulation Sequential compression devices Compression stockings |
| management of Venous Thromboembolism (medications) | LMWH, heparin |
| diagnosis of Venous Thromboembolism | Duplex venous ultrasonography D-Dimer |
| Duplex venous ultrasonography | measures the velocity of flow in veins |
| D-Dimer | Lab test A compound formed after thrombin converts fibrinogen to fibrin **Negative result use to rule out presence of a blood clot!! |
| management/treatment of Venous Thromboembolism | anticoagulants which are 1 of 3 most dangerous classes of meds associated with adverse events |
| Management -IV Heparin Therapy with PTT (Partial Thromboplastin Time) or Anti-Xa | PTT or Anti-Xa drawn frequently |
| PTT or Anti-Xa drawn frequently | every- 2-6 hours as per nomogram All values are drawn STAT |
| PTT or Anti-Xa | pt must achieve 2 consecutive therapeutic PTTs or Anti-Xa to be able to then draw PTT or Anti-Xa once daily |
| Management -IV Heparin Therapy Anti-Xa | Test that measures anti-thrombin activated factor Xa levels in plasma Therapeutic range: 0.3-0.7 IU/mL |
| Management-IV heparin therapy baseline | Baseline PT/PTT, Anti-Xa, H/H and Platelet count required before therapy is initiated |
| Management-IV heparin therapy plt and H/H | every day |
| Management-IV heparin therapy: assess for | HIT report plt count -<150,000 or a 30-50% reduction (any decrease) assess for signs of bleeding - stool guiac, hematuria |
| reversal agent for heparin | protamine sulfate!!! |
| management for Warfarin (coumadin) | Coumadin is given simultaneously with heparin until Coumadin is therapeutic and then Heparin is discontinued |
| when should coumadin be given | every day |
| how long is pt usually on coumadin | 3-6 months |
| pt on coumadin/heparin needs monitored of | INR, INR range therapeutic is usually 2-3 |
| reversal agent for warfarin | vitamin K!!! |
| why would a pt be on warfarin | pt can't go home on IV heparin, so they are bridged to warfarin and once that becomes therapeutic (INR 2-3) then they can be d/c |
| on warfarin, do not | take any over the counter medication or herbal supplements without consulting MD first |
| warfarin info cont | Wear a med alert bracelet No smoking No alcohol Obtain blood work as ordered Take precautions to avoid bleeding Report to ED for episode of bleeding |
| another option for anticoagulants | factor Xa inhibitors |
| surgery for venous thromboembolism | inferior vena cava filter thrombectomy |
| inferior vena cava filter | catch blood clots from going to lungs only if the pt cant be on anticoagulants |
| thrombectomy | minimally invasive procedure to remove blood clots from arteries or veins to restore blood flow |
| layers of artery | Tunica Intima Tunica Media Tunica Externa |
| Thoracic & Abdominal Artery Aneurysms | Localized dilation of aorta |
| common causes of Thoracic & Abdominal Artery Aneurysms | Atherosclerosis Hypertension |
| types of Thoracic & Abdominal Artery Aneurysms | True: saccular, fusiform False: dissecting |
| Thoracic & Abdominal Artery Aneurysms can involve | Aortic arch Thoracic aorta Abdominal aorta |
| who is at risk for Thoracic & Abdominal Artery Aneurysms | Male, 6th or 7th decade, increased BP, atherosclerosis, smoker |
| increased size of Thoracic & Abdominal Artery Aneurysms means | increased risk for rupture |
| symptoms of Thoracic & Abdominal Artery Aneurysms depend on | location, size, growth |
| diagnosis of Thoracic & Abdominal Artery Aneurysms | Angiogram Chest X-ray CT MRI Echocardiogram |
| medical management of abdominal artery aneurysms | if asymptomatic: Aggressive BP control Serial imaging Surgery when ≥ 5.5 cm |
| surgical management of abdominal artery aneurysms | Endovascular grafting (EVSG or EVAR) Open approach |
| mortality of surgical management | ≤ 5% elective; 40% emergent |
| Endovascular grafting (EVSG or EVAR) | take pressure off the weakened aortic wall |
| abdominal aortic aneurysms nursing management | Patient teaching – surveillance |
| what to monitor for in abdominal aortic aneurysms | Unexplained back, chest, flank pain Falling BP or hematocrit Smoking cessation |
| post op abdominal aortic aneurysms | Monitor VS, make sure BP is WNL Assess peripheral pulses - distal to where grafts placed Assess bleeding, pain, fever Avoid coughing, sneezing, vomiting |
| aortic dissection: type A is an | Life-threatening emergency Sudden severe excruciating (tearing or ripping) pain located in the back and/or chest |
| how does a type A aortic dissection occur | Tear in the tunica intima of the aorta Hemorrhage into tunica media Splits the vessel wall, forming a blood filled area between the two layers |
| main cause of type dissections | HTN, 70% |
| other symptoms of dissections | Syncope, dyspnea, hypotension, absent peripheral pulses If major arteries effected: ischemia or effect to major organs |
| type A aortic dissection surgery | Emergent surgery High risk for life threatening complications Only contraindication for surgery is if presence of comorbidities impact survival to one year or less |
| type B aortic dissection surgery | Surgery reserved for development of complications related to dissection If uncomplicated generally managed medically Medical management: Blood pressure control, Imaging surveillance |
Created by:
leh195