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93 Cards in this Set
- Front
- Back
what causes stroke
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redux in cerebral BF & O2
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when is recovery from stroke considered complete
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when circulation returns to normal
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what is a common warning sign of impending stroke
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TIA
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how long do TIA usually last
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30 secs to 24 hrs
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name some common causes of stroke
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thrombosis
embolism hemmorhage |
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what is the MOST COMMON cause of stroke
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thrombosis
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60-80% of clients with strokes are caused by
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thrombosis due to atherosclerosis
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what is 2nd most common cause of stroke
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embolus
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what puts pts at risk for embolus
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A-fib, orthopedic surgery
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what is 3rd most common cause of stroke
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hemorrhage
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a pt w/ A-fib has _____ greater risk of stroke
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5x
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what is the MOST IMPORTANT modifiable risk factor for stroke
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HTN
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what BMI is obese
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30 or >
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other than HTN what are some modifiable risk factors for stroke
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incr abd fat
obesity alcohol sedentary life smoking DM incr cholesterol |
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non-modifiable risk factors for stroke
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age
gender race |
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what age are at greater risk for stroke
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55 or > (double incidence)
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what races are at greater risk for stroke
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african american
hispanic american indian |
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objective s/s of stroke
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hemiplegia
hemiparesis dysphagia alexia agraphia aphagia - expressive/receptive dysarthia homonymous hemianopia proprioception reflexes poor judgement emotions - fear, anger, confusion |
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what is rtPA
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recombinant tissue plasminogen activator
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how soon must rtPA be administered
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within 3 hrs of s/s of stroke
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if a pt has a L cerebral stroke, what side of the body will be affected
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everything on the R except for ptosis
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if a pt has a R cerebral stroke, what side of the body will have ptosis
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right
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what kind of drugs should a pt w A-fib be on
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anticoags to prevent thrombi
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what is the difference btw heparin and rtPA
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heparin PREVENTS new clots
rtPA BREAKS clots |
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name some common medical interventions for stroke
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heparin
thrombolytics anti-platelet aggregation |
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how do antiplatelets work
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prevent platelets from aggregating on damaged vessel walls
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are platelet drugs used for non-cardioembolic causes of TIA
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yes
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what nursing intervetions are used for stroke pts
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same as caring for an unconscious pt
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what reflexes are evaluated for stroke pts
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gag/swallow
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who evaluates pts ability to eat
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speech therapy
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what is important to remember about nutrition for stroke pts
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place food in unaffected side of mouth
high fowlers during/after eating solid foods/thick liquids |
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safety measure for stroke pts
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keep clutter minimal
organized environment good lighting items within reach |
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what is important to remember about hemianopsia
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approach client on unaffected side
place items on unaffected side teach pt to scan |
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what is important to remember about pt positioning with strokes
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proper position prevents deformities
elevation prevents edema active/passive ROM q4hrs rehab |
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how often should ROM be done for stroke pts
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q 4 hrs
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when should rehab begin for stroke pts
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day 1
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what is important to remember about dressing stroke pts
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start on AFFECTED side
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nursing interventions for bowel/bladder control for stroke pts
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provide adequate fluid
diet w enuf roughage for BMs monitor for fecal impaction |
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nursing interventions for family coping
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monitor for depression in all family members
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nursing interventions for expresive aphagia
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associate words w/ physical objects
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there will be LOTS of questions about hemianopsia - know this forwards and backwards
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L side stroke means hemianopsia on R side
L side stroke - approach on L side, place personal items on L side, place food on L side of plate, etc |
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how do SCDs help stroke pts
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prevent further DVTs
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nursing interventions for receptive aphagia
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nonverbal techniques
slow commands |
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MOST COMMON s/s of PAD
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intermittent claudicaton
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describe intermittent claudication
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muscle aches and cramps, numbness - mostly in the legs
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what is LEADING cause of PAD
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atherosclerosis
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other than intermittent claudicaton what are other s/s of PAD
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smooth shiny skin w/o hair
no edema thickened nails cool, pale, mottled, cyanotic skin decr peripheral pulses |
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what are some predisposing factors for PAD
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HTN
hi cholesterol DM smoking |
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how is PAD diagnosed
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Ankle Brachial Pressure Index
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why are pulses less palpable w/ PAD than with DVTs
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pulses run thru arteries NOT veins - if arteries are affected (occluded) pulses will be less palpable - if DVT are present, pt will have edema which might make pulses harder to find, but they will still be present
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how is ABPI taken
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brachial BP over ankle BP - BP should be higher in legs
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why should pts w/ PAD walk
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walking causes vasodilation and will im
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what causes "rest pain"
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O2 deprivation during periods of inactivity
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how long should pts w PAD walk each day
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30-45 mins
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how could nifedipine help a pt w/ Raynauds
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dilates arteries and improves circulation
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what are some interventions/tx for PAD
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legs level w/ heart
NO elastic stockings palpate pulses distally stop smoking walking 30-45 mins/day antiplatelet drugs (ASA, plavix) PTA |
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describe PTA
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percutaneous transluminal angioplasty - balloon catheter passed thru artery
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how are arteries affected in a pt w/ Raynauds
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vasoSPASMS of digital arteries
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s/s of raynauds
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usually affects hands/feet
color change white/blue/red |
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predisposing factors for raynauds
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pressure to fingertips
smoking hand held vibrating equipment |
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what forms a clot in pts w DVT
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platelets, RBC and fibrin
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how is DVT dx
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ultrasound
D-dimer |
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what 3 things make up Virchows triad
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stasis
vascular damage hypercoagulability |
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name some cause of veinous stasis
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A-fib
orthopedic surgery prolonged immobility |
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what are some causes of endothelial damage
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trauma
surgery infections meds sclerosing catheters |
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what causes hypercoag of blood
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smoking
anemias pregnancy estrogen therapy birth control |
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what is the antidote of heparin
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protamin sulfate
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what lab values are used to monitor heparin
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PTT
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what lab values are used to monitor coumadin
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INR
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what is the antidote of coumadin
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vitamin K
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s/s of DVT
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edema
mescle tenderness warmth pain homans sign (dorsiflexion pain) malaise fever 50% are asymptomatic |
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know what food groups are high in Vit K
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for NCLEX know what foods are high in Vit K
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what are some sudden initial s/s of DVT
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sudden onset tachycardia
tachypnea anxiety hypoxia |
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what is MOST IMPORTANT reason for tx DVT
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preventing PE
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what drugs should b used for DVT tx
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anticoags
heparin lovenox coumadin |
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why is it important to overlap heparin and coumadin tx
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coumadin tx is delayed 5 days
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how does coumadin work
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blocks prothrombin formation by interfering w/ Vit K synthesis
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what labs are used to monitor lovenox
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platelets
CBC |
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how often should pts on coumadin have INR checked
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q 4-6 wks
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when is thrombectomy used
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when thrombus is RECENT and in LARGE vessel
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should PAD pts have legs elevated above heart
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NO
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should DVT pts have legs elevated above heart
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YES
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should DVT pts get leg massages
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no
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what resp factors should the nurse monitor in DVT pts
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s/s of PE
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what antidotes should be on hand for pts coumadin, heparin and lovenox
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protamin sulfate for heparin/lovenox
Vit K for coumadin |
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are elastic stockings used for PAD pts
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no
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are elastic stockings used for DVT pt
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yes
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preventions for DVT
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early ambulation post op
ROM avoid standing/sitting change IV tubing/catheters TEDs |
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how are PEs most commonly caused
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a DVT clot breaks loose
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predisposing factors for PE
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same as DVT
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what can be done for a pt w/ recurrent DVT
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vena cava surgery - filter/umbrella/clip installed to catch migrating thrombi
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describe post-thrombotic syndrome
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develops in 40-60% DVT pts
red-brown skin discoloration stasis ulcers - chronic, irregular borders, hard to heal |
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what does a D-dimer test measure
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degradation fragments generated by fibrinolysis
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