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163 Cards in this Set
- Front
- Back
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(Def)
Disorders which alter the normal flow of blood through the arteries and veins |
Peripheral Vascular Disease
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In contrast to PAD, venous diseases primarily affect what part of the body?
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lower extremities
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A client with the diagnosis of PVD implies what type of disease?
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arterial disease
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_______ ________ _______ involves progressive narrowing and degeneration of arteries of the neck, abdomen, and extremities.
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Peripheral Arterial Disease
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In PAD, what is the site most commonly affected in non-diabetic patients?
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the femoral-popliteal area
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What is the leading cause of PAD, regardless of location?
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atherosclerosis
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What is atherosclerosis?
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a gradual thickening of the arteries resulting in a narrowing of the vessel lumen
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What plays a major role in the development of atherosclerosis?
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inflammation and endothelial injury
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The pathologic changes that occur with atherosclerosis consist of what? (4)
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- replication of smooth muscle cells
- deposition of connective tissue - lymphocyte and macrophage infiltration - lipid accumulation |
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PAD typically appears in what age group?
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60s to 80s
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PAD is more common in men or women?
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men
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What ethnic group is at a greater risk for PAD?
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African Americans
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What are the 4 most significant risk factors for PAD? Of these, which is the worst?
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1. cigarette smoking (worst)
2. hyperlipidemia 3. hypertension 4. diabetes mellitus |
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PAD may affect what 5 arteries?
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- Aortoiliac artery
- Femoral Artery - Popliteal Artery - Tibial Artery - Peroneal Artery |
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What is intermittent claudication?
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a classic sign of PAD, it is ischemic muscle ache or pain that is precipitated by a constant level of exercise; reproducable event
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With rest, how soon does intermittent claudication resolve itself?
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within 10 minutes
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Clinical manifestations of PAD will usually present at ___-___% occlusion.
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60-75%
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Diseases involving the femoral or popliteal arteries will usually display intermittent claudication where?
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calf
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Paresthesia in PAD results from what?
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nerve or tissue ischemia
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Neuropathy produces what type of sensation in the extremity?
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shooting or burning pain
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Gradually diminishing perfusion to neurons produces a loss of what?
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sensation of pressure and deep pain sensations
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What is the largest problem with neuropathies and paresthesias in the extremities?
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injuries go unnoticed by the patient
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The skin in PAD may appear how?
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thin, shiny, taunt, loss of hair
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What pulses may be diminished or absent in PAD?
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pedal, popliteal or femoral
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What is elevation pallor?
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a paleness or blanching of the foot noted in response to leg elevation; seen in PAD
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What is reactive hyperemia?
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redness of the food observed when the food is dangling (aka dependent rubor); seen in PAD
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What is rest pain?
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Pain felt when there is insufficient blood flow to maintain basic metabolic functions; seen in advanced PAD
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Why is rest pain seen more often at night?
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b/c CO drops and the limbs are heart level
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PAD of the lower extremities progresses slowly. Prolonged ischemia leads to what?
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atrophy of the skin and underlying muscles
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Severe PAD has what effect on wounds?
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- delayed wound healing
- wound infection - tissue necrosis - arterial ulcers (over bony prominances) |
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What is the most serious complications of PAD?
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Nonhealing arterial uclers and gangrene; may result in amputation
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What can be used if palpation of a peripheral pulse is difficult b/c of severe PAD?
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doppler
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What is the purpose of segmental blood pressures? (BP at thigh, below the knee, and ankle while supine)?
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to detect PAD
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A falloff of more than ____ mm Hg while obtaining segmental blood pressures indicates PAD.
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30
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How is ankle-brachial index calculated?
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dividing the ankle systolic BP by the highest brachial SBP
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What is a normal Ankle-brachial index?
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0.91-1.30
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What is duplex imaging?
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a bidirectional, color doppler to map blood flow
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What are angiography and MRA used for in the diagnosing of PAD?
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to delineate location and extent of disease; useful when intervention is indicated
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For patients with PAD, what are 3 areas of aggressive treatment or control?
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- smoking cessation
- agressive treatment of hyperlipidemia - control of hypertension and DM |
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BP should be maintained at (or under) what for PAD patients?
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130/80
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What is a Hemoglobin A1C test?
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a test that indicates how much sugar a person has had over a 2-4 month period
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For diabetic patients with PAD, the desired glycosylated hemoglobin is less than what?
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7.0%
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What are 3 common antiplatelet agents used in the treatment of PAD?
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- aspirin
- ticlopidine - clopidogrel |
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Why is ticlopidine not often prescribed for PAD?
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severe side effects, including thrombocytopenia, neutropenia, and thrombotic thrombocytopenic purpura
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Based on evidence, what are the 2 best choices for first-line oral antiplatelet therapy in PAD?
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aspirin or clopidogrel
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What type of drug is ramipril?
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ACE inhibitor
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What are the benefits of using ACE inhibitors in PAD?
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- decrease in cardiovascular morbidity
- decrease in mortality - increase in peripheral blood flow - increase in ankle-brachial index - increase in walking distance |
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In the US, what 2 drugs are approved for the treatment of intermittent claudication?
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- Trental
- Pletal |
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How does Trental work?
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increases erythrocyte flexiblity
decreases blood viscosity |
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How does Pletal work?
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- increases vasodilation
- increases walking distance |
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What is the most effective exercise for individuals with claudication?
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walking, 30-60 minutes daily
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What is the ideal BMI and waist circumference for PAD patients?
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- <25 BMI
- <40" waist men <35" waist women |
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Dietary cholesterol should be less than ____mg/day.
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200
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What can be used in place of animal protein?
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soy products
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What is the purpose of Ginkgo biloba in PAD treatment?
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effective in increasing walking distance in patients with intermittent claudication
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What is the purpose of Folate, Vitamin B6, and cobalamin (B12) in PAD treatment?
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lowers homocysteine levels
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(def)
a chronic condition characterized by ischemic rest pain, arterial leg ulcers, and/or gangrene r/t advanced PAD |
Critical Limb Ischemia
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What are the conservative management goals in the care of a leg with critical limb ischemia?
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1. protect from trauma
2. reduce vasospasm 3. prevent/control infection 4. maximize arterial perfusion |
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Are arterial ulcers cared for with wet or dry dressings?
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Dry- never soak the foot; it should be kept clean and dry, preferably covered with a clean, sterile dressing
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What is the rate of amputation in critical limb ischemia?
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10-40%
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Should you lubricate the limbs affected by critical limb ischemia?
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yes, properly cleaning and lubrication helps to prevent cracking and infection
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What are 3 indications for interventional radiologic procedures with PAD?
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1. when intermittent claudication symptoms become incapacitating
2. rest pain 3. ulceration or gangrene severe enough to threaten the viability of the limb |
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What is percutaneous transluminal balloon angioplasty?
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insertion of a balloon tip catheter into the femoral artery followed by inflation of the balloon into the narrowed area of the artery; the balloon dilates the vessel by cracking the atherosclerotic intimal shell while stretching the media
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With percutaneous transluminal balloon angioplasty, what percent of patients will experience rebound stenosis?
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50%
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What is the purpose of placing intravascular stents during percutaneous transluminal balloon angioplasty?
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to prevent problems with restenosis and arterial dissection
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What is the most common surgical approach to treating PAD?
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A peripheral arterial bypass operation
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What are the 2 materials used for a peripheral arterial bypass operation?
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- autogenous vein
- synthetic graft material |
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What material is typically used for long peripheral arterial bypass operations?
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synthetic graft material
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What other procedures are commonly used in conjunction with peripheral arterial bypass operations?
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balloon angioplasty with stenting
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(def)
peripheral artery surgery that involves opening the artery and removing the obstructing plaque |
endarterectomy
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(def)
peripheral artery surgery that involves opening the artery, removing plaque, and sewing a patch to the opening to widen the lumen |
patch graft angioplasty
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What is arterial revascularization?
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surgically bypassing an occlusion with a saphenous vein or synthetic material
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After arterial revascularization surgery, the patient's operative extremity should be checked how often?
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Every 15 minutes for the 1st hour, and hourly thereafter
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After arterial revascularization surgery, what type of assessments are made on the operative extremity?
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- skin color
- temperature - capillary refill - peripheral pulses - sensation and movement |
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After arterial revascularization surgery, the loss of palpable pulses and/or a change in the doppler findings prompts what?
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immediate notification to the physician
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What change in ABI should be seen after arterial revascularization surgery?
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increase from preoperative baseline
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What activity should be allowed/encouraged after arterial revascularization?
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- ROM
- short periods out of bed - ambulation (even short distances) - frequent turning - elevate extremity |
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After arterial revascularization surgery, nursing care should focus on what 2 things?
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- continued circulatory assessment
- monitoring for potential complications |
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What activities should be avoided after arterial revascularization surgery?
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- knee-flexed positions (except for exercise)
- sitting for long periods of time - ROM of limb |
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All patients with PAD should be taught the importance of inspecting what? What methods should you teach the client that they can perform at home?
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legs and feet daily- teach capillary refill, palpate pulses; teach to inspect skin for color, temp, and hair growth
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(def)
a sudden interruption in arterial blood supply to tissue, and organ, or an extremity that, if left untreated can result in tissue death |
Acute arterial ischemia
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What are 3 causes of acute arterial ischemia? Which is the most common cause?
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- thromosis
- embolism (most common) - trauma |
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Embolization of a thrombus that developed where is the most common cause of acute lower extremity arterial occlusion?
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the heart
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What are the 6 "P"s of acute arterial ischemia?
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- pain
- pallor - pulselessness - paresthesia - paralysis - poikilothermia (adaptation of ischemic limb to environmental temp) |
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Is paralysis an early or late sign of acute arterial ischemia?
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very late sign- signals death of nerves supplying the extremity
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What is the 1st intervention implemented in acute arterial ischemia?
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IV unfractioned heparin
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What will likely have to be done to restore blood flow in a case of acute arterial ischemia?
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embolectomy
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What postoperative complications may be seen after an embolectomy?
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- spasms/swelling
- compartment syndrome |
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Arterial insufficiency ulcers most often develop where? why in these locations?
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- toe tips, web spaces, phalangeal heads around lateral malleolus
- these are areas exposed to pressure or repetitive trauma |
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What are 4 measures to improve tissue perfusion (thus avoid arterial insufficiency)?
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- reavascularization if possible
- lifestyle changes - avoidance of trauma - aspirin in doses of 75-325 mg |
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How often should a patient with arterial insufficiency walk?
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at least 3 times a week to near maximal pain
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Arterial ulcers should be kept wet or dry?
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dry
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Open wounds in arterial insufficiency (not ulcers) should be kept wet or dry? what type of dressing?
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wet, non-occlusive dressings (solid hydrogel)
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What is Raynaud's disease?
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exaggerate vasospasms of the arterioles and arteries in the upper and lower extremities, particularly the fingers and toes
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In raynaud's disease, what symptoms does the patient experience during the vasospastic episode? What do they experience after?
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- during spasm, numbness, coldness, pain, and pallor
- after the area becomes hyperemic |
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Although the cause of Raynaud's disease is unknown, it is associated with exposure to what?
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cold or stress
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While treatment of Raynaud's is geared towards prevention, medication is sometimes used. What is the current first-line therapeutic agent used?
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Calcium Channel Blockers
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Nifedipine and diltiazem are examples of what drug class?
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Calcium Channel Blockers
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What is the most commonly used calcium channel blocker for patients with Raynaud's phenomenon?
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Nifedipine
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What group does Raynaud's diseae primarily effect?
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Women 16-40
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What are some recommendations for the prevention of an outbreak in Raynaud's disease?
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- avoid stimuli that trigger episodes
- keep extremity warm - use hair dryer, warm water when vasospasms begin - protect area from trauma |
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What is Buerger's disease?
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an inflammatory disease of the small and medium sized arteries that result in occlusive disorders
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There is a strong relationship between Buerger's disease and what?
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cigarette smoking
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Buerger's disease may result in what damage to the perivascular system?
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fibrosis and scarring
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What is the first clinical indicator of Buerger's disease?
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pain in the arch of the foot
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What are signs/symptoms of Buerger's disease?
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- ischemic pain in distal upper and lower limbs
- increased sensation to cold - diminished pulses - cool extremities, red or cyanotic |
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Buerger's disease is rare, however most cases occur in what group?
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young adult men who smoke
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Treatment of Buerger's disease is similar to what other diseases?
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Raynauds
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(def)
dilated, tortuous leg veins with back flow of blood caused by incompetent valve closure, which results in venous congestion and vein enlargement |
varicose veins
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What vein is usually affected by varicose veins?
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saphenous vein and it's branches
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Although the exact cause of varicose veins is unknown, it may be r/t what?
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congenital weakness of valve
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What is the most frequent complication of varicose veins?
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superficial thrombophlebitis
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What are signs/symptoms of varicose veins?
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- aching, cramping, and pain
- feeling of heaviness - palpable nodules - ankle edema - dilated veins - pigmentation of calves and ankles |
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Superficial varicose veins can be diagnosed by what?
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appearance
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What is the most widely used test to diagnose deep varicose veins?
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duplex ultrasound (
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What body position is often used to diagnose varicose veins?
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trendelenburg's test (demonstrates the backward flow of blood in the venous system)
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What are some management therapies for varicose veins? (4)
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-avoid standing/sitting for long periods of time
-weight reduction -support hose (put on before getting out of bed) -no restrictive clothing |
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Surgical intervention for varicose veins is often indicated for what?
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recurrent thrombophlebitis
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What postop care is needed following surgical intervention for varicose veins?
(vein stripping, ligation, or sclerosis surgery) (4) |
- pain management
- elevate the leg 15 degrees - watch for bleeding - unwrap leg to observe (some bruising/discoloration normal) and rewrap every shift |
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What is the most common disorder of the veins?
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venous thrombosis
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What is venous thrombois?
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the formation of a clot associated with inflammation of the vein
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What are the 2 types of venous thrombosis?
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superficial thrombophlebitis
deep vein thrombosis |
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DVTs occur most in what 2 veins?
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iliac and femoral
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DVTs occur in at least __% of surgical clients.
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5%
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What are the 3 components of Virchow's triad?
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- venous stasis
- damage to the endothelium - hypercoagulability of the blood |
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Venous stasis occurs more frequently in what type of people? (6)
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- obese
- CHF - atrial fibrillation - traveler's (who sit for long periods of time w/o exercise) - prolonged surgical procedures - immobility |
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Damage to the endothelium of a vein may be cause when?
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- internal/external damage (ex. venipuncture)
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Increased endothelial damage occurs at IV sites when the patient is receiving what type of substance?
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a caustic one (ex. antibiotics, chemotherapy)
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What is polycythemia? What component of virchow's triad does it apply to?
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- disease state in which the proportion of blood volume that is occupied by red blood cells increases
- relates to hypercoagulability |
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What are 7 risk factors for DVTs?
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- bedrest
- surgery - leg trauma with cast - venous insufficiency - obesity - oral contraceptives - malignancy |
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While DVTs may or may not present symptoms, what are some that may possible appear? (5)
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- edema (unilateral)
- warmth, redness - pain, tenderness - positive homan's sign - possible elevation in temperature |
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What are non-surgical treatment measures for DVT?
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- anticoagulant therapy
- bedrest - elevate extremity - warm soaks - TED hose |
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What nursing interventions should be applied when caring for a patient with DVT? (7)
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- pain control
- monitor labs re: coagulation - monitor for bleeding risks - protection of skin - assess mental status/anxiety *mental status change could be re: to cerebral bleeding* - assess tissue perfusion - monitor respiratory status for signs of embolus |
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What special considerations should be made when administering UH, warfarin, or direct thrombin inhibitors when treating DVT?
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- check results of clotting studies before administering; these drugs are titrated according to the results
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What are signs/symptoms of DVT? (4)
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Acute SOB
Feeling of Doom Sudden chest pain Unexplained cough |
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Compression stocking for treatment of DVT should exert how much pressure at the ankle?
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30-40 mmHg
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What nursing interventions should be implemented for the Prevention of DVT?
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- early mobilization (easiest and most cost effective)
- change positions and do ROM- dorsiflex, rotate ankles - ambulate at least 3xs a day - TED hose (exert 18 mmHg) - ICDs for moderate-high risk patients - Lovanox (30-40mg prophylactic) |
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Describe proper positioning of TED hose?
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- toe hole under toes
- proper fit, no wrinkles - thigh gusset on inner thigh |
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What are 5 treatment measures for DVT?
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- anticoagulant therapy
- bedrest (initially) - elevation of extremity - warm compresses - Compression stockings |
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what is the anticoagulant of choice for long term anticoagulation?
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warfarin
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What is the antidote for warfarin?
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Vitamin K
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How long does warfarin take to affect PT? How long before maximum effect is achieved?
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2-3 days to affect prothrombin time
several days for maximum effect |
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Since warfarin takes several days to reach maximum effect, what is done in the meantime?
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UH or LMWH is required for 3-5 days
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When the patient is on warfarin, the level of anticoagulation is monitored with what test?
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INR (international normalized ratio): reports PT (prothrombin time)
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The normal INR is 0.75 to 1.25. What is the therapeutic range we try to achieve when administering warfarin?
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2-3
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What information should be obtained from the patient re: history prior to beginning warfarin?
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- pregnancy status
- drugs that interact with warfarin (NSAIDs, barbiturates, herbal supplements, and antiplatelet agents) |
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When given IV, heparin requires frequent monitoring of what?
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aPTT (activated partial thromboplastin time)
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Normal aPTT is 24-36 seconds. When giving heparin, the therapeutic range is what?
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46-70 seconds
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What is the antidote for heparin?
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protamine sulfate
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What are the benefits of LMWH vs. UH?
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- greater bioavailability
- more predictable dose response - longer half-life - less costly - does not require anticoagulant monitoring/dose-adjustment |
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What is the antidote for LMWH?
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LMWHs are only partially reversible with protamine sulfate
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What is the goal of using anticoagulants when a DVT has already formed?
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to prevent propagation of the clot and the development of new clots
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What is a venous thrombectomy?
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the removal of a DVT through an incision in the vein; poor results
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What is a Vena Cava interruption device (ex. Greenfield filter)?
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a filter device inserted through the right femoral or right jugular veins that filters clots without blood flow interruption
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(def)
a common medical problem in the elderly, a condition in which the valves in the veins are damaged resulting in retrograde venous blood flow, pooling of blood in the legs, and swelling |
Chronic venous insufficiency
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Chronic venous insufficiency can lead to what?
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venous ulcers
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Chronic venous insufficiency manifests how in patients?
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- brownish/brawny leathery leg appearance (due to iron deposition)
- edema - Eczema (statis dermatitis) - venous leg ulcers - cellulitus (oozing/weeping of tissues) |
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Are venous ulcers treated with moist or dry dressings?
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moist dressings
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What treatment method is essential to the management of CVI, venous ulcer healing, and prevention of ulcer recurrence?
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compression (at least 30mmHg at the ankle)
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Why must the nurse assess ABI before instituting compression therapy in CVI cases?
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b/c an ABI of <0.9 suggest PAD; high levels of compression are contraindicated in PAD cases
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For chronic or non-responding venous ulcers, what is indicated?
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Bi-layered cell therapy (bioengineered skin)
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What lifelong therapy is required for patients with venous insufficiency?
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compression therapy
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How often should compression stockings be replaced?
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q 4-6 months
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