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139 Cards in this Set
- Front
- Back
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Thrombi are formed due to these 3 things. This is called __________ ______
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endothelial injury, > coagulability, venous stasis
called Virchow's triad |
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superfcial thromboemboli are usually caused by ________ and usually treated with ________ and ___________
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IV therapy
warm compresses elevation |
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what material forms a thrombus
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RBC, WBC, platelets and fibrin
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These things contribute to hypercoagulability
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Polycythemia,
Septicemia Oral contraceptive use Pregnancy Malignancies Severe anemia Smoking Protein deficiencies/defects |
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venous stasis is most common in pts with Hx of these 3 disorders
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CHF, vericose veins, ulcerative colitis
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Things RN can do to promote health and prevent thromboemboli
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prevent dehydration
ambulation excersize legs don't use oral contraceptives compression stockings/devices |
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Clinical symptoms of thromboembolus
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Classic s/s calf or groin tenderness and pain
Sudden onset unilateral swelling of the leg Palpable, firm, subcutaneous cord like vein Surrounding area tender to touch, red and warm Mild systemic temp. Slight elevation of WBCs Pain in the calf with dorsiflexion of foot (positive Homan’s sign |
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diagnostic tests to Dx thromboembolism
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contrast venography (gold standard, but invasive)
duplex ultrasonography (most common) doppler flow studies MRI d-dimer test |
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complications of thrombophlebitis
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PE
chronic venous insufficiency (valvular destruction) phlegmasia cerulea dolens (sudden, massively swollen, blue leg) |
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non surgical interventions for thromboemboli
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bedrest, elevate extremity, warm moist soaks, do NOT massage, monitor for s/s of chest pain and SOB (PE)
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pharmacological interventions for thromboemboli
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anticoagulants
thrombolytics |
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anticdote to anticoagulant therapy
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protamine sulfate
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T or F: anticoags prevent clots, but cannot break down existing clots
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True
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Low molecular weight heparins
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enoxaparin (Lovenox)
dalteparin (Fragmin) tinzaparin (Innohep) fondaparinux (Arixtra) |
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antidote to warfarin
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Vit K
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coagulation occurs by _______ converting to ________ which acts on _________ to produce _________
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prothrombin
thrombin fibrinogin fibrin |
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heparin in produced naturally in the body - areas where it is produced the most?
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lungs and liver
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parenteral anticoags work by preventing
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fibrinogen turning to fibrin
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heparin dosage is based off of this lab finding
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activated partial thromboplastin time
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nursing considerations during heparin therapy
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monitor aPTT, H&H, platelets
monitor for bleeding Assess for hematuria, ecchymoses, petechiae, blood in stool Always administer on an IV controller pump. Use separate line for other medications IM injections should be avoided Usually given for 7 days |
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Advantages of low molecular weight heparins
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Has enhanced bioavailability
Longer half-life Interacts less with platelets Yields a predictable dose response No need to monitor APTT, because no dose adjustment Can be given twice daily SC Allows for outpatient therapy Safer and equally effective as heparin Research shows low-molecular weight heparin more effective in treatment of DVT |
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usual dose for lovenox
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1mg/kg
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clients PT should equal:
client's INR should equal |
1.4-1.6 times control
2-3 |
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Facts about warfarin Tx
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stops synthesis of vit K
Drug is bound to albumin Anticoagulant effect does not start for 24 hours Maximum effect (steady state) not reached for 3-4 days Takes 3-4 days for full effect after each drug dose change |
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considerations during warfarin Tx
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Monitor for S/S bleeding
Monitor for drug-drug and drug-food interactions Monitor PT, INR, H & H, platelets. Usually given for 3-6 months INR should be between 1.5 and 2.0 to prevent recurrent DVT and minimize risk of stroke or hemorrhage If bleeding occurs: d/c drug treat with Vitamin K (aquamephyton, phytonadione) - effective within 6 hours |
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foods containing vit K
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brussels sprouts, cabbage, spinach, leafy salad greens, plums, rhubarb, soybean or canola oil, brocc, asparagus
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Teaching associated with anticoags
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Take the meds the same time each day (preferably late afternoon or early evening.
Follow-up blood work Avoid trauma, contact sports Diet – maintain a consistent intake of foods rich in Vitamin K No A.S.A. & NSAIDS Limit alcohol Wear medic alert band Inform all health professionals about med (dentist) Don’t take supplemental K Maintain a consistent intake of foods containing Vitamin K Making big changes in the amount of Vitamin K-containing foods consumed can be problematic Avoid cranberries and cranberry juice |
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Contraindications to anticoag therapy
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Lack of client cooperation
Bleeding (GI, GU, Resp., Reproductive) Hemorrhagic blood dyscrasias Aneuryms Alcoholism Recent or impending surgery Severe hepatic or renal disease Recent CVA Open ulcerative wounds |
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Purpose of thromboembolytic therapy is to
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Break down formed blood clots
Prevent valve damage & venous insufficiency |
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thromboembolytics activate the conversion of _________ to ________, which digests _________
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plasminogen
plasmin fibrin (thrombi) |
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duration of thromboembolytic therapy
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4-12 hours
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side effects of thromboembolytic therapy
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internal/ intracranial and superficial bleeding, n/v, hypotension, dysrhythmias
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facts about streptokinase
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binds with plasminogen to form plasmin
1st thrombolytic agent Given IV Produced from beta-hemolytic steptococci From non-human source- can provoke allergic reaction Antibodies develop 5 days after SK tx- persist 6-12 mos. For DVT, arterial thrombosis & embolism,PE, AV cannula occlusion |
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facts about activase (alteplase)
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A naturally occurring tissue plasminogen activator (t-PA)
Secreted by vascular endothelial cells It is fibrin-specific and doesn’t induce and antigen-antibody reaction Can be re-administered immediately in case of re-infarction |
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complications of thromboembolytic therapy
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After administration, severe bleeding may occur (external and internal)
Fever occurs in 30% of those receiving the drug Reperfusion arrhythmias Urticaria |
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nursing considerations for thromboembolytic drug therapy
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Assess for recent strep infections (streptokinaise may not be effective)
Assess baseline H & H, platelet count, PT, APTT. Assess vitals Q 15 min X 1hour Q 15-30 min X 8 hours Then Q 4 hours |
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surgical mgmt options for DVT
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IVCF
ligation or external clips |
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post-op care for DVT client
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early ambulation
leg exercises elastic stockings hydration low dose heparin, Coumadin, Lovenox Vendodyne Boots Community-Based Care Implementation: Home Care Teaching compression stockings leg positioning no tight bands around legs/hips smoking cessation avoid oral contraceptives exercise/rest schedule anticoagulant teaching emotional suppory |
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characteristics of primary varisocities
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superficial veins are dilated
congenital weakness of the veins bilateral valves may or may not be incompetent |
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characteristics of secondary varicosities
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previous thrombophlebitis of deep femoral veins resulting in valve incompetence
esophageal varices hemorrhoids abnormal arteriovenous connections AV fistulas and malformations |
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in varicosities, as the veins enlarge
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valves become stretched and incompetent
blood flow becomes reversed calf muscle pump fails further distention results increased pressure transmits to capillary bed with resultant edema |
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s/s of varisoties
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mild ache to severe pain after prolonged standing
relief with walking or limb elevation nocturnal leg cramps disfigurement |
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complications of varicosites
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Superficial thrombophlebitis
rupture of the varicosity ulceration from infections chronic venous stasis ulcers |
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Tx for varicosities
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Sclerotherapy
ligation of vein prevention is key! |
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post operative nursing considerations for varicose vein surgery
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deep breathing
CMS temp, edema , pulse of extremity elevate 15 degrees compression stockings removed Q8 hours |
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Describe venous insufficiency
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prolonged venous HTN causes veins to stretch and damages valves
This results in a backup of blood Edema occurs due to the breakdown of RBC These waste products accumulate and cause venous stasis, ulcers, swelling, cellulitis |
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venous stasis is common in people who
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stand or sit for too long
are prego |
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How does venous stasis ulcer occur
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valves becomg incompetent, cause stasis of blood, and RBC break down into hemosiderin and melanin.
These cause brown discoloration on skin, and ulcers - usually over ankles |
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clinical manifestations of venous stasis ulcer
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edema, leathery/brown lowe extremity, concave ulcer, pain
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nursing care for venous stasis ulcer
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elevation, compression stockings, elastic bandages, Velcro wrap, Unna boot,
Hydocolloid dressings, Debridement and skin grafting |
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self care for venous stasis ulcer
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skin care, rest, diet high in protein and vitamins
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s/s of PE
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CP, dyspnea, crackles, cough, tachypnea, tachycardia, hemopytisis, fever, loud pulmonic chest sounds, sudden mental status change
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s/s (in addition to regular) of massive PE
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crushing chest pain, shock, pallor, collapse, severe dyspnea, acute cor pulmonale
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s/s (in addition to regular) of medium sized PE
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pleuritic CP, slight fever, blood tinged cough, pleural rub
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Complications of PE
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pulmonary infarction, pulmonary HTN
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pulmonary infarction
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death of lung tissue occurs with
occlusion of large or medium sized vessel insufficient collateral bronchial circulation preexisting lung disease infarcted tissue may become infected and form abscess pleural effusion also develops |
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pulmonary HTN
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with obstruction of 50% of lung bed and hypoxemia
occurs with massive PE or recurrent smaller PEs Eventually results in dilation and hypertrophy of the right ventricle |
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diagnostics for PE
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Lung Scan consisting of two components
a. Perfusion scanning - IV radioisotope assesses pulmonary circulation b. Ventilation scanning - inhalation of radioactive gas (xenon) assess ventilation of gas through the lung - not for intubated or confused patients Venous studies to detect DVT ABGs a.normal pH b.PaO2 and PaCO2 low Pulmonary angiography Spiral CT CXR is not diagnostic Continuous ECG CBC with diff |
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nursing care for PE
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Prevention in presence of thromboembolic disease
2. Prevent further development of thrombi in lower extremities 3. Prevent embolization to the pulmonary system 4. Provide cardiopulmonary support if needed 5. Administer O2 (nasal, mask, ventilator support/intubation) 6. Turning, coughing, deep breathing 7. Bed rest in semi-Fowler’s position 8. Emotional support |
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drugs for PE pts
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IV heparin, coumadin
Vasopressors in the presence of shock Digoxin and diuretics in presence of heart failure Morphine for pain Thrombolytics for some patients |
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describe a inflow obstruction
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involves distal end of aorta and common, internal and external iliac arteries
may not cause significant damage |
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describe outflow obstruction
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involves infra-inguinal artery (below superficial femoral artery)
causes significant damage to lower extremities |
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most common cause of acute arterial occlusive disease?
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embolization of a thrombus from the heart OR an atherosclerotic aneurysm
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which heart conditions put pt at risk for developing thrombi?
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MI, mitral valve disease, chronic a-fib, cardiomyopathy and prosthetic heart valves
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thrombi in R side of heart travel to ______, whereas from L side of heart travel _______
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lungs
anywhere in systemic circulation |
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the 6 P's of acute arterial ischemia
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Pain
Parethesias Poikithermia (limb gets cold and takes on temp of environment) Paralysis Pallor Pulselessness |
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if acute arterial ischemia isn't treated, result is:
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necrosis
gangrene death of nerves (paralysis) |
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Tx for arterial occlusive disease
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Anticoags
Thrombolytics Embolectomy or thrombectomy Direct arteriotomy |
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recommended Tx for carotid stenosis
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carotid endarterectomy (surgical removal of plaque)
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benefits of carotid endarterectomy
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stroke prevention
vision improves fluency of speech improved swallowing language comprehension limb function psychosocial improvement |
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potential complications of carotid endarterectomy
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Embolization during surgery
Increased cerebral pressure secondary to cerebral hemorrhage Cranial nerve damage -facial VII -vagus X -sp. accessory XI -hypoglossal XII |
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types of chronic arterial occlusive disease
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Lower Extremity Disease Buerger’s Disease
Raynaud’s Phenomenon |
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risk factors for chronic arterial occlusive disease
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HTN
hyperlipidemia diabetes mellitus cigarette smoking*** obesity family predisposition advancing age sedentary lifestyle Diet high in lipids Elevated Blood Glucose Stress (increase BP) |
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clients with PAD are at high risk of
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MI
CVA chronic angina *and are also 6x more likely to die within 10 years of Dx |
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Assessment findings for suspected arterial occlusive disease
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Intermittent claudication? (cramping/burning when walking due to lactic acid fermentation)
Rest pain? Dependent rubor? (leg turns dark red when hanging - < blood return) Altered pulses? Arterial ulcers? (FEET) Venous ulcer? (ANKLE/LEG) Diabetic ulcer? (HEEL/TOP OF METATARSAL) |
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describe arterial ulcers
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on feet, likely to be in between toes.
pain claudication ulcer bed is pale feet will be cool to touch < pulses on that foot rubor present |
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Tx for aterial ulcer
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surgery
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describe venous ulcers
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chronic, nonhealing
ankle or lower leg discolored/bruising around wound NO claudication NO rest pain |
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Tx for venous ulcer
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compression!
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describe diabetic ulcer
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peripheral neuropathy
NO claudication on heal or tops of metatarsal (pressure) pale skin around wound painless |
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Tx for diabetic ulcer
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manage BS
wet to dry dressing shoes that do not press on site |
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Key stages of chronic PAD (s/s)
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Stage 1: no claudication, possible bruit, possible aneurysm, < pedal pulses
Stage 2: intermittent pain which is relieved by rest Stage 3: Lactic acid increases, pain at rest - may wake at night, toe/heal/foot pain Stage 4: necrosis, gangrene, odor |
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formula for ABI (ankle-brachial index)
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ankle SBP / brachial SBP = ABI
.91 - 1.3 NORM .71-.9 mild disease .41-.7 moderate disease <.4 severe |
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diagnostisics for arterial occlusive disease
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arteriogram w/contrast
doppler segmental SBP exercise tolerance test plethysmography |
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general RN goals for client with arterial occlusive disease
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prevent trauma
slow atherosclerosis < vasospasm prevent infection improve circulation |
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Nonsurgical interventions for arterial occlusive disease
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exercise
positioning (elevation, non restrictive clothing) promote vasodilation (heat) smoking cessation glucose control Tx of high cholesterol |
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drug therapy for arterial occlusive disease
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cilostazole (Pletal) - vasodilates/prevents platelet aggreg.
pentoxifylline (Trental) - alter platelet function aspirin plavix ticlopidine (ticlid) for intermittent claudication |
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invasive procedures for arterial occlusive disease
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percutaneous transluminal angioplasty - opens diameter of vessel to improve blood flow
laser-assisted angioplasty - vaporizes plaque and opens up lumen atherectomy - "rotorouter" - shaves away plaque. limited damage to vessel |
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Priority RN care after laser-assisted angioplasty and percutaneous transluminal angioplasty
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BLEEDING at site
distal pulses |
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preop care for arterial revascularization surgery
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baseline VS
baseline pulses prophylactic antibiotics |
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postop care for arterial revascularization surgery
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assess extremity color, temp, pulses
pain VS bedrest cough and deep breath |
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potential complications of arterial revascularization surgery
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graft occlusion
compartment syndrome (>pressure, ischemia, tissue death) infection |
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RN Dx for PAD
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chronic pain
ineffective tissue perfusion risk for peripheral neurovascular dysfunction |
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client teaching r/t PAD
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keep feet clean and dry
avoid injury by wearing properly fitting shoes cut toenails straight across apply lotion to prevent cracking & drying avoid exposure to extreme temperatures avoid extended pressure on feet or legs see podiatrist/physician promptly for problems |
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describe Buergers disease and its s/s
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Characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and upper extremities
It results in thrombus formation and segmental occlusion of the vessels Pain is common symptom (especially foot cramps after exercise) Strongly associated with smoking intermittent claudication rest pain gangrene pallor, temperature changes, parasthesias thrombophlebitis cold sensitivity |
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Tx for Buergers disease
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vasodilation! - avoid the cold, avoid smoking
pain relief treat any ulcers anticoags amputation as needed |
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Describe Raynaud's phenomenon and its s/s
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intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes
occurs unilaterally usually in pts >30 unknown etiology |
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describe Raynaud's DISEASE and its s/s
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similar to phenomenon but occurs bilaterally
more common in women Pulses are present Vasoconstriction causes extremities get cold and numb throb, ache, tingle color changes (white, blue, red) |
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Tx for Raynauds disease
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smoking cessation
avoid caffeine reduce stress immerse hands in warm water Wear warm gloves in the winter, scarf over nose Meds: Calcium channel blockers Beta- Blockers (Procardia, Cardizem) They relax smooth muscle of arterioles by blocking entry of Ca+ into cells Reduces vasospasm |
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4 most significant risk factors for vascular diorders
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Cigarette smoking
Increases risk 2-3x Hyperlipidemia Diabetes Mellitus Hypertension |
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describe an aneurysm
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A permanent, localized dilation of an artery, which enlarges the artery to at least 2x its normal size
May rupture, leading to hemorrhage or death |
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characteristics of a true aortic aneurysm
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no bleeding until rupture
growth fusiform aneurysm - entire arterial segment dilates saccular - one sided dilation of vessel |
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causes and characeristics of pseudoaneurysm
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trauma to all 3 layers of arterial wall
blood leakage through vessel wall caused by: infection disruption of arterial suture line post-op damage post-cannulation for diagnostic testing or IABP |
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s/s of thoracic aortic aneurysm
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usually asymptomatic
constant CP when supine brassy cough hoarseness dysphagia distended neck veins dyspnea high likelihood of rupture |
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s/s of abdominal aortic aneurysm
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usually asymptomatic
pt may feel heartbear in abdomen back pain pulsatile mass in abdomen bruit heard over mass |
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complications of AAA
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posterior rupture (look for back/flank ecchymosis and back pain)
anterior rupture (look for s/s of shock, ab tenderness) these are both very serious and death is likely |
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interventions for AAA
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early detection and prevention
assess for systemic disease caused by atherosclerosis s/s of rupture gather baseline data for postop comparison |
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goals for client with aortic aneurysm
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put as little stress on the weakening wall
lower BP normal tissue perfusion intact motor/neuro status no post op complications |
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AAA diagnostic studies
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Chest xray
Abdominal xray ECG US Cat scan MRI angiography TEE |
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Tx for AAA
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aneurysmectomy
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preop care goals for aneurysmectomy
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hydration and electrolyte balance
correct any coag and blood count abnormalities systemic antibiotics as prophylactic IV heparin - only in the absence of a rupture |
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kidney damage is a risk if aortic aneurysm extends above _______ _______
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renal arteries
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most important post op assessment in surgical repair above renal arteries for AAA
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post op urine output
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post op care for aneurysmectomy
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intubation
hemodynamic monitoring catheter NGT Chest tube pain mgmt pulse assessment |
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Interventions for ensuring graft patency after AAA surgery
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adequate systemic BP (<risk of thrombus formation)
IV fluids/blood hemodynamic monitoring S/S of occlusion: change in pulses cold tempurature of extremities below graft pallor/cyanosis in extremities pain abdominal distention <UO hypotension |
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Interventions to ensure absence of ventricular arrythmias post AAA op
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monitor O2, electrolytes, temp
cardiac monitoring ABGs hyperthermia blankets post op |
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Post AAA Op complications
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graft occlusion
ventricular arrythmias Respiratory (vented) infection paralytic ileus Neuro changes impaired renal perfusion |
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Interventions for respiratory status post AAA Op
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weaning of vent support
lung sounds, ABGs, pulse ox |
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interventions for infection status post AAA op
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assess wound
monitor WBCs adequate nutrition assess temp antibiotic therapy as ordered |
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interventions for GI status post AAA op
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NGT to low, intermittent suction
assess NGT drainage bowel sounds mouth care |
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interventions for neuro status post AAA op
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LOC
pupils facial symmetry speech impairment UE and LE strength and symmetry strength |
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interventions for circulatory status post AAA op
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CMS
peripheral pulses |
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interventions for renal perfusion status post AAA op
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strict I/O
daily weight hemodynamic monitoring BUN and Cr |
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Teaching for home care post AAA op
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no heavy lifting 4-6 wks
fatigue, poor appetite, irregular bowel habits are expected monitor incision temp assess extremities for changes in color, temp report sexual dysfunction mgmt of HTN! |
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describe aortic dissection and its S/S
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small tear in intimal lining allowing blood to leak between layers, this separation only increases as systolic pulsation pushes more and more blood in
causes <blood supply to brain, abdomen, kidneys, spine and extremities |
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S/S of aortic dissection
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S/S include:
Sudden, severe pain in back, chest, abdomen, may be felt in the anterior chest, back,neck, throat , jaw, or teeth Mimics MI pain and dyspnea Neurological symptoms (if arch of aorta involved) altered LOC, dizziness weak or absent carotid and temporal pulses blood pressure elevated faintness paraparesis strokes can occur Aortic valve insufficiency and murmur with ascending aortic dissection Diaphoresis, nausea, vomiting and apprehension can occur Severe insufficiency can produce LV failure with pulmonary edema If subclavian artery is involved pulses will vary between arms Altered tissue perfusion |
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complications of aortic dissection
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cardiac tamponade - blood escapes from dissection into pericardial sac
rupture arterial occlusion/eschemia of renal ateries, abdominal arteries or spinal cord |
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s/s of cardiac tamponade
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narrowed pulse pressure
distended neck veins muffled heart sounds pulses paradoxus (SBP drops on inspiration) |
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what drug would be given to reduce SBP in the event of an aortic dissection
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IV sodium nitroprusside(nitropress) or fenoldopam (corlopam)
if ineffective, nicardipine hydrochloride (cardene) |
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goals for emergency care of aortic dissection
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pain mgmt
<SBP to 100-120 decrease aortic pulse |
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diagnostics for aortic dissection
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CXR
Ab Xray ECG echo TEE CT scan MRI aortography |
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long term med mgmt for aortic dissection
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Inderal (propanolol), labetalol (normodyne), nifedipine (Procardia)
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RN considerations for aortic dissection pt
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quiet environment
semi fowlers position antiHTN meds pain mgmt antianxiety meds continuous cardiac and BP monitoring peripheral pulses neuro checks |
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why is surgery delayed for aortic dissection
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to allow for edema to decrease
permit clotting in false lumen healing |
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surgery is required for aortic dissection when
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drugs dont work
dissection involves ascending aorta complications HF leaking arterial occlusion |
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what is aortoiliac disease
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Stenosis or occlusion of the aorto-iliac segment
May be asymptomatic May complain of low back or buttock pain with ambulation May have < or absent pulse |
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What is an aorto-iliac graft procedure?
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Distal graft is anastomosed to the iliac artery
This is surgery of choice for aortoiliac disease |
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preop assessments for aorto-iliac graft procedure
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Evaluate brachial, radial, ulnar, femoral, posterior tibial and dorsalis pedal pulses
Explain procedure Prepare for surgery Teach anticipated post-op plan |
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postop assessments for aorto-iliac graft procedure
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Monitor for s/s of thrombosis in arteries distal to surgical site
Assess color/ temp of extremity, capillary refill time, sensory and motor function, pulses by palpation and Doppler q1hx8h then q2hx24h Monitor for urine output ≥ 30ml/hr Monitor VS, I&O, pain when assessing extremities Assess abdomen for bowel sounds and paralytic ileus q8h |
