(5)F: Nursing Care of Clients with Vascular Disorder and Problems on Peripheral Circulation (Faller)

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Health History
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Angiographyinjecting a radiopaque contrast agent directly into the arterial system to visualize the vesselsMagnetic Resonance Angiographyperformed with a standard magnetic resonance imaging (MRI) scanner and special software programmed to isolate the blood vesselsAir Plethysmographyused to quantify venous reflux and calf muscle pump ejectionAir Plethysmographyprovides information about venous filling time, functional venous volume, ejected volume, and residual volumeAir Plethysmographyuseful in evaluating patients with suspected valvular incompetence or chronic venous insufficiency but is not used for diagnosis of DVTContrast Phlebography (Venography)injecting a radiopaque contrast agent into the venous systemContrast Phlebography (Venography)if a thrombus exists, the x-ray image reveals an unfilled segment of vein in an otherwise completely filled veinContrast Phlebography (Venography)test is generally performed if the patient is to undergo thrombolytic therapyLymphangiographyprovides a way of detecting lymph node involvement resulting from metastatic carcinoma, lymphoma, or infection in sites that are otherwise inaccessible to the examiner except by surgeryLymphangiographylymphatic vessel in each foot (or hand) is injected with contrast agentLymphoscintigraphyreliable alternative to lymphangiographyLymphoscintigraphyradioactively labeled colloid is injected subcutaneously in the second interdigital spacePeripheral Occlusive DiseaseArterial insufficiency of the extremities occurs most often in men and is a common cause of disabilityPADobstructive lesions are predominantly confined to segments of the arterial system extending from the aorta below the renal arteries to the popliteal arteryDistal occlusive diseasefrequently seen in patients with diabetes mellitus and in elderly patients-Nicotine use -Diet -Hypertension -Diabetes mellitus -Obesity -Stress -Sedentary lifestyle -Elevated C-reactive protein -HyperhomocysteinemiaModifiable Risk Factors for Atherosclerosis and PAD: _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________-Age -Gender -Familial predisposition/geneticsNonmodifiable risk factors for Atherosclerosis and PAD: _____________________________ _____________________________ _____________________________Peripheral Occlusive DiseaseHallmark symptom is intermittent claudicationPADUnequal pulses between extremities or the absence of a normally palpable pulse is a sign of _____________Pentoxifylline and cilostazolapproved for the treatment of symptomatic claudicationAntiplatelet agents such as ASA or clopidogrelprevent the formation of thrombo-emboli, which can lead to myocardial infarction and strokeStatin therapyreduces the incidence of new intermittent claudication symptoms in patients with prior myocardial infarctions or anginal symptoms and improves pain-free walking time in patients with PADSurgical ManagementReserved for treatment of severe and disabling claudication or when the limb is at risk for amputation because of tissue necrosis-Maintaining Circulation -Monitoring and Managing Potential Complications -Promoting Home and Community-Based CareNursing Management for Peripheral Occlusive Disease: _____________________________________ _____________________________________ _____________________________________Maintaining CirculationPulses, Doppler assessment, color and temperature, capillary refill, and sensory and motor function of the affected extremity are checked and compared with those of the other extremity; these values are recorded initially every 15 minutes and then at progressively longer intervals if the patient's status remains stableMonitoring and Managing Potential ComplicationsContinuous monitoring of urine output, central venous pressure, mental status, and pulse rate and volume permits early recognition and treatment of fluid imbalancesPromoting Home and Community-Based CareDetermines whether the patient has a network of family and friends to assist with ADLsUpper Extremity Arterial Occlusive DiseaseArterial occlusions occur less frequently in the upper extremities (arms) than in the legs and cause less severe symptoms because the collateral circulation is significantly better in the armsUpper Extremity Arterial Occlusive DiseaseStenosis and occlusions in the upper extremity result from atherosclerosis or trauma"Subclavian steal" syndromecharacterized by reverse flow in the vertebral and basilar artery to provide blood flow to the armTranscranial Doppler evaluationevaluate the intracranial circulation and to detect any siphoning of blood flow from the posterior circulation to provide blood flow to the affected armstent-graft placementIf a short, focal lesion is identified in an upper extremity arterysurgical bypassIf the lesion involves the subclavian artery with documented siphoning of blood flow from the intracranial circulation and an interventional radiologic procedure is not possible, a _________________ may be performed-bilateral comparison of upper arm blood pressures -Disappearance of a pulse or Doppler flow -Motor and sensory function, warmth, color, and capillary refill are monitored with each arterial flow (pulse) assessmenNursing Management for Upper Extremity Arterial Occlusive Disease: __________________________________ __________________________________ __________________________________Thromboangiitis Obliterans (Buerger's disease)characterized by recurring inflammation of the intermediate and small arteries and veins of the lower and upper extremitiesThromboangiitis Obliterans (Buerger's disease)occurs most often in men between 20 and 35 years of age, and it has been reported in all races and in many areas of the worldDuplex ultrasonographyused to document patency of the proximal vessels and to visualize the extent of distal diseaseContrast angiographyused to identify the diseased portion of the anatomy-improve circulation to the extremities -prevent the progression of the disease -protect the extremities from trauma and infectionMedical Management of Thromboangiitis Obliterans: _____________________________________ _____________________________________ _____________________________________regional sympathetic block or ganglionectomymay be useful in some instances to produce vasodilation and increase blood flow-Gangrene -Severe rest pain -Severe sepsisIndications for amputation: _____________________________ _____________________________ _____________________________-Assists in developing and implementing a plan to stop using tobacco -Encourages patient to make the lifestyle changes -Ensures that the patient has the knowledge and ability to assess for any postoperative complicationsNursing Management for Thromboangiitis Obliterans (Buerger's disease): ____________________________________ ____________________________________ ____________________________________Aortoiliac DiseaseIf collateral circulation has developed, patients with a stenosis or occlusion of the aortoiliac segment may be asymptomatic, or they may complain of buttock or low back discomfort associated with walkingaortoiliac graftSurgical procedure of choice in Aortoiliac Diseasedistal anastomosisIf the iliac vessels are diseased, the __________________ is made to the femoral arteries (aorto-bifemoral graft)-overview of the procedure to be performed -preparation for surgery -anticipated postoperative plan of carePatient teaching for Aortoiliac Disease includes: __________________________________ __________________________________ __________________________________30ml/hrNormal urine outputAneurysmsLocalized sacs or dilations formed at a weak point in the wall of the arterysaccular and fusiformMost common forms of aneurysmsThoracic Aortic AneurysmApproximately 85% are caused by atherosclerosisThoracic Aortic AneurysmMost common site for a dissecting aneurysmThoracic Aortic AneurysmOccur most frequently in men between the ages of 40 and 70 yearsAneurysmPain is the most prominent symptom, which is constant and boring but may occur only when the person is supineThoracic Aortic AneurysmDiagnosis is principally made by chest x-ray, CTA, and transesophageal echocardiographyAtherosclerosisMost common cause of Abdominal Aortic AneurysmAbdominal Aortic AneurysmMore common among Caucasians-Genetic predisposition -Tobacco use -HypertensionRisk factors for Abdominal Aortic Aneurysm: _____________________________ _____________________________ _____________________________Abdominal Aortic AneurysmMost important diagnostic indication pulsatile mass in the middle and upper abdomenDuplex ultrasonography or CTAused to determine the size, length, and location of the aneurysmSurgical ManagementTreatment of choice for abdominal aortic aneurysms more than 5.5 cm (2 inches) wide or those that are enlargingendovascular graftinginvolves the transluminal placement and attachment of a sutureless aortic graft prosthesis across an aneurysm-Functional capacity of all organ systems should be assessed -Medical therapies designed to stabilize physiologic function should be promptly implemented -Postoperative careNursing Management for Aneurysm: __________________________________ __________________________________Dissecting AortaOccasionally, in an aorta diseased by arteriosclerosis, a tear develops in the intima or the media degenerates, resulting in a dissectionArterial dissections (separations)are commonly associated with poorly controlled hypertension, blunt chest trauma, and cocaine useArterial embolism and Arterial thrombosisAcute vascular occlusion may be caused by an embolus or acute thrombosis-Iatrogenic injury -TraumaAcute arterial occlusions may result from: _____________________________ _____________________________Iatrogenic injuryinsertion of invasive catheters during arteriography, PTA or stent placement, or an intra-aortic balloon pump, or it may occur as a result of IV drug abuseTraumafracture, crush injury, and penetrating wounds that disrupt the arterial intimaArterial emboliarise most commonly from thrombi that develop in the chambers of the heart as a result of AF, MI, IE, or CHF-Pain -Pallor -Pulselessness -Paresthesia -Poikilothermia (coldness) -ParalysisSix Ps associated with Acute Arterial Embolism: __________________________ __________________________ __________________________ __________________________ __________________________ __________________________Arterial embolususually diagnosed on the basis of the sudden nature of the onset of symptoms and an apparent source for the embolusNon-invasive duplex and Doppler ultrasonographycan determine the presence and extent of underlying atherosclerosis, and arteriography may be performedEmergency embolectomythe procedure of choice if the involved extremity is viableEndovascular ManagementPercutaneous mechanical thrombectomy devices may also be used-active internal bleeding -cerebrovascular hemorrhage -recent major surgery -uncontrolled hypertension -pregnancyContraindications to Peripheral Thrombolytic Therapy: _____________________________ _____________________________ _____________________________ _____________________________ _____________________________Raynaud's phenomenonForm of intermittent arteriolar vasoconstriction that results in coldness, pain, and pallor of the fingertips or toes-Primary or idiopathic Raynaud's (Raynaud's disease) -Secondary Raynaud's (Raynaud's syndrome)Two forms of Raynaud's phenomenon: ___________________________________ ___________________________________Primary or idiopathic Raynaud's (Raynaud's disease)occurs in the absence of an underlying diseasSecondary Raynaud's (Raynaud's syndrome)occurs in association with an underlying disease-connective tissue disorder -trauma -obstructive arterial lesionsSecondary Raynaud's occurs with: _____________________________ _____________________________ _____________________________Secondary Raynaud'scharacterized by vasospasm and fixed blood vessel obstructions that may lead to ischemia, ulceration, and gangreneRaynaud's phenomenonAvoiding the particular stimuli that provoke vasoconstriction is a primary factor ofSympathectomyinterrupting the sympathetic nerves by removing the sympathetic ganglia or dividing their branches-Avoid stressful situations -Stress management -Exposure to cold must be minimized -Avoid all forms of nicotine -Caution in handling sharpsNursing Management of Raynaud's phenomenon: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________Chronic venous insufficiency/ Post thrombotic syndromeVenous insufficiency results from obstruction of the venous valves in the legs or a reflux of blood through the valvesDuplex ultrasonographyconfirms the obstruction and identifies the level of valvular incompetencePost-thrombotic syndromecharacterized by chronic venous stasis, resulting in edema, altered pigmentation, pain, and stasis dermatitis-Venous ulceration -Cellulitis/dermatitisComplications of Chronic venous insufficiency/ Post thrombotic syndrome: _________________________________ _________________________________Venous ulcerationthe most serious complication of chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremitiesCellulitis or dermatitismay complicate the care of chronic venous insufficiency and venous ulcerationsLeg UlcersExcavation of the skin surface that occurs when inflamed necrotic tissue sloughs offchronic venous insufficiencyAbout 75% of all leg ulcers result from20%Lesions due to arterial insufficiency account for approximately how many percent?5%Remaining are caused by burns, sickle cell anemia, and other factorsArterial Ulcers-intermittent claudication -onset is acute, ischemic pain -small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes -occur on the medial side of the hallux or lateral fifth toe and may be caused by a combination of ischemia and pressureArterial insufficiencydry gangrene of the toe (digital gangrene), which usually is caused by traumaVenous Ulcers-pain described as aching or heavy -foot and ankle may be edematous -ulcerations are in the area of the medial or lateral malleolus (gaiter area) and are typically large, superficial, and highly exudativeCompression Therapyapplication of external or counter pressure to the lower extremity to facilitate venous return to the heartDebridementremoval of nonviable tissue from woundsSurgical debridementFastest method of debridementNonselective debridementapplying isotonic saline dressings of fine-mesh gauzeEnzymatic debridementapplication of enzyme ointmentsCalcium alginate dressingsdebridement when absorption of exudate is neededFoam dressingsoption for exudative wounds, keeping the wound moistTopical Therapyused in conjunction with cleansing and debridement therapies to promote healing of leg ulcersTopical Therapygoals of treatment: remove devitalized tissue and to keep the ulcer clean and moist-Simplicity of application -Frequency of required dressing changes -Ability to absorb wound drainage -Expense -Patient comfortThe ff should be considered when applying dressing: __________________________________ __________________________________ __________________________________ __________________________________ __________________________________semi-occlusive or occlusive wound dressingsprevent evaporative water loss from the wound and retain warmthsemi-permeable film dressingsmay be selected because they keep the wound moist and are impervious to bacteria while allowing some gas exchangegrowth factor dressingsmay directly provide a growth factor or they may stimulate important growth substances within the woundStimulated Healingtissue-engineered human skin equivalent is a skin product cultured from human dermal fibroblasts and keratinocytes used in combination with therapeutic compressionHyperbaric Oxygenation (HBO)beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatmentNegative Pressure Wound Therapyvacuum-assisted closure (VAC) devices decrease time to healing in complex wounds that have not healed in a 3-week period-Restoring skin integrity -Improving physical mobility -Promoting adequate nutrition -Promoting home and community-based careNursing Management for Leg Ulcers: ___________________________________ ___________________________________ ___________________________________ ___________________________________Varicose VeinsAbnormally dilated, tortuous, superficial veins caused by incompetent venous valvesVaricose VeinsMost common in women and in people whose occupations require prolonged standing (salespeople, hair stylists, teachers, nurses and ancillary medical personnel, and construction workers)-decreased venous outflow -increased pressure by the gravid uterus -increased blood volumePregnancy may cause varicosities because of hormonal effects related to: __________________________________ __________________________________ __________________________________-Primary -SecondaryVaricose veins may be: _________________________ _________________________Primary Varicose Veinswithout involvement of deep veinsSecondary Varicose Veinsresulting from obstruction of deep veins-dull aches -muscle cramps -increased muscle fatigue in the lower legs -ankle edema -feeling of heaviness of the legsSymptoms of Varicose veins: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________Duplex ultrasound scandocuments the anatomic site of reflux and provides a quantitative measure of the severity of valvular refluxAir plethysmographymeasures the changes in venous blood volumeVenographynot routinely performed, but done to evaluate for valvular reflux-Avoid activities that cause venous stasis -Changing position frequently -Walking 1 or 2 miles each day -Graduated compression stockings -Weight reduction planPrevention of Varicose Veins: __________________________________ __________________________________ __________________________________ __________________________________Ligation and Stripping-requires that the deep veins be patent and functional -saphenous vein is ligated and divided, and sometimes removed (stripped)Thermal Ablationnonsurgical approach using thermal energyradiofrequency ablationuses an electrical contact inside the veinlaser ablationuses a laser fiber tip that seals the veinSclerotherapyinvolves injection of an irritating chemical into a vein to produce localized phlebitis and fibrosis, thereby obliterating the lumen of the veinSclerotherapymay be performed alone for small varicosities or may follow vein ablation, ligation, or stripping-Bed rest is discouraged -Instruction to walk every hour for 5 to 10 minutes -Graduated compression stockings -Nurse assists the patient to perform exercises and move the legNursing Management for Varicose Veins: __________________________________ __________________________________ __________________________________ __________________________________Analgesic agentsprescribed to help the patient move the affected extremities more comfortablyLymphangitisAcute inflammation of the lymphatic channelsLymphangitisArises most commonly from a focus of infection in an extremity, caused by hemolytic streptococcusLymphadenitisLymph nodes located along the course of the lymphatic channels become enlarged, red, and tender (acute)LymphadenitisLymph nodes become necrotic and form an abscess (suppurative_-Primary (congenital malformations) -Secondary (acquired obstructions)Lymphedema may be: __________________________________ __________________________________LymphedemaTissue swelling occurs in the extremities because of an increased quantity of lymph that results from obstruction of lymphatic vesselsLymphedema praecoxmost common type of congenital lymphedema caused by hypoplasia of the lymphatic system of the lower extremityElephantiasisLymphatic obstruction caused by a parasite (filaria) frequently seen in the tropicsManual lymphatic drainagetechnique designed to direct or shift the congested lymph through functioning lymphatics that have preserved drainage-compression bandages -exercises -skin care -pressure gradient sleeves -pneumatic pumps, depending on the severity and stage of the lymphedemaManual lymph drainage is incorporated in a sequential treatment approach used in combination with: _________________________________ _________________________________ _________________________________ _________________________________ _________________________________diuretic furosemide (Lasix)Initial therapy prevent fluid overload due to mobilization of ECFSurgeryperformed if the edema is severe and uncontrolled by medical therapy, if mobility is severely compromised, or if infection persists-Coronary artery disease with angina -Myocardial infarctionCommon consequences of hypertension: _________________________________ _________________________________HypertensionRenal damage may be suggested by elevations in BUN and creatinine levels or by microalbuminuria or macroalbuminuria