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3E Vascular Presentation

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Laura Campbell

on 6 May 2015

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Transcript of 3E Vascular Presentation

Patient Teaching
Surgery specific
Lifestyle modifications:
smoking cessation
Regular surgical exercises such as incentive spirometer, DB & C, splinting
No prolonged dangling
Recliner or walking
No pressure on new vascular area (axilla-femoral bypass, crossing legs)
Non-weight bearing for toe amputations
Diet
Co-morbities
Discharge Teaching
S&S of complications
How to prevent recurrence
Regular surgical problems i.e. infection
New meds
Activity Levels
Follow up
When to seek medical VS. emergency care
3 Components of Vascular Bypass
Deciphering Sx Names
(ex: Fermoral-popliteal bypass)
Femoral refers to the inflow
Popliteal refers to outflow


Type of Conduit
Artificial Graft - numerous small
incisions
Pre- Op Assessments for Vascular Surgeries
History - what brought them in/chief complaint
Baseline - vascular assessment (4 pulses on each side, CWMS, ulceration), VS, head to toe
Subjective Symptoms - day/nighttime pain, dangle/walk at night, claudication
Meds, co-morbidities, previou medical/surgical history
Risk factors - SMOKING
Post-Op Assessments for Vascular Surgeries
Vascular assessment form (CWMS, bilateral peripheral pulses)
Compare to pre-op symptoms and assessment
Look for common complications
Psychosocial
Pain
Ensure improvement
Assess incision site
Understanding Vascular Surgeries
By Laura Campbell, Emilee Daviduck, Jillian Dykstra, Steph Hillier, Chelsea McCutchan, & Montana Zaporzan
3E Vascular Presentation
Inflow
The vessel chosen to use as the blood supply
Where beginning of bypass is
Can always find adequate inflow
Conduit
Refers to the new channel created for the blood to flow through.
Can either be an artificial graft or in situ vessel from that limb or another
You need to be what the conduit is made of
Outflow
Where the end of the bypass will be connected
Where blood is being released
Needs to be a large vessel
Can be difficult to find
In situ vessel -
long incision from
vein harvesting

http://www.uahealth.com/library/sections/article/coronary-artery-bypass-graft-surgery-cabg
Vascular Conditions
Popliteal Artery Aneurysm
VIPS For Diabetics
Carotid Endarterectomy
Vascular Surgeries Case Studies
Acute Fasciotomy
Femoral Anterior Tibial Bypass
Aorta Bi Femoral Bypass
EVAR
Thank you to Shannon Desilets for providing us with a wealth of knowledge, we could not have done this without you!
Questions
Peripheral Vascular Disease
(venous disease)
Surgery if large and symptoms present (bypass, endovascular treatment)
If no symptoms present, prevention of complications and lifestyle change indicated
What is a carotid endarterectomy?
Operation where the inner lining of the carotid artery is removed due to damage or thickening
Specific Post-Op Assessments
What is it?
Weakened popliteal artery --> bulging wall
Risk Factors
Atherosclerosis
Smoking
HTN
High cholesterol
Obesity
Family hx
Assessment
Complications
Peripheral aneurysms can indicate aneurysms higher up (aortic)
Rarely rupture
Can embolize and stop blood flow to all 3 arteries in lower leg - ischemic lower leg
What:
Venous insufficiency, one's valves don't properly close or presence of varicose veins

Causes back flow & pooling in legs & feet

Fluid accumulates into subcutaneous tissue (edema)

Edema causes tissue to deteriorate into ulcers and is also a breeding ground for bacteria (risk for infection)
Risk Factors:
Inadequate nutrition
Genetics
Prolonged standing/sitting
Inactivity
Smoking
DVT
Obesity
Varicose veins
Gender (females more prone)
Age (over 50)
Pregnancy
Etc.
Treatment
S&S/Assessment:
Swelling
Feeling of heaviness in limbs
Pain and/or cramps in limbs
Discoloration of skin
Dermatitis
Weeping of skin
Venous ulcer
New varicose veins
Flaking and/or itching of skin
Complications:
Venous ulcers (sloughy looking, or shiny and red)
Infection of ulcers
Worsening/enlarging ulcers
Treatment:
Adequate nutrition
Smoking cessation
Regular exercise
Nonrestrictive clothing
Weight loss
Avoid prolonged sitting or standing
Elevate legs
Compression stockings
Antibiotics for infection
Other meds (anticoagulants for clots, etc.)
Skin care (creams for eczema/itching, proper hygiene)
Surgery (vein bypass)
Ward neuro/vital signs Q1H x 6, then Q4H if stable

Change dressing PRN, do not reinforce in order to monitor for bleed or hematoma

Headache and HTN are the most important S&S to look for

Ask patient to smile and stick out tongue -> hypoglossal nerve may be damaged from sx

Complications of A Carotid Endarterectomy
Endvascular Abdominal Aortic Aneursm Repair
Stroke (low risk)

Re-blockage of the carotid artery (restenosis)

Temporary nerve injury leading to hoarseness, difficulty with swallowing, or numbness in face or tongue
Discharge Teaching
Two small incisions
Less invasive than open surgery
Stent inserted from above to below aneurysm
Blood flows through stent, but not into aneurysm sac
Eat foods low in saturated fat, cholesterol, and calories

Exercise regularly, especially aerobic exercises such as walking

Maintain ideal body weight

Avoid smoking

Discuss cholesterol-lowering medications and antiplatelet therapy with your physician
V = Vascular sufficiency
I = Infection control
P = Pressure offloading
S = Sharp Debridement
What is it?
Post Op Assessments
Post-op Assessments
Teaching
Vascular Assessment - limb perfusion from iliac arteries
Vital signs
Incision assessment
Signs of infection
Signs of clot or stent migration
Signs of hemorrhage
Complications
Complications
Endoleak - blood entering aneurysm sac
Migration of stent
Damage to stent
Insufficient perfusion to legs (3 piece stent)
Fever for 2-10 days after stent inserton
allergy to contrast dye - impair kidney function
Infecion
Discharge teaching
Reduce atherosclerosis - quit smoking
Don't drive while on narcotics
No heavy lifting, prolonged sitting, or bending for 2 weeks
Do not bathe for 2 weeks (shower)
Keep incision clean and dry
Follow incision care orders (strip dressing, betadine)
Seek medical attention if pain, swelling, redness, drainage, fever occurs, decreased color temperature, sensation, movement to leg
CT scan in 6 weeks, then every 6 months for1-2 years
Surgery to bypass diseased large blood vessels in abd and groin.
To bypass the blocked blood vessel, blood is redirected through a graft
This graft is sewn above and below the blocked vessel, the graft looks like a upside-down Y
Who is eligible for a carotid endarterectomy?
Had a large stroke without recovery

Widespread cancer with a life expectancy of less than two years

High blood pressure that has not been adequately controlled by lifestyle changes or medications
Vitals q4hours with vascular assessments for first 48hours
Listen with Doppler, and feel for pulses and groin, and pedal to verify blood flow to extremity, should be present!
Assess for CWMS of legs
Assess drsg, OREEDA
Most important is the feeling femoral pulses BI laterally
Myocardial infarction
Hemorrhage
Wound infection
Edema
Thrombosis
Graft occlusion
Advise patient to lay-40 degree angle
Avoid periods longer then 5 mins at a 90 degree angle this will cause swelling in extremeties of the post op pt and increase heal time
Re-enforce leg exercises to be done in bed
Walking is good!
Discharge Teaching
See doctor if any signs of:
With these patients any little problem could be a very big issue for these pts, any surgeon will see you in the ER. Better to cry wolf then wait for appt.

Call 911 or go to ER if signs of:
-Chest pain
-Dizziness/and or fainting
-Loss of sensation/movement to legs
-fever/chills
-increased pain redness
-swelling
-firmness
- bleeding or pus drainage at incision sites
- coolness numbness in legs
-Food choices
-Exercise
-NO SMOKING
-Medications
What is it?
When there is an occlusion or severe disease between the femoral and popliteal arteries and there is no way to salvage the vessel, a femoral anterior tibial bypass is an effective way of restoring blood flow to the lower leg.
Specific Post-Op Assessments
Vascular assessment with VS q2H x 3, then q4H, pain assessment, and full head to toe
Graft will come across the proximal end of the tibia and a pulse will be palpable in this site.
Popliteal and posterior tibialis will not be palpable
Assess for CWMS
Assessment of surgical incisions for signs of infection etc...
Signs of bleeding
Signs of clotting
Complications

Bleeding from anastamosis between graft and femoral artery and between graft and anterior tibial artery (important to keep BP low in vascular patients).
Clot formation
Infection at anastamosis site and/or incision site
Infection of graft
Occlusion of graft
Inadequate blood flow through graft resulting in decreased perfusion of tissues.

Discharge Teaching
Patient teaching should be done around the following:
Following their medication regime as prescribed by their doctor
Pain management
Eating a diet high in fiber and low in fat, cholesterol and sodium
Cessation of smoking
and support for this, if needed
Sitting and dangling (not putting undue pressure on grafts and no crossing of legs!)
S&S of infection and when to seek help
Assistive devices needed (walkers, etc.)

What is it?
Post Op Assessment
Complications
Discharge Teaching
A surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area or tissue or muscle. This loss of circulation is due to an ACUTE occlusion. Fasiotomy is a limb-saving procedure when used to treat acute compartment syndrome.
The 6 P's
1. Pain
2. Pallor
3. Paralysis
4. Pulselessness
5. Paraethesia
6. Polar
Complications are common, especially if the diagnosis is missed or delayed
Irreversible nerve and muscle damage
With large amounts of muscle involvement rhabdomyolysis, renal failure, and shock can occur
Fasciotomies can also result in complications such as nerve injury, infection, wound healing issues, and the need for flap coverage.
Avoid standing or walking for long periods
Seek Medical Care if:
You have pain or difficulty moving the affected leg
Any S&S of infection
Seek Immediate Medical Care if:
Your leg starts to swell
Only done on internal carotid atery (ICA)
* If ICA <50% occluded, no surgery
* If ICA 100% occluded, no surgery
Unstable angina

Had a heart attack in the last six months

CHF

Signs of progressive brain disorders, such as Alzheimer's disease
Ask them to squeeze hands and check motor function of feet

Try to keep patient sitting up

S&S of hematoma at incision site (numbess is normal due to bruised nerves)

Notify surgeon
IMMEDIATELY
if respiratory distress or hematoma develops
References
Pictures
http://www.unmc.edu/surgery/Arterial_Bypass.htm
https://www.uofmhealth.org/health-library/zm2718
http://www.uahealth.com/library/sections/article/coronary-artery-bypass-graft-surgery-cabg
https://edc2.healthtap.com/ht-staging/user_answer/reference_image/6191/large/leg_cramps.jpeg?1349475253
http://assistednursingcare.net
www.prnhealthservices.com
http://www.brenetmedical.com/stockings.html
http://healthylogica.blogspot.ca/2012/07/how-to-prevent-onset-of-diabetic-foot.html
modestosurgery.com
mayfieldclinic.com
http://www.gpgcw.edu.pk/
www.scielo.br
www.lourdes.com
www.webmm.ahrg.gov
www.nejm.org
lifeinthefastlane.com
http://www.vasculardoc.com/popliteal-aneurym.aspx
www.food.newstipstricks.com
http://quizlet.com/15772142/venous-and-arterial-ulcers-flash-cards/
http://echrblog.blogspot.ca/2010/03/blood-transfusion-hiv-judgment.html
http://www.liveitwell.org.uk/ways-to-wellbeing/ways-to-better-health/stop-smoking/
http://www.cxvascular.com/vn-latest-news/vascular-news---latest-news/endurant-abdominal-aortic-aneurysm-stent-graft-shows-durable-performance-at-two-years-in-us-study-
http://www.unmc.edu/surgery/Aortobifemoral_Bypass.htm
www.acneeinstein.com
www.neurosurgeryinstruments.com
http://www.vasculardoc.com/popliteal-aneurym.aspx
www.acneeinstein.com
http://www.fultonmassagetherapy.com/?p=515
http://aorticstents.com/what-is-abdominal-aortic-aneurysm/
http://www.theveinclinic.com.sg/blog/i-have-swollen-veins-are-they-normal-what-are-different-types-of-varicose-veins-1745
http://upload.wikimedia.org/wikipedia/commons/8/88/Peripheral_Arterial_Disease.gif
http://4.bp.blogspot.com/-r-_FpBBe0dA/UN5xCFqNGQI/AAAAAAAAAJU/DwAH4si57xk/s1600/slide0006_image001.jpg




Text Material
Emedicine. http://emedicine.medscape.com/article/2058838-overview#aw2aab6b4

Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., Barry, M. A., Goldsworthy, S., & Goodridge, D. (2009). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (2nd ed.). Toronto: Mosby|Elsevier.

Shannon Desilets. (2013). PAD and Arterial Assessments. CSVN Newsletter.

Interior Health. (2005). KGH Vascular Flow Sheet.

Interior Health. (2004). KGH Neurological Record.

Vascular Web. https://www.vascularweb.org/Pages/default.aspx
Pulsating lump easily palpable behind knee
Pain, numbness and swelling can occur locally
Claudication
Pain at rest
radiating nerve pain
Severity of symptoms depend on size
Peripheral Artery Disease
PAD - condition of narrowing of arteries due to atherosclerosis or plaque formation
Blockage leads to ischemia of limbs
Causes rest pain, sleeping pain or critical ischemia
Main risk factor: SMOKING
Arterial disease affects all systems of the body - carotid, stroke, aorta, renal disease

Arterial Tree
The arterial tree will continue to branch off
Large arteries need to be used for bypass
You are eligible if you have severe narrowing of your carotid arteries, especially if you are experiencing TIAs and are in reasonably good health otherwise.
You may be eligible, but at a relatively increased risk, if you have:
Full transcript