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Care of the Patient with Vascular Impairments

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Kelly Nordstrom

on 8 October 2014

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Transcript of Care of the Patient with Vascular Impairments

Care of the Patient with Vascular Impairments
NU236 Fall 2014
Professor Nordstrom

Nursing Care of the Patient After Arteriogram
Nursing Care of the Patient Undergoing AAA Repair
Nursing Care of the Patient Undergoing Bypass Surgery
Describe important objective and subjective data to be collected with inspecting patients’ extremities.
Compare and contrast common diagnostic tests for arterial and venous disorders.
Describe primary and secondary prevention strategies for the patients with peripheral vascular disease.
Formulate and prioritize nursing diagnoses for the patient with vascular impairments.
Discuss nursing research related to caring for patients with arterial impairments.
Describe the post-operative nursing care and priorities for patients after an arteriogram, AAA repair, bypass surgery, and amputation.

Our objectives:

Surgical Interventions

Nursing Care of the Patient Undergoing Amputation
Indications
Sites
Traumatic Amputation
Complications
Hemorrhage
Infection
Phantom Limb Pain
Risks associated with immobility
Neuroma
Flexion Contractures


Angioplasty
A balloon is inserted through the catheter
Stents may be placed to support vessel wall
After the procedure contrast dye is again introduced through the catheter to check for increased patency

Nursing Care after percutaneous vascular intervention:
Often an outpatient procedure
PRIORITY: maintaining adequate circulation
moving the extremity, ambulation if possible
Administer anticoagulants
ASSESS:
frequent neurovascular checks
VS, I&O, physical assessment (heart, lungs, GI)
REPORT IMMEDIATELY:
cool, dusky color
weakened pulses
delayed capillary refill
decreased sensory/motor function
If unable to revascularize by angioplasty:
Endarderectomy
Thrombectomy or embolectomy
Nursing Care after bypass
Assess pulses and neurovascular checks of the lower extremities Q 15 minutes --> Q 30 minutes --> QH --> Q 4H
Assess pulses using the Doppler and compare the results to the baseline preoperative assessment and to the other extremity.
Report any absent pulse immediately to the surgeon.
Assess for pain with vital signs and provide pain medications as ordered.
The ankle-brachial index (ABI) should be assessed every 8 hours for the first 24 hours and then once daily until discharge.
Fluid volume status
Assess incision sites.
Assess for postoperative edema
Observe the patient using the incentive spirometer or PEP device
Administer oxygen as ordered
Ambulation as ordered to assess gait and stability.

Abdominal Aortic Aneurysms

A sac (outpouching) of an artery formed by weakness or stretching of arterial wall
Occur most commonly on aorta

Three types:
Fusiform - Entire circumference
Saccular - Outpouching on one side
Dissecting - When blood separates the layers of the artery wall


Anuersym

Characteristics of Arterial Aneurysms

Risk factors
Atherosclerosis, HTN, smoking, syphylis, familial risk, trauma, > men
Signs/symptoms
Most often asymptomatic
Constant abdominal or low back pain
SOB or difficulty swallowing
Diminished femoral pulses
On exam pulsating abdominal mass with bruits
Complication: rupture


Abdominal Aortic Aneurysm (AAA)

Non-surgical
Tight control of HTN
Monitor size with frequent CT scans or US
Nursing Interventions:
Modifiable risk factors: smoking, BP
Teach early s/s of rupture
Importance of compliance with meds and follow-up visits
Emotional support


AAA Non-Urgent Management

Signs/Symptoms
Symptoms vary from “small leak” to “complete rupture”, also depends on size of aneurysm
Severe abdominal or back pain
Abdominal distension (measure girth)
Hypotension, tachycardia/shock
Loss of consciousness
Urgent Management
Poor prognosis
Immediate transfer to OR

AAA Rupture

Thrombosis
Venous Insufficiency
Varicose Veins

Venous Disorders

Two things alter venous blood flow:
1) Thrombus formation “DVT" “Thrombophlebitis”
2) Defective valves


Vein functioning depends on:
1) Valves prevent backflow of blood (Unidirectional)
2) Also require muscle to help pump (squeeze) blood back to heart

Veins:

Blood flow and function of valves in veins. Note impaired blood return due to incompetent valve.

Weight-based heparin infusions
Serial measurements:
aPTT
Example from CMC
Goal is INR of 2.0 to 2.5
2- Nurses Required!
Risk: HIT
Type (bovine vs. porcine)
Duration of therapy (>4 days
Surgery
Monitor Platelet Count!!!

Treatment of DVT/PE

Distended, protruding veins that become tortuous
Risks –
occupation with prolonged standing (nurses), pregnant, obese, family hx, women, tight clothes
S/S: Pain, fullness in legs, distended firm veins
Treatment:
1) Conservative - wear TEDS, elevate legs often
2)   Sclerotherapy - surgeon injects veins
3)   Surgical ligation/stripping (removal) - If > 4 mm
4)   Light source treatment

Varicose Veins

Atherosclerosis leads to occlusions
Remember the
Nursing Process
Assessment:

Objective Data
color flow duplex
Diagnostic Testing
ABI
MRA

Exercise testing:

ABI (Ankle Brachial Index)
Ankle systolic pressure divided by brachial systolic pressure
normal = 1.0 - 1.2
below 1.0 suggests arterial obstruction
0.8 - 1.0 mild
0.5 - 0.7 moderate
< 0.5 severe


Plethysmography

Arteriogram

CT (with contrast or angiography)

Angiography:

Diagnosis
Altered Peripheral Tissue Perfusion
Acute or Chronic Pain
Risk for Impaired Skin Integrity
Major goals include:
increased arterial blood supply
promotion of vasodilatation
prevention of vascular compression
relief of pain
attainment or maintenance of tissue integrity
adherence to self-care program
Planning
Maintaining Tissue Integrity

Improving Peripheral Arterial Circulation

Medical Interventions
Prevention
Exercise program
Medications
Pentoxifylline (Trental)
Cilostazol (Pletal)
Use of antiplatelet agents

ARTERIAL vs VENOUS
Intermittent Claudication
Amputations
Arterial Disorders
Protection of extremities and avoidance of trauma
Regular inspection of extremities
Good nutrition, low-fat diet
Weight reduction as necessary

Exercises and activities: walking, graded isometric exercises.
Positioning strategies
Temperature; effects of heat and cold
Stop smoking
Stress reduction


Nursing Interventions
Elastic hose
Pneumatic compression devices
Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy
Positioning: periodic elevation of lower extremities
Exercises: active and passive limb exercises, and deep breathing exercises
Early ambulation
Avoid sitting/standing for prolonged periods; walk 10 minutes every 1-2 hours.
Preventive Measures/Interventions
Venous Disorders
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