Arteries – walls are thicker due to greater smooth muscle, hence stronger & can withstand high pressure



Yüklə 457 b.
tarix28.03.2017
ölçüsü457 b.



ARTERIESWALLS ARE THICKER DUE TO GREATER SMOOTH MUSCLE, HENCE STRONGER & CAN WITHSTAND HIGH PRESSURE

  • ARTERIESWALLS ARE THICKER DUE TO GREATER SMOOTH MUSCLE, HENCE STRONGER & CAN WITHSTAND HIGH PRESSURE



PHYSICAL PRINCIPLES THAT DETERMINE BLOOD FLOW

  • PHYSICAL PRINCIPLES THAT DETERMINE BLOOD FLOW

  • PRESSURE CREATED BY PUMPING OF HEART

  • RESISTANCE OF BLOOD PUMPED (PVR) PERIPHERAL VASCULAR RESISTANCE (CHANGE IN VESSEL RADIUS)



SUSTAINED HIGH ARTERIAL PRESSURE INCREASES THE EFFECTS OF INJURY AND DISEASE

  • SUSTAINED HIGH ARTERIAL PRESSURE INCREASES THE EFFECTS OF INJURY AND DISEASE

  • EFFECTS OF ARTERIAL DISEASE CAUSES

  • TISSUE ISCHEMIA  DEATH OF TISSUE

  • SEVERITY OF SYMPTOMS IS DEPENDENT UPON METABOLIC RATE & TISSUE NEEDS

  • SURGERY MAY RE-ESTABLISH CIRCULATION



PURPOSE: TO DETERMINE ADEQUATE TISSUE PERFUSION

  • PURPOSE: TO DETERMINE ADEQUATE TISSUE PERFUSION

  • GUIDE LINES

  • COMPARE UPPER & LOWER

  • COMPARE BILATERALLY

  • COMPARE DISTAL & PROXIMAL

  • SUPINE (VS) DEPENDENT CHANGES



MAJOR AREAS OF ASSESSMENT

  • MAJOR AREAS OF ASSESSMENT

  • CIRCULATION – PULSE MEANS PERFUSION

  • MOTION – MUSCLES NEED OXYGEN

  • SENSATION – PAIN, BURNING, PROPRIOCEPTION, NUMBNESS



CIRCULATION

  • CIRCULATION

  • CHECK PULSE POINTS

  • CAROTID

  • RADIAL

  • FEMORAL

  • DORSALIS PEDIS

  • POSTERIOR TIBIAL

  • CAPILLARY REFILL



PULSES ARE BASED ON A SCALE

  • PULSES ARE BASED ON A SCALE

  • 0 to 4+

  • 0 = NO PULSE

  • 1+ = THREADY PULSE

  • 2+ = NORMAL PULSE

  • 3+ = BOUNDING PULSE

  • 4+ = ANEURYSM



ARTERIAL INSUFFICIENCY

  • ARTERIAL INSUFFICIENCY

  • SKIN COOL, SHINY THIN, ONION LIKE

  • PAIN /W COLD

  • PALE /W ELEVATION

  • DISTAL PULSES  OR ABSENT

  • DECREASED OR ABSENT HAIR

  • ISCHEMIC ULCERS

  • THICK NAILS



NON-INVASIVE TECHNIQUES

  • NON-INVASIVE TECHNIQUES

  • DUPLEX ULTRASOUND

  • HELPS Dx NARROWING OR OCCULUSION OF INTERNAL CAROTIDS or DVT

  • NO PATIENT PREP

  • PAINLESS & SAFE

  • SUPINE POSITION



NON-INVASIVE TECHNIQUES

  • NON-INVASIVE TECHNIQUES

  • SEGMENTED ARTERIAL PRESSURE MONITORING

  • MEASURES PRESSURE DIFFERENCE BETWEEN EXTREMITIES AT DIFFERENT LEVELS

  • USES B/P MONITOR & DOPPLER



EXAMPLE:

  • EXAMPLE:

  • BRACHIAL PRESSURE =120mmHg

  • ANKLE PRESSURE = 96mmHg

  • ABI = 96 / 120 = 0.8



CLAUDICATION

  • CLAUDICATION

  • INTERMITTANT CRAMPING OF SKELETAL MUSCLES WITH EXERCISE

  • STANDARD – ABLE TO WALK ONE CITY BLOCK W/O PAIN

  • (+) = PAIN WITH AMBULATION, PAIN WITH ELEVATION, RELIEF WITH DEPENDENT POSITION

  • Tx: pentoxyphylline (Trental)

  • cilostazol (Pletal)



THE 5 P’s

  • THE 5 P’s

  • WHEN PRESENT = SURGICAL EMERGENCY!

      • PAIN
      • PALLOR
      • PULSELESSNESS
      • PARALYSIS
      • PARESTHESIA


ANGIOGRAPHY (ANGIOGRAM)

  • ANGIOGRAPHY (ANGIOGRAM)

  • INVASIVE TECHNIQUE – USED WHEN SURGICAL INTERVENTION IS BEING CONSIDERED

  • USED TO DIAGNOSE

  • EMBOLI, THROMBOSIS, TRAUMA, ANEURYSM, BUERGER’S DISEASE,

  • ARTERIOSCLEROSIS



ARTERIAL SYSTEM PROBLEMS CAN BE CONTROLLED BY MODIFYING RISK FACTORS:

  • ARTERIAL SYSTEM PROBLEMS CAN BE CONTROLLED BY MODIFYING RISK FACTORS:

  • SMOKING

  • DIET

  • GLUCOSE CONTROL

  • ACTIVITY LEVEL

  • HYPERLIPIDEMIA

  • BP (DOUBLES RISK)



HEALTHY ARTERIES ARE BLOOD VESSELS WHICH ARE FLEXIBLE,

  • HEALTHY ARTERIES ARE BLOOD VESSELS WHICH ARE FLEXIBLE,

  • STRONG & ELASTIC

  • THEIR INSIDE LINING IS SMOOTH SO BLOOD CAN FLOW WITHOUT RESTRICTION

  • Risk Factors cause arteries to become occluded.







PERIPHERAL ARTERIAL INSUFFICIENCY / OCCLUSION

  • PERIPHERAL ARTERIAL INSUFFICIENCY / OCCLUSION

  • ASSESSMENT:

  • WEAK/ ABSENT PULSES

  • PAIN /W LEG ELEVATION

  • SKIN COOL TO TOUCH

  • PALE SKIN COLOR

  • THICKENED TOENAILS



GOALS:

  • GOALS:

  • IMPROVE PERIPHERAL ARTERIAL CIRCULATION WITH EXERCISE

  • REGULAR EXERCISE SUCH AS WALKING INCREASES

  • CIRCULATION



GOALS:

  • GOALS:

  • PREVENT VASCULAR COMPRESSION

  • AVOID RESTRICTIVE CLOTHING, CROSSING LEGS, SITTING FOR PROLONGED PERIODS



GOALS:

  • GOALS:

  • RELIEVE PAIN

  • CONSIDER ANALGESICS SO PATIENT CAN PARTICIPATE IN ACTIVITIES



GOALS:

  • GOALS:

  • MAINTAIN TISSUE INTEGRITY

  • AVOID TRAUMA, WEAR CORRECT SHOE GEAR (NO BARE FEET!)

  • TEST WATER TEMP WITH HAND NOT FOOT!

  • REGULAR PODIATRY CARE

  • GOOD NUTRITION



BALLOON ANGIOPLASTY CATHETER

  • BALLOON ANGIOPLASTY CATHETER

  • INSERTED THROUGH AN ARTERY

  • BALLOON IS INFLATED AND COMPRESSES LESION





THROMBOLYTIC THERAPY

  • THROMBOLYTIC THERAPY

  • USED TO DISSOLVE CLOTS:

  • Retavase, streptokinase, tPa

  • SURGICAL MANAGEMENT

  • GRAFTING – BYPASS SURGERY

  • ENDARTERECTOMY – REMOVAL OF ATHEROSCLEROTIC PLAQUE

  • AORTO/FEMORAL/TIBIAL BYPASS



ALTERED PERIPHERAL TISSUE PERFUSION

  • ALTERED PERIPHERAL TISSUE PERFUSION

  • ( ARTERIAL BLOOD FLOW)

  • GOAL: MAXIMIZE TISSUE PERFUSION

  • ACTIVITY INTOLERANCE – VASCULAR SUPPLY CAN NOT KEEP UP WITH TISSUE DEMANDS

  • GOAL: MANAGE ACTIVITY WITHIN LIMITATIONS



  • ANTICIPATORY GRIEVING RELATED TO POTENTIAL LOSS OF LIMB

  • GOAL: EXPRESS CONCERNS

  • BODY IMAGE DISTURBANCE AS RELATED TO LOSS OF BODY PART

  • GOAL: DISCUSS IMAGE & OPTIONS



  • IMPAIRED TISSUE INTEGRITY AS RELATED TO  CIRCULATION

  • GOAL: MAINTAIN TISSUE INTEGRITY

  • KNOWLEDGE DEFICIT OF SELF CARE ACTIVITIES

  • GOAL: EDUCATE PATIENT



  • PAIN DUE TO ISCHEMIA

  • GOAL: RELIEVE PAIN

  • POTENTIAL FOR INJURY DUE TO  SENSATION

  • GOAL: EDUCATE PATIENT TO INSPECT FOR INJURY, WATCH FOR TRAUMA

  • SLEEP PATTERN DISTURBANCE DUE TO REST PAIN

  • GOAL: MAXIMIZE SLEEP



RISK FACTOR MODIFICATION

  • RISK FACTOR MODIFICATION

  • SMOKING (Most significant RISK FACTOR)

  •  NICOTINE CAUSES VASOSPASMS

  • WEIGHT LOSS

  •  REDUCES WORKLOAD IN EXTREMITIES

  • LOW FAT DIET WILL RETARD PROGRESSION OF ATHEROSCLEROSIS

  • CONTROL HTN



PAIN MANAGEMENT

  • PAIN MANAGEMENT

  • INTENSITY IS VARIABLE

  • MANAGEMENT- RTC

  • PAIN MEDICATION

  • (MAY NOT BE EFFECTIVE)

  •  DEPENDENT POSITION MAY  COMFORT



MAINTAIN FLUID VOLUME

  • MAINTAIN FLUID VOLUME

  • IN SEVERE STENOSIS PATIENT MUST MAINTAIN SUFFICIENT BLOOD PRESSURE TO AVOID COMPLETE OCCLUSION



ACTIVITY

  • ACTIVITY

  •  MONITOR CLAUDICATION

  •  TEACH PATIENT – PAIN IS NOT HARMFUL, BUT A BODY SIGNAL FOR NEED TO REST

  •  EMPHASIZE: EXERCISE INCREASES COLLATERAL CIRCULATION

  •  CHECK WITH DOCTOR ABOUT ANY EXERCISE

  • PROGRESSION SHOULD BE GRADUAL



MAINTAINING TISSUE INTEGRITY

  • MAINTAINING TISSUE INTEGRITY

  •  CHANGE POSITION FREQUENTLY

  •  AVOID CROSSING LEGS

  • & CONSTRICTIVE CLOTHING

  •  METICULOUS FOOT CARE (PODIATRIST)

  •  PROTECT FROM INJURY

  •  KEEP EXTREMITIES WARM

  • (NO HEATING BLANKET OR HOT WATER BOTTLES!)



S/P BYPASS SURGERY- Postop

  • S/P BYPASS SURGERY- Postop

  • NEUROVASCULAR ASSESSMENT

  • COMPLICATIONS

    • GRAFT OCCLUSION:THROMBOSIS
    • COMPARTMENT SYNDROME
    • GRAFT INFECTIONS
    • FISTULA/ULCER FORMATION
  • EDUCATE PATIENT TO

    • REPORT PAIN UNRELIEVED BY MEDS
    • STOP SMOKING
    • ID NORMAL HEALING PROCESS


S/P BYPASS SURGERY

  • S/P BYPASS SURGERY

  • POSITIONING

    • KEEP LOWER EXTREMITY LEVEL
    • AND AVOID CONSTRICTION
    • AVOID DEPENDENT POSITION WHICH ’s EDEMA , PAIN & HEALING
    • MOBILITY IS PROGRESSIVE


BUERGER’S DISEASE [TAO]

  • BUERGER’S DISEASE [TAO]

  • (aka: Thromboangiitis Obliterans)

  • DISEASE IS LINKED DIRECTLY TO SMOKING (REQUIRED HX FOR DX)

  • POSSIBLE IMMUNOPATHOGENESIS

  • INFLAMMATION PRODUCES CRITICAL LIMB ISCHEMIA

  • DISEASE CAN PROGRESS PROXIMALLY



VASOSPASTIC DISORDERS:

  • VASOSPASTIC DISORDERS:

  • BLOOD VESSELS (FINGERS & TOES) GO INTO SPASM

  • EXTREME SENSITIVITY TO TEMP CHANGES (ESPECIALLY COLD)

  • MORE COMMON FEMALE > MALE

  • Color changes are Red/White/Blue



CLASSIFIED:

  • CLASSIFIED:

  • RAYNAUD’S DISEASE = WHEN SYMPTOMS ARE THE ONLY PRESENTING FACTOR

  • RAYNAUD’S PHENOMENON = WHEN SYMPTOMS ARE SECONDARY TO ANOTHER CONDITION

    • EX: RA, SCLERODERMA, LUPUS, CARPAL TUNNEL SYDROME, THORACIC OUTLET SYNDROME


DX:

  • DX:

  • BILATERAL

  • OCCURS X 2 YEARS

  • NO OTHER CAUSE



ANEURYSM = AN LOCALIZED ABNORMAL DILATION OF A BLOOD VESSEL

  • ANEURYSM = AN LOCALIZED ABNORMAL DILATION OF A BLOOD VESSEL



Aneurysm-permanent localized dilation of an artery

  • Aneurysm-permanent localized dilation of an artery

  • -enlarges to 2x normal diameter

  • -middle layer of artery is weakened

  • -HTN produces more tension and enlargement within the artery



Location: Thoracic

  • Location: Thoracic

  • Abdominal aortic aneurysms

  • Etiology:

  • Atherosclerosis (+HTN & smoking)

  • Syphillis

  • Marfan Syndrome

  • Ehlers-Danlos syndrome



Upper abdomen pulsation, left of midline

  • Upper abdomen pulsation, left of midline

  • + bruit over mass

  • Abdominal, flank or back pain- if leaking or ruptured

  • Abd Xray- “Eggshell Calcification”

  • Cat scan

  • Aortic angiography

  • Ultrasonography



Nonsurgical

  • Nonsurgical

  • Surgical- AAA Resection

  • - Endovascular stent graft

  • Post-op care of the AAA patient:



VEINS – HAVE THIN WALLS

  • VEINS – HAVE THIN WALLS

  • (LESS SMOOTH MUSCLE)

  • ALLOW VESSELS TO DISTEND MORE THAN ARTERIES



BLOOD FLOWS AGAINST GRAVITY BECAUSE:

  • BLOOD FLOWS AGAINST GRAVITY BECAUSE:

  • VALVES – ONE WAY VALVES PREVENT BACKFLOW. (VALVE COMPETENCY DEPENDS UPON INTEGRITY OF VEIN WALL)

  • MUSCLE CONTRACTION MILKS BLOOD THROUGH VESSELS



VENOUS INSUFFICIENCY

  • VENOUS INSUFFICIENCY

  • DRY, FLAKY

  • (BROWN & BLOTCHY)

  • PURPLE – DEPENDENT

  • ELEVATION ’s DEPENDENT EDEMA

  • EDEMA MAY OBLITERATE PULSES

  • VENOUS STASIS ULCERS

  • PARESTHESIAS



PHLEBITIS-Vein inflammation

  • PHLEBITIS-Vein inflammation



PREDISPOSING FACTORS

  • PREDISPOSING FACTORS

    • VENOUS STASIS – Bedrest, BP, HYPOVOLEMIA,
    • HYPERCOAGULABILITY – CANCER,SMOKING, POLYCYTHEMIA, SURGERY, SEPSIS, OC
    • ENDOTHELIAL DAMAGE – STIMULATES PLATELET AGGREGATION, VENOUS INFLAMMATION


IMMOBILIZATION – PARALYSIS, PROLONGED BEDREST, LONG PLANE OR CAR RIDES

    • IMMOBILIZATION – PARALYSIS, PROLONGED BEDREST, LONG PLANE OR CAR RIDES
    • DISEASE PROCESSES – SEPSIS, SLE,HEMATOLOGICAL DISORDERS, MS,MALIGNANCY, CHF, MI, ULCERATIVE COLITIS
    • PRESSURE – OBESITY, PREGNANCY, TUMOR
    • TRAUMA – FRACTURES, VENIPUNCTURE
    • CLOTTING DYSFUNCTION
    • SURGICAL PROCEDURES – HIP, GYN & UROLOGICAL & in age >40
    • OC use- especially in women who smoke
    • OTHER – DEHYDRATION, ADVANCED AGE


DEEP VENOUS THROMBOSIS (DVT)

  • DEEP VENOUS THROMBOSIS (DVT)

  • PATHOPHYSIOLOGY – DEEP VEIN CLOT MOST COMMON IN LOWER LEG (CALF)

  • UNDIAGNOSED DVT OCCURS IN 50% OF PATIENTS WITH PULMONARY EMBOLI



S & S

  • S & S

  • -Calf or groin tenderness

  • -Pain that can be dull or aching, especially when walking

  • -Sudden onset of unilateral swelling of the leg

  • -Cyanosis of the affected extremity

  • -Slightly elevated temp

  • -General malaise



Homan’s Sign-pain on dorsiflexion of foot

  • Homan’s Sign-pain on dorsiflexion of foot

  • NO LONGER ADVISED-can increase the risk of detaching the thrombus as the calf muscle contract

  • Coag studies

  • D Dimer-increased values with venous thrombosis, PE, DIC and Malignancy

  • Duplex Scan



*Bedrest and leg elevation

  • *Bedrest and leg elevation

  • *Warm moist soaks may be ordered

  • *Evaluate for PE

  • *Anti-inflammatory drugs for superficial thrombophlebitis – ASA or NSAIDS

  • *Heparin therapy

  • *Warfarin (Coumadin)



1.Prior to initiation of therapy:

  • 1.Prior to initiation of therapy:

  • Hx of bleeding disorders

  • CBC w/ platelet count

  • UA

  • Stool for occult blood

  • Creatinine level

  • PTT,PT, INR baseline

  • 2. Heparin bolus is given IVP (100u/kg) followed by continuous infusion and protocol

  • 3. Goal is to attain aPTT level 1.5-2.5x normal



4. Assess for signs and symptoms of bleeding

  • 4. Assess for signs and symptoms of bleeding

  • 5. Monitor platelet counts- can lead to heparin induced thrombocytopenia.

  • 6. Antidote available- protamine sulfate

  • Other Options:

  • LMWH-Longer half-life and more predictable

  • Lovenox- 1mg/kg Adjust for renal pts

  • Fragmin

  • Coumadin- started while pt is on heparin

  • -takes 3-4 days to be therapeutic

  • -monitor INR/PT

  • -antidote-Vitamin K



TREATMENT

  • TREATMENT

    • PREVENTIVE
      • EARLY AMBULATION
      • EXTERNAL COMPRESSION (VCB)
      • PROPHYLACTIC ANTICOAGULANTS
        • LOW DOSE HEPARIN
        • LOW MOLECULAR WT. HEPARIN (FRAGMIN©)
    • WHEN DVT EXISTS
      • BR TO CHANCE OF EMBOLI
      • ELEVATION TO  VENOUS RETURN &  EDEMA
      • ANTICOAGULANTS PREVENT CLOTS FROM INCREASING (THEY DO NOT DISSOLVE THEM!)


AMBULATION – PERMITTED WHEN EDEMA . BELOW KNEE TEDS USED IF NO ARTERIAL DISEASE

  • AMBULATION – PERMITTED WHEN EDEMA . BELOW KNEE TEDS USED IF NO ARTERIAL DISEASE

  • (TEDS MAY INTERFERE WITH ARTERIAL FLOW)

  • THROMBECTOMY – SURGICAL TREATMENT OF CHOICE WHEN ARTERIAL FLOW IS AFFECTED BY DVT

  • (GREENFIELD FILTER PREVENTS “SHOWER” OF PULMONARY EMBOLI) INSERTED IN INFERIOR VENA CAVA



Inserted into Inferior Vena Cava

  • Inserted into Inferior Vena Cava

  • Filters out clots as blood returns to the right side of the heart



READILY IDENTIFIED ON X-RAY

  • READILY IDENTIFIED ON X-RAY



Safety and comfort measures

  • Safety and comfort measures

  • Balance rest and activity

  • Need for follow up

  • Importance of taking drugs and not missing doses

  • Medi-alert bracelet

  • Avoid OTC meds

  • Avoid hi fat and hi Vitamin K foods- cabbage, cauliflower,broccoli, asparagus, spinach, kale, fish and liver

  • Patient teaching re: LMWH injections



PATHOPHYSIOLOGY & EPIDEMIOLOGY

  • PATHOPHYSIOLOGY & EPIDEMIOLOGY

    • OCCURS IN 10% OF POPULATION /W DVT
    • Stasis of blood in lower extremity-due to prolonged standing, sitting in one position, pregnancy, and obesity
    • INCOMPETENT VALVES IN DEEP VEINS
    •  VENOUS PRESSURE IMPEDES CAPILLARY PERFUSION
    • PROTEINS LEAK INTO INTERSTITIAL TISSUES
    • EDEMA IS CHRONIC  ULCERS & SCARRING


SIGNS & SYMPTOMS – INDURATION  HYPERPIGMENTATION, STASIS DERMATITIS & ULCERATIONS, EDEMA

  • SIGNS & SYMPTOMS – INDURATION  HYPERPIGMENTATION, STASIS DERMATITIS & ULCERATIONS, EDEMA

  • GOALS: Decrease edema and Promote venous return

  • INTERVENTIONS:

    • COMPRESSION – STOCKINGS OR DRESSINGS
    • ULCERS TREATED WITH TOPICAL AGENTS-Unna,Accuzyme
    • AVOID TRAUMA
    • AVOID SITTING FOR LONG PERIODS
    • EXERCISE TO  MUSCLE ACTIVITY
    • Platelet derivative growth factor ointments-Regranex
    • Apligraf-type of skin graft


Protruding veins that are darkened/tortuous are caused by weak vein walls, increased venous pressure & incompetent valves

  • Protruding veins that are darkened/tortuous are caused by weak vein walls, increased venous pressure & incompetent valves

  • Common in patients that stand for long periods

  • Pregnancy

  • Obesity

  • Family hx of varicose veins

  • Systemic problems-heart disease



Severe, aching pain in leg

  • Severe, aching pain in leg

  • Leg fatigue and heaviness

  • Itching over the affected leg (statis dermatitis)

  • Feelings of heat in the leg

  • Visibly dilated veins

  • Thin, discolored skin above the ankles

  • Increased incidence of PE and thrombophlebitis



Tourniquet test

  • Tourniquet test

  • Trendelenberg test

  • Doppler ultrasound/ angiography



Elevate extremity

  • Elevate extremity

  • Elastic Stockings

  • Sclerotherapy-for small/limited # of veins



Monitor patient postop

  • Monitor patient postop

  • Assess circulation

  • Elevate legs and perform active ROM

  • Teach re: avoidance of venous stasis, compression stockings, exercise, leg elevation



LYMPHATIC SYSTEM – WORKS WITH CIRCULATORY SYSTEM

  • LYMPHATIC SYSTEM – WORKS WITH CIRCULATORY SYSTEM

    • THORACIC DUCT
    • RIGHT LYMPHATIC DUCT




CAUSES OF LYMPHEDEMA INCLUDE:

  • CAUSES OF LYMPHEDEMA INCLUDE:

  • LYMPHANGITIS CELLULITIS

    • INSUFFICIENT NUMBER OF VESSELS
    • SECONDARY FACTORS
    • MALIGNANCY
    • TRAUMA
    • SURGICAL REMOVAL


Pain at site of injury

  • Pain at site of injury

  • Redness of skin

  • Fever and chills

  • Red streak on skin extending toward the lymph nodes

  • Lymph nodes enlarged

  • WBC, Blood & Wound cultures

  • Lymphangiography-IV dye, Xrays

  • Lymphoscintigraphy-simple,no SE



Moist heat

  • Moist heat

  • Elevation and immobilization of the extremity

  • Elastic stockings

  • Na restriction

  • Antibiotics/antifungals for infection

  • Diuretics

  • Analgesics



MR. CHARLES HORSE WAS ADMITTED TO THE HOSPITAL TODAY WHERE HE PRESENTED HIS CHIEF COMPLAINTS AND RECENT MEDICAL HISTORY. THIS PATIENT IS A FIFTY-THREE YEAR OLD WHITE MALE. MR. HORSE IS A RUGGED INDIVIDUAL WITH AN EXTENSIVE HISTORY.

  • MR. CHARLES HORSE WAS ADMITTED TO THE HOSPITAL TODAY WHERE HE PRESENTED HIS CHIEF COMPLAINTS AND RECENT MEDICAL HISTORY. THIS PATIENT IS A FIFTY-THREE YEAR OLD WHITE MALE. MR. HORSE IS A RUGGED INDIVIDUAL WITH AN EXTENSIVE HISTORY.



HE SMOKES 1 PACK OF CIGARETTES PER DAY FOR MORE THAN TWENTY

  • HE SMOKES 1 PACK OF CIGARETTES PER DAY FOR MORE THAN TWENTY

  • FIVE YEARS. AS A SINGLE LUMBERJACK HIS DIET HAS RELIED HEAVILY ON FAST FOODS. OVER THE PAST SEVERAL MONTHS MR. HORSE REPORTED HE HAD GRADUALLY BEEN EXPERIENCING PAIN IN THE LEFT LEG. THESE PAINFUL SYMPTOMS INCREASED TO A POINT WHERE HE CANNOT WALK MORE THAN TWO CITY BLOCKS WITHOUT SEVERE CRAMPING IN HIS LEFT LEG.



HE STATES HE MUST STOP, SIT AND RUB HIS LEG UNTIL THE CRAMPING STOPS. MR. HORSE HAS GRADUALLY ADJUSTED HIS ACTIVITIES AROUND THESE SYMPTOMS.

  • HE STATES HE MUST STOP, SIT AND RUB HIS LEG UNTIL THE CRAMPING STOPS. MR. HORSE HAS GRADUALLY ADJUSTED HIS ACTIVITIES AROUND THESE SYMPTOMS.

  • THIS MORNING, MR. HORSE AWOKE FROM A DEEP SLEEP TO SUDDEN, SEVERE PAIN IN THE LEFT LEG. THE PAIN DIMINISHED SLIGHTLY WHEN HE SAT UP AND HUNG HIS LEGS OVER THE SIDE OF THE BED.



HE NOTICED CHANGES IN SKIN COLOR AND TEMPERATURE. CONCERNED ABOUT THE SUDDEN CHANGES, MR. HORSE HEADED DIRECTLY TO THE EMERGENCY ROOM.

  • HE NOTICED CHANGES IN SKIN COLOR AND TEMPERATURE. CONCERNED ABOUT THE SUDDEN CHANGES, MR. HORSE HEADED DIRECTLY TO THE EMERGENCY ROOM.

  • WHEN YOU ASSESS THIS PATIENT ATTENTION IS DIRECTED TOWARD HIS LEFT LEG. THE SKIN IS COOL TO TOUCH. ASSESSING PERIPHERAL PULSES YOU NOTE THAT HIS FEMORAL AND POPLITEAL PULSES ARE STRONG AND PALPABLE BILATERALLY.



HOWEVER, HIS POSTERIOR TIBIAL AND DORSALIS PEDIS PULSES ON THE LEFT LEG ARE NOT PALPABLE. A DOPPLER READING INDICATES THERE IS SOME DEGREE OF CIRCULATION PRESENT. NAIL BEDS ARE CYANOTIC; CAPILLARY FILLING IS SLOW (> 3 SECONDS) IN ALL DIGITS ON THE LEFT FOOT.

  • HOWEVER, HIS POSTERIOR TIBIAL AND DORSALIS PEDIS PULSES ON THE LEFT LEG ARE NOT PALPABLE. A DOPPLER READING INDICATES THERE IS SOME DEGREE OF CIRCULATION PRESENT. NAIL BEDS ARE CYANOTIC; CAPILLARY FILLING IS SLOW (> 3 SECONDS) IN ALL DIGITS ON THE LEFT FOOT.

  • ATTEMPTING TO IMPROVE MR. HORSE’S COMFORT, THE NURSE ELEVATES HIS FEET. MR. HORSE REPORTS THE PAIN IS SIGNIFICANTLY WORSE!



WHAT INFORMATION DOES INSPECTION OF THE PATIENT’S LEG PROVIDE?

  • WHAT INFORMATION DOES INSPECTION OF THE PATIENT’S LEG PROVIDE?

  • COLOR OF SKIN

  • COLOR OF NAIL BEDS



WHAT CAN PALPATION TELL YOU ABOUT THIS PATIENT’S CONDITION?

  • WHAT CAN PALPATION TELL YOU ABOUT THIS PATIENT’S CONDITION?

    • TEMPERATURE
    • PULSES


WHAT POSITION WOULD BE THE MOST COMFORTABLE FOR MR. HORSE?

  • WHAT POSITION WOULD BE THE MOST COMFORTABLE FOR MR. HORSE?

  • WHAT PROBLEM DO YOU THINK MR. HORSE HAS WITH HIS LEFT LEG?



WHAT WOULD PREDISPOSE MR. HORSE TO DEVELOPING THIS TYPE OF PROBLEM?

  • WHAT WOULD PREDISPOSE MR. HORSE TO DEVELOPING THIS TYPE OF PROBLEM?

  • WHAT IS THE CLINICAL TERM FOR A CONDITION CAUSING PERIODIC CRAMPING BROUGH ON BY WALKING?



WHAT ARE THE 5 P’s YOU SHOULD LOOK FOR?

  • WHAT ARE THE 5 P’s YOU SHOULD LOOK FOR?



FOLLOWING A SUCCESSFUL REVASCULARIZATION PROCEDURE, MR. HORSE WAS D/C’d TO HOME IN GOOD CONDITION. HIS LEFT LEG WAS WARM, PINK IN COLOR AND ALL TOES WERE MOBILE. MR. HORSE WAS PLACED ON MEDICATIONS TO MANAGE HIS CHF, WHICH WAS DISCOVERED DURING IHIS MEDICAL HISTORY AND PHYSICAL EXAM. TWO WEEKS LATER THIS PATIENT RETURNED TO THE HOSPITAL…

  • FOLLOWING A SUCCESSFUL REVASCULARIZATION PROCEDURE, MR. HORSE WAS D/C’d TO HOME IN GOOD CONDITION. HIS LEFT LEG WAS WARM, PINK IN COLOR AND ALL TOES WERE MOBILE. MR. HORSE WAS PLACED ON MEDICATIONS TO MANAGE HIS CHF, WHICH WAS DISCOVERED DURING IHIS MEDICAL HISTORY AND PHYSICAL EXAM. TWO WEEKS LATER THIS PATIENT RETURNED TO THE HOSPITAL…



PRESENTING WITH DYSPNEA, ORTHOPNEA AND BILATERAL +3 PITTING EDEMA. MR. HORSE WAS READMITTED TO THE HOSPITAL WITH A DX OF CHF. DIGOXIN (A CARDIOTONIC) WAS STARTED AND LASIX (A DIURETIC) ALSO WAS ADDED TO HIS MEDICATION PROFILE. ONCE AGAIN MR. HORSE WAS D/C’d TO HOME AND PROVIDED WITH A HOME HEALTH AIDE TO ASSIST HIM WITH HIS ADL’s. HE WAS INSTRUCTED TO REMAIN ON BED REST

  • PRESENTING WITH DYSPNEA, ORTHOPNEA AND BILATERAL +3 PITTING EDEMA. MR. HORSE WAS READMITTED TO THE HOSPITAL WITH A DX OF CHF. DIGOXIN (A CARDIOTONIC) WAS STARTED AND LASIX (A DIURETIC) ALSO WAS ADDED TO HIS MEDICATION PROFILE. ONCE AGAIN MR. HORSE WAS D/C’d TO HOME AND PROVIDED WITH A HOME HEALTH AIDE TO ASSIST HIM WITH HIS ADL’s. HE WAS INSTRUCTED TO REMAIN ON BED REST



FOR ONE WEEK. HE IS SEEN BY THE VISITNING NURSE IN HIS HOME ON F/U TO ASSESS HIS STATUS. THE NURSE TAKES NOTICE OF MR. HORSE’S +2 PITTING EDEMA IN HIS RIGHT LEG, EXTENDING FROM THE FOOT TO THE LOWER THIGH. SKIN COLOR IS NOTED TO HAVE A REDDISH/ PURPLE HUE AND THE SURFACE TEMP IS INCREASED LOCALLY. THE LIMB IS TENDER TO TOUCH AND PAIN INCREASES WITH DORSIFLEXION.

  • FOR ONE WEEK. HE IS SEEN BY THE VISITNING NURSE IN HIS HOME ON F/U TO ASSESS HIS STATUS. THE NURSE TAKES NOTICE OF MR. HORSE’S +2 PITTING EDEMA IN HIS RIGHT LEG, EXTENDING FROM THE FOOT TO THE LOWER THIGH. SKIN COLOR IS NOTED TO HAVE A REDDISH/ PURPLE HUE AND THE SURFACE TEMP IS INCREASED LOCALLY. THE LIMB IS TENDER TO TOUCH AND PAIN INCREASES WITH DORSIFLEXION.



THE NURSE ALSO NOTES THAT PERIPHERAL PULSES ARE MODERATELY DIMINISHED ON THE RIGHT SIDE ONLY. MR. HORSE COMPLAINS THAT HIS RIGHT LEG FEELS HEAVY AND THROBS.

  • THE NURSE ALSO NOTES THAT PERIPHERAL PULSES ARE MODERATELY DIMINISHED ON THE RIGHT SIDE ONLY. MR. HORSE COMPLAINS THAT HIS RIGHT LEG FEELS HEAVY AND THROBS.



WHAT DOES INSPECTION OF HIS RIGHT LEG REVEAL?

  • WHAT DOES INSPECTION OF HIS RIGHT LEG REVEAL?

    • SKIN COLOR
    • GIRTH / TENSION


WHAT DOES PALPATION TELL YOU ABOUT THE STATUS OF HIS RIGHT LEG?

  • WHAT DOES PALPATION TELL YOU ABOUT THE STATUS OF HIS RIGHT LEG?

    • TEMPERATURE
    • EDEMA


WHAT DO YOU THINK THE PROBLEM IS WITH MR. HORSE’S RIGHT LEG?

  • WHAT DO YOU THINK THE PROBLEM IS WITH MR. HORSE’S RIGHT LEG?

  • WHAT DO YOU THINK CAUSED MR. HORSE’S RECENT COMPLICATIONS?



HOW COULD THESE PROBLEMS HAVE BEEN AVOIDED?

  • HOW COULD THESE PROBLEMS HAVE BEEN AVOIDED?



LIST EXAMPLES THAT PREDISPOSE A PATIENT TO DVT

  • LIST EXAMPLES THAT PREDISPOSE A PATIENT TO DVT







Which of the following clients should the nurse assess first?

  • Which of the following clients should the nurse assess first?

  • A.The 76-year-old woman who has had laser-assisted angioplasty of the right distal femoral artery 30 minutes ago

  • B.The 65-year-old man with a history of hypertensive crisis who is on a labetalol drip and current blood pressure is 149/80

  • C.The 60-year-old woman with a history of peripheral vascular disease who has a venous leg ulcer draining purulent yellow fluid

  • D.The 55-year-old man with a history of axillofemoral bypass 5 years earlier who is currently admitted for a diagnostic cardiac catheterization



Which of the following statements indicates the caregiver does not understand proper care of the client with peripheral arterial disease of the lower legs?

  • Which of the following statements indicates the caregiver does not understand proper care of the client with peripheral arterial disease of the lower legs?

  • A.“The client should drink fluids to decrease risk for viscous blood.”

  • B.“We must remind the client to refrain from wearing restrictive clothing.”

  • C.“The client should apply heat directly to the legs in order to promote blood circulation.”

  • D.“The client should be encouraged to stop smoking because it increases the vasoconstriction of the arteries.”



You are caring for a 75-year-old man admitted to the hospital for lower leg cellulitis. On admission, the nurse notes that his blood pressure is 190/100 and notifies the physician. Of the following orders, which would you have the LPN implement?

  • You are caring for a 75-year-old man admitted to the hospital for lower leg cellulitis. On admission, the nurse notes that his blood pressure is 190/100 and notifies the physician. Of the following orders, which would you have the LPN implement?

  • A.Assess cardiac and respiratory status.

  • B.Administer Clonidine patch for hypertension.

  • C.Obtain an order from the doctor for dietary consult.

  • D.Develop plan for discharge and assess homecare needs.



A group of new graduate nurses is in orientation to work on a cardiothoracic stepdown unit. Which statement, if made by one of the nurses, demonstrates the need for further teaching regarding the difference between arteriosclerosis and atherosclerosis?

  • A group of new graduate nurses is in orientation to work on a cardiothoracic stepdown unit. Which statement, if made by one of the nurses, demonstrates the need for further teaching regarding the difference between arteriosclerosis and atherosclerosis?

  • A.“Arteriosclerosis is a thickening, or hardening, of the arterial wall.”

  • B.“Atherosclerosis is a type of arteriosclerosis that involves the formation of plaque within the arterial wall and is the leading contributor to coronary artery and cerebrovascular disease.”

  • C.“Atherosclerosis is caused by vascular damage.”

  • D.“Arteriosclerosis happens when platelets aggregate and then a group of blood lipids accumulate.”



Because Mr. Palan's condition has progressed to severe rest pain that is now threatening loss of his limb, an arterial revascularization has to be performed. Which statement, if made by Mr. Palan, demonstrates that further teaching is needed related to his postoperative care?

  • Because Mr. Palan's condition has progressed to severe rest pain that is now threatening loss of his limb, an arterial revascularization has to be performed. Which statement, if made by Mr. Palan, demonstrates that further teaching is needed related to his postoperative care?

  • A.“I should be concerned if my foot turns blue.”

  • B.“I should not get a fever or any drainage after the surgery.”

  • C.“I may get a feeling of tenseness after the surgery.”

  • D.“Warmth, redness, and swelling are expected after surgery.”



5.Clara is teaching a young woman ways to prevent venous thromboembolism during hospitalization. Which statement, if made by the client, indicates the need for further teaching?

  • 5.Clara is teaching a young woman ways to prevent venous thromboembolism during hospitalization. Which statement, if made by the client, indicates the need for further teaching?

  • A.“I need to stop taking my birth control pill.”

  • B.“I should drink a lot of water so I don't get dehydrated.”

  • C.“I should exercise my legs when I have been sitting or standing for a long time.”

  • D.“If I wear pantyhose, I don't have to wear the stockings that the hospital gives me.”



Yüklə 457 b.

Dostları ilə paylaş:




Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azkurs.org 2020
rəhbərliyinə müraciət

    Ana səhifə