Nursing Interventions plus Management of Peripheral Vascular Disorders by NgoRN

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									Peripheral Vascular Disorders

         Adult Health I
          NURS 400



                                1
      Pathophysiology of the
         Vascular System
• PVD characterized by reduced blood
  flow
• PVD caused by:
  • Heart failure
  • Arterial insufficiency
  • Venous insufficiency



                                       2
         Nursing Assessment
• Pain
  • Intermittent claudication – crampy pain
    associated with activity
• Pulses
• Skin appearance
• Skin temperature
• Edema

                                              3
    Characteristics of Arterial
         Insufficiency
• Intermittent claudication to sharp,
  unrelenting pain
• Diminished or absent pulses
• Pallor and coolness
• Loss of hair
• Thickened nails


                                        4
Characteristics of Arterial Ulcers

• Located in areas of pressure, tips of toes
• Very painful
• Deep, may involve joint
• Usually circular in appearance
• Wound base pale to black
• Little, if any, edema


                                           5
    Characteristics of Venous
         Insufficiency
• Achy, cramping pain
• Pulses present
• Hyperpigmentation of skin
• Lots of edema




                                6
Characteristics of Venous Ulcers

• Usually located on medial
  malleolus
• Tend to be superficial,
  infrequently painful
• Irregular borders
• Wet wounds, wound bed
  usually granular or yellow
  fibrous
                               7
                 Diagnostics
• Doppler ultrasound
• Ankle Brachial Index (ABI)
  • Measure brachial systolic pressure
  • Measure dorsalis pedis or posterial tibial systolic
    pressure
  • Calculate as follows:
     • Ankle systolic pressure / brachial systolic pressure
     • Ex: 80/100 = 0.8 ABI
  • Normal ABI > 0.9


                                                              8
             Diagnostics
•   Exercise testing
•   Duplex sonography
•   CT
•   CT Angiography
•   MR Angiography (MRA)
•   Arteriogram
•   Plethsmography
•   Venography

                           9
             Atherosclerosis
• Narrowing of the
  lumen of the artery
  related to plaque
  build up
• Can affect all
  arteries




                               10
Risk Factors for Atherosclerosis
Modifiable              Non-modifiable
• Tobacco use           • Age
• Diet                  • Gender
• Hypertension          • Family history
• DM
• Obesity
• Stress Sedentary
  lifestyle
• Elevated CRP and
  homocysteine levels
                                           11
Prevention of Atherosclerosis
• Dietary strategies
• Smoking cessation
• Control hyperlipidemia
• Control hypertension
• Reduce weight
• Increase activity


                            12
     Medical Management of
        Atherosclerosis
• Treat risk factors
• Vasodilators
• Surgery
• Angioplasty with ballooning or stenting




                                        13
     Nursing Management
• Patient teaching:
  • Smoking cessation
  • Exercise
  • Stress reduction techniques
  • Weight loss
  • Avoid exposure to cold
  • Avoid crossing legs
  • To warm, apply heat to lower abdomen


                                           14
    Peripheral Arterial Disease
              (PAD)
• Arterial insufficiency
• Most common in men
• Legs most often affected
• Obstructive lesions
  often found in
  abdominal aorta, renal
  arteries and popliteal
  arteries
• Distal disease more
  common in elderly and
  Diabetics
                                  15
                      PAD
Clinical Manifestations
  •   Intermittent claudication
  •   May progress to resting leg pain
  •   Resting leg pain more common at night
  •   Elevating leg increases pain
  •   Cold/numb feeling in limb
  •   Diminished or absent pulses
  •   Thick nails
  •   Pallor
  •   Loss of hair
  •   Wounds
                                              16
 Medical Management of PAD
Medications
  • Pentoxifylline (Trental) – increases flexibility of
    rbcs
  • Cilostazol (Pletal) – vasodilator with some
    antiplatelet activity
  • ASA or other antiplatelet (Plavix)
Surgery
  • Endarterectomy
  • Bypass grafts
  • Amputation
                                                          17
 Nursing Management of PAD
• Maintain circulation
  • Pulse checks q1-2h
• Monitor for potential complications
  • Vital signs
  • Fluid balance
  • Hematoma formation
  • Infection
• Pain management

                                        18
          Arterial Embolism &
           Arterial Thrombus
• Sudden arterial vascular occlusion
• Results from iatrogenic injury, trauma
• Associated with the 6 P’s
  •   Pallor
  •   Pulselessness
  •   Parasthesia
  •   Paralysis
  •   Pain
  •   Poikilothermia (coolness)


                                           19
        Arterial Embolism &
         Arterial Thrombus
Medical Treatment     Nursing Measures
  • Embolectomy         • Bedrest
  • Anticoagulation     • Keep leg level
  • Thrombolytics       • Monitor for bleeding
                          r/t thrombolytic
                          and/or
                          anticoagulant use
                        • Pulse checks
                        • Monitoring vital
                          signs


                                             20
               Aneurysm
• Localized dilation of an artery
• Abdominal Aorta accounts for majority
• Risk factors
  • Hypertension
  • Cigarette smoking
• Physical Exam
  • Bruit
  • Abdominal or back pain
  • SOB


                                          21
                 Aneurysm
• Diagnostics
  • CT or MRI
  • Ultrasound
• Medical
  Management
  •   Monitor growth
  •   BP control
  •   Smoking cessation
  •   Surgery

                            22
               Aneurysm
• Nursing Management
  • Maintain circulation
    • Pulse checks q1h
  • Elevate HOB no more than 45°
  • Monitor for potential complications
    • Vital signs
    • Fluid balance
    • Infection
  • Pain management

                                          23
 Deep Vein Thrombosis (DVT)
Development of a blood clot
  in the venous circulation

Three Factors Play Role
   (Virchow’s Triad)
  1. Venous stasis
  2. Vessel wall injury
  3. Altered blood coagulation

                                 24
        Risk Factors for DVT
Venous stasis              Vessel wall injury
  •   bedrest                • Trauma
  •   Obesity                • Surgery
  •   Varicosities           • Pacing wires
  •   Spinal cord injury     • Central venous
  •   Age >65y                 catheters
                             • Dialysis access
                               catheters
                             • Local vein damage
                             • Repetitive motion
                               injury
                                                   25
       Risk Factors for DVT
Altered coagulation        • Prothrombin 20210A
• Cancer                     defect
• Pregnancy                • Hyperhomocysteinemia
• Oral contraceptives      • Elevated factors II, VIII,
• Protein c deficiency       IX, XI
• Protein s deficiency     • Antithrombin III
                             deficiency
• Antiphospholipid Ab
                           • Polycythemia
• Factor V Leiden defect
                           • Septicemia


                                                     26
            S/S of DVT
• Often nonspecific
• May have:
  • Edema
  • Tenderness
  • (+) Homan’s sign
  • Redness
  • Increased warmth
  • (+) D-dimer

                         27
 Medical Management of DVT

• Un-fractionated Heparin
  • IV infusion given over 5-7d or until INR
    therapeutic (2-3_
  • Warfarin (Coumadin) started at the same
    time
  • Usual dose: 80units/kg bolus followed by
    18units/kg/hr
  • Requires monitoring of PTT levels

                                               28
 Medical Management of DVT

• Low Molecular Weight Heparin
  (LMWH)
  • Enoxaparin (Lovenox)
  • Dosed based on weight
  • Dose different for treatment of DVT vs
    prevention of DVT
  • Less bleeding issues
  • More cost effective

                                             29
 Medical Management of DVT

• Warfarin
  • Used for long-term therapy
  • Antidote = vitamin K
  • Dose individualized
  • Monitor PT/INR levels closely
  • Started on day 1 with LMWH or Un-
    fractionated heparin
  • Multiple drug and food interactions!

                                           30
 Medical Management of DVT

• Thrombolytics
  • Used less frequently
  • Big concern is hemorrhage
  • Dosing individualized
  • Patient must be monitored in critical care
    setting




                                                 31
 Medical Management of DVT
Contraindications to Anticoagulants
• Active bleeding
• Hemorrhagic blood dyscrasias
• Aneurysms
• Recent or impending surgery
• Recent stroke
• Recent delivery of a baby
• Hazardous Occupations
• Alcoholism
                                      32
 Medical Management of DVT

• Surgical
  Management
  • Thrombectomy
  • Insertion of
    Inferior Vena
    Cava filter




                             33
 Nursing Management of DVT

• Monitor for bleeding
• Monitor PT/INR with Warfarin
• Monitor PTT levels with unfractionated
  Heparin
• Pain management
• Elevate affected extremity
• AROM/PROM while on bedrest
• Patient education
                                       34
 Nursing Management of DVT

• Prevention of DVT is
  best!
  • Recognize who is at
    risk
  • Patient education
  • Early ambulation
  • Compression therapy
  • LMWH as
    appropriate
                             35
 Chronic Venous Insufficiency
• Occurs as result of venous obstruction
  or incompetent valves
• Leads to venous stasis and blood
  pooling
• Clinical manifestations
  • Edema
  • Altered pigmentation
  • Pain
  • Stasis dermatitis
                                           36
 Chronic Venous Insufficiency
• Complications
  • Chronic pain
  • Ulcers
  • Infection
• Management
  • Leg elevation
  • Compression hose
  • Avoid prolonged sitting or standing
  • Avoid pressure on popliteal spaces
                                          37
             Leg Ulcers
• Causes multifactorial
• Good assessment can often distinguish
  between arterial and venous ulcers
• Arterial Ulcers
  • Be careful with debridement techniques
    with poor circulation



                                             38
       Medical and Nursing
         Management of
           Leg Ulcers
• Antibiotics if infected
• Pain management
• Compression therapy (venous)
• Debridement
  • Surgical
  • Enzymatic
  • Autolytic
  • Mechanical

                                 39
       Medical and Nursing
         Management of
           Leg Ulcers
• Dressings
  • Calcium alginates
  • Hydrogels
  • Hydrocolloids
  • Wet to moist saline dressing
• Hyperbaric Oxygen
• Apligraf

                                   40
 Other Circulatory Problems
• Varicose Veins
  • Dilated superficial veins caused by
    incompetent valves
• Raynaud’s Disease
  • Intermittent arteriolar vasoconstriction




                                               41
       Nursing Diagnoses
• Altered tissue perfusion
• Chronic pain
• Risk for impaired skin integrity
• Deficient knowledge
• Risk for infection



                                     42
                 Case Study
JM is a 75y male who lives alone. He has a hx of CHF,
    Type II DM and CAD. He presents to your hospital
    with a non-healing ulcer of his left leg. His left DP
    and PT pulse is non-palpable and he has 3+ edema
    of both legs.

1.   What factors contribute to his leg ulcer?
2.   Is the leg ulcer likely to be venous or arterial?
3.   What medical and nursing interventions would be
     appropriate?
4.   What factors need to considered for home care?

                                                        43
        Practice Question
When obtaining a health history from a
 72y male with PAD of the lower
 extremities, the nurse asks about a
 history of related conditions such as:
 a. venous thrombosis
 b. venous stasis ulcers
 c. pulmonary embolism
 d. carotid artery disease

                                          44
          Practice Question
During the care of the patient following femoral
 bypass graft surgery, the nurse immediately
 notifies the health care provider if the patient
 experiences:
 a. fever and redness at the incision site
 b. 2+ edema of the extremity and pain at the
 incision site
 c. a loss of palpable pulses and numbness and
 tingling of the feet
 d. decreased ABI indices and serous drainage
 from the incision
                                               45
        Practice Question
The nurse teaches the patient that with
 any venous disorder the best way to
 prevent venous stasis and increase
 venous return is to:
 a. walk
 b. sit with legs elevated
 c. frequently rotate ankles
 d. continuously wear compression
 stockings
                                          46

								
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