PVD WORD - PVD etiology, diseases, nursing interventions, and pharm PDF

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PVD etiology, diseases, nursing interventions, and pharm...

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Wednesday, May 19, y PVD Describe the appropriate parameters for assessment of .1 : peripheral circulation • Peripheral Vascular Disease (PVD): An umbrella term that covers both arterial and venous diseases. Any condition that disrupts flow through the peripheral blood and lymphatic system. The normal function of the peripheral system is to circulate blood to all body tissues as well as ensure capillary exchange between blood plasma, interstitial fluid, and tissue cells. Any impairment of this system can result in impaired delivery of oxygen and nutrients to the tissues. - Peripheral Arterial Disease (PAD): Refers to any progressive and chronic disease process that affects the arteries. Obstruction can be from a variety of causes like atherosclerosis, inflammation, stenosis, embolus, or thrombus. Atherosclerosis is the most common risk factor for PAD. - Peripheral Venous Disease (PVD): This affects the veins, a blockage causing venous insufficiency. Leads to varicose veins and thromboembolism. Interpret the purpose and nursing implications for commonly .2 ordered laboratory and diagnostic prescriptions for peripheral :vascular disease - Nurse assessment: Patient history, BP, pulse, pulse ox, visual assess, temp, muscle tone, pain assess, calf circumference, anklebrachial index, and treadmill test for PAD. ‣ Ankle-Brachial Index (ABI): Uses a doppler prove to compare the BP obtained at the ankle with the pressure obtained at the brachial artery. ‣ Exercise Tolerance Test (“stress test”): Done with or without the use of treadmill (meds can be given to mimic the effects of exercise) with measurements if pulse volume and BP. Delay in return to normal indicates arterial disease. Also evaluate for claudication (pain from too little blood flow) during exercise. ‣ Bedside doppler: Nursing measure when it is difficult to feel client’s pulses, can also be used to see a difference in pulses (one side has bounding pulse while other side is weak). - Lab tests: Lipid profile, triglycerides, hemoglobin A1c, coagulation :Radiologic test ‣ Plethysmography: Used to evaluate arterial blood flow in the lower extremities. ‣ Arteriography: Injection of contrast medium to visualize areas of decreased arterial flow on an x-ray. ‣ Magnetic Resonance Angiography (MRA): Contract medium is injected to visualize blood flow through peripheral arteries. Compare the various peripheral artery diseases and their causes, .3 1

Wednesday, May 19, y pathophysiology, clinical manifestations, management and :prevention • Peripheral Arterial Disease: Refers to any progressive and chronic disease process that affects the arteries (carry oxygenated blood away from the heart). Obstruction can be from a variety of causes like atherosclerosis, inflammation, stenosis, embolus, or thrombus. Atherosclerosis is the most common risk factor for PAD. • Risk factors: Age (over 65), family history, pre-existing health conditions (HTN, hyperlipidemia, diabetes, coronary artery disease, clotting), sedentary lifestyle, obesity, smoking, and atherosclerosis. Assessment findings: All a result of reduced perfusion. At first, the • . patient may be asymptomatic - Decreased or non-palpable pedal pulses (may need a doppler) - Decreased capillary refill of toes (>3 sec) - Rest pain (pain at rest), relieves by putting affected limb in depend position (relieved by putting the limb beneath the heart, helps gravity to flow downward). - Hair less on lower legs, thicker nails, shiny/dry skin (diminished blood flow and nutrients to the hair follicles) - Cold or cyanotic extremities - Pallor with elevation (all of the blood drains out of veins) and rubor with dependency - Sensations changes: Numbness, tingling of extremities, burning pain in feet (when in bed). - Intermittent claudication (“a limping”): Happens when the patient is walking or exercising and there is an increased need for oxygen and nutrients to the lower legs, due to arterial narrowing, the oxygen and nutrients cannot get there and the patient has pain as the muscles and tissues are starving. Once they stop and rest, the pain subsides. - Ulcers or gangrene of toes • Patient management: The primary goal is to reduce symptoms and prevent the progression of arterial disease and cardiovascular complications. - Diet & lifestyle changes - Weight loss and adherence to a low fat diet will reduce the risk of cardiovascular complications - Exercise - Smoking cessation - Risk factor modification (control of diabetes, HTN, hypercholesterolemia) :Nursing interventions • - Tissue perfusion: Slight dependency - don’t elevate legs (can cause decreased arterial flow, pallor with elevation), full dependency contraindicated 2

Wednesday, May 19, y Skin integrity: Frequent skin assessments (monitor for deterioration), turned often (to avoid pressure ulcers/deep tissue injuries), trim nails carefully (avoid infection, thick nails), safety issues (if lesions develop healing may be delayed bc of poor perfusion). • Patient education: Measures to prevent tissue loss and amputation are high priority. - Avoid trauma, wear sturdy, well fitted shoes - Warm environment, dress appropriately for cold weather (cold = vasoconstriction = decreased perfusion) - No smoking, causes vasoconstriction - Avoid stress, causes vasoconstrictions by stimulating sympathetic NS - No constrictive clothing, leg crossing - Inspect skin daily, foot care - Avoid heating pads, hot water (risk for burns) :Specific types of PAD • Arteriosclerosis (“hardening”, “arteries”): A more general term that means hardening or thickening of the arterial wall. Therefore, a patient with arteriosclerosis may not have .atherosclerosis ‣ Atherosclerosis: When lipid/plaque particles build up in the walls of the artery. Is thought to begin from an inflammatory response to when a vessel becomes inflamed. It results is thickening of the inner layer of the artery, causing the diameter to shrink and the blood flow to reduce. The final outcome is that the tissues supplied by the vessel don’t receive the adequate blood and therefore oxygen supply. The plaques can become unstable and rupture, traveling throughout the body. When this happens, a clot can form around the clot, blocking blood flow entirely. Atherosclerosis is a type of arteriosclerosis. - Raynaud’s phenomenon: No occlusion but there is intermittent vasoconstriction which usually occurs in the hand/fingers and feet/toes. Sensitivity to cold, common in women. ‣ Assessment: Pallor —> Cyanotic —> Rubor. Intense spasm of the digital arteries produces initial pallor (white), followed over minutes of capillary dilation and filling with deoxygenated venous blood, resulting in cyanosis (blue). On relaxation of the arterial spasm, the circulation improves (warm red digits). Due to the loss of blood flow, it can be painful and cause numbness/tingling. ‣ Management: Patient should be taught to avoid triggers that can cause the phenomenon, including the cold, stress, or smoking. Calcium channel blockers can be used to treat patients with this phenomenon if it affects their quality of life. -

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Wednesday, May 19, y Buerger’s disease (Thromboangiitis Obliterans): ‣ Almost always occurs in smokers or those who chew tobacco, finger tips turn black. Patient have pain and intense rubor. Caused by an inflammatory process that causes vessels to swell and become occluded. Occurs more in men, believed to be autoimmune vasculitis (inflammation of a blood vessel). Treatment is the same as atherosclerotic. Can lead to gangrene, which usually ends in amputation. People can lose they fingers, toes, and even entire hand or foot. : Common complications • Critical limb ischemia: Sustained severe decrease in blood flow to lower extremity which leads to infection, gangrene, and ultimately . limb loss if left untreated. This patient will most likely need surgery Arterial ulcers: Are usually the result of critical limb ischemia, ‣ which is progressive loss of perfusion to an extremity due to peripheral artery disease. Are typically small, circular, and deep with smooth edges. Poorly fitted shoes, improperly uncut toe nails can lead to a wound that won’t heal and lead to ulcers . and/or amputation Acute limb schema: A sudden decrease/interruption in limb perfusion most commonly caused by either thrombosis or embolism. Emergent and will need surgery. This often happens after onset of . atrial fibrillation or MI Thrombosis: Blood clot that forms in a vein Embolism: Anything that moves through the blood vessel unit it . reaches a vessel too small to pass through Assessment signs: Six P’s - pain (severe and consistent), ‣ pallor, pulselessness, poikilothermia (inability to regular body temp, coldness), paresthesia (burning or prickling sensation), ( paralysis (late sign Management: Should be treated as an emergency. The goal is ‣ to preserve the limb, which can happen with early intervention. Patient should be on an anticoagulant, Heparin, which prevents further clot formation, but it doesn’t dissolve the existing clot. To remove the clot and restore blood flow, surgery may be needed. Once clot is removed, the patient will have relieved pain and . improved healing :Arterial procedures • Angioplasty/percutaneous transluminal (minimally invasive): . Uses a ballon stent to open artery and increase blood flow Laser-assisted angioplasty (minimally invasive): Uses a laser to vaporize (uses heat) atherosclerosis plaque and open the artery, . indicated for smaller occlusions Rotational atherectomy (minimally invasive): Used for very hard, calcified stenotic lesions. In this procedure, the plaque is -

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Wednesday, May 19, y broken into small fragments with high speed rotary brush. The small . fragments can pass harmlessly into circulation Embolectomy (surgery): Removal of a clot that’s blocking the .artery Bypass graft (Leg revascularization, surgery): Used to reroute the circulation around the arterial occlusion. Grafts can be from . another vessel in the patient or a synthetic graft Post-surgical care: Main objective is to maintain adequate ‣ circulation. Monitor graft for occasion, doppler for pulse, VS, leg elevated on pillow, pain control, turn/cough/deep breath, encourage to move the extremity, IV fluids, dry sterile dressing, report any signs of the six P’s. Monitor for compartment syndrome, which can occur as a result of swelling in a confined body space and restrict blood flow. Symptoms include severe . pain, edema, diminished pluses, and numbness Compare the various diseases of the peripheral veins and their .4 causes, pathophysiology, clinical manifestations, management :and prevention • Peripheral Venous Disorder: Problems with the vein that interfere with adequate return of blood flow from the extremities and can result in blood stasis. • Venous thromboembolism (VTE): A blood clot in a large vein believed to form as a result of venous stasis, endothelial injury, or hyper-coagulability. If the clot become mobile, it can travel and block blood supply to the lungs (pulmonary embolism), which is life threatening. This occurs as a result of three mechanisms known as Virchow’s Triad - decreased rate of flow in the blood stream (stasis), damage to the vessel wall, and increased tendency of the blood to clot. - Venous stasis risk factors: Result of immobility (bedrest, long plane/car/train rides, obesity, paralysis, recent surgery, pregnancy). Most patient in the hospital are at risk which is why they’re prescribed a med like Lovenox or Heparin to prevent formation of blood clots. - Vessel wall injury: Can occur as a result of trauma (fracture), central venous catheterization (central lines), vascular devices (PICC), IV meds, cancer therapy (chemo). Anything that disrupts the vessel can cause buildup of platelets and increase likelihood of a clot. - Hyper-coagulability: Increased tendency for blood to clot. Risk factors include pregnancy, cancers, septic shock, blood disorders. • Deep vein thrombosis: (DVT): Can occur in many large veins, but mostly occur in the calf. Patient presents with pain, swelling/edema, tenderness, induration/hardness, warmth, and erythema. :Diagnosis ‣ D-Dimer: A blood test that measures fibrin, a positive test can 5

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indicate that thrombus has possibly occurred. Is a marker of coagulation activity. If positive, a follow-up test should be done. ‣ Contrast CT venography: Uses contrast and CT scan to locate blockage. ‣ Doppler flow study: Non-invasive allows visualization of thrombi - Management: Anticoagulant therapy (heparin), early ambulation, elevation of extremities, analgesics, compression socks - Surgical intervention: DVTs are rarely surgically removed unless danger of PE. In the case of a massive occlusion, a thrombectomy can be done. Vena cava interruption is done to prevent PE. An inferior cava filter is placed to trap an emboli. - Prevention: In the hospital, the nurse should perform early ambulation/ROM, leg elevation, avoid pressure, hydration, and use compression stockings. Varicose veins: Enlarged, twisted, superficial veins that are most commonly observed in lower extremities and esophagus. They occur as a result of incompetent valves in the veins, allowing blood to seep backwards. - Risk factors: Female, over 30, prolonged standing, pregnancy/obesity, systemic disease, family history (hereditary weakness of vein wall). - Manifestations and assessment: Heaviness or achy feelings in legs, muscle cramps (nocturnal cramps common), edema, knotty/twisted veins, pain, discoloration, ulcerations (extreme). Can assess using Trendelenburg test. In this test, the patient is in a supine position with legs elevated. When the patient sits up, the veins will fill from the proximal end if varicosities are present (normally they fill from the distal end). - Management: Non-surgical management includes compression stockings, elevate legs, no standing for long periods/no crossing legs, weight reduction. Surgical includes sclerotherapy, radio frequency (thermal ablation), and venous ligation/stripping. - Post-procedure care: Assess groin/leg for bleeding and monitor pulses, elevate involved leg, ROM exercises for legs, compression stockings, once home avoid standing for long periods of time. Venous insufficiency: Occurs in deeper veins due to incompetent valves. Results in pooling of blood in the lower extremities which results in the veins inability to carry fluid and waste from the lower extremities - creates swelling, venous stasis, and cellulitis. Patients will usually have edema, brown discoloration of lower legs, and stasis ulcers around the ankles. - Management: Can be chronic and require long term management. Patients with neuropathy may not feel pain at ulcer site, ulcers will need to be treated by wound care specialist, legs should be

Wednesday, May 19, y elevated multiple times a day, legs shouldn’t be above the heart when in bed, no crossing legs, compression stockings. Examine the purpose and nursing implications for medications .5 commonly used in the treatment of clients with problems of the :peripheral vascular system Heparin: Given SQ or IV. Due to the peak and duration, it’s given • several times per day. Therefore, it’s important to use proper technique, rotation sites, don’t not aspirate, and do not massage. Client teaching includes soft toothbrush, electric razor to shave, . monitor for indications of bleeding - IV administration: Weight based and always given via IV pump. Usually, a bolus will be administered at the beginning via IV push to get the patient started followed by an IV infusion. Heparin in a high rose is a high alert drug, which means it needs double checking by another nurse. - Nursing implications: Monitor for complications such a bleeding. If patient becomes too anti-coagulated, protamine sulfate can be given. Base line VS, platelet count, and hematocrit levels. - Complications: Heparin-induced thrombocytopenia (HIT) is a serious complication of heparin infusion. Therefore, nurse should be monitoring patient’s platelet levels throughout admin. If HIT occurs, heparin must be stopped and a new med might be used. • Lovenox (Enoxaparin): Low molecular weight Heparin which works over a long period of time. Can be used for both prevention and treatment of DVT and is administered twice a day. No monitoring (labs) necessary, fewer bleeding complications, can self-admin at home. Air bubble must stay intact, admin at 90 degree angle, don’t aspirate or massage, pressure for 2 mins after giving. • Warfarin (Coumadin): An anticoagulant that prevent vitamin K synthesis in the GI tract, therefore, preventing clot formation. Side effects include bleeding, toxicity/overdose (monitoring needed). Antidote is vitamin K. Teaching includes monitoring PT/INR (prothrombin time), consistency with vitamin k foods (leafy green veggies), interacts with MANY meds and alcohol. • Rivaroxaban (Xarelto): Oral direct factor Xa inhibitor, prevent DVT and PE. No monitoring needed. Bedsides increased bleeding, there’s no way of telling if the dose is too high. No antidote in an event of major bleeding. Bleeding, bruising, headache, and eye pain are common complains. • Dabigatran Etexilate Mesylate (Pradaxa): Works by binding with and inhibiting thrombin, thus preventing a thrombus from developing. Prevents stroke or embolisms in patients who have atrial fibrillation. Also used to treat DVT and PE. Monitor for bleeding. •

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Aspirin: May be prescribed to reside risk of thromboemboli, which can

Wednesday, May 19, y lead to stroke or MI. This is an anti-

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platelet. Clopidrogel (Plavix): May be prescribed to reside risk of thromboemboli, which can lead to stroke or MI. This is an anti-platelet.

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