Download peripheral vascular disease

NUR 1021
STUDY GUIDE TOPIC:
PERIPHERAL VASCULAR DISEASE
A.
Objectives:
1.
Describe the changes that occur in the peripheral blood flow and tissue oxygenation from the
peripheral vascular structures
2. Explain the risk factors that lead to peripheral vascular disorders
3. Identify the assessments and diagnostic tests utilized in the diagnosis of peripheral vascular
disorders
4. Use the nursing process in caring for patients with vascular insufficiency of the extremities.
5. Compare the various diseases of the arteries and their causes, pathophysiological changes,
clinical manifestations, management & prevention.
6. Describe the prevention and management of venous thromboembolism.
7. Describe a brief care plan for a patient experiencing thrombophlebitis.
8. Compare strategies to prevent venous insufficiency, leg ulcers, and varicose veins.
9. Explain the nursing implications for medications and other interdisciplinary treatment used for
patients with peripheral vascular disorders
10. Discuss the condition of a pulmonary embolism and the therapeutic management of it.
11. Explain the common disorders that affect the lymphatic system and the related therapeutic care
focus.
B.
Required Readings:
1. Hinkle and Cheever. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing.
Ch. 30, pp.819-859.
2. Karch. Focus on Nursing Pharmacology. Chapter 48, pp. 799-816.
-2D.
Study Outline:
1.
Identify risk factors for peripheral venous disease.
2.
Discuss the pathophysiology of impaired venous return and varicose veins.
3.
State assessment findings that are typically present in a patient with peripheral venous
disease.
4.
Describe actions and side effects of medications used to treat deep vein thrombosis (DVT).
5.
Identify complications of peripheral venous disease.
-3-
6.
Describe interventions for venous ulcers.
7.
What interventions help prevent ulcers?
8.
9.
Describe the types of dressings used for venous ulcers.
Describe:
1) Nonselective debridement
2) Enzymatic debridement
3) Debriding agents, i.e., Debrisan Beads
4) Calcium alginate dressings
10. Write out a nursing care plan for a client hospitalized with thrombophlebitis.
11. Identify common nursing diagnoses for patients with a) venous insufficiency, and b) thrombophlebitis and/or DVT.
NUR 1021 Spr Pck PVD/
PULMONARY EMBOLISM
Pulmonary embolism refers to the obstruction of one or more pulmonary arteries by a thrombus (or
thrombi) that originates somewhere in the venous system or in the right side of the heart, becomes
dislodged, and is carried to the lung. An infarction of lung tissue caused by interruption of the
lung's blood supply results in 10% of embolic episodes. Pulmonary embolism is a common disorder
and is often associated with advanced age, postoperative states, and prolonged immobility. It may
occur in an apparently healthy person. Persons who are at risk of developing a pulmonary embolus
are listed in Chart 23-2.
The majority of thrombi originate in the deep veins or the legs. Other sources include the pelvic
veins and the right atrium of the heart. Stasis, or slowing of blood flow, owing to damage to the
blood vessel wall (particularly the endothelial lining) and changes in the blood coagulation
mechanism, are factors favoring formation of venous thrombi.
Pathophysiology. Following a massive embolic obstruction of the pulmonary arteries, there is an
increase in alveolar dead space since the area, although continuing to be ventilated, receives little or
no blood flow. In addition, a number of vasoactive and bronchoconstrictive substances are released
from the clot. These substances compound the ventilation-perfusion imbalance, causing venous
admixture and shunting.
The hemodynamic consequences are increased pulmonary vascular resistance due to reduction in
the size of the pulmonary vascular bed, a consequent increase in pulmonary arterial pressure, and in
turn, an increase in right ventricular work to maintain pulmonary blood flow. When the work
requirements of the right ventricle exceed its capacity, right ventricular failure occurs. When this
happens there is a decrease in cardiac output followed by a drop in systemic blood pressure and the
development of shock.
Clinical Manifestations. The symptoms of pulmonary embolism depend on the size of the thrombus
and the area of the pulmonary artery occluded. Dyspnea is the one symptom that is usually
consistently present with pulmonary embolism. A massive embolism occluding the bifurcation of the
pulmonary artery can produce pronounced dyspnea, sudden substernal pain, rapid and weak pulse,
shock, syncope, and sudden death.
If one or more branches of the right or left pulmonary arteries are obstructed, the patient experiences
dyspnea, mild substernal pain, anxiety, weakness, and tachycardia. Usually, these symptoms are
the result of pulmonary infarction. There may also be fever, cough, and hemoptysis. The patient's
respiratory rate is accelerated out of proportion to the degree of fever and tachycardia. If the
terminal pulmonary arteries are occluded, a pleuritic type of pain develops, together with cough and
hemoptysis. Multiple small emboli can lodge in the terminal pulmonary arterioles, producing
multiple small infarctions. The clinical picture may simulate that of bronchopneumonia or heart
failure. In some instances, the disease presents in an atypical fashion with few signs and symptoms,
while in other instances is mimics various cardiopulmonary disorders.
Preventive Measures. A liberal fluid intake is encouraged because dehydration predisposes to
thrombus formation.
Suppression of platelet function by pharmacologic agents (aspirin,
dipyridamole) is being used to prevent platelet aggregation to reduce the likelihood of
thromboembolism.
The American Heart Association recommends that patients who are over 40 and hemostatically
competent, and who are undergoing major elective abdominothoracic surgery, be given low doses of
heparin to diminish postoperative deep thrombus and pulmonary embolism. The heparin is given
subcutaneously two hours before surgery and continued every 12 hours until the patient is
discharged. Low-dose heparin is thought to enhance the activity of antithrombin III, a major plasma
inhibitor of clotting factor X. (This regimen is not recommended for patients who are experiencing an
active thrombotic process or those undergoing major orthopedic surgery, open prostatectomy, or
operations on the eye or brain.)
-2Emergency Interventions. Massive pulmonary embolism is a true medical emergency; the patient's
condition tends to deteriorate rapidly. The immediate objective of treatment is to stabilize the
cardiorespiratory system. The majority of patients who die of massive pulmonary embolism do so in
the first two hours following the embolic event. Emergency management consists of the following:
 Nasal oxygen is administered immediately to relieve hypoxemia, respiratory
distress, and cyanosis.
 An infusion is started to open an intravenous route for drugs/fluids that will
=be needed
 Pulmonary angiography, hemodynamic measurements, arterial blood gas
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NUR 1021 Spr Pck PVD/
determinations, and perfusion lung scans are carried out. A sudden rise in
pulmonary resistance increases the work of the right ventricle, which can
cause acute right-sided heart failure with cardiogenic shock.
If the patient has suffered massive embolism and is hypotensive, an
indwelling urethral catheter is inserted to monitor urinary volume.
Hypotension is treated by a slow infusion of isoproterenol (has a dilating
effect on pulmonary vessels and bronchi) or dopamine.
The electrocardiogram is monitored continuously for right ventricular
failure, which may have a rapid onset.
Sodium bicarbonate may be administered to correct metabolic acidosis.
Digitalis glycosides, intravenous diuretics, and antiarrhythmic agents are
given when appropriate.
Blood is drawn for serum electrolytes, blood urea nitrogen, complete blood
count, and hematocrit.
If clinical assessment and arterial blood gases indicate the need, the patient
is placed on a volume-controlled ventilator.
Small doses of intravenous morphine are given to relieve the patient's
anxiety, to alleviate chest discomfort, to help him accept the discomfort of
the endotracheal tube, and to ease his adaptation to the mechanical
ventilator.