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1/3/2008
1
MedicalMedical--Surgical Surgical Nursing CareNursing Care
Second EditionSecond Edition
Karen Burke
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Chapter 28Chapter 28Caring for Clients withCaring for Clients withPeripheral Vascular DisordersPeripheral Vascular Disorders
Priscilla LeMoneElaine Mohn-Brown
HypertensionHypertension
Blood pressure higher than 140 mm Hg systolic or 90 Blood pressure higher than 140 mm Hg systolic or 90 mm Hg diastolic on three separate readings several mm Hg diastolic on three separate readings several weeks apartweeks apartCommon in people over age 40Common in people over age 40
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
p p gp p gHypertension in the elderlyHypertension in the elderly
HypertensionHypertension
Often called the silent killerOften called the silent killerClassified by cause and courseClassified by cause and coursePrimary hypertensionPrimary hypertension
No identified causeNo identified cause
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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No identified causeNo identified causeRisk factorsRisk factors
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BOX 28BOX 28--22 Risk Factors for Hypertension.Risk Factors for Hypertension.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
HypertensionHypertensionSecondary HypertensionSecondary Hypertension
Elevated blood pressure related to another disorderElevated blood pressure related to another disorderKidney diseaseKidney diseaseCoarctation of the aortaCoarctation of the aortaPregnancyPregnancy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
g yg yEndocrineEndocrineNeurologic disorderNeurologic disorderUse of stimulantsUse of stimulants
Diagnostic tests: blood, urine testsDiagnostic tests: blood, urine tests
Hypertension Hypertension -- PathophysiologyPathophysiologyPeripheral vascular resistance primary factor Peripheral vascular resistance primary factor determining blood pressuredetermining blood pressureHypertensionHypertension
Increased resistance to blood flowIncreased resistance to blood flow
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Disrupted physiologic mechanismsDisrupted physiologic mechanismsOveractive sympathetic nervous systemOveractive sympathetic nervous systemOveractive reninOveractive renin––angiotensinangiotensin––aldosterone systemaldosterone systemAtrial natriuretic peptide participatesAtrial natriuretic peptide participatesInsulin resistance plays a roleInsulin resistance plays a role
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Hypertension Hypertension -- PathophysiologyPathophysiology
Blood volume and peripheral vascular resistance Blood volume and peripheral vascular resistance increaseincreaseWorkload of left ventricle increasesWorkload of left ventricle increasesLeft ventricular muscle mass increasesLeft ventricular muscle mass increases
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Left ventricular muscle mass increasesLeft ventricular muscle mass increases
HypertensionHypertensionManifestations and ComplicationsManifestations and Complications
Usually no symptoms other than increased blood pressureUsually no symptoms other than increased blood pressureComplaints of vague headache or dizzinessComplaints of vague headache or dizzinessMorning headacheMorning headacheBl d i iBl d i i
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Blurred visionBlurred visionUnsteadinessUnsteadinessDepressionDepressionNocturiaNocturia
Hypertensive CrisisHypertensive Crisis
Rapid increase in systolic pressure 240 mm Hg or Rapid increase in systolic pressure 240 mm Hg or diastolic pressure 120 mm Hgdiastolic pressure 120 mm HgMalignant hypertension: diastolic pressure > 130 mm Malignant hypertension: diastolic pressure > 130 mm HgHg
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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ggImmediate treatmentImmediate treatmentHeadache, confusion, blurred vision, restlessness, Headache, confusion, blurred vision, restlessness, motor/sensory deficitsmotor/sensory deficits
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Hypertension Hypertension -- TreatmentTreatment
No specific diagnostic testsNo specific diagnostic testsLab tests done to diagnose secondary hypertensionLab tests done to diagnose secondary hypertensionTreatment to lower blood pressureTreatment to lower blood pressureReduce the risk of damage to CV system and otherReduce the risk of damage to CV system and other
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Reduce the risk of damage to CV system and other Reduce the risk of damage to CV system and other target organstarget organsControl lifestyle variables and medicationControl lifestyle variables and medication
Hypertension Hypertension –– TreatmentTreatmentLifestyle ModificationsLifestyle Modifications
Restrict alcohol use, restrict cigarette smoking, increase Restrict alcohol use, restrict cigarette smoking, increase physical activity, stress reductionphysical activity, stress reductionWeight lossWeight lossDietDiet
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
DietDietReduce sodium and fatReduce sodium and fatPromote weight lossPromote weight lossDASH dietDASH diet
Hypertension Hypertension –– Nursing CareNursing CareIneffective Health MaintenanceIneffective Health Maintenance
TeachingTeachingPrescribed treatmentPrescribed treatmentLifestyle changesLifestyle changesS di i t kS di i t k
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Sodium intakeSodium intakeWeight loss strategiesWeight loss strategies
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Hypertension Hypertension –– Nursing CareNursing CareEvaluationEvaluation
Client informationClient informationResponse to treatmentResponse to treatmentTeachingTeaching
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Hypertension Hypertension –– Nursing CareNursing Care
TeachingTeachingPrimary care providerPrimary care providerNeed for home careNeed for home careDaily medicationDaily medication
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Realistic exercise planRealistic exercise planStress reductionStress reductionRegular followRegular follow--up careup care
AneurysmAneurysm
Weakness and localized dilation of blood Weakness and localized dilation of blood vessel wallvessel wallClassified by shape and locationClassified by shape and location
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
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Figure 28Figure 28--1.1. Aortic aneurysms. (A) Fusiform aneurysm of the abdominal aorta. (B) Saccular aneurysm of the descending Aortic aneurysms. (A) Fusiform aneurysm of the abdominal aorta. (B) Saccular aneurysm of the descending thoracic aorta. (C) Dissecting aneurysm of the ascending thoracic aorta.thoracic aorta. (C) Dissecting aneurysm of the ascending thoracic aorta.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
AneurysmAneurysmOften are asymptomaticOften are asymptomaticPressure on adjacent tissues and organs causes Pressure on adjacent tissues and organs causes manifestationsmanifestations
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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AneurysmAneurysmThoracic AorticThoracic Aortic
Often asymptomaticOften asymptomaticMight have substernal (anginal), neck, or back painMight have substernal (anginal), neck, or back painPressure on thoracic structures might cause SOB, stridor, Pressure on thoracic structures might cause SOB, stridor, cough swallowing difficulties facial edema JVDcough swallowing difficulties facial edema JVD
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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cough, swallowing difficulties, facial edema, JVDcough, swallowing difficulties, facial edema, JVDEnlarge, rupture, leading to deathEnlarge, rupture, leading to death
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AneurysmAneurysmAbdominal AorticAbdominal Aortic
Associated with HTN, smoking, advancing ageAssociated with HTN, smoking, advancing ageFound in adults over age 70Found in adults over age 70Asymptomatic; might have a pulsating mass in the Asymptomatic; might have a pulsating mass in the mid/upper abdomen with a bruitmid/upper abdomen with a bruit
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
mid/upper abdomen with a bruitmid/upper abdomen with a bruitComplaints of mild to severe midComplaints of mild to severe mid--abdominal/lower back abdominal/lower back painpainPain an indication of pending rupturePain an indication of pending rupture
AneurysmAneurysmAortic DissectionAortic Dissection
LifeLife--threatening emergencythreatening emergencyTear in the inner layer of aorta with bleeding into middle Tear in the inner layer of aorta with bleeding into middle layerlayerVessel wall splitsVessel wall splits
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Vessel wall splitsVessel wall splitsCommon in the ascending aortaCommon in the ascending aortaHTN, Marfan syndrome at higher riskHTN, Marfan syndrome at higher risk
Aortic DissectionAortic DissectionManifestationsManifestations
Ripping painRipping painHigh blood pressure followed by a sudden dropHigh blood pressure followed by a sudden dropAbsent peripheral pulsesAbsent peripheral pulses
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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AneurysmAneurysmDiagnostic testsDiagnostic tests
Abdominal or chest xAbdominal or chest x--rayrayAbdominal ultrasoundAbdominal ultrasoundCT scan/MRICT scan/MRI
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Aneurysm Aneurysm -- TreatmentTreatmentMedicationsMedications
AntihypertensivesAntihypertensivesAnticoagulantsAnticoagulants
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Aneurysm Aneurysm -- TreatmentTreatment
SurgerySurgeryRepair those that are tender or enlargingRepair those that are tender or enlargingExcise the aneurysm and replace with graftExcise the aneurysm and replace with graft
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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1/3/2008
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Figure 28Figure 28--2. 2. Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.(B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Figure 28Figure 28--2. (continued) 2. (continued) Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the Repair of an abdominal aortic aneurysm. (A) The aneurysm is exposed and clamped above the vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft. vessel dilation. (B) A synthetic graft is used to replace the aneurysm. The arterial wall is then sutured around the graft.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Aneurysm Aneurysm -- TreatmentTreatment
Surgery Surgery –– Preop Nursing CarePreop Nursing CareRoutine careRoutine careICU environmentICU environmentReport changes in medical conditionReport changes in medical condition
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Bed restBed restAvoid Valsalva maneuverAvoid Valsalva maneuver
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AneurysmAneurysmSurgery Surgery –– Postop Nursing CarePostop Nursing Care
General careGeneral careChest tubeChest tubeAssess for bleedingAssess for bleedingFl id/bl d t f iFl id/bl d t f i
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Fluid/blood transfusionsFluid/blood transfusionsComplicationsComplications
Aneurysm Aneurysm –– Nursing CareNursing Care
AnxietyAnxietyPainPainIneffective Tissue PerfusionIneffective Tissue Perfusion
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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AneurysmAneurysm
Continuing CareContinuing CareControl HTN, diet, stress reduction, alcohol, smoking, Control HTN, diet, stress reduction, alcohol, smoking, medicationsmedicationsPrevent complicationsPrevent complications
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Postop teachingPostop teachingRestRestPrevent constipationPrevent constipationFollow up appointmentsFollow up appointments
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Peripheral AtherosclerosisPeripheral AtherosclerosisPathophysiologyPathophysiology
Thick peripheral arteries, plaque deposits, lumen narrowsThick peripheral arteries, plaque deposits, lumen narrowsDecreased blood flow and oxygen to distal tissuesDecreased blood flow and oxygen to distal tissuesSymptoms after 60% vessel occludedSymptoms after 60% vessel occluded
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Peripheral AtherosclerosisPeripheral Atherosclerosis
ManifestationsManifestationsPainPainIntermittent claudicationIntermittent claudicationSkin color changesSkin color changes
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Pulse changesPulse changesBruitBruitComplications: gangrene, amputationComplications: gangrene, amputation
Peripheral Atherosclerosis Peripheral Atherosclerosis ––TreatmentTreatment
Improve/maintain blood supply and relieve symptomsImprove/maintain blood supply and relieve symptoms
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Peripheral AtherosclerosisPeripheral Atherosclerosis
Diagnostic testsDiagnostic testsSegmented blood pressuresSegmented blood pressuresExercise stress testingExercise stress testingDoppler ultrasoundsDoppler ultrasounds
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Transcutaneous oximetryTranscutaneous oximetryAngiographyAngiography
Peripheral Atherosclerosis Peripheral Atherosclerosis --TreatmentTreatment
MedicationsMedicationsAspirinAspirinPlavixPlavixPletalPletal
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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VasodilatorsVasodilators
Peripheral AtherosclerosisPeripheral AtherosclerosisTreatmentTreatment
Smoking cessationSmoking cessationExerciseExerciseWeight reductionWeight reductionC l t th iC l t th i
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Complementary therapiesComplementary therapies
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Peripheral AtherosclerosisPeripheral AtherosclerosisTreatmentTreatment
Percutaneous transluminal angioplastyPercutaneous transluminal angioplastyStentStentAtherectomyAtherectomy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Peripheral AtherosclerosisPeripheral AtherosclerosisTreatmentTreatment
SurgerySurgeryRevascularizationRevascularizationEndarterectomyEndarterectomy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Peripheral Atherosclerosis Peripheral Atherosclerosis ––Nursing CareNursing Care
Ineffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralPulsesPulsesWarmthWarmthFrequent position changesFrequent position changes
P iP i
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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PainPainPain scalePain scaleWarmthWarmthSmoking cessationSmoking cessationStress reductionStress reduction
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Peripheral Atherosclerosis Peripheral Atherosclerosis ––Nursing CareNursing Care
Impaired Skin IntegrityImpaired Skin IntegrityAssess every 8 hoursAssess every 8 hoursFoot and leg careFoot and leg careFoot cradleFoot cradle
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Peripheral Atherosclerosis Peripheral Atherosclerosis ––Nursing CareNursing Care
EvaluationEvaluationStrength/equality of pulsesStrength/equality of pulsesCapillary refillCapillary refillSkin colorSkin color
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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TemperatureTemperaturePainPainBleedingBleeding
Peripheral Atherosclerosis Peripheral Atherosclerosis ––Nursing CareNursing Care
TeachingTeachingExerciseExerciseSmoking cessationSmoking cessationLegs/foot careLegs/foot care
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Stress reductionStress reductionMedicationsMedicationsSurgical teachingSurgical teaching
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Arterial Thrombus/EmbolismArterial Thrombus/EmbolismOcclusion of blood flow through an arteryOcclusion of blood flow through an arteryAtherosclerotic changes can cause a thrombus or Atherosclerotic changes can cause a thrombus or blood clotblood clotBlood clot breaks away, becomes an embolusBlood clot breaks away, becomes an embolus
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Lodges in small vesselsLodges in small vesselsLeads to tissue necrosis, gangreneLeads to tissue necrosis, gangrene
BOX 28BOX 28--1212 Manifestations of Arterial Thrombosis or Embolus.Manifestations of Arterial Thrombosis or Embolus.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Acute Arterial OcclusionAcute Arterial Occlusion
Diagnosis and treatmentDiagnosis and treatmentPhysical examinationPhysical examinationAngiographyAngiographyThrombolytic therapyThrombolytic therapy
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Anticoagulant therapyAnticoagulant therapySurgerySurgery
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Acute Arterial Occlusion Acute Arterial Occlusion ––Nursing CareNursing Care
AssessmentAssessmentChief complainChief complainComplains of painComplains of painPulsesPulses
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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TeachingTeaching
Acute Arterial Occlusion Acute Arterial Occlusion ––Nursing CareNursing Care
Ineffective ProtectionIneffective ProtectionThrombolytic drugsThrombolytic drugsReport bleedingReport bleedingH&H levelsH&H levelsPT tiPT ti
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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PT timesPT times
Buerger’s DiseaseBuerger’s DiseaseManifestationsManifestations
Pain in the involved extremityPain in the involved extremityCramping in the instep of the foot or leg calves, relieved by Cramping in the instep of the foot or leg calves, relieved by restrestRest pain in fingers and toesRest pain in fingers and toes
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Rest pain in fingers and toesRest pain in fingers and toesSmoking, cold, emotional distress trigger burning painSmoking, cold, emotional distress trigger burning painPale, cool/cold to touchPale, cool/cold to touchSkin shiny, thin; nails thick and malformedSkin shiny, thin; nails thick and malformedPulses difficult to obtain or absentPulses difficult to obtain or absent
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Raynaud’s PhenomenonRaynaud’s PhenomenonSpasms of the small arteries of extremitiesSpasms of the small arteries of extremitiesSpasms limit blood flowSpasms limit blood flowManifestationsManifestations
S/S occur after exposure to cold or workS/S occur after exposure to cold or work--related vibrationrelated vibration
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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BlueBlue--whitewhite--red syndromered syndromeNumbness, stiffness, decreased sensation, aching painNumbness, stiffness, decreased sensation, aching pain
Venous ThrombosisVenous ThrombosisSmall clots develop in veinsSmall clots develop in veinsThree pathologic factors: Virchow’s triadThree pathologic factors: Virchow’s triad
Venous stasisVenous stasisIncreased blood coagulabilityIncreased blood coagulability
l ll i jl ll i j
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Vessel wall injuryVessel wall injuryDeep venous thrombosis (DVT)Deep venous thrombosis (DVT)
Figure 28Figure 28--4. 4. Common locations of deep venous thrombosis.Common locations of deep venous thrombosis.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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BOX 28BOX 28--1313 Risk Factors for Venous Thrombosis.Risk Factors for Venous Thrombosis.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Venous ThrombosisVenous ThrombosisCalf pain, muscle tendernessCalf pain, muscle tendernessDull, aching pain with walkingDull, aching pain with walkingEnlarged calf, cyanoticEnlarged calf, cyanoticPositive Homan’s signPositive Homan’s sign
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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ggPulmonary embolismPulmonary embolismSuperficial vein thrombophlebitisSuperficial vein thrombophlebitis
Trauma to vein wallTrauma to vein wall
BOX 28BOX 28--1414 Manifestations of Deep and Superficial Venous Thrombosis.Manifestations of Deep and Superficial Venous Thrombosis.
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Venous InsufficiencyVenous Insufficiency
Large veins of legs occludedLarge veins of legs occludedDistends veinsDistends veinsValves damagedValves damagedValves fail to closeValves fail to close
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Valves fail to closeValves fail to closeBlood collects and pools in lower extremitiesBlood collects and pools in lower extremitiesCongestion and edema of leg tissueCongestion and edema of leg tissueVenous stasis ulcers developVenous stasis ulcers develop
Figure 28Figure 28--5.5. Chronic venous insufficiency. Note the discoloration of the ankle and the stasis ulcer. (Source: Camera M.D. Chronic venous insufficiency. Note the discoloration of the ankle and the stasis ulcer. (Source: Camera M.D. Studios, Carroll H. Weiss, Director, 8290 N.W. 26th Place, Sunrise, FL 33322.)Studios, Carroll H. Weiss, Director, 8290 N.W. 26th Place, Sunrise, FL 33322.)
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Varicose VeinsVaricose VeinsIrregular, tortuous vein with incompetent valvesIrregular, tortuous vein with incompetent valvesCommonly affect lower extremitiesCommonly affect lower extremities
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Figure 28Figure 28--7. 7. (A) Normal leg veins. (B) Varicose veins(A) Normal leg veins. (B) Varicose veins
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Varicose VeinsVaricose VeinsPathophysiologyPathophysiology
Increased pressure stretches the vessel wallIncreased pressure stretches the vessel wallStanding increases pressure in the leg veinsStanding increases pressure in the leg veinsDecreases venous return to the heartDecreases venous return to the heartBl d ll t i th l iBl d ll t i th l i
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Blood collects in the leg veinsBlood collects in the leg veins
Varicose VeinsVaricose VeinsManifestationsManifestations
Severe, aching leg painSevere, aching leg painLeg fatigue/heavinessLeg fatigue/heavinessItchingItchingH t ft l d t diH t ft l d t di
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Heat after prolonged standingHeat after prolonged standingVisibly dilated veinsVisibly dilated veins
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Varicose VeinsVaricose VeinsComplicationsComplications
Venous insufficiencyVenous insufficiencyStasis dermatitisStasis dermatitisStasis ulcersStasis ulcersSki b kl thi d di l dSki b kl thi d di l d
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Skin above ankles thin and discoloredSkin above ankles thin and discoloredVenous thrombosisVenous thrombosis
Varicose Veins Varicose Veins
Diagnostic testsDiagnostic testsDoppler ultrasoundDoppler ultrasoundTrendelenburg testTrendelenburg test
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Figure 28Figure 28--3.3. A Doppler (ultrasound) stethoscope. Photographer: Elena Dorfman.)A Doppler (ultrasound) stethoscope. Photographer: Elena Dorfman.)
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Varicose Veins Varicose Veins -- TreatmentTreatment
ConservativeConservativeAntiembolic stockingsAntiembolic stockingsDaily walkingDaily walkingAvoid prolonged sitting/standingAvoid prolonged sitting/standing
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Elevate legsElevate legs
Reduce discomfortReduce discomfortNo real cureNo real cure
Varicose Veins Varicose Veins -- TreatmentTreatmentSurgerySurgery
SclerotherapySclerotherapyVein strippingVein stripping
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Varicose Veins Varicose Veins –– Nursing CareNursing CareIneffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralAssess pulses, capillary refill, skin temperature, Assess pulses, capillary refill, skin temperature, edemaedemaAntiembolic hoseAntiembolic hose
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Leg wraps as prescribedLeg wraps as prescribedLeg exercisesLeg exercisesLeg positioningLeg positioning
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Varicose Veins Varicose Veins –– Nursing CareNursing CareTeachingTeachingDaily walksDaily walksAntiembolic hoseAntiembolic hoseElevate legsElevate legs
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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ggAvoid sitting/standingAvoid sitting/standingCalf/thigh muscle exercisesCalf/thigh muscle exercises
Venous Conditions Venous Conditions -- TreatmentTreatmentMedicationsMedications
NSAIDsNSAIDsAnticoagulantsAnticoagulantsHeparinHeparinO l f iO l f i
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Oral warfarinOral warfarinThrombolyticsThrombolytics
Venous Conditions Venous Conditions -- TreatmentTreatmentSurgerySurgery
Venous thrombectomyVenous thrombectomyInsertion of filtering deviceInsertion of filtering device
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Figure 28Figure 28--6. 6. A vena caval filter to trap emboli from the pelvis and lower extremities.A vena caval filter to trap emboli from the pelvis and lower extremities.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Venous ConditionsVenous ConditionsDiagnostic testsDiagnostic tests
Duplex venous ultrasoundDuplex venous ultrasoundPlethysmographyPlethysmographyMRIMRIA di t t hl b h hA di t t hl b h h
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
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Ascending contrast phlebography or venographyAscending contrast phlebography or venography
Venous Conditions Venous Conditions -- TreatmentTreatmentPreventionPreventionElastic stockingsElastic stockingsPneumatic compression devicesPneumatic compression devicesLeg exercisesLeg exercisesE l b l tiE l b l ti
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Early ambulationEarly ambulationNo leg crossingNo leg crossingCompresses to relieve symptomsCompresses to relieve symptomsBed restBed restElevate legsElevate legsTED hoseTED hose
1/3/2008
25
Venous Conditions Venous Conditions –– Nursing CareNursing Care
Assess all clients who may be at riskAssess all clients who may be at risk
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
TABLE 28TABLE 28--66 Evaluating Edema.Evaluating Edema.
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
Stasis dermatitis and stasis ulcer careStasis dermatitis and stasis ulcer careWet compresses, boric acid, Burrow’s solution, isotonic Wet compresses, boric acid, Burrow’s solution, isotonic salinesalineTopical ointmentsTopical ointmentsUnna bootUnna boot
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Unna bootUnna boot
1/3/2008
26
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
Ineffective Tissue Perfusion: PeripheralIneffective Tissue Perfusion: PeripheralPeripheral pulsesPeripheral pulsesCalf and thigh diameterCalf and thigh diameterElevate legsElevate legsA ti b li h / t kiA ti b li h / t ki
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Antiembolic hose/stockingsAntiembolic hose/stockingsFrequent position changesFrequent position changesAnticoagulants/thrombolyticsAnticoagulants/thrombolyticsLab valuesLab values
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
PainPainPain scalePain scaleWarm, moist heatWarm, moist heatBed restBed rest
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
Impaired Skin IntegrityImpaired Skin IntegrityAssess every 8 hoursAssess every 8 hoursMild soap, solutions, lotionsMild soap, solutions, lotionsMattressMattressA ti / i ROMA ti / i ROM
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Active/passive ROMActive/passive ROMProgressive ambulationProgressive ambulation
1/3/2008
27
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
EvaluationEvaluationComfort levelComfort levelPeripheral circulationPeripheral circulationBruising/bleedingBruising/bleeding
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
Lab resultsLab results
Venous Conditions Venous Conditions –– Nursing Nursing CareCare
TeachingTeachingDisease processDisease processCourse of treatmentCourse of treatmentLab testsLab testsM di tiM di ti
Medical-Surgical Nursing Care, 2eKaren Burke, Priscilla LeMone, and Elaine Mohn-Brown
Copyright ©2007 by Pearson Education, Inc.
MedicationsMedicationsWound careWound careActivityActivityMeasures to prevent recurrenceMeasures to prevent recurrenceFollowFollow--up visitsup visitsEfforts to avoid complicationsEfforts to avoid complications
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