1 PERIPHERAL VASCULAR DISEASE?ETIOLOGY:? Atherosclerosis & Smoking? Infectious Processes (syphilis,TB, infection)? Trauma (sudden, chronic, operative)? Abdominal Pressure (obesity, pregnancy)? Sedentary Life-Style

2 ARTERIAL OCCLUSION?Sudden Onset?No Distal Blood Supply?Size and Site Determines Significance?5 P’s:? pain, pallor, pulselessness, paresthesia & poikilothermia

3 ACUTE ARTERIAL OCCLUSION?PULSELESS LIMB IS AN EMERGENCY?Heavy dose anticoagulants?Thrombolytic agents?Endarterectomy?Acute blockage of Iliac Bifurcation: ? Saddle embolus

4 Episodic Vasospasm: Reynauds?Paroxysmal, bilateral digital ischemia?Induced by cold & stress?Phenomenon? temporary disorder with quick resolution

?Disease: ?Digital Gangrene

5 CHRONIC ARTERIAL OCCLUSION?Intermittent Claudication?Poor peripheral pulses?Skin breakdown?Taut, shiny skin on shin?Bony prominence ulcers?Thick nails with ridges?Hairless legs

6 CHRONIC CARE1 ?STOP SMOKING AND CAFFEINE

?Keep feet warm?no not water bottles or electric pads

?Protect extremity from injury?Foot and Ulcer care (like a diabetic)

2 ?Bed cradles?ASA or Ticlid or Plavix?Weight reduction on lo fat diet?No leg crossing

7 Get Out and Exercise?GO TO THE MALL? Explain why a mall walking group would be a GOOD idea for a person with chronic

insufficiency.

?Buerger-Allen Exercises8 Surgical Care

?Doppler or Angiogram study to determine degree of vascular occulsion?By-Pass Graft

(dacron sheath to carry the blood past blockages is sometimes palpable)? new blood flow sensation ? LONG suture line

?Requires cross-clamping of Aorta9 Check Those Pulses!

?Mark spot on dorsalis pedis or posterior tib.?May need to use doppler?Color can be poor at first?monitor for color worsening due to spasms

?Check capillary refill?Be alert to increasing pain especially if rises even with pain meds

10 Question?How do you position of post-op patients with a grafted extremity??What about sitting?

11 POST-OP CARE?NO sitting or deep hip flexion or knee gatch?Anticoagulant precautions?BP control?Anticipate ileus?Assess for cross clamp complications? u/o, distal CMS

12 ANEURYSM?TRUE? fusiform: circumferential? saccular: pouch

?PSEUDOANEURYSM? pulsating hematoma? check after arterial punctures

?DISSECTION? blood between vessel layers

13 THORACIC ANEURYSMS?USUALLY ASYMPTOMATIC?S & S:? hoarseness? dysphagia? distended neck veins? upper extremity edema? anterior chest pain, deep, diffuse

14 ABDOMINAL ANEURYSM?Often Asymptomatic?Found on Routine PE & XRAY?S & S:? Pulsating Abdominal Mass?Bruits?Backpain?Bowel Complaints?Lower Extremity Pulses

15 ANEURYSM RUPTURE?Can Dissect Prior to Rupture?Bleed Into Retroperitoneal Space? can tamponade off? flank and back ecchymosis?Massive Shock

?Early Signs May Mimic MI?Fatal 50+%

16 MEDICAL TREATMENT?Surgical Repair or Bypass Graft? Synthetic Graft Used?Requires Cross-Clamping of Aorta? renal perfusion in jeopardy? spinal cord perfusion in jeopardy

?Multiple Transfusion Case? risk for transfusion reaction higher

?Anticoagulation17 POST-OP CARE

?FREQUENT checks of distal pulses

?Anticoagulant precautions?BP control?Anticipate ileus?NO sitting or deep hip flexion?Assess for cross clamp complications? u/o, distal CMS

18 Risks for DVT?Immobility? bedrest, long airplane flights

?Obesity?Pregnancy?Dehydration?BCP?Smoking

19 Virchow’s Triad?Stasis of blood?Increased coagulability?Injury to vessel wall?all or one contribute to development of DVT or venous disease

20 Don’t Guess!!?Is the limb swollen or not??How accurate is 1+ -4+ descriptions??What should be done to precisely know?

21 THROMBOPHLEBITIS1 ?SUPERFICIAL

?Visible, palpable?Varicose Veins?IVs, esp. chemotherapy?IV drug users?Rarely embolize?Rarely edema

2 ?DEEP?Tender with swelling?Risk for emboli?Bedrest?Estrogen & BCP?Abd. pressure?Auto-immune & debilitating disease

22 Questions

?Your patient, who just returned from a business trip to Australia, has a swollen left calf. It hurts when he walks on that foot.? Is he at risk for a DVT?? Should you check a Homan’s sign?

23 WARNING?Do NOT ?check Homan’s sign? if?you suspect a DVT?or if the?diagnosis is already made!

24 Venous Disorder Care?Elevation of extremities?Warm, moist heat?NSAIDS ?Anticoagulants?Vein ligation or sclerotherapy?Inferior Vena Cava Filter

25 TED HOSE?graduated compression elastic stockings?need to be fitted correctly?tourniquet effect at the knee?skin breakdown with wrinkles

26 Compression Devices?pneumatic sleeves?not only forces blood up but enhances fibrinolysis!?some are intermittant; some fulltime?pedal compression equal to leg compression?don’t turn off the alarms?check skin condition (hot, sweaty)

27 Anticoagulants?LMWH SQ bid? teach patient to use at home prn

?IV heparin? adjusted to lab PT/INR. ? drawn every 6 hours? sliding scale to dose changes?CAUTION: doses are in units per hour; IV pumps are set for ml per hour

28 Assessing Your Patient1 ?CNS

?change in mental status?meningeal irritation? (subarachnoid bleed)

?EENT?epistaxis?toothbrush bleeding

?ABDOMINAL?occult blood

2 ?drop in HCT?hematuria?abdominal tenderness

?SKIN?petichae?bruising?oozing from puncture sites?hematoma

29 BP and Anticoagulation?Use automatic cuffs with caution? significant pressures cause bleeding? repeated reading in same place causes trauma

?Don’t leave manual cuff “ in place” for same reason?Check for orthostatic VS changes

30 Chronic Venous Insufficiency?Edema? Increased pigmentation of skin? Varicosities balloon more? Stasis ulcers ?Dependent cyanosis?Unna Boots

31 Arterial vs Venous Ulcers1 ?Arterial

? little edema?pain more evident?pale legs with rubor on dependency?no pulses?ulcers deep and pale and frequently dry?toes, feet, shin

2 ?Venous?present to extreme?aching pain?brown discoloration and cyanosis depend.?pulses present?superficial, pink and frequently moist

? inner ankle

32 Questions

?If someone has a circulation problem to their feet, is elevation always a good intervention??If the DVT patient is on bedrest, should you have them do bed exercises to

stop the formation of new clots?33 Lymphatic Problems

?Not all edema is directly due to vascular problems? lymph channels can be blocked? obstruction from tumor? cellular debris from big infection

? overflow of fluid from vascular problems? lymph channels can be missing? breast surgery

34 Lymph Care?NO BP or venipunctures on limbs with lymph node dissections?Elastic stockings sometimes used?Elevation t/o night?Measure extremity girth?Monitor for skin breakdown