Download - Chronic Cardio Disorders Notes
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Chronic Cardiovascular Disorders
General Overview
Hypertension
Disorders of aorta and branches
Arterial thrombosis & embolism
Peripheral arterial disease (PAD)
Aortic aneurysms
Thromboangiitis obliterans
Raynauds disease/phenomenon
Venous disorders Venous thrombosis: Superficial & Deep
Chronic venous insufficiency
Lymphedema
General Overview Gender, Cultural, & Ethnic Differences Use of the Genogram Medication Reconciliation Risk factors Diagnostic Tests Collaborative Care Nursing Interventions Prioritization
Cardiac Markers
Creatine Kinase (CK)
Measures an enzyme that is released when there is muscle damage or breakdown
Does not tell specific muscle
CK-MM (skeletal); CK-BB (brain); CK-MB (cardiac)
Report Rise, Peak and Fall levels
Troponin
Elevated levels mean Myocardial Damage
Elevates earlier than CK-MB
Reaches peak @ 24 hours and may not fall for 7-10 days
Good indicator for patient who presents non-classic MI symptoms
Cardiac MarkersBLOOD STUDY RANGE RISE, PEAK, FALL
Creatine Kinase (CK) 36-160 Units/L (F)
50204 units/L (M)
CK-MB < 4-6% of total CK Rise 4-6 hrs
Peak 18-24 hrs
Return to baseline 24-36 hrs
Troponin
< 0.35 ng/ml (I)
< 0.2 mcg/L (T)
Rise 2 6 hrs
Peak 15-24 hrs
Return to baseline 7-10 days
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Lipid Panel (Cholesterol Test)
Blood study Range
Total Cholesterol < 200 mg/dL
Low-density lipoprotein (LDL) or bad cholesterol Without CAD 40 mg/dL (men)
> 60 mg/dl (women)
Triglycerides < 150 L
Brain (or B-type) Natriuretic Peptide (BNP) Test Hormone secreted by the left ventricular when the left ventricular is overstretched
from excess volume
BNP level Condition
< 100 Normal heart function
100-199 Mild heart failure
200-400 Moderate heart failure
>400 Moderate to severe heart failure
Diagnostic Studies
Homocysteine Level
Homocysteine is an amino acid your body uses to make protein and to build and maintain tissue.
Normal: 4.6-11.2 mcg/L
Damage inside lining of artery
Encourage clot formation
Stroke Heart disease
Chest X-ray
A chest x-ray is typically the first imaging test used to help evaluate symptoms such as:
Shortness of breath
Persistent cough
Chest pain
Takes 15 minutes
Painless procedure
PA & Lateral views
Portable AP view
Always check if there is a chance pt is pregnant
Echocardiogram (echo)
Non-invasive ultrasound procedure that utilizes ultrasound to image the heart, muscle, chamber sizes, valves, ejection
fraction, and blood flow
Hypokineases less movement of muscle
A-kineases non movement (MI)
Ejection Fraction tells how well heart is pumping
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Transthoracic Echocardiography (TTE) No special preparation
Transducer is applied to chest wall to evaluate:
Size and shape
Valves
Abnormal structures
Blood clots or tumors
Walls of heart
Pumping ability
Ejection Fraction (EF) Transesophageal Echocardiogram (TEE)
Prep
NPO for 6 hours prior to test
Consent
IV access
Remove dentures
During the procedure
Sedation (Versed)
Oxygen
Anesthetic gel or spray
Test takes about 15-20 minutes
Nursing Care after TEE Vital signs including pulse oximetry
No eating or drinking 2 hours after procedure, or until gag reflex returns
Monitor for shortness of breath, chest pain, bleeding, or fever
Electrocardiogram (EKG or ECG)
Painless test that records the hearts electrical activity
12 specific areas
No special preparation
Place nodes non-hairy area, instruct pt not to talk
Electrodes are placed on specific locations on chest wall and extremities
A machine records the signals on graphic paper
Test takes 5 minutes
Electrocardiogram (ECG)
Electrical activity of different walls of the heart
Stress Test
Exercise stress testing
Nuclear stress testing
Using radioactive isotopes
Shows how the heart responds to increased oxygen demands
Determine what the patients max HR is
Is they reach 80% of that then is considered a successful test
Looking for signs of ischemia as you increase workload (increase incline or speed of treadmill)
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What happens when stress test is performed?
Timed interval exercise
Underlying heart disease is suggested if patient develops:
Changes with ECG at low level exercise
Drop in blood pressure
Extreme or inappropriate shortness of breath, chest discomfort, and weakness
Test takes 1/2 to 3 hours
Return to normal activities
Other Names for Stress Test Exercise Treadmill test
Stress echocardiogram
Dobutamine stress echocardiogram (DSE)
Myocardial Perfusion Imaging (MPI)
Stress Thallium scan, Nuclear stress test
Typical Standing Orders for Stress Test
Consent
NPO
No caffeine for 12-24 hours
Hold medication that slows heart rate
Beta blockers (Metoprolol, Carvedilol)
Digoxin (Lanoxin)
Calcium channel blockers (Diltiazem, Verapamil only)
Angiography or Angiogram
X-ray pictures of arteries (arteriogram) or veins (venogram) using injection of x-ray dye (contrast)
Arteries: usually goes in at femoral artery
Invasive procedure using local anesthesia and conscious sedation
Consent required!!!
NPO
Check for allergy to iodine, shellfish, xray dye
What is Cardiac Catheterization?
Cardiac Catheterization (Cath) is a specialized study of the heart during which a catheter, or thin hollow flexible tube, isinserted into an artery in the groin or arm
Cardiac catheterization is performed to diagnose:
Coronary artery disease
Disease of heart valves Etiology of Congestive heart failure (ex: ischemia or malfunction heart valve)
Structural defects
Cardiac Catheterization (cardiac cath) Large vascular access sheaths are placed in the groin or arm Insertion of a catheter into the heart Contrast dye injected to detect impaired flow of blood to the coronary arteries
Typical Standing Orders for Cardiac Catheterization Explain procedure (Dr. Np or PA only, nurse cannot do this)
Consent
NPO
Intravenous access
Shave and prep right/left groin
Hold anticoagulants
Coumadin has longer half life than Heprin so need to check PT/INR to make sure back to normal before procedure
Do not give 0800 dose of Lovenox
Check allergy
Iodine, shellfish, contrast dye
If allergic, give Benadryl and Solucortef (several doses 24hr period ahead of time)
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Hold basal (ex: lispro) insulin and oral hypoglycemic agents bc NPO
Can give correction dose (sliding scale if BG is high in morning), but not scheduled basal dose
Preparation for Cardiac Catheterization
Several routine tests will be done:
ECG
Complete Blood Count (CBC)
WBC, Hgb, Hct, Platelets
Infection present, any bleeding
If severly anemic do not want to put them at risk for more blood loss Adequate patelets so they can clot
BMP: Electrolyte panel
Sodium, Potassium, BUN, creatinine
xRAY Dye could worsen kidney function
PT/INR (if on Coumadin/Heprin)
What to expect during a cardiac cath? Contrast dye used to visualize the coronary arteries
Procedure lasts one hour
Catheter is usually removed in cath lab
Pressure is held for 20 to 30 minutes
Pressure dressing applied If closure device used, only bandaid applied
Post Cardiac Cath Care
Bed rest for 3 to 4 hours
Head of bed elevated 20 to 30 degrees
Keep the affected extremity straight
Frequent vital signs
Bleeding: BP decrease, HR insrease
Monitor groin site for bleeding
Check pedal pulses
After 3 to 4 hours & stable, check blood pressure and heart rate lying, sitting, and standing
Most common cause of hypotension is dehydration
Complication of Cardiac Catheterization
Dissection of aorta or coronary artery
MI (Heart Attack)
Dislodged athlescrotic plaque
Thrombus/embolus
Stroke
Plaque breaks off, goes into Carotid artery and travels to brain
Hematoma
Retroperitoneal bleed
Pseudoaneursym or A-V fistula
Pseudoaneursym: Bleeding in layers of artery
AV Fistula: is a tear that forms between artery and vein
When palpating pulse @ site you will hear a Bruit and feel/palpate a Thrill
Allergic reaction to xray dye
Warmth, erythema, swelling of tissues lungs: stridor, hives, sneezing, itching
Cardiac CT (computed tomography)
A painless test
X-ray machine takes clear, detailed pictures of the heart.
Each picture shows a small slice of the heart.
A computer will put the pictures together to make a large picture of the whole heart.
Calcium score predicts cardiac events
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Electrophysiology Study (EPS)
An invasive study used to diagnose dysrhythmias - slow or fast rhythms
NPO
Consent
Shave & prep groin
Catheter inserted right femoral vein
Bed rest 3-4 hours
Monitor vital signs and puncture site
Assess pedal pulses
Arterial doppler study (Ultrasound) & Duplex Scan
Venous Doppler Study & Duplex Scan Noninvasive, painless ultrasound test to detect thrombosis in the superficial and deep veins.
May be done on the upper and lower extremities
Hypertension
Blood Pressure Classification SBP (mmHg) DBP (mmHg)
Normal < 120 and < 80
Prehypertension 120-139 or 80-89
Stage I
Hypertension140-159 or 90-99
Stage II
Hypertension>/= 160 or >/= 100
Types of Hypertension
Isolated systolic hypertension
Defined as an average SBP >140 and DBP < 90
More common in older sdults due to a loss of elasticity in large arteries and atherosclerosis
Pseudohypertension False hypertension
Happens a lot in elderly due to thickening in the walls of the arteries (atherosclerosis)
Sclerotic arteries dont collapse when cuff is fully inflatedCuff doesnt fit correctly
Much higher pressures than what are actually present
Susopect if arteries feel rigid and few retinal/cardiac signs are found relative to cuff reading
Primary hypertension
Essential hypertension (idiopathic htn)
Most common (90% of hyoertension)
Elevated BP without a primary cause
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Secondary hypertension
HTN related to a specific cause that can be identified and sometimes treated
Kidney Failure, medications, pregnancy
Anything or disease that causes excessive blood volume
Hypertensive crisis
Excessively high diastolic, sometimes high systolic
Risk factors Heredity
Male > 45 Female > 55 Excess dietary sodium Diabetes mellitus
Hyperlipidemia
Ethnicity Stress
Obesity
Alcohol
Lack of exercise
Smoking Medications
Socioeconomic
Gender, Cultural, & Ethnic Factors Men vs. women
Age onset Males -MI; Females CVA
Cultural & Ethnic African Americans
Highest prevalence Younger onset Women > men
Mexican Americans Lower awareness Less receipt of treatment & adequate control May need more patient teaching
Complications silent killer!!!
Target organ damage:
Heartcardiac hypertrophy, atherosclerosis, tearing of arteries
Brain stroke, encephalopathy
Peripheral vasculature atherosclerosis
Kidneys nephrosclerosis
Eyes Increased IOC, hemorrhage of retinal vessels
Diagnostic Evaluation
H&P Urinalysis detect kidney damage BMP Na, K, BUN, Cr, BG Lipid Profile detect additional risk factors that predispose a patient to CVD Serum uric acid establish a baseline bc often rise w diuretic therapy 12-lead Electrocardiogram Optional: 24 hr. urine (Cr clearance), Echocardiogram
Nursing Assessment of BP
Take BP in both arms
Check for Orthostatic Hypotension
Determine Mean Arterial Pressure (MAP)
MAP = SBP + (DBP X 2) / 3
Indicates tissue perfusion Normal is 70 100. Must be > 60 for organ perfusion
Nursing Judgment
Evidence Based Practice
Lifestyle modifications
DASH diet
Dietary Approaches to Stop HTN
Fish, Fruits and vegetables, Fiber, Water
Dietary Sodium Reduction
< 2.3 g/day (< 1.5 g/day DM, CKD, HTN)
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Research-based Collaborative Care
Additional lifestyle modifications
Losing excess weight
Exercise
Smoking cessation
Limiting alcohol intake
Stress management
Home BP monitoring
Adherence to health plan
Report sexual dysfunction OTC meds to avoid: sudafed (vasoconstriction), afrin
Collaborative Care: Drug Therapy
Medications Diuretics (1
st
choice)
hydrochlorothiazide
Beta blockers
ACE inhibitors
Angiotensin receptor blockers
Alpha blockers
Calcium channel blockers
Alpha-beta blockers Direct vasodilator
Antihypertensive Drug Therapy
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Nursing Implications for Med Administration Check BP prior to administration; Hold antihypertensives if SBP < 100
Atherosclerosis Coronary Artery Disease
CAD, Coronary Heart Disease, ASCHD, ischemic heart disease
Peripheral Arterial Disease
Carotid arteries
Abdomen
Extremities
Risk Factors - Atherosclerosis
Age
> 65 yrs, Men = women
Gender
Ethnicity
Genogram
Family History who, age of dx?
Genetics
Familial hypercholesterolemia
Risk factors Tobacco Use Dyslipidemia Hypertension Diabetes mellitus Physical Inactivity Obesity
Additional risks
Stress
Depression
Metabolic syndrome
Homocysteine
Alcohol
Age
Genetics
Health Promotion & Disease Management
Lifestyle modifications
Dietary measures, weight loss, Exercise, Smoking cessation
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Medications
Antidyslipidemic Therapy Restrict Lipoprotein Production
Statins (HMG-CoA reductase inhibitors) Lovastatin, pravastatin, atorvastatin, rosuvastatin Mainly decrease LDL, small increase in HDL
Niacin Decrease LDL & triglycerides Increase HDL (best drug)
Fibric Acid derivatives (fenofibrate, gemfibrozil)
Decrease triglycerides Increase HDL
Increase Lipoprotein Removal
Bile acid sequestrants (cholestyramine)
Decrease total cholesterol & LDL
Decrease Cholesterol Absorption
Ezetimibe (Zetia)
Vytorin = ezetimibe + simvastatin
Research proven enhanced reductions in LDL
Disorders of the aorta and branches (match columns)
Types of Disorders
Peripheral Arterial Disease
Acute arterial ischemia
Aneurysms
Thromboangiitis obliterans
Raynauds disease
Pathophysiology
Occlusive disease Inflammatory
Aneurysmal disease
Vasospastic phenomenon
Peripheral Arterial Disease (PAD)
Signs and Symptoms
Intermittent claudication
Calf pain
Blockage in femoral arteries
Buttock and thigh pain
Blockage in iliac arteries Erectile dysfunction
Paresthesia
Changes to skin
Diminished or absent pulses
Bruit
Complications
Atrophy of the skin and muscles
Delayed healing
Wound infections
Tissue necrosis
Arterial ulcers
Gangrene
Amputation
Diagnostic Studies
Arterial Doppler Ultrasound
Ankle Brachial Index (ABI)
Ankle systolic pressure/brachial SBP
Doppler used to take pressures
Normal ABI 0.91-1.30
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Treatment options Modification of risk factors Exercise therapy Nutritional therapy Protection from trauma or injury
Lubrication (avoid soaking ft) Dangle or reverse trendelenburg for improved perfusion Wear soft, roomy, protective shoes Arterial ulcers keep clean & dry, cover w/ drsg Thrombosis or embolism EMERGENCY!
Drug therapy Antiplatelet agents
Aspirin Plavix
Ace Inhibitors Pentoxyfylline (Trental) increase RBC flexibility Cilostazol (Pletal) inhibits platelet aggregation & vasodilates, significantly increases walking distance & QOL
Interventional & Surgical therapy Interventional Radiologic procedures
Percutaneous transluminal balloon angioplasty, Stent placement, Atherectomy Surgical therapy
Peripheral arterial bypass operation Native vein or synthetic graft used
Endarterectomy
Endarterectomy w/ patch graft angioplasty Amputation
Planning Care of the Patient
Nursing Diagnoses?
Inadequate tissue perfusion
Activity intolerance
Risk for infection
Pain
Skin integrity
Goals?
Pt will have increased tissue perfusion, decreased pain, Increased exercise tolerance..
Outcomes Peripheral Tissue Perfusion
Capillary refill Skin color Extremity skin color Femoral pulses Pedal pulses
Activity Intolerance Walking pace Walking distance Ease of performing ADLs
Nursing Care Assess peripheral pulses, skin color & temp, capillary refill, sensation, & movement Aggressive pain management
Monitor for complications: bleeding, hematoma, thrombosis, embolization, & compartment syndrome Avoid knee- flexed positions except w/ exercise Prioritization: Notify dr. of significant change increased level of pain, loss of palpable pulse distal to operative site, ext.
pallor/cyanosis, cold ext, numbness or tingling.
Patient Teaching
Risk factor management NO TOBACCO!
Meticulous foot care
How to check pulses, temp & capillary refill
Gradual increase in physical activity post-op
Regular physical activity
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Acute Arterial Ischemia
Causes: Thombosis, Embolism, Trauma
EMERGENCY!!!
Six Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (usually cool)
Treatment: Anticoagulation, Thrombolysis, Embolectomy, Surgical Revascularization, Amputation
Thromboangiitis obliterans
Buergers disease
Rare, nonathersclerotic, inflammatory disorder
Common in young men Affects:
small and medium size arteries, veins, and nerves
upper and lower extremities
Strong correlation with smoking
Pathophysiology
Inflammatory process damages arterial wall
Lymphocytes and giant cells infiltrate the vessel
Fibroblast proliferation
Thrombosis and fibrosis occur
Tissue ischemia develops
Signs and Symptoms Often confused with PAD or autoimmune disorders
Intermittent claudication of feet, hands, or arms Color and temperature changes in affected limbs
Paresthesia
Superficial thrombophlebitis
Cold sensitivity
Rest pain
Ischemic ulcerations
Treatment options
Smoking cessation
Avoid trauma to the extremity
Medication therapy
Surgical therapy Sympathectomy, bypass
Amputation
Raynauds disease/phenomenon
Episodic, vasospastic disorder
Affects small cutaneous arteries
Occurs primarily in young women
May be an early manifestation of scleroderma
Signs and Symptoms Vasospasm induced color changes of fingers, toes, nose, and ears
Pallor--decreased perfusion Coldness and numbness
Cyanosis--decreased perfusion Throbbing, aching pain
Rubor--hyperemia Tingling and swelling
Precipitated by cold weather, emotional upsets, smoking, or caffeine use Usually lasts for minutes
Treatment options
Prevention of recurring episodes
Avoid temperature extremes
Smoking cessation
Avoid vasoconstrictors (caffeine, meds)
Coping strategies
Drug therapies: Ca-channel blockers
Surgical options: Sympathectomy
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Aortic Aneurysms Aorta
Role: largest artery in the body with major role is tissue perfusion Aneurysm
Definition: bulging in artery wall Common in aorta
Aortic arch Thoracic aorta Abdominal aorta usually below renal arteries
Men > women Incidence increases with age
Etiology Atherosclerosis*** Hypertension** Congenital abnormalities Premature degeneration of vascular elasticity Penetrating or blunt trauma Inflammatory aortitis Infectious aortitis
Aneurysm classification True wall of the artery forms the aneurysm with atleast 1 vessel layer still intact
Fusiform: circumferential; uniform in shape
Saccular: bulging on one side of the vessel
False not an aneurysm but a disruption of wall layers with bleeding pseudoaneurysm
surgery, trauma or infection can cause
Signs and Symptoms
Thoracic aneurysm
Often asymptomatic
Deep, diffuse chest pain
Angina
Hoarseness
Dysphagia
Distended neck veins
Facial & upper extremity edema
Abdominal aneurysm
Often asymptomatic
Found on routine exam
Coincidence
Pulsatile mass
Bruit
Abdominal or back pain
Problems with bowel elimination
Distal emboli
Complications
RUPTURE!!
ExsanguinationBleed to death
People usually dont survive this unless it ruptures in the hospital or on the way to hospital
Retroperitoneal bleed flank area
Grey-Turner sign
Hypovolemic shock cold, clammy, pale, High HR, LOW MAP
Diagnostic Tests
Chest or abd. xray Electrocardiogram (ECG)
Echocardiogram
Abdominal Ultrasound
Computed tomography (CT scan) ***
Most accurate
Magnetic Resonance Imaging (MRI)
Angiography
Treatment options
Prevent rupture Evaluate coexisting disorders
Conservative therapy
Risk factor modification
Blood pressure control
Frequent monitoring of size
Surgical intervention: > 5.5 cm (males), > 5 cm
(females)
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Endovascular Graft Procedure Minimally invasive Used in older, higher risk patients Cannot use in aortoiliac or renal involvement Benefits Most common complication: perigraft leak
Open Surgical Repair
Cross clamping of aorta
Incising diseased segment of aorta Removing intraluminal thrombus & plaque
Inserting & suturing synthetic graft
Suturing native aortic wall around graft
Unclamping aorta
Actual Care of the Patient Pre-op: Bowel prep, NPO, shower with antimicrobial soap, IV antibiotics Post-op: ICU
Graft patency: Maintain adequate BP, IV fluids, blood transfusion as needed CV status: Telemetry monitoring, oxygen, electrolytes, ABGs, pain control Infection: antibiotics, monitor for fever & leukocytosis, Strict aseptic technique Foley, IVs, incisions
Actual Care of the Patient GI status: Monitor bowel sounds & passing of flatus; NG tube (100ml, normal color); early ambulation; NPO-mouth care
Monitor for bowel ischemia: abdominal pain/distension Neurologic status:
Ascending Ao & arch cerebral perfusion Descending Ao lower ext. movement
Peripheral perfusion Renal perfusion: hourly urine output (30 ml/hr), I/O & daily wts, BUN & Cr
Discharge Teaching Gradual increase in activity Expect fatigue, poor appetite, & irreg. bowel habits at first Avoid heavy lifting X 4-6 wks Report any fever; redness, swelling, pain, or drainage from incision Prophylactic antibiotics before future procedures Possible sexual dysfunction
Aortic Dissection Most common location: thoracic Aorta LIFE THREATENING! Causes: HTN, Marfans, Blunt Trauma Sx per location Tearing, ripping pain Complications Cardiac tamponade, exsanguination, death Diagnostic tests: CXR, Transesophageal echocardiogram, CT scan Collaborative care: Lower BP & myo. contractility, conservative rx if asx; emergency surgery
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Venous Disorders
Veins: deoxygenated blood back to heart
Valve malfunction results in stasis of blood clotting clots breaks off and travel to lungspulmonary embolism
Major Causes:
Weak and damaged vein walls
Stretched or injured one-way valves
Blood clot
Types:
Varicose Veins
Thrombophlebitis Deep Vein Thrombus
Chronic Venous Insufficiency
Diagnostic Tests for Venous Disorders
Venous Duplex, CT scan, MRI, Venogram
Varicose Veins
Incompetent valves
Risk Factors: FH, Gender, Occupation, Pregnancy, Deep vein obstruction, Trauma
Signs & Symptoms: Bulging large bluish veins, Pain/Discomfort, Dull, heavy ache, Throbbing, Burning, Cramping,
Swelling
Complications: Ulcers & Non-healing sores
Varicose Vein Treatment
Conservative Treatment
Weight loss
Exercise
Elevate leg
Compression stocking
Avoid activities that promote venous stasis
Treatment of Varicose Veins: Laser therapy, Sclerotherapy
Inflammation, scaring and closing of vein
Surgical Treatment of Varicose Veins
Endovenous Laser, Vein Ligation, Ambulatory Phlebectomy
Patient Education after Endovenous Laser and Ambulatory Phlebectomy
Compression bandage to minimize bruising
Walking is encouraged immediately following the procedure
Compression stocking
Anti-inflammatory medication
Heavy exercise avoided for 2 weeks
Avoid hot tubs and swimming for 2 weeks
Patient Education After Vein Ligation/Stripping Monitor for bleeding Assess extremities for color, movement, sensation, temperature, presence of edema
Check dorsalis pedis & posterior tibial Compression stocking Elevate leg Anti-inflammatory pain medication Resume normal activities in two weeks or less. Exercise
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Venous Thrombosis
Superficial
Typically not dangerous
Deep vein thrombosis (DVT) dangerous bc if breaks off can travel to lungs
Thrombophlebitis of Hand
Risk factors :
Catheter >3 days
Not flushing line
Highly irritating medications
Sign &Symptoms:
Redness
Tenderness
Pain
Treatment:
Immediate removal of catheter
Prevention
Observation
Treatment for Thrombophlebitis
Heat or cold application
Elevation of affected extremity Pain management
Tylenol
Non-steroidal anti-inflammatory drugs (NSAIDS)
Antibiotic Therapy if severe
Anticoagulants typically not needed
Deep Vein Thrombosis
Causes Major surgery Leg trauma--a broken hip or leg Prolonged travel Family history of a blood-clotting disorder
Cancer Oral contraceptives/HRT Smoking Varicose Veins Central venous lines (pacemaker & ICD leads) Repetitive motion
Symptoms of DVT
Unilateral Edema Majority have no symptoms Dull, aching pain in the affected extremity Leg pain that may worsen when you walk or stand Swelling, Redness, Warm to touch Homans sign
Diagnostic Lab Test for Deep Vein Thrombosis
D-dimer A blood test measuring fragments of fibrin as result of fibrin degradation & clot lysis.
Elevated result suggests deep vein thrombosis
Normal:
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Surgical Treatment of DVT
IVC Filter Greenfield Filter
Inserted in the inferior vena cava via femoral vein
Pre: Consent, check dye allergy, NPO, Shave
Post: same as angiography
May go home after 1-2 days
Anticoagulant Therapy: Prevention & Treatment
Heparin
Unfractionated Heparin High Alert Medication
Read dosage carefully
Practical Guideline:
Intravenous: treatment (must monitor aPPT levels closely if given IV)
Baseline CBC, PT, PTT, & Platelet Count
Bolus given
Frequent PTT monitoring (q6-8 hrs)
Dose adjustments by weight
Length of therapy 5-7 days or until INR therapeutic
Once INR gets to 3, pt can come off Heprin and switch to Coumadin
Lovenox (Enoxaparin)
Low molecular weight heparin (LMWH)
Practical Guidelines:
Subcutaneous
Baseline CBC, PTT, PT, INR, Platelet Count
No continuous PTT monitoring
Dose determined by weight of patient
1mg/kg every 12 hours
The average administration 7 days or until therapeutic goal of INR is achieved
Coumadin (Warfarin) (antidote: Vitamin K)
Practical Guideline
By mouth (PO)
Baseline CBC, PT, INR, Platelet Count
Dose varies between patients
Daily monitoring PT/INR
Therapy long term for 6 months or longer
Pt Teaching:
Food containing Vitamin K
Over the counter medication
ETOH, Safety, Report bleeding
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Laboratory Values to Monitor
Look at ppt chart!!
INR: 2-3 seconds is the goal
Higher INR, thinner the blood
More warfarin (Coumadin) = thinner blood i.e. a higher INR
Medication Value Frequency of Test Measures Normal Values Goal of Therapy
Heparin
(Antidote:
protamine
sulfate)
aPTT
Activated Partial
ThromboplastinTime
Q6 hrs until reach
goal of therapy,
then daily
Ability of the blood
to clot; effect on
intrinsic & common
pathway
24-36 sec. 46-70 sec.
Coumadin
(antidote: Vit K)
PT
Prothrombin Time
or Protime
Daily until reach
goal of therapy
Ability of the blood
to clot (inhibition of
Vit. K dependent
clotting factors
10-14 sec. 21-28 sec
Coumadin
(INR)
International
Normalized Ratio
Daily until reach
goal of therapy
Used to monitor
the effectiveness of
anticoagulant
0.9-1.2 sec. 2.0-3.0
seconds
Chronic Venous Insufficiency (CVI)
CVI is a condition characterized by valve dysfunction in deep veins causing backflow and pooling of blood in the legs leading
to edema and changes in the skin.
Causes of Chronic Venous Insufficiency
Smoking
Sitting/standing for prolonged periods of time
Varicose Veins
Superficial thrombophlebitis
DVT
Trauma Symptoms of CVI
Leg pain
Leg/ankle swelling
Discoloration of the skin hemosiderin
Thickened skin
Varicose veins
Leg ulcers
Complication of CVI: Venous Ulcer
Most venous skin ulcers develop on either side of the lower leg, above the ankle and below the calf.
Dark red or purple over the affected area
Thick, dry itchy skin
Shallow wound
Moderate to heavy drainage
Slow to heal
Prevention & Treatment for CVI
Lifelong Compression stockings
Customized Jobst stockings
Prevention of venous ulcers
Elevation
Avoid sitting or standing for long periods of time
Lifestyle changes
Weight loss
Exercise
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Medical/Surgical Intervention for CVI & Venous Ulcer
Wound therapy
Vacuum-assisted closure therapy (Wound VAC)
Surgery
Valve repair
Vein stripping
Skin grafts
Lymphedema
Definition: the accumulation of lymphatic fluid in the soft tissue that causes swelling, most often in the arm or leg. Types:
Inherited absent or malformed lymph vessels at birth
Acquired lymph node resection, radiation, infection, traumatic injury
Lymphedema
Signs and Symptoms:
Puffiness and a feeling of heaviness in the affected limb
Tightness of the skin
Limited range of motion
Graded 1 4+
Prevention and Treatment options for lymphedema Complex decongestive physiotherapy
Manual lymph drainage (MLD)
Compression bandage Compression stocking Skin care Exercise
Wear loose fitting clothes No blood pressure or needle sticks in the affected extremity
Have to get physician order to do so Drug Therapy for Lymphedema
Antibiotics
Coumadin
Lasix
Pain management
NSAIDs
Hydromorphone (Dilaudid)
KNOW:What statements made by client indicates a need for furthering teaching or what is a statement that pt understands teaching of
drug.