Maintain/improve arterial blood flow to the lower extremities. Protect tissues from further injury due to pressure and constriction of blood flow. Prevent wound infection. › Keep wounds clean, they’ll heal slowly! › Debridement (removing the dead tissue) if they get infected
Planning: Nursing Interventions Warm environment Avoiding restrictive clothing Smoking cessation Exercise Elevate legs for PAD or not??? › NOT
Figure 18-6 Raynaud’s Disease Spasm of the arteries of upper and lower extremities Unknown cause From cold & stress Do not apply heat Taking things out of the oven Avoid Caffeine and smoking Most common in young women
Aneurysm Outpouching of the wall of the artery d/t a structural defect caused by plaque, genetics, or hypertension Usually asymptomatic Diagnosis: › Chest or abdominal x-ray, ultrasound, MRI, or CT Surgical repair if able Nurse management › Monitor urine q 30min x2hrs then q 1hr x 2days › Should be 30mL/hour › Notify a physician
Carotid Artery Disease S/S › Carotid bruit, confusion, weakness/paralysis › visual abnormality in one eye, stroke-like symptoms Carotid endarterectomy – is the treatment › Must be a 70% occlusion or greater for surgery › Risk for stroke (CVA) following this is extremely high › Assess for disorientation, impaired speech/swallowing, facial asymmetry, aphasia
Thrombosis Formation, development, or presence of a “clump” of blood (usually platelets and fibrin) that from a clot in a blood vessel Risk factors › Venous stasis: Immobility, heart failure › Damage to inner lining of the vein: trauma, HTN › Hypercoagulability of blood: vessel inflammation › Smoking, hormone replacement, contraceptives Effects of thrombosis depend on: › Location and size of the thrombus › Complete or only partial occlusion › Collateral circulation
Thrombophlebitis Inflammation of a superficial vein D/t infection from an IV line, or contaminated IV drug needles Can cause clots S/S › Swelling, redness, warmth, tenderness/pain upon touch › Use warm pack Treatment › Stop source of inflammation, warm, moist, heat, elevate, NSAIDS and antibiotics if infected
Deep Venous Thrombosis Clot in deep vein (DVT) Diagnosed by ultrasound (Doppler flow study) › Coagulation labs and D-Dimer lab will be drawn DETERMINE BLOOD CLOTS Contributing factors: › Immobility, trauma, sepsis, clotting problems, surgical procedures, dehydration, or any condition that causes slowing of venous flow can cause a clot to form May lead to an embolus that can lodge in lungs leading to sudden onset resp. distress
DVT cont Classic sign – one extremity edema, warm Homan’s sign?
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- Fall '19