w/in the first 24 hr following surgery Nursing actions • Promptly notify the surgeon of manifestations of occlusion, such as absent or reduced pedal pulses, increased pain, change in extremity color, or temperature • Be prepared to assist w/ treatment: emergency thrombectomy (removal of clot), local intra-arterial thrombolytic therapy with an agent such as tissue plasminogen activator, infusion of a platelet inhibitor, or a combination of these. With these treatments, assess the client for manifestations of bleeding Compartment syndrome • Medical emergency – tissue pressure within a confined body space can restrict blood flow and the resulting ischemia can lead to irreversible tissue damage Nursing Actions • Manifestations of compartment syndrome include tingling, numbness, worsening pain, edema, pain on passive movement, and unequal pulses. Immediately report findings to the provider
Peripheral venous disorders • Are problems with the veins that interfere with adequate return of blood flow from the extremities • There are superficial and deep veins in the lower extremities that have valves that prevent backflow of blood as it returns to the heart. The action of the skeletal muscles of the lower extremities during walking and other activities also promotes venous return Three peripheral venous disorders: • Venous thromboembolism (VTE), venous insufficiency, and varicose veins • A VTE is a blood clot believed to form as a result of venous stasis, endothelial injury, or hypercoagulability. Thrombus formation can lead to
Risk Factors VTE • Associated with Virchow’s triad (hypercoagulability, impaired blood flow, damage to blood vessels) • Hip surgery, total-knee replacement, open prostate surgery • Heart failure • Immobility Venous insufficiency • Sitting or standing in one position for a long period of time • Obesity • Pregnancy • Thrombophlebitis
Subje ctive Data • Lim DVT and thrombop hlebitis • Client may be
• Laboratory Tests • D-dimer test measures fibrin degradation products present in the blood produces from fibrinolysis. A positive test indicates that thrombus formation has possibly occurred. • Diagnostic Procedures DVT and Thrombophlebitis • Venous duplex ultrasonography uses high-frequency sound waves to provide a real time picture of the blood flow through a blood vessel • Impedance plethysmography can be used to determine the variations of blood passing through a vein, thus identifying abnormal
Nursing care DVT and Thrombophlebitis • Encourage patient to rest • Facilitate bed rest and elevation of the extremity above the level of the heart as prescribed (avoid using a knee gatch or pillow under the knees) • Administer intermittent or continuous warm moist compresses as rx’d • Do not massage the affected limb • Provide thigh-high compression or antiembolism stockings • Prepare patient for an inferior vena cava interruption surgery (a filter traps emboli and prevents them from reaching the heart) as indicated Venous insufficiency •
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- Spring '14
- Nursing, Peripheral Venous Disorders