Exam 2 307 Vascular Problems (PE, PVD, DVT)

Pulmonary Embolism

Embolism that is carried into the pulmonary circulation; blocking pulmonary perfusion

Risk factors for PE

• prolonged immobility

• Surgery

• Pregnancy and postpartum

• Obesity

• History of thromboembolism

• covid 19 infection

Prevention of PE

• early ambulation for a pt who has had surgery

• Passive ROM for those unable to ambulate

• Compression devices (TEDs and SCDs)

• Hydration

• Leg exercises

• Smoking cessation

Passive range of motion being

Leg lifts, foot pumps, ambulating for them as nurses

TED hose should not

Be on for 24 hours (12 on and 12 off)

SCDs must be worn until

Pts are able to ambulate like they did coming into the hospital

S/s of PE

• chest pain

• Dyspnea

• Restlessness

• Cough

• Tachypnea

• Hypoxemia

• Hemoptysis (coughing up blood)

• Tachycardia

• Pleural friction rub

a patient can get oxygen as a treatment for PE but

If the clot is in their bronchioles the O2 isn’t very helpful because it can’t go anywhere

Treatment for PE

• high Fowler position

• Telemetry to make sure the clot doesn’t move

• Continuous pulse ox

• Assess respiratory and cardiac system constantly

• Administer anticoagulants as ordered

• Bleeding precautions

• Incentive spirometer

• Pt teaching

• Labs

What is a surgical procedure for PE and how does it work

Greenfield filter inserted only after embolism is resolved and used to prevent future embolisms

Peripheral Vascular disease diagnosis implies

Arterial disease (PAD) and some patients ma have both PAD and venous disease

Peripheral arterial disease

Arteries narrowing, particularly in the legs, reducing blood flow

cause of PVD/PAD is

Atherosclerosis

Peripheral Vascular disease means

Change in natural blood flow through arteries and veins

What does PVD affect

Perfusion

Risk factors for PVD

• abnormal lipids (HDL, LDL, triglycerides)

• Genetics

• Diabetes

• Obesity

• Sedentary lifestyle

• Stress

• African American ethnicity

• Aging adult

• Smoking

PAD is divided into 4 stages

1. Asymptomatic

2. Claudication

3. Pain at rest

4. Necrosis/gangrene

When you think of PAD think

Claudication (muscle pain, cramping, or fatigue)

Intermittent Claudication

Intense cramping or burning when moving that goes away when resting

What happens in intermittent Claudication

The blood is flowing faster through the body and the diseased artery so that is why it is painful

What does intermittent Claudication entail

• can only walk certain distance before the pain starts

• Pain is a cramping or burning feeling

• Pain stops with rest or when limbs hang down

• Resumes when walking again

Rest pain means

• nothing you do can make it better

• Like a toothache

• Might improve with dependent position(below heart)

What does rest pain indicate?

Advanced disease

PVD diagnosed by

• MRA; done via ultrasound

• ankle brachial index

• exercise tolerance testing

• Plethysmography; evaluate arterial flow

With PAD the blood

Can’t get to the area (legs)

PAD non-surgical interventions

• exercise and positioning

• Promote vasodilation

what does exercise and positioning intervention for PAD look like?

• improves collateral circulation (circulation from abdomen to foot to body)

• Avoid crossing legs

When is exercise contraindicated with PAD

• severe rest pain

• Venous ulcers

• Gangrene

Promote vasodilation with PAD means

• provide warmth (heavy thick socks but not tight)

What should you avoid with PAD

• direct heat through heating pads

• Thing that cause vasoconstriction (cold, smoking, TED hose)

Why should you avoid putting direct heat on a patient with PAD

They don’t have sensation so you could burn them

Drug therapy for PAD

• anti-platelet agents (aspirin, clopidogrel/plavix)

• Statins to lower cholesterol

• ACE inhibitors (most effective) to control BP

How do anti-platelet drugs help with PAD

• lower blood viscosity by inhibiting platelet clumping

• Reduces risk for stroke, MI, or vascular death

PAD invasive non-surgical procedures

• percutaneous vascular intervention; occlusion must be accessible via catheter

• Athrerectomy; scrapes away plaque in artery

Both Percutaneous vascular intervention and atherectomy are

Same day procedures where the patient stays about 6 hours after then goes home

Surgical management for PAD

Arterial revascularization

Arterial revascularization Is when

They select a graft site and replace damaged portion of the artery

Post op care for Arterial revascularization

• watch for bleeding at insertion site

• Monitor for shock

• Check distal pulses in both legs every hour to ensure adequate perfusion

Complication of PAD

Acute peripheral arterial occlusion

Acute peripheral arterial occlusion Or ischemia causes

• pain

• Pallor

• Pulselessness

• Parenthesia (numbness)

• Paralysis

• Poikilothermy (coolness)

thrombectomy is the treatment for Acute peripheral arterial occlusion meaning

Getting the thrombus out

Venous insufficiency occurs due to

Prolonged venous hypertension/pressure in the legs increased due to increased blood volume

Venous insufficiency

• stretches the veins and damages the valves

Venous insufficiency leads to

• back up of blood and further hypertension

• Edema and decreased perfusion

• Venous ulcers, cellulitis, and stasis

Risk factors for Venous insufficiency

• sitting or prolonged periods of time

• Obesity

Interventions for Venous insufficiency

• decrease edema

• Promote venous return

Nursing actions for Venous insufficiency

• Graduated compression stockings (TED HOSE)

• Elevation of the extremity

• Wound management for ulcers

• UNNA Boot

• Desired outcome is to be managed at home

What are UNNA boots

Specialized dressings with zinc oxide to prevent and heal ulcers

Venous thromboembolism causes

• clot formation (PE & DVT = VTE)

Most common type of VTE is

DTV or deep vein thrombosis

DVT can lead to

PE which is a medical emergency

Why is a PE a medical emergency

The clot can move into the lungs or heart

A surgery pt might receive what prophylactically

A blood thinner like heparin or lovenox to prevent VTE

Virchow’s triad

• hypercoaguable state

• Vascular wall injury

• Circulatory status (blood pooling in veins)

Virchow’s triad says if you have 1 from each of the three categories you

Have a 99% chance of getting a VTE

VTE cues

• maybe asymptomatic

• Calf or groin tenderness

• Unilateral leg swelling

• Pain with dorsiflexion of foot

• Presence of warmth or edema along the extremity

Diagnosing a VTE

• venous Duplex ultrasonography

• D-dimer (lab)

What is a d-dimer

Lab testing the hypercoaguable state of blood, it is not definitive

Nursing management of VTE

• moist heat (warm wet wash cloth, do not put in microwave)

• Do not massage

• Ambulation gradually as tolerated

• Monitor s/s pulmonary embolism

After a VTE what should nurses teach

• avoid use of contraceptives

• Compliance with medication (anticoagulant)

• Observe s/s of bleeding

Unfractionated heparin labs

aPTT

Unfractionated heparin antidote

Protamine sulfate

Unfractionated heparin complication

Heparin induced thrombocytopenia

If Heparin induced thrombocytopenia is suspected

STOP INFUSION

Warfarin labs

INR and PT

Warfarin take

3-4 days to reach therapeutic levels

Warfarin antidote

Vitamin K

What foods lessen the effects of warfarin

• leafy greens

• Broccoli

• Liver

• Cabbage

Low molecular weight heparin

Enoxaparin or lovenox

Direct Novak oral anticoagulants

• end in -ban

• Apixaban, rivaroxaban

• Do not require frequent lab drawing

PAD pain quality

Intermittent claudication; cramping and burning when walking

Peripheral venous disease (PVD)

Aching and heaviness

PAD pain timing

Pain starts with activity but stops with rest

peripheral venous disease pain timing

Worsens with prolonged standing or sitting

PAD pain relief

Limbs are dependent/below the heart

peripheral venous disease Pain relief

Limbs are elevated above the heart

PAD skin temperature

Cold/cool

peripheral venous disease Skin temperature

Warm

PAD skin color when elevated

Pallor/pale modeled

PAD skin color when dependent

Rubor (cyanotic), gray

peripheral venous disease Skin color

Reddened or brownish

PAD skin changes

• dry scaly

• Hair loss on lower leg, ankle/foot

peripheral venous disease Skin changes

Hyperpigmentation around the ankles

PAD edema

Absent or minimal

peripheral venous disease Edema

• present and pitting

• Worsens as the day goes on

PAD pulses

Diminished or absent

peripheral venous disease Pulses

Normal/present

PAD capillary refill

Prolonged, greater than 3-5 seconds

peripheral venous disease Capillary refill

Normal

PAD nails

Thickened toenails

peripheral venous disease Nails

Within normal limits

PAD muscle changes

Atrophy with prolonged disease

peripheral venous disease Muscle changes

Within normal limits

PAD ulcer location

• On toes, big toe

• Between toes

• On upper part of foot

peripheral venous disease Ulcer location

Medial malleus on foot (ankle bone)

PAD ulcer appearance

• small, round and well defined

• Often hollow in appearance

peripheral venous disease Ulcer appearance

• irregular borders

• Superficial

PAD ulcer pain

Very painful initially

peripheral venous disease Ulcer pain

Less painful or painless