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7/29/2019 Ms Handouts

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MEDICAL-SURGICAL NURSING

CARDIO VASCULAR SYSTEM

Consists: heart, arteries, veins, capillaries

Functions:

1. circulation of blood

2. delivery of oxygen and other nutrients to tissues

of the body

3. removal of carbon dioxide and other products of

cellular metabolism

HEART

ANATOMY and PHYSIOLOGY:

A. Heart wall

1. pericardium(covering) between the visceral

and parietal layer

fibrous pericardium serous pericardium2. epicardiumouter serous membrane

3. myocardiummiddle muscular layer

4. endocardiumthin inner lining

B. Chambers

1. Atria a. right

b. left

2. Ventricles a. rightb. left

C. Valves

1. Atrioventricular valves

a. Mitral valveleft side

b. Tricuspid valveright side

Function:

permit unidirectional flow of blood fromspecific atrium to specific ventricle during

ventricular diastole

prevent reflux during ventricular systole valve leaflets open during ventricular diastole

and close during ventricular systole;

valve closure produces the first heart sounds(S1)2. Semilunar valves

a. Pulmonary valvebetween right

ventricle pulmonary artery

b. Aortic valvebetween the left

ventricle and aorta

Function:

permit unidirectional flow of blood from specificventricle to arterial vessel during ventricular

systole

prevent reflux during ventricular diastole valves open when ventricles contract and close

during ventricular diastole; valve closure produces the second heart sound (S2)D. Conduction System

1. Sinoatrial (SA) nodepacemaker of theheart

2. Internodal Tracts3. Atrioventricular (AV) node4. Bundle of His

right bundle branch left bundle branch

5. Purkinje fibers

* Electrical activity of heart can be visualized by ECG

E. Coronary Circulation

1. Arteries

right coronary arterysupply blood to the rightatrium and right ventricles

left coronary artery2. Veins

coronary sinus veins thebesian veins

F. VASCULAR SYSTEMFunction:

supply tissues with blood remove wastes carry unoxygenated blood back to the heart

TYPES OF BLOOD VESSELSA. Arteries

B. Arterioles

C. Capillaries: the following exchanges occur:

- oxygen and carbon dioxide

- solutes between the blood and tissues

- fluid volume transfer between the

plasma and interstitial spaces

D. Venules

E. Veins

ASSESSMENTHEALTH HISTORY

A. Presenting problem

1. Nonspecific symptoms may include

- fatigue - shortness of breath

- cough - palpitations

- headache- weight loss/gain

- syncope - difficulty sleeping

- dizziness - anorexia

2. Specific signs and symptoms

a. chest pain

b. dyspnea (shortness of breath)c. orthopnea / paroxysmal nocturnal dyspnea

d. palpitations: precipitating factors

e. edema

f. cyanosis

B. Lifestyle:

occupation hobbies financial status stressors exercise smoking living conditions

C. Use of medications:

OTC drugs

contraceptives

cardiac drugs

D. Personality profile:Type A,

manic-depressive

anxieties

E. Nutrition:dietary habits,

Cholesterol


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salt intake

alcohol consumption

F. Past Medical History

G. Family history:

heart disease (congenital, acute, chronic);

risk factors (DM, hypertension, obesity)

PHYSICAL EXAMINATION

A. Skin and mucous membranes:

color/texture

Temperature

hair distribution on extremities

atrophy or edema

petechiae

B. Peripheral pulses:

palpate and rate all arterial pulses (temporal,carotid, brachial, radial, femoral, popliteal,

dorsalis pedis and posterior tibial) on scale of:

0 absent

1+ palpable/weak

2+ normal

3+ full/increased

4+ bounding

C. Assess for arterial insufficiency and venous impairment

D. Measure and record blood pressureE. Inspect and palpate the neck vessels:

jugular veins: note location, characteristics, jugularvenous pressure

carotid arteries: location and characteristicsF. Auscultate heart sounds

- normal (S1, S2)

- abnormal (S3, S4)

LABORATORY / DIAGNOSTIC TESTSA. Blood Chemistry and electrolyte analysis

1. Cardiac enzymes: in MI

a. Troponin T: detected 3-12 hours after chest pain.

N0- 0.2 ng/mlb. Troponin I: detected 3-12 hrs N -


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check peripheral pulses, color, sensation ofaffected extremity

if protocol requires, keep affected ext. straight forapprox. 8 hrs.

observe catheter insertion site for swelling,bleeding

assess V/S and report for sig. changesH. Coronary arteriography

visualization of coronary arteries by injection ofradiopaque contrast dye and recording on movie

film.

Purpose: evaluation of heart disease and angina,location of areas of infarction and extent of lesions,

ruling out coronary artery disease in clients with

MI.

Nursing care: same as cardiac catheterizationANALYSIS

Nursing diagnosis for the client with CVD include

Fluid volume excess Decreased cardiac output Altered peripheral tissue perfusion Impairment of skin integrity Risk for activity intolerance Pain Ineffective coping Fear Anxiety

PLANNING AND IMPLEMENTATION

GOALS

A. Fluid imbalance will be resolved, edema

minimized

B. Cardiac output will be improved.

C. Cardiopulmonary and peripheral tissue

perfusion will be improved

D. Adequate skin integrity will be maintained

E. Activity intolerance will progressively increaseF. Pain in the chest will be diminished

G. Clients level of fear and anxiety will be

decreased

INTERVENTIONS

CARDIAC MONITORING

A. ECG

1. strip: small square: 0.04secs.

large square: 0.2secs.

2. P wave: produced by atrial depolarization; indicates SA

node function

3. P-R interval (N= 0.12 - 0.20 secs.)

indicates AV conduction time or the time it takesan impulse to travel from the atria down and

through the AV node

measured from beginning of P wave to beginningof QRS complex

4. QRS complex (N= 0.06-0.10 secs.)

indicates ventricular depolarization measured from onset of Q wave to end of S wave

5. ST segment

indicates time interval between completedepolarization of ventricles and repolarization of

ventricles

measured after QRS complex to beginning of Twave

6. T wave

represents ventricular repolarization follows ST segment

Nursing Consideration

Tell the patient that an ECG only takes about 10minutes and causes no discomfort.

Explain that he must remain still, relax, breathenormally, and remain quiet.

Prepare the skin on the chest for electrodeattachment; cleanse area with alcohol to remove

dirt and oils; shave area if necessary.

HEMODYNAMIC MONITORING

(Swan Ganz Catheter)

A multilumen catheter with a balloon tip that isadvanced through the superior vena cava into the

RA, RV, and PA. When it is wedged it is in the

distal arterial branch of the pulmonary artery.

Purpose:1. Proximal port: measures RA pressure

2. Distal port: measures PA pressure and PCWP normal values: PA systolic and diastolic less than

20mmHg;

PCWP 4-12mmHgC. Nursing care

1. a sterile dry dressing should be applied to site andchanged every 24 hours

2. inspect site daily and report signs of infection3. if catheter is inserted via an extremity, immobilize

extremity to prevent catheter dislodgment or

trauma.

4. Obtain x-ray to check for placement andcomplication of pneumothorax5. Observe catheter site for leakage6. Ensure that balloon is deflated with a syringe

attached except when PCWP is read

7. Continuously monitor PA systolic and diastolicpressures and report significant variations

8. Irrigate line before each reading of PCWP9. Maintain client in same position for each reading10. Record PA systolic and diastolic readings at least

every hour and PCWP as ordered.

CENTRAL VENOUS PRESSURE (CVP)A. Obtained by inserting a catheter into the external jugular,

antecubital, or femoral vein and threading it into the vena

cava. The catheter is attached to an IV infusion and H2O

manometer by a three way stopcock

B. Purposes:

Reveals RA pressure, reflecting alterations in theRV

Provides information concerning blood volume andadequacy of central venous return

Provides an IV route for drawing blood samples,administering fluids or medication, and possibly


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inserting a pacing catheter

C. Normal range is 4-10 cmH20; elevation indicates

hypervolemia, decreased level indicates hypovolemia

D. Nursing care

Ensure client is relaxed Maintain zero point of manometer always at level

of right atrium (midaxillary line)

Determine patency of catheter by opening IVinfusion line

Turn stopcock to allow IV solution to run intomanometer to a level of 10-20cm above expected

pressure reading

Turn stopcock to allow IV solution to flow frommanometer into catheter; fluid level in

manometer fluctuates with respiration

Stop ventilatory assistance during measurement ofCVP

After CVP reading, return stopcock to IV infusionposition

Record CVP reading and position of clientDISORDERS OF THE CARDIOVASCULAR

SYSTEM

HEART

CORONARY ARTERY DISEASE (CAD)

A. General Information

refers to a variety of pathology that causenarrowing or obstruction of the coronary arteries,

resulting in decreased blood supply to the

myocardium

major causative factor: Atherosclerosis bet 30-50 y.o., men>women may manifest as angina pectoris or MI Risk factors:

- family history of CAD - DM

- el. Serum lipoprotein, - hypertension

- cigarette smoking - obesity- el serum uric acid - lifestyle

B. Medical management, assessment findings and nursing

interventionsAngina pectoris and MI

ANGINA PECTORIS

A. Gen. info:

1. transient, paroxysmal chest pain produced by insufficient

blood flow to the myocardium resulting in myocardial

ischemia

2. Risk factors:

- CAD - DM

- hypertension - aortic insufficiency- severe anemia - atherosclerosis

- thromboangiitis obliterans

3. Precipitating factors:

- physical exertion - sexual activity

- strong emotions - cigarette smoking

- consumption of a heavy meal

- extremely cold weather

B. Medical mgt:

Drug therapy: nitrates, beta adrenergic blockingagents, and/or calcium blocking agents, lipid

reducing drugs if cholesterol is elevated Lifestyle modification Surgery: coronary bypass surgery

C. Assessment Findings:

Pain: substernal with possible radiation to the neck,jaw, back and arms, relieved by REST

Palpitations, tachycardia, dyspnea, diaphoresis el. serum lipid levels Diagnostic tests:

- ECG may reveal ST segment depressionand T-wave inversion during chest pain

- Stress test may reveal an abnormal ECGduring exercise

D. Nursing interventions:

administer oxygen give prompt pain relief with nitrates or narcotic

analgesics as ordered.

Monitor V/S, status of cardiopulmonary function,monitor ECG

place patient in semi-high Fowlers position provide emotional support, health teachings and

discharge instructions.

Instruct client to notify physician immediately ifpain occurs and persists, despite rest andmedication administration.

MYOCARDIAL INFARCTION

A. General information:

The death of myocardial cells from inadequateoxygenation, often caused by a sudden complete

blockage of a coronary artery; characterized by localized

formation of necrosis (tissue destruction) with subsequent

healing by scar formation and fibrosis.

Risk factors:- atherosclerotic CAD - DM

- thrombus formation - hypertension

B. Assessment findings: Pain same as in angina, crushing, viselike with sudden

onset; UNRELIEVED by rest or nitrates

nausea/vomiting, dyspnea skin: cool, clammy, ashen elevated temperature initial increase in BP and pulse, with gradual drop in

BP

Restlessness Occasional findings: rales or crackles; presence of S4;

pericardial friction rub; split S1, S2

Diagnostic tests:o elevated WBC, cardiac enzymes (troponin,

CPK-MB, LDH, SGOT)

o ECG changes (specific changes dependent onlocation of myocardial damage and phase of

the MI;

inverted T wave and elevated ST segment, presence Q wave seen with

myocardial ischemia

o c. inc. ESR, el. serum cholesterolC. Nursing interventions:

establish a patent IV line


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provide pain relief; morphine sulfate IV Administer O2 as ordered to relieve dyspnea and

prevent arrhythmias

Provide bed rest with semi fowlers position Monitor ECG and hemodynamic procedures Administer anti-arrhythmias as ordered. Monitor I & O, report if UO


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C. Treatment:

IV push of Lidocaine (50-100mg)followed by IV drip of lidocaine at rate of

1-4 mg/min

Procainamide (Pronestyl),quinidine(quinora)

Treatment of underlying causeVENTRICULAR TACHYCARDIAA. General information:

3 or more consecutive PVCs; occurs from repetitivefiring of an ectopic focus in the ventricles

caused by:- MI - CAD

- digitalis intoxication - hypokalemia

B. Assessment findings:

Rate: atrial: 60-100 beats/minventricular: 110-250 beats/min

Rhythm: atrial(regular), ventricular (occly.irregular)

P wave: often lost in QRS complex P-R interval usually not measurable QRS complex: greater than 0.12 secs, wide

C. Treatment: IV push of lidocaine (50-100mg), then IV drip of

lidocaine 1-4 mg/min

Procainamide via IV infusion of 2-6 mg/min direct current cardioversion bretylium, propanolol

PERCUTANEOUS TRANSLUMINAL CORONARY

ANGIOPLASTY (PTCA)A. General information:

PTCA can be performed instead of coronary arterybypass graft surgery in various clients with single

vessel CAD.

Aim: revascularize the myocardiumo decrease anginaincrease survival a balloon tipped catheter is inserted into the

stenotic, diseased coronary artery. The balloon is

inflated with a controlled pressure and thereby

decreases the stenosis of the vessel

CORONARY ARTERY BYPASS SURGERY(CABG)

A. General information:

A coronary artery bypass graft is the surgeryof choice for clients with severe CAD

new supply of blood brought todiseased/occluded coronary artery by

bypassing the obstruction with a graft that is

attached to the aorta proximally and to the

coronary artery distally

Procedure requires use of extracorporealcirculation (heart-lung machine,

cardiopulmonary bypass)

B. Nursing interventions: preoperative

Explain anatomy of the heart, function of coronaryarteries, effects of CAD

Explain events of the day of surgery

Orient to the critical and coronary care units andintroduce to staff

Explain equipments to be used (monitors,hemodynamic procedures, ventilators, ET, etc)

Demonstrate activity and exercise Reassure availability of pain medications

C. Nursing interventions: post-operative

1. Maintain patent airway

2. Promote lung re-expansion

3. monitor cardiac status

4. maintain fluid and electrolyte balance

5. maintain adequate cerebral circulation

6. provide pain relief

7. prevent abdominal distension

8. Monitor for and prevent the ff. complications:

Thrombophlebitis / pulmonaryembolism

Cardiac tamponade arrhythmias CHF

9. Provide client teaching and discharge planning

concerning:

limitation with progressive increasein activities

sexual intercourse can usually beresumed by 3rd or 4th week post-op

medical regimen meal planning with prescribed

modifications

wound cleansing daily with mild soapand H2O and report for any signs of

infection

Symptoms to be reported:- fever, dyspnea, chest pain with minimal

exertion

CONGESTIVE HEART FAILUREA. Gen. Info:

- Inability of the heart to pump an adequate supply

of blood to meet the metabolic needs of the body

B. Types:

1. Left sided heart failure

2. Right sided heart failure

1. LEFT SIDED HEART FAILURE

a. Left ventricular damage causes blood to back up

through the left atrium and into the pulmonary veins.

Increased pressure causes transudation into the interstitial

tissues of the lungs with resultant pulmonary congestion

b. Caused by: left ventricular damage (MI, CAD) hypertension, aortic valve disease (AI, AS) mitral stenosis, cardiomyopathy

c. signs/symptoms

dyspnea, initially upon exertion paroxysmal nocturnal dyspnea cough orthopnea

restlessness


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crackles/rales pink frothy sputum

d. Diagnostic tests:

ECG, chest x-ray (cardiomegaly, pleuraleffusion), echocardiography, cardiac

catheterization, decreased. PO2, inc. PCO2

2. RIGHT SIDED HEART FAILURE

a. Weakened Right ventricle is unable to pump blood into

the pulmonary system; systemic venous congestion occurs

as pressure builds up.

b. caused by:

left sided heart failure RV infarction atherosclerotic heart disease COPD, pulmonic stenosis, pulmonary embolism

c. Assessment findings:

Symptoms:

easy fatigability, lower extremity swelling early satiety RUQ discomfortSigns:

elevated jugular venous pressure hepatomegaly Ascites lower extremity edemad. Diagnostic tests:

chest x-ray: reveals cardiac hypertrophy echocardiography: indicates inc. size of cardiac

chambers

elevated CVP, dec. PO2, inc. ALT(SGPT)C. Medical Management:

determination and elimination/control ofunderlying cause

Drug therapy:o Diuretics: Furosemide, Spironolactoneo Dilators: ACE inhibitors, nitrateso Digitalis: digoxin

Diet: low salt, low cholesterol* If medical therapies unsuccessful, mechanical assist

devices (intra-aortic balloon pump), cardiac

transplantation or mechanical hearts may be employed.D. Nursing Interventions:

Monitor respiratory status and provide adequateventilation (when CHF progresses to pulmonary

edema)

Provide physical and emotional rest Increase cardiac output Reduce/eliminate edema Provide client teaching and discharge planning

CARDIAC ARREST

A. General Info:

- sudden, unexpected cessation of breathing and adequate

circulation of blood by the heart

B. Medical management:

1. Cardiopulmonary resuscitation (CPR)

2. Drug therapy:

lidocaine, procainamide, verapamil

Dopamine, isoproterenol, Norepinephrine Epinephrine to enhance myocardial automaticity,

excitability, conductivity, and contractility

Atropine sulfate to reduce vagus nerves controlover the heart, thus increasing the heart rate

Sodium bicarbonate: administered during first fewmoments of a cardiac arrest to correct

respiratory and metabolic acidosis Calcium chloride: calcium ions help the heart beat

more effectively by enhancing the myocardium's

contractile force

DefibrillationC. Assessment findings:

unresponsiveness, cessation of respiration, pallor,cyanosis, absence of heart rate/ BP/pulses,

dilation of pupils, ventricular fibrillation


Begin precordial thump and if successful,administer lidocaine

If unsuccessful, defibrillation - CPR Assist with administration of and monitor effects of

emergency drugs

CARDIOPULMONARY RESUSCITATIONA. General info: process of externally supporting the

circulation and respiration of a person who has had a

cardiac arrest

B. Nursing interventions: unwitnessed cardiac arrest

Assess LOC Shake victims shoulder and shout if no response, summon for help

Position victim supine on a firm surface Open airway

Use head tilt, chin lift maneuver Place ear nose and mouth

1. look to see if chest is moving2. listen for escape of air3. feel for movement of air against face

If no respiration, proceed to #4 Ventilate twice, allowing for deflation between

breaths

Assess circulation: if not present, proceed to #6 Initiate external cardiac compressions

Proper placement of hands: lower half of thesternum

Depth of compressions: 1 - 2 in. for adults One rescuer: 30 compressions (80-100/min)

with 2 ventilations

Two rescuers: 30 compressions (80-100/min)with 2 ventilation

INFLAMMATORY DISEASES OF THE HEART

ENDOCARDITIS

A. General Info:

Inflammation of the endocardium; platelets and fibrindeposit on the mitral and/or aortic valves

o causing deformity, insufficiency or stenosis caused by bacterial infection:

- commonly S. aureus. S. viridans, Bhemolytic streptococcus, gonococcus


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Precipitating factors: RHD, open heart surgery, GU/OBGyn surgery, dental extractions


1.Drug therapy:

antibiotics specific to sensitivity or organismcultured

PenG and streptomycin if org. not known antipyretics Cardiac surgery to replace valve

C. Assessment findings:

Fever malaise, fatigue dyspnea cough acute upper quadrant pain joint pain Petechia Murmurs Edema splenomegaly hemiplegia confusion elevated WBC & ESR decreased Hgb & Hct. Hematuria Diagnostic tests: positive blood culture for

causative organism


antibiotics as ordered control temperature assess for vascular complications and pulm.

embolism

Provide client teaching and discharge planning

types of procedures, antibiotic therapy S/S to report: persistent fever, fatigue, chills,anorexia, joint pains avoidance of individuals with known

infections

MYOCARDITIS

A. General Info: an acute or chronic inflammation of the

myocardium as a result of pericarditis, systemic

infection or allergic response.

B. Assessment:

- fever, pericardial friction rub, gallop rhythm

- murmur, signs of heart failure, fatigue, dyspnea

- tachycardia, chest pain

C. Implementation:

1. Assist client to assume a position of comfort

2. Administer analgesics, salicylates, NSAIDS

3. Administer O2, provide adequate rest periods

4. Limit activities, to dec. workload of heart

5. Treat underlying cause

6. Administer meds. as ordered:

- antibiotics, diuretics, ACE inhibitors, digitalis

7. Monitor complications: thrombus, heart failure,

cardiomyopathy

PERICARDITIS

A. General Info:

An inflammation of the visceral and parietalpericardium

caused by bacterial, viral, or fungal infection;collagen diseases; trauma; acute MI, neoplasms,

uremia, radiation, drugs (procainamide,

hydralazine, Doxorubicin HCL)


chest pain with deep inspiration (relieved by sittingup), cough, hemoptysis, malaise

tachycardia, fever, pericardial friction rub, cyanosisor pallor, jugular vein distension

Elevated WBC and ESR, normal or inc. SGOT Diagnostic test:

o chest x-ray may show increased heart sizeo ECG: ST elevation, T wave inversion

C. Medical management:

Determination and elimination/control ofunderlying cause

Drug therapyo Medication for pain reliefo Corticosteroids, *salicylates (aspirin),

indomethacin, to reduce inflammation

Specific antibiotic therapy against the causativeorganism may be indicated

D. Nursing Interventions:

Ensure comfort, bed rest with semi- or highFowlers position

Monitor hemodynamic parameters Administer medications as ordered and monitor

effects

Provide client teaching and discharge planning: S/S of pericarditis indicative of recurrence (chest

pain intensified by lying down and relieved when

sitting up; medication regimenTHE BLOOD VESSELS

A. HYPERTENSION

- persistent elevation of the SBP above 140mmHg and of

DBP above 90mmHg (WHO)

Types:

Essential (primary, idiopathic): marked byloss of elastic tissue and arteriosclerotic

changes in the aorta and larger vessels coupled

with decreased caliber of the arterioles

Benign: a moderate rise in BP marked by agradual onset and prolonged course

Malignant: characterized by a rapid onset andshort dramatic course with a DBP of

>150mmHg

Secondary: elevation of the BP as a result ofanother disease such as renal parenchymal

disease, Cushings disease,

pheochromocytoma, primary aldosteronism,

coarctation of the aorta

A. Essential hypertension usually occurs between ages35-50; more common in men over 35, women over


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45; African-American men affected twice as often

as white men/women

Risk Factors:

(+) family history, obesity, stress, cigarettesmoking, hypercholesterolemia, inc. sodium

intake


Pain similar to anginal pain; pain in calves oflegs after ambulation or exercise (intermittent

dizziness; epistaxis; dyspnea on exertion

BP consistently above 140/90, retinalhemorrhages and exudates, edema of

extremities

Rise in SBP from supine to standing position(indicative of essential hypertension)

Diagnostic tests: elevated serum uric acid,sodium, cholesterol levels

C. Medical management:

Diet and weight reduction (restricted sodium, kcal,and cholesterol)

Lifestyle changes: alcohol moderation, exerciseregimen, cessation of smoking

Antihypertensive drug therapyD. Nursing interventions:

Record baseline BP in 3 positions (lying, sitting,and standing) and in both arms

Continuously assess BP and report any variablesthat relate to changes in BP

(positioning,restlessness)

Administer antihypertensive agents as ordered;monitor closely and assess for S/E

Monitor intake and hourly output Provide client teaching and discharge planning: risk factors, dietary instructions, compliance of

antihypertensive medications, routine follow up w/

ARTERIOSCLEROSIS OBLITERANSA.a chronic occlusive arterial disease that may affect the

abdominal aorta or the lower extremity. The obstruction to

blood flow with resultant ischemia usually affects the

femoral, popliteal, aortic and iliac arteries

occurs most often in men ages 50-60 caused by atherosclerosis Risk Factors: cigarette smoking, hyperlipidemia,

hypertension, DM


1. Drug therapy

Vasodilators:

Cilostazol (phosphodiesterase III inhibitor)produces vascular dilation in vascular bed and

inhibits platelet aggregation

Antiplatelet

ASA, ticlopidine, dipyridaqmole, clopidogrel(plavix)

o Xanthine derivatives Pentoxifyline (trental)increases erythrocyte

flexibility, lowers blood fibrinogen concentrations,

and has an antiplatelet effects

2. Surgery: bypass grafting, endarterectomy, balloon

catheter dilation, lumbar sympathectomy (to increase

blood flow), amputation may be necessary


Pain both intermittent claudication and restpain, numbness or tingling of the toes

Pallor after 1-2 mins. Of elevating feet, anddependent hyperemia/rubor; diminished or

absent

dorsalis pedis, posterior tibial and femoralpulses; shiny, taut skin with hair loss on lower

legs

3. Diagnostic tests:

Oscillometry may reveal decrease pulse volume Doppler U/S reveals decreased blood flow through

affected vessels

Angiography reveals location and extent ofobstructive process

4. Elevated serum triglycerides; sodium

D. Nursing Interventions:

Encourage slow, progressive physical activity Administer medications as ordered Assist with Buerger-Allen exercises qid

o client lies with legs elevated above heartfor 2-3 mins

o client sits on edge of bed with legs andfeet dependent and exercises feet and toes

upward and downward, inward and

outwardfor 3 mins

o client lies flat with legs at heart level for 5mins

Assess for sensory function; protect client frominjury

Provide client teaching and discharge planning:stop cigarette smoking, diet, drug compliance,

exerciseTHROMBOANGIITIS OBLITERANS(BUERGERS DISEASE)

Acute inflammatory disorder affecting medium/smallerarteries and veins of the LE. Occurs as focal,

obstructive process; results in occlusion of a vessel withsubsequent development of collateral circulation

Most often affects men ages 25-40; disease isidiopathic; high incidence among smokers

A. Medical management: same as arteriosclerosis obliterans

but only cessation of smoking is effective

treatment


Intermittent claudication, sensitivity to cold (skinof extremity may at first be white, changing to blue

then red)

Decreased or absent peripheral pulses (post. tibialand dorsalis pedis), ulceration and gangrene

(advanced)

Diagnostic tests: same as arteriosclerosis obliteransexcept no elevation in serum triglycerides

Nursing Interventions:

Prepare client for surgery Provide client teaching and discharge planning


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drug regimen, avoidance of trauma to the affectedextremity, need to maintain warmth esp. during

cold weathers, importance of stopping smokingRAYNAUDS PHENOMENON

intermittent episode of arterial spasms, mostfrequently involving the fingers; most often affects

women between the teenage years and age 40;

cause unknown

Predisposing factors: collagen diseases (SLE, RA),trauma (from typing, playing piano)

A. Medical management:

vasodilators catecholamine-depleting antihypertensive drugs

(reserpine, guanethidine monosulfate)


coldness, numbness, tingling in one or more digits; pain(usually pptd. By exposure to cold, emotional upsets,

tobacco use)

intermittent color changes (pallor, cyanosis, rumor);small ulcerations and gangrene tips of digits

C. Nursing interventions

1. provide client teaching concerning:

importance of stopping smoking need to maintain warmth need to use gloves in handling cold objects drug regimen

ANEURYSM

- a sac formed by dilation of an artery secondary to

weakness and stretching of an arterial wall. The dilation

may involve one or all layers of the arterial wall.

Classification

Fusiform: uniform spindle shape involving theentire circumference of the artery

Saccular: outpouching on one side only, affectingpart of the arterial circumference

Dissecting: separation of the arterial wall layers toform a cavity that fills with blood

False: the vessel wall is disrupted, blood escapesinto surrounding area but is held in place by

surrounding tissue

A. General info:

an aneurysm, usually fusiform or dissecting, inthe descending, ascending, or transverse

section of

the thoracic aorta usually occurs in men ages 50-70; caused by

arteriosclerosis, infection, syphilis,

hypertension


control of underlying hypertension Surgery: resection of the aneurysm and

replacement with a Teflon/Dacron graft; client

will need extracorporeal circulation


Often asymptomatic; deep, diffuse chestpain; hoarseness; dysphagia; dyspnea

Pallor, diaphoresis, distended neck veins

3. Diagnostic tests:

Aortography shows exact location of the aneurysm X-rays: chest film reveals abnormal widening of

aorta; abdominal film may show calcification

within walls of aneurysm

4. Nursing interventions: same as in Cardiac surgery

THROMBOPHLEBITIS

A. General info:

Inflammation of the vessel wall with formation of a clot(thrombus); may affect superficial or deep veins

Most frequent veins affected are the saphenous,femoral, and popliteal.

Can result in damage to the surrounding tissues,ischemia and necrosis

Risk Factors: obesity, CHF, prolonged immobility, MI,pregnancy, oral contraceptives, trauma, sepsis, cigarette

smoking, dehydration, severe anemias, venous

cannulation, complication of surgery


1. Anticoagulation therapy:

A. Heparin: blocks conversion of prothrombin tothrombin and reduces formation of thrombus

- S/E: spontaneous bleeding, injection site reactions,ecchymoses, tissue irritation and sloughing, reversible

transient alopecia, cyanosis, pain in arms or legs,

thrombocytopenia

B. Warfarin (coumadin): blocks prothrombinsynthesis by interfering with vit. K synthesi

- S/E: GI: anorexia, nausea/vomiting, diarrhea, stomatitis

- hypersensitivity: dermatitis, urticaria, pruritus, feve -

other: transient hair loss, burning sensation of feet, bleeding

complications.

2. Surgery

Vein ligation and stripping venous thrombectomy: removal of a clot in the

iliofemoral regionapplication of the inf. vena cava:insertion of an umbrella-like prosthesis into the

lumen of the vena cava to filter incoming clots


Pain in the affected extremity Superficial vein: tenderness, redness, induration

along course of the vein

Deep vein: swelling, venous distension of limb,tenderness over involved vein, (+) Homans sign

Elevated WBC and ESR Diagnostic tests:

o venography (phlebography): inc. uptakeof radioactive material

o Doppler ultrasonography: impairment ofblood flow ahead of thrombus

o Venous pressure measurements: high inaffected limb until collateral circulation is

developed

D. Nursing interventions

Provide bed rest, elevating involved extremity Apply continuous warm, moist soaks to dec.

lymphatic congestion

Administer anticoagulants as ordered


11/11

a. Heparin

monitor PTT, use infusion pump to administer IVheparin

assess for bleeding tendencies (hematuria;hematemesis; bleeding gums; epistaxis, melena)

have antidote ( protamine sulfate) availableb. Warfarin (Coumadin)

assess PT daily, advise client to withhold dose andnotify physician immediately if bleeding or

signs of bleeding occurs instruct client to use a soft toothbrush and to floss

gently,

prepare antidote: Vit. K monitor for chest pain or SOB (possible pulmonary

embolism)

Provide client teaching and discharge planning:o need to avoid standing, sitting for long

periods; constrictive clothing; crossing

legs at the

knees; smoking; oral contraceptiveso importance of adequate hydrationo use of elastic stockings when ambulatoryo importance of planned rest with elevation

of feet

o importance of weight reduction andexercise

VARICOSE VEINS

A. General info:

Dilated veins that occur most often in the lowerextremities and trunk. As the vessel dilates, the valves

become stretched and incompetent with resultant

venous pooling/edema

most common between ages 30-50 predisposing factor: congenital weakness of the veins,

thrombophlebitis, pregnancy, obesity, heart disease


vein ligation (involves ligating the saphenous veinwhere it joins the femoral vein and stripping the

saphenous vein system from groin to ankle)


Pain after prolonged standing (relieved byelevation)Swollen, dilated, tortuous skin veins

Diagnostic tests:Trendelenburg test: varicose veinsdistend very quickly (less than 35 secs)

Doppler U/S: decreased or no blood flow heardafter calf or thigh compression


Elevate legs above heart level Apply knee length elastic stockings Provide adequate rest Prepare client for vein ligation, if necessary Provide routine pre-op care keep affected extremity elevated above the

level of the heart to prevent edema

apply elastic bandages and stockings, whichshould be removed every 8hrs for short

periods.

assist out of bed within 24hrs, ensuring thatelastic stockings are applied.

assess for increased bleeding

ms handouts

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