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RESPONSIBILITIES OF PRE-OP
NURSE
-Accurate Identification of Pt
-2 patient identifiers
-Known last meal for patient
-Safe transport to OR via stretcher with side rails up
-Psychosocial support for Mr. Ball and his family
-Patent IV with Fluids infusing
-Mr. Ball voids before pre-operative medications
-Pre-operative dose of Ativan 0.5 mg IV given once on stretcher
-Signed consent form is in the chart
-OR Checklist completed and on the front of the chart
-Accurate identification of patient, surgical procedure & site. Done in holding room with
physician present
-All pertinent labs and diagnostics (CXR, ECG) are on the chart with appropriate interpretations.
-Review labs once more to make sure there are no abnormalities that will cause problems during
the intra operative and post operative periods.
Chest x-ray : to rule out any pulmonary disease that predispose pt to pneumonia or respiratory
difficulties after surgery.
Electrocardiography for > 40 yrs: Anesthesia will want to know that the heart is healthy enough
for anesthesia and that he is not likely to have a peri-operative heart attack.
Complete blood count: Again the anesthesiologist is looking for elevated WBC that might tip us off
to infection or a low hemoglobin and hematocrit that might make his recovery from anesthesia
complicated. Also a low hemoglobin could cause pt to have a peri operative heart attack.
Electrolyte levels:
Urinalysis: UTI
X-ray: Limbs that are poorly perfused often get severe infections that do not respond to antibiotics.
appropriate monitoring
parameters for the patient
recovering from general or spinal
anesthesia
5.
6.
OKAY TO GIVE:
Tranquilizers
Sedatives
Analgesics
Anticholinergics: to dry up secretions
H2 Blockers: prevent allergic reaction
Ativan: benzodiazepine to decrease stress
NOT OKAY:
Insulin- if pt is NPO
Anti-inflammatory: Aspirin, Motrin, Advil, Aleve (d/c 2 weeks prior)
Blood Thinners/Anticoagulant: Pletal, Warfarin, Heparin- Bleeding risk
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10.
Living Wills
Written and signed by the patient. The patient can opt out of this at any
given time. Patients are given the right to change their mind up to the last
moment.
Patient is usually a full code for 24 hours following surgery
Allows family to know patient wishes in the event of serious intraoperative complication
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How do you
determine risk for
latex allergy?
Genetic predisposition
Children with spina bifida
Urogenital abnormalities
Spinal cord injuries
Hx of multiple surgeries
Health care professionals
Allergies to avocado, tomato, banana
Urticaria
Rhinorrhea
Bronchospasm
Compromised respiratory status
Circulatory collapse & Death
General vs Local
Anesthesia/Conscious
Sedation
Patients who undergo general anesthesia are more likely to face complications than those who have only local
anesthesia or conscious sedation.
The patient who requires general anesthesia usually has extensive surgery and requires close monitoring in
the PACU for phase I recovery. This lasts for a few hours. Ultimately the patient returns to the acute care unit
for postoperative convalescence, which may last overnight or for several days.
In contrast, an ambulatory surgical patient who has had local anesthesia with no sedation or conscious
sedation most often only undergoes phase II recovery for a brief time (i.e., 1 to 2 hours). In phase II recovery
nursing staff prepare the patient for care in the home or extended care setting
15.
Surgical
considerations for
elderly pt's
Age alone is no longer a factor for determining the benefit that an individual can achieve from a surgical
procedure. Consequently nurses are caring for many more surgical patients of advanced age and are required
to know the age-related factors that affect a surgical procedure
A smaller margin of physiological reserve makes the older adult less able to compensate during the
perioperative period for changes that occur as a result of infection, hemorrhage, alterations in blood pressure,
and fluid/electrolyte abnormalities. Ongoing, focused assessments are necessary.
Older patients are at greater risk for postoperative delirium associated with an acute onset. Reduced level of
consciousness, reduced ability to maintain attention, perceptual disturbances, and memory impairment
characterize the typical presentation
Implement individualized measures to help the older-adult surgical patient achieve rest, sleep, and
orientation in the postoperative period to reduce the risk of delirium development.
Altered and unexpected drug responses are often related to different pharmacokinetics in the older adult.
Thus the nurse caring for the perioperative older patient needs to be alert to the possibility of a high risk for
adverse medication events with the administration of anesthetic agents and postoperative analgesics,
especially narcotics. "Start low and go slow" is the guiding principle when medicating older adults because of
their slow drug-clearance capability.
16.
Surgical
considerations for
bariatric pt's
Obesity increases surgical risk by reducing ventilatory and cardiac function. Obstructive sleep apnea,
hypertension, coronary artery disease, diabetes mellitus, and heart failure are common in the bariatric (obese)
population.
-Embolus, atelectasis, and pneumonia are common postoperative complications
-difficulty resuming normal physical activity after surgery and is susceptible to poor wound healing and wound
infection because of the structure of fatty tissue, which contains a poor blood supply.
-poor perfusion slows delivery of essential nutrients, antibodies, and enzymes needed for wound healing.
-It is often difficult to close the surgical wound of a patient who is obese because of the thick adipose layer;
thus he or she is at risk for dehiscence (opening of the suture line) and evisceration (abdominal contents
protruding through surgical incision)
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Surgical Considerations
for
Immunocompromised
pt's
Altered immune function are more at risk for developing infection after surgery.
Surgical Pain
Management
Before surgery conduct a comprehensive pain assessment, including the patient's and family's
expectations for pain management following surgery. Ask patients to describe their perceived tolerance to
pain, past experiences, and prior successful interventions used.
-Teach pt's how to score their pain before surgery
-Frequent pain assessments to alert nurses to treat pain and assess adequacy of pain interventions.
-Encourage the patient to use analgesics as ordered because, unless the pain is controlled, it is difficult for
the patient to participate in postoperative therapy.
-Pain relief has been shown to be more effective when analgesics are given around-the-clock (ATC) rather
than as needed (prn)
-Closely assess the patient's pain level, tolerance to activity, and response to pain-relieving interventions.
Spinal Block
The method of induction such as spinal, epidural, or a peripheral nerve block influences the portion of
sensory pathways that are anesthetized. No loss of consciousness occurs with regional anesthesia, but the
patient is often sedated.
Examples include patients with cancer, bone marrow alterations, and those who undergo radiation
therapy. Radiation is sometimes given before surgery to reduce the size of a cancerous tumor so it can be
removed surgically. It has some unavoidable effects on normal tissue such as excess thinning of skin
layers, destruction of collagen, and impaired vascularization of tissue. Ideally the surgeon waits to perform
surgery 4 to 6 weeks after completion of radiation treatments. Otherwise the patient may face serious
wound-healing problems.
The use of chemotherapeutic drugs for cancer treatment, immunosuppressive medications for preventing
rejection after organ transplantation, and steroids for treating a variety of inflammatory or autoimmune
conditions increases the risk for infection.
-the level of anesthesia can rise, which means that the anesthetic agent moves upward in the spinal cord
and affect breathing.
-migration of anesthetic depends on the drug type and amount and patient position.
-If level of anesthesia rises, respiratory paralysis can develop, requiring resuscitation. Elevation of the
upper body prevents respiratory paralysis.
-pt may have a sudden fall in blood pressure, which results from extensive vasodilation caused by the
anesthetic block to sympathetic vasomotor nerves and pain and motor nerve fibers.
-The patient requires careful monitoring during and immediately after surgery.
20.
General Anesthesia
General anesthesia results in an immobile, quiet patient who does not recall the surgical procedure.
-given by IV infusion and inhalation routes through the three phases of anesthesia: induction,
maintenance, and emergence.
-Surgery requiring general anesthesia involves major procedures with extensive tissue manipulation.
- The greatest risks from general anesthesia are the side effects of anesthetic agents, including
cardiovascular depression or irritability, respiratory depression, and liver and kidney damage.
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22.
Differentiate between
these three aspects of the
immune response:
1st Line Anatomical
Barriers (Natural
Defense)
2nd Line Inflammation
3rd Line Active Immune
Defense
Skin and mucous membranes are first line of defense- stop it from getting in
Compare anatomical
defense mechanisms and
the nursing interventions
that promote/maintain
these natural defense
mechanisms.
The skin & membranes are anatomical defenses, which nurses must monitor and support to keep integrity
and prevent injury
Respiratory, urinary, GI, reproductive systems all have normal flora and defense mechanisms that nurses
must keep healthy or keep in an environment where healing can take place.
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...
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Fever
Tachypnea
Tachycardia
Hypotension
Changes in LOC & activity
High WBC
Oozing, drainage
swelling
warm site
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Body launches a systemic response to infection including clotting cascade & fibrin.
In sepsis, the reaction does not stay local, it goes systemic. Body starts throwing clots
with thrombin and fibrin. Blocks perfusion, tissue oxygenation and can cause tissue
necrosis, organ failure and lead to severe sepsis.
Lowers immune response, so they don't always show typical signs of infection.
They have a harder time launching immune response like fever.
Outcomes:
Stable BP
RR 12-20
T 36.5-37.5
Lactate Lowered
CVP 8-12 mmHg
MAP >65 mmHg
Urine Output >0.5 mL/hr
Interventions:
Fluids
Antibiotics
Vasopressor & Dobutamine
Steroids?
Insulin to keep BG 70-110
35.
Systemic Infection
Ischemia
Trauma
Shock
Surgery (esp abdominal)
Burns
Chem. Aspiration
Cirrhosis
Pancreatitis
Immunodeficiency
Immunodeficiency
Transfusion reaction
Signs of Organ
Dysfunction
(Marker o Severe Sepsis)
-Altered consciousness,
Confusion,
Psychosis
-Tachypnea >20,
Sao2 <90%
PaO2/FiO2>300
-Jaundice,
High enzymes,
low albumin,
high PT
-Tachycardia >90
Hypotension
low perfusion
-Oliguria
Anuria
Increased creatinine
37.
Physio of SIRS
Vasodilation leads to hypotension, capillary permeability and edema. Leads to clotting, decreased
perfusion, refractory hypoxia
38.
Goals of Treatment
MAP>65 mmHg
CVP of 8-12 mmHg
Load up with fluid to flush out microclots in blood and kidneys, and antibiotics within one hour
39.
SIRS Criteria
Temp>38C
HR>90
RR>20
PaCO2<32 mmHg
WBC >12,000 or <4,000
Bands>10%
40.
Lactate
36.
42.
Onset of Parkinson's
Disease
Pathophysiology of
Parkinson's
Loss of neuro transmitter dopamine which is produced by substantia nigra is considered responsible for the
primary disease symptoms
By the time symptoms develop, 80-90% of the dopamine producing cells have been lost.
Dopamine governs movement, balance and walking
43.
44.
Etiology of PD
Clinical manifestations
of PD
Early Signs of PD
Severe Manifestations
Akinesia (rigidity)
Shuffling gait with short steps
Lack of swinging arms (akinesia)
Stooped posture
Mask like facial expression
Speech difficulty (volume low with dysarthria)
Lack of spontaneous swallowing
"Droopy eyes" or eyelid closure
Swallowing difficulty (50%)
Majority have NO intellectual compromise
Depression
Constipation
Weight loss
Sleep disturbances
Drooling
Urinary tract infections
Excessive sweating
Problems with sexual performance
49.
Treatment of PD
No cure
-Symptoms managed with medications:
levodopa & carbidopa most common
-surgical procedures where part of the brain is destroyed or stimulated.
-Transplantation of fetal dopamine producing cells is promising but ethically controversial.
50.
Sinemet
45.
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The tremor in Parkinson's is an essential resting tremor. It may be reduced with voluntary movement like
grasping the arm rest of a chair or rolling coins together.
Dopamine cannot cross the blood-brain barrier. The dopamine precursor Levodopa is able to cross the
blood brain barrier and is converted to dopamine in the basal ganglia, where it acts as naturally
occurring dopamine.
Levodopa is rapidly metabolized so only a small fraction of the drug is available to the CNS, so we give an
inhibitor to the metabolism, carbidopa.
51.
Selegiline (ELDEPRYL)
Anti-cholinergic
-used to inhibit re uptake and storage of dopamine in the CNS, thus prolonging action of dopamine.
This reduces the incidence and severity of akinesia, rigidity, tremor by about 20% and reduces drooling
because it reduces salivary production. (side effect it gives the patient a dry mouth).
Elderly patients may show an increased sensitivity to anti cholinergics thus requiring strict dosage
adjustment and monitoring.
52.
An on-off phenomenon may occur where the patient suddenly loses therapeutic value or oscillates
between therapeutic effect and no effect. 15 - 40% of patients experience this after 2 - 3 years.
53.
MAO Inhibitor
MAO inhibitor may be started at the time of diagnosis. It blocks the breakdown of dopamine.
54.
Thalamotomy
55.
Stimulator
implantation
Implantation of electrode with tip in target site in the brain. This is connected to wire run beneath the skin to a
stimulator (brain pacemaker) placed in the chest wall.
When electrical current is activated it modifies the function of the target site.
-used to address tremors.
-Can't be left on because when they control symptoms in one part of the brain, they often make other things
worse, like further weakening the throat muscles that effect ability to swallow or speak, so that is why the device
is activated and deactivated for specific activities and time.
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Goals for PD pt
Nursing
considerations for
pt with PD
Swallow evaluation
Work to improve voice volume, quality, and articulation.
Therapeutic exercises: verbalizations and tongue movements
For severely impaired speech: bring in resources (machine or computer-generated voice set up)
Teach families new communication strategies: verbal cuing and signals to understand or assist.
(Limited data about which techniques are most successful)
Etiology of MS
-susceptibility to MS appears to be inherited. First-, second-, and third-degree relatives of patients with MS are at
a slightly increased risk. Multiple genes confer susceptibility to MS.
Possible precipitating factors include infection, physical injury, emotional stress, excessive fatigue, pregnancy,
and a poorer state of health.
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64.
Pathophysiology
of MS
MS and
pregnancy
Some women with MS who become pregnant experience remission or an improvement in their symptoms during the
gestation period. -hormonal changes associated with pregnancy appear to affect the immune system.
-during the postpartum period, women are at greater risk for exacerbation of the disease.
Signs and
Symptoms of MS
Common signs and symptoms of MS include motor, sensory, cerebellar, and emotional problems.
Motor symptoms include weakness or paralysis of the limbs, trunk, or head; diplopia; scanning speech; and
spasticity of the muscles that are chronically affected.
Patients with MS experience a variety of sensory abnormalities, including numbness and tingling and other
paresthesias, patchy blindness (scotomas), blurred vision, vertigo, tinnitus, decreased hearing, and chronic
neuropathic pain. Radicular (nerve root) pains may be present, particularly in the low thoracic and abdominal
regions.
Lhermitte's sign is a transient sensory symptom described as an electric shock radiating down the spine or into the
limbs with flexion of the neck. Cerebellar signs include nystagmus, ataxia, dysarthria, and dysphagia.
Severe fatigue
65.
Diagnosis of MS
66.
Interferon
Immunomodulator drugs are used to modify the disease progression and prevent relapses.
Drugs used to
treat acute
exacerbations
67.
helpful in treating acute exacerbations of the disease, probably by reducing edema and acute inflammation at the site
of demyelination.
These drugs do not affect the ultimate outcome or degree of residual neurologic impairment from the exacerbation.
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What triggers
MS
exacerbations?
triggered by infection (especially upper respiratory and urinary tract infections), trauma, immunization, delivery after
pregnancy, stress, and change in climate. Each person responds differently to these triggers
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Cerebral thrombosis
A thrombotic stroke occurs from injury to a blood vessel wall and formation of a blood clot.
73.
Cerebral embolism
Embolic stroke occurs when an embolus lodges in and occludes a cerebral artery, resulting
in infarction and edema of the area supplied by the involved vessel.
- LEFT ATRIAL FIB CAUSES CLOTS TO LEAVE HEART
74.
Intracerebral hemorrhage
75.
Subarachnoid hemorrhage
occurs when there is intracranial bleeding into CSF-filled space between the arachnoid and
pia mater membranes on the surface of the brain.
Subarachnoid hemorrhage is commonly caused by rupture of a cerebral aneurysm
(congenital or acquired weakness and ballooning of vessels).
76.
SYMPTOMS OF HEMORRHAGE
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Penumbra - Zone of compromised neuronal cells that are unable to function but remain viable, swelling
could be reversed
(healthy -> penumbra -> ischemic core)
TX OF ISCHEMIC STROKE
Clinical Presentation of
Stroke
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EYE open
Spontaneously 4
To Speech 3
To pain 2
None 1
Best Verbal Response:
Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Best motor response:
Obeys commands 6
Localizes Pain 5
Flexion withdrawal 4
Abnormal Flexion 3
Abnormal Extension 2
Flaccid 1
87.
15-item neurologic examination stroke scale used to evaluate the effect of stroke
Procedure for Use
A trained observer rates the patent's ability to answer questions and perform activities. Ratings for
each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable
(UN) items. If an item is left untested, a detailed explanation must be clearly written on the form.
-measure the level of impairment caused by a stroke
-main use in clinical medicine is during the assessment of whether or not the degree of disability
caused by a given stroke merits treatment with tPA.
88.
NIH evaluations
Facial Droop:
1. Uneven smile
2. Flattening of the nasal fold
3. Drooping eye lid
4. Flattening of the brow furrow
Arm drift- Have patient hold arms up for 10 seconds, watch for drifting down of one side.
MORE ACCURATE WITH PALMS UP BECAUSE YOU CAN SEE HAND ROTATE EARLY
LEG- HOLD ONE AT A TIME FOR 5 SECONDS
TOUCH PT AND CK SENSATION, AND DON'T TOUCH A FEW TIMES
-USE ALCOHOL SWAB DIPPED IN ALCOHOL TO TEST SENSATION
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Early Stages of AD
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Severe AD
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Acetylcholinesterase inhibitors
101.
Acetylcholinesterase inhibitors
102.
Glutamine blockers
103.
25% goes to the kidneys, when they don't get that, they trigger mechanisms
to improve perfusion. (increase bp!)
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Aldosterone
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Primary hypertension
111.
Secondary hypertension
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causes:
Chronic renal disease,
Glomerulonephritis,
Renal artery stenosis,
Adrenal gland dysfunction
112.
White coat
hypertension:
htn in people who are actually normotensive except when their blood pressure is measured by a health care
professional.
Intermittent vasovagal response accounts for the transient elevations in blood pressure.
Tx of this is controversial
Treating produces hypotension.
However, essential or secondary htn disguised as white coat htn and left undiagnosed & untreated has
consequences over time.
113.
Isolated systolic
htn:
systolic BP is 140mm or higher but the diastolic BP remains less than 90.
Etiology: increased cardiac output or atherosclerosis induced changes in blood vessel compliance or both in
older adults.
Chances of developing of ISH increases with advancing age as does the severity.
Common in females
Persistent severe
hypertension
115.
Symptoms of HTN:
116.
BETA BLOCKERS
117.
DIURETICS
114.
Furosemide (Lasix)
20 - 40 mg per day
Given early in the day
Used for the CHF that can occur with longstanding HTN
Watch Potassium!
Hydrochlorothiazide (Dyazide)
HCTZ 12.5 - 25 mg per day
Used in combinations
118.
ACE INHIBITORS
-pril ending
stops RAA1 from working
good for hypertension and diabetics with HTN, protects kidneys
prevents heart remodeling
can cause swelling and airway ostruction
Lisinopril, enalopril, benazapril
Inhibits the conversion of Angiotension I to Angiotension II in the lungs
Stimulates bradykinins that can cause a chronic cough
Inhibits the CHF that can develop from HTN
Protects the kidneys from DM II and HTN
119.
-artan endings
expensive
Diovan
AKA - ARBs
Losartan, Candasartan, Irbesartan
Blocks the receptors sites of Angiotensin II
Lowering Blood pressure
Similar effects of ACEIs
No cough!
Fewer allergies than ACEIs
Used in combinations
120.
Alpha Blockers
Clonodine, Cozaar,
Simply blocks the alpha receptors that stimulate vasoconstriction
Not used as often as beta blockers, ACEIs and ARBs
121.
122.
Complications of HTN
Renal failure
Congestive heart failure
Cerebral vascular accident
Aortic aneurysm / dissection
Acute myocardial infarction
Peripheral vascular disease
123.
125.
Myocardial contractility:
126.
The greater the stretch of cardiac muscle fibers, the greater the force of contraction.
Increases contractile force leading to increased CO complication: increased myocardial
oxygen demand and is limited by overstretching.
127.
Neuroendocrine responses
Decreased cardiac output stimulates aortic baroreceptors which in turn stimulate SNS.
SNS causes release of catecholamines, causing increase in HR, BP and contractility.
Also causes increased vascular resistance and increased venous return.
Complication:
tachycardia with decreased filling times and decreased CO. Also causes increased vascular
resistance and increased myocardial work and oxygen demand.
124.
128.
130.
131.
Ventricular remodeling
occurs as the heart chambers and myocardium adapt to fluid volume and pressure increases.
129.
chambers dilate to accommodate excess fluid resulting from increased vascular volume and
incomplete emptying.
Initially, this additional stretch causes more effective contractions.
Ventricular hypertrophy occurs as existing cardiac muscle cells enlarge, increasing their
contractile elements and force of contraction.
132.
Left sided:
Blood backs into lungs, can't fill, CAD and HTN
Side effects:
Fatigue, activity intolerance, dyspnea, SOB, cough, orthopnea, inspiratory crackles,
wheezes, S3 gallop.
Right sided:
Blood backs in the periphery. Third spacing.
Side effects:
COPD, Peripheral edema, JVD, hepatomegaly, anorexia
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136.
Digitalis glycosides
137.
138.
Care of HF pt
139.
Pt teaching in HF
GET RRT
lung sounds, RR, O2 sats, HR, VS, EKG, CXR
Raise HOB,
!!!!!!!urine output!!!!!!!!! tells us about kidney failure
Acute Pulmonary Edema is a medical emergency and develops rapidly
Atherosclerosis
Diabetes
Smoking
Elevated lipid levels
Phlebitis
Autoimmune disease
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The lower limbs are more susceptible to arterial occlusive disorders and atherosclerosis than are
the upper limbs.
lower extremity:
aorto-iliac bifurcation and the femoral bifurcation.
Arteries can be occluded acutely from embolism, thrombosis, trauma, vasospasm or edema.
Emboli of a cardiac origin are usually due to atrial fibrillation.
Emboli tend to lodge at artery bifurcations or in areas where vessels abruptly narrow such as the
femoral artery bifurcation.
Progressive nature
Starves tissues of oxygenated blood
Collateral circulation can develop
Vasodialation : limited effect
Cellular anaerobic metabolism-lactic acid, pain, tissue pain
Sustained lack of arterial blood flow results in pain
Intermittent Claudication (muscle is forced to work without an adequate blood supply to meet its
metabolic demands.)
144.
Venous Disorders
145.
DVT
DVT- will still have pulse because clot is in the vein, so it will not block arterial pulse
Causes:
Prolonged position of hip flexion
Venous stasis
Previous DVT
Cardiac disease
Pregnancy
Trauma, especially of the lower extremities
Estrogen therapy or oral contraceptives
Malignancy
Obesity
Family history of clotting disorders.
Hypercoagulabiliy often accompanies malignant neoplasms, Cancer pt's more coagulable.
age over 75 in women, smoking & BC.
Dehydration and blood dyscrasias may raise the platelet count, decrease fibrinolysis, increase the
clotting factors or increase the viscosity fo the blood.
146.
Prevention of DVT
Activity
Passive or active contraction of leg muscles
Sequential compression devices (SCD's)
Applied after surgery until ambulation
Anticoagulation
Assessment
Homan's
Edema
Pain
143.
147.
Anticoagulant therapy
148.
149.
Leg pain
Decreased exercise tolerance
Paresthesias
May occur any where along the arterial system
Dependent rubor
Impotence
Ulcers
150.
151.
Smoking Cessation
Skin care
Exercise
Dietary changes
Promotion of arterial flow
Platelet inhibitors: Trental, Plavix
ASA
152.
Surgical Interventions
Endovascular Interventions
Angioplasty
Atherectomy
Stent Placement
Arterial Bypass
Revascularization of limbs
Arteriography to determine level of obstruction
Amputation
153.
Prevention of Complications
154.
Signs of problems
Pallor
Pulselessness
Pain
Paresthesias
Temperature Change
155.
Aneurysm Pathophysiology
156.
Abdominal Aortic
Aneurysm
157.
158.
Complications of
aneurysm repair
Aneurysm Rupture
159.
Raynauds
160.
s/s of Raynauds
-pallor
-cyanosis
-cold extremity
Criteria for
diagnosing
Raynaud's disease
Burger's Disease
161.
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164.
Clinical
Manifestations of
Burger's Disease
Treatment of
Burger's Disease
Use of well-fitting protective footwear to prevent foot trauma and thermal or chemical injury
Early and aggressive treatment of extremity injuries to protect against infections
Avoidance of cold environments
Avoidance of drugs that lead to vasoconstriction
NO SMOKING!
Amputation if it does not resolve, turns gangrenous