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Foot
ABI: at least once every 8 hours for the 1st 24 hours and then OD
until discharge.
** Disappearance of pulse that was present may indicate
thrombotic occlusion of the graft.. Notify surgeon STAT
Warm environmental temperature
Place leg in slight dependency to promote arterial flow
Avoid pressure on affected extremity; use padding for support
Avoid vigorous massage of extremities
Avoid: chilling and exposure to cold, avoid contractive clothing,
crossing legs
Quite smoking
Do not go barefooted
Trim toenails straight
Avoid scratching or rubbing feet
Acute arterial occlusion
Happens suddenly
Occlusion may affect upper extremities, but it more common in
the lower extermties
Most common cause: embolus or local thrombus
Risk factors: AMI within the preceding weeks, atrial fibrillation,
infective endocarditis, chronic heart failure
Assessment
Severe pain below level of the occlusion
Occurs even at rest
Affected extremity: cool or cold, pulseless, and mottled
Minute area on the toes may be blackened or gangrenous
Six Ps of ischemia: pain, pallor, pulselessness, paresthesia,
paralysis, coolness of the involved extremity
** HESI hints: decreased blood flow results in diminished sensation in
the lower extremities. Any heat source can cause severe burns before
the patient realize the damage is being done. **
Intervention
Anticoagulant therapy aka Heparin: bolus of up to 10,000 units
Buergers disease
Occlusive inflammatory disease strongly associated with smoking
Raynauds disease (think hands)
Form of intermittent arteriolar vasoconstriction that results in
coldness, pain, and pallor of the fingertips or toes
Triggered by extreme heat or cold
Occur bilaterally, ages 17 and 50 years, more common in women
Aortic aneurysm aka AAA
DX: abdominal X-rayeggshell, CT scanassess size and location,
ultrasonographycan also identify size and location
** HESI hint: a client is admitted with severe chest pain and states that
he feels a terrible sensation in his chest. He is diagnosed with
dissecting aortic aneurysm. What assessments should the nurse obtain
in the first few hours? Vital signs every hour, neurologic vital sign,
respiratory status, urinary output, and peripheral pulses.
*During aortic aneurysm repair, the large arteries are clamped for
period of time, and kidney damage can result. Monitor daily BUN and
normal creatine levels. Normal BUN is 10 to 20 mg/dl and normal
creatinine is 0.6 to 1.2 mg/dl. The ratio of BUN to creatine is 20:1.
When this ratio increases or decreases, suspect renal problems.*
Signs of impending rupture
Severe back pain or abdominal pain. May be persistent or
intermittent localized in the middle or lower abdomen to the left
midline
Low back pain- because of pressure of the aneurysm on the
lumbar nerves
Lower back pain is a serious symptom, usually indicating that the
aneurysn is expanding rapidly and it is about to rupture
Indications of a rupturing AAA: constant, intense back pain,
falling BP, decreasing hematocrit
What the difference between true and false aneurysm
True includes all three tunica layers
False- entire wall is injured blood escapes between tunica layer
and they separate. The blood is contained by the surrounding
Amputation
MEDS
UNFRACTIONATED HEPARIN GTT COUMADIN
ASA
LOW-MOLECULAR WT HEPARIN LOVENOX
Prevention
Start moving
Keep hydrated
No smoking
Leg exercises
Avoid contraceptives
TEDS
Venous compression boots
VENOUS INSUFFICIENCY
VENOUS CONGESTION FROM HTN DAMAGE VENOUS
VALVES
INC. EDEMA PRESENT
CELLULITIS DEVELOPS
STASIS ULCERS DEVELOP
BROWN DISCOLORATION OF SKIN NOTED STASIS
DERMATITIS
MANAGEMENT
GOALS
DECREASE EDEMA
PROMOTE VENOUS RETURN
MANAGING EDEMA
WEAR ELASTIC OR COMPRESSION STOCKINGS
ELEVATE LEGS
ELEVATE LEGS ABOVE HEART LEVEL
GENERAL
AVOID PROLONGED STANDING OR SITTING
DO NOT CROSS LEGS
NO RESRICTIVE CLOTHING PANTS, GIRDLES,
GARTERS, KNEE-HIS
MANAGEMENT
STASIS ULCERS
CHRONIC & RECURRENT
DRESSING TYPES
OXYGEN PERMEABLE
OXYGEN IMPERMEABLE:
DUODERM
UNNA BOOT
USED FOR AMBULATORY PT.