Nursing of adults with medical surgical conditions
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Nursing of Adults with Medical & Surgical Conditions. Disorders of the Peripheral Vascular System. Risk Factors. Similar to risk factors for heart disorders Age Gender Smoking Hypertension Hyperlipidemia Obesity Lack of exercise Emotional stress Diabetes Mellitus Family History.

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Nursing of Adults with Medical & Surgical Conditions

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Nursing of adults with medical surgical conditions

Nursing of AdultswithMedical & Surgical Conditions

Disorders

of the

Peripheral Vascular System


Risk factors

Risk Factors

  • Similar to risk factors for heart disorders

    • Age

    • Gender

    • Smoking

    • Hypertension

    • Hyperlipidemia

    • Obesity

    • Lack of exercise

    • Emotional stress

    • Diabetes Mellitus

    • Family History


Assessment of vascular disorders

Assessment of Vascular Disorders

  • Arterial Assessment

    • First symptom is usually pain

      • Occurs due to arterial insufficiency and ischemia

      • Dull ache in calf muscles

      • Leg fatigue and cramping

      • Intermittent claudication

        • Pain brought on by exercise

    • Later symptoms of pain

      • Pain at rest

      • Burning, tingling, and numbness at night even lying down

    • Pulses

      • May be weak, thready, or absent

        • Scale for documentation

          • 0 – absent

          • +1 – barely palpable, intermittent

          • +2 – weak , possibly thready, but constantly palpable

          • +3 – normal strength and quality

          • +4 – bounding, easily palpable, may be visible


Nursing of adults with medical surgical conditions

  • Assessment and Documentation

    • PATCHES

      • P for Pulses

        • Absence of pulses in generally a medical emergency

          • Compare with previous findings

          • Look for other symptoms – may just be hard to feel

          • Use Doppler device if necessary

      • A for Appearance

        • Pale, mottled, cyanotic or discolored (red, black, brown)

        • Necrosis or bleeding (ulcers)

          • Size, depth, and location

          • Edges jagged or smooth

          • Painful to touch

        • Shiny or dull

          • Shiny may indicate edema

          • Dull may indicate inadequate arterial blood supply

        • Superficial veins, erythema, or inflammation

        • Varicosities

          • Have patient to stand


Nursing of adults with medical surgical conditions

  • T for Temperature

    • Cool

      • Possible arterial problem

    • Warm

      • Possible venous problem

    • Temperature changes may be caused by other problems as well

  • C for Capillary refill

    • Less than 2 seconds

  • H for Hardness

    • Supple or hard and inelastic

      • Hardness may indicate chronic problems

  • E for Edema

    • Pitting edema

      • Usually acute problem

      • Assessment: Press on skin for 5 seconds and release (Page 317 --Figure 8-17 and Table 8-3)

    • Non-pittting

      • May be chronic condition

      • Assessment: Measure circumference of the extremity


Nursing of adults with medical surgical conditions

  • S for Sensation

    • Patient states extremity FEELS:

      • Numbness

      • Tingling

      • Hot

      • Cold


Nursing of adults with medical surgical conditions

  • Venous Assessment

    • First symptom is usually edema

    • Dark pigmentation

    • Dryness and scaling

    • Ulcerations

    • Pain, aching, and cramping

      • Usually relieved by rest or elevation

        Comparison of Arterial and Venous Disorders

        Page 331 – Table 8-5


Diagnostic tests

Diagnostic Tests

  • Noninvasive Procedures

    • Treadmill Test

      • Exercise to determine blood flow to extremities

    • Plethysmography

      • Assesses blood volume in the veins

    • Digital Subtraction Angiography (DSA)

      • IV contrast is administered

      • Blood vessels are visualized by radiography using an image intensifier video system and monitor

    • Doppler Ultrasound

      • Measures blood flow in arteries or veins


Diagnostic tests1

Diagnostic Tests

  • Invasive Procedures

    • Phlebography or venography

      • Radiographic visualization of veins

      • IV contrast is administered in a foot vein

      • X-rays are taken to detect filling defects

      • Assesses for condition of deep veins and to diagnose deep vein thrombosis

    • 125 I-fibrinogen Uptake Test

      • Assesses for acute calf vein thrombosis

      • Fibrinogen is tagged with iodine 125 and given IV - it can then be detected in the blood stream by a gamma ray detector

    • Angiography

      • IV contrast is administered

      • X-ray to visualize arteries


Nursing of adults with medical surgical conditions

  • D-dimer Serum Test

    • D-dimer forms when fibrin is broken down

    • When a thrombus is present D-dimer levels are elevated – usually greater than 1591 ng/ml

    • Normal value: 68-494 ng/ml

  • Duplex Scanning

    • Combination of ultrasound imaging and Doppler

    • Determines location and extent of thrombus within veins


Arteriosclerosis atherosclerosis

Arteriosclerosis & Atherosclerosis

  • Arteriosclerosis

    • thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply

  • Atherosclerosis

    • narrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium sized arteries

    • a type of arteriosclerosis


Atherosclerosis

Atherosclerosis


Hypertension

Hypertension

  • Etiology/Pathophysiology

    • A sustained elevated systolic blood pressure greater than 140 mm Hg and /or a sustained elevated diastolic blood pressure greater than 90 mm Hg.

    • Vasoconstriction (increases B/P)

      • caused by stimulation of the sympathetic nervous system and the release of epinephrine and/or norepinephrine. Decreased blood flow to the kidneys causes the release of renin and the formation of angiotensin which is a vasoconstrictor.


Hypertension1

Hypertension

  • Essential (primary) hypertension

    • 90-95% of all diagnosed cases

    • Theories of causes:

      • arteriolar changes, sympathetic nervous system activation, hormonal influence, genetic factors, obesity, sedentary lifestyle, increased sodium intake, excessive alcohol intake.

  • Secondary hypertension

    • Attributed to an identifiable medical diagnosis

      • renal vascular disease

      • diseases of the adrenal cortex

      • coarctation of the aorta

      • head trauma or cranial tumor

      • pregnancy-induced hypertension


Hypertension2

Hypertension

  • Malignant hypertension

    • severe, rapidly progressive elevation in blood pressure that causes damage to the small arterioles in major organs (heart, kidneys, brain, eyes)


Hypertension3

Hypertension

  • Signs & Symptoms

    • headache

    • blurred vision

    • epistaxis

    • angina

    • s/s of:

      • MI, CHF, renal failure, and stroke


Hypertension4

Hypertension

  • Treatment

    • Antihypertensive medications

      • Capoten, Vasotec, Altace, Lotensin, Zestril, Accupril, Monopril

    • Diuretics

      • Lasix, HCTZ, Aldactone

    • Diet

      • weight control, reduction of saturated fats, and low sodium

    • No smoking


Hypertension5

Hypertension

  • Decreased alcohol intake

  • Regular aerobic exercise

  • Relaxation techniques/stress management


Arteriosclerosis obliterans

Arteriosclerosis Obliterans

  • Etiology/Pathophysiology

    • narrowing or occlusion of the blood vessel with plaque formation

    • little or no blood flow to the affected extremity


Arteriosclerosis obliterans1

Arteriosclerosis Obliterans

  • Signs & Symptoms

    • Five P’s

      • Pain

        • intermittent claudication

      • Pulselessness

      • Pallor

      • Paresthesia

      • Paralysis


Arteriosclerosis obliterans2

Arteriosclerosis Obliterans

  • Treatment

    • Anticoagulants

      • Heparin and Coumadin

    • Fibrinolytics

      • Urokinase

      • administered directly into the thrombus

    • Surgery

      • embolectomy- removal of the embloism

      • endarterectomy- removal of the lining of the artery

      • arterial bypass

      • percutaneous transluminal angioplasty

      • amputation


Percutaneous transluminal angioplasty

Percutaneous Transluminal Angioplasty


Arterial embolism

Arterial Embolism

  • Etiology/Pathophysiology

    • Blood clots in the arterial bloodstream

    • May originate in the heart

      • arterial dysrhythmia, MI, valvular heart disease, CHF

    • Foreign substances

      • plaque, tissue, etc.


Arterial embolism1

Arterial Embolism

  • Signs & Symptoms

    • Pain

    • Absent distal pulses

    • Pale, cool, and numb extremity

    • Necrosis

    • S/S of shock with occlusion of a major vessel


Arterial embolism2

Arterial Embolism

  • Treatment

    • Anticoagulants

      • Heparin and Coumadin

    • Fibrinolytics

    • Endarterectomy

    • Embolectomy


Arterial aneurysm

Arterial Aneurysm

  • Etiology/Pathophysiology

    • Enlarged, dilated portion of an artery

    • Causes:

      • arteriosclerosis

      • trauma

      • congenital defect

    • Commonly affected arteries

      • popliteal

      • thoracic and abdominal aorta

      • coronary

      • cerebral


Arterial aneurysm1

Arterial Aneurysm

  • Signs & Symptoms

    • Asymptomatic

    • Large pulating mass

    • Pain, if large enough to press on other structures


Arterial aneurysm2

Arterial Aneurysm

  • Treatment

    • Assess for s/s of rupture, thrombi, ischemia

    • Control hypertension

    • Surgery

      • Ligation

      • Grafts


Surgical repair of arterial aneurysm

Surgical Repair of Arterial Aneurysm


Thromboangitis obliterans buerger s disease

Thromboangitis Obliterans(Buerger’s Disease)

  • Etiology/Pathophysiology

    • Occlusive vascular condition in which the small and medium size arteries become inflamed and thrombotic

      • affects the small arteries in the hands and feet

    • Cause not known

    • Affects men 20-40 years old who smoke


Thromboangitis obliterans buerger s disease1

Thromboangitis Obliterans(Buerger’s Disease)

  • Signs & Symptoms

    • Pain

      • may be frequent and persistent

    • Sensitivity to cold

    • Skin cold and pale

    • Ulcerations on feet or hands

    • Gangrene

    • Superficial thrombophlebitis


Thromboangitis obliterans buerger s disease2

Thromboangitis Obliterans(Buerger’s Disease)

  • Treatment

    • No smoking

    • Exercise to develop collateral circulation

    • Surgery

      • amputation of gangrenous fingers and toes

      • sympathectomy

        • clip nerves to prevent pain and vasospasm


Raynaud s disease

Raynaud’s Disease

  • Etiology/Pathophysiology

    • Intermittent arterial spasms

    • Primarily affects

      • fingers, toes, ears and nose

    • Exposure to cold or emotional stress

    • Secondary:

      • scleroderma

      • rheumatoid arthritis, SLE, drug intoxication, occupational trauma

    • Commonly affects women 20-40 years of age


Raynaud s disease1

Raynaud’s Disease

  • Signs & Symptoms

    • Chronically cold hands and feet

    • Pallor, coldness, numbness, cyanosis, and pain during spasms

    • Erythema following a spasm

    • Ulcerations on the fingers and toes with chronic disease


Raynaud s disease2

Raynaud’s Disease

  • Treatment

    • No smoking

    • Avoid exposure to cold

    • Medications

      • vasodilators

      • calcium antagonists

      • muscle relaxants

    • Surgery

      • sympathectomy

      • amputation for gangrene


Thrombophlebitis

Thrombophlebitis

  • Etiology/Pathophysiology

    • Inflammation of a vein in conjunction with the formation of a thrombus

    • More common in women

    • Risk factors

      • venous stasis

      • hypercoagulability

      • truama to the blood vessel

      • immobilization after surgery


Thrombophlebitis1

Thrombophlebitis

  • Signs & Symptoms

    • Pain

    • Edema

    • Positive Homan’s sign

    • Erythema, warmth, and tenderness along the vein


Thrombophlebitis2

Thrombophlebitis

  • Treatment

    • Superficial

      • Bedrest

      • Moist heat

      • Elevate extremity

      • NSAID’s

        • Motrin

        • aspirin


Thrombophlebitis3

Thrombophlebitis

  • Deep

    • Bedrest

    • Anticoagulants

      • Heparin & Coumadin

    • Fibrinolytics

    • Elevate extremity

    • Antiembolism stockings

    • Surgery

      • thrombectomy

      • vena cava umbrella (Greenfield filter)


Greenfield filter

Greenfield Filter


Varicose veins

Varicose Veins

  • Etiology/Pathophysiology

    • Tortuous, dilated vein with incompetent valves

    • Most common in women 40-60 years of age

    • Caused by:

      • congenital defective valves, absent valve, valve that becomes incompetent

      • Pregnancy or obesity

      • prolonged standing

      • constrictive clothing


Varicose veins1

Varicose Veins


Varicose veins2

Varicose Veins

  • Signs & Symptoms

    • Dark, raised, tortuous veins

    • Fatigue

    • Dull aches

    • Cramping of the muscles

    • Heaviness or pressure of extremity

    • Edema, pain, changes in skin color, and ulcerations with venous stasis


Varicose veins3

Varicose Veins

  • Treatment

    • Elastic stockings

    • Rest

    • Elevate legs

    • Sclerotherapy

      • injection of sclerosing solution

    • Surgery

      • Vein ligation and stripping


Venous stasis ulcers

Venous Stasis Ulcers

  • Etiology/Pathophysiology

    • Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs

    • Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue

    • Causes

      • varicose veins, burns trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factors


Venous stasis ulcers1

Venous Stasis Ulcers

  • Signs & Symptoms

    • Pain

    • Ulceration with dark pigmentation

    • Edema


Venous stasis ulcers2

Venous Stasis Ulcers

  • Treatment

    • Diet

      • Increased protein

      • Vitamin A & C and Zinc

    • Debridement of necrotic tissue

      • wet-to-dry dressings

      • Elase cream

      • surgical

    • Antibiotics

    • Unna boot


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