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Assessment
- History
- - watch for risk factor: atherosclerosis, DM, venous disorders, birth control pills
- Biological & demographics data
- - age: older
- - occupation: people who stand (nursing, hair dresser, clerks) or people who abuse their fingers- raynaud's disease
- Chief complaint, frequency, duration
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Assessment Arterial
- Intermittent claudification- doesnt happen all the time
- - result of ischemia
- - similar to angina
- - relieved with dependent position
- - "claudication distance"- how far can you walk
- Cause- decrease blood flow
- s/s: pain, numbness, cramping, tingling
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Assessment Arterial 2
- thin, shiny, hairless skin
- thick toe nails- fungal infection
- cool skin, dec or absent pulses
- mild/absent edema
- small painful ulcers on toes, pressure pts, heels: punched out, dry, black/necrotic
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Assessment Venous
- dull, aching pain
- not associated with rest/excerise
- heaviness in legs cramps at night
- inc risk with long standing, multiple pregnancies, abdominal obesity
- may have varicose veins
- - venous pressure
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Assessment venous 2
- Increased pressure gradients caused obstructed venous return, veins engorge, increasing capillary pressure, causing edema, blood flow slows and tissues become hypoxic (blood leaks out)
- Ulcers develop in lower 1/3 of legs
- exercise & elevation help venous return & collateral circulation- poor venous return
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Assessment venous- edema
- Edema worsens thru day, improves over night
- edema pitting at first, then scarring develops & pitting disappears
- skin changes
- - erythema (early)
- - thick brawny skin- stasis ulcers, stasis dermatitis (this is classic, looks like an old tan)
- - dry, flaky skin
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Hemosiderin: discoloration
- RBC leaking out- Heme gives it the brawny color
- chronic venous problem
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Assessment PMH
- CAD
- HTN
- VTE- DVT
- varicose veins
- smoking
- DM
- Fam hx- DM, CAD, HTN, PVD
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Assessment- inspection
- lower extremity color, temp
- turgor
- ulcers, scars
- capillary refill
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Assessment inspection 2
- hair distribution
- muscle atrophy
- venous pattern- varicose veins
- edema
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assessment- palpation
- dorsal surface of hand, compare sides
- Pulses- mark if difficult to find- 2+
- ** bilateral & compare except carotids
- document rate, rhythm and quality
- - 0 absent
- - 2+ norm
- - 1 + weak
- - 3+ bounding
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assessment- horman's sign
- AVOID USING
- reliability varies false +/-
- superfical phlebitis, achilles tendonitis can cause + horman's sign
- doppler studies more accurate
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assessment- auscultation
- stethoscope/doppler
- correct fit- too small false high, too big false low
- record both arms- document higher one
- check for bruits at pulse points- if blood is bouncing off the wall
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assessment - diagnostic test
- BP
- - MAP Mean Arterial Pulse
- SBP + 2DBP/3
- - normal between 70-100
- - < 60-65 End organ damage- not being perfused
- Ankle-brachial index (ABI)
- - SBP with doppler of Dorsal pedal or posterial tibal (lower extremity)
- - ABI: systolic ankle pressure/systolic brachial pressure
- - ankle pressure usually greater than brachial because it is further away.
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Assessment- ABI
- > 1 norm
- < 0.9 insuffiency
- - no good blood flow to the periphery
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Assessment diagnostic 2
- *** US most sensitive and specific for DVT
- CT scan/MRI- vessels and aneurysms
- Exercise testing
- - 5 min mild claudification
- - 1 min severe claudification
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Contrast angiography
- NPO 2-6 hrs before, document pulses
- Nsg care after like cardiac cath
- complications- allergic reactions, thrombus/emboli formation, vessel peforation, renal failure
- check VS, pulses, csm
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Contrast venography
- Nsg care before- document pulses, clear liquid x 3-4 hrs
- Nsg care after- pressure dsg to site
- - BR x 2hrs if femoral vein used
- - IV hydration x 8-24 hrs
- - check site, extremity as with angiography
- - check pulse, csm
- look for DVT or at valves
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Vascular endoscopy
- flexible fiberoptic scope
- Can ID thrombus, plaque
- can angioplasty, stent
- nursing care after, similar to angiography
- similar to PTCA check pulses
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