Transcript Imbalance between Myocardial Supply and Demand Part 2 2009

Imbalance Between Myocardial
Supply and Demand
Irma B.Ancheta,PhD,RN
Peggy McCartt, PhD (c), CCRN, ARNP
Peripheral Vascular Disease (PVD)
• PVD includes disorders that alter the natural
flow of blood through the arteries and veins of
the peripheral circulation. PVD affects the
lower extremities much more frequently than
the upper extremities. Generally a client with
PVD implies arterial disease (rather than just
venous disease)
Assessing for Peripheral Vascular Disease
(PVD)
Physical Assessment
– Assess blood pressure in both arms
– Palpate pulses
– Listen for a bruit
PVD
• Laboratory Assessment
– Lipid Profile
• Cholesterol
• Triglycerides
– Homocysteine
Amino acid found in the blood
homocysteine levels
blocks NO
elasticity promote plaque build-up
dec.
• B6 = Pyridoxine (nuts, soybeans, legumes)
• B9 = Folic acid “folium”
• B12 = cyanocobalamin (liver,shellfish,salmon)
Interventions
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Monitor for Metabolic Syndrome
Diet Therapy
Smoking Cessation
Complementary and Alternative Therapies
Exercise
Drug Therapy
 HMG-CoA
Mevalonic acid
terpenes and steroids (terpenoid lipid)
cholesterol
 (first enzyme in the metabolic pathway that produces cholesterol and other
lipids)
 (gene located on the long arm of 5th chromosome)
 HMG Co-Reductase inhibitors
– Niacin
– Fibric Acid Derivatives
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Peripheral Arterial Disease (PAD)
• PAD is a manifestation of systemic atherosclerosis
and is a chronic condition in which partial or total
arterial occlusion deprives the lower extremities of
oxygen and nutrients.
– Inflow Obstructions- distal end of aorta and the common,
internal and external iliac arteries
– Outflow obstructions involve infrainguinal arterial
segments ( femoral, popliteal, and tibial arteries) and are
below the superficial femoral artery.
PAD
• Risk Factors and Incidence/Prevalence?
• Physical Assessment
Intermittent claudication
Arterial ulcers
Diabetic ulcers
Venous stasis ulcers
• Radiographic Assessment
– Arteriography
• Other Diagnostic Assessments
– Segmental systolic blood pressure measurements with a
Doppler
– Ankle-brachial index (ABI)
– Exercise Tolerance Testing
Int. Claudi.
[1] + Pain
Cramping
Burning
Reproducible
Awakened at
night
Toes, foot
Arched heels
(-) calves
-(-) ankles
Arterial U DM U
[1]+ Pain [1] (-)
Great Toe Pain
Plantar
Well def foot
Venous U
[1]min Pain
Ankle
Foot warm
border
+Pulse
+discoloration
PAD Interventions
• Nonsurgical
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Exercise
Positioning
Promoting vasodilation
Drug therapy i.e. anti-platelet medications: aspirin and
Plavix
– Percutaneous Transluminal Angioplasty (PTA)- stents/ laser
angioplasty/ atherectomy
• Surgical Management
– Arterial revascularization- bypass grafting with PTFE, GoreTex or Dacron
PAD Nursing Diagnoses NICS/NOCS
• Chronic Pain
• Ineffective Tissue Perfusion: Peripheral
• Risk for Injury
– NICS• pain management
• circulatory care: arterial insufficiency
• surveillance: safety
Pre-operative Care for PAD Surgical
Patient
• General Preoperative Surgical Care as for any
surgery patient
• Postoperative Care– Assess for Graft occlusion
– Assess for Graft Patency
• Care for Graft occlusion (thrombectomy)
– Assess for Infection
Acute Peripheral Occlusion
• Six “Ps” of Ischemia
– Pain
– Pallor
– Pulselessness
– Parathesia
– Paralysis
– Poikilothermia (coolness)
PAD Home and Community Care
• Home Care Management
• Health Teaching
• Health Care Resources
Aneurysms
• Abdominal
• Aortic
• Thoracic
Abdominal Aortic Aneurysm (AAA)
• Diagnosis
• Interventions
– Nonsurgical
– Surgical
• AAA Resection
• Pre and Postoperative Care
Peripheral Venous Disease
Pathophysiology
• Venous Thromboembolism (VTE)
• Venous Insufficiency (Varicose Veins)
• Lack of Skeletal Muscle Contractility
Thrombus Definition
A thrombus is a blood clot believed to result from
an endothelial injury, venous stasis, or
hypercoagulability. The thrombosis may not be
specifically attributable to one element, or it
may involve all three elements. It is often
associated with an inflammatory process.
When a thrombus develops, inflammation can
occur around the clot, thickening the vein wall
and consequently leading to embolization
(formation of an embolus).
VTE
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Embolus
Thrombophlebitis
Phlebothrombosis
Deep Venin Thrombophlebitis or Deep Venin
Thrombosis (DVT)
• Pulmonary Embolism
• Virchos’s triad- stasis of blood flow,
endothelial injury, and hypercoagculability
VTE
• Assessment
Look for calf tenderness and pain, and sudden
onset of unilateral swelling of the leg. Pain in the calf
on dorsiflexion of the foot (positive Homan’s sign)
appears in only 10% of clients- many clients(40%)
may have no S&S
Localized edema
• Tests
Venous Doppler
Impedance plethysmography
MRI
D-dimer