Transcript Renal Failure Acute and Chronic

Camille N. Scronce, BSN, RN
MSN Candidate, Duke University School of Nursing
October 24, 2014
Objectives
 Discuss pathophysiological changes to the vascular system and
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lifestyle risk factors that predispose individuals to vascular
disorders.
Discuss the clinical manifestations, complications, diagnostic
studies and collaborative care for abdominal aortic aneurysms.
Discuss the lifestyle changes needed to avoid or minimize
lower extremity peripheral vascular disease.
Distinguish between the signs and symptoms of peripheral
arterial and peripheral venous disease.
Describe the assessment and nursing management of a patient
following peripheral artery bypass graft surgery.
Objectives
 Describe signs of acute arterial ischemia (the six P’s).
 Discuss management of venous thromboembolism, chronic
venous insufficiency and venous leg ulcers.
 Recognize the clinical manifestations of aortic dissection as a
medical emergency and when to seek appropriate assistance.
Peripheral Vascular Disease (PVD)
 reduction in blood flow and oxygen through the peripheral
vessels
 PVD commonly referred to as peripheral arterial disease
(PAD)
Factors that can contribute to the development of peripheral
vascular disorders:
 atherosclerotic changes
 thrombus formation
 embolus
  coagulability of blood
 hypertension
 inflammatory process/infection
Overview of Disorders
 Peripheral Arterial Disease (PAD)
 Aneurysms
 Aortic Dissection
 Acute Arterial Ischemia
 Chronic Peripheral Artery Disease of the Lower
Extremities
 Venous Disorders
 Chronic Venous Insufficiency
 Venous Thrombosis
Peripheral Arterial Disease (PAD)
 Atherosclerosis - most common cause of peripheral arterial
disease
 Risk Factors
 *Smokers*
 Older Age
 High Cholesterol
 High Blood Pressure
 Diabetes
 Metabolic Syndrome
 S/Sx
 Intermittent claudication: Hallmark of the disease
 Abnormal pulses in lower extremities
Common Locations of
Atherosclerotic Lesions
Aneurysms
Abdominal Aortic Aneurysms
(AAA)
AAA Risk Factors
 Men
 Older Age
 Smokers
 CAD
 PAD
 High Blood Pressure
 High Cholesterol
AAA Diagnosis
 S/Sx:
 Often asymptomatic
 Pain or tenderness in the mid-or upper abdomen
 Auscultation of a bruit over the aneurysm
 Presence of a pulsating abdominal mass
 The aneurysm may extend to impinge on the renal, iliac, or mesenteric
arteries
 Rupture of the aneurysm – most feared complication
 Can occur if the aneurysm is large
 Can lead to death: MEDICAL EMERGENCY
 Diagnosed with Ultrasound
 CT Scan, MRI and Arteriogram
AAA Treatment & Management
 Depends on size
 Watchful waiting if <5.5 cm
 Risk factor modification:
 Stop smoking
 Control lipids and hypertension
 Statins
 ASA
 Surgery:
 Graft. (pg. 869) with transabdominal approach
 Transfemoral endovascular repair w/ stents (graft) (pg. 870)
AAA Treatment & Management
AAA Post-Op Management
 Maintain patency of graft & renal perfusion
 maintain adequate BP
 check skin temp/color/ pulses in lower extremities
 watch for sudden increase in pain.
 Also GI concerns (if open approach)
 Watch for infection (Pt teaching)
 Pain control
 Fluid & electrolyte balance/renal function
 Avoid heavy lifting for 4-6 weeks
Aortic Dissection
 Tear develops in the inner layer of the aorta
 S/Sx
 Sudden onset of severe and persistent pain
 Tearing or ripping sensation
 Hypotension, sweating, pale, tachycardia
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MEDICAL EMERGENCY!!!!
 Diagnosed with TEE, CT Scan or MRI
 Treatment:
 Pain management; BP control; Surgery
 Complications: cardiac tamponade
Aortic Dissection
Acute Arterial Insufficiency
 A sudden decrease in limb perfusion
 Usually caused by thrombus, embolus or trauma to an
artery
 S/Sx: 6 P’s:
 pain
 pallor
 pulselessness
 paresthesia
 Polar/poikilothermia (cool to touch)
 paralysis (late sign)
Acute Arterial Insufficiency
 Tissue Ischemia  Gangrene
 No time to lose: H & H
 (Hospitalization (Arteriography) & Heparin (IV)
 Surgery if limb threatened: usually embolectomy
 Post surgery:
 Anti-platelet therapy?
 Patient & family education: Assess for return of ischemic
symptoms
Chronic Peripheral Artery Disease
of the Lower Extremities
 What is the hallmark sign? ___________________
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Precipitated by_________?
Resolves in _________minutes?
Reproducible???
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Why?
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 May progress to rest pain & ulcers
 Diagnosed by doppler, ankle-brachial index (ABI),
angiography
Physical Examination:
Examination:
What do to:
Inspection
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•
•
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•
Thick Shiny Skin
Hair Loss
Brittle Nails
Color Changes (pallor)
Ulcers
Palpation
•
•
•
•
Temperature (cool, bilateral/unilateral)
Pulses: diminished or absent
Capillary Refill: > 5 seconds
Sensation/Movement: decreased
Auscultation
•
Femoral Bruits
Ankle Brachial
Index (ABI)
= Systolic BP in ankle
Systolic BP in brachial artery
Buerger’s Test
•
•
Expose the skin
and look for:
•
Elevate the leg to 45° - and look for pallor
Place the leg in a dependent position 90°& look
for a red flushed foot before returning to normal
Pallor at <20° = severe PAD.
Chronic Peripheral Artery Disease
of the Lower Extremities
Chronic Peripheral Artery Disease
of the Lower Extremities
 Prevention & treatment by lifestyle modifications such as:
_____?
 Avoid tight knee highs, socks
 Supervised walking most effective exercise!!
 Meds: ASA or other meds anticoag/antiplatelets
 Teaching: low fat diet, regular exercise, no smoking, foot
care
 Surgery/Stents: if symptoms are incapacitating (pain at
rest)
 Amputation: if ulcers/gangrene/limb threatened
Bypass Surgery
Fem-pop
Fem-tib
Aorto bi-fem
Kaufman 2011
Bypass Surgery: Nursing Care
 Maintaining circulation by:
 Check pulses, color, temp, sensory and motor function of the affected
extremities (Compare extremities)
 Disappearance of a pulse that was present may indicate occlusion of the graft
 Maintain skin integrity and prevent infection by:
 Meticulous foot care, comfortable well-fitting shoes, avoid applying
direct heat over extremities, never go barefoot
 Assess wound for redness, swelling and drainage
 Patient education upon discharge
 No smoking, no constrictive clothing, avoid crossing legs, encourage pt.
to walk
Venous Disorders
Venous Disorders
 Alteration in the transport/flow of blood from the
capillary back to the heart
 Changes in smooth muscle and connective tissue
make the veins less distensible with limited recoil
capacity
 Valves may malfunction, causing backflow of blood
 Virchow’s triad: blood stasis, vessel wall injury, and
altered blood coagulation
Venous Thrombosis
Venous Stasis
Varicose veins
Surgery
Obesity
Pregnancy
Bed rest
CHF
A fib
Hypercoagulability
Virchow’s
Triad
Blood dyscrasias
Oral contraceptives
Smoking
Sepsis
Injury
IV therapy
Fractures
Abdominal & pelvic surgery
29
Venous Stasis
 S/Sx:
 Lower leg edema, itching, brown pigmentation, cyanosis of
skin of lower leg/foot
 Complication: Venous stasis ulcer
 Treatment
 Keep feet elevated above heart level, follow guidelines for skin
and foot care, walk, avoid anything that pinches skin, do not
cross legs & avoid pressure behind knees
 Compression therapy
 Debridement of ulcer to promote healing
Compression Therapy
 Compression bandages with…..
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Example: Unna boots or ace bandages w/ glycerin, calamine
lotion, zinc oxide, gelatin.
Clean technique.
Treat infection
Refer to wound/ostomy clinic…WOCN RN
 Compression stockings
Venous Ulcer
Venous Thrombophlebitis
 Inflammation of the veins caused by thrombus or
blood clot
 Develops in both the deep and superficial veins of the
lower extremity
 deep veins – femoral, popliteal, small calf veins
 superficial veins – saphenous vein, superficial veins in the
arms
Superficial
• Depends on site & etiology
• Heat (warm moist soaks)
• Remove IV catheter if causative
• Pain & NSAID
• Elastic compression stockings
Deep Vein Thrombosis
Deep Vein Thrombosis
 S/Sx: pain and edema of extremity,  circumference of the
thigh or calf, (+) Homan’s sign
 Prevention: early ambulation, post-op exercises, compression
stockings, hydration, anticoagulation post-op. Avoid prolonged
sitting; avoid smoking.
 Diagnosis: Ultrasound, D-dimer
 Treatment: IV Heparin or LMWH then Coumadin
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Bed rest with Bathroom privileges (BR with BRPs)
Measure extremity daily
Elevation
Elastic compression stockings
Avoid rubbing or massaging leg
Deep Vein Thrombosis
Anticoagulation Therapy
 Heparin - IV (labs – PTT)
 Low Molecular Weight Heparin (Lovenox)
 Antidote: Protamine Sulfate
 Coumadin
 Antidote: Vitamin K
 Patient teaching - no sudden diet changes in foods high in
Vitamin K and risk for bleeding
 Labs to check – INR or PT
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PT: 12-15 sec
INR: 0.75-1.25 (Therapeutic Range: 2-3)
Arterial Disease
Venous Disease
Skin
cool or cold, hairless,
dry, shiny, pallor on
elevation, rubor on
dangling
warm, though,
thickened,
mottled, pigmented
areas
Pain
sharp, stabbing,
worsens w/ activity and
walking, lowering feet
may relieve pain
aching, cramping,
activity and walking
sometimes help,
elevating the feet
relieves pain
Ulcers
severely painful, pale,
gray base, found on
heel, toes, dorsum of
foot
moderately painful, pink
base, found on medial
aspect of the ankle
Pulse
often absent or
diminished
usually present
Edema
infrequent
frequent, esp. at the
end of the day and in
areas of ulceration
Review
 Many factors contribute to PVD
 Educate patients on how to minimize the risk factors for
venous disorders
 Know the signs and symptoms of AAA rupture
 Know the signs and symptoms of aortic dissection and
educate patients on BP control
 Remember nursing management after peripheral arterial
bypass surgery focuses on maintaining circulation, skin
integrity, preventing infection and providing patient
education.
Review
 Three factors contribute to venous thrombosis
 The key to managing venous stasis is focusing
interventions that increase blood flow to the heart
 Remember that the focus for DVTs is prevention
 There are differences between peripheral arterial and
venous disease
Questions??
References
 Ignatavicius, D.D. & Workman, M.L. (2013). Medical-Surgical Nursing: PatientCentered Collaborative Care (7th ed.). St. Louis: Mosby
 Kaufman, J. (2011). Vascular Disorders [PowerPoint slides]
 Leonard, C. (2013). Vascular Disorders [PowerPoint slides]
 Lewis, S.M., Dirksen, S.R., Heitkemper, M.M. & Bucher, L. (2013). Medical-
Surgical Nursing: Assessment and Management of Clinical Problems (9th ed.).
St, Louis: Mosby
 National Guideline Clearinghouse. (2012). Diagnosis and management of
peripheral arterial disease. A national clinical guide. Retrieved from
http://www.guideline.gov/content.aspx?id=9924
 Neschis, D.G. & Golden, M.A. (). Clinical features and diagnosis of lower
extremity peripheral artery disease. In K.A. Collins (Ed.), UpToDate. Retrieved
from http://www.uptodate.com/contents/clinical-features-and-diagnosis-oflower-extremity-peripheral-artery
disease?source=search_result&search=peripheral+vascular+disease&selectedTi
tle=1~150
10 Minute Break
Socrative Space Race Game
 Get in groups based on the numbers you received
when you walked into the class
 Have one person in the group use their laptop, IPAD,
cell phone or any device with a web browser.
 Go to the following website to play this game as a
group:
http://m.socrative.com
Teacher Room Name: 4a042f38