Lecture 9: Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion – Flashcards
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ineffective tissue perfusion: peripheral
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decrease in nutrition/respiration at peripheral cellular level because of decreased capillary blood supply
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arterial insufficiency is usually due to ..
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1. atherosclerosis 2. arteriosclerosis 3. occlusion 4. vasospasms
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arteriosclerosis
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the elastic and muscular tissues of the arteries are replaced with fibrous tissue
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arteriosclerosis main cause(s)
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effects of aging, can't do much about it or stop it from happening
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atherosclerosis
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build up of fatty plaque in the arteries
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atherosclerosis main cause(s)
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1. smoking 2. obesity 3. family history 4. high BP 4. high cholesterol 5. age 6. sex 7. sedentary lifestyle
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venous insufficiency is usually due to ...
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1. valvular incompetency 2. venous stasis
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venous insufficiency caused by venous stasis can lead to _____ and be caused by ____
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1. DVT 2. CHF
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arterial pain venous pain
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arterial: intermittent; with activity venous: constant aching
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arterial pulse venous pulse
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arterial: absent or diminished venous: unchanged
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arterial CR venous CR
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arterial: >3 seconds venous: unchanged
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arterial skin color venous skin color
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arterial: pale venous: normal, or brown discoloration on the lower legs with chronicity
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arterial skin temp venous skin temp
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arterial: cold venous: warm
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arterial skin appearance venous skin appearance
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arterial: shiny with hair loss on legs venous: brown discoloration on legs
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arterial edema venous edema
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arterial: absent venous: present
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arterial sensory/motor venous sensory/motor
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arterial: impaired venous: unchanged
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arterial ulcers venous ulcers
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arterial: pale ulcer base with even edges venous: if present develops at side of ankle especially medially
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arterial healing venous healing
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arterial: delayed venous: delayed
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peripheral edema is a (arterial or venous problem)?
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venous
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assessment of edema includes
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1. visible? 2. palpable? 3. pitting? ----- (1+ - 4+)
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peripheral pulses is part of a (venous or arterial) assessment
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arterial
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how do you check peripheral pulse in an arterial assessment
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bilaterally, simultaneously note strength note symmetry (0-4+)
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what are some peripheral vascular alterations associated with venous problems
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1. VTE (DVT) 2. phlebitis
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phlebitis is a (arterial or venous) problem
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venous
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what is phlebitis
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inflammation of vein
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signs of phlebitis
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pain, tenderness, swelling, warmth and redness over the inflamed vein edema below obstruction mild increased temperature
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what are the potential risks for a patient who has phlebitis
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phlebitis promotes clot formation; increased risk for VTE (DVT)
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what are the risk factors associated with phlebitis
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1. obesity 2. immobility 3. surgery 4. trauma 5. oral contraceptives / hormone state 6. age 7. high risk conditions
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how do you assess for VTE and phlebitis
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1. know the symptoms 2. assess calf measurements 3. complaints of calf pain with walking 4. unilateral edema and or redness of the extremity
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signs/symptoms of VTE
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50% of the time there are none !! unilateral presence of ... 1. edema 2. pain 3. warmth 4. redness 5. calf tenderness may have a low grade fever
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how can you as the nurse prevent VTE and phlebitis
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1. assess and monitor 2. patient teaching 3. early ambulation/activity 4. calf pumping 5. prevent vasoconstriction (leg crossing)
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what is the most common preventable cause of death in hospitals
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VTE --> pulmonary embolus
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what are 2 abnormal PVS assessment findings during auscultation
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1. orthostatic BP changes >20 mmhg between positions 2. bruits
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what is a bruits
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blowing/swishing sound caused from turbulence thru a narrowed lumen
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how do you assess for bruits
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1. assess the carotid artery (most common vessel used to assess bruits) 2. ask the patient to turn head away and hold their breath for a few seconds 3. listen in the upper 1/3 on the neck (loudest in this area)
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if you hear a bruits what should the next step in your assessment be
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palpate for "thrills"
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a bruits heard in the carotid artery is a sign that the patient is at high risk for what
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stroke
