Arterial Surgeries Flashcards
(37 cards)
1
Q
?
A test to prove collateral circulation; involves the radial and ulnar arteries
> Test will show a hidden occlusion in the ulnar artery
A
Allen’s Test
2
Q
PAD
- A patient who has intermittent claudication at rest can progress to occlusion and pain can be felt at rest
A
- Once an artery is occluded and the collateral circulation does not compensate for this occlusion, tissue injury or death can occur
3
Q
?
Is indicated with incapacitating intermittent claudication, pain of extremity with rest or severe ulceration, and gangrene that threatens the viability of the limb
- Procedure consists of inserting a catheter with an internal balloon into the femoral artery
A
Percutaneous Transluminal Angioplasty (PTA)
4
Q
- Once in the artery, the catheter is placed in the area of stenosis and balloon is inflated
- Ballon cracks the shell of the intimal atherosclerotic plaque; stretches media of the vessel wall
- Procedure is most successful on lesions that are <10 cm in length
A
- High rate of restenosis; up to 50% in 1 year
- Stents at the time of angioplasty decrease the rate of restenosis and arterial dissection
- Paclitaxel-coated stents studied for decreasing the risk of new tissue growth. Antiplatelet agents are used to reduce the risk of platelet aggregation at the site
5
Q
- For plaques that don’t respond to PTA, there are laser-assisted angioplasties which emit heat and vaporize the plaque or an atherectomy is similar to a PTA with a rotational device known as a rotablator that scrapes the plaque from the vessel surface
A
6
Q
Complications of PTA
- Bleeding or hematoma @ insertion site
- Retroperitoneal bleeding (if there’s an arterial tear)
- Arterial thrombus or embolus
A
- Pseudoaneurysm or A/V fistula
- Acute renal failure (may be r/t contrast dye aeb decreased urine output and increased BUN and creatinine)
7
Q
- Patients are on bedrest & lying flat for a few hrs
- Retroperitoneal bleed - drop in BP w/tachycardia, drop in H/H and back or flank pain
- CMS checks of extremity & compare to nonsurgical site; pulse check & 6 P’s
A
- A pseudoaneurysm in a vessel that’s been through trauma like a PTA exhibits as a pulsatile mass at the insertion site (hear a bruit over that site)
- Monitor urine output, bun/creat, & provide adequate hydration
- Anticipate a renal protectant, like acetylcysteine (Mucomyst), & may be given pre & post-procedure
8
Q
?
Is the opening of the artery and physically removing the obstructing plaque
- A patch can be used to widen the lumen of the artery postop to prevent graft failure; anticoagulants & antiplatelet aggregates like aspirin, dextran, Lovenox (enoxaparin), heparin, Coumadin, & clopidogrel
A
Endarterectomy
9
Q
- Is commonly performed in the carotid arteries
- You’ll hear a bruit as the blood rushes past the plaque
- To bypass the blood flow, vessels may be clamped & there may be shunting of the blood flow. Stent also used to keep the vessel open
A
- Bleeding at site & hematoma; collection could put pressure on airway in trachea secondary to infection
! Thrombus occurring at the site or an embolus which would cause a stroke (monitor for FAST)
10
Q
What is FAST?
A
F = facial symmetry (smile, tongue)
A = Arms (no drift)
S = Speech
T = Timely
11
Q
- CN can be impaired from surgery or swelling (affect swallowing, hoarseness, gag reflex, facial palsy, asymmetry, ability to turn head w/sternocleidomastoid muscles, ability to shrug shoulders)
- Another risk factor is intracranial bleeding r/t HTN
A
- Increased intracranial pressure d/t plaque removal & nothing slowing down blood flow
- Hypotension can lead to under-perfusion of the brain
12
Q
Grafting
- Allows blood flow around or bypass the stenosis or occlusion
- Saphenous vein harvested & treated w/heparinized solution until it’s re-anastomosed is a common graft
A
13
Q
?
Is a possible complication of surgical procedures like grafting
If the area in the fascia swells, capillary perfusion to the tissues becomes impaired; low inflow of oxygen causes ischemia. Waste products cannot be cleared from the tissues which causes a buildup
> Combined waste buildup and low oxygen causes aching pain and increased edema in the compartment; necrosis will occur if action is not taken
A
Compartment Syndrome
14
Q
- Peripheral arterial pulses may be felt and cause a false sense of security. The particular compartment that is edematous may not involve arteries associated with pulses in the foot
A
Key is out of proportion pain in relation to surgery
- Fasciotomy is done to release rising pressures in the compartment
15
Q
Postoperative Nursing Diagnosis
- Pain r/t surgical site
- Potential pain r/t compartment syndrome and potential for fasciotomy
- Potential for alteration in tissue perfusion r/t graft occlusion, embolus, hypotension, etc.
A
- Potential for decreased cardiac output - s/s of hypovolemia (potentially from bleeding)
- Potential for infection - from the actual surgical site
> Surgery - monitor for pneumonia, UTI, cellulitis
16
Q
Amputation - Types/Levels
- AK = above the knee
- BK = below the knee
- Foot-ankle, hip disarticulation
- Upper extremity, digits
A
- Depend on trauma and level of disease
- Above knee (transfemoral)
- Through knee (knee disarticulation - Gritti-Stokes)
- Below knee (transtibial)
- Ankle (ankle disarticulation - Symes)
- Forefoot (transmetatarsal)
17
Q
- Most frequent indication for elective lower extremity amputation is __ or __, w/lower half attributed to diabetes
- Trauma as leading cause of amputation in younger population
A
PAD, PVD
18
Q
Rehabilitation
- Patient
- Family
- Nurse
- Prosthetist
- PT/OT/Vocational therapists
- Psychologist, sociologist
- Support groups
A
Postoperative Complications
- Hemorrhage
> From a loosened suture (keep tourniquet at bedside) - Hematoma
> Can surgically evacuate - Edema
- Infection
19
Q
- Skin breakdown, necrosis, irritation from prosthesis
> Daily skin care; look for breakdowns, abrasions - Contractures
- Phantom limb sensations/pain
A
- Monitor drainage [removed in 24-48 hrs] (Penrose, Hemovac, Jackson Pratt)
- Blood = red > pink > yellow > serous
- Compression dressings
- Circulation - check odor, monitor warmth/warmth under cast
- Monitor for fever & leukocytosis & if there’s any increasing pain
- Look for eschar on perimeter of flap where incision line is r/t collection, poor healing (debridement, antibiotics)
20
Q
- Prevent contractures at hip and knee (if BKA)
- Could have surgery to release contractures
A
Pain
- Incision pain
- Muscle spasm
- Chronic stump pain
- Neuroma formation
- Phantom limb sensation/pain
21
Q
- Wrapping above and below the knee (sterile procedure)
- Partial or full weightbearing (see MD orders)
A
Diagnoses
- Acute pain r/t trauma, muscle spasms, incision pain
- Risk for disturbed sensory perception r/t nerve trauma
- Impaired skin integrity r/t healing of surgical wound
- Impaired physical mobility r/t loss of limb
- Self-care deficit r/t loss of limb
- Risk of dysfunctional grieving r/t loss
22
Q
?
Are localized, permanent bulging and stretching of the arterial wall
> HTN & tobacco as contributing factors
A
Aneurysm
- Common locations are aortic arch, abdominal aorta, thoracic aorta, brain, & popliteal areas
23
Q
Types
> Saccular
Fusiform
Ruptured
A
Dissection
> Blood separates layers of arterial wall & starts to fill in the space
24
Q
Complications
- Aneurysm
- Dissection
- Rupture
- Hemorrhage
- Thrombus/embolus
A
25
Risk Factors
* Congenital
> Marfan, Ehlers Danlos, Turner
* Mechanical
* Traumatic
* Inflammatory (noninfectious)
> Autoimmune diseases [Kawasaki disease, lupus]
* Infectious (bacterial, viral, fungal, spirochete, parasitic)
* Degenerative (most common) from plaque formation
> Smoking, hyperlipidemia, poorly controlled diabetes, HTN
26
Thoracic Aortic Aneurysm - Symptoms
- Pain (constant, boring, worse when supine)
- Dyspnea
- Cough
- Aphonia (if pressure on laryngeal nerve)
- Dysphagia (pressure on esophagus)
- Upper body venous congestion/edema
- Unequal pupils with pressure on the cervical sympathetic chain
Diagnostics
- CXR
- CT, MRI/MRA
- TEE
27
? - Symptoms
- Pulsatile abd, non-tender, mass
- Bruit
- Pain in lower back, chest or scrotum
- 60% asymptomatic
- Inc BP
Abdominal Aortic Aneurysm
28
Diagnostics
- CT
- Duplex ultrasonography (done directly on the abdomen as there is no bony cage there)
- x-rays
- MRA
* Know diameter of abdominal aneurysm (is threshold for surgery)
29
Surgical Criteria
- __ cm threshold for surgery without symptoms
- Depends upon age of patient
- Rate of expansion
- Symptomatic or not
- Underlying congenital dz
- Location
7 cm
30
Preoperative Care
* Bedrest - semi-Fowler's position
* Pain relief w/opioids
* Anxiolytics
* BP control
* Control of myocardial contractility
* Mark baseline pulses
* Orientation to ICU
* Autologous blood banking
31
* To treat AAA - endograft/endovascular graft
- Suture-less, going through groin
- Migration of graft affecting urinary output, emboli formation
- Can go in through groin or open patient up to place graft
* Emergency surgery indicated for ascending thoracic aneurysms
* Put on coronary bypass & graft is sutured to native aortic wall
32
Postoperative Care
* Monitor for complications: bleed, thrombus, embolus (MI), ischemia, ileus, respiratory distress
> Ischemia picked up with CMS checks & VS (avoid flexion of graft; keep leg straight)
* IV fluids, antibiotics, and anti-hypertensives
* Pain: epidural or PCA, NGT for ileus
* Labs: H/H, WBC, platelet, electrolytes, bun/creat, urinary output
* HOB no greater than 45° to prevent graft occlusion
- Warm environment
- Check urine output (report <30-50 mL/hr)
- Orders for no strenuous activity or lifting "X" lbs
33
Discharge
- Teach medications: anticoagulants, anti-platelets, lipid lowering drugs, anti-hypertensives, smoke cessation
- Teach regarding return of symptoms
- Regular f/u visits
- No lifting/housework
34
Aneurysm diameter is the main indication for elective surgical intervention, as it correlates strongly with the risk of the ascending aortic aneurysm dissecting or rupturing
Diameter of abnormal aorta is influenced by age and BMI
35
Asymptomatic ascending aortic aneurysm > ___ cm in diameter
Symptomatic aneurysms irrespective of size
Asymptomatic ascending aortic aneurysm > ___ cm in patients with Marfan syndrome
5.0
4.5
36
Acute dissection or rupture of ascending aortic aneurysm
Pseudoaneurysm or traumatic aneurysm in ascending aorta
37
Ascending aortic aneurysm > ___ cm in patients undergoing aortic valve surgery
Growth rate of > ___ cm/yr when ascending aorta is < ___ cm in diameter
4.5
0.5; 5.0
