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NRSG 102: Med Surg 1 > Exam 4: Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation > Flashcards

Exam 4: Chapter 30: Assessment and Management of Patients with Vascular Disorders and Problems of Peripheral Circulation Flashcards

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1
Q

What is a leg ulcer?

A

An excavation of the skin surface that occurs when inflamed necrotic tissue sloughs off.

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2
Q

Patho behind leg ulcers?/

A

Inadequate exchange of oxygen and other nutrients in the tissue is the metabolic abnormality that underlies this development

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3
Q

Alternations in blood vessels at the arterial, capillary, and venous levels may affect

A

cellular processes and lead to the formation of ulcers

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4
Q

Chronic arterial disease is characterized by

A

intermittent claudication, which is pain caused by activity and relieved after a few minutes of rest

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5
Q

Patients with Arterial Ulclers may also complain of

A

digital or forefoot pain at rest

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6
Q

If arterial occlusion is acute, pain is

A

unrelenting and rarely relieved even with opoids

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7
Q

Typically, arterial ulcers are

A

small, circular, deep ulcerations on the tips of toes or in the web spaces between the toes

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8
Q

Ulcers often occur on the

A

medial side of the halllux, or lateral fifth toe and may be caused by a combination of ischemia and pressure

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9
Q

Arterial Ulcers and Edema and Pulses?

A

No Edema / No Pulse or Weak Pulse

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10
Q

Chronic Venous Insufficiency is characterized by

A

pain described as aching or heavy.

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11
Q

Venous Ulcers are in the area of

A

the medial or lateral malleolus and are typically large, superfiical, or lateral malleolus and are typically large, superfifical, and highly exudative

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12
Q

Venous Ulcers: Venous Hypertension causes

A

extravasation of blood, which discolors the area.

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13
Q

Arterial ulcer occurs where?

A

A clot at the very end of the foot

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14
Q

A ulcer from venous stasis happens around the

A

ankle

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15
Q

What Antiseptic Agents can inhibit the growth and development of most skin organisms?

A

Povidone-Iodine

Cadexomer Iodine

Acetic Acid

Chlorhexidine

Silver Wound Products

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16
Q

Once a wound is colonized with pathogens shows signs of infection, a

A

systemic antibiotic is necessary

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17
Q

What antibiotic is suaully prescribed for leg ulcers?

A

Oral Antibiotics usually are prescribed because topical antibiotics have not proven to be effective

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18
Q

Nutrition and Leg Ulcers

A

They need protein, and this can be tested by Albumin

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19
Q

Why does Compression Therapy work for Leg Ulcers?

A

Adequate compression therapy involves the application of external or counter pressure to the lower extremity to facilitate venous return to the heart

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20
Q

How long should the patient wear stockings for?

A

At all times except at night and to reapply the stockings in the mornin g

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21
Q

Debridement: To promote healing the wound is

A

kept clean of drainage and necrotic tissue

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22
Q

Debridement: Usual method is to

A

flush teh area with normal saline solution or clean it with a noncytotoxic wound-cleansing agent

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23
Q

Debridement: What is this?

A

Removal of nonviable tissue from wounds. Can be accomplished by several different methods.

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24
Q

What is Surgical Debridement:

A

Fastest method and can be performed by a physician or other qualified person

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25
What is Nonselective Debridement:
Can be accomplished by applying isotonic saline dressing of fine mesh gauze to the ulcer. When dressing dries, it is removed along with debris adhereing to gauze
26
What is Enzymatic Debridement:
Application of enzyme ointments may be prescribed to reat the ulcer. Ointment applied to lesion.
27
What are Calcium Alginate Dressings useful for?
Used for debridemenet when absorption of exudate is neded. Dressings changed when exudate seeps through the cover dressing or at least every 7 days
28
Why are foam dressings useful?
They absorb exudate into the foam, keeping the wound moist
29
Wound Dressing: SEmiocclusive or Occlusive Wound Dressings prevent
evaporative water loss from the wound and retain warmth; these factors facor healing
30
Wound Dressing: Available options that promote the growth of granulation tissue and reepithelization include
the hydrocolloids
31
Hydrocolloids also provide a
barrier for protection because they adhere to the wound bed and surrounding tissue.
32
Wound Dressing: Foam Dressings are permeable to both
gases and water vapor due to their hydrophilic properties and are indicated for wounds with moderate exudate, granulating, or slough covered
33
Wound Dressing: Semipermeable film dressings may be selected because
they keep the wound moist and are impervious to bacteria while allowing some gas exchange. May not be effective treatment for deep wounds and infected wounds
34
Wound Dressing: GRowth Factor dressings may directly provide
a growth factor, or they may stimulate important growth substances within the wound
35
Wound Dressing: Calcium Alginate, Hydrofiber, and Hydroconductive dresings are used for wounds with
moderate to high amounts of exudate
36
Wound Dressing: Hydroconductive dressings provide
a capillary action that lifts and moves exudate away from a wound into the core of the dressing form where is disperses into second layer
37
Stimulated Healing: Tissue-engineered human skin equivalent is a
skin product cultured form human dermal fibroblasts and keratinocytes used in combination with therapeutic compression
38
Stimulated Healing: When applied, it
interacts with the patients cells within the wound to stimulate the production of growth factors
39
Stimulated Healing: What is PriMatrix
A bioactive and regenerative extracellular matrix that binds with the patietns own cells and growth factors
40
Stimulated Healing: PriMatrix has been used successfully for
tunneling wounds, as well as wounds with exposed tendon and bone, in which Apligraf cannot be used.
41
Hyperbaric Oxygenation: May be beneficial as
an adjunct treatment in patietns with diabetes with no signs of wound healing after 30 days of standard wound treatment
42
Hyperbaric Oxygenation: Accomplished by
placing the apteitn into a chamber that increases barometric pressure while the patient is breathing 100% oxygem
43
Hyperbaric Oxygenation: Treatment regimens vary from
90 to 120 minutes once dail for 30 - 90 dessions
44
Hyperbaric Oxygenation: Edema in wound area decreased because
high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria.
45
Hyperbaric Oxygenation: Also thought to
increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production
46
Hyperbaric Oxygenation: Two most common adverse effects are
middle-ear barotrauma and confinement anxiety
47
Negative Pressure Wound Therapy: Research findings suggest that
negative pressure wound herapy using vacuum-assisted closure (VAC) devices decreases time to healing in complex wounds that have not healed in a 3-week period
48
Negative Pressure Wound Therapy: Wound VAC therapy has been found to be effective in treating pateints who develop
postoperative groind wound infections, decreasing hospital length of stay, rates of graft infection, and likelihood ofl imb loss
49
Nursing Diagnoses for Leg Ulcers
Impaired Skin Integrity RT Vascular Insufficiency Impaired Physical Mobility RT Active Restrictions of the Therapeutic Regimen and Pain Imbalance Nutrition
50
Potential complications of Leg Ulcers may include
Infection | Gengrene
51
Major goals for patient with Leg Ulcers include
restoration of skin integrity Improved physical mobility Adequate nutrition Absence of complications HEAL ULCER
52
Restoring Skin Integrity: Cleansing requires
very gentle handling, a mild soap, and lukewarm water
53
Restoring Skin Integrity: If there is arterial insufficiency, patient should be referred for
evaluation of vascular reconstruction
54
Restoring Skin Integrity: is there is venous insufficiency,
dependent edema cna be avoided by elevating the lower extremities
55
Restoring Skin Integrity: Decrease in edema promotes
the exchange of cellular nutrients and waste products in the area of the ulcer, promoting healing
56
Restoring Skin Integrity: Protective boots useful because
they are soft and provide warmth and protection from injury and displace tissue pressure to prevent ulcer formation
57
Restoring Skin Integrity: If pt on bed rest, important to
relieve pressure on the heels to prevent pressure ulcerations
58
Restoring Skin Integrity: When in bed, what can be used to relieve pressure from bed linens?
Bed cradle, and also prevents anything from touching the legs
59
Restoring Skin Integrity: HEating pads, hot water bottles, or hot baths are avoided because
they increase the oxygen demands and this the blood flow demands of the already compromised tissue.
60
Restoring Skin Integrity: Heating pads problematic with diabetics because
heating pads may produce injury before the patient is aware of being burned
61
Improving Physical Mobility: Physical activity is initally
restricted to promote healing
62
Improving Physical Mobility: When infection resolves and healing begins, ambulation should
resume gradually and progressively
63
Improving Physical Mobility: activity promotes
arterial flow and venous return and is encourage after the acute phase of the ulcer process
64
Improving Physical Mobility: Activity to promote blood flow;
encourage patient to move about in bed and exercise upper extremities
65
Improving Physical Mobility: If pain is present
Analgesic agents may be taken before scheduled activities to help the patient participate more comfortably
66
Promoting Adequate Nutrition: Eating a diet high in what promotes healing?
protein, Vitamins C and A, Iron, and Zinc is encouraged to promote healing.
67
Promoting Adequate Nutrition: Particular consideration should be given to
iron intake, because many older patients are at risk for iron deficiency anemia
68
Expected Outcomes
Demonstrates Restored Skin integrity Increased Physical Mobility Attains Adequate Nutrition
69
What is Cellulitis?
Most common infectious cause of limb swelling
70
Cellulitis can occur as
single isolated event or a series of recurrent events
71
Cellulitis occurs when
an entry point through normal skin barriers allows bacteria to enter and release their toxins in the subcutaneous tissues
72
Cellulitis: Pathogen is usually
Sreptoccus speices or S. Aureus
73
Cellulitis: Signs and Symptoms include
swelling, localized redness, warmth, and pain
74
Cellulitis: systemic signs include
fever, chills, and sweating Regional lymph nodes may also be tender and enlarged
75
Cellulitis: Redness may not be uniform and often skips areas and eventually develops
a pitting "orange" peel appearance.
76
Mild cases of Cellulitis can be treated on
an outpatient basis with oral antibiotic therapy
77
If Cellulitis is severe, patient is treated with
IV antibiotics
78
Key to preventing recurrent episodes of Cellulitis lies in
adequate antibiotic therapy for the initial event and in identifying the site of bacterial entry
79
Cellulitis: Cracks and Fisures that occur in the skin between the toes must be
examined as potential sites of abcterial entry
80
Cellulitis: Other entry points include
Drug Use Injection Sites, Contusions, Abrasions, Ulceration, Ingrown Toenails, Hangnails
81
Cellulitis: Patient is instructed to elevate the affected area to
3-6 inches above heart level and apply cool, moist packs at teh site every 2-4 hours until inflammation has resolved and then transition to warm packs
82
Cellulitis: ducation should focus on
preventing a recurrent episode. Patient with peripheral vascular disease or diabetes should recieve education or reinforcement about skin and foot care
83
Cellulitis:Labs for this?
WBC. Also monitor temperature
84
Stage 1 Pressure Ulcer
Sign of Risk. Intact skin with nonblanchable redness of localized area
85
Stage II Pressure Ulcer
Partial thickness loss of dermis presenting as shallow open ulcer with red or pink wound bed
86
Stage III Pressure Ulcer
Full-thickness tissue loss. Subcutaneous may be visible but bone, tendon, or muscle are not exposed. Slough may be present
87
Stage IV Pressure Ulcer
Bone is exposed here
88
If pressure continues long enoug,
small vessel thrombosis and tissue necrosis occur and pressure ulcer results
89
Susceptible areas for pressure ulcers include
sacrum and coccygeal areas, ischial tuberosities, greater trochanter, heel,, knee, malleolus, medial condyle of the tibia, fibular head, scapula, and elbow
90
Prolonged pressure impedes
blood flow, reducing nourishment of the skin and underlying tissues
91
Anemia decreases the
bloods oxygen carry ability and predisposes the patient to pressure ulcers.
92
Serum albumin and prealbumin levels are sensitive indicators of
protein deficiency
93
Serum albumin levels of less than 3 are associated with
hypoalbuminemic tissue edema and increased risk for pressure ulcers
94
Prealbumin levels are more sensitive indicator of
protein status than albumin levels
95
Shear is the result of
gravity pushing down on the patients body and resistance between the patient and the chair or bed
96
When shear occurs,
tissue layers slide over one another, blood vessels stretch and twist, and the microcirculation of the skin and subcutaneous tissue is disrupted
97
Improving Tissue Perfusion: Massage of erythematous areas avoided because
damage to the capillaries and deep tissue may occur
98
Improving Tissue Perfusion: In patients who hav evidence of compromised peripheral circulation (edema),
positioning and elevation of the edematous body part ot promote venous return and dimish congestion improve tissue perfusion

NRSG 102: Med Surg 1 (52 decks)

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