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Lecture 3

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Department
Nursing
Course
NURS 201
Professor
Marywyatt Sindlinger
Semester
Winter

Description
LECTURE 3 RAYNAUD’S PHENOMENON  Raynaud’s phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. The exact etiology of Raynaud’s phenomenon remains unknown.  Clinical symptoms include vasospasm-induced color changes of the fingers, toes, ears, and nose (white, blue, and red). An episode usually lasts only minutes but in severe cases may persist for several hours.  Symptoms usually are precipitated by exposure to cold, emotional upsets, caffeine, and tobacco use.  There is no simple diagnostic test for Raynaud’s phenomenon, and diagnosis is based on persistent symptoms for at least 2 years.  Patient teaching should be directed toward prevention of recurrent episodes: temperature extremes and all tobacco products should be avoided.  Calcium channel blockers are the first-line drug therapy. VENOUS THROMBOSIS  Venous thrombosis is the most common disorder of the veins and involves the formation of a thrombus (clot) in association with inflammation of the vein.  Superficial thrombophlebitis occurs in about 65% of all patients receiving IV therapy and is of minor significance.  Deep vein thrombosis (DVT) involves a thrombus in a deep vein, most commonly the iliac and femoral veins, and can result in embolization of thrombi to the lungs.  Three important factors (called Virchow’s triad) in the etiology of venous thrombosis are (1) venous stasis, (2) damage of the endothelium, and (3) hypercoagulability of the blood.  Superficial thrombophlebitis presents as a palpable, firm, subcutaneous cordlike vein. The area surrounding the vein may be tender to the touch, reddened, and warm. A mild systemic temperature elevation and leukocytosis may be present. o Treatment of superficial thrombophlebitis includes elevating the affected extremity to promote venous return and decrease the edema and applying warm, moist heat. o Mild oral analgesics such as acetaminophen or aspirin are used to relieve pain.  The patient with DVT may or may not have unilateral leg edema, extremity pain, warm skin, erythema, and a systemic temperature greater than 100.4 F (38 C).  The most serious complications of DVT are pulmonary embolism (PE) and chronic venous insufficiency. Chronic venous insufficiency (CVI) results from valvular destruction, allowing retrograde flow of venous blood.  Interventions for patients at risk for DVT include early mobilization of surgical patients. Patients on bed rest need to be instructed to change position, dorsiflex their feet, and rotate their ankles every 2 to 4 hours.  The usual treatment of DVT in hospitalized patients involves bed rest, elevation of the extremity, and anticoagulation.  Patients with hyperhomocysteinemia are treated with vitamins B , 6 ,12nd folic acid to reduce homocysteine levels.  The goal of anticoagulation therapy for DVT prophylaxis is to prevent DVT formation; the goals in the treatment of DVT are to prevent propagation of the clot, development of any new thrombi, and embolization.  Indirect thrombin inhibitors include unfractionated heparin (UH) and low-molecular- weight heparin (LMWH). o UH affects both the intrinsic and common pathways of blood coagulation by way of the plasma cofactor antithrombin. o LMWH is derived from heparin and also acts via antithrombin, but has an increased affinity for inhibiting factor Xa.  Direct thrombin inhibitors can be classified as hirudin derivatives or synthetic thrombin inhibitors. Hirudin binds specifically with thrombin, thereby directly inhibiting its function without causing plasma protein and platelet interactions.  Factor Xa inhibitors inhibit factor Xa directly or indirectly, producing rapid anticoagulation. o Fondaparinux (Arixtra) is administered subcutaneously and is approved for DVT prevention in orthopedic patients and treatment of DVT and PE in hospitalized patients when administered in conjunction with warfarin. o Both direct thrombin inhibitors and factor Xa inhibitors have no antidote.  For DVT prophylaxis, low-dose UH, LMWH, fondaparinux, or warfarin can be prescribed. o LMWH has replaced heparin as the anticoagulant of choice to prevent DVT for most surgical patients. o DVT prophylaxis typically lasts the duration of the hospitalization. o Patients undergoing major orthopedic surgery may be prescribed prophylaxis for up to 1 month postdischarge.  Vena cava interruption devices, such as the Greenfield filter, can be inserted percutaneously through right femoral or right internal jugular vein to filter clots without interrupting blood flow.  Nursing diagnoses and collaborative problems for the patient with venous thrombosis can include the following: o Acute pain related to venous congestion, impaired venous return, and inflammation o Ineffective health maintenance related to lack of knowledge about the disorder and its treatment o Risk for impaired skin integrity related to altered peripheral tissue perfusion o Potential complication: bleeding related to anticoagulant therapy o Potential complication: pulmonary embolism related to embolization of thrombus, dehydration, and immobility  The overall goals for the patient with venous thrombosis include (1) relief of pain, (2) decreased edema, (3) no skin ulceration, (4) no complications from anticoagulant therapy, and (5) no evidence of pulmonary emboli. o Depending on the anticoagulant prescribed, ACT, aPTT, INR, hemoglobin, hematocrit, platelet levels, and/or liver enzymes are monitored. o Platelet counts are monitored for patients receiving UH or LMWH to assess for HIT. o UH, warfarin, and direct thrombin inhibitors are titrated according to the results of clotting studies. o The nurse observes for signs of bleeding, including epistaxis, gingival bleeding, hematuria, and melena.  Discharge teaching should focus on elimination of modifiable risk factors for DVT, the importance of compression stockings and monitoring of laboratory values, medication instructions, and guidelines for follow-up. o The patient and family should be taught about signs and symptoms of PE such as sudden onset of dyspnea, tachypnea, and pleuritic chest pain. o If the patient is on anticoagulant therapy, the patient and family need information on dosage, actions, and side effects, as well as the importance of routine blood tests and what symptoms to report to the health care provider. o Home monitoring devices are now available for testing of PT/INR. o Patients on LMWH will need to learn how to self-administer the drug or have a friend or family member administer it. o Patients on warfarin should be instructed to follow a consistent diet of foods containing vitamin K and to avoid any additional supplements that contain vitamin K. o Proper hydration is rec
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