lOMoARcPSD|21646696
Deep Vein Thrombosis (DVT) Summarized
Notes Updated
, lOMoARcPSD|21646696
Deep Vein Thrombosis (DVT)
risk factors for DVT (age >60, being hospitalized and in bed for 3 days
neurovascular assessment of the extremities, including presence and quality of dorsalis
pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary
refill, and circumference measurements of both calves and thighs. Both extremities
should be assessed for comparison
clinical manifestations: unilateral edema, calf pain or tenderness to
touch, warmth and erythema, and low-grade temperature.
Discharge teaching for a client who has had DVT emphasizes
• Drink plenty of fluids and limit caffeine and alcohol intake to avoid
dehydration, which predisposes to blood hypercoagulability and venous
thromboembolism
• Elevate legs on a footstool when sitting and dorsiflex the feet often to
reduce venous hypertension, edema, and promote venous return
• Resume walking/swimming exercise program as soon as possible after getting
home to promote venous return through contraction of calf and thigh
muscles
• Change position frequently to promote venous return, circulation, and
prevent venous stasis.
• Stop smoking to prevent endothelial damage and vasoconstriction as
this promotes clotting.
• Avoid restrictive clothing (eg, Spanx, tight jeans) that interferes with
circulation and promotes clotting.
Cardiogenic shock
Cardiomyopathy is a group of diseases in which the heart muscle (myocardium) has a
reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock .
Cardiogenic Shock is manifested by reduced cardiac output (hypotension, narrow pulse
pressure), which can lead to pulmonary edema (tachypnea, bibasilar crackles, decreased
oxygen saturation)
decreased perfusion and oxygenation of tissues as well as death
Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme
testing, and interventions to reduce cardiac workload.
Failure to capture from the permanent pacemaker
Failure to capture appears on the cardiac monitor as pacemaker spikes that are not
followed by QRS complexes.
symptomatic (hypotension, dizziness) from insufficient perfusion. The nurse's priority is
to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood
pressure, and adequately perfuse organs until the permanent pacemaker is repaired or
replaced
Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very
uncomfortable for the client.
, lOMoARcPSD|21646696
Endovascular abdominal aortic aneurysm repair
minimally invasive procedure that involves the placement of a suture less aortic graft
inside the aortic aneurysm via the femoral artery.
It does not require an abdominal incision. The nurse will need to monitor the puncture
sites in the groin area for bleeding or hematoma formation
Peripheral pulses should be palpated and monitored frequently in the early post-op
period and routinely afterward
Renal artery occlusion can occur due to graft migration or thrombosis so careful
monitoring of urine output and kidney function should be part of nursing care
*Signs of graft leakage that are important to monitor after repair of an abdominal aortic
aneurysm include pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or
penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and
hemoglobin; increased abdominal girth; and decreased urinary output.
An aneurysm is an outpouching or dilation of a vessel wall. An abdominal
aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that
indicates turbulent blood flow in the aneurysm, is best heard with the bell of
the stethoscope. It may be auscultated over the aortic aneurysm in the
periumbilical or epigastric area slightly left of the midline.
Educational objective:
The nurse should listen for a bruit with the bell of the stethoscope over the
periumbilical or epigastric area.
Deep Vein Thrombosis (DVT) Summarized
Notes Updated
, lOMoARcPSD|21646696
Deep Vein Thrombosis (DVT)
risk factors for DVT (age >60, being hospitalized and in bed for 3 days
neurovascular assessment of the extremities, including presence and quality of dorsalis
pedis (DP) and posterior tibial (PT) pulses, temperature of the extremities, capillary
refill, and circumference measurements of both calves and thighs. Both extremities
should be assessed for comparison
clinical manifestations: unilateral edema, calf pain or tenderness to
touch, warmth and erythema, and low-grade temperature.
Discharge teaching for a client who has had DVT emphasizes
• Drink plenty of fluids and limit caffeine and alcohol intake to avoid
dehydration, which predisposes to blood hypercoagulability and venous
thromboembolism
• Elevate legs on a footstool when sitting and dorsiflex the feet often to
reduce venous hypertension, edema, and promote venous return
• Resume walking/swimming exercise program as soon as possible after getting
home to promote venous return through contraction of calf and thigh
muscles
• Change position frequently to promote venous return, circulation, and
prevent venous stasis.
• Stop smoking to prevent endothelial damage and vasoconstriction as
this promotes clotting.
• Avoid restrictive clothing (eg, Spanx, tight jeans) that interferes with
circulation and promotes clotting.
Cardiogenic shock
Cardiomyopathy is a group of diseases in which the heart muscle (myocardium) has a
reduced ability to pump blood effectively, placing clients at risk for cardiogenic shock .
Cardiogenic Shock is manifested by reduced cardiac output (hypotension, narrow pulse
pressure), which can lead to pulmonary edema (tachypnea, bibasilar crackles, decreased
oxygen saturation)
decreased perfusion and oxygenation of tissues as well as death
Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme
testing, and interventions to reduce cardiac workload.
Failure to capture from the permanent pacemaker
Failure to capture appears on the cardiac monitor as pacemaker spikes that are not
followed by QRS complexes.
symptomatic (hypotension, dizziness) from insufficient perfusion. The nurse's priority is
to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood
pressure, and adequately perfuse organs until the permanent pacemaker is repaired or
replaced
Administer analgesia and/or sedation as prescribed as transcutaneous pacing is very
uncomfortable for the client.
, lOMoARcPSD|21646696
Endovascular abdominal aortic aneurysm repair
minimally invasive procedure that involves the placement of a suture less aortic graft
inside the aortic aneurysm via the femoral artery.
It does not require an abdominal incision. The nurse will need to monitor the puncture
sites in the groin area for bleeding or hematoma formation
Peripheral pulses should be palpated and monitored frequently in the early post-op
period and routinely afterward
Renal artery occlusion can occur due to graft migration or thrombosis so careful
monitoring of urine output and kidney function should be part of nursing care
*Signs of graft leakage that are important to monitor after repair of an abdominal aortic
aneurysm include pain in the back, pelvis, or groin; ecchymosis of the groin, scrotum, or
penis; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and
hemoglobin; increased abdominal girth; and decreased urinary output.
An aneurysm is an outpouching or dilation of a vessel wall. An abdominal
aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that
indicates turbulent blood flow in the aneurysm, is best heard with the bell of
the stethoscope. It may be auscultated over the aortic aneurysm in the
periumbilical or epigastric area slightly left of the midline.
Educational objective:
The nurse should listen for a bruit with the bell of the stethoscope over the
periumbilical or epigastric area.
