115-NCLEX-RN Review Made Incredibly Easy, Fifth Edition (Incredibly Easy...

58 Cardiovascular system

Postoperatively Monitor the clients vital signs. Contin-uously assess his circulatory function by inspecting skin color and temperature and by checking for distal pulses. In charting, compare earlier assessments and observa-tions. Watch closely for signs of hemorrhage (tachycardia, hypotension) and check dress-ings for excessive bleeding to prevent or detect postoperative complications. In carotid, innominate, vertebral, or subclavian artery occlusion, assess neurologic status frequently for changes in level of con-sciousness or muscle strength and pupil size to ensure prompt treatment of deteriorating neurologic status. In mesenteric artery occlusion, connect a nasogastric tube to low intermittent suction. Monitor intake and output. (Low urine output may indicate damage to renal arteries during surgery.) Assess abdominal status. Increasing abdominal distention and tenderness may indi-cate extension of bowel ischemia with resulting gangrene, necessitating further excision, or peritonitis. In saddle block occlusion, check distal pulses for adequate circulation. Watch for signs of renal failure and mesenteric artery occlusion (severe abdominal pain) and cardiac arrhythmias, which may precipitate embolus formation, to ensure prompt recogni-tion and treatment of complications. In iliac artery occlusion, monitor urine output for signs of renal failure from decreased perfusion to the kidneys as a result of sur gery. Provide meticulous catheter care to prevent complications. In both femoral and popliteal artery occlu-sions, monitor peripheral pulses. Assist with early ambulation, but discourage prolonged sitting to encourage circulation to the extremities. After amputation, check the clients stump carefully for drainage and record its color and amount and the time to detect hemorrhage. Elevate the stump, and administer adequate analgesic medication to treat edema and pain. Because phantom limb pain is common, explain this phenomenon to the client to reduce the clients anxiety. When preparing the client for discharge, instruct him to watch for signs of recurrence (pain, pallor, numbness, paralysis, absence of pulse) that can result from graft occlusion or

TREATMENT Light exercise such as walking Surgery (for acute occlusion): atherec-tomy, balloon angioplasty, bypass graft, embo-lectomy, laser angioplasty, patch grafting, stent placement, thromboendarterectomy, or amputation

Drug therapy Anticoagulants: heparin, dalteparin (Fragmin), enoxaparin (Lovenox), warfarin (Coumadin) Antiplatelets: aspirin, pentoxifylline (Trental) Thrombolytic agents: alteplase (Activase), streptokinase (Streptase)

INTERVENTIONS AND RATIONALES Advise the client to stop smoking and to follow the prescribed medical regimen to modify risk factors and promote compliance.

Preoperatively (during an acute episode) Assess the clients circulatory status by checking for the most distal pulses and by inspecting his skin color and temperature. Decreased tissue perfusion causes mottling; skin also becomes cooler and skin texture changes. Provide pain relief as needed to help decrease ischemic pain. Administer I.V. heparin as needed to pre-vent thrombi. Use an infusion pump to ensure the proper flow rate.Reposition the foot frequently to prevent pressure on any one area. Strictly avoid ele-vating or applying heat to the affected leg. Directly heating extremities causes increased tissue metabolism; if arteries dont dilate nor-mally, tissue perfusion decreases and ischemia may occur. Watch for signs of fluid and electrolyte imbalance, and monitor intake and output for signs of renal failure (urine output less than 30 ml/hour). Electrolyte imbalances and renal failure are complications that may occur as a result of arterial occlusion and tissue damage. If the client has a carotid, innominate, vertebral, or subclavian artery occlusion, monitor him for signs of stroke, such as numbness in an arm or leg and intermittent blindness, to detect early signs of decreased cerebral perfusion.

Renal failure may occur as a result of arterial occlusion

and tissue damage.

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