Nursing: Med-Surg Competency

- thrombophlebitis of larger, deeper vein (large to small) - can result in embolization from deep vein to lungs - factors: Virchow's Triad - venous stasis, hypercoagulability, damage to endothelium - RBC, WBC, platelets, and fibrin stick together to form thrombus - thrombus develops tail and occludes lumen of vessel - endothelial cells may cover thrombus and lyse it - thrombus may detach and form emboli, which may lodge in pulmonary circulation (PE)

- asymptomatis - unilateral edema - pain - warm skin - temp > 100F - calf tenderness (Homan not reliable) - cyanosis - SVC: edema of upper ext and back - IVC: edema of lower ext

- PE - chronic venous insufficiency - phlegmasia cerulea dolens (swollen, blue, painful leg)

- doppler flow studies: determines blood flow through femoral, popliteal, and posterior tibial veins - duplex scan: US and Dopper combined, determine location and extent of clot - venogram: x-ray with contrast, determine location/extent of clot - d-dimer: assesses thrombin and plasmin activity in blood, suggestive of DVT/PE, abnormal is positive/normal is negative

- bed rest - prevent dislodging - elevation of limb - venous return - compression stockings - venous return (preventative) - frequent monitor distal pulses bilaterally - arterial blood flow - greenfield filter (surgical) - anticoagulants: heparin - continuous IV up to 7 days, moniter aPTT (norm 30-40 sec), monitor PTT (norm 60-70), therapeutic lvl 1.5-2 x normal; warfarin - PO for 3-6 mo, reach therapeutic lvl before d/c heparin; LMWH (lovenox): prophylaxis, predictable dose response, no monitoring req'd, SQ daily or BID - thrombolytics: tPA dissolves clot. increased risk hemorrhage, drugs streptokinase and alteplase

- assess for bleeding (nose, gums, stool, etc.) - positioning: elevation of lower ext - venous return - hydration - decrease blood viscosity - use of compression stockings: measure for size, wash and dry, put on before rising - avoid prolonged sitting/standing

- acute pain r/t venous congestion, impaired venous return, and inflammation - risk for impaired skin integrity r/t altered peripheral tissue perfusion - potential complication: bleeding r/t anticoagulant therapy - ineffective health maintenence r/t lack of knowledge about DVT and treatment - potential complication: PE r/t embolization of thrombus, dehydration, and immobility

- forms from thrombi in deep veins of lower ext - may be assoc with right side of the heart r/t A-Fib - emboli are mobile and travel until they lodge in a narrowed part of the circulation

- sudden onset of unexplained dyspnea - tachypnea - tachycardia - cough - chest pain - hemoptysis (bloody sputum) - crackles - fever - hypoxemia w/mental status changes

- ventilation-perfusion scan (V-Q scan): assesses pulmonary perfusion and ventilation - d-dimer: suggestive of PE, assesses thrombin/plasmin activity in blood - spiral CT scan of lungs: forms 3D picture - pulmonary angiography - invasive insertion of catheter into pulmonary artery, visualization of pulmonary vasculature via x-ray - ABG: O2 below normal w/inadequate oxygenation, CO2 below norm with hyperventilation, and normal pH

- O2 based on ABG - intubation - mechanical ventilation - TCDB - heparin/warfarin - tPA - greenfield filter

- assess for bleeding (nose, gums, stool, etc.) - positioning: elevation of lower ext - venous return - hydration - decrease blood viscosity - use of compression stockings: measure for size, wash and dry, put on before rising - avoid prolonged sitting/standing

- ineffective pulmonary tissue perfusion - acute pain r/t venous congestion, impaired venous return, and inflammation - risk for impaired skin integrity r/t altered peripheral tissue perfusion - potential complication: bleeding r/t anticoagulant therapy - ineffective health maintenence r/t lack of knowledge about DVT and treatment - potential complication: PE r/t embolization of thrombus, dehydration, and immobility

- disorder of glucose metabolism - absent of insuffiecient insulin supplies - poor utilization of available insulin - type 1: T cells attack/destroy pancreatic beta cells - source of body's insulin, virtual absence of insulin - type 2: pancreas produces some endogenous (self-made) insulin; however, it is insufficient for the body's needs and/or is poorly utilized by tissues - causes: genetic, autoimmune (T cells destroy betacells in type 1), viral, environmental (stress) DKA - patho: fat stores used, ketones build up in blood, spill into urine, high glucose production in liver, glucose spilled into urine, water/electrolyte loss leads to hypovolemia/shock - S/S: agitated, disoriented, weakness, lethargy abdominal pain, nausea, vomiting, fruity breath, dehydration, Kussmaul resp, abnormal labs - care: assess BG lvls, blood/urine for ketones, mental status, electrolytes, ECG monitor, IV fluids, reg insulin IVP/continuous, I&O HHS - similar to DKA - no ketones in blood/urine - neuro signs (mimic stroke) - Tx: IV fluids, reg insulin IV bolus/continuous, change IV fluids to one containing glucose when BG < 250 - more fluid replacement Hypoglycemia - BS < 70 - mimics ETOH intox - S/S: confusion, irritability, diaphoresis, tremor, hunger, weakness, loss of consciousness, seizure, coma, death - Tx: conscious: simple carb, unconscious: glucagon 1 mg SQ/IM

- type 1: weight loss, fatigue, n/v, abdominal pain, polyphagia, polydipsia, polyuria - type 2: asymptomatic, gradual onset w/organ damage occurring, fatigue weight gain, recurrent infections, recurrent yeast infections, prolonged/poor wound healing, visual changes - macrovascular: heart, brain, peripheral vasc sys - microvascular - retinopathy, nephropathy, neuropathy