Prepared by: Ancy Varghese Staff Nurse ICU Department
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- Prepared by: Ancy Varghese Staff Nurse ICU Department
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- Patient Name : xyz Age & sex : 80yrs/female MRN : 196388
Admission Date : 11-2-13@1200h Nationality :Saudi Diagnosis :AF
with Poplitial Artery embolization(embolectomy done)
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- The patient is 80yrs old female, approximately Weight 75kg..on
12 th February she was intubated on A/C mode.she was under sedative
& ionotropics support. .BP :130/80mmhg .PR : 70/mt .RR :12
.Temp:36.5C .SpO2 :98%
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- SKIN.Fair Complexion.Warm(but in second day lower extremities
were cold).No Palpable mass or lesions, with good tigor
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- HEAD.No palpable masses & lesion.No areas of deformity
LEVEL OF CONSCIOUS & ORIENTATION.patient was conscious &
oriented on admission. She was intubated on second day (12/2/13 )
and then on fully sedation. EYES.Pupils equally round and reactive
to light
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- EARS.No unusual discharges noted.Pink nasal mucosa NOSE.No
unusual discharges.No tenderness in sinus MOUTH.Pink and moist oral
mucosa and free of swelling and lesions
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- NECK AND THROAT.No palpable limb nodes.No masses and lesions
seen CHEST AND LUNGS.Equal chest expansion.Bilateral basal crept
present ABDOMEN. Soft abdomen.Bowel sounds present
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- GENITALS.Minimal pubic hair
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- PAST MEDICAL HISTORY No past medical history PRESENT MEDICAL
HISTORY 80yrs old female patient came in ER with the complaint of
shortening of breath and burning micturation. Primary care given
from ER and then shifted to new ICU.Chest x-ray done,it shows
patchy opacity was seen in both lower areas and cardiomegaly.Her
ECG shows AF with controlled rhythm.
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- The next day patient developed cold lower extremities with
absent pulses..So urgent vascular surgery consultation &
arterial doppler done. Bilateral poplitial artery embolus seen in
doppler. Patient was urgent taken to the OT by vascular surgeon and
bilateral poplitial artery embolectomy was done under L/A.Patient
developed bradycardia, hypotension, hypoxia and mild bleeding from
the wound site, patient was resuscitated with IV fluids and
ionotropic
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- Support and was mechanically ventilated. After all management
patient was extubated and fully conscious and oriented. Patient
shifted to peadia ward. MEDICATIONS DRUGDOSEROUTEACTION
Inj.augmentin1.2gmivAntibiotic(broad spectrum) Inj.nexium40mgivH2
receptor Inj.clexane60mgs/cLow molecular heparin
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- Tab. Aspirin81mgp/oAnt platelet Tab.astatin40mgp/oLipid
lowering agent
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- TESTPATIENT VALUENORMAL V ALUES WBC8.54.23-9.07 Hb10.513.7-17.5
PLT221163-337 UREA6.281.8-8.3 CREATININE107.8446-92
TROPONIN0.1010.120 CPK3726-308 CPKMB77.0-25.0 SODIUM138135-150
POTTASIUM4.43.5-5.0 CHLORIDE10198-111
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- Patchy opacity is seen in both lungs. Apparent cardiomegaly
Vascular markings are normal DOPPLER BOTH LIMBS It reveals thrombus
filling the lumen of both lower limbs poplitial arteries with flow
obstruction distal to it. CAROTID DOPPLER There is normal colour
filling and flow pattern. No evidence of any stenosis or plaque
seen
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- DOPPLER OF BOTH UPPER LIMB Normal colour flow in the both
subclavian,axillary,brachial,radial and ulanar arteries. ULTRASOUND
KUB Bilateral kidneys are normal in shape with increase cortical
echogenicity with partial loss of cortico-medullary demarcation.
Bilateral renal disease.
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- AFIB: very common arrhythmia and leading cause of embolic CVA
Initial Workup: trop, ECG, TSH, Echo, CXR Management: First must
determine if stable or unstable (medically manage or cardiovert
immediately) For stable Afib: rate and rhythm control (equal in
efficacy).
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- CHARACTERISTICS P Waves absent Rhythm irregular HR is above
150/mt QRS complex is narrow
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- Rhythm - Regular Rate - (68 bpm) QRS Duration - Normal P Wave -
Visible before each QRS complex P-R Interval - Normal 0.20sec(
- AFIB SBP 90-110 SBP 100 to 120 SBP >120 DIGOXIN Load : 0.5mg
IV 6 hrs later; 0.25mg IV 6 hrs later; 0.25 mg IV Maintenance:
0.125 mg daily B-Blocker Initial: Metoprolol 5mg IV 5min x3doses
Prn: metoprolol 5mg IV q6h Maintenance: Metoprolol 25 mg po BID
(max 100mg BID) Ca2+ Blockers Initial and prn: Diltiazem 10mg IV
q6hrs Maintenance: Diltiazem 30mg PO q6hs
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- The popliteal artery, like any other peripheral artery, can be
affected by embolism. Macroemboli have a tendency to lodge in the
popliteal artery at the bifurcation into the tibioperoneal trunk
and anterior tibial artery. An embolus in the lower extremities
most often has a cardiac source. Other sources include aortic
aneurysms and proximal arterial plaque or ulceration. Regardless of
the source, acute arterial embolism almost always requires urgent
treatment.
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- Figure 1b. Normal anatomy. 2004 by Radiological Society of
North America
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- ANATOMY OF ARTERY
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- acute bilateral ischemia of the lower extremities shows abrupt
occlusion of both popliteal arteries 2004 by Radiological Society
of North America
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- Embolism in the most common cause of arterial occlusion Emboli
may consist of thrombus, athromatous debris or tumor Emboli most
commonly originate in the heart as a result of AF, MI or Heart
failure Arteriosclerosis may cause roughening or ulceration of
atheromatous plaque which can lead to emboli. May also be
associated with immobility, anemia and dehydration. Emboli lead to
lodge at bifurcations & atherosclerotic narrowing Other cause
of acute occlusion include A. Trauma B. Thrombus C. venous outflow
obstruction PATHOPHYSIOLOGY
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- Immobility,anemia,dehydration heart arteriosclerosis AF,MI
Roughening or ulceration of artery emboli lodge in the roughened
artery arterial occlusion
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- Acute pain Paralysis of part Pallor & coldness Edema
Rigidity of extremity Pulselessness Numbness of the part
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- EMBOLUSTHROMBOSISTRAUMA AFVascular graftsBlunt
MIAtherosclerosisPenetrating Endo carditisThrombosis of
aneurysmlatrogenic Valvular diseaseEntrapement syndrome AneurysmLow
flow rate Atherosclerotic plaque
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- 1.MEDICAL MANAGEMENT Thrombolytic therapy Heparin and
anticoagulants 2.SURGICAL MANAGEMENT Embolectomy Balloon
embolectomy Aspiration embolectomy Surgical embolectomy
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- Balloon embolectomy Typically this is done by inserting a
catheter with an inflatable balloon attached to its tip into an
artery, passing the catheter tip beyond the clot, inflating the
balloon, and removing the clot by withdrawing the catheter. The
catheter is called Fogarty, named after its inventor catheter
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- Aspiration embolectomy Catheter embolectomy is also used for
aspiration embolectomy, where the thrombus is removed by suction
rather than pushing with a balloon. It is a rapid and effective way
of removing thrombi in thromboembolic occlusions of the limb
arteries below the inguinal ligament
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- Surgical embolectomy Surgical embolectomy is the simple
surgical removal of a clot following incision into a vessel by open
surgery on the artery. COMPLICATIONS MI TIA Gangrene Stroke Septic
embolism
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- Monitor vital signs(peripheral pulse) Assess the wound area,if
any bleeding present or not. Provide comfortable position Prevent
infection and potential complication Ventilator care 30 head end
elevation Mouth care Sedation score
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- Suction appropriately Prevent infection Prevent hemodynamic
instability Manage the airway Meet the patient nutrional needs Wean
the patient appropriately Educate the patient and family
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- Impaired physical mobility related to monitoring devices,
mechanical ventilation and medication as charecrized by imposed
restrictions of movement,decreased muscle strength &limited
range of motion. Ineffective breathing pattern related to decreased
energy as characterized by dyspnea. Knowledge deficit related to
health condition, new equipment& hospitalization as
characterized by increased frequency of
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- Questions posed by the relatives Risk for impaired skin
integrity related to prolonged bedrest,proloanged intubation Risk
for infection related to surgery Pain related to surgery NURSING
DIAGNOSIS
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- ASSESSMENTPLANNINGEVALUATION NURSI NG DIAG NOSIS GOALS OR
DESIRED OUTCOME NURSI NG INTER VENTI ON ACTION OR RATION ALE
Subjective data: patient in mechanical ventilator Objective
data:1.rapid shallow breathing 2.Nail bed cyanosis Ineffective
breathing pattern related to decreased energy as characterize d by
dyspnoea After 12 hrs of nursing intervention patient will maintain
good breathing pattern Endotrach eal suctioning done every 30mts.
Patient head is elevated at 30 Placed patient on ventilator with
75% o2 To maintain patent airway To reduce the breathing
difficulties To increase the oxygen saturation Breathing pattern
maintained with the help of ventilator
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- ASSESSMENTPLANNINGEVALUATION NURSI NG DIAGN OSIS GOALS OR
DESIRED OUTCOME NURSI NG INTERV ENTIO N ACTION OR RATIONA LE
Objective data: General body weakness present,ina bility to perform
motor skills due to sedation,pa ralysed for restricted movement
Impaired physical mobility related to monitoring device,mechanical
ventilation & decreased muscle strength and limited range of
motion After 24hrs of nursing intervention patient will maintain
good physical activity Position changed 2hrly.Suppo rt the bony
prominence with pillows. Isometric exercise given 6 th hrly Deep
breathing exercise given 2 nd hrly Head end elevated 30 Sedation
tapered slowly To prevent bedsore To improve the blood circulation
To helps to expand the lungs To avoid aspiration To help for
weaning Goal fully met,patient started obeying orders of nurse,
physiotherapist for exercise, mobilizing the legs &hands.
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- Teach prevention techniques, such as daily activity,
observation for skin breakdown, prevention of injury Teach the
importance of taking prescribed medications such as oral
anticoagulants. Teach for blood checking
regularly(PT,INR,D_DIEMER). Teaching about the nutritional status
Maintain regular health check-up Teach the patient to wear elastic
stockings as ordered Teach the patient to avoid restrictive
clothing(socks,shoes) Teach the patient never to walk barefoot
- Slide 42
- 80yrs old female patient came in ER with the complaint of
shortening of breath and burning micturation. Primary care given
from ER and then shifted to ICU.Her ECG shows AF with controlled
rhythm. The next day patient developed cold lower extremities with
absent pulses..So urgent vascular surgery consultation &
arterial Doppler done. Bilateral poplitial artery embolus seen in
Doppler. Patient was urgent taken to the OT by vascular surgeon and
bilateral poplitial artery embolectomy was done. Patient was
resuscitated with IV fluids and ionotropic because of desaturation.
After all management patient was extubated and fully conscious and
oriented. Patient shifted to peadia ward.
- Slide 43
- 1.What are the characteristics of AF? 2.What are the layers of
artery? 3.What are the etiology of arterial embolism? 4.What are
the signs & symptoms of arterial embolism? 5.What are the types
of embolectomy? 6.What is the other name of balloon catheter?
7.What is atherosclerosis? 8.What are the complications of
embolectomy?
- Slide 44
- WIKIPEDIA MEDICAL AND SURGICAL NURSING BOOK(BRUNNER) LUCK MAN
AND SORENSENS MEDICAL SURGICAL NURSING
- Slide 45
- THANK YOU