Angelite Nurses

• Coronary Artery Disease (CAD)
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• Angina Pectoris
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• Sinus Tachycardia
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• Sinus Bradycardia
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• Atrial Fibrillation
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• Premature Ventricular Contractions (PVCs)
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• Ventricular Tachycardia
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• Myocardial Infarction (MI)
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• Percutaneous Transluminal Coronary Angioplasty
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• Coronary Artery Bypass Surgery
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• Congestive Heart Failure (CHF)
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• Pulmonary Edema
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• Pacemakers
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• Cardiac Arrest
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• Cardiopulmonary Resuscitation (CPR)
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• Endocarditis
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• Pericarditis
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• Cardiac Tamponade
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• Hypertension
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• Arteriosclerosis Obliterans
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• Thromboangiitis Obliterans (Buerger's Disease)
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• Raynaud's Phenomenon
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• Aneurysms
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• Abdominal Aortic Aneurysm
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• Femoral-Popliteal Bypass Surgery
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• Venous Stasis Ulcers
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• Thrombophlebitis
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• Pulmonary Embolism
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• Varicose Veins
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• Amputation

1. General information
1. Surgical procedure done for peripheral vascular disease if medical management is ineffective and the symptoms become worse.
2. The level of amputation is determined by the extent of the disease process.
1. Above knee (AK): performed between the lower third to the middle of the thigh
2. Below knee (BK): usually done in middle third of leg, leaving a stump of 12.5-17.5 cm
2. Nursing interventions: preoperative
1. Provide routine pre-op care.
2. Offer support/encouragement and accept client's response of anger/grief.
3. Discuss
1. Rehabilitation program and use of prosthesis
2. Upper extremity exercises such as push-ups in bed
3. Crutch walking
4. Amputation dressings/cast
5. Phantom limb sensation as a normal occurrence
3. Nursing interventions: postoperative
1. Provide routine post-op care.
2. Prevent hip/knee contractures
3. Avoid letting client sit in chair with hips flexed for long periods of time.
4. Have client assume prone position several times a day and position hip in extension (unless otherwise ordered).
5. Avoid elevation of the stump after 12-24 hours.
6. Observe stump dressing for signs of hemorrhage and mark outside of dressing so rate of bleeding can be assessed.
7. Administer pain medication as ordered.
8. Ensure that stump bandages fit tightly and are applied properly to enhance prosthesis fitting.
9. Initiate active ROM exercises of all joints (when medically advised), crutch walking, and arm/shoulder exercises.
10. Provide stump care.
1. Inspect daily for signs of skin irritation.
2. Wash thoroughly daily with warm water and bacteriostatic soap; rinse and dry thoroughly.

Avoid use of irritating substances such as lotions, alcohol, powders.

1. General information
1. Dilated veins that occur most often in the lower extremities and trunk. As the vessel dilates, the valves become stretched and incompetent with resultant venous pooling/edema
2. Most common between ages 30 and 50
3. Predisposing factor: congenital weakness of the veins, thrombophlebitis, pregnancy, obesity, heart disease
2. Medical management: vein ligation (involves ligating the saphenous vein where it joins the femoral vein and stripping the saphenous vein system from groin to ankle)
3. Assessment findings
1. Pain after prolonged standing (relieved by elevation)
2. Swollen, dilated, tortuous skin veins
3. Diagnostic tests
1. Trendelenburg test: varicose veins distend very quickly (less than 35 seconds)
2. Doppler ultrasound: decreased or no blood flow heard after calf or thigh compression
4. Nursing interventions
1. Elevate legs above heart level.
2. Measure circumference of ankle and calf daily.
3. Apply knee-length elastic stockings.
4. Provide adequate rest.
5. Prepare client for vein ligation, if necessary.
1. Provide routine pre-op care.
2. In addition to routine post-op care
1. keep affected extremity elevated above the level of the heart to prevent edema.
2. apply elastic bandages and stockings, which should be removed every 8 hours for short periods and reapplied.
3. assist out of bed within 24 hours, ensuring that elastic stockings are applied.
4. assess for increased bleeding, particularly in the groin area.
6. Provide client teaching and discharge planning: same as for thrombophlebitis (see Thrombophlebitis).

1. General information
1. Most pulmonary emboli arise as detached portions of venous thrombi formed in the deep veins of the legs, right side of the heart, or pelvic area.
2. Distribution of emboli is related to blood flow; emboli involve the lower lobes of the lung because of higher blood flow.
3. Embolic obstruction to blood flow increases venous pressure in the pulmonary artery and pulmonary hypertension.
4. Risk factors: venous thrombosis, immobility, pre- and post-op states, trauma, pregnancy, CHF, use of oral contraceptives, obesity
2. Medical management
1. Drug therapy
1. Anticoagulants (see Thrombophlebitis)
2. Thrombolytics: streptokinase or urokinase
3. Dextran 70 to decrease blood viscosity and aggregation of blood cells
4. Narcotics for pain relief
5. Vasopressors (in the presence of shock)
2. Surgery: embolectomy (surgical removal of an embolus from the pulmonary arteries)
3. Assessment findings
1. Chest pain (pleuritic), severe dyspnea, feeling of impending doom
2. Tachypnea, tachycardia, anxiety, hemoptysis, shock symptoms (if massive)
3. Decreased pCO₂; increased pH (due to hyperventilation)
4. Increased temperature
5. Intensified pulmonic S₂; rales or crackles
6. Diagnostic tests
1. Pulmonary angiography: reveals location/extent of embolism
2. Lung scan reveals adequacy/ inadequacy of pulmonary circulation
4. Nursing interventions
1. Administer medications as ordered; monitor effects and side effects.
2. Administer oxygen therapy to correct hypoxemia.
3. Assist with turning, coughing, deep breathing, and passive ROM exercises.
4. Provide adequate hydration to prevent hypercoagulability.
5. Offer support/reassurance to client/family.
6. Elevate head of bed to relieve dyspnea
7. Provide client teaching and discharge planning: same as for thrombophlebitis.

1. General information
1. Inflammation of the vessel wall with formation of a clot (thrombus); may affect superficial or deep veins.
2. Most frequent veins affected are the saphenous, femoral, and popliteal.
3. Can result in damage to the surrounding tissues, ischemia, and necrosis.
4. Risk factors: obesity, CHF, prolonged immobility, MI, pregnancy, oral contraceptives, trauma, sepsis, cigarette smoking, dehydration, severe anemias, venous cannulation, complication of surgery
2. Medical management
1. Anticoagulant therapy
1. Heparin
1. blocks conversion of prothrombin to thrombin and reduces formation or extension of thrombus
2. side effects: spontaneous bleeding, injection site reactions, ecchymoses, tissue irritation and sloughing, reversible transient alopecia, cyanosis, pain in arms or legs, thrombocytopenia
2. Warfarin (coumadin)
1. blocks prothrombin synthesis by interfering with vitamin K synthesis
2. side effects
1. GI: anorexia, nausea and vomiting, diarrhea, stomatitis
2. hypersensitivity: dermatitis, urticaria, pruritus, fever
3. other: transient hair loss, burning sensation of feet, bleeding complications
2. Surgery
1. Vein ligation and stripping (see Thrombophlebitis)
2. Venous thrombectomy: removal of a clot in the iliofemoral region
3. Plication of the inferior vena cava: insertion of an umbrella-like prosthesis into the lumen of the vena cava to filter incoming clots
3. Assessment findings
1. Pain in the affected extremity
2. Superficial vein: tenderness, redness, induration along course of the vein
3. Deep vein: swelling, venous distension of limb, tenderness over involved vein, positive Homan's sign, cyanosis
4. Elevated WBC and ESR
5. Diagnostic tests
1. Venography (phlebography): increased uptake of radioactive material
2. Doppler ultrasonography: impairment of blood flow ahead of thrombus
3. Venous pressure measurements: high in affected limb until collateral circulation is developed
4. Nursing interventions
1. Provide bed rest, elevating involved extremity to increase venous return and decrease edema.
2. Apply continuous warm, moist soaks to decrease lymphatic congestion.
3. Administer anticoagulants as ordered
1. Heparin
1. monitor PTT; dosage should be adjusted to keep PTT between 1.5-2.5 times normal control level.
2. use infusion pump to administer IV heparin.
3. ensure proper injection technique.
1. use 26- or 27-gauge syringe with 1/2-5/8-in needle, inject into fatty layer of abdomen above iliac crest.
2. avoid injecting within 2 inches of umbilicus.
3. insert needle at 90° to skin.
4. do not withdraw plunger to assess blood return.
5. apply gentle pressure after removal of needle, avoid massage.
4. assess for increased bleeding tendencies (hematuria; hematemesis; bleeding gums; petechiae of soft palate, conjunctiva, retina; ecchymoses, epistaxis, bloody sputum, melena) and instruct patient to observe for and report these.
5. have antidote (protamine sulfate) available.
6. instruct client to avoid aspirin, antihistamines, and cough preparations containing glyceryl guaiacolate, and to obtain physician's permission before using other OTC drugs.
2. Warfarin (Coumadin)
1. assess PT daily; dosage should be adjusted to maintain PT at 1.5-2.5 times normal control level; INR of 2.
2. obtain careful medication history (there are many drug-drug interactions).
3. advise client to withhold dose and notify physician immediately if bleeding or signs of bleeding occur (see Heparin, above).
4. instruct client to use a soft toothbrush and to floss gently.
5. have antidote (vitamin K) available.
6. alert client to factors that may affect the anticoagulant response (high-fat diet or sudden increases in vitamin K-rich foods).
7. instruct client to wear Medic-Alert bracelet.
4. Assess vital signs every 4 hours.
5. Monitor for chest pain or shortness of breath (possible pulmonary embolism).
6. Measure thighs, calves, ankles, and instep every morning.
7. Provide client teaching and discharge planning concerning
1. Need to avoid standing, sitting for long periods; constrictive clothing; crossing legs at the knees; smoking; oral contraceptives
2. Importance of adequate hydration to prevent hypercoagulability
3. Use of elastic stockings when ambulatory
4. Importance of planned rest periods with elevation of the feet
5. Drug regimen
6. Plan for exercise/activity
1. begin with dorsiflexion of the feet while sitting or lying down
2. swim several times weekly
3. gradually increase walking distance
7. Importance of weight reduction if obese