Nursing Rationales And Interventions

Orthostatic hypotension results in temporary reduced cerebral perfusion. 2. Monitor neurological position; execute a neurological exam; and if symptoms of a cerebrovascular incident (CVA) occur (e.g., hemiparesis, hemiplegia, or dysphasia), call 911 and send to the er. New onset of these neurological symptoms can signify a stroke. If caused by a thrombus and the client receives treatment within 3 hours, a heart stroke can be reversed.

3. See treatment plans for Decreased Intracranial adaptive capacity, Risk for Injury, and Acute Confusion. 1. Check dorsalis pedis and posterior tibial pulses bilaterally. If unable to find them, use a Doppler stethoscope and inform present doctor if pulses not. 2. Note skin color and feel temp of the skin.

Skin pallor or mottling, frosty or cool skin heat range, or an absent pulse can signal arterial obstruction, which can be an emergency that will require immediate intervention. Rubor (reddish-blue color followed by dependency) signifies dilated or broken vessels. 3. Check capillary refill. 4. Note pores and skin consistency and the presence of locks, ulcers, or gangrenous areas on your feet or legs. Thin, shiny, dry skin with hair loss; brittle nails; and ulcerations or gangrene on toes and anterior surfaces of feet have emerged in clients with arterial insufficiency. 5. Note existence of edema in extremities and rate it on the four-point level. 6. Assess for pain in extremities, noting intensity, quality, timing, and exacerbating and alleviating factors. Differentiate venous from arterial disease.

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In clients with venous insufficiency the pain lessens with elevation of the hip and legs and exercise. In clients with arterial insufficiency the pain raises with elevation of the legs and exercise (Black, 1995). Some clients have both arterial and venous insufficiency. Arterial insufficiency is associated with pain when walking (claudication) that is relieved by rest.

Clients with severe arterial disease have feet pain while at rest, which keeps them awake at night. 1. Monitor peripheral pulses. If new starting point of loss of pulses with bluish, purple, or dark areas and extreme pain, notify physician immediately. These are symptoms of arterial obstruction that can result in lack of a limb if not immediately reversed.

2. Usually do not elevate legs above the known degree of the heart. With arterial insufficiency, leg elevation decreases arterial blood circulation to the legs. 3. For early arterial insufficiency, encourage exercise such as walking or traveling a fitness bike from 30 to 60 minutes per day. 4. Keep client warm, and also have client wear shoes and socks or sheepskin-lined house shoes when mobile.

Do not apply warmth. Clients with arterial insufficiency complain to be constantly frosty; keep extremities warm to maintain vasodilation and blood circulation therefore. 5. Pay careful attention to feet care. Make reference to podiatrist if client has a toe nail or feet abnormality. Ischemic feet are very susceptible to injury; meticulous foot treatment can prevent further damage.

6. If customer has ischemic arterial ulcers, see treatment arrange for Impaired Tissue integrity, but avoid use of occlusive dressings. 1. Elevate edematous legs as ordered and ensure that there surely is no pressure under the knee. Elevation improves venous return and helps decrease edema. Pressure under the leg decreases venous flow.

2. Apply support line as purchased. Wearing support hose helps to decrease edema. 3. Encourage customer to walk with support hose on and perform bottom up and point flex exercises. 4. If client is obese, encourage weight reduction to diminish venous disease. 6. If customer is immobile mainly, consult with physician regarding use of calf-high pneumatic compression device for prevention of DVT.

7. Observe for signs of deep vein thrombosis, including pain, tenderness, bloating in the leg and thigh, and inflammation in the involved extremity. Take serial knee measurements of the lower leg and thigh circumferences. In a few clients is a palpable there, tender venous cord that can be felt in the popliteal fossa. Usually do not rely on Homans’ sign. Thrombosis with clot formation is usually first detected as bloating of the involved calf and then as pain.

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