Question

Each situation must include a care plan, 3 nursing diagnosis, include a med card with 3 additional potential meds for the situation, a nurse note for each situation and SBAR note .

Situation: The nurse is completing a patient history during an admission. The patient's wife reports that when she and her husband go for their daily walks, he can only go two blocks and then must sit down because of pain in the calves of his legs. They rest a while and walk another two blocks, but then the pain is back.

1. What additional history and physical assessments are indicated?

Two days later, the patient is assigned to you for nursing care. His primary nursing diagnosis is ineffective tissue perfusion related to insufficient oxygenation of the lower limbs manifested by pain on walking two blocks and diminished popliteal pulses, bilaterally.

2. What nursing interventions are indicated during the patient's hospitalization?

3. His health care provider prescribes cilostazol (Pletal), 100 mg bid. Review the drug monograph and discuss the drug’s action and adverse effects.

4. What health teaching would be needed in relation to his prescribed drug therapy?

Situation: A 76-year-old patient has been experiencing arteriosclerosis obliterans with intermittent claudication. He refuses to give up smoking. At his last office visit, he was given a prescription for pentoxifylline (Trental), 400 mg PO tid with meals. After leaving the examination room, he tells you (the office nurse) that the health care provider did not explain how this would work to improve his “leg pain.”

5. Explain in lay terms to the patient what is thought to be the mechanism of action of pentoxifylline and draw a diagram that depicts erythrocyte flexibility. Use the visual aid to help him understand how the drug could improve his leg pain.

6. One week later, the patient calls the office and says, “That new medication you gave me for my leg pain isn’t working.” How should you respond?

Answer 1

1. What additional history and physical assessments are indicated?

Claudication is pain caused by too little blood flow to muscles during exercise. Most often this pain occurs in the legs after walking at a certain pace and for a certain amount of time — depending on the severity of the condition.The condition is also called intermittent claudication because the pain usually isn't constant. It begins during exercise and ends with rest. As claudication worsens, however, the pain may occur during rest.

History

Claudication refers to muscle pain due to lack of oxygen that's triggered by activity and relieved by rest.

• Pain, ache, discomfort or fatigue in muscles every time you use those muscles
• Pain in the calves, thighs, buttocks, hips or feet
• Less often, pain in shoulders, biceps and forearms
• Pain that gets better soon after resting

The pain may become more severe over time. You may even start to have pain at rest.Signs or symptoms of peripheral artery disease, usually in more-advanced stages, include:

• Cool skin
• Severe, constant pain that progresses to numbness
• Skin discoloration
• Wounds that don't heal

Physical examination

• physical examination of a patient with claudication is a complete lower-extremity evaluation and pulse examination, including measurement of segmental pressures
• Atrophy of calf muscles, loss of extremity hair, and thickened toenails are clues to underlying PAOD.
• Palpation of pulses should be attempted from the abdominal aorta to the foot, with auscultation for bruits in the abdominal and pelvic regions.
• The absence of a pulse signifies arterial obstruction proximal to the area palpated. For example, if no femoral artery pulse is palpated, significant PAOD is present in the aortoiliac distribution.
• if no popliteal artery pulse can be palpated, significant superficial femoral artery occlusive disease exists. The exception is the rare case of a congenital absence of a pulse
• Patients who report intermittent claudication and have palpable pulses can present a clinical dilemma

2. What nursing interventions are indicated during the patient's hospitalization?

Interventions	Rationales
Submit patient to diagnostic testing as indicated.	A variety of tests are available depending on the cause of the impaired tissue perfusion. Angiograms, Doppler flow studies, segmental limb pressure measurement such as ankle-brachial index (ABI), and vascular stress testing are examples of these tests.
Check for optimal fluid balance. Administer IV fluids as ordered.	Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.
Note urine output.	Reduce renal perfusion may take place due to vascular occlusion.
Maintain optimal cardiac output.	This ensures adequate perfusion of vital organs.
Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue.	These facilitate perfusion when interference to blood flow transpires or when perfusion has gone down to such a serious level leading to ischemic damage.
Ineffective Tissue Perfusion: Peripheral
Assist with position changes.	Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes.
Promote active/passive ROM exercises.	Exercise prevents venous stasis and further circulatory compromise.
Administer medications as prescribed to treat underlying problem. Note the response.	These medications facilitate perfusion for most causes of impairment.
· Antiplatelets/anticoagulants	These reduce blood viscosity and coagulation.
· Peripheral vasodilators	These enhance arterial dilation and improve peripheral blood flow.
· Antihypertensives	These reduce systemic vascular resistance and optimize cardiac output and perfusion.
· Inotropes	These improve cardiac output.
Provide oxygen therapy as necessary.	This saturates circulating hemoglobin and augments the efficiency of blood that is reaching the ischemic tissues.
Position patient properly in a semi-Fowler’s to high-Fowler’s as tolerated.	Upright positioning promotes improved alveolar gas exchange.
Arterial insufficiency
Monitor peripheral pulses. Check for loss of pulses with bluish, purple, or black areas and extreme pain.	These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed.
Do not elevate legs above the level of the heart.	With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.
For early arterial insufficiency, encourage exercise such as walking or riding an exercise bicycle from 30 to 60 minutes per day.	Exercise enhances the development of collateral circulation, strengthens muscles, and provides a sense of well-being.
Keep patient warm, and have patient wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat.	Patients with arterial insufficiency complain of being constantly cold; therefore keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissues.
Provide much attention to foot care. Refer to podiatrist if patient has a foot or nail abnormality.	Ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury.
Venous insufficiency
If patient is overweight, encourage weight loss to decrease venous disease.	Obesity is a risk factor for development of chronic venous disease.
Discuss lifestyle with patient to see if occupation requires prolonged standing or sitting.	These can result in chronic venous disease.
If patient is mostly immobile, consult with physician regarding use of calf-high pneumatic compression device for prevention of DVT.	Pneumatic compression devices can be effective in preventing deep vein thrombosis in the immobile patient.
Elevate edematous legs as ordered and ensure that there is no pressure under the knee.	Elevation improves venous return and helps minimize edema. Pressure under the knee limits venous circulation.
Apply support hose as ordered.	Wearing support hose helps decrease edema.
Encourage patient to walk with support hose on and perform toe up and point flex exercises.	Exercise helps increase venous return, build up collateral circulation, and strengthen the calf muscle pumps.
Observe for signs of deep vein thrombosis, including pain, tenderness, swelling in the calf and thigh, and redness in the involved extremity.	Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain.
Note results of D-Dimer Test.	High levels of D-Dimer, a febrin degradation fragment, is found in deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation.
If DVT is present, observe for symptoms of a pulmonary embolism, especially if there is history of trauma.	Fatal pulmonary embolisms have been reported in one-third of trauma patients.
Discuss with patient the difference of arterial and venous insufficiency.	Detailed diagnostic information clarifies clinical assessment and allows for more effective care.
Educate patient about nutritional status and the importance of paying special attention to obesity, hyperlipidemia, and malnutrition.	Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue.
Encourage smoking cessation.	Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction and ineffective tissue perfusion.
Monitor for development of gangrene, venous ulceration, and symptoms of cellulitis	Cellulitis often accompanies peripheral vascular disease and is related to poor tissue perfusion.
Provide knowledge on normal tissue perfusion and possible causes of impairment.	Knowledge of causative factors provides a rationale for treatments
Encourage change in lifestyle that could improve tissue perfusion (avoiding crossed legs at the knee when sitting, changing positions at frequent intervals, rising slowly from a supine/sitting to standing position, avoiding smoking, reducing risk factors for atherosclerosis [obesity, hypertension, dyslipidemia, inactivity]).	These measures reduce venous compression/venous stasis and arterial vasoconstriction.
Explain all procedures and treatments.	Understanding expected events and sensations can help eliminate anxiety associated with the unknown.
Teach patient to recognize the signs and symptoms that need to be reported to the nurse.	Early assessment facilitates immediate treatment.

3. His health care provider prescribes cilostazol (Pletal), 100 mg bid. Review the drug monograph and discuss the drug’s action and adverse effects.

PLETAL (cilostazol) is a quinolinone derivative that inhibits cellular phosphodiesterase (more specific for phosphodiesterase III). The empirical formula of cilostazol is C20H27N5O2, and its molecular weight is 369.46. Cilostazol is 6-[4-(1-cyclohexyl-1H-tetrazol-5-yl)butoxy]-3,4-dihydro-2(1H)-quinolinone,

Cilostazol occurs as white to off-white crystals or as a crystalline powder that is slightly soluble in methanol and ethanol, and is practically insoluble in water, 0.1 N HCl, and 0.1 N NaOH.PLETAL (cilostazol) tablets for oral administration are available in 50 mg triangular and 100 mg round, white debossed tablets. Each tablet, in addition to the active ingredient, contains the following inactive ingredients: carboxymethylcellulose calcium, corn starch, hydroxypropyl methylcellulose 2910, magnesium stearate, and microcrystalline cellulose.

INDICATIONS

PLETAL is indicated for the reduction of symptoms of intermittent claudication, as demonstrated by an increased walking distance.

Adverse reactions

• Blood And Lymphatic System Disorders:Aplastic anemia, granulocytopenia, pancytopenia, bleeding tendency
• Cardiac Disorders:Torsade de pointes and QTc prolongation in patients with cardiac disorders (e.g. complete atrioventricular block, heart failure; and bradyarrythmia), angina pectoris.
• Gastrointestinal Disorders:Gastrointestinal hemorrhage, vomiting, flatulence, nausea
• General Disorders And Administration Site Conditions:Pain, chest pain, hot flushes
• Hepatobiliary Disorders:Hepatic dysfunction/abnormal liver function tests, jaundice
• Immune System Disorders:Anaphylaxis, angioedema, and hypersensitivity
• Investigations:Blood glucose increased, blood uric acid increased, increase in BUN (blood urea increased), blood pressure increase
• Nervous System Disorders:Intracranial hemorrhage, cerebral hemorrhage, cerebrovascular accident, extradural hematoma and subdural hematoma
• Renal And Urinary Disorders:Hematuria
• Respiratory, Thoracic And Mediastinal Disorders:Pulmonary hemorrhage, interstitial pneumonia
• Skin And Subcutaneous Tissue Disorders:Hemorrhage subcutaneous, pruritus, skin eruptions including Stevens-Johnson syndrome, skin drug eruption (dermatitis medicamentosa), rash.
• Vascular Disorders:Subacute stent thrombosis, hypertension.

Mehanism of action

PLETAL and several of its metabolites inhibit phosphodiesterase III activity and suppress cAMP degradation with a resultant increase in cAMP in platelets and blood vessels, leading to inhibition of platelet aggregation and vasodilation, respectively.PLETAL reversibly inhibits platelet aggregation induced by a variety of stimuli, including thrombin, ADP, collagen, arachidonic acid, epinephrine, and shear stress.

Cilostazol's effects on platelet aggregation were evaluated in both healthy subjects and in patients with stable symptoms of cerebral thrombosis, cerebral embolism, transient ischemic attack, or cerebral arteriosclerosis over a range of doses from 50 mg every day to 100 mg three times a day. Cilostazol significantly inhibited platelet aggregation in a dose-dependent manner. The effects were observed as early as 3 hours post-dose and lasted up to 12 hours following a single dose. Following chronic administration and withdrawal of cilostazol, the effects on platelet aggregation began to subside 48 hours after withdrawal and returned to baseline by 96 hours with no rebound effect. A cilostazol dosage of 100 mg twice daily consistently inhibited platelet aggregation induced with arachidonic acid, collagen and adenosine diphosphate (ADP). Bleeding time was not affected by cilostazol administration.

4. What health teaching would be needed in relation to his prescribed drug therapy?

Cilostazol can temporarily lower the number of white blood cells in your blood, increasing the chance of getting an infection. It can also lower the number of platelets, which are necessary for proper blood clotting. If this occurs, there are certain precautions you can take, especially when your blood count is low, to reduce the risk of infection or bleeding:

• If you can, avoid people with infections. Check with your doctor immediately if you think you are getting an infection or if you get a fever or chills, cough or hoarseness, lower back or side pain, or painful or difficult urination.
• Check with your doctor immediately if you notice any unusual bleeding or bruising, black, tarry stools, blood in the urine or stools, or pinpoint red spots on your skin.
• Be careful when using a regular toothbrush, dental floss, or toothpick. Your medical doctor, dentist, or nurse may recommend other ways to clean your teeth and gums. Check with your medical doctor before having any dental work done.
• Do not touch your eyes or the inside of your nose unless you have just washed your hands and have not touched anything else in the meantime.
• Be careful not to cut yourself when you are using sharp objects, such as a safety razor or fingernail or toenail cutters.
• Avoid contact sports or other situations where bruising or injury could occur.

Contact your doctor right away if you have any changes to your heart rhythm. You might have a fast, pounding, or irregular heartbeat or pulse, fainting, or palpitations with cilostazol.

Dizziness, lightheadedness, or fainting may occur when you get up suddenly from a lying or sitting position. Getting up slowly may help. If this problem continues or gets worse, check with your doctor.

Cilostazol may cause heart problems. Check with your doctor right away if you have chest pain or tightness, decreased urine output, dilated neck veins, extreme fatigue, irregular heartbeat, swelling of the face, fingers, feet, or lower legs, troubled breathing, or weight gain.

Smoking tobacco products, such as cigarettes, may worsen your condition. It contains nicotine which may further narrow blood vessels and may also affect how cilostazol works. Therefore, it is best to avoid smoking.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.