Chronic limb ischaemia: case study and clinical literature review.

This article will discuss chronic limb ischaemia as the result of peripheral artery disease (PAD) using a case study. The patient's concurrent diagnosis of metastases meant clinical decision making was complex and treatment options were limited. PAD is the third most common clinical presentation of atherosclerosis after coronary artery disease and stroke. Although advances in radiological technology and biochemical screening offer the potential for earlier intervention and improved survival rates for patients with PAD, a review of the evidence suggests that commitment to more conservative approaches, such as exercise therapy and health promotion, could have more sustainable, longer-term benefits for patients with chronic limb ischaemia. The therapeutic nature of the nurse-patient relationship makes nurses ideally placed for encouraging lifestyle changes and signposting to support services. Active participation from the patient is imperative for any potential modifications, which should be individualised as part of a holistic care plan, to ensure patient engagement and compliance. Therefore emphasis should remain on the management and prevention of modifiable risk factors, for which the nurse's role is an integral part to ensure success.

Hair toe tourniquets: a review of two case studies.

Digit hair tourniquets are relatively uncommon. There are reports in the literature of hair tourniquets involving other appendages, such as the penis and uvula, however the phenomenon is not widely recognised and is often overlooked by healthcare professionals. This article discusses two case studies in which hair was responsible for creating a tourniquet around a digit. The article explores possible causes and management options for patients, with reference to the case studies. Midwives and health visitors are central to minimising the risk of injury to children as they can educate expectant mothers about this potential problem.

An integrative review of health-related quality of life in patients with critical limb ischaemia.

AIMS AND OBJECTIVES: To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life. BACKGROUND: Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation. DESIGN: The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al. RESULTS: The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia. CONCLUSIONS: Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required. RELEVANCE TO CLINICAL PRACTICE: A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.

The role of the community clinician in early detection, referral and treatment of critical limb ischaemia.

Critical limb ischaemia (CLI) is a significant public health issue worldwide, with an ever-growing incidence among people over 65. Awareness of CLI is low, particularly among non-vascular clinicians, leading to underdiagnosis and undertreatment. A diagnosis of CLI is known to have a grave effect on a person's quality of life, with devastating outcomes for both their life and limb, often resulting in uncontrolled pain, amputation or early death from a cardiovascular event. Community nurses and podiatrists are key clinicians who can play a crucial and active role in earlier identification, rapid referral and ongoing non-surgical care for this overlooked population.

[Lived experience and management of the every-day life after lower-limb amputation caused by vascular diseases]. / Wie Menschen mit einer Amputation der unteren Extremitäten ihren Alltag erleben und bewältigen.

A lower limb amputation seriously restricts people's lives. Suddenly, they lose a crucial part of their body and their usual mobility. The main reason of lower-limb amputation is diabetes mellitus. People living with a chronic illness have to face permanent uncertainty. There is little knowledge about the experience of living with a chronic illness, and suffering from a lower-limb amputation. This study examines how people with a lower-limb amputation caused by vascular diseases experience and manage their every-day life. Grounded Theory approach has been used to examine the research question. Qualitative interviews have been conducted with nine amputees, and data analysis has been done by using the method of Grounded Theory as well. As a result of an amputation, people have to cope with severe loss: the loss of a part of their body with consequences on their body image, the loss of mobility, a following dependency on means such as wheelchairs and prostheses, and the loss of the ability to manage daily activities. In order to be able to manage their daily activities again, amputees need to regain their mobility. At the same time, this regained mobility enables them to perform activities of individual importance within their disability. The results of this study help to understand the challenge of every-day live after a lower limb amputation caused by vascular diseases, which should serve for a basis of support for these people.

New targets for pharmacological intervention in the glutamatergic synapse.

Excitotoxicity is thought to be a major mechanism in many human disease states such as ischemia, trauma, epilepsy and chronic neurodegenerative disorders. Briefly, synaptic overactivity leads to the excessive release of glutamate that activates postsynaptic cell membrane receptors, which upon activation open their associated ion channel pore to produce ion influx. To date, although molecular basis of glutamate toxicity remain uncertain, there is general agreement that N-methyl-d-aspartate (NMDA) subtype of ionotropic glutamate receptors plays a key role in mediating at least some aspects of glutamate neurotoxicity. On this view, research has focused in the discovery of new compounds able to either reduce glutamate release or activation of postsynaptic NMDA receptors. Although NMDA receptor antagonists prevent excitotoxicity in cellular and animal models, these drugs have limited usefulness clinically. Side effects such as psychosis, nausea, vomiting, memory impairment, and neuronal cell death accompany complete NMDA receptor blockade, dramatizing the crucial role of the NMDA receptor in normal neuronal processes. Recently, however, well-tolerated compounds such as memantine has been shown to be able to block excitotoxic cell death in a clinically tolerated manner. Understanding the biochemical properties of the multitude of NMDA receptor subtypes offers the possibility of developing more effective and clinically useful drugs. The increasing knowledge of the structure and function of this postsynaptic NMDA complex may improve the identification of specific molecular targets whose pharmacological or genetic manipulation might lead to innovative therapies for brain disorders.

Intra-aortic balloon counterpulsation complicated by limb ischaemia: a reflective commentary.

Intra-aortic balloon counterpulsation (IABC) is widely used to support the failing myocardium, particularly in patients with a background of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). CS is primarily due to left ventricular failure and is the most serious complication of AMI. Using Driscoll's 'What?' reflective model to guide critical thinking, an incident involving a patient who required IABC following AMI is explored. There are various complications associated with IABC, limb ischaemia being very common. Risk factors, which predispose patients to the development of limb ischaemia following intra-aortic balloon pump insertion, are discussed as are the issues surrounding their care. Nurses are in an ideal position to detect any complications that may occur. They should be familiar with the patient's medical history, including any risk factors, which could predispose them to the development of limb ischaemia. Consideration of these factors and the adjunctive treatment the patient may require can be used to plan care accordingly. Anecdotal evidence suggests that more patients are requiring haemodynamic support from IABC. Nurses and health care professionals who have the responsibility of caring for these patients need to be adequately trained in order to maintain a high standard of care. However, there appears to be a lack of evidence-based guidelines determining the optimum frequency of limb observations to assess for limb ischaemia. Further evidence as to the timing of limb observations is required in order that protocols can be written to guide the practice.

Cardiac Monitoring in the Emergency Department.

Patients present to the emergency department (ED) with a wide range of complaints and ED clinicians are responsible for identifying which conditions are life threatening. Cardiac monitoring strategies in the ED include, but are not limited to, 12-lead electrocardiography and bedside cardiac monitoring for arrhythmia and ischemia detection as well as QT-interval monitoring. ED nurses are in a unique position to incorporate cardiac monitoring into the early triage and risk stratification of patients with cardiovascular emergencies to optimize patient management and outcomes.

Epidural sympathetic blockade to relieve vascular insufficiency in an infant with purpura fulminans.

The patient in septic shock who develops vascular insufficiency secondary to purpura fulminans is a challenge to the healthcare team. Initial management is directed toward reversing the disease process by administering antibiotics immediately and initiating life-support measures. Emergency measures include optimizing oxygenation and ventilation, reestablishing and/or maintaining circulation and end-organ perfusion and correcting electrolyte imbalances and coagulopathies. After the emergent life-saving needs of the patient have been addressed, attention may be directed toward saving extremities. Epidural sympathetic blockade proved to be successful as an essential adjunctive intervention in preserving the lower extremities of our patient. We encourage other healthcare providers to consider this treatment to help decrease the morbidity of vascular insufficiency secondary to meningococcal purpura fulminans.

Acute mesenteric ischemia.

Acute mesenteric ischemia is a potentially life-threatening vascular disorder affecting the gastrointestinal tract. The prognosis depends on early recognition, accurate diagnosis, and timely intervention to prevent extensive tissue necrosis and the onset of sepsis and multi-organ complications. Identifying the patient at risk, evaluating physical findings and laboratory data, maintaining adequate cardiac output and perfusion pressure, and implementing medical interventions are nursing care measures essential to patient survival. Future directions for the management of acute mesenteric ischemia are focused on identifying early markers of ischemia and mucosal injury to diagnose the condition accurately and reliably before the onset of systemic consequences.

Appraisal and coping with vaso-occlusive crisis in adolescents with sickle cell disease.

PURPOSE: To explore the relationships among appraisals of vaso-occlusive events, coping behavior during the event, and adjustment in adolescents with sickle cell disease. METHOD: A descriptive, correlation design used a purposive sample of 68 adolescents with sickle cell disease. Three questionnaires were used to collect the data: Pain Beliefs and Perceptions Inventory (PBPI), Coping Strategies Questionnaire (CQS), and a demographic questionnaire. Correlation and multiple regression were used to analyze the data. FINDINGS: Appraisal factors positively correlated with coping strategies and adjustment. Multiple regression found that appraisal of the event as catastrophic predicted the reinterpretation of pain sensations (p < .001). CONCLUSIONS: Adolescents with more negative thoughts during vaso-occlusion crisis used ineffective coping strategies and reported poorer adjustment.

Acute lower limb ischemia: a case study.

Acute ischemia of the lower extremity is a limb and life-threatening situation that demands prompt recognition and immediate treatment. The leading cause of acute limb ischemia is typically an arterial embolus of cardiac origin. Other significant causes are thrombosis of an atherosclerotic vessel and arterial injury/trauma. This case study examines complexities of diagnosis and treatment of acute ischemia while focusing on nursing care of a patient with an acute embolic occlusion.

Mesenteric ischemia.

In all forms of mesenteric ischemia, early diagnosis and treatment is imperative. As this disease entity can be evident as a sole clinical event or a secondary event, close observation and suspicion of the diagnosis is advised in those who are at high risk. As the nurse caring for these patients, careful monitoring of the patient's fluid and electrolyte status, nutritional and gastrointestinal status is essential. This, along with assessing for complications and recurrence of ischemia, are the sine qua non of treatment for mesenteric ischemia.

Extraanatomic bypass surgery.

The term "extraanatomic bypass" applies to grafts that pass through a different anatomic pathway than do the natural blood vessels they replace. These grafts are devised to circumvent complex problems when conventional vascular procedures are not possible or are too hazardous to perform. There are various indications, advantages, and disadvantages to each of these grafts. Extraanatomic bypass grafts are an accepted technique with known patency rates. Quality nursing care plays a significant role in successful patient outcome.

Anterior ischemic optic neuropathy.

Anterior ischemic optic neuropathy (AION) occurs when there is compromised blood supply to the optic nerve and can result in visual loss. Ophthalmic nurses are key health professionals to recognize this entity and triage the patient accordingly. A case study of a patient with non-arteritic AION is presented.

Assessment brings its own relief. Nursing care of individuals suffering from ischaemic leg pain.

Although pain has been the focus for much recent nursing research, little attention has been paid to relief of ischaemic leg pain. A structured and thorough assessment, which clearly identifies the pain experienced, and the use of analgesia and complementary methods of pain control can help reduce the chronic pain associated with this condition.

Diabetes and its effect on wound healing and patient care.

Diabetes is a multisystem disorder that affects the wound healing process. Physiological changes in tissues and cells may delay healing and complications of diabetes also have an impact. Given these factors, it is important for health care teams working across the acute community interface to manage diabetic wounds effectively.

Chronic critical limb ischemia: what is the benefit of radiological intervention? Indications and results.

Indications of interventional radiological procedures in patients with chronic critical limb ischemia are not clearly defined. PTA of limb arteries is used only in 3 of 4% of patients, although 20 to 40% might be candidates for a proximal intervention in the iliac arteries. Following PTA of intrapopliteal arteries, limb salvage varies from 56 to 82% and arterial patency rate from 34 to 100% after 1 to 2 years follow-up in non controlled case series studies. Arterial local thrombolysis shows better results than surgery in subgroups of patients in a few studies. Pulse spray technique does not show better clinical results than conventional infusion of the plasminogen activator. Overall, radiological interventions give similar results compared with surgery, concerning limb salvage rate, length of hospital stay, morbidity and mortality, but significantly more patients are discharged home versus a nursing institution after radiological treatment than after surgery. Radiological techniques seem to be cost effective compared to surgery. Amputation should be carried out only after all revascularization possibilities have been ruled out at a multidisciplinary vascular center.