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.

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.

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.

[Negative pressure therapy in traumatology]. / La thérapie par pression négative en traumatologie.

The treatment of complex wounds in traumatology is a source of concern for nurses. Negative pressure therapy constitutes a solution for difficult-to-treat situations in the framework of open fractures and loss of limb tissue.

[Setting up situated learning in vascular rehabilitation]. / Mise en place de situations apprenantes en rééducation vasculaire.

A pedagogical tool as well as a concept, situated learning describes the skills used in a situation in a given context, structuring the reflection, analysis and choice of nursing procedures, based on theoretical knowledge, know-how and interpersonal skills. A vascular rehabilitation team has chosen to formalise two situations from among the most common care procedures carried out in the department: the changing of complex dressings and ensuring the personal hygiene and comfort of a dependent patient with skin wounds.

Physiologic amputation: a case study.

Acute limb ischemia is a complication of severe peripheral arterial disease that can be a threatening limb as well as life. Multiple procedures exist today to help revascularize extremities; however, even with the latest technologies, surgical amputation of the limb may still be necessary. Cryoamputation, or physiologic amputation, is a method used to treat patients who are hemodynamically unstable for the operating room and who are in need of urgent amputation owing to arterial ischemia. This procedure is used in the rare instance where not only a persons' limb is threatened, but also their life. This is a case study regarding one patient who presented to the hospital with limb-threatening ischemia who became hemodynamically unstable owing to the rhabdomyolysis associated with the ischemia of his lower extremity. Cryoamputation was used to stabilize the patient and prevent further deterioration, so that he could safely undergo surgical amputation of the limb without an increase in mortality risk. Cryoamputation must be followed by formal surgical amputation when the patient is hemodynamically stabilized. It is not a limb salvaging, procedure but it is a life-saving procedure. This case study demonstrates the usefulness of the procedure and discusses the technique used for cryoamputation.

Systematic review of the operative and non-operative management of acute upper limb ischemia.

Acute upper limb ischaemia (AULI) can be managed surgically, via interventional radiology, and conservatively, but no real guidelines exist for when a conservative approach is appropriate. A systematic review of the literature is presented of the surgical, radiological and conservative management of AULI. A search was performed using the electronic databases Medline and Embase. Interventions and outcomes for each study were recorded. The consensus from the literature review was that operative management (embolectomy) is the most commonly used and best first-line treatment for AULI. No studies that used conservative anticoagulation management as a primary therapy, this mainly being reserved for patients deemed unfit for interventional treatment, appear in the literature. The consensus from the literature is that operative management is the most commonly used and best treatment. However, bias toward using operative management for the fittest patients appears in the literature. It is also possible that conservative management is underreported.

Actuación de enfermería ante un paciente con calcifilaxis / No disponible

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[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.

Health-related quality of life after revascularization for peripheral arterial occlusive disease: long-term follow-up.

AIM: This paper reports a study to measure quality of life, before and after revascularization, in patients with intermittent claudication and critical limb ischaemia from a long-term perspective. BACKGROUND: Patients with peripheral arterial occlusive disease have a number of problems which affect their quality of life and a successful revascularization results in immediate improvements in quality of life. However, knowledge of the durability of the improvements is sparse. Therefore, research on the outcomes of treatment and nursing care should investigate the long-term effects on quality of life and daily activities. METHODS: A quasi-experimental longitudinal follow-up study was conducted with 80 patients with intermittent claudication and 62 with critical ischaemia. Assessment with the Nottingham Health Profile was made before revascularization and 6 months, 12 months and up to 4 years afterwards. The data were collected between 1995 and 2000. RESULTS: Quality of life was improved 6 and 12 months after revascularization in patients with intermittent claudication in energy, pain, emotional reactions and physical mobility, while those with critical limb ischaemia also had improvements in pain and sleep. The improvement in pain was particularly evident for both groups and remained significantly improved up to 4 years after revascularization. Patients with critical limb ischaemia, however, deteriorated significantly with regard to physical mobility between 12 months and 4 years. Being a woman and belonging to the critical ischaemia group was significantly associated with high total Nottingham Health Profile score. Thus, patients with intermittent claudication had more durable benefits from revascularization than those with critical limb ischaemia. However, both groups had less pain than at baseline after 4 years. CONCLUSION: The degree to which quality of life was durable over time seems to depend on the severity of the disease and gender. Patients with critical limb ischaemia were older, had more other diseases and a lower quality of life than patients with intermittent claudication, which confirmed that patients with critical limb ischaemia need more ongoing nursing support to maintain independence in daily life a long time after revascularization.

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.