i bc27f85be50b71b1 (129 page)

VASCULAR SYSTEM AND HEMATOLOGY 425

J

l

�

c

Figure 6-4. Aortofemoral graft. A. Schematic illustration of a preoperative

aortogram. B. A segment of diseased aorta is resected, and the distal aortic

stump is oversellJII. C. End-to-end proximal anastomosis. D. Completed

reconstruction. (With permission from RB Rutherford led]. Vascular Surgery

[5th ed[. Philadelphia: Sal/llders, 2000;951.)

•

Pseudoaneurysm formation at the anastomosis

•

Infection

•

Renal failure

•

Sexual dysfunction

•

Spinal cord ischemia

•

Colon ischemia

Endarterectomy

Endarterectomy is a process in which the stenotic area of an artery

wall is excised and the noninvolved ends of the artery are reanastomosed. It can be used to correct localized occlusive vascular disease, commonly in the carotid arteries, eliminating the need for bypassing the areaB

426

ACUTE CARE HANDBOOK FOR PHYSICAL THE.RAPISTS

Clinical Tip

The abbreviation CEA is often used to refer to a carotid

endarterectomy procedure.

Aneurysm Repair and Reconstruction

Aneurysm repair and reconstruction involve isolating the aneurysm

by clamping off the vessel proximal and distal to the aneurysm, excising the aneurysm, and replacing the aneurysmal area with a synthetic graft. Performing the procedure before the aneurysm ruptures (elective surgery) is preferable to repairing a ruptured aneurysm (emergency surgery), because a ruptured aneurysm presents an extremely challenging and difficult operative course owing to the hemodynamic

instability from hemorrhage. The cross-clamp time of the vessels is

also crucial, because organs distal to the site of repair can become

ischemic if the clamp time is prolonged. Complications that may

occur after aneurysm repair are similar to those discussed in Peripheral Vascular Bypass Grafting' Figure 6-5 illustrates an aneurysm repair and reconstruction.

Clinical Tip

•

Incisions should be inspected before and after physical

therapy interventions to assess the patency of the incision,

as drainage or weeping may occur during activity. If drainage or weeping occurs, stop the current activity and

inspect the amount of drainage. Provide compression, if

appropriate, and notify the nurse promptly. Once the

drainage is stable or under the management of the nurse,

document the incidence of drainage accordingly in the

medical record.

•

Abdominal incisions or other incisional pain can limit a

patient's cough effectiveness and lead to pulmonary infection. Diligent attention to position changes, deep breathing, assisted coughing, and manual techniques (e.g., percussion and vibration techniques as needed) can help

prevent pulmonary infections.

•

Grafrs rhat cross rhe hip joint, such as aortobifemoral

grafts, require clarification by the surgeon regarding the

amount of flexion allowed at the hip.

• After a patient is cleared for out-of-bed activity, specific

orders from the physician should be obtained regarding

weight bearing on the involved extremities, particularly

those with recent bypass grafts.

• Patients may also have systolic blood pressure limita-

tions postoperatively to maintain adequate perfusion of

the limb or to ensure the patency of the graft area.

Blood pressures that are below the specified limit may

decrease perfusion, whereas pressures above the limit

may lead to graft damage. Thorough vital sign monitor-

ing before, during, and after activity is essential.7

428

AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• Patients who are status post bypass grafting procedures

should have improved peripheral pulses; therefore, any

reduction in the strength of distal peripheral pulses that

occurs after surgery should be brought to the attention of

the nurse and physician.

Physical Therapy Interventions for Patients with Vascular and

Hematologic Disorders

The primary goal of physical therapy for patients with vascular and

hematOlogic disorders is the optimization of functional mobililry and

activity tolerance. In addition to these goals, patients with vascular

disorders require patient education to prevent skin breakdown and

DVT formation, manage edema, and prevent joint contractu res and

muscle shortening. Patients with hematOlogic disorders may require

patient education for activity modification, pain management, or fall

prevention (especially if the patient is at risk of bleeding or on anticoagulant therapy).

Guidelines for the physical therapist working with the patient who