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chapter 36

vascular disorders for exam 4

layers of arteries 1. intima - inner most layer 2. media 3. tunica
resistance of vascular system is controlled by 1. diameter of the vessels 2. sympathetic NS 3. angiotensin II - vasoconstriction 4. serotonin, histamine, kinins, protaglandins - vasodilation
age related changes to vascular system 1. arteriosclerosis 2. loss of elasticity 3. the aorta stiffens, thickens and loses distensibility 4. decrease of hemoglobin 5. slowing of the HR and decreased stroke volume
nursing assessment of vascular system focus on the 6 P's of PVD - pain pulselessness - assess peripheral pulses poikilothermy - inspection pallor - inspection parethesia - protection paralysis - protection
nursing assessment of vascular system Pain Described as tenderness, heaviness, fullness in the extremities
Intermittent claudication decreased perfusion of major muscle groups - tightness, burning, fatigue, aching, cramping pain is better with rest
rest pain caused by ischemia - severe, burning pain in the legs and feet after lying flat pain is relieved by dangling, pt sleeps best in a chair
changes in integument associated with PVD thick and brittle nails taut, scaly and dry skin temperature variations skin ulcerations muscle atrophy localized redness and hardness hair loss on extremities
10% of people with DVT develop an PE
S&S of aneurysm hoarseness dysphagia dyspnea abd or back pain swelling of the head or arms
functional assessment determines the effect of the disease process on the pts life
arterial vs venous arterial complications involve multiple areas and venous complications are more localized, usually in lower extremities
arterial vs venous rubor - arterial occulsive pallor - arterial vasoconstriction brownish or cyanotic - venous
stasis dermatitis arterial vs venous venous stasis - begins in ankle area arterial - begins in toes
capillary refill more than 3 seconds denotes reduction in peripheral perfusion
temperature arterial vs venous arterial - cool venous - warm
dependent edema result of systemic disorders, lymphatic dysfunction, DVT, or chronic venous insufficiency
grading edema 1 - less than 1/4 in depression 2 - 1/4 to 1/2 in depression 3 - 1/2 to 1 in 4 - more than 1 in = pitting edema
upper extremity peripheral pulses brachial, ulnar, radial
lower extremity peripheral pulses femoral, popliteal, dorsalis pedis, posterior tibial
Homan's sign flex the knee and sharply dorsiflex the foot, pain is a positive sign and could indicate DVT
bruits can be the presence of an aneurysm or due to chronic arterial occlusive disease
plethysmography used to detect DVT
exercise treadmill test carefully monitor
angiography bed rest, monitor vitals hourly for hours, assess injection site for bleeding, hematoma, pulsating mass (pseudoaneurysm, neurovascular checks for pulses, sensation, movement, color and warmth
primary goal for pts with PVD increase arterial blood supply reduce venous congestion dilate blood vessels increase arterial blood flow prevent vascular compression provide relief from pain attain or maintain tissue integrity encourage adherence to treatment plan
pts are restricted to bed if they have leg ulcers, gangrene or thrombotic occlusion
Buerger-Allen exercises 1. elevate legs 45-90 degrees for 2-3 minutes 2. sit with feet in dependent position - dangle for 5-10 minutes 3. flex, extend, supinate, pronate each foot three times 4. rest supine for 10 minutes
correct placement of elastic stockings compresses superficial veins resulting in improved blood flow to the deeper veins
elastic stockings are best applied in the morning before rising from bed remove for 20 minutes twice a day - inspect skin at this time
intermittent pneumatic compression mimics the muscle pumping of the lower extremities, prevents venous pooling and stimulates circulation
lowering extremities enhances arterial blood supply
elevating extremities promotes venous return and reduces venous stasis
thermotherapy heat - vasodilation cool - vasoconstriction
pt teaching cleanliness, warmth, safety, comfort measures, prevention of constricting blood flow, exercise, s&s to report to the provider, drug therapy, importance of smoking cessation
embolectomy removal of a blood clot located in a large vessel; used for arterial embolism; catheter with balloon near tip is passed through the embolus and inflated - withdraw the entire embolus this way
percutaneous transluminal angioplasty PTA relieves arterial stenosis complications - hematoma, embolus, arterial dissection, allergic reaction to dye
endarterectomy plaque is stripped away from intima; vessel is surgically closed
sympathectomy improves vascular circulation in intermittent claudication; sympathetic ganglia is excised; not used when poor circulation is realated to atherosclerotic vessel
vein ligation and stripping to treat varicose veins; greater or lesser saphenous systems are removed; disadvantage= it won't be there if a CABG is done in the future
sclerotherapy vericose veins, cosmetic procedure complications - PE, thrombosis, injection site necrosis, vasospasm, hemolysis, allergic reaction
pre op nursing care activity restriction until the procedure is is done; affected extremity should be maintained in a level or slightly dependent position as ordered; kepp extremity warm, protect limb from further injury
post op nursing care primary goal - stimulate circulation by encouraging movement and preventing stasis within the extremity; if peripheral pulse disappears suspect a thrombus; do not let pt cross legs or place affected limb in dependent position for long periods of time; elevating helps prevent edema
heparin anticoagulant SE - thrombocytopenia, bleeding, hemorrhage, N/V, local irritation at inj site NC: aPTT 1.5-2 times normal, monitor for bleeding, platelet counts, avoid trauma, IV or subQ route, apply pressure but do not massage, protamine sulfate is antidote
LMWH anticoagulant SE: thromboscytopenia, anemia, edema, nausea, fever, confsion, cardiac toxicity and bruising NC: SubQ only, do not aspirate, rotate sites, leave bubble in syringe, monitor for bleeding, do not take aspirin, monitoring aPTT is not needed
warfarin anticoagulant SE: bruising, hemorrhage, nausea, anorexia NC: check PT/INR before each dose, monitor for bleeding, do not take aspirin
aspirin antiplatelet SE: GI irritation, tinnitus, pruritus, HA, bleeding NC: assess for brusing and bleeding, give with milk or food for GI upset
cilostazol antiplatelet SE: cardiac dysrhythmias, HA, dizziness, diarrhea NC: monitor for bleeding and HF, blood work must be done during therapy, may take up to 12 weeks for therapeutic effects
glycoprotein IIb/IIIa antiplatelet SE: major bleeding NC: immediately report GI, urinary or puncture site bleeding, stop infusiuon if major bleeding occurs, IV only
adenosine diphosphate antiplatelet SE: Gi disturbance, rash and TTP?, risk of bleeding, blood dyscrasias?
streptokinase clot buster SE: minor to major bleeding, thrombocytopenia, alopecia, hypersensitivity and hypotension, cardiac dysrhythmias with restored blood flow NC: monitor clotting tests, ECG and vital signs, protect from trauma, chest pain should be evaluated stat, may reduce mycardial damage, handle pt gently avoid IM and subQ injections and invasive procedures
calcium channel blocker vasodilator SE: drowsiness, dizziness, dysrhythmias, CHF, MI, hypotension, polyuria NC: monitor BP and pulse, check for edema, limit caffeine, avoid ETOH, swallow tablets and capsules whole, postural hypotension
alpha-andrenergic blockers vasodilator SE: dizziness, HA, drowsiness, nausea, orthostatic hypotension, , NC: monitor BP and pulse, weight daily, take 1st or any increased dose at HS due to hypotension,
pentoxifylline hemorrheologic agent - decreases viscosity SE: dyspepsia, epistaxis, dizziness, n/v, angina, tachycardia, dysrhythmias, leukopenia, HA, tremors, rash NC: assess vital signs, give with food, safety precautions due to dizziness, have pt report any rapid or irregular pulse, monitor WBCs
dietary interventions vitamin B, C and protein are needed to promote healing and improve tissue integrity
arterial embolism usually forms in the heart but can form in any artery with atheromatous plaque
S&S of arterial embolism severe, acute pain gradual loss of sensory and motor function in affected area pain aggreavated by movement or pressure absent distal pulses pallor and mottling sharp line of color and temperature demarcation
med and surg treatment of arterial embolism IV anticoagulants and thrombolytics, can not be given with active internal bleeding, CVA recent major surgery, uncontrolled hypertension, pregnancy embolectomy for pts that can't be treated with meds
NC for arterial embolism PVD assessment improve circulation and prevent further damage by maintaining extremities at or slightly below the horizontal position progressive exercise plan- 15 minutes 3 x/day protect limb teaching
peripheral arterial occlusive disease atherosclerosis obliterans, arterial insufficiency and PVD Plaque formations arise where the arteries branch, veer, arch or narrow Most common sites - femoral and popliteal arteries Develops gradually compensatory mech - collateral blood vessels, vasodilation, anaerobic metabolism
S&S of peripheral arterial occlusive disease intermittent claudication is classic sign absence of peripheral pulses rest pain tingling and numbness in the toes cold and numb muscle atrophy redness in dependent position shiny, scaly skin, hairlessness, ulcers with pale gray or yellowish hue at the ankles, size difference in unaffected side
med and surg treatment of peripheral arterial occlusive disease make life style changes regular exercise drug therapy stenting and endarterectomy
NC for peripheral arterial occlusive disease PVD assessment cessation of a pulse suggests possible arterial occlusion and the seurgeon must be notified stat monitor activity tolerance pain management is a priority maintain adequate warmth infected synthetic graft is very serious it necessitates the removal of the graft and amputation
decreased cardiac output monitor for tachycardia, restlessness, decreased urine output, pallor, hypotension; monitor weight and I&O, inspect dressing for bleeding and report stat edema is normal for 4-8 weeks elastic stockings are not used TX: IV and oral fluids
thromboangiitis obliterans unknown cause but only smokers get this S&S: int claudication, rest pain, skin color and temp changes, cold sensitivity, abnormal sensation, ulceration, gangrene QUIT SMOKING!!!!!!!
Raynaud disease intermittent constriction of arterioles, affects the hands, toes, tip of nose primary - unk cause - disease women 16-40 majority of cases secondary - connective tissue or collagen vascular disease - phenomenon
s&S of Raynaud disease and treatment cold hands, numbness, tingling and pallor, thumb is usually not affected, pallor to cyanosis to redness TX: prevent pain and promote vasodilation, sympathectomy - temporary
NC for Raynaud disease PVD assessment avoid stimuli that causes the vasoconstriction, interrupt an acute attack by placing affected parts in warm water, hair dryer, foot warming devices, protect from trauma,
aneurysms weakness and stretching of arterial wall congenital or acquired Marfan syndrome ehlers-Danlos syndrome atherosclerosis hypertension syphilis AAA is most common
s&s of aneurysms asymptomatic deep, diffuse chest pain hoarseness dysphagia edema or head and arms airway obstruction pulsating mass slightly to the left of umbilicus back pain, epigastric pain, constipation
med and surg treatment of aneurysms repain with synthetic graft or patching an AAA smaller than 5 cm is usually monitored with ultrasound complications: MI, sexual dysfunction, renal failure, emboli, spinal cord ischemia with paralysis, owel and bladder incontinence, impaired sensation
pre op care of aneurysm prepare pt physically and emotionally
post op care of aneurysm kept in CCU for 24-48 hours post op assessment monitor vs, hemodynamic status, renal function, fluid balance, palpate extremties for color, warmth and pulses, I&O hourly, BUN, creatinine and electrolyte levels daily, IV fluids as ordered high risk of atelectasis and pneumonia, mechanical ventilation,
aortic dissection small tear in intima permits blood to escape into the space between the intima and media, media splits lengthwise,
key aspect of post op surgical care for aortic dissection keep the blood pressure as low as possible
varicose vein disease vericosities are dilated, torturous, superficial veins in saphenous veins in lower extremities, from incompetent valves, cause pregnancy, obesity, prolonged standing, hereditary weakness, aging
S&s of varicose veins and treatment s&s:dull aching sensations when standing or walking, heaviness, muscle cramps at night, muscle fatigue, postphlebitic syndrome = persistent edema, brownish skin discoloration, ulcers on inner aspect of ankle TX: sclerotherapy or laser therapy, ligation and stripping large dilated veins, saphenous vein is tied shut at the groin
NC of varicose veins exam focuses on inspection of the legs for color, edema, turgor and capillary refill, palpate for tenderness, post op assessment for circulation and tissue perfusion teach self-care activity restrictions and positioning (15-30 degrees) the legs for 24 hrs wear compression stockings for 6 weeks
venous thrombosis phlebitis - inflammation of vein wall thrombophlebitis - clot at site of inflammation phlebothrombosis - thrombus from stasis, deviation of intima or hypercoagulability DVT - clot in deep veins complication = PE
risk factors of venous thrombosis bed rest surgery on pt over 40 yrs old leg trauma resulting in cast or immobilization previous venous insufficiency obesity oral contraceptives malignancy
virchow's triad 1 stasis of the blood 2 damage to the vessel walls 3 hypercoagulability two of the three must be present for thrombus to form
S&S of venous thrombosis depends on size, location, collateral circulation and existence of other medical problems prominent superficial veins, positive homan's sign pain, redness, warmth or tenderness
med and surg treatment of venous thrombosis goal= prevent thrombus extension and PE, reduce risk of further thrombus formation and reduce discomfort anticoagulants, thrombolytics rest, elevation, warm, moist soaks antiembolism hose
NC for venous thrombosis inspect skin for early signs of breakdown, compare for symmetry in color, warmth, pulses, and circumference, elevate, protect from trauma, massage is contraindicated, extablish a realistic exercise plan,
Chronic venous insufficiency the culmination of long-standing pressure that stretches the veins and damages the valves
Chronic venous insufficiency S&S edema around ankles, RBCs seep into the tissues and combine with metabolic wastes and give the tissues a brownish color called stasis dermatitis around the ankles, ulcers develop on medial malleolus, ulcers sometimes necessitate amputation, heaviness or full ache in calf or thigh, skin temp is cool and nails are normal, cyanosis of feet and ankles when in dependent position
Chronic venous insufficiency TX compression stockings (contraindicated if arterial blood flow is poor), Unna boots, hyperbaric o2 chamber, goal: preserve the extremity by stimulating granulation tissue in the ulcer
Chronic venous insufficiency NC elevate legs when sitting, wear antiembolism stockings, monitor for signs of infection, pt education
lymphangitis acute inflammation of the lymphatic channels, usually caused by streptococcus
lymphangitis S&S enlargement of lymph nodes along the lymphatic channel, tenderness, red streak from the infected wound extends up along the channel, fever, chills, abscess with necrotic, suppurative discharge
lymphangitis TX antimicobials, i&d, warm, wet dressings, support hose
lymphangitis NC pain relief, elevation of extremity, support hose used for several months after to prevent lymphedema
ugh its done
Created by: nursingTSJC2013