vascular disorders for exam 4
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| layers of arteries | 1. intima - inner most layer
2. media
3. tunica
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| 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
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| 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
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| 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
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| nursing assessment of vascular system Pain | Described as tenderness, heaviness, fullness in the extremities
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| Intermittent claudication | decreased perfusion of major muscle groups - tightness, burning, fatigue, aching, cramping
pain is better with rest
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| 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
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| 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
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| 10% of people with DVT | develop an PE
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| S&S of aneurysm | hoarseness
dysphagia
dyspnea
abd or back pain
swelling of the head or arms
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| functional assessment | determines the effect of the disease process on the pts life
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| arterial vs venous | arterial complications involve multiple areas and venous complications are more localized, usually in lower extremities
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| arterial vs venous | rubor - arterial occulsive
pallor - arterial vasoconstriction
brownish or cyanotic - venous
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| stasis dermatitis arterial vs venous | venous stasis - begins in ankle area
arterial - begins in toes
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| capillary refill | more than 3 seconds denotes reduction in peripheral perfusion
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| temperature arterial vs venous | arterial - cool
venous - warm
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| dependent edema | result of systemic disorders, lymphatic dysfunction, DVT, or chronic venous insufficiency
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| 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
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| upper extremity peripheral pulses | brachial, ulnar, radial
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| lower extremity peripheral pulses | femoral, popliteal, dorsalis pedis, posterior tibial
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| Homan's sign | flex the knee and sharply dorsiflex the foot, pain is a positive sign and could indicate DVT
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| bruits | can be the presence of an aneurysm or due to chronic arterial occlusive disease
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| plethysmography | used to detect DVT
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| exercise treadmill test | carefully monitor
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| 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
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| 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
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| pts are restricted to bed | if they have leg ulcers, gangrene or thrombotic occlusion
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| 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
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| correct placement of elastic stockings | compresses superficial veins resulting in improved blood flow to the deeper veins
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| elastic stockings | are best applied in the morning before rising from bed
remove for 20 minutes twice a day - inspect skin at this time
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| intermittent pneumatic compression | mimics the muscle pumping of the lower extremities, prevents venous pooling and stimulates circulation
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| lowering extremities | enhances arterial blood supply
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| elevating extremities | promotes venous return and reduces venous stasis
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| thermotherapy | heat - vasodilation
cool - vasoconstriction
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| 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
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| 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
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| percutaneous transluminal angioplasty PTA | relieves arterial stenosis
complications - hematoma, embolus, arterial dissection, allergic reaction to dye
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| endarterectomy | plaque is stripped away from intima; vessel is surgically closed
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| sympathectomy | improves vascular circulation in intermittent claudication; sympathetic ganglia is excised; not used when poor circulation is realated to atherosclerotic vessel
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| 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
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| sclerotherapy | vericose veins, cosmetic procedure
complications - PE, thrombosis, injection site necrosis, vasospasm, hemolysis, allergic reaction
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| 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
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| 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
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| 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
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| 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
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| warfarin | anticoagulant
SE: bruising, hemorrhage, nausea, anorexia
NC: check PT/INR before each dose, monitor for bleeding, do not take aspirin
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| aspirin | antiplatelet
SE: GI irritation, tinnitus, pruritus, HA, bleeding
NC: assess for brusing and bleeding, give with milk or food for GI upset
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| 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
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| glycoprotein IIb/IIIa | antiplatelet
SE: major bleeding
NC: immediately report GI, urinary or puncture site bleeding, stop infusiuon if major bleeding occurs, IV only
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| adenosine diphosphate | antiplatelet
SE: Gi disturbance, rash and TTP?, risk of bleeding, blood dyscrasias?
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| 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
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| 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
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| 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,
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| 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
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| dietary interventions | vitamin B, C and protein are needed to promote healing and improve tissue integrity
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| arterial embolism | usually forms in the heart but can form in any artery with atheromatous plaque
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| 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
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| 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
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| 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
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| 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
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| 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
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| med and surg treatment of peripheral arterial occlusive disease | make life style changes
regular exercise
drug therapy
stenting and endarterectomy
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| 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
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| 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
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| 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!!!!!!!
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| 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
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| 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
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| 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,
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| aneurysms | weakness and stretching of arterial wall
congenital or acquired
Marfan syndrome
ehlers-Danlos syndrome
atherosclerosis
hypertension
syphilis
AAA is most common
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| 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
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| 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
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| pre op care of aneurysm | prepare pt physically and emotionally
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| 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,
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| aortic dissection | small tear in intima permits blood to escape into the space between the intima and media, media splits lengthwise,
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| key aspect of post op surgical care for aortic dissection | keep the blood pressure as low as possible
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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
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| 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,
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| Chronic venous insufficiency | the culmination of long-standing pressure that stretches the veins and damages the valves
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| 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
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| 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
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| Chronic venous insufficiency NC | elevate legs when sitting, wear antiembolism stockings, monitor for signs of infection, pt education
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| lymphangitis | acute inflammation of the lymphatic channels, usually caused by streptococcus
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| 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
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| lymphangitis TX | antimicobials, i&d, warm, wet dressings, support hose
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| lymphangitis NC | pain relief, elevation of extremity, support hose used for several months after to prevent lymphedema
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| ugh | its done
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