Cardiovascular IV: Vascular Disorders

Vascular System 1. Function of the vascular system consist of 2 interdependent system a. Right side of heart pumps blood through the lungs to the pulmonary circulation and then to the left side of the heart b. Left side of the heart pumps blood to the other body tissues through systemic circulation c. Blood vessels in both systems channel the heart to the tissues back to the heart d. Contraction of the ventricles is the driving force that moves the blood through the vascular system 2. Arteries: distribute oxygenated blood from the left side of the heart to the tissues 3. Veins: carry deoxygenated blood from the tissue to the right side of the heart 4. Capillaries: connects the arterial and the venous system, prevent the exchange of nutrients and metabolic waste between the circulatory system and the tissues 5. Lymphatic vessels: transfer lymph and tissue fluid from the interstitial space through the systemic veins Peripheral Blood Flow 1. Flow rate = P/R 2. Movement of fluid across the capillary wall; hydrostatic and osmotic force 3. Hemodynamic resistance a. Blood viscosity b. Vessel diameter 4. Regulation of peripheral vascular resistance 5. Blood flows from arterial to venous system Gerontologic Considerations Aging produces changes in the walls of the blood vessels that affect the transport of oxygen and nutrients to the tissues. The intima thickens as a result of cellular proliferation and fibrosis. Elastin fibers of the media become calcified, thin, and fragmented, and collagen accumulates in the intima and the media. These changes cause the vessels to stiffen, which results in increased peripheral resistance, impaired blood flow, and increased left ventricular workload. Assessment 1. Health history and clinical manifestations a. Intermittent claudication b. Rest pain often worsens at night c. Changes in skin and appearance i. Gangrene can be the first sign of arterial insufficiency d. Pulses 2. Aging changes Assessment (Table 31-1) Characteristic Pain Arterial Intermittent claudication to sharp, unrelenting, constant Venous Aching, cramping

Arterial Disorders 1. Arteriosclerosis 2. Atherosclerosis: 2 types-fatty streaks and fibrous plaque a. Can occur anywhere on the artery Risk Factors for Atherosclerosis and Peripheral Arterial Disease (PAD)

Modifiable
Nicotine (ie, tobacco smoking Age
or chewing)

Nonmodifiable
Gender Familial predisposition/genetics

Diet (contributing to
hyperlipidemia)

Hypertension Diabetes (speeds the

atherosclerotic process by thickening the basement membranes of both large and small vessels)

Obesity Stress Sedentary lifestyle C-reactive protein Hyperhomocysteinemia

Common Sites of Atherosclerotic Obstruction 1. Clinical Manifestations a. Depends of the organ or tissue affected i. Coronary heart disease ii. Cerebrovascular stroke iii. Aorta aneurysm iv. Renovascular - ESRD Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: Assessment 1. Health history 2. Medications 3. Risk factors 4. Signs and symptoms of arterial insufficiency 5. Claudication and rest pain 6. Color changes in skin 7. Weak or absent pulses 8. Skin changes and skin breakdown 9. Pain associated with peripheral arterial insufficiency is chronic, continuous, and disabling. It limits activity and work responsibility, disturb sleep, it alters the patient's sense of well-being. Patient are often depressed, irritable, and enable to exert energy necessary to execute prescribed therapy.

Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: Diagnoses 1. Altered peripheral tissue perfusion related to compromised circulation 2. Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen 3. Risk for impaired skin integrity related to compromised circulation 4. Knowledge deficiency regarding self-care activities
Nursing Process: The Care of the Patient with Peripheral Arterial Insufficiency: Planning 1. Major goals include increased arterial blood supply, promotion of vasodilatation, prevention of vascular compression, relief of pain, attainment or maintenance of tissue integrity, and adherence to self-care program. Improving Peripheral Arterial Circulation 1. Exercises and activities: walking, graded isometric exercises. Consult primary health care provider before prescribing an exercise routine. 2. Positioning strategies 3. Temperature: effects of heat (promotes arterial flow) and cold (vasoconstriction) 4. Smoking cessation 5. Stress reduction Maintaining Tissue Integrity 1. Protection of extremities and avoidance of trauma (especially in patients with vision problems) 2. Regular inspection of extremities with referral for treatment and follow-up for any evidence of infection or inflammation 3. Good nutrition, low-fat diet a. Key nutrients that plays a key role in wound healings are: protein, Vitamin C, Vitamin A, Zinc 4. Weight reduction as necessary Medical Management 1. Prevention: modifying risk factors 2. Exercise program 3. Medications a. Lipitor b. Zocar c. Pentoxifylline (Trental) and cilostazol (Pletal) d. Use of antiplatelet agents 4. Surgical management: a. Inflow procedure: provides blood flow to aorta into the femoral artery (disease of aorta) b. Outflow procedure: provides blood flow to the vessels below the femoral artery (peripheral artery occlusion disease) c. Percutaneous transluminal angioplasty procedure: complication is bleeding, ruptured vessel 5. Radiologic interventions

Pulses

Diminished or absent

Present, but may be difficult to palpate through edema

Pigmentation in gait or area (area of medial and lateral malleolus), skin thickened and tough, may be reddish blue, frequently with associated dermatitis

Skin Dependent rub orelevation pallor of characteristics foot, dry, shiny skin, cool-to-cold temperature, loss of hair over toes and dorsum of foot, nails thickened and ridged Ulcer characteristics Location Tip of toes, toe webs, heel or other pressure areas if confined to bed

Medial malleolus; infrequently lateral malleolus or anterior tibial area

Pain
Depth of ulcer Shape Ulcer base

Very painful
Deep, often involving joint space Circular Pale to black and dry gangrene

Minimal pain if superficial or may be very painful

Superficial Irregular border Granulation tissuebeefy red to yellow fibrinous in chronic long-term ulcer Moderate to severe

Leg edema

Minimal unless extremity kept in dependent position constantly to relieve pain

Diagnostic Evaluation 1. Continuous-wave Doppler ultrasound 2. Color Flow Duplex Image 3. Exercise Testing 4. Computed Tomography 5. Computed Tomography Angiography 6. Magnetic Resonance Angiography 7. Angiography 8. Air Plethysmography 9. Contrast Phlebography 10. Lymphangiography 11. Lymphoscintigraphy

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Buergers Disease: Thromboangiitis Obliterans 1. Recurring inflammatory process of the small and intermediate vessels of (usually) the lower upper extremities; probably an autoimmune disorder. Results in thrombi formation and occlusion of vessels 2. Most often occurs in men ages 20-35 3. Risk or aggravating factor: tobacco 4. Progressive occlusion of vessels results in pain, ischemic changes, ulcerations, and gangrene. 5. Gerontologic considerations

Raynaud's Disease 1. Intermittent arterial vaso-occlusion, usually of the fingertips or toes 2. Raynaud's phenomenon is associated with other underlying disease, such as scleroderma 3. Manifestations: sudden vasoconstriction results in color changes, numbness, tingling, and burning pain 4. Episodes are usually brought on by a trigger such as cold or stress 5. Occurs most frequently in young women 6. Protect from cold/other triggers. Avoid injury to hands/fingers.

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Disorders of the Aorta

Wednesday, January 18, 2012 1:31 PM

Disorders of the Aorta 1. Aortoiliac disease: a. Men may experience impotent b. Decrease or absent femoral pulses 2. Aneurysms a. Thoracic aortic aneurysm b. Abdominal aortic aneurysm 3. Aortic dissection Aneurysm 1. Localized sac or dilation formed at a weak point in the wall of the artery 2. Classified by its shape or form 3. Most common forms of aneuryms a. Saccular: project from one point of the vessel b. Fusiform: entire arterial segment becomes dilated c. Mycotic aneurysms: very small aneuryms due to localized infections 4. Can rupture, leading to hemorrhage and death

Abdominal Aortic Aneurysm 1. Most common cause is atherosclerosis 2. More common among Caucasians, affects men 4X more often than woman 3. Most prevalent in elderly patients 4. Most occur below the renal artery (infrarenal aneurysms) 5. Death, from rupture if left untreated Abdominal pain in back or abdomen. Pain is localized in mid or lower abdomen. Falling B/P, decrease hematocrit. Clinical Manifestations 1. Asymptomatic 2. Heart beating in the abdomen when lying down 3. Palpate abdominal mass or abdominal throbbing 4. Cyanosis and mottling of the toes Assessment & Diagnostic Findings 1. Pulsatile mass in the middle and upper abdomen 2. Systolic bruit 3. Duplex ultrasonography or CT: determines size, length, and location of aneurysm Medical Management 1. Pharmacologic therapy a. Controlling blood pressure including diuretics, BB, ACE-I, Angiotensin II receptor antagonists, & CCB 2. Surgical management

Thoracic Aortic Aneurysm 1. 85% are caused by atherosclerosis 2. Occur most frequently in men ages 40-70 3. Thoracic is most common site for a dissecting aneurysm 4. About 1/3 die of rupture Clinical Manifestations 1. Variable and depends on how rapid the aneurysm dilates 2. Some are asymptomatic 3. Pain most prominent symptom: pain is usually constant and boring and may occur when in supine position 4. Other symptoms: a. Dyspnea b. Cough, hoarseness, Stridor, or weakness or complete loss of the voice (aphonia) c. Dysphagia due to pressure on esophagus Assessment & Diagnostic Findings 1. Cyanosis, unequal pupils 2. Chest x-ray, TEE, and CT a. Looking for abnormalities in the superficial veins of the neck, chest, and arms. Medical Management a. Surgical repair b. Controlling blood pressure and correct risk factors

Dissecting Aorta 1. A tear develops in the intima or the media degenerates 2. 3X more common in men than in women 3. Most common in the 50-70 yr. old age group Pathophysiology 1. Poorly controlled HTN, blunt chest trauma, & cocaine use 2. Caused by a rupture in the intimal layer 3. Arteries branching from the involved area shear & occlude 4. Ascending aortic dissection has the highest mortality rate Clinical Manifestations 1. Severe & persistent pain (tearing or ripping feeling in the back, chest, and abdomen) 2. Pallor, diaphoresis, tachycardia, elevated BP (markedly different from one arm to the other) 3. Patient will have neuro, gastro, and cardio symptoms Assessment & Diagnostic Findings 1. Early diagnosis is diffucult 2. Arteriography, CT, TEE, duplex ultrasonography, & MRI Medical Management 1. Same as thoracic aortic aneurysms (depends on the type) Nursing Management 1. Same as an aortic aneurysm requirement

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Venous Thromboembolism (DVT)

Wednesday, January 18, 2012 12:49 PM

Venous Thromboembolism (DVT) 1. Pathophysiology 2. Risk factors - See Chart 31-7 a. Endothelial damage b. Venous stasis c. Altered coagulation 3. Manifestations a. Deep veins b. Superficial veins Assessment & Diagnostic Findings 1. Health history & risk factors 2. Limb pain, heaviness feeling, functional impairment, ankle engorgement, & edema; differences in leg circumference, temperature elevation, tenderness or superficial thrombosis Preventive Measures 1. Elastic hose 2. Pneumatic compression devices 3. Subcutaneous heparin or LMWH, warfarin (Coumadin) for extended therapy 4. Positioning: periodic elevation of lower extremities 5. Exercises: active and passive limb exercises, deep-breathing exercises 6. Early ambulation 7. Avoid sitting/standing for prolonged periods; walk 10 minutes every 1-2 hours. Medical Management 1. Pharmacologic Therapy a. Anticoagulant therapy (Chart 31-8 contraindications) Surgical Management 1. Thrombectomy 2. Balloon angioplasty & stent placement Nursing Management 1. Assessing & monitoring anticoagulant therapy 2. Monitoring & managing potential complications

Venous insufficiency 1. Obstruction of the venous valves in the legs or a reflux of blood through the valves a. Back flow of blood 2. Superficial and deep vein leg can be involved in venous insufficiency 3. Venous hypertension can occur when there has been a prolonged increase in venous pressure. This can occur with DVT 4. Duplex ultrasonography 5. Chronic venous insufficiency is characterized by pain-aching or heaviness a. Foot and ankle may be edematous b. Ulceration on the area of the medial or lateral area of the ankle (discoloration) c. Neuropathy d. And ulcers are usually painless Clinical Manifestations 1. Chronic venous stasis, edema 2. Altered pigmentation changes 3. Pain 4. Stasis dermatitis Complications 1. Venous stasis ulceration: most serious complication chronic venous insufficiency and can be associated with other conditions affecting the circulation of the lower extremities a. Cellulitis or dermatitis may complicate the care 2. Stasis ulcer develops as a rupture of the small skin veins and subsequent ulcerations when the vessels rupture, the RBCs escape into the surrounding tissue and then degenerate, leaving a browning discoloration of the tissue. a. The pigmentation and ulceration usually occurs in the lower part of the extremities. (around the ankle area) b. Skin becomes dry, cracked, itchy, subcutaneous tissue fibrous, and atrophy c. Risk for injury and infection in extremities are increased 3. Atrial ulceration are small circular, deep ulcerations on the tip of the toes or in the web spaces between the toes Management 1. Reducing venous stasis & preventing ulcerations. 2. Measures to increase venous blood flow a. Antigravity activities b. Elevating the leg & compression of superficial veins with elastic compression stockings

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Varicose Veins 1. Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves a. Can cause backflow of blood 2. Occurs most commonly in the lower extremities, the saphenous veins, or the lower trunk a. Can also occur in other places (ex. Esophagus) 3. Occur in up to 60% of the adult population in the US 4. Most common in women & in people whose occupations require prolonged standing 5. Hereditary weakness of the vein wall, commonly occurs in members of same family Pathophysiology 1. Primary (without involvement of deep veins) or secondary (resulting from obstruction of deep veins) 2. Reflux of venous blood results in venous stasis Clinical Manifestations 1. Dull aches, muscle cramps, increased muscle fatigue in the lower legs, ankle edema, feeling of heaviness of the legs 2. Nocturnal cramps Assessment & Diagnostic Findings 1. Duplex scan, air plethysmography, venography Prevention 1. Avoid activities that cause venous stasis Medical management 1. Ligation & stripping 2. Thermal ablation 3. Sclerotherapy: inject irritating chemical in vein to produce a localized phlebitis Nursing management 1. Analgesics 2. Inspecting dressings 3. Exercises assistance

Nursing Process: The Care of the Patient with Leg Ulcers: Assessment 1. History of the condition 2. Treatment depends upon the type of ulcer. 3. Assess for presence of infection. 4. Assess nutrition. Medical Management 1. Anti-infective therapy is dependent upon infecting agent. a. Oral antibiotics are usually prescribed 2. Compression therapy 3. Dbridement of wound 4. Topical therapy 5. Wound Dressing 6. Stimulated Healing 7. Hyperbaric Oxygenation (HBO) Nursing Process: The Care of the Patient with Leg Ulcers: Diagnoses 1. Impaired skin integrity related to vascular insufficiency 2. Impaired physical mobility related to activity restrictions of the therapeutic regimen and pain 3. Imbalanced nutrition less than body requirements, related to increased need for nutrients that promote wound healing Collaborative Problems/Potential Complications 1. Infection 2. Gangrene Nursing Process: The Care of the Patient with Leg Ulcers: Planning 1. Major goals include restoration of skin integrity, improved physical mobility, adequate nutrition, and absence of complications. Mobility 1. With leg ulcers, activity is usually initially restricted to promote healing. 2. Gradual progression of activity 3. Activity to promote blood flow; encourage patient to move about in bed and exercise upper extremities. 4. Diversional activities 5. Pain medication prior to activities
Other Interventions 1. Skin integrity a. Skin care/hygiene and wound care b. Positioning of legs to promote circulation c. Avoidance of trauma 2. Nutrition a. Measures to ensure adequate nutrition b. Adequate protein, vitamins C and A, iron, and zinc are especially important for wound healing. c. Include cultural considerations and patient teaching in the dietary plan.

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Lymphatic Disorders and Case Study

Wednesday, January 18, 2012 1:39 PM

Lymphatic Disorders
1. Lymphangitis: inflammation/infection of the lymphatic channels 2. Lymphadenitis: inflammation/infection of the lymph nodes 3. Lymphedema: tissue swelling related to obstruction of lymphatic flow a. Primary: congenital b. Secondary: acquired obstruction c. Especially marked when extremity is in a deep pitted position, initially edema is soft and pitting, as condition progresses the edema becomes firm, non-pitting, unresponsive to treatment 4. Cellulitis: infection and swelling of the skin tissues a. S&S: swelling, redness, pain, fever & chills, sweating b. Often misdiagnose and usually as recurrent thrombophlebitis or chronic renal insufficiency Medical management 1. Reduce & control the edema & prevent infection 2. Active & passive exercise assist in moving lymph into the blood stream 3. External compression devices 4. Manual lymphatic drainage Pharmacologic therapy 1. Diuretic 2. Antibiotic

Surgical management: surgery is performed when edema is severe and uncontrollable 1. Excision with skin grafting 2. Surgical relocation into the deep lymphatic tissue Nursing Management 1. Management of skin grafts & flaps 2. Antibiotics therapy 3. Constant elevation of the affected extremity & observation for complications 4. Education

Case Study The nurse is completing the Admission Assessment for an 87-year-old patient admitted for treatment of arterial ulcers in the lower extremities. Upon examination, the patient has areas of ulceration on both legs with yellowish drainage, and describes increased pain when ambulation, that usually decreases with rest. The following admission orders were written for this patient: Vital signs every 4 hours Bed rest with bathroom privileges Consult to Wound Ostomy RN for wound management Amoxicillin 500 mg PO every 6 hours Correlate the patients clinical manifestations with pathophysiology of arterial ulcers. The Wound RN consults the patient, and orders hydrocolloid dressings. What is the rationale for this type of dressing? What dietary teaching is indicated in this patient? Case Study Answers 1. Correlate the patients clinical manifestations with pathophysiology of arterial ulcers. a. The pain on ambulation, intermittent claudication, and ulcers are secondary to the inadequate oxygen and other nutrients in the tissues. Arterial ulcers are open and inflamed with drainage or eschar. 2. The Wound RN consults the patient, and orders hydrocolloid dressings. What is the rationale for this type of dressing? a. Hydrocolloids promote growth of granulation and re-epithelialization. These dressings also provide a barrier for protection because they adhere to the wound bed and surrounding tissue. 3. What dietary teaching is indicated in this patient? a. The patient needs to be instructed on a diet high in protein, vitamins A and C, and zinc to promote healing. Because this patient is elderly and at risk for anemia, iron intake may need to be increased. NCLEX Question of the Day A patient is being instructed on the use of graduated compression stockings. The nurse should teach the patient that the stockings should be: A. Alternately kept on 2 hours and off 2 hours B. Worn only at night when activity is lessened C. Put on before getting out of bed in the morning D. Left in place until the physician advises otherwise Answer C

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