CARE OF PATIENTS WITH ATHEROSCLEROSIS, PERIPHERAL ARTERIAL DISEASE AND ANEURYSMS

Question 1

Thickening, or hardening, of the arterial wall that is often associated with aging

Answer 1

Arteriosclerosis

Question 2

type of arteriosclerosis
Which Involves the formation of plaque within the arterial wall
It is the Leading risk factor for cardiovascular disease
Usually affects larger arteries: coronary, aorta, carotid, vertebral, renal, iliac, femoral, or combo
Plaque protrudes into vessel lumen and partially/completely obstructs bloodflow through artery which means tissues either not getting as much blood flow or not getting any blood flow
Another issue: plaque becomes calcified: rupture causes thrombosis/blood clot obstructing vessel lumen causing inadequate perfusion and oxygenation to distal tissues
Plaque: stable/unstable
suddenly block blood vessel resulting in cardiac ischemia and infarction: MI

Answer 2

Atherosclerosis

Question 3

Some modifiable/not
Low HDL-C (high density lipoprotein) - good cholesterol; causes chemical injury to vessel wall
High LDL-C (low density lipoprotein) - bad cholesterol; causes chemical injury to vessel way
causes chemical injury to vessel way - may also be caused by renal failure/carbon monoxide from cig smoking
Increased triglycerides
Genetic disposition - big one; major effect on development of atherosclerosis; have familial hyperlipidemia and has higher serum lipids: higher risk for it
Diabetes mellitus: if have severe DM and severe hyperglycemia: due to microvascular damage and increase LDL and triglycerides and arterial damage
Obesity
Sedentary lifestyle
Smoking
Stress
African-American or Hispanic ethnicity
Older adult - natural

Answer 3

Risk factors for atherosclerosis

Question 4

Progress for yrs before s/s appear - identify at risk via lab screening
Lab assessment:
Interventions:

Answer 4

Atherosclerosis - assessments and interventions

Question 5

Elevated lipids (cholesterol and triglycerides)
Total serum cholesterol
LDL (bad) cholesterol
HDL (good) cholesterol
Low risk people 20 years age and older have total serum eval once every 5 yrs and more frequently for those with multiple risk factors and older than 40

Answer 5

Lab assessment:

Question 6

Should be below 200 mg/dL

Answer 6

Total serum cholesterol

Question 7

Increased levels indicate increased risk for atherosclerosis and CAD
Should be < 130

Answer 7

LDL (bad) cholesterol

Question 8

Increased levels, lower your risk of CAD
Should be >50

Answer 8

HDL (good) cholesterol

Question 9

Lifestyle modification such as stop smoking, weight management, exercise and nutrition - lower cholesterol, lipids, decrease risk for CAD
Drug therapy: Includes Statins or other lipid-lowering agents

Answer 9

Interventions:

Question 10

If lifestyle issues not causing cholesterol to adequately respond provide cholesterol lowering agent - commonly statin
Common statin examples:
Reduce cholesterol synthesis in the liver and increase clearance of LDL (bad) from the blood
Contraindicated in active liver disease or during pregnancy
Discontinued if the patient experiences muscle cramping (can happen - educate about this) or elevated liver enzyme levels (check labs)
Avoid grapefruit and grapefruit juice
First thing do is nutrition therapy; this given when cholesterol not responsive

Answer 10

Statins (HMG-CoA)

Question 11

Lovastatin (Mevacor)
Atorvastain (Lipitor)
Simvastatin (Zocor)
Rosuvastatin (Crestor)
Pravastatin (Pravachol)

Answer 11

Common statin examples:

Question 12

Progresses slowly
Chronic condition occurring with partial or total arterial occlusion - not getting adequate blood flow - anything below occlusion not get good below flow and everything below it affected
Causes Decreased perfusion to lower extremities
Atherosclerosis is the most common cause
Clinical manifestations:
Imaging assessment:

Answer 12

Peripheral artery disease (PAD)

Question 13

Intermittent claudication
Rest pain
Loss of hair on the lower calf, ankle and foot - where blood flows hair grows; no hair not adequate blood flow
Dry, scaly, dusky, pale, or mottled skin (over time from inadequate perfusion) - not adequate perfusion will have pale skin; look at both extremities
Thickened toenails - thick ridges
With severe disease

Answer 13

Clinical manifestations: - Peripheral artery disease (PAD)

Question 14

Magnetic resonance angiography (MRA) can assess blood flow in the peripheral arteries

Answer 14

Imaging assessment: - Peripheral artery disease (PAD)

Question 15

cramping, burning muscle discomfort or pain occurs during activity, stops after rest

Answer 15

Intermittent claudication

Question 16

numbness or burning sensation located in the toes, foot arches, forefeet, or heels that awakens patients at night and is usually relieved by placing the extremity in a dependent position (below the heart)
Pain at rest - indicates disease further at rest

Answer 16

Rest pain

Question 17

Very cold, cyanotic, and darkened extremity; posterior tibial pulse is most sensitive and specific indicator of arterial function; check foot pulses and have adequate perfusion; if further progressed may not feel pulses may need doppler; note signs of ulcer formation

Answer 17

With severe disease

Question 18

Try nonsurgical before surgical because less invasive
Exercise
Positioning
Promote vasodilation
Promote vasodilation
Drug therapy for PAD
Control BP/HTN -
Invasive nonsurgical procedures that improve arterial blood flow
Surgical management/procedure

Answer 18

Interventions for PAD

Question 19

Improve arterial blood flow to affected leg through build up of collateral circulation - provides blood to affected area through smaller blood vessels that developed to compensate for occluded blood vessels

Answer 19

Exercise

Question 20

To promote circ
Avoid crossing legs and wearing restrictive clothing
Elevate legs/feet but avoid raising above the heart level
extreme elevation slows arterial blood flow to the feet

Answer 20

Positioning

Question 21

Achieved by provided warmth to extremity and preventing long-term exposure to cold
Avoid cold exposure to the affected extremity with warm socks and room temperature modulation
Avoid applying direct heat (heating pad, hot water) to the limb
Avoid emotional stress, caffeine, and nicotine (all can cause vasoconstriction)

Answer 21

Promote vasodilation

Question 22

Hemorheologic agents Pentoxifylline (Trental): increases flexibility of RBC and decreases viscosity by inhibiting platelet aggregation and decreasing fibrinogen increasing blood flow to extremities
Antiplatelet agents ASA (aspirin), Clopidogrel (Plavix)
Sometimes take both

Answer 22

Drug therapy for PAD

Question 23

improves tissue perfusion - maintains pressure adequate to perfuse periphery but not constrict vessels - not want constrict more than already are

Answer 23

Control BP/HTN -

Question 24

Percutaneous transluminal angioplasty (PTA):
Mechanical rotational abrasive Atherectomy -

Answer 24

Invasive nonsurgical procedures that improve arterial blood flow

Question 25

arterial puncture in groin and 1+ arteries dilated with balloon advanced through cannula - adv into occluded/stenosed artery; when successful opens vessel and improves arterial blood flow; must have occlusions/stenosis to have this procedure - accessible to catheter - get to this through catheter in cath lab; reocclusions can occur - can happen quickly depending on pat and what going on
Blood flow comes back and feel so much better in regards to pain

Answer 25

Percutaneous transluminal angioplasty (PTA):

Question 26

roblater device designed to scrape plaque from inside artery while minimizing damage to vessel surface; useful at popliteal artery/below
Anticoag before and/or during procedure
Blood flow comes back and feel so much better in regards to pain

Answer 26

Mechanical rotational abrasive Atherectomy -

Question 27

Severe pain that interferes with ability work/at threat for losing limb
Arterial revascularization - increases arterial bloodflow; graft prepared for pat and used to reopen artery; put on bypass and use graft to reopen artery to get blood flow going again to extremities

Answer 27

Surgical management/procedure

Question 28

Occlusions may be sudden and dramatic
Caused by embolus or thrombus
More common in lower extremities but can affect UE
Most patients with an embolic occlusion have had a recent acute MI and/or atrial fibrillation - get on anticoag because not want emboli to cause occlusion; most often emboli from heart
Manifestations
“Six P’s” of ischemia - manifestations
Interventions

Answer 28

Acute peripheral arterial occlusion

Question 29

Embolus is the most common cause - piece clot that travels and lodges in new area

Answer 29

Caused by embolus or thrombus

Question 30

cool or cold extremity, pulseless, and mottled affected extremity appearance

Answer 30

Manifestations - Acute peripheral arterial occlusion

Question 31

pain, pallor, pulselessness, paresthesia, paralysis, poikilothermy (coolness)

Answer 31

“Six P’s” of ischemia - manifestations

Question 32

Prompt treatment is essential to avoid permanent damage or loss of an extremity - no blood flow occurring quickly where losing O2 to tissues needs be taken care of
Anticoagulant therapy (Heparin) - start IV hep drip
Surgical therapy: embolectomy or thrombectomy - be performed to remove occlusion - small incision followed by surgical opening into artery and catheter inserted into artery to retrieve embolus

Answer 32

Interventions - Acute peripheral arterial occlusion

Question 33

Permanent localized dilation of an artery, which enlarges the artery to at least two times its normal diameter - tend occur at specific anatomic sites
Occurs when middle layer/media of artery weakened producing stretching effect of inner layer/intima and outer layers of artery - as artery widens tension in wall increases causing further widening which enlarges aneurysm increasing risk for arterial rupture
Elevated BP also increases risk of enlargement and early rupture; dissecting aneurysm: aneurysm enlarges, blood is lost and blood flow to organs is diminished
Types
Rupture is the most frequent complication and is life threatening because abrupt and massive hemorrhagic shock results - critically ill; risk for hypovolemic shock caused by hemorrhage - more frequent comp
Symp seen in pats with aneurysms caused by it exerting pressure on surrounding sturectures or by rupturing
Etiology
Imaging
Size of the aneurysm and presence of symptoms determines patient management - nurses role: perform frequent pat assessments including: BP, pulse, peripheral circ checks
Nonsurgical management
Surgical management - elective/emergency depending on what going on

Answer 33

Aneurysms

Question 34

Abdominal aortic aneurysms (AAAs) account for most aneurysms seen, commonly asymptomatic, and frequently rupture
Thoracic aortic aneurysms (TAAs) - other seen; not as common; diff to diagnose and surgically manage
Lot asymptomatic when aneurysm first discovered; might not know have it until have screening and find it; sometimes have symp

Answer 34

Types

Question 35

Clinical manifestations: Known assess for abdominal, flank, or back pain that is usually steady, with a gnawing quality, is unaffected by movement, and may last for hours or even days; prominent pulsation in the upper abdomen - slightly to left midline between xiphoid process and umbilicus (do not palpate any pulsations because risk for rupture) - can auscultate for bruit

Answer 35

Abdominal aortic aneurysms (AAAs) account for most aneurysms seen, commonly asymptomatic, and frequently rupture

Question 36

Pain described as tearing, ripping, and stabbing and located in the chest, back, and abdomen; symptoms of hypovolemic shock; nausea, vomiting, and apprehension, hypotension, sweating, anxiety, decreased LOC, oliguria, loss distal pulses, sometimes dysrhythmias

Answer 36

Rupture is the most frequent complication and is life threatening because abrupt and massive hemorrhagic shock results - critically ill; risk for hypovolemic shock caused by hemorrhage - more frequent comp

Question 37

Atherosclerosis - most common cause aneurysms
HTN - contributes to it
Hyperlipidemia - contributes to it
Smoking - contributes to it
Age, gender, fam history plays role in developing aneurysms

Answer 37

Etiology

Question 38

CT scan with contrast is the standard tool for assessing the size and location of aneurysms
Sometimes US used but CT is gold standard to look at aneurysms

Answer 38

Imaging

Question 39

Desired outcome: Monitor growth and maintain BP at a normal level to decrease the risk for rupture - increased BP can increase risk for rupture
If have HTN treated with antihypertensive drug, treat decrease enlargement and risk for early rupture
Small aneurysms/asympatomatic frequent US/CT scan necessary to monitor growth of aneurysms to see if it growing
Remind pats that follow up with scheduled tests to monitor growth imp - not want miss if getting bigger; want them know s/s of aneurysms so report immediately

Answer 39

Nonsurgical management

Question 40

Rupturing aneurysms: emergency surgery
Smaller aneurysms that producing symp: advised have elective surgery
Resection or repair (aneurysmectomy) - most common treatment for AAA; mortality rate for elective rate is high and increases risk for emergency surgery
High risk
Endovascular stent graft - improved mortality rate and shortened hospital stay who have AAA repair

Answer 40

Surgical management - elective/emergency depending on what going on

Question 41

Now Procedure of choice on elective/emergency basis; stents inserted percutaneously and want avoid abdominal incisions decreasing risk of prolonged post-op recovery; have big abd incisions lot stuff can happen
Post-op: sim to post-angiogram - not nearly as extensive as open repair

Answer 41

Endovascular stent graft - improved mortality rate and shortened hospital stay who have AAA repair