Chapter 26 Assessment & Management of Patients w/ Vascular Disorders & Problems of Peripheral Circulation Flashcards
Where does the right side of the heart pump blood to?
This side of the heart pumps blood through the lungs into pulmonary circulation
Where does the left side of the heart pump blood to?
This side of the heart pumps blood to all other body tissues via systemic circulation
Function of the Vascular System
Supplies circulatory needs of tissues
Maintains blood flow & BP
Capillary filtration and reabsorption:
-Hemodynamic resistance
-Peripheral vascular regulating
mechanisms
What is the driving force that moves blood through the vascular system?
Ventricular contraction
Pathology of Peripheral Vascular Disorders
Pump failure = inadequate peripheral blood flow
* Heart Failure with reduced ejection fraction (HFrEF or systolic HF)
* Causes accumulation of blood in the lungs, reduced CO, and inadequate arterial blood flow to tissues
* Heart Failure with preserved ejection fraction (HFpEF or diastolic HF)
* Causes systemic venous congestion and reduced CO
Alterations in blood and lymphatic vessels (reducing flow)
* Arterial - damage or blockage to vessels by atherosclerotic plaque, thromboembolus, infection or inflammatory process, etc.
* Venous – thromboembolus obstructing vein, incompetent venous valves, or reduced effectiveness of surrounding muscles
* Lymphatic – tumor, damage from mechanical trauma, or inflammatory process
Circulatory insufficiency of the extremities
* Most disorders results in ischemia and produces symptoms of pain, skin changes, diminished pulses, and possible edema
Disorders & Diseases Seen in Peripheral Arterial Disease
Aneurysms
Aortic dissection
Embolism & Thrombosis
Raynaud’s phenomenon
Disorders & Diseases Seen in Peripheral Venous Disease
Venous Thromboembolism (VTE)
Venous Insufficiency or Postthrombotic Syndrome
Leg Ulcers
Varicose Veins
Physical Assessment of PAD
Areas to assess: Skin color, temperature, pulses
Expected Assessment Findings
-Cool & pale extremities
-Rubor
-Cyanosis
-Loss of hair, brittle nails, dry or scaling skin, atrophy & ulcerations
-Edema
-Gangrenous changes w/prolonged severe ischemia
Where do arteries distribute blood?
Distributes oxygenated blood from the LT side of the heart to the tissues
Arterioles
The smallest arteries that are generally embedded w/in the tissues
Function of Arterioles
Regulate volume & pressure in arterial system
Regulate blood flow to the capillaries
Arteries & Arterioles Wall Composition
3 layers: The intima, media, & adventitia
The Intima
Inner endothelial layer of arterial wall
Function of the Intima
Provides a smooth surface for contact w/moving blood
The Media
Middle layer made up of smooth muscle & elastic tissue
Function of the Media
Gives the vessel considerable strength
Allows to constrict & dilate to accommodate the blood ejected from the heart during each cardiac cycle (stroke volume)
Maintain an even steady blood flow
The Adventitia
Outer layer of connective tissue
Function of the Adventitia
Control diameter of the blood vessel via contracting & relaxing
How do arterioles offer resistance to blood flow?
Altering their diameter
Capillary Wall Composition
Lack smooth muscle & adventitia
Single layer of endothelial cells
What effect does the thin wall composition of capillaries have on circulation?
Permits rapid & efficient transport of nutrients to the cells & removal of metabolic wastes
What effect does a capillary wall’s diameter (5-10 mcm) have on red blood cell passage?
RBCs must alter their shape in order to pass through this blood vessel
As blood passes through tissue capillaries…
…O2 is removed & CO2 is added
What influences a capillary wall’s diameter?
Changes are passive
Influenced by contractile changes in the blood vessels that carry blood to and from the capillary
Precapillary Sphincter
A cuff of smooth muscle (located near arterioles end of capillary) that is responsible for controlling capillary blood flow (along w/arteriole)
What is the name of the larger blood vessel that capillaries join to form?
Venule
Where do veins distribute blood?
Carries deoxygenated blood from the tissues to the RT side of the heart
Venous System Equivalents of Arteriolar Vessels
Venules: Arterioles
Veins: Arteries
Vena cava: Aorta
Key Differences in Venous Wall Composition
Walls are thinner & less muscular
Layers are not as well-defined
How does the venous wall being thinner & less muscular affect blood flow?
Allows for the vessel to distend more than arteries
Greater distensibility & compliance allows for larger volumes of blood to remain in the veins under low pressure
SNS Stimulation Effect on Venous Blood Flow
Venoconstriction can reduce venous volume & increase volume of blood in the general circulation
Venoconstriction
Constriction of the veins
What happens when skeletal muscle contraction occurs in the extremities?
Creates the primary pumping action to facilitate venous blood flow back to the heart
Function of Lymphatic Vessels
Collects lymphatic fluid from tissues and organs & transports the fluid to the venous circulation
What are the two main structures of the lymphatic vessel system?
The thoracic duct & the right lymphatic duct
Where does the right lymphatic duct primarily convey lymph?
Conveys lymph primarily from the RT side of the head, neck, thorax, & upper arms
Where does the thoracic duct primarily convey lymph?
Conveys lymph from the remainder of the body
Factors that Affect Adequate Blood Flow
Efficiency of the heart to work as a pump, the patency & responsiveness of the blood vessels, & adequacy of circulating blood vol
Function of the Vascular System
Supplying the circulatory needs of tissue
Maintain blood flow & BP
Providing capillary filtration & reabsorption
Hemodynamic resistance
Factors that Affect The % of Blood Flow Received by Individual Organs
Rate of Tissue Metabolism
Availability of Oxygen
Function of the Tissue
When metabolic requirements increase…
…blood vessels dilate to increase the flow of O2 & nutrients to the tissues
When metabolic requirements decrease…
… vessels constrict & blood flow to the tissues decrease
Activities/Factors that Increase Metabolic Demand
Physical activity
Local heat application
Fever
Infection
Activities/Factors that Decrease Metabolic Demand
Rest/decreased activity
Local cold application
Cooling of the body
Ischemia
Lack of blood supply
What can cause ischemia to occur?
Ischemia can be caused if the blood vessels fail to dilate in response to accommodate for increased metabolic needs
Order of Blood Flow
LT side of the heart-> aorta-> arteries-> arterioles-> capillaries-> venues-> veins-> vena cava-> RT side of the heart
What is the cause of the unidirectional blood flow?
The differences in blood pressure between the arterial & venous system changes
Arterial vs Venous BP
Arterial BP: 100mmHg
Venous BP: 40 mmHg
(Fluid flows from an area of higher pressure->lower press)
When resistance increases…
…a greater press is req to maintain the same degree of flow
What happens if arterial pressure is chronically elevated?
Myocardium atrophies to compensate for the greater contractile force
Factors that Increase Blood Flow
Blood viscosity increases
Diameter of the vessels become greater than normal
Segments of the blood vessel are constricted
Bruit
Adventitious sound of blood flowing via narrowed portion of an artery
Hydrostatic Force
A driving pressure that is generated by the blood pressure
Osmotic Pressure
The pulling force created by plasma proteins
Which type of pressure is exerted at the arterial end of the capillary?
Hydrostatic pressure
Drives fluid out of the capillary-> tissue space
Which type of pressure is exerted at the venous end of the capillary?
Osmotic pressure
Osmotic pressure is greater than hydrostatic pressure->net reabsorption of fluid from the tissue space back into the capillary
Function of the Arterial End of the Capillary
Filtration
What happens to the excess filtrated fluid?
Enters lymphatic circulation
Edema
Accumulation of excess interstitial fluid
Possible Causes of Edema
Damage to capillary walls and subsequent increased permeability
Obstruction of lymphatic drainage
Elevation of venous pressure, or a decrease in plasma protein osmotic force
Function of the Venous End of the Capillary
Reabsorption
The Critical Factor that Determines Resistance in Vascular System
Vessel radius
Which system is responsible for regulating the peripheral vascular system?
SNS
Neurotransmitter responsible for SNS vasoconstriction
Norepinephrine
Increase in SNS activity causes vasodilation or vasoconstriction?
Vasoconstriction
Decrease in SNS activity causes vasodilation or vasoconstriction?
Vasodilation
What is formed from the interaction of renin & angiotensinogen?
Angiotensin I
Which organ is renin synthesized by?
The kidneys
What is angiotensin-converting enzyme (ACE) responsible for?
Converting angiotensin I-> angiotensin II
Is angiotensin II a potent vasodilator or vasoconstrictor?
It is a potent vasoconstrictor (especially arterioles)
Proinflammatory Cytokines
Substances liberated from platelets that aggregate at the damaged vessel site, causing arteriolar vasoconstriction & continued platelet aggregation at injury site
When does inadequate peripheral blood flow occur?
This occurs when the heart’s pumping action becomes inefficient
What does heart failure (HF) w/ reduced LT ventricular ejection fraction cause?
Causes an accumulation of blood in the lungs & reduction of forward flow (CO) -> inadequate arterial blood flow to the tissues
Which type of heart failure is characterized by a REDUCED LT ventricular ejection fraction?
Systolic HF (HFrEF)
What does heart failure (HF) w/ PRESERVED LT ventricular ejection fraction cause?
Causes systemic venous congestion & reduced CO (forward flow)
What type of heart failure is characterized by a PRESERVED LT ventricular ejection fraction?
Diastolic HF (HFpEF)
Thromboembolus
A blood clot that may have been dislodged from the vessel where it originally formed
Effects of a Sudden Arterial Occlusion vs. a Gradual Arterial Occlusion
Sudden: Can cause profound and irreversible tissue ischemia & tissue death
Gradual: Less risk of sudden tissue death due to collateral circulation that may develop-> giving the tissue time to adapt to gradually decreasing blood flow
Factors that Reduce Venous Blood Flow
Thromboembolus obstructing a vein
Incompetent venous valves
Reduction in the effectiveness of surrounding muscle pumping action
Effects of Reduced Venous Blood Flow
Increased venous pressure
Subsequent increase in capillary hydrostatic pressure
Increase of net filtration of fluid out of the capillaries-> interstitial space
Increase in subsequent edema
Gerontological Considerations for Venous Blood Flow
Cellular proliferation & fibrosis-> intima thickens
Elastin fibers of media become calcified, thin, & fragmented
Overall changes cause vessels to stiffen-:
- Increased peripheral resistance
- Impaired blood flow
- Increased ventricular workload-> hypertrophy, ischemia, systolic HF
General Arterial Insufficiency Characteristics
Pain: Intermittent claudication to sharp, unrelenting, constant pain
Pulses: Diminished/absent
Skin:
-Color: Dependent rubor w/ elevation pallor of foot
-Texture: Shiny, dry skin w/ cool to cold temp
-Hair: Loss os har over toes & dorsum of foot
-Nails thickened & ridged
General Venous Insufficiency Characteristics
Pain: Aching, throbbing, cramping
Pulses: Present but may be diff to palpate due to edema
Skin:
-Color: Pigmentation in area of medial & lateral malleolus, may be red & blue (freq associated w/dermatitis)
-Texture: Skin thickened & tough
Arterial Insufficiency Ulcer Characteristics
Location: Tip of toes, web spaces, heel or other pressure points if pt is immobile
Pain: Very painful
Depth of ulcer: Deep, often involving joint space
Shape: Circular
Ulcer base: Pale to black & wet to dry gangrene
Leg edema: Minimal unless kept in dependent position constantly to relieve pain
Venous Insufficiency Ulcer Characteristics
Location: Medial malleolus, lateral malleolus, or anterior tibial area
Pain: Minimal to very painful
Depth: Superficial
Shape: Irregular border
Ulcer base: Granulation tissue
-Beefy red to yellow fibrinous in chronic long-term ulcer
Leg edema: Moderate to severe
Intermittent Claudication
Pain, discomfort, or fatigue is caused by the inability of the arterial system to provide adequate blood flow to the tissues in face of increased demands for nutrients & O2 during exercise
-Described as aching, cramping, or inducing fatigue or weakness that occurs w/some degree of activity
What position can help alleviate intermittent claudication pain?
Placing the extremity in a dependent position reduces the pain
-Some patients may sleep w/affected leg hanging over the side of the bed or sleep in a reclining chair
What is known as the hallmark symptom of PAD?
Intermittent claudication
As the tissues are forced to complete the energy cycle w/out adequate nutrients & O2…
…muscle metabolites & lactic acid are produced
-Muscle metabolites aggravate nerve endings-> causes pain
Approximately what percentage of the arterial lumen must be obstructed before intermittent claudication is experienced?
~50% of the arterial lumen or 75% of the cross-sectional area must be obstructed
What helps alleviate intermittent claudication pain?
Rest (decreases metabolic needs of muscles)
Rest Pain
Persistent pain in the foot or digits when the patient is resting
What does the presence of rest pain indicate?
Rest pain indicates a severe degree of arterial insufficiency & critical state of ischemia
What can be done to increase perfusion to distal tissues in the presence of rest pain?
Lowering the extremity to a dependent position
How can the site of arterial disease be deduced from the location of claudication?
It can be deduced because pain occurs in muscle groups distal to the diseased vessel
If the patient is experiencing calf pain, where would the site of claudication be?
Insufficient blood flow through either the superficial or popliteal artery
Rubor
Reddish-blue discoloration of the extremities
-May be observed w/in 20secs-2mins after extremity is placed in dependent position
Cyanosis
Bluish tint of the skin that is manifested when amount of oxygenated hemoglobin contained in the blood is reduced
Nursing Considerations for Pulse Palpation
Palpation is subjective
Use light touch & more than just the index finger for palpation (strongest pulse) to avoid mistaking their own pulse for the pt’s pulse
-Same for thumb
Occlusive arterial diseases impairs blood flow & can reduce/obliterate palpable pulses in the extremities
Palpate bilaterally & simultaneously
Symmetry in:
-Rate
-Rhythm
-Quality
Handheld Continuous Wave (CW) Doppler Ultrasound
Used to detect blood flow when pulses cannot be reliably palpated
What determines at what depth where blood flow can be detected by a Doppler?
The frequency it produces
-The lower the frequency, the deeper the tissue penetration
Nursing Considerations for Doppler Ultrasound Flow Studies
Place the pt in supine position, elevate HOB 20 to 30 degrees to evaluate the lower extremities
-Externally rotate the legs, if possible, to permit access to medial malleolus
Apply acoustic water soluble gel to pt’s skin
Avoid excessive pressure (severely diseased arteries can collapse w/min pressure)
Ankle-Brachial Index (ABI)
Ratio of the systolic BP in the ankle to the systolic BP in the arm
What is the ABI used to determine?
The ABI is used to quantify the degree of stenosis
Steps to Determine ABI
1) Have patient lay in supine position for 5 mins
2) Apply appropriate-sized BP cuff to the patient’s ankle above the malleolus
3) After ID’ing an arterial signal of the posterior tibial & dorsalis pedis arteries, systolic pressures are obtained while listening to the Doppler signal for both arteries
-Diastolic pressures cannot be obtained via Doppler
Nursing Considerations for Obtaining ABI
Use correctly sized BP cuffs
Document cuff sizes used
Use sufficient inflation
-Do not inflate too rapidly
Suspect medial calcific sclerosis:
- Anytime the ABI is 1.20 or greater
- Ankle pressure is more than 250 mmHg
Be weary of arterial pressures recorded at less than 40 mmHg (venous signal was confused for arterial signal)
ABI >1.40
Abnormal, indicates non-compressible arteries
-Follow w/ toe-brachial index (TBI)
ABI of 1.00-1.40
Normal
ABI of 0.91-0.99
Borderline
ABI of less than or equal to 90
Abnormal
ABI of 0.50-0.90
Moderate to mild insufficiency
-Seen in pts w/claudication
ABI of <0.50
Found in patients w/ischemic rest pain
ABI of or less than 40
Found in pts w/ischemia or severe tissue loss
Nursing Considerations for Diagnostic Evaluations
Perform baseline ABI on any pt w/decreased pulses or any pt 65 yrs or older (especially hx of diabetes & nicotine use)
Pts who undergo arterial interventions should have ABIs performed per hospital protocol
Prior to Procedure: Educate pts about the indications of ABI and what to expect
Avoid nicotine use & caffeine prods for at least 2 hrs prior to testing
Exercise Testing
Used to determine how long a patient can walk & to measure the the ankle systolic BP in response to walking
Contraindications for Exercise Testing
Patients w/:
- Significant arterial insufficiency
- Severe cardiac, pulmonary, or orthopedic problems
- Physical disability
How is exercise testing performed?
Patients walk on a treadmill at 1.5 mph w/ 12% incline for at least 5 mins
or
Walks w/gradual increase in speed & incline to the point of claudication
Normal Exercise Testing Result
Little or no drop in ankle systolic BP after exercise
Patient w/ True Vascular Claudication Exercise Testing Result
Ankle pressure drops
Duplex Ultrasonography
Combine B-grade grayscale imaging of tissues, organs, & blood vessels w/capabilities of estimating velocity changes via pulsed Doppler use
What would duplex ultrasonography be used for?
Used to determine the level & extent of venous disease and how chronic it is
Nursing Considerations for Duplex Ultrasonography
Non-invasive
Patients who undergo abdominal vascular ultrasound need to be NPO status for at least 6hrs prior to exam
-Gas released from food can interfere w/ exam
Portable
Computed Tomography (CT) Scanning
Provides cross-sectional images of soft tissues & visualize area of volume changes to an extremity & the compartment where changes take place
Nursing Implications for CT Scan
Patients w/impaired renal function may req preprocedural treatment to avoid contrast-induced nephrotoxicity
-May include oral/IV hydration 6-12 hrs preprocedure or sodium bicarbonate admin
Nurse should encourage fluids & monitor patient’s urinary output post-procedure
-Should be at least 0.5 kg/mL/h
Contrast-induced acute kidney injury may occur 48-96 hrs post-op
-Notify & follow-up w/provider if this occurs
Screen for iodine & shellfish allergies
-Might be given steroids & histamine blockers ahead of time
What does sodium bicarbonate do?
Alkalinizes urine & protects against free radical damage
Angiography
May be used to confirm diagnosis of occlusive arterial disease when surgery/other interventions are considered
Aneurysm
Abnormal dilation of blood vessel
Nursing Considerations for Angiography
Patient experiences temporary wam sensation as contrast agent is injected & local irritation may occur at injection site
May have an immediate or delayed allergic response to the iodine present in the contrast agents
Any reaction must be reported IMMEDIATELY!!
Risks include: vessel injury, acute arterial occlusion, bleeding, or contrast nephropathy
Clinical Manifestations of Contrast Agent Induced Allergic Reaction
Dyspnea
N/V
Sweating
Tachycardia
Numbness of the extremities
Any of these signs MUST be reported IMMEDIATELY!!
Treatment for Contrast Agent Induced Allergic Reaction
Admin of epinephrine, antihistamines, or corticosteroids
Nursing Implications for Magnetic Resonance Angiography
Contraindicated in patients w/metal implants
Assess for presence of any incompatible devices:
-Aneurysm clips
-Old tattoos: May contain trace elements (newer ones may contain nitinol & titanium which are compatible)
-Med patches
-Cardiac implantable electronic devices
-> MUST be screened to determine if they can safely undergo a MRI
Inform pt that:
-They will be in a small, enclosed space
- May hear periodic banging sounds
-They will lay on a cold, hard table
Ask for pts to close their eyes and keep them closed during procedure to decrease symptoms of claustrophobia
Reassure patients that they will be provided a panic button to press if they feel they need to stop the procedure
Assess for claustrophobia: May be prescribed a sedative prior to procedure
MRA procedures use contrast: Use the same precautions as you would w/contrast angiogram
Contrast Phlebography (Venography)
Involves injecting a radiopaque agent into venous system
-If thrombus is present, x-ray will reveal an unfilled segment of vein in otherwise completely filled vein
Arteriosclerosis
Hardening of the arteries due to muscle fibers & endothelial lining of walls of small arteries & arterioles becoming thickened
Atherosclerosis
Inflammatory process involving accumulation of lipids, calcium, blood components, carbs, & fibrous tissue on the intimal layer of a large-or medium-sized artery
Which is more common: arteriosclerosis or atherosclerosis?
Arteriosclerosis
Risk Factors for Atherosclerosis
Modifiable Risk Factors:
-Nicotine use
-Hyperlipidemia
-Diet (contributing to hyperlipidemia)
-Hypertension
-Diabetes
-Obesity
-Stress
-Sedentary lifestyle
-C-reactive protein: Protein found in liver, indicative of inflammation (typically specific to cardiovascular conditions-increase)
-Hyperhomocysteinemia: Increase in protein that
promotes coagulation
Nonmodifiable Risk Factors:
-Age
-Gender
-Familial predisposition & genetics
Progression of Atherosclerosis
Asymptomatic-> Claudication-> Ischemic Rest Pain-> Gangrene (limb loss)
Nursing Actions/Considerations for Atherosclerosis
Provide patient education on disease prevention/management
* Dietary modifications
* Self-care programs
* Foot and leg care
Medication education
* HMG-CoA (statins): 1st line of therapy
* Long-term therapy requires close monitoring
Encourage elimination of all modifiable risk factors,
particularly nicotine use
Gerontological Considerations for Atherosclerosis
Symptoms of PAD may be more pronounced
-May have adjusted their lifestyle to accommodate the limitations imposed by the disease
-Limb ischemia or gangrene may be first sign of disease in inactive patients
-May not walk enough to develop symptoms of claudication due to other comorbid conditions (e.g., COPD, HF)
Decreased circulation, although may not be apparent until trauma occurs
Intermittent claudication may occur more quickly, with shorter distance or slight incline
Cognitive impairment may prevent some from verbalizing symptoms such as pain
1st Line of Therapy for Atherosclerosis
Statins
Medical/Surgical Interventions for Patients w/ PAD Atherosclerosis
Modifications of risk factors
Controlled exercise program
Medication therapy
* Cilostrazol (Pletal)
* Aspirin or Clopidogrel (Plavix)
* Statins
Surgical management
* Reserved for treatment of rest pain, severe and disabling claudication, or when limb is at risk for amputation due to tissue necrosis. Include:
* Inflow and outflow procedures
* Bypass grafting
* Amputation
Endovascular management
* Angioplasty
* Atherectomy
* Stent or Stent Graft placement
Endovascular Therapies for Patients w/ PAD/Atherosclerosis: Angioplasty
AKA: Percutaneous Transluminal Angioplasty (PTA) and atherectomy
-Atherectomy reduces the plaque buildup using a cutting device or laser
-Complications of both include hematoma formation, embolus, dissection, acute arterial occlusion & bleeding
Endovascular Therapies for Patients w/PAD/Atherosclerosis: Stent or Stent Graft Placement
Reduces risk for restenosis
Complications include: distal embolization, dissection, and dislodgement
Can be drug-eluting: Candidates must
take antiplatelet meds for 6 months post
procedure
Nursing Implications for PAD
Improving peripheral arterial circulation
Promoting vasodilation and preventing vascular compression
Relieving Pain
Maintaining tissue integrity
Post-op Care: Primary objective is to maintain circulation within arterial repair
-Pulses, Doppler assessment, color and temperature, cap refills, and sensory and motor function of affected extremity are checked can compared to other extremity
- Observation are every 15mins initially, then a progressively longer when stable
-Complete Doppler evaluation of vessel distal to bypass graft
ABI monitored every 8hrs for first 24hrs then once daily until discharge
* Not usually assessed with pedal artery bypasses due to risk of compression of anastomosis
-Absent pulses may indicate thrombotic occlusion of graft ->Notify surgeon immediately
Monitor and manage potential complications
* Fluid imbalances, bleeding, thrombosis, edema, and compartment syndrome
Compartment Syndrome
Dangerous complication where elevated tissue pressures in non-expansible space
-Impedes capillary perfusion
MEDICAL EMERGENCY: CALL PROVIDER!!!
Nursing Interventions for Compartment Syndrome
Limb flat, in neutral position at the level of the heart
Do not elevate or cross legs
Remove anything restricting limb
Treatment to Relieve Compartment Syndrome
Fasciotomy
Discharge Planning & Patient Education for PAD
Assess the patient’s ability to manage ADLs independently & patient’s support system
Modifications in diet, activity, & hygiene (skin care)
-Lose weight & adopt low-fat diet
-Slightly elevate feet at rest but not above heart level
-Keep feet dependent to increase blood flow to legs (as tolerated, avoid prolonged dependency)
-Inspect feet daily, keep clean & dry, go to professional for foot care
-Wear proper fitting shoes, avoid walking barefoot
-Begin and maintain walking program
Monitor for s/s of infection, occlusion of artery or graft, or decreased blood flow:
-Encourage plan to stop use of tobacco products
-Adherence with medications
Aneurysm
Localized sac or dilation formed at a weak point in the wall of the artery
Saccular Aneurysm
Projects from only 1 side of the vessel
Fusiform Aneurysm
An entire arterial segment becomes dilated
Mycotic Aneurysm
Very small aneurysms due to localized infections
Thoracic Aortic Aneurysm
Approximately 70% of all cases caused by atherosclerosis
Occur most frequently in hypertensive men between 50-70 years old.
Most common site for a dissecting aneurysm
-Can develop in ascending, transverse or descending aorta
Diagnostic testing include chest Xray, CTA, MRA, or transesophageal echocardiography (TEE)
Clinical Manifestations of Thoracic Aortic Aneurysm
Chest pain/ Upper back pain: May be more severe in supine position
Cough, dyspnea (result of pressure of the aneurysm sac against the trachea), hoarseness, and dysphagia
Patient may be asymptomatic
Assessment Findings for Thoracic Aortic Aneurysm
Superficial veins of chest, neck, or arms become dilated
Edematous areas on chest wall
Cyanosis
Unequal pupils: Due to pressure against the cervical sympathetic chain
Abdominal Aortic Aneurysm (AAA)
Most common site for formation is below the renal arteries
Most common cause is atherosclerosis
Prevalence:
* 2-6x more common in men than women
* 2-3x more common in white men than black men
* Most prevalent in patients >65yrs of age
Outcome may be rupture and death if left untreated
More than half of patients with aneurysms have HTN
-Rupture coexists with HTN and aneurysm >6cm
Diagnostic Testing includes duplex ultrasonography or
CTA
Clinical Manifestations of Abdominal Aortic Aneurysm (AAA)
40% of patients are symptomatic
Signs of HF or loud bruit may suggest rupture into vena cava
Abdominal pain often localized in the middle or lower abdomen to the left of the midline
Persistent or intermittent severe back or abdominal pain: sign of impeding rupture
May extend to impinge on the renal, iliac, or mesenteric arteries
Cyanosis and mottling of toes (“trashing” or “trash toes”)
Expected Assessment Findings for Abdominal Aortic Aneurysm (AAA)
Pulsatile mass in the middle and upper abdomen palpable during exam
Sensitivity depends on size, abdominal girth, and skill of examiner; more
difficult to palpate in obese patient
Systolic bruit heard over mass
Constant, intense back pain, decrease BP and hematocrit =
____________
Treatment & Management of Aneurysm Patients
Based on whether patient is symptomatic, aneurysm is expanding, contains a dissection, or involves branch vessels
Control BP: Maintain SBP at 90-120 mm Hg for MAP of 65-75 mm Hg, pre-op
* Thoracic: Beta-blockers, angiotensin receptor blockers (ARBs), hydralazine, and Nitroprusside
* Aortic - Diuretics, beta-blockers, ACE inhibitors, ARBs, and calcium channel blockers
IV fluid and/or blood administration to maintain graft patency
Open surgical repair or endovascular grafts
* > or equal to 5.5cm (2 inches)
* Grafts preferred
* Lumbar spinal drains used to decrease spinal cord ischemia and paraplegia w/ endovascular repairs
Cerebrospinal fluid drained to decrease the arterial to cerebral spinal fluid gradient, thereby improving spinal perfusion
* Keep cerebrospinal fluid pressure < 10 mm Hg (14 cm H2O) and keep MAP > 90 mm Hg for the first 36 to 48 hours, post-op to prevent neuro deficits
Assessments should be focused on anticipation of rupture
* System-based assessments
* Promptly implement medical therapies to stabilize physiologic function
Health Promotion and Risk Factor Management
* Controlling BP, smoking cessation, increasing physical activity, maintaining healthy body weight & serum lipids, and regular monitoring of smaller aneurysms
Pre-Op Management of Aneurysm Patients
Baseline labs and peripheral vascular assessments
Preoperative teaching, emotional support, prophylactic antibiotics, reinforcing NPO status, and bowel preparation
Post-Op Management of Aneurysm Patients
Supine position for 6hrs; HOB elevated up to 45 degrees after 2hrs
Assess access site, VS & pulses; doppler assessment q15mins initially, and temperature q4hrs
Monitor for complications:
-Bleeding or hematoma formation, infection, distal ischemia or embolization, dissection or perforation of aorta, post implantation syndrome, arterial occlusion, kidney injury or erectile dysfunction
Fluid maintenance
Aortic Dissection
MEDICAL EMERGENCY! CALL PROVIDER!!
Clinical Manifestations:
-Symptoms usually sudden
-Severe and persistent pain: Described as tearing or ripping; in anterior chest or back and extends to shoulder, epigastric area, or abdomen
-May be mistaken for an acute myocardial infarction (MI)
-Pale, diaphoresis, or tachycardia
-BP elevated or markedly different from one arm to the other if dissection involves the orifice of the subclavian artery on one side
Assessment & Management of Aortic Dissection
Assessment: Arteriography, multidetector-computed tomography angiography (MDCTA), TEE, duplex ultrasonography, and MRA
-Medical/surgical treatment and nursing management same as mentioned with aneurysms
Arterial Embolism & Thrombosis
May result from invasive catheters, illicit IV drug use or traumas (fracture, compartment syndrome…)
* Embolic or Thrombotic
Symptoms depend on size and organ involvement
* 6 Ps of pain: Pain, Pallor, Paresthesia, Pulselessness, Paralysis, Poikilothermia
Treatment of thrombosis depends on cause; embolic occlusion usually requires surgery; 4–6-hr window to restore blood flow & prevent irreversible tissue death:
* t-PA and heparin
* Embolectomy and Thrombectomy - Percutaneous or open surgery
The 6 Ps of Arterial Embolism & Thrombosis Pain
1) Pain
2) Pallor
3) Paresthesia
4) Pulselessness
5) Paralysis
6) Poikilothermia: Inability to regulate core body temperature
Nursing Actions for Arterial Embolism & Thrombosis
Assess for therapy contraindications:
-Active internal bleeding
-Cerebrovascular hemorrhage
-Recent major surgery
-Uncontrolled HTN
-Pregnancy
Protect affected extremity from trauma & minimize punctures
Obtain accurate weight (heparin drug admin)
Monitor VS – q15mins, then progressively longer when stabilize, pulses, doppler signals, ABI, and motor/sensory functions q4hrs for first 24hrs
Monitor for complications of arterial occlusion (acute kidney injury, compartment syndrome, etc.) and therapy (bleeding/systemic hemorrhage)
Raynaud’s Phenomenon
Form of intermittent arteriolar vasoconstriction
Raynaud’s Disease
Primary or Idiopathic Raynaud’s (w/out underlying disease)
Raynaud’s Syndrome
Secondary Raynaud’s (underlying disease, such as systemic lupus erythematosus, RA, or scleroderma trauma, etc.)
Triggers for Raynaud’s Phenomenon
Triggered by emotional factors, stress, or by unusual sensitivity to cold
Clinical Manifestations of Raynaud’s Phenomenon
Coldness, pain, and pallor of fingers and toes
Rubor, cyanosis, numbness, tingling, and burning pain; symptoms bilateral and symmetrical
Nursing Management of Raynaud’s Phenomenon
Provide patient education
* Avoid stimulus that provokes vasoconstriction – cold, stress, nicotine
No drugs with vasoconstrictive effects - decongestants and other OTC sympathomimetics
* Calcium channel blockers (nifedipine, amlodipine) effective in relieving symptoms
* Vasodilator; first line therapy
* Education about orthostatic hypotension
Analgesics for pain
Which type of meds are 1st line therapy for patients w/Raynaud’s phenomenon?
Vasodilators
Venous disorders cause a reduction in blood flow…
…results in stasis of blood
Virchow’s Triad
1) Endothelial damage
2) Hypercoagulation
3) Venous stasis
Risk Factors for Deep Vein Thrombosis & PE
Endothelial Damage:
-Central venous catheters
-Dialysis Access catheters
-Local vein damage
-Pacing wires
-Repetitive motion injury, surgery, & trauma
Venous Stasis:
-Age: Older than 65 yrs old
-Bed rest /immobilization
-HF
-History of varicosities
-Obesity
-Spinal cord injury
Altered Coagulation:
-Pregnancy
-Cancer
-Polycythemia
-Septicemia
-Oral contraceptive use
Deep Venous Thrombosis (DVT)
Thrombus formation in the deep veins in thigh, calf, and sometimes arms (patients with PICC lines)
Important predictor of Postthrombotic syndrome is lack of recanalization w/in first 6 months after DVT
DVT Assessment
Clinical Manifestations:
-Pain, warmth, tenderness, edema of extremity ->obstruction of venous flow
-Large circumference of the thigh or calf; compare to unaffected extremity
-Many cases are asymptomatic - Assess for high risk factors!
Venous duplex studies: Veins larger than normal, incompressible, and dilated
Lab studies:
-Baseline complete blood count (CBC),
-Coagulation studies: prothrombin time (PT), activated partial thromboplastin time (aPTT),
and international normalized ratio (INR)
Preventative Measures for DVT
Lifestyle modifications - smoking cessation, weight loss, and regular exercise
Graduated compression stockings
Intermittent pneumatic compression devices
* Early ambulation of hospitalized patients
* SQ unfractionated heparin or low-molecular-weight heparin (LMWH)
DVT Management Goal
Objectives are to prevent the thrombus from extending and fragmenting (thus risk of PE), recurrent thromboemboli, and postthrombotic syndrome
Pharmacological Management of DVT
Anticoagulant Therapy
Unfractionated Heparin (SQ or IV): Prevents extension of thrombus & development of new thrombus
Low-Molecular Weight Heparins (e.g., Lovenox)
Oral Anticoagulants (e.g., Coumadin)
Oral Direct Factor Xa Inhibitors (e.g., Apixaban)
Nursing Considerations for Unfractionated Heparin
Can be admin either SQ or intermittent/continuous IV
-IV dose is based on weight
Req aPTT & platelet count monitoring
Assess for bleeding
Admin protamine sulfate for overdose
-Monitor for hypotension & bradycardia if admin
Nursing Considerations for Low-Molecular Weight Heparins (Lovenox)
Can be admin either 1X daily or twice a day SQ
Associated w/fewer bleeding complications than unfractionated heparin
Admin protamine sulfate for OD: Less effective in reversing low-molecular weight heparin OD than unfractionated heparin
Can be used in pregnancy, IF clearly indicated
-Monitor for bleeding
Nursing Considerations for Oral Coagulants (Coumadin)
Vitamin K antagonist
Effects occur 12-24 hrs after dose admin
-Admin 1X day, at the same time each day
Req PT & INR monitoring
-PT goal: 1.5-2 times normal
-INR goal: 2.0-3.0
Req admin w/heparin during drug initiation until the desired effect is achieved
Assess pt for bleeding
Admin Vitamin K, fresh-frozen plasma, or prothrombin complex concentrate to reverse OD effects
CONTRAINDICATED FOR PREGNANCY!!!
Nursing Considerations for Oral Xa Inhibitors (Apixaban)
Admin 2X a day
Assess renal function
Alter dose for obese pts
Admin activated charcoal to reverse OD effects
Endovascular Management of DVT
For recurrent or extensive thrombi, high risk for pulmonary embolism, or when anticoagulants or thrombolytic therapy is contraindicated
Thrombectomy or Vena Cava Filter:
Assess and monitor anticoagulant therapy
Monitor and manage potential complications
* Bleeding, thrombocytopenia, signs of PE, and drug-drug interactions
* Be familiar with meds approved to reverse effects of various anticoagulants
Reduce discomfort/Pain Management
* Elevate affected extremity, graduated compression stockings, analgesic, or warm packs
Position the body and encourage exercise
* Periodic elevation of extremity and early ambulation
Pulmonary Embolism (PE)
Obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originate(s) somewhere in the venous system or in the right side of the heart
Clinical Manifestations of PE
Depends on size of thrombus and the area occluded
Dyspnea and tachypnea
* Most frequent symptoms
* Duration and intensity of dyspnea depends on extent of embolization
Chest pain: Common; usually sudden and pleuritic; may be substernal and mimic angina
Anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope
Few s/s in many cases; others may mimic other cardiopulmonary disorders (e.g., pneumonia, heart failure)
Assessment & Diagnostic Findings Associated w/PE
Chest Xray: Usually normal; useful in excluding other possible causes
ECG: Sinus tachycardia and nonspecific ST-T wave abnormalities
Pulse oximetry
Arterial blood gas analysis: Hypoxemia and hypercapnia from tachypnea or may be normal
D-dimer assay
Multidetector Computer Tomography (MDCT) and Pulmonary arteriogram (angiogram)
* MDCT standard for diagnosing; angiogram reasonable alternative to MDCT
- V/Q scan: Not as accurate as the MDCT or pulmonary angiogram
Medical Management for Unstable PE
Medical emergency
Thrombolytic therapy with t-PA or other agents
* Contraindications: a stroke in the past 2 months, other active intracranial processes, active bleeding, surgery within 10 days of thrombotic event, recent labor and delivery, trauma, or severe HTN
* Baseline INR, aPTT, HCT, Plt count needed
* Other anticoagulants are discontinued
* Only essential invasive procedures during therapy
Embolectomy
Inferior Vena Cava (IVC) filter
Medical Management for Stable PE
Immediate anticoagulation to prevent recurrence or extension of thrombus
* May continue for 10 days
* Long-term therapy indicated for 6 months; critical in preventing recurrence; extended indefinitely for high-risk patients
* Initial anticoagulant same as for DVT
* DOACs often prescribed for
outpatient therapy
* Long-term treatment options are warfarin and the DOACs.
-Regular blood draws and higher bleeding risk with warfarin
-DOACs don’t require regular blood testing, more costly
Choice of warfarin vs DOACs: Depends on risk of bleeding, cost, presence of comorbidities, and provider preference
General Nursing Considerations for PE
Monitor Thrombolytic Therapy: Monitor pt’s response to therapy, INR, or aPTT q3-4 hrs after start of thrombolytic infusion
-Maintain BR, frequent VS, & invasive procedure
Manage Pain: Place in Semi-Fowler’s Position (makes it more comfortable to breathe)
-Usually pleuritic chest pain than cardiac in origin
Manage O2 Therapy: Assess frequently for signs of hypoxemia
-Nebulizer therapy/percussion & postural drainage may be used for the management of secretions
Relieve Anxiety
-Encourage pt to talk about fears and concerns
-Answer patient and family questions concisely and accurately, explain therapy, and describe how to recognize untoward effects early
Monitor for cardiogenic shock or right ventricular failure
Monitor UOP, s/s of infection, maintain BP at level that supports perfusion
-Elevates foot of bed, encourages isometric exercises, SCD, and walking when permitted prevents peripheral venous stasis and edema of lower extremities
-Educate patient about preventing recurrence and reporting s/s
Monitor adherence to treatment plan and reinforce instructions and importance of keeping follow-up appointments for coagulation tests and with primary provider
Chronic Venous Insufficiency/Postthrombotic Syndrome
20-50% of patient with DVT develop Postthrombotic syndrome
Results from obstruction of the venous valves in the legs or a reflux of blood through the valves
Characterized by chronic venous stasis:
* Edema
* Altered pigmentation
* Pain
* Stasis dermatitis
Symptoms less in morning and more in the evening
Superficial veins may be dilated
Disorder is longstanding, difficult to treat, and often disabling
Increased risk for injury and infection
Venous ulceration is the most serious complication
Cellulitis and dermatitis can complicate care
Clinical Manifestations of Chronic Venous Insufficiency/ Postthrombotic Syndrome
Stasis ulcers develop as a result of rupture of small skin veins and subsequent ulcerations
Brownish discoloration of tissues, also known as hemosiderin staining, usually in lower part of extremity, medial malleolus of the ankle
Skin dry, cracked, and itchy
Subcutaneous tissues fibrose and atrophy
Chronic Venous Insufficiency/Postthrombotic Syndrome Management Goal
Goal is to reduce venous stasis and prevent ulceration
Management of Chronic Venous Insufficiency/Postthrombotic Syndrome
Protect extremities from trauma
Report signs of ulceration immediately to provider for
treatment and follow-up
Increase venous blood flow
* Compression of superficial veins: compression therapy
-Graduated compression stockings (not anti-embolism stockings/TED stockings), bandages, external or intermittent pneumatic compression devices
-Reduces the pooling of venous blood, enhances venous return to the heart and recommended for people with venous insufficiency
Varicose Veins
Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
-May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)
What class of medication lyses & dissolves thrombi?
Fibrinolytic
Which medications are specifically indicated for claudication treatment?
Pentoxifylline (Trental) & Cilostazal (Pletal)
Normal PTT Level Range
Between 21-35 secs
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of:
1.5 to 2.5 times the baseline control
What is the antidote for heparin?
Protamine sulfate
Varicose Veins
Abnormally dilated, tortuous, superficial veins caused by incompetent venous valves
-May be primary (w/o involvement of deep veins) or secondary (resulting from obstructions of deep veins)
Assessment Findings for Varicose Veins
Symptoms may include: dull aches, muscle cramps, increased muscle fatigue in lower legs, ankle edema, and heaviness in legs; nocturnal cramps
Edema, pain, pigmentation, and ulcerations are s/s of chronic venous insufficiency when deep venous obstruction occurs
Nursing Considerations for Varicose Veins
Provide appropriate post-procedural care and patient education regarding post-op care and/or prevention and proper skin care
* Gently pat dry, do not rub the incision
* Use sunscreen; avoid skin lotion until completely healed
Provide comfort/pain management
Monitor for bleeding and s/s of infection
Assess for temporary/permanent nerve injury
* Reported sensation of “pins and needles”
Prevention of Varicose Veins
Avoid activities that cause venous stasis
Change position frequently, elevate the legs 3 to 6 inches higher than heart level when tired, and getting up to walk for several minutes of every hour promote circulation
Graduated compression stockings, especially knee-high stockings
Overweight patients should be encouraged to begin a weight reduction plan
Management of Varicose Veins
Thermal ablation – targeted heat to seal veins
Microphlebectomy – removal of superficial vein w/ small incisions
Sclerotherapy – chemical injection
Ligation/stripping – surgical removal of deep veins
Lymphangitis
Inflammation or infection of the lymphatic
channels
Lymphadenitis
Inflammation or infection of the lymph nodes
Acute Lymphadenitis
Lymph nodes that are enlarged, red, and
tender
Suppurative Lymphadenitis
Lymph nodes that have become necrotic
and form an abscess
Lymphedema
Tissue swelling related to obstruction of lymphatic flow
-Especially marked when extremity in dependent position
-Edema initial soft and pitting; as it progresses, it becomes firm, non-pitting and unresponsive to treatment
Frequent bouts of acute infections (high fever & chills) and increased residual edema are seen with chronic swelling
* Leads to chronic fibrosis, thickening of the subcutaneous tissues, and hypertrophy of the skin
* This specific type of lymphedema is known as elephantiasis in which chronic swelling of the extremity recedes only slightly with elevation
Primary Lymphedema
Congenital Malformations
- Most common
-Usually seen in women
Secondary Lymphedema
Acquired obstruction
-Axillary node dissection (breast cancer)
-Leg in association w/ varicose veins or chronic thrombophlebitis
-> Usually caused by chronic lymphangitis
Lymphedema Treatment Goal
Goal of therapy is to reduce and control edema and prevent infection
Medical Management of Lymphedema
Manual lymphatic drainage by specially trained therapists
Diuretic furosemide
Antibiotic therapy when lymphangitis or cellulitis is present for 3-7 days
Surgical management
Nursing Management of Lymphedema
Constant elevation of affected extremity
Active and passive exercises
External compression devices; Custom-fitted graduated compression stockings or sleeves
Monitor for complications:
* Flap necrosis
* Hematoma
* Abscess under the flap
* Cellulitis
Patient/Family Education
* Inspect dressing daily
* Report any inflammation or unusual dressing
* Expected loss of sensation in surgical area
* Avoid use of heating pads or exposure to sun
* Skin care
Cellulitis
Occurs when a microbe enters through broken skin and release their toxins in the subcutaneous tissues, typically, staph or strep
Clinical Manifestations of Cellulitis
Localized swelling or redness, warmth and pain frequently associated with systemic symptoms fever, chills, and sweating
* Redness may not be uniform; develops a pitting “orange-peel” appearance
Nursing Management of Cellulitis
Treat with oral or IV antibiotics based on severity
Elevate affected area 3-6 inches above heart level
* Warm, moist packs to site every 2 to 4 hours
* Patients with sensory/circulatory deficits should use caution to avoid
burns
* Educate regarding prevention of recurrence
* Reinforce education about skin and foot care
Match Items Appropriately
Assessment Findings:
1) Dilated superficial veins in the chest, neck, or arms; edema in the chest wall
2) Intermittent claudication
3) Pain is described as aching or heavy
4) Ulcerations on the side of the foot over the metatarsal are painless
5) 6 Ps of Pain
6) Pulsatile mass in the abdominal wall
7) DVT
8) Small, circular, deep ulcerations on the tips of toes or web spaces between toes
Disorder
a) Peripheral Artery Disease
b) Peripheral Venous Disease
c) Arterial Ulcers
d) Venous Ulcers
e) Abdominal Aortic Aneurysm
f) Thoracic Aortic Aneurysm
1) f
2) a & c
3) d
4) d
5) a
6) e
7) b
8) c
