Chapter 38: Care Of Patients With Vascular Problems

Question 0

Risk factors for atherosclerosis

Answer 0

Low HDL, high LDL, increased triglycerides, genetic predisposition, diabetes mellitus, obesity, sedentary lifestyle, smoking, stress, African-American or Hispanic, Genetic predisposition, diabetes, hyperlipidemia.

Question 1

Arterialsclerosis/atherosclerosis

Answer 1

Thickening or hardening of the arterial wall usually associated with aging. Atherosclerosis involves formation of plaque is the leading risk factor for cardiovascular disease.

Assess hypertension in both arms. Palate pulses at all of the major body sites. Feel for temperature differences and capillary filling. The skin will be cool or cold with diminished pulses. A bruit may be heard if obstructed 50% and then not heard once it is 90%.

· Lab Assessment norms, if they are elevated they are at risk for atherosclerosis Total cholesterol < 100mg/dL for healthy, < 70mg/dL for
CVD or diabetes
HDL >40mg/dL
Triglycerides <135 women

Low risk people should have cholesterol level evaluated every five years. Interventions include lifestyle changes. Medication therapy after lifestyle changes do not work. Limit cholesterol two less than 300 mg per day. Use canola oil.

Question 2

Medications for atherosclerosis

Answer 2

Statins: They lower both LDL and triglyceride levels. Reduce cholesterol synthesis in the liver and increase clearance of LDL from blood. They are contraindicated in patients with active liver disease or during pregnancy because they can cause muscle myopathies and Decrease liver function. They are discontinued if muscle cramping or elevated liver enzymes.

Zetia: Inhibits the absorption of cholesterol through the small intestine.

Nicotinic acid or niacin, a B vitamin made lower LDL and increase HDL. Low doses are recommended because patients experience flushing and warm feeling all over.

Omacor an omega-3 fatty acid reduces triglycerides and decreases plaque growth and inflammation

Question 3

HTN

Answer 3

· Normal 160/>100
· Pts with DM need to have BP under 130/90
· Teaching: control sodium intake, weight reduction, exercise, smoking cessation, if normal BP check it at least every 2 years, monitor HTN closely, alcohol restriction, stress management, teach about meds and their schedule and importance of compliance,

Isolated systolic hypertension is a major health threat he specially for older adults. Systolic pressure is a better indicator for the risk of heart disease and stroke. >140/<90

Primary nursing diagnosis include deficient knowledge and risk for ineffective therapeutic regimen management.

Question 4

Malignant hypertension

Answer 4

Morning headaches, blurred vision, dyspnea, uremia.
>200/>130-150

Leads to renal failure, left ventricular failure, or stroke

Assess for severe headache, extreme high blood pressure, dizziness, blurred vision, disorientation. Place in high Fowlers position, apply oxygen, administer IV Nitropress or Cardene. Monitor blood pressure every five to ten minutes until diastolic 75. Then monitor it every 30 minutes. Observed for neurologic or cardiovascular complications such as seizures, numbness, weakness, tingling of extremities, dysrhythmias, or chest pain.

Question 5

Essential hypertension

Answer 5

No known cause. Risk factors include family history, high sodium, excessive calories, physical inactivity, excessive alcohol, low potassium. Hyperlipidemia, African-American, obesity, smoke, stress

Question 6

Secondary hypertension

Answer 6

Specific reasons for it. Renal disease primary aldosteronism, pheochromocytoma, Cushing’s disease, coarctation of the aorta, brain tumors, encephalitis, psychiatric disturbances, pregnancies, medications such as estrogen(especially birth control containing this) glucocorticoids, mineralocorticoids, sympathomimetics.

Creatinine clearance normal value is 1072 139 for men and 80 72107 for women.

Question 7

Peripheral arterial disease/ PAD

Answer 7

· peripheral circulation. Result of systemic atherosclerosis. Inflow obstructions involve the distal end of the aorta and the common, internal, and external iliac arteries. These pts will have discomfort in the lower back, buttocks, or thighs. Outflow obstructions involve the femoral, popliteal, and tibial arteries. These pts have burning or cramping in the calves, ankles, feet, and toes.
· Risk factors: HTN, hyperlipidemia, DM, smoking, obesity, familial disposition, advancing age
· Four stages see chart 38-2 page 805
· Usually seek treatment for intermittent claudication. They may have rest pain, a numbing or burning in the foot or toes that may awaken them at night. Observe for loss of hair on lower calf, ankle, foot. Dry, scaly, dusky, pale, or mottled skin. Thickened toenails. If severe: extremity is cold, cyanotic, pallor when elevated, dependent rubor, muscle atrophy. Palpate ALL pulses in both legs. Possible ulcers.
· Tests: arteriography, Doppler segmental systolic BP measurements, ABI ankle brachial index (compares ankle with brachial BP. Divide ankle by brachial. Less than 0.9 is diagnostic for PAD), exercise tolerance testing, plethysmography (traces arterial flow in the limb).
· Nonsurgical management: exercise (to the point of claudication, rest, then a little further), position changes (elevate, but not above the heart), promotion of vasodilation (never apply direct heat, avoid cold temps), drug therapy (hemorheologic agent and antiplatelet agents such as asprin, plavix)
· PTA percutaneous transluminal angioplasty: arteries are dilated with a balloon catheter to open the vessel and improve blood flow. Stents can also be inserted. Usually for those who are not good surgical candidates, and reocclusion can occur.
· Laser assisted angioplasty: heat from laser vaporizes the plaque to open artery. Priority after is observing for bleeding at puncture site, observe vitals closely, frequent checks of distal pulses. Limb straight for 6-8 hours
· Arthrectomy: uses a rotor to clean vessel out
· Arterial revascularization: bypasses the arterial occlusions with grafts from patient or synthetic. Post op: graft occlusion is an important complication and usually occurs in first 24 hours. Pain may be the first sign. Check every 15 min for 1st hour and then hourly for changes in color, temp, pulse. Warmth, redness, edema are expected cuz of the increased blood flow. Bedrest for at least 18-24 hours post op. Cough, deep breathe, Incentive spirometer. If occluded, notify doc, he may perform emergency thrombectomy at the bedside. Watch for compartment syndrome. Possible use of TPA. A throbbing pain is due to increased blood flow, so don’t mistake it for ischemic pain. Watch for graft and wound infections and use sterile technique when in contact with incision.
· Foot care chart page 810

Question 8

Six Ps of ischemia

Answer 8

Pain, pallor, pulselessness, paresthesias, paralysis, poikilothermic/coolness

Question 9

Aneurysms of central arteries

Answer 9

Fusiform affects entire circumference
Saccular just an out pouch
True congenital or acquired problem weakens it
False result of injury or trauma

Risk factors include atherosclerosis, hypertension, hyperlipidemia, cigarette smoking, family history, syphilis, Marfan syndrome, chronic inflammation, trauma

X-rays will show an egg shell appearance. CT scan is the standard tool. Ultrasound will work also.

Question 10

AAA. Abdominal aortic aneurysm

Answer 10

AAA: Most common, asymptomatic, located between the renal arteries in the aortic bifurcation. If greater than 6 cm they usually rupture within one year. Assess for abdominal, flank, or back pain. It is steady, unaffected by movement, and lasts for hours or days. There may be a pulsation in the upper abdomen slightly to the left of midline. Auscultate for bruits over the mass but do not palpate.
Patients with a rupturing AAA are critically ill and in hemorrhagic/hypovolemic shock. Signs include hypotension, diaphoresis, decreased LOC, oliguria, loss of pulses distal to the rupture, dysrhythmias. There may be abdominal distention or hematomas in the flank.

Question 11

TAA/thoracic aortic aneurysm

Answer 11

Frequently misdiagnosed. Originate in the left subclavian artery and the diaphragm. Rupture is the most frequent complication and is life-threatening because of abrupt and massive hemorrhage.

Assess For back pain and manifestations of compression of the aneurysm on adjacent structures. Find include shortness of breath, hoarseness, difficulty swallowing. A mess maybe visible about the suprasternal notch. There may be a sudden and excruciating back pain or chest pain if it has ruptured. Hypovolemic shock.

Question 12

Treatment of aneurysms

Answer 12

Monitor the growth and maintain blood pressure.

Emergency surgery if it is ruptured. If greater than 7 cm for symptomatic elected surgery can be done.

Aneurysmectomy: high mortality
Endothelial stent grafts

Question 13

AAA resection

Answer 13

AAA resection

Preop: bowel prep, breathing exercises, bank blood, baseline pulses, if ruptured administration of large volume IV fluids

Midline abdominal incision from the xiphoid process to the symphysis pubis or a wide incision from Flank to flank. Graph is sutured in.

Post op: complications include an eye, graft occlusion or rupture, hypovolemia, renal failure, respiratory distress, paralytic ileus. Blood-pressure is monitored with an art line. Hemodynamic monitoring is used. Assess for signs of graft occlusion or rupture. These include changes in pulse, cool cold extremities, white or blue extremities or flank, severe pain, abdominal distention, decreased urine output,.

Limit elevation to 45° or less. If urine output is less than 50 mL notify the surgeon. Monitor BUN and creatinine daily. You splinting when coughing. Early mobility decreases the risk of atelectasis and DVT. An NG tube to low suction is used until gas is passed.

Question 14

TAA repair

Answer 14

Tunnel cardiopulmonary bypass is necessary for excision of the ascending aneurysm. Partial bypass is used if it is in the descending aorta. Care is similar to that for thoracic surgery. Usually uses a thoracotomy or medial sternotomy.

Complications include hemorrhage, ischemic colitis, cerebral and spinal cord ischemia causing paraplegia, respiratory distress, infection, cardiac dysrhythmias. Assess the patient hourly for sensation and motion in all extremities and report changes immediately. Atelectasis and pneumonia is common. Assess for dysrhythmias.

Question 15

Endovascular repair of AAA

Answer 15

They do this when a patient is at high risk for major abdominal surgery. The graft is inserted thru skin incision into the femoral artery by the way of a catheter-based system. Complications include conversion to open repair, bleeding, aneurysm rupture, peripheral immobilization, misplacement of the graft or stent

Question 16

Aneurysms of the peripheral arteries

Answer 16

Popliteal aneurysm: pulsating mass in the popliteal space. Symptoms of limb ischemia, diminished or absent pulses, cool to cold skin, pain. Treatment is surgery because of the risk of thromboembolic conditions. The surgeon removes the Aneurysm, restore circulation using a graft. Report sudden development of pain or discoloration after the surgery. It can indicate graft occlusion.

Question 17

Aortic dissection

Answer 17

A sudden tear in the aortic intima, opening the way for blood to enter the aortic wall. Hypertension and degeneration can cause this. It is not common it is life-threatening. The most common symptom is pain. It is a tearing, ripping, stabbing pain and moves from its point of a region. The patient may feel pain in the anterior chest, back, neck, throat, job, or teeth. Diaphoresis, nausea and vomiting, fainting, apprehension, blood pressure is elevated until cardiac tamponade or rupture have occurred. Then they become rapidly hypotensive. Decreased or absent pulses, aortic regurgitation, Neurologic deficits such as altered level of consciousness, paraparesis, strokes.

Diagnosed with x-ray, CT, MRI, angiography, TEE

Emergency care includes elimination of pain, reduction of systolic pressure to 100 to 200, decrease in velocity of left ventricular ejection. Nitropress by continuous drip to lower blood pressure. Cardene may be used.

Surgical treatment includes a cardiopulmonary bypass. The surgeon removes and tear and sutures the edges of the dissected aorta. A prosthetic graft is usually used.

Question 18

Buergers disease

Answer 18

Uncommon occlusive disease in the medium and small arteries and veins. Usually the upper and lower limbs are affected. It is in adult man who smoke. Stop smoking is a necessity.

Claudication of the arch of the foot is the first manifestation. It can become ischemic, and aching pain more severe at night. Increased sensitivity to cold. Pulses are diminished and extremities are cool and red or cyanotic in the dependent position. Ulcers and gangrene may be seen. arteriogram done. Interventions include preventing progression, avoiding vasoconstriction, promoting vasodilation, relieving pain, managing ulcers.

Question 19

Raynaud’s phenomenon

Answer 19

Caused by vasospasm of the arterials and arteries. It is usually bilaterally. Usually in women. Superficial vessels are constricted and blanching of the extremity occurs followed by cyanosis. The patients extremities are numb and cold and they may have pain and swelling. Also maybe present. They are aggravated by cold or stress. Management includes relieving or preventing vasoconstriction by drug therapy. Side effects include facial flushing headache hypotension and dizziness.

Teach methods to prevent vasoconstriction such as minimizing exposure to cold, reducing caffeine, smoking sensation, decreasing stress. Wear warm clothes socks and gloves when exposed to cold.

Question 20

Venus thromboembolism/DVT

Answer 20

Thrombus is from and endothelial injury, venous stasis, hypercoagulability. It is often associated with information. Thrombophlebitis refers to a thrombus that is associated with inflammation. Phlebothrombosis Is with out information. Deep vein thrombophlebitis presents a risk for pulmonary embolism. It is usually in the legs but can be in the upper arms.

Classic signs and symptoms include calf or groin tenderness and pain, sudden onset of unilateral swelling. Positive Homans sign with dorsiflexion of the foot but is not advised.

Ultrasound, Doppler, impedance plethysmography, MRI, a D dimer test.

Nursing diagnoses include risk for ineffective tissue perfusion, acute pain. Potential for embolism

Question 21

Verchow’s triad

Answer 21

Stasis of bloodflow, endothelial injury, and hypercoagulability. These lead to thrombus formation.

Question 22

Risk for thrombus formation

Answer 22

Hip surgery, total me replacement, open prostate surgery, ulcerative colitis, heart failure, immobility, sitting for long periods of time, phlebitis, infections such as systemic lupus erythematosus, polycythemia vera, oral contraceptive, Trauma, cancer especially adenocarcinoma of the visceral organs.

Question 23

Health promotion for venous thromboembolism

Answer 23

If the patient has a history they should avoid oral contraceptives, drink adequate fluids, exercise legs during long periods of rest or sitting. In the hospital patient education, leg exercises, early ambulation, adequate hydration, compression stockings, STDs, venous plexus foot pump

Question 24

Treatment for venous thromboembolism

Answer 24

Rest, elevate legs when in bed and a chair, wear elastic stockings, do not massage

IV unfractionated heparin followed by oral anticoagulation. Thrombolytic therapy

Surgery includes a thrombectomy, inferior vena caval interruption

Question 25

Unfractionated heparin therapy

Answer 25

Before starting to obtain a baseline PT, PTT, and INR, CBC with platelet count, urinalysis, stool for occult blood, and creatinine level. Notify the doctor if platelets are below 120. IV bolus of 80 to 100 units per kilogram. Followed by a continuous infusion. It is given with 5% dextrose in water and the dose is usually 18 to 20 units per kilogram per hour. Measure PTT daily. Level should be one and a half to two times the baseline. Notify the doctor is greater than 70 seconds. Assess for signs and symptoms of bleeding including hemataurea, Frank or occult blood in the stool, ecchymosis, petechiae, altered level of consciousness, or pain.

Protamine sulfate is the antidote for heparin

Question 26

low molecular weight heparin

Answer 26

Lovenox, fragment, normiflo. They are the preferred treatment and prevention. They inhibit thrombin formation.

To be a candidate for home therapy they must have a staple DVT or PE, love risk for bleeding, adequate renal function, normal vital signs. Discontinue unfractionated heparin 30 minutes before the first Lovenox injection. Usual dose is 1 mg per kilogram of body weight up to 90 mg, given every 12 hours. If creatinine is greater than 2 mg, a lower dose may be needed. Monitor INR daily. Assess stools for blood.

Question 27

Warfarin therapy

Answer 27

It is started five days after I’m fractioned heparin, or given after the first dose of Lovenox. It inhibits vitamin K clotting factors and takes 3 to 4 days to become therapeutic. Monitor PT and INR. Therapeutic INR is between 1.5 and 2.0 for prevention. Start with a low dose of 5 mg in titrate up to therapeutic levels. Vitamin K is the antidote, and anticoagulation is not possible for three weeks after vitamin K is given.

Question 28

Thrombolytic therapy

Answer 28

Increases the risk for bleeding and is contra indicated after surgery, trauma, strokes, and spinal injuries. It must be started within five days after the onset of symptoms.
Altepase and reteplase are to prevent peripheral vascular occlusion. Read place is not compatible with heparin and should not be given in the same IV line. The most serious complication is intracerebral bleeding. Closely monitor for bleeding and a decreased level of consciousness

Question 29

Patient teaching for warfarin

Answer 29

Small amounts of vitamin K foods. Prevent dehydration, avoid alcohol and sitting for prolonged periods.

Vitamin K foods include broccoli, cauliflower, spinach, kale, green leafy vegetables, brussels sprouts, cabbage, liver, asparagus, turnips, fish,.

Avoid allopurinol, NSAIDs, acetaminophen, vitamin D, histamine blockers, cholesterol reducing drugs, antibiotics, birth control pills, antidepressants, thyroid drugs, antifungal’s, corticosteroids, St. John’s wort, garlic, ginseng, ginkgo biloba.

Question 30

Venous insufficiency

Answer 30

Edema both legs, stasis dermatitis or a reddish-brown discoloration along the ankles, ulcers often form. Ulcers usually form over the malleolus or inner ankle medially more often than laterally. Usually has irregular borders, they are chronic, difficult to heal, recurrence is common. Interventions Is to decrease edema and promote venous return from the affected leg. Compression stockings, elevate legs at least 20 minutes 4 to 5 times a day. Unna boot Hey dressing made of gauze and think oxide and hardens like a cast.

Question 31

Phlebitis

Answer 31

Redmond, warm area radiating up the arm, pain, soreness, and swelling. Apply warm moist soaks to dilate the vein and promote circulation. Complications include Necrosis, infection, pulmonary embolism.