Vascular - Conditions

Question 1

Venous Thromboembolism

Answer 1

• umbrella term for:
  
  • deep vein thrombosis
  • pulmonary embolus
• more common than arterial thrombi because flow and pressure are lower in the veins - more time, easier for blood vessels to clump together

Question 2

Deep Vein Thrombosis - Pathophysiology

Answer 2

• disorder involving a thrombus in a deep vein, most commonly iliac or femoral veins
• thrombi develop when intravascular conditions promote coagulation or if there is a slowing in blood flow
• blood clot forms & occludes the flow of venous blood back to the heart, in response, wall of vein becomes inflammed
• inflammation of the endothelium leads to activation of the coagulant cascade causing platelets to adhere readily
• anatomical changes can contribute, especially if the change leads to pooling of arterial blood
• inflammation around the thrombus promotes platelet aggregation & the thrombus grows
• inflammation may cause pain or redness, but as veins are deep, not accompanied by symptoms, if there is an obstruction increased pressure behind the clot may lead to oedema, most thrombi eventually dissolve

Question 3

DVT - Causes

Answer 3

• surgery (5%), trauma, CVC
• immobility, prolonged travel, sitting and hospitalisation
• trauma to the lower leg
• obesity
• smoking
• pregnancy
• AMI, CCF
• conditions with slow moving blood
  
  • diabetes, hypotension, AF, coagulation disorders
• affects of flying - alcohol - diuretic - frequent voiding - lower circulating volume - more viscous blood - sitting still - not pumping calf muscles - DVT

Question 4

Embolism

Answer 4

• obstruction of the vessel by an embolus
• travels through the through the bloodstream until it reaches a vessel through which it cannot fit
• will obstruct in vascular beds in lungs
• arterial thromboembolism - dislodged due to AF - left side of heart (into artery)
• air embolism
• amniotic fluid embolism
• bacterial embolism
• fat embolism

Question 5

DVT - Prevention

Answer 5

• phamacological therapies & mechanical devises
• anticoagulants
• graded compression stockings & pneumatic devices
• early ambulation post surgery

Question 6

DVT - Virchow’s Triad

Answer 6

• stasis of blood (ie - bed rest)
• increased blood coaguability (eg - contraception)
• injury to vessel wall (eg - fractures, chemical irritation, IV medications)
• only need 2 or 3 to form thrombi

Question 7

DVT - Clinical Manifestations

Answer 7

• symptoms often non-specific
• dull aching pain in affected limb
• severe pain especially when walking
• cyanosis of affected extremity
• slightly elevated temperature
• general malaise
• limb warm to touch
• redness
• oedema & swelling of extremities
• caudication pain - pain on walking

Question 8

DVT - Management - Medically

Answer 8

• aims
  
  • prevention of growing & fragmenting
  • prevent reoccurance
• medical
  
  • anticoagulation therapy
  • heparin
  • warfarin
  • APPT’s & INR’s monitored

Question 9

DVT - Management - Nursing

Answer 9

• pain management
  
  • providing pain interventions
    
    • assess level of pain
    • calf measurements
    • apply warmth to affected extremity
    • bed rest
    • antiembolic stockings
    • analgesia as required
• assessing & managing anticoagulant therapy
  
  • IV patiency and tissue infiltration
  • calculation of correct heparin doses
  • checking blood results
  • checking warfarin doses
  • education patient
• monitoring anticoagulant complications
  
  • check urine for + blood
  • check for bruising, bleeding
  • educate patient re: complications
  • handle effected limb with care
  • have reversing drugs - vitamin K & protamine sulphate

Question 10

DVT - Management - Nursing 2

Answer 10

• altered tissue perfusion
  
  • assess peripheral pulses, skin integrity, capillary refil & colour
  • elevate extremities
  • encourage position changes
  • promote passive exercises
  • anti embolic stockings
  • increase fluid intake
• patient comfort
• education: re - medication therapy
  
  • complications - bleeding from gums, skin, faeces, urine, minor injury, any dizziness or postural hypotension
• education: re - interventions required to reduce inflammation & complication prevention
• knowledge about cause of DVT

Question 11

Varicose Veins

Answer 11

• distended, visible superficial veins on the legs
• due to one way valves in the venous system failing, blood back flows, superficial veins overfill & distend, stretches, bulges veins & becomes visible

Question 12

Varicose Veins - Pathophysiology

Answer 12

• varicose veins develop when a valve is damaged in the vein
• section of the vein is subjected to larger volumes of blood, becomes engorged, hydrostatic pressure & increased movement of plasma through the wall results in intersistual oedema
• pressure in the veins damages the valves, making them unusable

Question 13

Varicose Veins - Causes

Answer 13

• most common in legs
• most common in women
• pregnancy
• obesity
• long periods of standing
• crossing legs at the knees

Question 14

Varicose Veins

Answer 14

• severe, dull leg aches
• muscle cramps (varicose veins, magnesium / calcium deficiencies)
• increased muscle fatigue in lower legs
• feeling of heaviness in lower legs
• visibly dilated veins
• may have
  
  • oedema
  • itching
  • pigmentation changes & ulceration

Question 15

Varicose Veins - Prevention

Answer 15

• do not
  
  • cross legs
  • wear tight, restrictive socks
• do
  
  • change position frequently
  • lose weight
  • exercise
  • walk to promote circulation
  • elastic stockings / TEDS
  • elevate legs

Question 16

Varicose Veins - Management

Answer 16

• reasons for surgery
  
  • severe symptoms (pain, swelling, inability to ove)
  • very large varicose veins
  • episodes of superficial phlebitis
  • rupture of varicose veins
  • development of ulcers
  • cosmetic reasons

Question 17

Varicose Veins - Surgery

Answer 17

• vein stripping
  
  • removal of varicose vein & litigation of branches
  • can reoccur
• scleotherapy
  
  • injecting vein with sclerosing agent, apply compression bandage & veins is obliterated & blood re-routes
  • can reoccur

Question 18

Aneurysms

Answer 18

• abnormal dilation of a blood vessel, commonly at the site of a weakness or tear in the vessel wall
• outpouching or dilation of the arterial wall
• more prevalent in men
• commonly found in the aorta & peripheral arteries
• classified upon
  
  • size
  • location
  • pathologic features
  • causative factors

Question 19

Aneurysms - Patho

Answer 19

• form when there is a disruption in the wall of the vessel, with changes in elastin & collagen, make the vessel more vulnerable to intravascular pressure
• common in aorta due to constant stress on the vessel wall
• atherosclerosis the most common cause as plaque formation erodes the vessel wall & contributes to inflammation that can weaken the vessels
• Berry
  
  • usually congenital abnormalities, leads to a sac-like out-pouching from the vessel wall, grows & weakens over time
• Fusiform
  
  • involve circumference of the vessel, usually found in ascending aorta & abdominal aorta due to atheroscloritc changes
• Dissecting
  
  • tear in the intima of the aorta - most common in ascending aorta where pressures are highest
  • aorta is largest artery in body, blood is pumped through at high force, vessel walls can break down, lead to ballooning out and damage to the intima leads to blood passing through into media layer causing a weaker false channel for blood flow

Question 20

Aneurysms - Causes

Answer 20

• arteriosclerosis
• atherosclerosis
• trauma
• hypertension
• congenital
• some diseases
• infection

Question 21

Aneurysms - Berry

Answer 21

• found in the circle of willis
• caused by a congenital abnormality
• generally small (<2cm in diameter)
• affects the media of the arterial wall
• ruptures without warning
• asymptomatic before rupture

Question 22

Aneurysms - Fusiform

Answer 22

• most commonly found in ascending aorta & abdominal aorta
• very large, involves the circumference of the vessel
• grows slowly but progressively

Question 23

Aneurysms - Dissecting

Answer 23

• tear in the intima of the aorta with haemorrhage into the media, the layers separate & swell
• causes a false weakened channel for blood to flow through
• most common in ascending aorta where pressures are highest
• abrupt ripping / tearing pain, if it bursts can be fatal
• aorta pumps fresh o2 through the body
• intima - inner layer, media - middle layer, externa - outside layer

Question 24

Aneurysms - Clinical Manifestations

Answer 24

• vary, depending on location
• may include
  
  • pain (localised / radiating)
  • symptoms of ischaemia
  • symptoms resulting from pressure on body structures (ie - dysphagia due to pressure of the oesophagus)

Question 25

Aneurysms - Investigations

Answer 25

• chest x-ray
• ECG
• CT scan
• angiogram
• ultrasound
• MRI (to confirm location)

Question 26

Aneurysms - Medical Management

Answer 26

• conservative
  
  • antihypertensives
  • beta blockers
  • anticoagulants
• surgery
  
  • excise the aneurysm
  • replace with synthetic graft (surgical stenting)

Question 27

Aneurysms - Nursing Management

Answer 27

• assessment of tissue perfusion
  
  • monitoring of pulmonary, cardiovascular, cerebral & renal status
• pain management
• decrease anxiety
• rupture - constant back pain, falling BP
• 50-75% mortality if ruptured

Question 28

Amputation - Indications

Answer 28

• peripheral vascular disease
• ateriosclerosis & PVD
• infection
• trauma
• congenital abnormalities
• malignant tumors

Question 29

Amputation - Considerations

Answer 29

• prior to amputation
  
  • persons condition based on physical assessment, results of diagnostic tests, emotional status
• type & level of amputation
  
  • amputate at most distal level that will heal and be functional, proposed level will have sufficient blood supply, prosthesis will fit limb
• rehabilitation potential
  
  • cooperative, patient, willing to undertake physio, need to consider age, disease process, physical & mental condition

Question 30

Amputation - Nursing Management

Answer 30

• major objectives
  
  • achieve healing of site
  • non tender, well shaped stump
  • healthy skin for prosthesis
  • management dependent on location of amputation
• nursing problems
  
  • disturbance of self concept
  • dysfunctional grieving
  • phantom pain, physical pain
  • impaired skin integrity
  • impaired physical mobility
  • self care defecit
• prevention of hip-knee flexion contractions
  
  • do not place residual limb on pillows
  • raise bed off floor
  • prone position a few times a day to stretch flexor muscles
  • discourage sitting for long periods
  • legs should remain close together to prevent abduction deformity
  • ROM exercises

Question 31

Amputation - Phantom Pain

Answer 31

• immediately or 2-3 months post surgery
• occurs on 80% of amputees
• feel limb is crushed, present, twisted in abnormal position
• have patient describe pain, frightening for patient, patient should be told what to expect
• pain usually disappears with time

Question 32

Amputation - Stump Bandaging

Answer 32

• increase venous return
• decrease oedema
• shape stump for prosthesis
• aim to have firm conical shape
• modify figure eight bandage