Vascular Problems - Arterial/Venous Flashcards
Vascular system starts with the left heart that pumps oxygen-rich blood through arteries, arterioles, capillary system (where you have O2 and CO2 exchange with the cells of the body)
Venules and veins return the O2 poor, CO2 rich blood to the right side of the heart to the lungs
- With peripheral circulation, we’re dealing with 2 groups of very different diseases - venous and arterial - that will exhibit with different symptoms and be treated differently
Peripheral Arterial Disease (PAD)
- Affects ~12% of people in the US
- Men are affected more commonly than women before menopause; then, women surpass men
- 50-75% of clients with PAD have clinically significant coronary artery disease (CAD)
- CAD may be silent because PAD prevents clients from exerting themselves enough to trigger angina
Pathophysiology of PAD
- Insufficiency of the peripheral circulation
- Atherosclerotic plaques narrow the arterial lumen impeding oxygenated blood flow to distal tissues
- Stenosis (narrowing) and occlusion (blockage)
Risk Factors
- # 1 > smoking (includes passive smoking)
- Male gender
- HTN
- High LDL/low HDL cholesterol
- Diabetes
- Family h/o atherosclerosis
- Obesity/sedentary lifestyle
- High homocysteine and CRP levels
- Stress
Homocysteine and C-reactive proteins increase __ formation and increase the propensity for __ formation; risk factor for atherosclerosis
thrombin
thrombus
Signs & Symptoms - What are the 6 P’s?
- Pain
- Pallor
- Pulse
- Paresthesia
- Paralysis
- Poikilothermia
?
Is the inability to maintain a constant core temperature independent of ambient temperature
Poikilothermia
- 20% asymptomatic (b/c not active enough to induce symptoms)
- Intermittent claudication/progress to pain at rest
- Nocturnal pain/improved with dangling extremity
- Delayed capillary refill
- Waxy appearance of extremity
> Extremity pallor when elevated
> Extremity rubor when dependent
- Diminished or absent peripheral pulses
- Skin is thin, waxy, and with hair loss
- Skin is cool to touch
- Cyanosis (r/t decreased arterial flow to tissues) [extremity may even be diaphoretic r/t sympathetic overactivity]
- Ulcers
- Dry and wet gangrene [risk of cellulitis]
- Painful
- Progression to paresthesia and paralysis
- Painful unless there is peripheral neuropathy from diabetes or alcoholism
- Pulseless, cold, painful, paresthesia and paralysis may be indicative of acute embolic syndrome
- PAD ulcers usually small, round, necrotic with minimal or no drainage
Diagnostics - Noninvasive
- Doppler - segmented systolic BP measurements of the LE
- (ABI) Ankle/Brachial Index
- MRI
- Exercise Tolerance
Diagnostics - Invasive
- Arteriography
Doppler - segmented systolic BP’s of LE
- Normally BP’s in LE are higher than UE
- With PAD, UE BP’s are higher than LE
- Mild disease - diff of 10-30 mmHg
- Severe disease - diff of 40-50 mmHg
?
Is the ratio of systolic BP in the ankle to systolic BP in the arm
Derived by dividing the ankle systolic pressure with brachial systolic pressure
With increased stenosis, there’s a decrease in the systolic pressure distal to the stenosis/occlusion
ABI
- Claudication 0.90-0.50
- Rest pain 0.49 or less, severe ischemia and tissue loss 0.25 or less
- > 1.3 indicates calcification of vessels from DM, CRF, hyperparathyroidism
Exercise Test
- If there’s a drop in ankle pressure by 40-60 mmHg for 20-30 sec and a decrease in pulse volume waveform, this is indicative of PAD
- Screen for CAD for surgical procedures
Nursing Interventions
- Meticulous foot care
- Monitor and treat pain (no cold or warm packs r/t ischemia and increased trauma)
- Legs in the dependent position
- Monitor for the development of ulcers
- Wound care as ordered
- Antibiotics as ordered for cellulitis
- Encourage moderate amount graded ambulation once initial infection resolved and healing begins
- Encourage adequate PO fluids (fluids to decrease viscosity of blood)
- Surgical interventions: aorta-femoral bypass, embolectomy
- Avoid the cold
- Diet of protein, vitamin A, C, zinc
- Avoid leg crossing
- CMS checks
> Palpate dorsal pedis, posterior tibialis, popliteal and femoral pulses > doppler
- NPO and IV for angiogram or surgical intervention
- ___ (cilostazol), ___ (pentoxifylline), ___ (clopidogrel), aspirin
- Review of antihypertensives
Pletal, Trental, Plavix
Pletal (antiplatelet/vasodilator)
- HA, diarrhea, abnormal stools, palpitations, tachycardia
Trental (hematological agent)
- Xanthine
- May potentiate antihypertensives and anticoagulants (! know bleeding precautions)
Plavix (clopidogrel) and asa (antiplatelets)
- Clopidogrel also is good for reducing MI and stroke
- Antihypertensives may decrease flow to LE and cause worsening symptoms, i.e., beta blockers, no vasoconstrictors
- Avoid tobacco
- Avoid caffeine
- Vasodilators
Other Arterial Diseases
- Aneurysm
> Thoracic, aortic - Buerger’s Disease
- Raynaud’s disease
> Raynaud’s phenomenon
?
- Cause unknown
- Chronic inflammatory disease
- Most common in men, ages 20-35
- Occurs in many areas of the world
- Smoking and chewing tobacco is causative and aggravating factor
Buerger’s Disease
Buerger’s Disease
- thromboangiitis obliterans
- Inflammation and scarring of small and medium arteries and veins of extremities
- Pulseless pedal, radial, ulnar
- But positive pulses in the femoral and popliteal areas
- Leads to clot formation and ulcers; gangrene in distal arteries, bilateral and symmetrical
- Color: rubor, pale, or cyanotic limb
Prevention/Treatment
- Smoke cessation
- Avoid cold
- Treat pain
- Vasodilators - calcium channel blockers
- Wound care - amputation
Raynaud’s ?
- Unilateral
- 30 years of age
- Either gender
phenomenon
Raynaud’s ?
- Bilateral
- 17-50 years
- Mostly women
disease
Raynaud’s assessment - S/S
- Skin pallor, then becomes cyanotic, and eventually turning red
- Numbness and tingling
- Burning pain as the skin color changes
- Possible ulcers
Treatment
- Avoid cold, caffeine, nicotine
- Stress management/biofeedback
- Vasodilating agents
- Preventive practices
> Avoid known vasoconstrictors
Venous Disease
- Deep venous thrombosis [clot]/embolus [travels to lung]
- Post thrombotic syndrome
- Varicose veins
- Venous stasis ulcers
?
Is permanent valve and vessel damage from DVT which makes the extremity at risk for future DVT’s, emboli, varicosities, and ulcers
Post thrombotic syndrome (PTS)
?
Is a clot or thrombus formation in the veins
DVT
DVT - S/S
- Warm, red skin
- Visible surface veins
- Calf, leg, or groin pain, tenderness, fatigue
- Sudden swelling of unilateral limb
- Induration
PE - S/S
- SOB
- Rapid pulse
- Diaphoresis
- Sharp chest pain
- Bloody sputum, fainting
What is Virchow’s triad?
- stasis of blood flow
- endothelial injury
- states of hypercoagulability
Risk Factors - Virchow’s Triad
- Previous DVT/Fhx DVT
- Immobility, recent injury, long distance travel
- Hormone therapy, oral contraceptives, pregnancy, post-partum
- Previous or current cancer
- Limb trauma, orthopedic procedures
- Coagulation abnormalities
- Obesity
- Varicose veins
- HF/MI
- Older than 40
Prevention
- Smoke cessation (smoking > increased platelet aggregation)
- ROM exercises when in bed
- Ambulate ASAP >surgery
- Change position q2h
- Pneumatic devices
- Elastic graduated compression stockings
- Anticoagulants
- Elevate your feet when sitting
- Avoid tight-fitting clothing
- Do not cross your legs
- SCDs (from the ankle to the thigh assisting blood return to the heart)
- TEDs
- Elastic graduated compression stockings
- Wear gradient compression socks or stockings everyday
- Use rubber gloves to get a better grip on the fabric
- If you can’t tolerate wearing them all day, wear for a few hrs at a time and increase amt of time daily
- Put on 1st thing in the morning
- If skin is moist, apply cornstarch or grease-free talcum
- Keep legs and feet warm to promote circulation
- Stockings last about 3-6 mos
- Pay attention to washing instructions
- Don’t allow wrinkles in the stockings
- Don’t cut or alter
- Don’t fold or roll down
- Remove if prolonged numbness or tingling occur or if you see bluish discoloration
Diagnostics
- D-dimer
- Duplex venous ultrasonography
- Venography
- MRI
Treatment/Goals
- Prevent thrombus
- Prevent growth of existing thrombus
- Prevent growth of new thrombi
- Prevent pulmonary embolus
> Anticoagulants do not dissolve existing thrombus but prevent new clots from forming
> Vena cava filter
- Heparin, Lovenox (enoxaparin) prevent new clots
What is the antidote for heparin and what coagulation factor are we looking at?
! Know HIT (drop in platelets)
protamine sulfate
PTT
What is the antidote for coumadin (warfarin) and what coagulation factor are we looking at?
Vitamin K
PT/INR
- Prevent post-thrombotic syndrome
> Catheter-directed thrombolysis
> Thrombolytic delivered directly to existing thrombus and dissolves it
What are some thrombolytics?
- Urokinase, tPA, Retavase, TNKase, Activase, streptokinase - dissolves existing clots
What is the antidote for thrombolytics?
Amicar
?
Are incompetent valves that lack surrounding muscle support; painful, tortuous bluish veins
Varicose veins
Varicose Veins Risk Factors
- Familial tendency
- Thrombophlebitis
- Obesity (only in women)
- Prolonged standing
- Pregnancy (2 or more greater risk)
Prevention/Treatment
- Avoid prolonged standing
- Promote weight loss
- Exercise, TEDS
- Chemical sclerosing
- Surgical vein ligation and stripping
?
A condition caused by chronic venous insufficiency
Edema, pain at site and discoloration can be noted here
Venous stasis ulcer(s)
Treatment
- Wound care and assessment
> Unna boot
> Debridement
> Elevation - Antibiotics for cellulitis
- Treat pain
- Provide adequate nutrition for wound healing (protein, vitamin A, C, zinc)
- Hyperbaric oxygenation
Nursing Diagnoses
- Ineffective peripheral tissue perfusion r/t compromised circulation
- Chronic pain r/t impaired ability of peripheral vessels to supply O2 to tissues
- Impaired skin integrity r/t vascular insufficiency
- Alteration in mobility r/t vascular insufficiency
