WEEK 2 (Stacy) Chapter 26 ppt: Assessment and Management of Patients with Vascular Disorders and Problems of Circulation Flashcards
Vascular System
Consists of two interdependent systems
o Right side of the heart pumps blood through
the lungs to the pulmonary circulation
o Left side of the heart pumps blood to all other
body tissues through the systemic circulation
Arteries and arterioles
Capillaries
Veins and venules
Lymphatic vessels
Function of the Vascular System
Circulatory needs of tissues
Blood flow
Blood pressure
Capillary filtration and reabsorption
Hemodynamic resistance
Peripheral vascular regulating mechanisms
Pathophysiology of the Vascular System
Pump failure
Alterations in blood and lymphatic vessels
Circulatory insufficiency of the extremities
Gerontologic Considerations
Aging produces changes in the walls of the blood
vessels that affect the transport of oxygen and
nutrients to the tissues
Changes cause vessels to stiffen and results in:
o Increased peripheral resistance
o Impaired blood flow
o Increased left ventricular workload
Assessment of the Vascular System
Health history
o Intermittent claudication,
o “Rest pain”
o Location of the pain
Physical assessment
o Skin (cool, pale, pallor, rubor, loss of hair,
brittle nails, dry or scaling skin, atrophy, and
ulcerations)
o Pulses
Diagnostic Evaluation
Doppler ultrasound flow studies
o Ankle-brachial index (ABI)
Exercise testing
Duplex ultrasonography
Computed tomography scanning
Angiography and magnetic resonance
angiography
Contrast phlebography (venography)
Lymphoscintigraphy
Continuous wave (CW) Doppler
Ultrasound
Photograph courtesy of Kim Cantwell-Gab, MN, ACNP, ANP.
Handheld ultrasound
device that detects blood
flow, combined with
computation of ankle or
arm pressures
Signals are reflected by
the moving blood cells
Diagnostic technique
helps characterize the
nature of peripheral
vascular disease
Assessment of the Patient with Peripheral
Vascular Problems
Health history
Medications
Risk factors
Signs and symptoms of arterial insufficiency
Claudication and rest pain
Color changes
Weak or absent pulses
Skin changes and skin breakdown
Planning and Goals for the Patient with
Peripheral Vascular Problems
Major goals include:
o Increased arterial blood supply
o Decrease in venous congestion
o Promotion of vasodilatation and prevention of
vascular compression
o Relief of pain
o Attainment/maintenance of tissue integrity
o Adherence to the self-care program
Improving Peripheral Arterial Circulation
Positioning strategies—body part below the level
of the heart
Exercise program and activities: walking, graded
isometric exercises
o Consult primary provider before engaging in
an exercise routine
Temperature; effects of heat and cold
Discourage use of nicotine
Stress reduction
Arterial Disorders
Arteriosclerosis and atherosclerosis
Peripheral artery disease
Upper extremity arterial disease
Aortoiliac disease
Aneurysms (thoracic, abdominal, other)
Aortic dissection
Arterial embolism and arterial thrombosis
Raynaud’s phenomenon and other acrosyndromes
Arteriosclerosis and Atherosclerosis
Arteriosclerosis
o Hardening of the arteries
o Diffuse process whereby the muscle fibers and the
endothelial lining of the walls of small arteries and
arterioles become thickened
Atherosclerosis
o Different process, affecting the intima of large and
medium-sized arteries
o Accumulation of lipids, calcium, blood
components, carbohydrates, and fibrous tissue on
the intimal layer of the artery
o Atheromas or plaques
Risk Factors for Atherosclerosis and PAD
Modifiable
Nicotine use
Diabetes
Hypertension
Hyperlipidemia
Diet
Stress
Sedentary lifestyle
C-reactive protein
Hyperhomocysteinemia
Nonmodifiable
Increasing age
Familial
predisposition/genetics
Peripheral Artery Disease (PAD)
Hallmark symptom is intermittent claudication
described as aching, cramping, or inducing
fatigue or weakness
Occurs with some degree of exercise or activity
Relieved with rest
Pain is associated with critical ischemia of the
distal extremity and is described as persistent,
aching, or boring (rest pain)
Ischemic rest pain is usually worse at night and
often wakes the patient
Pharmacologic Therapy for PAD
Phosphodiesterase III inhibitor
o Cilostazol
Antiplatelet agents
o Aspirin
o Clopidogrel
Statins
The nurse is teaching a patient diagnosed with
peripheral arterial disease (PAD). What should be
included in the teaching plan?
A. Elevate the lower extremities
B. Exercise is discouraged
C. Keep the lower extremities in a neutral or
dependent position
D. PAD should not cause pain
C. Keep the lower extremities in a neutral or
dependent position
Rationale: For patients with PAD, blood flow to the
lower extremities needs to be enhanced; therefore,
the nurse encourages keeping the lower extremities
in a neutral or dependent position. In contrast, for
patients with venous insufficiency, blood return to
the heart needs to be enhanced, so the lower
extremities are elevated. Exercise can be prescribed
to aid in the development of collateral circulation.
Some pain is associated with PAD.
Aneurysms
Localized sac or dilation formed at a weak point in
the wall of the artery
Classified by its shape or form
Most common forms of aneurysms are saccular
and fusiform
o Saccular aneurysm projects from only one
side of the vessel
o When an entire arterial segment becomes
dilated, a fusiform aneurysm develops
Raynaud’s Phenomenon
Intermittent arterial vasoocclusion, usually of the
fingertips or toes
o Raynaud’s disease: primary or idiopathic
o Raynaud’s syndrome: associated with other
underlying disease such as scleroderma
Manifestations: sudden vasoconstriction results in
color changes, numbness, tingling, and burning pain
Episodes brought on by a trigger such as cold or stress
Occurs most frequently in young women
Protect from cold and other triggers. Avoid injury to
hands and fingers
Venous Disorders
Venous thromboembolism (VTE) condition
o DVT and PE
Chronic venous insufficiency/postthrombotic
syndrome
Leg ulcers
Varicose veins
Venous Thromboembolism
Pathophysiology
Risk factors
Endothelial damage
o Venous stasis
o Altered coagulation
Manifestations
o Deep veins
o Superficial vein
Preventive Measures
Early ambulation and leg exercises
Graduated compression stockings
Intermittent pneumatic compression devices
Subcutaneous heparin or LMWH
Lifestyle changes
o Weight loss
o Smoking cessation
o Regular exercise
Question #2
Which patient is at highest risk for venous
thromboembolism?
A. A 50-year-old postoperative patient
B. A 25-year-old patient with a central venous
catheter in place to treat septicemia
C. A 71-year-old otherwise healthy older adult
D. A pregnant 30-year-old woman due in 2 weeks
Answer to Question #2
B. A 25-year-old patient with a central venous
catheter in place to treat septicemia
Rationale: Some risk factors for venous
thromboembolism include but are not limited to age
older than 65 years, patients undergoing surgery,
central venous catheter placement, septicemia, and
pregnancy. The client in this question with two risk
factors is the 25-year-old with a central venous
catheter in place to treat septicemia. All other
patients only have one risk factor.
Assessment of the Patient with Leg Ulcers
History of the condition
Assess pain, peripheral pulses, edema
Treatment depends on the type of ulcer
Assess for presence of infection
Assess nutrition
Medical Management of the Patient with
Leg Ulcers
Anti-infective therapy depends on the infecting
agent
o Oral antibiotics are usually prescribed
Compression therapy
Débridement of wound
Dressings
Other
Collaborative Problems and Potential
Complications of the Patient with Leg Ulcers
Infection
Gangrene
Nursing Interventions for the Patient with
Leg Ulcers
Restoring skin integrity
o Cleansing wound; positioning; avoiding trauma; avoid
heat sources
Improving physical mobility
o Physical activity initially restricted to promote healing;
gradual progression of activity
o Activity to promote blood flow; encourage patient to
move about in bed and exercise upper extremities
o Diversional activities
o Analgesic agents before scheduled activities
Promoting adequate nutrition
o Protein; Vitamins C and A; Iron; Zinc
Varicose Veins
Prevention
o Avoid activities that cause venous stasis (wearing
socks that are too tight at the top or that leave
marks on the skin, crossing the legs at the thighs,
and sitting or standing for long periods)
o Elevate the legs 3 to 6 inches higher than heart
level
o Encourage to walk 30 minutes each day if there
are no contraindications
o Wear graduated compression stockings
o Overweight patients should be encouraged to
begin weight reduction plans
Lymphatic Disorders
Lymphangitis: inflammation or infection of the
lymphatic channels
Lymphadenitis: inflammation or infection of the
lymph nodes
Lymphedema: tissue swelling related to
obstruction of lymphatic flow
o Primary: congenital
o Secondary: acquired obstruction
Question #3
Which of the following is an effective strategy used
to promote lymphatic drainage and prevent edema
in clients with lymphedema?
A. Antibiotic therapy for 14 days
B. Constant elevation of the affected extremity
C. Application of heat therapy twice per day
D. Daily exposure to the sun
B. Constant elevation of the affected extremity
Rationale: Constant elevation of the affected
extremity and observation for complications are
essential. After surgery, antibiotics may be
prescribed for 3 to 7 days. The patient is instructed
to avoid the application of heating pads or exposure
to sun to prevent burns or trauma to the area.
Cellulitis
S&S: localized swelling or redness, fever, chills,
sweating
Treat with oral or IV antibiotics based on severity
Nursing
o Elevate affected area 3 to 6 inches above
heart level
o Warm, moist packs to site every 2 to 4 hours
o Educate regarding prevention of recurrence
o Reinforce education about skin and foot care
Peripheral Arterial Occlusive Disease (PAD)
▶ Hallmark Sign: Intermittent Claudication
▶ Elevation Pallor and Dependant Rubor
▶ Symptomatic Claudication
▶ Pentoxifylline and Cilostazol
▶ Antiplatelets
▶ Statins
Diagnostics Review:
▶ Ankle-Brachial Index
▶ Doppler Ultrasound
▶ Duplex Ultrasonography
▶ Computed Tomography (CT) Scanning
▶ Angiography
▶ Magnetic Resonance Angiography (MRA)
▶ Contrast Phlebography (Venography)
▶ Lymphoscintigraphy
PAD Management
▶ Radiologic Intervention
▶ Balloon Angioplasty
▶ Stent
▶ Stent graft
▶ Atherectomy
▶ Surgical Management
▶ Bypass Graft (50% or more occlusion)
Critical Limb Ischemia
▶ Severe obstruction
▶ Pain at rest
▶ Non Healing wounds
▶ Gangrene
Upper Extremity Arterial Occlusive Disease
▶ Coolness and Pallor
▶ Stent or Stent Graft
▶ Percutaneous Transluminal Angioplasty (PTA)
▶ Bilateral BP Comparison
Aortic Aneurysms
▶ Aneurysm
▶ Abdominal
▶ Thoracic
Dissecting Aorta
▶ Dissection
▶ Severe pain
▶ Nausea and vomiting
▶ Tearing feeling
▶ Pulsating abdomen
Arterial Embolism and Thrombosis
▶ Acute Vascular Occlusion
▶ Arterial Emboli
▶ Acute Thrombosis
▶ Acute Arterial Occlusion
▶ Iatrogenic Causes
▶ IV Drug Use
▶ Trauma
Raynaud’s Phenomenon
▶ Microvascular vasoconstriction
▶ Coolness, pain, pallor
▶ Avoid stimuli
▶ Calcium channel blockers
Venous Thromboembolism (VTE)
▶ Deep Vein Thrombosis
▶ Pulmonary Embolism
Chronic Venous Insufficiency /
Postthrombotic Syndrome
▶ Obstruction of valves
▶ Reflux of blood
▶ Superficial or deep veins
▶ Prolonged venous pressure
▶ Increased risk of infection / injury
▶ Treatment:
▶ Leg elevation
▶ Compression stockings
The Six P’s of Acute Arterial Occlusion
▶ Pain
▶ Pallor
▶ Poikilothermia
▶ Pulselessness
▶ Paresthesia
▶ Paralysis
Why are these symptoms occurring?
Varicose Veins
▶ Abnormally dilated and tortuous
▶ Primary (no deep vein involvement)
▶ Secondary (obstruction of deep veins)
▶ Ligation and Stripping
▶ Micro Phlebectomy
Lymphatic Disorders
▶ Lymphangitis
▶ Lymphadenitis
▶ Lymphedema
▶ Elephantiasis
How is a DVT diagnosed?
▶Medical History
▶Physical Exam
▶Test Results
Venous Ultrasound RLE
Ultrasound uses high frequency sound waves to
create pictures and measure the amount of
blood flow through your veins.
DVT Medications: Why? Priority Assessments?
▶ Anticoagulation:
▶ Heparin Subcutaneous x 5 days
▶Normal vs. Therapeutic Level
▶q 6 hours initially
▶Reversal Agent
▶ Warfarin PO
▶Normal vs. Therapeutic Level
▶Bridge Therapy
▶Reversal Agent
Anticoagulation Therapy
Heparin
▶ Test: aPTT
▶ Normal Range: 20 - 39 seconds
▶ Therapeutic Range: 30 - 100 seconds
▶ Reversal Agent: Protamine Sulfate
Warfarin
▶ Test: INR
▶ Normal Range: 1 or less
▶ Therapeutic Range: 2.0 - 3.5
▶ Reversal Agent: Vitamin K
Focused Assessment:
▶ BP = 100/64
▶ HR = 110
▶ RR = 24
▶ Bibasilar Crackles on Auscultation
▶ Labored Breathing
▶ Restless in Obvious Distress
Nursing Diagnosis
▶ Risk for Impaired Gas Exchange
▶ Altered Peripheral Tissue Perfusion
▶ Knowledge Deficient
▶ Risk for Bleeding
▶ Acute Pain
Discharge Education
▶ Medications: Compliance, Risks, Monitoring
▶ Signs & Symptoms of Bleeding (r/t Anticoags)
▶ Signs & Symptoms of Recurrent Pulmonary
Embolism
▶ CP & SOB
Let’s recap the risk factors for a DVT/PE
▶ Sedentary Lifestyle
▶ Recent sedentary behavior
▶ Travel
▶ Prolonged bed rest
▶ Surgery
▶ Heart Failure
▶ Birth Control or Hormone Supplementation
▶ Smoking
▶ Obesity
▶ Pregnancy
▶ Cancer
▶ Genetic Clotting Disorders
