1. MCC NURSING DIANA BLUM MSN
Vascular
Common disorders in America:
hypertension
atherosclerosis
arterial occlusive disease
abdominal aortic aneurysms (AAA)
deep vein thrombosis (DVT)
venous insufficiency
MCC NURSING
DIANA BLUM MSN

2. hormones C reactive protein is a marker for cardiac inflammation
Increases mean: risk of damage
Homocysteine: protein that promotes coagulation by increasing factor 5 and factor 11 while depressing activation of protein C and increasing thrombus formation risk
Vitamin b6 and b12 and folate lowers homocysteine levels
hormones

3. Arterial diseases: Arteriosclerosis (atherosclerosis)
Aneurysm formation
Arteriosclerosis obliterans
Raynaud’s phenomenon
Arterial embolism
Thromboangiitis obliterans
Diabetic arteriosclerotic disease
hypertension
Arterial diseases:

4. Manifestations :ARTERIAL (50% occulsion before symptoms)
Prolonged capillary refill:
- 3 seconds or more
Ulcers:
- open lesions on feet from diminished distal perfusion
Ischemia (reduced oxygenation)
- leads to pain
Paresthesia (decreased sensation in
extremities = tingling/numbing)
Pain (in feet/leg muscles = burning,
throbbing, cramping)
-usually from exercise BUT also
with elevation of lower extremities
Hallmark sign: Intermittent claudication (pain in
exercising muscles – usually in calf
- directly related to decreased
blood supply during activity &
recedes with rest
Temperature: (COLD)
Skin color changes: skin pale on
elevation but red dependent
Reactive hyperemia: (reduced blood flow
to extremity results in arteriolar dilation so when the blood supply is restored,
the affected area becomes warm/red
from congestion
Pulse changes: Peripheral diminished or
absent

5. Arteriosclerosis -describes arterial disorders in which
degenerative changes result in
decreased blood flow
Atherosclerosis:
- most common form of arteriosclerosis, excessive accumulation of lipids
Arteriosclerosis
Hypertension (MOST SIGNIFICANT)
Cigarette smoking (nicotine has DIRECT
vasoconstricting effect)
Elevated serum cholesterol (fat causes
obstructive plaques)
Obesity (increased work to heart)
Diabetes (hyperglycemia causes damage to vessel wall)
Other: increase age, inactivity, family hx

6. Most common affected areas from arteriosclerosis:
Heart: coronary arteries (angina, MI,
death)
Brain (transient ischemic attacks =TIAs
CVA, death)
Kidneys (renal arterial stenosis lead to
chronic renal failure)
Extremities (gangrene of digits &
intermittent claudication)

7. Pathophysiology of atherosclerosis
-inflammatory process, begins as fatty streaks that are deposited in the intima of the arterial wall
Genetics and environment play a factor in the progression
Elastic arteries: aorta, carotid, lg & med. sized muscular arteries (popliteals) most
susceptible arteries.
Endothelial injury: may be initiated by smoking, hypertension, diabetes, hyperlipidemia, 
Pathophysiology of atherosclerosis

8. Inflammatory cells(including macrophages) become attracted to the wall
Macrophages infiltrate wall and ingest lipid which turns them into foam cells
They then release biochemical substances that cause further damage and attract platelets which then causes clots to form

9. Ankle-brachial index of blood pressure: Used to diagnose peripheral vascular disease
-compares the blood pressure at ankle with that of the arm.
-normally these should be the same (with a ratio of 1)
-lesser number than 1 shows decreased blood pressure at the ankle compared to upper extremity = = which indicates peripheral vascular disease to lower extremities

11. SURGERY Indications for fem-pop bypass: diabetes hypertension
vasculitis
collagen disease
Bueger’s disease
Also, Embolectomy (surgical removal)
SURGERY

12. Fem-pop bypass

13. MEDICAL MANAGEMENT ANTIPLATELET THERAPY
Aspirin, ticlid, plavix, pletal, trental
Beta blockers
ARBs
Statins
Radiation therapy
Angioplasty with stents

14. Nursing Interventions
Monitor BP for difference between arms
Could be indicative of aortic coarctation
Narrowing of aorta lumen
Monitor for carotid bruits
Assess cap refill, pulses,skin

15. Acute arterial stenosis
Monitor for the 5 P’s
pain, sudden
pallor
pulselessness
paresthesias
paralysis

16. Acute peripheral arterial occlusion
may result from rupture and thrombosis of an atherosclerotic plaque, an embolus from the heart or thoracic or abdominal aorta, an aortic dissection, or acute compartment syndrome
Symptoms and signs are sudden

18. Buerger Disease Autoimmune disease
Recurrent inflammation of small arteries and veins of the extremities resulting in thrombus formation and occlusion.
Unknown cause
Men years old
All races
Link to heavy smoking/chewing tobacco
s/s: rubor (reddish blue) color to foot, no Pedal pulse, discolored legs when dangled, eventually gangrene sets in

19. Aneurysms of Central Arteries
Enlargement of artery least 2X its normal
Aortic dissection
Medial & intimal layers separate
Risk Factors:
-hypertension
-cocaine use
- Marfan syndrome
85% are caused by atherosclerosis
More frequent in men b/w years old
Most common site for dissection
1/3 of pts with this die from rupture
s/s:
Asymptomatic
Pain is primary symptom—constant
Dyspnea
Cough
Hoarseness
Stridor
Aphonia (weakness or complete loss of voice)
Unequal pupils
Diagnostics:
Chest x-ray
TEE CT
Aneurysms of Central Arteries

20. Aortic Dissections: Type III most common type

21. Abdominal Aortic Aneurysm Size and Rupture Risk*
AAA Diameter (cm)
Rupture Risk (%/yr)
< 4
4–4.9 1%
5–5.9*
5–10%
6–6.9
10–20%
7–7.9
20–40%
> 8
30–50%
*Elective surgical repair should be considered for aneurysms > 5.0–5.5 cm.

22. Aortic dissection

23. Signs/symptoms of aortic dissection:
n/v, diaphoresis with pain
“tearing” pain
Sudden onset
not relieved with change of position
Dissection of ascending aorta: anterior CP with
radiation to neck, throat, jaw
Dissection of descending: interscapular back pain
radiation to lower back or abdomen
Signs/symptoms of aortic dissection:

24. Treatment of hypertension for aortic dissection:
IV propranolol
Nitropresside drip after beta blocker ( nitropresside by itself causes tachycardia AND  left vent. contractility that is why a beta-blocker should be given first, then start nitropresside drip)
Diagnosis:
CXR (but 10% normal) see medialstinal
widening
Contrast CT
MRI
GOAL: to keep blood pressure to lowest
possible but yet allows tissue perfusion
Per physican recommendations

25. Surgery for distal dissections:
Mortality in 1st 48 hrs if unrepaired proximal aortic dissections is 40%
Usually distal dissections treated medically unless:
rapid expansion
saccular formation
persistent pain
hemodynamic compromised
blood leakage
impending rupture

27. Dacron tube

28. Abdominal Aortic Aneurysm (AAA)
75% of all aneurysms
Located between renal arteries & aortic bifurcation
Symptoms from pressure exerted in surrounding structures.
Many nonsymtomatic until ruptures
Look for pulsating abdominal mass
With rupture: hypovolemic shock & mortality
around 90%
Monitor growth: freq. CT scans
Antihypertensives
SURGICAL:
graft

29. Post-op nursing interventions for graft:
Vitals
Pulses distal to graft
Report:
changes in pulse
cool extremities distal to graft
white/blue to extremities distal to graft
severe pain
abd. distention
decreased UO

30. Post-op nursing intervention (continued) Post graft
Elevation of head to 45° or less
Renal function lab
Respiratory status
Paralytic ileus (NG tube)
Assess for dysrhythmias post thoracic

31. Venous manifestations:
Skin color changes: reddened or
cyanotic
Edema: pooling of fluid results in edema
Venous stasis ulcers: skin breakdown
due to increased pressure from
chronic pooling of blood
Decreased mobility: may result from
the edema
Pain:
- in feet/ leg muscles; aching/throbbing
- results from venous stasis & increases
as day progresses (esp with sitting
or standing)
Temperature changes:
- warm to touch since blood can enter
but cannot leave affected parts
What dx are we talking about?
Venous thrombosis (thrombophlebitis)
known as DVT
Varicose veins
Venous stasis ulcers
DVT risk for pulmonary embolism
- legs
- seen post hip surgery, knee replacement
pregnancy, ulcerative colitis, hrt failure, immobility
Venous manifestations:

32. DVT : Groin tenderness/pain Unilateral sudden onset edema leg
Homan’s sign (appears in only 10% of pt
with DVT)
Ultrasonography

33. DVT interventions: Rest (do NOT massage area)
Low-molecular weight heparin
Coumadin
TPA
****Contraindications to anticoagulant therapy
Pt compliance, bleeding, aneurysms, trauma, alcohol, recent surgery, liver or kidney disease, hazard jobs, pregnancy
DVT interventions:

34. Nursing cares Monitor for hemorrhage Monitor PT/PTT
Heparin is therapeutic b/w on ptt
Coumadin is therapeutic b/w 2-3 on PT/INR
Monitor for Thrombocytopenia
Monitor Platelets
s/s; purpura, bruising, hematomas
Provide bedrest
Ted Hose or ace wraps for prevention of DVT
SCDs for prevention of DVT
Pain meds
Nursing cares

35. - excessive tension exerted on arterial walls which places pts at increased risk for target organ damage
-asymptomatic until complications develop
- elevation may be systolic or diastolic or both
- normal <120 mmHg systolic
<80 mmHg diastolic
Often none
Occipital headache more severe on rising
Lightheadedness
Epistaxis
Known as the ‘Silent Killer’
What factors determine arterial pressure?
Cardiac output which is the volume of blood pumped by the heart in 1 minute
Peripheral vascular resistance which is the force in the peripheral blood vessels that the left ventricular must overcome to eject blood out of the heart
Hypertension

36. Pathophysiologic processes for hypertension:
BP=CO X peripheral resistance
Elevated BP is direct result of increased
peripheral resistance, increased CO or
both
Renin-angiotensin-aldosterone system
Aldosterone: increased water/Na+ retention thus increasing ECF volume which leads to increased CO with subsequent increase BP

37. Possible Causes of PVR
Narrowing of blood vessels, PVD, CAD, kidney disease: > renin/angiotensin =vasoconstriction
Release of catecholamine (epinephrine and adrenalin) = vasoconstriction
> blood volume= more work to pump
> Blood viscosity=harder to pump
Ability of blood vessel to stretch
95% of cases of hypertension are 1st degree (essential)
2nd degree hypertension: CHAPS
Cushing’s syndome
Hyperaldosteronism
Aortic coarctation
Pheochromocytoma
Stenosis of renal arteries
Complications of Htn and pvr are
Damage to blood vessels of the eyes, heart, kidney, brain resulting in:
Stroke
CHF
AMI
Renal failure
Blindness

38. Target Organ Disease from hypertension
Large vessels: aneurysmal dilation
accelerated atherosclerosis
aortic dissection
Cardiac:
acute= pulm edema, MI
chronic= LVH
Cerebrovascular:
acute= Intracranial bleed, coma, seizure
mental status changes, TIA, stroke
chronic=TIA, stroke
Target Organ Disease from hypertension

39. Target organ disease from hypertension:
Renal: acute=hematuria, azotemia
chronic=elevated creatinine
proteinuria
Retinopathy:
acute=papilledema, hemorrhages
chronic=hemorrhages,exudates,
Target organ disease from hypertension:

40. Treatment of hypertension:
Lifestyle modification
ABCD:
ACE inhibitors; ARB
B-blockers
Calcium channel blockers
Diuretics

41. Hypertensive Crisis: Treatment
Parenteral agents for immediate redux of BP
In ICU for monitoring
Arterial line
Drug of choice: sodium nitroprusside
=direct acting arterial & venous vasodilator
= reduces BP rapidly but lower mean arterial pressure no more than 25% over 1st 2 hours
= easily titratable
= monitor closely for hypotension
= shield this drip from light
Sometimes rare sometimes fatal
Diastolic BP
Causes vascular damage
Can be caused by renal failure, HTN, Med withdrawal

42. STROKE: occlusion of cerebral vasculature
DUE TO:
1. emboli that lodges in cerebral vasculature
(from a-fib, vegetations on an infect valve)
2. atherosclerotic plaque (occludes carotid arteries)
3. venous occlusion (secondary to thrombosis)
4. arterial dissection (in carotid or vertebrobasilar system)
5. severe hypotension ( infarct in cerebral areas)
6. hemorrhage :occurs during activity
Chapter 22

43. Sudden loss of function resulting from disrupted blood supply to area in brain
5 types:
Large artery
Caused by atherosclerosis
Small penetrating artery
Most common
Also called lacunar strokes because it creates a cavity
Cardiogenic emboli
Usually from afib
Cryptogenic
No known cause
Other
Caused from Drug use, migraines,spontaneous
TIA

45. Hemorrhagic stroke
Bleeding into brain tissue or ventricles, subdural, or subarachnoid spaces due to ruptured aneurysm or from severe hypertension
VASOSPASM (after a bleed)
4-14 days post hemorrhage
Management is difficult
Manifestations:
Severe headache
LOC
Tinnitus
Dizziness
Hemiparesis
Prognosis: variable
Diagnostics: CT
Lumbar puncture
Angiography

46. Prevention
Manage HTN
Avoid alcohol
Increase public awareness

48. Assessment Tools
Neurological assessment upon admission or change in client status, including:
Level of consciousness
Orientation
Motor ability
Pupils
Speech/language
Vital signs
Blood glucose
Risk assessment for complications including fall, pressure ulcer, painful hemiparetic shoulder, spasticity/contractures, and deep vein thrombosis
Pain assessment
Administration and interpretation of dysphagia screen
Nutrition and hydration screening
Screening for alterations in cognition, perception, and language using validated tools
Assessment of activities of daily living (ADL) using validated tools
Assessment of bowel and bladder function
Depression screening using a validated tool
Assessment/screening of caregiver burden using a validated tool
Screening of stroke clients and their partners for sexual concerns
Assessment of stroke client and their caregivers' learning needs, abilities, learning preferences and readiness to learn
Referral for further assessment and management, as indicated
Documentation of all assessments and screenings

49. Treatment for stroke: (Note similar to measures for myocardial ischemia/MI)
Thrombolysis (who is not a candidate?)
Lower BP
Quit smoking
Decrease cholesterol
Antiplatelet (ASA)

50. Stroke treatment (continued)
ASA
Heparin (SQ or IV contin infusion)
Low-molecular wt heparin (lovenox)
Warfarin (coumadin)
Obtain PT, PTT prior to therapy
PT: monitor oral anticoag : goal=1.5 to 2 times pt baseline
PTT: monitor heparin: goal=1.5 to 2 times pt baseline
INR: monitor Warfarin: goal=2 to 3

51. More stroke treatment:
Carotid artery angioplasty
Arteriovenous Malformation (gamma radiation through Gamma knife)
Aneurysms (coils)
Craniotomy for clot removal
Assessments while on anticoags.:
Observe for bleeding
Also, antiplatelet meds (Plavix, Persantine) cause
bruising, hemorrhage, liver disease (need liver function tests)
GIVE clopidogrel (Plavix) with food

52. Nursing Diagnosis Impaired physical mobility: -flaccid, spasticity
Disturbed sensory perception:
-vision, proprioception, sensation
Unilateral neglect:
- use both sides of body (dress affected side first)
Impaired verbal communication::
-expressive, receptive, both
Impaired swallowing:
must be evaluated, must prevent aspiration !!! But yet meet caloric needs
Urinary and/or bowel incontinence
Nursing Diagnosis

53. Complications
Rebleed
Vasospasm
Hydrocephalus
Hypoxia of brain

54. Nursing interventions
Administer oxygen
Provide adequate hydration
Evaluate swallow function
Frequent neuro checks
Strict I/O
Seizure precautions
Monitor ICP
Monitor BP closely
Teach stress reduction techniques
Manage agitation

55. Surgery and complications
Evacuation of blood via craniotomy
Goal of surgery is to prevent further rupture/bleed
Post op complications
Disoriented
Amnesia
Korsaff’s syndrome (psychosis caused by lack of thiamine)
Personality changes
Intraop emboli
Electrolyte disturbances
GI bleed
Surgery and complications

56. QUESTIONS???