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1 Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN.

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Presentation on theme: "1 Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN."— Presentation transcript:

1 1 Nursing Care & Interventions for Clients with Vascular Problems Keith Rischer RN, MA, CEN

2 2 Todays Objectives… Review the pathophysiology of arteriosclerosis, including the factors that cause arterial injury Discuss drug therapy for hypertension Evaluate the effectiveness of interdisciplinary interventions to improve hypertension Prioritize nursing care for the patient experiencing vascular disorders Develop a continuing care plan for a client who has hypertension Prioritize postoperative care for clients who have undergone peripheral bypass surgery.

3 3 Serum Lipids:Cholesterol One of the several types of fats (lipids) Important component of cell membranes, and bile acids Building blocks in certain types of hormones Predominant substance in atherosclerotic plaques Circulates in the blood in combination with triglycerides, encapsulated by special fat-carrying proteins called lipoproteins <200 is desirable for total cholesterol

4 4 Lipoproteins LDL = Low Density Lipoproteins - bad cholesterol <130 is desirable HDL = High Density Lipoproteins - good cholesterol >30 is desirable- the higher the HDL, the lower the risk of CAD Triglycerides- combination of glycerol with 3 fatty acids Transportable fuel- energy source Strongly influenced by diet

5 5 Cholesterol Levels LDL Cholesterol <100Optimal Near optimal/above optimal Borderline High High >190Very high Total Cholesterol <200Desirable Borderline High >240High HDL Cholesterol <40Low >60High

6 6 Hypertension Vascular Disease Affects 1 in every 4 adults in the US Major risk factor for cardiovascular disease (CVD) Stroke, MI, Heart Failure Other Target Organ Damage LV hypertrophy Nephropathy Vascular Disorders PVD Retinopathy

7 7 Categories Primary (Essential)- without identified cause 90-95% of all hypertension Pathophysiology: (exact cause unknown) Heredity H2O & Na+ retention Altered renin-angiotensin mechanism Stress and increase sympathetic nervous system activity Insulin resistance and hyperinsulinemia Endothelial cell dysfunction Secondary- results from identifiable cause renal disease, endocrine disorders, neuro disorders, meds, PIH

8 8 Stages of Hypertension CategorySBP(mmHg)DBP(mmHg) Normal<120<80 Prehypertension Hypertension, Stage 1: Hypertension, Stage 2: Hypertension, Stage 3: >180>110

9 9 Clinical Manifestations Early Elevated BP Asymptomatic (silent killer) Later Symptoms secondary to effects on blood vessels in various organs or tissues Fatigue, reduced activity tolerance, dizziness, palpitations, angina, dyspnea

10 10 Risk Factors for Primary Hypertension Age Alcohol use Cigarette smoking DM Elevated serum lipids Excess dietary sodium Gender Family history Obesity Ethnicity Sedentary lifestyle Socioeconomic status Stress

11 11 Knowledge Deficit Encourage healthy lifestyles Lifestyle modifications for all patients with prehypertension and hypertension Components of lifestyle modifications include: weight reduction, DASH eating plan dietary sodium reduction aerobic physical activity moderation of alcohol consumption Stress reduction

12 12 Risk for Ineffective Therapeutic Regimen Management Interventions: Teach medication compliance, usually for the rest of life. goals of therapy potential side effects Assist client to understand therapeutic regimen. Discuss consequence of noncompliance Most African American clients will need at least 2 medications to achieve blood pressure control ACE inhibitor and calcium channel blocker.

13 13 Diuretics Loop Bumetanide (Bumex) Furosemide (Lasix) Thiazide-Type Chlorothiazide Hydrochlorothiazide (HCTZ) Potassium-Sparing Spironolactone (aldactone)

14 14 Pharmacologic: Diuretics Mechanism of Action: Thiazides, Loop, Potassium Sparing S/E: fluid and electrolyte imbalances –K+, Mg++ CNS effects GI effects Nursing Considerations: Monitor for orthostatic hypotension –dehydration Hypokalemia

15 15 Adrenergic Inhibitors: Beta Blockers Cardioselective (β 1 ) Atenolol (Tenormin) Metoprolol (Lopressor) Non-cardioselective (β 1, β 2 ) Propranolol (Inderal) Mechanism of Action Blocks beta actions causing: decreased heart rate decreased BP decreased contractility

16 16 Adrenergic Inhibitors: Beta Blockers S/E: Orthostatic hypotension Bradycardia Hypotension Fatigue Weakness Nursing considerations Use in caution with heart failure Diabetes who take BB may not have sx of hypoglycemia monitor pulse regularly

17 17 ACE Inhibitors Drug Interactions: NSAIDS (decrease BP control) Diuretics (excessive hypotensive effect) Potassium supplements, potassium-sparing diuretics (increased risk of hyperkalemia) Lithium (increased lithium serum levels) Precautions: First dose effect – severe hypotension. Remain in bed for 3 to 4 to prevent falls. Obtain BP before giving - hold if hypotensive Change positions slowly due to orthostatic hypotension Monitor liver and kidney function

18 18 Angiotensin Receptor Antagonists (Blockers) Losartan (Cozaar) Mechanism: Inhibit binding of angiotensin II receptors in blood vessels and other tissues vascular smooth muscle relaxation increased salt and water excretion reduced plasma volume Side Effects: Hypotension Dizziness Cough, Heart failure Angioedema Drug Interactions: Potassium-sparing diuretics ( serum K + )

19 19 Calcium Channel Blockers Amlodipine (Norvasc) Diltiazem (Cardizem) Nifedipine (Procardia) Mechanism of Action Blocks slow channels of Calcium Decreases contractility Vasodilation AV node slows

20 20 Calcium Channel Blockers S/E: Hypotension Bradycardia AV block Nausea H/A Peripheral edema Monitor I&O closely Nursing considerations: Always obtain BP-HR before giving use with caution in patients with heart failure Orthostatic changes Change position slowly contraindicated in patients with 2 nd or 3 rd degree heart block Concurrent use w/b-blockers incr risk of CHF

21 21 HTN Case Study 45yr African American male Complaint: new onset severe global HA VS: P-88 R-20 BP-210/142 sats 96% RA Slightly confused to place, time PMH: HTN x10 yrs-unable to afford meds, not taking the last week Labs: K+ 4.2, Na+ 138, creat 2.5, trop neg, 12 lead EKG no acute changes Nursing/medical priorities…

22 22 HTN Case Study MD orders: Metoprolol 5mg IV push q5 x3 for SBP mg/5cc….administer over 2…how much every seconds??? Nursing priorities/considerations… Admit to ICU VS before transfer: P-68 R-20 BP-192/118

23 23 In ICU… Started on Nipride gtt Started at 0.5mcg BP 180/90….in 2 hours Next am 140/90 Started on po: Lisinopril Diltiazem Metoprolol Concerns to address upon DC???

24 24 Peripheral Arterial Disease Altered flow of blood through arteries/veins of peripheral circulation Manifestation of systemic atherosclerosis a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

25 25 Physical Assessment Intermittent claudication Pain that occurs even while at rest; numbness and burning Inflow disease affecting the lower back, buttocks, or thighs Distal aorta Outflow disease causing cramping in calves, ankles, and feet Superficial femoral artery (knee and down) Hair loss and dry, scaly, mottled skin and thickened toenails Ulcers arterial ulcers diabetic ulcers venous stasis ulcers.

26 26 Nonsurgical Management Exercise Positioning avoid extreme raising legs above heart, do elevate for edema Promoting vasodilation warmth and avoid cold temp, stop smoking Drug therapy clopidogrel (Plavix), Pentoxifylline (Trental), ASA Percutaneous transluminal angioplasty Atherectomy.

27 27 Surgical Management Preoperative care Documentation of distal pulses Postoperative care Assessment for graft occlusion Promotion of graft patency Treatment of graft occlusion Monitoring for compartment syndrome Assessment for infection.

28 28 Acute Peripheral Arterial Occlusion Embolus most common cause of occlusions, although local thrombus may be the cause Assessment pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia (coolness) Surgical therapy arteriotomy Nursing care CMS Pain assessment Spasms/swelling Compartment syndrome.

29 29 Anticoagulation Therapy:Heparin Inhibits (does not dissolve) thrombus and clot formation Given IV/SQ Never given IM D/T risk of hematoma Does not cross placental barrier Antidote Protamine sulfate: Fast acting, short ½ life Note: If sxs of bleeding stop infusion, be prepared to give antidote

30 Aneurysms of Central Arteries 30 Patho Middle layer weakened Stretching of intima Fusiform aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissections) Thoracic aortic aneurysms Abdominal aortic aneurysms.

31 31 Thoracic & Abdominal Aortic Aneurysm Thoracic Back pain shortness of breath hoarseness, and difficulty swallowing Sudden excruciating back or chest pain is symptomatic of thoracic rupture Abdominal Pain steady with a gnawing quality unaffected by movement-may last for hours or days abdomen, flank, or back. Abdominal mass is pulsatile Rupture is the most frequent complication and is life threatening.

32 Aortic Dissection 32 Patho Pain Emergency care goals include: Elimination of pain Reduction of blood pressure Immediate OR Surgical treatment

33 Abdominal Aortic Aneurysm Repair 33 Preoperative care Assess peripheral pulses Operative procedure Postoperative care Monitor vital signs Assess for complications Paralytic ileus Assess for graft occlusion or rupture Change in CMS Severe pain Decreased u/o.

34 34 Thoracic Aortic Aneurysm Repair Preoperative care Operative procedure Postoperative care assessments: Vital signs CMS changes Complications Respiratory distress Cardiac dysrhythmias Hemorrhage Paraplegia.

35 35 Raynauds Phenomenon Patho Sx Blanching >cyanosis Pain Aggravated by cold/stress Treatment Procardia Side effects Education Cold exposure Stop smoking Stress reduction.

36 Venous Thromboembolism 36 Thrombus Virchows Triad Venous blood stasis Endothelial injury hypercoagubility Thrombophlebitis Thrombus w/inflammation Deep vein thrombosis (DVT) Pulmonary embolism Phlebitis Inflammation of superficial veins Assessment: Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Localized edema Venous flow studies-US Lab:D-Dimer.

37 37 Nonsurgical Management Treatment Priorities Prevent complications Rest Drug therapy includes: Heparin IV therapy Low–molecular weight heparin-Subq Lovenox q 12 hours Warfarin therapy Thrombolytic therapy TPA

38 38 Venous Insufficiency Patho Sx Edema TEDS Stasis dermatitis Stasis ulcers Occlusive dressings.

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