Nursing of Adults with Medical & Surgical Conditions Disorders of the Peripheral Vascular System

Risk Factors n Similar to risk factors for heart disorders – Age – Gender – Smoking – Hypertension – Hyperlipidemia – Obesity – Lack of exercise – Emotional stress – Diabetes Mellitus – Family History

Assessment of Vascular Disorders n Arterial Assessment – First symptom is usually pain n Occurs due to arterial insufficiency and ischemia n Dull ache in calf muscles n Leg fatigue and cramping n Intermittent claudication – Pain brought on by exercise – Later symptoms of pain n Pain at rest n Burning, tingling, and numbness at night even lying down – Pulses n May be weak, thready, or absent – Scale for documentation 0 – absent +1 – barely palpable, intermittent +2 – weak, possibly thready, but constantly palpable +3 – normal strength and quality +4 – bounding, easily palpable, may be visible

n Assessment and Documentation – PATCHES n P for Pulses – Absence of pulses in generally a medical emergency Compare with previous findings Look for other symptoms – may just be hard to feel Use Doppler device if necessary n A for Appearance – Pale, mottled, cyanotic or discolored (red, black, brown) – Necrosis or bleeding (ulcers) Size, depth, and location Edges jagged or smooth Painful to touch – Shiny or dull Shiny may indicate edema Dull may indicate inadequate arterial blood supply – Superficial veins, erythema, or inflammation – Varicosities Have patient to stand

n T for Temperature – Cool Possible arterial problem – Warm Possible venous problem – Temperature changes may be caused by other problems as well n C for Capillary refill – Less than 2 seconds n H for Hardness – Supple or hard and inelastic Hardness may indicate chronic problems n E for Edema – Pitting edema Usually acute problem Assessment: Press on skin for 5 seconds and release (Page Figure 8-17 and Table 8-3) – Non-pittting May be chronic condition Assessment: Measure circumference of the extremity

n S for Sensation – Patient states extremity FEELS: Numbness Tingling Hot Cold

n Venous Assessment – First symptom is usually edema – Dark pigmentation – Dryness and scaling – Ulcerations – Pain, aching, and cramping n Usually relieved by rest or elevation Comparison of Arterial and Venous Disorders Page 331 – Table 8-5

Diagnostic Tests n Noninvasive Procedures – Treadmill Test n Exercise to determine blood flow to extremities – Plethysmography n Assesses blood volume in the veins – Digital Subtraction Angiography (DSA) n IV contrast is administered n Blood vessels are visualized by radiography using an image intensifier video system and monitor – Doppler Ultrasound n Measures blood flow in arteries or veins

Diagnostic Tests n Invasive Procedures – Phlebography or venography n Radiographic visualization of veins n IV contrast is administered in a foot vein n X-rays are taken to detect filling defects n Assesses for condition of deep veins and to diagnose deep vein thrombosis – 125 I-fibrinogen Uptake Test n Assesses for acute calf vein thrombosis n Fibrinogen is tagged with iodine 125 and given IV - it can then be detected in the blood stream by a gamma ray detector – Angiography n IV contrast is administered n X-ray to visualize arteries

– D-dimer Serum Test n D-dimer forms when fibrin is broken down n When a thrombus is present D-dimer levels are elevated – usually greater than 1591 ng/ml n Normal value: ng/ml – Duplex Scanning n Combination of ultrasound imaging and Doppler n Determines location and extent of thrombus within veins

Arteriosclerosis & Atherosclerosis n Arteriosclerosis – thickening, loss of elasticity, and calcification of arterial walls, resulting in a decreased blood supply n Atherosclerosis – narrowing of the artery due to yellowish plaques of cholesterol, lipids, and cellular debris in the inner layers of the walls of large and medium sized arteries – a type of arteriosclerosis

Atherosclerosis

Hypertension n Etiology/Pathophysiology – A sustained elevated systolic blood pressure greater than 140 mm Hg and /or a sustained elevated diastolic blood pressure greater than 90 mm Hg. – Vasoconstriction (increases B/P) n caused by stimulation of the sympathetic nervous system and the release of epinephrine and/or norepinephrine. Decreased blood flow to the kidneys causes the release of renin and the formation of angiotensin which is a vasoconstrictor.

Hypertension – Essential (primary) hypertension n 90-95% of all diagnosed cases n Theories of causes: – arteriolar changes, sympathetic nervous system activation, hormonal influence, genetic factors, obesity, sedentary lifestyle, increased sodium intake, excessive alcohol intake. – Secondary hypertension n Attributed to an identifiable medical diagnosis – renal vascular disease – diseases of the adrenal cortex – coarctation of the aorta – head trauma or cranial tumor – pregnancy-induced hypertension

Hypertension – Malignant hypertension n severe, rapidly progressive elevation in blood pressure that causes damage to the small arterioles in major organs (heart, kidneys, brain, eyes)

Hypertension n Signs & Symptoms – headache – blurred vision – epistaxis – angina – s/s of: n MI, CHF, renal failure, and stroke

Hypertension n Treatment – Antihypertensive medications n Capoten, Vasotec, Altace, Lotensin, Zestril, Accupril, Monopril – Diuretics n Lasix, HCTZ, Aldactone – Diet n weight control, reduction of saturated fats, and low sodium – No smoking

Hypertension – Decreased alcohol intake – Regular aerobic exercise – Relaxation techniques/stress management

Arteriosclerosis Obliterans n Etiology/Pathophysiology – narrowing or occlusion of the blood vessel with plaque formation – little or no blood flow to the affected extremity

Arteriosclerosis Obliterans n Signs & Symptoms – Five P’s n Pain – intermittent claudication n Pulselessness n Pallor n Paresthesia n Paralysis

Arteriosclerosis Obliterans n Treatment – Anticoagulants n Heparin and Coumadin – Fibrinolytics n Urokinase n administered directly into the thrombus – Surgery n embolectomy - removal of the embloism n endarterectomy- removal of the lining of the artery n arterial bypass n percutaneous transluminal angioplasty n amputation

Percutaneous Transluminal Angioplasty

Arterial Embolism n Etiology/Pathophysiology – Blood clots in the arterial bloodstream – May originate in the heart n arterial dysrhythmia, MI, valvular heart disease, CHF – Foreign substances n plaque, tissue, etc.

Arterial Embolism n Signs & Symptoms – Pain – Absent distal pulses – Pale, cool, and numb extremity – Necrosis – S/S of shock with occlusion of a major vessel

Arterial Embolism n Treatment – Anticoagulants n Heparin and Coumadin – Fibrinolytics – Endarterectomy – Embolectomy

Arterial Aneurysm n Etiology/Pathophysiology – Enlarged, dilated portion of an artery – Causes: n arteriosclerosis n trauma n congenital defect – Commonly affected arteries n popliteal n thoracic and abdominal aorta n coronary n cerebral

Arterial Aneurysm n Signs & Symptoms – Asymptomatic – Large pulating mass – Pain, if large enough to press on other structures

Arterial Aneurysm n Treatment – Assess for s/s of rupture, thrombi, ischemia – Control hypertension – Surgery n Ligation n Grafts

Surgical Repair of Arterial Aneurysm

Thromboangitis Obliterans (Buerger’s Disease) n Etiology/Pathophysiology – Occlusive vascular condition in which the small and medium size arteries become inflamed and thrombotic n affects the small arteries in the hands and feet – Cause not known – Affects men years old who smoke

Thromboangitis Obliterans (Buerger’s Disease) n Signs & Symptoms – Pain n may be frequent and persistent – Sensitivity to cold – Skin cold and pale – Ulcerations on feet or hands – Gangrene – Superficial thrombophlebitis

Thromboangitis Obliterans (Buerger’s Disease) n Treatment – No smoking – Exercise to develop collateral circulation – Surgery n amputation of gangrenous fingers and toes n sympathectomy – clip nerves to prevent pain and vasospasm

Raynaud’s Disease n Etiology/Pathophysiology – Intermittent arterial spasms – Primarily affects n fingers, toes, ears and nose – Exposure to cold or emotional stress – Secondary: n scleroderma n rheumatoid arthritis, SLE, drug intoxication, occupational trauma – Commonly affects women years of age

Raynaud’s Disease n Signs & Symptoms – Chronically cold hands and feet – Pallor, coldness, numbness, cyanosis, and pain during spasms – Erythema following a spasm – Ulcerations on the fingers and toes with chronic disease

Raynaud’s Disease n Treatment – No smoking – Avoid exposure to cold – Medications n vasodilators n calcium antagonists n muscle relaxants – Surgery n sympathectomy n amputation for gangrene

Thrombophlebitis n Etiology/Pathophysiology – Inflammation of a vein in conjunction with the formation of a thrombus – More common in women – Risk factors n venous stasis n hypercoagulability n truama to the blood vessel n immobilization after surgery

Thrombophlebitis n Signs & Symptoms – Pain – Edema – Positive Homan’s sign – Erythema, warmth, and tenderness along the vein

Thrombophlebitis n Treatment – Superficial n Bedrest n Moist heat n Elevate extremity n NSAID’s – Motrin – aspirin

Thrombophlebitis – Deep n Bedrest n Anticoagulants – Heparin & Coumadin n Fibrinolytics n Elevate extremity n Antiembolism stockings n Surgery – thrombectomy – vena cava umbrella (Greenfield filter)

Greenfield Filter

Varicose Veins n Etiology/Pathophysiology – Tortuous, dilated vein with incompetent valves – Most common in women years of age – Caused by: n congenital defective valves, absent valve, valve that becomes incompetent n Pregnancy or obesity n prolonged standing n constrictive clothing

Varicose Veins

n Signs & Symptoms – Dark, raised, tortuous veins – Fatigue – Dull aches – Cramping of the muscles – Heaviness or pressure of extremity – Edema, pain, changes in skin color, and ulcerations with venous stasis

Varicose Veins n Treatment – Elastic stockings – Rest – Elevate legs – Sclerotherapy n injection of sclerosing solution – Surgery n Vein ligation and stripping

Venous Stasis Ulcers n Etiology/Pathophysiology – Ulcerations of the legs from chronic deep vein insufficiency and stasis of blood in the venous system of the legs – Open necrotic lesion due to an inadequate supply of oxygen-rich blood to the tissue – Causes n varicose veins, burns trauma, sickle cell anemia, diabetes mellitus, neurogenic disorders, and hereditary factors

Venous Stasis Ulcers n Signs & Symptoms – Pain – Ulceration with dark pigmentation – Edema

Venous Stasis Ulcers n Treatment – Diet n Increased protein n Vitamin A & C and Zinc – Debridement of necrotic tissue n wet-to-dry dressings n Elase cream n surgical – Antibiotics – Unna boot