1. Interventions for Clients with Vascular Problems

2. Arteriosclerosis and Atherosclerosis Arteriosclerosis: thickening or hardening of the arterial wall Arteriosclerosis: thickening or hardening of the arterial wall Atherosclerosis: type of arteriosclerosis involving the formation of plaque within the arterial wall Atherosclerosis: type of arteriosclerosis involving the formation of plaque within the arterial wall Etiology and genetic predisposition Etiology and genetic predisposition –Factors related to atherosclerosis include obesity, lack of exercise, smoking, and stress.

4. Laboratory Assessment Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis clients. Lipid level, including cholesterol and triglycerides, is elevated in atherosclerosis clients. High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup. High serum levels of homocysteine can allow cell walls to become vulnerable to plaque buildup.

5. Interventions Evaluation of total serum cholesterol levels and lifestyle changes Evaluation of total serum cholesterol levels and lifestyle changes Diet therapy Diet therapy Smoking cessation Smoking cessation Exercise Exercise Drug therapy Drug therapy

6. Hypertension Hypertension: systolic blood pressure ≥ 135 mm Hg and/or diastolic blood pressure ≥ to 85 mm Hg (not including diabetics) Hypertension: systolic blood pressure ≥ 135 mm Hg and/or diastolic blood pressure ≥ to 85 mm Hg (not including diabetics) Malignant hypertension: elevated blood pressure that progresses rapidly to systolic pressure > 200 mm Hg and diastolic pressure > 130 mm Hg Malignant hypertension: elevated blood pressure that progresses rapidly to systolic pressure > 200 mm Hg and diastolic pressure > 130 mm Hg

8. Diseases Diseases that commonly cause secondary hypertension: Diseases that commonly cause secondary hypertension: –Renal vascular –Renal parenchymal –Dysfunction of the adrenal medulla or the adrenal cortex –Primary aldosteronism (Continued)

9. Diseases (Continued) –Pheochromocytomas –Cushing’s syndrome –Coarctation of the aorta –Neurogenic disturbances, such as brain tumors, encephalitis, and psychiatric disturbances

10. Knowledge Deficit Interventions include: Interventions include: –Sodium restriction –Weight reduction –Moderation of alcohol intake –Exercise –Relaxation techniques –Tobacco and caffeine avoidance

11. Drug Therapy Diuretics Diuretics Calcium channel-blocking agents Calcium channel-blocking agents ACE inhibitors ACE inhibitors Angiotensin II receptor antagonists Angiotensin II receptor antagonists Aldosterone receptor antagonists Aldosterone receptor antagonists Beta-adrenergic blockers Beta-adrenergic blockers Central alpha agonists Central alpha agonists Alpha-adrenergic agonists Alpha-adrenergic agonists

12. Risk for Ineffective Therapeutic Regimen Management Interventions include: Interventions include: –Teach medication compliance, usually for the rest of life. –Discuss goals of therapy, potential side effects, and how to identify potential problems. –Assist client to understand therapeutic regimen. –Discuss consequence of noncompliance.

13. Peripheral Arterial Disease Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation Manifestation of systemic atherosclerosis: a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients Manifestation of systemic atherosclerosis: a chronic condition in which partial or total arterial occlusion deprives the lower extremities of oxygen and nutrients

15. Physical Assessment Intermittent claudication Intermittent claudication Pain that occurs even while at rest; numbness and burning Pain that occurs even while at rest; numbness and burning Inflow disease affecting the lower back, buttocks, or thighs Inflow disease affecting the lower back, buttocks, or thighs Outflow disease causing cramping in calves, ankles, and feet Outflow disease causing cramping in calves, ankles, and feet(Continued)

16. Physical Assessment (Continued) Hair loss and dry, scaly, mottled skin and thickened toenails Hair loss and dry, scaly, mottled skin and thickened toenails Ulcers: arterial ulcers, diabetic ulcers, venous stasis ulcers Ulcers: arterial ulcers, diabetic ulcers, venous stasis ulcers

18. Diagnostic Assessments Angiography Angiography Segmental systolic blood pressure measurements Segmental systolic blood pressure measurements Exercise tolerance testing Exercise tolerance testing Plethysmography Plethysmography

19. Nonsurgical Management Exercise Exercise Positioning Positioning Promoting vasodilation Promoting vasodilation Drug therapy Drug therapy Percutaneous transluminal angioplasty Percutaneous transluminal angioplasty Laser-assisted angioplasty Laser-assisted angioplasty Atherectomy Atherectomy

20. Surgical Management Preoperative care Preoperative care Operative procedures (bypass surgery) Operative procedures (bypass surgery) (Continued)

22. Surgical Management (Continued) Postoperative care Postoperative care –Assessment for graft occlusion –Promotion of graft patency –Treatment of graft occlusion –Monitoring for compartment syndrome –Assessment for infection

23. Acute Peripheral Arterial Occlusion Embolus: the most common cause of occlusions, although local thrombus may be the cause Embolus: the most common cause of occlusions, although local thrombus may be the cause Assessment: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia Assessment: pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia Drug therapy Drug therapy Surgical therapy Surgical therapy Nursing care Nursing care

24. Aneurysms of Central Arteries Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter Aneurysm: a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter Fusiform aneurysm Fusiform aneurysm Saccular aneurysm Saccular aneurysm Dissecting aneurysm (aortic dissections) Dissecting aneurysm (aortic dissections) Thoracic aortic aneurysms Thoracic aortic aneurysms

26. Assessment of Abdominal Aortic Aneurysm (AAA) Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days. Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days. Pain is in the abdomen, flank, or back. Pain is in the abdomen, flank, or back. Abdominal mass is pulsatile. Abdominal mass is pulsatile. Rupture is the most frequent complication and is life threatening. Rupture is the most frequent complication and is life threatening.

27. Assessment of Thoracic Aortic Aneurysm Assess for back pain and manifestation of compression of the aneurysm on adjacent structures. Assess for back pain and manifestation of compression of the aneurysm on adjacent structures. Assess for shortness of breath, hoarseness, and difficulty swallowing. Assess for shortness of breath, hoarseness, and difficulty swallowing. Occasionally a mass may be visible above the suprasternal notch. Occasionally a mass may be visible above the suprasternal notch. Sudden excruciating back or chest pain is symptomatic of thoracic rupture. Sudden excruciating back or chest pain is symptomatic of thoracic rupture.

28. Diagnosis and Management X-rays X-rays Computed tomography scan to assess size and location of aneurysm Computed tomography scan to assess size and location of aneurysm Aortic angiography Aortic angiography Ultrasonography Ultrasonography Goal of nonsurgical management: monitor growth of the aneurysm and maintain blood pressure at normal level Goal of nonsurgical management: monitor growth of the aneurysm and maintain blood pressure at normal level

29. Abdominal Aortic Aneurysm Resection Preoperative care Preoperative care Operative procedure Operative procedure Postoperative care Postoperative care –Monitor vital signs. –Assess for complications. –Assess for signs of graft occlusion or rupture.

31. Thoracic Aortic Aneurysm Repair Preoperative care Preoperative care Operative procedure Operative procedure Postoperative care assessments: Postoperative care assessments: –Vital signs –Complications –Sensation and motion in extremities –Respiratory distress –Cardiac dysrhythmias

32. Endovascular Repair of Abdominal Aortic Aneurysm Clients selected for endovascular repair are generally at high risk for major abdominal surgery. Clients selected for endovascular repair are generally at high risk for major abdominal surgery. Various designs Various designs

33. Aneurysms of the Peripheral Arteries Femoral and popliteal aneurysms Femoral and popliteal aneurysms Symptoms: limb ischemia, diminished or absent pulses, cool to cold skin, and pain Symptoms: limb ischemia, diminished or absent pulses, cool to cold skin, and pain Treatment: surgery Treatment: surgery Postoperative care: monitor for pain Postoperative care: monitor for pain

34. Aortic Dissection May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall May be caused by a sudden tear in the aortic intima, opening the way for blood to enter the aortic wall Pain described as tearing, ripping, and stabbing Pain described as tearing, ripping, and stabbing(Continued)

35. Aortic Dissection (Continued) Emergency care goals include: Emergency care goals include: –Elimination of pain –Reduction of blood pressure –Decrease in the velocity of left ventricular ejection Nonsurgical treatment Nonsurgical treatment Surgical treatment Surgical treatment

36. Buerger’s Disease Thromboangiitis obliterans: relatively uncommon occlusive disease limited to the medium and small arteries and veins Thromboangiitis obliterans: relatively uncommon occlusive disease limited to the medium and small arteries and veins Often identified with tobacco smoking Often identified with tobacco smoking Nursing interventions to prevent progression of disease Nursing interventions to prevent progression of disease

37. Other Disorders Subclavian steal occurring from artery occlusion or stenosis Subclavian steal occurring from artery occlusion or stenosis Thoracic outlet syndrome resulting in arterial wall damage Thoracic outlet syndrome resulting in arterial wall damage Popliteal entrapment Popliteal entrapment

38. Raynaud’s Phenomenon Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Caused by vasospasm of the arterioles and arteries of the upper and lower extremities Drug therapy: Procardia, Cyclospasmol, and Dibenzyline Drug therapy: Procardia, Cyclospasmol, and Dibenzyline Lumbar sympathectomy Lumbar sympathectomy Reinforcement of client education; restriction of cold exposure Reinforcement of client education; restriction of cold exposure

39. Venous Thromboembolism Thrombus: a blood clot Thrombus: a blood clot Thrombophlebitis Thrombophlebitis Deep vein thrombosis Deep vein thrombosis Pulmonary embolism Pulmonary embolism High rate of death High rate of death

40. Assessment Calf or groin tenderness or pain Calf or groin tenderness or pain Sudden onset of unilateral swelling of the leg Sudden onset of unilateral swelling of the leg Positive Homans’ sign Positive Homans’ sign Localized edema Localized edema Venous flow studies Venous flow studies

41. Nonsurgical Management Rest Rest Drug therapy includes: Drug therapy includes: –Unfractionated heparin therapy –Low–molecular weight heparin –Warfarin therapy –Thrombolytic therapy

42. Surgical Management Thrombectomy Thrombectomy Inferior vena caval interruption Inferior vena caval interruption Ligation or external clips Ligation or external clips

44. Venous Insufficiency Result of prolonged venous hypertension, stretching veins and damaging valves Result of prolonged venous hypertension, stretching veins and damaging valves Stasis dermatitis, stasis ulcers Stasis dermatitis, stasis ulcers Management of edema Management of edema Management of venous stasis ulcers Management of venous stasis ulcers Drug therapy Drug therapy Surgical management Surgical management

45. Varicose Veins Distended, protruding veins that appear darkened and tortuous Distended, protruding veins that appear darkened and tortuous Collaborative management includes: Collaborative management includes: –Elastic stockings –Elevation of extremities –Sclerotherapy –Surgical removal of veins –Radio frequency energy to heat the veins

46. Phlebitis Inflammation of the superficial veins Inflammation of the superficial veins Management: warm, moist soaks and elastic stocking Management: warm, moist soaks and elastic stocking Complications: tissue necrosis, infection, or pulmonary embolus Complications: tissue necrosis, infection, or pulmonary embolus