Week 8 Vascular Disorders
Surgical procedures for Aneurysms
-Open Aneurysm Repair (remove aneurysm & replace w/ graft) Endovascular Graft Procedure （femoral artery+inflate balloon; place graft in artery; usually w/ aneurysms below the renal artery) Complications Endoleak (blood seeps back into old aneurysm) Aneurysm growth above/below repair graft Artery occlusion (via graft migration) Bleeding Rupture Dissection
varicose veins Nursing Care
-Prevention- avoiding increased venous hypertension -Postop care- activity, analgesics, bleeding, TED hose *dont cross legs; leg movement; compression stockings
Venous Thrombus Risk Factors
-Venous stasis (blood pooling) Age(old), prolonged immobility, a-fib, orthopedic surgery (+pregnancy, prolonged sitting) Endothelial damage Surgery/trauma of abdomen/pelvis, fracture of hip/leg/pelvis, caustic IV fluids, PICC lines (damage causes coagulation => clot risk) Hypercoagulability of the blood Tobacco use, cancer, oral contraceptives (in smokers), dehydration/malnutrition, pregnancy & postpartum
post op management
-begin activity per orders -prevent & monitor for lot formation
Raynaud's risk factors
-cold exposure -emotional stress -gender (women) -age (16-40)
PAD Diagnostics
-doppler ultrasound to map blood flow through artery and degree of blood flow -segmental BP's at thigh, below knee, and ankle (drop in BP 30+) -angiography to show location/extent of PAD -Ankle brachial index (ABI)
Raynaud's Disease RN management
-education and support lifestyle changes -avoid cold, tobacco; dress warmly; wear gloves
Raynaud Treatment
-lfestyle modefication (limit stress, limit cold temps) -calcium channel blockers --digital Sympathectomy --> interrupt sympathetic nerves to fingers to decrease pain)
Venous ulcers
-medial ankles -yellow (slough) or red (ruddy) -irregular shape -moderate to large drainage
Raynaud's manifestations
-pallor,cyanosis, return rubor; "red, white, and blue" -numbness, tingling, burning pain (bilaterally (usually)
Nursing management
-post-operative management -pain management -education for lifestyle choices
Education for lifestyle choices
-quit smoking/tobacco use -manage BP, cholesterol, DM -lose weight/increase activity -monitor for complications: compartment syndrome; metabolic changes; kidney failure; hemorrhage
Arterial ulcers
-toes, heels, lateral ankles -pale o ischemic -smooth edges -minimal drainage dry "punched out" appearence
Raynaud Disease
-vasospasm with cold or stress -usually impacts fingers Unknown patho; associated with immunologic disorders
Aneurysms Manifestations (Abdominal)
Often Asymptomatic (found during routine physical) Pulsing mass in periumbilical area +Bruit auscultated Compression of surrounding structures can cause: Back pain Epigastric pain Altered elimination (constipation) Intermittent claudication
Superficial Vein Thrombus manifestations
Often in Varicosities in leg (squishy); thrombus = firm Palpable, firm, subQ cordlike vein Itchy, tender, painful Warm & red Edema is rare (DVT)
Aneurysms
Outpouching (ballooning) of the vessel wall Localized Permanent Larger size = greater risk for rupture Can occur in Thoracic arch (25%) Abdominal aorta (75%)
VTE manifestations
Pain & tenderness Unilateral Edema Warm & erythematous Elevated body temp
Phlebitis manifestations
Pain / tenderness Warmth Erythema Swelling
Thromboangitis Obliterans (Buerger's) Manifestations
Pain(bilateral) intermittent claudication rest pain ischemic ulcerations color and temperature changes paresthesia cold sensitivity
VTE Diagnostics
Ultrasound (Doppler) D-Dimer blood assay (markers of coagulation)
venous insufficiency: Associated problems
edema, varicosities, weeping ulcers
venous insufficiency: Relief
elevation, lying down, walking
venous insufficiency: what happens
follows DVT, incompetent valves of deep veins
thrombolysis
inject thrombolytic agent
Risk factors Buerger's
-Gender (male) -Age (younger than 45mins) -Tobacco use *HLD, HTN, DM
Phlebitis risk factors
-IV catheter Infusion of irritating drugs (vanco, potassium chloride) IV location
arterial insufficiency: Aggrevating factors
activity or elevation
Arterial insufficiency: character of pain
"intermittent claudication" -- worse after exercise
PAD Manifestations
- Intermittent claudication - Shiny, taut skin - Hair loss (& brittle nails) - Decreased peripheral pulses (dependent rubor; bruits) - Numbness/tingling in toes/feet (nerve ischemia) - Pain - Critical limb ischemia
PAD is...
arteriosclerosis atherosclerosis progressive narrowing of arteries strongly related to other types of CVD & their risk factors more common in lower extremities
A client with a AAA, waiting for surgery, develops symptoms of shock. Which nursing action is PRIORITY? a) Notify the physician STAT b) Prepare to administer blood transfusion c) Make patient NPO for surgery d) Administer prescribed pre-op medications
A) notify the physician STAT
peripheral artery bypass
avoid blocked artery by re-routing blood flow; "native vein" comes from patient; or synthetic
Aneurysms Risk Factors
Age (older than 50) Gender (male) Hypertension HLD CAD PAD of lower extremities Obesity History of stroke SMOKING!!! Family Hx *congenital abnormalities (bicuspid/aortic valve; narrow aortic arch; Turner syndrome & Marfan Syndrome)
Arterial insufficiency: What happens?
build up of fatty plaques
venous insufficiency: location of pain
calf, lower legs
angioplasty
catheter w/ balloon tip up femoral artery; balloon inflates at tip of artery
Medical Management of Aneurysms: Surgical Intervention
Asymptomatic aneurysms larger than 5.5 cm -sooner if pt has genetic disorder -rapidly expanding aneurysms -symptomatic patients -high rupture risk
Thromboangitis Obliterans (Buerger's Disease)
Autoimmune disease with recurring inflammation of intermediate/small vessels in upper & lower extremities --> thrombis formation -> subsequent vessel occlusion
Cardiac tamponade is a complication associated with aortic dissection. What symptoms would the nurse recognize is associated with cardiac tamponade? A) Bradypnea B) Narrowing pulse pressure C) Bradycardia D) Increased cardiac output
B) Narrowing Pulse pressure
Which clinical finding should the nurse expect when performing an assessment of a client with an unruptured AAA? a) Severe radiating abdominal pain b) Visible pulsating abdominal mass c) Signs of shock d) Visible peristaltic waves
B) visible pulsating abdominal mass
Buerger's Diagnosis
Based on symptoms and exclusion
Aortic Disecction Complications: Cardiac Tamponade
Blood from dissection leaks into pericardial sac and compresses the heart Chest pain Anxious & restless Confused Decreased cardiac output Muffled heart sounds (fluid around the heart) Tachypnea Tachycardia Narrowed pulse pressure Pulsus paradoxus (large decrease in SBP during inspiration; max distention in pericardial sac (fluid accumulation); normal pulse pressure =40 —> less = heart is not moving/limited moving (restricts heart beat)
venous insufficiency: onset & duration
chronic pain worse at end of the day
Emergency Repair Complications
Intra-abdominal Hypertension (pressure decreases; decreased blood flow) Abdominal Compartment Syndrome Blood flow is reduced Organ perfusion impaired Multisystem organ failure results
Which nursing diagnosis is most significant in planning care for a patient with Raynaud's disease? A) Disturbed sensory perception B) Activity intolerance C) Self-care deficit D) Acute pain
D) Acute pain
What is the most important assessment for RN to make after a client has a femoro-popliteal bypass for PVD? A) incisional pain B) popliteal pulse rate C) degree of hair growth D) lower extremity color
D) Lower extremity color
The nurse is caring for a client with abdominal aortic aneurysm (AAA). Which assessment finding is most likely to indicate a dissection of the aneurysm? a) Hematemesis b) Rectal bleeding c) Hypertensive crisis d) Severe back pain
D) Severe back pain
Types of Aneurysms
Damage to medial layer of vessel wall Classified as: True: Fusiform (A) Sacculated (B) False (C)
Venous Thromboembolism (VTE)
Deep veins of legs (femoral), pelvis (iliac), arms, vena cava, or pulmonary system
Aortic Dissection Nursing Management: Postoperative
Discharge teaching Therapeutic regimen Routine follow up Seek immediate help if pain returns
Aortic Dissection Diagnostics
ECG can rule out MI Chest X-ray CT Scan MRI Transesophageal Echo
VTE prevention and Prophylaxis
Early & aggressive mobilization (even if on bed rest) Compression stockings Sequential compression devices (SCDs) Anticoagulant therapy Short term - unfractionated or low-molecular-weight Heparin (antidote: protamine sulfate) Long term - Warfarin or other oral anticoagulants (antidote: vitamin K)
Buerger's RN management
Education Referral to stop tobacco use
cyroplasty
combo therapy of angioplasty; cold therapy to freeze stenosis (limits re-stenosis)
Arterial insufficinency: Associated symptoms
cool, pale skin, ecrased pulses, & sensation; hair loss
PAD medical management
GOAL: revascularization -angioplasty -stents -atherectomy -cyroplasty -peripheral artery bypass -thrombolysis -antiplatelet therapy -modify risk factors
Aortic Dissection Risk Factors
Gender - male Age - 60's - 70's Atherosclerosis Aortic or congenital heart diseases Smoking Use of cocaine or methamphetamine HTN
Goals for Acute Type A Dissection
HR & BP control ↓ HR, BP, & myocardial contractility limit extension of the dissection (BP below 120-100; HR below 60; only want heart to pump just enough to perfume vital organs) Pain management Morphine is preferred analgesic Surgical repair (Sx emergency (within hours!!)
Varicose veins manifestations
Heavy, aching muscles/pain Itching, burning, tingling Nocturnal leg cramps *lead to blood clots *incompetent valves; backward flow of blood
Additional Complications
Hemorrhage Mediastinal, plueral, abdominal cavities Rupture Results in exsanguination & death Occlusion of arterial supply to vital organs Spinal cord, renal, abdominal ischemia
Superficial Vein Thrombosis Complications
If untreated, can extend to deeper veins & VTE may occur
Phlebitis RN Management
Importance of IV monitoring (Q2Hrs) Pain management *draw border = progression
Acute Type B Dissection
More likely to report pain in back, abdomen, or legs
Aortic Dissection
NOT a type of aneurysm False lumen forms between intima (inner) & middle layers of the arterial wall Type A - ascending aorta & arch (emergency Tx) Type B - begins in descending aorta (conservative Tx; have a little more time)
Superficial Vein thrombosis Treatment
NSAIDS (helps w/ antiplatelet activity) Compression stockings Elevate affected limb Mild exercise
Varicose veins diagnostics
duplex scan or air plethysmography
Acute Care—Pre and Post Procedure (Aneurysms)
Pre-op - emotional support & education Post-op Graft patency - adequate BP 9cant be high or low; just right) Cardiac status/peripheral perfusion Infection GI status Neuro status Renal perfusion Post-op bedrest orders Monitor for post-implantation syndrome (fever like symptoms)
Aneurysms Complications
Rupture! Retro-peritoneal space —Bleeding may be controlled —Cullen sign —Grey Turner's Sign Thoracic or abdominal Cavity Massive hemorrhage Shock High mortality rate Smokers = highest risk for rupture
Aortic Dissection Nursing Management: Preoperative
Semi-fowler's position (flat legs) Quiet environment Anxiety & pain management Continuous heart monitoring IV antihypertensives Frequent assessment of VS & peripheral pulses
Buerger's Treatment
Similar to PAD Sympathetic nerve block Stop tobacco use (nicotine is the issue!!)
Phlebitis medical Management
Slow IV infusion, change drugs D/C IV and avoid site Warm, moist heat NSAIDS
medical Management of Aneurysms: Conservative therapy
Small aneurysm (4-5.4 cm) -modify risk factors -lower BP -frequent monitoring *can remain stable for several years
Venous thrombus
Superficial Vein Thrombosis (smaller) Usually greater or lesser saphenous veins Deep Vein Thrombosis (more concerning; can travel) Usually iliac or femoral veins Venous Thromboembolism (VTE)** Considers DVT & Pulmonary Embolism (PE) Preferred terminology
Complications
Superficial venous thrombosis
Aneurysm Manifestations (Thoracic)
Thoracic (TAA) Often asymptomatic Chest/back pain If in ascending/aortic arch: Jugular venous distention Facial edema TIAs Angina Dysphagia, hoarseness, cough If pressing on superior vena cava: -Jugular venous distention - Facial edema
RN Management (Aneurysms)
Thorough CV assessment Monitor for signs of rupture Diaphoresis, pallor, tachycardia, hypotension, pain, change in LOC, pulsating umbilical mass Gather baseline - important for post-op comparison Peripheral pulses Renal status Neuro status
Varicose veins medical management
Venoactive drugs: flavonoid fraction, rutosides, proanthocyanidins, Ruscus Ablation/Sclerotherapy —> IV injection; get them up and moving; stockings; analgesics for movement
Aneurysms Diagnostics
X-rays (chest & abdomen) Ultrasound CT Scan - most accurate measurement MRI Angiography
venous insufficiency: character of pain
aching, tired, feeling of fullness
antiplatelet therapy
low dose aspirin prevents platelet clumping in narrrow vessels
arterial insufficiency: who's at risk?
more men than women, diabetes, HTN, smoking, obesity
intermitent claudication
muscle pain caused by exercised & relieved with rest lactic acid build up (anaerobic metabolism) because we arent getting enough O2
most common sites for PAD
non-diabetics: popliteal artery diabetics: arteries belw the knee
Arterial insufficiency: location of pain
pain of deep muscles, usually calf/foot
Conservative management for Type B
pain relief, HR & BP control, CVD risk reduction; close surveillance Endovascular repair Surgery (Sx needed either way)
PAD
peripheral arterial disease
venous insufficiency: who's at risk
prolonged standing (nurses!) Obesity, pregnancy, prolonged bedrest
venous insufficiency: aggravating factors
prolonged standing or sitting
atherectomy
removal of obstructing plaque
arterial insufficiency: relief
rest, standing/dangling
Risk factors for PAD
smoking (nicotine reduces blood flow, increases platelet aggregation --> increases clot risk) high cholesterol HTN (accelerates rate at which atherosclerotic lesions form) Diabetes
compartment syndrome
sudden decrease in blood flow to tissues distal to area of injury ==> necrosis --> amputation of limb
Arterioclerosis
thickening of the arterial walls; affects inner lining of vessels
varicose veins risk factors
trauma previous VTE gender (women) profession (stand/sit too long) genetics *pregnancy
Atherosclerosis
type of arteriosclerosis in which build up of plaques in vessels
Superficial Vein Thrombosis Diagnostics
ultrasound
stents
used tp hold artery open; can become unpatent over time with build-up
Q: A patient with weeping ulcers on the medial ankle & leg pain that is better with elevation has:
venous insufficiency
Acute Type A dissection
• Abrupt onset of excruciating anterior chest pain • If arch involved - neuro deficits • Interruption of coronary artery blood flow • Angina, MI, left heart failure