NR 462 Vascular Disorder

PAD Drug therapy

Antiplatelet agents Aspirin Clopidogrel (Plavix) ACE inhibitors Ramipril (Altace) ↓ Cardiovascular morbidity ↓ Mortality ↑ Peripheral blood flow ↑ ABI ↑ Walking distance

Differences between Arterial Disease and Venous Disease

Arterial Disease Away: - Pale when elevated, rubber in dependent position - no or minimal edema - nails are thick and brittle - Pain is worse w/ elevations, exercise, rest pain - decreased, weak or absent pulses - cool temperature of extremity - dry and necrotic ulcers Venous Disease Toward: - Ruddy (brownish/red - hemosiderin; cyanotic (if dependent) - edema is present - pulses are normal - pain is better w/ elevation; dull or heaviness - nails are normal - warm temperature of extremities - ulcers are moist and malleolar

The nurse puts elastic stockings on a client following major abdominal surgery. The nurse teaches the client that the stocking are used for:

Facilitate the return of venous blood to the heart

Venous Thrombosis/Venous Thromboemolism Etiology

Formation of a thrombus in association with inflammation of the vein.

A client with a history of angina and intermittent claudication reports pain in both legs with a need to stop and rest after ambulating down the hall. Which statement by the nurse best addresses this concern?

"The pain is probably related to inadequately oxygenated blood getting through the arteries into the muscles of your legs."

PADComplications

- Atrophy of the skin and underlying muscles - Delayed healing - Wound infection - Tissue necrosis - Arterial ulcers - Nonhealing arterial ulcers and gangrene are most serious complications. - May result in amputation if blood flow is not adequately restored, or if severe infection occurs

Critical Limb Ischemia (CLI)

- Chronic ischemic rest pain lasting more than 2 weeks - Arterial leg ulcers or gangrene

PE Clinical Manifestations Objective Data

- Dyspnea, Chest pain & hemoptysis - Restlessness - Change in LOC (hypoxia) - Cough - Tachypnea - Tachycardia - Hypotension - Decreasing Pulse Ox - Crackles - Cyanosis - Petechiae (pika-dot red dot) - Murmur - S3&4

Venous Insufficiency Clinical Manifestation

- History - Warm skin - Leathery brownish skin - Hemosiderin - Edema - Eczema (stasis dermatitis) - Itching - Ulceration - Pain

PE Nursing Diagnosis

- Impaired gas exchange r/t alteration in supply of oxygen aeb hypoxemia and cyanosis - Ineffective tissue perfusion - Sleep deprivation - Acute confusion - Anxiety

Paresthesia (PAD)

- Numbness or tingling in the toes or feet - Produces loss of pressure and deep pain sensations - Injuries often go unnoticed by patient

Venous stasis, hypercoagulability, and endothelial damage lead to?

- Platelets aggregate (especially at vein valve cusps) - Clotting factors stimulated to produce fibrin - Fibrin entraps RBCs, WBCs, platelets and begins to adhere to vein wall Thrombus formation

Venous Insufficiency Etiology

- Valves in veins are damaged - Retrograde blood flow - Pooling of blood in legs and swelling - Exact cause unknown - Probable risk factors - Standing in the same position - Obesity - Pregnancy - Thrombophlebitis

PE Diagnosis Test

- Ventilation-perfusion (V/Q) scan- Looking at perfusion of lung versus oxygenation (Q is problem) - CT scan with contrast - ABG'S - ECG/ Troponin/ BNP - Blood test- Elevated D-Dimer - Duplex ultrasounds of LE - Ventilation and perfusion scan - Pulmonary Angiogram

peripheral arterial disease (PAD) or Vascular

- any disorder of the arteries outside of, or peripheral to, the heart - Involves progressive narrowing and degeneration of arteries of neck, abdomen, and extremities

Blood hypercoagulability

- imbalance in clotting mechanism --> coagulation - increase in fibrin production

Endothelial Damage

- release of clotting factors - activation of platelets

PAD teaching

-Stop smoking -Walk for exercise -Lose weight -Avoid crossing legs - Don't wear restrictive clothes - Don't apply direct heat to extremity - Avoid exposure to cold - Avoid vasoconstrictors - Check feet when shoes come off with a mirror on floor - Bleeding signs and symptoms - Diet (low NA and fat) - Dressing change - Medication

PAD clinical manifestations

1) Intermittent claudication (classic symptom), 2) paresthesia; 3) skin that is thin, shiny & taut, hair loss on limb, thickened toe nails 4) diminished/absent pedal/popliteal/femoral pulses, 5) elevation pallor, 6) RUBOR = reactive hyperemia (redness) when limb is in dependent position; dependent rubor; 7) "rest pain" as PAD progresses: usually at night when sleeping/resting; BP decreases in LE causing burning d/t loss of oxygenation 8) Ankle-Brachial Index ( <1 means less flow to LE than UE) 9) arterial ulcerations (usually "dry" ulcers that do not leak) 10) edema 11) muscular atrophy

Case Study 1D - B.D. undergoes bilateral PTA with stenting. - B.D. comes to the recovery area after PTA with stenting. - He has bilateral dressings on his groins. - He is positioned supine. 1) What nursing diagnoses are appropriate for him? 2) What goals would you develop for him postoperatively? 3) What are your priorities for assessment? 4) How will you proceed with ongoing care during recovery?

1) increase risk for clots and bleeding, pain, immobility, 2) 3)Pulses, temperature, skin color 4) Repositioning every 2 hours

Case Study 1A - B.D., a 62-year-old man, complains of pain in his lower legs when walking his dog. - Pain is relieved with rest. - He has a history of hypertension and hyperlipidemia. - He smokes one pack of cigarettes per day. 1) What risk factors does B.D. have? 2) What symptoms does he exhibit? 3) What other symptoms would you need to assess for?

1) smoking, hypertension, hyperlipidemia 2) Pain 3) Thin, shiny, and taut skin, decreased hair growth, decreased or absent pedal, popliteal, or femoral pulses, delayed cap refill, dependent Rubor (reddness in bad leg in dependent position), unequally cool extremities, ulcers or gangrene -- (classis P's)

Pulmonary Embolism

A blood clot that breaks off from a large vein and travels to the blood vessels of the lung, causing obstruction of blood flow.

Varicose Veins Etiology

Dilated, tortuous veins Related to increased venous pressure Incompetent vein valves Venous distention

Warfarin: Dosing & Monitoring

Dosing: - Pharmacy protocol or dosing by physician - Initial labs - Daily labs - Antidote- Vitamin K Monitoring: - Labs-INR - Bleeding - Same Time - Diet

Venous stasis

Dysfunctional vein valves Inactive extremity muscles Change in unidirectional blood flow

A female client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?

Dyspnea Tachypnea Tachycardia Increased respiratory effort

VTE Planning and Implementation

Education Pain relief Decrease edema Prevent skin ulceration Bed Cradle Prevent pulmonary emboli

PAD Causes

Emboli formation Infection Thrombosis Trauma fracture Vasculitis

Varicose Vein Treatments

Endoscopic vein surgery Ambulatory phlebectomy Sclerotherapy Laser Catheter-assisted procedures Vein stripping

D-dimer test

A global marker of coagulation activation and measures fibrin degradation products produced from fibrinolysis (clot breakdown). The test is used for the diagnosis of DVT when the patient has few clinical signs and stratifies patients into a high-risk category for reoccurrence. Useful as an adjunct to noninvasive testing, a negative D-dimer test can exclude a DVT without an ultrasound.

Endoscopic vein surgery

A small video camera inserted in your leg to visualize and close varicose veins, and then removes the veins through small

A patient with thrombophlebitis reached her expected outcomes of care. Her affected leg appears pink and warm. Her pedal pulse is palpable and there is no edema present. Which step in the nursing process is described above?

Evaluation

Venous Insufficiency Collaborative Care

Adequate nutrition- diabetic diet, monitoring blood glucose- weight management and wound healing Medication therapy: -- Topical agents- hydrocortisone, antifungal, zinc oxide -- Antibiotics -- Sclerosing agents

PE Treatment

Anticoagulation- This will stop further clot formation- Long term therapy to prevent future clots -- IV Heparin- Protocols INFUSED ON IV PUMP ---- Anti X-a - Low molecular weight heparin (Fragmin, Lovenox) - Coumadin (warfarin) orally- achieve an INR >2.0 - Thrombolytics- streptokinase/altepase- to restore pulmonary flow

PAD exercise therapy

Exercise improves oxygen extraction in legs and skeletal metabolism Walking is most effective exercise for individuals with claudication --30 to 45 minutes daily, 3 times/week

What are the side effects of anticoagulants?

BLEEDING Black or red feces, severe bruising, prolonged nosebleeds, vomiting blood, increased menstrual bleeding

PAD Nutritional Therapy

BMI <25 kg/m2 (maintain or lower than this) Waist circumference <40 inches for men and <35 inches for women Recommend reduced calories and salt for obese or overweight persons Diabetes will change diet

PE Care after discharge

Blood work- To monitor anticoagulation -- Anticoagulant therapy for at least 6 months Taking other medications- MANY drugs interact with anticoagulants Safety measures- -- Soft toothbrushes -- Report signs of bleeding to physician -- Shoes when ambulating- NO bare feet Symptoms of bleeding -- Hematuria -- Dark or blood stools -- Bleeding gums

PAD Surgical Therapy

Bypass Grafting - Peripheral artery bypass surgery with autogenous vein or synthetic graft to bypass blood around the lesion - PTA with stenting may also be used in combination with bypass surgery Endarterectomy Patch graft angioplasty Amputation

Revascularization Procedures

Bypass surgery

Venous Disorders

Chronis venous insufficiency Venous thrombosis Venous thromboembolism Varicose veins Pulmonary Embolism

PAD Risk Factors

Cigarette smoking (vape) Hypercholeserolemia Hypertension Chronic kidney disease Diabetes mellitus Family History

PAD Acute Care Nursing

Frequently monitor after surgery: -- Skin color and temperature -- Capillary refill -- Presence of peripheral pulses distal to the operative site -- Sensation and movement of extremity Monitor for potential complications Knee-flexed positions should be avoided except for exercise Turn and position frequently

Varicose Vein Planning and Implementation

Goal- Health Promotion Goal: improve venous circulation Goal: prevent skin breakdown Goal: Pain relief

Venous Insufficiency Planning and Implementation

Goal- Health Promotion Goal: increase venous blood return, decrease pressure Goal: treat venous stasis ulcers & restore skin integrity- Bed cradle

PAD Nursing Planning and Implementation

Goal- Health Promotion Goal-Promote circulation- ambulate/ increased exercise tolerance Goal: adequate tissue perfusion Goal: relief of pain Goal: intact, healthy skin on extremities Goal: increased knowledge of disease and treatment plan

Artherosclerosis

Hardening and narrowing of the arteries due to buildup of cholesterol plaques

Catheter-assisted procedures

Heated catheter destroys the vein by causing it to collapse and seal shut

PAD may affect

Iliac artery Femoral artery Popliteal artery Tibial artery Peroneal artery

PAD Discharge Evaluation

Improved peripheral perfusion Absence of ulcers Improved activity tolerance Effective pain management Knowledge of disease and treatment plan Plans for walking program Increased activity tolerance Verbalize key elements of -- Therapeutic regimen -- Knowledge of disease -- Treatment plan -- Reduction of risk factors -- Proper ulcer/foot care (mirror on floor)

Venous Insufficiency Nursing Diagnosis

Ineffective tissue perfusion Impaired skin integrity r/t impaired circulation Risk for infection Pain

Varicose Vein Nursing Diagnosis

Ineffective tissue perfusion Risk for impaired skin integrity Risk for peripheral neurovascular dysfunction Pain

PAD nursing diagnoses

Ineffective tissue perfusion Impaired skin integrity r/t impaired circulation Pain

PE Nursing Interventions

Initial Priority Actions -- Administer Oxygen reducing hypoxemia-Type? -- High Fowlers position - RRT- Rapid Response Team and notify health care provider - Continuous monitoring of VS - Medications as prescribed - Emotional support for patient and family - Watch for increasing pain or changes in LOC DOCUMENTATION OF EVENTS

Sclerotherapy

Injecting a saline solution closes those veins.

Arterial ulcers

Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis A painful complication in the patient with peripheral arterial disease. Typically, the ulcer is small and round, dry, with a "punched out" appearance and well-defined borders. Ulcers develop on the toes (often the great toe), between the toes, or on the upper aspect of the foot. With prolonged occlusion, the toes can become gangrenous.

Knee-high sequential compression devices have been prescribed for a newly admitted client. The client reports new pain localized in the right calf area that is noted to be slightly reddened and warm to touch upon initial assessment. What should the nurse do first?

Leave the compression devices off, and contact the health care provider (HCP) to report the assessment findings.

PAD Ambulatory Care Nursing

Management of risk factors Long-term antiplatelet Importance of supervised exercise training after revascularization Importance of meticulous foot care Comfortable shoes with rounded toes and soft insoles/ Shoes lightly laced

Varicose Vein Diagnostic Test

Manual compression test Positive trendelenberg Doppler ultrasound- a non-invasive diagnostic medical technique that uses high frequency sound waves to produce images of the internal structures of the body.

PAD and bleeding after surgery

Mucous membranes - bladder - gums LGI Nose bleeds

VTE Evaluation

No S/S of active bleeding Education- meds, wearing TED, SCD No further evidence of increased clot Stable assessment No pain edema, tenderness No impaired skin integrity

Nursing Implications of Heparin Administration

Obtain Baseline labs (Hgb, HCT, platelets, PTT or Anti-Xa) Double check your dose Teach the patient and family about the medication Monitor Know your equipment and protocols Antidote: Protamine Sulfate

Vein stripping for varicose veins

Outpatient procedure surgical removal vein removal

Risks of anticoagulation

Over anticoagulation may cause bleeding (or oozing): internally, intravascular, externally Under anticoagulation may increase risk of extending clot or causing clot Developing allergy (HIT) to heparin has extremely high risks to patient

PE Nursing Considerations

Oxygen- To optimize tissue oxygenation- Turn cough, deep breath patient, head of bed elevated, supplemental oxygen Semi-Fowlers Pain control- Analgesics Multiple education needs ---- Dietary changed- Food restrictions due to anticoagulation- Many foods contain Vitamin K- Vitamin K is part of the clotting process

VTE Nursing Diagnoses

Pain Ineffective tissue perfusion Risk for impaired skin integrity

Classical P's for PAD

Pain Pulse Paralysis Pallor Paresthesia

PAD Radiology Procedures

Percutaneous transluminal angioplasty (PTA) Atherectomy Cryoplasty Must carefully consider the patient medical history and current status before proceeding with surgery!

Malleolar

Pertaining to the malleolus (process on each side of the ankle). Common place for an ulcer

Case Study 1C - An angiography reveals nearly completely obstructed vessels in B.D.'s lower extremities. - He is diagnosed with peripheral artery disease. What treatment plan will you anticipate? - Based on this diagnosis and his known risk factors, what treatment plan would you anticipate?

Place on antiplatelet agents to help reduce build up

VTE Collaborative Care

Prevention and prophylaxis -- TED hose -- Sequential compression device -- Low molecular weight heparin- NPSG -- Unfractionated heparin -- Coumadin

Hemosiderin

Prolonged venous hypertension resulting in venous dilatation and passage of red blood cells through the endothelium into the interstitium results in breakdown and conversion of hemoglobin to hemosiderin. This remains as a brown pigment stain on the skin.

Pulmonary Embolism (PE)

Pulmonary embolism is a foreign object-thrombus, air, amniotic fluid or fat which has become dislodged- and implanted in the VASCULAR branches of the lung, NOT in the lung tissue Embolism has traveled through the right sides of the heart and pulmonary artery

Case Study 1B - When assessing B.D., you find that his feet are pale and cool to touch. - He has diminished pedal and posterior tibial pulses and decreased sensation. - He has a small open area on the lateral side of his left ankle. What are your concerns regarding these assessment findings?

Pulse decreases means not receiving oxygen leading to diminished sensation and nerve damage and ulcer.

PE Evaluation

RR WNL Pulse Ox WNL ABG's Alert and oriented Absence/resolution of chest pain Absence/resolution of anxiety Prevention of further thromboembolic phenomena Education

Venous Insufficiency Evaluation

Reduction of edema Healing/prevention of stasis ulcers

Revascularization

Reestablishment of blood supply to a part of the body

Varicose Vein Evaluation

Relief from discomfort Improved circulation Avoidance of complications

Ambulatory phlebectomy

Removal smaller varicose veins through a series of tiny skin punctures.

Anti-Xa

Sensitive to heparin's inhibitory effect on factor Xa. Check baseline, 6-hour intervals and all dose changes until stabilization, and then once daily (same as aPTT). -- Anti-Xa test is the most accurate assay for monitoring unfractionated heparin therapy and is the only assay available for monitoring low molecular weight heparin (Lovenox®)

Venous Thromboembolism (VTE) Assessment /Clinical Manifestations

Subjective: History, risk factors Objective: VTE lower extremity (Venous thromboembolism) -- Unilateral leg edema -- Pain -- Warm to touch erythema -- Evidence suggests that Homan's sign is not conclusive VTE pulmonary embolism- Needs IMMEDIATE Intervention -- SOB -- Chest pain worse with deep breath -- Hemoptysis

PE Clinical Manifestations Subjective Data

Sudden shortness of breath Air hunger Chest wall pain/ Pleurisy type pain on inspiration Anxious Feeling in impending doom

Varicose Vein Clinical Manifestation

Superficial of deep Disfigurement Superficial venous thrombosis

PE Risk Factors

Surgery Bed rest- Immobility Tobacco use Heart failure/ Atrial Fibrillation Lower extremity fracture Contraception/ estrogen therapy Pregnancy Hypercoagulability

A pregnant client who stands for long periods while working in a factory visits the prenatal clinic at 35 weeks' gestation, stating, "The varicose veins in my legs have really been bothering me lately." Which instruction would be most helpful?

Take frequent rest periods with the legs elevated above the hips.

A nurse on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?

The client with unilateral leg swelling who's complaining of anxiety and shortness of breath

PE Etiology

The common cause of a PE is a deep vein thrombosis which becomes dislodged-Some causes of a deep vein thrombosis (DVT) a.k.a. venous thromboembolism (VTE)

Venous thrombosis

The formation of blood clots within a vein

PAD Risk factor modification

Tobacco cessation Glycosylated hemoglobin <7.0% for diabetics Aggressive treatment of hyperlipidemia BP maintained <140/90 (ideally as close to 120/80 as possible)

VTE diagnostic tests

Venous duplex scanning Doppler ultrasound D-dimer Venograpgy and plethysmography MRI Lung scan

Chronis venous insufficiency

Venous pooling, bilateral, due to valve in veins being damaged and retrograde blood flow

Virchow's triad

Venous stasis, hypercoagulability endothelial damage (lining of the vein)

PAD diagnostic tests

assess pulse, LE skin doppler pulses ankle-brachial index MRA exercise tolerance test arterio-angiograms Plethysmography

Varicose veins

abnormally swollen, twisted veins with defective valves; most often seen in the legs

ABI

ankle brachial index

Venous thromboembolism

arises due to the Virchow triad: hyper coagulable states, venous stasis, and endothelial injury

Venous Thromboembolism (VTE)

deep vein thrombosis and pulmonary embolism

Laser therapy for varicose veins

fades the appearance of veins

superficial vein thrombosis

formation of a thrombus in a superficial vein, usually the greater or lesser saphenous vein

intermittent claudication

pain and discomfort in calf muscles while walking; a condition seen in peripheral arterial disease