cardio ch.31
surgical management of PAD
- percutaneous transluminal angioplasty - laser-assisted angioplasty - rotational atherectomy
nursing actions for HTN
Administer antihypertensive medications as ordered — Clinical outcome trial data prove that lowering BP with a combination of one or several classes of medications reduces the complications of hypertension. Provide patient with DASH diet for meals — A 1,600-mg sodium DASH eating plan has effects similar to those of antihypertensive single-medication therapy
about aortic artery disease
An aneurysm is a permanent localized dilation of an artery that forms when the middle layer (media) of the artery is weakened, producing a stretching effect in the inner layer (intima) and outer layers of the artery. While the artery widens, tension in the wall increases, further widening occurs, and the aneurysm enlarges. The diameter of the artery can be enlarged to at least two times the normal circumference. Hypertension is one cause of that tension and enlargement within the artery. Other causes include congenital problems such as Marfan's syndrome or acquired problems such as atherosclerosis.
aneurysm repair with surgery compared with stent placement
Aneurysm repair with surgery compared with stent placement. A, Aneurysmectomy; the aneurysm is excised, and a graft is applied. B, Endovascular aortic repair; placement and attachment of a sutureless aortic graft prosthesis across an aneurysm.
aortic artery disease
Approximately 15,000 people in the United States die each year of abdominal aortic aneurysms (AAAs). Men develop AAAs four to five times more often than women. Caucasians develop AAAs more commonly than other racial groups. Thoracic aortic aneurysms (TAAs), the most common site for a dissecting aneurysm, occur most often in men between the ages of 40 and 70 years and have a high mortality rate even with surgical intervention.
nursing interventions for carotid artery disease
Respiratory rate, SpO2, stridor, tracheal deviation — In CEA—Hematoma formation at the incision site can cause tracheal pressure resulting in respiratory distress, which can escalate rapidly as the hematoma enlarges. Vital signs: HR, BP — In CEA—Prior to treatment, the carotid baroreceptor sensed a low pressure in the stenotic carotid artery. Following CEA, a new "normal" pressure may be sensed as a high pressure signalling the vagus nerve to respond, resulting in vasodilation, bradycardia, and hypotension. Prolonged hypertension may result in damage to the arterial graft, causing hemorrhage as well as placing the patient at risk of intracerebral haemorrhage. In CAS—Bradycardia, related to manipulation of the carotid sinus baroreceptors located in the carotid bulb, may occur during the procedure just after the stent implantation; Persistent hypotension can be caused by the effect of the stent on the carotid sinus baroreceptors. Post-CEA—Cranial nerves, specifically VII, X, XI, and XII (see Table 31.10) — Retraction on the lower cranial nerves during surgery can result in temporary or permanent nerve damage due to trauma or edema. Post-CAS—Renal function — Angiogram dye is nephrotoxic, especially in those patients who already have kidney disease.
risk factors of HTN
Risk factors include age, gender, race, and socioeconomic status. Blood pressure tends to rise with age. Approximately 65% of Americans aged 65 or older have hypertension. People with a normal BP at age 55 have a 90% lifetime risk of developing hypertension.
risk factors of aortic artery disease
Risk factors include family history, advanced age, male gender, smoking, atherosclerosis, treated and untreated hypertension, high total serum cholesterol, known coronary artery disease, and genetic and/or metabolic abnormalities. Atherosclerosis accounts for 75% of all AAAs, but of these risk factors, smoking is one of the most important. It is a risk factor that the patient can control, thus modifying the risk
ECG sign of MI
ST-segment elevation.
evaluating care outcomes for PAD
The primary goals of medical treatment and nursing care for patients with PAD are to provide relief of symptoms, improve quality of life, provide education about the disease, and prevent the progression of arterial disease and cardiovascular complications. A well-managed patient is pain free and able to participate in normal physical activities without limitations.
triglyceride levels
Triglyceride levels may be elevated with atherosclerosis. Elevated triglycerides are considered a marker for other lipoproteins. A level of 150 mg/dL or above indicates hypertriglyceridemia - want less than 150 mg/dL
excess angiotensin
also results in increased aldosterone release.
atherosclerosis of coronaries
can result in chest pain or angina, shortness of breath, fatigue, and arrhythmias. As noted, it may also result in sudden cardiac death. Atherosclerotic disease in the carotids may result in a stroke. If blood supply to the arms or legs is reduced in a similar manner, it can cause significant pain and difficulty walking. If blood supply is completely occluded peripherally to the affected body part, it can eventually lead to gangrene. Gangrene is a medical term used to describe the death of tissues of the body. Gangrene can affect any part of the body; the most common sites include the toes, fingers, hands, and feet.
aldosterone
- Excess aldosterone release results in sodium and water retention, which results in increased stroke volume and blood pressure. - Enhanced potassium (K) excretion also occurs, resulting in low plasma K. - Low plasma K increases vasoconstriction through closure of K channels
atherosclerosis leads to what?
- HTN - carotid artery disease - peripheral vascular disease
glcosylated hemoglobin
- HgbA1c - hyperglycemia is a risk for the development of atherosclerosis. An HgbA1c of greater than 7% may indicate poor glycemic control.
how to prevent deep vein thrombosis
- ambulation - venous thromboembolism prophylaxis - low molecular weight heparin The first step in treatment is prevention. In low risk patients, early ambulation may be all that is necessary. Venous thromboembolism (VTE) prophylaxis is indicated in at-risk hospitalized populations. In patients with a low bleeding risk pharmacological prevention is recommended. Preferred medications include low molecular weight heparin (LMWH), unfractionated heparin, or, in patients with heparin induced thrombocytopenia (HIT), fondaparinux can be used. In patients with a higher risk of bleeding mechanical VTE prophylaxis is indicated. This includes the use of graduated compression stockings, venous foot pumps, and active external intermittent compression devices. The benefits of these methods include their effectiveness, ease of application, and safety especially in respect to bleeding. Intermittent compression devices apply external pressure to the limb which promotes blood flow velocity, reduces venous stasis, and increases levels of systemic fibrinolysis. Despite widespread use, there is limited evidence regarding the use of graduated compression stockings, venous foot pumps, or combined medical and mechanical prophylaxis.
risk factors of atherosclerosis
- elevated cholesterol levels - eevated triglycerides - elevated low-density lipoprotein cholesterol (LDL-C) - Low high-density lipoprotein cholesterol (HDLC) - HTN - Diabetes - smoking - family hx - obesity - sedentary lifestyle.
signs and symptoms of hypertension
- headache - chest pain - vision changes - SOB - Renal dysfunction - dizziness - fatigue - nosebleeds.
medications used to help hypertension
- healthy lifestyle - diuretics - antihypertensives - weight control - diet - decreased alcohol consumption
signs and symptoms of atherosclerosis
- maybe no signs till emergent depending on the arteries involved. - MI - sudden cardiac death - stroke - gangrene
nursing interventions for hypertension
- neurological assessment (assess for signs of TOD and cerebrovascular disease leading to possible complications such as stroke and aneurysm) - blood pressure ( early detection and treatment of HTN can prevent or minimize TOD. measurements determine the treatment regimen prescribed) - heart rate )increased PVR can cause increased HR or increased SV) - examination of optic fundi (HTN causes retinal damage) - auscultation for carotid, abdominal, and femoral bruits - palpate lower extremities for edema and pulses - serum creatinine, BUN, estimated glomerular filtration rate, and 24-hour urine collection for creatinine clearance. abnormal levels indicate renal disease, which may develop in patients with HTN. - albumin excretion rate (microalbuminuria is a significant marker of early cardiac renal, and retinal changes in HTN) - calculate BMI
signs and symptoms of deep vein thrombosis
- pain - swelling - tenderness - discoloration -redness - warmth People with DVT may or may not have symptoms. The clot(s) can cause partial or complete blockage of circulation in the vein, which can lead to pain, swelling, tenderness, discoloration, or redness and warmth in the affected area. The clinical manifestations vary depending on the size, location, degree of vessel occlusion, and adequacy of collateral circulation. Table 31.13 describes common clinical manifestations associated with calf, femoral, iliofemoral, and upper extremity thrombosis. The presence of Homans' sign, calf pain elicited on dorsiflexion of the foot, may indicate the presence of a DVT but its routine use in evaluation is not recommended as it is frequently misinterpreted and is not a reliable predictor
treatment of PAD
- prevent progression - manage symptoms - antihypertensives - antiplatelets - statins The primary goals of medical treatment and nursing care for patients with PAD are to provide relief of symptoms, prevent the progression of arterial disease and cardiovascular complications, improve quality of life, and provide education about the disease. Medications and nonsurgical and surgical interventions are options for treatment. The majority of patients with PAD are elderly with a significantly increased risk of myocardial infarction, stroke, and cardiovascular death. Nonpharmacological interventions such as weight reduction, smoking cessation, exercise, and adherence to a low-fat diet are first-line actions
deep vein thrombosis complcations
- pulmonary embolism - post thrombotic syndrome
surgical management for deep vein thrombosis
- rare - thrombectomy - balloon angioplasty - stent placement - vena cava interruption Surgical management is rarely utilized to remove a DVT unless there is a massive occlusion that does not respond to medical treatment and the thrombus is of recent (1-2 days) onset. Thrombectomy is the most common surgical procedure for removing a clot. Other less-invasive surgical procedures include balloon angioplasty, stent placement, and vena cava interruption. Balloon angioplasty widens the vein after a blood clot has been dissolved. As with other balloon angioplasty procedures, expanding the balloon in the vein causes the vein to widen and improves blood flow. Stent insertion can be utilized for DVT patients who have a vein that is prone to collapse. The stent expands once inserted and acts as a support for vein walls. The purpose of vena cava interruption is to prevent PE. In this procedure, a provider surgically positions a filter inside the inferior or, not routinely, the superior vena cava between the DVT and the heart. Blood flows normally through the umbrellalike filter, but emboli are trapped, ensuring that they do not reach the lungs.
risk factors of carotid artery disease
- smoking - HTN - diabetes - dyslipidemia - sedentary life - obesity - ineffective stress management Risk factors associated with carotid artery disease are similar to those that cause atherosclerotic occlusive disease in other vessels: smoking, hypertension, diabetes, dyslipidemia, sedentary lifestyle, obesity, and ineffective stress management. Nonmodifiable risk factors include age, gender, ethnicity, and family history. Younger than 75 years, men have a greater risk than women. Older than 75 years, women have a greater risk. People with coronary artery disease have a greater risk of developing carotid artery disease
irreversible issues of atherosclerosis
- stroke! - MI! - these things can be addressed but never 100% back to normal.
medications for deep vein thrombosis
- unfractionated heparin - low molecular weight heparin - venous thromboembolism prophylaxis
complications of hypertension
-called silent killer b/c it can cause considerable damage to the heart, brain, and kidneys before symptoms are seen - dilated cardiomyopathy - systolic dysfunction - renal failure - stroke - hypertensive crisis
nursing interventions for atherosclerosis
1- complete pt hx and cardio assessment 2- asses BP in both arms (HTN is a strong risk factor for atherosclerotic disease) 3- palpate pulses at all the major sites on the body (carotid arteries are palpated one at a time. weak pulses may suggest poor flow through the artery. palpate the carotids one at a time) - auscultate for bruits (bruits occur when blood is trying to pass through a narrowed artery.
normal fasting blood glucose
70-100 mg - if you have diabetes, this could go up to 150, 200, or more, then more when they eat. the nigher it is the more insulin they need.
how to diagnose aortic artery disease
A number of imaging modalities can be used to detect and diagnose aortic dilation. Computed tomography scanning with IV contrast is considered the gold standard for assessing the size and location of an abdominal or thoracic aneurysm. Abdominal ultrasound or transthoracic echocardiography (TTE) have also been preferred screening modalities because they can be done quickly and efficiently at the bedside and because of their noninvasive nature and lack of radiation. Cardiac MRI is an imaging modality that has shown improved sensitivity and specificity versus TTE in detecting aortic dilation. The lack of radiation exposure with MRI compared with CT may make it the imaging modality of choice for aortic dilation. An ECG is also routinely done to rule out an MI because complications of aneurysm usually involve chest pain.
nursing actions for carotid artery disease
Administer antihypertensive medication as ordered to maintain BP below 140/90 mm Hg — Prolonged increases in BP may cause vessel rupture, which leads to hemorrhage and stroke. Administer lipid-lowering medication as ordered — Reducing LDL-C helps reduce plaque formation in the carotid vessels. Administer antiplatelet aggregates as ordered — Antiplatelet therapy helps reduce platelet aggregation, resulting in decreased risk of obstruction in the vessel. Manage diabetes mellitus/maintain blood glucose within normal levels — Poorly controlled diabetes mellitus results in increased plaque formation in the vessels due to the breakdown of fats for energy, increasing the risk for ischemic stroke post: Keep systolic blood pressure strictly within ordered parameters—To maintain integrity of the graft and/or flow through carotids If patient is hypotensive: • Reposition patient flat—Increase blood flow to increase cerebral perfusion • Anticipate orders for vasoactive drips or intravenous fluid bolus—Vasoactive drips cause vasoconstriction to increase blood pressure. Fluid bolus increases circulating volume, increasing BP.
medications for PAD
Antihypertensives — Controlling hypertension is necessary to help manage comorbidities, and it can improve tissue perfusion by maintaining pressures that are adequate to perfuse the periphery but not constrict the blood vessels . • Antiplatelet agents — Patients with PAD and no contraindications to antiplatelet therapy should receive either aspirin or clopidogrel to inhibit clot formation. • Cilostazol— Cilostazol has antiplatelet and vasodilation properties that can improve PAD symptoms
complications of aortic artery disease
Aortic dissection (dissecting aneurysm) is thought to be caused by a sudden tear in the aortic intima creating a false lumen in the artery, opening the way for blood to enter the aortic wall. Degeneration of the aortic media may be the primary cause for this condition, with hypertension being an important contributing factor. Dissection is also frequently linked with Marfan's syndrome. This is a life-threatening emergency because of the loss of circulation to any major artery arising distal to the dissection. The ascending and descending thoracic aortae are the most common sites, but dissections can also occur in the abdominal aorta. Rupture of the aortic aneurysm is the most life-threatening complication. Rupture causes sudden and extreme loss of blood. Patients may present similar to those with a dissection with symptoms such as pain, tachycardia, and differing BPs between extremities, but in extreme cases, pain occurs then loss of consciousness due to hypovolemic shock from massive blood loss. The death rate in all patients with a ruptured abdominal aortic aneurysm (RAAA) or dissection is around 80%. One-third of all patients with an RAAA do not reach the hospital alive, and one-third do not have an intervention. Of the patients having an intervention, only half survive the intervention and admission. Emergency surgical procedures are indicated for patients with a ruptured or dissecting abdominal aortic or thoracic aneurysm. Mortality rates increase dramatically once dissection or rupture has occurred as compared to the mortality rate if surgery is performed electively.
atherosclerosis
Atherosclerosis comes from the Greek words "athero," meaning "gruel" or "paste," and "sclerosis," meaning "hardness." Well documented in the literature, atherosclerosis is a disease in which LDL-C particles build up in the arterial wall - a slow disease that starts in childhood and progresses while people grow older.- for some, rapid progression, with symptoms becoming evident as young as 30. The lesions of atherosclerosis accumulate in large- and medium-sized arteries. The exact pathophysiology remains under intense investigation, but the condition is thought to begin from vessel damage that causes an inflammatory response. After the vessel becomes inflamed, a fatty streak appears on the intimal surface, or inner lining, of the artery. Researchers believe that high circulating cholesterol levels promote the deposit of lipids into the arterial wall. In the presence of inflammatory mediators, they are oxidized by macrophages and perpetuate the inflammatory condition. It is best described as an inflammatory process comprising a series of highly specific cellular and molecular reactions that lead to the accumulation of atherosclerotic plaque. The presence of plaque thickens the inner layer of the artery significantly. The inner diameter of the artery shrinks, causing a decrease in blood flow, ultimately reducing oxygen supply to the affected tissues. Plaques can grow large enough to significantly reduce blood flow through an artery, but a more serious problem is when they become unstable and rupture. Plaques that rupture may cause blood clots to form that can block blood flow entirely. Ruptured plaques also have the potential to travel to another part of the body.
peripheral arterial disease risk factors
Atherosclerosis is the main contributor to PAD. Therefore, the risk factors for atherosclerosis apply to PAD as well. They include key modifiable risk factors such as smoking, hypertension, diabetes, dyslipidemia, sedentary lifestyle, obesity, and ineffective stress management. Nonmodifiable risk factors include age, gender, ethnicity, and family history. A strong family history of coronary artery disease or PAD is an important predictor of its occurrence and subsequent prognosis
nursing interventions of PAD
Bilateral blood pressures — Patients with diagnosed PAD have an increased risk of subclavian artery stenosis. Upper arm blood pressure difference of greater than 15 to 20 mm Hg is abnormal and suggestive of subclavian stenosis. Use the higher blood pressure measurement when calculating ABI and titrating blood pressure medications. Palpate all pulses in both legs — Weak or absent pulses indicate poor blood flow through the extremity. The most sensitive indicator of arterial function is the quality of the posterior tibial pulse. Visual assessment of feet and limbs — Signs of ulcer formation: sluggish capillary refill; dry, scaly, dusky, pale, or mottled skin; thickened toenails. Loss of hair on the lower calf, ankle, and foot indicate poor peripheral blood flow. Temperature — Cool or cold temperature in the extremities indicates poor flow. Assess bilateral muscle tone — Muscle atrophy can accompany prolonged chronic arterial disease. Assess pain — Pain in the affected extremity with activity that is relieved with rest is indicative of PAD.
assessment and analysis of carotid artery disase
Carotid artery disease is asymptomatic until the lumen of the vessel is obstructed to the point that cerebral perfusion is impaired. A bruit resulting from turbulent flow past the obstruction at the carotid bifurcation may be heard with a stethoscope. Symptoms of a stroke—slurring of words, weakness, severe headache, sudden vision loss, facial droop, or dizziness—are secondary to impaired perfusion to the cerebral tissues
signs and symptoms of peripheral arterial disease
Clinical manifestations of PAD vary with the tissues involved and the severity of altered blood flow. Although PAD is often unrecognized in its early stages, most patients initially seek medical attention for classic leg pain referred to as intermittent claudication, fatigue, and pain in a specific muscle group during exertion. With severe arterial disease, the extremity is cold and cyanotic or darkened. Pallor may occur when the extremity is elevated, and dependent redness may occur when the extremity is lowered. Muscle atrophy can also accompany prolonged chronic PAD
teachings of carotid artery disease
Clinical manifestations of a stroke: severe headache, facial drooping, loss of strength on one side, change in gag reflex, slurred speech, inability to stick out tongue and shrug shoulders equally; instruct patient and family to report neurological changes immediately—The best outcomes occur with rapid treatment. Lifestyle changes consistent with the management of atherosclerosis • DASH diet • Exercise • Smoking cessation • Limit alcohol —Atherosclerosis is implicated in the development and progression of carotid artery disease.
laser-assisted angioplasty
During this procedure, a laser probe is advanced through a cannula that is inserted into or above an occluded artery. This procedure is usually indicated for smaller occlusions in the distal superficial femoral, proximal popliteal, and common iliac arteries. Heat from the laser probe vaporizes the arteriosclerotic plaque to open the occluded or stenosed vessel. A PTA is often needed to further open the occlusion
nursing actions for deep vein thrombosis
Early ambulation — Bedrest has been recommended in the past, but recent studies show early ambulation does not result in more complications (see Evidence-Based Practice) and is key to prevention. Leg elevation — When at rest, the affected extremity should be elevated at least 10 to 20 degrees above heart level to enhance venous return and reduce swelling. Compression stockings — Should be worn at all times. Compression promotes venous return and decreases leg swelling. Avoid use of sequential compression devices (SCDs) in affected extremity — An SCD may cause the thrombus to break away, resulting in an embolus. Encourage adequate fluid intake — Prevents dehydration and sluggish blood flow, which exacerbates DVT growth Administer anticoagulation medications as ordered — Anticoagulation with unfractionated heparin followed by long-term oral anticoagulation prevents the formation of new thrombi and inhibits the growth of the existing thrombi. Administer thrombolytic agent as ordered — Thrombolytic agents dissolve existing thrombi and decrease the instance of vascular damage
homocysteine
Homocysteine is a sulfur-containing amino acid derived from dietary protein. High serum levels of homocysteine may block production of nitric oxide on the vascular endothelium, making the cell walls less elastic and permitting plaque to build up.
what to do post op CEA?CAS for carotid artery disease/
If patient is hypertensive: • Maintain head of the bed at 30 degrees—Facilitates venous drainage and avoids excessive increases in cerebral blood volume. Post-CEA—Keep head in neutral position—Decreases strain on incision site and carotid artery. Post-CAS - Encourage fluid intake/Maintain IV fluids—Flush the contrast dye through the kidneys
sympathetic nervous system
Increased sympathetic activity is a primary precursor to hypertension. It can cause vasoconstriction, resulting in increased peripheral vascular resistance and increased blood pressure. It may also increase heart rate. - Overactivity of the sympathetic nervous system may result from either inappropriately elevated sympathetic drive from brain centers, an increase in synaptically released neurotransmitters in the periphery, or amplification of the neurotransmitter signal at the target tissue.
low-density lipoprotein cholesterol
LDL! - high LDL levels indicate an increased risk for atherosclerosis. - normal levels are less than 100 mg/dL.
about aortic artery disease (aneurysm)
Most AAAs are small and do not cause any symptoms. The vast majority of thoracic aneurysms are silent, with rupture or dissection constituting the first symptoms. Overall, only 5% to 10% of patients experience symptoms such as chest, back, or flank pain depending on the location of the aneurysms.
peripheral arterial disease (PAD)
PAD is a progressive and chronic condition where the obstruction of blood flow through the large peripheral arteries causes a partial or total arterial occlusion. This obstruction can be caused by a combination of atherosclerosis, inflammation, stenosis, embolus, and thrombus. Peripheral arterial disease deprives the lower extremities of oxygen and nutrients. The result of this inadequate tissue perfusion can be ischemia and necrosis, or cell death
evaluating care outcomes of HTN
Patients need to understand and comply with the treatment regimen of antihypertensive medications and necessary lifestyle changes to achieve optimum health. A patient with well-controlled hypertension has a BP and HR within normal limits. Other indicators of well-controlled BP are increased energy and no headache, dizziness, or vision changes or other signs of TOD. The electrocardiogram (ECG) and echocardiogram remain normal or unchanged. Blood chemistries and urinalysis are within normal limits.
percutaneous transluminal angioplasty
Percutaneous transluminal angioplasty (PTA) is a nonsurgical, minimally invasive method of improving arterial blood flow. During this procedure, a cannula is inserted into or above an occluded or stenosed artery. The occluded artery is then dilated with a balloon catheter (Fig. 31.5). Success of the procedure is proven when it opens the vessel and restores or improves arterial blood flow. Stents may be used during this procedure to keep the vessel open. The transfemoral approach is the safest, most widely used, and most effective route for arteriography. If the femoral artery is not an option for catheterization secondary to surgery, arterial stenosis, or occlusion, alternative routes for arteriography include the brachial or axillary approach. Reocclusion may occur after percutaneous angioplasty. If this occurs, the procedure may be repeated. Some patients remain occlusion-free for up to 3 to 5 years, whereas other patients may experience reocclusion much sooner. The experience is patient specific. Patients must be educated on the importance of medication compliance and continued risk factor modifications. They are also educated on the signs and symptoms of reocclusion.
teachings for deep vein thrombosis
Prevention of recurrence with activities such as: • Early ambulation and active leg exercises • Monitor for adequate fluid intake to prevent dehydration and changes in blood flow • Avoid constricting clothing on the legs that might decrease venous flow, sitting with knees bent or crossed for long periods, standing for long periods • Remind patients that long car or airplane trips can increase the risk of DVT, so they should stay well hydrated and move around whenever possible or do leg exercises while sitting —Encourage patients to engage in activity that decreases the incidence of DVT by maintaining adequate blood flow through the extremity and avoid activities or actions that constrict or limit blood flow. Signs and symptoms of bleeding such as bruising, bloody stools, petechiae — It is important when taking anticoagulants that the patient (and family) is able to detect signs and symptoms of bleeding. Compliance with regular laboratory monitoring — It is important that the patient (and family) understand the importance of compliance with laboratory draws and the medication regimen to reduce bleeding risk. Safety precautions when taking anticoagulants
HTN and stroke risk
Prolonged increases in BP may cause vessel rupture, which leads to hemorrhage and a sudden loss of function, resulting from a disruption of the blood supply to a part of the brain. It is the fourth-leading cause of death in the United States and the leading cause of disability. Hypertension is the most important but modifiable risk factor related to stroke. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence averaging 35% to 40%. An aneurysm is another very serious complication of hypertension. An intracranial aneurysm is a dilation of the walls of the cerebral artery that develops as a result of weakness in the arterial wall. The aneurysm presses on nearby cranial nerves or brain tissue causing damage or ruptures causing subarachnoid hemorrhage and stroke
risk of deep vein thrombosis
Risk factors include increasing patient age, active cancer with or without concurrent chemotherapy, varicose veins, prior venous thrombosis, pregnancy, postpartum period, and oral contraceptive and hormone therapy. Surgery, trauma, hospital or nursing home confinement resulting in immobility, and procedures such as central vein catheterization or transvenous pacemaker insertion also increase the risk.
rotational artherectomy
Rotational atherectomy is more commonly used for very hard, calcified stenotic lesions that are not amenable to balloon angioplasty. Rather than compressing plaque and stretching an artery narrowed by atherosclerotic plaque, the goal of atherectomy is removal of the plaque by breaking it into micro fragments.
teachings for aortic artery disease (aneurysm)
Signs and symptoms of aortic aneurysm and aortic dissection such as any new chest, abdominal, or flank pain, especially new pain not associated with increased activity—It is important that the patient is able to detect signs and symptoms of an aortic aneurysm and aortic dissection to allow prompt intervention. Patients with Marfan's syndrome should be encouraged to do regular screening and call their provider with any new chest, abdominal, or flank pain—Patients with Marfan's syndrome are at increased risk for aneurysms due to the degeneration of the elastic fibers of the aortic media that occurs with that disease. Because of the emergent nature of aortic dissection, immediate recognition is essential to allow emergent repair. Following a strict treatment regimen which includes • Compliance with medications • Smoking cessation program if the patient is a smoker • Maintaining a healthy weight • Regular exercise • Avoid crossing or elevating legs to decrease pressure on the aorta and iliac arteries • Stress reduction • Following diagnostic testing and screening recommendations (includes regular blood pressure and cholesterol checks) • Obtaining regular ultrasounds to measure the aneurysm's growth — Compliance with the treatment regimen is essential in successful management of aortic disease.
carotid artery disease
Similar to atherosclerotic changes in other arteries, carotid artery disease is characterized by vessel wall thickening, plaque formation, and a progressive narrowing of the carotid artery. Plaque disruption and thrombus formation contribute to progressive narrowing of the lumen of the artery, which can cause adverse clinical events. Stenosis is most significant at the carotid bifurcation. This area is known as the carotid bulb, where the common carotid artery branches into the internal and external carotid arteries (Fig. 31.6). The carotid bifurcation is an area of low-flow velocity and low-shear stress. While the blood circulates through the carotid bifurcation, there is a separation of flow into the low-resistance internal carotid artery and the high-resistance external carotid artery. With increasing degrees of stenosis in the internal carotid artery, flow becomes more turbulent, increasing the risk of atheroembolization: an embolism from atherosclerotic plaque.
assessment and analysis deep vein thrombosis
The clinical manifestations of DVT vary depending on the size, location, degree of vessel occlusion, and adequacy of collateral circulation. Patients may complain of pain, and there may be redness, swelling, and warmth due to obstruction of flow in the affected extremity.
medications for carotid artery disease
The management of asymptomatic patients starts with optimal medical therapy (OMT) which includes a combination of healthy lifestyle changes such as weight management, smoking cessation, limited alcohol consumption, and control of comorbidities such as diabetes and hypertension, and use of medications to manage the cause of atherosclerotic vascular disease. Medication management includes antiplatelet therapy with aspirin. Clopidogrel is an option if aspirin in contraindicated. Antihypertensive therapy for blood pressure control is essential. The AHA recommends maintaining blood pressure below 140/90 mm Hg. Many classes of medications, such as calcium channel blockers, angiotensin-converting enzyme inhibiters, and angiotensin receptor blockers, are effective in blood pressure control. Lipid-lowering therapy with statins is also recommended. Without stating an LDL-C target level as evidence, current guidelines suggest that the use of high-intensity statins shows a 50% reduction in LDL-C levels. Somewhat controversial is the use of invasive procedures to treat the obstruction itself. Patients would benefit from either surgical or endovascular revascularization but are at risk for the complications of the procedures, which include stroke. Current guidelines suggest revascularization in medically stable patients with carotid endarterectomy (CEA) or carotid artery stenting (CAS). Both procedures will be discussed below in detail. The management of symptomatic patients includes OMT but requires revascularization with CEA or CAS due to the presence of stroke or stroke symptoms unless excessive comorbidities put the patient at unreasonable risk of death.
hypertension and the kidneys
The principal site of damage is in the arterioles leading to the renal system. The continual high pressures exerting force against the walls cause them to thicken, which narrows the lumen. The blood supply to the kidneys is gradually reduced. In response to the reduction in blood supply, the kidneys secrete more renin, which elevates the BP even more, complicating the problem. Eventually, the reduced blood flow may lead to the death of the kidney cells.
medications to control aortic artery disease
Treatment is focused on reducing the growth rate and preventing the complications of aneurysms. Hypertension is an important risk factor for rupture, so BP is aggressively managed with antihypertensive medications such as angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ARBs), and/or beta blockers. In addition to antihypertensive medications, macrolides and tetracyclines, antibiotics that may inhibit secondary infections implicated in aneurysm development, have been proposed as a treatment for AAA with varying rationales and degrees of success. There is also evidence from a number of studies suggesting that statins may influence aneurysm growth rate by reducing the progression of atherosclerosis.
deep vein thrombosis
Virchow's triad describes the factors implicated in the formation of a venous thrombosis: decreased flow rate of the blood or stasis of blood flow, damage to the blood vessel wall, endothelial injury, and an increased tendency of the blood to clot (hypercoagulability). Deep vein thrombosis, more common in the veins of the lower extremity, develops in the deep veins of the calf muscles or, less frequently, in the proximal deep veins of the lower extremity or upper arm. The deep veins that lie near the center of the leg are surrounded by powerful muscles that contract and force deoxygenated blood back to the lungs and heart. One-way valves prevent the backflow of blood between the contractions. Blood is squeezed up the leg against gravity, and the valves prevent it from flowing back to the feet. When the circulation of the blood slows down because of illness, injury, or inactivity, blood can accumulate or "pool," which provides an ideal setting for clot formation
nursing interventions for deep vein thrombosis
Vital signs with oxygen saturation — Hypotension, tachycardia, and decreased oxygen saturation could indicate the presence of a PE or bleeding, especially if the patient is anticoagulated. Assess extremity for pain, tenderness, warmth, redness, or swelling — Common symptoms of DVT that occur because of obstruction of blood flow and may indicate location of the clot Compare right and left calf, thigh, or arm circumferences — Localized edema due to obstruction to blood flow in one extremity may suggest a DVT. Gentle palpation to inspect for induration — Induration (hardening) helps to locate the placement of the clot in the blood vessel. D-dimer test — Measures fibrin degradation products produced from clot breakdown. A positive result stratifies the patient into a high-risk category for DVT. Laboratory values: INR, PT/aPTT, hemoglobin, and hematocrit • The INR and PT/aPTT should be prolonged. • The hemoglobin and hematocrit should be within normal limits. The PT/INR evaluates the extrinsic coagulation cascade and is used to evaluate the effectiveness of warfarin. The aPTT evaluates the intrinsic coagulation cascade and is used to evaluate the effectiveness of heparin. Assess for signs of bleeding such as bruising, petechiae, hematuria, bloody stools Signs of bleeding may indicate a need to modify or decrease anticoagulation therapy.
nursing interventions for aortic artery disease (aneurysm)
Vital signs — Hypotension and tachycardia may indicate hypovolemia secondary to a loss of circulating volume. Blood pressure may vary between extremities if dissection is occurring because of the lessening of blood flow distal to the dissection. Hypertension, elevated diastolic pressure, and tachycardia can further weaken the vessel wall, increasing the risk that the aneurysm will enlarge, dissect, or rupture. Neurological assessment — An aneurysm of the aortic arch can cause neurological symptoms similar to those of a TIA or stroke. The bulging aorta exerts pressure on the subclavian artery, decreasing blood flow through the common carotid arteries to the brain, causing neurological effects. Pain — Persistent abdominal, chest, or back pain indicates that the aneurysm is pushing on adjacent organs and structures and may help pinpoint the location. Pain is also an indicator of a change such as dissection or rupture. Peripheral pulses, skin color, and temperature — Weak peripheral pulses, poor color, and cool extremities indicate lack of arterial flow, potentially because of dissection or thrombus formation in the aneurysm. Peripheral sensation and motor response — Paresthesias or paralysis may indicate pressure against the arteries supplying the spinal cord. Gentle abdominal auscultation and palpation — Pulsatile abdominal masses may indicate an AAA. A bruit is caused by turbulent flow through the aneurysm. Administer antihypertensives as ordered — Antihypertensives control high BP, which is a major risk factor for aneurysm rupture. Administer statins as ordered — Statins lower cholesterol and therefore reduce the risk of atherosclerosis, which may reduce the aneurysm growth rate. Administer tetracyclines and macrolides as ordered — These types of antibiotics may inhibit AAA progression by reducing secondary infections within the aortic wall. Administer stool softeners as ordered — Prevent strain on the aneurysm during defecation Create calm environment to reduce stress — Reduction in stress has been shown to reduce BP and therefore lessen stress on the aneurysm.
hypertensive crisis
an umbrella term for acute, severe elevations in BP. It comprises two conditions on a continuum: hypertensive urgency and hypertensive emergency. Hypertensive urgency is severely elevated BP (diastolic BP greater than or equal to 120 mm Hg) with no obvious, acute TOD. Hypertensive emergency is differentiated from hypertensive urgency by evidence of TOD, which may include signs of stroke, papilledema, HF, or aortic dissection. Hypertensive emergency is the most serious but least common form of hypertensive crisis, representing only 5% of cases. It requires emergent attention. Blood pressure must be lowered immediately to halt TOD. The incidence is higher in older adults, African Americans, and men. Most patients seen in hypertensive crisis have a prior history of hypertension and have been prescribed antihypertensive medications at some point. Sudden escalation of essential, chronic hypertension is a common precipitant of hypertensive crisis. Medication interactions and/or withdrawal of treatment are also frequently precipitating factors.
complications of carotid artery disease
complications resulting from impaired cerebral perfusion such as stroke or transient ischemic attack (TIA) are discussed in Chapter 39. They include sudden weakness, sometimes noted more on one side than the other, dizziness and loss of coordination, difficulty talking, facial droop, sudden vision problems, and sudden and severe headache
aortic dissection
diagnosis in which the arterial wall splits apart
what is hypertension?
high blood pressure - caused by increased sodium intake, which causes increasing stroke volume and blood pressure
high-density lipoprotein choelsterol
low HDL levels indicate an increased risk for atherosclerosis. The target HDL level is greater than 40 mg/dL. - they carry out the bad cholesterol from the arteries
how can you help patients with diabetes when in pain?
remember, they have neuropathic pain. you treat this type of pain with gabapentin. - tell them to check their feet and heels every day for any cut or anything. they cannot feel it. at all. it can quickly become necrotic because there is no oxygen/blood supply to help heal the injury, so necrosis sets in and spreads.
excess angiotensin II
results in vasoconstriction and icnreased blood pressure.
types of aneurysms
saccular aneurysms project from only one side, a fusiform aneurysm is present when the entire arterial segment becomes dilated, a false or pseudoaneurysm is a leak from the artery typically caused by iatrogenic trauma that punctures the artery.
what is most commonly affected by hypertension?
the heart. when arterial pressure is high, the heart uses more energy to pump against the increased afterload caused by the elevated pressure in the aorta. - because of the increased afterload, the left ventricle gradually hypertrophies, causing diastolic dysfunction. - the ventricle eventually diabetes, causing dilated cardiomyopathy and HF due to systolic dysfunction.
carotid artery disease is asymptomatic until what?
the lumen of the vessel is obstructed to the point that cerebral perfusion is impaired. A bruit resulting from turbulent flow past the obstruction at the carotid bifurcation may be heard with a stethoscope.
lifestyle changes that help atherosclerosis
• Healthy diet — A low-fat, low-cholesterol diet helps manage risk factors and slows the progression of atherosclerosis. Elevated homocysteine levels may be lowered by a diet enriched with B-complex vitamins, particularly folic acid. • Smoking cessation — Toxins in tobacco smoke lower a person's HDL-C while raising levels of LDL-C. The nicotine and carbon monoxide in cigarette smoke damage the endothelium, which sets the stage for the build-up of plaque. If a smoker has hypertension, smoking can increase the risk of malignant hypertension. • Exercise — Exercise can help to lower LDL-C and increase HDL-C. Exercise can also help reduce other risk factors of atherosclerosis such as high BP, diabetes, obesity, and stress.
